Number and distribution of health facilities per 10,000 population
The number of health facilities per population of 10,000 or the number of health facilities per total population living in a designated area. Health facilities include all public, private, non-governmental and community-based health facilities defined as a static facility (i.e., has a designated building) in which general health services are offered. Health posts can be counted as static facilities, but because they are generally small with minimal supplies, they may need to be disaggregated for interpretation purposes. The indicator does not include mobile service delivery points and non-formal services such as traditional healers.
Where possible, geographic mapping of sites can be used to help determine coverage.
This indicator is calculated as:
(Number of health facilities / Total population in a designated area)
The ratio can be adjusted to per 10,000 population by multiplying the numerator and denominator by the same factor required for the denominator to equal 10,000.
This indicator is selected from the list of core indicators in the WHO Health System Strengthening (HSS) Handbook. For more background on the process and criteria used in developing the WHO Handbook of indicators for HSS and for details on this and related indicators, see WHO (2010); USAID (2009); and The Global Fund (2009).
District and national databases provide the number of public facilities, often by type (hospital, health center, health post, dispensary, etc.). Facility censuses may be required to obtain the number of private, non-governmental and community-based facilities, especially if there is no enforced registration system. Geographic locations of health facility sites using maps or computerized mapping system. Where a full-scale census of facilities may not be feasible or in order to validate census findings, a comprehensive facility survey instrument called the Service Provision Assessment (SPA) has been developed by USAID and Macro International Inc. to be used with nationally representative samples of health facilities to provide information on the characteristics of health services, including their quality, infrastructure, utilization and availability. The WHO service availability and readiness assessment (SARA) is specifically designed to assess, map and monitor service availability and readiness. For more details on the SPA and SARA, see WHO (2010) and MEASURE DHS (2011).
Data can be disaggregated by type of facility, districts, urban/rural location, and, where data are available, by area income median or quintiles and other relevant demographic and socioeconomic factors.
District and national databases; facility censuses, maps and/or computerized mapping systems
This standardized indicator measures levels of access to health services by the designated populations, can be used to identify underserved areas, and will allow comparisons within and between countries, regions, sectors, and programs. Geographic mapping will allow identification of where there are coverage gaps for certain populations. Data from multiple time points allow for monitoring progress in scaling up health interventions and overall HSS (WHO, 2010). There has been a shift in the global health agenda from focusing on disease-specific approaches to emphasizing HSS to improve the effectiveness of national and district-level health ministries and programs. This indicator can contribute to monitoring progress in the Millennium Development Goals #4. Reduce child mortality; #5. improve maternal health; and #6. combat HIV/AIDS. The usefulness of this indicator, as with all of the indicators in the WHO HSS Handbook, will be enhanced and better understood through continued research and utilization of the information that they generate.
Difficulties in identifying facilities that are not in the public sector or are not registered can result in undercounting. The size of health facilities may vary considerably making comparisons difficult and, when smaller geographical units such as districts are analyzed, the population may not necessarily use the facilities in the designated area. Consequently, comparisons of densities between districts and subpopulations need to be done with caution.
Indicators of service availability cannot accurately reflect access to and utilization of services. For example, clients may avoid use of local facilities or may use ones that lie outside the immediate catchment area because of travel logistics, sociocultural preferences and actual or perceived issues around quality. Urban areas present a particular challenge because, although facilities may be close in proximity, issues of affordability and acceptability become more important obstacles to access (WHO, 2010).
access, health system strengthening (HSS)
The primary aim of HSS is to improve access, quality, and utilization of health services, and growing evidence shows that health systems capable of delivering services equitably, efficiently, and in a coordinated manner are essential for achieving improved health outcomes.
The Global Fund, 2009, Monitoring and Evaluation Toolkit: HIV, Tuberculosis and Malaria and Health Systems Strengthening, http://www.hivpolicy.org/Library/HPP000485.pdf
MEASURE DHS. 2011, Service Provision Assessments (SPA) Survey Overview, DHS Website. http://www.measuredhs.com/What-We-Do/Survey-Types/SPA.cfm
USAID, 2009, Measuring the Impact of Health Systems Strengthening, A Review of the Literature, Washington, DC: USAID. https://www.researchgate.net/publication/274064201_Measuring_the_Impact_of_Health_Systems_Strengthening_A_Review_of_the_Literature
WHO, 2010, Monitoring the building blocks of health systems: a handbook of indicators and their measurement strategies, Geneva: WHO. http://www.who.int/healthinfo/systems/WHO_MBHSS_2010_full_web.pdf