Services availability and readiness assessment "SARA" Core Questionnaire

Transcription

1 Services availability and readiness assessment "SARA" Core Questionnaire Version 1.0 (11 October 2010)

2 Number Question Result COVER SECTION A: INFORMATION ABOUT THE SURVEY INFORMATION ABOUT THE SURVEY AND THE INTERVIEWER 001 Date Day... Month... Year Name of interviewer Interviewer code Interviewer visits: Mention if it is first, second or third visit. First... 1 Second... 2 Third Name of team leader FACILITY IDENTIFICATION AND GEOGRAPHIC COORDINATES 005 Province Province number District District number Name of facility 008 Code of facility (country registry code) 009 Location of facility 010 Urban/rural setting Result codes: 1= Urban 2= Rural Code... Code... Record the GPS reading according to the instructions. Set default settings for GPS: 1. Set coordinate system to latitude/longitude 2. Set coordinate format to decimal degrees 3. Set datum to WGS84 Move to main entrance of the building. Stand within 30 meters of door where entrance is in plain view to the sky. 1. TURN GPS MACHINE ON AND WAIT UNTIL SATELLITE PAGE CHANGES TO "POSITION". 2. WRITE ALTITUDE 3. PRESS "MARK" 4. HIGHLIGHT "AVERAGE" AND PRESS "ENTER" 5. HIGHLIGHT "WAYPOINT NUMBER" AND PRESS "ENTER" 6. ENTER FACILITY CODE 7. WAIT 5 MINUTES Health facility services availability and readiness assessment tool: 2/26 COVER SECTION B: INFORMED CONSENT

3 Number Question 8. HIGHLIGHT "SAVE" AND PRESS "ENTER" Result 9. PAGE TO MAIN MENU, HIGHLIGHT "WAYPOINT LIST" AND PRESS "ENTER" 10. HIGHLIGHT YOUR WAYPOINT 11. COPY INFORMATION FROM WAYPOINT LIST PAGE THIS IS THE AVERAGE OF ALL BE SURE TO COPY THE WAYPOINT NAME FROM THE WAYPOINT LIST PAGE TO VERIFY THAT YOU ARE ENTERING THE CORRECT WAYPOINT INFORMATION ON THE DATA FORM 011 Waypoint name 012 Altitude 013 Latitude N/S DEGREES/DEC. 014 Longitude E/W DEGREES/DEC. Number Question Result Skip COVER SECTION B: INFORMED CONSENT FIND THE MANAGER OR MOST SENIOR HEALTH WORKER RESPONSIBLE FOR THE FACILITY WHO IS PRESENT TODAY. READ THE FOLLOWING GREETING. Hello. My name is [YOUR NAME]. I am here on behalf of the Ministry of Health, [OTHER PARTICIPATING ORGANIZATIONS] to assist the government in knowing more about health services. Now I will read a statement explaining the survey we are conducting. Your facility was selected to participate in this study. I will be asking you questions about various health services. The information about your facility may be used by the Ministry of Health and organizations supporting services in your facility for planning service improvement or further studies of health services. The data collected from your facility may also be provided to researchers for analyses. We are asking for your help to ensure that the information we collect is accurate. If there are questions for which someone else is the most appropriate person to provide the information, I would appreciate your introducing me to that person. You may refuse to answer any question or choose to stop the interview at any time. Do you have any questions about the survey? 015 Do I have your agreement to proceed? Yes..1 No 2 END 016 SIGNATURE OF INTERVIEWEE INDICATING INFORMED CONSENT WAS PROVIDED Signature: Date: 017 RECORD THE TIME AT THE BEGINNING OF THE INTERVIEW (use the 24 hour clock Health facility services availability and readiness assessment tool: page 3/26 INFORMATION ABOUT THE SURVEY AND INTERVIEWER :

4 Number Question system) TYPE OF FACILITY AND MANAGING AUTHORITY 018 Managing authority (country specific) Result codes: 1 = Government facility public 2 = Government facility not public (military, etc) 3 = Parastatal 4 = Private for profit 5 = Faith based organization (FBO)* 6 = NGO, other than faith based 7 = Community 96 = Other (please specify) Result Code... *For FBOs, see add on module 019 Type of facility (country specific): Use SECONDARY/TERTIARY LEVEL questionnaire for: Tertiary level : National hospital/specialized hospital...1 Secondary level: Second level referral hospital (regional, provincial)...2 First level hospital (district) Use PRIMARY LEVEL questionnaire for: Primary level: Health center 4 Clinic/maternity.5 Health post 6 Dispensary Other (please specify) Use PHARMACY questionnaire for: Stand alone pharmacy...8 Drug store 9 Use LABORATORY questionnaire for: Stand alone laboratory.10 Code... Health facility services availability and readiness assessment tool: page 4/26 INFORMATION ABOUT THE SURVEY AND INTERVIEWER

5 Number Question Result Skip SECTION 1: INFRASTRUCTURE AND MANAGEMENT We will start with section one which covers items related to infrastructure and management. COMMUNICATIONS 101 Does the facility have a functioning land line telephone? 102 Does the facility have a functioning cellular telephone either private or supported by the facility? 103 Does the facility have a functioning short wave radio for radio calls? 104 Is there a phone or shortwave radio within less than 15 minutes walking distance from the facility that staff can use in an emergency? Yes 1 No.2 Yes 1 No.2 Yes 1 No.2 Yes, at all times 1 Yes, but not all times.. 2 No Does the facility have a functioning computer? Yes 1 No Is there access to or internet within the facility? BASIC AMENITIES 107 Is this facility connected to the central supply electricity grid? 108 During the past week was electric power continuously available in this facility at the times the facility was open for services? 109 Does the facility have other sources of electricity like generator or solar supply? CHECK ALL THAT APPLY Yes 1 No.2 Yes 1 No.2 Yes 1 No.2 Generator (fuel operated) A Generator (battery operated) B Solar supply.c None.D Other 96 (SPECIFY) Is the generator functional? Yes 1 No.2 Don't know Is there fuel or battery today? Yes 1 No.2 ENVIRONMENTAL HEALTH Health facility services availability and readiness assessment tool: 5/26 SECTION 1: INFRASTRUCTURE AND MANAGEMENT

6 Number Question Result Skip 112 What is the most commonly used source of water for the facility at this time? 113 Is a water outlet from this source available within 500 meters of the facility? 114 What is the most commonly used toilet facility available for patient use? REFERRAL CAPACITY AND EMERGENCY RESPONSE 124 Does this facility have an emergency transportation service or ambulance for patient transport? Piped into facility.1 Piped onto facility grounds..2 Public taps/standpipe..3 Tubewell/borehole...4 Protected dug well..5 Unprotected dug well...6 Protected spring...7 Unprotected spring.8 Rainwater..9 Bottled water 10 Cart with small tank/drum.11 Tanker truck..12 Surface water (river, dam, pond) 13 Other 96 (SPECIFY) Don't know 98 No water source 00 Yes 1 No.2 Flush/pour flush to: Piped sewer system or septic tank. 1 Pit latrine. 2 Elsewhere... 3 Unknown place/not sure Ventilated improved pit latrine (VIP) 5 Pit latrine with slab 6 Pit latrine without slab/open pit. 7 Composting toilet 8 Bucket.. 9 Hanging toilet/latrine. 10 No facilities or bush or field 11 Other 96 (SPECIFY) Health facility services availability and readiness assessment tool: 6/26 SECTION 1: INFRASTRUCTURE AND MANAGEMENT

7 Number Question Result Skip SECTION 2: BASIC EQUIPMENT AND INFECTION CONTROL GENERAL PURPOSE EQUIPMENT 201 This section covers general purpose equipment. I am interested in knowing if the following resources are available in this facility. For each equipment or item, please tell me if it is available in the facility and functional today or not available or not functional today. AND FUNCTIONAL NOT OR NOT FUNCTIONAL A Blood pressure machine or cuff B Stethoscope C Adult weighing scale D Weighing equipment for under five year olds Infant scale E Thermometer for measuring body temperature I Light source to ensure visibility such as lamp or flash light for patient examination K Infusion kits for intravenous solution BASIC SURGICAL EQUIPMENT 202 This section covers basic surgical equipment. I am interested in knowing if the following resources are available in this facility. For each equipment or item, please tell me if it is available in the facility and functional today or not available or not functional today. AND FUNCTIONAL NOT OR NOT FUNCTIONAL A Needle holder B Scalpel handle with blade C Retractor D Surgical scissors E Skin disinfectant F Nasogastric Tubes FG G Tourniquet H Sutures both absorbable and non absorbable I Ketamine RESPIRATORY TREATMENT SUPPLIES 204 This section covers respiratory treatment supplies. I am interested in knowing if the following resources are available in this facility. For each item, please tell me if it is available in the facility and functional today or not available AND FUNCTIONAL NOT OR NOT FUNCTIONAL Health facility services availability and readiness assessment tool: 7/26 SECTION 2: BASIC EQUIPMENT AND INFECTION CONTROL

8 or not functional today. A B Self inflating bag and mask for resuscitationadult Self inflating bag and mask for resuscitationpediatrics C Micronebulizer D Equipment to measure oxygen saturation such as a pulse oximeter 205 Does this facility have an oxygen distribution system? STANDARD PRECAUTIONS FOR PREVENTION OF INFECTIONS Yes... No... For additional questions on oxygen, see addon module Comment [kp1]: Not in SARA index hospital only? 209 Which of the following hand hygiene facilities are available at this facility today? A Soap Yes 1 No Is an environmental disinfectant such as bleach or alcohol available today in this facility? 1 Yes 1 No Which of the following personal protective equipment is available today in this facility for health care staff? A Latex gloves Yes 1 No.2 C Medical masks Yes 1 No Are needles and syringes available in this facility today? 213 Which of the following is currently the main type of needles and syringes used in this facility for general health services apart from immunization: disposable, re usable, or autodestruct? 214 Are sharps boxes available in this facility for the disposal of used needles and syringes? 215 What is the method most commonly used for disinfecting or sterilizing medical equipment before it is reused? IF DIFFERENT METHODS ARE USED FOR DIFFERENT TYPES OF EQUIPMENT, INDICATE THE METHOD USED FOR METAL EQUIPMENT SUCH AS MINOR SURGICAL EQUIPMENT. 218 How does this facility finally dispose of sharp items, or what is the final disposal process for filled sharps boxes? Yes 1 No Disposable..1 Re usable.2 Auto destruct 3 Other 96 (SPECIFY) Yes 1 No.2 Dry heat sterilization.1 Autoclaving..2 Boiling...3 Steam.4 Chemical method.5 Process outside facility...6 No equipment processed..7 Other 96 (SPECIFY) BURN INCINERATOR 2 chamber industrial ( C)..1 1 chamber drum/brick..2 OPEN BURNING 1 Includes nationally accepted disinfectant. Health facility services availability and readiness assessment tool: 8/26 SECTION 2: BASIC EQUIPMENT AND INFECTION CONTROL

9 Flat ground no protection 3 Pit or protected ground 4 DUMP WITHOUT BURNING Flat ground no protection..5 Covered pit or pit latrine..6 Open pit no protection..7 Protected ground or pit.8 REMOVE OFFSITE Stored in covered container..9 Stored in other protected environment 10 Stored unprotected 11 Other 96 (SPECIFY) Never has sharp waste.95 Health facility services availability and readiness assessment tool: 9/26 SECTION 2: BASIC EQUIPMENT AND INFECTION CONTROL

10 Number Question Result Skip SECTION 3: HUMAN RESOURCES I would like to know the number of staff in each of the following categories. Please count each staff member only once, on the basis of the nature of the work performed. 302 Generalist medical doctors NUMBER 303 Specialist medical doctors NUMBER 304 Of the total number of medical doctors, both generalist and specialist, how many are working part time? NUMBER I would like to know the number of staff in each of the following categories. Please count each staff member only once, on the basis of the nature of the work performed. 305 Nursing professionals NUMBER 306 Midwifery professionals NUMBER 307 Nursing and midwifery associate professionals NUMBER Health facility services availability and readiness assessment tool: 10/26 SECTION 3: HUMAN RESOURCES

11 Number Question Result SECTION 4: TRAINING AND GUIDELINES In this section I would like to know whether any of your staff has received training on the delivery of specific tasks or interventions in the last 2 years, and whether there are guidelines currently available for these interventions. 401 Has any of your staff received training in the last 2 years on (NAME OF INTERVENTION)? 402 Are guidelines currently available for (NAME OF INTERVENTION)? YES NO DON'T KNOW YES NO SURGERY AND STANDARD PRECAUTIONS Integrated Management of Emergency and Essential Surgical care Appropriate use of blood and safe transfusion practices Infection control polices and procedures Infection safety Health care waste management practices MATERNAL, NEWBORN AND CHILD HEALTH A Family planning 98 B Antenatal care 98 C Infant and young child feeding counseling 98 D Basic Emergency Obstetric Care (BEmOC) or Integrated Management of Pregnancy and Childbirth (IMPAC) 98 E Comprehensive Emergency Obstetric Care (CEmOC) 98 F Integrated management of childhood illness (IMCI) 98 G Expanded program on immunization (EPI) 98 COMMUNICABLE DISEASES Malaria Tuberculosis K Diagnosis and treatment of malaria 98 Intermittent Preventive Treatment (IPT) of malaria in pregnancy L Diagnosis and treatment of tuberculosis 98 M Management of MDR TB 98 HIV & AIDS and STIs Q HIV & AIDS counseling 98 R HIV testing 98 Health facility services availability and readiness assessment tool: 11/26 SECTION 4: TRAINING AND GUIDELINES

12 S Prevention of mother to child transmission (PMTCT) of HIV 98 T Management of TB/HIV co infection 98 U ARV therapy 98 NON COMMUNICABLE DISEASES V Diabetes diagnosis and treatment 98 W Mental health treatment 98 Chronic cardiovascular conditions Health facility services availability and readiness assessment tool: 12/26 SECTION 4: TRAINING AND GUIDELINES

13 Number Question Result Skip SECTION 5: SERVICES This section will cover questions on the services available at this facility. GENERAL CLINICAL SERVICES Inpatient Services 501 Does this facility routinely provide in patient care? 502 How many total beds for in patient care, meaning beds for overnight stay for adults and children, does this facility have excluding delivery beds? A Of the total number of in patient beds, how many are dedicated maternity beds? TOTAL NUMBER OF BEDS NUMBER OF MATERNITY BEDS During (THE LAST COMPLETED CALENDAR MONTH) how many in patients were admitted to this facility excluding deliveries? NUMBER OF IN PATIENTS 505 Does this facility have dedicated delivery beds? A How many dedicated delivery beds? NUMBER OF DELIVERY BEDS 507 Comment [kp2]: Do we need delivery beds? 508 During (THE LAST COMPLETED CALENDAR MONTH) how many out patients were seen at this facility? NUMBER OF OUT PATIENTS Surgical Services and Blood Transfusion 512 Does this facility provide blood transfusion services? 513 Does this facility offer any surgical services? Which of the following surgical services does this facility offer? A Incision and drainage of abscess B Wound debridement C Acute burn management D Suturing E Closed treatment of fracture F Cricothyroidotomy Health facility services availability and readiness assessment tool: 13/26 For additional questions on surgery, see add on module

14 MATERNAL AND NEWBORN HEALTH Family Planning 515 Does this facility offer any modern method of family planning? A. Which of the following contraceptive method does this facility offer? Combined oral contraceptive pills Condoms (male) Injectable contraceptives For additional questions on maternal health, see add on module Antenatal Care Condoms (male) 516 Does this facility offer antenatal services? Which of the following antenatal care services does this facility provide? A Tetanus vaccination B Iron supplementation C Folic acid supplementation D IPT E HIV counseling and testing for pregnant women F Counseling on PMTCT Folic acid tablets, TT, iron tablets Comment [kp3]: Here or in meds? Safe Delivery/Obstetric Care and Postpartum Services 518 Does this facility offer obstetric care services? Which of the following obstetric care services does this facility provide? A Delivery services at the facility B Parenteral administration of antibiotics C Parenteral administration of oxytocic drugs D Parenteral administration of anti convulsants to women with pre eclampsia or eclampsia Health facility services availability and readiness assessment tool: 14/26

15 Newborn Care E Manual removal of placenta F Removal of retained products after delivery 522 Does this facility provide newborn care services? Which of the following newborn care services does this facility provide? A New born resuscitation Newborn bag and mask Eye prophylaxis B Antibiotic eye ointment for newborn C Clean cord care 520 Does this facility offer postpartum services? Which of the following postpartum services does this facility provide? A HIV counseling B Family planning during postpartum period C Home visits by skilled worker to provide delivery care services at home D Counseling on infant and young child feeding CHILD HEALTH: Curative care 524 Does this facility offer any child health services? Which of the following services for children under five does this facility provide here or on an outreach basis? A Routine Vitamin A supplementation B Iron supplementation C Treatment of sick children D Growth monitoring For additional questions on child health, see add on module Health facility services availability and readiness assessment tool: 15/26

16 Growth charts E Treatment of child malnutrition Zinc supplementation Comment [kp4]: Here or meds? (not in list) Zinc, growth charts CHILD HEALTH: routine immunization F Immunization services Are immunization services provided only in the facility, on an outreach basis only, or both? Facility only... 1 Outreach only... 2 Both in facility and outreach Are the following vaccines in stock? A Measles B DPT HB C Polio D BCG 118 How many working refrigerators? NUMBER OF REFRIGERATORS 120 How many working cold boxes with ice packs for outreach? NUMBER OF COLD BOXES COMMUNICABLE DISEASES Malaria 528 Does this facility offer malaria services? Which of the following malaria services are offered in this facility? A Malaria diagnosis B Treatment of malaria C D Tuberculosis Insecticide treated bednet distribution to patients and their families and households Insecticide treated bednet voucher distribution to patients and their families and households Health facility services availability and readiness assessment tool: 16/26

17 530 Does this facility offer any TB services? Does this facility offer TB screening identification of suspects? 532 Does this facility offer TB diagnosis services? Which of the following TB diagnosis services does this facility offer? A B C Diagnosis of tuberculosis through sputum smear microscopy Diagnosis of tuberculosis through X ray for eligible patients Diagnosis of MDR TB through LPA (Line Probe Assay) for eligible patients 534 Does this facility offer TB treatment services? Which of the following TB treatment services does this facility offer? A Treatment of tuberculosis with 1 st line drugs C D E Directly Observed Treatment, Short course (DOTS) Directly Observed Treatment (DOT) outreach services Treatment follow up of tuberculosis patients during continuation phase HIV & AIDS and Sexually Transmitted Infections (STIs) 536 Does this facility offer any HIV & AIDS services? Which of the following HIV & AIDS services does this facility offer? A HIV counseling and testing Is there a private room or screened off area available in HIV/AIDS counseling area? B Antiretroviral therapy (ART) C Prevention of mother to child transmission (PMTCT) through ARVs D HIV & AIDS care and support services E Post exposure prophylaxis F Youth friendly services Health facility services availability and readiness assessment tool: 17/26

18 539 Does this facility provide treatment of sexually transmitted infections (STIs)? NON COMMUNICABLE DISEASES 540 Does this facility offer services for noncommunicable diseases? 541 Which of the following non communicable disease services does this facility offer? 601 A Cervical cancer screening B Breast cancer screening C Prostate cancer screening D Diabetes screening E Home based care F Palliative care G Rehabilitative care Health facility services availability and readiness assessment tool: 18/26

19 Number Question Result Skip To be reviewed/adapted at country level for national relevance 601 GENERAL MEDICINES In this section I would like to know if the following general medicines are available today in this facility. STRENGTH YES NO A Amitriptyline 25 mg cap/tab B Amoxicillin 500 mg cap/tab C Atenolol 50 mg cap/tab D Captopril 25 mg cap/tab E Ceftriaxone injection 1g/vial F Ciprofloxacin 500 mg cap/tab G Co trimoxazole 8+40 mg/ml suspension H Diazepam 5 mg cap/tab I Diclofenac 50/75 mg cap/tab J Glibenclamide 5 mg cap/tab K Omeprazole 20mg cap/tab L Paracetamol 24mg/1ml suspension M Salbutamol 0.1 mg/ dose inhaler N Simvastatin 20 mg cap/tab 602 INFECTIOUS DISEASE MEDICINES In this section I would like to know if the following infectious disease medicines are available today in this facility. STRENGTH YES NO C Albendazole mg chewable tablets D Mebendazole mg or 500 mg 2 Specify either Albendazole or Mebendazole depending on country standards Health facility services availability and readiness assessment tool: 19/26

20 603 CHRONIC DISEASE MEDICINES In this section I would like to know if the following chronic disease medications are available today in this facility. STRENGTH YES NO A Enalapril 2.5 mg cap/tab B Beclometasone inhaler C Metformin tablet D Insulin injection 604 REPRODUCTIVE HEALTH MEDICINES AND COMMODITIES In this section I would like to know if the following reproductive health medicines and commodities are available today in this facility. STRENGTH YES NO A Combined oral contraceptive pills B Injectable contraceptives 4 C Male condoms D Oxytocin injection 10IU in 1 ml ampoule E Magnesium sulphate injection 5 500mg/ml in 2ml ampoule 606 OTHER MEDICINES In this section I would like to know if the following other medicines are available today in this facility. STRENGTH YES NO B Oral rehydration salts (ORS) sachets 6 MALARIA MEDICINES In this section I would like to know if the following drugs for the treatment of malaria are available today in this facility. 607 Are any drugs for the treatment of malaria available today in this facility? 608 STRENGTH YES NO A ACT (Artemether + Lumefantrine) 7 TUBERCULOSIS MEDICINES In this section I would like to know if the following drugs for the treatment of tuberculosis are available today in this facility. 608 Are any drugs for the treatment of tuberculosis available today in this facility? Specify either Albendazole or Mebendazole depending on country standards 4 Use the name of the most common injectable contraceptive available in all health care facilities 5 Include only if country policies exist outlining the use of Magnesium Sulphate for this purpose 6 Include only if country policies exist outlining the use of ORS for this purpose at this level of facility 7 Include dose or formulation according to the specific country malaria treatment policies Health facility services availability and readiness assessment tool: 20/26

21 STRENGTH YES NO A Ethambutol 100mg B Ethambutol 400 mg C Isoniazid 100mg D Isoniazid 300 mg E Pyrazinamide 150 mg F Pyrazinamide 400 mg G Rifampicin 150mg H Rifampicin 300 mg I Streptomycin (injectable) 1g/vial J Isoniazid + Rifampicin 30mg+60mg K Isoniazid + Rifampicin 75mg+150mg L Isoniazid + Ethambutol (EH) (2 FDC) 150mg+400mg M Isoniazid + Rifampicin + Pyrazinamide (RHZ) (3 FDC) N Isoniazid + Rifampicin + Ethambutol (RHE) (3 FDC) O Isoniazid + Rifampicin + Pyrazinamide + Ethambutol (4 FDC) 30mg+60mg+ 150mg 75mg+150mg+ 275mg 75mg+150mg+ 400mg+275mg ARV MEDICINES Include only first line regimens In this section I would like to know if the following drugs for the treatment of HIV & AIDS are available today in this facility. 609 Are any drugs for the treatment of HIV & AIDS available today in this facility? 701 DOSAGE YES NO A Zidovudine (AZT, ZDV) B Abacavir (ABC) C Didanosine (DDI) D Efavirenz (EFV) E Lamivudine (3TC) F Nevirapine (NVP) G Stavudine (d4t) H D4T + 3TC (Stavudine + Lamivudine) I D4T +3TC +NVP (Staduvine + Lamivudine + Nevirapine) J AZT + 3TC (Zidovudine + Lamivudine) K AZT + 3TC + ABC (Zidovudine + Lamivudine + Abacavir) Health facility services availability and readiness assessment tool: 21/26

22 L AZT + 3TC + NVP (Zidovudine + Lamivudine + Nevirapine) M Tenofovir disoproxil fumarate (TDF/Viread) N TDF + FTC (Tenofovir + Emtricitabine) O TDF + 3TC (Tenofovir + Lamivudine) P TDF + 3TC + EFV (Tenofovir + Lamivudine + Efavirenz) Q TDF + FTC + EFV (Tenofovir + Emtricitabine + Efavirenz) Health facility services availability and readiness assessment tool: 22/26

23 Number Question Result Skip SECTION 7: LABORATORY This section will cover questions regarding laboratory services offered in the health facility. 701 Does this facility offer any laboratory services for example, collection of specimens, laboratory tests, and rapid diagnostic tests? CLINICAL CHEMISTRY For each of the following tests, please tell me if the test is available on site, available off site, or not available. If the test is available on site, does this facility also receive specimens from other facilities? 702 Is the following test available? Yes... 1 No ON SITE, INCLUDING SPECIMENS FROM OTHER FACILITIES ON SITE, ONLY SPECIMENS FROM THIS FACILITY OFF SITE NOT E Glucose dipstick 3 4 F Glucose manual method 3 4 G Glucose glucometer 3 4 HEMATOLOGY J Pregnancy testing by urine rapid test 3 4 For each of the following tests, please tell me if the test is available on site, available off site, or not available. If the test is available on site, does this facility also receive specimens from other facilities? 703 Is the following test available? F Hemoglobin (Hb) estimation automatic hemoglobinometer ON SITE, INCLUDING SPECIMENS FROM OTHER FACILITIES ON SITE, ONLY SPECIMENS FROM THIS FACILITY OFF SITE NOT 3 4 G Hb estimation by manual method 3 4 H Hb WHO color scale 3 4 I CD4 count absolute 3 4 J CD4 count percentage 3 4 PARASITOLOGY For each of the following tests, please tell me if the test is available on site, available off site, or not available. If the test is available on site, does this facility also receive specimens from other facilities? 704 Is the following test available? ON SITE, INCLUDING SPECIMENS FROM OTHER FACILITIES ON SITE, ONLY SPECIMENS FROM THIS FACILITY OFF SITE NOT A Malaria thick films 3 4 B Malaria thin films 3 4 Comment [kp5]: This whole section needs to be re_done to reflect th e basic tests Health facility services availability and readiness assessment tool: 23/26 SECTION 8: INTERVIEWER'S OBSERVATIONS

24 Number Question Result Skip C Malaria speciation of Plasmodium 3 4 D Direct stool preparations for protozoan cysts 3 4 F Malaria RDTs 3 4 BACTERIOLOGY For each of the following tests, please tell me if the test is available on site, available off site, or not available. If the test is available on site, does this facility also receive specimens from other facilities? 705 Is the following test available? A B C D Direct Ziehl Neelsen (ZN) microscopy for TB Concentrated Ziehl Neelsen (ZN) sputum smears centrifugation Direct microscopy for TB fluorescence microscopy Concentrated sputum smearsfluorescence microscopy ON SITE, INCLUDING SPECIMENS FROM OTHER FACILITIES ON SITE, ONLY SPECIMENS FROM THIS FACILITY OFF SITE NOT E Cell count 3 4 F Gram Smear 3 4 G VIROLOGY TB smear Ziehl Neelsen/ Fluorescence Microscopy (ZN/FM) 3 4 H Syphilis detection test (VDRL, RPR) 3 4 I Sputum culture for TB diagnosis 3 4 For each of the following tests, please tell me if the test is available on site, available off site, or not available. If the test is available on site, does this facility also receive specimens from other facilities? 706 Is the following test available? ON SITE, INCLUDING SPECIMENS FROM OTHER FACILITIES ON SITE, ONLY SPECIMENS FROM THIS FACILITY OFF SITE NOT A HIV antibody testing by RDT 3 4 B Hepatitis B testing by RDT 3 4 C Hepatitis C testing by RDT 3 4 D HIV antibody testing by ELISA 3 4 E HIV testing by RNA 3 4 F HIV testing by DNA 3 4 G HIV viral load testing 3 4 Health facility services availability and readiness assessment tool: 24/26

25 Number Question Result Skip 709 We have now completed all of the questions in this survey. Thank you for your participation. Number Question Result SECTION 8: INTERVIEWER'S OBSERVATIONS To be filled in after completing the interview. 801 RECORD THE TIME AT THE COMPLETION OF THE INTERVIEW (use the 24 hour clock system) 802 RESULTS CODE: 1 = Completed 2 = Partially completed 3 = Respondent not available 4 = Refused 5 = Facility closed 96 = Other COMMENTS ON SPECIFIC QUESTIONS ANY OTHER COMMENTS SUPERVISOR'S OBSERVATIONS NAME OF SUPERVISOR : Result code.. Health facility services availability and readiness assessment tool: 25/26

26 Number Question Result Skip DATE Health facility services availability and readiness assessment tool: 26/26