QST PHC-BHCPF Ebonyi supplementary Mobile Version
Welcome to the BHCPF Quality Scoring Tool for PHCs
(Facility Assessment Tool)
#####Section 1. **Permission**
1. Do you agree to be interviewed?
-
Yes
yes
-
No
no
2. What is your reason for refusal.
Any additional notes
#####Section 2. **Facility Information**
1. State
-
Abia
abia
-
Adamawa
adamawa
-
Anambra
anambra
-
Akwa-Ibom
akwa_ibom
-
Bauchi
bauchi
-
Bayelsa
bayelsa
-
Benue
benue
-
Borno
borno
-
Cross River
cross_river
-
Delta
delta
-
Ebonyi
ebonyi
-
Edo
edo
-
Ekiti
ekiti
-
Enugu
enugu
-
Federal Capital Territory
federal_cap
-
Gombe
gombe
-
Imo
imo
-
Jigawa
jigawa
-
Kaduna
kaduna
-
Kano
kano
-
Katsina
katsina
-
Kebbi
kebbi
-
Kogi
kogi
-
Kwara
kwara
-
Lagos
lagos
-
Nasarawa
nasarawa
-
Niger
niger
-
Ogun
ogun
-
Ondo
ondo
-
Osun
osun
-
Oyo
oyo
-
Plateau
plateau
-
Rivers
rivers
-
Sokoto
sokoto
-
Taraba
taraba
-
Yobe
yobe
-
Zamfara
zamfara
2. Local Government Area
3. Wards
3. Ward
4. Health Facility Name
4. Health Facility Name
4a. Type in facility name
Please remember to take necessary steps to add this facility to the master facility list
5. Health Facility Type
-
Primary health center
primary_health_center
-
Primary health clinic
primary_health_clinic
-
Health post
health_post
6. Health Facility Code
-
General Hospital (GH) – 001
general_hospital
-
Comprehensive Health Centre (CHC) – 002
com_health_centre
-
Primary Health-care Centre (PHC) – 003
prim_health_centre
-
Clinic/Maternity home – 004
clinic_mat_home
-
Health Post – 005
health_post
-
Mobile Clinic – 006
mobile_clinic
-
Dispensary – 007
dispensary
7. Is the facility rural or urban?
-
Rural
rural
-
Urban
urban
-
Peri-Urban
peri-urban
8. Is the building rented
-
Yes
yes
-
No
no
9. Arrival time for first visit
10. Collect the GPS coordinates of this facility.
#####Start of Survey
#####Section 3. **General Information**
1. Full name of Respondent
[First-name Last-name]
2. Phone Number of Respondent
3. Are you the OIC?
-
Yes
yes
-
No
no
4. Which position do you occupy in this facility?
-
Medical officer
medical_doctor
-
Nurse/Midwife
nurse_midwife
-
Registered nurse
registered_nurse
-
Midwife
Mid_wife
-
Community Health Extension Worker
chew
-
Junior Community Health Extension Worker
Jchew
-
Pharmacist
pharmacist
-
Lab technician
Lab_technician
-
Health records officer
Health_records_officer
-
Environmental health officer
Environmental_health_officer
-
Other
other
Specify other.
5. Who owns this facility?
-
Government (public)
government
-
Private not-for-profit/NGO
Private_not-for-profit/NGO
-
Private not-for-profit/Faith-based
private_not-for-profit/Faith-based
-
Private for-profit
private_for-profit
-
Other
other
Specify other.
6. Who mainly pays the salaries of staff at this facility?
-
Government (public)
government
-
Private not-for-profit/NGO
Private_not-for-profit/NGO
-
Private not-for-profit/Faith-based
private_not-for-profit/Faith-based
-
Private for-profit
private_for-profit
-
Other
other
Specify other.
7.Who mainly pays for medical supplies (equipment, drugs, commodities) for this facility?
-
Government (public)
government
-
Private not-for-profit/NGO
Private_not-for-profit/NGO
-
Private not-for-profit/Faith-based
private_not-for-profit/Faith-based
-
Private for-profit
private_for-profit
-
Other
other
Specify other.
8. Who mainly pays for operation & maintenance costs for this facility?
-
Government (public)
government
-
Private not-for-profit/NGO
Private_not-for-profit/NGO
-
Private not-for-profit/Faith-based
private_not-for-profit/Faith-based
-
Private for-profit
private_for-profit
-
Other
other
Specify other.
9. What type of health facility is this?
-
Primary health center
primary_health_center
-
Primary health clinic
primary_health_clinic
-
Health post
health_post
10. How many rooms does this health facility have?
11. Take a picture of the waiting area in the health facility
*If applicable
12. Take a picture of the consulting room in the health facility
*If applicable
13. What is the traveling time by car, in minutes, to the state capital in the DRY season?
-
0-10 minutes
zero_to_ten_minutes
-
11-20 minutes
eleven_to_twenty_minutes
-
> 20 minutes
greater_than_twenty_minutes
14. What is the traveling time by car, in minutes, to the state capital in the RAINY season?
-
0-10 minutes
zero_to_ten_minutes
-
11-20 minutes
eleven_to_twenty_minutes
-
> 20 minutes
greater_than_twenty_minutes
15. Does this facility have a specified catchment area—that is a defined geographic area for which the facility has direct responsibility for serving?
-
Yes
yes
-
No
no
16. How many people live in the catchment area for this facility?
#####Section 4. Administrative System and Infrastructure
Administrative System
1. Does the health facility offer 24 hour's services?
-
Yes
yes
-
No
no
2. Does the facility have a functioning mobile phone with ability to charge?
-
Yes
yes
-
No
no
3. Does this facility have a functioning computer?
-
Yes
yes
-
No
no
4. Is there access to email or internet within the facility today?
-
Yes
yes
-
No
no
5. Are there arrangements for emergency transport?
-
Yes
yes
-
No
no
6. Take a picture of the ambulance vehicle
6a. What type of arrangements does this health facility have for emergency transport? [state all]
-
Ambulance owned by facility
ambulance_owned_facility
-
Ambulance available on call
ambulance_on_call
-
Official vehicle (not an ambulance) owned by facility
official_vehicle_owned_by_facility
-
Official vehicle (not an ambulance) available on call
official_vehicle_on_call
-
Private vehicle (not ambulance) available on call
official_vehicle_on_call
-
Emergency patient transport
emergency_patient_transport
-
No ambulance/vehicle in the facility
no_vehicle_in_facility
-
Other
other
Specify other.
7. Is there a driver on call/available 24 hours?
-
Yes
yes
-
No
no
8. Is fuel available in the vehicle today?
-
Yes
yes
-
No
no
9. What was the purpose of the last trip that the vehicle or ambulance made?
-
Transport health worker to another post
transport_health_worker
-
Transport a patient to another health facility
transport_patient
-
Not Applicable
na
-
Other
other
Specify other.
10. Do patients have to pay to use this vehicle or ambulance?
-
Yes
yes
-
No
no
10a. How much?
11. Does this facility have any guidelines on standard precautions for infection prevention?
-
Yes
yes
-
No
no
12. Does this facility have any guidelines on health care waste management?
Please ask to see the guidelines
-
Yes
yes
-
No
no
13. Have you or any provider(s) received training in health care waste management practices in the past two years?
-
Yes
yes
-
No
no
14. Do you have a Quarterly (Business/Work) Implementation Plan?
Ask to see the document
-
Yes
yes
-
No
no
a. When did the facility submit the Quarterly (Business/Work) Implementation Plan for approval?
b. When did the facility receive written approval from the relevant authorities for the Quarterly (Business/Work) Implementation Plan?
c. Was there a delay in receiving Quarterly (Business/Work) Implementation Plan approval from the relevant authorities?
-
Yes
yes
-
No
no
-
Not Applicable
na
d. Why was there a delay?
-
Delay in submission of QIP by facility
delay_in _submission
-
Headquarters not approving QIP
hq_not approving_qip
-
Other
other
Specify other.
15. Does your health facility have a Quality Improvement Plan (QIP)?
ask to see the document
-
Yes
yes
-
No
no
a. Is the QIP costed?
-
Yes
yes
-
No
no
-
Not Applicable
na
16. Did the facility/hospital receive a supervision visit from the LGA-PHC in this calendar year?
-
Yes
yes
-
No
no
a. Did they leave a copy or written feedback?
-
Yes
yes
-
No
no
b. Did they use a checklist?
-
Yes
yes
-
No
no
-
Not Applicable
na
Infrastructure
1. What is the current state of the building?
-
Good; does not require renovation
no_renovation
-
Requires light renovation
light_renovation
-
Requires modest renovation
modest_renovation
-
Requires significant renovation
significant_renovation
2. Take a picture of the FRONT VIEW of the facility building
3. Take a picture of the SIDE VIEW of the facility building
4. Take a picture of the BACK VIEW of the facility building
5. What is the current state of the roof?
-
Good; does not require renovation
no_renovation
-
Requires light renovation
light_renovation
-
Requires modest renovation
modest_renovation
-
Requires significant renovation
significant_renovation
6.Take a picture of the roof of the health facility
6a. Take a second picture of the roof of the health facility
7. Take a picture of the facility ceiling
7a. Take a second picture of the facility ceiling
8. What is the current state of the fence?
-
Good; does not require renovation
no_renovation
-
Requires light renovation
light_renovation
-
Requires modest renovation
modest_renovation
-
Requires significant renovation
significant_renovation
-
No Fence
nofence
a. Take a picture of the fence of the health facility
b. Take a second picture of the fence of the health facility
9. Are the consulting rooms clean, clearly demarcated with adequate sitting and examination facility?
-
Yes
yes
-
No
no
10. Take a picture of the consulting room in the health facility
11. Are the walls free from cracks?
-
Yes
yes
-
No
no
12. Does the health facility have functional doors with functional locks?
-
Yes
yes
-
No
no
13. Is there any source of electricity?
-
Yes
yes
-
No
no
a. What is the main source of power or electricity for this facility?
-
Electric power grid
electric_power_grid
-
Fuel operated generator
fuel_operated_generator________
-
Battery operated generator
battery_operated_generator
-
Solar system
solar_system
-
Other electricity source
other_electricity_source
b. Specify power or electricity source
Please remember to take necessary steps to add this facility to the master facility list
14. How many hours per day does this facility have electricity from the main source?
15. Does this facility use any of the following as alternative power sources?
-
No source of power supply
no_source_of_power_supply
-
Fuel operated generator
fuel_operated_generator
-
Battery operated generator
battery_operated_generator
-
Solar system
solar_system
-
Other alternative power source
other_alternative_power_source
15a. Specify alternative power source
16. Is there any form of water?
-
Yes
yes
-
No
no
a. What is the main source of water for the facility?
-
Piped into facility
piped_into_facility
-
Piped onto facility grounds
piped_onto_facility_grounds
-
Public tap/standpipe
public_tap_standpipe
-
Borehole
borehole
-
Protected dug well
protected_dug_well
-
Unprotected dug well
unprotected_dug_well
-
Protected spring
protected_spring_______________
-
Unprotected spring
unprotected_spring
-
Rainwater
rainwater
-
Bottled water
bottled_water
-
Cart w/small tank/drum
cart_w_small_tank_drum
-
Truck
truck
-
Surface water
surface_water
-
Other source of water
other_source_of_water
b. Specify other water source
17. What is the average walking time, in minutes to and from the main source of water? (including waiting time)
-
0-10 minutes
0_10_minutes
-
11-20 minutes
11_20_minutes
-
> 20 minutes
>_20_minutes
18. Is water from this source available within 500 meters of the facility?
-
Yes
yes
-
No
no
19. Does this facility have any of the following as an alternative source of water supply?
-
No water source
no_water_source
-
Piped into facility
piped_into_facility
-
Piped onto facility grounds
piped_onto_facility_grounds
-
Public tap/standpip
public_tap_standpip
-
Borehole
borehole
-
Protected dug well
protected_dug_well
-
Unprotected dug well
unprotected_dug_well
-
Protected spring
protected_spring_______________
-
Unprotected spring
unprotected_spring_____________
-
Rainwater
rainwater
-
Bottled water
bottled_water
-
Cart w/small tank/drum
cart_w_small_tank_drum
-
Tanker truck
tanker_truck
-
Surface water
surface_water
-
Other alternative water source
other_alternative_water_source
a. Specify alternative water source
b. What is the average walking time, in minutes, to and from the alternative source of water? (including waiting time)
-
0-10 minutes
0_10_minutes
-
11-20 minutes
11_20_minutes
-
> 20 minutes
>_20_minutes
20. Is there a functioning toilet (latrine) for use by patients in the facility?
-
Yes
yes
-
No
no
a. Type of open defecation used
21. What type of toilet (latrine) is available for use by outpatients?
-
No functioning toilet
no_functioning_toilet
-
Bush
bush
-
Flush toilet
flush_toilet
-
Flush toilet (but no water)
flush_toilet_but_no_water
-
VIP latrine
vip_latrine
-
Covered pit latrine
covered_pit_latrine_no_slab____
-
Uncovered pit latrine w/ slab
uncovered_pit_latrine_w__slab
-
Other (specify)
other_specify
22. Other type of toilet(latrine) available
23. How many of the mentioned (outpatient) toilets/latrines are there?
24. How many of the mentioned (outpatient) toilets/latrines are currently functioning?
25. Do outpatients and inpatients use the same toilets?
-
Yes
yes
-
No
no
26. What type of toilet (latrine) is available for use by inpatients?
-
No functioning toilet
no_functioning_toilet
-
Bush
bush
-
Flush toilet
flush_toilet
-
Flush toilet (but no water)
flush_toilet_but_no_water
-
VIP latrine
vip_latrine
-
Covered pit latrine
covered_pit_latrine_no_slab_
-
Uncovered pit latrine w/ slab
uncovered_pit_latrine_w__slab
-
Other (specify)
other_specify
27. Other type of toilet(latrine) available for use by inpatients
28. Take a picture of the inpatient toilet in the health facility
29. How many of the mentioned (inpatient) toilets/latrines are there?
30. How many of the mentioned (inpatient) toilets/latrines are currently functioning?
31. Does this facility finally dispose of sharps waste (e.g., filled sharps boxes)?
-
Yes
yes
-
No
no
a. How does this facility finally dispose of sharps waste (e.g., filled sharps boxes)? [state all]
should be 2m deep, 15m from facility, 100m from water source and 50m from households
-
Incinerator
incinerator
-
1 chamber drum/brick
1_chamber_drum
-
Flat ground - no protection
flat_ground_no_protection
-
Flat ground - with protection
flat_ground_with_protection
-
Pit or protected ground
pit_protected_ground
-
Covered pit or pit latrine
covered_pit
-
Open pit - no protection
open_pit_no_protection
-
Protected ground or pit
protected_ground_pit
-
Stored in covered container
covered_container
-
Stored unprotected
stored_unprotected
-
Facility never has sharp waste
facility_no_sharp_waste
-
Waste collection agency
waste_collection_agency
-
Other
other
Specify other.
32. Does this facility finally dispose of medical waste other than sharps boxes?
-
Yes
yes
-
No
no
33. How does this facility finally dispose of medical waste other than sharps boxes? [state all]
It should be 2m deep, 15m from facility, 100m from water source and 50m from households
-
Incinerator
incinerator
-
1‐chamber drum/brick
1‐chamber_drum_brick
-
Flat ground ‐ no protection
flat_ground_‐_no_protection
-
Flat ground with protection
flat_ground_with_protection
-
Pit or protected ground
pit_or_protected_ground
-
Covered pit or pit latrine
covered_pit_or_pit_latrine
-
Open‐pit ‐ no protection
open‐pit_‐_no_protection_
-
Protected ground or pit
protected_ground_or_pit_
-
Stored in covered container
stored_in_covered_container
-
Stored unprotected
stored_unprotected_____________
-
Facility never has sharp waste
facility_never_has_sharp_waste
-
Waste collection agency
waste_collection_agency
-
Other
other
Specify other.
34. Are black bins for non-contaminated waste available?
-
Yes
yes
-
No
no
35. Are yellow and red bins for contaminated medical waste available?
-
Yes
yes
-
No
no
36. Is a security box for sharps available?
-
Yes
yes
-
No
no
37. Is the incinerator functional today?
-
Yes
yes
-
No
no
38. Is the power source for the incinerator available today?
-
Yes
yes
-
No
no
39. Is there an inpatient ward in this facility?
-
Yes
yes
-
No
no
40. Is the ward functional?
-
Yes
yes
-
No
no
41. Does the patient wards appear clean and in good condition?
-
Yes
yes
-
No
no
42. Take a picture of the in- patient ward in the facility
43. Is the facility equipped with in-patient beds?
-
Yes
yes
-
No
no
44. How many inpatient beds does the facility have?
45. Do you have a maternity waiting room where women can stay prior to giving birth?
-
Yes
yes
-
No
no
46. Is there staff accommodation in this facility?
-
Yes
yes
-
No
no
47. Is there a call room for staff on call duty?
-
Yes
yes
-
No
no
48. Is the on-call room equipped with basic conveniences (bed/couch, bed linen and ventilation)?
-
Yes
yes
-
No
no
#####Section 5. Financial System
1. Does this facility have a staff responsible for the financial/accounting system of the facility?
-
Yes
yes
-
No
no
2. Has he/she received financial training by appropriate organization/partner?
-
Yes
yes
-
No
no
Financial Bookkeeping
1. Which of the following financial management tools do you have?
-
Receipt books
receipt_books
-
Payment voucher
payment_voucher
-
Cash books
cash_books
-
Check Issue/Register
check_issue_ledger
-
General Ledger/Vote book
general_legder_vote_book
-
Stores Records
stores_records
-
Statement of expenditure
statement_of_expenditure
-
Did not receive any tools
did_not_receive_tools
-
Other
other
Specify other.
2. Have you submitted the financial report for the last quarter? [ask to see transmittal evidence]
-
Yes
yes
-
No
no
3. Monthly financial report (income and expenditure books) available and correctly filled and signed by the Health Facility Officer in Charge
-
Yes
yes
-
No
no
4. How often was the facility visited by a state/LGA/Ward level accounts person in the last calendar year?
-
Weekly
weekly
-
Biweekly (every two weeks)
biweekly
-
Monthly
monthly
-
Quarterly
quarterly
-
Yearly
yearly
-
Other
other
Specify other.
5. Does the facility share its financial information with the facility management committee?
-
Yes
yes
-
No
no
6. How does the facility share the information?
-
Hard copy reports
hard_copy_reports
-
During meetings
during_meeti
-
Chalkboard
chalk_board
-
Posters
posters
-
Other
other
Specify other.
Operational Funds
1. Did the facility receive any non-salary, operational funds from the state/local government in the calendar last year?
-
Yes
yes
-
No
no
2. Which level of government provided funds for non-salary, operational expenses in the last year?
-
State government only
state
-
Local government only
local
-
Both state and local government
state_local
3. Did the facility experience any delay in receipt of non-salary, operational funds from state/local government?
-
Yes
yes
-
No
no
4. Which level of government delayed funding for non-salary, operational expenses in the last year?
-
State government only
state
-
Local government only
local
-
Both state and local government
state_local
5. Please indicate the principle reason for the delays
-
Delay in submission of quality (business/work) implementation plan
delay_submission_quality
-
Delay in receiving authority to incur expenses (AIE) from authorities
delay_receive_authority
-
Unable to provide timely accounts to LGA or state treasury
unable_provide_timely_account
-
Audit issues raised on facility's account
audit_issues
-
Capacity problems at LGA or state treasury
capacity_problems
-
Other
other
Specify other.
6. Does the facility have alternate sources of funding?
-
Yes
yes
-
No
no
6a. Which of the following have been alternative sources of funding in the last year?
-
Drug revolving
drug_revolv
-
Registration
registration
-
Development partners/NGOs
dev_partners_ngos
-
Other
other
Specify other.
7. Does this health facility have a bank account?
-
Yes
yes
-
No
no
7a. How many active Bank accounts does the facility operate?
8. Are user fees/charges displayed at the facility?
-
Yes
yes
-
No
no
NHIS/Fee-for-service Processing
9. Do you have the appropriate NHIS utilization and claim forms?
-
Yes
yes
-
No
no
a. Does the utilization and claims data correspond and are accurate?
-
Yes
yes
-
No
no
b. The information of the enrollee is complete (including patient identification number, age, gender and contact details) - up to date for the preceding month
-
Yes
yes
-
No
no
c. Is there evidence to show that NHIS utilization claims are submitted regularly as required? (assumes monthly submission - cutoff date TBD
-
Yes
yes
-
No
no
QIP/Business Plan Financing
10. What proportion of facility allocation is spent on QIP and business plan?
-
There is no alignment between spending and the plans
no_alignment
-
Less than 60% of allocation spent on QIP
less_than_60_spent
-
≥ 60% of allocation spent on QIP
more_than_60_spent
Services and Costs
Please insert the costs of the health services below
1. Registration
2. Consultation- 5 years or older
3. Consultation- under 5 years of old
4. Laboratory: Malaria Test
5. Laboratory: Random blood sugar
6. Laboratory: Haemoglobin (Hb)
7. Laboratory: urinalysis
8. Laboratory: Other (Specify)
9. Drugs: Amoxicillin Syrup
10. U 5 services (Immunization, Diarrhea treatment, ARI)
*Insert service cost
a. Immunization
b. Diarrhea
c. Acute Respiratory Infection
11. ANC Visit
*Insert service cost
a. Registration
b. Drugs
*Insert cost
12. Normal Delivery
13. Family Planning
14. Malaria Drugs
*Insert service cost
a. Artesunate/Artemisinin combination therapy (ACT)/ Lumefantrine
b. Sulfadoxine/Pyramethamine(Fansidar), Chloroquine, Others
15. HIV/AIDS
*Insert service cost
a. Counselling
b. Screening
c. ARVs
16. TB
*Insert service cost
a. Sputum test
b. Chest x-ray
c. Treatment/DOTS
17. Are the user fees/charges displayed at the facility service charters?
Ask to see the boards
-
Yes
yes
-
No
no
18. In your facility, who is exempted from paying user fees?
-
Yes
yes
-
No
no
a. Patients with chronic diseases
-
Yes
yes
-
No
no
b. Elderly patients
-
Yes
yes
-
No
no
c. Very poor people
-
Yes
yes
-
No
no
d. Facility staff
-
Yes
yes
-
No
no
e. Relatives of staff
-
Yes
yes
-
No
no
19. What was the value for Waivers/Exemptions during the last financial year?
#####Section 6. Human Resources Management
1. How many health workers are employed in this facility
Doctors, nurses, midwives, CHEWs, lab scientist/technician, dentist, pharmacy scientist/technician, environmental officer, and medical record officer
2. How many non-health workers are employed in this facility
Drivers, cleaners, gardeners, security personnel, and health attendants/ward miads
3. Do your staff experience delay in payment of salary?
-
Yes
yes
-
No
no
3a. How frequently?
-
Seldom (Once in a year)
seldom
-
Often (Once every 3-6 months)
often
-
Always
always
4. Are there measures (attendance system) against lateness/absenteeism?
-
No attendance register available
none
-
Attendance register available but not monitored
avail_no_monitoring
-
Attendance register available and verified by the health facility supervisor
avail_monitored
5. Are there laid down procedures for contract staff recruitment
-
There are no laid down procedures for staff
none
-
Procedures exists but are not documented
proc_exist_not_monitor
-
Documented procedures exists and are implemented
doc_proc_exist_implemented
Please allow me to ask you a few questions about each health worker who works in this facility starting with you. Could you give me the name of the employee in the various categories starting with the physicians or medical officers?
*Only health workers information should be collected
######Staff Roster
######Staff Roster - Add staff details
1. First Name
2. Last Name
3. Cadre
-
Superintendent
super_intindent
-
Specialist
specialist
-
Medical officer
medical_officer
-
Community Health Officer
comm_health_officer
-
CHEW
chew
-
Junior CHEW
junior_chew
-
Environmental Health Officer
environ_health_offic
-
BSc Nurse
bsc_nurse
-
Registered Nurse
regist_nurse
-
Registered Midwife
regist_midwife
-
Psychiatric Nurse
psych_nurse
-
Dentist
dentist
-
Pharmacist
pharmacist
-
Laboratory Technician / Technologist
Lab_technician_technologist
-
Volunteer (indicate cadre)
volunteer
-
Other
other
Specify other.
3a. Volunteer (Specify)
4. Gender
-
Male
male
-
Female
female
5. Age
6. Does regularly perform outpatient consultation
-
Yes
yes
-
No
no
7. Is currently in the facility?
-
Yes
yes
-
No
no
8. Reason for absence
-
Sick / maternity
sick_maternity
-
In training / seminar
training_seminar
-
Official mission
official_mission
-
Approved absence
approved_absence
-
Not his / her shift
not_his_her_shift
-
Doing fieldwork or outreach work
field_outreach_work
-
Not approved absence
not_approved_absence
-
Gone to retreive salary
retreive_salary
-
On strike
strike
-
Other
other
Specify other.
#####Section 7. Maternal and Child Services
Family Planning
1. Are family planning services offered here?
-
Yes
yes
-
No
no
2. Which type of family planning services are offered here?
-
Counselling services
couns_services
-
Counselling and commodity services
couns_comm_services
3. Which family planning methods (commodities) are available today?
-
None
none
-
Condoms
condoms
-
Oral pills
oral_pills
-
Injectibles
injectibles
-
Implants
implants
-
IUC
iuc
4. Are FP individual cards available and filled according to the format?
-
Yes
yes
-
No
no
5. How many qualified staff are trained in Family Planning?
Antenatal Care
1. Does this facility provide antenatal care services?
-
Yes
yes
-
No
no
2. Is Antenatal Risk Assessment form (ARAF) used for ANC?
-
No antenatal risk assessment form
none
-
Antenatal risk assessment form present but not used regularly for ANC
araf_present_not_used
-
Antenatal risk assessment form present and used regularly for ANC
araf_present_used
3. Does this facility provide post-natal care services?
-
Yes
yes
-
No
no
Obstetric Care
1. Does this facility provide Basic Emergency Obstetric Care (BEOC)?
-
Yes
yes
-
No
no
2. How many staff present are qualified to offer BEOC? Insert number and cadre
3. Do you take deliveries at this facility?
-
Yes
yes
-
No
no
4. How many qualified staff are trained on Live Saving Skills (LSS)?
5. Is the delivery room is well-maintained? (Clean, delivery couch in good condition, water accessible and well lit)
-
Yes
yes
-
No
no
6. Take a picture of the interior of the delivery room, and specifically the delivery couch, in the facility
7. Is there light in delivery room for 24 hours
-
Yes, Electricity and rechargeable lamp
elect_rech_lamp
-
Yes, Only Electricity
elect_only
-
No
no
8. Is a partograph used for delivery? (Check via case note audits –5 case notes)
-
No partograph in the facility
none
-
Partograph is present but not used
present_unused
-
Partograph is present and used for delivery
present_used
9. How many case notes (out of 5 above) are with partographs?
Management of Childhood illnesses
1. Does this facility provide routine immunization services?
-
Yes
yes
-
No
no
2. How many staff have been trained on Integrated Management of Childhood Illnesses (IMCI)?
by appropriate agency e.g. MOH, Dev partners, certified CBOs and others
3. Do you offer growth monitoring services to all U5 patients?
-
The facility does not offer growth monitoring services
not_offered
-
There is no evidence that the facility offers growth monitoring services
no_evidence
-
There is documented evidence that the facility offers growth monitoring services
docum_evidence
4. Does the facility have basic nutritional assessment guide? (MUAC)
-
No measuring tapes available
no_tapes
-
Measuring tapes available but there is no documentation on MUAC
tapes_avail_no_doc
-
Measuring tapes and documentation available for MUAC
tapes_doc_avail
#####Section 8. Priority Area: Patient Care Management
Available Equipment (1/6)
1. Adult weighing scale
-
Yes (observed and functional)
yes_obs
-
No
no
2. Child weighing scale (250g gradation)
-
Yes (observed and functional)
yes_obs
-
No
no
3. Infant weighing scale (100g gradation)
-
Yes (observed and functional)
yes_obs
-
No
no
4. Thermometer
-
Yes (observed and functional)
yes_obs
-
No
no
5. Stethoscope
-
Yes (observed and functional)
yes_obs
-
No
no
6. Foetoscope
-
Yes (observed and functional)
yes_obs
-
No
no
7. Sphygmonometer
-
Yes (observed and functional)
yes_obs
-
No
no
8. Angle poised lamp
-
Yes (observed and functional)
yes_obs
-
No
no
9. Centrifuge, manual
-
Yes (observed and functional)
yes_obs
-
No
no
10. Chart holder
-
Yes (observed and functional)
yes_obs
-
No
no
Available Equipment (2/6)
11. Cooking pot (A set of 6)
-
Yes (observed and functional)
yes_obs
-
No
no
12. Delivery couch
-
Yes (observed and functional)
yes_obs
-
No
no
13. Dissecting forceps
-
Yes (observed and functional)
yes_obs
-
No
no
14. Dressing forceps
-
Yes (observed and functional)
yes_obs
-
No
no
15. Dressing scissors
-
Yes (observed and functional)
yes_obs
-
No
no
16. Dressing trolley
-
Yes (observed and functional)
yes_obs
-
No
no
17. Drip stand
-
Yes (observed and functional)
yes_obs
-
No
no
18. Enema can
-
Yes (observed and functional)
yes_obs
-
No
no
19. Episiotomy scissors
-
Yes (observed and functional)
yes_obs
-
No
no
20. Examination couch
-
Yes (observed and functional)
yes_obs
-
No
no
21. Fire extinguishers
-
Yes (observed and functional)
yes_obs
-
No
no
22. Forceps jar
-
Yes (observed and functional)
yes_obs
-
No
no
23. Growth charts
-
Yes (observed and functional)
yes_obs
-
No
no
24. Galipot(medium)
-
Yes (observed and functional)
yes_obs
-
No
no
25. Incision and drainage kit
-
Yes (observed and functional)
yes_obs
-
No
no
26. Instrument cabinet
-
Yes (observed and functional)
yes_obs
-
No
no
Available Equipment (3/6)
27. Instrument tray
-
Yes (observed and functional)
yes_obs
-
No
no
28. Fire extinguishers
-
Yes (observed and functional)
yes_obs
-
No
no
29. Kidney dishes(large)
-
Yes (observed and functional)
yes_obs
-
No
no
30. Kidney dish(medium)
-
Yes (observed and functional)
yes_obs
-
No
no
31. Surgical Knives
-
Yes (observed and functional)
yes_obs
-
No
no
32. Length measure for babies
-
Yes (observed and functional)
yes_obs
-
No
no
33. Linen cupboard
-
Yes (observed and functional)
yes_obs
-
No
no
34. Mackintosh
-
Yes (observed and functional)
yes_obs
-
No
no
35. Microscope cover slides (pack of 100)
-
Yes (observed and functional)
yes_obs
-
No
no
36. Newborn bag and mask (ambubag)
-
Yes (observed and functional)
yes_obs
-
No
no
37. Oro-pharyngeal airway (set of 7)
-
Yes (observed and functional)
yes_obs
-
No
no
Available Equipment (4/6)
38. Pedal bin
-
Yes (observed and functional)
yes_obs
-
No
no
39. Perineal sheet
-
Yes (observed and functional)
yes_obs
-
No
no
40. Autoclave (pressure and wet heat)
-
Yes (observed and functional)
yes_obs
-
No
no
41. Electric boiler or steamer (no pressure)
-
Yes (observed and functional)
yes_obs
-
No
no
42. Electric dry heat sterilizer
-
Yes (observed and functional)
yes_obs
-
No
no
43. Non-electric pot for boiling/steam or Heat source from non-electric equipment (stove or cooker)
-
Yes (observed and functional)
yes_obs
-
No
no
44. Delivery bed
-
Yes (observed and functional)
yes_obs
-
No
no
45. Battery – powered torch
-
Yes (observed and functional)
yes_obs
-
No
no
46. Partogram
-
Yes (observed and functional)
yes_obs
-
No
no
47. Sterilizable scissors
-
Yes (observed and functional)
yes_obs
-
No
no
48. Sterilizable cord ties
-
Yes (observed and functional)
yes_obs
-
No
no
49. Snellen's chart
-
Yes (observed and functional)
yes_obs
-
No
no
50. Soap box
-
Yes (observed and functional)
yes_obs
-
No
no
Available Equipment (5/6)
51. Soap/disinfectant dispenser
-
Yes (observed and functional)
yes_obs
-
No
no
52. Stainless bedpan
-
Yes (observed and functional)
yes_obs
-
No
no
53. Stainless ear syringe
-
Yes (observed and functional)
yes_obs
-
No
no
54. Stitch removal/ suture scissors
-
Yes (observed and functional)
yes_obs
-
No
no
55. Stitch removal/suture
-
Yes (observed and functional)
yes_obs
-
No
no
56. Stool specimen bottles(pack of 100)
-
Yes (observed and functional)
yes_obs
-
No
no
57. Stretcher trolley
-
Yes (observed and functional)
yes_obs
-
No
no
58. Suction pump
-
Yes (observed and functional)
yes_obs
-
No
no
59. Suture kit
-
Yes (observed and functional)
yes_obs
-
No
no
60. Suture needles
-
Yes (observed and functional)
yes_obs
-
No
no
61. Swivel stool
-
Yes (observed and functional)
yes_obs
-
No
no
62. Tape dispenser
-
Yes (observed and functional)
yes_obs
-
No
no
63. Tape measure
-
Yes (observed and functional)
yes_obs
-
No
no
64. Tenaculum forceps
-
Yes (observed and functional)
yes_obs
-
No
no
65. Test tube rack
-
Yes (observed and functional)
yes_obs
-
No
no
Available Equipment (6/6)
66. Theatre gown
-
Yes (observed and functional)
yes_obs
-
No
no
67. Tissue forceps
-
Yes (observed and functional)
yes_obs
-
No
no
68. Tongue depressor
-
Yes (observed and functional)
yes_obs
-
No
no
69. Tourniquet
-
Yes (observed and functional)
yes_obs
-
No
no
70. Tray test tube
-
Yes (observed and functional)
yes_obs
-
No
no
71. Tripod stand
-
Yes (observed and functional)
yes_obs
-
No
no
72. Umbilical cord clamp, pack of 100
-
Yes (observed and functional)
yes_obs
-
No
no
73. Urinal, female
-
Yes (observed and functional)
yes_obs
-
No
no
74. Urinary catheter
-
Yes (observed and functional)
yes_obs
-
No
no
75. Urine dipstick (multstix)
-
Yes (observed and functional)
yes_obs
-
No
no
76. Urine dipstick for sugar and albumin, pack of 100
-
Yes (observed and functional)
yes_obs
-
No
no
77. Vacuum extractor(manual)
-
Yes (observed and functional)
yes_obs
-
No
no
78. Vaginal speculum (sim) set of 3
-
Yes (observed and functional)
yes_obs
-
No
no
1. Are there documented rosters for facility coverage?
spot check workers in ANC, OPD and family planning against roster
-
The facility does not have any duty roster
no_duty_roster
-
The facility has a duty roster but is not followed
duty_ros_not_foll
-
The facility has a duty roster that is being followed
duty_ros_foll
2. Is there a documented referral and follow up system available for services (E.g. HIV, TB, and chronic illnesses)
Cross check referral register, facility copy of form and return/feedback slips.
-
Yes
yes
-
No
no
3. Where does the facility refer its patients to?
4. How many patients did the facility refer to another facility in the prior 3 months?
please check the referral register
5. Using the most common means for transportation, how long does it take for a referred patient to go from your facility to the most commonly used next level for referral during the DRY season?
-
0-10 minutes
zero_to_ten_minutes
-
11-20 minutes
eleven_to_twenty_minutes
-
> 20 minutes
greater_than_twenty_minutes
6. Using the most common means for transportation, how long does it take for a referred patient to go from your facility to the most commonly used next level for referral during the RAINY season?
-
0-10 minutes
zero_to_ten_minutes
-
11-20 minutes
eleven_to_twenty_minutes
-
> 20 minutes
greater_than_twenty_minutes
HIV/TB Services
1.Does this facility provide HIV/AIDS prevention and care services?
-
Yes
yes
-
No
no
2. Are staff trained in testing and counseling?
by appropriate structure e.g. LGA, development partners, MOH, certified CBOs
-
Yes
yes
-
No
no
3. Does this facility provide STI control services?
-
Yes
yes
-
No
no
4. Does this facility treat TB patients?
-
Yes
yes
-
No
no
Disease Management
Is there evidence of protocol being implemented in case notes? Randomly select 1 case note each from OPD, ANC and child clinic.
Use checklist as appropriate against one consultation.
Case Study: Malaria + Anemia
History Taking
-
Yes
yes
-
No
no
1. Duration of fever
-
Yes
yes
-
No
no
2. Pattern of fever/Presence or history of fever
-
Yes
yes
-
No
no
3. Shiver or sweat
-
Yes
yes
-
No
no
4. Convulsions
-
Yes
yes
-
No
no
5. Vomiting
-
Yes
yes
-
No
no
6. Appetite
-
Yes
yes
-
No
no
7. Diarrhoea
-
Yes
yes
-
No
no
8. Cough
-
Yes
yes
-
No
no
9. Severity of cough
-
Yes
yes
-
No
no
10. Difficulty in breathing
-
Yes
yes
-
No
no
11. Type of cough (productive or dry)
-
Yes
yes
-
No
no
12. Type of medication given
-
Yes
yes
-
No
no
13. Amount of dose given
-
Yes
yes
-
No
no
14. Vaccinations
-
Yes
yes
-
No
no
Notes/ Other questions
Physical Examination carried out
-
Yes
yes
-
No
no
15. Hands (palmar pallor)
-
Yes
yes
-
No
no
16. Tongue
-
Yes
yes
-
No
no
17. Eyes, sunken?
-
Yes
yes
-
No
no
18. Eyes, pale colour?
-
Yes
yes
-
No
no
19. Responsiveness / general condition
-
Yes
yes
-
No
no
20. Skin condition
-
Yes
yes
-
No
no
21. Temperature
-
Yes
yes
-
No
no
22. Pulse
-
Yes
yes
-
No
no
23. Neck stiffness
-
Yes
yes
-
No
no
24. Puffy face
-
Yes
yes
-
No
no
25. Swelling of the feet
-
Yes
yes
-
No
no
26. Abdomen/liver
-
Yes
yes
-
No
no
27. Weight
-
Yes
yes
-
No
no
28. Respiratory rate
-
Yes
yes
-
No
no
Notes/ Other questions
Tests administered
-
Yes
yes
-
No
no
29. Microscopy/ Blood slide for malaria parasite
-
Yes
yes
-
No
no
30. Rapid Diagnostic test
-
Yes
yes
-
No
no
31. Hb / Full Blood Count
-
Yes
yes
-
No
no
Diagnosis
-
Yes
yes
-
No
no
32. Malaria
-
Yes
yes
-
No
no
33. Anemia
-
Yes
yes
-
No
no
34. Malaria with Anemia
-
Yes
yes
-
No
no
35. Severe Malaria
-
Yes
yes
-
No
no
Notes/ Other questions
Treatment
-
Yes
yes
-
No
no
36. Artemizinin combination
-
Yes
yes
-
No
no
37. Paracetamol
-
Yes
yes
-
No
no
38. Adequate fluids and nutrition
-
Yes
yes
-
No
no
39. Chloroquine 1.5 tabs x 1/day x 3 days
-
Yes
yes
-
No
no
40. Quinine intramuscular injection
-
Yes
yes
-
No
no
41. Artesunate Amodiaquin
-
Yes
yes
-
No
no
42. Sulphadoxine Pyrimethamine .5 tab 250 mg tds x 3 days
-
Yes
yes
-
No
no
Notes/ Other questions
Was the patient counselled on any of the following (Confirm if documented in the case notes)
-
Yes
yes
-
No
no
43. Adherence to treatment.
-
Yes
yes
-
No
no
44. Prompt return if symptoms worsen
-
Yes
yes
-
No
no
45. Increased fluid intake
-
Yes
yes
-
No
no
Notes/ Other questions
Case Study: Antenatal Care
-
Yes
yes
-
No
no
1. History taken
-
Yes
yes
-
No
no
2. Clinical examination conducted
-
Yes
yes
-
No
no
3. Estimated date of delivery calculated
-
Yes
yes
-
No
no
4. Blood pressure taken
-
Yes
yes
-
No
no
5. Maternal height/weight measured
-
Yes
yes
-
No
no
6. Haemoglobin test conducted
-
Yes
yes
-
No
no
7. Rapid Plasma Reagin performed
-
Yes
yes
-
No
no
8. Urine tested
-
Yes
yes
-
No
no
9. Rapid ph performed
-
Yes
yes
-
No
no
10. Counselled and voluntary testing for HIV
-
Yes
yes
-
No
no
11. Tetanus toxoid given
-
Yes
yes
-
No
no
12. Iron and folic acid supplementation provided
-
Yes
yes
-
No
no
13. Calcium supplementation provided
-
Yes
yes
-
No
no
14. Information for emergencies given
-
Yes
yes
-
No
no
15. Clinical examination for anaemia
-
Yes
yes
-
No
no
16. Urine test for protein
-
Yes
yes
-
No
no
17. Uterus measured for excessive growth or poor growth
-
Yes
yes
-
No
no
18. Instructions for delivery/transport to institution and recommendations for lactation, and contraception done
-
Yes
yes
-
No
no
19. Antenatal card completed and given to woman. Woman told to bring it when in labour
-
Yes
yes
-
No
no
Notes/ Other questions
Case Study: Post-partum Hemorrhage
History Taking
-
Yes
yes
-
No
no
1. Were other symptoms reported?
-
Yes
yes
-
No
no
2. Was the blood loss quantified?
-
Yes
yes
-
No
no
3. Were the number of pads used indicated?
-
Yes
yes
-
No
no
4. Was the parity recorded?
-
Yes
yes
-
No
no
5. Was the duration of labor recorded?
-
Yes
yes
-
No
no
6. Was the mode of Placenta delivery indicated?
-
Yes
yes
-
No
no
7. Is there a record of medicines given to speed up delivery during Labor
-
Yes
yes
-
No
no
8. Is there a record of history of excessive bleeding after delivery?
-
Yes
yes
-
No
no
9. Is there a record of history of prolonged menses (Fibroids)?
-
Yes
yes
-
No
no
10. I there a record of excessive (amniotic) fluids during pregnancy?
-
Yes
yes
-
No
no
11. Confirm record of Attendance of ANC
-
Yes
yes
-
No
no
12. Is there a record of multiple pregnancy?
-
Yes
yes
-
No
no
13. Is there a record of Placenta praevia?
-
Yes
yes
-
No
no
14. Is there a record of Hypertension?
-
Yes
yes
-
No
no
Notes/ Other questions
Physical examination carried out
-
Yes
yes
-
No
no
15. Temperature
-
Yes
yes
-
No
no
16. Pulse
-
Yes
yes
-
No
no
17. Weight
-
Yes
yes
-
No
no
18. Respiratory rate
-
Yes
yes
-
No
no
19. Retained placenta
-
Yes
yes
-
No
no
20. Blood pressure
-
Yes
yes
-
No
no
21. Ruptured uterus
-
Yes
yes
-
No
no
22. Laceration / tears of genital tract (cervical / vaginal / vulvoperineal tears)
-
Yes
yes
-
No
no
23. Uterine palpation
-
Yes
yes
-
No
no
24. Genital examination
-
Yes
yes
-
No
no
Tests Administered
-
Yes
yes
-
No
no
25. Blood for grouping and cross matching
-
Yes
yes
-
No
no
26. Hemoglobin level
-
Yes
yes
-
No
no
27. Bleeding time
-
Yes
yes
-
No
no
28. Clotting time
-
Yes
yes
-
No
no
29. Coagulation factors
-
Yes
yes
-
No
no
Diagnosis
-
Yes
yes
-
No
no
30. Post-partum Hemorrhage
It will take some time to get the results. Please make a preliminary diagnosis.
-
Yes
yes
-
No
no
Notes/ Other questions
Which of the following treatments were administered
-
Yes
yes
-
No
no
31. IV line
-
Yes
yes
-
No
no
32. Blood taken for grouping and cross matching
-
Yes
yes
-
No
no
33. The self retaining catheter foley was inserted
-
Yes
yes
-
No
no
34. Was a bimanual uterine massage carried out?: this may also provoke contractions
-
Yes
yes
-
No
no
35. Was an oxytocin drip with dextrose saline given
20 units in 500 ml dextrose or normal saline to run at 20 drops per minute for about 2 hours
-
Yes
yes
-
No
no
36. Was prostaglandins and misoprostal given?
-
Yes
yes
-
No
no
37. Was the patient referred?
-
Yes
yes
-
No
no
Notes/ Other questions
Case Study: Pneumonia
History Taking
-
Yes
yes
-
No
no
1. Were other symptoms recorded?
-
Yes
yes
-
No
no
2. Was the duration of cough recorded?
-
Yes
yes
-
No
no
3. Was the nature of the cough (sputum production or dry cough) recorded?
-
Yes
yes
-
No
no
4. Was the presence of blood or colour of sputum recorded?
-
Yes
yes
-
No
no
5. Was there a record of the presence of chest pain?
-
Yes
yes
-
No
no
6. Was there a record on presence of difficulty in breathing
-
Yes
yes
-
No
no
7. Was there a record of patient's appetite?
-
Yes
yes
-
No
no
8. Was there a record of fever?
-
Yes
yes
-
No
no
9. Was there a record on general condition (awake / lethargic
-
Yes
yes
-
No
no
10. Was there a record on presence of convulsions?
-
Yes
yes
-
No
no
11. Was there a record on patient's difficulty in swallowing?
-
Yes
yes
-
No
no
12. Was the presence of running nose recorded?
-
Yes
yes
-
No
no
13. Was any medication /treatment received recorded?
-
Yes
yes
-
No
no
14. Was recent history of Measles recorded?
-
Yes
yes
-
No
no
15. Was family history of Asthma recorded?
-
Yes
yes
-
No
no
16.Was the redness of the eyes observed?
-
Yes
yes
-
No
no
Notes/ Other questions
Physical examination carried out
-
Yes
yes
-
No
no
17. Was the respiratory rate counted?
-
Yes
yes
-
No
no
18. Was the breathing of lower chest wall in-drawing observed?
-
Yes
yes
-
No
no
19. Breathing, is there wheezing?
-
Yes
yes
-
No
no
20. Was the chest auscultated?
-
Yes
yes
-
No
no
21. Was nasal flaring observed?
-
Yes
yes
-
No
no
22. Was temperature recorded?
-
Yes
yes
-
No
no
23. Was the throat examined?
-
Yes
yes
-
No
no
24. Were the child's ears examined?
-
Yes
yes
-
No
no
25. Were the lymph nodes examined?
-
Yes
yes
-
No
no
Notes/ Other questions
Tests administered
-
Yes
yes
-
No
no
26. Chest X-ray
-
Yes
yes
-
No
no
27. Haemogram
-
Yes
yes
-
No
no
28. BS for MPS
-
Yes
yes
-
No
no
Notes/ Other questions
Diagnosis
-
Yes
yes
-
No
no
29. Pneumonia
It will take some time to get the results. Please make a preliminary diagnosis.
-
Yes
yes
-
No
no
Notes/ Other questions
Treatment
-
Yes
yes
-
No
no
30. Treat as out-patient.
-
Yes
yes
-
No
no
31. Was Cortimoxazole 1 tab bd x 5/7 given or administered?
-
Yes
yes
-
No
no
32. Was Amoxycillin Dosage 250mg qds x 5 given or administered?
-
Yes
yes
-
No
no
33. Was Arthemeter-Lumefantrine 2 tabs x 2/day x given or administered?
3 days
-
Yes
yes
-
No
no
34. Was Artesunate+Amodiaquine 1 tabX 1/day x given or administered?
-
Yes
yes
-
No
no
35. Was Paracetamol dose 250 mg qds x 5 days given or administered?
-
Yes
yes
-
No
no
36. Were parents asked to bring child in 2 days?
-
Yes
yes
-
No
no
Notes/ Other questions
Was the patient counselled on any of the following (Confirm if documented in the case notes)
-
Yes
yes
-
No
no
37. Instruct parent on how to administer antibiotics for 5 days.
-
Yes
yes
-
No
no
38. Guidance on how to feed.
-
Yes
yes
-
No
no
39. Increase fluid intake.
-
Yes
yes
-
No
no
40. Instruct parent to return anytime in case the child worsens (or has any danger signs persisting fever, difficulty in breathing, poor feeding convulsions or new symptoms)
-
Yes
yes
-
No
no
Notes/ Other questions
Case Study: Acute Diarrohea
History Taking
-
Yes
yes
-
No
no
1.Were other symptoms recorded?
-
Yes
yes
-
No
no
2. Was the duration of diarrhoea recorded?
-
Yes
yes
-
No
no
3.Was the frequency of diarrhoea recorded?
-
Yes
yes
-
No
no
4. Was the consistency of stool recorded?
-
Yes
yes
-
No
no
5. Was the presence of blood in stool recorded?
-
Yes
yes
-
No
no
6. Vomiting
-
Yes
yes
-
No
no
7. Was the mother asked if her child is breastfeeding?
-
Yes
yes
-
No
no
8. Was the mother asked if her child is breastfeeding well?
-
Yes
yes
-
No
no
9. Was the presence of cough recorded?
-
Yes
yes
-
No
no
10. Was the mother asked if her child has fever?
-
Yes
yes
-
No
no
11. Was the general condition of the child recorded?
-
Yes
yes
-
No
no
12. Was the presence of tears recorded?
-
Yes
yes
-
No
no
13. Was the mother asked if her baby started taking other food recently?
-
Yes
yes
-
No
no
14. Was the mother asked how it been given?
-
Yes
yes
-
No
no
15. Was the mother asked who prepares and feed her child??
-
Yes
yes
-
No
no
16. Was the mother asked about her hand washing practice?
-
Yes
yes
-
No
no
17. Was the mother asked if their family members/neighbours have diarrhoea?
-
Yes
yes
-
No
no
18. Was the presence of abdominal discomfort/cramps recorded?
-
Yes
yes
-
No
no
19. Was the date of the last deworming recorded?
-
Yes
yes
-
No
no
20. Was the medication/treatment received before visiting the health facility recorded?
-
Yes
yes
-
No
no
Notes/ Other questions
Physical Examination
-
Yes
yes
-
No
no
21. Was the general health condition (awake/lethargic/tiredness/fatigue) recorded?
-
Yes
yes
-
No
no
22. Was the temperature recorded?
-
Yes
yes
-
No
no
23. Was the state of the child's skin recorded?
-
Yes
yes
-
No
no
24. Was the child offered a drink?
-
Yes
yes
-
No
no
25. Was the mucous membrane (oral mucosa) examined?
-
Yes
yes
-
No
no
26. Was palmar pallor (or other signs of anaemia) examined?
-
Yes
yes
-
No
no
27. Was thye stiffness of the neck examined?
-
Yes
yes
-
No
no
28. Was the ear/throat examined?
-
Yes
yes
-
No
no
29.Was the respiratory rate examined?
-
Yes
yes
-
No
no
30. Was the spleen examined?
-
Yes
yes
-
No
no
31. Was visible severe wasting examined?
-
Yes
yes
-
No
no
32. Was the weight of the child recorded?
-
Yes
yes
-
No
no
33. Sunken eyes
-
Yes
yes
-
No
no
34. Was the weight (against a growth chart) recorded?
-
Yes
yes
-
No
no
35. Was the presence of oedema of both feet (swollen feet) observed?
-
Yes
yes
-
No
no
Notes/ Other questions
Tests administered
-
Yes
yes
-
No
no
36. Stool for rota/adeno virus.
-
Yes
yes
-
No
no
37. Stool for ova and cyst.
-
Yes
yes
-
No
no
Notes/ Other questions
Diagnosis
-
Yes
yes
-
No
no
38. Acute diarrhoea with severe dehydration
It will take some time to get the results. Please make a preliminary diagnosis.
-
Yes
yes
-
No
no
Notes/ Other questions
Treatment
-
Yes
yes
-
No
no
39. Were Oral Rehydration Salts given/administered?
-
Yes
yes
-
No
no
40. Was 100ml/kg Ringer's Lactate Solution given or administer?
-
Yes
yes
-
No
no
41.Was the patient referred immediately?
-
Yes
yes
-
No
no
42. Was antibiotics given/administered?
-
Yes
yes
-
No
no
43. Were vitamin A capsules given or administered?
-
Yes
yes
-
No
no
44. Were zinc tablets given or administered? (one daily for 10days).
-
Yes
yes
-
No
no
Notes/ Other questions
Was the patient counselled on any of the following (Confirm if documented in the case notes)
-
Yes
yes
-
No
no
45. Education on using (ORS)
-
Yes
yes
-
No
no
46. Hand-washing education
-
Yes
yes
-
No
no
47. Proper cleaning of feeding utensils.
-
Yes
yes
-
No
no
48. Emphasis on not withholding feeding especially breast feeding
-
Yes
yes
-
No
no
49. Giving plenty of oral fluids.
-
Yes
yes
-
No
no
50. Notes/ Other questions
51. Is there evidence of implementation of universal precautions?
-
No appropriate PPE (gloves, aprons, covered footwear, face masks, etc.)/job aids guidelines
no_ppe
-
Appropriate PPE/job aids available but no evidence of implementation
ppe_unused
-
Appropriate PPE/job aids available and visibly in use
ppe_used
52. Are there handwashing facilities available at all service points?
-
Yes
yes
-
No
no
53. Is privacy/confidentiality provided for clients?
-
No privacy/confidentiality provided for clients
no_privacy
-
Provision for privacy/confidentiality is inadequate
privacy_inadequate
-
Privacy/confidentiality is provided for clients and is adequate
privacy_adequate
54. Do you treat malaria at this facility?
-
Yes
yes
-
No
no
55. Do you offer curative treatment for patients?
-
Yes
yes
-
No
no
#####Section 9. Minimum Drugs and Commodities
Availability of Drugs and Vaccines
Drugs
-
Yes (observed and functional)
yes_obs
-
No
no
1. Oxytocin (injectable)
-
Yes (observed and functional)
yes_obs
-
No
no
2. Misoprostol (cap/tab)
-
Yes (observed and functional)
yes_obs
-
No
no
3. Sodium chloride (Saline Solution)(injectable solution)
-
Yes (observed and functional)
yes_obs
-
No
no
4. Azithromycin (inj/cap/tab or oral liquid)
-
Yes (observed and functional)
yes_obs
-
No
no
5. Calcium gluconate (tablets)
-
Yes (observed and functional)
yes_obs
-
No
no
6. Benzathinebenzylpenicillin powder (for injection)
-
Yes (observed and functional)
yes_obs
-
No
no
7. Magnesium sulfate (inj/tab/cap)
-
Yes (observed and functional)
yes_obs
-
No
no
8. Dexamethasone (injectable)
-
Yes (observed and functional)
yes_obs
-
No
no
9. Ampicillin powder (for injection)
-
Yes (observed and functional)
yes_obs
-
No
no
10. Nifedipine (cap/tab)
-
Yes (observed and functional)
yes_obs
-
No
no
11. Gentamicin (injectable)
-
Yes (observed and functional)
yes_obs
-
No
no
12. Medroxyprogesterone acetate (Depo-Provera)(injectable)
-
Yes (observed and functional)
yes_obs
-
No
no
13. Metronidazole (inj/tab)
-
Yes (observed and functional)
yes_obs
-
No
no
14. Folic Acid Supplements (cap/tab)
-
Yes (observed and functional)
yes_obs
-
No
no
15. Iron supplements (cap/tab)
-
Yes (observed and functional)
yes_obs
-
No
no
16. Amoxicillin (syrup/suspension/dispersible tablet)
-
Yes (observed and functional)
yes_obs
-
No
no
17. Amoxil (syrup/suspension)
-
Yes (observed and functional)
yes_obs
-
No
no
18. Oral Rehydration Salts (ORS sachets)
-
Yes (observed and functional)
yes_obs
-
No
no
19. Ampicillin (powder for injection)
-
Yes (observed and functional)
yes_obs
-
No
no
20. Zinc (tablets)
-
Yes (observed and functional)
yes_obs
-
No
no
21. Zinc tablet (For Diarrhoea)
-
Yes (observed and functional)
yes_obs
-
No
no
22. Anti snake bites serum injection
-
Yes (observed and functional)
yes_obs
-
No
no
23. Anti tetanus immunoglobulin injection
-
Yes (observed and functional)
yes_obs
-
No
no
24. Zinc (oral liquid)
-
Yes (observed and functional)
yes_obs
-
No
no
25. Ceftriaxone (powder for injection)
-
Yes (observed and functional)
yes_obs
-
No
no
26. Artemisinin combination therapy (ACT-tablet)
-
Yes (observed and functional)
yes_obs
-
No
no
27. Vitamin A (capsules)
-
Yes (observed and functional)
yes_obs
-
No
no
28. Benzylpenicillin (powder for injection)
-
Yes (observed and functional)
yes_obs
-
No
no
29. Ergometrine tablet
-
Yes (observed and functional)
yes_obs
-
No
no
30. Ergometrine injection
-
Yes (observed and functional)
yes_obs
-
No
no
31. Anti Asthma Drugs: Beclomethasone inhaler
-
Yes (observed and functional)
yes_obs
-
No
no
32. Salbutamol inhaler
-
Yes (observed and functional)
yes_obs
-
No
no
33. Salbutamol tablet
-
Yes (observed and functional)
yes_obs
-
No
no
VACCINES
-
Yes (observed and functional)
yes_obs
-
No
no
1. Measles vaccine injection
-
Yes (observed and functional)
yes_obs
-
No
no
2. Rabies immunoglobulin injection
-
Yes (observed and functional)
yes_obs
-
No
no
3. Tetanus vaccine injection
-
Yes (observed and functional)
yes_obs
-
No
no
4. Polio vaccine (live attenuated)
-
Yes (observed and functional)
yes_obs
-
No
no
5. Diphteria + pertussis + tetanus vaccine
-
Yes (observed and functional)
yes_obs
-
No
no
6. BCG vaccine and diluent
-
Yes (observed and functional)
yes_obs
-
No
no
7. Pneumococcal (PCV 10) vaccines
-
Yes (observed and functional)
yes_obs
-
No
no
8. DTP-HepB-Hib vaccine
-
Yes (observed and functional)
yes_obs
-
No
no
Supply of Minimum Drugs and Commodities
1. Does the facility have a staff responsible for managing the ordering of medical supplies?
-
Yes
yes
-
No
no
2. Who is responsible?
-
Officer-in-Charge
off_in_charge
-
Medical Officer
medical_officer
-
Pharmacy Technician
pharm_tech
-
Pharmacy Assistant
pharm_ass
-
Pharmacist
pharmacist
-
CHEW
chew
-
JCHEW
jchew
-
Lab Technician
lab_tech
-
Other
other
Specify other.
3. Who determines this facility's resupply quantities?
-
Officer-in-Charge
off_in_charge
-
Medical Officer
medical_officer
-
Pharmacy Technician
pharm_tech
-
Pharmacy Assistant
pharm_ass
-
Pharmacist
pharmacist
-
CHEW
chew
-
JCHEW
jchew
-
Lab Technician
lab_tech
-
Other
other
Specify other.
4.How are the facility's resupply quantities estimated?
-
Facility itself (pull mechanism)
fac_itself
-
Higher level facility (push mechanism)
high_level_fac
-
Combination
combination
-
Other
other
Specify other.
5. Who is the direct supplier of health commodities to your facility?
-
LGA Store
lga_store
-
NGO/Donors
ngo_donors
-
Open Market
open_market
-
Other
other
Specify other.
6. How are the drugs from the main supplier delivered to this facility?
-
Supplier delivers to facility
supplier_to_facility
-
Facility arranges delivery
facility_arrange_del
-
Other
other
Specify other.
7. Who bears the transportation cost of delivery to facilities
-
Supplier
supplier
-
Facility
facility
-
Other
other
Specify other.
8. What was the date for the last delivery of essential medicines and/or medical supplies?
9. What was the date on which the order that corresponded to the last delivery was placed?
10. Was the last delivery of essential medicines and supplies verified and signed off by the health facility management committee?
-
Yes
yes
-
No
no
11. Was the community informed of the last delivery of essential medicines and supplies?
-
Yes
yes
-
No
no
12. How were they informed?
-
Hard copy reports
hard_copy_reports
-
During meetings
during_meeti
-
Chalkboard
chalk_board
-
Posters
posters
-
Other
other
Specify other.
Stock Control
1. Did the facility procure any out-of-stock items in the last quarter (3 months)?
-
Yes
yes
-
No
no
2. In the last quarter, did the facility purchase any essential medicines and medical supplies locally?
-
Yes
yes
-
No
no
3. Did any essential medicines in the facility expire during the last quarter (3 months)?
-
Yes
yes
-
No
no
4. Are stock control cards present & updated for the latest delivery?
-
Yes
yes
-
No
no
5. Are up-to-date records of expired drugs or losses kept?
-
No record of expired drugs or losses kept
no_record
-
Record of expired drugs kept but not up to date
record_not_uptodate
-
Record of expired drugs kept are up to date
records_uptodate
6. Is there proper storage and security (cool, dry place with a lock) for all drugs & consumables in the facility?
-
Yes
yes
-
No
no
6a. Take a picture of the facility medicines storage
7. How many of the staff involved in essential medicines and supplies management have received training on quantification and ordering of such products?
8. In the last fiscal year, how often was the facility visited by a qualified pharmacist for support supervision?
-
Weekly
weekly
-
Biweekly (every two weeks)
biweekly
-
Monthly
monthly
-
Quarterly
quarterly
-
Yearly
yearly
-
Other
other
Specify other.
9. Are drug price lists displayed?
-
No drug price list available
no_drug_list
-
Drug price list present but not displayed
list_pres_not_displayed
-
Drug price list present and displayed
list_pres_displayed
Availability of Minimum Commodities (1/2)
-
Yes (observed and functional)
yes_obs
-
No
no
1. Disposable syringes with disposable needles
-
Yes (observed and functional)
yes_obs
-
No
no
2. Vaccine carrier(s)
-
Yes (observed and functional)
yes_obs
-
No
no
3. Auto-disable syringes
-
Yes (observed and functional)
yes_obs
-
No
no
4. Set of ice packs for vaccine carriers (Note: 4-5 ice packs make one set)
-
Yes (observed and functional)
yes_obs
-
No
no
5. Clean running water (piped, bucket with tap, or pour pitcher)
-
Yes (observed and functional)
yes_obs
-
No
no
6. Hand-washing soap/liquid soap
-
Yes (observed and functional)
yes_obs
-
No
no
7. Alcohol based hand rub
-
Yes (observed and functional)
yes_obs
-
No
no
8. Waste receptacle (pedal bin) with lid and plastic bin liner
-
Yes (observed and functional)
yes_obs
-
No
no
9. Environmental disinfectant (e.g., chlorine, alcohol)
-
Yes (observed and functional)
yes_obs
-
No
no
10. Sharps container
-
Yes (observed and functional)
yes_obs
-
No
no
11. Disposable Gloves
-
Yes (observed and functional)
yes_obs
-
No
no
12. Condoms
-
Yes (observed and functional)
yes_obs
-
No
no
Availability of Minimum Commodities (2/2)
13. Are vaccines stored at this facility?
-
Yes (observed and functional)
yes_obs
-
No
no
14. Does the facility have a working refrigerator for the storage of vaccines?
Observe functioning
-
Yes (observed and functional)
yes_obs
-
No
no
15. Take a picture of the facility refrigerator
16. Take a picture of the facility vaccine coldchain box
17. Is there a functional thermometer to maintain a cold chain?
-
Yes (observed and functional)
yes_obs
-
No
no
18. If there is no storage at the facility, are the facility's vaccines stored at another facility (and picked up from when vaccine services are being provided)?
-
Yes (observed and functional)
yes_obs
-
No
no
**About how many weeks' supply of the following medicines is currently available in the facility?**
1. Amoxicillin (syrup/suspension/dispersible tablet)
2. Injectable antibiotics
3. Chlorhexidine
4. Magnesium sulfate (injectable)
5. Misoprostol (cap/tab)
6. Oxytocin (injectable)
7. Oral Rehydration Salts (ORS sachets)
8. Zinc (tablets)
9. Emergency contraception
10. Female condoms
11. Contraceptive implants
12. Antenatal corticosteroid (ANCs)
13. Newborn Resuscitation Device
#####Section 10. Laboratory
1. Is there a laboratory?
-
Yes
yes
-
No
no
2. Laboratory is open every day of the week
-
Yes
yes
-
No
no
3. Is there a laboratory scientist/technician available at least 5 days a week?
-
Yes
yes
-
No
no
4. Are laboratory price lists displayed?
-
No laboratory price list available
no_lab_list
-
Laboratory price list present but not displayed
list_pres_not_displayed
-
Laboratory price list present and displayed
list_pres_displayed
5. The facility offers PHC Laboratory services (According to the essential laboratory services in the tool) (Please tick as appropriate)
-
Heamatology (PCV, Haemoglobin)
heam_pcv
-
Pregnancy test
preg_test
-
Urine dipsticks for sugar and protein
sugar_protein_test
-
Syphillis rapid test
syph_rap_test
-
Malaria diagnostics
mal_diag
-
HIV diagnostics
hiv_diag
-
Dried Blood Spots (DBS) preparation
dbs_prep
-
TB diagnostics
tb_diag
-
venous collection for CD4
ven_collect_cd4
######Section 11. Health Management Information System
**Are relevant HMIS forms/Registers available in the facility?**
-
Yes
yes
-
No
no
1. NHMIS Health facility monthly summary form
-
Yes
yes
-
No
no
2. NHMIS health facility daily attendance register
-
Yes
yes
-
No
no
3. NHMIS health facility daily GMP (growth monitoring) register
-
Yes
yes
-
No
no
4. NHMIS health facility Immunization register
-
Yes
yes
-
No
no
5. NHMIS health facility Immunization Tally Sheet register
-
Yes
yes
-
No
no
6. NHMIS health facility TT register
-
Yes
yes
-
No
no
7. NHMIS health facility daily ANC register
-
Yes
yes
-
No
no
8. NHMIS health facility daily OPD register
-
Yes
yes
-
No
no
9. NHMIS health facility daily FP register
-
Yes
yes
-
No
no
10. NHMIS health facility daily PMTCT ARVs register
-
Yes
yes
-
No
no
11. NHMIS health facility labour/delivery register
-
Yes
yes
-
No
no
12. NHMIS health facility IPC register
-
Yes
yes
-
No
no
13. Are HMIS forms / register up to date and completed correctly?
-
No relevant HMIS forms/registers available
no_form_reg
-
Some HMIS forms/registers available but not up to date (month prior to assessment)
some_form_avail_not_uptodate
-
All relevant HMIS forms/registers available and up to date (month prior to assessment)
all_form_avail_uptodate
14. Is HMIS information displayed graphically?
-
HMIS information not represented graphically
not_rep_graph
-
HMIS information represented graphically, but not displayed
rep_graph_not_display
-
HMIS information represented graphically and displayed
rep_graph_display
15. Are the NHMIS data analysed and shared with the facility management committee?
-
Not analysed
not_analyzed
-
Analysed
analyzed
-
Analyzed and shared
analyzed_shared
-
Analysed and used for decision (minutes available)
analyzed_decision
16. Did the facility send last month's monthly summary form to the LGA?
-
Yes
yes
-
No
no
17. Does the information in the registers correspond with HMIS data sent to LGA? Compare summary sheet (last 3 months) with register for ANC, immunization and FP
-
The information registers does not correspond with the HMIS data sent to LGA
info_not_corres
-
Some of the information in the registers correspond with the HMIS data sent to LGA
some_info_corres
-
All the information in the register correspond with the HMIS data sent to LGA
all_info_corres
18. Do you participate in any LGA monthly M&E review meetings?
-
Yes
yes
-
No
no
19. Is HMIS information discussed in the facility management meetings (check for minutes of meetings)
-
Yes
yes
-
No
no
#####Section 12. Utilization and Clinical Outcomes
Utilization Pattern
1. How many deliveries have been conducted at this facility during the past 3 months?
a. Month 1
b. Month 2
c. Month 3
d. Total
Utilization Pattern
2. How many general outpatient visits have you had at this facility in the past 3 months?
a. Month 1
b. Month 2
c. Month 3
d. Total
Utilization Pattern
3. How many in-patient bed-days have you had during the past 3 months?
a. Month 1
b. Month 2
c. Month 3
d. Total
Utilization Pattern
4. How many Under-5 visits have you had at this facility in the past 3 months?
a. Month 1
b. Month 2
c. Month 3
d. Total
Utilization Pattern
5. How many immunization visits have you had at this facility in the past 3 months
a. Month 1
b. Month 2
c. Month 3
d. Total
Utilization Pattern
6. Number of ANC attendance in the past 3 months
a. Month 1
b. Month 2
c. Month 3
d. Total
Utilization Pattern
7. Number of PNC attendance in the past 3 months
a. Month 1
b. Month 2
c. Month 3
d. Total
Utilization Pattern
8. Number of pregnant women who had ANC 1st (booking) visit before 20 weeks?
a. Month 1
b. Month 2
c. Month 3
d. Total
Utilization Pattern
9. Number of patients screened for hypertension
a. Month 1
b. Month 2
c. Month 3
d. Total
Utilization Pattern
10. Number of patients screened for diabetes
a. Month 1
b. Month 2
c. Month 3
d. Total
Clinical Outcomes
11. Number of deaths (in relation to registered pregnant women) in the past 3 months?
a. Month 1
b. Month 2
c. Month 3
d. Total
12. Number of deliveries resulting in still births in the past 3 months?
a. Month 1
b. Month 2
c. Month 3
d. Total
13. Rate of re-admission of patients
a. Month 1
b. Month 2
c. Month 3
d. Total
14. Infection due to treatment in the health facilities
a. Month 1
b. Month 2
c. Month 3
d. Total
#####Section 13. Community Involvement
Outreach Services
1. Does this facility carry out planned community outreach services?
-
No community outreach services occurring
no_outreach
-
Community outreach services are occurring but not scheduled
outreach_occ_not_scheduled
-
Planned community outreach services are occurring
outreach_plan_occ
2. Does the PHC staff conduct outreach to the community?
-
Yes
yes
-
No
no
3. How often does the PHC staff conduct outreach to the community?
-
Weekly
weekly
-
Biweekly (every two weeks)
biweekly
-
Monthly
monthly
-
Quarterly
quarterly
-
Yearly
yearly
-
Other
other
Specify other.
4. Is there evidence of publicity (poster, flyers, signage, etc.) of available health services?
-
No publicity of available health services
no_pub_avail
-
There is no evidence of publicity of available health services
no_evidence_pub
-
There is evidence of publicity of available health services
evidence_pub_avail
5. Is there evidence that local communities are involved in outreach planning and implementation?
-
Outreaches are solely planned and executed by facility
exec_by_fac_sole
-
Outreaches are planned with local community/Facility Management Committee only, execution is solely carried out by facility staff
plan_w_local_comm
-
Outreaches are planned and implemented in collaboration with the local community/Facility Management Committee
plan_impl_w_loc_fac_man
6. Is there evidence that this facility do hold review meetings with important community members in attendance?
-
None exist
none
-
Review meeting does not occur regularly
not_regular
-
Review meetings are held regularly (monthly)
regular_monthly
Community Governance
1. Is there a Ward Development Committee (WDC)/Village Development Committee (VDC)/Community Development Committee (CDC) in place in this community?
-
Yes
yes
-
No
no
2. Has the committee met at least once in the last year?
-
Yes
yes
-
No
no
3. How often does the WDC/VDC/CDC meet?
-
Weekly
weekly
-
Biweekly (every two weeks)
biweekly
-
Monthly
monthly
-
Quarterly
quarterly
-
Yearly
yearly
-
Other
other
Specify other.
4. Did any member of this WDC/VDC/CDC visit the PHC during the prior 3 months?
-
Yes
yes
-
No
no
5. How many visits were made during the prior 3 months?
**Which of the following activities did the WDC/VDC/CDC carry out in the last 12months?**
6. Supported or helped improve the health facility
-
Yes
yes
-
No
no
7. Repairs to facility
-
Yes
yes
-
No
no
8. Mobilized community to use facility
-
Yes
yes
-
No
no
9. Provided transport for home visits
-
Yes
yes
-
No
no
10. Gave in-kind contributions
-
Yes
yes
-
No
no
11. Improved security (facility)
-
Yes
yes
-
No
no
12. Improved water supply
-
Yes
yes
-
No
no
13. Improved water quality
-
Yes
yes
-
No
no
14. Supported training for CHEWs
-
Yes
yes
-
No
no
15. Support to outreach teams
-
Yes
yes
-
No
no
16. Provided new infrastructure
-
Yes
yes
-
No
no
17. Provided drugs
-
Yes
yes
-
No
no
18. Supported environmental sanitation
-
Yes
yes
-
No
no
19. Other
1. Is there a Health Facility Management Committee in place for the facility?
-
Yes
yes
-
No
no
2. Has the committee met at least once in the last year?
-
Yes
yes
-
No
no
3. How often does the health facility management committee meet?
-
Weekly
weekly
-
Biweekly (every two weeks)
biweekly
-
Monthly
monthly
-
Quarterly
quarterly
-
Yearly
yearly
-
Other
other
Specify other.
4. How many members does the committee currently have?
5. Was the Health Facility/Hospital management committee involved in workplan development?
-
Yes
yes
-
No
no
6. Is the Officer-in-Charge a member of the committee?
-
Yes
yes
-
No
no
7. Are community members represented on the committee?
-
Yes
yes
-
No
no
8. How were community representatives selected?
9. Are the minutes available for all the meetings?
-
Yes
yes
-
No
no
**Which of these sub committees are in existence & operational?**
-
Yes
yes
-
No
no
1. Finance Committee
-
Yes
yes
-
No
no
2. Procurement Committee
-
Yes
yes
-
No
no
3. Audit Committee
-
Yes
yes
-
No
no
4. Quality Assurance Committee
-
Yes
yes
-
No
no
**Client View – exit interview for 1 adult client**
1. Is the health facility clean today?
-
Yes
yes
-
No
no
2. Were health staff courteous and respectful today?
-
Yes
yes
-
No
no
3. Did the health workers do a good job of explaining your condition today?
-
Yes
yes
-
No
no
4. Do you trust in the skills and abilities of the health workers of this facility?
-
Yes
yes
-
No
no
5. Were the health workers in this facility friendly and approachable?
-
Yes
yes
-
No
no
6. Are you confident that the health workers will maintain the confidentiality of your discussions?
-
Yes
yes
-
No
no
7. How long (in minutes) did you wait in the health facility before being seen for consultation by the health worker?
*In minutes
Enumerator name(s)
Enumerator (s) Phone Number
Enumerator(s) email address
Any additional comment
Departure time for first visit
End of Survey
Consent not given. End of Survey