Indicators

The Service Delivery Indicators (SDI) are sets of health and education indicators that examine teachers’ and health workers’ effort and ability, as well as the availability of key inputs and resources that contribute to the functioning of a school or health facility. The specific indicators are:

School absence rate

This indicator is measured as the share of teachers who are absent from school at the time of an unannounced visit. It is measured in the following way: During the first announced visit, a maximum of 10 teachers are randomly selected from the list of all teachers (excludes volunteer and part time teachers) who are on the school roster. The whereabouts of these 10 teachers are then verified in the second, unannounced, visit.

Teachers found anywhere on the school premises are marked as present.

Classroom absence rate

The indicator is measured as the share of teachers not in the classroom at the time of an unannounced visit. The indicator is constructed in the same way as school absence rate indicator, with the exception that the numerator now is the number of teachers who are either absent from school, or present at school but absent from the classroom.

Time spent teaching per day

This indicator reflects the typical time that teachers spends teaching on an average day. It combines data from the staff roster module (used to measure absence rate), the classroom observation module, and reported teaching hours. The teaching time is adjusted for the time teachers are absent from the classroom, on average, and for the time the teacher teaches while in classrooms based on classroom observations. While inside the classroom distinction is made between teaching and non-teaching activities.

Teaching is defined very broadly, including actively interacting with students, correcting or grading students’ work, asking questions, testing, using the blackboard, or having students working on a specific task, drilling or memorization. Non-teaching activities includes working on private matters, maintaining discipline in class, or doing nothing, and thus leaving students not paying attention.

Minimum knowledge

This indicator is measured as the percentage of teachers who can master the curriculum they taught. It is based on a mathematics and language tests covering the primary curriculum administered at the school and is calculated as the percentage of teacher who score more than 80 percent on the language and mathematics portion of the test. The test is given to all mathematics or language teachers who taught third grade last year or fourth grade in the year the survey was conducted.

It is measured as the overall score of mathematics, language, and pedagogy tests covering the primary curriculum administered at the school level to all mathematics and language teachers who taught third grade last year or fourth grade in the year the survey was conducted.

Minimum infrastructure availability

It is a binary indicator capturing availability of (a) functioning toilets and (b) classroom visibility. Functioning toilets is defined as whether toilets were functioning, accessible, clean, and private (enclosed and with gender separation) as verified by an enumerator. To verify classroom visibility we randomly select one fourth grade classroom in which the enumerator places a printout on the board and checks

whether it was possible to read the printout from the back of the classroom

Minimum equipment availability

It is a binary indicator capturing availability of (a) functioning blackboard and chalk and (b) pens, pencils, and exercise books in fourth grade classrooms. In one randomly selected fourth grade classroom in the school the enumerator assessed if there was a functioning blackboard by looking at whether text written on the blackboard could be read at the front and back of the classroom, and whether there was chalk available to write on the blackboard. We considered that the classroom met the minimum requirement of pens, pencils, and exercise books if both the share of students with pen or pencils and the share of students with exercise books are above 90%.

Share of pupils with textbooks

The indicator reflect the typical ratio in student to textbooks in the fourth grade classroom. It is measured as the number of students with the relevant textbooks (mathematics or language conditional on which a randomly selected class is observed) in one randomly selected fourth grade class and divided by the number of students in that classroom.

Observed pupil-teacher ratio

This indicator reflects the typical ratio in pupils to teachers in the fourth grade classroom. It is measured as the number of students in one randomly selected fourth grade class at the school.

Absence rate

Number of health professionals that are not off duty who are absent from the facility on an unannounced visit as a share of ten randomly sampled workers. Health professionals doing fieldwork (mainly community and public health professionals) were counted as present

Caseload per health provider

The number of outpatient visits recorded in outpatient records in the three months prior to the survey, divided by the number of days the facility was open during the three month period and the number of health professionals who conduct patient consultations (i.e. excluding cadre-types such as public health nurses and out-reach workers). 

Diagnostic accuracy

For each of the following five clinical cases: (i) acute diarrhea; (ii) pneumonia; (iii) diabetes mellitus; (iv) pulmonary tuberculosis; (v) malaria with anemia.

For each clinical case, assign a score of one as correct diagnosis for each clinical case if diagnosis is mentioned. Sum the total number of correct diagnoses identified. Divide by the total number of clinical case. Where multiple diagnoses were provided by the clinician, the diagnosis is coded as correct as long as it is mentioned, irrespective of what other alternative diagnoses were given.

Adherence to clinical guidelines

For each of the following five clinical cases: (i) acute diarrhea; (ii) pneumonia; (iii) diabetes mellitus; (iv) pulmonary tuberculosis; (v) malaria with anemia.

History Taking Questions: Assign a score of one if a relevant history taking question is asked. The number of relevant history taking questions asked by the clinician during consultation is expressed as a percentage of the total number of relevant history questions included in the questionnaire.

Relevant Examination Questions: Assign a score of one if a relevant examination question is asked. The number of relevant examination taking questions asked by the clinician during consultation is expressed as a percentage of the total number of relevant examination questions included in the questionnaire.

For each clinical case: Unweighted average of the: relevant history questions asked, and the percentage of physical examination questions asked. The history and examination questions considered are based on the Madagascar Standard National Guidelines and the guidelines for Integrated Management of Childhood Illnesses (IMCI).

Management of maternal and neonatal complications

For each of the following two clinical cases: (i) post-partum hemorrhage; and (ii) neonatal asphyxia. Assign a score of one if a relevant action is proposed. The number of relevant treatment actions proposed by the clinician during consultation is expressed as a percentage of the total number of relevant treatment actions included in the questionnaire.

Drug availability

Priority medicines for mothers: Assign score of one if facility reports and enumerator confirms/observes the facility has the drug available and non-expired on the day of visit for the following medicines: Oxytocin (injectable), misoprostol (cap/tab), sodium chloride (saline solution) (injectable solution), azithromycin (cap/tab or oral liquid), calcium gluconate (injectable), cefixime (cap/tab), magnesium sulfate (injectable), benzathinebenzylpenicillin powder (for injection), ampicillin powder (for injection), betamethasone or dexamethasone (injectable), gentamicin (injectable) nifedipine (cap/tab), metronidazole (injectable), medroxyprogesterone acetate (Depo-Provera) (injectable), iron supplements (cap/tab) and folic acid supplements (cap/tab).

Priority medicines for children: Assign score of one if facility reports and enumerator confirms after observing that the facility has the drug available and non-expired on the day of visit for the following medicines: Amoxicillin (syrup/suspension), oral rehydration salts (ORS sachets), zinc (tablets), ceftriaxone (powder for injection), artemisinin combination therapy (ACT), artusunate (rectal or injectable), benzylpenicillin (powder for injection), vitamin A (capsules)

We take out of analysis of the child tracer medicines two medicines (Gentamicin and ampicillin powder) that are included in the mother and in the child tracer medicine list to avoid double counting.

The aggregate is adjusted by facility type to accommodate the fact that not all drugs (injectables) are expected to be at the lowest level facility, CSB1, where health workers are not expected to offer injections.

Medical equipment availability

Medical Equipment aggregate: Assign score of one if enumerator confirms the facility has one or more functioning of each of the following: thermometers, stethoscopes, sphygmomanometers and a weighing scale (adult or child or infant weighing scale) as defined below. CSB2 and CHRD are expected to include two additional pieces of equipment: a refrigerator and sterilization device/equipment.

Thermometer: Assign score of one if facility reports and enumerator observes facility has one or more functioning thermometers.

Stethoscope: Assign score of one if facility reports and enumerator confirms facility has one or more functioning stethoscopes.

Sphygmomanometer: Assign score of one if facility reports and enumerator confirms facility has one or more functioning sphygmomanometers.

Weighing Scale: Assign score of one if facility reports and enumerator confirms facility has one or more functioning Adult, or Child or Infant weighing scale.

Refrigerator: Assign score of one if facility reports and enumerator confirms facility has one or more functioning refrigerator.

Sterilization equipment: Assign score of one if facility reports and enumerator confirms facility has one or more functioning Sterilization device/equipment.

Infrastructure availability

Infrastructure aggregate: Assign score of one if facility reports and enumerator confirms facility has electricity and water and sanitation as defined.

Electricity: Assign score of one if facility reports having the electric power grid, a fuel operated generator, a battery-operated generator or a solar powered system as their main source of electricity.

Water: Assign score of one if facility reports their main source of water is piped into the facility, piped onto facility grounds or comes from a public tap/standpipe, tubewell/borehole, a protected dug well, a protected spring, bottled water or a tanker truck.

Sanitation: Assign score of one if facility reports and enumerator confirms facility has one or more functioning flush toilets or VIP latrines, or covered pit latrine (with slab).