Key The BSC scores indicate that quantity of services provided by public sector health-facilities improved in 2011 compared to 2009 level but quality became worse than before. Though the time-gap between the surveys was only two years, BSC scores could identify short-term changes in performance. 10 out of 30 indicators showed improvements, 14 remained unchanged and 6 indicators declined.

Policy Implications- Health-sector policy-makers in developing countries should consider wider use of BSC for independent external monitoring of health-facility performance.

BSC should be also used as a guide to make amendments in five year plans, commonly made in developing countries, to achieve mission, vision, and goals of the plans.

Discussion

Using Balanced Score Card indicators to monitor changes in Health Facility performance: Case study based on Nationally Representative Health Facility

Surveys in BangladeshNaveed Sadiq, MPH & Mahmud Khan, PhD

BackgroundOver the past two decades, Government of Bangladesh has invested significant amount of resources to improve quality and quantity of services provided through public-sector facilities.

Demography1

Administratively, Bangladesh is divided into 7 divisions, 64 districts, and 545 Upazilas, each having a hospital at every level and sub-level. The current population of Bangladesh is over 150 million, majority of which resides in rural areas. Bangladesh has incorporated a Sector-Wide Approach (SWA) in its five year plan to provide essential and quality health care services to meet the needs of the population including but not limited to family planning, maternal and child care, workforce, systems support (management information system), and coordinated services. There had been a progressive decline in fertility rate, teenage marriages, and subsequently teenage pregnancies from 1991 to 2011. The prevalence of uptake of family planning services for any and modern methods increased over two decades. The receipt of antenatal and postnatal services from medically trained provider, and skilled assistance at delivery also increased in the past two decades. That resulted in a subsequent decrease in neonatal and under 5 child mortality. The percentage of children receiving immunizations increased significantly in two decades. Being largely rural and poor, the delivery of healthcare services had not been efficient.

Accessibility1

Bangladesh has an extensive health network throughout the country that provide a number of services free of cost to the people but the services are not client focused, needs based, of high quality and within the reach of the poorest2. Being largely rural country, only 8% of the rural population could avail the services while only 2% of the mothers could seek care for their children3.

Quality ImprovementHaving an extensive network of healthcare facilities but with poor planning and bad health policies, further improvements in utilization will require improved quality of services. In order to monitor the goals set up in the five year plan, Balanced Score Card (BSC) can be used to see the change in the quality of services.

Balanced Score Card“The Balanced Scorecard is an approach to performance measurement that combines traditional financial measures with non-financial measures to provide managers with richer and more relevant information about the outcomes they are targeting and the activities they are managing, increasing the likelihood of organizational objectives being achieved.”4

Case Study of Bangladesh Nationally representative health-facility surveys were conducted in 2009 and 2011 in Bangladesh. The purpose of this study was to use BSC, incorporated in health-facility assessment questionnaire, as a guide for observing changes in performance of health-facilities to monitor improvements in quantity and quality of health-care services provided through public-sector facilities over a period of two years.5

• Improvementsi. Health worker satisfaction index improved from 55 in 2009 to 65 in 2011.ii. Availability of functional basic clinical equipment improved from 67% in

2009 to 85% in 2011. However, the overall availability decreased from 69% to 65% in 2011.

iii. Essential drug availability (37 drugs) improved significantly. iv. Staffing index for physicians, auxiliary staff, and other healthcare

personnel also improved significantly over 2009 to 2011. v. The use of HMIS index and clinical guidelines index improved much in

2011 as compared to in 2009.vi. Patient history and physical exam index improved significantly over the

period of two years.

• Deteriorationi. The overall outpatient satisfaction score remained the same (84 out of

100) over these two years while the patient perception of quality of care declined from 86 to 80. 

ii. Availability of immunization equipment and family planning supplies declined.

iii. Provider knowledge score on child & maternal health, and STI decreased significantly over the period of two years in 2011.

iv. Facilities having TB register significantly decreased in 2011 to 36% from 100% (in 2009).

• Laboratory Equipment availability and functionality index remained more or less unchanged.

• On average, outpatient visit per-month per-facility increased by about 22%.

References

Background, Demographics, & Quality Table: Comparison of Balanced Score Card Indicators for 2009 and 2011

Case Study Results

Balanced Scorecard Indicators 2009 2011 Including

CCs

2011 Excluding

CCs

A. Patients & Community  Overall Patient Satisfaction, outpatient 84 85 84

Patient Perception of Quality Index 86 81 80

Overall Patient Satisfaction, inpatient NA ** 76

B. Staff  Health Worker Satisfaction Index 55 64 65

Salary payments current 100 100 100

C. Capacity for Service Provision  Equipment Availability Index 69 37 65

Equipment Functionality Index 67 33 85

Index of regular use of equipment NA 31 55

Essential Drug Availability Index (37 drugs) 35 69 63

Union Drug Kit Availability Index 80 82 79

EPI equipment and supply index 78 36 40

EPI index excluding refrigerator + thermometer - 60 57

Family Planning Availability Index 90 99 78

Laboratory Equipment Availability Index 58 ** 57

Laboratory Functionality Index 92 ** 93

Regular use index of Lab equipment NA ** 53

Staffing Index 64 75 76

Provider Knowledge Score : child health 59 52 54

Provider Knowledge Score : Maternal health 76 65 67

Provider Knowledge Score : STI 83 49 51

Staff received training in last year 42 44 43

HMIS Use Index 29 32 40

Clinical Guidelines Index 27 30 39

Infrastructure Index 67 42 63

Facilities having TB register 100 26 36

D. Service Provision  

Patient History and Physical Exam Index: under 5 42 59 59

Patient Counseling Index 60 58 59

Proper sharps disposal 69 41 61

Average outpatient visit per month per facility 1302 823 1587

Facilities providing antenatal care 90 55 87

Facilities providing delivery care 75 36 63

E. Financial Systems  

Facilities with user fee guidelines 3.1 3.2 3.0

Facilities with exemptions for poor patients 1.7 3.1 2.9

F. Overall Vision  

Females as % of new outpatients 51 62 65

1. Bangladesh Health & Demographic Survey, 2011.2. http://www.napsipag.org/pdf/Issues_of_inequality.pdf, accessed Nov. 14, 20143. BHFS Report 20114. Chowdhury, Rabi. 2004. Bangladesh's Crusade for Millennium Development Goal One: Impotent

without Basic Healthcare for the Poor. American International School: Dhaka5. http://2gc.eu/resource_centre/balanced-scorecard accessed Nov. 14th, 2014