ADVANCING PARTNERS

& COMMUNITIES
Health Facility Assessment Tool

Cover photo goes here

ADVANCING PARTNERS
& COMMUNITIES
Health Facility Assessment Tool

This publication was produced by Advancing Partners & Communities (APC), a five-year cooperative agreement
funded by the U.S. Agency for International Development under Agreement No. AID-OAA-A-12-00047, beginning
October 1, 2012. The authors' views expressed in this publication do not necessarily reflect the views of the U.S.
Agency for International Development or the United States Government.
Advancing Partners & Communities
Advancing Partners & Communities (APC) is a five-year cooperative agreement funded by the U.S.
Agency for International Development under Agreement No. AID-OAA-A-12-00047, beginning October
1, 2012. APC is implemented by JSI Research & Training Institute, Inc., in collaboration with FHI 360.
The project focuses on advancing and supporting community programs that seek to improve the overall
health of communities and achieve other health-related impacts, especially in relationship to family
planning. APC provides global leadership for community-based programming, executes and manages
small- and medium-sized sub-awards, supports procurement reform by preparing awards for execution
by USAID, and builds technical capacity of organizations to implement effective programs.

JSI RESEARCH & TRAINING INSTITUTE, INC.

1616 Fort Myer Drive, 16th Floor
Arlington, VA 22209 USA
Phone: 703-528-7474
Fax: 703-528-7480
Email: [email protected]
Web: advancingpartners.org
TABLE OF CONTENTS
INTRODUCTION ............................................................................................................. 1

PART A: GENERAL INFORMATION............................................................................. 3

PART B: SERVICE AVAILABILITY (NOTE: BASED OFF MOH ESSENTIAL

PACKAGE OF HEALTH SERVICES) ............................................................................. 7

PART C: STAFFING ....................................................................................................... 10

PART D: INFRASTRUCTURE ....................................................................................... 13

PART E: LABORATORY, SERVICES AND DIAGNOSTIC EQUIPMENT .............. 24

PART F: PHARMACEUTICAL SUPPLIES ................................................................... 29

PART G: TRAINING NEEDS (INTERVIEW STYLE) ...................................................... 33

EVALUATION GUIDE FOR INFRASTRUCTURE COMPONENTS ........................ 36

v
vi
INTRODUCTION
This facility assessment is aimed at measuring the following qualities of a health facility:
1. Staff capacity
2. Infrastructure capacity
3. Equipment capacity

The results from this assessment will inform the type and level of support JSI provides to target health
facilities. The aim of all support provided is to improve provision of medical care to Ebola survivors, and
as such, priority will be placed on improving areas most pertinent to survivor needs.

Proposed Methodology
The tool should be implemented using a three-stage process.

Stage 1 is an interview with the head of the health facility or a senior health facility staff member.
This interview will be comprised of Parts A-C of the tool.

Stage 2 is a physical assessment of the health facility and the equipment available. This will
comprise Parts D-E of the tool. This should be done jointly by two individuals accompanied by a
senior facility staff member.

Stage 3 is individual interviews with relevant facility staff members. This will comprise of Part F
for the tool. Part F should be completed with each relevant staff member. Relevant staff are to
be identified during Part C of the assessment.

Tool Contents
The assessment is broken down into the following sections:
 Part A: General Information
 Facility basic information
 Opening hours
 Referral capacity
 Utilization rates
 Interviewer details

 Part B: Service Availability

 Types of services offered
 Bed availability

 Part C: Staffing

1
  General staff numbers
 Specialist staff numbers

 Part D: Infrastructure
 Communications
 Power supply
 Water
 Fencing
 Waste Disposal
 Roof structure
 Building by building breakdown
 General
 Ceilings
 Walls
 Floors
 Windows
 WASH Facilities
 Electrical system
 Fire extinguisher

 Part E: Laboratory, Services and Diagnostic Equipment

 Delivery room equipment
 Sterilization equipment
 Eye health equipment
 Laboratory equipment
 Imaging equipment
 Medical storage

 Part F: Pharmaceutical Supplies

 Part G: Training Needs

2
 Name of interviewee _______________
Name of health facility _________________

JSI HEALTH FACILITY ASSESSMENT: October 2016

PART A: GENERAL INFORMATION

NO QUESTION RESPONSE SKIP
.
A1 Date
____________________________________
A2 Name of interview respondent
_________________________________

_________________________________
A3 Is the person being interviewed in charge of Yes..................................................................1
the facility?
No...................................................................2
(ie. If it is a Hospital should be a Medical
Director, if it is a Health Centre should be an
OIC/Nursing Director )
A4 Position title of interview respondent _______________________________________
_______________________________________
A5 Team Number Team 1
………………………………..................……...1
Team 2 ........................……………............……....2
A6 MOHS ID Number
____________________________________
A7 Facility Name Redemption
Hospital………………….…….......…...1
Duport Road Health
Center……………………......2
C.H. Rennie
Hospital……………………….…...........3
Tellewoyan Hospital
………………………….….......4
Kolahun
Hospital………………………………….........5
Phebe
Hospital………………………………………......6
Boma Hospital................................................7
Dolo Town Health Center...............................8

3
 Name of interviewee _______________
Name of health facility _________________
A8 Facility Type National Referral
Hospital…………………….....….1
County
Hospital…………………................…..…….2
Health
Center………………………………….…......….3
A9 County
Montserrado………………………………….…….....
….1

Lofa…………………………………………...............
…….2

Bong…………………………….............……….……
…...3

Margibi……………….........…………………….……
…...4
A10 Health District
_______________________________________
A11 Year of facility construction
_____________ year facility was constructed
A13 Number of buildings at health facility
_____________ number of buildings
A14 Does the facility take inpatients? Outpatients only.............................................0
Inpatients and Outpatients.............................1
*Inpatients: 24 hours or more Short stay and Outpatients.............................2
*Short stay: Less then 24 hrs
A15 Operating days for the facility Every day .......................................................1
Week days only (Monday – Friday) ...............2
Six days/week (Monday – Saturday) .............3
Other
________________________________
__________________________ ....................99
_______________________________________
_______________________________________
Notes about days of service
_______________________________________
_______________________________________

4
 Name of interviewee _______________
Name of health facility _________________
A16 Operating hours for the facility Four hours or less / day .................................1
5 to 8 hours / day ...........................................2
(Probe further to ensure it represents pratical 9 to 16 hours / day .........................................3
opening hours for patient care)
17 to 23 hours / day .......................................4
24 hours .........................................................5
A17 Size of the catchment population

(Write down range if exact number not _________________________________

available)
A18 Facility utilization rate Outpatients:
How many individual outpatients did the
____________ past week
hospital see in:
How many inpatient admissions did the ____________ past month
hospital have in:
Inpatients:
____________ past week

____________ past month

A19 Name of referral facility for emergency care _______________________________________

_______________________________________

A20 Is transport normally provided when Yes..................................................................1 If 2

referrals are made? selected,
No...................................................................2
skip to
A23
A21 Standard form of transport used by health Motorbike.......................................................1
facility for referral
Ambulance......................................................2
Commercial vehicle........................................3
Other _______________________________
______________________ .................................4
A22 Average wait time for transport _______________ minutes spend waiting for
transport
Note: If more than one form of transport used
please note times for all forms of transport

A23 Average travel time from this health facility _______________ mins in good conditions
to referral facility for patients being referred
using transport listed above. (Does not (dry season)
include wait time). _______________ mins in bad conditions
Note: If more than one form of transport used
(rainy season)
please note times for all forms of transport

5
 Name of interviewee _______________
Name of health facility _________________
A24 Are there referral forms or a referral Yes, referral forms/register is available and filled
register that documents these referrals and in..................................................................1
are they actively used?
Yes, referral forms/register available but not used
....................................................................2
Referral forms/register refers to referral No..................................................................3
documents kept at the health facility.

(This should be observed)

A25 Please describe what you see as the priority
health services for the hospital to develop
_______________________________________
and improve on during the next 5 years.
_______________________________________
_______________________________________
Probe: What speciality services do you hope to
further develop?

6
 Name of interviewee _______________
Name of health facility _________________

PART B: SERVICE AVAILABILITY (NOTE:

BASED OFF MOH ESSENTIAL PACKAGE OF
HEALTH SERVICES)
NO QUESTION RESPONSE SKIP
.
I am now going to ask you some questions
about the services offered at this facility.
Please indicate which of these services are
offered at this health facility
B1 Screening for non-communicable diseases Yes, full services..............................................1
including diabetes, cancer, hypertension and
Yes, partial services .......................................2
chronic respiratory disease
No...................................................................3
B2 Antenatal and newborn care (MNCH) Yes..................................................................1
No...................................................................2
B3 Labor and delivery care Yes, during day and night ..............................1
Yes, during day only ......................................2
No..................................................................3
B4 Postpartum care Yes..................................................................1
No...................................................................2
B5 Expanded Program on Immunization (EPI) Yes..................................................................1
No...................................................................2
B6 Integrated Management of Childhood Yes..................................................................1
Illnesses (IMCI)
No...................................................................2
B7 Infant and Young Child Nutrition Yes..................................................................1
No...................................................................2
B8 STI prevention, testing, and/or counselling Yes..................................................................1
and treatment
No...................................................................2
B9 HIV/AIDS testing, and counselling and Yes..................................................................1
treatment
No...................................................................2
B10 Tuberculousis testing and treatment Yes..................................................................1

7
 Name of interviewee _______________
Name of health facility _________________
No...................................................................2

B11 Malaria testing and treatment Yes..................................................................1

No...................................................................2
B12 Infectious/contagious diseases identification Yes..................................................................1
and treatment (eg. Viral Hemorrhagic Fever,
No...................................................................2
yellow fever)
B13 Mental health screening and support Yes..................................................................1
No...................................................................2
B14 Basic eye screening and referral Yes..................................................................1
No...................................................................2
B15 Family planning counselling and promotion Yes..................................................................1
No...................................................................2
B16 Gender based violence support and Yes..................................................................1
counselling
No...................................................................2
B17 Provision of family planning commodities Yes..................................................................1
No...................................................................2
B18 Which of these diagnostic services are Haematology ................................................1
offered?
Microscopy....................................................2
Clinical Chemistry..........................................3
(Select all that apply)
Ultrasound ....................................................4
X-Ray..............................................................5
Other
________________________________
______________________________________
______________________________...............99

B19 Does this facility offer health education Yes..................................................................1

materials or pamphlets that patients can take
No...................................................................2
home?
If yes, please list what topics are covered in the
educational pamphlets:
_______________________________________
_______________________________________
_______________________________________
B20 How many beds does this facility have?
______________________ overnight /

8
 Name of interviewee _______________
Name of health facility _________________
inpatient beds
B21 How many of these are dedicated maternity ______________________ delivery beds
or delivery beds?
______________________ postpartum beds
B22 How many of these beds are dedicated
emergency beds
______________________ emergency beds
B23 Does this facility provide counselling on Yes..................................................................1
sexual health to EVD survivors?
No...................................................................2
Probe: Focus on risk transmission
B24 Is PREVAIL / Men’s health present at this Yes..................................................................1
facility?
No...................................................................2
If yes, please ask the questions below at the PREVAIL
/ Men’s health centre.
B25 Please note down any additional comments _______________________________________
about services offered at this facility that you
would like to make. _______________________________________

_______________________________________

_______________________________________

_______________________________________

PREVAIL / Men’s health questions

B26 Does this organization conduct semen Yes..................................................................1
testing for EVD survivors?
No...................................................................2

B27 Does this organization conduct breast milk Yes..................................................................1

testing for EVD survivors?
No...................................................................2
B28 Please write down any additional comments _______________________________________
about PREVAIL / Men’s health activities
_______________________________________

_______________________________________

_______________________________________

_______________________________________

9
 Name of interviewee _______________
Name of health facility _________________

PART C: STAFFING
NO. QUESTION RESPONSE SKI
P
I am now going to ask some questions about
the health personnel at this facility.
C1 General medical doctors/Physicians - How many
general medical doctors/physicians: ______________ (men) work at this facility

______________ (women) work at this facility

______________ present at the facility today

C2 Specialist clinicians – What types of specialist

clinicians work at this facility? ______________ work at this facility

______________ present at the facility today

Surgery .................................................1
ENT (Otorhinolaryngology) ..................2
Gastroenterology..................................3 Write details on speciality and qualifications:
Gynaecology.........................................4
___________________________________
Neurology..............................................5
Ophthalmology.....................................6 ___________________________________

Psychiatry/Psychology .........................7 ___________________________________

Rheumatology ......................................8 ___________________________________

Sexual health........................................9
*Note: Identify these individuals for interviews in Part G
Nephrology ........................................10
C3 Mental health professionals - How many
mental health clinicians: ______________ (men) work at this facility

______________ (women) work at this facility

*Note: Should have receieved MH Clinician
training by Carter Centre ______________ present at the facility today

*Note: Identify these individuals for interviews in Part G

C4 Mental health –
How many clinicians have received additional ________ nurses trained in mental health
training in mental health
________ physician assistants trained in mental

10
 Name of interviewee _______________
Name of health facility _________________

Note: not including mental health clinicians health

trained by Carter Centre
________ medical doctors trained in mental health

Name of training attended/ Provider of

training
___________________________________

___________________________________ /
___________________________________

___________________________________

*Note: Identify these individuals for interviews in Part G

C5 Eye care –
How many staff members have been trained ________ nurses trained in eye care
in identifying/responding to eye health issues
________ physician assistants trained in eye care

Note: not including opthamologists ________ medical doctors trained in eye care

Name of training attended/ Provider of ___________________________________

training
___________________________________ /
___________________________________

___________________________________

*Note: Identify these individuals for interviews in Part G

C6 Physician assistants - How many physician
assistants: ______________ work at this facility

______________ present at the facility today

C7 Midwifery professionals - How many midwifery

professionals ______________ work at this facility

______________ present at the facility today

C8 Nursing professionals - How many nursing

professionals ______________ work at this facility

______________ present at the facility today

C9 Laboratory technicians/technologists - How

11
 Name of interviewee _______________
Name of health facility _________________

many laboratory technicians/technologists: ______________ technicians work at this facility

______________ lab assistants work at this facility

______________ present at the facility today

C10 Pharmacists and dispensers - How many

pharmacists or dispensers: ______________ pharmacists work at this facility

______________ dispensers work at this facility

______________ present at the facility today

C11 Social workers - How many social workers:

______________ work at this facility

______________ present at the facility today

C13 Please note down any additional comments _______________________________________

you would like to make. (Eg. Are staffing
_______________________________________
levels adequate, further staffing needs, particular
staffing gaps). _______________________________________
_______________________________________
_______________________________________

12
 Name of interviewee _______________
Name of health facility _________________

PART D: INFRASTRUCTURE
NO QUESTION RESPONSE SKIP
.
D1 How many individual buildings are there
within this health facility? ___________ number of buildings

D2 When were the last renovations of this _______________________________________

building completed?
_______________________________________
_______________________________________
Provide detail including years and locations
_______________________________________
_______________________________________
_______________________________________
Communications
D3 Is there a functioning mobile or landline Yes..................................................................1 If 1, go to
phone at the facility today owned by facility D4
No...................................................................2
(not staff member)?
(Functioning=phone signal and battery charged)
D4 Is there a functioning mobile or landline Yes..................................................................1
phone at the facility today owned by a staff
No...................................................................2
member?
(Functioning=phone signal and battery charged)
D5 Is there a functioning computer at the Yes..................................................................1
facility?
No...................................................................2

D6 Is there access to email/internet within the Yes..................................................................1

facility today?
No...................................................................2
Power Supply
D7 Is there a power supply at this health facility? Yes..................................................................1 If 2
selected,
No...................................................................2
skip to
D17.
D8 What is the facility’s main source of LEC.................................................................1 If 1 or 3
electricity? selected,
Generator (fuel or gasoline) ........................2
skip D10-
Solar system..................................................3 13. If 1 or
2 selected ,
Other _______________________________
skip D14.
_______________________ ............................99

13
 Name of interviewee _______________
Name of health facility _________________

(Observe and if 2 or 3 selected, take photograph)

D9 Other than the main source, does the facility No secondary source .....................................1
have a secondary or backup source of
LEC..................................................................2
electricity? If so, what is the secondary
source of electricity? Generator (fuel or gasoline) ..........................3
Solar system...................................................4
Other _______________________________
_______________________ .............................99
D10 During the past 7 days, how often has the At all times ....................................................1
facility had functioning electricity?
Regularly, but a few interruptions (2 hours or
less) .....................................................................2
Semi-regularly, many interruptions (2 hours or
more) ..............................................................3
D11 Are there any hours in the day/night that you _______________________________________
don’t run electricity?
_______________________________________

_______________________________________

_______________________________________

_______________________________________
D12 Is the generator functional? Yes..................................................................1 Asked in
response
No...................................................................2
to D7, D8.
Don’t know...................................................98
D13 Is there fuel/gasoline available for the Yes..................................................................1 Asked in
generator today? response
No...................................................................2
to D7, D8.
Don’t know..................................................98
D14 Is the generator in a separate Yes..................................................................1 Asked in
building/covering? response
No...................................................................2
to D7, D8.
D15 What is the size, manufacturing year and Asked in
model of the generator? Generator 1 response
to D7, D8.
________________________ KVA

________________________ Year manufactured

________________________ Manufacturer/
Model

14
 Name of interviewee _______________
Name of health facility _________________

Generator 2 (if applicable)

________________________ KVA

________________________ Year manufactured

________________________ Manufacturer/
Model

D16 Is the solar system functional? Yes, functioning .............................................1 Asked in

response
Partially functioning (needs servicing) ..........2
to D7, D8.
No, not functional .........................................3
Don’t know...................................................98
D17 When you are using your main power source _______________________________________
do you have to limit use of any of items? If
so, which ones? _______________________________________

_______________________________________

_______________________________________

_______________________________________
D18 Do all parts of the facilities have access to Yes..................................................................1
electricity?
No...................................................................2
Don’t know...................................................98
D19 What areas do not have access to electricity? _______________________________________

_______________________________________

_______________________________________

_______________________________________

_______________________________________
Water
D20 What water sources are available at the Piped into facility...........................................1 If 0
facility? selected,
Piped onto facility grounds............................2
skip to
Public tap/ Standpipe ...................................3 D21
Select all that apply
Tubewell / Borehole .....................................4
Protected dug well .......................................5
Unprotected dug well ...................................6

15
 Name of interviewee _______________
Name of health facility _________________

Protected spring ...........................................7

Unprotected spring .......................................8
Rainwater collection .....................................9
Tanker truck ................................................10
Surface water .............................................11
Don’t know..................................................98
Other _______________________________
___________________________ .....................99
No water source ...........................................0
D21 Of those selected above, what is the primary Piped into facility...........................................1 If 1 or 10
source of water? selected,
Piped onto facility grounds............................2
skip to
Public tap/ Standpipe ...................................3 D20
Tubewell / Borehole .....................................4
Protected dug well .......................................5
Unprotected dug well ...................................6
Protected spring ...........................................7
Unprotected spring .......................................8
Rainwater collection .....................................9
Tanker truck ................................................10
Surface water .............................................11
Don’t know..................................................98
Other _______________________________
___________________________ .....................99
D22 Is water available from this primary source Yes, inside the facility ....................................1
on faciity premises?
Yes, within the ground of the facility ............2
No, outside the facility grounds....................3
D23 Do you have water storage facilities? Yes..................................................................1
(ie. Water tank) No...................................................................2

What is the storage capacity? ______________________ capacity

D24 What months of the year do you not have _______________________________________
access to water?
_______________________________________
Fencing
D25 Does the facility have a gated perimeter Yes, complete ................................................1 If 2

16
 Name of interviewee _______________
Name of health facility _________________

fence? Yes, but incomplete ......................................2 selected,

skip to
No..................................................................3
D23
D26 Rate the condition of the fencing and gates Good...............................................................1
(Consult evaluation guide) Average..........................................................2
Poor ...............................................................3
Provide additional comments on sketch notes (eg.
visible deterioration, materials)
D27 If there a fence around the waste disposal Yes..................................................................1 If 2
section? selected,
No...................................................................2
skip to
D25
D28 Rate the condition of the fence Good...............................................................1
(Consult evaluation guide to complete) Average..........................................................2
Provide additional comments on sketch notes (eg. Poor ...............................................................3
visible deterioration, materials)
Waste Disposal
D29 How does this facility finally dispose of Burn incinerator ............................................1 If anything
sharps waste (eg. needles and blades)? except 1
Open burning ................................................2
selected,
Dump without burning ..................................3 skip D27
Remove off site .............................................4
Sharps pit ......................................................5
Other _______________________________
___________________________ .....................99
D30 How does this facility finally dispose of Same as for sharps above..............................0 If anything
medical waste other than sharps, such as except 1
Burn incinerator ............................................1
bandages? selected,
Open burning in pit .......................................2 skip D27
Dump without burning in pit ........................3
Remove off site .............................................4
Waste pit .......................................................5
Other _______________________________
___________________________ .....................99
D31 Is the incinerator functional today? Yes.................................................................1
No..................................................................2
Excreta Disposal

17
 Name of interviewee _______________
Name of health facility _________________

D32 What types of toilets are available to patients Flush toilet.....................................................1

at this health facility?
Ventilated improved pit latrine ....................2
Pit latrine .......................................................3
Composting toilet .........................................4
Bucket toilet ..................................................5
D33 What it the total number of toilets available Number of patient use toilets:
to patients at this health facility?
__________ Male toilets

__________ Female toilets

__________ Unisex toilets

D34 Is there a direct water supply to the main Yes.................................................................1

sets of toilets in the facility?
No..................................................................2

If not, please explain in more detail:

_______________________________________

_______________________________________

_______________________________________
Roof Struture (Primary Building)
D35 Type of roof structure Wood..............................................................1
Steel................................................................2
Bush sticks .....................................................3
Other _______________________________
___________________________ .....................99
D36 Condition of roof structure? Good...............................................................1
Average..........................................................2
(Consult evaluation guide) Poor ...............................................................3
D37 Condition of roof sheeting? Good...............................................................1
Average..........................................................2
(Consult evaluation guide) Poor ...............................................................3
D38 Is there termite damage on roofing? Yes..................................................................1
No...................................................................2

18
 Name of interviewee _______________
Name of health facility _________________

D39 Has the wood been treated against termites? Yes..................................................................1

No...................................................................2

If yes, what year __________________________

Individual Area Assessment - For each building complete the following set of questions.
In the next section we are going to assess
the quality of the infrastructure in each
individual building of the health facility.
DI1 Name of the building and list main functions
_______________________________________

_______________________________________

_______________________________________

_______________________________________

(eg. Waiting area, maternity ward, pathology)

DI2 Number of rooms in the building
_____________________
DI3 Is there a private consultation area where Yes..................................................................1
sound does not travel?
No...................................................................2
DI4 Ceilings A. Ceiling material type:
Wood..............................................................1
Concrete........................................................2
Metal..............................................................3
Plastic tiles.....................................................4
Hardboard......................................................5
Other _______________________________
___________________________ .....................99

B. Quality and condition of ceiling work:

(Consult evaluation guide)
Good...............................................................1
Average..........................................................2
Poor ...............................................................3

19
 Name of interviewee _______________
Name of health facility _________________

C. Holes, stains, paint peelings, dirty:

Yes.................................................................1
No...................................................................2
DI5 Walls A. Wall material type:
Masonry Block...............................................1
Concrete........................................................2
Soil block.......................................................3
Plastic sheets.................................................4
Other _______________________________
___________________________ .....................99

B. Wall finish type:

Bare (no paint) .............................................1
Painted...........................................................2
Tiled ..............................................................3

C. Quality of finish and condition:

(Consult evaluation guide)
Good...............................................................1
Average..........................................................2
Poor ...............................................................3

DI6 Floors A. Floor type:

Concrete .......................................................1
Screed (eg. Cement) .....................................2
Dirt ................................................................3
Other _______________________________
___________________________ .....................99
B. Floor finish type:
Painted ..........................................................1
Vinyl tiles ......................................................2
Sheet vinyl ....................................................3
Ceramic tiles .................................................4

20
 Name of interviewee _______________
Name of health facility _________________

Screed (eg. Cement) ......................................5

C. Quality of work (level, holes, stained):
(Consult evaluation guide)
Good...............................................................1
Average..........................................................2
Poor ...............................................................3
DI7 Windows
A. Number of windows: _________________

B. Window type:
Wood shutters................................................1
Aluminium sliding...........................................2
PVC................................................................3
Casement.......................................................4
Louvered window (window with slats) .........5
Other _______________________________
___________________________ .....................99
C. If wooden window, are there any signs of termite
damage?
Yes..................................................................1
No...................................................................2
D. Conditions of windows and screens:
(Consult evaluation guide)
Good...............................................................1
Average..........................................................2
Poor ...............................................................3
E. Are there security bars?
Yes..................................................................1
No...................................................................2
DI8 Doors A. Are there doors in all necessary areas?
Yes..................................................................1
No...................................................................2
B. Quality of doors:
(Consult evaluation guide)
Good...............................................................1
Average..........................................................2
Poor ...............................................................3
DI9 WASH facilities A. Is there a functioning toilet available to patients in
this area?
Yes..................................................................1
No...................................................................2
If no, go straight to E. If yes, skip QE.

21
 Name of interviewee _______________
Name of health facility _________________

B. Type of toilet available:

Flush toilet.....................................................1
Ventilated improved pit latrine ....................2
Pit latrine ......................................................3
Composting toilet .........................................4
Bucket toilet ..................................................5
C. Number of toilets for patient use:
__________ Male toilets

__________ Female toilets

__________ Unisex toilets

D. Is there a sink next to the toilets with water

available?
Yes..................................................................1
No...................................................................2
E. If no toilet, is there one available nearby?
Yes..................................................................1
No...................................................................2
F. Is there piped water available in this area of the
health facility?
Yes..................................................................1
No...................................................................2
DI10 Electrical system A. Is there power available in this area of the facility?
Yes..................................................................1
No...................................................................2

B. Number of lights in building:

_____________ lights

C. Number of functioning lights in the building today:

______________ lights

D. Number of electrical outlets in the building:

22
 Name of interviewee _______________
Name of health facility _________________

______________ outlets

E. Number of functioning electrical outlets in the

building today:

______________ outlets

F. Is there surface mounted wiring?

Yes..................................................................1
No...................................................................2
G. Is there concealed wiring?
Yes..................................................................1
No...................................................................2
DI11 Fire Extinguisher A. Is there a fire extinguisher located in this building
of the facility?
Yes..................................................................1
No...................................................................2

23
 Name of interviewee _______________
Name of health facility _________________

PART E: LABORATORY, SERVICES AND

DIAGNOSTIC EQUIPMENT
NO. QUESTION RESPONSE SKIP
In this section you will ask to see the equipment available at this facility. You will need to walk around the facility to ensure you observe these
equipment pieces.
E1 Delivery room No. available? No. functioning?
These questions are about Delivery bed and linen ______ observed ______ functioning
the equipment available in
the delivery area of the Blood pressure machine ______ observed ______ functioning
health facility.
Clinical thermometer ______ observed ______ functioning

Infant weighting scale ______ observed ______ functioning

Tissue forceps ______ observed ______ functioning

Artery forceps/ Hemostats ______ observed ______ functioning

Cord clamp ______ observed ______ functioning

Stethoscope ______ observed ______ functioning

Foethoscope ______ observed ______ functioning

Timer ______ observed ______ functioning

Lamp ______ observed ______ functioning

IV Set & tourniquet ______ observed ______ functioning

Speculums ______ observed ______ functioning

Suturing set ______ observed ______ functioning

Resuscitator with mask (infant) ______ observed ______ functioning

Incubator ______ observed ______ functioning

Sets of gloves ______ observed ______ functioning

Soap ______ observed ______ functioning

Hand washing station ______ observed ______ functioning

24
 Name of interviewee _______________
Name of health facility _________________

Complete PPE set – Risk appropriate PPE

______ observed ______ functioning
(Includes: Apron, Suit, Mask, Rain gear)

E2 Sterilization equipment A. Is there sterilization equipment available in this health facility?

Yes.....................................................................1
These questions are about No......................................................................2
the sterilization equipment If 2, go straight to C.
available at the health
facility. B. List the types of equipment available and the frequency of use:
Type
Please report if it is Frequency of use
(List voltage if applicable and known)
available and if it is used
regularly. Used in past week......1
__________________________
Used in past month ....2
__________________________
Add in types: Not used ....................3
- Autoclave
- Pots
- Used in past week......1
__________________________
Used in past month ....2
__________________________
Not used ....................3

Used in past week......1

__________________________
Used in past month ....2
__________________________
Not used ....................3

Used in past week......1

__________________________
Used in past month ....2
__________________________
Not used ....................3

Used in past week......1

__________________________
Used in past month ....2
__________________________
Not used ....................3

Now go straight to eye health equipment.

If any are not used, please explain why

_______________________________________________________
_______________________________________________________

C. If there are no sterilization equipment available, how is equipment cleaned before

use on another patient?

_______________________________________________________
_______________________________________________________
________________________________________________________

25
 Name of interviewee _______________
Name of health facility _________________

E3 Eye health equipment

No. Used within
No. available?
These questions are about functioning? past month?
the eye health equipment
available at the health Yes............1
Slit lamp ___ observed ___ functioning
facility. No ............2

Ophthalmo- Yes............1
___ observed ___ functioning
scope No ............2

Yes............1
Retinoscope ___ observed ___ functioning
No ............2

Jackson Cross- Yes............1

___ observed ___ functioning
Cylinder No ............2

Keratometer /
Yes............1
Opthalmo- ___ observed ___ functioning
No ............2
meter

Yes............1
Tonometer ___ observed ___ functioning
No ............2

Visual acuity Yes............1

___ observed ___ functioning
charts No ............2

E4 Laboratory equipment No. Used within

No. available?
functioning? past month?
These questions are about
the labatory equipment Yes............1
available at the health Microscopes ___ observed ___ functioning
No ............2
facility.

Please report number Hand Yes............1

___ observed ___ functioning
available and if they are Centrifuge No ............2
used regularly.
Electric Yes............1
___ observed ___ functioning
Centrifuge No ............2

Yes............1
Timer ___ observed ___ functioning
No ............2

Laboratory
Yes............1
scales and ___ observed ___ functioning
No ............2
weights

Microscope
Yes............1
slides and cover ___ observed ___ functioning
No ............2
slips

If any are not used, please explain why

______________________________________________________
______________________________________________________

26
 Name of interviewee _______________
Name of health facility _________________

E5 Imaging equipment No. Used within

No. available?
functioning? past month?
These questions are about
the imaging equipment Yes............1
available at the health X-Ray machine ___ observed ___ functioning
No ............2
facility.

Please report number X-Ray

Yes............1
available and if they are developing ___ observed ___ functioning
No ............2
used regularly. machine

Ultrasound Yes............1
___ observed ___ functioning
machine No ............2

Yes............1
EKG machine ___ observed ___ functioning
No ............2

If any are not used, please explain why

_______________________________________________________
_______________________________________________________
Medical storage
E6 Cold chain Refrigerators
A. How many refrigerators are there? __________
B. How many refrigerators have working thermostats? ___________

C. How many refrigerators are functioning? ___________

D. If any are not functioning, please explain why

_______________________________________________________
_______________________________________________________

E. Are the refrigeration needs of this facility met?

Yes....................................1
No ....................................2

F. If not met, please explain why

_______________________________________________________
_______________________________________________________

E7 Freezers
G. How many freezers are there? ___________
H. How many freezers have working thermostats? __________
I. How many freezers are functioning? ___________
J. If any are not functioning, please explain why
_______________________________________________________
_______________________________________________________
K. Are the freezing needs of this facility met?
Yes....................................1
No ....................................2

27
 Name of interviewee _______________
Name of health facility _________________

L. If not met, please explain why

_______________________________________________________
_______________________________________________________
E8 Lockable storage A. Number of lockable cupboards for storage ______________
B. Is the space/number of lockable cupboards sufficient for the facility?
(Lab and Dispensary)
Sufficient space..................................................................1
Insufficient space...............................................................2

C. Do the doors to the lab and dispensary have functioning locks?

Yes....................................1
No ....................................2

D. If insufficient, please explain what items do not currently fit in lockable

storage
_______________________________________________________
_______________________________________________________
_______________________________________________________

28
 Name of interviewee _______________
Name of health facility _________________

PART F: PHARMACEUTICAL SUPPLIES

NO. QUESTION / RESPONSE
In this section you will ask to see the pharmaceutical items available in this facility. If the item is observed,
please make sure you check the expiry date on the item. Check the relevant box for each item.
F1 TB Pharmaceuticals
OBSERVED NOT OBSERVED
Not
Available Available Reported
availa Never
- Not - expired available
ble available
expired but not
[2] today [5]
[1] seen [3]
[4]
Rifampicin, isoniazid,
1 pyrazinamide, ethambutol
(RHZE) (4FDC)
Rifampicin, isoniazid (RH)
2
(2FDC)
Rifampicin, isoniazid,
3 pyrazinamide (RHZ)
(3FDC)
Rifampicin, isoniazid,
4 ethambutol (RHE)
(3FDC)
5 Rifampicin
6 Streptomycin
7 Ethambutol
8 Isoniazid
9 Pyrazinamide

29
 Name of interviewee _______________
Name of health facility _________________

F2 EVD Sequelae Pharmaceuticals

*Where more than one OBSERVED NOT OBSERVED
item is listed, please
Available Available Reported Not
circle which item is Never
- Not - expired available available
observed. available
expired but not today
[2] [5]
[1] seen [3] [4]
1 Albendazole 400mg
Aluminium Hydroxide
2 + magnesium trisilicate
tabs
Amitriptyline 25mg
3
tabs
Amoxicillin 125mg/5ml
4
100 ml suspension
Amoxicillin 250mg/
5
500mg
Atenolol 50mg /
6 Lisinopril 5mg /
Captopril 25mg
Benzathine Penicillin
7
2.4 MU vial
Calcium Lactate
8 300mg tablets /
prenatal vitamin

OBSERVED NOT OBSERVED

Reporte
Available
Available d Not Never
- Not
- expired available available available
expired
[2] but not today [4] [5]
[1]
seen [3]
9 Carbamazepine 200mg
Chloramphenicol ear
10
drops

Chloramphenicol
11
250mg tabs

Ciprofloxacin 500mg
12
tab

30
Name of interviewee _______________
Name of health facility _________________

Diclofenac 50mg xx
13
tablets

Erythromycin 250mg
14
tabs
Ferrous Sulph. 200mg
+ Folic Acid 0.4mg
15
coated tablets /
prenatal vitamin
Furosemide 40mg tabs
16 / Spironolactone 50mg
tab
Hydrocortisone
17
100mg vial
Ibuprofen 100mg / 5ml
oral suspension 100ml
18
(paediatric
formulation)
Ibuprofen 200mg /
19
400mg

20 Insulin (cold chain)

Mebendazole 500mg
21
tabs

22 Methyldopa 250mg

Metronidazole 250 or
23
500mg tabs

Misoprostol 200mg
24
tabs

25 Nifedepine 20mg tab

OBSERVED NOT OBSERVED

Reporte
Availabl Availabl d Not
Never
e - Not e- availabl available
available
expired expired e but today
[5]
[1] [2] not [4]
seen [3]
26 Nystatin 100.000IU

31
Name of interviewee _______________
Name of health facility _________________

vaginal tabs + xxx

applicator x
Omeprazole 20 or
27 40mg tab /
Ranitidine 150mg tab
Oxytocin 10IU/1ml
28
injection
Paracetamol 100mg
29
tablets
Paracetamol
120mg/5ml, oral
30 suspension, bottle
100 ml (peds
formulation)
Phenytoin sodium
31
100mg tabs
Prednisolone 1%
32
eyedrop 5ml
Prednisolone 5mg,
33
tablets
Salbutamol
34 0.1MG/dose, 200
doses inhaler
Sodium chloride
0.9% infusion 500 or
35
1000 ml, Lactated
Ringer's
Tetracycline HCl 1%
38 eye ointment 5g
tubes
Tramadol 100mg
39
caps

40 Multi Vitamin

32
 Name of interviewee _______________
Name of health facility _________________

PART G: TRAINING NEEDS (INTERVIEW STYLE)

NO QUESTION RESPONSE SKIP
.
G1 Full name of health practitioner _______________________________________
_______________________________________
G2 Job title of health practitioner _______________________________________
_______________________________________
G3 Please select the academic qualifications you Diploma in Nursing ........................................1
have obtained?
Diploma in Midwifery ....................................2
Diploma in Physician Assistant ......................3
(Select all qualifications that apply)
Diploma in Social Work .................................4
Bachelor of Science in Midwifery ..................5
Bachelor of Science in Nursing ......................6
Bachelor of Science in Physician Assistants ...7
Bachelor in Social Work .................................8
Master of Science in Midwifery .....................9
Master of Science in Nursing .......................10
Master of Public Health ...............................11
Doctor of Medicine ......................................12
Other _______________________________
___________________________ .....................99
G4 Do you have a current licence in this your
area of practice?
Yes..................................................................1
No...................................................................2
Probe: Is the licence up to date?
G5 Please explain the type of training (formal or
informal) that you had in one of the ______________________________________
subspeciality clinical areas (include when it
was, what subspecialty area it covered, level ______________________________________
of knowledge)
______________________________________

______________________________________

33
 ______________________________________

G6 Please describe the three most common ______________________________________

procedures you perform in your daily work
in your area of specality. ______________________________________

______________________________________
(Note: Probe to ensure it refers to sub-specialty
topic) ______________________________________

______________________________________
G7 Please describe the most complex/ most ______________________________________
advanced procedures you have performed in
your area of specalty in the course of your ______________________________________
work in the past 6 months
______________________________________

(Note: Probe to ensure it refers to sub- specialty ______________________________________

topic)
______________________________________
G8 Please describe the biggest challenges you
face in completing your work effectively ______________________________________

______________________________________
(Note: Probe to ensure it refers to sub-specialty
topic. Might refer to capacity of health facility, ______________________________________
equipment available, support stuff trained)
______________________________________

______________________________________
G9 Please describe what technical support you
or the facility needs (if any) in order to be ______________________________________
more effective in your work.
______________________________________

(Note: Probe to ensure it refers to sub-specialty ______________________________________

topic.)
______________________________________

______________________________________
G10 Have you been trained in standard MoH IPC
procedures? Yes..................................................................1
No...................................................................2
Note: Current standard training package is SQS Please list the names of the training packages you
and older version is KS10.
have been trained on: ____________________

______________________________________

34
 ______________________________________

______________________________________

______________________________________
G11 Are the IPC job aids visible and accessible in
your facility? Yes..................................................................1
No...................................................................2
G12 Have you been trained or exposed to the
clinical guidelines for Ebola survivors? Yes..................................................................1
No...................................................................2
G13 Are the Ebola Survivor clinical guidelines
available and accessible in your facility? Yes..................................................................1
No...................................................................2

35
 EVALUATION GUIDE FOR INFRASTRUCTURE
COMPONENTS
GOOD AVERAGE POOR
Perimeter Straight structure, adequately held in Mild sloping, few missing palings, gate seized Large sloping on structure, parts/ palings
fence and gates ground, all palings attached, gate adequately or loose. fallen down/in disrepair, evidence of termite
functioning. infestation, gate non-functioning.
Waste disposal Straight structure, adequately held in Mild sloping, few missing palings, gate seized Large sloping on structure, parts/ palings
fence ground, all palings attached, gate adequately or loose. fallen down/in disrepair, evidence of termite
functioning. infestation, gate non-functioning.
Roof structure Roof frame is intact, no damaged portions. Roof frame not fully intact, some members Roof frame broken down, many members
damaged but intact. damaged and falling apart.

Roof sheeting Tight, working gutters, clean (no leaves Debris on roof, some sheets not securely Obvious leaks, sheeting is rusty, large
etc.), no water traces within building. attached, small rusting on sheets, some portion of sheeting not securely attached,
water traces within building. sheets missing, water damage.
Ceiling work Tight, even, no discolorations (lizard Some holes, dents, discolorations, loose Missing sheets, no ceiling at all.
droppings etc.), sturdy (eg. hardboard). sheets, not sturdy.
Wall condition Even, smooth surface, no discoloration, easy Rough surface, some dents, minor areas of Unfinished, uneven surface; large areas of
to clean (eg. Plater with intact paint coat). mold (water leakage), difficult to clean (eg. mold (water leakage), adequate cleaning
/ finish
Loose or missing paint areas or tiles). impossible (eg. Stamped earth).

Floor quality Even, smooth surface, easy to clean. Rough surface, some dents, difficult to clean Unfinished, uneven surface; adequate
(eg. Crude concrete or plans, some loose or cleaning impossible (eg. Shattered concrete
missing tiles). and tiles, stamped earth).
Windows/ Tight fit, panes intact, fittings operating, Loose fit, some panes broken or missing, Warped frames, most panes broken,
Screens smooth and & finished surface of frame. some fittings seized or loose, surface of missing windows, most fittings unusable,
frame rough. surface unfinished.

Doors Tight fit, fittings/lock operating, smooth & Loose fit, some fittings/locks seized or Warped, missing doors, most fittings/locks
finished surface. loose, surface rough. unusable, surface unfinished.

36
 ADVANCING PARTNERS & COMMUNITIES
JSI RESEARCH & TRAINING INSTITUTE, INC.

1616 Fort Myer Drive, 16th Floor

Arlington, VA 22209 USA
Phone: 703-528-7474
Fax: 703-528-7480
Web: advancingpartners.org