Delivery
Rapidly mapping health facilities in fragile and conflict-affected contexts: lessons from Somalia
By Jonny Barty & Abdiwahab Abdullahi Elmi
Somalia is one of the most difficult places to provide health services, following decades of conflict and political instability, and persistent limitations in capacity, infrastructure, and management.

Recent estimates suggest that just 30% of Somalis have consistent access to health services.

One of the biggest obstacles to improvement is the lack of data on the number, location, or management of facilities, or on the availability of inputs at them to ensure consistent services.

Without such data, it is challenging to ensure consistent service delivery, identify and solve performance issues, or improve accountability.

In advance of a major national program to contract-out service delivery across Somalia, the World Bank asked Acasus to map all public primary and secondary health facilities in five regions of Somalia.

The team mapped and assessed performance in 357 health facilities in ten days.In addition, during the short project, the team created:

  • A new survey tool, consisting of around 200 questions on inputs, outputs, and ‘quality’ aspects (e.g. health worker capacity, EHS guidelines, patient feedback), with supporting rubrics and training materials

 

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  • Interactive mapping dashboards, providing managers with dynamic views of facility location, inputs and outputs, overlaid against geographic, administrative, and population density data

 

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  • Advanced geospatial analytics, enabling estimated catchment populations for each facility, and the identification of likely underserved communities and areas requiring additional investments

 

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Completing these activities in Somalia required solving several challenges: 

  • There were no existing tools or surveys to conduct rapid data collection 
  • There was no complete, reliable list of facilities
  • There was no prior location data
  • There was no existing monitoring team available to collect data
  • Insecurity was high due to pending elections, coupled with sporadic flooding across project regions, presented dynamic access challenges

 

Overcoming these challenges was contingent on achieving several success factors: 

  • Global learnings: Leveraging learnings from similar work (for instance in. Afghanistan, Pakistan, etc.), and expert insights from Acasus, the World Bank, and others to inform the tools and approach
  • Data quality management before, during, and after data-collection: 
    • Minimize data entry issues through tool-design: Creating clear questions and answers in local languages, conducting repeated field testing, and ensuring simple UXP in the app 
    • In-person supervision: Conducting 80+ ‘spot-checks’ by Project Coordinators, often with Regional Government teams, to supervise monitoring  and ensure data quality at facilities
    • ‘Real-time’ quality analysis: Using ‘real-time’ dashboards to review the location and duration of monitoring visits, and the quality of data collected in them, to continuously monitor data quality and arrange targeted ‘revisits’ in case of suspected issues 
  • Flexible approach: Taking alternative approaches (e.g. phone-based monitoring) where necessary, e.g. when unexpected flooding suddenly blocked monitor-access to a small number of facilities, and taking the time to 
  • Rapid analytics and outputs: Designing an analysis framework that enabled data to be consolidated, analyzed, and visualized in weeks (2) rather than in months, to meet tight deadlines, and enable rapid use of the data by stakeholders 
  • Alternative data: Overlaying monitoring data with other sources (e.g. population density data, geographic data, etc,) to develop insights that would not have otherwise been possible, e.g. on catchment populations, access challenges, and investments to resolve gaps in service delivery, etc.
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