Assessment of FARA 1.0 Outcomes on the Capacity of MOH and CHTs, and the Quality of Service Provision at Health Facilities in Liberia April 25, 2017 This document was produced at the request of the United States Agency for International Development. It was prepared independently by InterMedia under the Liberia Strategic Analysis activity under contract AID-669-C-16-00002. DISCLAIMER The author’s views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development or the United States Government. Table of Contents List of Acronyms and Abbreviations ............................................................................................................ 3 List of Figures and Tables.............................................................................................................................. 3 Map of Liberia and Evaluated Facilities ......................................................................................................... 4 Executive Summary ................................................................................................................................. 5 Methodology ............................................................................................................................................. 5 Key Findings, Conclusions and Recommendations ................................................................................... 6 Theme 1 – FARA 1.0 Impact ................................................................................................................ 6 Theme 2 – General Capacity / Level of Service Provision ................................................................... 8 Theme 3 –Infrastructure Gap Analysis ................................................................................................. 9 Introduction ............................................................................................................................................. 11 Objective ................................................................................................................................................. 11 Research Questions ................................................................................................................................ 11 Methodology ............................................................................................................................................ 13 Design...................................................................................................................................................... 13 Analysis .................................................................................................................................................... 14 Respondent Selection and Site Evaluation Sampling ............................................................................... 14 Limitations ............................................................................................................................................... 15 Findings ..................................................................................................................................................... 16 Theme 1 – FARA 1.0 Impact (RQs 3, 4, 5, 7 and 8)............................................................................... 16 Research Question 3 .......................................................................................................................... 16 Research Question 4 .......................................................................................................................... 17 Research Question 5 .......................................................................................................................... 18 Research Question 7 .......................................................................................................................... 20 Research Question 8 .......................................................................................................................... 20 Theme 2 – General Capacity/Level of Service Provision (RQs 1, 2 and 6) ........................................... 23 Research Question 1 .......................................................................................................................... 23 Research Question 2 .......................................................................................................................... 26 Research Question 6 .......................................................................................................................... 27 Theme 3 – Infrastructure Gap Analysis (RQs 9 and 10) ........................................................................ 29 Research Question 9 .......................................................................................................................... 29 Research Question 10 ........................................................................................................................ 31 Conclusions and Recommendations .............................................................................................. 33 Theme 1 – FARA 1.0 Impact (RQs 3, 4, 5, 7 and 8)............................................................................... 33 Theme 2 – General Capacity / Level of Service Provision (RQs 1, 2 and 6) ......................................... 33 Theme 3 – Infrastructure Gap Analysis (RQs 9 and 10) ........................................................................ 35 Annexes .................................................................................................................................................... 36 Annex I: Desk Review Material............................................................................................................... 36 Annex II: Qualitative Fieldwork Participants .......................................................................................... 37 Annex III: Evaluated Facilities .................................................................................................................. 39 1 Annex IV: Qualitative Interview Guide ................................................................................................... 44 Annex V: Self-Assessment Questionnaires ............................................................................................. 45 Annex V.A – Central MOH Self-Assessment Questionnaire – USAID/Liberia FARA ...................... 45 Annex V.B – CHT Self-Assessment Questionnaire – USAID/Liberia FARA ..................................... 58 Annex VI: Facility Evaluation Form ......................................................................................................... 69 Annex VII: Analysis Outputs ................................................................................................................... 76 Annex VII.A – Output from Self-Assessment (MOH), Mean Score by Instrument Item .................. 76 Annex VII.B – Output from Self-Assessment (CHT), Mean Score by Instrument Item and Respondent Location .......................................................................................................................... 77 Annex VII.C – Output from Coding of Qualitative Interviews, Mean Score by Instrument Item and Respondent Location .......................................................................................................................... 78 Annex VII.D – Output from Coding of Qualitative Interviews, Inter-Rater Reliability Testing ........ 80 Annex VII.E – Output from Facility Evaluation Form, Mean Score by Instrument Item and Facility Type (i.e., FARA vs. Non-FARA) ........................................................................................................ 81 Annex VII.F – Output from Facility Evaluation Form, Mean Score by Instrument Item and Facility Type within FARA Counties ............................................................................................................... 86 Annex VII.G – Output from Facility Evaluation Form, Mean Score by Instrument Item and Facility Location .............................................................................................................................................. 91 Annex VII.H – Analysis of Differences in Performance on Facility Evaluation by Sets of Facility Type and Location........................................................................................................................................ 97 Annex VIII – Scope of Work .................................................................................................................. 99 2 List of Acronyms and Abbreviations CHT County Health Team EPHS Essential Package of Health Services EVD Ebola Virus Disease FARA Fixed Amount Reimbursement Agreement FGD Focus Group Discussion HFAS Health Facility Assessment Specialist HSCBE Health Sector Capacity Building Expert GoL Government of Liberia HMIS Health Management Information System KII Key Informant Interview LSA Liberia Strategic Analysis MOH Ministry of Health PBC Performance-based Contract PFMRAF Public Financial Management Risk Assessment Framework RBHS Rebuilding Basic Health Services SARA Service Availability and Readiness Assessment USAID United States Agency for International Development WASH Water, Sanitation and Hygiene List of Figures and Tables FIGURES Figure 1 – Rank Ordered Facility Evaluation Scores, By Facility Type 7 Figure