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

Background:

Over 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. This study has used Balanced Score Card (BSC) to monitor improvements in quantity and quality of health-care services provided through public-sector facilities.

Methods:

Nationally representative health-facility surveys were conducted in 2009 and 2011 in Bangladesh. Health-facility assessment questionnaire used BSC as a guide for observing changes in performance of health-facilities.  

Results:

Availability of basic clinical equipment improved from 67% in 2009 to 85% in 2011. Essential drug availability (37 drugs) also improved. Staffing index for physicians, auxiliary staff, and other healthcare personnel improved significantly over 2009 to 2011. In contrast, availability of immunization equipment and family planning supplies declined. Laboratory Equipment availability index remained more or less unchanged. On average, outpatient visit per-month per-facility increased by about 22%. 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. 

Conclusion:

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