Setting the Benchmark for Health System Strengthening: Baseline Score Cards for the Community Randomised Trial in Zambia:

Introduction: The primary bottleneck to achieving the MDGs in low-income countries is health systems that are too fragile. Strong and effective health systems are considered a prerequisite to reducing the disease burden and to achieving the health MDGs. The BHOMA project is a randomised step wedged Community intervention that aims to strengthen the health system in 42 Health Centers, in three districts of Zambia. In evaluating the BHOMA study, we propose monitoring performance of the health system by tracking changes within the six WHO building blocks for HSS. We present the baseline results of the BHOMA intervention by comparing scores across the three target districts. Methods: Health facility audit was conducted. Data analysis used a total of 111 indicators divided into categories as follows: Basic Infrastructure, Service availability,Basic equipment ,Laboratory capacity, Pharmaceuticals. Linear regression was used to determine the contribution of the subcategories. Results: All Health Centers had a qualified health worker though absenteeism was high (24%). 22% of Health Centers had no overnight beds. Communication facilities were lacking with 59% using own mobile phones. Access to emergency ambulance services was limited with 73% reporting no access. The overall District scores ranged between 77% and 72%. Chongwe had the highest score (77%) and Kafue the least (72%). The highest scores were noted at Hospital associated Health Centers (81%).The scores were lowest in rural Health Centers (74%). Disaggregation by sub-category showed that the highest scores were in Pharmaceuticals (Tracer drugs) in all the three districts. The Least scores were noted in Service availability. Linear regression model revealed highest variability in service availability (60%) and the least in Pharmaceuticals (13%), p<0.0001. Conclusion: Access to communication and ambulance was limited. This has implication on emergency and referral services. The baseline scores varied by residence and most Health Centers performed poorly in Service availability.