Design and implementation of a multi-country targeted health facility assessment to measure integrated, people-centered, quality of services

Integrated, people-centred, high-quality services are essential to achieving universal health coverage. Traditional health facility assessments, while valuable, often focus on structural inputs and are resource-intensive, limiting their frequency and programmatic utility. The Global Fund to Fight AIDS, Tuberculosis (TB), and Malaria, developed the Targeted Health Facility Assessment (tHFA) to inform country plans and monitor progress on the Global Fund Strategy (2023–2028) of maximizing people-centred integrated systems for health. This paper describes the development, methodology, and implementation of the tHFA baseline round and discusses key issues related to institutionalizing these assessments to monitor service delivery process and outcomes to improve health services in low- and middle-income countries (LMICs). The tHFA is a cross-sectional, multi-country facility assessment developed to support countries and monitor progress of four key performance indicators in the Global Fund’s strategic monitoring framework and seven programmatic indicators for the Global Fund’s investments to strengthen horizontal programs. In 2024, the Global Fund implemented a baseline survey across 2,272 facilities in 18 LMICs using a modular questionnaire covering integrated delivery of antenatal care, HIV, TB and malaria services, supportive supervision, community health worker (CHW) support, and patient-reported experience measures. Probability sampling was used to select 120 health facilities per country, and data were collected through direct observation, health worker interviews, and record reviews. Post-stratification weighting accounted for facility replacement and other sampling deviations. The Global Fund embedded data quality assurance through training, pilot testing, and real-time monitoring. The tHFA provides a pragmatic, agile and scalable approach to monitor integrated service delivery and people-centred quality of care in LMICs. Its focused scope on service delivery processes and outcomes, inclusion of CHWs, and alignment with the Global Fund’s strategic objectives make it a valuable tool to guide decision-making, inform grant monitoring, and support health system strengthening efforts across LMICs.