Service Use and Intervention Coverage

 

The service use and intervention coverage collection includes results-based financing indicators that track the number of people using a service and proportions of people who need a service who are using the service. The RBF Indicator Compendium has three other collections: structural, quality of services, and health outcomes and impact. 

Service utilization

Definition:

Number (and mean) outpatient department visits to the health facility per person per year.

Numerator:

Total number of outpatient department visits per year.

Denominator:

Total population (of the same geographical area).

Disaggregation:

Age, place of residence, sex.

See also: Number of outpatient department visits per 10,000 population per year; and Hospital admission rates (i.e. Number of hospital [inpatient] admissions per person per year)

Data Requirements:

Requires complete and reliable recording and reporting of the number of outpatient department visits by public and private facilities. Recall in population surveys can also be used.

Data Sources:

Routine facility information systems

Population-based health surveys

Purpose:

There has been a shift in the global health agenda from focusing on disease-specific approaches to emphasizing health systems strengthening to improve the effectiveness of national and district-level health ministries and programs. Strengthening outpatient service delivery and increasing utilization are fundamental to improving health status and outcomes. This standardized indicator shows the levels of utilization of outpatient healthcare services and can be employed to examine trends and variations in use of services by type of facility and healthcare service, geographic districts and urban/rural locations, and will allow comparisons between countries and programs. 

Issue(s):

Assessment of actual numbers of people utilizing services (including those individuals who make repeated visits) requires complete and reliable recording and reporting of the number of outpatient department visits by public and private facilities. 

References:

World Health Organization (WHO). 2015 Global Reference List of 100 Core Health Indicators.; 2015. http://apps.who.int/iris/bitstream/10665/173589/1/WHO_HIS_HSI_2015.3_eng.pdf

World Health Organization. Monitoring, Evaluation, and Review of National Health Strategies: A Country-Led Platform for Information and Accountability.; 2011. http://www.who.int/healthinfo/country_monitoring_evaluation/1085_IER_131011_web.pdf

MEASURE Evaluation. FP and Reproductive Health Indicators Database — MEASURE Evaluation. http://www.cpc.unc.edu/measure/prh/rh_indicators/ 

 

Further information and related links

World Health Organization (WHO). Monitoring the Building Blocks of Health Systems: A Handbook of Indicators and Their Measurement Strategies.; 2010. (Retrieved from http://www.who.int/healthinfo/systems/WHO_MBHSS_2010_full_web.pdf?ua=1)

Use of specified sexual and reproductive health services by young people

Definition:

The use of specified sexual and reproductive health (SRH) services by young people can be measured through either facility-based records (measuring service utilization only) or population-based methods such as surveys (which can give an estimate of the coverage of health services) (WHO, 2007).

Health services of particular interest include those concerned with HIV counseling, testing, and treatment; diagnosis and treatment or sexually transmitted infections (STIs); and counseling, provision, and referrals for contraceptives.  Evaluators may wish to specify other SRH services, including prenatal care, male circumcision services, counseling and treatment for victims of rape or sexual assault, abortion or postabortion care, treatment for obstetric fistula, etc.

This indicator generally refers to the use of facility-based SRH services only, however evaluators may choose to include SRH service provision from peer providers or community health workers.

At the facility level this indicator is calculated as:

(Number of young people aged 10-24 using an SRH service, disaggregated by service received, in a defined period / Total number of all clients using a specified SRH service in a defined period) x 100

At the population level this indicator is calculated as:

(Number of young people aged 10-24 who report receiving any of the specified SRH services in the preceding 12 months / Total number of young people surveyed who report being sexually active in a defined period) x 100

Data Requirements:

Facility-based data requires the total number of clients who sought specified SRH services in a given reporting period and the percentage of these clients who are aged 10-24.   Population-based data requires the number of young people reporting use of specified SRH services in the past year and the number who report having been sexually active in the past 12 months.

For both, data can be disaggregated by gender, age groups (10-14, 15-19, 20-24), in or out of school, marital status, urban/rural location and type of facility (WHO, 2007).

Evaluators may want to disaggregate by the following age ranges: 10-14, 15-19, and 20-24.

Data Sources:

Routine facility-based data collection; DHS or other nationally representative general population survey

Purpose:

This indicator tracks the number of young people seeking health services as an indication of care-seeking behavior, since such utilization appears to be low compared to the need (WHO, 2007). It also tracks the percent of all clients of health services who are young people and can be an estimate of the changes in care-seeking behavior among young people. Young people do not access health services in proportion to the health problems they experience (WHO,2004). A basic aim of an HIV/AIDS prevention program, therefore, is to increase the use of services by young people, specifically for STI testing and treatment, contraceptive use, and HIV counseling, testing and treatment.

Generally, an increase in the number and proportion of young clients is considered positive. However, the number and percentage must be interpreted together, as the percentage of clients who are young people may decrease if the overall use of SRH services by adults increases, even though the number of young clients may be increasing as well (WHO, 2004).

The correct interpretation of these numbers, moreover, requires some population-based estimates to understand the magnitude of need in order to interpret increases or decreases in specific services used. For example, if it is known that 40% of the population served by a particular health service are young people aged 20–24, and that in this population the prevalence of Chlamydia is 20%, an estimate can be obtained of the maximum number and percent of young clients who could, ideally, be expected to seek STI testing and treatment. In other words a ceiling is provided against which to gauge the increase or decrease in young clients(WHO, 2004).

At the population level this indicator estimates the proportion of sexually active young people who report seeking specified SRH services. In addition, if data are available on the proportion of young people in need of specific SRH services, either through epidemiological estimates or other surveys, this measure can be an estimate of the coverage of the specific health services. For example, if it is known that in a given region 50% of 15−19 females are sexually active; this provides a benchmark against which to gauge the number and percent of females aged 15−19 years that would theoretically need contraceptives. If more details are known about sexual risk behaviors (e.g. if, of the 50% who are sexually active, 40% report being with more than one partner in the preceding year and only 30% report frequent use of condoms) they can be benchmarks for the percent of girls aged 15-19 who would potentially need HIV testing services (WHO, 2004).

Issue(s):

An increase in the number of young people seeking services does not necessarily mean an increase in the percent of young people with SRH needs or issues. The increase may well be attributable to other factors, such as an information campaign advertising the services or a health promotion program that enables more young people to recognize the need for preventative or curative services, e.g. to recognize the symptoms of an STI or to increase the demand for contraceptives.  Changes in health seeking behavior are often attributed to changes in health policy as well, such as the instatement or removal of user fees.

A challenge with tracking this indicator is that it depends on facilities having well-maintained and accurate records and logbooks, including age-specific records or at least records in age brackets allowing for disaggregation of young people from adults (WHO, 2004). In many countries there may be no such records, or the recording of services in facilities may not be standardized. Furthermore, clients themselves may not know their exact age. Even where well-maintained clinical records exist, the way in which the information is recorded may limit the ability to collect data for this indicator.  Clients may seek multiple services at one visit and where services are not integrated, frequently the record keeping is decentralized, leading to problems in double counting. For example, they may come to a facility for flu like symptoms, but also receive SRH services in addition, and thus the reason for the visit may not reflect the use of SRH services.

Moreover, the measurement of service utilization provides no information about the quality of services.  In order to obtain a better understanding of the trends observed in utilization, these data should be complemented by measuring the quality and effectiveness of SRH services with additional indicators on Quality of Care/Service Provision Assessment.

Gender Implications:

Young women’s access to and use of SRH services may be limited by cultural gender norms and related barriers. Less mobility, fewer resources to pay for health services, and stigma associated with being a sexually active adolescent, and visiting facilities that offer HIV services may all contribute to young women not accessing care. Further, lack of female health care providers and or providers trained in youth-friendly services may deter women from accessing services. Young men may also be less likely to access services due to social norms around masculinity and not having a self-identified need.

References:

World Health Organization, 2004. National AIDS Programmes: A guide to indicators for monitoring and evaluating national HIV/AIDS prevention programmes for young people.

World Health Organization, 2007. Introduction Access to Health Services for Young People for Preventing HIV and Improving Sexual and Reproductive Health.

Percent service delivery points providing youth friendly services

Definition:

This indicator is a composite index measuring whether reproductive health services are “youth friendly.” Ser­vices are “youth friendly” if they “have policies and attributes that attract adolescents to the facility or pro­gram, provide a comfortable and appropriate setting for youth, meet the needs of adolescents, and are able to retain their adolescents for follow-up and repeat visits” (Senderowitz, 1999). Aspects of an “adolescent friendly” environment can include space or rooms dedi­cated to ARH services, policies and procedures to en­sure privacy and confidentiality, peer educators on site, nonjudgmental staff, and acceptance of drop-in clients.

Data Requirements:

Evidence as to whether reproductive health services satisfy standards for being “youth friendly.”  The fol­lowing characteristics make facilities/services “youth friendly:”

 

Evaluators create this index by assigning a score to each item: 2 points for complete fulfillment of the condition, 1 point for partial fulfillment of the condition, and 0 for lack of fulfillment. Evaluators may derive a total facil­ity score if they first sum the item scores and then di­vide that result by the total number of points possible (Nelson, MacLaren, and Magnani, 2000).

Data Sources:

Facility records; facility inventories; interviews with adolescent clients, providers, and managers at clinics; client exit interviews; interviews of youth in the com­munity

Purpose:

Because reproductive health services in most settings have been designed for older, married women, unmar­ried female and male adolescents face a variety of bar­riers to service use. Among these are policies that re­strict their access to services and information, negative community attitudes toward providing reproductive health services to unmarried adolescents, adolescent embarrassment at being seen at facilities, and fear that the facility will not honor privacy and confidentiality.

To overcome these barriers, a number of service-pro­viding organizations have sought to make their services more “youth friendly.” By offering more youth-friendly reproductive health services, programs may effectively attract young people and may provide quality reproduc­tive health services in a comfortable and responsive environment. Adolescents can receive services in a health facility, such as a clinic, health post or hospital, from trained personnel who provide services in a work­place or school setting, through community outreach workers or peer educators. Regardless of the venue, services must have special characteristics that attract, serve, and retain adolescent clients.

 This indicator is most appropriate for assessing facili­ties and services that were not specifically designed for adolescents (such as a family planning clinics, health posts, or pharmacies), because adolescent facilities were presumably designed with the characteristics of ado­lescent friendliness in mind. However, this indicator can also monitor the adolescent friendliness of adoles­cent-centered facilities over time. For example, after a baseline assessment, the program manager may plan to make changes in services over the next 6 months and may allow those changes to become part of the service-delivery protocols over the next 12 months. The pro­gram manager may then decide to undertake a follow-up assessment 18 months later to determine if the changes occurred. The follow-up assessment should measure the same characteristics it measured in the ini­tial assessment.

The Pathfinder International-developed Rapid Assessment of Youth Friendly Reproductive Health Services (2003) can be used for the initial assessment.  If a facility wishes to quantify its status as one that provides youth friendly services, the Certification Tool for Youth Friendly Services (Pathfinder, 2004) can be used.

Antenatal care coverage - at least four visits (%)

Definition:

Percent of women aged 15−49 years with a live birth in a given time period who received antenatal care, four times or more.

Numerator:

Number of women aged 15−49 years with a live birth in a given time period who received antenatal care four or more times.

Denominator:

Total number of women aged 15−49 years with a live birth in the same period.

Disaggregation:

Age, place of residence, socioeconomic status, type of provider.

See also: Percent of women attended, at least once during their pregnancy, by skilled health personnel for reasons relating to the pregnancy; and Percent women attended at least four times for antenatal care during pregnancy

Data Requirements:

The number of women aged 15−49 years with a live birth in a given time period who received antenatal care four or more times during pregnancy is expressed as a percentage of women aged 15−49 with a live birth in the same period.

(Number of women aged 15−49 years attended at least four times during pregnancy by any provider for reasons related to the pregnancy/total number of women aged 15−49 years with a live birth) x 100.

The indicators of antenatal care (at least one visit and at least four visits) are based on standard questions that ask if and how many times the health of the woman was checked during pregnancy. This is because the key national-level household surveys do not collect information on type of provider for each visit. The indicators of antenatal care (at least one visit and at least four visits) are based on standard questions that ask if, how many times, and by whom the health of the woman was checked during pregnancy. Household surveys that can generate this indicator include DHS, MICS, FFS, RHS and other surveys based on similar methodologies. Service/facility reporting systems can be used where the coverage is high, usually in industrialized countries.

Data Sources:

Household surveys

Routine facility information systems

Purpose:

This indicator provides information on women’s use of ANC services at the recommended level and can be used to track trends in utilization. Many health problems experienced by pregnant women can be prevented, detected and treated during ANC visits with trained health workers. 

Issue(s):

Receiving ANC care during pregnancy does not guarantee that women received all of the recommended and necessary interventions. However, at least four ANC visits increases the likelihood of receiving the full range of interventions (WHO, 2010). 

With population-based surveys, recall error is a potential source of bias given that the surveys ask the respondent about each live birth for a period up to five years before the interview. The respondent may or may not know or remember the number of visits, particularly as this number increases.  For data compiled at the health facility level, discrepancies are possible in recording and reporting numbers of visits and these data would differ from global figures based on survey data collected at the household level. In addition, data on women’s use of ANC from routine health records may lack information on pregnancies occurring outside the public health sector, including home and private facility deliveries. 

References:

World Health Organization (WHO). 2015 Global Reference List of 100 Core Health Indicators.; 2015. http://apps.who.int/iris/bitstream/10665/173589/1/WHO_HIS_HSI_2015.3_eng.pdf

World Health Organization. Monitoring, Evaluation, and Review of National Health Strategies: A Country-Led Platform for Information and Accountability.; 2011. http://www.who.int/healthinfo/country_monitoring_evaluation/1085_IER_131011_web.pdf

MEASURE Evaluation. FP and Reproductive Health Indicators Database — MEASURE Evaluation. http://www.cpc.unc.edu/measure/prh/rh_indicators/ 


Further information and related links

Countdown to 2015 decade report (2000−2010): taking stock of maternal, newborn and child survival. Geneva and New York (NY): World Health Organization/United Nations Children’s Fund; 2010 (Retrieved from http://www.countdown2015mnch.org/reports-and-articles/previous-reports/2010-decadereport).

Indicators for monitoring the Millennium Development Goals: definitions, rationale, concepts and sources. New York (NY): United Nations; 2012 (Retrieved from http://mdgs.un.org/unsd/mi/wiki/MainPage.ashx).

Keeping promises, measuring results. Commission on information and accountability for Women’s and Children’s Health. Geneva: World Health Organization; 2011 (Retrieved from http://www.who.int/topics/millennium_development_goals/accountability_commission/Commission_Report_advance_copy.pdf).

World Health Assembly governing body documentation: official records. Geneva: World Health Organization (Retrieved from http://apps.who.int/gb/or/).

Antenatal care use at age less than 20 years

Definition:

The percent of pregnant young women aged less than 20 years with a live birth within a given time period who attended antenatal care (ANC) with a skilled attendant at least once for reasons related to the most recent pregnancy.

WHO guidelines on the content of ANC visits include the following components: clinical examination, blood testing to detect syphilis and severe anemia (and HIV, malaria, etc. according to the epidemiological context), gestational age estimation, uterine height, blood pressure, maternal weight and height, test for sexually transmitted infections (STIs), urine test, request blood type and Rh, tetanus toxoid, iron/folic acid supplementation, and recommendations for emergencies (WHO, 2002). For more detail on this and related indicators, see WHO (2010); WHO (2006).

A skilled attendant is defined as an accredited health professional who has been educated and trained to proficiency in the skills needed to manage normal (uncomplicated) pregnancies, childbirth and the immediate postnatal period, and in the identification, management and referral of complications in women and newborns.  This includes midwives, doctors and nurses but excludes traditional birth attendants (WHO, 2006).

A live birth is the birth of a fetus after 22 weeks' gestation or weighing 500g or more that shows signs of life - breathing, cord pulsation or with audible heartbeat.  This cut-off point refers to when the perinatal period begins (WHO, 2006).

This indicator is calculated as:

(Number of women aged 20 years and under with a live birth who attended ANC at least once during most recent pregnancy / Total number of women with live births within the reference period) x 100

Data Requirements:

This indicator can be calculated from the survey questions in Demographic Health Survey (DHS), the Reproductive Health Survey (RHS), UNICEF Multiple Indicator Cluster Survey (MICS), and other national surveys that ask about the number of ANC visits women had with their most recent births. Specialized survey data and health facility records can also be used for more localized studies. Data must be disaggregated by age to determine the percentage of adolescents being served and can also be disaggregated by the type of facility (public, private, non-governmental, community-based), by district and urban rural location, and by women’s education, wealth quintile, and parity. 

WHO and UNICEF compile empirical data from household surveys and produce regional and global estimates based on population-weighted averages weighted by the total number of births. These estimates are used only if available data cover at least 50 percent of total births in the regional or global groupings (WHO, 2010).

Data Sources:

Population-based surveys, such as DHS, RHS, and MICS; facility records and health services data

Purpose:

The main purpose of an ANC indicator is to provide information on young women’s use of ANC services. It is important to give special attention to adolescents (those 10-19 years old) seeking obstetric care because they are at high risk of complications and death. Pregnancy in adolescence contributes to the cycle of maternal deaths and indicates limited access to reproductive health services.

The association between one antenatal visit (with care provision of unknown quality) and maternal mortality is weak (Bergsjø, 2001). This indicator measures a service delivery contact or opportunity which, in itself, does not save lives. Impact is achieved when these contacts are used to deliver high quality effective interventions.  Thus, the finding that women who attend ANC are more likely to use skilled health personnel for care during birth and that ANC may facilitate better use of emergency obstetric services supports the use of this indicator in combination with the indicator percent of deliveries attended by skilled personnel. Therefore, women's use of ANC is more strongly associated with improved perinatal survival (McDonagh, 1996) and measures of ANC coverage may have a greater role in the monitoring and evaluation of programs addressing newborn health and survival (WHO, 2006).

Although epidemiological studies show an association between improved maternal health outcome and ANC, most fail to control for selection biases that would positively influence the outcome (Villar, 2000).

Issue(s):

ANC coverage provides a crude measure of ANC utilization (Rooney, 1992), but it does not capture the number and timing of visits, the reasons for seeking care, the skills of the provider, or the quality of care received. Therefore, evaluators should not infer that similar rates of ANC coverage mean similar levels of care.

Receiving ANC care during pregnancy does not guarantee that adolescent women received all of the recommended and necessary interventions. In fact, it is unlikely. However, at least four ANC visits – the WHO recommended minimum - increases the likelihood of receiving the full range of interventions (WHO, 2010).

For data compiled at the health facility level, discrepancies are possible in recording and reporting numbers of visits and these data would differ from global figures based on survey data collected at the household level. In addition, data on women’s use of ANC from routine health records may lack information on pregnancies occurring outside the public health sector, including home and private facility deliveries. 

Collecting this data through vital registration sometimes means the data may not be collected in a format appropriate for constructing this indicator.  Frequently the data are episode- rather than woman-based (i.e. the number of consultations performed by the provider is recorded but not the number of times a specific woman is seen). Since women may be seen several times, and may also present at different facilities, this creates the potential for double counting and therefore overestimating ANC coverage. Health service data may also be poor quality and records may be incomplete or missing.

Gender Implications:

Adolescent girls tend to recognize their pregnancies later in gestation, often due to lack of knowledge of fertile periods and/or irregular menstrual cycles. In many places it is culturally taboo for a young girl to get pregnant out of wedlock, and even if she suspects her own pregnancy, she may not seek ANC services for fear of discrimination or being found out.

Because some countries deem it culturally inappropriate for women to discuss issues related to their bodies with men, women may not be able to communicate pregnancy related problems to male providers. In addition, where young women lack access to household resources or where they lack the autonomy to seek health care on their own, family members may not be willing to invest resources in ANC, particularly if a given pregnancy is progressing "normally."

References:

Bergsjø, P. (2001). What is the evidence for the role of antenatal care strategies in the reduction of maternal mortality and morbidity? In Vincent De Brouwere, Wim Van Lerberghe (Eds.), Safe Motherhood Strategies: A review of the evidence. Studies in Health Services Organisation and Policy no 17. Antwerp: ITG Press.

McDonagh, M. 1996. Is antenatal care effective in reducing maternal morbidity and mortality? Health Policy Plan. 11(1): 1-15.

UNFPA, 2010. How Universal is Access to Reproductive Health? A review of the evidence. http://www.unfpa.org/public/home/publications/pid/6526

Villar J, Carroli G, Khan-Neelofur D, Piaggio G, Gülmezoglu M. Patterns of routine antenatal care for low-risk pregnancy. Cochrane Database of Systematic Reviews 2001, Issue 4. Art. No.: CD000934.

WHO, 2011. Global Health Observatory (GHO), Antenatal care Situation and trends, Geneva: WHO. http://www.who.int/gho/maternal_health/reproductive_health/antenatal_care_text/en/index.html

WHO, 2010. Indicator Code Book: World Health Statistics - World Health Statistics indicators, Geneva: WHO http://www.who.int/whosis/indicators/WHS10_IndicatorCompendium_20100513.pdf  

WHO, 2006. Reproductive Health Indicators: Guidelines for their generation, interpretation and analysis for global monitoring, Geneva: WHO  http://whqlibdoc.who.int/publications/2006/924156315X_eng.pdf 

WHO, 2002. Antenatal Care Randomized Trial: Manual for the Implementation of the New Model, Geneva: WHO. http://whqlibdoc.who.int/hq/2001/WHO_RHR_01.30.pdf  

Percent of pregnant women who were counseled and tested for HIV and know their results

Definition:

The percentage of pregnant women attending antenatal care (ANC), labor & delivery (L&D), and postpartum care services (PPC), plus women with known HIV infection attending ANC for a new pregnancy, who received testing and counseling for HIV in the last 12 months and who know their HIV test results.  

The numerator can be summed from categories a-d below (PEPFAR, 2009):

The denominator is generated through a population estimate of the number of pregnant women giving birth in the last 12 months, which can be obtained from the Central Statistics Office estimates of births or the UN Population Division estimates. In countries with low-level and concentrated epidemics where policies to identify the HIV status of all pregnant women do not exist, the denominator should be adapted to the target population of pregnant women whose HIV status should be assessed (UNAIDS, 2008). For additional information on this and closely related indicators, see UNAIDS, (2008); PEPFAR (2009), UNAIDS, (2010); WHO/UNICEF/UNAIDS, (2011); WHO et al., (2006); USAID/CORE, 2004).   

Indicator is calculated as:

(Number of pregnant women receiving HIV testing and counseling who know their HIV test results/Total estimated number of pregnant women in the last 12 months. ) x 100

Data Requirements:

Data to construct the numerator should come from national program records aggregated from facility registers in ANC, L&D, and postpartum services. Health facility registers should include data on known HIV infection among HIV-infected pregnant women accessing ANC services for a new pregnancy in order for them to receive subsequent prevention of mother-to-child transmission (PMTCT) services. All service providers should be included (public, private, non-governmental and community-based) and data should be collected continuously at the facility and community levels.

If targeting and/or linking to inequity, classify outlets where counseling is taking place by location (poor/not poor) and disaggregate by area served.  Exit interviews can be conducted with clients to determine client's poverty status.

Data Sources:

For the numerator: ANC and L&D registers; HIV testing and counseling registers; HIV TOOLS: reporting forms. For the denominator: published estimates (e.g., estimates from the UN Population Division)

Purpose:

This indicator measures the percentage of pregnant women who were tested and counseled for HIV in the last 12 months and who received their HIV test results. This indicator reflects one goal of PMTCT, which is to increase the number of pregnant women who know their HIV status. Identification of a pregnant woman’s HIV status is the key entry point into PMTCT services and other HIV care and treatment services (PEPFAR, 2009). Mother-to-child transmission (MTCT) of HIV infection can occur during pregnancy, labor and delivery, or during breastfeeding. Receiving HIV testing and counseling services as early as possible during pregnancy enables HIV-positive pregnant women to benefit from HIV services and to access interventions for reducing HIV transmission to their infants. The risk of MTCT can be reduced by a range of interventions, including provision of antiretroviral prophylaxis given to women during pregnancy and labor and to the infant in the first weeks of life; obstetrical interventions; and either complete avoidance of breastfeeding or early postpartum exclusive breastfeeding where safe and affordable breast milk substitutes are not feasible (WHO/UNICEF, 2003). For more background and international recommendations on infant feeding and PMTCT, see the technical area in this database on Women’s Nutrition and HIV.

This indicator enables a country to monitor trends in HIV testing among pregnant women and women receiving postpartum services who may require antiretroviral (ARV) drugs to prevent mother-to-child transmission of HIV. In addition, it provides a good measure of how effectively HIV testing and counseling services are being provided to pregnant women and women receiving postpartum services.

Issue(s):

The indicator does not capture points at which drop-outs occur during the testing and counseling process; the reasons why drop-outs occur; the number of women who received pre-test counseling; nor the quality of HIV testing and counseling services. There is a risk for double counting women in the numerator since a pregnant woman can be tested more than once while receiving ANC, L&D, or postpartum services. This is particularly true where women are re-tested in different facilities, or where they come to the L&D without documentation of their HIV test result. While it may not be feasible to avoid double counting entirely, countries should take measures to minimize double counting, such as through the use of patient-held records that document, among other services, that HIV testing was done (UNAIDS, 2008).

Gender Implications:

The availability of ARVs which can prevent the transmission of HIV from mother to child increase the value that voluntary counseling and testing (VCT) could have for pregnant women. Yet many women refuse testing and treatment. Health workers must recognize that VCT entails significant risks for women which may include partner violence and ostracism. Applying strict standards of confidentiality and privacy to VCT, as well as to the treatment phase (if one is required), is necessary to ensure that pregnant women will have enough trust in their own safety to risk being tested. The lack of treatment options for the mother herself remains a serious obstacle to PMTCT.

References:

PEPFAR, 2009, The President’s Emergency Plan for AIDS Relief: Next Generation Indicators Reference Guide, Washington, DC: USAID/PEPFAR. http://www.pepfar.gov/documents/organization/81097.pdf

UNAIDS, 2008, Core Indicators for National AIDS Programmes: Guidance and Specifications for Additional Recommended Indicators, Geneva: UNAIDS. http://data.unaids.org/pub/BaseDocument/2009/20090305_additionalrecommendedindicators_finalprintversio_en.pdf

UNAIDS, 2010, Prevention of Mother-To-Child Transmission of HIV (PMTCT): Technical Guidance Note for Global Fund HIV Proposals, Geneva: UNAIDS. http://www.who.int/hiv/pub/toolkits/PMTCT_Technical_guidance_GlobalFundR10_May2010.pdf

USAID/CORE, 2004,Maternal and Newborn Standards and Indicators Compendium, Washington, DC: USAID. http://www.coregroup.org/storage/documents/Workingpapers/safe_motherhood_checklists-1.pdf

WHO/UNICEF/UNAIDS, 2011, A Guide on Indicators for Monitoring and Reporting on the Health Sector Response to HIV/AIDS. Geneva: WHO. http://www.who.int/hiv/data/UA2011_indicator_guide_en.pdf

WHO, UNAIDS, The Global Fund, CDC, USAID, UNICEF, MEASURE Evaluation, US Dept. of State: OGAC, 2006, Monitoring and Evaluation Toolkit: HIV/AIDS, Tuberculosis, and Malaria, Geneva: WHO. http://www.theglobalfund.org/documents/me/M_E_Toolkit_P2-HIV_en.pdf

WHO/UNICEF, 2003, Global Strategy for Infant and Young Child Feeding, Geneva: WHO.  http://whqlibdoc.who.int/publications/2003/9241562218.pdf

Intermittent preventive therapy for malaria during pregnancy

Definition:

Percent of women who received three or more doses of intermittent preventive treatment during antenatal care visits during their last pregnancy.

Numerator:

Number of women receiving three or more doses of recommended treatment.

Denominator:

Total number of pregnant women/surveyed with a live birth in the last 2 years.

Disaggregation:

Age, place of residence, socioeconomic status.

Data Requirements:

When data are collected by reviewing facility records, or through direct observation of ANC consultations or client exit interviews, the numerator is the number of pregnant women given or prescribed malaria medication in a given period.

Where data on the total number of pregnant women are absent, WHO recommends using 3.5% of the total population as an estimate of the number of pregnant women (i.e., number of pregnant women = total population x 0.035 [WHO, 1999a, 1999b]).

When the indicator is calculated from populationbased surveys, the numerator is defined as the number of women who were given or who purchased malaria medication during their most recent pregnancy, and the denominator as the number of women who had a recent live birth. The time-periods for the most recent pregnancy/live birth should be specified for both the numerator and denominator. In most surveys, this period is normally restricted to three to five years before the survey.

See also: Number/percent of pregnant women who received two or more doses of IPTp while attending antenatal care; and Number/percent of women aged 15-49 who received two or more doses of IPTp during their last pregnancy

Data Sources:

Household surveys

Facility information systems

Purpose:

This indicator measures both coverage and access to IPTp among pregnant women as well as service providers’ adherence to malaria in pregnancy protocols.

Malaria is a major health risk for womenand newborn in areas where Plasmodium falciparum malaria is endemic. In stable areas of malaria transmission, malaria infection causes anemia in the mother. The presence of malaria parasites in the placenta also damages placental integrity and interferes with the ability of the placenta to transport nutrients and oxygen to the fetus, thereby causing intrauterine growth retardation, a primary cause of low birth weight.

Pregnant women residing in low or unstable malaria transmission areas have a two to threefold higher risk of developing severe disease as a result of malaria infection. In such areas, malaria can cause maternal death directly from infection or indirectly by causing severe anemia. In addition, a range of adverse pregnancy outcomes, including spontaneous abortion, still births, and congenital malaria, can result from malaria, causing increased risk of infant mortality among all babies born to mothers living in areas of unstable malaria transmission.

Issue(s):

Some large household surveys, such as the DHS, routinely collect data for this indicator. In addition some health facility surveys that conduct record reviews, direct observation of ANC consultations, or exit interviews with ANC clients yield this information for client populations. The questions asked in most population-based surveys assume that women are able to report on malaria treatment reliably, but few validation studies have tested this assumption. Population-based studies also rely on self-reported data, which are subject to recall bias that is likely to increase with the length of the recall period.

One major limitation of this indicator is that current data collection approaches lack information on the completeness of the drug regimen taken during pregnancy. In addition to determining the type of malaria medication taken, information on the frequency and timing of drug administration is required to determine whether pregnant women are adequately protected against malaria. Information on the frequency and timing of drugs administered could theoretically be obtained if clinics maintain records on the numbers of patients attending and on the number of women given a first, second and third course of IPTp or the number of packets of medicine disbursed.

Facility records measure the proportion of women given or prescribed malaria medication but do not reflect the proportion of women who took the medication. Compliance with the treatment will rarely be 100% and will vary depending on many different local factors. Where malaria is sporadic or seasonal, programs focus on screening women that present with symptoms and on treating those who are infected.

References:

World Health Organization (WHO). 2015 Global Reference List of 100 Core Health Indicators.; 2015. http://apps.who.int/iris/bitstream/10665/173589/1/WHO_HIS_HSI_2015.3_eng.pdf

MEASURE Evaluation. FP and Reproductive Health Indicators Database — MEASURE Evaluation. http://www.cpc.unc.edu/measure/prh/rh_indicators/  

Gage AJ, Ali D, Suzuki C. A Guide for Monitoring and Evaluating Child Health Programs. MEASURE Evaluation. Carolina Population Center, University of North Carolina at Chapel Hill.; 2005.  http://www.coregroup.org/storage/documents/Workingpapers/ms-05-15.pdf


Further information and related links

Countdown to 2015 decade report (2000−2010): taking stock of maternal, newborn and child survival. Geneva and New York (NY): World Health Organization/United Nations Children’s Fund; 2010 (Retrieved from http://www.countdown2015mnch.org/reports-and-articles/previous-reports/2010-decadereport).

Household Survey Indicators for Malaria Control. Measure Evaluation / Measure DHS / President’s Malaria Initiative/Roll Back Malaria Partnership/ UNICEF/WHO. 2013 (Retrieved from http://www.malariasurveys.org/documents/Household%20Survey%20Indicators%20for%20Malaria%20Control.pdf).

Roll Back Malaria Partnership/WHO. Disease surveillance for malaria control: an operations manual. Geneva: World Health Organization; 2012 (Retrieved from http://www.who.int/malaria/publications/atoz/9789241503341/en/).

World Health Assembly governing body documentation: official records. Geneva: World Health Organization (Retrieved from http://apps.who.int/gb/or/).

Percent of women who received at least two doses of tetanus-toxoid vaccine in their last pregnancy

Definition:

The proportion of pregnant women receiving at least two doses of tetanus-toxoid vaccine (TT2)
This indicator is calculated as:

Total TT2 + TT3 + TT4 + TT5 x 100
_________________________
Total # of live births

Where TT2, TT3, TT4, TT5 refer to the 2nd, 3rd, 4th, or 5th dose of tetanus-toxoid vaccine administered (WHO, 1999a and c).

Data Requirements:

From service statistics:
Number of doses of TT2 + TT3 + TT4 + TT5 given to pregnant women in a reference period (usually a year)

From population-based surveys:
Number of women giving birth during a reference period (e.g., five years) who report receiving at least two doses of tetanus-toxoid during their last pregnancy and number of live births in the same reference period

The number of live births serves as a proxy for the number of pregnant women.

Where data on the numbers of live births for the denominator are unavailable, evaluators can calculate total estimated live births using census data for the total population and crude birth rates in a specified area. Total expected births = population x crude birth rate

In settings where the crude birth rate is unknown, the WHO recommends using 3.5 percent of the total population as an estimate of the number of pregnant women (number of live births or pregnant women = total population x 0.035) [WHO, 1999a and c.]

Data Sources:

Service statistics; population-based surveys

Purpose:

This indicator measures the percentage of women and births protected against tetanus at the time of delivery among clients in a given program or among the general population.

Neonatal tetanus is usually fatal. A woman immunized with at least two doses of tetanus toxoid according to the WHO schedule1 develops antibodies that protect her infant against tetanus in the first two months of life. Tetanus-toxoid immunization is therefore an integral part of the ANC package offered to women in most developing countries.

Many national HIS routinely collect this indicator to provide TT2+ coverage estimates for women attending facilities for ANC. Most large population-based surveys also collect data on self reported TT2+ coverage. Note: Variations in the methods used to measure TT2+ coverage, as well as in the definition of the numerator and denominator, give rise to differences in the magnitude and reliability of the estimates obtained. For example, service statistics record the total number of doses of a vaccine in the previous 12 months, whereas surveys tend to record the total number of women who report receiving at least two vaccinations during their last pregnancy in a reference period that may be up to five years.

Promoting clean delivery and cord care practices as well as ensuring that women are adequately immunized against tetanus prior to birth can prevent transmission of neonatal tetanus. TT2+ coverage should also be reported as well as the number of neonatal tetanus cases and the proportion of live births with a skilled attendant (as a proxy for clean births).

For prevention of neonatal and maternal tetanus, WHO recommends giving women a series of five doses of tetanus- toxoid vaccine with a minimum interval between each dose. Each dose increases the level and protection against tetanus. Each dose counts as a dose towards a five-dose schedule even if given before the recommended interval. A woman who receives five doses of tetanus toxoid is fully immunized and is protected against tetanus throughout her childbearing years.

Table III.E.3 WHO Recommended Tetanus-Toxoid Series

TT Time of Dose Given Level of Protection Duration of Protection
TTI At first contact NIL None
TT2 Four weeks after TTI 80% 3 years
TT3 At least 6 months after TT2 95% 5 years
TT4 At least one year after TT3 99% 10 years
TT5 At least one year after TT4 99% 30 years

Issue(s):

Service statistics have the disadvantage that they may be incomplete or inaccurate (WHO, 1999a). They are also subject to a selection bias and are not representative of the general population, particularly when ANC coverage is low. However, they provide the only way of monitoring coverage on an annual basis and may be more reliable than self-reported data are.

Surveys provide the only means of obtaining population based coverage, but because surveys rely on selfreporting, they are subject to recall bias that is likely to increase with the length of the recall period.

Both approaches, however, underestimate the true extent of TT2+ coverage because both exclude doses of vaccine administered at times other than specified in the definition of the numerator even though the doses offer protection. For example, the doses for the childhood or mass-immunization campaign are omitted.

Births attended by skilled health personnel

Definition:

Percent of live births attended by skilled health personnel during a specified time period.

Numerator:

Number of births attended by skilled health personnel (doctors, nurses or midwives) trained in providing life-saving obstetric care, including giving the necessary supervision, care and advice to women during pregnancy, childbirth and the postpartum period, to conduct deliveries on their own, and to care for newborns.

Denominator:

The total number of live births in the same period.

Disaggregation:

Age, parity, place of residence, socioeconomic status, type of provider.

Data Requirements:

Definition of skilled birth attendant varies between countries. The percentage of births attended by skilled health personnel is calculated as the number of births attended by skilled health personnel (doctors, nurses or midwives) expressed as a percentage of the total number of births in the same period.

Births attended by skilled health personnel = (number of births attended by skilled health personnel)/(total number of live births) x 100.

In household surveys, such as DHS, MICS and RHS, the respondent is asked about each live birth and who helped during delivery for a period up to five years before the interview.

Service/facility records could be used where a high proportion of births occur in health facilities and are therefore recorded.

Data for global monitoring are reported by UNICEF and WHO. These agencies obtain the data − both survey and registry data – from national sources. Before data can be included in the global databases, UNICEF and WHO undertake a process of data verification that includes correspondence with field offices to clarify any questions.

In terms of survey data, some survey reports may present a total percentage of births attended by a type of provider that does not conform to the MDG definition (e.g. total includes providers who are not considered skilled, such as community health workers). In this case, the percentage delivered by a physician, nurse or midwife are totalled and entered into the global database as the MDG estimate.

Predominant type of statistics: adjusted.

See also: Percent of deliveries attended by skilled health personnelPercent of births in health facilities; and Percent of all births in EmOC facilities

Data Sources:

Household surveys

Routine facility information systems

Purpose:

This indicator serves as a proxy for access to health services and maternal care.

The indicator gives the percentage of live births attended by skilled health personnel in a given period. A skilled birth attendant is an accredited health professional—such as a midwife, doctor or nurse—who has been educated and trained to proficiency in the skills needed to manage normal (uncomplicated) pregnancies, childbirth and the immediate postnatal period, and in the identification, management and referral of women and newborns for complications. 

Traditional birth attendants, whether trained or not, are excluded from the category of ‘skilled attendant at delivery’.

Issue(s):

Differences in what definitions are used and in how skilled attendants are reported may lead to discrepancies. Most surveys such as the DHS rely on women’s self-report, but how women interpret the question on “who
assisted with delivery?” and whether they accurately identify the health staff attending the delivery is unknown. Major differences are also likely to exist in how providers are trained, in what providers are allowed to practice and do practice, and in what resources, equipment and supplies are at their disposal.

As this indicator uses a birth-based analysis, the sample will over-represent women with multiple births in the survey period. Women with more than one birth are also more likely to have risk factors, such as high parity and lower rates of health services use. Delivery coverage may therefore be underestimated, although this underestimate is likely to be small. Furthermore, the strong correlation between skilled attendant and institutional delivery makes assessing the impact of skilled attendant alone difficult to determine.

Evaluators can disaggregate skilled attendant at delivery by place of delivery to further document the degree of care received at the time of delivery. This measure of care or “skilled attendance” will vary by setting and attendant. A skilled attendant conducting a delivery in hospital, for example provides a higher level of “skilled attendance” than does a skilled attendant conducting a delivery at home.

References:

World Health Organization (WHO). 2015 Global Reference List of 100 Core Health Indicators.; 2015. http://apps.who.int/iris/bitstream/10665/173589/1/WHO_HIS_HSI_2015.3_eng.pdf

World Health Organization. Monitoring, Evaluation, and Review of National Health Strategies: A Country-Led Platform for Information and Accountability.; 2011. http://www.who.int/healthinfo/country_monitoring_evaluation/1085_IER_131011_web.pdf

World Health Organization. Nutrition Landscape Information System (NLIS). Country Profile Indicators: Interpretation Guide. Geneva, Switzerland; 2010. http://apps.who.int/iris/bitstream/10665/44397/1/9789241599955_eng.pdf

Gage AJ, Ali D, Suzuki C. A Guide for Monitoring and Evaluating Child Health Programs. MEASURE Evaluation. Carolina Population Center, University of North Carolina at Chapel Hill.; 2005. http://www.coregroup.org/storage/documents/Workingpapers/ms-05-15.pdf

 

Further information and related links

Countdown to 2015 decade report (2000−2010): taking stock of maternal, newborn and child survival. Geneva and New York (NY): World Health Organization/United Nations Children’s Fund; 2010 (Retrieved from http://www.countdown2015mnch.org/reports-and-articles/previous-reports/2010-decadereport).

Countdown to 2015. Monitoring maternal, newborn and child health: understanding key progress indicators. Geneva: World Health Organization; 2011 (Retrieved from http://apps.who.int/iris/bitstream/10665/44770/1/9789241502818_eng.pdf).

Every newborn: an action plan to end preventable deaths. Geneva: World Health Organization; 2014 (Retrieved from http://www.everynewborn.org/Documents/Full-action-plan-EN.pdf).

Framework of actions for the follow-up to the Programme of Action of the International Conference on Population and Development beyond 2014. Report of the Secretary-General. New York (NY): United Nations; 2014 (Retrieved from https://www.unfpa.org/webdav/site/global/shared/documents/ICPD/Framework%20of%20action%20for%20the%20follow-up%20to%20the%20PoA%20of%20the%20ICPD.pdf).

Indicators for monitoring the Millennium Development Goals: definitions, rationale, concepts and sources. New York (NY): United Nations; 2012 (Retrieved from http://mdgs.un.org/unsd/mi/wiki/MainPage.ashx).

Keeping promises, measuring results. Commission on information and accountability for Women’s and Children’s Health. Geneva: World Health Organization; 2011 (Retrieved from http://www.who.int/topics/millennium_development_goals/accountability_commission/Commission_Report_advance_copy.pdf).

Postpartum care coverage

Definition:

Percent of mothers and babies who received postpartum care within two days of childbirth (regardless of place of delivery).

Numerator:

Number of women and babies who received postpartum care within two days of childbirth.

Denominator:

Total number of women age 15−49 years with a live birth in the specified time period.

Disaggregation:

Age, facility ownership, marital status, parity, place of residence, socioeconomic status.

Data Requirements:

See also: Percent of women receiving postpartum care by a skilled health personnel within two days of childbirth; and Percent of newborns receiving a postnatal care check within two days of birth

Data Sources:

Population-based health surveys

Routine facility information systems/health facility assessments and surveys

Purpose:

This indicator serves as a proxy for access to health services, maternal and child healthcare.

References:

World Health Organization (WHO). 2015 Global Reference List of 100 Core Health Indicators.; 2015. http://apps.who.int/iris/bitstream/10665/173589/1/WHO_HIS_HSI_2015.3_eng.pdf

 

Further information and related links

Countdown to 2015 decade report (2000−2010): taking stock of maternal, newborn and child survival. Geneva and New York (NY): World Health Organization/United Nations Children’s Fund; 2010 (Retrieved from http://www.countdown2015mnch.org/reports-and-articles/previous-reports/2010-decadereport).

Countdown to 2015. Monitoring maternal, newborn and child health: understanding key progress indicators. Geneva: World Health Organization; 2011 (Retrieved from http://apps.who.int/iris/bitstream/10665/44770/1/9789241502818_eng.pdf).

Every newborn: an action plan to end preventable deaths. Geneva: World Health Organization; 2014 (Retrieved from http://www.everynewborn.org/Documents/Full-action-plan-EN.pdf).

Keeping promises, measuring results. Commission on information and accountability for Women’s and Children’s Health. Geneva: World Health Organization; 2011 (Retrieved from http://www.who.int/topics/millennium_development_goals/accountability_commission/Commission_Report_advance_copy.pdf).

Standard foreign assistance indicators/standard foreign assistance master indicator list (MIL). Washington (DC): United States Agency for International Development (Retrieved from http://www.state.gov/f/indicators/index.htm).

Prevention of mother-to-child transmission of HIV

Definition:

Percent of HIV-positive pregnant women provided with ART to reduce the risk of mother-to-child transmission during pregnancy.

Numerator:

Number of HIV-positive pregnant women who received ART as recommended by WHO.

Denominator:

Estimated number of HIV-positive pregnant women.

Disaggregation:

Already on ART; newly on ART or other regimen categories specific to the setting.

Data Requirements:

Numerator: national programme records aggregated from programme monitoring tools, such as patient registers and summary reporting forms.

Denominator: estimation models such as Spectrum or antenatal clinic surveillance surveys, in combination with demographic data and appropriate adjustments related to coverage of antenatal care surveys.

See also: Percent of all HIV positive pregnant women who received a complete course of ART prophylaxis; and Percent of HIV positive pregnant women who received appropriate treatment in labor, according to PMTCT recommendations

Data Sources:

Routine facility information systems

Purpose:

The risk of mother-to-child transmission can be significantly reduced through the complementary approaches of providing antiretrovirals (as treatment or as prophylaxis) for the mother and antiretroviral prophylaxis to the infant, implementation of safe delivery practices, and safer infant-feeding practices.

This indicator allows for monitoring of the coverage of antiretrovirals among HIV-infected pregnant women to reduce the risk of HIV transmission to the child.

When disaggregated, this indicator can monitor increased access to more efficacious ARV regimens for PMTCT in countries that are scaling up newer regimen categories.

Issue(s):

Because the indicator measures ARVs dispensed and not ARVs consumed, it is not possible to determine adherence to the complete ARV regimen or distinguish between different ARV regimens and between pre- and intra-partum components.

References:

World Health Organization (WHO). 2015 Global Reference List of 100 Core Health Indicators.; 2015. http://apps.who.int/iris/bitstream/10665/173589/1/WHO_HIS_HSI_2015.3_eng.pdf

World Health Organization. Monitoring, Evaluation, and Review of National Health Strategies: A Country-Led Platform for Information and Accountability.; 2011. http://www.who.int/healthinfo/country_monitoring_evaluation/1085_IER_131011_web.pdf

Pan American Health Organization (PAHO). Regional Initiative for the Elimination of Mother-to-Child Transmission of HIV and Congenital Syphilis in Latin America and the Caribbean. Washington, D.C.:; 2010. https://www.unicef.org/lac/Regional_Monitoring_Strategy.pdf

 

Further information and related links

Consolidated Strategic Information Guidelines for HIV in the Health Sector. Geneva: World Health Organization; 2015 (Retrieved from http://apps.who.int/iris/bitstream/10665/164716/1/9789241508759_eng.pdf?ua=1).

Countdown to 2015. Monitoring maternal, newborn and child health: understanding key progress indicators. Geneva: World Health Organization; 2011 (Retrieved from http://apps.who.int/iris/bitstream/10665/44770/1/9789241502818_eng.pdf).

Framework of actions for the follow-up to the Programme of Action of the International Conference on Population and Development beyond 2014. Report of the Secretary-General. New York (NY): United Nations; 2014 (Retrieved from https://www.unfpa.org/webdav/site/global/shared/documents/ICPD/Framework%20of%20action%20for%20the%20follow-up%20to%20the%20PoA%20of%20the%20ICPD.pdf).

Global AIDS response progress reporting 2014: construction of core indicators for monitoring the 2011 United Nations political declaration on HIV/AIDS. Geneva: Joint United Nations Programme on HIV/AIDS; 2014 (Retrieved from http://www.unaids.org/en/media/unaids/contentassets/documents/document/2014/GARPR_2014_guidelines_en.pdf).

Keeping promises, measuring results. Commission on information and accountability for Women’s and Children’s Health. Geneva: World Health Organization; 2011 (Retrieved from http://www.who.int/topics/millennium_development_goals/accountability_commission/Commission_Report_advance_copy.pdf).

Next generation indicators reference guide: planning and reporting. Version 1.2. Washington (DC): The President’s Emergency Plan for AIDS Relief; 2013 (Retrieved from http://www.pepfar.gov/documents/organization/206097.pdf).

Percent of infants of HIV-positive mothers receiving ARVs for PMTCT at birth

Definition:

The percentage of infants born to HIV-positive pregnant women in the last 12 months who were started on Cotrimoxizole (CTX) prophylaxis within two months of birth for preventing mother-to-child transmission (MTCT) of HIV.  Depending on the country and setting, antiretroviral (ARV) drugs can be given to HIV-exposed infants shortly after delivery, at facilities for labor and delivery, at outpatient postnatal care and child clinics for infants born at home and brought to the facility, or at HIV care and treatment and other sites (WHO/UNICEF/UNAIDS, 2011). For more background and guidelines on CTX pophylaxis, see WHO (2006) and for further details on calculation and interpretation of the indicator, see PEPFAR (2009); WHO/UNICEF/UNAIDS (2011); UNAIDS (2008); WHO et al., (2006).

Indicator is calculated as:

(Number of infants born to HIV-infected women during the past 12 months who received ARV prophylaxis within two months of birth to reduce MTCT / Estimated total number of live births to pregnant HIV-infected women in the past 12 months) x 100 

Data Requirements:

Data for the numerator can be aggregated from the appropriate facility registers, which can include integrated maternal and child health registers, registers on the follow-up of HIV-exposed infants or pre–ARV therapy registers (WHO et al., 2006). The register used may vary depending on the country context, for example, where HIV-exposed infants are followed up in the HIV care and treatment setting, countries may aggregate information either from a pre–ARV therapy register adapted for follow-up of HIV exposed infants or from a separate register for HIV-exposed infants. Infants covered by ARVs (either to the mother or infant) during the breastfeeding period who also received the postpartum 1-4 week prophylaxis should be counted only once, in the category for "postpartum breastfeeding period prophylaxis" (WHO/UNICEF/UNAIDS, 2011).

The denominator is generated by estimating the number of HIV-infected women who were pregnant in the last 12 months. This is based on HIV surveillance data from antenatal clinics, and estimates can be generated by: 1) using a projection model, such as Spectrum; or 2) by multiplying the total number of women who gave birth in the last 12 months × the most recent national estimate of HIV prevalence among pregnant women.  The total number of women who gave birth in the last 12 months can be obtained from estimates of births from central statistics offices or the estimates of the United Nations Population Division. The most recent national estimate of HIV prevalence among pregnant women can be derived from HIV sentinel surveillance data collected in antenatal clinics (PEPFAR, 2009). For additional information on estimates of HIV prevalence and the use of Spectrum refer to UNAIDS/WHO (2010). The indicator can be disaggregated by timing of postpartum intervention, type of regimen used, and type of health care or HIV service facility.

Data Sources:

For the numerator, program or facility records; For the denominator, antenatal care surveillance, surveys in combination with demographic data or estimation models such as Spectrum.

Purpose:

This indicator allows countries to monitor progress in the early follow-up of HIV-exposed infants by measuring provision of CTX in line with international guidelines (WHO, 2006). The risk for MTCT can be significantly reduced by the complementary approaches of providing ARV drugs (as treatment or as prophylaxis) for the mother with ARV prophylaxis for the infant and use of safe delivery practices and recommended infant feeding (WHO/UNICEF/UNAIDS, 2011). CTX prophylaxis is a simple and cost-effective intervention to prevent Pneumocystis jirovecipneumonia (PCP) among HIV-exposed and HIV-infected infants. PCP is the leading cause of serious respiratory disease among young HIV-infected infants in resource limited countries and often occurs before HIV infection can be diagnosed. Because diagnosing HIV infection among young infants is difficult, all infants born to women living with HIV should receive CTX prophylaxis starting at 4 to 6 weeks after birth and continuing until HIV infection has been excluded and the infant is no longer at risk of acquiring HIV through breastfeeding.

A low value of the indicator can signal whether exposed-infants are not attending facilities within 2 months (WHO/UNICEF/UNAIDS, 2011) or potential bottlenecks in the system, including poor management of CTX supplies in country, poor data collection, and inadequate distribution systems (PEPFAR, 2009). Countries may also wish to document provision of CTX for HIV-exposed infants older than 2 months as a way to monitor overall progress of the program, identify existing challenges with early initiation of CTX, and to monitor usage for procurement needs. Data can also be used as a proxy for the number of exposed infants who are seen at a facility within 2 months of birth. If disaggregated by regimen, this indicator can monitor increased access to more efficacious ARV regimens for reducing MTCT in countries that are scaling up newer regimen categories.

Issue(s):

The indicator captures only those infants who are brought in for HIV-exposed infant follow-up services within two months of birth. It does not measure actual coverage of CTX prophylaxis for HIV-exposed infants as some infants may have been started on treatment after 2 months (PEPFAR, 2009). Inappropriate management of supplies can negatively affect the value of the indicator and significantly reduce access to CTX for HIV-exposed infants. Countries should ensure appropriate systems and tools, particularly tools for a logistics management and information system (LMIS, USAID/DELIVER, 2009), are in place to adequately procure, distribute, and manage supplies at facility, district and central levels. There is a risk of double-counting when antiretroviral drugs are provided during more than one visit or at different health facilities. Countries should establish data collection and reporting systems to minimize double-counting (WHO/UNICEF/UNAIDS, 2011).

References:

PEPFAR, 2009, The President’s Emergency Plan for AIDS Relief: Next Generation Indicators Reference Guide, Washington, DC: USAID/PEPFAR. http://www.pepfar.gov/documents/organization/81097.pdf

UNAIDS, 2010, Prevention of Mother-To-Child Transmission of HIV (PMTCT): Technical Guidance Note for Global Fund HIV Proposals, Geneva: UNAIDS.
http://www.who.int/hiv/pub/toolkits/PMTCT_Technical_guidance_GlobalFundR10_May2010.pdf

UNAIDS, 2008, Core Indicators for National AIDS Programmes: Guidance and Specifications for Additional Recommended Indicators, Geneva: UNAIDS http://data.unaids.org/pub/BaseDocument/2009/20090305_additionalrecommendedindicators_finalprintversio_en.pdf

USAID/DELIVER, 2009, Turning The Digital Corner: Essential Questions For Planning For A Computerized Logistics Management Information System, Washington, D.C.: USAID. http://deliver.jsi.com/dlvr_content/resources/allpubs/guidelines/Turn_Digi_Corn.pdf

WHO, 2009, New WHO recommendations: Preventing Mother-to-Child Transmission, Geneva: WHO. http://www.who.int/hiv/pub/mtct/mtct_key_mess.pdf

WHO/UNICEF/UNAIDS, 2011, A Guide on Indicators for Monitoring and Reporting on the Health Sector Response to HIV/AIDS. Geneva: WHO.
http://www.who.int/hiv/data/UA2011_indicator_guide_en.pdf

WHO, UNAIDS, The Global Fund, CDC, USAID, UNICEF, MEASURE Evaluation, US Dept. of State: OGAC, 2006, Monitoring and Evaluation Toolkit: HIV/AIDS, Tuberculosis, and Malaria, Geneva: WHO.
http://www.theglobalfund.org/documents/me/M_E_Toolkit_P2-HIV_en.pdf

WHO, 2006, Guidelines on co-trimoxazole prophylaxis for HIV-related infections among children, adolescents and adults: Recommendations for a public health approach. Geneva, World Health Organization, http://www.who.int/hiv/pub/guidelines/ctxguidelines.pdf

Early infant testing coverage

Definition:

Percent of HIV-exposed infants born within the last 12 months who received an HIV test within 2 months of birth

Numerator:

Number of infants who received virological testing in the first 2 months of life.

Infants should be counted only once. The numerator should include the initial test but not any subsequent tests. In addition, infants lost to follow-up by 12 months should be reported.

Denominator:

Estimated number of HIV-infected pregnant women giving birth in the preceding 12 months.

This is a proxy measure for the number of infants born to HIV-infected women.

Disaggregation:

Test result.

Efforts should be made to include all public, private, and NGO-run health facilities that provide HIV testing for HIV-exposed infants.

Countries should also collect and evaluate data on the number of infants not assessed as a result of loss to follow-up, by 12 months, including deaths.

Data Requirements:

The numerator is calculated from national program records compiled from data collected in registers at facilities. The number of infants tested, rather than the number of tests performed, should be counted, since many infants may be tested multiple times.

Data Sources:

Facility records

Purpose:

Infants infected with HIV during pregnancy, delivery, or early postpartum often die before they are recognized as having HIV infection. PAHO/WHO recommends that national programs be created to establish the capacity to provide early virological testing of infants for HIV and guide clinical decision making at the earliest possible stage. In instances in which virological testing is not available, initial antibody testing at 9 to 12 months is recommended to identify negative cases.

This indicator allows countries to monitor progress in providing early HIV testing to HIV-exposed infants, a critical tool for appropriate follow-up care and treatment.

A low value of this indicator could signal health system weaknesses, including poor country-level management of supplies of HIV test kits, poor data collection, and mismanagement of testing samples.

Issue(s):

Ideally, the indicator captures infants born to known HIV-infected women, but it may not be feasible in some settings to exclude infants tested for HIV using virological or antibody testing through provider-initiated testing in pediatric wards, malnutrition centers, and other sites where infants may be identified as exposed to or infected with HIV.

References:

World Health Organization (WHO). 2015 Global Reference List of 100 Core Health Indicators.; 2015. http://apps.who.int/iris/bitstream/10665/173589/1/WHO_HIS_HSI_2015.3_eng.pdf

Pan American Health Organization (PAHO). Regional Initiative for the Elimination of Mother-to-Child Transmission of HIV and Congenital Syphilis in Latin America and the Caribbean. Washington, D.C.:; 2010. https://www.unicef.org/lac/Regional_Monitoring_Strategy.pdf

Percent of girls vaccinated with 3 doses of HPV vaccine by age 15 years

Definition:

The percent of 15 year old girls in target population who have completed the full three dose vaccination schedule for the human papillomavirus (HPV).

This indicator is calculated as:

(Number of girls aged 15 in target population who have received three doses of the HPV vaccine / Total number of 15 year old girls in target population) x 100

 

Depending on the type of HPV vaccine, WHO recommends vaccinating girls as early as 9 or 10 years old. The key point is that the girl receives all three doses before she becomes exposed to HVP through sexual contact.  Although this can occur before 15 years of age, this is the most commonly used lower age limit for when girls typically become sexually active.

Only girls who have completed all three doses of the HPV vaccines should be counted in this indicator.

Data Requirements:

Total number of girls in target population; age of girl; response to survey questions on HPV vaccination; vaccine program service statistics

Data Sources:

Population-based surveys; service statistics; vaccine registers

Purpose:

In 2010 alone, approximately 200,000 women died from cervical cancer with the majority of these deaths having occurred in low-income countries, where HPV vaccinations and comprehensive cervical cancer screening programs are lacking (IHME, 2011). Nearly all cervical cancer cases are linked to HPV which is the most common sexually transmitted infection (WHO, 2006). The bivalent vaccine, which protects against HPV types 16 and 18, and the quadrivalent vaccine, which protects against HPV types 6, 11, 16, and 18 - the most common cancer-causing strains of HPV - have both been proven to be safe and effective in preventing cervical cancer, with the quadrivalent vaccine also effective in preventing genital warts in women and men.

HPV is highly transmissible through sexual contact, so vaccinating girls before sexual activity is initiated is a key strategy to prevent cervical cancer. The peak of HPV incidence occurs between the ages of 16 and 20 years old (GAVI 2007).

Although addressing cervical cancer is still in the initial stage in developing countries due to lack of resources for prevention, screening, and treatment, the HPV vaccine is slowly being added to national immunization programs. This indicator can be used to track the impact of comprehensive HPV and cervical cancer prevention programs and marketing campaigns aimed at increasing the use and coverage of the vaccine in girls under 15 years of age.

Issue(s):

Based on a pilot program in Uganda, PATH found it challenging to identify eligible girls based on their age. Selecting girls based on grade/class in school was more feasible, but presented challenges for age focused reporting and evaluation (PATH, 2011).

If this data is being collected through population-based surveys, girls may not know if they have received the full three doses for HPV, nor may they recall if it was an HPV vaccine they received.

Service statistics have the disadvantage that they may be incomplete or inaccurate (WHO, 1999). They are also subject to a selection bias and are not representative of the general population. However, they provide the only way of monitoring coverage on an annual basis and may be more reliable than self-reported data.

Gender Implications:

School-based immunization programs have had some success with achieving widespread vaccination coverage. However in many parts of the world, girls from poorer households are more likely to no longer be in school by the time they reach early adolescence (Kane, 2006). It is common in many parts of Africa for girls to stay home when they are menstruating.  In both cases, young women will be at a disadvantage for getting fully or even partially vaccinated against the HPV vaccine.

Because HPV is a sexually transmitted virus, more conservative countries have shown some resistance to vaccinating young girls, saying that giving the vaccination will give them permission for sexual promiscuity or that it is unnecessary since sexual activity is "not supposed to" take place outside of marriage. In other cases, the myth that the HPV vaccine is designed to sterilize young women has also been cited (Kane, 2006).

References:

Agosti JM, Goldie SJ (2007). Introducing HPV vaccine in developing countries–key challenges and issues. N Engl J Med 356:1908–1910.

Institute for Health Metrics and Evaluation (IHME). The Challenge Ahead: Progress and setbacks in breast and cervical cancer. Seattle, WA: IHME, 2011. http://www.healthmetricsandevaluation.org/sites/default/files/policy_report/2011/The_Challenge_Ahead_IHME_Policy_Report_0911.pdf

GAVI Alliance. HPV (Human papillomavirus) Fact Sheet. GAVI alliance in collaboration with PATH.

Kane, M.A., Sherris, J., Coursaget, P., Aguado, T. and Cutts, F. (2006). Chapter 15: HPV vaccine use in the developing world. Vaccine, 24 (Suppl. 3), S132–S139.

PATH. HPV Vaccination in Africa Lessons Learned From a Pilot Program in Uganda. January 2011. http://www.rho.org/files/PATH_HPV_lessons_learned_Uganda_2011.pdf

WHO Position Paper: Weekly epidemiological record. p. 118-132 April 2009.   http://www.rho.org/files/WHO_WER_HPV_vaccine_position_paper_2009.pdf   

WHO, 2006.  Preparing for the Introduction of HPV vaccines: policy and programme guidance for countries.

Immunization coverage rate by vaccine for each vaccine in the national schedule

Definition:

Percent of the target population that has received the last recommended dose for each vaccine recommended in the national schedule by vaccine. This should include all vaccines within a country’s routine immunization schedule (e.g., Bacillus Calmette–Guérin (BCG); polio; pneumococcal conjugate vaccine (PCV); rotavirus; diphtheria, tetanus, pertussis-Hepatitis B-Haemophilus influenzae type B vaccine (DTP-HepBHib); measles (MCV); rubella; human papilloma virus (HPV); tetanus toxoid (TT); influenza; and others as determined by the national schedule).

Numerator:

The number of individuals in the target group for each vaccine that has received the last recommended dose in the series. For vaccines in the infant immunization schedule, this would be the number of children aged 12–23 months who have received the specified vaccinations before their first birthday.

Denominator:

The total number of individuals in the target group for each vaccine. For vaccines in the infant immunization schedule, this would be the total number of infants surviving to age one.

Disaggregation:

Age, place of residence, sex, socioeconomic status.

DTP1-DTP3 dropout rate, MCV1-MCV2 dropout, full immunization coverage where possible.

Data Requirements:

Example of a national schedule is:

For survey data, the vaccination status of children aged 12–23 months is used for vaccines included in the infant immunization schedule, collected from child health cards or, if there is no card, from recall by the care-taker.

Data Sources:

Household surveys

Facility information systems

Purpose:

Child immunization is one of the most cost-effective public health interventions for reducing child morbidity and mortality. The ultimate goal of immunization programs is to reduce the incidence of vaccine-preventable diseases in children by attaining high levels of coverage with potent vaccines administered at the appropriate ages (and recommended intervals between doses for multiple dose vaccines).

Estimates of vaccination coverage among children are used to monitor vaccination services, to guide disease eradication and elimination programmes and as indicators of health system performance.

Issue(s):

Immunization coverage rates are usually based on routine data derived from tally sheets that are filled out at the health facility level. Coverage
rates can vary greatly by source of data. Users have to be aware, therefore, of the strengths and limitations of each data source in order to make sense of any data.

The indicator is only a measure of completion of the recommended immunization schedule, and does not measure protection. The impact of immunization on disease is dependent on the timing and number of doses received, as well as the efficacy of vaccine. The indicator does not reflect whether vaccines are given at the recommended ages or at the recommended minimum interval of four weeks between consecutive doses of DTP and OPV (and HEPB and Hib, if included in national definitions).

Information can usually be derived from population-based surveys. Surveys are expensive and done infrequently; so this indicator can only be estimated every 3-5 years (though in some countries, such as Bangladesh, it is estimated every two years). The absence of vaccination cards limits the reliability of this indicator. Care should be taken when designing cluster surveys to ensure representation and to avoid selection bias by following the protocol.

References:

World Health Organization (WHO). 2015 Global Reference List of 100 Core Health Indicators.; 2015. http://apps.who.int/iris/bitstream/10665/173589/1/WHO_HIS_HSI_2015.3_eng.pdf

World Health Organization. Nutrition Landscape Information System (NLIS). Country Profile Indicators: Interpretation Guide. Geneva, Switzerland; 2010. http://apps.who.int/iris/bitstream/10665/44397/1/9789241599955_eng.pdf

Gage AJ, Ali D, Suzuki C. A Guide for Monitoring and Evaluating Child Health Programs. MEASURE Evaluation. Carolina Population Center, University of North Carolina at Chapel Hill.; 2005. http://www.coregroup.org/storage/documents/Workingpapers/ms-05-15.pdf

 

Further information and related links

Countdown to 2015. Monitoring maternal, newborn and child health: understanding key progress indicators. Geneva: World Health Organization; 2011 (Retrieved from http://apps.who.int/iris/bitstream/10665/44770/1/9789241502818_eng.pdf).

Vitamin A supplementation coverage

Definition:

Percent of children aged 6–59 months who received two age-appropriate doses of vitamin A in the past 12 months.

Numerator:

Number of children who received two age-appropriate doses of vitamin A supplements in the last 12 months.

Denominator:

Number of children aged 6−59 months in the survey.

Disaggregation:

Age, place of residence, sex, socioeconomic status.

Data Requirements:

In accordance with WHO’s 2011 guidelines on vitamin A supplementation in infants and children aged 6–59 months.

Data Sources:

Household surveys

Routine facility information systems

Purpose:

The indicator is defined as the proportion of children aged 6–59 months who received two age-appropriate doses of vitamin A supplements in the last 12 months. This indicator measures the coverage achieved through national vitamin A supplementation program efforts in a specified period.

Vitamin A deficiency (VAD) is a major public health problem in developing countries. WHO estimates that between 100 and 140 million children are vitamin A deficient. For children, lack of vitamin A causes visual impairment, blindness, and significantly increases the risk of severe illness and death from common childhood infections such as diarrheal disease and measles. Supplementation as a vitamin A deficiency control strategy is the most immediate and direct approach to improving vitamin A status and the one most widely implemented.

Programmes to control vitamin A deficiency enhance children’s chances of survival, reduce the severity of childhood illnesses, ease the strain on health systems and hospitals and contribute to the well-being of children, their families and communities. Supplementation with vitamin A is a safe, cost-effective, efficient means for eliminating its deficiency and improving child survival.

Issue(s):

This indicator is a coverage indicator and does not provide any information regarding the prevalence of vitamin A deficiency (as manifested by night blindness, bitot spots, and corneal scarring). Although oral supplementation is used for both treatment and prevention of vitamin A deficiency, it is not recommended as the only longterm approach. In the home, vitamin A deficiency can be prevented by the regular consumption of vitamin A-rich foods, including fortified foods.

Service statistics are relatively inexpensive to collect and can be obtained at more frequent intervals than surveys. However, they are generally not representative of an entire population. Since the quality of health statistics can vary among facilities, indicators calculated from service statistics may be less accurate than those based on survey data in places where the quality of routine data is poor. In addition, it may be difficult to estimate the denominator for indicators based on service statistics. The population denominators are often extrapolated from census data that are several years old. If population growth and rural-urban migration patterns have substantially changed over time, then census information may be unsuitable for providing appropriate denominators for local program managers to determine vitamin A supplementation coverage.

References:

World Health Organization (WHO). 2015 Global Reference List of 100 Core Health Indicators.; 2015. http://apps.who.int/iris/bitstream/10665/173589/1/WHO_HIS_HSI_2015.3_eng.pdf

World Health Organization. Nutrition Landscape Information System (NLIS). Country Profile Indicators: Interpretation Guide. Geneva, Switzerland; 2010. http://apps.who.int/iris/bitstream/10665/44397/1/9789241599955_eng.pdf

Gage AJ, Ali D, Suzuki C. A Guide for Monitoring and Evaluating Child Health Programs. MEASURE Evaluation. Carolina Population Center, University of North Carolina at Chapel Hill.; 2005.  http://www.coregroup.org/storage/documents/Workingpapers/ms-05-15.pdf

 

Further information and related links

Countdown to 2015 decade report (2000−2010): taking stock of maternal, newborn and child survival. Geneva and New York (NY): World Health Organization/United Nations Children’s Fund; 2010 (Retrieved from http://www.countdown2015mnch.org/reports-and-articles/previous-reports/2010-decadereport).

Ending preventable child deaths from pneumonia and diarrhoea by 2025. The integrated Global Action Plan for Pneumonia and Diarrhoea (GAPPD). Geneva: World Health Organization/United Nations Children’s Fund; 2013 (Retrieved from http://apps.who.int/iris/bitstream/10665/79200/1/9789241505239_eng.pdf?ua=1).

Guideline: Vitamin A supplementation in infants and children 6–59 months of age. Geneva: World Health Organization; 2011 (Retrieved from http://apps.who.int/iris/bitstream/10665/44664/1/9789241501767_eng.pdf?ua=1&ua=1).

Standard foreign assistance indicators/standard foreign assistance master indicator list (MIL). Washington (DC): United States Agency for International Development (Retrieved from http://www.state.gov/f/indicators/index.htm).

World health statistics 2014. Geneva: World Health Organization; 2014 (Retrieved from http://apps.who.int/iris/bitstream/10665/112738/1/9789240692671_eng.pdf?ua=1)

Percent of eligible children in growth monitoring / promotion (MP)

Definition:

Percent of eligible children in growth monitoring/promotion (MP).

Numerator:

The number of children in growth monitoring/promotion.

Denominator:

The number of eligible children in the population.

Disaggregation:

Sex and age.

Data Requirements:

The classification of “in growth monitoring/promotion” is meant to reflect the total number of children whose weight has been monitored in clinic- and/or village-based activities. This number may be the total number of children weighed in the ‘round’ immediately before the reporting period, or it may be an estimate of the ‘usual’ total number of children attending weighing activities over the reporting period.

How the numerator is derived is not necessarily important, but it is most important to report clearly how the estimate was made. Because attendance at GMP programs varies widely with age, this number will be more meaningful if it is age specific - e.g., <12 months, 12-<24 months, 24-<60 months (ages reported will be influenced by the target age group of the project).

Usually the most reliable estimates of the denominator (i.e. number of eligible children in the population, by gender and age), will be those the project has gathered as part of its baseline survey, or other data collection activities.

Data Sources:

Routine facility information systems

Household surveys

Purpose:

This indicator supports program management by providing information on coverage,
and targeting, and may provide a useful basis for supervision of field staff. The indicator also provides information on context, or some explanation, in the reporting of anthropometric impact indicators; and provides an indication of patterns of, or trends in, service delivery and use. It thus has potential to demonstrate successes of efforts to achieve specified project results

Issue(s):

The indicator does not inform on the consequences or actions taken to support children participating in growth monitoring and promotion activities who are found to be underweight (or overweight).

References:

Cogill, Bruce. Anthropometric Indicators Measurement Guide. Food and Nutrition Technical Assistance Project, Academy for Educational Development, Washington DC, 2001. ftp://www.ufv.br/dns/sylvia/anthro.pdf

Sick child's weight checked against a growth chart

Definition:

Percent of sick children aged 2-59 months who are weighed the day they are seen and whose weights are checked against a recommended growth chart.

Numerator:

Number of sick children aged 2-59 months who are weighed the day they are seen and whose weights are checked against a recommended growth chart.

Denominator:

Total number of sick children aged 2-59 months seen.

Data Requirements:

The data are gathered by direct observation of sick child consultation. The observer records whether the health worker weighed the child and plotted the child’s weight on a recommended growth chart (usually a standard WHO or national growth chart).

Data Sources:

SPA (service provision assessment)

HFA (health facility assessment)

Supervision checklist

Purpose:

This indicator measures health worker compliance with Integrated Management of Childhood Illness (IMCI) guidelines for the routine assessment of the nutritional status of sick children by weighing the child and plotting the weight on a recommended growth chart.

There are two main reasons for this assessment. The first is to identify children with severe malnutrition who are at increased risk of mortality and need urgent referral. Second, an assessment of the nutritional status of sick children helps to identify children with low weight-for-age who may benefit from nutritional counseling. All sick children should be assessed for malnutrition.

Data for this indicator are easy to collect during sick child observation or routine supervisory visits. They give a good indication of health worker compliance with IMCI guidelines regarding the nutritional assessment of all sick children. The indicator can be applied at a specific interval post-training to those who attended IMCI training to evaluate the retention of this particular component of clinical assessment skills. This may help identify health workers who need refresher training or health centers in which weighing of sick children and recording the weight on a growth chart are not enforced.

Issue(s):

Limitations to the use of observation for measuring quality of sick child assessment include “observation bias,” in that a health worker may abide to the guidelines more strictly when he or she is conscious of being monitored. Another limitation of the indicator pertains to variability between observers in measurement. This is hard to measure but can be assessed by having two independent observers rate a sick child consultation and then comparing the degree of agreement or disagreement in their ratings.

Note that the indicator does NOT reflect the correct measurement of the child’s weight, whether the child’s weight was accurately plotted on a growth chart, how effectively health workers interpret the information on the growth chart, or whether the health worker took an appropriate course of action based on insights from the growth chart. It is also difficult to tell from the indicator whether health workers are weighing/not weighing the children at all, or whether children are weighed but their weights are not plotted on a growth chart.

References:

Gage, Anastasia J., Disha Ali, and Chiho Suzuki. (2005). A Guide for Monitoring and Evaluating Child Health Programs. MEASURE Evaluation. Carolina Population Center, University of North Carolina at Chapel Hill. http://www.coregroup.org/storage/documents/Workingpapers/ms-05-15.pdf

Children with diarrhoea receiving oral rehydration solution (ORS)

Definition:

Percent of children under 5 years of age with diarrhoea in the last two weeks receiving oral rehydration salts (ORS) (i.e. fluids made from ORS packets or pre-packaged ORS fluids).

Numerator:

Number of children under 5 years of age with diarrhoea in the two weeks preceding the survey given fluid from ORS packets or pre-packaged ORS fluids.

Denominator:

Number of children with diarrhoea in the two weeks preceding the survey.

Disaggregation:

Place of residence, sex, age, socioeconomic status.

Data Requirements:

According to the DHS, the term(s) used for diarrhoea should encompass the expressions used for all forms of diarrhoea, including bloody stools (consistent with dysentery), watery stools, etc. The term encompasses the mother’s definition as well as locally-used term(s).

Data Sources:

Household surveys

Routine facility information systems

Purpose:

This indicator describes the proportion of children aged 0–59 months who had diarrhoea and were treated with oral rehydration salts or an appropriate household solution and continued feeding. The terms used for diarrhoea should cover the expressions used for all forms of diarrhoea, including bloody stools (consistent with dysentery) and watery stools, and should encompasses mothers' definitions as well as local terms.

Diarrhoeal diseases remain one of the principal cause of morbidity and mortality among children under 5 years of age in developing countries. Diarrhea-related deaths are most commonly caused by dehydration produced by acute watery diarrhea and acute dehydration. As oral rehydration therapy is a critical component of effective management of diarrhoea, monitoring coverage with this highly cost–effective intervention indicates progress towards improving child survival. 

Issue(s):

This indicator is easy to measure. It assumes caretaker and community awareness of ORT. The use of a two-week reference period to ascertain
the occurrence and treatment of diarrhea decreases problems of recall. However, the indicator does not capture timely treatment of diarrhea, that is, whether ORT was provided as soon as the episode of diarrhea started. The indicator also does not measure whether ORT was prepared appropriately (electrolyte concentration in the case of ORS) or whether it was administered correctly (in sufficient volume) to prevent dehydration. It also does not take into account the severity of illness.

References:

World Health Organization (WHO). 2015 Global Reference List of 100 Core Health Indicators.; 2015. http://apps.who.int/iris/bitstream/10665/173589/1/WHO_HIS_HSI_2015.3_eng.pdf

World Health Organization. Monitoring, Evaluation, and Review of National Health Strategies: A Country-Led Platform for Information and Accountability.; 2011. http://www.who.int/healthinfo/country_monitoring_evaluation/1085_IER_131011_web.pdf

World Health Organization. Nutrition Landscape Information System (NLIS). Country Profile Indicators: Interpretation Guide. Geneva, Switzerland; 2010. http://apps.who.int/iris/bitstream/10665/44397/1/9789241599955_eng.pdf

Gage AJ, Ali D, Suzuki C. A Guide for Monitoring and Evaluating Child Health Programs. MEASURE Evaluation. Carolina Population Center, University of North Carolina at Chapel Hill.; 2005. http://www.coregroup.org/storage/documents/Workingpapers/ms-05-15.pdf

 

Further information and related links

Ending preventable child deaths from pneumonia and diarrhoea by 2025. The integrated Global Action Plan for Pneumonia and Diarrhoea (GAPPD). Geneva: World Health Organization/United Nations Children’s Fund; 2013 (Retrieved from http://apps.who.int/iris/bitstream/10665/79200/1/9789241505239_eng.pdf?ua=1).

Standard foreign assistance indicators/standard foreign assistance master indicator list (MIL). Washington (DC): United States Agency for International Development (Retrieved from http://www.state.gov/f/indicators/index.htm).

World health statistics 2014. Geneva: World Health Organization; 2014 (Retrieved from http://apps.who.int/iris/bitstream/10665/112738/1/9789240692671_eng.pdf?ua=1).

Pneumonia treatment (children)

Definition:

Percent of children ages 0-59 months who are correctly prescribed an antibiotic for pneumonia.

Numerator:

Number of children ages 0-59 months with valid classification who are correctly prescribed an antibiotic for pneumonia (including doses, number of times per day and number of days).

Denominator:

Total number of children ages 0-59 months with diagnosed pneumonia.

Disaggregation:

Place of residence, provider, sex, age, socioeconomic status.

Data Requirements:

Patient records, registers and direct observation.

Data Sources:

Presently collected in health facility surveys, hospital quality assessment tool.

Purpose:

This indicator assesses the ability of the health worker to provide correct treatment, given correct identification of common childhood diseases.

The indicator is a composite measure and is restricted to children with validated classifications. The data are collected through direct observation of sick child consultations during a health facility survey or routine supervisory visits.

The validator classification using the IMCI standard protocol is considered to be the gold standard and as close to the actual diagnosis as is possible to get in the outpatient setting.

Issue(s):

One of the limitations of this indicator is that it is not straightforward to calculate. It addresses multiple dimensions of the quality of sick child assessment and has many components. First, the health worker must prescribe each drug correctly in terms of all three of the following elements: how many tablets
or capsules or spoonfuls to take each time; how many times a day to give the medication; and how many days to continue treatment. The age or weight of the child should also be considered in determining the correct dose of antibiotic. If a
child has multiple classifications, each classification and prescribed treatment should be considered in the calculations.

Given the number of components that are included in the calculations, it would be difficult to interpret change in the indicator. The indicator requires that all required screening and assessment tasks have been performed correctly and, therefore, may not demonstrate change until these other preliminary tasks have been mastered. Second, correct
classification may not be possible if the health worker does not have some item of essential equipment, such as a timing device for counting respiratory rate or a scale for measuring weight.

References:

World Health Organization (WHO). Consultation on Improving Measurement of the Quality of Maternal, Newborn and Child Care in Health Facilities.; 2013. http://apps.who.int/iris/bitstream/10665/128206/1/9789241507417_eng.pdf

World Health Organization (WHO). 2015 Global Reference List of 100 Core Health Indicators.; 2015. http://apps.who.int/iris/bitstream/10665/173589/1/WHO_HIS_HSI_2015.3_eng.pdf

World Health Organization. Monitoring, Evaluation, and Review of National Health Strategies: A Country-Led Platform for Information and Accountability.; 2011. http://www.who.int/healthinfo/country_monitoring_evaluation/1085_IER_131011_web.pdf

Gage AJ, Ali D, Suzuki C. A Guide for Monitoring and Evaluating Child Health Programs. MEASURE Evaluation. Carolina Population Center, University of North Carolina at Chapel Hill.; 2005. http://www.coregroup.org/storage/documents/Workingpapers/ms-05-15.pdf