and monitoring of both health status and service delivery involve defining
measureable programme objectives (what the programme will strive
to achieve) and using indicators to measure progress toward achieving
those objectives. An indicator is a measurement that, when compared
to either a standard or the desired level of achievement, provides information
regarding a health outcome or a management process. Indicators are measurements
that can be repeated over time to track progress toward achievement
Manual, we use a simple framework for objectives and indicators.
target changes in morbidity and mortality expected to result from programme
target changes in knowledge attitudes, behaviours, or in availability
of needed services or commodities that result from programme activities.
They relate directly to the priority intervention(e.g., HIV/STD prevention,
child spacing), the target population (e.g., women of reproductive age),
or those charged with caring for the target population (such as health
care workers and family members.
specify the actions needed for programme implementation, and correspond
to various activities (such as training, supply of drugs and equipment
and health education) necessary to achieve the intended outcomes and
this chapter presents mainly core impact and outcome activities. Managers
can develop additional items for (especially process objectives) according
to the populations, available resources, and working environments.
of indicators is presented at the end of each chapter and the complete
list of suggested indicators is presented at the end of this chapter.
The RH Coordinator should select one or more indicators based on programme
objectives. Before the indicator can be calculated, data will have to
be collected for the numerator and denominator. Standard measures should
be used when possible for comparison purposes, such as expressing some
rates per 1,000 population. In some refugee settings, preliminary objectives
may have to focus on setting up a system to collect information on births
and neonatal deaths, for example, before the indicator neonatal mortality
rate can be calculated. Once the neonatal mortality rate is calculated,
this indicator can be followed monthly or for some specified time period,
in order to monitor outcomes from the safe motherhood programme.
is an example of the evaluation framework:
of community health workers trained to recognise and refer obstetric
of women with
obstetric emergencies are
in a timely manner and their complications managed appropriately
and neonatal mortality and morbidity reduced by ____%, in ____year
of health workers able to recognise and refer obstetric complications
of women with obstetric emergencies who received appropriate management
of neonatal mortality by ____%,
Eight-Step Approach to Surveillance and monitoring
Collect Basic Demographic Data
the following RH-related data as soon as possible.
population by age and sex
and sex specific mortality rates
of women/men of reproductive age
of pregnant women
of lactating women
to using information provided by refugee workers, estimates might be
made using registrations, or through community-based surveys (mortality,
nutritional or household). Information from the country of origin of
the refugees should also be obtained and used as estimates (For example,
the Crude Birth Rate in the country of origin).
a System of Simple and Essential Data Collection
programme design and implementation, programme planners should have
established measurable objectives. Based on these objectives, determine
which indicators will be used and what information is needed to calculate
the indicators, and establish case definitions (such as those for live
births and stillbirths) so that indicator measurements are clear. Next,
determine the logical data flow, including time periods and reporting
schedule. Identify people responsible for data collection, including
refugees (see step 3 below). Finally, incorporate into the routine programme/camp
health-information forms, the data needed to calculate the RH indicators.
(See sample worksheet for RH reporting -
sources of data are:
birth or delivery reports. At minimum, the reports must include age
of the mother, place of delivery, mode of delivery (vaginal, caesaerean
section), sex, birth outcome (live, stillbirth), and birth weight.
If over- or under-reporting is suspected, cross check the information
with the estimated number of pregnant women or with the agency responsible
for distributing rations.
log books or registries for antenatal care, referrals, family planning,
and STD syndromic case management as part of the out-patient log book.
Women seeking care for the complications of unsafe or spontaneous
abortion should also be tracked through clinic and hospital-based
facility records, community reporting, cemetery records and referral
facilities records outside the refugee situation. These should be
used to track maternal and neonatal deaths.
of data include community surveys, case investigations, laboratory reports
and community outreach-worker reporting.
and Train Workers from the refugee Community for Data Collection
identifying those refugees with midwifery skills and/or trained birth
attendants (TBAs), including those already providing services, who can
be trained to collect data. Otherwise, community members will have to
be recruited. Organise these workers (by geographical sector, for example)
and have them report to a key person and place. Organising them this
way will help gain access to and knowledge about the pregnant and lactating
women in the population and provide a communication system to help refer
women with serious complications related to pregnancy, delivery, the
post-partum period or spontaneous or unsafe abortion. Conduct training
on the objectives and flow of data collection, case definitions, completion
and timely submission of collection forms, and on the use of the data
to improve programmes.
Specific Reporting Procedures
has shown that several specific areas of RH monitoring and surveillance
have not been routinely conducted in refugee situations. These include
investigations of each maternal death and reporting on cases of sexual
Investigating the cause of maternal deaths can help identify gaps in
services and the need to improve referral procedures for obstetric complications.
By reviewing cases, health care providers can strengthen their skills
in identifying early warning signs of obstetric emergencies. Camp staff
should investigate deaths due to pregnancy (direct maternal mortality)
and deaths of pregnant women caused by the effects of pregnancy on pre-existing
conditions (indirect maternal mortality).
of information are essential, since direct mortality is often underestimated.
The goal is to determine which deaths were caused by pregnancy or childbirth,
or by complications or the management thereof, and how deaths can be
prevented in the future.
to be investigated include:
of onset of life-threatening illness;
of recognition of the problem and time of death;
to care, or logistics of referral; and
of medical care until death.
may come from grave watcher, hospital/health post staff or from community
reports. Verbal autopsy, which has been used in certain refugee situations,
has proved relatively successful when medical records are unavailable.
The person responsible for addressing sexual violence can devise an
appropriate tracking system, in collaboration with camp authorities
and health care workers. Survivors of sexual violence may be seen in
health facilities or or reported by TBAs, community workers or other
key informants. Since sexual violence is sensitive and usually under-reported,
note all reported cases or suspected cases. Confidentiality of survivors
must be ensured.
the data to address the problems raised by the programme objectives.
rates, ratios and proportions, and prepare tables, graphs and charts.
these rates with expected values or reference rates. Trends are more
important than point estimates.
the most important health problems as judged by cause-specific morbidity
the subgroups at highest risk for health problems by person, place
and time (such as by age and sex).
the factors potentially responsible for morbidity and mortality. For
example, a high number of reported cases of genital ulcer disease
among adolescent women could indicate a need to target them forsyphilis
prevention and treatment.
data analysis with service providers and the community.
6. Implement Programmes Based on the Analysis
the data to develop feasible, effective and efficient strategies for
achieving the programme objectives.
the selected strategies and a system to monitor their progress.
7. Assess Programme Progress
programme progress by confirming whether programme objectives have been
and distribute summary reports to all interested persons, agencies and
host-country authorities, as indicated.
programme objectives, indicators and interventions. Indicators can be
evaluated in terms of their accuracy, completeness, relevance and timeliness.
Assessment Capability and Surveillance Systems According to Need
incidences change, the situation stabilises and service provision becomes
more comprehensive, the surveillance system may need to be adapted.
The system may need to be expanded to include more conditions in the
list of reportable illnesses. Programmes can add or change indicators,
or they can add sources and methods of data collection.
List of Annexes
1 RH Indicators for Early Phase
2 RH Indicators in Stabilised Phase, part 2,
part 3, part 4, part
5, part 6, part 7,
part 8, part 9
3 RH Reference Rates and Ratios
4 Reference Rates and Ratios for RH Indicators
5 Estimating Number of Pregnant Women in a Population
6 Worksheet for Monthly RH Reporting, part 2,
7 Summary of RH Indicators
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