Economic and Social Commission for Asia and the Pacific Handbook on Reproductive Health Indicators
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Economic and Social Commission for Asia and the Pacific
Handbook on Reproductive Health Indicators - extracted text
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Economic and Social Commission for Asia and the Pacific
Handbook on Reproductive Health Indicators
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United Nations
New York, 2003
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Page
APPENDIX
I.
Indicators for policy and administrative procedures
related to reproductive health
41
II. Quality of care indicators
51
III. Adolescent RH information and services indicators....
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INTRODUCTION
Reproductive health (RH) indicators summarize data which
have been collected to answer questions that are relevant to the
planning and management of reproductive health programmes. The
indicators provide a useful tool to assess needs, and monitor and
evaluate programme implementation and impact. The indicators
capture the occurrence of events such as live births, the prevalence
of a characteristic in persons such as the use of contraceptive
methods or the prevalence of characteristics of a health facility, for
example, health centres which provide family planning services. The
indicators are expressed in rates, proportions, averages, categorical
variables or absolute numbers.
Following a number of international conferences in the 1990s,
in particular the 1994 International Conference on Population and
Development (ICPD), many countries have endorsed a number of
goals and targets in the broad area of reproductive health. Most of
these goals and targets have been formulated with quantifiable and
time-bound objectives as part of their national health policies and
programmes.
In order to assess the achievements of goals and targets, it is
necessary to establish a system for monitoring and evaluation. This
involves the definition of essential indicators and guidelines on how
to use them. With the expansion and evolution of services of
reproductive health, many agencies have been working on
developing indicators. As a result, there have been a number of
indicators put forward by these organizations, in addition to existing
national indicators.
With the trend towards the integration and development of
comprehensive reproductive health programmes and their decentralization,
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the responsibility for planning and management of programmes has
been placed at the subnational level. Therefore, indicators are not
only required at the national level but also at the subnational level to
monitor the effective implementation and evaluate the impact of
programmes. However, many reproductive health indicators that
have been produced are not necessarily appropriate at the
subnational level.
The objective of this handbook, therefore, is to present a guide
to a core set of illustrative and practical indicators with examples,
wherever possible, to enable programme managers at national and in
particular at the subnational level to monitor and evaluate
reproductive health programmes and projects. This handbook draws
heavily from previous work undertaken in this area (United Nations,
1998; UNFPA, 1996, 1998; Bertrand and others, 1994; Abeykoon,
1999; WHO, 1997a, 1997b).
I. CRITERIA FOR SELECTING INDICATORS
Indicator selection raises technical questions about the
implications of data collection as well as other operational issues.
For some programmatic issues, the basic statistics required to
construct indicators already exist, but the major task is to ensure
consistent use and proper interpretation. However, for others,
considerable innovative thinking is required. A good indicator has a
number of important attributes and those recommended by the
World Health Organization (WHO, 1997c) are outlined below.
> To be useful an indicator must be able to act as a “marker
of progress” towards improved reproductive health status,
either as a direct or proxy measure of impact or as a
measure of progress towards specified process goals.
2
> To be scientifically robust an indicator must be a valid,
specific, sensitive and reliable reflection of that which it
purports to measure. A valid indicator must actually
measure the issue or factor it is supposed to measure. A
specific indictor must only reflect changes in the issue or
factor under consideration. The sensitivity of an indicator
depends on its ability to reveal important changes in the
factor of interest. A reliable indicator is one which would
give the same value if its measurement was repeated in the
same way on the same population and at almost the same time.
> To be representative an indicator must adequately encompass
all the issues or population groups it is expected to cover.
> To be understandable an indicator must be simple to define
and its value must be easy to interpret in terms of
reproductive health status.
> To be accessible the data required for an indicator should
be available or relatively easy to acquire by feasible data
collection methods that have been validated in field trials.
> To be ethical an indicator requires data which are ethical to
collect, process and present in terms of the rights of the
individual to confidentiality, freedom of choice in
supplying data, and informed consent regarding the nature
and implications of the data required.
IL CONCEPTUAL FRAMEWORK
An important objective of a conceptual framework is to depict
clearly the desired programme and population outcomes targeted by
interventions and the main paths of influence that connect the
3
pertinent actions as shown in the figure on page 5. A conceptual
framework for reproductive health helps those involved in programme
design, management and implementation to select the appropriate
input, process, output and impact indicators to monitor and evaluate
whether and how these interventions have helped to achieve RH
objectives.
A. Input indicators
In a reproductive health programme, specific interventions
directed at achieving the desired outcomes need to be supported by a
conducive environment, where policies and organizational resources
are in place. The inputs needed to meet the desired implementing
processes are resources and the policy environment. Resources
include manpower, material and financial resources. Policies and
administrative procedures include national policies and legislation
with regard to reproductive health to create an enabling environment
for the effective implementation of activities. RH indicators directed
at policies and administrative issues are designed to show whether
the enabling national policy conditions and guidelines are in place to
support appropriate RH interventions. All these policy indicators
require qualitative information on the existence of policy statements
or legislation in support of RH goals.
B. Process indicators
Implementation of RH activities is the process through which
the desired interventions are carried out to achieve programme
outputs. The process indicators of reproductive health address
operational issues and questions that can be answered with
programme level data and measures. The indicators may enable
policy makers and programme managers to assess and improve RH
services so that clients can achieve their reproductive health intentions.
4
Figure
A Conceptual Framework for Monitoring and Evaluating
Reproductive Health Programme Components
Service
Outputs
^niplcmentadoi^
Organizational
Resources
and Policies
Reproductive
Health Impact
>
Service
Utilization
Inputs —
Resources
Manpower
Material
Finance
>
Policies &
Procedures
National Policies &
Legislation
Process ----Services
Contacts
Visits
Examinations
Morbidity
Referrals
> Outputs---Results
Knowledge
Acceptance
Practice
Utilization
Prevalence
Products
Advocacy and I EC
Materials
Contraceptives
Logistics
Source'. A.T.P.L. Abeykoon (1999).
5
> Outcomes
Impacts
Fertility
Mortality
IV. LIST OF SELECTED INDICATORS
The following provides illustrative lists of selected input,
process, output, and impact indicators to enable readers to
understand the concepts that are used to monitor and evaluate
reproductive health programmes. Appendix summarizes the
reproductive health indicators developed by UNFPA into input,
process, output and impact indicators (Abeykoon, 1999).
A. Input indicators
(a) Percentage of health personnel trained in midwifery
Definition:
The number of health personnel who are trained in midwifery
as a percentage of all health personnel who attended delivery in a
given period and in a given geographical area.
It is calculated as:
Number of health personnel who are trained in midwifery
---------------------------------------------------------------------- x ]00
Number of all health personnel who attended delivery
Data requirements:
The number of health personnel who are trained in midwifery
in a given period and in a given geographical area; and the total
number of health personnel who attended delivery in the same
period and in the same geographical area.
8
Data sources'.
Health service statistics; Facility-based surveys
Uses and limitations:
It is an indicator of the quality of services. The WHO defines
“trained midwifery” as those who have successfully completed a
prescribed course of midwifery and are able to give the necessary
supervision, care and advice to women during pregnancy and labour,
and in the post-partum period, and conduct deliveries and provide
care for infants.
(b) Percentage of public sector expenditures on contraceptive
commodities
Definition:
It is defined as the percentage of public sector expenditure on
contraceptive commodities to the total expenditure on contraceptive
procurements during a given year.
Data requirements:
Public sector expenditure on contraceptive procurements
during a year; and the total expenditure on contraceptives
procurements during the same year.
Data sources:
Ministry of Health statistics on expenditures on contraceptives;
Donors, NGOs and commercial sector expenditures on contraceptive
commodities.
9
Uses and limitations:
This is a measure of the commitment of resources by a country
to its reproductive health programme.
(c) Percentage of service delivery points offering at least two
methods of family planning.
Definition:
The number of service delivery points (SDPs) offering at least
two methods of contraception as a percentage of all service delivery
points offering family planning.
Data requirements:
Different types of contraceptive methods provided at SDPs in
a given period.
Data sources:
Service statistics; Facility-based surveys.
Uses and limitations:
It is an indicator of accessibility and availability of family
planning services. The number of methods available at SDPs
indicates the choices the clients have in practicing family planning.
(d) Percentage of service delivery points (SDPs) which routinely
screen and provide referral for infertility
Definition:
The number of service delivery points that routinely offer
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screening and provide referral for infertility per 100 health care
delivery facilities.
It is calculated as:
Number of SDPs providing screening and referrals
for infertility
x 100
Total number of SDPs
Data requirements:
Service statistics; Facility-based surveys
Uses and limitations:
This indicator measures the availability of screening facility
for infertility and the provision of referral services. However, the
measure does not reflect the quality of services and the personnel
needed to deliver the service.
(e) Percentage of trainees provided with knowledge and skills on
RH in a given year
Definition:
The number of trainees who received various training
programmes on RH as a percentage of the number scheduled for
training in a given year.
Data requirements:
List of all training programmes on RH during a given period;
and the total number of training programme on RH scheduled during
that period.
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Data sources:
Records maintained
administrative purposes.
by
implementing
agencies
for
Uses and limitations:
This indicator serves as a crude measure of determining whether
the programme meets its targets or in tracking progress from year to
year. However, the unit of measurement may not be strictly uniform,
as the type and duration of the training programme may vary.
(f) Percentage of service delivery points stocked with family
planning commodities according to needs.
Definition:
The percentage of SDPs having stock levels between their
calculated minimum and maximum levels at a given point in time.
Data requirements:
Minimum and maximum levels of stocks for each SDP; and
the actual stock levels at a specific point in time.
Data sources:
Service statistics; Facility-based surveys
Uses and limitations:
The indicator provides an overall measure of efficiency of the
logistics system.
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(g) Number of referral facilities providing essential and
emergency obstetric care per 100,000 married women in the
reproductive age group
Definition:
The number of referral facilities providing essential and
emergency obstetric care per 100,000 women in the reproductive
age group (15 to 49 years).
Data requirements:
The number of essential obstetric care referral facilities
available; and the number of married women aged 15-49 years.
Data sources:
Health services statistics; Health facility surveys; Census of
population.
Uses and limitations:
The indicator measures the availability of facilities towards the
reduction of maternal morbidity and mortality. National level
indicator may not reflect the disparities at subnational level.
(h) Number of service delivery points offering family planning
services per 10,000 women in the reproductive age group.
Definition:
Number of service delivery points offering family planning
services per 10,000 women in the reproductive age group (15 to 49
years).
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1
Data requirements:
Number of service delivery points offering family planning
services in a specific period and in the specific geographical area;
and the number of women in the reproductive age group (15 to 49
years) in the specified period and the specified geographical area.
Data sources:
Health service statistics; Health facility surveys; Population
census.
Uses and limitations:
The indicator provides a measure of accessibility and
availability of family planning services. It is, however, assumed that
the facilities are adequately staffed and have the required
commodities and supplies.
(i) Existence of the national population and reproductive health
policy
Definition:
This is an “ordinal scale” (yes/no) indicator. The value of
“yes” is given if: a) The policy document addresses reproductive
health including family planning and sexual health; and b) It reflects
clearly the population considerations in development sectors such as
health, education, food, housing, etc.
Data requirements:
Approved policy
reproductive health.
document
addressing
population
and
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Data sources:
National population and reproductive health policy document;
and National Development Plans addressing population and
reproductive health issues.
Uses and limitations:
The indicator reflects the policy environment in which the
government is committed in dealing with population and
reproductive health issues. It can be used for advocacy for
population and reproductive health programmes. The limitation is
that the indicator may suffer from subjectivity in interpretation.
(j) Government policy on abortion
Definition:
The existence of any government policy or laws which either
permit or restrict induced abortions. If abortion is permitted it may
be classified under the following circumstances:
a) Legal and available on request
b) Permitted on broad social and health grounds
c) Permitted on limited health grounds
d) Permitted only for special circumstances (rape, incest)
Data requirements:
Official policy and laws regarding induced abortion.
Data sources:
National policy documents and/or laws.
15
n
Uses and limitations:
The indicator reflects the conditions under which access to
safe abortion services are permitted and gives information on the
environment towards abortion services.
B. Process indicators
(a) Proportion of service providers trained in family planning
and reproductive health
Definition:
The number of service providers trained as a percentage of all
service providers in family planning and reproductive health during
a given perid.
Data requirements:
The number of persons in service delivery points who were
trained in family planning and reproductive health during the
reference period; and the total number of service providers in the
area of family planning and reproductive health.
Data sources:
Service statistics; Records on training programmes.
Uses and limitations:
The indicator provides information on the strength of IEC
(information, education and communication) and reproductive
health services.
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(b) Percentage of births attended by trained health personnel
Definition:
Percentage of births attended by trained health personnel in a
given period.
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The indicator is calculated as:
Number of births attended by trained health personnel
in a year
---------------------------------------------------------------------- x 100
Total number of live births occurred during the same year
Data requirements:
Number of births attended by trained personnel during a
specific year; and the total number of live births occurred during the
same year.
Data sources:
Health service statistics; Birth registration data.
I
Uses and limitations:
The indicator is useful in assessing maternal and child health
programme.
(c) Percentage of clients given counselling on family planning at
SDPs during a year
Definition:
The indicator is calculated as:
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(h) Percentage of follow-up visits by contraceptive users to the
total number of continued users of a particular method
Definition:
Number of recorded clinic visits for follow-up by clients using
a specific contraceptive method as a percentage to the total number
of continued users of that contraceptive method.
Data requirements:
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The number of clinic visits by client to the service delivery
points for follow-up advice, management of side effects and
complications of a contraceptive method; and the estimated total
number of continuous users of that method.
Data sources:
Clinic records; Service statistics
Uses and limitations:
The indicator measures the quality of care and user’s
satisfaction with the method.
(i) Proportionate share of contraceptives distributed to users by NGOs
Definition:
Number of contraceptive methods distributed by NGOs as a
percentage of all contraceptive methods distributed to users during a
specified period.
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Data requirements:
Distribution of contraceptives to users through NGOs by
method; and the total number of contraceptives distributed to users
by method from all sources.
Data sources:
Service statistics maintained by government and NGOs.
Uses and limitations:
The indicator provides a measure of the contribution of NGOs
to the overall national family planning programme.
C. Output indicators
(a) Contraceptive prevalence rate
Definition:
The proportion of currently married women aged 15-49 years
who are currently using a contraceptive method at the time of the survey.
The indicator is calculated as:
Number of currently married women aged 15-49 years
using a contraceptive method
x 100
Total number of currently married women aged
15-49 years
23
u
Data requirements:
Number of currently married women aged 15-49 years using a
contraceptive method; and the total number of currently married
women aged 15-49 years; The data should refer to a given point in
time. The contraceptive prevalence rate can also be calculated by
specific method and by age group if the data are available.
Data sources:
Population-based surveys, such as Demographic and Health
Surveys (DHS).
Uses and limitations:
The indicator measures the prevalence of contraceptive use
taking into account all sources of supply and methods of
contraception available to the target population. It is a widely used
indicator to assess the level of contraceptive use in a given
population.
(b) Number of new acceptors of modern methods of family
planning
Definition:
Number of clients who accept for the first time in their lives any
modern method of contraception in a given period, usually one year.
Data requirements:
Records of clients who accept a family planning method for
the first time during the given period.
24
Data sources:
Service statistics
Uses and limitations:
The indicator measures the effectiveness of the family
planning programme to attract new clients form the target
population. As the contraceptive prevalence rate reaches a high level
(e.g. over 70 per cent) the number of new acceptors is likely to
decrease because of the fact that most of the eligible couples have
been recruited as users.
(c) Percentage of women in reproductive ages with knowledge of
the modern methods of contraception
Definition:
Percentage of women in the reproductive age group, 15-49
years, who knows at least one modern methods of family planning.
Data requirements:
Number of women in the reproductive ages with knowledge of
contraceptives by methods; and the total number of women in the
reproductive ages.
Data sources:
Population-based surveys, such as DHS.
Uses and limitations:
The indicator provides a measure of the level of knowledge or
awareness in the target population of different methods of modern
25
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(f) Proportion of children aged 9-12 months who are fully immunized
Definition:
Number of children aged 9-12 months who are fully immunized
as a percentage of all children aged 9-12 years in a calendar year.
Data requirements:
Number of children aged 9-12 months who are fully immunized
in a given period and the given population; and all children aged 9-12
months during the same period and the same population.
Data sources:
Service statistics; Population census.
Uses and limitations:
The indicator shows the effectiveness of the immunization
programme. The “fully immunized” status generally includes
immunization with three doses of poliomyelitis, three doses of DPT
and measles.
(g) Prevalence of breast cancer among women aged 35 years and over
Definition:
Number of women aged 35 years and over diagnosed with
breast cancer during a given period per 1,000 of all women aged 35
years and over.
Data requirements:
Number of women aged 35 years and over who are clinically
28
diagnosed with breast cancer; and the number of women aged 35
years and over in the population screened.
Data sources:
Service statistics from health facilities providing diagnostic
and management service for breast cancer.
Uses and limitations:
As a measure of prevalence of breast cancer the indicator
provides the magnitude of the problem in the target population
during a given period. The indicator facilitates prevention and
treatment efforts of breast cancer. The data may be subject to
underreporting as the entire eligible population in the target
population may not be screened.
(h) Unmet need for family planning
Definition:
The proportion of currently married women aged 15-49 years
who do not want any more children during the next two years but
are not currently using any method of contraception.
Data requirements:
Desire for additional children of currently married women
aged 15-49 years in the future (next two years); and current
contraceptive use status of these women.
Data sources:
Population-based surveys, such as DHS.
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1
Uses and limitations:
The indicator provides a measure of the latent demand for
family planning. It indirectly shows the extent of accessibility and
availability to family planning services.
(i) Mean desired family size
Definition:
The average number of children that women of reproductive
age would choose if they could have exactly the number of children
desired.
Data requirements:
Desired number of children by women of reproductive age.
Data sources:
Population-based surveys, such as DHS.
Uses and limitations:
It is a widely used indicator of fertility preference. This
indicator is subject to errors such as inability or unwillingness on the
part of the respondents to quantify their fertility desires.
D. Impact indicators
(a) Total fertility rate (TFR)
Definition:
Total number of children a woman would have by the end of
30
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her reproductive period if she experienced the currently prevailing
age-specific fertility rates throughout her childbearing life.
Data requirements:
Number of live births occurred during a reference period
classified by five-year age group of women; and the total number of
women classified also by five-year age group.
Data sources:
Vital registration;
surveys, such as DHS.
Population
census;
Population-based
Uses and limitations:
TFR is one of the most widely used fertility measures to assess
the impact of family planning programmes. The measure is not
affected by the age structure of the female population.
(b) Maternal mortality ratio
Definition:
Number of women who die as a result of childbearing in a
given year per 100,000 live births. Maternal deaths are those caused
by complications of pregnancy and childbirth.
Data requirements:
Number of maternal deaths occurred during a given period and
given population; and the total number of live births during the same
period and same population.
31
mjh - ioS
8°li6
Po3
Data sources:
Vital registration; Health survey.
Uses and limitations:
The indicator is widely used as a measure of maternal health.
It is also used to indirectly assess the effectiveness of antenatal and
post-natal care for mothers.
(c) Neonatal mortality rate
Definition:
Number of infant deaths up to 28 days after delivery per 1,000
live births.
Data requirements:
Number of infant deaths occurred up to 28 days after delivery;
and the total number of live births.
Data sources:
Vital registration; Population-based survey, such as DHS.
Uses and limitations:
The indicator provides a measure of immediate post-natal care.
However, the indicator may be underestimated as newborn babies
who die within few hours after birth may not be reported.
32
• r*
Q! 1
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(d) Induced abortion rate
Definition:
Number of induced abortions per 1,000 women aged 15-49 in
a given year.
Data requirements:
Number of induced abortions in a given period; and the total
number of women aged 15-49 during the same period.
Data sources:
Population-based surveys; Population census.
Uses and limitations:
The indicator shows the extent to which unwanted pregnancies
occur in the population. The number of induced abortions may be
underreported in countries where abortion is not legal.
(e) Adolescent fertility rate
Definition:
Number of live births per 1,000 women aged 15-19.
Data requirements:
Number of live births occurred to women aged 15-19; and the
total number of women in the same age group.
33
Data sources:
Vital registration; Population census; Population-based surveys,
such as DHS.
Uses and limitations:
The indicator shows the prevalence of adolescent childbearing.
(f) Infant mortality rate
Definition:
Number of deaths to infants under one year of age per 1,000
live births in a given year.
Data requirements:
Number infants less than a year old who died during a given
year; and the total number of live births occurred during the same
year.
Data sources:
Vital registration; Population census; Population-based surveys,
such as DHS.
Uses and limitations:
The indicator provides a measure of antenatal and post-natal
care to mothers and infants. This is considered as a good indicator of
the health status of a given population.
34
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(g) Perinatal mortality rate
Definition:
Perinatal deaths comprise still births plus early neonatal deaths
(infants dying within 7 days). It is defined as the number of perinatal
deaths per 1,000 live births.
Data requirements:
Number of still births and infant deaths occurred within the
first 7 days in a given year; and the total number of live births
occurred in the same year.
Data sources:
Vital registration; Population-based surveys, such as DHS.
Uses and limitations:
The indicator directly reflects prenatal, intrapartum and
neonatal care and therefore, gives an indication of the quality of
maternal and child health services. However, accurate data on still
births and early infant deaths may be difficult to obtain.
(h) Annual population growth rate
Definition:
The rate at which a population is increasing (or decreasing) in
a given year due to the contribution of natural increase and net
migration, expressed as percentage of the base population.
35
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The indicator is calculated as:
a) The average annual rate of population growth can be
calculated from two points in time (e.g. two national population
censuses) using the following formula:
Pn
P0(l+r)n
Where Po = Population at the beginning of period
Population at the end of period
Pn
r
Average annual rate of population growth
n
Duration in years
b) Rate of natural increase
CBR-CDR
RNI
Where CBR = Crude birth rate
CDR = Crude death rate
RNI = Rate of natural increase
(usually expressed as a per cent)
In a population where net migration is negligible, the above
method can be employed as a close approximation to the rate of
population growth.
Data requirements:
Number of live births, deaths and mid-year population during
a calendar year. It can also be calculated from data available at two
national population censuses.
Data sources:
Vital registration; Population censuses.
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Uses and limitations:
It is one of the most widely used indicators to assess the
overall impact of family planning programmes.
(i) Life expectancy at birth
Definition:
Average number of years a newborn child would be expected
to live if the child is subject to the age pattern of mortality prevailing
at the time of its birth.
Data requirements:
Age-specific death rates by sex.
Data sources:
Vital statistics; Population census.
Uses and limitations:
It is an age-standardized mortality rate. The indicator is widely
used as a measure of the general level of mortality in a population.
(j) Prevalence of RTIs/STDs by type in a defined target population
Definition:
The number of persons diagnosed with a specific reproductive
tract infections (RTIs) or sexually transmitted diseases (STDs) at a
given point in time per 100 persons in the target population.
37
Data requirements:
Number of persons diagnosed either by clinical examination or
laboratory tests with a specific STD at a given point in time; and the
total number of persons screened.
Data sources:
Special laboratory-based surveys; case and laboratory reports
from clinicians and diagnostic laboratories.
Uses and limitations:
The indicator provides the prevalence of RTIs/STDs in the
target population. It is useful to assess the impact of RTIs and STDs
control programmes.
(k) Prevalence of HIV infection in a defined target population
Definition:
The number of persons diagnosed with an HIV infection at a
given point in time per 1,000 persons in the target population.
Data requirements:
Number of persons diagnosed with HIV infections at a given
point in time and in the specific group; and the total number of
persons in the target population group screened.
Data sources:
Special serologic surveys (i.e.
activities or sentinel surveillance).
38
blood
supply screening
Uses and limitations:
The indicator provides the prevalence of HIV infection in the
target population. It is useful to assess the impact of HIV/AIDS
control programmes.
39
REFERENCES
Abeykoon, A.T.P.L. (1999). “Monitoring Progress and Ensuring
Accountability of Reproductive Health Services Provision - A
Road Map”, Innovations, vol. 7-8: 213-238, (Kuala Lumpur,
International Council on Management of Population
Programme).
Bertrand, Jane T., Robert J. Magnani and Janies C. Knowles (1994).
Handbook of Indicators for Family Planning Program
Evaluation (Chapel Hill, Carolina Population Center,
University of North Carolina).
UNFPA (1996). Guidance Note on Reproductive Health Programme
Performance Indicators (New York, United Nations
Population Fund).
UNFPA (1998). Indicators for Population and Reproductive Health
Programmes (New York, United Nations Population Fund).
United Nations (1998). Asia-Pacific Population Policies and
Programmes: Future Directions: Report, Key Future Actions
and Background Paper at a High-Level Meeting, Asian
Population Studies Series No. 153 (Bangkok, Economic and
Social Commission for Asia and the Pacific and United
Nations Population Fund).
WHO (1997a). Monitoring Reproductive Health: Selecting a Short
List of National and Global Indicators (Geneva. World Health
Organization).
WHO (1997b). Selecting Reproductive Health Indicators: A Guide
for District Managers (Geneva, World Health Organization).
40
WHO (1997c).
Reproductive Health Indicators for Global
Monitoring: Report of an Inter-agency Technical Meeting, 911 April 1997 (Geneva, World Health Organization).
41
APPENDIX
I. INDICATORS FOR POLICY AND ADMINISTRATIVE
PROCEDURES RELATED TO REPRODUCTIVE HEALTH1
A. Policies Administrative Procedures
Input Indicators
National policy specifying written standards of quality of care for:
i.
FP information services
ii. Maternal care
iii. Prevention and management of RTIs and STDs
iv. Abortion care
v. Treatment of abortion complications
vi. Provision of post-abortion FP counselling and services
Legislation or policy that prohibits provision of family planning to
persons who are:
i. Unmarried
ii. Below a given age
iii. Without spousal and/or parental consent
National policy for the provision of reproductive health care in
i. Family planning
ii. Maternal care
iii. STD/RTI programmes
Provisions for:
i.
Enquiries/audits into maternal deaths
ii. Special measure(s) to reduce maternal mortality
‘These indicators are adopted from UNFPA (1997), Indicators for Populateon and Reproductive
Health Programmes, New York: Technical and Evaluation Division.
42
National strategic plan to prevent and control RTIs and STDs,
including HIV-AIDS
Provision to protect the basic rights of HIV infected individuals with
reference to:
Employment
i.
ii. Marriage/divorce
iii. Travel
Legislation about age at first marriage by sex:
i. Does a legal minimum age exist?
ii. What is the legal minimum age?
iii. Is the legal minimum age enforced?
B. Family Planning Indicators
Input Indicators
Ratio of contraceptive methods available at SDPs to number of
method officially approved by the programme
Percentage of SDPs with availability of:
i. Sterilized instruments
ii. Safely treated water
Number of contraceptive stock-outs within last six months
Process Indicators
Percentage of population within one hour walk from FP service
delivery point
43
Percentage of FP SDPs with provision of RTI/STD services
Percentage of post-partum women (six weeks after delivery) offered
FP
Output Indicators
Percentage of married women of reproductive age who want to
postpone or stop child-bearing and who are not currently using any
contraceptive method
Percentage of clients asked about their:
i. Reproductive intentions
ii. Concerns about contraceptive methods
Adolescent (<age 20) fertility rate
C. Maternal Health Indicators
Input Indicators
Percentage of SDPs able to provide basic obstetric care
Percentage of subnational level area hospitals able to provide Csections and blood transfusions
Percentage of pregnant women attended at least once by trained
health personnel
Percentage of deliveries that are C-section
44
Output Indicators
Percentage of delivering women who developed
complications and received emergency obstetric care
obstetric
Percentage of deliveries that are C-section
Percentage of pregnant women attending antenatal services who
received
i. Iron/folate (100 tablets)
ii. Tetanus immunization (two doses)
Percentage of pregnant women receiving maternal services expressing
satisfaction with:
i. Prenatal care
ii. Delivery services
iii. Post-natal care
Percentage of health personnel given in-service training over the
past two years
D. Reproductive Tract Infection and Sexually Transmitted
Disease Indicators
Process Indicators
Percentage of SDPs offering condoms
Percentage of SDPs offering diagnosis and treatment of:
i. Syphilis
ii. Gonorrhea
iii. Chlamydia
45
u
Percentage of SDPs offering
i. Pap smears at secondary/ tertiary facilities
Availability of counselling services for sexual health
Output Indicators
Prevalence of RTIs/STDs among women attending gynaecological
clinics
Estimated prevalence of HIV among adolescents, men and women
Prevalence of urethral discharge among men aged 15-49
Percentage of clients expressing satisfaction with R.TI services
Percentage of RH workers who have been provided with in-service
training in the past two years
E. Abortion and Post-Abortion Care Indicators
Process Indicators
Percentage of women
i. Having a legal abortion who are referred for post-abortion FP
counselling and services
11. Treated for abortion complications
iii. Referred for post-abortion FP and services
Availability of in-service training on post-abortion FP counselling for
health providers
46
Output Indicators
Annual number of:
i. Legal abortions
ii. Estimated illegal abortions
Percentage of obstetric and gynaecological admittances due to abortion
complications
Percentage of hospitals/clinics with personnel trained to treat abortion
complications
F. Infertility Indicators
Process Indicators
Percentage of women aged 20-44 who:
i. Have never been pregnant or
ii. Have had at least one pregnancy in the past and want to become
pregnant, are not using contraception and have not become
pregnant during past two years
G. Harmful Practices Indicators
Output Indicators
Estimated prevalence of women who have been genitally mutilated
Sex ratio of births
Implementation of policy measures to:
47
L
i. Eliminate female genital mutilation
ii. Eliminate prenatal sex selection and sex-selective abortion
Prevalence of wasting and stunting by sex (ratio)
H. Indicators for Clinic-based Counselling Services
Input Indicators
Percentage of SDP offering counselling services
Output Indicators
Percentage of service providers trained in counselling techniques/
interpersonal skills
Percentage of SDP clients expressing satisfaction with the
counselling services received
I. Indicators for Media Promotions
Input Indicators
Existence of national strategy for IEC in support of the RH/FP/
population programme
Process Indicators
Number of media programmes/materials used for RH/FP/population
campaigns:
48
u
Frequency of media campaigns in support of RH/FP/Population
programme
Use and type of media, outside of the clinic setting, to disseminate
information on RH/FP/population issues
Output Indicators
Level of media promotions in support of RH/FP/population
programmes
J. Indicators for Community Involvement and Outreach
Process Indicators
Number and types of IEC interventions/ directed at NGOs and
community leaders:
Percentage of NGOs with health/FP programmes offering
integrated RH services
Percentage of community leaders supporting RH/FP programmes
Output Indicators
Percentage of households visited by health workers
49
II
K. Indicators for Capacity-building of Personnel
Output Indicators
Percentage of service providers trained in counselling/interpersonal
communication skills
Percentage of media personnel trained in RH/population reporting:
Percentage of RH/FP personnel trained in
Media/public relations/production of radio/TV programmes
i.
ii. Planning and management of IEC programme
iii. IEC research/evaluation
L. Indicators for Knowledge, Attitude
Reproductive Health Family Planning
and
Practice
of
Output Indicators
Percentage of IEC target audience who can name at least one specific
contraceptive method
Percentage of IEC target audience who knows at least two methods to
prevent STD/HIV infection
Percentage of IEC target audience that can name one RH/FP service
delivery point
Percentage of IEC target audience that approves of using
contraception
Percentage of target audience that has discussed RH, STD/HIV and
sexual issues with their partners
Percentage of target audience using contraception
50
M. Indicators for Population Education
Output Indicators
Percentage of students who know about key population issues
Percentage of students who know about RH issues
Percentage of students having received family life education
Percentage of students knowledgeable about major gender issues
Percentage of students who know how to prevent STDs and HIV/AIDS
Percentage of school teachers trained in target areas to teach
Population Education
Percentage of students who have taken courses with population
contents
N. Other Advocacy/IEC Indicators
Process Indicators
Allocation of resources to RH as percentage of total health budget
Percentage of SDPs offering integrated RH services
Output Indicators
Number of organization/membership of coalitions formed to
achieve advocacy objectives
Users of male methods as percentage of all contraceptive users
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ujU ^0 5
II. QUALITY OF CARE INDICATORS2
A.
Quality of Care in RH Services for Women - Context and
Process Indicators
Type of indicator
Indicators
Judicial framework
(Context)
Legal regulation to prevent abuse regarding
caesarean section and sterilization.
Existence of training programmes on quality
of care aspects and gender approach for
health staff.
Education/Communication/ Existence of training programmes on quality
Services (Process)
of care aspects for health staff.
Existence of RH programmes for women
incorporating aspects other than family
planning and maternal/infant care.
Availability of contraceptive methods.
Possibility to choose (broad offer and
affordability).
Existence of programmes/regulations in
corporating and operationalizing sexual
and reproductive rights.
Resources allocated
(Process)
Availability of financial resources for
training on quality of care and gender
approach.
Amount of financial resources allocated to
structure/inputs.
2 Extracted from “The Cairo Consensus: Women Exercising Citizenship through Monitoring - The
Cairo+5 Process” LACWHN, December 1998.
52
III. ADOLESCENT RH INFORMATION AND SERVICES
INDICATORS
A.
Access of Adolescents to Information and Services Context and Process Indicators
Type of indicator
Indicators
Judicial framework
Judicial legal norms on sex education.
Judicial legal norms on the treatment of
pregnant adolescents at school.
Education/ Communication/ Regulations and RH care programmes
Services
exclusively for adolescents.
Number of centres
adolescent services.
for exclusive
Existence of networks for distribution of
condoms in places visited by adolescents.
Training courses in adolescent care.
Sex education programmes for adoles
cents in the formal education system.
Non-formal sex education programmes
and activities for adolescents.
B. Access by Adolescents to Education and Services: Impact
Indicators
Indicators
•
•
•
•
Percentage of adolescent births
Number of adolescents seen in RH services
Percentage of adolescents covered by sex education programmes
Percentage of maternal deaths among adolescent women
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