MONITORING AND EVALUATING PROGRAMMES
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MONITORING AND EVALUATING PROGRAMMES
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Primary Health Care Management Advancement Programme
MONITORING
AND EVALUATING
PROGRAMMES
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MODULE 5
USER’S GUIDE
AGA KHAN FOUNDATION
THE AGA KHAN UNIVERSITY
Primary Health Care Management Advancement Programme
MONITORING
AND EVALUATING
PROGRAMMES
&
Lynne Miller Franco
Paul Richardson
Jack Reynolds
Neeraj Kak
University Research Corporation
MODULE 5
USER’S GUIDE
URC/CHS
Aga Khan Health Services
University Research Corporation
Center for Human Services
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Dedicated to
Dr. Duane L. Smith (1939-1992),
Dr. William B. Steeler (1948-1992)
and all other health leaders, managers and workers
who follow their example in the effort to bring quality health
care to all in need.
—HMM
The monitoring of levels of health awareness among women of all
generations, particularly in rural areas like this village in China where
contamination from farmyard manure is frequently a problem, can help
track achievements, refine strategies and set improved priorities and
action plans
Photo by Jean-Luc Ray for AKF
i
An overview of PHC MAP
The main purpose of the Primary Health Care Management Advance
ment Programme (PHC MAP) is to help PHC management teams collect,
process and analyse useful management information.
Initiated by the Aga Khan Foundation, PHC MAP is a collaborative programme
of the Aga Khan Health Network1 and PR1COR.2 An experienced design team and
equally experienced PHC practitioner teams in several countries, including
Bangladesh, Chile, Colombia, the Dominican Republic, Guatemala, Haiti, India,
Indonesia, Kenya, Pakistan, Senegal, Thailand and Zaire, have worked together to
develop, test and refine the PHC MAP materials to make sure that they are
understandable, easy to use and helpful.
PHC MAP includes nine units called modules. These modules focus on essential
information that is needed in the traditional management cycle of planning-doing
evaluating. The relationship between the modules and this cycle is illustrated below.
PHC MAP modules and the
planning - evaluation cycle
S'
S/
t
PHC MAP
MODULES
1. Information needs
2. Community needs
3. Work planning
4. Surveillance
5. Monitoring indicators
6. Service quality
7. Management quality
8. Cost analysis
9. Sustainability
'■
MODULE 1
Module *
MODULE b
1 The Aga Khan Health Network includes the Aga Khan Foundation, the Aga Khan Health Services, and
the Aga Khan University, all of which are involved in the strengthening of primary health care
2 Primary Health Care Operations Research is a worldwide project of the Center for Human Services,
funded by the United States Agency for International Development
ii
Managers can easily adapt these tools to fit local conditions. Both new and
experienced programmers can use them. Government and NGO managers,
management teams, and communities can all use the modules to gather information
that fits their needs. Each module explains how to collect, process and interpret
PHC-specific information that managers can use to improve planning and moni
toring. The modules include User’s guides, sample data collecting and data process
ing instruments, optional computer programs, and Facilitator’s guides, for those who
want to hold training workshops.
The health and management services included in PHC MAP are listed below:
Health and management services
HEALTH SERVICES
GENERAL
PHC household visits
Health education
MATERNAL CARE
Antenatal care
Safe delivery
Postnatal care
Family planning
CHILD CARE
Breastfeeding
Growth monitoring
Nutrition education
Immunization
Acute respiratory infections
Diarrhoeal disease control
Oral rehydration therapy
OTHER HEALTH CARE
Water supply, hygiene and
sanitation
School health
Childhood disabilities
Accidents and injuries
Sexually transmitted diseases
HIV/A1DS
Malaria
Tuberculosis
Treatment of minor ailments
Chronic, non-communicable
diseases
MANAGEMENT
SERVICES
Planning
Personnel management
Training
Supervision
Financial management
Logistics management
Information management
Community organisation
Several Manager’s guides supplement these modules. These are: Better manage
ment: 100 tips, a helpful hints book describing effective ways to help managers
improve what they do; Problem-soluing, a guide to help managers deal with common
problems; Computers, a guidebook providing useful hints on buying and operating
computers, printers, other hardware and software; and The computerised PRICOR
thesaurus, a compendium of PHC indicators.
PHC technological breakthroughs, such as Sabin’s oral polio
immunization, given here by a community health worker to a young
child in a slum area of Dhaka, Bangladesh, can facilitate field work, the
monitoring of services and achievement of targeted outcomes
Photo by Jean-Luc Ray for AKF
Module 5: Monitoring
The Primary Health Care Management Advancement
Programme has been funded by the Aga Khan Foundation
Canada, the Commission of the European Communities, the
Aga Khan Foundation U.S.A., the Aga Khan Foundation’s
head office in Geneva, the Rockefeller Foundation, the
Canadian International Development Agency, Alberta Aid,
and the United States Agency for International Develop
ment under two matching grants to AKF USA. The first of
these grants was "Strengthening the Management, Monitor
ing and Evaluation of PHC Programmes in Selected Coun
tries of Asia and Africa" (cooperative agreement no.
OTR-0158-A-00-8161-00, 1988-1991); and the second was
"Strengthening the' Effectiveness, Management and Sus
tainability of PHC/Mother and Child Survival Programmes
in Asia and Africa" (cooperative agreement no. PCD-0158A-00-1102-00, 1991-1994). The development of Modules 6
and 7 was partially funded through in-kind contributions
from the Primary Health Care Operations Research project
(PRICOR) of the Center for Human Services under its
cooperative agreement with USAID (DSPE-6920-A-001048-00).
This support is gratefully acknowledged. The views and
opinions expressed in the PHC MAP materials are those of
the authors and do not necessarily reflect those of the
donors.
All PHC MAP material (written and computer files) is in
the public domain and may be freely copied and distributed
to others.
Module 5: Monitoring
Contents
QUICK START........................................................................................
i
INTRODUCTION ..........................................................................
Types of indicators to be monitored...................................................
How long should you monitor PHC activities? .................................
Keep it straightforward and simple (KISS) ........................................
Limitations of service monitoring.......................................................
5
6
15
17
17
MONITORING PROCEDURES............................................................
Step 1: Specify the monitoring objectives........................................
Step 2: Decide on the scope of the monitoring ...............................
Step 3: Select the indicators and performance standards ...............
Step 4: Choose information sources and develop data collection
procedures ................................................................
Step 5: Collect the data ......................................................................
Step 6: Tabulate and analyse the data ..............................................
Step 7: Present the findings ..............................................................
Step 8: Take appropriate action.........................................................
Step 9: Decide whether to continue monitoring .............................
19
20
23
24
27
29
30
33
34
35
APPENDICES
A. PHC service delivery indicators ................................................... 39
B. PHC management indicators
....... 65
C. Impact indicators for monitoring mortality, morbidity, disability,
and fertility.......................
75
D. Summary list of indicators for PHC activity monitoring ........... 79
E. Blank worksheets........................................................................... 103
Module 5: Monitoring
REFERENCES AND BIBLIOGRAPHY
107
ACRONYMS AND ABBREVIATIONS
108
GLOSSARY
110
Module 5: Monitoring
Acknowledgements
The first draft of this module was developed by Lynne Miller Franco and Jack
Reynolds in early 1991. It was reviewed by a number of outside experts and field
tested in several PHC programmes in mid and late 1991. Paul Richardson took
responsibility for revising the module in early 1992. The revision was reviewed by
participants at the International Conference on Management and Sustainability of
PHC Programmes, held in Bangkok in May, 1992. The participants recommended
the addition of indicators on a number of other PHC services, including sexuallytransmitted diseases, childhood disabilities, and accidents and injuries. Neeraj Kak
prepared these lists of indicators and Paul Richardson made the final revision.
Special thanks are due to Maria Francisco, who helped develop several of the
indicator lists, and Mary Millar, who developed the Facilitator’s guide for the module.
External Reviewers:
Donald Belcher. • Veterans Administration, Seattle WA, USA
David H. Peters • Johns Hopkins University School of Hygiene and Public Health,
Johns Hopkins University, Baltimore MD, USA
Paul Zeitz • Johns Hopkins University School of Hygiene and Public Health,
Johns Hopkins University, Baltimore MD, USA
Michael Bernhart. • University of Puget Sound, WA, USA
Internal Reviewers and Contributors:
Thailand:
Jumroon Mikhanorn • Somboon Vacharotai Foundation (SVF)
Thongchai Sapanuchart • SVF
Donna Robinson • SVF
Yawarat Porapakkham • ASEAN Institute for Health Development (AIHD)
Chaweewon Boonshuyar • AIHD
Nawarat Suwannapong • AIHD
Som-Arch Wongkhomthong • AIHD
Orapin Singhadej • AIHD
Peerasit Kamnuansilpa • Health and Population Research Company (HPRC)
Butsabar Subongkot • HPRC
Field tests:
Countries:
Participating organisations, field test facilitators
Bangladesh: Concerned Women for Family Planning; The Asia Foundation; Facil
itator: Barkat-E-Khuda, URC Bangladesh.
Pakistan:
Aga Khan University, Karachi; Facilitator: Khatidja Husein, Aga Khan
University.
Thailand:
Ministry of Public Health, Srisaket, SVF; AIHD; HPRC; Facilitator:
Peerasit Kamnuansilpa, HPRC.
India:
Junagadh PHC Project; Sidhpur Sustainable Health System Project,
Gujarat; Aga Khan Health Service, India; Facilitator: Neeraj Kak, URC;
Vijay Moses, Aga Khan Health Service, India.
Module 5: Monitoring
Kenya:
Senegal:
Indonesia:
Mombasa PHC Project; Kisumu PHC Project; Facilitators: Paul Rich
ardson, URC; Esther Sempebwa, Mombasa PHC Project; Matthew
Onduru, Kisumu PHC Project.
Ministry of Health; Facilitator: Mounir Toure.
Department of Health, Jakarta; Facilitator: Sandi Iljanto, University
of Indonesia.
1
Quick start
If you want to get started quickly, follow these instructions for monitoring PHC
activities. Monitoring is the periodic collection of data to determine if activities are
being implemented as planned. Most PHC managers already have a monitoring
system that records data regarding programme inputs and outputs.
In developing a practical monitoring system, you should consider the following
guidelines:
• Keep the data collection and reporting simple for managers and workers with
limited training.
• Collect only essential data. If there is no immediate need, do not collect the
data. There are limits as to how much information a manager can collect and
use effectively. Monitoring should not over-burden operational and MIS staff.
• Provide timely feedback and use the information. Make sure that managers
at all levels receive, analyse and utilise the information.
This basic Quick start analysis makes two assumptions: the analysis will use
existing data collection forms, or existing forms will be modified; and only input,
output and effect data will be monitored. Inputs are the resources which enable the
PHC programme to produce outputs. Outputs are the immediate services and
products that yourjDrogramme provides. Effects are the changes in knowledge, skills,
motivation, behaviour (including coverage) that result from your products and
services. You should already have an idea about the type of information that you
need.
The Quick start involves three stages: planning, implementing, and reviewing.
Stage 1: Planning
Specify the objectives by clarifying which PHC services or management services
will be monitored, why the data will be gathered, and who will use it. You should
be clear about the purpose of monitoring and who needs the information.
Determine the scope of monitoring by specifying the administrative areas, the types
of facilities or service components, and the duration of data collection. In most cases
data will be gathered for a short term to determine if programme resources and activities
have been implemented as planned.
Select input, output and/or effect indicators for PHC services or management
support services. The following are general indicators which can be used for most
PHC services. Appendices A and B provide detailed lists of indicators.
PHC services
(For example, ANC, growth monitoring, immunizations, ORT, and curative care for
ARI, malaria and other common diseases.):
Effects:
• Number or percent of target group covered by a PHC service, e.g., percent of
children < 2 years fully immunized
Module 5: Monitoring; quick start
2
• Number or percent of mothers who gain PHC skills, e.g., number who can
prepare ORS solution correctly
Outputs:
• Number of services and products provided to new and continuing users, e.g.,
number of ORS packets distributed
• Number of contacts to inform and motivate eligible clients, e.g., number of
community visits by programme teams
Inputs:
• Number of personnel per facility, e.g., number of nurses per clinic
• Number of supplies and equipment per facility or health worker (e.g., number
of health workers with IEC materials)
Management support services
For example, planning, training, supervision, personnel, MIS, logistics, and finance
Effects:
• Number or percent of health workers who gain needed skills, e.g., percent of
trained CHWs who can counsel mothers on nutrition
• Number or percent of staff who follow program policies, e.g., number of drivers
who use seat belts
Outputs:
• Number or frequency of management support activities completed, e.g., number
of training sessions completed
• Number of products produced, e.g., number of financial reports distributed
• Number of supplies inventoried and distributed, e.g., number of BCG ampoules
distributed to clinics
Inputs:
• Number of facilities with requisite personnel and skills, e.g., number of workers
employed with required education level
• Number of supplies procured, e.g., number of family planning methods received
from donors
Select performance standards. For each indicator select a "target." These
standards are compared with actual performance. For example, your target for
immunization coverage may be set at 70 percent. You would compare your actual
coverage to that target.
Choose the information sources and the data-gathering procedure. Most of this
information will probably come from existing or modified sources such as treatment
data, logistics records, and activity reports. In some cases, a new indicator will be
added to an existing form. Whenever possible use the existing data gathering,
compilation, and reporting system.
Stage 2: Implementing
• Collect the data. When a new form is developed or an existing form is substantially
modified, pre-test it on a small scale. Data collection should be carefully supervised
to ensure that the information is accurate and complete. This often involves
training and re-training field staff that collect and compile data.
Module 5: Monitoring; quick start
3
WORKSHEET FOR COMPARING ACTUAL PERFORMANCE
WITH ITS STANDARD OF PERFORMANCE
Components/
Indicators
Actual
performance
Standard
performance
% Achieved
of standard
Action to
be taken
PHC services
1.
No. HH with
latrine
400
500
80%
Organise teams
to construct
latrines
2.
No. of mothers
who can
interpret GM
card
600
600
100%
Increase target
to 750
15
13
115%
Provide
incentives for
performance
Management
1.
No. of CHW’s
with improved
performance
• Tabulate and analyse the data. Compute the results by comparing the actual
with the performance standards, i.e., divide the monitoring indicator by the
standard. For example, if the performance target for community activities
was 50, and 30 were actually completed, the performance achieved would be
only 60 percent. You can use the computer files in modules 4, 6 and 7 to
process your data quickly.
Look for discrepancies between the input and output indicators and the
targets; trends over time that are increasing or decreasing; and administrative
areas or facilities that fall substantially above or below the norm for
performance.
• Present the results of monitoring to those involved in service management
and delivery, and take action. Each monitoring report should include actions
to be taken and the staff responsible for implementing those actions.
Stage 3: Reviewing
• Indicators should be reviewed periodically to determine if they should be
dropped, modified, or continued. When monitoring results are not being used,
you should consider discontinuing the indicator.
• In most cases, monitoring data are not effectively utilised because managers
have not been trained and supervised to analyse the data and to develop an
action plan. Thus you should determine if information is not being used
because it is no longer useful or because managers have not been trained,
directed, or supervised.
• If your original intention was to monitor indicators over a short period of
time in order to ensure that activities were implemented as planned, you may
decide to incorporate one or two key indicators into the routine monitoring
system.
Module 5: Monitoring; quick start
4
A laboratory technician at the Kakamega General Hospital in Kenya
helps to evaluate the comparative advantages of cereal based ORT in
comparison with standard ORS solution to prevent death from the
dehydration caused by diarrhoea
Photo by Jean-Luc Ray for AKF
Module 5: Monitoring; quick start
5
Introduction
Monitoring is the periodic collection and analysis of
selected indicators to enable managers to determine
whether key activities are being carried out as planned and
are having the expected effects on the target population.
Monitoring provides feedback to project management in
order to improve operational plans and to take corrective
action. Indicators can be used to: measure achievement of
targets; assess changes/trends in health status; compare the
level of achievement between working areas or project sites;
and identify currently under-served areas. An indicator is
defined as an indirect measure of an event or condition. For
example, weight-for-age is an indirect measure (indicator) of
a child’s nutritional status.
Although most managers already have a monitoring
system, it may not allow them to monitor some of the PHC
and management services that they deem to be especially
important. This module is designed to fill that gap. Managers
can use it to select a limited number of indicators from lists
that have been compiled for each PHC service and manage
ment service. Guidelines in the module explain how to design
and implement simple monitoring "systems" using these (or
other) indicators.
Most PHC managers have to oversee a large number of
programme services. In this series of modules we have
divided those services into two categories: PHC services
(immunization, antenatal care, etc.) and management sup
port services (planning, supervision, etc.).
Module 5: Monitoring; introduction
Definitions
6
Types of indicators to be monitored
Generic
indicators
It is helpful to classify indicators into broad categories
and then to select one or two from each category so that
key parts of the activity can be monitored and overlap can
be avoided. PHC MAP uses a "systems framework" to de
scribe PHC programmes in broad categories of inputs,
processes, outputs, effects, and impacts (see Module 1).
This module suggests some generic indicators for four of
these categories: inputs, resources needed to carry out the
programme; outputs, the services or goods produced by the
programme; effects, the knowledge, attitude, and behaviou
ral changes that result, including coverage; and impacts,
changes in health or fertility status due to the effects. By
"generic," we mean indicators that can be applied to most
PHC services. This module focuses on monitoring inputs,
outputs, and effects. Generic impact indicators for mortality,
morbidity, disability, and fertility are included, but the user
who wants to monitor these should consult Module 4,
Surveillance of morbidity and mortality.
The recommended generic indicators are summarised
below. Appendix A provides an annotated list of suggested
indicators for each of the specific PHC services. Appendix
B provides a similar annotated list for each of the specific
PHC management support services. Appendix C provides a
separate list of annotated PHC impact indicators to monitor
mortality, morbidity, disability, and fertility. Appendix D is a
summary list of PHC service and management service indica
tors with cross-references to other PHC MAP modules.
PHC service indicators
Since the primary purpose of this module is to monitor
PHC services, the lists of generic indicators start with effects
to encourage linking the effect with the outputs and inputs
needed to carry out that activity. Table 1 illustrates this
linkage. Obviously, not every PHC service needs to be
monitored with all of the generic indicators. Indicators
should be selected to fit specific needs.
Module 5: Monitoring; introduction
7
Table 1: Generic indicator categories for PHC services
Effects
Behaviour (also called coverage)
Knowledge and skills
Outputs
Utilisation of services
Quality of care
Contacts, visits
Access to services
Unit costs
Inputs
Availability of personnel, supplies, equipment, funds
PHC service effect indicators
Effects are changes in knowledge, skills, attitudes, and
behaviour that result from the PHC service. Since attitudes
are very difficult to measure, three types of indicators are
emphasised: knowledge, skills, and behaviour, or practice.
Behaviour indicators tell whether the target group has
done or is doing what is needed to be protected by the PHC
intervention. You can also call this coverage, which is a
measure of the proportion of the target group that is
following a prescribed behaviour or practice, e.g., using
contraception. In PHC, coverage also refers to the propor
tion of the target group that has received the prescribed
treatment in a correct and complete manner, e.g., fully
immunized. Coverage measures usually include all people in
the target group in the denominator, including those who
do not receive services from the PHC programme. Thus, the
two sub-categories of behaviour indicators are:
• Practice, e.g., proportion of eligible couples using
modern contraceptives
• Treated, e.g., proportion of children under five years
of age who are fully immunized
Knowledge indicators tell the manager whether moth
ers have understood key health education messages.
Module 5: Monitoring; introduction
8
Skill indicators tell whether they know how to perform
important health tasks.
• Knowledge, e.g., number or percent of TB patients
who know why it is important to complete the treat
ment for tuberculosis
• Skills, e.g., number or percent of mothers who can
correctly administer ORT
Annual
monitoring
of effects
sufficient
Record systems that are based on complete household
registration may be able to provide some data on effects (see
Module 3) but, by and large, this information is rarely
available from service statistics and will usually require a
community survey (see Module 2).
Usually, effects data should not be collected frequently
since significant changes would not normally occur rapidly.
Furthermore, data collection can be time-consuming and
expensive. Annual monitoring of effects may be sufficient,
unless changes in strategy are being implemented and
short-term monitoring is being carried out. Analysis of
effects would look at changes over time, comparisons with
project norms, comparisons among health centres and
breakdowns of distributions by characteristics such as age,
parity, socio-economic status, and geographic area.
PHC service output indicators
Outputs are the services and products that the PHC
programme generates with its resources. They are what lead
to the effects on mothers or children.
Outputs can be seen as the immediate result of PHC
processes, or services. The result of a process can be mea
sured as an output. For example, the process of visiting
pregnant women can be measured as the number of preg
nant women visited, an output.
The most important types of outputs in PHC are: utilisa
tion of the service; quality of the service provided; con
tacts of those in need of, or eligible for, the service; and
access to the service. The generic indicators we suggest fall
into these four sub-categories.
Module 5: Monitoring; introduction
9
Utilisation: To have an effect on knowledge, skills, and
behaviour, PHC services must be utilised. This set of indicators
tells the manager whether they are utilised and, if so, how.
Utilisation is the initial link between the effort that goes into
providing a service and the improvement in health that should
result from using the service. Utilisation indicators are import
ant for both outreach and clinical services. Depending on the
intervention, utilisation can be expressed in several ways. For
services which require a long period of constant contact, such
as family planning, tuberculosis treatment, and growth moni
toring, it may be useful to distinguish between those ever using
(number of acceptors, number enrolled, number registered) and
those currently using (number of current users, number of
active cases). Useful negative indicators include the number of
drop-outs, past users, and inactive users.
• Acceptors/users, e.g., number or percent of chil
dren enrolled in growth monitoring
• Continuation, e.g., number or percent of current
users of family planning
• Drop-outs, e.g., number or percent of ANC drop-outs
Information on utilisation can usually be obtained from
clinic and outreach reports as well as community surveys.
The distribution of users can be compared to targets and
broken down by geographic area, age, sex, ethnic group,
socio-economic status, etc.
Quality of care: Information on the quality of service
delivery is often important to managers for two reasons.
First, poor service quality can lead to drop-outs, low service
utilisation, and poor knowledge, attitudes, and practice.
Second, gaps in service quality imply that staff training and
supervision may be required. Quality indicators that manag
ers will usually want to monitor are in diagnosis, education,
treatment, and counselling.
• Diagnosis, e.g., number or percent of health workers
who screen fever patients for signs of other serious
illnesses, e.g., meningitis, pneumonia, etc.
• Education, e.g., number or percent of women who
receive correct information on immunization schedules
Module 5: Monitoring; introduction
Utilisation
indicators
important
10
• Treatment, e.g., number or percent of babies
weighed correctly
• Counselling, e.g., number or percent of health workers
who counsel mothers on nutrition needs of their children
Data for these indicators are rarely collected routinely.
The best information usually comes from direct observation
of health workers and can be compiled from service delivery
quality assessment checklists (Module 6). For some specific
indicators, information may be available from health centre
registers or health cards. Exit interviews may also provide
the necessary information.
Analysis typically focuses on health worker performance
over time, comparisons with project norms, and comparisons
among health centres.
High-risk
contacts
Contacts: Services may not be utilised if target groups
are neither informed nor motivated to use them. This type
of indicator tells the manager the proportion of the target
group that is being contacted or visited by the programme,
usually through outreach workers, group health education,
or mass media. Such contacts, however, do not necessarily
result in utilisation.
Low contact rates may indicate that health workers are not
visiting all households in their catchment areas, are visiting
them too infrequently, or are not adequately conveying educa
tional and motivational messages. This indicator is especially
important for outreach services and can be further refined to
focus on high-risk women and children. That is, the pro
gramme could give priority to those most in need of services
by scheduling appropriate outreach and clinic sessions.
• Contact, e.g., number or percent of households con
tacted by malaria workers
• High-risk contact/visit, e.g., number or percent of
malnourished children followed up by health workers
Data can come from clinic records, outreach worker and
supervisor records, and community surveys.
Analysis is similar to that already described. The distri
bution of people contacted or visited can be compared to
Module 5: Monitoring; introduction
11
targets and broken down by geographic area, age, sex, ethnic
group, socio-economic status, etc.
Access: This type of indicator will assist managers to
determine whether the services are accessible to the in
tended target groups. This is likely to be of greater concern
in rural and remote areas than in urban areas. But even in
urban areas, PHC services may not be accessible due to
distance, schedules, costs, and cultural obstacles. Indicators
in this group are particularly important for preventive ser
vices and for outreach programmes covering large catch
ment areas. Access indicators are often critical for
monitoring new or revised services, since people must have
access to a service, before they can use it. Accessibility can
be measured in terms of distance from a service, time
required to get to a service or the number of service sessions
held in a given time period.
• Physical distance, e.g., number or percent of pop
ulation living within five kms of a health facility
• Time, e.g., number or percent of population within a
15-minute walk of clean water
• Frequency of service: e.g., number of sessions held
per week
Access indicators often require first mapping out the catch
ment area to determine the proportion of the target group that
is and is not being served (Module 3). How frequently these
indicators should be monitored depends on how quickly access
can be expected to change. In many cases, monitoring on an
annual or semi-annual basis would be sufficient Data on
accessibility can be collected from community surveys, health
session activity reports, and outreach worker reports.
Analysis of accessibility data usually involves examining
the distribution of the target group served and unserved by
geographic distance from the service site. This information
can also be gathered by a population-based survey (Module
2). The distribution can be compared to targets and broken
down by geographic area, age, sex, ethnic group, socio-eco
nomic status, etc.
Module 5: Monitoring; introduction
Access
indicators
12
PHC service input indicators
Monitor
essential
inputs
Inputs are the resources needed to carry out the projects
services. They enable the project to produce its outputs. Most
PHC services require certain essential resources. In addition
to personnel, nurses, physicians, outreach workers, volun
teers, community leaders, etc., there are often key supplies
that are needed to provide the service, vaccines for im
munization, scales for growth monitoring, contraceptives for
family planning. And for some services, it is imperative to
have the proper equipment, e.g., X-ray machines for TB,
vehicles for outreach, refrigerators for immunization.
Managers and staff usually know which resources are
essential and which are the most likely to be unreliable. If
problems are being experienced or are anticipated, it may
be useful to monitor the availability of these key resources.
We suggest formulating the input indicators in the negative
to trigger immediate action. The most common input indi
cators would monitor the availability of personnel, supplies,
equipment, and funds.
• Personnel, e.g., number of trained TBAs; population
per active CHW
• Supplies, e.g., number or percent of health centres
without sufficient ORS packets
• Equipment, e.g., number or percent of outreach
workers without operational motorbikes)
Potential information sources for these indicators include
logistic supply records, stock inventory forms, supervisor
reports, and CHW reports. An item could be added tempo
rarily to these or other routine reports if it is not already
available. Data can also be collected with Module 6 and 7
checklists. If the resources are supposed to be available in
households, e.g., growth monitoring cards, ORS packets, the
required data could come from home visit forms or could be
included in a community survey (Module 2).
Analysis and interpretation of input indicators are very
straightforward. If supplies are found to be inadequate, there
is a problem. This information should stimulate the obvious
solution of supplying the needed inputs. If the cause of the
Module 5: Monitoring; introduction
13
shortage is unknown, this should trigger further investiga
tion into the logistics system. The logistics checklist in
Module 7 could be of help in that case.
PHC management
Indicators for the eight management services can also be
categorised as effects, outputs, and inputs. Table 2
illustrates this linkage.
Table 2: Generic indicator categories for PHC management
Effects
Staff behaviour (and "coverage")
Staff knowledge, skills
Outputs
Services or activities completed
Frequency of management services
Quality of management services
Inputs
Availability of trained personnel, supplies, information
Guidelines/protocols
Management effect indicators
The management services are designed to support PHC
service delivery. Thus, the effects of the management services
can be measured in terms of the knowledge, skills and behavi
our of service providers and support staff. Figure 1 shows how
management services affect PHC services. Appendix B lists
effect indicators you should consider:
• Staff behaviour, e.g., number or percent of PHC
staff who follow travel guidelines
• Staff knowledge, e.g., number or percent of trained
PHC providers who know how to prepare a work plan
• Staff skills, e.g., number of PHC nurses who re
ceived training in the correct use of an autoclave and
can. correctly use autoclave equipment
Module 5: Monitoring; introduction
14
Figure 1: A systems diagram of management and services
relationships
Management services
INPUT
PROCESSES
OUTPUT
EFFECTS
trainers
ORS
packets
training
(lectures
practise
In ORT)
CHWs
trained
In ORT
CHWs
skills
In ORT
▼
INIF’UT
1
trailnod
CHWS &
ORS
pwcKoto
+
PROCESSES
CHWe
diagnose &
prescribe
ORT
/ ,. ...... t
OUTPUT
ORS
packet
given
]
—J
Z
mothers
use
ORT
avoid
dehydration
and death
of child
/
J
IMPACTS
PHC services
Management output indicators
Outputs are the services and products that PHC manage
ment services generate with their resources. There are
basically three types of management output indicators:
• Services or activities completed, e.g., the num
ber of PHC providers trained
• Frequency of activity, e.g., the percent of facilities
completing quarterly reports
• Quality of management activity, e.g., the number
of supervision visits that included review or follow-up
on problems from previous visit.
Information for these indicators can often be obtained
from review of programme plans, interviews and discussions
with health workers and managers, review of supervision
and training reports, personnel records, account books, stock
records, and activity plans. Module 7 provides a more de
tailed description of the various data sources for these
indicators. As with PHC service indicators, the analysis will
Module 5: Monitoring; introduction
15
typically focus on comparisons over time, comparisons with
performance standards, or comparisons among health units.
Management input indicators
Inputs are the resources needed to carry out the management
services. We have suggested a few that often pose problems:
Personnel, e.g., the number or percent of PHC pro
viders recruited with requisite skills
• Supplies, e.g., the number of IEC materials received
for training outreach providers
• Information, e.g., the number of monthly service
reports received from private physicians and midwives
• Guidelines/protocols, e.g., the number of supervi
sors with the written protocols for supervision.
•
Management may come from outside the PHC organisa
tion or from another department inside the organisation.
Information for these indicators can be obtained from inter
views, observations, personnel records, and programme
plans. Again, Module 7 discusses information sources and
use of this information.
How long should you monitor PHC
activities?
PHC managers carry out one of two types of monitoring,
which we will call "routine" and "short-term."
Example: Thailand
A simple monitoring system was put in place at the village level in a north
eastern province to track coverage of six child survival interventions (im
munizations, growth monitoring, ORT, antenatal care, family planning, and water
and sanitation). This monitoring system was based on "neighbourhood health
inventory cards." Data were collected by local village health volunteers, and cards
were displayed at the volunteer’s home to make it easy for the community to track
progress. Supervisors collected the data every two months, did quick on-the-spot
analyses, provided feedback to the volunteer and community leaders, and forwarded
the results to the province health office for data entry and aggregate analysis.
This system enabled PHC administrators, health workers, and community
leaders to remain informed about the PHC services and achievements made in each
village.
Module 5: Monitoring; introduction
16
Routine monitoring involves compiling information on
a regular, ongoing basis for a core set of indicators. The number
of indicators should usually be kept to a minimum but should
still provide the manager with sufficient information to track
progress. Routine monitoring can be used to identify where
programme implementation is or is not proceeding as
planned.
Short-term monitoring is done for a limited period of
time and usually for a specific activity. Often when new
activities or processes are implemented, managers need to
know whether they are being implemented as planned and
whether they are having the desired effect. Managers nor
mally use this information to make adjustments in the new
intervention. Once implementation is underway, key indica
tors are incorporated into routine monitoring.
Short-term monitoring is also used when managers have
identified a problem in the delivery of inputs and services
Example: Zaire
A health zone manager set up a special monitoring system to assess the
effectiveness of a solution he had implemented to address a nutrition problem. He
found that mothers of malnourished children often left growth monitoring sessions
without understanding their child’s nutritional status and what they should be doing
about it at home. He believed that the cause of this problem was that the health
workers had insufficient time to provide counselling to mothers. Time spent with
mothers averaged only one minute. As a consequence, he decided to reorganise the
growth monitoring sessions. Children were weighed by community volunteers who
performed a triage, directing malnourished children to be seen by the nurse. This
should have allowed the nurse to spend more time counselling those mothers with
children most in need of attention. The manager monitored the effects of his strategy
by collecting information on whether the new triage approach was being properly
implemented, the average amount of time that nurses spent with mothers of
malnourished children, and mothers’ knowledge of their children’s nutritional status
and of activities they needed to carry out at home. He found that the time per
mother for counselling tripled, and mothers’ knowledge upon leaving the growth
monitoring session improved substantially.
and additional information is needed. Monitoring in this case
is used to examine a problem and pinpoint gaps in service
provision and management support services.
There can be a complementary relationship between
routine and short-term monitoring. For example, problems
that have been identified through routine monitoring can
Module 5: Monitoring; introduction
17
lead to a special intervention to solve those problems. A
short-term monitoring system might then be set up tempo
rarily to make sure that the intervention is effective. Once
that has been achieved, short-term monitoring may be
reduced, eliminated, or partially incorporated into the rou
tine monitoring system.
Keep it straightforward and simple (KISS)
In designing a routine or short-term monitoring system,
a few guidelines should be considered: 1) select only key
indicators that will be used by managers and other key users;
2) do not overburden staff by collecting too much data; 3)
provide feedback in a timely manner; 4) use a reporting
format that facilitates data interpretation and action.
Limitations of service monitoring
Some important PHC activities may be difficult to mon
itor. For example, it is difficult to collect data about the
content and effectiveness of services provided by CHWs at
the household level. Collecting information for some indica
tors, such as changes in infant and maternal mortality, may
not be feasible, especially over a short period of time. For
this reason, we suggest focusing activity monitoring on
input, output, and effect indicators to determine whether a
PHC service or management service is being carried out as
planned. Community surveys (see Module 2) can also be used
periodically to assess the effects and impact of these services
on knowledge, behaviour, and health status. A surveillance
system (see Module 4) can be utilised to track mortality,
morbidity, disability, and fertility, and to investigate their
causes.
Although the indicators suggested in the appendices
include some of the most common and useful indicators
currently used in PHC, it is expected that you will modify
them to meet the specific needs of your programme.
Module 5: Monitoring; introduction
Monitoring
mortality
difficult
18
QikF
Mr ■*
r>
j|
The monitoring and evaluation of programmes can help identify health
research priorities. In Trinidad, a medical laboratory conducts research
on new methods of family planning and ways of overcoming infertility
Photo by E. Rice for WHO
Module 5: Monitoring; introduction
19
Monitoring procedures
Nine steps to activity monitoring are listed below and are
described in detail later in this guide. The first four cover the
planning stage and seek to ensure that the information
collected is relevant, specific, feasible to collect, and can be
analysed. The next four cover the implementation of moni
toring: collecting information, compiling and analysing it,
reporting, and using the results for management action. The
ninth step suggests taking a look at the system periodically
to decide whether to continue monitoring activities at the
current level.
Steps in activity monitoring
Planning
Step 1: Specify the monitoring objectives
Step 2: Decide on the scope of the monitoring
Step 3: Select the indicators and performance standards
Step 4: Choose information sources and develop data collection procedures
Implementation
Step 5: Collect the data
Step 6: Tabulate and analyse the data
Step 7: Present the findings
Step 8: Take appropriate action
Assessment
Step 9: Decide whether to continue monitoring
Module 5: Monitoring; procedures
20
These steps assume that the user will normally want to
select a limited number of indicators to monitor one or more
PHC services for a short period of time. However, the same
process would be followed by those who might want to
monitor all PHC services on a routine basis. Those who
already have an MIS may find it useful to review the steps
to determine if improvements can be made in their system,
for example, by reducing the number and frequency of collec
tion of indicators or by streamlining the current system.
Step 1: Specify the monitoring objectives
What
Why
Who
The first step in designing a monitoring system, no matter
how small, is to determine what services are going to be
monitored, for what purpose, and for whom. Different users
will have different information needs and purposes. For
example, a donor or board member may only be interested
in monitoring programme coverage on a routine basis to
determine whether to continue funding. On the other hand,
a manager may want information about service inputs and
outputs, largely to make sure that the PHC services are being
carried out as planned, and to make adjustments if they are
not.
The following worksheet is used to clarify: 1) what
services will be monitored, e.g., immunization, logistics; 2) for
what purpose, e.g., routine or short-term information; de
cisions about continuing or modifying the service; and 3)
who will use the monitoring results, e.g., manager, commu
nity, or health workers.
• Activities
If you have completed Module 1, you have already set
priorities among your monitoring information needs. You
should start by reviewing the PHC and management services
that you selected. If you have not completed Module 1, find
the lists of the most common PHC services and management
services (both in Module 1 and the PRICOR Thesaurus), and
use these lists to decide which services to monitor. Appen
dices A, B, and C of this module can be used as references,
as well. In Modules 6 and 7, each PHC service and manage
ment support service is broken down into major activities
and tasks. These lists might be of use to those who are
Module 5: Monitoring; procedures
21
interested in monitoring only a specific part of a service.
After you have reviewed these modules, rank each PHC
service and management service on a scale of 1 to 10
(highest) to determine what should be monitored. Next,
determine if you are going to monitor input, output, or effect
indicators for these PHC and management services.
• Purpose
In specifying your purposes, you should clarify why you
need information in each area.
Many monitoring systems merely produce data for gen
eral information, often because it is "required," nothing more.
It is quite possible that the user(s) only want to know what
the PHC services are doing (e.g., how many people were
served this month, what were the major illnesses reported).
If this is the intended use of the data, then data collection
may be quite simple. Only numerator data may be needed.
For example: 45 children vaccinated; 13 CHWs trained.
In other cases the user may want to know whether a
service is being performed as planned. A judgement about
the effectiveness of that service can be made based on a
comparison between what was planned and what actually
happened, such as in the case of special monitoring. This
will require collecting numerator and denominator data, for
example: 45 of 60 eligible children vaccinated (75%); 13 of
15 CHWs trained (87%).
Finally, if specific decisions are to be made based on the
results, then "decision rules" should be determined at the
outset so that the user will be assured of getting enough data
to make the decision, for example: close the health centre if
attendance falls below 100 visits per month and revenues
are less than Rp 3,000.
Module 5: Monitoring; procedures
22
• Users
Identifying the users is important and worth checking to
make sure that there are no misunderstandings and that the
information collected will be of real use. The users should be
involved in the selection of the indicators, and must be able
to explain how the information will be used. If there are
multiple users, their various needs may have to be negoti
ated.
The following worksheet may help you summarise the
monitoring objectives of each user.
WORKSHEET FOR SPECIFYING THE MONITORING OBJECTIVES
What to
monitor
Purpose (routine, R,
or short-term, S)
Internal users
External users
Providers
Managers
Donors
Others
measure coverage of
immunization (r)
Nurses
Physicians
Clinic
AKF
MOH
ORT (outputs) determine no. clients
served (s)
Physicians
Director
Clinic
CIDA
determine availability
of TT (r)
Nurses
Director
Clinic
USAID
Training
(effects)
determine % of staff
trained (s)
Trainers
Director
Programme
CIDA
Planning
(effects)
determine plans
Planners
produced/distributed (s)
Director of
planning
UNFPA
Logistics
(inputs)
measure purchases of
FP methods (r)
Logistics
USAID
PHC services
EPI (effects)
ANC (inputs)
MOH
Management
Purchaser
Director
BKKBN
Module 5: Monitoring; procedures
23
Step 2: Decide on the scope of the
monitoring
After specifying the purpose of monitoring, managers need
to determine how broad the monitoring should be: what
geographic area will be included in the monitoring (the entire
region, a sub-district); which facilities or sub-projects are to be
included; which staff or workers will be included in selected
facilities; and how long monitoring will continue.
WORKSHEET FOR SPECIFYING THE SCOPE OF MONITORING
1.
What geographic area will be covered? Kisumu and Mombasa Districts
2.
Which facilities or sub-projects will be monitored? Clinical services
3.
Which personnel (managers, providers & volunteers) will be selected? Physicians
and nurses
4.
How long will the monitoring continue? Six months
It may not be necessary to monitor all of the service facilities
or staff in a programme area. For routine monitoring, it may
be a good idea to test the new monitoring procedures in a few
areas before instituting them throughout the project area. For
short-term monitoring, it may be sufficient to limit the moni
toring to: a) low performance facilities, sub-projects, or staff, or
b) facilities or staff from each geographic area.
Just as important as the scope of the monitoring is the
duration of data collection and analysis. The duration will
usually depend on whether the monitoring is routine or
short-term. Routine monitoring procedures usually continue
for an indefinite period, or at least until the user(s) determine
that the data are no longer needed. Short-term monitoring,
as the name implies, is more likely to be used for evaluation
and decision making and to have a limited duration. Duration
would be determined by the deadlines the user(s) have (or
set) for making a judgement or decision about the activity
being monitored. For example, if a new case-finding proce
dure is being tested, the manager may want to know whether
it is effective before expanding it to the whole programme.
The manager might set a three- or six-month test period,
after which a decision can be made to continue testing,
Module 5: Monitoring; procedures
Routine or
short-term
24
expand the procedure, or drop it. By setting a specific time
frame for short-term monitoring, the project can avoid
continuing data collection beyond its utility.
Step 3: Select the indicators and
performance standards
Modify as
appropriate
This module emphasises input, output and effect indica
tors. Appendices A and B provide extensive lists of broad and
narrow indicators for each PHC service and management
service. The user should examine these lists and choose a limited
number of indicators for inclusion in the monitoring system.
It is expected that most programmes will need to modify
the indicators presented in this module. Field tests have
shown that the most typical modifications are in: 1) the
definition of the target group (for example, children under
age 2, under age 4, under age 5, between 12 and 60 months);
2) terminology (for example, "diarrhoea" may be defined
differently in different cultures); and 3) phrasing, to make the
indicator culturally acceptable.
Although the indicators listed in Appendices A and B are
thought to include most of those that PHC managers will
need, there may be additional indicators that some pro
grammes will need to develop. The worksheet on the next
page can be used to specify PHC service and management
indicators, formulate the indicators, set performance stan
dards, and determine the frequency of collection.
Formulation
Indicators can be formulated in the following ways:
• Count: The simplest type of measure; just count the
number of events or objects. For example, 56 visits, 432
CHWs, 9,765 children immunized.
• Rate: A measure of the frequency with which some
event occurs, such as household visits/day.
• Ratio: Two numbers related to each other in a fraction
or decimal, such as the number of ANC visits made per
pregnant woman (3.2:1) or the number of trained TBAs
per population (1:490).
• Proportion: A special type of ratio expressing a rela
tionship between a part and the whole. For example, the
Module 5: Monitoring; procedures
25
3,250 children immunized out of 5,000 (3,250/5,000 =
0.65). The numerator is the portion of the total, the
denominator is the total.
• Percentage: A proportion multiplied by 100. For
example, (3,250/5,000) * 100 = 65 percent of eligible chil
dren immunized.
WORKSHEET FOR SELECTING INDICATORS AND STANDARDS
Indicators
Formulation
Standards Frequency
PHC services
Effect
Output
% of households using latrines
No. of mothers who can interpret GM card
% of training sessions with materials
Input
Management services
50%
600
annually
80%
monthly
6 months
Effect
% of CHWs with improved performance
30%
quarterly
Output
No. of training sessions with clinic staff
20
monthly
Input
No. of FP methods received from donors
20,000
CYPs
quarterly
Performance standards: In addition to selecting the
indicators, the manager should set performance standards
for each indicator. This step is often overlooked, but it is very
important, especially for where the objective is to make an
evaluative judgement or decision. If performance standards
are not set at the outset, then it will be impossible to
determine whether the activity has been successfully carried
out or has been effective. Use the above worksheet to define
standards for each indicator.
A performance standard is often called a "target" and is
usually quantified. For example, suppose that the activity to
be monitored is growth monitoring and three indicators are
selected: number of GM sessions held, number of children
weighed, and percentages of mothers counselled. "Targets"
need to be set for each of the indicators. How many sessions
should be held during the monitoring period; how many
children should be weighed; what proportion of mothers
should be counselled? Only if these "performance standards"
are set will it be possible to reach agreement on whether
performance is acceptable.
Module 5: Monitoring; procedures
Standards
are targets
26
These "standards" are the denominators in the computa
tion of performance. An indicator involves a numerator
(what was achieved or the actual performance) and a de
nominator (the target or planned performance). For example-.
No. GM sessions actually held = 20
* 100 = 80%
No. GM sessions planned to be held = 25
In immunization coverage, a common objective is to fully
immunize 80 percent of the target population. That "stan
dard" is the denominator. The numerator would be the actual
proportion of eligible children immunized, say 65 percent.
The performance would be:
No. of eligible children immunized 3,250
* 100 = 81%
No. of eligible children to be immunized 5,000 * .80
The result shows that the programme met 81 percent of
its target. It also shows that actual coverage was 65 percent
(3,250/5,000), or 15 percentage points below the target.
Minimize
data
collection
Frequency of data collection. Information for some
indicators is easier to collect than for others and frequency
of collection should be kept to a minimum so as not to
overburden staff and raise costs. Frequency is important to
consider in planning because each round of data collection
involves effort that may reduce the amount of time available
for services and other important management services. If it
is important to know exactly how many times an event
happened, e.g., how many children were immunized, how
many latrines were built, then the data would have to be
collected continuously. But if the objective is to determine if
a procedure is being carried out as expected, e.g., are CHWs
counselling mothers properly, are there enough ORT sachets
on hand, then the data can be collected at periodic intervals.
However, data collection and examination of results do not
have to occur simultaneously. The users should also deter
mine how often they want to examine the results. For some
users, an annual or semi-annual assessment may be enough.
Others may want weekly reports. There are no hard and fast
rules about frequency. It depends on the user’s needs.
Module 5: Monitoring; procedures
27
Step 4: Choose information sources and
develop data collection procedures
For each indicator, determine the source and the proce
dure for collecting monitoring data. For many indicators,
more than one source could provide the necessary data. The
following worksheet can be used to specify sources and
techniques for collecting data for each indicator.
The choice of information sources will depend on the
manager’s existing information system. As such, most of the
data needed for monitoring will probably come from existing
Techniques for monitoring PHC services
In addition to routine records, several other techniques are available for gathering
data for monitoring purposes.
Observation
Direct observation at the site of service delivery offers the opportunity to collect
information on health worker performance and on the presence of inputs. For many
indicators, this is the most reliable source of information, although it also requires
a caveat: people tend to improve their performance when they are being watched,
and thus, the experience may not be representative of what routinely happens.
Observation data can be collected during supervisory visits, home visits, or
household surveys.
Rapid surveys
Rapid surveys provide information on the population of users and non-users. It
is particularly useful for information on coverage and on home treatments, as well
as mothers’ knowledge. Module 2 presents a whole series of rapid household surveys.
These models can be used to carry out comprehensive surveys, or a few questions
could be extracted on a specific topic and used in a small, quick survey.
Exit interviews
Exit interviews involve asking questions of patients as they are leaving the clinic
or session. This type of interview offers the opportunity to collect information on
what the health workers did and how well the patient/mother was able to absorb
the information given. This information source can be incorporated into routine
supervisory visits as well as carrying it out as an independent activity.
Interviews with health workers
Much information can be gained just by talking to health workers, whether in
structured individual interviews, informal conversation, or focus group discussions.
It offers a quick, inexpensive way to get information on such things as problems
with inputs, knowledge about treatments, and identification of high-risk patients.
This source offers sensitive information; if a problem is identified this way, it is most
likely a real problem. However, if no problems are identified, that does not mean
they do not exist. The information generated from this information source may
require verification through routine records or direct observation.
Module 5: Monitoring; procedures
28
Use existing
sources
Modify
current
forms
sources. Routine records include the information sources
that make up the health information system, such as logistics
records, treatment registers, individual patient records, ac
tivity reports, and population-based records, including family
files. The form of these routine records will vary from
programme to programme, but the first place to look for
information is among what is currently being collected.
Many input indicators could be derived from the routine
record system or by making a few modifications of routine
records so that they produce the specific information desired.
Some process/output indicators could also be calculated
from routine records. For example, reviewing treatment
records or the treatment register could provide information
for the indicator: % of health workers using antibiotics only
in cases of pneumonia, strep throat, and otitis.
If the needed data are not already collected, it is often
possible to modify one of the current forms so that they will
provide the desired information. This may require nothing
more than a slight change in the wording of the current form.
For example, change "number of ORS packets distributed"
to "number of mothers of children under age 5 given ORS
packets." In other cases, a new item could be added to an
existing form. Example: add a question to the CHW’s home
visit register to ask mothers, "Do you have a growth moni
toring card for your child?" Or instruct supervisors to ask
CHWs a few key questions during their routine visits, for
example: "Have you been trained this past month how to
counsel mothers about side effects from immunizations?"
In some cases, it may be necessary to develop new
instruments to collect the data. Modules 2, 6, and 7 provide
guidelines, examples, and instruments that can be adapted
to fit monitoring needs. They describe the most common
data collection approaches: how to collect new data from
surveys of mothers, from observations of PHC services, and
from reviews of available records and reports.
Module 5: Monitoring; procedures
29
Informal interviews and discussions with health workers,
administrative staff, community leaders, and others may be
a practical way to collect general impressions of how the
programme is going, if more formal and specific data collec
tion procedures cannot be afforded. Time and financial
constraints must be taken into account when choosing
where and how to obtain monitoring data.
WORKSHEET TO SELECT DATA SOURCES AND TECHNIQUES
Data source:
Records
Provider client
interface
Client
Health
worker
Data collections
Technique:
Review
Observation
Survey/
Interview
Interview
PHC services indicators
% HH use latrines
No. mothers who can interpret GM
card
% of training sessions with materials
rapid survey
rapid survey
service data
Management services indicators
% of CHWs with improved
performance
supervision
records
No. of training sessions with clinic
staff
No. of FP methods received from
donors
service
records
logistic
procurement
records
Step 5: Collect the data
When new data monitoring forms or instruments are
developed, the user should first pre-test them on a small
scale. This includes the selection and training of data collec
tion personnel and the establishment of procedures for data
collection supervision and processing. Module 2, in particu
lar, includes some guidelines on data collection, including
pretesting, training of interviewers, and supervision. Module
4 presents guidelines for establishing an impact surveillance
system. Modules 6 and 7 also include relevant suggestions
for collection of input and process data. The following
Module 5: Monitoring; procedures
30
worksheet can be used to specify responsibilities for data
collection, supervision, and processing.
WORKSHEET FOR SPECIFYING DATA COLLECTION,
SUPERVISION AND PROCESSING
Staff
Responsibility
Collection
Supervision
Processing
Health Worker
Collect
Clinic Staff
Collect
Supervise health worker
Send to district
District Manager
Receive
Use data to manage
Compile
MIS Manager
Receive
Send to district
Process and report
Again, the easiest approach would be to collect the
needed data through the existing system. This would elimi
nate the need to set up a special data collection effort. CHWs,
supervisors, physicians, and others could easily collect a
small amount of additional information, especially if it is only
for a limited period of time. However, it will probably be
necessary to carry out at least minimal training to ensure
that workers understand the changes in the existing system
and its purpose.
Step 6: Tabulate and analyse the data
The monitoring data should be tabulated and analysed to
meet the objectives and scope specified in steps 1 and 2. Step
3 showed how to compute the results by comparing actual
with planned achievement. The following worksheet can be
used to specify the actual performance observed, the perfor
mance standard or target, and the percent of the standard
achieved. Most tabulation will be straightforward counts
and/or percentages.
There are several ways in which data analysis can facili
tate interpretation of results. You can identify problems by
examining frequency distributions (Table 3), by comparing
the actual values of the indicators to the performance
standards or targets (Figure 2); by comparing performance
between health units or administrative districts (see Figure
4); and by comparing administrative units over time (see
Table 4).
Module 5: Monitoring; procedures
31
WORKSHEET FOR COMPARING ACTUAL WITH STANDARD PERFORMANCE
Components/
Indicators
Standard of % of standard Action to be taken
Actual
performance performance achieved
PHC services
1. Proportion HH with
latrine
2. No. of mothers who
can interpret GM
card
0.40
0.50
600
600
80%
Organise teams to
construct latrines
100%
Increase target to 750
0.55
0.80
69%
Secure funding to
purchase materials
1. Proportion of
CHWs with
improved
performance
0.35
0.30
116%
Provide incentives
for performance
2. No. of training
sessions with clinic
staff
12
20
60%
Provide transport
and materials for
training
3. No. of FP methods
received from donor
10,000
20,000
CPY
50%
Secure additional
methods locally
3. Proportion of
training sessions
with materials
Management service
CPY
The data can be displayed in various ways. The most
common are lists, tables, and graphs. Table 3 shows the
number and percentage breakdown of selected pregnancyrelated indicators for a six-month period.
The following examples are taken from a semi-annual
report of a PHC programme in Bangladesh.1
Figure 2 shows data in graphic form compared to stan
dards or targets set for the same periods.
The next example (Figure 4), shows how data from
different health centres can be compared. These data are of
Vitamin A-capsule coverage in 14 disaster-prone areas in
Bangladesh.2
1 From the "Aga Khan Community Health Programme, Dhaka, Bangladesh. Progress Report,
April 1990 - September 1990."
2 ibid.
Module 5: Monitoring; procedures
32
Table 3: Pregnancy-related indicators: April-September 1990
Total deliveries
Live births
Still births
Delivered by trained personnel
Home delivery
Delivered by AKCHP trained TEA
Delivered by other trained personnel
Delivered by untrained personnel
TT coverage of women delivered
Complete
Incomplete
None
N
%
575
559
16
375
332
70
73
189
100.0
97.2
2.8
66.5
57.7
12.2
12.7
32.9
393
132
39
69.7
23.4
6.9
Data can be presented in a tabular form to compare
results over time by administrative areas. The final example
(Table 4) shows the number of pills distributed each month
for eight districts. Overall, a total of 1,501 pill cycles were
distributed. The month of July 1989 had the highest level of
pill distribution. Among the eight districts, the Canca district
had the highest overall level of pill distribution.
Figure 2: Eligible children fully immunized: Sept 1989-Sept 1990
100
8
85
oi
61.9
55.6
0)
CD
I
85
75
3.
2
------ • ACTUAL
50
o
50
47.6
^=4^
49.3
49.7
9/89
12/89
3/90
TARGET
25
6/90
9/90
Quarter
Module 5: Monitoring; procedures
33
Figure 4: Vitamin A - capsule coverage
August, 1990
0)
W
ts<D
O'
oZ
Total Rural
Pirgani
Chilmari
Matlab Extension
Matlab MCH-FP
Gopalganj
Rojoir
Shakipur
Mirzapur
Santnia
Saturia
Total Urban
Chittagong
Khulna
Dhaka W 62
Dhaka W 60
0
10 20 30 40 50 60 70 80 90 100
Coverage (per cent)
Table 4: Number of pills distributed by district and by
month/year
District
Calle
Valle
Pasto
Santander
Caldas
Atlantico
Tolima
Canca
Total
05/89 06/89 07/89 08/89 09/89
10/89
11/89
Total
5
63
20
30
7
15
10
47
10
42
24
40
15
26
18
52
37
10
42
52
8
9
13
69
30
7
37
52
9
9
14
56
30
28
33
37
4
10
17
71
20
11
38
34
3
13
33
66
21
6
5
22
2
13
35
71
153
167
199
267
48
95
140
432
197
227
240
214
230
218
175
1501
Step 7: Present the findings
The results of activity monitoring should be presented to
those involved in service implementation: supervisors,
health staff, community members. You should review the
"Worksheet for specifying objectives" in Step 1 to
determine if the users, in fact, need the information. Al
though results can be presented graphically or in tables, the
presentations should be adapted to the level of the users.
Module 5: Monitoring; procedures
34
They should be simple and point out major findings. The
participants should be allowed to contribute their viewpoints
on potential causes of and solutions to problems identified.
Meetings with the users of information can promote the
sharing of perspectives among the different PHC partners.
Step 8: Take appropriate action
Explore
causes,
find
solutions
When the monitoring results have been presented and
discussed among the various PHC partners, you must use
your findings to decide whether action needs to be taken,
and if so, which action.
This means that you must first explore causes and then
develop solutions. In many cases, the causes may be obvious
or well-known to the staff. In Thailand, for example, health
workers did not counsel mothers during growth monitoring
sessions because the sessions were too noisy and there was
not enough time.
The checklists in Modules 6 and 7 can be helpful guides
for exploring the causes of problems. For example, if im
munization coverage is low, the immunization checklist
could be used to examine the service delivery process to
determine whether: health workers are contacting and fol
lowing up eligible households; mothers are coming to im
munization sessions; children are being immunized properly
and mothers counselled about possible side-effects; and if
vaccines, syringes, and other supplies are in adequate supply.
When the cause of the problem and/or the most likely
solution are not known, the PHC MAP Problem-solving
guide and the PRICOR Operations Research manuals can
help managers work their way through this problem-solving
process.
Once a solution has been agreed upon, its implementation
must be planned. This involves setting objectives and deter
mining what activities must take place, who should carry
them out, where the services should be provided, when the
services should be offered, and what resources are required.
The action decided upon may itself require additional
short-term monitoring to make sure that: a) the interven
tions selected are implemented as planned; and b) they have
the desired effects.
Module 5: Monitoring; procedures
35
Step 9: Decide whether to continue
monitoring
Activity monitoring is designed to meet the current needs
of managers and other users. As those needs change, so
these should monitoring requirements. As programmes im
prove over time, managers may have less need for frequent,
detailed information on some inputs and outputs. Effect
indicators usually take on more importance as input and
output indicators show improved implementation. The num
ber of indicators can ordinarily be reduced when sustained,
satisfactory performance has been achieved. Periodic review
of all MIS indicators can help managers keep their MIS
streamlined by reducing the number of indicators, reducing
the frequency of collection of data, and reducing the aggre
gation and reporting of data to higher levels.
Module 5: Monitoring; procedures
36
Health outcomes can be monitored by qualitative and anecdotal
evidence as well as by quantitative data, as exemplified by the happy
countenance of this obviously healthy Bengali boy who has been served
by the Aga Khan Community Health Programme in Dhaka, Bangladesh
Photo by Jean-Luc Ray for AKF
Module 5: Monitoring; procedures
39
Appendix A: PHC service indicators
This appendix presents an annotated list of selected indicators for the
following PHC services:
GENERAL PHC
General PHC household visit
Health education
MATERNAL CARE
Antenatal care
Safe delivery
Postnatal care
Family planning
CHILD CARE
Acute respiratory infections
Breast feeding
Diarrhoeal disease control/oral rehydration therapy
Childhood disabilities
Child immunization
Growth monitoring/nutrition education
COMMUNITY HEALTH
Water supply, hygiene, and sanitation
OTHER HEALTH CARE
Accidents and injuries
Chronic, non-communicable diseases:
Malaria
Treatment of minor ailments (general curative care)
Tuberculosis
Sexually transmitted diseases, HIV/AIDS
The indicators for each PHC service are divided into three categories:
effects, outputs, and inputs. In general, these categories include indicators
that cover one or more of the generic criteria described in the text. Examples
are shown below.
Effect indicators:
• coverage, e.g., number or percent of children fully immunized
• behaviour, e.g., number or percent of households that use a sanitary
latrine
Module 5: Monitoring; appendix A
I
40
• knowledge, e.g., number or percent of TB patients who know why it
is important to complete the treatment for tuberculosis
• skills, e.g., number or percent of mothers who can correctly administer
ORS
Output indicators:
• utilisation, e.g., number or percent of children under two years enrolled in
growth monitoring
• quality of care, e.g., number or percent of health workers using sterile
needles and syringes for each immunization injection
• contact/visit, e.g., number or percent of pregnant women con
tacted/visited by CHWs
• access, e.g., number or percent of population living within five kms of
health facility
Input indicators:
• personnel, e.g., number of trained TBAs; population per active CHW
• supplies, e.g., number or percent of health centres without sufficient
ORS packets
• equipment, e.g., number or percent of health units without functioning
laboratory equipment
Although these indicators represent practical and expert recommenda
tions, they may not be universally applicable and may need to be adapted
to fit local circumstances. For some indicators, local standards for treatment,
training of staff, and equipment must be reviewed and incorporated into
your data-gathering instrument in order to measure PHC inputs, outputs,
and effects. For other indicators which require the measurement of knowl
edge and skills, the user may need to review the content of PHC IEC and
training efforts to determine key knowledge areas.
Footnotes provide suggestions for data sources and, in cases where it is
not obvious, explain what the indicator is designed to measure and why it
is important.
In some cases, more than one indicator is suggested for a similar area.
As stated in the introduction, the target group and period of observation
need to be specified for many of these indicators. Those given are illustrative
only.
The term "health units" applies to health centres, health posts, or
community-level health services. This term should be interpreted to fit each
programme’s health system.
Most of the indicators are designed to be simple counts of activities or
simple percentages. In many cases counts will be sufficient, since the
objective will often be to determine whether a target has been met.
Module 5: Monitoring; appendix A
41
Percentages are recommended where possible, and ideally, both counts and
percentages would be calculated.
GENERAL PHC HOUSEHOLD VISIT
Output indicators
• number or percentage of households visited by CHW in last three
months
• number or percentage of PHC household visits during the last three
months where the health worker discussed:1
- growth monitoring/nutrition (if malnourished child)
- antenatal care (if pregnant woman)
- family planning (if woman of child-bearing age)
- water and sanitation
- immunizations
- oral rehydration therapy (if diarrhoea case)
• number or percentage of the target group visited by their CHW in the
last three months by type:2
- women 15-49 years of age
- children under 5 years of age
- high-risk cases
Input indicators
• number of households per CHW3
• population per CHW2
• number of active health workers by type:
-CHW
- public health nurse
- midwife
Notes on the general PHC household visit indicators
1 Care should be taken in analysing and interpreting results for this indicator, since not all
households visited would require an the messages listed. The denominators should beadjusted
to reflect this.
2 Information could be obtained from home visit forms, if they exist, or from rapid surveys (by
modifying the PHC rapid survey form).
3 Informotion for this indicator can be derivedfrom population/census information. See Appen
dix G of Module 2 for estimations of the target population.
HEALTH EDUCATION
Effect indicators
• number or percentage of respondents who practise health behaviour
outlined in the health education objectives7
Module 5: Monitoring; appendix A
42
• number or percentage of the target population who remember health
education messages on mass media, television, radio, billboards, posters,
etc., during the last 1-2 weeks2
• number or percentage of respondents who know the importance of the
health education topic discussed by CHW during the last visit3
Output indicators
• number of the target population that was visited at home and received
health information during the last three months4
• number or percentage of health workers using 1 or more health
education techniques (role playing, demonstration, flip charts, and others
used in the local area)
• number or percentage of clients receiving health information in a
community or group setting5
Input indicators
• number or percentage of CHWs trained in health education6
• number of community organisations which provide health education
services
• number of CHWs compared with 1,000 households or each village7
• number or percentage of respondents that wish to receive additional
health education information/topics3
Notes on health education indicators
1 Review the local norms for positive health behaviour, as explained in health education mate
rials. Survey respondents to determine if they practise each type of behaviour.
2 Respondents can be asked about specific messages from various sources of mass media.
3 This indicator is for households that were visited during the last 3 months (see Module 2).
4 Target groups may include women 15-49 years, children under age 5, high-risk cases (tubercu
losis, malaria, STD/HIV), and others.
5 Module 2 Assessing community health needs and coverage, provides interview questions for
measuring health education among reproductive age women, children under 24 months,
children 24-60 months, and other household members.
6 Health workers include CHWs, public health nurses, midwives, physicians and others.
7 The ratio of CHWs to households or number per village should be defined in the local context
and in accordance with local needs.
8 This indicator measures the demand among the population for more information.
ANTENATAL CARE
Effect indicators
• number or percentage of pregnant women identified that are "high-risk"1
• number or percentage of women who made three or more prenatal visits
during their last pregnancy2
• number or percentage of women who received two doses of tetanus
toxoid to confer protection prior to delivery3
• number or percentage of women who complied with iron folate supple
mentation regime during last pregnancy4
Module 5: Monitoring; appendix A
43
• number or percentage of women gaining less than 1 kg/month during
the second and third trimester
Output indicators
• number or percentage of women who received at least one antenatal
visit while they were pregnant
• average number of contacts per pregnant women5
• number or percentage of pregnant women seen in antenatal care who
were counselled about danger signs indicating the need to seek further
care
• number or percentage of workers who regularly track high-risk preg
nancies6
• number or percentage of high-risk women seen by a health worker who
were identified as such7
• number or percentage of health workers providing medical attention to
high-risk pregnant women or referring them5
Input indicators
• number or percentage of health units which experienced stock shortages
of iron supplements/malaria prophylaxis9
• number of days when iron supplements/malaria prophylaxis were out
of stock in the clinic
• number or percentage of women of reproductive age weighing less than
38 kg before pregnancy10
Notes on antenatal care indicators
1 High risk includes: maternal age less than 16 or over 35, first pregnancy over 30 years of age,
5-8past pregnancies, over 10 years since last pregnancy, previous caesarean section, previous
delivery complications, previous still birth, 2 or more previous miscarriages, previous neonatal
death, 3 or more abortions. 2 or more infant deaths, previous low birth weight baby, maternal
height less than local standard, small pelvic outlet, maternal limp/oolio leg, bleedi nasinee last
period, clinically anaemic, fever, blood pressure greater than 140/90, sputum AFd/ positive,
diabetes, heart disease, pre-eclampsia, abnormalfoetal presentation, sickle cell, malaria, AIDS,
breech presentation or transverse lie, large for date pregnancy, suspected twins.
2 Information for these indicators can be obtained from rapid or mini surveys of women having
delivered within the last 12 or 24 months, depending on local concerns. The norm for the
number of visits should be adapted to local policy.
3 This indicator shows how well women complete the necessary tetanus toxoid injections during
their last pregnancy. The numerator is the number of women that receive the full coverage; the
denominator is all ever-pregnant women.
4 This information can be gathered in a survey by asking if iron pills were taken during preg
nancy.
5 This indicator shows how often those women using antenatal care seek it. The numerator
would be total antenatal visits, and the denominator would be the number of women making
at least one antenatal visit.
6 "High-risk" will need to be defined locally. Information can be obtained from supervisory
checklists.
7 This indicator measures how well the high-risk system works. Information on high-risk preg
nancies could be compiled from antenatal cards or other individual service records kept in the
health facility which record high-risk factors.
8 Whether health workers need to refer, or can provide advice without referral, will depend on
the educational and training level ofhealth workers and the sophistication of the health facility.
Module 5: Monitoring; appendix A
44
9 Both indicators point out problems in the supply system, although the second provides a more
detailed picture of the extent of the problem. Data can be obtained from supervisory checklists
for antenatal care (interviews with health workers or review of stock records and inventories).
10 This is a measure of the risk ofpregnancy. This information can be gathered by survey or review
of records.
SAFE DELIVERY
Effect indicators1
• number or percentage of deliveries in preferred locations (e.g., hospital,
maternity clinic, health clinic, midwifery or birthing centre)2
• number or percentage of births attended by trained health provider
(physician, nurse, midwife, CHW, TBA)3
• number or percentage of mothers with knowledge of danger signs and
where to go if complications arise (danger signs include malaria, diabetes,
hypertension, liver disease, and others)
• number or percentage of families with members (men, women, mothers-in-law) aware of danger signs of pregnancy, labour, delivery, and
puerperium
• ratio of positively treated obstetrical complications to all complications
during the last 3-6 months4
• percentage of women with optimum weight gain (i.e., no more than 13
kg and no less than 6 kg from pre-pregnancy to childbirth)5
Output indicators1
• number or percentage of pregnant women who were trained about the
danger signs of delivery and instructed where to go6
• number or percentage of obstetrical complication cases treated7
Input indicators^
• number or percentage of TBA trained in family planning, recognition of
obstetrical complications, and hygienic birthing practices, and linked
with the formal health service delivery system9
• number or percentage of district hospitals equipped and functioning as
first referral centres10
'• number or percentage of facilities and staff using standardised referral
protocols to manage obstetrical complications11
• number or percentage of health cadres and staff trained in care of
obstetrical complications, especially emergency cases12
• number or percentage of communities with organised transport systems
in place to effect referral13
Module 5: Monitoring; appendix A
45
Notes on safe delivery indicators
1 Most of the effect and output indicators can be obtained from suruey interviews of women
having delivered during the last 12-24 months.
2 This indicator measures women’s practice in using preferred facilities. The indicator is only
relevant if the women have reasonable access. This inaicator could be used to focus only on
mothers from the low socio-economic status.
3 The indicator is only relevant if the woman has reasonable access to a trained provider. The
numerator is the number using a trained provider; the denominator is the number of women
with access.
4 Positive treatments refer to complications which are successfully treated versus unsuccessful
treatments which result in maternal mortality or chronic morbidity. This information can be
gathered from a review of records in obstetrical care facilities. If the information is gathered
directly from patients, a large sample of women will be required to collect data from those with
complications.
5 This indicator can be measured by using hospital records and surveys.
6 This information can be gatheredfrom a survey of clients or routine service records ofMCH
facilities or providers.
7 This indicator requires a review of obstetrical care facility records.
8 Information on input indicators can be obtained from providers and/or a review of service
records.
9 This indicator is only appropriate where TBAs provide a large proportion of deliveries and
their capability is ofmajor concern.
10 Periodic service records of health facilities usually provide information about the types of
services provided, i.e., obstetrical referral services, and equipment available, i.e., to manage
obstetrical complications.
11 lb measure this indicator,first determine ifstandardised referralprotocols exist and what they
are. Next, providers and clients can be surveyed to determine if the protocols are known by the
providers and followed.
12 lb gather this information, determine the types of complications handled by various types of
health staff. Then survey health cadres anastaff to determine if they have been trained (their
knowledge can also be measured). Results of this indicator permit an evaluation of the obstet
rical complication capability of various types of health staff and facilities.
13 This indicator measures clients’ access to emergency obstetrical services and is obtained by
surveying obstetrical care providers or facilities.
POSTNATAL CARE
Effect indicators
• number or percentage of women receiving postnatal care from health
workers
• number or percentage of postnatal women who return for follow-up
visits
• number or percent of women who have delivered and know when and
where to return for a postnatal follow-up visit
Output indicators
• number or percentage of women who have delivered and were seen at
least once during the postnatal period2
• number or percentage of health workers counselling mothers on poten
tial danger signs in postpartum period requiring consultation with health
worker
• number or percentage of health workers using sterile materials for
cutting and bandaging the umbilical cord, OR number or percentage of
Module 5: Monitoring; appendix A
46
mothers who said that health worker used clean materials for cutting
and bandaging umbilical cord2
• number or percentage of mothers delivered by a trained birth attendant
who received counselling on child services after delivery
Input indicators
• number or percentage of clinics/local health workers experiencing
shortages of sterile equipment and supplies for appropriate care of the
umbilical cord (razor blade, bandages, etc.)
• number or percentage of facilities with one or more health staff trained
in postnatal care and counselling3
Notes on postnatal care indicators
1 This indicator measures whether women are receiving postnatal follow-up. This information
can be obtained from rapid or mini surueys.
2 When sterile or clean materials are used, the incidence of postnatal infections is reduced.
Information for the first indicator can be obtained from supervisory checklists for deliveries
or from exit interviews with mothers. Although the latter may be less reliable, tne difficulties
of observing delivery practice in many settings may make this the only source of data available.
3 The type of person classified as a "trained birth attendant" will depend on local programme
norms. This could be a re-trained traditional birth attendant, a public health nurse, or a
midwife.
FAMILY PLANNING
Effect indicators7
• number or percentage of eligible women knowing at least one modern
family planning method and where to obtain it2
• number or percentage of women of child-bearing age currently using
modern family planning methods3
• number or percentage of last pregnancies not intended4
• average length of time current contraceptors of modern methods have
used the method5
• number or percentage of births, with less than 24 months’ spacing,
among younger women 15-29 years6
• ratio of births to women below 19 or above 34 years7
Output indicators
• number or percentage of eligible women contacted by health worker, for
outreach3
• number of women receiving methods from CHW, by contraceptive
method
• number of new acceptors by method, particularly longer acting methods9
• number or percentage of women seen who were referred from other
providers for clinic-based services70
Module 5: Monitoring; appendix A
47
• number or percentage of health workers who explain where and when
to go for routine follow-up for family planning services12
• number or percentage of acceptors followed up22
• number or percentage of women who received counselling on possible
side-effects of the contraceptive chosen, or who were asked about
side-effects on follow-up visits
Input indicators
• number or percentage of health units experiencing stock shortages of
each contraceptive method in the last month23
• number or percentage of health units who had less than two types of
contraceptives in stock at anytime during the month24
• number or percentage of villages without a regular supplier of contra
ceptives25
Notes on family planning indicators
1 The effect and output indicatorscan be measured by surveying eligible women or couples. The
woman should live in a conjugal relationship and still be at-risk to pregnancy.
2 Modern methods include pills, injectables, lUDs, implants, sterilisation, and condoms.
3 This indicator measures the coverage of contraceptive use among reproductive-age women,
usually 15-49 years.
4 This indicator measures unwanted pregnancies resulting in unwanted births or abortions. It
provides a measure of the unmet needforfamily planningservices. The numerator is unwanted
last pregnancies; the denominator is the number of women reporting one or more pregnancies.
5 This measure is obtained for each contraceptive method and indicates the continuity of
effective use. An alternative indicator is to determine if the current method has been used
continually for the last 6 or 12 months. The numerator is current contraceptors continually
using; the denominator is all current users (by method).
6 This indicator measures the spacing of children among young women to improve both the
health of mother and baby. Information can be gathered from a survey of mothers.
7 Women 15-19 and 34+ years should have substantially lower fertility levels. As women delay
marriage and older women limit additional pregnancies, fertility should be concentrated in the
ages 20-34 years. This indicator is appropriate for programmes which are targeting young
women either to delay marriage or to space births, and older women to use long-term or
permanent contraceptive methods.
8 This indicator measures the level of contact that family planning services have with their target
population. This information can be obtained from rapid or mini surveys.
9 IUD, sterilisation, and implant
10 This indicator measures now well women using other health services are being encouraged to
use family planning as well. It is a measure of service integration. This information could be
obtained by modifying the service records (to show if the women were referred and by whom)
or through exit interviews with clients.
11 Information can be obtained from supervisory checklists using observation of health worker
patient encounters.
12 This indicator provides more in-depth information about how well familyplanning clients are
being followed up to ensure continuation. Information could be obtained by compiling infor
mation from individual service records to see whether patients are returning or other actions
are being taken to ensure they return.
13 This indicator can point out problems in the supply system. Data for each method can be
obtained from supervisory checklists for family planning; interviews with health workers or
review of stock records and inventories. If monthly stock levels have been established for
each method, another indicator can be developed to measure low stocks and the risk of
shortages.
14 Some programmes may want to use this indicator which addresses the issue of contraceptive
choice in family planning programmes. This information can be obtained from supervisory
checklists. For facilities that have a wider range of methods (5-6) the minimal number can be
raised to, for example, three methods.
Module 5: Monitoring; appendix A
48
15 Information for this indicator presupposes knowledge of the villages in the catchment area and
their locations. Information about specific availability can come from rapid/mini-surveys or
from logistical reports and mapping of the area.
ACUTE RESPIRATORY INFECTIONS
Effect indicators
• number or percentage of ARI cases (cough, fever, difficulty breathing)
treated by health worker correctly1
• number or percentage of ARI patients or their caretakers who know the
correct dosage and duration of treatment for ARI
• average number of serious symptoms associated with ARI recognised
by mothers with children under age five2
• number or percentage of mothers who know the warning signs of ARI
and when to seek care3
• number or percentage of pneumonia cases receiving standard case
management at health facilities4
• number of ARI hospitalisations per year among children under age five
Output indicators
• number or percentage of women with children under age five that were
informed of serious ARI symptoms by CHW or other health provider
• number or percentage of health workers using antibiotics only in cases
of pneumonia, strep throat, and otitis (per local policy)5
Input indicators
• number or percentage of health units which experienced stock shortages
of antibiotics in the last month6
• number or percentage of health units/health workers without function
ing timepiece with second hand (to count respirations)
• number or percentage of health workers or facilities with health care
workers trained in ARI case management
• number or percentage of health facilities that have an ARI treatment
chart on the wall
• number of percentage of health facilities with national treatment guide
lines
Notes on treatment of acute respiratory infections indicators
1 This indicator measures the level of coverage for ARI treatments by health workers. Informa
tion for this indicator can be obtained only from rapid surveys. Some care should be taken in
interpreting this indicator since the denominator would be self-diagnosed ARI based on a
history of cough, fever, and difficult breathing. The exact criteria to be used to determine what
is considered an ARI case will need to be defined locally.
2 ARI symptoms include high fever, cough with sputum, rapid breathing, difficult breathing,
determined by chest indrawing or retracting, inability to drink, earache or discharge, seizures,
weakness or lethargy.
3 Mothers should seek care before the symptoms become serious. Symptoms of moderate ARI
include; a moist cough (often frequent), and frequent or difficult breathing, sometimes accomModule 5: Monitoring; appendix A
49
panted with wheezing or other sound. Moderate ARI is often accompanied by a fever and
weakness (lethargy), but these symptoms are associated with a variety of illnesses not just ARI.
4 This indicator measures the population that has access to standard ARI case management
through a health worker in a facility who is trained in standard ARI case management with a
source offree or affordable antibiotics. As ARI case management requires the administration
of antibiotics, emphasis remains on access to providers within the health system.
5 The denominator in this indicator is health workers prescribingantibiotics, and the numerator
is those health workers prescribing antibiotics for pneumonia, strep throat, or otitis.
6 This indicator can point out problems in the supply system. A second, more detailed indicator
could be "the percentage of health units with stock-outs of one day or more during the last
period." Data for both can be obtained from supervisory checklists for ARI; interviews with
health workers or review of stock records and inventories.
BREAST FEEDING
Effect indicators
• number or percentage of mothers breast feeding babies up to 12 (18)
months of age
• number or percentage of mothers who began breast feeding within
24 hours after birth1
• number or percentage of mothers who gave the baby colostrum (local
word)
• number or percentage of mothers who know why it is important to give
colostrum2
• number or percentage of mothers who breast fed and did not provide
food supplements during the first 4 months3
• number or percentage of mothers starting to give supplemental foods
(water, other liquids, solid foods) to infants 4-6 months of age4
• proportion of infants 6-9 months of age who received both breast milk
and complementary foods
• number or percentage of mothers who continued to breast feed during
the last case of diarrhoea5
• number or percentage of women with children under age two who know
how long to continue breast feeding
• number or percentage of currently breast feeding women who know
how to position the child and care for her breasts6
• number or percentage of currently breast feeding who know what to eat
during the lactation period7
Output indicators
• number or percentage of women who were informed during their
pregnancy by a health provider about the value of breast feeding and
when to start
• number or percentage of postnatal women with children under age two
who received breast feeding brochures, pamphlets, or other educational
materials
Module 5: Monitoring; appendix A
50
number or percentage of mothers who received information about breast
feeding during the neonatal period; 28 days after birth
Input indicators
• number of workers who have been trained in breast feeding education
• number of CHWs or other health providers with correct knowledge
about the benefits of breast feeding and when to start5
• number of health units which have prenatal and postnatal educational
materials for pregnant/postnatal mothers which explain breast feeding
(both benefits and procedures)
•
Notes on breast feeding indicators
1 This indicator shows correct knowledge of mothers about when to initiate breast feeding.
2 The numerator is the number of women who answer correctly; the denominator all mothers.
The targetgroup can be limited to women withchildren under ages 2-3 to provide more current
information.
3 Mothers should breast feed without supplements during the first 4 months of age.
4 Mothers should begin to introduce supplemental foods at 4-6 months of age.
5 Mothers should continuefeeding during diarrhoea. The numerator is mothers who breastfeed;
the denominator is mothers who reported a case of diarrhoea.
6 The baby’s head should be slightly elevated during feeding. The breast should be washed with
soap and water (before and alter) then dried.
7 The recommended diet for lactating women includes proteins, vegetables (particularly local
vegetables high in vitamin A), and calcium (from milk, other dairy products, bones, or supple
ment).
8 Develop a list of benefits; then ask the provider to identify the benefits to the child’s health.
Benefits of breastfeeding include improved nutrition, increased resistance to diseases, psycho
logical security of the child, and others. Breast feeding should start within the first 24 fours
and include the introduction of colostrum.
DIARRHOEAL DISEASE CONTROL/ORAL REHYDRATION
THERAPY
Effect indicators
•
•
•
•
•
•
number or percentage of mothers who have heard of ORT, ORS solution,
SSS, or local names
number or percentage of mothers who can state three rules of home
case management for diarrhoea (fluids, feeding, care seeking)
number or percentage of mothers who know how to prepare ORS
solution, SSS, or local name
number or percentage of mothers who know how to administer ORS
solution, SSS, or local treatment1
number or percentage of mothers who used ORS solution, or a recom
mended home fluid (total volume increased), and continued feeding
during their child’s last diarrhoea episode (last month)2
number or percentage of breast feeding women who know to continue
breast feeding during diarrhoea episode
Module 5: Monitoring; appendix A
51
• number or percentage of mothers who know how often to feed a child
with diarrhoea (at least every 3-4 hours)
Output indicators
• number or percentage of health workers who counsel mothers on
preparation and administration of ORS solution3
• number or percentage of health workers who correctly showed the
mother how to prepare and administer ORS solution4
Input indicators
• number or percentage of health units which experienced stock shortages
of ORS in the last month5
• number or percentage of mothers who live within a reasonable distance,
defined by local norms and expressed in terms of time, of a health facility
or provider that has a regular supply of ORS and antibiotics, and
practises correct case management6
Notes on diarrhoea disease control/oraI rehydration therapy indicators
1 ORS solution, SSS or local treatment should be administered until the diarrhoea stops.
2 This indicator can be used to reflect health unit treatment, community health worker treat
ment, or home treatment, or all three combined. The decision of what to include will depend
on programme objectives and norms.
3 Data from some countries have shown that health workers often discuss how to prepare ORS
solution with mothers, but few provide them with information on how to administer ORS
solution. This indicator requires information on more than one health worker task and would
require supervisors to judge health workers on whether they performed both tasks.
4 This indicator examines whether health workers actually demonstrate preparation and ad
ministration to the mother If health workers ape not administering ORS solution in the clinics,
mothers will have little chance to see what ORS solution preparation and administration
involve. This information can be obtained through ORT supervisory checklists.
5 Information can be obtained from supervisory checklists, interviews with health workers or
review of stock records. The second, more precise indicator, number of days when ORS mas
out of stock in the clinic or village, woula require review of stock records and inventories.
Another indicator that could be useful in programmes which promote home distribution of
ORS would be the "number or percentage of villages without a regular source of ORS."
Information could be compiled from programme reports, maps, and stock records. If the
programme distributes ORS through a community-based worker during home visits, the
indicator would be "number of days CHW experienced stock shortages of ORS,"and informa
tion could be obtained from records, inventory, or supervisory checklists.
6 Information can be obtained by 1) reviewing the stocks of health facilities and/or providers,
and 2) determining the target population that is accessible to the facilities. The numerator is
the target population with access to stocked facilities; the denominator is the total target
population.
CHILDHOOD DISABILITIES
Effect indicators
• number or percentage of disabled children enrolled in special schools or
community programmes1
• number or percentage of disabled children covered by appropriate health
services
Modul^Tpton'it'S-pg^ aiDj^ndjk^H
A#
pHC- iOO
'106:3
52
• number or percentage of clients/mothers with knowledge of special
schools, community programmes, and NGOs involved with disabled
children
• number or percentage of mothers who know appropriate care for
disabled child
• number or percentage of mothers with disabled children who know how
to prevent a similar disability2
Output indicators3
• number or percentage of clients with disabilities referred for diagnosis
or treatment
• number or percentage of health workers currently providing counsel
ling/ treatment for disabilities
Input indicators
• number or percentage of health workers who can identify signs and
symptoms associated with disabilities4
• number or percentage of health workers who know how childhood
disabilities can be prevented5
• number or percentage of health workers with correct knowledge of
national treatment/referral/counselling guidelines for disabilities
• number or percentage of health centres without treatment/counselling
facilities for clients with disabilities
• number or percentage of health centres without established treatment,
referral, and counselling guidelines
Notes on childhood disabilities indicators
1 These coveraqe indicators can be modified to reflect different sub-groupings ofdisabilities, e.g.,
physical disabilities, mentally handicapped patients, etc. Numerators can be derived from
reliable information on enrolment or client participation in disability-related activities and
programmes. Denominators can be derived from an inventory or survey of disability-related
services in the working area.
2 Disability impairments include movement, deformity, hearing, blindness, speech, behaviour,
and other.
3 Information for these indicators can be obtained from supervisory checklists of disability-re
lated service providers.
4 Information for these indicators can be obtained from supervisory checklists of disability-re
lated service providers.
5 To obtain this information list childhood disabilities of concern, how they occur, and what can
be done to prevent them. For each type of disability, develop two or more preventive measures.
Respondents are asked to identify preventive measures for each disability and are scored for
the number of correct responses.
CHILD IMMUNIZATION
Effect indicators
• number or percentage of children age 12-23 months who are fully
immunized with BCG, DPT, measles, and polio vaccines1
Module 5: Monitoring; appendix A
53
• number or percentage of children age 12-23 months never immunized
with BCG, DPT, measles, and polio vaccines2
• number or percentage of mothers who know the age at which children
should be immunized against measles (9-12 months of age)
• number or percentage of mothers whose children are not completely
immunized who know when to return for the next immunization
• number or percentage of children age 12-23 months whose mothers can
present a completely (per local standards) filled immunization card, given
the age of the child
Output indicators
• number or percentage of health workers using sterile needles and
syringes for each injection
• for outreach programmes number or percentage of immunization ses
sions held (per area)3
• number or percentage of health workers counselling mothers on possible
side-effects of vaccines
Input indicators
• number or percentage of health units [or number or percentage of
immunization sessions] which experience shortages of vaccines, needles,
syringes, and/or immunization cards4
• number or percentage of health units whose refrigerator has not been
at a temperature between 0°C and 8°C at all times during the previous
period5
Notes on child immunization indicators
1 This is a standard format for assessing immunization coverage. However, if your programme
is performing well according to this indicator, you may want to modify it to focus on younger
children, e.g.. children under one year of age. This more specific information could be obtained
from household surveys, by modifying slightly the information collected with the Module 2
rapid or mini surveys. The reason for emphasising younger children is that the risk of dying is
much higher in the younger age group. In addition, many older children may have already
contracted the disease, clinical or sub clinical, before being vaccinated. Datafor either version
of this indicator could be collected using Module 2 rapiclor mini-surueys. Data could also be
compiled from clinic-based records if these are organised by child, ana if an estimate of the
total target population exists. If no clinic-based records exist, and surveys are impractical,
information on the number of children fully immunized by age 23 months could be tallied as
children come in for immunization. Their cards could be marked toshow they had already been
counted. Doing this over a one year period would provide a measure of the number of children
completely immunized by a certain age, using an estimate of the number of children in that
age group in the target area as the denominator.
2 This inaicator helps managers identify which groups might be missed altogether by the
immunization activities. It can only be collectea through household surveys, because that is
the only way to collect information from those who do not receive immunization through the
programme. In addition, the household survey will also identify unimmunized children, and
that information can be used to plan service strategies.
3 The minimum standard for this indicator would be quarterly immunization sessions. Mapping
the area may be necessary to ensure that outreach sessions are planned in a way that affords
access to the whole population. Access must be defined locally, either in terms of distance or
travel time. Information on the number and location of immunization sessions can be obtained
from work plans or immunization reports.
Module 5: Monitoring; appendix A
54
4 A high percentage points out problems in the supply system. Data can be obtained from
supervisory checklists for immunizations and/or interviews with health workers or review of
stock records and inventories.
5 This information can be obtained from supervisory checklists when supervisors inspect tem
perature logs. An alternative to this would be to divide the numerator into three groups: those
without temperature logs, those whose temperature logs show constant temperature between
(FCand&C, and those whose temperature logs indicate unacceptable temperature uariations.
GROWTH MONITORING/NUTRITION EDUCATION
Effect indicators
• number or percentage of children under two years in the target area
weighed at least once during the past quarter1
• number or percentage of mothers breast feeding babies up to 12 (18)
months of age
• number or percentage of mothers starting to give supplemental foods
to infants between 4 and 6 months of age
• number or percentage of children whose weight-for-age is below the
normal range or whose growth is faltering (per local norms)2
• number or percentage of mothers with children under age two who
interpret growth chart information3
Output indicators
• number or percentage of children under two years enrolled in a growth
monitoring programme
• number or percentage of mothers with children under two years to
whom the growth monitoring chart was explained by CHW during the
last 3-6 months
• (for outreach programmes) number of growth monitoring sessions held
(per area)4
• number or percentage of health workers who track malnourished
children5
• number or percentage of high-risk children (malnourished ) followed up6
• number or percentage of mothers told child’s nutritional status7
• number or percentage of mothers with growth-faltering children who
received counselling on appropriate feeding
Input indicators
• number or percentage of health workers/health units which do not have
a functioning scale (accurate to 1/10 kg)
• number or percentage of health units (or growth monitoring sessions)
experiencing shortages of growth cards in the last month3
Notes on growth monitoring/nutrition education indicators
For indicators reflecting the target population, the denominator should be adapted to local
programme objectives: children under two, children under five, etc.
Module 5: Monitoring; appendix A
55
1 This standard^orfrequency ofweighing shouldfollow programme guidelines, and ideally would
coverage measures on those age groups most at risk, e.g, 18-36 months, or those who may
require more frequent weighings. The intervals between compilations/analyses should be long
enough for differences to appear in frequency of weighing. For example, if the indicator is of
quarterly weighing, the data should not be collected more than once, or at most, twice a year,
if the number ofchildren in the target area is known, and clinic-based recordsexist, information
could also be compiled from service records.
2 The phrasing of this indicator should reflect current programme objectives. Information can
be obtained from rapid surveys (if weights are taken).
3 This indicator measures mothers' ability to correctly interpret growth monitoring charts.
Information can be gathered in a survey of mothers with children under age five. The inter
viewer uses a chart designed for the survey to determine if the mother can identify an
underweight child. The numerator is mothers able to interpret the growth chart; the denomi
nator is all women participating in growth monitoring.
4 The minimum standard for this indicator would be quarterly growth monitoring sessions
(required to ensure coverage with quarterly weighings). Mapping the area may be necessary
to ensure that outreach sessions are plannee! in a way that affords access to the whole
population. Access must be defined locally, either in terms of distance or travel time.
Information on the number and location of growth monitoring sessions can be obtained
from work plans or growth monitoring reports.
5 "High-risk" will neecT\o be defined locally, e.g level 2 and 3 malnutrition, or not growing in the
last 3 months. Information can be obtainedfrom supervisory checklists.
6 If a high-risk system exists, this indicator measures how well it works. Information on high-risk
children could be compiled from growth cards or other individual service records kept in the
health unit.
7 This indicator could measure counselling at growth monitoring sessions or during routine
curative sessions where the child is weighed.
8 A high percentage can signify problems in the supply system. Data can be obtained from
supervisory checklists for growth monitoring (interviews with health workers or review of stock
records and inventories).
WATER SUPPLY, HYGIENE, AND SANITATION
Effect indicators
number or percentage of households receiving drinking water from a
clean source, faucet, tap, pipe, covered well, or other safe source, within
15 minutes’ walk7
• number or percentage of households using a clean facility (water-seal
latrine, pit privy, or WC)
• number or percentage of mothers knowing the importance of hand
washing2
• number or percentage of mothers with children under age two who use
a baby potty
Output indicators
• number or percentage of health workers inspecting latrines (per local
standards)
• number or percentage of health workers inspecting community man
agement of local water sources (per local standards)3
• number of latrines built during the last year4
• number of wells or other water sources constructed during the last years
•
Module 5: Monitoring; appendix A
56
Input indicators
• number of wells or other water sources constructed per 1,000 popula
tion6
• number of latrines built per 1,000 population2
• number or percentage of communities with access to health staff or
technicians with resources (information, funds, supplies) for building safe
water supply systems and latrines7
Notes on water supply, hygiene, and sanitation indicators
1 This indicator measures the populations access to water, an important factor in sufficient
water usage. Information can oe obtained using rapid surveys.
2 Information on mothers knowledge can be obtained from supervisory checklists for water and
sanitation which call for "exit" interviews with mothers, or by adding a question to the rapid
survey forms.
3 This indicator measures the performance of health workers who either inspect the water
sources themselves (if that is part of their tasks) or discuss maintenance of local water sources
with the community. This information can be obtained from supervisory checklists (observa
tions or interviews with health workers) or discussions with community members about health
worker activities. The indicator should be adapted to the workers’water and sanitation tasks
and job descriptions.
4 Information can be obtained from activity reports.
5 Information can be obtained from activity reports.
6 This indicator measures only the accessibility of water and sanitation facilities to a population,
not the use of those facilities. It also indicates access to inputs in the local area.
7 This indicator measures the access of communities to critical inputs.
ACCIDENTS AND INJURIES
Effect indicators
• number or percentage of respondents with knowledge of how to care
for accidents and injuries2
• number or percentage of respondents with knowledge of an emergency
care facility2
• number of respondents who use safety precautions and equipment on a
daily basis3
Output indicators
• number of respondents treated for an injury (by type)4
• (in a work place or other high-risk environment) number of safety
regulations implemented and enforced
• number or percentage of health workers (CHWs, factory or plant cadres,
traditional practitioners, etc.) trained in injury care
• number or percentage of health workers who received formal training
in hazard identification and intervention
Input indicators
• number or percentage of health care facilities without 24-hour emer
gency care services
Module 5: Monitoring; appendix A
57
• number or percentage of health care facilities without treatment and
referral procedures for clients with injuries
Notes on accidents and injuries indicators
1 This indicator is most useful in a context where risk of accident or injury is relatively high, such
as a factory, farm, or other place of work. Start by determining the profile of common accidents
and injuries; then determine appropriate first aid treatment. Ask respondents how they would
treat key accidents and injuries and compare against thestandard. Respondents are the target
population of accident/injury prevention and treatment efforts.
2 This includes phone number, address, or directions on how to go to a facility.
3 This indicator requires a revision of prescribed safety precautions and equipment in a partic
partu
ular context such as a factory, farm, hospital, chemical plant, etc. Respondents
laents are interviewed
interuieive
about the safety precautions followed and equipment available.
4 Respondents can be interviewed with a rapid survey (see Module 2).
CHRONIC, NON-COMMUNICABLE DISEASES
Hypertension1
Effect indicators
• number or percentage of patients with hypertension
• number or percentage of patients who developed other complications
of hypertension
• number or percentage of patients, diagnosed with chronic hypertension,
who are in a systematic anti-hypertensive therapy programme
• number or percentage of patients with moderate hypertension2 who
follow a prescribed diet on a daily basis
• number or percentage of patients who take medication as prescribed
• number or percentage of patients who practise the appropriate diet on
a daily basis
• number or percentage of patients who were given a special regimen
sheet for the use of medication and diet
Output indicators
• number of clients diagnosed for hypertension
• number of patients with hypertension who were treated
• number of patients who switched from prescribed medicine to diet
• number of health workers who are clinically knowledgeable in providing
diet and medication regimen to patients with hypertension
• number of systematic visits by patients with hypertension
• number or percentage of patients who have been assessed for renal
function
• number of patients with hypertension who were provided with instruc
tions for the use of medication and diet
Module 5: Monitoring; appendix A
58
Input indicators
number of health workers who can provide diet and medication infor
mation to patients with hypertension
• number of primary health centres with daily/weekly availability of
trained family doctor
• number of health centres with sphygmomanometers
• number of primary health centres with functioning laboratory equip
ment and medication for hypertension3
•
Notes on hypertension indicators
1 Developed by Walid Abubaker, MD, Senior Scientist, University Research Corporation
2 Diastolic blood pressure between 90 and 115, or local definition
3 As determined by local standards
Diabetes7
Effect indicators
• number or percentage of diabetic patients with annual assessment of
renal function
• number or percentage of diabetic patients with semi-annual measure
ment of glycosylated Hgb
• number or percentage of diabetic patients with documented home
glucose monitoring
• number or percentage of diabetic patients with discrepancies between
home and clinic monitored results2
• number or percentage of diabetic patients with family members who
know how to handle a diabetic emergency3
Output indicators
• number or percentage of persons diagnosed for diabetes mellitus
• number or percentage of patients treated for diabetes mellitus by a
physician
• number or percentage of patients treated for diabetic ketoacidosis
• number or percentage of patients treated for diabetic foot lesions
Input indicators
• number of general practitioners or family physicians per 1,000 house
holds
• presence of equipment and other materials in the health units (glucose
monitoring, blood pressure, protocol for home glucose monitoring, and
insulin schedule)
Notes on diabetes indicators
1 Developed by Walid Abubaker, MD, Senior Scientist, University Research Corporation
2 This data requires a comparison ofclinic records and results ofhome monitoring. The indicator
measures the client’s ability to monitor diabetes.
3 This information is gathered from interviewing household members (see Module 2).
Module 5: Monitoring; appendix A
59
Anaemia
Effect indicators
• number or percentage of anaemic patients with semi-annual evaluation
and follow-up of haemoglobin and haematocrit
• number or percentage of anaemic patients with documented improve
ment in anaemic condition
• number or percentage of anaemic women who know the treatment for
anaemia
Output indicators
• number or percentage of persons diagnosed for anaemia
• number or percentage of patients treated for anaemia
• number or percentage of patients treated for symptomatic anaemic
conditions (pale, weak, etc.)
• number or percentage of patients who received education for nutritional
health
Input indicators
• number of general practitioners of family physicians per 1,000 household
with knowledge or understanding of anaemia
• number of providers/primary centres with staff, equipment and other
materials for monitoring haemoglobin, haematocrit, blood count
(WBC/CBC)
MALARIA
Effect indicators
• number or percentage who know how malaria is spread1
• number or percentage of population who are protecting themselves
against malaria2
• number or percentage of malaria (fever) cases treated with anti-malarial
drugs at home (by mother who knows correct dosage)3
• number or percentage of patients who were prescribed anti malarial
drugs who know dosage, frequency, and duration of treatment4
Output indicators
• number or percentage of malaria (fever) cases treated at health unit5
• [in areas where confirmation is the norm] number or percentage of health
workers who take/request a blood slide from malaria/fever cases
• number or percentage of health workers who screen fever patients for
signs/symptoms of other serious illnesses (meningitis, pneumonia, etc.)
Module 5: Monitoring; appendix A
60
Input indicators
number or percentage of health units experiencing stock shortages of
anti-malarial drugs in the last month6
• number or percentage of health units without functioning laboratory
equipment
•
Notes on malaria indicators
1 The indicator measures knowledge of modes of transmission.
2 The following can be used to protect against malaria: mosquito nets, household spray, elimi
nating standing water, using anti-malarial drugs, and other locally appropriate means.
3 This indicator measures couerage for home treatment of malaria for programmes which are
promoting such an approach. Information for this indicator can only be obtained from rapid
surveys. A drawback to this indicator is that the denominator would bebased on self-diagnosed
fever or malaria. Local definitions of malaria will have to be developed to determine which
symptoms constitute a diagnosis of malaria.
4 The numerator is the number of clients who are knowledgeable of correct treatment divided
by all patients prescribed anti-malarial drugs. Data is gathered by a survey of individuals
diagnosed with malaria who received drugs from a CHW or health facility.
5 This indicator measures health worker treatment of malaria. Like the indicator above, infor
mation can be obtained from rapid surveys, and it, too, is based on self-diagnosed fever or
malaria.
6 Both indicators can point out problems in the supply system. A more detailed indicator,
number of days when anti malarial drugs were out ofstock during last period, can measure the
extent of the problem. Data can be obtained from supervisory checklists for malaria (interviews
with health workers or review of stock records and inventories).
TREATMENT OF MINOR AILMENTS
Effect indicators
• number or percentage of illness episodes treated at health unit1
• number or percentage of patients who were able to obtain all of the
medication prescribed in the health unit
• number of patients receiving laboratory services in the same health unit
per number requiring laboratory services
• number or percentage of patients or their attendants who understand
the treatment prescribed - how much, how long, how often2
Output indicators
• number of treatments given during last period by condition3
• number or percentage of health workers asking at least five history
questions and carrying out at least one physical exam4
Input indicators
• number or percentage of health workers who know the explicit criteria
for referring patients to a higher level (per local policy)5
• number or percentage of health units without functioning:6
- stethoscope
- scale
- thermometer
- blood pressure cuff
- watch with second hand
- microscope and slides
Module 5: Monitoring; appendix A
61
• number or percentage of cases where prescribed medicines were avail
able at the health unit at the time of consultation, compared to all cases
that were prescribed medicines7
• availability of drugs for high volume conditions
• availability of laboratory tests used more frequently
Notes on treatment of minor ailments indicators
1 This indicator is a rough measure of coverage for curative services. It should be interpreted
with care, since some illness episodes may not require health care services. The types ofillness
episodes to be counted in the denominator will need to be decided locally. Such an indicator
can suggest problems such as acceptability or financial accessibility. Interpretation can be
aided by using this indicator to compare "coverage" over time or with other health units.
2 lb apply this indicator develop a list of minor ailments to monitor. For each ailment determine
the treatment protocol - how much, how long, and how often. This indicator measures the
knowledge of patients/caretakers (effect) and can also be modified to gauge the knowledge of
health providers (input).
3 This indicator, plotted over time and compared among health units, can help managers track
trends and efficiency. Variations could be due to seasonal epidemiological patterns or financial
resources of the population. Changes could also reflect problems or strengths in acceptability
of services. Efficiency can be assessed by comparing the number of treatments among health
units to see if personnel allocation reflects use rates.
4 The numbers of history questions and exams can be adapted to reflect local policy. However,
a minimum number is necessary to ensure that workers are doing more than simply accepting
the patients diagnosis, and that they are able to identify potential multiple health problems.
Information can be obtained from curative care supervisory checklists which use observation.
In some cases, the supervisor may have to use some judgement about whether the worker did
the appropriate history and physical exams.
5 This indicator measures the knowledge of health providers and their ability to treat minor
ailments. Develop a list of key minor ailments of concern to your programme and the referral
criteria. Then ask the respondent to recall ailment-specific referral criteria.
6 The equipment to be included in this indicator will neea to be adapted to local policy and the
level of health worker being evaluated.
7 This indicator attempts to evaluate availability of essential drugs. The indicator can be revised
if local policy states that drugs are not to be distributed at the health unit, e.g, drugs are
distributed at a nearby drug outlet or clinic/hospital. Data can be gathered by checking drugs
prescribed with drug stocks.
TUBERCULOSIS
Effect Indicators
• number or percentage of children vaccinated with BCG2
• number or percentage of target group who know how TB is spread and
how to prevent infection2
• number or percentage of detected tuberculosis cases followed to cure3
• number of active tuberculosis cases4
• number or percentage of tuberculosis patients knowing why it is
important to complete treatment
• number or percentage of tuberculosis patients knowing the correct
dosage and duration of treatment for tuberculosis
• number or percentage of population with persistent cough lasting more
than two weeks who sought treatment for TB
Module 5: Monitoring; appendix A
62
Output indicators
• number or percentage of suspected tuberculosis cases sent for confir
mation5
• number or percentage of health workers who have a system for following
up suspected and confirmed tuberculosis cases6
• number or percentage of suspected and confirmed tuberculosis cases
followed up7
Input indicators
• number or percentage of health units without adequate equipment to
diagnose tuberculosis5
• if the health unit is a tuberculosis treatment centre, number of days when
tuberculosis drugs were out of stock
Notes on tuberculosis indicators
1 This measures the couerage of the immunization programme and the effectiveness of TB
prevention efforts.
2 This information can be gathered from a survey. Asking probing questions to explain (see
Module 2).
3 Information for this indicator, which is a partial measure of coverage, can be obtained by
compiling information from tuberculosis service records. The denominator for this indicator
would be the number of tuberculosis cases (detected by the health services) that should have
completed treatment during the period being evaluated.
A truer measure of coverage might be constructed if reliable information can be collected
about the number of tuberculosis cases in the community. The vital events rapid survey does
contain information about point prevalence for tuberculosis, but the value of this information
depends on the ability of the population and the interviewer to classify tuberculosis cases from
survey data. If this information is felt to be reliable enough, the indicator could be modified by
changing the denominator to ail tuberculosis cases in the community, rather than those
detected by the health services.
4 This indicator allows managers to follow changes in tuberculosis case detection over time or
among health units. Information can be compiled from tuberculosis registers.
5 Confirmation can be defined as laboratory examination of sputum or X-rays, depending on
local policy. This information can be obtained from supervisory checklists for tuberculosis or,
if the information is available, from compilation of curative consultation or tuberculosis re
cords.
6 Information can be obtained from supervisory checklists.
7 If a follow-up system exists, this indicator measures how well it works. Information on sus
pected and confirmed cases could be compiled from tuberculosis service records kept in the
health unit to determine the percent of active cases that presented themselves voluntarily for
their appointments or were visited/contacted by the health services if they defaulted on their
treatment.
8 Equipment includes thermometer, stethoscope, tuberculosis test, etc. per local policy.
SEXUALLY TRANSMITTED DISEASES AND HIV/AIDS
Effect indicators
• number or percentage of target groups screened last 3 months (or shorter
period if necessary) for HIV/STDs7
• number or percentage of target groups screened with an STD during
the past 12 months
Module 5: Monitoring; appendix A
63
• number or percentage of target population with correct knowledge of
the means of HIV/STD transmission2
• number or percentage of target population who know that condoms
provide protection against infection with HIV/STDs3
• number or percentage of target population reporting sex with use of
condom4
• number or percentage of pregnancies that occur among HIV-infected
women5
• number or percentage of HIV-infected women of child-bearing age who
use a barrier contraceptive method (male or female condom)
• number or percentage of the target population who report having had
at least one sex partner other than their regular sex partner(s) in the last
6 months
Output indicators
• number or percentage of injections given with sterile needles
• number or percentage of health workers who correctly dispose of
contaminated materials
• number or percentage of clients referred by health workers for diagnosis,
treatment, or testing
• number or percentage of clients receiving antibiotics for STDs
• number of condoms distributed to the target population
• number of IEC materials distributed to target population
• number of group HIV/STD prevention activities held during the last 1-3
months; meetings, presentations, TV/radio broadcasts, media events,
etc.6
Input indicators7
• number or percentage of the target population with access to STD-related services5
• number or percentage of appropriate outlet centres having uninter
rupted supply of condoms during preceding 12 months9
• number or percentage of health centres providing STD-related services
with uninterrupted supply of appropriate antibiotics during preceding
12 months
• number or percentage of health centres without proper equipment^0 or
laboratory facilities
• number or percentage of health units with identification, treatment,
referral, and follow-up guidelines
• number or percentage of treatment facilities without counselling activ
ities21
Module 5: Monitoring; appendix A
64
• number or percentage of health workers who are trained in care/counselling of HIV/STD patients
• number or percentage of health workers with correct knowledge of the
modes of transmission of HIV/STDs12
• number or percentage of health workers who know the correct diagnosis,
treatment, referral, or counselling guidelines for HIV/STDs13
Notes on sexually transmitted diseases indicators
1 This effect indicator measures the behaviour of the target group to receive screening. When
calculated as a percentage, the coverage ofscreening services is obtained. Ifscreening is largely
compulsory for high-risk populations, then the indicator is measuring the output of the
HIV/STD programme.
2 This indicator measures knowledge of HIV/STD transmission. For each type of HIV/STD,
develop a list of ways the disease can and cannot be contracted. Ask the target population to
identify the correct modes of transmission. Score the number of correct and incorrect re
sponses.
3 This type of indicator addresses clients’ knowledge of prevention of sexual transmission
through the use of condoms. Information can be obtained from knowledge, attitudes, and
practice (KAP) surveys or Module 2 rapid assessments for HiV/STD.
4 This indicator can be replaced with one concerning abstinence before marriage, sex with only
one partner or faithfulness within marriage, or other sexual behaviours which may prevent
transmission.
5 This indicator and the succeeding one address prevention of mother-to-foetus/child transmis
sion. Information for this indicator can be derived from KAP surveys and/or Module 2 rapid
assessments on maternal child care which includes an HIV/STD component.
6 The information can be obtained from providers or the target population (to determine
coverage of prevention efforts). Develop a list of prevention activities; then survey all or
ganisations (eg., in a city) involved in HIV/STD prevention. The list of organisations includes
public/private health services, schools, religious organisations, TV and radio stations, adver
tising groups, etc.
7 Input indicators include access to services (both preventive and treatment), training of health
workers, and their knowledge about transmission, treatment, and counselling.
8 This indicator is measured as the number of health units with IEC and screening facilities per
10,000 target population.
9 "Appropriate outlet centres" may include any health facility or service which distributes
condoms and which will be monitored by the programme This term is from: Heymann D,
Biritwum R, Paget W.J. Evaluation of AIDSprogrammes. The handbook for AIDS prevention
in Africa. Family Health International, 1990:234.
10 "Proper equipment" may include an examination table, gloves, speculum, sterilisation equip
ment, etc. Information for this indicator can be obtainedfrom inventory lists, purchase orders,
supply records, etc.
11 If counselling guidelines are established, review them to determine the key components
(inform client about transmission, prognosis, follow-on treatment, etc.). Use a checklist and ask
the provider or counsellor to identify or explain counselling components. Score those which
are correctly identified.
12 A list ofcorrect and incorrect transmission modes are developedfor each type ofdisease. Then
the respondent is asked to identify the correct modes of transmission. Information for this
indicator and the succeeding one can be obtained from supervisory checklists on HIV/STD
service delivery or interviews with health providers/counsetlors.
13 Determine the guidelines for diagnosis, treatment, referral, and counselling (where applicable).
Next, test the knowledge of health providers against the guidelines. The data can be checked
by asking exiting clients if guidelines were followed.
Module 5: Monitoring; appendix A
65
Appendix B: PHC management indicators
This appendix presents an annotated list of selected indicators for the
following management services:
Planning
Personnel management
Training
Supervision
Financial management
Logistics management
Information management
Community organisation
The indicators for each PHC management service have been divided
into three categories: effects, outputs, and inputs. In general, these catego
ries include indicators that cover one or more of the generic criteria
described in the text.
• Effect indicators measure how well the management service met its
goals. For example, indicators of the effects of training and supervision
could measure whether worker skills were increased. The desired effects
of planning could include the achievement of coverage objectives.
Monitoring the effects of personnel management could include the
number of vacant posts.
• Output indicators reflect the activities that need to be carried out to
achieve the desired effects. Output indicators for management services
include measures of frequency of activities, such as the percentage of
workers visited by, or meeting with, their supervisor in the last period.
They can also monitor the quality of the activity: e.g., the percentage of
training sessions that allowed participants to put new knowledge and
skills into practice during training using real life cases or role-play.
• Input indicators measure the presence of key resources needed for
carrying out the management activities, such as personnel, supplies, and
procedures/guidelines.
Management services can operate at many levels of the system, such as
the health centre, the district, the province/region, or the central level.
Management systems can vary widely between programmes, levels, and
countries; these indicators may not be universally useful as such, and may
require adaptation to your specific programme.
Module 5: Monitoring; appendix B
I
66
Footnotes provide suggestions for data sources and where it is not
obvious explain what the indicator is designed to measure and why it is
important.
The term "health unit" applies to a unit which is being monitored. For
example, if you are a district level manager, the health units could be health
centres or health posts. If you are a regional or provincial manager, the
health units could be districts. This term should therefore be interpreted to
fit each programme’s health system.
These suggested management indicators have been developed with the
assumption that management systems are already in place for these
services. If there is no system in place, you should refer to the Module 7
management checklists as a starting point
PLANNING
Planning is the process of defining community health problems, identi
fying needs and resources, establishing priority problems, and designing
strategies and administrative action to reach those goals.
Effect indicators
Outcomes for planning would be the implementation of planned activ
ities and the achievement of programme objectives. These should be
reflected in coverage and KAP indicators for specific service delivery
interventions (see Appendix A for indicators).
Output indicators
• number or percentage of health units which have a written mission
statement that defines their target population, the programmes activi
ties, and its goals2
• number or percentage of health units which have concrete, measurable
objectives for coverage, service quality, changes in population knowl
edge/ practice2
• number or percentage of health units whose plans have corresponding
budgets3
Input indicators
• number or percentage of health units which have clearly defined
catchment areas they are to serve4
• number or percentage of health units which have information on the
population they serve: total population size, number of children < 2 years,
number of births a year, number of women 15-49 years5
Module 5: Monitoring; appendix B
67
Notes on indicators for planning
1 Mission statements are important guides for programme planning. They specify who the
programme is trying to serve, what needs the programme is trying to address, and now it plans
to address them. Data can be obtained from Module 7 planning checklists and discussion
guides.
2 Staff should be aware ofprogramme objectives and know how close they are to achieving them.
The ongoing planning process should include regular revision of objectives to reflect pro
gramme progress. Data can be obtained from Module 7 planning checklist, using interviews,
informal discussion, or document reviews.
3 Information can be obtained from Module 7 planning checklists or from review of plans.
4 Proper planning requires knowledge of the geographic extent of the catchment area physical
barriers such as mountains or rivers, and the number of villages/neighbourhoods. Information
can be obtainedfrom Module 7 planningchecklists orfrom observation of health units (do they
have maps of the area with their service delivery points demarcated?) and from interviews with
health staff.
5 Information on the size of the target populations should be regularly updated. Information for
this indicator can be obtained from Module 7 planning checklists ana discussion guidelines.
PERSONNEL MANAGEMENT
Personnel management is designed to ensure that the organisation
attracts and retains skilled and competent people, that people are produc
tive in their jobs, and that they are rewarded appropriately by the organisa
tion for their output.
Effects indicators
• number or percentage of vacant posts1
• average duration at a post for each type of worker2
Output indicators
• number or percentage of staff whose job descriptions have been updated
in the last year to reflect current responsibilities3
• number or percentage of supervisors who develop specific work plans
with their staff at regular intervals (per local norms)4
• number or percentage of supervisors who review whether work assign
ments have been completed5
Input indicators
• number or percentage of staff members with job descriptions6
• number or percentage of facilities that provide cost-recovery (ex
pense/revenue) data
• number or percentage of local offices that submit budget estimates on
time
• number or percentage of facilities which have guidelines for developing
work plans
Notes on indicators for personnel management
1 This indicator reflects job retention rates and the ability to hire replacements. Information can
be compiled from personnel records.
2 This indicator reflects how long staff members stay on the job. If the attrition rate is high, this
means that salaries and benefits may not be adequate to retain staff. Information can be
compiled from personnel records.
Module 5: Monitoring; appendix B
68
3 Information can be obtained from Module 7 personnel management checklists, through
interviews with workers and supervisors, and through review ofjob descriptions.
4 Information can be obtainedfrom Module 7 personnel management checklists and discussion
guidelines.
5 Information can be obtainedfrom Module 7 personnel management checklists and discussion
guidelines.
6 Information can be obtained from Module 7 checklists and personnel records.
TRAINING
Training serves to continually improve the knowledge, skills, and com
petencies of health workers so that service delivery or management
activities can be carried out correctly.
Effect indicators
• number or percentage of participants in training who showed improve
ment between the pre- and post-tests1
Other outcome indicators would be improvements in worker perfor
mance in the field. Many service delivery output indicators for specific
interventions can be used for this purpose (see Appendix A).
Output indicators
• number or percentage of health workers having received training or
refresher training in the last period for any intervention, or for specific
interventions2
• number or percentage of training sessions that allowed participants to
put new knowledge and skills into practice during training, using real
life cases or role-play3
• number or percentage of training sessions in which technical content
was complete and accurate4
Input indicators
• number or percentage of health units using programme specific infor
mation (from MIS or supervision) about service quality to plan or focus
training sessions given in the last period5
• number or percentage of trainers who have received instruction in
training methods6
• number or percentage of health facilities that hold PHC training sessions
Notes on indicators for training
1 Information can be obtained from training reports. If reports of training sessions do not include
such information, then it could be added as a required element. This indicator could bephrased
as the average percentage improvement between pre- and post-test scores, or it could be
formulated as the percentage of participants whose post-test scores were higher than their
pre-test scores ana who reached a desired level at the post-test.
2 Information can be obtained from personnel records worker interviews, or training reports.
3 Information on training methods could be obtained from Module 7 training checklists and
using observation, reviewing training reports, or interviewing trainees.
Module 5: Monitoring; appendix B
69
4 Information can be obtained from Module 7 checklists, through review of presentation and
take-home materials, review of training curricula and reports, and structured observation of
training sessions.
5 Information could be obtained from Module 7 training checklists and discussion guidelines,
through review of training curricula or interviews with trainers.
6 Information can be obtained from personnel records or through interviews with trainers.
SUPERVISION
Supervision is the process of ensuring that staff perform their duties
effectively, through support, guidance, on-the-job training, and assistance
in identifying and solving problems.
Effect indicators
• number or percentage of health workers who feel they are receiving
adequate support from their supervisors7
Other outcome indicators for supervision include measures of improved
worker performance. These can be assessed using many of the service
delivery output indicators for specific interventions (see Appendix A) and
comparing them over time.
Output indicators
• number or percentage of supervisees visited by or meeting with their
supervisors during the last period (per local norms)2
• number or percentage of health workers whose supervisor observed
them during service delivery (or through role-play/simulation) during
the last supervision visit3
• number or percentage of supervision visits that included problems
identified and actions taken4
• number or percentage of supervision visits that included review or
follow-up on problems from previous supervision visits5
Input indicators
• number or percentage of field supervisors who have been trained in
guidance and quality assessment
• number or percentage of health units that have written guidelines or
protocols for supervision6
Notes on indicators for supervision
1 An important aspect of supervision is providing moral and technical support to workers. This
indicator measures the effects ofsupervision from the perspective of the workers. Information
can be obtained through individual interviews or focus group discussions with supervisees.
2 Information can be obtained from Module 7 supervision checklists, interviews with supervis
ees, and from supervision reports. For health units where supervisee and supervisor work in
the same location, this indicator could measure the number of supervisory meetings.
3 Information can be obtained from Module 7 checklists and discussion guidelines, using obser
vation, interviews with supervisees and supervisors, or review of supervision reports.
4 This indicator measures whether supervisors collect information that would tell them if prob
lems exist, analyse that information, and use it to support corrective action. Information can
Module 5: Monitoring; appendix B
70
be obtained from Module 7 supervision checklists. Supervision reports can be modified to
provide such information by requiring recording of problems and actions.
5 This indicator measures whether supervisors are using information they collected from previ
ous supervision visits to help structure current supervision visits ana to monitor progress.
Information could be obtained from Module 7 checklists, using observation or interviews with
supervisors and supervisees.
6 Information can be obtained from Module 7 supervision checklists.
FINANCIAL MANAGEMENT
Financial management seeks to manage programme finances, budgets,
cost-recovery, and fund-raising.
Effect indicators
• number or percentage of health workers that were paid on time in the
last period1
• number or percentage of health units that achieved cost-recovery and
their planned service goals2
• average percentage of costs recovered from revenue3
Other possible indicators for outcome of financial management could be
planned activities that were able to take place because there were sufficient
resources, or a budget that reflected both programme objectives and actual
expenditures.
Output indicators
• number or percentage of health units whose accounting records are up
to date and balanced monthly4
• number or percentage of health units with systems of checks and
balances for handling cash (including vouchers, disbursements by cheque,
verification of accounts)5
• number or percentage of health units whose financial reports are
evaluated by making comparisons of "budget" with "actual" financial
performance6
Input indicators
• number or percentage of health workers trained in financial manage
ment7
• number or percentage of financial management staff with training in
finance administration
Notes on indicators for financial management
1 Information can be obtained from account books or from interviews with workers.
2 Tnegoal of planning and financial management is to have sufficient resources to carry out the
desired activities. It is possible to have balanced books without achieving one’s goals. Thus, this
indicator looks at both together. Information can be obtained from account books and cover
age results (see indicators in Appendix A).
3 For programmes that generate revenue through user fees or other local mechanisms, this
indicator tracks progress towards sustainability and self-sufficiency. Information can be ob
tained from account books.
Module 5: Monitoring; appendix B
71
4 Information can be obtained from Module 7 financial management checklists, through ac
countingrecords and interviews with administrators/supervisors.
5 Information can be obtained from Module 7 financial management checklists, based on
interviews with staff and review of accounting records.
6 Information can be obtained from Module 7 financial management checklists, through inter
views with administrators.
7 Information can be obtained from personnel records and interviews with workers responsible
for financial management.
LOGISTICS MANAGEMENT
Logistics systems deal with procurement, storage, and tracking of
supplies in order to ensure that drugs, materials, equipment, and transpor
tation for service delivery and support services are available.
Effect indicators
• number or percentage of health units receiving the amounts of materials
they requisitioned2
• number or percentage of health or support activities cancelled due to
lack of transportation2
Other outcome indicators for logistics management can be derived from
the input indicators for specific service delivery interventions, such as lack
of stock shortages (see Appendix A).
Output indicators
• average interval between a health unit making a requisition and recep
tion of requested supplies3
• number or percentage of health units using stock inventory and con
sumption patterns as the basis of preparing requisitions4
• number or percentage of health units that carry out a physical inventory
to verify theoretical stock levels with actual physical counts5
• number or percentage of health units who have to cancel field visits and
other planned off-site activities for lack of adequate fuel supply6
Input indicators
• number or percentage of health units with established checklists or
procedures for procurement
• number or percentage of health units with schedules or appointment
books for health unit vehicle use7
Notes on indicators for logistics management
1 Information can be obtained from stock records, requisition forms, and interviews with health
workers.
2 Information can be obtained from interviews with health workers or from activity plans and
reports.
3 Information can be obtained from requisition forms and stock inventory records, and from
interviews with health workers.
4 Information can be obtained from inventory records and interviews.
5 Information can be obtained from Module / logistics checklists, through interviews, review of
stock records, and observation.
Module 5: Monitoring; appendix B
72
6 Information can be obtained from Module 7 checklists, interviews with health workers, and
reviews of activity plans.
7 Information can be obtained from Module 7 checklists, through interviews.
INFORMATION MANAGEMENT
Management information systems are designed to provide workers,
managers, funders, and community members with the information they
need to plan, implement, and monitor service delivery and support activi
ties.
Effect indicators
• number or percentage of health units that utilise monitoring information
to identify district-wide and localised problems and strengths, and
actions to take7
• number or percentage of local health units that receive feedback from
district level managers on results of district-wide monitoring2
Output indicators
• number or percentage of districts that compile monitoring information
from the health unit level3
Input indicators
• number or percentage of health units who have indicators they routinely
monitor4
• number or percentage of health units that maintain records on high risk
cases
Notes on indicators for information management
1 Information can be obtained from Module 7 management information systems checklists,
through interviews and review of monitoring reports.
2 Information can be obtained from Module 7 management information systems checklists,
through interviews with health unit managers.
3 Information can be obtained from Module 7 management information systems checklists,
through interviews with health unit managers.
4 Information can be obtained from Module 7 management information systems checklists,
through interviews with health workers and document review.
COMMUNITY ORGANISATION
Community organisation is designed to involve the community in health
activities to ensure that programme services reflect community needs and
desires. Community organisation activities can also provide the community
with organisational and planning skills they can apply in other development
areas. This is. one management service that will vary quite extensively from
one programme to another, and from one community to another.
Module 5: Monitoring; appendix B
73
Effect indicators
• number or percentage of community members who state that PHC
services are accessible, and convenient1
• number or percentage of community members who state that the PHC
services are acceptable, and relevant to their needs1
Other outcomes can be measured through coverage rates for specific
service delivery interventions, since satisfaction should be manifested in
service utilisation (see Appendix A for coverage indicators).
Output indicators
• number or percentage of community committees that met at least
monthly (per local norms) during the last quarter2
• (using an area relevant to your programme) number or percentage of
communities that participate in each of the following activities: e.g.,
health, religion, family planning, youth, sports, income generating, etc.3
• number or percentage of community committees that participate in
problem analysis and problem-solving4
• level of community contribution directed to PHC services5
• number or percentage of community members participating in health
activities6
Input indicators
• number or percentage of health units which have an affiliated health
committee or community organisation7
• number of trained community organisers
• availability of resources, labour, funds, buildings, political support, mass
activities and materials, to assist in organising communities
Notes on community organisation indicators
1 Information can be obtained from focus group discussions or more formal interviews with
community members (see Module 2).
2 Information can be obtained from Module 7 community organisation checklists, through
review of committee meeting minutes or reports, or through interviews with health staff and
committee members.
3 Information can be obtained from Module 7 community organisation checklists, using inter
views with health workers and community members. Data can be collected for each type of
community organisation. Also communities can be scored by the number of active community
organisations.
4 Information can be obtained from Module 7 community organisation checklists, through
interviews with health staff and committee members, and through review of meeting reports.
5 This indicator measures the degree of local resources, labour, buildings, money, equipment,
political commitment, and mass activities, used to support PHC services.
6 This can be calculated for different age groups and/or target populations (infants, children,
young people, married women, adult mafes, senior citizens, etc.). Information can be gathered
from a survey or examination of community organisation records.
7 Information can be obtained from Module / community organisation checklists.
Module 5: Monitoring; appendix B
15
Appendix C: Impact indicators for moni
toring mortality, morbidity, disability,
and fertility
This appendix provides an annotated list of impact indicators which can
be used to measure mortality, morbidity, disability, and fertility status of a
population.
Impact indicators can be used to;
• evaluate the impact of PHC services on the occurrence of deaths and
diseases,
• establish priorities among diseases,
• identify high-risk population groups so that PHC resources can be
used effectively,
• observe disease trends and patterns of illnesses and deaths, and
• identify, investigate, and control outbreaks or epidemics.1
Impact measures can be expressed as numbers, rates, and ratios.2
Impact information can be gathered through surveys, routine or sentinel
reporting systems, case/outbreak activities, special studies, and vital re
cords.3 Module 4, "Surveillance of morbidity and mortality," describes how
to design and implement a surveillance monitoring system to track PHC
service impacts.
Impact indicators for mortality, morbidity, disability, and fertility are
grouped by target populations of PHC programmes.
Notes
1 World Health Organization, Expanded programme on immunization, Disease surveillance:
Training for mid-level managers. WHO/EPIfMLM/91.4, p. 1, Geneva.
2 Ina rate, the numerator is part of the denominator, and time is essential. A rate measures the
speed with which the denominator becomes part of the numerator.
3 In sentinel reporting, only a small number of reporting units are selected, and these units often
collect additional information compared with routine reporting.
MORTALITY1
Infant mortality
perinatal mortality rate: number of late foetal 4- infant deaths in first 7
days of life per 1,000 live births
• neonatal mortality rate: number of infant deaths in first 28 days of life
per 1,000 live births
• infant mortality rate (IMR): number of deaths in first year of life per 1,000
live births
•
Module 5: Monitoring; appendix C
76
Child mortality2
• child mortality rate, 12-23 months: number of deaths, ages 12-23 months,
per 1,000 population, ages 12-23 months
• child mortality rate, 1-4 years: number of deaths, ages 1-4 years, per
1,000 population, ages 1-4 years
• child mortality rate, < 5 years: number of deaths, ages 0-4 years, per
1,000 population, ages 0-4 years
Maternal mortality3
• number of maternal deaths: number of women dying of childbirth;
pregnancy, labour, or within 42 days of delivery4
• maternal mortality ratio: number of women dying of childbirth; preg
nancy, labour, or within 42 days of delivery per 100,000 live births per
year5
• maternal mortality rate: number of women dying of childbirth per
100,000 women of reproductive age per year6
• life-time risk of death (LTR): cumulative risk of death from motherhood.7
Case fatality rate
• number of deaths due to a particular disease among members of a
population who have the disease during a given time period3
Notes on indicators for mortality
1 A measure of the frequency of deaths in a defined population during a given time period,
usually a year. A mortality rate is expressed as the number of deaths per 1,000,10,000, or
100,000 population.
2 Infant and child mortality can be measured for specific causes of death such as diarrhoea,
respiratory infections, tetanus, malnourishment, plus other outbreaks.
3 Deaths occurring while pregnant, during delivery, or within 42 days of termination of preg
nancy.
4 This indicator measures the magnitude of the problem in a particular setting. Sources of
information include survey, hospital, clinic and midwife records, and vital registration.
5 The ratio represents obstetric risk per birth. See Huque, A.A. and Koblinsky, M. Maternal
mortality: levels, trends and determinants. John Snow International Working Paper.10, Nou
91:24. Information can be obtained through a survey, health facility records, and vital registra
tion. Because maternal mortality is a rare event, a large sample is required for a survey.
6 Interventions that affect fertility and obstetric outcome would affect the rate. (Huque and
Koblinsky, 91:24)
7 Risk is associated with pregr[nancy and the number of times a woman becomes pregnant,
(Huque and Koblinsky, 91:24)
8 A case ffatality rate is expressed as the number of deaths per 100 cases, such as 10/100, as a
percentt (such as 10%), or as a decimal (such as 0.1).
MORBIDITY1
Children 0-11 months2
• neonatal morbidity rate; number of children with specific types of
morbidity3 per the number of surviving children
• infant morbidity rate: number of children with specific types of morbid
ity2 per the number of surviving children
Module 5: Monitoring; appendix C
77
Children 12-23 months
• number of vaccine preventable diseases, e.g., DPT, polio, measles, and
BCG, among children 12-23 months per 100 children age 12-23 months
• number of cases of measles, or other diseases which can be prevented
with a vaccine, among immunized children 12-23 months4
Children < 3 or < 5 years
• number of cases of 3rd degree malnutrition among children < 3 yrs/total
number of children < 3 yrs
• number of children age < 5 with diarrhoea during the past two weeks
per 100 children < 5 years
Maternal morbidity
• rate of pre-labour maternal morbidity: pregnancy or abortion complica
tions or acute morbidities prior to labour
• rate of labour complications: number of women with complications
during labour per 1,000 women experiencing labour5
Total population morbidity
• number of morbidity cases (select the types of morbidity to monitor) in
a specific time, compared with the total population6
Notes on indicators for morbidity
1 Morbidity measures reflect the incidence or prevalence of a disease. Incidence refers to the
number of new cases of a disease in a defined population aurino a given period, usually a year.
Prevalence is the number of all cases of a disease existing in a defined population at a specific
point in time or during a given time period.
2 Childhood morbidity indicators can be used to measure specific illnesses. Childhood morbidity
indicators are grouped into several age groups since morbidity profiles usually vary according
to the age of the child. Moreover PHC services target different age groups.
3 The following is a list of typical childhood health problems: diarrhoea/dysentery, anaemia,
scabies, diphtheria, whooping cough, tetanus, measles, polio, tuberculosis, API, fever, malaria,
and others. This needs to be updated to reflect local childhood morbidity.
4 lb measure the efficacy of a vaccine to prevent disease, compare the number of cases in
immunized children with the number of cases in unimmunized children. A vaccine efficacy of
80-90 percent means the vaccine is not as effective as it should be. Vaccine efficacy ofless than
80 percent means there is a problem with the vaccine, eg., cold chain, technique, age of child.
5 Complications include dystocia, haemorrhage and shock, eclampsia, infection, maternal dis
tress, foetal distress, abnormal presentation offoetus. This can be used to measure the impact
of safe delivery. The indicator could also be calculated as a ratio of women delivering without
complications to those with complications.
6 A review ofPHC service indicators in Appendix A will help determine which types of morbidity
are of concern and should be monitored. For example, the number of ARI cases per 1,000
population could be monitored. This indicator can also be used for specific age, socio-eco
nomic, areal, workforce, ethnic, etc. populations.
DISABILITY
Childhood disabilities1
• number of childhood disabilities: number of disabilities which occur to
children ages 5-10 years during a specific time period (e.g., one year)
Module 5: Monitoring; appendix C
78
• prevalence of childhood disabilities: number of children ages 5-10 years
with disabilities compared with all children ages 5-10 years
• incidence of childhood disabilities: number of disabilities occurring to
children ages 5-10 during the last year per 100,000 children ages 5-10
Adult disabilities2
• number of adult disabilities: the number of disabilities which occur to
adults (determine the desired age range) during a specific time period
(e.g., one year)
• prevalence of adult disabilities: number of adults (determine the desired
age range) with disabilities compared with all adults in the same age range
• incidence of adult disabilities rate: number of disabilities occurring to
adults (determine the desired age range) during the last year per 100,000
adults in the same age range
Notes on indicators for disability
1 The following indicators can be used to measure disabilities: for specific impairments, mouement, deformity, hearing, blindness, speech, behauiour and others, and among specific sub
populations, e.g., children, senior citizens industrial workers, with different risks.
2 indicators are similar to those for childhood disabilities and can be measured in terms of
prevalence or incidence.
FERTILITY - women 15-49 years
• number of births: number of live births in a population in a specific time
period
• age specific fertility rate (ASFR): number of live births during a 12-month
period per 1,000 eligible couples (women living in a conjugal relationship)
by 5-year age groups (15-19, 20-24, 25-29, 30-34,35-39,40-44, 45-49)
• total fertility rate (TFR): the average number of children that would be
born to a woman during her reproductive lifetime under current fertility
ages1
• crude birth rate (CBR): number of live births in a population during a 12
month reference period per the total size of the population
• median age of marriage: median age of women who were ever married2
• induced abortion rate: number of pregnancies that are terminated by
induced abortions per 1,000 pregnancies
Notes on indicators for fertility
1 TFR can be measured using several techniques. The last live birth method measures the
proportion of eligible women, in 5-year age groups, which had a live birth during the last 12
months. The proportions for each age group are multiplied byfive and added to determine the
TFR. The proportion of women with a birth in the last year is provided by age specific fertility
rates.
2 This indicator measures a primary determinant offertility. Higher age of marriage will reduce
the fertility rate by reducing exposure to the risk of pregnancy. A similar indicator is the
age-specific proportion married, which is the percentage of women married by 5-year age
groups, 15-49 years.
Module 5: Monitoring; appendix C
79
Appendix D: Summary list of indicators
for PHC activity monitoring
PHC service delivery
MOD MOD MOD MOD MOD
2
3
4
6
7
GENERAL PHC HOUSEHOLD VISIT___________
Output indicators
number or percentage of households visited by
1.1
CHW in last 3 months
number or percentage of PHC household visits
1.2
during the last 3 months where the health
worker discussed:
- growth monitoring/nutrition (if
malnourished child)
- antenatal care (if pregnant woman)
- family planning (if woman of child-bearing
age)
- water and sanitation
- immunizations
- oral rehydration therapy (if diarrhoea case)
number or percentage of the target population
1.3
visited by their CHW in the last 3 months by type:
- women 15-49 years of age
- children under 5 years of age
- high-risk cases
Input indicators
1.4
number of households per CHW
1.5
population per CHW
number of active health workers by type:
1.6
-CHW
- public health nurse
- midwife
HEALTH EDUCATION________________________
Effect indicators
2.1
number or percentage of respondents who
practise health behaviour outlined in the health
education objectives
2.2
number or percentage of the target population
who remember health education messages on
mass media (television, radio, billboards, posters,
etc.) during the last 1-2 weeks
Module 5: Monitoring; appendix D
x
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
80
MOD
2
Output indicators
2.3 number or percentage of respondents who
practise health behaviour outlined in the
health education objectives
2.4 number of the target population that was
visited at home and received health
information during the last three months
2.5 number or percentage of health workers
using one or more health education
techniques (role playing, demonstration, flip
charts, and others used in the local area)
2.6 number or percentage of clients receiving
health information in a community or
group setting.
Input indicators
2.7 number or percentage of CHWs trained in
health education
2.8 number of community organisations which
provide health education services
2.9 number of CHWs compared to 1,000
households or each village
2.10 number or percentage of respondents that
wish to receive additional health education
information/ topics
MOD
3
MOD
7
X
X
X
X
MOD
6
X
X
X
MOD
4
X
X
X
X
X
X
X
X
X
X
X
ANTENATAL CARE______________
Effect indicators
3.1
number or percentage of pregnant women
identified that are "high-risk"
3.2 number or percentage of women who made
three or more prenatal visits during their
last pregnancy
3.3 number or percentage of women who
received two doses of tetanus toxoid to
confer protection prior to delivery
3.4 number or percentage of women who
complied with iron folate supplementation
regimen during last pregnancy
3.5 number or percentage of women gaining
less than 1 kg/month during the second
and third trimester
X
X
X
X
X
Module 5: Monitoring: appendix D
81
MOD
2
Output indicators
3.6 number or percentage of women who received at
least one antenatal visit while they were pregnant
3.7 average number of contacts per pregnant women
3.8 number or percentage of pregnant women
seen in antenatal care who were counselled
about danger signs indicating the need to
seek further care
3.9 number or percentage of workers who
regularly track high-risk pregnancies
3.10 number or percentage of high-risk women
seen by a health worker identified
3.11 number or percentage of health workers
providing medical attention to high-risk
pregnant women or referring them
Input indicators
3.12 number or percentage of health units which
experienced stock shortages of iron
supplements/malaria prophylaxis
3.13 number of days when iron suppiements/malaria
prophylaxis were out of stock in the clinic
3.14 number or percentage of women of reproductive
age weighing less than 38 kg before pregnancy
MOD
3
MOD
4
MOD
6
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
SAFE DELIVERY________________
Effect indicators
4.1
number or percentage of deliveries in preferred
locations, e.g., hospital, maternity clinic, health
clinic, midwifery or birthing centre
4.2 number or percentage of births attended by
trained health provider, physician, nurse,
midwife, CHW, TEA
4.3 number or percentage of mothers with
knowledge of danger signs and where to go if
complications arise; danger signs include malaria,
diabetes, hypertension, liver disease, and others
4.4 number or percentage of families with
members, men, women, mothers-in-law,
aware of danger signs of pregnancy, labour,
delivery, and puerperium
4.5 ratio of positively treated obstetrical complications
to all complications during the last 3-6 months
Module 5: Monitoring; appendix D
MOD
7
X
X
X
X
X
X
X
X
X
X
X
82
MOD MOD MOD MOD MOD
2
4
3
6
7
4.6 percentage of women with optimum weight gain,
X
X
i.e., no more than 13 kg and no less than 6 kg
from pre-pregnancy to childbirth
Output indicators
number or percentage of pregnant women who
X
X
4.7
were trained about the danger signs of delivery
and instructed where to go
4.8 number or percentage of obstetrical complication
X
cases treated
Input indicators
4.9 number or percentage of TBA trained in family
X
X
planning, recognition of obstetrical complications,
and hygienic birthing practices, and linked with
the formal health service delivery system
4.10 number or percentage of district hospitals
X
X
equipped and functioning as first referral centres
4.11 number or percentage of facilities and staff using
X
X
X
standardised referral protocols to manage
obstetrical complications
X
4.12 number or percentage of health cadres and staff
trained in care of obstetrical complications,
especially emergency cases
X
X
4.13 number or percentage of communities with
organised transport systems in place to effect
referral
POSTNATAL CARE___________________________
Effect indicators
number or percentage of women receiving
5.1
postnatal care from health care workers
5.2
number or percentage of postnatal women who
return for follow-up visits
number or percent of women having delivered
5.3
who know when and where to return for a
postnatal follow-up visit
Output indicators
5.4 number or percentage of women who have
delivered and were seen at least once during the
postnatal period
number or percentage of health workers
5.5
counselling mothers on potential danger signs in
postpartum period requiring consultation with
health worker
X
X
X
X
X
X
X
X
X
Module 5: Monitoring; appendix D
83
5.6
number or percentage of health workers using
sterile materials for cutting and bandaging the
umbilical cord, OR number or percentage of
mothers who said that health worker used clean
materials for cutting and bandaging umbilical cord
number or percentage of mothers delivered by
5.7
a trained birth attendant who received
counselling on child services after delivery
Input indicators
5.8
number or percentage of clinics/local health
workers experiencing shortages of sterile
equipment and supplies for appropriate care of
the umbilical cord (razor blade, bandages, etc.)
number or percentage of facilities with one or
5.9
more health staff trained in postnatal care and
counselling
FAMILY PLANNING___________________________
Effect indicators
6.1
number or percentage of eligible women
knowing at least one modern family planning
method and where to obtain it
6.2
number or percentage of women of child
bearing age currently using modern family
planning methods
number or percentage of last pregnancies not
6.3
intended
6.4
average length of time current contraceptors of
modern methods have used the method
6.5
number or percentage of births with less than 24
months spacing, among younger women 15-29 years
ratio of births to women below 19 or above 34 years
6.6
Output indicators
number or percentage of eligible women
6.7
contacted by health worker (for outreach)
number of women receiving methods from
6.8
CHW (by contraceptive method)
number of new acceptors by method
6.9
(particularly longer acting methods)
Module 5: Monitoring; appendix D
MOD MOD MOD MOD MOD
2
4
3
6
7
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
84
number or percentage of women seen who were
referred from other services (for clinic-based)
6.11 number or percentage of health workers who
explain where and when to go for routine follow
up for family planning services
6.12 number or percentage of acceptors followed up
6.13 number or percentage of women who received
counselling on possible side-effects of the
contraceptive chosen, or who were asked about
side-effects on follow-up visits
Input indicators
6.14 number or percentage of health units
experiencing stock shortages of each
contraceptive method in the last month
6.15 number or percentage of health units who had
less than two types of contraceptives in stock any
time during the month
6.16 number or percentage of villages without a
regular supplier of contraceptives
6.10
ACUTE RESPIRATORY INFECTIONS __________
Effect indicators
number or percentage of ARI cases (cough, fever,
7.1
difficulty breathing) treated by health worker
correctly
7.2
number or percentage of ARI patients or their
caretakers who know the correct dosage and
duration of treatment for ARI
average number of serious symptoms associated
7.3
with ARI recognised by mothers with children
under age five
7.4
number or percentage of mothers who know the
warning signs of ARI and when to seek care
number or percentage of pneumonia cases
7.5
receiving standard case management at health
facilities
number of ARI hospitalisations per year among
7.6
children under age five
Output indicators
number or percentage of women with children
7.7
under age five that were informed of serious ARI
symptoms by CHW or other health provider
7.8
number or percentage of health workers using
antibiotics only in cases of pneumonia, strep
throat, and otitis (per local policy)
MOD MOD MOD MOD MOD
2
4
6
7
3
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Module 5: Monitoring; appendix D
85
MOD MOD MOD MOD MOD
2
4
3
6
7
Input indicators
number or percentage of health units which
7.9
experienced stock shortages of antibiotics in the
last month
7.10 number or percentage of health units/health
workers without functioning timepiece with
second hand (to count respirations)
7.11 number or percentage of health workers or
facilities with health care workers trained in ARI
case management
7.12 number or percentage of health facilities that
have an ARI treatment chart on the wall
7.13 number of percentage of health facilities with
national treatment guidelines
BREAST FEEDING_____________________________
Effect indicators
number or percentage of mothers breast feeding
8.1
babies up to 12 (18) months of age
number or percentage of mothers who began
8.2
breast feeding within 24 hours after birth
number or percentage of mothers who gave the
8.3
baby colostrum (local word)
8.4 number or percentage of mothers who know why
it is important to give colostrum
number or percentage of mothers who breast fed
8.5
and did not provide food supplements during the
first four months
8.6 number or percentage of mothers starting to give
supplemental foods (water, other liquids, solid
foods) to infants between 4 and 6 months of age
proportion of infants 6-9 months of age who
8.7
received both breast milk and complementary
foods
8.8 number or percentage of mothers who continued
to breast feed during the last case of diarrhoea
8.9 number or percentage of women with children
under age two who know how long to continue
breast feeding
8.10 number or percentage of currently breast feeding
women who know how to position the child and
care for her breasts
8.11 number or percentage of currently breast feeding
women who know what to eat during the
lactation period
Module 5: Monitoring; appendix D
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
86
MOD MOD MOD MOD MOD
2
3
4
6
7
Output indicators
8.12 number or percentage of women who were
informed during their pregnancy by a health
provider about the value of breast feeding and
when to start
8.13 number or percentage of postnatal women with
children under age two who received breast
feeding brochures, pamphlets, or other
educational materials
8.14 number or percentage of mothers who received
information about breast feeding during the
neonatal period (28 days after birth)
Input indicators
8.15 number of workers who have been trained in
breast feeding education
8.16 number of CHWs or other health providers with
correct knowledge about the benefits of breast
feeding and when to start
8.17 number of health units which have prenatal and
postnatal educational materials for pregnant/
postnatal mothers which explain breast feeding
(both benefits and procedures)
DIARRHOEAL DISEASE CONTROL/ORAL
REHYDRATION THERAPY_____________________
Effect indicators
number or percentage of mothers who have
9.1
heard of ORT, ORS, SSS, or local names
number or percentage of mothers who can state
9.2
three rules of home case management for
diarrhoea (fluids, feeding, care seeking)
number or percentage of mothers who know how
9.3
to prepare ORS solution, SSS, or local name
9.4 number or percentage of mothers who know how
to administer ORS solution, SSS, or local
treatment
number or percentage of mothers who used ORS
9.5
or a recommended home fluid (total volume
increased), and continued feeding during their
child’s last diarrhoea episode (last month)
9.6 number or percentage of breast feeding women
who know to continue breast feeding during
diarrhoea episode
number or percentage of mothers who know how
9.7
often to feed a child with diarrhoea (at least every
3-4 hours)
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Module 5: Monitoring; appendix D
87
MOD MOD MOD MOD MOD
2
4
7
3
6
Output indicators
9.8 number or percentage of health workers who
counsel mothers on preparation and admin
istration of ORS solution
9.9 number or percentage of health workers who
correctly showed the mother how to prepare and
administer ORS solution
Input indicators
9.10 number or percentage of health units which
experienced stock shortages of ORS in the last
month
9.11 number or percentage of mothers who live within
a reasonable distance as defined by local norms
and expressed in terms of time, of a health
facility or provider that has a regular supply of
ORS and antibiotics, and practises correct case
management
CHILDHOOD DISABILITIES__________________
Effect indicators
10.1 number or percentage of disabled children
enrolled in special schools or community
programmes
10.2 number or percentage of disabled children
covered by appropriate health services
10.3 number or percentage of clients/mothers with
knowledge of special schools, community
programmes, and NGOs involved with disabled
children
10.4 number or percentage of mothers who know
appropriate care for disabled child
10.5 number or percentage of mothers with disabled
children who know how to prevent a similar
disability
Output indicators
10.6 number or percentage of clients with disabilities
referred for diagnosis or treatment
10.7 number or percentage of health workers
currently providing counselling/treatment for
disabilities
Module 5: Monitoring; appendix D
x
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
88
MOD MOD MOD MOD MOD
2
3
4
6
7
Input indicators
10.8 number or percentage of health workers who can
identify signs and symptoms associated with
disabilities
10.9 number or percentage of health workers who
know how childhood disabilities can be prevented
10.10 number or percentage of health workers with
correct knowledge of national
treatment/referral/counselling guidelines for
disabilities
10.11 number or percentage of health centres without
treatment/counselling facilities for clients with
disabilities
10.12 number or percentage of health centres without
established treatment, referral, and counselling
guidelines
CHILD IMMUNIZATION_______________________
Effect indicators
11.1 number or percentage of children age 12-23
months who are fully immunized with BCG, DPT,
measles, and polio vaccines
11.2 number or percentage of children age 12-23
months never immunized with BCG, DPT,
measles, and polio vaccines
11.3 number or percentage of mothers who'know the
age at which children should be immunized
against measles (9-12 months)
11.4 number or percentage of mothers whose children
are not completely immunized who know when
to return for the next immunization
11.5 number or percentage of children age 12-23
months whose mothers can present a completely
(per local standards) filled immunization card,
given the age of the child
Output indicators
11.6 number or percentage of health workers using
sterile needles and syringes for each injection
11.7 for outreach programmes, number or percentage
of immunization sessions held (per area)
11.8 number or percentage of health workers
counselling mothers on possible side-effects of
vaccines
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Module 5: Monitoring; appendix D
89
MOD MOD MOD MOD MOD
7
6
4
3
2
Input indicators
11.9 number or percentage of health units, or number
or percentage of immunization sessions, which
experience shortages of vaccines, needles,
syringes, and/or immunization cards
11.10 number or percentage of health units whose
refrigerator has not been at a temperature
between 0°C and 8°C at all times during the
previous period
X
X
GROWTH MONITORING/
NUTRITION EDUCATION______________________
Effect indicators
12.1 number or percentage of children under two
years of age in the target area weighed at least
once during the past quarter
12.2 number or percentage of mothers breast feeding
babies up to 12 (18) months of age
12.3 number or percentage of mothers starting to give
supplemental foods to infants between four and
six months of age
12.4 number or percentage of children whose weightfor-age is below the normal range or whose
growth is faltering (per local norms)
12.5 number or percentage of mothers with children
under age two who interpret growth chart
information
Output indicators
12.6 number or percentage of children under two
years enrolled in a growth monitoring programme
12.7 number or percentage of mothers with children
under two years who were explained growth
monitoring chart by CHW during the last 3-6
months
12.8 for outreach programmes, number of growth
monitoring sessions held (per area)
12.9 number or percentage of health workers who
track malnourished children
12.10 number or percentage of high-risk children
(malnourished ) followed up
12.11 number or percentage of mothers told child’s
nutritional status
12.12 number or percentage of mothers with growth
faltering children who received counselling on
appropriate feeding
Module 5: Monitoring; appendix D
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
90
MOD MOD MOD MOD MOD
2
4
3
6
7
Input indicators
12.13 number or percentage of health
workers/health units which do not have a
functioning scale (accurate to 1/10 kg)
12.14 number or percentage of health units (or
growth monitoring sessions) experiencing
shortages of growth cards in the last month
X
WATER SUPPLY, HYGIENE, AND SANITATION
Effect indicators
13.1
number or percentage of households receiving
drinking water from a clean source, faucet,
tap, pipe, covered well, or other safe source,
within
15-minute walk
13.2 number or percentage of households using a
clean facility, water-seal latrine, pit privy, or
WC
13.3 number or percentage of mothers knowing
the importance of hand washing
13.4 number or percentage of mothers with
children under age two who use a baby potty
Output indicators
13.5 number or percentage of health workers
inspecting latrines (per local standards)
13.6 number or percentage of health workers
inspecting community management of local
water sources (per local standards)
number of latrines built during the last year
13.7
13.8 number of wells or other water sources
constructed during the last year
Input indicators
13.9 number of wells or other water sources
constructed per 1,000 population
13.10 number of latrines built per 1,000 population
13.11 number or percentage of communities with
access to health staff or technicians with
resources, information, funds, supplies, for
building safe water supply systems and latrines
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Module 5: Monitoring; appendix D
91
MOD MOD MOD MOD MOD
7
2
3
4
6
ACCIDENTS AND INJURIES_________________
Effect indicators
number or percentage of respondents with
14.1
knowledge of how to care for accidents and
injuries
14.2 number or percentage of respondents with
knowledge of an emergency care facility
14.3 number of respondents who use safety
precautions and equipment on a daily basis
Output indicators
14.4 number of respondents treated for an injury
(by type)
14.5 in a work place or other high-risk
environment, number of safety regulations
implemented and enforced
14.6 number or percentage of health workers,
CHWs, factory or plant cadres, traditional
practitioners, etc., trained in injury care
14.7 number or percentage of health workers who
received formal training in hazard
identification and intervention
Input indicators
14.8 number or percentage of health care facilities
without 24-hour emergency care services
14.9 number or percentage of health care facilities
without treatment and referral procedures for
clients with injuries
x
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
CHRONIC, NON-COMMUNICABLE DISEASES
Hypertension
Effect indicators
number or percentage of patients with
15.1
hypertension
number or percentage of patients who
15.2
developed other complications of hypertension
number or percentage of patients, diagnosed
15.3
with chronic hypertension, who are in a
systematic anti-hypertensive therapy
programme
15.4 number or percentage of patients with
moderate hypertension who follow a
prescribed diet on a daily basis
number or percentage of patients who take
15.5
medication as prescribed
Module 5: Monitoring; appendix D
X
X
X
X
X
X
X
X
X
X
X
X
X
X
92
number or percentage of patients who practise
the appropriate diet on a daily basis
15.7 number or percentage of patients who were
given a special regimen sheet for the use of
medication and diet
Output indicators
15.8 number of clients diagnosed for hypertension
15.9 number of patients with hypertension who were
treated
15.10 number of patients who switched from prescribed
medicine to diet
15.11 number of health workers who are clinically
knowledgeable in providing diet and medication
regimen to patients with hypertension
15.12 number of systematic visits by patients with
hypertension
15.13 number or percentage of patients who have been
assessed for renal function
15.14 number of patients with hypertension who were
provided with instructions for the use of
medication and diet
Input indicators
15.15 number of health workers who can provide diet
and medication information to patients with
hypertension
15.16 number of primary health centres with
daily/weekly availability of trained family doctor
15.17 number of health centres with
sphygmomanometers
15.18 number of primary health centres with
functioning laboratory equipment and medication
for hypertension
15.6
MOD MOD MOD MOD MOD
4
7
2
3
6
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Diabetes
Effect indicators
15.19 number or percentage of diabetic patients with
annual assessment of renal function
15.20 number or percentage of diabetic patients with
semi-annual measurement of glycosylated Hgb
15.21 number or percentage of diabetic patients with
documented home glucose monitoring
15.22 number or percentage of diabetic patients with
discrepancies between home and clinic monitored
results
15.23 number or percentage of diabetic patients with
family members who know how to handle a
diabetic emergency
X
X
X
X
X
X
X
X
X
X
X
Module 5: Monitoring; appendix D
93
MOD MOD MOD MOD MOD
4
2
3
6
7
Output indicators
15.24 number or percentage of persons diagnosed for
diabetes mellitus
15.25 number or percentage of patients treated for
diabetes mellitus by a physician
15.26 number or percentage of patients treated for
diabetic ketoacidosis
15.27 number or percentage of patients treated for
diabetic foot lesions
Input indicators
15.28 number of general practitioners or family
physicians per 1,000 households
15.29 presence of equipment and other materials in the
health units; glucose monitoring, blood pressure,
protocol for home glucose monitoring and insulin
schedule
Anaemia
Effect indicators
15.30 number or percentage of anaemic patients with
semi-annual evaluation and follow-up
haemoglobin and haematocrit
15.31 number or percentage of anaemic patients with
documented improvement in anaemic condition
15.32 number or percentage of anaemic women who
know the treatment for anaemia
Output indicators
15.33 number of percentage of persons diagnosed for
anaemia
15.34 number or percentage of patients treated for
anaemia
15.35 number or percentage of patients treated for
symptomatic anaemic conditions (pale, weak, etc.)
15.36 number or percentage of patients who received
education for nutritional health
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Input indicators
15.37 number of general practitioners of family
physicians per 1,000 household with knowledge
or understanding of anaemia
MALARIA____________________________________
Effect indicators
16.1 number or percentage who know how malaria is
spread
Module 5: Monitoring; appendix D
X
X
X
X
X
94
16.2
number or percentage of population that are
protecting themselves against malaria
16.3 number or percentage of malaria (fever) cases
treated with anti-malarial drugs at home, by
mother who knows correct dosage
16.4 number or percentage of patients who were
prescribed anti-malarial drugs who know dosage,
frequency, and duration of treatment
Output indicators
16.5 number or percentage of malaria (fever) cases
treated at health unit
16.6 in areas where confirmation is the norm, number
or percentage of health workers who take/
request a blood slide from malaria/fever cases
16.7 number or percentage of health workers who
screen fever patients for signs/symptoms of other
serious illnesses (meningitis, pneumonia, etc.)
Input indicators
16.8 number or percentage of health units
experiencing stock shortages of anti-malarial
drugs in the last month
16.9 number or percentage of health units without
functioning laboratory equipment
TREATMENT OF MINOR AILMENTS___________
Effect indicators
17.1 number or percentage of illness episodes treated
at health unit
17.2 number or percentage of patients who were able
to obtain all of the medication prescribed in the
health unit
17.3 number of patients receiving laboratory services
in the same health unit per number of patients
requiring laboratory services
17.4 number or percentage of patients or their
attendants who understand the treatment
prescribed; how much, how long, how often
Output indicators
17.5 number of treatments given during last period by
condition
17.6 number or percentage of health workers asking
at least 5 history questions and carrying out at
least one physical exam
MOD MOD MOD MOD MOD
4
2
3
6
7
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Module 5: Monitoring; appendix D
95
MOD MOD MOD MOD MOD
2
4
3
6
7
Input indicators
17.7 number or percentage of health workers who
know the explicit criteria for referring patients to
a higher level (per local policy)
17.8 number or percentage of health units without
functioning:
- stethoscope
- thermometer
- scale
- blood pressure cuff
- watch with second hand
- microscope and slides
17.9 number or percentage of cases where prescribed
medicines were available at the health unit at the
time of consultation, compared to all cases that
were prescribed medicines
17.10 availability of drugs for high volume conditions
17.11 availability of laboratory tests used more
frequently
TUBERCULOSIS______________________________
Effect indicators
18.1 number or percentage of children vaccinated with
BCG
18.2 number or percentage of target population who
know how TB is spread and how to prevent
infection
18.3 number or percentage of detected tuberculosis
cases followed to cure
18.4 number of active tuberculosis cases
18.5 number or percentage of tuberculosis patients
knowing why it is important to complete
treatment
18.6 number or percentage of tuberculosis patients
knowing the correct dosage and duration of
treatment for tuberculosis
18.7 number or percentage of population with
persistent cough lasting more than 2 weeks who
sought treatment for TB
Module 5: Monitoring; appendix D
x
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
x
X
X
96
MOD MOD MOD MOD MOD
2
3
4
6
7
Output indicators
18.8 number or percentage of suspected tuberculosis
cases sent for confirmation
18.9 number or percentage of health workers who
have a system for following up suspected and
confirmed tuberculosis cases
18.10 number or percentage of suspected and
confirmed tuberculosis cases followed up
Input indicators
18.11 number or percentage of health units without
adequate equipment to diagnose tuberculosis
18.12 if the health unit is a tuberculosis treatment
centre, number of days when tuberculosis drugs
were out of stock
SEXUALLY TRANSMITTED DISEASES_________
Effect indicators
19.1 number or percentage of target groups screened
last 3 months (or shorter period if necessary) for
HIV/STDs
19.2 number or percentage of target groups screened
with an STD during the past 12 months
19.3 number or percentage of target population with
correct knowledge of the means of HIV/STD
transmission
19.4 number or percentage of target population who
know that condoms provide protection against
infection with HIV/STDs
19.5 number or percentage of target population
reporting sex with use of condom
19.6 number or percentage of pregnancies that occur
among HIV-infected women
19.7 number or percentage of HIV-infected women of
child-bearing age who use a barrier contraceptive
method (male or female condom)
19.8 number or percentage of the target population
who report having had at least one sex partner
other than their regular sex partner(s) in the last
six months
Output indicators
19.9 number or percentage of injections given with
sterile needles
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Module 5: Monitoring; appendix D
97
19.10 number or percentage of health workers who
correctly dispose of contaminated materials
19.11 number or percentage of clients referred by
health workers for diagnosis, treatment, or testing
19.12 number or percentage of clients receiving
antibiotics for STDs
19.13 number of condoms distributed to the target
population
19.14 number of I EC materials distributed to target
population
19.15 number of group HIV/STD prevention activities
held during the last 1-3 months; meetings,
presentations, TV/radio broadcasts, media events,
etc.
Input indicators
19.16 number or percentage of the target population
with access to STD-related services
19.17 number or percentage of appropriate outlet
centres having uninterrupted supply of condoms
during preceding 12 months
19.18 number or percentage of health centres providing
STD-related services with uninterrupted supply
of appropriate antibiotics during preceding 12
months
19.19 number or percentage of health centres without
proper equipment or laboratory facilities
19.20 number or percentage of health units with
identification, treatment, referral, and follow-up
guidelines
19.21 number or percentage of treatment facilities
without counselling activities
19.22 number or percentage of health workers who are
trained in care/counselling of HIV/STD patients
19.23 number or percentage of health workers with
correct knowledge of the modes of transmission
of HIV/STDs
19.24 number or percentage of health workers who
know the correct diagnosis, treatment, referral, or
counselling guidelines for HIV/STDs
Module 5: Monitoring; appendix D
MOD MOD MOD MOD MOD
2
4
6
7
3
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
98
PHC management service
MOD MOD MOD MOD MOD
2
3
4
6
7
PLANNING____________________________________
Effect indicators
Outcomes for planning would be the implementation of
planned activities and the achievement of programme
objectives. These should be reflected in coverage and
KAP indicators for specific service delivery inter
ventions (See Appendix A for indicators).
Output indicators
1.1
number or percentage of health units which have
a written mission statement that defines their
target population, the programmes activities, and
its goals
1.2 number or percentage of health units which have
concrete measurable objectives for coverage,
service quality, changes in population
knowledge/ practice
1.3 number or percentage of health units whose plans
have corresponding budgets
Input indicators
1.4 number or percentage of health units which have
clearly defined catchment areas they are to serve
1.5 number or percentage of health units which have
information on the population they serve: total
number, number of children < 2, number of births
a year, number of women 15-49
PERSONNEL MANAGEMENT___________________
Effect indicators
2.1 number or percentage of vacant posts
2.2 average duration at a post for each type of worker
Output indicators
2.3 number or percentage of staff whose job
descriptions have been updated in the last year to
reflect current responsibilities
2.4 number or percentage of supervisors who develop
specific work plans with their staff at regular
intervals (per local norms)
2.5 number or percentage of supervisors who review
whether work assignments have been completed
x
x
X
X
X
X
X
X
X
X
X
X
X
Module 5: Monitoring; appendix D
99
MOD MOD MOD MOD MOD
7
2
4
6
3
Input indicators
2.6 number or percentage of staff members with job
descriptions
2.7 number or percentage of facilities that provide
cost-recovery (expense/revenue) data
2.8 number or percentage of local offices that submit
budget estimates on time
2.9 number or percentage of facilities which have
guidelines for developing work plans
TRAINING____________________________________
Effect indicators
3.1 number or percentage of participants in training
who showed improvement between the pre- and
post-tests
Output indicators
3.2 number or percentage of health workers having
received training or refresher training in the last
period for any intervention, or for specific
interventions
3.3 number or percentage of training sessions that
allowed participants to put new knowledge and
skills into practice during training, e.g., using real
life cases or role-play
3.4 number or percentage of training sessions in
which technical content was complete and
accurate
Input indicators
3.5 number or percentage of health units using
programme specific information (from MIS or
supervision) about service quality to plan or focus
training sessions given in the last period
3.6 number or percentage of trainers who have
received instruction in training methods
3.7 number or percentage of health facilities that hold
PHC training sessions
SUPERVISION________________________________
Effect indicators
4.1 number or percentage of health workers that feel
they are receiving adequate support from their
supervisors
Module 5: Monitoring; appendix D
x
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
100
MOD MOD MOD MOD MOD
2
4
3
6
7
Output indicators
4.2 number or percentage of supervisees visited by or
meeting with their supervisors during the last
period (per local norms)
4.3 number or percentage of health workers whose
supervisor observed them during service delivery,
or through role-play/simulation, during the last
supervision visit
4.4 number or percentage of supervision visits that
included problems identified and actions taken
4.5 number or percentage of supervision visits that
included review or follow-up on problems from
previous supervision visits
Input indicators
4.6 number or percentage of field supervisors who
have been trained in guidance and quality
assessment
4.7 number or percentage of health units that have
written guidelines or protocols for supervision
FINANCIAL MANAGEMENT___________________
Effect indicators
5.1 number or percentage of health workers that
were paid on time in the last period
5.2 number or percentage of health units that achieve
cost-recovery and their planned service goals
5.3 average percentage of costs recovered from
revenue
Output indicators
5.4 number or percentage of health units whose
accounting records are up to date and balanced
monthly
5.5 number or percentage of health units with
systems of checks and balances for handling cash,
including vouchers, disbursements by check,
verification of accounts
5.6 number or percentage of health units whose
financial reports are evaluated by making
comparisons of "budget" to "actual" financial
performance
Input indicators
5.7 number or percentage of health workers trained
in financial management
X
X
X
X
X
X
X
X
X
X
X
X
X
Module 5: Monitoring; appendix D
101
5.8
number or percentage of financial management
staff with training in finance administration
MOD MOD MOD MOD MOD
2
3
4
6
7
X
LOGISTICS MANAGEMENT____________________
Effect indicators
6.1 number or percentage of health units receiving
the amounts of materials they requisitioned
6.2 number or percentage of health or support
activities cancelled due to lack of transportation
Output indicators
6.3 average interval between a health unit making a
requisition and reception of requested supplies
6.4 number or percentage of health units using stock
inventory and consumption patterns as the basis
of preparing requisitions
6.5 number or percentage of health units that carry
out a physical inventory to verify theoretical stock
levels with actual physical counts
6.6 number or percentage of health units who have to
cancel field visits and other off-site activities
planned for lack of adequate fuel supply
Input indicators
6.7 number or percentage of health units with
established checklists or procedures for
procurement
6.8 number or percentage of health units with
schedules or appointment books for health unit
vehicle use
INFORMATION MANAGEMENT________________
Effect indicators
7.1 number or percentage of health units that utilise
monitoring information to identify district-wide
and localised problems and strengths, and actions
to take
7.2 number or percentage of local health units that
receive feedback from district level managers on
results of district-wide monitoring
Output indicators
7.3 number or percentage of districts that compile
monitoring information from the health unit level
Input indicators
7.4 number or percentage of health units who have
indicators they routinely monitor
X
X
X
X
X
X
X
X
X
fl h. p
■
BI
X
.)
PH C ' 'OO
Module 5: Monitoring; appendix D
X
bZ
10 6 13
5
X
102
7.5
MOD MOD MOD MOD MOD
2
3
4
6
7
X
number or percentage of health units that
maintain records on high-risk cases
COMMUNITY ORGANISATION_________________
Effect indicators
8.1 number or percentage of community members
who state that PHC services are accessible, and
convenient
8.2 number or percentage of community members
who state that the PHC services are acceptable,
and relevant to their needs
Output indicators
8.3 number or percentage of community committees
that met at least monthly (per local norms) during
the last quarter
8.4 using an area relevant to your programme,
number or percentage of communities that
participate in each of the following activities, e.g.,
health, religion, family planning, youth, sports,
income generating, etc.
8.5 number or percentage of community committees
that participate in problem analysis and problem
solving
8.6 level of community contribution directed to PHC
services
8.7 number or percentage of community participating
in health activities
Input indicators
8.8 number or percentage of health units which have
an affiliated health committee or community
organisation
8.9 number of trained community organisers
8.10 availability of resources, labour, funds, buildings,
X
X
X
X
X
X
X
X
X
X
political support, mass activities and materials, to
assist in organising communities
Module 5: Monitoring; appendix D
103
Appendix E: Blank worksheets
WORKSHEET FOR SPECIFYING THE MONITORING OBJECTIVES
What to
monitor
Internal users
Purpose & (r)outine
or (s)hort-term
External users
Providers Managers Donors
Others
PHC
services
Management
services
WORKSHEET FOR SPECIFYING THE SCOPE OF MONITORING
1.
What geographic area will be covered?
2.
Which facilities or sub-projects will be monitored?
3.
Which personnel (managers, providers, & volunteers) will be selected?
4.
How long will the monitoring continue?
Module 5: Monitoring; appendix E
I
104
WORKSHEET FOR SELECTING INDICATORS AND STANDARDS
Formulation
Indicators
Standards
Frequency
PHC services
Effect
Output
Input
Management services
Effect
Output
Input
WORKSHEET TO SELECT DATA SOURCES AND TECHNIQUES
Data Source: Records
DC Technique:
Review
Provider-client
interface
Client
Observation
Survey/
Interview
Interview
Health
worker
PHC service indicator
Management service
indicators
Module 5: Monitoring; appendix E
105
WORKSHEET FOR SPECIFYING DATA COLLECTION,
SUPERVISION AND PROCESSING
Responsibility
Staff
Supervision
Collection
Processing
WORKSHEET FOR COMPARING ACTUAL PERFORMANCE
WITH ITS STANDARD OF PERFORMANCE
Components
Actual
performance
Standard of
performance
PHC service
indicators
Management
service
indicators
Module 5: Monitoring; appendix E
% Achieved
of standard
Action to
be taken
107
References and bibiography
Articles and books
• Aga Khan Community Health Programme. Progress Report, April 1990
- September 1990. Dhaka, Bangladesh.
• Helen Keller International. HKI Nutritional Surveillance Newsletter,
October, 1990.
• Heymann, D. et al. Evaluation ofAIDS Programs. The handbook for AIDS
prevention in Africa. Family Health International, 1990.
• Huque, A. A. and M. Koblinsky. Maternal morality: levels, trends and
determinants. John Snow International, Working Paper-.IO, Nov. 1991.
• World Health Organization. Expanded Programme on Immunization,
Disease surveillance training for mid-level managers.
WHO/EPI/MLM/91.4, Geneva.
Manuals and computer programs
for monitoring PHC indicators
• Dean, A. G. et al. EPI-Info version 5: A word processing, database and
statistics system for epidemiology on microcomputers, Center for Disease
Control (CDC) and the World Health Organization (WHO).
• Economic and Social Commission for Asia and the Pacific (ESCAP).
Monitoring and evaluating family planning programmes in the 1990s,
Asian Population Studies Series No. 104, United Nations, 1990.
• Koblinsky, M. A. et al. Making motherhood safe, Population and Human
Resources Department, The World Bank, June, 1992.
Module 5: Monitoring; references
108
Acronyms and abbreviations
AIDS
Acquired immune deficiency syndrome
AIHD
ASEAN Institute for Health Development, Bangkok
AKCHP
Aga Khan Community Health Programme, Dhaka
AKE
Aga Khan Foundation
ARI
Acute respiratory infection
ASFR
Age-specific fertility rate
BCG
Bacillus of Calmette and Guerin (tuberculosis vaccine)
BRAC
Bangladesh Rural Advancement Committee
CBR
Crude birth rate
CHW
Community health worker
CMR
Child mortality rate
CYP
Couple-years protection
DPT
Diptheria, pertussis and tetanus vaccines
EPI
Expanded Programme for Immunization
FP
Family planning
GM
Growth monitoring
HH
Household
HIV
Human immunodeficiency virus
HPRC
Health and Population Research Corporation, Bangkok
IEC
Information, education, communication
IMR
Infant mortality rate
IUD
Intra-uterine device
KAP
Knowledge, attitudes, practice (behaviour)
LTR
Life-time risk of death
MIS
Management information system
MMR
Maternal mortality rate
MOH
Ministry of health
MOPH
Ministry of public health
NGO
Non-governmental organisation
OPV
Oral poliovirus vaccine
ORS
Oral rehydration salts
ORT
Oral rehydration therapy
PHC
Primary health care
PHC MAP Primary Health Care Management Advancement Programme
PNC
Peri-natal care
PRICOR
Primary Health Care Operations Research
Rp
Rupiah, the currency of Indonesia
SES
Socio-economic status
SSS
Sugar-salt solution
Module 5: Monitoring; acronyms
109
STD
SVF
TB
TBA
TFR
TT
WC
WHO
Sexually transmitted diseases
Somboon Vacharotai Foundation
Tuberculosis
Traditional birth attendant
Total fertility rate
Tetanus toxoid
Water closet
World Health Organization
Module 5: Monitoring; acronyms
110
Glossary
Assessment: An evaluation or judgement
Catchment (area): The geographic area surrounding one or more health
facilities. It refers to the population residing in that area, which includes
the programmes target populations.
Community health worker (CHW): A person indigenous to the com
munity who provides basic preventive and curative health services to
members of the community. Includes village health workers, health guides,
and other terms.
Coverage: The proportion of a target group that has received a service
or is protected from a disease or health problem.
Effectiveness: The degree to which desired outcomes are achieved.
Efficiency: The degree to which desired outcomes are achieved without
wasting resources.
Goals: The impact your programme hopes to have on health. Goal
statements specify improvement desired, target group, amount of change
expected and date for achievement.
Incidence: The number of new cases of a disease in a defined population
during a specified period of time.
Indicator: An indirect measure of an event or condition. For example, a
baby’s weight for age is an indicator of the baby’s nutritional status.
Inputs: Resources (personnel, equipment, supplies, information and
money)
Management: The art and science of getting things done through people.
Monitoring,
Routine: Compilation and analysis of a core set of indicators on a regular
basis.
Short-term: Compilation and analysis of a specific set of indicators on
specific activities for a limited period of time.
Objectives: The output and/or effect your PHC programme hopes to
have.
Outcomes: Results of your PHC programme, including outputs, effects
and impacts.
Outputs: Products and services provided by a PHC programme.
Effects: Changes in knowledge, skills, attitude, and behaviour (including
coverage) as a result of a PHC programme.
Impacts: Changes in health status, (mortality, morbidity, disability, fer
tility) as a result of a PHC programme.
Percentage: A proportion multiplied by 100. For example, 3,500 children
immunized out of 5,000 x 100 (3,250/5,000) * 100 = 65%.
Prevalence: The total number of cases of a disease in a defined popula
tion at a specified point in time. Also used with "coverage," as with the
Module 5: Monitoring; glossary
Ill
"contraceptive prevalence rate," meaning the proportion of the target
population that is currently practising family planning.
Primary health care: Essential health care, accessible at affordable cost
to the community and the country, based on practical, scientifically sound
and socially acceptable methods. It includes at least eight components:
health education, proper nutrition, basic sanitation, maternal and child
health care, immunization, control of common diseases and injuries, pre
vention of local endemic diseases, essential drugs.
Proportion: A special type of ratio expressing a relationship between a part
and the whole. For example, 3,250 children immunized out of 5,000
(3,250/5,000) = .65.
Processes: Activities or tasks carried out through the PHC programme.
Rate: A measure of the frequency of occurrence of an event, such as cases
per month.
Ratio: Two numbers related to each other in a fraction or decimal, such
as the number of cases of measles per 1,000 children. Any fraction, quotient,
proportion, or percentage is a ratio.
Resource: Available means, usually personnel, materials, funds, informa
tion
Register: A written or printed record containing regular entries of events
or other items, such as name, address, births, deaths, symptoms, treatments
given, and so forth. Typical registers are for households, families, individual
visits to health facilities, and daily visits of health workers to households.
System: A set of discrete, but interdependent, components designed to
achieve one or more objectives.
Target group: Specific groups of people designated to receive a PHC
service, such as children under age three.
Module 5: Monitoring; glossary
PHC MAP MANAGEMENT COMMITTEE
Dr. Ronald Wilson • Aga Khan Foundation, Switzerland (Co-Chair)
Dr. Jack Bryant • Aga Khan University, Pakistan (Co-Chair)
Dr. William Steeler • Secretariat of His Highness the Aga Khan, France (Co-Chair)
Dr. Jack Reynolds • Center for Human Services, USA (PHC MAP Director)
Dr. David Nicholas • Center for Human Services, USA
Dr. Duane Smith • Aga Khan Foundation, Switzerland
Dr. Pierre Claquin • Aga Khan Foundation, Switzerland
Mr. Aziz Currimbhoy • Aga Khan Health Service, Pakistan
Mr. Kabir Mitha • Aga Khan Health Service, India
Dr. Nizar Verjee • Aga Khan Health Service, Kenya
Ms. Khatidja Husein • Aga Khan University, Pakistan
Dr. Sadia Chowdhury • Aga Khan Community Health Programme, Bangladesh
Dr. Mizan Siddiqi • Aga Khan Community Health Programme, Bangladesh
Dr. Krasae Chanawongse • ASEAN Institute for Health Development, Thailand
Dr. Yawarat Porapakkham • ASEAN Institute for Health Development, Thailand
Dr. Jumroon Mikhanorn • Somboon Vacharotai Foundation, Thailand
Dr. Nirmala Murthy • Foundation for Research in Health Systems, India
PHC MAP TECHNICAL ADVISORY COMMITTEE
Dr. Nirmala Murthy • Foundation for Research in Health Systems, India (Chair)
Dr. Krasae Chanawongse • ASEAN Institute for Health Development, Thailand
Dr. Al Henn • African Medical and Research Foundation (AMREF), formerly of
the Harvard Institute for International Development
Dr. Siraj-ul Haque Mahmud • Ministry of Planning, Pakistan
Dr. Peter lugwell • Faculty of Medicine, University of Ottawa, Canada
Dr. Dan Kaseje • Christian Medical Commission, Switzerland, formerly of the
University of Nairobi, Kenya
KEY PHC MAP STAFF AT THE CENTER FOR HUMAN SERVICES
Dr. Jack Reynolds (PHC MAP Director)
Dr. Paul Richardson
Dr. David Nicholas
Dr. Wayne Stinson
Ms. Maria Francisco
Dr. Neeraj Kak
Ms. Lori DiPrete Brown
Ms. Pam Homan
Dr. Lynne Miller Franco
Ms. Mary Millar
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