Lesson 7

• Monitoring


  The systematic collection, analysis, and use of information from programs for three basic purposes: (1) Learning from the experiences acquired (learning function); (2) Accounting internally and externally for the resources used; and (3) the results obtained (monitoring function) and taking decisions (steering function)
• Evaluation


  Assessing an ongoing or completed program or policy as systematically and as objectively as possible. The object is to be able to make statements about their relevance, effectiveness, efficiency, impact, and sustainability
• Monitoring and Evaluation


  • Complementary
• Purpose of M&E


  To have a strong M&E and review system in place for the national health strategic plan that comprises all major disease programs and health systems
• M&E Plan

  1. Address all components of the framework and lay the foundation for regular reviews during the implementation of the national plan

  2. Generate the information needed for global monitoring while minimizing the reporting burden for countries

  3. Bring together the monitoring and evaluation work in disease-specific programs with cross-cutting efforts such as tracking human resources, logistics and procurement, and health service delivery
• M&E Framework


  Strengthening of a common country platform for M&E of health system strengthening, which should result in better alignment of country and global M&E systems
• Indicator Domains


  • Inputs & Processes
  • Output
  • Outcomes
  • Impact
• Monitoring indicators provides information on the strengths and weaknesses of implementation, and can help identify "red flags" where further investigation and adjustments may be needed
• Shifts in outcome and impact indicators may not be directly attributable to integrated service delivery efforts, as there are many other factors which influence these indicators
• HMIS Indicator


  A variable whose value changes, a measurement that measures the value of the change in meaningful units that can be compared to past and future units
• Key Performance Areas and Indicators

  • Reproductive Health
  • Immunization
  • Disease Prevention and Control
  • Resource Utilization
  • Data Quality
• Indicators in the Reproductive Health Area


  • Vaccine stockouts in a single month
  • Contraceptive stockouts
• OPD attendance per capita

  Key performance indicator
• Trace drug availability (in stock)

  Key indicator
• Inpatient admission rate


  Resource utilization indicator
• Average length of stay (inpatient)

  Resource utilization indicator
• Indicators for monitoring FP/Immunization integration

  • Vaccine stockouts in a single month (YES/NO, by type of vaccine)
  • Number of services providers trained in provision of EPI/FP integrated services
  • Number of service delivery points offering integrated FP and immunization services
  • Number/percent of women attending routine child immunization services who received information on family planning from a vaccinator
  • Number/percent of women (with children <12 months) going for family planning who receive information on immunization from the family planning provider
  • Number/percent of women attending routine child immunization services who accept a referral to family planning services
  • Number/percent of women attending routine immunization services who follow through on a FP referral from a vaccinator
  • Number/percent of women attending family planning services who follow through on referral to immunization services from a family planning provider
  • Number of children receiving DTP1, DTP3, measles, and DTP 1-3 dropout
  • Immunization coverage for DTP1, DTP3, measles, and DTP 1-3 dropout
  • Number of new family planning acceptors by method type and demographic/age group
  • Contraceptive prevalence rate
  • Total financial cost of inputs required to integrate FP and immunization services (per facility, per client exposed, per new FP acceptor)
• Health System Indicators and Data Sources

  • Total health expenditure as % of DGP
  • Total health expenditure per capita
  • % general government expenditure on health
  • Doctors per 10,000 population
  • Nurse/midwives per 10,000 population
  • Graduates of health training institutions per 10,000 population
  • Hospital beds per 10,000 population
  • Doctors using electronic health records
  • Tracer medicines availability
  • Median drug price ratio for tracer drugs
  • Index of service readiness
  • Service accessibility (distance to facility)
  • General practitioner utilization rate
  • TB treatment success rate (DOTS)
  • 30-day hospital case fatality rate AMI and stroke
  • Waiting time to elective surgeries: cataract, PTCA, hip replacement
  • Surgical wound infections (% of all surgical operations)
  • Cancer treatment delay (time between first GP visit and first treatment, for breast and colon cancer)
  • Antenatal care coverage (4+)
  • Antenatal care coverage (1)
  • Skilled birth attendance
  • DPT3 Immunization coverage
  • ART coverage
  • Contraceptive prevalence rate
  • TB smear+ case detection rate
  • ARI in under-fives taken to health facility
  • Diarrhoea in under-fives receiving ORT
  • ITN coverage among children
  • Breast cancer screening (50-69 years) coverage
  • Cervical cancer screening (20-64 years) coverage
  • Tobacco use (adults)
  • Access to safe water
  • Access to improved sanitation
  • Low birth weight newborns
  • Breastfeeding exclusive for 6 months
  • Obesity in adults (over 15 years)
  • Children under 5 anthropometry- stunting
  • Condom use at last higher risk sex, 15-49
  • Particulate Matter (PM10) exposure
  • Life expectancy at birth
  • Child mortality (under-5)
  • Life expectancy at age 65
  • Maternal mortality ratio
  • Mortality by major cause of death
  • TB prevalence in population
  • HIV prevalence among adults 15-49
  • Notifiable diseases (IHR)
  • Depression prevalence (last 12 months)
  • Out of pocket as % of total health expenditure
  • Insurance coverage (% covered by public or private health insurance)
• HMIS is a source of routine data that is necessary for monitoring different aspects of various health programs implemented in the country
• HMIS indicators have been carefully selected to meet the key information needs of monitoring the performance of various health programs and services and provide a snapshot of the available health resources
• The disease data provide the status report on communicable and non-communicable diseases
• Health programs and services that HMIS can be used to monitor

  • Maternal Survival Intervention
  • Child Mortality and Child Survival Intervention
  • STOP TB Program
• HMIS indicators related to pregnancy care interventions

  • 1st antenatal care attendances
  • 4th antenatal care attendances
  • Cases of abnormal pregnancies attended at outpatient departments (OPD) of health facilities
  • Institutional cases of maternal morbidity and mortality due to Antepartum Hemorrhage (APH), hypertension, and edema reported by inpatient departments (IPD) of health facilities
  • Cases of abortion cases attended at HF
  • Cases of medical (safe) abortions conducted at HF
• HMIS indicators related to intra-partum care


  • Deliveries by skilled attendance (at health facilities)
• Strategies aimed at all women include new and repeat FP acceptors, FP methods issued (by type of method), cases of abortion attended at HF, and cases of medical (safe) abortions conducted at HF
• HMIS indicators related to pregnancy care interventions

  • 1st antenatal care attendances
  • 4th antenatal care attendances
  • Cases of abnormal pregnancies attended at outpatient departments (OPD) of health facilities
  • Institutional cases of maternal morbidity and mortality due to Antepartum Hemorrhage (APH), hypertension, and edema reported by inpatient departments (IPD) of health facilities
• HMIS indicators related to family planning

  • New and repeat FP acceptors
  • FP methods issued (by type of method)
• HMIS indicators related to abortion

  • Cases of abortion cases attended at HF
  • Cases of medical (safe) abortions conducted at HF
• HMIS indicators related to intra-partum care


  • Deliveries by skilled attendance (at health facilities)
  • Deliveries by Health Extension Workers (HEW) (at home of Health Posts)
  • Institutional cases of maternal morbidity and mortality due to obstructed labor
• HMIS indicators related to post-partum care

  • 1st postnatal care attendance
  • Institutional cases of maternal morbidity and mortality due to Postpartum hemorrhage (PPH) and Puerperal sepsis
• HMIS indicators related to inter-partum (between pregnancies) period

  • Family planning method acceptors (New and Repeat)
  • Family planning methods issued by type of method
• Though not a complete set to monitor every facet of maternal survival strategies, these HMIS indicators duly capture data related to pregnancy, intra-partum and post-partum care, sufficient to give a broad indication of the ongoing performance of the package of maternal survival interventions, and having the ability to instigate further investigation if problems/issues are identified using these HMIS indicators
• HMIS indicators to monitor STOP TB Program

  • TB patients on DOTS
  • Number of new-smear pulmonary TB cases enrolled in the cohort
  • TB Case Detection
  • Number of new smear positive pulmonary TB cases detected
  • Number of new smear negative pulmonary TB cases detected
  • Number of new extra pulmonary TB cases detected
  • Proportion of newly diagnosed TB cases to HIV
  • HIV+ new TB patients enrolled in DOTS
  • Treatment completed PTB+
  • Cured PTB+, Defaulted PTB+, Deaths PTB+
• The primary aim is to have a strong M & E and review system in place for the national health strategic plan that comprises all major disease programs and health systems
• Monitoring and evaluation (M & E) is a core component of current efforts to scale up for better health
• Global partners and countries have developed a general framework for M & E of health system strengthening (HSS)
• There are different HMIS indicators which can be used for monitoring of key aspects of the health system performance