1. Definition of indicators Facilitators’ Workshop on District Health Performance Improvement Lilongwe, 25 th – 27 th March 2015

2. Steps Diagnose Select interventions Define indicators Identify information sources and collect data Identify the bottlenecks Identify areas lagging behind Analyse the root causes of bottlenecks Intervene Prioritize solutions with all stakeholders Define an implementation and monitoring plan Support implementation Verify Monitor frequently using existing opportunities Adjust Take corrective actions to ensure impact

3. Define coverage determinant indicators Indicators are standardized at country level, based on the data available in the information system and on data that are easy to collect Some rare exceptions can occur for which a specific indicator may be changed at district level (e.g. small underserved population that require a particular sampling)

4. Indicators to identify possible bottlenecks Determinants from supply Determinants from demand Determinants from quality

5. Information used to identify possible bottlenecks Availability of commodities (drugs, equipment, diagnosis kits, training materials…) Availability of trained human resources (community workers, doctors, nurses, midwives…) Geographic access through delivery points (health facilities, outreach activities, community care points…) Initial utilization (measures the demand barriers to initiate the utilization of a service, e.g. DPT/Pentavalent 1, ANC visit 1…) Continuous Utilization (measures the demand barriers to complete utilization of a service and the follow up/drop outs, e.g. DPT/Pentavalent 3, ANC visit 4…) Quality/effective coverage (measures the effectiveness of the intervention by assessing the quality of the service provided, usually in terms of adherence to guidelines)

6. Exercise in groups

7. Discussion after exercise

8. Antenatal care CommoditiesProportion of health centres with zero absolute stock- outs of essential commodities lasting more than 1 week in the past 3 months Human ResourcesProportion of facilities with availability of nurses and midwives compared to need (national standard) Geographic AccessProportion of pregnant women not reporting distance as a problem for access to health care UtilizationProportion of pregnant women who attended at least 1 ANC visits ContinuityProportion of pregnant women who attended at least 4 ANC visits Effective CoverageProportion of pregnant women who had their BP measured or urine analyzed during ANC

9. Indicators used to identify possible bottlenecks Availability of commodities  stock outs (absolute or use of buffer stock) Availability of trained human resources  vacancies of trained staff (defined according to national standards) Geographic access through delivery points  physical distance, time to reach the delivery point, direct assessment from target population Initial utilization  first measure of coverage, people using the services at least once Continuous Utilization  only for relevant interventions, for which continuity is a condition for effectiveness (we use knowledge in behavioral interventions) Quality/effective coverage  adherence to guidelines, often a proxy

10. How to measure the determinants of coverage (1) Commodities availability: – Ideally: percentage of the target population for which commodities are available for a given intervention – More often: percentage of delivery points without stock outs of such commodities – Challenges: difficulty obtaining data from private sector and other sources of info on commodities

11. How to measure the determinants of coverage (2) Trained human resources availability: – Ideally: percentage of the target population for which appropriately trained health professionals are available – More often: percentage of delivery points with insufficient human resources compared with national norms (vacancies and training)

12. How to measure the determinants of coverage (3) Geographic access: – Ideally: percentage of the target population able to access a delivery point for a given intervention – Usually measured in terms of: percentage of target population that lives within a certain distance from the delivery points (5 km, or 30 min. trip). Subjective assessment very reliable.

13. How to measure the determinants of coverage (4) Initial utilization: – Concept: percentage of the target population which has accessed a given service at least once – Usually measured in terms of: percentage of target population that used a given service.

14. How to measure the determinants of coverage (5) Continuous utilization: – Concept: percentage of the target population which has used a given service as recommended – Usually measured in terms of: percentage of target population that used a given service the recommended number of times. * Not usually necessary for interventions that are provided once only (e.g. early HIV diagnosis for HIV exposed children - EID)

15. How to measure the determinants of coverage (6) Effective coverage: – Concept: percentage of the target population which received a given service in an effective way and on time – Usually measured in terms of: percentage of target population that received a given service with good quality.

16. Additional indicators Sometimes is useful to collect indicators beyond the six determinants of coverage: To better interpret the determinants of coverage (e.g. early booking of ANC, To better understand key aspects of an intervention (e.g. care seeking behaviors)