East Central and Southern Africa-Health...

East Central and Southern Africa-Health Community

Monitoring and Evaluation Framework for Universal Health Coverage


East Central and Southern Africa Health CommunityPO Box 1009 Arusha TanzaniaTel: +255 272 549 362/5/6Fax: +155 272 549 392www. ecsahc.org

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Forward

The East Central and Southern Africa (ECSA) Health Community member states have made several commitments and pledges to scale-up coverage and accessibility of affordable health care services. The ECSA Health Community Secretariat has equally continued to work with member states in the development of strategies, policies, structures, and processes to accelerate progress towards Universal Health Coverage (UHC). The development of the framework is part of the fulfilment of the 25th Health Minister Conference (HMC) resolution 2 on information function of the Secretariat, the 44th HMC resolution 8 on monitoring and evaluation and 52nd HMC resolution 2 on UHC that directed the ECSA Health Community Secretariat to support Member States in its engagement with the international community on UHC and to track, document, disseminate and facilitate the sharing of information on developments towards UHC.Globally, there is consensus for the need for UHC to be a flagship for health in the context of sustainable development in the post-2015 agenda. There is also concurrence amongst key stakeholders on what UHC should entail. The dimensions of UHC include the range of services that are covered (service coverage); the proportion of the total costs covered through insurance or other risk pooling mechanisms (financial coverage); and the proportion of the population covered (population coverage). These need to be measured, but which indicators or measurement methods should be used or whether to use a single index that combines all the UHC dimensions, the data collection frequency and source(s), remains a matter of discussion.The ECSA Health Community Secretariat has supported the member states in these global discussions. At the regional level, the secretariat has facilitated the Monitoring and Evaluation (M&E) and the Health Systems experts in the region to develop this framework to guide the monitoring of UHC. During the development of the framework consideration has been given to the World Health Organization and the World Bank suggestions for monitoring health as part of the post-2015 development agenda. The process also took cognizance of the fact that there may be modifications in these indicators once the global consensus on the post 2015 development agenda is reached. The M&E framework for UHC was developed as part of the principles and approaches that helps us in answering “so what difference does our intervention make?” question. This is particularly important given that member states are undertaking initiatives, policy reforms and programs to enhance health care coverage and access. The framework therefore helps to guide measuring how far we have gone, and support cross-country comparison that may trigger sharing of best practices and lessons. To this end, the Experts have proposed benchmarks against which progress is to be assessed.This framework will help us and our partners to be even clearer about the higher-level results we want to achieve; to develop and act on strategies to achieve those results; to use systematic lessons drawn from monitoring and evaluations to make decisions that contribute to achieving UHC within the ECSA Health community.

Prof. Yoswa Dambisya Director General

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Preface

The Monitoring and Evaluation (M&E) framework for Universal Health Coverage (UHC) has been developed to enable measurement of impact of national policies as well as specific health policies and programs on Universal Health Coverage. In addition this framework will facilitate the cross-country comparison which is vital in triggering questions such as how are they doing it? How can we do it? The learning of best practices.

The M&E framework for UHC was developed through a consultative process involving experts from the member states, the academic and research institutions, USAID/East Africa and other development partners. The process took cognizance of the global processes for UHC in light of the post-2025 development agenda. The World Health Organization and World Bank discussion papers on UHC were among documents that enriched the development of the framework. The framework will support the member states and Secretariat in tracking, documenting and sharing of information on progress of universal health coverage in the ECSA Health Community. The information got through utilization of this framework will be a useful advocacy piece for health sector stewards and other relevant stakeholders.

The indicators in this framework are part of the revised ECSA Health Community regional core indicator compendium, 2014. These indicators are also found on the ECSA-Health Community portal of database. The member states have given their commitment in ensuring the relevant data entered in the M&E database portal. In addition, the database has been revamped to ease country level reporting and utilization of the data by the member states and other stakeholders including the civil society organizations, development partners, and researchers. Therefore, this framework is a useful tool to a number of stakeholders and it will facilitate effective monitoring of progress in UHC in the ECSA-Health Community.

Dr Walter D. OdochActing Manager, Health Systems and Services Development

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Acknowledgements

This Framework was prepared by members of the Health Systems and Services Development and the Monitoring and Evaluation experts’ committees. In particular the Secretariat would like to acknowledge the contribution of following who participated in the joint experts committee meetings: Mr. Stephen Banda and Dr Davies Gordon Dhlakama, Ministry of Health (MOH) & Child Care-Zimbabwe; Ms. Budaloo Navishta, Mrs. Patel Shameeman Bibi and Mr. Nasser Jeeanody, MOH & Quality of Life-Mauritius; Dr. Isaac Kadowa and Mr. James Mugisha, MOH-Uganda; Dr Ruth Kitetu and Dr Charles Nzioka, MOH-Kenya; Mr. Makhanya Phillip Themba and Mr. Sifiso Mavuso, MOH-Swaziland; Ms. Mapenane Anastacia Lesaoana, Mamolitsane Thoothe Malebo and Mr. Mohasi Matlotlo Sabastian, MOH-Lesotho; Mr. Macleod Mwale, MOH – Malawi; Ms. Nakapoko Nalungwe Mr. Calvin Kalimbo and Mr. Mubita Luwabelwa, MOH-Zambia; Mr. Josibert J. Rubona, MOH &Social Welfare; Dr. Bona M. Chitah, EQUINET; Dr. John Ataguba, University of Cape Town; Mr. Jean Malbrook and Mr. Ronnie Gayon, Seychelles-MOH; Mr. Moses N. Mukuna and Mrs. Wairimu Gakuo, USAID/East Africa; and Dr. David Manyanza, Development Solutions Consultancy.

In addition, ECSA-Health Community Secretariat Staff and management were very vital in the coordination and technical input to the framework development. In particular, the Secretariat acknowledges the contribution of Dr Walter D Odoch, Dr Stephen K. Muleshe, Mr. Edward Kataika, Ms. Upendo Letawo and Ms. Neema Yoyo.

The fund to facilitate the process of developing the UHC framework was provided by the Rockefeller Foundation. ECSA-Health Community is grateful for the support.

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Acronyms and Abbreviations

AIDS

BMI

ECSA-Health Community

GDP

GGHE

HSSD

IMR

M&E

MDG

MMR

NMR

PPP

TB

THE

U5MR

UHC

UNGASS

WB

WHO

Acquired Immune Deficiency Syndrome

Body mass index


General government expenditure on health

Gross domestic product

Health Systems and Services Development Program

Infant mortality rate

Monitoring and Evaluation

Millennium Development Goals

Maternal mortality ratio

Neonatal mortality rate

Purchasing Power Parities

Tuberculosis

Total expenditure on health

Under 5 mortality rate

Universal health Coverage

United Nations General Assembly Special Session on HIV and

World Bank

World Health Organization

Contents

Forward............................................................................................................................................i

Preface.............................................................................................................................................ii

Acknowledgements......................................................................................................................iii

Acronyms and Abbreviations.....................................................................................................iv

1.0 Introduction...............................................................................................................................1

2.0 The Process of Developing the Regional Framework for Monitoring UHC....................1

3.0 The ECSA-HC Regional UHC monitoring Framework......................................................4

4.0 Indicator Definitions.................................................................................................................7

5.0 Conclusions..............................................................................................................................19

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1.0 Introduction

Health is generally recognized as a priority sector in national development within East Central and Southern Africa-Health Community (ECSA Health Community) member states. However health care needed to produce health in the population are diverse and this calls for well performing health care systems. The need for good performing health systems therefore continues to dominate national and international policy circles. One key characteristic of a good health system is its ability to provide personal and population health care that in accessible when needed, whether be by poor or non-poor without any hardship. The phenomenon of access to quality health services without suffering impoverishment or spending catastrophically by any member of the population and where overall financing of health care is according to ability to pay and access according to need (or capacity to benefit more) has been defined as the Universal health Coverage (UHC) . The Member States of the ECSA-Health Community have made commitments at various regional and international forums to institute measures that facilitate UHC. Although, the ECSA Health Community member states have declared their commitment to achieving UHC and introduce policies and strategies to achieve that goal, the need for a robust UHC monitoring and evaluation (M&E) framework and/or mechanism remains large. There is a global consensus on the dimensions of the UHC that need to be measured, i.e. service coverage; financial coverage; and population coverage. But consensus has not yet been fully reached at, for example on which indicators should be used for measuring these UHC dimensions; which are the good standard measurement methods, whether a single index that combines all the UHC dimensions should be developed and/or used, the data collection frequency as well as data quality and source(s).

In light of the monitoring and evaluation framework gap for the UHC and the need to involve the countries in the global processes, the ECSA-Health Community Secretariat, in partnership with the Rockefeller Foundation initiated the process of developing a Regional Monitoring and Evaluation framework for UHC. Through this initiative, the ECSA Health Community secretariat is also meant to support the member states’ participation in the global processes shaping the health agenda post-2015 and facilitate UHC advocacy mechanism in the member states.

2.0 The Process of Developing the Regional Framework for Monitoring UHC

The ECSA-Health Community Secretariat with funding from the Rockefeller Foundation undertook a series of activities between November 2012 and December 2013 to develop a regional framework for monitoring and evaluating UHC. Firstly, the ECSA Health Community Secretariat conducted a baseline assessment of the existing M&E mechanism for monitoring UHC in the member states. The draft framework was presented to the first joint Health Systems and Services Development Program (HSSD) and M&E experts’ committees meeting, at the La Plantation Hotel, in Mauritius from 1st to 3rd July 2013. During the meeting, the experts from the member countries presented generally issues of UHC from their countries. The meeting recommended for a refinement of the framework and tasked the ECSA Health Community Secretariat to present a better draft for validation at another meeting.

World Health Report, 2010

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Subsequently, the Secretariat worked on the draft framework, and also collected data using the framework and presented it during the second joint HSSD and M&E experts’ committees meeting that took place in Zambia in December 2013.

The second meeting made necessary changes and adopted the framework as seen in table 1 below. The experts from the member states discouraged the ECSA Health Community Secretariat from using data from other sources including World Health Organization (WHO) and World Bank (WB). They argued that the data from WHO and the World Bank tend to generate unnecessary dissent amongst the countries’ policy makers. The meeting urged the ECSA Health Community Secretariat to use data submitted by the countries. The members committed to submit such data to the Secretariat once needed. Therefore, the Regional UHC monitoring framework was developed through consultative process involving all the ECSA-HC member states.

The HSSD and M&E experts’ committees meeting also proposed UHC benchmarks and timeframe for accessing progress. The framework and the benchmarks were informed by the global processes. The process of developing the framework was cognizant of the WHO/WB suggested 2030 timeframe based on the emerging post-2015 development framework. Therefore the benchmarks were considered in light of the goal and targets for UHC proposed for the post-2015 development agenda which are:-Goal: Achieve UHC – All people should have access to the quality, essential health services they need without enduring financial hardshipTargets: - By 2030, at least 80% of the poorest 40% of the population have coverage to ensure access to essential health services - By 2030, everyone (100%) has coverage to protect them from financial risk, so that no one is pushed into poverty or kept in poverty because of expenditure on health servicesIndicators: 1. Health Services Coverage: a) MDGs: i. Aggregate: A measure of MDG-related service coverage that is an aggregate of single intervention coverage measures ii. Equity: A measure of MDG-related service coverage as described in 1a.i for the poorest 40% of the population b) CCIs: i. Aggregate: A measure of CCIs-related service coverage that is an aggregate of single priority interventions to address the burden of NCDs, including mental health and injuries ii. Equity: A measure of CCI service coverage as described in 1b.i for the poorest 40% of the population

2. Financial Risk Protection Coverage: a) Impoverishing Expenditures: i. Aggregate: A measure of the level of household impoverishment arising from out of-pocket expenditures on health, equal to the ratio of the poverty gap in a world without out-of-pocket payments to the actual (larger) poverty gap

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b) Catastrophic Expenditures: i. Aggregate: The fraction of households incurring catastrophic out-of-pocket health expenditures ii. Equity: The fraction of households among the poorest 40% of the population incurring catastrophic out-of-pocket health expenditures

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3.0 The ECSA-HC Regional UHC monitoring Framework

After deliberations of the first and second HSSD and M&E experts committees meetings, and the ECSA-HC Secretariat refinement, the proposed indicators and benchmarks adopted for the ECSA Health Community is as listed in the table 1.

Table 1: Suggested indicators and benchmarks for UHC in the ECSA countries

No. Indicators by UHC dimensions Benchmark

1.0 Financial Protection1.1 Total expenditure on health per capita (at PPP

international dollar rate)

1.2 Total government expenditure on health per capital (at PPP international dollar rate)

1.3 Out of pocket health expenditure as % of total expenditure on health

Maximum of 20% of total health expenditure by 2030

1.4 Private expenditure on health as % of totalexpenditure on health

Maximum of 30% of total health expenditure by 2030

1.5 Total health expenditure as % of GDP Minimum of 5% of Gross Domestic product (GDP) by 2030

1.6 Total government expenditure on health as % of GDP

Minimum of 3.5% of GDP by 2030

1.7 General government expenditure on health as % of general government expenditure

At least 15% of general government expenditure by 2030

1.8 General government expenditure on health as % of total expenditure on health

Minimum of 70% of total health expenditure by 2030

1.9 % of households whose out of pocket health expenditures exceed 10% of total household expenditure i.e. incidence of financial catastrophe

0% by 2030

1.10 % of households whose out of pocket health expenditures exceed 25% of non-food expenditure

0% by 2030

1.11 % of population whose out of pocket health expenditures put them below the poverty line $1.25/day

0% by 2030

2.0 Health service coverage

2.1 Health service utilization2.1.1 % of pregnant women completing at least 4

ANC visitsMinimum of 90% coverage by 2030.Equity dimension: “80:40” - at least 80% of the poorest 40% of the population have coverage by 2030

2.1.2 % of eligible pregnant women receiving at least two doses of intermittent preventive therapy against malaria

Minimum of 90% coverage by 2030.Equity dimension: “80:40” - at least 80% of the poorest 40% of the population have coverage by 2030

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No. Indicators by UHC dimensions Benchmark2.1.3 % of births assisted by skilled health personnel Minimum of 90% coverage by 2030.

Equity dimension: “80:40” - at least 80% of the poorest 40% of the population have coverage by 2030

2.1.4 % of children fully immunized at age 1 Minimum of 90% coverage by 2030.Equity dimension: “80:40” - at least 80% of the poorest 40% of the population have coverage by 2030

2.1.5 Contraceptive prevalence rate Minimum of 90% coverage by 2030.Equity dimension: “80:40” - at least 80% of the poorest 40% of the population have coverage by 2030

2.1.6 Outpatient attendance (visits per person per year)

Minimum of 5 visits per person per year by 2030

2.1.7 Inpatient admission Minimum of 70 admissions per 1,000 persons per year by 2030

2.1.8 % of eligible people living with HIV accessing antiretroviral therapy (ART)

Minimum of 90% coverage by 2030.Equity dimension: “80:40” - at least 80% of the poorest 40% of the population have coverage by 2030

2.2 Other health service/tracer indicators2.2.1 Tuberculosis treatment success under DOTS At least 90% by 2030

2.2.2 TB case detection rate At least 90% by 2030

2.2.3 Prevalence of overweight, BMI ≥ 25Kg/M2 in a population of adults ≥ 25 years

At least 50% reduction from the baseline prevalence by 2030

2.2.4 Prevalence of high blood pressure (SBP ≥ 140 or DBP ≥ 90) in a population of adults ≥25 years

At least 50% reduction from the baseline prevalence by 2030

2.2.5 Cervical cancer screening (20-64 years) Minimum of 60% coverage by 2030

2.2.6 Prevalence of diabetes in a population of adults ≥ 25 years

At least 50% reduction from the baseline prev-alence by 2030

2.2.7 HIV prevalence (15+ years) At least 50% reduction from the baseline prevalence by 2030

2.2.8 Child underweight (weight-for-age) for children <5 years

At least 50% reduction from the baseline proportion by 2030

2.3 Health service availability and service readiness2.3.1a % of population within 5 km of a health facility 100% coverage by 2030

2.3.1b % of population within 30 minutes of a health facility

100% coverage by 2030

2.3.2 % of established posts filled with skilled personnel

At least 90% of the posts filled by 2030

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No. Indicators by UHC dimensions Benchmark2.3.3 Hospital beds per 10,000 population Minimum of 25 inpatient beds per 10,000 pop-

ulation by 2030

2.3.4 Health service providers (by type) per 10,000 people

Minimum of 23 (doctors + nurses) per 10,000 population by 2030

(a) Doctors(b) Nurses(c) Midwives

2.3.5 Service readiness index (obtained by SARAM method)

Minimum of 80% by 2030

3.0 Impact indicators3.1 Maternal mortality ratio (MMR) per 100,000 live

birthsMaximum of 40 death per 100,000 live births by 2030

3.2 Neonatal mortality rate (NMR) per 1,000 live births

Maximum of 20 deaths per 1,000 live births by 2030

3.3 Infant mortality rate (IMR) per 1,000 live births


3.4 Under 5 mortality rate (U5MR) per 1,000 live births


3.5 Life expectancy at birth (Male/Female) Minimum of 70 years by 2030

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Indicator number:Indicator name:

Data type:Reporting frequency: Rationale:

Indicator definition:







1.1Total expenditure on health per capita (at PPP interna-tional dollar rate) %3-5 years This is one of core indicators of health systems financing. It contributes to understanding the total expenditure on health relative to the beneficiary population, expressed in Purchasing Power Parities (PPP) to facilitate interna-tional comparisons.The sum of public and private health expenditures as a ratio of total population (at PPP)

1.2Total government expenditure on health per capita (at PPP international dollar rate)%3-5 yearsThis is one of the core indicators of health systems fi-nancing. This indicator contributes to understanding the relative level of public spending on health to the ben-eficiary population, expressed in international dollars to facilitate international comparisons. It also reflects government commitment to the health sectorPercentage of total general government (public) expenditure that is spent on health (at PPP international dollar rate)

1.3Out of pocket health expenditure (as % of total expenditure on health)%3-5 yearsThis indicator contributes to understanding the relative weight of direct payments by households in total health expenditures. High out-of-pocket payments on health are strongly associated with catastrophic and impoverishing spending. Thus it represents a key support for equity and planning processes.Level of out-of-pocket expenditure on health expressed as a percentage of private expenditure on health.

4.0 Indicator Definitions

The indicator definitions below are meant to support regional users to effectively utilize the framework, including ease with which they present and explain the data collected by the framework to the relevant stakeholders. This description is informed by the contribution of HSSD and M&E experts from the member countries and the World Health Statistics 2013: Indicator Compendium.

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Indicator number:Indicator name:Data type:Reporting frequency: Rationale:






1.4Private expenditure on health (as % of total expenditure on health)%3-5 years This indicator contributes to understanding the relative weight of private entities in total expenditure on health. Private expenditure on health includes expenditure from pooled resources with no government control, such as voluntary health insurance, and the direct payments for health by corporations (profit, non-for-profit and NGOs) and households. It includes all sources of funding pass-ing through these entities, including any donor (fund-ing) they use to pay for health.Level of private expenditure on health expressed as a percentage of total expenditure on health.

1.5Total health expenditure (as % of GDP)%3-5 yearsThis indicator provides information on the level of resources channeled to health relative to a country’s income.Level of total expenditure on health (THE) expressed as a percentage of gross domestic product (GDP).

1.6Total government expenditure on health (as % of GDP)%3-5 yearsThis indicator provides information on the level of government resources devoted to health relative to a country’s income. Total expenditure on health is the sum of all outlays for health maintenance, restoration or enhancement paid for in cash or supplied in-kind. It is the sum of General Government Expenditure on Health and Private Expenditure on HealthLevel of total government expenditure on health as a percentage of GDP.

1.7General government expenditure on health (as % of general government expenditure)%3-5 yearsThis indicator contributes to understanding the weight of public spending on health within the total value of public sector operations. It includes not just the resources that are channeled through government budgets but also the expenditure on health by parastatals, extra budgetary entities and notably the compulsory health insurance. It refers to resources collected and pooled by public agencies including all the revenue modalities.

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Data type: Reporting frequency: Rationale:



Data type:Reporting frequency:Rationale:





Level of general government expenditure on health (GGHE) expressed as a percentage of total government expenditure.

1.8General government expenditure on health (as % of total expenditure on health)%3-5 yearsThis indicator contributes to understanding the relative weight of public entities in total expenditure on health. It includes not just the resources channeled through government budgets to providers of health services but also the expenditure on health by parastatals, extra budgetary entities and notably the compulsory health insurance payments. It refers to resources collected and pooled by the above public agencies regardless of the source, so includes any donor (external) funding passing through these agencies.Level of general government expenditure on health (GGHE) expressed as a percentage of total expenditure on health (THE)

1.9% of households whose out-of-pocket health expenditures exceed 10% of total household expenditure%3-5 yearsThis indicator contributes to understanding the extent to which out-of-pocket payments exceeds a fixed percentage of household expenditure. Here, out-of-pocket expenditure that exceeds ten percent of total household expenditure is regarded as catastrophic expenditure.Level of a household’s out-of-pocket expenditure on health expressed as a percentage of total household expenditure

1.10% of households whose out-of-pocket health expenditures exceed 25% of non-food expenditure %3-5 yearsThis indicator contributes to understanding the extent to which out-of-pocket payments exceeds a fixed percentage of household expenditure net of food expenditure. Here, out-of-pocket expenditure that exceeds twenty five percent of total household non-food expenditure is regarded as catastrophic expenditure.Level of a household’s out-of-pocket expenditure on health expressed as a percentage of total household non-food expenditure

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Indicator number:Indicator name:Data type:Reporting frequency:Rationale:


Numerator:

Denominator:

Indicator number: Indicator name:



1.11% of population whose out-of-pocket health expenditures put them below the poverty line ($1.25/da%3-5 yearsLevel of an individual’s expenditure before and after out-of-pocket payments in comparison with the poverty line of $1.25 per person per day. Impoverishment occurs when an individual become poor after paying out-of-pocket for health services.

2.1.1% of pregnant women completing at least 4 ANC visits%Biennial (two-yearly)Antenatal care coverage is an indicator of access and use of health care during pregnancy. The antenatal period presents opportunities for reaching pregnant women with interventions that may be vital to their health and wellbeing and that of their infants. Receiving antenatal care at least four times, as recommended by WHO, increases the likelihood of receiving effective maternal health interventions during antenatal visits.This is an MDG indicator.The percentage of women aged 15-49 with a live b i r th in a given time period that received antenatal care four or more times.The number of women aged 15-49 with a live birth in a given time period that received antenatal care four or more times.Total number of women aged 15-49 with a live birth in the same period.

2.1.2% of eligible pregnant women receiving at least two doses of intermittent preventive therapy against malaria%Biennial (Two-yearly)Antenatal care coverage is an indicator of access and use of health care during pregnancy. The antenatal period presents opportunities for reaching pregnant women with interventions that may be vital to their health and wellbeing and that of their infants. Receiving at least two doses of intermittent preventive therapy against malaria increases the likelihood of receiving effective maternal health interventions against malaria.The percentage of women aged 15-49 at risk of being infected with malaria who receive at least two doses of intermittent preventive therapy against malaria during pregnancy.

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Numerator:

Denominator:

Indicator number: Indicator name:Data type:Reporting frequency: Rationale:


Numerator:

Denominator:

Indicator number:Indicator name:Reporting frequency: Rationale:


The number of pregnant women aged 15-49 at risk of being infected with malaria who receive at least two doses of intermittent preventive therapy against malaria during pregnancy in a given time period.Total population of pregnant women aged 15-49 at risk of being infected with malaria in the same period.

2.1.3% of births assisted by skilled health personnel%Biennial (Two-yearly)All women should have access to skilled care during pregnancy and childbirth to ensure prevention, detection and management of complications. Assistance by properly trained health personnel with adequate equipment is key to lowering maternal deaths. As it is difficult to accurately measure maternal mortality, and model-based estimates of the maternal mortality ratio cannot be used for monitoring short-term trends, the proportion of births attended by skilled health personnel is used as a proxy indicator for this purpose. This is an MDG indicator.The proportion of births attended by skilled health personnel.The number of births attended by skilled health personnel (doctors, nurses or midwives) trained in providing lifesaving obstetric care, including giving the necessary supervision, care and advice to women during pregnancy, child birth and the post-partum period; to conduct deliveries on their own; and to care for newborns.The total number of live births in the same period

2.1.4% of children fully immunized at age 1Biennial (Two-yearly)Immunization is an essential component for reducing under-five mortality. Immunization coverage estimates are used to monitor coverage of immunization services and to guide disease eradication and elimination efforts. It is a good indicator of health system performance. Percentage of children under one year of age immunized against measles is one of MDG indicators.The percentage of children under one year of age who have received at all doses of required vaccines in a given year.

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2.1.5Contraceptive use prevalence rate%Biennial (Two-yearly)Contraceptive prevalence rate is an indicator of health, population, development and women’s empowerment. It also serves as a proxy measure of access to reproductive health services that are essential for meeting many of the Millennium Development Goals, especially those related to child mortality, maternal health, HIV/AIDS, and gender equality.The percentage of women aged 15-49 years, married or in-union, who are currently using, or whose sexual partner is using, at least one method of contraception, regardless of the method used.

2.1.6Outpatient attendance (visits per person per year)RateBiennial (Two-yearly)Outpatient attendance is used to indicate service coverage and access.The number of outpatient attendance to a health facility per person per year in the given population.

2.1.7Inpatient admissionRateBiennial (Two-yearly)Inpatient admission is used to also indicate service coverage and access.The number of inpatient admissions to a health facility per 1,000 persons per year in the given population.

2.1.8% of eligible people living with HIV accessing antiretroviral therapy (ART)%Biennial (Two-yearly)As the HIV epidemic matures, increasing numbers of people are reaching advanced stages of HIV infection. Antiretroviral therapy (ART) has been shown to reduce mortality among those infected and efforts are being made to make it more affordable within low- and middle-income countries. This indicator assesses the progress in providing antiretroviral combination therapy to all people with advanced HIV infection.

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Numerator:

Denominator:






Data type:

The percentage of adults and children with advanced HIV infection currently receiving antiretroviral combination therapy in accordance with the nationally approved treatment protocols (or WHO/UNAIDS standards) among the estimated number of adults and children with advanced HIV infection.Number of adults and children with advanced HIV infection who are currently receiving antiretroviral therapy in accordance with the nationally approved treatment protocol (or WHO/UNAIDS standards) at the end of the reporting period.Estimated number people (adults and children) who need antiretroviral therapy in the country.

2.2.1Tuberculosis treatment success under DOTS%Biennial (Two-yearly)Treatment success is an indicator of the performance of national TB control programmes. In addition to the obvious benefit to individual patients, successful treatment of infectious cases of TB is essential to prevent the spread of the infection. Detecting and successfully treating a large proportion of TB cases should have an immediate impact on TB prevalence and mortality. By reducing transmission, successfully treating the majority of cases will also affect, with some delay, the incidence of disease.Number of tuberculosis patients who successfully complete treatment under DOTS out of the total cases diagnosed positive.

2.2.2TB case detection rateRateBiennial (Two-yearly)The proportion of estimated new smear-positive cases of TB detected (diagnosed and then notified to WHO) by national TB control programmes provides an indication of the effectiveness of national TB programmes in finding and diagnosing people with TBThe proportion of estimated new smear-positive tuberculosis (TB) cases detected under the internationally recommended tuberculosis control strategy. The term “case detection”, as used here, means that TB is diagnosed in a patient and is reported within the national surveillance system, and then to WHO.

2.2.3Prevalence of obesity, BMI ≥ 30 in a population of adults ≥ 25 years%

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Reporting frequency: Rationale:Indicator definition:


Data type:Reporting frequency: Rationale:Indicator definition:

Indicator number:Indicator name:Data type:Reporting frequency: Rationale:Indicator definition:


Data type:Reporting frequency: Rationale: Indicator definition:

Indicator number: Indicator name:Data type:Reporting frequency:Rationale:


Biennial (Two-yearly)-Percentage of defined population (in this case ≥ 25 years) with a body mass index (BMI) of 30 kg/m2 or higher.

2.2.4Prevalence of high blood pressure (SBP ≥ 140 or DBP ≥ 90) in a population of adults ≥25 years%Biennial (Two-yearly)-Percentage of defined population (≥ 25 years) with raised blood pressure (systolic blood pressure (SBP) ≥ 140 or diastolic blood pressure (DBP) ≥ 90)

2.2.5Cervical cancer screening (20-64 years)%Biennial (Two-yearly)-Percentage of defined women population (20-64 years) who have had at least one cervical cancer screening in the given year.

2.2.6Prevalence of raised fasting blood glucose in a population of adults ≥ 25 years%Biennial (Two-yearly)-Percentage of defined population with fasting blood glucose ≥ 126mg/dl (7.0mmol/l) or on medication for raised blood glucose.

2.2.7HIV prevalence (15+ years)%Biennial (Two-yearly)HIV and AIDS has become a major public health problem in many countries and monitoring the course of the epidemic and impact of interventions is crucial. Both the Millennium Development Goals (MDG) and the United Nations General Assembly Special Session on HIV and AIDS (UNGASS) have set goals of reducing HIV prevalence.The estimated number of people (15+ years) living with HIV, whether or not they have developed symptoms of AIDS, divided by the total population of people aged 15+ years

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Numerator:Denominator:

Indicator number: Indicator name:Data type: Reporting frequency: Rationale:



2.2.8Child underweight (weight-for-age) for children <5 years%Biennial (Two-yearly)This indicator belongs to a set of indicators whose purpose is to measure nutritional imbalance and mal-nutrition resulting in under-nutrition (assessed by underweight, stunting and wasting) and overweight.Child growth is the most widely used indicator of nutritional status in a community and is internationally recognized as an important public-health indicator for monitoring health in populations. In addition, children who suffer from growth retardation as a result of poor diets and/or recurrent infections tend to have a greater risk of suffering illness and death.Percentage of underweight (weight-for-age less than -2 standard deviations of the WHO Child Growth Standards median) among children aged 0-5 years.

2.3.1a% of population within 5 km of a health facility%Biennial (Two-yearly)It is generally considered that people living within 5 km (or within 30 minutes) of a health facility are in reasonably good proximity to health service. This indicator is used to indicate service access.The percentage of population living within 5 km of a health facility.Population living within 5 km of a health facilityTotal population

2.3.1b% of population within 30 minutes of a health facility%Biennial (Two-yearly)It is generally considered that people living within 5 km (or within 30 minutes) of a health facility are in reasonably good proximity to health service. This indicator is used to indicate service access.The percentage of population living within 30 minutes of a health facility.Population living within 30 minutes of a health facilityTotal population

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Indicator number:Data type:Reporting frequency:Rationale:



Indicator number: Indicator name:Data type:Reporting frequency: Rationale: Indicator definition:

Indicator number: Indicator name:Data type:Reporting frequency: Rationale: Indicator definition:



2.3.2%Biennial (Two-yearly)The number of established job positions describes the required level of staffing and competence level of a health facility. The indicator is used to indicate service readiness.The percentage of the job establishment of all health facilities staffed with qualified personnel.Number of job posts filled with qualified personnelTotal job establishment

2.3.3Hospital beds per 10,000 populationRatioBiennial (Two-yearly)-The number of hospital beds available per every 10,000 inhabitants in a population.

2.3.4Health service providers per 10,000 populationRatioBiennial (Two-yearly)-The number of types of health service providers per 10,000 inhabitants in a population.2.3.5Service readiness indexIndexBiennial (Two-yearly)Health service facilities are only as good as they are ready to provide effective and efficient services. They must maintain a high level of readiness in terms of qualified staff, facilities and equipment as well as drugs. This indicator is used to measure such readiness of service facilities. Readiness is defined as the availability of components required to provide services such as basic amenities, basic equipment, standard precautions, laboratory tests, and medicines and commoditiesGeneral Service readiness is described by an index using the five general service readiness domains (basic amenities, basic equipment, standard precautions, laboratory tests, and medicines and commodities). A score is generated per domain based on the number of domain elements present, then an overall general readiness score is calculated based on the mean of the five domains.

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3.1Maternal mortality ratio (MMR) per 100,000 live birthsRatio3-5 yearsComplications during pregnancy and childbirth are a leading cause of death and disability among women of reproductive age in developing countries. The maternal mortality ratio represents the risk associated with each pregnancy, i.e. the obstetric risk. It is also a Millennium Development Goal Indicator for monitoring Goal 5, improving maternal health.The indicator monitors deaths related to pregnancy and childbirth. It reflects the capacity of the health systems to provide effective health care in preventing and addressing the complications occurring during pregnancy and childbirth.The maternal mortality ratio (MMR) is the annual number of female deaths from any cause related to or aggravated by pregnancy or its management (excluding accidental or incidental causes) during pregnancy and childbirth or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, per 100,000 live births, for a specified year.

3.2Neonatal mortality rate (NMR) per 1,000 live birthsRatio3-5 yearsMortality during the neonatal period accounts for a large proportion of child deaths, and is considered to be a useful indicator of maternal and newborn neonatal health and care. Generally, the proportion of neonatal deaths among child deaths under the age of five is expected to increase as countries continue to witness a decline in child mortality.Number of deaths during the first 28 completed days of life per 1000 live births in a given year or other period.Neonatal deaths (deaths among live births during the first 28 completed days of life) may be subdivided into early neonatal deaths, occurring during the first 7 days of life, and late neonatal deaths, occurring after the 7th day but before the 28th completed day of life.

3.3Infant mortality rate (IMR) per 1,000 live birthsRate3-5 yearsInfant mortality represents an important component of under-five mortality. Like under-five mortality, infant mortality rates measure child survival. They also reflect the social, economic and environmental conditions in which children (and others in society) live, including their health care. Since data on the incidence and prevalence of diseases (morbidity data) frequently are unavailable, mortality rates are often used to identify vulnerable populations. Infant mortality rate is an MDG indicator.

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Infant mortality rate is the probability of a child born in a specific year or period dying before reaching the age of one, if subject to age-specific mortality rates of that period.Infant mortality rate is strictly speaking not a rate (i.e. the number of deaths divided by the number of population at risk during a certain period of time) but a probability of death derived from a life table and expressed as rate per 1000live births.

3.4Under 5 mortality rate (U5MR) per 1,000 live birthsRate3-5 yearsUnder-five mortality rate measures child survival. It also reflects the social, economic and environmental conditions in which children (and others in society) live, including their health care. Because data on the incidences and prevalence of diseases (morbidity data) frequently are unavailable, mortality rates are often used to identify vulnerable populations. Under-five mortality rate is an MDG indicator.The probability of a child born in a specific year or period dying before reaching the age of five, if subject to age-specific mortality rates of that period.Under-five mortality rate as defined here is strictly speaking not a rate (i.e. the number of deaths divided by the number of population at risk during a certain period of time) but a probability of death derived from a life table and expressed as rate per 1,000 live births.

3.5Life expectancy at birthNumber3-5 yearsLife expectancy at birth reflects the overall mortality level of a population. It summarizes the mortality pattern that prevails across all age groups – children and adolescents, adults and the elderly.The average number of years that a newborn could expect to live, if he or she were to pass through life exposed to the sex- and age-specific death rates prevailing at the time of his or her birth, for a specific year, in a given country, territory, or geographic area.

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5.0 Conclusions

The Secretariat will undertake the followings - Disseminate the Framework - Revamp the regional M&E portal and incorporate the UHC indicators in the overall regional health monitoring framework that can be accessed through the ECSA-Health Community M&E web portal - Report on the status of UHC in the ECSA region as part of its biennial status of health report - Support countries to generate data for indicators where information are not part of what is routinely collected by the countries existing information systems through for example specific surveys - Continue to support countries and regional advocacy efforts for UHC

The member states through the M&E expert members are to - Submit the necessary country level data to the ECSA-Health Community Secretariat to facilitate regional compilation and dissemination

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