HEALTH FACILITY ASSESSMENT CORE QUESTIONNAIRE

HEALTH FACILITY ASSESSMENT

CORE QUESTIONNAIRE

Data Collection Sections

Module 1: Consent Module 2: Identification of Facility and Infrastructure Module 3: Human Resources Module 4: Maternal & Neonatal Healthcare Medications, Equipment, and Supplies Module 5: EmONC Signal Functions and Other Essential Services Module 6: Documents, Protocols and Guidelines Module 7: Community Mobilization

____ ____ //____ _____ LGA Code // Facility Code

2 of 38

Module 1: INTRODUCTION AND CONSENT INSTRUCTIONS: Complete at the health facility. Section 1: Background Interview Information INSTRUCTIONS: To be completed by the Supervisor by the time the team arrives at the facility and before the data collectors interview the officer in charge or other staff. Date of HFA Interview: __ __ / __ __ / __ __ [dd/mm/yy] Interviewer Name # 1: _______________________________________________________ Interviewer Number: ___ ___ //____ ____ Interviewer Name #2: ________________________________________________________ Interviewer Number: ___ ___ //____ ____ Facility Name: _____________________________________________________________ Is this Facility a SURE-P Or MSS Supported facility? 1) Yes 2) No State: ____________________________ LGA: ___________________________________ Health facility level

Primary Facility .............................................. 1 Secondary Facility .......................................... 2 Tertiary Facility .............................................. 3

FACILITY GEOGRAPHIC COORDINATES (Taken by Supervisor at front gate of Facility; take measurements twice to confirm co-ordinates, write down ONLY the second measurements for latitude and longitude)

Latitude (North/South): ___ ___ . ___ ___ ___ ___ ___ ___ [decimal format to six decimal places]

Longitude (East/West): ___ ___ . ___ ___ ___ ___ ___ ___ [decimal format to six decimal places]


3 of 38

Section 2: Introduction and consent INSTRUCTIONS: Obtain consent from the officer in charge. Hello. My name is [state your name] and I am working with Jhpiego and Health Finance and Governance. The organizations are working together to conduct a health facility assessment of maternal and child health issues in selected health facilities in collaboration with the Ebonyi and Kogi States’ Ministry of Health and the Department of Community Health and Primary Health Care. The purpose of this assessment is to determine the current capacity of your health facility to provide obstetric and newborn care services. We want to learn more about existing resources and remaining gaps in maternal and newborn health care services. We would appreciate your participation in this assessment. We are expected to spend __ days in your facility conducting this assessment. [For Secondary and Tertiary facilities say 2 – 3 days. For Primary facilities say 1 day] Taking part in this survey is voluntary and the information you provide will strictly be kept confidential and none of your names will appear in any report. This information will be used only for program planning and implementation purposes with the aim of preventing deaths of women and children. Feel free to request for any clarification on unclear issues during this assessment. Choosing not to participate in this assessment will not involve any penalty, but your information will provide us with an enormous opportunity to support your health facility to provide better maternal and newborn health care services. You may also choose to withdraw from the assessment anytime during the interview without penalty to you or your facility. CONSENT TO PARTICIPATE: I have read (heard) the information provided above, and I understand it. I have been allowed to ask questions. All of my questions have been answered to my satisfaction. ___________________________________ ___________________________________ Name of Interviewee/Participant Phone Number of Interviewee/Participant ___________________________________ ____/____/____ Signature of Interviewee/Participant Date (DD/MM/YY) ___________________________________ Name of Interviewer ___________________________________ ____/____/____ Signature of Interviewer Date (DD/MM/YY) Consent Fully Executed Yes ......................................................................... Y

No ......................................................................... N


4 of 38

Module 2: IDENTIFICATION OF FACILITY AND INFRASTRUCTURE Section 1: Facility Identification Information INSTRUCTIONS: Direct these questions to the officer in charge. (if available) No. Item Response

1. What is your (interviewee) position at this facility? (circle/select one)

Obstetrician ............................................................. 1 Pediatrician ……………………………………………2 Neonatologist ………………………………………… 3 Medical Officer ........................................................ 4 Youth Corper Doctor ............................................... 5 Registered Nurse ..................................................... 6 Registered Midwife ................................................. 7 Registered Nurse/Midwife ...................................... 8 Community Nurse .................................................. 9 Community Health Officer (CHO) ............................ 10 Community Health Extension Worker (CHEW) ....... 11 Junior Community Health Extension Workers (JCHEW) 12 Other (specify): ....................................................... 99

2. Have any deliveries been attended in this

facility in the last 12 months? This includes women presenting to the facility within 72 hours of delivery.

No ............................................................................ N Yes. .......................................................................... Y

3. Have you attended post-natal care cases in this facility in the last 12 months?

No ............................................................................ 1 Yes Postnatal mothers only…………………………………..2 Yes Postnatal infants only………………………………………3 Yes Postnatal infants and mothers…………………………4

4. Is this facility designated urban or rural? Urban ...................................................................... 1 Rural ........................................................................ 2

5. What type of facility is this? (circle/select one)

Teaching Hospital .................................................... 1 General Hospital .................................................... 2 Comprehensive PHC ................................................ 3 Primary Health Care (PHC) ...................................... 4 Mission Hospital ..................................................... 5 Private Hospital ...................................................... 6 Private Clinic …………………………………………………………7 Other (specify): ....................................................... 99

6. Type of operating agency (circle one) Government ........................................................... 1 Private (for profit) ................................................... 2 Non-Governmental Organization ............................ 3 Religious Mission (Faith Based Organization) .......... 4 Other (specify): ....................................................... 99


5 of 38

Section 2: INSTRUCTIONS: Direct these questions to the officer in charge. (if available) Facility Capacity and

Infrastructure Facility Capacity and Infrastructure PROMPT: I would like to ask you a few questions about the facility's overall capacity and infrastructure.

No.

Item (Questions for Maternity where this is available-GHs and Tertiary Hospital)

Instruction to Interviewers: Check to ascertain & Tick what you observed)

Response

7. Are there cracked walls in the health facility?

Yes ……………………………………………… ………….Y No ……………………………………………………………N

8. Are the walls well painted? Yes No

9. Are there cracks and holes on the floor? Yes ……………………………………………… ………..Y No ……………………………………………….…………..N

10. Are there leaking roofs (observe the ceilings for patches)

Yes No

11. Do the consulting rooms and wards have cross ventilation?

Yes ……………………………………………………..….. Y No …………………………………………………………. N

12. Is there a separate Maternity ward in this facility? (Check to ascertain)

Yes ………………………………………………………….Y No ………………………………………………………..…N

13. How many beds are available for obstetric care patients in this facility? (write number)

|___|___|___| (range=0-995; don’t know=997;

refuse to answer=998; not applicable=999) 14. Do you think this number (in 13 above) is

adequate for the current caseload of obstetrics and gynecology clients?

Yes ………………………………………………………Y No ………………………………………………………N

15. What is the condition of the beds Check to ascertain the condition of the beds) (Mark one response)

All are in good shape ………………………………………..1 Half need minor repair …………………………………....2 One-quarter need minor repair…………………………3 Half need major repair …………………………………… 4 One-quarter need major repair ………………………..5 All need major repair or replacement ………………6

16. Are empty beds clean and ready for the next patient? Check to ascertain the condition of the beds)

Yes ………………………………………………………….Y No …………………………………………………………..N

17. Who provides linens for patients? Health Facility ……………………………………………… 1 Family ………………………………………………………… 2 Both family and facility ………………………………..3 No-one ……………………………………………..…………4


6 of 38

No.



Response

18. How often do obstetric patients share beds?

Never ................................................................... 0 Sometimes (at least once per month) .................. 1 Often (at least once per week) ............................. 2 Most of the time (daily) ........................................ 3 Don’t know ............................................................ 9

19. How often do obstetric patients sleep on the floor?

Never ................................................................... 0 Sometimes (at least once per month) .................. 1 Often (at least once per week) ............................. 2 Most of the time (daily) ......................................... 3 Don’t know ............................................................ 9

20. What proportion of deliveries in this facility takes place on the floor?

Never ................................................................... 0 Sometimes (at least once per month) .................. 1 Often (at least once per week) ............................. 2 Most of the time (daily) ......................................... 3 Don’t know ............................................................ 9

21. How long do women generally stay at the facility after an uncomplicated delivery?

Less than 6 hours ................................................ 1 6 - 24 hours .......................................................... 2 More than 24 hours ............................................. 3 Don’t know ............................................................ 9

22. Does this facility have electricity? (even if irregular, circle Y for “Yes”)

Yes ......................................................................... Y No ......................................................................... N (If “No” skip to # 29)

23. What is the primary source of electricity? (circle one)

Power lines (grid) .................................................. 1 Generator .............................................................. 2 Solar ...................................................................... 3 Other (specify) ...................................................... 4

__________________________________ 24. Is the primary electricity functioning at

the time of this interview? (Check to ascertain) (If Yes, skip to Q17)

Yes ......................................................................... Y No ......................................................................... N

25. If not currently functioning, why not? (Confirm from respondent)

No fuel ................................................................... 1 Needs maintenance/repair ................................... 2 PHCN offline ……………………………………….………………3 Other (specify) ...................................................... 4

________________________________ 26. Is back-up electricity supply available?

(Check to ascertain) Yes ......................................................................... Y No ......................................................................... N (If No, Skip to # 29)

27. Is the back-up power functional? Yes ......................................................................... Y No ......................................................................... N


7 of 38

No.



Response

28. In the past month, how often has the facility gone without electricity?

Never ................................................................... 0 Rarely (less than 24 hours per week) ................... 1 Sometimes (at least once per week) .................... 2 Often (at least daily) ............................................. 3

29. Is the maternity ward clean (Absence of dust, cobwebs, dirt, and blood stains, etc.?) (Check to ascertain. Question not applicable to most PHCs)

Yes ………………………………………………………….Y No …………………………………………………………..N

30. Does the maternity appear overcrowded? (patients and visitors)

Yes ………………………………………………………….Y No …………………………………………………………..N

31. Is functioning hand washing station available on the maternity ward? (with running water) (Check to ascertain)

Yes ………………………………………………………….Y No …………………………………………………………..N

32. Is soap available by the hand washing stand in the maternity ward? (Check to ascertain)

Yes ………………………………………………………….Y No …………………………………………………………..N

33. Does this facility have water for patient and staff use? (Check to ascertain)

Yes ......................................................................... Y No ......................................................................... N (If “No” skip to #82)

34. What is the primary source of water? (circle one)

Piped water ........................................................... 1 Hand pump/borehole ............................................ 2 Well ....................................................................... 3 River ...................................................................... 4 Other (specify) ...................................................... 5

35. Is there a back-up water tank? (Check to ascertain)

Yes …………………………………………………………….1 No ……………………………………………………………..2

36. Is the water system currently functioning in the: (read each item) (Check to ascertain)

a. Operating theater? b. Delivery room? c. Postnatal room?

Yes

Y Y Y

No

N N N

N/A

9 9 9

37. In the past month, how often has there been interruption to the water supply?

Never ................................................................... 0 Rarely (less than 24 hours per week) ................... 1 Sometimes (at least once per week) .................... 2 Often (at least daily) ............................................. 3

38. What type of toilet facility is available for obstetric services for staff and client use

Pit Latrine ……………………………………………………….... 1 Ventilated Improved Pit Latrine (VIP) ………………….2 Flush…………………………………………………………...........3 No toilet ………………………………………………….………….4 (If # 4, Skip to # 42)


8 of 38

No.



Response

39. Is toilet functioning and accessible for staff and client use? (Check to ascertain)

No .......................................................................... 0 Yes (staff only) ....................................................... 1 Yes (clients only) .................................................... 2 Yes (shared by staff and clients) ............................ 3 Yes (at least one designated for staff, and at least one designated for clients) .................................... 4

40. Is/Are the toilet(s) clean? (absence of dust, cobwebs, dirt, blood stains, excrement) (Check to ascertain)

Yes …………………………………………………….……………….Y No …………………………………………………….……………….N

41. Is there soap and water available in the toilet today? (Check to ascertain)

No ......................................................................... N Yes ......................................................................... Y

42. Are there curtains or other means being used to establish privacy during physical examination? (Check to ascertain)

Yes ……………………………………………………….…………….Y No ……………………………………………………………………..N

43. Who provides food for patients in this facility?

Health facility ………………………….………………………… 1 Family ………………………………………………..…………….. 2

The labor/delivery room (Question for Labor/delivery room-All facilities): Instruction to interviewers: Please, check to ascertain availability of items mentioned ) 44. How many delivery beds/tables do you

have for the current caseload? |___|___|___|

(range=0-995; don’t know=997; refuse to answer=998; not applicable=999)

45. Is this number of beds (in 44 above) adequate for the current caseload?

Yes ………………………………………………………….Y No …………………………………………………………..N

46. Is the labour and delivery room clean? (Absence of dust, cobwebs, dirt, and blood stains, etc.)

Yes ………………………………………………………….Y No …………………………………………………………..N

47. Is there adequate lighting for procedures?

Yes ………………………………………………………….Y No …………………………………………………………..N

48. Is there a functioning toilet in the labour and delivery room?

Yes ………………………………………………………….Y No …………………………………………………………..N (If No, Skip to # 46)

49. Is the labour and delivery room toilet clean? (Absence of dust, cobwebs, dirt, and blood stains, etc.)

Yes ………………………………………………………….Y No …………………………………………………………..N

50. Is there an available functioning hand washing station for the labour and delivery room toilets? (with running water and soap or alcohol handrub)

Yes ………………………………………………………….Y No …………………………………………………………..N

51. Are there curtains or other means used to maintain privacy?

Yes ………………………………………………………….Y No …………………………………………………………..N


9 of 38

No.



Response

52. Are delivery beds/tables clean and ready for the next patient?

Yes ………………………………………………………….Y No …………………………………………………………..N

53. Are supplies and equipment well organized? (i.e. emergency trolley, BP apparatus, etc.)

Yes ………………………………………………………….Y No …………………………………………………………..N

54. Are at least two pieces of cloth available for drying and wrapping baby?

Yes ………………………………………………………….Y No …………………………………………………………..N

55. Is chlorhexidine gel or aqueous solution available?

Yes ………………………………………………………….Y

56. Is eye ointment available? No …………………………………………………………..N 57. Are consumable supplies and equipment

easily accessible? (i.e. available when needed)

Yes ………………………………………………………….Y No …………………………………………………………..N

58. Is there a stock of emergency medications (e.g. Oxytocin, MgS04)?

Yes ………………………………………………………….Y No …………………………………………………………..N

59. Is the stock of emergency medications easily accessible?

Yes ………………………………………………………….Y No …………………………………………………………..N

60. When emergency medications are not available, what do you do?

Check only one Patients are given a shopping list to go and buy …….1 Patients are referred elsewhere …………………………….2 We do nothing ………………………………………….…………..3

61. Do you have an adequate space for a changing room?

Yes………………………………………………………….Y No………………………………………………………….N

62. Do you have an adequate space for a first stage room?

Yes……………………………………………………….…Y No………………………………………………………….N

63. Is the space for the delivery room adequate?

Yes……………………………………………………….…Y No………………………………………………………….N

Payment for services 64. When are patients expected to make

payment for health care in this facility? At registration point…………………….……………………..1 Before receiving treatment

after registration ……………………………..……….……2 Immediately after

receiving treatment ………….…....……………………3 65. In an emergency, is payment/purchase

of medications or other supplies required before treatment is provided to a woman?

Yes ………………………………………………………….Y No …………………………………………………………..N


10 of 38

No.



Response

66. Which of these possible costs is the most expensive for the woman and her family?

Check only one Admission fees ……………………………………………………. 1 Medications ………………………………………………………… 2 Delivery charges ……………………………………………..…… 3 Fees for procedures/operations ………………..…………4 Payment to staff …………………………………………..…….. 5 Food ……………………………………………………………….….. 6

Please estimate the following costs, including fees, payments, medications, etc, to be paid by patients and their families, in consultation with staff: 67. What is the cost for a normal vaginal

delivery in this facility? N

68. What is the cost for a Cesarean section? N 69. What is the cost for blood transfusion? N 70. What is the cost for vacuum or forceps

delivery? N

71. What is the cost for manual vacuum aspiration (MVA)?

N

72. What is the cost for newborn resuscitation if any?

N

73. Describe how costs and fees are recovered in this facility (i. e. formal vs. informal payments, payments required before treatment or after, etc.) Formal payment before treatment ………………………………………………………………………….….. 1 Formal payment after treatment ………………………………………………………………………………... 2 Informal payment before treatment ……………………………………………………………………………. 3 Informal payment after treatment ………………………………………………………………………………. 4 Other payment methods, specify -------------------------------------------------------------------------------

Section 3: Service and Referral Availability (24 hours a day, 7 days a week)

No. Item Response 74. Are labour and delivery services available at this facility 24

hours a day, 7 days a week? Yes ................................................... Y No ................................................... N

75. Is the operating theater available for procedures such as Caesarean section at this facility 24 hours a day, 7 days a week? (Not applicable to most PHCs)

Yes ................................................... Y No ................................................... N

76. Are medications available for EmONC procedures at this facility 24 hours a day, 7 days a week?

Yes ................................................... Y No ................................................... N

77. Are other essential supplies for EmONC services available at this facility 24 hours a day, 7 days a week?

Yes ................................................... Y No ................................................... N


11 of 38

78. Are laboratory services available for transfusions at this facility 24 hours a day, 7 days a week?

Yes ................................................... Y No ................................................... N

79. Is there blood supply available for transfusions at this facility 24 hours a day, 7 days a week?

Yes ................................................... Y No ................................................... N

80. Are anesthesia services available at this facility 24 hours a day, 7 days a week?

Yes ................................................... Y No ................................................... N

81. Are staff quarters available at or near the facility? No .................................................... 0 On the grounds of facility ................ 1 Within 20 min of facility .................. 2 >20 min but <1 hr from facility ...... 3 >1 hr from facility ............................ 4 Staff do not require quarters at this facility ..............................................9

Section 4: Communications PROMPT: The next few questions I will like to ask you are related to available communications to enable referrals of patients from your facility to another for needed services.

No. Item

Not available at facility

Available at facility & functional

Available at facility but not functional

Has been used for referral in past week?

Has been used for referral in past month?

Is the Cell Phone used for data transmission & reporting?

Yes No Yes No

82. Landline telephone in the maternity area 0 1 2 Y N Y N

83. Landline telephone elsewhere in facility 0 1 2 Y N Y N

84. Cell phone (owned by facility) 0 1 2 Y N Y N

85. Cell phone (owned by individual staff) 0 1 2 Y N Y N

86. Two-way radio 0 1 2 Y N Y N

87. Is there a cell phone signal at this facility? (Check to confirm) No .................................................. N

Yes .................................................. Y Section 5: Referral and Transportation PROMPT: The next few questions I will like to ask you are related to available transportation to enable referrals of patients from your facility to another facility for needed services.


12 of 38

No. Mode of Transportation At least 1 available Has been used for

referral in past week?

Has been used for

referral in past month?

Not available

at facility

Available at facility & functional

Available at facility but

not functional Yes No Yes No

88. Motor vehicle (4-wheeled) 0 1 2 Y N Y N 89. Motorcycle (2-wheeled) 0 1 2 Y N Y N 90. Motorized tricycle (3-wheeled) 0 1 2 Y N Y N 91. Boat 0 1 2 Y N Y N 92. Bicycle 0 1 2 Y N Y N 93. Bicycle ambulance 0 1 2 Y N Y N 94. Stretcher (hand carried) 0 1 2 Y N Y N 95. Stretcher (Attached to motor) 96. Animal drawn cart 0 1 2 Y N Y N

97. Other (specify)___________________

0 1 2 Y N Y N

98. If a vehicle is not available from the facility or district, are there funds (or vouchers) available at the facility to pay for private transport of emergency referrals?

No ..................................................... 0 Yes, always ....................................... 1 Yes, sometimes ................................ 2 Yes, rarely ......................................... 3 Not applicable .................................. 9

99. What is the main (most commonly used) means of transport to this health facility?

Public Bus ……………………………………… 1 Public Taxi ………………………………………2 Personal cars ………………………………… 3 Okada/Motor Bike ………………………… 4 Bicycle ……………………………………………5 Canoe …………………………………………... 6 Camel ……………………………….………….7 Others (Identify) …………………………… 9

100. How far is the nearest referral hospital that provides surgical care?

|___|___|___|___| km (range=1-995; surgical services are provided at this hospital facility=0000; facility does not refer=8888; don’t know=9999)

101. How long does it take to get to the referral hospital that provides surgical care?

(record time in minutes under normal circumstances)

|___|___|___|___| minutes (range=1-995; surgical services are provided at this hospital facility=0000; facility does not refer=8888; don’t know=9999)


13 of 38

102. Is there a formal written protocol for referring patients from this facility?

No ................................................... N Yes .................................................. Y Don’t know ..................................... 9

103. When referring a patient, do staff inform the referral clinic or hospital about the patients and needed services?

No ................................................... 0 Immediately by phone/radio .......... 1 Immediately by text message ......... 2 Upon referral by paper ................... 3 Don’t know ..................................... 8 Not applicable ( does not refer) ..... 9

104. Who pays for transportation when referring? Health Facility …………………………….. 1 Patients/Relations ……………………….2 Free/No payment …………………………3

105. For what purpose/s is the referral transportation used in this facility?

Maternal emergencies alone ………………….1 Newborn emergencies alone ………………….2 Both maternal and Newborn emergencies …………………………………………………………….….3 None ………………………….……………………………4


14

Module 3: HUMAN RESOURCES

Section 1: Staffing levels and training PROMPT: The next questions are related to staff who provide obstetric and newborn care at this facility. Please tell me how many in this facility

for each question.

Item

Tota

l

Cadre

Med

ical

Offi

cer

(gen

eral

pr

actit

ione

r, et

c.)

Yout

h Co

rper

D

octo

r

Regi

ster

ed N

urse

Regi

ster

ed M

idw

ife

Regi

ster

ed N

urse

/ M

idw

ife

Com

mun

ity N

urse

Auxi

liary

Nur

se

Com

mun

ity H

ealth

O

ffice

r Sp

ecia

list i

n ob

stet

rics

&

gyne

colo

gy

Spec

ialis

t in

pedi

atric

s

Phys

icia

n Sp

ecia

list

in a

nest

hesi

a

Anes

thet

ist, n

on-

doct

or

Com

mun

ity h

ealth

ex

tens

ion

wor

ker

(CH

EWs)

Juni

or c

omm

unity

he

alth

ext

ensi

on

wor

ker

Phar

mac

ist

Phar

mac

y As

sista

nt

Labo

rato

ry S

cien

tist

Labo

rato

ry A

ssis

tant

Radi

olog

ist

Radi

olog

ist

Assis

tant

106. Total number employed in the facility?

107. How many staff are at work at time of interview?

108. How many attend to normal deliveries?

109. How many provide Caesarean Section services?

110. How many are trained in labor and delivery?

111. How many provide basic newborn care?

112. How many are trained to manage preterm and Low Birth Weight babies?

113. How many are trained to manage sick newborn with sepsis?

114. How many are trained in post-natal care for Mothers?

115. How many are trained in


15

post-natal care for Newborn?

116. How many are trained in infection prevention & control?

117. How many are trained to provide AMTSL?

118. How many are trained in provision of C-Sections?

119. How many are trained to assist during C/S

120. How many are trained in PMTCT?

121. How many provide antenatal care?

122. How many are trained on LARC/PM

123. How many are trained on Youth Friendly services?

124. How many are trained on Gender-related matters?

125. How many have been trained/oriented on maternal death audits (MDR)?

126. How many have been trained/oriented on newborn and perinatal death audits?

127. How many are trained on Malaria prevention?

128. How many are trained on Malaria diagnosis and treatment?

129. How many trained on anemia diagnosis and management?

130. Is at least one person on duty and physically present


16

24 hours a day? (Insert Y if Yes and N if No in each column)

131. How many are on morning shift?

132. How many are on afternoon shift?

133. How many are on night shift


17

Module 4: MATERNAL & NEONATAL HEALTHCARE MEDICATIONS, EQUIPMENT, SUPPLIES Section 1: Medications for Maternal and Neonatal Healthcare PROMPT: The next questions are about availability of medications for obstetric and neonatal care. What is the availability of the following drugs and commodities at your facility (Check to confirm availability of the commodities on the day of the assessment)?

Item (Instruction to Interviewers: Check to

conform availability of the items)

At facility today

(Available today?)

When was the most recent stock out of ________ in past 12 months at your facility?

Within last

month Within 3 months

Within 6 months

Within 12

months

No stock outs in past

year Yes No Antibiotics

134. Amoxicillin (Amoxyl)Tablets Y N 4 3 2 1 0

135. Amoxicillin (Amoxyl)Syrup Y N 4 3 2 1 0

136. Chlorhexidine 7.1% Y N 4 3 2 1 0

137. Ampicillin (for adults) Y N 4 3 2 1 0

138. Ampicillin (Injection for newborn) Y N 4 3 2 1 0

139. Ceftriaxone (injection) Y N 4 3 2 1 0

140. Gentamicin (injection) Y N 4 3 2 1 0

141. Metronidazole (Flagyl) (for

mother)

Y N 4 3 2 1 0

142. Metronidazole (Flagyl) (Injection form for newborns)

Y N 4 3 2 1 0

143. Cefotaxine injection (for newborn) Y N 4 3 2 1 0

144. Oral flucloxacillin (for newborn - For use in combination with Oral Ampicillin and Cloxacillin, commonly called Ampiclox)

Y N 4 3 2 1 0

145. Trimethoprim/sulfamethoxazole (cotrimoxazole,Septrin) (for mother)

Y N 4 3 2 1 0

146. Trimethoprim/sulfamethoxazole (cotrimoxazole,Septrin) (syrup for infant)

Y N 4 3 2 1 0

147. Gentacyn eye ointment for eye prophylaxis

Y N 4 3 2 1 0

148. Tetracycline and Erythromycin eye ointment

Y N 4 3 2 1 0

149. Povidine 2.5% Y N 4 3 2 1 0

150. Ciprofloxacin (for Mother – Tablet) Y N 4 3 2 1 0


18

Item

(Instruction to Interviewers: Check to conform availability of the items)

At facility today

(Available today?)


Within last


Within 6 months

Within 12

months


year Yes No 151. Ciprofloxacin (for Mother –

Injection)

Y N 4 3 2 1 0

152. Injection crystalline penicillin for

newborn

Y N 4 3 2 1 0

Anticonvulsants 153. Magnesium sulfate (injection) 50

% concentration Y N 4 3 2 1 0

154. Phenobarbitone (injection for

newborn)

Y N 4 3 2 1 0

155. Calcium gluconate Y N 4 3 2 1 0

156. Diazepam (valium) Y N 4 3 2 1 0

Antihypertensives

157. Labetalol Y N 4 3 2 1 0

158. Methyldopa Y N 4 3 2 1 0

159. Hydrallazine Y N 4 3 2 1 0

Uterotonics

160. Oxytocin Y N 4 3 2 1 0

161. Ergometrine Y N 4 3 2 1 0

162. Misoprostol Y N 4 3 2 1 0

Antimalarial

163. Artemisinin-based combination

therapy (ACT)

Y N 4 3 2 1 0

164. Parenteral Artesunate Y N 4 3 2 1 0

165. Quinine Y N 4 3 2 1 0

Antiretroviral (ARV)

166. ARV prophylaxis for mother: AZT/3TC (Combivir)

Y N 4 3 2 1 0

167. ART (triple drug regimen) for Y N 4 3 2 1 0


19

Item


At facility today

(Available today?)


Within last


Within 6 months

Within 12

months


year Yes No mother

168. Trimethoprim/sulfamethoxazole (co-trimaxole, Septrin) for mother- double strength

Y N 4 3 2 1 0

169. Nevirapine (NVP) syrup for infant Y N 4 3 2 1 0

170. AZT syrup for infant Y N 4 3 2 1 0

Contraceptives (for this items, you will need to visit the FP clinic)

171. Intrauterine devices (IUDs) Y N 4 3 2 1 0

172. Jadelle implants Y N 4 3 2 1 0

173. Implanon implants Y N 4 3 2 1 0

174. Male condoms Y N 4 3 2 1 0

175. Female condoms Y N 4 3 2 1 0

176. Diaphragms with spermicide

(nonoxynol)

Y N 4 3 2 1 0

177. Low-dose combined oral

contraceptive (COCs)

Y N 4 3 2 1 0

178. Progestin-only oral contraceptive

(POPs)

Y N 4 3 2 1 0

179. Injectables (DMPA, Noristerat) Y N 4 3 2 1 0

180. Cycle beads Y N 4 3 2 1 0

181. Emergency contraceptive pills Y N 4 3 2 1 0

182. Family planning and contraceptive

job aids

Y N 4 3 2 1 0

ANC & Other drugs and supplies

183. Ferrous sulfate or fumarate Y N 4 3 2 1 0

184. Folic acid Y N 4 3 2 1 0

185. Insecticide-treated bednets (ITN) Y N 4 3 2 1 0

186. Tetanus toxoid vaccine Y N 4 3 2 1 0


20

Item


At facility today

(Available today?)


Within last


Within 6 months

Within 12

months


year Yes No 187. Vitamin K (for newborn) Y N 4 3 2 1 0

188. Mebendazole (antihelminths,

Vermox)

Y N 4 3 2 1 0

189. Sulfadoxine Pyrimethamine

(Fansidar for IPT)

Y N 4 3 2 1 0

190. Aminophylline injection for preterm newborn

Y N 4 3 2 1 0

191. Multivitamin drops for preterm

newborn

Y N 4 3 2 1 0

192. Syrup Iron for preterm neonates Y N 4 3 2 1 0

IV Fluids

193. Glucose 5% Y N 4 3 2 1 0

194. Glucose 50% Y N 4 3 2 1 0

195. Glucose 10% Y N 4 3 2 1 0

196. Normal saline (sodium chloride

0.9%)

Y N 4 3 2 1 0

197. Ringer's lactate Y N 4 3 2 1 0

Analgesics

198. Paracetamol (Panadol) Y N 4 3 2 1 0

199. Parenteral analgesics Y N 4 3 2 1 0

200. Parenteral narcotics- i.e.,

pethidine, morphine

Y N 4 3 2 1 0

201. Naloxone, promethazine Y N 4 3 2 1 0

Steroids

202. Dexamethasone Y N 4 3 2 1 0

203. Betamethasone Y N 4 3 2 1 0

204. Hydrocortisone (injection) Y N 4 3 2 1 0


21

Item


At facility today

(Available today?)


Within last


Within 6 months

Within 12

months


year Yes No Anesthesia and resuscitation

205. Local anesthetics, e.g. Lignocaine/Lidocaine 2% or 1%

Y N 4 3 2 1 0

206. Anesthesia machine and inhalational agents

Y N 4 3 2 1 0

207. Ketamine Y N 4 3 2 1 0 208. Spinal anesthesia drugs and

supplies (e.g. spinal needle) Y N 4 3 2 1 0

209. Nitrous oxide Y N 4 3 2 1 0 210. Oxygen cylinder, mask, tubing Y N 4 3 2 1 0 211. Adult resuscitation supplies, i.e.

ambu-bag, oral airway Y N 4 3 2 1 0

212. Newborn resuscitation supplies e.g. Infant Ambu Bag, Penguin Bulb Syringe

Y N 4 3 2 1 0

No.

Family Planning Infrastructural Items and Quality of practices

(Instruction to Interviewers: Check to confirm)

Response

213. Separate family planning area established?

Yes ………………………………………………………….Y No ………………………………………………………..…N

214. Seating area available for clients? Yes ………………………………………………………….Y No ………………………………………………………..…N

215. Table and seats available for provider? Yes ………………………………………………………….Y No ………………………………………………………..…N

216. Seats available for clients? Yes ………………………………………………………….Y No ………………………………………………………..…N

217. Family planning flip chart available? Yes ………………………………………………………….Y No ………………………………………………………..…N

218. IEC materials available? Yes ………………………………………………………….Y No ………………………………………………………..…N

219. IEC material available to give to clients? Yes ………………………………………………………….Y No ………………………………………………………..…N

220. Do you provide group education to clients on family planning?

Yes ………………………………………………………….Y No ………………………………………………………..…N

221. Private FP room established? Yes ………………………………………………………….Y No ………………………………………………………..…N


22

No.

Family Planning Infrastructural Items and Quality of practices

(Instruction to Interviewers: Check to confirm)

Response

222. Hand washing stand available in family planning room (with soap)

Yes ………………………………………………………….Y No ………………………………………………………..…N

223. Adequate lighting available in FP procedure room?

Yes ………………………………………………………….Y No ………………………………………………………..…N

224. Sharps box available? Yes ………………………………………………………….Y No ………………………………………………………..…N

225. Complete equipment kit available for FP procedure

Yes ………………………………………………………….Y No ………………………………………………………..…N

Section 2: Equipment & Supplies for Infection Prevention and Control PROMPT: The next few sets of questions are about the availability of equipment and supplies i for obstetric and neonatal care. Please state available only if functioning and available. What is the availability of the following supplies at your facility?


confirm availability of items)

At facility today

When was the most recent stock out of ________ in past 12 months at you facility? Within

last month

Within 3 months

Within 6 months

Within 12

months


year Yes No

Infection prevention

226. Soap Y N 4 3 2 1 0

227. Antiseptics, e.g. betadine,

chlorhexidine

Y N 4 3 2 1 0

228. Sterile gloves Y N 4 3 2 1 0

229. Non-sterile gloves Y N 4 3 2 1 0

230. Non-sterile protective clothing (e.g.

aprons/Macintosh)

Y N 4 3 2 1 0

231. Decontamination container solution Y N 4 3 2 1 0

232. Bleach or bleaching powder

(Chlorine)

Y N 4 3 2 1 0

233. Regular trash bin Y N 4 3 2 1 0

234. Covered contaminated waste bin Y N 4 3 2 1 0

235. Puncture-proof sharps containers Y N 4 3 2 1 0

236. Mayo stand (or equivalent for

establishing sterile tray/field)

Y N 4 3 2 1 0


23

Item

(Instruction to Interviewers: Check to confirm availability of items)

At facility today


last month

Within 3 months

Within 6 months

Within 12

months


year Yes No Other basic items

237. HIV rapid tests (first line, second line and a tie breaker)

Y N 4 3 2 1 0

238. Rapid syphilis tests Y N 4 3 2 1 0

239. Rapid malaria tests Y N 4 3 2 1 0

240. Urinalysis tests Y N 4 3 2 1 0

241. Needles and syringes (10-20cc) Y N 4 3 2 1 0

242. Point-of-care hemoglobin cuvettes Y N 4 3 2 1 0

243. Specimen tubes to collect blood for CD4 tests

Y N 4 3 2 1 0

244. Autoclave supplies Y N 4 3 2 1 0

245. Episiotomy/cervical/vaginal

laceration repair packs

Y N 4 3 2 1 0

246. Bubble Continuous Positive Airway Pressure (bCPAP) machine

Y N 4 3 2 1 0



At

facility

today?

Functional? Comment

247. Baby warmer Y N Y N

248. Incubator Y N Y N

249. Is the incubator functional? Y N Y N

250. Blood pressure equipment Y N Y N

251. Autoclave Y N Y N

252. Filled oxygen cylinder carrier and key to open valve

Y N Y N

253. Adult stethoscope Y N Y N

254. Fetal stethoscope Y N Y N

What is the availability of the following obstetric and newborn supplies at your facility? Item At facility

today When was the most recent stock out of ________ in past 12 months at you facility?


24

Instruction to Interviewers: Check to confirm availability of items)

Within last


Within 6 months

Within 12

months


year Yes No

Maternal and Newborn items and others 255. Clean, dry towels ( at least 2 per

baby) Y N 4 3 2 1 0

256. Clean bulb syringe (e.g. Penguin bulb syringe)

Y N 4 3 2 1 0

257. Ambu-bag (neonates) Y N 4 3 2 1 0 258. Face masks pre-term newborn (size

0) Y N 4 3 2 1 0

259. Face masks term newborn (size 1) Y N 4 3 2 1 0 260. Cord supplies (clamps/ties) Y N 4 3 2 1 0 261. Cord supplies (scissors) Y N 4 3 2 1 0 262. Uterine evacuation packs Y N 4 3 2 1 0 263. Manual vacuum aspiration (MVA)

packs Y N 4 3 2 1 0

264. Dressing instrument packs Y N 4 3 2 1 0 265. Tubing for oxygen administration Y N 4 3 2 1 0 266. Adult ventilator mask Y N 4 3 2 1 0 267. Thermometer for newborn Y N 4 3 2 1 0 268. Partograph Y N 4 3 2 1 0 269. Assisted delivery packs (obstetric

vacuum or forceps) Y N 4 3 2 1 0

270. Adult ventilator bag Y N 4 3 2 1 0 271. Labor/delivery table Y N 4 3 2 1 0 272. Newborn scale Y N 4 3 2 1 0

Does this facility have an operating theater? [Y] Yes [N] No If ‘No’ skip the following set of questions and go to next Module. What is the availability of the following operating theater supplies at your facility?

Item Instruction to Interviewers: Check to


At facility today

(Available today?)


last month

Within 3 months

Within 6 months

Within 12

months


year Yes No Cesarean Section


25

Item

Instruction to Interviewers: Check to confirm availability of items)

At facility today

(Available today?)


last month

Within 3 months

Within 6 months

Within 12

months


year Yes No 273. C-section instrument kits/packs Y N 4 3 2 1 0 274. Sutures-various sizes-0,2-0,3-0 Y N 4 3 2 1 0 275. Anesthetic face masks Y N 4 3 2 1 0 276. Suction aspirator, foot, operated Y N 4 3 2 1 0 277. Suction aspirator, electric Y N 4 3 2 1 0 278. Sterile drapes, gowns Y N 4 3 2 1 0 279. Oropharyngeal airways Y N 4 3 2 1 0 280. Laryngoscopes with spare bulbs and

batteries Y N 4 3 2 1 0

281. Endotracheal tubes with cuffs Y N 4 3 2 1 0 282. Intubating forceps Y N 4 3 2 1 0 283. Endotracheal tube connectors,

plastic (connect directly to breathing valve; three for each tube size)

Y N 4 3 2 1 0

284. Anesthetic vaporizer (draw-over system)

Y N 4 3 2 1 0

285. Oxygen cylinders with manometer and flowmeter (low flow)tubes and connector

Y N 4 3 2 1 0

Module 5: EmONC SIGNAL FUNCTIONS AND OTHER ESSENTIAL SERVICES INSTRUCTIONS: This module should be completed by facilities providing labor and delivery services (defined as delivery at facility, or woman presenting to facility within 72 hours of delivery at home, in past 12 months) Section 1: Signal Functions A. Have the following been administered or performed in past 12 months?

If ‘No’ skip question related to ‘past 3 months’ B. Have the following been administered or performed in past 3 months?

Item Past 12 months Past 3 months Yes No Yes No

286. Giving parental antibiotics to Mothers Y N Y N 287. Giving parental antibiotics to Newborns Y N Y N 288. Giving parenteral oxytocic Y N Y N 289. Giving parenteral anticonvulsants (Magnesium

Sulphate) or sedative Y N Y N


26

Item

Past 12 months Past 3 months Yes No Yes No

290. Manual removal of the placenta Y N Y N 291. Removal of retained products of conception (using

manual vacuum aspiration kit) Y N Y N

292. Assisted vaginal delivery (vacuum or forceps) Y N Y N 293. Newborn resuscitation with bag and mask Y N Y N 294. Blood transfusion related to labor and delivery Y N Y N 295. Cesarean delivery Y N Y N 296. Assisted care for preterm/LBW (Kangaroo Mother

Care) Y N Y N

297. Assisted care for preterm/LBW (Incubator/warmer care)

Y N Y N

298. Administration of antihypertensive drugs for raised BP Y N Y N 299. Administration of corticosteroids for preterm rupture

of membranes Y N Y N

300. If Yes to all questions 287-296 above, the facility provides Comprehensive EmONC.. If Yes to questions 287-294, but No to questions 295 and/or 296, the facility provides Basic EmONC. If No to any of the questions 287-294, the facility is Non-EmONC

1. CEmONC: The facility provides 287-296

2. BEmONC: The facility provides 287-294

3. Non-EmONC: The facility does not provide all services from 287-294

For CEmONC facilities only.

Medications for preterm care At facility today

(Available)

When was the most recent stock out of-------- in past 12 month at you facility?

Within last

month

Within 3

months

Within 6

months

Within 12

months

No stock

outs in past year

Yes No 4 3 2 1 0

301. Indomethacin Y N 4 3 2 1 0

302. Ritodrine Y N 4 3 2 1 0

303. Salbutamol Y N 4 3 2 1 0

Blood transfusion (for this items, you will need to visit the laboratory)


27

304. Blood bags Y N 4 3 2 1 0

305. Needles and tubing for transfusion Y N 4 3 2 1 0

306. Blood screening reagents Y N 4 3 2 1 0

307. Microscope Y N 4 3 2 1 0

308. Refrigerator Y N 4 3 2 1 0

Section 2: Other EmONC Essential Services

Item

Response

Yes

No NA (Mark NA only if service is not routinely available in the facility)

309. Do staff routinely practice Active Management of Third Stage of Labor (AMTSL)?

Y N

310. Do staff routinely use a Partograph to manage labor? Y N 311. Has a breech delivery been performed in the last 3 months? Y N 312. Do staff routinely practice the Newborn resuscitation when

needed? Y N

313. Do mothers with preterm births and LBW babies routinely practice Kangaroo Mother Care?

Y N

314. For mothers with unknown HIV status, has rapid testing been performed in the maternity/labor ward in the last 3 months? Y N NA

315. Have ARVs been given to HIV-infected mothers in the maternity/labor ward in the last 3 months?

Y N NA

316. Have ARVs been given to HIV-exposed newborns in maternity/labor ward in the last 3 months?

Y N NA

317. Has full treatment been provided for sick newborn with sepsis or possible severe bacterial infection in last 3 months? Y N NA

318. Has a sick newborn baby been referred from this health facility to another in the last 3 months? Y N NA

319. Has a sick newborn baby been put on bCPAP in the last 3 months? Y N NA

320. Have short-term family planning methods (pills, injectables or condoms) been provided in the last 3 months? Y N

321. Have long acting family planning methods (IUD or implants) been provided in the last 3 months?

Y N

322. Has a surgical method or permanent contraception been performed in the last 3 months?

Y N NA


28

Item

Response

Yes

No NA (Mark NA only if service is not routinely available in the facility)

323. Does the facility provide post abortion contraception to women?

Y N NA

324. Does this facility have a mothers' shelter? Y N 325. Are any of the following procedures routinely performed for

women during labor?

a. Episiotomies

Y

N

b. Shaving Y N

c. Enemas Y N Module 6: DOCUMENTS, PROTOCOLS AND GUIDELINES Section 1: Protocols and Guidelines Are there guidelines or protocols available in the maternity ward for _____________________?

Item (Instruction to Interviewers: Check to confirm)

Yes, within reach

Yes, on walls

Yes, but stored

(not accessible)

No

326. Management of obstetric hemorrhage 3 2 1 0 327. Management of pre-eclampsia/eclampsia 3 2 1 0 328. Immediate basic newborn care 3 2 1 0 329. Puerperal sepsis 3 2 1 0 330. Newborn resuscitation 3 2 1 0 331. Prolonged labour and retained placenta 3 2 1 0 332. Kangaroo mother care 3 2 1 0 333. Management of preterm/small baby 3 2 1 0 334. Prevention of mother-to-child transmission of HIV

(PMTCT) (maternal and newborn dosing) 3 2 1 0

335. Infection prevention for HIV/AIDS (universal precautions)

3 2 1 0

336. Safe abortion 3 2 1 0 337. Post abortion care 3 2 1 0 338. Management of malaria in pregnancy 3 2 1 0


29

Is this facility baby Friendly? (Tick Yes or No as applicable) Please make observation and ask interviewee to show items to confirm availability

Item Yes, No 339. Does the facility have a written breastfeeding policy that is routinely

communicated to all healthcare staff? If yes, view.

340. Has the facility trained all health care staff in the skills necessary to implement the breastfeeding policy?

341. Does the facility inform all pregnant women about the benefits and management of breastfeeding?

342. Does the health facility help mothers initiate breastfeeding after birth? 343. Does the health facility show mothers how to breastfeed and how to

maintain lactation even if they are separated from their babies?

344. Does the health facility give newborns infants no food or drink other than breast milk, unless medically indicated?

345. Does the health facility practice rooming-in, allowing mothers and infants to remain together 24 hours a day?

346. Does the health facility encourages\ breastfeeding on demand? 347. Does the health facility discourage giving artificial teats or dummies to

breastfeeding infants?

348. Does the health facility identify sources of national and local support for breastfeeding and ensure that mothers know how to access these prior to discharge from hospital

349. Are guidelines on breastfeeding on the facility wall? (Please, observe) 350. If the answer to all the questions are Yes, then the health facility is a

Baby Friendly Facility This health facility is:

1. Baby Friendly

2. Not Baby Friendly Section 2: Facility Registers INSTRUCTIONS: Ask to see the registers. PROMPT: We would like to know more about the routine registers you maintain for obstetric and neonatal care at this facility. (Columns refer to the information entered for each client/patient seen; Rows refer to entry or list of names of each client/patient seen.)

Item Register is

available & used Columns Filled

Completely Rows Up to Date

Yes No Yes No Yes No 351. General admission register Y N Y N Y N


30

352. Labor and delivery register Y N Y N Y N

353. Antenatal care register Y N Y N Y N

354. Postnatal register Y N Y N Y N

355. Pediatric register (for sick newborn on admission)

Y N Y N Y N

356. Outpatient pediatric register Y N Y N Y N

357. Operating theater register Y N Y N Y N

358. Gynecology register Y N Y N Y N

359. Family Planning register Y N Y N Y N

360. Safe abortion/Post-Abortion register Y N Y N Y N

361. Death register Y N Y N Y N

362. PMTCT labor and delivery register Y N Y N Y N

363. Referral register Y N Y N Y N

364. Drug inventory register Y N Y N Y N

365. Discharge register (Labour and delivery)

Y N Y N Y N

366. Discharge register (postnatal care)

367. Death/morgue register Y N Y N Y N Is the health facility using the harmonized 2013 National Health Information System registers and forms? 1. Yes 2. No


31

Section 3: Mortality Reviews PROMPT: We would like to know more about the maternal and neonatal death reviews in the facility

Item Response 368. Is there a formal audit or case review of maternal

deaths at the facility? Yes ........................................................ 1 No ........................................................ 0 Not Applicable or Never had a death ... 9 (If "No" or "Not applicable” skip to Item 370)

369. How often are maternal deaths audited or reviewed? After every maternal death .................. 1 On a scheduled basis ............................ 2 Only occasionally or Rarely .................. 3 Never ................................................... 0

370. Is there a formal audit or case review of perinatal deaths at the facility?

Yes ........................................................ 1 No ........................................................ 0 Not Applicable or Never had a death ... 9 (If "No" or "Not applicable” skip Q372)

371. How often are perinatal deaths audited or reviewed? After every neonatal death .................. 1 On a scheduled basis ............................ 2 Rarely ................................................... 3 Never ................................................... 0

372. How often are stillbirths audited or reviewed? After every neonatal death .................. 1 On a scheduled basis ............................ 2 Rarely ................................................... 3 Never ................................................... 0

Module 7: COMMUNITY SERVICES AND MOBILIZATION Section 1: Outreach

PROMPT: These questions deal with this facility’s community outreach activities to the community. Does this facility conduct community outreach to increase demand and use of the following:________?

Topic of Outreach No Yes, rarely

Yes, sometimes

Yes, ongoing & frequent

Don’t Know

373. HIV testing? 0 1 2 3 9 374. PMTCT? 0 1 2 3 9 375. Antenatal Care? 0 1 2 3 9 376. Facility based deliveries? 0 1 2 3 9 377. Newborn care? 0 1 2 3 9


32

Topic of Outreach No Yes, rarely

Yes, sometimes


Don’t Know

378. Family planning? 0 1 2 3 9 379. Male involvement in maternal and

neonatal health? 0 1 2 3 9

380. Does this health facility have a health management committee? 1) Yes 2) No

381. If Yes, is the community represented in the committee?

1) Yes 2) No 382. Are women health groups in existence to improve maternal and newborn health?

1) Yes 2) No Section 2: Demand Creation PROMPT: These questions deal with the community’s link to this facility. 383. Is there a community-based organization that links the community to this health facility to

improve community health and increase demand for the following service?

Topic of Demand Creation No Yes, rarely

Yes, sometimes


Don’t Know

384. HIV testing? 0 1 2 3 9 385. PMTCT? 0 1 2 3 9 386. Antenatal Care? 0 1 2 3 9 387. Facility based deliveries? 0 1 2 3 9 388. Newborn care? 0 1 2 3 9 389. Family planning? 0 1 2 3 9 390. Male involvement in maternal and

neonatal health? 0 1 2 3 9

391. Identification and management of sick newborns, care of very small babies?

0 1 2 3 9


33

Health Facility Level Use of Data for Clinical Governance

Question Yes No Comment 392. Does the facility have a list of priority indicators for

RMNH that should be monitored on a regular basis? 1 0

393. Ensures there are appropriate job aids (e.g. partograph, counseling flipcharts) available for the services provided in each RMNH service room (i.e. on the wall, on the desk, in providers’ pockets).

1 0

Data visualization and Use Does the health facility team regularly conduct

analysis for the priority RMNH interventions Graph, chart displayed and updated

Graph, chart displayed and updated

Targets available for each indicator

No graphs, charts or targets

394. 1. PPH 1. Yes 1. Yes 0. No 395. 2. Eclampsia/PEE 1. Yes 1. Yes 0. No 396. 3. Maternal deaths 1. Yes 1. Yes 0. No 397. 4. Newborn resuscitation 1. Yes 1. Yes 0. No 398. 5. Intra-partum still births 1. Yes 1. Yes 0. No 399. Is there a report submitted to districts on the

analysis of these priority RMNH indicators? 1. Yes, Observed

0. No

400. What is the frequency of these reports 1. Monthly 2. Quarterly 3. Bi-annual or

annual

Health Facility QI process 401. Does the facility have a “quality committee” that

works to promote the QI of RMNH services? 1.Yes 0.No

402. How many times did the “quality committee” meet during the last three months?

[___]___]

Please check official record of the meeting records for the last three months? to see if the following topics were discussed:

403. a) Data quality, reporting, or timeliness of RMNH indicators

1.Yes, observed 0. No

404. b) Discussion on data analysis, service coverage, medicine stock-out


405. c) Have they made any decisions based on the above discussions?


406. d) Has any follow-up action taken place on the decisions made during the previous meetings?


407. e) Are there any HIS related issues/problems referred to regional/national level for actions?


Other management meetings at the HF level 408. Are there daily handover meetings occur on the 1.Yes, observed 0. No


34

wards? 409. Are there regular clinical team/wards meetings

occur at least monthly? 1.Yes, observed 0. No

410. Do management committees occur regularly—with written agenda, minutes and action items with follow-up at the next meeting?


411. Do management committees, use data to assess progress and identify gaps from other meetings (ie, quality committee, audit committee, clinical teams, etc.) within 3 months.


Decision making using data What kinds of decisions are made in the past 3

months based on use of data for actions? Please check on types of decision based on types of analyses present in reports (Please give some examples).

412. a) Review strategy by examining service performance target

1.Yes 0.No

413. b) Review facility personnel responsibilities 1.Yes 0.No 414. c) Mobilization/shifting of resources based on

comparison by services 1.Yes 0.No

415. d) Advocacy for more resources 1.Yes 0.No 416. e) Review or revise policies, protocols 1.Yes 0.No 417. f) Staff training or supervision 1.Yes 0.No 418. g) Community education or mobilization 1.Yes 0.No 419. h) Improve data quality, use or analysis 1.Yes 0.No 420. Did the facility annual plan show that data on above

interventions is used during annual planning? 1.Yes 0.No

District level support 421. Has staff form the facility attended meeting at

district level related to review of MNH performance?

1.Yes 0.No

422. Number of meeting in the last 3 months Any decisions made

423. a) Facility’s performance in relation to RMNH indicators

1.Yes 0.No

424. b) Support to make decision using RMNH data 1.Yes 0.No Supervision by the district health office

425. Did the district supervisor visit the facility during the last three months?

1.Yes 0.No

426. How many times did the district supervisor visit the facility during the last three months?

1. Once1 2. Twice 3. Thrice 4. >3

427. Did supervisor check the data quality and analysis for priority RMNH indicators?

1.Yes 0.No

428. Did the district supervisor reviewed performance on 1.Yes 0.No


35

priority indicators of health facilities based on HIS information when he/she visited your facility?

429. Did the supervisor help make a decision based on MNCH-HIS information?

1.Yes 0.No

430. Did the supervisor send a report/feedback/note on the last two supervisory visits for MNCH indicators?

1.Yes 0.No

431. Identify capacity building needs in data analysis, problem solving and use.

1.Yes 0.No

Data dissemination and community engagement 432. Are results on priority indicators shared within the

team and key stakeholders regularly? 1.Yes 0.No

433. Do health facility staff document problem associated with lower performance.

1.Yes 0.No

434. Were decision taken and documented for improving performance on the priority interventions in the last quarter.

1.Yes 0.No

435. Are results on priority indicators are shared with community members?

1.Yes 0.No

In the last 3 months, how has the facility made RMNH information available to members of community or other partners?

1.Yes 0.No

436. a) Displayed on the wall of health facility 1.Yes 0.No 437. b) Respond to request from community or

NGOs 1.Yes 0.No

438. c) Shared at community meetings 1.Yes 0.No 439. d) Media – radio or television 1.Yes 0.No 440. e) None 1.Yes 0.No 441. Are there mechanisms in place to collect patient and

community feedback (ie, suggestions, praise, and complaints) and a process in place to review and address them?

1.Yes 0.No

442. Are there sufficient numbers of SBCC/IEC materials in local languages (posters, flyers, videos) and group educational sessions available to patients on issues identified as important to patients and prioritized by providers.

1.Yes 0.No

Death audit, surveillance and response 443. Are all Maternal, Perinatal and Neonatal Death

reported to higher levels 1. Yes 0. No

If yes, which level?

a. State only b. State and National Level c. National level only d. Community

444. What percentage of all Maternal, Perinatal and Neonatal Deaths are reported to higher levels

State the figure:


36

445. HF has a functioning committee for Maternal, Perinatal and Neonatal Death Audit and Near Miss Reviews

1.Yes 0.No

446. What percentage of Maternal, Perinatal and Neonatal Death reported are reviewed

State the figure:

447. HF has a written SOP on audit implementation with systematic approach as well as criteria for near miss cases

1.Yes 0.No

448. Every maternal death, intrauterine death, neonatal death or near-miss case is audited within a month.

1.Yes 0.No

449. Death audit committee meets regularly (ie, monthly if a death or near-miss occurs) and meetings are attended by related professionals (ie, ob/gyns, pediatrician, anesthesiologist, general practitioners, midwives, and nurses).

1.Yes 0.No

450. HF has records of regular Maternal and Neonatal Death Audit and Near Miss Review Committee meetings during the last year.

1.Yes 0.No

451. HF has records of Maternal, Perinatal and Neonatal Death Audits and Near Miss Reviews with written conclusions, recommendations and action plan.

1.Yes 0.No

452. HF has records of Maternal and Neonatal Death Audit and Near Miss Review Committee recommendations were implemented and action plan completed.

1.Yes 0.No

Data collection and use at health facility What prevents this facility from using data for

decision-making

453. a) Nothing, we make good use of data 1.Yes 0.No 454. b) We don’t get data on priority interventions in

MNCH 1.Yes 0.No

455. c) The format is difficult to understand and use 1.Yes 0.No 456. d) Shortage of time 1.Yes 0.No 457. e) Low capacity and confidence in using data 1.Yes 0.No 458. f) No motivation to use data 459. g) No resources to take action 1.Yes 0.No 460. h) No support/interest from management 1.Yes 0.No

How does this facility make decisions Strongly Agree

(4)

Agree (3)

Neither Agree Nor

Disagree

(2)

Disagree (1)

Disagree

Strongly (0)

Don’t

know

(9) 461. Decisions-makers’ personal preferences 4 3 2 1 0 9 462. Superiors’ directives 4 3 2 1 0 9


37

How does this facility make decisions Strongly Agree

(4)

Agree (3)

Neither Agree Nor

Disagree

(2)

Disagree (1)

Disagree

Strongly (0)

Don’t

know

(9) 463. Evidence/facts 4 3 2 1 0 9 464. Political interference or community

pressure 4 3 2 1 0 9

465. Comparing data with strategic health objectives 4 3 2 1 0 9

466. Health needs 4 3 2 1 0 9 467. What funds/resources are available 4 3 2 1 0 9

To what extent do you agree or disagree with the following statement?

Question Strongly Agree

(4) Agree

(3)

Neither Agree Nor Disagree

(2) Disagree

(1)

Disagree Strongly

(0)

Don’t know

(9) 468. In this facility, the senior staff

use data/information for setting targets and monitoring MNCH services and outcomes

4 3 2 1 0 9

469. I completely trust my data for accuracy and quality 4 3 2 1 0 9

470. I use MNCH data to help make day-to-day decisions 4 3 2 1 0 9

471. Display data for monitoring MNCH targets is very important

4 3 2 1 0 9

472. Data can help find the root cause of problems 4 3 2 1 0 9

473. Are able to say ‘no’ to senior staff and colleagues for demands/decision not supported by evidence

4 3 2 1 0

9

474. Use MNCH data for community education and mobilization

4 3 2 1 0 9


38

To what extent do you agree or disagree with the following statements

Question Strongly Agree

(4) Agree

(3)

Neither Agree Nor

Disagree (2)

Disagree (1)

Disagree Strongly

(0)

Don’t know

(9) 475. Collecting information which is

not used for decision-making discourages me.

4 3 2 1 0 9

476. Collecting information makes me feel bored. 4 3 2 1 0 9

477. Collecting information is meaningful to me. 4 3 2 1 0 9

478. Collecting information gives me the feeling that data is needed for monitoring facility performance.

4 3 2 1 0 9

479. Numerator can be larger than the denominator 4 3 2 1 0 9

For each of the following activities, please indicate whether you could do it with no difficulty, you do it with a little help/support, you could do it but would need a lot of help/support, or you could not do it at all. Please be honest in your answers – we will not tell anyone what you have said, we just need to find out how many people need further training or support in the use of data.

PLEASE TICK ONE BOX FOR EACH ACTIVITY.

Staff at this health facility is competent to: With no difficulty

(3)

With a little help (2)

With a lot of help (1)

Not at all (0)

480. Check data accuracy. 3 2 1 0 481. Calculate percentages and rates correctly. 3 2 1 0 482. Plot data on graph by months or years. 3 2 1 0 483. Explain findings and their implications. 3 2 1 0 484. Use data for identifying gaps and setting

targets. 3 2 1 0

485. Use data for making various types of decisions and providing feedback. 3 2 1 0

486. The staff in this facility has regular opportunity to update skills in data analysis, problem solving and use.

3 2 1 0