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A New Set of Composite Indicators for Integrated Service Delivery

Globally, there are not any widely agreed-upon composite indicators of integrated FP/MNCH/N (family planning; maternal, newborn, and child health; and nutrition) service provision. A lack of indicators hinders the ability of programs and Ministries of Health to measure integrated service delivery and impact. The INSPiRE project is introducing integrated performance indicators into policy and practice in francophone West Africa.

Most health practitioners can list indicators related to family planning, maternal health, child health, or nutrition. However, these indicators are usually listed individually and thought of as separate services. Yet, if we are to achieve universal health coverage (UHC), health systems need to provide people-centered, integrated primary health care. As a component of this, the principle of “no missed opportunities” needs to be capitalized on in thinking about how to provide clients with all relevant and needed services each time they visit a health facility.

This principle of integrated service delivery is particularly important in locations with a high disease burden and limited health workforce. This is the situation in West Africa where women face a 1 in 34 lifetime risk of maternal death; 34 of every 1,000 infants do not survive their first 28 days of life; and 24% of West African women have an unmet need for family planning –a rate that increases to almost 60% in the postpartum period. Exacerbating risks for maternal and infant mortality and unmet need for contraception, there are not sufficient health workers available to provide services for West African countries to achieve UHC or meet their Sustainable Development Goals.

By offering integrated family planning (FP); maternal, newborn, and child health (MNCH); and nutrition (N) services, clients have more opportunities to be offered a suite of needed health services and health workers can provide multiple services at one touch point.

How does service delivery integration work?

INSPiRE, IntraHealth International’s integrated FP/MNCH/N project, developed their integration model in close collaboration with national program leaders, technical experts from Ouagadougou Partnership countries, and INSPiRE partners Hellen Keller International and PATH.

Under the INSPiRE model, FP/MNCH/N services are offered as a combined package at five entry points of the health system (Figure 1). Services provided in this manner are more convenient and client-centered, saving women time and money while also increasing program efficiency and effectiveness. However, when developing the model to provide these services, we realized there was not a composite set of indicators providers can use to measure provision of integrated service delivery.

MNCH infographic

Development of composite indicators

To address this gap, the ministries of health of Burkina Faso, Cote d’Ivoire, and Niger formed inclusive technical working groups (TWGs) to develop a set of composite indicators of integrated FP/MNCH/N service provision. First, the TWGs identified services to be integrated at the facility and community level in accordance with local policy, standards, and protocols. Through iterative and consensus-driven discussion, the TWGs finalized the composite indicators of FP/MNCH/N service delivery.

The composite indicators combine several variables to measure provision of services at each of the five entry points of care in the INSPiRE model. The composite indicators show a continuum of care and provide important metrics for health professionals.

Example indicators include:

  • % of women seen for postnatal care who adopted a modern contraceptive method and whose infant aged 0-6 months is being exclusively breastfed.
  • Number of home visits by community-based health workers that covered FP, N, and vaccination.

Sustainability

Each country team ensured the composite indicators chosen were already included in country health data management systems and adapted existing data tools to include the new composite indicators. This not only eliminated a need to train providers on a new system, but also ensured rapid adoption and use of data collected. The revised data collection tools also serve as a daily reminder to providers to offer integrated services.

As data collection and reporting on the new indicators continues, providers can see constant improvements in FP/MNCH/N service delivery. Not only is this an incredible benefit for women and children in West Africa, the data are also compelling to policy makers as evidence to support FP/MNCH/N service integration. In the first year of implementation of the model ANC visits increased 188% at sites in Niger and visits for healthy infant/growth monitoring increased 300% at sites in Burkina Faso, Cote d’Ivoire, and Niger.

These results show both the importance of integrated service delivery and the need for continued monitoring to assess progress and to sustain implementation of these efforts. The participatory and country-led process of developing the indicators helped enhance service provider understanding and adherence, and rapid uptake in country health information systems. Over the next three years, the project will further refine the indicators and expand their adoption and use throughout West Africa. Read more here about the development and use of the composite indicators. Any additional inquiries about the integration indicators or the INSPiRE project can be directed to Marguerite Ndour, Project Director, at mandour@intrahealth.org.

Many thanks to Amadou Domboe and Marguerite Ndour for writing the first draft of the brief in French.

IntraHealth International website, LinkedIn, Twitter, and Facebook page.

MNCH infographic
Dr. Roy Jacobstein

Global Technical Lead for Family Planning, IntraHealth International

Dr. Roy Jacobstein is IntraHealth International’s Global Technical Lead for Family Planning. A public health physician who has worked on FP/RH in low-resource settings for over three decades, Dr. Jacobstein has served as an expert technical advisor for the development and updating of WHO’s Medical Eligibility Criteria for Contraceptive Use and Family Planning: A Global Handbook for Providers and as an international reviewer of its guidance subsequent to the ECHO Trial. Among his many peer-reviewed papers are those advocating vasectomy and documenting recent increases in implant use in Africa. Before joining IntraHealth, Dr, Jacobstein served for 12 years as Medical Director of EngenderHealth and 13 years as Chief of the Communication, Management, and Training Division in USAID’s Office of Population and Reproductive Health. He is also an Adjunct Professor of Maternal and Child Health in the University of North Carolina’s Gillings School of Public Health.

Dr. Marguerite Ndour

Director, Integrated Client Centered RMNCAH/N Care in West Africa (INSPiRE), IntraHealth International

Dr. Ndour is a public health professional with more than twenty-three years of experience leading health promotion projects and programs. Prior to joining IntraHealth International, she was the Sayana Press Program Country lead at PATH/Senegal where she provided technical support to the pilot introduction, research and scale up of the new generation of injectables. Before joining PATH, she worked as Head of the Reproductive Health Department at Population Services International/Benin for nine years and was the Advisor on Reproductive Health. In this capacity, she led the development and the implementation of Integrated RH/FP and MNCH programs funded by USAID and other donors. In addition, she has worked for four years as Benin Country Lead to the Canadian International Development Agency (CIDA) West African AIDS Project - Research and intervention. Through her years of public health leadership experience, Dr. Ndour has demonstrated a commitment to Reproductive Health, Family Planning and MNCH and likewise has gained considerable organizational development, management, team-building and program evaluation experience. Dr. Ndour has a doctorate in medicine from Dakar’s Universite Cheikh Anta Diop, a master’s degree in biomedical sciences & Public Health and a certificate of epidemiology from the Institute of Tropical Medicine in Belgium.

Sujata Bijou

Senior Measurement and Learning Technical Advisor, IntraHealth International

Sujata Bijou has spent over fifteen years in international program design, monitoring, quality improvement, evaluation, and field research. Sujata currently works as a Senior Measurement and Learning Technical Advisor at IntraHealth International supporting the projects in West Africa. Sujata is skilled at collaborating with and providing technical assistance to international agencies, ministries of health, NGOs, and local organizations. She has strong analytical and communication skills including four foreign languages (French, Gujarati, Haitian Creole, and Malagasy) and significant computer packages (SPSS, Stata, Access, and HTML).

Amadou Domboe, MPH

Regional Monitoring-Evaluation and Learning Expert, IntraHealth International

Mr. Domboe holds a master’s degree in Sociology with a major in Health Anthropology and a master’s degree in Epidemiology. In addition, he holds a Professional Master's degree in Public Health, Population and Health Orientation and a Professional Bachelor's degree in Health Statistics. With more than fifteen years of professional experience in public administration and NGOs, he has been involved in the management, monitoring and evaluation of development programs in general and in the field of health in particular. In addition, he has extensive experience in public health research, including operations research focusing on women, youth, sexual and reproductive health (SRH). In the past, he has held the positions of Director of Statistics at the Ministry of Social Action and National Solidarity in Burkina Faso, Monitoring-Evaluation and Database Coordinator at the Malaria Consortium in Burkina Faso, Monitoring-Evaluation Program Officer at Pathfinder International in Burkina Faso, and is currently the Regional Monitoring-Evaluation and Learning Expert for the Regional Hub Project in Francophone West Africa for Postpartum Family Planning, Nutrition and Essential Newborn Care at IntraHealth International.

Katelyn Bryant-Comstock

Senior Knowledge Management Specialist, IntraHealth International

Katelyn Bryant-Comstock has over ten years of experience in domestic and global public health. She is currently the Senior Knowledge Management Specialist at IntraHealth International supporting project and organization knowledge management goals. Prior to joining IntraHealth, she helped launch a new Center for Global Reproductive Health at the Duke Global Health Institute. She specializes in sexual reproductive health and rights and research utilization. She received her master’s degree from the University of North Carolina’s Gillings School of Global Public Health with a concentration in Maternal and Child Health.

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