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BackgroundMCHIP is USAID’s flagship global program for scaling up evidence-based interventions to helpcountries achieve the desired reductions in newborn and maternal mortality outlined inMillennium Development Goals (MDGs) 4 and 5. Since 2008, MCHIP has worked with Ministriesof Health and others in over 40 low-income countries to improve the quality and coverage of newand long-proven, evidence-based maternal, newborn, and child health (MNCH) interventions. Anintegral part of improving intervention coverage and quality is being able to accurately measurethe intervention of interest. To this end, MCHIP has worked to improve measurement of MNCHinterventions and services, and engaged key partners at the global, national, and sub-nationallevels to work to improve indicators and data collection tools used in population-based surveys,health facility surveys, and national HMIS. This paper focuses on the work MCHIP has supportedto improve MNCH-related elements of the routine national HMIS in multiple countries.The MDGs and the 2005 Paris Declaration on Aid Effectiveness focused attention on globalhealth targets and require reporting on progress towards targets. These initiatives have led to agrowing global emphasis on measurement and accountability in health, including what is beingmeasured, how it is being measured, the quality of those data, and how they are being sharedand used. The Countdown to 2015 and UN Commission on Information and Accountability forWomen’s and Children’s Health were established to address the need for changes in the scaleand scope of MNCH strategies to reach MDGs 4 and 5, to track progress, and to hold countriesaccountable for the progress or lack of progress they are making toward meeting national-levelcommitments. The Call to Action for Child Survival – A Promise Renewed focuses on threepriority aims, one of which is to promote transparency and accountability of governments, civilsociety, and private sector partners through tracking and reporting on child survival strategies.Taken together, these initiatives highlight the priority and urgency that should be given tostrengthening routine HMIS. Furthermore, as technical approaches to MNCH evolve,concurrent advances are required to adequately and accurately monitor health outcomes andthe impact these advances are having in saving women’s and children’s lives.The organizing framework for this paper is that put forward bythe Health Metrics Network (HMN) (see Figure 1). HMN,launched at the World Health Assembly in May 2005, wasestablished to help countries and partners work together toimprove health information and monitoring systems and supportevidence-based decision-making. The Secretariat of the HealthMetrics Network is hosted by the World Health Organization(WHO), and members include ministries of health and nationalstatistics offices, multilateral agencies, global healthpartnerships, bilateral donors, and technical experts. HMNmembers developed the framework with the intention that itserve as “the universally accepted standard for guiding thecollection, reporting and use of health information by alldeveloping countries and global agencies” and therefore it is themost appropriate framework to shape this paper.To gather information on MCHIP’s experience working toimprove MNCH elements of national HMIS, MCHIPconducted a short survey of program staff using surveymonkey and including coded and open-ended questions aboutthe scope of country-led HMIS interventions, how theintervention was implemented and the results achieved.2Figure 1. The HMN FrameworkComponents and Standards of aHealth Information SystemHIS ResourcesIndicatorsData SourcesData ManagementInformation ProductsDissemination andUseStrengthening Health Management Information Systems for Maternal and Child Health

MCHIP’s monitoring and evaluation (M&E) team also conducted follow-up interviews withprogram staff and stakeholders in six countries—Democratic Republic of Congo, India, Nigeria,Mali, Mozambique, and Rwanda. This information was supplemented with information fromMCHIP’s Annual and Quarterly Reports.Strengthening Health Management Information Systems for Maternal and Child Health3

HMIS StrengtheningFollowing the six components of the health information system as shown in the HMNFramework (Figure 1), below we provide examples of the types and breadth of support MCHIPhas provided across 28 countries to strengthen HMIS. Financial, human, and materialresources are the foundational inputs required for a strong and functional HMIS. Indicators,data sources, and data management are the processes leading to outputs such as informationproducts and dissemination and use of data (see Figure 2).Figure 2. Logic model for components of HMISInputs HMIS ResourcesProcess Indicators Data Sources Data ManagementOutputs Information Products Dissemination andUseHMIS RESOURCESStrong HMIS systems require a constant flow of resources—human, financial, and material—toestablish and maintain effective and efficient services. HMN’s Framework describes theseresources as ranging from legal and regulatory frameworks, leadership and coordination,financial and human resources, and logistical support to information and communicationstechnology (ICT). HMIS are often inadequately resourced and financed at national andsubnational levels in the countries where MCHIP works. Furthermore, when HMIS units arelocated outside of ministries of health, coordination can be cumbersome. To address this need,MCHIP has supported HMIS resources in numerous ways. Specifically, MCHIP hasparticipated in five international task forces and five national-level working groups that haveadvanced the measurement of maternal and child health intervention coverage. Moreover,MCHIP has invested in strengthening national-level MNCH M&E in six countries throughleadership, support for human resources, and financial support.At the global level, MCHIP spearheads technical initiatives, captures important lessons fromthe diverse settings and technical areas within which the project works, and makes themavailable to the global health community through various fora including technical workinggroups (TWGs) and task forces. Through the global Integrated Community Case Management ofChildhood Illness Task Force, the Interagency FP/HIV Integration Working Group, theNewborn Health Indicators Technical Working Group, the Child Health EpidemiologyReference Group, and the CORE Group, MCHIP has contributed to advancing state of the artmeasurement including indicator development, M&E guides or tools, and other related efforts.For example, MCHIP has contributed to global HMIS resources and child health monitoringthrough its role on the Integrated Community Case Management of Childhood Illness (iCCM)Task Force, which is composed of USAID, MCHIP, UNICEF, WHO, and Save the Children. Anaspect of the Task Force has been the development of CCMCentral.com, which is a globalcenter for resources that aims to provide examples of best practices and share tools related toiCCM. MCHIP has been integral in the development of suggested indicators for monitoringimplementation of iCCM programs that are included on the website. The site also includes anillustrative results framework supported by a list of benchmarks (standards) across all programcomponents including coordination and policy, costing and financing, human resources, supplychain management, service delivery, communication, supervision, and quality improvement andM&E. Each benchmark has an associated set of global and country-level core indicatorssuggested for monitoring iCCM, with related definitions, indicator type, data source, andfrequency of data collection. Democratic Republic of Congo, Madagascar, and Senegal haveuploaded monthly and quarterly M&E reporting form templates to the website in addition to4Strengthening Health Management Information Systems for Maternal and Child Health

other resources for countries to use. The indicators will serve as guidance to countriesimplementing CCM programs. See indicators and other resources at www.CCMcentral.com.As part of MCHIPs efforts to reduce maternal and newborn mortality in Africa, includingGuinea, Liberia, Rwanda, South Sudan, and Zimbabwe, country teams support maternal healthor safe motherhood working groups and task forces in these countries. For example, as part ofthe prevention of postpartum hemorrhage intervention in five countries, the MCHIP team hasbeen involved in working with the Technical Advisory Groups (TAG) consisting of membersfrom ministries of health and various technical partners. The TAG, supported by MCHIP,provides regular updates on the implementation of the intervention, including training, M&E ofcoverage of the intervention, supervision, and challenges.At national and state government levels, MCHIP has worked to strengthen HMIS coordinationand leadership through active participation in national M&E technical working groups andsupport to ministries of health to develop national HMIS guidelines. In Rwanda, MCHIPprovided inputs into the National Routine Data Quality Assessment Guidelines. Similarly, inMozambique, project staff contributed to preparation of data management guidelines (Directrizespara Avaliação Rotineira da Qualidade dos Dados). In addition to providing information explicitlyon the quality of data, the guidelines facilitate assessment of M&E capacity, training needs,indicator definitions, the data collection and managment process, and links with national system.Implementation of national guidelines helps to ensure that data standards are harmonized acrossprograms and that gaps are identified and monitored over time.Support for human and financial resources through the secondment of staff or financial support forstaff in countries is another mechanism of MCHIP’s support. At national level, in Kenya, MCHIPsupported M&E staff at the Division of Reproductive Health to develop a national M&E plan. InSouth Sudan, MCHIP supports an M&E Advisor who works at the national HIV/AIDS department.At the district level in Rwanda, MCHIP supported data managers at district hospitals offices tosupport the process of data collection, management, and reporting. MCHIP Rwanda providedfinancial support for computers, printers, and modems for district-level M&E staff. In both Indiaand Northern Nigeria, MCHIP supported ministries to print and distribute maternal healthregisters. In the absence of national registers and forms, providers there rely on handwrittenledgers and often do not report to the HMIS on a routine basis, leading to under reporting.Heightened global attention to MNCH measurement and accountability requires stronger andsignificant inputs into health management information system. National guidelines signal thatgovernments support and value high-quality data and seek to foster strong HMIS. WHO, amongother international agencies, recommends that M&E account for 10% of a program budget. Asprograms expand, it is critical to ensure that guidelines provide a foundation for and adequatehuman, financial, and material resources support to HMIS as a key component of healthprograms. Seconding staff, printing registers, and purchasing equipment provide an immediatebut not long-term solution to critical financial shortages for HMIS. For sustainable solutions,MCHIP country teams must continue to advocate with host countries for national HMISguidelines and the dedication of additional resources for HMIS.INDICATORSA core set of indicators that draw on those that are globally recommended and standardized andthat are relevant and useful for decision-makers at each level of the health systems are a vitalcomponent of HMIS. Indicators produced by national HMIS include production and utilizationof services, tracking of commodity and stock-out data, morbidity and mortality, and in somecases content and quality of care, which can be used for planning and management. Core healthindicators and related data collection strategies must be linked to a broader national statisticsstrategy and reviewed frequently. To improve routine availability of data on content and qualityStrengthening Health Management Information Systems for Maternal and Child Health5

of MNCH care, MCHIP has provided global and country-level leadership to formulate, test, andintegrate indicators on content and quality of maternal and child health care and has worked tointegrate these indicators into national HMIS.MCHIP was instrumental in forming, supporting, and co-leading a working group, incollaboration with WHO, to advance and achieve the WHO recommendation for a key routineHMIS indicator to capture provision of care to prevent postpartum hemorrhage (PPH)—administration of a uterotonic in the third stage of labor. Given the response of countries toWHO recommendations, this was a critical step toward mainstreaming monitoring of PPHprevention efforts in a standardized way. Currently, the project is collaborating with ministriesof health to incorporate the new WHO indicator: Prophylactic Uterotonic Coverage Indicator: thenumber of women receiving prophylactic uterotonics during the third stage of labour divided byall women giving birth into their routine HMIS systems. MCHIP has also worked closely withemergency obstetric and neonatal care (EmONC) clinical trainers to orient providers on M&Efor labor and delivery (L&D), including PPH prevention, in clinical training activities.Helping Babies Breathe (HBB) is an international Global Development Alliance thatincludes the Laerdal Foundation, American Academy of Pediatrics, USAID, MCHIP, and Savethe Children. HBB emphasizes skilled attendance at birth, assessment of every newborn,thermal care, temperature support, stimulation to breathe, and assisted ventilation as needed,all within "The Golden Minute" after birth. MCHIP worked with the Alliance to develop theM&E section of the global HBB Implementation Guide including a list of recommended outputand outcome indicators, one of which is number and percent of babies not breathing at birth whowere resuscitated successfully.MCHIP is supporting scale-up of the HBB approach in 28 countries, and as a part of thisinitiative is working to incorporate related output and outcome indicators into routine HMISsystems. To date, in Bangladesh, Malawi, Zambia, Zimbabwe, Colombia, and the DominicanRepublic, MCHIP is working with in-country partners to include resuscitation indicators intheir routine HMIS systems. Malawi has piloted a collection of the recommended indicatorsthrough a supplemental data register in the L&D ward. A similar activity in India, calledNSSK, is being scaled up nationally with MCHIP support, including support for M&E. MCHIPwill continue to support integrating these indicators as HBB is scaled up and out.The Every Newborn Action Plan focuses on ensuring accountability for commitments to endpreventable newborn deaths. A key aspect of this work is defining a core set of indicators andbenchmarks for service delivery to strengthen newborn health information. MCHIP is activelyengaged in the Newborn Indicators Interagency Technical Working Group, which developedguidance on routine newborn care indicators. MCHIP also contributed to the measurementsection of the Every Newborn Action Plan. These inputs have been shared with UNICEF forincorporation into the Plan.As new programs, such as cervical cancer prevention and screening, are created andinstitutionalized, MCHIP works closely with national partners to ensure that systems are inplace to capture and report activities. For example, in collaboration with the MozambicanMinistry of Health, MCHIP tested and integrated indicators into the national HMIS followingpilot-tests of new registers and data sources. New indicators included the number of first visualinspection with acetic acid (VIA) visits, number of subsequent VIA visits, and number of womentreated with cryotherapy. To improve measurement of the content of newborn care, inMozambique MCHIP aided the Ministry to pilot a new routine indicator on newborn skin-toskin contact with the mother; this indicator is now included in the national HMIS (see CaseStudy 4 for more information).6Strengthening Health Management Information Systems for Maternal and Child Health

In other countries, MCHIP has worked with national and subnational partners to revise andupdate indicators. For example, in the Zamfara and Katsina States of Nigeria, a review of thefacility-based record keeping and reporting system for maternal and newborn health revealedthat the system was inadequate to capture and report many essential indicators including thoseneeded to measure attainment of MDGs 4 and 5. The National HMIS unit retained more than90% of the indicators MCHIP and partners suggested in the national HMIS system that will berolled out in the country soon.Scaling up high-impact interventions without adequate measurement limits the extent ofinformation that national governments have regarding the adequacy of the content and qualityof MNCH outcomes. MCHIP’s role in summarizing global experiences and advocacy for bestpractices has led to consensus on and promotion of indicators to monitor evidence-based MNCHinterventions.DATA SOURCESThe Health Metrics Network framework delineates two overarching categories of healthinformation data sources: population-based sources (such as, censuses, civil registration, andhousehold surveys) and institution-based routine data sources for exampl

Strengthening Health Management Information Systems for Maternal and Child Health 1 Introduction Accurate and timely information on health intervention coverage, quality, and equity is the foundation of public health practice. Good measurement facilitates increased accountability of