UNFPAReproductive Health in Refugee Situations: An Interagency Field Manual
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Surveillance and Monitoring


Surveillance and monitoring are basic elements of programmes for both comprehensive reproductive health care (RH) and general health care. The person who coordinates RH activities should assure timely and appropriate inclusion of RH data and indicators in the general health-reporting system.

The Five Essential Components
of a Monitoring System

1. definition of essential data to collect, including case definitions (1);
2. systematic collection of data;
3. organisation and analysis of data
4. implementation of health interventions based on the data; and
5. re-evaluation of interventions


1) A case definition is "a set of standard criteria for deciding whether a person has a particular disease or health related condition". Criteria can be clinical, laboratory or epidemiological

Reproductive health in refugee situations
An inter-agency field manual





1. Fundamental Principles

2. Minimum Initial Service Package (MISP)

3. Safe Motherhood

4. Sexual and Gender-based violence

5. Sexually Transmitted Diseases, including HIV/AIDS

6. Family Planning

7. Other Reproductive Health concerns

8. Young People

9. Surveillance and Monitoring


a1. Information, Education, Communication

a2. Legal Considerations

a3. Glossary of Terms

a4. Reference Addresses


©1999 United Nations High Commissioner for Refugees

This document is issued for general distribution. All rights are reserved. Reproductions and translations are authorised, except for commercial purposes, provided the source is acknowledged.



The Aims of Monitoring are to:

  • identify high-risk groups

  • identify the most serious and/or the most prevalent conditions;and

  • monitor the trends of these conditions and the implementation and impact of intervention

System Framework

This chapter explains how to develop a system to collect and use essential RH data. The system starts when a refugee situation occurs and no existing services are present. It is described in chronological order and in order of priority. The scheme can be adapted and altered to respond to different situations.

Most RH surveillance should be integrated into the overall health-information system (HIS) During a refugee emergency, keep the HIS simple and limited to the most important causes of morbidity and mortality. Step 1 (of the eight-step approach described below) suggests the essential data relevant to reproductive health which staff should try to collect in the early phase. When more comprehensive services are available, other data can be incorporated (as described in subsequent steps).

Surveillance and monitoring of both health status and service delivery involve defining measureable programme objectives (what the programme will strive to achieve) and using indicators to measure progress toward achieving those objectives. An indicator is a measurement that, when compared to either a standard or the desired level of achievement, provides information regarding a health outcome or a management process. Indicators are measurements that can be repeated over time to track progress toward achievement of objectives.

In this Manual, we use a simple framework for objectives and indicators.

Impact objectives target changes in morbidity and mortality expected to result from programme activitiess.

Outcome objectives target changes in knowledge attitudes, behaviours, or in availability of needed services or commodities that result from programme activities. They relate directly to the priority intervention(e.g., HIV/STD prevention, child spacing), the target population (e.g., women of reproductive age), or those charged with caring for the target population (such as health care workers and family members.

Process objectives specify the actions needed for programme implementation, and correspond to various activities (such as training, supply of drugs and equipment and health education) necessary to achieve the intended outcomes and impact.

Note that this chapter presents mainly core impact and outcome activities. Managers can develop additional items for (especially process objectives) according to the populations, available resources, and working environments.

A selection of indicators is presented at the end of each chapter and the complete list of suggested indicators is presented at the end of this chapter. The RH Coordinator should select one or more indicators based on programme objectives. Before the indicator can be calculated, data will have to be collected for the numerator and denominator. Standard measures should be used when possible for comparison purposes, such as expressing some rates per 1,000 population. In some refugee settings, preliminary objectives may have to focus on setting up a system to collect information on births and neonatal deaths, for example, before the indicator neonatal mortality rate can be calculated. Once the neonatal mortality rate is calculated, this indicator can be followed monthly or for some specified time period, in order to monitor outcomes from the safe motherhood programme.

The following is an example of the evaluation framework:

Objectives 100% of community health workers trained to recognise and refer obstetric complications

100% of women with
obstetric emergencies are
referred in a timely manner and their complications managed appropriately

Maternal and neonatal mortality and morbidity reduced by ____%, in ____year
Indicators % of health workers able to recognise and refer obstetric complications % of women with obstetric emergencies who received appropriate management Reduction of neonatal mortality by ____%,
in ____year

An Eight-Step Approach to Surveillance and monitoring

1. Collect Basic Demographic Data

Collect the following RH-related data as soon as possible.

  • Total population by age and sex

  • Number of births

  • Crude birth rate

  • Age and sex specific mortality rates

  • Number of women/men of reproductive age

  • Number of pregnant women

  • Number of lactating women

In addition to using information provided by refugee workers, estimates might be made using registrations, or through community-based surveys (mortality, nutritional or household). Information from the country of origin of the refugees should also be obtained and used as estimates (For example, the Crude Birth Rate in the country of origin).

2. Define a System of Simple and Essential Data Collection

During programme design and implementation, programme planners should have established measurable objectives. Based on these objectives, determine which indicators will be used and what information is needed to calculate the indicators, and establish case definitions (such as those for live births and stillbirths) so that indicator measurements are clear. Next, determine the logical data flow, including time periods and reporting schedule. Identify people responsible for data collection, including refugees (see step 3 below). Finally, incorporate into the routine programme/camp health-information forms, the data needed to calculate the RH indicators. (See sample worksheet for RH reporting - Annex 6.)

Possible sources of data are:

  • Daily birth or delivery reports. At minimum, the reports must include age of the mother, place of delivery, mode of delivery (vaginal, caesaerean section), sex, birth outcome (live, stillbirth), and birth weight. If over- or under-reporting is suspected, cross check the information with the estimated number of pregnant women or with the agency responsible for distributing rations.
  • Clinic-based log books or registries for antenatal care, referrals, family planning, and STD syndromic case management as part of the out-patient log book. Women seeking care for the complications of unsafe or spontaneous abortion should also be tracked through clinic and hospital-based registration/log books.
  • Health facility records, community reporting, cemetery records and referral facilities records outside the refugee situation. These should be used to track maternal and neonatal deaths.

Other sources of data include community surveys, case investigations, laboratory reports and community outreach-worker reporting.

3. Identify,Organise and Train Workers from the refugee Community for Data Collection

Begin by identifying those refugees with midwifery skills and/or trained birth attendants (TBAs), including those already providing services, who can be trained to collect data. Otherwise, community members will have to be recruited. Organise these workers (by geographical sector, for example) and have them report to a key person and place. Organising them this way will help gain access to and knowledge about the pregnant and lactating women in the population and provide a communication system to help refer women with serious complications related to pregnancy, delivery, the post-partum period or spontaneous or unsafe abortion. Conduct training on the objectives and flow of data collection, case definitions, completion and timely submission of collection forms, and on the use of the data to improve programmes.

4. Implement Specific Reporting Procedures

Experience has shown that several specific areas of RH monitoring and surveillance have not been routinely conducted in refugee situations. These include investigations of each maternal death and reporting on cases of sexual violence.

Investigating Maternal Mortality
Investigating the cause of maternal deaths can help identify gaps in services and the need to improve referral procedures for obstetric complications. By reviewing cases, health care providers can strengthen their skills in identifying early warning signs of obstetric emergencies. Camp staff should investigate deaths due to pregnancy (direct maternal mortality) and deaths of pregnant women caused by the effects of pregnancy on pre-existing conditions (indirect maternal mortality).

Both types of information are essential, since direct mortality is often underestimated. The goal is to determine which deaths were caused by pregnancy or childbirth, or by complications or the management thereof, and how deaths can be prevented in the future.

Points to be investigated include:

  • time of onset of life-threatening illness;
  • time of recognition of the problem and time of death;
  • timeliness of actions;
  • access to care, or logistics of referral; and
  • quality of medical care until death.

The information may come from grave watcher, hospital/health post staff or from community reports. Verbal autopsy, which has been used in certain refugee situations, has proved relatively successful when medical records are unavailable.

Reporting Rape/Sexual Violence
The person responsible for addressing sexual violence can devise an appropriate tracking system, in collaboration with camp authorities and health care workers. Survivors of sexual violence may be seen in health facilities or or reported by TBAs, community workers or other key informants. Since sexual violence is sensitive and usually under-reported, note all reported cases or suspected cases. Confidentiality of survivors must be ensured.

5. Analyse the Data

Analyse the data to address the problems raised by the programme objectives.

  • Calculate rates, ratios and proportions, and prepare tables, graphs and charts.
  • Compare these rates with expected values or reference rates. Trends are more important than point estimates.
  • Prioritise the most important health problems as judged by cause-specific morbidity and mortality.
  • Identify the subgroups at highest risk for health problems by person, place and time (such as by age and sex).
  • Identify the factors potentially responsible for morbidity and mortality. For example, a high number of reported cases of genital ulcer disease among adolescent women could indicate a need to target them forsyphilis prevention and treatment.
  • Share data analysis with service providers and the community.

6. Implement Programmes Based on the Analysis

  • Use the data to develop feasible, effective and efficient strategies for achieving the programme objectives.
  • Implement the selected strategies and a system to monitor their progress.

7. Assess Programme Progress

Assess programme progress by confirming whether programme objectives have been met.

Prepare and distribute summary reports to all interested persons, agencies and host-country authorities, as indicated.

Reassess programme objectives, indicators and interventions. Indicators can be evaluated in terms of their accuracy, completeness, relevance and timeliness.

8. Improve Assessment Capability and Surveillance Systems According to Need

As disease incidences change, the situation stabilises and service provision becomes more comprehensive, the surveillance system may need to be adapted. The system may need to be expanded to include more conditions in the list of reportable illnesses. Programmes can add or change indicators, or they can add sources and methods of data collection.

List of Annexes

Annex 1 RH Indicators for Early Phase

Annex 2 RH Indicators in Stabilised Phase, part 2, part 3, part 4, part 5, part 6, part 7, part 8, part 9

Annex 3 RH Reference Rates and Ratios

Annex 4 Reference Rates and Ratios for RH Indicators

Annex 5 Estimating Number of Pregnant Women in a Population

Annex 6 Worksheet for Monthly RH Reporting, part 2, part 3

Annex 7 Summary of RH Indicators

Further Readings

Berg, C., I. Daniel, and D. Mora. “Guidelines for Maternal Mortality Epidemiological Surveillance”, Pan American Health Organization, Washington, DC, 1996.

Bryce, J. and J.B. Roungou, P. Nguyen-Dinh, J.F. Naimoli, and J.G. Breman. “Evaluation of National Malaria Control Programmes in Africa”, Bulletin of the World Health Organiza-tion, Vol. 72, Geneva, 1994.

Gosling, Louisa and Mike Edwards. “A Practi-cal Guide to Assessment, Monitoring, Review and Evaluation”, Development Manual 5, Save the Children Fund, London.

“Guidelines for Evaluating Surveillance Systems”, Morbidity and Mortality Weekly Report, Vol. 37, Centers for Disease Control and Prevention, Atlanta, GA, 1995.

“Guidelines for Monitoring Availability and Use of Obstetric Services”, UNICEF/UNFPA/WHO.

Hakewill, P.A. and A. Moren. “Monitoring and Evaluation of Relief Programmes”, Tropical
Doctor, 1991.

Hausman, Benson and Koert Ritmeijer. “Surveillance in Emergency Situations”, MSF Medical Department, Amsterdam, 1993.

Last, J.M. A Dictionary of Epidemiology, Oxford University Press, New York, 1883.

“Mother-baby Package”, WHO, Geneva, 1994.

“Primary Health Care Management Advancement Programme” (modules include Assess-ing Information Needs, Assessing Health Worker Activities, Morbidity and Mortality Sur-veillance, Monitoring and Evaluating, Assessing Service Quality, Management Quality, Cost Analysis and Other Relevant Topics; includes managers’ guides and computer programmes), Aga Khan Foundation, USA, 1993.

“Safe Motherhood Needs Assessment Part VI: Maternal Death Review Guidelines”, WHO, Field-test Draft, Geneva, 1997.

Teutsch, Steven M. and R. Elliott Churchill. Principles and Practice of Public Health Surveillance, Oxford University Press, New York.

Toole, M.J. and R.M. Malikki. “Famine Affected, Refugee and Displaced Populations:
Recommendations for Public Health Issues”, Morbidity and Mortality Weekly Report,
Vol. 41, 1992.

Toole, M.J. and R.J. Waldman. “Prevention of Excess Mortality in Refugee and Displaced Populations in Developed Countries”, Journal
of the American Medical Association, 1990.


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