Indicator 1a: Progress toward long-term goal for EmONC availability

Ensuring that there is an adequate number of health facilities that perform EmONC is the foundation on which high-quality effective maternal and neonatal mortality programs are built. An adequate quantity of EmONC facilities is the number that is needed, based on a country’s context, to serve all pregnant and birthing women and newborns. This is the long-term aspirational goal that countries can work toward. Although country policies/strategic visions may already reflect this aspirational goal, it is not always clear what is needed to actualize it, or how far a country is from doing so. This indicator is designed to help planners understand how close they are to having enough EmONC facilities to accommodate all women giving birth and newborns born small and sick.

The numerator is the number of facilities performing the complete set of EmONC signal functions. This should include all BEmONC, CEmONC, and IEmONC facilities. The denominator is the number of EmONC facilities that are recommended for the long-term goal, which can be produced using the Long-term EmONC Calculator. (Please refer to Instructions for using the Long-Term EmONC Calculator for more details.)

The indicator is typically expressed as a percentage.

A similar exercise focused only on BEmONC facilities, and then only on CEmONC facilities, will determine what percentage of the long-term number of Basic and Comprehensive EmONC facilities are available. The Calculator does not produce a recommended number of Intensive EmONC facilities, so when assessing the availability of CEmONC facilities, both CEmONC and IEmONC facilities should be included in the numerator (as IEmONC facilities are also able to perform all of the CEmONC signal functions). If a country has set its own long-term goal for how many intensive care units are needed, then the availability of IEmONC facilities can also be assessed separately (in addition to being counted as CEmONC facilities) against that goal. UN recommendations for how many IEmONC facilities are needed have not yet been developed.

If the number of facilities classified as EmONC falls short of the long-term goal (i.e., less than 100%), the next step is to plan a phased implementation strategy or roadmap to reach the goal. This will include designating facilities for EmONC strengthening in 3–5-year program cycles to ensure sustained functionality, equitable coverage, and incorporating other development sectors in the planning process (e.g., finance, roads, education). (See Step by step implementation.)

As part of the planning process, it is useful to disaggregate the indicator by sub-national area. It may also be useful to disaggregate the numerator (number of facilities performing EmONC) by facility managing authority and level of facility to reveal patterns and to flag problems. Disaggregation by managing authority to determine the distribution of public and private facilities performing EmONC can be particularly revealing. For example, if the analysis shows that a low-income sub-national area only has private facilities providing EmONC services for a fee and there is no government facility in that area providing free EmONC services, interventions to rectify this problem are needed and should be prioritized in short-term plans.

It may be helpful to separately calculate the indicator including facilities that are only missing one or two signal functions (BEmONC -1,-2 and CEmONC -1,-2) in the numerator, as this will provide a more complete picture of the care that is already available and to help prioritize where to efficiently invest in ensuring the sustained performance of all EmONC signal functions.

If country planners find that they have already reached their long-term goal in terms of number of EmONC facilities, then planners can focus on sustaining the quality of care, ensuring 24h/7d readiness, adequacy and wellbeing of the workforce and closely monitor the clinical appropriateness of care.