Indicator 3: Equipment, drugs & supplies

For health facilities to provide good-quality EmONC, they must be equipped every day with required drugs, supplies and functioning equipment (i.e., commodities) without stockouts. Unfortunately, the health systems in many low- and middle-income countries face persistent problems with their supply and maintenance systems making key drugs, supplies and functioning equipment unavailable. This can lead to health providers being forced to work in sub-optimal conditions, either denying women and newborns life-saving care or providing care that is inconsistent with evidence-based protocols and may therefore be unsafe. Dysfunctional drug supply systems that lead to stockouts of drugs and supplies can also lead to huge out-of-pocket expenses for women and their families who are forced to go outside of health facilities to purchase required items. And, when equipment is broken or unavailable, health providers must sometimes refer women and newborns to other facilities, causing critical delays in their receipt of treatment.

This indicator is built around a set of key commodities that are needed to perform the EmONC signal functions (Table 1).

A stockout is defined as: the absence of the drug, supply or other health product everywhere in the facility for at least one day in the past month.¹⁰¹¹ That means the item is not available in the pharmacy, medical storeroom or in any relevant unit/ward/department in the facility. The item must be absent from all of these locations for the facility to be considered to have a stockout. The total number of tracer items that a facility would aim to have would be determined by the expected EmONC level of the facility (Basic, Comprehensive, or Intensive).

The numerator for this indicator is the number of facilities that have all tracer commodities (i.e., no stockouts).

The denominator for this indicator is the total number of facilities that are being assessed.

This indicator is typically expressed as a percentage.

To monitor whether facilities have consistent supplies of tracer items, the list of commodities should be monitored by facilities on a monthly basis using the tool, Recording availability of tracer commodities for EmONC. The indicator should be calculated by sub-national and/or national planners every three to six months based on the results recorded in the tool. If the facility had all tracer commodities for the three or six month period, they are counted in the numerator for this indicator.

Key commodities needed for the delivery of good-quality EmONC must be available every day of every month in all facilities. Therefore, the benchmark is 100%.

If a country or sub-national area has less than 100%, it means that there are problems with drug and supply or maintenance systems and further investigation is required. Disaggregation by geographical area, level of facility, EmONC classification, and/or managing authority may uncover systemic problems.

The availability of individual commodities can also be analyzed alongside other data collected as part of the EmONC Framework, such as the performance of specific EmONC signal functions, cause specific case fatality rates, and workforce wellbeing, to examine what effect missing commodities may be having on patients and providers.

At the facility level, the data collected for this indicator can be visualized as a dashboard (Figure 1). This type of data presentation allows planners to track the duration of stockouts or to see how long pieces of equipment have been broken/missing.

Note that the tracer items being monitored with this indicator are not an exhaustive list of critical items that are required to perform EmONC with good-quality. It is still recommended that facility assessments (e.g., EmONC assessment, HHFA, SPA) with full commodities lists be conducted periodically.

All required drugs and supplies are in the locations where they are needed (e.g., emergency medications in delivery room)

Indicator 3 asks whether needed drugs are in the facility but it does not look at whether key drugs are in specific locations where they are needed. Therefore, periodic assessments of key units (e.g., the maternity unit, operating theater, SNCU) can be conducted to determine whether key drugs are easily accessible (e.g., not locked in a cabinet) and properly stored where they are needed.

Assess quality of commodities

Even when facilities have key tracer commodities, their quality may sometimes be questionable due to poor-quality manufacturing (health system problem), their degradation in the supply chain (health system problem) and/or their storage at the point of distribution (health system and health facility problem). One specific drug that demands particular attention is oxytocin which requires being transported and stored at 2-8° Celsius. When it is not stored or transported under appropriate conditions, it rapidly degrades and can become ineffective.¹²¹³ Various studies have shown the extent to which ineffective oxytocin is present within the health system.¹⁴¹⁵¹⁶ For this reason, national and sub-national managers may want to periodically assess cold chain procedures, from source to point of distribution, ensuring that oxytocin is always stored at the correct temperature. Studies such as these can also be analyzed alongside Indicator 2 in this set (“basic infrastructure”) which looks at the availability of electricity in key locations in health facilities.

Out-of-pocket expenses for EmONC-related tracer commodities

EmONC-related commodities are needed without delay but sometimes facilities require women and their families to pay before they can be used. This can potentially cause delays in providing EmONC. To capture this problem, women and their families can be interviewed about their out-of-pocket expenses for EmONC services. In some situations, when commodities are not available at facilities, health providers must pay for emergency medications for use in their work and then require patients to reimburse them when these medications are needed. When this is the situation, health providers can be interviewed to understand the nature of the problem as well as how to minimize families’ and health providers’ out-of-pocket expenditures.

• WHO, UNFPA, UNICEF. Managing complications in pregnancy and childbirth: a guide for midwives and doctors – 2nd ed. Geneva: World Health Organization; 2017. Licence: CC BY-NC-SA 3.0 IGO.
• WHO. Background document for the Technical Convening on Prioritizing
  WHO-recommended Maternal and Newborn Health Commodities” - 26
  October 2023.
• WHO Model Lists of Essential Medicines.
• WHO list of priority medical devices (MeDevIS).
• UNICEF Creating sustainable supply chains.
• WHO/UNICEF/UNFPA Joint Statement: Appropriate storage and management of oxytocin – a key commodity for maternal health.
• AMDD EmONC assessment tool.
• WHO Harmonized Health Facility Assessment (HHFA).
• Demographic and Health Surveys Service Provision Assessment (SPA).
• Stierman EK, Ahmed S, Shiferaw S, Zimmerman LA, Creanga AA. Measuring facility readiness to provide childbirth care: a comparison of indices using data from a health facility survey in Ethiopia. BMJ Glob Health. 2021 Oct;6(10):e006698. doi: 10.1136/bmjgh-2021-006698. PMID: 34610906; PMCID: PMC8493923.
• Cranmer JN, Dettinger J, Calkins K, Kibore M, Gachuno O, Walker D. Beyond signal functions in global obstetric care: Using a clinical cascade to measure emergency obstetric readiness. PLoS One. 2018 Feb 23;13(2):e0184252. doi: 10.1371/journal.pone.0184252. PMID: 29474397; PMCID: PMC5825011.
• Moxon SG, Guenther T, Gabrysch S, et al. Service readiness for inpatient care of small and sick newborns: what do we need and what can we measure now? J Glob Health. 2018;8(1):010702.
• PATH’s Asset Tracker.