Signal function measurement

Data collection

Signal function performance, as defined in the EmONC signal functions’ operational definitions table, is assessed by interviewing staff, and by looking at facility registers (and individual patient records if needed) to determine whether each individual signal function was performed at least once in the previous three-month period and if a complication requiring each signal function was reported in the register (confirming the plausibility that the signal function was performed in the previous three months). A three-month reference period for measuring the performance of the signal functions is recommended, based on the principle that skills must be performed with some frequency in order to maintain competence and confidence as well as to minimize concerns about longer recall periods.

The performance of EmONC signal functions is ideally recorded at the end of every quarter using EmONC signal function checklists, such as the ones below in Figure 1. Some countries may choose to monitor signal function performance more frequently (e.g., monthly) as part of their HMIS or a paper-based programme monitoring system. For routine programme monitoring (e.g., monthly and quarterly), facilities could assess their own performance of the signal functions. Typically, the facility in-charge or unit heads (e.g., maternity unit, SNCU) would be responsible for determining signal function performance. Periodically (e.g., annually and every 3-5 years), a team external to the facility (e.g., sub-national managers, national evaluators, supervisors/mentors, local research firm) could review facilities’ self-reports as well as conduct their own assessment of signal function performance for the three months prior to their assessment visit.

Note that the referral signal function (arrange ambulance, with trained and equipped provider, to a facility that can provide definitive care) is only required at the Basic EmONC level.¹

EmONC classification

Once signal function performance has been recorded, a facility is classified for the three-month period as a Basic EmONC facility, Comprehensive EmONC facility, or Intensive EmONC facility if all of the signal functions for that level of EmONC were carried out.

It may also be helpful to know how many facilities are close to being classified as EmONC, missing only 1 or 2 signal functions. For example, the following classifications can be used:

1. BEmONC -1,-2 describes a facility that performs all but one or two of the BEmONC signal functions.
2. CEmONC -1,-2 describes a facility that performs all but one or two of the CEmONC signal functions.
3. IEmONC -1,-2 describes a facility that performs all but one or two of the IEmONC signal functions.
4. Facilities missing more than two signal functions can be described as not yet EmONC.

The number of facilities by EmONC performance classification can then be counted and summarized as follows:

The classifications above are based solely on signal function performance and do not take into consideration at what level a facility is expected to be functioning. Once a designated set of EmONC facilities has been selected by country planners (see ‘Step-by-step implementation’), it is also possible to categorize facilities based on whether they are performing all the signal functions they are expected to perform. The table below shows various combinations of designation vs. performance levels.

In addition to performing these analyses for the full set of EmONC signal functions, it may also be useful to look at obstetric and newborn signal functions separately. For example, the following classifications could be used:

Analysis and interpretation

The number of facilities that are classified as EmONC is used to calculate Indicator 1a and Indicator 1b. The EmONC classification of facilities can also be used as a variable to disaggregate all other indicators in the EmONC Framework (e.g., institutional delivery rate in facilities classified as EmONC vs. institutional delivery rate in facilities that are not yet EmONC).

Analysis of individual signal function performance, or lack of performance, can also be used to plan and monitor implementation and change over time. These data can be presented in terms of the proportion of facilities providing each of the signal functions, and can be disaggregated by level of facility, managing authority (public vs. private) and sub-national area. For example, if it is determined that a specific signal function has been chronically missing from a large number of facilities, planners and implementers can study why that signal function is not being performed.

Common reasons for non-performance of a signal function include:

• The complication arose, but:
  • There were problems with infrastructure (e.g., operating theater not functional)
  • Drugs/supplies/equipment were missing – problems related to procurement, distribution, and/or maintenance
  • Health provider cadres working at the facility are not authorized to perform the signal function
  • Skilled health personnel require further training/coaching/mentoring to be competent and confident
  • Additional skilled personnel/specific cadres with EmONC capacity are needed
  • Facility, sub-national or national policies present barriers to the provision of care such as clinical interventions being absent from national treatment protocols, restrictive authorization of health provider cadres to perform certain signal functions, norms regarding what services are performed at what level, or deficits in pre-service curricula
• The complication did not arise within the time period due to:
  • Excellent routine and preventative care
  • Low caseload

Low caseload can be due to a number of factors and could be investigated by determining: whether the catchment population is too small given the incidence of the complication in question; if access is a serious problem for reasons related to information, cost, distance, transport or cultural practices; or if bypassing this facility for another, better-functioning facility is common practice.

Signal function performance can fluctuate from one quarter to the next for various reasons. For example, key personnel can be transferred; stock outs or supply chain failures can occur; and caseloads can drop because of a disease outbreak. Yet the sustained performance of all of the EmONC signal functions is the goal and routine monitoring can support that end by flagging potential problems for quick resolution, such as making adjustments to the workforce, addressing stockouts or repairing equipment. Triangulating with indicators such as “Health Workforce Adequate for Caseload,” or “Equipment, Drugs and Supplies” may help identify causes for non-performance to guide corrective efforts. Additional examination of health system elements that are not captured by the EmONC Framework (e.g., supportive supervision or continuing medical education) may also be required to identify problems (see example of assisted vaginal birth at the Basic EmONC level in Box 1).