Indicators For Monitoring Child Health

core indicators for monitoring child health • 379

Indicators for monitoring child health

Core indicators

Reduce thenumber ofchildren living inpoverty.

Type 1 Indicator:Child Status Child poverty Reasons for use: Childpoverty is associatedwith the widest rangeof insults to childsurvival, health anddevelopment,including mortality.Appropriate fornational andinternationalreporting: State of theWorld’s Children;MillenniumDevelopment Goals(MDGs).

Definition & Measure: Proportion of children inhouseholds experiencing the following:• Living in a household that has a household equivalent

income below R10 189 per annum (2006 value);• Living in a household without a refrigerator;• Living in a household with neither a TV nor a radio.Sources: Census and other household surveys (StatisticsSouth Africa); provincial poverty data.Period: Every 10 yearsNotes: This measure is used in the Provincial Indices ofMultiple Deprivation (PIMD) developed by Noble, Babitaet al. (2006). See Chapter 3 in this volume.1

A PIMD for children (PIMDC) will be available once thisvolume is published and should be seriously consideredfor these purposes as it will permit description of areasbelow provincial level and will take into account a range ofdeprivations experienced by children in poverty.

Policy goal Indicator and Definition, measure, period and data source reason for use

Reduce HIVprevalence amongyoung people aged15–24 years.

Type 1 Indicator:Child StatusHIV prevalence in15–24-year age group.Reason for use:Measure of theprevalence of thedisease in a high-riskage group.

Type 1 Indicator:Child StatusHIV prevalence inpregnant children.Reason for use:Measure of theprevalence of thedisease in a high-riskgroup.

Definition & Measure: Proportion of sampled pregnantwomen aged 15–24 years attending antenatal clinics whotest positive for HIV.Source: Annual HIV antenatal seroprevalence survey(DoH)Period: Annual

Definition & Measure: Number of HIV-positive pregnantchildren (<18 years) per 100 pregnant children.Source: Antenatal HIV seroprevalence survey (DoH)Period: Annual

Accelerate implementation of the National Action Plan for HIV and AIDS

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380 • monitoring child well-being


Expand treatment for infected children and their primary caregivers

Increase thePMTCT coverage(to 95% by 2010).

Type 4 Indicator:Service AccessAntiretroviral therapy(ART) cover ineligible newborns.Reasons for use:Marker of healthsystems’ ability toprevent new HIVinfections in children.

Definition & Measure: Number of newborns receivingprophylactic ART per 100 babies born to HIV-positivepregnant mothers.Source: PMTCT surveillance (DoH)Period: Annual

Increase access toART for children(to reach 55 000children by 2009).

Type 4 Indicator:Service AccessHighly active anti-retroviral therapy(HAART) cover ineligible children aged0–12 and 13–17 years.Reasons for use:Marker of healthsystems’ ability tomanage symptomaticHIV infection/AIDSin children.

Definition & Measure: Number of children (aged 0–12and 13–17 years) receiving HAART per 100 childreneligible for HAART.Source: ART roll-out surveillance (DoH)Period: Annual

Increase access toART for adults – in particular forcaregivers withchildren (to reach450 000 by 2009).

Type 4 Indicator:Service AccessHAART cover ineligible adults.Reasons for use: Adultaccess to ART willreduce orphaning.Marker of healthsystems’ ability tomanage symptomaticHIV infection/AIDSin adults.

Definition & Measure: Number of adults (>18 years)receiving HAART per 100 adults eligible for HAART(stratified by gender and into adults with children as far aspossible).Source: ART roll-out surveillance (DoH)Period: Annual

Reduce theincidence of HIVinfection inchildren.

Type 1 Indicator:Child StatusInfant HIV incidencerateReasons for use:Measure of animportant cause ofchild morbidity.

Definition: Children born to HIV-positive women who arepolymerase chain reaction (PCR) positive at 6 weeks ofage in a given period.Measure: Proportion of children born to HIV-positivewomen who are PCR positive at 6 weeks of age.Source: Provincial Prevention of Mother to ChildTransmission (PMTCT) ProgrammePeriod: Annual

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Reduce child mortality

Reduce thenumber of infantsdying in the first28 days of life.

Type 1 Indicator:Child StatusNeonatal mortalityrateReason for use:Measure of care andsupport provided tonewborns and younginfants.

Definition: Deaths <28 days of age per 1 000 live births insame calendar year.Measure: Proportion of deaths <28 days of age in samecalendar year.Sources: Stats SA; South African Demographic and HealthSurvey (SADHS); Maternal Registry.Period: Annual

Reduce theincidence ofdiarrhoeal diseasein children under 5 years.

Type 1 Indicator:Child StatusProportion ofdiarrhoea in <5s athealth facilities.Reason for use:Measure of animportant cause ofchild morbidity.

Definition: Diarrhoea is defined as 3 or more waterystools in 24 hours, but any episode diagnosed and/ortreated as diarrhoea after an interview with the adultaccompanying the child should be counted.Measure: Children <5 years presenting to health facilitieswith diarrhoea per 1 000 <5-year-old attendances in agiven period.Sources: District Health Information System (DHIS);SADHS.Period: Monthly

Reduce theincidence ofrespiratory diseasein children under 5years.

Type1 Indicator:Child StatusProportion of acutelower respiratorytract infections(pneumonia) in <5sat health facilities.Reason for use:Measure ofimportant cause ofchild morbidity.

Definition & Measure: Children <5 years presenting tohealth facilities with acute lower respiratory tractinfections (pneumonia) per 1000 <5-year-old attendancesin a given period.Sources: DHIS; SADHS.Period: Monthly

Vaccinate 90% ofchildren againstmeasles.

Type 5 Indicator:Service QualityMeasles 1st dosecoverage.Reason for use:Measure of quality ofhealth service(immunisation).

Definition: Children <1 year who received measles firstdose.Measure: Proportion of children <1 year who receivedmeasles first dose per population of infants eligible for thevaccine (Denominator: Mid-year estimate of targetpopulation [<1 year olds]).Source: DHISPeriod: Annual

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Combat non-communicable diseases

Increase thepercentage ofchildren at age 6years who are freeof caries (to 50%by 2010).

Type 1 Indicator:Child StatusChildren at age 6with no caries.Reasons for use:Measure of oralhealth.

Definition: Children at age 6 with no caries.Measure: Proportion of children at age 6 with no caries.Source: DHS Oral Health SurveyPeriod: Annual

Reduce the meannumber ofdecayed, missingand filled teeth(DMFT) at age 12 years (to 1 by2010).

Type 1 Indicator:Child StatusMean number ofDMFT in children at age 12 years.Reasons for use:Measure of oralhealth.

Definition: Children with DMFT at 12 years.Measure: Proportion of children with DMFT at 12 years.Source: DHS Oral Health SurveyPeriod: Annual

Reduce theprevalence ofstunting amongchildren less than 5 years.

Type 1 Indicator:Child StatusStunting rateReasons for use:Measure ofnutritional status ofchildren. May indicateeconomic hardship,infection or neglect.To identify children inEarly ChildhoodDevelopment servicesto be monitored forfollow-up action.Appropriate fornational andinternationalreporting: State of theWorld’s Children;Convention on theRights of the Child;United NationsChildren’s Fund;Multiple IndicatorCluster Survey;MDGs.

Definition & Measure: Children under 5 years with morethan 2 standard deviations below the median height forage reference value in a defined population of <5s in agiven period (per 100 children in that population in thesame period).Sources: Provincial and national departments of Health(DoH); SADHS; Food Consumption Survey; periodicnutrition surveys.Period: Annual

Improve the nutritional status of children

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Reduce theprevalence ofwasting amongchildren under 5 years.

Type 1 Indicator:Child StatusWasting rateReasons for use:Measure ofnutritional status ofchildren.

Definition & Measure: Proportion of children more than2 standard deviations below the median weight for heightreference value in a defined population of under-5s per100 children under the age of 5 years in that population inthe same period.Sources: Provincial and national DoH; SADHS; FoodConsumption Survey; periodic nutrition surveys.Period: Annual

Reduce childhoodoverweight andobesity.

Type 1 Indicator:Child StatusOverweight andobesity ratesReasons for use:Measure ofnutritional status ofchildren.

Definitions: 1: Overweight: Children with weight forheight over 2 standard deviations from the norm(reference population median).

2: Obesity: Children with a body mass index (body massin kg divided by the square of the height in m) equal toor more than 30kg/m2.

Measure: Children at school entry who are overweight orobese per 100 children in the relevant age group in thatpopulation in the same period; optionally also at 10 and15 years.Sources: Provincial and national DoH; SADHS; FoodConsumption Survey; periodic nutrition surveys.Period: Annual

Reduce severemalnutrition inchildren under 5years.

Type 1 Indicator:Child StatusSevere malnutritionrateReasons for use:Measure ofnutritional status ofchildren.

Definition & Measure: Children aged 0–5 years who weighbelow 60% expected weight for age (new cases thatmonth/year) per 1 000 children in the target age group.Source: DHISPeriod: Annual

Promotebreastfeeding.

Type 1 Indicator:Child StatusBreastfeeding:1. Initiation rates2. Exclusive

breastfeeding rate3. Duration of

breastfeedingReasons for use:Measure of uptakeand success ofbreastfeeding.

Definition: Exclusive breastfeeding rate: Percentage ofliving children receiving only breast milk from birth tovarious ages.Measures: 1. Proportion of newborn children exclusively

breastfed at hospital discharge or immediately after birth.2. Proportion of 6-month-old children receiving only

breast milk or expressed breast milk.3. Proportion of 12-month-old children receiving

breastfeeding at 12 months.Each of above per 100 live births in the same period.(Denominator for all: Live births in the same period.)Sources: SADHS; periodic nutrition surveys.Period: Annual

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Reduce theprevalence of irondeficiency amongchildren under 5 years.

Type 1 Indicator:Child StatusIron deficiency rateReasons for use:Measure ofnutritional status anddietary intake.

Definition & Measure: Number of children <5 years ofage with evidence of iron deficiency anaemia in a definedpopulation per 100 children under the age of 5 years inthat population in the same period.Sources: SADHS; periodic nutrition surveys.Period: Annual

Reduce theprevalence ofvitamin Adeficiency amongchildren under 5 years.

Type 1 Indicator:Child StatusVitamin A deficiencyrateReasons for use:Measure ofnutritional status anddietary intake.

Definition & Measure: Number of children <5 years ofage with biochemical evidence of vitamin A deficiency in adefined population and a given period per 100 childrenunder the age of 5 years in that population in the sameperiod.Sources: SADHS; periodic nutrition surveys.Period: Annual

Reduce theprevalence ofiodine deficiencyamong childrenunder 5 years.

Type 1 Indicator:Child StatusIodine deficiency rateReasons for use:Measure ofnutritional status anddietary intake.

Definition & Measure: Number of children <5 years ofage with evidence of iodine deficiency in a definedpopulation and a given period per 100 children under theage of 5 years in that population in the same period.Sources: SADHS; periodic nutrition surveys.Period: Annual

Reduce theprevalence of lowbirth weight (<2.5 kg).

Type 1 Indicator:Child StatusLow birth weight rateReasons for use:Indicator of thesocio-economicstatus and health ofthe community ingeneral. Also ameasure of maternalhealth duringpregnancy.

Definition & Measure: Number of children born with abirth weight <2.5 kg in a defined population and in agiven period per 100 live births in the same populationand period.Sources: Stats SA; Maternal Registry; SADHS; periodicsurveys; hospital midwife obstetric unit records; PerinatalProblem Identification Programme (PPIP).Period: Annual

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Reduce proportionof birthsattributable to girlsaged 15–19 years.

Type 1 Indicator:Child StatusTeenage birth rateReason for use:Teenage pregnancydisrupts the life of achild and heroffspring.

Definition & Measure: Proportion of all live births duringa specific year which are to women who are between 15and 20 years of age, irrespective of marital status per 100births among women of all ages.Source: SADHS; Maternal Registry.Period: Annual

To improve youth and adolescent health

Improve clinical management and care at all levels of the healthcare delivery system

Reduce thenumber of teenagepregnancies.

Type 1 Indicator:Child StatusTeenage pregnancyrateReason for use:Teenage pregnancydisrupts the life of achild and heroffspring.

Definition: Women aged 13–19 who are mothers or whohave ever been pregnant. The number of women who aremothers at the time of the survey is a more restrictivedefinition.Measure: Number of pregnancies in females aged 13–19years per 1 000 females aged 13–19 years in the sameperiod.Source: SADHSPeriod: Annual

Promotebreastfeeding byaccreditingmaternity unitswith ‘baby-friendly’ status(60% by 2009).

Type 5 Indicator:Service QualityBaby-friendlyhospitals andmaternity facilitiesReason for use:Measures ability ofmidwife obstetricunits and hospitals topromote successfulbreastfeeding.

Definition & Measure: Number of accredited baby-friendly hospitals and maternity facilities per 100 healthfacilities with maternity beds.Source: DoH: Baby-friendly hospital initiative assessmentsPeriod: Annual

Implement theIntegratedManagement ofChildhood Illness(IMCI) strategy(90% of facilitiesare saturated – i.e.>60% coverage –with IMCI trainedhealthcareproviders by 2009).

Type 5 Indicator:Service QualityPrimary healthcarefacilities equipped toimplement IMCI.Reason for use: IMCIis the approachchosen by the healthdepartment to deliverprimary care tochildren <5.

Definition & Measure: Number of facilities with at least60% of their staff who are IMCI trained in a given periodper 100 primary healthcare facilities.Source: DoH national IMCI co-ordinator statisticsPeriod: Annual

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Improve the use ofdrugs in childrenaged under 5 yearsin primary carefacilities.

Type 5 Indicator:Service QualitySick childrenreceiving drugmanagement thatconforms to IMCIguidelines.Reason for use: IMCIis the approachchosen by the healthdepartment to deliverprimary care tochildren <5.

Definition & Measure: Number of children correctlymanaged by primary health-care nurses in spotassessments at selected primary health-care clinics in agiven period per 100 nurses evaluated for prescribingpractices during the same period.Sources: DoH IMCI health facility survey; supervisoryvisit reports.Period: Annual

Increase thenumber of PHCclinics offeringyouth-friendlyservices (to 100%by 2009).

Type 5 Indicator:Service QualityYouth-friendly cliniccoverReason for use:Youth-friendly clinicshave been establishedto promote access to,and utilisation by,youth of appropriatehealth services.

Definition & Measure: Number of clinics which are youthfriendly per 100 clinics.Source: DoH provincial reportsPeriod: Annual

Increaseavailability oftermination ofpregnancy (TOP)services atcommunity healthcentres (to 50% ofall centres by2009).

Type 4 Indicator:Service AccessTOP facility coverReason for use:While facilities haveTOP-designatedstatus, they often donot provide thisservice.

Definition & Measure: Number of designated facilitiesproviding TOP in the public sector per 100 designatedTOP facilities.Source: DoH TOP statisticsPeriod: Annual

Increase theproportion ofdistricts with atleast onegenetically trainedhealthcare provider(to 70% of districtsby 2009).

Type 5 Indicator:Service QualityGenetics servicescoverReason for use:Genetically trainedstaff required toprovide basic geneticservices.

Definition & Measure: Percentage of districts rendering abasic genetic service as part of the comprehensive primaryhealthcare service.Source: DoH provincial reports Period: Annual

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additional indicators for monitoring child health • 387


Increase theproportion ofdistrictsimplementing thenew standardisedbirth defects datacollection tool (to50% by 2009).

Type 5 Indicator:Service QualityCompliance withbirth defectsurveillance policy.Reason for use:Measure of success ofthe surveillancesystem.

Definition: Sites are required to report on Neural TubeDefects, Albinism, Down Syndrome and cleft lip andpalate birth defects.Measure: Proportion of sites that report birth defects.Source: DoH Birth Defects Surveillance SystemPeriod: Annual

Note:1 See also <http://www.statssa.gov.za/census01/html/C2001Deprivation.asp>.

Additional indicators

Reduce thenumber of infantsdying in the firstyear of life.

Type 1 Indicator:Child StatusInfant mortality rateReasons for use:Importantdeterminants ofinfant mortality areaccess to safe water,sanitation, nutritionand the level ofmothers’ education.Determining factorswithin the healthsystem include thequality of maternalcare, availability ofvaccines given in thefirst year of life, andeffective referralsystems.Proxy measure ofdeterminants ofsurvival, includingsocio-economic andhealth service statusof a country.

Definition & Measure: The infant mortality rate is thenumber of deaths of infants <1 year of age, in a givenperiod of time, per 1 000 live births in the same period.Sources: Stats SA; Health and Demographic SurveillanceSystem. Presently available at national and provincial levelonly.Period: AnnualNotes on data collection: Unless the birth registrationsystem is complete, infant deaths in particular may not beregistered, which may seriously bias the result.Retrospective questions about the survival of children everborn included in censuses and surveys, and analysed usingindirect estimation procedures, are considered to bereliable sources.Surveys using maternity histories, in which women areasked to give the date of birth and age of death (ifapplicable) of each live-born child, are used in manyhousehold surveys, but care must be taken to avoid agemisreporting and to be sure that there is a complete reportof infant deaths.


Reduce child mortality

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Reduce thenumber ofstillbirths and earlyneonatal deaths.

Type 1 Indicator:Child StatusPerinatal mortalityrateReason for use:Measure of antenatalcare as well asneonatal services.

Definition: The number of perinatal deaths per 1 000births.Measure: Sum of stillbirths (≥28 weeks gestation or 1 000gor more) + early neonatal deaths (≤7 days of age) per 1 000 live births + stillbirths in same calendar year.Note: Current World Health Organisation definition ofperinatal mortality rate is different from the definitionused in South Africa, being the number of deaths from 24 weeks gestation/500g to 28 days neonatal life.Sources: Stats SA; SADHS; DHIS; hospital data; PPIP;Maternal Registry. Presently available at national andprovincial level only.Period: Annual

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Reduce thenumber ofchildren dying in the first 5 yearsof life.

Type 1 Indicator:Child StatusUnder-5 mortalityrate (U5MR)Reasons for use:Principal indicator ofhuman and economicprogress used byUNICEF. U5MRmeasures an endresult of thedevelopment processrather than an ‘input’such as per capitacalorie availability.U5MR reflects a widevariety of inputs: thenutritional health andthe health knowledgeof mothers; the levelof immunisation andORT use; theavailability ofmaternal and childhealth services(including prenatalcare); income andfood availability in thefamily; the availabilityof clean water andsanitation; and theoverall safety of thechild’s environment.The U5MR is lesssusceptible toaverages, it is moredifficult for a wealthyminority to affect anation’s U5MR, and ittherefore presents amore accurate pictureof the health status ofthe majority ofchildren.

Definition: The <5 mortality rate is the probability ofchildren dying between birth and their fifth birthday,expressed per 1 000 children born alive.Measure: Number of deaths between birth and exactly 5 years of age per 1 000 live births in same calendar year.Sources: Stats SA; SADHS. Presently available at nationaland provincial level only.Period: AnnualNotes on data collection: Complete vital registrationsystems, sample registration systems and demographicsurveillance systems, where available, provide goodestimates of child mortality.Retrospective questions about the survival of previouschildren from censuses and surveys, analysed usingindirect estimation techniques, are considered reliablesources.Demographic surveys using maternity histories, in whichwomen are asked to give the date of birth and age of death(if applicable) of each live-born child, are used in manyhousehold surveys.The preceding birth technique can be used in antenatalclinics, maternity clinics, and at the time of immunisation,to provide a useful recent estimate of the probability ofdying by age 2 years at a local level.

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Reduce thenumber ofchildren dying ofpreventable causesin the first 5 yearsof life.

Type 1 Indicator:Child StatusCause-specificmortality ratesReasons for use:Measurement ofcause-specificmortality is needed:• To establish the

relative publichealth importanceof the differentcauses of death;

• To evaluate trendsover time,especially as amethod ofevaluating theprobable impact of interventionprogrammes;

• To investigate thecircumstancessurrounding thedeaths of childrenfor devisingeffective actions todecrease mortality;

• To investigatereasons fordiffering rates ofinfant and childmortality amonggeographic areas,and to evaluate theeffectiveness ofspecific publichealthinterventions incontrolled settings.

Definition: Mortality from a specific cause in childrenaged <5 years.Measure: Dependent on the specific cause, but similar to<5 mortality rate.Sources: Stats SA; SADHS. Presently available at nationaland provincial level only.Period: Annual

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Improve the nutritional status of children



Combat communicable diseases and reduce mortality and morbidity

Eradicate polio (by2008).

Type 1 Indicator:Child StatusDeclared polio free.Reason for use:Confirmation oferadication of polio.

Definition & Measure: Number of confirmed cases ofpolio in given period..Sources: DoH disease notification system; poliosurveillance system; National Health Laboratory service.Period: Quarterly

Eliminate measles(by 2008).

Type 1 Indicator:Child StatusAnnual confirmedcases of measles.Reason for use:Confirmation oferadication ofmeasles.

Definition & Measure: Number of confirmed cases ofmeasles in given period.Sources: DoH disease notification system; measlessurveillance system; National Health Laboratory service.Period: Quarterly

Eliminate neonataltetanus.

Type 1 Indicator:Child StatusAnnual confirmedcases of neonataltetanus.Reason for use:Confirmation oferadication oftetanus.

Definition & Measure: Number of confirmed cases oftetanus during the first 28 days of life in a given periodand defined population.Source: DoH disease notification system Period: Quarterly

Reduce theprevalence ofunderweightamong childrenless than 5 years(to <4.7% by2015).

Type 1 Indicator:Child StatusUnderweight rate.Reason for use:Measure ofnutritional status ofchildren. MDGtarget.

Definition & Measure: Number of children more than 2standard deviations below the median weight for agereference value per 100 children under the age of 5 yearsin that population in the same period.Sources: SADHS; DHIS; periodic nutrition surveys.Period: Annual

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Increase thenumber of healthdistricts with morethan 90% fullimmunisationcoverage (to 95%of districts by2009).

Type 4 & 5Indicators: ServiceAccess and ServiceQualityProportion ofchildren <5 yearswho have been fullyvaccinated.Reason for use:Measure of coverageand success ofimmunisationprogramme and ofhealth systemfunctioning.

Definition: Fully immunised children have received all theExpanded Programme of Immunisation (EPI) vaccines bythe age of 5 years.Measure: The number of children 0–5 years inclusive whoare fully immunised, divided by the population <5 years(based on mid-year estimates of number of children <5 years and number of required doses for each vaccine).Source: DHISPeriod: Monthly; annual.

Improve clinical management and care at all levels of the healthcare delivery system

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Indicators For Monitoring Child Health

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