Lessons Learned from Reproductive Health Surveillance in Za’atari Refugee Camp — Jordan, 2013-2014 Michelle Dynes, EIS Officer/Epidemiologist, CDC Rachel Idowu, Medical Epidemiologist, CDC Ann Burton, Senior Public Health Officer, UNHCR Dina Jardaneh, Associate Public Health Officer, UNHCR Maysa Al-Khateeb, Emergency Reproductive Health Officer, UNFPA Shible Sahbani, Humanitarian Coordinator, UNFPA Sathyanarayanan Doraiswamy, Emergency RH Officer, UNHCR Basia Tomczyk, Health Scientist, CDC Today we are going to discuss findings from an evaluation of reproductive health surveillance in Za’atari Refugee Camp – Jordan, August 18 to September, 14, 2013. CLICK Center for Global Health Emergency Response and Recovery Branch

Za’atari Refugee Camp Reproductive Health Surveillance First, Background. CLICK Background

Syrian Refugees Today Since public demonstrations began in March 2011, the crisis in Syria has evolved into an ongoing armed conflict. 4.2 million Syrians have been internally displaced from their homes, 2 million have fled to neighboring countries, and over 110,000 people have died. Jordan is host to the 2nd largest population of Syrian refugees with more than 620,000 Syrian refugees. CLICK With this size of a population, it is estimated that there are more than 155,000 women of reproductive age and nearly 20,000 who are currently pregnant and in need of access to safe delivery. CLICK Among the challenges facing these women as a result of the conflict are malnutrition, lack of medical care, losing access to reproductive health services including family planning services, exposure to unwanted pregnancy in perilous conditions, and unsafe deliveries. CLICK Snap shot for the situation today , data references 1-http://data.unhcr.org/syrianrefugees/country.php?id=107 2-http://misp.lacrounfpa.org/unfpa/mispcalculator/advocacy/NjE5MTYwOzQwOzI0OzU7ODU%3D http://data.unhcr.org/syrianrefugees/country.php?id=107 http://misp.lacrounfpa.org/unfpa/mispcalculator/advocacy/NjE5MTYwOzQwOzI0OzU7ODU%3D

Syrian Refugees Today 155,647 Since public demonstrations began in March 2011, the crisis in Syria has evolved into an ongoing armed conflict. 4.2 million Syrians have been internally displaced from their homes, 2 million have fled to neighboring countries, and over 110,000 people have died. Jordan is host to the 2nd largest population of Syrian refugees with more than 620,000 Syrian refugees. CLICK With this size of a population, it is estimated that there are more than 155,000 women of reproductive age and nearly 20,000 who are currently pregnant and in need of access to safe delivery. CLICK Among the challenges facing these women as a result of the conflict are malnutrition, lack of medical care, losing access to reproductive health services including family planning services, exposure to unwanted pregnancy in perilous conditions, and unsafe deliveries. CLICK http://data.unhcr.org/syrianrefugees/country.php?id=107 http://misp.lacrounfpa.org/unfpa/mispcalculator/advocacy/NjE5MTYwOzQwOzI0OzU7ODU%3D

Syrian Refugees Today 155,647 Since public demonstrations began in March 2011, the crisis in Syria has evolved into an ongoing armed conflict. 4.2 million Syrians have been internally displaced from their homes, 2 million have fled to neighboring countries, and over 110,000 people have died. Jordan is host to the 2nd largest population of Syrian refugees with more than 620,000 Syrian refugees. CLICK With this size of a population, it is estimated that there are more than 155,000 women of reproductive age and nearly 20,000 who are currently pregnant and in need of access to safe delivery. CLICK Among the challenges facing these women as a result of the conflict are malnutrition, lack of medical care, losing access to reproductive health services including family planning services, exposure to unwanted pregnancy in perilous conditions, and unsafe deliveries. CLICK 18,678 http://data.unhcr.org/syrianrefugees/country.php?id=107 http://misp.lacrounfpa.org/unfpa/mispcalculator/advocacy/NjE5MTYwOzQwOzI0OzU7ODU%3D

Jordan and Za’atari Refugee Camp – Aug 2013 At the time of the evaluation in August 2013, more than 520,000 refugees lived in Jordan, with the majority of the refugees residing in urban settings. Over 120,000 refugees lived in Za'atri Refugee Camp, located near the Syrian border. The United Nations High Commissioner for Refugees (UNHCR) estimated that among Za’atri’s residents, 30,504 were women of reproductive age and 3660 are these women were currently pregnant. CLICK

Jordan and Za’atari Refugee Camp – Aug 2013 More than 520,000 refugees in Jordan Majority of refugees in urban settings At the time of the evaluation in August 2013, more than 520,000 refugees lived in Jordan, with the majority of the refugees residing in urban settings. Over 120,000 refugees lived in Za'atri Refugee Camp, located near the Syrian border. The United Nations High Commissioner for Refugees (UNHCR) estimated that among Za’atri’s residents, 30,504 were women of reproductive age and 3660 are these women were currently pregnant. CLICK

Jordan and Za’atari Refugee Camp – Aug 2013 More than 520,000 refugees in Jordan Majority of refugees in urban settings Over 120,000 Syrian refugees in Za’atari camp 30,504 women aged 15-49 3,660 pregnant women At the time of the evaluation in August 2013, more than 520,000 refugees lived in Jordan, with the majority of the refugees residing in urban settings. Over 120,000 refugees lived in Za'atri Refugee Camp, located near the Syrian border. The United Nations High Commissioner for Refugees (UNHCR) estimated that among Za’atri’s residents, 30,504 were women of reproductive age and 3660 are these women were currently pregnant. CLICK

This is an aerial view of Za’atari Camp in July 2013, right before the evaluation took place. With rapid growth of the camp came the need for the expansion of services and increased number of RH services provided including ANC, delivery, and PNC. CLICK Photo 7/2013: http://www.mirror.co.uk/news/world-news/syria-refugee-camp-aerial-pictures-2067144

health information system Za’atari Refugee Camp Reproductive Health Surveillance Moving on, I will now describe the Health Information System. CLICK health information system

UNHCR Health Information System (HIS) The UNHCR Health Information System (HIS) is a standardized tool to design, monitor, and evaluate refugee public health and HIV programs. The HIS is implemented in over 18 countries and targets over 2.1 million refugees in camp and non-camp settings. CLICK The HIS is comprised of up to10 technical sections, including Reproductive Health; the number of sections implemented depends on the context. CLICK The HIS identifies three core pillars CLICK including (1) Standards and indicators, CLICK (2) Tools and guidelines, and CLICK (3) Coordination and support. CLICK

UNHCR Health Information System (HIS) Standardized tool to design, monitor, and evaluate refugee public health HIS is implemented in over 18 countries Targets over 2.1 million refugees in camp and non-camp settings The UNHCR Health Information System (HIS) is a standardized tool to design, monitor, and evaluate refugee public health and HIV programs. The HIS is implemented in over 18 countries and targets over 2.1 million refugees in camp and non-camp settings. CLICK The HIS is comprised of up to10 technical sections, including Reproductive Health; the number of sections implemented depends on the context. CLICK The HIS identifies three core pillars CLICK including (1) Standards and indicators, CLICK (2) Tools and guidelines, and CLICK (3) Coordination and support. CLICK

UNHCR Health Information System (HIS) Standardized tool to design, monitor, and evaluate refugee public health HIS is implemented in over 18 countries Targets over 2.1 million refugees in camp and non-camp settings Up to 10 technical sections with three core pillars The UNHCR Health Information System (HIS) is a standardized tool to design, monitor, and evaluate refugee public health and HIV programs. The HIS is implemented in over 18 countries and targets over 2.1 million refugees in camp and non-camp settings. CLICK The HIS is comprised of up to10 technical sections, including Reproductive Health; the number of sections implemented depends on the context. CLICK The HIS identifies three core pillars CLICK including (1) Standards and indicators, CLICK (2) Tools and guidelines, and CLICK (3) Coordination and support. CLICK

UNHCR Health Information System (HIS) Standardized tool to design, monitor, and evaluate refugee public health HIS is implemented in over 18 countries Targets over 2.1 million refugees in camp and non-camp settings Up to 10 technical sections with three core pillars Standards and Indicators Tools and Guidelines Coordination and Support The UNHCR Health Information System (HIS) is a standardized tool to design, monitor, and evaluate refugee public health and HIV programs. The HIS is implemented in over 18 countries and targets over 2.1 million refugees in camp and non-camp settings. CLICK The HIS is comprised of up to10 technical sections, including Reproductive Health; the number of sections implemented depends on the context. CLICK The HIS identifies three core pillars CLICK including (1) Standards and indicators, CLICK (2) Tools and guidelines, and CLICK (3) Coordination and support. CLICK

UNHCR Health Information System (HIS) Standardized tool to design, monitor, and evaluate refugee public health HIS is implemented in over 18 countries Targets over 2.1 million refugees in camp and non-camp settings Up to 10 technical sections with three core pillars Standards and Indicators Tools and Guidelines Coordination and Support The UNHCR Health Information System (HIS) is a standardized tool to design, monitor, and evaluate refugee public health and HIV programs. The HIS is implemented in over 18 countries and targets over 2.1 million refugees in camp and non-camp settings. CLICK The HIS is comprised of up to10 technical sections, including Reproductive Health; the number of sections implemented depends on the context. CLICK The HIS identifies three core pillars CLICK including (1) Standards and indicators, CLICK (2) Tools and guidelines, and CLICK (3) Coordination and support. CLICK

UNHCR Health Information System (HIS) Standardized tool to design, monitor, and evaluate refugee public health HIS is implemented in over 18 countries Targets over 2.1 million refugees in camp and non-camp settings Up to 10 technical sections with three core pillars Standards and Indicators Tools and Guidelines Coordination and Support The UNHCR Health Information System (HIS) is a standardized tool to design, monitor, and evaluate refugee public health and HIV programs. The HIS is implemented in over 18 countries and targets over 2.1 million refugees in camp and non-camp settings. CLICK The HIS is comprised of up to10 technical sections, including Reproductive Health; the number of sections implemented depends on the context. CLICK The HIS identifies three core pillars CLICK including (1) Standards and indicators, CLICK (2) Tools and guidelines, and CLICK (3) Coordination and support. CLICK

Problem Statement RH component of the HIS in Za’atari needed improvement Many contributing factors Transition & consolidation of comprehensive RH services highlighted need for quality RH data Za’atari had nine health providers, all with varying degrees of exposure to health information systems. It had been recognized for some time that the RH data in Za’atari needed improving, and this was also well documented during the MISP assessment in March of 2013. The reproductive health component of HIS remained weak due to several factors which will described later in the presentation. As the health system moves more towards consolidating comprehensive RH services there was a need to improve the quality of the data collected. Delivery Room in Za’atari Camp/UNFPA

Za’atari Refugee Camp Reproductive Health Surveillance Following the MISP evaluation, UNHCP and UNFPA invited CDC to review RH health surveillance and to assist in addressing shortcomings. Evaluation Design

Evaluation Objectives The evaluation objectives included: To review the RH component of Za’atari’s HIS. CLICK To review the national RH HIS and reporting templates to ensure any proposed changes reflect national RH where possible. CLICK To implement a system for maternal and neonatal mortality audits in Za’atari. CLICK To provide technical support and facilitate implementation of the RH component of HIS to ensure relevant RH indicators are collected and monitored. CLICK And to develop an action plan to implement the proposed recommendations. CLICK

Evaluation Objectives Review the RH component of Za’atari HIS Review national RH HIS and reporting templates to ensure proposed changes reflect national RH Implement a system for maternal and neonatal mortality audits in Za’atari Provide technical support and facilitate implementation of RH component of HIS Develop an action plan to implement the proposed recommendations The evaluation objectives included: To review the RH component of Za’atari’s HIS. CLICK To review the national RH HIS and reporting templates to ensure any proposed changes reflect national RH where possible. CLICK To implement a system for maternal and neonatal mortality audits in Za’atari. CLICK To provide technical support and facilitate implementation of the RH component of HIS to ensure relevant RH indicators are collected and monitored. CLICK And to develop an action plan to implement the proposed recommendations. CLICK

Evaluation Objectives Review the RH component of Za’atari HIS Review national RH HIS and reporting templates to ensure proposed changes reflect national RH Implement a system for maternal and neonatal mortality audits in Za’atari Provide technical support and facilitate implementation of RH component of HIS Develop an action plan to implement the proposed recommendations The evaluation objectives included: To review the RH component of Za’atari’s HIS. CLICK To review the national RH HIS and reporting templates to ensure any proposed changes reflect national RH where possible. CLICK To implement a system for maternal and neonatal mortality audits in Za’atari. CLICK To provide technical support and facilitate implementation of the RH component of HIS to ensure relevant RH indicators are collected and monitored. CLICK And to develop an action plan to implement the proposed recommendations. CLICK

Evaluation Objectives Review the RH component of Za’atari HIS Review national RH HIS and reporting templates to ensure proposed changes reflect national RH Implement a system for maternal and neonatal mortality audits in Za’atari Provide technical support and facilitate implementation of RH component of HIS Develop an action plan to implement the proposed recommendations The evaluation objectives included: To review the RH component of Za’atari’s HIS. CLICK To review the national RH HIS and reporting templates to ensure any proposed changes reflect national RH where possible. CLICK To implement a system for maternal and neonatal mortality audits in Za’atari. CLICK To provide technical support and facilitate implementation of the RH component of HIS to ensure relevant RH indicators are collected and monitored. CLICK And to develop an action plan to implement the proposed recommendations. CLICK

Evaluation Objectives Review the RH component of Za’atari HIS Review national RH HIS and reporting templates to ensure proposed changes reflect national RH Implement a system for maternal and neonatal mortality audits in Za’atari Provide technical support and facilitate implementation of RH component of HIS Develop an action plan to implement the proposed recommendations The evaluation objectives included: To review the RH component of Za’atari’s HIS. CLICK To review the national RH HIS and reporting templates to ensure any proposed changes reflect national RH where possible. CLICK To implement a system for maternal and neonatal mortality audits in Za’atari. CLICK To provide technical support and facilitate implementation of the RH component of HIS to ensure relevant RH indicators are collected and monitored. CLICK And to develop an action plan to implement the proposed recommendations. CLICK

Evaluation Objectives Review the RH component of Za’atari HIS Review national RH HIS and reporting templates to ensure proposed changes reflect national RH Implement a system for maternal and neonatal mortality audits in Za’atari Provide technical support and facilitate implementation of RH component of HIS Develop an action plan to implement the proposed recommendations The evaluation objectives included: To review the RH component of Za’atari’s HIS. CLICK To review the national RH HIS and reporting templates to ensure any proposed changes reflect national RH where possible. CLICK To implement a system for maternal and neonatal mortality audits in Za’atari. CLICK To provide technical support and facilitate implementation of the RH component of HIS to ensure relevant RH indicators are collected and monitored. CLICK And to develop an action plan to implement the proposed recommendations. CLICK

Evaluation Methods The evaluation was conducted from August 18 to September 14, 2013. Qualitative methods were used to evaluate the HIS including key informant interviews, facility site visits, review of reproductive health documents, tools, and indicators, and stakeholder meetings at the national, organization, and camp level. And finally, HIS reproductive health data were reviewed. CLICK

Evaluation Methods August 18 to September 14, 2013 Qualitative Key informant interviews Facility site visits Review of RH documents, tools, and indicators Stakeholder meetings Quantitative HIS reproductive health data The evaluation was conducted from August 18 to September 14, 2013. CLICK Qualitative methods were used to evaluate the HIS including key informant interviews, facility site visits, review of reproductive health documents, tools, and indicators, and stakeholder meetings at the national, organization, and camp level. CLICK And finally, HIS reproductive health data were reviewed. CLICK

Evaluation Methods August 18 to September 14, 2013 Qualitative Key informant interviews Facility site visits Review of RH documents, tools, and indicators Stakeholder meetings Quantitative HIS reproductive health data The evaluation was conducted from August 18 to September 14, 2013. CLICK Qualitative methods were used to evaluate the HIS including key informant interviews, facility site visits, review of reproductive health documents, tools, and indicators, and stakeholder meetings at the national, organization, and camp level. CLICK And finally, HIS reproductive health data were reviewed. CLICK

Evaluation Methods August 18 to September 14, 2013 Qualitative Key informant interviews Facility site visits Review of RH documents, tools, and indicators Stakeholder meetings Quantitative HIS reproductive health data The evaluation was conducted from August 18 to September 14, 2013. CLICK Qualitative methods were used to evaluate the HIS including key informant interviews, facility site visits, review of reproductive health documents, tools, and indicators, and stakeholder meetings at the national, organization, and camp level. CLICK And finally, HIS reproductive health data were reviewed. CLICK

Za’atari Refugee Camp Reproductive Health Surveillance I will now move on to the findings of the evaluation. CLICK The findings

Multiple Non-traditional Health Actors RH data collection was particularly complex due to the presence of multiple non-traditional health actors which is displayed in this reproductive health service delivery profile. Data collection was further complicated by the fact that women could seek services at multiple providers and there was poor documentation of consultations early on. In addition, three of the health actors were military facilities which entailed long negotiations and compromise.

Multiple Non-Traditional Health Actors Varied data collection methods High staff turnover Lack of information sharing Each health actor used different data collection methods including varying health forms and different levels of charting on patient care. Health actors also had reporting mechanisms and timing of reporting within their own sites due to their specific program requirements. CLICK There was also high staff turnover, as frequent as every 3 weeks in some facilities. CLICK And finally, there was not a process in place to share individual patient health information across provider sites; this lack of access to patient records impacts the ability of clinicians to gather relevant health and care history data that is needed to provide high quality services. CLICK These factors all contributed to incomplete and inconsistent reporting of RH data. CLICK Which ultimately reduced the quality of RH data. CLICK

Multiple Non-Traditional Health Actors Varied data collection methods High staff turnover Lack of information sharing Each health actor used different data collection methods including varying health forms and different levels of charting on patient care. Health actors also had reporting mechanisms and timing of reporting within their own sites due to their specific program requirements. CLICK There was also high staff turnover, as frequent as every 3 weeks in some facilities. CLICK And finally, there was not a process in place to share individual patient health information across provider sites; this lack of access to patient records impacts the ability of clinicians to gather relevant health and care history data that is needed to provide high quality services. CLICK These factors all contributed to incomplete and inconsistent reporting of RH data. CLICK Which ultimately reduced the quality of RH data. CLICK

Multiple Non-Traditional Health Actors Varied data collection methods High staff turnover Lack of information sharing Each health actor used different data collection methods including varying health forms and different levels of charting on patient care. Health actors also had reporting mechanisms and timing of reporting within their own sites due to their specific program requirements. CLICK There was also high staff turnover, as frequent as every 3 weeks in some facilities. CLICK And finally, there was not a process in place to share individual patient health information across provider sites; this lack of access to patient records impacts the ability of clinicians to gather relevant health and care history data that is needed to provide high quality services. CLICK These factors all contributed to incomplete and inconsistent reporting of RH data. CLICK Which ultimately reduced the quality of RH data. CLICK

Multiple Non-Traditional Health Actors Varied data collection methods High staff turnover Lack of information sharing Contributed to incomplete & inconsistent reporting Each health actor used different data collection methods including varying health forms and different levels of charting on patient care. Health actors also had reporting mechanisms and timing of reporting within their own sites due to their specific program requirements. CLICK There was also high staff turnover, as frequent as every 3 weeks in some facilities. CLICK And finally, there was not a process in place to share individual patient health information across provider sites; this lack of access to patient records impacts the ability of clinicians to gather relevant health and care history data that is needed to provide high quality services. CLICK These factors all contributed to incomplete and inconsistent reporting of RH data. CLICK Which ultimately reduced the quality of RH data. CLICK

Multiple Non-Traditional Health Actors Varied data collection methods High staff turnover Lack of information sharing Contributed to incomplete & inconsistent reporting Reduced data quality Each health actor used different data collection methods including varying health forms and different levels of charting on patient care. Health actors also had reporting mechanisms and timing of reporting within their own sites due to their specific program requirements. CLICK There was also high staff turnover, as frequent as every 3 weeks in some facilities. CLICK And finally, there was not a process in place to share individual patient health information across provider sites; this lack of access to patient records impacts the ability of clinicians to gather relevant health and care history data that is needed to provide high quality services. CLICK These factors all contributed to incomplete and inconsistent reporting of RH data. CLICK Which ultimately reduced the quality of RH data. CLICK

Data Quality – Weekly HIS Profile Reports Review of the Weekly HIS Profile Reports uncovered more issues with data quality. CLICK   We found that few health actors reported family planning data, so the contraceptive prevalence rate noted here at 1% is likely greatly underreported. One factor that led to under-reporting is the complexity of data needed to calculate the FP HIS indicator. This is even more difficult when women are seeking care at multiple sites. Even if the data was accurately collected and reported, the indicator would still be limited by the fact that we only have estimates for the number of women in the camp who are of reproductive age. CLICK

Data Quality: Data Quality – Weekly HIS Profile Reports Few health actors reported family planning (FP) data Review of the Weekly HIS Profile Reports uncovered more issues with data quality. CLICK   We found that few health actors reported family planning data, so the contraceptive prevalence rate noted here at 1% is likely greatly underreported. One factor that led to under-reporting is the complexity of data needed to calculate the FP HIS indicator. This is even more difficult when women are seeking care at multiple sites. Even if the data was accurately collected and reported, the indicator would still be limited by the fact that we only have estimates for the number of women in the camp who are of reproductive age. CLICK

Data Quality: Weekly HIS Detailed Reports We found similar issues with the Weekly HIS Detailed Reports. CLICK Here, the coverage of complete postnatal care was reported at 84%, yet there is not a mechanism to accurately monitor complete postnatal care because women can seek care at multiple clinics. CLICK And over the entire year that HIS has collected data, not a single sexual and gender based violence case has been reported to HIS even though service providers report anecdotally that they have seen cases. CLICK

Data Quality: Weekly HIS Detailed Reports No mechanism to monitor complete postnatal care (PNC) We found similar issues with the Weekly HIS Detailed Reports. CLICK Here, the coverage of complete postnatal care was reported at 84%, yet there is not a mechanism to accurately monitor complete postnatal care because women can seek care at multiple clinics. CLICK And over the entire year that HIS has collected data, not a single sexual and gender based violence case has been reported to HIS even though service providers report anecdotally that they have seen cases. CLICK

Data Quality: Weekly HIS Detailed Reports No mechanism to monitor complete postnatal care (PNC) We found similar issues with the Weekly HIS Detailed Reports. CLICK Here, the coverage of complete postnatal care was reported at 84%, yet there is not a mechanism to accurately monitor complete postnatal care because women can seek care at multiple clinics. CLICK And over the entire year that HIS has collected data, not a single sexual and gender based violence case has been reported to HIS even though service providers report anecdotally that they have seen cases. CLICK No SGBV cases reported

Za’atari Refugee Camp Reproductive Health Surveillance Now I will describe the action plan. CLICK Action Plan

Health Information System Action Plan Standardize RH Data Collection Improve information Sharing Encourage timely submission Train on registers and user guides Develop FP register Development of a RH Tally Sheet First, RH data collection needed to be standardized across health actor sites. Training on Register User Guides for RH service delivery was conducted and a register for family planning was developed. A RH Daily Tally Sheet was implemented to simplify daily data collection for providers. CLICK To improve information sharing across sites, a Pregnancy Card was implemented. The card remains with the pregnant woman and is carried to each visit where the provider can review and update information. Training was also conducted with the community health worker network to spread reproductive health messages to Za’atri women, including a message about the importance of brining the pregnancy card to each health visit. CLICK And finally, encouraging timely submission of RH data was needed. One way to improve timeliness is for health actors to identify a dedicated RH focal point. In addition, a mortality event review and response protocol was developed. CLICK

Health Information System Action Plan Standardize RH Data Collection Improve information Sharing Encourage timely submission Train on registers and user guides Develop FP register Development of a RH Tally Sheet Pregnancy Card implementation Involve CHWs First, RH data collection needed to be standardized across health actor sites. Training on Register User Guides for RH service delivery was conducted and a register for family planning was developed. A RH Daily Tally Sheet was implemented to simplify daily data collection for providers. CLICK To improve information sharing across sites, a Pregnancy Card was implemented. The card remains with the pregnant woman and is carried to each visit where the provider can review and update information. Training was also conducted with the community health worker network to spread reproductive health messages to Za’atri women, including a message about the importance of brining the pregnancy card to each health visit. CLICK And finally, encouraging timely submission of RH data was needed. One way to improve timeliness is for health actors to identify a dedicated RH focal point. In addition, a mortality event review and response protocol was developed. CLICK

Health Information System Action Plan Standardize RH Data Collection Improve information Sharing Encourage timely submission Train on registers and user guides Develop FP register Development of a RH Tally Sheet Pregnancy Card implementation Involve CHWs Identify a RH Focal Point within each partner Implement a Mortality Event Review & Response protocol First, RH data collection needed to be standardized across health actor sites. Training on Register User Guides for RH service delivery was conducted and a register for family planning was developed. A RH Daily Tally Sheet was implemented to simplify daily data collection for providers. CLICK To improve information sharing across sites, a Pregnancy Card was implemented. The card remains with the pregnant woman and is carried to each visit where the provider can review and update information. Training was also conducted with the community health worker network to spread reproductive health messages to Za’atri women, including a message about the importance of brining the pregnancy card to each health visit. CLICK And finally, encouraging timely submission of RH data was needed. One way to improve timeliness is for health actors to identify a dedicated RH focal point. In addition, a mortality event review and response protocol was developed. CLICK

Za’atari Refugee Camp Reproductive Health Surveillance Lastly, we will discuss lessons learned. CLICK Lessons Learned

Lessons Learned A flexible, systematic approach to data collection and reporting is needed Through this evaluation, we have learned that: A flexible, systematic approach to data collection and reporting is needed. When we say flexible, we mean that the system for collecting and reporting data needs to be able to adapt to different contexts. A systematic approach ensures that all health actors are using the same data collection forms, ensuring that the appropriate RH indicators are captured and reported consistently and in a timely manner. CLICK All relevant health actors, including non-traditional actors, in humanitarian emergencies should be engaged with and provided training on key RH data to be collected at different phases; CLICK Agreement on and development of a standardized approach to data collection at a global level would facilitate implementation. CLICK Using RH registers early in a crisis helps to highlight the key RH outcomes and guide interventions for establishment of a comprehensive reproductive health response. CLICK Health care provider involvement in the development and adoption of quality improvement tools enhances commitment, collaboration, and information sharing from health actors. CLICK Data sharing between services that are provided inside and outside the camps is essential for accurately capturing health outcome data in a timely manner. CLICK Finally, it is critical to evaluate the quality of Health Information System data early and work in close collaboration with health actors to develop and implement a detailed action plan to guide improvements and respond to emerging challenges; interagency collaboration is critical to success. CLICK

Lessons Learned A flexible, systematic approach to data collection and reporting is needed Engagement with and training of health actors on key RH data to be collected at different phases Through this evaluation, we have learned that: A flexible, systematic approach to data collection and reporting is needed. When we say flexible, we mean that the system for collecting and reporting data needs to be able to adapt to different contexts. A systematic approach ensures that all health actors are using the same data collection forms, ensuring that the appropriate RH indicators are captured and reported consistently and in a timely manner. CLICK All relevant health actors, including non-traditional actors, in humanitarian emergencies should be engaged with and provided training on key RH data to be collected at different phases; CLICK Agreement on and development of a standardized approach to data collection at a global level would facilitate implementation. CLICK Using RH registers early in a crisis helps to highlight the key RH outcomes and guide interventions for establishment of a comprehensive reproductive health response. CLICK Health care provider involvement in the development and adoption of quality improvement tools enhances commitment, collaboration, and information sharing from health actors. CLICK Data sharing between services that are provided inside and outside the camps is essential for accurately capturing health outcome data in a timely manner. CLICK Finally, it is critical to evaluate the quality of Health Information System data early and work in close collaboration with health actors to develop and implement a detailed action plan to guide improvements and respond to emerging challenges; interagency collaboration is critical to success. CLICK

Lessons Learned A flexible, systematic approach to data collection and reporting is needed Engagement with and training of health actors on key RH data to be collected at different phases Agreement on and development of a standardized approach to RH data collection at global level Through this evaluation, we have learned that: A flexible, systematic approach to data collection and reporting is needed. When we say flexible, we mean that the system for collecting and reporting data needs to be able to adapt to different contexts. A systematic approach ensures that all health actors are using the same data collection forms, ensuring that the appropriate RH indicators are captured and reported consistently and in a timely manner. CLICK All relevant health actors, including non-traditional actors, in humanitarian emergencies should be engaged with and provided training on key RH data to be collected at different phases; CLICK Agreement on and development of a standardized approach to data collection at a global level would facilitate implementation. CLICK Using RH registers early in a crisis helps to highlight the key RH outcomes and guide interventions for establishment of a comprehensive reproductive health response. CLICK Health care provider involvement in the development and adoption of quality improvement tools enhances commitment, collaboration, and information sharing from health actors. CLICK Data sharing between services that are provided inside and outside the camps is essential for accurately capturing health outcome data in a timely manner. CLICK Finally, it is critical to evaluate the quality of Health Information System data early and work in close collaboration with health actors to develop and implement a detailed action plan to guide improvements and respond to emerging challenges; interagency collaboration is critical to success. CLICK

Lessons Learned A flexible, systematic approach to data collection and reporting is needed Engagement with and training of health actors on key RH data to be collected at different phases Agreement on and development of a standardized approach to RH data collection at global level Using RH registers early in a crisis highlight key women’s health outcomes and guide interventions Through this evaluation, we have learned that: A flexible, systematic approach to data collection and reporting is needed. When we say flexible, we mean that the system for collecting and reporting data needs to be able to adapt to different contexts. A systematic approach ensures that all health actors are using the same data collection forms, ensuring that the appropriate RH indicators are captured and reported consistently and in a timely manner. CLICK All relevant health actors, including non-traditional actors, in humanitarian emergencies should be engaged with and provided training on key RH data to be collected at different phases; CLICK Agreement on and development of a standardized approach to data collection at a global level would facilitate implementation. CLICK Using RH registers early in a crisis helps to highlight the key RH outcomes and guide interventions for establishment of a comprehensive reproductive health response. CLICK Health care provider involvement in the development and adoption of quality improvement tools enhances commitment, collaboration, and information sharing from health actors. CLICK Data sharing between services that are provided inside and outside the camps is essential for accurately capturing health outcome data in a timely manner. CLICK Finally, it is critical to evaluate the quality of Health Information System data early and work in close collaboration with health actors to develop and implement a detailed action plan to guide improvements and respond to emerging challenges; interagency collaboration is critical to success. CLICK

Lessons Learned Provider involvement in development and adoption of tools enhances commitment and collaboration Through this evaluation, we have learned that: A flexible, systematic approach to data collection and reporting is needed. When we say flexible, we mean that the system for collecting and reporting data needs to be able to adapt to different contexts. A systematic approach ensures that all health actors are using the same data collection forms, ensuring that the appropriate RH indicators are captured and reported consistently and in a timely manner. CLICK All relevant health actors, including non-traditional actors, in humanitarian emergencies should be engaged with and provided training on key RH data to be collected at different phases; CLICK Agreement on and development of a standardized approach to data collection at a global level would facilitate implementation. CLICK Using RH registers early in a crisis helps to highlight the key RH outcomes and guide interventions for establishment of a comprehensive reproductive health response. CLICK Health care provider involvement in the development and adoption of quality improvement tools enhances commitment, collaboration, and information sharing from health actors. CLICK Data sharing between services that are provided inside and outside the camps is essential for accurately capturing health outcome data in a timely manner. CLICK Finally, it is critical to evaluate the quality of Health Information System data early and work in close collaboration with health actors to develop and implement a detailed action plan to guide improvements and respond to emerging challenges; interagency collaboration is critical to success. CLICK

Data sharing between services provided inside and outside the camps Lessons Learned Provider involvement in development and adoption of tools enhances commitment and collaboration Data sharing between services provided inside and outside the camps Through this evaluation, we have learned that: A flexible, systematic approach to data collection and reporting is needed. When we say flexible, we mean that the system for collecting and reporting data needs to be able to adapt to different contexts. A systematic approach ensures that all health actors are using the same data collection forms, ensuring that the appropriate RH indicators are captured and reported consistently and in a timely manner. CLICK All relevant health actors, including non-traditional actors, in humanitarian emergencies should be engaged with and provided training on key RH data to be collected at different phases; CLICK Agreement on and development of a standardized approach to data collection at a global level would facilitate implementation. CLICK Using RH registers early in a crisis helps to highlight the key RH outcomes and guide interventions for establishment of a comprehensive reproductive health response. CLICK Health care provider involvement in the development and adoption of quality improvement tools enhances commitment, collaboration, and information sharing from health actors. CLICK Data sharing between services that are provided inside and outside the camps is essential for accurately capturing health outcome data in a timely manner. CLICK Finally, it is critical to evaluate the quality of Health Information System data early and work in close collaboration with health actors to develop and implement a detailed action plan to guide improvements and respond to emerging challenges; interagency collaboration is critical to success. CLICK

Data sharing between services provided inside and outside the camps Lessons Learned Provider involvement in development and adoption of tools enhances commitment and collaboration Data sharing between services provided inside and outside the camps Evaluate quality of HIS data early & work with partners to develop and implement an action plan Through this evaluation, we have learned that: A flexible, systematic approach to data collection and reporting is needed. When we say flexible, we mean that the system for collecting and reporting data needs to be able to adapt to different contexts. A systematic approach ensures that all health actors are using the same data collection forms, ensuring that the appropriate RH indicators are captured and reported consistently and in a timely manner. CLICK All relevant health actors, including non-traditional actors, in humanitarian emergencies should be engaged with and provided training on key RH data to be collected at different phases; CLICK Agreement on and development of a standardized approach to data collection at a global level would facilitate implementation. CLICK Using RH registers early in a crisis helps to highlight the key RH outcomes and guide interventions for establishment of a comprehensive reproductive health response. CLICK Health care provider involvement in the development and adoption of quality improvement tools enhances commitment, collaboration, and information sharing from health actors. CLICK Data sharing between services that are provided inside and outside the camps is essential for accurately capturing health outcome data in a timely manner. CLICK Finally, it is critical to evaluate the quality of Health Information System data early and work in close collaboration with health actors to develop and implement a detailed action plan to guide improvements and respond to emerging challenges; interagency collaboration is critical to success. CLICK

Acknowledgements UNHCR UNFPA Ministry of Health, Jordan Za’atari Health Actors - GSF, IMS, IRD, JHAS, MDM, MFH, MSF, RMS, Saudi Clinic CDC Syrian refugee population We would like to acknowledge numerous organizations and individuals for their support of this evaluation. Center for Global Health Emergency Response and Recovery Branch