SRH Facility Assessment Checklist Good day. Thank you for agreeing to participate in this brief survey, which will take approximately 90 minutes. Before we begin, I'd like to briefly explain the purpose of this exercise and why we're engaging with you. The SWAP Office, in collaboration with the Federal Ministry of Health (FMoH) and the National Primary Health Care Development Agency (NPHCDA), is implementing targeted interventions across eight priority states, including [insert state], to improve access to family planning and post-abortion care, in response to ongoing RMNCAH challenges. As part of this effort, the facility checklist will assess the availability, accessibility, affordability, and quality of Sexual and Reproductive Health (SRH) services, while capturing data on facility infrastructure, service delivery, costs, supply chain, human resources, and continuity of care. Your perspective will help us identify strengths, gaps, and opportunities for improvement with respect to SRH service delivery. Participation in this survey is voluntary. We will not collect direct personal identifiers such as names or contact details. Your responses will be treated confidentially, reported in aggregate, and you may withdraw at any time without consequence. However, your insights are critical to informing the assessment in [insert state] and influencing future improvements. Do you consent to participating in this? Yes yes No no Facility Location State Ondo ondo Ekiti ekiti Taraba taraba Zamfara zamfara Enugu enugu Akwa Ibom akwa_ibom Kebbi kebbi Benue benue LGA (Local Government Area) Ward Name of Facility Type of Facility Demographics Gender of the officer in charge Male male Female female Designation of health personnel accompanying the data collector for the facility assessment Service Availability Which maternal health services are offered at this facility? Please select all applicable services Antenatal care Delivery services anc Postnatal care pnc Referral services for high-risk pregnancies and complications ref Which family planning (FP) services are offered at this facility? Please select all app/icab/e services Contraceptive counselling couns Short-acting contraceptives (condoms, oral contraceptive pills) sac Long-acting reversible contraceptives (injectables, implants, IUDs) larc Permanent/irreversible contraceptives (e.g., vasectomy) pic Post-partum family planning ppfp N/A na Which cervical cancer prevention and care services are offered at this facility? Cervical cancer screening and prevention ccsp Treatment of cervical pre-cancers topc N/A na Which post-abortion care (PAC) services are offered at this facility? Please select all applicable services Medical management of complications following abortion m_management Counselling and emotional support couns_emo_s Family planning services to prevent unintended pregnancies fps_p Follow-up care for physical and mental health fuc_pm Surgical management of abortion (MVA) sma_mva Which adolescent sexual and reproductive health (ASRH) services are offered at this facility? Contraceptive counselling for adolescents cca Pregnancy testing for adolescents STI/HIV screening and treatment pt_hiv HPV prevention and vaccination hpv_p N/A na Which gender-based violence (GBV) services are offered at this facility? Screening and identification of GBV during health visits screen Emergency care for injuries related to violence ecirv Counselling and psychosocial support for survivors cpss Referral to legal aid and social support services referr HIV/STI screening hs_screen Post-Exposure Prophylaxis (PEP) pep N/A na Which outreach services are offered at this facility? Please select all applicable services Community mobilization and demand creation for SRH services, including adolescent and youth-focused outreach cmdc Community-based distribution of SRH commodities (e.g., condoms, oral contraceptives) cbdc Defaulter tracing, follow-up, and linkage of hard-to-reach populations to facility-based SRH services df_linkage Community-level risk identification and referral, including high-risk pregnancies, STI/HIV risks, and GBV cases clri N/A na Cost of Service(s) Which of the available services are free? Please select all applicable services Antenatal care Delivery services anc Postnatal care pnc Referral services for high-risk pregnancies and complications (including transport) reff Short-acting contraceptives (condoms, oral contraceptive pills) sac Long-acting reversible contraceptives (injectables, implants, IUDs) larc Permanent/irreversible contraceptives (e.g., vasectomy) perm_c Post-partum family planning ppfp Cervical cancer screening and prevention Treatment of cervical pre-cancers ccsp Surgical management of abortion (MVA) sma_mva Medical management of complications following abortion mmcfa Family planning services provided as part of PAC ffsp_pac Follow-up care for physical and mental health (where clinical visits or medications are involved) fu_pmh Pregnancy testing for adolescents STI/HIV screening and treatment ptasst HPV prevention and vaccination hpvpv Emergency care for injuries related to violence (clinical care, drugs, procedures) ec_irv Referral to legal aid and social support services ref_leg Community-based distribution of SRH commodities (e.g., condoms, oral contraceptives), where applicable cbd_srh Antenatal care Delivery services Postnatal care Post-partum family planning Referral services for high-risk pregnancies and complications (including transport) Short-acting contraceptives (condoms, oral contraceptive pills) Long-acting reversible contraceptives (injectables, implants, IUDs) Permanent/irreversible contraceptives (vasectomy, hysterectomy) Cervical cancer screening and prevention Treatment of cervical pre-cancers Surgical management of abortion (MVA) Medical management of complications following abortion Family planning services provided as part of PAC Follow-up care for physical and mental health (where clinical visits or medications are involved) Pregnancy testing for adolescents STI/HIV screening and treatment HPV prevention and vaccination Emergency care for injuries related to violence (clinical care, drugs, procedures) Referral to legal aid and social support services Community-based distribution of SRH commodities (e.g., condoms, oral contraceptives), where applicable Does the facility identify women eligible for existing health insurance or subsidy schemes and support their enrollment or linkage? Yes yes No no How many women are currently enrolled in an health insurance/subsidy scheme in your facility? Availability of essential SRH commodities in the facility Which essential maternal health commodities are available at this facility? Please select all applicable commodities. Verify availability of listed commodities before selecting an option Oxytocin injection ox_i Carbetocin / Heat-Stable Carbetocin ca_hc Misoprostol & Mifepristone tablet m_mt Ergometrine ergo Magnesium sulfate injection msi Tranexamic Acid (TXA) tran_acid Benzyl penicillin injection bp_i Gentamicin injection genta Ceftriaxone ceftri Amoxicillin tablets amox_tab Methyldopa meth Nifedipine nifed Fesolate fes Folic acid fol_a Sulfadoxine-Pyrimethamine sulf_pyri Tetanus toxoid tet_tox Urinalysis dipsticks uri_dip Vitamin K vit_k Others others Please specify others Duration of maternal commodities stockout Oxytocin injection (Number of Days) Carbetocin / Heat-Stable Carbetocin (Number of Days) Misoprostol & Mifepristone tablet (Number of Days) Ergometrine (Number of Days) Magnesium sulfate injection (Number of Days) Tranexamic Acid (TXA) (Number of Days) Benzyl penicillin injection (Number of Days) Gentamicin injection (Number of Days) Ceftriaxone (Number of Days) Amoxicillin tablets (Number of Days) Methyldopa (Number of Days) Nifedipine (Number of Days) Fesolate (Number of Days) Folic acid (Number of Days) Sulfadoxine-Pyrimethamine (Number of Days) Tetanus toxoid (Number of Days) Urinalysis dipsticks (Number of Days) Vitamin K (Number of Days) Which essential FP commodities are available at this facility? Please select all applicable commodities. Verify availability of listed commodities before selecting an option Male condoms male_c Female condoms female_c Oral contraceptives oral_c Emergency contraceptive pills emergency_p Injectable contraceptives injectable_c Implants implants_I Intra-Uterine Contraceptive Device (IUCD) iucd Others others_O Please specify others Duration of stockout for family planning commodities Male condoms (Number of Days) Female condoms (Number of Days) Oral contraceptives (Number of Days) Emergency contraceptive pills (Number of Days) Injectable contraceptives (Number of Days) Implants (Number of Days) Intra-Uterine Contraceptive Device (IUCD) (Number of Days) Which essential PAC commodities are available at this facility? Please select all applicable commodities. Verify availability of listed commodities before selecting an option Misoprostol & Mifepristone tablet miso_mife Oxytocin injection Tranexamic Acid (TXA) oxy_inj Gentamicin injection genta_inj Ceftriaxone ceftriax Doxycycline doxycycl Azithromycin tablets azithrom Metronidazole tablets metro_tab Ibuprofen tablets ibu_tab Diazepam tablets diaz_tab Others oth Please specify others Duration of PAC commodities stockout Misoprostol & Mifepristone tablet Oxytocin injection Tranexamic Acid (TXA) Gentamicin injection Ceftriaxone Doxycycline Azithromycin tablets Metronidazole tablets Ibuprofen tablets Diazepam tablets Which essential GBV commodities are available at this facility? Please select all applicable commodities. Verify availability of listed commodities before selecting an option HIV post-exposure prophylaxis (PEP) hiv_pep Emergency contraceptive pills ecp HIV test kits hiv_tk VDRL (syphilis test kits) vdrl Azithromycin tablets az_tab Doxycycline doxycycl Metronidazole tablets metronid Clotrimazole vaginal tablets clotrima Disposable sanitary pads disposab Others oth Please specify others Duration of GBV commodities stock-out HIV post-exposure prophylaxis (PEP) (Number of Days) Emergency contraceptive pills (Number of Days) HIV test kits (Number of Days) VDRL (syphilis test kits) (Number of Days) Azithromycin tablets (Number of Days) Doxycycline (Number of Days) Metronidazole tablets (Number of Days) Clotrimazole vaginal tablets (Number of Days) Disposable sanitary pads (Number of Days) Essential commodities stocking What other essential SRH commodities are in stock? What other essential SRH commodities are out of stock? What is the stock out duration of each? Which SRH commodities are stocked in excess? Does the facility have effective mechanisms to monitor and respond to stock-outs of SRH commodities, minimizing service disruption? Yes yes No no Does the facility have privacy-enhanced consultation spaces for SRH services? Do not rely on staffreports only. Observe the SRH consultation space directly before answering Yes yes No no Are SRH commodities stored in a site that meets the following criteria? Please indicate all that apply. Inspect the SRH commodity storage area and verify that it meets the listed criteria before selecting a response Clean and free from evidence of pests or animals clean_pa Well-ventilated and cool wellv_c Stored on shelves, pallets, or cabinets to prevent crushing or placement on the floor sh_pall Shielded from direct sunlight shild_sun Free from ceiling leaks fr_cl Expired products separated from usable products exp_usa Secure, with lockable storage or a security guard sec_sg Service Delivery Are the following services administered during antenatal care in this facility? Tick as appropriate; randomly select five (5) case notes to verify. Weight measurement wt_msmnt Blood pressure check bp_chck Check for signs of anaemia sgns_anae Examination of hands and feet for edema hf_exam Measurement of fundal height using measuring tape fund_ht Monitoring fetal heart rate fet_heart PCV/Hb Check pcv_chk VDRL (Syphilis) screening vdrl_screen HIV screening hiv_screen HBsAg screening hbsag_screen HCV screening hcv_screen Blood sugar level screening Urinalysis screening_Urinalysis Tetanus Inj. Administration inj_Administration Routine ANC drugs anc_drugs Are the following assessed and recorded when admitting women in labour? (Tick as appropriate: randomly select five (5) case notes to verify) ANC records anc_rec Pregnancy and labour history preg_hist Vaginal examination and confirmation of labour vag_conf Vital signs of the woman (Blood Pressure, Pulse Rate, Respiratory Rate, & Temperature) vit_signs Fetal heart rate fhr Foetal Lie, position, and presentation flpp Urinalysis urinalysis_labor HIV Screening (if not done previously) hiv_not Head positioning and moulding head_moul Cervix dilation and effacement cerv_effa Contraction frequency, duration and intensity cactionff Monitoring of Labor Does the facility consistently use partographs/labour care guides for all women in labor? Yes yes No no Are PPH bundles complete and available at the facility? Yes yes No no Are PPH cases correctly identified and managed according to the bundle? Yes yes No no Did referred obstetric emergencies receive appropriate care on arrival? Yes yes No no Are women allowed to have their companion of choice during labour and childbirth? Yes yes No no Family Planning Services Is family planning education and/or counseling routinely offered onsite to clients who wish to delay or prevent pregnancy? Confirm from FP register Yes yes No no Are education materials (IEC) about contraception and safe conception on display or available to clients (e.g., pamphlets, posters, brochures) accessing this service ? Yes yes No no Adolescent SRH services How many providers are trained on adolescent-friendly communication and confidentiality principles? None adol_non 1 adol_1 2 and above adol_2plus Is there a dedicated time or space for adolescents to receive FP services in this facility? Cite dedicated space/document Yes yes No no Is support available to provide adolescent-specific services (e.g., peer leaders, mentor mothers, support groups) Cite supporting document Yes yes No no Gender-Based Violence Services Are post-violence care services accessible and affordable? Tick all that apply Post-violence care is offered during all hours a facility is open either by staff who are physically at the facility or on-call to respond open_fac The survivor can receive essential care without reporting the assault to the police (review intake protocol and/or forms to ensure police report is not required to receive services) no_report Service charge reduced or waived for GBV services reduced_charges How many health care workers administering post-violence care services have been trained on these standard procedures (including clinical management specific to children and adolescents? Cite training certificates None hcw_non 1 hcw_one 2 and above hcw_2plus Are referrals for post-violence care documented? Yes yes No no Does your facility have equipment to carry out quality comprehensive post abortion care services? Verify the availability and functionality of PAC equipment before selecting a response Yes yes No no Does your facility have PAC preparedness guidelines? Request to see the documented guidelines before selecting a response Yes yes No no Do you have an effective waste disposal system for PAC services? Request to see the disposal system before selecting a response Yes yes No no Does the facility have reliable and approved suppliers for SRH commodities to ensure consistent supply? Yes yes No no Does the facility have a functional inventory management system for SRH commodities? Yes yes No no Which of these inventory management system is functional? Please select all applicable The facility uses inventory management tools to keep stock records (e.g. stock cards) mng_tool Stock cards are updated on a transactional basis (i.e., whenever stock is sent from the storage site to another site within the facility) stk_crds The facility submits timely orders for the SRH commodities (as defined by the in-country re-supply schedule or during the past 3 months)" tml_ord What transportation methods are employed for procuring and distributing SRH commodities? Please select all applicable Dedicated facility vehicles ded_vec Cold chain vehicles/Refrigerated trucks or vans) ccv_rtv Third-party logistics/courier services tp_cs Public transport (buses, taxis) pub Motorbikes/Motorcycles mb_mc Foot delivery ftd Are the transportation methods reliable, timely, and appropriate to maintain product quality? Yes yes No no Please indicate the availability and functionality of the following infrastructure and equipment items critical for SRH service delivery. Reliable power supply Available and Functional avf Available but Non-Functional av_nf Not Available nav Reliable water supply Available and Functional avf Available but Non-Functional av_nf Not Available nav Toilet Available and Functional avf Available but Non-Functional av_nf Not Available nav Dedicated SRH/Maternity ward Available and Functional avf Available but Non-Functional av_nf Not Available nav Operating theater (CEmONC only) Available and Functional avf Available but Non-Functional av_nf Not Available nav Blood bank/Transfusion services (CEmONC only) Available and Functional avf Available but Non-Functional av_nf Not Available nav Delivery beds Available and Functional avf Available but Non-Functional av_nf Not Available nav Neonatal resuscitation kit Available and Functional avf Available but Non-Functional av_nf Not Available nav Vacuum extractor / forceps Available and Functional avf Available but Non-Functional av_nf Not Available nav Sterile delivery kits (clamps, scissors, cord clamps) Available and Functional avf Available but Non-Functional av_nf Not Available nav Partograph/labour care guide for labor monitoring Available and Functional avf Available but Non-Functional av_nf Not Available nav Suction apparatus and Mucus extractor Available and Functional avf Available but Non-Functional av_nf Not Available nav Manual Vacuum Aspiration (MVA) kits Available and Functional avf Available but Non-Functional av_nf Not Available nav IUD insertion/removal tray with sterile instruments Available and Functional avf Available but Non-Functional av_nf Not Available nav Implant insertion/removal set Available and Functional avf Available but Non-Functional av_nf Not Available nav Blood pressure apparatus & stethoscope Available and Functional avf Available but Non-Functional av_nf Not Available nav Examination & forensic kits Available and Functional avf Available but Non-Functional av_nf Not Available nav Autoclave or sterilizer Available and Functional avf Available but Non-Functional av_nf Not Available nav Pregnancy test kits Available and Functional avf Available but Non-Functional av_nf Not Available nav Are procured SRH commodities received and distributed appropriately at this facility? Yes yes No no How many health facilities procured SRH commodities? How many health facilities received the procured SRH commodities? Human Resources for Health (HRH) How many of the following cadres are currently engaged and working at this facility? Obstetricians/GynecoIogists Medical Officers Nurses Midwives Community Health Officers (CHO) Senior Community Health Extension Workers (SCHEW) Junior Community Health Extension Workers (JCHEW) Pharmacists Pharmacy Technician / Assistant Medical Laboratory Scientist / Technician Medical Records Officer Health Attendants / Assistants How many health workers are available 24/7? Obstetricians/GynecoIogists Medical Officers Nurses Midwives Community Health Officers (CHO) Senior Community Health Extension Workers (SCHEW) Junior Community Health Extension Workers (JCHEW) Pharmacists Pharmacy Technician / Assistant Medical Laboratory Scientist / Technician Medical Records Officer Health Attendants / Assistants Are there valid certificates and/or current practicing licenses available for all health workers? Verify certificates and licenses. All HCWs have valid certificates and or current practising licenses all_hcw Some HCWs have valid certificates and or current practising licenses som_hcw No HCW had valid certificates and or current practising licenses non_hcw How many medical officers have been posted to this facility within the last 12 months? How many medical officers have been posted out of this facility within the last 12 months? How many nurses/midwives have been posted to this facility within the last 12 months? How many nurses/midwives have been posted out of this facility within the last 12 months? How many CHEWS (SCHEWS &JCHEWS) have been posted to this facility within the last 12 months? How many CHEWS (SCHEWS &JCHEWS) have been posted out of this facility within the last 12 months? How many community health officers (CHO) have been posted to this facility within the last 12 months? How many community health officers (CHO) have been posted out of this facility within the last 12 months? How many SBAs were trained on the following key SRH services in the last 12 months? Input number only Comprehensive abortion care services (includes legal indications for abortion, medical/surgical management of pregnancy termination, and pre/post procedure counseling) Post abortion care (including emergency treatment for incomplete abortion or complications, empathetic counseling, and immediate provision of voluntary contraceptive methods to prevent repeat unintended pregnancies) Trauma-informed care (includes clinical "stop signals" for clients, non-judgmenta/ counseling for survivors of violence, and managing secondary traumatic stress for providers) PAC stigma-reduction How many mentorship sessions on the following SRH areas were conducted at the facility in the last 12 months? Management of Postpartum Hemorrhage (PPH) Management of Eclampsia Comprehensive abortion care services (includes legal indications for abortion, medical/surgical management ofpregnancy termination, and pre/post procedure counseling) Post abortion care (including emergency treatment for incomplete abortion or complications, empathetic counseling, and immediate provision of voluntary contraceptive methods to prevent repeat unintended pregnancies) Trauma-informed care (includes clinical "stop signals" for clients, non-judgmental counseling for survivors of violence, and managing secondary traumatic stress for providers) Family planning (includes types of available contraceptive methods, common side effects, etc) Service Utilization Please indicate the number of women who accessed each service at this facility for the first time during the last 30 days Antenatal Care (ANC) Delivery services (including facility-based deliveries) Postnatal Care (PNC) Family planning- Counseling only Short-acting methods (condoms, pills, injectables) Long-acting reversible contraceptives (IUD, implants) Permanent/irreversible methods (e.g., sterilization, vasectomy) PAC counseling and medical management PAC complications management Counseling, health education, or screening services for adolescents Medical, psychosocial, or legal support services Screening, treatment, or counseling for STIs/HlV Cervical cancer screening Other reproductive health services (please specify) Are privacy screens or curtains consistently used during patient examinations and procedures to ensure confidentiality? Yes yes No no Which SRH service was the most commonly accessed by new clients in the last 30 days? Please state Using facility registers, please indicate the total number of the following services provided at this facility during the last 6 months Total Antenatal Care (ANC) Visits Total Institutional Deliveries Total Cesarean Sections (CEmONC) Post-Abortion Care (PAC) Clients Family Planning New Acceptors Total Referrals In (Emergency) Total Referrals Out (Emergency) Number of bookings (3 years prior) Number of pregnant women completing at least 4 ANC visits Referral & Emergency Systems Does the facility have a functional referral system for RMNCAH/SRH services? Yes re_yes Partially functional re_pf No re_no Are referral communication mechanisms functional? Yes re_yes Partially functional re_pf No re_no Are referral feedback mechanisms functional? Yes re_yes Partially functional re_pf No re_no What referral mechanisms are used to link clients to higher-level facilities? Standard referral forms srf_ref Phone calls phon Digital/electronic referrals de_ref Transport arrangements Community health worker accompaniment tachwa Other other_ref Please specify others Are referral feedback mechanisms functional? Always alws Sometimes smtms Rarely rare Not tracked nt_trck How many referred clients successfully reached higher-level care? Is there a functional emergency helpline for RMNCAH/SRH emergencies? Yes re_yes Partially functional re_pf No re_no What arrangements does this health facility have for patient emergency transport? None em_none Motorcycle or tricycle (keke) em_bike Functional ambulance em_ambu Other dedicated mechanism for emergency transportation service em_other Please state (other) emergency transport system Is there a dedicated ambulance driver that is available at all times (i.e., 24 hours)? Yes yes No no How many ambulances are available for use at this facility? Are follow-up mechanisms in place for clients referred or discharged from the facility? Yes yes No no What kind of client follow-up does your facility use? Appointment cards or written reminders apptmnt Phone calls to clients phone_cals SMS/text message reminders sms_text Home visits visit Community health worker tracking chwt Scheduled clinic appointments sch_apt Digital follow-up tools like whatsApp or other social media messaging dig_foll Facility outreach or community follow-up fam_outr Client-initiated follow-up only (no active tracking) cli_in_foll Referral follow-up with another facility ref_foll No formal follow-up mechanism no_form Are records of follow-up and referral outcomes maintained and accessible? Yes re_yes Partially functional re_pf No re_no Are women enrolled in community-based follow-up systems? Yes yes No no Health Management Information System Does the facility have a documented process or set of standard operating procedures to ensure that the data it collects and reports accurately reflect the services provided at the site? Cite SOPs/protocol Yes yes No no Did the health facility conduct service delivery data review meeting in the last quarter? Cite minutes of the data review meeting. Review meeting not conducted not_conduct Review meeting conducted with no evidence no_evide Review meeting conducted with evidence evidence Is there a monthly Maternal and Perinatal Death Surveillance and Response (MPDSR) meeting conducted at the facility? Review meeting not conducted not_conduct Review meeting conducted with no evidence no_evide Review meeting conducted with evidence evidence Are maternal and perinatal deaths reviewed and follow-up actions implemented? Review meeting not conducted not_conduct Review meeting conducted with no evidence no_evide Review meeting conducted with evidence evidence Is there a formal and accessible system in place for collecting patient feedback or complaints regarding SRH services? Review meeting not conducted not_conduct Review meeting conducted with no evidence no_evide Review meeting conducted with evidence evidence Using facility registers, please indicate the total number of the following services provided at this facility in the last 2 years Total Antenatal Care (ANC) visits in 2023 Total Antenatal Care (ANC) visits in 2024 Total Antenatal Care (ANC) visits in 2025 Percentage (%) of pregnant women completing at least 4 ANC visits (most recent year available) Number of pregnancy bookings in 2023 Number of Pregnancy bookings in 2024 Number of Pregnancy bookings in 2025 Total vaginal deliveries in 2023 Total vaginal deliveries in 2024 Total vaginal deliveries in 2025 Total cesarean deliveries in 2023 Total cesarean deliveries in 2024 Total cesarean deliveries in 2025 Total family planning/contraceptive service visits in 2023 Total family planning/contraceptive service visits in 2024 Total family planning/contraceptive service visits in 2025 Number of clients counselled and/or tested for STI/HIV in 2023 Number of clients counselled and/or tested for STI/HIV in 2024 Number of clients counselled and/or tested for STI/HIV in 2025 HIV prevalence among clients in 2023 HIV prevalence among clients in 2024 HIV prevalence among clients in 2025 Facility Maternal Mortality Ratio (MMR) in 2023 Facility Maternal Mortality Ratio (MMR) in 2024 Facility Maternal Mortality Ratio (MMR) in 2025 Facility Neonatal Mortality Ratio (MMR) in 2023 Facility Neonatal Mortality Ratio (MMR) in 2024 Facility Neonatal Mortality Ratio (MMR) in 2025 Number of outward referrals completed in 2023 Number of outward referrals completed in 2024 Number of outward referrals completed in 2025 Number of referrals received in 2023 Number of referrals received in 2024 Number of referrals received in 2025 Thank you for your time and and participation. Your responses are very valuable and will immensely help this assessment