Monitoring and Evaluation Tuberculosis Control Programs Learning Objectives

Monitoring and Evaluation: Tuberculosis Control Programs

Learning Objectives • Understand the principles of M&E for effective TB programming. • Construct conceptual and result frameworks. • Select and make proper use of indicators and data for TB M&E. • Be able to develop a monitoring and evaluation plan.

Content Outline • Problem statement • M&E (definitions) • Opportunities, challenges, and strategies for TB control • Conceptual and results frameworks • M & E frameworks

Content Outline…cont’d • • • Targets M & E indicators Source of data M&E tools for TLCP M & E challenges

Problem statement • 1/3 of world population (2 billion) infected with M. tuberculosis. • 9 million new cases of TB/year. • 2 million deaths/year. • Inadequate Control Programmes.

M&E What is monitoring? What is evaluation?

M&E Monitoring • is the routine tracking of programs using input, process and outcome data that are collected on a regular basis. • is used to assess whether or not planned activities are carried out according to schedule. • is usually done by insiders.

M&E …cont’d Evaluation Periodic assessment of programme or project against set targets. Usually done by outsiders. Types • Process evaluation • Outcome and impact evaluation

M&E…cont’d Process evaluation • is used to measure quality and integrity of programme implementation and to assess coverage • it may also measure the extent to which the intended target population uses services • inform midcourse corrections in the programme

M&E…cont’d Outcome evaluation • measures the extent to which stated objectives are achieved with respect to the programme’s goals • assesses influence of programme activities by measuring changes in knowledge, attitude, behaviors, skills, community norms, and health-service utilization.

M&E…cont’d Impact evaluation • is used to determine how much the observed change in outcomes can be attributed to specific programme efforts. • involves complex data collection and analysis procedures • assist to determine the success of a project for scaleup or replication.

Why M &E? • M& E assists in day-to-day management of health programmes. • M&E provides information for strategic planning, programme design and implementation. • M&E assists informed decision-making about human and financial resources, especially in resource-limited settings.

Good M&E • ensures the most efficient use of resources to generate the data needed for decision-making. • guides data collection and analysis to increase consistency and to enable managers to track trends over time. • serves as a catalyst to coordination.

Opportunities for TB Control • Low cost, accurate diagnosis and treatment available for over three decades. • M & E system is in place.

Challenges of TB Control • Global emergency - Rising incidence of TB. - HIV pandemic. - MDR- TB. • Gaps in coverage, case detection and treatment success

Control Strategy (DOTS) • Sustained political commitment. • Access to quality-assured TB sputum microscopy. • Standardized short-course chemotherapy. • Uninterrupted supply of quality-assured drugs. • Recording and reporting system enabling outcome assessment.

Basic Assumptions for DOTS • Government commitment avails sufficient funds and administrative support. • Microscopic exams detect the most infectious cases and are affordable. • Direct observation ensures adherence. • Uninterrupted drugs ensure cure. • Recording & Reporting help to monitor and evaluate.

Levels of intervention for TB Control • Primary – BCG vaccination - INH prophylaxis • Secondary – early diagnosis and proper treatment • Tertiary – Prevent complications

Conceptual Frameworks – TB Programmes External Factors Resources TB infection Health Systems (DOT) TB Morbidity • Availability Incidence Drugs • Access Laboratories • Quality HIV coinfection Clinical and managerial staff • Utilization Program Factors Political commitment Donor involvement National TB programme Prevalence TB mortality MDR-TB TB knowledge • Case detection Co-morbidity • Adherence • HIV • Stigma • Alcoholism Diabetes Malnutrition

M&E framework for TB programme INPUT PROCESS Policy environment NTP Mgt Human and financial resources Infrastructure Training OUTPUT OUTCOME IMPACT Diagnostic & Treatment services Case detection TB infection Case treatment TB morbidity Case holding TB mortality Improved KAP Drug Mgt Laboratories Reduced Stigma ACS CONTEXT Political commitment prevalence Health system Socio-economic conditions Epi-context Availability HIV Access Utilization Malnutrition Alcoholism

Results Frameworks - TB programmes SO 1: Increase tuberculosis case detection to 70% IRl: Increased availability IR 2: Increased demand for of quality services IRl. 1: Services increased IR 2. 1: Customer knowledge of TB improved IRl. 2: Practitioners’ skills and knowledge increased IR 2. 2: Social support for TB IRl. 3: Improved programme management practices increased

Global Targets (by 2005) Case detection Detect 70 % of all smear positive TB cases Treatment outcome 85% of detected TB cases are cured

Indicators • • Valid Reliable Specific Sensitive Operational Affordable Feasible Comparable

MDGs (by 2015) • Goal 6 : to combat HIV/AIDS, malaria, and other diseases • Target 8: to have halted and begun to reverse the incidence of malaria, TB, and other major diseases by 2015 Indicator 23: between 1990 and 2015, to halve the prevalence and death rates associated with tuberculosis; and Indicator 24: by 2005, to detect 70% of smear positive and successfully treat 85% of these cases.

Global Indicators • • • TB case detection. Treatment success rate. DOTS coverage. Surveillance of multi-drug resistant TB. HIV seroprevalence among TB patients.

Programme-outcome indicators • • Case-notification rate (all forms of TB) Case-notification rate (new smear-positive cases) Re-treatment of TB cases Smear-conversion rate Cure rate, Treatment-completion rate Treatment-failure rate Default rate Death rate

Sources of Information • • • Record forms at the health facility Record and report forms at the district level Laboratory records Report forms at the regional level Report forms at the national level

M&E tools for TLCP • Supervision checklist - checklist for programme management - checklist for health facility • Review meeting - annual and semi-annual - central, regional and district • External Quality Assurance

Additional sources of Information (Special studies) • • • Prevalence surveys Population-based surveys Health-facility surveys Vital registration surveys Tuberculin surveys Drug-resistance surveys

M & E challenges in TB • Incomplete recording and reporting • Inconsistent data collection • Lack of timeliness • Inappropriate use of information

Level of M&E in TB: The “ONION” estimated TB cases all true TB cases presenting to health facilities cases presenting to public health facilities cases presenting to DOTS facilities cases correctly diagnosed by DOTS facilities diagnosed cases reported by DOTS facilities Chris Dye, 2002

References 1. Compendium of Indicators For Monitoring And Evaluating National TB Programmes. Stop TB Partnership August 2004. 2. Toman’s Tuberculosis Case Detection, Treatment, And Monitoring. Second Edition WHO Geneva 2004 3. WHO REPORT 2005 GLOBAL TB CONTROL Surveillance, Planning, Financing