Monitoring and Evaluation of Tuberculosis Control Programs

1. Monitoring and Evaluation of Tuberculosis Control Programs

2. Learning Objectives • Understand the global threat and key drivers of the TB epidemic • Discuss the DOTS strategy and its implementation • Apply TB M&E tools and methodologies • Use and interpret key TB indicators

3. Session Outline • Global Threat of TB • TB Prevention and Control Strategies • Implementation of TB Strategies • Monitoring & Evaluation • Small Group Exercise

4. TB Facts • TB kills • TB affects poor countries • TB is treatable and can be cured • TB can be controlled

5. The Global Threat of TB1 • More than 2 billion people (1/3 of the world’s population) are infected with TB bacilli—1 in 10 will develop active TB • TB major health threat and economic burden:1.7 million deaths each year—primarily the poor in developing and transitional countries • TB leading cause of death among people living with HIV/AIDS; HIV important driver of TB epidemic, although not the only one • Multidrug resistant (MDR) and extensively drug resistant (XDR) TB is on the rise and major threat • 80% of TB burden is concentrated in 22 countries • 4-10 cases are not properly detected and treated 1WHO. 2008. Tuberculosis Facts (www.who.int/tb)

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

8. Stop TB Strategy Vision & Goal2 Vision: A World Free of TB Goal: To reduce dramatically the global burden of TB by 2015 in line with the MDG and the Stop TB Partnership targets 2WHO. 2006. Stop TB Strategy WHO/HTM/TB/2006.368

9. Stop TB Objectives • To achieve universal access to high-quality diagnosis and patient-centered treatment • To reduce the suffering and socioeconomic burden associated with TB • To protect poor and vulnerable populations from TB, TB/HIV and MDR-TB • To support the development of new tools and enable their timely and effective use

10. Six Principal Components of Stop TB Strategy • Pursue high-quality DOTS expansion and enhancement • Address TB/HIV, MDR-TB and other challenges • Contribute to health system strengthening • Engage all care providers • Empower people with TB, and communities • Enable and promote research

11. Key Elements of M&E for National TB Control Programs • Frameworks • Indicators • Data sources • Data use

12. Conceptual Framework for Proximate Risk Factors and Determinants of TB Lonnroth, K. et al. 2009

13. Results Frameworks—TB Programs SO1: Increase tuberculosis case detection IRl:Increased availability of quality services IR2:Increased demand for quality services IRl.1: Services increased IR2.1:Customer knowledge of TB improved IRl.2: Practitioners’ skills and knowledge increased IR2.2:Social support for TB practices increased IRl.3:Improved program management

14. M&E Framework for TB Program INPUT Policy environment Human and financial resources Infrastructure PROCESS NTP management Training Drug management Laboratories ACS OUTPUT Diagnostic & treatment services Improved KAP Reduced stigma OUTCOME Case detection Case treatment Case holding IMPACT TB infection TB morbidity TB mortality CONTEXT Political commitment Health system Socioeconomic conditions Epi-Context Availability HIV prevalence Access Malnutrition Utilization Alcoholism

15. Measuring Global Progress

16. Program Outcome Indicators • Case notification rate (all forms of TB) • Case notification rate (new smear-positive cases) • Re-treatment of TB cases • Smear-conversion rate • Treatment success rate, Cure rate, Treatment completion rate • Treatment failure rate • Default rate • Death rate

17. Source: Global TB Report 2010, WHO

18. Routine Sources of Information • Record forms at the health facility • TB Suspect Register • TB Laboratory Register • TB Treatment Card • TB Register (sometimes kept at district) • Record and report forms at the district level • Quarterly Report on TB Case Regisration • Quarterly Report on TB Treatment Outcomes and TB/HIV

20. estimated TB cases all true TB cases 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 Level of M&E in TB: The “ONION” Chris Dye, 2002

21. M&E tools for TB Programs • Supervision checklist - checklist for program management - checklist for health facility • Review meeting - annual and semi-annual - central, regional and district • External quality assurance

22. Additional Sources of Information(Special Studies) • Prevalence surveys • Population-based surveys • Health-facility surveys • Vital registration surveys • Tuberculin surveys • Drug-resistance surveys

23. Improving Measurements of Global TB Burden

24. Key TB/HIV Targets in High HIV Prevalence Settings • 100% people living with HIV and attending HIV Services screened for TB in 2015 • 31 m. newly diagnosed and eligible people living with HIV placed on IPT annually • 85% of TB patients in DOTS programs HIV-tested and counseled annually • 57% of HIV-positive TB patients placed on ART annually

27. Drug-Resistant TB • Scale up access to testing for MDR-TB first and second line drugs • Scale up access to treatment for MDR-TB • Scale up infection control in MDR-TB facilities • Strengthen surveillance, including recording and reporting of MDR-TB • Scale up capacity to manage MDR-TB

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

30. Strengthening M&E including Impact • Assessments of the quality and coverage of case notification and vital registration data • Development and strengthening of VR systems • Prevalence surveys in selected countries • Development of electronic recording and reporting systems • Strengthening TB/HIV and MDR-TB surveillance systems • Harmonize TB R&R with national HMIS

31. Resources • Compendium of Indicators for Monitoring and Evaluating National TB Programmes. Stop TB Partnership, August 2004. • Toman’s Tuberculosis Case Detection, Treatment, and Monitoring. Second Edition. WHO Geneva, 2004 • WHO REPORT 2005 GLOBAL TB CONTROL Surveillance, Planning, Financing

32. MEASURE Evaluation is funded by the U.S. Agency for International Development (USAID) and implemented by the Carolina Population Center at the University of North Carolina at Chapel Hill in partnership with Futures Group, ICF Macro, John Snow, Inc., Management Sciences for Health, and Tulane University. Views expressed in this presentation do not necessarily reflect the views of USAID or the U.S. government. MEASURE Evaluation is the USAID Global Health Bureau's primary vehicle for supporting improvements in monitoring and evaluation in population, health and nutrition worldwide.