Monitoring and Evaluation: Tuberculosis Control Programs

1. Monitoring and Evaluation: Tuberculosis Control Programs

2. 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.

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

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

5. 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.

6. M&E What is monitoring? What is evaluation?

7. 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.

8. 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

9. 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

10. 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.

11. 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 scale-up or replication.

12. 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.

13. 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.

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

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

16. 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.

17. 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.

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

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

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

21. Results Frameworks - TB programmes SO1: Increase tuberculosis case detection to 70% 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 programme management

22. Global Targets (by 2005)

23. Indicators • Valid • Reliable • Specific • Sensitive • Operational • Affordable • Feasible • Comparable

24. 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.

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

26. 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

27. 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

28. 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

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

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

31. 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

32. References • 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