Monitoring and Evaluation: Tuberculosis Control Programs

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Monitoring and Evaluation Tuberculosis Control
Programs
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Learning Objectives

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

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Content Outline

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

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Content Outlinecontd

• Targets
• M E indicators
• Source of data
• ME tools for TLCP
• M E challenges

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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.

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ME

• What is monitoring?
• What is evaluation?

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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.

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ME contd

• Evaluation
• Periodic assessment of programme or project
  against set targets.
• Usually done by outsiders.
• Types
• Process evaluation
• Outcome and impact evaluation

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MEcontd

• 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

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MEcontd

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

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MEcontd

• 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.

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Why M E?

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

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Good ME

• 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.

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Opportunities for TB Control

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

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Challenges of TB Control

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

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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.

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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.

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Levels of intervention for TB Control

• Primary BCG vaccination
• - INH prophylaxis
• Secondary early diagnosis and proper
  treatment
• Tertiary Prevent complications

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Conceptual Frameworks TB Programmes
External Factors Resources 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

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

• Valid
• Reliable
• Specific
• Sensitive
• Operational
• Affordable
• Feasible
• Comparable

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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.

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Global Indicators

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

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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

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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

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ME 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

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Additional sources of Information(Special
studies)

• Prevalence surveys
• Population-based surveys
• Health-facility surveys
• Vital registration surveys
• Tuberculin surveys
• Drug-resistance surveys

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M E challenges in TB

• Incomplete recording and reporting
• Inconsistent data collection
• Lack of timeliness
• Inappropriate use of information

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Level of ME in TB The ONION
Chris Dye, 2002
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References

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