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 scale-up 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

External

Factors Resources

Clinical and managerial staff

Drugs

Laboratories

TB infection

Program Factors

Political commitment

Donor involvement

National TB programme

Conceptual Frameworks – TB Programmes

Health Systems (DOT)•Availability

•Access

•Quality

•Utilization

TB Morbidity

Prevalence

Incidence

HIV co-infection

MDR-TB

TB mortality

TB knowledge

•Case detection

•Adherence

•Stigma

Co-morbidity

• HIV Malnutrition

•Alcoholism Diabetes

INPUT

Policy environment

Human and financial resources

Infrastructure

PROCESS

NTP Mgt

Training

Drug Mgt

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 Socio-economic conditions Epi-context Availability HIV prevalence Access Malnutrition Utilization Alcoholism

M&E framework for TB programme

IRl: Increased availability of quality services

Results Frameworks - TB programmes

SO1: Increase tuberculosis case detection to 70%

IR2: Increased demand for quality services

IRl.2: Practitioners’ skills and knowledge increased

IRl.3: Improved programme management

IRl.1: Services increased

IR2.2: Social support for TB practices increased

IR2.1: Customer knowledge of TB improved

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

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

Chris Dye, 2002

Level of M&E in TB: The “ONION”

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