Strategic Information forStrategic Information forAnti-RetroViral Treatment Anti-RetroViral Treatment

ProgrammesProgrammes

WorkshopWHO and UNAIDSGeneva June 30- July 2 2003

OBJECTIVES OF THE MEETING

• Assess the needs for strategic information in the context of ART programmes

• Share experiences in developing monitoring and evaluation systems and other strategic information efforts

• Explore methods and techniques that can be considered for monitoring ART programmes

2 days and 30 presentations later

What we learned

Lack of good data on human resourcesWork with functional classification of health workers

Scale Up of Existing programmes with holistic approachTreatment Acceleration Programmes (TAP)

ARV drug resistance containment as a programme goalSurveillance needed if drugs available 3-5 yrs to at least 1% of HIV infected persons

A M&E guide for M&E of care and support programmes is in the final stages of development

TB Control programmes and Stop TB have a comprehensiveframework for the generation and use of strategic information

Logistics Management Information Systems, parallel and short term success,integrated and long term savings, and need to be agile

7 different AIDS case definitions and the need for a definition that is congruent for surveillance and clinical purposes;

Proposal to move to more active AIDS sentinel surveillance in facilities with and without ARV

QoL - visual analogue scale, time trade off and standard gamble

What we learned

Brazil started slowly but now has 125,000 people on treatment in 900 SDPs - 140 per SDP

Thailand aims for 900 SDPs for ARVs and 50,000 patients by the end of 2004Simply M&E tools that generate policy relevant data and no ‘one size fits all’

In Senegal research initially drove the programme, now need for simplification, M&E plan, but M&E capacity problem

Economics of ART programmes: more monitoring and research than for any other health intervention

Districts are the core of the health system: One district with less than half a million people in Malawi has 7,500 people in need of treatment - simple tools, community survey, clinic / programme M&E

iNGO in coastal Kenya aims to have 300 patients on treatment over 5 years, developing 8 patient clinic monitoring forms, research and programme development

Haiti DOT HAART delivery through accompagnateurs basis for different M&E system with quarterly updates

Kenya has a national plan, expands rapidly including NGOand private sector, considers smart card, bar codes

What we learned

Good monitoring systems can provide excellent data on survival, retention and adherence;costs could be integrated as well - but … 1 nurse per 100 ART eligible persons ...

Technology: paper predominantly used, phones for drugs logistics, bar coding for drug cartons, fingerprints, smart cards and point of sale devices, multitude of software developed (each programme own software),real time management, web based data from ART programmes linked to drug supply, luddites

Urgent need for involving the community and clients - through surveys, through participatoryresearch, through qualitative research and as part of programme monitoring

M&E as a by-product of the work flow of information exchange

Gathering information on the prevention care interaction is complex and only limited data canbe gathered as part of routine M&E activities

OBJECTIVES OF THE MEETING

• Assess the needs for strategic information in the context of ART programmes

• Share experiences in developing monitoring and evaluation systems and other strategic information efforts

• Explore methods and techniques that can be considered for monitoring ART programmes

• Develop a list of priority strategic information issues faced by national programmes and large-scale projects and explore ways to address those issues

STRATEGIC INFORMATION NEEDS

• What strategic information do we need to deliver ART programmes efficiently and effectively?

• What will ART programmes be evaluated on?

WHAT KIND OF INFORMATION DO WE NEED?

Needs, resources, access, coverageWhat are and will be the needs for treatment?What resources are available and what will be needed?How many have access? Who has access?

Programme Monitoring & EvaluationIs the programme performing according to plans?

Is the programme able to contain drug resistance development?Does the programme make a difference? Is it achieving its goals?

How much does it cost and how cost effective is it?Patient monitoring

Operations ResearchHow can programme implementation be improved?What are the best models of implementation?What can be done to improve health systems?

ResearchCan we provide more efficacious and more effective interventions?

What impact do programmes have?

OPERATIONALIZATION OF INFORMATION NEEDS

Needs, resources, accessComputer modelling and surveillance dataResource tracking in special studies

Routine programme Monitoring & EvaluationBasis is Patient monitoring system which will

provide data on N of people on treatment, treatment outcomesDrug supply monitoring system

AIDS surveillance

Operations ResearchSpecial studies carried out with local institutionsto supplement M&E data and feed into the programmes

ResearchLong term partnerships between research institutions

Supplementary programme Monitoring & EvaluationHealth facility survey or district survey

Community and individual preparedness assessmentHousehold survey on prevention-care and programme

TREATMENT NEEDS AND RESOURCES

Strategic Information Field

Assessment tools…………….. Country needs

Estimates of people in need of treatment by residence and sex

Based on projected deathsfrom HIV prevalence usingEPP and Spectrum

Human resources:workforce size anddistribution

Data availability on current staffing,training, future staffing needs,health system capacity, impact HIV

Economics Prospective and retrospectiveassessment of costs and estimates of cost-effectiveness;national health accounts;resource flow tracking

Input Process Output Outcome Impact

DATA COLLECTION for Monitoring and Evaluation

HIV/STI surveillance,

surveys

Patientmonitoring

HouseholdSurveys

Facility surveys

Patient monitoring

Programme Monitoring

PROGRAMME MONITORING (SERVICE DELIVERY POINT LEVEL)

Strategic Information Field

Assessment tools ……………...Country needs

Clinic monitoring Protocol that specifies the kind of data that need to be collected, forms and technologiesto be used, communication/reporting etc.

Outline the systemLink patient data, drug supply, feesMethods / technology to be usedContents definitions - indicators - kind of outcomes

Priorities

Steps needed

OperationsResearch

PROGRAMME MONITORING

Strategic Information Field

Assessment tools ……………...Country needs

Programme M&E Plan that outlines framework, keyprocess, output, outcome, impact indicatorsand how data will be collected

Logistics Assessment of feasibility different systems Develop LMIS; Use of technology (mobile phone,software, bar codes etc.)

ARV drug resistancesurveillance

Surveillance among newlyinfected persons (e.g. VCT)every 2-3 years

Care and supportprogrammes

Health facility survey and indicatorsto assess the quality of treatment of OIand palliative care

Care and supportprogrammes

Community or household survey /Routine data from NGOs etc.to assess coverage of home based care and support

Priorities

Steps needed

OperationsResearch needs

PROGRAMME MONITORING

Strategic Information Field

Assessment tools ……………...Country needs

Human resources Assessment of current staffing, staffingneeds, provider survey, district level

Private sector Assessment of feasibility of including private sector in M&E system

Community preparedness Survey, qualitative research, withcommunities and PLWHA

Priorities

Steps needed

OperationsResearch needs

Risk behaviour trends Surveys, qualitative research, developstrategy to assess changes and maximizepositive prevention effects

HIV testing & counselling

Laboratory capacity assessmentPatient monitoring

Service assessment (access and quality),community readiness, stigma, disclosure, obstacles

PROGRAMME MONITORING (OUTCOME ASSESSMENT)

Strategic Information Field

Assessment tools Country needs

AIDS surveillance WHO clinical case definitionReporting forms by main health facilities

Quality of life WHOQoL, MOS-HIV, MQoL-HIV

Hospitalization Hospital statistics with HIV status(% HIV+ in medical ward, duration admission)

Costs Cost monitoring at facility andat central levels

Mortality / survival Individual patient monitoring, through paper recordssmart cards, etc. / special studies

Health, morbidity, etc. Monitoring of body weight, being ambulatory, engaged in work or employment etc. Priorities

Immunology CD4+ cell counts, viral loads

Operations research issues: examples

Integrated systems to track patients, drugs and fees at point of delivery

Appropriate human resource planning for ARV programmes Working with the private sector – the franchising approach Setting and supervising/regulating health standards in ART

programmes Equity of access to ART programmes Measurement of costs of implementing ART programmes Assessment of community preparedness and readiness Measurement of stigma and discrimination in the context of ART

programmes Strategies to maximize long-term adherence (chronic disease model) Delivering and sustaining ART in drug-using communities

Research

CLINICAL When to start treatment What therapies to be used What methods for patient treatment response and toxicity monitoring

OUTCOME Survival, health, quality of life of patient but also children, family,

community

PREVENTION Longitudinal studies with trends in behaviour, stigma, risk perception etc.

Group assignment

What are the priority issues for programmes that need strategic information?

What are the first steps that need to be undertaken (at country and international levels) to: design a M&E system for ART programmes (planning,

standardization, simplification, technology etc.) assess the current capacity to develop / scale up a ART

programme (situation analysis) develop specific tools for monitoring and evaluation provide relevant data for programmes through operations

research establish longer term research