Compendium of Indicators for Monitoring and Evaluating National Tuberculosis Programs

Objectives of Session Provide an overview of the development of Compendium Explain the organization of the Compendium and how indicators are used Provide examples of how each subheading for an indicator guides selection/use of indicators

What is the Compendium? A comprehensive and standardized collection of the most widely used and recommended indicators for monitoring and evaluation of National TB Programs.

Who is it for? NTP managers, data managers, regional and district officers NGO program managers/data managers involved in TB programming Evaluation specialists Health system planners (HMIS etc) Anyone with responsibility for collecting, processing, analyzing, and presenting data on tuberculosis programs.

Specific Objectives Standardize M&E terminology across indicators and programs Encourage consistent use of indicators to monitor and evaluate programs Provide guidance for the development of comprehensive evaluation plans Serve as a resource for the different components of the monitoring and evaluation process Bullet 1 – This refers to input, process, output, outcome, impact. The idea is to get everyone on the same “page” in terms of how we think about M&E Bullet 2 – Also aimed at standardization, but in terms of what is actually reported. Making sure everyone uses the same numerators and denominators, criteria for assessing qualitative indicators. Bullet 3 - Provide guidance for the development of comprehensive evaluation plans, including selection of indicators to measure progress in specific areas Bullet 4 – Go beyond indicators, provide information/guidance on planning for M&E and strengthening M&E systems.

Current status of TB M&E Patient follow up/case management using WHO standardized forms Small number of indicators focusing on outcomes of DOTS implementation Project-specific monitoring forms Periodic assessment visits at facility level Focus is on disease control, where a patient centered or quality approach may serve us better.

Why a new TB M&E Guide? (1) New Global Initiatives Global Fund for AIDS, TB & Malaria STOP TB Partnership Increased USAID involvement TB/HIV initiatives DOTS Plus Global Fund for AIDS, TB and Malaria, which recommends 10% of program budgets go to M&E Stop TB – encouraging M&E under expanded DOTS framework USAID – went from spending very little in 1998 (8 million) to over 200 million last year. Links between TB and HIV epidemic DOTS Plus – to qualify for drugs from Green Light Committee, countries needed more systematic monitoring and evaluation

Why a new TB M&E Guide? (2) Need for a broader view of M&E Inputs-processes-outputs-impact: allows better understanding of how to achieve impact Standardized guidance for global use Program-based to complement case-management Program-specific indicators for different settings, types of programs

M&E Framework for TB programs INPUT Policy environment Human and Financial Resources Infrastructure PROCESS Management Training Drug management Laboratories Communication Advocacy OUTPUT Diagnostic services Treatment services Improved knowledge, attitudes, and practices Reduced stigma OUTCOME Case detection Treatment success IMPACT Prevalence of TB infection Prevalence of TB disease TB morbidity TB mortality Red – this is the core of M&E prior to Compendium development It provides a visual of how all the elements fit together Tool for understanding and analyzing a program Process and output are murky areas p7, Compendium of Indicators for Monitoring and Evaluating National Tuberculosis Programs USAID, MEASURE, CDC, WHO, IUATLD, KNCV, MSH. WHO/HTM/TB/2004.344, August 2004

M&E Framework for TB Programs INPUT Policy environment Human and Financial Resources Infrastructure PROCESS Management Training Drug management Laboratories Communication Advocacy OUTPUT Diagnostic services Treatment services Improved knowledge, attitudes, and practices Reduced stigma OUTCOME Case detection Treatment success IMPACT Prevalence of TB infection Prevalence of TB disease TB morbidity TB mortality Red shows how Compendium contributes to expanded M&E activities through use of M&E framework, new indicators for key DOTS elements It provides a visual of how all the elements fit together Tool for understanding and analyzing a program Process and output are murky areas p7, Compendium of Indicators for Monitoring and Evaluating National Tuberculosis Programs USAID, MEASURE, CDC, WHO, IUATLD, KNCV, MSH. WHO/HTM/TB/2004.344, August 2004

Compendium Development Step 1: Assessment of existing M&E systems within National TB programs and MOH Step 2: Create an international TB M&E Working group to develop and review indicators Step 3: Field test indicators in selected countries Step 4: Build capacity in M&E to collect, disseminate and use information Overview of how Compendium was developed.

Step 1: Assessment of current M&E systems Field visits to examine M&E systems: data collection forms, reporting, supervision, data use South Africa, Russia, Honduras, Philippines Met with NTPs, USAID missions, WHO, CDC, local implementing partners Review of literature on TB indicators Purpose of assessment visits was to see what was already out there – we did not want to increase the burden of data collection but also knew that many programs already collected so much info – wanted to see if we could use data that are collected but not reported or even used to identify problems or for program improvement. Countries chosen based on region and presence of specific program types and challenges. In each country – met with key partners and visited faciity, district and national level offices to review data collection and use.

Results from assessment visits Substantial amount of data collected at facility level that is not reported Weakness in reporting mechanisms for facility level data Few indicators on political commitment, IEC activities, drug supply and TB/HIV Lack of data from private sector physicians Findings – go over these. Third bullet – case detection and treatment outcome data already there.

Step 2: Creation of international working group Similar goals to develop more informative indicators on program implementation Bring expertise from a wide variety of sources: Stop TB, WHO, UNION, KNCV, CDC, USAID, World Bank, MSH, MEASURE/Evaluation

Results of TB M&E Working Group Indicators for DOTS: Measure key aspects of the TB epidemic in a country and the programmatic response Based on WHO recommendations and collected through existing systems External & Expert review

Step 4: Building capacity Step 3: Field testing Peru, Kazakhstan, Haiti & Thailand Revision of indicators based on field testing results Step 4: Building capacity Egypt (March ‘05), Mexico (April ‘05), Tanzania (September ‘05), India (January ‘06), Eastern Europe (May ‘06) Technical assistance

Indicators (1) Global indicators (5) Case detection Treatment success DOTS coverage HIV seroprevalence among TB cases Surveillance of MDR-TB Routinely reported program outcomes Smear conversion Treatment outcome

Indicators (2) Indicators to measure DOTS implementation under expanded framework: Political commitment (12) NTP annual workplan and budget Diagnosis (7) Existence of comprehensive laboratory network Case management, including DOT (2) Proportion of patients with correct prescription Drug management (8) Existence of a quality assurance system for drug management Each component of expanded DOTS frameword and an example of an indicator from each category.

Indicators (3) Indicators to measure DOTS implementation under expanded framework: Recording & reporting (2) Accuracy of reports sent to NTP Supervision (2) Existence of supervision guidelines Human resources development (3) Proportion of health centers with at least one professional trained in the DOTS strategy Health systems (1) Equitable distribution of DOTS