MONITORING & EVALUATION OF HEALTH PROGRAMME By DR.I.SELVARAJ,I.R.M.S B.Sc., M.B.B.S.,(M.D, Community Medicine)., D.P.H.,D.I.H.,PGCH&FW (NIHFW, New Delhi)

Monitoring and evaluation are essential management tools which help to ensure that health activities are implemented as planned and to assess whether desired results are being achieved. Monitoring: 1. To provide concurrent feedback on the progress of activities 2.To identify the problems in their implementation 3.To take corrective action Evaluation: To assess whether the desired results of a programme have been achieved if not how it should be redesigned

MONITORING A process of measuring, recording, collecting and analyzing data on actual implementation of the programme and communicating it to the programme managers so that any deviation from the planned operations are detected, diagnosis for causes of deviation is carried out and suitable corrective actions are taken.

1.It helps in setting norms of performance 2.It helps in measuring level of performance 3.It helps in comparing performance level with standards or norms 4.It helps in identifying deviations and explain the reasons for the deviation for taking necessary corrective action

Monitoring and Planning The purpose of monitoring is to ensure that programmes are implemented as planned. Preparation of action plan The plan should specify what needs to be done, who is going to do it, and when it is to be done Inadequacy in planning will result in inadequacy in monitoring

Monitoring process Detecting deviations from plans Diagnosing causes for deviations Taking corrective action

Different levels of Monitoring Managers at top level They have to develop health plans based on objectives, goals, devise strategy and allocate necessary resources Managers at the middle level They are more concerned with whether they are getting desired output from the inputs that are being utilized Managers at the operational level They have to supervise actual operations and to ensure that planned activities are being carried out as per schedule

EVALUATION It is a systematic way of learning from experience and using the lessons learnt to improve current activities and promote better planning by careful selection of alternatives for future action

Reasons for carrying out an Evaluation To review the implementation of and services provided by health programmes so as to identify problems and recommend necessary revisions of the programme To assess progress towards desired health status at national or state levels and identify reasons for gap, if any To contribute towards better health planning To document results achieved by a project funded by donor agencies To know whether desired health outcomes are being achieved and identify remedial measures

To improve health programmes and the health infrastructure Allocation of resources in current and future programme To render health activities more relevant, more efficient and more effective

Types of Evaluation Total Evaluation Partial Evaluation Time related Evaluation Eye wash Evaluation Whitewash Evaluation Submerged Evaluation Concurrent evaluation Terminal evaluation Pre-evaluation Internal evaluation External evaluation

TOOLS OF EVALUATION Review of Records Monitoring Case studies Qualitative studies Controlled experiments and intervention studies Sample surveys

Who is performing Evaluation? The planner Adhoc research group Those responsible for health development Those responsible for implementation By the Community

Basic steps of Evaluation What is to be evaluated? At what level is the evaluation is to be made? What is the purpose of evaluation? What are the constraints that could limit the utility of evaluation? Basic steps of Evaluation Establishing standards and criteria Planning and methodology Collecting data Analyzing the data Taking action Re-evaluation

What is to be Evaluated? Evaluation of structure Evaluation of Process Evaluation of Outcome

Process of Evaluation The process of evaluation consists of the following components: Specify the particular subjects Information support Verify relevance Assess adequacy Review progress Assess efficiency Assess effectiveness And assess impact

INDICATORS The indicators based on a valid, reliable, reproducible, repeatable, sensitive, specific and relevant are used to monitor and evaluate the various activities

Types of indicators for evaluation Output indicators Process indicators Product indicators

The plan should identify key result areas and define how they will be measured The plan should specify prioritize activities, so that they receive adequate emphasis during monitoring The plan should cater to local variations

Identify all inputs to be provided Activities to be carried out Outputs desired for the programme Select the key inputs, activities, output variables for monitoring Identify the indicators for measuring the variables Prepare a plan for collecting and processing the information on the selected indicators Prepare a format for giving feedback on these indicators to managers responsible for implementation

Yes Evaluation GOALS&OBJECTIVES Assessment of health need No Monitoring Establish goals &objectives Implementation of programme PLANNING CYCLE Assessment of resources Time frame Select the best alternative Establishment of priorities Design alternative programme Action plan

EFFICIENCY &EFFECTIVINESS Monitoring & Evaluation are necessary to ensure efficiency and effective uses of measure Efficiency is usually measured by the ratio of activity to input Effectiveness is measured by the ratio of output to activities

Evaluation Monitoring It determines Programme effectiveness It identifies inconsistencies between the programme objectives and activities It alerts the management of discrepancies between actual and anticipated levels of programme impact It suggests changes in programme procedures, operation and objectives It identifies the possible side effects of the programme It determines Programme efficiency It establishes standard of performance at the activity level It forms a basis for Programme accountability It alerts the management of discrepancy It identifies strong &weak points of programme operations

EXISTING CONTROL PROGRAMMES National Anti Malaria Programme National Leprosy Elimination programme Revised National TB control programme National AIDS control programme National programme for control of Blindness Nutritional Surveillance National Diabetes control programme National Surveillance programme for Communicable Disease National Polio surveillance programme Reproductive child health programme

Monitoring & Evaluation of RCH PROGRAMME

The 5 year RCH phase II is being launched in TamilNadu on 2005 with a vision to bring about outcomes as envisioned in the Millennium Development Goals, the National Population Policy 2000 (NPP 2000), the Tenth Plan, the National Health Policy 2002 and Vision 2020 India, minimizing the regional variations in the areas of RCH and population stabilization through an integrated, focused, participatory programme meeting the unmet needs of the target population, and provision of assured, equitable, responsive quality services.

National Population Policy 2000 (by 2010)  Indicator Tenth Plan Goals (2002-2007) RCH II Goals (2005-2010) National Population Policy 2000 (by 2010) Millennium Development Goals       (By 2015) Population Growth 16.2% (2001-2011) - Infant Mortality Rate 45/1000 35/1000 30/1000 Under 5 Mortality Rate Reduce by 2/3rds from 1990 levels Maternal Mortality Ratio 200/100,000 150/100,000 100/100,000 Reduce by 3/4th from 1990 levels Total Fertility Rate 2.3 2.2 2.1 Couple Protection Rate 65% Meet 100% needs

THE ACTION PLAN FOR CARRYING OUT R.C.H SERVICES Goal: “Health For All” Objective: Population stabilization by 2045 Target : Total fertility rate to the replacement level by 2010 and to achieve the other indicators of health for all Programme: Comprehensive R.C.H services Plan : High quality, integrated, decentralized, needs based and holistic approach Monitoring & Evaluation: R.C.H indicators/Feedback data

ACCESSIBILITY INDICATOR No. of eligible couples registered/ANM No. of Antenatal Care sessions held as planned % of sub Centers with no ANM % of sub Centers with working equipment of ANC % ANM/TBA without requisite skill % sub centers with DDKs % of sub centers with infant weighing machine % sub centers with vaccine supplies % sub centers with ORS packets % sub centers with FP supplies

QUALITY INDICATOR % Pregnancy Registered before 12 weeks % ANC with 5 visits % ANC receiving all RCH services % High risk cases referred % High risk cases followed up % deliveries by ANM/TBA %PNC with 3 PNC visits % PNC receiving all counseling % PNC complications referred % Eligible couple offered FP choices % women screened for RTI/STDs % Eligible couple counseled for prevention of RTI/STDs % ADD given ORS % ARI treated % children fully immunized

IMPACT INDICATOR % DEATHS FROM MATERNAL CAUSES MATERNAL MORTALITY RATIO PREVALENCE OF MATERNAL MORBIDITY % LOW BIRTH WEIGHT NEO-NATAL MORTALITY RATIO PREVALENCE OF POST NATAL MATERNAL MORBIDITY % BABY BREAST FEED WITHIN 6 HRS OF DELIVERY COUPLE PROTECTION RATE PREVALENCE OF TERMINAL METHOD OF STERILIZATION PREVALENCE OF SPACING METHOD % ABORTION RELATED MORBIDITY PREVALENCE OF ADD PREVALENCE OF ARI PREVALENCE OF RTI/STDs

ACTION PLAN FOR R.N.T.C.P Goal : To extend the RNTCP to cover the entire population of the country by 2005 Objective:1) To cure 85% of the sputum positive cases 2) To detect 70% of the estimated cases of T.B Target : Three million cases have to be treated and 1.5 million cases have to be cured. Program : RNTCP Strategy: DOTS

Monitoring & Evaluation: Performance of RNTCP Monitoring & Evaluation: Total Population covered No of states covered Total cases treated New sputum + ve cases Annual case detection rate Ratio of sputum +ve to Sputum –ve Sputum conversion rate at the end of intensive phase ( New Sputum + ve cases)= 90% & any ratio below 80%=corrective action Cure rate (New sputum + ve cases)=85%

Expected rate of sputum examination among new adult outpatients (2%) Expected rate of proportion of patients undergoing sputum examination who are smear +ve (10%) At least 90% of patients who were smear +ve should be placed on treatment and registered Determine the ratio of New smear + ve to new smear – ve cases. Expected ratio is 1:1 Completed treatment rate (Not more than 3% smear +ve patients) Default rate Relapse rate MDR rate Death rate during treatment among new smear + ve patients ( not more than 4%)

Goal & objectives of National Anti Malaria Programme (MPO) Prevention of deaths due to malaria Reduction of Morbidity due to malaria Maintenance of industrial and green revolution due to freedom malaria, as well as retention of achievements gained so far.

Monitoring broadly covers two components 1.Monitoring of implementation efficiency of various activities 2.Monitoring/assessment of the impact of control measures

Monitoring of implementation efficiency of various activities Technical 1. Case detection by active and passive 2. Treatment & Referal services 3. Indoor residual insecticidal spray operations 4. Anti larval measures Logistic flow 1. Timely indenting based on epidemiological data of previous year Financial flow 1. Timely payment of wages for casual laborers involved in spraying operation 2. Repair of equipment and Local purchases

Malariometry Annual Blood Examination Rate Annual Parasite Incidence Annual Falciparum incidence Slide Positivity Rate Slide falciparum rate Parasite rate Infant parasite rate Spleen rate &parasite density index Vector indices Mosquito density Sporozoite rate Inoculation rate Man biting rate Human blood index

Indicators for spray operation % of villages covered % of houses sprayed % of rooms sprayed

Goal & objectives of National Filaria Control Programme To carry out survey in different parts of country to determine magnitude of problem. Delimitation surveys in hitherto unsurveyed areas Large scale pilot studies to evaluate known method of filariasis control To train professional and personnel required for the programme To control filaria in urban areas by anti-larval measures To control filaria in rural areas by case detection and treatment

Measurement of filarial problem Indicators of filarial measurement Micro filarial rate Filarial endemicity rate Micro filarial density Proportional case rate Measurement of vector problem Vector density Percentage of mosquitoes + ve for infective larvae Percentage of mosquitoes + ve for all stages of larvae Clinical indicators Incidence of acute manifestations Prevalence of chronic manifestations

POLIO ERADICATION PROGRAMME Conduct pulse polio immunizations for two days every year for three to four years or until polio is eradicated. Sustain high level of routine immunizations. Monitor OPV coverage at district levels and below. Improve surveillance capable of detecting all cases of polio. Ensure rapid case investigation, including the collection of stool samples. Arrange follow-up of all cases of paralytic polio at 60 days to check for residual paralysis. Conduct outbreak control for cases confirmed or suspected to stop transmission.

GOAL To assist governments in their efforts to immunize every child against polio until polio transmission has stopped, so that the world can be certified polio-free.

National Immunization Days 9.12.1995 - I st NID 20.01.1996 07.12.1996 – 2nd NID 18.01.1997 07.12.1997 – 3rd NID 18.01.1998 06.12.1998 – 4th NID 17.01.1999 24.10.1999 – 5th NID 21.11.1999 19.12.1999 23.01.2000 2004 - ( 5- NID, 3SID) 2005 – ( 2-NID, 6 SID)

Goal & objectives of National AIDS Control Programme Prevention of HIV infection Decrease the morbidity and mortality associated with HIV infection To minimize the socio- economic impacts resulting from HIV infection Phase-II To reduce the spread of HIV infection To strengthen India’s capacity to respond to HIV/AIDS on a long term basis

Medium term objectives To establish effective surveillance in all states to monitor the epidemic To provide sound technical support To ensure a high level of awareness of HIV/AIDS and its application in the population To promote the use of condoms for safe sex Target intervention to high risk group To ensure safety of blood To develop the services required for providing support to HIV infected persons, AIDS patients & their associate

Programme strategy Programme management IEC and social mobilization Blood safety Condom promotion Control of STD Clinical management Care & Support Surveillance

Monitoring & Evaluation Prevention indicator survey (PI) To assess the achievements made 10 indicators

Monitoring of family health awareness campaign Monitoring of IEC for availability and distribution of materials for awareness programme Ensuring the availability of condoms Ensuring availability of drugs for opportunistic infections in the hospital Ensuring the availability of Anti retroviral drugs STD/HIV/AIDS surveillance Financial control Monitoring of Blood banks

Goal & objectives of National Leprosy Eradication Programme To arrest the disease activity in all known cases of leprosy by the year 2000 A.D To reduce the prevalence rate to less then 1/10,000 population by the year 2000 A.D

GOAL AND OBJECTIVE OF LEPROSY ERADICATION PROGRAMME Goal: Elimination of leprosy as a public health problem i.e.to reduce the prevalence rate to less than I per 10000 population by the year 2000 AD. Objective: To arrest disease activity in all the known cases of leprosy by the year 2000AD Strategy: The elimination strategy

MONITORING INDICATORS Point Prevalence Rate – Indicator of magnitude of the problem Monthly&Annual New Case detection rate –Indicator of impact of the programme Timely detection of new cases Proportion of children among new cases – Indicator of early detection Proportion of new cases with deformity – Indicator of effectiveness of programme implementation Proportion of MB among new cases – Indicator of late detection Proportion of female patients among new cases Prevalence discharge ratio – Indicator of progress of the programme related to cure Clinic attendance –Indicator of regularity of treatment Proportion of new cases verified as correctly diagnosed Proportion of treatment defaulters Number of relapses Proportion of patients who develop new/additional disability during multi drug therapy

Goal & objectives of National Iodine Deficiency Disease Control Programme Survey to assess magnitude of problem in the community Supply of iodated salt in place of common salt Resurvey after 5 years Lab monitoring of iodated salt Health education

Goal & objectives of National Programme for control of Blindness To reduce blindness in India from 1.4% to 0.3% To provide comprehensive eye care through primary health care system

Goal & objectives of National Cancer Control Programme Primary prevention of cancers by health education regarding hazards of tobacco consumption and necessity of genital hygiene for prevention of cervical cancers Secondary prevention( Early detection and diagnosis of cancer, for example Ca Cervix, Ca breast, Ca oropharynx, by screening methods and patient education on self examining methods Strengthening of existing cancer treatment facility Palliative care of terminal stage of cancers

Goal & objectives of National Mental Health programme To ensure availability and accessibility of minimum health care for all in foreseeable future, particularly for most vulnerable/under privilege section of society To encourage application of mental health knowledge in general health care and in social development To promote community participation in mental health services and increase efforts towards self help in the community

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