Utilizing Facility Data for Program Monitoring Valerie Koscelnik Track 1 ART Program Meeting Maputo, August 12, 2010

Outline Framework for health system components and outcomes Transition short & long term goal/objective Transition Logic model Measurements: –Site and Regional readiness –Outcome indicators Data quality assessments Summary and conclusions

Health Systems Building Blocks and Key Health Outcomes Overall Health Outcomes

Transition monitoring: What are we looking for? Long term goal & shorter-term objective Long term goal: sustained local ownership with maintenance of excellent patient care and good patient outcomes. Ultimately, a vision of an effective strengthened health systems. Shorter term objective: Sites and local partners (governmental and/or NGO) able to accept/absorb and grow the program with delivery of high quality care Source: Transition Logic Model Working Group

The Transition Logic Model: Inputs &Outputs individualized per partner Transition Logic Model Inputs and outputs individualized per partner

Process/Health System Measurements Site maturity: SCA-like tools Technical and organizational competency of local government and NGO partners Ownership – Performance & accountability documentation TBD Source: Transition Logic Model Working Group

Site readiness Kenya Locally developed site readiness tools assessing key domains ICAP-Kenya Track I Rapid Maturity Assessment Tool for Health Facility Transition: Assessed (1) services offered, (2) HR, (3) general management, (4) financial management, (5) quality management (6) procurement/supply chain management and (7) performance indicator: retention of patients in last 12 month Facility is ready for transition if scores 90% or greater Facilities below 90% require continued capacity building for transition

State and site readiness: Nigeria Structured assessment of state institutions and sites by (1) governance/leadership, (2) organizational structure, (3 & 4) HR & fin management, (5) external relationships, (6) service delivery, (7) pharmacy and (8) laboratory Scale used to determine priority states for transition

State Y

State X

Clinical Quality of Care Outcome indicators Adult care and treatment Pediatric care and treatment PMTCT TB/HIV Laboratory Counseling & Testing Adherence and Psychosocial support Need to focus on priority set of key Quality of Care indicators

ICAP priority quality indicators: Standards of Care (SOC) Rationale: Five priority quality indicators selected to allow for comparisons across sites, programs and countries* Creates a limited, manageable core set of indicators for program monitoring and review of quality Data sources: Routinely-collected site-level indicator data reported every quarter for HIV care and treatment (Track 1 reporting indicators), TB/HIV, and PMTCT programs Data imported from country aggregate databases or hand-entered on on-line indicator database Data checks are run on the data to ensure internal and cross-quarter consistency * Countries and site can select specific SOCs for monitoring & CQI activities

Program area Priority indicator Definition Care and Treatment 1 Eligible patients in care and treatment receive cotrimoxazole at enrollment and last visit 2 HIV infected children under one year of age receive ART 3 Patients enrolled into treatment remain in care for at least 6 months TB/HIV4 All patients in care and treatment receive TB screening at enrollment and during the quarter PMTCT5 HIV-infected pregnant women in PMTCT services receive multi-drug ARV prophylaxis Priority Quality Indicators

Priority Indicator 1 Target: 95% of eligible patients in care and treatment receive cotrimoxazole Aggregate data Measured byProportion of eligible patients in care and treatment receiving cotrimoxazole at enrollment NumeratorNumerator: Number of HIV-positive persons receiving cotrimoxazole prophylaxis DenominatorDenominator: Number of HIV-positive persons eligible to receive cotrimoxazole prophylaxis according to national guidelines To start centrally collecting in fall 2010

Priority Indicator 2 Target: 95% of HIV infected children under one year of age receive ART Aggregate data Measured byProportion infected children under one year of age receiving ART (Track 1 reporting) NumeratorNumber of patients <2 who were newly started on ART during the reporting quarter DenominatorNumber of patients <2 who were newly enrolled in care during the reporting quarter

Priority Indicator 3 Target: 90% of patients enrolled into treatment remain in care for at least 12 months Aggregate data Measured by Proportion of patients >6 years of age enrolled into treatment who received ARVs for 6 out of 6 months (Track 1 reporting) Numerator Number of ART patients >6 years of age who received ARVs for 6 out of 6 months Denominator Number of patients >6 years of age started on ART in a given 3 month period (e.g. for Oct-Dec reporting, Aug-Oct of year prior)

Priority Indicator 4 Target: 95% of all patients in care and treatment receive TB screening at enrollment Aggregate data Measured by Proportion of all patients in care and treatment receiving TB screening at enrollment Numerator All new HIV patients screened for TB at enrollment during the reporting quarter Denominator All new HIV patients enrolled in care during the reporting quarter

Priority Indicator 5 Target: 95% of HIV-infected pregnant women in PMTCT services receive multi-drug ARV prophylaxis Aggregate data Measured by Proportion of HIV-infected pregnant women in PMTCT services in ANC receiving multi-drug ARV prophylaxis Numerator Number of HIV positive pregnant women in ANC receiving multi-drug ARV prophylaxis including HAART during the reporting quarter Denominator Number of HIV positive pregnant women enrolled in ANC (known positive and tested positive) during the reporting quarter.

Indicators across country programs

Site specific trends in priority quality (SOC) indicators Mozambique

Site-specific trends in priority quality (SOC) indicators by site Rwanda

DQA Indicators Routinely Reported Indicator Data Source DQA Sample for Quarter of Interest Gold Standa rd DQA Indicator Denominat or DQA Indicator Numerator (completeness base on gold standard) % Eligible patients receiving CTX when enrolling in HIV care* Pre-ART Register Random sample Clinical File # in CTX eligible in DQA sample # with documented CTX % HIV+ children <1 yrs of age receiving ART* Pre-ART Register All Children <1 yrs Clinical File # in DQA sample # with documented ART start date % Patients enrolled in ART who remain in care for 6 of 6 months* ART Register Random sample from respective 6- mo cohort period Clinical File # in DQA sample # with documented visit 6 of 6 months % Patients in HIV care and treatment receiving TB screening at enrollment* Pre-ART Register Random sample Clinical File # in DQA sample # documented TB screening at enrollment % HIV+ pregnant women in PMTCT services receiving multi-drug prophylaxis* PMTCT Register All HIV+ pregnant women ANC Register # in DQA sample # with documentation of multi-drug prophylaxis * Quality Indicator

DQA Indicators (con’t) Routinely Reported Indicator Data Source DQA Sample for Quarter of Interest Gold StandardDQA Indicator Denominator DQA Indicator Numerator (completeness base on gold standard) # Patients currently on ART ART Register All patients on ART ART RegisterN/A# visiting ART clinic and receiving ARVs % Patients enrolled on ART for 6 months with a CD4 value ART Register Random sample from respective 6- mo cohort period Clinical File# in DQA sample # with documented CD4 count at 6 months % Patients screened for HIV when enrolling in TB services TB Register All new patients TB Register# in DQA sample # with documented HIV screening % Patients screen for HIV when enrolling in VCT or other POS VCT/PO S Register All new clientsVCT/POS Register # in DQA sample # with documented HIV screening

Summary Readiness assessments critical to determine status of health system components and provide important information for transition preparation and monitoring Quality indicator data at site and country levels provide critical outcome data on quality of health system outcomes before, during and after transition Data quality audits are important and can serve to monitor performance and could inform continued funding and accountability

Conclusions Data must always inform programs Data must continue to inform all aspects of transition efforts