1. Integrated Monitoring and Evaluation of HIV Programs in Malawi Dr Andreas Jahn 1,2 1 Dept. for HIV and AIDS, MOH, Malawi 2 I-TECH Malawi

2. Malawi Context July 2011: Integration and Innovation – preART – Exposed Infant follow-up – ART – PMTCT – STI – TB – Family Planning – HTC Data Collection tools, reporting, Supportive Supervision and now Clinical Mentoring were and are the foundation of the successful HIV program

3. M&E: An iterative process… Data Collection in integrated M&E tools Quarterly Supportive Supervision to EVERY site Clinical Mentoring for select sites Comprehensive Quarterly Report disseminated

4. Integrated M&E for HIV Programs

5. ANC Integrated Register Double Duty: M&E tool is also a job aid 5 ANC visits Summary outcomes Deduplication at data entry

6. Line Register: Mother on left; Infant on right of page Labour and Delivery

7. ART Patient Card

8. Patient Cards

9. THYOLO DISTRICT HOSPITAL 48 Arch Back Files containing 2,400 patient cards

10. Quarterly Supervision Visits to all Sites Prevent protocol drift Rapid chart review – identify and discuss irregular cases Consultation & mentoring on complex cases Physical drug stock check Assess clinic infrastructure, staffing Review and discuss data (content and quality) Disseminate program and protocol updates Provide constructive feedback & encouragement

11. Logistics for ART Supervision Visits to all 650 PMTCT/ART sites each quarter 20 Teams of 3 supervisors (Pool of 75) – MOH HIV Dept. staff – Experienced ART clinicians & nurses – Quarterly supervisors training USD 110,000 (transport, accommodation, allowances)

12. Integrated HIV Service Supervision Form 1.Contact details of staff at each site 2.Quality of service checklist 3.Follow up on previous action points 4.Next visit date 5.M&E reports from HTC, ANC, maternity, exposed child and pre-ART follow-up, ART and TB 6.Physical drug stock count 7.Award of Certificate of Excellence / Book for clinical mentoring

13. Feedback & Encouragement Formal assessment on supervision form No problems on quality check list Few errors on cohort analysis

14. Outcomes from Supervision Round 2012 Q1

15. Running the M&E System Clinic Staff (Clinician, Nurse, Clerk) – Fill patient card at each visit – Enter all new patients in register – Perform quarterly cohort analysis – Fill report form Supervision Team – Review all treatment cards – Check updating of outcomes in register – Check cohort analysis (usually repeat tallies)

16. Quarterly Cohort Analysis Tallying of registration details of new patients Review of all patient cards Tallying of secondary outcomes (Regimen, Side effects, TB status, adherence) Updating of primary outcomes in register (Alive on ART, Died, Transfer Out, Stop, Lost) Tallying of all primary outcomes from register

17. Updating outcomes for reporting on Exposed Child, pre- ART, ART Person 1 (Cards): Read out loud the registration numbers of cards in the ACTIVE file Check for new deaths, defaults, TO, etc. Tally secondary outcomes at the same time on a separate paper on the side

18. QI Through Chart Review & Mentoring Expected number of new initiations Correct determination of ART eligibility Identification of ART interruptions Patients with side effects on wrong regimens Adherence problems Review of complicated cases on the ward

19. QI Through Logistics Support Estimation of drug needs at each site Monitoring of drug consumption Ad-hoc relocation of ARVs Communication with DHO about infrastructure improvements

20. Closing the communication loop Action points from Supervision team given to the Zonal and District ART Supervisors, and Implementing Partners – Plan clinical mentoring follow-up Debrief at central level: – Ongoing and emerging issues

21. Comprehensive Quarterly Reports – Data entry, cleaning, analysis Site level data based at MOH – Report writing – Dissemination by email and through TWG – Information feeds into SCM Closing the communication loop (2)

22. Thank you!