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Monitoring and evaluation toolkit - Conférence de la 2e édition du Cours international « Atelier Paludisme » - TUSEO Luciano - World Health Organization / Roll Back Malaria - maloms@iris.mg

Monitoring and evaluation toolkit - Conférence de la 2e édition du Cours international « Atelier Paludisme » - TUSEO Luciano - World Health Organization / Roll Back Malaria - maloms@iris.mg

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Monitoring and evaluation toolkit Monitoring and evaluation toolkit Document Transcript

  • MONITORING AND EVALUATION TOOLKITHIV/AIDS, TUBERCULOSIS AND MALARIA DRAFT 14/01/2004 World Health Organization
  • Table of contentsWHY THIS KIT?.......................................................................................................................................3WHO IS IT FOR?......................................................................................................................................3WHAT ARE ITS CONTENTS? ..............................................................................................................3BASIC ELEMENTS OF M&E ................................................................................................................4 BOX 1: CHECKLIST OF FEATURES OF A GOOD M&E SYSTEM. .................................................................5OVERALL FRAMEWORK FOR M&E ................................................................................................6 TABLE 1: THE M&E FRAMEWORK, WITH EXAMPLE AREAS, KEY QUESTIONS, AND INDICATORS ............7LEVELS OF MONITORING AND EVALUATION..........................................................................10HIV/AIDS .................................................................................................................................................13 SUMMARY TABLE FOR HIV/AIDS.........................................................................................................15 General resources .............................................................................................................................18 Technical assistance.........................................................................................................................19 Software products ............................................................................................................................19 Guidelines.........................................................................................................................................20TUBERCULOSIS ....................................................................................................................................21 SUMMARY TABLE FOR TUBERCULOSIS ..................................................................................................21 General resources .............................................................................................................................23 Technical assistance.........................................................................................................................24 Software products ............................................................................................................................24 Guidelines.........................................................................................................................................24MALARIA ................................................................................................................................................25 SUMMARY TABLE FOR MALARIA ...........................................................................................................27 General resources .............................................................................................................................29 Technical assistance and software products ....................................................................................29 Guidelines.........................................................................................................................................29FREQUENTLY ASKED QUESTIONS ................................................................................................32 TECHNICAL QUESTIONS .........................................................................................................................32 OPERATIONAL QUESTIONS .....................................................................................................................36ANNEX A..................................................................................................................................................40ANNEX B..................................................................................................................................................62ANNEX C..................................................................................................................................................74This document was based on a collaboration between WHO, UNAIDS, The GlobalFund to Fight AIDS, Tuberculosis and Malaria, USAID, CDC, UNICEF and theWorld BankM&E toolkit, Draft 14.01.04 2
  • Why this kit?With the global momentum to scale up the response to the three main infectious diseases,HIV/AIDS, tuberculosis (TB) and malaria, public health practitioners need to providevarious levels of accountability for their activities or policies to a variety ofconstituencies. It is becoming increasingly important for countries to be able to reportaccurate, timely and comparable data to donors and national authorities in order to securecontinued funding for expanding health programmes and, most importantly, to utilize thisinformation locally to strengthen evolving programmes. In sum, this toolkit is one steptowards assuring that countries are able to measure, report, and use good quality healthinformation in a manner that meets both donor and country needs. It is particularlyimportant for national programme implementers and managers to have access to thequality information they need to make adjustments and programmatic and technicaldecisions.Much progress has been made in the monitoring and evaluation (M&E) of these threediseases through the international community from global disease partnerships such asUNAIDS, StopTB, and Roll Back Malaria. Existing M&E guidelines and materials havebeen developed through the collaborative work of many partnership constituents such asWHO, bilateral agencies and NGOs. Developed with the support of international fundersand M&E experts, the purpose of this toolkit is to gather in one place the "essentials" ofagreed upon best practice in M&E, by applying a common M&E framework for the threediseases and providing users with references to key materials and resources. Althoughlabeled as a "monitoring and evaluation" toolkit, this document will focus mainly on themonitoring component.This toolkit aims to assist countries in the following:• Formulation of a national M&E strategy by providing an overview of key issues to consider;• Design of sustainable M&E systems that can be used to report on results and impact during the implementation stages of scaled up programmes;• Implementation and quality control of M&E systems and reporting of progress; and• Evaluation, review and improvement of M&E systems over time as the scale up of interventions to reduce morbidity and mortality associated with HIV/AIDS, TB and malaria occurs.Who is it for?This information package aims to provide those working at the country level on M&Esystems linked to expanded HIV/AIDS, TB and/or malaria programmes with rapid accessto key resources and standard guidelines. Users include national disease programmemanagers and project leaders and donor agencies, technical and implementing agenciesand NGOs to better harmonise information demands.What are its contents?The toolkit includes a standard framework for the development of a range of M&Eguidelines and tools, a summary of agreed upon illustrative core indicators for the threediseases, and references to more detailed indicator manuals on specific programme areas.M&E toolkit, Draft 14.01.04 3
  • In addition, this toolkit addresses frequently asked questions in relation to implementingM&E for HIV/AIDS, TB and malaria programmes.Note to users: The illustrative indicators presented have been developed for the nationallevel, although many of them can be used at various levels. Country users should designor modify their health information collection system bearing in mind the differentinformation that needs to be collected for use at different levels in order to construct “thebig picture” that these indicators allow. Additionally, new technologies anddevelopments will result in the need to periodically revise and update the illustrativeindicators presented here. This is the first time indicators from these diseases have beenbrought together in one manual. The approach includes the need to develop and improveindicators at different levels over time based on feedback. It is therefore a work inprogress. We will identify areas which require refinement in future editions asnecessary. This document is available electronically at the websites of partners involvedin its production.Basic elements of M&EWhile significant progress has been made in country M&E, much disease-specific M&Ehas been done in a vertical, isolated fashion that is often not linked or triangulated withother sources. For example, a surveillance system for HIV may be in place but notfunctioning well, and behavioral studies may have been done, though not necessarilyusing the same sampling methodologies or indicators. Extensive evaluation of a donor-sponsored project may have been carried out in an important area of programming,without the results ever being shared with others in the field. In short, the utility of muchof the disease-related measurement in a country may be lost because there is no coherentM&E system that can be used to capture necessary information on multiple diseases forusers at different levels. In addition, many countries rely on population surveys such asDHS and MICS that are funded through external donors to gather information on theimpact of their own and donor-supported programmes. This produces data that may bevaluable in the broader M&E context, but may not be well integrated with traditionalsources of health information, such as national health information and surveillancesystems.A common, comprehensive and coherent M&E system has several advantages. Itcontributes to more efficient use of data and resources by ensuring, for example, thatindicators and sampling methodologies are comparable over time and by reducingduplication of effort. Where resources are scarce, this is an important asset. Datagenerated by a comprehensive M&E system ought to serve the needs of manyconstituents, including programme or project managers, researchers or donors,eliminating the need for each to repeat baseline surveys or evaluation studies when theymight easily use existing data.From the point of view of the national programme, a coherent M&E system helps ensurethat donor-funded M&E efforts best contribute to national needs, rather than simplyserving the reporting needs of specific international donors or organizations. A furtheradvantage is that it encourages coordination and communication between differentgroups involved in the national response to diseases. Agreement among the major donor,technical and implementing agencies on the basic core M&E framework will reduce theburden of requests for data from different agencies. Shared planning, execution, analysisM&E toolkit, Draft 14.01.04 4
  • or dissemination of data collection can reduce overlap in programming and increasecooperation between different groups, many of whom may work more efficientlytogether than in isolation.Countries have different M&E needs, dictated in part by the state of their HIV, TB,and/or malaria disease burdens. Yet successful M&E systems will share commonelements. A list of some of these elements is given in Box 1.Box 1: Checklist of features of a good M&E system.M&E UNIT − An established M&E unit within the Ministry of Health with designated technical and data management staff − A budget for M&E that is between 5 and 10 percent of the combined national HIV/AIDS, TB, and malaria budgets from all sources − A significant national contribution to the national M&E budget (not total reliance on external funding sources) − A formalised (M&E) link, particularly with appropriate line ministries, NGOs and donors, and national research institutions aimed at enhancing operations research efforts − A multisectoral working group to provide input and achieve consensus on indicator selection and various aspects of M&E design and implementation − Epidemiological expertise in the M&E unit or affiliated with the unit − Behavioural/social science expertise in the M&E unit or affiliated with the unit − Data processing and statistical expertise in the M&E unit or affiliated with the unit − Data dissemination expertise in the M&E unit or affiliated with the unitCLEAR GOALS − Well-defined national programme or project plans with clear goals, targets and operational plans − Regular reviews/evaluations of the progress of the implementation of the national programme or project plans − Guidelines and guidance to districts and regions or provinces for M&E − Guidelines for linking M&E to other sectors − Coordination of national and donor M&E needsINDICATORS − A set of priority indicators and additional indicators at different levels of M&E − Indicators that are comparable over time − A number of key indicators that are comparable with other countriesDATA − An overall national level data collection and analysis plan,COLLECTION & including data quality assuranceANALYSIS − A plan to collect data and periodically analyse indicators at different jurisdictional levels of M&E (including geographical) − Second-generation surveillance, where behavioural data are linked to HIV/STI surveillance dataM&E toolkit, Draft 14.01.04 5
  • DATA − An overall national level data dissemination planDISSEMINATION − A well-disseminated, informative annual report of the M&E unit − Annual meetings to disseminate and discuss M&E and research findings with policy makers, planners and implementers − A clearinghouse for generation and dissemination of findings − A centralised database or library of all HIV/AIDS, TB, and malaria-related data collection, including ongoing research − Coordination of national and donor M&E dissemination needsOverall framework for M&EIndicators are used at different levels to measure what goes into a programme orproject and what comes out of it. The most commonly used framework for theselection of indicators for M&E is the input-process-output-outcome-impactframework illustrated below. For a programme or project to achieve its goals, inputssuch as money and staff time must result in outputs such as stocks and deliverysystems for drugs and other essential commodities, new or improved services, trainedstaff, information materials, etc. These outputs are often the result of specificprocesses, such as training sessions for staff, that should be included as key activitiesaimed at achieving the outputs. If these outputs are well designed and reach thepopulations for which they were intended, the programme or project is likely to havepositive short-term effects or outcomes, for example increased condom use withcasual partners, increased use of insecticide-treated nets (ITNs), adherence to TBdrugs, or later age at first sex among young people. These positive short-termoutcomes should lead to changes in the longer-term impact of programmes, measuredin fewer new cases of HIV, TB, or malaria. In the case of HIV, a desired impactamong those infected includes increased survival time and behavioral change. Foradditional information on M&E frameworks, readers may be interested in visiting thefollowing UNDP and MEASURE Evaluation sites:http://cfapp1.undp.org/undpweb/eo/evalnet/docstore3/yellowbook/http://www.cpc.unc.edu/measure/publications/evalman/Note: In many instances, behavioral change is considered a outcome of an HIVprogramme’s efforts. For the purposes of this guide, however, behavioral change isconsidered an impact indicator.Measuring impact requires extensive investment in evaluation, and it is often difficult toascertain the extent to which individual programmes, or individual programmecomponents, contribute to overall reduction in cases and increased survival. In order toestablish a cause-effect relationship for a given intervention, studies with experimental orquasi-experimental designs are necessary to demonstrate the impact.Therefore, focus is given here to output and outcome indicators, which are often moreeasily collected than impact indicators and used in the short to medium term forprogramme strengthening and reporting. As a programme or intervention matures, usersmay consider evaluating impact, using information that has been collected through theprogramme’s life and/or by undertaking special evaluation studies. As impact evaluationis not the focus of this document, the undertaking of such studies is not discussed here.M&E toolkit, Draft 14.01.04 6
  • Table 1 presents a generalised M&E framework for AIDS, TB and malaria. Examples ofthe areas measured at each level, key questions to answer, and indicators are provided.The aim of Table 1 is to familiarize users with this framework in order to facilitate theuse of this toolkit. This is particularly relevant for users familiar with otherinterpretations of the different levels. For example, the Global Fund to Fight AIDS, TBand Malaria (GFATM) generally defines process as a mixture of inputs and outputs, andcoverage as a mixture of outputs and outcomes. Depending on the level of programmedevelopment, there may be some overlap in indicators to measure inputs, processes andoutputs. For example, where trained personnel are available to the programme, theyrepresent an input for the programme. However, where human resources are lacking,trained personnel may be an output for the programme.Table 1: The M&E framework, with example areas, key questions, andindicators Level Area Key questions Indicator example Policy • National strategic plans • Policy and guidelines in place for each disease, at national level Disbursement including M&E and • Funding availability and operations research plans releaseINPUT Infrastructure exist • Distribution node selected • Policy and guidelines • Sentinel site selected(strategies,policies, exist • Providers selected Coordination • Funds have been • Coordination mechanism inguidelines, disbursed place for technical andfinancing) • Supply chain is in place operational issues • Coordination is • Coordination mechanism in established place for political issues • Infrastructure and equipment Human • Human resources for • Number of people trained per resources health services delivery number of people initially and supervision are targeted by training recruited, adequately • Number of people trainedPROCESS motivated, trained and according to national standards(human deployed for an interventionresources, • Human resources for • Number of people trained fortraining, supportive environment an intervention per 1,000commodities) are trained and deployed people in need of the intervention • Number with adequate supervision and motivationM&E toolkit, Draft 14.01.04 7
  • Level Area Key questions Indicator example Drugs and • Drugs are consistently • % of drug distribution nodes commodities available to consumers at reporting on stock status the right time and place (repletion, shortage, • Providers are equipped consumption, quality, losses) and available to people on a monthly basis seeking care • % of drug distribution • Standard treatment nodes/facilities reporting no guidelines and utilization drug shortage manuals have been • % of selected providers developed and produced equipped for the intervention (laboratories, nursing, others) Service • Intervention is • Number of districts or other delivery, accessible in a large administrative unit with at least technologies number or majority of one drug distribution center districts or other • % of districts or other administrative unit administrative unit with at least • Resources are available one drug distribution center for supervision • Number of districts or other administrative unit with the required number of providers of the intervention • % of districts or other administrative unit with the required number of providersOUTPUTS of the intervention(services, Knowledge, • Target population knows • Number of districts or othernumbers skills and about the benefit of the administrative unit withreached, practice intervention designated sentinel/providercoverage) operating according to guidelines for the intervention • % of districts or other administrative unit with designated sentinel/provider operating according to guidelines for the intervention • Number of target population with desired health behaviour/attitude • % of target population with desired health knowledge/attitudeM&E toolkit, Draft 14.01.04 8
  • Level Area Key questions Indicator example People on • A majority of target • Number of target population treatment, population is covered by covered by intervention people the intervention • % of target population covered benefiting from by intervention intervention • Number of target population receiving first line therapeutic regime • % of target population receiving first line therapeutic regime • Ratio of first to second lineOUTCOMES treatment regime(changed Changed • Increased number or • Number of target populationbehaviours, behaviour proportion of target with desired health seekingcoverage) population adopting behaviour (risk reduction, behaviours which reduce health care seeking) their vulnerability to • % of target population with infection, morbidity, desired health seeking and/or mortality behaviour (risk reduction, • Increased number or health care seeking) proportion of target population adopting beliefs and practices that create a supportive environment Morbidity, • Majority of target • Number of target populationIMPACT mortality population is in better showing clinical (and(biology and health as a result of the measurable) signs of recoveryquality of life) intervention after 6, 12 months • % of people showing clinical (and measurable) signs of recovery after 6, 12 months • Disease prevalence at regional or national levelsA note on target populations and denominators: In many cases, it may be difficult todetermine the denominator, or population, to use when assessing, for example, coverage.We have therefore focused on numerators, or the subset of the population that is affectedor benefits from interventions. In this toolkit, though, denominators should also beincluded where possible (if percentages are given, numerators should also always bereported to allow assessment of coverage). The publication Estimating the Size ofPopulations at Risk for HIV (UNAIDS/IMPACT/FHI, 2002) may help readers inaddressing the challenges faced in determining denominators when working with hiddenpopulations.In this toolkit, the term target population refers to the group of people who benefit froman intervention. The target population can be the total population or a smaller group suchas youth. In designing interventions, efforts should be made to clearly define the targetpopulation. Definition of these is usually based on knowing whom diseases affect most,directly and indirectly. For example, the definition of a target population for HIV/AIDSinterventions is often based on the epidemic state. In generalized epidemics where HIVM&E toolkit, Draft 14.01.04 9
  • prevalence is consistently over 1% in pregnant women, the target population could verywell be the general population. However, in concentrated and low-level epidemics whereHIV prevalence is concentrated within groups with specific risk behaviors, the targetgroup may be defined as a sub-group of the general population that shares these samebehaviors.Levels of Monitoring and EvaluationThis section presents illustrative core output, outcome, and impact indicators forHIV/AIDS, TB, and malaria. Users should be aware that these indicators have beendeveloped, discussed and agreed upon by a wide range of international and nationalexperts and donors. They have been developed for the specific purpose of minimizinginformation demands on countries while also assuring that indicators address specificinternational needs. The indicator development process was guided by five majorprinciples: • Building on existing indicators; • Harmonizing with other international frameworks such as the Millennium Development Goals (MDG); • Minimizing the number of indicators to be collected; • Covering a wide range of programme areas and sectors related to the different diseases; and • Addressing country programme needs.Input and process indicators are generally common across the three disease areas and aretherefore not specified for each. While there are some differences across the threediseases, these indicators generally take on the following forms: Generic input indicator: Existence of national policies, guidelines, or strategies. This is a “yes” / “no” question. Reporting of overall budget allocation is included as an input. Generic process indicator: Number of persons trained, number of drugs shipped/ordered, etc.For each disease, general programme areas have been defined. In the case of HIV/AIDS,for example, these include prevention, treatment, care and support, and supportivepolicy/implementation environments. A summary table showing the different programmeareas as well as indicators is presented for HIV/AIDS, TB, and malaria. When looking atthe summary tables, readers should be aware that sub-programmes often contribute tomultiple outcomes and impact. Although the tables give the impression of a linearprogression, assumptions regarding the overall outcome and impact of each sub-programme should be made with caution.Except for some output and outcome measurements (referred to as "counts", see below),specific information is provided for each of the indicators presented in the summarytables. This information can be found in the more detailed explanation of each indicator.Information provided for each indicator includes:M&E toolkit, Draft 14.01.04 10
  • • Rationale for use • Definition, including numerator and denominator • Measurement - i.e. details on instrument and process • Data collection platform, sources – i.e. survey, vital registration, in/out-patient registers, facility surveys, inventories, surveillance and sentinel reports • Recommended periodicity • Resources – i.e. reference groups, technical assistance sources, guidelinesOutputs and outcomes here are also monitored and reported as "counts" of increasedcapacity provided against a need that has been estimated as a pre-condition for changeand they can be quantified through direct observation or an annotated inventory. Forexample, it may be easier to collect the number of health providers trained in a specificarea through a record review. For these "counts", the toolkit does not provide a detaileddescription, and the definition of associated terms -where relevant-appears under thedetailed description of outcome indicators.Table 2 provides an overview of the service delivery areas and main objectives forHIV/AIDS, TB and Malaria.Table 2. Overview of service delivery areas and objectives for HIV/AIDS, TB andMalaria Delivery areas HIV/AIDS TB MALARIA Information, Education, Identification of Insecticide-treated nets (ITNs) Communication (IEC) infectious cases Youth Education Prevention of Malaria in pregnancy transmission by treating infectious cases Condom distribution Prevention of TB among Prediction and Containment of PLWHA epidemics Programmes for specific Indoor Residual Spraying Prevention groups Counseling and Information, education & voluntary testing communication (IEC) Prevention of mother to child transmission (PMTCT) STI diagnosis and treatment Post-exposure prophylaxis (PEP)M&E toolkit, Draft 14.01.04 11
  • Blood safety and universal precautions Antiretroviral treatment Timely detection and Prompt effective antimalarial and monitoring quality treatment of treatment Treatment cases Prophylaxis and Control of drug Monitoring of drug resistance treatment for resistance opportunistic infections HIV/TB Systematic monitoring Home based management of of performance in case malaria management Support for orphans Supporting patients Support through direct Care & observation of treatment Support for the chronically ill Strengthening of Civil Sufficient and quality Monitoring and Operations Society ensured drugs and lab Research supplies Stigma Building and Health systems strengthening maintaining human resource capacity Monitoring, evaluation, and operational research Health systems Supportive Environment strengthening Health systems Coordination and Coordination and partnership strengthening partnership development development (national, (national, community, community, public-private) Coordination and public-private) partnership development (national, community, Monitoring, evaluation, public-private) and operational research Monitoring, evaluation, Operational research and operational research agenda targeting barriers to DOTS Procurement and supply Procurement and supply Procurement and supply management capacity management capacity management capacity building building building Reduced adult HIV Reduced number of Reduced all-cause under 5 prevalence (ages 15-49) smear-positive cases per mortality (endemic areas) 100,000 population Reduced percentage of Reduced number of Reduced Malaria specific young people aged 15- deaths from TB (all mortality 24 who are HIV- forms) per 100,000 infected population per yearM&E toolkit, Draft 14.01.04 12
  • Reduced Malaria specific Reduced percentage of morbidity high risk groups (sex workers, clients of sex workers, men who have sex with men, injecting drug users) who are HIV infected Reduced percentage of HIV-infected infants born to HIV-infected mothers Increased survival among PLWHA Percentage of young people aged 15-24 reporting the use of a condom during sexual intercourse with a non- regular sexual partner Percentage of young people who have had sex before the age of 15 Percentage of young people who had sex with more than one partner last year Percentage of high risk groups who have adopted behaviours that reduce transmission of HIV Percentage of adults on ARV treatment who gain weight by at least 10% at 6 months after the initiation of treatmentHIV/AIDSThis section of the toolkit provides an overview of the core indicators and general M&Eresources for HIV/AIDS (in addition to those provided for each indicator). Each of theHIV/AIDS core indicators is applicable to all settings, with the exception of theM&E toolkit, Draft 14.01.04 13
  • indicators covering injecting drug users (IDU) and HIV prevalence. The IDU indicator isapplicable to countries where injecting drug use is an established, significant mode ofHIV transmission. Countries with low HIV prevalence or concentrated epidemics shouldreport on an alternative indicator of HIV prevalence among high-risk behavior groups, asopposed to prevalence among young people obtained from antenatal clinic sentinelsurveillance. Alternative indicators may be found in the UN General Assembly SpecialSession (UNGASS) on AIDS document entitled “Monitoring the Declaration ofCommitment on HIV/AIDS Guidelines on the construction of core indicators” (UNAIDS,2002).M&E toolkit, Draft 14.01.04 14
  • Summary table for HIV/AIDS Service Delivery Area Input Process Output Outcome Information, HIV/AIDS Increased numbers trained (health personnel, government, non-government, private sector), Commodities purchased (condoms, Drugs, Budget reporting by financial category, Monitoring and Evaluation Framework exists, Strategies and Guidelines developed and used, Education, radio/television Communicati programmes/newspapers on (IEC) produced* HIV/AIDS prevention brochures/booklets distributed* Peer educators active* Youth Schools with teachers Education trained in life-skills based HIV/AIDS education (PI1) Lab supplies [microscopes, reagents, slides]) Young people exposed to HIV/AIDS education Implementing Partners identified in school settings* (under development) Prevention Young people exposed to HIV/AIDS education out of school* (under development) Condom Retail outlets and service distribution delivery points with condoms in stock (PI2) Condoms sold through public sector* Condoms sold through private outlets* Programmes Sex workers & clients for specific exposed to outreach groups programmes* (number and percentage**) MSM exposed to outreach programmes* (number and percentage**)M&E toolkit, Draft 14.01.04 15
  • Service Delivery Area Input Process Output Outcome Mobile populations exposed to outreach programmes* (number and percentage**) IDUs reached by prevention services (number* and percentage) (PI3) Large companies with HIV/AIDS workplace policies and programmes (number* and percentage) (PI4) Counseling Districts with VCT People requesting and Voluntary services* (PI5) counseling and Testing voluntary testing (PI6)* PMTCT Health facilities offering HIV-infected pregnant minimum package of women receiving a PMTCT* (PI7) complete course of antiretroviral prophylaxis to reduce the risk of MTCT (number* and percentage) (PI8) STI diagnosis STI comprehensive case and treatment management (PI9) Post-exposure Number of people who prophylaxis receive post-exposure (PEP) prophylaxis* Blood safety Districts with access to and universal donor recruitment and precautions blood transfusion (PI10) Transfused blood units screened for HIV (PI11)M&E toolkit, Draft 14.01.04 16
  • Service Delivery Area Input Process Output Outcome Antiretroviral Health facilities capable People with advanced treatment(AR of providing advanced HIV infection receiving T) and interventions for antiretroviral monitoring prevention and medical combination therapy treatment for HIV (number* and infected persons (TI2) percentage) (TI1) Prophylaxis Health facilities with and treatment capacity to deliver basic Treatment for level counseling and opportunistic medical services for infections HIV/AIDS (number* and (OIs) percentage) (TI 3) HIV/TB Intensified TB case Provision of finding (among cotrimoxazole PLWHA) (TI 4) preventive therapy Counseling and and/or ART (TI 6 and voluntary testing for TB TI 7) patients (TI 5) Support for Orphans and vulnerable orphans children whose households received free basic external support (number* and Care and Support percentage) (CS1) Support for Chronically ill adults the whose households chronically ill received free basic external support (number* and percentage) (undergoing adaptation) Strengthening Number of NGOs of Civil dealing with HIV/AIDS Society services * Supportive Environment Stigma Number of PLWHA support groups fighting against discrimination* Monitoring, evaluation, and operational researchM&E toolkit, Draft 14.01.04 17
  • Service Delivery Area Input Process Output Outcome Health Number of patients who systems are accurately referred* strengthening Coordination Number of and networks/partnerships partnership involved* development (national, community, public- private) Procurement Percentage of service Unit costs of drugs and and supply delivery points with commodities management sufficient drug supplies capacity (under development) building* Outputs and outcomes here are also measured as "counts" of increased capacity provided against a needthat has been estimated as a pre-condition for change and they can be quantified through direct observationor an annotated inventory. For these "counts" the toolkit does not provide a detailed description in theannexes.,** Both percentages and numbers are required. However, if a denominator can not be obtained, focusshould be on raw numbers (the numerator).Note for HIV/TB service delivery area: TB/HIV programmes are complex in that twoseparate disease programmes are brought together, with each having individualapproaches and reporting mechanisms in place. For full details, refer to "Interim Policyon Collaborative TB/HIV Activities. WHO/HTM/HIV/2004.1 andWHO/HTM/TB/2004.330, and "A Guide to Monitoring and Evaluation for CollaborativeTB/HIV Activities" (WHO, in preparation)Detailed descriptions for each of the indicators listed above are provided in Annex A.General resourcesSince the creation of UNAIDS, a number of M&E resource groups – mainly at globallevel – were established to improve coordination among key M&E players. Currently,there are a total of five groups: • The UNAIDS Monitoring and Evaluation Reference Group (MERG) – composed of cosponsors/Secretariat M&E focal points, bilateral agencies, research institutes, and individual experts – that assists in harmonizing M&E approaches and improving methods.M&E toolkit, Draft 14.01.04 18
  • • The UNAIDS Estimates, Modelling and Projections Reference Group and UNAIDS/WHO working group on surveillance and estimates for HIV transmission and mortality. • The Inter-Agency M&E coordination working group – composed of key UNAIDS cosponsors, Secretariat and Global Fund to Fight AIDS, TB and Malaria M&E focal points – that assists in improving coordination among global M&E actors. • The UNAIDS Evaluation Unit – composed of UNAIDS Secretariat staff – that assists in the development of generic M&E systems for strategic information sharing. • The Global Monitoring and Evaluation Support Team (GAMET) – composed of World Bank personnel and staff seconded from technical agencies – that focuses on M&E country support in World Bank-supported countries.These resource groups have contributed to the development of the illustrative indicatorspresented here.UNAIDS and partners have been encouraging governments to set up a national levelM&E reference/support group to provide advice on national M&E strategies, and to assistin mobilizing resources for M&E and optimizing the use of data. Where those groupsexist, coordination among partners has tremendously improved.Technical assistanceAlthough technical support to governments is available through M&E technical supportgroups in some countries, additional assistance can be sought from the Evaluation Unit atthe UNAIDS Secretariat at UNGASSindicators@unaids.org for specific questions onUNGASS Declaration of Commitment (DoC) indicators, or at M-E@unaids.org forgeneral M&E questions. Other sources of support for all the diseases include: CDC,Measure Evaluation, Partners for Health Reform Plus (USA), Institute for HealthSystems Development (UK). Further support for HIV/AIDS includes: MeasureEvaluation and Measure DHS, FHI, The Synergy Project.Software productsUNAIDS has put at the disposal of countries a useful tool – the Country ResponseInformation System (CRIS) – that has the potential to house all national data obtained oncore and additional indicators and generate reports on those indicators. The CRISincludes two additional functions: resource tracking and research inventory.To learn more about the process of indicator development and the suggested actionsto implement the DoC M&E framework, readers are encouraged to consult theGuidelines on construction of core indicators that exist in four languages (English,French, Spanish and Russian) and that can be downloaded from UNAIDS web site.For more information on the CRIS, also please visit the UNAIDS web site.M&E toolkit, Draft 14.01.04 19
  • GuidelinesThe major sources for guidelines cited below are UNAIDS, WHO, USAID, CDC,MEASURE and FHI. The latest versions of these guidelines may be found on the Internetat:http://www.unaids.orghttp://www.who.inthttp://www.cpc.unc.edu/measurehttp://www.fhi.orghttp://www.cdc.govhttp://www.usaid.govUNAIDS/MEASURE (2000). National AIDS Programmes: A Guide to Monitoringand Evaluation. UNAIDS, Geneva.(http://www.cpc.unc.edu/measure/guide/guide.html) [SUGGESTION TO MOVETHIS TO FIRST ON THE LIST]UNAIDS (2002). Monitoring the Declaration of Commitment on HIV/AIDS Guidelineson the construction of core indicators(http://www.unaids.org/UNGASS/docs/JC894-CoreIndicators_en.pdf)UNAIDS/World Bank (2002). National AIDS Councils (NACs) Monitoring andEvaluation Operations Manual. UNAIDS/World Bank, Geneva.(http://www.unaids.org/publications/documents/epidemiology/surveillance/JC808-MonEval_en.pdf)Centers for Disease Control and Prevention (2002). Strategic Monitoring and Evaluation:A Draft Planning Guide and Related Tools for CDC GAP Country Programs. Centers forDisease Control and Prevention, Atlanta.Family Health International (2002). Evaluating Programs for HIV/AIDS Prevention andCare in Developing Countries: A Handbook for Program Managers and DecisionMakers. Family Health International, Arlington.(http://www.fhi.org/en/aids/impact/impactpdfs/evaluationhandbook.pdf)Family Health International (2000). Behavioural Surveillance Surveys (BSS):Guidelines for Repeated Behavioural Surveys in Populations at Risk for HIV. FamilyHealth International, Arlington.(http://www.fhi.org/en/aids/wwdo/wwd12a.html#anchor545312)WHO/UNAIDS (2000). Second Generation Surveillance for HIV: The Next Decade.UNAIDS, Geneva.(http://www.who.int/emc-documents/aids_hiv/docs/whocdscsredc2005.PDF)M&E toolkit, Draft 14.01.04 20
  • TuberculosisThis section provides an overview of the core indicators for TB control and offersresources for more in-depth consideration of monitoring and evaluation in TB. Theindicators are general in nature and appropriate for monitoring TB control, particularlythrough national TB control programmes. The indicators do not specifically address theadditional monitoring needs of innovations in service delivery such as community-basedcare or engagement of the private sector. Similarly, only a limited number of indicatorsare provided for monitoring TB/HIV interventions and the management of multi drug-resistant TB. Readers are guided to additional references for more comprehensivemonitoring of such activities. A compendium of indicators for monitoring TB controlactivities is under preparation by the Working Group on Indicators whose partners arelisted in the general resources. Many of the indicator definitions provided in this toolkitwere drawn from a draft of the compendium.Summary table for tuberculosis Sub- Programme Input Process Output Outcome international guidelines, financial resources consistent with operational plan, Identification of New smear positive TB infectious cases cases detected under Priority within overall health sector plan, TB policy consistent with supplies [microscopes, reagents, slides]), comprehensive laboratory international guidelines, mid-term operational plan consistent with government, private sector), Commodities purchased (Drugs, Lab DOTS (number* and Increased numbers trained (health personnel, government, non- percentage) (PI 1) Prevention of New smear-positive transmission by cases registered under treating DOTS who smear- Prevention infectious cases convert at 2 months of treatment (number* and percentage) (PI 2) Prevention of TB HIV seroprevalence Individuals dually among PLWHA among TB patients infected with TB and (PI 4) HIV who receive isoniazid preventive therapy (number* and percentage) (PI 3) network established Timely detection Population covered Number of death from TB Treatment and quality by DOTS (number* per 100,000 per treatment of and proportion) (TI 1) year(number* and cases percentage)M&E toolkit, Draft 14.01.04 21
  • Smear-positive TB cases registered under DOTS who are successfully treated (TI 2) (number* and percentage) Control of drug New smear-positive resistance cases registered under DOTS who default or transfer out of treatment (number* and percentage) (TI 3) (number* and percentage) Systematic Treatment facilities monitoring of submitting accurate, performance in timely and complete case management reports (number* and proportion) (TI 4) Supporting Patients cared for Care & Support patients through with directly directly observed observed therapy therapy (DOT) during intensive phase (number* and proportion) (CS 1) Sufficient and Number of health quality ensured facilities involved in drugs and lab DOTS with sufficient Supportive Environment supplies drug and laboratory supplies** (SE 1 and SE 2) Building and maintaining Number of health human resource facilities and capacity laboratories involved in DOTS with sufficient capacity for DOTS*M&E toolkit, Draft 14.01.04 22
  • Monitoring, Number of training evaluation, and activities conducted operational as per operational research plan* (focusing on barriers to DOTS Number and implementation) proportion of health workers receiving regular supervisory visits* Number of patients Health systems who are accurately strengthening referred* Health facilities and laboratories with capacity for DOTS implementation (number* and proportion) Coordination and Number of partnership networks/partnerships development involved* (national, community, public-private) Percentage of service Unit costs of drugs and Procurement and delivery points with commodities supply sufficient drug management supplies (under capacity building development)* Outputs and outcomes here are also measured as "counts" of increased capacity provided against a needthat has been estimated as a pre-condition for change and they can be quantified through direct observation oran annotated inventory. For these "counts" the toolkit does not provide a detailed description in the annexes.** Although this information focuses on reporting the number of health facilities, a detailed description ofthe associated indicator reporting on the proportion is provided.The detailed description of each of the indicators listed above is provided in Annex B.General resources− Tuberculosis Monitoring and Evaluation unit of Stop TB Department of World Health Organization: building capacity at country level for monitoring, evaluation and evidence-based planning, conducting global surveillance of epidemiological and financial trends in TB controlM&E toolkit, Draft 14.01.04 23
  • − Stop TB Partnership Working Groups: Three operational working groups provide a focus for coordinated action and support monitoring and evaluation of country-level activities related to o DOTS expansion, including sub-groups on laboratories and public-private mix o TB/HIV o MDR-TB− Global Working Group on Indicators – a partnership between the World Health Organization, World Bank, U.S. Centers for Disease Control and Prevention, International Union Against Tuberculosis and Lung Disease (IUATLD), Royal Netherlands Tuberculosis Association (KNCV), U.S. Agency for International Development (USAID) and Measure. Contact: cvincent@usaid.govTechnical assistance − International Union Against TB and Lung Diseases (IUATLD): www.iuatld.org − Royal Netherlands Tuberculosis Association (KNCV): www.tuberculose.nl − U.S. Centers for Disease Control: www.cdc.gov (mqualls@cdc.gov) − World Health Organization: www.who.int (dyec@who.int) − World Bank: www.worldbank.org (dweil@worldbank.org)Software products − WHO EpiCentre software to manage quarterly reporting data Contact: WHO SEARO (Nani Nair, nairn@whosea.org) − Electronic TB Register (ETR): a computerized TB register capturing individual patient data available from the U.S. Centers for Disease Control’s “Botusa” project in Africa Contact: Peter Vranken (pbv7@botusa.org). − New Windows (Access) application combines features of EpiCentre and ETR, and is accompanied by "specifications" for software tool development Contact: WHO Geneva (Dan Bleed, bleedd@who.int).Guidelines − World Health Organization (2002). An expanded DOTS framework for effective tuberculosis control. http://www.who.int/gtb/publications/dots/pdf/TB.2002.297.pdf − World Health Organization (1998). Tuberculosis handbook. http://www.who.int/gtb/publications/tbhandbook/index.htmM&E toolkit, Draft 14.01.04 24
  • − World Health Organization (2002). Global Tuberculosis Control: WHO Report 2003. http://www.who.int/gtb/publications/globrep/index.html − World Health Organization (2003). Management of Tuberculosis Training for health facility staff. − http://www.who.int/gtb/publications/training/management_of_tb/pdf/who_cds_tb _2003_314i.pdf − World Health Organization (1998). Laboratory services in tuberculosis control. http://www.who.int/gtb/publications/whodoc/who_tb-98- 258/en/98.258_org_management- .pdf − World Health Organization (2001). The Use of Indicators for communicable disease control at district level. http://www.who.int/gtb/publications/indicators/tb_2001_289.pdf − World Health Organization (2001). Good practice in legislation and regulations for TB control: An indicator of political will. http://www.who.int/gtb/publications/General/TB_2001_290legisl.pdf − World Health Organization (2000). Guidelines for establishing DOTS-PLUS pilot projects for the management of multidrug-resistant tuberculosis (MDR-TB). http://www.who.int/gtb/publications/dotsplus/dotspluspilot-2000- 279/english/index.htm − World Health Organization (2003). Guidelines for implementing collaborative TB and HIV programme activities. http://www.who.int/gtb/publications/tb_hiv/2003_319/tbhiv_guidelines.pdf − World Health Organization (1998). Guidelines for conducting a review of a national tuberculosis programme. http://www.who.int/gtb/publications/whodoc/who_tb_98.240.pdfMalariaThis section of the toolkit provides a generalized framework for monitoring andevaluation of specific interventions or service delivery areas within malaria controlprogrammes. An overview of the indicators for M & E across interventions ispresented and general resources that are available or in preparation. Each of theindicators is applicable to all malaria endemic settings, with the exception of theindicators covering impact and epidemics. The indicator for the prediction ofepidemics should only be used for countries with epidemic-prone areas. With regardto monitoring impact, the primary indicator to be monitored by all African countriesand high endemic settings is all-cause under-5 mortality, as measured by nationally-representative, household surveys. Malaria-specific mortality cannot be measuredroutinely, as it is difficult to measure in malaria-endemic Africa. Symptoms and signs(such as anemia) are not specific and sensitive, making autopsy and verbal autopsyM&E toolkit, Draft 14.01.04 25
  • inaccurate; and many deaths, especially in young children, may be malaria relatedrather than attributable to malaria exclusively without concurrent infections.Moreover, a majority of deaths do not occur in hospitals and are not routinelyrecorded in HMIS, and these are unlikely to be picked up in vital registration systems,which are often incomplete..M&E toolkit, Draft 14.01.04 26
  • Summary table for malaria Sub- Inpu Programme t Process Output Outcome Insecticide- Number of nets, LLNs, Households owning ITN Increased numbers trained (health personnel, government, non-government and private sector), commodities treated nets pretreated nets or (PI1) Budget reporting by financial category, Monitoring and Evaluation Framework exists, Strategies and (ITNs) retreatment kits distributed* Number of nets Children under 5 using retreated* ITN (PI 2) Guidelines developed and used, Implementing Partners identified Number of sentinel sites purchased (drugs, ITNs, insecticides, other, purchasing policy) established for monitoring insecticide resistance* Malaria in Number of nets, LLNs, Pregnant women using pregnancy pretreated nets or ITN (PI 3) retreatment kits distributed* Number of nets Pregnant women Prevention retreated* receiving treatment (IPT) or chemoprophylaxis (PI 4) Number of pregnant women receiving correct IPT* Prediction and Malaria epidemics containment of detected and properly epidemics controlled (PI 5) Indoor Number of homes and Residual areas sprayed with Spraying insecticide* Information, Number of targeted areas education, and with IEC services* communication (IEC)M&E toolkit, Draft 14.01.04 27
  • Sub- Inpu Programme t Process Output Outcome Prompt, Number of patients with Children under 5 years of effective uncomplicated and age with access to prompt antimalarial severe malaria receiving effective treatment (TI1) treatment correct diagnosis and treatment* Number of health Patients with severe facilities with no reported malaria receiving correct stockouts of antimalarial treatment (TI 3) Treatment drugs* (TI 2) Monitoring Number of sentinel sites drug resistance established for monitoring antimalarial drug resistance* Home-based Number of caretakers management of recognizing signs and malaria symptoms of malaria* % of budget Monitoring, spent of evaluation, and monitoring and operational operations research research Supportive Environment Health systems Number of patients who strengthening are accurately referred* Coordination Number of and partnership networks/partnerships development involved* (national, community, public-private) Procurement and supply management Percentage of service capacity delivery points with Unit costs of drugs and building sufficient drug supplies commodities* Outputs and outcomes here are also measured as "counts" of increased capacity provided against a need thathas been estimated as a pre-condition for change and they can be quantified through direct observation or anannotated inventory. For these "counts" the toolkit does not provide a detailed description in the annexes..The detailed description of each of the indicators listed above is provided in Annex C.M&E toolkit, Draft 14.01.04 28
  • General resourcesSince the creation of Roll Back Malaria (RBM), a Monitoring and Evaluation ReferenceGroup (MERG) has been established to improve coordination among key M&E players.The main function of the MERG is to act as an advisory body for the RBM Secretariat,hence to give technical guidance related to monitoring progress in malaria control. Theactual M&E work is being implemented by National Malaria Control Programmes withsupport from the inter-country teams and RBM partners. General information on theactivities and products of the MERG can be found at the following link:http://mosquito.who.int/partnership/wg/wg_monitoring/summary.htm.Technical assistance and software productsTechnical support to governments is available through a variety of sources, mostnotably through the RBM Monitoring and Evaluation Reference Group (MERG) andWHO headquarter and ergional offices, as well as RBM inter-country offices.Further, M&E technical support groups have been established in some countriesthrough the broader RBM partnership.GuidelinesMore information on monitoring and evaluation of malaria control activities can be foundin the following documents:General! Roll Back Malaria. Framework for Monitoring Progress and Evaluating Outcomes and Impact. 2000. Geneva. Available online: http://rbm.who.int/cmc_upload/0/000/012/168/m_e_en.pdf.! Roll Back Malaria/MEASURE. Guidelines for core indicators for assessing malaria intervention coverage from household surveys. 2004. In preparation.! Roll Back Malaria. Monitoring and Evaluation Reference Group, Mortality Task Force. Meeting Minutes. 16 July 2003. Available online: http://mosquito.who.int/partnership/wg/wg_monitoring/summary.htm! Roll Back Malaria. Malaria Indicator Survey (MIS). In preparation.! WHO/UNICEF. Africa Malaria Report 2003. Available online: http://mosquito.who.int/partnership/wg/wg_monitoring/summary.htmPolicies and guidelines! WHO. Management of Severe Malaria: A practical handbook. 2nd Edition. Geneva 2000. Available online: http://rbm.who.int/docs/hbsm.pdf.! WHO. The Use of Antimalarial Drugs: Report of an Informal Consultation, Geneva, 13-17 November 2000. Available online: http://rbm.who.int/cmc_upload/0/000/014/923/use_of_antimalarials.pdf.! WHO. Antimalarial Drug Combination Therapy: Report of a WHO Technical Consultation, Geneva, 4-5 April 2001. Available online: http://rbm.who.int/cmc_upload/0/000/015/082/use_of_antimalarials2.pdf.! WHO Regional Office for the Western Pacific. Malaria Rapid Diagnosis: Making it work. Meeting Report 20-23 January 2003. Manila. Available online: http://rbm.who.int/cmc_upload/0/000/016/750/rdt2.pdf.M&E toolkit, Draft 14.01.04 29
  • Drug supply management! Management Sciences for Health. Drug Management for Malaria. June 2000, revised July 2002. Rational Pharmaceutical Management Program.! John Snow International. Logistics Indicators and Monitoring and Evaluation Tools. DELIVER Project. Available online: http://deliver.jsi.com/2002/Pubs/Pubs_Guidelines/index.cfm.Drug resistance! WHO. Monitoring Antimalarial Drug Resistance. 2002. Report of a WHO consultation, Geneva, Switzerland 3–5 December 2001. Available online: http://rbm.who.int/cmc_upload/0/000/015/800/200239.pdf.Home-based management! Roll Back Malaria/UNDP/World Bank/WHO TDR. Scaling up home-based management of malaria: from research to implementation. 2003. Geneva. In preparation.! Carol Baume. A Guide to Research on Care-seeking for Childhood Malaria. Published by the Support for Analysis and Research in Africa (SARA) Project and the Basic Support for Institutionalizing Child Survival Project (BASICS II) for the United States Agency for International Development. Arlington, Virginia, April 2002. Available online: http://www.aed.org/publications/GuideResearch.pdf.Vector control including insecticide-treated nets (ITNs)! Roll Back Malaria. Scaling-Up Insecticide-Treated Netting Programmes in Africa: A Strategic Framework for Coordinated National Action. 2002. Geneva. Available online: http://rbm.who.int/cmc_upload/0/000/015/845/itn_programmes.pdf.! Roll Back Malaria. Insecticide-Treated Mosquito Net Interventions: A Manual for National Control Programme Managers. 2003. Available online: http://rbm.who.int/cmc_upload/0/000/016/211/ITNinterventions_en.pdf.! WHO. Space spray application of insecticides for vector and public health pest control: A practitioners guide. Geneva, 2003 (document WHO/CDS/WHOPES/GCDPP/2003.5. Available online: http://www.who.int/ctd/whopes/docs/Brochure_Space.pdf.Malaria in pregnancy! Roll Back Malaria. Strategic framework for malaria control during pregnancy. 1 November 2002.Malaria epidemics! Hook C. Field Guide for Malaria Epidemic Assessment and Reporting. DRAFT for Field Testing. World Health Organization. 2003. Available online: http://rbm.who.int/cmc_upload/0/000/016/569/FTest.pdf.! Roll Back Malaria. Prevention and Control of Malaria Epidemics: 3rd Meeting of the TSN, Geneva, 10-11 December 2001. 2002. Available online: http://rbm.who.int/cmc_upload/0/000/015/827/3epidemics_report.pdf.! Roll Back Malaria. Malaria Early Warning Systems: A Framework for Field Research in Africa . Available online:M&E toolkit, Draft 14.01.04 30
  • http://rbm.who.int/cmc_upload/0/000/014/807/mews2.pdf.Training and human resources development! Roll Back Malaria. RBM Human Resource Needs Assessment & Planning Tool. 2003. In preparation.M&E toolkit, Draft 14.01.04 31
  • Frequently asked questionsTechnical questions1. What is the difference between monitoring and evaluation?Monitoring is the routine tracking of the key elements of programme/projectperformance, usually inputs and outputs, through record-keeping, regular reporting andsurveillance systems as well as health facility observation and client surveys. Monitoringhelps programme or project managers determine which areas require greater effort andflag questions that might contribute to an improved response. In a well-designedmonitoring and evaluation system, monitoring contributes greatly towards evaluation.Indicators selected for monitoring will be different depending on the reporting levelwithin the health system. It is very important to select a limited number of indicators thatwill actually be used by programme implementers and managers. There is a tendency tocollect information on many indicators and report this information to levels where it willnot and cannot be used for decision-making.In contrast, evaluation is the episodic assessment of the change in targeted results that canbe attributed to the programme or project/project intervention. In other words, evaluationattempts to link a particular output or outcome directly to a particular intervention after aperiod of time of implantation of a particular programme has passed. Evaluation helpsprogramme or project managers determine the value or worth of a specific programme orproject.2. What is the difference between national and sub-national M&E?In view of scarce M&E resources at sub-national level, emphasis is placed on monitoringprogramme inputs and outputs and assessing whether or not implementation progressesaccording to a sub-national plan. A small facility assessment as part of a routinesupervision could serve to provide information on the quality of care or the availabilityand utilization of services. At national level, both monitoring and evaluation are needed.Sub-national data is extremely relevant for national level M&E provided that nationalguidelines are followed to make aggregation possible. For example, if a country hasactual data on condom distribution by district (or equivalent) instead of one nationaloverall figure, monitoring of trends in condom use may become more meaningful andmore accurate.3. What is the difference between programme and project M&E?Programme refers to an overarching national or sub-national response to the disease.Within a national programme, there are typically a number of different areas ofprogramming. For example, the HIV/AIDS programme has a number of “sub-programmes” such as blood safety, STI control, or HIV prevention for young people.M&E toolkit, Draft 14.01.04 32
  • Project refers to a mix of interventions that aim at a specific population definedgeographically or otherwise.In view of its wider scope (thematic, geographic, target population), programmemonitoring tends to be more complex than project monitoring and requires strongcoordination among all implementing agencies. Programme evaluation is even moredifficult, especially for certain types of evaluations (outcome and impact evaluations).For such evaluations to be conducted, the design of the programme/project must includeits own baseline and follow-up assessments measuring not only specific outcomes butalso the level of exposure to the programme/project and its activities. (See question 4 formore details on evaluations)4. When is the appropriate timing for an evaluation?The timing for a specific type of evaluation depends on the implementation status of aprogramme or project. There are four types of programme or project evaluations:• Formative evaluation• Process evaluation• Outcome evaluation• Impact evaluationFormative evaluation is conducted in the design phase of a prevention and careprogramme to identify and resolve intervention and evaluation issues before theprogramme is widely implemented. Formative evaluation identifies transmissiondynamics, assists in identifying effective interventions and helps define realistic goals.Process evaluation involves the assessment of the programme or project’s content, scopeor coverage together with the quality of implementation. If the process evaluation findsthat the programme/project has not been implemented, or is not reaching its intendedaudience, it is not worth conducting an outcome evaluation. However, if processevaluation shows progress in implementing the programme/project as planned, then it isworth carrying out such an evaluation.In outcome evaluation, the evaluation is designed specifically with the intention of beingable to attribute the changes to the intervention itself. At the very least, the evaluationdesign has to be able to plausibly link observed outcomes to a well-defined programmeor project, and to demonstrate that changes are not the result of non-programme/projectfactors.If the evaluation shows a change in outcomes, then it is time for impact evaluation. Trueimpact evaluation, able to attribute long-term changes to a specific programme or project,is very rare. Rather, monitoring impact indicators taken in conjunction with process andoutcome evaluations are considered to be sufficient to indicate the overall impact.5. Does evaluation require more than monitoring?As seen in questions 1 to 4, the objectives and the methodology used in monitoring andevaluation are different. In general, evaluations are more difficult in view of theM&E toolkit, Draft 14.01.04 33
  • methodological rigor needed; without such rigor, wrong conclusions on the value of aprogramme or project can be drawn. They are also more costly, especially outcome andimpact evaluations which require population-based surveys.6. What is operations research?Operations Research (OR) is a rigorous type of evaluation that complements M&Esystems. The main objective of OR is to provide programme managers and policymakers with the required information to develop, improve, or scale-up programmes. Itcan be thought as a practical, systematic process for identifying and solving programme-related problems. The process has five key steps:1. Problem identification and diagnosis2. Selection of a programme strategy3. Strategy testing and evaluation4. Information dissemination5. Information utilization and scaling-upOnce operations research shows that a given intervention can be effective, tracking moregeneralized implementation is needed through a strong national M&E system. Forexample, if OR shows that sex education in selected high schools can reduce riskbehavior, repeated behavioral surveys among a national sample of high-school studentswould be needed to reflect changes in risk behavior following the integration of sexeducation into the nation-wide curriculum.7. Are all indicators equal?The M&E conceptual framework discussed earlier shows that the different types ofindicators are not equal but linked to each other to reach the intended goals and objectivesof a specific programme. Inputs such as money and staff time result in outputs such asstocks and delivery systems for drugs or other essential commodities, new or improvedservices, trained staff, informational materials, etc. If these outputs are well designed andreach the populations for which they were intended, the programme is likely to havepositive outcomes – depending on the context in which it operates. These positiveoutcomes should lead to changes in the longer-term impact of programmes on targetpopulations or systems.8. How often are different indicators measured?The frequency of reporting will depend on the place of the indicators within the M&Econceptual framework – taking into account a reasonable time frame for an expectedchange and programme capacity for M&E. The following reporting schedules aresuggested:M&E toolkit, Draft 14.01.04 34
  • Type of indicator Frequency of measurementInput continuouslyProcess quarterlyOutput quarterlyOutcome 2 to 3 yearsImpact 3 to 5 years9. Why do we need standard indicators?The use of standard indicators provides the National Programme with valuable measuresof the same indicator in different populations, permitting triangulation of findings andallowing regional or local inconsistencies and differences to be noted and addressed.This helps to direct resources to regions or sub-populations with greater needs and toidentify areas for intensification or reduction of effort at the national level, ultimatelyimproving the overall effectiveness of the national response. The use of standardindicators also ensures comparability of information across countries and over time.In designing their own evaluation activities, projects should also bear in mind thenational standard for indicators in that field. Projects may have their own informationneeds that conform to a rigorous evaluation design. However, whenever possible theyshould choose indicators with standard reference periods, denominators, etc. that wouldallow the data they collect to be fed easily into the national M&E system.10. What do we mean by a sound, comprehensive or coherent M&E system?A sound M&E system has the following key features:• An established M&E unit in the government (Ministry of Health or national disease-specific councils) with formalized links with different line ministries (depending on the disease), research institutions, donors, and NGOs• Well defined national programme goals and targets• A national M&E plan including a set of priority indicators at different levels of M&E based on the national strategic plans; comparable over time; a subset comparable with other countries; and data collection, quality control, analysis, dissemination and use plan.A coherent M&E system is closely linked to effective M&E coordination among keystakeholders, leading to more efficient use of resources and data. It helps ensure thatdonor-funded M&E efforts best contribute to national needs, rather than to simply servethe reporting needs of agencies. It also encourages communication between differentgroups involved in the national response. Shared planning, execution, analysis ordissemination of information can reduce overlap in programming and increasecooperation between different groups, many of whom may work more efficientlytogether than in isolation.11. How do M&E of HIV/AIDS, Tuberculosis and Malaria fit into national healthinformation systems?M&E toolkit, Draft 14.01.04 35
  • Building or strengthening national health information systems (NHIS) is a pre-requisitefor proper monitoring of the three diseases and the response to them. Increased funding inthe three disease areas creates an opportunity to strengthen not only programme orproject specific health information, but also the health information and surveillancesystems as a whole. HIV/AIDS, TB and malaria have different strengths related to thecollection, dissemination, and use; opportunities exist for the three diseases to leverageeach other’s strengths.An effective NHIS provides a solid basis for evaluations of large-scale programmes,ultimately leading to improved planning and decision-making. Urgent decisions such ashow to allocate new resources to achieve the best overall result will become easier tomake.Operational questions1. How to select indicators from the core list provided in this toolkit?In deciding on a set of indicators, countries are not limited to the core list presented inthis toolkit and should not necessarily collect all of them. The choice of indicatorsshould be driven instead by the goals of the national programme or project. There is nopoint in collecting data on areas that are not relevant to the local context, bearing in mindthat it costs time and money to collect and analyze data for each indicator. However,where they fit their needs, national programmes are encouraged to use the core indicatorsproposed in this toolkit to ensure standardization of information across countries and overtime.The following guiding principles help in choosing the most appropriate set of indicatorsand associated data collection instruments:1. Use a conceptual framework for M&E for proper interpretation of the results (see above for suggested framework);2. Ensure that the indicators are linked to the programme or project goals and are able to measure change;3. Ensure that standard indicators are used to the extent possible for comparability between countries or population groups;4. Consider the cost and feasibility of data collection and analysis; and5. For HIV/AIDS, take into account the stage of the epidemic6. Keep the number of indicators to the minimum needed, with specific reference to the level of the system that require and will use which indicators to make programming and management decisions. Additional indicators can always be identified later.2. Does planning data collection for selected indicators require different strategies?The cost, difficulty, and capacity required for collecting information increase asindicators shift from input through outputs and from outcome to impact.M&E toolkit, Draft 14.01.04 36
  • Input and output data are often easy and cheap to collect. It should be possible to collectdata for input and output indicators centrally from regular health monitoring systems,provided that such systems are functional . Programme planners should take strategicadvantage of the increased attention to HIV/AIDS, TB, and malaria programmes torequest funding for strengthening national health information and surveillance systemsthat can be used to report on all these as well as other disease-specific programmes.Data for many outcome and impact indicators are collected through more costly anddifficult population-based or health facility surveys, requiring some expertise in researchmethods. Outcome measurement is usually more difficult in view of the sensitivity andspecificity of each indicator.3. How to capitalize on existing data collection efforts?In devising their data collection plans, countries should take into account to the extentpossible: • The timing of costly population-based surveys such as DHS in which modules can be included to obtain data on a number of indicators relevant to the three diseases; • The existence of data already collected by agencies not directly involved in one of the three specific diseases, but that can help in monitoring,4. How much from the total national programme budget should be allocated toM&E?Ensuring that resources are well used requires a coherent M&E system. It is, therefore,recommended that about 5-10 percent of the national programme budget are used forM&E. This percentage should be calculated taking into account external donor andnational resources together. Also, between 3 percent and 5 percent of regional and district(where appropriate) financial resources should be devoted to M&E activities at thoselevels.Funders are increasingly realizing that project funds should be allocated to thedevelopment of an M&E system in order to assure that information related to the projectcan be collected, reported, and used. As a result, additional resources have becomeavailable as part of larger grants. This allows for the development of coherent systemsrather than ad hoc efforts.5. How to optimize the use of M&E funds?The following recommendations help ensure that M&E funds are properly invested: • Develop systems rather than implement ad hoc data collection efforts. The initial cost is to be seen in light of the incremental benefit of more regular or more extensive data collection, ultimately resulting in a cheaper exercise.M&E toolkit, Draft 14.01.04 37
  • • Consider both short and long-term needs to ensure smooth continuity of national programmes. • Mobilize key M&E players in the country through an M&E support group to avoid duplication of efforts. • Use commonly agreed upon M&E frameworks for comparability purposes.6. How to optimize the use of data?The ultimate goal of data collection is to ensure that data are fed back into the decision-making process. Data are powerful tools for advocacy, generating resources, andattributing changes to specific interventions and programming (or reorientation ofprogrammes) where possible. Based on lessons learnt over the past years, the followingsteps help optimize the use of data: • Produce quality data, requiring serious investment throughout the data collection process; • Identify the different end-users, and present and package the data according to their needs, focusing on a minimal number of indicators at each level; • Set up mechanisms for an efficient data-use system, including feedback through supervision at all levels, and assurances that data at a given level is relevant and actionable at that level. o Ensure government ownership throughout the data collection exercise, which means that national M&E capacities must be strengthened to guarantee uniform and quality data within a sustainable framework; o Ensure that an M&E support group with strong presence from the government, donor agencies, and academic institutions is established to guide the government throughout the development and implementation of national M&E strategies. This will improve the credibility of the data generated by the government; and o Allocate sufficient resources for the data-use plan.7. How to avoid that donor demands drive all health information investments?To ensure that donor demands do not drive all health information investments – with therisk of having different demands – the following steps are recommended: • Establish a platform under country leadership with strong donor involvement; • Advocate for building a health information system that provides quality and timely information;M&E toolkit, Draft 14.01.04 38
  • • Use – to the extent possible - commonly agreed upon M&E frameworks and standard indicators. Such frameworks are found in global M&E guidelines developed through a participatory process that involved M&E stakeholders from major donor agencies; • In cases where two or more donors have multiple demands, refer to global guidelines to reconcile differences.8. What are the key lessons learnt from successful M&E systems?1. All implementing partners should collect complete input and output data. Many of them should collect process data. Far fewer should assess outcomes. Even fewer will assess impact.2. Good M&E requires both internal self-assessment and external verification. Thus, while implementing partners should collect and verify their own internal data, an external agency should verify the completeness and accuracy of the data collected by those implementing partners. Supervisory visits should be based on the analysis of internal self-assessment and externally verified primary data3. M&E systems must be as simple as possible. Most programmes and projects collect far more data than they use. The more complex an M&E system is, the more likely it will fail.4. M&E systems must include a standardized core. If each implementing partner uses different systems or tools, the data cannot be analyzed or summarized effectively. The need for a standardized core does not preclude individual implementing partners from collecting additional situation-specific M&E data.5. A specialized entity is required to collect, verify, enter and analyze primary M&E data from each partner. Without such an entity, data collection, verification and analysis are unlikely to happen. Ministries and other public agencies are seldom equipped to manage such a process. Increased resources devoted to HIV/AIDS, TB and malaria should be used build local capacity within such a national entity.6. M&E must be built into the design of a programme and must beoperational when grant implementation begins, not added later. It is much harder and less effective to “retrofit” M&E after grant implementation is underway.7. Sub national data are important for the national level data collection as they can be aggregated up to this level. However, subnational data are more relevant to programme managers in making day to day decisions.No matter how sound an M&E system may be, it will fail without widespread stakeholder“buy-in.” Thus, a large-scale, participatory process in the development andimplementation of M&E strategies is essential to build ownership and “buy-in” from thestart.M&E toolkit, Draft 14.01.04 39
  • ANNEX A Description of HIV/AIDS IndicatorsM&E toolkit, Draft 14.01.04 40
  • PREVENTION INDICATOR (PI) 1: YOUTH EDUCATION Schools with teachers trained in life-skills based HIV/AIDS education Percentage of schools with teachers who have been trained in life-skills based HIV/AIDS education and who taught it during the last academic year. RATIONALEV Schools that offer participatory and interactive life-skills training on individual, social and environmental factors that affect the risks of HIV transmission have proven to be more effective in bringing about behaviour change - delayed age at first sex, condom use, reduced number of sexual partners etc. - than more formal approaches that concentrate on information provision. The indicator provides useful information on trends in the coverage of life-skills based HIV/AIDS education within schools. DEFINITION OF INDICATOR Numerator: Number of schools with staff members trained in and regularly teaching life-skills based HIV/AIDS education Denominator: Number of schools surveyed Note: Analysis and reporting in percentage broken down by primary/secondary levels; public/private schools and combined is recommended MEASUREMENT Principals/heads of a nationally-representative sample of schools (to include both private and public schools) are briefed on the meaning of life-skills based HIV/AIDS education and then are asked the following questions: 1. Does your school have at least one qualified teacher who has received training in participatory life-skills based HIV/AIDS education in the last 5 years? 2. If the answer to question 1. is “yes”: Did this person teach life-skills based HIV/AIDS education on a regular basis to each grade in your school throughout the last academic year? Platform: School survey or education programme review Frequency: Biennial REFERENCES − UNAIDS (2002) Monitoring the Declaration of Commitment on HIV/AIDS: Guidelines on Construction of Core Indicators. Geneva: UNAIDS. http://www.unaids.org/UNGASS/docs/JC718-CoreIndic_en.pdf M&E toolkit, Draft 14.01.04 41
  • PREVENTION INDICATOR (PI) 2: CONDOM DISTRIBUTION AND SALES Condoms available, retailThe proportion of randomly selected retail outlets and service delivery points that havecondoms in stock at the time of a survey, of all retail outlets and service delivery pointsselected for survey.RATIONALEThis indicator reflects the success of attempts to broaden the distribution of condoms sothat they are more widely available to people at locations and times when people arelikely to need them. It measures actual distribution of condoms at designated points atany one point in time.DEFINITION OF INDICATORNumerator: Number of retail outlets and service delivery points that have condoms in stock at the time of a surveyDenominator: Total number of retail outlets and service delivery points that have beenselected for the surveyNote: Sites in both urban and rural areas should be selectedMEASUREMENTA number of sites of different types (i.e. pharmacies, clinics, bars and clubs) arerandomly selected for a retail survey from a standard checklist of venues wherecondoms should be accessible, including bars and night clubs, different classes ofretail shops, STI clinics and other service provision points. While the indicator gives asingle summary figure, the data can also be disaggregated by outlet type.Platform: Retail surveys (PSI protocol to evaluate social marketing programmes,WHO/GPA prevention indicator 3)Frequency: quarterlyREFERENCES − UNAIDS/MEASURE (2000) National AIDS Programs: A guide to monitoring and evaluation. Geneva: UNAIDS. http://www.cpc.unc.edu/measure/guide/guide.htmlM&E toolkit, Draft 14.01.04 42
  • PREVENTION INDICATOR (PI) 3: PROGRAMMES FOR SPECIFIC GROUPS Injection Drug Users (IDUs) reached with prevention services Percentage of injecting drug users who are reached with HIV/AIDS prevention services.RATIONALEProviding services such as outreach, needle and syringe programmes and drugdependence treatment, including substitution therapy, to injecting drug users is essential,especially in countries with a significant or growing drug-related HIV epidemic. Thepurpose of this indicator is to estimate to what extent HIV/AIDS prevention services areprovided to injecting drug users.DEFINITION OF INDICATORNumerator: Number of regular injecting drug users, who were, in the past month,reached with (outreach) prevention services plus the number of injecting drug users indrug dependence treatment, either longer-term drug-free or substitution therapyDenominator: Estimated total number of injecting drug usersNote:: Disaggregation by sex is recommendedMEASUREMENTN/aPlatform: Programme monitoring (Service statistics from outreach projects andprogrammes, and treatment facilities for the numerator)Frequency: BiennialREFERENCES! UNAIDS (2002) Monitoring the Declaration of Commitment on HIV/AIDS: Guidelines on Construction of Core Indicators. Geneva: UNAIDS. http://www.unaids.org/UNGASS/docs/JC718-CoreIndic_en.pdfM&E toolkit, Draft 14.01.04 43
  • PREVENTION INDICATOR (PI) 4: PROGRAMMES FOR SPECIFIC GROUPS Companies with HIV/AIDS workplace policies and programmesPercentage of large enterprises/companies which have HIV/AIDS workplace policies andprogrammes.RATIONALEThe workplace is often a highly convenient and conducive setting for HIV controlactivities and workplace-based interventions have been proven to be effective. Theindicator is useful even in countries where HIV prevalence is low because early action ineducating workers on HIV prevention is essential if the serious economic and socialconsequences of HIV/AIDS are to be avoided.DEFINITION OF INDICATORNumerator: Number of employers with HIV/AIDS policies and regulations that meet all* criteriaDenominator: Number of employers surveyedNote: Analysis and reporting by private/public sectors and combined is recommendedMEASUREMENTPrivate sector employers are selected on the basis of the size of the labour force. Publicsector employers should be the ministries of transport, labour, tourism, education andhealth. Employers are asked to state whether they are currently implementing personnelpolicies and procedures that cover a minimum of specified aspects (*see reference fordetails). Copies of written personnel policies and regulations should be obtained andassessed wherever possible.Platform: Survey of the 30 largest employers – 25 private sector; 5 public sectorFrequency: BiennialREFERENCES− UNAIDS (2002) Monitoring the Declaration of Commitment on HIV/AIDS: Guidelines on Construction of Core Indicators. Geneva: UNAIDS. http://www.unaids.org/UNGASS/docs/JC718-CoreIndic_en.pdfM&E toolkit, Draft 14.01.04 44
  • PREVENTION INDICATOR (PI) 5: COUNSELLING AND VOLUNTARY TESTING Coverage of counselling and testing services Percent of districts that have at least one centre staffed by trained counsellors providing specialized HIV counselling and testing services free or at affordable rates.RATIONALEThe coverage of quality VCT services will go a long way towards determining whetherthose services achieve their threefold aims of providing an entry point for care andsupport, promoting safe behaviour and breaking the vicious circle of silence and stigma.This indicator focuses particularly on coverage of specialised VCT services.DEFINITION OF INDICATORNumerator: Number of districts that have at least one centre staffed by trained counsellors providing specialised HIV counselling and testing services free or at affordable ratesDenominator: Total number of districtsNote: Analysis and reporting by district is recommendedMEASUREMENTUsing key informants and health systems records of counsellor training, a list isconstructed of all facilities offering counselling by trained counsellors and HIV testingservices. Since price is a major part of accessibility, this should be considered informulating this indicator. A suggested formula is: the price of voluntary counselling andHIV testing does not exceed one half of the daily minimum wage, or one half of the grossnational product per person per day, calculated at purchasing power parity. “Low” or“affordable” prices may vary by district, and thus the measures should be adjusted. Afurther criterion is that the staff who provides counselling meet specified minimumnational standards of training for counsellors. Facilities meeting the criteria for serviceprovision, staff training and price are mapped by district or similar administrative unit.Platform: Health Systems recordsFrequency: quarterlyREFERENCES− UNAIDS/MEASURE (2000) National AIDS Programs: A guide to monitoring and evaluation. Geneva: UNAIDS. http://www.cpc.unc.edu/measure/guide/guide.html− UNAIDS (2004) National AIDS programmes. A guide to monitoring and evaluating HIV/AIDS care and support. Geneva : UNAIDS (in preparation).M&E toolkit, Draft 14.01.04 45
  • PREVENTION INDICATOR (PI) 6: COUNSELLING AND VOLUNTARY TESTING Population requesting testing and receiving resultsPercent of people aged 15-49 surveyed who have ever voluntarily requested an HIV test,received the test and received their results.RATIONALEThis indicator aims to give an idea of the reach of HIV testing services in the generalpopulation and of the percentage of people who now know their HIV status.DEFINITION OF INDICATORNumerator: Number of respondents having ever requested a test and received the resultsDenominator: Total number of respondents in the surveyNote: Analysis and reporting by component and gender is recommended. It issuggested that data also be collected on those requesting an HIV test, receiving thetest and receiving their results in the last 12 monthsMEASUREMENTIn a general population or sub-population survey, respondents are asked whether theyhave ever requested an HIV test, whether they were tested and if so whether they havereceived the results. Additionally, it will be useful also to know the percentage of thepopulation surveyed who have been tested and received the results in the last 12months, a more time-sensitive measure.Platform: UNAIDS general population survey; DHS AIDS module; FHI adult BSS;youth BSSFrequency: every 2-3 yearsREFERENCES− UNAIDS/MEASURE (2000) National AIDS Programs: A guide to monitoring and evaluation. Geneva: UNAIDS. http://www.cpc.unc.edu/measure/guide/guide.html− UNAIDS (2004) National AIDS programmes. A guide to monitoring and evaluating HIV/AIDS care and support. Geneva: UNAIDS (in preparation).M&E toolkit, Draft 14.01.04 46
  • PREVENTION INDICATOR (PI) 7: MOTHER TO CHILD TRANSMISSION Facilities with minimum package of services The percentage of public, missionary, and workplace venues (family planning and primary health care clinics, ANC/MCH, and maternity hospitals) offering the minimum package of services to prevent HIV infection in infants and young children in the past 12 months.RATIONALEThis indicator provides critical information on the national availability of prevention andcare efforts for women and infants. It is useful to programme planners in determiningwhere services may be needed, or where facilities are providing the full spectrum ofservices to prevent HIV infection in women and infants.DEFINITION OF INDICATORNumerator: Number of public, missionary, and workplace venues (family planningand primary health care clinics, ANC/MCH, and maternity hospitals) offering theminimum package of services to prevent HIV infection in infants and young childrenin the past 12 months.Denominator: All public, missionary, and workplace venues (family planning andprimary health care clinics, ANC/MCH, and maternity hospitals)Note: Analysis and reporting by type of service is recommendedMEASUREMENTThe information required for this indicator can be collected through a variety of differentmethods, and depends on resource availability as well as the amount of detail sought. Itfocuses on the minimum package of services which is defined by the type of clinicalsetting (see reference below). One option is to send a questionnaire to all public,missionary and workplace health facilities offering family planning and primary healthcare clinics, ANC/MCH, and maternity services. Another way to collect the relevantinformation is by adapting other instruments that already exist.Platform: Health facility surveysFrequency: 2-3 yearsREFERENCES! WHO (2004) National guide to monitoring and evaluating programmes for the prevention of HIV in infants and young children. Geneva: WHO (in preparation).M&E toolkit, Draft 14.01.04 47
  • PREVENTION INDICATOR (PI) 8: MOTHER TO CHILD TRANSMISSION ARV prophylaxisPercentage of HIV positive pregnant women receiving a complete course of ARV prophylaxisto reduce MTCT in accordance with nationally approved treatment protocol (orWHO/UNAIDS standards) in last 12 months.RATIONALEThis indicator assesses the progress in preventing mother to child HIV transmissionthrough the provision of ARV prophylaxis.DEFINITION OF INDICATORNumerator: Number of HIV positive pregnant women receiving a complete courseof ARV prophylaxis to reduce the likelihood of MTCT in accordance with nationallyapproved treatment protocol (or WHO/UNAIDS standards) in last 12 months.Denominator: Estimated number of HIV-infected pregnant women giving birth in last 12months.Note: Brake down by type of service is recommendedMEASUREMENTThe number of HIV-infected pregnant women provided with antiretroviral prophylaxis toreduce the risk of MTCT in the last 12 months is obtained from programme monitoringrecords. Only those women who completed the full course should be included Thenumber of HIV-infected pregnant women to whom antiretroviral prophylaxis to reducethe risk of MTCT could potentially have been given is estimated by multiplying the totalnumber of women who gave birth in the last 12 months (Central Statistics Officeestimates of births) by the most recent national estimate of HIV prevalence in pregnantwomen (HIV sentinel surveillance antenatal clinic estimates).Platform: Programme monitoring records Central Statistics Office estimates of birthsFrequency: 2-3 yearsREFERENCES− UNAIDS (2002) Monitoring the Declaration of Commitment on HIV/AIDS: Guidelines on Construction of Core Indicators. Geneva: UNAIDS. http://www.unaids.org/UNGASS/docs/JC718-CoreIndic_en.pdfM&E toolkit, Draft 14.01.04 48
  • PREVENTION INDICATOR (PI) 9: SEXUALLY TRANSMITTED INFECTIONS DIAGNOSIS AND TREATMENT STI comprehensive case managementPercentage of patients with STIs at health care facilities who are appropriately diagnosed,treated and counselled.RATIONALEThe availability and utilization of services to treat and contain the spread of STIs canreduce the rate of HIV transmission within a population. One of the corner stones of STIcontrol is comprehensive case management of patients with symptomatic STIs. Thiscomposite indicator reflects the competence of health service providers to appropriatelyprovide these services, and the quality of services provided.DEFINITION OF INDICATORNumerator: Number of STI patients for whom the correct procedures were followed on: (i) history taking; (ii) examination; (iii) diagnosis and treatment; and (iv) effective counselling on partner notification, condom use and HIV testingDenominator: Number of STI patients for whom provider-client interactions were observedNote: Disaggregation by gender and for patients under and over 20 years of ageScores for each component of the indicator (i.e., history taking, examination, diagnosisand treatment, and counselling) must be reported as well as the overall indicator scoreMEASUREMENTData are collected in observations of provider-client interaction at a sample of health carefacilities offering STI services. Providers are assessed on history taking, examination,proper diagnosis and treatment of patients, and effective counselling includingcounselling on partner notification, condom use and HIV testing. “Appropriate”diagnosis and treatment and counselling procedures in any given country, are thosespecified in national STI service guidelines.Platform: Health facility survey – based on WHO/UNAIDS revised guidelines onevaluating STI services and/or MEASURE service provision assessment (SPA)Frequency: biennialREFERENCES− UNAIDS (2002) Monitoring the Declaration of Commitment on HIV/AIDS: Guidelines on Construction of Core Indicators. Geneva: UNAIDS. http://www.unaids.org/UNGASS/docs/JC718-CoreIndic_en.pdfM&E toolkit, Draft 14.01.04 49
  • PREVENTION INDICATOR (PI) 10: SAFE BLOOD Coverage of blood transfusion servicesPercent of districts or regions with access to blood transfusion services which do not payblood donors, and do not recruit donors from among relatives of the patient.RATIONALEMany countries working to improve access to safe blood have established bloodtransfusion services including blood banks at the regional or district level, and areworking systematically to enhance the recruitment of voluntary donors, and to reduce oreliminate reliance on blood donations from relatives and paid donors. This indicatorassesses to what extent this has been implemented at the level dictated by national policy.DEFINITION OF INDICATORNumerator: Number of districts or regions with access to blood transfusion services which do not pay blood donors, and do not recruit donors from among relatives of the patientDenominator: Total number of districts or regionsMEASUREMENTA district or region is considered to score positively on this indicator if at least 95% ofblood transfused is supplied by a regional or provincial blood transfusion service thatscreens donors for risk behaviours and excludes donations from relatives and paiddonors.Platform: MEASURE Evaluation Draft Blood Safety ProtocolFrequency: quarterlyREFERENCES− UNAIDS/MEASURE (2000) National AIDS Programs: A guide to monitoring and evaluation. Geneva: UNAIDS. http://www.cpc.unc.edu/measure/guide/guide.htmlM&E toolkit, Draft 14.01.04 50
  • PREVENTION INDICATOR (PI) 11: SAFE BLOOD Screening of blood units for transfusion The percentage of blood units transfused in the last 12 months that have been adequately screened for HIV according to national or WHO guidelines.RATIONALEBlood safety programmes aim to ensure that the overwhelming majority (ideally 100percent) of blood units are screened for HIV, and those that are included in the nationalblood supply are indeed uninfected. This indicator gives an idea of the overall percentageof blood units that have been screened to high enough standards that they can confidentlybe declared free of HIV.DEFINITION OF INDICATORNumerator: Number of blood units screened for HIV in the previous 12 months,and among those, the number screened up to WHO or national standardsDenominator: Total number of blood units transfused in the previous 12 monthsNote: Brake down by components of the indicator is recommendedMEASUREMENTThe number of units transfused and the number screened for HIV should be availablefrom health information systems. Quality of screening may be determined from a specialstudy that re-tests a sample of blood previously screened, or from an assessment of theconditions under which screening occurred. In situations where this approach is notfeasible, data on the percentage of facilities with good screening and transfusion recordsand no stockouts of test kits may be used to estimate adequately screened blood for thisindicator.Platform: MEASURE Evaluation Draft Blood Safety ProtocolFrequency: every 2-3 yearsREFERENCES− UNAIDS/MEASURE (2000) National AIDS Programs: A guide to monitoring and evaluation. Geneva: UNAIDS. http://www.cpc.unc.edu/measure/guide/guide.htmlM&E toolkit, Draft 14.01.04 51
  • TREATMENT INDICATOR (TI) 1: ANTIRETROVIRAL TREATMENT People on treatmentPercentage of people with advanced HIV infection receiving antiretroviral combinationtherapyRATIONALEAs the HIV pandemic matures, increasing numbers of people are reaching advancedstages of HIV infection. Antiretroviral combination therapy has been shown to reducemortality amongst those infected and efforts are being made to make it more affordableeven within less developed countries. Antiretroviral combination therapy should beprovided in conjunction with broader care and support services including counselling forfamily caregiver.DEFINITION OF INDICATORNumerator: Number of people with advanced HIV infection who receive antiretroviral combination treatment according to the nationally approved treatment protocol (or WHO/UNAIDS standards)Denominator: Number of people with advanced HIV infectionNote: This indicator should be disaggregated by public/private servicesMEASUREMENTThe numerator of this indicator is consists of the number of people receiving treatment atstart of year plus the number of people who commenced treatment in the last 12 monthsminus the number of people for whom treatment was terminated in the last 12 months(including those who died). The number of people with advanced HIV infection isassumed to be 15% of the total number of people currently infected (for the purposes ofthis indicator). The latter is estimated using the most recent national sentinel surveillancedata. The start and end dates of the period for which the number of people givenantiretroviral therapy is given should be stated. Overlaps between reporting periodsshould be avoided wherever possible.Platform: Programme monitoringFrequency: BiennialREFERENCES− UNAIDS (2002) Monitoring the Declaration of Commitment on HIV/AIDS: Guidelines on Construction of Core Indicators. Geneva: UNAIDS. http://www.unaids.org/UNGASS/docs/JC718-CoreIndic_en.pdfM&E toolkit, Draft 14.01.04 52
  • TREATMENT INDICATOR (TI) 2: ANTIRETROVIRAL TREATMENT Health facilities capable of providing advanced level medical and psychosocial support services for HIV/AIDS Percentage of facilities with the capacity and conditions to provide advanced level HIV care and support services, including provision of ARTRATIONALEThis indicator measures the capacity of services specific to people living with HIV/AIDS.It is assumed that the systems and items measured in this indicator require substantialinput and personnel training beyond what is routine for most health systems.DEFINITION OF INDICATORNumerator:1. Number of facilities with some components describing a list of advanced level services (see below for the list of services)2. Number of facilities with all components for all servicesDenominator:1. Total number of health facilities surveyed2. Total number of facilities where identified services are offered or relevantNote: The specific components for each service should be presented individuallyMEASUREMENTThe capacity to provide advanced level HIV/AIDS care includes: systems and items tosupport management of opportunistic infections and provision of palliative care foradvanced care of clients with HIV/AIDS; systems and items to support advanced servicesfor HIV/AIDS care; systems and items to support ART services; conditions to provideadvanced inpatient care for clients with HIV/AIDS; conditions to support home careservices; and post-exposure prophylaxis.Platform: Health facility surveysFrequency: every 2-4 yearsREFERENCES− UNAIDS (2004) National AIDS programs. A guide to monitoring and evaluating HIV/AIDS care and support. Geneva : UNAIDS (in preparation)M&E toolkit, Draft 14.01.04 53
  • TREATMENT INDICATOR (TI) 3: OPPORTUNISTIC INFECTIONSHealth facilities capable of providing phrophylaxis and treatment for opportunisticinfections (OIs) Percentage of health facilities with the capacity and conditions to provide basic level HIV testing and HIV/AIDS clinical managementRATIONALEMany facilities that provide general curative care also provide services related toHIV/AIDS and are caring for HIV-infected clients. It is, therefore, essential to evaluatethe status of existing capacity.DEFINITION OF INDICATORNumerator:1. Number of facilities with some components describing a list of basic services (see below for the list of services)2. Number of facilities with all components for all servicesDenominator:1. Total number of health facilities surveyed2. Total number of facilities where identified services are offered or relevantNote: The specific components for each service should be presented individuallyMEASUREMENTThe capacity to provide basic HIV counselling and medical services includes: a systemfor testing and providing results for HIV/AIDS; systems and qualified staff for pre- andpost-test counselling; specific medical services relevant to HIV/AIDS including resourcesand supplies for providing these services; elements for prevention of nosocomialinfections; trained staff and resources for providing basic interventions for prevention andmedical treatment for HIV-infected persons.Platform: Health facility surveysFrequency: every 2-4 yearsREFERENCES− UNAIDS (2004) National AIDS programmes. A guide to monitoring and evaluating HIV/AIDS care and support. Geneva: UNAIDS (in preparation)M&E toolkit, Draft 14.01.04 54
  • TREATMENT INDICATOR (TI) 4: HIV/TBIntensified TB case finding among people living with HIV/AIDSProportion of clients attending HIV testing and counselling who test positive and who arescreened for TB symptoms.RATIONALEIdentification of TB suspects is the first step in active case finding, and their promptreferral will promote early diagnosis and treatment of TB cases. In addition, TB symptomscreening will help determine eligibility for TB preventive therapy. This indicator can beused for assessing intensified TB case finding in all situations where HIV counselling andtesting is conducted or where PLWHA receive regular care and support, including HIVcare clinics, inpatient medical services, VCT and PMTCT sites.DEFINITION OF INDICATORNumerator: Number of HIV positive clients who are asked about TB and TB symptomsDenominator: Total number of HIV positive clients seen in each all situations whereHIV care and support is provided or HIV counselling and testing is conductedIn programmes where only HIV positive clients are screened:Numerator: Number of HIV-positive clients who are asked about TB and itssymptomsDenominator: Total number of HIV-positive clientsMEASUREMENTData should be collected routinely at all HIV testing and counselling facilities (includingthose associated with PMTCT and within the private sector) and any situation whereregular HIV care and support are provided. A suggested method of conducting thescreening would be to ask patients whether they are currently on TB treatment. If not,they are then asked for some key symptoms of TB disease. By these questions all clientscan be included in intensified TB case finding. Depending on local requirements thenumber of TB patients and TB suspects could also be collected from the same screen.Such screening may also form the basis of identifying HIV positive clients who have noevidence of active TB and would benefit from TB preventive therapy with isoniazid.Platform: Modified testing and counselling registerFrequency: continuous data collection; reporting in quarterly returnsM&E toolkit, Draft 14.01.04 55
  • REFERENCES− WHO "A Guide to Monitoring and Evaluation for Collaborative TB/HIV Activities" , in preparation− “Interim Policy on Collaborative TB/HIV Activities. WHO/HTM/HIV/2004.1 and WHO/HTM/TB/2004.330M&E toolkit, Draft 14.01.04 56
  • TREATMENT INDICATOR (TI) 5: HIV/TBCounselling and voluntary testing for TB patients Proportion of all TB patients who are tested for HIV and receive the results.RATIONALEThis indicator assesses to which extent staff involved in TB recognises the importance ofHIV/AIDS testing and counselling and is able to act accordingly. The proportion of TBpatients tested also gives an indication about the availability, accessibility andaffordability of CT services and provides information necessary for targeting ofresources, planning of activities and for monitoring the effectiveness of counseling andtesting over time.DEFINITION OF INDICATORNumerator: Total number of TB patients who are tested for HIV (after having beenoffered VCT) and receive the results, over a given time periodDenominator: Total number of tuberculosis patients registered over the same giventime periodMEASUREMENTThe information will be collected from facility level, where each facility may have aspecific recording system in place indicating whether the patient was referred forcounseling and testing, taking into account measures of confidentially. The informationof HIV test including HIV status should be recorded in the district TB register kept by thedistrict TB co-ordinator. The reporting of the information will be incorporated into theexisting TB reporting system.Platform: TB district register, quarterly reports, HIV laboratoryFrequency: The data would be collected continuously and reported in quarterlycohortsREFERENCES! WHO "A Guide to Monitoring and Evaluation for Collaborative TB/HIV Activities" , in preparation! “Interim Policy on Collaborative TB/HIV Activities. WHO/HTM/HIV/2004.1 and WHO/HTM/TB/2004.330M&E toolkit, Draft 14.01.04 57
  • TREATMENT INDICATOR (TI) 6: HIV/TBProvision of cotrimoxazole preventive therapyPercentage of HIV positive patients who are given cotrimoxazole preventive therapy.RATIONALECommon HIV-related opportunistic infections contribute to the high mortality rates seenin HIV positive TB patients. A few studies from Sub-Saharan Africa have shown thebenefit of cotrimoxazole preventive treatment (CPT) in reducing morbidity and mortalityamong HIV positive people on TB treatment. For this reason, CPT is recommended forHIV-positive adults and children living in Africa, and may be considered in othersettings. The indicator measures the degree to which CPT is considered a component ofthe package of care offered to HIV positive patients with TB.DEFINITION OF INDICATORNumerator: HIV-positive patients with TB who are given CPTDenominator: All HIV positive patients with TB who have been post-test counselledMEASUREMENTWhen HIV positive TB patients are provided CPT through the TB programme, amodified TB register should be used. A column can be added which can be tickedwhen CPT is given. These results should be reported at the completion of TBtreatment in order to include all persons started on CPT over the course of theirtreatment. In cases in which CPT is provided through HIV treatment programmes, areferral system must be established to provide these results to the NTP at TBtreatment completion on each person. In this case, a modified TB register (asdescribed above) may still be used to collect this information once it has beenreported back from HIV treatment programmes.Platform: Modified TB register, referral system to TB programme if collected byNACPFrequency: continuous data collection; reporting in quarterly returns at the end of TBtreatment along with the outcome of TB treatmentREFERENCES− Provisional WHO/UNAIDS Secretariat recommendations on the use of cotrimoxazole prophylaxis in adults and children living with HIV/AIDS in Africa (www.unaids.org/publications/documents/care/general/recommendations-eng.pdf)M&E toolkit, Draft 14.01.04 58
  • − WHO "A Guide to Monitoring and Evaluation for Collaborative TB/HIV Activities" , in preparation− “Interim Policy on Collaborative TB/HIV Activities. WHO/HTM/HIV/2004.1 and WHO/HTM/TB/2004.330M&E toolkit, Draft 14.01.04 59
  • TREATMENT INDICATOR (TI) 7: HIV/TBProvision of ARTProportion of HIV-positive TB patients who are given ART.RATIONALEExperience from high and middle-income countries has shown that ART significantlyimproves the quality of life and enhances the survival of people with advanced HIVinfection or AIDS. Since TB patients are one of the largest identifiable groups who arelikely to be eligible for and benefit from ART, efforts should be undertaken to identifyand treat eligible candidates. The indicator measures the degree to which ART isconsidered a component of the package of care offered to HIV positive patients with TB.DEFINITION OF INDICATORNumerator: Registered TB patients who are HIV positive and given ARTDenominator: Registered TB patients who are HIV positive and have been post-testcounseledMEASUREMENTIn programmes where ART is offered through the TB programme, a modified TB registercan be used by adding an extra column which can be ticked when an HIV-positive TBpatient is given ART during the course of TB therapy. These results should be reportedat the completion of TB treatment in order to include all persons started on ART over thecourse of their TB treatment. In cases in which ART is provided by HIV treatmentprogrammes, a referral system must be established to provide these results to the NTP atTB treatment completion on each person. In this case, a modified TB register may stillbe used to collect this information once it has been reported back from HIV treatmentprogrammes.Platform: Modified TB register with referral system (where appropriate)Frequency: continuous data collection; reporting in quarterly returns at the end of TBtreatment along with the outcome of TB treatmentREFERENCES− WHO "A Guide to Monitoring and Evaluation for Collaborative TB/HIV Activities" , in preparation− “Interim Policy on Collaborative TB/HIV Activities. WHO/HTM/HIV/2004.1 and WHO/HTM/TB/2004.330M&E toolkit, Draft 14.01.04 60
  • CARE AND SUPPORT (CS) 1: ORPHANS AND VULNERABLE CHILDRENExternal support for households with orphans and vulnerable childrenPercentage of orphans and vulnerable children whose households received, free of usercharges, basic external support in caring for the child.RATIONALEThis indicator measures support coming from a source other than friends, family orneighbours (unless they are working for a community-based group or organization) givenfree of user charges to households with orphans and vulnerable children.DEFINITION OF INDICATORNumerator: Number of orphans and vulnerable children residing in households thatreceived: ! health care support within the past 12 months; ! emotional support within the past 3 months; ! school-related assistance within the past 12 months; ! other social support, including material support, within the past 3 months; and ! all four types of supportDenominator: Total number of orphans and vulnerable childrenNote: Data should be analysed and reported by age (0–5, 6–9, 10–14 and 15–17 years)and gender when sample size allows. Depending on the epidemiological situation andavailable resources, programme managers may decide to aggregate age data into largerranges (0–9, 10–14 and 15–17 years).MEASUREMENTAs part of a household survey, household rosters can be used to identify all eligibleorphans and vulnerable children (under 18 years of age). For each household withorphans and vulnerable children, a series of questions is asked about the types andfrequency of support received and the primary source of the help. This survey tool mayalso be used in low-prevalence settings or targeted populations with similar but adaptedmethods.Platform: Household surveysFrequency: every 2-4 yearsREFERENCES− UNAIDS (2004) National AIDS programmes. A guide to monitoring and evaluating HIV/AIDS care and support. Geneva: UNAIDS (in preparation)M&E toolkit, Draft 14.01.04 61
  • ANNEX B Description of TB IndicatorsM&E toolkit, Draft 14.01.04 62
  • PREVENTION INDICATOR (PI) 1: IDENTIFICATION OF INFECTIOUS CASESNew smear-positive TB case detectionProportion of new smear-positive TB cases detected among the total estimated number ofnew semar-positive TB cases per year.RATIONALEThis indicator measures the DOTS program’s ability to detect and identify smear-positivecases. If a country has low case detection, it should find alternative approaches todetecting new cases beyond the traditional methods. For example, the country shouldexplore implementing DOTS in the private and NGO sectors as well as other areas wherecases would be likely to present themselves. It is possible for the calculated detection rateto exceed 100 percent due to intense case finding in an area that has a backlog of chroniccases, over-reporting, over-diagnosis and the under-estimation of incidence. A casedetection rate of 70% or greater is the global target.DEFINITION OF INDICATORNumerator: Annual number of new smear-positive TB cases detectedDenominator: Total annual number of estimated new smear-positive TB cases(incidence)MEASUREMENTThe numerator is available from the TB Register or quarterly case detection reports. Thedenominator is estmation based on calculations by WHO from case notifications for each countryand adjusted for countries with high HIV incidence. These estimations are reported every year byWHO in the annual “Global Tuberculosis Control” report.Platform: TB Register; WHO estimates of incidence for countriesFrequency: annuallyREFERENCES − WHO. Compendium for monitoring TB control activities (in preparation)M&E toolkit, Draft 14.01.04 63
  • PREVENTION INDICATOR (PI) 2: PREVENTION BY TREATING INFECTIOUS CASESSmear–conversion rate at end of 2 months of treatmentPercent of new smear-positive TB cases registered in a specified period that converted tosmear-negative at the end of 2 months of treatment.RATIONALESputum smear conversion after two months of treatment is a good predictor of eventualcure if treatment is completed. This indicator also has treatment implications since insome countries patients who have not converted their sputum smears after two months oftreatment should extend the intensive phase of therapy. This indicator is useful forfollowing trends within a country or region and for comparison between centers.DEFINITION OF INDICATORNumerator: Number of new smear positive pulmonary TB cases registered in a specifiedperiod that are smear negative at the end of 2 months of treatmentDenominator: Total number of new smear positive pulmonary TB cases that wereevaluated for smear conversion in the same periodMEASUREMENTThe numerator is the number of new smear positive pulmonary TB patients registered ina specified period (e.g., quarter or year) that had at least one negative smear result at theend of two months of treatment (intensive phase). This number can be obtained from theTB Register. Similarly, the denominator is the total number of new smear positivepulmonary TB cases registered for treatment during the same period and can also beobtained from the TB Register.Platform: TB RegisterFrequency: quarterly and annualREFERENCES! WHO. Compendium for monitoring TB control activities (in preparation)M&E toolkit, Draft 14.01.04 64
  • PREVENTION INDICATOR (PI) 3: PREVENTION OF TB AMONG TB/HIV INFECTED PEOPLEProvision of isoniazid preventive therapyProportion of HIV positive clients given TB preventive therapy.RATIONALEThe risk of developing TB is significantly increased in PLHA. TB preventive therapywill reduce the incidence of active TB in PLHA. This indicator provides information onone of the main objectives for collaborative TB/HIV activities.DEFINITION OF INDICATORNumerator: Number of clients given at least the first dose of TB preventive therapyDenominator: Total number of HIV-positive clients eligible for TB preventive therapyMEASUREMENTThe data needed for this indicator will be collected at all HIV testing and counsellingfacilities (including those associated with PMTCT) or at HIV care services depending onwhere TB preventive therapy is to be administered. In these different situations clientswill be screened for TB. Those clients found NOT to have TB will be offered TBpreventive therapy according to locally determined guidelines.In programmes which need more complete data for accurate prediction of drug usage andsupplies a reporting mechanism similar to that which is used for TB will need to be used.Staff would need to record attendance (usually monthly) for further drug supplies, andreport new cases, continuing cases and completed cases on a quarterly basis. Theindicator of choice would be the proportion of HIV-positive clients completing TBpreventive therapy.Platform: TB preventive therapy registerFrequency: continuous data collection; reporting in quarterly returnsREFERENCES − WHO. A guide to monitoring and evaluation for collaborative TB/HIV activities (in preparation)M&E toolkit, Draft 14.01.04 65
  • PREVENTION INDICATOR (PI) 4: TB/HIVSurveillance of HIV seroprevalence among all TB patientsPercent of all tuberculosis patients who are HIV positive.RATIONALEMeasuring HIV prevalence among tuberculosis patients will inform about the degreeof overlap in the epidemics in any given setting as well as the contribution of HIV tothe TB epidemic in any given setting. Estimating the prevalence of HIV among TBpatients is an important step in planning TB control activities, planning and targetingintegrated TB-HIV activities and monitoring the effectiveness of these activities overtime.DEFINITION OF INDICATORNumerator: Total number of all registered tuberculosis patients who are HIV positive,over a given time periodDenominator: Total number of all tuberculosis patients registered over the same giventime periodMEASUREMENTIdeally all newly registered tuberculosis patients should be considered for HIVsurveillance. However, if surveys or sentinel methods are used and resources are limited,countries may choose to focus only on adult smear positive pulmonary patients.Countries with scarce resources where the HIV epidemic state is either low orconcentrated may also chose to only include patients between the ages of 15 and 59years. Relapse cases should be excluded from surveillance systems, because of the risk ofsurveying the same patient twice, unless they are identified as such and the results areanalysed separately. However, relapse cases may be included and need not be identifiedas such, if surveillance is based on survey methods and these surveys are undertaken overa short period of time, ideally less than 2 -3 months. Periodic surveys have a specific rolewhere the prevalence of HIV among tuberculosis patients has not been previouslyestimated. Surveys using representative sampling methods and appropriate sample sizescan provide accurate estimates of the burden of HIV upon the tuberculosis situation andare an essential part of the initial assessment of the situation. This information may alerttuberculosis programmes to a potential HIV problem and enable action to be taken,which may include the institution of more systematic surveillance.Platform: Special surveys or sentinel surveillanceFrequency: In the absence of a national recording and reporting system where datashould be continuously collected and reported quarterly, data should be collectedevery 2-3 years.REFERENCES− WHO. Revised guidelines for the surveillance of HIV among people with tuberculosis (in preparation)M&E toolkit, Draft 14.01.04 66
  • TREATMENT INDICATOR (TI) 1: TIMELY DETECTION AND TREATMENTPopulation covered by DOTSProportion of the population with geographic access to DOTS.RATIONALEThis indicator measures the availability of DOTS within a country. The target is tomake DOTS available to 100% of the population.DEFINITION OF INDICATORNumerator: Number of people living within the catchment area of facilities thatimplement DOTS as per national guidelinesDenominator: Total populationMEASUREMENTFor a programme review, the numerator will be the number of people living withinthe catchment are of facilities that implement DOTS, per NTP guidelines, and thedenominator will be the total population. For routine monitoring, the data should beincluded in quarterly reports.Platform: NTP annual report; quarterly and annual reports submitted fromintermediate to central level of NTPFrequency: This indicator should be measured on an annual basis for the purposes ofexternal monitoring, and quarterly for routine monitoring by the NTP.REFERENCES− World Health Organization (2002). Global Tuberculosis Control: WHO Report 2003. http://www.who.int/gtb/publications/globrep/index.htmlM&E toolkit, Draft 14.01.04 67
  • TREATMENT INDICATOR (TI) 2: TIMELY DETECTION AND TREATMENTSmear- positive TB cases registered under DOTS successfully treated Percent of new smear positive pulmonary TB cases registered under DOTS in a specified period who were cured plus the percent who completed treatment.RATIONALEThe cure rate and treatment completion rate indicators should be added together in orderto determine the treatment success over a specified period. Evaluation of treatmentoutcomes of new pulmonary smear-positive patients is used to determine the quality andeffectiveness of DOTS implementation. When cure cannot be established, treatmentcompletion is the best means of ensuring patients have been adequately treated, and in theabsence of confirmatory documentation, are likely to be cured. A treatment success rateof 85 percent or greater is the global target. This indicator is useful for following trendswithin a country or region and for cross-country comparisons and can be used to monitorand evaluate the impact of specific interventionsDEFINITION OF INDICATORNumerator: Number of new smear positive pulmonary TB cases registered under DOTSin a specified period that were cured plus the number that completed treatmentDenominator: Total number of new smear positive pulmonary TB cases registered underDOTS in the same periodMEASUREMENTAt the end of the treatment course, each sputum smear positive TB case is assigned atreatment outcome, which is recorded in the TB Register. The numerator for thisindicator is the number of patients registered in a specified period (e.g., quarter or year)and recorded with the treatment outcome “treatment complete” and “cured”. Thisnumber can be obtained from quarterly treatment outcome reports or the TB Register.The denominator can also be obtained from quarterly treatment outcome reports or theTB Register.Platform: TB Register; quarterly reports of treatment outcomes (TB-08)Frequency: quarterly and annual basisREFERENCES! WHO. Compendium for monitoring TB control activities (in preparation)M&E toolkit, Draft 14.01.04 68
  • TREATMENT INDICATOR (TI) 3: CONTROL OF DRUG RESISTANCE New smear-positive cases who default or transfer out of treatment Percent of new smear positive pulmonary TB cases registered in a specified period that interrupted treatment for more than two months in the past year or who were transferred to another basic management unit for which there is no treatment outcome information.RATIONALEEvaluation of treatment outcomes of new pulmonary smear-positive patients is used todetermine NTP quality and effectiveness. One of the overall objectives and the highestpriority of TB control is to cure cases of infectious TB. For patients that are notclassified as cured, it is essential to determine to which treatment outcome they areassigned so that appropriate interventions can be designed and implemented.DEFINITION OF INDICATORNumerator: Number of new smear positive pulmonary TB cases registered in a specifiedperiod that interrupted treatment for more than two months in the past year or who weretransferred to another basic management unit for which there is no treatment outcomeinformationDenominator: Total number of new smear positive pulmonary TB cases registered in thesame periodMEASUREMENTAt the end of the treatment course, each sputum smear positive TB case is assigned atreatment outcome, which is recorded in the TB Register. Patients whose treatment wasinterrupted for two or more consecutive months (e.g., patients that did not collect drugsfor 2 or more months any time after registration) are designated as “default”. Patientswho were transferred to another basic management unit for which there is no treatmentoutcome information are classified as having “transferred out”.Platform: Quarterly reports of treatment outcomes (TB-08)Frequency: quarterly and annual basisREFERENCES! WHO. Compendium for monitoring TB control activities (in preparation)M&E toolkit, Draft 14.01.04 69
  • TREATMENT INDICATOR (TI) 4: MONITORING OF PERFORMANCE IN CASE MANAGEMENTCompleteness of reporting to national tuberculosis programme Proportion of units submitting case finding and treatment outcome reports to the NTP each quarter.RATIONALEThis indicator measures if the NTP receives the essential data necessary for programmemanagement. The on-going systematic recording, analysis, interpretation and reportingof TB data will facilitate planning, implementation, and evaluation of the NTP andrelated public health programmes.DEFINITION OF INDICATORNumerator: Number of units that submitted case finding and treatment outcome reportsto the NTP in the previous quarter*Denominator: Total number of units required to submit case finding and treatmentoutcome reports to the NTP each quarterNote: *A unit is included in the numerator only if it submits both reports to the NTP It is recommended to separate the indicator into levels of reportingMEASUREMENTThis indicator measures the completeness and timeliness of TB report submission, whichis essential for efficient programme management since it provides the data to evaluate TBprogramme targets, guide efforts to allocate staff, and to monitor results. This indicator ismeasured at the central health level in a country on a quarterly basis and should becollected for the most recent reporting period for monitoring purposes.Platform: NTP Statistics and ReportsFrequency: quarterly, unless the NTP guidelines for recording and reporting specifyanother timeframeREFERENCES! WHO. Compendium for monitoring TB control activities (in preparation)M&E toolkit, Draft 14.01.04 70
  • CARE AND SUPPORT INDICATOR (CS) 1: SUPPORT THROUGH DIRECT OBSERVATION OF TREATMENTPatients under direct observation of therapy (DOT)Proportion of TB patients whose therapy was directly observed by a trained, regularlysupervised individual according to NTP guidelines*.RATIONALEThis indicator measures an essential element of the DOTS strategy: direct observation oftherapy (DOT) to ensure patient and provider adherence to treatment. WHOrecommends that a health care worker or trained and regularly supervised person observethe patient swallowing each dose of medicine and record the dose on the individualtreatment card throughout the intensive phase of treatment. Each facility should attemptto achieve 100 percent on this indicator in order to comply with international guidelinesand prevent drug resistance.DEFINITION OF INDICATORNumerator: Number of new pulmonary smear positive TB patients who reportobservation of every dose of medication per NTP guidelinesDenominator: Total number of new pulmonary smear positive TB patients interviewedregarding direct observation of therapyNote: *NTP guidelines should specify direct observation of therapy for at least the firsttwo months of treatment. In some countries, the guidelines may specify directobservation for the full course of treatment if rifampin is used in the continuation phase.MEASUREMENTIt is recommended that multiple sources be used to determine the numerator value: 1) Inexit interviews, the patient should be asked if a health worker or treatment supervisor hasobserved every dose of medication, or alternatively, if s/he can recall any time whentreatment was not directly observed. 2) Observation of patient-provider interaction. 3)Review of treatment cards to verify if every dose was recorded for each patient registeredfor treatment during the quarter. If patients are hospitalized during the intensive phase,the same methods should be used to determine who receives DOT.Platform: Routine measurement, or as part of a special facility level survey assessingclinic performanceFrequency: annual for the purposes of external monitoring, and quarterly for routinemonitoring by the NTPREFERENCES! WHO. Compendium for monitoring TB control activities (in preparation)M&E toolkit, Draft 14.01.04 71
  • SUPPORTING ENVIRONMENT INDICATOR (SE) 1: DRUGS AND LABORATORY SUPPLYTB drugs out of stock – treatment facilitiesAverage percentage of time that first-line TB drugs are not available in treatment facilities.RATIONALEThe availability of medication is critical to the successful management of tuberculosis,and an uninterrupted supply of drugs at treatment centres is crucial to cure patients and toavoid the emergence of drug resistant strains of tuberculosis. This indicator measures akey DOTS strategy component, uninterrupted drug supply.DEFINITION OF INDICATORNumerator: Total number of stock out days for all first-line drugs stocked x 100Denominator: 365MEASUREMENTData should be collected from as many treatment facilities as possible. Collection from20 established sentinel sites is ideal. To calculate this indicator record the number ofdays each drug was out of stock last year (or last 12 months) and sum the total number ofdays out of stock for all drugs. Then divide the number of days by 365 times the totalnumber of drugs normally stocked. Multiply the fraction by 100.Platform: Health centre drug stock cardsFrequency: quarterlyREFERENCES− World Health Organization (1999). Indicators for Monitoring National Drug Policies. WHO/EDM/PAR/99.3.M&E toolkit, Draft 14.01.04 72
  • SUPPORTING ENVIRONMENT INDICATOR (SE) 2: HUMAN RESOURCE CAPACITYHealth facilities and laboratories with sufficient capacity for DOTSProportion of diagnostic centers with at least one laboratory technician trained in acid-fastbacilli microscopy in the last three years.RATIONALEOne of the five components of DOTS is the use of smear microscopy to diagnosepulmonary TB. Trained individuals, along with adequate laboratory capacity andsupplies, are critical to the provision of these services for the NTP. Thus, the indicator isimportant for measuring the human resources input for this critical DOTS component,hence whether or not the NTP has the minimum human resources required to carry outdiagnosis by sputum microscopy throughout the network of diagnostic centers. The NTPshould work towards achieving 100 percent on this indicator or at least an increasingtrend over time.DEFINITION OF INDICATORNumerator: Number of diagnostic centers with at least one laboratory technician trainedin acid-fast bacilli microscopy in the last three years*Denominator: Total number of diagnostic centers providing smear microscopy in thecountryNote: *This number should include new technicians who received their initial training inAFB microscopy within the last three years AND technicians who received refreshertraining during the same period.MEASUREMENTCenters with at least one full time technician who was trained in AFB microscopy in thelast three years are included in the denominator. Given that technicians may not use thenecessary skills every day and often need refresher training to maintain them, the upperlimit at which the most recent training should have occurred is three years. Alldiagnostic centers utilized by the NTP should be included in the denominator.Platform: NTP training records; list of certified laboratory technicians and laboratoryof employmentFrequency: annualREFERENCES − World Health Organization (2003). Management of Tuberculosis Training for health facility staff, http://www.who.int/gtb/publications/training/management_of_tb/pdf/who_cds _tb_2003_314i.pdfM&E toolkit, Draft 14.01.04 73
  • ANNEX C Description of Malaria IndicatorsM&E toolkit, Draft 14.01.04 74
  • PREVENTION INDICATOR (PI) 1: INSECTICIDE TREATED NETSHouseholds owning ITNsProportion of households with at least one insecticide-treated net.RATIONALEITNs have been shown to be associated with reductions in all-cause child mortality,malaria-related morbidity, and low birth weight, within malaria endemic areas of sub-Saharan Africa. There is also some evidence of a ‘community effect’ where promptlytreated ITNs are associated with reductions in all-cause child mortality and malaria-related morbidity among unprotected children within close proximity to households withITNs. In addition, there is evidence of a correlation between ownership and usage of nets.This indicator captures household ITN possession among the general population at thenational level.DEFINITION OF INDICATORNumerator: Number of households surveyed with at least one mosquito net, which hasbeen treated with approved insecticide within the last 6 monthsDenominator: Total number of households surveyedNote: Analysis and reporting by province and according to urban/rural settingis recommendedMEASUREMENTThis indicator requires data collected at the household level from nationally-representative sample surveys. The limited number of questions required to ascertainthe data for this indicator can be easily added to any nationally-representative samplesurvey of households. It is important that these data be collected on a householdquestionnaire, rather than from an individual, as individuals may not be representativeof household possession. It is also important that surveys be conducted withsufficient design and sample size to allow comparisons between provinces andurban/rural strata at the household level.The numerator for this indicator is obtained from asking household respondent if thereis any mosquito net in the house that can be used to avoid being bitten while sleeping,and whether it has been treated in the last 6 months. The denominator is simplymeasured by the total number of surveyed households.Suggested questions: 1.1, 1.3 and 1.4 from malaria add on household questions inM&E toolkit, Draft 14.01.04 75
  • Guidelines for core indicators for assessing malaria intervention coverage fromhousehold surveys.Platform: DHS (USAID/MACRO), MICS (UNICEF), MIS, ‘Rider’ on other nationallyrepresentative surveysFrequency: every 2-3 yearsREFERENCES! Roll Back Malaria/MEASURE. Guidelines for core indicators for assessing malaria intervention coverage from household surveys. 2004. In preparation.! Roll Back Malaria. Malaria Indicator Survey (MIS). In preparation! UNICEF MICS: http://www.unicef.org/reseval/micsr.html! MEASURE Demographic and Health Surveys: http://www.measuredhs.com/M&E toolkit, Draft 14.01.04 76
  • PREVENTION INDICATOR (PI) 2: INSECTICIDE TREATED NETSChildren under five using ITNsProportion of children <5 years old who slept under an ITN the previous night.RATIONALEThe use of ITNs within areas of intense transmission are of particular importance as theireffect on reducing all-cause mortality and malaria-related morbidity is concentratedamong young children. For these reasons coverage of children with ITNs is a keycomponent of the technical strategy for transmission prevention and vector controladvocated by RBM. This indicator captures the level of ITN use by children <5 years ofage at the national-level.DEFINITION OF INDICATORNumerator: Number of children under five years old who slept under a mosquitonet the previous night, which has been treated with approved insecticide within thelast 6 monthsDenominator Total number of children under five years old who slept in surveyedhouseholds the previous nightNote: Analysis and reporting by province and according to urban/rural setting isrecommendedMEASUREMENTThis indicator requires data collected from nationally-representative householdsample surveys. The limited number of questions required to ascertain the data forthis indicator can be easily added to any nationally-representative sample survey.However, it is important that the survey contain a household listing that captures allchildren under five years old within each surveyed household. Such surveys shouldbe conducted with sufficient design and sample size to allow comparisons betweenprovinces and urban/rural strata at the individual level.! The data for the denominator is obtained during the household listing procedure when every child under five who slept in the house the previous night is identified. The data for the numerator is then obtained from a listing of children in the house who slept under a mosquito net the previous night, in combination with information on whether the net had been treated with insecticide within the last 6 monthsSuggested questions: 1.1 and 1.3-1.6 from malaria add on household questions inGuidelines for core indicators for assessing malaria intervention coverage fromhousehold surveysM&E toolkit, Draft 14.01.04 77
  • Platform: DHS (USAID/MACRO), MICS (UNICEF), MIS, ‘Rider’ on other nationallyrepresentative surveysFrequency: every 2-3 yearsREFERENCES! Roll Back Malaria/MEASURE. Guidelines for core indicators for assessing malaria intervention coverage from household surveys. 2004. In preparation.! Roll Back Malaria. Malaria Indicator Survey (MIS). In preparation.! UNICEF MICS: http://www.unicef.org/reseval/micsr.html! MEASURE Demographic and Health Surveys: http://www.measuredhs.com/M&E toolkit, Draft 14.01.04 78
  • PREVENTION INDICATOR (PI) 3: MALARIA IN PREGNANCYPregnant women using ITNsProportion of pregnant women who slept under an ITN the previous night.RATIONALEITN use by pregnant women has been shown to be associated with reductions in malaria-related maternal morbidity, as well as improved birth outcomes, including the reductionof low birth weight babies. For these reasons coverage of pregnant women with ITNs is akey component of the technical strategy for control and prevention of malaria inpregnancy advocated by RBM. This indicator captures the level of ITN use by pregnantwomen at the national-level.DEFINITION OF INDICATORNumerator: Number of pregnant women who slept under a mosquito net theprevious night, which has been treated with approved insecticide within the last 6monthsDenominator: Total number of pregnant women who reside within surveyedhouseholdsNote: Analysis and reporting by province and according to urban/rural setting isrecommendedMEASUREMENTThis indicator requires data collected from nationally-representative householdsample surveys. The limited number of questions required to ascertain the data for thisindicator can be easily added to any nationally-representative sample survey.However, due to small number of currently pregnant women at any given time, asurvey designed to collect these data should have an overall sample of ≥5000 women(in order to be comparable with MICS and DHS). If questions are to be added on as a‘rider’ to a survey, it is important that the survey contain a household listing thatcaptures all women of reproductive age within each surveyed household. Suchsurveys should be conducted with sufficient design and sample size to allowcomparisons between provinces and urban/rural strata at the individual level.The data for the denominator is obtained from a series of questions asked of allwomen of reproductive age in the household about their current pregnancy status.The data for the numerator is then obtained from a listing of these women that sleptunder a mosquito net the previous night, in combination with information on whetherthe net had been treated with insecticide within the last 6 months.Suggested questions: 1.1, 1.3-1.6, and 2.1 from malaria add on household questions inM&E toolkit, Draft 14.01.04 79
  • Guidelines for core indicators for assessing malaria intervention coverage fromhousehold surveysPlatform: DHS (USAID/MACRO), MICS (UNICEF), MIS, ‘Rider’ on other nationallyrepresentative surveysFrequency: every 2-3 yearsREFERENCES! Roll Back Malaria/MEASURE. Guidelines for core indicators for assessing malaria intervention coverage from household surveys. 2004. In preparation.! Roll Back Malaria. Malaria Indicator Survey (MIS). In preparation.! UNICEF MICS: http://www.unicef.org/reseval/micsr.html! MEASURE Demographic and Health Surveys: http://www.measuredhs.com/M&E toolkit, Draft 14.01.04 80
  • PREVENTION INDICATOR (PI) 4: MALARIA IN PREGNANCYPregnant women receiving Intermittent Preventive Therapy (IPT)Proportion of pregnant women who receive IPT as prophylaxis for malaria.RATIONALEIPT of sulphadoxine-pyrimethamine (SP) given to pregnant women has been shown toreduce the risk of maternal anemia, placental parasitemia, and low birth-weight. IPT inpregnancy is therefore a key component of the technical strategy for control andprevention of malaria in pregnancy advocated by RBM. This indicator captures thenational-level use of IPT to prevent malaria among pregnant women.DEFINITION OF INDICATORNumerator: Number of women who took an antimalarial drug treatment to preventmalaria during their last pregnancy that led to a live birth within the last 2 yearsDenominator: Total number of women surveyed who delivered a live baby within thelast 2 yearsNote: Analysis and reporting by province and according to urban/rural setting isrecommendedMEASUREMENTThis indicator requires data collected from nationally-representative householdsample surveys. The limited number of questions required to ascertain the data for thisindicator can be easily added to any nationally-representative sample survey. Ifquestions are to be added on as a ‘rider’ to a survey, it is important that the surveycontain a household listing that captures all women of reproductive age within eachsurveyed household as well as a female questionnaire to collect data on previousbirths and antenatal care. Additionally, due to the limited number of women whodelivered a live baby within the previous 2 years, care should be taken to ensure suchsurveys are conducted with sufficient sample size and design to allow comparisonsbetween provinces and urban/rural strata at the individual level.Data from the female questionnaires for all women who delivered a live baby withinthe last 2 years within surveyed household is used to calculate the denominator. Thenumerator is derived from the number of women who mention taking an antimalarialfor prevention (NOT treatment) during pregnancy from among all women who havegiven birth in the last 2 years.It is important to differentiate between a treatment dose for prevention (as prescribedfor IPT) and actual treatment of an existing malaria infection. Although it isextremely difficult to differentiate in the context of a survey interview, the latter isM&E toolkit, Draft 14.01.04 81
  • curative care, and does not count as standard IPT procedure. Similarly, women takingweekly cholorquine prophylaxis are not considered to be covered by IPT.Suggested questions: 2.2-2.7 from malaria add on household questions in Guidelines forcore indicators for assessing malaria intervention coverage from household surveysPlatform: DHS (USAID/MACRO), MICS (UNICEF), MIS, ‘Rider’ on other nationallyrepresentative surveysFrequency: every 2-3 yearsREFERENCES! Roll Back Malaria/MEASURE. Guidelines for core indicators for assessing malaria intervention coverage from household surveys. 2004. In preparation.! Roll Back Malaria. Malaria Indicator Survey (MIS). In preparation.! UNICEF MICS: http://www.unicef.org/reseval/micsr.html! MEASURE Demographic and Health Surveys: http://www.measuredhs.com/M&E toolkit, Draft 14.01.04 82
  • PREVENTION INDICATOR (PI) 5: PREDICTION AND CONTAINMENT OF EPIDEMICSMalaria epidemics detected and properly controlled Proportion of epidemics detected within 2 weeks of onset and properly controlled.RATIONALEWith an increasing occurrence of epidemics in both low-risk areas and areas ofmoderate transmission of malaria, the institution of special responses to epidemics ontop of the regular malaria control activities is imperative. The impact of epidemics canbe greatly reduced if they are timely detected or, even better, predicted, and preventionstarted. This indicator captures the national response to epidemics.DEFINITION OF INDICATORNumerator: Number of epidemics detected in a specific geographical area (country,district) within two weeks during the last 12 months and for which appropriate controlmeasures* have been initiatedDenominator: Number of malaria epidemics recorded during the last 12 monthswithin a specific geographical areaNote: * Action based on preparedness plan of action, according to global WHOguidelines, where applicableMEASUREMENTThe Management survey forms are designed for collating general policy andimplementation guidelines with emphasis on management issues. Thy should beadministered to the National Programme Officers and District Health Managers. Thereare several scenarios that can be adopted to facilitate easy collection of the information.The survey forms must not be sent out as questionnaires. The interview teams areexpected to ask additional questions, clarifying issues during the interview.Platform: Management SurveyFrequency: 2-3 yearsREFERENCES! Hook C. Field Buide for Malaria Epidemic Assessment and Reporting. DRAFT for Field Testing. World Health Organization. 2003, Available online: http://rbm.who.int/cmc upload/0/000/016/569/FTest.pdf! Roll Back Malaria. Framework for Monitoring Progress and Evaluating Outcomes and Impact. 2000. Geneva.M&E toolkit, Draft 14.01.04 83
  • http://rbm.who.int/cmc_upload/0/000/012/168/m_e_en.pdf! WHO. Roll Back Malaria Initiative in the African Region. Monitoring and Evaluation Guidelines. Harare, WHO Regional Office, 2000.M&E toolkit, Draft 14.01.04 84
  • TREATMENT INDICATOR (TI) 1: PROMPT EFECTIVE TREATMENTChildren under five years of age with access to treatmentProportion children under five with fever in last 2 weeks who received antimalarialtreatment according to national policy within 24 hours from onset of fever.RATIONALEThe majority of deaths from severe malaria in childhood are caused by the delayedadministration of effective antimalarial treatment. Prompt access to effective malariatreatment among children is therefore a key component of the technical strategy forcontrol and prevention of malaria in pregnancy advocated by RBM. This indicatorcaptures the national-level access to prompt and effective treatment for malaria.DEFINITION OF INDICATORNumerator: Number of children <5 years old who had a fever in previous 2 weeks whoreceived antimalarial treatment according to national policy <24 hours from onset offever.Denominator: Total number of children <5 years old who had a fever in previous 2weeksNote: Analysis and reporting by province and according to urban/rural setting isrecommendedMEASUREMENTIn order to collect data on this indicator, the survey must be nationally representative andcollect data on children <5 years old. The child-level data are obtained during thehousehold listing procedure when every child <5 who slept in the house the previousnight is identified. Questions are asked about whether the child has had a fever in thepast two weeks, and if and where s/he was given antimalarial treatment. At a minimum,the following data will also need to be collected to assist with interpretation and controlfor potential confounding:! Age of listed children in years! Confirmation of type of malaria retreatment given to child! Socioeconomic variables at the household and community levels routinely collected by DHS and MICSPlatform: DHS (USAID/MACRO), MICS (UNICEF), MIS, ‘Rider’ on other nationallyrepresentative surveysFrequency: 2-3 yearsM&E toolkit, Draft 14.01.04 85
  • REFERENCES! Roll Back Malaria/MEASURE. Guidelines for core indicators for assessing malaria intervention coverage from household surveys. 2004. In preparation.! Roll Back Malaria. Malaria Indicator Survey (MIS). In preparation.! UNICEF MICS: http://www.unicef.org/reseval/micsr.html! MEASURE Demographic and Health Surveys: http://www.measuredhs.comM&E toolkit, Draft 14.01.04 86
  • TREATMENT INDICATOR (TI) 2: PROMPT EFECTIVE TREATMENTHealth facilities with no reported stock out Percentage of health facilities with no stock outs of nationally recommended antimalarial drugs continuously for one week during the last 3 monthsRATIONALEThe continuos supply of antimalarial drugs is key to prompt effective treatment at healthfacilities. This indicator captures the availability of nationally recommended antimalarialdrugs in health facilities.DEFINITION OF INDICATORNumerator: Number of health facilities with nationally recommended antimalarialdrugs on the day of survey and with no stock outs in the last 3 monthsDenominator: Total number of Health facilities surveyedNote: Analysis and reporting by province and according to urban/rural setting isrecommendedMEASUREMENTThe health facility survey forms are administered to the head of each section of the healthfacilities identified for the survey. They are expected to include the District hospital, andat least two other Health centres/posts serving selected communities in the district.Examination of in-patient records and an assessment of the appropriateness of treatmentof severe malaria cases admitted to the District Hospital as well as observation of healthcare providers providing services to clients should be part of data collection.Platform: Health Facility SurveyFrequency: yearlyREFERENCES! Roll Back Malaria. Framework for Monitoring Progress and Evaluating Outcomes and Impact. 2000. Geneva. http://rbm.who.int/cmc_upload/0/000/012/168/m_e_en.pdf! WHO. Roll Back Malaria Initiative in the African Region. Monitoring and Evaluation Guidelines. Harare, WHO Regional Office, 2000.M&E toolkit, Draft 14.01.04 87
  • TREATMENT INDICATOR(TI) 3: CASE MANAGEMENTPatients with severe malaria receiving correct treatment Percentage of children under five admitted with severe malaria and correctly treated at health facilities.RATIONALESevere malaria usually occurs as a result of a delay in treating uncomplicated malaria.Sometimes, especially in children, severe malaria may develop very rapidly. Because ofthe often fatal outcome, the correct management is key to saving lives. This indicatorcaptures the ability of health facilities to correctly manage severe malaria.DEFINITION OF INDICATORNumerator: Number of children under five and other target groups admitted withsevere malaria and correctly given antimalarials and supportive treatment according tonational policyDenominator: Total number of children under five and other target groups admittedwith severe malaria surveyed at health facilitiesMEASUREMENTThe health facility survey forms are administered to the head of each section of the healthfacilities identified for the survey. They are expected to include the District hospital, andat least two other Health centres/posts serving selected communities in the district.Examination of in-patient records and an assessment of the appropriateness of treatmentof severe malaria cases admitted to the District Hospital as well as observation of healthcare providers providing services to clients should be part of data collection.Platform: 1) Part of routine supervision of NMCP; 2) Health facility survey (Form 7)Frequency: 1) yearly; 2) every 2-3 yearsREFERENCES! Roll Back Malaria. Framework for Monitoring Progress and Evaluating Outcomes and Impact. 2000. Geneva. http://rbm.who.int/cmc_upload/0/000/012/168/m_e_en.pdf! WHO. Roll Back Malaria Initiative in the African Region. Monitoring and Evaluation Guidelines. Harare, WHO Regional Office, 2000.M&E toolkit, Draft 14.01.04 88