Module 9 Part A: Monitoring and Evaluation

*Image courtesy of: World Lung Foundation

• Describe the difference between monitoring and evaluation

• Explain why we monitor programmes

• Explain how to monitor a TB programme

– What to monitor– Principles and techniques

• Describe how to conduct a supervisory visit

Learning Objectives

What is M&E?

*Image courtesy of: World Lung Foundation

Differences between Monitoring and Evaluation

Why Monitor and Evaluate?

1. Collect accurate information about the TB Programme

2. Use that information to improve the TB Programme

Management Reporting Accountability Advocacy Evaluation

Monitoring serves several purposes

• Episodic assessment of specific indicators– determine effectiveness or impact of services or

activities – during a given interval

• Determine whether goals are being met• Assess impact of a specific service or intervention

- HIV testing among TB patients• Advocacy

Why Evaluate?

• Determine if staff activities follow BNTP guidelines

• Measure key indicators related to case detection, quality of diagnosis, and TB treatment

• Identify problems in implementing TB control activities (e.g., laboratory reporting delays)

• Inform the annual evaluation of TB Programme

• Use the findings to modify programme goals and strategies (e.g., implementing RHT)

Benefit for BNTP

Surveillance Data and Programme Monitoring within BNTP

Clinic-level: TB Suspect and TB Case Registers

District-level: District TB Register and ETR

National-level: ETR

How should I monitor?

The first step is observation, but talking and analysis help you understand the cause

Observe Talk Analyse

Actions Attitudes ConsistencyProcesses Understanding AccuracyConditions Morale Effectiveness

Observe

Take a look around the clinic

Are there signs of disorganization? Are the patient treatment cards for all registered patients available? Are the cards in a binder in numerical order?Are the meds organized?

Are there IEC materials? Are there masks for patients and respirators for staff? Are patients being triaged appropriately?Is the condom dispenser full?

Other Visual Indicators

Communication with Clinic Staff

Find Out More from People

Through communicating we can:

Test level of knowledge

Gauge attitude and morale

Seek guidance on priority areas

DO’s: Listen and be prepared to learn Take notes – it’s your job. Don’t be embarassed! Ask follow-up questions and explore the issues Compare one story against another! “Triangulate”

DONT’s: Don’t worry if the person knows more than you Don’t take anything at face value – CHECK all verbal information against the data Don’t threaten or intimidate the people you speak to

Some Communication Tips

Level of knowledge: ‘Who should be entered into this register?’ ‘Explain the process of how the register is used’

Attitude / Perception ‘Whose job is it to enter the data?’ ‘How important is it that this register is

used properly?’ ‘Are you comfortable with using it?’

Seek guidance ‘What needs to be done to improve how it is used?’

Apply this Approach to Determine How Register is Used

Analysing the Suspect and Sputum Dispatch Register

• % of new pulmonary TB (NPTB) suspects who have 3 initial sputums collected consecutively

• Formula:

Number of who have 3 initial sputums collected consecutively

Number of NPTB suspects worked up for TB

• Tip: compare the result you get to last time. You can learn a lot by comparing indicators over time

Indicator: Quality of Programme Management

The TB Register

Use your experience and common sense Are the entries recorded correctly?

– Proper chronological sequence– Proper identification of class and type

Are there signs that the register is being completed in “batches”? – Multiple entries on the same date with different

treatment start dates (all in the same pen!)

How does the data ‘look’?

Analysing the DistrictTB Register Recording and reporting Calculating Indicators

Use your experience and common sense Are the entries recorded correctly

– Proper chronological sequence– Proper identification of class and type

Are there signs that the register is being completed in “batches” – Multiple entries on the same date with different

treatment start dates (all in the same pen!)

How does the data ‘look’?

Example: Review of District TB Register

Is there a report for each facility in this quarter? For cases registered 3 months ago, are there follow-up

sputum examination results (that is, for those collected at month 2 / end of the intensive phase?)

For cases registered > 6 months ago, are there more follow-up sputum exam results, or blanks in these columns?

For cases registered 12 months ago, are there treatment outcomes, or gaps in that area of the register?

Are there cases who were registered on the basis of sputum exam results but never started treatment?

Analysing the DistrictTB Register via the ETR Calculating Indicators Recording and reporting

Calculating TB Rates Death Rate = deaths / proportion of incident cases

that dieCase Detection Rate = annual new smear-positive

notifications (country) / estimated annual new smear positive incidence (country)

Other Useful TB Rates Include:Notification Rate, Cure Rate, Treatment Success

Rate, Default Rate, Treatment Failure Rate, Transfer Out Rate

TB CasesPulmonary

EP Total %Smear + Smear - No Smear Total

New cases 91 15 105 211 45 256 97%Relapses 3 2 3 8 0 8 3%After default 0 0 0 0 0 0 0%After failure 0 0 1 1 0 1 0%Total 94 17 109* 220 45 265 100%% 35% 6% 41% 83% 17% 100%* of which children aged 0-7: 6

TB Cases 0-14 15-24 25-34 35-44 45-54 55-64 65-74 >75 Total %

AllTBCases

M 9 16 66 44 17 5 2 0 159 60%F 5 17 39 33 9 3 0 0 106 40%

Total 14 33 105 77 26 8 2 0 265 100%% 5% 12% 40% 29% 10% 3% 1% 0% 100%

AllSmear + Cases

M 1 7 23 15 6 2 0 0 54 59%F 0 7 15 13 3 0 0 0 38 41%

Total 1 14 38 28 9 2 0 0 92 100%% 1% 15% 41% 30% 10% 2% 0% 0% 100%

AllSmear +Re-treat

M 0 0 2 0 0 0 0 0 2 67%F 0 1 0 0 0 0 0 0 1 33%

Total 0 1 2 0 0 0 0 0 3 100%% 0% 33% 67% 0% 0% 0% 0% 0% 100%

0 record(s) with missing age

Botswana Tuberculosis Programme

Case Finding Report

Report on New and Retreatment Cases of Tuberculosis(WHO)

15 – GABORONE Quarter 1 of 2004

FormulaSS+ cases

Registered cases

Example94 = 35%265

AFB Diagnosis RateThe proportion of notified cases diagnosed with sputum smear microscopy

43%

What can it mean if cases diagnosed through AFB is under 50%?

% Cases diagnosed with AFB Microscopy

0102030405060708090

1st Qtr 2nd Qtr 3rd Qtr 4th Qtr

District A District B District C

1. Too many cases being diagnosed through x-ray

2. Too many extra-pulmonary cases3. In comparison with previous

quarters an increase may imply increasing reliance by clinicians on smear microscopy…• Is that good or bad?• What could have caused the

change in District A?• Take a look at District C – if you

were monitoring this province what would you think if you saw this trend?

• What about District B?• Which is probably the best

result?

Category Outcome Status No %

AllTBCases

Treatment completedSmear negative at completion 28 8%Smear positive at completion 0 0%Smear results not available 67 19%Treatment not completedDied during treatment 12 3%Transferred to another unit 26 7%Defaulted from treatment 20 6%Treatment outcome not evaluated 195 56%All tuberculosis cases 347 100%

AllSmear +New

Treatment completedSmear negative at completion 21 18%Smear positive at completion 0 0%Smear results not available 16 13%Treatment not completedDied during treatment 3 3%Transferred to another unit 11 9%Defaulted from treatment 6 5%Treatment outcome not evaluated 63 53%All tuberculosis cases 120 100%

AllSmear +Re-treatment

Treatment completedSmear negative at completion 0 0%Smear positive at completion 0 0%Smear results not available 1 25%Treatment not completedDied during treatment 0 0%Transferred to another unit 0 0%Defaulted from treatment 0 0%Treatment outcome not evaluated 3 75%All tuberculosis cases 4 100%

Botswana Tuberculosis Programme

Treatment Outcome ReportReport on the Outcome of Tuberculosis Treatment

15 – GABORONE Quarter 1 of 2004

FormulaNo of registered cases that defaultTotal no of registered cases

Example20 = 6%347

Program Default Rate:How many patients are defaulting from treatment. In other words, how many people stop taking their medications.

Less than

5%

Something is wrong in the program and needs to be fixed.The patient is quite likely sill sick

and contagious.

Less than

5%It’s important to understand what

‘default’ means:

“A TB Patient is classified as a ‘default’ when their treatment is interrupted for

2 consecutive months or more.”

This is an easy indicator to get from the data, but it can be deceptive!

Every defaulting patient = a risk of MDR-TB in the community.What do we know for sure if

we’re missing the target?

1. Is it to do with the patient?• Is it embarassing for the patient?• Are patients scared of the

side-effects?• Does the patient know that you have to KEEP taking

the tablets?2. Is it to do with the nurse?

• Are nurses doing the DOT?• Is it dangerous / difficult to get to the patient?

3. Is it a problem of drug supply?The defaulter rate is an important indicator for measuring quality of treatment. But what are its limitations? Take a closer look at the definition of ‘default’.

What does it mean if the program default rate is not on target?

Category Sputum Conversion StatusAt 2 months At 3 monthsNo % No %

All Smear +Cases

Treatment still ongoingConverted to smear negative 29 23% 49 40%Remaining smear positive 9 7% 7 6%Smear results not available 75 60% 54 44%Treatment discontinuedDied during treatment 1 1% 1 1%Transferred to another unit 9 7% 10 8%Defaulted from treatment 1 1% 3 2%All smear + cases 124 100% 124 100%

All Smear +New

Treatment still ongoingConverted to smear negative 28 23% 46 38%Remaining smear positive 8 7% 7 6%Smear results not available 73 61% 53 44%Treatment discontinuedDied during treatment 1 1% 1 1%

Transferred to another unit 9 8% 10 8%Defaulted from treatment 1 1% 3 3%All smear + new cases 120 100% 120 100%

AllSmear +Re-treatment

Treatment still ongoing

Converted to smear negative 1 25% 3 75%Remaining smear positive 1 25% 0 0%Smear results not available 2 50% 1 25%Treatment discontinuedDied during treatment 0 0% 0 0%Transferred to another unit 0 0% 0 0%Defaulted from treatment 0 0% 0 0%All smear + new cases 4 100% 4 100%

Botswana Tuberculosis Programme

Sputum Conversion ReportReport on Response to Initial Phase Tuberculosis

Treatment

15 – GABORONE Quarter 1 of 2004

FormulaSS+ converting to smear negative

SS+ registered cases

Example29 = 23%124

The Sputum Conversion RateAre enough patients converting to smear negative at the end of 2 months of treatment?

To do this we use a conversion Rate

Equal to or greater than

85%

What can it mean if sputum conversion rate is under 85%?

Equal to or greater than

85%

0102030405060708090

100

1st Qtr 2nd Qtr 3rd Qtr 4th Qtr

Sputum Conversion (%)

1. The drug treatment regimen may not be working• Are the correct regimens being

used?• Could MDR-TB be an issue?

2. Patients are not taking their TB medications• Are the nurses doing their job?• Is Directly Observed Treatment

actually happening?• Are patients scared of taking

the tablets?

What kind of detective work would you do to find the cause?

FormulaNo of registered cases with test takenTotal no of registered cases

Example6 = 84%7

Proportion of notified cases tested for HIV:

What % of TB cases were tested for HIV?

100%

HIV StatusResultDate

Test 1 Test 2

N

P

N

N

N

N

6

RegNumber

Registered

Date

(mm

ddyy)

001/05 01/01/05

002/05 01/02/05

003/05 01/03/05

004/05 01/04/05

005/05 01/05/05

006/05 01/06/05

007/05 01/07/05

7

What can it mean if less than 100% of patients are tested for HIV?

1. Lack of training among clinical staff

2. Shortage of test kits3. High refusal rates among

patients4. Other factors requiring

consultation with the TBFP or relevant clinical staff

100%

Low testing rates may indicate that the policy of routine HIV testing has not been implemented properly in a site or district.

Analysing the treatment card

• Patient’s information is complete• Patient’s DOT and weights correctly recorded• All HIV Status results are correctly recorded• For HIV-infected patients

– Receipt of ART noted?– Receipt of IPT?

Reviewing the Treatment Card

We have: An understanding of the principles of M&E Some experience and guidelines you can take

away with you on good ways to: Observe Communicate Analyse

By now (hopefully)…

Next steps

In the next session we will apply these practices to the supervision checklist, which means we have to: Use the whole supervision checklist Practice communicating with actual field staff Interpret actual data to develop indicators Observe the environment Develop a list of action-items

Thank youand

Good Luck!