Transcript Research

Strategic Information for
Anti-RetroViral Treatment
Programmes
Workshop
WHO and UNAIDS
Geneva
June 30- July 2 2003
OBJECTIVES OF THE MEETING
• Assess the needs for strategic information in the context
of ART programmes
• Share experiences in developing monitoring and
evaluation systems and other strategic information efforts
• Explore methods and techniques that can be considered
for monitoring ART programmes
2 days and 30 presentations later
What we learned
TB Control programmes and Stop TB have a comprehensive
framework for the generation and use of strategic information
Lack of good data on human resources
Work with functional classification of health workers
Scale Up of Existing programmes with holistic approach
Treatment Acceleration Programmes (TAP)
ARV drug resistance containment as a programme goal
Surveillance needed if drugs available 3-5 yrs to at least 1% of HIV infected persons
A M&E guide for M&E of care and support programmes is in the final stages of development
Logistics Management Information Systems, parallel and short term success,
integrated and long term savings, and need to be agile
7 different AIDS case definitions and the need for a definition
that is congruent for surveillance and clinical purposes;
Proposal to move to more active AIDS sentinel surveillance in facilities with and without ARV
QoL - visual analogue scale, time trade off and standard gamble
What we learned
Economics of ART programmes: more monitoring and research than for any other health intervention
Brazil started slowly but now has 125,000 people on treatment in 900 SDPs - 140 per SDP
Kenya has a national plan, expands rapidly including NGOand private sector,
considers smart card, bar codes
Thailand aims for 900 SDPs for ARVs and 50,000 patients by the end of 2004
Simply M&E tools that generate policy relevant data and no ‘one size fits all’
In Senegal research initially drove the programme, now need for simplification,
M&E plan, but M&E capacity problem
Districts are the core of the health system: One district with less than half a million people in Malawi
has 7,500 people in need of treatment - simple tools, community survey, clinic / programme M&E
iNGO in coastal Kenya aims to have 300 patients on treatment over 5 years, developing 8 patient
clinic monitoring forms, research and programme development
Haiti DOT HAART delivery through accompagnateurs basis for
different M&E system with quarterly updates
What we learned
Technology: paper predominantly used, phones for drugs logistics, bar coding for drug cartons,
fingerprints, smart cards and point of sale devices,
multitude of software developed (each programme own software),
real time management, web based data from ART programmes linked to drug supply, luddites
M&E as a by-product of the work flow of information exchange
Good monitoring systems can provide excellent data on survival, retention and adherence;
costs could be integrated as well - but … 1 nurse per 100 ART eligible persons ...
Urgent need for involving the community and clients - through surveys, through participatory
research, through qualitative research and as part of programme monitoring
Gathering information on the prevention care interaction is complex and only limited data can
be gathered as part of routine M&E activities
OBJECTIVES OF THE MEETING
• Assess the needs for strategic information in the context
of ART programmes
• Share experiences in developing monitoring and
evaluation systems and other strategic information efforts
• Explore methods and techniques that can be considered
for monitoring ART programmes
• Develop a list of priority strategic information issues
faced by national programmes and large-scale
projects and explore ways to address those issues
STRATEGIC INFORMATION NEEDS
• What strategic information do we need to deliver ART
programmes efficiently and effectively?
• What will ART programmes be evaluated on?
WHAT KIND OF INFORMATION DO WE NEED?
Needs, resources, access, coverage
What are and will be the needs for treatment?
What resources are available and what will be needed?
How many have access? Who has access?
Programme Monitoring & Evaluation
Is the programme performing according to plans?
Is the programme able to contain drug resistance development?
Does the programme make a difference? Is it achieving its goals?
How much does it cost and how cost effective is it?
Patient monitoring
Operations Research
How can programme implementation be improved?
What are the best models of implementation?
What can be done to improve health systems?
Research
Can we provide more efficacious and more effective interventions?
What impact do programmes have?
OPERATIONALIZATION OF INFORMATION NEEDS
Needs, resources, access
Computer modelling and surveillance data
Resource tracking in special studies
Routine programme Monitoring & Evaluation
Basis is Patient monitoring system which will
provide data on N of people on treatment, treatment outcomes
Drug supply monitoring system
AIDS surveillance
Supplementary programme Monitoring & Evaluation
Health facility survey or district survey
Community and individual preparedness assessment
Household survey on prevention-care and programme
Operations Research
Special studies carried out with local institutions
to supplement M&E data and feed into the programmes
Research
Long term partnerships between research institutions
TREATMENT NEEDS AND RESOURCES
Strategic Information
Field
Assessment tools…………….. Country needs
Estimates of people in need
of treatment by residence
and sex
Based on projected deaths
from HIV prevalence using
EPP and Spectrum
Human resources:
workforce size and
distribution
Data availability on current staffing,
training, future staffing needs,
health system capacity, impact HIV
Economics
Prospective and retrospective
assessment of costs and
estimates of cost-effectiveness;
national health accounts;
resource flow tracking
DATA COLLECTION for
Monitoring and Evaluation
Input
Process
Output
Outcome
Household
Surveys
Programme Monitoring
Facility
surveys
Patient
monitoring
Impact
HIV/STI
surveillance,
surveys
Patient
monitoring
PROGRAMME MONITORING
(SERVICE DELIVERY POINT LEVEL)
Strategic Information
Field
Assessment tools ……………...Country needs
Clinic monitoring
Protocol that specifies the kind of data that
need to be collected, forms and technologies
to be used, communication/reporting etc.
Outline the system
Link patient data, drug supply, fees
Methods / technology to be used
Contents definitions indicators - kind of outcomes
Priorities
Steps needed
Operations
Research
PROGRAMME MONITORING
Strategic Information
Field
Programme M&E
Logistics
ARV drug resistance
surveillance
Care and support
programmes
Care and support
programmes
Assessment tools ……………...Country needs
Plan that outlines framework, key
process, output, outcome, impact indicators
and how data will be collected
Assessment of feasibility different systems
Develop LMIS; Use of technology (mobile phone,
software, bar codes etc.)
Surveillance among newly
infected persons (e.g. VCT)
every 2-3 years
Health facility survey and indicators
to assess the quality of treatment of OI
and palliative care
Community or household survey /
Routine data from NGOs etc.
to assess coverage of home based
care and support
Priorities
Steps needed
Operations
Research needs
PROGRAMME MONITORING
Strategic Information
Field
Human resources
Private sector
Patient monitoring
Assessment tools ……………...Country needs
Assessment of current staffing, staffing
needs, provider survey, district level
Assessment of feasibility of including
private sector in M&E system
Laboratory capacity assessment
Community preparedness Survey, qualitative research, with
communities and PLWHA
Priorities
Steps needed
Operations
Research needs
Risk behaviour trends
Surveys, qualitative research, develop
strategy to assess changes and maximize
positive prevention effects
HIV testing & counselling
Service assessment (access and quality),
community readiness, stigma, disclosure, obstacles
PROGRAMME MONITORING
(OUTCOME ASSESSMENT)
Strategic Information
Field
Assessment tools
Country needs
AIDS surveillance
WHO clinical case definition
Reporting forms by main health facilities
Health, morbidity, etc.
Monitoring of body weight, being
ambulatory, engaged in work or
employment etc.
Quality of life
WHOQoL, MOS-HIV, MQoL-HIV
Costs
Cost monitoring at facility and
at central levels
CD4+ cell counts, viral loads
Immunology
Priorities
Hospitalization
Hospital statistics with HIV status
(% HIV+ in medical ward, duration admission)
Mortality / survival
Individual patient monitoring, through paper records
smart cards, etc. / special studies
Operations research issues:
examples
 Integrated systems to track patients, drugs and fees at point of
delivery
 Appropriate human resource planning for ARV programmes
 Working with the private sector – the franchising approach
 Setting and supervising/regulating health standards in ART
programmes
 Equity of access to ART programmes
 Measurement of costs of implementing ART programmes
 Assessment of community preparedness and readiness
 Measurement of stigma and discrimination in the context of
ART programmes
 Strategies to maximize long-term adherence (chronic disease
model)
 Delivering and sustaining ART in drug-using communities
Research




CLINICAL
When to start treatment
What therapies to be used
What methods for patient treatment response and toxicity
monitoring
 OUTCOME
 Survival, health, quality of life of patient but also children, family,
community
 PREVENTION
 Longitudinal studies with trends in behaviour, stigma, risk
perception etc.
Group assignment
 What are the priority issues for programmes that
need strategic information?
 What are the first steps that need to be
undertaken (at country and international levels) to:
 design a M&E system for ART programmes (planning,
standardization, simplification, technology etc.)
 assess the current capacity to develop / scale up a ART
programme (situation analysis)
 develop specific tools for monitoring and evaluation
 provide relevant data for programmes through operations
research
 establish longer term research