Utilizing Facility Data for Program Monitoring

Valerie Koscelnik

Track 1 ART Program Meeting

Maputo, August 12, 2010

Outline• Framework for health system components and

outcomes• Transition short & long term goal/objective• Transition Logic model• Measurements:

– Site and Regional readiness – Outcome indicators

• Data quality assessments• Summary and conclusions

Health Systems Building Blocks and Key Health Outcomes

Overall Health Outcomes

Transition monitoring: What are we looking for? Long term goal & shorter-term objective

• Long term goal: sustained local ownership with maintenance of excellent patient care and good patient outcomes. Ultimately, a vision of an effective strengthened health systems.

• Shorter term objective: Sites and local partners (governmental and/or NGO) able to accept/absorb and grow the program with delivery of high quality care

Source: Transition Logic Model Working Group

Transition Logic Model Inputs

and outputs individualized per partner

Process/Health System Measurements

• Site maturity: SCA-like tools• Technical and organizational competency of

local government and NGO partners• Ownership – Performance & accountability

documentation TBD

Source: Transition Logic Model Working Group

Site readinessKenya

• Locally developed site readiness tools assessing key domains

ICAP-Kenya Track I Rapid Maturity Assessment Tool for Health Facility Transition:

• Assessed (1) services offered, (2) HR, (3) general management, (4) financial management, (5) quality management (6) procurement/supply chain management and (7) performance indicator: retention of patients in last 12 month

• Facility is ready for transition if scores 90% or greater• Facilities below 90% require continued capacity building for

transition

State and site readiness:Nigeria

• Structured assessment of state institutions and sites by (1) governance/leadership, (2) organizational structure, (3 & 4) HR & fin management, (5) external relationships, (6) service delivery, (7) pharmacy and (8) laboratory

• Scale used to determine priority states for transition

State Y

State X

Clinical Quality of CareOutcome indicators

• Adult care and treatment• Pediatric care and treatment• PMTCT• TB/HIV• Laboratory• Counseling & Testing• Adherence and Psychosocial support

Need to focus on priority set of key Quality of Care indicators

ICAP priority quality indicators: Standards of Care (SOC)

Rationale:• Five priority quality indicators selected to allow for comparisons

across sites, programs and countries*• Creates a limited, manageable core set of indicators for program

monitoring and review of qualityData sources: • Routinely-collected site-level indicator data reported every quarter

for HIV care and treatment (Track 1 reporting indicators), TB/HIV, and PMTCT programs

• Data imported from country aggregate databases or hand-entered on on-line indicator database

• Data checks are run on the data to ensure internal and cross-quarter consistency

* Countries and site can select specific SOCs for monitoring & CQI activities

Program area Priority indicator Definition

Care and Treatment

1 Eligible patients in care and treatment receive cotrimoxazole at enrollment and last visit

2 HIV infected children under one year of age receive ART

3 Patients enrolled into treatment remain in care for at least 6 months

TB/HIV 4 All patients in care and treatment receive TB screening at enrollment and during the quarter

PMTCT 5 HIV-infected pregnant women in PMTCT services receive multi-drug ARV prophylaxis

Priority Quality Indicators

Priority Indicator 1

Target: 95% of eligible patients in care and treatment receive cotrimoxazole

Aggregate data

Measured by Proportion of eligible patients in care and treatment receiving cotrimoxazole at enrollment

Numerator Numerator: Number of HIV-positive persons receiving cotrimoxazole prophylaxis

Denominator Denominator: Number of HIV-positive persons eligible to receive cotrimoxazole prophylaxis according to national guidelines

To start centrally collecting in fall 2010

Priority Indicator 2

Target: 95% of HIV infected children under one year of age receive ART

Aggregate dataMeasured by Proportion infected children under one year of age receiving

ART (Track 1 reporting)

Numerator Number of patients <2 who were newly started on ART during the reporting quarter

Denominator Number of patients <2 who were newly enrolled in care during the reporting quarter

Priority Indicator 3

Target: 90% of patients enrolled into treatment remain in care for at least 12 months

Aggregate dataMeasured by Proportion of patients >6 years of age enrolled into treatment

who received ARVs for 6 out of 6 months (Track 1 reporting)Numerator Number of ART patients >6 years of age who received ARVs

for 6 out of 6 monthsDenominator Number of patients >6 years of age started on ART in a given 3

month period (e.g. for Oct-Dec reporting, Aug-Oct of year prior)

Priority Indicator 4

Target: 95% of all patients in care and treatment receive TB screening at

enrollment Aggregate data

Measured by Proportion of all patients in care and treatment receiving TB screening at enrollment

Numerator All new HIV patients screened for TB at enrollment during the reporting quarter

Denominator All new HIV patients enrolled in care during the reporting quarter

Priority Indicator 5

Target: 95% of HIV-infected pregnant women in PMTCT services receive multi-drug

ARV prophylaxis Aggregate dataMeasured by Proportion of HIV-infected pregnant women in PMTCT services

in ANC receiving multi-drug ARV prophylaxisNumerator Number of HIV positive pregnant women in ANC receiving

multi-drug ARV prophylaxis including HAART during the reporting quarter

Denominator Number of HIV positive pregnant women enrolled in ANC (known positive and tested positive) during the reporting quarter.

Indicators across country programs

Site specific trends in priority quality (SOC)

indicators

Mozambique

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

Rwanda

DQA IndicatorsRoutinely Reported Indicator

Data Source

DQA Sample for Quarter of Interest

Gold Standard

DQA Indicator Denominator

DQA Indicator Numerator (completeness base on gold standard)

% Eligible patients receiving CTX when enrolling in HIV care*

Pre-ART Register

Random sample

Clinical File

# in CTX eligible in DQA sample

# with documented CTX

% HIV+ children <1 yrs of age receiving ART*

Pre-ART Register

All Children <1 yrs

Clinical File

# in DQA sample

# with documented ART start date

% Patients enrolled in ART who remain in care for 6 of 6 months*

ART Register

Random sample from respective 6-mo cohort period

Clinical File

# in DQA sample

# with documented visit 6 of 6 months

% Patients in HIV care and treatment receiving TB screening at enrollment*

Pre-ART Register

Random sample

Clinical File

# in DQA sample

# documented TB screening at enrollment

% HIV+ pregnant women in PMTCT services receiving multi-drug prophylaxis*

PMTCT Register

All HIV+ pregnant women

ANC Register

# in DQA sample

# with documentation of multi-drug prophylaxis

* Quality Indicator

DQA Indicators (con’t)Routinely Reported Indicator

Data Source

DQA Sample for Quarter of Interest

Gold Standard DQA Indicator Denominator

DQA Indicator Numerator (completeness base on gold standard)

# Patients currently on ART

ART Register

All patients on ART

ART Register N/A # visiting ART clinic and receiving ARVs

% Patients enrolled on ART for 6 months with a CD4 value

ART Register

Random sample from respective 6-mo cohort period

Clinical File # in DQA sample

# with documented CD4 count at 6 months

% Patients screened for HIV when enrolling in TB services

TB Register

All new patients

TB Register # in DQA sample

# with documented HIV screening

% Patients screen for HIV when enrolling in VCT or other POS

VCT/POS Register

All new clients VCT/POS Register

# in DQA sample

# with documented HIV screening

Summary

• Readiness assessments critical to determine status of health system components and provide important information for transition preparation and monitoring

• Quality indicator data at site and country levels provide critical outcome data on quality of health system outcomes before, during and after transition

• Data quality audits are important and can serve to monitor performance and could inform continued funding and accountability

Conclusions

Data must always inform programsData must continue to inform all aspects of

transition efforts