Program Evaluation: a potential platform for cross site analyses Louise C. Ivers, MD, MPH and Joia S. Mukherjee, MD, MPH Partners In Health, Division of Global Health Equity, Brigham and Women’s Hospital, Harvard Medical School

Context: Reason for Program Evaluation GHI spending may not be distributed evenly throughout countries Sub-recipients / partners at district, local or grassroots level are involved Program-level evaluation gives opportunity to examine variability in impact that may not otherwise be seen at a macro level

Program Evaluation: Aims Evaluate performance of local health system –impact of GHI on HS –Impact of HS on GHI Facility level evaluation Community level evaluation

Methods Quantitative data at program level –Comparative analysis –Historical control –Projected targets Qualitative data via ethnographic surveys and focus groups with patients and providers

Performance of Health System Scale Scope Distribution Quality/safety of services System capabilities (response to emerging and changing challenges)

Process: Human Resources Number Distribution / per population served Skill level Skill mix Accreditation

Outcomes Targeted disease/health outcomes –GHI specific Non-targeted health outcomes Child Health DTP3 Diarrheal illness (2 weeks) Under 5 malnutrition (diagnosis and treatment) Maternal Health Births assisted by skilled worker Family planning uptake

Outcomes: Patient-focused lens Quality of services Diversity of services Health literacy Fairness

Delivery / access / linkages Attendance at antenatal clinic Attendance at primary care clinics Number of children weighed Existence of functional referral systems Community  health clinic  secondary/tertiary  community

Lascahobas, Haiti: Attribution of Financing % GHI% MOH% external% private 34%6%60%<1%*

Lascahobas, Haiti: Work force, 2002 vs BeforeAfter MD02 Nurse23 Nurse aux14 Pharmacist01

Lascahobas, Haiti: Health Service Utilization, 2002 vs BeforeAfter PHC visits daily10400 ANC visits annual HIV cases total01200 TB cases annual5150 Family planning? 5178

Care Targets MOH targets for primary health care utilization: 10% of population per month, 1.2 visits per capita per annum WHO targets for ANC: 4% of total population is pregnant in a given year Global TB report TB incident and prevalence UNAIDS and country reports for HIV prevalence

Lascahobas, Haiti: Is it stronger? Utilization% of target PHC visits daily400110% ANC visits annual % HIV cases total % TB cases annual150120% Family planning %

Using the Yard Stick Disease specific: HIV detection, ART enrollment, TB case detection and treatment, pMTCT Total number : general visits, ANC, family planning uptake, immunization Health personnel: numbers and cadres Drugs: % of full “essential drug package” Diagnostics: number of diseases “diagnosable”

Rusumo, Rwanda: 2006 vs % GHI% MOH% external% private 42%7%48%3% BeforeAfter MD02/5 Nurse07 Nurse aux57 Pharmacist00

Rusumo, Rwanda: Is it stronger? BeforeAfter% of Target PHC visits daily ANC visits annual HIV cases total TB cases annual Family planning ??

Further Challenges Outcomes Temporal changes—strengthening, integraton Evaluating quality of services Evaluating counterfactual—clinics that have not had the benefits of GHI monies OR the GHI monies were used only vertically

Next steps: Developing a data abstraction tool Aug 28, 2009 Evaluation of 2-3 PIH supported MOH clinics in Haiti, Rwanda, Malawi, Lesotho and one counterfactual in each Jan 1, 2009 Visits to 4-5 other countries to analyze a clinics with tool Mar 1, 2009 Analyze and interpret and write May 1, 2009