1. Use of routinely collected service delivery and M&E indicator data for timely feedback Denis Nash, PhD, MPH Associate Professor of Epidemiology Director, ICAP M&E Unit Mailman School of Public Health, Columbia University, NYC, USA dn2145@columbia.edu

2. Common M&E Challenges in scale-up (1) Large number of sites with relevant info residing with multiple individuals – e.g., sites, districts, partner country teams, partner HQ, etc. Increasingly complex array of services to report on/evaluate – Collection, management and use of indicator data within country Traditionally siloed areas of reporting for program activities that are integrated at the site level – e.g., care and treatment, PMTCT, TB/HIV, testing & counseling Separate M&E reports for each program area Comprehensive program evaluation? Triangulation? MOH vs. donor reporting requirements Many important aspects of implementation and program quality not captured in conventional, routinely collected M&E indicators – Generally M&E systems do not take context into account

3. Common M&E Challenges in scale-up (2) Providing timely data processing and feedback of information to implementation staff for program improvement – National-level (i.e., technical and management staff, IPs) – District-level – Site-level (and below) Program improvement ultimately happens and most often starts at the site level Integrated data management – Adequate database to house M&E indicator data is essential – Capture/store/process/utilize reported data in a streamlined and efficient way – Dynamic and flexible to accommodate changes in indicators Data quality – Missing or incomplete data – Incorrect data Demand for indicators that reflect quality of care/program – M&E indicators do not typically measure quality of care/program

4. Feeding data back to programs in the form of information Scale-up and sheer number of sites and geographic spread makes regular and timely feedback challenging, especially at site level Need for information at multiple levels – For implementation teams at national and district-levels Which sites to focus scarce mentoring and implementation support resources? Are efforts to maximize quality of care having an impact? – For site staff How is our site doing? Where can we improve? Are our efforts to improve things working? Difficult to do without some form of automation (e.g., reports) and decentralization of information (e.g., web-based)

5. Number of sites Number of sites by country, as of March 31, 2010 Source: ICAP Site Census, March 2010 Total number of sites supported by ICAP : 1,219

8. Feeding data back to programs in the form of information Scale-up and sheer number of sites and geographic spread makes regular and timely feedback challenging, especially at site level Need for information at multiple levels – For implementation teams at national and district-levels Which sites to focus scarce mentoring and implementation support resources? Are efforts to maximize quality of care having an impact? – For site staff How is our site doing? Where can we improve? Are our efforts to improve things working? Difficult to do without some form of automation (e.g., reports) and decentralization of information (e.g., web-based)

10. Priority indicators by site

11. Examples of feedback tools used by ICAP Mainly aimed at providing feedback from ICAP-NY to ICAP country teams on reported data But some tools can also be used to feedback data to district and sites Examples ICAP URS dashboards and reports Maps (static and interactive) PFaCTS reports Quarterly eUpdate Patient-level data reports

12. Patient-level data

13. ICAP patient-level data warehouse elements Enrollment Table Basic demographic information Age Sex enrollment date Prior ARV use Point of entry Transfer Visit Table: Visit date, WHO stage, height, weight, Hb, ALT, next scheduled visit date CD4 Table: CD4 test date, CD4 count, CD4 percent ART Table: ART regimen, regimen start & end date, reason(s) for switching ART regimen Medication Table: TB screening date and result, TB medication reason (treatment or prophylaxis) and dates, CTX & fluconazole Status Table: Patient disposition status (dead, transferred, withdrew, LTF, stopped ART, etc) and status date Pregnancy Table: Visit date, weeks gestation at visit, due date, actual pregnancy end date Baseline: 1 row Per patient Follow-up data: 1 row per measure per patient *measures at key points of interest (e.g., enrollment, ART initiation) calculated based on visit dates Databases are anonymized using an automated tool. Data use governed by MOH approved protocols.

14. Patient-level data feedback reports Multi-site feedback reports – Combines and compares data across multiple sites – One for adult patients and one for pediatrics patients Site-specific feedback reports – General feedback report Summary of information on currently enrolled patients – Standards of care (SOC) report Quality of care indicators Reports are: – 100% automated and are in PDF format – generated and shared with sites within two weeks of submission of database – Currently generated in NYC at ICAP HQ – Report generation tools can be deployed, owned, and maintained by MOHs where capacity exists or where it can be developed

15. Multi-site report

18. Site-specific general feedback report

19. PDF format, 100% automated

27. Site-specific SOC report

30. Dissemination of patient-level data reports

31. M&E Indicator data

32. Integrated data at site level

34. Filterable home page and program area dashboards

35. Example of care and treatment dashboard table

37. Filterable home page and program area dashboards

41. Conclusions Timely feedback and dissemination of routinely collected service data and M&E data is an increasing challenge, especially as the number of sites increases (i.e., scale-up) – National, district, site, IPs Database tools, automation, and decentralization of information are critical – Improves data quality and utility of information! Capacity building on interpreting and applying disseminated data to program improvement is needed

42. Thank you!