utilizing facility data for program monitoring valerie koscelnik track 1 art program meeting maputo,...
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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 quality
Data 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
1Eligible patients in care and treatment receive cotrimoxazole at enrollment and last visit
2HIV infected children under one year of age receive ART
3Patients enrolled into treatment remain in care for at least 6 months
TB/HIV 4All patients in care and treatment receive TB screening at enrollment and during the quarter
PMTCT 5HIV-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 data
Measured 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 data
Measured 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 months
Denominator 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 data
Measured by Proportion of HIV-infected pregnant women in PMTCT services in ANC receiving multi-drug ARV prophylaxis
Numerator 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 programs
Data must continue to inform all aspects of transition efforts