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Program Evaluation: Program Evaluation: a potential platform for cross site analyses 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 Context: Reason for Program EvaluationEvaluation
• 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: AimsProgram Evaluation: Aims
Evaluate performance of local health system– impact of GHI on HS– Impact of HS on GHI
Facility level evaluation
Community level evaluation
MethodsMethods
• 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 SystemPerformance of Health System
• Scale
• Scope
• Distribution
• Quality/safety of services
• System capabilities (response to emerging and changing challenges)
Process: Human ResourcesProcess: Human Resources
Number
Distribution / per population served
Skill level
Skill mix
Accreditation
OutcomesOutcomes
• 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 lensOutcomes: Patient-focused lens
• Quality of services• Diversity of services• Health literacy• Fairness
Delivery / access / linkagesDelivery / 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: Lascahobas, Haiti: Attribution of FinancingAttribution of Financing
% GHI % MOH % external % private
34% 6% 60% <1%*
Lascahobas, Haiti:Lascahobas, Haiti:Work force, 2002 vs. 2007Work force, 2002 vs. 2007
Before After
MD 0 2
Nurse 2 3
Nurse aux 1 4
Pharmacist 0 1
Lascahobas, Haiti:Lascahobas, Haiti:Health Service Utilization, Health Service Utilization,
2002 vs. 20072002 vs. 2007Before After
PHC visits daily 10 400
ANC visits annual 10 16920
HIV cases total 0 1200
TB cases annual 5 150
Family planning ? 5178
Care TargetsCare 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:Lascahobas, Haiti:Is it stronger?Is it stronger?
Utilization % of target
PHC visits daily 400 110%
ANC visits annual
16920 130%
HIV cases total 1200 100%
TB cases annual 150 120%
Family planning 5178 47%
Using the Yard StickUsing 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: Rusumo, Rwanda: 2006 vs. 20072006 vs. 2007
% GHI % MOH % external % private
42% 7% 48% 3%
Before After
MD 0 2/5
Nurse 0 7
Nurse aux 5 7
Pharmacist 0 0
Rusumo, Rwanda:Rusumo, Rwanda:Is it stronger?Is it stronger?
Before After % of Target
PHC visits daily
20 84 55
ANC visits annual
200 1925 26
HIV cases total
4 263 36
TB cases annual
7 40 71
Family planning
? ?
Further ChallengesFurther 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: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