Monitoring and Evaluation Plan for the National Tuberculosis Strategic Plan

Transcription

1 Monitoring and Evaluation Plan for the National Tuberculosis Strategic Plan Government of Papua New Guinea August 2014

2 Monitoring and Evaluation Plan for the National Tuberculosis Strategic Plan

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4 Table of Contents Acronyms... 5 I. Tuberculosis in Papua New Guinea... 7 II. National Strategic Plan for TB Control III. Overview of the Health Information System in PNG IV. Rationale for the Monitoring and Evaluation Plan V. Components of the Monitoring and Evaluation Plan A. Guiding Principles B. Core Indicators: Definitions and Measurement C. Routine data collection and data management system Data Collection and Reporting of Drug Sensitive TB Recording and Reporting for MDR-TB D. Data quality assurance mechanism E. Data dissemination and utilization F. M&E Coordination G. Evaluation, reviews, survey, surveillance or special studies VI. Challenges and Interventions in the present M&E System Annexes Annex A Performance Indicator Reference Sheet Annex B BMU Tracking Annex C Routing and Transmittal Slip Annex D Data Validation Forms Annex E: Training Report Template Annex F: Feedback report to provinces (Sample) Annex G Technical Working Group for TB Terms of Reference Annex H Template for Partner s Update during TWG meeting Annex I: Costed M&E Operational Plan... 90

5 Acronyms AIDS ART BMU CBO CCM CNR CPHL CPT CXR DGH DOT DOTS DST EPTB EQA FDC GDF HSS HIV IC IEC IPT LTFU MDG MDR-TB M&E MRB MSPD MTDP NDOH NDNA NSP NTP NTRL PDCO PHA PNG Acquired Immuno-Deficiency Syndrome Antiretroviral therapy Basic Management Unit Community-based organisation Country Coordinating Mechanism Case notification rates Central Public Health Laboratory Co-trimoxazole preventive therapy Chest X-ray Daru General Hospital Directly Observed Treatment Directly Observed Treatment, Short Course Drug Susceptibility Testing Extra-pulmonary Tuberculosis External Quality Assurance Fixed-dose Combination tablets TB Global Drug Facility Health System Strengthening Human Immunodeficiency Virus Infection Control Information, Education, and Communication Isoniazid Preventive Therapy Loss To Follow-Up Millennium Development Goal Multidrug-Resistant Tuberculosis Monitoring and Evaluation Medical Research Branch Medical Supply Procurement and Distribution Medium-Term Development Plan National Department of Health Sputum Not Done/Not Available National Strategic Plan National Tuberculosis Programme National Tuberculosis Reference Laboratory Provincial Disease Control Officer Provincial Health Authority Papua New Guinea

6 PR PSM PUDR PITC PLWH PMP PMGH PMDT PSSB RDQA RR-TB SDA SLD SR TB TWG WHO WV Principal Recipient Procurement and Supply Management Progress Update and Disbursement Report Provider-Initiated Testing and Counselling People Living with HIV/AIDS Performance Monitoring Plan Port Moresby General Hospital Programmatic Management of Drug Resistant TB Pharmaceutical Services Standards Branch Routine Data Quality Audit Rifampicin Resistant TB Service Delivery Area Second Line Drug Sub-Recipient Tuberculosis Technical Working Group World Health Organization World Vision

7 Number of Cases I. Tuberculosis in Papua New Guinea Papua New Guinea (PNG) ranks 2 nd in the Western Pacific Region, next to Cambodia, in terms of estimated tuberculosis (TB)prevalence, incidence and mortality. According to the World Health Organization, TB (including HIV) incidence in 2012 was 348 per 100,000 population (25,000 cases), and prevalence was 541 per 100,000 (39,000 cases). Mortality rate excluding HIV was 54 per 100,000 (3,900) 1. Despite potential declines in TB prevalence and mortality rates, estimated TB incidence rates have not shown any decline since 1990 (Fig.1). TB prevalence surveys have not been carried out in PNG..Figure1. Estimated TB prevalence, incidence and mortality rates in PNG (Source: WHO Global TB Report, 2013) Because of Global Fund support, implementation of the Directly Observed Treatment Short-Course (DOTS) Strategy expanded from two provinces (2008) to 22 provinces (2012). During this period, an increasing trend was noted in TB case notification (Fig.2). This can be attributed to improvement in diagnostics services and expansion of reporting sites. Figure 2. Case notifications (all TB cases) from 2008 to ,000 25,000 20,000 15,000 10,000 5,000 6,367 12,297 15,989 17,388 22,554 24, Year 1 NSP P a g e

8 CNR per 100,000 Although case notifications showed an increasing trend, case notification rates for sputum smear positive (CNR SS +) still remained below the national target for 2013 based on the National Strategic Plan (NSP) for (Fig. 3). This suggests limitations in smear microscopy diagnosis in spite of expansion in smear microscopy laboratory services. A high number of Sputum Not Done/Not Available (NDNA)cases ( % of all TB cases) was also noted in 2013 notifications. Figure 3: Case Notification Rates New SS+, All TB and New + Relapse cases, Papua New Guinea, CNR SS(+) CNR ALL TB New + Relapse Considered as a hot spot for TB, the National Capital District, which makes up 5 percent of the PNG population, contributes 25 percent of all TB cases in the country. Over the past years, NCD TB case notification rates had consistently been higher than the national average (>1200/ population) hence necessitating more specific and coordinated initiatives to fight TB in the province. High case notification rates are also observed in Western, Oro, Gulf, Morobe, and West Sepik provinces (Fig 4). Figure 4. Case notification rate for all TB cases per 100,000 population bacteriologically confirmed plus clinically diagnosed (new and relapse) by province (2011, 2012 and 2013) Southern Regions Highlands Region New Island MOMASE 8 P a g e

9 Figure 5 showed skewing of the age distribution of sputum smear positive cases among the 15 to 35 years age group who are the economically productive adults. This indicates an ongoing transmission within communities. The 2013 data also showed high numbers of children diagnosed with TB (26% of all TB cases) which essentially reflect TB transmission within households. Figure 5. Age and sex distribution of new smear positive TB cases PNG (absolute numbers, N=10,029) M F to Ancillary evidence from hospital surveillance data reported by 10 large referral hospitals (Angau, Buka, Goroka, Kavieng, Kimbe, Mendi, Modilon, Mt. Hagen and PMGH) indicates that TB was the fourth most common reason for hospital admission in children; after pneumonia, severe malnutrition, and diarrhoea 2. As a cause of death it also ranked fourth with 199 deaths attributed to TB, while additional TB deaths may be included in children dying from malnutrition, pneumonia and meningitis. Figure 6: Age distribution, PNG The fact that more children in the 5 to 14 year-age group were diagnosed than among the very young (<2 to 5 years of age) is unexpected (Fig. 6). The natural history of disease identifies young children as the most vulnerable age group. In high-burden countries with 2 NSP P a g e

10 good diagnostic infrastructure, children below five years of age are most frequently affected suggesting that more acute cases (especially in the very young) may remain undetected. The ratio male/female for the whole country is quite equal, but some provinces have more males (Enga, Western Highlands and Simbu). While females are in a majority in New Island and Southern Highlands, there is no obvious explanation for the difference. Figure 7: Ratio male/female in all new smear positive TB cases, 2012 by province In 2013, 22,796 probable TB patients were examined. Among the provinces, Chimbu and Southern Highland provinces have very low positivity results among the TB suspects examined. Out of 116 functional laboratories performing smear microscopy, only 52 (45%) participated at least once in external quality assurance activities. A total of 1,229 (28%) SS (+) TB patients were not enrolled to treatment. Nine provinces have high initial defaulters namely: Western, Western Highland, Gulf, National Capital District, Sandaun, Milne Bay, West New Britain, Bouganville and Morobe (Table 1). These provinces should develop a system of tracking the SS (+) patients who are highly infectious TB patients. On the other hand, ENGA and New Island have more patients enrolled on treatment than those diagnosed by smear microscopy. Although it is possible that these patients may have been diagnosed elsewhere, the numbers for these provinces were unusually high. Review and cross validation of registers should be done to eliminate any data quality issues. 10 P a g e

11 Table 1: Initial defaulters by province 2013 Region/ Province Suspects Examined Suspects Positive Percent Positive New SS+ Initial Defaulters Percentage of Initial Defaulters Highlands % % CHIMBU % 15-8 EHP % % ENGA % SHP % 46 1 WHP % % Islands % BVILLE % % ENB % MANUS % 27-5 NI % WNB % % Momase % ESEPIK % % MADANG % % MOROBE % % SANDAU N % % Southern % CENTRAL % 89-8 GULF % % MILNE BAY % % NCD % % ORO % % WESTERN % % Grand Total % % Cure rate had been declining for the past five years. Treatment success rate had remained steady at 68 percent for the past two years. However, defaulter rate had been increasing until 2011 at which it stabilized at 20 percent (Fig.9). Figure 8. Treatment outcomes for sputum smear positive cases cohort 11 P a g e

12 TB/HIV PNG has 70 percent of the Pacific region s population, but over 95 percent of the HIV cases 3. The country has the highest incidence and prevalence for HIV in the Pacific and is ranked 11 th in terms of the number of people living with HIV, out of 12 countries in Asia Pacific 4. The prevalence of HIV among the general adult population (15-49 years of age) is estimated to be percent in 2010 and This translates to an estimated 31,421 (range 27,385 36,312) adults and children living with HIV. Current information indicates that PNG is experiencing an HIV epidemic concentrated in key population groups and in certain geographical locations. In 2013, Enga, Western Highlands, and Jiwaka provinces in the Highlands and the National Capitol District reported >1 percent HIV prevalence amongst pregnant women attending an antenatal clinic 6. The HIV epidemic in the country is predominantly driven by heterosexual transmission with a background of high rates of untreated sexually transmitted infections (STIs). The modes of HIV transmission are: heterosexual sexual intercourse (93%); mother to child transmission (4%); body piercing and homosexual contact (<2%) 7. In NCD, a study in 2010 showed an HIV prevalence of 19 percent amongst women who sold or exchanged sex in Port Moresby, 8.8 percent amongst men who sold or exchanged sex in Port Moresby, and 23.7 percent amongst transgendered individuals who sold or exchanged sex in Port Moresby 8. A study conducted by FHI360 amongst MSM in Port Moresby reported 9 percent HIV prevalence. 9 HIV testing among TB cases has increased over years, although it remains very low (<25% of all TB cases). Based on 2013 NTP and HIV program data, 10 high TB/HIV burden provinces were identified. Table 1 shows these provinces to be Chimbu, Eastern Highland, Enga, Southern Highland, Western Highland, East New Britain, Madang, Morobe, National Capital District and Western. 3 Mid Term Review of Papua New Guinea HIV Strategy ( ) 4 UNAIDS 2013 Asia and Pacific Report NDoH HIV testing database 7 Narrative, UNAIDS report, Askim na Save, PNG Institute of Medical Research, Behaviours Knowledge Exposure to Interventions. A Behavioural Surveillance Survey, Port Moresby. FH! P a g e

13 Table 3: TB/HIV figures for 2013 Provinces TB patients tested for HIV HIV positive TB patients CHIMBU 15% 14% EHP 31% 6% ENGA 57% 24% SHP 24% 16% WHP 17% 52% BVILLE 8% 28% ENB 29% 6% MANUS 22% 0% NIRELAND 3% 0% WNB 4% 16% ESEPIK 1% 12% MADANG 22% 6% MOROBE 52% 6% SANDAUN 37% 1% CENTRAL 6% 11% GULF 17% 1% MILNE 12% 15% BAY NCD 24% 11% ORO 1% 29% WESTERN 33% 36% MULTIDRUG-RESISTANT TB In 2012, MDR-TB was estimated to be present in 4.9 percent ( %) of new cases and 23 percent (20-27%) of previously treated cases, representing 590 new and 500 previously treated MDR-TB cases in PNG 10. In 2012, 85 cases had been tested for MDR-TB. Of these, 58 were confirmed to have MDR-TB and 82 started MDR treatment in Western, Madang, Morobe and Milne Bay provinces. In 2012, 124 Rifampicin- resistant cases were identified among 636 patients tested with Xpert. In 2013, 116 Rifampicin-resistant cases were identified among 1,933 tested. In 2013 in NCD and Central provinces, sputum specimens from 945 patients were tested for Xpert MTB/RIF, in which 94 (10%) were found resistant to Rifampicin. Sputum specimens from 65 Rifampicin-resistant cases were sent to the SRL for TB culture and Drug Sensitivity Testing. Of the 65 specimens, 6 did not isolate mycobacterium tuberculosis complex, 42 were confirmed as MDR-TB, 2 were fully susceptible, one was streptomycin mono-resistant, one was poly- resistant to Streptomycin and Rifampicin and the remaining 13 were Rifampicin 10 WHO Global TB report P a g e

14 mono-resistant. The confirmed cases of new MDR-TB from Western Province reached 12 (2011), 44 (2012), and 30 (2013), respectively. In 2012, the first two confirmed cases of XDR-TB were identified in Western Province. The following year (2013), additional six confirmed cases of XDR-TB were reported in Western Province. Two of these cases were acquired XDR-TB, as they had been previously identified as MDR-TB in Currently, the Drug Resistance Survey is underway in four provinces, namely: Western, NCD, Morobe and Madang. Preliminary results indicate that DR-TB rates are high in all DrugResistant Survey provinces. II. National Strategic Plan for TB Control After extensive consultations with partners, the National Tuberculosis Program developed the PNG National Strategic Plan for Tuberculosis Control covering the period with the following three strategic objectives: Objective 1: Strengthen implementation of local/png TB care and prevention strategy, specifically by a) increasing case notification rate of all forms of TB per 100,000 populations - bacteriologically confirmed plus clinically diagnosed, new and relapse cases from 293 in 2013 to 297 in 2020; b) increasing the case notification rate for bacteriologically- confirmed, new and relapse cases, from 43 in 2013 to 93 per 100,000 population in 2020 and; c) achieving treatment success rate of bacteriologically - confirmed new TB cases of 88 percent in 2020 from 68 percent in 2012 Objective 2: Improve the programmatic management of drug resistant TB in all the provinces, with particular focus on high prevalence provinces (Western, NCD, Morobe and Madang) by: (a) increasing the percentage of previously treated TB patients receiving DST from 16 percent in 2013 to 96 percent in 2020; and (b) increasing treatment success rate for MDR-TB from 14percent in 2011 to 60 percent in 2020; Objective 3: Through strengthened HIV/TB collaborative activities, increase the coverage of HIV and TB testing from 24 percent in 2013 to 91 percent in 2020 in all provinces, but with particular focus on 10 high HIV burden provinces. Objective 4: Improve the TB Control program in the National Capital District (NCD) by: 1) increasing case notification rate of bacteriologically confirmed, new and relapse cases from 148 in 2013 to 733 by 2020; and 2) increasing treatment success rate for new bacteriologically confirmed cases from 51 percent in 2012 to 85 percent by P a g e

15 The implementation of these four objectives will contribute to the reduction of TB prevalence, incidence, and death rates in PNG in line with the Millennium Development Goals. III. Overview of the Health Information System in PNG According to the Public Hospitals Administration Act (1997) and the New Organic Law, all government-funded health facilities must provide health information requested by government. The National Health Information Monthly Report is a four-page document that captures health information relevant to the major infectious and non-infectious diseases in PNG. It also provides information on the causes of morbidity and mortality throughout the nation. Information is collected at all provincial healthcare delivery sites (provincial hospitals, district hospitals, health centres, and basic management units). The monthly report is forwarded to district health information officers (DHIO) (wherever available), provincial health information officers (PHIO) (where available) or directly to the National Health Information System Office s Monitoring and Research Branch (MRB) in Port Moresby. PHIOs also reports to provincial health advisers. The other main sources of government information on health in PNG include: a) the National Census, which is undertaken approximately every ten years (last one in 2011); b) the Papua New Guinea Demographic and Health Survey, which was undertaken in 1996 and 2006, c) the Household Income and Expenditure Survey; and d) the National Health Accounts. These surveys are mainly organised by the National Statistics Office of the Ministry of National Planning. However, surveys are jointly organised or coordinated with the MRB. MRB has developed a Monitoring and Evaluation Strategic Plan which specifies the core health system indicators with targets. It also describes the data collection, management, analysis, use and communication of information to various stakeholders. IV. Rationale for the Monitoring and Evaluation Plan An efficient Monitoring and Evaluation (M&E) system is important to determine the progress and level of implementation of the National TB Program. The National Department of Health (NDOH) has made a strong commitment to improve the current M&E system for the health sector in general, as well as program areas.. Through strategic enhancements of the M&E system, NDOH M&E intends to systematically collect, collate, and report key health indicators to accurately measure its programs. Some outcome 15 P a g e

16 TB and TB/HIV indicators have also been included in the performance assessment framework of the NDOH which is the tool being used to evaluate the yearly performance of the whole health sector. This M&E Plan, together with the National Strategic Plan, will provide the basis for the strengthening of the M&E System for the National Tuberculosis Program of PNG. The National M and E plan contains the indicators by which the interventions of the NSP for TB will be measured. It also describes the recording and reporting system of the TB program along the different levels of structure. It provides the definition of the indicators, source document for the data to be collected, how it will be analysed and the targets for each indicator. The document also enumerates the various tools to be used to ensure the quality of data to be collected. V. Components of the Monitoring and Evaluation Plan A. Guiding Principles The following principles guided the development of indicators for the M&E plan : Building on existing nationally and globally agreed indicators and linking these indicators to the objectives; Harmonizing with other international frameworks, such as the framework of the Millennium Development Goals and the Stop TB Partnership; Limiting the number of indicators to be collected to avoid overburdening the M&E system and to stay focused on issues that directly affect decision-making; Selecting indicators that are collected regularly through routine recording and reporting systems, a health information system, health facility surveys, and ensuring that these indicators have clear data sources and methods of analysis; Aligning the M&E needs of the country and donors; and Ensuring that all components of the National Strategic Plan for TB control are covered. B. Core Indicators: Definitions and Measurement Impact indicators The Strategic Plan identified two impact indicators as measures of program success, these are: prevalence of TB and TB mortality. These indicators are in line with the Millennium Development Goals and the STOP TB Partnership. 16 P a g e

17 1. Prevalence of TB. This is the number of cases of TB in a population at a given point in time (expressed as number of cases per 100,000 population). The prevalence of TB determines the risk of TB infection in a community, that is, how much transmission is occurring. The prevalence of TB is approximately the incidence of TB multiplied by the average duration of the disease. Improved case-finding and treatment both shorten the duration of the disease, so prevalence responds more rapidly than incidence to changes in TB control. Periodic assessment of the prevalence of TB disease can therefore be more useful for measuring the short-term impact of TB control (for example, within five to ten years) than efforts to measure changes in TB incidence. Changes in TB prevalence over time are best measured by implementing at least two surveys at sufficient intervals. There are two methods for estimating the TB prevalence. Direct measurement uses a cross-sectional population based survey. TB prevalence surveys typically require sample sizes of 50,000 to 100,000 people in high TB burden countries, and implementation is expensive and logistically challenging. Current strategic plan does not recommend conducting of the prevalence survey taking into account that funds are more needed to improve the quality of TB services to the population. Indirect estimates of TB prevalence published each year by WHO will be used to track changes over years. 2. TB mortality. This is the number of deaths from TB that occur in a given year (expressed as deaths per 100,000 populations per year). There are three ways to measure TB mortality: 3. a) Routine measurement using vital registration data. This is used if collected death registration data in vital registration systems are coded according to the International Statistical Classification of Diseases (ICD-10) and the data are proven complete and accurate; b) Direct measurement using verbal autopsy studies. Caregivers or family members of people who have died are asked a structured set of questions with the aim of determining the cause of death. Cause of death is validated medical records; c) Indirect measurement using estimates of case-fatality rates and TB incidence. This is used if vital registration is weak and does not allow direct measurement of TB mortality rate and no verbal autopsy study is planned to determine causes of death. Indirect estimates of TB mortality rate published each year by WHO will be used to track changes over years. If the strategic plan is fully funded and implemented, the following will be achieved: 1. Estimated TB prevalence rate will be reduced from the current level of 541 per 100,000 population in 2012 to 339 per 100,000 population by P a g e

18 2. Estimated TB mortality rate will be reduced from 54 per 100,000 in 2012 to 41 per 100,000 population by Outcome and Output Indicators Strategic Objective 1: Strengthen implementation of local/png TB care and prevention strategy, specifically by a) increasing case notification rate of all forms of TB per 100,000 populations - bacteriologically confirmed plus clinically diagnosed, new and relapse cases from 293 in 2013 to 297 in 2020; b) increasing the case notification rate for bacteriologically- confirmed, new and relapse cases, from 43 in 2013 to 93 per 100,000 population in 2020 and; c) achieving treatment success rate of bacteriologically - confirmed new TB cases of 88 percent in 2020 from 68 percent in 2012 The strategic objective 1 will be evaluated by three main outcome indicators: Case notification rate of all forms of TB per 100,000 population - bacteriologically confirmed plus clinically diagnosed, new and relapse cases Case notification rate per 100,000 population, bacteriologically confirmed, new and relapse cases Treatment success rate of bacteriologically confirmed new TB cases This objective will be pursued through the following interventions with corresponding output indicators Interventions 1.1 Improve and strengthen the support of the central level NTP to provinces in terms of capacitating; 1.2 Improve and strengthen the provincial local ownership to control TB in their respective provinces; 1.3 Provide support to health care workers to implement DOTS; 1.4 Address the patient- side reasons contributing to high smear-not-done and loss to-follow-up rates; 1.5 Engage the community and provide necessary support; 1.6 Improve the laboratory services focusing on smear microscopy; Output Indicators Smear not done rate among new pulmonary TB cases ; Smear not done rate among new pulmonary adult TB cases Treatment success rate- all forms: Percentage of all forms of TB cases (i.e. bacteriologically confirmed plus clinically diagnosed) successfully treated (cured plus treatment completed) Loss to follow up rate among all TB cases (new SS positive plus previously treated plus others) Loss to follow up rate among all new bacteriologically confirmed TB cases Proportion of laboratories performing microscopy that are participating in EQA Percentage of laboratories showing adequate performance 18 P a g e

19 1.7 Strengthen drug procurement and supply management system; 1.8 Strengthen the recording and reporting system in external quality assurance for smear microscopy among the total number of laboratories that undertake smear microscopy during the reporting period Annual Average Percentage of reporting units reporting no stock-outs of CAT 1 kit drugs on the 30 th of the month following the previous quarter. Percentage of BMUs reporting in time. Strategic Objective 2: Improve the programmatic management of Drug resistant TB in all the provinces, with particular focus on high prevalence provinces (Western, NCD, Morobe and Madang) by: (a) increasing the percentage of previously treated TB patients receiving DST from 16 percent in 2013 to 96 percent in 2020; and (b) achieving treatment success rate for MDR-TB from 14 percent in 2011 to 60 percent in 2020; Strategic Objective 2 will be evaluated by one outcome indicator, namely:, the treatment success rate for MDR- TB patients This objective will be pursued through the following interventions with corresponding output indicators Intervention 2.1 Improve the programmatic management of Drug Resistant TB Output Indicators Percentage of previously treated TB patients receiving DST Number of bacteriologically confirmed, drug resistant TB cases (RR-TB and/or MDR-TB) detected Number of cases with drug resistant TB (RR-TB and/or MDR-TB) that began second-line treatment Percentage of cases with drug resistant TB (RR-TB and/or MDR-TB) started on treatment for MDR-TB who were lost to follow up during the first six months of treatment Percentage of DST laboratories showing adequate performance on External Quality Assurance Strategic Objective 3: Through strengthened HIV/TB collaborative activities, increase the coverage of HIV and TB testing from 24 percent in 2013 to 91 percent in 2020 in all provinces, but with particular focus on 10 high HIV burden provinces. Intervention 3.1: Strengthen mechanism for TB-HIV collaboration will be measured by one output indicator: Percentage of HIV-positive registered TB patients given anti-retroviral therapy during TB treatment Strategic Objective 4: Improve the TB control program in the National Capital District (NCD). 19 P a g e

20 The fourth objective is measured by the following outcome indicators: TB case notification rate per 100,000 populations, bacteriologically confirmed, new and relapse cases, for National Capital District (NCD), and the treatment success rate for bacteriologically confirmed new TB cases. This objective will be pursued through the following interventions with corresponding output indicators. Intervention 4.1 Provide technical support to the 9 priority BMUs by improving the quality of diagnosis and treatment 4.2 Conduct systematic screening for TB of household contacts, especially among children under five years old in NCD province Output Indicators Smear not done rate among new pulmonary adult TB cases, NCD Loss to follow up rate among all new bacteriologically confirmed TB cases, NCD Number of children < 5 years old in contact with TB patients who began IPT Number of TB cases (all forms) notified among key affected populations/high risk groups Summary of Indicators: A total of 23 indicators will be used to monitor TB program performance as indicated in the National Strategic Plan for TB The details (definition, source documents and targets) of each indicator are presented in Annex A: Performance Indicator Reference Sheet. Table 4. Program Indicators: Impact, Outcome and Output National Strategic Plan Indicator Name of Indicator Type Impact Estimated TB Prevalence rate Estimated TB Mortality Rate Outcome Case Notification Rate of all Forms of TB per 100,000 population Case Notification rate per 100,000 population, bacteriologically confirmed, new and relapse cases Treatment Success rate of bacteriologically confirmed new TB cases Treatment Success rate for MDRTB patients (final outcome) Output Smear not done rate among new pulmonary TB cases Smear not done rate among new pulmonary adult TB cases Treatment Success rate all forms Loss to follow-up rate among all TB cases Loss to follow-up rate among all new bacteriologically confirmed TB cases Proportion of laboratories performing microscopy that are participating in EQA Percentage of HIV positive registered TB patients given anti-retroviral therapy during TB treatment Number of children less than 5 years old in contact with TB patients who began IPT Number of TB cases (all forms) notified among key affected populations/high risk groups Percentage of laboratories showing adequate performance in external quality 20 P a g e

21 assurance for smear microscopy among the total number of laboratories that undertake smear microscopy during the reporting period Annual Average Percentage of reporting units reporting no stock-outs of CAT I kit drugs on the 30 th of the month following the quarter Percentage of BMUs reporting on time Percentage of previously treated TB patients receiving DST Number of bacteriologically confirmed drug resistant TB cases (RR and/or MDRTB detected Number of cases with drug resistant TB (RR-TB and/or MDRTB that began second-line treatment Percentage of cases with drug resistant TB (RR-TB and/or MDR-TB) started treatment for MDR-TB who were loss to follow-up during the first six months of treatment Percentage of DST laboratories showing adequate performance on External Quality Assurance C. Routine data collection and data management system Data Collection and Reporting of Drug Sensitive TB The TB information system is a subsystem of the national Health Information System (HIS). It is mostly paper-based at the facility level and computerized at the central level. The data collection system for the Tuberculosis Program is patient-centered and starts at the health facility where the patient is screened (Fig 10). When the patient is admitted to the health facility, the case is registered in a standardized TB register book. The register book captures information on patient data, type of TB, type of regimen followed, TB/HIV information, sputum smear examination results, referral sites, and treatment outcome. The patient information is also registered in an individual blue card for TB treatment (BMU). If the treatment is provided by the treatment supporter, the same information is copied to the yellow TB treatment card and this card is kept by the treatment supporter. The treatment supporter needs to bring the yellow card each time he or she comes to the health care facility. The patient is also provided with the TB identity card which the patient needs to bring each time the he or she comes to the health facility. 21 P a g e

22 Fig. 10 Data Collection Process TB Suspect Patien Patient TB identity TB Laboratory TB Register and Blue Treatment 1 Copy should be filed in the facility BMU report Treatment Partner with Yellow TB End of the month Provincial District Health 15 th of the month 2 Copies submitted to the Department of Health BMUs reports reviewed for completeness and accuracy of information. Data are encoded BMUs reports reviewed for completeness and accuracy of information. A copy of the BMU The following are the records, registers and forms used at the Health Facility for the TB program: TB Suspect Register register of all TB Suspects with patient s information and details of sputum examinations and results and actions taken. 2. TB Register register of TB patients with information on patient s particulars, diagnosis and treatment details, results of investigations, follow-up and outcome. 3. TB Treatment cards contains information on patient s particulars, diagnosis and treatment details, results of diagnosis, treatment calendar. 4. TB Referral Register register of patients that are diagnosed in a diagnostic facility but referred to BMUs for registration and continuation of treatment. 5. TB Laboratory Register registers sputum and results of investigations eg. AFB detected. 6. Request Form for Sputum Examination contains patient s information and purpose for investigation and accompanies samples for investigation and returned with results. 7. Request Form for culture and sensitivity testing This form should be filled and should accompany the specimen for culture and sensitivity 8. Referral and transfer forms contains information on patient s particulars, diagnosis and treatment results and accompanies patients transferring or referred to another facility 11 National Tuberculosis Management Protocol 2013, p P a g e

23 The BMU quarterly report form has seven pages. It contains different types of quarterly reports and a yearly report which are described below: 12 Quarterly Report on TB Case Registration this contains case detection information for all patients identified in the quarter that just ended: 1. Quarterly Report on Sputum Conversion This report is filled in for the new smear positive patients registered in the previous quarter i.e. the quarter that ended 3 months ago. 2. Quarterly Report on TB Treatment Outcome This report is for the treatment results for the cohort of patients registered in the quarter that ended one year ago 3. Quarterly Order form for TB drugs based on the consumption from the last quarter 4. Quarterly Order Form for Laboratory Supplies based on consumption from the last quarter 5. Yearly Report on Program Management filled in once on an annual basis The entire set of the BMU report is filled out in triplicate. One copy remains in the BMU, the other copy is for the Provincial Health Office. The Provincial TB/Leprosy Officer will ensure that all reporting BMUs had submitted their reports to the province by the 15 th of the month. He will review all BMU reports for completeness and accuracy of information written on the report. He will be responsible for sending all BMU reports (with cover letter) to the NTP before the 30 th of the month following the quarter. The Central level aggregates data coming from the BMUs and filed at NTP office. The data is encoded in the data base for analysis. Table 5. TB report and source documents Sections of BMU Report Source Documents Location 1. Quarterly Report on TB Case Registration 1.1 Block 1: All TB Cases Registered TB Register TB clinic (BMU) 1.2 Block 2:New Pulmonary Sputum Smear TB Register TB Clinic (BMU) Positive Cases Age Group 1.3 Block 3: Laboratory Activity sputum smear microscopy TB Laboratory Register Smear Microscopy Laboratory 1.4 Block 4: TB-HIV Activities TB Suspect Register TB Clinic (BMU) TB Register 2. Quarterly Report on Sputum Smear TB Register TB Clinic (BMU) Microscopy Conversion 3. Quarterly Report on TB Treatment 12 National Tuberculosis Management Protocol 2013, p P a g e

24 Outcome 3.1 Block 1: TB Treatment Outcomes Treatment Card TB Clinic (BMU) TB Register 3.2 Block 2: TB/HIV Activities TB register TB Clinic (BMU) 4. Quarterly Order Form for TB Drugs Stock Bin cards TB Clinic (BMU) Recording and Reporting for MDR-TB The reporting and information system for MDR-TB is an extension of the basic TB-DOTS information system. MDR-TB recording and reporting forms were developed and piloted in the TB clinic of the Daru hospital of the Western Province and Port Moresby General Hospital. However, the recording and reporting system for MDR-TB failed to materialize. Recording had been poor and reporting was irregular. Therefore, available data for MDR- TB indicators may not be reflective of the actual cases and outcomes for MDR-TB. The NSP prioritize strengthening the Programmatic Management of Drug Resistant TB (PMDT) that includes reviewing and finalizing all recording forms (PMDT register, Second Line Drug Treatment Card; and Laboratory Culture and DST register) and reporting forms (Treatment Center Reporting Form and National PMDT Reporting Form). A Treatment Center PMDT Report includes indicators for the following: Detection Enrolment Interim outcome Final treatment outcomes The nursing officer in charge of TB will be the point person for reporting, supervised by the physician. The Provincial TB /Leprosy officer or the physician treating the patient will assist in the preparation of the report. This quarterly report will be accomplished on the first seven (7) days of the next month following the quarter. The PMDT Coordinator will track all submitted reports and note late reports. She will review the provincial reports for completeness and accuracy, consolidate, and conduct initial analysis. The PMDT coordinator will draft a report and will accomplish the National PMDT Report for the Central PMDT Core Team within two weeks. The PMDT Core Team will review the National PMDT Report and make recommendations. The National PMDT Report, together with recommendations from the Core Team, will be sent to the provincial TB/Leprosy Officer and treating physicians. Data analysis is done at the central level while provincial-specific feedback reports are sent to provinces to for action. 24 P a g e

25 D. Data quality assurance mechanism Fig. 11 Data Quality Process Department of Health Tuberculosis Unit Health Facility TB recording and BMU report completion BMU report submitted Province District/Province review, collates, validates and analyse Copy of BMU report submitted to NTP NTP review BMU reports for completeness and accuracy Provides feedback to the province and health Facility Encoded in the data base Conducts RDQA semi-annually NTP analyse data and report writing, policy direction NTP M and E Advisor cleans data set prior to analysis Timely, quality data is needed for a program to set its direction and the development of policies that will support its implementation. The Joint Program Review identified data quality issues to be addressed by the program. Generally, the quality of reported data is dependent on the underlying data management and reporting systems. Stronger systems should produce better quality data. For high-quality data to be produced by and flow through a data management system, key functional components need to be in place at all levels of the system: District health facilities: assist the provinces in the collection and validation of BMU reports prior to submission to the province. It may also consolidate BMU reports within its catchment area and produce a District level accomplishment; The intermediate level(s) where the data are aggregated (e.g. provinces or regions); and The M&E unit at the highest level to which data are reported. In response, NTP will strengthen its data management process across the different levels of its structure (Fig. 11). Basic Management Unit (BMU) Level: BMUs are the main source of TB data. Services rendered to a TB patient are being recorded in the BMU. Intrinsically, data quality should begin at the facility where data are being 25 P a g e

26 recorded and collected. Accuracy of the information recorded (e.g. typing of TB patients, completeness of the information and consistencies of information across the different recording forms (registers) affects data quality. NTP ensures that these data processes are in place by: a) TB clinic staffs are trained on basic TB; b) post-training supervisory visits are conducted to follow through the participants skills; and c) continuous mentoring at the facility site during supervisory visits are provided. Provincial Level: At the provincial level, the provincial team is composed of the Provincial TB/Leprosy Coordinator, Health Information Officer, and M&E Officer (if position is available)/trained epidemiologist who will perform the M&E functions. The team was capacitated by the National M&E team (M&E Advisor, M&E Officer and PMDT Coordinator) to conduct data validation using the five components of data quality assessment (availability, completeness, consistency, accuracy and timeliness) across the different recording and reporting forms. Data validation procedures will be developed and disseminated at the provincial level to be used as a guide by the provincial team. At the District level, District officers will also be trained on data validation procedures to augment the provincial team. Provinces will also develop their supervisory plan as part of the provincial annual investment plan. The Provincial/District team will conduct data validation activity during supervisory visits to the different facilities based on their findings from the quarterly reports received. Upon receiving the BMU reports, the team will review the said reports for completeness and accuracy. A routing and transmittal slip will be used for tracking submitted reports. The same transmittal slip will be attached to the BMU reports submitted to the national level. Supervisory reports and the Data Quality Checklist for BMUs visited during the quarter will be included as part of the reports submitted at the NTP-DOH. National Level At the national level, the National TB Program is headed by the TB Manager. Beside the TB Manager, there are four Regional Medical Coordinators that provide technical guidance during field visits; act as facilitators for training and provide over-all technical oversight to TB program implementation. An M&E Officer is also a part of the TB National team. The M&E officer reviews BMU reports submitted at NTP for completeness, consistency and accuracy (for certain sections). The M and E Advisor will develop the tools that will help in improving the quality of data and trainings. These tools are the following: 1) the BMU tracking form; 2) routing and transmittal slip; 3) data validation tools; 4) training report template; and post training monitoring checklist. The BMU tracking form is a data base program used to track the timeliness of BMU report submission (Annex B). This will be updated upon receiving the BMU reports. The said form will facilitate in identifying BMUs that needs to be followed-up for their reports. The routing and transmittal slip (Annex C) is 26 P a g e

27 a form to track the date when the BMU report was submitted and received at NTP. It also track who reviewed the reports for consistency and completeness. The data validation tools (Annex D) is a set of forms to be used during supervisory visits that will look into the 5 components of data quality availability, completeness, consistency, accuracy and timeliness. The training report template (Annex E) is a standard format for a training report that will be used for all trainings to be conducted. This includes training conducted at the provincial level and any partners working for the program. The training report should contain the result of the pre-test and post-test, course evaluation and facilitator s evaluation and recommendations on the participants performance during the training. A post training monitoring checklist will also be developed in consultation with the different training facilitators. The post training checklist will be used during follow through supervisory visits of the facilitators/program coordinators. The BMU reports will be reviewed for completeness and accuracy prior to encoding to the data base system. The M&E Officer will communicate data quality issues identified by or phone call for immediate action and rectification of the data. Quarterly written feedback will be provided officially to the province (Annex F). Field data validation will also be conducted during supervisory visits for data submitted from the previous reporting period. The feedback report contains output tables and graphs providing information on national provincial program status. The report may also include any data quality issue findings with the submitted reports or during supervisory visits within the reporting quarter. Supervisory reports from other partners (e.g. World Vision, MSF) should be shared to the National TB program. A supervisory plan will be developed and shared with other partners. NTP will also require partners to submit their supervisory plan in order to have a coordinated plan of visits wherein all BMUs are visited. The integrated supervisory plan should reflect that NCD priority BMUs are visited at least twice every quarter and the other priority BMUs visited at least once every quarter. E. Data dissemination and utilization The main recipients for the TB data are the TB program manager and Provincial Disease Control Officers/TB/Leprosy Officers. Data will be used for policy-making, planning, resource mobilization, partner support and research purposes However, information is available for the stakeholders and general public through annual reports,, technical reports distributed to partners/donors, presentation about NTP during seminars, meetings, international conferences, scientific papers, media appearance and news releases (especially during the activities organized for the World TB Day). 27 P a g e

28 F. M&E Coordination The National TB program, with its lean staff, has to provide technical guidance to 275 Basic Management Units distributed to 22 decentralized provinces. With the government resource limitation, the program appreciates the presence and support of other stakeholders and development partners. In order to manage the various development partners and ensure that all activities are in line with the National Strategic Plan, a Technical Working Group (TWG) was created to provide coordination, oversight, technical advice and technical approval to plans and programmatic activities that will be conducted by different stakeholders and development partners. Annex G (Terms of Reference) provides a more detailed discussion of the role of the TWG. Originally created to monitor Global Fund grants, the TWG now covers all funding donors and development partners relevant to TB implementation. This serves also as avenue to discuss and agree on M&E related matters. The TWG will ensure that a wide consultation process occurs involving all existing and potential stakeholders and constituencies and should be representative of all sectors of society, including government, NGOs, civil society, multilateral and bilateral agencies, the network of people living with TB, key NGOs and activists working on TB prevention, care and treatment and TB/HIV co-infection in vulnerable communities, and the private sector. 13 During TWG meetings partners will be requested to present updates of their activities and accomplishments. A standard template (Annex H) will be used by all partners to ensure consistency of information being reported The Global Fund Grant, specifically the Tuberculosis and Health Systems Strengthening Grant, is a major development and funding partner for the TB program. Through the Grant, additional manpower was provided at each level of the government structure. These encompass interventions/activities to ensure quality of data collected and submitted to the NTP. Management structure of the TB-HSS grant with full description of the coordination between the PR and NTP to ensure data quality is fully discussed in the Performance Monitoring Plan (PMP) of the Primary Recipient of the Global Fund. At the national level, NTP will approve and endorse all tools that will be developed to ensure quality of TB data. G. Evaluation, reviews, survey, surveillance or special studies The external review of TB program will be organised in 2020 to evaluate the strengths and the weaknesses of national TB control efforts through an in depth review of the National TB Control Programme, evaluating progress made in the past six years (since the last joint program review in 2014), in order to identify priority actions for enhanced TB control in PNG. The members of the team which will carry on the review exercise are expected to contribute to the following tasks: 13 Technical Working Group for Tuberculosis, Terms of Reference 28 P a g e

29 Briefing about the review Meetings and interview with relevant National Authorities and health Partners Appraisal of reference documents for the NTP Field visits to two districts of two provinces selected for each of the 4 regions (Southern Coastal (Papuan), Northern Coastal (MoMaSe = Morobe, Madang and Sepik provinces), Highlands, and New Guinea Islands) Presentation of the field visit reports using a standardized format Preparation of the review report with summary findings and recommendations Debriefing to disseminate summary findings and recommendation with the main stakeholders VI. Challenges and Interventions in the present M&E System Epidemiologic and External Review noted gaps and challenges in the present M&E system. These are: Incompletely filled-up, not properly filled-up and not updated registers (TB Suspect Register, TB Register, Laboratory Register, and PMDT Register); Facility staff not trained on the recording and reporting forms for regular TB and MDR-TB; Irregular supervisory visit from the province and central NTP; No supervisory plan developed at the provincial level, only monthly schedules; Supervisory checklist not frequently used during supervisory visit; Inadequate capacity of provincial staff to perform M&E function; Provincial staff performing M&E function are project-based staff; Late BMU reports; number of BMUs reporting varies in each of the reporting period No feedback reports from the province and central on the submitted BMU reports and supervisory visits conducted MDR-TB reporting system not in place. 29 P a g e

30 Strengthening of the present M&E system aims to 1) ensure timely data are available at the national level for policy development and program direction; 2) develop local capacities to secure reliable and complete information that can be used for service delivery and planning. The Technical Initiatives will cover the different levels of the government (Fig. 12). At the facility level, it is important that the quality of data submitted is reliable. On site mentoring and coaching will be done during supervisory visits. Understanding the basic TB indicators would lead to the appreciation of the data collected and its use. The Provincial/ District level are the immediate supervisors of the health facilities. To build the M&E system at the provincial level, the province should develop the skills of a provincial team (project-based staff and government paid staff) who will take on M&E functions. This is to ensure continuity of the activities/functions once project based staff are no longer available. The Central/National level will take on the development/revisions of policies and guidelines needed to provide path/direction to those providing service delivery; establish/refine information system that will effectively collect information/data for decision making; develop other tools/checklist needed in program implementation and provide technical assistance to provinces in performing their monitoring and evaluation functions such as provincial program reviews; data validation workshops and regular updates to enhance their skills. Specific activities are reflected in the Operational Plan (Annex I). 30 P a g e

31 Fig. 10 Technical Initiatives in Strengthening the M and E System Gaps/Problems Interventions BMU reports received have incomplete entries and with quality issues Late BMU reports; no system to track late reports No validation procedures in place Feedback mechanism not in place Quarterly reports consist mainly of output tables and graphs Weak MDRTB recording and reporting system M and E function performed by project staff no sustainability No government position for M and E Late BMU reports and poor quality submitted to the National level Supervisory visit focused mainly in collection of reports Inadequate skills of M and E and provincial staff to perform M and E function No feedback mechanism in place TB registers are incompletely filled-up and with quality issues on accuracy Health Facility staff were confused on how to fill-up the recording and reporting forms No appreciation of TB data and its use Inadequate skills to monitor and oversee treatment supporters/community-based activities Central Provincial Level/ District Level Facility Level (Health Centers/ Hospitals Revision of National Guidelines/Policies to incorporate changes in the recording and reporting tools and flow (both regular and MDR-TB) Establish the MDR-TB recording and reporting system Strengthen supervisory and feedback mechanisms Develop other M and E tools like validation guidelines; post-training monitoring checklist; tracking tools for BMU reports submission Provide TA support to provinces like regional reviews and strategic planning Identifying and forming a provincial team performing M and E function Improve M and E skills of Provincial Team that includes effective supervision; data management and validation; instituting feedback mechanisms, facilitating District planning Develop skills on technical report writing and use of data for advocacy Quarterly meetings/reviews Defining the final list of reporting BMUs Mentoring the facility staff on proper recording and reporting Strengthen superviory skills and provide tools that will assist Health facilities to monitor treatment supporters and community-based initiatives Monthly meetings of treatment supporters and other local partners Data utilization WS Patients Treatment supporters Local partners/ community 31 P a g e

32 Annexes 32 P a g e

33 Annex A Performance Indicator Reference Sheet Impact Indicators: Name of Result Measured: PERFORMANCE INDICATOR REFERENCE SHEET Outcome Indicator TB 1-1: TB Prevalence Rate Name of Indicator: Estimated TB Prevalence rate per 100,000 Precise Definition: Unit of Measure: Rate per 100,000 Disaggregated By: Rationale or Justification for indicator (optional): Data Source(s) Method of Data Collection and Construction Time/Frequency of Data Acquisition Responsible Individual DESCRIPTION Estimated number of cases of tuberculosis (all forms) in a population at a given point in time expressed as the rate per 100,000 populations. Estimates include cases of TB in people with HIV. Numerator: Number of TB cases at a given point in time Denominator: Estimated population No disaggregation The prevalence of TB determines the risk of TB infection in a community (how much transmission is occurring). Improved case finding and treatment both shorten the duration of the disease, so prevalence responds more rapidly than incidence to changes in TB control. Periodic assessment of the prevalence of TB disease can be more useful for measuring the short term impact of TB control than efforts to measure changes in TB incidence. 14 PLAN FOR DATA ACQUISITION WHO estimates of TB prevalence Based on the number of cases notified at the National TB program through the BMU reports submitted by the province quarterly Annual National M&E Officer; WHO TB Program Officer PLAN FOR DATA ANALYSIS, REVIEW AND REPORTING Data Analysis: Presentation of Data Review of Data Reporting of Data Known Data Limitations: Annually Line Graph showing national trend TB Program Manager; WHO TB Program Officer Annual Reporting DATA QUALITY ISSUES Proper diagnosis and typing of cases BMU reports submitted late to the National TB program 14 TB Impact Measurement: Policy and Recommendations for how to assess the epidemiologic burden of TB and Impact of TB Control; WHO 2009, p P a g e

34 Actions Taken or Planned to Address Data Limitations Train and mentor TB clinic officers Data validation Providing feedback to provinces on the data submitted at the National level THIS SHEET LAST UPDATED ON: August P a g e

35 Name of Result Measured: Name of Indicator: Precise Definition: PERFORMANCE INDICATOR REFERENCE SHEET Outcome Indicator TB 1-3: TB Mortality Rate Estimated TB mortality rate Unit of Measure: Rate per 100,000 Disaggregated By: Rationale or Justification for indicator (optional): Data Source(s) DESCRIPTION Estimated number of deaths attributable to tuberculosis (TB) in a given year, expressed as a rate per 100,000 populations Numerator: Number of deaths caused by TB (all forms) in HIV negative people/year Denominator: Estimated population No disaggregation TB mortality usually be reduced more quickly than TB incidence because drug treatment reduces not only transmission but also case fatality. Increases in case detection and treatment success rate should reduce TB incidence, prevalence and mortality because 1) the average duration of infectiousness should fall; and 2) the proportion of cases dying should decrease. The grater the effect on the duration of infectiousness and the greater the reduction in the risk of dying on treatment, the greater will be the combined effect on TB mortality. 15 PLAN FOR DATA ACQUISITION WHO estimates of TB prevalence Method of Data Collection and Construction Time/Frequency of Data Acquisition Responsible Individual Based on the number of cases notified at the National TB program through the BMU reports submitted by the province quarterly Annual National M&E Officer; WHO TB Program Officer PLAN FOR DATA ANALYSIS, REVIEW AND REPORTING Data Analysis: Presentation of Data Review of Data Reporting of Data Known Data Limitations: Actions Taken or Planned to Address Data Limitations Annually Line Graph showing national trend TB Program Manager; WHO TB Program Officer Annual Reporting DATA QUALITY ISSUES Proper diagnosis and typing of cases BMU reports submitted late to the National TB program Train and mentor TB clinic officers Data validation Providing feedback to provinces on the data submitted at the National level THIS SHEET LAST UPDATED ON: August TB Impact Measurement: Policy and Recommendations for how to assess the epidemiologic burden of TB and Impact of TB Control; WHO 2009, pp P a g e

36 Outcome Indicators Name of Result Measured: Name of Indicator: Precise Definition: PERFORMANCE INDICATOR REFERENCE SHEET Outcome Indicator TB 0-1a Unit of Measure: Rate per 100,000 Disaggregated By: Rationale or Justification for indicator (optional): Data Source(s) Case Notification Rate (CNR), all forms DESCRIPTION TB Case Notification Rate (CNR) is the proportion of all forms of TB (new bacteriologically confirmed; new clinically diagnose cases; plus relapse) notified to NDOH NTP. Numerator: No. of TB cases (all forms) reported to the NDOH. Denominator: Total population of the area (National/provinces) Can be disaggregated by province CNR is the measure of the number of priority TB cases registered under DOTS in each province. If compared with the rate of the previous year, an increasing CNR trend implies improved capacity of the government and private sector to make quality DOTS services accessible and also points to better health seeking behaviour of the communities. PLAN FOR DATA ACQUISITION Recording and Reporting TB System (BMU Reports) Method of Data Collection and Construction Time/Frequency of Data Acquisition Responsible Individual Review and consolidation of validated quarterly BMU reports of pulmonary (new smear positive, new smear negative, new registered cases with sputum not done/not available), relapse and extra-pulmonary TB cases submitted to PHO or DHO. Quarterly Regional Coordinator; National M&E Coordinator PLAN FOR DATA ANALYSIS, REVIEW AND REPORTING Data Analysis: Presentation of Data Review of Data Reporting of Data Known Data Limitations: Actions Taken or Planned to Address Data Limitations Annually Tables/Line Graph showing national/provincial trend TB Program Manager; M&E Advisor; Grant Compliance Manager and National M&E Coordinator Annual Reporting DATA QUALITY ISSUES Number of BMUs submitting quarterly reports fluctuates across reporting periods Proper diagnosis and typing of cases Data quality needs to be consistent for comparability Provinces finalize list of reporting BMUs by sending official communication to NTP Manager Train and mentor TB clinic officers Data validation 36 P a g e

37 Targets and Accomplishments Year Targets Actual Comments FY 2015 (Yr 1) 336/100,000 FY 2016 (Yr 2) 327/100,000 FY 2017 (Yr 3) 318/100,000 FY 2018 (Yr 4) 309/100,000 FY 2019 (Yr 5) 300/100,000 FY 2020 (Yr 6) 297/100,000 Cumulative Total THIS SHEET LAST UPDATED ON: August P a g e

38 Name of Result Measured: Name of Indicator: Precise Definition: PERFORMANCE INDICATOR REFERENCE SHEET Outcome Indicator: TB O-1b Unit of Measure: Rate per 100,000 Disaggregated By: Rationale or Justification for indicator (optional): Data Source(s) Case Notification Rate (CNR), bacteriologically confirmed new and relapse cases DESCRIPTION Notification Rate of bacteriologically confirmed cases is the proportion of all new bacteriologically confirmed (microscopy, culture, genexpert) TB cases reported by the BMU facilities per 100,000 population. Numerator: No. of new bacteriologically confirmed TB cases notified to the NDOH. Denominator: Total population of the country/province Can be disaggregated by province Case Notification Rate (expressed as per 100,000 population) of bacteriologically confirmed cases (new plus relapse cases) reported to the NTP-NDOH per year per 100,000 population. It is a direct measure of the program's capacity to detect infectious TB cases in the area. PLAN FOR DATA ACQUISITION Recording and Reporting TB System (BMU Reports) Method of Data Collection and Construction Time/Frequency of Data Acquisition Responsible Individual Review and consolidation of validated quarterly BMU reports of bacteriologically confirmed Tb cases TB cases submitted to PHO or DHO by the reporting health facility (BMUs). Quarterly Regional Coordinator; National M&E Coordinator PLAN FOR DATA ANALYSIS, REVIEW AND REPORTING Data Analysis: Presentation of Data Review of Data Reporting of Data Known Data Limitations: Actions Taken or Planned to Address Data Limitations Annually Tables/Line Graph showing national/provincial trend TB Program Manager; M&E Advisor; Grant Compliance Manager and National M&E Coordinator Annual Reporting DATA QUALITY ISSUES Number of BMUs submitting quarterly reports fluctuates across reporting periods Bacteriologically confirmed cases refer mostly to positive smear microscopy. National guidelines refer to smear microscopy as the primary diagnostic method for TB. The indicator maybe affected by the availability of microscopy services and clinicians conforming to the national guidelines in the diagnosis of TB. Data quality needs to be consistent for comparability Provinces finalize list of reporting BMUs by sending official communication to NTP Manager Train and mentor TB clinicians Data validation Targets and Accomplishments 38 P a g e

39 Year Target Actual Comments FY 2015 (Yr 1) 63/100,000 FY 2016 (Yr 2) 73/100,000 FY 2017 (Yr 3) 81/100,000 FY 2018 (Yr 4) 85/100,000 FY 2019 (Yr 5) 89/100,000 FY 2020 (Yr 6) 93/100,000 Cumulative Total THIS SHEET LAST UPDATED ON: August P a g e

40 PERFORMANCE INDICATOR REFERENCE SHEET Name of Result Measured: Name of Indicator: Precise Definition: Unit of Measure: Disaggregated By: Rationale or Justification for indicator (optional): Data Source(s) Method of Data Collection and Construction Time/Frequency of Data Acquisition Responsible Individual Outcome Indicator: TB O-2a Treatment Success Rate, All forms DESCRIPTION Proportion of all forms TB cases that were cured and completed treatment among the all forms of TB Percentage Can be disaggregated by province If compared with the rate of the previous year, an increasing trend implies improved capacity of the facility to hold patients until completion of treatment and follow-up smear microscopy shows sputum conversion. PLAN FOR DATA ACQUISITION Recording and Reporting TB System (BMU Reports) Review and consolidation of validated quarterly BMU reports on treatment outcomes of all forms of Tb submitted to PHO or DHO by the reporting health facility (BMUs). Quarterly Provincial Coordinator; Regional Coordinators; National M&E Coordinator PLAN FOR DATA ANALYSIS, REVIEW AND REPORTING Data Analysis: Presentation of Data Review of Data Reporting of Data Known Data Limitations: Actions Taken or Planned to Address Data Limitations Quarterly; annually Tables/Graph showing national/provincial trend TB Program Manager; M&E Advisor; Grant Compliance Manager and National M&E Coordinator Semi-annual Reporting DATA QUALITY ISSUES Incorrect cohort being evaluated Present BMU reporting has no consolidation of outcomes for all forms TB patients Revision of BMU reporting forms Data validation Targets and Accomplishments Year Target Actual Comments FY 2015 (Yr 1) 62% FY 2016 (Yr 2) 70% FY 2017 (Yr 3) 77% FY 2018 (Yr 4) 79% 40 P a g e

41 FY 2019 (Yr 5) 81% FY 2020 (Yr 6) 83% Cumulative Total THIS SHEET LAST UPDATED ON: August P a g e

42 PERFORMANCE INDICATOR REFERENCE SHEET Name of Result Measured: Name of Indicator: Precise Definition: Unit of Measure: Disaggregated By: Rationale or Justification for indicator (optional): Data Source(s) Method of Data Collection and Construction Time/Frequency of Data Acquisition Responsible Individual Outcome Indicator: TB O-2b Treatment Success Rate, Bacteriologically confirmed DESCRIPTION Proportion of bacteriologically confirmed TB cases that were cured and completed treatment among the bacteriologically confirmed cases registered for treatment during the same reporting period Numerator: Total number of bacteriologically confirmed new TB cases successfully treated (cured plus treatment completed) Denominator: Total bacteriologically confirmed new TB cases registered during the same reporting period Percentage Can be disaggregated by province If compared with the rate of the previous year, an increasing trend implies improved capacity of the facility to hold patients until completion of treatment and follow-up smear microscopy shows sputum conversion. PLAN FOR DATA ACQUISITION Recording and Reporting TB System (BMU Reports) Review and consolidation of validated quarterly BMU reports on treatment outcomes of bacteriologically confirmed new Tb cases submitted to PHO or DHO by the reporting health facility (BMUs). Quarterly Provincial M&E Coordinator; National M&E Coordinator PLAN FOR DATA ANALYSIS, REVIEW AND REPORTING Data Analysis: Presentation of Data Review of Data Reporting of Data Known Data Limitations: Actions Taken or Planned to Address Data Limitations Quarterly; annually Tables/Graph showing national/provincial trend TB Program Manager; M&E Advisor; Grant Compliance Manager and National M&E Coordinator Semi-annual Reporting DATA QUALITY ISSUES Incorrect cohort being evaluated Data validation Targets and Accomplishments Year Target Actual Comments FY 2015 (Yr 1) 72% 42 P a g e

43 FY 2016 (Yr 2) 77% FY 2017 (Yr 3) 81% FY 2018 (Yr 4) 83% FY 2019 (Yr 5) 86% FY 2020 (Yr 6) 88% Cumulative Total THIS SHEET LAST UPDATED ON: August P a g e

44 PERFORMANCE INDICATOR REFERENCE SHEET Name of Result Measured: Name of Indicator: Precise Definition: Unit of Measure: Disaggregated By: Rationale or Justification for indicator (optional): Data Source(s) Method of Data Collection and Construction Time/Frequency of Data Acquisition Responsible Individual Outcome Indicator: TB-04 Treatment success rate of MDR-TB: Percentage of bacteriologically confirmed drugresistant TB cases (RR-TB and/or MDR-TB) started on prescribed MDR-TB treatment regimen who were cured and/or completed treatment DESCRIPTION Proportion of bacteriologically confirmed RR-TB by Expert and/or MDR-TB by conventional DST cases that were cured and completed treatment during the period of assessment Numerator: Number of cases with drug-resistant TB (RR-TB and/or MDR-TB) cases registered and started on a prescribed MDR-TB treatment who were cured and completed treatment Denominator: Total number of confirmed RR-TB by Xpert and/or MDR-TB by conventional DST patients registered and started on SLD treatment on the same period of assessment Percentage Can be disaggregated by province It is a direct measure of the program's capacity to successfully treat RR-TB and/or MDR-TB patients using the prescribed second line treatment regimen. The program should be able to document that these patients have completed treatment as prescribed by the national guidelines anchored on WHO guidelines. PLAN FOR DATA ACQUISITION PMDT Register; PMDT Final Outcome report Review and consolidation of validated PMDT Final Outcome reports of confirmed RR-TB and MDRTB cases submitted to NTP-NDOH by the reporting PMDT facility. Annually: Timing would be 2 years and 3 months after the end of the cohort, e.g., Jan-Jun 2014 cohort will be report Oct 2016, then every Oct yearly. Provincial PMDT Coordinator; National PMDT Coordinator PLAN FOR DATA ANALYSIS, REVIEW AND REPORTING Data Analysis: Presentation of Data Review of Data Reporting of Data Known Data Limitations: Annually Tables/Line Graph showing national/provincial trend TB Program Manager; M&E Advisor; Grant Compliance Manager and National PMDT Coordinator, National PMDT Committee Annual Reporting DATA QUALITY ISSUES PMDT recording and reporting tools are still being pre-tested PMDT provincial clinical committee not yet established Existing practice of some PMDT sites to start SLD treatment but registration in the PMDT register is delayed until DST result is available leading to delayed registration date 44 P a g e

45 Actions Taken or Planned to Address Data Limitations Finalization of revised PMDT Guidelines defining clearly recording and reporting guidelines Training of PMDT facility staff on recording and reporting Continuous mentoring and coaching; Data validation Targets and Accomplishments Year Target Actual Comments FY 2015 (Yr 1) 35% FY 2016 (Yr 2) 40% FY 2017 (Yr 3) 45% FY 2018 (Yr 4) 50% FY 2019 (Yr 5) 55% FY 2020 (Yr 6) 60% Cumulative Total THIS SHEET LAST UPDATED ON: August P a g e

46 PERFORMANCE INDICATOR REFERENCE SHEET Name of Result Measured: Name of Indicator: Precise Definition: Unit of Measure: Disaggregated By: Rationale or Justification for indicator (optional): Data Source(s) Method of Data Collection and Construction Time/Frequency of Data Acquisition Responsible Individual DOTS 5 Number of children <5 in contact with TB patients who began IPT DESCRIPTION Number of children less than 5 years of age with history of contact with TB patients but with no sign and symptoms of active TB disease who was started on IPT in the said reporting period Number of cases Can be disaggregated by sex; province It may reflect the strength of the contact tracing process of the health facility. It may also measure the TB program capacity to provide services to vulnerable groups (under-five children exposed to TB disease); drug availability and capacity of health care providers to encourage families on the benefits of IPT. PLAN FOR DATA ACQUISITION Data capture form will be used as temporary reporting form until NTP has revised the BMU reporting form to include this indicator The information will be reported using the data capture form together with other process indicators that will be collected by the PR. Temporary recording form will be discussed with NTP to be the source document for this indicator. Quarterly Regional Coordinators; National M&E Coordinator PLAN FOR DATA ANALYSIS, REVIEW AND REPORTING Data Analysis: Presentation of Data Review of Data Reporting of Data Known Data Limitations: Actions Taken or Planned to Address Data Limitations Quarterly; annually Tables/Graph showing national/provincial trend TB Program Manager; M&E Advisor; Grant Compliance Manager and National M&E Coordinator Semi-annual Reporting DATA QUALITY ISSUES No existing recording and reporting form Health staff in TB clinics not familiar in reporting this information Data capture form as temporary reporting form Continuous supervision and caching during field visits Data validation Targets and Accomplishments Year Target Actual Comments FY 2015 (Yr 1) 1,306 FY 2016 (Yr 2) 1, P a g e

47 FY 2017 (Yr 3) 2,012 FY 2018 (Yr 4) 2,456 FY 2019 (Yr 5) 2,974 FY 2020 (Yr 6) 3,576 Cumulative Total THIS SHEET LAST UPDATED ON: August P a g e

48 PERFORMANCE INDICATOR REFERENCE SHEET Name of Result Measured: Name of Indicator: Precise Definition: Unit of Measure: Disaggregated By: Rationale or Justification for indicator (optional): Data Source(s) Method of Data Collection and Construction Time/Frequency of Data Acquisition Responsible Individual Output Indicator: TB DOTS 3 Percentage of laboratories showing adequate performance in external quality assurance for smear microscopy DESCRIPTION Proportion of laboratories showing adequate performance (no major error) in external quality assurance for smear microscopy among the total number of laboratories that undertake smear microscopy for the said reporting period. Numerator: Number of laboratories showing adequate performance for smear microscopy Denominator: Total number of laboratories undertaking smear microscopy Percentage No disaggregation It may measure the program s quality assurance system to ensure quality diagnosis services are available in any part of the country. CPHL EQA report PLAN FOR DATA ACQUISITION CPHL submits a summary report that includes name of smear microscopy laboratories who submitted slides for EQA; number of slides submitted; to the PR on a quarterly basis. Quarterly Regional Coordinators; National M&E Coordinator PLAN FOR DATA ANALYSIS, REVIEW AND REPORTING Data Analysis: Presentation of Data Review of Data Reporting of Data Known Data Limitations: Actions Taken or Planned to Address Data Limitations Quarterly; annually Tables/Graph showing national/provincial trend TB Program Manager; M&E Advisor; Grant Compliance Manager and National M&E Coordinator Semi-annual Reporting DATA QUALITY ISSUES The time for collection of slides and EQA testing is not in line with the timeline of TB reporting and GF reporting. Thus it affects the number of smear microscopy laboratories who have submitted slides for EQA at the time GF report is due. The number of smear microscopy laboratories participating in EQA activities is still low compared to the total number of functional smear microscopy laboratories. Request GF for a change in the timeline of report Coordinate with CPHL to discuss solution to increase the number of smear microscopy laboratories participating in EQA Continuous supervision Targets and Accomplishments 48 P a g e

49 Year Target Actual Comments FY 2015 (Yr 1) 52% FY 2016 (Yr 2) 57% FY 2017 (Yr 3) 62% FY 2018 (Yr 4) 67% FY 2019 (Yr 5) 72% FY 2020 (Yr 6) 77% Cumulative Total THIS SHEET LAST UPDATED ON: August P a g e

50 PERFORMANCE INDICATOR REFERENCE SHEET Name of Result Measured: Name of Indicator: Precise Definition: Unit of Measure: Disaggregated By: Rationale or Justification for indicator (optional): Data Source(s) Method of Data Collection and Construction Time/Frequency of Data Acquisition Responsible Individual Output Indicator: DOTS Other 1 Loss to follow-up rate among all new bacteriologically confirmed TB cases DESCRIPTION Proportion of bacteriologically confirmed TB cases that whose treatment was interrupted for 2 months or more among the bacteriologically confirmed cases registered for treatment during the cohort period Numerator: Total number of bacteriologically confirmed new TB cases whose treatment was interrupted for 2 months or more Denominator: Total bacteriologically confirmed new TB cases registered during the same cohort period Rate Can be disaggregated by province If compared with the rate of the previous year, an increasing trend implies failure of the facility to hold patients until completion of treatment. PLAN FOR DATA ACQUISITION Recording and Reporting TB System (BMU Reports) Review and consolidation of validated quarterly BMU reports on treatment outcomes of all forms of Tb submitted to PHO or DHO by the reporting health facility (BMUs). Quarterly Provincial Coordinator; Regional Coordinators; National M&E Coordinator PLAN FOR DATA ANALYSIS, REVIEW AND REPORTING Data Analysis: Presentation of Data Review of Data Reporting of Data Known Data Limitations: Actions Taken or Planned to Address Data Limitations Quarterly; annually Tables/Graph showing national/provincial trend TB Program Manager; M&E Advisor; Grant Compliance Manager and National M&E Coordinator Semi-annual Reporting DATA QUALITY ISSUES Incorrect cohort being evaluated Data validation Targets and Accomplishments Year Target Actual Comments FY 2015 (Yr 1) 16% FY 2016 (Yr 2) 12% 50 P a g e

51 FY 2017 (Yr 3) 7% FY 2018 (Yr 4) 5% FY 2019 (Yr 5) 3% FY 2020 (Yr 6) 3% Cumulative Total THIS SHEET LAST UPDATED ON: August] P a g e

52 PERFORMANCE INDICATOR REFERENCE SHEET Name of Result Measured: Name of Indicator: Precise Definition: Unit of Measure: Disaggregated By: Rationale or Justification for indicator (optional): Data Source(s) Method of Data Collection and Construction Time/Frequency of Data Acquisition Responsible Individual Output Indicator: DOTS Other 2 Smear Not Done Rate among new pulmonary Adult B cases DESCRIPTION Proportion of Smear Not Done TB cases among new pulmonary adult TB cases Numerator: Total number of smear not done TB cases Denominator: Total number of new adult pulmonary cases of the same cohort period Rate Can be disaggregated by province An increasing trend may reflect availability or accessibility problem of smear microscopy services; failure of health worker to counsel patient properly to submit sputum samples before enrolment to treatment. PLAN FOR DATA ACQUISITION Recording and Reporting TB System (BMU Reports) Review and consolidation of validated quarterly BMU reports on treatment outcomes of all forms of Tb submitted to PHO or DHO by the reporting health facility (BMUs). Quarterly Provincial Coordinator; Regional Coordinators; National M&E Coordinator PLAN FOR DATA ANALYSIS, REVIEW AND REPORTING Data Analysis: Presentation of Data Review of Data Reporting of Data Known Data Limitations: Actions Taken or Planned to Address Data Limitations Quarterly; annually Tables/Graph showing national/provincial trend TB Program Manager; M&E Advisor; Grant Compliance Manager and National M&E Coordinator Semi-annual Reporting DATA QUALITY ISSUES Inconsistencies of data across the different registers Data validation Targets and Accomplishments Year Target Actual Comments FY 2015 (Yr 1) 43% FY 2016 (Yr 2) 39% FY 2017 (Yr 3) 34% 52 P a g e

53 FY 2018 (Yr 4) 31% FY 2019 (Yr 5) 28% FY 2020 (Yr 6) 25% Cumulative Total THIS SHEET LAST UPDATED ON: Augus P a g e

54 PERFORMANCE INDICATOR REFERENCE SHEET Name of Result Measured: Name of Indicator: Precise Definition: Unit of Measure: Disaggregated By: Rationale or Justification for indicator (optional): Outcome Indicator: MDR TB -1 MDR TB-1: Percentage of previously treated TB patients receiving DST DESCRIPTION It is the proportion of culture confirmed previously treated TB patients that had conventional DST for H and R. Numerator: Number of previously treated TB cases with DST done result for both isoniazid and rifampicin during the period of assessment Denominator: Total number of culture positive previously treated TB patients identified during the period of assessment. Percentage Can be disaggregated by province Groups to be targeted for DST vary by national policy, but WHO generally recommends DST for all previously treated patients and contacts of MDR-TB cases. This indicator is limited to the number of previously treated patients only on whom DST is done. PLAN FOR DATA ACQUISITION Data Source(s) Method of Data Collection and Construction Time/Frequency of Data Acquisition Responsible Individual Data Analysis: Presentation of Data Review of Data Reporting of Data Known Data Limitations: Presumptive DR-TB Register; PMDT Detection report Facility PMDT trained staff should count the number of previously treated patients registered in the Presumptive DR-TB Register during the period of assessment. Next she will count how many among them were culture-positive. And finally she will count from the culture positives those who had conventional DST done for H and R. The suggested period of assessment is six calendar months. This is usually counted from January to end June and July to end December. Indicators are measured three months after the end of the six-month period. There will be a six month time lag in reporting results from the end of a six monthly cohort. Provincial PMDT Coordinator for facility reporting; National PMDT Coordinator for consolidation PLAN FOR DATA ANALYSIS, REVIEW AND REPORTING Semi-annually Tables/Line Graph showing national/provincial trend TB Program Manager; M&E Advisor; Grant Compliance Manager and National PMDT Coordinator, National PMDT Committee Semi-annual Reporting DATA QUALITY ISSUES PMDT recording and reporting tools are still being pre-tested Delay in the availability of culture and DST results PMDT cohort is longer than DS cohort and more difficult to analyse. Facility staff needs training on R and R 54 P a g e

55 Actions Taken or Planned to Address Data Limitations Training of PMDT facility staff on recording and reporting Continuous mentoring and coaching Data validation Targets and Accomplishments Year Target Actual Comments FY 2015 (Yr 1) 41% FY 2016 (Yr 2) 52% FY 2017 (Yr 3) 63% FY 2018 (Yr 4) 74% FY 2019 (Yr 5) 85% FY 2020 (Yr 6) 96% Cumulative Total THIS SHEET LAST UPDATED ON: April P a g e

56 PERFORMANCE INDICATOR REFERENCE SHEET Name of Result Measured: Name of Indicator: Precise Definition: Unit of Measure: Disaggregated By: Rationale or Justification for indicator (optional): Data Source(s) Method of Data Collection and Construction Time/Frequency of Data Acquisition Responsible Individual Outcome Indicator: MDR TB-2 Number of bacteriologically confirmed, drug- resistant TB cases (RR-TB and/or MDR- TB) detected DESCRIPTION Number of confirmed RR-TB cases and/or MDRTB cases (with culture and DST results) reported by the PMDT facilities (from high burden provinces) to NTP-DOH during the period of assessment Number of cases Can be disaggregated by province It is a direct measure of the size of RR and/or MDR-TB cases in the area (province and country). PLAN FOR DATA ACQUISITION Presumptive DR-TB Register; PMDT Detection report Review and consolidation of validated PMDT detection reports of confirmed RR by Xpert and/ or MDRTB cases by conventional DST submitted to NTP by the reporting PMDT facilities Data collection for this indicator may be done right after the end of the cohort and reported during the next reporting period, e.g., Jan-Jun cohort reported in Oct of the same year; Jul-Dec reported in Apr of the following year. Semi-annually Provincial PMDT Coordinator; National PMDT Coordinator PLAN FOR DATA ANALYSIS, REVIEW AND REPORTING Data Analysis: Presentation of Data Review of Data Reporting of Data Known Data Limitations: Actions Taken or Planned to Address Data Limitations Semi-annually Tables/Line Graph showing national/provincial trend TB Program Manager; M&E Advisor; Grant Compliance Manager and National PMDT Coordinator, National PMDT Committee Semi-annual Reporting DATA QUALITY ISSUES PMDT recording and reporting tools are still being pre-tested Delay in the availability of culture and DST results Xpert and DST results will be available at different periods of time and there is a possibility of double-reporting. Training of PMDT facility staff on recording and reporting Pre-testing of forms Continuous mentoring and coaching Data validation Targets and Accomplishments Year Target Actual Comments FY 2015 (Yr 1) P a g e

57 FY 2016 (Yr 2) 209 FY 2017 (Yr 3) 293 FY 2018 (Yr 4) 388 FY 2019 (Yr 5) 496 FY 2020 (Yr 6) 639 Cumulative Total THIS SHEET LAST UPDATED ON: August P a g e

58 PERFORMANCE INDICATOR REFERENCE SHEET Name of Result Measured: Name of Indicator: Precise Definition: Unit of Measure: Disaggregated By: Rationale or Justification for indicator (optional): Data Source(s) Method of Data Collection and Construction Time/Frequency of Data Acquisition Responsible Individual Outcome Indicator: MDR TB-3 Number of cases with drug-resistant TB (RR-TB and/or MDR-TB) that began secondline treatment DESCRIPTION Number of cases with drug-resistant TB (RR-TB and/or MDR-TB) registered and started on a prescribed MDR-TB treatment regimen during the period of assessment Number of cases Can be disaggregated by province It is a direct measure of the program's capacity to enrol TB patients to prescribed second line treatment regimen once detected as RR-TB and/or MDR-TB cases. PLAN FOR DATA ACQUISITION PMDT Register; PMDT Enrolment report Review and consolidation of validated PMDT Enrolment reports of confirmed RR-TB and MDRTB cases submitted to NTP-NDOH by the reporting PMDT facility. Data collection for this indicator may be done right after the end of the cohort and reported during the next reporting period. Semi-annually Provincial PMDT Coordinator; National PMDT Coordinator PLAN FOR DATA ANALYSIS, REVIEW AND REPORTING Data Analysis: Presentation of Data Review of Data Reporting of Data Known Data Limitations: Actions Taken or Planned to Address Data Limitations Semi-annually Tables/Line Graph showing national/provincial trend TB Program Manager; M&E Advisor; Grant Compliance Manager and National PMDT Coordinator, National PMDT Committee Semi-annual Reporting DATA QUALITY ISSUES PMDT recording and reporting tools are still being pre-tested PMDT provincial clinical committee not yet established Existing practice of some PMDT sites to start SLD treatment but registration in the PMDT register is delayed until DST result is available leading to delayed registration date Finalization of revised PMDT Guidelines defining clearly recording and reporting guidelines Training of PMDT facility staff on recording and reporting Continuous mentoring and coaching Data validation Targets and Accomplishments Year Target Actual Comments FY 2015 (Yr 1) P a g e

59 FY 2016 (Yr 2) 188 FY 2017 (Yr 3) 263 FY 2018 (Yr 4) 349 FY 2019 (Yr 5) 447 FY 2020 (Yr 6) 575 Cumulative Total THIS SHEET LAST UPDATED ON: August P a g e

60 PERFORMANCE INDICATOR REFERENCE SHEET Name of Result Measured: Name of Indicator: Precise Definition: Unit of Measure: Disaggregated By: Rationale or Justification for indicator (optional): Data Source(s) Method of Data Collection and Construction Time/Frequency of Data Acquisition Responsible Individual Outcome Indicator: MDR TB-4 Percentage of cases with drug-resistant TB (RR-TB and/or MDR-TB) started on treatment for MDR-TB who were lost to follow up during the first six months of treatment DESCRIPTION Proportion of bacteriologically confirmed RR-TB and/or MDR-TB cases who were lost to follow-up during the first six months of treatment among all RR-TB and/or MDRTB cases enrolled on treatment during the period of assessment Numerator: Number of cases with drug-resistant TB (RR-TB and/or MDR-TB) registered and started on a prescribed MDR-TB treatment who were lost to followup during the first six months of treatment Denominator: Total number of RR-TB and/or MDR-TB patients registered and enrolled on the same period of assessment. The denominator also includes XDR-TB cases started on prescribed treatment with second-line drugs. Percentage Can be disaggregated by province Lost to follow up refers to treatment interruption for two or more consecutive months for any reason without medical approval. Treatment regimen for MDR-TB usually takes 20 months or more. The final outcomes can only be assessed two to three years after the treatment enrolment date. However, in order for the programme manager gain some information on the proportion of interrupting patients from the prescribed treatment regimen, he needs an indication of how patients are faring even before completion of the course regimen PLAN FOR DATA ACQUISITION PMDT Register; PMDT Interim Outcome report Review and consolidation of validated PMDT Interim Outcome reports of confirmed RR-TB and MDRTB cases submitted to NTP-NDOH by the reporting PMDT facility. All laboratory confirmed RR-TB and MDR-TB patients registered and had started treatment during the period of assessment will be counted for reporting of Interim Results. The suggested period of assessment is six calendar months. This is usually counted from January to end June and July to end December. Indicators are measured three months after the end of the six-month period. There will be a six month time lag in reporting results from the end of a six monthly cohort. Timing would be at least 6 months after the end of the cohort, e.g., Jan-Jun 2014 cohort may be reported any time after June of the same year. Semi-annually Provincial PMDT Coordinator; National PMDT Coordinator PLAN FOR DATA ANALYSIS, REVIEW AND REPORTING Data Analysis: Presentation of Data Semi-annually Tables/Line Graph showing national/provincial trend 60 P a g e

61 Review of Data Reporting of Data Known Data Limitations: Actions Taken or Planned to Address Data Limitations TB Program Manager; M&E Advisor; Grant Compliance Manager and National PMDT Coordinator, National PMDT Committee Semi-annual Reporting DATA QUALITY ISSUES PMDT recording and reporting tools are still being pre-tested PMDT provincial clinical committee not yet established Existing practice of some PMDT sites to start SLD treatment but registration in the PMDT register is delayed until DST result is available leading to delayed registration date Finalization of revised PMDT Guidelines defining clearly recording and reporting guidelines Training of PMDT facility staff on recording and reporting Continuous mentoring and coaching Data validation Targets and Accomplishments Year Target Actual Comments FY 2015 (Yr 1) 46% FY 2016 (Yr 2) 42% FY 2017 (Yr 3) 38% FY 2018 (Yr 4) 34% FY 2019 (Yr 5) 30% FY 2020 (Yr 6) 26% Cumulative Total THIS SHEET LAST UPDATED ON: August P a g e

62 PERFORMANCE INDICATOR REFERENCE SHEET Name of Result Measured: Name of Indicator: Precise Definition: Unit of Measure: Disaggregated By: Rationale or Justification for indicator (optional): Data Source(s) Method of Data Collection and Construction Time/Frequency of Data Acquisition Responsible Individual Outcome Indicator: TB-HIV 1 Percentage of TB patients who had an HIV test result recorded in the TB register DESCRIPTION Proportion of TB patients who had an HIV test result recorded in the TB register among all TB patients registered during the reporting period. Numerator: Number of TB patients registered during the reporting period who had an HIV test result recorded in the TB register at the time of TB diagnosis Denominator: Total number of TB patients registered during the reporting period Percentage Can be disaggregated by province This indicator measures the ability of TB program to determine the HIV status of people with TB. A high proportion of TB patients with HIV status detected will provide a sufficiently solid estimate of the true HIV prevalence among TB patients for surveillance purposes. TB Register; BMU report PLAN FOR DATA ACQUISITION Review and consolidation of validated BMU reports submitted to NTP-NDOH by the provinces. The number of TB patients tested and with positive results will be obtained from the TB register of each health facility. The national guideline directs health staff to test all TB patients for HIV and results be recorded in the TB register. Quarterly Regional Coordinator; National TB-HIV M&E Officer PLAN FOR DATA ANALYSIS, REVIEW AND REPORTING Data Analysis: Presentation of Data Review of Data Reporting of Data Known Data Limitations: Actions Taken or Planned to Address Data Limitations Quarterly Tables/Line Graph showing national/provincial trend TB Program Manager; M&E Advisor; Grant Compliance Manager; National TB-HIV Coordinator Semi-annual Reporting DATA QUALITY ISSUES At the health facility level, not all TB patients are being referred for HIV testing. Not all TB clinics have HIV testing sites within the proximity of the health facility. Thus status of patients referred may not be recorded in the TB register. Reiteration of the national guidelines among the health staff in the TB clinics Strengthen the referral system between the TB clinics and HIV testing sites Continuous supervision Data validation Targets and Accomplishments Year Target Actual Comments 62 P a g e

63 FY 2015 (Yr 1) 41% FY 2016 (Yr 2) 51% FY 2017 (Yr 3) 61% FY 2018 (Yr 4) 71% FY 2019 (Yr 5) 81% FY 2020 (Yr 6) 91% Cumulative Total THIS SHEET LAST UPDATED ON: August P a g e

64 PERFORMANCE INDICATOR REFERENCE SHEET Name of Result Measured: Name of Indicator: Precise Definition: Unit of Measure: Disaggregated By: Rationale or Justification for indicator (optional): Data Source(s) Method of Data Collection and Construction Time/Frequency of Data Acquisition Responsible Individual Outcome Indicator: TB-HIV 2 Percentage of HIV-positive registered TB patients given anti-retroviral therapy (ART) during TB treatment DESCRIPTION Proportion of HIV positive TB patients registered provided with ART among all HIV positive TB patients registered during the reporting period. Numerator: Number of HIV positive TB patients given ART during the reporting period who had an HIV test result recorded in the TB register Denominator: Total number of HIV positive TB patients registered during the same reporting period Percentage Can be disaggregated by province This indicator measures the ability of TB and HIV program to collaborate in providing services for vulnerable groups. A high proportion of HIV positive TB patients provided with ART within the period of its diagnosis reflects the quality of services and coordination between the two programs. TB Register; BMU report PLAN FOR DATA ACQUISITION Review and consolidation of validated BMU reports submitted to NTP-NDOH by the provinces. The number of TB patients tested and with positive results will be obtained from the TB register of each health facility. The national guideline directs health staff to test all TB patients for HIV and results be recorded in the TB register. HIV positive TB patients should be referred to HIV treatment centers for evaluation and enrollment to ART. Quarterly Regional Coordinator; National TB-HIV M&E Officer PLAN FOR DATA ANALYSIS, REVIEW AND REPORTING Data Analysis: Presentation of Data Review of Data Reporting of Data Known Data Limitations: Quarterly Tables/Line Graph showing national/provincial trend TB Program Manager; M&E Advisor; Grant Compliance Manager; National TB-HIV Coordinator Semi-annual Reporting DATA QUALITY ISSUES At the health facility level, not all TB patients are being referred for HIV testing. Not all TB clinics have HIV treatment clinics within the proximity of the health facility. The number of TB patients given ART in some facilities includes both the TB patients with HIV positive results and those HIV patients (under HIV treatment care centers) referred for TB treatment. Thus some facilities report higher number of patients given ART than those tested and with HIV positive results. 64 P a g e

65 Actions Taken or Planned to Address Data Limitations Strengthen the referral system between the TB clinics and HIV treatment centers Continuous supervision Data validation Targets and Accomplishments Year Target Actual Comments FY 2015 (Yr 1) 43% FY 2016 (Yr 2) 55% FY 2017 (Yr 3) 66% FY 2018 (Yr 4) 77% FY 2019 (Yr 5) 89% FY 2020 (Yr 6) 100% Cumulative Total THIS SHEET LAST UPDATED ON: April P a g e

66 Annex B BMU Tracking BMU Reports Tracking Form Highlands CHIMBU CHUAVE DISTRICT HOSPITAL GEMBOGLE GUMINE HC KEROWAGI HC KILAU HC KOGE HC KUNDIAWA HP MINGENDI HC EHP ASARO HC GOROKA BASE HP HENGANOFI HC KAINANTU TB CLINIC KASSAM SC KWONGI SC LUFA NAPURU OKAPA HC OMAMUGA OMAURA S.I.L. UC SIGEREHE SC WATABUNG YAUNA SC ENGA KOMPIAM Hospital MAMBISANDA HC PAIAM Hospital PORGERA UC WABAG HP YAMPU HC SHP EPEANDA IALIBU HP MENDI HP PIMAGA KAUPENA NIPA PANGIA MOGOL YARIA TARI TARI HP WHP BUKAPENA KOTNA HC KUMDI Mt HAGEN HP TB Clinic TAMBUL HC TINSLEY HC TOGOBA HC WARAMZ Jiwaka KINDENG KIMIL HC KUDJIP HC MINJ HC 1st Q 2nd Q 3rd Q 4thQ Received Encoded Received Encoded Received Encoded Received Encoded 66 P a g e

67 Annex C Routing and Transmittal Slip BMUs/Province Province/Independent City: Reporting period: Summary of submitted reports: Completed BMU report PMDT reporting (for PMDT sites) Training report Supervisory report Others, specify Remarks: Submitted by: _Printed name with signature Date submitted : Name of Liaison Officer/ Province/Central: Summary of reports received: Completed BMU report PMDT reporting (for PMDT sites) Training report Supervisory report Others, specify Submitted Reports and supporting documents recorded at the Reports Tracking Checklist (please attach hard copy of Reports Tracking Checklist) Remarks: Received by: _Printed name with signature Regional Coordinator (RC)/Province) Date: Data quality of reports and supporting documents were validated (please attach Data Quality Assessment Checklist as support to data validation activity conducted within the reporting quarter) For review Remarks: Data Quality Checked by: _Printed name with signature National M&E Coordinator For encoding Date: Remarks: Approved by: _Printed name with signature National M&E Coordinator Encoded Date: Filed at NTP Encoded and filed by: _Printed name with signature M&E Officer Date: 67 P a g e

68 Annex D Data Validation Forms DQA form 1 (Availability) This form serves as a checklist to supervisors conducting monitoring activities at the BMU. All documents listed in the table below should be available and presented to the monitoring team. Items 1, 2, and 3 should be present for each patient listed in the Laboratory and TB Registries. All sputum examinations for diagnosis and follow-up should have corresponding lab request forms attached to the treatment card (Example: for a Category 1 patient, there should be 4 lab request form since one is required for diagnosis and three for follow-ups). All the other documents (Items 2-9) should be available. There are other optional documents that should be available at the RHU which are recommended and provided by the NTP for use by the health worker in performing recording and reporting NTP activities. These are items 10 to 15. Instruction: Check column Y if the document/s is/are available and N if not and write your remarks on the column provided. Document Available Remarks Y N 1. Laboratory request form 2. Treatment card 3. Laboratory registry 4. TB registry 5. BMU Report (copy of previous reports filed properly) 6. BMU Report (blank copies) 7. TB suspect register 8. Counting sheet for laboratory activities report 9. Bin cards for TB drugs 10. TB referral register Form 2 (Completeness) This form will be used by the monitoring team to ensure that all information and data in the records and reports are complete. It is ideal that the health worker do not leave any information blank in all the records and reports. This includes completeness in the information of the patient such as name, address, contact person, contact numbers of both the patient and the contact person, etc. Instruction: Check column Y if all entries and information for the document is complete and N if not and write on the Remarks column the noted incompleteness. 68 P a g e

69 Document Available Remarks 1. Laboratory request form 2. Treatment card 3. Laboratory registry 4. TB registry 5. BMU Report (copy of previous reports filed properly) 6. BMU Report (blank copies) 7. TB suspect register 8. Drug inventory and requirement report 9. Bin cards for TB drugs 10. TB referral register Y N Form 3 (Consistency) The monitoring team should ensure that the information collected and written in the record and reports are consistent with each other. Gathering of information starts during the initial consultation of a TB suspect in a BMU facility and will be registered in the TB Suspect Register. The same patient being referred to smear microscopy laboratory should have a concomitant Lab Request form. Same patient should be registered in the Laboratory Register once a specimen is submitted. If the said patient will be enrolled for treatment, a Treatment Card will be opened and be registered in the TB Register. All information between these records should be the same. The monitoring team should then check consistencies from these records. From the registries, all information and data should be consistent as the TB clinic Officer perform reports for submission to the higher level. Using this form, the monitoring team will check for inconsistencies between records and reports. Instruction: Check Y if the monitor finds inconsistency and N if not and write in the Remarks column the inconsistency identified. 69 P a g e

70 Documents Consistent Remarks Y N 1. TB Suspect Register with Laboratory Register 2. Lab request forms with treatment cards 3. Lab request forms with Lab registry 4. Treatment cards with TB registry 5. Lab registry with TB registry 6. TB registry with quarterly report on all TB cases 7. TB registry with quarterly report on treatment outcomes Form 4 (Timeliness) A. Updated records The documents listed in the table below should be checked if updated. The portion on the Treatment card showing patients daily intake should be updated during the time of the review. All Registers should be updated at the time of the review. Instruction: Check column Y if the document is updated and N if not and write on the Remarks column the noted out-datedness. Document Updated Remarks Y N 1. Treatment card 2. Lab Register 3. TB Register 4. TB Suspect Register B. Turnaround time from diagnosis to treatment Part of quality DOTS services is the fast turnaround time from diagnosis to treatment. This will ensure that cases especially the smear positive cases once identified should be immediately treated to render them smear negative 70 P a g e

71 as soon as possible, thereby cutting the transmission to the family members and the community. The monitoring team can determine this by looking at the lab request form when the patient submitted the specimen up to time the patient was started on treatment on the treatment card. Date of specimen submission: Date started treatment: Turnaround time: Factors affecting the turn-around time of sputum microscopy results C. Timely submission reports It is important that all reports should be submitted on time. The monitoring team should note the date when the BMU facility submitted the period being reviewed and provincial record of the time the province actually receive the report. The monitoring team should also note during the supervisory visit when the province submitted the BMU reports to NTP. The monitoring team should validate this with the tracking form maintained at the Central level. The monitoring team should note any problems raised by the facility in relation to timely submission of report and the agreements on how to ensure that the health workers are able to comply with prescribed dates in reporting. Form 5 (Accuracy) (This is an optional tool to assess the health worker in case the monitoring team has doubt on the health worker s knowledge on definitions of NTP terms and formulas for indicators.) A. Capacity to label cases based on classification, type, category, and treatment outcome The health worker should be able to label cases based on: classification (pulmonary or extra-pulmonary), Type (new, relapse, treatment failure, RAD, trans-in, if new either new smear positive or new smear negative), Category (I, II) and treatment outcome (cured, treatment completed, failed, defaulted, died, transferred-out). Instruction: The monitoring team should note any error in classification, typing, categorization, and classifying the outcomes as the monitoring team 71 P a g e

72 reviews the records. The monitoring team may also ask the TB clinic staff to verbally define the items mentioned above and check column Y if all were defined correctly and N if not and write on the Remarks column the identified incorrect response or any noted error.. The monitoring team should also check the accuracy of the numbers reported (BMU report) by actually counting it from the Registers. Labeling of cases 1. Classification 2. Type 3. Category 4. Treatment outcome Correctly defined Y N Remarks B. Knowledge of indicators and computation Instruction: Ask the medical technologist and the nurse to compute certain indicators. Give the health workers Form 6 for them to answer. Check column Y if all formulas were correctly written and N if not and write on the Remarks column the identified incorrect answer. Indicator tested 1. 3 sputum collection rate 2. Positivity rate 3. CNR 4. CDR 5. Sputum conversion rate 6. Cure rate 7. Treatment completion rate 8. Default rate Knowledgeable on formulas and computation Y N Remarks 72 P a g e

73 Annex E: Training Report Template Name of Training: Training Report Date of Training: Objectives of the training Expected Output: Attach training design Guide Question: What basic knowledge to be gained by the participants? What skills to be developed by the said training? Name of Trainors/ Facilitators Narrative report Total staff trained; positions and area of assignment - Narrative summary in 1 to 2 paragraphs only Highlights of the training per module/topic - 2 to 3 paragraph narrative description only of the main points and methodology used by the facilitator/lecturer Summary of issues/recommendations raised by the participants per module/topic - Bulleted list with 1 to 2 sentence-description of issues/recommendations raised Pre-test and post test result and analysis Summary of course evaluation findings This section should not exceed 10 pages Summary - 1 to 3 paragraph narrative report only Attach evaluation form Facilitators/Trainors comments Guide questions: How many of the participants need close monitoring and which specific skills need reinforcement during follow through post training visits? Schedule of post training monitoring visits for the next three months after the training Note: Please attach the attendance sheet 73 P a g e

74 Attendance Sheet Name of Training Dates Venue Name Gender Designation Name of Facility (Office) 1. Contact details (Mobile number) Signature Date P a g e

75 Annex F: Feedback report to provinces (Sample) 75 P a g e

76 76 P a g e

77 77 P a g e

78 78 P a g e

79 79 P a g e

80 80 P a g e