Indicators

Regional Workshop on the Monitoring and Evaluation of HIV/AIDS Programs

February 14 – 24, 2011New Delhi, India

Session Objectives Understand how indicators are linked to

frameworks Describe how to operationalize indicators Identify the role of indicators at different levels

(national, sub-national, project) and the linkages between them

List sources of indicators that are international standards

Select indicators and define indicators for an M&E plan

An Indicator is…

a variable (its value changes)

that measures (objective calculation of value)

key elements of a program or project Inputs, processes, outputs, outcomes

Indicators provide critical M&E data at every level (and stage) of program implementation

Inputs, Process Was the program carried out as planned?

How well was it carried out?

Outputs, Results Did the expected change occur?

How much change occurred?

Outcome, Impact Has the outcome changed in desired direction?

Does the change signal program “success”?

INPUT

• Human and financial resources

• Development of training materials

PROCESS

• Conduct one PMTCT training workshop in each district for providers

OUTPUT

• Providers trained in updated PMTCT service provision

OUTCOME

•Increased use of PMTCT services

IMPACT

• Reduced perinatal transmission of HIV

Logic Model IndicatorsLogic Model Indicators

Indicator: # of providers who have completed clinical training

Indicator: % of pregnant women who are HIV tested

Indicator: percent of HIV+ women receiving a complete course of ARV prophylaxis

Indicator: percent of infants HIV+ born to HIV+ women

Results Framework Example – PEPFAR funded ART Program

SO: Increased utilization of ART services

IR-1: Availability of quality services

IR-2: Demand for services

IR-1.1: Increase ART sites

IR-1.2: Supply sites with ARVs

IR-1.3: Training for providers

IR-2.1: Increase knowledge ofART

IR-2.2: Increase referral from VCT

Results Framework Indicators PEPFAR funded ART Program

IR-1: Availability of quality services

IR-1.1: Increase ART sites

IR-1.2: Supply sites with ARTs

IR-1.3: Training for providers

# of districts with at least one facility providing ART services in line with national standards

# of ART sites

% of ART delivery points experiencing stock-outs in the preceding six months

# of health workers trained on ART delivery in accordance with national or international standards

Results Framework Indicators PEPFAR funded ART Program

SO: Increased utilization of ART services

# of HIV + persons receiving ART therapy

Indicator Pyramid

District, Facility, ProjectIdentify progress, problems, and challenges

National/Sub-national Assess effectiveness of response

Reflect goals/objectives of national/sub-national response

Number of Indicators

Decreases

Increases

GlobalCompare countries

Overview world-wide situation

Linkages between levels

Often, indicators at the higher levels in the pyramid are linked to those at the lower levels.

Data may be collected at the district level and passed up to the national level and on up to the global level.

Requires an M&E system to support data flow, compilation, and aggregation

Characteristics of good indicators

Valid: accurate measure of a behavior, practice or task

Reliable: consistently measurable in the same way by different observers

Comparable: can be measured in different contexts or time periods

Non-directional: subjective criteria not part of definition

Characteristics of good indicators (cont.)

Precise: operationally defined in clear terms Measurable: quantifiable using available tools and

methods Timely: provides a measurement at time intervals

relevant and appropriate in terms of program goals and activities

Programmatically important: linked to a public health impact or to achieving the objectives that are needed for impact

Common Indicator Metrics Counts

# of providers trained

# of condoms distributed

Calculations: percentages, rates, ratios

% of facilities with trained provider

% of FSW who used a condom at last sex with a client

Index, composite measures

Index on infection control prevention

DALY (Disability Adjusted Life Years)

Thresholds

Presence, absence

Pre-determined level or standard

Operationalizing indicators

Establish exactly how a given concept / behavior

will be measured precise definition and metric

how the value will be reliably calculated (anyone using the same data will arrive at

exactly the same indicator value)

Always specify the details!

who/what qualifies to be counted, and when

Number of providers trained in PMTCT services

“providers”: any clinician providing direct clinical services to women seeking ANC at government health facilities

“trained”: attended a two-week training course on PMTCT in past year

Always specify the details!

How to calculate it

Percent of health facilities with a provider trained in PMTCT services

“Numerator”: Number of public facilities with a provider who attended a two-week PMTCT training course in past year

“Denominator”: Number of public facilities offering ANC services in the past year

Always specify the details!Threshold indicator for VCT program

VCT centers with minimum conditions to provide quality services

• Facility provides quality VCT services if the following necessary structural elements are present– Trained staff– Adequate privacy for counseling– Systems for maintaining confidentiality– Directory of services for referral– Adequate conditions for ensuring quality control of specimen

tests

LimitationsAll indicators have limitations, even those

commonly used:

Blood safety: cannot monitor private facilities adequately Sexual behavior (e.g. condom use, number of partners):

self reporting bias Sero-surveillance: get biased population (pregnant

women and other populations) Population-based HIV prevalence: refusal bias ,

sampling bias

Frequency of Reporting on Indicators Input/Process: Continuously

Output: Quarterly, semi-annually, or annually

Outcome: 1-3 years

Impact: 2-5 years

Managing indicator systemsBasic Indicator Matrix

Indicator

Data Source Frequency

Decision Points/Comments

Outputs# of peer outreach contacts in the past 12 month

Program records

Quarterly Disaggregate by district

Outcomes% of FSW who used a condom at last sex with a client

Target group survey

1-3 years Disaggregate by age and type (brothel, non-brothel based)

The Role of Target Setting

Important element of strategic planning

Tracking progress towards achieving targets assists with resource allocation and improves program management

Often a requirement for performance-based funding

Main Steps in Target Setting

Define the populations and subpopulations in need of services (treatment, diagnostic, care, prevention, etc)

Assess existing coverage to identify gaps

Determine potential achievements within the time frame given resource availability, opportunities, and constraints

⇒ Set ambitious but realistic targets!

Indicator Reference Sheets

Assist in detailed documentation of indicators

Clear definition of indicator, numerator, and denominator

Collection details – data source, frequency, who responsible

Content of Indicator reference sheets (see handout)

The linked result

Precise definitions for every term used

Reason for selection, how to interpret

Data requirements, data quality issues

How to measure and calculate

Data source, responsibilities, and frequency

Issues, limitations, significance

Data table (baseline and target values)

Guiding Principles to selecting indicators

Ensure that the indicators are linked to the program goals and are able to measure change

Ensure that standard indicators are used to the extent possible

Consider the cost and feasibility of data collection and analysis.

Keep the number of indicators to the minimum and include only those needed for program and management decisions or for reporting.

Good indicators: A Synopsis

Provide information useful for program decision-making Are consistent with international standards and other

reporting requirements, as appropriate Are defined in clear and unambiguous terms

Non-directional, “independent,” and SMART Have values that are:

Easy to interpret and explain Precise, valid and reliable measures Comparable across relevant population groups,

geography, other program factors, as needed

Indicator Guides National AIDS Programmes. A guide to monitoring and evaluation.

UNAIDS (2000)

National AIDS Programs. A guide to indicators for monitoring and evaluating national HIV/AIDS prevention programs for young people. WHO (2004).

National guide to monitoring and evaluating programmes for the prevention of HIV in infants and young children. UNAIDS/WHO (2004)

National AIDS Programs. A guide to monitoring and evaluating HIV/AIDS care and support. WHO (2004).

National AIDS Programmes. A guide to indicators for monitoring and evaluating national antiretroviral programmes. WHO (2005).

Indicator Guides (cont.) Guide to monitoring and evaluation of the national response for

children orphaned and made vulnerable by HIV/AIDS. UNAIDS/WHO (2005)

A framework for monitoring and evaluating HIV prevention programs for most-at-risk populations (UNAIDS 2007)

Monitoring and Evaluation Toolkit. HIV/AIDS, Tuberculosis, and Malaria. GFTAM (2009).

Monitoring the Declaration of Commitment on HIV/AIDS. Guidelines on construction of core indicators. UNAIDS (2009)

….and others!

Additional References

HIV/AIDS Survey Indicators Database

www.measuedhs.com/hivdata

UNAIDS 2010. Indicator Standards: Operational Guidelines for Selecting Indicators for the HIV Response.

http://www.globalhivmeinfo.org/

UNAIDS Indicator Registry

http://www.indicatorregistry.org/

Not everything that can be counted counts, and not

everything that counts can be counted.

Albert Einstein

Group Activity: Adding Indicators to a Framework

Assemble group-work members

Use the worksheet “Linking Indicators to Frameworks”

Take about one hour to complete sheet

Resulting framework with indicators will to presented back by a group representative (5 minutes for each group)

The selection of indicators will form the basis of your plan, You will have the opportunity to revise this further based on feedback

MEASURE Evaluation is a MEASURE project funded by the

U.S. Agency for International Development and implemented by

the Carolina Population Center at the University of North Carolina

at Chapel Hill in partnership with Futures Group International,

ICF Macro, John Snow, Inc., Management Sciences for Health,

and Tulane University. Views expressed in this presentation do not

necessarily reflect the views of USAID or the U.S. Government.

MEASURE Evaluation is the USAID Global Health Bureau's

primary vehicle for supporting improvements in monitoring and

evaluation in population, health and nutrition worldwide.