The Monitoring and Evaluation (M&E) of the 3 by 5 Initiative

1. Introduction

Tracking progress towards the milestones established for measuring project success at the country, regional and global levels is one of the essential 5 pillars of the key WHO actions and deliverables.

Clear milestones have been set as outcomes (measured by the number of men, women and children with advanced HIV infection receiving antiretroviral therapy) up to 2005:

Dec  2003   400 000
June 2004   500 000
Dec  2004   700 000
June 2005 1 600 000
Dec  2005 3 000 000

2. Strategies and steps

The main strategy foreseen in order to implement a global M&E is to simplify and standardize tools for tracking the performance of antiretroviral therapy programmes, including surveillance of drug resistance (op. cit., p. 46), with the following steps:

  • develop simple, standard, easy-to-use monitoring and evaluation indicators for ART programmes,
  • develop simple, standard, easy-to-use monitoring and evaluation indicators for ART programmes,
  • promote the universal adoption and use of the core indicators for ART programmes,
  • develop guidelines and networks for surveillance of antiretroviral drug resistance,
  • develop guidelines and networks for monitoring risk behaviour,
  • establishment of a Strategic Information Centre to collect data analyse and present the information on progresses made towards 3 by 5 for all to use.

3. International standards

The “emergency scale-up of ART in resource-limited settings: technical and operational recommendations to achieve 3 by 5“ (report from the WHO/UNAIDS Zambia consultation, November 18-21, 2003) identified a number of essential recommendations towards setting up sound M&E systems at different levels:

Health Centre/ ART Site

  • Maintain confidential and individual patient records at each ART site, using a unique patient identifier to link information
  • Use standardized patient records and data collection forms, developed centrally for use across districts
  • Monitor regularly the uptake of HIV testing, care provision, ARV uptake and other key indicators

District

  • Plan, monitor, evaluate, and provide feed back regarding ART scale-up activities within each district’s catchment area that includes training, HIV testing, access and use of care, ART and drug supply

Central

  • Develop a harmonized, simple, standard national ART monitoring, and evaluation system agreed upon by the national government, in collaboration with donors and implementers to be used at all levels and linked to the overall national monitoring and evaluation system.

The first element of the M&E strategy that can and must be developed is a common foundation at the national level. It is crucial that key indicators for the national level be developed and that these be comparable across countries. In order to accomplish this, the World Health Organization (WHO) has released (1 December 2003) two documents developed with international partners that should be instrumental in setting up sound M&E in-countries, describing the exact methods, tools and intervals for collecting the key indicators of the 3 by 5:

It is expected that all countries will adopt and use these international standards. It is implicit in national ART implementation plans in line with 3 by 5.

4. Key lessons learned to succeed with national indicators

WHO has extensive experience in developing international guides and setting up logistics, health and management information systems (LHMIS) to recommend, with partners, essential national programmatic indicators. From these it has learned some key lessons:

  • Firstly, the number of indicators must be kept to a minimum, as the effort and expense required to collect the necessary data can be daunting, especially for national M&E systems with limited staff time and capacity.
  • Secondly, the indicators developed must be agreed by international and national partners to harmonize the monitoring of the programme. For example WHO and Partners could recommend an HIV/ART Care Card that could include minimum information on ARV Treatment. These could include the 4 “S’s” i.e. the Start of the ARV first-line treatment, the Substitute drug, the Switch to the new regimen, and when the treatment Stopped (treatment failure).
  • Thirdly, indicators that can be compiled using data collection systems that already exist are preferable to those that will require special efforts to collect.

Subsequent efforts, in close collaboration with the countries, to capture the specific and more detailed features of the programme efforts in the 3 by 5 Initiative and the delivery of ART, are crucial but can be considered in a second stage.

5. Overall essential measurement of progress at a glance

For the 3 by 5, all national programmes should be able to demonstrate progress in their efforts by tracking and reporting the following indicators phased in over time by the countries.

The essential indicators listed next are proposed from the “Guide to monitoring and evaluating national antiretroviral treatment (ART) programmes in the rapid scale up to 3 by 5”.

These indicators cover the keys areas necessary to track the scaling-up efforts of the 3 by 5, and follow the essential categories and classification with which countries are already familiar with in National AIDS Programmes:

  • Policies (inputs): Existence of the national policy, guidelines, and target for ART programmes
  • Capacity-building (process): Number of health workers trained to deliver ART services according to national or international standards
  • Stocks (process): Percentage of (ARV) antiretroviral drug distribution nodes that report on inventory consumption, quality, losses and adjustments on a monthly basis
  • Coverage (outputs): Percentage of districts with at least one centre that provides ART services in-line with national standards
  • Quality of services (outputs): Percentage of designated facilities providing ART in line with national standards
  • Prevention aspects of service delivery (outputs): Total number of persons tested, by age and sex, and proportion of tests that are positive
  • ARV service delivery (outcomes): Proportion of people with advanced HIV receiving ART, number of drug regimes distributed, ARV resistance containment
  • Treatment adherence (impact): Percentage of people remaining on treatment at 6, 12 and 24 months, and
  • Quality of life (impact): Percentage of adults on treatment who gain weight by at least 10% six months after initiation of treatment

Milestones: Mid 2004: 20 countries using the standardized M&E tools 2005: 50 countries using the standardized M&E tools

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