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Monitoring and Evaluation for schistosomiasis control programmes in Africa
Neerav DhananiSenior MER Advisor: Biostatistics
Natural History Museum, 26 September 2019
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Support treatment
delivery
Monitoring
and evaluation
Research
What does SCI do?
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To guide government programmes in optimum SCH and STH control
▪ To provide a continual cycle of feedback for MoH to enable programme adaption
▪ Support WHO recommendations for M&E of SCH and STH
▪ Developed and revised over 13 years of supporting programme implementation
▪ Demonstrate impact for country use, donor reporting and community engagement
▪ Build the capacity and skills of in-country experts and technicians
▪ Foster south to south technical exchange and capacity building
▪ To determine if we are reaching global goals for SCH and STH control/elimination
Purpose of Monitoring and Evaluation (M&E)
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https://www.who.int/intestinal_worms/resources/9789241548267/en/
• Published in 2011 by WHO• Defines key indicators and targets
• Updates in 2013 with publication of the Schistosomiasis: Progress Report 2001 – 2011 and Strategic Plan 2012 -2020
https://apps.who.int/iris/handle/10665/78074
These guides give us WHO’s three components of M&E:• Process indicators• Performance indicators• Impact indicators
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WHO Components of M&EWHO (2011) Helminth control in school-age children: A guide for managers of control programmes
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Control of Morbidity Elimination as a public health
problem Elimination of transmission
100% geographical and 75% national coverage with Preventive
Chemotherapy (PC)
Adjusted PC and complementary interventions recommended
Intensified PC and complementary interventions essential
Prevalence of heavy intensity infection <5%
Prevalence of heavy intensity infection <1%
Reduction of incidence of infection to zero
Up to 5-10 years from joining the group
Up to 3-6 years from joining the group Up to 5 years from joining the group
WHO Strategy for Elimination of SCHWHO (2013) Schistosomiasis: progress report 2001 - 2011, strategic plan 2012 - 2020.
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1Step
Mapping
2Step
Strategy
3Step
Logistics
4Step
Training
5Step
Social mobilisation
6Step
Treatment
7Step
Reporting
National programme for SCH with preventive chemotherapy (PC)
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M&E Framework for SCH
Programs
Mapping
Process
Performance
Impact
VfM
+ interventions
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M&E Framework for SCH Programs
Mapping
Process
Performance
Impact
VfM
+ interventions
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• Prior to treatment, SCI works with in-country
programme partners (primarily the Ministries of
Health) to assess the level of infection
• SCI supports the development of risk maps,
detailing predicted levels of infection across
mapping units
• These maps show which areas require
treatment and how often to distribute
treatment
Mapping
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Mapping
Kato KatzCirculating Cathodic Antigen
Urine filtration
Urine dipstick
Diagnostic tools
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MappingWhere is infection?
Liberia
Treatment strategy based on WHO guidelines
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M&E Framework for SCH
Programs
Mapping
Process
Performance
Impact
VfM
+ interventions
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ProcessAre routinely reported treatment data reliable and accurate?
School/community Registers
Summary Forms District Report National Report
Fragile paper formsIn-correct data in Summary Forms
In-complete District Report
Over or under reported numbers
Inaccurate and untimely reporting to
WHO
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Process: Data Quality Assessment (DQA)
Ethiopia & Madagascar Confirmed validity of routinely reported data
Cote d’Ivoire: Strengthened supervisionMalawi: Improved registration forms + reporting system
Many errors in recounting school and community registers
Insufficient tools at aggregation levels for cascaded recording
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M&E Framework for SCH
Programs
Mapping
Process
Performance
Impact
VfM
+ interventions
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Performance: Coverage evaluation surveyIs survey treatment coverage >75% in school-age children?
Random selection of 30 clusters per IU (PPES)
Random selection ~15 households per cluster
All eligible household members interviewed
https://www.ntdsupport.org/resources/coverage-survey-builder-coverage-evaluations
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Performance: Coverage evaluation survey Is survey treatment coverage >75% in school-age children?
87% 77%
85% 81%
88%81%
<40% of non-attending SAC
ingesting praziquantel
<50% non-attending SAC not
hearing about treatment
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M&E Framework for SCH
Programs
Mapping
Process
Performance
Impact
VfM
+ interventions
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Impact: cross-sectional sentinel surveys in SACHas control of morbidity been achieved?
• Indicators are assessed routinely in the same randomly selected sentinel schools
• Cross-sectional assessment of school-aged children for these indicators: o prevalence of infectiono intensity of infectiono prevalence of heavy intensity of infectiono macro and micro haematuria
Baseline disease prevalence and
intensity
Preventive chemotherapy
round 1Follow-up 1
Preventive chemotherapy
round nFollow-up n
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Impact
Kato KatzCirculating Cathodic Antigen
Urine filtration
Urine dipstick
Diagnostic tools
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Fig 2. S. haematobium prevalence, Malawi
Each coloured line represents a sentinel school
Black line indicates mean prevalence
Fig 1. Overall prevalence of S. mansoni and S. haematobium, multi-country*
Each coloured line represents a country
Parasitological (impact) surveysPrevalence of infection
*Deol et. al., Achieving global 2020 and 2025 goals for schistosomiasis: rapidly reaching the thresholds for control and elimination as a public health problem. Under review
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Impact: cross-sectional sentinel surveys in SAC
Has control of morbidity been achieved?
Malawi
Reduced prevalence of heavy and
light intensity successfully in SAC
Heterogeneity in school level
prevalence of heavy intensity
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M&E Framework for SCH
Programs
Mapping
Process
Performance
Impact
VfM
+ interventions
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0 0.25 0.5 0.75 1 1.25 1.5 1.75
Average
Yemen
Sudan
Rwanda
Madagascar
Burundi
Zanzibar
Uganda
Tanzania
Mozambique
Malawi
Ethiopia
DRC
Cote d'Ivoire
Cost per treatment (£)
*Only countries delivering > 100,000 treatments between April 2015
and March 2016 shown. Cost based on monies transferred to country
during the same time period.
Cost: cost per treatment in FY15/16*
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Cost: ToolsAre we achieving a ‘best buy’ = low/high cost AND good quality?
Cashbook: Completed in-country and audited by Finance
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Are we achieving a ‘best buy’ = low cost AND good quality?Value for Money
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Knowledge ManagementTranslating evidence in to practice
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Knowledge ManagementTranslating evidence in to practice
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Knowledge ManagementTranslating evidence in to practice
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M&E Framework for SCH
Programs
Mapping
Process
Performance
Impact
VfM
+ interventions
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“Complimentary Interventions”
Behaviour Change Communications What WASH?
Snail Control
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M&E Framework for SCH
Programs
Mapping
Process
Performance
Impact
VfM
+ interventions
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Summary points• Monitoring and evaluation is critical to ensure programmes are
reaching their goals and to adapt and improve i.e. knowledge management
• Adequate tools are available for measuring process, performance and impact measurements
• We need to strengthen our understanding of why uptake of treatment varies
o Further identification of supply and demand-side barriers
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Summary points• For moving from control phases to interruption of transmission
we need to build operational research on to existing M&E to:
o Determine what the most effective and cost-effective ‘complementary interventions’ are
o Identify the optimum combinations of PC and other interventions to break transmission
o Understand factors for focal heterogeneity and how to address areas of persistent moderate and high infection of SCH
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Acknowledgements
▪ All the communities, health centre, district level and central level staff who invest and participate in control programmes
▪ All our partners in sub-Saharan Africa
▪ Our funding and research partners
▪ The SCI Team!
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Acknowledgements
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Thank you for listening!