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Session X: Technical
Leadership in Monitoring and
Evaluation
MEASURE Evaluation
End-of-Phase-III Event, May 22,
2014
Responsive M&E Systems
for Program Success
Heidi W. Reynolds, PhD, MPH
MEASURE Evaluation
End-of-Phase-III Event, May 22, 2014
Technical Leadership in Monitoring and Evaluation
Number Of Malaria Donors In
Recipient Country, 2009-11
Number Of HIV Donors In
Recipient Country, 2009-11
Develop
and refine
tools to
improve
measures
Build Evidence
Support National Systems
Build Capacity
Sharing
M&E
Investments
Better Data
Measure
infections and
deaths
“ For time and the
world do not stand still.
Change is the law of
life. And those who
look only to the past or
the present are certain
to miss the future.”
-John F. Kennedy
Epidemiology
Program
response
Data needs
What is Changing?
Looking Forward
Monitoring resistance
and adherence
Understanding structural
factors
Subnational data to
tailor response
Malaria M&E
Looking for Impact, Finding a System
Dr. Leopoldo Villegas, MD, DTM&H, MSc,
DrPH, AdvDPHM
MEASURE Evaluation
End-of-Phase-III Event, May 22, 2014
What is Malaria?
Malaria – The Basics
BiomedicalBehavioral
Physical
environment
Political, Legal
& Economic
Social & Cultural
Knowledge
Management
Clinical Spectrum
Distribution ≠ Use
Interventions
Control
Pre-
elimination
Elimina-
tion
Prevention of
reintroduction
Malaria
free
SPR<5%
<1 case/1000
pop at risk
0 locally
acquired cases 3 years
From Control to Elimination
National: DHS, MICS, MIS, RMIS
State: DHS, MICS, MIS, RMIS
District: RMIS
Facility/Sentinel: RMIS
Community/Individual: RMIS
No households surveys (2011-2013)
At least 1 households surveys (2011-2013)
Measuring Malaria
Control
Pre-
elimination
Elimina-
tion
Prevention of
reintroduction
Malaria
free
3.4 B
Population at
risk
207.4 M
Cases
627 K
Deaths
Malaria 2012
Artemisinin
Resistance
80%
Financial
>3.3 M
Deaths prevented
50%
# children
dying
Cases
Deaths
Funding
2000 2012
Impact
Contribution & coordination
M&ETools
Technical leadership
Building capacities
Country Support
Malaria Portfolio
Global Contribution
World Malaria Report (2010, 2011)
Global plan for artemisinin resistance
containment (GPARC)
Reports Presentations Articles
Secretarial and technical support
to RBM MERG
M&E Tools
MIS
2013
Updated MIS toolkit
Supported Regional Malaria Framework
for South East Asia
Finalized Released Household Survey Indicators
for malaria control
Framework for evaluating the impact of malaria
control programs – June 2014
Malaria M&E training curriculum
Technical Leadership
Publication in peer-reviewed journals
Symposium/presentations at international conferences
Multi-Agency Malaria Impact Evaluation PMI
15
Building Capacities
Malaria M&E courses
2010-2013 2011-2014 2011 2013
Malaria M&E short course
Extensive mentoring/capacity building
Curriculum development – M&E cascading training
Country Support
Challenges
Implementation & priorities
Difficult global consensus
Uncoordinated & duplication of efforts
Difficulties measuring achievements
Global financial gap
Increase Artemisinin resistance
Changing Context
Intervention Coverage
Malaria Burden
Focal local transmission
From control to elimination
Data from lowest ADM level
Adaptation
Adaptive Local Systems
Understand your system
Multisectoral approaches – tailored to
local conditions
Combination optimal “mix” interventions
Knowledge of your malaria epidemiology,
actors & roles
Common goal > Elimination
Monitoring and evaluation knowledge
management
Acknowledgements
 Countries
 National programs
 USAID teams
 Malaria Stakeholders
Thank you!
MEASURE Evaluation partners
Session X:
Advances in Monitoring and Evaluation
of Programs for Key Populations
Sharon S. Weir
MEASURE Evaluation
End-of-Phase-III Event, May 22,
2014
THIS IS A TEST
ANSWER SHEET
1 COMMON THEME: _________________________________
2 CIRCLE ONE ANSWER:
3 CIRCLE ALL THAT APPLY:
4 CIRCLE BEST ANSWER:
5 How many questions did you answer correctly? 0 1 2 3 4
WINNERS GET A PRIZE!
Your Name:____________________________________________
0 1 2 3 4 5 6 7 8 9
A B C D
0 1 2 3
1. 3 STATEMENTS. WHAT IS THE COMMON THEME?
Welcome to Lake
Wobegon, where all
the women are
strong, all the men
are good-looking,
and all the children
are above average.
A Garrison Keillor
1. THEME?
For the first time ever,
overweight people outnumber
average people in America.
Doesn't that make overweight
the average then? Last month
you were fat, now you're average
- hey, let's get a pizza!
B
Jay Leno
1. THEME?
“She said,
You’re not Mr.
Right, but Mr.
O.K. will do….”
C
Lyrics, Just Say No,
Beres Hammond
1. COMMON THEME?
Fill in the blank.
A
C
B
EACH STATEMENT
CHALLENGES OUR
NOTION OF WHAT IS
AVERAGE.
ANSWER:
-- AND BY EXTENSION
WHAT IS NOT AVERAGE,
WHAT LIVES IN THE TAILS.
ANSWER:
2. HOW MANY OF THESE 3 STATEMENTS
COMMUNICATE THAT KEY POPULATIONS
LIVE IN THE TAILS?
1. Key populations (also referred to as most-at-risk
populations) are
 people who inject drugs,
 gay men and other men who have sex
with men,
 transgender persons and
 sex workers.
2. They are disproportionately infected with HIV compared to the general
population.
3. There is no way toward an AIDS-free future without targeting approaches
toward these highly marginalized and often hard to reach populations.
Source:
FROM USAID WEBSITE APRIL 22 http://www.usaid.gov/what-we-do/global-health/hiv-
and-aids/technical-areas/key-populations-targeted-approaches
2. ANSWER: ALL 3
1. Key populations (also referred to as most-at-risk populations)
are
 people who inject drugs,
 gay men and other men who have sex with men (MSM),
 transgender persons and
 sex workers.
2. They are disproportionately infected with HIV compared to
the general population.
3. There is no way toward an AIDS-free future without targeting
approaches toward these highly marginalized and often hard to
reach populations.
Figure 2 Forest plot showing meta-analysis of risk of HIV infection among female sex workers
compared with women aged 15–49 years in low-income and middle-income countries, 2007–11,
Stefan Baral , Chris Beyrer , Kathryn Muessig , Tonia Poteat , Andrea L Wirtz , Michele R Decker,
Susan G Sherma, The Lancet Infectious Diseases, Volume 12, Issue 7, 2012, 538 - 549
It’s true. Meta-analysis shows
HIV infection among Sex
Workers is much higher than
among women 15-49.
But….
IS SOMETHING
MISSING?
DIGGING DEEPER
1. Who are key
populations?
2. Why are they
more likely to
be infected?
3. What
programmatic
response is
needed?
4. Where?
TOOLS TO DIG DEEPER
DEFINITIONS
MATTER
3. WHO Are Key Populations Per
Global Definitions?
KEY
POP?
A) Alli A 29 year old female who
exchanges sex for cash?
Yes or No
B) Bob A 24 year old man with 5 female
partners in the past 4 weeks who
pays women for sex?
Yes or No
C) Chip A 34 year man who has had sex
with men?
Yes or No
D) Daisy A 17 year old female student who
has had 4 partners in the past 4
weeks and exchanges sex for cash
Yes or No
3. WHO Are Key Populations? A and C
ARE YOU SATISFIED WITH THE DEFINITIONS?
KEY
POP?
Vulnerability STI PLACE
A) Alli – A 29 year old
female who exchanges sex
for cash
Yes Jailed HIV Yes
B) Bob – A 24 year old man
with 5 female partners in
the past 4 weeks who pays
women for sex
No None None Yes
C) Chip – A 34 year man
who has had sex with men Yes Jailed
Gonorrhea,
Chlamydia
Yes
D) Daisy – A 17 year old
student who has had
4 partners in the past
4 weeks and exchanges
sex for cash
No
Youth
Sex age 13
Chlamydia Yes
Of 678 female
workers at a
sample of venues
where people meet
new sexual
partners in Liuzhou
China, how many
are sex workers?
678
•Ever
had sex 648 • 50+
231•Exchanged sex
for cash/gifts
148 • 26+
 35+
• 148 Exchanged
sex for cash
past 4 weeks
• 50+
Number with a
a positive rapid
test for syphilis.
Illustrates limitation of a narrow
sex worker definition. PLACE
approach includes all 50 workers
at venues who had a positive rapid
syphilis test.
WHY?
? ? ? New HIV
Infections
Extra credit: Fill in the
blanks.
CAUSAL MODEL
Underlying Proximate Biological
New HIV
Infections
Determinants Transmission
 Exposure to HIV
 Susceptibility to HIV
 Number of partners
 Lack of condom use
 Anal Sex
 Lack of Circumcision
UNDERLYING DETERMINANTS
Based on Boerma, Weir JID 2004
and collaboration with JP Figueroa
General
• Age
• Sexual
Orientation
• Location
Vulnerability
• Unemployment
• Low Education
• Stress
• Inadequate
support
• Genetics
Adverse Life
Events
• Rape
• Jail
• Untreated
infections
• Homeless
• Violence
TAILORED RESPONSE
Combination Prevention Programme
Package of Individual Level High Quality Health
Services
Programme Enabler
Interventions
 SiteOutreach
 Improveavailability,acceptability
andaccessibilityofservices
 Improvedqualityofservices
Social Enabler Interventions
 Empowermentactivities
 Improvelegalandpolicyenvironment
 Programstoaddressstigma,violence
anddiscrimination
EnablingEnvironmentatthe
CommunityLevel
Biomedical Services
 HIVtestingandcounselling
 Linkagetocare,viralload
reduction
 STIscreeningandtreatment
 Psychosocialinterventions
 Harmreduction includingneedle
andsyringeprogramsandopioid
substitutiontherapy
 HBVImmunization
Behaviour Change
Services
 Condompromotion&
distribution
 Targetededucation
andriskreduction
counselling
Figure 1 Combination Prevention Programme (modified from Operational
Guidelines for Monitoring and Evaluation of HIV Programmes for Sex Workers,
Men who Have Sex with Men and Transgender People)
PLACEStudy2012inAngolaIdentifiedVenuesWherePeople
MeetNewSexualPartnersButInterventionProgramsare
Insufficient
Area with
clusters of
venues but
no prevention
program.
WHERE?
Programmatic Mapping
To adequately focus effective,
locally tailored HIV prevention
response where it is most needed.
“Superstar lawyers and math whizzes and software
entrepreneurs appear at first blush to lie outside
ordinary experience. But they don't. They are
products of history and community, of opportunity
and legacy. Their success is not exceptional or
mysterious. It is grounded in a web of advantages
and inheritances, some deserved, some not, some
earned, some just plain lucky – but all critical to
making them who they are. The outlier, in the end, is
not an outlier at all.”
Malcolm Gladwell, Outliers: The Story of Success
“Sex workers, and gay men, transgender people, and people
who inject drugs appear at first blush to lie outside ordinary
experience. But they don't. They are products of history and
community, of opportunity and legacy. The higher prevalence
of HIV infection they share, their lack of access to services,
their vulnerability, is not exceptional or mysterious. It is
grounded in a web of disadvantages and disinheritances,
prejudices and prison sentences, mostly undeserved, some
just plain unlucky – but all critical to making them who they
are, how they live, and what they will die from. The outlier, in
the end, is not an outlier at all.”
― Sharon Weir, Edited text from Malcolm Gladwell,
Outliers: The Story of Success
ACKNOWLEDGEMENTS
AND LAST QUESTION
 MEASURE PLACE Team
o Sarah Hileman, Zahra Reynolds, William Miller, Jess Edwards,
Grace Mulholland
 Mentors , Colleagues, Supporters
o Peter Figueroa, Freddie Ssengooba, Ties Boerma, Keith Sabin,
Abu Abdul-Quader, Jamie Blanchard, Jinkou Zhao, Ludo Bok,
Jenny Butler, Lovette Byfield, Krista Stewart, Erin Balch,
Joseph Mwangi, MEASURE Evaluation team
4) How many Jamaica references (loosely defined) appear
in this presentation?
ANSWER: 8
Based on Boerma, Weir JID 2004 and
in collaboration with JP Figueroa
Malcolm Gladwell,
Outliers:
2 Mentors, Colleagues, Supporters
Peter Figueroa, Lovette Byfield
Jamaica Venue:
Alli, Bob, Chip,
Daisy
www.measureevaluation.org/eop

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Technical Leadership in Monitoring and Evaluation

  • 1. Session X: Technical Leadership in Monitoring and Evaluation MEASURE Evaluation End-of-Phase-III Event, May 22, 2014
  • 2. Responsive M&E Systems for Program Success Heidi W. Reynolds, PhD, MPH MEASURE Evaluation End-of-Phase-III Event, May 22, 2014
  • 4. Number Of Malaria Donors In Recipient Country, 2009-11
  • 5. Number Of HIV Donors In Recipient Country, 2009-11
  • 12. “ For time and the world do not stand still. Change is the law of life. And those who look only to the past or the present are certain to miss the future.” -John F. Kennedy
  • 14. Looking Forward Monitoring resistance and adherence Understanding structural factors Subnational data to tailor response
  • 15. Malaria M&E Looking for Impact, Finding a System Dr. Leopoldo Villegas, MD, DTM&H, MSc, DrPH, AdvDPHM MEASURE Evaluation End-of-Phase-III Event, May 22, 2014
  • 17. Malaria – The Basics BiomedicalBehavioral Physical environment Political, Legal & Economic Social & Cultural Knowledge Management
  • 20. Control Pre- elimination Elimina- tion Prevention of reintroduction Malaria free SPR<5% <1 case/1000 pop at risk 0 locally acquired cases 3 years From Control to Elimination
  • 21. National: DHS, MICS, MIS, RMIS State: DHS, MICS, MIS, RMIS District: RMIS Facility/Sentinel: RMIS Community/Individual: RMIS No households surveys (2011-2013) At least 1 households surveys (2011-2013) Measuring Malaria Control Pre- elimination Elimina- tion Prevention of reintroduction Malaria free
  • 22. 3.4 B Population at risk 207.4 M Cases 627 K Deaths Malaria 2012 Artemisinin Resistance 80% Financial
  • 23. >3.3 M Deaths prevented 50% # children dying Cases Deaths Funding 2000 2012 Impact
  • 24. Contribution & coordination M&ETools Technical leadership Building capacities Country Support Malaria Portfolio
  • 25. Global Contribution World Malaria Report (2010, 2011) Global plan for artemisinin resistance containment (GPARC) Reports Presentations Articles Secretarial and technical support to RBM MERG
  • 26. M&E Tools MIS 2013 Updated MIS toolkit Supported Regional Malaria Framework for South East Asia Finalized Released Household Survey Indicators for malaria control Framework for evaluating the impact of malaria control programs – June 2014 Malaria M&E training curriculum
  • 27. Technical Leadership Publication in peer-reviewed journals Symposium/presentations at international conferences Multi-Agency Malaria Impact Evaluation PMI 15
  • 28. Building Capacities Malaria M&E courses 2010-2013 2011-2014 2011 2013 Malaria M&E short course Extensive mentoring/capacity building Curriculum development – M&E cascading training
  • 30. Challenges Implementation & priorities Difficult global consensus Uncoordinated & duplication of efforts Difficulties measuring achievements Global financial gap Increase Artemisinin resistance
  • 31. Changing Context Intervention Coverage Malaria Burden Focal local transmission From control to elimination Data from lowest ADM level Adaptation
  • 32. Adaptive Local Systems Understand your system Multisectoral approaches – tailored to local conditions Combination optimal “mix” interventions Knowledge of your malaria epidemiology, actors & roles Common goal > Elimination Monitoring and evaluation knowledge management
  • 33. Acknowledgements  Countries  National programs  USAID teams  Malaria Stakeholders Thank you! MEASURE Evaluation partners
  • 34. Session X: Advances in Monitoring and Evaluation of Programs for Key Populations Sharon S. Weir MEASURE Evaluation End-of-Phase-III Event, May 22, 2014
  • 35. THIS IS A TEST
  • 36. ANSWER SHEET 1 COMMON THEME: _________________________________ 2 CIRCLE ONE ANSWER: 3 CIRCLE ALL THAT APPLY: 4 CIRCLE BEST ANSWER: 5 How many questions did you answer correctly? 0 1 2 3 4 WINNERS GET A PRIZE! Your Name:____________________________________________ 0 1 2 3 4 5 6 7 8 9 A B C D 0 1 2 3
  • 37. 1. 3 STATEMENTS. WHAT IS THE COMMON THEME? Welcome to Lake Wobegon, where all the women are strong, all the men are good-looking, and all the children are above average. A Garrison Keillor
  • 38. 1. THEME? For the first time ever, overweight people outnumber average people in America. Doesn't that make overweight the average then? Last month you were fat, now you're average - hey, let's get a pizza! B Jay Leno
  • 39. 1. THEME? “She said, You’re not Mr. Right, but Mr. O.K. will do….” C Lyrics, Just Say No, Beres Hammond
  • 40. 1. COMMON THEME? Fill in the blank. A C B
  • 41. EACH STATEMENT CHALLENGES OUR NOTION OF WHAT IS AVERAGE. ANSWER:
  • 42. -- AND BY EXTENSION WHAT IS NOT AVERAGE, WHAT LIVES IN THE TAILS. ANSWER:
  • 43. 2. HOW MANY OF THESE 3 STATEMENTS COMMUNICATE THAT KEY POPULATIONS LIVE IN THE TAILS? 1. Key populations (also referred to as most-at-risk populations) are  people who inject drugs,  gay men and other men who have sex with men,  transgender persons and  sex workers. 2. They are disproportionately infected with HIV compared to the general population. 3. There is no way toward an AIDS-free future without targeting approaches toward these highly marginalized and often hard to reach populations. Source: FROM USAID WEBSITE APRIL 22 http://www.usaid.gov/what-we-do/global-health/hiv- and-aids/technical-areas/key-populations-targeted-approaches
  • 44. 2. ANSWER: ALL 3 1. Key populations (also referred to as most-at-risk populations) are  people who inject drugs,  gay men and other men who have sex with men (MSM),  transgender persons and  sex workers. 2. They are disproportionately infected with HIV compared to the general population. 3. There is no way toward an AIDS-free future without targeting approaches toward these highly marginalized and often hard to reach populations.
  • 45. Figure 2 Forest plot showing meta-analysis of risk of HIV infection among female sex workers compared with women aged 15–49 years in low-income and middle-income countries, 2007–11, Stefan Baral , Chris Beyrer , Kathryn Muessig , Tonia Poteat , Andrea L Wirtz , Michele R Decker, Susan G Sherma, The Lancet Infectious Diseases, Volume 12, Issue 7, 2012, 538 - 549 It’s true. Meta-analysis shows HIV infection among Sex Workers is much higher than among women 15-49. But…. IS SOMETHING MISSING?
  • 46. DIGGING DEEPER 1. Who are key populations? 2. Why are they more likely to be infected? 3. What programmatic response is needed? 4. Where?
  • 47. TOOLS TO DIG DEEPER
  • 49. 3. WHO Are Key Populations Per Global Definitions? KEY POP? A) Alli A 29 year old female who exchanges sex for cash? Yes or No B) Bob A 24 year old man with 5 female partners in the past 4 weeks who pays women for sex? Yes or No C) Chip A 34 year man who has had sex with men? Yes or No D) Daisy A 17 year old female student who has had 4 partners in the past 4 weeks and exchanges sex for cash Yes or No
  • 50. 3. WHO Are Key Populations? A and C ARE YOU SATISFIED WITH THE DEFINITIONS? KEY POP? Vulnerability STI PLACE A) Alli – A 29 year old female who exchanges sex for cash Yes Jailed HIV Yes B) Bob – A 24 year old man with 5 female partners in the past 4 weeks who pays women for sex No None None Yes C) Chip – A 34 year man who has had sex with men Yes Jailed Gonorrhea, Chlamydia Yes D) Daisy – A 17 year old student who has had 4 partners in the past 4 weeks and exchanges sex for cash No Youth Sex age 13 Chlamydia Yes
  • 51. Of 678 female workers at a sample of venues where people meet new sexual partners in Liuzhou China, how many are sex workers? 678 •Ever had sex 648 • 50+ 231•Exchanged sex for cash/gifts 148 • 26+  35+ • 148 Exchanged sex for cash past 4 weeks • 50+ Number with a a positive rapid test for syphilis. Illustrates limitation of a narrow sex worker definition. PLACE approach includes all 50 workers at venues who had a positive rapid syphilis test.
  • 52. WHY? ? ? ? New HIV Infections Extra credit: Fill in the blanks.
  • 53. CAUSAL MODEL Underlying Proximate Biological New HIV Infections Determinants Transmission  Exposure to HIV  Susceptibility to HIV  Number of partners  Lack of condom use  Anal Sex  Lack of Circumcision
  • 54. UNDERLYING DETERMINANTS Based on Boerma, Weir JID 2004 and collaboration with JP Figueroa General • Age • Sexual Orientation • Location Vulnerability • Unemployment • Low Education • Stress • Inadequate support • Genetics Adverse Life Events • Rape • Jail • Untreated infections • Homeless • Violence
  • 55. TAILORED RESPONSE Combination Prevention Programme Package of Individual Level High Quality Health Services Programme Enabler Interventions  SiteOutreach  Improveavailability,acceptability andaccessibilityofservices  Improvedqualityofservices Social Enabler Interventions  Empowermentactivities  Improvelegalandpolicyenvironment  Programstoaddressstigma,violence anddiscrimination EnablingEnvironmentatthe CommunityLevel Biomedical Services  HIVtestingandcounselling  Linkagetocare,viralload reduction  STIscreeningandtreatment  Psychosocialinterventions  Harmreduction includingneedle andsyringeprogramsandopioid substitutiontherapy  HBVImmunization Behaviour Change Services  Condompromotion& distribution  Targetededucation andriskreduction counselling Figure 1 Combination Prevention Programme (modified from Operational Guidelines for Monitoring and Evaluation of HIV Programmes for Sex Workers, Men who Have Sex with Men and Transgender People)
  • 56. PLACEStudy2012inAngolaIdentifiedVenuesWherePeople MeetNewSexualPartnersButInterventionProgramsare Insufficient Area with clusters of venues but no prevention program. WHERE? Programmatic Mapping To adequately focus effective, locally tailored HIV prevention response where it is most needed.
  • 57. “Superstar lawyers and math whizzes and software entrepreneurs appear at first blush to lie outside ordinary experience. But they don't. They are products of history and community, of opportunity and legacy. Their success is not exceptional or mysterious. It is grounded in a web of advantages and inheritances, some deserved, some not, some earned, some just plain lucky – but all critical to making them who they are. The outlier, in the end, is not an outlier at all.” Malcolm Gladwell, Outliers: The Story of Success
  • 58. “Sex workers, and gay men, transgender people, and people who inject drugs appear at first blush to lie outside ordinary experience. But they don't. They are products of history and community, of opportunity and legacy. The higher prevalence of HIV infection they share, their lack of access to services, their vulnerability, is not exceptional or mysterious. It is grounded in a web of disadvantages and disinheritances, prejudices and prison sentences, mostly undeserved, some just plain unlucky – but all critical to making them who they are, how they live, and what they will die from. The outlier, in the end, is not an outlier at all.” ― Sharon Weir, Edited text from Malcolm Gladwell, Outliers: The Story of Success
  • 59. ACKNOWLEDGEMENTS AND LAST QUESTION  MEASURE PLACE Team o Sarah Hileman, Zahra Reynolds, William Miller, Jess Edwards, Grace Mulholland  Mentors , Colleagues, Supporters o Peter Figueroa, Freddie Ssengooba, Ties Boerma, Keith Sabin, Abu Abdul-Quader, Jamie Blanchard, Jinkou Zhao, Ludo Bok, Jenny Butler, Lovette Byfield, Krista Stewart, Erin Balch, Joseph Mwangi, MEASURE Evaluation team 4) How many Jamaica references (loosely defined) appear in this presentation?
  • 60. ANSWER: 8 Based on Boerma, Weir JID 2004 and in collaboration with JP Figueroa Malcolm Gladwell, Outliers: 2 Mentors, Colleagues, Supporters Peter Figueroa, Lovette Byfield Jamaica Venue: Alli, Bob, Chip, Daisy