Malaria M & E Data Sources

1. Malaria M & E Data Sources

2. Objectives By the end of this session participants will be able to: • Recognize different data types and sources • Differentiate between routine and non-routine sources • Recognize the strengths and weaknesses of different sources • Recognize strategies for linking data sources • Recognize appropriate data sources for measuring malaria intervention coverage and impact

3. Introduction

4. Potential Data Sources Health Facility Survey Data Routine Data (HMIS) Verbal Autopsy Data Focus Group discussion, Key informant interview Household Surveys Meteorological Data GIS, Satellite Data Malaria M&E Rapid Assessment Data Sentinel Surveillance Census Data Activity Monitoring System Routine Monitoring at the Community Level Data Health & Demongraphic surveillance system data

5. Data collection process

6. Classification by Data collection process Routine Non-Routine • RHIS/HMIS (Routine) • Surveillance • Administrative systems • Vital registration systems • Special program reporting systems • Facility surveys • Household surveys • Censuses • Key informant Interview • Focus groups • Direct observations • Research and special studies • Rapid assessments • GIS • Remote sensing

7. What is the difference between data on the number of bed nets distributed and data collected from interviews on why people are not using bed nets?

8. Types of data

9. Classification by Data Type Qualitative Quantitative • Key informants Interview • Focus groups • Direct observation • Special program reporting systems • Rapid assessments • Research and special studies • HMIS • Surveillance • Facility surveys • Household surveys • Censuses • Routine service reporting • Vital registration systems • GIS, Remote sensing

10. Other considerations Similar to when defining indicators: • Does the data exist for the specified time period? • Year, Month, … • Does the data exist for the specified population? • General population, Age group, Gender… • Does the data exist for the specified geographic area? • Rural, urban, spatial, Program area, … • Does the data exist for the administrative/functional level? • National, Sub-national (e.g. district), Policy or program, Service environment

11. Surveillance

12. Surveillance Surveillance: Ongoing, systematic collection, analysis and interpretation of health data* *McGraw-Hill Dictionary of Modern Medicine Surveillance Systems: • Routine Health Information System • Sentinel Site Surveillance

13. Objectives of Surveillance • Provide accurate andtimelytrend data on malaria prevalence, mortality, and severity of illness • Detect and track outbreaks • Monitor progress toward elimination • Facilitate rapid medical and programmatic response • Evaluate control and prevention activities • Document the distribution of health events/disease by person place and time • Use data for planning

14. Surveillance Strengths Weaknesses • Flexible, can be adapted to cover specific issues/topics to collect information that is otherwise hard to obtain • Can collect a wide range of information from input to impact • Especially useful and necessary when event being monitored is rare and requires a rapid response • Expensive and resource intensive because need to: • Identify sites and adequately resource them • Train staff at sites • Create system to monitor and transfer data to central authorities • Active surveillance even more resource intensive • Not representative because: • limited catchment area • sites are frequently more resourced than regular facilities

15. Routine Health Information Systems (RHIS)

16. Routine Health Information Systems RHIS: Ongoing data collection of health status, health interventions, and health resources *McGraw-Hill Dictionary of Modern Medicine • Examples: facility-based service statistics, vital events registration, community-based information systems • Also known as: HMIS-Health Management Information System • Can be used for passive surveillance 16

17. Health Facility Data • Malaria morbidity (Uncomplicated –outpatients) • Severe malaria morbidity (admissions) • Severe anemia (outpatients and admissions) • Malaria Deaths in Health Facilities • Malaria Treatment Failures • Availability of Antimalarial Drugs or stock-outs • IPTp • Confirmed and suspected malaria • Side Effects to Treatment • Malaria Epidemics • (Records of early detection and appropriate response)

18. RHIS Strengths Weaknesses • Ideally reflective of and integrated within health system activities • Continuously collected, so suitable for frequent reporting • Systems already exist • Typically available at lowest administrative levels (e.g. district, facility) • Data limited to health services users • Difficult to determine population at risk • Indicators already defined • Quality and completeness of reporting frequently varies • May only cover government facilities • Potential for double-counting, both within and between facilities

19. Sentinel Surveillance

20. Surveillance Systems: Sentinel Surveillance Sentinel surveillance: Surveillance undertaken in a limited number of health facilities *McGraw-Hill Dictionary of Modern Medicine • Can be passive/routine and enhanced OR • Active surveillance OR • Combination of both

21. Sentinel Surveillance is Useful When: • Routine information system is inadequate (morbidity and mortality) • High quality data is needed to monitor trends • Disease outbreaks need to be rapidly identified • Geographical distribution of malaria varies greatly • Data on other malaria indicators is needed (Entomological data, Parasitological data, Pharmacology)

22. Limitations of Sentinel Surveillance • Costly to equip and operate • Require frequent supervision • Sites not representative of all health facilities • Patients not representative of the community • Data not easily generalizable • Record keeping is burdensome to facility staff • Changes in use of health services can bias trend data

23. RHIS Sentinel Surveillance All health facilities reporting Few facilities reporting Usually monthly or quarterly Daily, weekly or monthly May be suspected or confirmed cases Confirmed cases (requires testing 100% of suspected cases) Aggregate counts Patient cards RHIS vs Sentinel Surveillance

24. ExerciseComparing malaria data collection tools Individual patient form Aggregate health facility form

25. Selection of Facilities for Sentinel Surveillance Sites Location of site depends on: • Distribution of disease prevalence (endemic regions) • Variation in climate • Area of intervention • Capacity of health facility to serve as sentinel site • NOT selected to be representative of population The number of sites depends on: • Funding level • Population density and distribution

27. Surveys

28. Why Do a Survey? • To gather information not available from other sources • To obtain an unbiased representation of the population of interest through probability sampling • To collect the same information from every respondent using standardized measurement • To complement existing data from secondary sources • To obtain data on population and services

29. Basic Survey Designs • There are two basic types of surveys: • Cross-sectional surveys • Longitudinal surveys

30. Population-Based National Surveys • Usually cross-sectional and requires sampling • Measures household characteristics and behaviors • Can yield national or regional estimates • Repeated surveys of the same target population • Trend analyses comparing changes over time

31. Population Surveys - Merits Advantages • Can measure a wide array of outcomes and predictors • Cheaper than longitudinal studies • Nationally representative • Can be used for multi-country comparisons • Can be used for multi-year comparisons in the same population Disadvantages • Complex to design • Not usually suitable for district-level estimates • Recall bias • Expensive, time-consuming • Information rapidly outdated, unless repeated • Difficult to establish causation between predictors and outcomes

32. Malaria Indicator Surveys (MIS) • Collect data to calculate indicators listed in the Household Survey Indicators for Malaria Control • malaria control and prevention interventions • malaria-related morbidity • Provide more frequent national data than what is collected by DHS/MICS • Collect data during height of malaria transmission season • Often during rains, more challenging logistics than dry season

33. Why Malaria Indicator Survey instead of DHS/MICS? • Requires smaller samples if not collecting mortality data • Less expensive • Less time-consuming • Targets malaria transmission season

34. Health Interventions Measured by MIS • Ownership and use of bed nets • Any nets • Insecticide Treated Nets • Long-lasting insecticidal nets • Use of Indoor Residual Spraying (IRS) of insecticides • Intermittent Preventive Treatment in Pregnancy (IPTp) • Case management in children

35. Health Impacts Measured by MIS • Parasite prevalence • Rapid Diagnostic Test (RDT) Results • Microscopy Results • Anemia • Altitude adjusted hemoglobin <8g/dL • Children <5 • Under five child mortality (5q0)

36. MIS Questionnaire Data Used for M & E Household • IRS • Bednet Roster • Totals • Types • Treatments • Use • Anemia (6-59 months) • Parasite prevalence (6-59 months) • Rapid diagnostic test (RDT) results • Microscopy results Woman’s • Current pregnancy status • Pregnancy in past 2 years • ANC • IPTp (doses, type) • Children under five • Birth history • Child health • Fever • Diagnosis • Treatment seeking

37. Health Facility Surveys – What are they? • Cross-sectional studies to assess health facilities using a standardized instruments • Usually use a simple random sample • Survey usually conducted by trained health workers (often doctors) • Examines different aspects of service delivery including technical quality of care

38. Facility Surveys - Purpose • To understand the links between households and providers • Patterns of Use /Barriers to Care • To assess provider behavior and performance • Quality of services • To understand relationships between providers • To understand linkages between government & providers • To identify gaps between community health needs and available services

39. Facility Surveys – Data Collection Methods • Health Facility Surveys also vary in the way they collect data: • Direct observation • Record review • Interview (Staff, Clients, etc) • Some quality data are collected through clinical vignettes

40. Facility Surveys – Uses • Facility data have been put to a variety of uses: • Planning and budgeting • Monitoring & evaluation • Promoting accountability • Research • Improving quality of care • Shaping or reforming health policies

41. Health Facility Surveys - Merits Advantages • Can assess quality of care • Can be independent of service providers • Timing can coincide with program implementation • Can combine with population survey for outcome evaluation • More detailed information than is typically available in routine systems Disadvantages • Complex to design • Lots of data, can overwhelm • Cannot provide information on coverage, equity • Expensive, time-consuming • Information rapidly outdated, unless repeated

42. Vital Registration

43. Vital Registration • Demographic Data • Systematic collection of those variables that describe the characteristics of a population (i.e., population size and how it changes over time) • Vital Statistics (events) • Births • Deaths • Marriages • Divorces • Migration

44. Vital Registration • Demographic Variables • Age • Sex • Income • Occupation • Health Services untilisation • Geographic location • Geographic density

45. Vital Registration Merits Advantages • Can be an excellent source of data on mortality when data are accurate and complete • Can provide a basis for calculating population at risk or target population Disadvantages • Does not capture most births and deaths which occur outside of facilities in developing countries

46. Verbal Autopsy

47. Verbal Autopsy Process VA is an indirect, community-based, method of ascertaining cause of death • Deaths identified through surveillance, household surveys, national census • VA interview occurs - respondents are asked about the circumstances and events leading to death of a person, including signs and symptoms and their durations in the period before death • ‘Death certificates’ produced by a panel of physicians, and UCOD (Underlying Cause of Death) coded to ICD-10 • Mortality statistics tabulated using agreed list based on ICD-codes

48. Verbal Autopsy- Merits Advantages • Replicable, crude, but moderately reliable for estimating malaria mortality in the absence of vital registration systems • Readily adaptable to different platforms Disadvantages • When using physicians to code deaths there can be variation between individuals in sensitivity and specificity • Costly and time consuming • Requires a large sample size to capture enough deaths

49. Health and Demographic Information Systems (HDSS)

50. What is a HDSS? Capturing episodes of disease and hospital admission Intervention trials (randomised) Verbal autopsy for cause of death Measure characteristics of environment or household members (e.g. SES, vaccines, HIV, nutrition)