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Program Evaluation
Regional Workshop on the Monitoring and Evaluation of HIV/AIDS
ProgramsFebruary 14 – 24, 2011
New Delhi, India
Objectives of the Session
By the end of this session, participants will be able to:
Understand the purpose and role of program evaluation
Distinguish between different evaluation types and approaches
Link evaluation designs to the types of decisions that need to be made
Why Evaluate HIV/AIDS Programs?
To improve the design an implementation of a program
To reach informed decisions on the allocation of existing limited resources, thereby increasing program performance and effectiveness
To identify factors that influence health and social outcomes
To generate knowledge, to know what works and what does not.
Good evaluations are public goods
Current Challenges in Evaluating HIV Preventon Programmes HIV prevention programmes are increasingly
complex, multi-component and context-specific
The underlying behavioural theories leading to multiple behaviour changes and ultimately impact are difficult to assess;
Many projects/interventions/services aim to affect HIV risk factors and/or vulnerabilities rather than averting HIV infections directly.
Source: Strategic Guidance for Evaluating HIV Prevention Programmes. UNAIDS 2010
All Programs/Projects have (implicitly or explicitly): Objectives Expected outcomes Target population
Mechanism(s) to deliver services (the intervention)
Criteria for participating in the program
A conceptual framework that provides rationale for program existence (sometimes called the Development Hypothesis)
Monitoring vs. Evaluation
Objectives of Monitoring:
To provide information on the functioning of the program:
a) Is it progressing according to plan?
b) Identify problems for correction
To track key program elements over time (to assess changes)
Characteristics of Monitoring:
•Mostly tracks key quantifiable indicators of key program elements:• inputs, processes, outputs, and outcomes
•Often done on a routine basis
•Key issue: good measurement using relevant indicators
•No assessment of what is the cause of the change in the indicators
Objectives of Evaluation:
- To determine whether a program achieved its objectives
- To determine the impact of the program on the outcome
intended by the program
- How much of the observed change in the outcome can be
attributed to the program and not to other factors?
Characteristics of Evaluation:
- Key issues: causality, quantification of program effect
- Use of evaluation designs to examine whether an observed change in outcome can be attributed to the program
Note: Monitoring tells you that a change occurred; Impact Evaluation will tell you whether it was due to the program
Monitoring vs. Evaluation
Deciding Upon An Appropriate Evaluation Design
Indicators: What do you want to measure?
Provision
Utilization
Coverage
Impact
Type of inference: How sure to you want to be?
Adequacy
Plausibility
Probability
Other factors
Source: Habicht, Victora and Vaughan (1999)
Clarification of Terms
Provision Are the services available?
Are they accessible?
Is their quality adequate?
Utilization Are the services being used?
Coverage Is the target population being reached?
Impact Were there improvements in disease patterns or health-related behaviors?
Clarification of Terms
Adequacy assessment
Did the expected changes occur?
Are objectives being met?
Plausibility assessment
Did the program seem to have an effect above and beyond other external influences?
Probability assessment
Did the program have an effect (P < x%)
Source: Habicht, Victoria and Vaughan (1999)
Adequacy Assessment Inferences Are objectives being met?
Compares program performance with previously established adequacy criteria, e.g. 80% ORT use rate
No control group
2+ measurements to assess adequacy of change over time
Provision, utilization, coverage
Are activities being performed as planned?
Impact
Are observed changes in health or behavior of expected direction and magnitude?
Cross-sectional or longitudinal
Source: Habicht, Victora and Vaughan (1999)
Plausibility Assessment Inferences (1) Program appears to have effect above & beyond impact of
non-program influences
Includes control group Historical control group
Compares changes in community before & after program and attempts to rule out external factors
Internal control group Compares 3+ groups/individuals with different intensities of exposure to program
(dose-response)
Compares previous exposure to program between individuals with and without the disease (case-control)
External control group Compares communities/geographic areas with and without the program
Source: Habicht, Victora and Vaughan (1999)
Plausibility Assessment Inferences (II)
Provision, utilization, coverage Intervention group appears to have better performance than
control
Cross-sectional, longitudinal, longitudinal-control
Impact Changes in health/behavior appear to be more beneficial in
intervention than control group
Cross-sectional, longitudinal, longitudinal-control, case-control
Source: Habicht, Victora and Vaughan (1999)
Probability Assessment Inferences
There is only a small probability that the differences between program and control areas were due to chance (P < .05)
Requires control group
Requires randomization
Often not feasible for assessing program effectiveness Randomization needed before program starts
Political factors
Scale-up
Inability to generalize results
Known efficacy of intervention
Source: Habicht, Victora and Vaughan (1999)Source: Habicht, Victoria and Vaughan (1999)
Evaluation Flow from Simpler to More Complex Designs
Type of evaluation Provision Utilization Coverage Impact
Adequacy 1st 2nd 3rd 4th (b)
Plausibility 4th (a) 5th
Probability
Source: Habicht, Victoria and Vaughan (1999)
Possible Areas of Concern to Different Decision Makers
Type of evaluation Provision Utilization Coverage Impact
Adequacy Health center manager
International Agencies
District health managers
International Agencies
Plausibility International Agencies
Donor agencies
Scientists
Probability Donor Agencies & Scientists
Source: Habicht, Victora and Vaughan (1999)
Process Evaluations Assess whether the program was implemented as
intended
May look at Access to services
Reach and coverage of services
Quality of services
Client satisfaction
May also provide an understanding of cultural, socio-political, legal and economic contexts that affect implementation of the programme.
Outcome/Impact Evaluations
Assess whether changes in outcome/impacts are due to the program.
May look at
Outcomes such as HIV-related behaviors,
Health impacts such as HIV status, life expectancy
Programstart
Programmidpoint or end
Time
Outcome
The EvaluationQuestion:How much ofthis change is due to theprogram?
Evaluating Program Impact
Withprogram
Withoutprogram
Programstart
Programmidpoint or end
Time
Outcome
Evaluating Program Impact
Net Program Impact
Features of Different Study Designs
True experiment Quasi-experiment Non-experimentalPartial coverage/ new programs
Control group
Strongest design
Most expensive
Partial coverage/ new programs
Comparison group
Weaker than experimental design
Less expensive
Full coverage programs
--
Weakest design
Least expensive
Readiness criteria for Outcome & Impact Evaluation The program
is implemented with sufficient quality
has achieved adequate coverage
is of long enough duration that expected change in the specified outcomes for the evaluation has had time to occur
When to use an experimental or quasi-experimental design
The program has unknown effectiveness
There is the potential for negative effects
The program is politically or otherwise risky
Source: Strategic Guidance for Evaluating HIV Prevention Programmes. UNAIDS 2010
Who should plan for Evaluation?
All programs should conduct basic monitoring
Most programs should conduct process evaluations Implementation assessments
Quality assessments
Coverage assessments
Some programs should conduct outcome evaluation when evidence is needed as to whether the program is effective
References Adamchak S et al. (2000). A Guide to Monitoring and Evaluating
Adolescent Reproductive Health Programs. Focus on Young Adults, Tool Series 5. Washington D.C.: Focus on Young Adults.
Fisher A et al. (2002). Designing HIV/AIDS Intervention Studies. An Operations Research Handbook. New York: The Population Council.
Habicht JP et al. (1999) Evaluation designs for adequacy, plausibility and probability of public health programme performance and impact. International Journal of Epidemiology, 28: 10-18.
Rossi P et al. (1999). Evaluation. A systematic Approach. Thousand Oaks: Sage Publications.
UNAIDS (2010). Strategic Guidance for Evaluating HIV Prevention Programmes.
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.