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Introduction to Program Evaluation

Victor Balaban, PhDProgram Evaluation Team (PET)

Field Services and Evaluation Branch (FSEB)

Division of Tuberculosis Elimination (DTBE)

NCHHSTP/CDC

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Disclaimer

• The contents and conclusions in this presentation have not been formally disseminated by CDC and should not be construed to represent any agency determination or policy.

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What is Evaluation?

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Evaluation

• Evaluation is the systematic investigation of the merit, worth or significance of an object, hence assigning “value” to a program’s efforts means addressing those three inter-related domains:

• Merit (or quality) • Worth (or value, i.e., cost-

effectiveness) • Significance (or importance)

source: CDC Framework for Program Evaluation in Public Health: http://www.cdc.gov/eval/framework/index.htm

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Evaluation

• Evaluation is:• An activity that assists in planning and

measuring programs• a way of managing, improving and being

accountable for:• resources• activities• results

• Evaluation answers the question- “Is the program doing what we intend it to do?”

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What Can Be Evaluated?

• Direct service interventions

• Community mobilization efforts

• Research initiatives

• Surveillance systems

• Policy development activities

• Outbreak investigations

• Laboratory diagnostics

• Communication campaigns

• Infrastructure-building projects

• Training and educational services

• Administrative systems

Source: MMWR, 1999, Framework for Program Evaluation in Public Health

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Why Do We Evaluate?

Effectiveness - to determine if a program achieved it’s objectives

Impact - to assess how well program(s) are working

Improvement - to modify programs that are not working according to plan or take advantage of something that is working exceptionally well

Accountability - to report to stakeholders

To help develop new efforts

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How Does Evaluation Differ from Surveillance?

• Surveillance is the routine tracking of disease status or behavior over time

• Surveillance is not necessarily in relation to any specific program or intervention.

• Evaluation is conducted in relation to specific program(s) or intervention(s)

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How Does Evaluation Differ from Research?

The purpose of research is to produce knowledge about how the world works.

Evaluation studies are used to improve programs and inform decisions about future resource allocations.

The standards for evidence are higher in research, and the time lines for generating knowledge can be longer than for evaluation.

adapted from: Michael Patton as interviewed by Lisa Waldick (IDRC). 2002-02-08

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Why is Evaluation Important?

• Improve knowledge of program design• Improve program implementation• Reporting• Ensure that a program reaches those

who need it most • Give visibility to work• Demonstrate accountability • Share information• Enhance understanding of what works

best and what does not work – and why

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Example: TB – Completion of Treatment

• In a State, an organization received funds for a TB program. The program’s goal was to increase the proportion of newly diagnosed TB patients who complete treatment within 12 months to 93.0%.

• Records showed that in the three years since the program was funded, 85.0% of patients completed treatment within 12 months.

• Was the program successful?

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Example: TB – Completion of Treatment

• The State felt that the target of 93.0% treatment completion within 12 months was not reached and therefore the program had failed.

• The program staff, however, were confident that the program was a success because only 74.0% of patients had completed treatment within 12 months in the three years before the program was funded.

• Who is correct?

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Example: TB – Completion of Treatment

• Was the program a success or a failure?• What program management issues

does this example present? • What information is needed to make

management decisions for the way forward?

• How could evaluation have helped in this case?

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Remember

• The apparent success or failure of a program or activity must always be closely examined

• What you measure will determine what you are able to find out

• Evaluation can help us to do things differently and better understand the why and how of program/activity success

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Summary

• Evaluation is an activity that helps in program management

• Evaluation involves assessing a program or activity to find out:• What has been achieved• What progress has been made• What the successes and challenges

are

• What difference has been made by the program

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Types of Evaluation

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Types of Evaluation

Impact Evaluation

Outcome Evaluation

Process Evaluation

Formative EvaluationPlanning Effective Activity

Determining if ActivityWas Implemented As Intended

Determining If ActivityCaused Outcomes

DeterminingBroader Impacts

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When to Evaluate?

Conception Completion

Planning a

NEW program

Assessing a DEVELOPIN

Gprogram

--Public Health Program--

Assessing a STABLE, MATURE program

Assessing a

program after it has

ENDED

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Formative Evaluation

• Collects data describing the needs of a system or population, including those needs to be addressed by a program or activity.

• Answers questions such as:• How should the activity be designed or

modified to address participants’ needs?• What can we learn from pilot-testing our

approach?• Are the materials we are going to use

appropriate?

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Process Evaluation

• Collects more detailed data about the quality of the activity, factors that affected quality, and differences between intended and actual delivery of the activity .

• Answers questions such as:• Was the activity implemented as

intended?• Did the activity reach the intended

audience?• Why where there differences between

intentions and actual delivery?

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Outcome Evaluation

• Collects data to determine if, and by how much, program activities or services achieved their intended outcomes among the targeted population (often with a comparison or control group).

• Answers questions such as:• Did the activity result in the expected

outcomes?• Can we attribute observed changes among

the targeted population to the activity?• Can we indicate what might happen in the

absence of the activity?

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Impact Evaluation

• Collects data about a population or region over time to establish a causal association between programs and what they aimed to achieve beyond the outcomes on individuals targeted by the program(s)

• Answers questions such as:• What long term effect does the

activity, combined with other initiatives, have?

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Selecting an Appropriate Evaluation Method

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Criteria for Selecting Evaluation Method

• What evaluation question needs to be answered?

• Who needs the data?• What resources are available for

evaluation?

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What Information Is Needed? • Different stakeholders or users have different

information needs based on how they will use the information.

• Information needs also vary at the different stages of a program and the type of evaluation being conducted

• Staff• Funds

• Materials• Facilities• Supplies

Input (Resources)

• Trainings• Services• Education• Treatments

• Interventions

Activities (Interventions,

Services)

• # staff trained• # condoms

distributed• # test kits distributed

• # clients served• # tests conducted

Output (Immediate

Effects)

• Provider behavior• Risk behavior• Service use • Behavior

clinical outcomes• Quality of life

• TB incid/prev• Social norms• STI incid/prev

• AIDS morb/mort• Economic

impact

Outcomes(Intermediate

Effects)

Impact(Long-term

Effects)

Impact EvaluationProcess Evaluation Outcome Evaluation

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Most Some Few*All

Monitoring and Evaluation Pipeline

Adaptation of Rehle/Rugg M&E Pipeline Model, FHI 2001

Input/Output Monitoring

Process Evaluation

Outcome Evaluation

Impact Evaluation

Nu

mb

er of P

rog

rams

Levels of Evaluation Effort

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What Information Is Most Important?

• How do you prioritize your evaluation questions?

• Identify the use for the information

• Consider the feasibility of answering questions given the available resources

• Determine what you “need to know” vs. what is “nice to know”

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Three Types of Questions

• Descriptive Questions - “What is”• Describe a program/process

• Normative Questions – Compare “What is” to “What should be”• Measuring against a stated standard

• Cause and Effect Question – “Effect”• Measure before and after – with and

without comparisons

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Main Evaluation Question/Issue

Questions

Sub-Questio

ns

Type of (Sub)

Questions

Measures or

Indicators

Targetor

Standard

Baseline

Data ?

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Indicators

• A measurable piece of information that helps answer your evaluation question

• Indicators are signposts, markers or clues of change; they are intended to indicate whether objectives are being achieved

• Provide a reference point for program or project planning, management, and reporting

• Relates to the objectives of your evaluation

• Can be related to processes or outcomes

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Indicators

• Is also referred to as a performance measure in the NTIP

• Can use existing ones or develop ones tailored to a particular question

• Allow you to assess trends and identify problems

• Can act as early warning signals for corrective action

• An indicator is not the actual result, or the data collection method or tool

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Measures vs. Indicators

• Measures are descriptions of program functioning, while indicators measure one aspect of a program or a project that is usually directly related to particular objectives.

• Measures alone do not necessarily provide enough information to indicate how effective a program is in reaching its intended results

• Anything can be measured, however, every measure is not an indicator of program functioning

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Example

• You are buying a used car and want to know what condition the car is in: • You can measure many things when you

inspect the car: • Tire tread• How clean the oil is• Wear on brake pads• Rust on body of car

OR• You can examine the number of miles the

car has been driven

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Example

• You are developing indicators to measure HIV testing within your TB program: • You can measure many things

• # of people tested • # of people diagnosed• # of test kits purchased

OR

• You can examine the percent of program participants aged 15–49 receiving HIV test results in the past 12 months

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Key Elements of a Good Indicator

Specific: An indicator must be related to the conditions that the program/project wishes to change

Measurable: An indicator must be quantifiable and allow for analysis of the data

Appropriate: An indicator must be necessary and have relevance to the management of information needs of the persons who will use it

Realistic: An indicator must be attainable at a reasonable cost using appropriate collection methods

Time-based: An indicator must have a time period for collection clearly stated

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Examples of Indicators (from NTIP)

• proportion of patients, with newly diagnosed TB for whom 12 months or less of treatment is indicated, who complete treatment within 12 months

• proportion of contacts to sputum AFB smear-positive TB patients with newly diagnosed latent TB infection (LTBI) who start treatment

• percent of cooperative agreement recipients that have a TB training focal point

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Targets

• Reasonable expectations about what “success” means

• Should create one for each indicator

• Based on the current status of an activity

• Consider program requirements

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Collecting Evaluation Data

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Why Use Data?

• Data can help your program evaluate its program effectiveness and keep the focus on program outcomes

• Data can provide feedback to stakeholders about what is working, what needs to continue, and what can be reduced

• Data can convince stakeholders of the need to change

• Data can uncover problems that might otherwise remain invisible

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Types of Data

Quantitative Data Numbers More objective Epidemiological data

Qualitative Data Words and/or concepts More subjective Observations

Both can be used in evaluation

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Data Collection Methods

Quantitative Data Collection Surveys/Questionnaire Secondary data Surveillance data Epidemiological data

Qualitative Data Collection Focus groups Interviews/Case study Observations

Mixed Methods

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Comparison of Data Collection Methods

Methods Advantages DisadvantagesSurveys •Anonymity possible

•Can administer to groups

•Efficient & cost effective

•Forced choices limit response •Wording may bias response•Impersonal

Individual interviews

•Can build rapport•Can probe for more info

•Can get breadth/depth of info

•Time consuming•Expensive•Interview style may bias

Focus groups

•Can get breadth & depth of info in short time frame

•Can convey key info re program

•Need trained facilitator•Time consuming to analyze responses

Observation

•Can assess fidelity as activities occur

•Interpretation of behavior difficult•Expensive & time consuming

Document review

• Info already exists•Doesn’t disrupt program

•Depends on quality of info•Time consuming

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Data Sources

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Data Sources

Two Options:

1. Collect information from existing sources: surveys. program records, databases, documents, etc.

2. Collect new data

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Data SourcesWhere or from whom will you get data for each of your indicators to answer your evaluation questions?

Data Sources

Examples

Documents medical records, meeting minutes, surveillance reports, interview records

Individuals staff, providers, partnership members

Observations

data obtained from observations of staff, environment (reception area), office flow, activities, etc.

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Existing vs. New Data

• Be aware that gathering and analyzing new data can be expensive and time consuming

• Before making any plans to gather new data make sure to check if there are existing data sources that have the information you need

• If no existing data sources provide the information you need, then you may need to consider collecting new data

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Data Needs and Sources

• Needs• What data do we need to achieve

objectives?• For whom do we need to use it?• Does the system do what it is supposed

to do?• What is the timeframe for data use?

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Good Data Sources

• Provide the necessary information to answer your evaluation questions

• Are feasible to access given the available resources

• Offer confidence in the quality of information gathered

• Are relevant to the time period you are interested in

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Existing TB Data Sources

• Routinely collected data:• Record forms at the health facility• Record and report forms at the

city/county/state level• Record and report laboratory forms• Census / Vital statistics• Surveillance / BRFSS• NHANES / NHIS

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Existing TB Data Sources

• Other data sources at various levels:• Work plans and budgets• Annual reports• Audits• Meeting reports• Planning documents• Procurement records• Storage facility stock cards

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Conducting an Evaluation

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1. Identify program goals and objectives

2. Define the scope of the evaluation

3. Define evaluation questions & indicators

4. Define methods

5. Design instruments and tools

6. Carry out the evaluation

7. Analyze data and write a report

8. Disseminate and use data

source: FHI, Impact, USAID manual

Essential Steps to Evaluation

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Evaluation ProcessC

ap

aci

ty B

uild

ing

Involv

em

en

t of

Sta

kehold

ers

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Gathering the Information You Need

1) Determine your evaluation question2) Identify the type of data you need to

answer your questions 3) Identify sources where you can find the

information you need4) Determine the methods you will use to

review existing information or collect new data

5) Identify the tools you will use to collect new data

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Evaluation Barriers

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Evaluation Barriers

Unrealistic targets/goals

Objectives not linked to program

Not meaningful to the program activities

Measures poorly defined – not useful

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Overcoming Barriers

Include evaluation during planning phase Involve key stakeholders from outset Establish realistic goals/objectives with

time frames Establish appropriate, well-defined

evaluation measures Provide training and/or technical

assistance Build in feedback loops to program

(quality improvement) Establish baseline Build into existing work processes

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If We Remember Nothing Else …..

• Evaluation is not surveillance or research

• Evaluation is an activity to help us make decisions about a program and to document its improvements

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Thank you

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Acknowledgements• DTBE/FSEB/

Program Evaluation Team (PET)• Awal Khan• Christina

Dahlstrom• Judy Gibson• Lakshmy Menon• Brandy Peterson• Lauren Polansky

• DTBE/FSEB/Field Services Teams I & II• Greg Andrews• Dan Ruggiero• Bruce Bradley• Gail Burns-Grant• Alstead Forbes• Regina Gore• Andy Heetderks• Mark Miner• Vic Tomlinson• Dawn Tuckey