The results highlight that the HIV M&E system was designed at the national level (centrally), guided by a standardised HIV M&E framework. The HIV M&E system collected a large number of data elements that were not all analysed or used. There were numerous HIV data recording tools, some developed by staff themselves and so were not standardised across facilities. The M&E system comprised different data ‘silos’ – initially a parallel process was established for producing HIV prevention information (non-ART data) and later, with the introduction of antiretroviral treatment (ART) services, another parallel process was established solely for ART data (Paper 1 (182)). A summary of the extent of operational and administrative integration is presented in Table 14.
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Table 14: Nature and extent of operational and administrative integration of HIV M&E
Nature Extent of integration
No integration Partial integration Full integration
Operational& M&E system for Non-ART data
Rural site: Various forms were
in use for recording HIV prevention data (non-ART data) separately (e.g. different forms for VCT, PMTCT, and HIV/TB). These forms were separate from those used for the DHIS.
Both sites: dedicated HIV
programme personnel (nurses and data capturers) record most data.
Both sites: Some sharing where
generalist nurses record some PMTCT data.
Urban site: HIV prevention
data were recorded on a single integrated PHC data recording form.
Both sites: data collated on
DHIS forms, reported through DHIS and analysed by general HIS staff at district and provincial levels.
M&E system for ART data
Both sites: ART data recording
forms separate from DHIS forms. Dedicated data clerks capture only ART data. ART data collated monthly on summary forms that are separate from DHIS forms.
Rural site: ART data reported
through dedicated channels that by-pass the DHIS, captured in an ART dataset (excel spreadsheet) not linked to DHIS and managed at provincial level by HIV M&E manager located in HIV unit.
Urban site: ART M&E system
evolved from fully vertical to one with formal links to the DHIS. ART data collected on paper-based forms and reported to the DHIS office where captured on electronic ART register (Tier.net). ART data on Tier.net exported to DHIS, and managed at provincial level by an HIV M&E manager who is however located within a general HIS unit.
Administrative HIV programme managers largely use HIV data in programme and sub- programme silos, excluding district managers. #
Programme staff located within districts informally account to programme managers at provincial level (dual lines of accountability).
District managers exercise a HIGH degree of authority over HIV data collection and collation, but their tasks overlap with those performed by programme managers.*
District managers exercise LOW degree of authority over the USE of HIV data, while programme managers exercise a HIGH degree Provincial HIV managers perform routine oversight tasks more than they do specialist support tasks.
All programme personnel and managers in districts are formally accountably to district managers - fall within the district management chain of command.
&
For operational integration: results for the rural site are presented in Paper 1 ((182); data for urban site not published
#
Factors predictive of higher use of HIV data include: HIV M&E knowledge, being a programme manager. * Significant overlap of roles (duplication of effort) except programme managers focus only on programme data.
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Nature and extent of operational and administrative integration
Table 14 shows the extent of operational and administrative integration varies depending on the type of data (ART or non-ART data) and across the two sites (182). In both sites non- ART data were mostly collected, collated, analysed and disseminated through the district health information system (some aspects of non-ART data collection were partially or not integrated while collation, analysis and dissemination were fully integrated). However, all processes and personnel for producing ART information ran completely outside the DHIS in the rural site (Site A) (182), while in the urban site (Site B) ART data collection and collation were not integrated while data analysis were partially integrated (Table 14). In the urban site, during the course of the research the ART M&E system progressed from an entirely vertical and paper-based system to one in which ART data are collected and collated on paper-based sheets at facility level and captured at district level onto electronic registers – on software termed Tier.Net. Tier.Net software is not compatible with DHIS software – the former processes individual patient-linked longitudinal data, including data on HIV treatment outcomes, while the latter processes non patient-linked data on service activities. Summary ART data could however be exported from Tier.Net to the DHIS. As such, the ART M&E system was rated as “partially integrated” in the urban site and “not integrated” in the rural site where no linkage with the DHIS had been created (Table 14) (182).
Further, the ART M&E system captured a significant amount of energy and resources to produce ART data, but since it by-passed the DHIS, it did not make ART data readily available to district managers. Paper 1 reveals that real and perceived poor DHIS capacity and strict reporting requirements attached to the HIV conditional grant (which was intended primarily for the rapid scale-up of ART services) are potential drivers of a parallel ART M&E system (182). It emerged the National Departments of Health and Treasury required
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provinces to submit ART data to them monthly and quarterly, using dedicated reporting channels (a condition for receiving the grant). This was not a requirement for non-ART data.
Regarding administrative integration, the results depict a mixed picture with similar findings across the two sites (Table 14). As shown in Paper 2 (129), administration of HIV data collection and collation was partially integrated within district health management. This was rated as “partial” because though district managers exercised a high degree of authority over the collection and collation of HIV data (and statistically significantly higher than programme managers), there was some duplication of tasks as programme managers performed the same data collection and collation tasks (though focussing only on HIV-specific data) (129) Table 14). The results show that there has been little transfer of authority for using HIV data from programme to district managers – programme managers exercise high degrees of authority over HIV data, and statistically significantly higher than district managers who exercise low degrees of authority. Based on this finding and the tendency for programme managers to use HIV data in silos and not provide M&E specialist support to district managers, administrative integration of HIV data use was rated as “no integration” (Table 14) (129). HIV M&E is thus described as a “hybrid ‘indirect’ programme” (129) because operationally it is largely partially (non-ART data) integrated and administratively is partially (HIV data collation) or not integrated (HIV data use) within the district health system M&E function (129, 182)
Nature and extent of collaborative actor relations
The social network analysis study reveals complex and varied interactions, including some collaborative as well as siloed communication amongst programme and district actors. The results show that district and district-based programme managers shared more cohesive communication interactions than district and provincial-based programme managers about
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using HIV data for monitoring services in districts (Figure 8 (183)). Figure 8 also depicts that communication also occurred in programme silos across levels of hierarchy. As shown, provincial programme managers shared more cohesive communication with their district- based programme counterparts than with district managers (however, this was more the case in the rural site). Other data show that provincial programme managers tended to talk about using HIV data amongst themselves as a group (a high degree of homophily) and seldom talked to other actors about HIV data use, especially the district managers to whom they were supposed to provide specialist HIV M&E support.
Figure 8: Extent of communication about using HIV data for monitoring services
Programme managers
Senior management team (provincial level District Head (Director) District-based general health service managers District managers District-based programme managers (HIV, TB, MCH) Programme managers Provincial-based HIV programme managers Moderately cohesive M od er at el y co he si ve
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Finally, unlike programme managers, district managers were largely excluded from management committee meetings where HIV data were reviewed and used for monitoring HIV interventions within districts) (183).