Evidence Action — Syphilis Screening and Treatment in Pregnancy in Zambia and Cameroon (July 2022)

Note: This page summarizes the rationale behind a GiveWell grant to Evidence Action's syphilis screening and treatment in pregnancy program. Evidence Action staff reviewed this page prior to publication. The page reflects our rationale at the time the grant was recommended.

Published: February 2023

The organization

We have a longstanding relationship with Evidence Action and have supported a number of its programs over the years, including the Deworm the World Initiative and Dispensers for Safe Water. GiveWell also partners with and has recommended grants to the Evidence Action Accelerator to support a dedicated incubator portfolio focused on GiveWell-aligned, evidence-backed, cost-effective interventions.

The intervention

There is reasonably strong evidence showing that treating syphilis in pregnancy with benzathine penicillin G (BPG) is effective in substantially reducing adverse outcomes that can result from syphilis in pregnancy, such as neonatal mortality, stillbirth, preterm birth, and incidence of congenital syphilis. See our report on screening and treatment of syphilis in pregnancy for our review of this evidence.

In 2015, WHO prequalified a dual HIV/syphilis rapid diagnostic test that can be used to simultaneously diagnose both HIV and syphilis in under 20 minutes.1 With this grant, Evidence Action will provide technical assistance to the governments of Cameroon and Zambia to facilitate a switch from HIV rapid tests to dual HIV/syphilis rapid tests and to scale up syphilis treatment in routine antenatal care nationally. This presents an opportunity to leverage the existing antenatal HIV screening platforms in those countries to increase screening and treatment of syphilis in pregnancy.2

The grant

Planned activities

This six-year, $15 million grant will allow Evidence Action to support the roll out of the rapid dual HIV/syphilis test in Zambia and Cameroon. Evidence Action has told us that its activities will include:

• Supporting Zambia and Cameroon in updating national antenatal care guidelines and national HIV testing guidelines to include guidelines on dual HIV/syphilis rapid test administration and treatment of syphilis
• Supporting Zambia and Cameroon in the procurement of the dual rapid tests, syphilis-only rapid tests (where needed) and penicillin for treatment of syphilis, via the Global Fund, PEPFAR, and direct procurement
• Supporting Zambia and Cameroon in managing and monitoring the supply chain for both dual rapid tests and penicillin
• Supporting the revision of facility reporting templates to ensure integration of syphilis screening and treatment indicators
• Working with the governments of Zambia and Cameroon to train providers to use the dual rapid test and provide treatment for syphilis and to provide ongoing supportive supervision
• Working with the governments to develop tools for training and supportive supervision of health facilities
• Monitoring program activities and the impact of the program on coverage of syphilis screening and treatment among pregnant people and recommend appropriate program design and policy changes to the local governments to achieve optimal efficiencies

Budget and timeline

Evidence Action has proposed a total budget of approximately $15 million for the activities described above, including approximately $7 million over a period of five years in Zambia and $8 million over a period of six years in Cameroon.

Very roughly, the budget breaks down as follows:

Budget Category	Amount	% of grant
Personnel Costs	$5,556,680	37%
Travel Costs	$444,000	3%
Operating Costs	$383,830	3%
Program Implementation Costs	$4,333,478	29%
Monitoring and Evaluation Costs	$1,260,179	8%
Other Costs	$3,174,953	21%

See here for more details on the budget breakdown.

The case for the grant

Cost-effectiveness

Based on our cost-effectiveness analysis of Evidence Action’s syphilis screening and treatment program in Zambia and Cameroon, we estimate that the program supported by this grant is 29 times as cost-effective as unconditional cash transfers.

Note that our cost-effectiveness analyses are simplified models that do not take into account a number of factors. There are limitations to this kind of cost-effectiveness analysis, and we believe that cost-effectiveness estimates such as these should not be taken literally due to the significant uncertainty around them. We provide these estimates (a) for comparative purposes and (b) because working on them helps us ensure that we are thinking through as many of the relevant issues as possible.

The high cost-effectiveness is largely due to the high prevalence of syphilis among pregnant people in both Zambia and Cameroon3 and the relatively low costs of the intervention.4 Although there are a number of uncertain parameters in the cost-effectiveness analysis, the portfolio still looks cost-effective under a range of plausible values for those parameters.5

Important inputs to our cost-effectiveness estimate about which we have particular uncertainty include:

• Syphilis treatment rate: We are highly uncertain about the extent to which Evidence Action’s support will increase the syphilis treatment rate among pregnant people who attend ANC over the counterfactual. For instance, the barriers to treatment (e.g. supply chain issues, provider adherence, patient acceptance of treatment)6 may be higher or lower than we guessed.
• Likelihood of failure: We’ve assumed some chance that the program fails to achieve significant scale at all due to implementation barriers such as supply chain issues, but our assumption is highly speculative.
• Crowding out government or other external funding:7 Zambia and Cameroon have demonstrated strong interest in the dual test (see below), and we may be underestimating the likelihood that the governments would scale up dual tests on their own in the absence of an NGO partner and external funding.
• Likelihood of government transition: Evidence Action plans to work closely with Zambia and Cameroon’s Ministries of Health throughout the program scale-up and to integrate the program activities into the countries’ existing routine HIV programming.8 It expects that the governments, PEPFAR, and Global Fund will likely be able to cover ongoing procurement of dual tests.9 We’ve assumed a fairly high likelihood of the program being successfully transitioned to the government, but we could be significantly over- or underestimating the likelihood.

True funding gap

In the absence of GiveWell support, we think it’s unlikely that another organization would support these countries in rolling out this program.10 We think it’s more likely that in the absence of Evidence Action’s support, the country governments may eventually switch to dual tests, but on a slower timeline and with lower quality implementation.11

Evidence Action as a partner

We have an existing grantee relationship with Evidence Action and are already generally aligned on the importance of factors such as cost-effectiveness, impact, transparency, and monitoring and evaluation. Moreover, we believe that Evidence Action has the organizational experience to successfully implement the program, due to the following:

• Evidence Action has experience in working with the Liberia National AIDS and STI Control Program (NACP) to launch the rollout of a very similar program in Liberia,12 and facility-reported data in Liberia suggests that the program has been successful in achieving high syphilis screening rates.13
• Evidence Action has demonstrated that it is able to provide impactful technical assistance to national governments on similar large-scale public health programs, such as deworming and iron folic acid supplementation.14
• As of the recommendation of this grant, Evidence Action seems to have made strides in engaging with global and country stakeholders.15

Risks and reservations

Lack of existing country presence

As of our recommendation of this grant, Evidence Action does not have country offices in Zambia or Cameroon, and the relationships that it has built with country stakeholders are relatively new.16 There is some risk that Evidence Action may gain less traction than we expect in engaging effectively with stakeholders in each country and successfully scaling up the program.

It is also plausible that, since Evidence Action does not yet have an existing presence in Zambia and Cameroon, funding it to provide technical assistance in those countries may enable it to build stronger relationships with the Ministries of Health and learn more about the policy environments and antenatal care systems, which could be leveraged in the future for other technical assistance programs in Zambia and Cameroon.

We are uncertain about the level of government commitment

Evidence Action has told us that the governments in both Zambia and Cameroon have shown interest in this program by beginning to adopt HIV/syphilis dual testing into national policy, procuring dual tests, and/or beginning the planning process for piloting;17 however, we have not triangulated these claims. It’s possible that we’re overestimating the level of government buy-in for switching to dual HIV/syphilis tests, which could make policy change, scale-up, or successful transition of the program to the government less likely than we’ve estimated.

Too early to know how successful this program is in Liberia

In August 2020, GiveWell recommended a grant to Evidence Action to implement a switch from HIV rapid tests to dual HIV/syphilis rapid tests in Liberia. We have seen some facility-reported data that suggest high syphilis screening rates in the facilities where Evidence Action has implemented the program in Liberia. However, Evidence Action has not yet concluded its initial monitoring and evaluation to triangulate these facility-reported syphilis screening rates nor to estimate syphilis treatment rates among patients who test positive.18 Thus, we are as of yet uncertain how successful the program has been in Liberia, and we could be overly optimistic about how successful the program will be in Cameroon and Zambia.

In addition, our understanding from conversations with Evidence Action is that the program roll-out in Liberia has been slower than expected (about 6 months behind Evidence Action’s initial projections), so it’s plausible that there may be delays in Zambia and Cameroon as well. However, Evidence Action has told us that the delays were primarily caused by the COVID-19 pandemic, so may not be indicative of future timelines. Moreover, Evidence Action claims to be in a significantly better position to roll the program out smoothly in Zambia and Cameroon, particularly in the area of monitoring and evaluation, due to its learnings from Liberia and the stronger data environments of both Zambia and Cameroon.

Plans for follow-up

Evidence Action will provide six-monthly updates on progress with dual HIV/syphilis rapid test rollout. They have also developed a monitoring plan to assess the syphilis screening and treatment rates achieved among pregnant people following introduction of the dual test.

Monitoring and evaluation

Evidence Action’s proposed monitoring and evaluation plan for this grant consists of:19

• Using routine country monitoring systems to track the number of pregnant people screened and treated
• Routine program reporting via supportive supervision
• “Comprehensive facility surveys” that will include reviewing facility-level data tools, commodity stock, qualitative interviews, and knowledge and skills assessments of healthcare providers to assess the gaps in care at the facility-level and triangulate facility-reported coverage data

We think it is fairly likely that the facility-reported data obtained from this monitoring plan may not be reliable or accurate enough for us to estimate the coverage of syphilis screening and treatment achieved by the program. However, we have recommended the grant with this monitoring plan rather than a more rigorous direct observation study due to Evidence Action’s concerns that such a study would cause disruptions in facilities and because accurate estimates of screening and treatment coverage may not be highly valuable if the overall funding we direct to this program is likely to be limited.

Forecasts

With X% confidence,	We predict that…	…by Y time
55%	Evidence Action will have fully transitioned this work to the government in Zambia in 5 years (2027), spending less than $150,000 per year in-country on this program (ongoing political support, monitoring support, etc.)	August 2027
50%	Evidence Action will have fully transitioned this work to the government in Cameroon by 6 years (2028), spending less than $150,000 per year in-country on this program (ongoing political support, monitoring support, etc.)	August 2028
40%	The 3rd facility survey will find that at least 60% of clinics surveyed in Cameroon have adequate stock of dual tests (enough to cover at least 2 months of projected need)	August 2028
40%	The 3rd facility survey will find that at least 60% of clinics surveyed in Zambia have adequate stock of dual tests (enough to cover at least 2 months of projected need)	August 2028
65%	Syphilis screening rates among ANC attendees in Cameroon will reach at least 90% of the level of HIV screening rates, based on facility-reported data	August 2028
65%	Syphilis screening rates among ANC attendees in Zambia will reach at least 90% of the level of HIV screening rates, based on facility-reported data	August 2028

Our process

• We recommended a grant to Evidence Action Accelerator to build out a dedicated portfolio focused on scoping and bringing to scale evidence-backed, cost-effective interventions.
• As part of this work, Evidence Action investigated opportunities to address syphilis in pregnancy, spoke with experts, and conducted initial in-country scoping visits to Liberia, Indonesia, Zambia, Cameroon, and Nigeria. In 2020, we recommended a grant to Evidence Action to support the scale up of syphilis testing and treatment in pregnancy in Liberia.
• We had several calls and many email exchanges with Evidence Action to understand its proposed activities, programmatic risks, monitoring and evaluation plan, and budget.
• Using our cost-effectiveness analysis of syphilis screening and treatment in pregnancy as a base, we created a program-specific cost-effectiveness analysis of Evidence Action’s program in Zambia and Cameroon. This cost-effectiveness analysis was based partly on our conversations with Evidence Action and partly on our research.

Sources

Document	Source
2022 GiveWell cost-effectiveness analysis — version 5	Source
Bill and Melinda Gates Foundation, Committed grants database, syphilis (accessed January 23, 2023)	Source (archive)
Evidence Action, Maternal Syphilis Monitoring and Evaluation Narrative, 2022	Source
Evidence Action, Scoping Report on Cameroon, March 2022	Source
Evidence Action, Scoping Report on Zambia, March 2022	Source
Evidence Action, Zambia and Cameroon maternal syphilis program budget, 2022	Source
GiveWell, "Cash Transfers," 2018	Source
GiveWell, "Evidence Action — Impact Evaluation of Iron and Folic Acid Supplementation ("Phase 2")," 2019	Source
GiveWell, "Evidence Action — Syphilis Screening and Treatment in Pregnancy," 2021	Source
GiveWell, "Evidence Action Accelerator – Renewal grant for 2022-2025"	Source
GiveWell, "Evidence Action Beta — Incubator Program," 2021	Source
GiveWell, "Evidence Action's Deworm the World Initiative – August 2022 version"	Source
GiveWell, "Evidence Action's Dispensers for Safe Water program - December 2018 Version"	Source
GiveWell, "Syphilis Screening and Treatment During Pregnancy," 2021	Source
GiveWell, cost-effectiveness analysis of Evidence Action technical assistance to Liberia for syphilis screening and treatment	Source
GiveWell, Maternal syphilis cost-effectiveness analysis for Zambia and Cameroon	Source
GiveWell, Syphilis screen and treat in pregnant women cost-effectiveness analysis	Source
The GiveWell Blog, "Revisiting leverage," February 13, 2018	Source
The GiveWell Blog, "Why we can’t take expected value estimates literally (even when they’re unbiased)," 2016	Source
World Health Organization, Information Note on the Use of Dual HIV/Syphilis Rapid Diagnostic Tests, 2017	Source (archive)
World Health Organization, Public Report for STANDARD Q HIV/Syphilis Combo Test, 2020	Source (archive)

• 1
  • “In 2015, the first multiplex rapid diagnostic test (RDT) for detection of anti- HIV and anti-treponema pallidum (dual HIV/syphilis RDT) was listed on the WHO list of prequalified in vitro diagnostic products (IVD).” World Health Organization, Information Note on the Use of Dual HIV/Syphilis Rapid Diagnostic Tests, 2017, p. 1.
  • "Time to result: 15 minutes." World Health Organization, Public Report for STANDARD Q HIV/Syphilis Combo Test, 2020, p. 6.

• 2
  • "According to numerous sources, HIV screening among first time ANC attendees generally exceeds 80% ... Syphilis screening lags far behind HIV screening among ANC attendees. According to the 2017-2020 Annual Health Statistical Report, the syphilis screening rate in ANC was 56.3% in 2018, 54.1% in 2019, and 47.6% in 2020." Evidence Action, Scoping Report on Zambia, March 2022, p. 5.
  • "Looking to 2020, there were 785,253 pregnant women who visited a health facility during the course of their pregnancy which therefore yields a syphilis screening coverage of 49.8%. In the same year, the HIV screening coverage was 90.3%; thus, nearly half of all pregnant women are being screened for HIV but not for syphilis." Evidence Action, Scoping Report on Cameroon, March 2022, p. 6.

• 3
  • We use 3.00% as the prevalence of syphilis among pregnant people in Zambia. This comes from Evidence Action’s scoping report on Zambia and is based on the ZAMPHIA 2016 study.
    • "Among 789 currently pregnant women tested across the sampled households, the ZAMPHIA study found an active syphilis prevalence of 3.0%." Evidence Action, Scoping Report on Zambia, March 2022, p. 3.
    • “Overall, Evidence Action recommends relying on the active syphilis prevalence measured via the ZAMPHIA study as the survey was nationally representative and a sequence of tests was used to directly measure active syphilis. Thus, the prevalence of active syphilis is 3.0% nationally." Evidence Action, Scoping Report on Zambia, March 2022, p. 3.
  • We use 4.55% as the prevalence of syphilis among pregnant people in Cameroon. This comes from Evidence Action’s scoping report on Cameroon and is based on a sentinel surveillance survey.
    • "In 2016, the National AIDS Control Committee (NACC) implemented a sentinel survey to estimate the prevalence of HIV and syphilis among pregnant women." Evidence Action, Scoping Report on Cameroon, March 2022, p. 2.
    • "Overall, among the estimates available, Evidence Action recommends relying on the 2016 Sentinel Survey as it provides the most rigorous estimate of active syphilis prevalence. Thus, the prevalence of active syphilis in Cameroon is 5.63%. … Using 2015 population data from Projections Demographique, the population-weighted prevalence is 4.55%." Evidence Action, Scoping Report on Cameroon, March 2022, p. 3.
  • We estimate that the prevalence of syphilis among pregnant women attending antenatal care in Liberia is roughly 2.23%, significantly lower than the prevalence in Zambia and Cameroon.

• 4

  The additional cost of screening for syphilis, rather than HIV only, is approximately $0.15 (note that this figure does not account for all costs, but the total cost estimate in our cost-effectiveness analysis does). We estimate that the cost per life saved for this grant is less than $1,000.

• 5

  We conducted sensitivity analyses that suggest that the cost-effectiveness of this program remains relatively high under a range of plausible assumptions for key parameters, ranging from about 6 times as cost-effective as cash transfers under pessimistic assumptions to about 66 times as cost-effective as cash transfers under optimistic assumptions.

• 6
  • "Based on observations during the scoping visit, there were several potential gaps identified in syphilis treatment, especially in same day treatment. First, it was noted by stakeholders that availability of benzathine penicillin may be intermittent as it is a commodity procured solely by the MoH. Within the same survey by EpiC, 15 facilities/district health offices (60%) were stocked out of benzathine penicillin while 7 had low stock and only 3 had adequate or excess stock. Second, many facilities rely on lab-based testing for syphilis which often means results are not available until a later date thereby preventing same day treatment. Finally, there are a few key misconceptions that exist related to syphilis treatment which may delay access by pregnant women -- it is believed by some midwives benzathine penicillin cannot be given on an empty stomach (so women are asked to return another day after having eaten) and it is believed treatment is ineffective if the partner is not treated too (so women are only treated when they present with a partner or after much effort is made to bring the partner in)." Evidence Action, Scoping Report on Zambia, March 2022, p. 7.
  • "Syphilis treatment coverage likely falls short of the WHO target of 95% for many of the same reasons which lead to the gap in syphilis screening coverage. Many women cannot afford treatment when they are found positive; the out-of-pocket expenses can be as high as 4.30 USD per dose of benzathine penicillin. There is also assumed to be some variability in the availability of benzathine penicillin among facilities. Finally, the current reliance on lab-based testing means that women have to return to the health facility after their ANC visit to obtain their results; this delay in care often leads to drop off in treatment." Evidence Action, Scoping Report on Cameroon, March 2022, p. 7.

• 7

  "Expenditure on a program can also crowd out funding that would otherwise have come from other sources. We call this “funging” (from “fungibility”)." The GiveWell Blog, "Revisiting leverage," February 13, 2018.

• 8
  • "According to numerous sources, HIV screening among first time ANC attendees generally exceeds 80% ... Syphilis screening lags far behind HIV screening among ANC attendees. According to the 2017-2020 Annual Health Statistical Report, the syphilis screening rate in ANC was 56.3% in 2018, 54.1% in 2019, and 47.6% in 2020." Evidence Action, Scoping Report on Zambia, March 2022, p. 5.
  • "Looking to 2020, there were 785,253 pregnant women who visited a health facility during the course of their pregnancy which therefore yields a syphilis screening coverage of 49.8%. In the same year, the HIV screening coverage was 90.3%; thus, nearly half of all pregnant women are being screened for HIV but not for syphilis." Evidence Action, Scoping Report on Cameroon, March 2022, p. 6.

• 9

  Evidence Action, conversation with GiveWell, January 28, 2022 (unpublished).

• 10
  • Based on our understanding of the funding landscape from conversations with Evidence Action, the World Health Organization, and other implementers, we are aware of only a few other implementers providing technical assistance to countries to scale up dual HIV/syphilis testing. The Bill and Melinda Gates Foundation has made limited grants to syphilis, viewable here.
  • We have triangulated our understanding via the following sources:
    • Dr. Melanie Taylor, Centers for Disease Control and Prevention, Former Medical Officer at the World Health Organization, conversation with GiveWell, March 28, 2022 (unpublished)
    • Cameroon Ministry of Health staff member, conversation with GiveWell, March 7, 2022 (unpublished)
    • Clinton Health Access Initiative staff member in Cameroon, conversation with GiveWell, February 28, 2022 (unpublished)

• 11
  • Because country governments have demonstrated interest in the dual test, e.g. by procuring their own dual tests or starting the planning process for a pilot, we think there’s a fairly high chance that governments would switch to dual tests in the absence of external support. However, we think Evidence Action’s support makes that switch more likely, may speed up the switch (we assume by a year), and may increase the quality of implementation and focus on syphilis treatment following testing.
  • "Many stakeholders believe the country’s high and rising incidence of stillbirth and neonatal death are due in part to unaddressed maternal syphilis and the absence of coordinated partner support to address the issue. The government (namely, the Prevention of Mother-to-Child Transmission Coordinator), with the support of a core team of largely laboratory stakeholders, has taken initial steps to combat this issue and introduce a dual HIV/syphilis rapid test into antenatal care settings. Further partner support would aid in taking this program to national scale and eliminate mother-to-child transmission of syphilis once and for all in Zambia." Evidence Action, Scoping Report on Zambia, March 2022, p. 2.
  • "The MoH, championed by the National AIDS Control Committee (NACC) and the Department of Family Health (DFH), has taken initial steps toward adopting the HIV/syphilis dual test. The dedicated support of a technical assistance partner would aid the country in formally adopting the dual test into national policy and subsequently scaling up the dual test across all antenatal care sites, thereby eliminating mother-to-child transmission of syphilis once and for all in Cameroon." Evidence Action, Scoping Report on Cameroon, March 2022, p. 2.

• 12
  • See our write-up on our grant to Evidence Action to scale up syphilis screening and treatment in pregnancy in Liberia here.
  • The timeline of training rollout has been slower than the original planned timeline by approximately 6 months. However, Evidence Action has told us that the delay is mainly due to disruptions from COVID-19. We have taken this delay into consideration (see Risks and reservations section of this page), but we have not made downward adjustments in our cost-effectiveness analysis to the expected speed of roll-out in Zambia and Cameroon.

• 13

  Evidence Action, conversation with GiveWell, May 2022 (unpublished).

• 14
  • "The support that Deworm the World provides is of two types: 1) offering technical assistance to governments implementing deworming, and 2) funding components of deworming programs." GiveWell, "Evidence Action's Deworm the World Initiative – August 2022 version"
  • "In March 2019, GiveWell recommended that Open Philanthropy make a grant of $800,000 to Evidence Action for the monitoring and evaluation of the Phase 2 pilot stage of its technical assistance to the Government of India's national school-based iron and folic acid (IFA) supplementation program." GiveWell, "Evidence Action — Impact Evaluation of Iron and Folic Acid Supplementation ("Phase 2")," 2019.

• 15

  This is our impression from our calls with Evidence Action and with a Ministry of Health staff member and a Clinton Health Access Initiative staff member in Cameroon, as well as from Evidence Action’s notes from its own stakeholder conversations (all unpublished).

• 16

  However, Evidence Action notes that the relationships it has built in Zambia and Cameroon are stronger than the ones it had built in Liberia prior to starting implementation of a similar program there. Evidence Action, conversation with GiveWell, April 2022 (unpublished).

• 17
  • "There are several policy documents which are being used as the backbone for dual test adoption. The first is the National ANC Guidelines, which, according to the MoH’s Chief Safe Motherhood Officer, list syphilis screening and treatment as essential components of the ANC package. The second is the EMTCT of HIV and Syphilis National Operational Plan 2019-2021, which lists the adoption of HIV/syphilis dual testing as one of the strategic interventions that will enable greater syphilis screening among pregnant women. Finally, the Zambia Consolidated Guidelines for Treatment and Prevention of HIV Infection list syphilis screening as an essential service to be provided for pregnant women alongside HIV screening." Evidence Action, Scoping Report on Zambia, March 2022, p. 10.
  • "In 2021, the NACC released the ‘Operational Plan of the National Strategic Plan for the Fight against HIV/AIDS and STIs 2021-2023 of Cameroon’. One of the objectives outlined in the plan is that, by 2023, 95% of pregnant women are to be screened for HIV and have their results disclosed to them. Under this objective, there are a number of goals that relate to HIV/syphilis dual testing including:
    • To acquire HIV/syphilis dual tests for pregnant women and then to distribute the dual tests to health facilities and community actors;
    • To ensure there are drugs available for treating syphilis in pregnant women and partners;
    • To counsel HIV and syphilis infected pregnant women and their partners on the importance of treatment;
    • To produce and disseminate HIV and syphilis screening algorithms;
    • To train providers and communities on HIV/syphilis dual testing." Evidence Action, Scoping Report on Cameroon, March 2022, p. 11.

• 18

  We expect that data around the first quarter of 2023. Evidence Action, comments on a draft of this page, January 20, 2023 (unpublished).

• 19

  "Our general approach to achieving each M&E objective is outlined below and is likely to be very similar among the countries in which the program is being implemented. Throughout, we make reference to three core sources of data:

  • National data systems for service delivery and commodity consumption. In each country, the MoH has its routine mechanisms for monitoring the number and types of services provided by health facilities and how much facilities are consuming key commodities. These are often in the form of monthly, bimonthly, or quarterly reports generated by health facilities and entered into online databases like the dhis2 and/or a logistics management information system platform.
  • Routine program reporting via master trainers during supportive supervision. During supportive supervision visits to health facilities, master trainers often fill out and submit reporting forms which detail some of the successes and challenges faced at the facility-level. In addition, the master trainers often provide qualitative feedback on how facilities are doing which can be useful in identifying gaps.
  • Comprehensive Facility Survey. This is a survey we intend to implement via independent enumerators every 12-24 months of the program (roughly three times during the estimated 5-6 year length of the technical assistance support). The survey has multiple modules, including a commodity stock assessment, review of facility-level data tools, qualitative interviews, and knowledge and skills assessments of healthcare providers." Evidence Action, Maternal Syphilis Monitoring and Evaluation Narrative, 2022, pp. 1-2.