CARDIO4Cities: from global evaluation framework to local monitoring in Dakar and São Paulo

CARDIO4Cities is a multisector initiative that aims at improving cardiovascular population health in urban areas across the globe. Shared measurement systems are key to systematize reporting on progress and health outcomes and to provide comparable evidence across countries. This article documents the development of a global theory of change (TOC) and its evaluation framework (EF) to serve as scalable, global reference tool. It further describes the adaptation of the EF for long-term impact evaluation in Dakar, Senegal and São Paulo, Brazil. A mixed-method approach was applied including a document review and key informant interviews with seven individual CARDIO4Cities partners. The information obtained revealed a three-phased process for developing the global TOC and EF and the adaptation into local EFs: 1) planning of the global CARDIO4Cities strategy; 2) development of the global TOC and its EF; 3) co-creation of local EFs. Coherence between the global EF and local frameworks was assessed as an indication of the perceived local value and applicability of the global EF tool. The final TOC was composed of 14 interventions leading towards the overall expected impact of a 10% decrease in strokes in the target cities’ populations. The resulting global EF consisted of 52 quantitative programmatic (medical and non-medical) and qualitative performance indicators, of which 33 were designated key priority indicators (KPIs). Both, Dakar and São Paulo adopted half (50% and 52%) of the total global EF indicators. While 20 global EF indicators were taken up by both cities, 19 indicators were excluded by both, and 13 indicators were adopted by only one of the cities. The most consistently adopted indicators across cities were the performance KPIs (86% for both cities) and the optional non-medical program indicators (100% for both cities). Conversely, the non-medical program KPIs (0% for both cities) and the optional performance indicators (33% and 17%) were least consistently adopted by the two cities. We provide a roadmap for developing a reference EF which offers a simple shared means of tracking cardiovascular health initiatives across different countries. The EF allowed global partners to have a consolidated overview of program implementation and to compare results across cities.