In November 2009, the Ministry of Health (MoH) of Uganda and the USAID Health Care Improvement Project (HCI) initiated an improvement collaborative in 14 HIV treatment clinics to increase the proportion of people living with HIV and AIDS (PLWH) who are under HIV clinic care.  Among participating health centers, five addressed low coverage by improving efficiency of clinic operations. The purpose of the study was to measure the effectiveness of the improvement collaborative in terms of improved staff efficiency, decreased wait times, and improved worker productivity and relate these benefits to the cost of the program in these five facilities.

This study used a pre-/post-intervention design in which we compared baseline measures taken before the start of the collaborative in October 2009 to the endline measures on the same indicators collected in May 2010. Key indicators of success were patient waiting time, staff time utilization, clients seen per staff member, staff time saved, and cost of the intervention. Client flow was determined by giving patients a form to complete during their clinic visit. Staff productivity was measured by direct observation by the researchers.  A structured interview of clinic managers was used to collect data on the clients seen per staff member, staff time saved, and the cost of the intervention. Costs were considered from the perspective of HCI and the MoH.  

Our results suggest that the improvement collaborative implemented at these five facilities significantly decreased client waiting times by facilitating some or all of the following changes in clinical practice: pre-packing drugs before clinics, triaging clients before consultation, ensuring all clinic areas are suitably staffed, and having a clear and signposted path of client flow through the clinic. The changes also allowed clinics at all five sites to finish their work two to three hours earlier, suggesting that the QI interventions improved clinic efficiency. Four of the five sites closed earlier at follow-up than at baseline despite seeing the same or more clients per staff member per week. The remaining sites, closed earlier but saw fewer clients per staff member per week at follow-up, possibly due to commencing outreach clinics and the expansion of clinic teams.

A cost-benefit analysis of the coverage collaborative showed that, assuming the improvements were sustained, the cost savings in terms of staff time saved would be equal to the total cost of the intervention after 16.5 months.  Sensitivity analysis showed that this result changed the most with changes in the cost of the staff time spent on collaborative activities.  If the collaborative was conducted by the MoH in facilities not currently part of the collaborative, costs would be lower and the break-even point would be reached even sooner.