Follow Us
Uganda – Retention Collaborative
Sponsors/partners:
USAID, Health Care Improvement Project, Ministry of Health Uganda.
Topics: Adherence to treatment, Antiretroviral therapy/ART/ARV, HIV/AIDS, HIV/AIDS basic care and support, Pediatric HIV/AIDS, PMTCT, Retention in care
Region and Country: Africa, Sub Saharan, Uganda
Date improvement activities began:
October, 2009
Aims/objectives:
The collaborative ensures that patients started on Antiretroviral Therapy remain in care at any one time. Retained patients are those known to be alive and are receiving ART at any one time. The collaborative focuses on:
• Identification of barriers to patient retention
• Selection of feasible solutions to improve patient retention.
• Improving appointment keeping for patients on ART
• Ensuring that PLHIV receive timely ART refills.
Implementation package/interventions:
For all sites in the collaborative, the first step to improving patient retention is conducting of patient interviews to understand the barriers to retention. Common problems for majority of the sites are transport and distance.
Patients propose solutions from which site teams prioritize and select the most feasible solution. Each site introduces a set of feasible changes depending on resources, skills, knowledge, capacity and time. For example some sites have introduced 2 monthly doses to patients to patients with transport or distance challenges who are 95% adherent to treatment.
Some sites have recruited patient’s representatives to the site QI teams to continue understanding and responding to patient’s issues. Currently improvement changes are being synthesized which will form the implementation package for retention.
Measurement:
a) Proportion of patients on ART retained in care each month
b) Proportion of patients on ART who missed appointments each month
c) Number of ART doses dispensed to HIV+ patients each month.
Spread strategy:
Results of the improvement changes will be synthesized to form an improvement package for retention. The package will then be shared with other sites to achieve the same effect as the implementing site.
Number of sites/coverage:
The total number of facilities participating in the collaborative is 14 consisting of 4 District Hospitals, 5 Faith Based Hospitals, 4 Health Center IVs and 1 Health Center III out of a total of 354 functional facilities providing ART in Uganda. These facilities cover 8 out of 80 districts and are located in 3 of 12 MOH regions.
Coaching:
At the start of the HCI ART Collaborative, a group of coaches, known as the Core Team, was formed at the national level from Ministry of Health and HCI staff to support sites and develop technical strategy for the project. The Core Team build capacity of MOH regional staff, called Regional Coordinators to conduct trainings and coaching sites in quality improvement and clinical treatment. Regional Coordination Teams were set up in 12 health regions of Uganda with 5 members each representing data, laboratory services, pediatric HIV, and 2 for general HIV care. For the Retention Collaborative, sites are being coached by HCI, Core Team and Regional Coordinators once per two months. Selection of the coaches depends on the site’s needs in the preceding visit.
The aim of the coaching visits is to support facility teams to implement QI activities, monitor progress and improve HIV care. Technical support, on-job training, providing update on HIV care, collection of data on improvements from changes is also done. Stocks of patient monitoring tools are replenished during such visits.
Learning sessions & communication among teams:
Learning sessions are held at the end of each action period which lasts about 6 months. Two representatives - one is the Site QI Team Leader - from each of the participating sites are invited. For subsequent sessions, participation is rotational for the other member. HCI staff, Regional Coordinators and a member of the Core Team also attend.
General topics covered in the learning session include updates on HIV care, understanding and measuring patient retention (focus of the next learning session), using QI to improve patient retention.
In preparation for the learning session, improvement changes –whether successful or not - are discussed with each of the participating sites, synthesized and shared with other sites to learn interventions which are effective or not.
Facilitation techniques include group discussions and exercises, mini lectures, experience sharing, use of visual cards and presentations.
Communications between sites between learning sessions is facilitated by the visiting coaching teams. Sites are updated on what others are working on and contacts of other sites given.
Results:
Eight sites have conducted patient’s interviews to understand barriers to patient retention and are introducing changes to close identified retention gaps. For example at Entebbe Hospital the main problem to retention is lack of transport. The site has introduced 2 months doses to patients with transport problems and are 95% adherent.
Changes introduced at other sites include;
• Pill counting to avoid giving more pills which prevent patients from keeping their appointment.
• Grouping of patients and representatives collect other’s refills
• Use of community volunteers to remind patients of their appointments or collect drugs.
Sites are collecting data on improvements from the changes introduced.
Sites are beginning to implement changes and no results have been recorded yet. Below are graphs showing the retention gap, problems to retention, and solutions at Entebbe Hospital. [See attached file.]
