Uganda ART Collaborative
Improvement Topics: Adherence to treatment, HIV/AIDS, Antiretroviral therapy/ART/ARV, HIV laboratory services, HIV-family planning integration, HIV-TB, HIV/AIDS basic care and support, Pediatric HIV/AIDS, PMTCT, Retention in care
Region and Country: Africa, Sub Saharan, Uganda
The collaborative seeks to improve the quality of ART and pre-ART services in hospitals and health facilities. Specifically, the collaborative focused on improving TB assessment, linkages between PMTCT and HIV clinics, clinical outcomes, and improved adherence to ARVs.
The project started in 2006 with 57 sites in all 12 regions of Uganda and spread to an additional 32 sites in 2007 and 31 sites in early 2008. Facility-level teams are made up of representatives from HIV care clinics and related services such as PMTCT/ANC, TB, family planning and laboratory services. Community representatives, PLHIV clients, and outreach workers are encouraged to join the QI teams. Teams are trained to assess the current status of their facility through monthly collection of data and to take steps for developing, testing and implementing improvements in their system of care. HCI supports sites through training in quality improvement, monthly on-site coaching and ‘Learning Sessions’ in which facility-level QI teams have the opportunity to share best practices from their sites and receive focused training, such as changes in MOH policy.
There was a demonstration collaborative which sought to develop best practices which could be spread to other facilities focused around a few key areas of improving adherence to ART, improving TB assessment, increasing links to PMTCT clinics to retain patients and improving clinical outcomes. The first group of 57 sites (called the “Demonstration sites”) developed interventions which were introduced informally to subsequent groups through presentations at learning sessions and coaching visits. Some health workers from the first group of 57 sites became coaches for the subsequent teams as part of regional coordination teams. While no formal change package was created based on the results of the first sites, HCI and the MOH learned from the original group and refined content for learning sessions and coaching based on the lessons learned from the first group.
HCI together with the MOH Uganda developed a list of 45 indicators to measure quality of HIV/AIDS and ART services. Teams were required to collect information on 4 indicators:
• % of HIV+ patients seen in the clinic who are in general care and/or receiving ART who are assessed for active TB at every visit
• % of HIV+ pregnant women seen in the PMTCT or ANC clinic who are enrolled in general care or ART at the clinic OR % pregnant women on ART who are referred to PMTCT
• % of patients on ART who are 95% adherent to ARV medicines
• % of patients on ART for the past six months who have shown clinical improvement ((1) Weight is steady or increasing, and (2) Functional status is ambulatory or better, and (3)There are no OIs)
Most sites were unable to collect the indicator on clinical improvement because of a lack of weighing equipment and difficulties in tracking data over a 6 month period. In addition, teams were able to chose additional indicators to measure from the other 40 covering reproductive health/family planning, lab services, pediatiric ART, PMTCT and referral systems. Teams were encouraged to take on new indicators only once they had reached a sustained level of improvement in the first set of activities.
The collaborative started in 2006 with 57 sites which were regional referral and district or general hospitals and a few health centre IVs (HC IV). HCI’s focus was to work in sites accredited for providing ART. The spread waves repeated a similar strategy as the Demonstration with more lower level facilities (HC IVs). In 2007, the project added 32 additional sites, referred to as Wave 1 Spread Sites, which were general/district hospitals and Health Center IVs. In 2008, an additional 31 facilities, or Wave 2 Spread Sites, were added including HC IVs and a few HCIIIs. All sites have now finished the cycle of learning sessions for the collaborative and will continue working with HCI on new initiatives.
As of August 2009, HCI continues to directly support or maintain communication with 113 facilities of the original 120 consisting of 1 national referral hospital, 5 regional referral hospitals, 51 general/district hospitals, 48 health center IVs, 6 health center IIIs, and 1 health center II which are located in 71 out of 80 districts distributed between 11 out of 12 regions of Uganda.
At the start of the project, 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. As each of the spread waves began, 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 Coaching visits were conducted by Core Team members once per month together with regional coordinators. Regional Coordinators would coach independently once they had developed strong skills and capacity in quality improvement. Following the 5th Learning Session for each wave, coaching visits were conducted once in every 3 to 4 months.
For the first few years of the collaborative, learning sessions were held regionally and separately for each spread wave. For the Demonstration Sites, 4 concurrent learning sessions were held with 2 representatives from 13 -15 sites per group in the western, northern, southern and eastern sections of the country. Sites from Spread Wave 1 were divided into two groups of 15 to 16 sites as were sites from spread Wave 2. During these learning sessions, sites would each give a 15 minute presentation on their work to date and results with a short time for questions and answers. In addition, there would be presentations and information on specific clinical topics such as pediatric ART, HIV/TB co-infection, and MOH documentation. In 2008, HCI began to try new methods of conducting learning sessions, including bringing all sites from one wave together. New facilitation methods used have included small group discussion to share and synthesize best practices and poster presentations to view the best changes. Each wave had a total of 5 learning sessions each.
• Learning sessions with a lot of time and different methods of sharing what sites have done promotes more learning between sites.
• Monthly coaching visits were motivating for teams, but difficult for staff. For future collaboratives, HCI will explore options of supporting teams with less frequent site visits.