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Health facility factors associated with improvements in the quality of HIV/AIDS care at health facilities in Uganda
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Publications
Several factors are associated with HIV patient enrollment, retention in ART care and treatment outcomes. These factors can broadly be categorized into patient and health facility factors. To improve the quality of HIV care services at health units, there is need to account for the modifiable and fixed characteristics of the health units. This study investigated the relationship between characteristics of the facility and the changes in quality of care indicators in the context of an intervention to improve services delivered in the facilities.
MethodologyThis was a quantitative pre/post intervention study to identify facility factors associated with improvements achieved at health facilities participating in quality improvement activities. Improvements in service delivery were measured by comparing performance on some indicators collected at the start of the intervention to the endline measures (six month later) on the same indicators. Data on health facility characteristics were collected using a standard questionnaire administered to health unit in-charges and heads of HIV clinics. Simple descriptive statistics were used to define characteristics of the health facilities while health facility factors associated with the quality of HIV/AIDS care were obtained through univariate linear and logistic regressions.ResultsA total of 45 health facilities were involved in improvement activities for at least six months and these were predominantly rural. Most facilities had separate HIV clinics but only a third had a dedicated HIV clinical team. At the outpatient department, the patient to staff ratio was 576:1 with an average 6.7 clinical staff members working on an HIV clinic day. There were no statistically significant associations between the region a facility was located in or the type of facility and any measure of performance in indicators. Health facilities located in rural areas perform slightly better than those in urban areas and clinics with more medical officers were worse at having patients adhere to clinic appointments (OR 0.38: P= 0.042). Other significant findings were that facilities with higher clinic staff members per clinic day did worse on indicator 1 (OR 0.79; P = 0.041) as did facilities with CD4 testing facilities (OR 0.32; P = 0.084).Conclusions and RecommendationsThe study found very few significant associations between characteristics of the participating facilities examined in this study and their performance in the improvement intervention. The variation in improvements seen in clinics may be due more to other characteristics of the facilities not measured, such as the types of patients they serve. Based on our findings, we recommend that facilities working to improve performance in service delivery focus on changing factors identified as causes of deficits in quality independent of considerations of the immutable characteristics of their facility. Any future study on this topic should take into account patient factors because patients with certain characteristics associated with HIV treatment indicators might be unevenly distributed among the facilities.
A final version of this study will be avaible soon.
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Adaptability of better care practices to improve HIV/AIDS care as they spread across sites in Uganda
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Publications
26 facilities in the Northern Region of Uganda are participating in the collaborative improvement effort implementing the ART Framework. This study aims to understand how best practices to improve HIV/AIDS care are modified and adapted as they are spread across and implemented at these various sites, which are free to choose which changes they wish to apply and to modify those changes to suit their needs. This study will identify best practices that are being spread throughout the facilities and gather details of the implementation of specific changes. Tentatively, the following three practices will be studied: 1) giving 2-3 months supply of ARVs to adherent patients to improve retention, 2) pre-packaging medicines to reduce waiting time and ultimately improve coverage and clinic efficiency, and 3) using a screening tool for detecting tuberculosis in HIV/AIDS patients to improve clinical outcomes. The study will look at best practices that are implemented by five or more of the 26 participating facilities in order to understand how that change is modified across different sites.
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Effets du collaboratif d’amélioration sur les indicateurs PTME et ARV en Côte d’Ivoire : Etude Comparative
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Publications
La Côte d’Ivoire a une prévalence élevée du VIH, avec 4,7 % de la population infectée par le virus. Cependant en 2008, une évaluation nationale de la prévention de la transmission mère-enfant du VIH (PTME) et les services de thérapie antirétrovirale (ARV) ont montré un écart important dans la qualité des soins tant dans le secteur privé que public. Pour mesurer les effets du collaboratif quant à la réduction des écarts, le Projet d’Amélioration des soins de santé de l’USAID (HCI) en Côte d’Ivoire, a comparé les résultats obtenus dans les sites de démonstration et ceux obtenus sur de nouveaux sites qui allaient rejoindre le projet. Ce rapport décrit le collaboratif d’amélioration qui a été mis en place par HCI en 2009 pour améliorer les soins et services ARV/PTME offerts aux PVVIH (Personne Vivant avec le VIH).
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Améliorer la documentation et le maintien des patients dans le programme de prise en charge du VIH en Côte d’Ivoire
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Publications
En 2008, à la demande du Ministère de la santé, avec l’appui financier du PEPFAR, le Projet d’Amélioration des Soins de Santé de l’USAID (HCI) a été invité à assister le Programme National de Prise en Charge des personnes vivant avec le VIH (PNPEC) pour conduire une évaluation nationale de la qualité des soins dans le domaine du VIH en Côte d’Ivoire. HCI et les partenaires de mise en œuvre ont conduit une évaluation nationale de la qualité des soins et services offerts aux PVVIH. Sur la base de l’évaluation, un comité technique dirigé par le PNPEC avec l’appui technique d’URC a développé un paquet de changement pour améliorer la documentation, le suivi et la rétention des patients. Ce rapport décrit les résultats du collaboratif d’amélioration d’ARV/PTME.
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Nicaragua | Antiretroviral Therapy (ART) Improvement Collaborative
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Collaborative Profile
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Feasibility of Proposed Quality Criteria for Monitoring and Improving HIV Services
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Publications
At the request of the Office of the Global AIDS Coordinator (OGAC), the United States Agency for International Development (USAID) and the Global Fund to Fight HIV/AIDS, Tuberculosis, and Malaria (Global Fund), the USAID Health Care Improvement Project (HCI) developed an approach to yield meaningful information about the quality of HIV services for users at multiple levels of the health system. The approach proposes 16 quality criteria (QC) that were assessed through 25 existing indicators. The indicators were based on measures previously required or recommended by funders and other stakeholders, such as the Global Fund, PEPFAR, and the World Health Organization. This report presents the findings from a field test of the approach in five countries in three world regions: Africa, Eurasia, and Southeast Asia.
As a result of its findings, the report offers three recommendations:1.) Increase facilities’ ability to use indicator data by requiring denominators that reflect the number of patients who visit a facility;2.) Encourage monthly monitoring and the use of data to make decisions to manage and improve care processes; and3.) Improve the use and reporting of quality criteria data by: (a) supporting countries in using up-to date, centralized record systems to record patient status, (b) establishing systems to track and ensure attendance, (c) linking different service areas, and (d) supporting countries in building capacity to use their data to make decisions and improve the quality of their services. -
Quality Improvement of HIV and AIDS programs: experiences from South Africa (2007 - 2010)
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Publications
This presentation was given by Dr. Donna Jacobs, HCI Country Director for South Africa, at the 28th International Conference of the International Society for Quality in Health Care, Ltd. (ISQua), which took place in Hong Kong, China from September 14-17, 2011. The conference theme was, “Patient Safety: Sustaining the Global Momentum."
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Feasibility of Using Quality Criteria to Monitor and Improve the Quality of HIV Services
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Publications
This short report describes assistance that the USAID Health Care Improvement Project (HCI) is providing to the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) and to the Office of the Global AIDS Coordinator (OGAC) to develop an approach that can be used to harmonize global reporting and improve the quality of HIV services and health outcomes. This study details HCI’s approach that employs 16 quality criteria for 5 HIV service delivery areas: testing and counseling, care and treatment, PMTCT, TB/HIV, and harm reduction. Field tests were conducted in five selected countries: 3 in Africa, 1 in Eurasia and 1 in Southeast Asia.
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The Partnership for Quality Improvement to Improve PMTCT and ART Services in Tanzania: Assessment of Results, Capacity, and Potential for Institutionalization
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Publications
The USAID Health Care Improvement Project was asked by USAID in 2007 to assist the Tanzanian Ministry of Health and Social Work (MoHSW), regional and district level stakeholders, and implementing partners to set up a national Quality Improvement (QI) program for ART/PMTCT services in line with the Tanzania National Quality Improvement Framework. The QI program soon became known as the Partnership for Quality Improvement (PQI). The main aims of the PQI were to: 1) Build capacity for a harmonized QI approach among the many implementing partner organizations working this area, thereby accelerating the speed of and increasing the resource pool for QI in Tanzania; 2) Strengthen capacity for QI at national, regional, district and health facility levels (particularly in light of recent health care reforms to decentralize health services); and 3) Demonstrate the effectiveness of QI collaborative methods in improving patient outcomes in a limited number of regions (a prototype prior to spreading to additional regions).
HCI worked with the National AIDS Control Program (NACP) and the Dutch NGO PharmAccess to develop and implement the PQI. PQI was first launched in Tanga in May 2008 in partnership with AIDS Relief; the second region, Morogoro was included in February 2009, with Family Health International (FHI); and the third region, Mtwara, was added in June 2009 with The Clinton Health Access Initiative (CHAI) and Elizabeth Glaser Pediatric AIDS Foundation (EGPAF). CHAI and EGPAF also committed their own funding and began to replicate PQI in late 2009 to the Lindi region.
The evaluation study examined how well the PQI has worked in the three first regions (Tanga, Morogoro, and Mtwara) and identified how the approach could be further strengthened or modified for spread to other regions in Tanzania in the future.
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The Story of establishing an HIV/AIDS clinic in Tiriri HC IV, Soroti district in Uganda
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Improvement Report
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ENROLLMENT OF HIV POSITIVE CLIENTS IN TO CHRONIC CARE AT NAMAWANGA HCIII
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Improvement Report
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Improving the quality of care for adolescents living with HIV/AIDS by introducing Psychosocial Support services at Beatrice Road Infectious Disease Hospital (BRIDH) Opportunistic Infections and Antiretroviral Therapy (OI/ART) Clinic in Harare, Zimbabwe
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Improvement Report
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PSYCOLOGICAL CARE IN NEUROCOGNITIVE DYSFUNTION RESULTING FROM HIV AIDS
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Improvement Report
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Baseline Assessment of HIV Service Provider Productivity and Efficiency in Tanzania
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Publications
Tanzania, like many other countries in Africa, is facing a severe shortage of qualified health professionals. Only 35% of positions in government health facilities have been filled, leaving Tanzania in the wake of burgeoning human resources for health crisis. According to the Annual Health Statistical Abstract from 2008, the national average of the population per medical officer was 64,000, 31,000 per assistant medical officer, and 7,000 per clinical officer. The shortage of health professionals has been exacerbated by the HIV/AIDS pandemic and other communicable diseases such as malaria and TB.
In an effort to improve the quality of care of HIV services delivered in Tanzania, the USAID Health Care Improvement Project (HCI) and the Ministry of Health and Social Welfare (MOHSW) began implementing a partner improvement collaborative in the Mtwara region in nine care and treatment centers in June of 2009. The aim of the collaborative is to apply QI methods to ART and PMTCT services in order to ensure a high quality of care is being delivered to clients. The collaborative is now looking to integrate HR interventions into its work in order to improve efficiency of service delivery, and strengthen health worker performance and engagement. Health worker productivity and engagement are integral to improving efficiency as they determine what tasks health workers perform and how engaged and motivated they are to perform at a high level.In collaboration with the Government of Tanzania, HCI designed a baseline assessment of HIV/AIDS service providers to gather information on productivity and engagement. The information gathered from this baseline assessment will be used to develop a set of HR improvement packages based on best practices that will be integrated into the ongoing ART collaborative. The baseline was conducted in six sites in the region of Mtwara from June 30th- July 6th, 2010.The assessment identified several areas where human resource management systems can be improved to strengthen provider efficiency and productivity and improve the quality of HIV/AIDS service delivery. All health workers should be provided with written job descriptions that clearly align their tasks and goals. Without written job descriptions, it is impossible to implement strong performance management. Recognition and reward systems can be improved to ensure that health workers get the acknowledgement and praise they deserve when they perform well. The process for performance evaluations needs to be communicated clearly with lower level facilities. Facility managers and providers should also learn how to set performance objectives. Promotion and career advancement opportunities are somewhat rare, which may affect worker motivation. The majority of employees are moderately engaged, regardless of the type of facility or the position they hold, but specific areas of engagement, such as recognition and materials, could be improved. Productivity appears to vary throughout the day with providers being very productive in the morning when patients arrive and productivity levels decreasing dramatically in the afternoon when client loads are low. Client flow does not appear to be a problem, but is something that should continue to be monitored since client loads can vary dramatically by day. -
Chronic Care Design Meeting: Transforming Health Systems and Improving Quality Care for Chronic Conditions in Africa
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Publications
As patients throughout Africa are living longer with chronic conditions such as HIV, hypertension and diabetes, health systems must adapt to meet their needs. Chronic conditions are defined as those with which patients live for many months or years. This report details the discussions and conclusions of a Chronic Care Design workshop held in Uganda to explore how to improve care for these conditions, focusing on HIV, in Africa. Officials from the Ministry of Health of Uganda, the United States Agency for International Development (USAID), USAID Health Care Improvement Project (HCI), and experts in HIV and chronic care, participated in this three-day workshop held at Speke Resort, in Munyonyo, Kampala, Uganda from May 26-28, 2010.As Uganda has been a leader in HIV care for African nations—exhibited in its implementation of programs such as the Ministry of Health Quality of Care Initiative in HIV and AIDS—its health system is optimal for analyzing the current and future ability to respond to chronic care conditions.During the three-day meeting, about 50 participants engaged in group work, discussions, and presentations in order to understand the current Ugandan chronic care system and how it can be improved and adapted to better care for patients with long-term illnesses and medical conditions.
Conclusions from the workshop and success stories from Uganda were presented on May 31, 2010, the first day of a four-day international conference on “Transforming Health Systems and Improving Quality Care for Chronic Conditions in Africa,” held in Kampala. More than 250 participants from 10 African countries (Cote d’Ivoire, Nigeria, Ethiopia, Rwanda, Kenya, Tanzania, Namibia, Malawi, South Africa and Uganda) gathered at the Imperial Royale Hotel in Kampala, Uganda and listened to highlights from the chronic care design meeting and learned how to redesign a health system to meet chronic care conditions in their home countries.
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Maximizing Resources Where Resources are Limited: a Rural Health Facility's Efforts to Improve Storage of HIV Records in Uganda
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Improvement Report
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Spread of PMTCT and ART Better Care Practices through collaborative learning in Tanzania
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Publications
This evaluation takes place in the context of the “Partnership for Quality Improvement” (PQI) initiative in Tanzania. The partnership was initiated in 2007 by the Tanzania National AIDS Control Program (NACP) and PEPFAR to improve the quality of ART/PMTCT services in Tanzania through the implementation of a harmonized approach to modern quality improvement. At the time of this report, the Health Care Improvement Project (HCI) and PharmAccess International (PAI) are providing technical leadership to facilitate shared learning among ART/PMTCT collaboratives managed by implementing partners (FHI, CHAI. EGPAF, AIDS Relief etc.) and regional health management teams in Tanga, Morogoro, Mtwara and Lindi.
Within the partnership, learning developed within one partner’s collaborative should lead to rapid uptake of effective changes by other teams, leading to desired level of results for all teams. Sharing this learning should not be limited just within that region or that implementing partner, but spread to other regions supported by other partners as well. This ability to build on learning within regions, within partners, across regions and across partners is important for efficient achievement of better care and better outcomes for people affected by HIV and AIDS.Research questions/objectives:This evaluation seeks to study the mechanisms and results of the spread of better care practices in the Partnership for Quality Improvement. Identifying facilitating and hindering factors for shared learning and spread will help determine how learning among peers and spread of better care practices can be strengthened within the PQI context. The specific objectives of this evaluation are:1. To describe the various steps involved in the change process including the origin of ideas, their testing and implementation and their subsequent spread to other teams.2. To determine the various internal and external factors influencing the change process and identify means to augment the effects of favorable factors and remove barriers.3. To explore the role of the higher levels of the health system and collaboratives in catalyzing the spread of best practices and their scale up.The lessons learnt from this evaluation will provide guidance to quality improvement programs in other countries for strengthening learning among peers and improving spread within a collaborative approach or in other quality improvement efforts.Methodology:This is a cross-sectional evaluation which involves both quantitative and qualitative methods of data collection. All sites in the 3 regions (Tanga, Morogoro and Mtwara) whose collaboratives have been operative for more than 6 months were included in this evaluation (total of 29 facilities). Data was collected by interviewing the quality improvement focal person of facility teams and through focus group discussions with QI team members.Results:Results of the evaluation showed that the improvement collaborative is indeed facilitating sharing of ideas. Across the three regions, the great majority of ideas are “borrowed “from other teams, managers and coaches; with Tanga and Morogoro borrowing almost 70% of ideas, while in Mtwara 40% of the ideas had been borrowed. This indicates that ideas gained from participating in the collaborative are the main sources of adopted changes. The HCI/Tanzania project team composed a list of 16 effective changes (as of January 2010. Of these 16 effective change ideas teams had tried an average 12.6 changes per facility. Four of these 16 changes were tried by all facilities: issuing a 2 month supply for clients living far away; reorganizing patient charts for easy retrieval, establishing a mother-child register to link children to their HIV+ mother; and issuing Co-trimoxazole in the Reproductive Health Clinics.Learning sessions and coaching were the primary mechanisms for being exposed to or sharing changes with other teams, but other meetings, site visits, and phone calls were also used. Teams desired detailed information about “how to carry out” the changes they are being exposed to. Not all changes were found to be equally spreadable – spread of ‘better care practices” depended upon how straight-forward their implementation is and whether teams possessed the authority or resources to implement the activity. Staff engagement and staff resistance were cited as important factors impacting the implementation of a change. Implementation also depended upon external technical support, facility leadership and capacity for change. At present, the sharing across collaboratives has been mainly dependent on the role of the HCI/PAI team to create the linkages across collaboratives and regions. Additional mechanisms for sharing learning across a network of regions are needed, as well as mechanisms for sharing learning within a region that build on existing structures and opportunities. -
Effects of participating in collaborative improvement on the quality of HIV/AIDS care in facilities in Cote d’Ivoire: a comparison of intervention and control sites
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Publications
Collaborative improvement is one approach being used in many countries to improve prevention of mother to child transmission (PMTCT) and treatment with anti-retroviral therapy (ART) services. Collaborative improvement is consists of a network of teams engaging in a structured effort to learn from one another. A recent study analyzing the experiences of 27 collaboratives in 12 countries has shown collaborative improvement’s potential in achieving significant improvements in the level of the quality of care and the sustainability of such results. However, this is one of the first studies in developing countries that examines the effect of collaborative improvement in comparison to a control group.The Ministry of Health of Cote d’Ivoire and the USAID Health Care Improvement Project (HCI) launched a collaborative improvement initiative in December 2008, in collaboration with implementing partners. The collaborative operated in two phases: the initial demonstration phase, which began in January 2009, and the extension (spread) phase, initiated in August 2010. This collaborative provided an opportunity to: 1) examine whether there is a significant difference in the level of the quality of care between sites that have participated in an improvement collaborative versus those sites that will be in the extension phase and have therefore not yet participated in the collaborative activities; and 2) identify the factors contributing to this difference (if any) in the quality of care provided in the intervention and control sites.MethodologyThis study uses a modified quasi experimental design, in which the intervention group includes those sites participating in the demonstration phase of the ART/PMTCT collaborative, and the control group is composed of spread sites which had not yet been exposed to the collaborative activities but were planned to be included in the spread phase. Data were collected from 36 of the original 41demonstration (intervention) sites, and 42 spread (control) sites.ResultsIntervention sites saw significantly more improvement in quality of care indicators than control sites for completeness of documentation for PMTCT and ART, and for testing of children born to HIV+ mothers. Complete documentation for PMTCT at intervention sites rose from 22% at baseline to 83% after the collaborative, whereas at control sites during the same period there was only an 8% increase (from 0% to 8%); Complete documentation for ART at intervention sites rose from 22% at baseline to 87% after the collaborative, control sites had a higher baseline at 46% but this indicator barely showed any improvement at the end of the year (49%). Testing of children born to HIV+ mothers also increased at intervention sites. Results related to loss to follow-up for intervention sites do show initial improvement but some of the gains were lost towards the end of the study period. However, control sites experienced significant increases in loss to follow-up over time. Data availability was significantly lower in control sites than in intervention sites.QI competency and implementation were significantly higher in the intervention group, as were having a standardized process that would allow maintaining gains, mechanisms for orienting new staff, and systems for ensuring resource availability. Few differences in resource availability were noted. Control sites had a higher percentage of clinically trained providers. Intervention sites were likely to have generated change ideas themselves or borrowed these ideas from other participating sites rather than control sites, which, if they implemented the change, were mostly likely to have received the idea from their implementing partner.Regression analyses, holding other independent variables fixed (resources and clinical competence), showed a strong association between being involved in the collaborative and results related to documentation and testing of children born to HIV+ mothers.Conclusions and RecommendationsThis study has shown that facilities involved in collaborative improvement are able to achieve significant improvement over their own baseline results in comparison to sites that have not participated in a collaborative. Regression analysis indicates a strong association between being involved in the collaborative and improved documentation and increased testing of children born to HIV+ mothers. Time series charts also indicate potential impact on loss to follow-up, although the results were not as well maintained over time. This study is one of the first of its kind in a developing country to demonstrate the effects of participating in collaborative improvement on results achieved in comparison to a control group.
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Health Care Improvement Project: Provincial Glimpses
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Publications
This short booklet describes some of the results and lessons learned from HIV/AIDS and TB care improvement efforts in five provinces of South Africa.
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A Portfolio of Health Care Improvement Success Stories, 2001-2008
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Publications
The United States Agency for International Development (USAID) funded Quality Assurance Project (QAP) and its follow on, the USAID Health Care Improvement (HCI) Project under URC have, since 2001, been engaged in work that is crucial for health system strengthening with respect to HIV and AIDS programmes and TB. These diseases require ongoing intervention, monitoring and treatment, and when they present on a mass scale, as they do in South Africa, necessitate measures that are not easy to institute. Indeed, an entire infrastructure has to be put in place wherever affected people require treatment, and especially so in rural areas, where rates of infection are high but medical facilities are scarce.
USAID’s QAP and HCI Projects intervened to answer this need, creating small but effective infrastructures at crucial nodes to support South Africa’s health systems, and to bolster the health of the population in general with basic health care programmes. This publication is a compilation of success stories written over an eight-year period to document developments supported by QAP and the HCI Project.
