Experiences of quality improvement coordination, strengthened partnerships and achieving good results from Tanzania's PHFS intervention
Partnership is a common phenomenon in health care delivery literally standing for ‘working together’ but is always difficult to build, nurture and maintain. Sometimes this is because of existing but silent inter-partner and inter-disciplinary territories within the health care systems, lack of trust among would-be partners and silent competition for resources. We applied quality improvement approaches to create transparency, supportive environment and compelling drive to achieve better postnatal outcomes which in turn strengthened the Partnership for HIV-Free Survival (PHFS) and ultimately reduced HIV mother-to-child transmission (MTCT).
Quality improvement methods earmarked to improve antenatal and post-natal Care (ANC and PNC) in the context of HIV/AIDS programs in Tanzania also provided opportunities to maximize communication, coordination, trust and motivation among various partners supporting these programs. Through joint-planning, integration of efforts, sharing of connections and some resources together with regular feedback sessions; ART uptake increased from 0% in (October 2013) to 95% in (September 2015) in 10 sites of Mufindi District, and from 13% in (August 2013) to 88% (September 2015) in 10 sites in Nzega and from 5% in (June 2013) to 85% in (September 2015) in 10 sites of Mbeya and reduced HIV transmission from the mother-to-child from more than 10% to less than 5% in the Mbeya district.
Members of PHFS came from all walks of life and disciplines – from policy levels at the Tanzanian Ministry of Health and Social Welfare (MOHSW), leadership levels at Regional Health Management Teams (RHMT), middle level management at Council Health Management Teams (CHMTs), and frontline levels at facilities and from homes and communities. Also participating members included HIV/AIDS implementing partners and other multilateral partners such as WHO and UNICEF, all promoting HIV-free births while letting mothers live longer. Despite all their inherent differences in agenda, methods and interests; this network of partners working together was able to significantly improve access to quality ANC and PNC and HIV/AIDS care for pregnant and breastfeeding women.
When Tanzania was invited by the PMTCT Inter-Agency Technical Teams Working Group on Child Survival and Infant Feeding to participate in the six country Partnership for HIV-Free Survival (PHFS) in September 2013, the ASSIST project was requested to provide quality improvement technical assistance to the local PHFS group. Three districts (Nzega, Mufindi and Mbeya Urban) with high rates of HIV prevalence and low retention rates of HIV-positive pregnant and lactating mothers to care were selected as pilot areas.
How to start was an issue. First of all, the playing field was oversubscribed - there were a number of independent partners running subsets of the HIV-free survival activities and each of the pilot districts had a different PMTCT implementing partner. HIV testing and counseling was a responsibility of yet another partner and so was nutrition, reproductive & child health, TB, etc. There were also rumors that successful piloting of the intervention may lead to additional funding to scale-up the intervention. It was therefore not surprising that during the first meeting most partners were busy trying to position themselves for their Shakespeare’s ‘pound of flesh’. During this meeting, everybody wanted to be heard and there were a lot of good suggestions but one question took hold: what were we trying to accomplish? In response, we started drafting a short protocol to define the activities, procedures, rules of engagement and assign roles to all partners. The MOHSW was asked to lead the partnership and ASSIST to provide quality improvement support to all levels. Other partners included EGPAF, TUNAJALI and Baylor to execute PHFS activities in a total of 30 health facilities in three districts. JHPEIGO and FHI360/FANTA provided technical support in maternal, newborn, and child health (MNCH) and infant and young child nutrition (IYCN) areas. The arrangement took some time but provided a purpose and direction of the partnership.
During implementation, ASSIST oriented the partnership to quality improvement methods and organized site level, district level and national level learning platforms to discuss progress, share learning from different sites as well as strengthening commitment and resolve among partners. In these meetings, site managers backed by the resident implementing partners, would present to the partnership how they are testing changes to close the performance gaps towards a common goal e.g. improving access to ART for all HIV+ pregnant and breastfeeding women and share notes on what is working and challenges they face. The presentations are then debated upon and a way forward agreed upon.
The arrangement brought in some levels of competition among the different sites with each promising to do better in the follow up meeting. These meetings strengthened the partnership by providing a forum for accountability, learning and increasing openness to each other.
After each learning session, ASSIST and the resident implementing partner, RHMT, CHMTs and site staff conduct coaching visits to all sites to strengthen capacity for testing changes to improve performance and prepare the teams for the upcoming learning session. The anticipated learning sessions with other sites motivated site staff, implementing partners and other partners to organize sufficient preparations to test more and better ideas so that they can shine during the meeting.
In summary, repetition of these quality improvement processes that includes working together to define what needs be accomplished, revisiting the processes of work and identifying the performance gaps as a group as well as testing changes to close the gap indirectly strengthened the partnership as the process reinforced a common purpose. Regular learning sessions in addition to providing a forum for knowledge exchange also strengthened the bonding between partners as the account to each other and silently compete for results.