Improving uptake and retention of PMTCT services
Under the USAID Health Care Improvement Project (HCI), my colleagues in Tanzania and I have been working with the Ministry of Health and Social Welfare (MOHSW) and EngenderHealth in the Iringa Region of Tanzania to improve uptake, retention, and the quality of prevention of mother-to-child transmission (PMTCT) of HIV services. Rather than focusing solely on improving care at one point of service along the PMTCT continuum, our improvement efforts looked at improving PMTCT services across the entire continuum of care, from the antenatal period, through the entire breastfeeding period, until the HIV status of the exposed infant is definitively determined at 11 facilities in Iringa.
In order to address the gaps in PMTCT care that were identified at the 11 facilities, a data system was developed, quality improvement (QI) teams were formed, and facility QI teams began to track indicators for various PMTCT services that should be delivered during antenatal care (ANC), labor and delivery as well as in the post-natal/infant follow-up period. Providers began testing changes at their respective facilities to address areas in need of improvement. However, we noticed that some indicators improved (i.e. HIV positive pregnant women started on ARV or ART; and definite testing of the HIV exposed infant), while others lagged behind (i.e. early booking for antenatal care (ANC); male partner involvement; exclusive breastfeeding; and infant and child follow-up visits). After providers tested several different changes at the facility level and saw little to no improvement in those indicators, it became apparent that improvement efforts would need to go beyond the facility.
We supported the facilities to begin working with local governments and communities in an attempt to improve the indicators that lagged behind via a community approach. This community component strived to enhance PMTCT efforts primarily through sensitization meetings between local governments and facility QI teams. However, after eight months of spreading health messages in the community and testing changes, there was limited improvement in the indicators. At that point, we needed a more effective approach. We brought on our community health expert, Dr. Ram Shrestha, who had been mobilizing existing community groups (i.e. agricultural, religious, sports, education, credit & savings groups, etc.) in Ethiopia and Uganda to increase uptake of ANC services. In both locations, after implementation of the CHSS model, there were significant increases in pregnant women attending ANC services and testing for HIV.
Dr. Shrestha’s approach is known as the Community Health Systems Strengthening Model (CHSS). In this model, active and established community groups use their existing networks to strengthen the linkage between the community and health facilities. The community groups are the “eyes and ears” on the ground. In their daily interactions they are able to identify and refer the target population to the health facilities.
We brought the CHSS model to Tanzania, where we trained facility outreach nurses to serve as community QI coaches. In their role as community QI coaches, the nurses helped to identify and mobilize existing community groups in their catchment areas to support the uptake and retention of PMTCT services. These community groups have been actively identifying and referring pregnant women, their partners, and exposed-infants in the community to the health facilities. Community groups are tracking data of their referrals on a monthly basis. Every month the community groups and facility nurses attend the monthly village health committee meetings, where they compare the number of referrals, to the number of pregnant women who actually came into the facilities. When gaps are identified, the community groups, local government, village health workers, and facility nurses discuss possible solutions on how to ensure that everyone who is identified and referred makes it into the facility. As the system matures, we anticipate seeing an increase in women identified and attending health facilities.
The decisions to seek PMTCT care, adhere to treatment, and return for care are complicated and influenced by factors beyond the clinic. It is important to engage the community to support these decisions and improve health outcomes.