Assessment of quality of ART services in the private sector in Uganda

Of Uganda’s 4639 health facilities, 2154 (46 %) are privately owned for profits (PFPs). Of these, 36 are accredited to provide care and treatment to people with HIV/AIDS. To learn more about the quality of HIV care in PFPs, Uganda’s Ministry of Health and USAID requested that HCI assess the quality of HIV and antiretroviral therapy (ART) care in Ugandan PFPs; 30 health facilities were chosen for assessment. The study sought 1500 patient records, 25 records for each cohort for each facility, but found only 327. Of them, 57% used the MoH HIV/ART care card; the remaining 43% used other formats for medical records. Of the 117 pre-ART records found, 36% indicated that these patients had their baseline weight measured; 74% had their baseline CD4 count measured; 53% had their WHO stage recorded; and 51% had evidence of a TB evaluation, all in accordance with MoH guidelines. The Ministry also recommends that a patient be clinically staged at every visit and have a CD4 done at least once every six months, but of these pre-ART records, only 54% showed a visit 6–12 months after registration. Patient retention in care was poor: After the initial visit, pre-ART patients returned to the PFP a median of four times in the next 12 months, well short of the Ministry’s recommendation that a patient return monthly. After the first month, 81% of patients were still in care; this fell to 61% after three months, 54% after six months, and 42% after nine. Provider adherence to selected standards was generally higher in the ART cohort than the pre-ART cohort. Of 210 ART records found, MoH-recommended ART care cards were used in 68%. For the clinical standards, weight was recorded for 76%, CD4 for 86%, and WHO stage for 74%. Safety blood work was performed for 71% of these patients before initiating ART, but only 28% had their TB status recorded at the first visit. For the selected psychosocial standards, 67% received pre-ART education, 59% had a treatment supporter named in the medical record, and 91% had contact-tracing information recorded. However, only 20% were linked to home-based care. The major findings of this assessment of Ugandan PFPs were: 1) adherence with standards was good in the first visit, particularly for clinical activities, but declined over time; 2) retention is the main cause of poor quality care; and 3) sites are making changes to improve quality, but, at least in efforts to improve retention, the changes do not always effectively address the problems. Recommendations: • Regularly measure quality: PFPs should be supported to regularly measure and report on indicators of patient retention, adherence with standards, and patient outcomes. • Adapt and incorporate elements of the chronic care model. • Establish and support quality improvement teams at the site level to make these changes.

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