The USAID Health Care Improvement (HCI) Project has been supporting the Ministry of Health in Uganda since 2009 to implement programs to improve HIV/AIDS services in the Northern, Eastern, Southwestern and Western regions of Uganda. During the first phase of this activity (November 2009 to May 2010) 39 sites tested various change ideas to improve clinical care. The change ideas that resulted in improvements in the initial sites were then documented, and, in the second phase of this activity (June 2010 to June 2011), these ideas were spread to a total of 96 sites in the four regions. The purpose of the study is to describe how these change ideas were adapted and modified as they spread across other health facilities participating in the collaborative improvement effort.
Two change ideas were selected to be studied - pre-packing of medicines to improve clinic efficiency and providing two to three months’ supply of ARVs to adherent clients at one visit. Sites were chosen on the basis of being located in the northern region and having implemented either one or both of the two selected change ideas within the previous fourteen months. Fourteen of the 26 participating facilities from the Northern region met the criteria and were included in the study.
This retrospective case series used. qualitative data on how change ideas were chosen, modified and implemented collected through interviews with members of quality improvement teams from participating health facilities. Qualitative data were quantified for analysis.
Eleven of the 14 sites included reported pre-packing medicines and 13 reported providing two to three months’ supply of ARV to clients. The most common way sites arrived at both these ideas was through brainstorming in a QI team meeting and learning sessions. Prior to implementing the change ideas all sites made some preparations. The average length of preparations for pre-packing medicines was 43.2 days (range 0.5 day to 168 days) and an average of 63.8 days (range one day to 168 days) to prepare for providing two to three months’ supply of ARVs to clients. During implementation the sites faced challenges such as stock outs of ARVs and co-trimoxazole, understaffing and loss of clients to follow-up. Sites were able to come up with solutions and adapt these changes to suit the needs of both the health providers and their clients.
Conclusions and Recommendations
Sites demonstrated the ability to adapt change ideas and sites also improved other areas of care such as pre-packaging drugs other than ARVs and co-trimoxazole, improving drug forecasting and management, and building the capacity of expert clients and nursing assistants to implement the changes. In addition to sharing change ideas, sites should continue to share their experiences implementing the changes as some of the challenges may be similar across the sites. This report also highlights the importance of not only spreading change ideas but also ensuring that new sites understand and apply iterative testing during implementation to enable effective adaptation of changes at new sites.