Improving quality of HIV services and health worker performance in Tandahimba District, Tanzania: An evaluation
The USAID Health Care Improvement Project (HCI) and Tanzania’s Ministry of Health and Social Welfare (MOHSW) implemented an improvement collaborative aimed at improving the quality of HIV services and health worker performance in 12 health care facilities in Tandahimba District starting in June 2010. Tandahimba is one of six districts in the Mtwara Region, where a larger improvement collaborative to improve clinical processes related to antiretroviral therapy (ART) and prevention of mother-to-child transmission of HIV (PMTCT) had started in September 2009. The goal of the Tanzania HIV Care and Health Worker Performance Improvement Collaborative was to improve the efficiency of service delivery for patients receiving services related to HIV and to strengthen the performance and engagement of health workers providing HIV services.
The collaborative applied human resources management practices to address factors affecting health worker performance and improvement methods to strengthen the processes in the delivery of HIV services. The collaborative aimed to improve: enrollment of pregnant women attending ANC who tested positive for HIV in care and treatment centers (CTC); cotrimoxazole prophylaxis uptake among HIV-exposed children; screening for active TB among HIV-positive patients seen at CTC; CD4 testing every six weeks; retention in care and treatment of clients on ART; and performance, productivity and engagement of health workers providing HIV care. The human resources aspects focused on improving performance management, addressing the first three of seven steps in a performance management cycle: 1) establishing achievable workloads, clear expectations, and measurable objectives; 2) assuring health workers had the knowledge and skills necessary to accomplish the required tasks; and 3) providing frequent feedback to health workers on their performance according to defined expectations.
This report presents the findings of an evaluation of the collaborative performed in November 2011. The evaluation had four objectives: 1) document the process of and lessons learned in implementing changes to improve care and health workforce management, 2) assess workers’ awareness of their roles and responsibilities and the impact the changes had on the way they work, 3) document changes in the way services were delivered and in process indicators, and 4) determine whether workers’ productivity and engagement improved.
The evaluation covered nine facilities (a district hospital, three health centers, and five dispensaries, all similar to facilities assessed in the baseline). Four site managers completed questionnaires specifically for them, and 16 health workers completed another for them. In addition, 12 workers were observed to measure their time use, and 20 completed a questionnaire on engagement. Finally, 25 clients at the hospital and two health centers were followed by data collectors as the clients visited the facility seeking care; the collectors recorded information on how long the clients waited, their time with providers, etc.
The evaluation also looked at data collected by the 12 participating sites for five quality of care process indicators. Improvements occurred in four of the five indicators between July 2010 and August 2012: The percentage of pregnant women attending antenatal care who tested positive for HIV and enrolled into CTC per month increased from 81% to 100%; the percentage of patients assessed for active TB increased from 35% to 98%; the percentage of exposed children under 18 months receiving daily cotrimoxazole prophylaxis increased from 13% to 95%; and the percentage of HIV-positive patients on ART that are lost to follow-up each month declined from 7% to 1%. The percentage of HIV-positive patients receiving a CD4 test every six months declined due to CD4 equipment failure.