Tanzania | Morogoro ART/PMTCT Improvement Collaborative
To increase the quality of HIV/AIDS health care services, including PMTCT and ART services through building the capacity of regional and district teams and ART/PMTCT providers in modern QI methods to enable the redesign of essential ART/PMTCT care delivery processes.
QI Teams in Morogoro have implemented a number of changes throughout this collaborative. To reduce loss to follow-up, teams have established exit desks with information for patients; issued two month ARV supplies for clients who are far from the health facilities; reorganized the patient filing system for easy retrieval and storage; developed strategies for loss to follow-up data verification and cleaning; used home-based care workers, village health workers, and community members to verify clients’ physical addresses and status; some facility teams developed treatment support groups and used treatment supporters from community-based organizations. To increase enrollment in CTC for HIV-positive pregnant women, teams initiated intensive PMTCT health education sessions; conducted meetings among service providers to strengthen linkages between HIV-related service areas; conducted same-day collection of CD4 samples at reproductive and child health clinics as opposed to sending patients to another department; and orienting providers on improved documentation in the PMTCT registers. To increase delivery of cotrimoxazole to HIV-exposed infants, teams established mother-child registers to link HIV-exposed children with their mothers; began issuing cotrimoxazole in reproductive and child health (RCH) clinics; established exit desks to remind patients of next visits, etc; and some facility teams engaged home-based care providers to track infants missing appointments. To increase screening for active TB during consultations, teams began forecasting needs and ordering TB screening tools together with the rest of stationery; and embedded TB screening tools in patients’ files. To increase CD4 testing, some teams developed a CD4 testing appointment register at CTC.
In 2011, Patient Self-Management and Community Resource Support components were added to the collaborative in Morogoro. Baseline research in Morogoro found that support for patients with HIV to manage their own health was poor, with 25% reporting they did not know HIV was treatable, and 60% not knowing that HIV treatment was life-long. Only 25% had worked with health workers to set their own health goals. To address this in an innovative way, HCI is supporting the RHMT to apply the Chronic Care Model by piloting use of Expert Patients in patient self-management of HIV/AIDS. In 14 facilities, Expert Patients have been introduced to supplement the work of health care personnel by providing support to people living with HIV as only one who has the same experience can do.
Teams track the following key indicators monthly: proportion of pregnant women attending ANC tested for HIV; proportion of pregnant mothers tested and enrolled in PMTCT and at a care and treatment center (CTC); proportion of HIV-exposed infants receiving ARV prophylaxis; proportion of exposed infants receiving cotrimoxazole prophylaxis; proportion of HIV-infected women receiving infant feeding counseling during pregnancy and during labor and delivery; proportion of patients started on ART within the past six months showing clinical improvement; proportion of patients with documented contact-tracing information; proportion of patients started on ARVs who are lost to follow-up; proportion of HIV patients from CTC receiving CD4 test once every six months; proportion of days in a month that any ARV is out of stock; and proportion of HIV-positive patients assessed at every visit for active TB.
In April – June 2011, FHI-360 (Tunajali Project) in collaboration with RHMTs was able to spread QI efforts to four new sites using their own funding and tools for QI developed by HCI. The plan is spread to four more sites in 2011.
This collaborative was initiated in ten facilities (one regional hospital, three district hospitals and five health centers, and two private hospitals). The Patient Self-Management activity is being implemented in 14 facilities.
During July – September 2010, QI coaching visits were made to participating facilities focusing on improving TB screening for HIV-positive patients, increasing enrollment of HIV-positive pregnant women and children in care and treatment, reducing loss to follow-up, and expanding delivery of cotrimoxazole prophylaxis. Other support provided included training on continuous quality improvement (CQI) principles of data management, improved organization of QI teams, developing small tests of changes, and the use of performance measures in monitoring improvements. Five RHMT members were tasked with overseeing the implementation of CQI activities and capacity building with on-the-job training and coaching while taking the lead in coaching and mentoring as well as facilitating learning sessions with support from HCI staff. During the October – December 2010 period, one coaching visit was held. The RHMT made coaching visits to six sites during January – March 2011. During April – June 2011, coaching visits were made to 11 sites and FHI 360 was able to spread QI efforts to four new sites using their own funding and tools for QI developed by HCI.
During the October – December 2010 period, one learning session was held with 76 participants, led by the RHMT. During this learning session, teams shared changes and results. During July – September 2011, another learning session was held with 55 QI team members, 16 CHMT, and 5 RHMT.
Coaching and mentoring is one of the strategies to strengthen skills of service providers. Between October and December 2010, a total of 152 service providers benefited and the process was led by RHMT. During a period of July to September 2011, a total of 117 QI team members were visited for coaching and mentoring by a team of coaches from URC lead by RHMT. CHMT from the relative sites participates in coaching as they too are overseeing QI activities in their districts.
Improvements have been achieved across the indicators in this collaborative. The percentage of HIV-exposed children under 18 months of age receiving daily cotrimoxazole (measured monthly) increased from a baseline of 4% in October 2008 up to 45% in September 2011. The percentage of women attending ANC who tested positive for HIV and enrolled in CTC per month rose from 57% in October 2008 to 92% in September 2011. ART patients lost to follow-up reduced from the baseline of 24% to 15% by September 2011. The percent of HIV-positive patients assessed for TB at each visit has increased from 71% to 97% by September 2011.
Best practices emerging from the collaborative in Morogoro include issuing a two-three month supply of ARV drugs to clients residing far from refill centers; introducing the Mini-CTC at the RCH clinic and for the clinic which are far from the main CTC they provide the ARVs; involving the regional top management to priorities the drug Cotrimoxazole syrup by ordering and emphasizing the facilities to buy in the nearby pharmacies using cost sharing funds; and taking blood for CD4 testing on the same day of the regular clinic visit or as the HIV diagnosis.
Since their introduction into facilities in May 2011, Expert Patients have provided educational outreach in clinics and communities, helped patients identify personal challenges and develop action plans to address these, and helped bring back patients who had left treatment. Providers have noted that the presence of Expert Patients has changed their work as they have helped to reduce the burden of their work load by taking patients’ weight and sorting files, and in the Morogoro Regional Hospital it was remarked that the Expert Patients are like nurses themselves and are seen as a part of the health system.