Tanzania | Mtwara ART/PMTCT 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 Mtwara 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 - three months of 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, status and track lost cases; 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; increased number of CD4 testing days, shifted sample collection point from laboratory to CTC to minimize clients’ movements and waiting time.
In 2010, QI activities to strengthen human resources (HR) were integrated into the collaborative in Tandahimba district in Mtwara. In this, health care workers have begun to prepare individual work plans derived from facility ART/PMTCT work plans and develop individual job description. They have developed competency models for the ART/PMTCT tasks’ service delivery to help identify skills and knowledge gaps- and keep SES journals for the data on the ART/PMTCT indicators.
Teams track the following key indicators monthly: proportion of pregnant mothers tested and enrolled at a care and treatment center (CTC); proportion of exposed infants receiving cotrimoxazole prophylaxis; 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; and proportion of HIV-positive patients assessed at every visit for active TB.
In September 2011 it was determined that the HR QI collaborative would be scaled up to other districts in the region through integration of the HR collaborative lessons learnt into the ART/PMTCT program ongoing in the other districts of Mtwara region. It is planned that after synthesis of Tandahimba Human Resource (HR) improvement collaborative is conducted in November 2011, lessons learnt will be applied to improve provider performance for the while region.
This collaborative began in nine facilities including one government regional hospital, four government district hospitals, one mission hospital, and three health centers.
During FY10, HCI, PharmAccess, EGPAF, and CHAI worked with the RHMT and CHMTs to conduct two coaching visits to teams in the Mtwara collaborative. During March 2011, HCI and implementing partners organized and conducted the fifth coaching and mentoring for the Mtwara ART/PMTCT Improvement Collaborative in nine sites in its six Districts. During this coaching, a total of 69 QI team members were reached. The main area of focus was to improve documentation, understanding of indicators, and data interpretation. Participants were also assisted to improve their competence and compliance to documentation using SES; onsite training on formulation of changes, filing in the journal and plotting data on run charts. Overall, coaching visits have emphasized on improving documentation, understanding of indicators, data interpretation and team building while learning session was used for sharing experience and learning from other teams and developing new work plans for the next action period. One common challenge was, frequent staff rotation in health facilities which brought in healthcare providers who were new to the principles of Quality Improvement.
During FY 2010, HCI in collaboration with RHMT, CHAI, PharmAccess and EGPAF conducted seven coaching and mentoring visits in Tandahimba District for the HR activities. During this time, 57 QI team members were trained on mapping and redesign of service delivery processes; formulation of changes; filling in the journal and preparation of draft job model for each designation/position; data interpretation and documentation using SES journal, preparation of draft job model for each designation/position which is the basis for individual work plans and Job descriptions.
The sixth coaching session for the HR activities in Tandahimba was conducted from 25th July to 2nd August with the objectives of assessing the functionality of facility QI teams and provides support on identified gaps, help the teams to finalize individual job description for each designation/position at their sites and discuss with their supervisors on how the draft job description can be improved.
The seventh coaching session was then conducted in September 2011 reaching 42 providers from all 12 facilities. The objectives of this session were to help team improve their job models, job descriptions, individual work plans and competency models and submit to the District Health Secretary for reference, Follow up on the use of individual work plan by health care workers to see how helpful they are in relation to achieving collaborative objectives and explore the health facility supportive feedback mechanism instituted in each of the 12 HR QI Collaborative sites and suggest way forward for improved ART/PMTCT services.
From the coaching visit, the District Management Team (CHMT) collected copies of the provider’s job models, job description, individual work plans and competency models for reference. District managers will make use of the tools during supervision and performance evaluation. Providers were mentored on the use of the individual work plans. Mechanisms for feedback of the individual performance by the supervisors are usually offered through regular supportive supervision and feedback by the facility in-charge during monthly QI meetings when facility in-charges meet with the facility QI team and during quarterly coaching and mentoring visits by the district and regional supervisors.
During FY10, HCI, PharmAccess, EGPAF, and CHAI worked with the RHMT and CHMTs to conduct one learning session. In January 2011, HCI conducted the second Learning Session reaching 25 QI team members, two RHMT and four CHMT members. In September 2011, HCI conducted a learning session with 65 health care workers. The purpose of the session was to share experience and progress made since the last LS among 9 collaborating sites. It was found that all QI teams were able to implement their previous work plans and produced progress updates from the previous quarter and created new work plans for the next quarter. A good number of healthcare workers were quite new to QI principles necessitating a quick orientation. This challenge was attributed to constant staff rotations in various sections in large health facilities and hence interrupting implementation of planned QI activities. QI teams shared various strategies on CTC/RCH services integration, ensuring consistent availability of TB screening tools, strengthening community home based care activities to reduce attrition and maintain reagents for CD4 to ensure consistent testing of clients.
Significant improvements were noted in follow-up CD4 testing for HIV patients following an expansion in the number of days when CD4 testing was available at sites’ laboratories. Screening for TB among HIV patients also improved from 74% at baseline in June 2009 to 97% by August 2011, due primarily to revision of the screening tool to allow a single tool to be used for over 24 months (eliminating the need for a new form at each visit, which proved cumbersome and led to difficulty in tracking TB status of individual patients). Having the tool embedded in the patient file simplified the screening process, made it possible to track monthly performance data across patients, reduced the number of forms needed, and reduced stock-outs of screening tools. The percentage of pregnant women attending ANC who tested positive for HIV and enrolled into CTC per month increased from 83% in June 2009 to 100% in August 2011. The percentage of HIV-exposed children under 18 months of age receiving daily Cotrimoxazole (measured monthly) increased from 8% in June 2009 to 51% in August 2011. ART patients lost to follow-up dropped from the baseline 22% to just 6% in August 2011.
The intervention has built the capacity of the facility to make use of their collected data for decision making. Team spirit among members has positively changed thus improved health service delivery outcome. The HRH work at Tandahimba has demonstrated that despite the critical shortage of human resources in rural areas of Tanzania, improved engagement of staff can significantly increase their efficiency and productivity, thereby improving health outcomes.