Uganda – HIV/ART Coverage Collaborative

Date improvement activities began: 
October, 2009
Aims/objectives: 

Objectives
• To increase number of clients accessing HIV/AIDS care
• To increase number of clients accessing ART

Processes of care to be focus on are:
• HIV Counseling and Testing
• Enrollment in general care
• Enrollment on ART

During the 1st learning session the teams decided that specific objectives for them to work on would be:
• Improving clinic efficiency
• Improving linkages to the HIV clinic

Implementation package/interventions: 

Improving clinic efficiency
- Introduction of triage systems in the HIV clinics to reduce client waiting time
- Re- allocation of tasks within the clinic to balance work loads
- General reorganization of service points in the clinic to reduce congestion and improve client flow through the clinic.
Improving linkage of HIV positive clients to care
- Allocation of a PMTCT focal person in the Maternity to counsel and refer HIV positive mothers to the care clinic
- Use of codes on immunization charts to identify exposed infants when they return for immunization
- Strengthening HIV counseling and testing in the Health facility through health education at different units and referral for testing.
- Engaging all health workers to identify and refer clients who test positive to the HIV clinic

Measurement: 

1. Percentage of clients tested HIV positive enrolled in general care
2. Percentage of children born to HIV positive mothers who have been tested for HIV
3. Percentage of eligible clients started on ART
4. Average client waiting time

Spread strategy: 

During Learning session 2 a package of best practices from the participating sites will be compiled and the sites will choose what practices to implement at their facilities and how to measure the changes. Thereafter this information will be shared with other collaboratives.

Number of sites/coverage: 

The total number of facilities participating in the collaborative is Fourteen (14) consisting of 6 District Hospitals, 6 Health Center IVs and 1 Health Center IIIs and 1 Health center II out of a total of 130 facilities in Uganda. These facilities cover 11 out of 80 districts and are located in 4 of 12 MOH regions. The estimated population covered by these sites 2,005,000 people and 130,325 PLHIV. By the end of November 2009 data from participating sites showed the collaborative had 9,851 adults and 540 children enrolled on ART.

Coaching: 

At the start of the HCI ART Collaborative, a group of coaches, known as the Core Team, was formed at the national level from Ministry of Health and HCI staff to support sites and develop technical strategy for the project. The Core Team build capacity of MOH regional staff, called Regional Coordinators to conduct trainings and coaching sites in quality improvement and clinical treatment. Regional Coordination Teams were set up in 12 health regions of Uganda with 5 members each representing data, laboratory services, pediatric HIV, and 2 for general HIV care. For the Coverage Collaborative, sites are being coached by either HCI/Core Team/Regional Coordinators once a month Regular follow up telephone calls are made to the teams to ask about progress and provide any needed guidance/ support.

Learning sessions & communication among teams: 

Learning session 1 was proceeded by a one day Stakeholders’ meeting attended by the District Health officer(DHO) or a representative, head of the facility ,QI team leaders and host district Persons living with HIV(PLWHA) representative.
Two days learning session was attended by the head of the facility, QI team leader and 1 team members.
During the Learning Session 1 an exercise to determine potential challenges to meeting the objectives of the coverage collaborative was done and two major categories stood out. These were;
a) Poor linkages between care entry points and the HIV/AIDS care clinics and community.
b) Clinic inefficiency that directly affect the clinics’ function and ability to enroll more people in care.
The facilitating team included staff from HCI and MOH
At the end of the discussion eight (8) sites decided to work on improving linkages to the HIV clinics and six (6) on improving clinic efficiency.

Learning session 2 will focus on sharing of results across the collaborative and identification of best practices which will be packaged and spread within the collaborative sites then later with other collaborative.

The facilitation technique during LS1 was:
a) Making presentation by the technical team.
b) Group work in teams to discuss their situation and present what they decide to focus on to meet the collaborative objectives.
c) Posters were used to enable cluster challenges mentioned by the site teams and come up specific improvement objectives for the teams to work on.
A database was set up to compile data from the sites and help with the synthesis process. On every occasion when data from a particular site is sent the database is updated.

During coaching visits (in the action period) contact is made with sites with clear terms of reference for visit and it is also an opportunity to validate the results/ data that has been presented by the teams.

Results: 

Six (6) sites introduced changes by starting up or strengthening triage system in the clinic. These specific changes were allocation of a person responsible for sorting clients as they come in for care and sending them to the appropriate service point. In the baseline assessment it was reported that clients spent a lot of time waiting to see a clinician and the clinicians overwhelmed by the fact that they had to see all the clients. By improving triage, clients who are doing well see a nurse who prescribes medicine refills and also checks other important things like adherence to ARVs. This reduces clients waiting long in the clinic and also provided time for the clinicians to provide quality services to the few clients who must see them.

Four (4) sites involving Maternity midwives to register exposed infants and write a code on the immunization chart for identification of the infants during immunization so as to link them to early infant diagnosis.
Two (2) sites allocated PMTCT focal persons to counsel & register HIV positive mothers in the maternity and have them registered in general care before they leave the facility.
[See file below for example of graph from one facility.]

Baseline Assessment of HIV Service Provider Productivity and Efficiency in Uganda

 

Countries: 
Report Author(s): 
Juliana Nabwire
Organization(s): 
USAID, Uganda Ministry of Health, USAID Health Care Improvement Project
ASSIST publication: 
no
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