Quality Improvement of HIV and AIDS programs: experiences from South Africa ( )

Transcription

1 Quality Improvement of HIV and AIDS programs: experiences from South Africa ( ) Dr D Jacobs Country Director: Health Care Improvement Project (South Africa) University Research Co.,LLC 1

2 Global prevalence of HIV, 2009 Source: UNAIDS 2010

3 Trends in Women living with HIV, Source: UNAIDS 2010

4 Regional HIV and AIDS statistics, 2001 and 2009 Regional figures on adults and children living with HIV, and AIDS-related deaths Source: UNAIDS 2010 Source: UNAIDS 2010

5 Source: UNAIDS 2010

6 Background Quality Assurance Project ( ) Health Care Improvement Project ( ) Work in 5 priority provinces KZN, Eastern Cape, North West, Mpumalanga, Limpopo Focus on Quality Assurance and Quality Improvement Expansion of HIV and AIDS services (Prevention, Care, Treatment) Provision of Technical Assistance at all levels facility, subdistrict, district, province, national Facility based QI/QA activities 197 facilities (FY10) HIV/AIDS TB

7 HCI focus: Programmatic Areas Prevention PMTCT; CT Care Basic Health Care; TB/HIV Treatment ART System strengthening Training of individuals from PEPFAR funded organizations on QA methodology to build institutional capacity Cross-cutting activities Clinic supervision (revision of PHC supervisor s manual) Infection Prevention & control Clinical mentoring & Clinical audit QA in OVC care (development of Child-Headed Household Guidelines) Appraisal of health care facilities (National Core Standards for Health Establishments) - accreditation readiness 1000 facility QIP initiative with focus on 6 key priorities (Ministerial imperative)

8 Framework for Systems Strengthening in South Africa Goals Strategic Programs Health Outcomes Patient Safety Patient satisfaction Improved Efficiency Subprograms MNCH TB, TB/HIV HIV, HIV/TB STI Infection control Technology Adherence Compliance Attitudes Perceptions Motivation Staff skills Waste Turnaround Patient Flow Case Management District Delivery Platform Hospital Services Primary Care Services Strengthening Program Management and Policy Framework Building Blocks Integration of Services and Community Linkages Capacity-building of Staff Information Patient and Program Levels Drugs and Supplies Source: adapted from WHO HSS framework

9 HCI: Methodology Facility level: Fortnightly visits to supported facilities - onsite mentoring, supervision & coaching for DOH staff Record review & data analysis done onsite with DOH staff Monthly patient record audits - ensure compliance / quality of service Quality gaps identified & problem solving approaches documented, action plan (with timelines) agreed upon Charting of progress towards DOH programmatic targets (e.g. HCT barometer) District level: Monthly & Quarterly reporting to District Management team (including MCWH, HAST & PMTCT managers) Assistance with development of DHP Integration of stakeholder efforts to meet District targets (HCT, NIMART, training) Provincial level: Integration of HCI activities into Provincial work plans Quarterly reporting to District and Provincial Management team Support for Quality month (Nov) initiatives; Open Days to showcase best practices National level: Policy and guideline development support Quarterly reporting to senior managers Support for National HIV/AIDS, TB, PHC and QA initiatives

10 Results Data analysis from from HCI-supported sites demonstrates: fourfold increase in uptake in HIV counseling and testing, from 22,278 to 79,719 with consequently greater numbers of HIVinfected patients accessing care and treatment services. General HIV testing rate improved from 90%- 95%, HIV testing of pregnant women at the first antenatal visit improved from 78% - 94%. TB screening rate and referral for CD4 count testing for HIVinfected patients improved significantly from 45% - 87% and 40% 93%, over this period. There have also been significant quality gains, demonstrated by overall improvements in compliance with national and provincial HIV and AIDS guidelines.

11 HCT: Clients offered HIV counseling & testing, Data from 197 facilities HCT Campaign TB Screening tool introduced Public Health Strike 0 Q2 07 Q3 07 Q4 07 Q1 08 Q2 08 Q3 08 Q4 08 Q1 09 Q2 09 Q3 09 Q4 09 Q1 10 Q2 10 Q3 10 Q4 10 # Pre-test counseled # Tested # Post-test counseled # Tested # Referred for CD4 Test # Referred for TB Screening HIV testing rate (%) TB screening rate (%) /20/2011

12 PMTCT: 1st antenatal clients offered HIV counseling & testing services, Data from 196 facilities HCT Campaign Q2-07 Q3-07 Q4-07 Q1-08 Q2-08 Q3-08 Q4-08 Q1-09 Q2-09 Q3-09 Q4-09 Q1 10 Q2 10 Q3 10 Q4 10 # of 1st Ante natal visits # Pre test counseled # Tested # Post-test counseled # Tested # Provided with CD4 test HIV test rate (%) HIV positive rate CD4 test rate /20/2011 Tools revised to includecd4 test Public Health Strike

13 Lessons Learnt 1. Do what you do best: A focus of QI initiatives at all levels of the health system (National facility), has worked synergistically to improve care 2. Be sensitive: Recognition that there are extensive inter and intra-provincial differences. Local context-specific solutions ensure buy-in and sustainability from DOH & facility staff. 3. Motivate staff: QA Open days are vital to showcase improvements - recognize & reward good performance (sustained in several provinces, conducted during Quality month) 4. Think of the end (before you begin): Integration of work with DOH staff has ensured transfer of skills, knowledge & sustainability of interventions. 5. Check constantly: Quality gaps still exist, which require ongoing onsite supervision, mentoring & training.

14 Conclusions Implementation of a continuous quality improvement strategy has contributed to significant and sustained quality improvement within HIV and AIDS programs at HCI-supported facilities in South Africa. The formation of health-facility level QA teams, coupled with monthly monitoring and evaluation of programmatic data, plays an important role in integrating and sustaining improvement initiatives. Participation of health care staff in data analysis strengthens ownership of the program, which leads to improved motivation and better performance. Identification of quality gaps and health system weaknesses plays an important role in improving integration and problem-solving efforts. Ongoing one-on-one mentorship with facility staff has been shown to be critical for capacity building and transfer of knowledge and skills. The successful implementation of this program in South Africa, despite various resource constraints, provides valuable lessons for other countries within the Southern African region.

15 Acknowledgements HCI national & provincial staff NDOH, PDOH, district managers & staff Community staff URC colleagues USAID & PEPFAR