Quality Improvement of HIV and AIDS programs: experiences from South Africa (2007 2010) Dr D Jacobs Country Director: Health Care Improvement Project (South Africa) University Research Co.,LLC 1
Global prevalence of HIV, 2009 Source: UNAIDS 2010
Trends in Women living with HIV, 1990-2009 Source: UNAIDS 2010
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
Source: UNAIDS 2010
Background Quality Assurance Project (2001 2007) Health Care Improvement Project (2008 2013) 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
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)
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
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
Results Data analysis from 2007 2010 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.
HCT: Clients offered HIV counseling & testing, 2007-2010 Data from 197 facilities 100000 90000 80000 70000 HCT Campaign 60000 50000 40000 30000 20000 10000 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 27065 20721 30773 26552 31691 33629 35481 45938 51132 52184 57790 57878 59193 86355 84100 # Tested 24278 18718 27386 24383 28489 29943 32135 49148 45700 48147 53825 54404 57353 83277 79719 # Post-test counseled 24023 18575 27320 24065 29211 29916 32060 41293 46088 48022 53454 54202 56931 82886 79508 # Tested + 10569 7660 11444 9987 10735 10865 11345 14686 14940 15197 16457 15300 16661 17765 15289 # Referred for CD4 Test 11178 7995 11551 10654 11722 12500 12283 16319 18023 18589 19862 16775 15694 17106 14738 # Referred for TB Screening 7372 10255 13411 15249 13310 HIV testing rate (%) 90 90 89 92 90 89 91 107 89 92 93 94 97 96 95 TB screening rate (%) 45 67 80 86 87 9/20/2011
PMTCT: 1st antenatal clients offered HIV counseling & testing services, 2007-2010 Data from 196 facilities 20000 18000 16000 14000 12000 HCT Campaign 10000 8000 6000 4000 2000 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 # of 1st Ante natal visits 15058 12430 14051 11913 15909 13733 13412 16202 16885 15675 16008 14502 17279 15034 12852 # Pre test counseled 13718 10738 12284 10413 13287 13223 12734 15113 15773 14581 15743 14342 17206 14951 12729 # Tested 11735 9425 10425 9011 12525 12141 11771 14252 15135 13932 15375 13789 16077 14393 12075 # Post-test counseled 11691 9383 10466 8946 11211 11231 11093 12800 14591 13813 14926 13501 16334 14388 12244 # Tested + 3407 2502 2862 2554 3202 3393 3535 4519 4407 3844 4081 3686 4498 3974 2920 # Provided with CD4 test 3779 3590 2724 HIV test rate (%) 86 88 85 87 94 92 92 94 96 96 98 96 93 96 95 HIV positive rate 29 27 27 28 26 28 30 32 29 28 27 27 28 28 24 CD4 test rate 45 67 84 90 93 9/20/2011 Tools revised to includecd4 test Public Health Strike
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.
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.
Acknowledgements HCI national & provincial staff NDOH, PDOH, district managers & staff Community staff URC colleagues USAID & PEPFAR