S t r e n g t h e n i n g U g a n d a s S y s t e m s f o r T r e at i n g Ai d s N at i o n a l ly Increasing Access to Healthcare Services in the Karamoja Sub-region, Uganda June 2014 USAID/SUSTAIN is funded by the United States Agency for International Development (USAID) and is made possible by the generous support of the American people. SUSTAIN is managed by University Research Co., LLC (URC) in partnership with The AIDS Support Organisation (TASO), Integrated Community Based Initiatives (ICOBI), Initiatives Inc., and Health Research Inc. 1
About the Karamoja Sub-Region Karamoja, in northeastern Uganda, is considered by many a hard to reach and hard to live in subregion. Characterised by cattle rustling, insecurity from armed nomadic tribes and a semi-arid climate, the sub-region supports very little economic activity. For years, infrastructure including roads, healthcare facilities and adequate water has been solely lacking, making the subregion the least socially and economically developed in Uganda. The HIV prevalence rate in Karamoja has risen in the last decade from 3.5% to 5.3%*. In 2010, the USAID Strengthening Uganda s Systems for Treating AIDS Nationally (USAID/SUSTAIN) project, working closely with the Ministry of Health, started implementing interventions to improve public healthcare systems to provide quality HIV prevention, care and treatment services in seven districts of the sub-region. Major areas of intervention include: HIV prevention, care and treatment (including Prevention of Mother-to-Child Transmission of HIV, HIV Testing and Counselling and Voluntary Medical Male Circumcision), laboratory services strengthening, management of TB/HIV collaborative activities and drug-resistant TB, healthcare financing and human resources for health strengthening. Kaabong GH Kotido HC IV Abim GH Matany H Moroto RRH Tokora HC IV Amudat H * Compared to the national average of 7.3% USAID/SUSTAIN-supported healthcare facilities in Karamoja Key Areas of Support HIV Prevention, Care and Treatment Laboratory Services Human Resources for Health The Provider-Initiated Approach Increases Uptake of HIV Testing and Counselling Services HIV testing and counselling (HTC) remains the primary entry point to HIV prevention, care, treatment and support services. The USAID/ SUSTAIN project supports delivery of comprehensive HIV services at two hospitals in the sub-region Moroto Regional Referral Hospital and Kaabong General Hospital. In collaboration with the Ministry of Health, the project intensified implementation of a Provider-Initiated Testing and Counselling (PITC) approach to increase uptake of HTC services. The PITC approach has led to establishment of additional HIV testing points at these hospitals, resulting in patients accessing more than one clinical service at each point of service delivery. A client accesses HIV testing services at Moroto Regional Referral Hospital As a result of using the PITC approach, 29,506 adult clients were tested for HIV and given results at Moroto and Kaabong Hospitals between October 2012 and March 2014. 344 clients who tested HIV-positive were linked to care. The project supported hospital teams to integrate HTC in the routine healthcare package offered to clients. This helps to ensure universal access to HIV testing and knowledge of one s HIV status, which are fundamental for linkage to care, treatment, prevention and support services. At least 50 healthcare staff were given skills to enable them implement the PITC approach, which led to the creation of HIV testing points at both Out-patient and In-patient units at Moroto and Kaabong Hospitals. Moroto Hospital currently runs up to 13 HTC service points. Other approaches were used to improve HTC in Karamoja, including introduction of Know Your Child s HIV Status (KYCS) Campaigns to improve HTC coverage for children, role clarity for various hospital staff and formation of internal HTC supervision teams to conduct regular performance review meetings. 2
Scaling Up Prevention of Mother-to-Child Transmission of HIV (PMTCT) and Antiretroviral Therapy (ART) Services A month after the Uganda Ministry of Health introduced the PMTCT Option-B Plus intervention package, USAID/SUSTAIN began supporting selected public hospitals to operationalise this new strategy. Training and mentoring of healthcare workers were conducted to equip service provider teams with the required skills, including counselling and birth planning for HIV-infected pregnant women, managing ART in antenatal care settings, monitoring of mothers and their infants, Early Infant Diagnosis and integration of family planning into HIV care, among others. A total of 41 healthcare workers at Moroto RRH and Kaabong GH were trained. By March 2014, a total of 101 HIV-positive pregnant and lactating women had been enrolled on PMTCT Option B-Plus interventions at Moroto and Kaabong Hospitals. Up to 6,964 pregnant women attended their first antenatal visit at Kaabong and Moroto Hospitals between October 2010 and March 2014 and all were tested for HIV. Of these, 223 pregnant women were found HIV-infected and101 were given interventions for PMTCT. A healthcare worker explains to the Director General of Health Services, Dr. Jane Ruth Achieng(left), the various HIV services offered at Moroto RRH during the campaign launch event, September 2013 USAID/SUSTAIN, together with other partners, supported the Ministry s Elimination of Mother-to-Child Transmission (EMTCT) of HIV regional campaign launch event in Karamoja. During the one-month campaign (September 2013), 346 pregnant and lactating mothers were tested for HIV, and ten mothers who tested HIV-positive were given the PMTCT Option B-Plus. Uganda s Minister of Health Visits Moroto Regional Referral Hospital, Applauds Quality of Healthcare Services D uring a visit to Karamoja sub-region, the Uganda Minister of Health Hon. Dr. Ruhakana Rugunda expressed his appreciation to the USAID/SUSTAIN project for its outstanding work in supporting the Ministry of Health to improve the quality of HIV/AIDS and general healthcare services in the sub-region. Hon. Rugunda was in the sub-region to participate in the launch of the Ministry s Elimination of Mother-to-Child Transmission of HIV campaign. Accompanied by the Moroto Hospital Director, hospital staff Moroto Regional Referral Hospital, despite known challenges and difficulties, is on the right track. Hon. Rugunda Minister of Health Hon. Dr. Ruhakana Rugunda (left) talks to mothers with their children in the Children s ward at Moroto Regional Referral Hospital and the USAID/SUSTAIN project team, the Minister toured the antenatal and maternal and child health sections, the main hospital laboratory and the hospital stores. He specifically noted how far the hospital has progressed in improving health service delivery, cleanliness, infrastructure and staffing. Recognising the achievements that the hospital has accomplished with support from the USAID/SUSTAIN project, Hon. Rugunda assured the hospital team of the Ministry s commitment in ensuring sustainability of project-supported activities, including human resources, physical infrastructure improvement and maintenance and repair of laboratory and other biomedical equipment. 3
Making In-roads into Strengthening Laboratory Services Strengthening laboratory services is an essential part of the USAID/SUSTAIN project scope. In the Karamoja sub-region, the project supports strengthening and improving the quality of laboratory services at five healthcare facilities: Moroto RRH, Abim and Kaabong GHs and Tokora and Kotido Health Centre IVs. Some of the laboratory interventions include: u Physical infrastructure renovations and equipment installations. The Moroto RRH laboratory has been renovated, expanded and equipped with modern automated equipment, a power back-up facility and other tools. Renovations for laboratories at Abim, Kaabong, Kotido and Tokora will be completed in 2014. Various sets of equipment for these laboratories are already procured. u Laboratory systems improvement towards international accreditation. Three laboratories (Kaabong, Moroto and Tokora) were supported to participate in the MOH s ongoing Strengthening Laboratory Management Toward Accreditation (SLMTA) initiative. Laboratory staff from Abim, Kaabong and Moroto Hospitals and Tokora and Kotido HC IVs were trained and mentored in good clinical laboratory practices, equipment usage and maintenance, as well as design, implementation and tracking of laboratory processes improvement projects. u Support to national laboratory sample transportation network operations (hubs). Hubs at Abim, Kaabong, Kotido, Moroto and Tokora healthcare facilities are given routine logistics, coordination and technical support to function optimally. Each of the five healthcare facilities has been given support to recruit extra personnel to ensure effective hub coverage. Before USAID/SUSTAIN started supporting us, Alex Ogwal, a laboratory technologist at Moroto RRH operates a clinical chemistry analyser in the laboratory renovated by USAID /SUSTAIN The renovated and equipped laboratory at Moroto Regional Referral Hospital we were severely understaffed. Working with manual analysers was rather cumbersome and slow. Turnaround time for CD4 samples referred to Mbale Regional Referral Hospital was, at the earliest, two weeks. But now, with automated analysers, enough staff, adequate work space and constant power supply, turnaround time for Complete Blood Count tests is two days, and patients requiring CD4 tests get their results on the same day the sample is taken. Nicholas Okengo, a technician at Moroto Hospital USAID Uganda Mission Director, Ms. Leslie Reed at the opening of the renovated laboratory at Moroto Regional Referral Hospital in January 2013 4
Improving Tuberculosis Infection Control Activities in Karamoja The migratory nature of the Karamajong population presents a significant barrier to managing long-term treatment for illnesses such as tuberculosis. Moreover, successful tracking of patients for treatment progression is constrained by low telephone access coupled with poor telecommunication network coverage in the sub-region. The USAID/SUSTAIN project supports efforts to ensure increased TB case detection, linkage to TB treatment, HIV collaborative services, and tracking of TB patients throughout the treatment course at two hospitals in the region (Kaabong General Hospital and Moroto Regional Referral Hospital). The project introduced the following interventions to improve the quality of TB services provided at the two hospitals: u Provider skills strengthening through training and mentorship of TB and HIV care teams to offer integrated HIV services u Supporting TB/HIV care teams to apply Quality Improvement methods in routine work. TB/HIV process improvement teams were established, trained and coached to initiate improvement projects to close performance gaps related to linkage of TB/HIV co-infected patients to anti-retroviral therapy (ART), case detection, sputum monitoring for TB patients on treatment and TB treatment completion u Implementation of TB infection control measures through training of care teams in infection control, provision of job aids, personal protective equipment (N-95 respirators and masks) and establishment of hospital infection control committees u Strengthening networks and partnerships for provision of a continuum of TB care. This has required collaborating with other healthcare facilities, engaging volunteers who help with client tracking and follow-up, ensuring availability and use of telephones for TB patient-tracking and relevant coordination, and facilitating quarterly Zonal TB performance review meetings. Participants at the review meetings discuss progress and challenges encountered in TB patient management and develop improvement action plans u Supporting TB sputum sample referral for diagnosis of drug-resistant tuberculosis and linkage of patients identified to have DR-TB infection to establish treatment centres outside the region The TB treatment success rates improved to 79% for the cohort of TB patients evaluated in the period July September 2013, compared to 55% for the period October December 2011. From July September 2013, Kaabong and Moroto Hospitals achieved a 70% rate (the national target) for case detection and registered coverage of 100% HIV testing for all TB patients. 12% of TB clients tested were identified as co-infected with HIV, 82% of whom were subsequently initiated on ART. Healthcare Financing & Human Resources for Health Support The USAID/SUSTAIN project contributes to healthcare financing through sub-grants to the seven supported Karamojong healthcare facilities (through their respective district local governments or governing bodies) to bridge critical service delivery financing gaps. The grants support routine operational activities such as: u Client follow-up and tracing u Transportation of laboratory samples for specialised tests to national reference laboratories u Service delivery quality improvement and performance review activities u Stationery and other administrative costs The financing also supports recruitment of healthcare workers to bridge critical clinical personnel gaps. Over 50 healthcare workers (medical and clinical officers, nurses and midwives, laboratory technologists and technicians, data officers and laboratory hub riders) have been recruited across the seven healthcare facilities. A nurse attends to a TB client in the TB Out-patient Clinic at Moroto RRH Strengthening Uganda s Systems for Treating AIDS Nationally (SUSTAIN) is a 5-year project funded by the United States Agency for International Development (USAID) and works closely with the Ugandan Ministry of Health to strengthen sustainable and innovative approaches for improving HIV and TB service delivery at selected healthcare facilities. The project supports comprehensive coverage of HIV care and treatment services at 12 Regional Referral, 3 General Hospitals, 2 Health Centre IVs and 2 private notfor profit hospitals throughout the country. These services include the basic care package for people living with HIV and AIDS, anti-retroviral therapy, prevention of mother-tochild transmission of HIV, co-management of tuberculosis (TB) and HIV infection, laboratory services, HIV testing and counselling and safe male circumcision. 5
USAID Strengthening Uganda s Systems for Treating AIDS Nationally (SUSTAIN) Project Plot 7, Ntinda View Crescent Naguru, Kampala, Uganda +256 (0) 312-202-046 / +256 (0) 312-307-300 Fax: +256 (0) 414-287-614 www.sustainuganda.org University Research Co., LLC 5404 Wfisconsfin Ave., Sufite 800 Chevy Chase, MD 20815 Tel: (301) 654-8338 Fax: (301) 941-8427 www.urc-chs.com This brief is made possible by the support of the American People through the United States Agency for International Development (USAID). The contents are the sole responsibility of University Research Co., LLC and do not necessarily reflect the views of USAID or the United States Government.