CASE STUDY Improving the quality of VMMC services at Mangochi, Mzimba North, and Nkhotakota District Hospitals in Malawi With support from United States Agency for International Development (USAID), multi-sectoral quality improvement (QI) teams at Mangochi, Mzimba North and Nkhotakota district hospitals providing voluntary medical male circumcision (VMMC) services were trained to apply QI methods to improve the quality of VMMC services. In December 216, baseline assessments in the three hospitals, using the Ministry of Health VMMC continuous quality improvement (CQI) assessment tool adopted from the WHO standards on male circumcision, found the following total mean scores: 26% for Mangochi; 49% for Nkhotakota; and 42% for Mzimba North. These low-quality scores were associated with a number of quality gaps, including in the areas of management systems, monitoring and evaluation, infection prevention services, and client follow-up. The QI teams conducted root cause analyses associated with these low scores and tested possible solutions. While Mangochi and Mzimba North district hospitals were able to improve their already good rates of client follow-up at 48 hours post-operation, Nkhotakota District Hospital made substantial gains, increasing the proportion of clients that came back for the 7 day post-operation follow-up from % in October/December 216 to 1% in September 217. After six months, the three district hospital QI teams were assessed again using the same tool, and their total mean scores had improved to 77%, 57%, and 6%, respectively. Background Malawi s HIV prevalence rate is at 1.6% among 15-64 year olds, with prevalence being higher among females (12.8%) than males (8.2%) (MPHIA 215-216 Reports). It is estimated that 9, people aged 15-64 are living with HIV and AIDS. In 27, the World Health Organization (WHO) and Joint UN program on HIV and AIDS (UNAIDS) recommended voluntary medical male circumcision (VMMC) to be offered as part of a comprehensive HIV prevention strategy due to its 6% effective rate in reducing the risks of transmission of HIV in regions with high HIV prevalence and low male circumcision rates. Malawi is one of the fourteen countries in Eastern and Southern Africa scaling up VMMC for HIV prevention following these recommendations. 1 The VMMC program in Malawi began in late 211 and was launched in 212. There is evidence of significant heterogeneity in HIV prevalence and incidence by age and across geographic areas in the country. 2 Adult males aged 3-49 represent only 1% of VMMC clients, according to program data, while 3% of the VMMC clients seen were aged 1-14 years old. 2 According to the National Statistical Office (21) there are also variations in HIV prevalence among rural (8.9%) and urban areas (17.4%). Similarly, significant differences were also observed across the three regions with the Southern region registering 14.5%, Central region 7.6%, and the Northern region registering 6.6%. The situational analysis revealed that only one in five men reported being circumcised. The Ministry of Health (MOH) in its National Strategic Plan (211-1 WHO, UNAIDS, Joint Strategic Action Framework to accelerate the scale up of VMMC in Eastern and Southern Africa, 212-216, Geneva Switzerland: UNAIDS; 211 2 Kripke K., et. al., Voluntary Medical Male Circumcision for HIV prevention in Malawi: Modelling the Impact and cost of focusing the program by client Agen and Geography, July 216. JUNE 218 This case study was authored by Tiwonge Moyo and Stephano Mjuweni of University Research Co., LLC (URC) and produced by the USAID Applying Science to Strengthen and Improve Systems (ASSIST) Project, funded by the American people through USAID s Bureau for Global Health, Office of Health Systems. The work described was supported by the U.S. President s Emergency Plan for AIDS Relief (PEPFAR). The project is managed by URC under the terms of Cooperative Agreement Number AID-OAA-A-12-11. URC s global partners for USAID ASSIST include: EnCompass LLC; FHI 36; Harvard T.H. Chan School of Public Health; HEALTHQUAL International; Initiatives Inc.; Institute for Healthcare Improvement; Johns Hopkins Center for Communication Programs; and WI-HER, LLC. For more information on the work of the USAID ASSIST Project, please visit www.usaidassist.org or write assist-info@urc-chs.com
216) endorsed VMMC as one of the HIV prevention strategies. Since then, some progress has been made in the country such as the development of Standard Operating Procedures (SOPs) and a national policy and a communication strategy on VMMC. However, as the country is poised to scale up VMMC as a prevention strategy for HIV, health facilities offering the services need to be ready to provide safe and quality services. In 215, the USAID Applying Science to Strengthen and Improve Systems (ASSIST) Project expanded its PEPFAR-supported technical assistance to the Government of Malawi by helping the MOH to improve the quality and safety of VMMC services for nine USAID-funded mobile and outreach teams in eight PEPFAR districts. In 216, ASSIST expanded its technical support in VMMC continuous quality improvement (CQI) to 1 MOH sites receiving support through the World Bank, bringing the total number of sites supported in CQI to 27 VMMC sites (17 PEPFAR and 1 World Bank supported sites) in Malawi. Since late 216, ASSIST supported the MOH in building the capacity of health workers providing VMMC services to continuously identify quality gaps and brainstorm solutions of how to improve services. ASSIST also supported the MOH to facilitate peer-to-peer quarterly learning across the VMMC sites to expedite improvements in the quality of VMMC service delivery across various sites providing VMMC services. Objectives The objectives of this work were to improve the proportion of VMMC clients returning for postoperation follow-up visits at 48 hours and 7 days. Methods 1. Identifying quality gaps In November 216, ASSIST supported the MOH to conduct baseline and follow-on assessments of the 1 MOH World Bank supported district hospitals providing VMMC services. The baseline assessment was conducted with the MOH s HIV and AIDS Department, Zonal Quality Assurance Officers, and representatives of the District Health Management Teams. Two sites in the Northern Region and four each in the Central and Southern Regions were assessed with a two-fold aim of measuring the quality of VMMC services and determining the best CQI support for the teams. After the baseline assessment, CQI activities were done with all the teams to help them work through the quality gaps identified during the baseline assessment. Firstly, ASSIST organised and conducted CQI trainings of MOH VMMC service providers in Dedza, Mapiri Lodge from January 16-2, 217. ASSIST supported the MOH to conduct the CQI training session. A total of 58 VMMC service providers from ten CQI supported District Hospitals received capacity building in using QI techniques to improve the quality of health services in their targeted hospitals. Secondly, ASSIST conducted QI coaching sessions for all the ten MOH District Hospitals from April 3-14, 217. The MOH coaches, with support from ASSIST, conducted the QI coaching sessions to provide technical support to the ten static sites to follow up on their progress on improving VMMC services. The coaches also helped the VMMC sites to develop specific action plans and improvement plans to address some of the identified quality gaps from the assessments. Within the same month, ASSIST and the MOH conducted a CQI learning sessions for the VMMC service providers from 24-25 th April 217. This was done to follow-up with the teams on the progress they made on CQI activities. From May 8-12, 217, a similar methodology was used in a follow-on assessment for the 1 teams. Good improvements were observed after six months of CQI mentoring of the VMMC sites as shown in Figure 1. 2
Figure 1. Comparison of average scores by VMMC service standard between baseline and follow up assessments across 1 MOH teams (May 217) 9 8 7 6 5 4 3 2 1 19 58.2 6 Management system 42 Supply, eqp, environment 31 Reg, Group Edu, IEC 8 8 51 HIV test, Councelling 44 55.8 19 39 53 74.5 MC Procedure M&E Infection Prevention % Mean Scores for baseline-nov-216 % Mean Scores for follow-on assessment-may- 217 From the follow-on assessment, it was observed that the MOH supported teams had a mean score of 64% across all the service areas, which was a substantial improvement over the 37% mean score observed during the baseline assessment. The maximum mean score of the teams was 89% (up from the baseline score of 53%), while the minimum mean score was 45%. Teams performed very well in registration; group education; information, education, and communication (IEC); and in individual counselling and HIV testing, which had mean scores of 8% each. During the follow-on assessment, some teams, such as those from Kasungu and Mangochi VMMC sites, demonstrated remarkable improvements across the service areas assessed, while others, such as Nsanje, Salima, and Mzimba North VMMC sites, showed improvements in some service areas more than others. The teams still faced some challenges in some standards such as surgical procedure and monitoring and evaluation. After the assessments, the teams developed specific action plans to clear some of the identified gaps. Below is a picture from Mangochi DHO which addressed some of the quality gaps identified in infection prevention service area from 11% at baseline to 7% at follow-on assessments. After the follow-on assessment the MOH teams were followed up again on May 22 to June 2, 217 to ensure that the MOH teams were really working on addressing the assessment challenges. 2. CQI activities conducted to improve the quality of VMMC services in the district hospitals From January 16-2, 217, the MOH HIV and AIDS Department and ASSIST staf facilitated a CQI training of the district hospital VMMC teams to comprehensively use QI processes in VMMC service delivery. In total, 58 providers from 1 MOH VMMC facilities supported by the World Bank and the 3 District Health Office (DHO) teams were trained. This training guided the teams on how to have vibrant and functional teams, how to develop and work through the improvement plans to achieve desired quality VMMC services; and how to effectively use data being generated by the teams to make informed decisions to improve VMMC service delivery. Further, ASSIST supported the MOH HIV and AIDS Department to conduct monthly coaching field visits to the 1 supported VMMC teams on April 3-14, 217. The visits supported teams to apply QI to comprehensively strengthen VMMC service delivery processes. This support guided the teams on how to strengthen team functionality in improving VMMC services and how to address the quality gaps identified during the baseline assessment. 3
ASSIST also supported the MOH to bring together the 1 MOH teams on April 14-15, 217 to share lessons and results of their improvement plans and discuss issues identified during the baseline assessments, such as understanding of denominators used to calculate proportions on improvement indicators. By the end of the learning session, the teams refined their improvement plans and developed new action plans outlining how they planned to address the quality gaps identified during the baseline and follow-on assessments. Teams also shared progress on trends on HIV referrals, adverse events, gender integration, circumcisions by age groups, 48-hour, and 7-day post-operation follow-up. 3. Changes tested by the VMMC teams The three static VMMC teams of Mangochi, Mzimba North, and Nkhotakota district hospitals tested a number of changes to improve the VMMC quality indicators on improving the proportion of VMMC clients returning for post-operation follow-up visits at 48 hours and 7 days. The following changes were tested across the three sites: VMMC counsellors gave in-depth instructions to VMMC clients emphasizing the need for clients to turn up for 48-hour and 7-day post-operation visits. Surgical procedure waste being taken to incineration area, Mangochi District Hospital. Photo by Stephano Mjuweni, URC, November 216 Providers emphasized the importance of 48-hour follow-up throughout the VMMC process at the sites, from group counselling to discharge points. Surgical waste segregation observed at Mangochi District Hospital. Photo by Stephano Mjuweni, URC, May 217 The hospitals assigned some VMMC providers to make phone calls to clients that had scheduled appointments to remind them of their appointment dates. Providers documented the appointment dates in the VMMC clients health passport books to act as reminders to VMMC clients for when to come back for follow-up. The hospitals made arrangements with the nearest health centers to conduct review of VMMC clients from outreach sites in the catchment areas. The hospitals also clustered day 7 post-operation VMMC clients in the communities for reviews during outreach and VMMC campaign period. One of the crucial areas the teams worked on and resulted in improvement was changing the information given to VMMC clients during the counselling sessions about the importance of day 7 follow-up. The teams discovered that the information that was provided during counselling session was not comprehensive; as a result the VMMC clients saw no need of coming back at 48 hours and 7 days. In order to improve the day 7 post-operative follow-up, the team re-packaged the messages in all the points of contact with the VMMC clients throughout the flow of VMMC clients at the clinic. The VMMC providers began to emphasize to clients the importance of returning to the VMMC clinic for the removal of wound dressing at the hospital and return to the clinic on day 7. Further, the teams utilized the patients health passport booklet for the VMMC clients to document the clients hospital return dates as reminders to the clients. The QI teams also agreed to start including the VMMC clients or 4
guardians telephone numbers during the registration of VMMC clients at the district hospitals. The QI team agreed that the team leader and the data clerk at the district hospital were responsible for making phone calls to the VMMC clients who did not return for their scheduled appointments at the hospital. This change also helped the teams to improve the proportion of VMMC clients that returned for review at 48 hours and 7 days. Results Follow-up visits are recommended to all circumcised VMMC clients for quality HIV prevention outcomes. From December 216 to August 217, the 7 day follow-ups amongst the three district hospitals improved from to 1% for Nkhotakota (Figure 2) and from 78 to 98% for Mzimba North (Figure 3). Figure 2. Proportion of VMMC clients who return for their 48-hour post operation review, Nkhotakota District Hospital (Oct 216-Sept 217) Proportion of VMMC clients who return for their 48-hours and 7 days post operation reviews, Nkhotakota District Hospital % of MC clients who reported for 48hrs post-op care % of MC clients who reported for the day 7 post-op care 12 1 8 1 1 94 1 1 1 1 1 1 8 7 91 82 1 %of 6 5 4 2 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Months 216-Sept 217 Number of circumcisions done as part of the minimum package of MC for HIV Prevention services Axis Title 3 2 1 2,63 925 41 531 4 2 8 6 11 2 233 13 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 5
Figure 3: Proportion of VMMC clients who return for their 48-hours and seven days post operation review, Mzimba North District Hospital (Oct 216-Sept 217) Proportion of VMMC clients who return for their 48-hours and 7 days post operation reviews, Mzimba North District Hospital 12 1 8 6 4 2 95 94 95 1 1 98 96 86 89 78 8 83 75 79 74 78 6 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 % of MC clients who reported for 48hrs post-op care % of MC clients who reported for the day 7 post-op care Number of circumcisions done as part of the minimum package of MC for HIV Prevention services 1 452 577 5 7 12 17 2 14 12 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Lessons Learned VMMC teams at district hospitals need to apply QI techniques to sustainably improve their compliance to national and international standards of quality VMMC service delivery and consistently review their own progress on closing specific quality gaps at the site level. Use of evidence at district level needs to be emphasized in tracking the performance and progress of quality VMMC indicators to reduce adverse events at site level. Peer learning of the VMMC teams is crucial for the teams to expedite learning across teams in various districts. Following these lessons, teams made the following recommendations: Consistent and targeted monitoring based on the existing site level quality gaps should be encouraged from district and national level. Awareness and orientation of district health management leadership on the status of the VMMC program by district and how to apply QI principles to improve VMMC services is required. MOH-supported district hospitals should continue to be supported in application of CQI to increase follow-up rates of circumcised clients and reduce adverse events. 6