WHAT WAS THE PROBLEM?

Uganda has made significant progress towards epidemic control through the scale-up of critical strategies including Test and Treat, differentiated service delivery models, the roll-out of the consolidated HIV guidelines, and ART optimization. However, the country still faces several challenges, including fidelity to implement the national strategies at scale. In January 2019, the AIDS Control Program (ACP) prioritized four areas for improvement: 1) improve viral load suppression (VLS) through the management of non-suppressed patients, 2) improve management of non-suppressed pregnant and lactating mothers, 3) improve early retention of people newly initiated on ART, and 4) improve Isoniazid Preventive Therapy (IPT) initiation and completion.

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WHAT IS THE SOLUTION?

The Ministry of Health, with support from PEPFAR/Uganda through the USAID RHITES-N, Acholi activity implemented by University Research Co., LLC (URC) and other partners, set up a national quality improvement (QI) initiative to take innovations and best practices to scale for improved viral load suppression, early retention, Elimination of Mother to Child Transmission (eMTCT), and IPT completion. This initiative is coordinated through the national and sub-national QI structures (see Figure 1 below). The QI initiative has three major components: 1) a national task force to oversee and coordinate the national initiative; 2) national, regional and district coaches to provide technical support to health facilities implementing QI initiatives; and 3) a robust data management system to monitor results. PEPFAR implementing partners facilitate implementation and monitoring across all levels.

Tree table showing national and sub-national QI structures

Figure 1. Uganda National Quality Improvement Initiative Structure

A QI coach acts as a facilitator whose role is to support either district or health facility teams to utilize QI tools, set improvement aims, identify indicator measures and implement improvement activities. The regional coaches oversee and coordinate QI implementation within their respective regions. At the end of every quarter, the regional coaches, with support from PEPFAR implementing partners, convene at the national level with the central level task force to review progress, share learning, identify high impact interventions tested through the QI process, and address challenges. Figure 2 (below) outlines the series of activities that have been completed or planned in the initiative.

Figure 2. National QI Initiative Road Map

Another key component of the QI initiative is data management through a web-based system with different user rights. The QI database permits analysis of data at different levels and displays performance by district and facility against national targets. The data is utilized by health facility, district and regional coaches to course correct in real time.

WHAT WAS THE IMPACT?

Quality improvements were seen across all four priority areas where the national QI initiative was implemented. The management of clients with non-suppressed virus (intensive adherence counseling (IAC), repeat VL, switch to optimal ARV regimens) resulted in a statistically significant improvement (noted by five consecutive upward measurements) in the percentage of non-suppressed patients eligible for IAC who received three consecutive IAC sessions (see Figure A in the Appendix). A similar trend was observed for non-suppressed patients who were eligible for a repeat viral load test and received it. A significant improvement was also noted for patients who received a second consecutive non-suppressed viral load test result and were switched to an appropriate ARV regimen.

Among eMTCT mothers, viral load suppression processes (IAC, repeat VL, switch) improved over the period of the national QI initiative (see Figure B in the Appendix). There were statistically significant trends for non-suppressed patients eligible for IAC who received three consecutive IAC sessions; for those eligible for repeat viral load test who received it; and for non-suppressed patients who receive the second consecutive non-suppressed viral load test result and who were switched to an appropriate ARV regimen.

Furthermore, the proportion of the patients who re-suppressed and those who were switched to an appropriate regimen improved over the intervention period (see Figure C in the Appendix). Results further show that eMTCT mothers had a higher percentage of cumulative VL suppression than any other group of patients. Additionally, the viral load coverage for pregnant and lactating mothers increased from 59 percent in January 2019 to 72 percent in July 2019 (see Figure D in the Appendix). Similar results were achieved in improving Isoniazid Preventive Therapy (IPT) initiation and completion. The completion of six months of IPT progressively improved between January and July 2019 (see Figure E in the Appendix).

HOW DOES IT WORK?

INDIVIDUAL LEVEL

Engaging Recipients of Care to better understand client-level barriers to retention and viral suppression

To better define the problem and identify root causes and contributing factors to poor retention, the PEPFAR Implementing Partners supported QI teams in health facilities with a high number of missed appointments to conduct Root Cause Analysis (RCA). Through counseling sessions with clients who missed appointments, data was collected to the point of response saturation (the point when no new reasons are being given) using standardized tools. Patient responses were captured almost word-for-word to maintain the same meaning across regions. The Pareto analysis was used to determine the root causes contributing to most missed appointments using the 80:20 rule. The RCA activity targeted 4,973 patients from 152 health facilities with a high number of missed appointments (see Figure F in the Appendix). The QI interventions were prioritized based on the highest reported root causes. The RCA showed variation across regions and highlighted the importance of implementing QI interventions at sub-national/regional level for effective programming. Reasons change quarterly, which requires routine RCA until the program finds or achieves a reduction in main causes. No significant difference in root causes for poor retention were reported across age and sex.

The following interventions were prioritized to address root causes associated with forgetting appointments, away from home, busy with work, or still have drugs:

  • Writing appointment dates with a marker on the tin.
  • Dispensing drugs only up to next appointment.
  • Provider-client consensus on next appointment date; Giving shorter periods of appointment for patients with a higher risk of missing appointments.
  • Clarifying next appointment dates during health education sessions.
  • Institutionalizing follow up reminders/phone calls to patients ahead of their appointment dates.
  • Attaching a patient to a community linkage facilitator for follow up.

To address the problem of long-distance to the facility, lack of transport, and illness, the program is:

  • Scaling-up community differentiated service delivery models to bring services to the patients and to enable sick patients access to drugs.
  • Supporting transfer of clients to nearby facilities.
  • Assigning community linkage facilitators to each patient for follow-up.
  • Supporting accreditation of more ART sites to bring services closer to the people.

Other interventions include: Disseminating root causes to providers, counselors, linkage facilitators in facilities with high volumes of missed appointments and integrating the root causes into community awareness campaigns.

The RCA approach has been replicated in the viral load program to identify and address underlying causes for non-suppression and develop solutions that address the barriers to adherence in real time from the patient perspective. The pilot documented (see Figure 3 below) the root causes categorized as adherence factors (79 percent), retention factors (37 percent) and drug resistance factors (3 percent).

Figure 3. Summary Results from VL RCA Pilot

The detailed analysis (see Figure 4 below) shows that side effects of drugs, domestic violence, traveling away from home, lack of food, caretaker busy and drug abuse/alcohol were the underlying causes of non-suppression among 143 non-suppressed patients in one high volume facility with a high proportion of non-suppressed patients. This approach and tested tools will be taken to scale to support implementation of viral load suppression interventions and QI initiatives in the country.

Figure 4. Pilot Results: Root Causes for VL non-suppression (n=143 clients). Age disaggregation: 21 clients (15%) are below 15 years, 122 clients (75%) are 15 years and above. Sex disaggregation: 74 clients (52%) are females, 69 clients (48%) are males. Other Barriers (≤6 counts) Stigma associated with Treatment, Drug Abuse, Missing Appointments, Lack of Transport, and non-disclosure of treatment to partner.

LOCAL ENVIRONMENT

The health facility work improvement teams are supported by their respective district QI coach to prioritize the processes they would like to work on based on the data. The coach assesses the QI skills and technical knowledge on the subject matter and, as appropriate, reinforces teams’ capacity to address the selected work processes. All the regional PEPFAR Implementing Partners (IPs) operating in Uganda are providing logistical and financial support in their area of jurisdiction to facilitate the implementation of this initiative.

Civil society organizations are engaged in assessing, identifying and prioritizing community-level solutions such as client follow-up, community support networks and services.

NATIONAL ENVIRONMENT

In September 2018, the Ministry of Health (MOH) released the consolidated guidelines for the prevention and treatment of HIV and AIDS in Uganda. The release of the guidelines was a necessary precursor for the quality improvement work as its guided QI interventions on multiple technical standards for HIV care and treatment. Other key policy and strategic guidance that have been relevant to the implementation of the National QI Initiative are: Guidance on the scale-up of IPT (including Isoniazid stock management, initiation and completion of TPT); Provision of psychosocial support to non-suppressed patients through the roll out of psychosocial support training and tools; The National Quality Improvement Strategy and Framework. The national QI initiative functions through the existing national and sub-national QI structures. At the national level, a National Task Force (NTF) led by the MOH was formed to provide policy and strategic guidance, coordinate and oversee the initiative. The task force has the representation of MOH/AIDS Control Program (ACP)/Standards, Compliance, Accreditation and Patient Protection (SCAPP) Department, PEPFAR, and United States Government (USG) above-site QI technical assistance partners. The task force meets quarterly to review the progress of the initiative and address strategic issues that arise from implementation, including resource allocation and advocacy. Furthermore, at the national level, all fourteen health regions in Uganda participate in the national review meetings on a quarterly basis. The meetings are structured to provide quality improvement skills and tools to the regional QI coaches who further cascade this training to the district coaches and the work improvement teams at the health facility level.

SCALABILITY

The National QI Initiative is designed to reach scale. By September 2019 (nine months after the initiative started), all health regions, 126 of 127 districts, and 1,460 of 1,948 ART sites were participating in the initiative, reaching 55,167 of 90,717 (61 percent) non-suppressed patients in the national program with refined viral load non-suppression management services. The initiative and best practices continue to scale to all ART health facilities.

MANAGEMENT & OVERSIGHT

Indicators for monitoring and evaluating the implementation of improvement activities were developed along the VLS cascade by MOH and agreed upon in stakeholder meetings. M&E for the improvement activities and indicators were aligned to existing systems to enhance the utility of the tools and data by both IPs and health facilities. Standardized tabulation sheets depicting the VLS cascade capture client demographics, IAC session dates and adherence scores, repeat VL tests outcomes and switching to the alternative ARV regimen. The non-suppression register was the primary source of data at the facility, while the coaching guide was the primary source of information on coaching support activities. QI teams at the facility used the root cause analysis tool and QI electronic database to identify root causes for their respective performance gaps and to identify at least two improvement aims to close those gaps.

Data was uploaded in an electronic QI database (DB) for each health facility to capture national, regional, district and facility performance for each indicator and time period. The QI database generates run charts for each indicator and shows the number of districts and sites contributing to it. As shown in Figure G (see Appendix), the color codes are automated to show the performance of each indicator based on minimum thresholds of the national target and to facilitate data utilization by health workers with different skill sets. The initiative provides real-time data to frontline health workers, their management, coaches, IPs and the MOH for timely decision making and refining interventions in real time. The lessons learned from these experiences are discussed at each coaches’ review meeting and used to update the indicators and harmonize the efforts.

RESOURCES

Appendix [940 KB]

 

U.S. Department of State

The Lessons of 1989: Freedom and Our Future