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10 36 1 5 DELIVERING DIFFERENTLY, TOGETHER: THE ROLE OF COMMUNITIES TO SUSTAINABLY IMPROVE LOCAL SYSTEMS, REVITALISE PRIMARY HEALTHCARE AND END AIDS IN BOTSWANA Kesaobaka Dikgole (HRH2030/University Research Co., LLC), Cecil Max Haverkamp & Dintle Molosiwa (HRH2030/Chemonics International) BACKGROUND From the late 1970s, community-centered PHC was the bedrock for health service delivery in Botswana. The advent of HIV/AIDS and this nation‘s massive, two-decade long emergency response, however, have also fundamentally changed and weakened Botswana’s health system. Today, burdened with one of the highest HIV prevalence rates in the world, the country is finally closing in on epidemic control amidst concerns over the sustainability of its TREAT ALL initiative and largely verticalized, hospital-based disease programmes. Determined to revitalise primary healthcare and refocus on the role of local communities, the Ministry of Health and Wellness and its USAID-funded community health system partners started the “Delivering Differently” initiative: to systematically adapt, integrate and differentiate existing service delivery models through collaborative improvement efforts at central, district and community level. METHODS Under both the USAID-funded ASSIST and HRH2030 projects, the local project team facilitated a truly bottom-up but elaborate, iterative and targeted process of consensus building across different levels of the health system. We worked with Botswana government counterparts at the central level (Ministry of Health and Wellness); in districts (district health management teams, district administrations, councils); and community level di-Kgosi (traditional leaders) and village development committees) to revitalize functioning community health system structures as part of broader efforts to end AIDS, improve primary health care and achieve sustainable human development in Botswana. ASSIST improvement specialists coached community improvement teams (on a volunteer basis) established under the mandate of di-Kgosi and embedded in the local governance context. Community coaching followed a systematic step by step Model of Improvement to analyze problems, develop and test change ideas as well as evaluating improvement efforts toward improved, more patient-centered services to the community, families, and individuals. Periodic district and national ‘learning sessions’ created a platform for horizontal learning on practical application of quality improvement at community level as well as exploration of practical opportunities to integrate improved processes and service innovations across the districts. Building on this approach, the HRH2030 project approached the Ministry of Health and Wellness for a joint “Delivering Differently” initiative to expand the collaborative focus on the systematic adaptation of service delivery models more broadly’ in support of the ambitious challenges of achieving sustainable HIV epidemic control and longer-term primary health care goals. REVITALISING COMMUNITY HEALTH SYSTEMS From 2015-2017, the USAID-funded Applying Science to Strengthen and Improve Systems (ASSIST) project developed a community health system approach specifically tailored for Botswana’s unique context. In line with PEPFAR Botswana strategies and other USAID-funded efforts, ASSIST facilitated community-based improvement teams (CITs) to support a massive scale up of quality HIV care and treatment. In collaboration with district health managers, community members and representatives guided local NGO and facility- based health workers in understanding and systematically analyzing acute local barriers to quality care. Together they applied practical improvement methods and developed change ideas to sustainably address and overcome those barriers. Aside from generating a wide range of innovative people-centered adaptations in how services are provided, the approach also helped revitalise dormant community-level governance structures that are seen as essential to achieve broader sustainable health and human development in Botswana. Since late 2017, ASSIST‘s work has been adapted by the Human Resources for Health in 2030 project, combining the collaborative improvement approach with an HRH perspective to best support the Ministry of Health and Wellness in systematically implementing community-oriented differentiated service delivery. CONCLUSIONS AND LESSONS LEARNED With a dedicated programmatic focus on joint learning, the ASSIST project continuously involved communities, local and central government, and other partners in its reviews of local progress and system-level implications: • Dedicated community/provider collaboratives under DHMT mandate have effectively reconnected local accountability loops and revitalised traditional volunteerism to extend the existing reach of healthworkers and HIV care programmes into the community, eg to identify, reconnect “lost” patients and bring them back to life-saving care. • Achieving and sustaining HIV epidemic control in Botswana fundamentally requires a systematic effort to effectively revitalise community-based governance, to reconnect it with effective district level coordination across providers, and to involve communities and patients in the identification of differentiated strategies to test for, link with and be retained in quality care. • Both the challenge of reaching those not yet identified and treated, and of supporting an ever-increasing cohort of people already on life-long ART underline the need for continuous adaptations in how services are provided, including systematric efforts to improve, simplify and integrate care more efficiently for those who need it, as well as the health workers who serve them. • Existing delivery models and the management of health services need to re-organized systematically around the needs of patients and patient populations, rather than around the programmes that deliver them, to differentiate services according to preferences of people facing life-long chronic care in the context of often difficult socio-economic conditions. • As Botswana is finally closing in on epidemic control of HIV/AIDS, the sustainability of these efforts will depend directly on the immediate context of how the health system as a whole manages to continue adapting and integrating its delivery models, health workforce development, and coordination of providers under a shared agenda of primary healthcare. The HRH2030 program is aligning its support under PEPFAR Botswana with this important agenda to “deliver differently” in 2018/19. KEY OUTCOMES • Institutionalisation of the intrinsic value of communities as a foundation for the health system to improve health outcomes • Tangible improvements in testing, retention, and adherence, and return of unclarified (or “lost”) patients to ART at rates between 38 percent and 100 percent, once communities and providers coordinated their activities around community preferences and “rewired” local accountability loops • Practical application of quality improvement methods at the community level across 7 districts and around 40 improvement teams of volunteers finding local solutions and innovating patient-centred service delivery • Generation of evidence for new community-based service delivery strategies and innovations, to improve care and move toward a broader differentiation and intergation of delivery mechanisms • Establishment of Government-mandated mechanisms for the systematic exploration and collaborative implementation of differentiated service models to Deliver differently“ (Model of Care Community Adapations, or MOCCA). This material is made possible by the generous support of the American people through the United States Agen- cy for International Development (USAID) under the terms of cooperative agreement no.AID-OAA-A-15-00046 (2015-2020) in partnership with The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR). The contents are the responsibility of Chemonics International and do not necessarily reflect the views of PEPFAR, USAID, or the United States Government. www.hrh2030program.org THE PRACTICAL IMPACT OF INVOLVING COMMUNITIES: CLOSING ACUTE GAPS IN COMMUNITY ART RETENTION ACROSS 5 DISTRICTS Community/facility collaboration to clarify status of ‘lost-to-follow-up’ patients and return them to care: Illustration from Molepolole (February to June 2017) RESULTS ACROSS DISTRICTS 2/2/2017 2/16/2017 3/14/2017 4/27/2017 6/30/2017 HCW called ‘lost patients’ based on number on file IDCC focal per- son checked IPMS at the local facility and at district referral level HCW did house-to-house follow-up visits HCW did house-to-house follow-up visits Patients‚ lost or unclarified Confirmed Deceased Confirmed to be in care elsewhere Confirmed to be currently not in care Patients returned to care and treatment 105 53 13 26 30 67 51 43 3 3 4 14 18 21 8 7 7 KWENENG: MOLEPOLOLE • 93% reconnected and clarified • 38% returned to ART (ongoing) • 20% already deceased GABARONE: BLOCK 9 • 100% reconnected and clarified • 100% returned to care and ART • 6% already deceased KGATLENG: BOKAA • 91% reconnected and clarified • 71% returned to care and ART • 5% already deceased GOODHOPE: PITSANE • 100% reconnected and clarified • 63% returned to care and ART • 15% already deceased MAHALAPYE: PALLA ROAD • 94% reconnected and clarified • 57% returned to care and ART • 44% already deceased

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Page 1: DELIVERING DIFFERENTLY, TOGETHER - URC · 10 36 1 5 delivering differently, together: the role of communities to sustainably improve local systems, revitalise primary healthcare and

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DELIVERING DIFFERENTLY, TOGETHER: THE ROLE OF COMMUNITIES TO SUSTAINABLY IMPROVE LOCAL SYSTEMS,

REVITALISE PRIMARY HEALTHCARE AND END AIDS IN BOTSWANA

Kesaobaka Dikgole (HRH2030/University Research Co., LLC), Cecil Max Haverkamp & Dintle Molosiwa (HRH2030/Chemonics International)

BACKGROUND From the late 1970s, community-centered PHC was the bedrock for health service delivery in Botswana. The advent of HIV/AIDS and this nation‘s massive, two-decade long emergency response, however, have also fundamentally changed and weakened Botswana’s health system. Today, burdened with one of the highest HIV prevalence rates in the world, the country is finally closing in on epidemic control amidst concerns over the sustainability of its TREAT ALL initiative and largely verticalized, hospital-based disease programmes. Determined to revitalise primary healthcare and refocus on the role of local communities, the Ministry of Health and Wellness and its USAID-funded community health system partners started the “Delivering Differently” initiative: to systematically adapt, integrate and differentiate existing service delivery models through collaborative improvement efforts at central, district and community level.

METHODS Under both the USAID-funded ASSIST and HRH2030 projects, the local project team facilitated a truly bottom-up but elaborate, iterative and targeted process of consensus building across different levels of the health system. We worked with Botswana government counterparts at the central level (Ministry of Health and Wellness); in districts (district health management teams, district administrations, councils); and community level di-Kgosi (traditional leaders) and village development committees) to revitalize functioning community health system structures as part of broader efforts to end AIDS, improve primary health care and achieve sustainable human development in Botswana. ASSIST improvement specialists coached community improvement teams (on a volunteer basis) established under the mandate of di-Kgosi and embedded in the local governance context. Community coaching followed a systematic step by step Model of Improvement to analyze problems, develop and test change ideas as well as evaluating improvement efforts toward improved, more patient-centered services to the community, families, and individuals. Periodic district and national ‘learning sessions’ created a platform for horizontal learning on practical application of quality improvement at community level as well as exploration of practical opportunities to integrate improved processes and service innovations across the districts.

Building on this approach, the HRH2030 project approached the Ministry of Health and Wellness for a joint “Delivering Differently” initiative to expand the collaborative focus on the systematic adaptation of service delivery models more broadly’ in support of the ambitious challenges of achieving sustainable HIV epidemic control and longer-term primary health care goals.

REVITALISING COMMUNITY HEALTH SYSTEMS From 2015-2017, the USAID-funded Applying Science to Strengthen and Improve Systems (ASSIST) project developed a community health system approach specifically tailored for Botswana’s unique context. In line with PEPFAR Botswana strategies and other USAID-funded efforts, ASSIST facilitated community-based improvement teams (CITs) to support a massive scale up of quality HIV care and treatment. In collaboration with district health managers, community members and representatives guided local NGO and facility-based health workers in understanding and systematically analyzing acute local barriers to quality care. Together they applied practical improvement methods and developed change ideas to sustainably address and overcome those barriers. Aside from generating a wide range of innovative people-centered adaptations in how services are provided, the approach also helped revitalise dormant community-level governance structures that are seen as essential to achieve broader sustainable health and human development in Botswana. Since late 2017, ASSIST‘s work has been adapted by the Human Resources for Health in 2030 project, combining the collaborative improvement approach with an HRH perspective to best support the Ministry of Health and Wellness in systematically implementing community-oriented differentiated service delivery.

CONCLUSIONS AND LESSONS LEARNED With a dedicated programmatic focus on joint learning, the ASSIST project continuously involved communities, local and central government, and other partners in its reviews of local progress and system-level implications:

• Dedicated community/provider collaboratives under DHMT mandate have effectively reconnected local accountability loops and revitalised traditional volunteerism to extend the existing reach of healthworkers and HIV care programmes into the community, eg to identify, reconnect “lost” patients and bring them back to life-saving care.

• Achieving and sustaining HIV epidemic control in Botswana fundamentally requires a systematic effort to effectively revitalise community-based governance, to reconnect it with effective district level coordination across providers, and to involve communities and patients in the identification of differentiated strategies to test for, link with and be retained in quality care.

• Both the challenge of reaching those not yet identified and treated, and of supporting an ever-increasing cohort of people already on life-long ART underline the need for continuous adaptations in how services are provided, including systematric efforts to improve, simplify and integrate care more efficiently for those who need it, as well as the health workers who serve them.

• Existing delivery models and the management of health services need to re-organized systematically around the needs of patients and patient populations, rather than around the programmes that deliver them, to differentiate services according to preferences of people facing life-long chronic care in the context of often difficult socio-economic conditions.

• As Botswana is finally closing in on epidemic control of HIV/AIDS, the sustainability of these efforts will depend directly on the immediate context of how the health system as a whole manages to continue adapting and integrating its delivery models, health workforce development, and coordination of providers under a shared agenda of primary healthcare.

The HRH2030 program is aligning its support under PEPFAR Botswana with this important agenda to “deliver differently” in 2018/19.

KEY OUTCOMES • Institutionalisation of the intrinsic value of communities

as a foundation for the health system to improve health outcomes

• Tangible improvements in testing, retention, and adherence, and return of unclarified (or “lost”) patients to ART at rates between 38 percent and 100 percent, once communities and providers coordinated their activities around community preferences and “rewired” local accountability loops

• Practical application of quality improvement methods at the community level across 7 districts and around 40 improvement teams of volunteers finding local solutions and innovating patient-centred service delivery

• Generation of evidence for new community-based service delivery strategies and innovations, to improve care and move toward a broader differentiation and intergation of delivery mechanisms

• Establishment of Government-mandated mechanisms for the systematic exploration and collaborative implementation of differentiated service models to Deliver differently“ (Model of Care Community Adapations, or MOCCA).

This material is made possible by the generous support of the American people through the United States Agen-cy for International Development (USAID) under the terms of cooperative agreement no.AID-OAA-A-15-00046 (2015-2020) in partnership with The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR). The contents are the responsibility of Chemonics International and do not necessarily reflect the views of PEPFAR, USAID, or the United States Government.

www.hrh2030program.org

THE PRACTICAL IMPACT OF INVOLVING COMMUNITIES: CLOSING ACUTE GAPS IN COMMUNITY ART RETENTION ACROSS 5 DISTRICTS Community/facility collaboration to clarify status of ‘lost-to-follow-up’ patients and return them to care: Illustration from Molepolole (February to June 2017)

RESULTS ACROSS DISTRICTS

2/2/2017 2/16/2017 3/14/2017 4/27/2017 6/30/2017

HCW called ‘lost patients’ based on

number on file

IDCC focal per-son checked IPMS at the local facility

and at district referral level

HCW did house-to-house

follow-up visits

HCW did house-to-house

follow-up visits

Patients‚ lost or unclarified

Confirmed Deceased

Confirmed to be in care elsewhere

Confirmed to be currently not in care

Patients returned to care and treatment

105

53

13 26 30

67 51 43

3 3 414 18 218 7 7

KWENENG: MOLEPOLOLE

• 93% reconnected and clarified• 38% returned to ART (ongoing)• 20% already deceased

GABARONE: BLOCK 9

• 100% reconnected and clarified• 100% returned to care and ART• 6% already deceased

KGATLENG: BOKAA

• 91% reconnected and clarified• 71% returned to care and ART• 5% already deceased

GOODHOPE: PITSANE

• 100% reconnected and clarified• 63% returned to care and ART• 15% already deceased

MAHALAPYE: PALLA ROAD

• 94% reconnected and clarified• 57% returned to care and ART• 44% already deceased