South to South Presentation

Ntiyiso Shingwenyana

12 September 2016

Presentation Outline

• South to South Results Overview• South to South Quality Improvement

Collaboratives• Pilot and Demonstration Phase Achievements• Progress of Rapid Scale-up Phase• Key outputs of South to South activities• Challenges and mitigation Strategies

South to South - Location

To develop and institutionalize an innovative capacity building program to support

the South African Government priorities and to

improve HIV/TB health outcomes for

priority populations: pregnant women, infants, children, adolescents, and those who are HIV/TB co-infected.

Programmatic Goal

Results FrameworkGoal: To improve maternal and child HIV/TB outcomes

Improved health systems performance

Improved health service access, quality, safety, coverage

Individual Organizational Systems/policyImproved individual

performance: competencies and job

requirements

Improved internal organizational systems

and processes

Improved maternal and child HIV/TB policy

environment

Individual health worker capacity building through

training

Facility Quality Improvement Collaboratives

Participation in national and provincial expert

dialogue for a and support diffusion of

innovations

Long Term

Outcomes

Medium Term

Outcomes

Activities

Relevance to District Priorities

• Maternal health• PMTCT• Infant feeding• Paediatric care,

treatment and support• Psychosocial

support/Disclosure• Pharmacy support• Community health

Programme Topic Areas

Who:– Healthcare workers (individual level)– Cluster of health facilities (organizational level)– Sub-district structures (organizational level)– Health system support (system level)

How:– Quality Improvement Collaborative Approach– Establishing sub-district and facility QI Teams– Quarterly Learning Network– On and Off site Training– Coaching

South to South Support

Amathole eMTCT and Paeds QI

CollaborativesRapid QI Scale up

112 Facilities

M and E SupportEvaluation of eMTCT and Paeds QI Collaboratives

Evaluation of Master Training Networks

Writer’s Workshop and Research CoordinationCompetency Dictionary

CompilationImplementation science

Workshop

South to South Organizational Overview

Master Trainer NetworksLearning Material Development

SupportAd Hoc Training Requests

S2S QI Approach

Clusters

Situational Analysis(Problem Analysis)

Facility Based QI Teams

LearningNetwork

1

LearningNetwork

2

LearningNetwork

3 ….

Sub-District Learning Network

Quality Improvement Approach

April 2016 June 2016

*Figure adapted from IHI (2003)

South to South Quality Improvement Collaborative Approach*

Sept 2016

Learning session 4

Nov 2016

Learning session 5

Phase 0: Pilot Phase

Phase 1: Demonstration

Learning session 6

Phase 2: Rapid Scale-up Phase

Learning session 1

Learning session 2

Learning session 3

Capacity building at Sub district, District, Province, Partners

QI COACHING, TRAININGS, PROGRAM TECHNICAL SUPPORT

Preparation

S2S Quality Improvement Collaborative

Pilot Phase: Jan 2013 to Dec 2013 - 4 Facility QI Teams in 4

Facilities (Mquma)

Demonstration Phase: Jan 2014 to Mar 2015 - Maintain 4 QI Teams Established and Additional 10

Facility QI Teams (Mnquma)Rapid Scale Up Phase –Mar 2016 todate Total of 112

Facility Based QI Teams (AMATHOLE DISTRICT)

Learning Session 1: ANC

Learning Session 2: ANC

Learning Session 3: DEL

Learning Session 4: POST

Learning Session 5: POST

Learning Session 6:

Maint.

PDSA PDSA PDSA PDSA PDSA

Capacity building at Sub district, District, Province, Partners

QI COACHING, TRAININGS, PROGRAM TECHNICAL SUPPORT

Stakeholder Engagement and Ethics Clearance

• 90 90 90 PMTCT Tracer Indicators – Antenatal 1st visit before 20 weeks rate– Antenatal client HIV re-test rate– Antenatal client start on ART rate– Mother postnatal visit within 6 days

rate– Infant 1st PCR test positive around 6

weeks rate– Child rapid HIV test around 18 months

uptake rate– Child rapid HIV test around 18 months

positive rate– Couple year protection rate

• 90 90 90 Paeditric and Adolescents Tracer Indicators

– HIV test positive child 19-59 months– HIV test positive child 5-14 years– Child under 1 year naïve started ART– Child 12-59 months naïve started ART– Child 5-14 years naïve started ART– Child under 15 years remaining on ART -

total

South to South supported indicators

Total ANC

Clients

ANC Clients Known status

93%

Pos. ANC

Clients

ANC Pos.

Clients on

ART

98%

PCR tested

(6 weeks)

Live births

to ANC Positive

PCR Positive

(6 weeks)

Rapid Test (18

Mnts)

Rapid Test

Positive (18

mnths)

64%

S2S Demonstration Phase PMTCT Cascade 12 months after 1st Learning Session 1 (June 2014– July 2015)

*N=14 facilities

PMTCT Program

Paeds Program

71%

Baseline versus post learning session median rates for PMTCT cascade indicators amongst S2S supported sites in the Eastern

Cape 2012 - 2015

*p<001 for difference between median rates for baseline vs post learning using Wilcoxon Signed-Ranks Test

Learning session

Learning session

Learning session Learning session

Learning sessionLearning session

Feedback about S2S supportFeedback about S2S support

Improved Knowledge of Data for Programme Monitoring

“They helped me track whether I’m going to meet our monthly targets. I never worried myself about that graph until S2S came, but now I can interpret that graph…for instance, when I saw that my utilisation rate target was 5.5.% but realised that I’m not going to reach it I decided to do an internal campaign” Focus Group Discussion, QI Team Member, EC.

Feedback about S2S Support

Improvement of adherence tracking and adherence at facility

“There was an adherence tool that was designed…where you count the pills when someone comes; you write the percentage then you will be able to see whether they are taking treatment correctly …what I really liked about this tool is that they didn’t only teach it to the PN’s-even our lay counsellors were taught…now the lay counsellor can count and I just check every now and then if they counted correctly then I can congratulate the client…” Focus Group Discussion, QI Team Member, EC

South to South Quality Improvement Collaborative Rapid scale-up phase

Progress and plans2016 - 2017

Amathole District Entry Workshop – Full House Attendance (54 Participants)

Baseline median rates (March 2015 to April 2016) of key PMTCT and Paediatric 90 90 90 tracer indicators for S2S scale per sub-district

90 90 90 Tracer Indicator Amahlati Mbashe Mnquma Nkonkobe2016/2017

District Target

Antenatal client HIV re-test rate 103% 85% 62% 89% 100% Antenatal client initiated on ART rate 99% 99% 99% 100% 95% Infant 1st PCR test around 6 weeks uptake rate

96% 80% 45% 71% No district target

Child rapid HIV test around 18 months uptake rate 103% 85% 62% 89% 100%

Child 1 to under 5 years start ART rate 47% 30% 20% 18.8% 100%

Child 5 to under 15 years start ART rate 39% 50% 54% 63% 90%

Child under 1 year start ART rate 11% 17% 20% 21% 100%

Mother postnatal visit within 6 days rate 86% 92% 38% 74% 90% Infant exclusively breastfed at HepB 3rd dose rate 21% 41% 42% 33% 40%

Case study: Improving early infant diagnosis

Case Study Example: Problem of low birth PCR

Birth PCR Not Done

Results poorly or not Recorded

Results not Sent to PHC

Results not Sent to New Mom

Poor Facility - Community

and Client Linkages

• Plan Do Study Act plan was designed • Two ENA`S will follow up results at laboratory and then write results in labour ward book.• The PN in labour ward write in the request book a COPY to be sent via the lab to the patient health clinic.• PCR results will only be written in the labour ward book when results are available.• Labour ward staff highlight in babies record with PN contact no to do “Please call” to prevent LTFU• Labour ward now keeping list of all PCRs per catchment area.

The Change Ideas

Birth PCR Done at Butterworth Hospital – Mnquma Sub District

Median Line

Target Line

50% Increase

Case Study 2The Problem? SS Gida Gateway Clinic: HCT uptake stagnant at 40%

• Plan Do Study Act plan was designed on April 2016• Two ENA to coordinate community mobilization for HCT.• Aggressive efforts to promote community and facility PICT.• Set monthly testing targets for ALL PN’s, ENA and Lay Counsellor –

higher allocation for the L/C.• Conduct community outreaches to improve numbers of HCT uptake

The Change Ideas

Desired Outcome: To increase HCT Uptake from 40% to 60% by June 2016

HCT Uptake at SS Gida Gateway Clinic - Amahlati

HCT Uptake 15 – 49 SS Gida Gateway Clinic Amahlathi

MarchQI Team Formed

AprilIntervention

started

Close to 10% Increase

PDSA Cycle: Example

Key outputs from S2S Capacity Building Events FY2015 % Achieved FY2016 %

Achieved

Number of sub-districts supported to improve HIV/TB outcomes 8 100% 4 100%

Facilities supported to create QI teams and implement learning networks to improve 90 90 90 indicators 54 100% 112 100%

Number trained in Paediatric HIV/TB University Short Course (old course) 22 110% N/A N/A

Number of DCST/District Trainers Master Trainers capacitated with Paediatric HIV/TB University Short Course in District 29 96% 30 60%

Subdistrict managers coached to use quality improvement to improve maternal and child health outcomes 27 100% Ongoing N/A

Facility based health workers coached in Collaboratives 473 305% 120 66%

Health workers provided with needs based training in Collaborative 186 155% 20 40%

Health workers attending Learning Session in Collaborative 290 145% 280 80%

Number NDoH Stakeholders attending standardisation of IMCI workshop 46 100% In planning

stage N/A

Number of co-authored conference presentation at national conferences sharing best practices and recommendations 6 100% 7 116%

Number of NDoH and PEPFAR stakeholder attending implementation science workshop to enhance use to improve 90 90 90 targets

55 120% In planning stage N/A

Number NDoH Stakeholders attending Writers Retreat and Co-Publication workshop 46 100% 15 100%

Number NDoH Stakeholders and Development Partner Representatives attending Implementation Science workshop 46 100% 50 100%

South to South supporting Amathole to Define Competencies

Key Products & Tools

Research Output 2016

Quality Improvement Course16 Operational Managers

1 Registered Nurses All Amathole

Other Training

Challenges and Mitigation Strategies

Challenges Mitigation StrategiesDHIS data quality Strengthening site level data collection through QI

Provide TA to district and sub-district data personnel. Develop system for linking babies born at hospitals to facilities

Reporting cycles Site level data collection

Limited duration of scale up phase

Multiple indicator roll out

Human Resources compared to changes in scope as project grows

Continued effort to recruit skilled technical personnel to implement programme

Delay in political drive in National IMCI curriculum review

Continuous engagement

Jul - Sept Oct - Dec

2016

Ongoing support for NDoH and Province

Learning session 3CHW Forum QI & implementation science capacity buildingCompetency Dictionary

Jan - Mar Apr - Jun Jul - Sept

Remaining Activities

Action periodTest & treatCHW forum 2Paeds capacity building for managers

Learning session 4 & action periodCHW forum 3QI capacity buildingMid-term assessment

Learning session 5 & action periodCHW forum 4QI capacity building

Learning session 6 & action periodCHW forum 5End of programme assessment

Program Write Up &

closure

2017