Leveraging an HIV Care and Treatment Program to Strengthen Local Health Care Networks_Mwayab Kazadi_4.23.13
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Leveraging an HIV Care and Treatment Program to Strengthen Local Health Care Networks_Mwayab Kazadi_4.23.13
- 1. Leveraging an HIV Care and Treatment Program to Strengthen Local Health Care Networks Mwayabo J. C Kazadi, MD, MPH, MBA Senior Technical Advisor, Catholic Relief Services
- 2. • Nine years • Ten countries • USD 740 million, funded by PEPFAR • Designed for transition to local ownership
- 3. Over nine years, the CRS-led AIDSRelief consortium delivered high-quality HIV care and treatment in ten countries with more than $700M in PEPFAR support. • 19 local partners working directly through 276 facilities 700,000+ clients, including 395,000+ who initiated ART Viral suppression = 88.2% Retention = 83% Mortality = 7.8% Loss to follow up = 10.6%
- 4. Capacity Strengthening = Capacity Building + Institutional Strengthening + Accompaniment The AIDSRelief Approach
- 5. Comprehensive, interdisciplinary approach based on a framework: Organizational capacity Technical capacity Funding capacity Policy and advocacy capacity Key Interventions and Approaches
- 6. Key Interventions and Approaches • Baseline assessment of organizational strengths and gaps • Clear milestones based on assessment results • Dynamic capacity building plans
- 7. Ongoing assessment using: • Site Capacity Assessment (SCA) • Clinical Assessment for System Strengthening (ClASS) Key Interventions and Approaches
- 8. • Joint site visits • Long-term accompaniment/mentoring • Proven practices of adult learning (didactic work, practical application, on-site training) • Exchange visits Key Interventions and Approaches
- 9. • Continuous quality improvement teams • Clinical task shifting • Continuing, locally-owned education • Incremental transfer of responsibilities Key Interventions and Approaches
- 10. Results • Partners sustained quality patient services • Managed USG sub-grants • From 2008-2012, more than 30,000 participants trained • Transition: 14 local partners in 8 countries secured direct PEPFAR funding to manage the programs.
- 11. Conclusion Disease-specific resources can improve organizational capacity to better manage operations and service delivery, thereby strengthening the overall health system.
- 12. Lessons learned • Begin early • Dedicate resources • Leverage local resources • Work with host government • Disengage gradually
Editor's Notes
- AIDSRelief was a five-member consortium funded through the President’s Emergency Program for AIDS Relief (PEPFAR). The consortium brought together a powerful set of international experts working hand in hand with local partners to build the skills and systems needed to support high-quality HIV care.Over nine years, the project supported rapid scale-up and expansion of lifesaving antiretroviral therapy to poor and under-served populations in ten countries.Program resources were leveraged to reinforce service delivery and strengthen the overall health system. The capacity strengthening model was targeted, hands-on, and resource intensive; it was also highly effective.
- In addition, LTFU was 10.6%. These are all averages across all ten countries.These quality outcomes could only become a reality and reach scale with a health systems strengthening approach. If anyone asks, this is how we qualify viral suppression:In seven of the ten AIDSRelief countries where viral loads for program evaluation were conducted, median time on treatment was 16 months and the average viral suppression proportion —the gold standard for treatment success—among a 10% random sample of all patients initiated on therapy was 88.2 percent, a rate comparable to or even better than those seen in industrialized countries.
- The AIDSRelief Capacity Strengthening ApproachCapacity strengthening is essential to any organization’s functioning. It includes capacity building, which focuses on individuals or teams, enhancing or developing new knowledge, skills, and attitudes in order for people or teams to function better; institutional strengthening, focusing on an organization, enhancing or developing its systems and structures to function more effectively, work towards sustainability, and achieve goals; and accompaniment, which includes consistent coaching, mentoring, and supportive supervision and allows new skills to be mastered or new organizational systems to become standard operating proceduresThe aim is to capacitate local partners, increase local ownership as a way to reduce poverty and reach out to more needy in remote and neglected or hard to reach areas.
- For ART programs, scale up, integration of ART with other clinical services, decentralization and sustainability are all dependent on strong planning, management, and systems. ART programs are not unique in needing these strengths, but the AIDSRelief program brought with it resources for overall capacity strengthening of our local partners.With ten country programs, we tailored capacity strengthening top each country context. However in general we followed a similar framework
- Several tools were used to monitor capacity strengthening progress at both the site and the local partner level. These included:SCA – developed jointly by CRS, IHV and Futures. Is used to assess a health facility’s overall ability to deliver consistent and sustainable HIV care and treatment. The SCA Tool does not assess program outcomes; rather, it assesses the capacity of program operations.Learn more on our website at: http://www.crsprogramquality.org/hiv-and-aids-sca-tool/. Tool is free, just email aidsrelief@crs.orgClASS assessment was designed and carried out by our USG donor. It covers administrative, clinical and financial competencies.These tools are similar and between them we had comprehensive ongoing assessment
- To help ensure ongoing access to the education necessary to maintain the achievements, country programs established and reinforced in-country education. For example:• AIDSRelief Zambia worked with the Ministry of Health and General Nursing Council to establish a one-year diploma program for nurse practitioners (HIV NP). Also, with University of Zambia Teaching Hospital and the MOH, AIDSRelief established an 18-month Master’s of Science (MSc) program in HIV medicine. • AIDSRelief Nigeria successfully lobbied the National Nursing Council to include HIV care and treatment in nursing school curriculums, and subsequently helped to develop curriculums.• AIDSRelief Rwanda supported clinicians for acquiring expert certifications conferred by the American Academy of HIV Medicine (AAHIVM), and also sent physicians and nurses to attend exchange programs. • AIDSRelief Haiti established the first postgraduate medical education program of its kind at the University of Notre Dame Haiti (UNDH), supported a network of hospitals in Port-au-Prince and North and South departments for clinical rotations and trainings, and hosted infectious disease symposiums at UNDH for 110 providers, students, and NGO staff in Haiti.
- The AIDSRelief approach to treatment, systems strengthening, and transition to local ownership is broadly applicable. It demonstrates that disease-specific resources can improve the overall system and better serve patients suffering from other chronic diseases; neglected tropical diseases; and routine health concerns such as malaria, safe motherhood, and childhood illnesses.
- Begin early: Capacity strengthening is a lengthy process and should be incorporated into the earliest stages of project design rather than later stages of implementation.Capacity strengthening is related to, but distinct from implementation. Dedicated resources are required. Utilize local resources. The linkages established with local resource people and institutions will provide continued long-term, cost-effective support for the local partners after the external funding has come to an end. However, in countries where local experts are oversubscribed and institutions stretched to the limit, external experts may be the best option. The challenge is to guide the external experts to ensure that their input is appropriate to the country context and that they work collaboratively with their local counterparts. An international exchange of knowledge and perspectives can be an enriching experience for all stakeholders and can pave the way for transition down the road.Work with the host government. In most countries, health services are the responsibility of government. External donor funding for PLHIV will not continue forever. If life-long treatment is to be sustained, local government must be on board.
- We have done case studies of the South Africa, Zambia, Uganda and Nigeria programs. Find them on our website at www.crsprogramquality.org