Using Data for Continuous Quality Improvement and Improved ART and PMTCT Outcomes in Tanzania – The Collaborative Approach Authors: Kalokola F, Hobokela S, Mgunda F, Hizza E, Kinoti S and Rumisha D

The Message Demonstrate the potentials for utilization of routine health data at the point of collection for facility management and ultimately improvement of quality of service

The Outline The rationale for QI for ART and PMTCT services Methodology and achievements How data was used Summary of the results

The rationale for QI for ART and PMTCT services

Methodology and achievements

How data was used

Summary of the results

Why QI in HIV/AIDS Treatment and Care Services? By October 2005, just over 1600 PLWA were on ARV but by December 2008, about 184,000 (46% of the eligible PLWA) were on ARV in about 700 sites across the country - increased by 125 fold in 3 years. The improved access through rapid scale-up of the services in the background of a weak health infrastructure and health systems compromised the quality of services. . In addition, the HIV Treatment and Care component of the control program in Tanzania is supported by various IP each supporting one or more regions – therefore the need for coordination.

By October 2005, just over 1600 PLWA were on ARV but by December 2008, about 184,000 (46% of the eligible PLWA) were on ARV in about 700 sites across the country - increased by 125 fold in 3 years.

The improved access through rapid scale-up of the services in the background of a weak health infrastructure and health systems compromised the quality of services.

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In addition, the HIV Treatment and Care component of the control program in Tanzania is supported by various IP each supporting one or more regions – therefore the need for coordination.

The main objectives of the USAID HCI Project in Tanzania Increase capacity of Care and Treatment Partners and MOHSW (RHMTs and CHMTs) in all regions of TZ to implement QI in ART/PMTCT using the Collaborative Approach To facilitate scaling up of CQI in ART/PMTCT to all regions of Tanzania Improve ART/PMTCT Coverage and outcomes To strengthen Infant Feeding (IF) Counseling Training component of PMTCT to cover all the regions

Increase capacity of Care and Treatment Partners and MOHSW (RHMTs and CHMTs) in all regions of TZ to implement QI in ART/PMTCT using the Collaborative Approach

To facilitate scaling up of CQI in ART/PMTCT to all regions of Tanzania

Improve ART/PMTCT Coverage and outcomes

To strengthen Infant Feeding (IF) Counseling Training component of PMTCT to cover all the regions

The QI Methods - Improvement Collaborative Approach Why? ART and PMTCT is a new intervention in TZ, and the Collaborative Approach directs improvements through sequential testing of changes to processes. Teams find local solutions to implementation problems and share their innovations so that all teams can quickly benefit. The process strengthens participation of local stakeholders and brings to bear the intelligence, energy and creativity of the health workers actually involved in the ART service delivery. The approach affords forum where implementing teams can share questions, problems and solutions with their peers without feeling isolated. In the process, teams become motivated to track results and achieve improvements. In long run a “culture of measuring” is established.

ART and PMTCT is a new intervention in TZ, and the Collaborative Approach directs improvements through sequential testing of changes to processes. Teams find local solutions to implementation problems and share their innovations so that all teams can quickly benefit.

The process strengthens participation of local stakeholders and brings to bear the intelligence, energy and creativity of the health workers actually involved in the ART service delivery.

The approach affords forum where implementing teams can share questions, problems and solutions with their peers without feeling isolated.

In the process, teams become motivated to track results and achieve improvements. In long run a “culture of measuring” is established.

PQI: Spread of ART/PMTCT QI activities to all regions of Tanzania

Main HCI Project Achievements to Date Tanga Region: the RHMT and all 8 districts implementing ART/ PMTCT Improvement Collaborative 5 RHMT members, 15 CHMT members and 52 health providers trained in Collaborative Approach in Tanga. Increased the pool of district personnel familiar with care process analysis, team building sharing experiences and measuring improvement in Tanga. Reduced lost to follow up, better uptake of CD4 tests and increase in HIV+ ANC mothers enrolled to PMTCT and in CTC in Tanga region. Strengthened coordination among Care and Treatment IP in QI and IF

Tanga Region: the RHMT and all 8 districts implementing ART/ PMTCT Improvement Collaborative

5 RHMT members, 15 CHMT members and 52 health providers trained in Collaborative Approach in Tanga.

Increased the pool of district personnel familiar with care process analysis, team building sharing experiences and measuring improvement in Tanga.

Reduced lost to follow up, better uptake of CD4 tests and increase in HIV+ ANC mothers enrolled to PMTCT and in CTC in Tanga region.

Strengthened coordination among Care and Treatment IP in QI and IF

Data was used to identify, measure, benchmark, evaluate and sustain QI

Using Data in Coordinating Partnership and Team Work The Partnership Quality Improvement (PQI) Initiative is a unique innovation bringing together IP, the MOHSW, RHMTs, CHMTs and Facility Quality Teams to address a common goal. To a greater extent, knowledge management for improved ART and PMTCT outcomes is the glue bonding the partnership – use of common indicators, standards and QI method – Collaborative Approach. In the process of introducing Improvement Collaborative Approach the HCI Project strengthened capacity for NACP, RHMTs, as well as CHMTs to use scientific methods to assess, measure quality changes in their own setting and deliberately spread, learn and adapt the new knowledge to several other sites.

The Partnership Quality Improvement (PQI) Initiative is a unique innovation bringing together IP, the MOHSW, RHMTs, CHMTs and Facility Quality Teams to address a common goal.

To a greater extent, knowledge management for improved ART and PMTCT outcomes is the glue bonding the partnership – use of common indicators, standards and QI method – Collaborative Approach.

In the process of introducing Improvement Collaborative Approach the HCI Project strengthened capacity for NACP, RHMTs, as well as CHMTs to use scientific methods to assess, measure quality changes in their own setting and deliberately spread, learn and adapt the new knowledge to several other sites.

Using Data to Define the Quality Problem In Tanga however, teams started with a local baseline assessment to identify the quality gap and local priorities. This was followed by definition of change objectives and package as well as monitoring indicators and targets. The process of conducting the baseline assessment also facilitated team building and self introspection for the local teams.

In Tanga however, teams started with a local baseline assessment to identify the quality gap and local priorities.

This was followed by definition of change objectives and package as well as monitoring indicators and targets.

The process of conducting the baseline assessment also facilitated team building and self introspection for the local teams.

Using Data to Monitor and Evaluate QI Through routine data, progressive performances were measured and shared between teams to decide on what is working and what should be changed. Data from facilities were used to monitor compliance to standards pointed out centers that needed more attention.

Through routine data, progressive performances were measured and shared between teams to decide on what is working and what should be changed.

Data from facilities were used to monitor compliance to standards pointed out centers that needed more attention.

The Results

Percentage of HIV+ Pregnant Women Enrolled from RCHC to CTC (4 sites Tanga Region)

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Conclusion What we measure we can also improve. Therefore, Knowledge Management is central to QI. The Tanga experience has shown that it can be done even under conditions of limited resources. Successful PQI requires commitment to the principles of QI and enhances coordination of the various partners as well as motivation of stakeholders. Promotion of Use of Data at the point of collection enhances, data quality, add value on the data and promotes the culture of informed decision making.

What we measure we can also improve. Therefore, Knowledge Management is central to QI. The Tanga experience has shown that it can be done even under conditions of limited resources.

Successful PQI requires commitment to the principles of QI and enhances coordination of the various partners as well as motivation of stakeholders.

Promotion of Use of Data at the point of collection enhances, data quality, add value on the data and promotes the culture of informed decision making.