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What’s Next? Practical Implementation Lessons from the Partnership for HIV-Free Survival


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This webinar took place September 2019.

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What’s Next? Practical Implementation Lessons from the Partnership for HIV-Free Survival

  1. 1. What’s Next? Practical Implementation Lessons from the Partnership for HIV-Free Survival Emily A. Bobrow Heather B. Davis David K. Hales MEASURE Evaluation 25 September 2019 Webinar
  2. 2. Partnership for HIV-Free Survival (PHFS) • Innovative project designed to prevent and eliminate mother- to-child transmission of HIV (PMTCT and eMTCT) • Brought together proven practices from PMTCT, quality improvement (QI), nutrition, and community outreach to improve health outcomes for mothers living with HIV and their HIV-exposed infants • Supported by USAID and PEPFAR, PHFS was active between 2012 and 2016 in six countries in sub-Saharan Africa: Kenya, Lesotho, Mozambique, South Africa, Tanzania, and Uganda
  3. 3. PHFS evaluations by MEASURE Evaluation • PHFS Legacy Evaluation Report • Country-Specific Briefs Kenya: Lesotho: Mozambique: South Africa: Tanzania: Uganda: • Outcome Evaluation of PHFS in Uganda
  4. 4. Intended users of the guide • People who are keenly interested in improving the performance of PMTCT/eMTCT programs and related activities (e.g., retention in antiretroviral therapy [ART]) • People with different expertise, including advocacy, policy, planning, oversight, and implementation
  5. 5. Many combinations • Conception of the guide originated from the PHFS evaluations by MEASURE Evaluation • PHFS approach was successful in many facilities across the 6 PHFS countries, but not all approaches were the same • Explored how facilities were successful • Conceptual image of a stew o Baseline ingredients required • Minimum number of baseline ingredients o Recipes can differ o Circumstances and availability of ingredients is important to consider o Need to end up with a well-balanced, nourishing stew using your winning recipe
  6. 6. “How-to” guide • Practical information • Designed to be flexible, so countries can identify and take advantage of opportunities in their existing systems to shift toward the PHFS approach • Can take an incremental approach to implementation; not required to do everything at once
  7. 7. Format of the “how-to” guide • Key lessons from PHFS o Short descriptions, definition of terms, tips o Three main areas: • Service delivery • Quality improvement • Community engagement • Checklists o Preparing to implement the PHFS approach o Launching the PHFS approach o Sustaining the PHFS approach o Extending the PHFS approach
  8. 8. Key lessons from PHFS 1. Mother-baby pairs 2. Mother-baby clinics 3. Integrated services 4. Nutrition 5. Quality-improvement tools and techniques 6. Coaching and mentoring 7. Knowledge exchange 8. Community workers 9. Metrics and data sets
  9. 9. Mother-baby pairs • What o Mothers living with HIV and HIV-exposed infants are seen together at the same appointment • Why o More efficient approach leading to better outcomes for mother and baby • How o One appointment for mother-baby pair o Combined records o Recommending joint appointments for as long as possible o Continued dialogue with the mother
  10. 10. Mother-baby clinics • What o Mother-baby pairs are seen at designated mother-baby clinics • Why o Stigma reduction o Less travel time and waiting time for mothers o Establishment of relationships with peers including participation in formal and informal support groups o Health facility improvements in quality of care and support • How o Designated time and date—be consistent o Possibly designated space for a mother-baby clinic
  11. 11. Integrated services • What o All relevant and/or required services are available to mother-baby pairs at each visit to the mother-baby clinic • Why o Efficient and more-effective visits o Better satisfaction contributing to better retention in care • How o Map how services are currently delivered o Propose changes to integrate services
  12. 12. Nutrition—Breastfeeding • What o Changing breastfeeding beliefs and practices among mothers living with HIV • Why o Benefits of breastfeeding for the baby and the mother are high o Risk of transmitting HIV through breastmilk is extremely low when mothers living with HIV are on ART • How o Health facility staff need to consistently communicate the current breastfeeding recommendations
  13. 13. Nutrition Assessment, Counseling and Support (NACS) • What o NACS activities, including breastfeeding practices, are available to mother-baby pairs as a component of integrated services • Why o Pregnant women and mothers who are living with HIV and HIV-exposed babies will have better health outcomes if they are properly nourished • How o Ensure NACS is an integral part of PMTCT programming o Consider having a nutritionist at district level and at health facilities
  14. 14. Quality-improvement Tools and techniques • What o Basic, facility-led quality improvement practices • Why o Improvement of facility performance and outcomes for mother-baby pairs • How—specific tools and techniques o QI teams o Change ideas o QI journals
  15. 15. Coaching and mentoring • What o Coaches and mentors provide regular support to frontline staff to implement the overall PHFS approach, including QI activities • Why o Coaching has been shown to solidify PHFS-related outcomes through supporting frontline staff to implement QI o Coaches provide a level of quality control to the QI activities • How o Hands-on support and instruction to supplement training o Work directly with frontline staff o Consistent, frequent visits lead to success
  16. 16. Knowledge exchange • What o Frontline staff share knowledge and experience with colleagues at other facilities, to learn from each other and continue to improve their program • Why o Efficient and cost-effective way to improve performance and outcomes • How o Formal knowledge exchange • Quarterly review meetings • Staff exchange visits • Organized sessions with multiple facilities • Webinars and conference calls o Informal knowledge exchange • Encouraging sharing ideas in day-to-day work environment
  17. 17. Community workers • What o Community workers, including peer mothers, conduct outreach work to support retention in HIV care and treatment for mother-baby pairs. • Why o Creating and maintaining productive relationships with patients plays a significant role in retention of mother-baby pairs • How o Capitalize on different cadres • Community health workers, peer mother organizations, family support groups, support groups for people living with HIV (PLHIV) o Ensure community health workers have basic counseling skills o Foster partnership between facility and community o Tracing for loss to follow-up o Develop a compensation plan for community health workers
  18. 18. Metrics and data sets • What o Appropriate and practical metrics and data sets to track and improve the performance and outcomes of PMTCT programs • Why o Facility staff are invested in their own data and in making real-time changes to improve services and retention • How o Identify metrics that will generate useful and useable data o Frontline staff should be consulted on core metrics o Revisit metrics over time to ensure relevance • E.g., Tracking indicators with stable performance may not be needed, or a core indicator like retention might be retained for quality assurance purposes
  19. 19. Additional considerations • Reducing the burden of primary data collection o Data collection is so cumbersome that it reduces the time for patient care o 3 ways to reduce the burden • Limit the number of indicators • Streamline the process • Increase staffing levels • Leveraging the lessons and effectiveness of the PHFS approach o Extending PHFS approaches to general ART centers could have a positive effect on broader ART retention among PLHIV • Potentially starting with mothers living with HIV transferring back to these centers at the end of the PMTCT cycle
  20. 20. “How-to” guide • Key lessons from PHFS • Checklists o Preparing to implement the PHFS approach o Launching the PHFS approach o Sustaining the PHFS approach o Extending the PHFS approach
  21. 21. Checklist #1 1. Planning and approval 2. Site selection 3. Community partners 4. Technical assistance 5. Services 6. Quality improvement practices 7. Performance metrics and data sets 8. Coaches and mentors 9. Knowledge exchange 10.Tools and training Preparing to launch the PHFS approach
  22. 22. Checklist #1 SITE SELECTION  2.1. Develop a core set of selection criteria  2.2. Use the criteria to identify facilities for PHFS  2.3. Conduct a rapid assessment to determine capacity and readiness/willingness  2.4. Use the results to select facilities to implement PHFS activities  2.5. Work with managers and staff at the selected facilities to plan the launch of the PHFS approach Preparing to launch the PHFS approach EXAMPLE
  23. 23. Checklist #1 SITE SELECTION  2.5. Work with managers and staff at the selected facilities to plan the launch of the PHFS approach. Issues to address include:  An initial facility plan to identify where and when the mother-baby clinic could operate  A preliminary staffing plan that matches qualified and available staff with different PHFS activities.  A basic assessment of areas where technical assistance may be required to effectively launch these activities (e.g., service delivery, QI, counselling, community outreach, nutrition, data collection/quality/use)  A basic budget to implement the PHFS approach, including any up-front costs (e.g., facility refurbishment) and specific recurring costs that are not covered by the facilities existing operating budget (e.g., funding for outreach workers) Preparing to launch the PHFS approach EXAMPLE
  24. 24. Checklist #2 11. Human resources 12. Clinic logistics 13. Operations 14. Outreach education 15. Messaging 16. QI tools and techniques Launching the PHFS approach
  25. 25. Checklist #2 OPERATIONS  13.1. Designate PHFS clinic days and times  13.2. Agree on mother-baby services  13.3. Set up mother-baby pair appointment system  13.4. Set up mother-baby pair tracking system  13.5. Set up a coordination system • Ensure consistent and complementary information, guidance, and support to mother-baby pairs  13.6. Set up mother-baby pairs tracing system  13.7. Establish a positive, patient-centered atmosphere Launching the PHFS approach–EXAMPLE
  26. 26. Checklist #2 OPERATIONS  13.4. Set up a simple record keeping system that can keep track of pairs, including the critical information for both mothers and babies (e.g., height/length & weight, growth monitoring, ART regimen, infant HIV test, mother’s viral load testing) • This system is likely to be an informal modification or workaround to an existing record keeping system (e.g., patient cards and registers) • Ensure staff have ready access to patient information for both mother and babies at every appointment Launching the PHFS approach–EXAMPLE
  27. 27. Checklist #3 17. Human resources 18. QI tools and techniques 19. Coaching and mentoring 20. Knowledge exchange 21. Patient input Sustaining the PHFS approach
  28. 28. Checklist #3 HUMAN RESOURCES  17.1. Assess integrated staffing plan for frontline workers  17.2 Assess the knowledge and skills of frontline staff and their managers  17.3 Consult with frontline staff about their job satisfaction • Workload • Patient interactions • Knowledge and skills • Coaching and mentoring • QI practices • Management and compensation Sustaining the PHFS approach–EXAMPLE
  29. 29. Checklist #3  17.1. At least two times per year, assess the integrated staffing plan for frontline workers, including facility-based and community-based staff  Talk directly with frontline workers about the strengths and weaknesses of the staffing plan and possible ways to improve the plan  Consult with coaches and mentors about the strengths and weaknesses of the staffing plan and possible ways to improve it  Use the basic QI tools and techniques to identify ways to improve the staffing plan and the related issues  Implement identified improvements Sustaining the PHFS approach–EXAMPLE
  30. 30. Checklist #4 IDENTIFYING AND EXPLORING NEW OPPORTUNITIES  22.1 Identify groups in health facilities implementing the PHFS approach  22.2 Discuss with managers and staff  22.3 Plan for who will be involved and how  22.4 Discuss how the approach will be adapted  22.5 Ensure process is collaborative  22.6 Review elements of the checklist that apply to this effort Extending the PHFS approach–EXAMPLE
  31. 31. Checklist #4 22.1. Identify departments, centers, and/or programs in health facilities implementing the PHFS approach where the approach could be adapted to improve performance and outcomes  Consult with frontline staff who are using the PHFS approach about departments, centers, and/or programs that could implement an adapted version of the approach  Initial assessment of these opportunities should be done at the facility level, where frontline staff have the best perspective on where and how to adapt the PHFS approach within their facility  Existing management structures are likely to require facilities to get agreement/sign-off from a higher level (e.g., district or above) Extending the PHFS approach–EXAMPLE
  32. 32. Conclusion • Designed to be flexible, so countries can identify and take advantage of opportunities in their existing systems to shift PMTCT programs toward the PHFS approach • Takes an incremental approach to implementation; not required to do everything at once • Practical information in two sections • Key lessons from PHFS • Checklists
  33. 33. This presentation was produced with the support of the United States Agency for International Development (USAID) under the terms of MEASURE Evaluation cooperative agreement AID-OAA-L-14-00004. MEASURE Evaluation is implemented by the Carolina Population Center, University of North Carolina at Chapel Hill in partnership with ICF International; John Snow, Inc.; Management Sciences for Health; Palladium; and Tulane University. Views expressed are not necessarily those of USAID or the United States government.