Team PATA: improving HIV care for children through action learning

“Our conferences are very different to any other, our PATA Forums,” said Dr Paul Cromhout of the Small Projects Foundation (which works in community development in the Eastern Cape of South Africa), but who also serves on the steering committee of Paediatric AIDS Treatment in Africa (PATA), sometimes called Team PATA.

And indeed, as I would learn, the PATA forum wasn’t simply a place to catch up with the state-of-the-art medical information, share best practice or learn about innovative approaches to patient-centred care, although there was plenty of that to be had. In fact, I marvelled at how creative, forward thinking, and yet practical many of the programmes and projects described were, and the meeting provided enough material for at least one HATIP article, and enough case studies to fill this blog for a few months. But the way the meeting was structured merits attention because the process was designed not only to increase the knowledge of the meeting’s participants—all front-line healthcare workers—but to translate what they learned into action plans for quality improvement at their own health facilities.

Dr Cromhout provided me with an orientation on PATA and on the PATA-Pan African Forum, held 14-18 November in Phakalane, Botswana (near Gaborone). I had missed the briefing they give all first timers, because a funny thing happened on the way to the forum (not really — I had just gotten hopelessly lost driving around for hours somewhere in the Northwest Province). I also made the mistake of staying offsite in Gaborone, which I came to regret immensely, not only because of the commute, but because it was clear that there was a spirit of camaraderie, sharing and learning from each other, even when workshops weren’t in session, and being part of one big team that’s rare at a meeting.

That is partly because PATA is a team of healthcare professionals who have come together with a common purpose: improving the quality of care delivered to children infected and affected by HIV and their families.

But another reason is that PATA actually is a network of teams. While this meeting included doctors, nurses, counsellors, psychologists and pharmacists, they didn’t come to the forum alone, but came as members of treatment teams from the same healthcare facility.

Team PATA

“Basically it started as exchange between teams. Nobody else was looking specifically at treatment teams, they were looking at doctors and nurses but not treatment teams,” said Dr Cromhout. “Sometimes people working in a clinic are not a treatment team, the team element certainly is missing. So the idea is to build teamwork, and regard for each other. I still have some nurses saying, ‘I don’t want to go to a conference with a counsellor, what does a counsellor know?’ And yet if we are going to use these disparate resources, that’s the only way — by working really closely together as teams in resource-limited settings.”

Team PATA’s origin seems somewhat serendipitous. It was founded by two men, entrepreneur David Altschuler of the One to One Children’s Fund, based in the UK and Dr Paul Roux, a paediatrician at Groote Schuur Hospital in Cape Town (Dr Roux is on HATIP’s advisory panel). Groote Schuur was one of the first facilities where paediatric antiretroviral therapy was provided in Africa. Partners in Health (PIH) in Rwanda told Dr Roux that they would like to bring a team down to see what he was doing. Dr Roux was able to raise some money, and sponsored the PIH team to come and shadow the treatment team at Groote Schuur for a week. Then the PIH team went back to Rwanda and began implementing paediatric ART—a very rewarding outcome.

It occurred to David Altschuler and Dr Roux that this could be a model for something they should really be doing this for treatment teams closer to home. And very soon after they started, word got around, and there was a huge amount of interest from other teams who felt they had been working in isolation and who needed support. Unlike other large networks or programmes, PATA is not the product of an American university-PEPFAR funded implementer (not that there is necessarily anything wrong with that). It is indigenous and came together spontaneously.

So in 2005, the first PATA forum was held in Cape Town, primarily sponsored by One to One Children’s Fund and Sidaction.

“Mr Altschuler and Dr Roux, who were sort of the leading lights, looked at what sort of methodologies could be effectively used that will encourage and inspire the people who are trying to bring access to paediatric HIV/AIDS and health services, and more luckily now, specifically also looking at eradicating HIV/AIDS,” said Dr Cromhout.

Structuring the meetings

The meeting is quite deliberately designed. After the opening, there are three full days of meetings, with a different theme each day. This year these were early infant care, care of adolescent girls, and quality improvement. During the morning plenary, there are presentations made by leading experts, and representatives from notable projects or initiatives. 

After the plenary, the participants split up according to their profession for workshops to discuss the day’s topic, framed with a simple question. For example, on day 1 this year, the participants discussed ‘In your profession, what challenges have you experienced in caring for infants (under 1 year)’. In order to get input from as many voices as possible, they are divided into small groups, seated at different tables and discuss their experiences regarding that issue with the others in their group, The groups then prioritise the most important points that came out of their discussion, and select someone from their table to report back to the profession as a whole at the end of the workshop. Then there is further discussion about the most salient issues, and someone is selected to present these to the whole forum in the afternoon plenary.

Then, after lunch, the treatment teams meet together.

“Then we say, okay, these experts gave their little spiel this morning, if you are a doctor, you’ve spoken to other doctors, if you are a nurse you’ve spoken to other nurses, So, on this issue, ‘how do we bring this back into our own treatment, our own processes', and what are the three things we’re going to be looking at, taking back home',” said Dr Cromhout . “That’s how PATA is really different. It is action learning.”

Indeed, the process would seem to promote or reinforce professional linkages in their own discipline, and provides many participants who normally don’t have such opportunities, a chance and place to share, develop confidence, and perhaps distinguish themselves — and they also have a chance to learn from others within their own discipline, people who may have new ideas that they haven’t tried. The team workshop is of course a team-building exercise that gives the participant the space to work as a team, which most of them never get the time to do back in their clinics or hospitals.

On the final day, the theme was quality improvement. But each year, the forum culminates with a session where the team plots out on the PATA ‘team grid’ the Quality Improvement tasks that they have prioritised for the next three months, the next six months and before the end of the upcoming year. Thus begins a continuous quality improvement project that PATA supports and monitors.

PATA is made up of more than 170 clinics in 24 sub-Saharan African countries. The forum this year included 41 of them. We asked how Dr Cromhout how the teams get there.

“The teams fund their own way to the best of their abilities… we ask any team that wants to come to make a commitment of some kind,” he said. “Then we go and look for funding also, so the more that teams can contribute, the better, but we also make sure that those teams that are really poor get sponsored and subsidised.”

Another one of PATA’s strengths is that every participant also has something to offer.

“From the most sophisticated teams to the most rural and under-resourced, and yet each of them has something really valuable to bring, in terms of their experiences, their cases, their situation. Our approach is that we can learn from each other, from the guys at the University Teaching Hospital to the guy from the most rural district clinic. Plus, it’s action knowledge,” he added.

Action learning

At medical conferences, people often take notes in sessions, pick up abstract books and posters, maybe write something up in a report, but when they get back home, most of that material just gets filed away, and never looked at again. But while proceedings of previous PATA conferences are also published in book form (and online), what gets presented at PATA forums is much less likely to just be buried in a book, gathering dust on the shelf. The meeting’s interactive process makes participants engage and share their experiences regarding the meeting’s key clinical issues with peers from their own professions, then discuss with their clinic teams how what they’ve learned could be used to develop solutions to clinical challenges or activities that could improve clinic performance. They leave with a plan in hand of the key interventions for the following year, and return home energised and empowered to put what they’ve learned into practice.

What struck me was how these action-oriented learning processes could be applied in other areas. Indeed, Dr Cromhout and I spent some time talking about how aspects could be adapted to bring together CBO/NGOs, community health workers, and expert patients to better support primary healthcare clinics (to be discussed in a later issue of HATIP).

“That’s where we’ve had our greatest successes in developing that kind of methodology, and that really is what PATA does. That sort of action learning process is nothing new but it is one of the only effective ways. Building our healthcare systems, and the whole of primary health care, going back as far as Albert Schweitzer and Koch, that’s what it’s about. And yet we seem to largely have lost it, or lose sight of it, unless there is a constant interplay between us and the people we are trying to serve and we need to get them fully engaged and empowered to take care of their own health in the long term. When the doctor’s gone and the nurses are gone, people need to have mastery in their own community. “

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