The Implementers meeting was thus rather unique in that a number of potentially replicable innovations were described that could significantly improve the quality of PMTCT services in many countries. Nevertheless, putting these emerging best practices into place in a way that works locally will still present a challenge for many programmes.
However, one poster presentation described a process that the PMTCT programme in Rwanda used to introduce a number of innovations into the system and quickly identify and scale up those that worked.
The Rwandan team had noted a number of shortfalls in their programme’s performance. For instance, not all women returned for their HIV test results, and there was a large gap between those who needed and those who received PMTCT. In addition, there were essentially no data available on other important aspects of the programme such as partner testing, provision of sd-NVP to infants or follow-up testing and care.
The team chose to adapt the Collaborative Quality Improvement Model (CQIM), developed by the Institute for Healthcare Improvement (http://www.ihi.org/IHI/) to try to improve some of these key indicators of PMTCT.
The collaborative method involves identifying key objectives and areas for improvement, site selection and key personnel that will be involved and then repeated cycles of planning, experimentation, monitoring and sharing results.
At each site, a quality improvement team is created, and they develop/adapt ideas for changes. They are encouraged to think about what they are trying to accomplish, how will they recognise improvement, and what what changes they can make to achieve some of their key objectives. Once a plan of action is developed, the experiment is implemented, evaluated and results are documented over a period of three to four months. During this time, the key indicators (areas for improvement) are monitored. Any important lessons learned are immediately communicated with teams from other sites via email. But then every three or four months, a few representatives from each site across the programme are drawn together for structured “learning sessions” lasting two or three days. At these learning sessions, data, results and lessons learned and challenges are shared by each site. In addition, technical presentations on standards and norms are made; and participants discuss their plans for the next quarterly period.
In the case of Rwanda, the key objectives were that: 1) all pregnant women 2) and their partners receive testing and counselling and 3) get their results; 4) that all those who test positive receive sd-NVP (to self administer at labour if necessary); 5) that all pregnant women in the programme give birth at health sites (and take their sd-NVP then); and 6) that all HIV-exposed infants are tested for HIV at 15 months.
The Ministry of Health and USAID selected 18 out of the 32 total PMTCT sites (with one site in each province that could help other sites in the district scale up).
Within four or five quarters most of these sites reported dramatic improvements and the poster contained a wealth of information about changes that helped the teams achieve results.
HIV testing for all pregnant women (achieved 100% in 14 sites)
- Reinforce counselling to encourage testing
- Increase available personnel and ANC days
- Improve patient flow and confidentiality
- Shorten wait times
Returning for results (achieved 100% at 13 sites)
- Change personnel and make some available during lunch hour
- Make sure that a lab technician is there on ANC days
- Analyse samples as they arrive
Partner testing (from 10% to over 40% at 14 sites, with one site now at 100%)
- Educate on importance of getting partner tested
- Written invitations to partners
- Home visits
- Increase testing availability to 7 days
- Require partners to accompany pregnant women to at least one ANC visit
- Partners required to come to health site for insecticide treated bednets and other materials while mother recuperating
Providing sd-NVP (achieved over 90% at 10 sites, 100% at some)
- Improve documentation of women who test positive
- Home visits (with reminder to go to delivery site or provision of sd-NVP for those who live far from site)
- Offer sd-NVP at every contact with pregnant woman
- Hold regular meetings with associations of people living with HIV and AIDS
- Improve documentation of HIV-exposed infants
- Develop scheduling system
- Make home visits (to find infants lost to follow-up)
- Work with community volunteers (who can provide some of the follow-up)
While the project is far from over, (and not every supervisor bought into it), it has spread improvements across most of the Rwandan PMTCT network.
According to the poster, “the methodology... [was able] to inspire and unleash creativity of healthcare providers [with] local identification of solutions that work.” It also “increased motivation of health worker [who found the] ability to make change is within their control.”