There were a couple of oral presentations to suggest that it was the
efforts of health workers to improve the quality of the PPTCT service they were
providing, that may have been largely responsible for the reductions in
vertical transmission being seen in the country.
“Quality improvement approaches have helped to close the service
delivery gaps for PMTCT interventions and seem to be contributing to the
reduced number of HIV infections in children in KZN,” said Dr Wendy
Dhlomo-Mphatswe, of the 20,000+ Partnership.10
The claim appears to be supported by evidence showing concurrent
improvement in a number of indicators of performance at different steps of the
HIV accounts for 50-60% of hospital deaths in children and 30-40% of all
childhood deaths in KwaZulu Natal, with poor health system performance
negatively affecting perinatal transmission rates. As already noted, previous studies suggest the
rates of HIV diagnosis at first immunisation was above 21%.
The KZN Department of Health and the University of KwaZulu Natal
developed the 20,000+ partnership. The Institute of Healthcare Improvement (IHI)
which specialises in health systems intervention, and using data for quality
improvement, contributed experienced staff to the project team.
The partnership aims to decrease the vertical transmission of HIV to
infants a target of below 5%; this is the target set by the South African
National Strategic Plan 2007-2011, and to improve overall child survival in KZN
through health systems support interventions using Quality Improvement methods.
The partnership is working across the three districts of Ethekwini,
Umgungundlovu and Ugu, which each have an antenatal prevalence above 40%.
20,000 is the number of HIV infections in infants that can be prevented each
year in KZN if every pregnant HIV-infected woman receives care according to the
National PMTCT guidelines.
The partnership was tasked to work with the existing
staff to improve the health system performance in the PPTCT programme, and to
use routine health information (DHIS).
The project involves 15 hospitals, over 200 clinics serving a population
of around 5 million people, and runs from April 2008 until April 2013. In
addition to the reducing PPTCT, the partnership’s objective was to develop
health systems improvement capacity at provincial, district and facility level
that could sustain effective PMTCT programmes, but that could be applied to any
other health domain and service delivery.
The partnership staff worked with improvement teams and leadership at
every level. These included the district information office data team that fed
data back and forth with the clinic and hospitals team, and each of these
teams was in turn supervised by the district task team. The district task team
reported back to the district leadership which reported to the provincial
The quality improvement
“Quality Improvement” in healthcare is a simple
method to identify gaps in the healthcare system, and a systematic way to close
those gaps and safely improving the process of care,” said Dr Dhlomo-Mphatswe.
She said the project sought to “apply local wisdom; focus on the data (stop the
blame game); work `smarter` not just `harder`, and that partnership and
teamwork is the only way forward.”
The process begins with discussing the problem with the team, performing
a system analysis of the activity or process to be affected. The team then
exchange ideas about possible solutions, and choose a good one to move forward.
Then the team follows the cycle of ‘plan, do, study, act.’ A plan is drawn up
of what will be tried, how will it be done and by whom. Then the team ‘do’ the
intervention, and ‘study’ the results closely. If the idea results in improvement,
then the ‘act’ upon it. Then implementation goes forward to see whether the
intervention continues to succeed and is sustainable.
In the case of PPTCT, they first needed to map out the processes
of PMTCT care and track progress with data. For PPTCT, these are many, starting
with the first ANC visit, then HIV counselling and testing, HIV positive women
are then supposed to have get a CD4 cell test, the results of which determine
whether she is referred to ART, or provided with AZT, while the infant is given
nevirapine prophylaxis, and six weeks after childbirth (around immunization),
the caregiver and child pair should return for early infant diagnosis.
There should be data to track each part of this process resulting from
data recording and reporting from each site. Then the data are processed and
sent back in a form that allows the clinic team to see how they are doing,
which in turn makes them realise the value of their data (and perhaps improve
their data recording practices). Initially however, there were problems with
the data, so the partnership then first had to focus on data improvement
initiatives. Once that issue was take care of, the teams could compare their
performance with targets.
Dr Dhlomo-Mphatswe displayed graphs showing improvement in a number of
indicators. For instance, the goal is to get all the women who come into the
antenatal clinic tested for HIV at their first visit but when the project began
there was a significant gap. Over time, that gap has been dramatically reduced.
Likewise, there were significant increases in the number of women referred for
ART, as all the districts can online, a subsequent increase during the ART
campaign, and a further increase when ART started being initiated at the
primary health centre.
The initiation of life-long ART for eligible women is following the same
trend upwards — with a increase as the new art guidelines were released, though
not, at first, when ART first started being initiated at the primary health
centre. It turned out that despite training and now being qualified to
prescribe, nurses still lacked confidence to do so. A separate presentation
discussed in more detail in next week’s HATIP described quality improvement of nurse-initiation
management of ART in the Ugu district.11
From June –September 2010, the percentage of clinics initiating eligible
pregnant women on ART increased from 32% to 100% by December 2010. The absolute numbers also increased
dramatically. Overall, though, the districts being supported by the 20,000+ Partnership
are still about 25% shy of their targets for starting eligible pregnant on ART.
Early infant diagnosis remained mostly stable during the first year of
the project, however, there are clear improvements when two of the districts
began to focus on PCR from just under 40% to about 70%, and another jump when
the infant testing guideline changed, to reach about 80% of exposed infants.
At roughly the same time as improvements of these indicators, the 6-week
HIV transmission rate in Ugu district was declining, from 12% in 2008, to 8% in
2009, to the target of 5% in the first quarter of 2010 (and with about 90% of
the HIV-exposed infants being tested for HIV).
Implications of a quality improvement approach on the
While the PPTCT regimens also improved significantly over this period,
it would have had little impact if the poor performance of the health service
persisted. For instance, changing the CD4 cell criteria on which to initiated
ART or allowing the nurses to initiate ART doesn’t matter if women are being
referred for ART — which was the situation previously, or if nurses don’t
prescribe. Rather these quality improvement measures were synergistic and
likely essential for outcomes to improve to the great extent they did.
“The quality improvement approach is a multi-faceted and
multi-disciplinary approach that effectively improves the working and
coordination of the health system through engaging the leaders, and the
workforce to be part of the solution,” said Dr Dhlomo-Mphatswe. “Data is used
to guide improvement — and the end-product is better use of existing
resources…. And in addition to reducing the number of HIV infections in
children in KZN, the same approaches can be applied to other areas of MCH care
and help strengthen health systems.”