Improving the coverage of the PMTCT programme through a participatory quality improvement intervention in South Africa

BMC Public Health, Volume 9, Year 2009

Ukuhunyushwa

Background: Despite several years of implementation, prevention of mother-to-child transmission (PMTCT) programmes in many resource poor settings are failing to reach the majority of HIV positive women. We report on a data driven participatory quality improvement intervention implemented in a high HIV prevalence district in South Africa. Methods: A participatory quality improvement intervention was implemented consisting of an initial assessment undertaken by a team of district supervisors, workshops to assess results, identify weaknesses and set improvement targets and continuous monitoring to support changes. Results: The assessment highlighted weaknesses in training and supervision. Routine data revealed poor coverage of all programme indicators except HIV testing. Monthly support to all facilities took place including an orientation to the PMTCT protocol, review of local data and identification of bottlenecks to optimal coverage using a continuous quality improvement approach. One year following the intervention large improvements in programme indicators were observed. Coverage of CD4 testing increased from 40 to 97%, uptake of maternal nevirapine from 57 to 96%, uptake of infant nevirapine from 15 to 68% and six week PCR testing from 24 to 68%. Conclusion: It is estimated that these improvements in coverage could avert 580 new infant infections per year in this district. This relatively simple participatory assessment and intervention process has enabled programme managers to use a data driven approach to improve the coverage of this important programme. © 2009 Doherty et al; licensee BioMed Central Ltd. The package of care for the PMTCT programme at the time of this intervention included routine offer of antenatal voluntary counselling and testing (VCT), infant feeding counselling, single dose nevirapine to mothers and infants, infant PCR testing at six weeks and six months of free formula milk to women choosing not to breastfeed[16]. The PMTCT policy in the country has recently been revised to include dual short course prophylaxis consisting of AZT from 28 weeks together with single dose nevirapine to mothers and nevirapine plus seven days of AZT to infants[17]. South Africa has a district health system in which comprehensive primary health care (PHC) clinics provide primary level care, referring patients to district and regional hospitals for secondary level care. PHC services are nurse driven. Clinic nurses are responsible for the diagnosis and management of infectious diseases such as tuberculosis, HIV and sexually transmitted infections, preventive care such as childhood immunisations and growth monitoring, antenatal care, as well as providing an acute curative service and attending to chronic conditions such as hypertension and diabetes. The intervention was carried out in one district in KwaZulu-Natal province, Amajuba. In 2006 the district was estimated to have a total population of 585 858 and a population under one year of 13 259[14]. The antenatal HIV prevalence in 2006 was 46%, the highest in the country[18]. The district has a total of 3 hospitals, 18 comprehensive PHC clinics and 7 mobile clinics. The fixed clinics were included in the intervention but not the mobile clinics. PMTCT services are offered through comprehensive PHC clinics (antenatal HIV testing, CD4 count and provision of nevirapine) and the intrapartum component within the three district hospitals (delivery, provision of nevirapine if not already taken and administration of infant nevirapine syrup). All facilities have facility managers who together with the PHC supervisors and district programme co-ordinators represent the middle level of management in the health system. Routine maternal and child health indicators for the district are good with an antenatal care coverage rate of 94%; 92% of deliveries undertaken by trained health professionals (midwives or doctors) and an immunisation coverage rate under one year of 83%[14]. PMTCT was introduced into the district in 2002 and whilst the uptake of HIV testing has increased from 30% in 2003/2004 to 78% in 2006/2007, other indicators have not shown much improvement. For example nevirapine coverage to women was 45% in 2003/2004 and 57% in 2006/2007 despite the programme being in its 5th year[13]. Anthropological research in South Africa[19] has identified several health systems failures as contributing to the low uptake including non availability of counsellors and lack of testing supplies and consent forms. The intervention consisted of a participatory assessment phase followed by a feedback and planning phase and then an implementation and monitoring phase. Each phase of the intervention had a focus on using routine data for problem identification, target setting and monitoring (Table (Table11). Description of the three intervention phases During the participatory assessment phase a task team consisting of programme managers for HIV, PMTCT, maternal and child health (MCH), unit managers for hospital labour and postnatal wards and PHC clinic supervisors was formed to improve the performance of the PMTCT programme. The purpose of the participatory assessment phase was to build the capacity of local programme managers to conduct a simple assessment of maternal and child health services in their district. The process was introduced at a workshop held with this team in May 2007. During the workshop the team was oriented to the assessment framework, introduced to the assessment tools and supported in a short phase of piloting. An evaluation guide was developed to give step by step instructions about how to plan, prepare for and undertake the assessments. Three data collection tools were developed for the assessments; a structured interview tool for facility managers, an observation tool for PHC clinics and a structured interview tool for lay counsellors. These tools are described in Table Table1.1. The conceptual framework chosen for development of the tools was based on an expanded health systems approach which has been proposed for evaluating PMTCT programmes[20]. This framework is based on the critical conditions managers need to consider in ensuring that a programme moves from efficacy (a programme’s capacity to reduce the problem in ideal conditions) to effectiveness (its capacity to improve a problem in routine field conditions)[21]. The domains used in the assessment tools are: quality of services and human resources, availability of key resources and management systems and access and continued use of services. Assessment teams consisted of three to four people (district and sub-district co ordinators and PHC supervisors) who visited facilities over a one week period. Each facility visit took approximately 3-4 hours. Assessment of the entire district took 7 days. Routine district PMTCT data from the district information officer was also collected in order to assess performance of key PMTCT indicators. The feedback and planning phase and the intervention and monitoring phase are described in the results section of the paper as these were developed following review of the findings of the participatory assessments. All eighteen comprehensive PHC clinics were visited in the assessment phase. At three facilities the facility manager was not present at the time of the assessment due to meetings or training resulting in a total of 15 facility manager interviews. Sampling of lay counsellors was determined by their availability but at least half of the total number assigned to each facility were included resulting in a total of 35 lay counsellor interviews. Interview and observation tools were submitted at the end of each day to the project facilitator who entered the data into excel. Epi-Info was used to generate basic frequencies for all tracer indicators as shown in Table Table2.2. Routine district PMTCT data was extracted from the District Health Information System (DHIS) and analysed using excel. Routine PMTCT indicators were calculated for the six month period prior to the assessment. Basic data quality checks were done by the project facilitator and any errors identified with the indicators (for example, coverage levels over 100%) were verified with the district information officer. The three key conditions of effectiveness were used as the analysis framework. Key input and output indicators for Amajuba District collected during the participatory assessment phase

I-AI Digest

Study Justification:

– The study aimed to improve the coverage of the Prevention of Mother-to-Child Transmission (PMTCT) program in South Africa.
– Despite several years of implementation, PMTCT programs in resource poor settings were failing to reach the majority of HIV positive women.
– The study used a data-driven participatory quality improvement intervention to address weaknesses in training and supervision and improve program indicators.

Highlights:

– The study implemented a participatory quality improvement intervention consisting of an initial assessment, workshops to assess results and set improvement targets, and continuous monitoring.
– The assessment revealed weaknesses in training and supervision, and poor coverage of program indicators except HIV testing.
– After one year of the intervention, significant improvements were observed in program indicators, including CD4 testing, maternal nevirapine uptake, infant nevirapine uptake, and six-week PCR testing.
– These improvements in coverage could potentially avert 580 new infant infections per year in the district.

Recommendations:

– The study recommends the use of a data-driven approach to improve the coverage of the PMTCT program.
– It suggests implementing a participatory assessment phase, followed by a feedback and planning phase, and an implementation and monitoring phase.
– The study highlights the importance of addressing weaknesses in training and supervision, and using routine data for problem identification, target setting, and monitoring.

Key Role Players:

– District supervisors
– Facility managers
– PHC supervisors
– Programme managers for HIV, PMTCT, maternal and child health (MCH)
– Lay counsellors

Cost Items for Planning Recommendations:

– Training and capacity building for local program managers
– Data collection tools and resources
– Workshop and meeting expenses
– Monitoring and evaluation activities
– Support for facility managers and PHC supervisors
– Supplies and resources for PMTCT services (e.g., nevirapine, testing supplies, consent forms)

Amandla Obufakazi

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is strong, as it presents the results of a participatory quality improvement intervention in a high HIV prevalence district in South Africa. The intervention led to significant improvements in program indicators, which could potentially avert new infant infections. However, the abstract does not provide detailed information on the study design or methodology, limiting the ability to fully assess the strength of the evidence. To improve the evidence, future studies could include a randomized controlled trial design and provide more information on the intervention implementation process and data collection methods.

Abstract

The package of care for the PMTCT programme at the time of this intervention included routine offer of antenatal voluntary counselling and testing (VCT), infant feeding counselling, single dose nevirapine to mothers and infants, infant PCR testing at six weeks and six months of free formula milk to women choosing not to breastfeed[16]. The PMTCT policy in the country has recently been revised to include dual short course prophylaxis consisting of AZT from 28 weeks together with single dose nevirapine to mothers and nevirapine plus seven days of AZT to infants[17]. South Africa has a district health system in which comprehensive primary health care (PHC) clinics provide primary level care, referring patients to district and regional hospitals for secondary level care. PHC services are nurse driven. Clinic nurses are responsible for the diagnosis and management of infectious diseases such as tuberculosis, HIV and sexually transmitted infections, preventive care such as childhood immunisations and growth monitoring, antenatal care, as well as providing an acute curative service and attending to chronic conditions such as hypertension and diabetes. The intervention was carried out in one district in KwaZulu-Natal province, Amajuba. In 2006 the district was estimated to have a total population of 585 858 and a population under one year of 13 259[14]. The antenatal HIV prevalence in 2006 was 46%, the highest in the country[18]. The district has a total of 3 hospitals, 18 comprehensive PHC clinics and 7 mobile clinics. The fixed clinics were included in the intervention but not the mobile clinics. PMTCT services are offered through comprehensive PHC clinics (antenatal HIV testing, CD4 count and provision of nevirapine) and the intrapartum component within the three district hospitals (delivery, provision of nevirapine if not already taken and administration of infant nevirapine syrup). All facilities have facility managers who together with the PHC supervisors and district programme co-ordinators represent the middle level of management in the health system. Routine maternal and child health indicators for the district are good with an antenatal care coverage rate of 94%; 92% of deliveries undertaken by trained health professionals (midwives or doctors) and an immunisation coverage rate under one year of 83%[14]. PMTCT was introduced into the district in 2002 and whilst the uptake of HIV testing has increased from 30% in 2003/2004 to 78% in 2006/2007, other indicators have not shown much improvement. For example nevirapine coverage to women was 45% in 2003/2004 and 57% in 2006/2007 despite the programme being in its 5th year[13]. Anthropological research in South Africa[19] has identified several health systems failures as contributing to the low uptake including non availability of counsellors and lack of testing supplies and consent forms. The intervention consisted of a participatory assessment phase followed by a feedback and planning phase and then an implementation and monitoring phase. Each phase of the intervention had a focus on using routine data for problem identification, target setting and monitoring (Table (Table11). Description of the three intervention phases During the participatory assessment phase a task team consisting of programme managers for HIV, PMTCT, maternal and child health (MCH), unit managers for hospital labour and postnatal wards and PHC clinic supervisors was formed to improve the performance of the PMTCT programme. The purpose of the participatory assessment phase was to build the capacity of local programme managers to conduct a simple assessment of maternal and child health services in their district. The process was introduced at a workshop held with this team in May 2007. During the workshop the team was oriented to the assessment framework, introduced to the assessment tools and supported in a short phase of piloting. An evaluation guide was developed to give step by step instructions about how to plan, prepare for and undertake the assessments. Three data collection tools were developed for the assessments; a structured interview tool for facility managers, an observation tool for PHC clinics and a structured interview tool for lay counsellors. These tools are described in Table Table1.1. The conceptual framework chosen for development of the tools was based on an expanded health systems approach which has been proposed for evaluating PMTCT programmes[20]. This framework is based on the critical conditions managers need to consider in ensuring that a programme moves from efficacy (a programme’s capacity to reduce the problem in ideal conditions) to effectiveness (its capacity to improve a problem in routine field conditions)[21]. The domains used in the assessment tools are: quality of services and human resources, availability of key resources and management systems and access and continued use of services. Assessment teams consisted of three to four people (district and sub-district co ordinators and PHC supervisors) who visited facilities over a one week period. Each facility visit took approximately 3-4 hours. Assessment of the entire district took 7 days. Routine district PMTCT data from the district information officer was also collected in order to assess performance of key PMTCT indicators. The feedback and planning phase and the intervention and monitoring phase are described in the results section of the paper as these were developed following review of the findings of the participatory assessments. All eighteen comprehensive PHC clinics were visited in the assessment phase. At three facilities the facility manager was not present at the time of the assessment due to meetings or training resulting in a total of 15 facility manager interviews. Sampling of lay counsellors was determined by their availability but at least half of the total number assigned to each facility were included resulting in a total of 35 lay counsellor interviews. Interview and observation tools were submitted at the end of each day to the project facilitator who entered the data into excel. Epi-Info was used to generate basic frequencies for all tracer indicators as shown in Table Table2.2. Routine district PMTCT data was extracted from the District Health Information System (DHIS) and analysed using excel. Routine PMTCT indicators were calculated for the six month period prior to the assessment. Basic data quality checks were done by the project facilitator and any errors identified with the indicators (for example, coverage levels over 100%) were verified with the district information officer. The three key conditions of effectiveness were used as the analysis framework. Key input and output indicators for Amajuba District collected during the participatory assessment phase

Izinto zokwakha

N/A

Emisha

Based on the provided information, here are some potential recommendations for innovations to improve access to maternal health:

1. Mobile Clinics: Introduce mobile clinics equipped with necessary resources and staff to reach remote areas and provide maternal health services, including PMTCT programs.

2. Telemedicine: Implement telemedicine solutions to enable remote consultations and follow-ups for pregnant women, reducing the need for travel and improving access to healthcare professionals.

3. Community Health Workers: Train and deploy community health workers to provide education, counseling, and support to pregnant women in their communities, ensuring they receive the necessary care and information.

4. Digital Health Tools: Develop and implement digital health tools, such as mobile applications or SMS-based platforms, to provide information, reminders, and support to pregnant women, improving their engagement and adherence to maternal health programs.

5. Task Shifting: Expand the roles and responsibilities of healthcare workers, such as nurses and midwives, to perform certain tasks traditionally done by doctors, increasing the availability and accessibility of maternal health services.

6. Public-Private Partnerships: Foster collaborations between public and private healthcare providers to leverage resources, expertise, and infrastructure to improve access to maternal health services, including PMTCT programs.

7. Supply Chain Management: Strengthen supply chain management systems to ensure the availability of essential maternal health commodities, such as HIV testing kits, nevirapine, and formula milk, in all healthcare facilities.

8. Quality Improvement Interventions: Implement participatory quality improvement interventions, similar to the one described in the provided study, to identify and address weaknesses in the delivery of maternal health services, leading to improved coverage and outcomes.

9. Health Education and Awareness Campaigns: Conduct targeted health education and awareness campaigns to increase knowledge and understanding of maternal health issues, including PMTCT, among women and their communities, promoting early and regular access to care.

10. Policy and Regulatory Reforms: Advocate for policy and regulatory reforms that prioritize and support maternal health, ensuring adequate funding, training, and resources are allocated to improve access and quality of care.

It is important to note that the specific context and needs of each setting should be considered when implementing these innovations to ensure their effectiveness and sustainability.

AI Innovations Description

The recommendation to improve access to maternal health in South Africa is to implement a participatory quality improvement intervention. This intervention involves conducting an initial assessment of the PMTCT (prevention of mother-to-child transmission) program, identifying weaknesses, setting improvement targets, and continuously monitoring progress.

The assessment phase should involve a team of district supervisors who assess the program’s performance and identify areas for improvement. This assessment should include an evaluation of training and supervision, as well as an analysis of routine data to identify coverage gaps in program indicators.

Based on the assessment findings, workshops should be conducted to review the results, identify weaknesses, and set improvement targets. These workshops should involve program managers, supervisors, and facility managers.

During the implementation phase, monthly support should be provided to all facilities, including an orientation to the PMTCT protocol, review of local data, and identification of bottlenecks to optimal coverage. A continuous quality improvement approach should be used to address these bottlenecks and improve program coverage.

Monitoring should be conducted to track progress and ensure that improvements are being made. Routine data should be collected and analyzed to assess changes in program indicators.

By implementing this participatory quality improvement intervention, it is expected that there will be significant improvements in program coverage and outcomes. For example, in the case study mentioned, coverage of CD4 testing increased from 40% to 97%, uptake of maternal nevirapine increased from 57% to 96%, uptake of infant nevirapine increased from 15% to 68%, and six-week PCR testing increased from 24% to 68%. These improvements can have a significant impact on reducing new infant infections.

Overall, this intervention provides a data-driven approach to improving the coverage of the PMTCT program and can be used as a model to improve access to maternal health in other resource-poor settings.

AI Innovations Methodology

Based on the information provided, here are some potential recommendations to improve access to maternal health:

1. Strengthen training and supervision: The assessment revealed weaknesses in training and supervision. Improving the quality and effectiveness of training programs for healthcare providers involved in maternal health can help ensure that they have the necessary skills and knowledge to provide high-quality care. Regular supervision and mentorship can also help identify and address any gaps or challenges in service delivery.

2. Continuous quality improvement approach: Implementing a continuous quality improvement approach can help identify and address bottlenecks in the delivery of maternal health services. This involves regularly monitoring and evaluating the performance of the PMTCT program, analyzing data to identify areas for improvement, and implementing targeted interventions to address those areas.

3. Increase coverage of program indicators: The assessment revealed poor coverage of program indicators, except for HIV testing. Efforts should be made to increase coverage of other important indicators, such as CD4 testing, uptake of maternal nevirapine, uptake of infant nevirapine, and six-week PCR testing. This can be achieved through targeted interventions, such as improving awareness and education about the importance of these services, addressing barriers to access, and ensuring the availability of necessary resources and supplies.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could be developed as follows:

1. Baseline data collection: Collect data on the current status of maternal health access indicators, such as the coverage of PMTCT services, HIV testing rates, CD4 testing rates, and uptake of nevirapine. This data can be obtained from routine health information systems, surveys, or other relevant sources.

2. Intervention implementation: Implement the recommended interventions, such as strengthening training and supervision, and implementing a continuous quality improvement approach. Ensure that these interventions are implemented consistently across the target area or population.

3. Data monitoring and evaluation: Continuously monitor and evaluate the impact of the interventions on the targeted indicators. Collect data on the coverage of program indicators and other relevant outcomes, such as the number of new infant infections averted. This data can be collected through routine health information systems, surveys, or other data collection methods.

4. Data analysis: Analyze the collected data to assess the impact of the interventions on improving access to maternal health. Compare the baseline data with the post-intervention data to determine any changes or improvements in the targeted indicators. Use statistical methods, such as descriptive statistics or regression analysis, to quantify the impact of the interventions.

5. Interpretation and reporting: Interpret the findings of the data analysis and report the results. Provide clear and concise information on the impact of the interventions on improving access to maternal health, including any changes in coverage rates and the estimated number of new infant infections averted.

By following this methodology, it is possible to simulate the impact of the recommended interventions on improving access to maternal health and assess their effectiveness in achieving the desired outcomes.

Umbhali

Dima Health

Statistics:

Citations: 82

Identifiers:

DOI: 10.1186/1471-2458-9-406

Research Areas:

Community Interventions, Health System and Policy, Infectious Diseases, Maternal Access, Maternal and Child Health, Noncommunicable Diseases, Quality of Care, Sexual and Reproductive Health, Social Determinants, Workforce

Study Countries:

South Africa

Study Design:

Cross Sectional Study, Grounded Theory, randomised-control-trial

Participants Gender:

Female

Yabelana ngalokhu: