Dr Rochelle AdamsACC Project Manager

On behalf of the ACC team

AWACC 201519 November 2015

Health systems Strengthening for Success and Sustainability

Presentation Outline

• Background• Objectives of ACC• Proposed Approach• Aim• Methods• Progress• Capacity Building and Sustainability• Conclusion

Background• KZN has close to 1 000 000 patients on ART.• *Only 40% of adult ART patients receive12 monthly VL

testing *20-25% of these patients have unsuppressed viral loads *25% of patients who begin ART are lost to follow-up by 12

months

Source: Massyn N, Day C, Peer N, Padarath A, Barron P, English R, editors. District Health Barometer 2013/14. Durban: Health Systems Trust; October 2014. (*SANAC Report Nov 2014)

TB & HIV account for a third of all premature causes of death in eThekwini district

4

Courtesy of H. Ngobese - KZN HAST Manager 17 April 2014

Mortality in HIV positive:• 33% in patients not on

ART• 5% in patients on ART• 44.2% of all in hospital

deaths • 60% TB /EPTB

Critical Issues that Undermine the Success and Sustainability of the ART rollout

Current DHIS/TIER.NET/NHLS limited in understanding gaps in care or in informing HSS interventions

• Improve management of complicated HIV, TB and DR TB patients through Training and mentorship of frontline HCW’s to increase capacity for

identification and management of complex medical problems strengthening of referral pathways, improvement in understanding of clinical guidelines, algorithms Improve systems and procedures for effective triage Improve capacity for specialized clinical, laboratory and

pharmaceutical support services

• Establish systems and capacity to identify and manage viraemia on ART and manage 2nd and 3rd line ART and TB drug failure

• Collect strategic information to track patient and program outcomes

• Transition to KZN DoH

5Objectives of the ACC programme

The Proposed Approach (1)

• Training and capacity building in complex patient management

• Work with DSP’s and DMT’s in identifying gaps in access to care, in service delivery and guideline implementation that contribute to:– Poor clinical outcomes– Failure to detect and manage patients failing ART– Ineffective triage within referral pathways– Provide a better understanding of “why are patients

dying”• Evaluate findings and develop an intervention plan targeting

improved management of complex TB, HIV and DR TB, including management of treatment failure 6

Aim

• To ascertain patient and health systems factors that contribute to poor TB and HIV outcomes and provide recommendations for targeted Health Systems strengthening activities aimed at improving outcomes

Methods (1) • Devise systems for evaluating coverage and

quality of services for complex patient management and care of patients failing ART

• Located within the QI department in the District

• Process and Tools for evaluation defined over several months with multiple stakeholder input including: DCST and Technical Advisor Quality Assurance Manager HAST Manager and TB Cluster Manager Academics incl Departments of Infectious Diseases, Public

Health, Family Medicine, Virology District Support Partner

Methods (2)

• Evaluate high burden facilities with > 2500 patients on ART

• Facilities will be chosen to get an adequate representation of the level of services by facility type Hospital Community Health Centre Primary Health Care Clinics.

Progress

• Data tools and systems finalised• Review of 3 facilities completed• Generate report highlighting trends • Review findings with the DMT• Develop targeted recommendations for HSS for

each facility type• Develop final report by end Jan 2016• Take this process to each District in KZN

Capacity Building and sustainability

• Training of EThekwini District staff teams Quality Improvement How to conduct facility and file audits

• Collaborate with the district to select key indicators and variables to monitor programme outcomes

• Provision of tablets for electronic database collection

• Assist the district with in implementing first facility and file review

Conclusion• UNAIDS 90-90-90 Strategy is an ambitious target to

help end the AIDS Epidemic Aims to ensure that 90 % of ALL people with HIV

are on ART and are virologically suppressed• Use of data feedback loops to understand and

improve HIV and TB service delivery is an important step in ensuring that we are responsive to this strategy

• High quality services necessary for sustaining a successful ART rollout, and in reducing morbidity and mortality

Acknowledgements

This training was supported by the Grant or Cooperative Agreement Number U2G GH001142, funded by the Centers for Disease Control and Prevention.  Its contents are solely the responsibility of the presenters and do not necessarily represent the official views of the U.S. Centers for Disease Control and Prevention or the U.S. Department of Health and

Human Services