Tanzania Partnership for HIV-Free Survival (PHFS) Implementation Experience and Change Package JUNE 2017 This report was prepared by University Research Co., LLC (URC) for review by the United States Agency for International Development (USAID) and authored by Dr. Stella Kasindi Mwita, Monica Ngonyani, Dr. Davis Rumisha, Delphina Ntangeki, and Katherine Fatta of URC. It was developed as part of the Partnership for HIV-Free Survival work in Tanzania funded by the U.S. President s Emergency Plan for AIDS Relief (PEPFAR) and carried out under the USAID Applying Science to Strengthen and Improve Systems (ASSIST) Project, which is made possible by the generous support of the American people through USAID.
Tanzania Partnership for HIV-Free Survival (PHFS) Implementation Experience and Change Package JUNE 2017 Dr. Stella Kasindi Mwita, University Research Co., LLC Monica Ngonyani, University Research Co., LLC Dr. Davis Rumisha, University Research Co., LLC Delphina Ntangeki, University Research Co., LLC Katherine Fatta, University Research Co., LLC DISCLAIMER The contents of this report are the sole responsibility of University Research Co., LLC (URC) and do not necessarily reflect the views of the United States Agency for International Development or the United States Government.
Acknowledgements The USAID Applying Science to Strengthen and Improve Systems project (ASSIST) would like to acknowledge all the partners who worked effortlessly in implementing the Partnership for HIV-Free Survival (PHFS) in Tanzania and who participated in preparing this change package including MOHCDGEC officials, RHMTs and CHMT from all the three districts of Nzega, Mufindi and Mbeya Urban in Tabora, Iringa and Mbeya regions who participated in the initiative. ASSIST would specifically wish to acknowledge Grey Saga from USAID Tanzania who was the driving force behind this write-up. Dr. Deborah Kajoka who is the head of the PMTCT section, RCHS section and TFNC who worked together to provide National lead for the program. The RHMT are from the 3 regions. ASSIST also appreciate Implementing partners and Technical Assistant partners (EGPAF, Delloite- Tunajali, Baylor - Tanzania and the technical partners are URC-ASSIST, JHEPEIGO, and FHI 360/FANTA. UN organizations mainly UNICEF and WHO were technical partners at the level of the UN) who have worked together to support the implementation of the project. This report was prepared by University Research Co., LLC (URC) under the USAID Applying Science to Strengthen and Improve Systems (ASSIST) Project, which is funded by the American people through USAID s Bureau for Global Health, Office of Health Systems. The project is managed by URC under the terms of Cooperative Agreement Number AID-OAA-A-12-00101. URC's global partners for USAID ASSIST include: EnCompass LLC; FHI 360; Harvard T. H. Chan School of Public Health; HEALTHQUAL International; Initiatives Inc.; Institute for Healthcare Improvement; Johns Hopkins Center for Communication Programs; and WI-HER, LLC. For more information on the work of the USAID ASSIST Project, please visit www.usaidassist.org or write assist-info@urc-chs.com. Recommended citation Mwita S, Ngonyani M, Rumisha D, Ntangeki D, Fatta K. 2017. Tanzania Partnership for HIV-Free Survival (PHFS) Implementation Experience and Change Package. Technical Report. Published by the USAID ASSIST Project. Chevy Chase, MD: University Research Co., LLC (URC).
TABLE OF CONTENTS 1. Introduction... 1 Implementation of demonstration phase... 1 Outcomes of PHFS demonstration phase... 3 Challenges in implementing changes... 3 2. Results... 3 Retention of mother-infant pairs... 3 Ensure mother-infant pair receive nutritional assessment, counselling and support... 4 Know the HIV status of mothers and infants... 5 Ensure optimal ARV coverage for mothers and infants... 5 Issues for considerations for sustainable program... 6 3. Detailed change package for improving retention of mother-baby pairs at 30 demonstration facilities in Tanzania... 7 List of Figures and Tables Figure 1: The 4 steps of mother-infant care... 1 Figure 2: Improvement in monthly retention of HIV positive mother-baby pairs to ART in demonstration sites (June 2013-December 2015)... 4 Figure 3: Improvement in nutrition counseling for HIV positive pregnant and post-natal women in demonstration sites (June 2013 December 2015)... 4 Figure 4: Improvement in HEI receiving HIV tests and their results in the demonstration sites (June 2013- December 2015)... 5 Figure 5: Improvement in HIV positive pregnant women on ART in Nzega and Mufindi demonstration sites and HIV positive pregnant and lactating women on ART in Mbeya demonstration sites, June 2013 to December 2015... 6 Table 1: Retention of mother-infant pairs... 7 Table 2: Ensure mother-infant pair receive nutritional assessment, counselling and support... 10 Table 3: Know the HIV status of mothers and infants... 13 Table 4: Ensure optimal ARV coverage for mothers and infants... 13 Tanzania PHFS Change Package i
Acronyms ACT ANC ART ARV ASSIST CCHP CHMT CHW CTC CTC 1 Card CTC 2 Card DACC DNuO DRCHCO EID emtct FANTA FBO FP HBC HCI HEI HR IP LTFU M&E M2M MOHCDGEC MPSS MTCT MTUHA MUAC NACS NSC PDSA PEPFAR Accelerated Children Treatment Ante-Natal Clinic Anti-Retroviral Therapy Anti-Retrovirals USAID Applying Science to Strengthen and Improve Systems Project Comprehensive Council Health Plan Council Health Management Team Community Health Workers Care and Treatment Clinic Care and Treatment Clinic card for the client Care and Treatment Clinic card stored at the health facility District AIDS Coordinator District Nutrition Officer District Reproductive and Child Health Coordinator Early Infant Diagnosis Elimination of Mother to Child Transmission of HIV Food and Nutrition Technical Assistance Project Faith-based organization Family Planning Home-Based Care USAID Health Care Improvement Project HIV Exposed Infant Human resources Implementing Partner Lost to follow up Monitoring and evaluation Mother-to-Mother Ministry of Health, Community Development, Gender, Elderly and Children Mother Psycho-Social Support Mother to Child Transmission Mfumo wa Taarifa za Uendeshaji wa Huduma za Afya (HMIS) Mid-Upper Arm Circumference Nutrition Advice, Counselling and Support National Steering Committee Plan, Do, Study, Act Presidential Emergency Plan for AIDS Relief ii Tanzania PHFS Change Package
PHFS PITC PLHIV PNC QI RCH RHMT SES TFNC URC USAID WHO Partnership for HIV-Free Survival Provider Initiated Counselling and Testing People Living with HIV Post-Natal Care Quality improvement Reproductive and Child Health Regional Health Management Team Standard Evaluation System Tanzania Food and Nutrition Centre University Research Co., LLC US Agency for International Department World Health Organization Tanzania PHFS Change Package iii
I. Introduction Since September 2013, the USAID Applying Science to Strengthen and Improve Systems (ASSIST) Project has been working with other USAID partners and UN agencies in Tanzania including EGPAF, Delloite Tunajali, Baylor Tanzania, JHPEIGO, FHI 360/ Food and Nutrition Technical Assistance (FANTA), UNICEF, and the World Health Organization (WHO) in supporting the Ministry of Health Community Development, Gender, Elderly and Children (MOHCDGEC) to implement the Partnership for HIV-Free Survival (PHFS). The PHFS initiative is a multi-country initiative that supports national efforts to achieve goals of the Global Plan Towards the Elimination of New HIV Infections among Children by 2015 and Keeping their Mothers Alive ' through development and scale up of interventions to provide optimal nutrition for infants and their mothers and promote their well-being; and protect infants from HIV infection to assure reduced mother to child transmission of HIV (MTCT) to less than 5%; and keep HIV positive mothers on antiretroviral treatment (ART) through prevention of MTCT (PMTCT) option B+. In Tanzania, the PHFS initiative is led by the MOHCDGEC in the PMTCT unit as well as Tanzania Food and Nutrition Centre (TFNC) through USAID support. It is currently implemented in 90 health facilities in three districts including Nzega in Tabora region, Mufindi in Iringa region and Mbeya Municipal in Mbeya region. The implementation is based on the pilot experience in 30 initial sites scaled to 90 sites in the same districts. This document tells the story of what the 30 improvement teams achieved, the changes they found the most effective in improving PMTCT care and how teams implemented the changes. Implementation of demonstration phase In Tanzania, PHFS activities have been focused on the four steps of mother-infant care to lead to elimination of MTCT (emtct) as stipulated by the global PHFS initiative. (See figure 1). The first step is to retain all mother-infant pairs in care, this includes the recommended four ante-natal care visits and four post-natal care (PNC) visits at 24 hours to 2 days post birth, 7 days, 28, and 42 days. The second step is to ensure that all mother-infant pairs receive nutritional assessment and guidance, counseling, and support through the nutrition assessment, counseling, and support (NACS) initiative to identify and treat malnutrition in mothers and children. The third step is to know the HIV status of every mother and infant. If they are both HIV negative, the focus remains on ensuring they attend their PNC visits. If the mother or mother and baby are HIV positive, the next step is to ensure linkage to care and treatment coverage in ART clinic (CTC) is done. Figure 1: The 4 steps of mother-infant care Following initial participation in PHFS partners meetings, a National Steering Committee (NSC) for PHFS was established in July 2013, led by the Head of PMTCT in the Reproductive Health section of the MOHCDGEC and with participation of all of the IPs involved in PHFS. The NSC began by creating a national protocol, a monitoring and evaluation framework and a quality improvement (QI) framework. PHFS partners working with Regional Health Management Teams (RHMT) and Council Health Management Teams (CHMT) conducted baseline assessment in the three demonstration districts. The national partners designed the program and conducted meetings with the region and district to introduce the program and get feedback on the design. The assessment concentrated on four major areas including status of improvement activities, status and readiness for option B+, PNC, nutritional services, and community services linkage with health facility services for pregnant and post-natal women within reproductive and child health clinics (RCH). Within community services implementation some of the issues assessed included presence of mother-to-mother Tanzania PHFS Change Package 1
(M2M) groups activities and lost to follow up (LTFU) of clients services which were also assessed as preparation for PMTCT option B+. The following were recommendations from the baseline assessments: 1. Improve coverage of QI trainings, PMTCT Option B+, NACS, and early infant diagnosis (EID); 2. Support establishment and function of district and facility QI teams; 3. Ensure access of ART for HIV + pregnant, post-natal women and pediatric patients; 4. Establish and maintain nutritional assessments and support to mothers and infants. Ten sites in each of the 3 districts were selected for the demonstration phase and received orientation on PHFS and improvement from ASSIST and regional IP. The improvement teams focused their improvement efforts on the following four aims during the initial years of the pilot implementation: Increase coverage of ARVs uptake by HIV+ pregnant women, mothers and infants attending post-natal care from 46% to 80% by September 2015 through timely and correct ordering of ARV and adherence counseling. Increase the proportion of mother-infant pairs retained in PNC at 10 sites in each of the three districts from 20% to 80% by September 2015 through system strengthening, community involvement and QI innovations. Increase the proportion of less than two years HIV exposed infants who are confirmed of their HIV status through DNA/PCR or antibody testing from 26% to 70% by September 2015 through system strengthening. Increase the uptake of the NACS care package at 10 sites of each of the districts from the current 0% to 50% by September 2015 through provision of NACS tools and training of health care workers on NACS and system strengthening. A set of draft indicators was developed by all partners in Mbeya region and later refined by improvement teams in each district based on feasibility. National partners (IPs, Ministry Officers from PMTCT and TFNC) and regional level representatives from the RHMT conducted short awareness creation training on improvement methods in each district/region and formed improvement teams at the facilities. Improvement training was given to three to four health care workers at each health facility in the district together with the District AIDS Coordinator (DACC), District Reproductive and Child Health Coordinator (DRCHCO) and District Nutrition Officer (DNuO). District coaches began providing biweekly and eventually monthly coaching and mentoring support to help the facilities set up and support improvement teams, pick improvement aims, test changes, study their data to understand what worked and what did not, and document in Standard Evaluation System (SES) journals. This was also emphasized in the first learning sessions which started in July September 2013 for the three districts. Illustration of composition of improvement team Clinician Head Nurse Pharmacist Expert Patient RCH Nurse CTC personnel Home-based care Laboratory personnel Community representative The teams started implementation of the set objectives by designing tested changes that would address the gaps observed during the baseline assessment and during initial learning sessions. For example, they started to identify all pregnant women that were eligible to start ART and started them on ART either during that month of September 2013 or prior to the start point of PHFS. This had coincided with guideline change to PMTCT Option B+ which was started in Tanzania by September 2013. Each tested change selected was tried out for at least three months in PDSA cycles while evaluating the results of the output from the implementation. Changes that demonstrated results were shared and documented as scalable changes while those that did not yield results were discarded. Throughout the demonstration phase, ASSIST, IPs, and RHMT/CHMT convened improvement teams in learning sessions to share their experiences with each other, including achievements, challenges, next steps, receive refresher training and support on QI and use of the SES journal for documentation of improvement work. During the three-year period, 12 district learning sessions and three national learning platforms were held. These were an opportunity for all teams to come together with IPs, R/CHMT, 2 Tanzania PHFS Change Package
MOHCDGEC and USAID to share experiences across all pilot districts. During the second National Learning Platform conducted by all partners and all implementation districts in Mbeya region in February 2015, the draft change package was reviewed. The districts were given opportunity to include all working changes through intense discussion and review of gathered changes. The working tested changes as ranked by health workers in the three pilot districts that could be institutionalized in other districts in Tanzania, were identified and collated in one document. These changes are also shared as part of this report. Community members were engaged to facilitate linkage and retention of targeted mother and infant pairs to health care services offered under the PHFS initiative. They worked with members of the QI teams directly addressing the component of retention, ART, testing and nutrition. Outcomes of PHFS demonstration phase Generally, use of QI methods enabled health workers and identified QI champions to serve as peerto-peer mentors for other health workers during coaching visits and learning sessions. The QI champions were the health workers who had encompassed the QI approach, understood the QI methods and who really grasped and understood the program s QI activities to the level of having the capacity to train others. Documentation was one of the areas that needed intense workout and improvement as this was a weak area specifically in some of the RCH registers and tools, as well as CTC registers and patient information tools. Teams were able to improve documentation within reproductive clinics specifically for information on HIV testing and ART, PNC and follow-up, and nutrition. Teams were able to improve provision of ART to HIV positive pregnant and lactating women through PMTCT Option B+ and increase the proportion of postnatal mothers completing all four standard visits and of mother-baby pairs retained in care. Reduced transmission of HIV to babies as one of the primary outcomes was achieved whereby in the districts the rate of transmission decreased to around 4%. Community tracking of pregnant and lactating women helped to increase attendance to antenatal care (ANC) and RCH services through community volunteers (home-based care [HBC], PLHIV expert patients, M2M groups) and support. Creation of district ownership for the program enabled members of the CHMT or other district level health workers to capacitate more health workers and monitor the program. Strong partnership developed under the MOHCDGEC leadership created a forum for discussion during all phases of implementation through the NSC. Challenges in implementing changes Some of the sites were under staffed which impaired efficiency of services provision and documentation. Staff turnover meant that new staff had to be re-trained on QI processes during the implementation. A major challenge to the nutrition component was the initial lack of therapeutic foods, usually out of stock and a reflection of poor logistical support at the sites. Overall the results are not generalizable to other health facilities since the implementation sites were not compared to control groups. However, the QI process and the associated changed package was able to drive improvement on the selected indicators and the project highlights the relevance of QI in improving key process indicator in health facilities that can ultimately improve health outcomes. 1. Results Retention of mother-baby pairs The 10 improvement teams in Mbeya were able to increase retention of HIV positive mother-baby pairs to care from 18% in June 2013 in to 91% by December 2015. In Mufindi, the teams were able to increase retention from 0 to 82% between June 2013 and December 2015, and Nzega increased from 0 to 90% in the same time period (Figure 2). These results were great improvement from the initial rates before PHFS. Tanzania PHFS Change Package 3
Figure 2: Improvement in monthly retention of HIV positive mother-baby pairs to ART in demonstration sites, June 2013-December 2015 Ensure mother-infant pair receive nutritional assessment, counselling and support Three indicators were used to monitor nutrition support whereby two indicators were tracking nutrition assessments for mothers and babies and one was focusing on nutrition counselling for the mothers. Taking the example of nutrition counselling it was demonstrated in the three districts that this was done for 70 100% of the women who attended the services (Figure 3). Figure 3: Improvement in nutrition counseling for HIV positive pregnant and post-natal women in demonstration sites, June 2013 December 2015 4 Tanzania PHFS Change Package
Know the HIV status of mothers and infants From prior experience in Tanzania, the indicator selected to track HIV testing was assessing the number of HIV Exposed Infants (HEI) who had a DNA/PCR test done and the parents received results. After tracking and instituting QI measures for the three years of PHFS, this indicator was at 100% in all three districts as shown in Figure 4. Figure 4: Improvement in HEI receiving HIV tests and their results in the demonstration sites, June 2013 December 2015 Ensure optimal ARV coverage for mothers and infants One of the main aim of PHFS was to ensure that women initiated ART stays on ART, and after follow up and QI support to the demonstration sites, it was observed that for all the three pilot districts pregnant and lactating women on ART continued at rates above 90% and was sustained at those rates for 2 years of follow up from December 2013 to December 2015 as shown in Figure 5. Tanzania PHFS Change Package 5
Figure 5: Improvement in HIV positive pregnant women on ART in Nzega and Mufindi demonstration sites and HIV positive pregnant and lactating women on ART in Mbeya demonstration sites, June 2013 December 2015 Issues for considerations for sustainable program The need for the initiative to be included in the comprehensive council health plans (CCHP) to maintain service provision at the district level. Sustaining Peer Mothers and Community Health Workers (CHWs) by incorporating this support into CCHPs or cover it through Council Own Source. Sustaining CHWs and volunteers to strengthen community-facility linkages and promote retention is now being supported at the national level through formal course. Sustaining increased retention of mothers on ART through mother baby pair support, Mother Psycho- Social Support (MPSS) club, CHW/HBC and Moby application. Sustaining proper quantification and timely ordering of HIV and nutrition commodities and distribution of NACS materials into the new sites and existing sites (where there is deficiency). Strengthen monitoring and evaluation for nutrition services component by distributing the updated NACS registers and follow up on proper documentation. Explore ways to integrate QI training into the existing training and pre-service education system. Strengthen data use at all levels (facility, district, regional and national level). Create systems to sustain changes proven to improve processes at the clinic level; for example, document new way of working and consider having health workers performance appraisals contain a section that assesses worker s performance. 6 Tanzania PHFS Change Package
2. Detailed change package for improving retention of mother-baby pairs at 30 demonstration facilities in Tanzania The following change package summarizes the recommendations from QI teams who were involved in the demonstration phase of PHFS in the three districts. The changes recommended are the changes that yielded the best results for each of the four improvement aims they worked on. Teams provided details on how they implemented the changes for other facilities to more readily replicate the improvement work. Table 1: Retention of mother-baby pairs Challenge being addressed Mothers missing appointments Change tested and number of sites that tested this change Follow up by HBC of mothers with missed appointments change Calling mothers who have mobile phones if they missed appointment and it was deemed very successful Writing on mothers cards the specific date and day that they should come to the clinic All 30 health facilities tested this change Counseling pregnant women and mothers on the importance of the four PNC visits and risks of missing them All 30 health facilities How was change tested? The CTC2 card (kept at the facility) lists mothers village and registration number of their HBC For mothers who had disclosed to HBC and were reachable by the HBC, health facility personnel created and provided monthly a list of names of all mothers and babies with missed appointments to HBCs HBCs used the list to locate mothers and remind them to come. Providers recorded mobile phone numbers of mothers or the Treatment Supporter named in the CTC2 card Providers created a list of mothers who had missed the appointment that month and called them or the Treatment Supporter Teams emphasized the importance of providers giving return date to mothers on their take-home CTC1 card Providers also discussed with the mother to enhance recall memory Nurses led group health education sessions, when possible. If nurses were too busy, expert patients (where they exist) would lead group health education sessions. Depending on work load, providers (usually the nurse) would counsel patients individually on PNC, importance of FP, nutrition, and taking care of their health generally. Most sites would provide the counseling after women attended to the clinician Mothers were continuously counseled on the importance of the four visits at ANC, Tanzania PHFS Change Package 7
Challenge being addressed Incomplete documentation in registers of mothers visits hinders providers ability to review who has attended and who has missed their appointments Mothers cannot leave work for appointments Lack of transport for women and long distance to health facility Percentage of HIV+ mother-baby pair attending HIV services each month Change tested and number of sites that tested this change Weekly review of MTUHA register by the in-charge Nzega facilities tested this change Conducted outreach Clinics Two facilities of Mufindi where mothers worked in Tea plantations Involvement of male partners to escort their spouses One facility in Nzega tested this Same day appointment for the 6-week vaccination visit for the baby and the 42 days (4 th PNC) appointment One facility in Mufindi carried out this change Giving same day appointment for the mother and infant to come for services All sites implemented this change and there were very positive results Stapling together mother s CTC2 cards to the HIV Exposed Infant (HEI) cards All facilities tested this change How was change tested? Labor ward and RCH Friday review of PNC register by RCH nurses, HBC and CHWs jointly Together they reviewed for attendance and made list of who had missed their visit that week regardless of HIV status Reviewed to determine if documentation was done correctly and see if women that did not attend were recorded HBC and CHW were given information of missed appointments to follow up with patients Health workers followed the mothers at their place of work place and attended to them there This was a practice already in place, but they added PNC and CTC to the care provided Health education to women at facility to invite their male partners to attend Providers also used standard letter of invitation developed from ART services to invite them to come The health care staff arranged appointments so that the vaccination and 4 th postnatal visit fell on the same date Another facility that tried this planned the women s consultation first because mothers sometimes leave after their child is seen, failing to be seen by a provider themselves Providers synched the appointments of mothers and babies Providers staple together all CTC2 cards for identified HIV positive pregnant women, to a blank HEI card to prepare for information recording of the mother and the HIV exposed baby, when the baby is born This served as a reminder to the provider 8 Tanzania PHFS Change Package
Challenge being addressed Bringing lost to follow-up Mother- Baby pairs back to care Change tested and number of sites that tested this change Allocating specific family day for fathers, mothers and their babies One facility in Nzega district tried this change Documentation of the cards immediately after the service is carried out (instead typically would wait until end of the day) All facilities tested this change Update appointment register daily to detect missed appointments All facilities tested this change Compile a list of mother-baby pair who have missed appointments (2 weeks) and give it to the community health workers to track All facilities How was change tested? as soon as they use the mother s card and the baby s card. During stock outs of cards, facilities made photocopies and used those in place of cards Usually stapling of the cards is done by triage nurse who is first point of contact in larger facilities To get men to come, they organized a special clinic on Saturdays when they were not working in the mines or in businesses for the mines. Clinician and RCH nurses led the clinic day for ART Clinician visited leaders and community meetings to introduce the Saturday clinic and used these meetings to promote it Health providers documented in the registers immediately after the service was done In Mbeya, nurses have special allocation for filling registers One mission hospital assigned someone on the team to be responsible for the ART register would fill it based off the CTC2 cards information At the end of the day the appointment registers were reviewed to detect missed appointments and planned visits for the next day and write down who has missed for more than 3 days Triage or registration nurses (where they exist) or nurses would review Providers look at list from the daily appointment review to see who has missed for two weeks Discuss retention in monthly meetings with community health workers, homebased care staff and mothers psychosocial groups for members of that group who had missed (all disclosed) and setting reminder messages to attend. In places where they did not exist, Mothers psychosocial groups with the help of the specific CHMT and Tanzania PHFS Change Package 9
Challenge being addressed Change tested and number of sites that tested this change How was change tested? implementing partners had to be formed. Nurses and HBCs advised them and guided them on how to form support groups. Formation of mother to mother groups was also encouraged locally by HBC/CHW Table 2: Ensure mother-infant pair receive nutritional assessment, counselling and support Challenge being addressed Incomplete documentation hindering ability to understand patients nutritional progress Pregnant and post-natal women who are malnourished and not receiving assessment Change tested and number of sites that tested this change Improved documentation in the NACS register to make sure patient status was being recorded change Insert NACS forms for assessment for the mother and child in each of the mothers CTC2 cards change Identification of focal persons and specific points for nutrition assessments at the reproductive and child health clinics change How was change tested? Each health facility was provided with NACS register and health workers trained how to record information. NACS management form for the infant was inserted in each CTC2 card of the mother. This is a NACS management form for any patient, regardless of HIV status. Providers completed the CTC2 card and the NACS summary form. The information in the NACS management form is used for compiling summaries that are reported to the district. The district nutrition officer goes to each facility and compiles the summary forms. One staff was allocated to conduct Nutrition assessment for all pregnant and post-natal women each day One facility decided to have nutritional assessments at the end of services flow. This was so if the patient was discovered to need RUTF, they could give it to them right then, making it easier for the patient in terms of flow of services. Other facilities did nutrition assessment during registration by the triage nurse so it was part of routine checks for every patient. Some facilities created a special space for assessment to be provided, either a table, or a room depending on space available. 10 Tanzania PHFS Change Package
Challenge being addressed Malnourishment in infants Change tested and number of sites that tested this change Introduce NACS tools at RCH and children wards All 30 facilities Link community-based nutritional support initiatives to the health facility through referral Health education Counsel mothers on how to properly feed their infants Orientation of staff on NACS to conduct nutritional assessments using MUAC and document in NACS registers at each visit for mothers and their babies change Link community-based nutritional support initiatives to the health facility through referral How was change tested? There were no NACS tools (Mid-upper arm circumference tape, charts, registers) they were provided by the district through FANTA and USAID working with TFNC support and introduced at RCH and children wards. Mothers or children found with malnutrition were linked by health workers at health facility level to the community for further follow up by HBC or CHW staff Continuous individual counselling or group health education by nurses to pregnant and lactating women was done specifically regarding nutrition and healthy lifestyles NACS focal personnel were counseling individual mothers at the allocated spaces for counselling On the job training for those who did not attend the NACS training which was done through feedback to other staff who did not attend the training. Mothers or infants with nutritional problems as identified at the facility were linked to existing community support groups. These groups are made up of people in their communities who have received training from the Ministry of Health and IPs on nutrition and income generating activities. They also support people by doing infant food preparation demonstrations. Each facility has peer mother groups. When clients came who needed referrals to community-level support, the facility would connect them to the peer mother groups who would then connect them with the community groups and HBC to provide support and referrals at the community level. The referrals would be to community level in appropriate support networks. Generally low Orientation of staff on NACS Nutrition counseling was already part of Tanzania PHFS Change Package 11
Challenge being addressed levels of nutrition counseling provided to HIV+ pregnant and post-natal women who attend RCH Low levels of exclusive breastfeeding for infants Change tested and number of sites that tested this change to conduct nutritional counseling and document in NACS registers at each visit for mothers and their babies All 30 facilities Repeated individual counseling of mothers on the importance of exclusive breast feeding and the dangers of mixed feeding in the first six months of life carried out at ANC, Labor and at RCH Improved documentation in the Mother-child follow up register Demonstrations provided to mothers on how to position and attach their babies after delivery. Early management of breast conditions How was change tested? their job but not everyone had capacity and the counseling was not consistent in content. All staff at RCH were oriented on how to assess, categorize and counsel the mother by either those trained in NACS or the CHMTs staff from FANTA and TFNC All mothers attending the RCH were documented in the NACS register so that they assessed and then counseled and prescribed if needed. Each facility has a focal person for NACS. When started, counseling was mostly done at RCH. They began advising pregnant women on the importance of EBF during ANC and repeated the messaging throughout her pregnancy. Individual counseling was done at ANC, labor ward, RCH and children s ward every time mother comes for service. The mother child follow-up register was updated to see if all the information is documented including the dates the service was given. Most providers would only document first two months of the babies life therefore follow up months were incomplete. Coaches stressed on importance of documentation to address this component. Poor positioning is a common challenge faced by mothers trying to breastfeed. To address this, nurses began providing group health education using a doll or, when possible, a mother with her baby, as models. They would show how to attach and hold the baby to feed. Facilities also provided individual counseling at RCH that repeated the same demonstrations. More time was spent working with mothers with small babies and twins to practice. Patient history is critical to addressing breast conditions, so teams focused on building providers skills in collecting complete histories during PNC special visits. Use those four visits to find out what problems there are and treat right away. 12 Tanzania PHFS Change Package
Table 3: Know the HIV status of mothers and infants Challenge being addressed Improper dried blood spot (DBS) collection Many infants who are tested never receive their DNA/PCR results from DNA/PCR Central laboratories Change tested and number of sites that tested this change Orientation of staff on proper DBS samples collection and use of recording tools This change was tested in dispensaries One focal person allocated to track DNA-PCR results at the facility 10 facilities Recording contacts of the mothers whose babies have DNA/PCR results and making phone calls to track them How was change tested? Those who were trained on DBS collection gave an orientation to the rest of the staff at RCH or coaches who supported the dispensaries trained the staff as needed Facility staff were tracking children whose results were not received from referral laboratories by compiling lists and telephone calls to the central lab. Special forms at the facility that prints out the result were used to identify the results of HIV exposed infants One staff, usually a nurse, was chosen to trace DBS results and fill in the appropriate registers Mothers are counseled on the importance of the results and their mobile numbers recorded in CTC2 cards. The numbers are then used when results are back at the specific facility whereby they are called to come to collect the results of their babies Incomplete documentation hinders ability to know who has been tested and received their results Incomplete testing coverage of infants Improved documentation in the Mother-Baby Follow Up register Test all infants for HIV who come for other services in order to detect them (PITC) change. After 42 day visit, the pairs are recorded into the mother-child follow-up register Coaches showed providers how to fill this in and discussed the benefits of finishing the flow, emphasizing that it can help identify those who are lost to follow-up Providers updated mother follow up registers to improve documentation comparing with the CTC2 and HEI card Nurses would initiate rapid test If positive, depending on age, under 12 months, would confirm with DNA/ PCR test later Table 4: Ensure optimal ARV coverage for mothers and infants Challenge being addressed Stock-outs and inconsistent supplies of ARVs Change tested and number of sites that tested this change Timely ordering of adequate stock of ARVs and reagents All 30 facilities How was change tested? The health facilities were given an orientation by CHMT on how estimate the number of clients and order enough stocks which will last 3 months or beyond until Tanzania PHFS Change Package 13
Challenge being addressed Patients stop taking treatment Change tested and number of sites that tested this change Request ARVs from other facilities in times of shortages A few health facilities that experienced stock-outs during the pilot phase tried this change Counseling mothers on the importance of adherence to taking ARVs and dangers of not taking them (part of routine ART services, but not RCH HIV) All facilities tested this Promote disclosure to their partners How was change tested? another time of ordering Emphasis was placed on reviewing their own data to understand their supply needs Facilities began making true estimates based off the numbers expected who have appointments. They began looking at the numbers of patients seen last quarter using the R&R In-Charge led the efforts Some facilities have excessive first line drugs because ordering estimates were not right while other facilities had insufficient stocks CHMT would monitor stocks during supervision visits looking at level, expiration, determine shortages and surpluses CHMT would deliver medications where they needed to go and CHMT would record the redistribution if the supplies are from another health facility CHMT and IP made an inventory as to detect facilities with surplus of ARVs and redistributed them to sites with stock-outs Redistribution was done usually within the same district Mothers were given continuous adherence counseling at each visit With Option B+ nurses at RCH were trained on ARV for the first time Most nurses already trained in counseling In clinic flow from registration to clinician to dispenser to adherence counselor the emphasis was that adherence nurse/appointment nurse (oftentimes the same person) provided the counseling Facilities that didn t have adherence counseling set it up and those that did strengthened it Facilities always appointed a point person who is responsible to make sure it was getting done Nurses counseled mothers on the importance of disclosure to partners or 14 Tanzania PHFS Change Package
Challenge being addressed Incomplete enrollment of HIV positive infants into treatment Change tested and number of sites that tested this change Weekly review of data in the ART register Nzega facilities had done this change. This helped to note if mother really took the ARVs and if they were documented. Follow up of mothers whose children are HIV positive through mobile phones or HBC change. How was change tested? close relatives so that they could help the women in taking their treatment The in-charge of the facility checks the documentation in the ART registers One staff was allocated to check the records to determine which HIV positive children had not been enrolled into care and started on ART When one was discovered to not have been enrolled, they called the mother if they had her phone number of file or, if her records indicated she had disclosed to the HBC, they notified the HBC to track her and encourage her to come to enroll the child Tanzania PHFS Change Package 15
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