by Amy Stern and Rhea Bright
December 1, 2011
On this World AIDS Day, December 1, 2011, people around the world are promoting the "Getting to Zero" campaign – the goal backed by the United Nations to have zero new HIV infections and zero AIDS-related deaths. For those who work on the frontlines of HIV care, reaching this goal involves addressing a host of underlying factors at each level of a complex and multifaceted system. Just two of these factors are: 1) how we ensure that every patient who needs care gets it and 2) how we evaluate the care provided.
Health care facilities collect and report large amounts of data to fulfill multiple requests from donors and to report to their district/regional and national offices. Donors and technical partners use these data to make funding decisions. Yet the data provide little meaningful information to assess the quality of HIV services.
Assessing quality, or how well HIV programs perform, is vital for all health system levels. With such knowledge, country governments can make informed decisions about national HIV strategies; facilities can address gaps in their HIV services; and donors can measure the impact of their programs and gain insight for making funding decisions.
To strengthen this capacity within countries, the Office of the Global AIDS Coordinator (OGAC), the US Agency for International Development (USAID), and the Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria (Global Fund) asked the USAID Health Care Improvement Project (HCI) to develop an approach to yield meaningful information about the quality of HIV services for users at multiple levels of the health system (Figure 1).
Together with the Global Fund, we developed an approach that uses 16 proposed HIV program quality criteria (QC). The QC, listed in Table 1, relate to five HIV service delivery areas: testing and counseling, care and treatment, prevention of mother-to-child transmission (PMTCT), tuberculosis/HIV (TB/HIV); and harm reduction. Global technical partner organizations, such as the Joint United Nations Programme on HIV and AIDS (UNAIDS) and the World Health Organization (WHO), participated in defining the QC and in identifying existing mechanisms to measure the criteria.
The QC are designed to be general enough to allow country programs flexibility in evaluating the quality of program performance for reporting and improvement purposes, without restricting countries to indicators that may not all be applicable or feasible in their context. We field tested the QC approach in five countries representing different types of HIV epidemics: three in Africa and one each in Eurasia and Southeast Asia. The three African countries are in East Africa, West Africa, and Southern Africa.
Table 1: Proposed Quality Criteria
A Feasible Approach
Countries should be able to report on the QC if the data are available in the facilities. However, field test findings indicated that this was not always the case. Facilities fulfill reporting requirements by gathering numerator data (the volume of patients who received a service). Country governments collect these data at the national level, compile it, and calculate national coverage using population estimates as the denominators. As a result, little to no denominator data (patients eligible to receive a service) are being tracked or used at the facility level. This means that facilities, government agencies, and donors often have an incomplete picture of what is actually happening on the ground and whether services are reaching everyone who needs them.
This was most evident relative to the QC for PMTCT. All PMTCT QC were feasible for reporting from the national level in all countries. However, the field tests exposed, in the African countries, an inability to track HIV-positive mothers and their exposed infants through the PMTCT services that they should receive. Even when data collectors could identify those who were eligible for the services (the denominator), problems in tracking patients prevented the collectors from determining the number who received each service (the numerator). Such problems arose from a least three causes: facilities had multiple registers and identification numbers in different wards and clinics, mothers used different name combinations in wards and clinics, and infants had different last names than their mothers.
Table 2: Feasibility of tracking PMTCT patients,
PMTCT QC numbers 8, 9, and 10 – relating to transmission prevention, antiretroviral drugs for the mother, and HIV care for the infant — are not likely to be feasible using alternative indicators: Table 2 shows the data that could not be located when collectors attempted such tracking in the African countries.
In addition to an absence of meaningful data, many facilities were not using the data they did have to assess their performance and improve their HIV services. Of 35 facilities visited during the field test, data collectors noted three where staff members used quality improvement methods, such as analysis and use of data, to make and track changes to address facility needs and client services. One such facility was located in each of the three regions in Africa.
Overall, national officials, providers, and facility staff interviewed found the QC to be "very useful" or "useful" for all service delivery areas, with the exception of the harm reduction QC proposed for drug treatment programs. This encouraging finding supports using the QC to produce the data vital for improvement and informing decision-making so that facility staff can track their progress, and performance data can be shared with donors to monitor program performance and spread lessons learned and success stories.
Ultimately, improved data use and information about services will lead to fewer gaps in care, stronger links between services, and better health outcomes – all necessary components in our shared goal of "Getting to Zero."