The South African IHI projects continue to grow and help scale up HIV/AIDS care: February 2007
Sister de Wee: January 2007
Unsung Heroes and Heroines: December 2006
Justin's Visit to a Mobile HIV Testing Center in a Shopping Mall: November 2006
Lloyd Provost's Blog (Part 3): July 2006
Lloyd Provost's Blog (Part 2): July 2006
Lloyd Provost's Blog (Part 1): July 2006
Mhlontlo Update from Pierre: January 2006
Read the Blog Archive (2004-2005)
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New Collaborative to Decrease HIV Transmission to Newborn Infants Launched in Zululand District, South Africa — March 2008
In partnership with the Centre for Rural Health at the University of KwaZulu-Natal, IHI is expanding its support of HIV care programs in South Africa. Today over 50 health workers from 7 hospitals (who support over 50 clinics) came together in Ulundi, KwaZulu-Natal (KZN), to design interventions to reach an ambitious target of decreasing mother-to-child transmission (PMTCT) by over 50% in the next 18 months.
From previous experience, we learned that the District health structures need to be deeply involved in the improvement process from the outset.
- Leadership from the District office is crucial for legitimacy and generating the will for change.
- A functioning reliable data system that can feed back site-specific data needs to be in place to support the improvement work.
- District managers need to be directly involved in the planning and on-the-ground improvement work from the outset.
Brandon looks out over his new improvement "fiefdom"
of the Zululand District
Over the past three months Linda Dlamini, project manager from our partner organization at the Centre for Rural Health, and Brandon Bennett, IHI's KZN provincial improvement advisor, have traveled hundreds of miles over unpaved roads together with Sizathu Mbambo (District PMTCT Coordinator) to introduce the improvement process and methods to the District health office and health facility leadership. In preparation for the launch, Brandon has also worked with the Boston office to refine a simple Excel database to track the processes and outcomes for PMTCT. The database has been installed in the District office and has provided our baseline understanding of the strengths and weaknesses of the program with a focus on identifying failing processes. District Health Coordinators directly responsible for the PMTCT program have been traveling with Linda on every visit.
District Coordinator opens the first Zululand learning session
The first learning session was opened by Sizathu Mbambo, who gave a strong commitment that the District would do whatever it will take to decrease HIV transmission. At current transmission rates, of the 13,500 births each year, we expect over 1,000 infants to be infected with HIV by 6 weeks of age. Without access to further treatment, 800 of these infants will die before their second birthday. The systematic process that has been initiated today is our best chance to eliminate these unnecessary deaths and leave behind a durable mechanism for continuous improvement.
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A Summer in KZN — September 2007
Jessica Greenberg, a second year medical student at the Harvard Medical School (pictured at right in the photo below), traveled to South Africa for two months this summer to work with clinics on data collection and tracking techniques
In the past two years, HIV/AIDS treatment has become more commonplace for adults in some areas of South Africa. Indeed, the growing local knowledge that desperately ill people can recover rapidly after receiving treatment has created an enormous demand for antiretrovirals (ARVs). Despite this, effective treatment for HIV-positive pregnant women during their pregnancies remains a rarity. The main reason for this is that the system designed to prevent mother-to-child transmission of HIV is very dysfunctional.
In June and July of 2007, I worked with the physicians, nurses and HIV/AIDS counselors at two hospitals and six clinics in rural KwaZulu-Natal (KZN). These communities are deeply rural and very poor. 
Unemployment hovers near 70% and more than one of every three pregnant women are HIV positive. Our project’s goal is to improve efforts to place eligible pregnant women on HAART (Highly Active ART) treatment in order to prevent the transmission of HIV to their children.
I sat down with the nurses and counselors at each clinic to understand how pregnant women seeking antenatal care move through the clinic system and why many women are not offered treatment early enough in their pregnancy. Each clinic’s data was illuminating; though many women learn their HIV status, few were having the blood work needed to determine whether treatment was right for them. And of those women having CD4 counts (a method of determining the immune systems health), very few actually learned their test results and were referred for lifesaving treatment.
With some coaching, each of these clinic teams began looking for solutions to improve their success at treating eligible pregnant women. Each clinic began a “lives saved” campaign, creating a clinic poster that counts each two lives saved — the child and the mother — for every pregnant woman put on treatment. The practical solutions the teams devised were often elegantly simple. Mbazwana Clinic simply moved its HIV counseling from outside the clinic in a nearby building to a room adjacent to where antenatal care is provided. In one week, the team went from sending blood tests for 20% of pregnant women, to sending 100% of the necessary tests. Mseleni Hospital began to screen women waiting for an ultrasound to ensure that all women who had blood drawn for CD4 counts got their results. At each site, we held a brief celebration to congratulate the staff on their successes, applauded those who contributed to the change, and asked what more we could do.
Small changes such as these promise tremendous benefits to communities devastated by a growing pediatric HIV epidemic. All of the health workers in this region are touched personally by HIV and AIDS. Many of the nurses and counselors I worked with have children in their own families who are HIV positive. The will to protect children is enormous, and simple tools that harness this will are the key for change to occur.
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TB/HIV and Sister de Wee — July 2007
Michele Youngleson discusses the tuberculosis tracking system and its many evolutions at the Ikhwezi Clinic.
Tuberculosis (TB) and HIV care should go hand in hand, but current health systems in South Africa are not designed to easily integrate care for these two diseases. Last year we analyzed records of 220 adult TB patients at Ikhwezi, a primary health care clinic in Cape Town, and showed that 70% of those who were voluntarily counseled and tested (VCT) were HIV positive and that nearly 60% of these dual infected patients were in urgent need of antiretroviral (ARV) treatment. Yet, less than a third of known dual infected patients had accessed these lifesaving drugs. Our assessment was that there was no system in place to track TB patients through the processes (VCT, CD4, referral) that would successfully lead to initiation of ARVs.
This is the story of the ongoing effort to design a tracking system that works. Each attempt has bumped into an obstacle which has demanded a rethink. A year later, we are on the fourth design which attempts to reduce complexity, build on existing strengths, and do away with duplication. But are we there yet? Only continuous assessment of results over time will tell...
Design Version 1:
About a year ago, Sister de Wee, the TB sister at Ikhwezi Clinic, started a computer-based register (Excel spreadsheet) 
that tracked each of the many steps in preparing patients for ARVs and automatically highlighted patients for whom further interventions were necessary. This helped Sr. de Wee track the dual infected patients and improve their access to ARVs, but after initial great enthusiasm the computer crashed and was not fixed for four months! By then the data backlog was huge and no one had the heart to restart the tracking system.
Design Version 2:
In the interim, Sr. de Wee’s idea had been adapted for a clinic that did not have access to a computer. This adaptation took the form of a box register 
with cards for individual patients and dividers that indicate where the patient is in the continuum of care (see picture at right). Each divider in the box represents a column in the Excel spreadsheet. The box register was being successfully used by Sr. Jacobs in the Maccassar Clinic TB room, so when Sr. de Wee no longer had her Excel spreadsheet we suggested she try out the "box" system at Ikhwezi. This also went well for a time, but then Sr. de Wee went on a long-term training course and the box lay unused in the corner.
Design Version 3:
While Sr. de Wee was away, Bongi, the data capturer, attempted to maintain a separate paper register of HIV+ TB patients. This register worked well initially. However, it duplicated much of the demographic information already recorded in the TB register and she soon lost enthusiasm for this intervention.
Design Version 4:
Now Sr. de Wee is back in the TB room and it’s time to try out something new.
The TB clinic already has a detailed register for tracking the TB management of TB patients — demography, folder numbers, 2-month and 6-month sputums, outcomes, etc. The obvious intervention is to insert additional columns to the existing register to track the processes required for HIV testing and referral, but lack of space makes this impossible. The answer comes in a flash of counterintuitive insight! We can add the extra columns to the back of the previous page and expand the existing TB register to the left rather than the right. This will maximize existing strengths and do away with duplication.
We also decide to reduce the number of indicators to the bare minimum, and list only whether a patient needs ARVs and whether they have actually been initiated.
Sr. de Wee thinks this method will be “fun” and attains the essence of what she liked about the Excel register, the fact that she could follow her patients and make sure they received adequate HIV care. She laughed at how the original idea had become progressively simpler, and feels that the latest version has the greatest chance of success.
What Have We Learned?
- Complex data management tools (such as computer-based systems) are very attractive, but may not be sustainable in a developing country setting where continuous and timely technical support is not dependable.
- Just about any intervention may work well if it is "driven" by an enthusiastic champion in a specific setting, but unless there is shared ownership of the intervention, it will not be sustained when the champion leaves.
- Systems that contain redundancy are not sustainable and will not be adopted by front-line staff that have to do the work.
- The simplest systems are often the most likely to succeed and endure.
- We need to be able to quickly test and reflect on interventions to ensure we do not get "stuck" with an unworkable system.
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Unsung Heroes II: Joubert Park — May 2007
Cathy Green reports from the Joubert Park Primary Health Care Clinic.
Joubert Park is in the very center of Johannesburg. Home to the city’s Art Gallery, it was once a tranquil site offering a place of retreat and refreshment at the heart of this bustling city. Now it is a notorious hotspot for crime. Despite this, local residents still gather to talk or sleep on its benches and grassy areas. Many are immigrants with no prospect of finding work. These immigrants often call “home” a room in one of the many dilapidated hotels and hostels that distinguish the community of Hillbrow from its more affluent neighbors. In the middle of these inauspicious surroundings lies Joubert Park Primary Health Care Clinic.
When we were first introduced to staff from the clinic, they talked about themselves and their patients being held up at gunpoint and robbed as they provided care or sat in the waiting areas. The clinic was one of nine health care facilities serving inner city Johannesburg that had come together for a collaborative learning event, run through a partnership between the Institute of Healthcare Improvement (IHI), the Reproductive Health Research Unit (RHRU) and the City of Johannesburg. Colleagues immediately committed to work together to try and help resolve or lessen this problem.
It was during this one-day workshop that the Joubert Park clinic staff really understood the plight of children born HIV+ along 
with recognition of the contribution they could make to a child's life-expectancy. Over half of HIV+ children die before reaching two years of age because their HIV status is not known and appropriate treatment is not provided. Nurses at primary health care clinics were asked to start performing a simple test (PCR) by taking blood from an infant’s heel to enable an early diagnosis. Positive babies could then be referred to other parts of the health care system for antiretroviral therapy as required. This message was further reinforced when one of Joubert Park’s professional nurses attended a funeral the following day and noticed how many graves belonged to young children.
So the clinic committed to beginning the job of testing as many babies born to HIV+ mothers as possible, particularly taking advantage of the mother’s attendance at immunization sessions beginning when the baby is 6 weeks of age.
The impact was dramatic. From testing no children whatsoever, the clinic moved to testing 40 per month in the space of 9 months.
Lack of space within the clinic continues to present huge problems in enabling the range of confidential conversations necessary to provide basic health care. It is impossible to counsel patients about their own or their child’s HIV status without privacy.
Undeterred by these substantial challenges, team members have been creative in the way they have utilized space, coming up with a number of ideas to test to establish their practicality and acceptability with patients. IHI and RHRU have worked to facilitate this process, leading improvement meetings within the clinic and teaching rapid tests of change (Plan-Do-Study-Act) methodology.
One idea was to move some of the immunization activity out into the main waiting area, cordoning off the space with filing
cabinets and screens. This was controversial but was reportedly seen as an acceptable compromise by patients. However, as unprecedented cold weather swept through the country the arrangements needed to change again. It was too cold in the waiting room for babies to be undressed. The staff are once again working to generate alternative solutions to enable them to maximize their HIV testing of adults and children without providing inferior levels of care across other services.
It is always a pleasure to work with this group of individuals who show such optimism, commitment, energy, and willingness to innovate as they attempt to continually improve their services in the most challenging of environments.
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The Team from Ekombe — March 2007
Brandon Bennett reports from KwaZulu-Natal on the incredible improvement of one of the smallest hospitals in the region.
Three hours from Empangeni, one long stretch through the Mondi Forest and down maybe the harshest road in South Africa, lays the small community of Qudeni (the Q is pronounced as a click, popping in the roof of the mouth). Five kilometers from this village is Ekombe Hospital. Twenty years without a doctor, this hospital has a solid history of nurse-driven care.
When Linda, project manager in Umkhanyakude from the Center for Rural Health, and I arrived at Ekombe Hospital the HIV team there was conducting between 1 and 2 HIV tests per day, but that represented a VCT (Voluntary Counseling and Testing) success rate of 100%. The counselors were doing a superb job of convincing the people they counseled to get an HIV test but they wanted more. They wanted an increase in the total number of people tested. Together we plotted, we planned, and after just one month and three change ideas, implemented using the Model for Improvement, the nurses and counselors at Ekombe (see image below) were able to increase fourfold the number of people tested each day (from 1.7 to 7.5).
Ekombe Hospital Nurses and Counselors
Before testing any change ideas the Ekombe Hospital was on track to administer just over 400 HIV tests this year and now they are on track to complete 1,800. What an incredible result for Ekombe Hospital.
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The South African IHI projects continue to grow and help scale up HIV/AIDS care — February 2007
Updates from Pierre Barker, Program Director in South Africa, on continued scale up of work in the country
In three regions, KwaZulu-Natal (KZN), Western Cape and Gauteng, IHI has recently undertaken expansion — either within current districts or into adjacent districts. In KZN, Brandon Bennett launched a new district collaborative in Uthungulu, a rural area north of Durban that is adjacent to an existing IHI supported collaborative in the Umkhanyakude District, home to nearly one million people.
In partnership with the Centre for Rural Health (University of KwaZulu-Natal) we held a learning session that was attended by about 50 health care workers from 11 of the districts’ 14 hospitals. Brandon laid the groundwork during the previous four months, visiting sites, generating excitement around IHI's improvement methods, and getting teams started on small PDSA cycles. At the learning session, the teams pledged to increase capacity to treat all patients who need HAART (highly active antiretroviral treatment), and to decrease perinatal transmission of HIV to less than 10%.
Brandon Bennett teaching the Model for Improvement at the first learning session in Uthungulu District, KZN
In the Western Cape, Michéle Youngleson has been developing innovations in HIV and tuberculosis (TB) care with teams from clinics and hospitals in half of the Eastern sub-district, located outside Cape Town. She is now helping to introduce more effective HIV and TB care to health care sites for the remainder of the sub-district. Michéle will be training managers and coordinators from this district to ensure sustainability of the improvement methods after IHI leaves.
Shanty town outside Cape Town where IHI is helping to introduce novel approaches to integrate HIV and TB care
In Gauteng Province, Cathy Green has picked up the Johannesburg Inner City project from Justin Yarrow who ended a 12-month stint with IHI in December 2006. Cathy led a highly successful learning session in February, and the project is about to double in size, with the incorporation of an adjacent sub-district into the learning collaborative. This project has an ambitious goal to double initiation rates in 12 months, providing access to HAART to all people in the district who need this treatment.
In the next six months we expect to launch three additional major initiatives: (1) a PMTCT (Prevention of Mother-To-Child-Transmission) project covering half the population of KZN province, (2) an inner city project to support clinic-based HAART in partnership with McCords Hospital in Durban, and (3) a district-wide PMTCT project in the North West Province.
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If we had a prize for Improvement Personality of the Month it would go to Sister de Wee! — January 2007
Michéle Youngleson describes the Ikhwezi Clinic and one special nurse who has recently taken on new improvement work to better manage patient care and raise joy in her work.
Ikhwezi is a primary health care clinic in the Helderberg Basin, a peri-urban area about a 40-minute drive north of Cape Town. It serves two informal settlements, Nomzamo and Llwandle. Residents have strong ties with rural Ciskei, a group of indigenous black Africans living on a tribal reserve, and the settlements have grown rapidly as people are drawn to the city in search of work.
A menacing sculpture guards the entrance to the settlement. Its alien demeanor contrasts starkly with the community 
which, despite the dire poverty, retains a sense of warmth and humanity. Adults and children sit or play in the baked-earth alleyways between their small lodgings. Clothes, hung out to dry in the sultry heat, punctuate the shanty town with color while restless dogs scour the ground or lie sullenly in the sparse shadow. A woman sets up a make-shift fruit stall outside the clinic and music blares from a nearby tavern.
Yet, this sense of harmony belies a stealthy horror: Ikhwezi is at the epicenter of the HIV epidemic in the Helderberg Basin — 60% of all HIV+ people in the area come from Ikhwezi and almost one in three pregnant women are HIV+.
Tuberculosis (TB) is rife too. Because HIV suppresses the body's ability to deal with infection, patients with HIV and TB can have very fragile health.
Sister de Wee (second from left in picture below) has been in charge of the TB room at Ikhwezi for four years. Initially she was reluctant to take part in the improvement project, but over a few months became curious about what was happening to her paitents living with HIV and TB. Having never used a computer before, she and Bongi, the TB data capturer, began to design an Excel program to track their dual infected patients. Darshna Bhatt, a public health intern from the University of North Carolina offered to assist her with this and together they developed a program that flags patients needing intervention for HIV.
Sister de Wee described how her life has changed because of the program she set up:
“I learned that you can’t just go on doing what you’ve always been doing — you have to be accountable! For the four years I was running the TB room, I’ve been cross. People would come and ask me ‘what’s the ratio of this patient to that patient?’ and I didn’t know so I just wanted everyone to leave me alone. Now when I sit at the computer, I can see what’s happening to every patient. I know how to interpret the data and this has empowered me. Now if there’s a problem I don’t go to the facility manager and ask him to ‘please help me,’ I take the data and say ‘this is the problem, how are we going to fix it?’. Before, I lived my life hiding in a cupboard, but this computer program has taught me that I can take the next step forward! It’s changed my life, not only in the clinic but outside — now I have a destiny. I have so many new ideas, I just have to find a way of making them happen.”
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Unsung Heroes and Heroines: Cathy's Reflections on Her Visit to the Mdjobe Clinic — December 2006
Cathy Green recently made a trip to the Mdjobe Clinic with its senior nurse to learn about the extraordinary effort one woman has made towards the fight against HIV/AIDS.
We drive for one-and-a-half hours down a dirt track to get to the Mdjobe Clinic. Along the way, we pick up two ladies laden down with large duffle bags. They are standing by the roadside hoping for a lift. It is not advisable to pick up hitchhikers in South Africa; car-jacking is rife. But I’m accompanied by a wise, senior nurse who was born in this district. I take my lead from her.
We arrive at the clinic and the crowded waiting area falls silent as we walk in. I attempt a poorly pronounced Xhosa greeting and it seems to break the ice. There are a few giggles and some sheepish responses.
The Mdjobe Clinic
We are here to visit Sister Kumalo, one of only two qualified nurses who run the primary health care clinic that meets the immediate health needs of this rural community. Sister Kumalo is an extraordinary woman. Soon after becoming involved in a learning community, supported by the Institute for Healthcare Improvement and the Regional Training Center, she committed to finding ways in which her HIV-positive clients could get access to the drugs they needed to improve their health. Read more about the visit.
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Justin's Visit to a Mobile HIV Testing Center in a Shopping Mall — November 2006
Justin Yarrow, IHI's Project Manager based in Johannesburg, recently visited a mobile HIV testing center located in a busy shopping mall to better understand the HIV testing experience. The following entry recounts his reflections.
Who would you disclose to if you were HIV positive? What would their response be? What is your plan for remaining negative? What will you do if your result is positive? These are not questions that you normally answer on a trip to the mall, but in a country with a lot of malls and young at-risk citizens, innovative mobile voluntary counseling and testing (VCT) centers bring these questions into the heart of South African's favorite destination.
