In partnership with local health care leaders and organizations, the Institute for Healthcare Improvement has been working in several regions of South Africa since 2004 to increase treatment rates for patients with HIV. Now IHI has expanded its support for HIV care by working with the Department of Maternal and Child Health, housed within the Department of Pediatrics, at the University of KwaZulu-Natal and the Provincial Department of Health to improve the existing Prevention of Mother-to-Child Transmission program (PMTCT) targeting HIV.
The effort, which began in March 2008, focuses on three of the eleven districts in the province of Kwa-Zulu Natal (KZN), and aims to decrease transmission from the current rate of 21 percent of births to under 5 percent in two years’ time. The project has a secondary aim: to help leaders evaluate two levels of intervention for the improvement work, with the intention of discovering which level is most appropriate, cost effective, and results in the greatest sustainability.
“There is the potential for this work to have a dramatic effect over a larger scale,” says IHI’s South Africa Director Pierre Barker, MD, who is already looking ahead at the implications of taking the program province-wide. “There are about 250,000 births in the province every year, and the highest antenatal prevalence of HIV in the country. About 40 percent of all pregnant mothers are HIV-positive, and over 20,000 babies each year are unnecessarily infected by HIV due to the lack of an effective PMTCT program.” Quite deliberately, improvement leaders are calling the effort to alter this situation the 20,000+ Partnership.
Comparing Improvement Models
The project includes 300 health care sites, broken into two, roughly equal groups. Half of the sites, explains Barker, have enrolled teams of front-line workers and managers in conventional Breakthrough Series Collaborative model
. The teams attend Learning Sessions led by Barker and IHI’s KZN Provincial Improvement Advisor Brandon Bennett, and keep in touch with their counterparts as they implement tests of change during Action Periods.
In the other sites, nurse supervisors receive intensive training in quality improvement, systems thinking, and data analysis, and form a Collaborative with other supervisors. The supervisors are supported by five Quality Mentors from the University of Kwa-Zulu Natal trained by Brandon Bennett. Professor Nigel Rollins, chair of the Department of Maternal and Child Health at the University, leads the University’s involvement.
“We’re trying to determine if bringing the clinic teams themselves into the Breakthrough Series significantly accelerates improvement compared to focused learning at the nurse supervisor level,” says Barker. “This has very important implications for cost, because the cost of running a Breakthrough Series is high. We also want to see how fast we can move to effect change.”
Both Barker and Bennett say that one of the most exciting parts of this project is the strong partnership between IHI, the University, and the district health coordinators. “We are extremely fortunate to work with the University and with Professor Rollins,” says Bennett. “He is widely trusted and respected and, as relative newcomers to the region, we benefit tremendously from his help.”
The working partnership with the Department of Health is equally critical to the program’s success. “The closeness of our collaboration with the Department of Health is novel, and so important to this work,” says Barker. “This is the first situation where we are training existing Department of Health managers to be change agents. They have given us access to their database, and are making modifications in their infrastructure to accommodate this work. And by introducing improvement and new infrastructure within the Department, the program will be self-sustaining.”
“Anytime you approach improvement work in the developing world — or anywhere, really — you are faced with issues of sustainability,” says Bennett. “How are you going to create a system of care that will outlast your particular intervention? By working with the Department of Health we are able to create an enduring place for knowledge as well as practices around improvement. We are expanding the capacity of people with careers in the Department of Health to lead improvement work.”
At the clinical level, the work involves first making sure that reliable data collection processes are in place, a task that is sometimes more challenging in very rural settings that are chronically under-resourced, says Barker. “Data collection is usually amenable to the improvement process,” he says. “We can make some quick gains in fixing the data systems and start feeding back the information, which is a very powerful tool in getting people to take ownership of their clinic system and start planning and testing.”
Being able to efficiently identify the HIV status of pregnant women is an important first clinical step, as is identifying the disease’s progression in women who are HIV-positive. Bennett says clinics have begun to bundle these steps together at the woman’s first prenatal visit. “When women first come for antenatal care, they are offered an HIV test,” says Brandon Bennett. “If the test is positive, the patient’s CD4 count is also checked, which helps identify the strength of her immune system.” Prior to the improvement work, Bennett says the CD4 test would typically be done several weeks after the HIV test.
Women with CD4 counts below 200 — indicating that the disease has progressed and the immune system is weak — are placed immediately on a triple drug therapy called HAART (highly active antiretroviral therapy).
“Only about 15 percent of pregnant mothers need HAART, but they account for about 50 percent of all HIV transmissions to babies,” says Barker, so getting them into treatment is important. “Creating a care pathway and making sure it happens reliably 100 percent of the time is something IHI improvement methodology is well suited to doing,” he says.
HIV-positive mothers with relatively strong immune systems receive a two-drug therapy in the three months preceding their delivery, aimed at knocking the virus down during the baby’s birth, thus dramatically reducing the chance of transmission. “There has been a change in protocol for what drugs are used to treat these mothers, and that’s happening at the same time we are introducing system changes,” says Barker, “so we are riding a wave of change.”
Working Within Existing Resources
Though the 20,000+ Partnership project is in its early stages, Barker reports that there is much enthusiasm for it in the hospitals and clinic sites. He says the biggest challenges occur in rural areas where “everyone works within a ‘waiting for resources’ paradigm. Resources are often promised and never come. But our experiences in other rural projects is that people can take control of their own environments and can make improvements by optimizing the systems they already have. That’s a critical element we can bring to this process.”
Brandon Bennett agrees. “The issue of resources comes up everywhere,” he says. “People think they need more staff or more money to provide better care. The reality in South Africa is that those resources are not readily available, and IHI offers a methodology for optimizing the care process within existing resources. We know that with best practice we can get the transmission rate down to five percent within the existing resource constraints.” As an example, he cites the bundling of the HIV and the CD4 tests, which allows for streamlining the process of getting eligible women onto HAART. “The therapy is already provided by the government, so it requires no new resources, it’s just a matter of identifying the women and getting them on it in a timely fashion.”
Barker is excited about the possibilities this project holds. “If we can produce the results we expect, there will be a lot of will to spread this rapidly through the province, and we’ll have a phenomenal amount of information about how to design large-scale projects like this going forward.”