This "blog" tracks the progress of collaborative improvement projects in South Africa to improve HIV/AIDS treatment. This archive contains blog entries from 2004 through 2005, written by the IHI South Africa Team and Staff.
Read the current blog entries
We are currently active in six projects in five provinces — Western Cape, Eastern Cape, KwaZulu-Natal, Gauteng, and North West (see map below) — covering rural/urban and adult/pediatric practices. We are at the point now where we have generated a lot of enthusiasm at the sites we are working in, and provincial administrations are showing interest in our work. In particular, the Deputy Minister of Health of South Africa, Nozizwe Madlala-Routlege, has been very supportive of our strategy.
Projects that IHI is supporting in South Africa
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A New District-wide Collaborative is Launched Near Cape Town
IHI turned an exciting corner last week in Western Cape Province when we launched an 8 clinic, 2 hospital collaborative to improve HIV and TB care for patients in the Eastern Helderberg District. The district has 200,000 people, about 20,000 of whom are HIV positive, and about 2,000 need ART. At present only 400 people are receiving ART. In addition, TB infection rates in South Africa are the highest in the world and cure rates are falling due to the effect of untreated HIV. Over the past 9 months IHI's representative in the Western Cape, Michele Youngleson, has worked with local partners and the Department of Health to test requirements for HIV/AIDS care in a "wedge" of the health system that includes primary care clinic, a District hospital and an academic tertiary care hospital. The new collaborative is the first wave of what we expect will be an exponential scale-up of HIV services in the province.
IHI's Michele Youngleson teaching the Model for Improvement at the 1st Helderberg learning session
The day before the learning session, Michele and I, together with an ART physician and a district representative visited the local clinic sites and gathered critical information about systemic impediments to HIV/AIDS and TB care. This information allowed us to generate a discussion at the learning session the following day to map 6 roadblocks to effective pre-ARV management, coordinated HIV/TB care, and referral for ARV management.
At the learning session, clinic health workers identified 6 roadblocks
to work-up and management of HIV patients
The health workers shared success stories for overcoming these barriers and provided several change ideas to test. After some teaching about rapid cycle improvement methods, each facility chose one of these change ideas and undertook to test the change idea that would lead to most improvement in their clinic. Michele will visit next week to check on formation of clinic improvement teams, PDSAs, and planning of further tests.
Working with the Center for Rural Health in Ugu, Kwa-Zulu Natal - November 2005
In July 2005 IHI’s SA team was asked to help out with the ARV program in Ugu, the southernmost district in KZN. This provided an excellent opportunity for us for a couple of reasons. First, our biggest supporter in the national department of health, Deputy Health Minister Mrs. Madlala Routledge, was born in, and represents this area, and had encouraged us for months to work there. Second, we had an opportunity to test the methods developed in the northern part of the province in a District that had many fewer resources, one where we would have to work extra hard with caregivers on the ground to make sustainable changes.
Together with our Kwa-Zulu Natal partners, the Centre for Rural Health and the local project manger, Sandy Glajchen, we started work in an impoverished corner of the District, St. Andrew's. In July, the St. Andrew's ARV program was a mess with only 30 clients initiated on ART over the previous nine months as compared with the other three subdistricts, which had ~400-500 clients on ARV. An obvious problem was a draconian enrollment process that had been developed at St. Andrew's that excluded the involvement of the local clinics in the program and expected potential clients to be super-clean-living humans before they were allowed to start treatment.
Sandy Glajchen (standing) of the Center for Rural Health leads a monthly improvement team meeting with nurses, doctors, counselors, and pharmacists in Ugu, KZN.
Our first task in the area therefore was to bring everyone (nurses and counselors from clinics and hospital, doctors, hospital management, district staff, pharmacy, and transportation) together from the hospital and surrounding clinics to form a collaborative that could identify these problems and start testing solutions. In addition to our monthly improvement team meetings, Sandy and I have visited the clinics and hospital to follow up on projects and to see if folks were making headway with the PDSAs they had designed. Participants present to the group at monthly meetings and troubleshoot any ongoing problems before spreading improvements to other sites.
The results of this process are dramatic. Since the IHI/CRH group started in St. Andrew's, monthly enrollment has tripled from 6-7 per month to now 20 per month (now over 100 clients in chronic ARV care). Further, up and down referral mechanisms between hospital, clinic, and laboratory have been established and strengthened. Finally, a clear, less arbitrary flow from HIV test to ARV initiation has been designed, which we hope will improve efficiency and ensure more patients "make it" through the system.
Patient flow diagram developed at St. Andrew's by the IHI/CRH collaborative. This diagram clarifies and streamlines the process of bringing a new HIV+ patient onto treatment.
There's of course a lot more work to be done in this area, but we're working hard to create an environment where change is not only valued to solve immediate problems but also integral to everyone's day-to-day job.
Deputy Minister Visits IHI-assisted District in Eastern Cape Province - July 2005
The IHI’s work in the Mhlontlo District in the Eastern Cape recently got a high-profile boost when the project was visited by Nozizwe Madlala-Routledge, National Deputy Minister of Health, in mid-July. The Deputy Minister was given an overview of the progress in the District. The principal success of IHI's involvement has been to greatly accelerate the rate at which patients are being initiated on antiretroviral therapy (ART). She attended a debriefing at the Regional Training Centre at the Walter Sisulu University in Mthata, and was then taken on a tour of two of the principal sites in the District – Tsolo and Qumbu. At both sites, nursing and counseling staff confidently described the major changes in work practice over the past six months that have enabled them to identify obstacles to good care, as well as the tests of change that have resulted in this phenomenal progress. A remarkable feature of the project is that the service is almost entirely nurse-run, with only one doctor providing HIV care to a District which has a population of 250,000. Health staff strongly proclaimed their ownership of the process and their determination to meet their goal of providing access to ART to all eligible patients in the District by December 2006. The meeting was addressed by the major stakeholders in the project, including patient representatives and District administrators. The Deputy Minister took time to speak directly to patients about their experiences with the HIV/AIDS program. Her visit was covered in an article that ran in the Eastern Cape Daily Dispatch, the principal newspaper of the Eastern Cape.
Deputy Minister of Health, Nozizwe Madlala-Routledge greets
the District HIV coordinator at the Qumbu Clinic in the Eastern Cape
before hearing from nurses and patients about the IHI-assisted program.
IHI Develops Strategic Partners in South African HIV/AIDS Improvement Work - June 21, 2005
Over the past 10 months, our focus has been on learning to run improvement and collaborative projects in a variety of resource-poor HIV/AIDS treatment sites in South Africa. The development of close partnerships with key players on the ground and within the Departments of Health has been a key strategy for expansion and sustainability of the projects. In all 6 projects that we are currently supporting, we are working with a partner (academic centers or NGO) who provides technical expertise (medical training, temporary medical personnel, equipment etc.) while IHI provides systems improvement
training and facilitates collaborative learning. In addition, we are working, either through independent relationships or through our partners with Ministries of Health at a District, Provincial and National level. A key supporter of our South African activities has been the National Deputy Minister of Health, Nozizwe Madlala-Routedge, who was profiled this week in a Sunday Times
article that extolled her passionate efforts to remove barriers to the national ARV rollout [read the article: "A handshake of hope for the ill and fearful
"]. These partnerships are crucial as we expand from the initial pilot sites (Johannesburg General, Baragwanath, Tygerberg, Taung, Umkhayakude and Mhlontlo) to District and Region-based projects over the next few months. In each case, IHI is working closely with its strategic partners to develop the infrastructure and funding required to support BTS Collaboratives that will run over the next 18 months. In all cases, we expect to build our partners’ capacity for self-sustained improvement work to allow projects to expand independently of IHI within this time frame. In July, IHI will host a Planning and Learning Forum in Cape Town where IHI faculty will meet with project leaders and project managers from IHI-supported sites around the country. At this three-day meeting, we will learn from experiences to date and collaboratively plan our strategy and timelines for the expanding projects for the next year.
Expanding IHI Support for ARV Rollout in KwaZulu-Natal (KZN) - April 9, 2005
The IHI is on the brink of a major expansion of its South African ARV projects, with the prospect of assisting the rollout in four rural Districts in KZN. At the suggestion of the National Deputy Minister of Health, Nozizwe Madlala-Routledge, I met together with Prof. Steven Reid from the University of KZN Center for Rural Health and the KZN Provincial Minister of Health, Mrs. Peggy Nkonyeni, in Durban on March 31. At the meeting we proposed expanding the Improvement and Breakthrough Series Model approaches that we have piloted in similar rural ARV projects in the Eastern Cape and Northern KZN. The Minister requested that we submit a proposal for IHI-assisted projects in four Districts in KZN. If these projects go ahead, we would be assisting in Districts that cover nearly half the area of the Province, covering a population of ~4 million.
The scenic Umkhanyakude district of the KwaZulu-Natal Province
The day after the meeting I joined Nupe, who was traveling in the Umkhanyakude District way up in Northern KZN. We had done our first Learning Session there nearly four weeks previously, and Nupe was spending the week visiting the sites, helping to design improvement cycles, and offering help with database development. I joined him in Richards Bay, about two hours' drive from Durban, at the southern end of the District. The District stretches nearly 200 miles northwards to the Mozambican and Swaziland borders. We covered huge distances in two days, visiting four of the five sub-districts, and working with the key players at each of the main hospital sites. Nupe had visited some of the more rural clinic sites before I arrived. Amazingly, Nupe (who speaks only five words of Zulu, normally drives on the “US” side of the road, and has never previously driven a stick-shift) planned and drove the entire trip through this most remote region of South Africa without a map (which he believes self-respecting males do not need) in a stick-shift car without A/C. (Nupe clocked 2000 kilometers for the 1000 km roundtrip.) Nupe seems quite oblivious to the well-sign-posted dangers in the region. We have since sent him a map of the region.
Mapless, Nupe uses his innate sense of direction to find his way
Pierre points out the dangers along the road
The meetings were a great success. At each site we helped to design test cycles, set goals, and establish measures. We are establishing a set of common measures to track the work and plan to share experiences through a network that links the sites in this District. A listserv for the District and the first of structured monthly conference calls will happen this week. Hopefully, this experience will provide us with a template for our planned expansion into other Districts in the Province.
Learning Session in Mhlontlo - March 25, 2005
A week ago, Nupe and I held our 1st learning session at the Qumbu Health Center in the Mhlontlo District of the Eastern Cape. Nupe and I had spent the day before schmoozing with the District managers and Qumbu clinic staff (it's clear that Nupe has made a great impression, greeted with affection and enthusiasm by all we encountered). Those of you who know that I am always 5 - 10 minutes late for any meeting may be interested to know that I am getting my come-uppance as we work in South Africa. The representatives from 12 clinics and hospitals traveled great distances, much of it over bad dirt roads to meet us, so it was no real surprise that the 9 AM meeting finally got going at
10:20 AM. As is common here, we were not able to secure the 2 days for a learning session that is usual in the US, but were given a 2 hour timeframe extracted from their busy day.
The meeting started with a moving multipart harmony hymn (see photo above), and was then chaired by the District CEO who had unexpectedly turned up, and who we rapidly briefed on why we were holding this meeting, and what we would like him to say. After he, and then the District Manager, the District HIV/AIDS manager, and the Regional Training Center Director (Dr Ola) had finished, Nupe’s plan for a state-of-the-art Powerpoint presentation on the Chronic Care Model
(that I had already cut by 2/3) was not going to happen. I urged him to cut it shorter, and to follow Don’s great example a week earlier of keeping it very simple and engaging the crowd.
(Nupe): The overwhelming message from the ARV sites was that a) clinic capacity was overburdened with the current staff shortages and b) there are numerous structural/systems issues preventing people from getting on treatment. The biggest systems issues were that clients were being asked to attend too many clinic visits (often up to 10!) before starting ARVs, the requirement for home visits was a barrier to starting treatment because of transportation issues, and that many potential ARV clients are still afraid to start treatment because of stigma.
After I gave a brief introduction on using small tests of change to improve a system, the nurses and counselors came up with a number of innovative ideas to further the Chronic Care Model
1) The 8 “new” ARV sites wanted to try ARV counseling on 5-10 patients so that they can become familiar with the pre-treatment preparation phase.
2) The Tsolo clinic wanted to shorten the ARV preparation time by reducing the number of “required” visits by ½ on 5-10 patients.
3) The Qumbu health center identified a large group of 50 clients who were completely assessed with the exception of a home visit. They wanted to test deferring the home visit on 10 clients and measuring how they differ from clients who went through the usual procedure.
4) Qumbu also wanted to see if an “expert ARV patient” living with AIDS would be helpful in convincing their clients to start on treatment.
The monthly "selection committee" meeting in the Mhlontlo district of the Eastern Cape
The following week, Pierre and I attended the monthly meeting of the “selection committee,” which is a multidisciplinary team who decides which clients are accepted for ARVs. Right away, we could see that the group was enthusiastic and energized about their progress, and could barely wait to present their clients to the group. Of the 32 patients who were presented, all 32 were accepted for ARV. This is in comparison to the 26 in March and the 12 from February (see graph below). All 10 of the Qumbu “fast track” patients were accepted for treatment when they would have otherwise been languishing in the queue waiting for someone to visit their home. This is a very exciting time for the district as the number of people on treatment (and therefore the number of lives saved) seems to be escalating rapidly. Just glad to be along for the ride.
IHI Intensive Learning Forum in Johannesburg a Great Success - March 14, 2005
The IHI held a highly successful Intensive Learning Forum last week in Johannesburg – the first session of its kind in Africa. The conference brought together leaders from IHI-supported ARV sites in four of South Africa’s provinces, representatives from South Africa’s National and provincial Departments of Health, and observers from Mozambique and the Democratic Republic of the Congo. The meeting was opened with a visionary talk on improving and changing healthcare systems by Don Berwick (see photo), followed by a series of presentations on improvement methods (chronic care, improvement, collaborative, and scale up models) by the IHI faculty – Pierre Barker, Uma Kotagal, Joe McCannon.
Below: Donald M. Berwick, MD, President and CEO of IHI, discusses the basic principles of collaborative improvement in Johannesburg, South Africa
Left: Dr. Nkhangweni Mmbara of the Johannesburg General Hospital provides a summary of the conference
Right: Shalom Ncala, describes her experience from a patient's perspective
The following day’s workshops fostered remarkable interactions between healthcare workers from urban and rural settings who committed themselves to a bold plan to treat all eligible HIV patients in their catchment area. Sensing the power of working collaboratively, the groups set treatment targets well beyond those in the SA Government Rollout Plan. We expect that these groups will set national benchmarks for ARV care in both rural and urban settings.
On the last day, we heard state-of-the-art presentations on the early results of HIV care at the Johannesburg General Hospital and the first reporting of improvements in process and outcomes at the paediatric HIV collaborative in Johannesburg. The conference concluded with participation from national and provincial heath department leaders including Deputy Health Minister Nozizwe Madlala-Routledge (see photo below) and national head of HIV/AIDS programs, Namonde Xundu. The Deputy Minister gave a strong endorsement of IHI’s approach to supporting the SA rollout.
A major output of the Forum was a proposed network of the participating sites that will facilitate the sharing of knowledge and report on progress. This network will be a crucial tool in moving forward the national plan to reach all South Africa’s 500,000 people who need ARVs right now. With the energy and commitment seen from healthcare workers at this meeting and IHI’s ongoing commitment to support the ARV rollout, we’re hopeful that IHI and its local partners will play a major role in developing innovative and sustainable chronic care programs that will save thousands of lives in the AIDS epidemic, and improve care of all chronic diseases in this country.
Report on Trip to the Ugu District of KwaZulu Natal (KZN) - February 25, 2005
Nupe and I traveled to southern KZN Province at the invitation of Deputy Minister of Health, Nozizwe Madlala-Routledge. The purpose of the visit was to visit the District ARV rollout sites plus some of the potential sites located at peripheral clinics, and then to attend a HIV/ARV summit called by District Managers. The background to this is that both the Deputy Minister as well as the Provincial Minister of Health, Peggy Nkoyani (who also attended the summit), were born in the Ugu District and have a particular interest in this area.
The Ugu District is very large — extending +/- 100 miles x 100 miles, with 750,000 people, 25% HIV +ve = 185,000, and 18,000 people needing ARV right now. They currently have 283 people on treatment at 3 sites having started the program in October 2004. A fourth site is accredited and will be starting treatment soon — all sites are located along the coastal belt and there are patients in the inland areas who have to travel 100 miles for care. There are plans in the District to spread care out to more rural sites using primary health clinics. (We heard of plans to spread out to 8 clinics, with issues of equity being discussed.)
On the first day we got some sense of the great area and rural nature of the District, covering very large distances and seeing only 3 sites. We visited the main ARV site at Port Shepstone clinic, and 1 primary care clinic under consideration for spreading care, and 1 rollout site (hospital) not yet started on treatment. We got the impression that the docs and nurses were all eager to participate in the rollout and there was no fear or hesitation similar to that we had encountered in the Eastern Cape. There was some confusion about the guidelines and the process for identifying patients who needed ARVs was misinformed (no CD4 counts done after HIV diagnosis, just waiting for patients to get symptomatic before testing CD4 count).
Pictured (Left to Right): Pierre, Deputy Minister of Health, Nozizwe Madlala-Routledge, and Nupe visiting Port Shepstone's Regional Hospital in the KwaZulu-Natal Province of South Africa
On the second day, we attended the summit (+/- 200 people — health care workers, administrators, traditional healers, community leaders, etc.). The meeting was addressed by the Deputy Minister of Health (national DoH), and Provincial Minister of Health, and (with equal promininence!) by myself. The Deputy Minister gave an inspiring talk and challenged the audience to get more active in the rollout. I spoke about the Eastern Cape project and drew analogies to the situation in Ugu and the potential for accelerating the rollout and strengthening the health system.
The Deputy Minister is very keen for us to become involved in this District. I am working with Steve Reid on a plan that would cover rollout in 4 large rural districts (total pop ~2 million). Next steps to be discussed include getting political buy-in, project staffing, and funding.
An Extraordinary March - February 23, 2005
Last week I attended the rally and march organized by the Treatment Action Campaign (TAC). The TAC is a pressure group that has mounted several successful legal challenges to try to get ARVs more readily available — most notable of which was the court case that resulted in Nevirapine becoming widely available to HIV+ve pregnant mothers. The rally was entertained by a spirited band, “Freshly Ground,” (see photo below) who set the mood before the speeches that preceded the march. The crowd of 5,000 set off under a perfect blue sky for the 2 mile route through the heart of downtown Cape Town to the doors of the Parliament Building. The crowd was good natured, with singing and chanting as well as dancing, but with a determined message “Treat 200,000 people with ARVs by February 2006.” Currently only about 25,000 people have been treated with ARVs in South Africa, well below the government’s target of 50,000 by March 2005, a drop in the ocean considering the estimated 700,000 South Africans who need ARVs today.
Outside Parliament, the crowd listened to an impassioned plea to the government to accelerate the national ARV rollout program. In response, the head of communications from the President’s office called the TAC “our conscience” and praised them for “calling attention to the blind spots that the government was unable to see.” This was a remarkable encouragement from the President’s office that has been highly critical of the TAC and accused of lackluster support of the rollout. It felt like perhaps a corner was being turned in the efforts to get more treatment to South Africa’s AIDS population.
The Treatment Action Campaign takes to the streets of Cape Town
The IHI Roadshow: 3 IHI-ites, 3,000 Miles, 5 Sites, 7 Days - February 10, 2005
When IHI faculty guru Lloyd Provost flew into Cape Town at 25 minutes to midnight last Friday, he’d been traveling for 30 hours since leaving Austin, Texas. It was the start of a grueling 7 days. In Cape Town, he was debriefed on a recently initiated project at the Tygerberg Hospital — a joint adult and paediatric ARV clinic that is 3 weeks out from its first learning session.
Lloyd Provost at the tip of Africa
Then, after a couple days of recovery on the dazzling Cape Peninsula, a 5:50 am flight to East London and a 3-hour drive to Umtata to join up with IHI's newly arrived Nupe Metha. There we visited local clinics and charted a plan to form a collaborative of clinics in the Mhlontlo District.
Idyllic views of the Mhlontlo District in the Eastern Cape
After 2 days of learning and planning, we presented our draft plan for an ambitious rollout strategy to get ARVs to all 5,000 eligible AIDS patients through an improvement collaborative of primary health clinics and hospitals in the district, with a planned first learning session in early March. Currently, there is only one pharmacist for the District (see below) — this will present a major challenge as the District scales up ARV treatment. Then on to Johannesburg and up early to help review progress at the Paediatric ARV clinic at Baragwanath Hospital and the adult ARV clinic at the Joburg Gen. Twenty-four hours later another 5:50 am flight took us to Kimberley and, after a 2-hour car trip, we were in Taung in the Northwest Province, site of another IHI-assisted project in early development. The great success of the day was identifying a local primary heath care clinic to pilot a down referral system for chronic stable ARV patients — a primary strategy to increase capacity at the main site (to get more patients started on ARVs). On the drive back we recruited (maybe) another 2 primary heath care clinics, and, oh yes, Lloyd saw a tornado across in the distance. By the time we stopped the car, it had all but dissipated. Then back to Kimberley, with Lloyd heading back to the U.S., Nupe to Umtata, and me to Cape Town.
The lone pharmacist of the Mhlontlo District, Eastern Cape
Learning to Do a Learning Session in 2 Hours - February 2004
My first exposure to the classic "learning session" was in a swanky hotel in San Diego, where I was gently introduced to the treasured “models” of quality improvement by 6 attentive faculty over 2.5 days. So I felt a bit stressed when I did my first equivalent session at the Johannesburg General Hospital with one other IHI faculty in 2.5 hours. That’s all the time you get in a busy week at the “Joburg Gen” where the average clinic cares for more than 100 patients on ARVs per session. In that time we set aims, discuss a change package, draw up measures, and design the first PDSAs. It does mean a lot of hand holding and intensive support, certainly through the first few months, and the project sinks or swims depending on the abilities of local project managers. To accelerate the learning curve of local leaders, the IHI arranged for 5 site representatives to attend the IHI National Forum in Orlando in December 2004. Here the South Africans met other developing country attendees and were immersed in "IHI speak" for 4 days.