1/10/2014

1

Technical Assistance Models to Build

Capacity:

Experience of the Elizabeth Glaser

Pediatric AIDS Foundation

Mary Pat Kieffer

Elizabeth Glaser Pediatric AIDS Foundation

17th ICASA, Cape Town, South Africa

10 December 2013

Background

• Weak health systems; low

national health budgets

• Development aid in

health historically funds

“projects” of limited

duration

• This has created to

vertical and specialized

health programs, often at

the expense of long-term

and sustainable support

for the health system

1/10/2014

2

EGPAF and other NGO partners provide many

kinds of support to MOH

• Technical assistance at national level

• Participation in Technical Working Groups

• Supporting sub-national structures (districts, regions)

• Supporting facility level services

• Providing training, BCC materials, commodities or drugs

• Seconding staff at national, regional or facility level

• Data and M&E support

How can we best use our resources to provide the RIGHT

KIND of support?

Focus of today’s talk:

Critical levels of human resource shortages

in all areas of health care in Africa

• Sub-Saharan Africa has 24% of the overall global burden of

disease, 69% of people living with HIV, and only 3% of the

global health workforce1

• Globally, 61 countries have a critical shortage of healthcare

workers - 41 of them are in Africa2

• The absolute shortage of health workers is compounded by

misdistribution between urban and rural areas

• Heavy workloads, insufficient training, weak management and

low staffing ratios mean increased stress and burn-out for

health workers, often with a resulting poor quality of care3

1. WHO Working Together for Health. The World Health Report 2006; UNAIDS Report on the Global

AIDS Epidemic 2012.

2. Moore A, Morrison JS. Health Worker Shortages Challenge PEPFAR Options for Strengthening Health

Systems A Report of the Task Force on HIV/AIDS. Center for Strategic and International Studies,

Washington DC, September 2007

3. Iglesias ME, Vallejo RB, Fuentes PS. Reflections on the burnout syndrome and its impact on health

care providers. Ann Afr Med 2010;9:197-8.

1/10/2014

3

0 1 2 3 4 5 6

AngolaBotswanaBurundi

CameroonCote d’Ivoire

DR CongoEthiopiaGhanaIndia

KenyaLesothoMalawi

MozambiqueNamibiaNigeria

South AfricaSwaziland

UgandaUR Tanzania

Zambia

2.3/1000 global minimum

22

Pri

ori

ty C

ou

ntr

ies

Source; World Health Report 2006

Doctors, nurses and midwives (skilled providers)

per 1,000 population in 22 priority countries

Our scarce human resources suffer from poor management systems

– Staff not fully trained in services

they are expected to deliver

– Rotation of trained staff to other

areas, replaced by untrained staff

– Necessary commodities are out

of stock

– Registers incomplete and

inaccurate

– Good clinical practice is not

rewarded

Photo: Jon Hrusa

-

Best practices and the global policy guidelines built on

these practices come up against a harsh reality on the

ground in facilities:

1/10/2014

4

Q3FY12 Q4FY12 Q1FY13 Q2FY13 Q3FY13 Q4FY13

VHP 45% 31% 64% 32% 59% 50%

HP 50% 59% 31% 54% 39% 25%

MP 5% 10% 4% 12% 2% 14%

LP 0% 0% 1% 2% 0% 9%

VLP 0% 0% 0% 0% 0% 2%

45%

31%

64%

32%

59%

50%50%

59%

31%

54%

39%

25%

5%10%

4%

12%

2%

14%

0% 0% 1% 2%0%

9%

0% 0% 0% 0%2%

0%

10%

20%

30%

40%

50%

60%

70%

A group of key indicators can be selected to

create a performance index

A group of key indicators can be selected to

create a performance index

At facility level, monitoring performance is

key to developing support plansWidespread stock -

outs or national

training efforts can

affect performance

Mentoring clinical staff is an important part of

our support

• Improve

understanding of

guidelines

• Support provision of

practice

• Address specific

clinical issues

• Record data correctly

so that it can be USED

for monitoring of

performance

• Develop job aids and

reminder systems

1/10/2014

5

QI Model for Improvement:PDSA

• Plan – who, what, when, where

• Do – implement change, collect data

• Study – analyze results – if test was successful, then Act, if not, then Plan again

• Act – Implement on a broad scale and move to next cycle Reproduced with permission from Associates in Process

Improvement

Health workers use PDSA cycles to identify

causes and develop solutions

Apr-

June

12

Jul-Sep

12

Oct-

Dec 12

Jan-

Mar 13

Apr-

June

13

Jul-Sep

13

Alive and on ART 1209 1908 1954 1997 1926 2556

Number in Cohort 1905 2834 2884 2918 2812 3599

0

500

1000

1500

2000

2500

3000

3500

4000

Nu

mb

er

ali

ve

an

d o

n A

RT

Tanzania - Alive and on ART 12 month cohort

PDSA short tool to plan improvement

projects for retention in care

1/10/2014

6

Staff rotations often cause

performance declines

Staff rotation & off site training

0

10

20

30

40

50

60

70

80

90

100

10/1

/12

11/1

/12

12/1

/12

1/1

/13

2/1

/13

3/1

/13

4/1

/13

5/1

/13

6/1

/13

7/1

/13

8/1

/13

Change in assessment & documentation of good adherence to ART in 2 facilities in Uganda

Median

Percent

DCC Maternity leave

MCH Nurse moved

MoH withdraws

counselors

New MCH nurse in place

0

10

20

30

40

50

60

70

80

90

100

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

Attempts to improve repeat HIV testing in Infants 2012 Lesotho Hospital x

Median

Percent

High performing facilities face constraints they

cannot control

1/10/2014

7

Jan-Mar 2012 April-June 2012 Jul-Sept. 2012 Oct.-Dec 2012 Jan-Mar. 2013 Apr-Jun. 2013 Jul-Sept. 2013

Subgroup 6.00 10.00 82.00 46.00 89.00 99.00 98.00

Median 82.0 82.0 82.0 82.0 82.0 82.0 82.0

Staff rotation & new staff

issues with reporting

Facility leadership

intervenes

0

10

20

30

40

50

60

70

80

90

100

% PW retested in L&D Swaziland 12 Facilities Median

Perc

enta

ge

Building capacity of facility, district and

national leadership is our key goal

Health workers need good data to

become high performers

14

1/10/2014

8

Consumer involvement makes facilities accountable to their communities

• C I protocols include:

– Leader sensitization

– Training community resource persons

– Facility staff training

– Community meetings

– Feedback to facility

– Implement improvement project

– Patient satisfaction survey

1/10/2014 15

Conclusion

• While our funding comes

through projects, we have a

responsibility to use our

resources to build sustainable

capacity

• QI and mentoring help HCW to

identify issues at each level and

guide them to find and

implement solutions

As local leadership grows, our work

changes character from less direct

support to higher level strategic

support

1/10/2014

9

Thank you for your attention

Acknowledgements

EGPAF country staff

Mary Morris, EGPAF QI lead

Our donors

Our MOH colleagues

Our clients