Quality improvement in HIV treatment services in Rwanda ( using the existing electronic recording and reporting systems), and the transition of these services from international partners to MOH. Endris Mohammed 1,2, Byringiro Vianney 2, Sabin Nsanzimana 2 1: Rwanda Family Health Project 2: Rwanda Bio Medical Center (RBC) IAS 2013, Kuala lumpur, Malaysia July 1, 2013

 Country profile  Track 1.0 transition in Rwanda  RBC/IHDPC/HIV division QI program overview  Rwanda electronic recording and reporting system  QI program strategies-real time accessible health data driven  Selected results  Conclusions  Lessons Learned & recommendations

Total Population: approx. 11 million HIV Prevalence: 3% (2010 DHS) Total No. of patients on ART by the end of April 2013: 118,657 (> 94% of those in need) Total number of health facilities: PMTCT sites 490 VCT sites 458 ART sites By the end of April 2013

CDC-Rwanda began transitioning financial and technical responsibilities for HIV clinical services at 76 Health Facilities from international NGOs to MoH-Rwanda in 2010 Transition completed by February 2012 Financial and clinical performance of transitioned sites monitored every 6 months MOH-Rwanda and HEALTHQUAL developed site- level QI program in March 2011 to help maintain the quality of clinical care

May Jun e July Aug. Sept Oct. Nov. Dec. Jan. Feb. March April May June July Aug. Sept Cohort 1 Transition* 18 Sites Cohort 2 Transition 6 Sites Cohort 3 Transition 26 Sites C1 BaselineC1 6- Month FU C1 12-Month FU C2 BaselineC2 6-Month FU C3 Baseline Track 1.0 Transition M&E Timeline: Reference CDC-Rwanda C3 6-Month FU Cohort 3.5 Transition** 20 Sites C3.5 Baseline **The financial transition for Cohort 3.5 sites will occur in March 2011 C3.5 6-Month FU *The Cohort 1 transition occurred in March 2010

Track 1.0 Transition M&E Timeline: Reference CDC- Rwanda Oct. Nov. Dec. Jan. Feb. Marc h April May June July Aug. Sept. Oct. Nov. Dec. Jan. Feb C1 18-month FUC1 24- Month FU C2 12-Month FUC2 18-Month FU C3 12-Month FU C2 24-Month FU Cohort 4 Transition 6 Sites C4 Baseline C4 6-Month FU C3 18-Month FU 2013 C Month FU C Month FU March C4 12-Month FU C3 24-Month FU C Month FU

1. The proportion of HIV+ pregnant women eligible for triple therapy prophylaxis who received triple therapy prophylaxis 2. The proportion of HIV+ pregnant women eligible for triple therapy for life who received triple therapy for life 3. Proportion of partners of pregnant women presenting for their first antenatal care consultation who are tested for HIV 4. Proportion of infants born to HIV+ mothers who received ART prophylaxis at birth 5. Proportion of infants born to HIV+ mothers that have PCR at the age of 6 weeks 6. Proportion of currently enrolled patients on Pre-ART and ART who are on CTX

1. The proportion of ART patients who are still on treatment 12 months after initiation 2. The proportion of patients newly enrolled in HIV services who were screened for TB 3. Number of patients newly initiating on ART during the reporting period a. Pediatric patients b. Adult patients 4. Number of patients currently on ART at the end of the reporting period 5. Proportion of patients who received ARVs for 12 out of 12 months 6. Proportion of ART patients who received CD4 control at 6 months

 Goals:  Improve and sustain quality of HIV/AIDS clinical services at health centers and district hospitals.  Build national capacity in quality management  Maximize utilization of National & facility level electronic recording & reporting systems to identify areas for QI  Integrate QI in the existing clinical mentorship system  QI team  Coordinates, monitors implementation  Selects sites for inclusion based on transition monitoring data & priorities of MoH  Phased approach to implementation: 9 sites in first phase

 Facility level recording systems:  IQ chart  Open MRS  National level reporting system  Tracnet

Cell Phone PCs/ Internet PDA/ Smartphone A GoR information system that supports the national HIV/AIDS and other health programs. Builds on existing telecommunications infrastructure Allows TRACplus to: Collect real-time information from the field via web, phone, mobile application, paper... Communicate and send alerts and information back out to the field in a timely and systematic way. View Rapid visualization of data – in charts, tables, graphs and dashboards Local Applications Phone

 Baseline and follow up data & training  Source: Trac net, IQ chart and Open MRS  Validation of clinical performance data  Site-level prioritization, gap analysis & changes to improve care  Coaching Visits  Peer learning meetings

% infants born to HIV INFECTED mothers who are tested for HIV using DNA PCR at 6-8 weeks % HIV INFECTED pregnant women that receive ARV prophylaxis % lost to follow ups among patients in Pre-ART care who are enrolled into care 4-15 months prior to assessment period % ART patients still on treatment 12 months after initiation % patients on ART who receive CD4 cell count measurement 6 months after being initiated on ART % patients who received ARVs for 12 out of 12 months

Onsite trainin g Monthly & quarterly visits Quarterly data validation exercises QI indicators Tracnet indicators

May Jun e July Aug. Sept Oct. Nov. Dec. Jan. Feb. March April May June Basic QI Training 9 Sites Coaching Visits 9 Sites Performance Measurement Training 9 Sites Baseline Data Collection 9 Sites 9 Month Data Collection 9 Sites Data Validation 9 Sites 6 Month Data Collection 9 Sites QI Project Activities & Timeline Baseline Data Collection 15 Sites

Lack of harmonized appointment system In adequate provider & patient appointment reminder system Appointment registers with list of expected patients-not available: CD4 & clinical follow up visits

 In sufficient use of the ARV drug pick up appointment book ( table on the next slide)  Lack of early patient tracking mechanism  Relatively long waiting time in some clinics  Patient- level service satisfaction survey  Not routinely conducted  Utilization of site level data:  to systematically improve quality of service

N o. NameTrac net Number ART regimen/cotrimo xazole

Site Level: Waiting time reduced Patient with missed appointments contacted early 2 days after the actual date of appointment Grouping of patients for appointments (table on the next slide)

Easy identification of patients with repeated missed appointments Solicited feedback from patients Harmonized clinic visits Utilization of site level data : Using QI approaches and methods National Level: QI integrated in clinical mentorship guideline & program

Identific ation Trac Net Nu mbe r SexAge Date of appointment ( mark √ if patient comes on the exact date, if not leave it blank & write the date when she/he comes in the blank space Next Date of appo intm ent Next date of appo intm ent Next Date of appoin tment

QI program improves country capacity & ownership by supporting MOH staff & health workers to: incorporate performance data, patient feedback and, a system approach to improve quality of care utilize real time accessible health data for decision making The 6,9, 12, 18 and 24 months follow up data show improved results on CD4 control indicator

 Improvement goals can be achieved  Leadership: a key component to support site-level program ownership  Patient feedback enhances improvement effort  MoH-Rwanda  Scale-up QI to additional facilities,  Develop district level pool of coaches

MoH Rwanda RBC/IHDPC/HIV Division HQ-I CDC-Rwanda The pilot sites ICAP IHV/UMB

Thank You Murakoze Merci