Enhancing the culture of multi-disciplinary workshops on using data for decision-making: Tanzanian efforts to improve completeness of CD4 assessments Molly Strachan, ICAP Tanzania M&E Technical Meeting Johannesburg, South Africa July 28, 2010

Outline CD4 Data Challenges in Tanzania Data sharing meeting concept Data sharing meeting agenda Meetings Results Conclusion

Proportion of patients with CD4 count at baseline, 6, and 12 months after ART initiation (subset of ART patients*) Percent of patients with CD4 count n=19,026n=11,927 n=908 n=17,789 n=13,294 n=15,193 n=11, ,836 n=36,904 Source: ICAP URS March 2010 Notes: * Data only included for patients who were followed for 12 months. n=33,216

Percentage of patients with CD4 count in 6 and 12 month cohort, Jan-Mar %49%24%69%43%73%40% 45% 24% 38% 23%

SITE 1 80/80 64/80 68/80 65/80 100% 80% 85% 81.3% SITE 2 28/28 0/28 13/28 1/28 100% 0% 46.4% 3.6% SITE 3 294/ / / / % 90.5% 86.4%90.1% SITE 4 356/ / / / % 83.1% 57.6% 54.8% Lab Register Lab Slips In Patient File CTC2 Card NACP Database Example from CD4 Data Flow Analysis at 4 ICAP sites in Kagera

Data Sharing Meeting Concept Started in 2008 as 2-day meeting to review all data per region; held on a semi-annual basis Purpose: Increase data use towards improvement of program quality and planning Participants: regional and district AIDS coordinators, health mgmt teams, site staff + ICAP regional team (M&E + program) ICAP presents regional data, district present data for their district and sites Strengths and weaknesses discussed and action plans developed

Data Sharing to Strengthen & Improve CD4 Testing Kagera (May 11; x attended), Kigoma (May 31; 82 attended), Zanzibar (July 2), Pwani (TBD) Agenda: – Review national guidelines on CD4 testing – Share best practices from other partners and countries – Data Feedback: Regional and district trends, district trends for 6 month F/U (award to highest performing district) – Presentation of CD4 database – Group work (by district): SWOT analysis & action plan – Way Forward: Short and Long term solutions

Changamoto (Challenges) Sample transportation (delays, no $, logistical issues) Broken CD4 machines Data flow & recording/reporting TESTS AREN’T GETTING ORDERED Priority to new enrollees (baseline) Reagent & supply stockouts Lack of knowledge that follow up CD4 is needed Unreliable power/water to run CD4 machines Weak systems for disbursing funds to sites Treatment supporters may pick up drugs at time CD4 is required PLHAs not informed of need for test

Proposed Short term Solutions Increased % of clients with CD4 Nurses/data clerks to update CD4 IMMEDIATELY in chart when results arrive back from lab Registration Nurse adds reminder note to file at registration Pharmacy staff review client card to remind clinicians to order test Adherence nurse to reinforce importance of CD4 to client Hold data reconciliation meetings between Lab & CTC staff to rectify reporting errors Implement registers at CTC to record lab samples & results Regular informed Supportive Supervision and Mentoring at sites Regular MDT meetings

Proposed Long Term Solutions Districts to develop logistics systems to disburse funds to sites Sites to prepare their annual plans and budgets and include sample transportation and other needs (CD4 machines, other equipments, solar power etc)

Conclusions: General Multi-disciplinary meetings prove a successful forum for program improvements using an evidence-base Enabled ICAP to illustrate that if sites can test a high proportion of patients at baseline there’s no reason for lower proportions at follow up Focusing on one topic enabled teams to develop actionable workplans to address program weaknesses Highlighted need for focussed follow up support by ICAP clinical teams on key elements of patient care

Conclusions: Capacity Building Increased political support for improving quality of care by regional and district leaders – Kagera Regional Medical Officer: Called for comparison of trends for upcoming quarter to last quarter to note improvements – Kigoma Regional Medical Officer: Highlighted importance of adequate budgeting and district work planning to ensure consistent supplies and funding at sites – Zanzibar Program Manager: Noted usefulness to help improve services Called for regular data sharing meetings to share strategies for addressing challenges Built capacity for cohort reporting – Sites compiled cohort data (complex). – Data sharing meeting reinforced proper steps to prepare cohort report which may strengthen follow through on submitting this report to NACP