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Improving the Retention of Patients on Anti-retroviral Therapy (ART): A Case Study from the Democratic Republic of Congo (DRC)

Case Study by James Heiby, Medical Officer in the Office of Health Systems in the Global Health Bureau of USAID 

James Heiby serves as Medical Officer in the Global Health Bureau of the US Agency for International Development (USAID), the foreign assistance agency of the US government. He developed and continues to manage the Bureau's program for applying quality improvement in USAID's health assistance. Prior to joining USAID in 1978, Dr. Heiby worked in the Bureau of Epidemiology at the Center for Disease Control. He received an MD degree from Johns Hopkins and a MPH from Harvard.  


This case study describes how the Ministry of Health in the Democratic Republic of Congo used a common QI approach based on teams of providers who are given a mandate to test changes in the design of health care processes. The mandate for these teams is to identify promising improvements in HIV services.

Please read the case study below and consider the following questions:

The Ministry of Health (MOH) in the DRC supports an extensive clinical treatment program for patients with HIV/AIDS. Of the 26 provinces in the country, Lualaba Province, on the southern border, was one that was selected by the MOH to receive external technical assistance to improve the quality of care received by HIV patients. The MOH and its external advisors agreed that the support for HIV services would focus on the service delivery processes for HIV, rather than providing material resources, such as drugs or travel payments—a quality improvement (QI) strategy. The MOH used a common QI approach based on teams of providers who are given a mandate to test changes in the design of health care processes. The mandate for these teams is to identify promising improvements in HIV services . Such improvements usually increase the effectiveness or efficiency of widely-used care processes. Facility-based provider teams, in turn, are supported by trained supervisors, referred to as “coaches.” QI strategies often include arrangements for teams to learn from the experiences of other teams, resulting in the rapid spread of successful changes. Such spread can also increase the cost-effectiveness of QI since the initial step of identifying improved care processes is the most resource-intensive.
In Lualaba, health officials identified low levels of retention of the patients that started ART as the focus of the QI effort. At any point in time, only about 40% of active patients on ART met the program’s definition of successfully retained over the long-term. Since HIV is not cured by current treatments, an effective program for clinical control would be expected to accumulate a large population of old patients, who would remain on lifetime treatment. The treatment provided in Lualaba could be labeled “usual care,” which followed established patterns used in the health system for a wide range of conditions, usually acute infectious diseases. The effective management of HIV, however, requires a chronic care model. But program managers did not monitor the coverage of the ART program and had not developed a program response for the many patients who dropped out of care.

As the first step in addressing low retention of ART patients, program managers began monitoring the number of patients receiving care on an ongoing basis. As the primary quality indicator, they adopted the percentage of ART patients retained on care in 10 sentinel sites, measured monthly. The managers then organized and trained facility improvement teams to test changes in care processes by measuring their impact on patient retention in the 10 sites. The teams met periodically to share findings, particularly those related to changes that increased retention.

Although the facility improvement teams had no prior experience with QI, and received only brief training and monthly visits by coaches, these teams demonstrated impressive insight into the care processes that they had long implemented, often for years. With the support of the coaches, these teams of providers were able to measure the impact of the changes they were testing on their chosen quality indicator. In general, the teams tested one change at a time until it produced a clear result, either positive or negative.

The most successful changes included:
• Replacing the program’s monthly AIDS day with individualized appointments for ART patients
• Eliminating registration procedures for returning patients
• Initiating a monthly review and analysis of service data in each facility
• Assigning a senior health professional responsibility for managing clinical and program information
• Establishing a separate patient register for ART
• Establishing a central appointment book
• Initiating home visits by clinic staff to promote retention
• Routinely following up when patients missed reminder phone calls about their appointment  

After a four month baseline observation period, during which retention remained at about 40%, these improvements were adopted and maintained by virtually all of the facilities. Over a six month period, the overall level of ART patient retention in Lualaba rose to nearly 90%, and remained at that level for an additional five month observation period.

During the implementation period, the external QI advisers observed that the DRC facility teams demonstrated key elements of performance associated with familiar QI principles. These included development of detailed QI plans, and thorough documentation of the changes tested. The advisers also judged the teams to be “functional,” exhibiting a set of organizational behaviors associated with successful QI efforts in a wide range of settings, such as clear job descriptions. As with many other countries, the DRC teams of regular providers selected for this QI program required specific training in data collection and analysis. Another common issue that was also seen in the DRC was the shortage of data collection tools, which were then provided by an external agency. The providers also needed training in the use of these tools. With these minor accommodations, the QI teams in the DRC produced impressive improvement in health care quality. 

(Please note all answers must be a minimum of 100 words)
1. The case describes an improvement strategy that is focused on "service delivery processes for HIV." Select a high-level component of HIV care, such as clinical history or the follow up of patients who missed appointments. For the chosen component, list the concrete service delivery processes that make up this component.  

2. From your list of concrete service delivery processes, randomly select a sample of five and develop a quantitative measure of the outcome of each process.

3. For each of the five selected process outcome measures, describe in a paragraph how you would use tests of change to develop potential improvements.

4. The case refers to the chronic care model for managing HIV over the long term. What are the main features of a health system strategy for providing care to patients with a chronic condition? 

5. From the perspective of an improvement team, what do you want to learn from other teams that have had good results?  Do teams that had negative results have anything to teach you? How important is documentation for learning from other teams?

6. The case lists the most successful changes made by this group of improvement teams. Do unsuccessful changes have anything to teach us?

7. The case refers briefly to how "functional" the improvement teams were. What features contribute to a functional improvement team?