USAID ASSIST Project Democratic Republic of Congo Final Country Report
Cooperative Agreement Number: AID-OAA-A-12-00101
Performance Period: October 1, 2013 – September 30, 2016
DECEMBER 2016
This final country report was prepared by University Research Co., LLC for review by the United States Agency for International Development (USAID). The USAID Applying Science to Strengthen and Improve Systems (ASSIST) Project is made possible by the generous support of the American people through USAID.
USAID ASSIST Project
Applying Science to Strengthen and Improve Systems Democratic Republic of Congo Final Report
Cooperative Agreement Number AID-OAA-A-12-00101 Performance Period: October 1, 2013 - December 31, 2016
DECEMBER 2016
DISCLAIMER This country report was authored by University Research Co., LLC (URC). The views expressed do not necessarily reflect the views of the United States Agency for International Development or the United States Government. Acknowledgements This final report was prepared by University Research Co., LLC (URC) for review by the United States Agency for International Development (USAID) under the USAID Applying Science to Strengthen and Improve Systems (ASSIST) Project, which is funded by the American people through USAID’s Bureau for Global Health, Office of Health Systems. The following URC staff provided improvement technical assistance in Democratic Republic of Congo: Dr. Teddy Manday, Cecile Edambolo, Elie Twite from the Kinshasa Office; Aime Eyane and Cyprien Tendo, from the Haut Katanga office, and Fidele Kanyanga and Julien Saleh from the Lualaba office.URC regional staff based in Niger provided technical support for ASSIST activities in the Democratic Republic of Congo: Maina Boucar, Zakari Saley, and Sabou Djibrina. Support for the preparation of this final report was also provided by Mayssa el Khazen and Silvia Holschneider of URC. The USAID ASSIST Project is managed by URC under the terms of Cooperative Agreement Number AID-OAA-A-12-00101. URC's global partners for USAID ASSIST include: EnCompass LLC; FHI 360; Harvard T.H. Chan School of Public Health; HEALTHQUAL International; Initiatives Inc.; Institute for Healthcare Improvement; Johns Hopkins Center for Communication Programs; and WI-HER, LLC. For more information on the work of the USAID ASSIST Project, please visit www.usaidassist.org or write [email protected]. Recommended citation USAID Applying Science to Strengthen and Improve Systems (ASSIST) Project. 2016. Democratic Republic of Congo Final Report. Published by the USAID ASSIST Project. Bethesda, MD: University Research Co., LLC (URC).
Table of Contents List of Tables and Figures ...... i Abbreviations ...... ii 1 INTRODUCTION ...... 1 2 PROGRAM OVERVIEW ...... 1 3 KEY ACTIVITIES, ACCOMPLISHMENTS, AND RESULTS ...... 2 Activity 1. Quality improvement technical assistance for integrating NACS into HIV care and treatment services ...... 2 Background ...... 2 Key Accomplishments and Results ...... 2 Activity 2. Improve HIV care and treatment for people living with HIV (PLHIV) ...... 6 Background ...... 6 Key Accomplishments and Results ...... 7 Activity 3. Build capacities at all levels in QI and related health system strengthening ...... 15 Background ...... 15 Key Accomplishments and results ...... 15 IMPROVEMENT IN KEY INDICATORS ...... 16 4 SUSTAINABILITY AND INSTITUTIONALIZATION ...... 17 5 KNOWLEDGE MANAGEMENT PRODUCTS AND ACTIVITIES ...... 17 6 GENDER INTEGRATION ...... 18
List of Tables and Figures Table 1:Changes implemented at NACS target sites (July-Sept 2014) ...... 3
Figure 1: Percentage of PLHIV assessed correctly according to standards (anthropometric, clinical, and food security) at 4 sites in Lubumbashi (Jan 2014-Sept 2014) ...... 4 Figure 2: Percent of PLHIV who received a nutritional assessment according to norms, 9 NACS sites, Kinshasa Province (Jan – Sept 2015) ...... 6 Figure 3: Quality gaps among the HIV continuum of care, 39 sites, Kinshasa, Katanga and Orientale provinces (sample: 1,048 patient files) (July-Aug 2015) ...... 8 Figure 4: Percentage of items filled in files of patients coming for ART follow-up, 39 sites, Kinshasa, Katanga and Orientale provinces (sample: 1,048 files) (July – Aug 2015) ...... 8 Figure 5: Percentage of PLHIV retained on ART, Lualaba, by Health Zone, 10 sites (Aug 2015 - Sept 2016) ...... 11 Figure 6: Percentage of PLHIV retained on ART by sex, Lualaba, 10 sites (Aug 2015 - Oct 2016) ...... 12 Figure 7: Percentage of PLHIV retained on ART by sex in Lualaba provincial referral hospital (HPK) (Aug 2015 - Oct 2016) ...... 13 Figures 8: Evolution of the retention gap in ART clients, 10 sites, Lualaba Province, Aug 2015 – Oct 2016 ...... 14
USAID ASSIST Democratic Republic of Congo Country Report FY16 i Abbreviations ART Antiretroviral therapy ARV Antiretroviral ASSIST USAID Applying Science to Strengthen and Improve Systems Project DRC Democratic Republic of the Congo FANTA Food and Nutrition Technical Assistance Project FY Fiscal year HIV Human immunodeficiency virus IP Implementing partner KM Knowledge management LIFT Livelihoods and Food Security Technical Assistance Project MNCH Maternal, newborn, and child health MOH Ministry of Health MSH Management Sciences for Health NACS Nutrition assessment, counselling, and support PEPFAR U.S. President’s Emergency Plan for AIDS Relief PLHIV Persons living with HIV PMTCT Prevention of mother-to-child transmission of HIV PNLS National AIDS Control Program PNMLS National Multisector AIDS Control Program PROSANI Projet des Soins Intégrés (Integrated Health Program) ProVIC Integrated HIV/AIDS Project Q Quarter QI Quality improvement QIT Quality improvement team TA Technical assistance URC University Research Co., LLC USAID United States Agency for International Development
ii USAID ASSIST Democratic Republic of Congo Final Report 1 Introduction The USAID Applying Science to Strengthen and Improve Systems (ASSIST) Project, managed by University Research Co., LLC (URC), provided technical assistance to the Ministry of Health (MOH) in the Democratic Republic of Congo (DRC) from October 2013 to December 2016 to improve nutrition services for HIV clients and improve HIV care and treatment services for persons living with HIV (PLHIV). In fiscal year (FY) 2014, the USAID ASSIST Project worked collaboratively with FHI 360’s Food and Nutrition Technical Assistance Project (FANTA) and Livelihoods and Food Security Technical Assistance project (LIFT) to improve nutrition services for HIV clients through the integration of nutritional assessment, counselling, and support (NACS) into HIV care and treatment. Together they prepared and delivered trainings, developed tools, and monitored the integration of the NACS approach at 16 targeted health facilities in the DRC. ASSIST jointly with these partners also supported the MOH in the DRC to improve quality of nutrition services for HIV clients through the integration of NACS into HIV care and treatment. In FY15, ASSIST expanded work to improve nutrition services for HIV clients by scaling up best practices to new sites in Kinshasa and Katanga provinces in partnership with LIFT and FANTA. ASSIST was also asked to improve prevention of mother-to-child transmission of HIV (PMTCT) services and retention in care assuring good adherence to antiretroviral therapy (ART) for PLHIV, including children and key populations, in targeted facilities in Orientale and Katanga provinces. This was done in collaboration with the Integrated HIV/AIDS Project (ProVIC) implemented by PATH and the Management Sciences for Health (MSH)-led Project de Santé Intégré (PROSANI, Integrated Health Project). In FY16, ASSIST shifted its focus to address only improvement in HIV care and treatment services for PLHIV in targeted sites in three provinces: Haut-Katanga, Lualaba, and Kinshasa. This work was conducted with ProVIC and PROSANI. In addition, work was focused on strengthening the capacities of national, provincial and Health Zone managers and providers to apply improvement skills. In the first quarter of FY17, ASSIST only worked in the province of Lualaba until the project closed down at the end of December 2016. The technical content was the same as in in FY16. 2 Program Overview What are we trying to accomplish? At what scale? 1. Quality improvement (QI) technical assistance for integrating NACS into HIV care and treatment services Improve management and nutritional status of Provinces: 2 out of 11 (Kinshasa and Katanga) malnourished HIV clients by: Districts: 6 out of 13 in 2 provinces Integrating NACS into facility-based ART, Facilities in selected districts: 16 out of 494 (3%) PMTCT and maternal and child health Catchment population: 597,000 out of services 19,900,000 2. Improve HIV care and treatment for people living with HIV
Improve HIV services and retention in care and FY 15: (Phase 1) assure good adherence to therapy for all people Provinces: 3 out of 11 (Kinshasa, Province living with HIV in target facilities in collaboration Orientale and Katanga) with other implementing partners (IPs) Districts: 5 out of 17 in 3 provinces Facilities in selected districts: 35 out of 335 (10%) Catchment population: 1,689,798 out of 16,897,975 FY 16: (Phase 2) Provinces: 3 out of 26 provinces (Kinshasa, Haut-Katanga, and Lualaba)
USAID ASSIST Democratic Republic of Congo Final Report 1 Health zones: 4 out of 35 in Kinshasa; 8 out of 28 in Haut Katanga; 2 out of 14 in Lualaba Facilities in selected Health Zones: 39 out of 393 (10%) 9 out of 144 health facilities in Kinshasa; 18 out of 256 in Haut Katanga; 12 out of 63 in Lualaba Catchment population: 5,448,112 out of 15,674,078 3. Build capacities at all levels in QI and related health system strengthening
Strengthen the capacities of national, National HIV Program (PNLS), provincial, and provincial, and district health managers and district levels care providers to apply improvement skills
3 Key Activities, Accomplishments, and Results Activity 1. Quality improvement technical assistance for integrating NACS into HIV care and treatment services BACKGROUND The nutritional assessment, counselling, and support approach aims to improve the nutritional status of targeted populations by integrating nutrition and economic strengthening activities into policies, programs, and health service delivery. FANTA, LIFT, and ASSIST worked collaboratively in the DRC to support and scale up a multi-sectoral approach to strengthen the continuum of care for HIV-affected populations. ASSIST supported the MOH to improve nutrition service delivery using quality improvement methods in 16 health facilities in Kinshasa and Katanga provinces. The project conducted periodic coaching visits to support Health Zones and facility teams and conducted learning sessions for the teams to share and learn from each other. KEY ACCOMPLISHMENTS AND RESULTS Conducted joint trip to DRC with partner organizations to determine NACS opportunities (FY14, Q2). At the request of USAID, FANTA, LIFT, and ASSIST made a joint trip to the DRC in order to assess opportunities to integrate NACS into HIV care and treatment services in the country, including referrals of NACS clients between health care facilities and economic strengthening, livelihoods, and food security support and Partners discussed the nutritional value of local food quality improvement of NACS services. for people living with HIV during a training for A joint work plan was developed from trainers and supervisors at the 16 target sites. Photo which ASSIST was tasked with developing by Zakari Saley, ASSIST, May 2015 these key activities: o Implement a collaborative improvement approach in Kinshasa and Katanga provinces for rapid improvement of NACS activities in 16 sites. o Build capacities of health system managers for QI institutionalization in the health system, with an initial focus on services for PLHIV. o Conduct supportive supervision and coaching sessions to improve quality of services.
2 USAID ASSIST Democratic Republic of Congo Final Report o Implement a NACS monitoring and evaluation plan to be integrated into the national monitoring and evaluation system. o Develop an extension plan based on lessons learned from initial NACS sites. Agreed upon target sites and provinces for the intervention (FY14, Q2). Sixteen (16) facilities were selected for the initial NACS intervention in the two provinces of Kinshasa and Katanga (city of Lubumbashi). Jointly conducted a training and site visits to introduce NACS integrated curriculum to target sites (FY14, Q3). ASSIST together with FANTA and LIFT introduced an innovative NACS integrated curriculum, including processes, economic strengthening, and quality improvement components. ASSIST along with partners trained 64 local trainers and supervisors from the 16 sites. In addition, the ASSIST team helped establish internal and external coaching teams for each site and defined their roles and responsibilities, as well as outlined next steps of the joint initiative. In Dec 2014, a joint coaching visit by ASSIST, FANTA, and LIFT was conducted in 16 NACS sites in Kinshasa and Lubumbashi. The coaching visit involved preparing quality improvement teams for their first learning session. Conducted coaches’ training and completed a joint visit to all target sites (FY14, FY15). o In FY14, Q4, ASSIST- trained coaches from the MOH and implementing partners conducted a visit to all the 16 target sites in both Katanga and Kinshasa provinces. o In FY15, Q1 After ASSIST built the capacity of the trainers (through the senior improvement advisor from the ASSIST regional office in Niamey), the trainers conducted coaching visits in Kinshasa and Lubumbashi. Provided technical assistance to newly-trained site representatives (FY14, Q4). The newly trained representatives from these sites implemented a variety of changes in order to create a positive environment for NACS activities (Table 1). Table 1:Changes implemented at NACS target sites (July-Sept 2014) NACS Improvement Changes implemented Objectives 1. Improve nutritional Reorganization of work to comply with NACS processes assessment of Assuring availability of essential inputs for anthropometric measures people living with (scales, height rods, mid-upper arm circumference measurement tape) HIV for adults and children at the point of contact with NACS target groups Job aids on anthropometric measurements and nutritional classification Modifying registers to add columns to record weight and other anthropometric measures to encourage providers to systematically consider these items Gradual integration of nutritional assessment in NACS target services Integration of arm circumference in the anthropometric parameters 2. Improve quality of Provision of nutritional counseling job aids (counseling map) by nutritional counseling GATHER during NACS Counseling according to the nutritional status of PLHIV after the activities nutritional classification 3. Improve support Setting a special register for nutritional surveillance of PLHIV activities Providing an additional register for PLHIV that contains information on the nutritional status of the patient Monthly report sent to the central office 4. Integrate NACS into Review of PMTCT process in order to integrate NACS activities PMTCT services Systematic assessment of the nutritional status of HIV-positive pregnant women at each visit Pregnant women with clear signs of malnutrition are evaluated and classified accordingly Figure 1 shows the progress of NACS indicator over a period of five months of collaborative (from May 2014) at four NACS sites.
USAID ASSIST Democratic Republic of Congo Final Report 3 Figure 1: Percentage of PLHIV assessed correctly according to standards (anthropometric, clinical, and food security) at 4 sites in Lubumbashi (Jan 2014-Sept 2014) 100 90 tly tly c s e d
rr 80 ar o d c assessed c 70 an st an 60
tog 50 n id 40 IV roc 30 ac PLVH 20 % 10 0 janv-14 fev-14 mars-14 avr-14 mai-14 juin-14 juil-14 aou-14 sept-14 # of PLHIV Assessed properly 0 0 1 0 1 13 59 43 76 according to standards Total PLHIV seen 11 15 14 15 18 52 74 52 76 at the facility % of PLHIV Assessed according to standards (Anthropometric, 0 0 7 0 6 25 80 83 100 clinical, food security) # of Sites Reporting 4 4 4 4 4 4 4 4 4
ASSIST organized the first trainers’ meeting in Kinshasa and Lubumbashi (Dec 2014). Discussions during the meeting centered on the trainers’ coaching experiences, functionality of QI teams, ideas tested, changes implemented, and challenges and constraints faced by QI teams. The opportunity was used to strengthen trainers’ capacity in QI, data validity, performance analysis, and documentation of changes. ASSIST organized the first learning session in Kinshasa and Lubumbashi (Dec 2014). Representatives from sites shared their work including changes implemented, level of their performance, and challenges encountered in trying to improve their performance and satisfy clients. Change ideas and lessons learned included: more effective integration of NACS into the PLHIV management and care processes; ensuring that equipment for anthropometric measures are in place; having nutritional monitoring sheets in place to document NACS items; deploying job aids for NACS; and having QI teams draw process diagrams to better visualize and understand their processes.
4 USAID ASSIST Democratic Republic of Congo Final Report The best QI team from Kenya General Referral Hospital in Lubumbashi, December 2014. Photo by Zakari Saley, URC.
ASSIST helped reformulate the aims of the project to be specific, measurable, achievable, realistic and timely in conjunction with the MOH and the two main PEPFAR partners, FANTA and LIFT (Dec 2014). ASSIST conducted two coaching visits in Kinshasa and Lubumbashi along with the National AIDS Control Program (PNLS) and the National Nutrition Program to help develop a sound QI plan and to guide QI teams to identify and test changes (July and Sept 2015). ASSIST, FANTA, LIFT, and ProVIC conducted two coaching visits in Kinshasa and Lubumbashi to review compliance with NACS norms and the existing environment to support quality NACS services (July and Sept 2015). ASSIST organized two meetings with FANTA and ProVIC in Kinshasa and Lubumbashi to discuss data quality and draw up lessons learned that should be shared with sites and coaches (June and July 2015). Figure 2 shows that changes tested yielded significant improvement in assessing nutritional status of PLHIV. Key changes that were tested included the following: o Nutritional assessment and organization of PLHIV according to norms o The expansion of the nutrition assessment to maternal and child care and reception o Patient record cards were updated to ensure that anthropometric measurements are routinely taken for all patients o All PLHIV must have anthropometric measurements documented on the back of their antiretroviral (ARV) drug prescription prior to pick-up at the pharmacy o Reform of the PLHIV reception process: HIV-positive patients will immediately proceed to doctor’s office for consultation instead of waiting in the reception area to be seen o Establishment of an HIV-nutrition shop: the package is entirely done by a nurse specialized in HIV activities in order to reduce wait time and fill the coverage gap
USAID ASSIST Democratic Republic of Congo Final Report 5 Figure 2: Percent of PLHIV who received a nutritional assessment according to norms, 9 NACS sites, Kinshasa Province (Jan – Sept 2015)
Activity 2. Improve HIV care and treatment for people living with HIV (PLHIV) BACKGROUND In FY15, ASSIST started an HIV care and treatment intervention in DRC. Between May and August 2015, ASSIST developed a protocol and seven assessment tools, in conjunction with the URC research and evaluation department. A training of trainers and data assessors was conducted. Before starting activities to improve retention in care and adherence to treatment, a baseline assessment was conducted to evaluate the quality of care provided to PLHIV at the facility level and to determine the strengths and weaknesses of support services. Data was collected in 39 sites throughout the three target provinces of Kinshasa, Province Orientale, and Katanga. ASSIST worked in Kinshasa, Haut-Katanga, and Lualaba provinces in 39 health care facilities in partnership with the MOH, PATH/ProVIC, and MSH/PROSANI to improve HIV care and treatment for PLHIV and ensure good adherence to therapy. The project provided technical support to these facilities in QI through the collaborative approach by supporting QI teams (QIT) to initiate, test, and implement changes, to reduce gaps in ART coverage, retention in care and well-being of PLHIV. As the technical and standard-setting body of the MOH on HIV/AIDS, the National AIDS Control Program is involved in the implementation process of the collaborative approach to ensure that it is consistent with national norms and guidelines on HIV care and treatment. The National Multisectoral AIDS Control Program [Programme National Multisectoral de Lutte contre le VIH/SIDA (PNMLS)], which ensures the coordination and the leadership of activities against HIV/AIDS in the DRC, is involved in QI activities to ensure advocacy, resource mobilization and institutionalization. The Provincial Health Division for Kinshasa, Haut Katanga, and Lualaba are also involved in their respective Health Zones to implement national norms and guidelines on HIV care and treatment. Once a month, ASSIST, PATH/ProVIC, MSH/PROSANI, and MOH coaches conducted a joint coaching visit to accompany QI teams in their work. ASSIST and Health Zones’ coaches organized follow-up visits to ensure that QI teams are well functioning, testing change ideas, implementing them, and documenting best practices. They closely monitored the quality of data being collected and the level of performance reached.
6 USAID ASSIST Democratic Republic of Congo Final Report KEY ACCOMPLISHMENTS AND RESULTS Built provisional consensus with USAID/PEPFAR in DRC, key IPs, and the MOH on ASSIST targeted content areas for improvement, provinces, and sites (Dec 2014). Based on the major constraints of PEPFAR implementing partners and USAID recommendations, improvement objectives were defined based on four areas: 1) Improve and reinforce NACS activities, 2) quality case management, 3) adherence of PLHIV to HIV treatment, and 4) retention in HIV care and treatment for PLHIV. Per consensus, it was determined that the work would focus on three target provinces and 38 sites: 10 sites in Kinshasa Province, 14 sites in Katanga Province, and 14 sites in Orientale Province. ASSIST developed assessment tools and conducted an assessment to evaluate quality of care provided to PLHIV (June-July 2015). ASSIST organized a training of trainers for baseline assessment data collection for HIV care and treatment (July 2015). Participants came from national, provincial, and operational levels of the targeted provinces. Seven participants from the Ministry of Health and five ASSIST technical advisors were trained as trainers on seven data collection tools. Once in the field, they trained 46 individuals as surveyors. A pre-test was organized, and supervisors oversaw data collection in 38 sites in Kinshasa, Katanga, and Orientale provinces. o 38 sites were evaluated in three provinces (Kinshasa, Orientale, and Katanga), including 10 general hospitals, three provincial hospitals, 18 peripheral health facilities, five referral health facilities, and two hospital centers. Among these sites, 16 were urban, seven rural, and 15 urban- rural; 4,560 patient charts were reviewed (July 2015). o The main focus areas of the baseline assessment were: enrollment in treatment; adherence to initial assessment norms; adherence to clinical, treatment, and follow-up norms; adherence to ART for PLHIV; adherence to appointments; retention in care; drug procurement; and enabling environment for quality. Seven assessment tools were used: general information, interview with the PMTCT in-charge, adherence to initial evaluation norms for HIV-positive patients, adherence to norms for follow-up of adult patients on ART, six-months trends for some indicators, chart reviews for a cohort of patients on ART, and chart reviews for a cohort of patient on pre-ART. The data from the baseline assessment are currently being analyzed. Conducted a baseline assessment and analysis for 39 health care facilities (Kinshasa, Katanga and Orientale provinces) (July-Nov 2015). ASSIST in collaboration with the DRC MOH (National AIDS Control Program and National AIDS Multisector Control Program) conducted a baseline assessment to identify strengths and weaknesses of HIV services in PEPFAR targeted provinces. HIV-positive patient records were reviewed for those receiving ART treatment and those who were not being treated according to the national standard norms set by the government. The baseline assessment results were presented to the USAID Mission in DRC, PNLS, PEPFAR IPs who are working in collaboration with ASSIST (PROSANI and ProVIC), provincial health management teams, other stakeholders, health zones, and health facilities assessed. The analysis for the baseline assessment was finalized between September and November 2015. Organized a three-day workshop in each of the three provinces to share baseline findings (Nov 11-13, 2015 in Kinshasa, Nov 17-19, 2015 in Haut Katanga, and Nov 21-23, 2015 in Lualaba). The objective was to share the baseline results and orient providers and managers from target health care sites, health zones, provinces, and the central level of MOH on: (1) quality improvement, (2) HIV gaps analysis framework, and (3) the improvement package. Participants included PNLS staff, PNMLS, 5th Directorate of the MOH (national health information system directorate-QI unit), health provincial divisions, Health Zones, PATH/PROVIC, PROSANI, ICAP and Glaser Foundation staff. The three workshops were facilitated by the Regional Director and a Senior Improvement Advisor, both from the ASSIST regional office for Francophone Africa and ASSIST DRC staff. As a result of these workshops: o 137 health care providers and 8 individuals from IPs were oriented o A quality improvement team was set up in each targeted health care facility under the supervision of the related Health Zone o A QI plan with improvement objectives, change ideas, timeline, indicators and person responsible was developed by each facility according to its HIV care and treatment initial process diagram
USAID ASSIST Democratic Republic of Congo Final Report 7 Data showed key quality gaps among the HIV continuum of care (Figure 3) and for HIV-positive patients under ART treatment follow-up (Figure 4). The results were first shared with the USAID Mission in DRC, then key IPs and the MOH. Figure 3: Quality gaps among the HIV continuum of care, 39 sites, Kinshasa, Katanga and Orientale provinces (sample: 1,048 patient files) (July-Aug 2015)
Figure 4: Percentage of items filled in files of patients coming for ART follow-up, 39 sites, Kinshasa, Katanga and Orientale provinces (sample: 1,048 files) (July – Aug 2015)
• The 39 sites evaluated include 10 general hospitals, three provincial hospitals, 18 peripheral health facilities, five referral health facilities, and two hospitals centers. Among these sites, 16 were urban, seven rural and 15 urban-rural; 4,560 patient charts were reviewed. Key findings from the baseline assessment include: o Counseling / Screening • HIV is not integrated to care processes in health facilities; many missed opportunities for screening
8 USAID ASSIST Democratic Republic of Congo Final Report • Only 30.8% of surveyed sites claim to offer specific services for key populations (commercial sex workers, men having sex with men, and intravenous drug users) and only 25.6% offer services for orphans and vulnerable children o Linkage and initial assessment • TB diagnosed in 56% of the sites • CD4 in 51% of sites • Viral load in 5% of sites • CPR in 0% sites • Basic laboratory tests in pre-treatment such as renal function tests (10%), liver (9%) and blood count (8%) are limited o Pre-ART • 53.1% of pre-ART patients missed at least one follow-up visit • 9% of pre-ART patients are lost to follow-up (that is, three successive missed appointments) • Only 30% of non-eligible patients are monitored once per month in the first three months • Pre-ART files are not complete (n = 565 cases) including: the date of laboratory tests (49.9%); the final weight (43.5%); the TB status at last consultation (33.8%); initial CD4 result (48.5%); last CD4 last result (26.2%) o ART • 43.6% of sites experienced ARV drug stock-outs in the last three months preceding the survey • 36% of ARV drug stock cards are outdated • 35.2% of patients missed at least three successive visits while patients classified as "lost" are 5% • Only 7% of patients are looked for after each missed visit • The dosage of prescribed ARV drug is respected in 66.2% of cases • Low biological monitoring of patients on ARV drugs (e.g., CD4 latter in 34.4% of cases, and viral load 0%) • Low clinical monitoring of patients on ARVs (e.g., weight 54.9%, TB status at the last visit 36.5%) • The evaluation of adherence to treatment is recorded at the last visit in only 14.3% of cases o Tuberculosis • The diagnosis of TB is only available in 22 of 39 sites (56%) • The TB status checked and inserted into the register at the last consultation among only 35.6% of patients on ART • Only 18.5% of TB patients are put on anti-TB treatment • Isoniazid prophylaxis of HIV patients, although recommended by national standards, is provided in one of 39 (2.6%) sites Conducted monthly coaching visits in each of the improvement collaborative facilities (Dec 2015 – June 2016, Sept 2016). ASSIST provided support for coaching visits to ensure that QI activities in 39 health facilities, in 14 Health Zones within the three provinces are effective. To improve ART coverage, the retention of patients in care and their wellness, ASSIST continued to provide technical support to Health Zones’ coaches to ensure that the national minimum package of HIV care (nutrition, cotrimoxazole, screening for TB, OVC care, psychosocial support, management of opportunistic infections) was implemented at all 39 health facilities. During these visits, QI teams used the Plan-Do-Study-Act (PDSA) cycle to test and document changes. In Lualaba Province, particularly, there was a lack of data collection tools and a high number of HIV positive clients on ART lost to follow-up. Many health providers were not oriented on how to fill in the data collection tools. To resolve these challenges, in April and May 2016, ASSIST in collaboration with health provincial division of Lualaba and MSH/PROSANI, conducted an audit of PLHIV in all the improvement collaborative facilities in the province to determine the exact number of patients on ART. PROSANI provided the facilities with data collection tools in June 2016. ASSIST then oriented health providers on site during coaching and follow up visits on how to fill in the tools. Health facilities and health zones developed QI plans (Feb 2016).
USAID ASSIST Democratic Republic of Congo Final Report 9 USAID conducted SIMS visits in high volume sites in Kinshasa (Elonga Health center) Haut Katanga (Kamalondo General Hospital), and Lualaba provinces (Mwangeji and Gecamines Hospitals) (April, June 2016). The DRC USAID team’s most important finding was that all QI teams visited were functional, developed their QI plans, and are documenting changes. The ASSIST team continued to support QI teams to document changes, and provided health zone management teams with technical assistance to develop their respective QI plans. Another SIMS visit was conducted in Lualaba Province (July 2016) in Manika health center, Luilu, Mupanja and Kawama health centers. Findings from the USAID visit showed: the unavailability of HIV data management tools and poor record of HIV data; poor archiving files; a discrepancy between the data source documents, transmission and compilation; low HIV screening of children, poor documentation and tracking of PLHIV lost to follow up, reference of key populations from the community to health facilities; the lack of integration of nutritional assessment counselling and support activities; non-functionality of PLHIV support groups; the absence of procedures for archiving ARV drugs provision to PLHIV. It was observed in all sites visited that the monitoring of the outcome of exposed children 6 weeks after breastfeeding to assess the number of infections averted is not done. It was highly recommended for ASSIST to integrate QI activities within new health facilities in Lualaba Province. Organized a meeting with PROVIC/PATH to reinforce partnership on QI activities in colocation facilities (June 2016). ASSIST provided feedback on PROVIC/PATH’s annual work plan for the period from April 1, 2016 to March 31, 2017, mainly concerning QI activities. Conducted the first learning session in each province: Lualaba, Kinshasa, and Haut Katanga (July, Aug 2016). A total of 170 participants including QI teams’ members, managers from Health Zones, health provincial divisions, National AIDS Control Program, National Multisector AIDS Control Program, implementing partners (PATH and MSH) participated in the session. A gender specialist from ASSIST HQ participated in the Kinshasa learning session to discuss integrating gender in QI. QI teams presented results on reducing ART coverage and retention gaps in each province. The best QI team was identified. A “synthesis of successful changes” was developed for hospitals and health centers. Figure 5 shows the percentage of PLHIV retained on ART in Lualaba, by Health Zone. is the first time that a time series was plotted to show gaps in retention. Discussions among providers and between patients and providers found many reasons clients did not return for services: poor treatment at the facility, stock-out of drugs, and insufficient data requiring considerable improvement. Examples of changes introduced included data audit, patients’ files updated regularly, and identifying a person in charge of information and documentation. The changes implemented to achieve the results in Figure 3 include: o Introduction of a four-day appointment personalized for PLHIV instead of only one day per month for all PLHIV o Returning patients with old cases are directly welcomed without administrative formality at reception o Conduct monthly internal data audit and analysis in each facility o Update regularly patients’ files o Identify a nurse in charge of information and documentation o Set up a register for patient ART provision o Create an appointment agenda o Organize home visits o Call clients frequently at different times during a day
10 USAID ASSIST Democratic Republic of Congo Final Report Figure 5: Percentage of PLHIV retained on ART, Lualaba, by Health Zone, 10 sites (Aug 2015 - Sept 2016)
100% Dilala Health Zone 90% 80%
70% Lualaba Province 60% 50% 40% 30% Manika Health Zone 20%
10% Start of improvement work 0% Aug-15 Oct-15 Dec-15 Feb-16 Apr-16 Jun-16 Aug-16 Oct-16
3,000 2,000 1,000 0 Aug-15 Oct-15 Dec-15 Feb-16 Apr-16 Jun-16 Aug-16 Oct-16
Figure 6 shows the disaggregation by sex of PLHIV retained on ART in 10 facilities in the province of Lualaba. It shows that that ART retention for both males and females increased from August 2015 to October 2016, and a clear gap with fewer males than females retained on ART. Change ideas to target gender-related issues were not implemented across sites.
USAID ASSIST Democratic Republic of Congo Final Report 11 Figure 6: Percentage of PLHIV retained on ART by sex, Lualaba, 10 sites (Aug 2015 - Oct 2016) Rate of retention of males living with HIV on ART Rate of retention of females living with HIV on ART Total rate of retention of people living with HIV on ART 100%
80%
60%
40%
20% Start of improvement work 0% Aug-15 Oct-15 Dec-15 Feb-16 Apr-16 Jun-16 Aug-16 Oct-16
Number of males living with HIV on ART Number of females living with HIV on ART Total number of people living with HIV on ART 5000
0 Aug-15 Oct-15 Dec-15 Feb-16 Apr-16 Jun-16 Aug-16 Oct-16
Figure 7 shows us the percentage of PLHIV retained on ART by sex in the Lualaba provincial referral hospital.
12 USAID ASSIST Democratic Republic of Congo Final Report Figure 7: Percentage of PLHIV retained on ART by sex in Lualaba provincial referral hospital (HPK) (Aug 2015 - Oct 2016)
Rate of retention of males living with HIV on ART Rate of retention of females living with HIV on ART Total rate of retention all people living with HIV on ART 100% 90% 80% 70% 60% 50% 40% 30% 20% Start of improvement work 10% 0% Aug-15 Oct-15 Dec-15 Feb-16 Apr-16 Jun-16 Aug-16 Oct-16
Number of males living with HIV on ART Number of females living with HIV on ART Total number of people living with HIV on ART
2000
0 Aug-15 Oct-15 Dec-15 Feb-16 Apr-16 Jun-16 Aug-16 Oct-16
USAID ASSIST Democratic Republic of Congo Final Report 13 Figure 8 shows the evolution of the gap retention in the province of Lualaba. Since the launch of the collaborative, there was better documentation and tracking of patients on ART. However, from July to Sept 2016, the number of expected ART clients increased significantly but the number of active ART clients decreased. Figures 8: Evolution of the retention gap in ART clients, 10 sites, Lualaba Province, Aug 2015 – Oct 2016
3265 3179 3141 3031
2620 2631 2523 2536 2474 2475 2421 2358 2315 2221 2249
1908 1871 1814 1822
1576 1566 1425 1343 1360 1293
1055 1075 944 900 858
ASONDJFMAMJJASO
Number of expected ART clients Number of active ART clients
14 USAID ASSIST Democratic Republic of Congo Final Report Activity 3. Build capacities at all levels in QI and related health system strengthening BACKGROUND ASSIST actively continued to engage national policy makers, provincial, and Health Zone managers in all phases of the improvement work. ASSIST supported and trained Health Zone managers, and provincial, and central level supervisors not only on coaching techniques but also on sustaining and institutionalizing improvement in the DRC health system. MOH managers and coaches at different levels of the health system, with support from ASSIST, are responsible for implementing plans for improving quality of all of the target services. Each QI team was provided with sufficient support so that they are able to conduct improvement activities independently of ASSIST staff members to address ongoing technical and system level gaps. Building capacity from lessons learned and from the institutionalization of these practices is strengthening the health system at all levels and providing information and evidence to inform strategic planning at the Health Zone, provincial, and central levels. To ensure the quality of data, ASSIST provided monthly technical support for data validation at facility, and Health Zone levels. Once a quarter, this support was also provided to the provincial and central levels. ASSIST also provided technical support to the MOH General Secretariat to develop a draft document on DRC National QI Policy and Strategies. KEY ACCOMPLISHMENTS AND RESULTS ASSIST developed capacity of district supervisors as coaches for NACS activities (June 2015). ASSIST oriented IP supervisors in coaching and NACS data management (May 2015). As part of the sustainability and institutionalization of the project, supervisors from Health Zones and IPs were trained in coaching techniques. The training consisted of analyzing a coaching visit step by step and reviewing points discussed during the last visit. Provided QI and knowledge management training to key MOH staff including Health Zone and provincial managers/supervisors/coaches (Nov 2015). These staff participated in developing the aims, indicator, and provisional content package. The objective of the training was to orient participants on their future role as coaches: o Some key staff from the MOH were also used to review the baseline assessment results prior to being shared with larger groups o A total of 40 individuals from all targeted Health Zones and provincial managers and supervisors were oriented on QI collaborative in line with the baseline results. They were also oriented on general roles following coaching visit. Organized a three-day workshop in orientation of HIV collaborative coaches in Haut Katanga (February 11-13, 2016) and Kinshasa (February 17-19, 2016). The objective was to reinforce the capacities of 85 MOH managers at all levels and ASSIST DRC technical advisors on coaching techniques. The two workshops were facilitated by the Senior Improvement Advisor from the ASSIST regional office for Francophone Africa and the ASSIST Resident Advisor in DRC. Conducted an improvement seminar to engage the MOH particularly the central level on how to lead a reflection on the quality improvement (March 10, 2016). ASSIST Director, Dr. Rashad Massoud conducted the seminar which was attended by MOH director of planning, MOH Director of Primary Health Care and Health Information-QI unit, PNLS, PNMLS, USAID, CDC, ProVIC, PROSANI, FHI, EGPAF, and ASSIST DRC staff. All participants displayed strong commitment and interest in improvement. Supported the HIV/AIDS 2015 annual review organized by the National AIDS Control Program (April 2016) by printing documents that helped to integrate a QI component and multiplied the strategies, Provided technical and administrative support to the 2016 annual work plans of Haut Katanga and Lualaba provinces (April 2016). ASSIST ensured that the work plans integrate QI activities. Organized monthly internal data analysis meetings in each facility and provided technical assistance on data validation at Health zone and provincial levels (April, May, June 2016). To improve the quality of data, ASSIST provided technical and administrative support to facilities to
USAID ASSIST Democratic Republic of Congo Final Report 15 organize monthly meetings. The aim of the meetings was for facilities to internally analyze data for reliability and consistency with patient register records. Data were analyzed in 39 sites by QI team members, ASSIST, and Health Zone coaches before their validation at the Health Zone and provincial levels. Organized an experience exchange meeting (July 2016). The meeting took place in Uganda between the DRC MOH delegation and the Uganda MOH Quality Assurance Department (QAD). QI integration in the Uganda health system and ART framework implementation by ASSIST in Uganda were discussed. ASSIST provided technical, financial and administrative support to the MoH to develop or update QI tools and to organize annually the national QI meeting. This valuable experience was shared during a feedback meeting at the MOH national level (July 2016). Organized the first coaches’ meeting in Kinshasa, Haut Katanga and Lualaba between the MOH, ASSIST, MSH and PATH coaches (July- Aug 2016). The objective of this meeting was to evaluate the coaching visits that had been conducted by identifying strengths and weaknesses and learn how to improve coaching visits by providing technical guidance to QI teams to test changes and to document them. Organized the second coaches’ meeting of the province of Lualaba in Kolwezi (Nov, 10, 2016) which brought together both external and internal coaches of the two health zones in order to discuss the functioning of the coaching system in the province. The meeting evaluated assignments from the previous meetings. Organized the second Learning Session in Lualaba (November 11-13, 2016). This session brought together participants from the 12 target sites, Health Zone and Provincial managers as well as HIV focal persons. The purpose was to share performance levels and consolidate improvement changes that led to these performances. Key activities in action plans to continue the work at all levels were discussed and ways to mobilize funds shared. Organized a training of a national pool of 37 trainers in QI and strategies and mechanisms for developing QI policy and strategy documents in Kinshasa (Nov 30 – Dec 2, 2016). The training brought together 37 senior staff from the MOH possessing a strong background on HIV/AIDS including 15 national supervisors from the National HIV Program; eight from the national HIV multisector secretariat at the Presidency, eight from the National Reproductive Program, four from the National TB program and two from National QI unit. The aim of this training was to have a pool of senior staff able to guide and follow up on the QI policy, strategies and operational action at the national level. As such, the QI institutionalization process can take place in the country.
IMPROVEMENT IN KEY INDICATORS Activity Indicators Baseline, Aug Last value 2015 Percentage of PLHIV who received a 0% 100% (9 sites) nutritional assessment according to (Sept 2015) norms in Kinshasa Province NACS Percentage of PLHIV assessed on 100% (9 sites) nutrition who received appropriate 0% (Sept 2015) nutritional counselling 3,141 (10 sites 2,221(10 sites ART coverage in target area (number) Lualaba Lualaba Province) Province) 58% (10 sites in HIV Gap Lualaba Framework Province) (Oct 41% (10 sites % of PLHIV retained on ART 2016) 88% in Lualaba province) Dilala province (4 sites)
16 USAID ASSIST Democratic Republic of Congo Final Report Activity Indicators Baseline, Aug Last value 2015 99.9% (n=188), % of target key population counselled, 2 sites in Lualaba tested and received their results Not available Province (Sept Counseling / 2016) screening 20.6% (n=344), % of male partners counselled and 20%, 39 sites in 3 10 sites in tested provinces Lualaba Province (Sept 2016) 82,8% (n=116), 11.7% (n=1048), Linkage and initial % of individuals tested HIV+ and 10 sites in 39 sites in 3 assessment enrolled in a month of identification Lualaba province provinces (Sept 2016) 6.3% (n=95), 10 % of patients eligible for ART at initial 26.2% (n=571), sites in Lualaba Pre-ART assessment who received CD4 count 39 sites in 3 province (Sept within six months provinces 2016) 2.5% (n=1962), 35.2% (n=661), % of HIV-positive patients on ART lost 10 sites in ART 39 sites in 3 to follow-up Lualaba province provinces (Sept 2016) 72.4 (n=1575), 35.6% (n=661), % of HIV-positive patients screened for 10 sites in TB 39 sites in 3 TB Lualaba province provinces (Sept 2016) 4 Sustainability and Institutionalization ASSIST strengthened the capacity of MOH staff at all levels, including national policy makers, and provincial and Health Zone managers to plan and implement sustainable changes in the system. The project’s technical assistance led to identifying key structures within the MOH, including HIV, quality improvement, planning, and health information, to launch discussions on QI institutionalization. Explicit discussions were conducted during management meetings, coaches’ meetings, and learning sessions on what changes or management reorganizations were needed to maintain gains over time. ASSIST harvested best practices during the second quarter of FY15 and developed spread strategies in collaboration with the MOH and implementing partners. Significant improvement in nutritional assessment and counselling of targeted populations has been attained. In addition, ASSIST has been conducting all its work in partnership and collaboration with the MOH and other IPs, strengthening their capacity to coach and support improvement teams at the facility level. During FY16, ASSIST involved MOH managers and coaches to spread improvement for HIV care and treatment. They acquired skills on QI and on conducting coaching visits by themselves without ASSIST support. Thus, in Lualaba Province, with ASSIST’s technical support, managers developed a sustainability plan and the change package that will be disseminated in new sites to help improvement activities. 5 Knowledge Management Products and Activities ASSIST DRC staff received knowledge management training (May 2015). Ms. Kate Fatta, Improvement Advisor for Knowledge Management from ASSIST headquarters, worked with Dr. Bede Matituye from ASSIST Burundi to orient new staff in the DRC on knowledge management (KM). During this brief orientation, staff were introduced to the three steps of KM: collection, synthesis, and dissemination. Upon conclusion, staff practiced a few KM techniques. Dr. Matituye shared with the
USAID ASSIST Democratic Republic of Congo Final Report 17 DRC staff the PMTCT/HIV care change package developed in Burundi with how-to guidance based on the work done by improvement teams in the demonstration phase. He shared copies with the team, and Ms. Fatta followed up by interviewing him about the change package, discussing how he gathered the information, how he synthesized and validated it with the teams, and how he plans to disseminate it. A group conversation followed, allowing DRC staff to ask him questions about it and about quality improvement more generally. The ASSIST team in DRC created nine job aids on ART in French (June 2016). These job aids are posters that are currently hung on our targeted clinics’ walls to assist healthcare providers in their work and for the treatment of clients. They can be accessed here: https://www.usaidassist.org/resources/antir%C3%A9troviraux-arv-aide-memoires-en-rdc DRC Baseline Assessment (Dec 2016). Prior to implementing activities to improve retention in care and adherence to treatment, a baseline assessment of the quality of HIV / AIDS care was conducted from July 22 to August 20, 2015 to determine the strengths and challenges to improve care services for adults and children living with HIV in the ASSIST project sites in DRC. DRC Change package of QI of HIV care and treatment (Dec 2016). 6 Gender Integration In FY15 for the NACS work in Activity 1, ASSIST engaged sites in collecting sex-disaggregated data and identified that women are more likely to be seen at the clinic monthly than are men, but the percentage of females whose nutrition status was accurately calculated was lower than the percentage for males. The work ended before targeted changes were tested to achieve possible solutions and close the identified gaps. In FY 15 for Activity 2, the baseline assessment to evaluate the quality of care provided to PLHIV at the facility level included sex-disaggregated data, but the data were not analyzed by sex to identify gender- related gaps and issues, and therefore no such analysis was incorporated into the “Aims, Indicators and Content” packages. Activity data were also collected sex-disaggregated, with some analysis and gender- related change ideas tested. As a result, one facility QI team added clinic hours on Saturday and Sunday afternoons in an effort to increase HIV testing for males because they realized that males tended to be at work and unable to visit the clinic during its normal weekday hours; the additional weekend hours were not male-only, just meant to be friendly to males who tend to work during normal business hours during the week. In another effort to increase male HIV testing, as well as improve maternal and child health outcomes, ANC clinics offered HIV testing for male partners. QI teams used HIV testing to measure male partner involvement in ANC, found it to be low everywhere, and did not drastically increase it. ANC clinics invited male partners to accompany pregnant women to the clinic through phone calls and letters. ASSIST continually reiterated that such invitations should only come with the consent of the pregnant woman and her HIV status should never be shared without her consent; however, some clinics invited all male partners regardless of the pregnant woman’s wishes, but ASSIST did not learn of any providers disclosing the woman’s HIV status without her consent. All clinics counselled HIV+ pregnant women on the importance of inviting their male partners to the clinics and involving male partners. All clinics also counselled HIV+ clients to share their status with their partner and/or another person for support. Clinics also used the opportunity of male partners coming to the facility after delivery to see the mom and baby to encouraged male partners to test for HIV. ASSIST staff believed that stigma and discrimination were large contributors to PLHIV not accessing and being retained in care, and there was anecdotal evidence that stigma and discrimination were worse from health providers and in health facilities than from communities. ASSIST staff and QI teams identified the following as issues of stigma and discrimination: that PLHIV were blamed for their HIV status, and that pregnant women with HIV faced increased levels of stigma and discrimination. ASSIST Gender Specialist Julia Holtemeyer of WI-HER, LLC participated in the Kinshasa Learning Session held in August 2016, to discuss what gender integration is and how to integrate gender into quality improvement activities. The components of the 3 hours of training included defining gender and related concepts; defining gender analysis; understanding how to develop, analyze, and report on sex- disaggregated data and gender-sensitive indicators; and the importance of identifying and addressing and gender-sensitive program planning. All training materials were in French, and Ms. Holtemeyer conducted the training in English, with translation into French. Activities included completing a driver diagram;
18 USAID ASSIST Democratic Republic of Congo Final Report discussions about gender norms in DRC; discussions about how gender affects HIV transmission, testing, care, treatment, and adherence to and retention in care; discussions about how gender is relevant to the ASSIST DRC QI work; and slide presentations explaining the ASSIST approach to gender integration. Participants were initially hesitant to answer questions and volunteer their opinions, but quickly became more vocal and engaged as the discussion turned to gender norms in DRC and how they affect HIV improvement work.
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