Enhancing the culture of multi-disciplinary workshops on using data for decision-making: Tanzanian efforts to improve completeness of

CD4 assessments

Molly Strachan, ICAP TanzaniaM&E Technical Meeting

Johannesburg, South AfricaJuly 28, 2010

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

Overall Rwanda Cote d'Ivoire

South Africa Lesotho Ethiopia Nigeria Kenya Mozambique

Tanzania0%

50%

100%

83%

96% 95% 94%91% 91%

82%

74% 73%

66%

45%

76%

51%56%

45% 46%43% 42%

30% 32%

44%

72%

63%

45% 43% 42% 41%

48%

38%34%

Baseline 6-Month 12-Month

Proportion of patients with CD4 count at baseline, 6, and 12 months after ART initiation

(subset of ART patients*)

Perc

ent o

f pa

tient

s w

ith C

D4

coun

t

n=19,026n=11,927n=908 n=17,789n=13,294 n=15,193 n=11,579159,836 n=36,904

Source: ICAP URS March 2010Notes: * 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 2010

May, June, July 09 (6MTH)

Nov, Dec 08, Jan 09 (12MTH)

May, June, July 09 (6MTH)

Nov, Dec 08, Jan 09 (12MTH)

May, June, July 09 (6MTH)

Nov, Dec 08, Jan 09 (12MTH)

Kagera Pwani Kigoma

0

100

200

300

400

500

600

700

800

900

745

830

694

482

207

154

480

409

480

351

9459

553

771

432

392

135

84117

182 184155

32 19

Number in cohort at baseline Number with CD4 done at baseline Number in cohort at 6 ,12 month Number with CD4 done at 6,12 month

64% 21% 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 3 294/294 266/294 254/294 265/294 100% 90.5% 86.4% 90.1%

SITE 4 356/356 296/356 205/356 195/356 100% 83.1% 57.6% 54.8%

LabRegister

Lab SlipsIn

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