HIV/AIDS and TB Newsletter

Newsletter from the national HIV/AIDS and TB Programme, Pretoria

Number 33, 20 March 2003

With World TB Day on Monday, 24 March 2003, this newsletter will focus on TB issues.

Quality Improvement Approach to Increasing TB Programme Outcomes

Quality Assurance Project’s Approach – Integrating Disease Knowledge with Improvement Knowledge

The integration of knowledge about disease management with improvement and change in expertise is illustrated in the Framework for the Continual Improvement of Health Care. The Quality Assurance Project (QAP) has played a major role in developing and refining this framework, particularly in integrating the concept of evidence-based clinical guidelines with system changes necessary for implementing such guidelines (Figure 1). This framework has relevance for the South African tuberculosis program to assure that the healthcare providers know and accept the evidence-based treatment guidelines and that the system changes are made to ensure the proper implementation of DOTS therapy.

Content of Care – Evidence-Based Care: To achieve significant improvements in the tuberculosis program, QAP is ensuring that the healthcare providers follow national guidelines for the DOTS therapy. For this, QAP develops strategies for enhancing knowledge and skills of providers as well as systems to ensure provider compliance with the guidelines.

Process of Care – Quality Design Methodology: The quality design methodology developed by QAP ensures that new systems are created in a way that maximizes the chance of high-quality outcomes, efficiency, and client satisfaction. In applying quality design methodology for the case management of TB in the public sector, we start by reviewing current systems to identify gaps and opportunity for improvement. For this we make program managers seek inputs from both internal and external clients, including TB patients with diagnosed TB, their families, healthcare workers, laboratory personnel, and lay supporters/observers. Based on inputs from these groups, QAP helps to create a common purpose and vision. In this example, it might be "reliable and supportive DOTS care will be provided to all patients who are diagnosed with TB." We then proceed to define measurable objectives of the process, such as the numbers of patients receiving DOTS care and completing DOTS care. Next, a high-level flowchart of the re-designed system of care is developed, showing the major elements of the system. In the example of designing the DOTS care system, the flowchart would have six elements: the screening/diagnosis, intensive DOTS treatment, re-testing, maintenance phase follow-up testing, and treatment completion (see Figure 2). At each block in this flowchart, client needs are specified. This is followed by the identification of key service features (how the patients’ needs will be fulfilled). This is proceeded by linking activity blocks, key client needs, and key service features. This assures appropriate coordination along the continuum of care. At this stage, the design features of the DOTS care system become clearer, as the system or the process of care gets better defined. Finally, the redesigned system of care is launched, but even after the launch, the system is monitored to see if any of its elements need to be further modified.

Figure 2. Components of Continuum of Care for TB Patients

Results – Improvements in the South African TB Program

In South Africa this In the past year yearin South Africa, QAP has applied the improvement methods to the TB program in Mpumalanga. As a result, shown that significant improvements in case detection, sputum conversion and cure rates have been can be achieved at most clinics participating in the programthrough the use of improvement methodology (see charts at right). In tensixteen sub-districts of the Mpumalanga province(of what province?) , facilitythe staff of facilities where TB isTB casesfacilities are managed received training in modern quality assurance methodologies. At each facility, multi-disciplinary teams were created to perform a baseline assessment, analyse problem areas, develop appropriate improvement interventions and then test interventions to improve quality. No additional resources were provided for quality improvement. To encourage providers to follow treatment guidelines more closely, the teams focused on systematically communicating the guidelines and their rationale, expanded monitoring and performance feedback by supervisors, and and provided needed training. 

They reorganized record keeping, the ; and reorganized the process of care within each facility. and patient follow-up procedures. Teams also reorganized record keeping, including follow up of patients. The community element of DOTS was addressed by introducing mapping of patients' homes for follow up and through more formal management of the role of community volunteers. 

Over the last 12 months, significant improvements in case finding, case holding and cure rates have been observed in most participating health facilities in the province (see graph s highlighting results from two one oof the sub-districtsfacilities). Number of new cases detected in the Philadelphia sub-district increased from 18 per month to 143. Sputum conversions rose in Rob Ferreira from 20% to 43% (the target being 85%). Based on the successes in the pilot areas, the TB interventions are being spread to other parts of the Mpumalanga province (What province?) as well as to other districts in KwaZulu-Natal.

For more information, contact Dr. Neeraj Kak at nkak@urc-chs.com

World TB Day, 24 March 2003

This year World TB Day will see the launch of the first National TB Advocacy and Social Mobilisation campaign 2003-2005 with the theme Stop TB because YOU can.

Activities started the 17th of March with the official press conference where the Minister of Health Dr Manto Tshabalala-Msimang announced the national TB campaign.

During this press conference, the TV documentary " Precious breaths, South Africa's needless deaths" was previewed. It features the stories of South Africans who have struggled against this scourge. This documentary will be broadcast on SABC 3 Special Assignment Tuesday 18th of March at 21:30 and be repeated on Sunday 23rd at 22:00.

Five Public Service Announcement in six language groups have also been developed from this documentary. Limited copies are available on request.

On World TB day, the official launch will take place in the Nelson Mandela Metropole. The Minister of Health, the Premier of Eastern Cape, the MEC of Health from Eastern Cape and the Mayor of the Metropole (Port Elizabeth) will:

For more information, please contact Mr. Phumlani Ximiya at (012) 312-0113 or ximiyap@health.gov.za

Important Dates and Meetings

24 March: World TB Day

Useful Websites

www.health.gov.za
www.aidsinfo.co.za
www.aidsdirectory.co.za
www.dpp.org.za
www.hst.org.za
www.global-campaign.org (for news on microbicides)
www.who.int/hiv
www.saavi.org.za
www.afroaidsinfo.org
www.lovelife.org.za
www.childaidsservices.org
www.equityproject.co.za
www.learnscapes.co.za
www.hivan.org.za
www.unaids.org
www.caprisa.org

You are also encouraged to share information on other useful websites. Feedback on the Department of Health website would be especially valuable.

Compiled by Celicia M Serenata
Project Manager: HIV/AIDS
Tel: (012) 312-0128
Fax: (012) 326-2891
e-mail: serenc@health.gov.za

Red Ribbon Resource Centre

For all requests of HIV/AIDS materials (posters etc.), please contact:

Tel: (011) 880-0405
Fax: (011) 880-8552

Address List for Chief Directorate

Fax: (012) 312-3122

Dr. Nono Simelela
Chief Director: HIV/AIDS and TB
Tel: (012) 312-0121
simeln@health.gov.za

Collen Bonnecwe
Director: HIV/AIDS (NGOs)
Tel: (012) 312-0137
bonnec@health.gov.za

Thami Skenjana
Director: GAAP
Tel: (012) 312-0133
Fax: (012) 325-0165

Dr. Refiloe Matji
Director: TB
Tel: (012) 312-0106
Fax: (012) 326-4365 
matjir@health.gov.za

Dr. Rose Mulumba
Director: HIV/AIDS and STIs 
mulumr@health.gov.za

Ms. Celicia Serenata
Project Manager: HIV/AIDS
serenc@health.gov.za