Article

Providing universal access to antiretroviral therapy in Thyolo, Malawi through task shifting and decentralization of HIV/AIDS care

Médecins Sans Frontières, Blantyre, Malawi.
Tropical Medicine & International Health (Impact Factor: 2.3). 10/2010; 15(12):1413-20. DOI: 10.1111/j.1365-3156.2010.02649.x
Source: PubMed

ABSTRACT To describe how district-wide access to HIV/AIDS care was achieved and maintained in Thyolo District, Malawi.
In mid-2003, the Ministry of Health and Médecins Sans Frontières developed a model of care for Thyolo district (population 587, 455) based on decentralization of care to health centres and community sites and task shifting.
After delegating HIV testing and counseling to lay counsellors, uptake of testing increased from 1300 tests per month in 2003 to 6500 in 2009. Shifting responsibility for antiretroviral therapy (ART) initiations to non-physician clinicians almost doubled ART enrollment, with a majority of initiations performed in peripheral health centres. By the end 2009, 23, 261 people had initiated ART of whom 11, 042 received ART care at health-centre level. By the end of 2007, the universal access targets were achieved, with nearly 9000 patients alive and on ART. The average annual cost for achieving these targets was € 2.6 per inhabitant/year.
The Thyolo programme has demonstrated the feasibility of district-wide access to ART in a setting with limited resources for health. Expansion and decentralization of HIV/AIDS service-capacity to the primary care level, combined with task shifting, resulted in increased access to HIV services with good programme outcomes despite staff shortages.

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Available from: Beatrice Mwagomba, Aug 29, 2015
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    • "Within each hospital, an ART clinic provides outpatient care for patients with HIV or autoimmune deficiency syndrome (AIDS) on schedules ranging from two to five days per week, depending on the demand for ART services at the hospital. Staff who are trained to initiate and provide ART are mid-level healthcare providers, including clinical officers, nurses, and certified nursemidwives [33]. In Malawi's district hospitals, like hospitals in many low-income countries, care is routinely provided without physician oversight or on-site consultation services due to critical shortages of healthcare providers [34]. "
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    ABSTRACT: Sub-optimal performance of healthcare providers in low-income countries is a critical and persistent global problem. The use of electronic health information technology (eHealth) in these settings is creating large-scale opportunities to automate performance measurement and provision of feedback to individual healthcare providers, to support clinical learning and behavior change. An electronic medical record system (EMR) deployed in 66 antiretroviral therapy clinics in Malawi collects data that supervisors use to provide quarterly, clinic-level performance feedback. Understanding barriers to provision of eHealth-based performance feedback for individual healthcare providers in this setting could present a relatively low-cost opportunity to significantly improve the quality of care. The aims of this study were to identify and describe barriers to using EMR data for individualized audit and feedback for healthcare providers in Malawi and to consider how to design technology to overcome these barriers. We conducted a qualitative study using interviews, observations, and informant feedback in eight public hospitals in Malawi where an EMR system is used. We interviewed 32 healthcare providers and conducted seven hours of observation of system use. We identified four key barriers to the use of EMR data for clinical performance feedback: provider rotations, disruptions to care processes, user acceptance of eHealth, and performance indicator lifespan. Each of these factors varied across sites and affected the quality of EMR data that could be used for the purpose of generating performance feedback for individual healthcare providers. Using routinely collected eHealth data to generate individualized performance feedback shows potential at large-scale for improving clinical performance in low-resource settings. However, technology used for this purpose must accommodate ongoing changes in barriers to eHealth data use. Understanding the clinical setting as a complex adaptive system (CAS) may enable designers of technology to effectively model change processes to mitigate these barriers. Copyright © 2015. Published by Elsevier Ireland Ltd.
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    • ". National programs [10] [11] [12] [13] have reported large-scale data of HIV treatment in both urban and rural populations [14] [15] [16] [17]; however, delivery of HIV treatment in some settings presents unique challenges and current ART delivery models may significantly limit the accessibility of ART. To have the greatest impact on public health, HIV treatment programs will have to be decentralized and integrated into the existing health care system. "
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    AIDS research and treatment 06/2014; 2014. DOI:10.1155/2014/560623
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    • "Generally, the effectiveness of scale-up programmes involving CHWs has been difficult to determine given the variation in the scale-up approach and the difficulties measuring outcomes [5-8,17]. However, locally the Médecins Sans Frontières experience in Thyolo district Malawi provides some evidence of feasibility and good outcomes for a programme of decentralized HIV care to clinics and community settings using task-shifting in which HSAs provided the HIV testing and counselling, and, treatment initiation was transferred to non-physician clinicians [18]. Between 2003 and 2009, the programme achieved universal access targets and achieved significant gains in human resources efficiency [18]. "
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