Transcript Document

RSQA
Findings and Next Steps
LFA M&E Training
February 2014
1
Content
• Background and implementation
• Disease specific findings
• Preliminary feedback and way forward
Background - Global Fund strategy on Quality of
Services
• Rapid Services Quality Assessment (RSQA):
– main objective: to assess and improve quality of
services at country level, and to continuously build
capacity in establishing and using quality improvement
as an integral part of program management
– applied during program implementation
– findings from assessments -> complemented other
relevant indicators from the performance framework
– implemented in general by the LFA, in conjunction with
OSDV
Background- RSQA tool
Assessment at two different levels:
1) The central/policy level questionnaire which assesses the availability of national disease
program policies and guidelines for the Service Delivery Areas funded by the Global Fund, and
whether these are in line with latest international recommendations relevant to the prevention and
treatment of HIV, TB and malaria, e.g. the WHO recommendations
Background- RSQA tool
2) The facility level questionnaire assesses compliance of service delivery under the
Service Delivery Areas funded by the Global Fund with nationally defined standards.
Implementation to date
• 37 RSQAs have been completed, covering 26
countries and 45 disease programs (dp)
– 15 for HIV
– 11 for Malaria
– 11 for TB
• 43 RSQAs planned for 2014
RSQA review process
LFA sends to
Country Team
One hour meeting with the technical
advisor, FPM, PO, PH/M&E Specialist,
and at least one RSQA focal point to
review and document findings and final
recommendations
M&E Specialist
initiates review
CT, Technical
Advisor, RSQA
focal point
review
CT shares
recommendations
with PR & follow
up during grant
management
Percentage of LFA-proposed
recommendations that were modified
during the internal review*:
• HIV- 32.7%
• TB-29.2%
• Malaria-6.3%*
* Based on the total number LFA recommendations, excluding duplicate committee recommendations
* The analysis for malaria only included 3 grants
HIV findings: distribution of issues by
countries
Supervision
Strategy and policy
Recording and reporting
Provider practices and knowledge
At least
one issue
identified
Product Management
Pharmacovigilance
Guidelines and protocols
No issues
identified
Facility conditions
Coordination
Access to care
n=13 (Cambodia, Namibia, Lesotho, Ghana, Benin, Honduras, Bosnia, Senegal,
Sierra Leone, Liberia, Azerbaijan, Nigeria and Madagascar)
HIV: illustrative findings by type
Supervision
“Support supervision and mentoring of service providers, especially those offering ART
services, is weak”
Strategy and policy
“There are no clear and formally established mechanisms for the referral of HIV
positive pregnant women, before and after delivery, and neither is there an established
linkage to the care of the HIV exposed babies”
Recording and reporting
“Recording of the assessment of TB status is not systematic done in the medical files”
Provider practices and knowledge
“Recommendations on repeat HIV test after equivocal test are not homogenously
followed-up”
Product management (storage
conditions)
“Inadequate storage space for drugs, irregular use of shelves and wooden pallets due
to insufficient space and unavailability of wooden pallets/shelves”
Pharmacovigilance
“Absence of any documents or written guidance on pharmacovigilance and lack of
systematic reporting of adverse drugs reactions”
Guidelines and protocols
(distribution)
“The national PMTCT guidelines, specifically the PMTCT circular, have not been fully
disseminated to all PMTCT sites”
Facility conditions
“Used injecting equipment is not properly disposed of; in all places there is no
adequate mechanism for disposal of containers”
Coordination
“Weak collaboration between TB and HIV programs”
Access to care
“Beneficiaries' and implementers consider Methadone Maintenance Treatment (MMT)
as not accessible to most of those in need”
Malaria findings: distribution of issues by
countries
Supervision
Resistance and efficacy studies
Recording and reporting
Provider practices and knowledge
Product Management
Pharmacovigilance
Guidelines and protocols
Access to care
n=5 (Namibia, South Sudan, Nigeria, Sierra Leon and Liberia)
At least
one issue
identified
No issues
identified
Malaria: illustrative findings by type
Supervision
“Supervision is minimal and written feedback for the facilities to implement
absent in most facilities”
Resistance and efficacy “According to the central policy level review, the most recent efficacy tests
studies
took place in 2003”
Recording and reporting
“Retrieving cards after names had been selected from the register was
difficult because of poor record keeping”
Provider practices and
knowledge
“Some facilities are practicing polypharmacy, others still using chloroquinine
or giving non recommended medication”
Product management
“Stockouts of IPT drug (sulfadoxine+pyrimethamine) found in facilities”
Pharmacovigilance
“Pharmacovigilance not in practice at most service delivery points
Guidelines and protocols “New policy and guidelines developed in 2011 have not been disseminated to
facilities”
(distribution)
Access to care: system
issues
“Virtually no diagnostic capacity exists outside the major hospitals and
diagnosis is considered to be unreliable even at these facilities”
TB findings: distribution of issues by
countries
Supervision
Strategy and policy
Resistance and efficacy studies
Recording and reporting
Quality Assurance
At least
one issue
identified
Provider practices and knowledge
Product management
Pharmacovigilance
No issues
identified
Guidelines and protocols
Coordination
Access to care
n= 11 (Senegal, Indonesia, Ukraine, Gambia, Guinea, Honduras, Benin, Nicaragua,
Nigeria, Eritrea and Central African Republic )
TB: illustrative findings by type
Supervision
“No feedback is given after any supervision visit to the pharmacy”
Strategy and policy
“Lack of national training plan”
Resistance and efficacy
studies
“Drug resistance study is outdated”
Recording and reporting
“The use of different versions of reporting forms at particularly the facility and LGA levels
leading to the inability to capture and report some relevant indicators”
Quality assurance
“Although the percentage of agreement among of the laboratories participating in EQA
was high, the percentage of laboratories that participated in EQA was low (67%)”
Provider practices and
knowledge
“Not all TB/HIV patient are on CPT and ART even when they meet the eligibility criteria”
Product management
(Stockout commodities)
“In most facilities, there were some stock-out of health products, in particular sputum
containers”
Pharmacovigilance
“Adverse drug reactions seems to be a topic that is not given sufficient attention. Report
of a Suspected Adverse Drug Reaction (ADR) was known by none of them”
Guidelines and protocols
(amendment/creation)
“TB guidelines are in place, but these are not updated (2007)”
Coordination
“The sputum scoring system used by MRC is different from the scoring system of the NTP
(scanty, 1+, 2+, 3+)”
Access to care (financial)
“The isolated perception from the exit interviews suggest that patients may be paying
some user fees particularly for diagnosis of TB”
Preliminary feedback on the RSQA
• Useful exercise – providing information on how
services are provided
• Provides an opportunity to integrate quality of
services into the grant management cycle
• Reveals more in-depth issues than other
assessments (good OSDVs provide some
programmatic information but not systematically)
• Provides important information for risk
management
Preliminary feedback on the RSQA
• The quality and subsequent use of an RSQA
varies greatly with the LFA team
• Findings/recommendations vary from detailed and
specific to very general or generic, limiting their
use in grant management
• Recommendations are not prioritized and the
timeframes do not always take into account the
country context and what is feasible
Feedback to the LFA
• Recommendations should be detailed and
precise/accurate – with all the relevant, specific
and contextualised information
• Recommendations on actionable points should be
made in the context of the grant lifecycle
– important timeframes
– possible sources of funding
– main entity responsible for implementation
Feedback to the LFA
• The most serious issues should be noted upfront
– In that line, not every identified issue should be raised
to the Global Fund. Use Judgement to assess the
severity of an issue and prioritise the most
important/significant ones
• Sites with multiple issues should be highlighted or
specified in the findings
• Fragmented recommendations should be
grouped under an overarching issue if it makes
sense
• Examples_.xlsx
Problem identified
The current National Guideline for Diagnosis and Treatment of
malaria was produced in 2006
some examples
Proposed follow up action
Complete the on-going process of producing a
guideline in view of the current changes in the
field of malaria
Measure and record temperatures to ensure
proper storage of commodities, and move
Lack of temperature chart in the storage room and shelves being shelves from the walls as instructed
closed to the walls
Guidelines for good storage are not available and the shelves
were close to the wall
The team recommended the facility to reposition
the shelves. The facility need to be provided
with SoP for storage.
Type of follow up action
Management Action
Recommendation
Recommendation
Repositioning
Storage shelves placed against walls
Recommendation
There is need for conducting supportive
supervision and documenting
There was no eveidence of supportive supervision be conducted
Verification of malaria treatment regimens was not possible due
to lack of documents. No OPD register was available for review
and the recently introduced HMIS books were not used
Very congested store room with cartons on the floor. There is no
monitoring of temperature
Recommendation
This facility should use HMIS books for
registering patients
Management Action
Proper arrangement of commodities is required
as well monitoring and recording of temperature
Recommendation
Frequent stock out of HIV test kits especially Determine, which
the first HIV test kit according to the National Algorithm for HIV
testing
Both Determine and Unigold HIV test kits should
always be available. Testing of patients for HIV
infection should follow national guidelines i.e.
Recommendation
Determine followed by Unigold (for those tesing
positive with Determine)
The facility experiences frequent shortage of CD4 reagents for
assessing ARV eligibility and monitoring of patients on ARVs
At this level of health service delivery emphasis
should be on clinical staging of patients for ARV
eligibility.
Lack of awareness on availability of the yellow forms used to
monitor adverse drug reactions
Yellow forms be provided and staff be trained
on their use
Recommendation
This facility continues to use single dose nevirapine for
prophylaxis
This regimen should be changed to conform
with the current guidelines
Management Action
Outdated national guidelines for HIV counselling and testing
dated 2006, with SD-bioline and Determine as test kits
The facility should acquire the most recent
guidelines which came out in 2012
Recommendation
Lack of paediatric ARV formulations
Provide Pediatric ARV formulations
Recommendation
RSQA – feedback from LFAs
• You have been given a questionnaire to gauge
LFA opinions about RSQA
• If not yet done, please kindly fill out the
questionnaire and hand it to facilitators
• Please be detailed and provide specific examples
• Feedback on areas not included in the
questionnaire is also welcome
Your feedback … What are the triggers?
Your feedback … Did you triangulate?
Your feedback … The future of RSQA?
Your suggestions… in words
•
•
Streamline the tool
Remove duplicate
questions
Make it
flexibile/userfriendly
•
•
•
•
•
Fix calculation error
by facility/area
Weight the scores for
each aspect, and not
just major issues in
red
Ensure feedback
to PR, CCM
Ensure PR/MOH
lead the
process/report/
participation
RSQA way forward
• It is clear that the RSQA tool has limitations in the
design, content of sections and interpretation of
results…
• Therefore a comprehensive review is underway to
improve how the GF assess quality of services
with the following objectives:
– Are findings used in grant management
– Best entity to conduct the RSQA
– Feedback on RSQA tool and process