Process evaluation of quality of HIV clinical care in Wollayta soddo Hospital
Evaluation of Quality of HIV Clinical Care in Wollayta soddo Hospital SNNP Regional State, South Ethiopia
Evaluation thesis submitted to health monitoring and evaluation Department in partial fulfillment of the requirements for master’s degree in health monitoring and evaluation.
Department of Health Planning and Health Services Management, Public Health Faculty, Jimma University
Prepared by:
Marshet Weldeyohanns
Jimma, Ethiopia
April, 2009
13
Marshet Weldeyohanns 2nd year M and E student
Process evaluation of quality of HIV clinical care in Wollayta soddo Hospital
Process evaluation of quality of HIV Clinical care in Wolayta Soddo Hospital, SNNP Regional State, Ethiopia
Evaluation thesis submitted to health monitoring and evaluation Department in partial fulfillment of the requirements for master’s degree in health monitoring and evaluation, public health faculty
Jimma University,
Prepared by:
Marshet Weldeyohanns
E-mail-
June 2008
Jimma, Ethiopia
Advisors:
Professor Abebe Gebremariam (BSc. MPH)
Yibeltal Kiflie (BSc. MSc.)
Jemal Aliy (MD, MPH)
13
Marshet Weldeyohanns 2nd year M and E student
Process evaluation of quality of HIV clinical care in Wollayta soddo Hospital
Abstract
Background: - Currently at global level and Sub-Saharan Africa in particular the acquired immuno deficiency syndrome pandemic continues largely unabated. Beyond the substantial human toll, the pandemic has broader impact throughout many parts of a society. AIDS remains fatal disease primarily affecting those who are young and in their productive years which requires strengthened preventive efforts, care and support. Effective HIV/AIDS care requires antiretroviral therapy as a treatment option. With out access to antiretroviral therapy, people living with HIV/AIDS can not attain the full possible physical and mental health and can not play their role as actors in the fight against the epidemic. Scaling up of AIDS treatment in developing countries is faced with a lot of challenges including; limited quality standards of health system to provide treatment, in terms of human resource, infrastructure needed to deliver ART, lack of data, and lack of adequate drug management system to ensure adequate supplies of antiretroviral drugs.
Objective of evaluation: - The objective of this study is to assess the quality of HIV clinical care provided by Wollayta soddo Hospital.
Methods of evaluation - The focus of this evaluation is process and the approach is formative. Case study design was use for the evaluation. The study was conducted in Wollayta soddo Hospital, which is found in SNNPR of Wolayta zone and the data was collected from December 1-20, 2008. After analyzing the data by using SPSS soft ware, the findings was summarized using frequency tables, graphs and charts. The final reports of this evaluation will be distributed both in hard and electronic copy to all stakeholders and interested organizations.
Result: -The target of the study are all HIV positive patients with or without ART, accordingly all sampled targets of the study are reached (100). Based on the accreditation requirement of the national guide line 81.8 % of the recommended resource are available, which is judged to be very good. Based up on the national guideline and agreed judgment criteria, 72.7 % of HIV clinical care is given compliance with the standard operational procedures. In concrete term the final finding of this evaluation study revealed, averagely near to 80% of the expected quality indicators are achieved.
Conclusion: The overall quality of HIV clinical care implementation in the study hospital was rated as good, but is not more than average level of the expected achievements. Still improvement in clinical service is highly needed.
Table of contents
Abstract I
Table of contents III
List of Figures V
Figure 1 Logic Model of ART program V
Figure 2 Theoretical Model of Evaluation V
List of Tables--- V
Acknowledgment VI
List of Acronyms VII
Chapter I Background 1
1.1 Introduction 1
1.2 Statement of the problem 1
1.3 Literature review 5
1.4 Purpose of Evaluation 7
1.5 Rational of HIV/AIDS care and treatment 8
1.6 Antiretroviral combination therapies 10
1.7 General Objective of the HIV clinical service 11
1.8 Specific objective of HIV clinical service 11
1.10 Stage of development 12
Chapter-II Stakeholder Identification and Analysis 14
Stakeholder participation and degree of involvement 14
Chapter-III Objectives of Evaluation and Evaluation Questions 17
3.1 General objectives 17
3.2 Specific objectives 17
3.3 Evaluation Questions 17
Chapter-I V Methods 18
4.1 Study area and study period 18
4.2 Design of evaluation 19
4.3Target population 18
4.4 Study units and sampling unit. 19
4.5 Sample size and Sampling Procedures 19
4.6 Focus of Evaluation 20
4.7 Dimension of the evaluation 20
4.8 Approach to evaluation 20
4.9 The theoretical Model of Evaluation 21
4.10 Data Collection Procedures 23
4.11 Data Collection Instrument 24
4.12 Inclusion and Exclusion criteria 24
4.13 Data Management and analysis 25
4.14 Information matrixes of Evaluation 26
4.15 Development of Indicators and Judgment matrixes of Evaluation 27
4.16 Consent and Ethical Issues 27
4.17 Limitation of the study 27
4.18 Report writing and dissemination plan 28
Chapter -V Result------29
Chapter -VI Discussion------46
Chapter VII Conclusion and recommendation------52
7.1 conclusions------52
7.2 Recommendation------54
Chapter -VIII Meta- evaluation 56
Chapter- VIIII. References 57
Annex 61
Annex 1 Relevance matrix 61
Annex -2 ART resource assessment questioner 63
Annex 3 HIV clinical care reviewing tools. 67
Annex 4 expert interview guides 69
Annex 5 patients exit interview guide------70
Annex- 6 Indicators of Evaluation 72
List of Figures
Figure 1 Logic Model of ART program
Figure 2 Theoretical Model of Evaluation
List of Tables
Table 1 Stakeholder identification and analysis
Table 2 Judgment matrix of evaluation
Table 3 Availability of ART and OI drugs in Wollayta soddo Hospital
Table 4 Availability of lab and pharmacy supplies and equipments
Table 5 Socio demographic characteristics of study population
Table 6 The level of acivments of jugement matrix of evaluation
Table 7 Relevance matrix of evaluation
Table 8: Clinical service minimum package by level of facility
Table 9: Pharmacy service minimum package by level of facility
Table 10: Laboratory service minimum package by level of facility
Acknowledgment
First and for most ,I would like to express my deepest gratitude to my advisors professor Abebe Gebremariam, Mr.Yibeltal Kiflie and Dr. Jemal Aliy for there constructive and valuable comments. My deepest appreciation also goes to professor Elisabeth Moreira Dossantos and professor Carl Kendal, who made me competent to prepare this evaluation proposal. Next I wish to express my heart felt tanks to Dr Wuleta Lemma and Tulane University who supported me financially to attend M and E masters program. Finally I would like to express my great admiration to Wolayta zone health department and Wollayta soddo Hospital that supported me by availing the necessary information to conduct this evaluation.
List of Acronyms
AIDS Acquired Immune deficiency syndrome
ART Antiretroviral Therapy
ARV Antiretroviral
BUN Blood urea nitrogen
CDC Center for disease control
FHI Family health International
HIV Human Immunodeficiency virus
HO Health Officer
M and E Monitoring and Evaluation
MD Medical Doctor
OI Opportunistic infection
PE Principal Evaluator
PLWHA People living with HIV/AIDS
CNS central nerves system
TLC T- lymphocytes count
13
Marshet Weldeyohanns 2nd year M and E student
Process evaluation of quality of HIV clinical care in Wollayta soddo Hospital
Chapter I Background
1.1 Introduction
Effective program evaluation is a systematic way to improve and account for public heath actions by involving procedures that are useful, feasible, ethical, and accurate.1
Program evaluation is applied research used as part of the managerial process.2 Programs are evaluated basically because administrative decision have to be made and it is important to know (or to show) that our program are good programs.2
The corner stone of a country’s response to the human immunodeficiency virus- acquired immunodeficiency syndrome (HIV/AIDS) epidemic is the development of an appropriate and efficient monitoring and evaluation (M and E) system. Such system is essential to make optimal use of limited resource and integrate lesson learned with the response required for scaling up HIV/AIDS programs to achieve national- level effects.3
1.2 Statement of the problem
We are in the third decade of what has become the most important infectious disease epidemic (pandemic) in the last century. UNAIDS fact sheet 2007, estimated that, 33.2 million (30.6 – 36.1 million) people world wide were living with HIV/AIDS, at end of 2007. An estimated 2.5 million (1.8 - 4.1 million) become newly infected with HIV and estimated 2.1 million (1.9 – 2.4 million) lost their lives to AIDS.4
Favorable trends in incidence in several countries are related to change in behavioral and prevention programs. Changes in incidence along with rising AIDS mortality have caused global HIV prevalence to level off. However, the numbers of people living with HIV have continued to rise, due to population growth and more recently, the life prolonging effect of antiretroviral therapy.4
Africa remains the global epicenter of the AIDS pandemic. Africa is estimated to have more than 60% of the AIDS infected population (4). Africa’s HIV/AIDS epidemic has had important Effects on society, economics and politics continent.
The economic impact of AIDS is noticed in slower economic growth, distortion in spending, and changing demographic structure of the population. The social impact of HIV/AIDS is most evident in the continent’s orphan’s crisis. Approximately 12 million children in sub- Saharan Africa are estimated to be orphaned by AIDS.5
With an estimated 1.03 million people living with HIV/AIDS and a national prevalence rate of 2.2 % in 2008, Ethiopia is one of the hardest hit Countries by HIV/AIDS epidemic.6 Ethiopia hosts the fifth largest number of people living with the virus globally.
The annual number of death due to AIDS is estimated of 58,290. Death due to AIDS brought down life Expectancy gain from 53 to 46. If the current death trend continues the projected life expectancy gain to 59 years in 2014 will be reduced to 50 years. In 2005, an estimated 68,136 persons, needed antiretroviral treatment.6 7
According to the single point HIV prevalence estimates, due to the combined effect of both relatively high HIV prevalence and large population size, SNNPR region is one of the areas with high prevalence and Incidence of HIV/AIDS. The adult HIV/AIDS prevalence is estimated to be1.5% with 0.2% Adult incidence. There were about 141,545 PLWHA of whom 38,136 Needs ART. In the region there were 8,489 AIDS related deaths out of those 3,236 are children.6
Since 1996 an overwhelming amount of evidence from clinical trials has been published validating the use of HAART for the treatment of human immunodeficiency virus (HIV) infection. Suppression of HIV replication, immune reconstitution, a halt in diseases progression, increased survival: reduced morbidity and a better quality of life have been defined as the biological and clinical goals of treatment. In counters where access to this standard of care is available; AIDS related mortality and morbidity have significantly declined.8
To get the required out comes of HAART treatment care with standardized quality is mandatory .Quality of care remains an area for improvement, despite the increased attention it has received in recent years. Though researchers and survey organizations have focused on safety and quality through public campaigns and quality measurement and reporting, largely of a voluntary nature, little has been done with this information to make changes that would improve quality.9
There are many people who do not receive quality care because of their race, ethnicity, gender, socio-economic status, and age or health status. As evidenced in the current national debates over universal health care, not everyone has insurance, or access to health care. Beyond that, there are many specific groups that often find themselves unable to access the same quality of care as the general population. Some of these groups include: women, children, elderly, racial and ethnic minority groups, residents of rural areas, disabled or mentally handicapped persons, people in need of long-term-care, and others with special needs. In the 2003 National healthcare disparities report, the agency for healthcare research and quality cite four factors that are key barriers to the provision of quality care. These include:
· Entry into the Health care system; the accessibility of care.
· Structural barriers; the ease of navigating through the system to receive the best care.
· Patients’ Perceptions; cultural and socio-economic relationship problems between patients and providers.
· Utilization of care; accessing appropriate care at the appropriate time.
(Agency for Healthcare Research and Quality 2003)
These factors result in sometimes severe disparities in the quality of health care provided to the general population and care received by minority populations. It is important for both consumers and advocates to be aware of the multiple factors causing such disparities of care, and to learn how to combat them.10
America’s health care system, while among the best in the world, faces multiple systemic barriers to providing the best care possible to every patient. In its 2003 State of health care quality report, the national Committee for quality assurance cites six main factors that prevent many Americans from receiving the highest standards of care. They include:
· The slow pace with which new technology, information and guidelines are adopted by the health care industry.
· Current and historical lack of government incentives, standards, or direction.
· Inconsistent care by physicians and other health care professionals.
· Lack of widespread collaboration and information sharing among health care organizations.
· The failure of existing financing and reimbursement mechanisms to provide incentives for excellence.
· The failure of the health care system to measure and report on performance.
(National Committee for Quality Assurance 2003)
These problems are widespread and endemic to the health care system, and need to be addressed on a national level, as well as by each individual facility.11,12
1.3 Literature review
The U.S. Institute of Medicine (IOM) defines ‘quality’ as: the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. What this really means is that each individual consumer should receive the best possible health care available every time services are needed. Health care providers should provide care that meets the needs of each individual patient, including the use of appropriate advances in medical technology. Healthcare should also be non-discriminatory, providing the same quality of service regardless of race, ethnicity, age, and sex or health status. 12, 13