Author: Anne Fox

I-TECH Ukraine Initiates National Discussion on Performance-based Incentives Model in HIV

Participants of the national consultation on PBI model development discuss international best practices. Photo courtesy of I-TECH Ukraine.

In response to the need to quickly revitalize efforts to reach targets in Ukraine, CDC Ukraine has asked International Training and Education Center for Health (I-TECH) to support a performance-based incentive (PBI) model.

On March 28, 2019, I-TECH facilitated a high-level stakeholder workshop centered on PBI evidence and “best practices.” Participants from the U.S. Centers for Disease Control and Prevention (CDC) in Ukraine and the Public Health Center (PHC) of the Ministry of Health of Ukraine, and I-TECH gathered to discuss options for adapting proven methodologies to Ukraine’s HIV services.

PHC launched the model in December 2018 at five pilot sites across the country. In the pilot, monetary incentives were paid to individual doctors at the facilities to double efforts toward initiating new patients on ART.

PHC plans to expand the model to all 12 priority regions in the country. On the heels of COP ’19 discussions in South Africa, CDC Ukraine is looking for additional areas of the HIV cascade to which PBI could be applied to reach the FY2020 targets set by the U.S. Office of the Global AIDS Coordinator (OGAC).

The March meeting and the preceding preparatory meetings provided catalytic opportunities for identifying additional HIV services–including index partner testing, linkage to care, and loss-to-follow-up search–that could potentially benefit from the PBI model; discussing lessons learned from other PBI global initiatives; and utilizing evidence-based practices to design well-conceived and context-driven programs.

Marianne Holec, Senior Program Manager for I-TECH Zimbabwe’s voluntary medical male circumcision program; Efison Dhodho, Results-based Financing Health Specialist from the Programs Coordination Unit of the Ministry of Health of Zimbabwe; and Charbel El Bcheraoui, PhD, Assistant Professor at the Institute for Health Metrics and Evaluation (IHME) were keynote speakers at the event.

These working meetings resulted in meaningful exchanges between the guest speakers and Ukrainian experts about the successes (e.g., an increase in short-term achievement of targets and the opportunity to identify and target largest areas of need) and challenges (e.g., workplace friction, dissatisfaction with incentives, lack of teamwork, and reduced quality of care) of PBI implementation globally and in Ukraine to date.

Meeting participants appreciated the practical advice given by the guest speakers on designing effective, intentional, and sustainable PBI models for the longer term for HIV services. Experts advised developing a well-designed program that is adapted to local context; starting at a few sites and try different strategies to see what works best; gathering input from the providers as to what will work best; building in health competition between sites; and having a strong M&E framework.

With input from local stakeholders and international experts, I-TECH Ukraine has accepted the challenge of incorporating the key outcomes from the series of PBI meetings to structure the Ukrainian PBI model for HIV services. This narrative will include an outline of additional technical assistance required around its implementation.

THIS PROJECT IS SUPPORTED BY THE HEALTH RESOURCES AND SERVICES ADMINISTRATION (HRSA) OF THE U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES (HHS) UNDER U91HA06801, THE INTERNATIONAL AIDS EDUCATION AND TRAINING CENTER (IAETC). THE CONTENT OF THIS POST IS THE AUTHOR’S AND SHOULD NOT BE CONSTRUED AS THE OFFICIAL POSITION OR POLICY OF, NOR SHOULD ANY ENDORSEMENTS BE INFERRED BY HRSA, HHS OR THE U.S. GOVERNMENT.

MetaECHO Conference Examines New Frontiers in TeleHealth

Liz Blanton, M&E advisor at I-TECH, presents her poster at MetaECHO.

On March 13-16, Liz Blanton, Monitoring and Evaluation Advisor at the International Training and Education Center for Health (I-TECH), joined more than a thousand clinicians, funders, academic leaders, government officials, and public health experts for the MetaECHO™ conference in Albuquerque, New Mexico. The University of New Mexico’s Project ECHO® model aims to bring specialized health care and expertise to rural and underserved communities in the U.S. and worldwide.

Blanton presented a poster titled “An Evaluation of Pilot Project ECHO in the Republic of South Sudan and Implications for Implementation in Fragile States.” The evaluation, still in its early stages, will assess the feasibility and acceptability of the model, which is implemented by Columbia University’s ICAP and is the first of its kind in a fragile state.

It will also gauge the impact of the ECHO model – based on telementoring and case presentation from a panel of experts – on providers’ sense of self-efficacy and professional satisfaction, as well as assess outcomes at the facility and systems levels.

“It’s the outcomes piece that really interested people,” said Blanton, pointing out that most of the outcomes studies to date have been fairly small. “It’s something a lot of people at the conference were talking about: how effective is Project ECHO at improving health outcomes?”

In light of this year’s theme of “Infinite Possibilities,” there were also deep discussions about the evolution of the model and how it might be adapted to improve communication between providers and patients, not just among providers. “There were several ‘ECHO Talks’ – TED-style talks – that were really moving,” said Blanton. “Some of the best were by patient advocates,” who highlighted the need for patient-centered care.

A fireside chat with keynote speaker Dr. Don Berwick, President Emeritus and Senior Fellow at the Institute of Healthcare Improvement, underscored the question: how can ECHO teams best deliver what patients need?

Today, Project ECHO operates more than 220 hubs for more than 100 diseases and conditions in 31 countries. The MetaECHO community encompasses all those dedicated to reaching the collective goal of touching 1 billion lives by 2025.

Project ECHO at I-TECH

Several programs at I-TECH utilize the Project ECHO model as a mentoring tool and force multiplier:

  • The first I-TECH-supported ECHO program in the Caribbean was established in January 2018, with the hub site in Jamaica. In that initial year, 41 ECHO sessions were provided, with participation by nearly 300 health care workers. Topics centered on viral load suppression and also included a series on TB prevention, diagnosis, and treatment in people with HIV; tenofovir toxicity; and HIV and lymphoma. During an I-TECH assessment, it was found that the majority of complicated cases presented during ECHO sessions in the Caribbean involved patients with mental health and substance use disorders that negatively impact their ability to adhere to medication and care. Plans are under way to include a psychiatrist/mental health specialist on the ECHO expert panel, and one Wednesday per month will be focused on HIV/mental health co-morbidities. The Jamaica Ministry of Health has also requested that I-TECH include an additional 20 HIV care and treatment sites, as well as a small group of private practitioners, in the current HIV ECHO program community of practice. In service of this request, I-TECH will support the development of a second ECHO program based in Trinidad, which will be launched this month.
  • I-TECH is implementing ECHO to build the capacity of laboratory staff and improve the quality of lab services in Côte d’Ivoire. Sessions include up to 17 laboratories and nearly 30 participants apiece; topics have included management of non-conformities in laboratories. laboratory equipment preventive maintenance, best practices in HIV serology, and external quality assurance.
  • In Malawi, I-TECH supports Project ECHO in partnership with the U.S. Centers for Disease Control and Prevention (CDC), the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF), and Lighthouse Trust. The program has more than 40 participants from five different sites, and case presentation topics have ranged from tuberculosis to HIV encephalitis to Kaposi’s sarcoma. Benefits of the program include not only increased engagement of providers to discuss difficult cases, but also an improved referral system between clinics.
  • ECHO is installed and supported by I-TECH at 41 sites in Namibia, and monthly participation reaches up to 400 subject matter experts and staff. Dozens of topics were discussed during the pilot period (November 2015 to September 2016) alone – the most widely attended were on HIV disclosure to children, PMTCT Option B+, and presentation of tuberculosis. In an evaluation of the Namibia pilot, nearly 80% of participants cited that access to the expertise of HIV specialists and inter-disciplinary consultation was a major area of need for them and their clinics. Ninety-three percent of the participants reported that the presentations during the pilot ECHO sessions provided them with useful, up-to-date knowledge.

 

I-TECH and CHARESS Teams Present Lessons Learned at the Global Digital Health Forum

Casey-Iiams Hauser, Senior Informatics Implementation Specialist, presents on laboratory information systems at the Global Digital Health Forum in Washington, D.C.

The Fifth Annual Global Digital Health Forum was held from 10-11 December in Washington, D.C., attracting more than 300 participants to the FHI 360 Conference Center. At the forum, representatives from the new Digital Initiatives Group at I-TECH (DIGI) and its partner in Haiti, CHARESS, shared knowledge and lessons learned from 15 years of experience implementing digital health solutions worldwide.

The theme for this year’s forum was “A Shared Language for Digital Health,” and built on a foundation of the World Health Organization’s Classification of Digital Health Interventions.

“I welcome the messages from donors funding digital health work that they are shepherding a new era through the Digital Investment Principles,” said Joanna Diallo, DIGI Managing Director. “The conference provided DIGI an opportunity to present our contributions to global goods like OpenELIS, OpenMRS, and OpenHIE.”

Diallo moderated a panel titled “Different Labs Need Different Systems: An Exploration of Open Source Laboratory Information Systems Use in Global Health and the Community of Practice that Brings Them Together.” Jan Flowers, DIGI Faculty Co-Lead and Director of Global Health Informatics at the University of Washington Clinical Informatics Research Group, and Casey Iiams-Hauser, Senior Informatics Implementation Specialist with DIGI, were panelists, along with Steven Wanyee of IntelliSOFT, a former member of the I-TECH Kenya team.

The panel highlighted LIS as a critical component of national health information systems (HIS) architecture, exploring a complementary suite of open source LIS that are implemented across low- and middle-income countries, describing the laboratories and use cases each serves.

“The forum is a fantastic opportunity to meet with funders, on-the-ground implementers and technologists to discuss our work and learn about new initiatives and technologies,” said Iiams-Hauser. “We can leverage this knowledge for success both in our existing health information projects and in future partnerships.”

CHARESS HIS Lead Nathaelf Hyppolite participated in a session highlighting the development, implementation, and transition of EMR in developing countries, drawing on I-TECH and CHARESS’s work in Haiti. Participants heard about the benefits of an interoperable EMR: a unified data format, the ability to back up data, and that same data can be used to generate reports via DHIS2 from both the cloud servers and hardware EMR system. Hyppolite also shared the advantages and limitations of transitioning to an OpenMRS and OpenHIE platform, which bring experts together to share knowledge, standards, and best practices, as well as collaborate on technologies.

This focus on community and communication was noted by Diallo and the other participants. “DIGI really appreciated the opportunity to learn more about new standards and technologies, how to best approach digital health governance work, and how a shared language will help us collaborate and work together to ultimately improve health outcomes,” said Diallo.

Renewed Awards Totaling $24 Million Help Usher Zimbabwe Toward HIV Epidemic Control

Dr. Batsi Makunike (L), I-TECH ZImbabwe Country Director, presents Dr. Ann Downer, I-TECH Executive Director and former PI of the Zimbabwe Care and Treatment project, with a farewell gift. The batik was made by using sadza porridge to apply the dye to the fabric.

Last Saturday, 1 December 2018, marked the 30th World AIDS Day, with a focus on urging all people to know their HIV status, as well as on ensuring access to prevention, care, and treatment services for those affected by the disease. Two programs at the International Training and Education Center for Health (I-TECH) are working in concert with local partners to help make those goals a reality in Zimbabwe.

A center in the University of Washington (UW) Department of Global Health, I-TECH has worked in Zimbabwe since 2003, starting with a $150,000 grant for an assessment of the need for HIV training in the country. Since then, work in the country has expanded to two awards totaling more than $24 million for the current year—one of which focuses on HIV testing, care, and treatment and the other on voluntary medical male circumcision (VMMC) for HIV prevention.  Both projects are funded by the U.S. Centers for Disease Control and Prevention, through the President’s Emergency Plan for AIDS Relief (PEPFAR), and operate through consortia comprising I-TECH and local partners.

The consortium for the VMMC award, ZAZIC, will continue to be led by Dr. Scott Barnhart, Professor in the UW Department of Global Health and School of Medicine. However, the consortium for the care and treatment award, the Zimbabwe Partnership to Accelerate AIDS Control (ZimPAAC), has undergone a change in leadership: its new Principal Investigator (PI) is Dr. Stefan Wiktor, Professor in the UW Department of Global Health. Dr. Wiktor was handed the baton by the project’s previous Principal Investigator, Dr. Ann Downer, I-TECH Executive Director and also a Professor in the department, during a ceremony in Harare in October 2018.

“We are all so grateful to Dr. Downer for the past five years; for gently, but firmly leading us through the transition from a training and mentoring grant to a high-impact service delivery grant in five provinces,” said Dr. Batsi Makunike, I-TECH Zimbabwe Country Director. “Looking ahead, we welcome Dr. Wiktor to our team and the opportunity to tap into the wealth of experience that he brings as our new PI.”

Dr. Wiktor expressed hope that, through the continued hard work of the Zimbabwe consortium, the country will achieve its national and global targets. “Zimbabwe is one of the countries in Africa closest to reaching the UNAIDS 95-95-95 targets, and ZimPAAC is a critical partner to the Ministry of Health in that effort,” said Dr. Wiktor. “I am delighted to be working with such an outstanding team of public health professionals.”

Through ZimPAAC, I-TECH provides direct service delivery and site support for care and treatment at 372 public sector health facilities to strengthen health systems and improve the quality of care and treatment services and increase enrollment, initiation and adherence.

The VMMC project has already performed 313,267 VMMCs, as of October 2018, surpassing PEPFAR targets. The new award aims to circumcise 500,000 men over five years, resulting in the prevention of approximately 100,000 new cases of HIV.

“It has been such a privilege to work in Zimbabwe, a country that has a real chance to control the AIDS epidemic—both because of generous funding from PEPFAR and, more importantly, because of the caliber of the Zimbabwean people who live and work here,” said Dr. Downer at the handover ceremony.

“Our Zimbabwe team, consisting of both Harare- and Seattle-based members, is one of the finest I’ve ever worked with,” she continued. “Dr. Wiktor inherits a highly productive consortium that is partnering with ZAZIC and the Ministry of Health to propel Zimbabwe toward a healthier future and an AIDS-free generation.”

I-TECH’s Samantha Dolan Wins Gates Foundation Grand Challenges Explorations Award

Samantha Dolan, a Monitoring and Evaluation Advisor with the Kenya team at the International Training and Education Center for Health (I-TECH), has received the Bill & Melinda Gates Foundation Grand Challenges Explorations award. Along with I-TECH Kenya’s Ian Njeru and I-TECH PI Peter Rabinowitz, professor in the Department of Global Health, Dolan has been awarded $100,000 to conduct a project over the next 18 months to improve digital data collection and monitoring of childhood immunizations at Kenyan health facilities.

Read more about Dolan and her project on the UW Department of Global Health website–and congratulations from the I-TECH family!

Formulating Guidelines and Operating Procedures

I-TECH India PL is part of various national ART and testing guideline groups of NACO in India, including Journey of ART Programme in India; HTS Guidelines; ART Guidelines for HIV-Infected Adults and Adolescents, May 2013; National Guidelines on Second-line and Alternative First-line ART For Adults and Adolescents, May 2013; Operational Guidelines for ART Centers, July 2012; HIV/TB Guidelines, 2015; and National ART Technical Guidelines, October 2018 (http://www.naco.gov.in/care-support-treatment).

The team also assisted NACO in designing standard operating procedures for implementing newer program initiatives such as Treat All, Pre-ART mop-up, co-located ART and OST (Oral Substitution Therapy) Centres, ART through targeted intervention programs, and multi-month dispensation of ART.

Enhancement of Health Information Systems and Data Quality in India

I-TECH India PL has provided national, state, and facility level technical assistance for improving quality, analysis and presentation of ART program data; developed innovative tools for tracking program progress based on data analysis of selected indicators over a period of time and submitted for national scale-up; and provided technical mentoring to improve quality of data collection and reporting by the ART Centers at 48 sites of India in the last three years.

Building the Capacity of the Health Workforce in India

I-TECH India PL has worked with stakeholders to develop national training curricula for health care staff on delivering HIV care and treatment services. In addition, it has:

  • Planned and implemented training programs for various cadres of clinical and program staff;
  • Participated in medical officer training programs at the national level;
  • Designed and conducted five regional continuing medical education (CME) courses in North, South, West and Northeastern regions on “Invigorating HIV Care” for ART center medical officers;
  • Designed and conducted four workshops in two weeks reaching 164 ART counselors for improving care support and treatment services provided to key population clients accessing ART centre services in Maharashtra;
  • Conducted National Distance Learning Seminars (webinars)—an average of 25 sessions per year on clinical- and program-related topics for the past five years reaching over 50% of ART Centers in India, with average participation of 1000 per session. These sessions are recorded and are available on YouTube channel “I-TECH India.”
  • Conducted Regional Distance Learning Seminars (webinars)—an average of 60 sessions per year through 15 HIV/AIDS Centres of Excellence in more than six languages during the last five years reaching over 50 % of ART Centers in India, with average participation of 50 per session; and
  • Coordinated certificate courses from UW on Leadership and Management in Health, Principles of STD (Sexually Transmitted Diseases) and HIV Research, Introduction to Epidemiology for Global Health, Clinical Management of HIV, and Fundamentals of Implementation Science for over 500 individuals during the past five years.

Strengthening Health Service Delivery in India

  • I-TECH India PL has successfully designed and implemented four differentiated ART service delivery models, including models for key population clients, in collaboration with other stakeholders in states of Maharashtra, Nagaland, Manipur and Mizoram to develop a proof of concept for the national level scale up;
  • Improved delivery of health services through onsite technical mentoring and supervison of health care staff in 9% of the ART centers of the country in the last three years;
  • Technically assisted successful implementation of newer initiatives such as treatment of TB through the ART centers, the “Treat All” initiative, and routine viral load monitoring at 48 ART centers; and
  • Conducted/participated in health service delivery assessments of facilities such as the national HIV/AIDS Centers of Excellence, ART Centers, Link ART Centers, and other care and support centers for the NACO.

I-TECH India and Haiti Offices Transition to Local Organizations

I-TECH India will continue to support a complete array of educational services and technical assistance to 17 Centers of Excellence in India.

In spring 2018, the International Training and Education Center for Health (I-TECH) made University of Washington (UW) history when two of its country offices transitioned into independent organizations. I-TECH’s office in India is now the independently run I-TECH India, and its former office in Haiti now operates as CHARESS (Centre Haïtien pour le Renforcement du Système de Santé). Both organizations are sub-contractors on current I-TECH awards.

“With the India and Haiti I-TECH office transition to a local identity, we are applying what we already know about transition to creating new relationships with these independent entities,” says Dr. Ann Downer, I-TECH Executive Director and Professor in the UW Department of Global Health. “To help ensure long-term sustainability, we are working together on business plans and mapping out strategic priorities and mutual interests. This transition has intensified our partnership rather than creating distance.”

A roadmap for the university

I-TECH has worked closely with UW Global Operations Support over the past decade to inform the internal procedures and structures necessary for international office registrations. According to Doug Divine, Director of UW Global Operations Support, this work has promoted operational effectiveness by enabling a safe, compliant, and legal environment for conducting international work.

“I-TECH has been our key partner in the justification and implementation of these registrations, establishing 11 of the 15 entities registered abroad,” says Divine. “It has been so rewarding to have partnered with I-TECH on such an innovative administrative approach. Seeing these registrations become fully functioning independent entities not only fulfills a key mission of I-TECH to help establish sustained capacity where it is needed most, but also reflects the commitment of the UW community toward international engagement.

I-TECH’s close work with Global Operations Support has also prepared I-TECH India and CHARESS for success, helping to create the administrative and policy structures necessary for them to more easily fledge.

New opportunities

The team at CHARESS will continue to oversee clinical mentoring activities at 20 sites and provide technical assistance to the Ministry of Public Health and Population and other implementing partners in Haiti.

The transition of the India and Haiti offices marks new territory in I-TECH’s move toward country ownership, allowing in-country teams to simplify administration and explore funding opportunities that weren’t available to them as UW entities.

The I-TECH India team looks forward to these new opportunities. “This really opens doors to new things,” says Dr. Anwar Parvez Sayed, Clinical Programs Director for I-TECH India. “We were previously looked at as a foreign entity, and we can now apply for local grants.”

I-TECH India has provided technical assistance to 10 Indian Centers of Excellence (CoE) on HIV/AIDS since 2003. In the years ahead, it will continue to support a complete array of educational services and technical assistance to the CoE network in India, plus an additional seven pediatric sites, called pCoE.

“We will now be complying with local Indian regulations, which simplifies things,” says Madhuri Mukherjee, Country Representative of I-TECH India. “Though we no longer have the layer of Washington State and federal compliance, we will remain closely aligned with I-TECH’s and UW’s missions. It’s beneficial from both sides to maintain a close relationship.”

In fact, I-TECH India and CHARESS will each have a memorandum of understanding (MOU) with I-TECH/University of Washington. Each MOU will underscore the organization’s shared history with I-TECH and outline elements of an ongoing commitment — including being preferred partners on new funding opportunities.

In Haiti, CHARESS will continue to maintain, train, and deploy health information systems (HIS) such as iSantéPlus and the Système d’Echange d’Information de Santé d’Haïti (SEDISH), a national health information exchange. It will also ensure that the national sites for both receive on-site and remote technical assistance. In addition, the team will oversee clinical mentoring activities at 20 sites and provide technical assistance to the Ministry of Public Health and Population and other implementing partners in Haiti.

“As CHARESS, we look forward to continuing the programming that we have been so proud of,” remarks Dr. Jean-Guy Honoré, CHARESS Executive Director. “Our HIS work, in particular, has had a real impact in Haiti, and our new local status will allow CHARESS to pursue even more opportunities to become a global leader.”

An updated vision of sustainability

In its 16 years of operation, I-TECH’s ultimate goal has always been to strengthen local capacity and to help build sustainable health systems. To that end, I-TECH’s direct service and technical assistance programs are tailored from the initial planning stage to produce projects that can be successfully absorbed into national systems. Its main partner in this endeavor is always the local Ministry of Health.

At the International AIDS Society conference this year in Amsterdam, Dr. Downer presented recently completed research on six transitioned I-TECH programs (of more than 350 that have transitioned), exploring the degree to which investments had been sustained by local partners, as well as identifying the key elements of successful transition.

I-TECH’s experience with transition to local ownership and long-term sustainability of interventions aligns with those presented by Vogus and Graff (PEPFAR Transitions to Country Ownership, June 2015), including the need to plan for:

  • Communication of transition strategies through high level diplomacy;
  • Stakeholder participation in transition planning;
  • Government support of the plan, including alignment with local government policies, practices, and salaries;
  • Use of planning tools (i.e., a roadmap); and
  • Adapting approaches to the local context during transition.

“In addition to the known characteristics of successful transition of projects to local ownership, I-TECH has found that we also need to identify a champion within local government to advocate long-term for the adopted interventions,” says Dr. Downer. “We also need to plan intentionally for how much and what type of technical assistance or short-term funding will be needed in order to ensure sustainability.”

Doug Divine sees massive benefits at each stage of I-TECH’s country office relationships, from registration to independence. “Without I-TECH and the projects it has spearheaded, I’m not sure UW would have made the advancements it has made on the international front,” he says. “I-TECH had the vision, the infrastructure need, and the boots on the ground — which gave us impetus to set up structures for the rest of the university. Other departments can now leverage those resources, and now the spin-off offices fulfill our commitment to allow these structures to grow in their own context.”