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MOU Signed with the Ukrainian Centre for Socially Dangerous Disease Control

From L to R: Igor Kuzin, Head of the National M&E Center at UCDC; Dr. Natalia Nizova, Director of UCDC; Matt Heffron, I-TECH Informatics Implementation Specialist; Anna Shapoval, I-TECH Ukraine Country Director; and Mykhailo Rabinchuk, PR and Event Manager at UCDC.

From L to R: Igor Kuzin, Head of the National M&E Center at UCDC; Dr. Natalia Nizova, Director of UCDC; Matt Heffron, I-TECH Informatics Implementation Specialist; Anna Shapoval, I-TECH Ukraine Country Director; and Mykhailo Rabinchuk, PR and Event Manager at UCDC.

On March 11, the University of Washington Department of Global Health (DGH) signed a Memorandum of Understanding (MOU) with the Ukrainian Centre for Socially Dangerous Disease Control of the Ministry of Health of Ukraine (UCDC).

This landmark event consolidated cooperation between the International Education and Training Center for Health (I-TECH) — a DGH center — and UCDC. This partnership started in 2013 with the launch of the I-TECH-developed Clinical Assessment for Systems Strengthening (ClASS) tool within a project to build clinical and managerial capacity of HIV/AIDS services in Ukraine.

All parties expressed confidence that this MOU would help foster relationships and the development of possible collaborative projects in capacity building, monitoring and evaluation, and research aimed at quality improvement of health care services in Ukraine.

“I-TECH is very excited about this new development in our collaboration with UCDC,” said Anna Shapoval, Country Director of I-TECH Ukraine. “The MOU will help to formalize, fortify, and, hopefully, expand our partnership with the UCDC in the coming year and beyond —  in particular in the area of health systems strengthening through development of human resources for health and supporting strategic information systems.”

Faculty Partnerships with University of Namibia Lead to Strengthened School of Public Health

UNAM School of Nursing Science and Public Health

UNAM School of Nursing Science and Public Health

Despite a decrease in the estimated annual HIV/AIDS incidence since 2001, HIV/AIDS remains a significant source of morbidity and mortality in Namibia.[1]

In 2008, the International Training and Education Center for Health (I-TECH) at the University of Washington (UW) was invited to conduct a rapid assessment of the University of Namibia (UNAM) master’s degree program in public health, with the goal of identifying ways to strengthen UNAM’s School of Nursing Science and Public Health. Dr. Virginia Gonzales, Senior Lecturer in the UW’s Department of Global Health and Senior Technical Specialist with I-TECH, led that study along with Lee Pyne-Mercier, UW Affiliate Instructor and former I-TECH Country Program Manager.

New award based on study findings

Recommendations included the suggestion that UNAM attract lecturers from outside the university to strengthen teaching in subjects such as research methods, epidemiology, and biostatistics. Based on these and other findings from the assessment, UNAM and UW/I-TECH submitted a joint application to the US Centers for Disease Control and Prevention (CDC) and were awarded a five-year cooperative agreement in 2010, with Dr. Ann Downer, Executive Director of I-TECH, serving as principal investigator.

The goal of the agreement was to improve and enhance the UNAM School of Nursing Science and Public Health. Objectives for this project included:

  • Plan for sustainability and transfer of resources to UNAM.
  • Strengthen professional development and faculty support at UNAM.
  • Strengthen content and delivery of the MPH program at UNAM.
  • Improve research capacity and output of lecturers and students at UNAM.
  • Strengthen institutional capacity and infrastructure for teaching public health at UNAM.

With this new award, I-TECH/UW and UNAM embarked upon a series of faculty partnerships. The group also began to explore how to separate the UNAM School of Nursing Science and Public Health into two programs, creating both a School of Nursing and a School of Public Health. The UNAM Senate issued a proclamation in 2014 that this would occur.

“The focus of curriculum [in the new School of Public Health] will be needs-driven,” says Dr. Käthe Hofnie Hoëbes, Associate Dean of the UNAM School of Nursing Science and Public Health, “and it will support new job growth in Namibia, as it promotes the creation of new cadres of public health specialization.”

From partnership comes growth

Retreat with UW and UNAM faculty, 2009

Retreat with UW and UNAM faculty, 2009

The CDC award has now come to an end; however, through this project, UW and UNAM created 16 strong faculty partnerships, all determined by the priorities of the UNAM faculty through a Public Health Working Group (PHWG).

“The benefit of working with the PHWG was one of the key takeaways from this project,” says Dr. Gonzales. “It ensured that UNAM was in the position to offer continual input, guide project activities, and truly lead the project.”

The faculty partnerships occurred in health policy, bioethics, nutrition, research, environmental health, and epidemiology, linking interested faculty at UW and UNAM. Through these relationships, UW faculty visited the main UNAM campus in Windhoek to facilitate workshops and review curriculum, and the UNAM faculty visited UW to observe classes and work on curriculum revision.

As a result of the trust among faculty at both universities, partnerships evolved in unexpected areas as well, including social work, nursing, medicine, pharmacy, teaching technologies, and with the Namibian Ministry of Health and Social Services’ (MOHSS) Primary Health Care Program.

“Working in partnership was a cross fertilizing, fulfilling and enriching exercise for all of us who were involved,” says Magdaleena Nghatanga, former Director of the Directorate of Primary Health Care, MOHSS. “Across the ocean we shared experiences and professional expertise. Utilizing technology such as Skype, Dropbox, and e-learning helped the team in developing and revising the curriculum, as well as in building and improving teaching at the university level. As a result, the Primary Health Care Program and curriculum were revised and updated, and the students were thrilled with the new lectures.”

Outcomes echo throughout the country

Leaders in Health--Namibia! working group, 2010

Leaders in Health–Namibia! working group, 2010

The collaboration also focused attention on teaching skills, and evaluations of faculty by students at UNAM improved considerably. In addition, UNAM graduates reported improved skills and knowledge in HIV/AIDS, nutrition, health policy, epidimiology, and research and increased knowledge of and interest in public health. Thesis supervisors at UNAM reported greater skills in supervision and student mentoring, and UNAM lecturers reported increased knowledge, skills, and confidence in teaching course materials.[2]

The workshops offered on learning theory and teaching skills were later scaled to all of UNAM, including remote campuses. Several faculty also participated in the Leaders in Health – Namibia! (LIH) program that was designed by I-TECH/UW in collaboration with the MOHSS in order to strengthen the health care delivery system in Namibia through effective mentoring of health leaders and managers. The UNAM faculty who participated in LIH later improved course content on leadership and management at UNAM by using material and content from LIH.

“This partnership has yielded benefits on many fronts,” says Dean Hofnie Hoëbes. “Lines of collaboration have been initiated with other world-class universities, and technical support was provided for the roadmap for establishing a standalone School of Public Health. This will benefit the nation as a whole by supporting public health care in the country and preparing a larger, professional workforce with specialized skills to address shortages in public health practitioners in Namibia.”


[1] Namibia Global Health Initiative, 2011-2015/16.

[2] University of Namibia and I-TECH Namibia. Evaluation of the Impact of the UNAM/I-TECH Collaboration upon the Master of Public Health Program, 2009-2012. 2013.

Tablets Help Tanzanian Health Care Workers Upgrade Skills

Students in Kilosa, Tanzania, try out the new tablet app.

Students in Kilosa, Tanzania, try out the new tablet app.

In November 2014, the Tanzania Ministry of Health and Social Welfare (MOHSW) launched a program that allows practicing Clinical Assistants to upgrade to the level of Clinical Officerthe first MOHSW distance learning program in Tanzania to use tablet computers to deliver medical course material.

The International Training and Education Center for Health (I-TECH) and the University of Washington Department of Global Health’s e-learning group (eDGH) collaborated with the MOHSW on the In-Service Programme for Ordinary Diploma in Clinical Medicine, a blended distance learning program.

Credential upgrades expand the range of health care services that these practitioners can provide, including care and treatment of HIV and AIDS. They are also expected to have a positive impact on retention of healthcare workers. The use of tablet technology makes these upgrades more convenient and accessible.

“Working students need learning that will not take them off their workstations for relatively long periods of time,” says Dr. Fabian Mghanga, Principal of Mtwara Clinical Officers Training Center. “Being appropriate to their situation and context, this tablet e-learning [program] provides answers to their demands.”

Support for this project was provided through the U.S. President’s Emergency Fund for AIDS Relief (PEPFAR) by the U.S. Department of Health and Human Services’ Health Resources and Services Administration (HRSA). Programmatic oversight was provided by the U.S. Centers for Disease Control and Prevention (CDC) in Tanzania.

A comprehensive educational experience

Sixty-five students have enrolled in the inaugural cohort.

Sixty-five students have enrolled in the inaugural cohort.

I-TECH has worked with the MOHSW since 2010 to redesign the Clinical Officer upgrading program to align with current clinical guidelines and competency-based training approaches. Sixty-five students, based at health facilities throughout the country, have enrolled in the inaugural cohort, at three Clinical Officer Training Centers based in Kilosa, Mafinga, and Mtwara. Scale-up to additional training centers is planned for next year.

The new two-year Clinical Officer upgrading program incorporates three modalities: self-paced learning using interactive e-learning materials on tablet computers, face-to-face classroom activities and instruction, and hands-on practical training in clinical settings.

Upon completion of all course requirements, students will earn a Diploma in Clinical Medicine after achieving a passing mark on the National Qualifying Examination.

An app for self-directed learning

Learning materials for the  In-Service Programme for Ordinary Diploma in Clinical Medicine.

Learning materials for the In-Service Programme for Ordinary Diploma in Clinical Medicine.

I-TECH and eDGH instructional designers and e-learning specialists collaborated with the MOHSW to design a digital textbook application for the Android platform. Students will complete e-learning modules using this app during self-study periods.

The app is designed to enhance self-directed learning by embedding interactive quizzes, anatomy tutorials, and other learning exercises into the course text. It also includes full-color photos and videos that are not available in the traditional residential training program.

MOHSW and training center representatives designed the course schedule and clinical rotation plan, provided clinical review, app testing, and assisted in the design of learning exercises.

“This modality of learning is quite amazing,” says Dr. Mghanga. “Our students can learn almost anything, wherever they are, at their own time and pace, yet feel they are no less [informed] than the on-campus students.”

Preparing for sustainability

In preparation for the official launch, I-TECH officially handed over all teaching and learning materials, including a donation of 73 tablet computers, to the Human Resource Development Department of the MOHSW. Tablets were distributed to students and faculty at each participating training institution.

I-TECH and the MOHSW conducted a faculty orientation to prepare principals and instructors at each training institution to successfully facilitate a distance learning program. In turn, training center faculty conducted student orientations at each site during the first face-to-face session.

In the coming weeks, the MOHSW and I-TECH will orient distance education mentors based near students’ homes, who will support students during practical rotations.

I-TECH will evaluate the first year of course implementation, and results will inform future scale-up and transition planning with the MOHSW to help ensure a sustainable program. To further support sustainability, the MOHSW has established a revolving fund to purchase tablets for future student cohorts.

E-Learning Increases Accessibility to HIV Diploma Program in the Caribbean

HIV Diploma Program in the Caribbean

Students of the graduate diploma program in the management of HIV infection have the opportunity to receive instruction from a hand-selected group of experts. Photo courtesy of Ben Depp.

In the Caribbean, an estimated 250,000 people are living with HIV (UNAIDS, 2013).  To address this epidemic, health workers must have the latest information to guide the treatment and care of those living with HIV and AIDS. The University of the West Indies (UWI) St. Augustine campus in Trinidad and Tobago offers a one-year graduate diploma program in the management of HIV infection.

In partnership with UWI and the Caribbean HIVAIDS Regional Training Network (CHART), the International Training and Education Center for Health (I-TECH) and University of Washington Department of Global Health’s eLearning Program (eDGH) helped to transition the program to a blended learning platform — one that offers courses online as well as an in-person practicum.

Support for this transition was provided by the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) through the Department of Health and Human Services’ Health Resources and Services Administration (HRSA).

The program recently completed its first semester in this new format. With the expanded platform, students have the flexibility to access the course material “anytime and anywhere,” says Professor Zulaika Ali, Program Coordinator, “and it allows students to organize their training around their routine activities, which is important for mature working individuals.”

The conversion of courses online creates a one-of-a-kind program in the Caribbean, increasing access for mid-career health professionals working in the public sector, for non-governmental organizations (NGOs), and for commercial organizations. The program was designed for medical doctors, pharmacists and dentists, as well as nurses with bachelor degrees from any recognized university; registered nurses with a minimum of three years of experience; social workers; management staff from government ministries, private sector and NGOs; and tutors and lecturers in training institutions.

After a week-long online student orientation, students explore the following topics through online instruction and relevant resources, synchronous virtual classroom sessions, and collaborative activities and discussions. At the end of each semester, students complete an in-person exam. After completion of the online courses, students participate in an in-person practicum or dissertation. Courses include:

  • Research Methods and Design
  • HIV Epidemiology and Pathogenesis
  • Laboratory Techniques for Diagnosis of HIV
  • General Management of HIV/AIDS
  • HIV Co-Infection and Other Related Issues
  • HIV Health Systems
  • Sexual and Reproductive Health

In addition to the flexibility this part-time program offers, students also have the opportunity to receive instruction from a hand-selected group of experts from around the globe, including professors, health care workers from the Ministry of Health and NGOs, and professionals practicing in the region.

Transition from in-person to blended learning

In late 2013, I-TECH and eDGH were approached by UWI to convert the in-person diploma program into its second, blended rendition. The team started by piloting two courses online in the Moodle learning management system (LMS). From there, they obtained critical feedback for the remainder of the conversion.

Their research showed that students felt the course content was clear, appropriate, interesting, and applicable to their work and reported a preference for recorded lectures and relevant videos, anytime/anywhere access, and interactions with instructors and peers. Likewise, faculty enjoyed building new skills through online instruction.

“We conducted two in person, on-site faculty workshops, countless Skype calls, online trainings, and emails to build the capacity of faculty to develop and teach online,” says Elizabeth Scott, Senior E-Learning Developer with eDGH. “Working with faculty was a highly rewarding experience. They were motivated and dedicated, and they worked tirelessly side-by-side with us to create the best possible experience for students.”

As part of the project, the I-TECH/eDGH team also developed a commercial for the program (see below), as well as a number of introductory materials that can be used for a variety of online and blended learning programs. Among them are a general student orientation to help learners identify skills and characteristics necessary for success in online courses and an e-learning basics module for instructors.

“The informational materials developed for the program will help to improve the delivery of health care more generally,” says Dr. Ali.

A robust transition guidebook was also assembled, containing roles and expectations, best practices, online orientation materials, processes, budgeting templates, evaluation tools, job aids, and tasks and timelines for faculty and staff for ease of handover from year to year.

“The delivery of this program in the blended format will have a tremendous impact on the quality of care delivered to people infected with and affected by HIV,” says Dr. Ali. “The Faculty of Medical Sciences looks forward to welcoming regional and international students into the program. This new platform will surely enrich the learning experience of all involved.”



Stories of Success from Ethiopia: Mother’s Support Groups for PMTCT

In Mothers’ Support Groups, trained mentors counsel HIV-positive pregnant women and mothers on optimal child-rearing practices and encourage them to adhere to PMTCT programs. Photo courtesy of Julia Sherburne.

The following is the second in a three-part series of I-TECH success stories from Ethiopia.

In Ethiopia, only 24 percent of HIV-positive pregnant women receive antiretroviral therapy (ART) to prevent transmission of the virus to their children (UNICEF, 2012). The importance of counseling for these pregnant women is critical to increase treatment rates and ensure more children are born HIV-free.

In 2009, the International Training & Education Center for Health (I-TECH), with support from the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), began managing support groups for HIV-positive pregnant women and mothers in three regions of Ethiopia: Axum, Gondar, and Dubti.

This case management program, which came to a close at the end of 2014, was the first of its kind in the country, training a group of 63 mentors to counsel pregnant HIV-positive mothers on optimal child-rearing practices and offering psychosocial support to help them adhere to prevention of mother-to-child transmission (PMTCT) programs.

Yirgalem Taye is one of the trained mentors from the Mother’s Support Group based at St. Mary’s Hospital in Axum, Northern Ethiopia.

In addition to urging mothers to follow treatment regimens, “we encourage mothers to give birth in a hospital to reduce the risk of transmission during delivery,” says Yirgalem. “We teach mothers breastfeeding practices, family planning, as well as the importance of disclosure to a partner and the need to get all partners to come and test with us.”

Offering consolation, solidarity, and friendship

Alem Tsehaye sits by a bowl of smoldering frankincense while playing with her 7-month-old baby girl, Heyab.

In 2009, Alem tested HIV-positive, forcing her to change her plan to move abroad and work as a domestic servant. In 2013, she became pregnant, which caused anxiety about the well-being of her child.  She enrolled herself in the Mother’s Support Group at St. Mary’s Hospital and started to receive counseling.

“I learned that it’s possible to be HIV-positive and have a HIV-negative child,” says Alem, “which might not have been possible had I not joined the group.”

Alem notes the consolation and solidarity she derived from spending time with other young mothers in the support group. “If one of us came to the group feeling low, we would build each other up again,” she says. “I have made new friends. Between us we continue sharing the support within the community.”

One of the biggest challenges facing a woman diagnosed with HIV is disclosure to her husband. If a person with HIV status fails to make a disclosure to his or her partner, the uninformed partner becomes a risk to home and community health. One role of a Mother’s Support Group mentor is to mitigate this risk by encouraging group members to inform their partners so that they can be tested without delay.

Real results for child and mother

From 2009 to 2014, nine hundred mothers were enrolled in the mentorship program at Gondar University Hospital. Out of those 900 births, only 72 infants – or 8 percent – tested HIV-positive. The World Health Organization estimates that, in the absence of any intervention, transmission rates can range from 15-45 percent.

Outside the Mother’s Support Group ward at Gondar University Hospital is a courtyard where a group of young mothers sit doting over their babies. Many of these mothers do not have an appointment but have come to see their mentors.

“The mothers love the support and security of this small community group,” says Rachel Birhanu, a mentor. “The mentors attend their children’s birthdays and ceremonies. We have become close. They confide in us and know we are the few people who will listen and not judge them.”

The I-TECH program may have come to an end, but the Mother’s Support Groups are acknowledged for their comprehensive service delivery and for their successful efforts to reduce the number of HIV-positive babies born in Ethiopia – and to increase the productivity and well-being of HIV-positive mothers.

Helen Alebachew has two children. In 2007 she discovered her HIV-positive status after undergoing a test while suffering from tuberculosis. She says she benefited from learning about HIV-friendly family planning practices and coping strategies within the group.

“The solidarity I experienced in the mother’s group saved me from losing my mind,” Helen says while roasting coffee beans in a pan over a small fire.  “After starting ART treatment, I made a fast recovery and was soon living a normal life again.”

Haiti’s Electronic Medical Records System iSanté Proves Useful Tool to Improve Patient Outcomes

For nearly a decade, iSanté has allowed providers to share information among care team members and health professionals.

For nearly a decade, iSanté has allowed providers to share information among care team members and health professionals.

Over the past several years, the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) has invested heavily in health systems and clinical data analyses in low-income countries around the world, in its efforts to support the care and treatment of those affected by HIV and AIDS.

With the support of PEPFAR, through the Health Resources and Services Administration (HRSA), in 2005, the International Training and Education Center for Health (I-TECH), together with Haiti’s Ministère de la Santé Publique et de la Population (MSPP) and the U.S. Centers for Disease Control and Prevention (CDC), developed and implemented iSanté — an electronic medical record system to capture and report information on patients living with HIV and AIDS.

For nearly a decade, this system has allowed providers to document HIV patient care, look up patient care histories, and share information between care team members and health professionals.

The MSPP has been particularly concerned with patient adherence to antiretroviral therapy (ART) and treatment failure due to a number of factors, including the 2010 Haiti earthquake. While iSanté has gotten kudos in Haiti for storing and linking patient data, three recent papers, lead-authored by I-TECH Research and Evaluation Advisor Nancy Puttkammer, have illustrated the potential of using this data source to identify and help solve the challenges of adherence and patient attrition.

  • Before and After the Earthquake: A Case Study of Attrition from the HIV Antiretroviral Therapy Program in Haiti,” published in Global Health Action in August 2014, compared attrition from the national HIV ART program at two large public-sector hospitals where I-TECH works. One site was less than 30 km from the epicenter of the devastating earthquake of January 2010, while the other site was outside of the area strongly affected by the earthquake. Surprisingly, the paper showed that attrition improved after the earthquake in the site closest to the epicenter. This finding underscores the resilience of patients and providers, and contributes evidence that it is possible to maintain continuity of HIV services even in the context of a complex humanitarian emergency.
  • “Patient Attrition from the HIV Antiretroviral Therapy Program at Two Hospitals in Haiti,” currently in press at the Pan American Journal of Public Health, examines ART attrition at the same two hospitals, during the period 2005-2011. The study found higher risk of attrition among patients who lived farther away from the hospital, who started on non-standard ART regimens, who did not receive ART adherence counseling before initiating ART, and who rapidly started ART following their enrollment in HIV care and treatment. The findings suggest opportunities for several quality improvement interventions at the two hospitals.

“This research has provided a valuable contribution in documenting health outcomes and encouraging improvement in the ART program in Haiti,” says Dr. Scott Barnhart, Professor of General Internal Medicine and Global Health at the University of Washington. “We are at the dawn of translating large investments in EMRs into useful data for improving the care of patients, as well as supporting important pub

TrainSMART Database Customized for Ebola Response

The Training System Monitoring and Reporting Tool (TrainSMART), a web-based training data collection system designed by the International Training and Education Center for Health (I-TECH), was recently tapped by the U.S. Centers for Disease Control and Prevention (CDC) Ebola Emergency Operations Center. I-TECH is a center within the University of Washington’s Department of Global Health.

The CDC approached the TrainSMART team to create databases to track safe handling procedures and training of health care staff at non-Ebola health care facilities – that is, facilities not solely focused on Ebola but likely to receive infected patients when they first seek care. Databases were configured for Liberia and Sierra Leone in a matter of days using existing TrainSMART functions, which allow the system to be customized for local needs.

Trainings tracked by the CDC will include basic infection control, sprayer training, community-level (non-health care worker) training, and training of trainers, among others.

TrainSMART is an open-source, web-based software built on technologies appropriate to contexts with limited resources, expertise, and connectivity. The system allows users to accurately track data about health training programs, trainers, and trainees, to better evaluate training programs, plan new programs, and report activities to stakeholders.

The initial development of TrainSMART was funded by a grant administered by the U.S. Health Resources and Services Administration (HRSA) through the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR).

For more information, contact the Digital Initiatives Group at I-TECH (DIGI).

KenyaEMR Implemented at More Than 340 Sites in Under Two Years

The I-TECH Kenya team celebrates implementing KenyaEMR at more than 340 facilities -- along with a congratulations card from I-TECH HQ.

The I-TECH Kenya team celebrates implementing KenyaEMR at more than 340 facilities — along with a congratulations card from I-TECH HQ.

A shifting government structure, power outages, and even the threat of crocodiles didn’t deter the International Training and Education Center for Health (I-TECH) from implementing the electronic medical records system KenyaEMR at more than 340 clinics and district hospitals across Kenya.

One of the largest EMR rollouts in Africa, this work was supported by the U.S. Health Resources and Services Administration (HRSA) and the Centers for Disease Control and Prevention (CDC) through the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR).

When PEPFAR care and treatment partners in Kenya identified lack of timely and complete patient data as a major barrier to effective HIV/AIDS patient management, I-TECH and in-country partners set out to design and develop KenyaEMR, expanding on the OpenMRS platform to build an EMR system to collect health data and improve patient care.

These efforts were first led by I-TECH Kenya’s then-Country Director, Dr. Patrick Odawo, and were assumed by his successor, Dr. Willis Akhwale, supported by dedicated teams in Nairobi and at Seattle headquarters.

Challenges along the way

The KenyaEMR team wades across the Turkwel River.

The KenyaEMR team wades across the Turkwel River.

This was no small feat – there were many obstacles overcome to equip the sites in just under two years.  Among these were the devolution of the Kenyan government to a county-based government halfway through the implementation, lack of reliable power, and establishing server rooms in facilities that were never designed to protect electronic systems.

In fact, Implementation Assistant Wilfex Terer remembers obtaining an escort and wading across a crocodile-infested river to reach a health facility in North Rift Valley, one of the most remote areas of Kenya.

“Because of high insecurity in the southern parts of Turkana County, we hired two Kenya police reservists to provide security escort,” says Terer. “We then left our vehicle and waded across the Turkwel River to a health facility vehicle awaiting us on the other side. After some minutes we arrived at the facility in wet clothing.”

Implementing the system

KenyaEMR is a customized system that supports the care and treatment of HIV/AIDS. The system was designed and developed by I-TECH and partners in 2012, following Standards and Guidelines developed by I-TECH in collaboration with the Kenyan Ministry of Health.

The pre-implementation phase comprised engaging stakeholders, specifically the Kenyan Ministry of Health, forming technical working groups to share strategies, and assessing the networking and hardware at the facilities.

Particularly important to effective implementations were sensitization meetings with county, hospital, and facility administrators to build their awareness of the benefits of KenyaEMR and to obtain their support for its implementation and operations.

During implementation, the team purchased hardware, installed intranets, and set up and deployed the software. This phase also included mentorship and on-the-job training: I-TECH supports use of the system by building the capacity of Health Managers and through on-site training to mentors, who then train staff at local facilities.

This approach to capacity building allowed I-TECH to maximize training time, build local capacity, and ensure sustainability when staff transition to other facilities. To date, I-TECH has oriented 625 Health Managers and trained 1,409 system users and champion mentors.

The future of KenyaEMR

Wired for a training in North Rift.

Wired for a training in North Rift.

Post-implementation, I-TECH is providing ongoing software maintenance, support for use of system, and guidance on data use for patient monitoring.  I-TECH is working on expanding the functionality to handle pharmacy and laboratory orders, as well as additional functions at the facility.

“The main focus now is on improving meaningful use of data and defining exactly what that is,” says Steven Wanyee, Implementation and Interoperability Manager.

One example of “meaningful use” is that physicians and other health workers can now see a summarized profile before meeting with a patient, which helps improve quality of care and physician decision making.

Likewise, at the policy level, an electronic database means that various stakeholders in Kenya can collect public health data to assist them in assessing needs and making broad-reaching policy decisions.

“EMRs have been seen as very useful in discussions about the HIV treatment cascade,” says Wanyee, and there is interest in finding out how KenyaEMR can help to identify gaps.

“This project does more than just save space dedicated to paper records,” he continues. “It helps to inform and improve patient care at every level.”

UW Physician Delivers Keynote at Groundbreaking Ukrainian Conference

Dr. Joseph Merrill speaks at the Ukrainian National Conference.

Dr. Joseph Merrill (left) speaks through an interpreter at the Ukrainian National Conference.

On Sept. 25-26, Ukraine hosted “The Principles for the Management of Drugs, Psychotropic Substances and Its Precursors in General Practice Settings,” the first national conference of its kind. Initiated and organized by the International Renaissance Foundation (IRF) and other international and national stakeholders, including the International Training and Education Center for Health (I-TECH), the event brought together more than 300 experts, including general practitioners and family physicians, state officials, policy makers, infectious disease doctors, narcologists, psychiatrists, and palliative care providers.

The key goal of the conference was to educate primary health care providers on the application of controlled substances in key areas of their practice – such as medication assisted treatment (MAT), often referred to as opioid substitution therapy (OST); palliative care; and mental health – as well as initiate a dialogue about decentralization of these services through primary health centers (PHC) and coordination with specialized facilities and medical specialists.

Joseph Merrill, MD, MPH, an internal medicine physician and associate professor in the University of Washington’s Department of Medicine, delivered a keynote speech on OST in the practice of the family doctor. He also facilitated a day-long section on OST in partnership with local OST expert Vadim Klorfain, MD, from Poltava.

“Dr. Merrill’s contribution was greatly appreciated by the IRF and other conference organizers,” said Anna Shapoval, I-TECH Ukraine Project Director. “His successful participation in the conference seems to indicate a promising start to expanding I-TECH’s activities in this area in the future.”

Topics discussed included the basics of addiction and measuring success in addiction treatment; OST with methadone and buprenorphine; co-occurring medical and psychiatric conditions such as HIV infection, depression, tuberculosis, and viral hepatitis; and the advantages of integrating OST into the practice of family doctors.

Dr. Merrill says the last topic is particularly important to ensure increased access to care. “With the current siloed system, specialties have narrowly defined roles, which often has a negative impact on people with co-existing problems, such as HIV, mental health, and addiction,” says Dr. Merrill. “These individuals currently have to access multiple systems to get reasonable care.”

He also cites efforts to integrate HIV specialists into OST sites as a step in the right direction, as the HIV epidemic in Ukraine is driven in large part by injecting drug users and their sexual partners.

Dr. Merrill had the opportunity to visit an overburdened OST site at the City Clinical Hospital #5, next to the Kyiv City AIDS Center. “There were too many patients for the amount of staff, and there wasn’t any onsite counseling or psychosocial treatment when I was there,” he says. “We continue to have the same issues here in the U.S., where it is easier to implement medication than the treatment around the medication.”

To inform efforts to bring this care into family practice, Ukraine hopes to learn from the experiences we’ve had in the U.S., he says.

Recent health care reform, still under way in Ukraine, brought significant changes in legislation and regulations that now enable access to narcotic, psychotropic, and precursor substances at PHC facilities. The 2013-2020 National Drug Strategy of Ukraine envisions development of a humanistic model of drug policy, moving away from law-enforcement approaches to prevention and treatment, including broadening access to controlled substances – such as OST – to those patients in need.

“Ukraine is in a crisis situation, and that is both an obstacle to change and an opportunity for change,” says Dr. Merrill. “They are making a really strong effort to change their health care systems for the better, and they seem to really rally around each other and try to move forward in spite of the challenges they face.”

Collaborative Creates ‘Culture of Quality Improvement’ in Jamaica

A JaQIC team's storyboard illustrates inspiration points and accomplishments.

A JaQIC team’s storyboard illustrates inspiration points and accomplishments on the journey toward quality improvement. Storyboards are a creative way for teams to learn from one another.

Despite strong clinical capacity, systemic barriers may prevent local care teams from executing CD4 count and HIV viral load tests. These tests are critical for monitoring the health of people living with HIV — and their response to antiretroviral therapy (ART).

In response to this challenge, in October 2013, ten treatment sites from the four Regional Health Authorities kicked off the Jamaica Quality Improvement Collaborative, or JaQIC (Ja-quick).

The collaborative is led by the International Training and Education Center for Health (I-TECH), in partnership with the Caribbean HIV/AIDS Regional Training Network (CHART), and supported by the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) through the U.S. Health Resources and Services Administration (HRSA).

The project is coordinated by I-TECH Senior Quality Improvement Advisor Shay Bluemer-Miroite, with Dr. Chris Behrens, Clinical Associate Professor of Medicine, Family Medicine & Global Health at the University of Washington, serving as clinical advisor.

“The aim of the project was to significantly increase CD4 and viral load testing by March 2014, and it succeeded in that in all ten sites,” said Bluemer-Miroite, noting that within six months, JaQIC was seeing measurable results. (In fact, from baseline to March 2014, sites improved incidence of CD4 testing by up to 34 percentage points.)

“But,” she added, “the collaborative has achieved so much more than that.”

Working Together to Improve Quality

Building on the existing investment in training and capacity development, quality improvement collaboratives such as JaQIC empower frontline health care workers to implement best practices and improve quality of care.

They also rely on the knowledge of existing clinical care teams, who are most familiar with health systems challenges and best positioned to identify solutions to resolve them. These challenges run the gamut from the availability of patient forms, to problems with transport of samples, to equipment failures during sample processing.

Through the collaborative, sites identify potential problems that can crop up at each step in the process, test these ideas via plan-do-study-act (PDSA) cycles, and share learning. As JaQIC teams gathered during a series of Learning Sessions to “share seamlessly, steal shamelessly,” they not only improved the quality of care, they also built excitement for quality improvement and demonstrated that frontline staff can make impactful changes.

Far-Reaching Impact

“Programs struggle with obtaining the data to prove that they are having an impact,” said Bluemer-Miroite. “Through the collaborative, tracking data became particularly meaningful to the health care teams – because they were the ones who were using the data. By tracking patient-level data from the outset, it’s easy to see how the quality of care is being affected, and it increases the data quality, too.”

The success of the program has led to the buy-in of the Jamaican Ministry of Health (MOH) – so much so that the MOH has added the role of QI Coach to its Treatment, Care and Support Officers (TCSOs), and all of the collaborative’s activities will fully transition to the MOH in December.

The collaborative has also spread to four additional countries in the Caribbean (CaReQIC): Trinidad and Tobago, Barbados, the Bahamas, and Suriname, which have joined a new group from Jamaica to form CaReQIC. While gearing up for CaReQIC Learning Sessions, coordinators realized that more foot soldiers would be needed to liaise with the sites directly, so I-TECH helped to develop training for a cadre of QI Coaches in all five countries.

The effects of this program will be far-reaching, even after its transition.

“What’s really exciting about JaQIC is its potential for a sustained impact on multiple levels,” said Dr. Behrens. “JaQIC has dramatically increased rates of CD4 and viral load testing via systemic changes that are likely to persist into the future. More importantly, however, JaQIC has introduced a ‘culture’ of quality improvement in the region that has been enthusiastically adopted across a broad spectrum of local and regional stakeholders.”