Since 2017, I-TECH worked closely with the Ministry of Gender Equality and Child Welfare, Ministry of Health and Social Services, UNICEF, Centers for Disease Control and Prevention, and the Namibia Statistics Agency to implement a nationally representative survey on youth experiences as well as HIV incidence and prevalence. Survey results will inform policy and practice to improve the overall well-being of children and young people in Namibia and further focus HIV prevention efforts.
Survey collaborators are in the process of data analysis with a final report expected in early 2020. I-TECH will continue to support these efforts as well as continue to work to strengthen HIV prevention and promote the overall well-being of youth in Namibia.
In 2017, I-TECH began the DREAMS program in Khomas and Zambezi regions. The DREAMS program aims to reduce HIV infections among adolescent girls and young women (AGYW) through a core package of evidence-based interventions across health, education, and social sectors. At a safe space such as a school or community center, participants meet with a mentor who is trained to deliver a curriculum focused on the prevention of HIV and gender-based violence (GBV). Mentors help AGYW build strong social networks and empower them to make healthy and positive decisions. AGYW can also access on-site services like HIV testing, family planning, PrEP, counseling, and screening for GBV to protect against HIV infection. I-TECH has supported over 150 safe spaces since its launch and enrolled over 20,000 AGYW in the program.
I-TECH also supports programming for caregivers through the Families Matter! Program, which promotes healthy communication between parents and AGYW around HIV and GBV topics. I-TECH works closely with the Ministry of Education, Arts, and Culture; Ministry of Gender Equality and Child Welfare; Ministry of Health and Social Services; Centers for Disease Control and Prevention; and other implementing partners.
In South Africa, the International Training and Education Center for Health (I-TECH) has begun facilitating an in-service skills development training program for community health workers (CHWs) and their supervisors in their roles on the Ward-Based Primary Health Care Outreach Team (WBPHCOT). To maximize the impact of this training, I-TECH is working with two PEPFAR District Support Partners across seven of South Africa’s nine provinces to reach an estimated 20,000 CHWS, which is approximately half of the country’s CHW workforce. Training began in February 2019 and will continue through September 2019.
The WBPHCOT In-Service Skills Development Package aims to strengthen the capacity of CHWs to provide high-quality health services in the community. The program emphasizes development of core, cross-cutting service delivery skills, including communication, screening, psychosocial support, ethics, and confidentiality that enable CHWs and their supervisors, known as Outreach Team Leaders (OTLs), to effectively carry out their work.
During training, CHWs and OTLs build their skills in both classroom and on-the-job settings using group discussions, case presentations, scenario-based role play, small group activities, and interactive presentations. Priority health conditions and related clinical topics are included, and the realistic scenarios cover all components of the CHW scope of work.
Snapshot of the app used to capture training data.
Leveraging Technology to Improve Training
All training data collected for the skills development program will be captured via a mobile application and stored using the CommCare platform, a mobile data collection system developed by Dimagi. The app allows I-TECH access to real-time data, which can inform targeted measures to ensure that all CHWs are receiving high-quality trainings.
To tailor the program to the needs and realities of the field, I-TECH has implemented a blended tablet and paper-based data collection approach.
“There is such a large number of CHW trainees in the field that using this blended approach allows the OTLs to dedicate their time to training CHWs rather than focus on paperwork,” says Ilyse Jacobson, I-TECH South Africa Technical Director of Programs. “This flexibility allows for more in-depth and efficient training.”
Dashboard used by stakeholders and implementing partners to track the progress of the program.
Due to its role as the sole repository for all training-related data, the CommCare database will also generate reports linked to an interactive stakeholder dashboard.
“The dashboard not only brings I-TECH’s data visualization and dissemination approach into the 21st century,” says Jacobson, “it allows project stakeholders access to the data that helps with decision-making both in and outside of this program.”
The design of the Stakeholder Dashboard allows donors, implementing partners, and the National Department of Health to track current progress against training targets on a weekly basis.
The Kuunika Project: Data for Action was a four-year program implemented by a consortium of organizations, including the International Training and Education Center for Health (I-TECH), that began in 2016 to improve healthcare service delivery through the effective use of data. Consortium activities aimed to improve data systems, data use, and data governance in five districts throughout Malawi. I-TECH’s main focus was to build the capacity of healthcare workers (HCWs) to access, manage and use health data in high-burden HIV/AIDS facilities and communities.
I-TECH conducted an HCW training needs assessment with support from the Ministry of Health (MOH) in 2017. Using the assessment data, I-TECH collaborated with MOH, district health teams, local university representatives, and subject matter experts to design and develop a training curriculum that was piloted in 2018.
In January 2019, I-TECH rolled out a national training comprised of seven-day, in-person workshops and complementary eLearning modules with the goal of establishing a culture of data use, a strong base of high-quality data, and improve the availability of high-quality information to decision makers with the ultimate goal of improving health outcomes. The eLearning program, Building Effective Health Information Systems, is comprised of seven modules that introduce frontline healthcare workers and managers to health information systems. The modules include:
Introduction to Health Information Systems
Health Information Systems: Data Management Concepts
Using EMR Data for Decision Making
Improving and Maintaining the Quality of EMR System Data
Logic Models and System Classification
Overview of System Architecture
Introduction to Interoperability at the Facility Level.
An average of 150 HCWs per district were trained for an overall total of more than 800 HCWs trained across the country.
In May 2019, I-TECH launched a mentorship program designed to bridge the gap between training and practice, and to help participants apply their newly gained knowledge on the job. By the end of Phase 1, the I-TECH team had oriented over 100 district mentors to the mentorship program and tools. I-TECH’s role in the consortium concluded in August 2019 when Phase 1 of the Kuunika Project ended.
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.
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.
From September 2013 to September 2016, I-TECH conducted an implementation science research project to improve laboratory quality in Cambodia. The primary objective of the project was to implement a mentored laboratory quality stepwise implementation (LQSI) program to strengthen the quality and capacity of Cambodian hospital laboratories. As a result, target laboratories improved their operations in the areas of: biosafety, organization, personnel, equipment maintenance, purchasing and inventory, testing accuracy, process management, documentation and communication.
The project recruited and trained four laboratory technician to be mentors, training staff from 12 referral hospital laboratories in quality management systems (QMS), and reinforcing skills acquisition through in-person mentoring. Participating laboratories reported a 36% increase in quality management, 29% improvement in data management, and 25% improvement in specimen collection and handling. The laboratories established the foundational practices of a QMS, and the LQSI program has improved the recognition of the laboratory within the hospitals.
The I-TECH Cambodia Lab team. L to R: Sophanna Song, Cat Koehn , Siew Kim Ong, and Sophat Sek
I-TECH’s laboratory program began in Cambodia in 2013 with the goal to improve operations and regional biosurveillance and biosecurity through improved laboratory quality assurance and management practices. In collaboration with the Cambodian Ministry of Health, the World Health Organization (WHO), and the U.S. Centers for Disease Control and Prevention (CDC), and with funding provided by the Department of Defense and DTRA, I-TECH strengthens the Cambodian laboratory system through:
Implementation of an intensive mentoring program at 12 national and provincial public health laboratories;
Leadership and management capacity building of MoH laboratory leaders;
Mentoring and capacity building the National Animal Health and Production Research Institute (in collaboration with Washington State University);
Job specific training delivered in service and through educational programs such as the Quality Assurance Certificate Course (in collaboration with the University of British Columbia);
Support for laboratory workforce development through on-site technical assistance and training;
Support for national laboratory system policy development.
The overall goal of the Enhancing Quality of Healthcare Activity (EQHA) program in Cambodia is to improve the quality of public and private health services in national and sub-national health systems by August 2023. The project, funded by the US Agency for International Development (USAID), is being implemented by Family Health International (FHI360) in collaboration with I-TECH and other partner organizations. I-TECH’s scope of work focuses on improvements to 1) the national health policy regulatory framework and 2) national pre-service health education and training institutions.
I-TECH Tanzania led the development of the task-sharing policy guidelines for Health Sector Services approved in 2016 as well as the policy’s operational plan. While task-sharing is a widely known HIV service delivery efficiency strategy, still there is continues gaps between national strategies and actual implementation at the site-level [1,2].
