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CSiM, a Center for Rural Health Stewardship, Joins I-TECH as Key Network Partner

The Center for Stewardship in Medicine (CSiM) has joined the International Training and Education Center for Health (I-TECH) Network as a partner, operating within the University of Washington’s Department of Global Health. CSiM is a collaborative of over 80 rural hospitals across nine states in the U.S. working together on stewardship challenges through education, quality and process improvement, and mentoring.

I-TECH and CSiM will mutually benefit from collective decades of experience tackling rural health challenges – including workforce shortages, staff who wear “many hats,” and disparities in services – in the U.S. and around the world.

“CSiM is a collaborative of physicians, nurses, laboratory professionals, and pharmacists working to bridge bi-directional knowledge gaps between academic medical centers and rural health care facilities,” said John Lynch, MD, MPH, co-director of CSiM. “Like I-TECH, we value collaborative, anti-hierarchical work that honors expertise and experience at all levels of the health care system, and from all sectors.” Dr. Lynch leads the center with Chloe Bryson-Cahn, MD, and Zahra Kassamali-Escobar, PharmD.

The CSiM team with guest speakers at the center’s conference in Spokane, WA, May 2023. Photo courtesy of CSiM.

CSiM works in antimicrobial stewardship and infection prevention, building sustainable quality improvement programs, and providing customized, long-term technical assistance to rural health facilities. The center’s main activities include leading the UW Tele-Antimicrobial Stewardship (TASP ECHO®) project, a telementoring program; coordinating Intensive Quality Improvement Cohorts; and providing resources and tools to support facilities in reaching their goals and improving the quality of healthcare.

“I-TECH and CSiM share a dedication to finding innovative and local solutions to provide ongoing education and mentoring to health care workers in resource-limited settings,” said Pamela Kohler, BSN, PhD, I-TECH co-director. “We are incredibly excited about the opportunity to learn from each other.”

Currently, CSiM has projects in Arizona, Idaho, Illinois, Louisiana, Maine, Montana, Oregon, Utah, and Washington and is exploring opportunities to extend its model globally.

“CSiM’s inclusive, team-based approach results in work that really matters to communities in need – particularly those in underserved, hard-to-reach, rural areas,” said Ivonne Ximena “Chichi” Butler, MPH, I-TECH co-director. “This approach makes it a perfect fit within the I-TECH Network.”

I-TECH and Zim-TTECH Publish Paper on Transitioned Programs

Faculty and staff from the International Training and Education Center for Health (I-TECH) and its network partner the Zimbabwe Training, Technical Assistance and Education Center for Health (Zim-TTECH) have published a new paper in the journal PLOS One.

Working toward sustainability: Transitioning HIV programs from a USA-based organization to a local partner in Zimbabwe catalogs the challenges and lessons learned as I-TECH laid the groundwork to transition the voluntary medical male circumcision (VMMC) and HIV care and treatment programming in Zimbabwe to the newly established Zim-TTECH, a fully independent local organization.

“I-TECH prides itself on working collaboratively with our international partners. We held the principle from day one that the most successful programs happen when the locus of control sits in-country,” said Marrianne Holec, Senior Program Manager at I-TECH. “We had the foundation in place with our local staff, what was missing was the organizational structure to allow the team in-country to truly lead the project. With the formation of Zim-TTECH, I’m happy to say we are there.”

Among USG funders, it’s recognized that future models for sustainable healthcare rely on local country ownership and leadership.[1] But making the transition from US-based ownership to country ownership isn’t a one-time event, added Holec, “It’s a process that takes time. We wanted to document our process so that other international organizations who are looking to pursue decolonizing global health programming can learn from our experience.”

Through 16 key informant interviews, the team gathered views on transition planning, implementation, and technical support, ethics, and success. Five themes emerged from the data collected:

  • Develop a vision and empower leadership for change by delegating clear roles and supporting local ownership;
  • Plan and strategize for transition in a manner that accounts for historical context;
  • Communicate with and inform stakeholders to understand transition perceptions, understand barriers to transition, and enable open communications related to risks and benefits;
  • Engage and mobilize staff by constructing necessary infrastructure and providing technical assistance as needed; and
  • Define short-term and long-term success.

“Sustainability of successful donor funded public health programs is critical if we want to maintain the important gains that have been made over the years,” says Dr. Batsi Makunike, Executive Director of Zim-TTECH. “Strong local organizations with good governance, management, and technical capacities are an important cornerstone of sustainability.

“The process of transitioning from an international to a local organization is daunting,” she continues. “We hope that this study is helpful to other organizations in their efforts to transition.”

[1] Goosby E, Von Zinkernagel D, Holmes C, Haroz D, Walsh T. Raising the Bar: PEPFAR and New Paradigms for Global Health. JAIDS Journal of Acquired Immune Deficiency Syndromes. 2012;60.

HIV ECHO Tele-Mentoring in the Caribbean

I-TECH facilitates an HIV ECHO® program, a distance-based tele-mentoring program for providers and clinics across the region. Weekly sessions provide access to brief HIV clinical updates along with an opportunity to present and receive consultation on challenging or unusual clinical care issues from a team of multi-cadre HIV experts as well as from other members of the community of practice. In response to an identified need, the program added a monthly mental health and HIV session.

In 2019, I-TECH began supporting the Medical Research Foundation to initiate a similar HIV/STI ECHO® program that will target HIV and STI care and treatment sites in Trinidad and Tobago as well as with in other countries in the region.

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.

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.

Stefan Wiktor

Stefan Wiktor, MD, is a physician with more than 25 years of experience in epidemiologic research and public health programs related to the control of infectious diseases. He leads I-TECH’s work on hepatitis prevention and control, and is Acting Professor in the Department of Global Health. Prior to joining I-TECH, Dr. Wiktor was the Team Lead of the World Health Organization’s Global Hepatitis Programme.

Dr. Wiktor previously worked at the U.S. Centers for Disease Control and Prevention (CDC) where he conducted research studies of HIV-1 and HIV-2 in Cote d’Ivoire, West Africa, and led a large-scale HIV/AIDS prevention and treatment program in Tanzania. His research showed that anti-retroviral medications were effective in preventing mother-to-child HIV transmission. Other research he did proved that antibiotics reduced bacterial infections in HIV-infected adults, a finding that led to the WHO recommendation for use of antibiotic prophylaxis to prevent deaths in HIV-infected adults.

Program Highlights

Expanding HIV Care and Treatment in Zimbabwe

The ZimPAAC consortium collaborates with the Ministry of Health and Child Care (MoHCC) in Zimbabwe to meet the following primary ...
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Using Innovative Technology for Better Data in Zimbabwe

The ZimPAAC consortium has supported high-quality health care worker (HCW) knowledge and skills in Zimbabwe with technologies such as applications ...
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Driving Collaboration with Local Implementation Partners in Zimbabwe

I-TECH builds local ownership and sustainability through collaborations throughout Zimbabwe. Under the CDC and PEPFAR awards, I-TECH has formed and ...
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Expanding Cervical Cancer Screening in Zimbabwe

I-TECH began the expansion of cervical cancer screening for women living with HIV aged 25-49 in Zimbabwe in 2019. I-TECH ...
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Improving HIV Care and Treatment across the Caribbean

I-TECH supports a variety of activities aimed at improving HIV care and treatment in the Caribbean region, such as on-site clinical mentoring, development of training curricula, and providing clinical support materials to improve care and treatment for HIV/AIDS in the Caribbean region.
Continue reading “Improving HIV Care and Treatment across the Caribbean”

Continuous Quality Improvement Collaborative in the Caribbean

Since 2013, I-TECH has led quality improvement (QI) collaboratives in the Caribbean region, enabling multidisciplinary teams at health facilities to work toward a common goal of improving care and treatment for HIV-positive patients.
Continue reading “Continuous Quality Improvement Collaborative in the Caribbean”

Gabrielle O’Malley

Gabrielle O’Malley, MA, PHD, is I-TECH’S Director of Implementation Science. Dr. O’Malley has worked as an applied research and evaluation professional for over 25 years. Her experience includes a wide variety of international and domestic programs including child survival, private agricultural enterprise, medical education, community technology, reproductive health, HIV prevention (PrEP), and care and treatment as well as applied research for private industry. Her research interests include innovative practices for program evaluation and improvement, formative research, qualitative methods, and the relationship of gender and health.

Dr. O’Malley received her PhD from UW, an MA from Johns Hopkins University and a BA from Smith College.

Program Highlights

Birth Defects Surveillance in Malawi
Malawi is one of first countries in Southeast Africa to respond to the World Health Organization’s call for robust birth surveillance systems. Routine surveillance is essential for public health monitoring of pregnancy outcomes and birth defects, especially in high-HIV burden settings where women living with HIV initiate the use of ...
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Cervical Cancer Screening and Treatment in Namibia
I-TECH supported the Ministry of Health and Social Services in 2017 and 2018 in the development and dissemination of the national Cervical Cancer Prevention Guidelines including algorithms for screening, referral, and post cryotherapy instrument disinfection, and monitoring and evaluation tools ...
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COVID-19 Sentinel Surveillance in Malawi
Despite establishing  COVID-19 monitoring measures within the existing routine national surveillance system and significant efforts to conduct testing, contact tracing, and case investigations, Government of Malawi institutions at both the national and district levels faced many challenges in mounting an effective response to the COVID-19 pandemic. The existing COVID-19 surveillance ...
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Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe women (DREAMS) 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 ...
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Pamela Kohler

Pamela Kohler, PhD, MPH, BSN, co-directs I-TECH and holds a joint appointment in Child, Family, and Population Health Nursing, and the Department of Global Health. At I-TECH, Dr. Kohler led the Tanzania Intermediate Field Epidemiology Training Program (FETP) and currently leads the evaluation and continuous quality improvement activities of the Afya Hatua Project under Tanzania Health Promotion Support. She has led multiple evaluations of programs and policies throughout Eastern and Southern Africa, including HIV differentiated care, cervical cancer screening and treatment, and cryptococcol meningitis services.

Dr. Kohler’s research involves development and testing of health services interventions to improve engagement in HIV care. She led two trials using standardized patient actors to destigmatize HIV prevention and treatment services for adolescents in Kenya and currently leads a stepped care intervention, assigning intensity of services to those with highest need, in Western Kenya. Dr. Kohler completed her nursing training at Johns Hopkins University, and worked clinically in HIV care and Emergency Departments. She holds a PhD in Nursing and an MPH in Health Services from the University of Washington.

Publications

McConnico C, Jed SL, Marumo E, Mazibuko S, Mema GM, DeKadt J, Holmes K, Kohler PK. Systems Mapping of Sexually Transmitted Infection Services at Three Clinical Sentinel Surveillance Sites in South Africa: Opportunities for Integrated Care. J Assoc Nurses AIDS Care. 2017 Jan-Feb. pii: S1055-3290(16)30121-2. doi: 10.1016/j.jana.2016.09.004.

Kohler PK, Marumo E, Jed SL, Mema G, Galagan S, Tapia K, Pillay E, DeKadt J, Naidoo E, Dombrowski JC, Holmes KK. A national evaluation using standardised patient actors to assess STI services in public sector clinical sentinel surveillance facilities in South Africa. Sex Transm Infect. 2017 Jan 27. pii: sextrans-2016-052930. doi: 10.1136/sextrans-2016-052930.

Kohler PK, Tippett Barr BA, Kangʼombe A, Hofstee C, Kilembe F, Galagan S, Chilongozi D, Namate D, Machaya M, Kabwere K, Mwale M, Msunguma W, Reed J, Chimbwandira F. Safety, Feasibility, and Acceptability of the PrePex Device for Adult Male Circumcision in Malawi. J Acquir Immune Defic Syndr. 2016 Jun 1;72 Suppl 1:S49-55. doi: 10.1097/QAI.0000000000000774.

Kohler PK, Namate D, Barnhart S, Chimbwandira F, Tippet-Barr BA, Perdue T, Chilongozi DA, Tenthani L, Phiri O, Msungama W, Holmes KK, Krieger JN. Classification and rates of adverse events in a Malawi male circumcision program: impact of quality improvement training. BMC Health Serv Res. 2016 Feb 17;16(1):61. doi: 10.1186/s12913-016-1305-x.

Program Highlights

Field Epidemiology Training Program (FETP) in Tanzania
For Tanzania to meet a WHO-specified target of one or more epidemiologists per 200,000 population [1] it will require an additional 250 epidemiologists who are well-trained and geographically distributed in all regions of the country. To help address this gap, I-TECH, in collaboration with the Centers for Disease Control and ...
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Nursing Efficiency and Task-Sharing in Tanzania
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] ...
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