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.
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.
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.
High-quality, effective, and evidence-based service delivery for HIV care and prevention requires a broad continuum of integrated and linked services to ensure consistent and high-quality client management over time. With the World Health Organization’s (WHO) recommendation to “Treat All,” eligibility for antiretroviral therapy (ART) among People Living with HIV (PLHIV) is eliminated, and all populations and age groups are linked in one universal policy. This recommendation change erases the distinction between all groups. However, a substantial number of PLHIV still present late to care and have advanced disease, and require interventions that prioritize clinical packages to reduce mortality and morbidity and eventually enable them to become clinically stable .
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.
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.
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.”
On June 1, 2018, the University of Washington’s International Training and Education Center for Health (I-TECH) country office in Haiti officially became a local non-governmental organization (NGO). The office will be rebranded as the Centre Haïtien pour le Renforcement du Système de Santé (CHARESS) and will continue to implement programs to improve HIV services via a trained health workforce, robust health information systems (HIS), and clinical mentoring.
CHARESS will be responsible for maintaining, training, and deploying HIS such as iSantéPlus and the Système d’Echange d’Information de Santé d’Haïti (SEDISH), a national health information exchange, across Haiti and ensure the sites receive on-site and remote technical assistance. The team will also oversee clinical mentoring activities at 20 sites and provide technical assistance to the Ministry of Public Health and Population (MSPP) and other implementing partners in Haiti.
“I-TECH has a mission to support sustainable development,” says Scott Barnhart, MD, MPH, Professor in the Department of Global Health and an I-TECH Principal Investigator overseeing programs in Haiti. “The conversion of the I-TECH country office and launch of a fully independent NGO to take up those activities is testament to I-TECH’s commitment to fostering locally owned and led development.”
The announcement of the shift to local ownership comes after two years of strategic planning by key stakeholders and partners to successfully transition I-TECH Haiti’s country office into an independently functioning NGO. As such, CHARESS will aim to allocate more of its funding to program activities, as well as pursue local funding opportunities restricted to Haitian organizations.
“The programs that are shifting to CHARESS have already proved to have had a dramatic impact on the health care landscape in Haiti,” remarked Jean-Guy Honoré, MD, I-TECH Haiti’s Country Director. “Transitioning of the key programs, specifically our HIS work, to a local ownership will allow CHARESS to become a leader in sustainability on the global stage. We are proud of the work that we have accomplished and look forward to the future.”
For 16 years, I-TECH has helped develop strong national health systems in low- to middle-resource countries while promoting the importance of local ownership as a way to sustain those effective health systems. I-TECH will continue to be a close partner in supporting CHARESS and looks forward to continued collaboration.