Zimbabwe DSD Performance Review, June 2019 · 2021. 7. 6. · Sanyati 172 (14%) Zvimba 185 (16%) Matabeleland North 76 Bubi 42 (55%) Umguza 34 (45%) Matabeleland South 1310 Beitbridge

Zimbabwe DSD Performance Review, June 2019

Dr. Clorata Gwanzura

Differentiated Care Medical Officer

Zimbabwe Ministry of Health and Child Care

13 November 2019

The CQUIN ProjectThe CQUIN ProjectThe CQUIN Project

Background and Approach

Overview of key results

Summary, lessons learned, and future steps

Overview

Annual Cross-sectional data collection for Facility

Coverage

Sampling method for client uptake and coverage: Semi-

annually

Comprehensive collection for Facility and Client Uptake

and Coverage: Quarterly

Electronic system for collection of Uptake,

Coverage and Outcome Indicators: Quarterly Analysis,

2020

M and E Plan

Background

• Implementation of Review meetings part of the DSD

M and E Plan• Method of data collection also earmarked for reporting in

non-partner supported districts

• The MOHCC and its stakeholders i.e. implementing

partners, and the ICAP CQUIN team developed

objectives of review

• Provincial teams from Mash West, Mat South and

Mat North were engaged to guide the planning and

implementation of the review

The CQUIN ProjectThe CQUIN ProjectThe CQUIN Project 4

Approach: Population

• 17 districts across the 4 provinces were identified for inclusion• 73 facilities were selected for data

collection• 2 facilities failed to do/complete data collection

• Selected via stratified random sampling • All districts in 2 provinces, 5 facilities in each

provinces (District hospital, 2high volume sites, 2 low volume sites)

• Selected districts and facilities (total of 3) in 2 provinces

• Two patient cohorts: 12 and 24 months on ART


• Data collection via abstraction of patient data from facilities• Patient ART booklet main data source with additional data sources in some

cases – pragmatic approach

• Standardized data entry form in MS Excel

• Data collection supervised by district teams

Approach: Data collection


• Convened a 3-day meeting to review results• District, Provincial, and National MOHCC teams; PEPFAR implementing partners

• Provincial overview presentations and discussions led by province teams

• District-level presentations and discussions led by district teams

Approach: Sharing and discussion of results

Key Results


Numbers of Patients, by Province and District

Number of patients, by province and

district, both cohorts combinedn (%)

Mashonaland West 1188Chegutu 182 (15%)

Hurungwe 149 (13%)

Kariba 138 (12%)

Makonde 181 (15%)

MhondoroNgezi 181 (15%)

Sanyati 172 (14%)

Zvimba 185 (16%)

Matabeleland North 76Bubi 42 (55%)

Umguza 34 (45%)

Matabeleland South 1310Beitbridge 305 (23%)

Bulilima 165 (13%)

Gwanda 168 (13%)

Insiza 184 (14%)

Mangwe 170 (13%)

Matobo 153 (12%)

Umzingwane 165 (13%)

Total 2574

Mashonaland West1188(46%)

Matabeleland North

76(3%)

Matabeleland South1310(51%)

Number of patients, by provinceBoth cohorts combined (N=2574)


1306

1114

607

415

131

1268

1081

474

289

760

200

400

600

800

1000

1200

1400

Initiated on ART Active on ART Received VL TestWithin 12 Months

Suppressed ViralLoad

Enrolled in Non-Mainstream Model*

24 month 12 month

*For all clients active on ART and with documented VLS 9

Overall Modified HIV Care Cascade, by cohort

32% of patients with VLS


85% 85%

46%

37%32%

23%

10%6%

54% of active patients

44% of active patients

68% of patients with a VL

test

61% of patients with a VL

test


90%

82%

71%

42% 42%38%

25%30% 32%

8% 7%

25%

0%

20%

40%

60%

80%

100%

MashWest(n=1188)

MatSouth(n=1310)

MatNorth(n=76)

Active on ART Received VL Test Within 12 Months

Suppressed Viral Load Enrolled in Non-Mainstream Model*10

Provincial Modified HIV Care Cascades12- and 24-month cohorts, combined

79% of patients with VLS25% of

patients with VLS

*For all clients active on ART and with documented VLS



Overall DSD CoverageAll patients active on ART - 12 and 24 month cohorts combined (n=2148)

1573(73%)

97(4%)

103(5%)

144(7%)

226(11%)

5(0%)

Conventional Care

CARG

Facility Club (+CATS)

Family Refill

Fast Track

Outreach


DSD Coverage by ProvinceAll patients active on ART - 12 and 24 month cohorts combined

71%

39%

77%

6%

2%

3%

4%

6%

6%

9%

33%

3%

10%

20%

10%

MashWest(n=1017)

MatNorth(n=54)

MatSouth(n=1077)

Conventional Care CARG Facility Club (+CATS)

Family Refill Fast Track Outreach


0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

24 month* 12 month**Not eligible no DSD Unknown Eligibility no DSD Eligible no DSD Not eligible + DSD Unknown Eligibility + DSD Eligible + DSD

Appropriate

Missed Opportunity

Inappropriate

Appropriate

14

Overall Fidelity of DSD Enrollment, by cohort

For clients active on ART, where eligibility is defined as a either 1) a VL test ≤12 months ago and a result of <1000 copies or 2) a CD4 test ≤

12 months ago and a result of 200+, as well as an absence of any OIs or TB

*Excludes 19 individuals for missing information **Excludes 28 individuals for missing information

Unknown

Unknown

(N=1095) (N=1053)

132 (12%)

173 (16%)

16 (1%)

292 (27%)

452 (41%)

30 (3%)

86 (8%)

155 (15%)

557 (53%)

13 (1%)

199 (19%)

43 (4%)

The CQUIN ProjectThe CQUIN ProjectThe CQUIN Project15

Model Switch: Current ART model and 12 months prior Among 24 month cohort patients

CARG

Conventional Model

Facility Club (+CATS Model)

Family Refill

Model

Fast Track

Outreach

19

797

45

42

46

1

53

670

53

77

108

1

Current Model,

May 2019

Prior Model,

May 2018

*All clients active on ART (combined cohorts, regardless of VLS)

The CQUIN ProjectThe CQUIN ProjectThe CQUIN Project *All clients active on ART (combined cohorts, regardless of VLS) 16

Numbers of clinical visits and ART pickups per year,

conventional model vs. DSD models

Yearly number of clinical visits per person, by model type

Yearly number of ART pickups per person, by model type

25%

29%

25%

20%23%

30%26%

22%

0%

5%

10%

15%

20%

25%

30%

35%

1-2 3-4 5-6 7+

Number of clinic visits

Conventional % DSD %

11%

36%

28%24%

7%

55%

21%18%

0%

10%

20%

30%

40%

50%

60%

1-2 3-4 5-6 7+

Number of ART pickups

Conventional % DSD %

Post-hoc assessment of DSD model uptake by sex: DSD Performance Review

Question: Are women more likely than men to enroll in DSD models providing less-intensive services?


Current ART model coverage, by sex (May 2019)DSD Performance Review, 70 facilities in 3 provinces

The CQUIN Learning Network

Source: Zimbabwe Ministry of Health and Child Care

11%

4%

8%

5%

72%

Men

Fast Track

Facility Club

Family Refill

CARG

Conventional ART

10%

5%

6%

4%

74%

Women

DSD uptake and model of choice was similar for men and women (n=2,148)

Note: Patients receiving MMS/MMD but not other DSD model features are classified within Conventional ART group


• 85% ART patients were retained at 12 and 24 months after initiation; overall, 27% of these pts were enrolled in a DSD ART model• In the post-hoc analysis, we saw no clear differences in DSD enrollment by sex

• About 50% of retained patients had a VL test within the past 12 mos; approx. 65% of these pts had documented VLS

• Roughly 30% of patients with VLS were in a DSD model

• Fast track and family refill were the most common DSD models overall, though popularity of models varied across provinces and districts

Summary of Key Results (1)


• Fidelity of DSD model enrollment criteria was low; a small % of ART patients had a VL result and were enrolled in the expected ART model based on results

•Model switch was common across the past year among the 24-month cohort patients• Most common was switch from conventional model, though switch between DSD models

also occurred

• A lower % of patients in DSD models (39%) than in the conventional model (52%) had 5+ ART pickups over the past year• The number of clinical visits did not differ across DSD vs. conventional models

Summary of Key Results (2)


•Data provided helpful insights on DSD implementation• Extensive participation in discussions by facility and district teams

• Support for DSD scale-up can be targeted using these findings• Increase uptake and coverage in priority DSD models

• Improve VL testing coverage and fidelity of implementation

• Eligibility/enrollment, and appointment/ART pickup spacing

• Monitor and manage DSD model switch

• Steps can be taken to improve data review process as well as data quality

Lessons Learned and Next Steps


• Strengthen data collection process• Provide a more detailed job aid on indicators collected

• Ensure rigorous supervision, e.g., through daily review and sign-off on data collection sheets

• Ensure adequate resources are available for data cleaning, analysis, and development of slides

• Ask districts and regions to develop structured Action Plans based on results• Develop strategy for following up on Action Plan progress

Recommendations for Future Performance Reviews


•Ministry of Health and Child Care • ATP

• Provincial and District Teams

• I-tech, OPHID, ICAP

•CQUIN TA Team

•DSD TWG Stakeholders

Acknowledgements

Documents

Zimbabwe DSD Performance Review, June 2019 · 2021. 7. 6. · Sanyati 172 (14%) Zvimba 185 (16%) Matabeleland North 76 Bubi 42 (55%) Umguza 34 (45%) Matabeleland South 1310 Beitbridge