A PRACTICAL HANDBOOK FOR HIV MANAGERS

Introduction Background: Health outcomes across different sites are variable, despite funding, and are often linked to the ability of health care workers to innovatively overcome common and sometimes severe health system challenges matching service delivery to patient or service provider barriers and constraints without necessarily requiring additional resources to deliver high quality services. These innovations would relate to management of human resources, distribution of roles and responsibilities at facility level, patient flow design, facility management, local strategies and tools. To standardize quality of care across the country, dissemination of replicable practices in Kenya’s devolved system of government cannot be over emphasized. Therefore among other strategies, the development of the Kenya HIV Quality Improvement Framework marked a key step in the institutionalization of Quality Improvement in HIV Programming in Kenya. Kenya’s situational Analysis Kenya’s vision, as described in the Kenya AIDS Strategic Framework, is to be free of new HIV infections, stigma, and AIDS-related deaths by 2030. With 1.6 million people living with HIV nation-wide, and an estimated 101,560 new cases added yearly, HIV and AIDS have been identified as one of the leading causes of death in Kenya, and a significant contributor to ill health.1 The Ministry of Health (MOH) has continued to make significant progress in the fight against HIV and tuberculosis (TB). At the national level, mortality due to AIDS has dropped yearly since the year 2000, to currently stand at 35 per cent of what they used to be (58,465 in 2013 vs. 167,000 in 2003).2 Prevalence and incidence rates have been decreasing consistently since mid-1990s. However, county-level variations are significant, with 9 of the 47 counties accounting for 65 percent of new infections,3 thus highlighting the demographic complexities of the epidemic. Mother-to-child transmission (MTCT) rates remain high, at 14 percent, and 13,000 children are infected with HIV every year,2 further highlighting the challenges of achieving that vision. ! "#$%&'( 5 ) * '+,-',. 412"1$$.'49'53 /0&.&1232"41'536738&'94%'2:&' %&' Improving The Quality And Efficiency Of Health Services In Kenya 1 A Practical Handbook For Hiv Managers And Service Providers On Differentiated Care Viewed as a cascade (Figure 1 ), the continuum of HIV care has five steps: identification of people living with HIV (PLHIV), linkages to care, initiation of treatment, retention, and viral suppression. Life-saving services are not yet available to everyone who needs them. According to the 2015 data from the Kenya District Health Information System (DHIS) 2, Antiretroviral Therapy (ART) coverage rates were 64 percent for adults and 47 percent for children less than 15 years old Among those who know their status and are accessing care, ART uptake is very high for adults (88 percent) and 89 percent for children less than 15 years6,7,8, Viral suppression, a function of retention in care and adherence to treatment among those currently receiving ART, is 55 percent among adults, and 64 percent among children less than 15 years, highlighting a key challenge along the cascade of care and treatment9 Thus, despite notable successes in the past 20 years, it is increasingly apparent that in order to improve on treatment coverage and retention rates with existing funds, program managers and service providers must find ways to work more efficiently along the cascade, with special focus on linking adolescents and children to treatment. Reaching these targets requires a synergistic way of working, one based on efficiencies gained through continuous improvement of existing models of service delivery. The use of differentiated care in service delivery has contributed to identifying more HIV-positive patients, improved coverage and uptake of ART, and improved quality of services, while facilitating more efficient use of resources as illustrated by case examples throughout this handbook. Three inter-related categories of successful approaches have been observed and documented from health facilities: • • • Differentiated care in service delivery Improved management of the facility Better utilization of site data to identify potential improvements This handbook is concerned primarily with differentiated care (see box). 2 Improving The Quality And Efficiency Of Health Services In Kenya A Practical Handbook For Hiv Managers And Service Providers On Different