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Kirunda Ibrahim, MB. Ch.B, MPH - Quality Assurance Project , University Research Co., LLC Uganda

Dr. Kirunda Ibrahim is a public health specialist and medical practitioner.  Currently he works as a Quality Improvement Advisor with University Research Co. (URC), LLC-Uganda. He is a MOH core team coach in the Quality of Care Initiative in HIV care. He has previous experience working in the family planning sector in Uganda through his work with the Family Planning Association of Uganda and Islamic Medical Association of Uganda during the implementation of the SEATS Project, funded by USAID.  Dr. Ibrahim has previously served as an acting District Director of Health Services of a large Ugandan District. 

The HIV/SRH Integration site interviewed Dr. Ibrahim about his experience with providing integrated services in Uganda under the courtesy of University Research Co., LLC that is implementing the Health Care Improvement Project.

Please tell us about a project/program experience integrating HIV/AIDS and sexual and reproductive health services.

The Ministry of Health (MOH) in Uganda identified prevention of HIV infection and improvement of linkages between family planning (FP) services and HIV care and support as a priority in implementing an improvement collaborative focusing on integration of FP and HIV Services.

Integration of FP and antiretroviral therapy (ART) services in Uganda had not previously been given proper attention in the push to expand ART services in the country. The only commonly used FP method was a condom, but even then, condoms were given for prevention of re-infection but not for family planning, although they are an important dual method.

With core funding from Maximizing Access and Quality (MAQ), USAID`s SO1 element, the Quality Assurance Project initiated a demonstration collaborative in Uganda to strengthen the integration of FP and HIV/AIDS care services.

It was quite challenging at the start. Nevertheless, the self selection by participating sites opened the opportunities for sharing in the collaborative and we were able to identify the service providers' FP-HIV integration training needs that were addressed, and now, with MOH logistical support, a promising business of FP/HIV care integration is being realized.

How did you decide on the approach to take?

Decision on the demonstration collaboration was based on the assumption that already service providers in ART clinics had the basic knowledge and skills and what was missing was the creating awareness of the importance of integration and sharing their past experiences and paving a way forward towards improving the health care in this aspect of HIV-SRH integration.

What were the dates of the project/program?

Dates for the demonstration collaborative are January 2007 to June 2008.

Your funding was from USAID?

Yes.  The funded program is in collaboration with URC, EngenderHealth, and Family Health International, and in collaboration with the Ministry of Health.

What is the actual name of the program?

The Quality Assurance Project (QAP) was changed to Quality of Care Initiative in HIV Care.  Within the same initiative is where we have the demonstration collaborative with the intention of strengthening the FP/HIV integration.

What was the problem you were responding to when you developed the program?

Participating sites in the demonstration collaborative reported increasing pregnancy numbers among HIV-positive clients on ART and lacked FP services in the same clinics.

Who was involved in the discussion and decision-making on the approach to take to address the problem?

All stakeholders were involved, including MOH Uganda, QAP Uganda, District Health Officers, service providers, and operating partners such as EngenderHealth.

The collaborative took place in ten sites?

It was a kind of piloting.  We started with ten sites, but then went nationwide. 

Will it expand to more sites?

We've been encouraging other sites that have peaked interest. We gave the performance indicators to all the sites.  We have been collecting data from these ten.  We've encouraged all sites to integrate.

Who were the providers that were delivering the ART services before the collaborative started?  What type of providers were they?

They are mixed cadres.  So we have doctors in some facilities, nurses, midwives, and clinical teachers. 

Who were the people who trained the providers?

We worked with EngenderHealth/ACQUIRE Project. Then we also got information and training materials from Family Health International in the form of CDs.  We worked with the staff of URC, Uganda Office, and we had medical doctors who have the knowledge to impart to the people.  We were able to come up with good materials for the providers.

Before the collaborative began, what kind of knowledge about family planning did the providers have?

When we were introducing the integration collaborative, we realized that they lacked some information because most of them had been trained in FP knowledge ten years ago. So we had to give them some kind of update.  We normally conduct quality assurance collaborative, learning sessions.  In between the learning sessions, we have action periods.  We introduce the concepts of quality improvement and we introduce the idea of integration, what is meant by FP/HIV integration.  We give them the advantages of integrating and we also introduce the indicators meant for FP/HIV care integration.  We also made them aware of the current options of family planning methods provided by the Ministry of Health.  At the end of the learning sessions, we required them to come up with an action plan.

What type of contraceptives does the Ministry of Health offer?

We mainly provide oral contraceptives such as the combined and progestin-only pill.  Then we have the barrier methods such as condoms, for dual protection, and then we provide Norplants (those willing to undergo surgical intervention) and rarely do we provide surgical intervention methods such as vasectomy and tubal ligation. Those ones are rare. In faith-based organizations and facilities, we encourage them to talk about abstinence and breastfeeding.

How did the project team decide on a system to balance work activities (e.g., addition of new activities with existing activities for the purpose of integration)?

Because of funding constraints and need for proper utilization of field time, we did this through core team meetings. We felt that integrated site coaching and reporting would be a resource- saving and user-friendly approach.

Were there systems you developed to manage integrated services, such as client follow-up or special complicated cases?

We have always opted to have those and even more, but we are financially constrained.

What makes it a collaborative?  Is it many people working together?

The improvement collaborative, developed by the Institute for Healthcare Improvement (IHI), seeks to rapidly spread existing knowledge/best practices to multiple settings through systematic efforts of a large number of teams. We had the assumptions that already some of our health providers in the participating sites knew a number of things and therefore could share with the others who don`t know when brought together in a training (learning) session. This would be achieved through sharing ideas, visiting sites and coaching them during the action periods in addition to finding out what health providers are doing at their respective sites thus sharing best practices.  That's why we call it a collaborative.

Are there links between the collaborative and community support groups?

Yes, there are links between the collaborative and the community support groups such as the support peer groups, village health committees, and expert clients¹. Through the Alliance, a USAID-funded project, we have closely worked with expert clients who have done a commendable job with community health facility linkage.  We provide technical expertise at health facilities.  We help health providers identify areas that these community support groups can help and encourage them to link with the same. Also, our clients are a bridge between us and their respective communities. The main challenges have been not using better strategies such as mass media and integrated outreaches to reach large population in the community.

How did you work with the District Health Office in setting up the program; for example, in strengthening the systems and services?

The core team, with the help of the MOH Steering Committee, involved the District Health Officer in the development of the idea as well as the specific performance objectives and indicators. Furthermore, the collaborative core team involves these district health officers in planning during stakeholder meetings, and even in the current implementation at the respective sites and their districts at large.

How do the providers and clients feel about the integrated activity?

The health providers feel the arrangement is worth having at a time when it is greatly needed, when almost all health facilities share the same prevailing understaffing problem. Clients are happier and no longer inconvenienced to walk to separate FP clinics for the services.

So when the integration began, did the providers, who were already providing ART, find that it was a lot of extra work for them to also provide family planning at the same time?

Initially they had a feeling of being assigned extra work but later, in the course of the collaborative, they appreciated the need for integration. The reasons they gave us were dual fold: that their patients used to be inconvenienced before this collaborative being referred for the obvious FP services that would be provided by the same health provider; and the other issue was that these clients did not feel comfortable going to another clinic where they were not familiar with the health providers.  On the side of the providers, they somehow felt relieved.  Sometimes they would be forced to accompany the patients to direct them to a FP clinic. So there was some relief.

After integration, did you have more patients coming to the clinic?

After the integration, clients experienced a better service and with time increased in attendance at the different sites.  With the exception of a few, most sites (health facilities) had specific days for HIV care/ART services during which the providers organize the materials and logistics in the same room and when dispensing the ART, FP services are dispensed as well to those who choose to have them after having undergone a thorough counselling session.  So they don't find it a problem.  But of late what we have learned is that health providers have started leaving for further medical studies and, somewhat, this has stressed the work stations, thereby making some remaining health providers complaining of heavy workload.

What obstacles did you encounter from a program standpoint and how did you address them?

Increasing demand of FP services by clients attending faith-based institutions and yet management of these institutions is not supportive to clients' FP needs and expectations. We have endeavored to discuss other FP natural options other than the artificial ones. Also, we had reports of sites experiencing irregular supplies of commodities before the implementation phase of the collaborative. Nevertheless, with the logistical support from the MOH and its supportive guidelines and policy makers, sites no longer have such logistical constraints.

Did you make adjustments to your approach as you went along? 

Yes!  We had restricted the participating site number to 10 but due to enthusiasm more sites were added on the list. However, we still report on the initial participating number. In addition, we have emphasized to the site providers the need for promotion of the idea of dual protection.

Did you have need for special resources to implement your approach (e.g., funding, staffing, supplies, and consultants)?

Yes! We need special resources such as funding, staffing, supplies and occasionally consultants to implement our demonstration collaborative and if possible scale it throughout the whole country at all ART services providing sites.

How did you evaluate the success of your activity?

We are using developed FP/HIV care integration performance indicators (see chart) and also other parameters such as presence of FP services in the ART clinic, and reduced number of unwanted pregnancies among HIV clients on ART.

What did you find to be the most difficult part of enacting this program?

The most difficult part is encouraging sites to collect data, this being more serious in the public health facilities where the few staff don't include a data collection personnel, and therefore finding it difficult to get data in time.

Any lessons learned from the program?

The whole essence of the FP-HIV integration program is to integrate FP and HIV services, and strengthen counseling, referral, and follow-up for current HIV-positive clients. The MOH provided supportive policy guidelines and service standards for sexual and reproductive health, including FP-HIV care integration, which was important. With the program providing user-friendly contraceptive request forms and lines of credit for facilities to ensure availability of method mix and mechanisms for promoting informed choices at sites, integration is very possible even in rural-based facilities.  The Health Care Improvement Project has organized providers at each participating ART site into a quality improvement team so they can assess and improve their own performance. Staff were trained to counsel clients on the availability of FP services, assess unmet need and provide methods or refer clients. HIV-positive clients of reproductive age and older are counseled, given a method, or referred to an FP clinic.  Site teams can monitor, on a monthly basis, their performance on FP-HIV/AIDS indicators, including percentage of HIV/AIDS patients counseled on FP methods. This includes dual method and percentage using at least one FP method and percentage being referred for services not provided.  Although faith-based organizations were not positive towards FP-HIV integration, they surprisingly find it okay to dispense condoms that are taken to be a tool for STI prevention. We see this as a way through for our clients who might otherwise be denied a FP-HIV integration service.  Finally, but not the least, the other pertinent issue that has been learned is the tremendous reduction in unwanted pregnancies among our HIV clients and prolongation of their life span.

[1]   “Expert clients” are peer educators trained to provide practical and emotional support to fellow HIV/AIDS clients. Among other roles, expert clients promote adherence–a major challenge to HIV/AIDS care and treatment programs–and help pregnant women to better understand and access HIV/AIDS services. Expert clients themselves are enrolled in care and treatment programs and/or prevention of mother-to-child transmission of HIV programs at the sites where they will work. (Explanation of experts clients adapted from: “Swaziland Expert Clients Take More Active Role in Care and Treatment Programs,” ICAP News, September 2007, http://www.columbia-icap.org/news/icapnews/SeptemberENews.html)

Contact Information

Dr. Kirunda Ibrahim MB. Ch.B, Dip (HSM), MPH
Quality Improvement Advisor/ Family Planning-HIV Integration Activity Manager University Research Co., LLC
Health Care Improvement Uganda
Plot # 80 Kira Rd P.O. Box 28745, Kampala, Uganda
Fax: +256 0414 535006
Mobile phone: +256 772 964722
Office phone: +256 0414 535010.
ikirunda@URC-CHS.COM