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Successes in increasing capacity, strengthening service delivery and improving data systems in South Africa

Successes in increasing capacity, strengthening service delivery and improving data systems in South Africa
Publication date: 
Aug 2019

Since 2016, the United States Agency for International Development (USAID) Tuberculosis South Africa Project has provided technical support to the South African TB Program at national, provincial and district levels. Working closely with the National Department of Health (NDoH), the USAID TB South Africa Project currently supports 14 districts in six provinces, works directly with more than 30 local non-governmental organizations (NGOs), civil society organizations and faith-based organizations and engages private providers and other private sector partners for important programmatic gains. 

The project’s main priorities include reducing TB infections, ensuring the sustainability of an effective TB response system, and improving TB care and treatment among vulnerable populations. Within these priorities, the project implements strategies to align with global and national goals of ending TB by 2030, combatting multidrug-resistant TB and finding missing TB patients, all while leading the country toward self-reliance.

A Sustainable Quality Improvement Model

The USAID TB South Africa Project engages the South African government on multiple levels, starting at the facility level and propagating through the district, provincial and national levels. The project works to identify gaps in the TB care cascade, primarily through the establishment of QI clusters at the sub-district level. Currently, 32 quality improvement teams support 191 facilities to support the development and monitoring of facility-level quality improvement plans. Regular cluster meetings have helped identify key gaps within the understanding of data, oversight of data capturers and TB screening quality. 

At the national and district levels, the USAID TB South Africa Project works within supported districts to assist the National Department of Health in implementing the National Quality Improvement Program. The project provides technical assistance to the NDoH through the secondment of a technical advisor and two Quality Improvement Officers. These staff members oversee the implementation of the national Quality Assurance and Improvement (QA/QI) initiative in ten districts across four provinces.  

The project is also a premier partner in technical assistance and continuous quality improvement for the NDoH, District Departments of Health and at the facility level.  The project has established 32 QI teams in eight subdistricts to implement QA/QI activities and oriented over 1,200 HAST managers, Primary Healthcare (PHC) supervisors and local area managers on drug-susceptible (DS) and drug-resistant (DR) TB management, FAST and infection prevention and control procedures. At the facility level, the project has trained nearly 4,200 health care workers on DS and DR-TB management, FAST and infection prevention and control. As well, through partnerships with regional training centers (RTCs), the USAID TB South Africa Project helps build health care worker capacity within DS and DR-TB management, FAST, infection prevention and control and QA/QI. 

Supporting the National Training Record (SkillSMART Database)

The project supports the NDoH and Regional Training Centres (RTCs) to update SkillSMART, the national training database. SkillSMART is a central database of health care workers trained in the different health care programmes in South Africa. The project acknowledges that different provinces are at diverse stages of rolling out SkillSMART and continues to work with NDoH and RTCs on rollout and implementation of the standardized platform.

Data Quality

The USAID TB South Africa Project works in 14 districts within six provinces to improve data reporting and recording within the existing government Electronic TB Register (ETR.net), Electronic Drug-Resistant Tuberculosis Register (EDRWeb) systems and the new TB/HIV Information Systems meant to better coordinate TB and HIV care. This support is delivered primarily through training and capacity building events and the project has trained over 1,000 Health Care Workers on data reporting. The project also supports quarterly data reviews at the district level in which TB program performance is discussed with managers, gaps are noted and quality improvement plans are developed. These reviews are often paired with training activities to target areas of highest need. 

Rifampicin Resistant Alerts (Rif Alerts)

The USAID TB South Africa Project implements a variety of innovative strategies to improve linkage to care and reduction of initial loss to follow up (ILFTU). Through Rif Alerts, the project has received 2,292 notifications of Rifampicin Resistant patients and has managed to link 616 of the 766 among them to care that were considered lost. This activity has reduced initial loss to follow up by 80% in the supported areas. 

The DR-TB Supportive Care Package

The DR-TB Supportive Care Package pilot was implemented in South Africa under the USAID TB South Africa Project to support the National Action Plan for Combatting Multidrug-Resistant Tuberculosis (MDR-TB) within eight clinics in three provinces. The care package focused on home-based risk assessments for infection control, treatment education and counseling for patients and family members, community- and home-based care, management of negative side effects, assessment of patient nutrition, nutritional supplements, referral for HIV treatment as necessary, stigma reduction campaigns through radio broadcasts and community dialogues, assistance to patients for obtaining access to social grants, and transport assistance through the provision of social grants.

Patient satisfaction showed that patients in the pilot group felt that providers treated them with respect, made them feel at ease, and that providers listened to them. Community members were generally happy to discuss the supportive care package and how it helped them complete DR-TB treatment. A provider satisfaction survey showed that 100% of providers felt that the approach to care under the care package was an improvement over the previous method. The model will be scaled up to further improve DR-TB care experiences.