Clubs for Managing Large Numbers of Patients on ARVs
Western Cape Provincial Health Department, City of Cape Town Health, Institute for Healthcare Improv

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
Within South Africa, approximately 6.1 million people, or 17.9% of the adult population, suffers from HIV/AIDS. This is the largest total number of people in any country. Such prevalence has resulted in significant numbers of disease-related illnesses and deaths. In 2011 alone, more than 270,000 adults and children died from the disease. South African health clinics have problems effectively treating HIV/AIDS. While overall the prevalence of HIV/AIDS has decreased, a large number of infected South Africans do not receive antiretroviral (ARV) treatment. From 2007 to 2011, approximately 80% of adults with a CD4 count below 200 received antiretroviral treatment. At the end of 2011, the government adjusted criteria to include patients with a CD4 count of below 350. This criterion increased the number of eligible adults dramatically. Only approximately 52% of eligible adults are currently being treated with antiretroviral medication. As the number of eligible adults has increased, the quality of care has diminished as many clinics suffer from issues of over congestion, poor infection control, long waiting times, inferior quality of care, increases in staff burnout and long waiting times for antiretroviral medication. In 2010, half of the 47 ARV treatment facilities in Cape Town had over 1000 patients each. These facilities anticipated growing numbers of patients and feared that they lacked the capacity to treat them. It is important that a method is put in place to increase the effectiveness of clinics in managing patients while providing patients with quality care.

B. Strategic Approach

 2. What was the solution?
Medecins San Frontiere (MSF) proposed the ARV Adherence Club Model in Khayelitsha, South Africa. This initiative was designed to decrease patient numbers at high volume clinics by diverting patients who are well and managing their health into clubs, so that doctors can concentrate on those who are chronically ill. The intention was to provide a patient-friendly service as well. With this model, patients spent less time in clinics, decreasing overcrowding and giving workers the opportunity to focus on a greater number of patients. The program works by organizing patients into groups of thirty. Group members receive support from both a clinical team and other group members. The clinical process is streamlined: patients meet every two months, receive pre-packaged medication and have the ability to have a friend pick up their medication for them. Stable patients can choose to visit a clinic as infrequently as every four months. Patients are asked questions regarding their health and are weighed. If tests determine that the patient is becoming very sick, they are removed from the club and placed in more intensive care. The Breakthrough Series Collaborative (BTS) program was developed as a means of spreading this club model to other clinics, while addressing issues of implementation and sustainability. This program created ARV clubs at 14 high-volume clinics in the Cape Town area. Club faculty participated in workshops, taught ‘Quality Improvement’ (QI) skills and shared their experiences in a collaborative environment.

 3. How did the initiative solve the problem and improve people’s lives?
The initiative provides patients with higher quality care. Patients receive greater support and spend less time waiting for treatment and hence are free to go to work after a clinic visit. This leads to greater retention of patients and more favorable treatment outcomes. Since a non-clinical facilitator manages patients, clinicians have the opportunity to focus on the treatment of chronically sick patients or the needs of a larger number of patients. They can also initiate new patients on ARV treatment. By reducing overcrowding, the risk of contracting TB and other diseases is decreased. Since clinicians do not have to interact with as many patients, burnout among clinicians is reduced. Furthermore, the Breakthrough Series Collaborative is an innovative method of implementing and improving large-scale healthcare systems. It has successfully created clubs at 14 high-volume facilities in the Cape Town area. Their combined efforts are facilitated in workshops, quality improvement seminars and among their peers. This model can be applied to other aspects of the healthcare system in order to improve service delivery.

C. Execution and Implementation

 4. In which ways is the initiative creative and innovative?
The Institute for Health-care Improvement (IHI), Medecins Sans Frontiere (MSF), Cape Town City Health Department (CoCTCHD) and the Western Cape Provincial Department of Health (DoH) worked in collaboration to spread the ARV Adherence Club model to clinics throughout the Cape Town area. The Breakthrough Series Collaborative (BTS) program created ARV clubs at 14 major ARV facilities in the Cape Town Area. More than 300 clubs at these facilities were created and approximately 11,000 patients were accommodated. Facility members met every six months to attend daylong workshops (Learning Sessions). At the first Learning Session, all participating facilities agreed to have 30% of their ARV patients managed with ARV Clubs within 18 months. In order to accomplish this objective, they learned about the ARV club model from experienced MSF staff and developed an improvement methodology that encouraged facilities to start small and gradually test out new ideas. At the two subsequent Learning Sessions, faculty shared challenges and solutions. Between workshops, facilities were supported by mentors and were required to submit monthly data in order to track progress. In 2012, another 21 clinics were selected to create clubs. Participants from the first group were used to share their experiences with the new clinic faculty members. Today there are 950 clubs attending to around 28,000 patients.

 5. Who implemented the initiative and what is the size of the population affected by this initiative?
ARV Clubs had partnerships with the TB Association/Tutu Foundation, the Western Cape Department of Health (DoH), the Cape Town City Health Department (CoCTCHD), the Institute for Healthcare Improvement (IHI) and the Medicins San Frontieres (MSF) foundation. The program was initially piloted by MSF at the Khayelitsha clinic in South Africa. The program received support from a large number of clinics after successful efforts by the IHI in using the Breakthrough Series Collaborative (BTS) program to implement the club model in other Cape Town area clinics. The DoH and CoCTCHD worked in collaboration to design the project, select facilities, and mentors and create workshops.
 6. How was the strategy implemented and what resources were mobilized?
The Institute for Healthcare Improvement (IHI) used a previous Impumelelo award of R25,000 as seed money to plan the project and facilitate workshops. Aspen Pharmaceutical and the Provincial Department of Health (DoH) provided refreshments for learning sessions. The UCT Medical School and the DoH provided free venues wherein workshops were conducted. Employees of the DoH, Medicins san Frontieres (MSF), TB/HIV Care and the IHI participated in the project.

 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
The two most successful outputs were the ARV Adherence Club model and the Breakthrough Series Collaborative (BTS) model. These two models created a framework for patient treatment and care. The ARV Adherence Club model put patients in groups of 30 and streamlined the care process, which gave clinicians the opportunity to devote resources to taking care of new patients. The Breakthrough Series Collaborative (BTS) started ARV clubs in 14 clinics and effectively trained staff to implement and sustain ARV clubs. Staff were trained through a process of attending workshops, participating in collaborative efforts and working closely with mentors. Workshop groups created operating procedure that outlined the roles of club faculty members, methods of addressing problems and how to distribute pre-packaged medication.

 8. What were the most successful outputs and why was the initiative effective?
The Institute for Healthcare Improvement (IHI) and the Department of Health (DoH) monitored and evaluated the implementation ARV clubs. Clubs initially reported data to the IHI coordinator monthly and later reported data directly to the DoH. This information was then reported directly to senior management. The Breakthrough Series Collaborative (BTS) provided members of the project with the ability to monitor the implementation of the club strategy and the tools to adjust the strategy when needed. It has been credited as a successful method of identifying and resolving problems regarding implementation.

 9. What were the main obstacles encountered and how were they overcome?
Lack of space to conduct club meetings was an issue at many facilities. This problem was solved when staff used non-traditional spaces, such as the boardroom, the staff tearoom, the blood room, the waiting room, outbuildings and local libraries as venues in which to conduct meetings. The size of some clubs was also reduced in order to accommodate members in the available spaces. Additional obstacles included failing to quickly create support structures or replace mentors; failing to effectively use monthly data to identify and respond to clinics with inadequate performance. Clinics are now taught to slowly implement the club system and to use experienced mentors when creating new clubs. Additionally, as data collection has become systematic, it is becoming easier to identify and address issues of inadequate performance.

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
The initiative creates better patient outcomes. There has been improved retention of patients as compared to patients who are not in clubs. The Cape Town metro area has more than 820 clubs that contain more than 20,000 patients. Approximately 97% of club members remain in the program, whereas only 85% of patients remain in mainstream care. This high retention rate leads to superior quality of care. Club participants are 67% less likely to experience symptoms of virological rebound than those in mainstream care. Shifting the management of stable patients to a non-clinical facilitator reduces the number of patients in clinics. This allows clinicians to focus on patients that are especially sick or who need to begin ARV treatment. Hout Bay pharmacies provide sick patients with the correct medication and ensure that new patients understand correct dosage procedure. Since clinicians aren't as busy, they are less likely to experience burnout. Less crowded clinics also decrease the likelihood that patients will contract TB. Since patients spend limited time in clinics, they take less time off for work and are better able to engage in other activates. Club participants from the Hout Bay Community clinic and the Khayelitsha Ubuntu clinic praise the program for saving them time that can be devoted to work or leisure activities.

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
The initiative is both sustainable and transferable. ARV clubs exist at more than 37 clinics and plans are being drafted to implement it in other areas. Both the standardization of procedures and the education of staff support sustainability. Materials that carefully outline general procedures are readily available and the use of workshops and peer support networks to educate staff have been extremely effective. The Western Cape Provincial Department of Health (DoH) has information pertaining to the operation of ARV clubs and has expressed a willingness to share its experiences with clinics that express interest in the club model. The Breakthrough Series Collaborative (BTS) program in collaboration with a pilot group can be used in order to slowly expand the program to other clinics.

 12. Were special measures put in place to ensure that the initiative benefits women and girls and improves the situation of the poorest and most vulnerable? (If applicable)
Faculty learned to be creative to find space in which to conduct meetings. Since the lack of space available to conduct meetings was a problem, the boardroom, tearoom, the blood room of clinics and local libraries were used. Clubs also became smaller and more manageable as a result. Faculty also learned to gradually implement ARV clubs, develop a system of mentorship in which knowledge is effectively transferred to new faculty members and use monthly data to identify and respond to clinics that are not performing adequately. They found that clinics that did not take these steps were less likely to develop effective ARV clubs. Additionally, faculty determined that collaboration, between both supporting organizations and faculty members, was a successful method of supporting and improving the project. Members of the Western Cape Provincial Department of Health (DoH), Cape Town City Health (CoCTCH), Medecins Sans Frontiere (MSF) and the Institute for Healthcare Improvement (IHI) worked together to design the project, facilitate workshops, provide venues, participate in clubs and collect club data. The Breakthrough Series Collaborative (BTS) program was used in order to expand the program and improve operating procedure. The replication of these practices throughout clinics in South Africa can help South Africa to reach the goal of treating all HIV/AIDS patients with ARVs much more effectively.

Contact Information

Institution Name:   Western Cape Provincial Health Department, City of Cape Town Health, Institute for Healthcare Improv
Institution Type:   Government Department  
Contact Person:   Jannie Mouton
Title:   Dr  
Telephone/ Fax:   27214833116
Institution's / Project's Website:  
Address:   P O Box 2060
Postal Code:   8000
City:   Cape Town
State/Province:   Western Cape

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