1. SERVICE DELIVERY AS AN ENTRY POINT TO HEALTH SYSTEM STRENGTHENING A Case Study from Senegal: Improving the Tuberculosis System of Care Dr. Bruno Bouchet, Director Health Systems Assessment & Development

2. Three Key Messages Formal Quality Improvement (QI) efforts improve the performance of public health programs (disease-specific health outcome) QI addresses systems issues that affect service delivery, with potential spillover to other services/health conditions QI should be a key component of a Health Systems Strengthening (HSS) strategy

3. What Did We Want to Accomplish? Goal: Improve the health systems for patients with TB in Mbao District, Senegal: – Lost-to-follow-up: 23% to 7% (national target < 5%) – Cure rate: 55% to 77% in 5 years (target 85%) We used the Collaborative Model for Improvement: – Improvement objectives, systems analysis & QI teams – Monthly monitoring of process/output/outcome measures on run charts – Coaching of QI teams/health providers – Testing changes through PDSA (Plan-Do-Study-Act) – Learning sessions to share results and ideas – Scaling-up improvements

4. Improvement Matrix ProcessesImprovement ObjectivesChanges Identification of Chronic Coughers All chronic coughers screened within 7 days of the referral CHWs integrate TB messages in community talks CHWs identify chronic coughers during home visits CHWs refer chronic coughers to a health facility ( community component) Physical Screening First sputum smear within 24 hours Nurses stop advising clients to fast before going to lab Laboratory Diagnostic Three sputum smear exams within 48 hours At least 95% of sputum smear exams are correct Lab hours for sputum smears exams are extended (service delivery) Two lab technicians perform sputum smear exams (human resources) Care & Treatment Patients with confirmed TB start treatment the same day All patients with active TB receive complete information Lab technician accompanies TB patient to health center (service delivery) Follow-up All patients benefit from a bacteriological follow-up All patients benefit from a directly observed treatment All patients benefit from a HIV test DOT monitors register daily drug intake of patients (information) Health providers offer HIV testing (and counseling), using rapid tests (governance & products) Final Evaluation and Discharge Lost-to-follow-up rate < 5% Cure rate > 85% Rate of lost-to-follow-up patients is measured monthly (information) Irregular patients are immediately contacted

5. Did the Quality of TB Care Processes Improve? HIV testing Changes Regular Intake under TDO Changes Bacteriological Exams M2, M5, M6 Changes TB Tx Started Same Day Changes

6. Did the Performance of the TB System of Care Improve? Introducti on de Changem ents Arrêt de la collecte des données 0,00 5 10 15 20 25 30 March-08 March-10 Months Percentage LTFU Changes QI Stopped August-09 % of TB Patients Lost-to-Follow-Up 40 50 60 70 80 90 100 Sept-08Mar-09 Aug- 09 Mar- 10 National Objective 85% Changes First Cohort of QI patients QI Stopped Cure Rate

7. Is the Senegal Health System Stronger? Depends on the interactions between a public health goal (or program) and the health system. 3 options: 1.Yes, The HS is stronger because the TB system of care is stronger… …provided TB improvement does not come at expense of another service 2.Maybe improved TB services also benefit other services …provided we have the data to demonstrate the spillover (by design or by chance?) 3.No, improved TB services had no effect on cross-cutting national functions (5 other building blocks)

8. Added Value of QI for Health Programs and Health Systems QI zone Public Health Program National Target: 80% 8

9. Key Issues for Debate Why is not modern QI a systematic component of every public health program or HSS strategy? How should a disease-control program be designed to also strengthen the health system?

10. Thank you!