PROCESS IMPROVEMENT MODELCASE OF - MACRO LILONGWE BRANCHLEVELS OF THE PROCESS IMPROVEMENT MODELSTEP 1- DEFINING THE PROCESSMethodology: Process AnalysisRationale: To analyze and identify pertinent processes.IntroductionMalawi AIDS Counseling and Resource Organization [MACRO] is a local NGO established in April 1995 with a mission purpose to provide Voluntary HIV Counseling and Testing [VCT] services and other HIV related support services to individuals, families and communities in order to reduce transmission of HIV and impact of HIV and AIDS in Malawi. MACRO has gone through several structural changes having been founded in 1992 as LACE then transforming into BACE in 1994.Strategic ObjectivesThe main MACRO strategic objectives include the following: To provide HIV and AIDS related training services. To increase access and availability of VCT and other HIV-related support. To improve the quality of VCT and other HIV-related support services. To increase demand for VCT and other HIV-related support services.Program goalsThe goals of MACRO HIV and AIDS Program are two-fold namely: To accelerate access and availability of VCT, treatment, care and support services. To reduce new HIV infection and impact of HIV and AIDS among individuals, families and communities in Malawi.MACRO provides its services through 6 static sites namely Karonga, Mzuzu, Kasungu, Lilongwe, Zomba and Blantyre. It also provides services through outreach and mobile sites across the country using motor vehicle, motor cycle and Van. MACRO has also borrowed the moonlight VCT from other countries where clients patronize services at night but this service is being piloted in Karonga. MACRO secretariat located in Lilongwe coordinates all the branches. The population targeted includes couples, ordinary people, high profile individuals, youth, high risk behavioral groups, etc. Overtime MACRO has realized that the urban population is reducing in terms of VCT uptake possibly attributable to saturation of the population by static sites and as such strategies to use mobile van, moonlight and outreach programs have been intensified to target the rural community [MACRO Annual Report, 2009].BackgroundAccording to annual reports reviewed [2007, 2008, and 2009] the annual rates of VCT uptake were tagged at, 102% [2007], 107% [2008] and 55% [2009] respectively. The rate is calculated against the annual target which fluctuates every year. It is calculated by computing the percentile of the total number of tested and counseled clients against the organizational target per annum. In 2007 for instance a total of 129, 968 clients were tested and counseled against the organizational target of 127, 691 thus representing 102% of the target, an increase of 74% from 2006. In 2009 on the other hand, 148,887 clients were tested and counseled against the organizational target of 271,410 representing 55% of the target a decrease of 52% from 2008 which registered a rate of 107%. Several factors contribute towards the overall uptake rate per annum- some structural or functional and others client related with dichotomies and disparities evident for example in patronage when comparisons are made between male and female clients.Program processes - MACRO1. Provision of VCT [static, mobile, outreach]2. Quality Assurance control in HIV testing3. Infection prevention through sensitization programs4. Outreach mobilization and publicity campaigns5. Data collection and reporting6. Client counseling, testing and registrationSelected process- Female VCT uptakeIf we improve this process what will be the impact on Customer satisfaction- Female clients will be motivated to uptake VCT. Satisfaction of other stakeholders- Controllers will be more keen to fundprograms having pinpointed the gap. Waste- Resources will be utilized to improve other processes. Compliance with technical standards- MACRO 50/50 policy, National HIV Prevention Strategy [2009-2013] 5.2 Strategic Objective 2. Broad Activity [b]- Scale up HTC in hard to reach areas in all the districts through door to door, outreach and mobile approaches.Customers- Female VCT clientsProducts and services- Outreach testing, mobile testing, collaborative[Ante-natal, PMTCT] testing, ART, condom access.Customers wants/needs- Accessibility, confidentiality, respect and dignity,privacy.Other stakeholdersControllers PACT Malawi NAC CDC Board of TrusteesSuppliers MOH- DHO UNFPAProviders Secretariat Branch Managers Counselors Monitoring and Evaluation specialist Data Analysts BLM SDA FAIR DAPP Hunger project Johns Hopkins [Bridge project] MOE [Theatre for change] Local Government Welcome Trust Dignitus International Post-test clubsQualification of existing processFemale VCT Uptake Female client arrives at site [static, mobile, or outreach] Female client registers Counselor provides pre-test counseling Counselor takes blood sample Testing is conducted using test kit Counselor provides post test counselingSTEP 2 PERFORMANCE MEASUREMENTMethodology: Analysis of Reports [Quarterly & Annual], Customer FGDRationale: To qualify and quantify performance measurements.Gaps gleaned and teased out in the MACRO report reviews [2007, 2008, 2009]Three major gaps were identified from the review exercise namely:1. Low couple VCT patronageIn 2007, irrespective of the overall high uptake rate registering an overwhelming 102%, only 6% of project beneficiaries in counseling and testing were couples irrespective of an expected higher rate. This increased by only 1% to 7% in 2008 irrespective of drastic measures put in place to ameliorate the anomaly against an overall uptake rate of 107%.2. Low female VCT patronage compared to their male counterpartsIn 2008, 46% of project beneficiaries in counseling and testing were females with a decline to 41% against 59% of their male counterparts in 2009 which fell short of a targeted 50-50 percentile and was rather contrary to the expected higher female patronage considering the fact that over 52% of the entire Malawian population are females.The reviewed reports document that when focus group discussions were conducted with female samples in a bid to delineate factors that act as barrier or de-motivate women from uptaking VCT the following variables cropped up: Long distances to testing centers Stigma Fear of a positive serostatus The need to seek permission from their male counterparts [either partner or husband].In 2007 these results were used to redesign the strategies to address their concerns culminating in an uptake increase of 39% by the end of the reporting period respectively.In 2009 the major factor documented as determining the significantly lower female patronage rate relative to the male clients was: Long distances to service centers.According to the focus group discussions women found it difficult to walk long distances in search for VCT services because of the reproductive, productive and community roles that they are expected to handle in their respective homes.In 2008 MACRO introduced the following activities to address gender concerns: Collaborations with ante-natal clinics during outreach testing targeting females who are exposed to HIV testing messages with the approach seeing more female patronage at the time. Couple counseling: counselors were trained to provide couple counseling with information being provided to both males and females to encourage individuals to bring their partners. Partner disclosure: individuals were encouraged to disclose results to their partners after testing. This was due to discordance results. Thus the partner would encourage the other to also come for testing. Regular outreach visits to women social and religious groups for HIV and AIDS Education, Information and Education which focused on the benefits of VCT and PMTCT were integrated into the program. These activities assisted in addressing concerns in the communities such as stigma and discrimination, giving out HIV information and disclosure problems.Project Performance measurement [Case of Lilongwe Branch]Reporting period: 1st October- 31st December 2010Objective 1: Increase availability of and access to VCT and other HIV-related support services.Activity specification: Conduct HIV counseling and testing.VCT uptake decreased from 6, 676 in the previous quarter to 5, 993 in this current quarter representing a 10% decrease. Referencing the quarterly project target for Lilongwe Branch tagged at 10, 350; the total number of clients tested and counseled during the quarter represents an achievement of 58%.Uptake by genderWhen analysis is conducted across gender lines for the quarter in perspective, out of the total number tested and counseled, 2, 438 were female representing 41% of the overall, against 3, 555 of their male counterparts represented by, 68% respectively. The former has remained constant from the previous quarter [this gap of low female patronage compared to male counterparts is evident across MACRO and is rather contrary to the expected higher female patronage considering the fact that over 52% of the entire Malawian population is female].Outreach testing programs implemented in the quarter in perspective continued to make services accessible and affordable to female clients with 71% of those seen at outreach sites being female. On the other hand the static site saw increased female patronage with 32.5% tested and counseled [considering the outreach and static statistics another gap emerges though indirectly- low couple patronage].Suggested branch level solution to gap- low female uptakeTo improve women uptake of VCT services, deliberate effort must be made to integrate VCT with other women services at community level, including PMTCT and antenatal services through collaboration with NGOs and/or CBOs providing these services.Problem statement:From 1st July to 31st December 2010 the female uptake rate for VCT at MACRO Lilongwe branch was 41% which is lower than the expected target [50%] considering the fact that over 52% of the Malawian population is female.Improvement objective:We intend to improve the female uptake of VCT at Lilongwe Branch from 41% to 45% by the end of December 2011.STEP 3 -ACOVMethodology: Analysis of Causes of Variation [ACOV]Rationale: ACOV helps identify and qualify causes of variation.Causes of variation- Case of Lilongwe branch [OCT-DEC 2010 quarter] Scaling down of activities: mobile and outreach VCT activities were scaled down because of the use of the only vehicle and motor cycles on the MDHS thus significantly reducing the impact of services to rural and mobile communities. Inadequate condom supply: the condom supply chain is unreliable with need to accommodate procurement of condoms in the MACRO budget since the supply from the DHO is limited. Apart from being another support service condom supply can attract clients by default to VCT services but can also be used by community campaigners as in post-test clubs to motivate others to come for VCT. Inadequate BCC materials: BCC materials are inadequate underscoring the need to produce own materials since these are one of the most effective sensitization tools that can reach a wider spectrum of the populace and attract more clients to screen for HIV through VCT. Inadequate supply of drugs: inadequate supply of drugs for STIs, OIs, other HIV related illnesses and for palliative care is a big challenge since most clients are diagnostically lured by the availability of and access to treatment if they may test positive. Not only that, those who are already enrolled and are accessing treatment may be demotivated and drop off with negative ramifications on compliance. QA system not fully implemented: although, the QA system is functional, the activities involved were not fully implemented in the quarter. Exit interviews and client satisfaction surveys were not conducted underscoring the need to draw general guidelines on conducting these specialized QA activities. Lack of outreach mobilization and publicity campaigns: there is need to revive outreach mobilization and publicity campaigns which were not conducted in the quarter due to financial constraints. Vehicle problems: frequent vehicle breakdowns and problems with servicing old vehicles which are expensive to maintain hampered project implementation.CAUSES OF VARIATION [GENERAL VCT UPTAKE]Findings from PROCESS ANALYSIS stakeholder consultation[21 Jan- 2 Feb]Staffing Attitude of service providers- some service providers have negative attitudes which tend to demotivated would be clients. Lack of confidentiality- some service providers disclose the test results of clients and this lack of confidentiality prompts clients to fear for their privacy and shun away from testing. Lack of motivation- due to uncertainties and organizational constraints some service providers lack motivation with implications on provision of quality services.Structural Poor timing of services- Most VCT services are provided during working hours only and during working days in the week, making it difficult for couples to go together for HIV testing [men are mostly at work during the day ]. This underscores the need to revive and intensify services such as moonlight. Lack of other unique and supportive services- women may patronize more hospital or health center based services because they are mostly associated with reproductive health issues e.g., PMTCT, antenatal and family planning services and also because they combine other unique and supportive programs as early infant diagnosis and the CD4 count highlighting the need to diversify and incorporate other such services. Problematic program designs- some program designs might not necessarily be taking into consideration various needs of the population by not necessarily being gender friendly [gender blind] or youth friendly or targeting the most at risk populations e.g., CSW. Poor location of some centers- some centers are located in crowded environments and because of poor location people are likely to be ashamed of patronizing such centers since they fear for their privacy and confidentiality. Lack of adequate community structures- lack of or inadequate community structures e.g., volunteers and CBOs resulting in low direct community sensitization.Technical Lack of equipment stock outs of HIV testing kits may demotivated people who might have come for VCT at such a time and may never consider to go for a test again.Programmatic Inadequate targeting of communities- more communities still remain underserved in remote rural areas calling for a scale up to VCT services within the regions. There is more competition in the urban environ with several organizations involved in HTC leading to the saturation of the urban sphere- e.g., Lighthouse, Partners in Hope, BLM, MANASO etc. Missed opportunities- unstrategic selection of outreach and mobile sites leads to missed opportunities and hence partenering with organizations such as Malawi Interfaith and MOH may lead to the extension of programs to areas like churches where couples might be readily targeted.Customer based Accessibility- long distances to service centers has been leading to some form of cost-benefit analysis with VCT being traded off against productive, reproductive and other feminine roles with implications on female uptake underscoring the need to scale up female friendly services such as outreach and mobile. Low risk perception- low risk perception among the youth [15-24 age group] has resulted in lower uptake rates within the age group underscoring the need for more youth focused outreach mobilization and publicity campaigns. Fear of stigma and discrimination- most would be clients still fear the stigma and discrimination of a positive sero-status. Gender-related constraints- women need to seek permission from their husbands and girls their partners to access VCT services because they have no power to decide their fate in the home unless the husband agrees due to gender related sterio-types which are rather retrogressive and affect the turnout of women and girls for VCT. Lack of motivation and incentive- general lack of motivation and the incentive to screen for VCT among the general populace with HTC being perceived as irrelevant is greatly hampering efforts to scale up and utilize the strategy in preventing further transmission of HIV/AIDS.Categorization of causes of variation [Wen- 9/2/11]TNP model [T & P]Structural Poor timing of services [T] -1 Lack of other unique and supportive services [P] -2 Problematic program designs [P] -3Programmatic Missed opportunities [P] -4 Lack of outreach mobilization and publicity campaigns [T] -5 QA system not fully implemented [P] -6 Scaling down of activities [T] -7 Vehicle problems [T] -8Service provider based Attitude of service providers [T] -9 Lack of confidentiality [T] -10 Lack of motivation [T] -11Customer based Low risk perception [P] -12 Gender-related constraints [P] -13 Lack of motivation and incentive [P] -14 Accessibility [T] -15 Fear of stigma and discrimination [T] -16TPN model [N]Supplies Inadequate condom supply [N] -17 Inadequate BCC material [N] -18 Inadequate supply of drugs [N] -19 Stock outs of HIV test kits [N] -20Structural Poor location of some centers [N] -21 Lack of adequate community structures [N] -22Programmatic Inadequate targeting of communities [N] -23CAUSES OF VARIATION [FISHBONE DIAGRAMMING]Multi-voting to select critical causes of variation Mon 14/02/11COV VotesF M M MeanPoor timing of services 4 3 3 3Lack of outreach mobilization and publicity campaigns 5 5 5 5Vehicle problems 3 5 5 4.5Attitude of service providers 3 3 3 3Lack of confidentiality 3 5 2 3Lack of motivation 1 2 3 2Accessibility 4 4 4 4Fear of stigma and discrimination 2 4 2 2.55 4.5 4SELECTED COV- Lack of outreach/Vehicle problems/AccessibilityKey1- Not significant2- Fairly significant3- Significant4- Strongly significant5- Extremely significantSTEP 4- PLANNINGPROCESS IMPROVEMENT PLANMethodology: Development of Logical Framework [ Work Breakdown Structure] Fri 18/02/2011Rationale: Document- Activities, task dependencies, schedule, indicators,deliverables [etc].GOAL- To increase female VCT uptake.Specific Objectives Determine factors contributing to the low female VCT uptake by month 1. Develop strategies for process improvement based on feedback from clients by month 6. Implement the process improvement strategy by month 8. Monitor and evaluate female uptake by month 16. Maintain, revise or replicate process model by month 18.Process improvement implementation plan Discussion with Lilongwe Branch staff on the Improvement process including scheduling of Focus Group Discussions with women groups. Conduct FGDs with women groups. Analyze and communicate the FDG findings. Develop strategies for process improvement based on feedback from FGDS. Implement the process improvement strategy. Monitor and evaluate the process improvement. Revision of process model to improve, maintain or replicate.STEP 5- IMPLEMENTATIONCOMMUNICATION OF PLANRationale:TRAINING [IF NECESSARY]Rationale:PROCESS CHANGE INTRODUCTIONRationale:STEP 6- STUDYING IMPROVEMENTMONITORING AND EVALUATION OF PROCESS IMPROVEMENTRationale:STEP 7- ACTIONMODEL MAINTANANCE/ MODIFICATION/ OR REPLICATIONRationale: