Challenges faced in the implementation of patient tracing in Thyolo, Malawi: A descriptive study Authors: Katharina Hermann¹, Isabella Panunzi¹§, Winnie Gomani¹, Rebecca M. Coulborn¹ ¹Médecins Sans Frontières, Thyolo, Malawi § Presenting author (msfocb-blantyre-mfp@brussels.msf.org)
Background prevalence was 14.5%.
40,000
36,697
35,000
Project
12.5% were lost-to-follow-up. Retention in care is challenging. In the absence of national guidelines, MSF and the MOH developed and piloted patient tracing guidelines (Figure 2).
# People
people had initiated ART (Figure 1): 76.3% were alive on treatment, 11.0% died and
72%
25,000 20,000 15,000
29,127
74%
30,000
MSF has assisted in scaling-up ART in Thyolo since 2003. By 2011 year-end, 36,697
78% 76% 76% 74% 72% 70% 68% 66% 64% 62% 60% 58%
23,128
16,106 65%
11,636
64%
10,000 5,000 0 2007
2008
2009
Ever initiated
The objectives were to identify patients who missed appointments, understand their
2010
% Alive on ART
In Thyolo, a rural district in Southern Malawi with 603,129 inhabitants, the 2011 adult HIV
2011
% Alive on ART
Figure 1: Cumulative ART scale-up in Thyolo by year
reasons and use this knowledge to improve ART services.
Evaluation of guidelines Our aim was to find out whether the documentation of tracing activities and a separate tracing database, both initiated in July 2011, had resulted in a reliable and complete registration of missed appointments, defaulters and proportion of clients who returned into care. Our methods involved two steps: 1. Quantitative analysis of the data collected in the patient tracing database and review of the routine data collected by the health workers on missed appointments and defaulters in the facilities; 2. Qualitative assessment of the process of patient tracing and its documentation. This was done by using key informant interviews with at least 2 health workers involved in patient tracing in a total of 8 health centres. Figure 2: Operationalisation of patient tracing guidelines in Thyolo
Health Surveillance Assistants, responsible for tracing activities in the community
Outcomes/lessons learnt Between July -December 2011 the tracing guidelines were implemented in 37 sites. Our programme evaluation identified numerous limitations. While 155 ART patients were recorded as missing appointments (monthly average: 22) and 32% were reported as traced within one month, data accuracy is questionable given incomplete recording. In addition, high workload contributed to delays between steps, and tracing of patients residing outside the ART site catchment was complicated. The poorly-designed data tool disregards patients who returned to care after a set date or of their own accord (without tracing) and includes an inadequate
Discussion & conclusions
checklist of reasons for missed appointments undermining an assessment of ways
Our tracing guidelines require significant changes, including
to improve ART delivery. Finally, the tracing guidelines themselves are incomplete
revision of the data collection tool and addition of mechanisms for
as they focus on the tracing activity rather than reintegration of patients into care;
reintegrating patients into care. Reasons for missed appointments
they lack structure and guidance for ensuring that patients receive specific
may be better assessed through qualitative research, rather than
counselling and support upon their return.
routine data collection by health workers without training or time for in-depth probing. Importantly, the time-intensive steps and Health Surveillance Assistant on her way to a village
extensive oversight necessary to ensure quality data and results suggest that individual patient tracing may not be sustainable or effective in overburdened healthcare systems. Other models of service delivery, such as the community ART groups in Tete, Mozambique—which utilise social networks to reduce defaulter rates—may be better suited for these contexts.