5/23/18 Systems Analysis and Improvement Approach (SAIA) SAIA-SCALE Systems engineering is a SAIA is a package of systems engineering tools including methodical, disciplined approach for Micro-costing a government-led the design, realization, technical § Cascade analysis management, operations, and program § Flow mapping retirement of a system. § Continuous quality It is a way of looking at the “big improvement (CQI) picture” when making technical Well suited to prevention of decisions. mother-to-child transmission (PMTCT) process improvements Jonny Crocker -NASA System Engineering Handbook (2007) May 23, 2018 PMTCT & Linkages Cascade Increase in PMTCT Cascade Population (estimated completion of #preg women 6 months) SAIA Step 1 maternal & newborn 1,920 ART/PPO if drop-off 1st ANC Visit 4 1,868 97.3% Tested for HIV 14 1,707 93.9% Antenatal care HIV+ Describe pMTCT performance and 345 • ANC attendance 20.2% identify priority areas for improvement • HIV counseling & testing Maternal ART/effective PPO 2 • CD4 testing 508 99.0% • Provision of ARV prophylaxis/cART to mother o Use of the pMTCT Cascade Newborn with PPO in the maternity Analysis Tool (PCAT) to provide a 286 Birth 227 44.2% ‘systems view’ of the sequential, • Safe delivery Increase in children on ART if drop-off • Provision of prophylaxis to infant eliminated linked pMTCT cascade steps • Education on safe infant feeding and care Children enrolled in HIV care 1 482 94.0% Postpartum care Children with PCR <8 weeks 3 416 • Viral load testing 86.3% • Safe infant feeding Children dx HIV+ • Infant follow up care and HIV testing 42 10.1% • Family planning Gimbel, et al. The prevention of mother-to-child transmission of HIV cascade Children on ART • Linkages to long-term HIV care and treatment analysis tool: supporting health managers to improve facility-level service delivery. 23 19 2014. 45.2% 1
5/23/18 SAIA Step 2 SAIA Step 3-5 Tica Rural Health Center pMTCT Flow Day 1 CD4 Nurse • Blood draw for CD4 count (if initial Day 1 MCH community health Day1 Process Preg ♀ arrives for 1st worker (CHW) accompanies visit is on Monday, Tuesday or + HIV HIV+ ♀ to reception Reception CHW Wednesday) ANC visit with Rapid Continuous Quality Improvement opens chart Test • Triage for immediate care MCH nurse mapping to • Determines WHO clinical stage At 28 weeks o Define & implement facility- > 250 identify ♀ receives AZT & sdNVP ≥ Day 28 pMTCT Following week CD4 blood specific workflow adaptations modifiable returns to draw (if I-II CD4 Stage nurse for initial visit CD4 was facility-level Labor Starts At Home results Thursday or o Monitor changes in performance; Postpartum Friday) Contractions start III-IV Newborn gets: ♀ takes NVP sdNVP & AZT ≤ 250 initiate additional iterations bottlenecks CD4 nurse prescribes CTZ no and orders blood tests At Hospital Maternity (biochemistry, haematology) During labor Repeat analysis and o Duovir (AZT+3TC) ART eligible ? ART Committee Picks up ART at improvement cycle In The Home yes (at Nhamatanda ♀ starts 3 phases of ART pharmacy Rural Hospital) For one week postpartum to determine adherence counseling with a AZT ~1-4 weeks after dx eligibility social worker (total 1-3 weeks). 2-3 days later Social worker gives ♀ the ~1-4 weeks after dx ART (triple Drops off ART Evaluation with Phase Phase Phase DOT for the first 14 therapy) physician’s card at pharmacy 3 2 1 days of ART prescription asst (Tuesdays) SAIA 3-Country Study (2013-2015) SAIA-Scale Study (2017-2021) Overall objective • ~Effectiveness trial § ~Efficacy trial • Evaluate a district government-led, at-scale programming approach to § Cluster RCT conducted in Côte d’Ivoire, Kenya and the SAIA intervention Mozambique § Tested impact of SAIA on the PMTCT cascade Study setting: Manica Province, Central Mozambique § Intervention implemented by HAI study nurses • Total population: ~2 million § Resulted in improvements in • 15.3% adult HIV prevalence § ART uptake (13.3% vs. 4.1% increase) • 12 districts; 9-13 total health facilities per district • Three highest-volume health facilities per district to § Early infant diagnosis (11.6% vs. 0.7% be included in the intervention increase) 2
5/23/18 SAIA-Scale Study design We are here (2 months into implementation) § Stepped wedge § 3 x 12 month waves § 4 districts per wave § Implemented by MCH Retro- spective district nurses data § Mentored by HAI study nurses in the intensive Year 0 Year 1 Year 2 SAIA-SCALE Year 3 phase Control period Intensive implementation period Roll out (2 months) Sustainment phase SPECIFIC AIMS & METHODS Aim 1: RE-AIM Aim 2: Cost-effectiveness • Using activity-based micro-costing and mathematical • Develop an effective district-based dissemination and implementation models of HIV transmission, estimate the budget and strategy for the SAIA intervention (SAIA-SCALE), using the RE-AIM model to program impact from the payer perspective to scale-up the evaluate the program’s SAIA intervention compared to the standard of care. Reach : Health facilities and population reached R Effectiveness : PMTCT process, HIV infections averted, viral suppression E Adoption : Proportion and determinants of districts and facilities adopting the intervention A Implementation : Successes, failures, process evaluation I Maintenance : Districts and facilities sustaining the intervention at 12, 24, 36 months M 3
5/23/18 Aim 2 detailed objectives • Program cost of SAIA in Manica province • Incremental cost-effectiveness ratio (ICER) per: – HIV infections averted – HIV-related deaths averted – Disability-adjusted life year (DALY) averted • Projected cost and ICER for different scale-up scenarios , e.g: SAIA-SCALE COSTING – Nationwide METHODS – High-prevalence provinces only – Largest health facilities only Costing methods Activity-based cost analysis 1. Micro-costing 1. Cost analysis framework development – List broad program activities (e.g. supervision of health facilities) • Results can be disaggregated – List components of each activity that incur costs (e.g. supervisors’ time) – Review and refine together with program implementers – Brainstorm data collection methods to quantify each component 2. Bottom-up, activity-based 2. Data collection • Based on project activities – Extract data from existing sources as much as possible • More accurate and comprehensive (e.g. public records of government salaries) – Measure as many remaining cost components as possible • However, more time-consuming and complex (e.g. person-time) – Estimate remaining variables (e.g. travel time, distances) 3. Multiply cost components by unit costs 4
5/23/18 Main SAIA-SCALE implementation Supervision visits to health facilities activities • Description: 1. Training district supervisors – District MCH supervisors visit health facilities 2. Supervision visits to health facilities – Guide health facility staff through PCAT, flow 3. Micro-interventions within health facilities mapping, and CQI Main cost-incurring components of – Monitor progress this activity: • Data collection: Tablet-based survey, filled by a. Person-time district MCH supervisors b. Transportation • Status: underway (2 months into 36-month implementation period) Snapshot of cost analysis framework Form 2B, Facility visit survey ACTIVITY COST COMPONENT DATA TYPE DATA SOURCE Costable units Data collected Supervision visits to health facilities Metadata (date, location, etc.) Measured REDCap Form2B Date Number of district supervisors (health Measured REDCap Form2B Time facility visitors) GPS coordinates Enumerator Health facility staff visited Measured REDCap Form2B District Duration supervision visit Measured REDCap Form2B Health facility visited Transportation type and origin Measured REDCap Form2B Arrival time Drive time or distance for supervisors Estimated Google Earth, interviews with Departure time district supervisors Transportation type Unit costs Transportation origin District supervisor salaries Measured Public records Health facility visitors (organization, job position) Health facility staff salaries Measured Public records Staff visited (by level) Transport cost per mile or hour Estimated Modeled based on vehicle type, Activities description age, purchase cost, fuel cost Any other notes 5
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