Background

Background and Need
Thailand , with a population of 62.5 million, is one of the Asian countries hard hit by the HIV epidemic since 1984. As of the end of 2005, there have been an estimated 1.1 million cumulative persons infected with HIV and 560,000 AIDS related deaths, and there are 540,000 persons living with HIV/AIDS. National comprehensive care programs including ARV treatment since 2001 have increased care accessibility. As of the end of 2005, more than 80,000 persons had received ARV treatment under the national program. During the first GAP/Thailand cooperative agreement, BATS adapted an HIV care quality improvement (QI) model to Thailand (HIVQUAL-T), and successfully improved care quality in 63 hospitals. Data below show the percentage of eligible patients who received each service, from 2002 through 2005:

Year	No. of hospitals	No. of patients	% CD4 tested	% received ARV	% received OI prophylaxis		% screened
Year	No. of hospitals	No. of patients	% CD4 tested	% received ARV	PCP	Crypto	TB	Syphilis	Pap smear
2002	12	4,855	28	87	77	52	NA	16	6
2003	41	11,786	58	78	80	57	42	5	5
2004	63	15,702	80	81	79	69	57	9	8
2005	63	22,122	93	88	87	84	81	40	45

The Institute of Hospital Quality Improvement & Accreditation (IHQIA) in Thailand also supports quality systems for clinical care. Currently, 914 government and private hospitals have initiated quality processes for hospital accreditation with support from IHQIA. Recently, the national HIV care program has been transferred, and integrated with the national health insurance scheme (30-baht scheme) managed by NHSO. Therefore, cooperation among these organizations is important to establishing a common national system (HIVQUAL-T) for HIV care monitoring and QI. BATS, IHQIA and NHSO propose this project to develop and scale up a national QI system and to establish mechanisms to make HIV care QI sustainable.

Capacity

BATS has experience leading the national HIV programs for many years, is responsible for technical oversight of the national HIV treatment program, and has direct experience developing and implementing the HIVQUAL-T model since 2002. The 12 regional Offices of Disease Prevention and Control (ODPC) have experience and responsibility to improve the quality of HIV care and prevention, and have direct relationships with hospitals in their regions. They can provide regular supervision of participating hospitals and lead the local (regional and provincial) learning networks. Provincial health offices have responsibility for providing technical supervision and coordination for services delivered under the 30-baht scheme. NHSO has the role of service purchaser, and therefore needs to monitor and ensure the quality of clinical services, including HIV care and treatment. NHSO will take the lead in formulating national policies and plans for care packages, standards of quality, benchmarks, and QI resources. Its 13 regional offices will help support training, M&E, and strengthening learning networks for sustainability. IHQIA has had direct responsibility for QI for most hospitals in Thailand since 1997. Its QI processes, hospital surveyors, and hospital staff experience provide strong support for scale-up of the HIVQUAL-T system. See Appendix B – CT1 – Attachment 1 for project management structure details.

Objectives and technical approaches

          1. Expand hospital implementation of the HIVQUAL-T system (strengthen existing QI committee and working team, annual performance measurement, continuous QI processes) to cover 900 hospitals by 2011.
                a. Develop common policies and practices on HIV care QI with NHSO and IHQIA, develop program and performance measurement tools, conduct training of trainers for regional ODPCs, provincial health offices, and key hospital staff for each province, to train hospitals for implementation
                b. Promote implementation of hospital-led QI cycles, including annual performance measurement with HIVQUAL-T software, supervised by local and regional trainers
                c. Benchmark HIVQUAL-T performance measurement results at the provincial, regional, and national level
                d. Establish and build capacity for provincial and regional learning networks, and local QI coaching, with support from regional NHSO and IHQIA surveyor offices
                e. Organize annual national forum on quality HIV care, as an IHQIA Forum satellite
           2. Evaluate the accessibility and utilization of care and treatment services and address barriers to services, annually
                a. Regional ODPCs jointly conduct national survey
           3. Develop care networks among hospitals and health centers
                a. Develop guidelines (HIV care package) for health centers, pilot implementation (first year) and scale-up (2 nd -5 th year)
           4. Develop ARV adherence model
                a. Develop guidelines and pilot in 2-4 sites
           5. Develop new national occupational HIV post-exposure prophylaxis guidelines (medical practices, nursing practices, case management, report-support system)
                a. Hold working group meeting to develop guidelines, conduct expert reviews and revise guidelines, print and distribute guidelines, train hospitals and monitor implementation by monthly reports to regional ODPCs and BATS
          The project will result in a sustainable system because it is based on existing resources (hospital infrastructure, hospital accreditation system, 30-baht program, national guidelines) and coordination among responsible organizations (BATS, IHQIA, NHSO). In addition, the project will support capacity building on QI for trainers from regional offices and for hospital staff. NHSO will fund the hospital performance measurement and QI activities, and will monitor and benchmark the performance measurement results.

Plan for evaluation

Output/Outcome/Evaluation	Tools	Time-frame
Quality of HIV care service in the hospital Infrastructure for QI HIV day care center programs Patient satisfaction	HIVQUAL-T software (adult, pediatric, VCT, day care centers, etc.) Organizational assessment forms QI process records (by internal and external IHQIA surveyors) HIV service activity reports Patient satisfaction survey	Annual Annual Quarterly Monthly Annual
Care networks	Hospital and health care center survey, network process records	Year 2-5
ARV adherence model PEP guideline utilization	Process records, user survey Monthly ODPC reports, user survey	Year 1

Implemented sites
Hospitals in 75 provinces of Thailand

Period
5 Years (September 2006 – August 2011)

Organizations
      • Bureau of AIDS, TB and STIs (BATS)
      • National Health Security Office (NHSO)
      • The Institute of Hospital Quality Improvement and Accreditation (HA)
      • 12 Departments of Disease Prevention and Control
      • 75 provincial health offices

Workplan (1st Year: 2007 )

List

Activity

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