مقیاس بندی سیستم اطلاعات بیمار برای بهبود درمان HIV: ارزیابی سیستم های مانیتورینگ بیمار در موزامبیک Scaling-up health information systems to improve HIV treatment: An assessment of initial patient monitoring systems in Mozambique

BACKGROUND AND SIGNIFICANCE Since antiretroviral therapy (ART) scale-up began in sub-Saharan Africa in 2004, ministries of health, international donors and technical assistance partners in the region have worked to develop and implement patient monitoring systems (PMS) to support quality HIV care and treatment. PMS is an umbrella term used for either paper-based or electronic systems to track a patient‘s care over time.[1] Many countries have expanded HIV services and related systems with funding from the US Government‘s President‘s Emergency Plan for AIDS Relief (PEPFAR) and other international donors. Functional PMS are essential for quality HIV/AIDS care and treatment. Antiretroviral treatment requires ongoing monitoring of clinical outcomes such as CD4 and viral load1 , daily medication adherence, and long-term retention in HIV clinical services.[2] PMS help health care providers initiate and monitor patients on treatment, facilitate identification and tracking of patients with missed appointments, and assist in following a patient‘s status and outcomes over time.[3-4] PMS can generate information for program managers to use for evidenced-based planning and program management. At the population level, effective PMS can contribute to the prevention of HIV drug resistance and reduced incidence of HIV transmission.[5-6] While PMS require significant infrastructure and human resource investments to establish and maintain, they have the potential to maximize the individual and population health benefits of HIV treatment. In 2004, Mozambique began rapidly expanding HIV care and treatment programs and accompanying PMS. The Ministry of Health (MOH) in Mozambique, as in many countries, has the mandate to define policies and standards in areas that support HIV service delivery, including health information systems. To this end, the MOH in Mozambique established national, standardized paper-based data collection and reporting tools for HIV services, routine training for all clinicians, and a data flow protocol to aggregate HIV data from the clinic level to the district and provincial level to national-level MOH. As HIV services began to scale-up in many sub-Saharan countries including Mozambique, health systems were weak and faced challenges to expand HIV care and treatment programs. To support scale-up of HIV services, international donors including the US Government PEPFAR program, the Global Fund to Fight AIDS, Tuberculosis and Malaria, and others prioritized financial and technical assistance to the MOH to strengthen human resources, laboratory and diagnostic systems, patient care/service delivery, commodities and health information systems. Often this funding and technical assistance was implemented through international and local non-governmental organization (NGO) clinical partners who supported public health facilities to strengthen the health system to support quality service delivery, including PMS. In Mozambique, these clinical partners facilitated implementation of paper-based and electronic systems for individual patient care and routine aggregate reporting of key HIV indicators, as part of their overall support to MOH to strengthen systems for HIV service delivery. Because the need for robust patient data outpaced the development of national guidelines for PMS implementation during ART scale-up, clinical partners developed a number of disparate PMS. Although most of these systems responded to the Mozambican MOH reporting requirements, there was no framework or governance to oversee and harmonize the various PMS. Decisions around development and implementation of electronic or paper-based PMS depended on the resources and technical knowledge available within each clinical partner.