A Phone Call for Health: Improving HIV Patient Care and Adherence to Treatment in Ethiopia

 {Photo credit: Annette Scheckler/MSH.}Pharmacist Bethlehem Nega counsels a patient.Photo credit: Annette Scheckler/MSH.

Updated January 30, 2015

A Phone Call for Health

Alongside a road in a remote area of the Amhara Region, Solomon Dawit*, a truck driver from the Ethiopian capital Addis Ababa, sits waiting for a ride to the nearest town. He has two big problems: his truck has broken down and he doesn’t know how long it would take to get the parts needed to fix it. Another problem?  He is running out of his lifesaving antiretroviral (ARV) medication. After one month of waiting, Dawit’s truck is fixed, and he heads back home to Addis Ababa.

In Addis Ababa, pharmacist Bethlehem Nega sits at her computer in the antiretroviral therapy (ART) unit of the Bole Health Clinic. Using the Electronic Dispensing Tool (EDT), she looks at the names of “lost patients”—people who have missed their appointments by 25 days.  Solomon Dawit’s name pops up.  Nega calls Dawit to remind him to come to the clinic for his medicine. Upon seeing that he needs his regular six months CD4 count, she also makes an appointment for him.

Dawit comes into Bole Health Clinic that very same day and receives a three-month supply of ARVs; his CD4 count is tested as well.  He is relieved to have his medication because he knows his health is dependent upon his taking the pills every day.

When Dawit first came to the Bole Health Clinic, the pharmacist managing the clinic’s drug information service (DIS), Belete Wale, provided group counseling on ARVs to Dawit and other patients as they waited for their appointments. Dawit has a good understanding of what the drugs do, how to take the drugs, and how other factors, such as good nutrition, play an important role in maximizing adherence to ART. 

Dawit is also happy about the call he received from Nega:

When the pharmacist called me about my missed appointment, it showed they care about me as a person.

According to Bole Health Clinic’s Head Pharmacist, Workye Molla, the ART department serves an average of 800 patients per month. Every month, there is an average of 40 patients considered lost. And every month, these 40 patients receive a phone call from the ART pharmacy reminding them to come in for their lifesaving ARVs.

The Electronic Dispensing Tool 

Before the implementation of EDT, pharmaceutical management and information systems in Ethiopia were poor at capturing, aggregating, and reporting data relevant for informing decision-making. This was especially true at service delivery points. According to Molla:

We could not follow the patients, their appointments, and regimens. We did not know the amount of drugs that were in our inventory at dispensing units. We did not even know how many patients we served per day.

With the introduction of ART in Ethiopia, it became clear that without an effective information system, it would be challenging—if not impossible—to ensure the uninterrupted availability and rational use of the newly acquired ARVs.

Dawit and the other patients receiving ART at the Bole Health Clinic are benefitting from the partnership of the US Agency for International Development (USAID)-funded, Management Sciences for Health (MSH)-led Systems for Improved Access to Pharmaceuticals and Services Program (SIAPS) Ethiopia team and Ethiopia’s public health system. SIAPS has partnered with the Ministry of Health’s Pharmaceuticals Fund and Supply Agency (PFSA) in all of its pharmaceutical systems-strengthening support to make sure that government ownership and sustainability is institutionalized. The team is working with the Bole Health Clinic—as well as an estimated 200 ART sites using EDT software and 700 sites using the paper-based EDT system around the country—to establish and maintain an effective electronic information system at ART pharmacies to monitor patient adherence; drug resistance; access to medicines; prescribing, dispensing, and medicine use practices; and patient safety.

EDT is a cutting-edge information system that uses the patient as a focal point and captures critical information needed to make decisions about an individual’s drug regime, as well as stock inventory and aggregate patient statistics. For example, when Dawit first entered the Bole Health Clinic for treatment, the pharmacist used EDT to create a comprehensive patient profile, which included his medicine history.  Aggregate data on patient uptake, regimen profile, consumption, and stock on-hand informs decision-making by the pharmacist to make sure that all of the patients at the ART pharmacy are getting an uninterrupted supply of the right medicine, in the right amounts, at the right time.

Based on Dawit’s patient information, along with the other some 800 patients who are treated at the Bole Health Clinic, Molla is able to manage the stock; report adverse drug events, medication errors, and drug usage information; and, generate customized reports for national HIV & AIDS programs and other relevant stakeholders.

An Integrated Package of Pharmaceutical Systems-Strengthening Support

Dawit’s visits to the Bole Health Clinic are a very important factor in keeping him healthy, despite his status of living with a life-threatening disease. He isn’t aware that MSH-led SIAPS supports many of the services he receives at the Bole Health Clinic ART unit. For example, SIAPS provided the ART pharmacy with the software-based information system, EDT, that keeps track of his treatment; the computer, printer, and office furniture; and the in-service training and mentoring to all facilities staff managing EDT at the ART pharmacy.  SIAPS paid for the phone call from the pharmacist when Dawit missed his appointment. He didn’t know that the patient counseling he received from the pharmacist was based on the drug reference books, computer, and internet access supported by SIAPS. Dawit doesn’t know about the support provided by SIAPS to establishing the Drug and Therapeutics Committee—a key player in providing the health center with evidence-based selection and quantification of medicines and the rational practice and use of medicines.

Dawit is also unaware of the partnerships established between SIAPS and the PFSA, the Food, Medicine and Health Care Administration and Authority (FMHACA) of Ethiopia, and other public health agencies and health facilities that drive the success of these efforts.

The SIAPS/Ethiopia technical team has an on-the-ground understanding of the problems and challenges facing the country’s pharmaceutical sector. They understand that only country ownership can sustain the successful transformation of Ethiopia’s pharmaceutical sector. The technical team has developed partnerships with government stakeholders to work toward a common goal. Dawit only knows that despite his HIV status he feels strong and healthy and looks forward to living a long and productive life.

The Numbers 

SIAPS has rolled out EDT to some 200 sites around the country—the rest are using the paper-based system. The SIAPS/Ethiopia team supports the collection of patient uptake from 657 ART sites (113 government hospitals, 518 government health centers, and 26 private and nongovernmental health facilities). A total of 306,490 patients are covered, more than 95 percent of all ART patients in Ethiopia (see figure below). The SIAPS/Ethiopia team collects regimen breakdown reports from about 370 ART sites, covering 252,830 ART patients, about 80 percent of all patients on ART.

A year before, SIAPS provided an analysis of prescription patterns using data generated from the EDT that showed an irrational prescribing of d4T regimes, a common first-line drug regime for new patients initiating ART, which was contrary to recommendations of the new guidelines. On the basis of this information, the Federal Ministry of Health issued an amendment guideline for phasing out d4T regimens for adults. The progress of phasing out d4T regimens was closely monitored using information from EDT and by now it is almost complete (see figure below). Ethiopia’s Ministry of Health, along with other US Government partners, are using the same information to monitor implementation of the new ART guideline for pediatric ARV treatment program.

*Name changed to protect privacy.