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| (1) Stock management of syphilis tests and penicillin |
| Problems | Solutions |
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(i) Frequent outages of lab tests and penicillin
(ii) No communication within health facility between clinic staff using tests/drugs and stock room/pharmacy
(iii) Multiple approvals and administrative layers for facility to reorder rapid syphilis tests and penicillin from national supplier
(iv) Requisitions from facility to national supplier often late
(v) National supplier often has stock outages of penicillin | (i) Clinic inventory and communication between clinic staff and pharmacy
(ii) Earlier requisition by facility of larger stocks from national supplier
(iii) Creation of a reserve stock of penicillin
(iv) Emergency budget for local procurement of penicillin
(v) National supplier of medications includes penicillin as essential drug |
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(2) Task shifting among health facility staff as syphilis testing moves from laboratory to the point-of-care
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| Problems | Solutions |
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(i) Clinical staff reports insufficient time to perform rapid syphilis tests on every pregnant woman
(ii) Laboratory staff reluctant to give up work and fear job loss
(iii) Injectable benzathine penicillin located in pharmacy and given by pharmacists only and not in clinic
(iv) Job descriptions do not match new responsibilities | (i) Staff becomes more “polyvalent” and performs multiple tasks
(ii) Staff backs each other up in case one becomes busy
(iii) Laboratory staff comes to clinic to draw blood and perform test on site
(iv) HIV counselors taught to draw blood
(v) Retraining and continuing education
(vi) Team building with goal of preventing newborn death |
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(3) Patient flow through the health facility
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| Problems | Solutions |
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(i) Multistep process between pregnant woman’s arrival to clinic, testing for syphilis, and penicillin injection. “The clinic process resembles an obstacle course for pregnant woman”
(ii) Bottlenecks (waiting for clinic chart; waiting for test results; etc.)
(iii) Long lines and waits between each step
(iv) Frustrated pregnant women leave clinic between steps | (i) Simplify flow and decrease number of steps
(ii) Give priority to pregnant women at key points of care (phlebotomy, pharmacy)
(iii) “Mobile laboratory staff” within facility to perform lab test in clinic rooms
(iv) Group counseling, education, and phlebotomy of all pregnant women in clinic waiting areas
(v) Decentralize prenatal care and syphilis screening to satellite facilities to decrease patient volume at large clinics |
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| (4) Data collection and evaluation |
| Problems | Solutions |
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(i) Clinic data flows up to administration, ministry, and PEPFAR but is not available in real time for clinic staff
(ii) No locally available indicators on percent of pregnant women tested for syphilis and percent of syphilis positive women treated
(iii) Need immediate feedback to reward and motivate staff
(iv) Need to correct problems in real time and not wait for a report from a central authority | (i) Use local registers to track a few key indicators
(ii) Local “improvement teams” meet regularly to review and report indicators to all staff
(iii) Data entry programs redesigned to generate local reports in real time |
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| (5) Patient and community participation |
| Problems | Solutions |
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(i) Women do not know about the dangers of congenital syphilis and importance of screening during pregnancy
(ii) Women afraid of injection needle and refuse penicillin
(iii) Community needs to hold health facility accountable for syphilis screening | (i) “Bottom up accountability,” by informing women in the community about dangers of congenital syphilis and that they have a right to free prenatal syphilis screening
(ii) Community health workers encourage pregnant women to seek prenatal care and screening
(iii) Include community members in discussions of how best to provide prenatal care and syphilis screening |
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