| Ordering medicines |
| Gap: Orders not submitted on time, lack of commitment to meet the ordering deadline, no person responsible for ordering | Clarifying staff roles and responsibilities and to have a designated person responsible for ordering: |
| Gap: Limited knowledge on how to order medicines, needs from different departments were not properly quantified | Engaging key staff with information necessary to the ordering process in the process:Involving the dispenser, records, stores and incharge of the ART clinic in the ordering process Forming a therapeutic committee at the health facility to identify the medicines needs Involving departmental heads in the ordering process
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| Medicines storage |
| Gap: Cluttered medicines stores making it difficult to find medicines | Reorganising stores to create space for medicines and other non-medicine materials using 5S approach Creating another dispensing point to decongest stores Identifying and placing cupboards in different departments to store medicines
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| Gap: Medicines are not entered into stock cards or stock cards are incompletely filled | Placing stock cards next to each item so that they are readily available to be immediately filled in Mentoring staff on stock card completion Changing the process so that stock cards are updated before medicines are issued out Setting aside specific days to receive medicines requisitions from departments
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| Dispensing medicines to clients |
| Gap: Low percentage of clients that can correctly explain how to use their medicines | Improving knowledge of staff on ARVs and dispensing Continuing medical education provided to staff on ARV use Mentoring staff on how to correctly fill the dispensing logs Rotating of staff through dispensing responsibilities Putting up an example of a well labelled dispensing pack for staff to refer to Counselling clients on medicines use Writing and verbally explaining clear instructions on how and when to take medicines Using expert clients and volunteers to give more information to clients Crosschecking clients’ understanding on how to take their medicines Asking clients to repeat the instructions of when and how much to take their medicines Establishing client exit points for random checks of client understanding Correct labelling of dispensed medicines Preparing and checking prepacked medicines
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| Gap: Limited time available for dispensing, congestion in the clinic at the point of dispensing leading to long waiting times | Assigning dispensing responsibilities to specific staff Allocating responsibilities within the dispensing process to staff Using community health workers to help explain how to take medicines to clients Reallocating available staff in the health facility to the dispensary Providing written roles and responsibilities Improving efficiency of the dispensing process Prepacking and prelabelling medicines before the clinic day begins Putting up medicines dispensing flow chart for staff to refer to while dispensing Supervisory support by the QI team leader to provide feedback to dispensers Improving client flow through clinic to minimise congestion Creating a dispensing corner within the ART room Creating dispensaries in different departments to minimise waiting time at the central pharmacy
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| Adherence to ART |
| Gap: Poor documentation of client adherence in records, clients not carrying their medicines on person or refusing to bring their medicines | Improving staff competencies on how to complete documentation on the HIV care/ART card Training on how to fill the cards Developing a guide on the critical parameters to be documented Demonstrating how to calculate adherence to staff Re-introducing pill counting Encouraging clients to bring back their medicines on the clinic day Giving feedback to clients on their adherence Encouraging clients to come personally wherever possible for clinic days (rather than sending a representative) Providing envelopes to clients to carry their medicines to/from the facility
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| Gap: Inadequate adherence counselling, inadequate information about the importance of adherence, non-adherence due to religious beliefs, misconception, stigma, alcoholism, side effects | Improving counselling Staff training and mentoring on the use of ARVs Using linkage facilitators and treatment supporters Conducting home visits where necessary and feasible Increasing client contact time for counselling Increasing the number of points within the clinic where clients can access information on adherence (eg, waiting room, clinician’s place, dispensing table) Providing counselling in language clients understand Engaging staff who can speak the language to provide instructions Involving expert clients to give testimonies during health education Conducting sessions with religious leaders especially those that discourage use of ART Forming family support groups Associating medicines taking with routine activities (eg, brushing teeth, breakfast) to act as reminders
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