Welcome and introductions

1. Change management processes to implement integrated TB and HIV data management in facilities, using TIER.Net Comprehensive training to support the national TB/HIV Information System (THIS) integration initiative

2. Welcome and introductions Facilitators for training: Riona Govender – NDoH M&E (NIT) Nevilla Somnath – NDoH TB RIMES (NIT) Barbara Franken – NDoH* (NIT) Ipeleng Mojaki – NDoH* (NIT) Moeketsi Finger – NDoH* (NIT) Catherine White – NDOH* (NIT) * Seconded from CHAI

3. Acknowledgements NDoH appreciates the contributions into this complex initiative by: NDoH TB, HIV and M&E teams. Staff at the 11 Learning Implementation sites, and all (sub)district and provincial colleagues involved. TIER.Net developers: UCT - Centre for Infectious Diseases Epidemiology and Research (CIDER). Developers of interlinked systems: WAMTech (ETR.Net and EDRWeb), CSIR (HPRS), and HISP (DHIS). CDC. Clinton Health Access Initiative (CHAI). BroadReach, Anova Health Institute, The Aurum Institute, TB/HIV Care Association, Stellenbosch Univ, VitalWave.

4. Welcome and acknowledgements You, the participants! Thank you, re a leboga, enkosi, avuxeni, dankie, siyabonga for being here, in the midst of many other current demands on your time. Your commitment and effort will turn the TB/HIV integration strategy into an integration reality.

5. Welcome and acknowledgements Let’s do some origami. Participants from DoH, local authority, partners and special welcome to Correctional Services. Round of introductions, or show of hands?

6. Ice breaker Anonymous. But will ask for 5 volunteers to share with group. Please express how you feel about TB / HIV Information Systems integration, • In one word, • Or, in one sentence, • Or, in a picture. Then stick it on the wall. 3 minutes

7. Training objectives and approach Training goals, objectives, overview, approach, pledge, and house rules

8. End goal of the training It is not just about the software! • To capacitate PITs and DITs and TKIs on implementing the national initiative to integrate THIS. • This includes rollout of the TB module for digitising the paper TB register in TIER.Net, and all related change management processes.

9. Acronyms quiz Q. What does TIER stand for? • Three Interlinked Electronic Registers. Q. What three registers does it refer to? • ART since 2011. TB rolling out now. MCH in the making. Q. What do NIT, PIT and DIT stand for? • National / Provincial / District Implementation Team. Q. What does TKI stand for? • TIER Key Implementer. Q. What does THIS stand for? • TB / HIV Information Systems. Q. What does digitising mean? • Capturing into an electronic system. Q. Pronounciationof TIER is to rhyme with …... • Dear.

10. Objectives of the training To capacitate participants to: • Be fully conversant with the TB module in TIER.Net, • Understand the associated change management processes to integrate data management for HIV and TB within facilities, • Support facilities to drive the digitisation of TB data in an effective and sustained manner, • Drive the integration of TB and HIV Information Systems at (sub)district level and above.

11. In other words, TKIs will learn to: • Adequately prepare districts and facilities for rollout • Implement • Oversee the initial transition • Maintain the integrated TB/HIV information system • Monitor

12. In other words, TKIs will learn to: • Adequately prepare districts and facilities for rollout • Includes: informational buy-in meetings, facility assessments with remedial action, adjusting the flow of patients/folders/data as per Ideal Clinic and Implementation Guide, and training facility staff on record-keeping, data entry, and data use. • Implement • Includes: upgrading facilities to TIER v1.10. • Oversee the initial transition • Includes: onsite handholding during back-capturing of all active TB patients, data audit, sign-off, and retiring of paper TB registers.

13. In other words, TKIs will learn to: (continued) • Maintain the integrated TB/HIV information system • Includes: regular (and documented) site visits and quarterly audits, to assess adherence to SOPs, quality of record-keeping and data entry, and optimal use of TIER reports and lists for the benefit of clinical patient management. • Monitor • Includes: ensuring timely flow of monthly and quarterly data into ETR.Net and DHIS, reporting on rollout progress to the next level, and analysing data to improve clinical governance and programme management.

14. Overview of the training • Key focus is TB/HIV integration. • In wake of Dr Pillay’s pronouncement at THIS kick-off meeting (7 March 2016), TKIs will also be orientated on: • Digitisation of HIV testing data in TIER.Net. • Digitisation of pre-ART data in TIER.Net (as not all patients take up UTT). • Data management in TIER.Net for patients in Adherence Clubs or CCMDD PuPs(i.c.w. increased drive to decongest facilities by decanting stable patients with chronic conditions).

15. Overview of the training (continued) • Training includes a refresher on the National vision for TB / HIV integration. • Training also covers many new functionalities in TIER.Net, e.g. • Viral Load Due report • Bulk capture of lab results • Interface with HPRS • Duplicate folder merge • Facility Management report • (Sub)District Management reports • Many other new reports and lists • Etcetc

16. Overview of the training (continued) • The components of the M&E system will be introduced in broad strokes. • E.g. the M&E SOP, support tools and documents, data flow and timelines. • Lastly, TKIs will be guided on how to carry this training forward – how to operationalise the rollout.

17. Next steps – team exercise for districts • Operationalising the rollout requires ongoing effort, detailed planning and team work. • District team exercise for this week: complete the handout (also on memory stick): “Next steps for initial rollout in minimum of 5% of eligible facilities before 31 March 2017.” • Submit via e-mail by Thursday evening. • Each district to present summary key points on Friday morning (strictly 2 minutes per district, verbal, no slides).

18. Next steps – team exercise for districts

19. Next steps – team exercise for districts

20. Next steps – team excercise for districts

21. Inclusion of Correctional Services in the training • Special welcome to Department of Correctional Services (DCS). • Acknowledged that historically DCS and DoH have worked largely in siloes. • Recent years DoH and DCS are addressing this gap: • Gradually increasing collaboration, and alignment of structures, systems and programmes, at all levels. • Recognition of partners’ valuable role in this.

22. Inclusion of Correctional Services in the training • In THIS initiative, in form of: • Inclusion of DCS in SOPs, guidance, training by NDoH, • Inclusion of DCS in PIT and DIT structures, • TIER.Net software being aligned to DCS needs, • Master Facility List being amended to include all Correctional Centres. • All the above still in fairly early stage of iterative development. • Hence training can give only very little overt guidance for rollout of TIER.Net in Correctional Centres at this stage.

23. Inclusion of Correctional Services in the training • Importance of having DCS and DoH in same training (and in PIT and DIT structures) is to have all cogs of public health system in one room. • Collaboration to be mainstreamed, become the ‘new normal’. • Break through the siloes – all TKIs must work as a team: • TKIs from DoH and partners are experienced in TIER implementation, and are thus expected to support DCS colleagues with rollout within Correctional Centres, • But they need to understand the operational differences between DoH and DCS, and work to support DCS’ needs.

24. Approach of the training All data in all training materials are dummy data. • All sections on HIV and TB are couched within the framework of the 90-90-90 cascades. • All sections are aligned with the prescripts of Ideal Clinic and ICDM / ICSM. • All sections describe the data source for capturing and the importance of proper clinical record-keeping. • All sections focus heavily on the reporting functionalities, and how to use those reports to improve clinical governance of patients. • Participants will do some practical exercises. However, this is limited, as this is NOT a data entry training. • Main focus is change management for integration.

25. Approach of the training • All TKI’s are expected to fulfil allTKI roles and responsibilities, not only in ‘their’ field. • Audience is very diverse group: • Cadres from Programmes and M&E / Data / Info Mgt. • Provincial, district, sub-district levels. • Experienced TIER implementers and TIER newcomers. • What is basic knowledge for some is new terrain for others. • Training is based on assumption that all participants either already know the basics of the TB programme, HIV programme, and TIER.Net, or will upskill themselves within the coming weeks.

26. Tools provided for upskilling yourself on TIER On your memory sticks: • Training videos • User Guide • Slides Today: sneak preview On TIER.Net: Help functionality On internet: Vula portal In your area: your colleagues!!

27. Approach of the training roll-out This is a training for implementers, not for spectators. This is NOT a Master Training, or a Train-the-Trainer. I.e. for TKIs, the do-ers who are direct stewards of the integration effort in facilities. That is you, the ‘chosen ones’!

28. Participants’ commitment District Management has selected you to be part of THIS initiative, and placed their trust in you to drive it. On Fri, you will be asked to sign a Pledge to commit yourself to fulfilling all your TKI duties, and rolling out accordingly in facilities in your (sub)district.

29. I, the undersigned, [name] hereby confirm that: • I have participated in the 5-day TB / HIV Information Systems (THIS) Integration Training, including TIER.Net. • I have thus been capacitated to be a TIER Key Implementer (TKI). • I pledge to complete my training by watching the training videos from www.VULA.ac.za . • I commit myself to make adequate time available to fulfill my roles and responsibilities as a TKI. • I commit myself to adhering to the prescripts of this training, the Implementation Guide TIER.Net TB Module, the integrated HIV/TB M&E SOP, and other national TIER.Net-related SOPs, support documents, and tools. • I commit myself to capacitating, mentoring and monitoring facility personnel in the geographic area for which I am responsible, to likewise adhere to the abovementioned prescripts.

30. I, the undersigned, [name] hereby confirm that: Without you, there will be no TB / HIV integration. • I have participated in the 5-day TB / HIV Information Systems (THIS) Integration Training, including TIER.Net. • I have thus been capacitated to be a TIER Key Implementer (TKI). • I pledge to complete my training by watching the training videos from www.VULA.ac.za . • I commit myself to make adequate time available to fulfill my roles and responsibilities as a TKI. • I commit myself to adhering to the prescripts of this training, the Implementation Guide TIER.Net TB Module, the integrated HIV/TB M&E SOP, and other national TIER.Net-related SOPs, support documents, and tools. • I commit myself to capacitating, mentoring and monitoring facility personnel in the geographic area for which I am responsible, to likewise adhere to the abovementioned prescripts.

31. Certificate Managers of TKIs are requested to create an enabling environment where TKIs have sufficient protected time for their TKI duties. You will also receive a Certificate, if you have attended all 5 days. Asikhulume

32. Sustainability and ownership This training aims to steer this major transition towards integrated TB/HIV data management in a manner that fosters sustainability, ownership and institutionalisation. This training is expressly aimed at capacitating primarily DoH and DCS managers. The implementation and maintenance of the M&E system is the responsibility of government officials. It is therefore critical that the TB/HIV Integration is led by Province and District.

33. Sustainability and ownership (cont.) Prov/District management must optimally use all resources to drive implementation and capacitation efforts. Partners are part of those resources, And have played major and invaluable role in TIER rollout since 2011. HOWEVER….

34. Sustainability and ownership (cont.) Partners have in most cases taken the lead with rollout. DoH has mostly allowed and often even encouraged that. TIER.Net often perceived as ‘partner system’, instead of the national system that it is. 25 districts no longer have partner support. Partners will not be funded forever. How sustainable is that?

35. Sustainability and ownership (cont.) Asking others to do your work for you = robbing yourself of an opportunity to empower yourself. Prov/District management is to clearly map out roles and expectations (and limits) for partners, focusing on health system strengthening, not on parcelling out DoH work to partners. Partners are to collaborate with the stewards (not be the stewards). Partners who feel they are not being used effectively by Province/District are requested to inform their PEPFAR leads, who will then inform NDoH.

36. Questions? Discussion?

37. House Rules - TO BE ADOPTED • You are all here to be capacitated as TIER Key Implementers. Hence you are all here to learn, absorb, participate, ask questions, and engage. • You are expected to commit yourself to implementing what you will learn this week in facilities in your geographic area. • Ask questions, as and when they arise. • There are no dumb questions. • The facilitators may ‘park’ questions if it will be covered in another session, or is best answered by a facilitator who is not in the room, or is not relevant to the majority of the group. • Take notes for yourself.

38. House Rules - TO BE ADOPTED • Respect your facilitators and co-participants. • Be punctual; arrive on time, do not leave early, return promptly after breaks. • No side conversations. • Keep walking around to an absolute minimum. • Keep computers closed, except during pc-based exercises. • During pc exercises, do not get sucked into e-mails etc. • Keep phones on silent. • Ideally, keep phones stowed away in your bag. • No answering of phone calls. (No, not even at a whisper.) • Wait for next break to attend to phone calls, e-mails, etc.

39. House Rules - TO BE ADOPTED • Please sign Attendance Register every day. • If unable to attend on a certain day for a valid reason, please inform a facilitator at the registration table the previous day or next day. • STAY AWAKE! When dozing off, feel free to ask for an energiser.  • If you cannot read this on the screen, please find a seat in the front. On Friday, please check out of your accommodation BEFORE the training starts!

40. House rules Any edits or additions to these house rules? Can we adopt?

41. National TB / HIV Integration strategy and vision Background, benefits, data flow mapping

42. Background to TB / HIV integration • In spite of high co-infection of TB and HIV – data remains separate. • Care increasingly integrated – however data has not supported this. • WHO-led 2013 evaluation of HIV, TB and PMTCT programmes recommended integrating information systems. • Independent systems review was done in 2014. January 2015 - NDoH decided to proceed withintegrating TB and HIV data management in facilities. • 7 March 2016 - kick-off meeting to inform stakeholders of THIS integration initiative. • Integrated management supports HSS initiatives such as 90-90-90 and EWI.

43. Benefits of TB/HIV integration Problem: Fragmented data systems compromise patient management, and duplicate effort and resources to manage these systems. Integrated system will support patient management: • Patient care is being integrated – and must be supported by integrated data management. • In-facility digitisation of TB data puts ownership of TB data back into the hands of facility staff. • Clinicians will have direct access to wide range of patient management reports – data can be used to improve care, • E.g. following up on tests due to be done, test results due back, patients due for treatment, defaulter tracing, outcome allocation, etc.

44. Benefits of TB/HIV integration • Integrated data flow: TB data will follow same flow as HIV data, from folder flow and clinical record-keeping, to capturing, to in-facility data usage, and reporting/exporting data to (sub)district. • Makes it easier for facilities and (sub)districts, and improvestimeliness and completeness of reporting to DHIS. • Integrated SOP and guidance: sets foundation to improve data quality and ultimately patient outcomes, from facility-level up. • Rationalised support: streamlined processes for monitoring, maintenance, IT equipment and support, training, system upgrades / updates, etc. • Economy of scale – more efficient use of time by (sub)district teams.

45. Benefits of TB/HIV integration • Inter-sectoral alignment: same system and processes will be used in non-DoH facilities, e.g. Correctional Centres. • Towards EMR: all change management processes that are implemented now, will benefit any future implementation of an Electronic Medical Record system.

46. Benefits of TB/HIV integration Key point: putting ownership of TB data back into the hands of facility staff So, we will be doing what we already do, but better.

47. National vision (future 2-3 years) TB/HIV Programme Data • When TB Module fully rolled out, all TB & ART data will be captured in facilities, and flow up through TIER.Net and the DHIS. • HIV &TB patient information consolidated in 1 database. • All can draw reports via the Internet. If no connectivity, reports drawn directly from the TIER.Net on the PCs. • This is a step on the path to an electronic medical/ patient record (EMR). National IntegratedHIV/TBPatient Database Province TIER (sub)District WebDHIS TIER Facility FACILITY PC with TIER.Net FACILITY PC with TIER.Net FACILITY PC with TIER.Net TB & HIV data from patient folder TB & HIV data from patient folder TB & HIV data from patient folder

48. Interim data flow mapping Paper TB facilities Electronic HIV & TB facilities Sites with EDR National EDR WEB TIER ETR DHIS Province EDR WEB DHIS ETR TIER Export DR-TB data (sub)District Export DS-TB data Export ART data Export DS-TB data EDR WEB DHIS TIER ETR Facility DR-TB Register TBRegister TBRegister TBRegister TIER TIER TIER HIV, DS-TB & DR-TB data from patient folder HIV, DS-TB & DR-TB data from patient folder HIV, DS-TB & DR-TB data from patient folder

49. Integration headlines - transition • Changes will be measured. • During transition, each district will have a mixture of electronic and paper TB registers at their facilities. • TIER.Net, ETR.Net and EDRWeb will run in parallel during transition. • Initially most will be paper; after a couple of years, most TB facilities will have digitised their TB data. • ETR and EDR will remain TB reporting systems for TB cohort outcomes data into DHIS, until TB Module in TIER.Net is universally implemented in a district.

50. Integration headlines Debunking a myth: • THIS initiative is NOT about interlinking / interfacing TIER with ETR – i.e. maintaining two linked information systems. • THIS initiative is ultimately about replacing the paper TB register and ETR with TIER TB module at the facility level – i.e. having a single information system for TB and HIV at the facility.