Lessons Learned from the Star Rating Assessment Tool in Tanzania

In 2019, to better assess how well health care facilities provide HIV/AIDS treatment, the Technical Support Services Project (TSSP) integrated HIV/AIDS indicators into the Star Rating Assessment (SRA) Tool. The SRA assesses service delivery of health care facilities and rates them on a scale of one to five stars. More stars correspond to better quality service. TSSP also supported the Ministry of Health, Community Development, Gender, Elderly, and Children (MoH) in updating and digitizing the SRA tool to prepare for future rounds of health facility assessments, including dispensaries, health centers, and council hospitals.

Funded by the US President’s Emergency Plan for AIDS Relief (PEPFAR) through the Centers for Disease Control and Prevention, and implemented by Management Sciences for Health (MSH), TSSP worked with the MoH to support and strengthen the SRA tool system. 

MSH spoke with Salli Mwanasalli, DDS, TSSP Senior Technical Advisor, Quality Assurance and Improvement, and Dr. Talhiya Yahya, Head, Quality Management Subunit in the Health Quality Assurance Unit (HQAU), at MoH, about integrating HIV/AIDS service indicators into the SRA Tool and implementing the Android mobile app in Tanzania’s Coast and Mbeya regions.

What was the goal of integrating HIV/AIDS services into the SRA Tool System? 

Salli Mwanasalli (SM): The SRAs conducted in 2015 to 2016 and 2017 to 2018 found that Tanzania needed to assess health facilities’ compliance with the national HIV/AIDS program and case management standards and recommend necessary changes. Integrating HIV/AIDS service indicators into the SRA contributes to complying with PEPFAR Quality Standards and achieving the national 95-95-95 goals of diagnosing 95% of HIV-positive persons, providing antiretroviral therapy to 95% of those diagnosed, and reaching viral suppression for 95% of those treated.

Talhiya Yahya (TY): After the two countrywide assessments, stakeholders recommended an increase in indicators in services, including HIV/AIDS services, which previous SRA assessments did not cover.

What is MSH’s role in developing the SRA indicators for HIV/AIDS, and how did it come about?

SM: MSH helped develop quality indicators for priority clinical programs, which are aligned with national QI/QA [quality improvement/assurance] guidelines and plans. These HIV-specific indicators were necessary to assess programs, including HIV testing and counseling; adult and pediatric treatment and care of TB and HIV; preventing mother-to-child transmission of HIV; and nutrition. MSH also integrated indicators for malaria; human resources for health; reproductive, maternal, newborn, child, and adolescent health; and the Global Health Security Agenda into the tool.

Who are MSH’s partners on the SRA Tool project?

SM: MSH worked with the MoH through the HQAU, the President’s Office, the Regional Administration and Local Government Tanzania (also known as PORALG), and the Department of Computer Science and Engineering-DHIS 2 at the University of Dar es Salam to integrate HIV-specific quality indicators in the SRA Tool. Through the national level meetings of the technical working group on CQI [continuous quality improvement], partners updated standards and supporting documentation, incorporated the updates into the SRA database, and built the capacity of critical technical and managerial staff involved in CQI work.

MSH helped create a mobile Android app (SRA Offline Tool) to help assess health facilities in the Kibaha Town Council and Bagamoyo District Council in the Coast Region and the Chunya District Council in the Mbeya Region. Can you tell us a bit about why was the app created?

SM: Since 2017, the MoH has implemented an Online Quality Improvement Plan, or QIP, tracking tool following the SRA conducted at health facilities in Bagamoyo and Chunya. Previously, assessors recorded the results on paper and then manually entered the data into an Excel spreadsheet to calculate the facility’s star rating and generate council, regional, and national feedback reports and facility-level QIPs. The offline Android mobile app now allows stakeholders to enter data into the central DHIS 2 database by using a phone or tablet without relying on internet connectivity. TSSP also facilitated incorporating HIV/AIDS indicators into the online MOH DHIS 2 system and the offline mobile app.

How does the app work?

SM: The free mobile-based app is available for download in Google Play for Android Users. The interface has features for input, processing, and output. Data input can be offline or online. Once data are entered into the SRA QIP, the app automatically computes and checks data validity and synchronization for availability on the web-based system. The app provides offline reporting for automated routine analysis.

How did this improve HIV/AIDS services in health care facilities? 

SM: The mobile app feature allows health facilities to collect data in areas with no internet connectivity and generate the follow-up QIP reports on time. The app ensures that data is available in real-time and provides an avenue for the council health management team to simultaneously access and correct identified gaps in service. 

TY: The goal was to pilot the SRA mobile app in these regions to determine whether it could have a wider rollout. Overall, there was an improvement in services. Assessors reported service gaps to the district medical officer, district executive director, and the council health management team. Interviews with local government and community leaders helped identify additional challenges and strategize solutions with the council health management team. A meeting arranged with the regional health management team provided further feedback.

What were the challenges of integrating HIV/AIDS indicators into the SRAs?

SM: Integrating these indicators into SRAs was a lengthy process that involved several meetings with MoH health teams, PORALG, and other stakeholders. Piloting the tool was a long process that included validating the HIV/AIDS indicators into the SRA and later finalizing DHIS 2. TSSP facilitated the phased implementation of the SRA in the Coast and Mbeya regions by ensuring that national assessors received training and orientation on the new indicators in the revised SRA according to MoH specifications. TSSP also supported the development of the QIP and SRA feedback reporting systems in DHIS 2.

What were lessons learned from this initiative in Kibaha Town Council, Bagamoyo in the Coast Region, and Chunya District in Mbeya Region?

SM: TSSP’s collaboration with the Government of Tanzania helped ensure that the SRA is a priority and positioned it as a promising initiative to motivate change at the health facility levels. A MoH-led approach will enhance national ownership and commitment for monitoring interventions to address the HIV epidemic.

TY: The SRA tool created an awareness of QI and a competitive spirit to succeed in health facilities. As facilities’ performances improved, the tool was revised to introduce higher standards and better service indicators. Assessment of the facilities leads to an awareness of the minimum standard for primary health care facilities.

What comes next? 

SM: TSSP handed the SRA system to MoH for approval and planning the national rollout of SRA in late 2021.

TY: We, the MoH, will conduct countrywide assessments of all primary health facilities and plan to roll out a new tertiary care facility tool.

Read more about the Technical Support Services Project here.