In Costa Rica, health managers and providers of HIV services considered a problem. With services concentrated in just three hospitals, all located in San Jose, the capacity for providing HIV care and treatment was overtaken by the demand. Waiting lists for enrolling newly diagnosed clients ran up to three months. For increased access, HIV services needed to be decentralized to other facilities. Yet some worried that the quality of care might suffer in the transition.

“In our laboratories, highly qualified staff and modern equipment are available to process samples—which is something that we are proud of,” says Dr. Gloria Terwes, national officer of the HIV Prevention and Control Unit of Costa Rican Social Security (Caja Costarricense de Seguridad Social, or CCSS). Yet an assessment revealed that “infection prevention practices are not being followed rigorously,” she explains. “Underlying problems range from mistakes in the purchase of gloves—various sizes to fit different staff members have not been considered—to underestimating the risk of accidental exposure to any infection, for staff and for our clients.”

Most Central American hospitals that provide decentralized HIV services struggle with issues such as weak infection prevention practices, poor nutritional care and persistent discriminatory practices. The Capacity Project is helping national HIV programs in Belize, Costa Rica, El Salvador, Guatemala, Nicaragua and Panama to improve performance and supervision systems that will help address these issues.

In Costa Rica, CCSS and the Capacity Project are focusing on three secondary-level hospitals—De la Mujer, Alajuela and Max Peralta de Cartago. “The Project’s performance support approach is strengthening various management processes relating to HIV service provision,” observes Dr. Terwes. Local teams identified gaps between expected and real performance in service provision, then prioritized deficiencies, analyzed causes and developed action plans. Meanwhile, national and regional authorities led similar processes to support local plans and identify issues that can be addressed through central-level interventions. “This methodology responds to one of the priorities of our National Policy on HIV/AIDS,” says Dr. Lidieth Carballo, the country’s vice minister of health.

“Multidisciplinary teams at HIV clinics are being empowered and are implementing a series of unprecedented change and improvement efforts,” Dr. Terwes remarks. “The teams are now able to identify specific needs that should be addressed by the central level. This is a very significant change,” she emphasizes, “because it has helped us identify that [the] technical accompaniment of operational services by central-level programs has been weak. The performance support approach is allowing us to address this topic in a more systematic, sustainable and friendly manner.”

These efforts have contributed to impressive results. A baseline assessment in August 2007 reported that the three secondary hospitals achieved 55%, 35% and 43% of performance standards for HIV services, respectively. A follow-up assessment conducted in March 2008 showed that those figures had risen to 90%, 84% and 91%. All three hospitals made these leaps in a short time period and with very few additional resources.

“Expected staff performance has now become one of the key elements considered in recruiting, hiring and orienting new staff within the organization,” Dr. Terwes explains. “This has allowed us to better outline the profile and role of each type of professional.” For example, “when the baseline assessment revealed the need for additional human resources, a description of the expected performance helped us to quickly identify them within the service network; consequently, human resources were relocated to the places where they were most needed.”

She adds, “The Project is bridging a technical gap in our planning. While most projects are focused on clinical and technical aspects, working with the Capacity Project is helping us to address key topics, such as establishing needs in terms of human resources in order to achieve the expected performance in HIV clinics, which is an approach that is directly linked to achieving strategic results.”

Looking ahead, Dr. Terwes asserts that “CCSS is very interested in continuing this process. We will improve tools by further defining expected performance in the area of psychological and social care—which is key to achieving adherence to antiretroviral therapy—and we are advancing towards institutionalization of this approach, since it is yielding very positive results.” Dr. Solón Chavarría, officer of the CCSS, concludes, “The Project fits as ring to the finger to strengthen the decentralization process on ARV treatment.”