title: Improving performance of Zambia Defence Force antiretroviral therapy providers: evaluation of a standards-based approach.
abstract: BACKGROUND
  The Zambia Defence Force (ZDF) has applied the Standards-Based Management and Recognition (SBM-R®) approach, which uses detailed performance standards, at some health facilities to improve HIV-related services offered to military personnel and surrounding civilian communities. This study examines the effectiveness of the SBM-R approach in improving facility readiness and provider performance at ZDF facilities.
  
  
  METHODS
  We collected data on facility readiness and provider performance before and after the 2010-2012 intervention at 4 intervention sites selected for their relatively poor performance and 4 comparison sites. Assessors observed whether each facility met 16 readiness standards and whether providers met 9 performance standards during consultations with 354 returning antiretroviral therapy (ART) clients. We then calculated the percentages of criteria achieved for each readiness and performance standard and conducted bivariate and multivariate analyses of provider performance data.
  
  
  RESULTS
  Facilities' ART readiness scores exceeded 80% before the intervention at both intervention and comparison sites. At endline, scores improved on 4 facility readiness standards in the intervention group but on only 1 standard in the comparison group. Multivariate analysis found that the overall provider performance score increased significantly in the intervention group (from 58% to 84%; P<.01) but not in the comparison group (from 62% to 70%). The before-and-after improvement in scores was significantly greater among intervention sites than among comparison sites for 2 standards-initial assessment of the client's condition and nutrition counseling.
  
  
  CONCLUSIONS
  The standards-based approach, which involved intensive and mutually reinforcing intervention activities, showed modest improvements in some aspects of providers' performance during ART consultations. Further research is needed to determine whether improvements in provider performance affect client outcomes such as adherence to ART.
authors.affiliation: Jhpiego/USA, an affiliate of Johns Hopkins University , Baltimore, MD , USA.
authors.forename: Young Mi
authors.initials: YM
authors.lastname: Kim
authors.affiliation: Jhpiego/Zambia, an affiliate of Johns Hopkins University , Lusaka , Zambia.
authors.forename: Joseph
authors.initials: J
authors.lastname: Banda
authors.affiliation: Jhpiego/Zambia, an affiliate of Johns Hopkins University , Lusaka , Zambia.
authors.forename: Webby
authors.initials: W
authors.lastname: Kanjipite
authors.affiliation: Jhpiego/USA, an affiliate of Johns Hopkins University , Baltimore, MD , USA.
authors.forename: Supriya
authors.initials: S
authors.lastname: Sarkar
authors.affiliation: Jhpiego/USA, an affiliate of Johns Hopkins University , Baltimore, MD , USA.
authors.forename: Eva
authors.initials: E
authors.lastname: Bazant
authors.affiliation: Jhpiego/USA, an affiliate of Johns Hopkins University , Baltimore, MD , USA.
authors.forename: Cyndi
authors.initials: C
authors.lastname: Hiner
authors.affiliation: Jhpiego/USA, an affiliate of Johns Hopkins University , Baltimore, MD , USA.
authors.forename: Maya
authors.initials: M
authors.lastname: Tholandi
authors.affiliation: Jhpiego/USA, an affiliate of Johns Hopkins University , Baltimore, MD , USA.
authors.forename: Stephanie
authors.initials: S
authors.lastname: Reinhardt
authors.affiliation: Zambia Defence Force (ZDF), Defence Force Medical Services (DFMS) , Lusaka , Zambia.
authors.forename: Panganani Dalisani
authors.initials: PD
authors.lastname: Njobvu
authors.affiliation: Jhpiego/USA, an affiliate of Johns Hopkins University , Baltimore, MD , USA.
authors.forename: Adrienne
authors.initials: A
authors.lastname: Kols
authors.affiliation: Jhpiego/USA, an affiliate of Johns Hopkins University , Baltimore, MD , USA.
authors.forename: Bruno
authors.initials: B
authors.lastname: Benavides