PEPFAR's annual planning process is done either at the country (COP) or regional level (ROP).
PEPFAR's programs are implemented through implementing partners who apply for funding based on PEPFAR's published Requests for Applications.
Since 2010, PEPFAR COPs have grouped implementing partners according to an organizational type. We have retroactively applied these classifications to earlier years in the database as well.
Also called "Strategic Areas", these are general areas of HIV programming. Each program area has several corresponding budget codes.
Specific areas of HIV programming. Budget Codes are the lowest level of spending data available.
Expenditure Program Areas track general areas of PEPFAR expenditure.
Expenditure Sub-Program Areas track more specific PEPFAR expenditures.
Object classes provide highly specific ways that implementing partners are spending PEPFAR funds on programming.
Cross-cutting attributions are areas of PEPFAR programming that contribute across several program areas. They contain limited indicative information related to aspects such as human resources, health infrastructure, or key populations programming. However, they represent only a small proportion of the total funds that PEPFAR allocates through the COP process. Additionally, they have changed significantly over the years. As such, analysis and interpretation of these data should be approached carefully. Learn more
Beneficiary Expenditure data identify how PEPFAR programming is targeted at reaching different populations.
Sub-Beneficiary Expenditure data highlight more specific populations targeted for HIV prevention and treatment interventions.
PEPFAR sets targets using the Monitoring, Evaluation, and Reporting (MER) System - documentation for which can be found on PEPFAR's website at https://www.pepfar.gov/reports/guidance/. As with most data on this website, the targets here have been extracted from the COP documents. Targets are for the fiscal year following each COP year, such that selecting 2016 will access targets for FY2017. This feature is currently experimental and should be used for exploratory purposes only at present.
Years of mechanism: 2008 2009
The Mozambican Ministry of Health (MOH) is committed to reducing HIV transmission from mother to child.
In 2007 the MOH implemented a plan to improve the quality of services in sexual and reproductive health
and infant health utilizing guidelines entitled "Gestao e Reconhecimento dos Servicos com Base em
Padroes de Desempenho (GRBP)" (Management and Recognition of Services Based on Performance
Patterns). The program aims to improve coordination between all facilities that serve HIV+ pregnant women
including antenatal clinics, maternity clinics, postpartum clinics and ART clinics. Some women will access
PMTCT services prior to and after a home delivery. The first phase of the program was focused in 6
provinces and included provision of training and education of standards of care and materials to support
these standards. Data comparing services provided in 2007 to early 2008 showed a significant increase in
services provided to pregnant women and their infants. The 2nd phase (2008-2009) of the program will
focus on the 5 remaining provinces.
While access to PMTCT services increases dramatically in Mozambique, a mechanism to monitor the
quality of the services provided is critical. HIVQUAL accomplishments and ongoing activities in FY08
include development of PMTCT indicators, key stakeholders meeting, identification of pilot facilities, and
baseline data collection and analysis and QI training for PMTCT providers. HIVQUAL-Mozambique will build
on FY08 activities to further develop a framework to assess the quality of services provided by PMTCT
services. The core components of the HIVQUAL model are 1) Performance Measurement; 2) Quality
Improvement; and 3) Quality Management Program or Infrastructure to support Quality Improvement. This
model promotes a balance between data and improvement activities. It emphasizes the importance of
national, provincial, district and site level leadership to promote and support quality activities in a
sustainable way.
The HIVQUAL model has been used in Mozambique since being adopted by the MOH in 2006, and has
been successfully implemented in 42 adult HIV treatment programs across the country. The program has
worked in close collaboration with USG implementing partners. Multiple trainings for data collection and QI
methodology have occurred nationally, regionally and at the facility level. The ART committees in most
facilities function as the quality committee where HIVQUAL data is reviewed and analyzed and priorities for
improvement identified. The MOH has expanded from 32 facilities to 42 and has asked that the program be
implemented to 100 facilities in 2009, expanding to all 215 HIV treatment facilities in 2010.
This successful model will be also applied to facilities providing PMTCT programs. The following activities
will be conducted during the project period:
1. Continued meetings of key stakeholders
2. Ongoing implementation of project workplan/timeline
3. Review and expansion of relevant, reliable and improvable indicators related to PMTCT and coordination
of these services in concert with MOH and CPIP
4. Expansion of involved facilities
5. Update HIVQUAL-Mozambique software package
6. Training of new facilities in data collection methodology
7. Collection of baseline data at expanded group of facilities, analysis and report generation
8. Training of new facilities in Quality Improvement Methodology following baseline data collection.
9. Support ongoing Quality Improvement Projects at pilot facilities and implementation of QI projects in new
facilities
10. Planning to add indicators for routine antenatal care and integrated services
In addition to the above activities the HIVQUAL team will perform an annual Organizational Assessment
(OA) on each new facility. The OA assesses the current program and infrastructure in place to support and
sustain the QI program at the facility level. The OA includes the following components: Leadership
understanding of the need to support QI activities, planning, measurement, consumer involvement, staff
involvement and education, QI
projects and an assessment of the facilities information systems capability.
The HIVQUAL-Mozambique program, funded through HRSA, is directed by the New York State Department
of Health, AIDS Institute, under the directorship of Dr. Bruce Agins. Margaret Palumbo, Deputy Director of
HIVQUAL-International and the lead for HIVQUAL-Mozambique will oversee these activities in collaboration
with the MoH. The AIDS Institute contracts with a two local NGO's, JHPIEGO, and FGH (Vanderbilt
University) to coordinate these activities in country. Currently Dr. Mussa Calu is the program coordinator
who has ably led the implementation of HIVQUAL-Mozambique. Dr. Calu works closely with the Ministry of
Health and was invited to attend weekly MoH meetings to develop a national quality management program
and address quality issues related to integration of HIV and Primary Care. Antonio Langa, serves as the
projects Data Manager, responsible for the data collection and reporting process. Mr. Langa provides hands
on training to facilities and works closely with implementing partners to assure data is collected and
reported in a timely manner. Mr. Langa will provide data analysis and report generation in
conjunction with the MoH.
New/Continuing Activity: Continuing Activity
Continuing Activity: 15807
Continued Associated Activity Information
Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds
System ID System ID
15807 15807.08 HHS/Health New York AIDS 6418 3586.08 HRSA IAA $170,000
Resources Institute
Services
Administration
Emphasis Areas
Human Capacity Development
Estimated amount of funding that is planned for Human Capacity Development $100,000
Public Health Evaluation
Food and Nutrition: Policy, Tools, and Service Delivery
Food and Nutrition: Commodities
Economic Strengthening
Education
Water
Table 3.3.01:
Pediatric HIVQUAL
New activity
This activity will build on the ongoing quality improvement programs that were implemented starting in FY06
through HIVQUAL. The goal of HIVQUAL-MZ is to allow individual health care providers to engage in a
participatory process of quality improvement based on evidence and data collected locally by their own
teams. Using the HIVQUAL model, Health Units, Districts, Provinces, and the MoH at the central level
gauge the quality of the health services provided to HIV-infected persons using indicators based on national
guidelines, and propose feasible and sustainable strategies to improve the quality through implementing
established standards of care and treatment.
Established indicators measured through HIVQUAL-MZ determine the level of continuity of care, access to
antiretroviral therapy, CD4 monitoring, TB screening, prevention education, cotrimoxazole prophylaxis,
adherence assessment, and post-exposure prophylaxis (PEP) implementation. The specific focus of this
activity is at the clinic level, adapting the methods of quality improvement to each facility's particular
systems and capacities. An assessment tool to measure the capacity of the quality management program
at each clinic is used, and measures the growth of quality management activities as well as guides the
coaching interventions. Facility-specific data that are aggregated provide population-level performance data
that indicate priorities for national quality improvement activities and campaigns.
From FY06 to FY08 HIVQUAL focused on adult care and treatment. A pediatric component will be added to
the adult version to be able to regularly measure the quality of pediatric services being provided. CDC and
the Ministry of Health will develop a model for national evaluation of HIV care and treatment in children
under 15 years. The main objective is to build capacity to support clinical data collection and analysis at the
clinical level, linking these activities to building systems that improve quality of care and treatment of HIV
positive children. This quality improvement activity will complement the adult HIVQUAL, started in 2006 with
the first round of data collection being completed early 2008.
The key indicators to be developed for this evaluation will be guided by findings that will come out of the
ongoing national Pediatric ART program evaluation.
Using FY 2009 funds, HIVQUAL-MZ activities will expand to include pediatrics quality improvement
measures as follows: a) in collaboration with MOH and other stakeholders, select performance indicators for
pediatric care and treatment b) engage and select pilot sites with the partner agencies, c) conduct site visits
with organizational assessments, d) establishs designs and implement Quality Improvement projects aiming
to improve service delivery at health facilities; e)update data collection every six months.
New/Continuing Activity: New Activity
Continuing Activity:
Table 3.3.11:
ACTIVITY UNCHANGED FROM FY2008
This activity will expand upon the USG support of HIVQUAL-MOZ which began in FY06 to improve
capability of HIV healthcare providers to monitor the quality of care in 45 HIV clinics throughout the country.
The HIVQUAL model emphasizes integrating performance measurement and quality improvement, and
developing a quality management program to support activities at the clinic level. In FY08 the program will
be expanded by including quality monitoring of Counseling and Testing (CT) services in three selected pilot
sites.
The national CT expansion strategy has undergone some major changes which aside from greater
emphasis on expansion of Provider Initiated CT (PICT), and the implementation of first pilot experiences in
Community-based CT (CCT), a new approach has been promoted and piloted in three sites in Maputo City.
The "CT in Health" (CTH) approach was promoted by the Health Minister in 2006 as a way to implement
health promotion and prevention activities aiming at enhancing the number of people that access health
services. This health promotion package proposes continuation and expansion of HIV counseling and
testing as well as the inclusion of TB, Sexually Transmitted Diseases (STD) and hypertension screening
and referrals where necessary, counseling on malaria prevention, environmental health education, and
sexual reproductive health orientation - especially in relation to early pregnancy diagnosis and institutional
delivery. One of the results of the CTH pilot was an increased number of HIV-negative clients screened for
TB, STDs and hypertension and referred to services when necessary for early diagnosis, care, and
treatment related to these diseases.
In FY09, the continuation and expansion of HIVQUAL-Mozambique will continue to be executed under the
leadership of the Ministry of Health (MOH) in close collaboration with CDC-Mozambique and the US-based
HIVQUAL team for technical support. HIVQUAL indicators will be devised and extended to include CT
program indicators. Cooperation with implementing partners, other donors and WHO will occur so that a
participatory process is implemented for indicator development. Activities will include: 1) Quality
Improvement (QI) training of CT providers and program staff; 2) assessment of quality management
programs at the participating CT sites 3) performance measurement (at six month intervals) of selected CT
core indicators; 4) ongoing quality improvement coaching at participating CT sites; and 5) promotion of
client engagement in HIV Care. Data analysis and planning for expansion based on the results of the pilot
will also occur. Activities will result in strengthening CT services delivery through improved information
available on potential gaps and opportunities for improving the quality of CT services. The emphasis of this
method is to develop skills for use of performance data by providers within their settings and for the specific
purpose of driving improvements in their systems of care. Quality improvement training will be conducted for
groups of CT providers and to key MOH CT staff at the provincial level. The HIVQUAL team will expand its
focus to build quality improvement coaching skills among MOH CT staff and CT providers in Mozambique,
and provide advanced level trainings for sites as well as basic trainings for new participants. The training
activities will be done in collaboration with JHPIEGO and the University of Pittsburgh through subcontracts
with the New York State AIDS Institute funded through USG/HRSA. This project will work in partnership with
all CT partners in Mozambique who will help disseminate quality improvement strategies and activities
throughout their networks.
Funding for these expansion activities will benefit from economy of scale since HIVQUAL-MOZ has already
been supported for implementation in health care facilities. Part of the funds will be used to support
additional specific activities and travel to CT sites, development of program-specific materials and
engagement of consultants with expertise in these fields.
Continuing Activity: 15806
15806 15806.08 HHS/Health New York AIDS 6418 3586.08 HRSA IAA $120,000
Table 3.3.14:
ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS:
This activity will continue activities launched in FY 2006 and continued through FY2008. HIVQUAL-
Mozambique anticipates expanding beyond the 36 facilities it has successfully worked with in FY2007 and
those added in FY2008, totaling 42 sites. The HIVQUAL model is designed to integrate performance
measurement and quality improvement at the clinic level and to develop a quality management program to
sustain activities. The HIVQUAL model strives to fully integrate quality improvement activities into the
national healthcare infrastructure.
In 2009 the program will expand to 18 additional sites as determined by the Ministry of Health in each
region with emphasis on community health centers and rural areas. Implementing partners will continue to
be engaged to spread HIVQUAL-Moz throughout their networks of supported facilities, as part of their role
in providing TA as treatment services begin to transition to local partners. HIVQUAL-Moz will also play a
role in monitoring the quality of HIV/AIDS care during the MOH-mandated transition to integrated primary
and HIV/AIDS care, adding indicators that reflect chronic disease management as patients respond to
antiretroviral therapy. The program will implement the third round of measurement and support QI activities
related to PMTCT, while expanding initial work in pediatrics and Counseling and Testing guided by the
leadership of the Ministry of Health and DPS officials, in close collaboration with PEPFAR, coordinated by
CDC. Indicators and facilities will be selected by the Ministry of Health.
Activities and Expected Results
Activity 1:
Performance Measurement
The goal of HIVQUAL is to allow health services and individual health care providers to engage in a
teams. Using the HIVQUAL model, Health Units, Districts, Provinces and the Ministry of Health (MoH) at
central level will gauge the quality of services provided to the HIV+ population. Indicators based on national
guidelines and chosen by the MoH have been developed and methods for feasible and sustainable
strategies to improve quality through implementation of these established standards of treatment and care
adopted.
Performance measurement will continue in the 42 participating sites and expand to an additional group as
determined by the Ministry of Health, especially targeting underserved area where quality of care may be of
concern relative to urban areas and those supported by partners. Although implementing partners will
continue to facilitate implementation in clinics they support, HIVQUAL staff will continue to mentor them and
technically support MOH leadership of these activities at both national and regional levels.
antiretroviral therapy and CD4 monitoring, TB screening, prevention education, adherence assessment and
PEP implementation. Data will be collected and reported by participating facilities semi-annually with
results being reviewed immediately at the site level for use in quality improvement activities. Indicators will
be reviewed by an advisory group following each data collection phase. Facility-specific data that are
aggregated provide population-level performance data that indicate priorities for national quality
improvement activities and campaigns. The HIVQUAL team will continue to support meetings of key
stakeholders led by the Ministry of Health to review data from measurement of quality indicators, evaluate
the process of review, refine indicators and prioritize areas for improvement at the national level.
Aggregated results will be reviewed by the Ministry of Health to assess and evaluate progress.
Additional measures are under development for PMTCT (15807.23589.09), Pediatrics ART (23593.09) and
Counseling and Testing (15806.23590.09). A narrative description can be found in the respective activity
sheets for those program areas.
Activity 2:
Quality Improvement
Results of the data are utilized at the clinic level, adapting the methods of quality improvement to the
system and capacity of each organization. Priorities for improvement are established at the site level and
QI projects implemented. A central database will be used to track QI activities and intervention strategies.
Regional groups will be held semi-annually to promote peer learning and share improvement successes. It
is expected that all facilities will implement at least two quality improvement projects in FY 09. Coaching
and mentoring of regional and district level personnel will continue, reaching all regions and enhancing
penetration of districts in FY09. The unique approach of HIVQUAL-MZ involves fostering regional networks
of providers who are engaging in quality improvement activities that enables them to work together, while
sharing improvement strategies, to address common problems that are unique to each area, including, for
example, human resource shortages, coordination of care among multiple agencies as well as maintenance
in care. Quality improvement training will be conducted as needed for providers and government officials. A
training-of-trainers program will be facilitated in Portuguese to build capacity for QI training among national,
regional and district health officials. The Project will work in partnership with all treatment partners who will
help disseminate quality improvement strategies and activities throughout their networks.
Additional staff is necessary to provide coaching and mentoring because of wide geographic territory and
constraints of transportation and rural sites, as well as availability of regular flights. Regional staff will
continue to be supported through a subcontractual agreements with FGH-Vanderbilt University (Friends of
Global Health) who will either second staff to regional health units (DPS) as regional quality leads or hire
staff who will work in the office with of a partner agency. In either case these individuals will provide
guidance to all of the 11 DPS units and provide coaching and mentoring in their regions in addition to
facilitating regional QI groups. The role of these advisors will focus on technical expertise and prioritization
of quality management at the regional level as services continue to expand.
Activity Narrative: Activity 3:
Infrastructure development and systems strengthening
An assessment tool to measure the capacity of the quality management program at each facility is used to
measure the growth of quality management activities as well as guide the coaching interventions. The
USG HIVQUAL team will expand its focus to build quality improvement coaching skills among MOH staff
and providers in Mozambique and provide advanced level trainings for sites as well as basic trainings for
new participants. Mentoring of MZ-based staff will continue throughout the activity.
Work will continue in partnerships with JHPIEGO and FGH which have recruited the project manager and
data manager and supported regional staff. These individuals provide logistical coordination for activities,
including data collection, training and QI training as well as assessments of quality management at
participating clinics. Working with JHPIEGO facilitates the coordination of other QI activities in Mozambique
which address infection control practices.
The HIVQUAL-Mozambique team will also provide training to partners and work closely with MOH staff to
implement the national quality management program.
Activity 4:
Support of National Quality Management Program
HIVQUAL-International will continue to support the implementation of the national quality management
program in Mozambique. Technical review of the quality management plan and its routine updating will be
continued. Assessment of the national quality program will continue to identify areas for improvement. The
team will continue to support MoH in this activity and work closely with other units within the Ministry of
Health, especially TB services, to assure coordination of activities, under the guidance of MoH officials. The
national team will be supported to develop publications and to present their work at international
conferences.
Continuing Activity: 13220
13220 5121.08 HHS/Health New York AIDS 6418 3586.08 HRSA IAA $550,000
8803 5121.07 HHS/Health New York AIDS 4943 3586.07 HRSA IAA $500,000
5121 5121.06 HHS/Health New York AIDS 3586 3586.06 HRSA IAA $300,000
Estimated amount of funding that is planned for Human Capacity Development $200,000
Estimated amount of funding that is planned for Education $50,000
Table 3.3.17:
