The importance of quality assurance (QA) and quality improvement (QI) of programs can not be overstated. The QA/QI program supports the Partnership Framework as it aims to improve the quality of data to improve programming and the quality of treatment and care services (Goals 4 and 5).

A robust adult care and treatment QA/QI program has been in place in Mozambique since 2006 and to date, two rounds of QA/QI of adult HIV care and treatment programs have been conducted in all provinces. Significant deficiencies in care and treatment were identified, solutions were proposed and implemented. The MOH has requested that QA/QI activities be expanded to cover many more sites, with the eventual goal of establishing a QA/QI system in every health centre providing HIV related services. In FY 2010, QA/QI activities will expand to an addition 18 sites, bringing to total number to 64. The third round of QA/QI will begin in the first quarter of FY 10.

The QA/QI TBD partner 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 training 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.

Building on the success of the initial program QA/QI on adult HIV care and treatment, the MOH has requested QA/QI of PMTCT services and pediatric HIV care and treatment services.

The pediatric QA/QI activity is scheduled to take place as part of round 3 in the first quarter of FY 10 and will be implemented in all 64 existing and new sites. Please note that the previous partner will use FY 09 funds to conduct this activity.

Some preliminary work has already been done to prepare for the upcoming PMTCT QA/QI programme.

The previous implementing partner, in conjunction with partners and the MOH, developed PMTCT indicators, held a key stakeholders meeting, identified pilot facilities, gathered baseline data for analysis and conducted QI training for PMTCT providers. The programme is scheduled to begin in the second quarter of FY 10.

In line with the Partnership Framework principles and goals, an essential component of the TBD implementing partner's approach must be a model of active and continuous MOH participation. The previous QA/QI partner coordinated the collation of data by MOH staff and analyzed it in order to provide useful and actionable feedback to health teams in a timely manner regarding the quality of the care they are providing. The process provides continuous feedback to the MOH in order to ensure an incremental improvement in the quality of service received by patients accessing the HIV care and treatment program.

The benefits of the currently employed approach for QA/QI is that it draws on existing MOH resources and builds upon them. By only gathering data using MOH staff and then involving them every step of the way until the improvements are implemented ensures that the MOH takes ownership of the process and in so doing embeds the notion of QA/QI in the culture of healthcare professional in Mozambique. It is very encouraging that the MOH, at the highest level, has forcefully voiced its support for QA/QI programs.

The cross cutting attributions of QA/QI are human resource for health strengthening and SI.

This QA/QI is cost-effective since the majority of the human resources are drawn from the MOH as part of their routine responsibilities. As such, the overhead and administrative costs for implementing this type of activity are low. There are also downstream effects that result in improved utilization of resources as a result of the improvement in the quality of care being provided.

Key Activities for FY 2010: 1) meetings of key stakeholders; 2) implementation of project workplan/timeline; 3) expansion of QA/QI activities to new facilities 4) training of new facilities in data collection methodology and Quality Improvement Methodology following baseline data collection analysis, and report generation 5) review and finalization of PMTCT indicators; 6) update existing software package; 7) support for ongoing Quality Improvement Projects at pilot facilities and implementation of QA/QI projects in new facilities.

In FY 2010, the MOH plans to include an additional 14 sites in the adult care and treatment QA/QI activity to enable regular measurement of quality in adult care and treatment services.

This activity will build on the ongoing QA/QI programs that were implemented starting in FY 2006 through HIVQUAL. The main objective is to build local 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 for HIV positive adults.

2 rounds of data collection will take place in FY 2010.

1) include additional performance indicators in collaboration with MOH and other stakeholders, for adult care and treatment; 2) Select additional pilot sites with the guidance of the MOH; 3) Conduct site visits with organizational assessments; 4) Implement Quality Improvement Projects aiming to improve service delivery at health facilities; 5) Update data collection update data collection every six months.

Established and newly adopted indicators will be measured through the QA/QI TBD to 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 collected every six months are aggregated and provide population-level performance data that indicate priorities for national quality improvement activities and campaigns.

Quality assurance programming for PMTCT activities will be aligned with overall FY 2010 priorities, focusing on coordination with MOH and scale up of PMTCT services within an integrated MCH system.

While access to PMTCT services has increased dramatically in Mozambique, a mechanism to monitor the quality of the services provided is critical. A continuous quality improvement project supported by USG has included development of indicators, key stakeholders meeting, identification of pilot facilities, and baseline data collection for analysis and QI training for PMTCT providers.

Activities in FY 2010 will build on this program to further develop a framework to assess the quality of PMTCT services. Core components include performance measurement and quality improvement. This model promotes a balance between data and improvement activities and emphasizes the importance of national, provincial, district and site level leadership to promote and support quality activities in a sustainable way.

The following activities will be conducted during the project period: 1) Continued meetings of key stakeholders; 2) Review and expansion of relevant, reliable and improvable indicators related to PMTCT and coordination of these services in concert with MOH; 3) Training of new facilities in data collection methodology; 4) Collection of baseline data at expanded group of facilities, analysis and report generation; 5) Training of new facilities in quality improvement methodology following baseline data collection; 6) Completion of an annual assessment at facility level, including the current program and infrastructure in place to support and sustain the QA/QI program at the facility level, including 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.