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. Currently there are 80 sites implementing QA/QI activities, and in FY 2011 the program will expand to an addition of sites, bringing to total number to 140 health facilities all across the 11 provinces of the country.

Building on the success of the initial program QA/QI on adult HIV care and treatment, the MOH has requested and approved indicators for QA/QI of PMTCT services and pediatric HIV care and treatment services. In FY 2010 the third round of QA/QI took place and it included adults and pediatric HIV care and treatment services for the first time, the latter covered 64 sites.

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.

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.

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 are 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 2011:

1) Perform the IV round of data collection for adult and pediatric HIV care and treatment

2) Implement the project workplan/timeline;

3) Expand QA/QI activities to cover 140 new facilities

4) Perform 3 regional training seminars of new facilities in data collection methodology and Quality Improvement Methodology following baseline data collection analysis, and report generation

5) Coaching and mentoring selected sites to monitor QI activities

6) Perform data collection to evaluate the progress implementation of clinical care to HIV infected patients every six month.

7) Provide TA to the provincial teams;

8) Perform the II round of data collection for PMTCT indicators;

9) Data analysis of PMTCT indicators and QI activities for improving performance;

10) Expand QI program for counseling and testing

In FY 2011, the MOH plans to increase the number of sites from the current 80 to a total of 140 sites in all 11 provinces in the adult care and treatment QA/QI activity. This will enable regular measurement of quality in adult care and treatment services and also includes pediatric 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.

In FY 2011 the IV round of data collection will take place.

The following specific activities will be conducted during the project period: 1) Implement Quality Improvement Projects aiming to improve service delivery at health facilities; 2) Include additional performance indicators in collaboration with MOH and other stakeholders, for adult care and treatment; 3) Training of new facilities in data collection methodology; 4) Coaching and mentoring selected sites to monitor QI activities 5) Perform the IV round of data collection for adult and pediatric care and treatment services; 6) Perform data collection to evaluate the progress implementation of clinical care to HIV infected patients every six month. 7) Provide TA to the provincial teams;

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 will be collected every six months and aggregated to 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 2011 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. In order to improve this, a continuous QI project will be implemented taking that MOH has already approved the activities supported by USG listed in the key priorities.

Activities in FY 2011 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 specific activities will be conducted during the project period:

1) Implementation of PMTCT QI activities

2) Training of new facilities in data collection methodology;

3) Perform the II round of data collection for PMTCT indicators;

4) Perform data analysis of PMTCT indicators and QI activities for improving performance;

5) Provide TA to the provincial teams;

6) Coaching and mentoring selected sites to monitor QI activities