The Nigerian Federal Ministry of Women's Affairs and Social Development (FMWASD) in coordination with PEPFAR/ Nigeria, has been engaged in the Initiative to improve quality for orphans and vulnerable children (OVC) services during the past years and has began efforts to improve quality through the development of an OVC National Plan of Action and National Guidelines and Standards of Practice for OVC. The Ministry has taken a leadership role in engaging its partners towards increased effective and efficient OVC programs within the country.

In July 2009, at the request of PEPFAR/Nigeria, the USAID-Health Care Improvement (HCI) project provided technical assistance to FMWASD and its implementing partners towards developing standards to define quality care for OVC programs. This initiative was grounded in the FMWSD priority to clearly define what is "meant by serving a child and family" in pursuit of improved coordination and harmonization across implementing partners. Thus with the Ministry leadership, PEPFAR funded partners and UNICEF gathered during a five-day workshop to develop DRAFT quality standards for OVC programs. In addition to the Draft service standards, stakeholders committed themselves to the process of quality improvement for OVC Programming. Based on these results, USAID-HCI proposes to provide the following technical assistance to:

Objectives:

Support the country-leadership role in improving quality care for OVC Programs to mitigate the impact of HIV/AIDS on most vulnerable families and children.

Strengthen integration of OVC Standards of Care within a national strategy response.

Strengthen local partners and international partners' abilities to organize for improvement.

Create a community of shared learning across all OVC stakeholders.

Specific activities:

1. Support the country-leadership role in improving quality care for OVC Programs to mitigate the impact of HIV/AIDS on most vulnerable families and children.

One of the priorities of PEPFAR programming is to strengthen country-driven approach. The FMWASD has already taken the leadership in engaging all stakeholders towards improving quality as demonstrated during the efforts to develop draft-standards. It is thus essential to continue to provide support to the Ministry to continue its quality improvement efforts for OVC Programs. HCI proposes to identify a quality improvement advisor, embedded in the Ministry who can lead and coordinate efforts across all partners. The QI efforts will also reflect the PEPFAR priorities of ensuring that USG investments are programmed within a national strategy, in close collaboration with other donors, to ensure institutionalization and sustainability of the process.

Provide technical support (such as the secretariat) towards the establishment of a QI Task Force, chaired by the Ministry and regrouping major representatives of IPs and donors. By establishing a National QI Task Force, the Ministry will ensure the commitment and buy-in of its partners as the QI Task Force will develop clearly goals and objectives and work plan for the year.

2. Strengthen integration of OVC Standards of Care within a national strategy response

Provide technical support to complete the Draft Quality of Care Standards by vetting the DRAFT standards (July 2009 version) with other line Ministries (Ministry of Education, the Ministry of Labor, Ministry of Youth and Sports, Ministry of Agriculture, as identified by the QI Task Force) and local partners at the point of service delivery (local NGOs and CBOs) and other partners engaged in development programs and strategies to address children's needs. (experts in nutrition, HIV care and treatment, maternal health, child survival, early childhood development partners as example). The vetting process is an important step in the standards development process to 1) strengthen coordination and integration across Nigeria's institutions; 2) assure integration of best practices at the point of service delivery and ensure that standards reflect the context of the country; 3) strengthen and ensure the sustainability of the response to HIV/AIDS as institutions and local partners are involved in the improvement process all along.

Client-centered care is one of the key principles of quality care. HCI in collaboration with the QI Task Force will provide guidance in how best to include children's and family/guardians' voices. Based on experiences from other countries, where HCI has provided TA towards improvement of quality care, HCI will propose to organize several youth workshops (10-14yrs; 15-17yrs) and focus group discussions in different regions to capture as much as possible the realities and needs of different segments of children based on gender, location (regions, urban/rural), education, living arrangements (child-headed households for example). The process of seeking youth involvement will be led by the Ministry through a consultative process with the QI Task Force.

Once evidence is gathered on DRAFT standards, the QI Task Force with support from HCI will organize a review of the DRAFT standards to integrate findings and best organizational practices to improve quality of services. It would be expected that the set of Draft Standards are thus endorsed as a national policy guiding document.

3. Strengthen local partners and international partners' abilities to organize for improvement.

Once DRAFT standards are completed, HCI will provide TA to local implementing partners (at the point of service delivery) to gather evidence on the feasibility of the standards and if applying standards actually make a measurable difference in organizational practices. Evidence will be collected to document if applying standards lead to improved sustainable OVC Programming strategies such as increased community participation, increased retention of service providers/community-based volunteers/or workers; increased public and private partnership and commitment of resources; increased access to services, etc. In collaboration with the QI Task Force, HCI will provide TA to develop a set of quality indicators to document how applying standards and organizing for improvement actually improve the quality of care processes (strategies).

In addition to tracking evidence that applying standards is making difference in processes of care, HCI, in close collaboration with the Ministry and other partners tasked to improve monitoring and evaluation of OVC programs, will provide support to local NGOs and INGOs to measure if applying standards actually make a measurable difference in children's well-being.

To gather such evidence, HCI will provide support to local organizations to organize for improvement by applying the principles of science of improvement: 1) process analysis; 2) team work; 3) client-centered; 4) decision making grounded in data. In close collaboration with the Ministry and PEPFAR, the gathering of evidence will be organized through the improvement collaborative approach in two regions in Nigeria. The two regions are to be identified by the QI Task Force. One of the regions will be around Abuja (as the QI Advisor at the Ministry can provide support), and HCI proposes that the second region be where URC has already a project of improving quality of care to leverage resources and expertise. However, identifying regions and partners to be included in the "piloting of standards" will be done by the FMWASD and in close consultations with the QI Task Force.

Improvement Collaborative Overview

An improvement collaborative is an organized improvement effort of shared learning about how to improve an area of care by people providing the actual services. The goal of an improvement collaborative is to rapidly develop and test changes that allow programs to overcome obstacles toward consistent application of standards, by bringing together a number of teams to work on rapidly achieving significant improvements in processes, quality, and efficiency of those services.

Representatives of local government, local NGOs and their partners (CBOs and volunteers) are organized into QI teams to analyze what the standards describe as quality services and reflect on their current practices with respect to the essential actions as described in the standards. The teams form the core of a collaborative. Teams meet individually on a regular basis to analyze, plan and test changes to improve services. Changes, grounded in data, that actually make a difference in quality of programs are shared regularly across representatives of the QI Teams through learning sessions.

Create a community of shared learning across all OVC stakeholders

The QI Advisor (embedded in the Ministry) will lead, organize and coordinate all QI efforts across the Ministries, donors and IPs. Thus at a national level, communication across partners involved in improvement of programs will be strengthened. It is expected that the QI Task Force will meet regularly (once a month at least) to lead the QI efforts.

One of the organization principles for an improvement collaborative is for partners involved in improvement to share changes in organizational practices that lead to measurable results (improved strategies and improved children's outcomes). HCI will support the organization of regular learning sessions (every three months) within the two regions where representatives of the collaborative (Regional MWASD representatives, representatives of line ministries and IPs) will share changes that have led to their improved ability to operationalize the standards and improve children's well-being.

At the end of the "piloting" of standards, a national workshop will be organized to review evidence gathered about the standards and best operational practices.

In addition to the piloting efforts, HCI will continue to explore with the Ministry best mechanisms to strengthen communication and sharing across IPs, such possibilities might include regional Implementing Partners Group meetings led by the Regional Representatives of FMWASD.