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
ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS:
Health Care Improvement (HCI) is a follow on to the organization known as University Research Co./Quality
Assurance Project described in COP 2008. HCI will continue to focus on the activities described in COP
2008, but will expand them in 2009:
ACTIVITY 1: Establish Quality Improvement (QI) Teams at the Facility Level
By improving and institutionalizing QI teams at a facility and district level, HCI provides the knowledge and
skills required for leadership and sustainability for the program. This is an ongoing initiative, specific to each
area, due to the variable nature of the stakeholders and geographic location of HCI-supported sites.
ACTIVITY 2: Training
In FY 2009, HCI will develop accredited HIV and AIDS and home-based care training materials, including a
comprehensive package of manuals, posters, flip charts and job aids. These materials will include modules
on basic HIV, staging of HIV disease, care of HIV-infected individuals, PMTCT issues and challenges, infant
feeding options, eligibility for antiretroviral treatment (ART), initiation of ART in HIV-infected pregnant
women, disclosure, adherence issues, poly-pharmacy (addressing concomitant administration of
medication), living positively with HIV, TB/HIV co-infection in PMTCT clients and provision of integrated
management of childhood illness care to HIV-exposed infants and children.
HCI will revise existing quality assurance (QA) training materials and expand on proposed training initiatives
to include QA/QI methodology for all cadres of health-care staff, including informal staff such as community
workers, lay counselors and home-based caregivers. This is particularly important at primary health-care
facilities where HIV-infected pregnant women interact with a wide range of formal and informal health staff.
ACTIVITY 3: Human Capacity Development
HCI is recruiting and placing medical staff in health facilities, and these staff will be tasked to (a) provide
clinical services to HIV-infected clients each day, and (b) train and mentor health facility staff on HIV and
AIDS care, focusing on PMTCT treatment and care on a weekly and monthly basis. To ensure
sustainability, HCI seeks to build capacity and develop local skills by providing training and support to DOH
clinic staff (doctors, nurses, counselors, pharmacists, etc.) providing them with appropriate knowledge and
skills to deliver quality PMTCT services to all clients. HCI and DOH staff meet regularly to share new
knowledge on PMTCT treatment options and research findings.
ACTIVITY 4: Referrals and Linkages
Building on previous experiences, HCI can facilitate linkages between stakeholders within the health system
by coordinating and providing leadership.
To improve existing referral networks, HCI will identify and strengthen linkages between PMTCT, CT and
ART sites, by working with health facility staff at different levels of care and advocating for the development
of integrated referral and follow-up networks. All staff at PMTCT and CT sites will be responsible for
referring HIV-infected mothers and their newborns for onward care, treatment and support, while staff at
ART sites is responsible for care, treatment, support and follow-up of these patients. It is essential to ensure
that all patients receive optimal care and remain within the health-care system, ensuring compliance and
adherence with treatment and an improved quality of life.
HCI will also ensure that health-care workers are capacitated to ensure appropriate infant care follow-up,
opportunistic infection prophylaxis, and basic preventive care to HIV-exposed infants identified in the
PMTCT programs, as well as capacitating community-based tracers to identify and follow-up PMTCT, TB or
ART defaulters, including HIV-exposed babies who have been 'lost to follow-up'.
HCI plans to strengthen linkages between Orphans and Vulnerable Children (OVC) programs, routine
maternal and child health services and ART services. This will serve to identify and strengthen existing
networks; highlight gaps in the quality of services provided; and provide information about the feasibility of
incorporating relatively rapid QA approaches into ongoing OVC programs.
ACTIVITY 5: Strengthening Supervision Systems
HCI has been extensively involved in revising the Clinic Supervision Manual for health-care facilities, and
will continue to lead the implementation and monitoring of supervision systems by training district and
facility-level supervisors in QA methods and facilitative supervision techniques for improving the quality of
PMTCT and follow-up services.
ACTIVITY 6: Policy
URC/QAP will actively collaborate with national and provincial DOH staff, and contribute to the
development, revision and implementation of the national PMTCT guidelines and PMTCT monitoring and
evaluation framework to ensure long term sustainability of this program.
------------------------------------------
SUMMARY: Through training, mentoring and the introduction of quality assurance (QA) tools and
approaches, University Research Co., LLC/Quality Assurance Project (Health Care Improvement -
URC/QAP/HCI) will assist South African Department of Health (DOH) facilities in five provinces to improve
the quality of PMTCT and follow-up services. Facilities identified for support differ from those of other
PEPFAR partners. Training and other activities are coordinated to avoid duplication and redundancy.
URC/QAP will capacitate healthcare workers to ensure rapid identification and referral of HIV-infected
Activity Narrative: pregnant women and their babies to appropriate services. The essential elements of QA include technical
compliance with evidence-based norms and standards, interpersonal communication and counseling and
increasing organizational efficiency. The major emphasis areas for this activity are QA and supportive
supervision, with minor emphasis on development of networks, linkages, referral systems, training and
needs assessment. The target populations include adults, people living with HIV, HIV-infected pregnant
women, HIV and AIDS affected families, HIV-exposed infants, HIV-infected children, policy makers, public
and private healthcare workers, community-based organizations (CBOs) and NGOs.BACKGROUND:Using
FY 2007 funding, URC/QAP has been supporting PMTCT programs in 120 facilities in four provinces.
URC/QAP also supported two home-based care organizations (HBOs) to improve the quality of their
program targeting HIV-infected mothers and their babies. A collaborative model has been used to rapidly
expand access to PMTCT services in a large number of antenatal care (ANC) facilities. In FY 2008,
URC/QAP plans to expand the support to an additional 40 facilities and to assist health facilities to integrate
PMTCT with ANC services. Loss to follow-up of infants is one of the major challenges to PMTCT as the
majority of HIV-exposed babies do not receive appropriate follow-up care. URC/QAP will assist healthcare
facilities in integrating follow-up strategies into postnatal/well-baby services. Changes will be made and
monitored to ensure implementation and compliance with national guidelines in all supported URC/QAP
facilities. URC/QAP coordinators will facilitate training in integrating clinical practices. URC/QAP will
continue to provide support to additional CBOs to improve the quality of their services to peripartum women.
Support will focus on improving infant feeding practices and follow-up care of HIV-infected infants.
URC/QAP will work with district supervisors to ensure that they provide ongoing support and mentoring to
healthcare workers. URC/QAP is collaborating with the National Department of Health (NDOH) and the
provincial departments of health to ensure sustainability of the program.ACTIVITIES AND EXPECTED
RESULTS:ACTIVITY 1: Facility-level Quality Improvement TeamsURC/QAP will work with each facility to
support teams representing various service delivery components such as ANC, and HIV care and
treatment. Facility teams, with URC/QAP and DOH staff support, will be responsible for developing facility-
based plans to increasing the uptake and quality of PMTCT services. Each facility team will conduct regular
rapid assessments to identify factors affecting access to and quality of PMTCT services. Using standardized
quality assurance (QA) tools, the assessments will measure/track changes in compliance with the NDOH
PMTCT standards. URC/QAP will assist each facility team to develop a strategic plan for improving the
uptake and quality of PMTCT and follow-up services. Interventions will include: (1) integration of ANC,
intrapartum, postpartum with HIV and AIDS services; (2) re-design of clinical processes to improve patient
flow and service times using QA/QI tools; and (3) promote facility teams to carryout ongoing monitoring by
analyzing individual and facility level compliance with various standard indicators. ACTIVITY 2: Training for
ANC and other HIV and AIDS service providers in PMTCTURC/QAP will build knowledge and skills of
healthcare providers in PMTCT technical issues. This will be done through training workshops for
healthcare workers as well as through on-the-job mentoring at facilities which only QAP supports. Training
includes two days of formal training sessions, with ongoing monthly follow-up at each facility. QAP training
compliments the NDOH PMTCT and Infant Feeding Curriculum as it has a specific focus on quality
assurance methods and quality improvement techniques. The measurement of quality is also highlighted
with emphasis placed on the indicators used to monitor clinical performance, such as the proportion of
women attending antenatal services who were offered HIV counseling and testing case studies and data
sheets are used and participants work in groups to identify quality gaps within the case study and make
recommendations on possible solutions to improve the quality of service provision in PMTCT. Participants,
either individually or as a group, are also required to analyze/interpret the data from the data sheets,
graphically illustrate their analysis and make quality improvement plans based on this. Trainings are done
by the URC/QAP staff and are scheduled to complement the district HAST/PMTCT trainings in each
province.ACTIVITY 3: Facility-Community Linkages URC/QAP will assist participating facilities in building
linkages with community-based groups to increase awareness about PMTCT as well as address issues of
psychosocial support, stigma reduction and prevention of domestic violence for HIV-infected pregnant
women. This will involve working with communities, community-based and home-based care organizations,
specifically community-based workers/tracers who will work to improve the visibility of PMTCT activities;
increasing voluntary counseling and testing (VCT) in communities by education (in facilities and door-to-
door/household visits); and hosting open days for clinic staff and community members, to showcase
improvement activities and encourage support for improvement initiatives. ACTIVITY 4: Referrals and
LinkagesURC/QAP staff members will identify and strengthen linkages between PMTCT and ARV treatment
sites, by working with facility staff at different levels of care and advocating for the development of
integrated referral and follow-up networks. PMTCT sites will be responsible for referring HIV-infected
mothers and their newborns for onward care, treatment and support, while staff at ARV sites are
responsible for care, treatment, support and follow-up of these patients. It is essential to ensure that all
patients receive optimal care and remain within the health care system, ensuring compliance / adherence
with treatment and an improved quality of life. URC/QAP will strengthen the ability of healthcare workers to
provide infant care follow-up, opportunistic infection (OI) prophylaxis, and basic preventive care to HIV-
exposed infants identified in the PMTCT programs, as well as capacitating community-based tracers to
identify and follow-up defaulters, including HIV-exposed babies who have been 'lost to follow-up'. URC/QAP
will continue to promote improvements in counseling of mothers regarding infant follow-up and best
practices, early infant diagnosis, ongoing training and onsite mentoring, and support for national initiatives.
URC/QAP plans to strengthen linkages to Orphans and Vulnerable Children (OVC) programs and to routine
maternal and child health services, including family planning. It is envisaged this will serve to identify and
strengthen existing networks; highlight gaps in the quality of services provided; and provide information
about the feasibility of incorporating relatively rapid QA approaches into ongoing OVC programs.ACTIVITY
5: Strengthening SupervisionURC/QAP will visit each facility fortnightly to provide on-the-job support and
mentoring to staff. In most cases, the visits will be conducted together with district staff. This will ensure that
the district staff take ownership of the program and can sustain the program when URC/QAP support ends.
The mentoring will focus on improving clinical skills of staff and ensuring that the improvement plans are
implemented correctly. During these visits, URC/QAP and facility staff will compare performance data with
expected results. URC/QAP will conduct quarterly assessments in each facility to assess whether the facility
staff is in compliance with the national guidelines. Facility staff will be provided with feedback regarding
compliance with national guidelines. All facilities exhibiting 100% compliance for all programs assessed for
at least three consecutive quarters will be judged to be sustainable. Sample-based surveys will be done in a
small number of QAP-assisted facilities annually to assess compliance with quality assurance standards
Activity Narrative: and key performance indicators. Although the coverage area for the URC/QAP PMTCT project is primarily
in four provinces, some activities are also directed at the national level. URC/QAP will actively participate in
the training and development of the National NDOH PMTCT monitoring and evaluation framework, to
ensure accountability and long-term sustainability of the program. URC/QAP will advocate for strategies to
address male norms and behaviors (Key Legislative Area) specifically seeking their involvement in PMTCT
and highlighting the importance of partner testing at all levels. In addition, the URC/QAP PMTCT program
includes sensitizing staff to the importance of male testing and participation in PMTCT programs. Male
counselors are being trained at some facilities, to enhance the current system. Promoting integration of
services at the facility level ensures the development of links between services, promoting holistic
care.URC/QAP will contribute to 2-7-10 PEPFAR goals by ensuring a strengthened PMTCT program.
New/Continuing Activity: Continuing Activity
Continuing Activity: 13871
Continued Associated Activity Information
Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds
System ID System ID
13871 3111.08 U.S. Agency for University 6639 1201.08 QAP $485,000
International Research
Development Corporation, LLC
7431 3111.07 U.S. Agency for University 4415 1201.07 QAP $500,000
3111 3111.06 U.S. Agency for University 2713 1201.06 $300,000
Emphasis Areas
Gender
* Increasing gender equity in HIV/AIDS programs
Health-related Wraparound Programs
* Safe Motherhood
Human Capacity Development
Estimated amount of funding that is planned for Human Capacity Development $276,450
Public Health Evaluation
Food and Nutrition: Policy, Tools, and Service Delivery
Food and Nutrition: Commodities
Economic Strengthening
Education
Water
Table 3.3.01:
While Health Care Improvement (HCI), the follow-on to the URC/Quality Assurance Project (QAP), will
continue to focus on the five key activities described above, the emphasis during FY 2009 will be on
expanding these activities and other activities, in the following ways:
ACTIVITY 1: Establish Quality Improvement Teams at the Facility Level
By improving and institutionalizing the formation of quality improvement teams at a facility and district level,
HCI staff is involved in providing the knowledge and skills required for leadership and sustainability for the
program. This is an ongoing initiative, which is specific to each area / district/ province, due to the variable
nature of the different stakeholders involved and geographic location of HCI-supported sites and districts.
ACTIVITY 2: Human Capacity Development
As HCI is already in the process of recruiting and placing medical staff in health facilities, these medical
staff will be tasked with provision of clinical services to HIV-infected clients on a day-to-day basis and
provision of training and mentoring for health facility staff regarding HIV and AIDS care, with specific
reference to antiretroviral therapy (ART) and care services on a weekly and monthly basis. As part of HCI's
sustainability initiatives, HCI staff seek to build capacity and develop local skills, by providing training and
support to DOH clinic staff (doctors, nurses, counselors, pharmacists, etc.) to ensure that providers have
appropriate knowledge and skills to deliver quality ART services to all ART clients enrolled on the program /
eligible for ART treatment and care. HCI staff and department of health (DOH) staff meet regularly to ensure
that any additional knowledge regarding newer ART medication / treatment options and research findings
are readily shared.
ACTIVITY 3: Strengthening Supervision Systems
HCI has been extensively involved in revision of the Clinic Supervision Manual for health care facilities, and
will continue to lead the implementation and monitoring of supervision systems within the country, by
training district and facility-level supervisors in quality assurance methods and facilitative supervision
techniques for improving the quality of ART and follow-up services.
ACTIVITY 4: Care Support Groups
HCI has been involved in providing assistance to implement, run and facilitate community and facility-based
care support groups at all HCI-supported health care sites in the five provinces. In FY 2009, it is envisioned
that this support will be expanded to include counseling on remaining HIV negative, Prevention with
Positives (PwP), HIV wellness programs, care for the caregivers' activities and community outreach
programs.
ACTIVITY 5: Training
In FY 2009, HCI staff will work to develop accredited HIV and AIDS and home-based care training
materials, including a comprehensive package of manuals, posters, flip charts and job aids. The
development of these materials will include modules on basic HIV, staging of HIV disease, care of HIV-
infected individuals, eligibility for ART, initiation of ART in both adult and pediatric patients, disclosure,
adherence issues, poly-pharmacy (addressing concomitant administration of medication), living positively
with HIV and TB/HIV co-infection.
In addition, HCI will revise existing QA training materials and expand on proposed training initiatives to
include QA/QI methodology for all cadres of health care staff, including informal staff such as community
workers, lay counselors and home-based carers. This is particularly important at primary health care
facilities where HIV-infected clients interact with a wide range of formal and informal health staff.
ACTIVITY 6: Referrals and Linkages
Building on lessons from previous experiences, HCI is able to facilitate linkages between different
stakeholders within the health system, by coordinating and providing leadership.
To improve existing referral networks, HCI staff members will identify and strengthen linkages between
prevention of mother-to-child transmission, counseling and testing, family planning, sexually transmitted
infections, TB and ART treatment sites, by working with health facility staff at different levels of care and
advocating for the development of integrated referral and follow-up networks. All staff at these sites will be
responsible for referring HIV-infected clients for onward care, treatment and support, while staff at ART sites
is responsible for care, treatment, support and follow-up of these patients. It is essential to ensure that all
with treatment and an improved quality of life.
ACTIVITY 7: Policy
HCI will actively participate in the development, revision and implementation of the National HIV and AIDS
guidelines, Continuum of Care for HIV-infected people and HIV and AIDS monitoring and evaluation
framework policy in collaboration with the national and provincial DOH staff, to ensure accountability and
long-term sustainability of this program.
-----------------------
SUMMARY:
Activity Narrative: University Research Co. LLC/Quality Assurance Project (URC/QAP) will support Department of Health
(DOH) facilities in 5 provinces to improve the quality of basic health care for people living with HIV (PLHIV)
by improving compliance of healthcare workers with treatment guidelines through capacity building and
strengthening of monitoring and supervision The essential elements of QAP support include streamlining of
process of care for PLHIV as well as helping improve technical compliance with evidence-based norms and
standards, interpersonal communication and counseling and increasing organizational efficiency. The major
emphasis area for this activity is quality assurance and supportive supervision, with minor emphasis on
development of referral systems, training and policy/guidelines. The activity targets public health workers,
program managers, volunteers and PLHIV. These activities will result in improving the continuum of care for
adults and children living with HIV and their families as they pass through different stages of the disease or
through different levels of healthcare system ensuring that they receive high quality services.
BACKGROUND:
URC/QAP currently works with 70 DOH facilities in five provinces improving the quality of basic healthcare
and support services for PLHIV. In FY 2008 the number of DOH facilities that URC/QAP mentors will be
expanded. In FY 2008, URC/QAP will work with the South Africa (SA) DOH and Department of Social
Development, community-based organizations/home-based organizations (CBOs/HBOs) and other
PEPFAR partners to ensure the delivery of comprehensive family-centered services for PLHIV. Using
Quality Assurance (QA) tools and approaches, URC/QAP will help facilities provide an essential package of
activities following national guidelines and standards, to ensure that PLHIV receive high quality basic
healthcare and support services. Temporary medical staff will be made available to healthcare facilities to
initiate and strengthen provision of basic health services for PLHIV. URC/QAP will also work with
HBOs/CBOs to improve home-based care services by linking home-based caregivers to facilities providing
care and support. It is envisioned that URC/QAP activities will support integrated programming in a network
of services for all HIV-infected clients and their families by integrating preventive messages and condoms
into HIV and AIDS care activities, screening and referral for PLHIV to other service delivery areas, stigma
reduction activities and involvement of community/home-based caregivers to promote adherence to ART
and anti-tuberculosis (TB) regimens.
ACTIVITIES AND EXPECTED RESULTS:
ACTIVITY 1: Establish Facility-level Quality Improvement Teams
URC/QAP will work with each facility to identify core teams representing various clinical services involved in
care and support for PLHIV These teams, with support from URC/QAP and district staff, will be responsible
for implementing plans for improving access to quality basic primary healthcare and support services for
PLHIV, particularly issues pertaining to equitable access for women and girls/related gender considerations.
Each team will conduct baseline assessments to identify and address quality gaps in clinical services.
These assessments will be used by the facility teams to develop and implement a quality improvement plan.
URC/QAP will assist facility teams in developing and implementing strategic plans for improving access to
quality healthcare services. URC/QAP activities will focus on improving preventive care services for PLHIV
and their families, including access to HIV counseling and testing services, TB/OI screening and provision
of cotrimoxazole prophylaxis. Addressing prevention with HIV-infected individuals is an important part of a
comprehensive care strategy. Through healthy living and reduction of risk behaviors, these prevention with
positives interventions can substantially improve quality of life and reduce rates of HIV transmission. The
goal of these interventions is to prevent the spread of HIV to sex partners and infants born to HIV-infected
mothers and protect the health of infected individuals. URC/QAP will monitor staff interventions to provide
high quality services in nutrition counseling, diarrhea management, screening for pain and symptoms,
treatment for OIs and ARV services, home-based support, social service linkages and community-based
ART follow-up and adherence support, in accordance with the national guidelines. URC/QAP will facilitate
linkages to treatment and care for eligible clients by training facility staff on the need for treatment referrals.
Effort will be made to ensure equitable access to care services for both males and females. URC/QAP will
work with facility staff to design and implement referral plans and strengthen the development of networks
with CBOs/HBOs to improve referral patterns.
URC/QAP activities at facility level will include an integration of key HIV and AIDS prevention messages
and provision, including prevention with positives, and referral for condoms into all care activities. At
national and provincial levels, URC/QAP will continue to collaborate with the NDOH on the development of
infection control guidelines, emphasizing measures such as good hygiene practices and use of safe water
for PLHIV. At a community level, CBOs/HBOs linked to DOH facilities will be assisted to provide home-
based care services to PLHIV and expand outreach services to the community. URC/QAP will also train
facility and CBO/HBO staff in pain and symptom management for all PLHIV, including basic assessment
and management of common pain and symptoms related to HIV disease and appropriate use of the WHO
analgesic ladder and referral when necessary.
ACTIVITY 2: Human capacity development
URC/QAP will train facility staff in QA strategies, specific to basic health care. In addition, job-aids and wall
charts will be provided to improve compliance with clinical and counseling guidelines. All training will be in
accordance with the SA National DOH training guidelines for community and home-based care, HIV and
AIDS Care and Treatment Guidelines and PMTCT guidelines for pediatric care. At the community level,
URC/QAP will fund and capacitate CBOs/HBOs to better utilize community health workers and strengthen
the capacity of families and community members to meet the needs of PLHIV.
ACTIVITY 3: Strengthening supervision
URC/QAP will visit each facility/CBO at least twice a month to provide onsite mentoring to healthcare
workers. This will focus on improving clinical skills of staff as well as ensuring that improvement plans are
being implemented correctly. During these visits URC/QAP will also review program performance data to
Activity Narrative: ensure expected results are being achieved. URC/QAP will conduct quarterly assessments in each
facility/CBO/FBO to assess whether staff is compliant with national guidelines. To ensure staff is being
supported on an ongoing basis and promote sustainability, URC/QAP will train district, facility-level, and
CBO supervisors in QA and facilitative supervision techniques.
ACTIVITY 4: Care support groups
URC/QAP will provide assistance with set up, running and facilitation of community and facility-based care
support groups at all QAP-supported health care sites in the five provinces. The focus will include
Prevention with Positives (PwP), wellness programs and care for the caregivers activities.
ACTIVITY 5: Support for families of PLHIV
URC/QAP will provide support to improve support and care services provided to families of PLHIV by facility
- and community-based healthcare workers. To this end, staff at URC/QAP-supported facilities and home-
based care organizations will be encouraged and mentored on the importance of provision of
clinical/physical, psychological, spiritual, social and preventive services to families of PLHIV. URC/QAP staff
will focus on identification of clinical/social needs within these families and the development of appropriate
referral linkages and networks.
In all of the above activities, PLHIV will receive at least one clinical and one other category of palliative care
service. Palliative care to family members of PLHIV or OVC will be provided in at least two or the five
categories of palliative care services.
This activity contributes to the PEPFAR target of 10 million people in care. URC/QAP will assist PEPFAR in
reaching the vision outlined in the USG/South Africa Five-Year Strategy by improving the continuum of care
for PLHIV.
Continuing Activity: 13872
13872 3109.08 U.S. Agency for University 6639 1201.08 QAP $1,000,000
7429 3109.07 U.S. Agency for University 4415 1201.07 QAP $1,300,000
3109 3109.06 U.S. Agency for University 2713 1201.06 $300,000
Estimated amount of funding that is planned for Human Capacity Development $456,000
Table 3.3.08:
continue to focus on the four key activities described above, the emphasis during FY 2009 will be on
In FY 2009, HCI staff will work to develop Continuing Professional Development (CPD)-accredited
antiretroviral therapy (ART) training materials, including a comprehensive package of manuals, posters, flip
charts and job aids. The development of these materials will include modules on eligibility for ART, initiation
of ART in both adult and pediatric patients, disclosure, ART adherence issues, poly-pharmacy (addressing
concomitant administration of medication) and specific ART challenges.
In addition, HCI will revise existing quality assurance (QA) training materials and expand on proposed
training initiatives to include QA/QI methodology for all cadres of health care staff, including informal staff
such as community workers, lay counselors and home-based carers. This is particularly important at
primary health care (PHC) facilities where HIV-infected clients interact with a wide range of formal and
informal health staff.
reference to ART treatment and care services on a weekly and monthly basis. As part of HCI's sustainability
initiatives, HCI staff seek to build capacity and develop local skills, by providing training and support to
department of health (DOH) clinic staff (doctors, nurses, counselors, pharmacists, etc.) to ensure that
providers have appropriate knowledge and skills to deliver quality ART services to all ART clients enrolled
on the program / eligible for ART treatment and care. HCI staff and DOH staff meet regularly to ensure that
any additional knowledge regarding newer ART medication / treatment options and research findings are
readily shared.
prevention of mother-to-child transmission (PMTCT), counseling and testing (CT) and ARV treatment sites,
by working with health facility staff at different levels of care and advocating for the development of
integrated referral and follow-up networks. All staff at PMTCT and CT sites will be responsible for referring
HIV-infected mothers and their newborns for onward care, treatment and support, while staff at ARV sites is
HCI staff will also ensure that health care workers are capacitated to ensure appropriate infant care follow-
up, opportunistic infection (OI) prophylaxis, and basic preventive care to HIV-exposed infants identified in
the PMTCT programs, as well as capacitating community-based tracers to identify and follow-up PMTCT,
TB or ART defaulters, including HIV-exposed babies who have been 'lost to follow-up'.
maternal and child health services and ART services. It is envisaged that this will serve to identify and
about the feasibility of incorporating relatively rapid QA approaches into ongoing OVC programs.
ACTIVITY 5: Strengthening supervision systems:
training district and facility-level supervisors in QA methods and facilitative supervision techniques for
improving the quality of ART and follow-up services.
ACTIVITY 5: Policy:
HCI will actively participate in the development, revision and implementation of the National ART guidelines,
ART monitoring and evaluation framework, ART adherence tool and ART-accreditation policy in
collaboration with the national and provincial DOH staff, to ensure accountability and long-term
sustainability of this program.
--------------------------
Through training, mentoring and the introduction of quality assurance (QA) tools and approaches,
URC/QAP will work with 65 South African Department of Health (DOH) antiretroviral therapy (ART) sites in
Activity Narrative: 5 provinces (Eastern Cape, KwaZulu-Natal, Limpopo, Mpumalanga and North West) to improve provider
and patient compliance with ART treatment guidelines and improve the delivery of quality ARV treatment
services to HIV clients. The essential elements of QAP support include technical compliance with evidence-
based norms and standards, interpersonal communication and counseling and increasing organizational
efficiency. The emphasis area for this activity is human capacity development. The activity targets public
and private health care workers, and people living with HIV (PLHIV).
URC/QAP is currently training healthcare providers in 25 DOH ART service delivery sites in the use of QA
tools and approaches for increasing compliance with ART guidelines. URC/QAP has developed a number
of QA tools for healthcare facilities offering ART services. URC/QAP will increase the number of DOH ART-
accredited facilities that it supports in the five provinces to improve the quality of care provided to all clients
on ART. To strengthen HIV and AIDS services at facility level, URC/QAP plans to enhance community-
based support for ART patients to ensure treatment adherence and active facility-based quality
improvement using QA tools and approaches. In addition, URC/QAP will hire sessional medical staff in
facilities in the 5 provinces to provide ART services. These providers will serve as mentors to DOH staff for
six months to a year. This strategy will create local capacity to provide treatment services over time.
URC/QAP will assist healthcare facilities to develop operational strategies to improve the care, treatment
and follow-up of children and adolescents on ART. URC/QAP will also capacitate local community-based
organizations (CBOs) and home-based care organizations (HBOs) to integrate QA tools and approaches for
improved quality of their home-based case management and follow-up of ART patients.
URC/QAP will work with provincial DOH facilities to identify a core team representing staff from ART and
other service providers. Based on a review of better practices, the facility-based teams, with support from
URC/QAP coordinators and other district staff, will be responsible for developing and implementing plans for
improving the quality of ARV services as well as the continuum of care for patients on ART. Each facility
team will be responsible for conducting periodic assessments to identify quality gaps in screening, treatment
and follow-up of PLHIV on ARV treatment. These assessments will be used to design interventions for
improving the quality of specific services. The assessments will use QAP-developed (based on the national
guidelines) patient chart audits, patient-provider observations, interviews with providers, patients and care
givers, among others.
URC/QAP will assist facility teams in developing and implementing strategic plans for expanding access to
and improving the quality of ART services, in line with national guidelines. The key elements of the plan will
include training, infection control and prevention, patient information, nutrition support and counseling,
community involvement, follow-up system at treatment and other levels of care, use of data at facility level,
and monitoring and evaluation of the program.
Additional ART service providers and other staff will receive training in the provision of high quality ART
services in FY 2008. URC/QAP will strengthen the supervision and support systems at community, facility,
district and provincial levels. In addition, URC/QAP will provide job-aids/wall charts to improve compliance
with clinical and counseling guidelines. URC/QAP will also work with facility staff, CBOs/HBOs and PLHIV
associations to develop strategies for identification and referral of ARV defaulters as well as provision of
treatment support to PLHIV on ART in their community, reducing loss of clients to follow-up. URC/QAP will
visit each DOH facility/CBO/HBO at least twice a month to provide onsite mentoring and support to staff.
URC/QAP will assist staff to provide family-centered and pediatric ART services. Within existing ART
programs there is an identified need to strengthen pediatric ART care. In FY 2008, URC/QAP will expand
these programs to ensure that ART accredited sites as well as sites providing follow-up care to pediatric
and adult patients are capacitated to incorporate pediatric care and treatment into existing ART programs.
Training will be provided to facility staff to ensure that ART programs are family-centered, enabling parents,
children and other dependents to have access to HIV care and treatment services. In addition, emphasis
will be placed on training facility staff to recognize the value of wellness programs for PLHIV, of which
prevention with positives (PWP) is a key component. Wellness programs are essential to ensure that PLHIV
not eligible or ready for ART are retained within the health system to enable regular follow-up and review of
client ART eligibility. URC/QAP is developing linkages with these NDOH ART programs to target health
facilities and HBO programs for adherence support. This process will continue in FY 2008, with expansion
at QAP-supported facilities within all 5 priority provinces. Finally, URC/QAP will train facility and CBO/HBO
staff in analyzing performance and quality indicators.
URC/QAP will recruit physicians and nurses to provide ART services at facilities in 5 provinces, this will
increase the human capacity available at each facility and increase the number of HIV clients that are able
to receive ART and other services. These providers will serve as mentors to local DOH clinical staff. This
strategy will help in building capacity of local staff in providing ARV as well as high quality follow-up
services.
URC/QAP will continue to train district and facility-level supervisors in QA methods and facilitative
supervision techniques to improve the quality of ART services. URC/QAP has contributed to the
development of the continuum of care for PLHIV policy document currently under development by the
NDOH and will continue to support its development and implementation. URC/QAP will conduct quarterly
assessments in each DOH facility, CBO, and HBO to assess compliance with national ART guidelines.
Activity Narrative: ACTIVITY 4: Referrals and Linkages
URC/QAP will facilitate linkages to treatment for eligible PLHIV. All facility staff will be trained in national
guideline compliance, QA methods specific to ART programs, and developing and implementing quality-
specific improvement plans. These improvement plans include process redesign, integration of services,
and enhancement of network development to improve referral patterns. URC/QAP has prioritized plans to
strengthen the approach and referral of HIV-infected pregnant women and their infants from PMTCT
programs to ART programs, with a well-functioning down referral system, and will continue to promote and
expand these linkages. In addition, URC/QAP plans to strengthen linkages from OVC programs to routine
maternal and child health services and ART programs. URC/QAP will also assist the DOH to scale-up best
practices for ART referrals.
URC/QAP work contributes to the PEPFAR 2-7-10 goals by improving access to and quality of ART
Continuing Activity: 13875
13875 3108.08 U.S. Agency for University 6639 1201.08 QAP $1,463,800
7428 3108.07 U.S. Agency for University 4415 1201.07 QAP $1,240,000
3108 3108.06 U.S. Agency for University 2713 1201.06 $655,000
Estimated amount of funding that is planned for Human Capacity Development $570,000
Table 3.3.09:
FY 2008 COP activities will be expanded to include:
-Establishing Quality Improvement Teams at the District / Facility Level; and
-Recruitment of medical staff tasked with the provision of clinic services.
-Expansion of support services to include counseling on remaining HIV negative, Prevention with Positives
(PwP), HIV wellness programs;
-Development of accredited HIV and AIDS and home-based care training materials; and
-Development, revision and implementation of the National HIV and AIDS guidelines.
While HCI will continue to focus on the five key activities described above, the emphasis during FY 2009 will
be on expanding these activities in the manner described below.
HCI will continue to build of activities described in FY 2008. The expansion of activities seek to build on
program strengths in HCD and clinical and support services.
ACTIVITES AND EXPECTED RESULTS:
ACTIVITY 1: Establish Quality Improvement Teams at the District / Facility Level
By improving and institutionalizing the formation of Quality Improvement teams at a facility and district level,
nature of the different stakeholders involved and geographic location of HCI-supported sites / districts.
reference to ART treatment, care and support services on a weekly and monthly basis. As part of HCI's
appropriate knowledge and skills to deliver quality HIV and AIDS services to all HIV-infected clients enrolled
ACTIVITY 3: Strengthening supervision systems
improving the quality of HIV and AIDS services and follow-up services.
programs / projects.
workers, lay counselors and home-based carers. This is particularly important at PHC facilities where HIV-
infected clients interact with a wide range of formal and informal health staff.
PMTCT, CT, FP, STI, TB and ART treatment sites. By working with health facility staff at different levels of
care, HCI staff will advocate for the development of integrated referral and follow-up networks. All staff at
these sites will be responsible for referring HIV-infected clients for onward care, treatment and support,
while staff at ART sites is responsible for care, treatment, support and follow-up of these patients. It is
Activity Narrative: essential to ensure that all patients receive optimal care and remain within the health care system, ensuring
compliance / adherence with treatment and an improved quality of life.
URC/QAP will actively participate in the development, revision and implementation of the National HIV and
AIDS guidelines, Continuum of Care for HIV-infected people and HIV and AIDS, monitoring and evaluation
framework policy in collaboration with the national and provincial DOH staff, to ensure long term
New/Continuing Activity: New Activity
Continuing Activity:
* Child Survival Activities
Estimated amount of funding that is planned for Human Capacity Development $25,000
Table 3.3.10:
Through training, mentoring and the introduction of quality assurance (QA) tools and approaches, Health
Care Improvement (HCI), the follow-on to the URC/Quality Assurance Project (QAP), will work with 65
South African Department of Health (DOH) antiretroviral therapy (ART) sites in five provinces (Eastern
Cape, KwaZulu-Natal, Limpopo, Mpumalanga and North West) to improve provider and patient compliance
with ART treatment guidelines and improve the delivery of quality ARV treatment services to HIV clients.
The essential elements of HCI support include technical compliance with evidence-based norms and
standards, interpersonal communication and counseling and increasing organizational efficiency. The
emphasis area for this activity is human capacity development. The activity targets public and private health
care workers, and people living with HIV (PLHIV).
HCI is currently training healthcare providers in 25 DOH ART service delivery sites in the use of QA tools
and approaches for increasing compliance with ART guidelines. HCI has developed a number of QA tools
for healthcare facilities offering ART services. HCI will increase the number of DOH ART-accredited
facilities that it supports in the five provinces to improve the quality of care provided to all clients on ART. To
strengthen HIV and AIDS services at facility level, HCI plans to enhance community-based support for ART
patients to ensure treatment adherence and active facility-based quality improvement using QA tools and
approaches. In addition, HCI will hire sessional medical staff in facilities in the 5 provinces to provide ART
services. These providers will serve as mentors to DOH staff for six months to a year. This strategy will
create local capacity to provide treatment services over time. HCI will assist healthcare facilities to develop
operational strategies to improve the care, treatment and follow-up of children and adolescents on ART.
HCI will also capacitate local community-based organizations (CBOs) and home-based care organizations
(HBOs) to integrate QA tools and approaches for improved quality of their home-based care management
and follow-up of ART patients.
While HCI will continue to focus on four key activities described before, the emphasis during FY 2009 will be
on expanding these and other activities, in the following ways:
ACTIVITY 1: Establish Quality Improvement Teams at District / Facility Level
By improving and institutionalizing the formation of quality improvement (QI) teams at a facility and district
level, HCI staff is involved in providing the knowledge and skills required for leadership and sustainability for
the program. This is an ongoing initiative, which is specific to each area, district, or province, due to the
variable nature of the different stakeholders involved and geographic location of HCI-supported sites /
districts.
With FY 2009 funds, HCI staff will work to develop Continued Professional Development (CPD) -accredited
ART training materials, including a comprehensive package of manuals, posters, flip charts and job aids.
The development of these materials will include modules on eligibility for ART, initiation of ART in both adult
and pediatric patients, disclosure, ART adherence issues, poly-pharmacy (addressing concomitant
administration of medication) and specific ART challenges.
The measurement of quality is also highlighted with emphasis placed on the indicators used to monitor
clinical performance, such as interruption rates for HIV-infected clients on ART and the proportion of HIV-
infected clients on ART who are linked to treatment supporters, which impacts directly on the continuum of
care and the quality of care provided to clients. Improvement and institutionalization of quality within the
context of ART services is also an important issue.
Participants are given skills for applying these principles in the work setting by focused training on
monitoring quality of service provision and measurement, data analysis and interpretation, reporting /
feedback, and improvement techniques. These are learnt practically through the use of role plays and
specific case studies. Participants work in groups to identify quality gaps within the case studies and make
recommendations for quality improvement strategies in the ART service based on these.
In addition, participants, either individually or as a group, are provided with raw data and are required to
analyze / interpret the data from the data sheets, graphically illustrate their analysis and make quality
improvement plans based on them.
HCI staff specifically undertakes human capacity development activities for health facility staff within HCI-
supported districts. These activities include formal training workshops, regular fortnightly support visits,
identification of knowledge and skills gaps and on-site mentoring and coaching activities by HCI staff.
Training, as defined by HCI, includes two days of formal training sessions, for which registers are
maintained by HCI Coordinators. HCI training involves specific quality assurance methods and quality
improvement techniques.
Activity Narrative: staff will be tasked with provision of clinical services to HIV-infected pediatric clients on a day-to-day basis
and provision of training and mentoring for health facility staff regarding HIV and AIDS care, with specific
initiatives, HCI staff seek to build capacity and develop local skills, by providing training and support to DOH
clinic staff (doctors, nurses, counselors, pharmacists, etc.) to ensure that providers have appropriate
knowledge and skills to deliver quality ART services to all ART clients enrolled on the program / eligible for
ART treatment and care. HCI staff and DOH staff meet regularly to ensure that any additional knowledge
regarding newer ART medication/treatment options, specific pediatric interventions and research findings
HCI will work with DOH staff to strengthen facility-community linkages with the objective of addressing
issues of psychosocial support, stigma reduction and prevention of domestic violence for HIV-infected
pregnant women. This will involve working with community-based workers/tracers to improve the visibility of
PMTCT and CT activities, increasing routine offers of voluntary counseling and testing (VCT) in
communities through education (in facilities and door-to-door/household visits), and hosting opportunities for
clinic staff and community members to showcase improvement activities and encourage support for
improvement initiatives.
improving the quality of ART and follow-up services. This is particularly important in the context of pediatric
ART, as there has been minimal supervision of these programs in the past.
collaboration with the national and provincial DOH staff to ensure long term sustainability of this program.
Estimated amount of funding that is planned for Human Capacity Development $37,104
Table 3.3.11:
expanding these and other activities as follows:
the program. These teams, with HCI support, are responsible for implementing facility plans for improving
access to TB screening, treatment and follow-up among people living with HIV (PLHIV). Each facility team
conducts rapid ongoing assessments to identify and to address quality gaps in current services for
screening, treating and following up of PLHIV for TB. This is an ongoing initiative, which is specific to each
area/district/province, due to the variable nature of the different stakeholders involved and geographic
location of HCI-supported sites and districts.
In FY 2009, HCI staff will work to develop accredited HIV and AIDS, TB HIV and home-based care training
development of these materials will include modules on basic HIV and TB, staging of HIV disease, care of
TB/HIV co-infected individuals, eligibility and initiation of antiretroviral treatment (ART) in adult and pediatric
co-infected patients, disclosure, adherence issues, poly-pharmacy (addressing concomitant administration
of medication), living positively with HIV and TB/HIV.
training initiatives to include QA/QI methodology for all cadres of health-care staff, including informal staff
such as community workers, lay counselors and home-based caregivers. This is particularly important at
primary health-care facilities where co-infected clients interact with a wide range of formal and informal
health staff.
HCI is already recruiting and placing medical staff in health facilities, and these staff will be tasked to
provide of clinical services to TB/HIV-infected clients on a day-to-day basis. In addition, staff will provide
training and mentoring to health facility staff on HIV and AIDS care, with specific reference to TB/HIV and
ART and care services on a weekly and monthly basis. As part of HCI's sustainability initiatives, HCI staff
seek to build capacity and develop local skills, by providing training and support to Department of Health
(DOH) clinic staff (i.e., doctors, nurses, counselors, pharmacists, etc.) to ensure that providers have
appropriate knowledge and skills to deliver quality TB/HIV services to all co-infected clients enrolled on the
program. HCI staff and DOH staff meet regularly to ensure that information regarding newer treatment
options and research findings are readily shared.
ACTIVITY 4: Strengthening Supervision Systems
HCI has been extensively involved in revision of the Clinic Supervision Manual for health-care facilities, and
training district and facility supervisors in QA methods and facilitative supervision techniques for improving
the quality of TB/HIV and follow-up services.
ACTIVITY 5: Care Support Groups
HCI has provided assistance in the implementation and facilitation of community- and facility-based care
support groups at all HCI-supported health-care sites in the five provinces. In FY 2009, it is envisioned that
this support will be expanded to include counseling on remaining HIV negative, Prevention with Positives
(PwP), HIV wellness programs, care for the caregivers, and community outreach programs.
prevention of mother-to-child HIV transmission, counseling and testing, family planning, sexually transmitted
infections, TB and ART sites, by working with health facility staff at different levels of care and advocating
for the development of integrated referral and follow-up networks. All staff at these sites will be responsible
for referring TB/HIV-infected clients for onward care, treatment and support, while staff at ART sites is
patients receive optimal care and remain within the health care system, ensuring adherence to treatment
and an improved quality of life.
ACTIVITY 7: Policy:
HCI will actively participate in the development, revision and implementation of the National TB/HIV
guidelines, Continuum of Care for HIV-infected people and the HIV and AIDS Monitoring and Evaluation
Framework Policy in collaboration with the national and provincial DOH staff, to ensure long-term
Activity Narrative: SUMMARY:
University Research Co., LLC / Quality Assurance Project (URC/QAP) will work with the Department of
Health (DOH) through training, mentoring and introduction of quality assurance (QA) tools/approaches to
improve the quality of services for Tuberculosis/HIV (TB/HIV) for co-infected patients in 100 DOH health
facilities in 5 provinces. The essential elements of Quality Assurance support include strategies to improve
technical compliance with evidence-based norms and standards as well as improving interpersonal
communication and counseling and increasing organizational efficiency. The major emphasis area for this
activity is quality assurance/supportive supervision with minor emphasis on development of
network/linkages/referral systems, training and needs assessment. The activity targets public health
workers, NGOs and community leaders, program managers, volunteers and people living with HIV (PLHIV).
Since 2001, URC/QAP has worked with the DOH to improve the quality of TB services. A number of
challenges continue to hamper the TB/HIV program, including provider knowledge and skills about TB, poor
access to laboratories and poor supervision and follow-up of patients on treatment. The rising TB burden in
South Africa (SA) as well as the emerging XDR epidemic is further complicating treatment of TB/HIV co-
infected patients. The large pool of TB/HIV co-infected patients necessitates the development of creative
strategies to address TB/HIV as a single entity and develop suitable service delivery models. URC/QAP will
assist 100 health facilities in 5 provinces to improve screening, referral, treatment, and follow-up of PLHIV to
identify those co-infected with TB in line with NDOH standards and guidelines. URC/QAP will assist facilities
offering HIV services to better integrate TB screening and treatment services into their programs. URC/QAP
will also provide small grants to selected local community-based organizations/home-based organizations
(CBOs/HBOs) to integrate TB screening, referral and follow-up into their home-based care programs for
PLHIV.
ACTIVITY 1: Establish Facility-Level Quality Improvement Teams
URC/QAP will work with each facility to identify core teams representing TB and HIV service providers as
well as other staff. These teams, with support from URC/QAP coordinators and district staff, will be
responsible for implementing facility plans for improving access to TB screening, treatment and follow-up
among PLHIV. Each facility team along with URC/QAP staff will conduct rapid ongoing assessments to
identify and address quality gaps in current services for screening, treating and following up of PLHIV for
TB. URC/QAP will assist the facility teams in the 5 provinces to increase HIV counseling and testing (CT)
for TB patients, utilizing various models for CT, including provider-initiated CT with opt-out option.
URC/QAP will assist teams in developing a strategic plan for improving access to quality TB services for
PLHIV at all levels, including provision of cotrimoxazole prophylaxis for co-infected TB/HIV patients.
URC/QAP will facilitate linkages to ARV treatment for eligible clients by training facility staff on the NDOH
National guidelines; and training facility staff in QA methods specific to TB and HIV; designing with facility
staff referral improvement plans, including strengthening networks with CBOs/HBOs to improve referral
patterns. URC/QAP is already in the process of developing a continuum of care model to ensure cross
referral, with improved case finding/case detection rates, and continuity of care, with improved follow up and
DOT support for all TB/HIV co-infected patients. Emphasis will also be placed on DOTS support/treatment
adherence to prevent multidrug-resistant TB among PLHIV. At the national level, URC/QAP will continue
assisting the South Africa National Tuberculosis Control Program (NTCP) in the implementation of the
NDOH guidelines for management of HIV-infected TB patients and will utilize this data to support and
advance the concept of best practice TB/HIV models of care.
URC/QAP will train health care providers to screen all HIV-infected clients for symptoms of active TB and
support referral of all TB suspects for diagnosis and treatment. It is expected that this will lead to the
development of a model protocol which will then be shared with other PEPFAR partners. In collaboration
with facility staff, URC/QAP will support "fast-tracking" of clients with TB symptoms for appropriate
diagnostic tests to assure timely treatment and to reduce the risk of nosocomial transmission to susceptible
PLHIV. URC/QAP will also work with facility staff on the development of a "retrieval" or back-referral system
to assure that TB patients continue to access HIV-care within facilities and CBOs/HBOs.
URC/QAP will provide job-aids such as wall charts to improve compliance with national TB guidelines.
URC/QAP will work with CBOs/HBOs to develop strategies for providing TB screening, referrals and DOT
support as part of their home-based programs. URC/QAP will train facility and CBO/FBO staff in analyzing
their performance (outputs) and quality (compliance) indicators. On a monthly basis staff will use trend lines
to see if the interventions are having the desired results of increasing identification of co-infected patients.
URC/QAP will visit each facility/CBO/HBO at least twice a month to provide onsite mentoring to staff. This
will focus on improving skills of staff in TB screening/treatment as well as ensuring that improvement plans
are being implemented correctly. During these visits URC/QAP will review program performance data.
ACTIVITY 4: Building Sustainability
URC/QAP will train district and facility-level supervisors in QA methods and facilitative supervision
techniques for improving the quality of TB/HIV coordinated activities at facility and community-levels. To
address the short-and long-term human resource needs to manage the enormous burden of HIV-infected
TB patients, URC/QAP will work with CBOs/HBOs and health care facilities to provide DOT supporters in
order to improve follow-up of co-infected patients as well as provide home-based care for these patients.
Activity Narrative: URC/QAP will also conduct quarterly assessments in each facility/CBO/FBO to assess whether staff is in
compliance with national guidelines.
ACTIVITY 5: Infection Prevention and Control
URC/QAP sees itself as an integral part of the network of IC delivery, as quality initiatives span a wide
range of health systems and processes. This is important to reduce the incidence of nosocomial infections
in both in- and out-patient settings. URC/QAP is part of the National Committee of infection prevention and
control and will work in partnership with the TASC II TB project and other partners to support the NTP to
finalize the development of infection control guidelines for TB program. URC/QAP will provide training and
support to QAP-supported facilities in 5 provinces to strengthen infection prevention and control on the
implementation of the national policy and guidelines. In addition URC/QAP will be involved in the
development and dissemination of information and education materials for TB infection control in work
settings for health care workers. In addition, URC/QAP staff will be involved in the dissemination and
implementation of the TB/HIV infection control policy guidelines within all facilities and home-based and
faith-based organizations supported by URC/QAP.
URC/QAP will assist PEPFAR in reaching the vision outlined in the USG Five-Year Strategy for South Africa
by facilitating the expansion of HIV CT to high risk groups (TB patients) and increasing recognition of TB in
PLHIV. URC/QAP work contributes to the PEPFAR goal of providing care to 10 million people affected by
HIV.
Continuing Activity: 13873
13873 3110.08 U.S. Agency for University 6639 1201.08 QAP $751,750
7430 3110.07 U.S. Agency for University 4415 1201.07 QAP $775,000
3110 3110.06 U.S. Agency for University 2713 1201.06 $385,000
* TB
Estimated amount of funding that is planned for Human Capacity Development $428,498
Table 3.3.12:
While Health Care Improvement (HCI), the follow-on to the University Research Corporation, LLC
(URC)/Quality Assurance Project (QAP), will continue to focus on the four key activities described in the FY
2008 COP, with the emphasis during FY 2009 placed on expanding these and other activities, in the
following ways:
By improving and institutionalizing the formation of quality improvement teams at facility and district levels,
program. This is an ongoing initiative, which is specific to each area, district, and province, due to the
variable nature of the different stakeholders involved and geographic location of HCI-supported sites and
As HCI is already in the process of recruiting and placing medical staff and lay counselors in health
facilities, these staff will be tasked with ensuring all clients are referred for or offered CT services, as well as
provision of clinical services to HIV-infected clients on a day-to-day basis. The medical staff will specifically
provide training and mentoring for health facility staff regarding HIV/AIDS care, with specific reference to CT
modalities and HIV treatment and care services on a weekly and monthly basis. As part of HCI's
support to Department of Health (DOH) clinic staff (doctors, nurses, counselors, pharmacists, etc.) to
ensure that providers have appropriate knowledge and skills to deliver quality CT services to all clients
enrolled in the program. HCI staff and DOH staff meet regularly to ensure that any additional knowledge
regarding newer CT treatment options and research findings are readily shared.
ACTIVITY 3: Referrals and Linkages
prevention of mother-to-child transmission (PMTCT), CT and antiretroviral treatment (ART) sites, by working
with health facility staff at different levels of care and advocating for the development of integrated referral
and follow-up networks. All staff at PMTCT and CT sites will be responsible for referring HIV-infected
mothers and their newborns for onward care, treatment and support, while staff at ARV sites is responsible
for care, treatment, support and follow-up of these patients. It is essential to ensure that all patients receive
optimal care and remain within the health care system, ensuring adherence to treatment and an improved
quality of life.
HCI staff will also ensure that health care workers are capacitated to provide appropriate infant care follow-
the PMTCT programs. HCI staff will also build the capacity of community-based tracers to identify and
follow-up PMTCT, tuberculosis (TB) or ART defaulters, including HIV-exposed babies who have been 'lost
to follow-up.'
HCI plans to strengthen linkages between orphan and vulnerable children (OVC) programs, CT, routine
maternal and child health and ART services. It is envisaged that this will serve to identify and strengthen
existing networks; highlight gaps in the quality of services provided; and provide information about the
feasibility of incorporating relatively rapid QA approaches into ongoing OVC programs.
HCI has been extensively involved in revision of the Clinic Supervision Manual for Healthcare Facilities, and
improving the quality of CT and follow-up services.
ACTIVITY 5: Policy
URC/QAP will actively participate in the development, revision and implementation of the national CT
guidelines and CT monitoring and evaluation framework, in collaboration with the national and provincial
DOH staff, to ensure long term sustainability of this program.
--------------------------------
University Research Co., LLC/Quality Assurance Project (URC/QAP) will work in 140 South African
Department of Health (DOH) facilities in five provinces to improve the quality of provider-initiated testing and
counseling (PITC) services through training, mentoring and introducing quality assurance (QA) tools and
approaches. The essential elements of QA support include assuring technical compliance with evidence-
based norms and standards, improving interpersonal communication and counseling, and increasing
organizational efficiency. The major emphasis area for this activity is quality assurance/supportive
supervision with minor emphasis on development of network/linkages/referral systems, training and needs
assessment. The activity targets public health workers, community-based organizations (CBOs), faith-based
organizations (FBOs), program managers, community volunteers, children, youth, adults, family planning
clients, and pregnant women.
Activity Narrative: BACKGROUND:
URC/QAP has been supporting DOH facilities in five provinces (Eastern Cape, KwaZulu-Natal, Limpopo,
Mpumalanga, and North West) to improve CT services. The focus of this activity has been on improving
counseling skills, as well as better integration of CT in several high-volume services. South Africa continues
to face major problems in increasing CT uptake among high-risk groups. Stigma, as well as fear of knowing
one's HIV status, remains primary reasons for low uptake of CT. In addition, most men do not visit health
centers unless they are very sick, resulting in a low number of men requesting CT. URC/QAP will increase
the awareness about CT among communities by creating linkages between public and community-based
facilities, and by actively promoting strategies that involve men. Integrating HIV and AIDS services with
other high volume and problem-prone health services such as antenatal care, family planning, sexually
transmitted infection services, as well as other curative health services, will improve social mobilization and
public awareness.
URC/QAP will work with facilities to identify a core team representing staff from various clinical services.
The facility-based teams, with support from URC/QAP and DOH staff, will be responsible for plans for
improving uptake of quality of CT services in various clinical settings. Each facility team will conduct a rapid
baseline assessment (if this has not already been completed) to identify quality gaps in current CT services.
The facility teams will use these assessments and QA tools to develop and implement the quality
improvement plan. URC/QAP will assist facility teams in developing strategic plans for improving access to
and quality of CT services. PICT services will be linked with high-volume and problem-prone services, such
as TB, STI, FP, and antenatal care services, which have large proportions of HIV-infected clinic attendees.
URC/QAP will also integrate routine HIV testing services, thereby increasing access to CT in all clinical
settings. Emphasis will be placed on increasing recruitment of couples and families, including children and
adolescents, to CT services. Facility staff will promote access and availability of confidential HIV testing,
ensure that HIV testing is informed and voluntary, ensure effective and prompt provision of test results for
all clients who undergo HIV testing, utilize a prevention counseling approach aimed at personal risk
reduction for HIV-infected persons and those who have a higher risk of HIV exposure. URC/QAP will ensure
that all facility staff are aware that HIV prevention counseling should focus on the client's unique personal
circumstances and risk, and counseling should help the client set and reach an explicit behavior-change
goal to reduce the chance of acquiring or transmitting HIV.
Staff will receive QA training which will include specifics on CT quality, the meaning of quality in services,
and compliance with national guidelines. Emphasis will be placed on the indicators used to monitor clinical
performance, such as the presence of guidelines at facility level or the knowledge and skills of counselors.
Specific case studies will be presented during the training, and participants will work in groups to identify
quality gaps and suggest possible solutions. URC/QAP will provide job-aids such as wall charts to improve
compliance with clinical and counseling guidelines. URC/QAP will visit each facility and CBO/FBO at least
twice a month to provide on-the-job support and mentoring to healthcare workers in participating facilities.
The mentoring will focus on improving skills of CT and other high-volume clinical service staff on HIV
counseling and referring. During these visits, URC/QAP will also review program performance data.
URC/QAP is working on a continuum of care model for all HIV-infected persons. The model emphasizes the
identification and early referral of all people living with HIV (PLHIV) to care, treatment, and other support
services. As part of this mandate, URC/QAP works to link different levels of care (facility, CBO, FBO, home-
based organization) and different services to minimize missed opportunities. To ensure that CT is widely
available, various innovative CT approaches -- such as family-based, door-to-door, community-based,
outreach services, youth focused and within home-based care -- will be incorporated into existing programs.
URC/QAP will continue to expand this focus and promote available methods for prevention for all clients,
including a specific focus on discordant couples. In addition, URC/QAP will continue to work with local
CBOs and FBOs to increase community outreach and support for knowing one's HIV status. URC/QAP will
train facility, CBO and FBO staff in analyzing their performance (outputs) and quality (compliance)
indicators. The staff will use site-specific data to see if the interventions are increasing uptake of basic
healthcare and support services on a monthly basis.
techniques for improving the quality of CT services. URC/QAP has begun the process of reviewing the
national CT guidelines and evaluating the quality of CT at facility level, in partnership with the provincial
health departments at all levels. This will be a key focus area in the next 12 months. To ensure the quality
and reliability of data obtained at all QAP supported sites, it has been necessary to ensure uniform reporting
structures, with the introduction of QAP-specific data collection tools. Only URC/QAP staff utilize these
tools, as DOH facility staff have their own reporting registers which are facility and district specific.
URC/QAP will conduct quarterly assessments in each facility/CBO/FBO to assess whether the staff are in
compliance with the NDOH CT guidelines. At least once a year, sample-based surveys will be undertaken in
a small number of QAP and non-QAP sites to assess the differences in compliance and other performance
indicators.
URC/QAP will assist PEPFAR in reaching the vision outlined in the South Africa Five-Year Strategy by
increasing access to CT services. URC/QAP work contributes to the PEPFAR goal of providing care to 10
Activity Narrative: million people affected by HIV.
Continuing Activity: 13874
13874 3114.08 U.S. Agency for University 6639 1201.08 QAP $446,200
7432 3114.07 U.S. Agency for University 4415 1201.07 QAP $460,000
3114 3114.06 U.S. Agency for University 2713 1201.06 $160,000
Estimated amount of funding that is planned for Human Capacity Development $254,334
Table 3.3.14:
As the Health Care Improvement (HCI) project is relatively new, it will continue to focus on the four key
activities described in the FY 2008 COP narrative. The emphasis during FY 2009 will be on expanding
these activities, maximizing on gains and consolidating lessons learned. One of the important activities
through FY 2009 will be to start the process of acquiring South Africa Qualifications Authority (SAQA)
accreditation for the Quality Assurance (QA) training modules, which is often a lengthy and daunting
process.
-------------------
Through introduction of quality assurance (QA) tools and approaches and practical work, University
Research Co., LLC/Quality Assurance Project
(URC/QAP) will train 600 staff members of PEPFAR partners to gain a better understanding of quality
improvement and quality assurance tools and
approaches. Emphasis will be put on practical application of the quality assurance and improvement
concepts in HIV/AIDS care, support and treatment
settings. The training will also look at quality improvement and how its links with overall system
strengthening activities. The training will seek to improve
the quality of PEPFAR programs in general and HIV and AIDS programs in particular.
The essential elements of QA include technical compliance with evidence-based norms and standards,
interpersonal communication and counseling and increasing organizational efficiency. The major emphasis
areas for this activity are QA and supportive supervision, with minor emphasis on development of networks,
linkages, referral systems, training and needs assessment. The target populations include policy makers,
public and private healthcare workers, community-based organizations (CBOs), and NGOs.
This is a new activity, initiated at the request of the South African USAID mission and various PEPFAR
partners. The Quality Assurance Project (URC/QAP) has been working with the National and provincial
Departments of Health in South Africa since 2000 on improving the quality of health services. Over the
years, URC/QAP has successfully tested various interventions for improving and assuring quality of
healthcare services. Since
2004, URC/QAP has assisted DOH facility staff in five provinces in applying these same tools and
approaches for improving the uptake and quality of HIV and AIDS services. Currently, URC/QAP is
supporting HIV and AIDS programs in 120 healthcare facilities in five provinces as well as two community-
based organizations. The use of QA/QI tools and approaches have helped facility teams in integrating
services (HIV testing with antenatal care program, TB and HIV integration among others), enhancing quality
(increasing compliance of healthcare workers with national guidelines and patients/caregivers with
treatment regimens). This has resulted in increased uptake of services as well as improved treatment
outcomes. URC/QAP has conducted a number of studies to evaluate the impact of the use of QA/QI models
on various services (neonatal health, TB, etc. over the past two years). These studies have highlighted both
improvements in patient outcomes as well as program sustainability.
In order to broaden the reach of the QA/QI model, which has been integrated within the South African
Government DOH QA Program, many USG partners have requested QA/QI training to improve the quality
of their respective HIV/AIDS prevention, care and treatment programs.
In FY 2008, URC/QAP has been requested to implement a QA training program for up to 600 staff members
of 20 PEPFAR partners to improve the theoretical and practical understanding of quality improvement.
These partners will be identified in consultation with USG. It is envisioned that this training will be designed
for PEPFAR partners who work in public health facilities and who request the QA/QI training.
ACTIVITY 1: Identify PEPFAR Partners for Capacity Building
This activity was initiated at the request of the South African USAID mission and various PEPFAR partners.
An assessment will be done to identify PEPFAR partners who work in public health facilities and who
request the QA/QI training. URC/QAP will work with USG partners to identify who all should participate in
the QA/QI training program.
ACTIVITY 2: Finalize training package
URC/QAP will conduct a rapid needs assessment of various partners for QA/QI training. Based on the
assessment results, URC/QAP will design targeted training for various types of partners (clinic, community,
faith-based etc.). The focus of training will reflect clinical or community-based interventions implemented by
targeted partners. The training will include the following key elements:
-Basic QA/QI principles
-Integrating QA/QI in clinical settings
-Integrating QA/QI in community-based settings
-Monitoring quality of clinical and community-based services
-Tools for improving quality of services
-Plan-Do-Study-Act
-Story-boarding for dissemination of results
ACTIVITY 3: Conduct Training
URC/QAP will conduct training sessions for the PEPFAR partner staff. Each course will last 3 days in and
Activity Narrative: will not include more than 30 participants. The
training programs will be interactive and participants will use case studies for learning various QA/QI tools.
URC/QAP training will also facilitate
linkages between different organizations by emphasizing training and compliance of facility staff with
national guidelines and implementing quality improvement plans including process re-design, integration of
services, and enhancement of network development with CBOs to improve referral patterns. URC/QAP staff
will emphasize the strengthening of referral networks and URC/QAP staff will demonstrate that promoting
integration of services at the facility level ensures the development of links between services such as
sexually transmitted infections, family planning and VCT, promoting holistic care. It is envisaged this will
serve to identify and strengthen existing networks; highlight gaps in the quality of services provided; and
provide information about the feasibility of incorporating relatively rapid QA approaches into ongoing routine
health care programs.
ACTIVITY 4: Follow-up Support
URC/QAP will assist the partner staff to develop a strategic plan for improving the quality of specific HIV
and AIDS services. Interventions will include: (1) use of QA tools to improve compliance with national and
provincial guidelines; (2) re-design of clinical processes to improve patient flow and service times; and (3)
train QI teams to analyze their performance and compliance in relation to standard indicators. URC/QAP will
at least visit each partner organization once or twice in a year to provide hands on TA in improving the
quality of services. All partner staff supporting specific HIV and AIDS programs will be capacitated to ensure
that programs are in compliance with the national guidelines and to assess compliance with quality
assurance standards and other key performance indicators. URC/QAP will also be involved in training
district and facility-level supervisors in QA methods and development of supervision techniques to improve
the sustainability of QA within HIV and AIDS programs. The training will be done in collaboration with NDOH
staff, to ensure accountability and long-term sustainability of the program URC/QAP staff will also
capacitate organizations to train other members of staff with their "train-the-trainer" program, where at least
2 members of each organization will be invited to attend an extended QA/QI training workshop. This will
ensure transfer of skills & capacity building of local organizations.
Continuing Activity: 13876
13876 13876.08 U.S. Agency for University 6639 1201.08 QAP $727,500
Workplace Programs
Estimated amount of funding that is planned for Human Capacity Development $618,375
Table 3.3.18:
