Improving patient outcomes through health systems strengthening is the goal in line with the NSP, PHC and NHI strategies. The 4 objectives have cross linkages with the SAGs 10 Point Plan for overhauling the health system to achieve zero transmission, initiation of 80% of eligible patients, retention of 70% in care at 5 years, reducing new TB infections and deaths by 50%.These will be achieved through strengthening the SAGs health systems in the areas of service delivery through a process of assessing the quality gaps as per the National core and clinical safety standards through supporting District Health Management Teams. Staff transitioning, appropriate staff levels, and retention are critical enablers to achieving these objectives .The use of strategic Information will be strengthened through capacity development of District M&E officers. Governance will be strengthened through leadership and management skills development, district planning and target setting processes, and mentoring on supervision using SAG mentoring guidelines. Human resource capacity will be strengthened through in-service training and new skills development. Supply chain processes will be strengthened by supporting the quantification and forecasting procedures, stock inventory, and medicine management processes. Community systems will be strengthened by the formation of networks, coordination, and partnerships between community organizations in the districts as well as training and mentoring of CCGs and ward AIDS councils. Districts supported are: Amajuba, ILembe, Umsunduzi and the Cape Metro. Communities are disadvantaged due to poverty, unemployment and high HIV/TB prevalence and are mainly women, pregnant young women and children who live in poor rural or informal peri-urban areas.

The KI program will continue to strengthen governance and leadership capacity of SAG District Health Management Teams (DHMT) and District Clinical Specialist Teams (DCST) to improve quality of care and support of adults in poor previously disadvantaged communities, with the special focus on young women. All government facilities and services across the districts of Amajuba, ILembe, the Cape Metropole and the Umsunduzi sub-district are supported from district hospitals to PHCs. Service strengthening will build on the previous years review of services to ensure the National Core and Patient Safety standards meet the Council of Health Services Accreditation criteria. Data from these reviews will assist with more accurate budget construction improving health financing. District managers will be trained to better mentor and support the PHC nurses and NIMART nursesto initiate and improve care for adult HIV and TB patients, tp ensure that turnaround time for lab speciments is acceptable and to ensure efficient supply chain for drugs and commodities. KIs district teams will continue to strengthen the capacity of DCSTs to supervise the nurses providing services. The DCSTs will be supported in scaling up basic care packages through regular meetings and reviews of district services and data outputs, ensuring that all facility staff adhere to and implement the latest treatment guidelines. The DHMTs will be capacitated to support and strengthen the district health model of service delivery from testing, staging, care and treatment. Referral linkages to other services will be systematized and applicable services will be integrated, such as MCH, FP/RH, nutrition, counselling, PICT, palliative care and pain management. The chosen centres of excellence will be further developed as demonstration sites for these services.

Pre-ART services which include psychological and social support; diagnosis; risk reduction including positive prevention, counselling, family planning and condom distribution; management of OIs; pain and symptom assessment and management; and nutritional and preventive care to ensure improved clinical quality. The capacity of the DHMT will be increased to ensure that patient retention is strengthened through the expansion of adherence clubs and the community care giver (CCG) adherence programme. Patients will be linked to CCGs and defaulters will be followed up and provided with ongoing counselling and support. Expansion of community HCT with adherence support and PMTCT will be implemented. Psychosocial home assessments will continue to be implemented by CCGs to ensure that domestic challenges to adherence are addressed and households are screened for HIV and TB. Where required, CCGs will refer patients to other SAG departments and NGOs for food security, domestic violence, substance abuse, and to facilitate social grants.

Ongoing patient monitoring as per the DHIS and Tier.net roll out will ensure availability and use of strategic information. Regular updates will ensure that this national data system functions optimally. Operations will be regularly evaluated to extract new learnings to inform the SAG of trends in disease demographics that need to be monitored or where interventions need to be made. The POPART treatment as prevention study in the Western Cape will be conducted in 9 sites as part of an international trial to assess innovative strategies for HIV prevention.

The KI program will continue to support the NDOH with the development and finalization of policies and guidelines to strengthen the TB/HIV program in an integrated manner. Working with COHSASA, KI will build capacity of the DHMT in performing facility assessments around TB/HIV services pertaining to the implementation of the 5 I's (intensive case finding (ICF), Isoniazid prophylactic therapy (IPT), Infection control (IC), integration of HIV/TB services, and initiation of ART in TB patients) using the data driven approach for regular programmatic assessment and review. Capacity of the program managers, DCST and operations managers to mentor and coach staff on the operationalization of the 5 I's will continue.

The KI training teams will build the capacity of the DHMT to train, mentor, and supervise key staff and the District Clinical Specialist Teams (DCST) to increase awareness, diagnosis, and treatment of TB and HIV co-infection.

The KI district teams will build the technical skills of the District TB managers to ensure that they support the facility staff with sputum review at 2 and 5 months to improve clinical quality and thus improve TB cure and treatment completion rates. The capacity of the DCST to engage with the NHLS around ensuring timely delivery of results and proper feedback to facilities will be strengthened. The District Health Management Team (DHMT) capacity to stock control, thereby ensuring no stock out of TB medication using tracer medicines will be enhanced through KI training of district pharmacy managers.

The KI community support component will work with the PHC community component and community care givers (CCGs) to continue to provide adherence supporters for dually infected patients. The district CCGs will be trained in the provision of adherence support, defaulter tracing, and ICF. Innovative interventions like CCGs screening the household members of index patients on ART for TB/HIV and advising on infection prevention and control will lead to an increase in case finding to reduce the incidence of TB and HIV.

The KI teams will build the technical skills of the DCST and operations managers to strengthen their support of clinical teams on TB prevention and infection control measures in the clinics, TB screening of HIV adult and pediatric patients, provision of INH preventive therapy as well as time to HIV treatment. KI will build the capacity of the sub-districts and DHMTs to improve the availability and use of strategic TB information and regular data review and to report high quality data using standardized tools and indicators.

TB and HIV integration is complex and challenging, particularly in larger facilities with large case loads. There are varying levels of integration and each facility will be able to determine their level of integration to ensures better patient outcomes.

The KI program will continue to strengthen governance and leadership capacity of SAG District Health Management Teams (DHMT) and District Clinical Specialist Teams (DCST) to improve quality of care and support of HIV infected children in poor previously disadvantaged communities, with special focus on adolescents. All government facilities and services across the districts of Amajuba, ILembe, the Cape Metropole and the Umsunduzi sub-district are supported from district hospitals to PHCs. Service strengthening will build on the previous years review of services to ensure the National Core Standards and patient safety standards are met with the assistance of COHSASAs tools. Data from these reviews will assist with budget construction improving health financing. District managers will be capacitated to better mentor and support the PHC nurses and NIMART nurses initiate and improve care for pediatric and adolescent HIV and TB patients, ensure turnaround time for lab specimens is acceptable, and ensure efficient supply chain for paediatric drugs and commodities to reduce the barriers to paediatric and adolescent treatment access at the PHCs. Centres of excellence will form the hub for service excellence delivery. The KI Paediatric specialist mentors will provide mentorship and training to DCSTs, DHMTs, and facility managers on paediatric and adolescent continuum of care and support. The KI Nurse Quality Mentors (NQMs) will capacitate the paediatric nurses in PHC teams to increase early infant diagnosis of HIV, 6 week and post weaning PCR testing for all exposed infants under 12 months, and paediatric TB diagnosis by training of facility staff in the district and providing mentorship on IMCI. The paediatric nurses will ensure that regular ELISA testing of exposed infants during vaccination visits is encouraged to ensure increased HIV free survival. The KI NQMs will capacitate sub-district management teams through coaching to increase provision of ELISA testing for all babies at 18 months with unknown status at immunization and baby clinic visits. The KI district teams will continue supporting the DCST to arrange quarterly meetings with all medical officers rendering paediatric ART care for quality improvement and sharing best practices as well as improving protocols for referral or care of children with viral load (VL) failure. KI will assist the DHMT improve VL suppression and retention in care by providing counselling and psychosocial support, including food security through community caregivers (CCGs) with ongoing training of CCGs in tracing and follow up of HIV/TB paediatric treatment defaulters. All children born in these districts will be systematically registered and birth certificates obtained to facilitate access to child care support grants.

The KI quality improvement team will attend district and sub district meetings to provide input, guidance, and support on using strategic information to improve perinatal outcomes. Ongoing paediatric patient outcome monitoring as per the DHIS and Tier.net roll out will ensure availability and use of strategic information. Regular updates will ensure that this national data system functions optimally. Operations will be regularly evaluated to inform the SAG of trends in disease demographics that need to be monitored or where interventions need to be made.

The KI QI team with COHSASA will capacitate the leadership and governance of District Health Management Team (DHMT) in the performance of facility baseline assessments for all services to ensure compliance with National Core and patient safety standards. KI will continue to capacitate the DHMT, sub district and facility managers in the implementation and review of standards. This review will identify gaps in all focus areas of HSS. Following the analysis and gap identification, the KI District Teams (DTs) will support the DHMT to facilitate management, training, and mentoring of selected DOH managers as required and facilitate workshops/ courses at facility and district level, including operational managers. KI will build the capacity of the DHMTs in achieving and sustaining clinical and managerial quality through training of clinic supervisors and coaching and mentoring of the PHC supervisors and the DCST on effective implementation of the clinical supervision manual. Determining staff to patient ratios and human resource training needs will assist with budget constructs for ongoing health financing. KI DTs will continue to build the capacity of the district training managers in the provision and/or coordination of HIV technical content training, and training on the integration of HIV with other services and will continue to provide in-service training and treatment updates for all staff on changes in HIV and TB related guidelines. The capacity of the DHMT to scale up and implement TIER.NET as per the DOH schedule in line with the district implementation plans will be strengthened. The district information officers will be skilled and supported to ensure compliance with the standards of proper patient health record maintenance, district management data analysis, information planning, and usage to inform clinical care and to design quality improvement processes and facility management strategies. The increased capacity will embed quality processes across all sub-districts and support the identified centres of patient care excellence in line with the district NHI rollout planning. KI DTs will continue to build the capacity of the DHMT and District Clinical Specialist Team (DCST) to support and mentor facilities on the continuous quality improvement process based on self-evaluation and validation/progress monitoring processes. KI will build the capacity of the DHMT to ensure quality laboratory services and management of specimens and results; strengthen the management of services, prevention and control of infection; and institute a quality management system and risk management system pertaining to lab specimens. The pharmaceutical services capacity will be improved through the training of DHMT on resource allocation and strategic operational planning on procurement of supplies and forecasting drug needs to ensure proper management of the service, ensuring the proper control and storage of medication, SOP availability, and patient access to appropriate and safe medication. KI will support the districts by attending and contributing to the DOH district program meetings on CCMT, TB, PMTCT, MNH, as well as community support meetings within the district to address challenges and explore opportunities for supporting health needs of communities through community systems strengthening.

KIs district teams (DTs) will continue to capacitate DHMTs scale up PMTCT services in Ilembe and Amajuba and working with HST in Umsunduzi. The DTs will capacitate the DOH MCH managers to improve the quality of services provided by the antenatal nurses, ensuring adherence to current PMTCT guidelines and implementation cascade towards eMTCT. Increased management skills will result in improved early attendance of pregnant women, scale up PICT for early diagnosis of HIV, increased access to CD4/VL testing, (supporting POC testing in line with the Provincial/District priorities), adherence to the new breast and infant feeding guidelines, increase retention in care and treatment adherence of mother-baby pairs, ensuring increased 6 week, post weaning HIV DNA PCR testing under 12 months and 18 month HIV antibody testing. The DTs will capacitate the DHMT to support operations managers in strengthening linkages and referrals to MCH and RH services; adult and paediatric/adolescent treatment, care and support services; linking of community-based partners at PHCs and their CCGs for community mobilization and demand creation for PMTCT services. The capacity of the DOH training managers to up skill, mentor and coach facility based DOH staff in ensuring adherence to ART initiation guidelines for eligible HIV+ pregnant women will be increased. The program management capacity, using the data driven approach and PDSA cycles, of the DHMT will be increased. Regular data quality and program review and evaluation capacity will be increased at facility, sub district and district levels in an effort to institutionalise program management and quality improvement processes. This will further strengthen the district in the review of district and national dash board PMTCT indicators. The targets of the program will ensure that all pregnant women are tested at their first ANC visit, that 100% of those tested receive their results, that 98% of women receive ART prophylaxis, and that all women eligible for ART are treated. The activity plan for achieving these targets will range from: the provision of current guidelines to all facilities; DOH staff skills building on IMCI and PMTCT; ensuring adherence to guidelines; and strengthening the governance capacity of the DOH DHMT and PMTCT managers. This will enhance their technical and supply chain management skills to prevent drug and test kit stockouts; ensure lab services adhere to agreed blood result turnaround timelines; and mentor and coach staff on the PMTCT cascade. Staff mentoring and coaching capacity of the DOH district information officers will be increased to improve data collection, availability, and use of strategic Information guiding the regular review of data. Regular program review meetings will support quality improvement processes. Currently 24700 pregnant women have been managed in these districts with 31.95% HIV positivity until Sep 2012. 8800 positive women are projected in FY 2012 and 9600 in FY 2013.The innovative follow up of all pregnant women by CCGs, positive and negative, at their homes for HIV/TB screening will ensure testing of households further reducing HIV and TB.

The KI program will continue to strengthen governance and leadership capacity of SAG District Health Management Teams (DHMT) and District Clinical Specialist Teams (DCST) to improve quality of adult treatment in poor, disadvantaged communities. The program will strengthen capacity of the DCST and DHMT to offer onsite training, support and supervision for clinical staff on adult ART and TB treatment, including treatment updates, adverse event management, appropriate referral, detection and management of treatment failure and appropriate treatment options to increase treatment access and support the delivery of quality care.

Pre-service training of learner basic and post basic pharmacist assistants and phlebotomy technicians will continue to fill critical gaps. Training of all available nursing staff (post service) at facility level on the various aspects of ART will continue. The DCST will also be trained to support the practice of roving teams on treatment service provision. All PHC professional nurses will be trained and mentored to ensure a well-integrated family centred PHC based treatment service with functioning referral networks. Quality assurance is a key health system element of KI with virologic suppression for patients on ART being the focus of treatment success. This involves ongoing DHMT health systems review and strengthening with the use innovative interventions, utilizing tools and training from COHSASA.

The KI nurse quality mentors (NQMs) will capacitate the DCST to strengthen the integration of HIV/TB, HIV/PMTCT/MNCH, and FP/RH by continually assessing and making recommendations to service improvement at regular District Team meetings. Adequate supply chain of critical commodities, ART, and laboratory strengthening are aspects of governance that will be supported by KI. Adherence is critical for ongoing viral suppression and is critical to ensure the continuum of quality care, including strengthening of community networks. Patients will continue to be offered adherence support through community caregivers (CCGs) trained on adherence and management of viral suppression. The DCST and DHMT will review the implementation of the National Core Standards and patient safety standards to address challenges in service delivery across the district. KI teams are currently working with COHSASA , the International Health Institute, and South to South to transfer improvement skills and tools for adult quality improvement (QI) to district QI team leaders who will cascade the continuous quality assurance processes to all staff. Strategies such as Plan-Do-Study-Act (PDSA) cycles will be used to strengthen leadership, construct improvement goals, test proposed changes, and implement adjustments to increase quality of operations, service delivery and care. Critical to the sustainability of QI will be the institutionalization of routine and consistent use of tested systems like medical records, laboratory and pharmacy audits, health facility inspection and peer review of systems designed to improve efficiencies. Ongoing patient monitoring as per the DHIS and Tier.net roll out will ensure availability and use of strategic information. Operations will be regularly evaluated to inform the SAG of trends in disease demographics and interventions needed. The innovative POPART treatment as prevention study in the Western Cape will be critical in paving the way for newer treatment guidelines.

Currently KI supported sites support 8560 children under 15 years remaining in care as of the end of FY 2012. Predicted numbers for the next 2 years for the current supported sites will total over 4000 if levels continue as is given that KI has moved out of 4 districts.

The KI program will continue to strengthen governance and leadership capacity of SAG District Health Management Teams (DHMT) and District Clinical Specialist Teams (DCST) to improve quality of child and adolescent treatment in poor, disadvantaged communities. The program will strengthen capacity of the DCST and DHMT to offer onsite training, support and supervision for clinical staff on pediatric ART and TB treatment, including treatment updates, adverse event management, appropriate referral, detection and management of treatment failure and appropriate treatment options to increase treatment access and support the delivery of quality care. This will occur through the ongoing links with South to South and other trainers in support of the DCST training programs for health care workers in the diagnosis of HIV/TB in children, early infant diagnosis, and treatment of HIV infected children and adolescents.

Program activities include ensuring the latest paediatric treatment and breastfeeding guidelines and policies are available at all supported sites and staff are trained and supported in the implementation of these guidelines to ensure the ongoing scale up of provider-initiated counselling and testing at IMCI and immunization clinics, scale up of PCR testing at 6 weeks and post weaning; 18 months ELIZA HIV antibody and CD4 testing availability, and scale up of viral load monitoring; improved transition from testing to treatment; reduced loss to follow up through active support of carers with follow-up of early defaulters; improved adherence and overall treatment retention; and improved capacity at the district and sub-district level to supervise the program by routine collection and analysis of strategic data. This patient care model will focus on greater integration of services where possible to improve clinical outcomes based on clinic headcount, the nature of the intervention and population characteristics including key populations and the prevalence of health problems, and the overall support from the District as well as human resources available to provide these services. The focus has been on a family centred approach which facilitates the transition of services from child to adolescent to adult. Where child clinics are large, support groups or adherence clubs for adolescents are being constructed to address these issues of disclosure, acceptance, and transition into adulthood. Links to adherence community caregivers (CCGs) will continue to be strengthened to reduce defaulting and poor viral suppression.

Failing patients will be managed by the DCST paediatrician who will either ensure management at services of excellence or refer to specialist units better able to manage these patients. Data collection parallel that of adults as they are all seen at the same clinics and usually followed up by the same adherence workers or CCGs. Pharmacy services staff will continue to be trained by KI or partners in paediatric pharmacy needs and forecasting within the accepted SOPs.