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 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 Teams

URC/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 PMTCT

URC/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 Linkages

URC/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

Activity Narrative: 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 Supervision

URC/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 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.

SUMMARY:

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

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

Activity Narrative: 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.

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).

BACKGROUND:

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.

ACTIVITIES AND EXPECTED RESULTS:

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.

ACTIVITY 2: Training

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.

ACTIVITY 3: Human Capacity Development

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.

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

Activity Narrative: 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.

SUMMARY:

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.

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.

ACTIVITIES AND EXPECTED RESULTS:

ACTIVITY 1: Establish Facility-level Quality Improvement Teams

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.

ACTIVITY 2: Human Capacity Development

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.

ACTIVITY 3: Referrals and Linkages

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.

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 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

Activity Narrative: 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

million people affected by HIV.

SUMMARY:

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

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).

BACKGROUND:

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.

ACTIVITIES AND EXPECTED RESULTS:

ACTIVITY 1: Establish Facility-level Quality Improvement Teams

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.

ACTIVITY 2: Training

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.

ACTIVITY 3: Human Capacity Development

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

services.

SUMMARY:

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.

BACKGROUND:

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

ACTIVITIES AND EXPECTED RESULTS:

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

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

Activity Narrative: 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.

URC/QAP will contribute to 2-7-10 PEPFAR goals by providing care services to 10 million. The activities

also support the USG strategy for South Africa by collaborating closely with the DOH to improve access to

and improve the quality of basic care and support.