TITLE: URC QUALITY IMPROVEMENT in PMTCT SERVICE DELIVERY

NEED AND COMPARATIVE ADVANTAGE: The Government of Tanzania (GoT) and the United States

Government (USG) have collectively identified a need to improve the very low coverage and quality of

PMTCT services throughout Tanzania. University Research Company/Quality Assurance Project

(URC/QAP) has proven successful in preventing mother to child transmission (PMTCT), identifying and

testing children potentially infected with HIV, and referring individuals to care and treatment centers (CTC)

for follow up care including PCP prophylaxis and antiretroviral treatment (ART). During 2007, URC

partnered with the Ministry of Health and Social Welfare (MOHSW), the National AIDS Control Program

(NACP), and other USG partners to strengthen access and quality of comprehensive PMTCT services.

ACCOMPLISHMENTS: During the last two years, URC/QAP pediatric AIDS collaborative trained 362 health

workers in HIV case management; assessed quality improvement (QI) and collaborative methods;

established, trained and mentored QI teams in 17 referral facilities; provided technical guidelines, job aids,

and self assessment tools; assisted with reorganization of patient flow and provision of emergency pediatric

care. In addition, the program improved monitoring of emergency drugs, supplies and equipment. The

program supported initiatives stemming from. NACP and partners to develop nationally endorsed whole

facility training curricula on infant feeding (IF) counseling in the context of HIV/AIDS. Close collaboration

with GoT organizations has facilitated the creation of a necessary infrastructure for future successful

initiatives in FY 2008.

ACTIVITIES: URC/QAP will utilize lessons learned from best practices in other countries (e.g., Uganda and

Rwanda) to implement quality improvement measures using a collaborative approach. Core activities will

include: improving quality of ART services for adults and children; linking PMTCT to pediatric AIDS care;

and improving rates of TB testing among ART clients. To ensure synergy and success, URC will continue

to develop innovative methods linking lower level facilities and communities for improved follow up and

comprehensive management of PLWHA. URC will strengthen essential linkages between PMTCT, infant

diagnosis and follow-up in addition to linking PMTCT with overall HIV/AIDS care and treatment services to

increase numbers of exposed infants who benefit from services, (e.g., nevirapine, staging and

Cotrimoxazole prophylaxis).

URC/QAP will focus on building and strengthening quality improvement (QI) capacity within MOHSW and

USG partners in order to set up and maintain a standard adequate PMTCT quality of service system using a

collaborative approach. This includes developing a continuous QI system for PMTCT that is linked to care

and treatment while building on quality improvement collaborative work, current experience, and best

practices. URC/QAP will expand capacity through collaboration with GoT and USG partners for continuous

QI in PMTCT services; monitor progress; develop PMTCT QI framework; train and support regional and

district QI teams in developing coaching and mentoring skills; and document and share experiences in

learning sessions. URC will train regional and district teams on roll-out procedures and use of tools in

addition to coordinating national training coinciding with PMTCT quarterly meetings to share experiences,

monitor progress, and train future trainers to ensure sustainability. Adoption of QI methods and service

tools nation-wide to improve quality of PMTCT services is necessary to provide sustainable and effective

services. Therefore, URC/QAP will identify and address key systems barriers to quality PMTCT services for

pregnant women and their partners. Furthermore, URC will incorporate do, study, act (PDSA) cycles to test

improvement changes in anti-retroviral therapy (ART), PMTCT and IF.

Results from a networking and continuum of care pilot will be available by COP 2008 implementation, and

URC/QAP will disseminate information gathered from the pilot regarding best practices, quality of services,

interventions, and management procedures to regions designated by GoT to ensure a continuum of care.

Best practices identified by the pilot will be put into practice nationwide. Emphasis will be placed on building

ways to sustain the model of care and linkages between facilities and communities such as using Network

Support Agents.

Activities will include identifying members of the PMTCT service to be included in the HIV QI team at each

facility; developing procedures for networking and referral between PMTCT, Well Child clinics and ART

service areas at facility levels and with Community Based Organization (CBO's) at the community level;

identification of exposed infants born at home for referral within 72 hours for nevirapine and essential

newborn care and establishing indicators for PMTCT quality performance as part of the overall HIV/AIDS

prevention, care and treatment Program. In addition, URC/QAP will work with MOHSW and USG PMTCT

partners to roll-out QI monitoring in sites integrating PMTCT and RH services, including maternal and child

survival activities practices, to manage and prevent HIV transmission.

LINKAGES: URC/QAP will continue to work closely with the PMTCT and ART units within the NAC, the

inspectorate unit of MOHSW, the Tanzania Food and Nutrition Centre, and all USG supported PMTCT

partners. URC will also work with other related units such as Counseling and Testing, OVC, HBC, RCHS,

NMCP, etc to ensure that the quality framework and related tools and methodology are in keeping with the

programs and necessary adoptions are made.

CHECK BOXES: This activity addresses the in-service training needs of PMTCT counselors and other

health workers to counsel on infant feeding and gain competencies in QI to improve quality of PMTCT

services. Local Capacity: RHMTs and CHMTs will be strengthened in their ability to supervise and monitor

QI activities.

URC has developed pre/post test assessments for IF training participants, training evaluation, job aids

evaluation and supportive supervision tools. We have developed M&E tools for IF counseling performance:

facility checklist, counselor observation checklist, and client exit interviews.

We use QI improvement tools that capture patient data for use and analysis at site level. Run charts will be

produced monthly and quarterly to highlight programmatic strengths, weaknesses and QI changes.

SUSTAINAIBLITY: By involving the RHMTs and CHMTs, quality improvement activities will be included in

the Council Comprehensive Health Plans (continued education, peer coaching, continued sharing of

outcomes, continuous monitoring quality improvement, data collection and management). We will

collaborate with partners at National, Regional and District levels in line with the organization of national

health care system. Using QI methodologies we will empower the facility QI teams to use PDSA cycles to

Activity Narrative: identify, test and adopt quality care improvements in PMTCT services. Based on successful best practices,

URC/QAP will utilize peer coaches and mentors across QI Teams to ensure sustainability.

TITLE: URC Quality Improvement for HIV/AIDS Care and Treatment in Tanzania

NEED AND COMPARATIVE ADVANTAGE:

The GOT and the USG have identified a major gap in the quality and coverage of HIV/AIDS care including

provision of ART. The need to harmonize quality improvement (QI) and quality assurance (QA) approaches

and monitoring of quality of HIV/AIDS services nationwide has been recognized.

Recognizing URC's experience in QI and in providing TA to HIV QI in Tanzania, Rwanda, Uganda and

Russia, the USG/T and the GOT have assigned responsibility to URC to take the lead in harmonizing and

applying a uniform approach to the institutionalization of QI. URC will assist the GOT and its partners in

implementing QI (including the improvement collaborative approach), developing systems for monitoring

quality of services, and linking services to lower levels of the health system and to the communities.

ACCOMPLISHMENTS:

In the last two years, URC/QAP pediatric AIDS collaborative trained 362 health workers in case

management, QI and collaborative methods. Specifically, URC/QAP:

1) Established, trained and mentored QI teams in 17 referral facilities

2) Provided technical guidelines, job aids, and self assessment tools

3) Assisted reorganization of patient flow and provision of emergency pediatric care.

4) Improved monitoring of emergency drugs, supplies and equipment

Key results:

1) In FY 2006, 3,086 hospitalized children were screened for HIV, 2094 were tested, 50%were found

positive, and 90% of these were referred to CTC

2) In FY 2007, 1000 children have been screened

3) Compliance to HIV care guideline improved from 30% at baseline to 90% in 2007

ACTIVITIES:

I. Build QI capacity of the Ministry of Health and Social Welfare (MOHSW) system and partners in HIV/AIDS

care and ART using the collaborative approach.

URC, MOHSW and partners will build an ART quality improvement system that is linked to PMTCT using

the QI collaborative approach. They will build on current experience and be guided by the revised ART

guidelines, and QI framework developed by the inspectorate unit of MOHSW. The quality of the ART

framework and simplified tools to rapidly assess quality and coverage at the national level will be adopted

by partners.

The collaborative will train trainers who will in turn train QI teams in self-assessment, use of data, and plan-

do-study-act (PDSA) cycles to test improvement changes in ART, PMTC,T and infant feeding. Based on the

approaches designed in FY 2007-2008 URC will work with MOHSW, the National AIDS Control Program

(NACP) and partners to expand capacities for continuous QI in ART services, monitor progress, and

document and share experiences in learning sessions. The mechanism to guide the QI process for HIV care

and ART will be built within the national ART sub-committee. URC will help train and support regional and

district QI teams in coaching and mentoring to roll out continuous quality improvement (CQI) at the service-

level.

II. Facilitate adoption of Quality Improvement (QI) methods and service tools by the MOHSW and partners

to improve quality of ART services.

Various mechanisms will be used to review best practices, identify, and address key systems barriers to

quality ART services for both adult and child PLWHA. URC will help build partner consensus for the

collaborative model through advocacy to spread throughout the health system.

III. Work with MOHSW and USG ART partners to roll-out QI monitoring in sites integrating ART and RH

services including PMTCT and infant feeding practices to prevent HIV transmission.

Through the cascade of training described above institutionalize the training of QI among ART and PMTCT

partners and initiate the roll-out training in QI of ART at the regional, district, and lower level facilities in the

regions supported by The Elizabeth Glaser Pediatric AIDS Foundation (EGPAF), Columbia, Harvard, Family

Health International (FHI) and AIDS relief and other partners. Best practices emerging from the ongoing roll

out of the ART program will be documented and shared.

IV. Spread the experiences from the networking and the continuum of care pilot undertaken in COP 2007

(FY 2007-2008) to regions designated by the MOHSW and the Mission.

By COP 2008 implementation, the pilot will have been completed and results documented giving

organization, quality of services interventions, management procedures, and communication channels for

continuum of care. URC and partners will expand the pilot's best practices and models to other parts of the

country by spreading implementation of the model, and building capacity of CBOs and primary-level

providers to implement best practices developed by the pilot. In addition, URC and partners will train staff in

QI monitoring, documentation, reporting, using simple tools, and building ways to sustain the model of care

and linkages between facilities and communities such as using network support agents and use of simple

tools to monitor in the spread districts.

V. Facilitate development and implementation of a framework for monitoring quality of ART services at the

service site within and outside the collaborative.

With MOHSW and partners develop key quality improvement objectives and processes, facilitate use of well

defined indicators and tools to monitor processes and compliance with standards of care, methods of

recording the data, analysis, sharing, and use. URC will facilitate training of trainers (TOTs) who will in turn

train QI teams in self-assessment, use of the data, and use of PDSA cycles to test improvement changes.

Vi. Based on COP 2007 (FY 2007-2008) experiences, URC will strengthen linkages between PMTCT and

overall HIV/AIDS care and treatment services to increase numbers of exposed infants who benefit from

services (e.g. nevirapine, testing, and cotrimoxazole prophylaxis).

Activities will include identifying members of the PMTCT service to be included in the HIV QI team at each

facility; developing procedures for networking and referral between PMTCT, well child clinics and ART

service areas at facility levels and with CB's at the community level; identification of exposed infants born at

home for referral within 72 hours for nevirapine and essential newborn care and establishing indicators for

PMTCT quality performance as part of the overall HIV/AIDS prevention, care and treatment program.

Activity Narrative: LINKAGES:

1) URC/QAP will hold a consultative meeting with key partners to explain the task assigned to URC by the

mission.

2) URC/QAP shall work closely with the MoHSW, NACP and USG partners to identify and prioritize

objectives, indicators of performance and monitoring frameworks.

3) URC/QAP shall work closely with the MoHSW, NACP and USG partners to build a national level capacity

to implement continuous quality improvement in HIV/AIDS care and ART (including using collaborative

approach).

4) URC/QAP will assist in the dissemination of networking best practices learned in the pilot area

5) URC will work with partners to strengthen inter-facility and intra-facility network.

6) URC process will strengthen peer mentoring and peer-coaching.

M&E

URC will work with the national core team, the MOHSW and all USG partner in setting up, adopting and

rolling out the Quality Improvement (QI) system. The system will have a QI framework, tools with

appropriate indicators and will be linked to the ongoing quality improvement initiative in reproductive health,

ART monitoring and evaluation tools and commodity logistics management (LMIS) tools. It will support

regional and district teams to collect and report quality related ART information on the agreed national

protocol, and provide feedback on tool performance. URC will work with these key institutions to document

the process and strengthen the implementation of ART quality framework by providing regular supervision.

SUSTAINAIBLITY:

1) By involving the RHMTs & CHMTs, quality improvement activities will be included in the council

comprehensive health plans (continuing education, peer coaching, continuous sharing of results, continuous

monitoring of quality improvement activities, data collection, and management)

2) Collaborating with partners at the national, regional, and district levels will improve networking.

3) Using collaborative methodologies empowers the hospital QI teams to use PDSA cycles to improve care.

4) Promoting the use of peer coaches and mentors among the QI Teams.

The implementation of the program will involve all of the partners with guidance of the MoHSW/Quality

Improvement Unit using the Tanzania QI framework. The core QI team, which involves members from all

the parties, will institutionalize the best practices.