The Health Care Improvement (HCI) Project provides technical support to the Ministry of Health (MOH)

Quality of Care (QoC) Initiative in HIV/AIDS using a quality improvement (QI) approach to ensure the quality

of service delivery and ART provision. In 2 years, HCI has established a structure for sustainable QI in 120

health facilities. The project started in 2006 with 57 sites in all 12 regions and spread to an additional 32

sites in 2007 and 31 sites in 2008. A Core Team at the national level and 60 Regional Coordinators trained

and coached facility-level teams in QI methodologies. Site QI teams are made up of representatives from

HIV/ART clinics, related services such as PMTCT/ANC, TB, family planning and laboratory services and

community and PLHIV representatives. Teams are trained to assess the quality of their services through

monthly collection of data and to take steps for developing, testing and implementing improvements in their

system of care. HCI supports sites through training in QI, monthly on-site coaching and ‘Learning Sessions'

in which facility-level QI teams have the opportunity to share best practices from their sites and receive

focused training, such as changes in MOH policy. HCI contributes to Adult and Pediatrics Care and

Treatment by working with sites to improve the quality of services provided and to develop best practices

which are shared with other sites.

FY 2008 Results

As of July 2008, HCI trained 280 providers to deliver ART services; 328 providers on HIV-related

institutional capacity building; 280 providers on treatment for TB to HIV infected individuals; and held 5

Learning Sessions (LS) in which providers were trained on QI approaches and methods, the application of

chronic care model in HIV, MOH policies, clinical updates on aspects of adult and pediatric ART and HIV

care, logistics management, and use of MOH patient monitoring, cohort analysis and reporting tools. HCI

supported 540 site visits to provide follow-up coaching in these areas. In June 2008, HCI graduated the 57

sites which began in 2006. These sites have shown the ability to collect and utilize data on a regular basis,

implement QI activities with minimal supervision, sustain improvements and assist other facilities in QI.

Following up on an assessment conducted in June 2007, HCI held a laboratory training session in

collaboration with Central Public Health Laboratories (CPHL) for a lab representative from 85 sites in

January 2008 to introduce QI principles and encourage lab participation on the QI team.

QI site teams have introduced changes to improve record keeping, filing and retrieval systems,

documentation and use of MOH patient monitoring tools, and timely reporting to MOH and procurement

requests. HCI sites have a higher average of timely correct reporting to the MOH than the national average.

They have implemented changes such as providing continuous medical education sessions for facility staff;

introducing triage systems to streamline visits and reduce waiting time; task shifting of care between staff or

to lower level facilities; including clients in peer counseling; improving referral systems and integration with

TB, FP and PMTCT services; dispensing commodities such as ARVs and family planning (FP) within ART

clinic instead of the pharmacy; organizing the provision of TB and HIV treatment in the same clinic or on the

same day; and linking with community based health workers to follow up clients on TB/ART co-treatment.

QI teams created links with pediatric services to improve referrals of dry blood spot samples for DNA-PCR

for early infant diagnosis; coordinate with outreach workers to improve case finding and follow-up of

exposed infants; schedule the same appointment dates for children and parents/caretakers; provide Septrin

prophylaxis at PMTCT clinic; assess for ART eligibility and increase initiation on ART; and introduce specific

clinic days for children. HCI sites have achieved the following results: 45% of sites have reached an ARV

adherence level of 95% or more in at least 95% of their patients; 69% of sites are assessing 95% or more of

their patients for ART eligibility at every clinic visit; 71% of sites are prescribing Septrin prophylaxis to 95%

or more of their patients at every clinic visit; 66% of sites are screening 95% or more of HIV patients for

active TB at every clinic visit; 96% of sites are referring 95% or more of HIV patients identified with active

TB for TB treatment; 71% of sites are assessing 95% or more of infants and children for ART eligibility at

every clinic visit; and 47% of sites are conducting CD4 tests for their clients every six months for 50% or

more of their clients.

FY 2009 Activities

HCI will continue activities to improve HIV care and ART in 114 of its original 120 sites. As HIVQUAL and

HCI overlapped in some sites, the two projects have agreed to divide follow-up; 6 will now be HIVQUAL

sites. HCI will follow up 51 of the 57 graduated sites through quarterly coaching visits. The remaining 63

sites will be supported through monthly coaching visits. HCI will conduct 3 Learning Sessions for these

groups and plans to graduate the all sites by the end of FY 2009. Learning sessions are an opportunity to

provide targeted training on areas of ART service delivery which are found to be weak during site visits.

Approximately 575 site visits are planned for the 114 continuing HCI sites, which consist of 1 national

referral hospital, 6 regional referral hospitals, 53 general/district hospitals, 48 health center IVs, 5 health

center IIIs, and 1 health center II. Sites are located in 66 districts distributed throughout 12 regions of

Uganda.

The primary focus of technical assistance will shift from facilities to District Health Teams (DHT). HCI aims

to further spread ART care in both breadth and depth through expanding to new sites and building capacity

at the district level. The goal is to sustain and institutionalize a culture of continuous improvement in the

DHT. HCI will build capacity of DHTs to coach teams to plan, manage, monitor and spread QI activities in

HIV/AIDS in their districts. In addition to the DHTs, HCI will build capacity of other institutions to support the

DHTs including health sub-district managers, key staff from district hospitals, and representatives from NGO

clinics and CBOs. HCI will have up to four phases of implementation over 3.5 years with each phase

including between 15 and 30 districts. Each phase is expected to last 1.5 - 2 years with 6 to 9 months

between the start of each phase. The first two phases will begin in FY 2009. Each district coaching team will

work with 2 to 3 facilities consisting of current HCI and new sites. HCI will support the DHTs through

coaching visits for the first three months followed by quarterly visits. HCI, Core Team and Regional Team

members will work with DHTs to conduct QI trainings at new sites. The DHTs will in turn support sites to

implement improvement changes and monitor their progress. DHTs will have the opportunity to share their

experiences in implementing QI activities and on the progress of their sites in improving the quality of HIV

services in learning sessions every 4 to 6 months. These activities will develop the management and

leadership capacity at the district level and within sites as they learn to monitor the quality of their services,

take action to improve them and expand to other health areas. HCI will continue to spread the best

practices mentioned in FY 2008 Results in adult and pediatric care and treatment within its current and new

sites. We will also build DHT capacity to manage the health care teams to improve their engagement and

Activity Narrative: productivity. Specific activities planned include 3 Learning Sessions (LS) for Phase I districts, 1 4-day

training on HIV care and ART for District Managers for each Phase, 1 Stakeholders' Meeting for Phase II

districts, 1 LS for Phase II districts, on-site training in QI for 60 new sites, and around 120 district coaching

visits during which HCI, Core Team, and Regional Coordinators will conduct close to 350 facility visits with

DHTs. QI training at LSs and on-site at facilities provides the DHTs and site team members with the tools

they need to analyze gaps in service and take steps to test possible solutions to improve ART service

provision and develop more effective and efficient work processes within existing resources.

HCI will introduce a framework on the quality of ART services to address quality gaps in access, retention

and wellness to improve service outcomes and universal access. HCI will build capacity of DHTs and site

teams to monitor the proportion of PLHIV eligible for ART who actually receive ART, proportion of PLHIV

who are started ART and are still on therapy at any given time and the proportion of PLHIV who are

currently on therapy and have good clinical outcomes. Districts and facilities will be encouraged to develop

strategies for chronic care management to provide their clients with self management support and links to

community support. HCI will work with sites in monitoring ART drug resistance through early warning

indicators indentified with MOH, such as measures of declining clinical outcomes. HCI supports MOH M&E

activities by collecting and using data to inform facility QI activities, review progress at coaching visits and

aggregate indicators to determine quality of the national ART program. We will continue to assist the MOH

by training sites in the use of the pre-ART and ART cards, cohort analysis, logistics requisition, and

reporting data. HCI plans to conduct small operations research studies to assist the MOH in the

implementation of ART programs through investigating factors affecting loss to follow-up and referrals of

PMTCT mothers and infants following delivery and comparing of adherence rates in facility-based and

home-based care programs.

For the DHT capacity building activities there will be 15 districts in Phase I and 20 districts in Phase II

distributed in 12 regions. All Phase I and II districts will be from the current 66 HCI districts. HCI will add at

least 60 new sites which will be a mix of Health Center IVs and IIIs. HCI's target population is all HIV

positive adults and children and exposed children who are in need of and receiving ART services. HCI

reaches this population through working with QI teams consisting of health care providers, outreach

workers, and expert clients to improve the quality of services at the clinic including improved screening,

referral systems with other services such as VCT/RCT, PMTCT and TB, and connections with outreach

workers, such as Network Support Agents, at the facility and district level.

In partnership with Business PART Project, HCI included four private for profit (PFP) facilities in the 32 sites

which started in 2007. HCI has conducted a quality assessment in 30 PFP sites and will use the

assessment findings and recommendations, such as improving record keeping, follow-up of patients, and

referral systems, to develop a strategy for QI in ART for PFP sites. DHTs will be encouraged to support a

PFP site within its catchment area. HCI will partner with HIPS project to support additional PFP sites. HCI

will also draw on existing partnerships with IDI, Mildmay, SCMS, and NMS to find opportunities that will

support PFP sites in technical area and logistics systems training.

HCI will continue our work in improving laboratory processes such as referrals for samples, adherence to

MOH laboratory standard operating procedures (SOP) and reducing supply stock outs through participation

of lab representatives on QI teams and experience sharing at learning sessions. Lab Regional Coordinators

in all 12 regions provide feedback to lab personnel during regular coaching visits. HCI is working together

with the MOH and Core Team representative from CPHL on activities including development and

distribution of policy documents, feedback on lab logistics problems, and the status of major equipment at

facilities. Each district coaching team will include a representative of lab management and will be

encouraged to improve adherence to lab SOP and referrals.

Partner Collaboration

NuLife will be utilizing the existing HCI structure to roll-out activities related to nutrition and HIV, specifically

nutritional assessment/counseling and prescription of RUTF as needed, infant feeding in the context of HIV,

and integrated management of acute malnutrition in selected HCI facilities. A nutritionist will be added to the

Core Team and nutrition focal persons will be added to Regional Teams, District QI teams and site QI

teams. Nulife will introduce food and nutrition interventions through HCI Learning Sessions with follow-up

during monthly and quarterly coaching visits.

HCI will continue to maximize its program's impact through close partnerships with other USG-funded

projects, such as NUMAT and other projects working at the district level, to coordinate activities and

leverage funding. HIVQUAL and HCI are coordinating activities to maximize the impact of QI activities by

covering different facilities; harmonizing indicators and data collection processes where possible; and

ensuring that DHTs can coach for all sites. HCI will coordinate with the MOH, IDI and Mildmay to prepare

and conduct trainings on HIV care and ART for district managers. HCI coaches will refer public, NGO and

PFP facilities to IDI and Mildmay for HIV/AIDS and lab trainings. HCI will provide monthly feedback from

sites on the availability of logistics (ARVs, HIV testing kits, patient monitoring tools) to NMS and SCMS. HCI

will coordinate with FHI and EngenderHealth to disseminate FP and HIV integration best practices during

LSs and coaching visits. HCI will strengthen partnership with institutions involved in TB/HIV care integration

such as WHO, MOH Makerere-Mbarara Joints AIDS Program, National Tuberculosis and Leprosy

Programme, and TB CAP. HCI will partner with PIDC and JCRC for CD4 testing and DNA-PCR tests and

with EGPAF to review and develop training materials on pediatric treatment and care. Most of the partners

listed are members of the Core Team and will continue to participate in monthly review meetings and as

needed participate in coaching visits and LSs to provide training, policy updates and solutions to problems

at regional, district and facilities levels.

New/Continuing Activity: Continuing Activity

Continuing Activity: 15773

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

15773 15773.08 U.S. Agency for University 7257 7257.08 HCI (Health $2,700,000

International Research Care

Development Corporation, LLC Improvement

Project)

Emphasis Areas

Health-related Wraparound Programs

* Family Planning

* TB

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $1,485,000

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Estimated amount of funding that is planned for Food and Nutrition: Policy, Tools $15,000

and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.09:

The Health Care Improvement (HCI) Project provides technical support to the Ministry of Health (MOH)

Quality of Care (QoC) Initiative in HIV/AIDS using a quality improvement (QI) approach to ensure the quality

of service delivery and ART provision. In 2 years, HCI has established a structure for sustainable QI in 120

health facilities. The project started in 2006 with 57 sites in all 12 regions and spread to an additional 32

sites in 2007 and 31 sites in 2008. A Core Team at the national level and 60 Regional Coordinators trained

and coached facility-level teams in QI methodologies. Site QI teams are made up of representatives from

HIV/ART clinics, related services such as PMTCT/ANC, TB, family planning and laboratory services and

community and PLHIV representatives. Teams are trained to assess the quality of their services through

monthly collection of data and to take steps for developing, testing and implementing improvements in their

system of care. HCI supports sites through training in QI, monthly on-site coaching and ‘Learning Sessions'

in which facility-level QI teams have the opportunity to share best practices from their sites and receive

focused training, such as changes in MOH policy. HCI contributes to Adult and Pediatric Care and

Treatment by working with sites to improve the quality of services provided and to develop best practices

which are shared with other sites.

FY 2008 Results

As of July 2008, HCI trained 280 providers to deliver ART services; 328 providers on HIV-related

institutional capacity building; 280 providers on treatment for TB to HIV infected individuals; and held 5

Learning Sessions (LS) in which providers were trained on QI approaches and methods, the application of

chronic care model in HIV, MOH policies, clinical updates on aspects of adult and pediatric ART and HIV

care, logistics management, and use of MOH patient monitoring, cohort analysis and reporting tools. HCI

supported 540 site visits to provide follow-up coaching in these areas. In June 2008, HCI graduated the 57

sites which began in 2006. These sites have shown the ability to collect and utilize data on a regular basis,

implement QI activities with minimal supervision, sustain improvements and assist other facilities in QI.

Following up on an assessment conducted in June 2007, HCI held a laboratory training session in

collaboration with Central Public Health Laboratories (CPHL) for a lab representative from 85 sites in

January 2008 to introduce QI principles and encourage lab participation on the QI team.

QI site teams have introduced changes to improve record keeping, filing and retrieval systems,

documentation and use of MOH patient monitoring tools, and timely reporting to MOH and procurement

requests. HCI sites have a higher average of timely correct reporting to the MOH than the national average.

They have implemented changes such as providing continuous medical education sessions for facility staff;

introducing triage systems to streamline visits and reduce waiting time; task shifting of care between staff or

to lower level facilities; including clients in peer counseling; improving referral systems and integration with

TB, FP and PMTCT services; dispensing commodities such as ARVs and family planning (FP) within ART

clinic instead of the pharmacy; organizing the provision of TB and HIV treatment in the same clinic or on the

same day; and linking with community based health workers to follow up clients on TB/ART co-treatment.

QI teams created links with pediatric services to improve referrals of dry blood spot samples for DNA-PCR

for early infant diagnosis; coordinate with outreach workers to improve case finding and follow-up of

exposed infants; schedule the same appointment dates for children and parents/caretakers; provide Septrin

prophylaxis at PMTCT clinic; assess for ART eligibility and increase initiation on ART; and introduce specific

clinic days for children. HCI sites have achieved the following results: 45% of sites have reached an ARV

adherence level of 95% or more in at least 95% of their patients; 69% of sites are assessing 95% or more of

their patients for ART eligibility at every clinic visit; 71% of sites are prescribing Septrin prophylaxis to 95%

or more of their patients at every clinic visit; 66% of sites are screening 95% or more of HIV patients for

active TB at every clinic visit; 96% of sites are referring 95% or more of HIV patients identified with active

TB for TB treatment; 71% of sites are assessing 95% or more of infants and children for ART eligibility at

every clinic visit; and 47% of sites are conducting CD4 tests for their clients every six months for 50% or

more of their clients.

FY 2009 Activities

HCI will continue activities to improve HIV care and ART in 114 of its original 120 sites. As HIVQUAL and

HCI overlapped in some sites, the two projects have agreed to divide follow-up; 6 will now be HIVQUAL

sites. HCI will follow up 51 of the 57 graduated sites through quarterly coaching visits. The remaining 63

sites will be supported through monthly coaching visits. HCI will conduct 3 Learning Sessions for these

groups and plans to graduate the all sites by the end of FY 2009. Learning sessions are an opportunity to

provide targeted training on areas of ART service delivery which are found to be weak during site visits.

Approximately 575 site visits are planned for the 114 continuing HCI sites, which consist of 1 national

referral hospital, 6 regional referral hospitals, 53 general/district hospitals, 48 health center IVs, 5 health

center IIIs, and 1 health center II. Sites are located in 66 districts distributed throughout 12 regions of

Uganda.

The primary focus of technical assistance will shift from facilities to District Health Teams (DHT). HCI aims

to further spread ART care in both breadth and depth through expanding to new sites and building capacity

at the district level. The goal is to sustain and institutionalize a culture of continuous improvement in the

DHT. HCI will build capacity of DHTs to coach teams to plan, manage, monitor and spread QI activities in

HIV/AIDS in their districts. In addition to the DHTs, HCI will build capacity of other institutions to support the

DHTs including health sub-district managers, key staff from district hospitals, and representatives from NGO

clinics and CBOs. HCI will have up to four phases of implementation over 3.5 years with each phase

including between 15 and 30 districts. Each phase is expected to last 1.5 - 2 years with 6 to 9 months

between the start of each phase. The first two phases will begin in FY 2009. Each district coaching team will

work with 2 to 3 facilities consisting of current HCI and new sites. HCI will support the DHTs through

coaching visits for the first three months followed by quarterly visits. HCI, Core Team and Regional Team

members will work with DHTs to conduct QI trainings at new sites. The DHTs will in turn support sites to

implement improvement changes and monitor their progress. DHTs will have the opportunity to share their

experiences in implementing QI activities and on the progress of their sites in improving the quality of HIV

services in learning sessions every 4 to 6 months. These activities will develop the management and

leadership capacity at the district level and within sites as they learn to monitor the quality of their services,

take action to improve them and expand to other health areas. HCI will continue to spread the best

practices mentioned in FY 2008 Results in adult and pediatric care and treatment within its current and new

sites. We will also build DHT capacity to manage the health care teams to improve their engagement and

Activity Narrative: productivity. Specific activities planned include 3 Learning Sessions (LS) for Phase I districts, 1 4-day

training on HIV care and ART for District Managers for each Phase, 1 Stakeholders' Meeting for Phase II

districts, 1 LS for Phase II districts, on-site training in QI for 60 new sites, and around 120 district coaching

visits during which HCI, Core Team, and Regional Coordinators will conduct close to 350 facility visits with

DHTs. QI training at LSs and on-site at facilities provides the DHTs and site team members with the tools

they need to analyze gaps in service and take steps to test possible solutions to improve ART service

provision and develop more effective and efficient work processes within existing resources.

HCI will introduce a framework on the quality of ART services to address quality gaps in access, retention

and wellness to improve service outcomes and universal access. HCI will build capacity of DHTs and site

teams to monitor the proportion of PLHIV eligible for ART who actually receive ART, proportion of PLHIV

who are started ART and are still on therapy at any given time and the proportion of PLHIV who are

currently on therapy and have good clinical outcomes. Districts and facilities will be encouraged to develop

strategies for chronic care management to provide their clients with self management support and links to

community support. HCI will work with sites in monitoring ART drug resistance through early warning

indicators indentified with MOH, such as measures of declining clinical outcomes. HCI supports MOH M&E

activities by collecting and using data to inform facility QI activities, review progress at coaching visits and

aggregate indicators to determine quality of the national ART program. We will continue to assist the MOH

by training sites in the use of the pre-ART and ART cards, cohort analysis, logistics requisition, and

reporting data. HCI plans to conduct small operations research studies to assist the MOH in the

implementation of ART programs through investigating factors affecting loss to follow-up and referrals of

PMTCT mothers and infants following delivery and comparing of adherence rates in facility-based and

home-based care programs.

For the DHT capacity building activities there will be 15 districts in Phase I and 20 districts in Phase II

distributed in 12 regions. All Phase I and II districts will be from the current 66 HCI districts. HCI will add at

least 60 new sites which will be a mix of Health Center IVs and IIIs. HCI's target population is all HIV

positive adults and children and exposed children who are in need of and receiving ART services. HCI

reaches this population through working with QI teams consisting of health care providers, outreach

workers, and expert clients to improve the quality of services at the clinic including improved screening,

referral systems with other services such as VCT/RCT, PMTCT and TB, and connections with outreach

workers, such as Network Support Agents, at the facility and district level.

In partnership with Business PART Project, HCI included four private for profit (PFP) facilities in the 32 sites

which started in 2007. HCI has conducted a quality assessment in 30 PFP sites and will use the

assessment findings and recommendations, such as improving record keeping, follow-up of patients, and

referral systems, to develop a strategy for QI in ART for PFP sites. DHTs will be encouraged to support a

PFP site within its catchment area. HCI will partner with HIPS project to support additional PFP sites. HCI

will also draw on existing partnerships with IDI, Mildmay, SCMS, and NMS to find opportunities that will

support PFP sites in technical area and logistics systems training.

HCI will continue our work in improving laboratory processes such as referrals for samples, adherence to

MOH laboratory standard operating procedures (SOP) and reducing supply stock outs through participation

of lab representatives on QI teams and experience sharing at learning sessions. Lab Regional Coordinators

in all 12 regions provide feedback to lab personnel during regular coaching visits. HCI is working together

with the MOH and Core Team representative from CPHL on activities including development and

distribution of policy documents, feedback on lab logistics problems, and the status of major equipment at

facilities. Each district coaching team will include a representative of lab management and will be

encouraged to improve adherence to lab SOP and referrals.

Partner Collaboration

NuLife will be utilizing the existing HCI structure to roll-out activities related to nutrition and HIV, specifically

nutritional assessment/counseling and prescription of RUTF as needed, infant feeding in the context of HIV,

and integrated management of acute malnutrition in selected HCI facilities. A nutritionist will be added to the

Core Team and nutrition focal persons will be added to Regional Teams, District QI teams and site QI

teams. Nulife will introduce food and nutrition interventions through HCI Learning Sessions with follow-up

during monthly and quarterly coaching visits.

HCI will continue to maximize its program's impact through close partnerships with other USG-funded

projects, such as NUMAT and other projects working at the district level, to coordinate activities and

leverage funding. HIVQUAL and HCI are coordinating activities to maximize the impact of QI activities by

covering different facilities; harmonizing indicators and data collection processes where possible; and

ensuring that DHTs can coach for all sites. HCI will coordinate with the MOH, IDI and Mildmay to prepare

and conduct trainings on HIV care and ART for district managers. HCI coaches will refer public, NGO and

PFP facilities to IDI and Mildmay for HIV/AIDS and lab trainings. HCI will provide monthly feedback from

sites on the availability of logistics (ARVs, HIV testing kits, patient monitoring tools) to NMS and SCMS. HCI

will coordinate with FHI and EngenderHealth to disseminate FP and HIV integration best practices during

LSs and coaching visits. HCI will strengthen partnership with institutions involved in TB/HIV care integration

such as WHO, MOH Makerere-Mbarara Joints AIDS Program, National Tuberculosis and Leprosy

Programme, and TB CAP. HCI will partner with PIDC and JCRC for CD4 testing and DNA-PCR tests and

with EGPAF to review and develop training materials on pediatric treatment and care. Most of the partners

listed are members of the Core Team and will continue to participate in monthly review meetings and as

needed participate in coaching visits and LSs to provide training, policy updates and solutions to problems

at regional, district and facilities levels.

New/Continuing Activity: Continuing Activity

Continuing Activity: 15773

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

15773 15773.08 U.S. Agency for University 7257 7257.08 HCI (Health $2,700,000

International Research Care

Development Corporation, LLC Improvement

Project)

Emphasis Areas

Health-related Wraparound Programs

* Family Planning

* TB

Human Capacity Development

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Estimated amount of funding that is planned for Food and Nutrition: Policy, Tools $15,000

and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.11: