USAID/Uganda through field-support is funding The Healthcare Improvement Project (HCI) implemented by University Research Co. (URC) to support the Ministry of Health's (MoH) Quality of Care Initiative (QoC) to improve the quality of comprehensive HIV care for adults and children, building upon work initiated by HCI's predecessor the Quality Assurance Project (QAP). In FY2009, HCI supported 136 facilities in 71 health districts in all regions and 39 District Health Teams (DHT) to coach sites in QI. The overall objective of the program is to improve the quality of HIV services available in Uganda and to build a quality improvement structure that is integrated into all levels of the health system.

Some of the major accomplishments of HCI include supporting sites to make their care delivery system more efficient and effective so as to improve patient outcomes. In HCI supported sites over 95% of patients in our sites are assessed for TB at their last visit; over 95% of HIV infected patients were prescribed cotrimoxazole at their last visit; the % of exposed children who are tested for HIV has increased from 60% to over 80%.

HCI supports health facilities through training staff to form a QI team and guide them through the improvement process: identifying problems and setting improvement goals, forming the correct team, analyzing their system, designing changes to improve the system and collecting and analyzing data to measure the effects of these changes. HCI uses a two-pronged approach to supporting health facilities: a two day classroom training on the basics of QI to new teams and bimonthly on-site visits. The on-site approach not only reduces absenteeism but also adapts support to the context of each facility. On-site coaching visits are conducted by HCI staff, central, regional and district MoH staff. In addition to building QI capacity, these visits strengthen communication within the health system and add accountability. Examples of the benefits of communication are that HCI keeps a registry of untrained staff in facilities and works with the MoH to link these people with relevant trainings. This builds upon other partner's training activities and helps ensure that training is targeted to the right people according to need.

In addition to supporting sites, HCI works extensively to support the National Quality of Care Initiative of the MoH. This government initiative is designed to ensure a consistent approach to improving quality of care in Uganda. HCI has trained coaches at the national, regional and district level. This improves government ownership of the program, increases the chances of sustainability and dramatically decreases the costs associated with HCI operations (it is substantially cheaper for a District Health Team member to coach a site than for a HCI staff to travel for a coaching visit). HCI will continue with this approach and also focus on supporting the Quality Assurance Department in the Ministry. With the current restructuring, this department is taking an increasingly important role in support supervision and quality improvement. It is severely under-resourced and thus would warrant continued support.

Health Systems Strengthening: HCI interventions are expected to improve the functioning of the health system at all levels including: health facility management; MoH central support supervision, improving referral mechanisms for patients and laboratory tests and improving communication between various facilities and between different levels of the system. HCI's current focus is on improving HIV care but the systems put in place also benefit other areas in health service delivery.

In FY2010, increased focus will be placed on key areas of paediatric care, reproductive health and TB. HCI will continue to emphasize improving programme cost-efficiency through a number of strategies such as increasing the proportion of coaching visits being carried out by regional and district level staff rather than HCI or Central MoH staff. For sustainability and possibly increasing coverage in a low-cost manner, HCI will develop a QI toolkit that sites can use to orient new staff so as to ameliorate the effect of high staff turnover. QI team members who move to a new site without a QI team can also use the toolkit to set up a new team and start improvements in their new facility.

In regard to monitoring and evaluation of the program, HCI will report to PEPFAR on number of health workers trained in strategic information, adult ART and paediatric ART. HCI will also continue to monitor data that supported health facilities individually collect to measure their own performance and, where appropriate, HCI will aggregate this and report in quarterly reports.

HCI supports teams in 136 facilities providing ART to over 70,000 people to improve the quality of the care they provide. Provision or ART, cotrimoxazole and TB screening are key elements of good quality care and are emphasized in the HCI approach. Over 95% of patients are assessed for eligbility for ART (between 9-25 sites), provided with cotrimoxazole (between 5-37 sites) and screened for TB (between 21 - 84 sites) at sites working on improving these aspects of care. HCI support also emphasizes the importance of adherence support. HCI supports facilities to explore innovative adherence mechanisms that are best suited and appropriate to context. This includes adherence counselling, involving caregivers and family members, community outreach programs, adherence groups for patients to learn from each other.

In addition to measuring these process or proxy indicators, HCI will encourage sites to measure patient outcomes. Some sites use MoH cohort forms and some use the MoH outcome indicator which is defined as the % of patients with no opportunistic infection, no weight loss and a functional status that enables them to be ambulatory or working. HCI plans to train 1120 individuals in adult ART and 630 individuals in paediatric care and treatment as the budget targets for FY2010. Paediatric HIV will increasingly become a priority area of focus. The targets are calculated based on support to 7 people in each site: 160 sites in 2010, 90 sites in 2011 and 80 using COP 2010 funds. The decrease in targets reflects HCI handing over activities to the STAR district-based projects.

1. Activities related to objective 1: to improve the quality of HIV services available in Uganda

In COP 10, HCI plans to address five key quality gaps in HIV care in Uganda. Each site will work in collaboration with other facilities on one of these areas and HCI will synthesize the lessons learned by the sites to develop a series of best practices in each area which will then spread to other sites and partners.

The Coverage Collaborative: The aim of sites working in the coverage collaborative will be to increase the number of people who start antiretroviral therapy. Because it is unlikely additional health staff will become available in the near future, it is imperative that HCI uses existing human resources as efficiently as possible. Sites will develop efficient triage systems and innovative approaches to using expert clients and to applying patient self management approaches to increase clinic efficiency. Sites will also build stronger links between different parts of the health facility and the HIV care clinic. In particular, weak links to PMTCT, HCT and TB programs lead to attrition of patients in need of care and ultimately lead to an inefficient system. Strengthening these links is expected to bring people in to care earlier which is associated with improved patient outcomes and is less resource intense than focusing on the sickest patients. Sites that make rapid progress in this collaborative will then focus on improving links between community-based testing programs and the HIV care clinic.

The Retention Collaborative: Another problem that leads to poor patient outcomes and wasted resources is attrition of patients or loss to follow-up. Sites in the retention collaborative will work with the patients to identify reasons for patients not remaining in care and to develop strategies that patients think will help improve retention and that sites have control over. Examples of these types of problems may include poor privacy in the clinic, long waiting times, rude staff or inconvenient visit schedules. They may also identify issues such as long distance from clinics and community stigma which may require support from other levels of the health system and from partners.

The Tuberculosis Collaborative: Tuberculosis (TB) remains the leading killer of people with HIV. HCI will, therefore, plan a new collaborative focused on improving TB services. This will apply to both HIV infected and uninfected persons. The goals will be for sites and districts to improve case detection and treatment completion rates. Special emphasis will be placed on the integration of HIV and TB diagnosis and treatment. QI teams from the District and the Facilities will work together to ensure all components of the TB system (and its links with the HIV system) are coordinated. This will include improving active case finding in high risk groups, improving specimen referral to laboratories and improving laboratory diagnosis, improving treatment adherence support and provider adherence with standards for follow up of patients with TB. Sites will also improve infection control procedures in their clinics. HCI will work closely with TB CAP and the Regional Centre for Quality of Health Care to ensure that sites and districts in this collaborative receive training in TB.

The Data Management Collaborative: The provision of HIV care is very data intense. This is a major shift for health facilities that are used to dealing with acute diseases with no need for longitudinal patient information. Consequently, many sites are struggling with data management. Sites in this collaborative will work to improve data collection and storage (retrieval of patient records is a major component of long patient waiting time in some sites), the use of data for making good decisions about clinic management, and data reporting. This will include forecasting for ART's and other supplies.

The Nutrition Collaborative: The NuLife project has built on HCI's structure and used a QI approach to integrate nutrition into HIV care. HCI will continue to support them in COP2010 or to continue to emphasize the importance or nutrition. Most of this work is being carried out by NuLife but it is more cost-effective for the QI activities related to nutrition integration to be carried out by HCI.

2. Activities related to objective 2: to build a quality improvement structure that is integrated into all levels of the health system

HCI works with all levels of the health system to ensure that there is the appropriate support mechanism for health facility level QI teams.

District level: HCI will continue to support 39 Districts. HCI will provide mentoring to DHT staff to improve their ability to provide QI coaching to the sites in their Districts. DHT are currently supporting an average of 3 in their Districts through HCI - one old site so that they can see a well functioning QI program and two new sites so that can practice their coaching skills. Transferring the coaching responsibilities to the DHT will dramatically increase the cost-effectiveness of HCI program and lead to a more sustainable national QI program.

Sites currently supported through the District approach are currently working on improving specific processes related to quality of care: assessing all patients for TB at each visit, assessing patients for eligibility for ART at each visit, improving patient adherence and improving clinic flow. Once sites are comfortable in applying their new QI skills to these areas they (and their District coaches) will join one of the new collaboratives.

HCI provides various forms of training to District Health Team (DHT) staff. In the classroom HCI provides training on quality improvement methods as well as technical updates related to HIV care. DHT staff have generally been overlooked in HIV training programs and therefore, HCI will work with the MoH to develop a one week training course for DHTs focusing on clinical HIV care. This is essential for DHT to be able to appropriately supervise facility level staff. HCI will undertake regular joint coaching visits with District staff to continue to strengthen their QI and coaching skills. DHT staff from different districts will be brought together to learn from each other.

Regional level: HCI supports multidisciplinary QI teams in all 12 regions. The teams include an adult clinician, a paediatrician, a data person, laboratory person and pharmacist. Regional QI teams provide some coaching visits for sites in their regions as well as updates on their technical area to sites supported by HCI. In addition, the teams play an important role in improving communication between the sites and higher levels to address problems such as stock outs and training gaps. The regional coordinators also support the DHT QI teams to strengthen their coaching skills. HCI will continue to support the regional teams to coach sites and will hold two learning sessions to bring all the teams together in 2010 to learn from each other about how to best support sites.

National level: HCI supports the National Quality of Care Coordinator in the Department of Clinical Services who coordinates quality issues in HIV for the Ministry of Health. With the restructuring of the Ministry, the Quality Assurance Department is taking on additional responsibilities of support supervision and quality issues. The department is currently dramatically understaffed and HCI plans to second a staff member to the Quality Assurance Department who will assist them in revitalizing their activities. This person will be responsible for increasing the focus on quality of care and improvement within the MoH in all areas of care. Their specific roles will depend on MoH priorities but it is likely that they will continue to revise the supervision guidelines to integrate QI into routine support supervision visits and to manage a mentorship program to improve new QI coaches in addition to new activities.

Working with partners:

STAR District-based Projects: HCI initiated meetings with JSI and MSH to ensure collaboration. From the meetings it was clear that the new projects did not have a clear strategy for quality improvement. It was agreed that all USG partners work within the framework of government's Quality of Care Initiative as the failure to harmonize could lead to multiple QI approaches that may negatively impact investments/gains achieved so far in QI. HCI has attempted to address this through organizing a coordination meeting with the Quality of Care Initiative steering committee unfortunately nothing concrete materialised. HCI will continue to liaise with USG district-based programs to ensure coordination and collaboration. Once the programs have sufficiently developed their QI strategy and began implementation, HCI will hand over sites and districts to the district-based programs to continue providing QI support. HCI will continue to ensure that communication between the ministry and these districts remains intact.

HIVQUAL: HCI continue to work closely with HIVQUAL to ensure no duplication. One important new initiative is that HIVQUAL will be starting to work with the regional coordinators and district staff that HCI has trained and supported. HIVQUAL will provide funding to these staff to visit HIVQUAL facilities while HCI will provide overall support for regional and district staff to build their QI skills.

Other partners: HCI will continue to work closely with the NuLife project to integrate nutrition into HIV care HCI supported sites. HCI will also work closely with training partners such as Mildmay, IDI, EGPAF, Baylor College and others to link untrained staff in supported facilities with the appropriate training. After classroom trainings by these partners, HCI will continue to help sites apply their new knowledge to their own clinics to improve care for their patients.

HCI supports teams in 136 facilities providing ART to over 70,000 people to improve the quality of the care they provide. One of our areas of focus is to increase the availability and quality of care for children. To accomplish this HCI will form the supported sites into five groups who will work in a collaborative fashion to improve care in these key areas: coverage of ART, retention in care, paediatric care and treatment, nutrition integration, data management.

HCI plans to train 380 people in paediatric ART in FY2010, 280 in FY 2011 and 210 during the period we will spend FY 2010 money. These targets are calculated from supporting 7 people in each site ans supporting 40 sites in 2010 plus also training 100 District health staff, supporting 40 sites in 2011 and 30 sites using COP 2010 funds (the decrease is due to handing sites over to the STAR projects).

Improving paediatric HIV requires a strong link with general paediatric care to not only identify HIV infected children but to ensure that these children get the correct non-HIV care. HCI will therefore be working with QI teams to involve paediatric clinic staff in their improvement activities. Possible shared goals may include improved detection of HIV infected children, stronger referral mechanisms between the different units, increased access to cotrimoxazole for exposed infants and improved nutrition support for new mothers.

Activities related to objective 1: to improve the quality of HIV services available in Uganda

The coverage collaborative: The aim of sites working in the coverage collaborative will be to increase the number of children who start antiretroviral therapy. Because it is unlikely additional health staff will become available in the near future, it is imperative that existing human resources are used as efficiently as possible. Sites will develop efficient triage systems and innovative approaches to using expert clients and to applying patient self management approaches to increase clinic efficiency. Sites will also build stronger links between different parts of the health facility and the HIV care clinic. In particular, weak links to PMTCT and child health clinics lead to attrition of children in need of care and ultimately lead to an inefficient system. Strengthening these links is expected to bring children in to care earlier which is associated with improved patient outcomes and is less resource intense than focusing on the sickest patients. Sites will also work on improving early infant diagnosis (EID). HCI recently completed an assessment of 10 laboratories in facilities ranging from a regional referral hospital to Health Centre IV. EID was identified as a major area in need of improvement. Only 37% of infants born to women who delivered in the facilities were tested in the first 6 months of life and fewer than 50% of those tested received their results. Median turn-around time for sites to get the results was as long as 60 days in some sites. Addressing these issues will require teamwork between clinic and laboratory staff and on improving specimen referrals within the facility and between facilities.

The retention collaborative: Another problem that leads to poor patient outcomes and wasted resources is attrition of patients after they are in the HIV care clinic. Sites in the retention collaborative will work with the patients they care for and their families to identify reasons for children not remaining in care and to develop strategies that will help improve retention and that sites have control over. Examples of these types of problems may include poor privacy in the clinic, long waiting times, rude staff or inconvenient visit schedules. Health workers may also identify issues such as long distance from clinics and community stigma which may require support from other levels of the health system and from partners to address.

The Paediatric HIV and TB Collaborative: Paediatric care for HIV and TB still lags behind adult care. HCI plans to bring 15-20 sites and their DHT's together to improve paediatric care. They will focus on ensuring that standards for paediatric HIV and TB are met in facilities and that systems to link children to the services they need are strengthened. Sites will develop systems to diagnose HIV and or TB in children wherever they are receiving care and then link these children with the appropriate treatment services. HCI plans to work with the African Network for Care of Children Affected by HIV/AIDS (ANNECA) to ensure that the correct standards of care are applied.

The Nutrition collaborative: The NuLife project has build on HCI's structure and used a QI approach to integrate nutrition into HIV care. Most of this work is being carried out by NuLife but it is more cost-effective for the QI activities related to nutrition integration to be carried out by HCI. HCI will not provide any commodoties (these are provided by NuLife) but will work to improve the system of care.

The Data management collaborative: The provision of HIV care is very data intense. This is a major shift for health facilities that are used to dealing with acute diseases with no need for longitudinal patient information. Consequently many sites are struggling with data management. Sites in this collaborative will work to improve data collection and storage (retrieval of patient records is a major component of long patient waiting time in some sites), the use of data for making good decisions about clinic management, and data reporting. This will include forecasting for ART's and other supplies.

Activities related to objective 2: to build a quality improvement structure that is integrated into all levels of the health system

District level: HCI will continue to support the 39 Districts we are currently working with. HCI will provide mentoring to DHT staff to improve their ability to provide quality improvement coaching to the sites in their Districts. DHT are currently supporting an average of 3 in their Districts through HCI - one old site so that they can see a well functioning QI program and two new sites so that can practice their coaching skills. Transferring the coaching responsibilities to the DHT will dramatically increase the cost-effectiveness of our program and lead to a more sustainable national QI program.

Sites currently supported through the District approach are currently working on improving specific processes related to quality of care: assessing all patients for TB at each visit, assessing patients for eligibility for ART at each visit, improving patient adherence and improving clinic flow. Once sites are comfortable in applying their new QI skills to these areas they (and their District coaches) will join one of the six new collaboratives.

Regional level: HCI supports multidisciplinary QI teams in all 12 regions. The teams include an adult clinician, a paediatrician, a data person, laboratory person and pharmacist. They provide some coaching visits for sites in their regions as well as updates on their technical area to sites supported by HCI. In addition they play an important role in improving communication between the sites and higher levels to address problem such as stock outs and training gaps. The regional coordinators also support the DHT QI teams to strengthen their coaching skills. HCI will continue to support the regional teams to coach sites and will hold two learning sessions to bring all the teams together in 2010 to learn from each other about how to best support sites.

National level: HCI supports the National Quality of Care Coordinator in the Department of Clinical Services. He coordinates quality issues in HIV for the Ministry of Health. HCI will continue to fund this position to strengthen QI activities in HIV. With the restructuring of the Ministry, the Quality Assurance Department is taking on additional responsibilities of support supervision and quality issues. They are currently dramatically understaffed and HCI will second a staff member to the Quality Assurance Department who will assist them in revitalizing QI activities. This person will be responsible for increasing the focus on quality of care and improvement within the MoH in all areas of care. Their specific roles in FY 2011 will depend on MoH priorities but it is likely that they will continue to revise the supervision guidelines to integrate QI into routine support supervision visits and to operate the mentorship program to improve new QI coaches in addition to new activities.