NuLife - URC-CHSNuLife - Food and Nutrition Interventions for Uganda, was a technical assistance...

NuLifeFinal Report

Prepared for USAID by University Research Co., LLCwww.urc-chs.com

NuLife - Food and Nutrition Interventions for Uganda, was a technical assistance program to support improved health and nutrition outcomes for people living with HIV/AIDS in Uganda. This program was managed by University Research Co., LLC (URC) in collaboration with Save the Children, ACDI/VOCA, and Reco Industries, LLC. The project was funded by the United States Agency for International Development (USAID), under Cooperative Agreement No. 617-A-00-08-00006-00.

DISCLAIMERThe views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development or the United States Government.

Prepared for USAID by University Research Co., LLC in collaboration with Save the Children, ACDVI/VOCA, and Reco Industries, LLC

www.urc-chs.com

NuLife Final Report

SeptembeR 2011

table of Contents

executive Summary...................................................................................................................1

project Highlights ......................................................................................................................2

Introduction ................................................................................................................................4Goal and Objectives .............................................................................................................................................................. 4

Nulife Vision ...............................................................................................................................6

major Results and Strategies ..................................................................................................7Main Strategies........................................................................................................................................................................... 7

Supporting Development of National-Level Nutrition Materials ............................................................. 7

Partnerships and Collaboration with other USAID Projects and others ............................................. 9

Building Capacity for Integration of Nutrition into HIV Services .............................................................. 9

Using Quality Improvement to Integrate Nutrition into HIV Services ................................................... 10

Nutritional Assessment, Counseling and Support (NACS) .......................................................................12

Strengthening Community Health Facility Linkages ........................................................................................18

Promoting Baby-Friendly Hospitals ............................................................................................................................18

Building Capacity for Local Production of RUTF .............................................................................................. 20

Establishing a Delivery System for RUTF ................................................................................................................21

Supply Chain System for RUTF .....................................................................................................................................21

Sustainable Livelihoods .....................................................................................................................................................22

Monitoring, Evaluation and Documentation........................................................................................................ 23

Challenges and Opportunities .............................................................................................25Opportunities ......................................................................................................................................................................... 26

Appendix A: NuLife pmp Indicator table .........................................................................27

Appendix b: List of Documents and tools Developed during NuLife .......................32

ii NuLife FINAL RepORt

ACDI/VOCA Agricultural Cooperative Development International/ Volunteers in Overseas Cooperative Assistance

ACP AIDS Control Programme

AIDS Acquired Immune Deficiency Syndrome

ANC Antenatal Care

ART Anti Retro-Viral Therapy

BFHI Baby Friendly Hospital Initiative

CAO Chief Administrative Officer

CBO Community Based Organization

CHAI Clinton HIV/AIDS Initiative

CHW Community Health Workers

CME Continuous Medical Education

CSCD Community Support for Capacity Development

DHE District Health Educator

DHO District Health Officer

DHT District Health Teams

DNU Diocese of Northern Uganda

FBF Fortified Blended Food

GH General Hospital

GOU Government of Uganda

GRRH Gulu Regional Referral Hospital

HC Health Centre

HCI Health Care Improvement

HIV Human immunodeficiency Virus

HMIS Health Management Information System

HSSP Health Sector Strategic Plan

ICCM Integrated Community Case Management

ICN International Congress on Nutrition

IEC Information, Education and Communication

IMAM Integrated Management of Acute Malnutrition

IBFAN International Baby Food Action Network

IP Implementing Partners

ITC Inpatient Therapeutic Care

IYCF Infant and Young Child Feeding

JCRC Joint Clinical Research Centre

MAM Moderate Acute Malnutrition

MOH Ministry of Health

MUAC Mid Upper Arm Circumference

M&E Monitoring and Evaluation

MSF Médecins Sans Frontières

MT Metric Ton

NACS Nutrition Assessment, Counseling and Support

NGO Non Governmental Organization

OTC Outpatient Therapeutic Care

OVC Orphans and Vulnerable Children

PEPFAR U.S. President’s Emergency Plan for AIDS Relief

PLWHA People Living with HIV

PMTCT Prevention of Mother to Child Transmission

PNC Postnatal Care

PREFA Protecting Families Against HIV/AIDS

QI Quality Improvement

RCT Routine Counseling and Testing

RRH Regional Referral Hospital

RUTF Ready to Use Therapeutic Food

SAM Severe Acute Malnutrition

SCiUG Save the Children, Uganda

SCN Sub Committee on Nutrition

STAR –EC Strengthening TB and HIV & AIDS Responses in East-Central Uganda

TASO The AIDS Support Organization

TB Tuberculosis

TBA Traditional Birth Attendant

TC Town Council

TOT Training of Trainer

TWG Technical Working Group

UNBS Uganda National Bureau of Standards

UNICEF United Nations Children’s Fund

URC University Research Co, LLC

U.S. United States

USAID United States Agency for International Development

USG United States Government

VHT Village Health Team

WHO World Health Organization

AbbReVIAtIONS AND ACRONYmS

NuLife FINAL RepORt 1

The USAID funded NuLife– Food and Nutrition Interventions for Uganda

project contributed significantly to the integration of nutrition care into the care of those infected with or affected by HIV/AIDS. Implemented in close collaboration with the Uganda Ministry of Health, NuLife was managed by University Research Co., LLC (URC) in partnership with Save the Children, ACDI/VOCA, and Reco Industries from January 2008 through August 2011. NuLife engaged multiple stakeholders to ensure nutrition care for people living with HIV/AIDS, pregnant or lactating women, and orphans and vulnerable children. NuLife carried out its work in 54 health facilities in all four regions of Uganda.

Executive Summary

NuLife was unique in its comprehensive approach: it simultaneously improved the organization of HIV clinical services and processes to integrate nutrition care into treatment, engaged community health workers in referral and follow-up, aided in the development of a locally-produced ready-to-use therapeutic food to treat malnutrition, supported the central government to develop standardized guidelines for IMAM and IYCF, and boosted sustainable livelihood opportunities for local farmers, especially those living with HIV/AIDS. The processes that NuLife developed are sustainable; the Government of Uganda has adopted new guidelines and has included RUTF in the list of essential medicines and supplies, and documented best practices are ready to be scaled up to all health facilities so that Uganda’s most vulnerable populations will continue to have access to the life-saving nutrition care that they need.

2 NuLife FINAL RepORt

Developed a 7-step process to provide care for malnourished individuals infected with and affected by HIV/AIDS.

NuLife engaged with health care professionals and clients in 54 facilities across the country to utilize a quality improvement approach to nutrition integration.

Project Highlights

Trained and supported 1,205 community health workers (CHWs) to identify members of the community that may need medical care and to follow-up with individuals that have been treated for malnourishment.

Nulife designated a community coordinator at each supported facility to liaise with CHWs. These coordinators met monthly with CHWs to support and motivate them in their work.

Assessment

All HIV–infected patients are assessed at each visit

Categorization

The nutrition status is recorded on the care card for each HIV-infected patient

Counselling

All malnourished patients receive counselling

Food by Prescription

All moderately and severely malnourished patients who pass the appetite test receive RUTF

Follow-up

All patients receiving RUTF receive follow-up

Community Links

Links are established between community and facility

Education

All HIV-infected patients receive education on good nutrition and hygiene

Seven Steps to Good Nutrition Care

100%

80%

60%

40%

20%

0%Jan 2008 Sept 2009 Sept 2010 April 2011

0.0%

48.4%76.2% 83.8%

percentage of HIV+ Clients Assessed for malnutrition with mUAC*

* MUAC (Middle Upper Arm Circumference) tape is a simple and accurate tool for determining nutrition status. The tape is wrapped around the middle part of the upper arm and has three sections indicating nutritional status: green for adequately nourished, yellow for moderate acute malnutrition, and red for severe acute malnutrition.

Increased the number of HIV-positive individuals assessed for malnutrition upon arrival at health care facilities from 0% in 2008 to 83.8% in 2011. Treated 16,076 HIV-positive individuals for severe and moderate malnutrition.

NuLife-supported facilities conducted assessments using Middle Upper-Arm Circumference (MUAC) tapes, which simplify the assessment process and make diagnosis easier for all levels of health facility staff.


Supported the MOH (Ministry of Health) to develop nutrition protocols, guidelines, training curriculums and manuals, job aids, and M&E tools to enable comprehensive nutrition care.

The tools enable the MOH to train, guide, and aid facility-based health workers and community health workers in infant and young child feeding and comprehensive nutrition care for people living with HIV.

Infant and Young Child Feeding

National Counselling Cards for Community Volunteers

Supported the local economy by establishing capacity within Reco Industries, Ltd., a Ugandan food manufacturer, to produce a ready-to-use therapeutic food (RUTF), which is used to treat malnutrition.

RUTAFA, the RUTF produced by Reco (the name means “will not die” in a local language), is made largely of sustainably- and locally-available raw materials. To date, more than 120 metric tons of RUTAFA have been produced.

Provided sustainable incomes for more than 4,000 farmers, more than 50% of whom are women and about 20% of whom are HIV-positive.

NuLife supported the development of partnerships in two regions to engage local farmers to grow and harvest a quality supply of groundnuts used to make RUTAFA. In both partnerships, Reco provides seeds and technical assistance to farmers and then buys the groundnuts back at market price, thus providing an income for individuals participating in the program and stimulating the local economy. Farmers grow the nuts on land owned by Reco or by another local partner, the Diocese of Northern Uganda. In one region, the local hospital refers individuals that have recently undergone treatment for malnourishment for participation as farmers in the program.

Successfully advocated for the inclusion of RUTF on the Essential Medicines List for Uganda, ensuring RUTF availability after project closure.

The Ugandan government can now continue to purchase RUTF; consequently, Uganda’s most vulnerable populations will have sustainable access to life-saving nourishment.

Thabit Obed, a Ugandan farmer and community volunteer, is one of the 4,000 farmers who grow and sell groundnuts for the production of RUTAFA through the support of NuLife and Reco Industries. He has brought a number of HIV-infected farmers into the program. His sister Rose declares:

“All the farmers are

appreciative. We are

all able to sustain our

families doing an activity

that we love: farming.”

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Introduction

From January 2008 through August 2011, the USAID funded NuLife – Food and Nutrition

Interventions for Uganda project contributed significantly to the integration of nutrition care into the care of those infected with or affected by HIV/AIDS. Implemented in close collaboration with the Uganda Ministry of Health, NuLife was managed by University Research Co., LLC (URC) in partnership with Save the Children, ACDI/VOCA, and Reco Industries. Using an integrated and innovative approach, NuLife developed solutions by engaging multiple stakeholders to ensure nutrition care for people living with HIV/AIDS, pregnant or lactating women, and orphans and vulnerable children.

When NuLife began, Ugandan malnutrition rates were high. In 2006, the Uganda Demographic and Health Survey (UDHS) reported 38% of children under five stunted, 16% underweight and 6% wasted (see Figure 1). Of the acutely malnourished children admitted to health facilities, 30% to 40% were HIV-infected.

The extent of malnutrition among adults suffering from chronic diseases like HIV/AIDS and TB remained unknown in 2006, with limited progress in linking nutrition support into HIV/AIDS and TB programs (Severe Malnutrition: Report of a consultative workshop organized by the Ministry of Health to review the magnitude and current management of acute malnutrition in selected health facilities in Uganda, Hotel Africana, 2004).

Goal and ObjectivesNuLife was designed to improve the health status of malnourished people infected with and affected by HIV. The goal of the project was to improve the quality of life of people living with HIV/AIDS (PLWHA) and increase utilization and adherence to anti-retrovirals and efficacy of anti-retroviral therapy through food and nutrition interventions.

NuLife was accomplished by providing leadership in development, integration, and expansion of a comprehensive nutrition package in the continuum of HIV/AIDS care.

The specific objectives of the project were to:

1. Provide technical and financial support to the MOH, community-based organizations/non-governmental organizations (CBOs/NGOs), PLWHA networks, United States Government (USG) implementing partners (IPs) and district health teams to integrate food and nutrition interventions into HIV/AIDS prevention, care and treatment programs;

2. Develop a nationally acceptable ready-to-use therapeutic food (RUTF) using locally available ingredients;

3. Establish a system for effective development and delivery of RUTF to severely malnourished PLWHAs.

50

45

40

35

30

25

20

15

10

5

0Stunted Underweight Wasted

1989199520012006

4339 38 38

2325 26

16

25 5 6

Figure 1. Prevalence of malnutrition among children below five years in Uganda (in %)


NuLife’s target groups were PLWHA, including children under 18 years of age and adults, orphans and vulnerable children (OVC), and HIV-positive pregnant or lactating women.

To meet these objectives, NuLife used four primary interventions:

• Strengthening human capacity by training and coaching health workers at community and facility levels in nutrition care and counseling

• Building health facility capacity to provide high-quality, integrated nutrition and HIV/AIDS programs using equipment, job aids and ready-to-use therapeutic food (RUTF)

• Improving the linkages between health facilities and communities for case finding, referral and follow-up care to improve treatment adherence and recovery

• Establishing local capacity to produce ready-to-use therapeutic food from locally-available raw materials


NuLife Vision

USAID conceptualized a nutrition program to address the gap between

policy and practice using a comprehensive approach that simultaneously improved clinical care processes for integrating nutrition care into treatment, engaged community health workers, aided in the development of a locally-produced therapeutic food to treat acute malnourishment, and boosted the local economy by promoting sustainable sources of income for local farmers.

Ministry of Health• Guidelines, protocols and training curricula for HIV-nutrition established • Training national trainers• Logistics management, HMIS, and results monitoring• Production of national counseling and training materials and job aids

Health Facility• Competence training in comprehensive nutrition management for PLWHA.• Strengthen links with community• Supply chain systems• HMIS, equipment provision• QI and coaching activities

Community ComponentWorking with implementing partners to:• Train community volunteers, identify community members at nutritional risk, establish referral systems, follow up for RUTF adherence

District• QI and coaching activities

Policies and guidelines

ReferralServices providedfollow-up

Orders placed/procurementRUTF production

RUTF storage and logistics

Orders placed/procurement

Orders placed/procurement

Figure 2. Integrating nutrition into existing systems and structures


Major Results and Strategies

main Strategies• Developing national level

nutritional guidelines and job aids

• Strengthening capacity for nutritional service delivery within HIV/AIDS care

• Using a quality improvement approach to improve outcomes

• Strengthening community-facility linkages

• Promoting baby-friendly services in hospitals and communities

• Establishing local production of RUTF with Ugandan manufacturer

• Integrating delivery system for RUTF with existing systems

• Improving monitoring of nutritional services at clinic, community and national levels

Supporting Development of National-Level Nutrition materialsNuLife worked in close collaboration with the MOH Nutrition Unit and STD/AIDS Control Programme (STD/ACP), and other nutrition stakeholders: Joint Clinical Research Centre (JCRC), International Committee of the Red Cross (ICRC), Uganda Health Marketing Group (UHMG), Food and Science and Technology Dept. of Makerere University, UN agencies (United Nations Children’s Fund [UNICEF], World Health Organization [WHO], United Nations World Food Programme [WFP]), Ministry of Education, Ministry of Agriculture, Mwanamugimu Nutrition Unit at Mulago Referral Hospital, FANTA project, and other USG IPs). Together, these groups provide technical direction in developing, adapting, and updating existing guidelines, protocols, training materials and assessment and referrals tools for nutrition, including information, education and communications (IEC) materials, counseling tools and job aids. The project also supported the development of training curriculum and assessment tools. A list of all materials and tools developed is included as Annex B.

table 1. Key results on integrating nutrition into routine HIV care and support programs

IndicatorsBaseline

(2008)Annual HFI*

(2011)Program

Reports (2011)

HIV care and treatment facilities with a minimum set of anthropometric equipment

7.0% 95.5%

HIV-positive individuals receiving nutritional assessment utilizing MUAC during HIV clinic visits

0.0% 83.8%

HIV-positive individuals receiving nutritional counseling during HIV clinic visits

0.0% 40.7%

HIV-positive individuals assessed and treated for acute malnutrition

0 16,076

HIV-positive individuals receiving ART assessed and treated for acute malnutrition

0 6,664

Number (in metric tons) of RUTF produced locally

n/a 120

* Health Facility Inventory


Comprehensive Nutrition Care and Support for pLWHA• Advocated for the formation

of the Sub-Committee for Nutrition (SCN) and Task Force on Nutrition and HIV

• Developed curriculum for Nutrition and HIV/AIDS (currently under review by the Technical Working Group [TWG] on Nutrition)

• Supported the consensus- building process that led to finalization of the Strategic Plan on Nutrition in the Context of HIV and Tuberculosis Infection

• Developed Comprehensive Nutrition Care and Support for PLWHA curricula, training materials, job aids and counseling cards

Infant and Young Child Feeding• Updated the infant and young

child feeding (IYCF) policy guidelines to reflect global policy guidelines on IYCF, including the key recommendation that all infants and young children are given an opportunity to be exclusively breastfed for the first six months regardless of exposure to HIV

• Updated the existing IYCF training materials for facility and community health workers

• Developed counseling materials to support implementation of the training materials

Integrated management of Acute malnutrition• Provided technical expertise

for the national guidelines on integrated management of acute malnutrition (IMAM), which addresses malnutrition in all age groups, and developed a training plan in collaboration with other MOH partners

• Developed the training curricula, counseling and other support materials for both facility and community health workers on IMAM

Community-Level Integration of Nutrition and HIV• Developed a curriculum and

job aids for community health workers on integrating nutrition into HIV/AIDS programs

Comprehensive Nutrition Care and Support Facility-Level Job Aids

For Out Patient Therapeutic Care in Health Facilities Supported by NuLife



Guidelines for Integrated Management

of Acute Malnutrition in Uganda

December 2010

A Trainer’s Manual

Supply Chain Management, Monitoring and Reporting of Outpatient Therapeutic Care Programs

NuLife – Food and Nutrition Interventions for Uganda

Community Intervention Strategy for Integration of Nutrition into HIV/AIDS ServicesNovember 2009

Submitted: November 17, 2009

This publication was produced for review by the United States Agency for International Development. It was prepared by URC LLC.

Supply Chain and monitoring and evaluation• Developed training materials,

counseling cards, and job aids on supply chain management and monitoring and evaluation


partnerships and Collaboration with Other USAID projects and OthersCollaboration between implementing partners is key in providing care for PLWHA, avoiding duplication of efforts and leveraging resources to provide the best care for clients. NuLife built and supported partnerships with other USAID projects and implementing partners through:

• Providing technical support to partners such as STAR EC, who were providing nutrition care and support for PLWHA in health facilities

• Providing training materials on comprehensive nutrition care for PLWHA so the partners could train staff and volunteers

• Training community volunteers already supported by particular implementing partners to strengthen community-facility linkages

• Training key staff from partner organizations as master trainers in nutrition care for PLWHA

• Negotiating with partners to continue supporting sites and implement nutrition activities after the scale down of the NuLife program

• Sharing experiences and best practices for implementing the NuLife program

building Capacity for Integration of Nutrition into HIV Services

training of Facility-based Health Workers to provide Nutrition Care for pLWHAHealth workers from NuLife-supported sites were trained in comprehensive nutrition care for PLWHA, supply chain management and monitoring and evaluation. A phased approach was used so that work in HIV/ART clinics was not disrupted, and not all health workers in a facility received training at the

same time. The health workers participated in a 5-day training and a site visit and were provided with job aids.

NuLife trained a total of 873 facility-based health care providers in comprehensive nutrition care for PLWHA. In addition to training health care providers, NuLife provided technical and financial support to sites to hold CMEs on nutrition, thus mitigating the effects of staff attrition.

Integrating Nutrition into Formal mOH processes and DocumentsTo ensure continuation of the nutrition activities after the NuLife program, key nutritional indicators and RUTF needed to be included in

the MOH Health Sector Strategic Plan and district planning/budget. NuLife took the lead in advocating and lobbying for inclusion of nutritional indicators and RUTF in national and district health plans. NuLife, in collaboration with partners, heightened advocacy and lobbied for nutrition care:

• Nutritional assessment, malnutrition diagnosis and RUTF included in the revised anti-retroviral therapy (ART) patient card

• Inclusion of key nutritional indicators and RUTF to be included in the Health Sector Strategic Plan (HSSP) 2011–2015

• Inclusion of RUTF in the list of essential medicines stocked by national medical stores

table 2. Total number of health providers trained by type of training, participant category, and gender

Type of training Participants Female Male Total

Integrating nutrition into HIV/AIDS care & support programs at community level

Regional Trainers - Community 76 93 169

Master Trainers - Community 18 11 29

Community Health Workers 599 638 1237

Comprehensive nutrition care for PLWHAFacility Health Workers 293 555 848

Trainers of FHWs 11 14 25

BFHIFacility Health Workers 29 1 30

Community Health Workers 0 0 0

Supply chain and monitoring and evaluation 74 871 161


• Inclusion of nutrition in the ART treatment card

• Inclusion of an addendum on treatment of acute malnutrition in the clinical guides for health professionals

• For the first time, a section on nutrition has been included in the revised integrated ART, prevention of mother-to-child transmission of HIV/AIDS (PMTCT), and IYCF guidelines (formerly ART treatment guide)

Using Quality Improvement to Integrate Nutrition into HIV Services The NuLife project utilized quality improvement to help facilities integrate nutritional services within the HIV/AIDS clinics. This allowed facilities to actively think through how to add a new service to already-busy clinics and staff. All trained health workers were encouraged to join the quality improvement effort. The introduction of quality improvement for nutrition-HIV integration was facilitated by the fact that NuLife-supported facilities already had been exposed to and working with QI tools through the work of the USAID’s Health Care Improvement Project (HCI), a URC sister project supporting the MOH Quality of Care Initiative in 220 health

Figure 3. Seven steps to good nutrition care

facilities in the country. NuLife and HCI together with the MOH developed the “Seven Steps to Good Nutrition Care” to integrate nutrition into routine treatment, care and support activities (see Figure 3). Breaking down nutrition services into smaller steps allowed facilities to gradually introduce services and focus improvements on small, feasible increments. Process indicators for each step measured progress and improved performance (see Table 3).

Quality improvement included several important approaches: coaching, quality improvement team meetings, supportive supervision by MOH, and peer-to-peer learning.

Coaching by Regional mOH Staff In close collaboration with the Health Care Improvement Project (HCI) and MOH Quality of Care Initiative, NuLife used existing tools to train

MOH regional coordinators and regional nutritionists in comprehensive nutrition care for PLWHA and in how to coach for nutrition interventions. Many practical sessions helped to improve their capacity.

After the training, the teams carried out monthly coaching visits and provided feedback to the NuLife team. Once teams demonstrated competency, coaching visits were bi-monthly.

Coaches’ meeting

Assessment

All HIV–infected patients are assessed at each visit

Categorization

The nutrition status is recorded on the care card for each HIV-infected patient

Counselling

All malnourished patients receive counselling

Food by Prescription

All moderately and severely malnourished patients who pass the appetite test receive RUTF

Follow-up

All patients receiving RUTF receive follow-up

Community Links

Links are established between community and facility

Education

All HIV-infected patients receive education on good nutrition and hygiene


table 3. Indicator definitions for the seven steps to good nutrition care

Steps for Integration

Assessment and Categorization Counselling Food by

Prescription Follow-up Community Links Education

Goal/definition All HIV-infected patients are assessed at each visit. The nutrition status is recorded on the care card for each HIV-infected patient.

All malnourished (mild, moderate or severe) patients receive nutrition counselling.

All moderate and severely malnourished patients receive RUTF.

All patients receiving RUTF receive follow-up (MUAC measured, weight taken, appetite test done, etc).

Links are established between community and facility through referral and counter referral of clients.

All HIV-infected patients receive education on good nutrition and hygiene regularly.

Guideline MUAC result:

• Green: well nourished

• Yellow: moderately malnourished

• Red: severely malnourished

Job aids Moderate or severe malnutrition–passed appetite test?

• Yes: prescribe

• No: inpatient

Protocol Job aids

Indicators % of HIV-positive clients who have been assessed for malnutrition using MUAC

% of HIV-positive clients who receive counselling on nutrition and use of RUTF

% of people needing RUTF who received it

% of HIV-positive clients assessed to be moderately or severely malnourished receiving treatment

% of people receiving RUTF who need it

% of clients receiving RUTF who are returning for scheduled follow-up visit

% of clients referred from the community to the facility enrolled into outpatient therapeutic care (OTC)

% of HIV-positive clients who receive nutrition education each clinic day


The coaches met regularly to review progress and share best practices. Through coaching, the QI teams and team leaders were supported to:

a. become self-sufficient in their ability to make quantifiable and sustainable improvements in the delivery of nutrition services;

b. generate solutions based on the appropriate use and application of QI tools and procedures; and

c. analyze their own systems, processes, data, and results to determine next steps in the quality improvement process.

Quality Improvement team meetings The QI teams were composed of a QI team leader, a nutrition focal person, other staff trained in nutrition and the community coordinator. The community coordinator represented community health workers (CHWs) at the meeting, sharing key issues emerging from the community and bringing agreed action plans back to CHWs.The teams met either weekly or bi-weekly as needed to review progress, identify gaps and decide on changes to be tested.

Quarterly Joint technical Supervision Visits In an effort to strengthen ownership, commitment and sustainability, key stakeholders including the MOH, district health teams (DHT) and implementing partners (IPs) undertook joint technical support visits to NuLife supported sites.

peer-to-peer Learning Sessions One of the most effective ways of spreading change and good care practices throughout the sites was through peer-to-peer learning. Collaborative learning sessions brought sites together and enabled them to share experiences, challenges, solutions, and emerging better care practices.

Nutritional Assessment, Counseling and Support (NACS)The following sections detail how each of the Seven Steps to Good Nutrition (see Figure 3) were implemented.

Step 1 Assessment of Nutritional StatusBy December 2010, all the 54 health facilities had integrated nutritional assessment of clients using MUAC tapes into routine clinic activities. All the sites carry out assessments at registration or triage when the

Figure 4. Color-coded MUAC tapes used at both facility and community level

0 cm

0 cm

Infants from 6 months and children up to 6 years

Adults older than 18 years, pregnant and postpartum women

Children 6 years up to 10 years

Children 10 years up to 18 years

Child is assessed for malnutrition using a mUAC tape


clients’ vital signs are being taken, thereby ensuring that clients are assessed each clinic day. Figure 5 shows that the percentage of clients routinely assessed and categorized at each clinic visit improved from 24% in April 2009 to over 90% in December 2010.

Step 2 Categorization of ClientsAll clients whose nutrition status was assessed using MUAC were categorized based on the colors of the MUAC tapes: normal (green), moderate acute malnutrition (yellow) and severe acute malnutrition (red). Figure 6 shows the percentage

malnourished child at admission (3.4 kgs)

of assessed clients who were categorized as acutely malnourished in HIV/ART clinics. On average 6% of clients were diagnosed with acute malnutrition.

Step 3 Counseling of malnourished ClientsAll the sites reported that they counseled all clients who were assessed and categorized as acutely malnourished. Using QI methods and regular coaching ensured the health providers had the capacity and the tools to counsel clients. However, the main challenge with counseling was documentation of the activity itself.

table 4. Key Changes Leading to Sustained Improvement

Steps 1 and 2: Assessment and Categorization

Using expert clients and volunteers (called task shifting) to assess clients using MUAC

Ensuring that every client is assessed by assessing clients at registration or triage, which are the entry points of the clinic

Adding a column to the daily attendance or HMIS registers to record MUAC assessment and categorization, enabling staff to easily transfer the results of the assessment onto the HIV/ART care cards of clients

Recording the color of the MUAC measurements to enable easy categorization of clients’ nutritional status

Step 3: Counseling

Assigning one person to document counseling on the clients’ ART care card or the outpatient therapeutic register

Providing group counseling to malnourished clients to reduce waiting time

Using counseling cards and other job aids to provide key messages to malnourished clients

Step 4: Treatment with RUTF

Displaying job aids on admission criteria in clinicians’ rooms

Conducting continuing medical education sessions to orient new staff to the eligibility criteria

Steps 5 and 6: Follow-up and Community-Facility Links

Synchronizing return dates for ART and RUTF

Involving CHWs in organizing and mobilizing clients to attend outreach visits where the facility team distributed RUTF and did follow-up

Involving CHWs in outreach visits; attaching clients to CHWs who also carried out home-based counseling of clients

Updating registers and using stickers to identify clients returning for follow-up to increase speed of service delivery

Asking CHWs to search for clients lost to follow-up2 months on RUtF (5.3 kgs)


Figure 5. Percentage of clients assessed using MUAC at each clinic visit at NuLife-supported sites (March 2009 – February 2011)

100

90

80

70

60

50

40

30

20

10

0Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb

2009 2010 2011

% assessed 0 24 32 53 63 62 54 57 66 67 72 78 83 75 84 87 84 67 73 83 85 91 93 95

Figure 6. Percentage of clients categorized as acutely malnourished in HIV/ART clinics in NuLife-supported sites (March 2009 – February 2011)

20

18

16

14

12

10

8

6

4

2

0Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb

2009 2010 2011

% assessed 0 24 32 53 63 62 54 57 66 67 72 78 83 75 84 87 84 67 73 83 85 91 93 95

% found malnourished 0 7.2 5.2 6.7 6.1 4.8 4.4 3.9 6.9 7.7 6.7 7.1 9.6 6.9 7.0 6.1 4.7 4.4 13.3 3.7 4.7 5.0 4.1 3.6

HIV/ART clinics have a high client load and are understaffed. Health workers are focused on serving as many clients as possible, leading to inconsistent documentation of the services offered on the client cards or in the register.

Results from the semi-annual health facility inventories showed a gradual improvement in the documentation of nutrition counseling on client ART care cards. The percentage of malnourished client cards on which nutrition counseling was recorded increased from 22% in August 2009 to 70% in January 2011.

Step 4 treatment with RUtFMalnourished clients who were eligible for RUTF based on the admission criteria and on passing the appetite test were treated with ready-to-use therapeutic food (RUTF). Health facilities did not face many challenges in the prescription of RUTF, with the exception of two sites that reported that new clinicians who were not aware of the eligibility and admission criteria sometimes did not prescribe RUTF to clients.

Figure 7. Percentage of malnourished clients who received nutrition counseling in NuLife-supported sites (March 2009 – January 2011)

100

90

80

70

60

50

40

30

20

10

0Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan

2009 2010 2011% counselled 0 85 48 38 26 22 28 44 21 33 33 54 80 74 83 89 93 88 96 93 89 87 70


The sites addressed this challenge by ensuring that job aids on admission criteria were clearly displayed in clinicians’ rooms and by conducting continuing medical education (CME) to orient new staff to the eligibility criteria. As of April 2011 over 24,000 individuals

Figure 8. Number of outpatient therapeutic clients assessed and treated for acute malnutrition in 54 NuLife-supported facilities by client category and HIV status (April 2009 – April 2011)

25,000

20,000

15,000

10,000

5,000

0Children

6 months – < 18 yearsAdults

18 years and abovePregnant and

Lactating WomenTotal

HIV postiveHIV negativeExposed/UnknownTotal

HIV-positive 4454 11446 289 16189

HIV negative 4828 0 0 4828

Exposed/unkown 3780 0 0 3780

Total 13062 11446 289 24797

Figure 9. Number of HIV-positive unique individuals assessed and treated for acute malnutrition in OTC at 54 NuLife supported sites by ART status (April 2009 – March 2011)

1,600

1,400

1,200

1,000

800

600

400

200

0Apr – Jun

2009

Pre-ARTOn ART

2010

Apr – JunJul – Sept Oct – Dec Jan – Mar Jul – Sept Oct – Dec Jan – Mar

2011

Pre-ART 660 1218 1051 1000 1354 1587 1446 771

On-ART 678 663 599 680 1049 1196 1233 891

Total=16,076; 57% (9,087) Pre-ART; and 43% (6,989) On-ART

were prescribed and treated with RUTF. Of clients treated with RUTF, 52.7% were children aged 6 months to 17 years, 1.2% were pregnant and postpartum women with a child less than 6 months, and 46.2% were other adults.

Step 5 Follow-Up of malnourished Clients Receiving RUtFOf the seven steps, follow-up with clients receiving RUTF is the most challenging. As is often the case in chronic care for PLWHA, frequent return visits to the health facility become tedious and expensive, so clients do not return for their scheduled appointments. Health care providers participating in quality

improvement work asked their clients why they did not return for scheduled outpatient therapeutic care (OTC) follow-up visits. The most common responses were length of distance to health facilities, forgetting appointment dates, different refill dates for ARV and RUTF (resulting in too many clinic visits), lack of need to come back due to improvement on RUTF already prescribed, and long waiting lines.


Figure 10. Percentage of OTC-enrolled clients returning for follow-up in NuLife-supported sites (January 2010 – April 2011)

100

90

80

70

60

50

40

30

20

10

0Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb

2010 2011

Mar Apr

% follow-up 55 77 85 87 87 64 59 58 66 65 60 59 70 83 79 84

On the facility side, there were challenges in updating the register so that staff knew which clients had kept their appointments or not.

Once the health care providers were aware of these factors, the QI teams developed and tested changes which enabled clients to return for follow-up. The overall follow-up of clients improved as a result of these changes.

Kisoro Hospital addressed the clients’ needs by taking services closer to their clients.

Figure 11. Results of taking RUTF closer to clients through outreach visits and attaching clients to CHWs (December 2009 – April 2011)

140

120

100

80

60

40

20

0Dec Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb

2009 2011

Mar AprJan

2010

Outreaches

Attached CV to clients for

follow-up

Home-based counselling of

clients by CHWs

OTC clients expected to returnOTC clients who returned

OTC clients expected to return 0 46 52 32 42 95 124 98 49 84 79 81 71 75 82 39 32

OTC clients who returned 0 41 48 32 42 95 116 91 48 84 77 81 69 75 79 39 32

% of clients returning 0 89 94 100 100 100 94 93 100 100 97 100 97 100 96 100 100

The site strengthened its community-facility linkage by involving CHW in outreach visits and attaching clients to CHWs who also carried out home-based counseling of clients. The CHWs were involved in organizing and mobilizing clients to attend outreach visits where the facility team distributed RUTF and did follow-up. These key changes led to a sustained improvement in the number of clients that received follow-up care.

Villa maria Hospital outreach team gets ready to go to the field


Step 6 Health Facility-Community LinkageAs noted under Step 5, assigning trained CHWs to follow up with particular clients became a key strategy for ensuring follow-up with clients on OTC. Through its community intervention strategy (detailed in the next section),

Figure 12. Number of individuals assessed, categorized as acutely malnourished and referred to 54 NuLife-supported sites for nutrition interventions by trained CHWs (April 2009 – January 2011)

14,000

12,000

10,000

8,000

6,000

4,000

2,000

0Regional Referral

Hospitals

Severe acute malnutritionModerate acute malnutritionTotal malnourished# referred to health facility

Health Center IVs

GeneralHospitals

Severe acute malnutrition 1042 2892 573

Moderate acute malnutrition 3039 10095 2028

Total malnourished 4081 12988 2601

# referred to health facility 3698 10479 2130

% referred to health facility 90.6% 80.7% 81.9%

NuLife supported the election of a community coordinator at each of its 54 sites to oversee and strengthen the community-health facility linkage.

NuLife also successfully participated in lobbying for nutrition to be included in the village health team (VHT) training manual.

Step 7 Health and Nutrition educationPrior to the introduction of the nutrition program, health facilities conducted health education on many different topics. All NuLife–supported sites incorporated nutrition messages in their routine health education sessions and used the information, education, and communication materials developed and provided by NuLife.

Figure 13. Number of PLWHA who received health and nutrition education at Kayunga Hospital (March 2010 – August 2010)

500

450

400

350

300

250

200

150

100

50

0

Mar Apr May Jun Jul Aug

# educated# seen

wk 9

wk10

wk33

wk32

wk31

wk30

wk29

wk28

wk27

wk26

wk25

wk24

wk23

wk22

wk21

wk20

wk19

wk18

wk17

wk16

wk15

wk14

wk13

wk12

wk11

wk34

part of health and nutrition education materials at Luweero Health Center IV


Strengthening Community Health Facility LinkagesTo provide a continuum of care for PLWHA, it was essential for NuLife to strengthen the linkages between health facilities and communities and integrate nutrition into ongoing community-level HIV/AIDS activities.

NuLife collaborated with the MOH, district health teams and implementing partners to develop nutrition-related training curricula and job aids for community HIV and nutrition interventions. Using a cascade model, NuLife trained 28 master trainers and 168 regional trainers from NGO partners, who in turn trained 1,205 existing community health workers established by district health teams, health facilities and NGO partners to integrate nutrition into ongoing HIV/AIDS activities. These trainers will remain a resource for other partners to utilize for scale-up on nutrition activities.

Training focused on raising awareness in the community on the importance of nutrition in HIV/AIDS treatment and care, early identification of PLWHA in need of therapeutic nutritional

interventions, improved referral processes, improved adherence to treatment through client follow-up and counseling, nutrition counseling, and links between clients and other available services including sustainable livelihoods programs.

Working through NGO and USG implementing partners and with existing community health workers garnered commitment and ownership from partners and avoided duplication of efforts. It also facilitated the transfer of the training curricula to other groups, contributing to sustainable use of the NuLife-developed training package. Several partners, have since trained many more CHWs and supported them to continue implementing nutrition activities at the community level.

As noted above, NuLife established a support mechanism for community health workers by starting up activities such as monthly progress review meetings and inviting community coordinators to join facility quality improvement team meetings.

promoting baby-Friendly Hospitals NuLife piloted the baby-friendly hospital initiative (BFHI) in two hospitals, Jinja and Iganga, in collaboration with their surrounding communities. The pilots included:

• A baseline assessment to identify existing baby friendly/infant and young child feeding practices, gaps, challenges and opportunities

• Orientation for 150 decision-makers and managers on optimal IYCF in general and the BFHI

• Design of the implementation strategy with district and hospitals decision makers (solidified by the signing of certificates of commitment)

• 20 hours of training for 30 facility health workers followed by intensive on-the-job supportive supervision and coaching

An internal assessment confirmed that within six months the hospitals had met the minimum standards and were ready for external assessment by UNICEF.

Figure 14. Percent scores of Jinja Regional Referral Hospital and Iganga General Hospital on WHO/UNICEF-adapted tools for assessing baby-friendly hospital status

100

90

80

70

60

50

40

30

20

10

0Baseline

August 2010

Jinja Regional Referral HospitalIganga General Hospital

Internal AssessmentApril 2011

Self AppraisalDecember 2010


The 16 Steps to Successful Breastfeeding(extracted from the National Policy Guidelines for Infant and Young Child Feeding, MOH, 2009)

1. Communicate written breastfeeding policy routinely to all health care staff.

2. Train all health care staff in breastfeeding policy.

3. Inform all pregnant women about the benefits and management of breastfeeding.

4. Help mothers initiate breastfeeding within the first hour of birth.

5. Show mothers how to breastfeed and maintain lactation even if they are separated from their infants.

6. Give newborn infants no foods or drinks other than breast milk, unless medically indicated.

7. Practice rooming-in (allow mothers and infants to remain together) 24 hours a day.

8. Encourage breastfeeding on demand.

9. Do not use artificial teats or pacifiers (also called dummies or soothers) for infants and young children.

10. Give all new born babies delivered in health facilities or clinics BCG and Polio “O” vaccines before discharge.

11. Give all mothers who deliver in health facilities or clinics 200,000 IU of Vitamin A before discharge. Give non-breastfed infants 50,000 IU of Vitamin A before discharge.

12. Issue a correctly-filled-in Child Health Card for each newborn and the “Woman’s Passport” where available to the mother before discharge from the maternity ward.

13. Foster the establishment of community-based support groups for optimal Infant and Young Child Feeding (IYCF) and refer mothers to them on discharge from the health facility.

14. Support infant feeding in the context of HIV.

15. Comply with the Food Safety (Marketing of Infant and Young Child Foods) Regulations of 2005.

16. Offer mother-friendly care.

A NuLife breastfeeding counselor talks to women in the community about the baby-friendly health facility initiative

The BFHI was simplified into a 16-step model to successful breastfeeding to facilitate implementation at the facility level.

To extend this effort to the communities surrounding Jinja and Iganga hospitals, NuLife worked with Community Support for Capacity Development (CSCD), a local NGO, to establish community-based mother support structures

for optimal IYCF in 76 villages. 158 VHT members were trained to support mothers to breastfeed exclusively for six months and introduce safe and timely home-prepared complimentary foods. These VHT members conducted 62 growth monitoring and promotion sessions, followed up with 380 mothers to provide support and conducted 76 community dialogue sessions focusing on optimal feeding


and care for infants and children up to 3 years. 76 mother support groups have been established in Nakigo (25), Bugembe (15) and Njeru (36). Trained VHT members refer mothers who have recently delivered to the health facility or a facility outreach site for antenatal care (ANC) and immunization support or to Jinja or Iganga hospital for specialized care.

The role of selected CHWs was expanded to include that of peer counselors for IYCF. They encouraged mothers to attend ANC visits; to receive routine counseling and testing; and, if HIV-positive, to enroll in prevention of mother-to-child transmission of HIV (PMTCT) counseling. They provided mothers with information on appropriate maternal and infant feeding methods and carried out community-based growth promotion and monitoring for children under 36 months. Pregnant and lactating mothers were counter-referred from the hospitals to trained community health workers for support.

building Capacity for Local production of RUtF

Local production of RUtFThe ready-to-use therapeutic food (RUTF) that NuLife used for the treatment of acute malnutrition in NuLife-supported sites followed the specifications outlined by the United Nations in their joint statement about community therapeutic care, May 2007, and was recently referenced in an international expressions of interest document issued by UNICEF. A selection committee made up of the NuLife technical team, USAID technical and contract representatives, representatives of the Ministry of Health and the Makerere University Department of Food Science and Technology selected to partner with Reco Industries, a local food manufacturer, through a competitive bidding process. Reco’s new food product, developed and tested in two health facilities, became locally available in July 2009 and was named RUTAFA.

Part of the process to establish local production included certification by the Ugandan National Bureau of Standards (UNBS) and UNICEF certification.

The UNBS certified Reco in 2010 and has continued to support and supervise production quality.

Reco has obtained licensure from Nutriset, the internationally-recognized patent-holder for RUTF. This alliance has provided Reco with valuable technical support and access to new equipment. Reco is taking the prescribed steps to become a member of Nutriset’s PlumpyField network, the international backing required to pursue UNICEF certification. As of August 2011, USAID has continued to support Reco Industries through direct purchasing of RUTF.

Figure 15 illustrates the quantity of RUTAFA that Reco Industries has produced.

Secured Certification of RUtAFA by UNbSUNBS is Uganda’s body for certifying quality standards. UNICEF assisted UNBS by providing them with the 2009 international standards for RUTF, and these were used as a basis for certifying Reco Industries’ RUTAFA and for developing national standards.

Figure 15. Amount of RUTF in metric tons locally produced by Reco Industries (October 2009 – March 2011)

120

100

80

60

40

20

0

Qua

ntity

(MT)

Apr-Jun

11.472

Jul-Sep

35.064

Oct-Dec

28.290

Total

119.925

Oct-Dec

1.148

2009Jan-Mar

0.743

2010Jan-Mar

43.208

2011


establishing a Delivery System for RUtFNuLife established an effective short-term supply chain system for the distribution of commodities including RUTF, anthropometric equipment, and tools to health facilities. Concurrently, NuLife worked with the MOH to develop a long-term supply chain for RUTF. An action plan was provided to the MOH and to the leadership of the national medical stores and joint medical stores to be used when RUTF is placed on the Essential Medicines List and after the launching of the national guidelines for integrated management of acute malnutrition.

The biggest challenge at the beginning of the project and with the addition of new sites was determining supply needed. No data were available for the number of patients who would be diagnosed with severe malnutrition. The numbers were much higher than originally anticipated, thus requiring substantially more RUTF in facilities.

Reco Industries and RUTAFA

“...UNBS has assessed the product and the process of manufacturing and these have been found to be compliant as per UNICEF requirements...” – Extract from UNBS Letter of

Certification to Reco Industries

UNBS has continued to support Reco Industries to ensure that the required standards are adhered to. UNBS certifies every batch of RUTAFA that is produced.

Reco Industries was also visited by US Ambassador Jerry Lanier, and in his remarks he noted that, “…this is the most impressive project I have visited…”

A sachet of locally produced RUtF

Supply Chain System for RUtFUsing the short-term distribution approach mentioned earlier, NuLife has distributed over 436.189 MT of RUTF (produced by Reco and imported other from manufacturers) and 25.359 MT of Fortified Blended Food (FBF) to 54 sites and 7 sites, respectively.

Notably, the Clinton HIV/AIDS Initiative (CHAI) donated amost 240 MT of RUTF to treat acutely malnourished children at NuLife sites.

bugiri Hospital receives RUtF

NuLife provided supportive supervision visits to OTC implementing sites to enhance the training in supply-chain management that health facility staff received.


Figure 16. Amount in metric tons of RUTF and FBF distributed to NuLife-supported sites (April 2009 – May 2011)

1500

400

300

200

100

0Apr - Dec

2009TotalJan - Dec

2010

Qua

ntity

(MT)

Jan - May2011

RUTFFBFTotal

RUTF 57.587 236.752 141.850 436.189

FBF 0.000 3.465 21.894 25.359

Total 57.597 240.217 163.744 461.548

Figure 17. Amount of RUTF and FBF in metric tons dispensed and lost at 54 NuLife-supported sites (April 2009 – April 2011)

150

100

50

0

Qua

ntity

(MT)

RUTFFBF

(Apr 09 - Sep 09) (Oct 09 - Sep 10) (Oct 10 - Apr 11)

Dispensed Loss Dispensed Loss Dispensed Loss

42.2

0.0 0.00.00.3

133.5

2.6 0.5 0.50.812.3

103.3

Sustainable LivelihoodsWhile not a primary goal of NuLife, two successful initiatives were undertaken to link cured patients with sustainable livelihood opportunities.

In Kasese district, Reco industries supports more than 4,000 farmers by providing them with seeds and technical assistance to produce good quality groundnuts. NuLife encouraged Reco Industries to

incorporate PLWHA in their existing farmer groups. Now, more than 50% of these farmers are women and about 20% of all farmers are living with HIV/AIDS.

In Gulu district, a similar model was applied to that of Kasese. NuLife fostered a partnership between Reco Industries, Gulu Regional Referral Hospital (GRRH), TASO (a Ugandan NGO provide HIV

mr. thabit Obed, a farmer in Kasese


services), and the Diocese of Northern Uganda (DNU).The objective of this partnership was to ensure that formerly-malnourished clients and their families stay well nourished. In the agreement, GRRH and TASO link cured clients discharged from the OTC with the DNU. The DNU provides 160 acres of land to farmers who were part of this project. Reco Industries uses the ground nuts they grow to make RUTF.

monitoring, evaluation and Documentation With NuLife support, key indicators for nutrition and HIV/AIDS services were defined, routinely tracked, and integrated in the national health information management system. Data were also used by health facilities to guide performance improvement and by NuLife to provide important policy input. NuLife accomplished the following in monitoring and evaluation:

Developing and Revising Facility-Level monitoring toolsMonitoring tools were developed to allow performance monitoring of the nutrition program in the context of HIV care and support.

The monitoring tools currently in use at all supported health facilities include:

• HIV/ART cards. The existing card was revised to include recording of clinical assessment using MUAC, categorization of nutrition status, and prescription of RUTF.

• Health facility entry point client register at the HIV Clinic. The register was revised to include a column for recording MUAC color code.

• Outpatient therapeutic care patient register. This register captures patient demographics, anthropometric results, HIV status, visit and revisit dates, RUTF dispense and refills, and patient outcomes. A monthly OTC report

OtC register

was also developed and is in use by supported health facilities to report on monthly progress.

• OTC ration card. This is given to all clients enrolled on OTC. The card records client weight, MUAC, number of sachets prescribed and received, and appointment dates.

• Community nutrition assessment form. This is a simplified color-coded form used by community health workers to report on individuals assessed in their communities using MUAC and referred to the health facilities. This form lists malnutrition status, sex, age, and nutrition counseling provided.

• Community referral form. This form is used by the community health workers to refer individuals identified as acutely malnourished using the MUAC tapes to health facilities. This form is also used by facility health workers to counter-refer clients to community health workers for follow-up.

NuLife trained facility and community health workers in the use of the revised tools. In addition, data collection, quality assessment, and data use were incorporated in the coaching guide currently in use by regional MOH staff who provide coaching and on-job mentoring to facilities.

Community referral formCommunity nutrition assessment form


Integration of Nutrition Indicators into National HmISAware of the vitality of the national information system in improving health care management decisions, NuLife provided evidence and worked with partners to lobby for nutrition indicators be included in the national health management information system (HMIS) when the system was being reviewed. The following indicators were incorporated:

• Number of children 5 years and below who are malnourished (MUAC color yellow or red).

• Number of pregnant women who are malnourished (MUAC color yellow or red).

• Number of children under 5 years or 5 years and above who have severe acute malnutrition.

time and Cost for RUtFIn the course of implementation, the program was able to determine the average number of days it took for different individuals to be cured once enrolled in OTC. The average weight gained during treatment was also determined. The findings are depicted in Table 5. This is information, which has never before been analyzed in Uganda, has implications for programming and determining the cost of treating malnutrition using RUTF.

table 5. Average length of stay and average weight gained by age, sex, malnutrition status, HIV status, and ART status

Average duration (days)

Average weight gain (kgs)

SexMale 69 5.8

Female 65 6.9

AgeChildren (6 mo. – 17 yrs.) 66 3.8

Adults (18 years +) 68 8.3

Malnutrition status

Severe Acute Malnutrition 69 8.6

Moderate Acute Malnutrition 66 3.7

HIV statusHIV-positive 67 8.3

HIV negative 69 3.3

ART statusOn-ART 67 9.1

Pre-ART 67 7.8


Challenges and Opportunities

NuLife has achieved many important results to support the MOH and USG

implementing partners in integrating food and nutrition interventions in HIV care, treatment and support services. Challenges and solutions are depicted in the table on this page. Opportunities identified are described in the next section.

Challenge Solution

National guidelines on management of acute malnutrition originally not officially approved Launched the IMAM guidelines

Mainstreaming delivery of RUTF into the MOH logistics system difficult

Inclusion of RUTF onto the medicines list will allow health facilities to order RUTF and integrate it into routine supply system

Continuous reformulation of district boundaries caused changes in personnel and made it difficult to maintain staff competence

Focused on regional referral hospitals as conduits for support to health facilities and VHT/community volunteers

High attrition and transfer rate of trained staff made it difficult to maintain staff confidence

Encouraged inclusion of nutrition into medical training at all levels and into continuous medical education credits to ensure staff competence

High expectation by facility and CHWs for monetary incentives made incentivizing difficult Provided facilities and CHWs with other non-financial incentives

High number of pregnant and lactating mothers cause strain on capacity of trained village health teams resulting in inadequate mother support groups at the community level

MOH and implementing partners collaborated with CBOs to foster establishment of more community-based mother support groups

Continued support for trained community health workers after completion of NuLife needed

Expert clients agreed to continue working; district health teams in many sites agreed to take on NuLife-trained CHWs during the next VHT training


Opportunities

On Sustainability and Health Systems Strengthening

• Supporting the MOH from the outset to roll out nutrition integration and working at all levels from policy to practice has enhanced the sustainability of nutrition and HIV/AIDS integrated service delivery.

• Building the capacity of the MOH, district and NGO staff as trainers creates resources for other partners to scale up this intervention even after NuLife phases out.

• Ensuring the availability of RUTF means that sites will not experience stock-outs and health workers will continue to assess all clients for malnutrition.

• Successfully advocating for nutrition indicators to be included in HMIS ensures sustainability.

• Integrating nutrition indicators within ART cards as opposed to introducing a whole set of data collection tools saves on reporting time for health workers.

On the Use of Quality Improvement and the Use of Data for Decision making

• Using a quality improvement approach to integrating nutrition into HIV/AIDS programs has proven effective to help streamline processes of care and improve quality of overall services.

• Regular coaching and mentoring to put into practice what health workers learn through training is critical for sustained improved performance.

• With ongoing support and awareness of monitoring as an integral part of improvement, staff are recognizing the value of improved documentation.

On Community Involvement

• Sites that already had a strong community structure prior to NuLife’s intervention enabled smooth integration of nutrition activities at the community level.

• Community coordinators play a critical role in ensuring that feedback from health facilities is taken back to community health workers. Clear and regular channels of communication are necessary to enable a client to move smoothly from the community to a health facility and back.

• Supervision through monthly progress review meetings motivates community health workers to remain active.

• Networking and collaboration with NGO and community-based projects enhanced opportunities to link the hospitals with the communities in the vicinity.


Appendix A

NuLife performance management plan Indicator table

Indicator FY 2008

FY 2009 (Apr 09 – Sep 09)

Achievement

FY 2010 (Oct 09 – Sep 10) FY 2011 (Oct 10 – Apr 11)GRAND TOTAL

CommentTarget Achievement Target Achievement Achievement

Strategic Objective: Improved quality of life of people living with and affected by HIV/AIDS in Uganda through improved nutrition

Indicator 1a Number of HIV-positive individuals receiving ART with evidence of severe malnutrition who received food and nutrition supplementation (Previously PEPFAR)

0 1,341 1,600 3,524 2,000 2,185 7,050Target surpassed for all the three (3) years.

Indicator 1b Number of HIV-positive individuals receiving food and nutrition supplementation

0 3,219 4,000 8,516 4,600 4,454 16,189Target surpassed for all the three (3) years.

Intermediate Result 1: Nutrition interventions integrated into HIV care and treatment

Indicator 1.1Percent of HIV-positive individuals receiving nutritional assessment utilizing MUAC during HIV clinic visits

0% 48% 85% 74% 75% 83% n/aSignificant improvement in achievement on target over the project life

Indicator 1.2 Percent of HIV-positive individuals receiving nutritional counseling during HIV Clinic visits

0% 20% 40% 13% 20% 40% n/aFinal achievement on target two times higher than that achieved in the first year.

Indicator 1.3 Number of HIV-positive pregnant or lactating women receiving food and nutrition supplementation in a PMTCT setting (Previously PEPFAR)

0 75 100 153 80 61 289


Indicator FY 2008

FY 2009 (Apr 09 – Sep 09)

Achievement



Indicator 1.4 Number of OVC receiving food and nutritional supplementation through OVC programs (Previously PEPFAR)

0 1,774 3,000 4,439 2,300 2,395 8,608

Indicator 1.5 Percentage of PLWHA who know at least two of the three recommended ways to increase energy intake

5% n/a 15% n/a n/a n/a n/aA survey to report on this indicator was not regularly undertaken.

Indicator 1.6 Percent of HIV-positive adults and OVCs treated with RUTF for acute malnutrition who defaulted

n/a 33% 10% 53% 40% 47% 49%

Caution should be exercised in using this indicator as a measure of performance. The initial methodology for tracking this indicator was based on aggregating clients defaulting from their program irrespective of their admission dates.

Indicator 1.7 Number of HIV-positive adults and children receiving a minimum of one clinical service (PEPFAR NGI)

n/a 3,219 41,310 8,516 4,600 4,454 16,189

It was not possible to record unique numbers assessed at the HIV clinics. Hence, only numbers for clients who received OTC have been used.

Indicator 1.8 Number of HIV-positive clinically malnourished clients who received therapeutic or supplementary food (PEPFAR NGI)

n/a 3,219 4,000 8,516 4,600 4,454 16,189

Indicator 1.9: Number of eligible clients who received food and/or other nutrition services (PEPFAR NGI)

n/a 4,933 3,000 12,955 7,000 6,849 24,797This represents all unique clients admitted on OTC.

Indicator 1.10 % PLWHA that know the two recommended replacement feeding options

12% n/a n/a n/a 25%* n/a n/aA survey to report on this indicator was not regularly undertaken.

* A survey will be undertaken to gauge achievement of this indicator (target- Jinja & Iganga Hospital catchment areas)


Indicator FY 2008

FY 2009 (Apr 09 – Sep 09)

Achievement



Sub Result 1.1: Guidelines and protocol developed

Indicator 1.1.1 Percent of HIV care and treatment facilities with guidelines on comprehensive nutrition care and support for PLWHA

0% 94% 100% 11% 20% 50% 50%

Sub Result 1.2: Facility capacity strengthened

Indicator 1.2.1 Percent of HIV care and treatment facilities with a minimum set of anthropometric equipment

7% 100% 100% 85% 85% 95% 95%

Indicator 1.2.2 Percent of HIV care and treatment facilities with nutrition and HIV-related counselling materials or job aids updated by NuLife

0% 94% 100% 70% 75% 61% 61%

Indicator 1.2.3 Number of health facilities certified as mother-baby friendly

n/a n/a 2 0 2 2** n/a

Sub Result 1.3: Human capacity strengthened

Indicator 1.3.1 Number of health care workers who successfully completed an in-service training program within the reporting period (PEPFAR NGI)

0 1,493 300 254 n/a n/a 1,747

** The two facilities have completed an internal assessment and are awaiting an external assessment leading to certification.


Indicator FY 2008

FY 2009 (Apr 09 – Sep 09)

Achievement



Sub Result 1.4: Linkages between facility and community strengthened

Indicator 1.4.1 Number of acutely malnourished individuals assessed by community health workers and referred to sites providing comprehensive nutrition care

0 863 900 8,587 5,000 n/a n/a

Indicator 1.4.2 Percent of trained community volunteers who are actively referring clients for nutritional interventions

n/a n/a 60% 71% 75% n/a n/a

Intermediate Result 2: Nationally acceptable RUTF developed and produced locally

Indicator 2.1 Number (in metric tons) of RUTF produced locally

0 0 80 48 72 72 n/a

Indicator 2.1.1 Local capacity for the development of RUTF that meets national and international standards established

n/a n/a n/a n/a n/a n/a n/a

Indicator 2.1.2 Uganda manufacturer certified

0 n/a n/a n/a n/a n/a n/a


Indicator FY 2008

FY 2009 (Apr 09 – Sep 09)

Achievement



Intermediate Result 3: Effective systems for the delivery and storage of RUTF established

Sub result 3.1: Effective system for distribution of RUTF developed

Indicator 3.1.1 Number of metric tons of RUTF or FBF distributed to health facilities

0 58 160 240 312 164 462

Sub result 3.2: Effective stock management systems for RUTF developed

Indicator 3.2.1 Percent of sites experiencing stock-outs of RUTF or FBF in the past three months

n/a n/a n/a n/a 0% 35.2% 35.2%

There was delay in formalizing transport contract with a service provider during the March/April 2011 period. This caused a delay in getting RUTF to sites. 19 sites were affected.

Indicator 3.2.2 Percentage loss of the RUTF or FBF distributed to NuLife supported facilities

n/a 0.7% 0% 0.3% 0% 1.1% 2.1%

Almost 85% of the loss/damage reported was as result of administering the appetite test to clients.


Appendix B

List of Documents and tools Developed during NuLife

training and Implementation tools for Comprehensive Nutrition Care for pLWHA Developed by Nulife in Support of mOH

Level Type of Material Title

Theme: Infant and Young Child Feeding

Infant and Young Child Feeding for Health Facility and Community-Based Levels

Training Manual Infant and Young Child Feeding: A Training Manual for Community Volunteers

Counselling Cards 1. Infant and Young Child Feeding National Counselling Cards for Health Workers

2. Infant and Young Child Feeding National Counselling Cards for Community Volunteers




Booklet Key and Supporting Messages: Counselling Cards for Community Volunteers

Booklet Infant and Young Child Feeding with a Focus on HIV/AIDS: A Question and Answer Guide

1

2



Brochures (7) and Insert (1) 1. Nutrition During Pregnancy and Breastfeeding

2. How to Breastfeed Your Baby

3. How to Feed a Baby After 6 Months

4. How to Hand Express Breast Milk

5. How to Feed Your Baby Fresh Animal Milk

6. How to Feed Your Baby Infant Formula

7. How to Feed a Sick Child

8. How to Safely Heat-Treat Breast Milk


Theme: Comprehensive Nutrition Care for People Living with HIV

Facility Level Health Providers

Training Manual Comprehensive Nutrition Care for People Living with HIV/AIDS: A Trainers Manual for Facility-Based Health Providers

Training Manual Comprehensive Nutrition Care for People Living with HIV/AIDS: Participants Manual for Facility-Based Health Providers

Counselling Cards Nutrition Care and Support for People Living with HIV: National Counselling Cards

1 2

3

4

56

7

8



Job Aids Comprehensive Nutrition Care and Support- Facility-Level Job Aids for Outpatient Therapeutic Care in Health Facilities Supported by NuLife

Wall Charts (4) 1. Steps to Accurately Use a MUAC Tape

2. RUTF Dosing Chart

3. Weight at Admission & Target Weight for Discharge

4. Patients Eligible for OTC through Nulife Supported Programs


Supply Chain and M&E (Facility-Level Health Providers)

Training Manual Supply Chain Management, Monitoring and Reporting of Outpatient Therapeutic Care Programs

Community-Level Volunteers

Training Manual Integrating Nutrition into Community HIV/AIDS Care and Support Programs: A Trainer Manual for Training Community Volunteers

Handbook Integrating Nutrition into Community HIV/AIDS Care and Support Programs: A Handbook for Trainers of Trainers

1

2

3

4



Training Manual Integrating Nutrition into Community HIV/AIDS Care and Support Programs: A Trainer Manual for Trainers of Community Volunteers (TOT)

Counselling Cards Nutrition Care and Support for People Living with HIV: National Counselling Cards (Community)

Job Aids Comprehensive Nutrition Care and Support- Community-Level Job Aids for Community Volunteers Working with Health Facilities Supported by NuLife

M&E Tools Community RegisterReferral FormsMonthly Reporting Forms


Tools Anthropometric Tools Mid-Upper Arm Circumference Tapes for 4 Age Different Categories (For Use by Facility-Based and Community-Based Workers)

Others CDs with:

1. Community intervention strategy

2. QI write up

3. Conference presentations

4. Poster presentations

5. Success stories

a. Frank

b. Luwero child

c. Farmers-livelihoods

d. Reco and RUTF production

1. IYCF policy guidelines

2. Samples of RUTF and FBF

Date post:	27-May-2020
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