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“Getting the Knack of NACS”
Feb 22-23, 2012
The QA/QI Approach: Uganda’s Experience
Margaret Kyenkya
USAID HEALTH CARE IMPROVEMENT PROJECT
Outline of the presentation
• Describe the Service Delivery Model used in Uganda, with a special emphasis on the Health Facility-Community Continuum (quality assurance along this continuum)
• Describe the Quality Improvement Approach, including site-level coaching/mentoring
• Example of the case management approach
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USAID HEALTH CARE IMPROVEMENT PROJECT
Integrated approach involved 3 strategies:1. Policy
• MOH partnership for guideline development, implementation, and scale-up
• Multi-stakeholder engagement2. Service Delivery
• Quality improvement in clinics• Strengthening community-facility linkages
3. Production• Establishing local RUTF production• Integrated supply chains • Linking to agricultural livelihoods
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NuLife – Food and Nutrition Interventions for Uganda: USAID-funded project, Jan 2008-Aug 2011
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Development of Training Manuals and Job Aids
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Ministry of Health Policies, strategies, Guidelines, Protocols and training curricula for HIV-Nutrition, Training national trainers, coaches
Health FacilityHR capacity strengthening Strengthen links with communitySupply chain systemsHMIS, equipment provision
Community ComponentTrain community based workers and establishing standards, establishing referral systems, Provision of essential tools
RUTF (Rutafa) production, storage, distribution and logistics
DistrictQ.I and supervision activities (Coaching/mentoring)
RUTF and FBP procurement
Ser
vice
s pr
ovid
ed
Ref
err
al
Fol
low
-up
Pol
icie
s an
d
guid
elin
es
Actors and Levels Involved in the Program
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1 ½ weeks later3.8kg21/1/2010
1 month on RUTF 4.6 kg, 19/2/10
At admission to OTC3.4 kg-21/1/2010
2 months on RUTF 5.3 kg 19/3/10
Frank 7 months old6
Service Delivery
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USAID HEALTH CARE IMPROVEMENT PROJECT
Service Delivery: 7 Steps
Process allows for gradual integration of nutrition into HIV/AIDS care and support using the QI approach:
Assessment
All HIV-infected patients are assessed at each visit
Education
All HIV-infected patients receive education on good nutrition and hygiene
Community Links
Links are established between community and facility
Follow-up
All patients receiving RUTF receive follow-up
Food by Prescription
All moderately and severely malnourished patients who pass the appetite test receive RUTF
Counseling
All malnourished patients receive counseling
Categorization
The nutrition status is recorded on the care card for each HIV- infected patient
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USAID HEALTH CARE IMPROVEMENT PROJECT
Key Changes for Improvements in Assessment and Categorization
• Introduction and use of color-coded MUAC tape• Task shifting to use expert clients and community volunteers to
assess clients using MUAC tape• Amendment of the daily clinic register to track assessment and
categorization• Streamlining of client flow so that only moderate acute
malnourished (MAM) and severe acute malnourished (SAM) clients with complications see clinicians
• Development and display of job aids reminding clinicians to categorize all clients seen
• Increase in the number of days clinics are open
Assessment EducationCommunity Links
Follow-upFood by Prescription
CounselingCategorization
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USAID HEALTH CARE IMPROVEMENT PROJECT
Taking Mid Upper Arm Circumference (MUAC)
Checking for Bilateral Pitting Oedema
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USAID HEALTH CARE IMPROVEMENT PROJECT
Assessment and Categorization Results
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2009
Mar
2009
Apr
2009
May
2009
Jun
2009
Jul
2009
Aug
2009
Sep
2009
Oct
2009
Nov
2009
Dec
2010
Jan
2010
Feb
2010
Mar
2010
Apr
2010
May
2010
Jun
2010
Jul
2010
Aug
2010
Sep
2010
Oct
2010
Nov
2010
Dec
2011
Jan
2011
Feb
% As-sessed
0 0.24 0.32 0.53 0.63000000000000
1
0.62000000000000
1
0.54 0.57000000000000
1
0.66000000000000
2
0.67000000000000
2
0.72000000000000
1
0.78 0.83000000000000
1
0.75000000000000
1
0.84000000000000
1
0.87000000000000
1
0.84000000000000
1
0.67000000000000
2
0.73000000000000
1
0.83000000000000
1
0.85000000000000
1
0.91 0.93 0.95000000000000
1
5%15%25%35%45%55%65%75%85%95%
Percentage of Clients Assessed Using MUAC at NuLife-Supported Sites (March 2009 - February 2011)
% o
f Clie
nts
Ass
esse
d
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USAID HEALTH CARE IMPROVEMENT PROJECT
Key Changes for Improvements in Counseling
• Training and incorporation of volunteer counselors and expert clients to overcome staffing challenges and carry out nutrition counseling
• Development and use of counseling cards to inform clients on appropriate nutrition practices and the use of RUTF
• Amendment of clients’ general registers to record and track counseling
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Assessment EducationCommunity Links
Follow-upFood by Prescription
CounselingCategorization
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USAID HEALTH CARE IMPROVEMENT PROJECT
Counseling Results
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2009
Mar
2009
Apr
2009
May
2009
Jun
2009
Jul
2009
Aug
2009
Sep
2009
Oct
2009
Nov
2009
Dec
2010
Jan
2010
Feb
2010
Mar
2010
Apr
2010
May
2010
Jun
2010
Jul
2010
Aug
2010
Sep
2010
Oct
2010
Nov
2010
Dec
2011
Jan
% Counseled
0 0.85000000000000
1
0.48 0.38 0.26 0.22 0.28 0.44 0.21 0.33 0.33 0.54 0.8 0.74000000000000
1
0.83000000000000
1
0.89 0.93 0.88 0.96000000000000
1
0.93 0.89 0.87000000000000
1
0.70000000000000
1
5%15%25%35%45%55%65%75%85%95%
Percentage of Malnourished Clients Who Received Nutrition Counsel-ing in 54 NuLife-Supported Sites (March 2009 - January 2011)
% o
f Clie
nts
Coun
sele
d
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USAID HEALTH CARE IMPROVEMENT PROJECT
Key Changes for Improvements in Food by Prescription
• Supply of RUTF dosing charts for all clinicians’ rooms and dispensaries to help calculate appropriate RUTF prescriptions
Assessment EducationCommunity Links
Follow-upFood by Prescription
CounselingCategorization
• Training of staff and development of job aids on guidelines for client RUTF eligibility and dosing
• Training of nurses to prescribe RUTF
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USAID HEALTH CARE IMPROVEMENT PROJECT
Food by Prescription Results
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Children 6 Months to 18
Years
Adults 18 Years and Older
Pregnant and Lactating Women
Total
HIV Positive 4454 11446 289 16189
HIV Negative 4828 0 0 4828
Exposed/Unknown 3780 0 0 3780
Total 13062 11446 289 24797
1250
3750
6250
8750
11250
13750
16250
18750
21250
23750
Number of Outpatient Therapeutic Clients Assessed and Treated for Acute Malnutrition in 54 NuLife-Supported Facilities by Client Cate-
gory and HIV Status (April 2009 - April 2011)
HIV PositiveHIV NegativeExposed/UnknownTotal
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USAID HEALTH CARE IMPROVEMENT PROJECT
Key Changes for Improvements in Follow-up
At return appointments: • Synchronization of ART and RUTF check-ups and
refill dates• Re-organization of clinics to streamline client flow on
follow-up and pharmacy visitsAt home:• trained community based workers follow up at home
or community organised events• Collection or supplies for home-based delivery to
weak clients16
Assessment EducationCommunity Links
Follow-upFood by Prescription
CounselingCategorization
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USAID HEALTH CARE IMPROVEMENT PROJECT
Follow-up Results
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2010 Jan
2010 Feb
2010 Mar
2010 Apr
2010 May
2010 Jun
2010 Jul
2010 Aug
2010 Sep
2010 Oct
2010 Nov
2010 Dec
2011 Jan
2011 Feb
2011 Mar
2011 Apr
% Fol-lowed-Up
0.55 0.7700000000000
01
0.8500000000000
01
0.8700000000000
01
0.8700000000000
01
0.6400000000000
02
0.59 0.58 0.6600000000000
02
0.6500000000000
02
0.6000000000000
01
0.59 0.7000000000000
01
0.8300000000000
01
0.79 0.8400000000000
01
5%
15%
25%
35%
45%
55%
65%
75%
85%
95%
Percentage of Oupatient Therapeutic Care-Enrolled Clients Return-ing for Follow-Up in NuLife-Supported Sites (January 2010 - April
2011)
% o
f Clie
nt R
etur
ning
for
Follo
w-U
p
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USAID HEALTH CARE IMPROVEMENT PROJECT
Key Changes for Improvements in Community-Facility Links
• Facility-based volunteers to liaise with community-based volunteers to support a client
• Joint monthly meetings with volunteers and community coordinators to improve dialogue, and improve quality of support
• Inclusion of community coordinators on QI teams• Identification of funding opportunities from NGOs and CBOs• Monitoring of number of clients referred by community volunteers• Motivation of volunteers by providing them with additional
training, involving them in clinic work, and recognizing their work, and stipend to cover transport
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Assessment EducationCommunity Links
Follow-upFood by Prescription
CounselingCategorization
Health Facility
● Re-assess ● Categorize
● Prescribe RUTF
● Counsel
● Document
● Counter-refer
Community Health Workers ● Mobilize communities ● Counsel on nutrition ● Identify malnourished cases ● Refer malnourished cases to health facility and follow up ● Link to sustainable livelihood & other programs ● Document
Partner Organizations
Community – Facility Linkage
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USAID HEALTH CARE IMPROVEMENT PROJECT
Community-Facility Links Results
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Regional Referral Hospitals
General Hospi-tals
Health Center IVs Total
Total Malnourished 4081 12988 2601 19670
Total Referred by CHW
3698 10479 2130 16307
1250
3750
6250
8750
11250
13750
16250
18750
91%
81%
82%
83%
Number of Individuals Assessed, Categorized as Acutely Malnour-ished, and Referred to NuLife-Supported Sites by Trained Com-
munity Health Workers (CHWs) (April 2009 - January 2011)
Total MalnourishedTotal Referred by CHW
USAID HEALTH CARE IMPROVEMENT PROJECT
Key Changes for Improvements in Nutrition Education
• Support of implementing partners with materials for health and nutrition education
• Training of expert clients to carry out health education sessions
• Provision of additional education sessions for late comers
• Recording and summarization of health education sessions to track topics addressed and number of clients educated
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Assessment EducationCommunity Links
Follow-upFood by Prescription
CounselingCategorization
Service Delivery
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USAID HEALTH CARE IMPROVEMENT PROJECT
Quality Improvement
Roles of Quality Improvement (QI) teams at all sites
• Determined barriers to NACS
integration
• Tested methods for
integrating NACS
• Analyzed data to determine
effectiveness of changes
• Ensured replenishment of
supplies
• Scaled up changes that led to
improvement
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USAID HEALTH CARE IMPROVEMENT PROJECT
Quality Improvement
Role of coaches and mentors:
• Support facility-level QI team meetings
• Technical visits by NuLife/MoH/DHT/Partners
• CPD/CME on nutrition topics
• Peer-peer learning sessions
• Sharing with nutrition stakeholders/implementers at meetings/workshops
• Replenishment of RUTF, job aides & equipment
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QI support mechanism
NuLife
& MoH
CC & Nutrition Focal Person
at H/FCHW
QI team meetings & Coaching
at H/F
DHT representative
FHW
Monthly CHW
progress review & planning meetings
Monthly CPDs/CMEs
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USAID HEALTH CARE IMPROVEMENT PROJECT
Conclusion
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USAID HEALTH CARE IMPROVEMENT PROJECT
Case Study: Road to Recovery; “Hills and Valleys”
MAM
(46 years old)
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Acknowledgements
The Uganda Ministry of Health
United States Agency for International Development
President’s Emergency Plan for AIDS Relief (PEPFAR)
Food and Nutrition Interventions for Uganda (NuLife) Project
University Research Co. LLC and implementing partners (Save the Children and ACDI/VOCA, RECO
Industries, Networks in Uganda of those Living Positively with HIV/AIDS)
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Thank you