Margaret Kyenkya

1

“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

2


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

3

NuLife – Food and Nutrition Interventions for Uganda: USAID-funded project, Jan 2008-Aug 2011

3

Development of Training Manuals and Job Aids

4

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

5

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

7


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

88


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

99


Taking Mid Upper Arm Circumference (MUAC)

Checking for Bilateral Pitting Oedema

10


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

11


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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12


Counseling Results

13

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

13


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




• 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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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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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




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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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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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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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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


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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Service Delivery

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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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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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Conclusion

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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

Health & Medicine

Margaret Kyenkya