“Getting the Knack of NACS”      Feb 22-23, 2012The QA/QI Approach:Uganda’s Experience    Margaret Kyenkya                ...
Outline of the presentation • Describe the Service Delivery Model used in Uganda,   with a special emphasis on the Health ...
NuLife – Food and Nutrition Interventions forUganda: USAID-funded project, Jan 2008-Aug 2011Integrated approach involved 3...
Development of Training Manuals and Job Aids                                               4
Actors and Levels                                     Ministry of HealthInvolved in the                      Policies, str...
At admission to OTC  3.4 kg-  21/1/2010                        1 ½ weeks later                        3.8kg               ...
Service Delivery                   7
Service Delivery: 7 StepsProcess allows for gradual integration of nutrition intoHIV/AIDS care and support using the QI ap...
Key Changes for Improvements in   Assessment and CategorizationAssessment   Categorization   Counseling   Food by        F...
Taking Mid Upper Arm       Checking for BilateralCircumference (MUAC)         Pitting Oedema                       USAID H...
Assessment and Categorization Results                                  Percentage of Clients Assessed Using MUAC at NuLife...
Key Changes for Improvements in   CounselingAssessment   Categorization   Counseling   Food by        Follow-up   Communit...
Counseling Results                            Percentage of Malnourished Clients Who Received Nutrition Counseling        ...
Key Changes for Improvements in Food by   Prescription                                           Food by                  ...
Food by Prescription Results         Number of Outpatient Therapeutic Clients Assessed and Treated for           Acute Mal...
Key Changes for Improvements in Follow-upAssessment   Categorization   Counseling   Food by                    Community  ...
Follow-up Results                                       Percentage of Oupatient Therapeutic Care-Enrolled Clients Returnin...
Key Changes for Improvements in Community- Facility Links             CategorizatiAssessment                  Counseling  ...
Health Facility                               ● Re-assess                               ● Categorize                      ...
Community-Facility Links Results               Number of Individuals Assessed, Categorized as Acutely           Malnourish...
Key Changes for Improvements in Nutrition   EducationAssessment   Categorization   Counseling   Food by        Follow-up  ...
Service Delivery                   22
Quality ImprovementRoles of Quality Improvement (QI) teams at all sites•   Determined barriers to    NACS integration•   T...
Quality Improvement Role of coaches and mentors: • Support facility-level QI team meetings • Technical visits by NuLife/Mo...
Monthly             CPDs/FHW          CMEs              Monthly               CC & Nutrition               CHWCHW         ...
Conclusion             USAID HEALTH CARE IMPROVEMENT PROJECT                                                     26
Case Study: Road to Recovery; “Hills andValleys”                 (46 years old)      MAM                          USAID HE...
Acknowledgements             The Uganda Ministry of Health             United States Agency for International             ...
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  • Job aids play an important role in assuring policies are clear and “implementable” – but they also play an important role in scaling up and sustaining the proper delivery of the policy message.Same training content for health facility based workers and for community based workers, but different methodologies. For community workers, used adult learning/hands-on approach.
  • In May 2007, WHO, WFP, UNICEF, and the UN’s Standing Committee on Nutrition endorsed the use of MUAC and testing of nutritional oedema as assessment criteria for identifying acute malnutrition in the community. Source: Community-based Management of Severe Acute Malnutrition: A Joint Statement by the World Health Organization, the World Food Programme, the United Nations Standing Committee on Nutrition, and the United Nations Children’s Fund, May 2007.
  • For example, facilities would retain a record of clients by village and share these with the community coordinator. Made it possible for the community based volunteer to visit and give feedback
  • Margaret Kyenkya

    1. 1. “Getting the Knack of NACS” Feb 22-23, 2012The QA/QI Approach:Uganda’s Experience Margaret Kyenkya 1
    2. 2. 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 USAID HEALTH CARE IMPROVEMENT PROJECT 2
    3. 3. NuLife – Food and Nutrition Interventions forUganda: USAID-funded project, Jan 2008-Aug 2011Integrated 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 linkages3. Production • Establishing local RUTF production • Integrated supply chains • Linking to agricultural livelihoods USAID HEALTH CARE IMPROVEMENT PROJECT 3 3
    4. 4. Development of Training Manuals and Job Aids 4
    5. 5. Actors and Levels Ministry of HealthInvolved in the Policies, strategies, Guidelines, Protocols and training curricula forProgram HIV-Nutrition, Training national trainers, coaches District guidelines Policies Q.I and supervision activities and (Coaching/mentoring) RUTF and FBP Health Facility RUTF (Rutafa) procurement HR capacity strengthening production, Strengthen links with community Supply chain systems storage, HMIS, equipment provision distribution and logistics Follow-up Services provided Referral Community Component Train community based workers and establishing standards, establishing referral systems, Provision of essential tools 5
    6. 6. At admission to OTC 3.4 kg- 21/1/2010 1 ½ weeks later 3.8kg 21/1/2010 1 month on RUTF 4.6 kg, 19/2/10 2 months on RUTFFrank 7 months old 5.3 kg 19/3/10 6
    7. 7. Service Delivery 7
    8. 8. Service Delivery: 7 StepsProcess allows for gradual integration of nutrition intoHIV/AIDS care and support using the QI approach:Assessment Categorization Counseling Food by Follow-up Community Education Prescription LinksAll HIV- The nutrition All All patients All HIV-infected status is malnourished All receiving Links are infectedpatients are recorded on the patients moderately RUTF receive established patientsassessed at care card for receive and severely follow-up between receiveeach visit each HIV- counseling malnourished community education on infected patient patients who and facility good nutrition pass the and hygiene appetite test receive RUTF USAID HEALTH CARE IMPROVEMENT PROJECT 8 8
    9. 9. Key Changes for Improvements in Assessment and CategorizationAssessment Categorization Counseling Food by Follow-up Community Education Prescription Links • 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 USAID HEALTH CARE IMPROVEMENT PROJECT 9 9
    10. 10. Taking Mid Upper Arm Checking for BilateralCircumference (MUAC) Pitting Oedema USAID HEALTH CARE IMPROVEMENT PROJECT 10
    11. 11. Assessment and Categorization Results Percentage of Clients Assessed Using MUAC at NuLife-Supported Sites (March 2009 - February 2011) 100% 90% 80%% of Clients Assessed 70% 60% 50% 40% 30% 20% 10% 0% Mar 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% USAID HEALTH CARE IMPROVEMENT PROJECT 11 11
    12. 12. Key Changes for Improvements in CounselingAssessment Categorization Counseling Food by Follow-up Community Education Prescription Links • 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 USAID HEALTH CARE IMPROVEMENT PROJECT 12 12
    13. 13. Counseling Results Percentage of Malnourished Clients Who Received Nutrition Counseling in 54 NuLife-Supported Sites (March 2009 - January 2011) 100% 90% 80%% of Clients Counseled 70% 60% 50% 40% 30% 20% 10% 0% Mar 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 % Counseled 0% 85% 48% 38% 26% 22% 28% 44% 21% 33% 33% 54% 80% 74% 83% 89% 93% 88% 96% 93% 89% 87% 70% USAID HEALTH CARE IMPROVEMENT PROJECT 13 13
    14. 14. Key Changes for Improvements in Food by Prescription Food by Community EducationAssessment Categorization Counseling Follow-up Prescription Links • 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 USAID HEALTH CARE IMPROVEMENT PROJECT 14
    15. 15. Food by Prescription Results 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) 25000 22500 20000 17500 15000 12500 10000 HIV Positive 7500 5000 HIV Negative 2500 Exposed/Unknown 0 Total Children 6 Pregnant and Adults 18 Years Months to 18 Lactating Total and Older Years Women HIV Positive 4454 11446 289 16189 HIV Negative 4828 0 0 4828 Exposed/Unknown 3780 0 0 3780 Total 13062 11446 289 24797 USAID HEALTH CARE IMPROVEMENT PROJECT 15 15
    16. 16. Key Changes for Improvements in Follow-upAssessment Categorization Counseling Food by Community Follow-up Education Prescription Links 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 visits At home: • trained community based workers follow up at home or community organised events • Collection or supplies for home-based delivery to weak clients USAID HEALTH CARE IMPROVEMENT PROJECT 16 16
    17. 17. Follow-up Results Percentage of Oupatient Therapeutic Care-Enrolled Clients Returning for Follow-Up in NuLife-Supported Sites (January 2010 - April 2011) 100% 90%% of Client Returning for Follow-Up 80% 70% 60% 50% 40% 30% 20% 10% 0% Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr 2010 2011 % Followed-Up 55% 77% 85% 87% 87% 64% 59% 58% 66% 65% 60% 59% 70% 83% 79% 84% USAID HEALTH CARE IMPROVEMENT PROJECT 17 17
    18. 18. Key Changes for Improvements in Community- Facility Links CategorizatiAssessment Counseling Food by Follow-up Community Education on Prescription 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 USAID HEALTH CARE IMPROVEMENT PROJECT 18
    19. 19. Health Facility ● Re-assess ● Categorize ● Prescribe RUTF ● Counsel ● Document ● Counter-referCommunity – FacilityLinkage 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 19
    20. 20. Community-Facility Links Results Number of Individuals Assessed, Categorized as Acutely Malnourished, and Referred to NuLife-Supported Sites by Trained Community Health Workers (CHWs) (April 2009 - January 2011) 20000 17500 83% 15000 12500 81% 10000 7500 Total Malnourished 5000 91% Total Referred by CHW 2500 82% 0 Regional General Health Center Referral Total Hospitals IVs HospitalsTotal Malnourished 4081 12988 2601 19670Total Referred by CHW 3698 10479 2130 16307 USAID HEALTH CARE IMPROVEMENT PROJECT 20
    21. 21. Key Changes for Improvements in Nutrition EducationAssessment Categorization Counseling Food by Follow-up Community Education Prescription Links • 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 USAID HEALTH CARE IMPROVEMENT PROJECT 21
    22. 22. Service Delivery 22
    23. 23. Quality ImprovementRoles 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 USAID HEALTH CARE IMPROVEMENT PROJECT 23
    24. 24. 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 USAID HEALTH CARE IMPROVEMENT PROJECT 24
    25. 25. Monthly CPDs/FHW CMEs Monthly CC & Nutrition CHWCHW progress Focal Person review & at H/F planning meetings QI teamQI support NuLife meetings &mechanism & MoH Coaching at H/F DHT representative 25
    26. 26. Conclusion USAID HEALTH CARE IMPROVEMENT PROJECT 26
    27. 27. Case Study: Road to Recovery; “Hills andValleys” (46 years old) MAM USAID HEALTH CARE IMPROVEMENT PROJECT 27
    28. 28. 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, RECOIndustries, Networks in Uganda of those Living Positively with HIV/AIDS) 28
    29. 29. Thank you
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