QI Deliverable_PharmAccess

1 BUSPH IH743: Brown, Cain, Forbush, Jang, Kadangs, Kalal Feb. 2014
Quality Improvement Consulting Report for the
Namibia Adherence and Retention Project
ExecutiveSummary
PharmAccess Namibia, a subcontractor for the 3-year USAID funded Namibia Adherence and
Retention Project (NARP), has requested quality improvement assistance with their
Implementation Plan, Performance Management Plan (PMP) and monitoring and evaluation
(M&E) plan. NARP aims to strengthen and improve health outcomes of those infected and
affected by HIV, and will track its progress through six Intermediate Results. This consulting
report includes recommendations for aligning the M&E plan to their Intermediate Results,
ensuring the Intermediate Results data will be recorded and analyzed accurately.
One of PharmAccess Namibia’s key functions in NARP is to collect and process the data
recorded by NARP’s four implementing partners: Project Hope, Catholic AIDS Action, Positive
Vibes and Life Line/Child Line. This report contains suggestions for improving data capture by
PharmAccess Namibia’s implementing partners. Overarching recommendations for NARP data
collection include ensuring there are denominators for the PMP indicators, and confirming that
implementing partners’ reporting forms are correctly formatted to record all information
necessary. This quality improvement report organizes our recommendations by Intermediate
Result, detailing the key activities within each Intermediate Result, the numerator of the
indicator of the activity, and the denominator of the indicator of the activity. Additional
suggestions relating to the Intermediate Results are also included below each Intermediate
Result table.
Introduction
In an effort to increase adherence and retention to HIV/AIDS treatment and mitigate its
burdensome effects on People Living with HIV (PLHIV) in Namibia, several organizations,
including PharmAccess, are responsible for implementing programs based on their respective
area of expertise as seen in Table 1.
Recently, there has been a shift in the management of HIV/AIDS amongst PLHIV, from a fatal
disease to one that can be managed. By adjusting services to make them more personable,
NARP seeks to increase retention and adherence. There are several approaches that NARP will
address: the shift from management of illness to wellness through engagement, patient-
centered referrals to address various needs of the patient, a comprehensive supervisory system
with clear communication, the leveraging of human resources by engaging existing health
workers, the strengthening of relationships between parts of the private sector, and the
leveraging of community resources with the use of village savings and loans.

Table 1: NARP Collaborators
Organization Area of Expertise
Project HOPE Namibia - Project management of NARP & coordination between
stakeholders
- Build on & strengthen existing referral networks
- Family focused approaches to OVC PMTCT programs
- Village savings & loans
Catholic AIDS Action - Care & support services to PLHIV
- Referrals
- Orphans,Vulnerable Children package of care
- Adolescent programming
- Community Health Workers
Positive VIBES - Training for PLHIV & staff using positive health, dignity, &
prevention model
- Adolescent clubs/support groups for those living with HIV
Lifeline/ChildLine - Training staff on gender issues on HIV & gender mainstreaming
- Training on child protection services & enhancement of referral
systems
- Transpose gender mainstreaming into programming, provide
technical assistance, supportive supervision
PharmAccess - Build on & strengthen mHealth applications for PLHIV
- Operational research on interventions for NARP
- Strengthen monitoring & evaluation
- Collaborate with other organizations & assist in project reviews
Project HOPE - The
People-to People
Health Foundation, Inc.
- Give technical assistance in project coordination
- M&E and implementation to Project HOPE Namibia
Methodology
The quality improvement deliverables were developed over a two week period in February
2014. Once our consulting team received the scope of work, several days were spent reading
over the provided background material: the NARP concept note, the implementation plan, and
accompanying annexes. Included in the annex attachment were documents outlining the PMP
and numerous other forms for data collection and reporting. There was an extensive amount of
information to cover, so our team divided up the project by the six intermediate results and then
formulated specific questions for our PharmAccess contact, Ingrid de Beer, setting up a Skype
call for mid-week. Five team members spoke with Ingrid who was able to provide our team with
a basic overview of the project. We were directed to speak further with Marthe van Andel, the
PharmAccess Namibia NARP project manager. We contacted Marthe via email with questions
about the PMP and M&E plan. The following day we received a reply with detailed answers and
further background information on the project.
The next step in our consulting process consisted of our team meeting to discuss each of our
intermediate results, ideas for quality improvement and ways to present the data. With this
background information, the ideas from Ingrid and Marthe, and personal knowledge, we
formulated our tailored product for PharmAccess’ current needs. After this initial development,

our team met to revise each individual portion to ensure that it satisfied all of PharmAccess’
requirements and provided a comprehensive quality improvement report.
Scope of Work
The scope of work for this quality improvement consulting assignment asked for:
 An analysis of the PMP and M&E plan of the project indicating alignment to goals and
identifying possible gaps.
 A quality improvement plan to ensure on-going improvement in the collection, capturing,
consolidation, and reporting of data.
This report is focused on analyzing the PMP and M&E for each particular Intermediate Result.
This report is organized by analysis of each IR. The analysis discusses the alignment to the
goals, the gaps discovered and areas for quality improvement of capture and collection of data.
The following deliverables are included in this report based on their corresponding IR:
Result 1: Increased access by PLHIV and OVC to integrated and comprehensive HIV care and
support services for an improved quality of life
1.1 Improved retention in care and adherence to treatment rates among enrolled PLHIV
through integrated community- and home-based care
1.2 Improved well-being of OVC and other affected individuals
Result 2: Enhanced capacities of community systems and structures to support a continuum of
care for PLHIV and affected families, including OVC
2.1 Strengthened coordinated and standardized bi-directional referrals for HIV-positive
clients & affected individuals
2.2 Strengthened community systems and models of care delivery that support a continuum
of care for infected and affected individuals
2.3 Strengthened community support for and increased linkages to quality Nutrition,
Assessment, Counseling, & Support (NACS) services for all beneficiaries
2.4 Strengthened community structures that facilitate active follow-up and care of other-
infant pairs from pregnancy to 18 months post-partum
Our team developed these materials with the guidance of our PharmAccess contact, Marthe van
Andel and assistance from Ingrid de Beer. If you have any questions or comments regarding the
deliverables or the development process, please don’t hesitate to contact any member of the
consulting team:
Rachel Jang rcj@bu.edu
Daniel Brown browndc@bu.edu
Devon Cain dbcain@bu.edu
Leigh Forbush lforbush@bu.edu
Casi Kadangs dkadangs@bu.edu
Michele Kalal mmkalal@bu.edu

Result 1: Increased access by PLHIV and OVC to integrated and
comprehensive HIV Care and Support services for an improved quality
of life
Intermediate Result 1.1: Improved retention in care and adherence to treatment rates
among enrolled PLHIV through integrated community- and home-based care
Key Activities Indicator Numerator Indicator Denominator
Positive Health,
Dignity, and
Prevention Services
for PLHIV
1.1a) # of project staff who have
completed PHDP integrated care and
support training
# of project staff including
CHWs
1.1b) # of PLHIV reached with PHDP # of PLHIV enrolled in pre-
ART or ART OR in target
communities
1.1c) # of PLHIV reached with PHDP
BCC messages
# of PLHIV enrolled in pre-
ART or ART OR in target
communities
Village Savings and
Loan Groups
1.1e) # of participants with expanded
asset base
# of project participants in
target communities
1.1f) # of participants with improved
nutritional intake
target communities
1.1g) # of participants with increased
ability to share resources with others
target communities
1.1h) # of community facilitators trained
to start up and manage VSL groups
# of target communities
1.1i) # of VSL groups formed # of target communities
1.1j) # supervisory visits to VSL groups # of VSL groups
1.1k) # of people who complete one
saving cycle
# project participants in target
communities
Gender Training
1.1l) # of project staff trained in gender # of project staff including
CHWs
1.1m) # of people reached by an
individual, small group, or community-
level intervention or service that
explicitly addressed norms about
masculinity related to HIV/AIDS
communities
1.1n) # of people reached with
prevention messages regarding GBV
and coercion related to HIV/AIDS
communities
1.1o) # of people reached with
messaging on male involvement in
PMTCT
communities
Diversifying the
Volunteer Pool
1.1p) # of people trained as community-
based care providers (including PLHIV,
men & under age 35)
# of volunteers recruited

First, several of the key indicators for this intermediate result were lacking denominators. Our
suggestions are indicated in the above table in italics/ blue colored font. We feel that
denominators for these indicators are very important in producing comparable values from the
collected data. Denominators facilitate assessment of the project impact that can be related to
other statistics produced outside of NARP. For monitoring and quality of data, it needs to be
very clear who the target population includes (pre-ART and ART clients), the target communities
for the village savings and loan (VSL) groups, and who the volunteer pool includes. As a result,
we recommended denominators for indicators 1.1b, 1.1c, 1.1e, 1.1f, 1.1g, 1.1h, 1.1i, 1.1j, 1.1k,
1.1l, 1.1m, 1.1n, 1.1o, and 1.1p.
Additionally, we found that indicators 1.1e and 1.1f were not directly correlated with any of the
questions in the Member Profile tool, found in Annex 6 of the background information. Thus, it
will be difficult to quantify and assess any changes regarding these indicators. We recommend
modifying the Member Profile tool to include more direct questions so that these specific
outcomes can be better observed. Conversely, the indicators can be changed to be more
aligned with the Member Profile tool.
Quality Improvement Plan: The first essential ingredient is ensuring the integrity and quality of
the data collected for this Intermediate Result is assigning clearly defined denominators for each
indicator. It is extremely important to take this first step as it will provide the framework for
interpreting the results. In addition to providing denominators, the Member Profile tool must be
revised to reflect and support the indicators that have been attached to it. This will make it
easier to observe and measure the desired outcomes.
Intermediate Result 1.2: Improved well-being of OVC and other affected individuals
1.2) # of OVC scoring achievement in
75% (23/30) or more indicators on the
parenting map
# of parenting map tests given
Prevention
training for
children/
adolescents
1.2a) # of eligible children/adolescents
provided with age-appropriate
evidence-based HIV prevention
education who attended 80% or more
of the required sessions (Session
amount dependent on age and
program enrolled for each child)
# of eligible children/adolescents
who enrolled in one of the
programs
enrolled in an HIV prevention
education program
who have not taken an HIV
prevention education course
previously and are in the correct
age range
Home-based care
and support
services
1.2b) # of eligible adults, adolescents,
and children provided with a minimum
of one care service
# of eligible adults, adolescents,
and children

1.2c) # of eligible adults, adolescents,
and children referred/linked to
protection and legal services
and children
1.2d) # of eligible adults, adolescents,
and children provided with
psychological, social, or spiritual
support
and children
1.2e) # of children referred to foster or
residential care
# of children eligible for foster or
residential care
1.2f) # of HIV positive children who
were screened for TB at last visit in a
community care setting (by CHWs in
home visits or at support groups)
# of HIV positive children who
were visited in a community care
setting
Activities for
OVC: after
schools, out of
school, and
feeding programs
# of OVC fed at soup kitchen # of OVC eligible to use the
soup kitchen
# of activities conducted after school
for OVC focusing on various
educational aspects per year
12 (theoretically one activity per
month)
Linkages to
vocational training
opportunities
1.2g) # of eligible children provided
with education support services
(school uniforms, school fees for
secondary education)
# of eligible children
1.2h) # of eligible children linked
through scholarships, apprenticeships,
and internships
# of eligible children
Indicator 1.2 needs clarification in the M&E plan. The parenting map indicators and materials
should be attached to the plan as an annex so that the PMP can be interpreted in one document
without needing to search. Additionally, the data collection which will be used to assess the
indicator will be gathered by using a sample of OVC. This needs to be altered to ensure a
random sample that represents the entire NARP population; the plan needs to collect data from
a variety of locations at different time points so that not all of the parenting maps are completed
at the same location or in only urban facilities.
Prevention Training for Adolescents
Prevention training is assessed through the use of a PEPFAR indicator. However, this PEPFAR
indicator (P8.1.D) is lacking a denominator. The suggested denominator for 1.2a involves
tallying the total number of eligible children who enrolled in one of the programs. Furthermore a
new indicator to determine if enough children are getting enrolled in an HIV prevention
education course could be measured. This would be attained through assessing how many
children enroll in the course out of those who are eligible. “Eligible” could be defined as those in
the correct age range who have not taken an HIV prevention education course previously. The
end result would measure what percentage of eligible children are being educated.
Home-Based Care and Support Services
A wide variety of home-based care and support services are offered to clients of many different

age ranges. All five of the indicators are assessed using three separate forms, two of which are
not contained at all within the M&E packet. The OVC registration form and the client registration
form are not included in the annex and we could not assess whether they meet the correct
standards for recording the information needed for each indicator. The Individual volunteer form
was found in Annex 7 with two forms, one for home-based care and one for OVC support. The
two forms are very similar and could be combined into the same form for ease of data collection
and reporting. All recording forms, volunteer or otherwise, need to be similar and collect the
exact same information; if community health workers or nurses are involved in data collection
their forms need to report the back in the same way as the others to ensure no data is lost.
Three of the five indicators are PEPFAR (C1.1D, C5.5D, and C5.6D) and all require a
denominator to improve the interpretation of the indicator. Our suggestion it to simply make the
indicator for 1.2b, 1.2c, and 1.2d the number of eligible adults, adolescents, and children with
the word “eligible” relating back to what the indicator is assessing. Thus, it could be those who
are eligible for care service or those eligible for psychological support. Additionally, the three
age ranges being evaluated need to be defined on the volunteer form. Currently it just has the
volunteer record for child or adult. The form must include all three options along with their
respective definition such as adult (20+), adolescent (15-19), and child (0-14).
We also think that the volunteer form could benefit from clarification under the three columns
describing ‘what was done during the visit’, ‘supplies given’, and the ‘referred to’ categories.
These have a lot of options under each of them, which don’t seem to relate to any of the data
that is being recorded; also some of the indicators would benefit from having their category
spelled out more plainly. We recommend that under the ‘what was done during visits’ column
that psychological, social, and spiritual support all receive their own label to better document the
results. Indicator 1.2e needs this as the ‘referred to’ category mentions social workers, but not
foster care. This could mean the same thing, but it would clarify proceedings to create a
separate category under referrals and to use consistent terminology.
Lastly indicator 1.2f lacks a denominator and is not being accurately tracked on the volunteer
form. A suggested denominator is the number of HIV positive children who were visited in a
community care setting. That way the indicator identifies how many children missed screening
that potentially needed it. The form only asks what type of treatment was provided, but it fails to
mention screening and patient HIV status.
Activities for OVC: After Schools, Out of School, and Feeding Programs
No indicators were developed for this IR1.2 key activity. We came up with two possibilities that
can be implemented to monitor progress towards this particular goal. First we noticed Annex 7of
the M&E plan contained a soup kitchen recording form. Thus an indicator cold monitor the
number of OVC fed at the soup kitchen out of the number of OVC eligible to use the soup
kitchen. Another indicator was to host 12 activities per year after school for OVC children. The
other activities form in Annex 7 could be modified to record after school activities. Then each
year the indicator would determine whether the goal was met or not. The number 12 per year
can be altered depending on how frequently activities can be held and/or include out of school

activities.
Linkages to Training Opportunities
Indicators 1.2g and 1.2h are both PEPFAR indicator C5.4.D. Denominators for these can be
developed as above, consisting of the number of eligible children for the respective numerator.
These two indicators would benefit immensely from alterations to the individual volunteer form
and any other form documenting those who provide education and vocational trainings. The
current form does not mention scholarships, apprenticeships, or internships and it lumps all
supplies given under a blanket educational supplies category. We recommend this be altered to
better capture the data needed for the indicators.
Quality Improvement Plan: We have concerns that include: PEPFAR indicators lacking
denominators, no indicators for key activity ‘Activities for OVC,’ and incomplete data capturing
through current collection forms. Recommendations included developing denominators for all
indicators and creating indicators for the ‘Activities for OVC’ category. Additionally, all collection
forms need to be modified to ensure they capture the correct information for the indicators.
Annex 1 displays the individual volunteer form with boxes depicting information that is missing.
Volunteers, community health workers, and others who collect data need to have forms that
utilize the same language to create consistency in the data collection. All of these collection
forms need to be placed in the PMP packet in order to coordinate all the data collection and
ensure no information gets lost.
Result 2: Enhanced capacity of community systems and structures to
support a continuum of care for PLHIV and affected families, including
OVC.
Intermediate Result 2.1: Strengthened coordinated and standardized bi-directional
referrals for HIV-positive clients & affected individuals
Client Centered
Referrals
2.1a) # of health facilities with
functioning bidirectional referral system
# of target health facilities
2.1b) # of pregnant women referred to
ANC that reached ANC services
# of pregnant women
referred to ANC services
2.1c) # of persons referred for NACS
that reached NACS services
# of persons referred to
NACS
2.1d) # of persons referred to TB
screening that reached TB care
services
# of persons referred for TB
screening
2.1e) # of persons referred for psycho-
social support related services that
reached those services
# of persons referred for
alcohol related services
# of persons attending adherence clubs # of people referred to
adherence clubs

Leveraging human
resources
2.1f) # of CHWs assigned to facilities # of PLHIV in the assigned
community
2.1g) # of PLHIV registered with CHWs # PLHIV in community
Comprehensive
Supervisory System
2.1h) # of regional review meetings for
M&E review
# of scheduled regional
meetings
2.1i) # of patients over 29 days late for
an appointment
# of patients
Technical
Assistance to
Government
Agencies
2.1j) # of reports shared with RACOCs
and CACOCs
# of reports
2.1k) # of PH supportive supervisory
visits attended by RACOC & CACOC
# of PH supportive
supervisory visits
2.1l) # of times RACOCs and CACOCs
met with to share annual plans
# of RACOCs and CACOCs
planned meetings
Bi-Directional Referral System
There are numerous challenges when designing and implementing a large scale bi-directional
referral system across Namibia. Currently, many stakeholders use some form of a referral
system, but it is usually developed internally, leaving some stakeholders unaware of the system
developed for NARP. In order to accomplish indicator 2.1a, it is necessary to communicate to
all stakeholders that there is a standard referral form and procedure that has been agreed upon
and will be used to refer patients to all points of care. This will ensure that data is collected in
the same way throughout all health districts and if needed, will make it easier to develop quality
measures to improve the system. Similarly, there should be standards on what constitutes a
functioning bi-directional referral system. Include measures on percent of patients using the
system or set a benchmark for receiving feedback. According to the “Linkages to and Retention
in HIV Care and Support Programs” PowerPoint, 37% of referrals did not receive any form of
feedback. To ensure timely feedback and reporting, new measures would include the four week
tracking of patients after referral to verify point of referral was reached and a time-bound
reporting of feedback to the referring organization to better track patient adherence. Project
Hope Namibia (PHN) should continue to collect the data from the referral registrar and cross
check data with the feedback system. As a long term improvement, we suggest PharmAccess
collect all data electronically at point of referral and link through a computer-based system to all
referred providers. This will allow a portal between the community based health facilities,
community based care, and intermediate/district hospitals that gives feedback to the referring
organization. This will require extensive computer training and system strengthening to ensure
the process will be supported by the electronic systems.
Bi-Directional Monthly Report
The bi-directional referral network monthly report form box 7, located in Annex 8 of the M&E
plan, would benefit from more detailed data collection. Our suggestion would be to have
numbers on each specific referral service completed (ART, PMTCT/ANC, etc.), not just overall
number of referrals services completed. Please refer to Annex 2 in this document. This change
would allow better tracking of regions that are successful referring patients to services.
For indicator 2.1f, we suggest collecting data based on number of CHW/number of PLHIV in a

community. This would involve establishing an acceptable level of CHW/patient ratio and a
continuous collection of data based on the CHW tracking registry and would reference the CHW
logs for PLHIV. This will ensure CHWs have adequate time to treat each patient in their
community. Also, for better data collection, the monitoring plan for PHN and Positive Vibes (PV)
should include defined roles on tracking PLHIV registered with CHWs as part of indicator 2.1g to
ensure there is not duplicate data collection.
Collecting Data at Point of Referral
For much of IR 2.1 there are clearly defined indicators with both numerators and denominators,
and where they are lacking, recommendations have been made in blue italic type. However,
there are concerns surrounding the collection of the indicator data. Indicators 2.1b, 2.1c, 2.1d
and 2.1e are lacking consistency in the collection of data on patients reaching point of referral.
When discussing the current state with our contact, Marthe van Andel, we discovered that the
tracking of patients to referrals is not clear. In some cases the referral data is collected based
on patients per facility and others are followed by unique identifying number. We suggest to
add a standard operating procedure for the collection of data and we suggest that the data be
shared on a monthly basis at each health facility and tracked visually (ex. run chart/control
chart) to show staff how referral adherence is changing over time. The use of control charts
would show the percentage of patients reaching point of referral each month based on their
specific information and show when the numbers are dropping below acceptable levels. Also,
tracking based on their unique identifying number allows organizations to link referrals to
individual patients and specific community health facilities.
Within intermediate result 2.1 the key activities refer to adherence clubs that are not included in
the PMP. In order to better link these two implementation plans, we recommend that PHN and
community based organizations facilitate the creation of adherence clubs and tracking their
attendance based on the indicators outlined blue italics.
EDTs and ePMS
Currently, EDT and ePMS systems are not being used optimally throughout all health facilities
and, where they are used, not all departments have access to them. The EDT software should
be rolled out to all participating health facilities in NARP and the results for pill counts and
missed appointments should be collected for each individual patient. This data should be put
into run and control charts to show how adherence is changing from month to month.
Additionally, this data should be included throughout health facilities to share with all levels of
staff. The systems should be available to all staff from the pharmacy department to CHWs to
allow tracking of patients lost to follow up in indicator 2.1i. Also, the results should be
discussed further through the quarterly reporting meetings and monthly meetings/newsletters
within individual facilities. If possible, use these systems to track if patients reach their referral
point of care and compare data to the bi-directional referral system to ensure quality of data.
RACOCs and CACOCs
For indicator 2.1l it is inconsistent as to how often RACOCs and CACOCs meet to share annual
plans and they are usually not formally planned and documented. We suggest adding

formalized dates for meetings between these two organizations to share plans quarterly. This
can be built into the PMP chart for implementation and shared between all districts to ensure
that the meetings times are agreed upon and followed through with.
Quality Improvement Plan: In order to accomplish this specific Intermediate Result it is first
important to establish sound, quality indicators as denominators where they had previously
been lacking. These indicators must be agreed upon by each stakeholder involved in NARP
and communicated effectively through quarterly meetings. Once these have been established;
MoHSS, PHN and CAA will need to jointly develop standardized protocol and procedure for
using one standardized bi-directional referral form and collect data based on specific patient
identification and referral service. Furthermore, the EDT and ePMS patient tracking systems
will need to be uniformly rolled out by PHN to each health facility participating in NARP,
including proper training of all staff/departments and sharing of information between all staff to
ensure patients can be best tracked.
Intermediate Result 2.2: Strengthen community systems and models of care delivery
that support a continuum of care for infected & affected individuals
Key Activities Indicator Numerator Indicator
Denominator
Training CHWs and linkage to
health extension workforce
(HEW)
2.2a) # of HEWs trained in Adherence
& Retention
# in assigned
community
Leverage private resources
2.2b) $ from leveraging private
sector/community resources
Overall Project Cost
($)
Use M&E data for evidence-
based results
2.2c) % of clients LTFU that were
returned to care through community
tracking
# of persons referred
Indicators 2.2a and 2.2c would be improved through defined denominators. Possible
denominators for these indicators can be found in the chart above. We suggest that
denominators are composed of the total population defined by the indicator. For 2.2a and 2.2c
this could be total number of staff assigned to the community and total number of patients
referred. Data for indicators 2.2a, 2.2b and 2.2c will be collected on a quarterly basis by Project
Hope. Suggestions for indicator 2.2c are related to 2.1i.
Quality Improvement Plan: Each indicator used to measure this Intermediate Result must have
a clearly defined denominator. Once indicators have appropriate denominators, the progress
made in achieving this Intermediate Result can be interpreted. In addition to providing
denominators, the EDT system must be rolled out by PHN to each health facility participating in
NARP to ensure that LTFU can be accounted for.
Intermediate Result 2.3: Strengthened community support for and increased linkages
to quality NACS services for all beneficiaries

NACS Training for
Community Nurses
2.3a) # of project staff (nurses and
program staff) that participate in NACS
training.
# of total project staff
2.3b) # of community care workers who
successfully completed NACS training and
MUAC training
# of total community care
workers
Disseminating
nutrition messages
and services
through CHW
2.3c) # of adults, adolescents, pregnant
women and children who have been
screened for malnutrition (with MUAC) by
community care workers
# of total adults,
adolescents, pregnant
women and children who
have been seen by
community care workers.
Leverage nutrition
support at the
community level
2.3d) # of adults, pregnant women,
adolescents and children who were
referred to the NACS program who
completed the program.
# of adults, pregnant
women, adolescents, &
children referred to the
NACS program.
2.3e) # of adults, adolescents and children
who received nutritional support at the
community level.
# of eligible clients for food
and nutrition services
Indicators 2.3a, 2.3b, 2.3c, 2.3e would be improved through defined denominators. Possible
denominators for these indicators can be found in the chart above. We suggest that
denominators are composed of the total population defined by the indicator. For 2.3a and 2.3b
this could be total number of project staff and total number of community care workers. For 2.3c
this could be all the adults, adolescents, pregnant women and children visited by community
care workers. Finally, for indicator 2.3e, which is a PEPFAR indicator, the denominator could be
the total number of eligible clients defined by PEPFAR for food and nutrition services.
Catholic AIDS Action Volunteer Form
Data for indicators 2.3c, 2.3d and 2.3e will be collected through Catholic Aids Action’s individual
volunteer daily activity form and referral forms. However, the individual volunteer daily activity
form has no specific nutrition category under the column “what was done during visits”. The
closest options are “counseling” or “prevention information which include PMTCT, TB, HIV &
malaria”. To be able to fully track the number of people screened for malnutrition (indicator 2.3c)
or people referred to NACS program (indicator 2.3d) or number of eligible clients receiving food
or nutrition services (2.3e), we recommend additional options be created on the individual
volunteer daily activity form under the column “what was done during visits”.
NACS Training
Also, indicator 2.3d needs further definition about what it means to “complete” the NACS
program. Other indicators for the Performance Monitoring Plan have included specific
measurements, such as attending 80% of classes as a requisite for completing the class. This
NACS definition of “completion” needs to be further determined by Catholic Aids Action to
ensure standardization of data collected about the number of participants completing the NACS
program.

Quality Improvement Plan: Along with ensuring that there are quality denominators for each
indicator, it is essential that Catholic AIDS Action make their volunteer activity form more
specific. Catholic AIDS Action needs to revisit their volunteer form and confirm that NACS
indicators can be monitored appropriately through the volunteer activity form. If in doubt,
Catholic AIDS Action should edit their volunteer activity form so that PharmAccess can easily
identify the data that the NACS indicators use. Finally, “completion of NACS training” must be
further defined in the Performance Monitoring Plan to ensure that all providers being trained
have a standardized level of training.
Intermediate Result 2.4: Strengthened community structures that facilitate active
follow-up & care of mother-infant pairs from pregnancy to 18 months post-partum
Community mobilization
on early pregnancy
detection & danger signs
2.4a) # pregnant women referred for
ANC & PMTCT services by CHWs
# of pregnant women
encountered by CHW
Mother-to-Mother (m2m)
groups
2.4b) # of m2m groups established # of interested groups
# of women in group attending
regularly
# of women in group
2.4c.) # women in m2m groups who
attend with their partner
# of women in m2m
groups
Community-based follow-
up of new mothers
2.4d) # of mothers referred for
mother/baby follow-up services at
community level
# of pregnant women
referred to PMTCT
program
mHealth follow-up of new
mothers
2.4e) # of mothers reached via SMS
in targeted regions for PMTCT
# of mothers referred for
PMTCT
2.4f) # of mothers reached via SMS
in targeted regions for pre-ART
adherence
# of mothers referred for
pre-ART adherence
Encourage male
involvement in PMTCT
2.4g) # of partners of pregnant
women referred to couples ANC or
HCT
# of pregnant women
referred to ANC or HCT
Promotion of family
planning to support
EMTCT
# of couples referred for family
planning services by CHWs
# of women who have
expressed interest in
family planning methods
Indicators 2.4a, 2.4e, 2.4f, and 2.4g need a denominator. Some appropriate denominators could
be the total number of pregnant women encountered by CHWs, number of mothers referred to
PMTCT and pre-ART adherence, and total number of pregnant women referred to ANC or HCT,
respectively. For indicator 2.4b, there is no mention of a denominator for the number of m2m
groups established, furthermore, it is possible for an m2m group to be formed, but never meet.
We suggest that in order to best evaluate this indicator, the percentage of women in the group
that attends meetings regularly should be tracked using attendance logs.
EMTCT Indicator

Regarding the promotion of family planning for EMTCT, we suggest creating a new indicator.
This indicator specifies the number of referrals by trained CHWs to the health clinic for
contraceptive use. Catholic AIDS Action can examine at the health clinic's distribution rate of
contraceptives quarterly to assess interest in family planning options. Because some family
planning options don't require the use of extraneous tools, CHW referral forms should also be
collected quarterly to record the number of couples who have opted for natural family planning
options.
Quality Improvement Plan: Based on our observations, develop appropriate denominators for
the indicators that are lacking them. This will ensure that the set indicators will have weight,
since the number of mothers or partners of mothers is meaningless without comparison against
the total number of mothers who are referred to a health clinic. Additionally, create an indicator
and denominator for family planning methods to eliminate EMTCT.

Annex 1
Annex 2
Suggested data collection for “Bi-directional Referral Network Monthly Report Form”
7 Number of referral services completed Referred out Referred in
7.1 ART
7.2 PMTCT/ANC
7.3 PEP
7.4 TB
7.5 CD4
7.6 Nutritional support
7.7 Psycho-social support
7.8 Male Circumcision
7.9 Total referrals completed

QI Deliverable_PharmAccess

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