1. “Getting the Knack of NACS”
Feb 22-23, 2012
The QA/QI Approach:
Uganda’s Experience
Margaret Kyenkya
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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
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3. NuLife – Food and Nutrition Interventions for
Uganda: USAID-funded project, Jan 2008-Aug 2011
Integrated approach involved 3 strategies:
1. Policy
• MOH partnership for guideline development,
implementation, and scale-up
• Multi-stakeholder engagement
2. 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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4. Development of Training Manuals and Job Aids
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5. Actors and Levels
Ministry of Health
Involved in the Policies, strategies, Guidelines,
Protocols and training curricula for
Program 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. 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 RUTF
Frank 7 months old 5.3 kg
19/3/10 6

7. Service Delivery
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8. Service Delivery: 7 Steps
Process allows for gradual integration of nutrition into
HIV/AIDS care and support using the QI approach:
Assessment Categorization Counseling Food by Follow-up Community Education
Prescription Links
All HIV- The nutrition All All patients All HIV-
infected status is malnourished All receiving Links are infected
patients are recorded on the patients moderately RUTF receive established patients
assessed at care card for receive and severely follow-up between receive
each visit each HIV- counseling malnourished community education on
infected patient patients who and facility good nutrition
pass the and hygiene
appetite test
receive RUTF
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9. Key Changes for Improvements in
Assessment and Categorization
Assessment 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
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10. Taking Mid Upper Arm Checking for Bilateral
Circumference (MUAC) Pitting Oedema
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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%
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12. Key Changes for Improvements in
Counseling
Assessment 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
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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%
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14. Key Changes for Improvements in Food by
Prescription
Food by Community Education
Assessment 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
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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
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16. Key Changes for Improvements in Follow-up
Assessment 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
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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%
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18. Key Changes for Improvements in Community-
Facility Links
Categorizati
Assessment 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
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19. Health Facility
● Re-assess
● Categorize
● Prescribe RUTF
● Counsel
● Document
● Counter-refer
Community – Facility
Linkage 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
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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
Hospitals
Total Malnourished 4081 12988 2601 19670
Total Referred by CHW 3698 10479 2130 16307
USAID HEALTH CARE IMPROVEMENT PROJECT
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21. Key Changes for Improvements in Nutrition
Education
Assessment 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
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22. Service Delivery
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23. 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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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
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25. Monthly
CPDs/
FHW CMEs
Monthly CC & Nutrition
CHW
CHW progress
Focal Person
review & at H/F
planning
meetings
QI team
QI support NuLife meetings &
mechanism & MoH Coaching
at H/F
DHT representative
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26. Conclusion
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27. Case Study: Road to Recovery; “Hills and
Valleys”
(46 years old)
MAM
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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, RECO
Industries, Networks in Uganda of those Living Positively
with HIV/AIDS)
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29. Thank you