qi deliverable_pharmaccess

Quality Improvement Consulting Report for the Namibia Adherence and Retention Project

Executive Summary 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.

1 BUSPH IH743: Brown, Cain, Forbush, Jang, Kadangs, Kalal Feb. 2014

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 [email protected] Brown [email protected] Cain [email protected] Forbush [email protected] Kadangs [email protected] Kalal [email protected]


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


1.1g) # of participants with increased ability to share resources with others


1.1h) # of community facilitators trained to start up and manage VSL groups

# of target communities

1.1i) # of VSL groups formed # of target communities1.1j) # supervisory visits to VSL groups # of VSL groups1.1k) # 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


1.1n) # of people reached with prevention messages regarding GBV and coercion related to HIV/AIDS


1.1o) # of people reached with messaging on male involvement in PMTCT


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

Key Activities Indicator Numerator Indicator Denominator1.2) # 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

# of eligible children/adolescents enrolled in an HIV prevention education program

# of eligible children/adolescents 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, # 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

# of eligible adults, adolescents, 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 AdolescentsPrevention 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 ServicesA 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 ProgramsNo 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 OpportunitiesIndicators 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 SystemThere 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 ReportThe 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 ReferralFor 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 ePMSCurrently, 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 CACOCsFor 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


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

Key Activities Indicator Numerator Indicator Denominator NACS Training for 2.3a) # of project staff (nurses and # of total project staff


Community Nurses

program staff) that participate in NACS training.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 FormData 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 TrainingAlso, 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

Key Activities Indicator Numerator Indicator DenominatorCommunity 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 IndicatorRegarding 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 in7.1 ART7.2 PMTCT/ANC7.3 PEP7.4 TB7.5 CD47.6 Nutritional support7.7 Psycho-social support7.8 Male Circumcision7.9 Total referrals completed


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