Using QI to strengthen the system of care for patients with HIV/AIDS in Niassa province, Mozambique

This improvement story was provided by Nilufar Rakhmanova of FHI 360.


In Cuamba Rural Hospital, staff identified problems with the uptake of PMTCT services, specifically low rates of: pregnant women receiving HIV counseling and testing (CT) during the first prenatal care visit, HIV-positive pregnant women who attended prenatal care after testing positive, and children born from HIV-positive mothers who enrolled into the child atrisk care (CRC) system. The team formulated following improvement aims: 1. Increase the percentage of pregnant women counseled and tested during the first prenatal care visit to 90% by February 2010, and 2. Increase the follow-up of HIV-positive pregnant women and their children (enrollment in CRC services) to 70%.

In Mandimba Health Center, a considerable number of patients hospitalized to treat opportunistic infections (OIs) discontinued antiretroviral (ARV) treatment during their hospitalization. Therefore, staff designed their quality improvement efforts to increase ARV adherence and continuity in patients hospitalized with OIs. The teams improvement aim was to reduce nonadherence to ARV treatment among HIV patients being treated for OIs to 20%.


Cuamba hospital identified following interventions for testing:

  • All consultation rooms will provide integrated care in maternal and child health (MCH).
  • All consultation rooms will have available the SOP for integrated services to mother and child.
  • Two new consultation rooms will be available to provide MCH services to women below the age of 25.
  • All nurses will dedicate their time to assist MCH and will rotate to maternity-only duties no more than once a week for just one period (morning or afternoon). Registry books will be available within all consultation rooms.

Mandimba health center proposed following interventions:

  • Redesign the client flow at the health center.
  • If the patient is on ART, obtain information from the pharmacy, hospital registry, or family member, and include this information in the CARDEX (prescription form).
  • Encourage the participation of a family member or friend in at least one counseling session for ART.
  • Develop a specific protocol to assist OI patients on ART. Community health agents will be involved to improve the outreach to pregnant women who have tested HIV-positive.


Cuamba’s QI team regularly measured the following indicators:

  • No. of pregnant women receiving HIV counseling during the first prenatal care visit /total no. of pregnant women attending their first prenatal care visit
  • No. of pregnant women tested for HIV during the first prenatal care visit / total no. of pregnant women attending their first prenatal care visit
  • No. of children born to HIV-positive mothers enrolled in CRC / no. of children born to HIV-positive mothers

The data related to the HIV counseling and testing of pregnant women, though regularly measured, were not reliable. Staff encountered problems with correctly determining the proportion of women who received these services. The facility reported that it reached its objective of increasing the proportion of pregnant women counseled and tested during the first prenatal care visit to 90%. The indicator—proportion of children enrolled into child at-risk care (CRC) out of those
born to HIV-positive mothers—increased to 100% in September 2009, the first month of introducing changes.

The QI team in Mandimba monitored ART adherence among patients hospitalized for opportunistic infections (OIs) on a monthly basis using the following indicator:

  • No. of patients adherent to ART while hospitalized for OI treatment / no. patients on ART that are hospitalized due to Ois.

After implementing changes in September 2009, improvement in ART adherence among patients hospitalized for OI treatment was observed. In July 2010, the facility first reached its improvement objective of reducing ART nonadherence to 20% or less among HIV patients being treated for OIs. Although this result was not maintained, the trend ofimproving ART adherence was clearly observed. The proportion of the patients who were monitored for ART adherence reached 100% upon initiation of the pilot in September 2009, and it remained at this level throughout the life of the project.


This is the first time that health care workers in Mozambique used a modern approach to quality improvement that put them in the driver’s seat, with a focus on
the service delivery processes that are under their control. Health care providers who attended the QI training expressed their satisfaction with the content
and quality of the instruction. In fact, one HCW from Mandimba commented, “It was the best training I ever had.” When asked specifically about supportive supervision and mentoring, HCWs were generally satisfied with the technical support in QI provided by FHI 360.

Additionally, most HCWs described an increase in job satisfaction as a result of employing QI tools. They felt that the QI approach supported the provision of improved services to patients and were proud of the positive results. HCWs in Mandimba explained that implementing a QI approach has supported a sense of teamwork among staff in the facility and has made them more confident in their ability to solve problems themselves.

In terms of challenges, nearly every person interviewed identified human resources as a significant challenge to implementing QI activities, a significant yet common challenge to the provision of health care services in resource-constrained settings.

Report Author(s): 
Rebecca Dirks, Bruno Bouchet, Joaquim Fernando, Jorge Blanko, Paultre Desrosiers
Quality for Leadership Initiative/FHI 360
ASSIST publication: 
Facebook icon
Twitter icon
LinkedIn icon
e-mail icon