HIV Peer Mentors in Morogoro

As coverage of HIV prevention, care and treatment services expands and programs mature, greater attention is being paid to strengthening the capacity of health systems to provide and sustain high quality HIV and AIDS services, including antiretroviral therapy (ART), prevention of mother-to-child transmission (PMTCT), voluntary medical male circumcision (VMMC), HIV counseling and testing, integration of HIV services with other clinical services, home-based care and community support, injection safety, and medical waste management.

Improvement methods help HIV and AIDS programs to: 1) provide services for all who need them, 2) retain all those who access services in the continuum of care, and 3) achieve optimal health outcomes for all those who are retained in care.  Strategies to improve coverage of HIV-infected mothers by PMTCT services, especially in antenatal care and at delivery, and improve the follow-up of mother-baby pairs can maximize the uptake of PMTCT services and promote HIV-free survival by assuring that all eligible infants and mothers get needed PMTCT services.  Adult treatment, care, and support can be improved by applying a chronic care model to service delivery and strengthening linkages with community and home-based care.

The Chronic Care Model is making its mark in Central Uganda

Martin Muhire

Improvement Advisor, Uganda, USAID ASSIST Project/URC

Throughout my time of working on HIV chronic care, I learned that an improvement of one component of the chronic care model is always amplified by working on the other components. A case in point: an improvement in patient self-management required that the goals patients set and progress made toward meeting those goals be well documented for reference during joint planning between a health worker and a patient. Teams had to first work on improving the level of accuracy and completeness of records for them to have reliable self-management data.

Could a focus on "numbers" have an effect on the quality of SMC services?

Anna Lawino

Quality Improvement Officer, Uganda, USAID ASSIST Project/URC

‘‘We had very many clients for circumcision at the outreach, so we had to use several beds in the same tent to circumcise clients without separator screens and we could not provide all of them with SMC individual counselling and testing for HIV’’ – One of the Improvement team members responding to why they had quality gaps at their facility during one of my coaching visits. The site had offered counselling and testing for HIV to only 602 of the 1107 clients [54%] who registered for circumcision in that month.

Taking strides in SMC: A health worker’s experience in female partner involvement

Jude Thaddeus Ssensamba

Quality Improvement Officer, Uganda, USAID ASSIST Project/URC

The USAID ASSIST team in Uganda has developed an innovative approach which has been shown to improve outcomes and decrease adverse events for males undergoing voluntary medical male circumcision (VMMC), known as safe male circumcision (SMC) in Uganda: engaging female partners to attend educational sessions and clinic visits with male partners who undergo the procedure to improve health outcomes. I was really encouraged by the experience of a Busolwe hospital SMC team member during the second learning session held in Jinja.

Is female participation in voluntary medical male circumcision of any value? Experiences from Uganda

John Byabagambi

Improvement Advisor, USAID ASSIST Project/URC

Uganda adopted voluntary medical male circumcision (VMMC) as part of its comprehensive HIV prevention strategy in 2009. From its inception, the service was designed to target males and most of the efforts were focused on ensuring that as many males as possible were circumcised. In December 2012, a PEPFAR interagency team conducted an external quality assessment for the Uganda program and found several quality gaps. One of the major gaps was the lack of a system for continuous quality improvement.

Giving hope: A story on how community networks support persons living with HIV/AIDS

Mabel Namwabira


The USAID ASSIST Project and Uganda’s Ministry of Health supported a project to improve the quality of chronic care services in 10 villages in Buikwe district from June 2012. This followed an assessment at 14 health facilities in September 2011 which revealed minimal community support for HIV/AIDS patients. At one health facility in Buikwe district in May 2012, over 90 People Living with HIV (PLHIV) had dropped out of care for more than 3 months. Out of 90, only 10 were traced due to incorrect contact information given by PLHIV to their care providers.

One small snip for man, one giant leap for HIV Prevention: SMC successes in Uganda

Pamela Marks

Senior Improvement Advisor, USAID ASSIST Project/URC

Earlier this year, USAID ASSIST was asked by USAID to support the Safe Male Circumcision (SMC) sites in Uganda.  Two EQAs conducted in 2012 highlighted numerous gaps in the quality of SMC services delivered at PEPFAR supported sites in Uganda.  The evaluation was based on the standards highlighted in the WHO male circumcision services Quality Assessment Toolkit.  The initial evaluation had been conducted in April 2012 with a follow up one later in 2012.

Bringing Women on Board in Safe Male Circumcision in Uganda

Jude Thaddeus Ssensamba

Quality Improvement Officer, Uganda, USAID ASSIST Project/URC

As part of our discussion with facility health workers during a technical support visit to eastern Uganda Nankoma Health Centre IV, Bugiri District, I asked for some experiences on cases where women have not been involved in Safe Male Circumcision. One of the health workers in the group had this experience to share:

Keeping mothers and babies in care to eliminate transmission of HIV

Nigel Livesley

Regional Director for South Asia, USAID Applying Science to Strengthen and Improve Health Systems (ASSIST) Project, University Research Co., LLC (URC)

My colleagues in Uganda are working with rural clinics to improve their capacity to prevent mother-to-child transmission of HIV.  Recently, we visited one rural clinic whose records showed that 177 exposed babies had been born in the clinic or had come there for care at some point in the past 18 months.  Yet only 9 had come back to the clinic in April 2013.

Improving uptake and retention of PMTCT services

Rhea Bright

Quality Improvement & Human Resources for Health Advisor, USAID Bureau for Global Health Office of Health Systems
AIMGAPS nurse explains CHSS in Tanzania

An AIMGAPS facility nurse explains the Community Health Systems Strengthening Model (CHSS) to her colleagues during a training session in Iringa, Tanzania, where these nurses are being prepared to serve as community QI coaches for their catchment areas.

Photo by Rhea Bright, URC

Under the USAID Health Care Improvement Project (HCI), my colleagues in Tanzania and I have been working with the Ministry of Health and Social Welfare (MOHSW) and EngenderHealth in the Iringa Region of Tanzania to improve uptake, retention, and the quality of prevention of mother-to-child transmission (PMTCT) of HIV services. Rather than focusing solely on improving care at one point of service along the PMTCT continuum, our improvement efforts looked at improving PMTCT services across the entire continuum of care, from the antenatal period, through the entire breastfeeding period, until the HIV status of the exposed infant is definitively determined at 11 facilities in Iringa.

In order to address the gaps in PMTCT care that were identified at the 11 facilities, a data system was developed, quality improvement (QI) teams were formed, and facility QI teams began to track indicators for various PMTCT services that should be delivered during antenatal care (ANC), labor and delivery as well as in the post-natal/infant follow-up period.  Providers began testing changes at their respective facilities to address areas in need of improvement.  However, we noticed that some indicators improved (i.e. HIV positive pregnant women started on ARV or ART; and definite testing of the HIV exposed infant), while others lagged behind (i.e. early booking for antenatal care (ANC); male partner involvement; exclusive breastfeeding; and infant and child follow-up visits).  After providers tested several different changes at the facility level and saw little to no improvement in those indicators, it became apparent that improvement efforts would need to go beyond the facility.

Viewing Healthcare Locally Through a “Gender Lens”

Caitlyn Lutfy

URC Uganda staff in the gender integration training

URC Uganda staff in the gender integration training, Taroub Faramand April 2013

“You’re breaking a ‘gender rule’ right now by eating chicken,” said one of the male participants during the lunch break at our Gender Integration training in the URC Uganda office. In a murmur of laughter and banter, the Ugandan staff members explained that for some, it is taboo for a Ugandan woman to eat chicken. For the most part, Ugandans no longer practice the rule, though some say older relatives and a few tribes still observe the gender-related chicken restriction.

The roles, expectations, behaviors and interactions between men, women, boys and girls are intimately tied to local people and change with time. “Gender” is a social construct shaped by these customs and perceptions. In the previously mentioned example, the male-exclusive entitlement to eat chicken as a sign of reverence interacts with other customs to shape sex disparities of power and capabilities in the society. If  the women at our training abided by this restriction, our catering would have been gender-blind and, in effect, we would have only been serving lunch to men. Women, men, boys and girls also differ in their healthcare needs and the ways they access, utilize and benefit from care.