USAID ASSIST Project Lesotho Country Report FY16
Cooperative Agreement Number: AID-OAA-A-12-00101
Performance Period: October 1, 2015 – September 30, 2016
DECEMBER 2016
This annual country report was prepared by University Research Co., LLC for review by the United States Agency for International Development (USAID). The USAID Applying Science to Strengthen and Improve Systems (ASSIST) Project is made possible by the generous support of the American people through USAID.
USAID ASSIST Project
Applying Science to Strengthen and Improve Systems Lesotho Country Report FY16
Cooperative Agreement Number AID-OAA-A-12-00101 Performance Period: October 1, 2015 - September 30, 2016
DECEMBER 2016
DISCLAIMER This country report was authored by University Research Co., LLC (URC). The views expressed do not necessarily reflect the views of the United States Agency for International Development or the United States Government. Acknowledgements This country report was prepared by University Research Co., LLC (URC) for review by the United States Agency for International Development (USAID) under the USAID Applying Science to Strengthen and Improve Systems (ASSIST) Project, which is funded by the American people through USAID’s Bureau for Global Health, Office of Health Systems. The project is managed by URC under the terms of Cooperative Agreement Number AID-OAA-A-12-00101. URC's global partners for USAID ASSIST include: EnCompass LLC; FHI 360; Harvard T.H. Chan School of Public Health; HEALTHQUAL International; Initiatives Inc.; Institute for Healthcare Improvement; Johns Hopkins Center for Communication Programs; and WI-HER, LLC. For more information on the work of the USAID ASSIST Project, please visit www.usaidassist.org or write [email protected]. Recommended citation USAID Applying Science to Strengthen and Improve Systems (ASSIST) Project. 2016. Lesotho Country Report FY16. Published by the USAID ASSIST Project. Bethesda, MD: University Research Co., LLC (URC).
Table of Contents List of Figures ...... i Abbreviations ...... i 1 INTRODUCTION ...... 1 2 PROGRAM OVERVIEW ...... 2 3 KEY ACTIVITIES, ACCOMPLISHMENTS, AND RESULTS ...... 4 Activity 1. Strengthen linkages and retention to improve clinical services ...... 4 Activity 2. Strengthen the capacity of DHMTs in five “sustained response districts” to oversee and monitor the quality of services for PLHIV currently enrolled in PMTCT and care and treatment ...... 9 Activity 3. Build capacity for national level QI program coordination and management ...... 12 Activity 4. Quality improvement in OVC programming ...... 12 4 IMPROVEMENT IN KEY INDICATORS ...... 15 5 SUSTAINABILITY AND INSTITUTIONALIZATION ...... 17 6 KNOWLEDGE MANAGEMENT PRODUCTS AND ACTIVITIES ...... 17 7 GENDER INTEGRATION ...... 19 8 DIRECTIONS FOR FY17 ...... 19
List of Figures Figure 1. Improving retention, quality of care and data quality, Lithipeng Health Center, Mohale’s Hoek (April 2014-Sept 2016) ...... 6 Figure 2. Improving retention, quality of care and data quality, Morifi Health Center, Mohale’s Hoek (April 2014-Sept 2016) ...... 7 Figure 3. Improving retention, quality of care and data quality, Mofumahali-Oa-Rosari Health Center, Mohale’s Hoek (April 2014-Sept 2016) ...... 8 Figure 4: Slice of the health system ...... 8 Figure 5: Slice of the health system in multiple districts ...... 9 Figure 6. Percentage of mother-baby pairs retained, 12 PHFS sites (Nov 2013-Sept 2016) ...... 11 Figure 7. Percentage of mother-baby pairs receiving standard package of care, 4 faith-based facilities, 2 government hospital, and 6 other government facilities (Nov 2013 – Sept 2016) ...... 11 Figure 8. Progress among sub-grantees in registering and developing care plans for vulnerable families, 8 sub-grantees (Sept 2016) ...... 14
Abbreviations AIDS Acquired immunodeficiency syndrome ANC Antenatal care ART Antiretroviral therapy ASSIST USAID Applying Science to Strengthen and Improve Systems Project CBO Community-based organization CC Community Council CDC U.S. Centers for Disease Control and Prevention CHAL Christian Health Association of Lesotho COP Country Operation Plan
USAID ASSIST Lesotho Country Report FY16 i DCPT District Child Protection Teams DHMT District Health Management Teams FY Fiscal year GOL Government of Lesotho HBC Home-based care HIV Human immunodeficiency virus HTC HIV testing and counselling IP Implementing partner LENASO Lesotho Network of AIDS Services Organisations LVHIT Lesotho Vulnerable Household Identification Tool M&E Monitoring and evaluation M2M Mothers 2 Mothers MNCH Maternal, newborn, and child health MOH Ministry of Health MOSD Ministry of Social Development MSH Management Sciences for Health NGO Non-governmental organization OVC Orphans and vulnerable children PEPFAR U.S. President’s Emergency Plan for AIDS Relief PHFS Partnership for HIV-Free Survival PLHIV People living with HIV PMTCT Prevention of mother-to-child transmission QA Quality assurance QI Quality improvement REPSSI Regional Psychosocial Support Initiative RFA Request for Applications SIMS Site Improvement through Monitoring System SRD Sustained response district SUD Scale-up district TA Technical assistance TWG Technical working group USAID United States Agency for International Development WHO World Health Organization
ii USAID ASSIST Lesotho Country Report FY16 1 Introduction The Government of Lesotho (GOL) launched its National Antiretroviral Therapy (ART) Program in November 2004. Since the national program was launched, the GOL’s efforts to provide ART have been hampered by chronic shortages of staff due to high staff attrition rates and historically high costs of drugs. In recent years, the country has made significant progress in scaling up treatment for HIV and AIDS. The number of people on treatment has risen steadily since the onset of the national program, in spite of service delivery gaps. A key problem still being encountered is that only a few of the children requiring therapy receive it. Since November 2013, the GOL has worked with the USAID Applying Science to Strengthen and Improve Systems (ASSIST) Project on the following areas: Development of a national strategy for improving the quality of clinical services. This strategy is to be consistent with the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) Quality Framework; Strengthening linkages between HIV testing and counselling (HTC), antenatal care (ANC), maternal, newborn, and child health (MNCH), HIV care and treatment, prevention of mother-to-child transmission of HIV (PMTCT), and home-based care (HBC) services; Improving the quality, uptake, and retention of services along the continuum of PMTCT care; and Scaling up of quality improvement (QI) within integrated clinical services. In fiscal year 2016 (FY16), ASSIST’s work in Lesotho was revised to align it to the PEPFAR Country Operational Plan (COP 15). COP 15 defines the intention of USAID to increase the number of eligible people receiving ART with the key aim of achieving 80% coverage in five priority scale-up districts (SUDs) defined as being most burdened by HIV: Berea, Leribe, Mafeteng, Maseru, and Mohale’s Hoek. The other five districts have been designated as sustained response districts (SRDs). In the SRDs, ASSIST has been asked to direct support to the District Health Management Teams (DHMTs) and health unit in- charges. In June 2016, Lesotho became the first country in the world to launch the new World Health Organization (WHO)-recommended “Test and Treat Initiative” for managing the HIV pandemic. This initiative is expected to exponentially increase the number of patients of all ages on ART in Lesotho. ASSIST has been requested by USAID to support an enhanced supportive supervision program to oversee the implementation of the initiative. The MOH has requested the institution of a QI project for the implementation of the Test and Treat Initiative. In FY16, USAID Lesotho invited ASSIST to work on enhancing service delivery and improving outcomes for vulnerable children and their families at the national, district, and community levels in coordination with the Ministry of Social Development (MOSD). This has been undertaken through engaging and capacitating national and local social service structures. ASSIST is supporting programming for orphans and vulnerable children (OVC), targeting 44,597 children, in the five high-priority, high HIV-burden districts of Berea, Leribe, Mafeteng, Maseru, and Mohale’s Hoek. ASSIST has built on and extended the work previously accomplished under Management Sciences for Health’s Building Local Capacity.
USAID ASSIST Lesotho Country Report FY16 1
Scale of USAID ASSIST’s Work in Lesotho
HIV: MOH, 3 IPs OVC: MOSD, 8 IPs
HIV: 10 out of 10 districts: 5 sustained response and 5 scale-up districts
OVC: 5 out of 10 districts (scale-up districts)
172 facilities
63 QI teams (9 district and 54 facility)
1,916,574 out of 1,916,574
OVC: 44,597 targeted beneficiaries
2 Program Overview What are we trying to accomplish? At what scale?
1. Strengthen linkages and retention to improve clinical services Eliminate new infections among children 5 scale-up districts: Entails intensive support through implementation of evidence-based, high at site level and technical support to the impact interventions District Health Management Team Reduce AIDS-related maternal deaths through Technical support will be provided to the implementation of evidence-based, high-impact MNCH program to build capacity for QI interventions Support and provide technical assistance (TA) to Technical Working Group/Steering Committee/PMTCT Program to create capacity for QI oversight Increase ART coverage by establishing linkages 103 sites in 5 scale-up districts: Mafeteng, to ART programs and home-based care Maseru, Berea, Leribe, and Mohale’s Hoek. Entails intensive support at site level and Improve patient knowledge, skills, and self- technical support to the DHMT confidence to manage their HIV as a chronic condition through implementation of the Chronic Care Model Build capacity of the 5 DHMTs of the scale-up districts to oversee and monitor the quality of services for PLHIV currently enrolled in PMTCT, prevention, and care and treatment
2 USAID ASSIST Lesotho Country Report FY16 What are we trying to accomplish? At what scale?
2. Strengthen the capacity of DHMTs in five “sustained response districts” to oversee and monitor the quality of services for PLHIV currently enrolled in PMTCT and care and treatment Determine the capacity-building requirements Interventions will be directed towards the for each DHMT and Health Unit in-charges provision of support to the DHMTs and (collective and individual member capacities) Health Unit in-charge in the SRDs 5 sustained-response districts: Butha-Buthe, Define and set site- and district-level targets for Mokhotlong, Quthing, Qacha’s Nek, and combination prevention aligned to PEPFAR- supported ART passive enrolment Thaba-Tseka Define QI benchmarks for monitoring site-level DHMTs as well as selected health centers in quality of care each district Ensure and support the conduct of quarterly DHMTs in the SRDs supportive supervision and coaching visits to sites to monitor QI benchmarks Conduct bi-annual district learning sessions These will be undertaken initially by ASSIST but will, over time, be handed over to the DHMTs. Ensure that DHMTs hold monthly data DHMTs and the in-charges and strategic validation exercises to monitor both site- and information focal points at the sites in the district-level data accuracy SRDs Develop a system for recognizing and Proposed categories of “prizes” include best “rewarding” the best-performing district (in district performance by indicator, best overall relation to retaining PLHIV on treatment) performance, best district QI team, and best facility QI team 3. Build capacity for national level QI program coordination and management Provide long-term QI TA to the QA/QI Unit to Interventions will be directed at district and create central-level capacity for QI national levels and cover all districts Facilitate the establishment of an HIV/AIDS and National-level activity with the MOH (QA/QI TB QI Technical Working Group/Steering Unit, and MOH QI Team) Committee Support the development of a National QI Strategy for HIV and AIDS services Organize and facilitate joint quarterly partner and DHMT performance review meetings to address issues that arising from site support and data validation reports Support creation of a National QI Training Curriculum and Plan 4. Quality improvement in OVC programming Issue and manage fixed obligation grants 5 scale-up districts – 8 local non- (FOGs) to local organizations governmental organizations (NGOs) awarded grants to provide services in 47 Community Councils
USAID ASSIST Lesotho Country Report FY16 3
What are we trying to accomplish? At what scale?
Build capacity of MOSD at central and local National – 5 district QI teams in place in the 5 levels to coordinate and sustain effective and scale-up districts, 1 community QI team timely interventions Improve the well-being of vulnerable children 5 scale-up districts: Berea, Leribe, Mafeteng, through accessing quality essential services in Maseru, and Mohale’s Hoek five priority districts Improvement Activity Cross-cutting Activity 3 Key Activities, Accomplishments, and Results Activity 1. Strengthen linkages and retention to improve clinical services BACKGROUND For FY16, and based on COP 15 guidance, ASSIST’s aim was to reach all facilities providing HIV/PMTCT services, including referral and district hospitals and health centers in all five of the scale-up districts. The activity is focusing on strengthening the linkages along the PMTCT continuum of care, including ANC/MNCH, HIV care and treatment, PMTCT, and HBC services. KEY ACCOMPLISHMENTS AND RESULTS Partnership for HIV-Free Survival review meeting (Nov 10, 2015). This meeting focused on the district of Mohale’s Hoek. Results to-date have shown Mohale’s Hoek, especially the District Hospital, to be a “poor performer” in terms of PHFS. QI introductory visits undertaken to the scale-up districts (SUDs) of Mafeteng, Maseru, Berea, and Leribe (Jan 2016). Mohale’s Hoek is already a participant in QI through PHFS. Mining of PHFS-related data (children under age five registers and maternal ART records) in Mohale’s Hoek to gather data to facilitate an assessment of impact of PHFS on clinical outcomes (Jan 2016 – present). Conducted sensitization meeting at Maseru DHMT (May 6, 2016). This meeting entailed sensitizing the Maseru DHMT on QI and on the design of the QI intervention being implemented by the MOH and ASSIST, as well as the requirements on the part of the DHMT (i.e., the roles and responsibilities of the DHMT in QI). Conducted management skill and competency assessments in four scale-up districts [Mafeteng (April 19, 2016), Mohale’s Hoek (April 20, 2016), Berea (April 21, 2016) Leribe (April 22, 2016)]. Conducted management knowledge and skill assessment at Maseru DHMT and jointly selected the sites for Phase 1 QI implementation (May 23, 2016). These sites were chosen based on their patient volumes as well as the prevailing quality challenges. They include: Botśabelo Center [Senkatana] HIV and AIDS Treatment Center; Qoaling Filter Clinic, Likotsi Filter Clinic, Nazareth Health Center, Domiciliary Health Center, St Joseph Hospital, Scott Hospital, Paki Health Center, St Leonard Health Center, and Thamae Health Center. Conducted QI training for two scale-up districts (Berea and Leribe) (June 6-8, 2016). The training objectives were to: introduce quality improvement in clinical care; describe and discuss the principles, concepts and approaches of quality improvement; analyze health service delivery problems in the context of PMTCT and care and treatment; develop appropriate solutions to the problems; discuss commonly used QI tools; and share lessons learnt from PHFS. Conducted coaching visits and verified data at three facilities in Mohale’s Hoek namely, Mofumahali-oa-Rosary Health Center, Morifi Health Center and Lithipeng Health Center (June 15-16, 2016). See Figures 1-3 for results in improving retention, quality of care, and data quality in each of these facilities.
4 USAID ASSIST Lesotho Country Report FY16 Formal QI trainings conducted in three scale-up districts (Maseru Group 1: Aug 17-19, 2016; Maseru Group 2: Aug 24-26, 2016; Mafeteng: July 12-15, 2016; Mohale’s Hoek: July 20-22, 2016). Three DHMTs were represented. Of the expected 30 participants, 21 persons attended. Collectively, these districts are comprised of 66 facilities. Sixty-one (61) of the 66 were represented during the trainings conducted in the reporting period. Twenty (20) of 66 were selected as Phase 1 facilities; 18 have established QI teams, and these are all functional. Two QI teams (in Maseru and Mohale’s Hoek) are in development (this will complete Phase 1). The rest of the health facilities were coached on how to build QI teams. The terms of reference for facility QI teams were defined and will be included in subsequent spread activities. Onsite/in-service trainings were conducted in five scale-up districts (Aug-Sept 2016). The purpose was to orient all facility staff on QI and facilitate establishment of QI teams and projects. Seventy-seven percent (77%) (27/35) of the planned onsite trainings were achieved. There was a delay in the deployment of the Berea ASSIST team [i.e., ASSIST Monitoring and Evaluation (M&E) Officer and District Improvement Coordinator] and this resulted in delayed initiation of QI interventions. At the end of the onsite trainings, all facilities managed to establish facility QI teams and projects. Joint supportive supervision visits. Of the targeted 35 joint supportive supervisions, 17 (49%) were achieved. The challenge is that assigned members of the DHMTs had competing activities within the district which resulted in ASSIST district-based staff undertaking the planned supportive supervision activity on their own. Coordination of ASSIST project activities within each district (Aug 2016). This refers in particular to establishing effective linkages between the OVC, HIV care and treatment, and Southern Africa Regional Nutrition Project. Working relationships to support linkages with ASSIST OVC program sub- grantees in the scale-up districts were established, and three out of the five SUDs mapped a referral flow from community to facility-level for enhanced HIV care and treatment linkages (Maseru and Berea sub grantees have not yet met). Facilitated meeting between three Maseru sub-districts (Morija, Scott, and QE II) to orient management on QI principles, approaches, and concepts (Aug 2016). The outcome of this meeting was that the district QI team was developed with balanced representation from these three subdistricts. Each subdistrict will continue to monitor the progress in its supported facilities and report on a monthly basis to the entire team. Participated in IP meeting in Leribe District to share how each implementing partner is to support the district without duplicating efforts (Aug 2016). Key implementing partners (IPs) in this district are Elizabeth Glaser Pediatric AIDS Foundation, Baylor, Lesotho Network of AIDS Service Organisations (LENASO), and Clinton Health Access Initiative. Facilitated the PHC meeting in Leribe where all facilities presented their performance and gaps (Aug 2016). ASSIST was announced as the partner that is going to support the facilities in integrating QI in HIV and other clinical services. Integration of QI into the National Adolescent Health Program (Aug 2016). ASSIST had a meeting with national adolescent health manager to develop interventions to integrate QI in adolescent health programs. ASSIST to provide technical assistance to shape interventions for adolescents, focusing not only on HIV-positives but also targeting HIV-negatives for primary prevention. Spreading the lessons learnt from demonstration sites on three core PMTCT indicators – retention of mother-baby pairs and data quality (Sept 2016). The service package for PMTCT was rolled out and adopted in 35 facilities in the SUDs during Phase 1. The PHFS/PMTCT database has been modified to accommodate these new facilities. Two learning and sharing sessions were conducted: at Thaba-Tseka with 18 health facilities and at Qacha’s Nek with 12 health facilities (Sept 28-30, 2016). The purpose was for the experienced facilities to share the ideas and lessons learned with the relatively new facilities. Key results: At Lithipeng Health Center in Mohale’s Hoek, retention of HIV-positive mothers and their babies improved from 58% in April 2014 to 100% in September 2016 (Figure 1). The percentage
USAID ASSIST Lesotho Country Report FY16 5
of mother-baby pairs receiving the standard package of care increased from 93% in April 2014 to 100% in September 2016. The percent of mother-baby pairs with complete and accurate data decreased slightly from 100% in April 2014 to 95% in September 2016. At Morifi Health Center in Mohale’s Hoek, retention of HIV-positive mothers and their babies improved from 58% in April 2014 to 96% in September 2016 (Figure 2). The percentage of mother-baby pairs receiving the standard package of care was variable throughout the time period, changing from 91% in April 2014 to 88% in September 2016. The percent of mother-baby pairs with complete and accurate data changed from 100% in April 2014 to 88% in September 2016. At Mofumahali-Oa-Rosari Health Center in Mohale’s Hoek, teams struggled with retention of HIV-positive mothers and their babies, going from 89% in April 2014 to 67% in September 2016 (Figure 3). The percentage of mother-baby pairs receiving the standard package of care increased from 0% in April 2014 to 76% in September 2016. The percent of mother-baby pairs with complete and accurate data increased from 89% in April 2014 to 94% in September 2016. Figure 1. Improving retention, quality of care and data quality, Lithipeng Health Center, Mohale’s Hoek (April 2014-Sept 2016)
Retention of M‐B Pairs % of M‐B Pairs Receiving Standard Package % M‐B Pairs with Complete and Accurate Data
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0% Apr‐14 Jul‐14 Oct‐14 Jan‐15 Apr‐15 Jul‐15 Oct‐15 Jan‐16 Apr‐16 Jul‐16
Number of M‐B Pairs scheduled for care Number of M‐B Pairs Retained in Care Number of M‐B Pairs Retained in Care 30
20
10
0 Apr‐14 Jul‐14 Oct‐14 Jan‐15 Apr‐15 Jul‐15 Oct‐15 Jan‐16 Apr‐16 Jul‐16
6 USAID ASSIST Lesotho Country Report FY16 Figure 2. Improving retention, quality of care and data quality, Morifi Health Center, Mohale’s Hoek (April 2014-Sept 2016) Retention of M‐B Pairs % of M‐B Pairs Receiving Standard Package % M‐B Pairs with Complete and Accurate Data 100% 90% 80%
70% 60%
50% No Team Work. Focal Inconsisten/fragmented 40% person attending documentation of data (by district trainings and 30% nursing staff and M2M) on leave. 20% 10%
0% Apr‐14 Jul‐14 Oct‐14 Jan‐15 Apr‐15 Jul‐15 Oct‐15 Jan‐16 Apr‐16 Jul‐16
Number of M‐B Pairs scheduled for care Number of M‐B Pairs Retained in Care Number of M‐B Pairs Retained in Care 40 30 20 10 0 Apr‐14 Jul‐14 Oct‐14 Jan‐15 Apr‐15 Jul‐15 Oct‐15 Jan‐16 Apr‐16 Jul‐16
USAID ASSIST Lesotho Country Report FY16 7
Figure 3. Improving retention, quality of care and data quality, Mofumahali-Oa-Rosari Health Center, Mohale’s Hoek (April 2014-Sept 2016) Retention of mother-baby pairs % of mother-baby pairs receiving standard package of care % of mother-baby pairs with complete and accurate data 100% 90% 80% 70% 60% 50% Filing system 40% challenges. Inconsistent documentation of data. 30% MB Pairs not appointed 20% as pairs. Self transfers 10% without records. 0% Aug-14 Oct-14 Dec-14 Feb-15 Apr-15 Jun-15 Aug-15 Oct-15 Dec-15 Feb-16 Apr-16 Jun-16 Aug-16
60 Tot.# M-B Pairs Scheduled for Care in Month Tot.# M-B Pairs Retained in Care in Month 50 40 30 20 10 0 Aug-14 Oct-14 Dec-14 Feb-15 Apr-15 Jun-15 Aug-15 Oct-15 Dec-15 Feb-16 Apr-16 Jun-16 Aug-16
SPREAD OF IMPROVEMENT The ASSIST strategy was to reach all facilities providing HIV/PMTCT services, including referral and district hospitals, and health centers initially in all 10 districts but later focusing on just the five scale-up districts. The activity was to focus on strengthening the linkages along the PMTCT Figure 4: Slice of the health system continuum of care, including ANC/MNCH, HIV care and treatment, PMTCT, and HBC services. Implementation was undertaken in a phased Diagram Showing a Slice of the System in one District manner such that a three-month demonstration was undertaken in a slice of the system in all five scale-up districts. The selection of the facilities was undertaken in conjunction with the MOH and the Referral Facility x 1 Christian Health Association of Lesotho (CHAL) to Health Centers x 1-2 select different types and levels of facilities in order Health Posts x 2-3 to include a representative slice of the health care system (Figure 4). (A Slice of the System in that Administrative Region) ASSIST worked closely with the DHMT in each district to select suitable health facilities for the demonstration (Figure 5). Quality improvement teams were set up in the demonstration facilities and at the district management levels.
8 USAID ASSIST Lesotho Country Report FY16 ASSIST provided quality improvement Figure 5: Slice of the health system in multiple districts capacity building for demonstration facilities’ improvement teams, district officials, and implementing partners to align the improvement approach among partners. Members from DHMTs were capacitated by ASSIST to serve as district improvement coaches to provide technical guidance and support to facility improvement teams as challenges arise. ASSIST worked alongside DHMTs during supportive supervision visits (every 4-6 weeks) to aid DHMTs in providing improvement technical support to facility teams. Facility teams were capacitated by ASSIST and the DHMT to perform the continuous process of identifying gaps (process analysis), redesigning processes of care, and testing several rounds of changes to determine best practices for integrating HIV/PMTCT care. In addition, facilities were capacitated to be able to monitor and analyze data on selected indicators to determine whether improvements were occurring; modify processes of care to achieve an improvement; and document how changes in processes led to that improvement. Facilities were also encouraged to document what did not work to generate learning that can be shared across facilities and inform the larger scale roll out. ASSIST provided intense support to the demonstration sites during the demonstration period, and over time reduced to a light support mode, to allow the DHMT to lead coaching and mentoring support. Learning sessions were undertaken during initial implementation to bring the demonstration sites together to share identified gaps in services, operational challenges, and possible solutions. ASSIST provided guidance to the DHMT and implementing partners on how to lead these sessions and ways to facilitate knowledge exchange between sites. Activity 2. Strengthen the capacity of DHMTs in five “sustained response districts” to oversee and monitor the quality of services for PLHIV currently enrolled in PMTCT and care and treatment BACKGROUND The revised PEPFAR Strategy has defined five districts as being “sustained response districts” (Butha- Buthe, Mokhotlong, Quthing, Qacha’s Nek, and Thaba-Tseka). For these five districts, PEPFAR has defined a maintenance package as a core package of HTC, PMTCT, and ART services and support for COP 15. The districts collectively serve 22% (22,717) of the total number of PLHIV receiving ART in Lesotho. Under the revised strategy, these districts will not be prioritized by PEPFAR for accelerated epidemic control and as such will receive only the maintenance package. The mandate from PEPFAR is that support in the SRDs should focus on building the capacity of the DHMTs to oversee and monitor the quality of services for PLHIV currently enrolled within the treatment cascade. ASSIST support is therefore focused on providing assistance to the DHMTs to set site- and district-level targets for prevention, care, and treatment and PMTCT services. The DHMTs will also be supported to define quality improvement benchmarks for monitoring site-level quality of care with respect to uptake of treatment/services, adherence, retention, clinical outcomes, and routine laboratory testing. KEY ACCOMPLISHMENTS AND RESULTS ASSIST provided on-site QI and PHFS training at two health centers (Mohlanapeng in Thaba- Tseka District and St. Paul in Butha-Buthe District) (Sept 29, 2015 – Oct 1, 2015). Given high staff turnover rates, it was necessary to introduce staff in the poorer-performing facilities to the basics of QI and PHFS to equip them with the necessary skills to maintain the work.
USAID ASSIST Lesotho Country Report FY16 9
ASSIST provided support for coaching visits in 12 health facilities in three districts (Oct – Dec 2015). To improve the retention of mother-baby pairs in care, ASSIST continued to provide technical support to district coaches to ensure that the standard package for mother-baby pairs (which includes ART for the mother, Cotrimoxazole or Nevirapine for her baby, infant and young child feeding counselling, nutrition assessment, and an appointment for the next visit) is being implemented at all 12 health facilities. Organized and undertook a learning and sharing session/meeting for district coaches from the three PHFS districts and 11 health facilities (Oct 14-16, 2015). The purpose of the meeting was to facilitate sharing experiences in the implementation of the PHFS activity in the pilot sites. A secondary purpose was to prepare the districts of Thaba-Tseka and Butha-Buthe (both of which are now categorized as SRD) for the upcoming spread of PHFS into all remaining facilities in the districts. Subsequent to this meeting, all facilities in Butha-Buthe and Thaba-Tseka are undertaking QI projects under the auspices of PHFS. PHFS scale-up training at Butha-Buthe hospital (Dec 15-18, 2015). With the requirement for an exclusive focus on SUDs after March 2016, ASSIST has embarked on a process to “spread” PHFS to all remaining sites/facilities within the three pilot districts. Of the eight remaining sites in Butha-Buthe, seven were able to participate in this training. Financed and technically supported MOH to conduct orientation meetings disseminating new HIV guidelines (“Test & Treat”) in 4 out of the 5 sustained response districts (May 9-11, 2016). Jointly, with relevant DHMTs, conducted site selection for Phase 1 implementation of QI initiatives (April 19-22, 2016). The sites were chosen based on the volume of patients seen as well as on the prevailing “quality challenges”. ASSIST conducted a formal training on QI in Qachas’ Nek District (Aug 31- Sept 2, 2016). The 26 participants included the DHMT members, two hospital managers, health facilities representatives, and one representative from correctional services. The purpose was to capacitate health care workers and DHMT members on QI principles, concepts, and approaches and guide them on how to integrate QI in HIV and other clinical services. The MOH and ASSIST conducted supportive supervision in SRD districts (Sept 4-9, 2016). The purpose was to follow-up on the implementation of new Test and Treat HIV guidelines and integration of QI in HIV, using the comprehensive supervision tool jointly developed by the MOH and ASSIST. Out of the targeted 62 facilities, 41 facilities were jointly supervised while the remaining 21 facilities were supervised by MOH alone due to competing activities. Coordination meeting in the SRDs (Aug 10-11, 2016). ASSIST participated in two PHC meetings at Thaba Tseka and Butha-Buthe. Participants included DHMTs in these two districts and all health facilities within those districts. The purpose was for all health facilities to present their performance and gaps as well as learn from the best-performing facilities. The sustained response districts were guided on how to establish QI teams at both the district and facility levels. The expected number of teams is 61, but the number of functional teams at the end of FY16 is 34. The remaining teams for the facilities are in development, however there are challenges with owning QI in the facilities. Most health workers still view QI interventions as an added workload. District Improvement Coordinators and M&E officers deployed to the districts are well integrated in the district technical working groups (Q4). Capacity building is ongoing for DHMTs and health facilities. Significant progress has been made in the Phase 1 facilities in terms of establishing QI teams and starting QI projects. A spread strategy has been drafted that clearly indicates how the spread to new sites is going to be executed. Key results: Results from 12 PHFS demonstration sites: As a part of strengthening the linkages along the PMTCT continuum of care, including ANC/MNCH, HIV care and treatment, PMTCT, and HBC services, results from 12 facilities have been disaggregated to show the variety of performance in four faith-based facilities, two government hospitals, and six other government facilities. Figure 6 shows progress across all 12 sites to keep mothers and baby in care. Figure 7 shows results for providing mother-baby pairs with a standard package of care, disaggregated by the three types of facilities. Figure 7 shows that improvements in performance have been the most difficult to achieve in the two large government hospitals.
10 USAID ASSIST Lesotho Country Report FY16 Figure 6. Percentage of mother-baby pairs retained, 12 PHFS sites (Nov 2013-Sept 2016)
Figure 7. Percentage of mother-baby pairs receiving standard package of care, 4 faith-based facilities, 2 government hospital, and 6 other government facilities (Nov 2013 – Sept 2016)
Percentage of Mother‐Baby pairs receiving standard package of care in four faith‐ based facilities, two government hospitals, and six other government facilities
100%
80%
60%
40%
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0% Nov‐13 Feb‐14 May‐14 Aug‐14 Nov‐14 Feb‐15 May‐15 Aug‐15 Nov‐15 Feb‐16 May‐16 Aug‐16
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Activity 3. Build capacity for national level QI program coordination and management BACKGROUND The national QI program is ultimately the responsibility of the Senior Management of the MOH. Oversight responsibility for the coordination of the development, implementation, and monitoring and evaluation of QI plans is vested in senior management. Senior management, clinicians, DHMTs, and site staff should be engaged in its development. Senior management should ensure that the targets set out in the QI program are met. Given the “newness” of QI in the MOH, as well as the attendant responsibility that Senior Management in the Ministry has in this regard, it was felt necessary to include a component that would ensure that the MOH develops capacity, across all its functions, for QI. KEY ACCOMPLISHMENTS AND RESULTS ASSIST-MOH plenary meeting (Nov 29 – Dec 1, 2015). This meeting was organized to facilitate a review of the indicators currently in use in Lesotho for PHFS. It was felt that the three indicators in use did not adequately enable an assessment of progress towards the attainment of PHFS goals and objectives. To that end, additions were made to the list of indicators to be collected. The meeting also had the objective to develop a standard approach to the collection of data on indicators given the wide disparity in results related to data quality. The third objective of the meeting was to update the PHFS database to make it complete up to the end of FY15. The piloting of the standardized data collection tools was successfully undertaken at 2 facilities in Mohale’s Hoek (Mpharane Health Center and Tsepo Health) (Q2). The tool has now been approved for use throughout all facilities collecting data on services for mother-baby pairs. Contribution to MOH training on elimination of mother-to-child transmission of HIV (Dec 9, 2015). ASSIST oriented health workers from the districts of Mafeteng and Mohale’s Hoek (both scale- up districts) on QI principles and approaches, and their potential role in the elimination of mother-to- child transmission of HIV. As a result of the meeting, ASSIST was requested to orient all DMHTs on this aspect during the regularly district supervisory visits. Both districts were visited during the month of January 2016. Two members (Director, Primary Health Care, and Manager, Clinical Nursing Services) of the Senior Management of MOH were supported by ASSIST to attend a “Quality Improvement Framework Review Meeting” hosted by the MOH of Uganda (April 18-22, 2016). Held quarterly progress review meetings jointly with the MOH QA unit (April 12, 2016). Three MOH/QA members provided in-house training on QI facilitated by ASSIST (April 4-7, 2016). Activity 4. Quality improvement in OVC programming BACKGROUND Consistent with the PEPFAR 3.0 and COP 15 OVC Technical Considerations, the technical focus of ASSIST QI work for OVC services in Lesotho has been on core and near-core interventions for most vulnerable children and adolescent girls, building resilience in children and families, preventing HIV infections, identifying HIV-positive children, and linking and retaining those children in care and treatment. With an emphasis on family-centered socio-economic interventions, ASSIST aims to improve processes of care such as case management, referrals and linkages, and the coordination of care between government and service delivery partners. KEY ACCOMPLISHMENTS AND RESULTS Start-up activities Recruitment and orientation of OVC ASSIST team (Q1). Developed scope of work, reviewed and approved by USAID Lesotho and the Ministry of Social Development (Q1). Organized and attended several meetings with the MOSD, including a National OVC Coordinating Committee quarterly meeting, to introduce the program (Q1).
12 USAID ASSIST Lesotho Country Report FY16 A Memorandum of Understanding detailing the nature of the relationship between the MOSD and ASSIST has been approved and signed by the Principal Secretary in the MOSD (Feb 2016). Issue and manage fixed obligation grants to local organizations Conducted capacity assessment for the consortium partners who received funding from the Building Local Capacity for Delivery of HIV Services Project (Q1). Request for Applications (RFA) was drafted and submitted for review (Q1). These requested local organizations to apply for fixed obligation grants (FOGs) for the provision of services at selected councils in the five sustained response districts. These were then posted in the local media in January 2016. Seventeen (17) applications were received during the month of February, and eight organizations were selected for grant award. Target definitions for all District Councils have been completed, and each grant recipient was made aware of the targets for their organization (Q2). Issue and manage fixed obligation grants to local organizations. After signing of the contractual agreements for the 8 sub-grantees in April, the first disbursement of funds to partners was paid out (April and May 2016). Grant agreements for 8 sub-grantees were later reviewed and amended to take into consideration time delays for project start, leading to the revision of the 2nd and 3rd milestones and deliverables. The revisions were approved and signed (May 2016). The Non-US Pre-Award Assessment Survey was undertaken to assess the financial and management capacities of the 8 sub-grantees (June 2016). The activities involved organizational self-assessment (May 31 – June 10, 2016); in-country assessment (June 20-24, 2016); needs-based training to address gaps (June 27-30, 2016); and subsequent action planning. Data and financial verification processes were conducted on all sub-grantees before payments were disbursed. Two sub-grantees, LIRAC and SWAALES, were supported with standard psychosocial training package for their secondary caregivers or caseworkers, conducted by Regional Psychosocial Support Initiative (REPSSI) facilitators (Sept 2106). REPSSI is a regional partner of ASSIST. Build capacity of the Ministry of Social Development at central and local levels to coordinate and sustain effective and timely interventions Knowledge exchange visit undertaken to Malawi (included ASSIST program staff as well as Director of Children’s Services and OVC coordinator from the MOSD) (Feb 2016). Development of terms of reference for ASSIST District Improvement Coordinators (DICs) for their deployment to the districts (June 2016). They are placed in offices of MOSD to reinforce coordination capacity and that of sub-grantees. Three Community Councils (CCs) in 2 districts were identified for testing of QI by the URC OVC team. One CC QI team was set up in one council, where the improvement aim and a change idea were chosen for testing (improving the performance of a group of primary school OVC through homework) (April 2016). All five districts’ District Child Protection Teams (DCPTs), District and Urban Councils have been oriented on the ASSIST OVC QI project, and all have set up inter-sectoral District QI teams. Two QI teams have received QI training, facilitated by external technical assistance (May 2016). Held a strategic program orientation and advocacy meeting with the new Principal Secretary of the MOSD (Aug 2016). Provided technical and financial support to the annual DCPT Peer Review Meeting forum where all 10 DCPTs convene to share learning and review individual progress (Sept 2016). Improve the well-being of vulnerable children through accessing quality essential services in five priority districts Convened Case Management workshop with MOSD staff (managers, child welfare officers and auxiliary social workers), program managers, and M&E staff from the eight sub-grantees. Data collection tools have been designed/adapted for use by partners (May 2016).
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All project tools have been developed and shared with partners for identification and prioritization of households to determine “most vulnerable” and for assessment of individual beneficiaries for provision of needs-based services (June 2016). These tools include: o Lesotho Vulnerable Household Identification Tool (LVHIT) o Guidelines for Administering the OVC Vulnerability Prioritization Tool o Action Record -- this is for use by service providers to whom OVC and caregivers have been referred o Child Assessment and Care Plan Tool o Vulnerable Household Selection Form o Standard Operating Procedures for Case Management o Health Services Referral Form o Project databases: Household prioritization, assessment and care plan, and service provision Partners conducted trainings for their secondary-level caregivers on the project tools developed (June 2016). Sub-grantees introduced themselves and ASSIST to the Community Councils within which they are active (June 2016). They further obtained acceptance or acknowledgement letters to submit to URC as a deliverable and proof of their undertaking to introduce the project and themselves to the CCs. All partners embarked on the identification and registration of vulnerable households using the LVHIT. This was undertaken in all 49 Community Councils (June 2016). See Figure 8 showing their progress in registering, assessing, and setting up care plans with vulnerable households. Five community QI teams established in Leribe District with the aim of improving nutritional status of 10 households through homestead gardens (Aug - Sept 2016). One community QI team established by a Leseli community-based organization (CBO) in Sebelekoane Mafeteng District (Aug 2016). Developed a documentation journal for the Berea QI team (Q4). Figure 8. Progress among sub-grantees in registering and developing care plans for vulnerable families, 8 sub-grantees (Sept 2016)
14 USAID ASSIST Lesotho Country Report FY16 SPREAD OF IMPROVEMENT Given the delays in the allocation of funding by PEPFAR, the targets for the OVC project were revised such that they were limited to the identification and prioritization of vulnerable families and the attendant definition of care plans for all orphans and vulnerable children in the prioritized families. Improvement activities (and resultant spread) will be reported on in FY17. 4 Improvement in Key Indicators Baseline Mar Indicators Facility (April Apr May Jun Jul Aug Sep 2016 2014) 2016 2016 2016 2016 2016 2016
MOHALE’S HOEK DISTRICT Nts’ekhe 17% 26% 30% 17% 49% 51% 77% No data Hospital (131) (99) (90) (90) (63) (39) (90) Morifi Health 58% 84% 76% 61% 59% 100% 84% 96% Center (19) (31) (33) (33) (17) (24) (25) (25)
Lithipeng Health 58% 96% 92% 92% 100% 100% 92% 100% Center (26) (23) (24) (24) (26) (25) (24) (21)
Mofumahali-Oa- 89% 83% 75% Rosari Health 67% 89% 82% 98% 92% Center (19) (48) (48) (48) (54) (49) (47) (50) BUTHA-BUTHE DISTRICT 66% 13% 3% 32% Butha-Buthe 65% No data 23% 21% (90) (90) (78) Hospital (132) (134) (90) (90) Retaining 94% 77% 73% 68% mothers and Linakeng Health 71% 85% babies in (34) 80% 74% (44) (22) (22) Center (24) (34) care (35) (35) Motete Health 89% 82% 89% 80% 75% 58% 93% 100% Center (18) (11) (9) (10) (12) (12) (14) (18)
St. Paul Health 79% 66% 48% 43% 33% 33% 90% 72% Center (38) (41) (42) (42) (42) (63) (62) (53)
THABA-TSEKA DISTRICT 71% 84% 61% Health Division (17) (19) (23) 75% 63% 44% 40% 60% 80% Mohlanapeng No data (8) (8) (9) (10) (10) (10) 44% 54% 80% 62% 73% 90% 69% Paray (50) (67) (71) (73) (77) (61) (70) 75% 20% 18% 41% 43% Linakeng (8) (20) (22) (22) (21)
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Baseline Mar Apr Jun Indicators Facility (April May Jul Aug Sep 2016 2014) 2016 2016 2016 2016 2016 2016
MOHALE’S HOEK DISTRICT Nts’ekhe 41% 58% 44% 40% 29% 5% 49% No data* Hospital (22) (26) (27) (15) (31) (20) (69) Morifi Health 92% 96% 90% 50% 42% 95% 88% No data* Center (26) (25) (20) (10) (24) (21) (24) Lithipeng Health 100% 100% 100% 65% 80% 86% 95% No data* Center (22) (22) (22) (26) (25) (22) (21) Mofumahali-Oa- 98% 92% Rosari Health No data* 94% 77% 80% 85% 78% Center (40) (36) (32) (48) (40) (46) (46) Data quality: BUTHA-BUTHE DISTRICT Percentage of Butha-Buthe 50% 48% 86% 68% 64% 67% 80% mothers and No data* babies whose Hospital (86) (88) (21) (19) (11) (3) (25) data are Linakeng Health 91% 79% 82% 54% 18% 100% 87% accurately No data* Center (32) (29) (28) (26) (34) (16) (15) and completely Motete Health 67% 88% 100% 44% 57% 100% 100% No data* filled by the Center (9) (8) (2) (9) (7) (13) (18) end of the St. Paul Health 96% 100% 100% 100% 76% 100% 39% month No data* Center (27) (20) (18) (14) (21) (56) (38) THABA-TSEKA DISTRICT 100% Health Division No data* (16) 67% 80% 75% 75% Mohlanapeng No data* (6) (5) (4) (4) 67% 75% 76% 73% 69% 79% Paray No data* (36) (57) (45) (56) (55) (48) 0% 0% 22% 56% Linakeng No data* (4) (4) (9) (9)
Baseline Mar Apr Sep Indicators Facility (April May Jun Jul Aug 2016 2014) 2015 2015 2015 2016 2016 2016
MOHALE’S HOEK DISTRICT Routine visits: Nts’ekhe 59% 58% 48% 53% 100% 100% 72% No data* Percentage of Hospital (22) (26) (27) (15) (31) (20) (69) mother-baby Morifi Health 92% 96% 90% 50% 100% 95% 92% pairs who No data* Center attend under (26) (25) (20) (10) (24) (21) (24) 5 and ART Lithipeng Health 100% 100% 100% 88% 96% 100% 100% No data* clinics and Center (22) (22) (22) (26) (25) (22) (21)
16 USAID ASSIST Lesotho Country Report FY16 Baseline Mar Apr Sep Indicators Facility (April May Jun Jul Aug 2016 2014) 2015 2015 2015 2016 2016 2016 receive the Mofumahali-Oa- 98% standard 92% 94% 81% 78% 85% 78% Rosari Health No data* (40) package of Center (36) (32) (48) (40) (46) (46) services BUTHA-BUTHE DISTRICT Butha-Buthe 50% 48% 86% 68% 58% 67% 80% No data* Hospital (86) (88) (21) (19) (12) (3) (25) Linakeng Health 91% 79% 82% 54% 41% 100% 87% No data* Center (32) (29) (28) (26) (34) (16) (15) Motete Health 78% 100% 25% 56% 57% 100% 100% No data* Center (9) (8) (8) (9) (7) (13) (18) St. Paul Health 96% 100% 100% 100% 76% 100% 39% No data* Center (27) (20) (18) (14) (21) (56) (38) THABA-TSEKA DISTRICT 100% Health Division No data* (16) 67% 80% 75% 75% Mohlanapeng No data* (6) (5) (4) (4) 58% 82% 80% 80% Paray No data* (36) (57) (45) (56) 0% 0% 22% 56% Linakeng No data* (4) (4) (9) (9) 5 Sustainability and Institutionalization ASSIST is supporting the MOH to establish QI teams at the different levels of the health care system. This serves to ensure that QI becomes entrenched within the MOH in all its activities. In addition, ASSIST will support the establishment of a QI Technical Working Group whose membership shall include the major health-related development partners, as well as key implementing partners under the PEPFAR/USAID/CDC umbrella. Within the context of the revised PEPFAR strategy, ASSIST has embarked on a process to provide intensive capacity building support to the DHMTs in the SRDs to enable them to undertake their oversight responsibility over the health centers. To that end, ASSIST conducted a capacity assessment to determine baseline capacities in the areas of supportive supervision, development of annual work plans, performance appraisal, and coaching and mentoring. The findings of the assessment shall be used to develop a capacity-building program in FY17 to address the gaps identified. 6 Knowledge Management Products and Activities Case Studies Four case studies have been drafted and are now under review: Tsoloane Community Support Group: ASSIST through the OVC program conducted the quality improvement exercise at Tsoloane area in Siloe Community Council, Mohale’s Hoek. The ASSIST OVC team organized a meeting with Tsoloane Support Group, as a group working with vulnerable children in the council and in five villages, under the facilitation of LENASO as a sub-partner responsible in the council. The objective for the meeting was to understand the vulnerability issues
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and challenges faced by children in the council. Among the several challenges spelled out, it was realized that there is an essential problem of underperforming children in Tsoloane Primary School. Most of the children were either orphaned or vulnerable in some way. In addition, the children were not getting any form of support on school work once at home, including guidance in doing home-work. The team together with the CBO decided to develop an improvement aim to address the school performance gap. Uncoordinated data management -- a source of significant data variation and confusion: Butha-Buthe Hospital: Butha-Buthe District Hospital is among the 12 PHFS pilot sites and is the heart of the health system of the Butha-Buthe District. There are non-governmental organizations supporting this facility in scaling up HIV related activities, and among them is Mothers2Mothers (M2M), an organization that uses HIV-positive mothers to provide guidance to their peers. Even though services were geared towards the same clients, M2M and MOH had a parallel system of reporting which has had an unintended negative impact on the programming for HIV-related interventions. Through the PHFS project, retention of mother-baby pairs in care was a key objective. M2M also tracked the same indicator for the same clients accessing care at Butha-Buthe but their data sources and results of retention reflected a huge variation. The facility seemed to routinely use improvised registers (more than the official under-5 register) and failed to use the information collected on the improvised registers to update MOH standard tools. M2M on the other hand had developed mother-baby cards that they used to capture the services provided to pairs but this was never used to feed information into under-5 register and appointment book. During reporting and data verification processes, improvised registers are disregarded as a means of data sources in order to discourage the use of improvised registers, and at the same time encourage the use of the MOH standard tools. Improving retention of mother-baby pairs through improved teamwork: Lithipeng health center: Retention of mother-baby pairs in care at Lithipeng had been a major challenge in the provision of quality maternal and child health services. At baseline, retention of mother-baby pairs was 62%, with only 29 pairs in care. Despite the manageable numbers of pairs, Lithipeng health center had been struggling to retain majority of pairs in care due to poor documentation, fragmented services, and a non-functional facility QI team. Teamwork is central to successful quality improvement, and good team work is observed when a group of people work together cohesively, towards a common goal, creating a positive working atmosphere, and supporting each other to combine individual strengths to enhance team performance. At Lithipeng, it was found that quality improvement initiatives towards retention of mother-baby pairs were dependent on only one nurse. In her absence, no one continued with quality provision of services for mother-baby pairs. The pairs were inconsistently appointed and even when they came to the clinic, the records (e.g., under-5 register and maternal chronic care card) were either inaccurately or incompletely filled. Improving health care service delivery to meet legitimate expectations of clients through effective integration of their complaints: According to Lesotho quality assurance accreditation standards, all facilities are expected to have a system which enables participation of patients and their families in care that is being provided to them. PEPFAR recognizes consumer involvement as a key component in improving healthcare quality. This is assessed through the Site Improvement through Monitoring System (SIMS) tool on a monthly basis in PEPFAR-supported sites. The supportive supervision that was conducted jointly by MOH and ASSIST in the five sustained response districts from September 4-9, 2016 where approximately 60 health facilities were reached, revealed that while suggestion boxes were physically available in the majority of health facilities, there is no clear system for how the suggestion boxes, as well as the patients’ complaints and comments, are utilized for service improvement. There are no client exit interviews or client satisfaction surveys being conducted. For most health facilities, these improvised suggestion boxes are placed in patients’ waiting rooms but clients are seldom informed, educated, or encouraged to write their suggestions or complaints. Even when they have commented, the complaints are not translated into changing the way things are done at the service delivery point to accommodate the needs and expectations of clients. These challenges suggest that there are limited platforms for clients to be involved in their care.
18 USAID ASSIST Lesotho Country Report FY16 7 Gender Integration The nature of the pandemic in Lesotho (women disproportionately more affected and infected than men) means that gender is integral to all discussions during trainings, supportive supervisory visits, and meetings. However, gender has not yet been fully integrated into formal QI trainings. Health care workers are mentored to identify and address gender-related challenges (e.g., despite a test and treat policy, women have been refused ART because they have to seek permission of their husbands first). In such cases, change ideas targeting male involvement are implemented (e.g., social mobilization targeting males). Participant data for all trainings are disaggregated by sex. OVC gender workshops will be conducted in 2017 Q2 that will address the topic of gender-based violence. 8 Directions for FY17 Strengthen linkages and retention to improve clinical services Conduct QI capacity-building for QI teams from demonstration facilities and implementing partners Conduct monthly coaching visits to sites to ensure integration of QI Conduct supportive supervision visits with DHMTs Capacitate DHMTs and facility teams in the collection, analysis, and use of improvement data Conduct quarterly learning and sharing sessions to facilitate exchange of ideas between different district and facility teams Strengthen the capacity of DHMTs in five SRDs to oversee and monitor the quality of services for PLHIV currently enrolled in PMTCT and care and treatment Facilitate supportive supervision and coaching visits by DHMTs to facilities Support conduct of bi-annual learning and sharing sessions for sustained response districts Support joint monthly DHMT and IP performance review meetings (assessment of facility performance) Develop capacity-building program for DHMTs based on results of skills and competency assessments Facilitate “spread” of changes found to be effective in improving the quality of services in the SRDs Build capacity for national level QI program coordination and management Engage consultant to develop National QI Strategy and Implementation Framework for both MOSD and MOH Support development of National QI Curriculum for both in-service and pre-service trainings of health care workers Support MOH and MOSD to host a joint international QI conference Provide technical support for capacity building in QI for senior management of the MOH Quality improvement in OVC programming Issue and manage fixed obligation grants to local NGOs for the provision of quality services to vulnerable households in the five scale-up districts Build capacity of MOSD at central and local level for design and implementation of programs that address issues facing vulnerable households in Lesotho Improve the well-being of vulnerable children through accessing quality essential services, including HIV services, in five priority districts Strengthen the capacity of community structures through local leadership to ensure sustainability of OVC response at that level
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