2. What systems need to be put in place to ensure Quality of Clinical systems in this phase of transition HIV Care and Rx programs and ensure sustainability ? Question Question

3.  Define “models of care” - program standards in line with the national guidelines in @ program area  Define minimum standards of care (SOC)  Structured mentoring systems  Structured way to monitor the quality on a continuous basis  Robust Health system in place  Local Staffing development and motivation plan  Conducive policy environment  Avoid documentation overload problem

4.  Regular data feedback & sharing to staff encourages quality  Invest in management and leadership skills on the government/local partners  Indicators as soon as possible to align to national indicators  Ensure QI across the health system:National- >Regional/Provincial->District->Site level  Distinguish between site versus national standards  Incorporate QI in pre-service training modules and the in- service modules

5. Quality improvement initiatives – various models:

6.  Minimum indicators (HIV or non-HIV) assigned a unique cost based on quality and complexity e.g.  Monthly reports – quarterly scores and checks  Staff motivation based on scores  Team work encouraged by system  Tanzania GOT will start PBF system soon, IPs could take advantage

7.  Need to evaluate the PBF and how well it has worked and what portions of the system are responsible (money, scrutiny, incentive/punitive aspects)  How responsive is it to deficiencies?  Involve community and patients in getting feedback to avoid forgery

8.  Kenya (AIDS Relief) Mentorship with goal of improving quality. Involving hospital leadership in establishing indicators to increase quality  Tanzania (Harvard) Improve staff satisfaction through an internal quality improvement program, staff competition, rewarding best achievers in site evaluations with small incentives, like books, journals.

9.  Zambia (CIDRZ) Quality must be inherent in the program – not linked to incentives. Deliver # of patients that meet quality standards – funds used in site specific and determined by site staff depending on priority. Elected members from community provide quality improvement  Tanzania & Kenya (ICAP, DOD) Innovations like PLHIV as Peer educators to task shifting to increase quality of service from HCWs. Also gradually overcomes stigma in community.

10.  Quality and outcomes will be dynamic : need to establish processes that will be responsive to changing indicators of quality. (e.g. change in drugs, different outcome measures for patients on longer term ART, drug resistance).  Sustainability - Patient input will be critical, transparency of process. HCW involvement and motivation Challenges

11.  Practical issues: ensure regular revision of protocols, logarithms, update of training manuals,  Comprehensive approach - need to evaluate management, administrative processes and finance. If these aren’t working – little support for clinical care. Need to evaluate what kind of new processes might to needed to maximize the funding from PEPFAR.  Dialogue with govts to provide living wages and conducive working environment to HCWs Conclusion

12. Thank you!