MINISTRY OF HEALTH – UGANDA

MINISTRY OF HEALTH – UGANDA

In Uganda it is estimated that roughly 146,000 children under 14 years are living with HIV/AIDS. Roughly 76,750 of these are in immediate need of ARV treatment and yet only 24% (18,500) have access to ART. However, without ART, 50% of HIV-positive children will die before reaching the age of three years and an additional 25% will die by age five. Most of these deaths can be prevented if children born to HIV-infected mothers are diagnosed early, receive proper health care and nutrition and are initiated on HIV treatment as soon as they are eligible.

In Uganda paediatric ART services remain low with 68% and 58% of General Hospitals and HC IVs respectively providing any form of Paediatric ART provision, compared with 100% and 82% respectively providing adult ART services. This presents a major barrier to testing at-risk children and enrolling HIV-positive children in ART programmes. In addition, most health care workers lack the skills to identify, treat and care for children at risk of HIV and to counsel and provide psycho-social support for HIV-positive children and their caregivers. A number of partners are involved in training paediatric ART service providers and providing paediatric HIV/AIDS services, but guidelines and curricula to support these activities have not been harmonised.

The Regional Centre for Quality of Health Care (RCQHC) in partnership with the Health Communications Partnership (HCP) are currently implementing a 2-year initiative to support the MOH/AIDS Control Programme (ACP) to scale up paediatric HIV services in Uganda by strengthening the capacity of health care providers at hospitals and health centres in Uganda to refer children at risk of HIV for testing and HIV/AIDs services; to counsel caregivers and children affected by HIV/AIDS; and to offer quality HIV/AIDS counseling, care, support and treatment services for children with HIV/AIDS. This will be achieved through training of health care providers, training of trainers from districts and partner organizations, and mentoring /support supervision of health care providers.

A standardised Paediatric HIV Care and Treatment training curriculum was developed and mid level health workers have been trained with the aim of greatly improving their capacity to manage paediatric HIV/AIDS patients The five day practical in-service training is a part of the package of trainings for health care professionals requires mentor team follow up-visits to offer individualized support and follow up.

The goal of the support supervision is to determine the extent to which trained health workers have translated the acquired knowledge, skills and attitudes into practice as frontline pediatric HIV care service providers.

The support supervision exercise will specifically achieve the following objectives

1. 
   Follow up on the implementation of the three specific pledge actions that health workers made at the end of the training
   
2. 
   Assess the effectiveness of the referral system (intra-facility, Inter facility and community-facility referrals)
   
3. 
   Determine the extent to which the facilities have defined and provided a comprehensive care package (10 point management plan, functional care team etc)
   
4. 
   Ensure proper use of the Health management information systems; proper recording, utilization of data tools, completeness of data and reporting.
   
5. 
   Identify and address challenges related to paediatric HIV care and treatment service provision at the facility
   

TIME TABLE FOR POST TRAINING SUPPORT SUPERVISION VISIT

	Day 1			Day 2
	Team member 1	Team member 2		Team member 1	Team member 2
8:30-9:00 am	Meeting with DHO		8:30-9:00 am	Work with Site to implement some of the action point discussed in the debrief
9:00-9:30 am	Meeting with facility In charge		9:00-9:30 am
9:30-10:00 am	Meeting with Trainees		9:30-10:00 am
10:00-10:30 am	Break Tea		10:00-10:30 am
10:30-1:00pm	Observe case management and improve skills	Chart Review	10:30-12:00	Development of key follow up actions with Team
			12:00-1:00pm	Debrief to Health facility in charge
1:00-2:00pm	Lunch		1:00-2:00pm	Lunch
2:00-3:30 pm	Checking Availability of Paed Formulations and test kits	Client satisfaction review	2:00-3:00 pm	Debrief to DHO
3:30-4:00 pm	Team meets to prepare feed back		3:00-5:00 pm	Travel to the Next district
4:00-5:00 pm	Debrief meeting

1. PREPARATION FOR POST TRAINING FOLLOW UP VISIT (to be filled before leaving for the field)

Check list for preparation:

Item	Yes	No	Comment
Has district been communicated to about Visit?
Has health facility been communicated to about Visit?
Is the list of trainees available?
Are pledge of action cards available for each site?
Have sufficient forms for the Visit been printed?

Names of Trainees being followed

	Names	Cadre	Tel contact	Was trainee available to be follow up on site
1				Yes	No
2
3
4
5

2. INTRODUCE THE FOLLOW-UP ACTIVITY

• 
  Make a brief stopover at DHO’s office: Introduce yourself and explain purpose of Visit
  
• 
  Introduce your self to the Health facility in charge, explain the purpose of the visit, and identify the health worker(s) you would like to observe.
  

3. MEET BRIEFLY WITH RELEVANT STAFF. (Review the pledge of action cards)

• 
  Explain what you will do.
  
• 
  Ask staff what they are doing differently or have seen since the training.
  

• 
  Become oriented to the facility: See the examination and treatment areas and areas where patient records and drug supplies are kept.
  
• 
  Identify a place to observe case management practices and give feedback.
  

	Pledge of action	Action taken ( yes or No)	Comments
1
2
Indicate any other actions or changes the team has instituted since after training

Availability of Job Aides.

Job Aide	Is it available?		Are they being Used?		Are the Job aides Placed in the right Place? If in a wrong place, help the worker place it in the right place. If nonexistent, leave behind the new guidelines.
	Yes	No	Yes	No	Yes	No
HIV testing algorithm
National Paediatric ART guidelines 2011
Paediatric ART dosing by formulation and wt range Feb. 2011
Paediatric ART dosing Pamphlet Feb 2011
WHO Paediatric ART clinical staging
Atlas of common opportunistic infections in children

4. OBSERVE CASE MANAGEMENT AND REINFORCE SKILLS (should be done with patients with a range of problems)

• 
  Select some children in the waiting area, introduce yourself, explain what you intend to do and ask permission. Choose different types of patients. For chronic HIV care patients, include Pre-ART and ART, quick and regular circuit patients by quickly asking them the reason why they are there.
  
• 
  Follow the patient through the entire sequence of care. Follow through and record steps the patient goes through and observe the process. Privately, help the health worker identify problems in case management and solve them. Note problems with patient flow/team work/task shifting and save them for the clinical team meeting.
  

Area	Aspects to be observed	Response		Comment
		Yes	No
Triage	Is there Triage Area? ( if no establish one with staff)
	Is Triage being done? (reception, wt taken, BP, Temp, retrieval of charts)
	Are Patients are triaged into regular and quick circuits [Help train team member in triage.]
Immunization	Is immunization status of children under 5 being reviewed
Growth monitoring	Are Weights taken for all children’s
	Are weight’s being interpreted.
Development monitoring	Does the clinician review the developmental milestones of the children?
Clinical assessment, Clinical Staging, CD monitoring and OI prophylaxis.	Are clinical assessments done for possible opportunistic infections?
	Are patients assessed for TB?
	Is TB status recorded on the Charts?
	Do clinicians do WHO clinical staging correctly? ( Support clinician to use WHO Paediatric HIV clinical staging charts)
	Do clinicians stage children at every visit? ( Emphasize the need to conduct staging at every visit and its importance for monitoring either progress in treatment or eligibility for ART)
	Is WHO stage documented at each visit?
	Are CD4’s requested for children? (Check whether clinician knows the frequency for doing CD4’s)
	Are they recorded in Patient chart?
	Can the clinician identify eligible patients using WHO and CD4 clinical staging criteria? ( Review criteria for initiation of ART in children)
	Are all children given cotrimoxazole prophylaxis?
	Are the doses correct? ( Check for use of the Dosing charts if not being used support the clinicians to use these)
Psychosocial and adherence support	ART readiness counseling and evaluation for ART eligible patients done?
	Is adherence counseling and assessment done at every visit?
	Are pill counts done? (Review how to calculate adherence based on pill counts).
	Is all the psychosocial information documented on the charts?

5. CHART REVIEW FOR COMPLETENESS AND ART INITIATION

From the Pre ART register select 5 children (under 2 years of age) enrolled into care in the past 3-4 months. Retrieve these Patients charts and do this review per chart. If the children under 2yrs are not five in number, pick other children above 2 years.

	Use one column per chart
	Patient 1	Patient 2	Patient 3	Patient 4	Patient 5
Assessment for ART eligibility and initiation of ART	Tick box if the parameter was recorded in the ART card. Mark 0 if it was not done. Draw a line through the boxes that are not applicable to the case. Use codes: 1-yes and 2-No.					Total number of ticks of number interviewed on the subject
Was Weight taken?
Is MUAC done?
Was TB status filled?
Are any OI’s recorded?
Was functional status recorded?
Is WHO clinical stage done?
Was cotrimoxazole prescribed?
Was dose correct?
Was CD4 done?
Has this patient identified as eligible for ART?
Was adherence counseling done?
How many adherence counseling visits has the child had?
Was patient given weekly appointments for adherence counseling (Longer appointment durations for adherence counseling often delays initiation of ART)
Is the child Initiated on ART?
What is the ARV regimen? Is it the recommended 1st line regimen
If patient was initiated on NVP based regimen, was leading In done?
Are the ARV doses correct? ( review use of dosing charts and check if dispensing team as well has dosing chart)
If patient has had subsequent visits after initiation of ART, Was adherence assessed?

6. CONDUCT EXIT INTERVIEWS (this will apply if your visit was on a clinic day where patients are available)

• 
  Select 5 caretakers of HIV positive children (0-14 yrs) leaving the facility and introduce yourself.
  
• 
  Interview patients/caretakers and record notes on the Exit Interview Form below
  

	Use one column per interview
	Patient 1	Patient 2		Patient 3		Patient 4		Patient 5
Caretaker/patient knowledge	Tick box if patient has correct knowledge of all items mentioned. Mark 0 if patient does not know all. Draw a line through the boxes that are not applicable to the case									Total number of ticks of number interviewed on the subject
Patient/caretaker given co-trimoxazole: knows how many tablets to give child per day; why is it important for the child?
Patient/caretaker given ART: knows correct number of tablets to give child; times per day
Patient/caretaker given another drug: knows how many tablets to take; times per day
Patient/caretaker knows when next follow-up appointment is
Patient/caretaker satisfaction	Score on scale of (indicate the score per patient interviewed) 0 1 2 3 4 5 6 7 8 9 10 Poor Excellent									Indicate the total score for each row.
	Patient1		Patient2		Patient3		Patient 4		Patient 5
Time health worker spent with me
Way health worker examined child
Treatment given child
Way health worker talked with me
What I learned from health worker

7. REVIEW OF DATA

From the Pre ART and ART Register, Please indicate the numbers of children enrolled into care and on ART for the months of Dec 2010 to May 2011. Please mark the month when training was done.

	Dec	Jan	Feb	March	April	May
Pre ART
ART

8. GUIDE FOR DEBRIEFING MEETING (Facilitate problem solving with the staff)

• 
  Congratulate the staff on progress they have made in implementing paediatric HIV care and explain that the purpose of meeting is to solve problems they face.
  
• 
  Ask the staff what problems they have found in starting to provide paediatric HIV care and treatment. Listen as they discuss each problem, summarize what you hear; and add any other problems that you have identified.
  
• 
  For each problem, ask about possible solutions. Listen; summarize decisions made; add and discuss any other practical solutions from the Checklist of Facility Supports.
  
• 
  Remember: Give each staff member time to think
  
• 
  Ask questions to support good solutions
  
• 
  Make notes on your checklist
  
• 
  Support, do not undermine, the trained health worker
  
• 
  With the staff, identify problems to communicate to the district or national level to request assistance.
  
• 
  Review with the staff evidence of their progress implementing Paediatric HIV care and Treatment. Thank the staff.
  
• 
  Provide any Tools or Job aides
  

9. WRITE SUMMARY REPORT OF THE VISIT

Leave copy of the report with facility and district

	Strength	Areas of Improvement	Action taken	Pending Action	By who?

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