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INTEGRATING PMTCT WITH POST

NATAL CARE SERVICES IN UGANDA:

PROCESS DOCUMENTATION AND

MONITORING OUTPUTS

BY

MAUREEN KWIKIRIZA

2012

INTEGRATING PMTCT WITH POST NATAL CARE

SERVICES IN UGANDA: PROCESS DOCUMENTATION

AND MONITORING OUTPUTS

BY

Dr. MAUREEN KWIKIRIZA

MBCHB, MSC.EPIDEMIOLOGY

MakSPH-CDC Fellow

NOVEMBER 2012

ii

DECLARATION

I, Maureen Kwikiriza do hereby declare that this programmatic activity

report titled Integrating PMTCT with post natal care services in

Uganda: Process Documentation and Monitoring outputs, has been

prepared and submitted in fulfillment of the requirements of the MakSPH-

CDC Fellowship Program and has not been submitted for any academic

qualifications.

Signed…………………………………. Date……………………..

Dr. Maureen Kwikiriza, Fellow

Signed…………………………………. Date……………………….

Dr. Francis Engwau, PM PREFA

Host Institution mentor

Signed…………………………………….. Date………………………

Dr. David Serukka, ED PREFA

Host institution mentor

Signed……………………………………. Date………………………..

Dr. Elizabeth Nabiwemba, MakSPH

Academic mentor

iii

DEDICATION

This work is dedicated to all the mothers of this nation and those who are

yet to be.

iv

ACKNOWLEDGEMENT

Great thanks to my mentors for the support and time given to me.

I would also like to thank PREFA staff especially the Program Officers of

Wakiso and Nakasongola districts for their effort during this project.

Finally, I am indebted to my family, fellow Fellows and friends for all the

support and encouragement during this project.

v

Table of contents

DECLARATION ....................................................................................... ii

DEDICATION .......................................................................................... iii

ACKNOWLEDGEMENT ......................................................................... iv

LIST OF TABLES AND FIGURES .......................................................... vi

ACRONYMS ............................................................................................ vi

OPERATIONAL DEFINITIONS ............................................................. vii

EXECUTIVE SUMMARY ..................................................................... viii

1.0 INTRODUCTION ....................................................................... 1

Table 1: PMTCT services integrated in PNC .............................................. 3

2.0 DOCUMENTATION OF THE INTEGRATION PROCESS,

MONITORINGAS WELL AS INDENTIFYING CHALLENGES ......... 4

2.1 Pilot health facilities.......................................................................... 4

Table 2: Facilities piloting the integration model ........................................ 4

2.2 Steps in the implementation of integrated PMTCT and PNC services 4

2.2.1 The assessment phase…………………………………………...6

2.2.2Planning phase…………………………………………………...9

2.2.3 Implementation and monitoring phase .......................................... 11

2.3 PMTCT indicator performance following integration ...................... 11

3.0 DISCUSSION…………………………………………………….14

3.1 Discussion of the implementation and progress of integrated PMTCT

and PNC services .................................................................................. 14

3.2 Lessons learnt from the implementation of integrated PMTCT and

PNC services ........................................................................................ 15

4.0 CONCLUSION AND RECOMMENDATIONS ............................. 17

5.1 REFERENCE ................................................................................. 18

6.0APPENDICES ................................................................................. 19

6.1 Set targets for the health facilities after the assessment……….19

6.2Checklist .......................................................................................... 22

6.3 DATA EXTRACTION TOOL................................................................ 28

vi

LIST OF TABLES AND FIGURES

Table 1: PMTCT services integrated in PNC .................................................................... 3 Table 2: Facilities piloting the integration model............................................................... 4 Table 3: Set targets and responsible persons after the assessment phase ........................... 10 Table 4 : Weaknesses and action taken for Buwambo HC IV .......................................... 19 Table 5: Action points for Nabiswera HC III following the assessment ............................ 20 Table 6: Action points for Nakasongola HC IV following the assessment ........................ 21 Table 7:Action points for Ndejje HC IV following the assessment .................................. 21 Figure 1: steps involved in implementation of integrated PMTCT and PNC

services at health facility level…………………………………………….5

Figure 2: Uptake of PMTCT services by mothers during PNC …………..12

Figure 3: Uptake of EID services in PNC ………………………………..13

ACRONYMS

AIDS Acquired Immune Deficiency Syndrome

ART Anti-Retroviral Therapy

CDC Center for Disease Control

vii

DBS Dry Blood Sample

EID Exposed Infant Diagnosis

FP Family Planning

HIV Human Immunodeficiency Virus

MNCH Maternal, Newborn and Child Health

MOH Ministry of Health

NVP Nevirapine

PCR Polymerase Chain Reaction

PEPFAR Presidential Emergency Plan For AIDS Relief

PREFA Protecting Families Against HIV/AIDS

PNC Postnatal care

PMTCT Prevention of Mother–To- Child Transmission of HIV

VHT Village Health Teams

OPERATIONAL DEFINITIONS

viii

Integration: Two or more services are offered in the same facility and by

the same health worker and a strong referral system for services which

cannot be got at that facility.

Monitoring: Supervising activities in progress to ensure they are on-course

and on-schedule in meeting the performance targets.

Processes: Sequence of activities through which inputs are converted into

outputs. All processes are directed at achieving one goal

Process Documentation: This is a descriptive, non-evaluative procedure

where data is collected on a project to identify working approaches to

challenges of implementing an effective intervention/program.

EXECUTIVE SUMMARY

This report documents the processes of implementing integrated PMTCT

with postnatal care services at health facilities in Wakiso and Nakasongola

ix

districts of Uganda. It also focuses on monitoring progress of outputs

following the implementation. The integration was a pilot conducted by

PREFA, a local NGO as recommended by Ministry of Health.

In the integration, PMTCT services are part of PNC package offered on the

same day under the same roof. The objectives of the pilot were to identify

best practices for PMTCT and PNC integration at the health facility level as

well as attempt to demonstrate the results.

The implementation of integrated PMTCT and PNC services at health

facility level involved three major steps, which are; the Participatory

assessment phase, Feedback and planning phase and Implementation and

monitoring phase.

The assessment was conducted to inform the planning phase to set targets

for the implementation of the integration services. This was done in May

2012 by PREFA program officer and district PMTCT focal person with

participation of the health workers. The areas of focus were: human

resource, support supervision, availability of key supplies, recording of data

in the registers, continued use of services, infrastructure, flow of finances

and information, education and communication materials.

The findings of this assessment were then shared with all health workers

who made suggestions for implementing integration and improving the

services. Suggestions included mentoring health workers on records

management, logistics management and follow up of mother–baby pair,

regular integrated support supervision visits, and relocating immunization

and EID clinics to PNC ward.

x

From June to August 2012, the assessment team visited the health facilities

every month to monitor performance and progress of the output. Data of

key indicators was extracted, during these visits, from the registers and

analyzed for any improvement.

More mother-baby pairs were followed up in the community with an overall

average of 15 per month compared to five in the months of March and April

before the pilot began. The number of HIV exposed infants done PCR to

determine their HIV status also increased from less than 10 in April to 14 in

June. As these babies were tested, they also received their results.

Lessons learnt include: The participatory approach to problem identification

and solving motivated health workers to work towards the improved

indicators. Also, involving the district health leaders and facility in charges

in the planning and implementation of the integrated PMTCT and PNC

services promoted ownership

Integrating PMTCT with PNC services leads to increased uptake of

PMTCT services. For maximum benefit, there should be no staff

absenteeism and adequate stocks of drugs and supplies. To ensure the latter,

training of health unit managers in logistic management should be done

urgently. For sustainability of improvements, regular support supervision to

health facilities should be conducted.

1.0 INTRODUCTION

Prevention of Mother -To- Child Transmission of HIV (PMTCT) is a

program for preventing the transmission of HIV from an infected mother to

her child. With availability of antiretroviral drugs, HIV transmission from

mother to child can be reduced to less than 5%(WHO 2010a ; AIDSTAR-

One February 2011).The PMTCT program comprises four prongs(WHO

2010a) which are:

1. Primary prevention of HIV infection among women of reproductive

age

2. Prevention of unwanted pregnancies among women living with HIV

3. Prevention of HIV transmission from pregnant women living with

HIV to their infants

4. Providing appropriate treatment, care, and support to mothers living

with HIV and - their children and families.

In Uganda, the PMTCT program was started in 2000 and by March 2011

had scaled up to 1,320 health centers, including 90% of health center III

facilities. Despite the success in increasing geographical access, many HIV

positive mothers and their babies are being lost at some point in the

PMTCT- Early Infant Diagnosis process(MOH 2009/10). This is evidenced

in 2009/2010 PMTCT review report which showed that only 8% of

mothers were offered post natal care services including family planning and

only 35% of HIV exposed infants had a Dry Blood Spot (DBS) taken for

HIV diagnosis(MOH 2009/10; UNICEF 2010), despite the high turn up of

children for immunization (over 80%). To address the above challenges,

2

the National PMTCT scale up plan 2010-2015 recommends integration of

PMTCT with the already existing Postnatal care (PNC) services.

Ministry of Health (MOH) defines integration as both PMTCT and PNC

services being available and offered at the same time by the same provider

or referred to another provider within the same premises, and a network of

providers linked by a well-developed and monitored referral system. In the

integration, PMTCT services are part of PNC package offered on the same

day under the same roof. When a woman comes for post natal examination

or family planning, her HIV status should be established and if found to be

HIV positive enrolled into HIV chronic care. Similarly, an infant born to

HIV positive mother brought for immunization is offered Early infant

diagnosis (EID) services or the other way round.

Protecting Families Against HIV/AIDS (PREFA) thus piloted integration of

PMTCT and PNC in Wakiso and Nakasongola districts. PREFA is a local

Non-governmental Organization formed in 2004 to support the government

of Uganda to develop and maintain standards in capacity building for

PMTCT service provision, implementation and monitoring of PMTCT

services and, to identify service delivery gaps and seek solutions for them.

With funds from PEPFAR through CDC, the organization supports quality

PMTCT service provision in 40 districts of Uganda.

The health workers are trained and mentored to offer quality services. Table

1 below shows PMTCT services to be integrated in to PNC.

3

Table 1: PMTCT services integrated in PNC

Period Basic services Suggested PMTCT services

to be added/integrated in the

basic services

Postnatal

care

General examination and

treatment of the mother,

Family planning

counseling and provision,

Screening for cervical and

breast cancer, Health

education and counseling,

Community Outreaches,

General examination of

the baby, growth

monitoring and

Immunization.

TB screening

Establishing HIV status of

mother, EID services, referral

for ART & Comprehensive

Care, Prevention and treatment

of opportunistic infections,

Cotrimoxazole prophylaxis for

HIV positive mothers and their

babies

The integration is dependent on improved systems at the health facility

which include: adequate and trained human resource, logistics and supplies,

well-functioning laboratories, sound health management and information

system for monitoring and evaluation; and working referral and linkage

system both within and outside the facility.

The objective of the pilot was to identify best practices for PMTCT and

PNC integration at the health facility level. This would lead to

recommending working approaches for roll out and replication to other

sites.

This report, therefore, documents the processes and monitoring outputs of

integrating PMTCT with PNC services being piloted in Wakiso and

Nakasongola districts of Uganda by PREFA.

4

2.0 DOCUMENTATION OF THE INTEGRATION PROCESS,

MONITORINGAS WELL AS INDENTIFYING CHALLENGES

This section describes the steps involved in the implementation of

integrated PMTCT and PNC services and monitoring of outputs as well as

identifying best practices.

2.1 Pilot health facilities

The health facilities where the documentation and monitoring was

conducted are included in table 2 below.

Table 2: Facilities piloting the integration model

Facility Name Facility level District

Ndejje HC IV Wakiso

Buwambo HC IV Wakiso

Nakasongola HC IV Nakasongola

Nabiswera HC III Nakasongola

2.2 Steps in the implementation of integrated PMTCT and PNC

services

The steps in the implementation of integrated PMTCT and PNC services are

summarized in the figure 1 below.

5

Figure 1: Steps involved in implementation of integrated PMTCT and PNC

services at health facility level

Participatory assessment phase

1. Orientation workshop on assessment framework and

tools

2. Complete assessment of facilities including interviews

with health workers and observation of facility functioning

3. Collection of routine PMTCT data from registers.

Feedback and planning phase

1. Review of assessment results

2. Identification of areas of weakness

3. Target setting and action plans

Implementation and monitoring phase

1. Planned interventions implemented

2. Monthly support visits by the task force to

determine progress towards targets

6

2.2.1 The assessment phase

As part of the implementation process, an assessment of obtaining

conditions in the pilot health units was first conducted. This would inform

the planning phase to set targets of what would assist the implementation of

the integration model.

The assessment was conducted by a team of three people that included the

MakSPH-CDC fellow, PREFA program officer and district PMTCT focal

person. This was to determine the capacity of the health facilities to offer

quality and integrated PMTCT and PNC services. The assessment was done

in the month of May 2012 and looked at the following domains: human

resource, support supervision, availability of key supplies, documentation of

data in the registers, continued use of services, infrastructure, flow of

finances and information, education and communication (IEC) materials.

Two data collection tools were developed and used for the assessments: a

checklist and a tool to extract data of key indicators on PMTCT and PNC

services from the registers. The findings of the assessment were as follows:

a)Human resource

i) Staff number

On average, each facility had one midwife and a nursing assistant to

manage post natal care services. However, they are also expected to give a

helping hand in antenatal and maternity wings.

ii) Staff availability

Staff absenteeism and late coming to work was common in three out of the

four facilities which increased the work load for the already stretched

7

human resource. During the monthly visits in one of the facilities a mother

lamented that; “Last week I came at about 11:00 am. The midwife told me to

go back because I was late. Today I was here by 8:00 am; it is now 11:00

am and there is no midwife to work on us”. The team arrived at this facility

at about 10:30 am and the midwife had not yet arrived, yet there were

many mothers waiting for services ranging from antenatal care, Family

planning , EID and PNC. The excuse the midwife gave for late coming was

she resides far from the facility (which was true) and transport to the facility

is sometimes difficult to get.

iii) Knowledge and skills

Each facility had at least 2 midwives and one laboratory assistant trained in

PMTCT-EID strengthening program. The nursing assistant, though not

trained in the program, benefited from the mentorship which was conducted

for the health workers at the facility.

b) Support supervision

Supervision for PMTCT and MNCH services was done separately as there

was no integrated support supervision tool. The Support supervision from

the district health team was irregular.

c) Availability of logistics and supplies

Though by the time of the assessment all the facilities were stocked with

EID supplies, family planning commodities and PMTCT antiretroviral

drugs (ARVS), only one health unit was placing in timely orders to National

Medical Stores for supplies.

There was shortage of equipment and supplies like Blood pressure

machines, Stethoscope, weighing scales, gloves, cotton, detergents, gum

boots and aprons in all the facilities.

8

d) Recording data in the registers

All the four facilities had the recommended and up to date PNC register

and EID data tools as by Ministry of Health. However, incomplete and

inaccurate documentation was common to all facilities. Post natal register is

hardly used though on observation and interviews, there are post natal

services given to both the mother and baby but not documented. In two

health facilities, EID data tools were available but kept in the cupboard. It

was difficult to trace these babies as the details of their address could not be

got from the registers.

e) Access and continued use of services

At all the health facilities, EID care point was located in a different site

(ART clinic or laboratory) from PNC. Also at 2 facilities, immunization

clinic was located in outpatient department. EID and immunization were

offered once a week while post natal care to the mother including family

planning was done upon request.

f) Infrastructure

The postnatal wing could be structured to accommodate all the service

points during postpartum period. However, the waiting areas are small and

lacked enough seats for the waiting clients.

g) IEC materials

There were few job aides for PMTCT and PNC services at the health

facilities.

9

h) Flow of finances

All the four health facilities were under local government with limited

budget allocated for PMTCT and PNC services. Funds from implementing

partners to the facilities are through the district. Three facilities had

difficulties in finance management.

2.2.2Planning phase

The analysis of the findings was done together with the health workers and

the results shared. Targets were set according to the weak areas highlighted

for integration. Some of the set targets after the assessment are included in

table 3 below.

10

Table 3: Set targets and responsible persons after the assessment phase

Weakness Action Responsible person

Staff Absenteeism Call for staff meeting and

discuss the issue

DHT/ In charge

Stock out of Nevirapine

syrup

Correct ordering of PMTCT

ARVS

Midwives/ In charge

Provide buffer PREFA

Facilities not ordering Mentor health workers on

logistic management

PREFA/DHT

Immunization clinics in

OPD

Shift immunization clinics

to PNC wing

Facility in charge

Lack weighing scales Provide adult weighing

scale

PREFA

Missed opportunity for

mothers to get PNC

Midwives should be active

and also offer PNC to

mothers. During

Immunization, a midwife

should be present to attend

to the mothers

In charges

Weak EID care point Shift EID care point from

ART clinic to MCH

Facility PMTCT focal

person

Provide another EI register PREFA

Mentor/Coach HW on EID

and the data tools

PREFA

Loss to follow up of HIV

positive mothers and

their babies

Ensure the facilitation for

follow up goes to the right

people, and coach Midwives

on how to use appointment

book to follow up mother-

baby pair

PREFA , In charge

and PMTCT focal

person

Incomplete

documentation in the

registers

Mentor/ coach health

workers on proper

documentation

PREFA

Weak community

linkages

Orient VHTs on PMTCT-

EID program

PREFA/District

Few PMTCT posters Provide with missing charts PREFA

Few internal support

supervisions

In charge to improve on

support supervisions to his

subordinates

In charge

11

2.2.3 Implementation and monitoring phase

The overall unit in charge and head of maternal and child health department

coordinated the implementation of activities to achieve the set targets at

their respective health facilities. Each month, from June to August 2012, the

monitoring team (one that led assessment) visited the pilot health facilities

to monitor performance towards the set targets; and set new targets. This

monthly follow up of performance at the health facilities constituted the

monitoring phase. In July 2012, health workers from the facilities in Wakiso

district were taken to a nearby health unit with good PMTCT indicators to

witness best practices.

Data of key indicators were extracted, during these visits, from the registers

and analyzed for any improvement. The main indicators monitored are:

number of new women tested for HIV in PNC, number of HIV positive

women receiving any modern family planning method and followed up in

the community. For HIV exposed infants, indicators were: number refilled

with nevirapine syrup, initiated on cotrimoxazole, had first PCR done and

received results.

2.3 PMTCT indicator performance following integration

Overall, the monitored indicators improved over the period of implementing

integrated PMTCT and PNC services. Mothers, who had missed HIV

counseling and testing during antenatal visits, were captured in PNC period.

More HIV positive mothers and their babies were followed up in the

communities every month following the introduction of the pilot integration

12

project. The maximum number was 25 in June, with an overall average of

15 per month compared to five in the months of March and April before the

pilot began (Figure 2). This is as a result of actively involving the Village

Health Teams (VHTS) in conducting home visits to HIV positive mothers

and their babies.

Figure 2: Uptake of PMTCT services by mothers during PNC

Similarly, more HIV exposed infants (from less than 5 in April to 9 infants

in August) were initiated on cotrimoxazole prophylaxis at 6 weeks (Figure

3). The number of infants done PCR to determine their HIV status also

increased from less than 10 in April to 14 in June. As these babies were

tested, they also received their results.

13

Figure 3: Uptake of EID services in PNC

Generally, there was an upward trend in all the indicators. More HIV

positive mothers and their babies were able to utilize the services. However,

there was a notable decline in the number of women receiving family

planning methods in months of August; and number of women with

unknown HIV status tested and babies receiving Nevirapine refills in the

months of July due to stock outs of these supplies. This is because most

health facilities were not placing in timely orders for the supplies to

National Medical Stores (NMS). It takes about two months for delivery of

supplies following an order.

The number of HIV positive mothers and babies getting PMTCT services

during postnatal is highest in the months of June and July. This is because

of many mother-baby pairs who had missed out on these services before

integration was implemented. This number is expected to slightly drop

because of few missed opportunities thereon.

14

3.0 DISCUSSION

3.1 Discussion of the implementation and progress of integrated

PMTCT and PNC services

The first step of assessing the capacity of health facilities made it possible

to identify bottlenecks for the implementation of integrated PMTCT and

PNC services. Involving the health workers in both assessment and setting

the targets for performance promoted ownership of the program by the

facility. In addition, it also built the capacity of the facility in charges to

conduct a simple assessment about quality of services at their respective

health units.

Identification of weak areas and implementation of a regularly supervised

participatory approach to problem solving that was data driven, resulted in

improvement of integration of PMCT/PNC services. Consequently, there

was some improvement in all indicators despite the short period of

implementation. These findings are in agreement with an intervention that

used a participatory approach in South Africa resulting in improved

PMTCT indicators(Tanya Doherty, Mickey Chopra et al. 2009). Also in

Zimbabwe, a district approach using regular team meetings was successful

in enhancing HIV testing acceptance(Perez F, Mukotekwa T et al. 2004).

The implementation process had quality improvement aspects of target

setting and monthly monitoring of performance. Continuous quality

improvement interventions have showed improvement in health services

(Center for Applied Research on Population and Development 2003;

Berwick DM 2004). Studies show that feedback on performance and small

group meetings have a positive effect on changing health worker

15

behavior(Grol R and Grimshaw J 2003). Therefore, since this intervention

involved these elements which could be part of the explanation for the

results.

The main limitation of the pilot was the short time of observation as some

set targets like orienting village health teams was not done but plans were

made to do so.

During this period of observation, there were no new health programs or

media activities taking place. It is therefore possible that the improvement

seen is due to integration of PMTCT and PNC services.

3.2 Lessons learnt from the implementation of integrated PMTCT and

PNC services

The lessons are drawn from the observation of the implementation process

of integrated PMTCT and PNC services at the health facility level. They

include the following:

Participatory approach to problem identification and solving

motivates health workers to work towards improved indicators

Technical support through supervision and mentorships enhance the

knowledge and skills of health workers

When there is linkage between service-delivery points in the facility,

there are few missed opportunities

16

With proper documentation in the registers, details for mother-baby

pair who have missed could be got and then followed up in the

communities.

Involving district health leaders and facility in charges in the

planning and implementation of integrated PMTCT and PNC

services promoted ownership of the program. Some of the set targets

were to be effected by the district health team authority.

When VHTS are facilitated, they sensitize and mobilize

communities for PMTCT and PNC services; and conduct home

visits to HIV positive mothers and their babies. This reduces

workload for the health workers.

The central supply chain system through NMS has encouraged

facilities to place in timely orders for the needed supplies. However,

lapses on the part of health units results in stock outs.

Staff absenteeism increases the workload stretching the available

health workers.

17

4.0 CONCLUSION AND RECOMMENDATIONS

Integrating PMTCT with PNC services reduces missed opportunities and

thus increase uptake of PMTCT services. Involving health workers in

monitoring progress and quality of services motivated them to implement

the new changes. However, inadequate monitoring of stocks of supplies and

drugs affects quality of care.

To ensure sustainability of improvements, regular support supervision to

health facilities should be conducted. In addition to that, staff should be

mentored on supplies management.

18

5.1 REFERENCE AIDSTAR-One (February 2011). Integrating Prevetion of Mother-To-Child Transmission

of HIV interevtions with Maternal. newborn and child health services: Technical Brief.

Berwick DM (2004). "Lessons from developing nations on improving health care." BMJ

328: 1124-1129.

Center for Applied Research on Population and Development, Ed. (2003). Using data to

improve service delivery: a self evaluation approach. . CERPOD.

Grol R and Grimshaw J (2003). " From best evidence to best practice: effective

implementation of change in patients' care. ." Lancet 362: 1225-1230.

MOH (2009/10). Uganda National PMTCT report.

Perez F, Mukotekwa T, et al. (2004). " Implementing a rural programme of prevention of

mother-to-child transmission of HIV in Zimbabwe: first 18 months of experience

" Tropical Medicine and International Health

9: 774-783.

Tanya Doherty, Mickey Chopra, et al. (2009). "Improving the coverage of the PMTCT

programme through a participatory quality improvement intervention in South Africa."

BMC Public Health 9: 406

UNICEF (2010). Uganda : PMTCT fact statistics, UNICEF.

WHO 2010a PMTCT Strategic Vision 2010–2015:Preventing mother-to-child transmission

of HIV to reach the UNGASS and Millennium Development Goals. Geneva, Switzerland:

WHO.

6.0APPENDICES

6.1 Set targets for the health facilities after the assessment

Table 4 : Weaknesses and action taken for Buwambo HC IV



discuss the issue

DHT/ In charge


mothers to get PNC



mothers. During



to the mothers

In charges

MCH unit lacking adult

weighing scale

Provide adult weighing

scale

PREFA


ART clinic to MCH


person

Provide another EI register PREFA


and the data tools

PREFA



their babies






baby pair

PREFA , In charge

and PMTCT focal

person

Incomplete


registers

Mentor/ coach H/W on

proper documentation

PREFA

Weak community

linkages


EID program

PREFA/Dht


Few support supervision

VISITS

DHT to conduct regular

support supervision visits

DHT

20

Table 5: Action points for Nabiswera HC III following the assessment



discuss the issue

DHT/ In charge

Stock out of Nevirapine

syrup

Correct ordering of PMTCT

ARVS

Midwives/ In charge

Provide buffer PREFA


mothers to get PNC



mothers. During



to the mothers. Shift

Immunization clinic to

MCH from OPD.

In charges


Lab to MCH


person


and the data tools

PREFA



their babies






baby pair

PREFA , In charge

and PMTCT focal

person

Incomplete


registers



PREFA

Weak community

linkages


EID program

PREFA/DHT

PMTCT posters kept in

the cupboard

Hang posters on the wall In charge

Irregular support

supervision

DHT conduct regular

support supervision

DHT

21

Table 6: Action points for Nakasongola HC IV following the assessment



mothers to get PNC



mothers. During



to the mothers.

Midwives

Record in PNC register Midwives



their babies

Provide funds for follow up

of mother baby pair

PREFA , In charge

and PMTCT focal

person

Weak community

linkages


EID program

PREFA/District

Table 7:Action points for Ndejje HC IV following the assessment


Small client waiting area Expand the waiting area/

provide a tent

District/ PREFA

Shortage of TT and DPT

vaccines

Order enough vaccines In charge


mothers to get PNC



mothers

Mid wives

lacking blood pressure

machine

Get the B.P machine from

the theater

In charge

PCR results given to

caregiver by lab tech

PCR results from the lab

should be taken to the EID

care point who then will

give to the caregiver


person



their babies






baby pair

PREFA , In charge

and PMTCT focal

person

Incomplete


registers



PREFA

Weak community

linkages


EID program

PREFA/District


Irregular support

supervisions

DHT conduct regular

support supervisions

In charge

6.2Checklist This checklist will be used by the supervisors during the support visits to the health facility

Purpose: To assess the capacity of the health facility to offer quality integrated PMTCT/PNC services.

Section 1

Name of health facility…………………………………………………………………………………………..

Name of supervisors……………………………………………………………………………………………………………..

Date of visit----------/---------/--------

Indicator Means of verification YES/NO/NUMBERS Comments

Staff availability Observe facility

records, training

reports

1. Doctors

2. Clinical officers

3. Midwives

4. Nurses

23

5. Lab technician

6. Nursing aide

7. Records assistant

8. VHT

Number of staff trained in PMTCT-EID

Number of staff trained in EMOC

Number of staff trained in newborn

care

Infrastructure

The waiting area protects clients from

the sun and rain

Observation of waiting

area

The area is clean, walls and ceiling are

reasonably clean

Observation of the floor,

walls, roof/ceiling

Examination rooms are private and

privacy is maintained during

procedures

Observation of

examination rooms

The clinic has clean toilets/ latrines for

clients

Observation of the

toilets/latrines

Clinic provides adequate infection

prevention/control in area of hand

Observation of available

water and soap, and

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washing, with soap and water available provider practice

Clinic has a container for sharps and

needles

Observation of procedure

room /injection room

Clinic has a rubbish pit for disposal of

refuse and medical waste

Observation of rubbish

pit or garbage bin

Logistics and supplies Examine stock cards,

store

Does the clinic have the following

commodities?

-Vaccines for Mother and baby

-ARVs prophylaxis

-HAART

-HIV test kits

-Family planning supplies

-Sterilization

-Gloves

-Delivery sets

-Gum boots

-Plastic sheet/ Apron

-Eye goggles

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Have there been stock outs of any of

the above commodities in the last 3

months?

If yes, specify which commodities

Service availability Examine registers

How many days a week are the

following services offered at the health

facility:

Ante natal care

Maternity

Post natal care

Which routine lab tests are done during

(Examples: HCT, CD4 count, DBS,

PCR):

ANC

Maternity

Post natal

Which post natal care services are

available for the mother, and number of

days in a week offered

Which post natal care services are

available for babies , and number of

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days in a week offered

Partnerships and referrals Examine referral

forms, registers

Where do they refer their patients

What is the procedure of referral

Is there any communication means to

where they refer clients (provide

ambulance, feedback)

Records management Examine recording

tools

Do staffs use recommended HMIS

forms?

Do staffs use recommended HMIS

forms?

IEC materials Observe on walls, clinic

rooms for charts

-Which IEC materials are available

-In which languages?

--Are there materials you could use that

you do not have?

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Conclusions Summarize your findings as below

Strengths

Weaknesses/ Areas that need strengthening

Recommendations/ Action points

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6.3 DATA EXTRACTION TOOL

This form will be used to extract data of key indicators that monitor progress of PMTCT/PNC integrated services at the health facilities.

Information will be got from PNC register, PMTCT-dispensing log, HIV test register, Referral books, Exposed Infant register, clinical

charts and Child Health cards.

Section 1:

Name of health facility……………………………………………………………………………..

Reporting month …………………… Year…………………………..

Section 2: Information about mother

2.1 Number of women attending post natal care-----------

2.2 Number of women with known HIV status--------------------

2.3 Number of women attending post natal care with unknown HIV status--------------

2.4 Number of women attending post natal care with unknown HIV status tested for HIV--------------------

2.5 Number of women attending post natal care counseled about modern family planning method------------------------

2.6 Number of women supplied with any method of family planning---------------------------

2.7 Number of HIV positive women on ART---------------------

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2.8 Number of HIV positive women referred for HIV chronic care-----------------

Section 3; Information about Infants

3.1 Number of babies attending immunization clinic----------

3.2 Number of children confirmed HIV positive ----------

3.3 Number of children born to HIV positive mothers--------------

3.4 Number of HIV exposed children refilled for Septrin------------

3.5 Number of HIV exposed children refilled with Nevirapine syrup----------

3.6 Number of HIV exposed children PCR done at 6 weeks------------

3.7 Number of HIV exposed babies first PCR done after 6 weeks-------------

3.8 Number of children HIV results returned at the health facility--------------

3.9 Number of children received HIV results-------------

3.10 Number of HIV exposed children turned HIV positive--------------

3.11 Number of HIV positive children referred for HIV chronic care--------------

3.12 Number of referred HIV positive children enrolled into pre-ART care------------

integrating pmtct with post natal … pmtct with post natal care...ii declaration i, maureen...

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