This report was written for USAID/Haiti and various implementing partners to describe the monitoring and quality improvement (QI) activities that have been conducted by SPRING over the last several years. It is not a report of all SPRING/Haiti activities.
At the request of USAID/Haiti, SPRING established a presence in Haiti in February 2012. SPRING/Haiti’s early efforts were focused on finalizing work initiated by the USAID-funded Infant & Young Child Nutrition (IYCN) project—specifically, finalization of the national infant and young child feeding (IYCF) counseling package. Since early 2013, project efforts have shifted to focus exclusively on supporting the rollout of nutrition assessment, counseling, and support (NACS) in Haiti. This work is funded through Field Support and NACS Acceleration funds.
The NACS approach is a framework for ensuring delivery of a nutrition continuum of care. The components of NACS include nutrition assessment, counseling, and support. Nutrition assessment is a critical first step in improving and maintaining nutritional status. It involves measurement and classification of nutritional status by gathering and interpreting anthropometric and clinical information. Nutrition counseling is an interactive process between a client and a health provider/counselor that uses information from the nutrition assessment to prioritize actions to improve nutritional status. Nutrition support includes both clinical management of malnutrition at facility level and ensuring that clients have access to prevention and follow-up services at the community level. The NACS approach emerged from the HIV care and treatment community, but is now recognized as an approach for strengthening the nutrition continuum of care for all nutritionally vulnerable populations.
In Haiti, SPRING’s work provides technical leadership for strengthening NACS in 17 health facilities (see Annex 1a). Specifically, SPRING/Haiti has built capacity of project facilities to deliver the full NACS continuum of care. SPRING efforts have focused on ensuring that all clients are nutritionally assessed, classified, identified as malnourished (or not), referred to appropriate services, provided with high-quality nutrition counseling, and prescribed ready-to-eat therapeutic foods (RUTF) if malnourished. A complete list of health facility staff trained by SPRING has been provided in Annex 1b of this report.
An important aspect of SPRING’s work in Haiti has been the collection and reporting of priority PEPFAR indicators, nutrition advocacy among health facility staff and QI teams, and the promotion of nutrition-related QI activities.
To monitor and evaluate process and outcomes, SPRING has been collecting data on the following indicators:
- Number and percentage of clinically undernourished people living with HIV (PLHIV) who received therapeutic and supplementary feeding1,2 (USAID indicator FN_THER).
- Number3 of PLHIV clients who were nutritionally assessed4 and found to be clinically undernourished1 (denominator of the USAID indicator FN_THER).
- Percent of assessments that result in an accurate categorization, by client type (pregnant woman, child, or PLHIV).
- Number and percent of clients who were nutritionally assessed via anthropometric measurement, by client type (pregnant woman, child, or PLHIV) (USAID indicator FN_ASSESS).
- Percent of clients who received nutrition counseling, by client type (pregnant woman, child, or PLHIV).
- Number of people trained in child health and nutrition through USG-supported health area programs.
All but the last have been collected during visits to health facilities.
Approach to Data Collection
In addition to tracking training attendance and pre- and post-training test result, SPRING has conducted a number of data collection activities during facility visits prior to trainings and then semi-annually, coinciding with USAID’s reporting schedule. The purpose of these visits was to assess the performance of the trained personnel and to provide any technical support required. They have been conducted jointly with government counterparts and Nutrition Focal Points (NFPs).
Effective supervision is important in improving the quality of health services because it gives providers the direction and support they need to apply guidelines to their day-to-day work. Traditionally upper-level supervisors conduct monitoring and supervision, but often visits are focused on administrative issues and do not focus on quality of care or improving health worker and system performance. Rather than seeing supervisory visits as an opportunity to increase knowledge and skills and improve the quality of services they provide, staff members are often put on guard by being observed, critiqued, and possibly criticized.
For this reason, SPRING has referred to these facility visits as Reinforcement Visits (RV) and SPRING staff has always made a point to not find fault but to assist and support health facility staff in their technical functions. They have conducted the RVs with health facility staff, measuring performance, comparing desired and actual performance, identifying the causes of gaps, and developing action plans to fill them.
It is critical for success of NACS and intrinsic to SPRING/Haiti’s overall approach that responsibility for certain aspects of SPRING RVs be passed to and sustained by the Ministère de la Santé Publique et de la Population (MSPP). Therefore, SPRING has planned and designed the content of and approach to the RVs with the MSPP Nutrition Directorate and has conducted RVs with the MSPP NFPs from each department. Since the end of FY14, NFP and SPRING/Haiti have been using an MSPP Nutrition Supervision Tool5 (revised by SPRING/Haiti upon MSPP request in FY14), during the facility visits.
There are three main parts to the RV or supportive supervision process:
- Planning RVs (prior to the visit)
- Call health facility managers to schedule the visit and explain the objectives of the visit. Ask them to inform key staff at the pediatric, prenatal, and HIV units, the food supply person, and the stock management staff. Follows this with an email.
- Print and save on a Flash drive all prior reports on facility services, checklists, tools, and guidelines.
- Remind MSPP and health facility managers of the visit several days before the visit by email and phone.
- Conducting RVs (during the visit)
- Cordially greet and meet with the health facility manager, the manager or director of each unit of the health facility, and/or staff with whom s/he interacts.
- Distribute hard copies of the RV agenda and discuss any concerns or scheduling conflicts.
- Conduct relevant data collection activities.
- Discuss main findings (positive and negative) from the current RV and use graphs/tables to identify possible causes of any problems identified.
- Encourage facility manager to give positive feedback for good work—NOT scold or focus on service gaps.
- Develop or update a plan of action that specifies realistic solutions (rapid and low cost), people responsible, as well as a timeline for next steps.
- Sharing findings from RVs (after the visit)
- After the visit, report the findings with SPRING staff and the MSPP Nutrition Directorate.
Data Collection Activities
In this section we describe the primary data collection activities that have been conducted during facility visits (coaching RVs) by SPRING staff and/or MSPP NFPs. MSPP and/or health facility staff have been encouraged to conduct additional RVs and/or repeat some of the data collection activities.
- Register reviews: In prenatal and pediatric units of health facilities where the iSanté electronic medical record (EMR) system is not yet fully in use, we have reviewed registers to see if clients in these units were nutritionally assessed according to guidelines. SPRING or a designated NFP chose two pages of the register randomly (from different days/months during the reporting period) and recorded the number of entries on those pages (minimum of 20 per unit). In the prenatal unit, the following information was recorded for each entry: middle-upper arm circumference (MUAC) in cm, classification, and prescription/referral for RUTF. In the prenatal unit, the following information was recorded for each entry: age, gender, height in cm, weight in kg, classification, and prescription/referral for RUTF. Using this information, SPRING has determined the percent of clients from these units that were nutritionally assessed according to guidelines. Worksheets for these register reviews are provided in Annex 2a.
- Analyze iSanté data: Until recently, SPRING collected raw data from the iSanté EMR system from each facility's HIV unit. Where the iSanté electronic medical record (EMR) system was not functioning in HIV units, SPRING reviewed registers and/or client cards to calculate and report the priority USAID indicators. Where the EMR system was functioning, data clerks provided required information in tables (see Annex 2b). To report FN_ASSESS and calculate the denominator of FN_THER to USAID, we removed duplicates (only count each person once in the reporting year, starting in October), then calculated age in months. We then used age, gender, height, and weight data to calculate nutritional status using BMI, BMI-for-age, weight-for-height Z scores (WHZ), or MUAC (as appropriate), and determine nutritional status. Now that iSanté reports the number and percentage nutritionally assessed and found to be malnourished, SPRING can access information at the national level. However, analysis/interpretation and use of these data at the facility remains a priority.
- Track distribution of therapeutic food to malnourished clients: Unfortunately, distribution of RUTF is not yet tracked in iSanté. Further, the units responsible for distribution for RUTF do not use the same unique identifiers as used in HIV units. Therefore, SPRING has followed a lengthy manual process to determine the number and percentage of malnourished HIV clients (FN_THER). SPRING and/or the NFP asked facility staff (e.g., data clerks) to access iSanté and identify new PLHIV found to be malnourished during the reporting period. Using this list, they then determined how many of those malnourished received RUTF. To confirm HIV and nutritional status, SPRING reviewed cards of clients who received RUTF in malnutrition units for the first time during the reporting period. However, due to necessary and appropriate confidentiality restrictions, it is not always possible to access names of HIV patients. This information was recorded in the table found in Annex 2c.
- Observe client-provider interactions: Observations of client-provider interactions have been used to collect data and coach providers on NACS services. Prior to observing, consent from the provider and the client is sought. If one or the other does not consent, the observation is not conducted. Approximately 20 client-provider interactions were observed in each of the priority units of the health facilities (prenatal, pediatric, and HIV). To report the percentage of clients nutritionally counseled, the observer only needed to note if the provider communicated any nutrition-related information to the client or the client's caretaker. A tool for this simple observation can be found in Annex 2d. More lengthy observation tools have been included in Annexes 3a-c. Regardless of the observation checklists used, the SPRING staff or NFP used the opportunity to suggest ways the provider could improve NACS service delivery.
- MSPP Nutrition Supervision tool: In October 2014, SPRING began to use the MSPP Nutrition Supervision tool (“Formulaire de Supervision des Activités de Nutrition,”, Annex 4) in accordance with the “Guide du Superviseur des Activites de Nutrition” (available upon request from the MSPP or SPRING).
As described above, nutrition-related data is critical for strengthening NACS services. This has required increased attention to key aspects of quality nutrition services and the integration of data collection, analysis, and use activities into facility-based and -owned Quality Improvement (QI) processes. In an effort to collaborate and coordinate with HEALTHQUAL, SPRING trained HEALTHQUAL departmental coaches on the provision of quality nutrition services (NACS), and emphasized attention on nutrition. At the facility level, SPRING/Haiti advocated the importance of nutritional assessment and the adoption of nutrition-related QI activities among directors, heads of units, clinic staff, data clerks, and QI teams. As a result, several health facilities have taken on nutrition activities.
Challenges and Lessons Learned
Through this process of data collection, analysis, reporting, and use, SPRING has encountered a number of challenges and learned valuable lessons, described below.
- Collaborating with QI teams: Initially, QI was promoted by HIVQUAL as an activity of HIV units for HIV-specific services. Since then HIVQUAL has transitioned to HEALTHQUAL, with the goal of establishing the QI process in all units of targeted health facilities. However, this transition has taken time. SPRING has found that in many facilities, only HIV units and staff have functioning QI committees and their focus remains on HIV-specific services. SPRING has found it challenging to get QI committees to expand their scope to nutrition services across the continuum of care. With continued regular engagement and the roll-out of the small-grant Innovation Fund, SPRING has been able to improve collaboration and increase interest in nutrition-related services.
- Accessing iSanté and finding disaggregated data: SPRING was not able to properly access iSanté data at the national level until May 2015. This meant that SPRING had to ask health facilities to manually extract data from facility-based databases for analysis and reporting to USAID. This was extremely burdensome for health facilities and SPRING, and prone to data quality errors. Accessing iSanté at the national level makes the process of data reporting, analysis, and use infinitely easier and has improved the quality of data reported.
- Collecting data where iSanté is not functional or electronic: Where the iSanté EMR system was not functioning in HIV units, SPRING reviewed registers and/or client cards to calculate and report on the priority USAID indicator FN_ASSESS and the denominator of FN_THER. This was a lengthy process.
- Collecting data on therapeutic food distributed: The malnutrition units that distribute therapeutic food in Haiti do not use the same unique identifiers that the HIV units use. Despite gaining access to iSanté in May 2015, SPRING has found it necessary to continue with the procedures described above.
With the upcoming closure of SPRING in September 2015, SPRING understands that HEALTHQUAL will assume responsibility for nutrition-related data collection and reporting as well as advocacy for nutrition among QI committees. To assist in this transition, USAID and HEALTHQUAL have requested that SPRING document the processes followed and provide recommendations to conduct these tasks successfully. Based on challenges faced and lessons learned, SPRING recommends the following:
- Follow the process described above and make use of national-level access to iSanté data.
- Nurture partnerships with MSPP/NFPs and health facilities to validate access to health facilities and to sustain data collection on nutrition indicators.
- Routinely visit health facilities and meet with key target units, nurses in charge, and facility directors to ensure successful roll-out of trainings, supportive supervision, NACS implementation fidelity, and sustainability of implementation of priority nutrition services.
- Provide additional technical support to QI committees, particularly for the expansion of scope to non-HIV units and increased focus on nutrition service delivery.
- Continue to provide facilities with small grants for innovative ideas proposed by QI committees to address gaps and/or challenges to delivering quality nutrition services. This SPRING initiative has been met with great enthusiasm, increased attention to nutrition, and resulted in a number of creative, simple solutions for improving nutrition services.
- Reinforce the importance of NACS services along the continuum of care. As mentioned above, it has been difficult to get facilities to embrace this.
- Data collection activities should be led by each facility’s Disease Reporting Officer DRO and an integrated process including each facility’s QI committee to ensure the quality (accuracy and timeliness) and use of nutrition data (e.g., USAID cascade of FN indicators).
- Explore the possibility of establishing an EMR system in malnutrition units and/or using the same unique identifier for each client in all units of a health facility. This would greatly facilitate the assessment of therapeutic food distributed and reporting of USAID’s FN_THER indicators.