The Strengthening Community Safety Nets (SCSN) project, managed by ChildFund International with its partners University Research Co., LLC (URC) and Christian Children’s Fund of Canada (CCFC), was a three-year (September 2008 – August 2011) project in Ethiopia. Its goal was to promote healthy child development for 50,000 orphans and vulnerable children (OVC) and to assist 8,500 primary and secondary caregivers through comprehensive, family-centered, and child-focused care and support services. The project served nine Ethiopian catchment areas with high HIV prevalence rates, poverty levels, and numbers of vulnerable children and with limited coverage of social and health services. The catchment areas served were five urban areas of Addis Ababa (Gulele, Kolfe Keranyo, Nefasilk Lafto, Arada, and Akaki Kality sub-cities) and four woredas (districts) of the Oromia region (Fentale, Dugda, Debre Zeit, and Shashemene).

Due to an increase in the number of children affected by HIV and AIDS in Kenya, efforts to provide services for orphans and vulnerable children have expanded quickly in recent years. Lately, stakeholders have realized more attention should be given to outcomes and service quality. To address this, seven implementing organizations were identified to participate in the piloting of standards for services to vulnerable children in four districts. This study evaluates the effectiveness, efficiency and equity of implementation of standards of service to vulnerable children, which are of particular interest to USAID and the government of Kenya.

1. 1) Was there a difference in the welfare of children receiving services from participating community-based organizations as measured by the difference between baseline and end line CSI scores?
2. 2) What was the incremental cost to the implementing partners and USAID / HCI of implementing the new standards?
3. 3) What was the proportion of girls and boys enrolled in vulnerable children care in the participating sites?
4. 4) Were there differences in the effectiveness of the service delivery in improving child welfare between boys and girls and between younger and older children?
5. 5) As reported by coaches and QI team members, what were key activities, the progress seen, the challenges and the role of stakeholders in implementing the new standards of vulnerable children care?

Lessons Lessons learned from OVC programs have revealed the need to improve service quality and to strengthen harmonization across partners around the questions: How can our programs make a measurable difference in children’s well-being? What are the essential actions that we all agree need to be part of a service to best to mitigate the impact of HIV/AIDS on children and families, in the pursuit of efficiency, effectiveness, equity, reach, and scale and sustainability? In response to the observed need to improve the quality of services provided to orphans and vulnerable children, in 2007, PEPFAR, through the United States Agency for International Development (USAID), sought to create a regional initiative to support countries and implementing partners in improving the quality of OVC programming. With support from the USAID Health Care Improvement Project (HCI), a regional OVC quality improvement initiative was organized. The initiative, which has come to be known as Care that Counts, has engaged national stakeholders, program implementers, and donor agencies throughout sub-Saharan Africa in improving the quality of OVC programming. 

This short report describes the efforts of the Care that Counts Initiative to support to implementers at the country level to:
1) Build constituencies and commitment for quality in OVC programming,
2) Develop OVC service standards through consensus processes involving key stakeholders, including children and their families,
3) Undertake quality improvement activities at the point of service delivery with community-based volunteers and organizations, and
4) Gather evidence that standards and other quality improvement approaches have a measurable impact.

During the week of November 18-21, 2008, representatives from more than 16 countries came together to share experiences and enhance their understanding of Quality Improvement (QI) for programming and services targeting orphaned and vulnerable children (OVC). The African Regional Training and Exchange Event, “Care That Counts: Quality Improvement in OVC Programming” was held in Adama, Ethiopia. The team of 14 facilitators for the event included representatives from international organizations (INGOs), local non-governmental organizations (NGOs), and donors from the United States, Kenya, Tanzania, Zimbabwe, Namibia and Ethiopia. The training built upon concepts and priorities highlighted in the first meeting of OVC experts which was held in Tanzania in 2007.

The centerpiece of the training was a proposed “Roadmap for Quality Improvement for OVC Programs,” a conceptual framework to guide the process of developing and implementing OVC standards. Facilitators highlighted the fact that the Roadmap is a work in progress and that this training would provide important opportunities for feedback from participants in an effort to improve the Roadmap. The Roadmap highlights the overall partnership and work of key stakeholders, including government, INGOs, NGOs, beneficiaries, etc. It also highlights processes and activities at the organizational level, frequently referred to as the “point of service delivery.”  To achieve a measurable difference when working on behalf of orphans and vulnerable children there needs to be a comprehensive understanding of their needs and providing services which are effective, efficient and equitable.

The creation of service standards through consensus is a key element of the QI process. Stakeholders are involved in defining in operational terms what OVC services at the point of delivery should look like and what outcomes they should bring. The idea of “minimal essential actions” is a key component of a service standard; it is necessary to define what is “good enough.” Service standards are also developed incorporating evidence and best practice and consensus among stakeholders. Once service standards are developed they need to be communicated, piloted, evaluated, and improved.

Other materials presented at the training event addressing principles of quality improvement, dimension of quality, developing consensus-based standards, steps to vetting and gathering evidence to refine draft standards, steps in communicating standards, and a vignette about measuring quality improvement based on experiences in Ethiopia.

Link below to the final report about the Training and Exchange Event and to materials developed by the HCI Project for the event.

These illustrative standards are composites of standards developed by leaders in a number of African countries, based on the participatory approach set forth in Quality Programs for Orphans and Vulnerable Children: A Facilitator’s Guide to Establishing Service Standards. Nine service standards are covered: Food and Nutrition, Shelter and Material Care, Protection, Health Care,  Psychosocial Support, Education and Vocational Training, Economic Strengthening, and Coordination of Care. 

Each standard includes a statement of desired outcome, measurable goals based on the Child Status index, essential actions that define the service, and guidelines that explain how the essential actions should be carried out. It is an important goal of this process to enable implementers in a given country to reach agreement about a common core of essential actions that should be carried out for each service. However, it is expected that detailed guidelines would vary somewhat by organization in order to adapt the standards to the local context. Thus, the standards provide flexibility, while assuring that consistency across programs is achieved.

The Quality Improvement Initiative for OVC Programs, funded by the United States Agency for International Development through the USAID Health Care Improvement (HCI) Project, brings together U.S. Government, other national government, and civil society partners with both OVC program and quality improvement expertise. Together these partners discuss, share and reflect on quality improvement processes for OVC services, especially at the point of service delivery and during contact with the children.

Key to the QI Initiative is sharing of experiences.  Monthly Quality in Focus Calls provide an opportunity for OVC program implementers to share and learn more about QI processes for OVC services. To join in on the Quality in Focus monthly conference calls, contact Louis Camara at lcamara@urc-chs.com to receive email announcements of upcoming calls.

Minutes of previous Quality in Focus Calls are linked below.