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.

This short report describes assistance that the USAID Health Care Improvement Project is providing to the National Program for HIV Care and Treatment (PNPEC) of the Ministry of Health, implementing partners, the National Program for Orphans and Vulnerable Children (PN-OEV) and the Ministry of the Family, Women and Social Affairs (MFFAS) in Cote d'Ivoire to apply improvement methods to improve the quality of antiretroviral therapy services, PMTCT, OVC programs, and peer prevention of HIV.  The report also highlights results from 41 sites that have been engaged in an improvement collaborative on ART and PMTCT since 2008.

Lessons learned from programs serving orphans and vulnerable children (OVC) affected by HIV/AIDS have revealed the need to improve quality in OVC services 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 range of 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 and sustainability?

Several countries in sub-Saharan Africa have joined together in the quest for improving quality of services, through the USAID-funded Care that Counts Initiative, implemented by the USAID Health Care Improvement Project. These countries are engaged in applying the “science of improvement” to OVC services by 1) defining quality using service standards, 2) organizing for improvement at the point of service delivery; 3) and gathering evidence on the draft service standards that can be shared across countries. This case study highlights how Save the Children, as the leading organization of the USAID-funded Positive Change, Children, Communities and Care Program, together with local non-governmental organizations, and community-based organizations in Dire Dawa, Ethiopia, applied the science of improvement to pilot test the draft service standards.  The case study describes the design and organization of the pilot of draft service standards and the tools used to document and measure results from community level improvement activities. This case study has a “sister” case study developed by Save the Children that concretely details the actual results of implementing the standards, entitled "Communities in Action: Improving Quality in Service Delivery for Enhanced Wellbeing of Children in Ethiopia."

Lessons learned from programs serving orphans and vulnerable children (OVC) affected by HIV/AIDS have revealed the need to improve quality in OVC services 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 range of 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 and sustainability?

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.

OVCsupport.net is a global hub for the exchange of experience, practice and tools on policy and programming around children and HIV funded by USAID.   The web site was originally developed by the International HIV/AIDS Alliance and Family Health International to serve as an an electronic library of resources about support to orphans and vulnerable children that have been collated by the Alliance and FHI from a wide range of organizations, based on the understanding that there are many good approaches to supporting orphans and vulnerable children.  Known as the "OVC Toolkit", the site addressed a wide range of themes related to support for orphans and vulnerable children– for example: situation assessments, access to education, psychosocial support, children’s participation, and monitoring and evaluation. In addition to over 500 downloadable resources, the site highlights key issues to consider for orphans and vulnerable children support programming.  Most of the resources contained on the site are in English.

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.

Pact Tanzania has implemented a comprehensive approach to improve quality of the service provision for OVC. Standards and related guidelines have been drafted and have been used by volunteers in five regions (Mbeya, Mtwara, Kagera, Tabora, and Mara) under the Jali Watoto programme. Pact Tanzania’s Jali Watoto programme is working with the USAID Health Care Improvement Project to implement learning groups in two districts: Nzega and Kyela.

The Child Status Index (with its accompanying Child Status Record) is a tool that can be helpful in assessing and tracking priority services a vulnerable child needs. Equally useful for initial assessment and follow-up monitoring, the tool focuses on essential actions and is flexible enough that users can adapt criteria to the local context. Data from the Child Status Index and community mapping of services can be used together to inform coordination of care.

Over the last year or so, several countries and programs have developed service standards for their OVC programs in order to improve the quality of services provided to children, and address the variation in, and lack of equity among, OVC service providers on what constitutes “an OVC served.” These draft standards are an important step in improving OVC programming and reflect current practice, common sense, and the collective wisdom of people involved in programs. Yet, the evidence base that the application of these standards will result in improved outcomes for vulnerable children is very thin. This document outlines a suggested strategy that programs and countries could use to strengthen the standards themselves and knowledge about how best to implement them. It will also expand the evidence base that other countries and programs can use to improve their own OVC programs.