Follow-up after training and
supportive supervision
The IMAI District Coordinator
Course
Strengthening Health Systems
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District focus: Fills gaps and complements
existing training/modules for specialized doctors,
higher resource settings; for home-community
Builds on and strengthens routine health
services
Focus on building a district system with
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Clinical teams
Referral, back-referral; improved communication
Clinical team
may include
nurse and ART
Aid at first-level
and doctor at
second-level
Regional
Referral
Hospital
Second-level
health workers
District
Hospital
Health
Centre
Health
Centre
District
Hospital
Health
Centre
Health
Centre
First-level health
workers
District
Hospital
Health
Centre
Health
Centre
Health
Centre
Health
Centre
Health
Centre
National,
Regional and
District ART
Management
CENTRAL / PROVINCIAL
Specialised referral (physicians,
pediatricians, subspecialists)
Patient
monitoring
DISTRICT HOSPITAL
Doctors/medical officers/
inpatient RN
HEALTH CENTRE
Clinical care—nurses, medical assistants;
ART counsellors (ART Aids)
COMMUNITY
Treatment supporters, community health workers, peer support
groups, CBOs, advocates
Drugs,
diagnostics,
commodities,
logistics
support
Referral, backreferral, clinical
mentoring
Individualised care for patients
A Public Health approach facilitates broad coverage and enables the
majority to access care and ART
Some patients will develop complex problems and need specialist
input to their clinical or psychosocial management
 Mentoring: Specialists in apex or tertiary centres linked with
district generalist clinicians
 Referral: complex cases referred upwards for specialist care and
management
It is not either specialist services or a public health approach – it
is both together
The IMAI district coordinator course:
Administrative and managerial tasks
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Planning for scale up
Preparing the community
Establishing collaboration with partners
Planning capacity building
Establishing distance communication for clinical team
support
Follow-up support and supervision after training
Medicines, diagnostics and health supplies
Patient monitoring
Orienting and optimizing entry points
Prevention acceleration
Follow-up after training:
•District/regional managementsupportive supervision to sites:
Preparation
clinical, drug supply management
before
Training
patient monitoring
•Clinical supervision
training
•Facility accreditation
•Health worker certification
•Team to team exchange
•Other QA methods
Community/PLHA/stakeholder/other programme involvement
On-site visits after training
Mentorship
Team to team support
Setting targets and
choice of sites for
HIV Care/ART
Choose clinical teams, plan
training by cadres
Preparation IMAI training
IMAI
Training
by cadre
and
team
Orient and optimize entry
points
Prevention acceleration
Logistics: maintaining the supply of drugs, diagnostics, equipment
Establish good communication for clinical team support
Patient monitoring system: registers, reports, data use
Evaluation
Patient Monitoring
Supportive supervision
 Collection/aggregation of reports

National Office
Aggregate data
Regional Office
Aggregate data
District
Coordinator
Hospital
Monthly report,
cohort analysis
HC
HC
HC
Aim of Clinical Mentorship
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As part of emergency HIV care/ART scale-up,
mentorship is aimed to:
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Support decentralized delivery of HIV care, ART and
prevention with quality of care at all levels
Build capacity of primary-care providers to manage
unfamiliar or complicated cases by consultation and
on-site management where appropriate
Promote and facilitate ongoing learning, skill
development and quality promotion
Regional Referral
Hospital
Basic administrative
subunit: the district
Regular supportive supervision
provided by the existing district
management team (e.g. district
medical officer, district matron)
Regular mentoring visits
provided by experienced
clinicians at the regional
level
District Hospital
External mentors
(e.g. expatriate)
paired with local
mentors on initial
visits if sufficient
expertise does not
exist at regional level
Health Centre
Health Centre
Health Centre
Sequence of steps in the clinical mentoring visit
Observe case
management
and reinforce
skills
Review
patient
monitoring
system
Clinical
case
review
Clinical
team
meeting
Document
the visit
Agreed minimum essential
data elements
What happens to
the data
Indicators or other aggregated data
1.Entry point
2.Why eligible for ART
3.Reasons for:
Substitution within first-line
Switch/Substitution to or
within second-line
STOP ART
1.Number and weeks of each
ART treatment interruption
2.Pregnancy status
3.Start/stop dates of
prophylaxis:
•Cotrimoxazole
•Fluconazole
•INH
1.TB treatment
2.Adherence on ART
Source: II. HIV Care, III. ART
Summary, IV. Patient
Encounter and Family Status
Transferred to
pre-ART or ART
register but used
only by clinical
team /district ART
coordinator—not
transferred to
quarterly report or
cohort analysis
Indicators for patient and programme
management at the facility/district level:
Distribution of entry points in patients enrolled in
HIV care
Why eligible for ART: clinical only, CD4 or TLC
Distribution of patients not yet on ART by clinical
stage
•Distribution of reasons for substitute, switch,
stop to investigate problems; whether
substitutions and switches are appropriate (use
in context reviewing medical officer log)
•ART treatment interruptions:
Number/Percentage of patients
Number weeks
Percentage of pregnant patients linked with
PMTCT interventions (or simply use to generate
lists to assure linkage)
Number on cotrimoxazole, fluconazole, INH
prophylaxis at end of quarter (for ordering
prophylaxis drugs)
Number/Percentage of patients on both TB
treatment and ART
3b. % patients with good adherence to ART