Training and Clinical Mentorship to Support the Scale-Up of Pediatric HIV Care: Lessons Learned from Uganda

Edward Bitarakwate
Elizabeth Glaser Pediatric AIDS Foundation, Uganda

Despite the significant progress that has been achieved in Uganda in increasing access to combination antiretroviral therapy (ART), only about 9,200 of the 100,000 individuals receiving ART (9.2%) are children.¹ This rate of treatment coverage falls short of the national pediatric treatment target of 15% of the total number of patients on ART. This rather slow scale-up of pediatric HIV care and treatment has been attributed to inadequate HIV diagnosis, poor access to care, and limited capacity to treat children. For instance, while HIV care is largely centered at referral health units, a majority of HIV-positive children seek care at lower-level health facilities. Another reason for the low proportion of pediatric patients in HIV care and treatment is the failure of health-care providers to systematically identify HIV-exposed or infected children.

Experiences in Uganda and other African countries show that even where basic resources for the provision of HIV care and treatment exist, providing health workers with formal didactic training alone does not significantly impact the total number of children who access care and treatment. A 2005 Ugandan national assessment highlighted limited health-worker skills as a key impediment to pediatric HIV care and treatment scale-up.² Subsequent stakeholder meetings conducted by the Uganda Ministry of Health (MOH) produced recommendations in support of the decentralization of standardized basic training in pediatric HIV care and clinical mentorship in order to increase clinical staff capacity to offer pediatric HIV care.

The goal of the Ugandan clinical mentorship program was to build sustainable capacity for scaling up access to and improving the quality of pediatric HIV care and treatment. The specific objectives outlined to achieve this goal were (1) to enhance the application of classroom learning to patient care, (2) to support decentralized pediatric HIV service delivery and develop clinical expertise at lower-level health-care facilities, (3) to improve health-worker motivation by providing effective technical support, and (4) to maintain high clinical standards and practices through the provision of technical support to health workers. Key activities of the program included the creation of systems to support clinical mentorship, the recruitment and professional development of mentors, the completion of a needs assessment of participating programs, and the creation of an action plan, followed by the initiation of mentoring activities. Monitoring and evaluation (M&E) activities were used to inform and improve the mentorship program, as well as to improve overall pediatric HIV care service delivery.

The principles and practices outlined in this chapter are based on the author’s experience with creating a clinical mentorship program for pediatric HIV care in Uganda.

Principles of Clinical Mentorship

The World Health Organization (WHO) defines clinical mentorship as a system of practical training and consultation that fosters ongoing professional development to yield sustainable, high-quality clinical care outcomes.³ Mentoring should be seen as part of the continuum of education required to create competent health-care providers (see Figure 1). Mentorship should therefore be integrated with and immediately follow initial pre- and in-service training.

The design and management of a clinical mentorship program must take into consideration the technical and administrative structures of the “parent” care and treatment program. The mentorship model used in Uganda is based on the existing hierarchy of supportive supervision within the district health services. Senior clinical and nursing staff based at regional hospitals and district health offices are targeted for enrollment as clinical mentors, who then offer practical training and consultation to health-care workers at lower-level health facilities. Through a process of training and retraining, these select groups of health workers progressively acquire HIV care and treatment expertise in aspects including, but not limited to, leadership and team building, training, M&E, and quality assurance (QA).

Focal persons within the regional HIV care and treatment team coordinate with and create linkages between the national- and district-level HIV care and treatment programs. Program activities designed by this team of clinical mentors form an integral part of the broader regional HIV-related work plans. Activity reports generated by the clinical mentorship team are then shared with the participating health facilities, the district health office, the MOH AIDS control program, and supporting partner organizations.

Figure 2 shows the technical hierarchy of ART services support in Uganda. Guiding policy at the national level allows for the organization of clinical mentorship at the regional level and its implementation at the district and health-center level.

The following considerations are crucial to the implementation of a sound clinical mentorship program.

Planning and Coordination

Key stakeholders must be involved in the development and adoption of a strategy for clinical mentorship within the host HIV care and treatment program. A participatory approach at this initial stage builds ownership and commonality of purpose by incorporating views from a diverse range of interests, a key prerequisite for ensuring the successful implementation of national programs. In the Ugandan experience, stakeholder involvement was most successfully achieved under the auspices of the national AIDS control program through its pediatric ART subcommittee. A WHO regional working meeting on clinical mentoring held in Uganda provided significant incentive for the buy-in and launching of this process.³ A core group of organizations, including the Elizabeth Glaser Pediatric AIDS Foundation, the African Network for Care of Children Affected by AIDS (ANECCA), and the Pediatric Infectious Disease Clinic in Mulago then took the lead in planning, developing, and piloting a clinical mentorship program. This collaborative process among nongovernmental and governmental partners pooled the necessary resources required to initiate the pediatric HIV care and treatment mentorship program.

Central coordination of the mentorship program is necessary for promoting the adoption of new training approaches and formalizing their integration into existing health-service provision structures. By promoting clinical mentorship as a necessary component of pediatric HIV care and treatment scale-up, the MOH motivated and encouraged other development partners to buy in to this program. This central role also served as a pivotal mechanism for coordinating ongoing activities, sharing experiences, and continuously reviewing programming objectives to respond to emerging needs.

Technical Support

Technical expertise will be required at different levels during the development of a clinical mentorship program. At the national level, technical support is needed to develop and adapt policies, standards, and guidelines for clinical mentorship. Technical support may include the engagement of national and international experts to support these processes. This external expertise can provide additional technical resources for national-level program design and planning. The quality of the training will need to be monitored, and curricula will need to be regularly reviewed and updated based on current requirements and evolving science. These quality measures are necessary to ensure the continued professional development of clinical mentors through ongoing training and preceptorships at clinical “centers of excellence.”

Organizations such as the Elizabeth Glaser Pediatric AIDS Foundation that have developed expertise in health-service delivery programming are often required to support the development of regional or district activity plans and budgets.

While it is essential that clinical mentorship be integrated into existing health-care delivery support systems, it is only through deliberate planning and guidance that both program managers and implementers can make the distinction between clinical mentoring and supportive supervision. Clinical mentoring focuses on the development of the professional or clinical skills of health workers; clinical mentors need to be experienced, practicing clinicians in their own right. Supportive supervision, in contrast, is defined as “a process that promotes quality at all levels of the health system by strengthening relationships within the system, focusing on the identification and resolution of problems, and helping to optimize the allocation of resources—promoting high standards, teamwork, and better two-way communication.”⁵ Rather than focusing on clinical skills, this type of supervision focuses on the conditions necessary for the proper functioning of the clinic and clinical team, such as issues of space, logistics, and drug supply chain management.³

Special expertise may be required to adapt existing M&E frameworks to include clinical mentorship activities. In a related process, health management information systems (HMIS) may need to be strengthened in order to effectively capture any gains in patient care outcomes resulting from clinical mentorship.

Long-distance technical resources and support could also be provided through telephone warm lines and Web-based discussion forums to enhance continuing medical education (CME) and real-time clinical problem solving at participating health facilities. The AIDS Treatment Information Center (ATIC), a referral network housed at the Infectious Diseases Institute at Mulago Hospital in Kampala, Uganda, utilizes the Internet and cellular phones to provide health workers with access to the latest medical information and advice to assist them with their treatment of patients. Through a toll-free phone service, contact visits, and the Internet, health workers are able to consult HIV experts in various aspects of patient management.

Human Resources Support

Clinical mentorship can only be provided where a minimum level of the targeted service is being offered. For example, clinical mentorship for HIV care can only be implemented at a health facility that is offering at least basic (or palliative) HIV care. In some instances, existing staffing levels at the participating health facility may not permit effective delivery of services. In such circumstances, it may be necessary to second clinicians, nurses, and laboratory staff to support either general or specialized HIV service delivery. Likewise, a given region may not have clinical staff with the basic qualifications for enrollment into the mentorship program. This would necessitate the recruitment or redeployment of additional personnel to initiate the mentorship program. Both these scenarios require the close support and cooperation of the local or regional health authorities. Innovative approaches in which staff members are compensated for time contributed to clinical mentorship activities may attract regular short-term commitments.

Logistical Support

Once the mentorship program is developed, resources for national and regional roll-out should be mobilized. Development partners to the Ugandan national AIDS control program responded positively to a call to contribute resources to clinical mentorship programs in the country’s health districts. Start-up activities should be planned and provided for by the implementing organization. The assessment of programming needs at the district and health-facility level, the development of work plans, and the routine operation of clinical mentorship activities present significant logistic and financial requirements.

Where major resource gaps exist within the health-care system, the provision of essential commodities for pediatric HIV prevention, care, and treatment may need to be considered as part of overall support for clinical services delivery. Supplies of HIV test kits, materials for collecting dry blood-spot samples for DNA polymerase chain reaction (PCR) tests, cotrimoxazole for opportunistic infection prophylaxis, and antiretroviral drugs (ARVs) may need to be secured in order to ensure delivery of basic HIV services.

The development of regional health facilities into pediatric HIV learning sites, when feasible, should be considered. These relatively high-volume clinics can accommodate staff from lower-level health facilities during training attachments. Such training and exchange visits by health facility staff require financial and logistical support. For example, clinical mentor teams that are based at the regional level would require support for transport, communications, field allowances, office equipment, and training materials. The ability of the clinical mentors to conduct program activities, follow up on implementation recommendations at the participating health facilities, file reports, and undertake operations research requires significant logistical support for transportation, meetings, and other operating expenses.

Ensuring Program Quality

The following are some general guidelines for enhancing the quality of a clinical mentorship program.

Characteristics of a Good Mentorship Program

Mentoring programs should be well integrated within the existing service delivery structures to ensure their long-term sustainability. Long-term mentorship activities (i.e., lasting several weeks to several months) are generally more effective than short-exposure activities (i.e., lasting a few days per mentorship relationship). Built-in post-mentorship follow-up, with long-term, on-site supervision and/or backup by a competent health professional who is able to reinforce lessons taught during the initial mentorship exercises, often leads to better outcomes. Repeat visits by the same mentor are particularly reinforcing.^3,6

A mentor’s familiarity with local issues and national and/or institutional HIV care and treatment guidelines and practice strengthens the program by shortening the mentor’s learning curve and period of adaptation. Mentoring activities carried out within the trainee’s usual working environment allow for more tailored advice and foster the adaptation of solutions to local conditions; this approach may be more effective than preceptorships at more sophisticated, higher-level facilities (i.e., centers of excellence). A balance between these two approaches is recommended in order to achieve the best results. Additionally, the mentoring of clinical teams has proven more effective than the mentoring of individuals, who in turn are expected to influence their teams’ practices.^3,6

There should be a well-defined process for coordination and communication between mentors assigned to the same site. Such a process can help mentors use experiences and lessons learned to collectively plan and/or refine their approach so that the mentoring program is specifically relevant to the mentoring site. Mentoring teams also must have the ability to relate clinical and process activities at health facilities to care and treatment outcomes. In this way, outcome data can be used to design or strengthen care interventions resulting in more favorable outcomes.

Characteristics of a Good Mentor

A good mentor should be at a professional level equal to or higher than that of the trainee in the same or a closely related field. The mentor’s practical clinical experience in pediatric HIV care and patterns of related comorbidities in the trainee’s (or similar) work setting should be extensive, and his or her knowledge base should be up-to-date. The mentor should also have proven experience in supervision, training, and team building, as well as an ability to work with people of diverse backgrounds and knowledge and skill levels. A good working knowledge of the trainee’s language as well as the language(s) used by the majority of clients further increases the effectiveness of the mentor.

In order to effectively plan for the training needs of prospective clinical mentors, it is necessary to assess their knowledge and skills for a given clinical service. In Uganda, a rapid survey was conducted through a self-administered, semistructured questionnaire. The rapid assessment explored mentors’ current levels of competence in the areas of clinical care, trainer skills, supervision, and clinical mentoring. This approach enabled program managers to identify critical aspects of the mentors’ technical and professional abilities that required development and/or strengthening. Upon completion of the assessment, short- and medium-term training plans can then be tailored to address specific gaps in mentors’ knowledge and skills.

Lessons Learned: Building a Clinical Mentorship Program

The following discussion outlines the key considerations for building a quality clinical mentorship program. A list of required steps for program initiation is presented in Figure 3.

Ensuring a Sound Training Base

As a basic requirement, mentors must have sound knowledge and skills in a given field of clinical care. In the absence of a standardized national curriculum, there is likely to be limited coordination of training programs, making an objective evaluation of the mentors’ background training difficult. Based on the report Rapid Assessment of Capacity for Pediatric HIV/AIDS ART Training,⁷ the Uganda MOH mandated a working collaboration of key players in training, including ANECCA, the Elizabeth Glaser Pediatric AIDS Foundation, and the Pediatric Infectious Diseases Clinic / Baylor College of Medicine Children’s Foundation–Uganda. These partners were together charged with the planning and roll-out of the national training program in comprehensive pediatric HIV/AIDS care in Uganda.

In the first three months of the program, all prospective mentors participated in a course in advanced pediatric HIV care to ensure the same level of basic training. By enrolling the core group of clinical mentors from among a team of MOH HIV clinical care trainers, the mentorship program utilizes the experience of these persons to continually guide training improvement based on needs that are identified over time.

Training in advanced pediatric HIV care provides prospective clinical mentors with specialist knowledge and skills for pediatric HIV care and treatment. Major areas covered include clinical treatment reviews and updates, practical clinical experience, clinic management (including patient flow), mentorship skills, and regional program development/planning.⁸ Additional advanced training in the form of regular clinical attachments to pediatric HIV centers of excellence ensures continuity of skills and knowledge acquisition for the clinical mentors. These attachments are also designed to provide mentorship to the regional clinical mentors by senior national-level HIV care experts, thereby ensuring the transfer of knowledge and skills to the district and regional levels.

An advanced training of trainers (TOT) workshop was developed to further enhance training skills among the participants. At the end of this course, participants develop and refine action plans for their respective regions. This approach serves to decentralize training capacity from the large cities, while the built-in follow-up mechanisms ensure that training activities translate into expanded and improved pediatric HIV service delivery.

Policy and Strategy

To ensure coordinated planning and implementation of mentorship activities, the roles and functions of the various levels of health service delivery must be understood. A clinical mentorship program should be designed to fit into a national strategy for HIV/AIDS control, including scale-up plans for HIV care and treatment services. The Uganda MOH national AIDS control program’s pediatric ART committee prioritized the initiation of a mentorship program in order to directly increase access to quality pediatric HIV care. In addition, the MOH participated in the identification of the prospective regional mentors. This high degree of commitment at the national level enabled the integration of clinical mentorship activities into regional and district HIV/AIDS care programming.

Human Resource Capacity Development

A successful clinical mentorship program will be dependent on a skilled human resource base that includes the following components:

• Skilled, experienced, multidisciplinary team mentors
• Engaged and willing service providers to work with the mentoring team
• Consistent technical support for the mentor development program

This will require access to national HIV care centers of excellence and teaching institutions where senior pediatric HIV experts are found. Where local pediatric HIV care expertise is lacking, clinicians may need to be sourced from other countries. The mentors would also require periodic supervisory and monitoring visits from national-level program managers and pediatric HIV care experts. Additional technical resources might include resource materials (print, electronic, CME courses, etc.) and access to various forms of continued technical exchange.

Logistics

The clinical mentorship program should always work within the existing health system to avoid additional pressure on already overburdened public health services. However, additional logistics are needed to facilitate the movement of mentors to the various health facilities and the movement of clinical staff from lower-level health facilities to the regional referral hospitals for clinical training attachments. Mobile telephony could be provided as a practical means of efficient communication with and between different levels of health service delivery. Mentors should also be provided with training materials and job aids to establish and improve site-level systems to deliver pediatric HIV care and treatment.

Monitoring and Evaluation / Quality Improvement

An M&E framework and QA program are essential to ensure that the clinical mentorship program achieves its objectives. Ideally, these systems should be integrated with, and complementary to, existing M&E and QA systems within the national ART program.

The main goal of the M&E activities is to assess increased access and enhanced quality of pediatric HIV care services. In the Ugandan case, monitoring activities are scheduled as follows: monthly for health facility mentoring activities, quarterly for numbers of patients served, and semiannually for mentor development processes (e.g., training, individual evaluations). The focus of monitoring is on the numbers of individuals served and on qualitative aspects of the mentorship program (e.g., the establishment of a patient flow pattern that ensures the provision of adherence counseling to parents/caregivers of children attending the HIV care clinic). Service statistics (e.g., numbers of children identified as HIV-positive, numbers of HIV-positive children enrolled into HIV care) are collected through regular reporting systems, while specific mentoring activities are monitored using a set of tools developed to capture data on systems for HIV care, processes for providing clinical mentorship, provider skills, and key outputs of the mentorship program (e.g., number of mentors per district/region/national program, number of site visits over a specified period of time, number of mentor-hours per month per facility, and number of health workers engaged).

The results of M&E activities can be used to inform and improve the mentorship program as well as overall pediatric HIV care service delivery. In this way, the clinical mentorship program provides an opportunity to strengthen existing national systems.

In Uganda, a collaborative effort between multiple development partners and the MOH has led to the development of a framework for a national clinical mentorship program as a part of efforts to deliver scaled-up prevention, treatment, and care infrastructure for children affected by HIV and AIDS. The Ugandan experience has shown that it is feasible to develop a clinical mentorship program based primarily on locally available human resources.

To date, 16 doctors from eight health regions within Uganda have been recruited into the mentorship program. This team of clinical mentors has participated both in training lower-level health providers on various aspects of pediatric HIV care and in the development and field testing of clinical mentorship tools. The national roll-out of a program for early identification of HIV-exposed and infected infants has been supported through the clinical mentorship program, and improvements have been noted in the quality of care offered to HIV-positive children.

Reference List

1. Comprehensive HIV/AIDS Unit. AIDS Control Program national ART program data. Kampala, Uganda: Ministry of Health (MOH); 2007.

2. Waiswa PK. Framework for Capacity Building of Pediatric HIV/AIDS Training in Uganda: A Report Submitted to WHO and Ministry of Health, Uganda. Kampala, Uganda: MOH; 2005.

3. Seung K. Guidelines for Clinical Mentoring to Support Scaling-Up of HIV Care, ART and Prevention in Resource-Poor Settings. Geneva, Switzerland: World Health Organization (WHO); 2006.

4. Kayita J. A National Pediatrics HIV/AIDS Treatment and Care Clinical Mentorship Program (CMP): A Concept Paper Submitted by ANECCA/EGPAF. Kampala, Uganda: African Network for Care of Children Affected by AIDS (ANECCA) and Elizabeth Glaser Pediatric AIDS Foundation (EGPAF); 2006.

5. Marquez L, Kean L. Making Supervision Supportive and Sustainable: New Approaches to Old Problems. MAQ Paper No. 4. http://www.maqweb.org/maqdoc/MAQno4final.pdf. Published 2002. Accessed July 9, 2008.

6. International Training and Education Center on HIV/AIDS (I-TECH). Clinical Mentoring Tool Kit: A Resource for Clinical Mentorship in Resource Constrained Settings. Seattle, WA: University of Washington, I-TECH; 2006.

7. Waiswa P. Rapid Assessment of Capacity for Pediatric HIV/AIDS ART Training: A Report Submitted to WHO and Ministry of Health Uganda. Kampala, Uganda: MOH; 2005.

8. Natukunda E. Pediatric HIV/AIDS Care Trainers / Clinical Mentors Training Course for Senior Clinicians from Regional Hospitals–Uganda. Workshop Report. Kampala, Uganda: ANECCA, EGPAF, Baylor College of Medicine (BCM), and Makerere University; 2006.

9. Kiguli S. Consultancy Report on Regional Pediatric Experts HIV/AIDS Care & Treatment Training of Trainers Course. Kampala, Uganda: ANECCA and EGPAF; 2006.