Data Quality Assessment Report 2016 FINAL

Quality of HIV Program Data Reported by Health Facilities and
Implementing Partners in Uganda

Findings from Data Quality Assessments, September 2016
Report Prepared by
Monitoring and Evaluation of Emergency Plan Progress – Phase II

(MEEPP II)
November 2016
Additional information and copies of this report may be obtained from:
Social & Scientific Systems, Inc.

Monitoring and Evaluation of Emergency Plan Progress – Phase II (MEEPP II)
Plot 51 Mackenzie Vale, Kololo
P. O. Box 12761 Kampala-Uganda
Tel: 0414 230 304/7; Fax: 0414 230 306
Suggested Citation:
Quality of HIV Program Data Reported by Health Facilities and Implementing Partners in Uganda:
Findings from Data Quality Assessments, September 2016. Unpublished manuscript.
The Monitoring and Evaluation of Emergency Plan Progress – Phase II (MEEPP II) project and this
report are made possible by the generous support of the American people through the United States
Agency for International Development (USAID) and President’s Emergency Plan for AIDS Relief
(PEPFAR) under the terms of USAID/Social & Scientific Systems (SSS) Contract No. AID-617-C-10-
00008. The contents do not necessarily reflect the views of PEPFAR or any United States government
agency.
TABLE OF CONTENTS
Executive Summary................................................................................................................................. 1
1 Introduction ...................................................................................................................................... 4
2 DQA Objectives................................................................................................................................. 4
3 DQA Methodology ............................................................................................................................ 5
3.1 Selection of DQA Data Sets ...................................................................................................... 5
3.2 Sampling the Service Outlets ................................................................................................... 6
3.3 Data Collection ......................................................................................................................... 6
3.4 Data Analysis ............................................................................................................................ 6
3.5 Assessment of the Data Management Systems ....................................................................... 7
3.6 Validation of Reported Data..................................................................................................... 7
3.7 Overall Data Quality Assessment for Each Indicator................................................................ 8
4 DQA Findings .................................................................................................................................... 9
4.1 ART Retention Indicators.......................................................................................................... 9
4.2 PMTCT – Known Status Indicator ........................................................................................... 11
4.3 PMTCT – ARV Prophylaxis Indicator ....................................................................................... 12
4.4 PMTCT – EID Indicators .......................................................................................................... 14
4.5 Voluntary Medical Male Circumcision Indicator .................................................................... 15
4.6 Sexual Prevention – Priority Populations Indicator................................................................ 16
4.7 Sexual Prevention – Key Populations Indicator...................................................................... 18
4.8 Post-GBV Care Indicator ......................................................................................................... 20
4.9 HRH – Pre-Service Training Indicator ..................................................................................... 22
5 Conclusion ......................................................................................................................................23
Annex 1: Sites, Partners, and Schedule of Field Visits ..........................................................................24
Annex 2: Data Management System Assessment Tool – PEPFAR Multiple Indicator DQA, 2016 ........27
Annex 3: Indicator Data Management System Rating based on Five Critical Assessment Criteria ......29
Annex 4: Overall Status of Data Management Systems for ART Retention Indicators at the Sampled
Sites ................................................................................................................................................30
Annex 5: Overall Status of Data Management Systems for PMTCT – Known Status Indicator at
Sampled Sites .................................................................................................................................30
Annex 6: Overall Status of Data Management Systems for PMTCT – ARV Prophylaxis Indicator at the
Sampled Sites .................................................................................................................................31
Annex 7: Overall Status of Data Management Systems for PMTCT – EID Indicators at the Sampled
Sites ................................................................................................................................................31
Annex 8: Overall Status of Data Management Systems for VMMC Indicator at the Sampled Sites ....32
Annex 9: Overall Status of Data Management Systems for Priority Populations Indicator at the
Sampled Sites .................................................................................................................................32
Annex 10: Overall Status of Data Management Systems for Key Populations Indicator at the Sampled
Sites ................................................................................................................................................33
Annex 11: Overall Status of Data Management Systems for Post-GBV Care Indicator at the Sampled
Sites ................................................................................................................................................33
Annex 12: Data Validation Tools – PEPFAR Multiple Indicator DQA, 2016 ..........................................34
Quality of HIV Program Data: Findings from Data Quality Assessments, September 2016 i
LIST OF ACRONYMS
AIDS Acquired Immune Deficiency Syndrome
ART Antiretroviral Therapy
ARV Antiretroviral
DCT Data Collection Tools
DMS Data Management System
DQA Data Quality Assessment
HC Health Centre
HCT HIV Counseling and Testing
HIV Human Immunodeficiency Virus
HRH Human Resources for Health
IP Implementing Partner
M&E Monitoring and evaluation
MEEPP Monitoring and Evaluation of Emergency Plan Progress
VMMC Voluntary Medical Male Circumcision
OPD Out-patient Department
PEPFAR President’s Emergency Plan for AIDS Relief
SOP Standard Operating Procedures
TWG Technical Working Group
USAID United States Agency for International Development
Quality of HIV Program Data: Findings from Data Quality Assessments, September 2016 ii
EXECUTIVE SUMMARY
Data quality assessments (DQAs) for data quality improvement are a good performance
management practice, and are required through the U.S. Government Performance and Results Act.
In the PEPFAR inter-Agency arrangement, DQAs are an integral part of program implementation for
the Centers for Disease Control and Prevention performance indicators while United States Agency
for International Development (USAID) requires that a DQA be conducted every 3 years for each of
the prime performance indicators. A rapid assessment of the PEPFAR Level One indicators showed
that a number of them had not been subjected to a DQA for more than 3 years.
The Monitoring and Evaluation of Emergency Plan Progress (MEEPP) project, as part of its HIV/AIDS
performance monitoring mandate, undertook a multi-indicator DQA exercise covering the following
indicators:
1. Antiretroviral Therapy (ART) Retention – 12 months: Number of adults and children enrolled in
ART cohort 12 months before the reporting period
2. ART Retention – 12 months: Number of adults and children known to be alive and on treatment
12 months after initiation of ART
3. PMTCT – Known HIV Status: Number of pregnant women with known HIV status
4. PMTCT – Prophylaxis: Number of pregnant women provided antiretroviral (ARV) prophylaxis
under Prevention of Mother to Child Transmission (PMTCT) settings
5. PMTCT – Exposed Infants Tested: Exposed infants tested for HIV below 18 months
6. PMTCT – Exposed Infants Who Tested Positive: Exposed infants testing HIV positive below 18
months
7. Voluntary Medical Male Circumcision (VMMC): Number of males circumcised as part of the
minimum VMMC package for HIV prevention
8. Sexual Prevention – Priority Populations: Number of individuals from priority populations who
completed a standardized HIV prevention intervention during the reporting period
9. Sexual Prevention – Key Populations: Number of key populations reached with individual and/or
small-group-level HIV preventive interventions that are based on evidence and/or meet the
minimum standards required
10. Post-Gender Based Violence (GBV) Care: Number of people receiving post-GBV clinical care
based on the minimum package
11. Human Resources for Heath (HRH) – Pre-service Training: Number of new health workers who
graduated from a pre-service training institution or program as a result of PEPFAR-supported
strengthening efforts, within the reporting period
The MEEPP team targeted the latest reported data set for each indicator for the DQA exercise. The
selection of service outlets was done using the Lot Quality Assurance Sampling (LQAS) methodology,
with 19 Lots in the clinical and 19 Lots in the community based service outlets. The purpose of the
exercise was to assess the quality of data for each of the targeted indicators which required
assessment of the data management system (DMS) as well as the validity of the reported data for
the selected sites supported by PEPFAR-funded implementing partners (IPs).
A combination of approaches to data collection were employed, including use of key informant
interviews to generate information about the services provided, and a DMS assessment tool to
evaluate the systems at the various service outlets. Data validation tools for each of the indicators
Quality of HIV Program Data: Findings from Data Quality Assessments, September 2016 1
were also handy in assessing the validity of the reported data at the various outlets. Due to the
indicator-focused nature of this exercise (with the exception of the Human Resources for Health
(HRH) – Pre-service Training indicator), the DMS Rating and the Data Validation Rating for the
indicators were calculated through triangulation of the data from different sites supported by
different PEPFAR partners. The DMS Ratings for the different indicators were focused on five
assessment criteria which are the core of a DMS: level of understanding of the indicator, adequacy
of data collection methods, completeness of data, procedures for capturing unique individuals, and
availability of adequate data quality checks. The data validation approach was to see if there was
any variation between the gold standard (the joint site count) from the primary data sources at the
site, and the reported output for the specific indicator (the DHIS2 reports). Based on the amount of
variation, validity of reported data was rated as Adequate, Acceptable, or Inadequate as shown in
Table 1.
Table 1. Data Validation Ratings of Reported Data

Data
Validation
Rating Rating Criteria
Adequate Percentage variation between joint count and reported output of ≤ ± 5%
Acceptable Percentage variation between joint count and reported output of > ± 5% to ≤ ± 10%
Inadequate Percentage variation between joint count and reported output of > ± 10%
DQA Findings
The DQA exercise was conducted in the districts of Arua, Gulu, Soroti, Mbale, Jinja, Buikwe,
Mubende, Mpigi, Gomba, Sembabule, Wakiso, Kayunga, Mukono, Buvuma, Nakasongola, Bugiri,
Iganga, Namayingo, and Mayuge. The targeted service outlets were supported by several PEPFAR IPs
including SUSTAIN, Mildmay, Walter Reed, STAR-EC, PREFA, TASO, and Baylor Uganda. The overall
findings of the DQA exercise are summarized in Table 2.
Table 2. Overall Findings of the DQA

Data Validation Overall Data
Indicator DMS Rating Rating Quality Rating
ART Retention – 12 Months (2 indicators) Acceptable Inadequate Inadequate
PMTCT – Known HIV Status Acceptable Acceptable Acceptable
PMTCT – ARV Prophylaxis Acceptable Inadequate Inadequate
PMTCT – EID (2 indicators) Acceptable Acceptable Acceptable
VMMC – Number of Males Circumcised Adequate Adequate Adequate
Sexual Prevention – Priority Populations Served Inadequate Inadequate Inadequate
Sexual Prevention – Key Populations Served Inadequate Inadequate Inadequate
Post-GBV Care Inadequate Inadequate Inadequate
HRH – Pre-service Training Adequate Inadequate Inadequate
The FY 2016 third quarter (Q3) VMMC data for number of males circumcised was of Adequate
quality, both in terms of the DMS and in terms of data validity. The PMTCT – Known Status and
PMTCT – EID indicators both had Acceptable data quality ratings. The rating for the remaining
indicator data sets was Inadequate.
The 12-month ART Retention indicator data was largely under reported for both the Cohort Before
and the Cohort After. This was mainly due to not updating the ART registers. The PMTCT – ARV
Prophylaxis indicator data were equally under and over reported which was the result of erroneous
PMTCT coding in the antenatal care (ANC) registers. The quality of Priority Population and Key
Population indicators was hampered by lack of primary data collection tools, as well as the sub-
optimal understanding of the indicators. The PEPFAR Post-GBV Care data set that was reported for
Annual Program Results (APR) 2015 covered a period when the indicator was poorly understood,
and when the primary data collection tools were scarce. This situation has changed and the data
quality rating for subsequent data sets should improve. However, there is need to harmonize the
existing national HMIS 105 GBV Care reporting requirements with the PEPFAR indicator definition so
as to minimize the current confusion faced by the health information staff at the health facility level.
As for the HRH – Pre-Service Training data, the under reporting at the aggregate level can be partly
attributed to not having received records from the training institutions until after the PEPFAR
reporting period. However, at the individual cadre level, there is strong evidence to suggest that the
reported outputs for midwives and that of laboratory professionals were unintentionally
interchanged.
Conclusion
The quality of data for the majority of the assessed PEPFAR indicators was inadequate. This is
especially so in regard to the sexual prevention indicators. In the spirit of data quality improvement,
the Strategic Information Technical Working Group needs to focus on the data quality weaknesses
identified in this exercise and find solutions to them. One of the proposed solutions is the adoption
of Electronic Health Records (EHRs). These will ease the burden on the insufficient human resources
available for data management, and will also reduce the number of human errors that negatively
impact the quality of data. However, all these efforts will only bear fruit when all the critical service
providers have internalized the definitions and interpretations of the respective indicators.
1 INTRODUCTION
Data Quality Assessments (DQAs) are a good performance management practice, and are required
through the U.S. Government Performance and Results Act. At the Agency level, the United States
Agency for International Development (USAID) requires that a DQA be conducted every 3 years for
every performance indicator. The Monitoring and Evaluation of Emergency Plan Progress (MEEPP)
project performance monitoring mandate is largely confined to the HIV/AIDS portfolio indicators. A
rapid assessment of the PEPFAR HIV indicators showed that the following indicators had not been
subjected to a DQA for 3 or more years:
1. Antiretroviral Therapy (ART) Retention – 12 months

Number of adults and children enrolled in ART cohort 12 months before the reporting period
(Cohort Before)
2. ART Retention – 12 months
Number of adults and children known to be alive and on treatment 12 months after initiation of
ART (Cohort After)
3. Prevention of Mother to Child Transmission (PMTCT) – Known HIV Status
Number of pregnant women with known HIV status
4. PMTCT – Prophylaxis
Number of pregnant women provided antiretroviral (ARV) prophylaxis under Prevention of
Mother to Child Transmission (PMTCT) settings
5. PMTCT – Exposed Infants Tested
Exposed infants tested for HIV below 18 months (PMTCT_EID)
6. PMTCT – Exposed Infants who Tested Positive
Exposed infants testing HIV positive below 18 months
7. Voluntary Medical Male Circumcision (VMMC)
Number of males circumcised as part of the minimum VMMC package for HIV prevention
8. Sexual Prevention – Priority Populations
Number of individuals from priority populations who completed a standardized HIV prevention
intervention during the reporting period (PP_PREV)
9. Sexual Prevention – Key Populations
Number of key populations reached with individual and/or small-group-level HIV preventive
interventions that are based on evidence and/or meet the minimum standards required
(KP_PREV)
10. Post-Gender Based Violence (GBV) Care
Number of people receiving post-GBV clinical care based on the minimum package (GEND_GBV)
11. Human Resources for Health (HRH) – Pre-service Training
Number of new health workers who graduated from a pre-service training institution or program
as a result of PEPFAR-supported strengthening efforts, within the reporting period
In response to the USAID requirements, and as part of the PEPFAR inter-agency collaboration effort,
a multi-indicator DQA was organized to assess the quality of data reported for the above indicators.
2 DQA OBJECTIVES
In the context of the PEPFAR program, the purpose of conducting a DQA is to assess and document
the Data Management Systems (DMSs)—the data collection, management, and reporting systems—
that implementing partners (IPs) have in place to generate the data reported to the Inter Agency
Team. Assessing data quality defines strengths and areas in need of improvement in an IP’s
monitoring and evaluation (M&E) system, and recommends changes that the IP can make to further
improve on their strengths and to overcome shortfalls. Data validation is a core element of a DQA
and is aimed at certifying the accuracy and completeness of a specific data set.
The purpose of this DQA exercise was to focus on the identified indicators, and to assess the quality
of data generated by the health facilities and community service outlets supported by partners
funded under PEPFAR for the relevant reporting periods.
Specifically, this exercise was meant to:

1. Establish the implementation processes of the program components that contribute to the
targeted performance indicators
2. Establish the methods employed by the various partners in the collection, storage, analysis, and
reporting of the data for the various indicators
3. Ascertain whether the data reported during the relevant reporting periods reflected the actual
output in the primary data collection tools at the selected service outlets
4. Assess the DMS in place at the various service outlets
5. Identify problems encountered by providers in delivering the relevant services and in managing
the data, and suggest ways to solve them
3 DQA METHODOLOGY
A cross-sectional assessment using mixed methods (observations, key informant interviews, and
records reviews) was conducted in the selected clinical service outlets and community facilities with
a focus on:
 The DMS at the primary data generation sites
 Validation of the reported data
 Generation of an overall data quality profile for each indicator
3.1 Selection of DQA Data Sets

The most recently reported data sets, based on the reporting frequency of each indicator, were
selected to be the subjects of the DQA, as shown in Table 3.
Table 3: Data Sets Selected for the DQA
Reporting
Indicators Frequency Data Set by Reporting Period
ART Retention – 12 Months (2 indicators) Annual APR 2015
PMTCT – Known HIV Status Quarterly FY 2016 – Q3
PMTCT – ARV Prophylaxis Semi-Annual FT 2016 – Q1 and Q2
PMTCT – EID (2 indicators) Quarterly FY 2016 – Q3
VMMC – Number of Males Circumcised Quarterly FY 2016 – Q3
Sexual Prevention – Priority Populations Semi-Annual FT 2016 – Q1 and Q2
Sexual Prevention – Key Populations Semi-Annual FT 2016 – Q1 and Q2
Post -GBV Care Annual APR 2015
Reporting
Indicators Frequency Data Set by Reporting Period
HRH – Pre-service Training Annual APR 2015
3.2 Sampling the Service Outlets

The choice of partners and sites to be involved in the DQA exercise was largely dictated by the
relevant data sets for the multiple targeted indicators. The data sets helped to identify the PEPFAR
IPs that contributed data for the respective reporting periods, and the sites that were the origin of
the primary data. Lot Quality Assurance Sampling (LQAS) methodology was then applied to each of
the lots to identify 19 sites. The sites and associated partners are shown in Annex 1.
3.3 Data Collection

The data collection exercise was conducted from September 26, 2016, to October 10, 2016. Data
collection was preceded by:
 Team Selection: In order to successfully conduct a multi-indicator DQA of this nature, it was
imperative to conduct due diligence in putting together a team that would ably handle the
exercise. A search was conducted in the various MEEPP databases to identify competent
consultants and support staff, and other recruitment efforts were undertaken, until a team of 13
individuals combining clinical and sexual prevention expertise was constituted.
 Team Orientation: The team underwent a 1-day orientation course. The team members were
already conversant in the DQA processes, so emphasis was placed on:
 Internalizing the indicators in terms of definitions and interpretations: Except for ART
Retention, the clinical indicators were fairly straightforward. The team was least conversant
in the sexual prevention group of indicators, and more time had to be devoted to them.
 Data sources for the various components of the indicators: The various primary data
collection tools were demonstrated and explored to make sure there was a common
understanding regarding the primary data sources for the various indicators.
 The DQA tools for the different indicators: A common DMS assessment tool was shared, as
were the data validation tools for the various indicators.
 Brushing up on the approaches and tactics for Data Quality Assessment and Improvement:
The focus was on the appreciative approach, as well as the ethical and professional
considerations during the DQA process.
After the orientation, the group was divided into five teams, and were set out to conduct the DQA
exercise according to the schedule in Annex 1. One member of each team was assigned the team
lead responsibility. At the end of each day, the team leader would submit an electronic version of
the DQA results for the site to the MEEPP supervisory team.
3.4 Data Analysis

The DQA teams submitted site-specific IP data, with clear indication of the DMS and data validation
assessments. This was then disaggregated into indicator-specific data sets. From here, specific
indicator data quality variables were computed.
3.5 Assessment of the Data Management Systems
The DMS at each of the sampled service outlets was assessed, specifically focusing on the adequacy
of the data collection, management, and reporting system that was in place to generate the data
that were reported to PEPFAR. The cardinal criteria of interest were:
 Level of understanding of the indicator
 Data collection methodology with emphasis on its adequacy and consistency
 Completeness of the targeted dataset
 Potential for transcription errors
 Procedures for capturing unique individuals provided with the relevant services
 Documentation and utilization of Standard Operating Procedures (SOPs)
 Quality control systems for data completeness and accuracy
 Level and evidence of data utilization
This assessment of the DMS helped identify strengths and vulnerabilities in the facility M&E systems,
and provided a basis for recommending changes that were needed to further improve on the
strengths and to overcome the vulnerabilities.
The DMS Assessment Tool in Annex 2 was used at each selected service outlet to provide a
qualitative assessment of the DMS for the relevant indicator.
The Indicator DMS Rating for the different indicators shown in Annex 3 is focused on five
assessment criteria that form the core of a DMS, namely: high level of understanding of the
indicator, adequate data collection methods, completeness of data, procedures for capturing unique
individuals, and adequate data quality checks. In order to derive a DMS Rating, the percentage score
for each of the five criteria in the overall DMS status reports was converted into a numerical
equivalent. For example, 87% of service outlets had adequate data collection methods for the ART
Retention indicators, so a score of 87 points was assigned to that column for that indicator on the
table in Annex 3. Finally, an average indicator score was calculated for each indicator to arrive at the
DMS Rating according to the system described in Table 5.
Table 5: Data Management System Rating Criteria for Each Indicator
DMS Rating Rating Criteria

Adequate Average score of 75 and above
Acceptable Average score between 50 and 74
Inadequate Average score below 50
The specific indicator assessments for the different sites by the different IPs were aggregated to
produce the Overall DMS Status reports that are shown in Annexes 4–11, based on the percentage
of service outlets that exhibited the various measures of the assessment criteria. For example, of the
14 service outlets that were selected for the ART Retention indicators, 12 of them (87%) had an
adequate data collection system for the indicator data. Reporting timeliness, which was uniformly
good, and data utilization which was consistently low, were left out of the assessment.
3.6 Validation of Reported Data

The purpose of the data validation was to verify whether the reported data at the defined service
outlet measured what they were intended to measure and the accuracy of specific data reported for
the defined period against each of the indicators. The Data Validation Tools for the various
indicators are shown in Annex 12. The data validation approach was to examine any variation
between the gold standard (the joint site count) and the primary data sources at the site, and the
reported output for the specific indicator (the DHIS2 reports). Based on the amount of variation, the
validity of reported data was categorized as shown in Table 4.
Table 4: Site-Level Data Validation Rating Criteria
Data
Validation
Rating Rating Criteria
Adequate Percentage variation between joint count and reported output of ≤ ± 5%
Acceptable Percentage variation between joint count and reported output of > ± 5% to ≤ ± 10%
Inadequate Percentage variation between joint count and reported output of > ± 10%
Since many service outlets supported by different PEPFAR partners contributed to the same
indicator data set, the final Data Validation Rating for an indicator was calculated according to the
percentages of service outlets that registered Adequate, Acceptable, or Inadequate ratings as shown
in Text Box 1.
Text Box 1: Indicator Level Data Validation Rating Criteria

 75–100% of facilities registering Adequate or Acceptable ratings = Adequate
 50–74% of facilities registering Adequate or Acceptable ratings = Acceptable
 Below 50% of facilities registering Adequate or Acceptable ratings = Inadequate
In addition, the volume of data rated Adequate, Acceptable, or Inadequate was recorded, to get a
sense of the validity of the complete data set. The validation based on the volume of data followed
the same classification criteria as health facilities. The assessment based on volume of data,
however, is used for comparative discussion only. For the purposes of this exercise, based on the
principle of data quality improvement across IPs and service outlets, the data validation based on
the performance of the different facilities was what was used to grade the data validation
performance for each indicator.
3.7 Overall Data Quality Assessment for Each Indicator

An overall data quality assessment was derived from the combined DMS and Data Validation
Ratings, taking into account all the service outlets that contributed to the indicator data set (sections
3.1 and 3.2). Overall data quality rating criteria are presented in Table 6.
Table 6: Overall Data Quality Rating Criteria
Overall Data
Quality Rating Criteria
Percentage variation ≤ ± 5% with Adequate DMS
or
Adequate Percentage variation ≤ ± 5% with Acceptable DMS
Overall Data
Quality Rating Criteria
Percentage variation > ± 5 to ≤ ± 10% with Adequate DMS
or
Acceptable Percentage variation > ± 5 to ≤ ± 10% with Acceptable DMS
Percentage variation > ± 10% with Adequate, Acceptable, or Inadequate
Inadequate DMS
4 DQA FINDINGS
Since this was a multi-indicator DQA, with contributions from multiple IP-supported sites for a given
indicator, the assessment findings are presented in the following nine sections as summaries of
indicators or groups of indicators.
4.1 ART Retention Indicators

The indicators that focus on “before” and “after” cohorts help to measure the proportion of
individuals who have been kept on ART over a defined period of time. Death and loss to follow-up
are the two highest causes of patient attrition from ART, especially in the first few months after
initiating ART. A high retention rate is one important measure of program success, specifically in
reducing morbidity and mortality, and is a proxy for overall quality of an ART program. Monitoring
the retention is a critical quality-of-service indicator at site, national, and PEPFAR program levels as
it can highlight barriers to health-seeking behaviors and/or gaps in access to and provision of health
services.
4.1.1 Data Management Systems for the ART Retention Indicators

As indicated in Annex 3, the DMS for assessing these indicators at the 14 health facilities that took
part in the DQA exercise showed a good level of understanding of the indicators, adequate data
collection methods, and the ability to document and follow up on unique individuals. In the final
analysis, the DMS was rated as Acceptable. However, at the individual service outlet level, there was
evidence of both good practices and those that could be improved, as indicated in Text Box 2.
Text Box 2: DQA Team Observations with Respect to the ART Retention Indicator
 ART registers were well updated and easily retrievable
 Some ART data from client cards were not fully entered into the ART register
 Wrong postings of cohorts were observed, e.g., January 2014 entered into
May 2014
The evidence on the ground showed that at many service outlets, the ART registers were not fully
updated, and the quality control checks were not sufficient.
4.1.2 Validation of Reported ART Retention Data

The validation results presented in Table 7 indicate that the individual facility data for the Cohort
Before was largely under reported, and the Cohort After data was both equally over and under
reported. As indicated in section 3.2, the final appraisal was a Data Validation Rating of Inadequate.
(Validation using the volume of data puts the Cohort Before into the Acceptable category, and the
Cohort After into the Inadequate category.)
Table 7: Data Validation Results for the ART Retention Indicators at the Selected Sites
COHORT BEFORE APRIL 2015 COHORT AFTER APRIL 2015
Actual Actual
Joint Joint
Implementing Reported Count Variation Reported Count Variation
Partner Health Facility (a) (b) (a - b/b) (c) (d) (c - d/d)
Sustain Arua RRH 1,282 664 + 93.1% 942 345 + 173%
Sustain Gulu RRH 1,352 1,404 - 3.7% 1,089 1,352 - 19.5%
Sustain Lira RRH 2,195 2,393 - 8.3% 1,576 1,663 - 5.2%
Sustain Soroti RRH 366 427 - 14.3% 318 333 - 4.5%
Mildmay Kanoni HC 3 233 284 - 17.9% 130 215 - 39.5%
Mildmay Buwama HC 3 329 556 - 40.8% 204 390 - 47.7%
Mildmay Lwebitakuli HC 3 108 130 - 16.9% 61 109 - 44.0%
Mildmay Entebbe Hospital 644 833 - 22.7% 367 550 - 33.3%
Walter Reed Kayunga Hospital 581 578 + 0.5% 514 494 + 4.0%
Walter Reed Kangulumira HC 4 145 381 - 61.9% 142 291 - 51.2%
Walter Reed Mukono T/C HC 4 1,266 1,321 - 4.2% 777 820 - 5.2%
Walter Reed Kojja HC 4 328 292 + 12.3% 312 217 + 43.8%
Walter Reed Kabanga HC 3 83 79 + 5.1% 63 52 + 21.2%
Walter Reed Kkoome HC 3 374 507 - 26.2% 145 341 - 57.5%
4.1.3 Overall Quality of ART Retention Data

The combined DMS Rating and Data Validation Rating for this indicator, as shown in Table 8, place it
in the Inadequate category.
Table 8: Overall Quality Rating for ART Retention Data
Data Validation Rating – Data Validation Overall

Indicator DMS Based on Rating – Based on Quality
Component Rating # of Service Outlets Volume of Data Rating
Inadequate (Data at 33% Acceptable (59% of
of health facilities rated reported data rated
Cohort Before Acceptable Adequate/Acceptable) Adequate/Acceptable) Acceptable
Inadequate (Data at 27% Inadequate (48% of
of health facilities rated reported data rated
Cohort After Acceptable Adequate/Acceptable) Adequate/Acceptable) Inadequate
Overall ART
Retention – 12
Months Acceptable — — Inadequate
The main reasons cited for this data quality status are:
 Incompleteness of data due to failure to update the ART registers in a timely manner
 Improper documentation of transfer-in and transfer-out patients
 Shortfalls in the interpretation of the indicator
4.2 PMTCT – Known Status Indicator

A “known HIV status,” in the PMTCT context, is defined as either a confirmed HIV-positive test result
from a test during this pregnancy, an already-known positive test result, or a confirmed negative test
result during the current pregnancy. This indicator reflects one goal of PMTCT, which is to increase
the number of pregnant women who know their HIV status. Identification of a pregnant woman’s
HIV status is the key entry point into PMTCT and other HIV care and treatment services.
4.2.1 Data Management Systems for the PMTCT – Known Status Indicator
The DMS for assessing the PMTCT program with respect to the Known Status indicator was found to
be Acceptable. Good data collection processes were in place, with the ability to identify unique
individual service beneficiaries. The weaknesses in the system included incompleteness of the
primary data collection tools, and low levels of clarity regarding the indicator definition.
4.2.2 Validation of Reported PMTCT – Known Status Indicator Data

The Data Validation Rating, from both the service outlet and data volume perspectives, was in the
Acceptable range as shown in Table 9.
Table 9: Data Validation Results for the PMTCT – Known Status Indicator at the Selected Sites
FY 2016 Q3 Health Actual
Variation
Implementing Reported Facility Joint Count
Partner Health Facility Output (a) Summary (b) (a - b/b)
SUSTAIN Arua RRH 1,808 1,971 1,756 + 2.9%

SUSTAIN Gulu RRH 1,036 1,036 1,081 - 4.2%
SUSTAIN Lira RRH 1,416 1,416 1,444 - 1.9%
SUSTAIN Soroti RRH 562 570 557 + 0.9%
SUSTAIN Mbale RRH 920 638 1,774 - 48.1%
SUSTAIN Jinja RRH 1,293 1,357 1,315 - 1.7%
SUSTAIN Kawolo Hospital 1,102 1,527 1,221 - 9.7%
SUSTAIN Mubende RRH 1,514 101 787 + 92.4%
Mildmay Kyabadaza HC 3 115 102 97 + 18.6%
Mildmay Kanoni HC 3 373 376 357 + 4.5%
Mildmay Buwama HC 3 422 436 499 - 15.4%
Mildmay Lwebitakuli HC 3 194 202 205 - 5.4%
Mildmay Entebbe Hospital 3,073 3,355 3,489 - 11.9%
Walter Reed Kayunga Hospital 621 609 634 - 2.1%
Walter Reed Kangulumira HC 4 534 506 507 + 5.3%
Walter Reed Mukono T/C HC 4 2,830 3773 2885 - 1.9%
Walter Reed Kojja HC 4 373 521 521 - 28.4%
Walter Reed Kabanga HC 3 108 114 102 + 5.9%
FY 2016 Q3 Health Actual
Variation
Implementing Reported Facility Joint Count
Walter Reed Kkome HC 3 140 116 113 + 23.9%
4.2.3 Overall Quality of PMTCT – Known Status Data

Both the DMS Rating and the Data Validation Rating were in the Acceptable range. Therefore, the
overall quality of the PMTCT – Known Status indicator data was Acceptable, as shown in Table 10.
Table 10: Overall Quality Rating for PMTCT – Known Status Indicator Data
Overall
DMS Data Validation Rating Data Validation Rating Quality
Rating Based on # of Service Outlets Based on Volume of Data Profile
Acceptable (Data at 63% of Acceptable (64% of reported
facilities rated PMTCT–Known Status data rated
Acceptable Adequate/Acceptable) Adequate/Acceptable) Acceptable
Even with overall quality deemed Acceptable, a number of challenges need to be addressed to
further improve the quality of this data. Data entry into the ANC, Maternity, and postnatal care
(PNC) registers needs to be improved in terms of quality and for longitudinal follow up. The use of
data quality checks, including monthly summaries, would go a long way to improve the overall
quality of PMTCT data.
4.3 PMTCT – ARV Prophylaxis Indicator

The number of HIV-positive pregnant women who received ARV drugs to reduce risk of mother-to-
child-transmission measures the provision and coverage of ARV prophylaxis and treatment for HIV-
positive pregnant women in order to:
 Identify progress toward the USG and global goals of increasing ARV coverage (prophylaxis and
treatment) among pregnant women living with HIV and eliminating mother-to-child transmission
of HIV
 Assess progress toward implementing more efficacious PMTCT ARV regimens
 Determine the coverage of HIV-positive pregnant women on ARV prophylaxis and ART for life
among all HIV-positive pregnant women identified
4.3.1 Data Management Systems for the PMTCT – ARV Prophylaxis Indicator
The DMS for assessing the PMTCT – ARV Prophylaxis indicator was borderline Acceptable (Annex 3).
This was largely due to the national data collection system that is able to capture unique service
beneficiaries. However, the levels of understanding of the indicator were deemed to be low, and so
was data completeness.
4.3.2 Validation of Reported PMTCT – ARV Prophylaxis Indicator Data

Only 21% of the health facilities assessed had Adequate or Acceptable data validation scores (Table
11). These accounted for 12% of the reported PMTCT – ARV Prophylaxis data volume. Overall, data
validation for the indicator was in the Inadequate category; with 88% of health facilities having
either over or under reported the data.
Table 11: Data Validation Results for the PMTCT – ARV Prophylaxis Indicator at the Selected Sites
FY 2016 Q1
and Q2 Health Actual
Implementing Reported Facility Joint Variation
Partner Health Facility Output (a) Summary Count (b) (a - b/b)
SUSTAIN Arua RRH 196 124 222 - 11.7%
SUSTAIN Gulu RRH 245 228 232 + 5.6%
SUSTAIN Lira RRH 247 242 116 + 112.9%
SUSTAIN Soroti RRH 52 44 60 - 13.3%
SUSTAIN Mbale RRH 97 99 165 - 41.2%
SUSTAIN Jinja RRH 109 109 155 - 29.7%
SUSTAIN Kawolo Hospital 182 199 445 - 59.1%
SUSTAIN Mubende RRH 170 114 216 -21.3%
Mildmay Kyabadaza HC 3 5 6 5 0%
Mildmay Kanoni HC 3 57 57 50 - 12.3%
Mildmay Buwama HC 3 71 53 61 + 16.4%
Mildmay Lwebitakuli HC 3 17 17 8 + 112.5%
Mildmay Entebbe Hospital 1,012 872 278 + 264%
Walter Reed Kayunga Hospital 101 92 75 + 34.7%
Walter Reed Kangulumira HC 4 85 94 64 + 32.8%
Walter Reed Mukono T/C HC 4 398 411 312 + 27.6%
Walter Reed Kojja HC 4 88 91 91 - 3.3%
Walter Reed Kabanga HC 3 11 11 20 - 45%
Walter Reed Kkome HC 3 40 43 44 - 9.1%
4.3.3 Overall Quality of PMTCT – ARV Prophylaxis Data

The combined DMS and Data Validation Rating for the PMTCT – ARV Prophylaxis indicator falls in the
Inadequate category as shown in Table 12.
Table 12: Overall Quality Rating for PMTCT – ARV Prophylaxis Data
DMS Data Validation Rating – Based Data Validation Rating – Based Overall Quality
Rating on # of Service Outlets on Volume of Data Rating
Inadequate (Data at 21% of Inadequate (12% of reported
facilities rated PMTCT–Prophylaxis data rated
Acceptable Adequate/Acceptable Adequate/Acceptable) Inadequate
The main cause of problems for this indicator was the poor understanding and erroneous application
of the PMTCT codes, cutting across the ANC, Maternity, and Post Natal registers. In some cases, this
occurred because student nurses and midwives were being used in response to insufficient human
resources.
4.4 PMTCT – EID Indicators
Early diagnosis of infants who acquired HIV during pregnancy, delivery, or in the early postpartum
period is critical as infants have an increased risk of mortality if they go undiagnosed and untreated.
These indicators measure the extent to which infants born to HIV-positive women (exposed infants)
receive virologic testing to determine their HIV status within the first 12 months of life.
4.4.1 Data Management Systems for the PMTCT – EID Indicators

The DMS for assessing the PMTCT – EID indicators showed that the indicators were well understood,
and the data collection methodology was efficient. The data set for these indicators tended not to
be complete due to the time lapse between specimen collection and receipt of HIV test results.
However, on the whole, the DMS for the indicators was rated as Acceptable.
4.4.2 Validation of Reported PMTCT – EID Indicators Data

The Data Validation Rating for the two PMTCT – EID indicators was within the Acceptable range as
shown in Table 13. Even when viewed from the volume-of-data perspective, the rating remains the
same. One notable weakness that affected the validity of the data for HIV-positive infants was the
failure to relate a positive second PCR test to the first PCR result. This tended to result in over
reporting of HIV-positive infants.
Table 13: Data Validation Results for the PMTCT – EID Indicators at the Selected Sites
Exposed Infants who Tested HIV
Exposed Infants Tested Positive
Implementing Actual Actual
Partner Health Facility Reported Count Variation Reported Count Variation
Sustain Arua RRH 79 63 + 25.4% 0 0 0%
Sustain Gulu RRH 83 85 - 2.4 % 3 3 0%
Sustain Lira RRH 139 141 - 1.4% 7 7 0%
Sustain Soroti RRH 44 30 + 46.7% 1 0 -
Sustain Mbale RRH 48 60 - 20% 1 1 0%
Sustain Jinja RRH 79 90 - 12.2% 12 11 + 9.1%
Sustain Kawolo Hospital 62 62 0% 3 2 + 50%
Sustain Mubende RRH 88 98 - 10.2% 2 1 + 100%
Mildmay Kyabadaza HC 3 2 2 0% 0 0 0%
Mildmay Kanoni HC 3 27 31 - 12.9% 0 0 0%
Mildmay Buwama HC 3 41 31 + 32.3% 3 0 0%
Mildmay Lwebitakuli HC 3 12 11 + 9.1% 0 0 0%
Mildmay Entebbe Hospital 121 112 + 8.0% 8 4 + 100%
Walter Reed Kayunga Hospital 43 44 - 2.3% 2 2 0%
Walter Reed Kangulumira HC 4 25 25 0% 1 1 0%
Walter Reed Mukono T/C HC 4 73 75 - 2.7% 0 1 - 100%
Walter Reed Kojja HC 4 25 24 + 4.2% 2 2 0%
Walter Reed Kabanga HC 3 3 7 - 57.1% 0 0 0%
Exposed Infants who Tested HIV
Exposed Infants Tested Positive
Implementing Actual Actual
Partner Health Facility Reported Count Variation Reported Count Variation
Walter Reed Kkoome HC 3 23 21 + 9.5% 0 0 0%
4.4.3 Overall Quality of PMTCT – EID Data

Both the DMS Rating and the Data Validation Rating for the PMTCT – EID indicators are Acceptable.
Therefore, the overall Data Quality Rating is Acceptable as shown in Table 14.
Table 14: Overall Quality Rating for PMTCT – EID Data

Data Validation Rating – Data Validation Rating – Overall
Indicator DMS Based on # of Service Based on Volume of Quality
Component Rating Outlets Data Rating
Exposed Acceptable (Data at 58% Acceptable (60% of EID
Infants of facilities rated data rated
Tested Acceptable Adequate/Acceptable) Adequate/Acceptable) Acceptable
Exposed
Infants who Acceptable (Data at 74% Adequate (79% of EID
Tested HIV of facilities rated data rated
Positive Acceptable Adequate/Acceptable) Adequate/Acceptable) Acceptable
4.5 Voluntary Medical Male Circumcision Indicator

Voluntary medical male circumcision (VMMC) is a surgical procedure that involves the removal of
the male prepuce (penile foreskin) by a trained health professional. The name of the procedure
differentiates it from other forms of circumcisions which are traditionally performed for religious,
ritual, or cultural reasons.
VMMC is an HIV risk-reduction biomedical strategy that has shown efficacy and was approved by the
World Health Organization following results from randomized controlled clinical trials conducted in
the sub-Saharan African countries of Uganda, Kenya, and South Africa between 2005 and 2007.
These studies found that if male circumcision is done well, the procedure has the potential for
reducing the risk of men acquiring HIV from their infected female partners. Since then, Uganda has
adopted a national MMC policy that is currently being implemented at various health facilities by
some projects drawing support from PEPFAR.
4.5.1 Data Management Systems for the VMMC Indicator

Over the years, primary tools for data capture have gone through a transition from only capturing
individuals who have received a circumcision to capturing the whole VMMC package including HIV
counseling and testing (HCT), follow-up, and adverse events. In addition to MMC registers, sites have
client forms such as pre-operative assessment, surgical consent, and client follow-up. The data
collection and compilation tools adequately captured unique individual service beneficiaries,
minimized the potential for transcription errors, had in-built data quality checks, and were
supported by visible SOPs in most of the sampled facilities. The DMS for assessing the indicator was,
therefore, judged to be Acceptable.
4.5.2 Validation of Reported VMMC Data

The team validated the Q3 data generated from April 1–June 30, 2016, for each of the sampled
service outlets. The data validation results at VMMC service outlet are summarized in Table 15.
Table 15: Data Validation Results for the Selected VMMC Sites
FY 2016 Q3
Reported Health Actual
Variation
Implementing MMC Facility Joint Count
SUSTAIN Gulu RRH 374 273 373 + 0.3%
SUSTAIN Lira RRH 763 763 779 - 2.1%
SUSTAIN Jinja RRH 661 661 658 - 0.5%
Mildmay Kyabadaza HC 3 228 228 No Records N/A
Mildmay Kanoni HC 3 1,186 1,186 No Records N/A
Walter Reed Kayunga Hospital 104 104 105 - 1.0%
Walter Reed Kangulumira HC 4 51 51 51 0%
Walter Reed Mukono T/C HC 4 143 177 131 + 9.2%
Walter Reed Kojja HC 4 98 96 95 + 3.2%
Walter Reed Kabanga HC 3 82 82 83 - 1.2%
Walter Reed Kkoome HC 3 698 698 694 + 0.6%
At the two Mildmay sites where there were no records for validation, Rakai Health Sciences project
had conducted VMMC camps in May and June of 2016, and had left with all the registers. Other than
those two, the data validation was within Adequate or Acceptable limits at the remaining sites. The
overall Data Validation Rating was therefore Adequate.
4.5.2 Overall Quality of VMMC Data

The missing primary data at the two Mildmay sites notwithstanding, the DMS and the validity of the
data at the remaining service outlets were of good quality, and the overall quality of VMMC data for
the sampled sites was deemed to be Adequate as shown in Table 16.
Table 16: Overall Quality Rating for VMMC Data

Data Validation Rating – Based Data Validation Rating – Overall Quality
DMS Rating on # of Service Outlets Based on Volume of Data Rating
Adequate (Data at 100% of Acceptable (68% of VMMC
facilities rated data rated
Acceptable Adequate/Acceptable) Adequate/Acceptable) Adequate
4.6 Sexual Prevention – Priority Populations Indicator

Individual and small-group-level prevention interventions have been shown to be effective in
reducing HIV-transmission-risk behavior when delivered with emphasis on effective interpersonal
communication strategies. This indicator shows trends in the reach and depth of a standardized HIV
prevention intervention that includes the specified minimum components. Activities counted under
this indicator focus on promoting safer sexual behaviors and uptake of services for the targeted
priority populations.
4.6.1 Data Management Systems for the Priority Populations Indicator
Sexual prevention indicators have undergone significant changes over the past 3 years or so. The
current priority populations indicator and its predecessor are summarized below:
 Current Indicator: Number of individuals from priority populations who completed a
standardized HIV prevention program, including the specified minimum components
 Predecessor Indicator (P8.1.D): Number of targeted population reached with individual and/or
small-group-level preventive interventions that are backed by evidence and/or meet the
minimum standards required
In general, STAR-EC and Mildmay used a clinical facility approach, while Walter Reed deployed
community based volunteers that provided health education on HIV prevention. The discussions
held with the primary implementers of these sexual prevention interventions pointed to the
following challenges:
 Defining Priority Populations: In spite of the national level PEPFAR guidance, there was general
lack of clarity as to the targeted priority populations. There was a general tendency to confuse
priority populations with key populations, and include old category most-at-risk populations
such as boda boda riders in the priority populations.
 Standardized HIV Prevention Program: This requires that an activity or a set of activities be
designed for a specific priority population for purposes of reducing HIV transmission, and
implemented the same way each time. This was difficult to find in any of the implementing sites.
 Tracking and Reporting Intervention Elements: There were no systems in place to document and
track the various elements of the intervention, partly because they were ill-defined in the first
place.
As a result of the above challenges, the data collection methods were generally inadequate. In the
same vein, procedures for documenting and capturing unique individual priority population
beneficiaries were not in place, and there were insufficient provisions for conducting data quality
checks. In summary, the DMS Rating for the indicator was Inadequate.
4.6.2 Validation of Reported Priority Populations Indicator Data

Apart from the Walter Reed community sites where the volunteers used special forms for data
collection for the health education beneficiaries and entered data into the computer at the program
level, the other selected partners had clinical records of HCT that could not be attributed to specific
priority populations.
Table 17 clearly shows the difficulties encountered in trying to validate the reported priority
population data for the SAPR 2016. Only at four Walter Reed sites was the variation between the
joint site count and reported output within acceptable limits. At 38% of the sites, there was no
primary data to use for validation, and 43% of sites over reported the data compared to the
available primary data. The Data Validation Rating for the indicator is Inadequate.
Table 17: Data Validation Results for the Selected Priority Populations Support Sites
FY 2016 Q3
Implementing Reported Actual
Partner Community Site Output Count Variation
Mildmay Najja S/County 347 0 —
Mildmay Ngogwe S/County 214 0 —
Mildmay Kyegonza S/County 795 85 + 835%
FY 2016 Q3
Mildmay Kira Town Council 151 0 —
Mildmay Kalungi S/County 482 13 + 3,608%
Mildmay Lwampanga S/C 527 0 —
Mildmay Nakasongola T/C 308 0 —
Walter Reed Kayunga T/Council 4,278 4,142 + 3.3%
Walter Reed Nazigo S/County 143 143 0%
Walter Reed Ntenjeru S/County 157 138 + 13.8%
Walter Reed Kkoome Island S/C 335 335 0%
Walter Reed Goma Division 96 94 + 2.1%
STAR-EC Bugiri Town Council 4,171 264 + 1,480%
STAR-EC Bulidha S/County 1,548 0 —
STAR-EC Nankoma S/County 2,093 0 —
STAR-EC Iganga T/C Central Division 1,901 0 —
Iganga T/C Northern
STAR-EC 1,278 33 + 3,773%
Division
STAR-EC Jagusi S/County 3,739 2,900 + 28.9%
STAR-EC Kityerera S/county 1,620 153 + 959%
STAR-EC Banda S/County 1,231 65 + 1,794%
STAR-EC Sigulu Island S/County 9,805 40 + 24,413%
4.6.3 Overall Quality of Priority Populations Data

The reported data pertaining to sexual prevention services provided to priority populations was
found to be Inadequate. This is supported by the DMS and Data Validation Ratings shown in Table 18.
Table 18: Overall Quality Rating for Priority Populations Indicator Data
Data Validation Rating – Data Validation Rating – Overall Quality

DMS Rating Based on # of Service Outlets Based on Volume of Data Rating
Inadequate (Data at 19% of Inadequate (14% of Priority
service outlets rated Populations data rated
Acceptable Adequate/Acceptable) Adequate/Acceptable) Inadequate
As a matter of urgency, the national and PEPFAR HIV prevention Technical Working Groups need to
develop a common indicator definition and data collection tools to help service providers harmonize
performance in this area of sexual HIV prevention.
4.7 Sexual Prevention – Key Populations Indicator

Individual and small-group-level prevention interventions have been shown to be effective in
reducing HIV transmission risk behavior when delivered with emphasis on effective interpersonal
communication strategies. This indicator shows trends in the reach and depth of a standardized HIV
prevention intervention that includes the specified minimum components for key populations.
Activities counted under this indicator focus on promoting safer sexual behaviors and uptake of
services for the targeted key populations.
It is important to know how many people complete an intervention in order to monitor how well
programs are reaching the intended population with HIV sexual prevention programming.
4.7.1 Data Management Systems for Key Populations Indicator

The DMS for assessing the key populations indicator was in the same Inadequate category as for
priority populations. The majority of the community service outlets did not have proper data
collection methods, they were not able to document and report unique individual service
beneficiaries, and had no data quality checks.
4.7.2 Validation of Reported Key Populations Indicator Data

As shown in Table 19, 10 out of the 17 sampled sites (59%) had no primary data to use for validation,
three sites (18%) had accurately reported data, while the remaining 23% of sites had over or under
reported the data compared to the available primary data. The Data Validation Rating, therefore,
falls in the Inadequate category.
Table 19: Data Validation Results for the Selected Key Populations Support Sites
FY 2016
Q1and Q2
Mildmay Najja S/County 91 0 —
Mildmay Ngogwe S/County 93 0 —
Mildmay Kyegonza S/County 19 0 —
Mildmay Kira Town Council 282 0 —
Mildmay Kalungi S/County 33 0 —
Mildmay Lwampanga S/C 75 0 —
Mildmay Nakasongola T/C 152 0 —
Walter Reed Kayunga T/Council 1 1 0%
Walter Reed Ntenjeru S/County 48 48 0%
Walter Reed Kkoome Island S/C 271 239 + 13.4%
Walter Reed Goma Division 77 77 0%
STAR-EC Bugiri Town Council 213 77 + 177%
STAR-EC Bulidha S/County 62 0 —
STAR-EC Nankoma S/County 55 0 —
STAR-EC Iganga T/C Northern Division 34 141 - 76%
STAR-EC Jagusi S/County 105 78 + 35%

STAR-EC Kityerera S/county 12 0 —
STAR-EC Banda S/County 69 0 —
FY 2016
Q1and Q2
STAR-EC Sigulu Island S/County 283 0 —
4.7.3 Overall Quality of Key Populations Data

Overall, the DMS for monitoring Key Populations interventions was found to be Inadequate, and
similarly, the quality of data reported for Key Populations was in the Inadequate category as shown
in Table 20.
Table 20: Overall Quality Rating for Key Populations Indicator Data
Data Validation Rating – Data Validation Rating – Overall Quality

DMS Rating Based on # of Service Outlets Based on Volume of Data Rating
Inadequate (Data at 16% of Inadequate (6% of Key
service outlets rated Populations data rated
Inadequate Adequate/Acceptable) Adequate/Acceptable) Inadequate
4.8 Post-GBV Care Indicator

In the PEPFAR context, GBV is defined as any form of violence that is directed at an individual based
on his or her biological sex, gender identity or expression, or his or her perceived adherence to
socially defined expectations of what it means to be a man or woman, boy or girl. It includes
physical, sexual, and psychological abuse; threats; coercion; arbitrary deprivation of liberty; and
economic deprivation, whether occurring in public or private life. The indicator measures delivery of
a basic package of post-GBV care services.
4.8.1 Data Management Systems for the Post-GBV Care Indicator

The GBV pilot indicators were introduced in FY 2012, and have since undergone significant changes.
The Post-GBV Care indicator is relatively new and many of the IPs did not have robust management
systems to handle the indicator data. On the whole, the following observations applied across the
board:
 The level of understanding of the indicator was rather low. Only a few health workers had been
taken for an off-site GBV training, and, in many cases, these workers had, in the course of time,
been transferred elsewhere.
 Most PREFA sites had a GBV register that had hardly been used due to insufficient knowledge on
what to do. Interestingly, at some sites, Walter Reed had also introduced a GBV register in
addition to the one previously provided by PREFA.
 In the PREFA-supported sites, the most common source of data was the Out-patient Department
(OPD) register, where cases of assault were the primary sources for GBV services data. However,
it was rare to find clear documentation showing that the assault was due to GBV. In fact, a
breakdown of cases of injuries due to GBV in the HMIS 105 showed that there were more male
than female victims of GBV.
 In the Walter Reed-supported sites, police forms for rape and assault were the main source of
data, not taking into consideration whether any services had been provided to the referred
victims.
 The health information assistants at the facilities reported GBV data based on the HMIS 105
requirements of:
 Item 22: Sexually Transmitted Infections due to SGBV
 Item 38: Abortions due to GBV
 Item 69: Injuries due to GBV
For purposes of PEPFAR reporting, it was virtually impossible to identify the unique individual
recipients of the HMIS 105 reported cases. The DMS Rating for assessing the indicator, was,
therefore, Inadequate.
4.8.2 Validation of Reported Post-GBV Care Indicator Data

Table 21 shows an attempt to validate the Post-GBV Care data that was reported for the APR 2015.
In a number of cases, no data were available because the service providers made it very clear that
they provided no GBV care services during the reporting period. In other cases, the health
information assistants admitted counting all assault cases in the OPD register, with or without being
related to GBV. Clearly, the reported data were not for the Post-GBV Care indicator. It was therefore
not possible to validate the reported data. However, where data are indicated under the actual joint
count on Table 21, if a facility indicated its primary source of data, the MEEPP team conducted a
count to ascertain the accuracy of reporting. Even then, as Table 21 shows, there was only one
facility that accurately reported the data, albeit for the wrong indicator.
Table 21: Data Validation Results for Selected Post-GBV Care Sites
APR 2015 Actual

Implementing Reported Joint
Partner Community Facility Output Count Variation
PREFA Buikwe Town Council 38 0 —
PREFA Nkokonjeru T/Council 135 0 —
PREFA Nyenga Town Council 49 0 —
PREFA Kalungi Sub-county 42 12 + 250%
PREFA Lwampanga Sub-county 70 0 —
PREFA Nakitoma Sub-county 52 53 - 1.9%
Walter Reed Kayunga Town Council 359 403 - 10.9%
Walter Reed Nazigo Sub-county 84 54 + 56%
Walter Reed Ntenjeru Sub-county 139 166 - 16%
Walter Reed Kkoome Island Sub-County 138 72 + 92%
TASO Gulu Laroo Division 588 0 —
TASO Soroti Northern Division 218 0 —
TASO Mbale Northern Division 157 637 - 75%
TASO Entebbe Entebbe Division A 105 0 —
At TASO Entebbe, the GBV data, having been extracted from HIV-positive clients’ files on chronic
care at the TASO center, is kept electronically. There was no specific register at the center for GBV,
nor was there an HIV-related register with a column for noting GBV-related events.
4.8.3 Overall Quality of Post-GBV Care Data
Overall, the quality of Post-GBV Care data for the APR 2015 reporting period was Inadequate, largely
because the reported data were for different indicators (Table 22). The main contributing factors
were low levels of understanding the indicator and lack of tools for collecting the relevant data.
There is a notable conflict between the national and PEPFAR indicator definition and data collection
instruments, and this needs to be addressed.
Table 22: Overall Quality Rating for Post-GBV Services Data
DMS Data Validation Rating – Data Validation Rating – Overall Quality

Rating Based on # of Service Outlets Based on Volume of Data Rating
Inadequate (Data at 7% of Inadequate (2% of Post-GBV
service outlets rated data rated
Acceptable Adequate/Acceptable) Adequate/Acceptable) Inadequate
4.9 HRH – Pre-Service Training Indicator

Human resources are the most important resources in the delivery of health services. Baylor
Uganda, from 2010 to 2016, received funding from CDC/PEPFAR for the Support and Improve
National Training Systems (SAINTS) program, in order to contribute to addressing shortages of
critical staff in the health sector. In conjunction with the Uganda Ministry of Health and Ministry of
Education and Sports, the program focus was mainly on laboratory personnel, health tutors, and
enrolled midwives. The output targeted in this DQA were the supported health workers who
graduated from the affiliated institutions and were available to be taken up into the health sector
workforce between October 2014 and September 2015.
4.9.1 Data Management Systems for the HRH Pre-Service Training Indicator
Only one IP, Baylor Uganda, contributed to the indicator data for this DQA exercise. The program put
in place an electronic database system that tracks each trainee beneficiary right from the time of
enrollment up to graduation. The few that were either discontinued, had to repeat, or to retake
exams, were appropriately documented. The major bottleneck was the timeliness of information
updates from the training institutions into the database. At the time the APR 2015 report was
compiled, some of the training schools had not provided information on the course completion
status of their trainees. This weakness notwithstanding, the DMS for assessing the indicator was
judged to be Acceptable.
4.9.2 Validation of Reported HRH Pre-Service Training Indicator Data

The validation of HRH – Pre-Service Training data was done at the individual cadre level (see Table
23), and then at the aggregate level.
Table 23: Data Validation Results for HRH Pre-Service Training
New Health Workers who Graduated from a Training Institution or Program

Midwives Laboratory Professionals Others (Health Tutors)
Actual Actual Actual
Reported Count Variation Reported Count Variation Reported Count Variation
316 755 - 58% 526 294 + 79% 17 16 + 6.3%
The validation picture indicates that midwives were under reported, and laboratory professionals
were over reported. However, a quick look at the targeted outputs for the two cadres for the
reporting period strongly points to the possibility that the reported data for midwives and lab
professionals were transposed.
Overall, the combined reported output of new health workers that graduated from training
institutions during the reporting period was 859 versus 1,065 that were actually counted. This
represents an under reporting of 19.3%. This could partly be explained by the fact that, at the time
of reporting, some institutions had not submitted results of the candidates, and so they could not be
counted as having completed their training. Unfortunately, the data set used for reporting at the
APR 2015 was not preserved as a separate entity. The validation of the existing dataset places it in
the Inadequate category.
4.9.3 Overall Quality of HRH Pre-Service Training Data

The overall quality of HRH – Pre-Service Training data reported by Baylor Uganda for the APR 2015
was Inadequate.
Table 24: Overall Quality Rating for Pre-Service Training Data
Data Validation Overall Quality

Indicator DMS Rating Rating Rating
HRH - Pre-service Training Adequate Inadequate Inadequate
5 CONCLUSION
The DQA exercise focused on multiple indicators in the clinical and community-based HIV service
delivery areas. Overall, the quality of data for the majority of the assessed PEPFAR indicators was
inadequate. This is especially so in regard to the sexual prevention indicators. In the spirit of data
quality improvement, the Strategic Information Technical Working Group needs to focus on the data
quality weaknesses identified in this exercise and find solutions to them. One of the proposed
solutions is the adoption of Electronic Health Records. These will ease the burden on the insufficient
human resources available for data management, and will also reduce human errors that negatively
impact the quality of data. However, all these efforts will only bear fruit when all the critical service
providers have internalized the definitions and interpretations of the respective indicators.
Annex 1: Sites, Partners, and Schedule of Field Visits
DQA – 2016: Proposed dates for URC/SUSTAIN Sites
District Facility DQA Dates Team

Arua Arua RRH 26th and 27th September Team 1
Gulu Gulu RRH 29th and 30th September Team 1
Lira Lira RRH 3rd and 4th October Team 1
Soroti Soroti RRH 5th and 6th October Team 1
Mubende Mubende RRH 26th and 27th September Team 2
Mbale Mbale RRH 29th and 30th September Team 2
Jinja Jinja RRH 3rd and 4th October Team 2
Buikwe Kawolo Hospital 5th and 6th October Team 2
DQA – 2016: Proposed dates for Mildmay Sites
District Sub-county Health Facility Dates

Sembabule Lwebitakuli Lwebitakuli HC 3 (Govt) 26th September
Mpigi Buwama S/County Buwama HC 3 27th September
Gomba Kanoni Town Council Kanoni HC 3 28th September
Gomba Kyegonza 29th September
Butambala Budde S/County Kyabadaza HC 3 30th September
Kalungi S-County 3rd October
Lwampanga S/C 3rd October
Nakasongola Nakasongola T/C 3rd October
Najja S/C 4th October
Buikwe Ngogwe S/C 4th October
Wakiso Entebbe Division A Entebbe Hospital 5th October
Wakiso Kira Town Council 6th October
DQA – 2016: Proposed dates for Walter Reed Sites

Kayunga Kayunga T/Council Kayunga Hospital 26th September
Kayunga T/Council 27th September
Kangulumira Kangulumira HC 4 28th September
Nazigo S/County 28th September
Mukono Mukono Municipality Mukono HC 4 (Govt) 29th September
Ntenjeru S/County Kojja HC 4 30th September
Kkoome Island S/County Koome HC 3 3rd October
Kkoome Island S/County 4th October
Ntenjeru S/County Kabanga HC 3 5th October
Ntenjeru S/County 6th October
Goma Division 7th October
DQA – 2016: Proposed dates for STAR-EC Sites
District Sub-county Dates

MAYUGE Kityerera 26th September
Jagusi 26th September
IGANGA T/Council – Central Division 27th September
T/Council – Northern Division 27th September
BUGIRI Bugiri Town Council 28th September
Bulidha 28th September
Nankoma 28th September
NAMAYINGO Banda 29th September
Sigulu Island 30th September
DQA – 2016: Proposed dates for PREFA Sites
District Sub-county Dates

BUIKWE Buikwe Town Council 3rd October
Nkokonjeru Town Council 3rd October
Nyenga Town Council 3rd October
NAKASONGOLA Kalungi 4th October
Lwampanga 4th October
Nakitoma 4th October
DQA – 2016: Proposed dates for TASO GBV Sites
District Sub-county Dates Comments

Laroo Will be conducted by the team covering GULU RRH
th
GULU Division 30 September under SUSTAIN
Northern Will be conducted by the team covering MBALE
MBALE Division 30th September RRH under SUSTAIN
Entebbe Will be conducted by the team covering ENTEBBE
ENTEBBE Division A 5th October Hospital under Mildmay
District Sub-county Dates Comments
Northern Will be conducted by the team covering SOROTI
SOROTI Division 6th October RRH under SUSTAIN
DQA – 2016: Proposed dates for Baylor HSS – Pre Service Data
Place Date
Baylor Capacity Building Offices 27th October 2016
Annex 2: Data Management System Assessment Tool – PEPFAR Multiple Indicator DQA, 2016
Implementing Partner District S/County
Facility Name Level Date
Assessment Team
Data Quality Criteria Response Options Indicator 1 Indicator 2 Indicator 3 Indicator 4

1. Understanding the Indicator High/Medium/Low
2. Adequacy of data collection

methodology Adequate/Not Adequate
3. Potential for transcription Errors High/Low
4. Data Completeness Complete/Incomplete
5. Procedures for recording and

reporting Unique Individuals Adequate/Not Adequate
6. Documentation of SOPs for data

handling YES/NO
7. Adequacy of Data Quality Checks Adequate/Not Adequate
Data Quality Criteria Response Options Indicator 1 Indicator 2 Indicator 3 Indicator 4
8. Sufficiency of Human Resource for
data handling Sufficient/Insufficient
9. Timeliness of Report Timely/Delayed
10. Level of Data Utilization High/Low
Annex 3: Indicator Data Management System Rating based on Five Critical Assessment Criteria
Converted Score for the Critical Data Management System Criteria
Level of
Understanding of Adequate Data Procedures for Adequate
the Indicator Collection Data Capture of Unique Data Quality Average
Indicator (High) Methods Completeness Individuals Checks DMS Score DMS Rating*
ART Retention – 12 Months 67 87 60 100 47 72 Acceptable
PMTCT – Known HIV Status 47 74 53 74 21 54 Acceptable
PMTCT – ARV Prophylaxis 47 68 42 68 26 50 Acceptable

PMTCT – EID 63 88 56 88 56 70 Acceptable
VMMC – Number of Males
Circumcised 100 100 100 89 89 96 Adequate
Sexual Prevention – Priority
Populations 56 0 31 0 0 17 Inadequate
Sexual Prevention – Key
Populations 69 25 25 0 0 24 Inadequate
Post-GBV Care 18 9 9 9 0 9 Inadequate
* DMS Ratings:
Adequate: Average score 75 and above
Acceptable: Average score between 50 and 74
Inadequate: Average score below 50
Annex 4: Overall Status of Data Management Systems for ART Retention Indicators at the Sampled Sites
DMS Assessment Criteria – Percentage of service outlets that exhibited the various measures of the assessment criteria
Potential for Procedures for SOPs for
Understanding Data Collection Transcription Data Capture of Unique Data Data Quality Sufficient HR for
the Indicator Methods Errors Completeness Individuals Management Checks Data Handling
High – 67% Adequate – 87% High – 40% Complete – 60% Adequate – 100% YES – 80% Adequate – 47% YES – 67%
Medium – 33% Inadequate – 13% Low – 60% Incomplete – 40% Inadequate – 0% NO – 20% Inadequate – 53% NO – 33%
Low – 0%
Annex 5: Overall Status of Data Management Systems for PMTCT – Known Status Indicator at Sampled
Sites
Potential for Procedures for SOPs for Sufficient HR
Understanding Data Collection Transcription Data Capture of Unique Data Data Quality for Data
the Indicator Methods Errors Completeness Individuals Management Checks Handling
Low – 6%
Annex 6: Overall Status of Data Management Systems for PMTCT – ARV Prophylaxis Indicator at the
Sampled Sites
Low – 6%
Annex 7: Overall Status of Data Management Systems for PMTCT – EID Indicators at the Sampled Sites
Low – 6%
Annex 8: Overall Status of Data Management Systems for VMMC Indicator at the Sampled Sites
Low – 0%
Annex 9: Overall Status of Data Management Systems for Priority Populations Indicator at the Sampled
Sites
Potential for Procedures for Sufficient HR
Understanding Data Collection Transcription Data Capture of Unique SOPs for Data Data Quality for Data
Low – 13%
Annex 10: Overall Status of Data Management Systems for Key Populations Indicator at the Sampled
Sites
High – 69% Adequate – 25% N/A Complete – 25% Adequate – 0% YES – 0% Adequate – 0% YES – 100%
Medium – 25% Inadequate – 75% N/A Incomplete – 75% Inadequate – 100% NO – 100% Inadequate – 100% NO – 0%
Low – 6%
Annex 11: Overall Status of Data Management Systems for Post-GBV Care Indicator at the Sampled Sites
Procedures for
Potential for Capture of
Understanding Data Collection Transcription Data Unique SOPs for Data Data Quality Sufficient HR for
the Indicator Methods Errors Completeness Individuals Management Checks Data Handling
Low – 82%
Annex 12: Data Validation Tools – PEPFAR Multiple Indicator DQA, 2016
UGANDA PEPFAR Data Validation: Facility Level
Voluntary Medical Male Circumcision (VMMC) - Data Validation Tool
Implementing Partner: Interviewer Initials: Date:
District: Sub-County:
Facility Level (Hospital, HC IV, HC III, Community based, Other):
Facility Name:
Instructions:
Enter value for each indicator based on a count of the number of cases in the appropriate register.
Total the columns in the "Total" column and enter the reported total from the monthly summary.
2016 % Variation
Reported (Joint COUNT-REPORTED)
Number of: APRIL MAY JUNE Total Total /Joint COUNT
Joint Joint Joint Joint
Count Sum Count Sum Count Sum Count Sum
Males circumcised as part
of VMMC Column 8 0
Comments:
PMTCT Data Validation Tool
Facility Name:
Instructions:
Total the columns in the "Total" column and enter the reported total from the monthly summary.
2015 2016
Number of: OCT NOV DEC JAN FEB MARCH TOTAL
% Variation
(Joint COUNT-
Joint Joint Joint Joint Joint Joint Joint Reported REPORTED) /Joint
Count Sum Count Sum Count Sum Count Sum Count Sum Count Sum Count Sum Total COUNT
Pregnant women
Provided ARV
prophylaxis 0 0 0 0 0 0 0 0 0 0 0 0 0 0
A18: HIV +ve pregnant Column
women already on ART 15,
before ANC 1 ARTK 0 0
2015 2016
Number of: OCT NOV DEC JAN FEB MARCH TOTAL
% Variation
(Joint COUNT-
Joint Joint Joint Joint Joint Joint Joint Reported REPORTED) /Joint
Count Sum Count Sum Count Sum Count Sum Count Sum Count Sum Count Sum Total COUNT
A16: HIV +ve pregnant
women initiated on ART Column
for PMTCT in ANC 15, ART 0 0
M7: HIV +ve women
initiating on ART in Column
Maternity 17, ART 0 0
P5: HIV +ve women
initiating on ART in PNC 0 0
Comments:
2016
Total
APRIL MAY JUNE
% Variation
Reported (Joint COUNT-REPORTED) /Joint
Number of: Joint Count Sum Joint Count Sum Joint Count Sum Joint Count Sum Total COUNT
Pregnant women with
Known HIV Status 0 0 0 0 0 0 0 0 0
A17: Pregnant women
who knew their HIV Column 13,
status before ANC 1 TRK, TRRK 0 0
A13: Pregnant women
newly tested for HIV this Column 13,
pregnancy (TR&TRR) TR, TRR 0 0
2016
Total
APRIL MAY JUNE
% Variation
Reported (Joint COUNT-REPORTED) /Joint
Number of: Joint Count Sum Joint Count Sum Joint Count Sum Joint Count Sum Total COUNT
M5: Women tested for
HIV in labor for the 1st Column 16,
time this pregnancy TR, TRR 0 0
P3: Breast feeding
Women tested for HIV in Column 13,
PNC for the 1st time TR, TRR 0 0
Comments:
PMTCT - EID Data Validation Tool
Facility Name:
Instructions:
Total the columns in the “Total” column and enter the reported total from the monthly summary.
2016
Number of: APRIL MAY JUNE Total % Variation
(Joint COUNT-
Joint Joint Joint Reported REPORTED)/Joint
Babies born Nov 2014 onwards Joint Count Sum Count Sum Count Sum Count Sum Total COUNT
Exposed Infants Tested (1st DNA PCR) 1st PCR test, Tick 0 0
Exposed Infants that Tested HIV positive 0 0 0 0 0 0 0 0
Exposed Infants that Tested HIV positive, 1st
PCR, <18 months Column 18, Positive
Exposed Infants that Tested HIV positive, 2nd
PCR, < 18 months Column 24, Positive
Comments:
Antiretroviral Services (ARV Services) - 12 Months ART Retention - as of end of September 2015
Facility Name:
Instructions:
Enter value for each indicator based on a count or as reported in the appropriate register.
Number of Cohort Alive

Net Current Cohort before and on RX after 12
(Total New, plus Transfer In, months: that Started on
Started Minus transfer out or (A+B- ART in July - Sept 2014 and Percentage of
on ART Transfer Transfer C), Cohort (Net) Before; evaluated in July - Sept Cohort alive and on
(A) in (B) out ( C) Started July - Sept 2014) 2015) ART
Record % Variation
Months/year (Joint COUNT-
when cohort Joint Joint Joint Joint Joint Joint REPORTED)/Joint
started Count Count Count Count Reported figure Count Reported figure Count Reported COUNT
Jul-14 0
Aug-14 0
Number of Adults and
Sep-14 0
Children in the cohort of
July-Sept 2014 Total in QTR 0 0 0 0 0 0 0
Comments:

Data Quality Assessment Report 2016 FINAL

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Data Quality Assessment Report 2016 FINAL

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Quality of HIV Program Data Reported by Health Facilities and

Implementing Partners in Uganda

Monitoring and Evaluation of Emergency Plan Progress – Phase II

Social & Scientific Systems, Inc.

Table 1. Data Validation Ratings of Reported Data

Table 2. Overall Findings of the DQA

1. Antiretroviral Therapy (ART) Retention – 12 months

Specifically, this exercise was meant to:

3.1 Selection of DQA Data Sets

Table 3: Data Sets Selected for the DQA

3.2 Sampling the Service Outlets

3.3 Data Collection

3.4 Data Analysis

Table 5: Data Management System Rating Criteria for Each Indicator

DMS Rating Rating Criteria

Inadequate Average score below 50

3.6 Validation of Reported Data

Table 4: Site-Level Data Validation Rating Criteria

Text Box 1: Indicator Level Data Validation Rating Criteria

3.7 Overall Data Quality Assessment for Each Indicator

Table 6: Overall Data Quality Rating Criteria

4.1 ART Retention Indicators

4.1.1 Data Management Systems for the ART Retention Indicators

4.1.2 Validation of Reported ART Retention Data

4.1.3 Overall Quality of ART Retention Data

Table 8: Overall Quality Rating for ART Retention Data

Data Validation Rating – Data Validation Overall

4.2 PMTCT – Known Status Indicator

4.2.2 Validation of Reported PMTCT – Known Status Indicator Data

SUSTAIN Arua RRH 1,808 1,971 1,756 + 2.9%

Walter Reed Kkome HC 3 140 116 113 + 23.9%

4.2.3 Overall Quality of PMTCT – Known Status Data

4.3 PMTCT – ARV Prophylaxis Indicator

4.3.2 Validation of Reported PMTCT – ARV Prophylaxis Indicator Data

4.3.3 Overall Quality of PMTCT – ARV Prophylaxis Data

4.4.1 Data Management Systems for the PMTCT – EID Indicators

4.4.2 Validation of Reported PMTCT – EID Indicators Data

4.4.3 Overall Quality of PMTCT – EID Data

Table 14: Overall Quality Rating for PMTCT – EID Data

4.5 Voluntary Medical Male Circumcision Indicator

4.5.1 Data Management Systems for the VMMC Indicator

4.5.2 Validation of Reported VMMC Data

4.5.2 Overall Quality of VMMC Data

Table 16: Overall Quality Rating for VMMC Data

4.6 Sexual Prevention – Priority Populations Indicator

4.6.2 Validation of Reported Priority Populations Indicator Data

4.6.3 Overall Quality of Priority Populations Data

Data Validation Rating – Data Validation Rating – Overall Quality

4.7 Sexual Prevention – Key Populations Indicator

4.7.1 Data Management Systems for Key Populations Indicator

4.7.2 Validation of Reported Key Populations Indicator Data

STAR-EC Iganga T/C Northern Division 34 141 - 76%

STAR-EC Jagusi S/County 105 78 + 35%

4.7.3 Overall Quality of Key Populations Data

Data Validation Rating – Data Validation Rating – Overall Quality

4.8 Post-GBV Care Indicator

4.8.1 Data Management Systems for the Post-GBV Care Indicator

4.8.2 Validation of Reported Post-GBV Care Indicator Data

APR 2015 Actual

Table 22: Overall Quality Rating for Post-GBV Services Data

DMS Data Validation Rating – Data Validation Rating – Overall Quality

4.9 HRH – Pre-Service Training Indicator

4.9.2 Validation of Reported HRH Pre-Service Training Indicator Data

Table 23: Data Validation Results for HRH Pre-Service Training