USAID ASSIST Prject Cte d Ivire Cuntry Reprt FY17 Cperative Agreement Number: AID-OAA-A-12-00101 Perfrmance Perid: Octber 1, 2016 September 29, 2017 SEPTEMBER 2017 This annual cuntry reprt was prepared by University Research C., LLC fr review by the United States Agency fr Internatinal Develpment (USAID). The USAID Applying Science t Strengthen and Imprve Systems (ASSIST) Prject is made pssible by the generus supprt f the American peple thrugh USAID.
USAID ASSIST Prject Applying Science t Strengthen and Imprve Systems Côte d Ivire Cuntry Reprt FY17 Cperative Agreement Number AID-OAA-A-12-00101 Perfrmance Perid: Octber 1, 2016 - September 29, 2017 SEPTEMBER 2017 DISCLAIMER This cuntry reprt was authred by University Research C., LLC (URC). The views expressed d nt necessarily reflect the views f the United States Agency fr Internatinal Develpment r the United States Gvernment.
Acknwledgements This cuntry reprt was prepared by University Research C., LLC (URC) fr review by the United States Agency fr Internatinal Develpment (USAID) under the USAID Applying Science t Strengthen and Imprve Systems (ASSIST) Prject, which is funded by the American peple thrugh USAID s Bureau fr Glbal Health, Office f Health Systems. The prject is managed by URC under the terms f Cperative Agreement Number AID-OAA-A-12-00101. URC's glbal partners fr USAID ASSIST include: EnCmpass LLC; FHI 360; Harvard T. H. Chan Schl f Public Health; HEALTHQUAL Internatinal; Initiatives Inc.; Institute fr Healthcare Imprvement; Jhns Hpkins Center fr Cmmunicatin Prgrams; and WI-HER, LLC. Fr mre infrmatin n the wrk f the USAID ASSIST Prject, please visit www.usaidassist.rg r write assist-inf@urc-chs.cm. Recmmended citatin USAID Applying Science t Strengthen and Imprve Systems (ASSIST) Prject. 2017. Côte d Ivire Cuntry Reprt FY17. Published by the USAID ASSIST Prject. Chevy Chase, MD: University Research C., LLC (URC).
Table f Cntents List f Figures and Tables... i Abbreviatins... ii 1 INTRODUCTION... 1 2 PROGRAM OVERVIEW... 2 3 KEY ACTIVITIES, ACCOMPLISHMENTS, AND RESULTS... 3 Activity 1. Imprve the quality f HIV and AIDS care and treatment services... 3 Activity 2. Health systems strengthening... 14 4 IMPROVEMENT IN KEY INDICATORS... 16 5 SUSTAINABILITY AND INSTITUTIONALIZATION... 17 6 KNOWLEDGE MANAGEMENT PRODUCTS AND ACTIVITIES... 17 7 GENDER INTEGRATION... 18 List f Figures and Tables Figure 1. Percentage f ART client recrds with all items filled, 90 IP-supprted sites, 15 health regins, 30 districts (pilt sites: May 2015 August 2017; extensin sites: Mar 2016 August 2017)... 5 Figure 2. Percentage f recently diagnsed HIV-psitive clients enrlled in care, 90 IP-supprted sites, 15 health regins, 30 districts (pilt sites: May 2015 August 2017; extensin sites: Mar 2016 August 2017)... 6 Figure 3. Percentage f HIV-psitive clients alive and n ART, six mnths after starting treatment, 90 IPsupprted sites, 15 health regins, 30 districts (pilt sites: May 2015 August 2017; extensin sites: Mar 2016 August 2017)... 7 Figure 4. Percentage f HIV-expsed infants between 6 and 8 weeks initiated n Ctrimxazle tw mnths prir t cllectin f dried bld spts, 90 IP-supprted sites, 15 health regins, 30 districts (pilt sites: May 2015 August 2017; extensin sites: Mar 2016 August 2017)... 8 Figure 5. Percentage f client recrds with all items filled, 4 CHUs (Ccdy, Treichville, Ypugn, and Buake), Abidjan and Gbêke regins (Mar 2016 Aug 2017)... 9 Figure 6. Percentage f inpatient children (0-10 years) tested fr HIV, 4 CHUs (Ccdy, Treichville, Ypugn, and Buake (Mar 2016 Aug 2017)... 10 Figure 7: Percentage f pediatric inpatients (ages 0-10) tested fr HIV, Ccdy CHU vs 4 CHUs (Mar 2016- Aug 2017)... 11 Table 1: Dmain, imprvement bjectives, and indicatrs f the prpsed Phase II f the cllabrative. 13 Table 2: Imprvement indicatrs fr the 60 riginal PEPFAR IP-supprted sites... 16 Table 3: Imprvement indicatrs fr the 30 scale-up PEPFAR IP-supprted sites... 16 Table 4: Imprvement indicatrs fr 4 CHUs... 17 USAID ASSIST Cte d Ivire Cuntry Reprt FY17 i
Abbreviatins AIBEF AIDS ART ASSIST CAT CDC CHU CHR CSAS CSU DGS DMH EGPAF FANTA FY HAI HIV ICAP IP MOH NACS OVC PCR PDSA PEPFAR PLHIV PMI PNN PNLS PNOEV PSHP Q QI SEV-CI TA URC USAID Assciatin Ivirienne pur le Bien Etre Familial (Ivrian Assciatin f Family Welfare) Acquired immundeficiency syndrme Antiretrviral therapy USAID Applying Science t Strengthen and Imprve Systems Prject Centre Anti-Tuberculeux (Tuberculsis Treatment Center) U.S. Centers fr Disease Cntrl and Preventin Centre Hspitalier Universitaire / University Teaching Hspital Centre Hspitalier Reginal (Reginal Hspital Center) Chef de Service de l Actin Sanitaire (Head f Public Health Service) Centre de Santé Urbain (Urban Health Center) Directin Generale de la Santé (General Health Directrate) Directin Medecine Hspitalière et de Prximité (Directrate f Hspital Medicine) Elizabeth Glaser Pediatric AIDS Fundatin USAID Fd and Nutritin Technical Assistance Prject Fiscal year Health Alliance Internatinal Human immundeficiency virus Internatinal Center fr AIDS Care and Treatment Prgrams Implementing partner Ministry f Health (Ministère de la Santé et de l'hygiene Publique) Nutritin assessment, cunseling, and supprt Orphans and vulnerable children Plymerase chain reactin Plan-d-study-act U.S. President s Emergency Plan fr AIDS Relief Peple living with HIV Prtectin Maternelle et Infantile (Maternal and Child Prtectin) Prgramme Natinal de Nutritin (Natinal Nutritin Prgram) Natinal HIV and AIDS Care and Treatment Prgram Natinal Prgram fr Orphans and Vulnerable Children Private Sectr Health Prject Quarter Quality imprvement Santé Espir Vie Côte d ivire (Health Hpe Life) Technical assistance University Research C., LLC United States Agency fr Internatinal Develpment ii USAID ASSIST Cte d Ivire Reprt FY17
1 Intrductin Frm 2013 t 2017, the USAID Applying Science t Strengthen and Imprve Systems (ASSIST) Prject, with PEPFAR funding, wrked t build a quality imprvement (QI) apprach int the health system in Côte d Ivire. When ASSIST started, n infrastructure existed in the Ministry f Health and Public Hygiene (MOH) t rient r guide managers n quality imprvement, r t manage QI in the health system. Specifically, ASSIST wrked t: Prvide technical expertise t implementing partners (IPs) in the implementatin f their HIV and AIDS imprvement activities at PEPFAR-supprted facilities and establish a QI system in the fur University (teaching) hspitals; and Build the capacity f the General Health Directrate (DGS) within the newly established MOH QI unit [Directrate f Hspital Medicine (DMH)] t strengthen the capacity fr imprving care at the central level. USAID s instructin t ASSIST was t wrk abve-site while the PEPFAR clinical partners prvided direct supprt t health facilities. The rle f ASSIST was t prvide sufficient technical assistance (TA) t PEPFAR partners s that they culd supprt health facilities in prducing quality health services. In fiscal year (FY)16, PEPFAR defined three types f interventin districts in Côte d Ivire. These districts represented scale-up fr saturatin, scale-up, and maintenance. During the September 25, 2015 crdinatin meeting held at the Public Health Natinal Institute (INSP), it was decided that ASSIST wuld supprt cllabrative imprvement in the scale-up fr saturatin districts. Thus, ASSIST aligned with PEPFAR s directives the prject s apprach t imprving the quality f HIV and AIDS care and treatment services and implementing health systems strengthening activities. In FY17, ASSIST cntinued t develp these activities and supprt the scale-up f effective practices that cntribute t achieving the bjectives f 90-90-90 t ther sites. T d s, three pririty areas f interventin were identified: (1) Imprved quality f ART care and PMTCT services, (2) Health systems strengthening, and (3) Develpment f a strategic infrmatin system. The prject wrked with 109 (ut f 529) facilities in the cuntry, prviding technical assistance t implementing partners and 109 QI teams. The supprted sites included: 10 sites supprted by the Glbal Fund thrugh the Natinal HIV and AIDS Care and Treatment Prgram (PNLS); five private clinics supprted by the USAID-funded Private Sectr Health Prject managed by Abt Assciates; fur University Hspitals (Centre Hspitalier Universitaire, CHU): University Hspital f Ccdy, University Hspital f Treichville, University Hspital f Ypugn, and University Hspital f Buake; and 90 public health facilities supprted by six CDC/PEPFAR implementing partners (SEV-CI, ICAP, EGPAF, Ariel Glaser Fundatin, ACONDA, and HAI). Eleven f the 90 sites were als supprted by FHI 360 (FANTA) fr nutritin assessment, cunseling, and supprt (NACS). ASSIST wrked clsely with FANTA t help the 11 sites apply QI t NACS. The 90 sites included 30 extensin sites t which best practices develped in the initial 60 IP-supprted sites that received QI supprt frm ASSIST since 2014. USAID ASSIST Cte d Ivire Cuntry Reprt FY17 1
Scale f USAID ASSIST s Wrk in Côte d Ivire MOH, DMH, PNLS, 6 CDC/PEPFAR Implementing partners 2 USAID Technical partners 1 Glbal Fund partner (PNLS) 15 ut f 20 health regins 30 ut f 82 health districts 109 ut f 529 health facilities (30 interventin districts) 109 QI teams HIV/AIDS 15,745,741 (in 30 interventin districts) 25,236,000 ttal ppulatin 2 Prgram Overview What did we try t accmplish? At what scale? 1. Imprve the quality f HIV and AIDS care and treatment services Imprve timeliness, cntinuity, effectiveness, efficiency, Health regins: 15 ut f 20 and patient-centeredness f HIV and AIDS services Districts: 30 ut f 82 and their cnsistency with clinical guidelines thrugh 100 public health facilities (60+30 the imprvement cllabrative apprach new IP sites+ 4 CHUs and 10 MOH- Strengthen capacity f medical prviders t prvide supprted) in selected districts: 19% safe, timely, cntinuus, effective, and efficient medical (100 ut f 529) + 5 private clinics care =109 health facilities Imprve awareness n quality imprvement 11 ut f the 90 IP-supprted experiences cuntrywide sites are wrking n NACS Strengthen the health infrmatin system t supprt 4 University Hspitals (District develpment f evidence-based decisins n Abidjan Suth, East and Nrth; imprvement quality f medical care and Buake) Ensure equitable access t pririty best-buy high- Catchment ppulatin impact medical services in demnstratin regins facilities/cmmunities served: Prvide TA in QI fr FANTA-supprted sites 15,745,741 ut f 25,892,248 peple in 30 interventin districts Establish QA/QI system in the fur University Hspitals 2. Health systems strengthening Strengthen leadership, management, and planning f Central level MOH: DMH and PNLS MOH quality imprvement unit in crdinating quality imprvement activity design and implementatin Supprt develpment f natinal standard dcuments Imprvement Activity Crss-cutting Activity 2 USAID ASSIST Cte d Ivire Reprt FY17
3 Key Activities, Accmplishments, and Results Activity 1. Imprve the quality f HIV and AIDS care and treatment services BACKGROUND ASSIST wrked t imprve health care services delivery t HIV-infected patients. The prject prvided technical assistance t the six PEPFAR IPs, tw USAID technical partners, and the PNLS t imprve their capacity t supprt sites in delivering high quality HIV and AIDS care and treatment services t peple living with HIV (PLHIV). KEY ACCOMPLISHMENTS AND RESULTS Prvide TA in QI fr FANTA-supprted sites Organized a NACS learning sessin (Oct 17-21, 2016). ASSIST in cllabratin with FANTA and the Natinal Nutritin Prgram (Prgramme Natinal de Nutritin, PNN) rganized a learning sessin fr the 11 NACS QI teams in Yamussukr. During this sessin, the sites presented their results and the changes tested t imprve the nutritin services fr PLHIV. Held a meeting with FANTA (FHI 360) (Dec 21, 2016). ASSIST and FANTA rganized a meeting t discuss the prcess f scaling up NACS activities t new sites and the preparatin f the wrkshp t present the results f the QI nutritin services with the eight health districts. Participated in a wrkshp n results f quality imprvement prcesses in nutritin and HIV services (Mar 6-10, 2017). The wrkshp was rganized by PNN in cllabratin with PNLS, Prgramme Natinal des Orphelins et Enfants Vulnerables du fait du VIH (PNOEV) and the supprt f FHI 360 / FANTA in Yamussukr. During this wrkshp, results frm applying QI appraches t nutritinal care and supprt services were presented and discussed. Als, strategies fr scaling up and sustaining the nutritin imprvement wrk were discussed, such as integrating QI activities (caching visits, learning sessins, etc.) int thse carried ut by the Reginal Directrate f Health. Imprve the quality f HIV and AIDS care and treatment services in public and private health care facilities Held meetings with the Private Sectr Health Prject (PSHP) frmerly SHOPS (Oct 20 and Nv 2, 2016) t discuss quality imprvement activities in the private sectr and hw t start QI activities in private clinics. During the meeting, imprvement indicatrs that needed t be disaggregated by sex were discussed, alng with gender-sensitive indicatrs. These indicatrs are: % f ART client recrds with all items filled (disaggregated by sex) % f clients diagnsed HIV-psitive and enrlled in care (disaggregated by sex) % f patients, alive, and n ART six mnths after treatment initiatin (disaggregated by sex) % f pregnant wmen tested and received HIV results Cnducted caching visit f 90 PEPFAR IP-supprted sites (Oct - Nv 2016). ASSIST prvided technical assistance t PEPFAR IPs (SEV-CI, ICAP, EGPAF, ARIEL, ACONDA, and HAI) and health districts during caching visits. During these visits, caches checked n the feedback frm learning sessin give t ther QI members, whether change ideas were being tested ut, the functinality f QI teams, and the dcumentatin and the quality f the data frm the mnthly evaluatins. Cnducted caching visits t 10 PNLS sites (Nv 2016). ASSIST prvided technical assistance t PNLS during the caching visits in Sud Cmé. They checked n the functinality f QI teams, the dcumentatin f change ideas, and indicatrs. USAID ASSIST Cte d Ivire Cuntry Reprt FY17 3
Participated in learning sessin f ARIEL GLASER extensin sites (Nv 22-25, 2016). ASSIST prvided technical assistance t the ARIEL GLASER Fundatin in a catch-up learning sessin f the five extensin sites in Yamussukr. In ttal, 20 persns participated, including the facility staff, the IP s QI fcal pints, and the head f the health district. Cnducted a learning sessin fr 10 QI teams frm Sud Cmé cllabrative sites (Feb 6-8, 2017). This sessin was rganized by PNLS with the technical supprt frm ASSIST. Twenty health wrkers frm the sites participated, during which each site presented the results f the activities carried ut. During the sessin, the level f implementatin f the imprvement actin plans develped t implement the ideas fr change identified in Nv 2016 were assessed. Organized SEV-CI, ACONDA, HAI, and ARIEL cllabrative learning sessins (Mar 13-14 and Mar 27-28, 2017). Tw learning sessins were rganized by ASSIST in cllabratin with PEPFAR IPs fr 60 sites in the cllabrative. The sessins registered 140 participants, including the District Health Chiefs (Chef de Service de l Actin Sanitaire, CSAS). The verall bjective was t share the results f QI activities and ideas fr change implemented at sites. Held a caching visit f the imprvement cllabratin in 20 pilt sites (Aug 8-11, 2017). ASSIST prvided technical assistance t IPs SEV-CI and HAI t hld caching visits in their cllabrative sites. During this visit, a secnd cllabrative was initiated and the fllwing activities were carried ut: Results: Analyzed the rt causes f prblems Trained participants t calculate indicatrs Develped an imprvement plan accrding t identified pririty areas Strengthened prviders' capacities t initiate ideas fr change Figure 1 shws imprvement in the percentage f ART clients with all elements filled in in the recrds. At the 60 pilt sites, there was imprvement frm 33% befre engagement in QI t 92% after engagement (May 2015 - July 2017), and at the 30 extensin sites frm 25% (Mar 2016) t 84% (July 2017). The sites participating in QI activities were ften verladed with patients. At times, the health wrkers frgt t fill in parts f the medical recrd because f the heavy wrklad. Change ideas that were intrduced t address this prblem included: assigning a nurse t check medical recrds fr cmpleteness; returning thse patients recrds that were incrrectly cmpleted back t the dctrs; and dividing recrding tasks amng the different prviders invlved in care. 4 USAID ASSIST Cte d Ivire Reprt FY17
Figure 1. Percentage f ART client recrds with all items filled, 90 IP-supprted sites, 15 health regins, 30 districts (pilt sites: May 2015 August 2017; extensin sites: Mar 2016 August 2017) 100% 90% 80% 70% 60% 50% 40% Pilt sites (60) Extensin sites (30) 94% 30% 20% 10% 33% Befre engagement 60 sites 25% Befre engagement 30 sites 0% May-15 Aug-15 Nv-15 Feb-16 May-16 Aug-16 Nv-16 Feb-17 May-17 Aug-17 1500 Number f patients recrd (Pilt sites (60)) Number f patients recrd (Extensin sites (30)) 1000 500 0 May-15 Aug-15 Nv-15 Feb-16 May-16 Aug-16 Nv-16 Feb-17 May-17 Aug-17 USAID ASSIST Cte d Ivire Cuntry Reprt FY17 5
Figure 2 shws results fr recently diagnsed HIV-psitive clients enrlled in care at 90 sites supprted by IPs. Enrllment at the 60 pilt sites increased frm 68% (May 2015) t 97% (August 2017) and at the 30 extensin sites increased frm 75% befre direct engagement at the site level (March 2016) t 99% in August 2017. The decrease in January 2017 can be explained by the state f scial unrest in the cuntry (military mutiny, strike in the public sectr). Changes intrduced and implemented included: enrlling newly tested HIV-psitive clients in care n the same day, referring all clients wh tested psitive t the enrllment ffice with a referral dcument, and delegating the enrllment f clients wh tested psitive t nurses and midwives, as well as assigning new HIVpsitive clients t the cmmunity cunsellrs wh are part f care and treatment fr PLHIV. Figure 2. Percentage f recently diagnsed HIV-psitive clients enrlled in care, 90 IP-supprted sites, 15 health regins, 30 districts (pilt sites: May 2015 August 2017; extensin sites: Mar 2016 August 2017) 100% Pilt sites (60) Extensin sites (30) 99% 90% 97% 80% 70% 68% 75% 60% 50% 40% 30% 20% Befre engagement Befre engagement 60 sites 30 sites 10% 0% May-15 Aug-15 Nv-15 Feb-16 May-16 Aug-16 Nv-16 Feb-17 May-17 Aug-17 1500 Number f clients tested HIV psitive (Pilt sites (60)) Number f clients tested HIV psitive (Extensin sites (30)) 1000 500 0 May-15 Aug-15 Nv-15 Feb-16 May-16 Aug-16 Nv-16 Feb-17 May-17 Aug-17 6 USAID ASSIST Cte d Ivire Reprt FY17
Figure 3 shws imprvements in retentin in care at 90 sites supprted by IPs. Retentin in care f HIV-psitive clients alive and n ART at the 60 pilt sites increased frm 72% (May 2015) t 87% (August 2017), and at the 30 extensin sites, frm 73% befre direct engagement at the site level (March 2016) t 83% in August 2017. Changes intrduced included: referral f patients t HIV care and treatment services t facilities clser t their hme; creating a list f expected patients at six mnths t issue appintments reminders; negtiating appintments with clients during their visit t the health center; systematically calling patients 48 hurs befre the date f the appintment; and fllwing up with patients n their next appintment every day. Figure 3. Percentage f HIV-psitive clients alive and n ART, six mnths after starting treatment, 90 IP-supprted sites, 15 health regins, 30 districts (pilt sites: May 2015 August 2017; extensin sites: Mar 2016 August 2017) 100% Pilt sites (60) Extensin sites (30) 90% 87% 80% 72% 83% 70% 60% 73% 50% 40% 30% Befre engagement Befre engagement 60 sites 30 sites 20% 10% 0% May-15 Aug-15 Nv-15 Feb-16 May-16 Aug-16 Nv-16 Feb-17 May-17 Aug-17 1000 Number f patients n ART (Pilt sites (60)) Number f patients n ART (Extensin sites (30)) 500 0 May-15 Aug-15 Nv-15 Feb-16 May-16 Aug-16 Nv-16 Feb-17 May-17 Aug-17 USAID ASSIST Cte d Ivire Cuntry Reprt FY17 7
Figure 4 shws results f HIV-expsed infants (6-8 weeks) wh initiated Ctrimxazle tw mnths prir (May 2015 August 2017) and had a dried bld spts fr PCR test at 90 IP-supprted sites, including 60 pilt sites (May 2015 t August 2017) and 30 extensin sites (Mar 2016 t August 2017). Initiatin n Ctrimxazle increased gradually frm 76% t 92%. The gradual increase can be explained by the many change ideas that were implemented such as: designating a midwife service cmmitted t taking the Dried Bld Spt (DBS) during vaccinatin clinics; ntifying HIV-psitive mthers by phne ne week prir t the six-week appintment t take the sample DBS and prvide ctrimxazle fr their child; carrying ut daily tracking f children cming t pediatric check-up (vaccinatin, healthy child weighing, nutritinal cunselling); taking the DBS sample daily; and caching ther prviders n site n DBS cllectin. Figure 4. Percentage f HIV-expsed infants between 6 and 8 weeks initiated n Ctrimxazle tw mnths prir t cllectin f dried bld spts, 90 IP-supprted sites, 15 health regins, 30 districts (pilt sites: May 2015 August 2017; extensin sites: Mar 2016 August 2017) Pilt sites (60) Extensin sites (30) 100% 90% 80% 74% 97% 92% 70% 76% 60% 50% 40% 30% 20% 10% Befre engagement 60 sites Befre engagement 30 sites 0% May-15 Aug-15 Nv-15 Feb-16 May-16 Aug-16 Nv-16 Feb-17 May-17 Aug-17 300 Number f infants expsed (Pilt sites (60)) Number f infants expsed (Extensin sites (30)) 200 100 0 May-15 Aug-15 Nv-15 Feb-16 May-16 Aug-16 Nv-16 Feb-17 May-17 Aug-17 8 USAID ASSIST Cte d Ivire Reprt FY17
Establish QA/QI system in the fur University Hspitals: Cnducted caching visits t fur CHUs (Feb 28 - Mar 3, 2017). The DMH, in cllabratin with IPs (ARIEL, ACONDA and HAI) and ASSIST, carried ut caching visits at the 4 CHUs (Ypugn, Treichville, Ccdy, and Buake). This visit made it pssible t fllw up the recmmendatins f the learning sessin, check the functinality f the QI teams, check n the identificatin and testing f ideas fr change, review dcumentatin jurnals, and check n the status f data cllectin. Learning sessin fr the 4 CHUs (Mar 30-31 2017 and Jul 5-07, 2017). Tw learning sessin brught tgether 28 participants frm the gyneclgy, pediatrics, and quality departments f the fur CHUs. During these sessins, emphasis was placed n analyzing the causes f prblems, identifying ideas fr change, the Plan, D, Study, Act (PDSA) cycle, calculating indicatrs, and curve analysis and interpretatin. All CHUs presented their results frm March 2016 t June 2017. During the learning sessin, a new list f change ideas was elabrated by the participants. Held a mnthly meeting with CHU quality managers (Aug 3 and 31, 2017). ASSIST prvided technical assistance t DMH t rganize tw meetings with quality managers t assess the prgress f activities at each CHU. All quality managers and the partners wh supprted them were present. During this meeting, the participants discussed the implementatin f recmmendatins frm the furth learning sessin. At the end, the quality managers cmpleted their wrk plans f QI activities fr each CHU. Results Figure 5 shws results f pediatric client recrds with all items filled in fr the fur University Hspitals (CHUs) Ccdy, Treichville, Ypugn, and Buake (Mar 2016 Aug 2017). We see a gap between male and female client recrds with all items filled, with a higher rate f recrd cmpletin fr girl patients. The gap increased after Nvember 2016, and the team cntinued t mnitr gender-sensitive change ideas t reduce the gap. Tw changes implemented were: Task a midwife t fill the client recrd; and check systematically the files and display the items t be filled in the cnsultatin rms. Figure 5. Percentage f client recrds with all items filled, 4 CHUs (Ccdy, Treichville, Ypugn, and Buake), Abidjan and Gbêke regins (Mar 2016 Aug 2017) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 100 0 Task a midwife t fill the client recrd Males Females Check systematically the files and display the items t be filled in the cnsultatin rms M-16 A-16 M-16 J-16 J-16 A-16 S-16 O-16 N-16 D-16 J-17 F-17 M-17 A-17 M-17 J-17 J-17 A-17 # f patients recrd M-16 A-16 M-16 J-16 J-16 A-16 S-16 O-16 N-16 D-16 J-17 F-17 M-17 A-17 M-17 J-17 J-17 A-17 USAID ASSIST Cte d Ivire Cuntry Reprt FY17 9
Figure 6 shws results fr HIV testing amng pediatric inpatients in the fur CHUs in Abidjan and Gbêke regins (Mar 2016 Aug 2017). Since engagement in QI activities, n large variatins in the results between girls and bys were fund. The decrease in testing rates in January 2017 may be als explained by the state f scial unrest in the cuntry. Overall, the change ideas implemented yielded nly mst effect n HIV testing cverage amng pediatric inpatients. Figure 6. Percentage f inpatient children (0-10 years) tested fr HIV, 4 CHUs (Ccdy, Treichville, Ypugn, and Buake (Mar 2016 Aug 2017) Males Females 100% 90% 80% 70% Create testing bx in emergency service 60% 50% 40% Invlve medical dctr in the inpatient HIV testing activities 30% in pediatric service 20% 10% 0% 1000 M-16 M-16 J-16 S-16 N-16 J-17 M-17 M-17 J-17 # f infants inpatient 500 0 M-16 M-16 J-16 S-16 N-16 J-17 M-17 M-17 J-17 10 USAID ASSIST Cte d Ivire Reprt FY17
Figure 7 shws the percentage f pediatric inpatients tested fr HIV at Ccdy CHU vs. the average percentage acrss all fur CHUs (Mar 2016 - Aug 2017) The dark blue line shws results f pediatric inpatients tested fr HIV frm all fur teaching hspitals (CHUs), increasing gradually frm 50% (March 2016) t 60% (Aug 2017). The light blue line shws the results f inpatients tested fr HIV at Ccdy, increasing frm 10% (March 2016) t 99% (Aug 2017). Change ideas implemented in Ccdy included: screening each child during the first cntact with the dctr and nte whether the prvider-initiated HIV testing and cunseling (PITC) is negative r psitive n the cver f the patients recrd; cmmunity advisrs reminded the physicians t screen, after having selected the flders f tested inpatient children. This change idea ensured the ptimizatin f HIV testing fr children inpatient in the pediatric department. Figure 7: Percentage f pediatric inpatients (ages 0-10) tested fr HIV, Ccdy CHU vs 4 CHUs (Mar 2016- Aug 2017) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Cmmunity cunselrs remind dctrs t screen fr HIV after selecting inpatient children s files that were nt screened 50% 10% 4 CHU CHU Ccdy Prvide HIV testing materials t physicians at week-ends and public hlidays fr infants; HIV test in pediatric service During the first visit with the dctr, carry ut the child s screening and nte PITC negative r PITC psitive" n the cver f the patient recrd Mar-16 Jun-16 Sep-16 Dec-16 Mar-17 Jun-17 99% 60% 1500 1000 500 0 # f infants inpatient tested fr HIV (4 CHU) # f infants inpatient tested fr HIV (CHU Ccdy) Mar-16 Jun-16 Sep-16 Dec-16 Mar-17 Jun-17 USAID ASSIST Cte d Ivire Cuntry Reprt FY17 11
Strengthen the health infrmatin system t supprt develpment f evidence-based decisins fr the imprvement f the quality f medical care Cllected data fr validatin f 25% f indicatrs (Dec 2016). ASSIST prceeded t cllect data fr the validatin f 25% f reprted indicatrs frm 12 sites supprted by PEPFAR implementing partners. The five indicatrs are: % f ART client recrds with all items filled % f clients diagnsed HIV-psitive and enrlled in care % f patients, alive and n ART six mnths after treatment initiatin % f children aged 6 and 8 weeks brn t HIV-psitive mthers wh initiated Ctrimxazle tw mnths prir t cllectin f dried bld spt % f children tested HIV-psitive wh receive ART treatment Prvided capacity building n indicatrs fr the Abidjan sites, which are registered in the cllabrative (Feb 14-16, 2017). Data clerks (46) frm fur PEPFAR implementing partners (ARIEL, ICAP, EGPAF, and ACONDA) were trained n the calculatin f imprvement indicatrs at the ASSIST Cte d Ivire ffice. The sessin fcused n indicatrs t be cllected mnthly, data analysis, interpretatin f time series charts, and mechanisms fr data sharing. Imprve timeliness, cntinuity, effectiveness, efficiency, and patient-centeredness f HIV and AIDS services and their cnsistency with clinical guidelines thrugh the imprvement cllabrative apprach Training f caches and champins t disseminate gd practices in districts supprted by ICAP (Sept 11-12, 2017). ASSIST prvided technical assistance t ICAP fr training extensin agents t disseminate the best practices f the cllabrative. There were 14 participants frm Adzpe, Div, Agbville, Ccdy-Bingerville, and Abb Est districts. They were instructed n the fllwing: Cllabrative imprvement Extensin strategy Imprvement teams Data cllectin and analysis Change package fr imprvement f ART and PMTCT services Planning fr testing f changes Caching f imprvement teams Rles f agents Organizatin f a perfrmance evaluatin meeting PEPFAR IP extensin agents (caches and champins) will disseminate gd practices in selected IP-supprted sites. Held a brainstrming wrkshp (Jan 23, 2017). ASSIST participated in a reflectin wrkshp rganized by the US Embassy n innvative appraches t encurage the use f health services by men in Côte d'ivire. Held a brainstrming wrkshp n cllabrative extensin with CDC/PEPFAR implementing partners (Feb 8-10, 2017). This tk place with PEPFAR implementing partners, Prgramme Natinal de Nutritin (PNN), DMH, FHI 360, PNLS, and USAID ASSIST. Participants discussed the implementatin framewrk fr cllabrative utreach activities, validated the utreach strategy, identified the specific rles and respnsibilities f stakehlders, develped an implementatin plan and a timeline, and discussed which extensin sites t chse. Held a meeting with IP quality fcal pints (July 13; Aug 2; Aug 30, 2017). Three crdinatin meetings were rganized at the ASSIST Côte d Ivire ffice with the IP quality fcal pints. During these meetings, the verall results f the cllabrative were presented. Pints discussed: 12 USAID ASSIST Cte d Ivire Reprt FY17
Presented the disseminatin strategy f gd practices frm the cllabrative. Each partner was asked t identify within the districts and sites the champins and caches t assist the new sites in the disseminatin f gd practices. Identified new pririty areas and indicatrs fr Phase II f the cllabrative: Due t the bjectives f PEPFAR and the gaps bserved in the 90-90-90 data analysis, three new imprvement bjectives and fur indicatrs were identified t start Phase II f the cllabrative (Table 1). The limitatin n new funding that ASSIST culd accept if the prject were extended int FY18 meant that ASSIST wuld nt be able t supprt the planned Phase II f the cllabrative imprvement wrk. Table 1: Dmain, imprvement bjectives, and indicatrs f the prpsed Phase II f the cllabrative Dmain Imprvement bjectives Indicatrs Testing Increase the percentage f clients tested HIV psitive frm 2.8% t 90% by June 2018 Increase the percentage f men tested fr HIV frm 24% t 90% by June 2018 Percentage f clients wh tested HIVpsitive Percentage f men wh were tested fr HIV Viral lad Increase the percentage f ARV patients with a viral lad belw 1000 cpies/ml frm 78% t 90% by June 2018 Percentage f patients wh received ARV Percentage f patients with viral lad suppressed Prject ECHO Cnducted an ECHO test run with the teaching hspitals n the HIV Pediatric E-cllabrative (Jun 7 and 29, 2017). Prject ECHO (Extensin fr Cmmunity Health Outcmes) is a guided practice mdel develped by the University f New Mexic t increase capacity building in bestpractice specialty care while increasing access t care and reducing health disparities. Prject ECHO leverages videcnferencing thrugh the Zm platfrm t cnduct virtual teleecho clinics with prviders. By cnducting clinics virtually, experts are able t regularly cnnect with and supprt prviders in need f guidance. In Côte d Ivire, the ECHO mdel was intrduced t address the issue f lack f QI skill f health prviders t address care and treatment f HIV fr children in teaching hspitals. This wuld allw fr increased cmmunicatin and knwledge sharing acrss the fur teaching hspitals that ASSIST supprted and create a peer QI netwrk. Thrugh the telecnferencing platfrm and teleclinic mdel f ECHO, ASSIST sught t virtually cnnect with these pediatrics units t prvide technical assistance n a regular, cntinuus, real-time basis and be mre respnsive t their needs. During the last quarter f FY17, ASSIST supprted tw successful test runs with the fur CHUs. Due t the clsure f ASSIST in Côte d Ivire in September 2017, the planned ECHO activity with the fur CHUs was suspended. SPREAD OF IMPROVEMENT Fr the demnstratin phase (Oct 2015 - Jun 2016), 75 health facilities participated in cllabrative imprvement activities. During the spread phase (Jul - Sept 2016) 30 additinal sites participated (five per IP). In ttal, ASSIST staff prvided technical assistance t 105 sites supprted by PEPFAR IPs. After this phase, ASSIST in cllabratin with the PEPFAR IPs drafted the dcument f strategies fr USAID ASSIST Cte d Ivire Cuntry Reprt FY17 13
disseminatin entitled: «Stratégies de disséminatin des bnnes pratiques du cllabratif d améliratin de la qualité des sins et services fferts au PVVIH en Côte d Ivire». This draft dcument was distributed t the PEPFAR IPs t encurage them t adpt the strategies defined fr intrductin f best practices in supprted sites. Activity 2. Health systems strengthening BACKGROUND ASSIST prvided supprt t the MOH t build a QI apprach within the current health system. During a plicy meeting held in February 2014, it became clear that there was little engagement n QI in health care settings in the cuntry. There was n infrastructure t lead the QI prcess and develp the QI system in rder t integrate it t the natinal health system. In Nvember 2014, the frmer QI department, Service de la Prmtin de l Assurance Qualité en Santé, disslved after being peratinal fr five years. In February 2015, a new MOH department, the Directrate f Hspital Medicine (Directin Medicine Hspitalière), was put in charge f QI with new leaders and a new rganizatinal structure. During 2015-2017, ASSIST rganized several wrkshps and meetings with the MOH t draft the plicy and strategy dcuments fr quality imprvement. These dcuments were finalized and validated by all the stakehlders. ASSIST then printed them fr distributin. KEY ACCOMPLISHMENTS AND RESULTS Capacity building wrkshps n quality imprvement Hsted and participated in the ASSIST Francphne reginal cuntries meeting Abidjan, Côte d Ivire (Oct 3-7, 2016). Participants included ASSIST headquarters staff as well as staff frm Burundi, Côte d Ivire, Mali, and Niger. The gal f the meeting was t bring tgether ASSIST Francphne cuntry Chiefs f Party and key technical advisrs t share their experiences and t cntribute t discussins n new directins n applied science f imprvement and related health system strengthening in develping cuntries. Develped Natinal QI Strategy and Plicy The strategic plan prvides the MOH with a natinal plan fr implementing quality imprvement in health and patient safety and prvides the framewrk fr implementing the natinal health care quality plicy develped with ASSIST supprt in 2016. The natinal strategic plan has 17 strategic areas, including gvernance, leadership, management, and research, and builds n existing natinal plicy dcuments. It als addresses quality imprvement, public health, and health security. Held a wrkshp n the quality imprvement strategic plan The third brainstrming wrkshp f the natinal quality imprvement strategy was jintly rganized by the DMH and ASSIST (Oct 26-28, 2016). Technical assistance was prvided t participants n QI inputs, utputs, activities, budget, and indicatrs. In additin, the participants wrked n the lgical framewrk f the strategy, the framewrk f actin, and financial plan. Strategic Dcument Cver The DMH rganized, with the technical assistance f ASSIST, the wrkshp t develp the natinal strategy fr imprving the quality f health care and services (Dec 5-10, 2016). It 14 USAID ASSIST Cte d Ivire Reprt FY17
included the budget, the mnitring and evaluatin plan, and the natinal strategic plan, Plan strategique natinale d ameliratin de la qualité, l hygiene et la securité. Validatin f the natinal strategic plan fr imprving quality, hygiene, and safety (Mar 23, 2017). The DMH, with the technical supprt f ASSIST, rganized a wrkshp t validate the Natinal Strategic Plan fr imprving quality, hygiene, and safety with 131 participants. At the end f this wrkshp, the dcument was validated cnsidering cmments and suggestins. Natinal QI strategy and plicy delivered t the MOH (May 10, 2017). Fllwing the validatin f the natinal strategic plan fr quality, hygiene and Natinal Strategic plan fr quality, Hygiene and safety imprvement fficial delivery t MOH- May 10, 2017 Pht Credit: Assa Serge safety imprvement n March 23, 2017, ASSIST and the DMH presented t the Ministry f Health the Natinal Strategic Plan fr Quality Imprvement, Hygiene and Safety (PSNAQHS) during the fficial delivery ceremny held n May, 10th 2017. It can be dwnladed thrugh the USAID ASSIST website: https://www.usaidassist.rg/resurces/cte-divire-natinal-strategic-plan-qualityimprvement-hygiene-and-safety. USAID ASSIST Cte d Ivire Cuntry Reprt FY17 15
4 Imprvement in Key Indicatrs Table 2: Imprvement indicatrs fr the 60 riginal PEPFAR IP-supprted sites Activity Indicatrs May 2015 (Baseline) July 2015 (Baseline) Oct 2015 (Baseline) Feb 2016 May 2016 Aug 2016 Nv 2016 Feb 2017 August 2017 Imprve quality f HIV care and treatment services in Cte d Ivire % f ART client recrds with all items filled % f clients diagnsed HIV-psitive and enrlled in care % f patients, alive and n ART 6 mnths after treatment initiatin % f children aged 6 and 8 weeks brn t HIV-psitive mthers wh initiated Ctrimxazle tw mnths prir t cllectin f DBS 33% (57/60 68% (57/60 72% (59/60 73% (51/54 39% (55/60 74% (55/60 71 % (59/60 72% (49/54 45% (56/60 72% (56/60 71% (58/60 81% (50/54 67% (54/60 86% (55/60 81% (54/60 89% (49/54 80% (58/60 85% (57/60 82% (59/60 89% (52/54 84% (59/60 92% (58/60 88% (58/60 95% (54/54* 91% (52/60 96% (52/60 91% (52/60 100% (45/54* * 5 sites did nt implement QI activities (CAT Dala, CAT San Pedr, CAT Adjamé, Espace Cnfiance, and Centre Plus, CHR Krhg) 88% (55/60 91% (54/60 87% (54/60 98% (48/54* 94% (40/60 99% (40/60 87% (40/60 97% (36/54 Table 3: Imprvement indicatrs fr the 30 scale-up PEPFAR IP-supprted sites Activity Indicatrs March 2016 (Baseline) June 2016 (Baseline) Sept 2016 (Baseline) Dec 2016 Feb 2017 August 2017 Imprve quality f HIV care and treatment services in Cte d Ivire % f ART client recrds with all items filled % f clients diagnsed HIVpsitive and enrlled in care % f patients alive and n ART 6 mnths after treatment initiatin 26% (11/30 75% (14/30 72% (14/30 38% (20/30 86% (20/30 78% (20/30 43% (23/30 84% (21/30 80% (21/30 62% (26/30 85% (26/30 86% (26/30 73% (26/30 88% (26/30 89% (26/30 94% (19/30 97% (19/30 83% (19/30 % f children aged 6 and 8 weeks brn t HIV-psitive mthers wh initiated Ctrimxazle tw mnths prir t cllectin f DBS 75% (12/30 79% (18/30 79% (19/30 91% (24/30 96% (24/30 92% (19/30 16 USAID ASSIST Cte d Ivire Reprt FY17
Table 4: Imprvement indicatrs fr 4 CHUs Activity Indicatrs March 2016 (Baseline) April 2016 (Baseline) May 2016 (Baseline) June 2016 (Baseline) July 2016 (Baseline) August 2016 (Baseline) Nv 2016 Feb 2017 Aug 2017 Imprve quality f HIV care and treatment services in Cte d Ivire % f ART client recrds with all items filled % f pediatric inpatients tested fr HIV % f children tested HIV-psitive wh were put n ART 38% 42% 100% 26% 29% 78% (3/4 48% 27% 90% 52% 45% 100% (3/4 50% 43% 25% (2/4 52% 50% 93% 55% 74% 71% 68% 66% 63% 98% (3/4 62% (3/4 100% (3/4 5 Sustainability and Institutinalizatin Thrughut this year, USAID ASSIST has cntinued t wrk t build and strengthen the QI capacity f tw key MOH units: DMH and PNLS. With ASSIST s mentrship, these units gained hands-n experience in c-facilitating and supprting QI wrk with IPs. In additin, t prmte sustainability and institutinalizatin, ASSIST helped create a critical mass f health prviders wh are cmpetent in using QI cncepts at the health facility level; develped a netwrk f QI experts t allw experience and best practice sharing; and prmted transfer f QI cmpetencies t PEPFAR IPs and health facility staff. At the natinal level, ASSIST prvided technical assistance t the MOH t develp a plicy Plitique Natinale d Améliratin de la Qualité des Sins et des Services and a strategic plan t imprve the quality f health care in Côte d Ivire Plan Strategique Natinale d Améliratin de la Qualité, l Hygiene et la Securité. At the central level, ASSIST wrked clsely with the unit in charge f quality, the HIV prgram, the nutritin prgram, and the unit in charge f health infrmatin t define natinal pririties abut QI and integrate the perfrmance indicatrs in the rutine data management system. At the reginal and district levels, ASSIST prvided technical assistance t the reginal and district managers t crdinate imprvement activities in their respective regins/districts. At the health facility level, ASSIST prvided technical assistance t facility management units fr the develpment f imprvement teams per the guidelines f health activities in Côte d Ivire. In additin, thrugh the test runs f Prject ECHO in Cte d Ivire, ASSIST facilitated increased cmmunicatin and knwledge sharing acrss the fur teaching hspitals that ASSIST supprted. ASSIST virtually cnnected these pediatric units t frm a cllabrative and share learning. 6 Knwledge Management Prducts and Activities USAID Success stry: Expsed infants receive early testing t imprve survival rates. Available at: https://www.usaid.gv/results-data/success-stries/cllabrative-apprach-and-quality-imprvementincrease-hiv-treatment Created a QI Facebk grup: https://www.facebk.cm/grups/1918456188377821 Drafted the Natinal Strategic Plan fr Quality Imprvement, Hygiene and Safety. Available here: https://www.usaidassist.rg/resurces/cte-divire-natinal-strategic-plan-quality-imprvementhygiene-and-safety USAID ASSIST Cte d Ivire Cuntry Reprt FY17 17
Drafted a case study n the implementatin f the quality imprvement cllabrative in the 60 pilt sites in CI (French). 7 Gender Integratin ASSIST, in cllabratin with the PEPFAR IPs, retrspectively cllected data frm May 2015 t Nv 2016 by sex in 90 sites in the cllabrative. The sites benefited frm analyzing the sex-disaggregated data because it allwed fr the identificatin f gaps in care and adapting change ideas t imprve the care and health services fr bth male and female patient. Analysis f these sex-disaggregated data identified sme small gaps in care between males and females, mst f which have clsed. Remaining gaps may be due t small denminatrs creating vlatility in percentages. At the ASSIST Francphne Reginal Meeting in Octber, staff discussed what gender integratin is, why it is imprtant, and using sex-disaggregated data t identify, mnitr, and address gaps in care. This led t the retrspective cllectin f sex-disaggregated data and discussing sex-disaggregated data and gender integratin with implementing partners. Sme pilt sites in Activity 1 (HIV care and treatment) did nt cllect data by sex (arund 15, thugh the 30 extensin sites did cllect data by sex. Since September 2016, all sites started cllecting and reprting sex-disaggregated data fr HIV care and treatment. We expect that they will cntinue t cllect sex-disaggregated data after the clsure f ASSIST. In September 2017, ASSIST in cllabratin with FHI 360, develped the data cllectin tls fr disseminatin f best practices. These tls integrated sex desegregatin. The PEPFAR IPsupprted sites will use the tls fr cllecting data t measure the imprvement f activities. 18 USAID ASSIST Cte d Ivire Reprt FY17
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