PEPFAR's annual planning process is done either at the country (COP) or regional level (ROP).
PEPFAR's programs are implemented through implementing partners who apply for funding based on PEPFAR's published Requests for Applications.
Since 2010, PEPFAR COPs have grouped implementing partners according to an organizational type. We have retroactively applied these classifications to earlier years in the database as well.
Also called "Strategic Areas", these are general areas of HIV programming. Each program area has several corresponding budget codes.
Specific areas of HIV programming. Budget Codes are the lowest level of spending data available.
Expenditure Program Areas track general areas of PEPFAR expenditure.
Expenditure Sub-Program Areas track more specific PEPFAR expenditures.
Object classes provide highly specific ways that implementing partners are spending PEPFAR funds on programming.
Cross-cutting attributions are areas of PEPFAR programming that contribute across several program areas. They contain limited indicative information related to aspects such as human resources, health infrastructure, or key populations programming. However, they represent only a small proportion of the total funds that PEPFAR allocates through the COP process. Additionally, they have changed significantly over the years. As such, analysis and interpretation of these data should be approached carefully. Learn more
Beneficiary Expenditure data identify how PEPFAR programming is targeted at reaching different populations.
Sub-Beneficiary Expenditure data highlight more specific populations targeted for HIV prevention and treatment interventions.
PEPFAR sets targets using the Monitoring, Evaluation, and Reporting (MER) System - documentation for which can be found on PEPFAR's website at https://www.pepfar.gov/reports/guidance/. As with most data on this website, the targets here have been extracted from the COP documents. Targets are for the fiscal year following each COP year, such that selecting 2016 will access targets for FY2017. This feature is currently experimental and should be used for exploratory purposes only at present.
Years of mechanism: 2010 2011 2012
The Healthcare Improvement Project (HCI) managed by the University Research Co. (URC) provides technical assistance in support of the Ministry of Health's National HIV/AIDS Care and Treatment Program (PNPEC), the Ministry for the Fight Against AIDS (MLS), the National OVC Program (PNOEV), and PEPFAR implementing partners to optimize the quality and effectiveness of HIV/AIDS prevention, treatment, and care and support interventions in Cote d'Ivoire.
Starting work in Cote d'Ivoire in January 2008, URC supported the PNPEC in performing an assessment of the quality of clinical care and treatment of HIV/AIDS patients at 41 sites, with the involvement of the health districts and PEPFAR clinical care partners. The assessment was the starting point for an improvement plan, based on "improvement collaboratives" promoting quality and efficiency through shared learning and information dissemination, that is being implemented by PNPEC and partners with technical assistance from URC at 41 sites and will be expanded to 120 sites with FY 2010 funding.
URC is also using FY 2009 funding to work with national programs and implementing partners to conduct quality-improvement activities for HIV/AIDS prevention and OVC care and support, and URC will continue and build on these activities with FY 2010 funds. In addition, FY 2010 funds will support quality-improvement work in support of PMTCT sites and of laboratory accreditation.
In all program areas, URC will continue to place a particular emphasis on the development of national standards and tools to measure interventions and program outcomes, as well as on hands-on mentoring of implementing partners and national counterparts.
Funding for URC is requested in HVAB, HVOP, HTXS, and HKID and for the first time the MTCT and HLAB. URC's significant funding increase reflects the USG team's emphasis on quality improvement as a major strategic emphasis, as well as the positive results of URC's work so far, including improvements in key indicators at intervention ART and PMTCT sites:
More than 60% of ART patients and 50% of PMTCT patients had complete medical records, compared to 20% and 15%, respectively, during the initial assessment.
Loss to follow-up among ART patients was reduced from 45% to 18%.
50% of children born to HIV-positive women were tested for HIV, compared to 9% during the assessment.
FY 2010 activities will focus on strategies and interventions that continue to build capacity and improve upon existing standards across all technical areas. URC will conduct capacity building through joint identification, development, and refinement of improvement objectives, indicators, and care processes. This will be accomplished through training stakeholders from national programs and district-level partners through learning sessions, coaching, and supervisory systems that will serve to improve data collection and analysis.
URC/HCI professional staff will provide technical assistance to partners to organize improvement activities, provide training in quality improvement at learning sessions, accompany regional coaches for mentorship, and assist with problem solving, data validation, and analysis. The HCI staff will also prepare consolidated reports of collaborative achievements.
URC's activities contribute to the key issues of 1) TB, through the inclusion of TB clinics in quality-improvement collaboratives; 2) increasing women's legal rights and protection, by helping define and apply OVC quality standards that address protection of girls; and 3) increasing gender equity, by emphasizing the participation of girls in OVC programs and working to ensure that ART/PMTCT collaboratives include at least one women from each participating facility.
In May 2010, using central funds, URC/HCI expects to organize an African Conference and Workshop on Developing an HIV Chronic Care Model in Kampala. Once designed and tested, this model could be adapted for Cote d'Ivoire.
The Health Care Improvement Project (HCI), managed by the University Research Company (URC), will continue to provide technical assistance to the National OVC Program (PNOEV) of the Ministry of Family, Women, and Social Affairs as well as to PEPFAR implementing partners to improve the quality of OVC interventions in Cote d'Ivoire.
URC has provided technical support to develop and pilot OVC interventions and build capacity among "learning groups" of community care providers. In working to improve the quality of OVC services, URC has also sponsored large-scale capacity building events and shared best practices.
With FY 2010 funding, URC will continue to support the National OVC Program (PNOEV) to implement a quality-improvement strategy and build consensus among OVC stakeholders to produce measurable outputs in which stakeholders can observe tangible improvements in the lives of OVC.
The quality improvement strategy includes the following key interventions:
Planning for quality improvement of OVC programs will be conducted. This intervention will involve a situational analysis of quality issues for OVC programming in which best practices and barriers to quality care will be examined. Key stakeholders will be identified to build support for OVC advocacy and bolster policy level national programming.
Quality service standards will be further defined. The technical working group focusing on the quality of OVC services will be reconvened to update the national framework for OVC service delivery standards.
Communicating quality standards to the point of service delivery will be critical to improving existing OVC services. Capacity building workshops will be organized for service providers to develop communication strategies and discuss service standards.
Service providers will be increasingly engaged in quality improvement processes. URC will work toward building the capacities of the MFFAS/PNOEV and local organizations to support quality improvement through "learning groups." Periodic coaching support will be provided.
The indicators used to measure quality will be a combination of outcome measures (e.g., the Child Status Index) and process indicators that measure providers' adherence to the standards developed in this project. Routine data collection, monitoring, and evaluation will be conducted in collaboration with implementing partners and with technical assistance by Measure Evaluation to ensure that program area targets are being met and the quality of OVC services are up to national standards.
Starting work in Cote d'Ivoire in January 2008, URC supported the PNPEC in performing an assessment of the quality of clinical care and treatment of HIV/AIDS patients at 41 sites, with the involvement of the health districts and PEPFAR clinical care partners. The assessment showed that the two biggest problems were inadequate documentation of patient care and the attrition of patients (perdus de vue) at every step of the testing, care, and follow-up processes for both ART and PMTCT. Fewer than 20% of ART patients had complete medical records. Six months after initiating care, 66% of pre-ART patients and 45% of ART patients had been lost to follow-up.
The assessment was the starting point for an improvement plan, beginning with a demonstration "improvement collaborative" involving four partners and 41 sites. An improvement collaborative is an organized network of sites (e.g., districts, facilities, or communities) that work together for a limited period of time, usually nine to 24 months, to rapidly achieve significant improvements in processes, quality, and efficiency of a specific area of health care through shared learning and intentional spread methods. The two initial improvement objectives of the demonstration collaborative were to improve documentation and to reduce patient attrition. Reducing patient attrition is crucial to improving outcomes of care and long-term survival of HIV-infected persons. The initial plan also included an expansion collaborative to follow the demonstration collaborative a year later.
The collaborative was launched in January 2009, followed by three learning sessions to train teams and share results, as well as coaching visits to help site teams with monitoring and improvement work. Trainings and coaching visits were conducted with PNPEC, PSP, DIPE and partners (EGPAF, Care International, ACONDA, ICAP, and UNICEF).
Work at the site level is led by QI teams that develop and test changes. The teams comprise MOH facility staff, including doctors, nurses, midwives, community workers, pharmacists, and laboratory technicians. After seven months of collaborative site activities, there have been a number of improvements:
New DIPE forms and registers have been distributed by partners, which has facilitated improved documentation and the collection of data needed for the collaborative indicators.
Sites have implemented changes to reduce attrition, including:
Identifying patients not keeping scheduled appointments or lost to follow-up
Calling patients or contacts to encourage them to return to the clinic
Using local NGOs to trace lost patients
Improving counseling to prevent attrition
Carrying out CD4 counts the day the patient tests HIV-positive
Reporting the results of the CD4 count within two days of the test
Scheduling the first physician visit for ART-eligible patients within two weeks of the CD4 count
There have been improvements in the key indicators:
More than 60% of ART patients had all (100%) of items filled in the medical record.
Loss to follow-up was reduced to 18% of ART patients
With FY 2010 funding, URC will build on and extend its quality-improvement work from 41 to 120 ART and PMTCT sites. Objectives will include:
Continue QI capacity building with the PNPEC, implementing partners, districts, and facilities
Significantly improve outcomes of ART care by dramatically reducing attrition through an expansion collaborative building on lessons learned from the first demonstration collaborative
Work with the PNPEC to develop, test, and expand an HIV chronic care model to maximize long-term patient survival
Reinforce the national information system by improving the quality of the data from the HIV care system
URC will assist the PNPEC, other partners, and district facilities to plan and implement an expansion collaborative (starting in April 2010) aimed at improving the quality of documentation and adherence to standard procedures. Specific activities will include:
Continue capacity building through joint identification, development, and refinement of improvement objectives, indicators, and care process changes.
Continue capacity building by training the PNPEC, partners, and districts to direct learning sessions, to coach, and to strengthen supervisory systems, including coaching site teams in data collection, analysis, and use.
Collect and document best practices in attrition prevention and reduction in the demonstration collaborative, thus producing a package of best practices for spread during the expansion collaborative.
Provide technical assistance to partners to organize improvement activities, provide training in QI at learning sessions, accompany and mentor regional coaches, and assist with problem solving, data validation, and data analysis.
None
Starting work in Cote d'Ivoire in January 2008, URC supported the PNPEC in performing an assessment of the quality of clinical care and treatment of HIV/AIDS patients at 41 sites, with the involvement of the health districts and PEPFAR clinical care partners. The assessment showed that the two biggest problems were inadequate documentation of patient care and the attrition of patients (perdus de vue) at every step of the testing, care, and follow-up processes for both ART and PMTCT. Fewer than 15% of PMTCT clients had complete medical records. Only 25% of HIV+ women were referred for HIV care; among infants of HIV+ mothers, only 11% received cotrimoxazole, and only 9% were tested for HIV.
The assessment was the starting point for an improvement plan, beginning with a demonstration "improvement collaborative" involving four partners and 41 sites. An improvement collaborative is an organized network of sites (e.g., districts, facilities, or communities) that work together for a limited period of time, usually nine to 24 months, to rapidly achieve significant improvements in processes, quality, and efficiency of a specific area of health care through shared learning and intentional spread methods. The two initial improvement objectives of the demonstration collaborative were to improve documentation and to reduce patient attrition. The initial plan also included an expansion collaborative to follow the demonstration collaborative a year later.
1. New DIPE forms and registers have been distributed by partners, which has facilitated improved documentation and the collection of data needed for the collaborative indicators.
2. Sites have implemented changes to reduce attrition, including:
Accompanying pregnant women testing HIV-positive immediately to the lab for the CD4 test and facilitating attendance at the follow-up clinic
Ensuring that the infant's health record notes the mother's HIV status and that the infant is tested for HIV at two weeks
There have been improvements in key indicators:
More than 50% of PMTCT patients had all (100%) of items filled in the medical record.
50% of children born to HIV-positive women were tested for HIV.
With FY 2010 funding, URC will build on and extend its quality-improvement work from 41 to 120 PMTCT and ART sites. Objectives will include:
Significantly improve outcomes by dramatically reducing attrition through an expansion collaborative building on lessons learned from the first demonstration collaborative
Accreditation is an important milestone on the path of continuous quality improvement. Successful participation in accreditation programs should be a long-term operational goal for both public health and medical laboratories. While laboratories strive to support scale-up toward universal access to HIV testing, it is vital that testing services be of consistent high quality and that clinicians be able to rely on lab results for patient-care decisions. The establishment of the WHO-AFRO Lab Accreditation Program provides an important opportunity to improve laboratory quality practices in Cote d'Ivoire. It is now feasible to set laboratory accreditation as an explicit priority and goal. Laboratory accreditation is also among the new PEPFAR laboratory indicators.
Major changes in Cote d'Ivoire's laboratory systems are required and will require significant time, effort, and investment. The regional accreditation institution CRESAC (Centre Regional d'Evaluation en Santé et d'Accreditation) has been asked by the Ministry of Health (MOH) to lead the WHO AFRO accreditation process nationwide, in collaboration with key central laboratory institutions, including the National Public Health Laboratory (LNSP). A national accreditation plan developed in 2009 includes 20 regional and district hospital laboratories that are already engaged in the URC-supported quality improvement program for HIV/AIDS services, along with three central reference laboratories and the national blood bank laboratory.
With FY 2010 funding, URC will work to strengthen the capacity of CRESAC to develop national laboratory accreditation documents based on WHO-AFRO standards and to establish a national vision for laboratory accreditation, with accreditation as a strategic objective in the national laboratory strategic plan. With technical assistance by URC and ASCP, CRESAC will strengthen coordination among key central laboratory institutions and partners for policy and planning, implementation, human resources and training, procurement and supply chain, facilities and equipment, and quality management.
URC will work closely with the LNSP, the CDC/Retro-CI Lab, and PEPFAR care and treatment implementing partners (EGPAF, ACONDA, ICAP, and Health Alliance International) for to assess the 24 laboratories, establish and implement a training plan, develop laboratory documentation, and address infrastructure and equipment needs. In collaboration with ASCP and Retro-CI, URC will organize two training-of-trainer workshops leading to the training and certification of a pool of at least 20 national assessors.
