Note: To align the UTAP budget and new COP submission cycles, FY 2012 funding will support activities through March 2014.Goal: To improve government of Cote dIvoire (GoCI) capacity to reduce the mortality of people living with HIV/AIDS and prevent HIV in newborns by increasing access to high-quality PMTCT and care and treatment services and to cervical cancer prevention.Objectives are to 1) evaluate implementation of standards based management and recognition (SBM-R) quality improvement approach at 40 pilot sites; 2) assist the GoCI in rolling out cervical cancer prevention (CECAP); 3) support the GoCI to implement a task shifting policy; 4) integrate HIV and OVC content into curricula at national training schools (INFS and ENSEP).Cost-efficiencies will be pursued through SBM-R, which improves performance and decreases inefficiencies; task shifting, which enables nurses to provide treatment at a lower cost; curriculum work enabling graduates to provide OVC services without additional training; and single-visit cervical cancer screening.To transition to Ivoirian entities, JHPIEGO works with national entities and district health directors.For quality M&E, JHPIEGO will strengthen CECAP M&E using lessons learned from other CECAP country programs. For SBM-R, JHPIEGO will develop appropriate outcome indicators beyond improved adherence to standards. For task shifting, JHPIEGO is evaluating the pilot project.Vehicles: Through COP11:1. New in COP12:1 ($40,000), to work closely with health districts for the national roll-out of programs. For life of mechanism: 2.

For COP 12, Jhpiego will continue to support activities for cervical cancer prevention and treatment (CECAP) for women living with HIV and AIDS to ensure that women receive high quality care at 20 health facilities and 2 referral sites. Jhpiego will also assist the government on a national level to roll out cervical cancer prevention programs. To do this, Jhpiego will:Collaborate with Ivorian government to develop CECAP policies and training materials (guidelines, training toolkits, , monitoring and evaluation tools)Assist in monitoring the implementation of cervical cancer prevention and treatment in the 22 existing sitesWork closely with the national HIV/AIDS care and treatment program (PNPEC) and health districts to train regional trainersContinue to participate and facilite the CECAP technical working group (TWG)Work with Ministry of Health and AIDS department of maintenance to train indicated persons in maintaining cryotherapy and LEEP machinesWork with CECAP TWG to develop CECAP information and education materials (pamphlets, flipcharts, etc) and print copies for use at sitesEstablish a linkage system to the labs for women with large lesions to provide treatment (LEEP)

The objective of integrating OVC contents into social workers curricula is to increase the number of qualified social workers who are competent to provide care and support to OVCs. Jhpiego has been working with health training institutions for the past three years through the ERCACI project, which was terminated in March 2011. Under this project, , Jhpiego led the process of identifying and integrating HIV content into curricula at the national training school of social workers (INFS) for the different cadres (e.g. social workers, pre-school educators, specialized educators), and developing a technical working group (TWG) that led the process at INFS to identify the relevant HIV/AIDS content.

Through the COP12, Jhpiego will work with the National OVC Program (PNOEV) and national training schools INFS and ENSEP (national school for continuing educatino) to:Reactivate the TWG at INFS and create one at ENSEP;Conduct technical update trainings for faculty in charge of OVC contents;Develop course syllabus and lesson plan for OVC contents;Follow up and mentor classroom teachers and instructors when they teach HIV contents;Identify a room/space to be used in each school for simulation.Evaluate the integration of OVC at INFS

The objective of task shifting is to develop and implement a policy allowing nurse and midwives to prescribe ARVs freeing up doctors and increasing access for patients.Jhpiego and ICAP have worked in partnership to: 1) advocate with government to implement a national policy allowing nurses to prescribe ARVs; and 2) develop a national training curricula for nurses and midwives and an orientation for doctors to act as supervisors/coaches of the nurses and midwives;Unfortunately, implementation of the policy has been delayed because there are still doubts by some that nurses and midwives can competently prescribe ART. After two years of advocacy, PNPEC agreed to allow a pilot project at 27 sites to determine if in the Ivoirian context nurses and midwives could prescribe ART. Jhpiego developed the training curricula and conducted the training for 49 nurses and midwives from 27 sites in: Haut Sassandra (Daloa, Issia, Zoukougbeu), Lagunes (Abidjan), Fromager (Gagnoa), Bas Sassandra (Tabou), Sud Bandama (Divo), Zanzan (Bondoukou), Marahoué (Bouaflé, Zuénoula, Sinfra), Vallée du Bandama (Béoumi, Bouaké). They also conducted an orientation for 25 medical doctors to serve as supervisors. Jhpiego and ICAP are currently developing the protocol to assess the nurses and midwives competency.

Once the policy is passed and the country is ready to roll out the policy then Jhpiego will work with PNPEC, ICAP, and other national partners to develop a national scale roll out plan to enable nurses and midwives to prescribe ARVs by training nurses/midwives and medical supervisors who will provide ongoing supportive supervision and coaching to the nurses/midwives at new sites. This will entail getting the training curricula developed for the pilot project endorsed nationally, developing regional pools of trainers, and rolling out training to all regions. The selection of regions will be based on the developed roll out plan. Jhpiego will also assist MSLS to identify and establish regional clinical training hospitals/sites.

For the past three years Jhpiego has successfully implemented the quality assurance methodology, SBM-R, at 25 existing PMTCT sites where implementing partners, EGPAF and ACONDA, are providing ART. These sites have all graduated and the quality assurance is undertaken by the sites themselves. Under COP 11 Jhpiego is adding 10 additional PMTCT and care and treatment sites. The sites are located in: Vallée du Bandama (Bouaké), Savanes (Korhogo, Ferkessédougou). For COP 12, Jhpiego continue to supervise the 10 existing sites until they graduate and are self-sufficient. No new site will be involved in SBM-R approach through COP 12. In collaboration with its partners, Jhpiego will conduct a retrospective evaluation of the implementation of SBM-R in Côte dIvoire. Please note that this section focuses only on improving quality for PMTCT and the section to improve quality for care and treatment is under Adult Treatment Activity section.

SBM-R is a sustainable model because it involves the health facility from the beginning and by the end, the site is self-sufficient and maintains the approach itself. District health staff and facility staff are trained to assess their compliance with the national standards then trained to determine the underlying causes and develop and implement a plan to improve the uncovered barriers. Jhpiegos role is to train, coach, assist and conduct the final evaluation to determine status. SBM-R is divided into three modules:oModule 1:?Orient new sites what standards are, how they can be used for self-assessment, supervision, monitoring of progress during a five day orientation.?Link previous sites to new sites to encourage cross-sharing.?Jhpiego then helps sites measure their baseline for how the standards have been implemented to that point in time and develops initial activity plan.?Implement easy fixes to gaps identified.oModule 2 (~2 months after module 1):?Sites completes internal evaluation then participate in a 3 day meeting where sites present what they did and how they improved implementation of standards, and develop action plan for the difficult tasks analyzing and addressing the root causes.oModule 3 (~3 months later):?External assessment by Jhpiego followed by a 3 day meeting where sites review progress and measurement on SBM-R then develop action plan for achieving 80% and how to reach recognition.?National committee already selected from previous years will verify 80% and in collaboration with Jhpiego will hold a recognition ceremony.

There is clear evidence that this model has increased health clinics compliance with the standards: in sites where Jhpiego has already worked, performance has improved greatly 17/25 health sites achieved 80% or more on the assessment compared to an average baseline of less than 25% and not one health site scored above 40% at baseline.

Nonetheless, Jhpiego will undertake a retrospective analysis of health sites where SBM-R was implemented to determine if implementation of standards lead to better health outcomes (e.g., increased percentage of women attending ANC getting tested for HIV, more pregnant women living with HIV receive CD4 count, increased number of eligible women placed on ARVs, or receive therapy, etc.)

Jhpiego uses the same quality assurance approach for care and treatment, as they do for care and treatment so the approach outlined above to do an evaluation of SBM-R in Cote divoire is the same approach for SBM-R at care and treatment sites.

Under COP 11, Jhpiego is working with the Ivoirian government to review and revise the existing the national standards for care and treatment that were developed in 2006. Given that HIV care and treatment has changed in the past year, Jhpiego is ensuring that the new standards are aligned with national care and treatment policies for: patient tracking (evaluating clinical outcomes, retention of patients, etc.), integrating services with maternal child health and family planning services, access to nutrition, and access to water and sanitation. Jhpiego will work with implementing partners and Ivoirain government at national and district levels to ensure adherence to these standards at 10 sites.

Under COP 12, Jhpiego will evaluate whether implementing these standards has led to improved health outcomes. (e.g., improved adherence to therapy, improved retention of patients, improved infection prevention, improved integration with family planning, etc.)