During FY07, the Emergency Plan will build on previous activities and continue to prioritize HIV-TB integration and increased service coverage. Of ~26,500 TB patients, 60% will receive routine CT services, while of 33,000 HIV-infected clients attending HIV service sites, at least 50% will receive routine screening for TB disease at "HIV" points of entry (i.e. CT, PMTCT, etc). Integration of routine CT and comprehensive care and treatment for both HIV and TB is planned for at least 86 TB diagnostic and care service sites (94% of the 91 national sites). EP-supported sites will use adapted WHO screening tools and data recorded in the facility reporting systems.

As part of a family-centered approach, children will be the focus of intensified case detection and household follow-up. Care for TB/HIV co-infected persons and their families will be linked with other prevention and palliative-care services.

A range of individually focused health education and support, referrals, community interventions, and advocacy will be integrated. The EP will also support expanded TB diagnostic capabilities for mycobacterial culture and drug-susceptibility testing. Substantial efforts will be made to prevent and manage drug-resistant TB among HIV-infected TB patients, including support for an application to the Green Light Committee. The EP will also work with WHO and other partners to adapt the national TB surveillance system to include HIV and improve systems to capture TB screening data at HIV entry points.

With the approval of additional plus-up funds, the PNLT will:

• Improve TB infection control (IC): In collaboration with WHO, PNPEC, and other key partners, the PNLT will develop guidance on developing national TB IC plans (including national TB infection guidelines) and a training curriculum and provide TA for risk assessments, translation of national guidelines into facility-level implementation plans, and related M&E. Funds will be used to ensure that all partners (e.g. in ART, care and treatment, PMTCT, etc.) implement basic TB IC activities in their workplans. Particular attention will be given to screening for TB signs and symptoms in PEC sites to identify and treat active TB and thus reduce the period of infectiousness. • Establish effective collaboration between TB and HIV programs, including referral networks and co-location of services. This would include opt-out testing at all TB sites. • Improve the national program's diagnostic testing capabilities. • Expand access to TB services by creating a TB lab referral center in the North to support TB identification and treatment. • Coordinate with Global Fund activities and other EP partners to expand decentralized TB services, especially in the North. • Provide basic equipment and laboratory supplies to TB centers at the central and peripheral levels. • Support development and validation of operational guidelines, standardized training manuals, job aids and standard operating procedures. • Develop human-resource capacities by provision of trainings in biosafety and quality management. • Adapt the WHO/CDC training package and reinforce training in direct smear microscopy and maintenance of microscopes. • Develop a comprehensive national strategic plan for enhancing HIV/TB diagnosis and surveillance. • Reinforce the quality-assurance system, especially for external quality assessment, including on-site supervision and proficiency testing.

This activity relates to other activities described in Measure SI (#10076), Abt Associates Other Policy (#9924), FHI Other Policy (#10078), Projet RETRO-CI SI (#10199), and SCMS Basic Health Care (#10189).

The Government of Cote d'Ivoire is implementing decentralization reforms in response to the growing challenges it faces in financing health and other services and maximizing efficient allocation of resources. It also faces a growing demand for local participation in the design, delivery, and monitoring and evaluation of health services.

To support the decentralization of HIV/AIDS interventions, the MOH received EP support in FY06 to promote the planning, coordination, monitoring, and evaluation of HIV activities. An assessment of the HIV/AIDS National Plan 2002-2004 found a debilitating lack of SI guidance and skills at the decentralized level. As part of the new National HIV/AIDS Strategic Plan 2006-2010, the SI unit of the MOH aims to achieve the following objectives: 1. Upgrade the routine data-collection system for HIV/AIDS interventions 2. Improve the surveillance and evaluation system 3. Harmonize HIV/AIDS-related epidemiological surveys and studies 4. Coordinate the HIV/AIDS M&E system to address issues raised in the 2002-2004 assessment 5. Improve M&E of the new national strategic plan

The MOH will place a special emphasis on the district as the operational unit for the overall strategy. With FY06 funds, the MOH set up a project management unit and coordinated an evaluation in the San Pedro IRIS pilot (IRIS), a district network of comprehensive prevention, care, and treatment services involving many EP ministry and NGO/CBO/FBO partners.

With FY06 funds, the MOH is conducting a mapping analysis of the HIV interventions by capturing all CT, PMTCT, ART, and other HIV services by implementing partners, including donors or funding source and location (site, district and region). The mapping analysis will allow the MOH to develop a consolidated work plan for 2006 and 2007 for all HIV/AIDS activities in the health sector including.

Major activities for 2007 will focus on improving the quality and dissemination of HIV/AIDS data through the support of HIV-related planning, surveillance, monitoring and evaluation and capacity building for data collection and management in targeted districts and regions prior to national scale-up.

Planning: To strengthen national capacity to program and plan HIV/AIDS care and treatment activities in the health sector, the MOH will finalize its consolidated three-year national plan for HIV/AIDS activities in the health sector (2007-2009); which incorporates all existing and planned health sector-specific HIV/AIDS activities, financed by the key stakeholders. This plan will assist the MOH in coordinating multiple partners and interventions as well as in monitoring, and eventually rationalizing the geographic distribution of HIV/AIDS services. As follow-on to the consolidated national plan, the MOH will develop a decentralization plan for HIV prevention, care and treatment services. This plan will lay out the MOH's strategy and timeline for devolving administrative and financial management of HIV/AIDS services in the health sector to the decentralized level in collaboration with Abt Associates. Furthermore, the MOH will provide TA to decentralized authorities in 10 districts for the development of HIV/AIDS "micro-plans" tailored to the specific needs of districts.

Coordination: To reinforce national capacity to coordinate HIV/AIDS care and treatment activities in the health sector through routine system data collection and analysis, the MOH will support the development of a GIS map of clinical HIV/AIDS prevention, care and treatment interventions in CI in order to facilitate deployment and coordination of partners and services within the health sector. A central database will be established to track financial inputs from all sources for HIV/AIDS activities in the health sector. Specific activities will include collecting GPS coordinates and basic profile information from all health facilities offering HIV/AIDS services, integrating this information into a national GIS map, developing regional GIS maps and relevant overlays (e.g. regional population density, HIV prevalence rates, TB services) and training key stakeholders at the central

and regional levels in the use of the map for intervention planning, coordination and monitoring.

M&E: To strengthen national capacity for improved M&E of medical care and treatment activities, the MOH will continue to build HIV/AIDS program monitoring capacity through a series of activities targeting the central and decentralized levels. The MOH will develop a national M&E work plan that corresponds to the consolidated national HIV/AIDS plan mentioned earlier. In collaboration with JSI/MEASURE, the MOH's Office of Planning, Information and Evaluation (DIPE) will revise data collection tools for HIV/AIDS services in the health sector, integrate a module on HIV data collection and management into the national care and treatment training curriculum, and train 25 data management officers at all levels of the health care system in data collection, analysis and report writing and build their capacities in planning of M&E HIV/AIDS interventions.

MOH will improve human capacity for M&E by supporting the short- and long-term training of key health sector staff in HIV/AIDS monitoring and evaluation. Infrastructural capacity for M&E of HIV/AIDS activities will be reinforced through the provision and maintenance of telecommunications and ICT equipment for DIPE, PNPEC, PNLT and targeting regional and district health offices. MOH will expand and reinforce the use of TIM'S software (JHPIEGO) drawing decentralization actors in collaboration with MEASURE and RETRO CI. With MEASURE EVALUATION technical assistance the HMIS will be fully functional with the new integrated software SIGVISION at targeted districts prior to national roll out.

In order to facilitate improved monitoring of TB/HIV co-infection and ARV drug stocks at the decentralized level, the MOH, with technical assistance from SCMS, will train 25 district officers in the use of TB management software and adapt/test the ARV stock management software at district pharmacies.

Surveillance and targeted evaluations: In order to improve Cote d'Ivoire's strategic information capacity and better inform future HIV/AIDS interventions, MOH will undertake several activities in 2007: coordination of the 2007 ANC sentinel surveillance in collaboration with Projet RETRO-CI, including revising the survey protocol, training 15 trainers and 115 health agents, delivering survey materials, supervising sample collection, collecting and testing samples, and analyzing and disseminating results. The Ministry will also initiate the establishment of a system for ARV resistance surveillance by launching the first national ARV resistance survey in 2007. The National TB Program will conduct an evaluation on the effectiveness of INH prophylaxis in people living with HIV/AIDS (PLWHAs). In the area of training, the Ministry will train 25 regional and district directors in the use of HIV/AIDS data for local decision-making and program improvement.

Supervision/quality assurance: The Ministry will continue to build capacity for improved quality of HIV/AIDS data and services by training 25 regional and district directors in supervision of data collection and management, training and supporting 20 district health team officials in the supervision of facility-level data collection and management, and providing logistical and infrastructural support for the regular supervision of HIV/AIDS services and data collection at the district level. Plus up funds will be used to build the national capacity of systems and personnel to improve M&E and surveillance for rapid scale-up at health sector delivery sites nationwide.

This activity relates to other activities described in Measure SI (#10076), Abt Associates Other Policy (#9924), FHI Other Policy (#10078), and Projet RETRO-CI SI (#10199).

MOH has been working with Abt Associates to assess human-resource needs and available capacity in the public and private sectors, as the human and institutional capacities remain key issues constraining the scale-up of quality health services, including HIV/AIDS services. The shortage of human resources for health has become critical in Cote d'Ivoire given the prolonged politico-military and economic crisis. Building on FY06 activities and the strong relationship developed between Abt and the MOH, the USG proposes in FY 07 that Abt provide substantial technical assistance, beyond the human resources component to the MOH to complement the new MOH award in support of decentralized, sustainable, quality HIV services.

Based on discussions with the USG/CI and the MOH, a key objective is to strengthen the managerial and leadership capacity of health managers and administrators at central, district, and community levels to respond to the HIV/AIDS epidemic. These activities will support USG partners and the government of CI in implementing the EP and contributing to the achievement of national goals. To accelerate the decentralization process led by the MOH, Abt Associates will provide technical assistance to continue national studies on human capacity and the development of a human resource strategy for the health sector. In addition, Abt in collaboration with the MOH with provide TA for coordination, planning, harmonization of M&E tools and resource mobilization activities specifically in 10 districts that are the capitals of their region. This will allow the MOH to evaluate and expand its work nationally to reach all 16 regions by the end of the project. Furthermore, Abt Associates will provide technical assistance to the Ministry of Health to build institutional capacity at decentralized levels in key areas such as supervision, HR information systems, planning, policy implementation, coordination and use of data. The MOH and Abt will support training for (1) developing a coordination and planning matrix, (2) holding 3 consensus-building workshops on planning and coordination at central, regional and district levels, (3) building capacity (through a training-of-trainers approach) in planning and management of services in a decentralized system, and (4) developing and piloting tools for monitoring and evaluation tools of health workers performance in selected sites. The MOH will fund the conference logistics, trainers per diems, transport etc. To work in seamless coordination, Abt will fund a senior-level consultant to assist the Ministry of Health in planning and coordinating decentralized HIV activities with a focus on sustainability.

With FY06 funds, the MOH has set up a project management unit that meets Ivorian and US legal and financial requirements, including tax exempt status. A coordination of an evaluation was initiated in the district pilot initiative in San Pedro (IRIS). The pilot initiative in San Pedro involves a number of EP implementing partners that are providing a comprehensive continuum of prevention, care and treatment services across an entire district, both urban and rural. EP partners that are involved in this effort include FHI, EGPAF, ALLIANCE, ANADER as well as the Ministries of Health, Education and Social Services.

With FY06 funds, the MOH plans to perform a mapping analysis of the HIV interventions by capturing all CT, PMTCT, ART and other HIV-services by implementing partners, including donor or funding source and location (site, district and region). To build on the mapping analysis, the MOH will document existing collaborations with mayors, local governments and other stakeholders with the desire to foster these partnerships and promote local ownership and sustainability.

The MOH is also working with EP partners to develop systems, improved forecasting and other mechanisms to improve ARV drugs and other commodities procurement to avoid stock out and to consolidate expansion of PMTCT, VCT and ART services in close collaboration with SCMS/MSH. The MOH is developing a framework to coordinate laboratory activities between the national reference laboratory (LNSP) and laboratory network and EP funded partners Project RETRO-CI and APHL. The framework emphasizes quality assurance with supervision and support to decentralized HIV laboratory services.

Planning/Policy and Coordination: In order to strengthen its capacity for improved planning and coordination of HIV/AIDS programs and activities at all levels of the public

health system, the MOH will further develop and disseminate planning and supervision guides and tools for HIV/AIDS services (including ART, VCT, PMTCT, TB/HIV and STI). These guides will be geared to the district level and will help the staff make technically sound decisions in support of decentralized quality services

The MOH will also help districts develop integrated plans for HIV services (only within targeted districts in FY07). These districts will then have quarterly review meetings to measure their progress against the integrated plans. As part of its coordination effort, the MOH will organize the following meetings and will draw on the expertise of EP partners as necessary for the meetings: • Joint quarterly coordination meetings with partners implementing HIV/AIDS activities in the health sector; • Organize an annual review meeting (‘bilan") of HIV/AIDS activities in the health sector at national level; • Organize quarterly meetings of national HIV/AIDS technical working groups (care and treatment/palliative care, PMTCT, SI and VCT/biology); and • Organize bi-annual regional review meetings of HIV/AIDS services in the health sector in targeted regions including pilot regions of San Pedro/Bas Sassandra and Abengourou/Moyen Comoe. • Organize quarterly review meetings of HIV/AIDS services in the health sector in targeted districts;

Monitoring and Data Management: In order to strengthen the monitoring and support of decentralized HIV activities the MOH will complete a procurement plan to equip central and decentralized facilities with essential transport and communications equipment, especially for data managers and their offices. Data managers will also conduct monthly site visits and benefit from quarterly supportive supervision from regional or central (MSHP/DIPE) staff. The MOH will conduct supervision visits with district health teams to progressively transfer competence from the central or regional level to the district teams with on the job training for supervisors of HIV/AIDS clinical services, TB/HIV, data collection and management. The MOH and partners will also ensure that the DIPE maintains adequate archiving and documentation of HIV service related data in coordination with PNPEC, PNLT and PSP (electronic and paper-based).

Much of this work will building on previous efforts by EP funded partners such as the MOH, MSH, EGPAF, Measure Evaluation and MLS. The MOH (district and central level) will be assisted to submit budget requests to the GoCI (Ministry of Finance) and other donors or funding sources in 2008 with regards to the resource needs associated with the maintenance and extension of M&E activities in their districts.

Supervision and Quality Assurance: The LNSP will work with PNPEC, the national laboratory network and EP partners Project RETRO-CI and APHL to coordinate supervision and quality assurance of laboratory HIV and TB services at regional and district and site level focusing on targeted districts. To improve the quality of HIV services, the MOH will also revise and validate key policies limiting service expansion by WHO, the EP, and other large programs - especially policies relating to ARV treatment initiation and simplified HIV testing algorithms.