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: 2008 2009
SUMMARY
The Ministry of Health will continue to support 34 sites in staffing, equipment, and materials to test 90% of
pregnant women attending those facilities (50,000) and provide prophylaxis to at least 80% of the estimated
number of those who test positive. More focus will be put this year on in- depth education during pregnancy
alongside with psychosocial support, maternal care and prophylaxis regimen tailored to respond to
individual needs of women. Furthermore, support will be provided to sustain and expand an effort initiated in
2008, which consisted into the blending of community-based activities into PMTCT by a handful of sites.
With lessons drawn from that earlier experience 15 selected sites will be able to : carry out in collaboration
with I-TECH / INHSAC (See PMTCT narrative from ITECH) training sessions for traditional birth attendants
(TBA), equip and assist those latter for delivery of pregnant women at home, and use their channel to carry
out prophylaxis for pregnant women and their babies. Provisions will also be made to create better linkages
of PMTCT sites with the emerging USG supported community-based programs existing in their vicinity.
BACKGROUND
In FY 2008, through this cooperative agreement with the Ministry of Health about 30,758 women have been
tested at the 30 supported sites. Of the 897 women who tested HIV positive only 30% received a complete
package of prophylactic treatment. The basic package of services provided includes mainly: provision of
counseling services by providers in prenatal and maternity wards; prophylactic treatment to pregnant
women and their babies; support for delivery in hospital settings, and basic HIV care, as most of the PMTCT
sites provide HIV care as well. Despite the package available coverage remains low because of the weak
capacity of the system to adapt to individual needs; the absence of dedicated staff to manage cases and
navigate them through the different points of services as women and their babies must receive services
from different wards in the case of large hospitals ; the lack of manpower to track women and their babies at
home as 80% of women continue to deliver home and as existing community health agents tends to focus
more on patients on ARV and in care. There is a need in FY 2009 to go beyond the generic support offered
so far to bring to bear a new set of measures aimed at ensuring in-depth education for all positive women,
providing psychosocial support adapted to their individual needs, ensuring systematic adoption and
education of buddy companion (accompagnateur) to ensure treatment compliance, tailoring assistance
during delivery according to venue chosen by beneficiaries, and tracking systematically both women and
their babies. This enhanced strategy will require assignment of dedicated personnel such as case
managers, social workers and community health agents at the ANC and the maternity ward to ensure
individual monitoring of cases, and materialization of the integration of traditional birth attendants and
midwives to serve as buddy companion and supervise uptake of drugs.
Activity 1: Provision of a refined package of PMTCT services at 34 sites: The MOH will keep to 34 the
number of PMTCT sites and will provide them with support in staffing, equipment, materials and operational
costs to enable them to offer a full package of PMTCT services as defined by the national guidelines. The
scaling up to greater number of sites has been halted this year to allow the program to go much deeper in
its support to the sites by ensuring that enough resources are devoted to: the hiring of dedicated case
managers, social workers, and community health agents for PMTCT as opposed to continuing to
overburden existing ANC and maternity wards staff; the creation of support groups for positive pregnant
women; subsidies to defray costs for hospital visits, hospital delivery, and transportation to the hospital; the
setting up of infrastructure (personnel, file cabinets, PC) for supporting a newly revamped information
system, which is being developed by the Ministry of Health with the support of ITECH for the monitoring of
pregnant women.
Activity 2: Development of an enhanced community outreach component at 15 sites: Resources will be
provided to 15 sites to incorporate a community outreach component into their PMTCT program. More
specifically those sites will be able to set forth training programs and activities with TBAs, matrons, lay
counselors, community groups and agents to capacitate them to assist at home positive pregnant women
during pregnancy, delivery and post partum. The selection criteria for the sites include existing capacity to
host training activities, existence of nurse midwives or community who can backstop the outreach activities,
proximity of USG supported community programs that can wrap around the initiative. The funding will cover
the costs associated with: the logistics of training for the outreach component, and the home visits made by
the outreach component to pregnant women; and the procurement of materials for deliveries carried out by
TBA' and matrons
Activity 3: Promotion of PMTCT. The MOH will continue to promote PMTCT services via community events
including health fairs, face-to-face communication using a variety of channels such as churches, schools,
health facilities, home visits, and the media.
New/Continuing Activity: Continuing Activity
Continuing Activity: 17197
Continued Associated Activity Information
Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds
System ID System ID
17197 3851.08 HHS/Centers for Ministre de la 7688 3125.08 National AIDS $1,200,000
Disease Control & Sante Publique et Strategic Plan
Prevention Population, Haiti
9308 3851.07 HHS/Centers for Ministre de la 5134 3125.07 National Plan $580,000
Disease Control & Sante Publique et Mechanism
3851 3851.06 HHS/Centers for Ministre de la 3125 3125.06 $200,000
Disease Control & Sante Publique et
Table 3.3.01:
To supplement Track 1 activities.
SUMMARY: The project's main objective is to provide a safe and adequate blood supply to people living in
Haiti's 10 Departments. All program activities are coordinated by the Ministry of Health's National Blood
Safety Program (NBSP) trough a national network of Blood Service outlets. At the end of FY08 this network
consisted of 38 service units nationwide, including the National Blood Center in Port-au-Prince.
BACKGROUND: Since 1986, the Haitian Red Cross (HRC) has been mandated by law to manage the
blood transfusion system in Haiti. However, in 2004 only about 9,000 units of blood were available for
transfusion for a population of approximately 8.5 million. This shortfall indicated a significant need to
strengthen the blood service to meet the demand, estimated at between 20,000 and 40,000 units per year.
The need would be attained rapidly 50,000 to 80,000 if the Health System improved with some hospital
infrastructures. To address this issue, the NBSP was established with PEPFAR support. Within the MOH
the National Blood Management Unit was established to administer the program. The National Blood Safety
Committee was established to develop national policies and guidelines. The Haitian blood system is
comprised of a network of 18 blood collection and distribution centers supported by a central laboratory and
20 blood banks or blood depots (projected end of FY08). The goals of the program include : (1) To increase
the proportion of blood donated by volunteer, non-remunerated donors (VNRD); (2) to ensure that 100% of
all donated units are adequately screened for HIV1/2, HBsAG, HCV, syphilis, and HTLV 1-2); and (3) to
ensure proper storage, transportation, and distribution of blood under cold chain conditions. The NBSP has
sub-contracts with the HRC to manage the collection, screening and distribution network; with Population
Services International (PSI) for donor recruitment support; and with GHESKIO for laboratory QA/QC. Since
last year, we began to cooperate with Supplies Chain Management System (SCMS) for purchasing
reagents and materials.
ACTIVITIES AND EXPECTED RESULTS:The following activities will contribute to the PEPFAR 2-7-10
goals by reducing the incidence of transfusion-associated HIV infections. They will also strengthen the
overall health sector through training, QA/QC oversight, and outreach activities to build public trust in the
MOH.
Actvity 1: Continue to implement the Quality Management System throughout the national blood service
network and ensure that samples from all blood collected by the 18 blood collection units and mobile blood
drives are screened for HIV, HBsAG, HCV, Syphilis (Elisa), and HTLV 1-2 in a timely manner with adequate
quality controls.
Activity 2: Ensure that all 38 service units are fully functional particularly the new 20 blood depots. These
depots will supply blood to local and/or regional hospitals. Increasing the availability of blood at peripheral
hospitals will improve access to blood transfusion services for the community. We expect greater access to
blood transfusion will have a positive impact on patient survival rates, especially for women and children.
Work to expand the network will also include an initiative to strengthen the logistical network between
peripheral sites and the National Blood Center laboratory in Port-au-Prince. All laboratory testing will
continue to be done at the NBC.
Activity 3: Strengthening the relationships between the Haitian Red Cross, PSI and the MOH's health
promotion department to develop a large network of public "ambassadors" (promoteurs) to assist the blood
service to recruit and retain VNRD. These individuals will help promote voluntary blood donation in their
communities. We advocate and lead creation of Voluntary Regular Donors Club around the regions of the
country. This work will contribute to the blood service's goal of increasing the proportion of blood collected
from VNRD from 40% to 80%. During all the past period, the rate of ITT stays at 10%, we consider it as a
long diffusion period for promoting voluntary blood donation, now we have to consolidate it and expect that
the rate of ITT decreases at least of 7%.
Activity 4: Launching the National Blood Distribution Network. This system will improve the management of
safe blood stocks, decrease blood wastage (e.g., sites with low stocks of certain blood types will use the
network to identify excess stocks at nearby sites), and improve the public's access to safe blood. Improved
communication, via conventional voice (i.e., cellular) and new e-mail systems, will enable relevant stock
data to be shared in a timely manner. The MOH will achieve cost efficiencies by reducing the amount of
blood lost to spoilage. Patients will benefit from an increased availability of blood throughout the network.
The electronic communication network is phased in using appropriate technologies (e.g., local internet
service providers instead of VSAT). We have to realize monitoring and evaluation to maintain its
performance and to ensure that the goal is attained.
Activity 5: Strengthen links with other program areas. This work will ensure that advances in blood safety
contribute to national public health goals. Priority will be given to regions or facilities with high rates of
maternal mortality, as identified by the MOH division of family health. The blood service will also strengthen
its referral system to ensure that donors who test positive for HIV or other infectious markers receive
appropriate follow-up testing (VCT) and/or care and treatment. The blood service will also share guidelines
and experiences with the National Public Health reference laboratory on testing methods and with the
Expanded Programme on Immunization (EPI) on ways to strengthen the national blood cold chain and to
extend immunization against HBV to young regular blood donor as the Club 25 members. We work for
having a strong link with MOH departmental directions and epidemiology services (regional and national).
Activity 6: Continue implementing a solar energy strategy in part of the national blood service network: four
solar freezers are successfully installed in four regions for permitting to have frozen plasma in regions. We
plan for having solar refrigerator in some areas where gas provision is so difficult. This strategy will help
address a chronic lack of electrical power throughout the network. Some technical assistance in the area of
solar and other energy options will be provided by USAID.
Activity 7: Increase the number of units of blood collected, especially from repeat VNRD. The goal is to
collect 27,500 units of whole blood and incorporate in the national network of blood transfusion MSF
Activity Narrative: (Médecins Sans Frontières) blood activities. Half of these units will be fractionated into blood products (e.g.,
red cell, platelets, fresh frozen plasma). Recruiting a larger pool of voluntary blood donors who donate
several times a year will ultimately reduce mobilization costs and decrease the prevalence of TTI in the
donor pool.
Activity 8: Continue training physicians, nurses and other clinical staff (e.g., midwives) in the proper clinical
use of blood. In the first four years of the project, training focused on staff in the departmental hospitals.
The training program will now be expanded to all clinical professionals in the departments (regions) who
interact with the blood service. Training will also target blood bank managers to ensure that barriers to
patient access are identified and removed. Additional training will be held within hospitals to strengthen
hemovigilence committees. Reducing unnecessary blood transfusions will avoid unnecessary blood
shortages. Continuing Education appears as an important way to fill some gaps of the professional training
in transfusion practice. Removing barriers to patient access (e.g., requiring patients to provide their own
cold boxes) will improve the public's trust in the blood service. We continue to improve blood service
delivery by encouraging delivery from professional to professional as it is done in many regions of the
country.
Activity 9: Monitoring and Evaluation. Information collected via the National Blood Distribution Network
database will be constantly monitored and studied for trends. These data will be used to improve the
program or blood transfusion practices in Haiti. Data will also be used to inform donor recruitment efforts
and blood transfusion realization for permitting to MOH authorities to take better decisions in Public Health
Activity 10: Sustainability. Continue to advocate for increased funding from the national treasury.
Negotiation is begun with MOH for increasing national participation funds, the need to have a New National
Blood Transfusion Center is accepted and we expect to have available funds for beginning the building.
Diversifying the National Blood Safety Program's funding sources (currently dominated by PEPFAR) and
realizing advocacy for having more funds will ensure the long-term sustainability of the safe blood initiative
in Haiti, and help Haiti reach its goal of eliminating patient fees for blood. These fees currently present a
barrier to access for many poor Haitians. The NBSP will also continue to advocate for final passage of the
new blood service legislation now before the Haitian parliament.
Activity 11: Implement a National Hemovigilence System in cooperation with the Quebec National Institute
of Public Health and French blood transfusion services via Martinica. We expect to track blood transfusion
accidents or incidents for improving the service and participating to solve some gaps in the health system
Activity 12: Continue to improve relationship with local representatives of SCMS (System Chain
Management Services) for preventing shortage of reagents and materials and for ensuring a good quality
service to the population.
New/Continuing Activity: New Activity
Continuing Activity:
Table 3.3.04:
SUMMARY: The main goal of this project is to reduce the transmission of HIV/AIDS by promoting safe
injections through implementing the three-part strategy recommended by the Safe Injection Global Network
(SIGN): 1) Change behavior of health care workers and patients to ensure safe injection practices and
reduce demand for unnecessary injections, 2) Ensure availability of safe injection equipment and supplies,
3) Manage sharps waste safely and appropriately. In FY08, JSI expanded the program to nationwide
coverage. In FY09, JSI will transition the program to the Ministry of Health.
BACKGROUND: The Safe Injection project started in Haiti in July 2004 with funds from PEPFAR. This
project is commonly known by the abbreviated project name Making Medical Injections Safer (MMIS). The
main goal of this project is to reduce the transmission of HIV/AIDS by promoting safe injections through
implementing the three-part strategy recommended by the Safe Injection Global Network (SIGN). An
assessment of injection safety and waste management issues was conducted in 2004, and the results
reveled that there were no norms and standards for injection safety. Specifically, the problems were
associated with the following identified issues: non-motivated, non-trained staff unaware of the risk
associated with unsafe injections; lack of injection materials in health facilities; lack of infrastructure for
waste collection, treatment and disposal which included no municipal waste disposal, and lack of
supervision of health facilities.
These factors resulted in waste being accumulated on the grounds of the health facilities because of a lack
of knowledge, lack of high performance incinerators, and lack of transportation and a municipal waste
disposal system. Since the initiation of the PEPFAR funding for safe injections, JSI has been working to
address the identified issues through training health care workers regarding safe disposal of shapes waste,
distribution of wall mounted disposal boxes, supporting and strengthened the MOH to develop regulations,
coordinating installation of incinerators throughout Haiti, and implementing a behavior change
communication program targeted at health care workers and clients to reduce the demand for unnecessary
injections.
ACTIVITIES AND EXPECTED RESULTS
JSI will work collaboratively with the MSPP on the following activities until mid FY09. Once JSI's agreement
ends, the transition will be complete to the MSPP who will be responsible for the continuation of the
following activities:
Activity 1: Implement safe and necessary injections as a quality standard in the curative sector. Training will
be conducted with health personnel and support staff in all health facilities at the departmental level. The
training will cover safe injection practices, use of safe injection devices, improved waste logistics
management training as well as interpersonal communication. Training will be conducted on a large scale in
order to achieve nationwide coverage. Thus training will be conducted with, training of trainers, students at
INSHAC and Nursing schools, pre-scribers, frontline health care providers, waste handlers, and supply
managers.
Activity 2: Planning workshops will be conducted at the departmental level in the expansion departments
(Artibonite, centre, Nord-oeust and Ouest) to improve injection safety and waste management in the
facilities. This activity aims at designing and implementing plans for training roll out, supervision, logistics
and supply (mainly syringes and safety boxes), BCC and sharp waste disposal.
Activity 3: Implementation of a behavioral change strategy to reduce unnecessary injections and promote
safe injection practices. BCC materials produced during the FY07 will be disseminated. They were
elaborated with the participation of BCC staff in all 10 departments. They consist of flyers, posters, radio
and TV messages.
Activity 4: Strengthening systems to improve waste management in target areas. MSPP will continue to
promote the need for a national waste management plan, will work with target department for the
elaboration of waste management departmental plan, will help build two waste storage sites, will work with
UNICEF for the installation of the new incinerators and ensure that the staff is properly trained to use them
correctly.
EMPHASIS AREAS:
Commodity procurement
Logistics
IEC
Training
Table 3.3.05:
The narrative will be modified as follows:
In order to improve results and to better focus resources, the MOH will target only 25 clinics to be enhanced
to deliver a full package of care and support services. The 5 other sites that are still targeted to provide
counseling and testing (CT) services will be linked to other sites where basic care and ARV services are
being provided for continuum of care for the HIV positive patients detected at these sites.
MOH will strengthen linkages between the care and support sites and antiretroviral (ARV) sites located in
the same geographic area to ensure continuum of care for patients in need of ARV services.
Narrative:
SUMMARY: The Ministry of Health (MOH) will sustain the provision of a basic package of palliative care
services within a network of 30 public sites including dispensaries, community hospitals, departmental
hospitals and University Hospital spread across the 10 geographical departments of the country. In Fiscal
Year (FY) 2008 efforts will be devoted to: (i) ensuring that the ratio of clinical personnel per patient is
adequate, (ii) hiring more social workers and community health workers (iii) creating more people living with
HIV/AIDS (PLWHA) supports groups, and (iv) continuing to subsidize patients for hidden costs linked to the
access to services. The program will focus on: (i) expanding capacity of palliative care sites to perform
follow up of stable patients on anti-retroviral (ARV) services, (ii) developing a post graduate nurse
practitioner program, and (iii) creating at the regional level capacity to provide training in basic community
care and support to community health workers. The emphasis areas for this component are: (i) community
mobilization and, (ii) human resource development. The primary targets are the 15,000 patients expected to
be served by this network in FY 2008.
BACKGROUND: The President's Emergency Plan for AIDS Relief (PEPFAR) funds a network of public
health sites through a variety of funding mechanisms. In FY 2006 and FY 2007, many of these sites have
become voluntary counseling and testing (VCT) sites though United States Government (USG) support.
The 25 sites currently functional out the 30 planned for FY 2007 have tested 45,466 patients from October
2006 to May 2007 and have enrolled 6,958 patients over two years of providing services. One of the
challenges to the program has been retaining positive patients after they are screened.
For instance 58% of the 4,665 patients who tested positive from October 2006 to May 2007 have been
enrolled into care. This suggests interventions are needed not only at the site level, but also at a broader
level to remove some of the structural constraints that affect the provision of care, generally. Indeed, the
fact that providers of care, so far, remain restricted only to physicians (who are in short supply) limit the
number of providers available to provide care. The re-introduction of community health agents in the public
sector, after more than 30 years, has provided the sites with increased capacity to reach patients within
their families and their communities. However, there are very few places where community health agents
can receive training and acquire the competencies needed to do their job. The Ministry of Health (MOH) is
ready to take the necessary steps in FY 2008 to address those structural problems by, for instance,
initiating a nurse practitioner program to prepare nurses to head services at the peripheral sites, and by
creating capacity to train health workers in several departments.
ACTIVITIES AND EXPECTED RESULTS:
Activity 1: Provision of field support to 30 sites to enhance their clinic-based activities for management of
OIs through appropriate diagnosis and treatment, and organization of nutrition and psychological support
services. These sites include: three large university hospitals, nine geographical departmental hospitals,
and multiple community hospitals and health centers. The sites are expected to provide services to a
network of 15,000 patients. Funding will cover the cost for a trained multidisciplinary team composed of
physicians (only for large sites), dedicated nurses, social workers, laboratory technicians, and community
health workers. The funding will also support basic office and medical equipment, supplies, and utilities
such as water, communication, and power. Some refurbishing will be allowed especially to enhance
laboratory capacity, drug storage, and clinical management.
Activity 2: PLWHA retention package: Across the board, the attrition of patients enrolled in care remained
fairly high (about 40%). The program this year will try to address some of the contributing factors in a
discrete fashion by earmarking funding destined to these activities so that they are not used for other
priorities at the facilities. Social workers, who are directly in contact with patients, will trigger the expenses.
This component will cover the: (i) the multiplication of PLWHA support groups so that at least 80% of
patients can join those groups. It has been noted that participation in support groups has improved patient
adherence to treatment as well as their acceptance of the disease. However, limited resources has only
allowed each site to constitute, on average, three groups of 25 patients, (ii) subsidies for travel cost for
patients and their accompagnateurs when they visit the clinic, and (iii) subsidies for additional costs related
to laboratory and medical procedures not covered directly by the program, but which are necessary.
Activity 3: Home based care: MSPP will increase the number of community health workers to
accommodate a scale-up of care to patients at each of the sites within its network. The community workers
will be in charge of tracking patients (including pregnant women enrolled in PMTCT and infected and
exposed children), provide at home adherence support, health education on best health and nutrition
practices, counseling for positive behavior, distribution of care and preventive commodities such as
condom, ORS, and pain medications, according to the guidelines, and to make appropriate referrals.
Appropriate training will be provided to the community workers on symptom recognition, and syndromic
treatment, particularly when they have patients experiencing health or psychosocial problems.
Activity 4: Development of a post graduate nurse practitioner training program. Currently nurses are the
most vital and the most stable element of the program with functions varying from site managers,
counselors, nursing care, to drug dispensers. The majority live in the communities where they work and
represent six to eight times the number of physicians available nationwide. Having nurses trained as
practitioners would rapidly increase access to services. There is also need to improve skills in nutrition
assessment and management of malnourished PLWHA. Nurses would not only provide palliative care
Activity Narrative: services, but would also provide primary clinical management of stable ARV patients under the oversight of
their referral centers. This will increase the operational capacity of the ARV sites, which are overburdened
currently, to recruit and treat more patients. The curriculum of the course is in development by ITECH and
the Ministry of Health would support training logistics, which would take place at two of the university
hospitals: Hopital Universaire d'Etat de haiti (HUEH) and Hopital La Paix. One hundred nurses would be
trained at an average cost of US $ 800 per nurse. A total of $800,000 would cover living stipends of the
fellows.
Activity 5: Development of capacity at the regional level to train community health workers. Community
health workers (CHW), under the supervision of the social worker, serve as the principal liaison between the
health facility and PLWHA. They usually conduct home visits of PLWHA, ensure adherence to drug
regimens, provide advice on personal care, identify or help develop self-support groups to which PLWHAs
could be enrolled, help plan community meetings to dispel myths about HIV and combat stigma, refer
PLWHAs needing acute care to the nearest health facility, and refer PLHWAs in need of economic or
nutritional support to the appropriate agency. Initially, when there were only two training models on which to
build—GHESKIO and PIH—training was limited. However, there are now centers of excellence in each
departmental directorate, and it is possible to tap into existing teaching capacities and train community
health agents locally. Four hundred CHWs would be trained.
Continuing Activity: 17198
17198 5472.08 HHS/Centers for Ministre de la 7688 3125.08 National AIDS $1,100,000
9314 5472.07 HHS/Centers for Ministre de la 5134 3125.07 National Plan $800,000
5472 5472.06 HHS/Centers for Ministre de la 3125 3125.06 $600,000
Table 3.3.08:
The narrative is modified in the following way:
Thru COP 09, the MOH will undertake the following additional activities:
1. The MOH, through the electronic database system, will closely monitor the outcomes of the treatment
program at each of its five ARV sites such as: Cluster of Differentiation 4 (CD4) changes, mortality rate,
patient adherence etc. The data will be reviewed every three months by a team of mentors and poor
outcomes will be addressed and corrected.
2. MOH will collaborate with training institutions such as the Haitian Group for the Study of Kaposi's
sarcoma and Opportunistic Infections (GHESKIO) and the International Training and Education Center on
HIV (I-TECH) to train nurses to deliver treatment services in order to reinforce and expand this program at
the different sites.
3. MOH will collaborate with NYAIDS Institute and Center for Disease Control to ensure that the HIVQUAL
QA/QI model is fully integrated in its five ARV sites to ensure continuous improvement in the infrastructure
and service quality at these sites.
SUMMARY: Through a cooperative agreement (CoAg) with the Ministry of Health (MOH), the United States
Government (USG) team in Haiti will support the scale up of on-going ARV services at the State University
Teaching Hospital (HUEH) and five other major public sites: La Paix Hospital (a new university teaching
hospital) serving the large commune of Delmas, Sainte Therese Hospital in the Nippes Regional
Department, Immaculee Conception Hospital and Jean Rabel Hospital in the North West Regional
Department, and Isaie Jeanty Hospital (another University teaching hospital) in the West Department. The
major focus of this activity will be to support the overall service organization at these sites to deliver quality
treatment services. These resources will continue to be integrated with those allocated through International
Training and Education Center on HIV (I-TECH) to support technical assistance and clinical mentoring at
the HUEH and Isaie Jeanty as well as with those allocated through the MOH to support CT, PMTCT, and
palliative care services at the four targeted public sites. In addition, Isaie Jeanty, HUEH and La Paix, as
University Teaching Hospitals, will serve as venues to train interns and residents on HIV treatment. With
these resources, the MOH will directly manage six of the forty-one anti-retroviral (ARV) sites which will be in
place by the end of September 2008. The other thirty-five sites are being supported through the Haitian
Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Partners in Health
(PIH), AIDS/Relief Consortium, Management Science for Health (MSH), and I-TECH. MOH will continue to
be supported to play its critical role in creating a good policy environment and coordinator of the program.
BACKGROUND: Over the last three years, the publicly-managed sites have increasingly become the major
focus of the USG effort to expand clinical and ARV services. Most of these sites serve large and needy high
-risk populations in the urban and metropolitan area. The major departmental hospitals have been
supported through GHESKIO, PIH and, more recently AIDS/Relief, to deliver all clinic-based services (CT,
PMTCT, clinical care and anti-retroviral treatment [ART]) in integration with other support from the Global
Fund to Fight AIDS, Tuberculosis and Malaria (GFATM). Many deficiencies in these hospitals led to multiple
challenges to the implementation of services at these public sites; however, the USG was able to allocate
the necessary resources to make this approach successful.
Over the last two years, the USG has provided resources directly to the MOH through a cooperative
agreement (CoAG) with CDC to implement ARV services in six publicly managed sites, including HUEH, the
biggest university teaching hospital in the country. These resources have been complementary with other
resources provided to the MOH to support a network of 20 institutions to provide integrated CT, PMTCT,
TB/HIV and basic care.
Because of the delay in receiving FY 2007 resources, most activities planned this year to strengthen the
MOH network have just begun. This includes the launch of 10 new palliative care sites (for a total of 20),
and the expansion of ARV services to Isaie Jeanty, one of the largest maternity wards in the country. The
new launch of ARV services in the four other publicly managed hospitals are on track as planned. These
include: Sainte Therese and Immaculee Conception/Port-de-Paix hospitals, which are departmental
hospitals located in departments with the highest prevalence of HIV; Jean Rabel Hospital, which is located
in the very hard-to-reach North West Regional Department and is in need of more accessible ARV
services ;and La Paix Hospital serving Delmas and Tabarre communes. HUEH, in spite of many
challenges, including numerous personnel strikes that has jeopardized its ability to provide services, was
able to commence delivering ARV services. This facility has also benefited from resources from GFATM
which was used to support expansion of counseling and community outreach activities. HUEH is enrolling a
mean of 30 ARV patients each month. In coordination with I-TECH, the MOH has recently launched a new
in-service training center at HUEH that will complement GHESKIO and PIH's ARV service delivery training
capacity.
MOH has also has support to reinforce its logistic and human capacity at central and departmental levels to
play a greater role in coordinating the program. Through HIVQUAL and CDC, and with the support of major
stakeholders, the MOH has started to strengthen the national system of QA/QI. MOH plans to use experts
from HUEH and the regional centers of excellence to be the technical arms through which QA/QI activities
could be implemented .
FY 2008 resources will be used to maintain all these activities with particular emphasis on rolling out a good
QA/QI system. MOH will ensure that national norms and procedures are followed for the delivery of
continuous quality of HIV treatment across all the networks.
ACTIVITIES AND EXPECTED RESULTS: Activity 1: The MOH will continue to build on resources
allocated for other program activities such as CT, PMTCT, and palliative care, to enhance infrastructure,
provide medical equipment and materials (including laboratory), hire additional clinical personnel
(physicians, nurses, psychologists, counselors and social workers), and support additional community
personnel to expand ARV services at HUEH and at other ARV sites in the network. Training and refresher
courses will be realized for the personnel of the MOH network at HUEH . Resources will be used to
Activity Narrative: continue supporting the current successful models of treatment which are based on high-quality clinical and
lab assessments of patients to determine ARV eligibility; high-quality counseling and education of patients,
family members and "accompagnateurs;" and on a high-quality pharmacy and community support plan to
ensure adherence to treatment.
Activity 2: The MOH will continue to build on resources available through I-TECH for clinical mentoring,
training and technical assistance to reinforce the teaching of HIV treatment protocols for interns and
residents at the three teaching hospitals--HUEH and Isaie Jeanty and La Paix. MOH will provide resources
to enhance training capacity and support logistic equipment and materials costs. Continuing education
sessions will be held for the staff to keep them abreast of new developments in ART care relevant to their
functions.
Activity 3: Strengthen referral linkages. In the different areas where the five MOH sites are located, there
are a number of private and public hospitals offering voluntary counseling and testing (VCT) services. The
MOH will establish a referral system between these peripheral sites and the ARV sites to ensure a
continuum of care to patients. In addition, these ARV sites will be linked to the community-based-
organizations (CBO) and People living with HIV/AIDS (PLWHA) support groups to provide integrated
community support for patients enrolled in treatment.
Activity 4: At the MOH Central Office, a multidisciplinary team (clinician, counselor, social worker and lab
technician) will be established to coordinate the program. With the technical support of CDC and HIVQUAL,
MOH will build his capacity to expand the national system of QA/QI that will be launched this year. Funding
will also be used to disseminate the national treatment guidelines that were updated this year.
Targets:
Number of interns and residents trained (pre-service training): 350
Number of health professionals trained (in service training): 100
Number of PLWA actively enrolled in ARV: 2300
Continuing Activity: 17201
17201 5412.08 HHS/Centers for Ministre de la 7688 3125.08 National AIDS $7,800,000
9313 5412.07 HHS/Centers for Ministre de la 5134 3125.07 National Plan $4,645,000
5412 5412.06 HHS/Centers for Ministre de la 3125 3125.06 $300,000
Emphasis Areas
Human Capacity Development
Estimated amount of funding that is planned for Human Capacity Development $1,000,000
Public Health Evaluation
Food and Nutrition: Policy, Tools, and Service Delivery
Food and Nutrition: Commodities
Economic Strengthening
Education
Water
Table 3.3.09:
The narrative will be modified in the following ways:
SUMMARY. The Ministry of Health (MOH) will sustain the provision of a basic package of palliative care
BACKGROUND. The President's Emergency Plan for AIDS Relief (PEPFAR) funds a network of public
ACTIVITIES AND EXPECTED RESULTS.
Activity2: PLWHA retention package: Across the board, the attrition of patients enrolled in care remained
Activity Narrative: assessment and management of malnourished PLWHA. Nurses would not only provide palliative care
services, but would also provide primary clinical management of stable ARV patients under the oversight of
Targets.
Number of service outlets providing HIV-related care palliative care: 30
Number of individuals provided with HIV-related care and support (excluding TB): 12,000
Number of individuals trained to provide HIV-related palliative care: 500
Emphasis areas:
Development of networks/linkages/Referral systems: 70%
Linkages with other sectors/initiatives: 20%
Training: 10%
Estimated amount of funding that is planned for Food and Nutrition: Policy, Tools $50,000
and Service Delivery
Table 3.3.10:
1. The MOH, thru the electronic database system, will closely monitor the outcomes of the treatment
program at each site such as CD4 changes, mortality rate, patient adherence etc. The data will be reviewed
every three months by a team of mentors and poor outcomes will be addressed and corrected.
2. MOH will collaborate with training institutions such as GHESKIO and I-TECH to train nurses to deliver
treatment services in order to expand this program at the different sites.
continue supporting the current successful models of treatment which are based on high-quality clinical and
Activity Narrative: residents at the three teaching hospitals--HUEH and Isaie Jeanty and La Paix. MOH will provide resources
Program Budget Code: 12 - HVTB Care: TB/HIV
Total Planned Funding for Program Budget Code: $3,270,000
Total Planned Funding for Program Budget Code: $0
Program Area Narrative:
The national incidence of tuberculosis (TB) in Haiti is 132/100,000 in 2006, down from 180/100,000 in 1995. There is an estimated
20% seroprevalence of HIV in TB patients. This situation is aggravated by a growing number of multi-drug resistant TB (MDRTB)
cases in the country. Although the prevalence of MDRTB in Haiti is not known it is, however, potentially a very serious problem as
the neighboring Dominican Republic (DR) has the highest rates of MDRTB in the Caribbean, while Haiti has the highest sero-
prevalence rates of HIV/AIDS in the region. Since 1998, the Minister of Health (MOH) has embraced the directed observed
treatment short-course (DOTS) strategy in order to strengthen the national TB program. In partnership with three non-
governmental organizations (NGOs), International Child Care (ICC), Cooperative for American Relief Everywhere (CARE) and
Center for Development and Health (CDS), the Ministry of Health (MOH) has taken steps to implement TB/DOTS clinics in all 10
geographical departments in Haiti.
In addition efforts were made to improve the management capacity of the TB program at central and departmental levels by
putting in place national systems for planning, monitoring, quality assurance/quality improvement (QA/QI) and logistics. Recently
the TB MOH central staff has been reinforced with a TB/HIV coordinator. So far, there are 200 TB/DOTS clinics throughout the
country. Many of these clinics are integrated in facilities with other health services and primary health care programs; however,
very few of them (about 8) are stand alone TB clinics with no other health services. The United States Agency for International
Development (USAID) and the Global Funds (GF) are major donors for this TB program. Most of their resources are channeled
through the three NGOs (ICC, CARE and CDS) that provide direct support for services at the TB clinics as well as technical
management support to the MOH. In addition, the MOH has established a system of QA/QI for TB testing thru the National
Reference Lab and ICC. There is limited infrastructure capacity compared to needs. The Haitian Group for the Study of Kaposi's
Sarcoma and Opportunistic Infections (GHESKIO) is the only setting in Haiti that can perform TB culture. There are only two
hospitals that provide treatment for MDRTB patients: one managed Partners In Health (PIH) and the other one by GHESKIO.
Since 2005, the USG Team has been taking steps to reinforce TB/HIV program building on the national TB/DOTS program and
the successful implementation of counseling and testing (CT), HIV clinical care and ARV services throughout the country. This
takes advantage of the fact that most of the facilities with HIV care and ARV sites offer TB services. The overall strategy has been
to integrate TB screening and prophylaxis in all HIV care services thru the different HIV care and treatment networks, to integrate
HIV testing and care in TB services thru the TB networks and to establish linkages between the TB and HIV services in order to
provide a continuum of care for co-infected patients based on the national norms. This strategy has been implemented with few
efforts and resources in facilities where both TB and HIV services co-exist. Most of the HIV sites have been reinforced to perform
TB screening with Purified Protein Derivative (PPD) testing and to provide isoniazid (INH) prophylaxis according to national
protocols. In TB clinics with no HIV services, particularly those with high volume of TB patients, efforts were made to integrate
there a package of CT and HIV care services and to refer patients in need of highly active antiretroviral therapy (HAART) to ARV
sites. So far throughout the country ten (10) of these TB clinics have been reinforced with this package thru ICC. In the rest of the
TB clinics with no HIV services, efforts were made to refer TB patients to the closest HIV sites for testing and HIV care and
treatment as needed.
As a result of these efforts, thru the care and treatment and TB networks about 90 sites are offering integrated TB/HIV services.
All HIV patients have access to TB screening as well as to TB prophylaxis and treatment as needed. Most of the TB patients have
access to HIV screening and care if needed. Although the monitoring system for TB/HIV is yet to be well structured to capture the
outcomes of this program, this year it was reported that at least 7000 TB patients, that represent about 60% of the patients treated
this year, have been tested for HIV.
With FY 2008 resources, efforts are being made to strengthen the TB/HIV program by ensuring that all HIV patients enrolled in
care at every site receive access to TB screening as well as needed prophylaxis and treatment. Emphasis is being placed on
establishing chest X-ray diagnosis capacity in at least 20 public sites to improve TB screening and diagnosis. A better referral
system is being established between HIV and TB wards to improve care for co-infected patients. Five additional TB clinics with no
HIV services and with high volume of patients will be targeted to be integrated with a package of testing, CT, and HIV basic care.
In collaboration with GHESKIO, a leading Haitian HIV care and treatment institution, the USG has recently launched a center of
excellence in TB/HIV at Sigueneau Hospital, specializing in TB care, that can deliver state of the art training in TB/HIV for all the
other networks and, in collaboration with the Global Fund, treatment services for MDRTB. Efforts are also being made to
establish TB culture, initiate monitoring of drug resistance, and reinforce the system of QA/QI for TB testing thru the National
Reference Laboratory. In addition, tools to improve monitoring of the outcomes of patients with co-infection have been developed
and steps are being taken to implement them.
With FY 2009 resources, the USG will continue to expand ongoing activities and address major issues. The USG will continue to
address some of the major gaps such as the lack of TB infection control activities and full integration of TB/HIV in the national HIV
QA/QI system and in pediatric care, as well as the lack of a decentralized capacity to perform TB culture and monitor resistance.
The USG will work closely with MOH, the Global Fund and key leading TB NGOs (ICC, CARE, and CDS) and leading HIV
networks, such as MOH, GHESKIO, PIH, AIDSRelief and MSH, to address these gaps. The USG will ensure that the TB/HIV
programs and activities are in accordance with national policies and that strategies to diagnose and manage co-infection TB/HIV
are an integral part of the HIV and TB National Strategic Plan.
At the policy level, the USG will ensure that norms and protocols for TB/HIV are fully integrated in HIV training curricula. A
particular emphasis will be placed on reviewing and updating protocols and guidelines for infection control, TB/HIV pediatric care
and monitoring of TB drug resistance. At the program level, emphasis will be placed on improving coordination, planning and
monitoring of TB/HIV programs through the lead TB and HIV NGOs and the MOH. Additionally, the program will focus on
improving management at the departmental level and integrating the overall USG effort to decentralize PEPFAR planning and
coordination. The program will expand training on TB/HIV co-infection through Sigueneau Hospital, the TB/HIV center of
excellence. The logistics of key laboratory commodities and drugs will be improved thru the Supply Chain Management System
(SCMS) with funds allocated for this purpose. Monitoring tools will be in place in concert with the electronic medical record (EMR)
and the QA/QI system that are being enrolled in the HIV sites with the technical support of HIVQUAL.
At the operational level, HIV care and treatment sites will continue to receive support to screen (with both PPD and chest X-ray)
all HIV positive patients for TB and to provide TB treatment and prophylaxis as needed in integration with TB services. All TB
patients will continue to be targeted to receive CT services as well as HIV care and treatment services if needed. Efforts will be
made to ensure that TB/HIV is fully integrated in pediatric care as this is being expanded. In addition to Sigueneau, a new TB/HIV
center of excellence for training and QA/QI will be created through Grace Children's Hospital. A system to track suspected TB
drug resistance cases, to collect sputum specimens from these cases and to process them to the National Lab for TB culture and
resistance testing will be implemented at all the HIV/TB sites (see Laboratory section). TB infection control measures will be fully
implemented at all major hospitals according to norms.
The main partners for this program will be: 1) the lead TB networks such as ICC and a new TBD partner; 2) the lead HIV care and
treatment NGOs to maintain TB screening, prophylaxis and treatment for HIV patients in their respective networks; 3) GHESKIO
to support Sigueneau Hospital as a Center of excellence. The National Reference Laboratory (see Laboratory section) will
receive funding for expansion of TB culture diagnosis and drug resistance testing that will be initiated this year in order to monitor
TB drug resistance throughout the country. SCMS will continue to manage the logistics of drugs and laboratory commodities while
the MOH will receive support to continue ensuring coordination at both central and departmental levels of the program.
Table 3.3.12:
SUMMARY: The Ministry of Health (MOH) is the primary regulatory entity for health care service delivery in
Haiti, including HIV services. It is also the most important provider of health services, with a network of
dispensaries, community hospitals, regional departmental hospitals and a University Hospital. With support
from the President's Emergency Plan for AIDS Relief (PEPFAR), counseling and testing (CT) services, care
and treatment services, including TB/HIV have been implemented at numerous public facilities. The
challenge has been to reinforce infrastructure, equipment and human capacity to provide quality services at
these facilities. PEPFAR resources will be used to continue supporting TB diagnosis capacity at all major
public sites in order to enhance TB/HIV services. As HIV care and treatment is being expanded thru the
MOH important network of 30 sites, resources will be also used to ensure that all HIV patients get access to
TB screening, prophylaxis and treatment. This effort will be integrated in existing effort to reinforce human
capacity, infrastructure, lab and logistic to expand HIV services at these sites.
BACKGROUND: TB/HIV activities have been fully integrated within the MOH network. Based on MOH
norms and policies, all of the CT, care and treatment centers of this network have been reinforced to
perform TB screening and diagnosis with PPD, test sputum smear and to provide INH prophylaxis. Also the
TB clinics located in the facility where HIV services have been integrated were reinforced with counseling
services and linkages were also established between the two programs to ensure continuum of care for co-
infected patients. Based on national norms, it's critical to make available the capacity to perform chest Xray
for TB diagnosis in the context of HIV/AIDS. This year, with FY 2008 resources, 10 major public hospitals
will be reinforced thru MOH with equipment and materials to perform chest XRay for HIV patients.
This year a particular effort will be made to improve the quality of care to co-infected patients by ensuring
better integration of TB services in the HIV care and treatment units. Particular emphasis will be put on
building the capacity of the personnel of these units to manage these co-infected patients.
Activity 1: Within the MOH network of 30 HIV sites, resources will be used to continue supporting TB
screening and diagnosis capacity including purified protein derivative (PPD) and sputum smears as well as
training of health professionals in TB screening and prophylaxis. As 10 of the major public hospitals of this
network will be, in addition, reinforced this year with XRay equipment for TB diagnosis, MOH will ensure
continuing supply of related materials and commodities to perform chest XRay. Resources will be also
used to ensure regular maintenance of the equipment. The MOH will establish referral system between the
sites with XRay capacity and peripheral sites at each department to ensure that all eligible patients get
access to chest XRay for TB diagnosis.
Activity 2: The MOH will continue to ensure that TB services are more integrated within the HIV care and
units by ensuring that HIV patients infected with TB get proper treatment at these units. Efforts will be made
to train the personnel in the delivery of care and treatment to co-infected individuals and to provide them
with appropriate tools and logistics for TB care. Particular emphasis will be put on improving the monitoring
system to ensure proper follow up of patients and of the program.
Activity 3: The MOH will reinforce its supervision and QA/QI team to improve in collaboration with other
stakeholders, such as International Child Care (see ICC activity narrative), the monitoring of the TB/HIV
program. Resources will be used to train this team in TB/HIV thru GHESKIO and to support its travel costs
to the different sites.
Activity 4:The MOH will work with stakeholders to review and disseminate the norms, protocols, guidelines,
and training tools for TB/HIV, particularly those related to TB infection control, TB/HIV pediatric care,
monitoring of the program, and of TB drug resistance. MOH will be a key player for implementing and
monitoring infection control measures according to the national norms and guidelines. MOH will also
participate in the national TB drug resistance plan by allocating resources to the network for tracking of
suspected TB drug resistance cases, collection of sputum specimens from these cases and processing of
these specimens to the national lab for TB culture and resistance testing.
Continuing Activity: 17199
17199 12376.08 HHS/Centers for Ministre de la 7688 3125.08 National AIDS $500,000
12376 12376.07 HHS/Centers for Ministre de la 5134 3125.07 National Plan $300,000
Health-related Wraparound Programs
* TB
ACTIVITY UNCHANGED
SUMMARY: With Fiscal Year (FY) 2008 resources, the United States Government (USG) plans to
strengthen the capacity of the Ministry of Health (MOH) and continue to expand counseling and testing (CT)
services to patients seen at hospitals using a provider-oriented approach to optimize the potential for testing
patients. Currently, MoH as 25 active sites and is expected to have 30 sites by the end of FY2007. This
support will enable expansion to 40 sites. Particular consideration will be given to: (i) training a generation of
lay-counselors to counsel at public health sites so that more people can get access to counseling services,
(ii) providing health center users more opportunities for exposure to prevention messages, especially those
that test negative, (iii) decentralizing capacity to carry out training and quality assurance and quality control
(QA/QC) for counseling and testing at the department level. The emphasis areas for this component are: (i)
community mobilization and, (ii) human resources as some tasks will be shifted from health care personnel
to lay-counselors. The primary targets are the 700,000 users of services that on average attend these
facilities each year. These sites are spread across the 10 geographical departments of the country and
includes three major teaching hospitals, 10 referral regional hospitals and various community hospitals.
The MOH is the prime regulatory entity for health care service delivery in Haiti, including HIV services. It is
also the most important provider of health services with a network of dispensaries, community hospitals,
regional departmental hospitals and three university hospitals. During FY 2007, many of these hospitals and
health centers have established CT services with USG support. Currently 25 of the main public sites receive
this support through a direct cooperative agreement with the MOH managed by an executing unit under the
supervision of the central level, five other major department hospitals receive support through other USG
mechanisms. This year, all public sites will receive funding under the MoH cooperative agreement as this
mechanism has matured and shown capacity to play the fiduciary role for the entire network. From October
2006 to May 2007, this network of public sites have tested 45,466 people and detected 4,068 HIV +
patients.
For the most part, counseling services at the health institutions have been provided by health care
providers, thus considerably limiting access. This year the task will be shared with lay counselors at the
peripheral sites where the work load of health care providers is enormous. To increase access to training,
more capacity will be created at the regional level. The lack of logistics for training at the local level has
limited capacity to train personnel at all sites in counseling activities.
Activity 1: Expansion of counseling and testing services to 10 new sites. This will be done as part of an
effort to fill gaps in coverage identified by the departmental directorates, especially in the West Department
where there are very few sites in the region sharing borders with the Dominican Republic (Fonds Parisein,
Ghanthier, Thomazeau). Moreover, the departmental directorates are currently engaged, with the help of
the USG team, in a process of assessing coverage and laying out departmental plans. This has led to the
identification of new sites with high potential. We estimate that an initial investment of US $70,000 per site
for a total of $700,000 could enable the new sites to: (i) carry out needed renovations, (ii) procure office and
lab equipment, (iii) ensure promotion of services within the institutions and in the neighboring communities,
(iv) procure equipment and materials for promotional activities (TV, VCR), (v) hire lay-counselors,
phlebotomists and community health agents, (vi) procure critical utilities such as gas for refrigerators, and
(vi) organize post tests clubs and PLWA support groups. This does not include the cost of test kits.
Activity 2: Field support to CT services at 30 existing sites, including six public sites currently funded under
other mechanisms (Justinien-Cap, HIC-Cayes, St Antoine-Jeremie, St Michel-Sud Est, Gonaives-Artibonite,
Petit Goave- Ouest). This activity will emphasize fully integrating CT into routine clinical services offered to
all patients and providing more partner referral services as well as couple and family counseling. We will
continue to carry out pre- and post-test counseling at various wards, and test results communicated the
same day. Funding will cover salaries of current counselors and phlebotomists, hire lay counselors, and
procure critical utilities. Activity 3: In-service training and QA/QC for counseling at the departmental level. In
FY 2006 and FY 2007 several resource persons from various departments completed their training of
trainers, using the teach-back method. However, further iterations of the expected cascade never took
place because the resources to sustain the logistics for the sessions were not planned. By allocating US
$150,000 to each of the 10 departments, for a total of US $ 1,500,000, it will possible to: (i) equip existing
facilities, such as the nursing school in the Southern Department and Grande Anse or the Department in the
South East to hold regional training sessions. Some renovation might be needed to support rapid test
training at those locations (e.g. adding sinks, counters), (ii) provide available training materials at the
regional level, (iii) support the logistics of theoretical and practicum sessions and, (iv) support the cost of
QA/QC activities that the department directorates will carry out throughout the year. Training will be directed
at health centers' staff, residents in transit in the departments and lay counselors. ITECH/INHSAC will
provide technical assistance to the departments to strengthen the training and QA/QC activities of the
department (see ITECH proposal on Counseling and Testing).
Continuing Activity: 17200
17200 3902.08 HHS/Centers for Ministre de la 7688 3125.08 National AIDS $1,000,000
9309 3902.07 HHS/Centers for Ministre de la 5134 3125.07 National Plan $1,050,000
3902 3902.06 HHS/Centers for Ministre de la 3125 3125.06 $100,000
Table 3.3.14:
ACTIVITY UNCHANGED:
SUMMARY: The purpose of this activity is to help materialize the "three ones" concept by capacitating the
Ministry of Health (MOH) to: (i) implement the national monitoring and evaluation (M&E) framework; (ii)
consolidate the HIV/AIDS information system into the Health Management Information System (HMIS); (iii)
support the production and rolling out of standardized paper-based forms and registers both for facility and
non-facility activities; (iv) assume a greater role in data validation and processing; (v) manage and process
data, as well as monitor performance in all HIV/AIDS program areas; (vi) expand and maintain information
technology (IT) infrastructure that currently links the different levels of the system (sites, department and
central levels); (vii) expand the use of electronic databases such as the Monitoring Evaluation Surveillance
Interface (MESI) and electronic medical records (EMR) and; (vii) coordinate and consolidate all monitoring
and evaluation (M&E) training. The emphasis areas for this activity are: HMIS, IT, and HIV surveillance. The
primary beneficiaries are MOH officials and staff, donors, service providers, and sites' personnel.
BACKGROUND: Haiti's health care system is divided into three sectors: public facilities, accounting for
about 40% of service delivery; private not-for-profit and mixed facilities and programs, accounting for
another 40% and; private for-profit providers (medical clinics and hospitals) accounting for the remaining
20%. In addition to its role as service provider, the MOH governs and regulates the system through several
central departments in charge of standards, supervision, quality control and strategic planning. Within the
MOH, the units which play the most prominent role with regard to strategic information are: (i) the Unité de
Coordination de la Lutte contre les IST/VIH/SIDA (UCC), responsible for planning, monitoring and oversight
of all HIV activities in the country; (ii) the Department of Epidemiology (DELR), in charge of surveillance,
control, regulation, and integration of priority programs and; (iii) the departmental directorates (DDs)
responsible for operations and oversight of field activities.
Through a cooperative agreement (CoAg) with the MOH, funding has been provided by the President's
Emergency Plan for AIDS Relief (PEPFAR) in Fiscal Year (FY) 2005 through FY 2007 and has allowed: (i)
greater access to data by DDs and the central level through the electronic applications developed (MESI
and EMR); (ii) reinforcement of the M&E structures at the DDs, where dedicated M&E staff has been hired;
(iii) establishment of an information technology ( IT) infrastructure comprised of national and regional
servers allowing the local hosting of data; (iv) establishment of a dependable system for distribution of
paper based materials (Forms and registers) utilized for data collection and reporting; (v) revitalization of a
case notification system at pilot sites that has paved the way for expanded surveillance activities; and (vi)
setting up of a national M&E course for HIV/AIDS professionals with the help of Tulane University, (vi)
consolidation of all M&E training under the umbrella of the MOH and; (vii) an increase in the number the
field visits carried out by the departments and the UCC.
Activity 1: M&E framework and Consensus building: The MOH will continue to conduct consensus-building
activities among all stakeholders (donors, MOH officials, and service providers) to develop a national health
information system. To build consensus, the MOH will maintain and support the M&E cluster by calling
regular cluster meetings, keep minutes of the meetings, and provide adequate follow-up to all meeting. The
MOH will organize a national M&E framework conference focusing on the steps to materialize the
framework. US funding will cover the logistics of the multiple meetings and the workshop, the acquisition of
services of a consultant to handle the details and the production and dissemination of the M&E framework.
Activity 2: Producing and distributing data collection and reporting tools and registers. Various tools have
been designed or adapted for clinical care and community services. Most of these tools, developed with
United State Government support, have been extensively tested in the field. The MOH has in place a
functional distribution system which has reduced the frequency of out of stock forms experienced in the
past. The system functions with a central warehouse at the UCCC and regional hubs at the DDs. The MOH
will continue to ensure seamless supplies to the sites and the community-based activity outlets. The tools to
be produced and distributed include: voluntary counseling and testing (VCT) and preventing mother to child
transmission (PMTCT) registers and reporting forms, patients charts (intake, follow up, laboratory,
pharmacy, and discontinuation forms), pre anti-retroviral (ARV) and ARV registers, and community based
registers and reporting forms (prevention, OVC, and palliative care). USG funds will be used to reinforce
storage capacity at the UCC and the 10 DDs, produce the multiple forms and registers and cover the cost of
handling and shipping.
Activity 3: Expanding and enhancing Information Technology( IT) infrastructure by (i) providing hubs and
network equipment, (ii) ensuring protection of existing assets through installation of UPS and inverters, and
(iii) supporting basic computer training for field staff. With an objective to take advantage of the possibility
offered in IT and facilitate processing and sharing of information, PEPFAR and other donors have
supported, through different mechanisms, the procurement and installation of IT equipment. The results
have been remarkable. Monthly data are now available for 98% of implementing partners. As new sites are
launched and as the information system for community services is rolled out, efforts will concentrate in FY
2008 on: (i) equipping the new sites and reinforcing IT capacity for the community-based partners and, (ii)
expanding training in basic computer skills and computer maintenance for M&E field staff. The MOH has
also initiated in FY 2007 the creation of an intranet, which will be expanded in FY 2008. PEPFAR funds will
(i) cover the cost of training for personnel in 150 sites and 100 collaborating community based organizations
(CBO) implementing non facility-based program, (ii) procure and install IT equipment and accessories, and
(iii) reinforce the intranet.
Activity 4: Data processing, analysis and data quality control (QC) both at the central and departmental
levels. The DDs have been reinforced in FY 2007 by hiring dedicated M&E staff and have taken on more
responsibilities for data validation and QA/QC. Several mechanisms developed by the USG partners have
been progressively transferred to the DDs. Efforts are now needed to allow the UCC, which only has one
M&E contact person, to backstop the DDs.
Activity 5: Coordination and logistics of M&E training. The MOH will continue to coordinate and support the
logistics of all M&E trainings and workshops. This mechanism has given the MOH leverage to encourage
partners to consolidate training. Instead of having multiple partners holding various training sessions on
different topics, the MOH has been able to create for each target audience (providers, field data staff), one
curriculum integrating contributions from each partners. This consolidation of curriculum which started in
FY 2006 with the organization of workshops for providers and M&E field staff will culminate in FY 2007 with
the implementation of an M&E post graduate course for interns, residents, and other health professionals.
Activity Narrative: Activity 6: Surveillance and case notification. IN FY 2007 the DELR received technical assistance from
NASTAD to launch an HIV surveillance system with the participation of private laboratories in the
metropolitan area, and initiate the development of an epidemiologic profile for four geographical
departments regrouped under the denomination of "the Great South." These activities will be sustained and
expanded nationwide in FY 2008 for a total of US $300,000. These funds will allow the DELR to (i) scale up
the epidemiologic profile in the 10 departments, (ii) train the DD staff in updating the profile, (iii) expand the
HIV case notification system to the provinces by working with private labs throughout the country, and (iiv)
reinforce its own capacity to process, analyze and disseminate data on surveillance.
Activity 7: Development of MESI into a national aggregate reporting system for HMIS. With the
interconnection of MESI and the EMR and its use for case notification of HIV, MESI will soon become the
sole source for HIV data, statistics and surveillance. In FY 2008 the MOH will expand MESI use to
reporting for the entire HMIS. MESI implementers will work with JSI MEASURE for the interconnection with
their HMIS application.The MOH will also provide training on the use of the new HMIS module.
Activity 8: Leadership for the data triangulation process: The MOH will constitute a task force with different
stakeholders to guide the process and assign a point person to chair it. Undre the facilitation of University
of California in San Francisco (UCSF) the task force will help identify key questions based on country
context , convene large stakeholders meeting and disseminate results
•Number of local organizations provided with technical assistance for strategic information activities = 250
•Number of individuals trained in strategic information (includes M&E, surveillance, and/or HMIS) = 500
Continuing Activity: 17203
17203 3912.08 HHS/Centers for Ministre de la 7688 3125.08 National AIDS $1,200,000
9310 3912.07 HHS/Centers for Ministre de la 5134 3125.07 National Plan $700,000
3912 3912.06 HHS/Centers for Ministre de la 3125 3125.06 $250,000
Program Budget Code: 18 - OHSS Health Systems Strengthening
Total Planned Funding for Program Budget Code: $5,812,000
During the first four years of execution of this program, several policy issues have found traction through the implementation of its
various technical areas. Indeed the environment in which testing, care for HIV patients, assistance to OVC has been performed
has permanently been modified to allow more access to those services and prompt a more compassionate attitude toward the
disease and people infected and affected by it. The best illustration of the policy changes brought about by the program comes in
the fact that a new generation of nurses is now being trained to serve as practitioners and will be permitted to examine HIV
patients and prescribe drugs to circumvent the fact that not enough physicians are available in the country to deliver care.
Great strides have also been made with regard to the four areas targeted for system strengthening through this specific
component of the program: human resources capacity development; strengthening of Ministry of Health regional structures and
development of local response to the epidemics; fight against stigma and discrimination; and improvement in supply of energy to
the facilities implementing the program.
As part of the human resource capacity building strategy, HIV/AIDS-related content has been integrated into standardized
curricula at the major public-sector schools for health professionals (medicine, nursing, laboratory, social sciences) , teaching
capacity have been built through faculty development activities, and standardized student evaluation tools and processes based
upon mastery of core competencies have been developed.
The strengthening of systems at the Ministry of Health has focused on assisting departmental directorates for planning, monitoring
and supervision of HIV/AIDS activities in their jurisdiction as well enabling them to put in place competitive mechanisms for
financing local response to the epidemics. Height out of the ten departmental directorates of the MOH have been able through this
support to hold partner forums, put together integrated HIV action plans, operate QA/QI and supervision teams. Four have been
able to manage competitive grants for grass root organizations involved in sensitization, mobilization, community-based care and
OVC activities
The fight against stigma and discrimination has mobilized in first place the patients receiving services in the program by providing
them opportunities to create support groups around the sites where they are receiving services. The majority of sites providing
basic care or ARV maintain active at least one or two PLWA support groups, which constitute platforms to keep patients active in
the fight against stigma, while providing them opportunities to channel their grief. In five departments of the country the support
groups have converge into five strong departmental associations of PLWA, which are very much involved in advocacy activities,
community mobilization, and provision of community-based care.
In FY09, the USG will continue in collaboration with its partners to further the same agenda for system strengthening. ITECH will
set up curriculum working groups for schools yet to be covered such as the pharmacy, dentistry and ethnology schools to launch
the process of integrating HIV content into their programs and support for faculty development activities, including a TOT to
support strong teaching skills. ITECH will also roll out TrainSMART, which is an open-source, web-based training data collection
system, which will allow users, including all PEPFAR-supported training organizations in Haiti, to accurately track training, trainer
and trainee data in a consistent manner. I-TECH will provide funding and technical assistance to establish a regional HIV clinical
training center (RTC) in the South Department. GHESKIO and POZ will continue to provide support to the PLWA associations and
the PLWA support groups. They will inventory this year the support groups and transfer capacity through training and assistance,
to the departmental teams to enable them to assist and monitor the support groups. MOH will expand its support to all 10
departmental directorates
Table 3.3.18:
SUMMARY: This component of the program comes in direct support to the Government of Haiti to help: (i)
establish within the Minister Of Health (MOH) a functional system for regulation of the provision of HIV/AIDS
services, coordination of quality assurance and quality control and QA/QC and training activities
nationwide; (ii) strengthen the MOH's financial management and absorptive capacity; (iii) reinforce the
departmental level support to community activities by enabling 10 health departmental directorates to lead
and coordinate all community mobilization activities as well as manage 30 small competitive grants to
community organizations, especially associations of PLWHAs; and (iv) conduct policy and advocacy
activities to develop and finalize norms and protocols, promote the passing of specific laws for protection of
PLWHA and OVC and promote bi-national cooperation between the Haiti and Domincan National AIDS
Programs. This program component should increase the country absorptive and financial management
capacity, contribute to the establishment of a regulatory environment in the provision of HIV/AIDS services,
and reinforce the creation of a grass root national response against HIV-AIDS. The major emphasis areas
for the activity are local organization capacity development and training. The primary targeted populations
are the country coordinating mechanisms, the MOH staff at central and departmental levels, the grass roots
community-based organizations (CBOs), and PLWHAs.
BACKGROUND: Haiti's health care delivery system is divided into three sectors: public facilities,
accounting for about 40% of service delivery; private not-for-profit and mixed public/private partnership
facilities, accounting for another 40%; and private for-profit providers (medical clinics and hospitals),
accounting for 20%. In addition, the MOH fulfills normative, regulatory and supervisory functions through
different directorates established both at the central and the departmental levels.
Years of political instability have led donors to exclusively rely on emergency mechanisms to channel
funding to Haiti. During the first two years of the President's Emergency Plan for HIV/AIDS Relief
(PEPFAR), in the absence of mechanisms to directly fund the publicly-managed activities, support was
channeled through United States Government (USG) private sector partners. While this approach allowed
quick launching of activities, it was accompanied by high overhead costs that reduced funds available for
field activities. With various funding streams linked to different program areas from PEPFAR, the USG
established a cooperative agreement with the MOH, which enabled the Ministry to develop a
comprehensive program involving all levels (central, departmental and publicly managed sites). The
program included: (i) field support for the development of CT, PMTCT, palliative care and ARV services at
25 of the major public hospitals of the country; (ii) the development of lab infrastructures throughout the
country to support the biological monitoring of patients enrolled in services and the reinforcement of a
national laboratory quality assurance/quality control (QA/QC) program; (iii) the reinforcement of a national
monitoring and evaluation (M&E) system to monitor national HIV/AIDS program performance and results
with increased participation of the departmental directorates and; (iv) the creation of small competitive
grants under the leadership of the regional departmental directorates to foster and support local initiatives
from community groups and local public agencies and taking advantage of the decentralized management
at the departmental level. The execution of this program component has resulted in an increased capacity
of the public sector to manage USG funds. In addition, participation of various sectors of the civil society
has been enhanced through the increased channels of support to community activities and the
reinforcement of governance of the program.
Activity 1: Reinforcement of technical, grant and financial management capacity both at the executing unit
of the MOH and at the departmental directorates. The Executing Unit has successfully managed $4,4
million allocated in FY05 and FY06 and has started the execution of a $5.7 million grant in FY07. Money
allocated to the unit has been spent within the limit allowed, in compliance with the USG standard
provisions, and with an overhead cost of less than 20%. In FY08 additional capacity will be needed to allow
both the unit and the 10 departmental directorates to play their technical and fiduciary roles. Focus will be
put on hiring highly skilled professionals, reinforcing the management mechanisms and processes, and
providing training to managers of the sub-recipients in the area of financial management and control. The
estimated cost of the package is US$ 1.5 million, including all overhead cost for the management of the
MOH program.
Activity 2: Competitive grants for grass root- community activities. This activity, which reached four
departments in FY05, and seven in FY07, will be expanded to all 10 in FY08. The grants will finance a
menu of activities proposed exclusively by local community groups or local administrative entities, with
priority to PLWHA organizations. Those activities may include, but are not limited to: awareness and
educational activities, community care or home-based care initiatives, and community day-care centers for
OVC. The regional department directorates will ensure the promotion of this grant facility, interface with
local organizations, facilitate the review of proposals by the regional committees to be put in place,
administer the grants, and oversee the execution of activities by awardees. A total of 30 local organizations
are expected to participate in this initiative. They will receive technical assistance, training and support from
both the Executing Unit and the departmental directorates for management of their awards. Each
department will manage a grant portfolio of $ 40,000 for a total of US $400,000 for the 10 departments.
Activity 3: The setting up of a functional system for accreditation, training, and QA/QC. So far training and
QA/QC are being carried out by multiples entities, including the MOH, which has established with FY06
funding its own capacity to provide training and QA/QC through a consortium of its University hospital,
which has constituted a pool of trainers and mentors with the assistance of I-TECH. Technical assistance
using the methodology HIV/QUAL is planned for this structure in FY07. We propose in FY08 is to organize
this embryonic structure, regroup some senior specialists and broad the national mandate of : (i)
accreditation of centers providing HIV/AIDS services, (ii) train trainers in different areas of HIV/AIDS, (iii)
organize a fellowship for infectious disease specialists, (iv) provide technical assistance and support to the
departmental structures providing training and QA/QC, (v) coordinate all training activities and maintenance
of a training database an, (vi) coordinate the contribution of Haitian health professionals living in the
diaspora, in the context of the national HIV/AIDS curriculum. Trainers and mentors will be organized under
a coordinator working under the supervision of UCC. About US $1,000,000 is needed to improve teaching
capacity at two university hospitals, support the logistics of training, support the logistics of field visits in the
departments and the sites for QA/QC and accreditation purposes, support the logistics of travel and
accommodations for the Haitian mentors from the diaspora.
Activity Narrative: Activity 4: Support for and participation in the MOH technical committees to revise national norms for ARV
treatment drug regimens and finalize national norms for TB/HIV co-infection management, food and
nutritional support for PLWHA and OVC. Support and participate in efforts to pass the National AIDS Law
and reinforce the legal structures for improved protection of HIV/AIDS-related double orphans, counseling
and testing of children and job protection in the National Haitian Police and other national uniformed
services and in the private sector.
Emphasis areas % of effort
Human resources 51-100
Local Organization Capacity Development 10-50
Policy and Guidelines 10-50
Continuing Activity: 17204
17204 4348.08 HHS/Centers for Ministre de la 7688 3125.08 National AIDS $1,000,000
9312 4348.07 HHS/Centers for Ministre de la 5134 3125.07 National Plan $500,000
4348 4348.06 HHS/Centers for Ministre de la 3125 3125.06 $390,000
