In Haiti, the 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%. The Ministry of Health fulfills normative, regulatory, and supervisory functions through different directorates established both at the central and the departmental levels.The USG is supporting the MOH to develop a comprehensive program involving all levels (central, departmental, and publicly managed sites). The support is being used to 1) provide services in the areas of CT, PMTCT, palliative care and ARV services at all HIV/AIDS sites managed by MOH; 2) strengthen 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; 3) reinforce the national monitoring and evaluation system for the national HIV/AIDS program performance and results; 4) create a small competitive grants under the leadership of the regional departmental directorates to foster and support local initiatives from community groups and local public agencies, taking advantage of the decentralized management at the departmental level; and 5) reinforce a policy environment supportive a strong national HIV/AIDS response.

Activity 1: The MOH will enroll every person who receives a positive HIV test into a palliative care program designed to monitor the patients status, prevent and manage OIs, and provide psycho-social support according to the national norms and protocols. It is estimated that approximately 25,000 patients will be monitored, including 5000 new enrollees.Activity 2: The MOH will continue to support a network or community health workers to serve as the principal liaison between the health facility and people living with HIV/AIDS (PLHIV) and extend each site coverage into the community. They will conduct home visits, refer family members of PLHIV for testing, ensure adherence; encourage no shows to return for follow-up visits; provide advice on personal care; help plan community meetings to address myths about HIV and combat stigma; refer PLHIV needing acute care to the nearest health facility; and refer PLHIV in need of economic and nutritional support, and reproductive health service to the appropriate agency.Activity 3: The MOH will organize PLHIV support groups around the existing sites to create a setting for patients and their families to share knowledge and experiences. It has been noted that participation in support groups has improved patient adherence to treatment as well as their acceptance of the disease.Activity 4: The MOH will subsidize critical costs linked to services, such as transportation for patients and their companions to sites for treatment and other services.Activity 5: The MOH will link all MOH palliative care sites with ARV sites, to ensure that eligible patients get access to ART.Activity 6. The MOH will monitor input, process, outcome indicators pertaining to palliative care as identified in the National Monitoring and Evaluation System Interface (MESI) as well as PEPFAR indicators by ensuring that all sites report these indicators into the MESI system. In addition, the MOH will monitor the quality of palliative care and support services through field supervisory visits by its QA/QC team .

MSPP is committed to the program goal that all children born from HIV-infected parents be identified, tested, and enrolled as OVC and offered a full package of services whether infected or exposed. Therefore it will work with its participating sites to offer an expanded package of direct support to Orphans and Vulnerable Children (OVC) with the goal of reaching at least three services or more per child. Types of services to be provided will include: psychological support, access to Integrated Management of Childhood Illnesses (IMCI) and basic pediatric care (immunization, vitamin A supplementation, de-worming, and growth curve control). Community-health nurses assigned at each sites will coordinate both institutional services to be provided by the pediatric ward and the community-based services to be provided through networks of community health agents.

The reality is that the two programs TB and HIV are embedded at all the sites supported within the network. The following objectives will be pursued in Fy12 under that component : (i) 100% of patients seeking care during the period will be screened for TB (ii) All 100% of HIV patients diagnosed for TB will be put under TB treatment (iii) all TB patients will be tested for HIV (iv) all TB patients tested positive for HIV will be put under ARV, even without CD4. The following activities will be supported:Training and involvement of HIV providers in TB treatment: MSPP will guarantee the training for its staff by supporting the logistics of its participation to sessions offered by ITECH, All possible arrangements will be made to maintain HIV providers involved in management of TB treatment using one or a combination of those different options: (i) Allow HIV staff to monitor co-infected patients with or without dispensation of TB drugs at the HIV clinic (ii) Backstop the TB staff by the HIV personnel and fold both program under one umbrella for its management at sites where management of TB patients is done exclusively at the TB clinics (iii) seize the opportunity to offer TB treatment at sites where capacity exist to set up TB clinics in compliance with infection control requirements

Increased access of HIV patients to TB diagnosis procedures : Currently there are only 8/27 sites that have X-RAY capacity. A modest expansion is envisioned to bring it at 12. At those 12 sites all HIV infected patients get systematically an X-Ray to rule out TB prior to TB prophylaxis and that the respiratory symptomatic gets systematically a smear.

HIV Testing of TB patients: HIV testing of TB patients will be systematic. The network will guarantee: (i) training in HIV counseling to all TB providers (ii) and TB patients, convenient access to HIV testing services

Fast tracking ARV enrollment to TB patients tested positive for HIV: Simplified procedures will be implemented across the network to give to co-infected patients convenient access to ARV, regardless of presence or not of CD4 cell count at time of initiation. In parallel to that no hurdle access, heightened psycho-social support will be provided to these patients to guarantee adherence.Field support to TB distressed clinics: Following the debacle of the Global Fund Program, the Ministry was forced to field different TB clinics to enable them to maintain their services. That had represented an opportunity to usher HIV testing at those clinics.

The Ministry was the first mechanism used by the program to hire pediatricians at Public Health facilities to launch the expansion of pediatric care services, which were thus far limited at GHESKIO and PIH. The plan in FY12 is to move from 13 sites providing Care and Support to Children to all 21 Care and treatment sites supported in the Network. Entry to the program, which is the Prevention of Mother-to-Child Transmission (PMTCT) will be strengthened through coordinated efforts of Case Managers who ensure capture of all babies born form pregnant mothers and make sure that they get their Early Infant Diagnosis (EID). The Orphans and Vulnerable Children (OVC) programs to be implemented this year will also reach out to children not captured by the PMTCT program. Children enrolled in the program will be received a package of services including: Post-partum prophylaxis for children within 72 hours after delivery, Cotrimoxazol prophylaxis, Integrated Management of Childhood Illnesses (IMCI) and basic pediatric care immunization, regular growth monitoring, routine vitamin A supplementation, oral rehydration therapy (ORT)/zinc supplementation for treatment of acute diarrhea and de worming, particularly for children under five.

Funding under this component will be used to make sure that patients enrolled in care and treatment has a basic lab package which includes: HIV rapid test, malaria microscopy, TB AFB smear microscopy, hematology manual test, manual CD4 testing, urine dipsticks, serology rapid tests, ova & parasites exam. Efforts will be done throughout the network to enhance capacity of existing labs to support automated equipment available in the program such as: automated hematology, automated chemistry, and automated CD4 at sites selected by LNSP to serve as regional hubs. Areas of improvement includes : Infrastructure, power supplies, manpower.

MSPP has incorporated NSSS into the HIV/AIDS MESI system to have a unified surveillance system with integrated information systems for data collection. The integrated system is now operational.Activity 1: MSPP will continue to support the HIV/AIDS information system and will interconnect surveillance for other conditions of public health importance, such as malaria and other vector-borne diseases, diseases that disproportionately affect women and children, childhood vaccine preventable diseases, and reproductive health (SR). These activities will not only enhance the HIV/AIDS system but also improve information systems for the other programs. CDC will help to ensure links with partners in the planning phase in order to align activities and support the overall direction of the MSPP.Activity 2: Assessment of systems for strengths and weaknesses and develop overall plan to improve and integrate information systems across various programs, including NSSS and MESI, and IDPSS.Activity 3: Conception and revision of data collection and reporting tools including automation of analyses and reports for HIV and other disease of public health importance, including 1) production, storage, and distribution of data and reports; development of improved tally forms for data collection for diseases newly incorporated in MESI; and training on use of data collection and reporting tools.Additional key activities under this budget code include: 1) data quality assurance for HIV and other diseases of public health importance, including monitoring and evaluation of data collection systems; 2) dissemination of information technology; 3) working with Solutions, an IT company, to better integrate the surveillance within MESI and incorporate program-specific information systems into the overall HMIS at all three tiers of the health system; 4) build capacity to ensure the implementation of the collection, analysis, and dissemination of HIV/AIDS behavior and biological surveillance data; and 5) continue to maintain a national web-based electronic data management system.

The goal of this effort is to contribute to strengthening the 6 building blocks of the Haitian health system. Activities will cover the following areas:1. Service Delivery: the MOH will foster more synergistic relationships among programs by supporting integration at both the service delivery level and the central level for programs such as TB, vector-borne diseases, childhood vaccine preventable diseases and reproductive health. Activities will include improving IT technology across programs, integration of HIV services into other service packages, and coordinating joint supervisory visits. The capacity of the directorates in charge of these programs at the central level will be enhanced to better coordinate with the HIV units. Particular focus will be placed on Director de Santé de la Famille (DSF), lUnité de Coordination de la Tuberculose, and lUnité de Coordination de la Malaria.2. Supply Chain Management (for program-related drugs and supplies): the peripheral components of the supply chain management (such as the drug policy apparatus, the departmental warehouses, and the healthcare centers pharmacies and laboratories) will be strengthened. The focus will be on policy development, improved management of departmental warehouses and improved facility management of inventories to ensure the sustainability of local commodity operations.3. Human Resources: we will continue to support the training of new cadres of personnel (primarily nurse midwives, nurse anesthetists, and nurse practitioners); the inclusion of HIV/AIDS curriculum in the medical and nursing schools to provide training for interns and residents at teaching hospitals, and the assistance to post-graduate training in management of HIV related opportunistic infections, and other communicable diseases. This assistance may include provision of scholarships for advanced training as well as expanding the program for training of nurse practitioners. We will invest in the development of centers of excellence for patient care and management at departmental hospitals as a means to build regional expertise and support peripheral centers.4. Finance: In addition to support to improve financial management at the Departmental (provincial) and facility levels, the MOH will initiate steps to take greater responsibility in program financing by enacting cost analyses of various interventions and developing plans and scenarios to analyze how greater local resources could be allocated to HIV.5. Health Information Systems: This effort will focus on systems integration and data quality and use.6. Leadership and Governance: MOH will expand the use of improved management tools to increase its oversight capacity and improve the management of its sub-grantees. Additional efforts will improve MSPPs planning and budgetary capacity with a focus on the Directorate for Organization of Health Systems (DOSS).

During FY 2011, MSPP receive support for PEPFAR to undertake injection safety (IS) and healthcare waste management (HCWM) activities. Support was also provided to strengthen the procurement and distribution of safe needles, syringes, and sharps containers throughout the country.

In FY 2012, the MSSP will reinforce its support to the direction of health promotion public hygiene et and environmental protection (DPSPE) to build its capacity to develop, adapt and distribute behavior change communication materials for reducing unnecessary injection and using oral medications as alternatives to injections.

For HCWM, the priority will be to improve the capacity of major hospital to dispose of biomedical waste. The DPSPE will set up a team specifically dedicated to IS and HCWM and tasked to work on the recommendations resulting from last years site assessment on IS and HCWM. Support will be also provided for the acquisition of incinerators of high capacity for the ten (10) departmental hospitals in the country. In addition to direct support through PEPFAR, MSPP will leverage resources from other donors to further expand the capacity of appropriate disposal of medical waste throughout the country.

During FY2012, infection control committees will be established and/or reinforced starting with PEPFAR supported sites. Technical assistance will be provided to these committees to develop an infection control plan including TB infection control, universal precautions, injection safety and healthcare waste management. These committees will also be responsible for ensuring that supplies (color coded bags, sharp containers, syringes, etc) and equipments (autoclaves, incinerators, shredders, UV lights, fans, etc) costs are considered during sites budget development.

Counseling and testing services will take place at 28 sites. Activity 1: The MOH will test150,000 individuals over the next 12 months. The bulk of funding, aside from testing within the context of PMTCT, will go to test hospital patients regardless of their reason for coming to the hospital. This goes along with the full integration strategy of the MOH as well as the PITC approach.Activity 2: The MOH will promote site and community based HIV testing to create demand and encourage patients to be tested. Funding will be used to procure equipment and materials for promotional activities (TV, VCR) for the sites; produce posters, brochures and other communication and information materials to be distributed to patients along with banners and street signs to create greater awareness of the opportunity offered by the facilities. In addition, the MOH will support community testing days at all sites and will sponsor special radio spots promoting testing events.Activity 3: The MOH will follow the national testing algorithm and perform all related tasks.Activity 4: To ensure full enrollment of HIV positive individuals in care services, each site will maintains accurate CT registers, appointment books with return dates and maintain continuous follow-up records with the identification of no-shows. A CT QA/QC team (see below) will assess each site and its client management system to ensure that there are no factors discouraging patients from returning such as staff attitudes, waiting time (analysis of patient flow), prompt services, and good psychosocial support.Activity 5: The MOH will reinforce activities to ensure adequate quality assurance and quality improvement (QA/QI) processes are in place. The USG Team will support the services of a national CT QA/QI team that will periodically visit all sites, use a supervision checklist, and ensure that all sites respect norms regarding CT and that personnel is fully aware of policies regarding discordant results in couples.

The goal for the next two years is to expand PMTCT coverage to 50,000 pregnant women per year. Progress will be measured through individual site reports with control of data quality as reported to the national information system (MESI). The unit cost per patient is approximately US$43 per patient, excluding drugs. The cost per unit will be decreased by improving integration of PMTCT services into the routine obstetric care and pediatric treatment services provided by each facility.Decentralization: the decentralization of PMTCT services will be achieved through the implementation of the Integrated Management of Adolescent and Adult Illnesses (IMAAI), a strategy that aims at building the capacity of health care providers peripheraally to provide HIV-related services. PMTCT is a major part of this approach.Capacity-building: the executing unit will assist facilities to set up and improve PMTCT services, and will support the entire hierarchy of systems supervisors, from the district level office, through the provincial directorates and the national unit that oversees all HIV activities in the country. This will increase the capacity at each level of the system for program oversight, assessing the quality of services and for ensuring the requisite data are collected and submitted.PMTCT interventions: provider initiated testing and counseling is now the norm at all sites supported by this program. In addition, the MOH is applying the WHO-initiated protocol on PMTCT and will monitor any recommended changes in ARV regimen in the following years. Various approaches will be used to ensure retention and adherence of mother-infant pairs depending on the individual policies and capabilities of each site. Some utilize the services of accompagnateurs whereas others use the services of community health workers.Demand creation: most facilities in the program are for the most part participants in a CIDA (Canada) funded MCH project that renders prenatal care and deliveries free of charge to the pregnant women. This has increased utilization of obstetric services and concurrently PMTCT testing and other related services.

The MOH will provide ARV treatment at 8 sites. The MOH has adopted the IMAAI strategy, which encourages decentralization of ART services, once the patient has initiated treatment. The main activities will include the following.Activity 1: At the two teaching hospitals, HUEH and Isaie Jeanty, the MOH will support the reinforcement of the clinical mentoring, training and technical assistance to strengthen the teaching of HIV treatment protocols for interns and residents via I-Tech.The Executing unit will assign one of its staff members to supervise training activities and observe and report on interactions between mentors and trainees in real-time clinical situations.Activity 2: The MOH will support staff (physicians, nurses, psychologists, counselors and social workers) and community personnel to expand ARV services at the targeted ARV public sites.Activity 3: The MOH will continue the use of electronic medical records, which will serve as the principal tool to measure clinical outcomes. Assessment of various factors including consistency in following appointments as well as receipt of ARV drugs on a timely basis and adherence will be followed on an individual and cohort basis for each individual site along with biologic monitoring including CD4 cell counts and viral loads. Other clinical outcome factors will include hospitalization, drug resistance and death.Activity 4: The MOH will use performance measurement data for quality improvement. The performance data used for assessing clinical outcome will be evaluated at each site to measure gaps in visits, gaps in biologic monitoring, gaps in receiving medications on time, clinical assessments such as patient weight, occurrence of opportunistic infections and drug resistance. Activity 5: With the assistance of a QA/QC team, efforts for patient retention and adherence will be expanded. Each site will maintain accurate patient registers, appointment books with return dates and continuous follow-up records with the identification of no-shows. Community health workers will be retained to do home visits of PLHIV particularly those that miss appointments. To improve adherence, in addition to home visits by community health workers, PLHIV support groups and supervisory visits to assess physical and logistical factors will be implemented. Patients will be provided small stipends for public transport costs to the clinic.Activity 6: The target population is made up primarily of patients visiting public facilities, including large departmental hospitals as well as other regional public hospitals. These patients receive a comprehensive care and treatment package including ART provision, cotrimoxasole prophylaxis, and TB screening. At each site, efforts are under way for improved integration of services so as to increase program efficiency.

Pediatric treatment will be expanded to all sites already providing pediatric care. Responsibilities for monitoring of treatment patients will be shifted gradually to trained nurses in order to fill gaps where medical personnel are in short supply. Efforts to identify children in need of treatment will be stepped up by increasing site access to EID by Dried Blood Spot- Deoxyribonucleic acid-Polymerase Chain Reaction (DBS-DNA-PCR). The community health agent will be organized to play vital role in adherence monitoring. The program will support home-visits.