SUMMARY:

The Child Healthcare Problem Identification Programme (ChIP) is a University of Pretoria prevention of

mother-to-child transmission (PMTCT) monitoring project aimed at improving the quality of PMTCT service

delivery. Using PEPFAR funds in FY 2005, FY 2006 and FY 2007, the foundations for ChIP were

established. FY 2008 funding will be used to continue monitoring the impact of:

(1) properly managing HIV-infected pregnant women and their children;

(2) the intervention on perinatal and infant mortality; and

(3) cotrimoxazole prophylaxis, infant feeding choice and antiretroviral therapy on HIV-infected children.

The premise of ChIP is that through ongoing monitoring and analysis of data on child deaths, key indicators

can be identified, which will provide health-care providers and policy makers with the necessary empirical

basis from which to advocate for the design and implementation of improved quality of care strategies. In

the long term, this approach should make a significant contribution toward reduced childhood mortality from

HIV and other causes. The major emphasis of the work falls in Health Management Information Systems,

with a lesser emphasis on monitoring, evaluation and reporting, as well as other strategic information (SI)

activities. Target populations for the activity include infants and children, HIV-infected pregnant women, HIV

-infected infants and children, policy makers, and public and private health-care workers.

BACKGROUND:

HIV infection has a major impact on fetal, infant and child mortality. The impact on fetuses is mostly indirect,

resulting in pre-term delivery, growth restriction or infection; whereas, children younger than age 5 tend to

die from the direct results of the HIV infection. The Perinatal Problem Identification Programme (PPIP)

currently monitors perinatal mortality in South Africa. Prior to FY 2005, there was no routine collection of

information on the causes of death in children, nor was there a methodology to determine the impact of

PMTCT. With FY 2005 and FY 2006 PEPFAR funding, and in collaboration with the National Department of

Health (NDOH), the PPIP system was updated to include fields for antiretroviral therapy (ART) during

pregnancy and neonatal nevirapine administration. These updates will allow the NDOH to determine the

uptake of antiretroviral treatment (ART) in children and the number of children dying from HIV-related

infections, as well as provide an indirect proxy for the impact of PMTCT.

Health-care workers were trained to use the PPIP and ChIP monitoring systems. Analysis of the 2005 data

from 26 sites indicated that only 65% of children who died had an HIV test and of these, 82% were exposed

or infected. In addition, of the children who died, 49% did not receive appropriate cotrimoxazole prophylaxis,

and only 15% of those children qualifying for ART received it. Although the purpose of ChIP is to monitor

the causes of death in children, particularly as they relate to HIV, it also enables hospitals to identify

preventable causes of death and identify strategies to address them. Health professionals from these sites

were trained to use ChIP, and to understand how the data obtained from the program can feedback into

improving the quality of health care for children. Because of this quality improvement feedback mechanism,

ChIP has become a valuable tool that affects morbidity and mortality, and service delivery as a whole.

ACTIVITIES AND EXPECTED RESULTS:

Five activities will be carried out in this program area.

ACTIVITY 1: The Rollout and Training on ChIP

FY 2008 funding will be used to continue promoting, supporting, and expanding ChIP implementation

across South Africa. This will include a national data sharing workshop and the development of training

packages for 22 sites (12 established and 10 in-training sites). A minimum of two health professionals from

each site will be trained, better ensuring sustainability. Sites will be monitored and evaluated annually to

assess quality and sustainability, as well as to ensure that ChIP is used as a quality improvement

mechanism. The project has established linkages with the national and provincial departments of health,

and will continue to liaise with the NDOH.

ACTIVITY 2: Saving Children Report

With FY 2005, FY 2006 and FY 2007 funding, ChIP used data from the existing sites to develop three

annual versions of the Saving Children Report. In FY 2008, data from established sites will be used to

compile the fourth annual Saving Children Report. The target audience for the report is healthcare workers

and policy makers. It is anticipated that the fourth report will be used to highlight gaps and challenges within

child health service delivery, giving special attention to HIV, as well as to advocate for the implementation of

recommendations aimed at improving quality of care for HIV-exposed and -infected infants and children.

The reports will be disseminated at national and provincial level to ensure continued communication with

the NDOH and to ensure further expansion of the project in FY 2009.

ACTIVITY 3: Strengthening Linkages

This activity focuses on strengthening the linkages between ChIP and PPIP sites to provide information on

improving the quality of PMTCT service delivery. Data from the updated PPIP (which focuses on PMTCT

compliance) will be analyzed and the impact of PMTCT at these sites will be assessed using ChIP data.

Improved PMTCT service delivery will be achieved through feedback of this information to the department

of health at facility, provincial and national levels.

FY 2008 activities will be expanded to include:

ACTIVITY 4: Setting up a ChIP Technical Task Team

During FY 2007 a ChIP Technical Task Team was established. The team is comprised of the ChIP Exco, a

representative from each province, as well as one or two specialist members. The roles of the Task Teams

are to provide provincial leadership (identify, train and support local sites, liaise with the Maternal, Child

and Women's Health (MCWH) Unit and strengthen links with PPIP); to assist with planning of the national

and provincial workshops; to contribute to the Saving Children report; and to provide general assistance to

Activity Narrative: the ChIP Exco.

ACTIVITY 5: Provincial Workshops to be Held During FY 2008

FY 2008 funding will be used to conduct provincial ChIP workshops in each of the nine provinces. Data will

be presented and further training offered to strengthen sites and expand ChIP. These workshops will also

provide healthcare workers with the opportunity to share quality improvement projects that were

implemented as a result of the site specific and provincial data that can be abstracted from ChIP.

ChIP contributes to the PEPFAR goals by strengthening PMTCT information and monitoring systems, and

ensuring a quality of care feedback mechanism aimed at improving quality of care for HIV-infected children.

In addition, this project contributes to PEPFAR's 2-7-10 objectives by early identification of children born to

HIV-infected mothers and linking them to appropriate treatment and care programs.