Health system: what dynamic changes are needed to better serve Children and youth living with HIV

1. Health system: what dynamic changes are needed to better serve Children and youth living with HIV Rene Ekpini, On behalf of Dr Mickey Chopra Chief & Associate Director Health, UNICEF New York

2. Decline in new HIV infections among children, UNAIDS 2009-2011

3. Key operational bottlenecks to MTCT elimination Working with communities for communities Health Systems Strengthening

4. Strategic shift 1: assess the performance of the MNCH platform

5. Weak linkages and retention in care within the PMTCT cascade and the MNCH care continuum in Tanzania, 2012

6. Strategic shift 2: Identify where the missing mothers and children are

7. % of pregnant women living with HIV receiving ARVs for PMTCT, in Botswana

8. Where are the missing mothers and children in Botswana?

9. Strategic shift 3: investigating the weakest links through supply and demand bottleneck analysis

10. What and who to assess?

11. Investigating the weakest links • Identify the weakest links in the health and community systems • Identify the managerial shortcomings • Investigate the root causes (the WHY) Commodities – Human resources – Geographic access – Initial utilization – continuous utilization – Effective coverage/quality – Demand side barriers Local governance – Service organization – PSM – HR – Information management – Financial management

12. Identifying key PMTCT bottlenecks in Samfya district, Zambia (health facility and qualitative surveys data) Some don’t have access Facilities don’t have enough HIV tests Some are left out (ANC1: 52%) Some are drop out or start late (ANC4: 24%) Source: UNICEF 2012, HPP bottleneck analysis in Samfya district

13. Investigating the why - whether driven by geographic access, quality, or demand-side factors Key bottlenecks Root causes Management weaknesses Frequent stock out of HIV test kits Delayed reporting & underestimation Inadequate logistics management and forecasting skills Inadequate infrastructure Seasonal mobility Irregular outreach Failure to coordinate ANC and EPI outreach services Geographical inaccessibility HIV tests: See above ANC: Failure to prioritize demand creation & community-based activities Low ANC utilization Perceived poor quality of ANC due to frequent stock-outs and staff attitude More than ½ of HIV infected women missed in MCH despite high ANC testing rates CD4 requirement Late booking Long distance Perceived quality of care HIV tests: See above ANC: Failure to prioritize demand creation & community-based activities More than ½ of HIV+ women drop out after HIV testing

14. Diagnosing the weakest links: why women do not access health services? Sources: Anthony Hodges. Presentation at the ACSD meeting, Dakar, 22-26 June 2009

15. Strategic shift 4: tailoring programme strategies and interventions to prioritize, and maximize investment and impact

16. Conceptual framework Working with communities for communities Health Systems Strengthening: capacity building; improved service delivery; timely monitoring for course correction

17. Investigating the why - whether driven by geographic access, quality, or demand-side factors Key bottlenecks Root causes Management weaknesses Proposed Solutions/ Strategies Frequent stock out of HIV test kits Delayed reporting & underestimation Inadequate logistics management and forecasting skills Train DHMT in SCM esp. in forecasting Establish monthly radio reporting in concerned RHC Geographical inaccessibility Inadequate infrastructure Seasonal mobility Irregular outreach Integrate ANC and EPI outreach services Build zonal waiting mothers home Failure to coordinate ANC and EPI outreach services Low ANC utilization Perceived poor quality of ANC due to frequent stock-outs and staff attitude Prioritize ANC and SBA promotion through C-MNCH in district plan Empower women (e.g. spouses of local leaders) as MNCH champions Establish 6-monthly quality of care monitoring More than ½ of HIV infected women missed in MCH despite high ANC testing rates HIV tests: See above ANC: Failure to prioritize demand creation & community-based activities CD4 requirement Late booking Long distance Perceived quality of care HIV tests: See above ANC: Failure to prioritize demand creation & community-based activities More than ½ of HIV+ women drop out after HIV testing Introduce POC CD4 testing Establish a pregnancy register for cohort follow up Establish C-based PMTCT for early ID, support and follow up through CHWs: adherence, SMS-based reminders

18. Engaging communities as partners Regular integrated ANC-PMTCT-EPI outreach services to the unreached populations Partnership with the MCH and EPI program groups on outreach services Partnership with the Pediatric ART group on SMS Mwana project Promotion of timely ANC and SBA through women and women’s groups Early identification and referral of pregnancy through CHW home visits Adherence counseling by CHWs through home visits and support groups Active follow up by CHWs using innovative technologies e.g. SMS reminders Partnership with Community-based groups (leader spouses, women) and programs (iCCM, IMCI, SMAGs)

19. Strategic shift 5: improving local capacity on data collection, analysis, and use for decision making

20. Summary • Accountability and sustainability: ensure government commitment and ownership • Equity reaching the unreached: identify where the missing mothers and children are to ensure equitable access • Investigate the weakest links focusing on the root causes to tailor programme interventions and ensure prioritization and more efficient use of resources • Access: bringing services closer to communities, families and individuals through innovation and engaging communities as partners • Local capacity: build local capacity for better use of data for decision making • Harmonized support: leveraging partners