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. Country% reduction Country% reduction Ethiopia Ghana Kenya Namibia South nAfrica Swaziland Zambia Zimbabwe 31 43 60 49 39 55 45 Botswana Burundi Cameroon Cote d’Ivoire Lesotho Malawi Uganda 22 30 24 20 21 26 24 About 330,000 children were newly infected with HIV in 2011 Decline in new HIV infections among children, UNAIDS 2009-2011

3. Key operational bottlenecks to MTCT elimination C Geographic coverage (Population – Facility): bringing services closer to all women and children in need Q Quality/efficacy of interventions: providing the most efficacious/quality interventions U Access to and utilization of services 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? DeterminantsDescription Enabling Environment Social NormsWidely followed social rules of behaviour Legislation/PolicyAdequacy of laws and policies Budget/expenditure Allocation & disbursement of required resources Management /Coordination Roles and Accountability/ Coordination/ Partnership Supply Availability of essential commodities/inputs Essential commodities/ inputs required to deliver a service or adopt a practice Access to adequately staffed services, facilities and information Physical access (services, facilities/information) Demand Financial accessDirect and indirect costs for services/ practices Social and cultural practices and beliefs Individual/ community beliefs, awareness, behaviors, practices, attitudes Continuity of use Completion/ continuity in service, practice Qty Quality Adherence to required quality standards (national or international norms)

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 are left out (ANC1: 52%) Some are drop out or start late (ANC4: 24%) Some don’t have access Source: UNICEF 2012, HPP bottleneck analysis in Samfya district Facilities don’t have enough HIV tests

13. Key bottlenecks Root causes Management weaknesses Frequent stock out of HIV test kits Geographical inaccessibility More than ½ of HIV infected women missed in MCH despite high ANC testing rates Investigating the why - whether driven by geographic access, quality, or demand-side factors Delayed reporting & underestimation 1.Inadequate infrastructure 2.Seasonal mobility 3.Irregular outreach Inadequate logistics management and forecasting skills Failure to coordinate ANC and EPI outreach services 1.Low ANC utilization 2.Perceived poor quality of ANC due to frequent stock- outs and staff attitude HIV tests: See above ANC: Failure to prioritize demand creation & community- based activities More than ½ of HIV+ women drop out after HIV testing 1.CD4 requirement 2.Late booking 3.Long distance 4.Perceived quality of care HIV tests: See above ANC: Failure to prioritize demand creation & community- based activities

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

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

16. Conceptual framework C Simplifying approaches to increase service coverage and access in health facilities and communities Q Optimizing service quality and intervention effectiveness U Increasing uptake and retention in care Working with communities for communities Health Systems Strengthening: capacity building; improved service delivery; timely monitoring for course correction

17. Key bottlenecksRoot causes Management weaknesses Proposed Solutions/ Strategies Frequent stock out of HIV test kits Geographical inaccessibility More than ½ of HIV infected women missed in MCH despite high ANC testing rates Delayed reporting & underestimation 1.Inadequate infrastructure 2.Seasonal mobility 3.Irregular outreach Inadequate logistics management and forecasting skills Failure to coordinate ANC and EPI outreach services 1.Train DHMT in SCM esp. in forecasting 2.Establish monthly radio reporting in concerned RHC 1.Integrate ANC and EPI outreach services 2.Build zonal waiting mothers home 1.Low ANC utilization 2.Perceived poor quality of ANC due to frequent stock- outs and staff attitude HIV tests: See above ANC: Failure to prioritize demand creation & community- based activities 1.Prioritize ANC and SBA promotion through C-MNCH in district plan 2.Empower women (e.g. spouses of local leaders) as MNCH champions 3.Establish 6-monthly quality of care monitoring More than ½ of HIV+ women drop out after HIV testing 1.CD4 requirement 2.Late booking 3.Long distance 4.Perceived quality of care HIV tests: See above ANC: Failure to prioritize demand creation & community- based activities 1.Introduce POC CD4 testing 2.Establish a pregnancy register for cohort follow up 3.Establish C-based PMTCT for early ID, support and follow up through CHWs: adherence, SMS-based reminders Investigating the why - whether driven by geographic access, quality, or demand-side factors

18. Engaging communities as partners ↘ left out ↘ drop outs ↗adherence Supply Demand creation Quality 1.Regular integrated ANC- PMTCT-EPI outreach services to the unreached populations 2.Promotion of timely ANC and SBA through women and women’s groups 3.Early identification and referral of pregnancy through CHW home visits 4.Adherence counseling by CHWs through home visits and support groups 5.Active follow up by CHWs using innovative technologies e.g. SMS reminders Partnership with the Pediatric ART group on SMS Mwana project Partnership with the MCH and EPI program groups on outreach services 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 1.Accountability and sustainability: ensure government commitment and ownership 2.Equity reaching the unreached: identify where the missing mothers and children are to ensure equitable access 3.Investigate the weakest links focusing on the root causes to tailor programme interventions and ensure prioritization and more efficient use of resources 4.Access: bringing services closer to communities, families and individuals through innovation and engaging communities as partners 5.Local capacity: build local capacity for better use of data for decision making 6.Harmonized support: leveraging partners