1. Washington D.C., USA, 22-27 July 2012www.aids2012.org Bottlenecks analysis – a critical step to evidence based- planning for eMTCT: Cameroon experience 1 Dr Ebogo M. Mesmey, 2 Dr Bissek Anne Cécile, 3 Dr Souleymane Kanon 1: National AIDS Control Committee 2: Ministry of Health 3: UNICEF Cameroon Abstract no.WEAD0604

2. Washington D.C., USA, 22-27 July 2012www.aids2012.org Background data Cameroon Costal Central Africa 465 650 km2 of surface Population: 20.4 million (2012 51% female and 49% male 44% less than 15 years Under five Mortality: 122 ‰ Maternal Mortality: 669/100000 HIV Prevalence: 4.3%, (2011) – Gender disparities – Regional disparities – Women and children most vulnerable

3. Washington D.C., USA, 22-27 July 2012www.aids2012.org Women, children and HIV in Cameroon ( 2011 ) Percent of pregnant women seen at ANC1: 35,05% Percent of women seen at ANC1 tested for HIV: 79.5% prevalence among pregnant women: 7.6% ( 2011) HIV positive pregnant women receiving ARV for prophylaxis: 80.6% ( EMTCT Plan) Estimated number of HIV new pediatric infection : 7300. Current PMTCT Coverage: 65.4%. Cameroon is among the 22 countries with the highest burden of PMTCT unmet needs worldwide HIV geographic disparities in Cameroon

4. Washington D.C., USA, 22-27 July 2012www.aids2012.org Rationale for developing an elimination plan for MTCT in Cameroon HIV, a critical public health problem in Cameroon About 537 623 people infected with 62 098 being children ( UNGASS report 2011) High prevalence among pregnant women ( 7.6%) Many babies continue to be infected during pregnancy, delivery or breastfeeding. Best practices and lessons from other countries Government has committed to eliminate MTCT by 2015

5. Washington D.C., USA, 22-27 July 2012www.aids2012.org A participatory multistage process to developing an elimination plan for eMTCT Building government buy-in and leadership In country partners and stakeholders mobilization National technical consultation with professionals In-depth Bottlenecks analysis with external Assistance Participatory bottom-Up planning process Building government buy-in and leadership In country partners and stakeholders mobilization National technical consultation with professionals In-depth Bottlenecks analysis with external Assistance Participatory bottom-Up planning process Building government buy-in and leadership In country partners and stakeholders mobilization National technical consultation with professionals In-depth Bottlenecks analysis with external Assistance Participatory bottom-Up planning process

6. Washington D.C., USA, 22-27 July 2012www.aids2012.org The Bottleneck Analysis for PMTCT Innovating for result oriented planning A comprehensive analysis using an innovative tool adapted from the Tanahashi* model to assess PMTCT demand and offer bottlenecks in order to orient evidence and result based planning ofr e-MTCT The tool uses an Exel application to critically analyze the determinant of MNCH/PMTCT service offer and demand in order to highlight in a given country, region or district the bottleneck to performance. This consequently provides clear suggestion for appropriate actions to be taken to address bottlenecks and thus have more chances to significantly improve performance and impact PS: * Tanahashi, 1978: A model to assess health systems bottlenecks by looking at 5 determinants in relation to service demand and offer.

7. Washington D.C., USA, 22-27 July 2012www.aids2012.org An overview of the tool

8. Washington D.C., USA, 22-27 July 2012www.aids2012.org Methods (1) Process involved Advocacy and capacity building on the methodology. Selecting Key tracer interventions. Active data collection Data quality control TANAHASHI Model Six Determinants Inputs, Human ressources Accessibility, UtilisationContinuity, Quality

9. Washington D.C., USA, 22-27 July 2012www.aids2012.org Methods (2): Important considerations for process National consensus on tracer indicators Primary prevention Family planning ANC ARV regimens for HIV + pregnant women. ARV for infected infants. Criteria used to select indicators Availability of acurate data Evidence base strategy Applicability of intervention locally

10. Washington D.C., USA, 22-27 July 2012www.aids2012.org Added value of the Bottleneck analysis tool using the Tanahashi Model applied to PMTCT Systematic analysis of bottlenecks based on consensual indicators agreed with policy makers, program managers and service providers Clarity on regional, district and zonal disparities which helps to better focus action on priority zones, key for efficiency resource allocation Consensus on priority lever interventions based on evidence which is also key for effectiveness en enhancing results Sets the scene for evidence base development of the elimination plan for effectiveness and efficiency

11. Washington D.C., USA, 22-27 July 2012www.aids2012.org Results(1): Disparity of needs ( national level )

12. Washington D.C., USA, 22-27 July 2012www.aids2012.org Results (2): Disparity of unmet needs (regional) Example of Center Region Most critical zones include: –Efoulan Health District (Yaoundé) –Mbalmayo and Obala Health Districts (Yaoundé suburbs )

13. Washington D.C., USA, 22-27 July 2012www.aids2012.org Results (3): Priorities interventions Identified Bottelnecks 1. Low utilization of ANC services and PMTCT Uptake 2.Poor procurement and supply management systems at all level leading to stock out and thus service discontinuity 3.Quality of comprehensive PMTCT services Delivery 4.M&E of PMTCT and MNCH services Priority Interventions 1.Capacity building and meaningful engagement of communities including civil society and leaders to boost service utilization and PMTCT Uptake 2.Strengthening procurement and supply management system 3.Set up Quality assurance mechanisms and build system capacity for quality service delivery 4.Health system strengthening with emphasis on Strengthening monitoring and evaluation to meet PMTCT needs

14. Washington D.C., USA, 22-27 July 2012www.aids2012.org Conclusions  To meet the challenges of eMTCT there an urgent need to focus on results and evidence based planning and programming  Policy makers, programme managers and service providers should now strive to use innovations that use evidence base to enhance effectiveness and efficiency  The Tanahashi model for bottleneck analysis was successfully adapted to develop an innovative tool for analysis PMTCT bottlenecks in order to feed evidence based planning for e-MTCT  It is indeed a Powerful method for identifying and analysing disparities and factors impeding MNCH&PMTCT  It could recommended to be used to help us make our way to impact making actions for PMTCT if we are to meet the elimination goal and the MDG in general

15. Washington D.C., USA, 22-27 July 2012www.aids2012.org ACKNOWLEDGEMENTS Authors Thanks to the Government of Cameroon and the special leadership of the Minister of Public Health and his cabinet We would like to thank all those at national regional and district level who have enthusiastically taken part in this process and help to develop an elimination plan for the country which is already validated and owned by the government We also thank UN Agencies in General and the UN country Joint team on HIV in particular for a terrific technical assistance We finally thank UN agencies regional teams and headquarters for their guidance and assistance A special thanks to UNICEF, WHO, UNAIDS, UNFPA for financial support