bottlenecks analysis – a critical step to evidence based- planning for emtct: cameroon experience

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


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


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


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


A participatory multistage process to developing an elimination plan for eMTCT


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.


An overview of the tool

BOTTELNECK ANALYSIS TOOL FOR PMTCTCountry Cameroun

RegionDistrict

Basic Indicators

Bottelnecks analysis

Geographical Disparities

Disparity per Quintile

Expected ResultsReduction of identified

bottelnecks

Early Infant Diagnosis

Partnership analysis

Integration

Inputs analysis

Policy and M&E analysisNational objectives

Intervention

Norm

Budget

Summary

Units costs

Detealed budget

Financial analysis


Methods (1)

Process involved

• Advocacy and capacity building on the methodology.

• Selecting Key tracer interventions.

• Active data collection• Data quality control

TANAHASHI Model

Six Determinan

ts

Inputs, Human

ressources

Accessibility, Utilisation

Continuity, Quality


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


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


Results(1):Disparity of needs ( national level)

51%

10%2%

8%

9%

9%

10%3%

ANC unmeet needs in three regions : 51%

Liitoral,Nord,CentreNorth-WestEstSouth-westOuestAdamaouaExtrême-NordSud


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 )


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


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


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

bottlenecks analysis – a critical step to evidence based- planning for emtct: cameroon experience

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