info@HealthSystems2020.org w w w. H e a l t h S y s t e m s 2 0 2 0 .

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Health Systems 20/20 at Work in cte dIvoire

I. IntroductIon
In Cte dIvoire, the Health Systems 20/20 project, funded by the U.S. Agency for International Development (USAID), has worked closely with the Ministry of Health (MOH) since 2006. The objective is to provide technical assistance to strengthen the national health system, particularly in order to improve HIV/AIDS service provision. Specifically, the project aims to: y Build institutional capacities of three ministries: y MOH, in particular, the following units: Department of Human Resources (DRH), National Institute of Health Workers Training (INFAS), Directorate of In-Service Training (DFR), Directorate of Finance (DAF), National Program of AIDS Care (PNPEC), Directorate of Information, Planning and Evaluation (DIPE), Department of Decentralization (SASED), Directorate of Infrastructure, Equipment (DIEM); y Ministry for the Fight Against HIV/AIDS (MLS); and y Ministry of Higher Education through the Abidjan University of Science and Medicine (UFR-SMA) y Reinforce management and leadership capacities of the directors, administrators and policy specialists at the central and district levels to respond to the HIV/AIDS epidemic y Lead studies targeted to inform decision making related to planning and provision of HIV/AIDS services, and expanded availability of human resources for health (HRH) to provide services. Health Systems 20/20s portfolio in Cte dIvoire comprises five of the six World Health Organization (WHO) health system building blocks: service delivery, health workforce, information systems, financing, and governance. Working across these building blocks allows for a consistent approach to health system strengthening. This Country Brief describes how the project is supporting Cte dIvoire to strengthen its national health system, as well as highlight key achievements and lessons learned. Now is a good time to take stock of progress; the political situation first slowed and then forced suspension of project activities (April June 2011); but activities now have resumed, with government support.

Health Systems 20/20, USAIDs Flagship Project for Health System Strengthening Since its inception in 2006, the Health Systems 20/20 project has worked in more than 40 countries, implementing new and proven interventions that address health system constraints and increase the use of priority health services. The project works in eight strategy areas: organizational capacity building, financial risk protection/health insurance, governance, human resources for health, measuring and monitoring health systems performance, resource tracking/ National Health Accounts, performance-based incentives/pay for performance, and costing and sustainability planning. These areas interface with the World Health Organizations six health system building blocks: service delivery, health workforce, information systems, financing, governance, and pharmaceutical management. Health Systems 20/20 tailors interventions to each countrys needs and priorities, as determined with country stakeholders, and works in one or more of the strategy areas to strengthen the countrys health system.

Country Brief

II. Background
Cte dIvoire is a low-income country in West Africa; its gross domestic product per capita is US$530 (2008).1 The country has a population of 20.6 million, of which 51 percent lives in rural areas. While 60 percent of deaths are still due to infectious diseases and perinatal causes, the country has witnessed notable improvements in several health indicators (Banque Mondiale 2010). The under-five mortality rate (U5MR) has steadily declined to 114 per 1,000 (2008), approaching the Millennium Development Goal. The maternal mortality ratio (MMR) has decreased substantially from 690 per 100,000 births in 1990 but remains relatively high at 470 in 2008 (see Figure 1). The decline in MMR is matched by a consistent decline in the total fertility rate, from 7.6 in 1980 to 4.6 in 2008, and an overall increase in contraceptive prevalence from 2.9 percent in 1980 to 12.9 percent in 2006. The contraceptive prevalence is still low compared with the average for countries in sub-Saharan Africa of 23.4 percent. Finally, the HIV/AIDS prevalence rate for people age 1549 years was 3.4 percent in 2009, compared with the sub-Saharan Africa average of 5.6 percent. Health Systems 20/20 and the MOH conducted the first National Health Accounts (NHA) estimations in Cte dIvoire on expenditure data for 2007 and 2008. Figure 2 shows health expenditures by function for 2007 and 2008. Other findings revealed a high level of household out-of-pocket spending on health equivalent to 66 percent of total health expenditure (THE) in 2008 (Cte dIvoire Ministre de Sant et Hygiene Publique and Health Systems 20/20 2010). In that same year, total household expenditure on health accounted for 69 percent of THE, public expenditure on health 17 percent, donor expenditure on health 12 percent, and other private expenditure (not including household expenditure) 2 percent. Figure 3 shows trends in these expenditure proportions since 1995, but using data from WHO.

FIgure 1: u5Mr and MMr trendS In cte dIvoIre

800 300

700 250 600

Maternal Mortality Ratio

200 500

400

150

300 100 200 Maternal mortality ratio (per 100,000 births)-WDI Mortality rate under-5 (per 1,000 live births)-WDI 50

100

0
Ye ar 19 80 19 81 19 82 19 83 19 84 19 85 19 86 19 87 19 88 19 89 19 90 19 91 19 92 19 93 19 94 19 95 19 96 19 97 19 98 19 99 20 00 20 01 20 02 20 03 20 04 20 05 20 06 20 07

Year

Source: Health Systems Database (healthsystems2020.healthsystemsdatabase.org)

FIgure 2: HealtH expendItureS By HealtH FunctIon

Source: Cte dIvoire NHA 2007

1 Unless otherwise noted, data in the background section are from the Health Systems Database (healthsystems2020.healthsystemsdatabase.org), which pulls data from multiple international sources

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Under-5 Mortality Rate

FIgure 3: donor, puBlIc, and oop SpendIng trendS In cte dIvoIre

Donor, Public, and OOP expenditures, as a % of THE from 1995-2008 80

III. key project acHIeveMentS

Table 1 lists Health Systems 20/20s portfolio of activities in Cte dIvoire. Following the table are descriptions of key project activities and achievements, focusing on HRH, governance, and geographic information system (GIS) activities.

70

60
% of Total Health Expenditure

50

40

Strengthening human reSourceS for health

In collaboration with the MOH, Health Systems 20/20 and its predecessor project Partners in Health Reformplus (PHRplus) did two HRH assessments that have informed the design and implementation of HRH strengthening activities. An assessment of public sector health workers was done in 2005 (Butera et al. 2005); an assessment of private sector health workers followed, in 2006 (Lee et al. 2006). The assessments found major challenges in the following three areas: availability of HRH (and related financial) resources, geographic distribution of HRH, and core HRH competencies. In response to these findings, Health Systems 20/20 and the MOH developed the National HRH Strategic Plan for 20092013. The plan provides comprehensive, costed solutions in respect to demand and supply elements in both the public and private sectors. In addition, Health Systems 20/20 is supporting various HRH management strengthening initiatives: y Support to INFAS, such as emergency hiring and training of instructors y Implementation of a pilot P4P incentive scheme in one district y Customization and roll-out of a HRIS y Strengthening of the record management infrastructure, including rehabilitation of the DRH archiving system and provision of IT equipment y Provision of technical assistance to improve HRH management practices including a performance evaluation system and the development of HRH position standards and job descriptions.

30

20

10

1995

1996

1997

1998

1999

2000

2001 Year

2002

2003

2004

2005

2006

2007

2008

Donor spending on health--WHO

Public (government) spending on health--WHO

Out-of-pocket expenditure--WHO

Source: Health Systems Database (healthsystems2020.healthsystemsdatabase.org) Note: Cte dIvoire NHA estimates for 2007 and 2008 are the most recent expenditure data produced and therefore are used in the text. However, the WHO provides the best historic data and therefore these are used in this figure. NHA and WHO data differ for 2007 and 2008.

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taBle 1: portFolIo oF HealtH SySteMS 20/20S actIvItIeS In cte dIvoIre activity purpose Assessments of HRH in public (2005) Informed National HRH Strategic Plan for 20092013, developed by MOH with Health Systems 20/20 support and private (2007) sectors Guided HRH strengthening program, designed with Health Systems 20/20 support Strengthening HRH Improved training through support to INFAS Piloted a performance-based incentive (PBI) scheme to improve distribution of HRH Developed a human resources information system (HRIS) to improve HRH planning, coordination, and management Piloted national task-shifting project Evaluated and updated the training program for doctors, nurses, and midwives at INFAS and UFR-SMA (the nursing and medical schools) to ensure core competencies for each cadre match the health needs of the local populations. Updated holdings of three INFAS libraries (Abidjan, Aboisso, Korhogo) to include e-reference materials (more than 360 medical books and 112 scientific journals); also did infrastructure upgrades and built capacity of library staff Health System Assessment (2009), Conducted assessments and studies to inform country needs and priorities, and program design HIV/AIDS Program Sustainability Analysis (HAPSAT) (2008), Service USAID used assessment findings to inform MLS Strategic Plan 20112015, and Provision Assessment (2007) HAPSAT findings to inform national plan for PEPFAR II Resource tracking/ NHA Supported MOH in production of Cte dIvoires first NHA estimates, for 2007 and 2008 Built local capacity to produce and use NHA findings and institutionalized the approach for future NHAs Governance: Decentralization Improved accountability, coordination, and collaboration between MOH and decentralized entities by establishing a Technical Working Group Capacity building: Management and Trained 361 managers of HIV/AIDS and other health activities in the private and public sectors (December 2007 to March 2009) leadership training Institutionalized training program at the National Institute of Public Health GIS for health Improved MOH and DIPE capacity to develop and use health maps for planning and implementing interventions

The first three initiatives are described below.

for approximately 1,436 students at the four INFAS campuses (Abidjan, Aboisso, Bouak, and Korhogo). Analysis shows that the Health Systems 20/20 assistance to INFAS has had the following impacts: y A more adequate student-to-teacher: about 1:28 (vs 1:39 without the supplemental hiring); y Improved student attendance, mentoring, and oversight; and y A strengthened INFAS management team, which has been able to align the training curricula to local needs.

Support to INFAS
Since 2007, Health Systems 20/20 has provided financial and training support to INFAS, Cte dIvoires leading nurse training institution. Financial support included paying salaries for the hiring of 35 (20 new and 15 retired) pre- and in-service instructors to strengthen the schools theoretical and practical training. The instructors, who received training to update their teaching competencies, currently are responsible

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During the four years of Health Systems 20/20 support, INFAS has graduated 2,022 nurses and 1,286 midwives.

y Facilities used incentive payments for institutional capacity building (equipment and training). y The posting of new health workers increased the availability of and therefore the populations access to HIV and other priority health services in outlying areas; the services include antiretroviral treatment, prevention of mother-to-child transmission (PMTCT), and counseling and testing. For example, 9,781 clients including 7,426 pregnant women received counseling and testing and 501 HIV-positive women received PMTCT services. In its second phase, which will end in June 2011, the pilot was expanded to 11 facilties. Results from the pilot scheme will demonstrate to MOH how performance incentives can be used within the public sector.

Pilot Performance-based Incentive Scheme

The PHRplus and Health Systems 20/20 assessments found that HRH in Cte dIvoire were geographically maldistributed nearly 60 percent were based in and around the countrys commercial capital of Abidjan, leaving many underserved rural areas and zones affected by the socio-political crisis of 2002. In response, Health Systems 20/20 is working with several MOH units (DAF, DRH, DIPE, PNPEC, and District Medical Offices [DMO]) to attract health care professionals to the underserved areas. A pilot PBI scheme is being implemented jointly with the Elizabeth Glaser Pediatric AIDS Foundation to attract health workers back to Ferkessedougou district. The PBI scheme, the first to use such incentives in the public sector in Cte dIvoire, began in six facilities and offered three types of incentive payment, as shown in Figure 4. Results from the first phase of the pilot scheme were the following: y Existing health workers were attracted back to participating facilities, and six recent graduates (three nurses, two midwives, and one lab technician) agreed to serve in the facilities.

Human Resources Information System

Health Systems 20/20 helped the MOH to implement a national HRIS to improve HRH planning, coordination, and management. Support included improving local infrastructure and training staff to use the GESPERS (HRIS) software. The HRIS is functional at the central-level DRH and in 35 health districts (one third of health districts in Cte dIvoire). A total of 110 health sector personnel were trained to use the

FIgure 4: IncentIve payMentS In pIlot pBI IncentIve ScHeMe

Note: USG=U.S. Government

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GESPERS software. Strengthening of MOH personnel record management is in progress at the DRH; 70 percent of personnel files have been scanned and formatted, and are accessible.

uSing geographic information SyStem to improve health SyStem planning

Using GIS to present health and other data allows policymakers to visualize numbers and distribution of health services in terms of health workers, facilities, laboratories, and other components of care, and thereby to identify and fix gaps in the system. In Cte dIvoire, GIS displays will be especially useful in informing the political decisions needed to plan the post-crisis recovery of the health system. Health Systems 20/20 provided GIS support to DIPE, the MOH unit charged with information, planning, and evaluation. The collaboration has achieved the following results: y Equipped a dedicated health map laboratory; y Trained 15 DIPE staff on the use of GIS software; and y Produced the first post (2002)-crisis health atlas, of 22 health maps. Figure 5 is illustrative of the maps in the health atlas. It shows the current regional distribution of doctors and nurses in Cte dIvoire, and compares their numbers with the WHO standard based on the regions population.

Supporting Decentralization through Better governance

A Health Systems 20/20 evaluation of health system decentralization revealed that SASED, the MOH unit in charge of decentralization, lacked capacity to effectively carry out its role. Specifically, the evaluation identified the following challenges: lack of coordination and collaboration between MOH and the communes, conseils gnraux (general councils), and districts; limited autonomy of managers at regional and district levels of the health system; weak regional and district supervision of health establishments; and absence of policies that make the managers accountable for their actions. In response, Health Systems 20/20 has: y Updated the physical infrastructure of SASED offices, including installation of a basic IT system that allows staff to design and monitor decentralization activities. y Developed a training manual and provided training for personnel from communes, conseils gnraux, and districts (Abidjan and Yamoussoukro), so they can participate in health planning activities. y Developed a framework for accountability and collaboration for decentralization. This included establishing a health system decentralization Technical Working Group, members of which come from the MOH; Ministry of Interior, which is in charge of overall decentralization activities; Union of Towns and Communes of Cte dIvoire (Union des Villes et Communes de Cte dIvoire, or UVICOCI); and Assembly of Districts and Departments of Cte dIvoire (Assemblee des Districts et des Departements de Cte dIvoire, or ADDCI). Working group members meet monthly to increase collaboration between the MOH and the newly decentralized levels and develop a consensus on a strategic direction for the health system.

concluSIon
As listed above in Table 1 and discussed in the ensuing text, Health Systems 20/20 has conducted much-needed assessments and evaluations of the health system in Cte dIvoire over the past four years. The identification of system weaknesses has allowed for the design of interventions targeted to fix the weaknesses and thereby strengthen the health system. Project activities focus on capacity building, HRH, governance, financing, and information systems. The following actions were important in meeting project objectives: y Engage key stakeholders and counterparts early in the process to build consensus for development of the HRH policy and establishment of the decentralization Technical Working Group that is improving accountability and collaboration.

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y Promote counterpart ownership and sustainability of capacity building, as was demonstrated by institutionalization of NHA, management and leadership training, and the PBI scheme. y Have a champion at the MOH to lead the process, and gain support from the Cabinet.

As part of the projects vision for country ownership and sustainability, Health Systems 20/20 interventions used mechanisms that will allow the MOH to maintain the efforts to strengthen the health system. In partnership with the new leaders in Cte dIvoire, the new MOH and other local health institutions should be able to manage the health system to improve efficiency, equity, access, and quality of services.

FIgure 5: HrH dIStrIButIon By regIon and cadre

Source: C. de la Madrid for Health Systems 20/20, unpublished

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reFerenceS
Banque Mondiale. 2010. Rpublique de Cte dIvoire. Sant, Nutrition et Population; Rapport Analytique Sant Pauvret. Rapport No. AAA56 CI. Le Groupe Banque Mondiale, Rgion Afrique Dveloppement Humain et Ministre de la Sant et de lHygine Publique, Cte dIvoire. En partenait avec USAID et PEPFAR. Butera, Damascene, John Vincent Fieno, Suzanne D. Diarra, Gilbert Kombe, Catherine Decker, and Soumahoro Oulai. August 2005. Comprehensive Assessment of Human Resources for Health in Cte dIvoire. Bethesda, MD: Partners for Health Reformplus, Abt Associates Inc. Cte dIvoire Ministre de Sant et Hygiene Publique (MSHP) et Health Systems 20/20. Septembre 2010. Les Compte Nationaux de la Sante de la Cte dIvoire Exercises 2007, 2008: Comptes General, Sous Compte VIH/SIDA. Lee, Won Chan, Gilbert Kombe, Suzanne D. Diarra, Damascene Butera, Amy Holdaway, Alison Bishop, Kreda Boci, and Olai Soumahoro. December 2006. Human Resources for Health in the Private Sector: Understanding the Capacity, Motivation, and Skills Mix in Cte dIvoire. Bethesda, MD: Private Sector Partnerships-One project, Abt Associates Inc.

Health Systems 20/20 (2006-2012) is USAIDs flagship initiative for strengthening health systems.The project helps USAID-supported countries address health system barriers to the use of life-saving priority health services. Health Systems 20/20 focuses on improving the financing, governance, operations, and capacity-building constraints that impede the delivery of health services, particularly those related to HIV/AIDS, tuberculosis, malaria, maternal and child health, and reproductive health. Abt Associates Inc. leads a team of partners that includes: | Aga Khan Foundation | Bitrn y Asociados | BRAC University | Broad Branch Associates | Deloitte Consulting, LLP | Forum One Communications | RTI International | Training Resources Group | Tulane University School of Public Health

www.healthsystems2020.org | E-mail: info@healthsystems2020.org Abt Associates Inc. | www.abtassociates.com 4550 Montgomery Avenue, Suite 800 North | Bethesda, MD 20814 USA June 2011

The authors views expressed here do not necessarily reflect the views of the U.S. Agency for International Development or the U.S. Government.

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