West and Central Africa is one of the most challenging regions for Global Fund grants. A recent Office of the Inspector General (OIG) advisory review found that weak health systems and insufficient monitoring are linked to low grant execution and slow progress against the diseases. UNAIDS data show the region is lagging far behind on HIV treatment targets (Figure 1).
Figure 1. Progress Towards The 90-90-90 Targets, by Region (UNAIDS, 2017)
The OIG review says there is limited granular data available to support decision-making at the regional level (see article in GFO 356). UNAIDS’ West and Central Africa Catch-Up Plan calls for the establishment of community monitoring systems for commodity stocks, service fees and quality of care.
In January 2017, the Global Fund granted €3.6 million to the International Treatment Preparedness Coalition (ITPC) to implement a regional community treatment observatory in 11 West African countries (RCTO-WA): Benin, Côte d’Ivoire, Gambia, Ghana, Guinea, Guinea-Bissau, Liberia, Mali, Senegal, Sierra Leone, and Togo. The grant supports the national network of people living with HIV in each country to collect and analyze facility-level data along the HIV care continuum. It also supports data-driven advocacy at the national and regional level for improved service provision.
In a new report entitled ‘Data for a Difference’, ITPC shares key findings, analysis and advocacy opportunities emanating from the first year and a half of this grant’s implementation.
Following intensive training of the national networks, the RCTO-WA conducted 538 monthly monitoring visits to 103 health facilities in the 11 focus countries between July 2017 and June 2018. The monitored facilities cater to more than 80,000 people on antiretroviral therapy (ART).
The RCTO-WA also conducted 279 key informant interviews and 110 focus group discussions with service providers and beneficiaries.
The results of the community monitoring are presented in the report using a ‘Five A’s’ framework — availability, accessibility, acceptability, affordability and appropriateness.
With a great deal of variation between countries, the RCTO-WA documented stock-out frequency as 8.8% for HIV test kits, 23.4% for antiretroviral drugs (ARVs) and 17.2% for viral load lab supplies (such as reagents and consumables) (Table 1).
Table 2. Frequency of Recorded Stock-outs at RCTO-WA Health Facilities
On average, ARV stock-outs lasted for 41 days. In the most extreme case, one health facility in Côte d’Ivoire had a Tenofovir and Lamivudine stock-out lasting nearly seven months. The regional community treatment observatory is working to alleviate such stock-outs.
“At the Bethesda Hospital in Cotonou we noticed that the site had not been supplied with lab reagents for more than ten months,” said Valentin Roch Houngbo, Coordinator of the Benin National Network of PLHIV (REBAP+). “We presented this data to the Deputy Coordinator of The National AIDS Control Program during one of our community consultative group meetings and a solution was found. At our next monitoring visit, the site was stocked.”
While stock-outs are a major concern in the region, qualitative RCTO-WA data from key informant interviews and focus group discussions highlight long distances to health facilities as a key barrier to access for HIV testing services and ART (Figure 2 and Figure 3).
Figure 2. Reasons Given for Not Accessing HIV testing services (n=289)
Figure 3. Reasons Given for Not Accessing ART (n=321)
The RCTO-WA is using this data to advocate for differentiated service-delivery options, so that HIV testing services and ART can be made available at community level.
“On 4 March 2019, we presented our community monitoring data in the National HIV/AIDS Control Program conference hall, highlighting the low uptake of services, especially among key populations,” said Martin Philip Ellie, the Program Manager at the Network of HIV Positives in Sierra Leone (NETHIPS). “Following our presentation, we secured a commitment from the government to develop a differentiated service-delivery policy for Sierra Leone. The policy was signed by government and the National AIDS Secretariat in May 2019.”
ITPC’s report points out that poor quality of care may be as critical as non-access to health services, citing a recent study. The RCTO-WA asks people to rate the quality of services they receive at the monitored health facilities on a scale of one (lowest) to five (highest).
One third of people consulted by the RCTO-WA rated the quality of services a 3 or less on a scale of 1 to 5 (Figure 4). Quality of care was rated lowest among men who have sex with men (3.16/5.00) and highest among pregnant women (4.00/5.00). Adolescent girls and young women age 15-24 years rated quality of care slightly lower than their male counterparts (3.73/5.00 vs. 3.86/5.00).
Figure 4. Average Quality of Care Rating (out of 5) at RCTO-WA Health Facilities (n=55)
The Gambia Network of AIDS Support Societies (GAMNASS) has used RCTO-WA data to secure a commitment from the National Assembly Health Select Committee to engage the Ministry of Health and National AIDS Secretariat on performance improvement plans for health facilities.
The Malian Network of People Living with HIV Associations (RMAP+) used RCTO-WA data to improve data quality and patient monitoring. During a recent monitoring visit to the Gabriel Touré University Teaching Hospital in Bamako, RMAP+ drew the attention of health facility managers to data entry issues with viral load test results. Nurses now record viral load test results by individual patient, rather than clustering them by date.
According to Gavin Reid, a Technical Advisor in Community Systems and Responses at the Global Fund, community-based monitoring is an important priority for the Fund. “Communities and beneficiaries of services have an invaluable role to play in generating evidence on the availability, accessibility and quality of services,” said Reid. “Using this data collected by the RCTO-WA to address bottlenecks in a timely manner is key to improving the responsiveness and effectiveness of HIV programs and realizing national and global targets.”
Despite high out-of-pocket payments for health in the region, less than 5% (n=334) of people consulted at RCTO-WA-monitored health facilities said that user fees are a major barrier to accessing services. The ITPC report concedes that this is a puzzling finding, endeavoring to explore the issue further in future monitoring visits.
Lastly, RCTO-WA data sheds light on whether the health services provided at the monitored health facilities are targeted and tailored to key and vulnerable populations most in need. In spite of the commitment of countries in the Dakar Declaration to strengthen strategic information on key populations, just 38 out of 103 (37%) RCTO-WA health facilities report data for at least one key population.
Where data is reported, RCTO-WA analysis shows a distinct linkage-to-care issue for key populations. Men who have sex with men, sex workers, people who inject drugs and young people (age 15-24 years) make up 16% of people who test HIV-positive, but only 7% of people on ART, at RCTO-WA facilities (Figure 5).
Figure 5. Key and Vulnerable Populations Reached Along the Cascade at RCTO-WA Facilities
The National Network of Persons Living with HIV in Ghana (NAP+) has used RCTO-WA data to open up dialogues with Imams, women’s groups and chiefs in Tamale, discussing ways of addressing human rights and gender-related barriers to access for key populations.
Managing a grant of this size and scope is not without its difficulties. “The differences in geographic coverage of country activities and the varying capacities of the national networks presented challenges,” said Alain Manouan, ITPC’s Community Treatment Monitoring Project Director. “We innovated by classifying the national monitoring activities into tiers,” Manouan continued. “Some were in progress, some at district-level, and others at the national level. This allowed us to be more efficient with our support to our sub-recipients.”
ITPC’s regional office for West Africa, based in Côte d’Ivoire, performs quarterly quality assurance checks in each of the 11 countries, overseeing data collection, checking data accuracy and supporting data analysis and advocacy planning. This is both time consuming and costly, but ultimately necessary for the grant’s success. “It is important that people know they can trust community data,” said Solange Baptiste, ITPC’s Executive Director. “The rigor we employ in verifying the data we collect is the reason our advocacy is taken seriously at national, regional and global levels.”
Priorities for the way forward
The report closes with a data-driven advocacy plan, set by the RCTO-WA’s Regional Advisory Board (RAB) during its October 2018 meeting in Abidjan, Côte d’Ivoire.
Currently, the top advocacy priorities for ITPC and its partners are to:
- Expand the availability of non-facility-based HIV testing options, including community-led and community-based HIV testing services
- Improve communication along the supply chain to prevent stock-outs of antiretrovirals
- Increase funding to ensure the availability of adequate viral-load testing machines and laboratory supplies.
“Differentiated service-delivery approaches have emanated from RCTO-WA’s advocacy,” said Sonia Florisse, the Fund Portfolio Manager for ITPC’s grant at the Global Fund. Florisse noted that the 11 national networks supported through the grant have been pushing for greater accessibility and community-based services. “Everywhere, Global Fund HIV grants are now supporting the implementation of these differentiated approaches. In this way, the ITPC grant has been catalytic for Global Fund investment in the countries covered,” she said.
The RCTO-WA’s community monitoring activities are ongoing through June 2019, after which ITPC will release a second advocacy report. ITPC is also gearing up to host a community treatment observatory learning event in October 2019 in Abidjan, sharing lessons from the grant and building capacity of others to roll-out ITPC’s model. “Ultimately, what we have been able to accomplish during this grant is a community oversight mechanism that produces quality data for targeted action,” says Baptiste. “This means that any community in any part of the world can adapt this model for any issue that they see fit.”
The results in Côte d’Ivoire have encouraged PEPFAR to include funding in its 2019 Country Operational Plan to continue the community treatment observatory work.
With the 2020-2022 Global Fund funding cycle fast approaching, further opportunities to sustain the gains and scale-up ITPC’s model are on the table. “The examples of the networks being able to convince national programs to change HIV provider practices are extremely powerful,” said Florisse. “They might look like baby steps, but they are advancing patients’ rights and ultimately human rights.”
- The full ITPC report, ‘Data for a Difference: Key Findings, Analysis and Advocacy Opportunities from the Regional Community Treatment Observatory in West Africa’
- The summary ITPC report, ‘Regional Community Treatment Observatory West Africa Fact Sheet’
Gemma Oberth is an independent consultant and the lead author of the ITPC report. Gemma also consults directly with the Global Fund, supporting the Community, Rights and Gender Strategic Initiative. This was declared to Aidspan and was not considered a conflict of interest in light of the authors’ unpaid contribution to the GFO in order to share the ITPC report findings.