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Côte D'ivoire Cote d'Ivoire Operational Plan Report FY 2012 Custom Page 1 of 377 FACTS Info v3.8.8.16 2013-05-24 13:00 EDT Operating Unit Overview OU Executive Summary Country Context Côte d'Ivoire is returning to stability after more than 10 years of civil unrest that divided the country, impoverished the population, decimated health and social services, and culminated in a six-month political and military standoff that brought the country to a virtual halt. About half the population of 22 million lives in rural areas with high illiteracy rates; a similar proportion survives on less than $2 a day. Maternal and infant mortality remain high, at 4.7 and 63.2 deaths per 1,000 live births, and life expectancy is low (57.25 years, 194th in the world). According to the National Poverty Reduction Strategy (2009), “Côte d’Ivoire has been weakened by a break in social cohesion, increasing insecurity, a slowdown in economic development, massive youth unemployment, and the spread of poor governance.” The poverty rate worsened from 10% in 1985 to 48.9% in 2008. According to the World Bank Governance Matters 2009 report, Côte d’Ivoire fell from the 41st to the 7th percentile in government effectiveness and corruption control between 1998 and 2008. Despite these problems, the country has remained a regional economic and migratory hub, and prospects are hopeful. After average gross domestic product growth of 2.8% in 2004-2010, predictions are for 8.5% growth in 2012 (National Development Plan 2012-2015). Following the 2010-2011 crisis, the new government moved quickly to develop ambitious reforms aimed at improving security, governance, and infrastructure, with a focus on attracting foreign investment for economic development. The achievement of highly indebted poor country (HIPC) benchmarks, a goal for 2012, would trigger significant funding, including for the health and social sectors, from the World Bank, the French and possibly other donors. Parliamentary elections in December 2011, the first in 10 years, were peaceful but were boycotted by the previous president’s political party. A disorganized security sector remains a concern. A new National Development Plan posts ambitious targets in every sector, and a culture of accountability is being promoted at the highest levels, with ministers held responsible for achieving results. Although complex social and institutional challenges may pose speed bumps, the country is clearly on the road to recovery. The Health System Shortly after his inauguration in May 2011, the new president enacted a policy of free public health services and medicines. Although welcomed as proof of the new government’s social welfare intentions, the policy suffered from insufficient planning, and increased service utilization soon strained providers and equipment in a system weakened by a decade of poor governance and under-funding. Slow public procurement has led to stockouts in essential medicines and supplies, although HIV commodities remain Custom Page 2 of 377 FACTS Info v3.8.8.16 2013-05-24 13:00 EDT available. Health care personnel continue to be paid and are present in sites, but health centers have been only partially reimbursed for billed costs, and with no income from patient contributions, services have declined. In early 2012, the Government of Côte d’Ivoire (GoCI) shifted toward a program of “targeted free services” for pregnant women, children, and medical emergencies. Implementation is being planned now, and will be included within the National Plan for Health Development (PNDS). A national health insurance scheme is being developed to generate funding, however at present, the planned budget for the MSLS does not cover estimated needs in terms of essential medicines, let alone ARVs. Given that HIV/AIDS services are fully integrated into the public health system, PEPFAR is participating with other donors in this process to try and ensure that the new policy is based on realistic assumptions, draws from best practices, and is appropriately costed both now and into the future. In the organization of the fight against HIV/AIDS, the national response has been strengthened by the fusion of two former ministries into a single Ministry of Health and AIDS (MSLS). Two General Directorates are charged, respectively, with the planning, budgeting, and coordination of the national HIV/AIDS response (DGLS) and with oversight and coordination of health services at all levels (DGS). Specific roles and processes, important for the success of the HIV response, are still being clarified. Epidemiology of HIV/AIDS Côte d’Ivoire has the highest adult HIV prevalence in West Africa, estimated at 3.4% (UNAIDS, 2010). Both HIV-1 and HIV-2 are prevalent. Among 450,000 adults and children with HIV/AIDS, about 150,000 are estimated to be in need of antiretroviral treatment (ART) based on CD4 =200,and about 230,000 based on CD4 count =350 (UNAIDS, 2010). HIV-related orphans and vulnerable children (OVC) are estimated to number 440,000, including 63,000 children living with HIV; about 29,000 of these are estimated to be in need of ART. About 24% of TB patients tested for HIV are HIV/TB co-infected (PNLT, 2010), and TB is the leading cause of AIDS-related deaths. Data from the National AIDS Indicator Survey (AIS, 2005) describe a generalized epidemic marked by striking differences in prevalence between men and women and among geographic areas. In all age groups, females are far more likely than males to have HIV (6.4% vs. 2.9% overall, 4.5% vs. 0.3% among ages 20-24). Prevalence peaks among women ages 30-34 at 14.9%. Lower male prevalence may be explained in part by near-universal (96%) circumcision. Adult prevalence is marginally higher in urban settings and markedly higher in the South and East (5.5% or higher) than in the Northwest (1.7%). Prevalence is higher among employed men and women, and among women in the highest wealth quintile. By mid-2012, the country’s first Demographic Health Survey in 12 years, which includes HIV testing, will provide updated population-based health and HIV-related data. Custom Page 3 of 377 FACTS Info v3.8.8.16 2013-05-24 13:00 EDT The epidemic is driven by early sexual debut, multiple and concurrent sexual partnerships, transactional and intergenerational sex, weak knowledge about HIV, and low condom use during at-risk sex (occasional, transactional, etc.). Most-at-risk populations (MARPs) include sex workers and men who have sex with men (MSM); recent data on male sex workers at a clinic in Abidjan showed HIV prevalence of 50%. Other at-risk groups include sero-discordant couples, the uniformed services, economically vulnerable women and girls, transportation workers, migrants, prisoners, and OVC. Gender inequality and gender-based violence (GBV) heighten HIV risk across all socio-economic and cultural backgrounds. More than 35% of women ages 15-49 have undergone some form of female genital cutting, with rates above 80% in some regions (UNICEF MICS, 2006). A study in Abidjan found that 68% of women in relationships had experienced physical violence (UNFPA, 2007), and the AIS noted that 17% of women reported that their sexual debut was a rape. Status of the Response While a review of the National Strategic Plan for HIV/AIDS (NSP-HIV/AIDS) 2006-2010 indicated greatly expanded access to prevention, care, and treatment services, the national response remains hampered by poorly equipped and under-staffed health and social services, particularly at decentralized levels. Access to and uptake of prevention of mother-to-child HIV transmission (PMTCT) and other gateway services remain insufficient, particularly in rural areas. As of December 2010, only 8% of HIV-positive children and 18% of children in need of ART had been identified and were receiving lifesaving care. National guidelines and tools to ensure a continuum of response (CoR) are in place, but implementation is a challenge, and ART patients lost to follow-up after one year remains high at 19% (ART study, 2011). A PEPFAR-World Bank health sector assessment in 2010 revealed systemic barriers to improved performance. The national budget allocation for health lingers below 5%. Human resources for health (HRH) remain a barrier to service scale-up. A series of HRH assessments found irrationally deployed staff, new graduates lacking critical skill sets, high attrition rates (24% among nurses, 20% among physicians), limited public-sector ability to absorb and retain professionals, and limited HIV/AIDS services in the better-staffed private sector. Data from non-public health facilities is not collected regularly, although it is estimated that 80% of the population seeks care from private clinics and traditional healers. The national HIV testing and counseling (TC) and ART programs have continued to grow, with monthly ART enrollment increasing from 1,800 in May 2009 to 2,500 in May 2010 and stabilizing at 2,000 by October 2011. The GoCI has adopted WHO guidelines prescribing ART enrollment at a CD4 count below 350, and roll-out in 2012 will increase the number of ART-eligible clients. The national quantification committee was revising HIV-related commodity estimates in February 2012, Custom Page 4 of 377 FACTS Info v3.8.8.16 2013-05-24 13:00 EDT after seven months of delays during which an outdated supply plan was revised and used for ordering. This process epitomizes Côte d’Ivoire’s key challenges – a lack of accurate and timely information and of central leadership. In the Partnership Framework (PF) spirit, it also represents an important opportunity for joint action to address these challenges. The Role of PEPFAR In this evolving context, PEPFAR stands as the most significant partner for the HIV/AIDS sector, providing trusted procurement of 75% of national ARV and laboratory commodities, bringing technical expertise to all major HIV-related forums, supporting technical assistance (TA) and direct services by 35 partners and more than 200 subpartners, and insisting on systems–strengthening aspects of every funded activity.
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