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Evaluation database

Evaluation report

2016 Cote d'Ivoire: Formative Evaluation of the OHTA project



Author: Tanya Doherty, Donnela Besada, Sarah Rohde, Barbara Torresi, Ameena Goga, Vundli Ramokolo, Emmanuelle Daviaud, Nobuntu Noveve, Nika Raphaely, Vuyolwethu Magasana

Executive summary

With the aim to continuously improve transparency and use of evaluation, UNICEF Evaluation Office manages the "Global Evaluation Reports Oversight System (GEROS)". Within this system, an external independent company reviews and rates all evaluation reports. The quality rating scale for evaluation reports is as follows: “Highly Satisfactory”, “Satisfactory”, “Fair” or “Unsatisfactory”. You will find the link to the quality rating below, labelled as ‘Part 2’ of the report, and the executive feedback summary labelled as ‘Part 3’.

Background:

Eliminating mother to child transmission of HIV (E-MTCT) is at the forefront of HIV-prevention strategies. Several countries in sub-Saharan Africa (Malawi, Democratic Republic of Congo, Rwanda and Uganda) have shifted to WHO PMTCT Option B+ policy, a pragmatic public health approach which involves lifelong HAART for HIV infected pregnant women irrespective of their CD4 count1. The rationale behind option B+ is that it will enable better access to treatment in settings with limited access to CD4 testing, will have benefits beyond MTCT for the woman’s own health, facilitate the prevention of sexual transmission to uninfected partners and protect future pregnancies.

The Global Plan Towards the Elimination of New HIV infections Among Children by 2015 and Keeping their Mothers Alive was launched at the UN General Assembly High Level Meeting on HIV and AIDS in June 2011. One of the identified challenges in the Global Plan is the need for extraordinary community, subnational, national, regional and global leadership, with high-level advocacy, to reduce obstacles to uptake of and retention in HIV services.

In December 2012, Sida and Norad approved a three-year grant to support the “Optimizing HIV Treatment Access for Pregnant Women (OHTA) Initiative” focussing on four countries; Cote d’Ivoire, Malawi, Uganda and the Democratic Republic of Congo. The grant began in January 2013 and ends in December 2015. This report presents findings from the formative, mid-term evaluation of OHTA, undertaken between May and September 2015.

Purpose/Objective:

The mid-term evaluation sought to assess the relevance of the OHTA initiative, its effectiveness in providing catalytic support for countries to transition to Option B+ and its contribution to the sustainability of Option B+. As such, the main purposes of the evaluation was to:

  1. Contribute to management and operational learning by making strategic and operational lessons learned available to the partnership involved in the OHTA Initiative and beyond.
  2. To promote accountability to the donors, Sida and Norad, by reviewing OHTA operationalization, strategies and early results in line with the objectives of the initiative and its specific targets.

Methodology:

A mixed method approach (qualitative and quantitative) was used for this evaluation2,3.  Quantitative data sources included the quarterly OHTA indicators from each of the countries and the baseline OHTA facility assessments undertaken in 2014. Qualitative data sources included a desk review of relevant documents and policies as well as key informant interviews and focus group discussions during 10 day country missions in June and July 2015.

Findings and Conclusions:

Across the four countries OHTA investments focussed on highly relevant gaps not filled by other PMTCT partners namely demand creation, community-facility linkages, male involvement, monitoring and evaluation (M&E) and support to clinical services where required. The multi-partner focus, while resulting in delays in some countries due to grant-making processes, capitalised on existing strengths and experience of well-established organisations with regional spread across the countries. Under the OHTA initiative, the district-focussed approach, in particular the data quality improvement initiatives have fostered greater ownership of data and attention to closing implementation gaps highlighted in regular data review forums.
Over the period of OHTA support there have been increases in antenatal attendance, particularly in Uganda and CDI, and increased coverage of Option B+ initiation, most notably in Malawi.  These achievements could plausibly be due to the demand creation strategies of various community cadres who have been engaged to support PMTCT through the OHTA grant.
The OHTA countries have also successfully reached the target number of sites to provide Option B/B+ by the second quarter of 2015 thus contributing to the scale up of PMTCT services and ensuring increased access, including in some hard to reach areas of the target countries.

Recommendations:

Relevance: It is recommended that the lessons learnt from OHTA are shared beyond OHTA sites within and across countries.
Effectiveness: Increased efforts are needed to improve timely antenatal attendance within the first trimester as well as coverage of EID which is currently at around a quarter of expected HIV exposed infants. Retention monitoring systems are still new a little data exists to assess the effectiveness of strategies to improve retention in care.
Sustainability: It is recommended that a costing exercise be undertaken to inform the additional costs of activities undertaken by community cadres in support of PMTCT.

Lessons Learned:

The OHTA funding addressed important gaps in demand creation, male involvement, community-facility linkages and data quality. It also raised the profile of these aspects of Option B+ implementation and catalysed greater focus by other partners.  Involving districts from the outset was strategic in generating buy-in and a faster speed of implementation
Initiatives funded though the OHTA grant contributed to increases in male involvement in PMTCT, ANC attendance, pregnant women tested and initiated onto lifelong treatment and, facilitated the use of data for management and client tracing and retention in care. A receptive environment for policy change, strong leadership by the Ministries of Health, and effective collaboration and communication between partners helped the OHTA grant achieve programme objectives and ensured a complementarity of services with other partners. Working through the districts for programme implementation fostered a sense of ownership of the programme at the local levels and contributed towards a culture of regular data informed policy assessment and recourse.
OHTA funding has led to the establishment of community involvement in PMTCT through the use of various community cadres (CHWs, mentor mothers etc.) These initiatives, although drawing largely on existing cadres, require ongoing funding to support the additional community-facility linkage activities. Specifically support for stipends and travel allowances to enable these critical retention activities to continue.



Full report in PDF

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Report information

Year:
2016

Country:
Cote d'Ivoire

Region:
WCAR

Type:
Evaluation

Theme:
HIV-AIDS

Language:
English

Institution:
South African Medical Research Council

Sequence #:
2016/007

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