The AWARE Project- CBC Health Board

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BACKGROUND
The AWARE project is a five year regional project focused on 18 countries in the West and Central African region. The countries are the 15 ECOWAS countries plus Tchad, Cameroon and Mauritania. It is funded by United States Agency for International Development (USAID) through the West African Regional Program (WARP) based in Accra – Ghana. The countries are seen on the map below;

The Cameroon Baptist Convention Health Board (CBCHB) and Action for West Africa Region (AWARE) started exploring partnership options in July 2003. A series of evaluations of the CBCHB health system and the PMTCT program in particular were carried out including the use of a Technical and Organizational Capacity Assessment Tool (TOCAT). The CBCHB PMTCT program met the rigorously pre-defined standards and was selected as a “best and promising practice”.
"A best and promising practice (PBP)" is defined as an experience, initiative or program that has proven its effectiveness and its contribution to the response to the HIV/AIDS epidemic, and that can serve as an example and inspiring model for others ( program planners, managers, and implementers )."
Partnership opportunities were exploited, developed and on November 23, 2004, the partnership agreement was officially signed and launched at the Regional Training Center in CBC Health Services Complex, Buea Road Mutengene - Cameroon.

There are two arms of AWARE – AWARE HIV/AIDS and AWARE Reproductive Health. Both have different areas of focus and the CBCHB had the privilege to work with both of them. Both projects also have other partners in Cameroon.
AWARE HIV/AIDS
In the area of capacity development, AWARE HIV/AIDS believes that an expanded and comprehensive response to the HIV/AIDS epidemic in the West African region requires strong national and regional institutions and networks capable of fully playing their respective roles in the response. Working under the leadership of Family Health International (FHI), AWARE HIV/AIDS use various methods of "skills transfer” to scale up HIV/AIDS programs with quality and sustainability. Thus, focus is on;

Training
Coaching
Mentoring and
Systems developme

AWARE-HIV/AIDS identifies and works with health care institutions involved in the fight against HIV/AIDS to assist them in their efforts to strengthen their organizational, technical and marketing capacities to enable them to expand the reach and impact of their work nationally and regionally.
The project also supports the documentation and dissemination of the “best and promising” practices identified.
Other areas of focus are “advocacy for policy change” and “Communication for Behaviour change”.
More information can be obtained from www.awarehiv.org.
AWARE Reproductive Health
AWARE-RH is guided by a vision of strong, capable, relevant, vibrant, and sustainable regional health institutions and networks, proactively assisting national and cross border health programs in developing quality health services that meet the needs of their people. The managing partner of AWARE RH is EngenderHealth which brings strengths in family planning, reproductive and maternal health care, quality improvement, and training.
The project focuses on;

Stimulating governments, donors, and the private sector to develop a progressive region wide agenda promoting family planning, reproductive health, and child survival services and their integration with HIV and AIDS services
Advocating and influencing policy for this agenda by promoting dialogue, compiling and sharing best practices, and disseminating research findings
Helping national and regional institutions strengthen their technical capacity and address resource constraints by leveraging and diversifying funding, forming public-private partnerships, and strengthening the response to health-sector reform efforts.

More information can be obtained from www.aware-rh.org.

PARTNERSHIP WITH CBCHB
Goal
“Strengthen the CBCHB PMTCT program so as to replicate it in the region covered by AWARE”.
Objectives

Strengthen the capacity of the CBCHB as an institution

Capacity Building for staff in areas of need as identified during the TOCAT assessment
Infrastructural improvement

Establish a Regional Training Center (RTC) for PMTCT in Health Services Complex – Mutengene

Identify and strengthen six CBCHB institutions to serve as practicum sites.

Train health care workers from the rest of the AWARE countries on PMTCT at the RTC and practicum sites
Assist the CBCHB to provide technical assistance in the replication and scale-up of the PMTCT program in other AWARE countries.
Strengthen Family Planning & other reproductive health activities within the CBCHB.

Achievements
A lot has been achieved from the partnership after just three years of implementation. The impact of the partnership on CBCHB, her clients, the community, the country and the region is enormous. We will highlight a few of the achievements below;Capacity Development for CBCHB

A) The partnership between the CBCHB/AWARE/USAID has helped to build the capacity of the CBCHB staff for quality improvement in the following domains;

Five staff were trained in project financial management according to USAID requirements. This has led to effective financial management of the project, other projects & CBCHB institutions and an improved financial management system for the organization.
Sixteen (16) staff were trained as trainers on the use of Client Oriented Provider Efficient (COPE) Services – a tool for quality improvement. These trainers trained several other staff in all CBCHB institutions and assisted the institutions to set up COPE committees. The committees organize bi-annual COPE exercises in the institutions and assist staff members in the development and implementation of action plans. A refresher course for facilitators

Five staff were trained in Monitoring and Evaluation (M&E) of the project. Technical Assistance (TA) was provided by AWARE in the development of M&E tools for the project. The staff trained in turn organized M&E training for eighteen (18) other CBCHB staff who were assigned to implement M&E at the level of the sites. This has generally improved on M&E in the system. There is improved reporting and the CBCHB staff have improved capacity in drawing up M&E plans.

Five different training sessions were organized to train family planning (FP) providers on various aspects. Training topics included basic knowledge of family planning, contraceptive technology, IUD revitalization, counseling for effective FP and Minilaparatomy. Family planning services have indeed been revitalized in CBCHB. USAID donates all FP commodities to CBCHB which are distributed to institutions as needed. This has greatly reduced the stock out problem which was a general cry in Cameroon and has enhanced access to services.
held after one year and bi-annual meetings are held to review progress and seek ways to improve on activities.
Four of the facilitators were empowered to train 16 committee leaders as facilitators to ease implementation of activities at the sites and increase sustainability. The CBCHB facilities have embraced COPE and have included it in the facility’s annual budget. A lot of success stories have been written for COPE as indicated below.

Thirty-six (36) CBCHB Supervisors have been trained and retrained in Facilitative supervision (FS). Facilitative Supervision has been scaled up within CBCHB replacing traditional supervision. Annual refresher courses are organized and all heads of department have been trained and guided to make personal action plans for improvement on their supervisory skills. This has greatly improved on supervision at all levels. All PMTCT site supervisors have received training on FS which they find very helpful.

Two CBCHB staff were trained in project management and they have gradually transferred the skills to other staff working on other projects within the programs. This has led to high quality project management skills within the CBCHB.

The three staff trained by AWARE HIV on Resource Development and marketing trained 16 others. This team has worked actively to greatly improve on the marketing ability of CBCHB. Several institutions produced brochures, programs produced posters, the website has been developed, staff are conscious of the need to always promote the services they offer and the entire organization recognizes the need to promote services both to internal and external customers.

Ten Infection prevention (IP) trainers and 36 infection prevention staff were trained. The trainers organized IP workshops in all major institutions and trained on levels of staff (from doctors to house keepers) and set up IP committees. IP committee members review IP procedures in the various institutions, ensure safe waste management and educate the staff and administration on what needs to be improved upon. Most institutions now have good autoclaving and incineration facilities thanks to the awareness created through the IP workshops.

Thirty – six staff were trained on leadership – coaching and mentoring. This training served as an eye opener to most of the trainees who did a self evaluation as the lessons were being presented, especially lessons like ‘who is a good leader’ and ‘leadership styles’. All the participants called for refresher courses which will always help them to identify their errors and improve on their leadership skills.

Eighty CBCHB staff and some community peer educators (mostly People Living with HIV and AIDS) received training on various techniques used to involve more men in PMTCT services through the Men As Partners (MAP) project. Lessons learnt from the workshops have been implemented to a great extent in six pilot sites and the results are very encouraging. Many more men are getting involved in PMTCT and other reproductive health services and very supportive to their wives. More than 5000 men were tested for HIV in the six pilot sites within a period of 8 months. The project is on-going and lessons learnt will be documented and shared with interested partners soon.

Twenty CBCHB clinical supervisors received training on Fundamentals of Care and Medical Monitoring organized with support from AWARE –RH and Engenderhealth. Clinical supervision has been greatly strengthened within the board and the quality of services offered to clients improved.

Technical assistance received
Apart from the capacity building trainings mentioned above, the CBCHB staff received technical assistance from AWARE in the following activities;

TOCAT assessment. TOCAT refers to ‘Technical and Organizational Capacity Assessment Tool. This tool was used at the beginning of the project and also after two years of project implementation to assess the capacity of the CBCHB. This helped the CBCHB to identify the areas which were doing very well and those needing improvement. The results of this assessment were used to develop the project activities for the first two years of the project. These activities were implemented and the second TOCAT exercise revealed that a lot of progress was made after the first two years. The results of the second exercise were used to develop activities for the two subsequent years of implementation. TOCAT has proven to be a very useful tool for quality improvement within organizations and institutions.

Documentation of the PMTCT program. The CBCHB staff received assistance from AWARE HIV/AIDS in the documentation of the program for dissemination within the AWARE region. This document was one of the best practices disseminated at a regional dissemination workshop in Accra in 2005. Many other countries learnt about the CBCHB experience and have been coming to CBCHB to receive training so as to replicate the model in their own countries.

Skills transfer capacity assessment. AWARE HIV/AIDS sent a consultant (Dr. Henry Akplu) who assisted the CBCHB staff to assess their capacity to transfer skills acquired to others within the organization. Selected staff from all levels worked with him for two weeks and used the SWOT (strengths, weakness, opportunities and threats) analysis to assess the organization, the programs and develop strategic action plans for various institutions and programs. A five year strategic plan document for the entire organization was developed and adopted by the end of the exercise. This document is used to develop yearly action plans and budgets for the various institutions and programs.

Adaptation of World Health Organization (WHO) PMTCT training modules to suit the African context. The CBCHB developed a training manual in 2002 which was being used for PMTCT trainings in Cameroon. In 2004, the AWARE project sent a consultant who worked with the CBCHB staff to adapt the WHO training modules to the African context using the CBCHB training manual as a base. This was successfully done and the adapted modules together with the national PMTCT technical guide are used to train PMTCT trainers in Cameroon and the AWARE region. It is worth noting that the consultant was from Family Health International (FHI) and had worked with the CBCHB in 2002 to develop the training manual. This manual is found at www.womenchildrenhiv.org.

Involving men in PMTCT. By Dec 2005, the CBCHB PMTCT program had received more than 175,000 women but less than 2% of the partners of these women got tested for HIV. Involving men in the program, which is very important for the life of their families and up bringing of the babies, was very difficult. Two Engenderhealth staff assisted CBCHB staff in the assessment of the PMTCT program to identify possible reasons for the low level of male involvement. Three main hindrances were identified. It was discovered that men generally did not know about PMTCT and the benefits of participating in it to the entire family. Men hardly have reasons to go to health facilities like women hence do not have the chance to receive the wonderful health lectures the women have at antenatal clinics. Also, they do not feel comfortable in places like ANC sites which are ideally meant for women. There was also the problem of poverty – lack of money to pay for an HIV test. A plan of action was developed to improve on the situation. This was implemented from Feb 2007 and by September 2007, more than 5,000 men had been tested for HIV at PMTCT clinic

Equipment and infrastructure
The major achievement in this area was the establishment of a Regional Training Center (RTC) for PMTCT at CBC Health Services Complex – Mutengene in the Southwest province of Cameroon. The following renovations were done to the existing structures at the site;

Renovation of existing hall & an existing building into guest rooms
Refurbishment of the hall by providing Air Conditioners, breakout rooms, toilets, chairs, tables, an LCD projector, and a laptop computer.
Refurbishment of the kitchen by providing chairs, a fridge, cooker & air conditioners
Provision of office equipment and computers

In addition to the RTC, six CBCHB health institutions were identified and strengthened to function as practicum sites during trainings. Some equipment and renovation work was provided to the institutions as follows;

Provision of diagnostic equipment such as three ultrasound machines with printers and probes, a fast count machine for doing CD4 counts for HIV positive clients, family planning instruments like IUCD kits, norplant kits and minilap kits.
Renovation of practicum sites – Baptist Hospital Mutengene maternity & Etoug-Ebe Baptist Health center – Laboratory.
Construction of an incinerator for Baptist Hospital Mutengene
Improvement of water supply system for the regional training center and Baptist Hospital Mutengene
Provision of a 30 seater bus for transportation of trainees during trainings
Provision of internet services in four of the practicum sites

The Regional Training Center has played host to trainees from Senegal, Mauritania, Togo, The Gambia, Liberia, Sierra Leone, Mali, Guinea, Niger, and Tchad. In addition to these AWARE countries, EGPAF assisted the CBCHB to host trainees from other Africa countries like Botswana, Zambia, Tanzania, Nigeria and Ivory Coast as seem on the map.
Some of these countries have started PMTCT services thanks to the training received at the CBCHB meanwhile services have greatly improved in countries which had PMTCT services before the training. This is because the countries are replicating some of the lessons learnt during the trainings such as opt-out approach, bottom up approach, good counseling, good M&E systems, visionary leadership which are key to the success of the CBCHB program.

AFRICAN MAP SHOWING COUNTRIES TRAINED BY CBCHB ON PMTCT

The CBCHB didn’t just end at training health care workers from these countries. Technical assistance was provided to these countries as they implemented lessons learnt from the training sessions. A total of eleven technical assistance visits were provided to some of these countries (Liberia, Sierra Leone, The Gambia, Mauritania, Ivory Coast) in terms of situational analysis, training of service providers, training on use of quality improvement tools, development of M&E tools, etc.

SUCCESS STORIES
Quality Improvement (QI) is the watch word in the CBCHB. Staff at all levels are very conscious of clients rights and all are working towards improving on the quality of services offered daily. The organization has recorded a lot of successes in the course of using the various QI tools such as COPE, IP, FS, MAP, M&E, Medical Monitoring and marketing to improve on services. Click on the title above to see some of them.

MAJOR CHALLENGES

In the course of implementing the project activities, the CBCHB staff had to go through a lot of changes. The change process wasn’t completely smooth as there was some resistance to new ideas. Staff gradually saw the importance of this change and more than 90% now see the new methods of doing things as the way to go in order to ensure client satisfaction.
The provision of TA to countries depends on the needs of the country concerned and the CBCHB cannot single handedly plan a TA visit. Some of the countries have been slow in requesting for TA. Some of the planned visits were therefore not implemented.