Picking up the pieces: Implementing pMTCT and strengthening public sector health systems in a post-conflict setting – the case of Bouake, Cote d'Ivoire

What happens to a public sector health care system in the aftermath of a civil war, and what happens to a region's most vulnerable populations? Using Bouaké, Côte d'Ivoire as a case study, we will examine how fledgling public health sector HIV programs, interrupted by a military coup in 1999 and again by an army-led rebellion that began in 2002, fared in the aftermath when health care workers fled conflict areas and services were offered by local and international NGOs. As we will see, implementation of HIV testing services was ultimately fragmented into a complex system with sporadic availability in public sector sites and inconsistent referral systems to private centers, resulting in a large loss of follow up and that left vulnerable populations, including pregnant women, underserved. We believe the piecemeal implementation of HIV services by NGOs in Bouaké undermined the strength of the local public health care sector and its potential to rebuild in the aftermath of the conflict. In 2007, Health Alliance International, in partnership with the Ministry of Health, began working with public sector health sites to implement integrated HIV testing services and prevention of mother-to-child transmission services. Since then, testing rates in the region have increased dramatically, as have treatment, care, and psychosocial support service utilization. HAI's current approach, including working in close collaboration with the Ministry of Health, onsite coaching and mentoring, and strengthening leadership and management systems will be examined. Current programmatic priorities and future directions will also be discussed.