From October 2007 USAID PEPFAR funding has supported an integrated health system strengthening activity, Angola Essential Health Services Program (EHSP), leveraging with PMI, FP and TB funding. The activity received funding for its last implementation year in COP 10. In COP 11, a follow on activity will replace the current EHSP. The TBD will also be an integrated activity with leveraged funding from PMI and FP. 0

The purpose of the HIV/AIDS component is to prevent HIV/AIDS transmission in Angola by improving the national and provincial capacity to address the HIV/AIDS epidemic, and to increase access to quality VCT and PMTCT services including follow-up for HIV-positive individuals. The integrated project will target three key provinces; Luanda, Huambo and Cunene. The HIV/AIDS component will further give support, building on previous interventions under the EHSP project, in additional provinces. In selecting the final geographical target areas, priority will be given to provinces with the highest HIV prevalence, as well as all along the transport corridor between Luanda and Cunene.

The overall objective for this TBD Activity is to contribute to the improved capacity of the health system in targeted provinces to plan, budget, and deliver quality health care and services. In core provinces the activity will work closely with the DPS to develop a strategic approach to target the whole health system in the province, including targeting all municipalities. A lesson learned from previous intervention is the importance of local presence to build relationships and maintain close collaboration with the DPS. Therefore it is expected that the TBD implementer recruit and place key staff locally, in at least the core provinces, establish a working relationship with the DPS and develop an implementation approach tailored for each province during the first year of implementation. It is also important that this project closely coordinates with other USG supported activities such as the Community Based Prevention and MARPs intervention in areas where there is overlap, and with other relevant donors and stakeholders in each province.

It is crucial that his TBD activity builds on achievements and lessons learned from four previous years of implementation within the EHSP activity; A major achievement of the EHSP/SES three year (Oct. 2007-Sept.2010) HIV and AIDS component was the establishment and supporting of 37.2% of all new PMTCT sites within the country, and 48.5% just in Luanda. A total of 66 PMTCT services have been established and supported exceeding the target of 41 services for the three year period, providing the minimum package of PMTCT services according to national and international standards. Additionally, A total of 1,149 women were provided with ARV to prevent the risk of Mother to - Child HIV transmission against a target of 783. The coverage for prophylaxis increased from 22.1% in 2009 to 43.3% in Sept. 2010. Numbers of health care workers trained also surpassed expectations. A total of 303 Health workers received PMTCT training exceeding the target of 215. EHSP's successes were greatly enhanced by a strong working relationship between EHSP and the INLS and DPS teams that facilitated the trainings, supervision and logistical support; The project work plan took into consideration the priorities set by INLS and DPSs; Community mobilization to promote the use of PMTCT and VCT services; Innovative approaches such as use of mobile phones to reach the rural areas and investing more in supervision and refresher training. Additionally EHSP participated in the elaboration of the Round 10 proposal to be submitted to the Global Fund and the development of the National Strategic Plan 2011-214.

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A major achievement in the three years of the project in CT was that 144,432 individuals received counseling and testing exceeding the targeted 93,610. EHSP supported a total of 54 VCT service outlets surpassing the target of 43 outlets providing counseling and testing for HIV according to national and international standards which represents 16% of the total VCT outlets in the country. Number of counselors trained surpassed their targets with 381 trainees.

In the three year period EHSP, trained 1,941 in both HIV related stigma and discrimination reduction and HIV-related community mobilization for prevention, care and/or treatment.

The follow on TBD project will build on the achievements and lessons learned from the EHSP projects. In this context, close coordination with the Community Based Prevention and MARPs activities are central, since core components of these projects include technical and institutional capacity building of local organizations and stakeholders, including staff from GRA such as health staff and activists on local level. Behavior change communication and outreach communication activities within the CBP and MARPs also include promotion of, referral and link up to health services. As well, the systemic approach of the HSS TBD of aiming to target, not a set of clinics but, the health system on all levels in each province on requires increased coordination with not only service providers but civil society, traditional leaders and private sector etc.

In COP 11, this TBD plans to continue to support VCT; prioritizing provinces with the highest HIV prevalence. Additionally, the transport corridor between Luanda and Cunene province is a critical area of focus.

The project will increase VCT in reproductive health services at the municipal level. The TBD will support the GRA effort of increasing VCT, with expansion to both new centers and mobile clinics, in key geographic regions. The TBD will work with the GRA to establish new VCT service sites if possible together with PMTCT by rehabilitating existing health centers with GoA, USG and GFATM funds and integrating services at government health facilities.

Specific activities include the provision of equipment and small scale refurbishment for counseling and testing services; training in Counseling and Testing including lay counselors; increased provision of supportive supervision and in-service training.

In COP 11 the project will focus on a strategic set of activities contributing to the overall efforts for health systems strengthening.

The TBD will help the DPSs to coordinate meetings at provincial levels between partners in the fight against HIV/AIDS to share information, discuss challenges and strengthen linkages

The TBD will provide support to MOH in the decentralization process by providing technical assistance in the areas of finance and planning, national health accounts, and gap analysis. The TBD will work to expand quality control system at municipal and provincial levels to strengthen supervision of health staff and community health workers. Additionally, the TBD will support the MOH to develop capacity of existing health care workers (doctors, nurses, nurse-midwives, medical assistants, laboratory technologists; pharmacy technicians) work on upgrading the clinical, leadership, management, planning, supervision, information systems, quality improvement of services, and stigma reduction skills of health care workers via in-service training at provincial and municipal levels. Collaboration with the MOH will also include support to develop a policy and plan for task shifting to nurses, auxiliaries and community health workers; the establishment of a policy for community health workers to guarantee appropriate follow up to diagnosis (both positive and negative), care and support, and treatment (adherence), and assistance in formulating a strategy to reinforce the referral system.

Some specific activities will include: the provision of technical assistance to train health personnel for PMTCT/VCT; support and management of the mobile clinic; updating national guidelines for CT policies, development of Standard Operating Procedures (SOP); an emphasis the quality of counseling; follow-up for HIV+ in treatment adherence; training of lay-counselors training; improvements of M&E for CT and the follow-up of PMTCT at the provincial level; as well as training and support to staff in to strengthen M&E and supervision.

To promote health seeking behaviors and raise awareness among general population and increase access and accessibility of health services for the general population, this TBD will support community mobilization and communication activities using the successful implementation of community health workers training, the link between the health services and the CHW and through capacity building of CSOs and local NGOs and church groups in prevention, care, stigma and discrimination reduction. Prevention activities, conducted mostly through community agents put an emphasis on understanding risk reduction and promoting key behavior change messages, in line with the overall, national behavior change messages and campaigns. The capacity of community agents will continue to be built through training, supportive supervision, management and technical assistance, in close collaboration with the Provincial government. Technical assistance in provision of quality other prevention programming, including STI prevention and treatment and condom promotion and distribution will be provided by EHSP. This component of the project will leverage and coordinate with the prevention projects PROACTIVO targeting MARPs to promote the access of 'friendly' health services, and the Community based prevention to include and engage communities.

In COP 10, this TBD plans to continue to support to PMTCT services ; prioritizing provinces with the highest HIV prevalence and along the transport route. The aim is to achieve 100% coverage of ANC facilities in both Luanda and Cunene province as well as the transport corridor between the cities in the upcoming two years.

Specific activities will include the on-going collaboration with GRA, USG and GFATM in order to establish new PMTCT sites by rehabilitating existing ANC centers. These sites will be integrated into existing services at government health facilities and will utilize personnel and funds from GRA, USG and GFATM. Plans are to increase CT coverage in prenatal services, and CT and PMTCT at delivery and post partum, at both the provincial and municipal levels. The EHSP will also strengthen integration and articulation with Maternal -Infant Services and Family Planning at municipal level, as well as increase the provision of reproductive health/family planning services at PMTCT sites. Activities will also include training of health staff in integrated PMTC and Family Planning services and M&E.

Increased emphasis will be placed on quality monitoring and follow-up of HIV positive pregnant women and exposed newborns, increased supervision and in-service training; and strengthened south to south cooperation.