08.P0109 MOH - Infant Nutrition Support

The Botswana draft Infant and Young Child Feeding (IYCF) policy states that HIV-infected women will be

counseled about the risks and benefits of breastfeeding and formula feeding, and will be guided to choose

formula only if it is acceptable, feasible, affordable, sustainable, and safe (AFASS) to do so. This policy has

been in draft since 2001 and training to support the policy has not been conducted. In practice, HIV-infected

women are advised to feed their infants formula, and in 2006, 97% of all HIV-exposed infants were started

on formula at birth.

The Botswana Child Welfare card was recently updated to include HIV, PMTCT, and improved nutritional

information. The Botswana Nutrition Surveillance System (BNSS), which is based on data from the child

welfare card recently completed an assessment that recommended strengthening data collection methods

and quality and training of health workers in use of nutritional data.

2007 Accomplishments

The Food and Nutrition Unit (FNU) adapted the WHO/UNICEF 5-day IYCF counseling course and began

training government health workers using the adapted training. The training incorporates counseling on

exclusive breastfeeding, exclusive formula feeding and optimal nutrition.

2008 plans

To improve the effectiveness of the adapted WHO/UNICEF training course, the FNU will print course

materials, purchase teaching aids and produce IEC materials for mothers. The FNU will continue to train all

PMTCT health care providers (nurses, midwives and counselors) as well as Pathfinder senior staff and

Peace Corps Volunteers assigned to government health facilities.

The USG will support printing and distribution of the new child welfare card that includes HIV, PMTCT and

nutrition information. Health workers will train on its use for clinical management of children and for program

reporting. Technical assistance will update the software for capturing information about growth, HIV

exposure status and feeding method in-line with the new child welfare card. The USG will provide technical

assistance to assist with the regular creation of reports on child nutrition as it relates to HIV exposure and

infant feeding method. FNU staff will make site visits within the SADC region to learn about other nutrition

programs and share experiences.

08.P0101: Ministry of Health - PMTCT Program Support

This activity is a direct support to the MOH and addresses the PMTCT strategic plan, including improving

human capacity and the quality of PMTCT services.

In FY2008, the USG will continue to support several project positions in the national and regional PMTCT

program and related MOH departments, including one national coordinator, two regional coordinators, two

IEC officers, one nutrition officer, and one training coordinator. This component complements the Botswana

government's effort in building human resource capacity to manage the PMTCT program both at the

national and district levels.

Health care providers' knowledge and skills will improve through in-service training programs. The

Botswana PMTCT Handbook was revised and harmonized with the WHO/CDC PMTCT generic training

package to provide health workers with the latest evidence-based PMTCT information and

recommendations to enable providers to deliver quality PMTCT services. Efforts are ongoing to integrate

PMTCT content into the current pre-service curricula at the Institutes of Health Sciences (IHS). This will

ensure that health workers will be familiar with PMTCT services upon graduation from health training

institutions. Meanwhile the need still exists for regular in-service training in PMTCT at all levels. The USG

will support workshops for 300 lay counselors, 150 trainers and 24 focal persons.

The USG continues to strengthen information, education, and communication (IEC) activities. The PMTCT

social marketing campaign targets men as influencers and gatekeepers to increase their support of

pregnant women. The campaign will develop an overall mass media effort that helps the community link to

PMTCT with special messages through radio and theatre drama that show men engaged in PMTCT

services and supporting their use. Health learning materials are part of the campaign and their strategic

placement to ensure that consumers encounter them in the normal path activities is part of the strategy.

08.P0108 MOH - Family Planning

Data from surveys in Francistown in 2003 and 2004 indicated that 65% of pregnancies among HIV positive

and HIV negative women were unplanned and 35% of them were unwanted. Family planning is available in

all clinics, but these data suggest there are problems in use of family planning by women generally, and that

unintended pregnancies among HIV-positive women are common. A recent assessment conducted by

UNFPA and GOB on reproductive health commodity security indicated that since the advent of HIV/AIDS,

condoms are promoted above other methods of contraception, though condoms are not sufficient

contraception for women wishing to avoid pregnancy. Existing local guidelines advocate for informed

decision making in the choice of method as well as use of dual method (using a condom and another

method of family planning). For HIV-positive women, contraceptive drugs are not provided in ART clinics,

though condoms are usually available. A 1996 curriculum on family planning is still in use, and does not

include adapted, evidence-based family planning counseling for women with HIV or primary HIV prevention

messages.

2008 Plans

The Sexual & Reproductive Health (SRH) Unit will collaborate with the PMTCT Unit to increase access to

dual protection (condoms plus contraceptive drugs) through every relevant service including maternal child

health clinics, family planning clinics, maternity units and ART clinics. PEPFAR will support the SRH to

review existing family planning policies, guidelines and curriculum to incorporate adapted, evidence-based

guidance on family planning for HIV-positive women, ensure the reproductive rights of HIV-positive women

are respected and ensure that primary HIV prevention messages are incorporated into family planning

counseling. Once the curriculum review is complete health workers will be trained on its use. MOH staff will

make on site visits to other countries in the SADC region to learn about their family planning programs and

share experiences.

08.C0613: MOH Palliative Care Support

The USG provided financial support to train 250 health workers in FY05 and 100 health workers in FY06.

Funds were allocated to development of training modules. Capacity in the Palliative Care Unit has been

strengthened with recruitment of three officers; two have expertise in Palliative Care and one in NGO

support. Clinical guidelines for management of opportunistic infections were revised in 2004 and will

continue to be revised periodically.

The GFATM fund has supported the recruitment of 204 lay counselors who were trained in basic HIV/AIDS

counseling. Strengthened psychosocial support is needed for families and communities that provide care to

ill PLWHA in their homes. Some PLHWA and their care givers experience care related burdens and/or

stigma. Hence the need to continue training of lay counselors and family welfare educators to effectively

provide psychological support in the community.

In 2008, PEPFAR funds will support the following activities:

Basic Palliative Care training: The training will target service providers from health care institutions and from

NGOs, CBOs, FBOs dealing with Palliative Care. This will be achieved through the TOT model so as to

facilitate the roll out of palliative care training country wide and ensure sustainability. A total of 280 Health

Care providers will be trained in Basic Palliative Care.

Review of the Clinical Guidelines: The government intends to review clinical guidelines for management of

opportunistic infections to integrate TB, PMTCT, and ART and to strengthen the pediatric component and

train clinicians, lay counselors and family welfare educators on the use of the revised guidelines. Training

will be done in collaboration with HAVARD master training and Baylor University for provision of technical

expertise in adult and pediatric palliative care.

Printing of Nutritional Guidelines: In order to enhance the nutritional status of PLWA and other chronically ill

patients the Units will print nutritional guideline to be used in training and to guide service providers.

Strengthen collaboration with CBO/NGO: The civil society plays a very critical role in provision of palliative

care at community level. There is need to establish a strong linkage for improvement of quality care to

patients as well as strengthen referral system from civil society to health care facilities.

08.C0701: MOH - TB/HIV & IPT support

2007 Accomplishments

FY07 funds were used to support the finalization of the national TB management manual. The new manual

incorporates guidance on the management of HIV-related TB and drug-resistant TB, which are consistent

with current international recommendations. The manual is now the basis for training of all health cadres in

Botswana on TB management and control.

A significant increase in HIV/TB activities was programmed in FY07 to further integrate HIV/TB care with

core programs for people living with HIV/AIDS (PLWHA). PEPFAR funds expanded RHT among pediatric

and adult TB clients to fund supervisory visits from the national level to the districts. In January 2007, 24 TB

coordinators were trained on IPT, Community-based TB care (CTBC), and TB/HIV surveillance.

Francistown, and Kgalagadi South trained 114 health care workers on TB/HIV surveillance and 64

community volunteers on TB/HIV.

The IPT program is well accepted and available in all 24 districts. FY07 funds were used to train 33 trainers

of trainers (TOTs) on IPT, and 51 health workers were trained on IPT. The IPT Program has registered

more than 50,000 HIV-infected persons since 2001. FY07 funds will support the comprehensive external

evaluation of the program, which will provide Botswana (and other focus and non- countries) with essential

data on the implementation of a national Isoniazid Preventive Therapy (IPT) program. A Drug Resistance

Survey (DRS) began with FY07 support and will provide data to guide programmatic policy and

management.

To improve coordination of TB/HIV activities, FY2007 funds resuscitated the national TB/HIV advisory

committee, a key component to establishing mechanisms of coordinated TB/HIV care at all levels of the

health sector. This committee met for the first time in a year in August 2007, and revised its terms of

reference.

PEPFAR funds support nine posts at the national and regional level of the IPT program. To strengthen the

technical capacity of the BNTP staff, FY07 funds were used to send two participants to the WHO Global

TB/HIV course in Sondalo, Italy and two staff to the International Union Against Tuberculosis and Lung

Disease (the UNION) TB management course in Arusha, Tanzania. To provide a perspective on the

practicalities of implementing nation-wide interventions, FY07 funds will support a team of three staff from

the central BNTP to go on a study tour to Malawi focusing on community based TB/HIV collaborative

activities, and to send three staff to the Annual IUATLD Conference in Cape Town, South Africa.

2008 Plans

FY08 funds will be used to continue supporting the BNTP to conduct supervision and monitoring visits and

trainings. To bolster the capacity of the NTRL to perform its activities as a reference laboratory, it is

proposed to use FY08 funds to meet the salaries for two laboratory technicians who will be based at the

NTRL. Funding is also requested to support quarterly meetings of the national TB/HIV Advisory Committee

and to support quarterly meetings of two regional TB/HIV advisory Committees to be formed for the north

and south regions.

General program support to the BNTP is requested to continue training health care workers on these

guidelines to increase the number of TB patients diagnosed and successfully treated, including enhanced

referral to HIV care services. USG funds will be used to conduct a cross-sectional survey in a 50% sample

of high HIV-burden districts to measure HIV testing uptake, determine impediments to testing uptake, and

develop strategies to overcome them.

These activities support Botswana's Round 5 TB grant from the GFATM which seeks to scale up community

TB care, improve treatment success rate, strengthen TB/HIV collaborative activities and strengthen

supervision, monitoring and evaluation.

08.C0803 Ministry of Health - Nutrition Rehabilitation for OVC

The project entailed the renovation of two buildings at Nyangabgwe Referral Hospital (NRH), Francistown

and Princess Marina Hospital (PMH), Gaborone. The overall goal of this project is to ensure an effective

and comprehensive nutritional management of malnourished children affected and infected with HIV/AIDS.

Specific objectives include: registering of new clients; nutritional assessment, counseling and monitoring of

orphans and vulnerable children; provision of psychosocial support; training of care givers on meal

preparation and feeding of OVC.

2007 Accomplishments

The project recruited an expert in child nutrition to train 20 health care professionals (Pediatricians,

Dietitians, and Nurses) with skills in the management of malnourished children, affected and infected with

HIV/AIDS. About 500 children were enrolled and benefited from the project. The USG funded the

recruitment of two Principal Dietitians, two Social Workers and two Home Economists. A needs assessment

established nutritional needs of OVC and developed nutritional care standards.

2008 plans

The FY2008 activities will be a continuation and scale up of activities. The project equips OVC serving

CBOs with skills on care for malnourished OVC. An additional 2,000 OVC will be enrolled into the program,

100 more health workers will be trained as well as 100 representatives from CBO/NGO/FBOs serving OVC.

Human resource capacity will be strengthened at the two referral hospitals to increase availability of quality

services to OVC. One Project Manager will provide oversight for the two Centers.

In order to improve the care of HIV infected children, the project will create linkages with the PMTCT

program, the Infectious Disease Care Clinic (IDCC, the sites for ART) for children in PMH and NRH to come

up with a nutrition monitoring program for HIV infected children. The Botswana PMTCT programme in

collaboration with HHS/CDC/BOTUSA has initiated a program for testing for HIV infection on HIV exposed

infants at 6 weeks. The MOH also has a nutrition surveillance program that monitors children's weight for

age every month. Comprehensive monitoring of the growth of HIV infected children has been a gap in

service delivery. This gap will be addressed by the Nutrition Rehabilitation Centres in Princess Marina and

Nyangabgwe hospitals.

Nutritional assessments will be performed at every visit and early recognition of problems and appropriate

remedial interventions applied. Monitoring of these children will include identification of the multiple factors

which contribute to poor growth, including the environment in which the child is raised. Accordingly, the

centres will closely monitor the growth and development of HIV infected children seen at primary care

health facilities and at the Baylor Children's Centre of Excellence (for those on ART).

During 2008, the nutrition rehabilitation centres will work with MLG's DSS to advocate for development of a

food basket for HIV infected children. It has been documented that HIV infected children enrolled in nutrition

rehabilitation centres, even those that recover to normal nutritional status, take longer to recover completely

and often relapse if additional nutritional support is not available. Currently, the DSS provides food baskets

to orphaned children without regard to their HIV or nutritional status, except for the few referred by dieticians

(with individualised food basket prescriptions). Guidelines for food basket contents and placement will lead

to more targeted use of food support for OVC.

The rehabilitation project will continue to collaborate with MOH's Food and Nutrition Unit, DSS, UNICEF and

other relevant stakeholders.

The expected results for 2008 include: Project Manager added to manage program, Nutrition Rehabilitation

Project evaluated, additional 2000 OVC enrolled and benefiting from the project, 200 health workers and

CSO staff trained, sites for rolling out identified and community needs determined, monitoring of HIV

infected children in the program and food baskets and implementation guidelines developed for HIV infected

children.

08.C0902 Ministry of Health - Counseling and Testing Unit

2007 accomplishments

A rapid assessment of the capacity of civil society organizations to provide C&T resulted in the selection of

six NGOs/CBOs/FBOs to be supported to provide services. An in-depth evaluation of the selected sites has

led to the development of a capacity building plan.

The USG supported the MOH in training of health workers in various aspects of C&T service delivery. To-

date, the MOH trained over 80 trainers in couples HIV counseling and testing (CHCT), and over 200 health

workers and counselors. Training has so far covered 11 of the 24 health districts.

Through routine HIV testing (RHT), 178,176 tests were performed in 2006, representing a 25% increase

from the previous year. Eventually, the program aims to expand routine testing to the private sector as well.

Over 300 health workers were trained in how to perform the rapid HIV tests, including 35 from the private

sector. Through follow-up and support visits conducted to public facilities by MOH in 2007, a number of

challenges facing RHT were identified. These included: inadequate on-site support supervision and

mentoring of lay counselors; inconsistent supply of rapid HIV test kits in some facilities; health facilities lack

the human resources needed to take on increased HIV testing and counseling; policy guidelines are not

available to most health workers, and the private sector has not been adequately brought on board to

provide routine testing. PEPFAR funds were approved for an evaluation of routine HIV testing in 2007,

however, a contractor is still to be identified to carry out this activity.

In FY 2007, a consultant was engaged to work with the MOH and a reference group of key stakeholders to

develop national guidelines for counseling and testing, based on recent release from WHO of guidelines for

provider-initiated C&T. These include guidelines for C&T in the various settings (e.g. client-initiated and

provider-initiated CT services). WHO/AFRO has provided a technical officer to provide assistance in this

activity.

The identification of a contractor to support the development of the counselor supervision curriculum and

training of a core team of trainers is underway. Applicants have submitted proposals to MOH and the review

and selection process is in progress.

Plans for 2008

The goal of the Botswana NSF is for 95% of sexually active adults counseled and tested by 2009. At this

point, it is estimated that at least 50% of adults in Botswana know their HIV status. USG funds will support

MOH in increasing access to and availability of VCT through the six civil society organizations. Activities will

include provision of services, training of 18 lay counselors, mentoring support and monitoring and

evaluation. The new sites will become part of the referral networks that have been established in various

locations to enhance referral of clients to care and treatment and to community-based support groups. An

estimated 7,718 first-time testers will receive services at these sites.

Funds for FY2008 will support on-going monitoring and quality assurance efforts by MOH. Activities will

include rolling out of CHCT to the remaining 13 health districts not yet covered, support supervision and

mentoring to counselors.

The USG will continue to support capacity development by funding the salaries of two program counselor

trainers in the MOH/C&T unit.

PEPFAR funds will also support the development of IEC materials for RHT and VCT, targeting groups, e.g.

couples, children, youth and men.

08.T1004: Ministry of Health - National Drug Quality Control Laboratory Support

The NDQCL is a unit in Pharmaceutical Services within the Department of Clinical Services in MOH.

NDQCL ensures that medicines and related medical products produced, imported, exported, distributed and

used in Botswana are of acceptable quality, safety and efficacy through testing. There has been heavy

dependence on manufacturer's documentation on the quality of medicines and related medical products

imported, distributed and used in Botswana due to shortage of skilled manpower and inadequate

infrastructure. The NDQCL has lacked independence. The Botswana Government has since approved and

supported the construction of an independent NDQCL by the end of the National Development Plan (NDP)

9, as stipulated in the Botswana National Drug Policy of 2002 in assuring the quality, safety and efficacy of

medicines in the country.

2007 accomplishments

The NDQL used USG support to:

--Train two staff in pharmaceutical analysis for eight weeks at the Medicines Control Authority of Zimbabwe

--Train staff in courses on Advanced Technical Techniques, Instrumentation, Good Laboratory Practice,

Stability studies in-county.

--Train two staff in understanding ISO/IEC 17025 at Botswana Bureau of Standards

--Procurement of reference textbooks that contain official test methods of ARV medicines, other relevant

reference books and international standards

--Procurement of pharmacopoeial primary reference standards of ARV medicines, opportunistic infection

medicines and other drugs

--Study tour / visits to organizations / laboratories with in South Africa with LIMS installed.

2008 plans

USG funds for FY2008 will continue to assist in strengthening the quality control of ARV medicines for OIs

imported, distributed, and used in the country.

Training as the major activity for the laboratory will continue to improve staff analytical skills and

competence as the number of staff involved in testing increases and new improved instruments/equipment

are produced to improve testing of pharmaceuticals. The impact of the training of staff will be seen as the

testing of ARVs and other medicines increases yearly and the establishment of a quality management

system in the laboratory in accordance to ISO 17025 Standards is done. Documentation and other

operating procedures will visibly improve in the laboratory ensuring that accurate test results are produced.

USG funds will continue to supplement GOB funds in the procurement of reference textbooks and ARV and

OIs primary reference standards.

Since testing of ARVs is now being performed it is important that the required resources such as primary

reference standards and other laboratory consumables are available at all times.

Training of staff (old and new) will be the major new activity. Training will be done through attachment

training and short courses, to improve staff analytical skills, enhance proficiency in testing; getting

acquainted with new analytical techniques and new instruments / equipment that will assist in producing

accurate test results in the shortest time possible. The training will also include ISO/IEC 17025 Standard in

order to establish a quality management system in the laboratory.

The continuation of the procurement of reference textbooks that contain official specifications and test

methods of ARVs and medicines for OIs and the procurement of ARV pharmacopoeial primary reference

standards in order to continue testing each batch supplied in the country.

Study tours to other laboratories are necessary to assess the operations of the laboratory. Study tours /

visits to at least three laboratories will allow NDQCL to benchmark its operations with other laboratories and

assist it to develop methods of improvement. The locations for the study tours are being identified.

Challenges

One major challenge that the laboratory foresees is being able to sustain testing of each batch of ARV

medicines and OIs medicines supplied in the country with the limited skilled manpower and current

laboratory space until the construction of the new laboratory building. Further, the laboratory is also tasked

with the responsibility to test all other medicines and related medical products distributed and used in the

country. Such testing of each batch of ARV medicines and OIs circulating in the country is pivotal, as it will

assist in detecting counterfeit or substandard drugs increasingly used worldwide.

Currently there are more than 2,000 medicines in the Drugs Regulatory Unit List of Drugs Allowed in the

Botswana market Document and more than 2,000 medicines and related medical products that are supplied

and distributed to the public sector through CMS Stores to all Government Health Facilities, Mission and

Mine Hospitals and some non-governmental organizations. These medicines and related medical products

require quality testing to be performed on continuous basis for registration / pre-market authorization, post-

marketing surveillance and national procurement.

08.T1001: Ministry of Health - Central Medical Stores Support

CMS is a unit of Pharmaceutical Services which is under the Department of Clinical Services in the MOH. It

is entrusted with the responsibility of providing the nation with good quality and cost effective

pharmaceuticals, laboratory and related medical supplies timely. It serves all government health facilities,

missions, mine hospitals and non-governmental organizations in Botswana.

The GOB provides free ART to PLWHAs since 2002. Since its inception the program has grown and serves

62 ART facilities (32 hospitals and 30 satellite clinics) with approximately 90,478 patients on treatment (July

2007). The projected number of patients on ART is 102,500 by end of 30 September 2008.

This objective of the program is achieved through procurement, quality assurance, warehousing and

distribution by CMS. The program is faced with a number of challenges such as shortage of staff,

inadequate storage space, inadequate logistics skills, inadequate quality assurance skills, inadequate ARV

security infrastructure, and lack of offices as well as limited funds. In the past the GOB received assistance

from partners such as PEPFAR, Bill and Melinda Gates Foundation, Merck Foundation, Boerhinger

Ingelheim, UNFPA, Cliniton HIV/ADS Initiative (CHAI) and Pfizer in the form of donations of ARVs and

drugs for the treatment of OIs and price reductions. CMS has been able to procure ARVs, strengthen the

security system, pre-qualify suppliers and train 15 employees on supply chain management and 15

employees on quality management system to improve organizational efficiency and effectiveness through

2007.

In 2007, 63% of the PEPFAR funds were used to procure generic drugs, while 21% of the funds were used

for procurement of pediatric formulations. The DRU, which has been receiving support from PEPFAR, is in

the process of registering generic ARVs which will enable CMS to increase drug purchase and make

savings. The NDQCL has also been receiving support from the USG to improve their analytical skills to

assist in testing of procured generic ARVs. Through the cooperative agreements between the GOB and

partners, the MOH (CMS) will use FY2008 funds to supplement procurement and distribution of drugs for

ART and commodities used in treatment of OIs in the management of HIV/AIDS. Supplies will help support

HIV/AIDS Care/Treatment services for PLWHAs their families, children, caregivers. The purchased drugs

will be distributed to 50 more clinics operated by the MLG thereby greatly expanding access in 2008. CMS

will also secure provision of ARV drugs to 180 legal refugees from the Dukwe refugee center.

There is acute shortage of skilled staff at CMS. The employment period of two Chief Supplies officers and

one pharmacist to implement and monitor the project will be extended to additional two years. The

employed officers will be deployed as follows: the Pharmacist will be employed at Quality Assurance Unit to

support the continuous prequalification following work done by the consultants. He/she will perform quality

assurance activities of a selection of suppliers, technical evaluation of tender quotations to support

purchasing unit and also address quality matters throughout the supply chain. The Chief Supplies Officers

will strengthen the procurement, receipt, inspection and distribution of ARVs, drugs used in the treatment

and management of OIs. The services provided by them will lead to an effective system of ensuring that

orders will be received, processed and distributed to the health facilities timely and cost effectively.

In order for CMS to improve its organizational efficiency and effectiveness in provision of ARVs there is

need to continue with the outsourced technical assistance from SCMS to strengthen the implement a quality

management system and the quality assurance system and training of CMS staff on the systems. The

program will review and strengthen forecasting and quantification of national needs for ARV drugs and

related products used in the management and treatment of HIV/AIDS related diseases through the ART

program.

08.T1003: Ministry of Health - Drug Regulatory Unit Support

The DRU is a unit within the MOH responsible for the regulation of medicines in Botswana. With the

expansion of the MASA program and increase in number of patients on ART, the Ministry faced a number of

challenges in the provision of the medicines including increased costs of medication. The increasing costs

necessitated looking at different options of sources of medicines, including generic ARVs. To ensure that

the quality of the products used would not be compromised it was necessary to strengthen the regulatory

unit, hence DRU became one of the beneficiaries of the PEPFAR funds. The areas for strengthening

included the inspectorate, the registration; and the setting up and training of a pharmacovigilance section.

2007 accomplishments

The activities for FY2007 continued the previous two years work. These include further training activities

within the DRU as well as training of other health care professionals in reporting of adverse drug reactions.

The need to develop a monitoring and evaluation of the processes within the unit was also recognized. Part

of the funds for FY07 budget period developed a quality management system. The unit will have quality

manual, updated standard operating procedures as well as the staff trained in the system by the end of

2007. The system now has a monitoring and evaluation component which will help with the continuous

improvement of processes and procedures to allow for effective regulation of medicines.

2008 plans

The DRU proposes to increase human resources by at least two officers with regulatory skills. For more

generic ARVs to be registered, bioequivalence data needs to be evaluated to ensure equivalence with the

innovator products. The pharmacovigilance section must be able to process and evaluate adverse drug

reaction reports. These officers will also help in review and updating processes and procedures to minimize

multicycle evaluation of dossiers for registration. The unit plans to continue with the activities of registration

and pharmacovigilance next year.

08.T1107: MOH - Human resource support

The Pediatric ART program has witnessed tremendous progress in the past five years. Starting from scratch

with no HIV-experienced Pediatricians, Botswana has moved to becoming one of the largest Pediatric

HIV/AIDS treating countries in the world. There are close to 4,000 children now on treatment in the two

referral hospitals and local medical staff had built up expertise in Pediatric antiretroviral treatment.

With the improvement of treating staff, especially specialist Pediatricians, emphasis is now being shifted to

decentralizing therapy, rolling it out to peripheral facilities. These are then supported by outreach visits by

the specialists from PMH, the COE and NRH. We are now able to effectively participate in the weekly

outreach visits to selected facilities in Botswana, thanks to the support we received under COP06 and

COP07 for two Pediatricians each in PMH and NRH.

Since more HIV-infected children are now surviving, we are now seeing a gradual rise in those presenting to

our Specialist Pediatric Clinics with co-morbid chronic conditions requiring long-term follow up, such as LIP,

bronchiectasis, tuberculosis; and non-HIV associated diseases such as asthma, diabetes, heart diseases.

AT the HIV clinic we are also seeing a steady rise in resistant viral mutations. The general clinics see at

least 100 patients a week on the average, in both facilities, and over half of whom are children with

HIV/AIDS.

The Pediatric KITSO training is now well established and PMH and Baylor Centre form the core training

team going. Trainings are conducted in clusters around the country on biweekly schedules. The trainings

are supported by UNICEF Botswana. The four PMH-based PEPFAR-funded Pediatricians have made it

possible to strengthen these training activities.

The Departments of Pediatrics at PMH and NRH conduct scheduled outpatient-based specialist clinics four

days of the week (PMH and five days a week, (NRH). These are mainly to follow up children who would

have been admitted to the Pediatric Medical Ward treated and discharged; but because a long-term follow

up is required, they are registered in these clinics usually under the same specialist that looked after them

while on admission. Secondly the clinics in these two hospitals also receive referrals from all hospitals in

Botswana. These are usually cases that require specialist consult and management on a long-term basis.

Most of these cases have several co-morbid conditions that require an integrated approach to their

management.

There is only one dedicated room for the clinic per week in the MCH clinic complex in PMH and in NRH.

This is certainly inadequate. It has become increasingly difficult to accommodate them at the current sites

The UB Pediatrics residency training will begin in 2008. The new UB medical school will also start in 2008.

These undergraduate and postgraduate medical training programs will require adequate space. There is

therefore a growing need to provide adequate clinic space that will be used for the care of patients as well

as for teaching purposes. University of Pennsylvania is assisting UB in the development of these academic

activities and we are collaborating with them on these issues.

The Nutrition Rehabilitation Centre for children (supported by PEPFAR) is on the offing in both hospitals

and we shall be collaborating with our Dietetics colleagues to provide the out patient medical care for the

malnourished children being managed at the centers.

During FY07 four Pediatricians were supported in the FY06/ FY07 to strengthen the pediatric ARV service

delivery as well as capacity building of health care providers in the country. Their activity include as well an

outreach component to try and cover thee country.

In FY08, these pediatricians will continue to provide clinical care to HIV/AIDS children in the two hospitals,

conduct outreach services, train health care workers and run the outpatient clinics.

08.T1117

In May of 2007, Airborne Lifeline Foundation (herein referred to as "Airborne"), a US registered 501 (c) (3)

non profit corporation, commenced the operation of what is regarded as the first regularly scheduled

medical air service in Africa- to provide regular health care and health monitoring service to underserved

areas. After substantial analysis, Airborne chose remote portions of Botswana to commence service.

This service was undertaken, following the signing of a Memorandum of Understanding (MOU) between

Airborne and the Botswana Ministry of Health (herein referred to as "MOH") in August 2006. Minister of

Health. The purpose of the MOU was "The implementation of regularly scheduled medical air service to

hospitals and clinics in the Republic of Botswana".

The core benefits of the program are:

- To substantially improve the utilization of scarce medical profession talent by dramatically reducing travel

time of professionals to remote areas. Turboprop aircraft are substantially faster than overland

transportation options.

- Introduce "regular" service, and therefore inspire confidence in patients that doctors, medications, etc. will

be there and their travel from the bush to hospital/clinic will be justified.

- To ensure lab samples are transported with dispatch to laboratory facilities- in terms of hours instead of

days-with increased reliability and less risk of contamination and spoilage.

- Ensure that patients in remote locations might have the ability to establish regular, same physician doctor-

patient relationship-with increased benefits to patients and the broader medical community in terms of

collecting and tracking health information. From the inception, it was made crystal clear that the raison

d'être of this proposed air service was driven by the desire to take HIV/AIDS treatment, testing, training,

education, etc. to remote parts of Botswana. While this scheduled air service would be available (if capacity

existed) to other health care services, HIV/AIDS treatment was deemed paramount.

Presently Airborne aircraft are organized through its chartered air provider NAC Botswana, and are flying

capacity loads on three flights a week on two routes. Both routes carry both medical cargo and health care

professionals. The Tuesday route, flown both in the morning and evening, goes from Gaborone to Hukuntsi

and Tshabong. The second route, flown on Thursday, flies from Gaborone to Ghanzi, Gumare and Maun.

Depending on the amount of cargo carried, each flight can carry up to 10 passengers.

Airborne is carrying large amounts of ARV boxes to all five locations presently being flown. We have also

been flying infant CD4 samples on a regular basis back to the Harvard Lab from locations, such as Gumare.

We also carry test results and cool boxes back from the Harvard Lab to these locations.

In addition to the cargo, we have been ferrying medical personnel engaged in HIV/AIDS work.

There have already been requests to expand the number of flights to other locations. Once we get past this

initial start up and assessment phase of operations, we intend to expand it to additional cities/routes and/or

a larger plane. Additional stops conceivably would include, but not be limited to, Kasane , Shakawe ,

Francistown, Orapa/Lethlakhane, and Selibe Phikwe..

Airborne's scheduled service will support the USG PEPFAR's treatment, care, monitoring and evaluation

programs in Botswana by transporting ARVs and medical personnel to rural areas, as well as samples to

the Harvard Lab. Currently, health care to these areas are erratic as the only way providers can access

these areas are by road, which can take up to 8-hours travel time. Airborne's regularly scheduled flights

already has resulted in an increase in the number of patients supported by the various HIV/AIDS programs

as medical personnel can now treat more patients.

08.T1201: Ministry of Health - Laboratory Support

Activity 1: Quality Assurance (QA): $40,000

In FY2007 funding was requested to improve the QA laboratory. Equipments were purchased, and training

for two staff members was provided.

FY2008 funds will continue the activities at the QA laboratory: carry on the EQA program for all the

laboratory tests, rapid test EQA for voluntary counseling and testing (VCT) and hospital laboratories,

hematology and chemistry EQA, continue the development of national laboratory standards for hematology,

chemistry, and CD4. Funds will also support the QA Unit to conduct the annual laboratory assessment and

provide one additional staff to the unit to support the QA program in the country because three critical

laboratory scientists from the QA unit resigned leaving the unit without manpower to carry on the activities.

Activity 2: Development of a laboratory maintenance service at NHL and NyangagbweHIV reference

laboratory: $60,000

Frequent break down of laboratory equipment has been one of the main problems in the laboratory system

in Botswana, equipment purchased or donated are not under service contracts or have to wait for several

weeks before maintenance because repair services are not available. FY2008 funds will procure

maintenance equipment and support training for biomedical engineers for the support of the reference

laboratories in Gaborone and Francistown.

08.X1306: MOH - DPPME Strategic information support

Activity 1: Salaries of Staff in MOH's DDPPME

Cost: $ 136,290

With USG financial support, GOB is in the process to recruit short-term staff to address immediate and short

-term workforce requirements. These are key positions within government agencies. The planned positions

will strengthen the ability of DPPME to support different existing HIV/AIDS M&E systems within MOH,

integrate them to improve reporting, linkages among these programs and support accountability.

The implementation of this activity was delayed and it is yet to yield results. These positions include one

chief health information officer, one principal systems analyst, two IT officers, and one senior systems

analyst programmer

The senior System Analyst and the Chief Health Information Officer will work closely with the consultant

who will develop the national HMIS strategic framework. They will be the drivers behind the implementation

of the recommendations to be formulated in the strategic framework.

With the support of all the IT and system analyst and programmer, this team will work towards an integrated

system with harmonized HIV/AIDS indicators, user friendly and facilitating information sharing among all

stakeholders.

These positions are to be absorbed into the public structure in the future. The pay structure will be similar to

that of the GOB to facilitate the integration of the new positions in the public structure

Activity 2: ICD-10 Training

Cost: $80,000

This is a continuation activity from 2007. The Health Statistics Unit (HSU) remains the focal point for all

issues relating to health information system in the MOH. It facilitates the data collection, processing,

verification, analysis and dissemination of health service data throughout the country. It also coordinates

health data sharing with other stakeholders.

The HSU revised its data collection tools in 2004 using the International Classification of Diseases 10th

Edition (ICD-10). In order to build capacity in ICD-10, USG supported the training of 15 staff from HSU in

ICD-10 in FY 2007. For cost effectiveness, this training will be organized in Botswana by staff from

Queensland University of Technology in Australia in January 2008. This training will ease the coding

problem HSU is faced with and therefore speed up the production of the annual health reports.

Despite this training, there is a dire need to support the training of records keepers in all the 32 government

hospitals in the country and to support the sensitization of health care workers about the importance

mortality and morbidity coding and the necessity to write properly the diagnosis in their patients' charts.

These initiatives will facilitate the coding process at central level and therefore allow HSU to produce the

annual Health statistical reports, necessary for planning, in a timely manner.

Part of these funds will be used to purchase at least one set of ICD-10 reference tools for each hospital in

the country and add 6 computers and software to the current infrastructure to allow extra data entry points

to speed up the production of the health statistics reports.

Therefore, the MOH's DPPME, is requesting PEPFAR funds to urgently train all 18 HSU staff in the use of

ICD-10. This will allow the office to be effective, efficient, and able to promptly report quality data that meet

international standards.

Activity 3: Botswana Health Information Strategic Plan

Cost: $70,000

Botswana has several information systems for capturing data on health services, resulting in a fragmented

approach to patient management and outcome monitoring. Program data are stored on independent

systems that run on different platforms and collect data at different levels of detail, e.g. patient level,

aggregated. This creates a challenge to integration of health information systems, as well as integration of

health data into a longitudinal patient record for the national HIV data warehouse. In 2008 USG will support

the development of a national health informatics strategic plan to provide a framework for future information

systems development by all stakeholders in Botswana (GOB, donors, etc.) that includes appropriate

international ICT standards and guidelines, as well as addresses long term sustainability of health

information systems.

Activity 4: Roll-out of District Health Information System (DHIS) at district level

Cost: $ 55,000

Botswana is facing a challenge of proliferation of vertical information systems in the MOH. The problem is

accentuated by the current use of multiple data collection tools, multiple formats of data collection and

multiple data flows. There is also excessive collection of data that ends up not being efficiently converted to

indicators used for planning and management. There are delays in data capturing, data analysis and

production of statistical reports. This results into poor availability of timely and quality health data affecting

the decision-making.

The implementation of EU-funded BEANISH (Building Europe Africa Network for applying Information

technologies in the Healthcare Sector) project was initiated in 2005 whereby the DHIS software was piloted

in 4 health districts. The pilot phase of this project gave a lesson that timely and accurate information

collection and compilation in all primary health care programs including HIV/AIDS will be made easy in

Botswana. Through funding from the EU, DHIS will rollout to 8 health districts before the end of 2007.

Activity Narrative: Training of Health Information Management Officers, Public Health Specialists, Matrons and others in the

districts is essential part of the roll-out.

As the funding from EU ends by December 2007, USG funds will support the MOH to complete the rollout in

the remaining 16 health districts in FY08. MOH is putting emphasis on training of support personnel (IT

Officers) in the districts as well as at the centre to ensure sustainability of the DHIS. It is planned that the

central support team shall visit the districts half-yearly, conduct short-term refresher courses for users, and

support personnel.

08.X1305

MOH DHAPC - Surveillance and strategic information support

Activity 1: Salaries of Surveillance Staff in MOH's DHAPC

Estimated cost: $75,280

USG will continue to support the salaries of officers conducting surveillance activities in MOH's DHAPC as

surveillance is the cornerstone of monitoring and evaluation of the national HIV response.

The Surveillance Section has conducted and will continue to conduct the antenatal HIV prevalence among

pregnant women aged 15-49 years. This year the ANC HIV surveillance will include incidence testing, HIV

drug resistance tests and HIV prevalence testing.

The team also compiles, analyses and disseminates data on HIV routine testing in government health

facilities

For the FY08, the MOH will require $75,280 to pay the salary of these personnel. These positions are to be

absorbed into the public structure in the future. The pay structure will be similar to that of the GOB to

facilitate the integration of the new positions in the public structure.

Activity 2: Evaluation of new techniques for surveillance

Cost: $50,000

Dried Blood Spot (DBS) has increasingly proved to be the simplest and cost-effective technique of

specimen collection for HIV testing in resource limited settings. Its use in early diagnosis of HIV infection

among infants using the polymerase chain reaction method has opened opportunities to improve pediatric

access to HIV/AIDS care and treatment. We are planning to test this specimens' collection method if it can

replace the current sample collection methods for HIV infection testing, HIV incidence testing and ARV

resistance tests among pregnant women attending ANC services.

In FY08 USG funds will be used to evaluate the sensitivity, specificity and positive predictive values of DBS

in HIV diagnosis, HIV incidence testing, and ARV resistance testing by comparing findings obtained through

routine specimen collection techniques for these tests. Representative sample of de-identified specimens

will be obtained and subjected to the standard test procedures for HIV testing, incidence testing and ARV

resistance tests.

The USG funds in this section of the COP will mainly cover the fieldwork, result dissemination and other

logistic costs while funds coming from the laboratory infrastructure section will cover the cost of specimen

collection, purchase of laboratory supplies and reagents and the actual conduction of laboratory tests.

Activity 3: PIMS Upgrade and HIV Data Warehouse

Cost: $175,000

With the planned scale up of the national ART program to serve over 100,000 patients in the future and the

need for enhanced patient monitoring, the scalability of the current MS Access system, PIMS, is an issue. In

2007, MOH began the process of upgrading PIMS. Thus far, they have finished gathering requirements

and are planning site visits to Kenya and Rwanda to evaluate their patient monitoring systems as possible

replacements for PIMS in order to meet the future needs of the program. Once an IT solution is selected,

USG will assist MOH in 2008 in acquiring additional IT resources for the development, testing, and

implementation of the upgraded system, including deployment to the current ART sites.

MOH will require two IT consultants for a minimum of six months until the new system is deployed in all 28

sites. Deployment will consist of travel across Botswana to each site for installation, conversion of data to

the new system, and training of users. At least two teams will be required so that all sites get deployed

within three months to minimize the time sites are using different patient monitoring systems. The upgraded

system will improve data collection and provide the necessary data for creating appropriate indicators for

more effective monitoring of the ART program. In addition, the system will provide data to the national HIV

data warehouse, which is under development.

Because Botswana has several independent systems for capturing health data, it is not possible to get a

comprehensive picture of the services PLWHA access, much less how effective these services are, unless

a longitudinal record is created for each patient. To address this problem, the MOH decided to develop a

national HIV data warehouse to store integrated patient level data on health services provided to PLWHA.

The data warehouse will allow various health personnel, such as program managers, healthcare workers,

researchers, etc. access to up-to-date information for patient management and outcome monitoring. The

data for the warehouse will come from diverse information systems, each with its own data formats and

coding standards.

In order to link patient data together, MOH is in the process of evaluating Identity Systems' Identity Search

Server (ISS) software to match patient identifiers from disparate systems. If ISS is purchased in 2007, in

2008 USG will fund the maintenance cost (18% of purchase price), which becomes due three months after

delivery of the software and upon each anniversary of the delivery of the software. The maintenance fee

allows MOH to benefit from enhancements, software fixes, and upgrades.

Linking patient data is only one part of the data warehouse process, however. Specialized programs must

be developed to obtain the data from each system, clean and convert the data, integrate the patient data

after the identifiers have been linked, and load the integrated data into the data warehouse. USG will

support MOH in building IT capacity via a skills transfer from an experienced data warehouse developer,

who will be contracted for a minimum of 6 months to assist in coding the required programs. In addition,

once the data warehouse is operational, data analysts will need access to the data for reporting purposes,

ad hoc queries, and research to improve patient care and outcomes. In 2008 USG will support the MOH in

Activity Narrative: procuring terminal service licenses for user access and Business Intelligence (BI) software for analysis and

reporting.

08-X1401: MOH - Human Resources Development support

This project began in 2004 as part of the Southern Africa Capacity Initiative (SACI) with initial financial

support from the United Nations Development Program (UNDP) and technical assistance from both UNDP

and the World Health Organization (WHO). In 2005, the USG provided funding for an assessment of

human resources and health service, resulting in a revised ten-year human resource plan that takes into

account the HIV/AIDS epidemic and the GOB's response. The assessment revealed major inequities in the

distribution of health services in the country. These inequities, exacerbated by the recent and rapid

expansion of national HIV/AIDS prevention, care and treatment services by the Government, have led to an

urgent need for the development of an integrated service delivery framework that will make possible the

implementation of quality health programs.

In 2006, PEPFAR provided funding to the MOH's Department of Policy, Planning, Monitoring and

Evaluation (DPPME) to undertake this next phase of the project. The overall purpose of this two-year

activity is to develop an integrated service plan and framework to enable the health sector in Botswana to

cope with changes in workload brought about by the HIV/AIDS pandemic, to rectify inequities in service

delivery and to improve quality health care. DPPME is a new department in the MOH and as such is

currently experiencing huge capacity shortages. Therefore, it will be critical that the process used to

implement this project develops the capacity of the MOH. With the ultimate aim of providing appropriate and

equitable access to all levels of service for the general population, an integrated national framework and

plan will provide:

•A national overview of the current status of service provision.

•A detailed assessment of actual service requirements through analysis of patient/case referrals and

services offered.

•A service configuration plan that is affordable and sustainable and that ensures that resource use is

effective and efficient.

•A basis for a long term vision to enable integration of key initiatives (such as capital development and

equitable human resource distribution); aspects that can be implemented only over extended time frames.

•A basis for ensuring (1) that all levels of service delivery are addressed, and (2) that primary health care

and hospital care are integrated.

•A rational basis for addressing health needs and national health priorities in a resource-constrained

environment.

The health service delivery framework will guide the provision of accessible, affordable, and equitable

health services to the population of Botswana. The framework will include service delivery standards and

facilitating policies and will be used to realign the type, number and location of health facilities in Botswana,

the magnitude of services that should be rendered and the optimum mix of resources needed.

Because of funding and bureaucratic delays, it was not possible to award this project to a contractor during

year one (FY07). In addition, funding provided by PEPFAR in COP 06 and COP 07 was inadequate to cover

the cost of a project of this magnitude. Therefore, we are requesting additional funding in COP 08 to cover

the cost of the second year of this two-year project.

By the end of 2009, results will include:

1. A 10-year Integrated Service Delivery Plan for Botswana's Health Services

2. Revised national HRH plan aligned to the health service plan

3. Recommendations on aligning the MOH Corporate plan to the health service plan

4. Cost analysis of implementing the plan, with the recommended most feasible scenario of financing the

plan that takes into account issues of equity and sustainability, including strategies of bridging the identified

financial gaps (i.e. the recommended resource allocation formulae)

5.Implementation guidelines, including the monitoring and evaluation mechanisms and Facility Management

Toolkit and Procedure Manual

6.Recommendations of key policy issues and how they impact on/should influence the current National

Health Policy

7.Strengthened capacity within the Department of Policy Planning Monitoring and Evaluation

08-X1415: MOH - HIV/AIDS Pre-service Training

The Institutes of Health Sciences (IHS), a tertiary institution for the training of health personnel, trains the

vast majority of nurses and other allied health workers for the country. The IHS, which falls under the MOH,

consists of eight health training institutes with over 1,500 students. A basic diploma is offered in general

nursing, medical laboratory technology, pharmacy technology, dental therapy, health education and

environmental health. Post-basic level courses are offered in midwifery, family nurse practice, community

health nursing and nurse anesthesia.

Since 2003, USG has provided technical assistance to IHS for the strengthening of pre-service training in

HIV/AIDS for nurses and other allied health professionals. In addition to this technical assistance, an HIV

Training Coordinator supported by USG began working in MOH in 2005. This officer is responsible for staff

development and training in HIV, strengthening HIV content in all programs/courses and bridging the gap

between in-service and pre-service training. This officer works closely with technical assistance

contractors, implements local capacity building activities and leads the workplace program initiative.

In addition to curricula and faculty development, a workplace program to provide HIV education and

services to both faculty and students is currently being established at all the Institutes.

This activity support the coordinator's salary, training and resources for faculty and the development of the

workplace program.

2007 achievements:

Provided journal subscriptions, HIV/AIDS guidelines and in-service curricula to all 8 institutions; conducted

annual PMTCT update for 16 midwifery faculty; conducted HIV/AIDS annual update for 17 faculty of first

year students; trained 51 lecturers in research methods; trained 38 lecturers in HIV/AIDS treatment

(KITSO); conducted situational analysis of workplace activities; developed draft workplace policy; trained 16

peer educators/counselors and 12 workplace focal persons

2008 plans:

Capacity Building: Conduct PMTCT update for 35 midwifery lecturers; conduct HIV and AIDS update

workshop for 45 participants; conduct pediatric HIV/AIDS care training for 30 faculty; conduct a workshop

for 35 participants to develop competencies for Pharmacy Technology, Dental Technology, Medical

Technology programs and strengthen HIV and AIDS content in the curricula

Workplace Program: Conduct update workshops for 16 peer educators and 12 focal persons; provide

materials for workplace programs, e.g. condom dispensers

08-X1419: MOH - Health Care Workers Wellness Program

The impact of HIV/AIDS on Botswana's healthcare system, coupled with health workforce shortages, has

substantially increased the physical and emotional demands placed on health workers. Throughout the

epidemic, health workers have been in the forefront of care and prevention activities, managing greatly

increased numbers of severely ill patients and assuming responsibilities for new HIV/AIDS services. At the

same time, many health workers have found it more difficult to respond to the demands of work because

they are HIV infected themselves or are personally affected by ill family members or friends. Though

knowledgeable about HIV/AIDS, many health workers are the last to seek HIV treatment and care services.

The Government of Botswana seeks to ensure that the present and future health workforce is able to cope

with the demands of the epidemic and effectively perform its duties and, to this end, has developed a

national Wellness Program for Health Workers. This program aims to provide a minimum package of

services which include: health services for staff that incorporate wellness (physical and emotional) services

and workplace safety; stress management programs (e.g., workshops, social and emotional support

committees; networking opportunities, e.g., support groups, resources for rest/tea breaks at work, recreation

(e.g., choir, football, social celebrations); training and staff development (e.g., workplace safety, team

building, stress management); health worker recognition/appreciation initiatives.

MOH is leading this program with PEPFAR funds and technical support. The program coordinator, who

began working in 2005, is supported by PEPFAR. To date, a national needs assessment has been

conducted, program structures are in place and foundation materials have been developed.

2007 Achievements:

Developed national structure for the program; visited the wellness center for health professionals in

Swaziland to learn best practices; conducted a hospital readiness assessment; developed the foundation

materials (three-year program implementation plan, program guidelines - Implementation, Support Groups,

Staff Morale), promotional materials (brochure, poster), training materials; established coordination

structures (workplace wellness committees in 18 hospitals and 3 headquarters units); disseminating

guidelines; conducting quarterly support visits to monitor implementation and provide technical assistance;

training facilitators on the formation of support groups; training trainers and health workers in stress

management and team building; developing additional brochures and program launch

2008 Plans:

Conduct quarterly support visits to monitor the implementation of the program and provide technical

assistance; train 250 health workers in HIV/AIDS, Stress Management, Team Building, Occupational Health

and Death and Dying