09.T.LS09 NACA - Botswana Bureau Of Standards

Implementation of PEPFAR has been a challenge for many African countries because of the lack of local

capacity, in terms of human resources. Additionally, there are limited human resources internationally to

support PEPFAR in the fifteen focus countries, hence building local capacity to carry on the PEPFAR

activities has become necessary.

The Botswana Bureau of Standards (BOBS) is a Botswana Government structure supporting industry

through training on various Quality Management Systems (QMS), Environmental Management System

(EMS), and Laboratory Management courses in accordance with ISO 9001, 14001 and 17025/15189,

respectively. In addition to organizing these training courses, the Bureau helps laboratories with the testing

of products and calibration of certain types of laboratory equipment.

In the laboratory training courses, BOBS is lacking the capacity to offer training in method validation,

uncertainty of measurement and statistical techniques for laboratory analytical results. The Bureau is also

lacking in the capacity to carry out calibrations of certain types of medical equipment, e.g., centrifuges,

pipettes, and biological cabinets, among others. There is need to build capacity in the areas indicated above

in order for BOBS to support the medical laboratories in the country effectively.

Funds are requested from PEPFAR to strengthen BOBS's capacity through the twinning system with the

Association of Public Health Laboratory (APHL), and to undertake training for specific activities that will be

necessary to provide technical support to the Ministry of Health laboratory services.

Funds will also be used to support onsite training for documentation of QMS in the four district upgraded

laboratories, namely Mahalapye, Molepolole, Maun, and Serowe, to collaborate with the Quality Assurance

Program at the Ministry of Health (MOH) to conduct annual laboratory assessments, and to conduct training

on documentation, ISO 17025/15189, and auditing. BOBS will also support the laboratories by providing

calibration of laboratory equipment, specifically pipettes, thermometers, and centrifuges, and certification

and maintenance of biosafety cabinets.

New/Continuing Activity: New Activity

Continuing Activity:

Program Budget Code: 17 - HVSI Strategic Information

Total Planned Funding for Program Budget Code: $5,271,858

Total Planned Funding for Program Budget Code: $0

Program Area Narrative:

In response to the challenges that HIV and AIDS present to Botswana, efforts continue to be made to diversify approaches, fine

tune technical support, and plan for future program sustainability with the support of the Presidents' Emergency Plan for AIDS

Relief (PEPFAR). The national HIV prevalence rate is 23.9% among adults ages 15 to 49, according to recent UNAIDS data, and

an estimated 300,000 are living with HIV/AIDS. About 53.2% of Batswana know their HIV status up from 25% in 2004, 95% of

pregnant mothers gaining that information through the Prevention of Mother to Child Transmission program. The Botswana 2007

Sentinel Survey indicated that HIV prevalence among pregnant women (15-49 years) is 33.7%, though the overall trend appears

to be decreasing from 37.4% in 2003. The Department of HIV/AIDS Prevention and Care reports that, as of the end of July 2008,

a total of 109,991 patients were receiving HAART, 97% of the 113,000 patients estimated to require treatment. Challenges

remain, however, with prevention, particularly the issue of multiple concurrent partnerships, alcohol abuse, nascent civil society,

and human capacity development.

Botswana has almost achieved universal coverage in most program areas responding to HIV/AIDS, particularly in Prevention of

Mother to Child Transmission (PMTCT), routine HIV testing (HRT) and anti-retroviral ARV provision. As with many countries, the

HIV/AIDS response of the information management system is still struggling to catch up with the success achieved in other

programs.

The President's Emergency Plan for AIDS Relief (PEPFAR), through its Botswana United States Government (USG) Strategic

Information (SI) section, has been working with different governmental departments and stakeholders to assist the Government of

Botswana (GOB) to respond to these challenges. Capacity development initiatives at district health and AIDS coordinating offices

through placement of information management officers have begun to show visible results in improving frequency, completeness

and quality of data generated at their level. The future envisages solidifying these gains and encouraging local data utilization for

resource prioritization and decision making.

In FY2009, the SI team will continue to provide technical support to the United States agencies in the country PEPFAR team and

implementing partners by strengthening their staff base and through collaboration with partners such as International Training and

Education Center on HIV (I-TECH), the University of California-San Francisco (UCSF) and others. These institutions have the

necessary technical staff and use appropriate methodologies to transfer skills in the area of monitoring and evaluation (M &E) and

strategic information to the local partners and entities in Botswana. This constitutes the biggest advantage the USG brings to the

capacity building arena in Botswana in the SI area.

USG support to the Government of Botswana (GOB) and other partners covers many aspects of M&E and SI, including

strengthening of the monitoring and evaluation system, data quality assurance, enhancing the Health Management Information

System (HMIS), improving HIV surveillance and human resource capacity development.

Through previous USG supports, the Ministry of Local Government (MLG) hired 44 Monitoring and Evaluation (M&E) Officers to

work with the District AIDS Coordinators (DACs) and the District Health Teams (DHT). These officers, also known as Information

Management Officers (IMOs), were hired to improve data quality, conduct data analyses to inform programmatic decision-making,

and facilitate communication and data exchange between the DAC Offices and DHTs.

This project also supported two senior M & E officers at the headquarters of MLG to supervise the IMOs and provide them with

technical and administrative support.

In FY2009, MLG will undertake two regional data analysis and report writing workshops for the IMOs and pilot data quality

improvement (DQI) activities in 2 districts in collaboration with I-TECH. Experience gained from the pilot DQI will be supplemented

with another rapid assessment of data transfer and flow mechanism that I-TECH will undertake to help institutionalize and rollout

data quality assurance (DQA) program in all districts in 2010.

During FY2009, I-TECH will continue its mentoring role to support the IMOs with additional activities to map out different data

quality management challenges at different levels including service facilities, the headquarters of the Ministry of Health (MOH), the

National AIDS Coordinating Agency (NACA) and MLG. I-TECH will continue to provide human resource secondment to the MOH

in FY2009. A senior epidemiologist was hired in May 2008 through the I-TECH funding mechanism and seconded to the

Department of HIV/AIDS Prevention and Care (DHAPC) to build capacity in HIV surveillance. I-TECH also provides management

backing for the two senior M&E officers at the MLG in building their management capacity to supervise and provide technical

support to the IMOs.

PEPFAR has been supporting civil society capacity development for the past five years and yet there are practical challenges to

meet the widespread demands for their in put. The National Strategic Framework (NSF) for the HIV/AIDS response in Botswana

denotes that civil society contribution shall remain critical in the area of advocacy, design and implementation of workplace

programs, counseling, and care and support. Other areas of this key role included research and evaluation undertakings,

performing "watch-dog" responsibilities on behalf of the HIV-infected and -affected, and conceptualizing innovative strategies.

Current realities on the ground show that this sector lacks core implementing expertise on the HIV/AIDS response, which seems

to be visible only among network organizations and large NGOs, rather than among community-based organizations. There are

obvious duplications of efforts for certain priority areas among NGOs and within the GOB as well as a lack of organizational and

program management capacities.

Based on the aforementioned background, USG funds will support the Botswana HIV/AIDS Response Information Management

System (BHRIMS) Division of NACA to undertake a formative evaluation to assess the contribution of civil society in the national

HIV/AIDS response in Botswana.

In FY2008, PEPFAR supported five targeted program evaluations. Two targeted evaluation programs were conducted with

support from the University of California—San Francisco: The HIV-related Mortality Validation and The Qualitative Behavioral

Study in Adults, the results of which will be disseminated soon. Two other program evaluations are in the development process:

Sexual Behavior among Alcohol Users and The Behavioral Surveillance Survey among High-School Students. Although USG

support was pledged through MACRO International to participate in the Botswana AIDS impact survey (BAIS III), PEPFAR

disengaged itself from participating and supporting the survey because of USG ethical queries around returning HIV test results to

survey participants.

At this time, of the four public health evaluations (PHE) that were proposed to the Office of the Global AIDS Coordinator (OGAC)

from Botswana, two have been accepted to be continued, one on infant morbidity and mortality and one on infant circumcision,

and two, on interventions for high-risk negative counseling and testing and adult male circumcision, are still being reviewed. The

PHE about male circumcision in adults will engage Botswana in participation in a multi-country evaluation, while the other two are

country focused.

Botswana still has a challenge in adopting a unique electronic monitoring system or harmonizing of the various vertical electronic

monitoring systems. Last year, PEPFAR supported the strengthening of the patient management information system (PMIS),

which is an interim electronic monitoring system, access based, and used in majority of health facilities. With increasing number of

patients on ARV treatment (over 100,000 in 2008) and dilemma on the future fate of the Integrated Patient Management System

(IPMS), USG support to strengthen the PMIS is deemed necessary. Moreover, as the data warehouse server ages, it becomes

necessary to pay attention to the maintenance and the upgrading of the hardware.

The overriding focus for upgrading of the PIMS in the coming year is for additional disk space. The volume of data from the data

extracts is growing rapidly. By August 2008, the Masa M&E unit was already extracting more than 45 million records and if this

rate of growth is maintained, the projection is that by February 2010, the unit is anticipated to be extracting more than 60 million

records.

In FY2009, USG funds will, therefore, support the installation of a new disk array to complement the existing disk space. During

FY2008, PEPFAR supported key positions in the Department of Policy, Planning, Monitoring and Evaluation (DPPME) and the

Department of HIV/AIDS Prevention and Care (DHAPC) in the Ministry of Health. In addition to these positions, a senior health

information management consultant will be hired in FY2009 through I-TECH to oversee the development of HMIS strategic plan,

which will guide future developments and provide support to the HMIS in Botswana.

USG has been supporting HIV Surveillance since 2003. In 2007, the national ANC sentinel surveillance HIV prevalence rate was

33.7%, a slight increase from 2006, however, the declining trend among the youth is still observed. There was no ANC sentinel

surveillance in FY2008 because of the Government decision to undertake it every 2 years. Dried blood spot (DBS) sample

collection techniques will be used in the 2009 HIV sentinel surveillance. Thus, USG funds will be used to provide funding to

purchase reagents for Elisa test, incidence testing and threshold HIV drug resistance testing. In addition to the senior

epidemiologist position, USG funds will be used to pay salaries for a data manager and two data clerks within the DHAPC.

During FY2008, USG funded training of three trainers and 26 staff from the Health Statistics unit at the MOH in ICD-10 coding.

This effort is meant to improve mortality and morbidity data capturing to allow an accurate assessment of the impact of different

programs, such as the ARV program on mortality. The same activity will continue in FY2009 using funds leftover from FY2008.

Currently, the USG SI section has only four people handling issues related to monitoring and evaluation, surveillance, HMIS and

informatics. One Full Time Equivalent (FTE) position for the SI team lead post and one locally hired M&E officer will be added to

the existing SI team. USAID is still re-strategizing its presence in the country, especially in civil society capacity development and

SI is expected to be an important focus area. Other USG agencies have limited presence on the ground and inter-agency SI

coordination is critical. The SI team organizes an introductory M&E training session with Peace Corps Volunteers (PCVs) working

on USG HIV/AIDS programs every year. SI assists all agencies to set targets, compiles data on achievements, and prepares and

submits the semi-annual and annual progress report. This team also provides technical support to different government agencies,

such as NACA, MOH, MLG, and Ministry of Education [MOE]) for capacity building in M&E systems design, HMIS, data quality

assurance and HIV surveillance.

Table 3.3.17:

09.X.SI11: NACA - National Evaluation Agenda

The National Strategic Framework (NSF) for the HIV/AIDS response in Botswana denotes that civil society

contribution shall remain critical in the area of advocacy, design and implementation of workplace programs,

counseling, and care and support. Other areas of this key role included research and evaluation

undertakings, performing "watch-dog" responsibilities on behalf of HIV-infected and -affected, and

conceptualizing innovative strategies. Current realities on the ground show that:

1. "Formation of core implementing expertise" on the HIV/AIDS response is not visible at all structural and

administrative levels within the non-governmental organization (NGO) community.

2. Civil society activities seem to be concentrated in the area of prevention, care and support.

3. Civil society presence seems to be more visible among network organization and large NGOs, rather

than among community-based organizations, so the linkage is between the top and bottom.

4. Duplication of efforts for certain priority areas among NGOs and with the Government of Botswana

cannot be ruled out.

5. The lack of organizational and program management capacities are by and large bottlenecks for civil

society effectiveness and efficiency.

6. Accountability and transparency in resource allocation and utilization are constrained.

7. Coordination of donor support to civil society is a serious challenge.

Based on the aforementioned background, the Botswana HIV/AIDS Response Management System

(BHRIMS) Division of the National AIDS Coordinating Agency (NACA) is planning to undertake a formative

evaluation to assess the contribution of civil society in the national HIV/AIDS response in Botswana. The

project concept emanated from a national workshop held in November 2007 which aimed at setting

priorities for HIV/AIDS program evaluation agendas - an idea born by the global Monitoring and Evaluation

Reference Group (MERG). The workshop identified eight broad questions spanning over the five key goals

of the national strategic plan.

Specific Evaluation Questions

1. To what extent are civil society programs addressing the identified gaps according the NSF?

2. How is that influencing civil society's participation and engagement in the HIV/AIDS response?

3. What are the missed opportunities in HIV prevention, care and support due to civil society's inability to

play its role effectively?

4. What structural reforms can be implemented to enhance linkages between different levels and

coordination within civil society?

Proposed Evaluation Methods

A formative evaluation research project using multiple data collection techniques will be employed. Key

informant interviews, document reviews, community meetings, and participatory appraisal of conveniently

sampled NGOs, faith-based organizations (FBO), community-based organizations (CBO) will be used to

collect the required information.

Management of the Evaluation Project

NACA will lead the evaluation through its Monitoring and Evaluation (M&E) Division, BHRIMS. Participation

of the broader stakeholders will be ensured through the BHRIMS Technical Working Group, specifically the

Evaluations Sub-Committee. Special attention would be given to maximizing Civil Society representation in

the Evaluations Sub-Committee. This evaluation will be carried out through a collaborative consultancy

between an international partner and the University of Botswana.

New/Continuing Activity: New Activity

Continuing Activity:

Table 3.3.17:

09.X.SS10: NACA - NASA

ONGOING ACTIVITY FOR WHICH NO ADDITIONAL FY2009 FUNDS ARE REQUESTED - DELAYED

IMPLEMENTATION

From COP08:

The monitoring and evaluation of the policy responses would be greatly facilitated if policymakers were

continually well informed about the overall flow of funds for health in Botswana, both from the perspective of

who is financing such spending, and the purposes for which it is being used. The resource envelope

revealed by these flows and their current uses will enable policymakers to assess overall resource

constraints, choose among competing demands on health resources and, depending on the nature of these

flows, identify policy mechanisms best able to achieve desired health objectives.

The National AIDS Spending Assessment (NASA) resource tracking algorithm is designed to describe the

financial flows and expenditures using the same categories as the globally estimated resource needs. This

alignment is recommended in order to provide the necessary information (as advised by the Global UNAIDS

Resource Tracking Consortium) on the financial gap between resources available and resources needed,

as well as a greater harmonization of different policy tools frequently used in the field of HIV and AIDS.

By doing so, NASA provides indicators of the financial country responses to HIV/AIDS and supports the

monitoring of resource mobilization. Thus, NASA is a tool to install a continuous financial information

system within the national monitoring and evaluation framework. NASA serves several purposes within

different time-frames. In the short term, NASA aims to contribute to the production of an UNGASS indicator

for public expenditure; in the longer term, more comprehensive information provided by NASA may be used

to:

--monitor the implementation of the National Strategic Plan;

--monitor advances towards completion of nationally or internationally adopted goals such as universal

access to treatment or care;

--provide evidence of compliance with the principle of additionality required by a few external donors or

international agencies; and fulfill other information needs as these emerge always more demanding

Within the Mid-Term Review of the NSF, the National AIDS Coordinating Agency (NACA) examined the

actual resource environment by conducting a NASA for financial years 2003-2005. The NASA found that

the actual annul funding made available was 79% of the estimated need. When compared with the

intended NSF proportional allocations to the NSF goals, the funding allocations were generally comparable.

Only prevention activities were being significantly under-funded; having approximately 8% of the public

expenditure, when the NSF intended it to be 10-13%. A follow up NASA for 2006/07 is currently underway

and will further the institutionalization of the process and provide trend data for the initial ramping up of

PEPFAR funding.

Objectives

1.To develop country estimates of total flows of financing and expenditures for HIV/AIDS, from all

international and public (domestic and private) sources of financing for GOB financial year 2007/08.

2.Expand the scope and details of financial information collected to include:

a.Government

b.Development partners

c.Private

d.Out of pocket expenses

3.Improve the robustness of data collated from government and development partners

4.Provide refresher and on the job training to Government of Botswana staff in the execution of national

HIV/AIDS accounts and further institutionalize the government fiscal data capturing process.

New/Continuing Activity: Continuing Activity

Continuing Activity: 17921

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

17921 17921.08 HHS/Centers for National AIDS 7849 1330.08 U62/CCU02509 $75,000

Disease Control & Coordinating 5-

Prevention Agency, Botswana Strengthening

Prevention,

Care &

Treatment

through Support

to Programs

Managed by the

Government of

Botswana

Table 3.3.18:

09.X.SS14: NACA - PEPFAR Administration Support

ACTIVITY UNCHANGED FROM FY 2008

From COP08:

The GOB has a Cooperative Agreement with HHS/CDC for five years from September 15, 2005 to

implement a significant multi-disciplinary initiative targeting HIV/AIDS. This is the most significant financial

agreement managed by HHS/CDC/BOTUSA with $14.8 million from COP05, $22.2 million from COP06,

and $17.9 million from COP07. This agreement therefore has substantial programmatic management,

monitoring and reporting requirements which must be maintained.

The National AIDS Coordinating Agency (NACA) under the Office of the President has been charged in

government to provide strategic oversight and management to all HIV/AIDS related activities in Botswana.

NACA, using Pepfar funds has a full time ‘Principal Program Planning Officer' to conduct the routine

business management of the GOB Cooperative Agreement on behalf of the government.

The purpose of this activity is to continue financial support to the post, which can, in collaboration with

HHS/CDC/BOTUSA and the ministries, provide comprehensive financial and programmatic support to the

implementing partners under the GOB CoAg. The post will supply high quality oversight and transparency

documentation to the GOB Principal Investigator, business official and HHS/CDC/BOTUSA in a routine and

timely manner.

In addition to the HR support, PEPFAR funds will be used to conduct the annual financial cooperative

agreement audit as required by 45CFR 74.26(d).

New/Continuing Activity: Continuing Activity

Continuing Activity: 17661

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

17661 10323.08 HHS/Centers for National AIDS 7849 1330.08 U62/CCU02509 $100,000

Disease Control & Coordinating 5-

Prevention Agency, Botswana Strengthening

Prevention,

Care &

Treatment

through Support

to Programs

Managed by the

Government of

Botswana

10323 10323.07 HHS/Centers for National AIDS 5299 1330.07 Technical $220,000

Disease Control & Coordinating Assistance

Prevention Agency, Botswana

Table 3.3.18: