Context

Mullan & Associates (Pty) Ltd, is a private consulting firm specializing in Human Resources, Capacity Building, Program and Project Management and Operations Research.

Formed in 1982 and based in Gaborone, Botswana, Premiere was awarded a cooperative agreement in 2008 for "Building Human Resource Capacity to support Prevention, Care and Treatment Strategies" by CDC utilizing PEPFAR funds.

Working in collaboration with the CDC/BOTUSA office and several Government of Botswana (GOB) Ministries (Health, Local Government and Education), other organizations and individuals, Premiere's Co-Ag is a funding mechanism to provide support and assistance in the implementation of activities enhancing the country's health polices and procedures, and to build capacity across a range of programmatic areas.

Goals and Objectives

Build capacity within the Republic of Botswana health system

Major Activities

Premiere will support the following programmatic activities: Prevention of Mother to Child Transmission (PMTCT), Counseling and Testing (C&T) Care and Treatment, Laboratory Support, Institutional Developmental Management (IDP) Sustainable Management Development Program and Botswana Network of Ethics Law and HIV/AIDS (BONELA)

The following will receive support with carryover funding: Media Institute of Southern Africa, Orphans and Vulnerable Children, National AIDS Coordinating Agency and Sub-partners, Botswana Harvard Partnership, Associated Fund Administrators and the School of Public Health Consultancy

Target Populations

For PMTCT support: infants from 6 weeks, HIV+ mothers, clinicians, healthcare workers and lay counselors.

For activities undertaken by the NGO coordinator, Lab DMO, C&T, IDM and BONELA: Government healthcare workers

BONELA's target extends to schoolchildren, teachers and NGOs.

C&T: counselors, CBOs and FBOs

Geographic Coverage

The entire geographical area of Botswana (except the Impact of Infant Feeding Practices evaluation study which is limited to the health districts of Francistown Tutume and Tonota)

Supporting Health Goals and System Strengthening

The NGO coordinator will leverage resources within Botswana-based CBOs and NGOs to ensure a coordinated approach to the country's health objectives.

The Lab Data Management Officer's (DMO) role is to strengthen the dissemination of information relating to TB and the national response.

Cross-Cutting Areas

Education is addressed by a number of programs leading to the training of more than 1000 people during the year, through the Sustainable Management Development Program by International Development Management, the training of critical Health workers in specific infant survival issues (Early Infant Diagnosis [EID] and infant formula feeding practices [IFFP]) and Botswana Network of Ethics, Law, and HIV/AIDS (BONELA) program on awareness of stigma and discrimination for children and Teachers.

EID and IFFP training programs are closely linked to the key priority areas of child survival and safe motherhood.

IFFP is also linked to the issues of Food and Nutrition service delivery.

TB is addressed by the employment of the Lab DMO, enabling information regarding TB lab results to be disseminated quickly and ensuring information on key issues of drug resistant TB and infection rates are readily available.

Gender issues, including women's legal rights and gender equality in HIV/Aids activities are addressed in the policy advocacy program undertaken by BONELA

Enhancing Sustainability

Premiere, in collaboration with CDC/BOTUSA and the Ministry of Health (MOH), are working towards government absorption of the seconded staff positions (NGO Coordinator, Lab DMO and others)

Some of the other programs, e.g. IFFP, EID are shorter-term programs designed to support the GOB strategic health and HIV plans by ensuring that the appropriate policies are in place and fully implementable.

Premiere is careful to negotiate cost-efficient contracts with sub-awardees and with established reputable providers of goods and services to ensure the best possible pricing. Needs for equipment and supplies is looked at not just on an individual program basis but holistically across projects when possible.

Monitoring and Evaluation

Premiere, together with BOTUSA, will provide project management, support and monitoring, both financial and programmatic to all sub-awardees.

Premiere works closely with MOH and other GOB departments to ensure all projects are within the Botswana national health strategy and objectives.

Projects are closely tracked and monitored in line with PEPFAR indicators. Information gathered is used to shape and enhance ongoing project design and implementation.

10.C.AC14: Mullan - NGO Coordinator & Technical Advisor - 100,000.00

The involvement of civil society organizations can be traced back to the first Short Term Plan of Action (1987-1989) on HIV and AIDS, the Medium Term Plan I and II, respectively, and now the National Strategic Framework for HIV/AIDS 2003-2009. The Government of Botswana (GOB), communities and other development partners have acknowledged the strategic role played by civil society organizations in responding to HIV and AIDS.

Civil society's role became evident in the early 1990s when the epidemic became more mature resulting in many people suffering from chronic conditions related to HIV/AIDS, thus increasing the demand for HIV/AIDS-related services. This increased need has overwhelmed the capacity of the public sector to deliver services to all people in need, resulting in many of them, still needing care and support, being discharged back to their families and communities who are not always capable of handling the varying situations.

In 1995, the government adopted community home-based care (CHBC) as a strategy to ensure continuity of care and to support people living with HIV and AIDS (PLWHA) and other chronically ill patients. The government realized it had limited capacity to implement the program, hence family and community mobilization was adapted as a major intervention. The community response has been very supportive, as evidenced by the emergence of several civil society organizations working country-wide. In 1998, there were 78 community groups and, currently, there are more than 300 local Civil Society Organizations (CSO) involved in the response to HIV and AIDS, including Faith Based Organization (FBOs), NGOs such as Botswana National AIDS Service Organization (BONASO), Botswana Network of People Living with HIV/AIDS (BONEPWA), Botswana Network for Ethics, Law and HIV/AIDS (BONELA), Botswana Christian AIDS Intervention Program (BOCAIP), and others. It is obvious that the public sector in Botswana recognizes the importance of CSOs, so they have played an active role in establishing the CSO sector and continue to nurture its growth.

CSOs, therefore, provide a strategic opportunity to increase geographical coverage of services and reach marginalized, vulnerable and underserved communities with ease. They can provide a range of services, both stand alone and integrated, depending on a given organization's capability and comparative advantage. These services include traditional community mobilization, distribution of health resources such as condoms, bed nets, and community TB Dots, dissemination, health information, psychosocial support, voluntary counseling and testing, peer education on HIV, income generating activities, care for orphans and vulnerable children (OVC), awareness campaigns, training on human rights, and advocacy to more complex activities, such as anti-retroviral (ARV) treatment literacy and adherence counseling, palliative care, home based care, hospices and day care centers, and youth and adolescent friendly reproductive health services. They also play a role in the development of health sector HIV and AIDS related policies and programs and in shaping the health systems. There is, however, significant variability in the scope and quality of their services, as well as in their levels of accountability. The public sector, particularly the Ministry of Health (MOH) still has the overall accountability to the public at large on the quality of services provided by these CSOs in the health sector.

Needs assessments done in the country indicate that most of these organizations are faced with challenges in terms of service delivery, adequate coverage, insufficient funding, and inadequate material and human resources. Due to a lack of skilled personnel, most of them are operating with a minimal number of skilled staff for both management and technical operations with most of staff being lay or unskilled volunteers.

Since the inception of the CHBC program, the government has been providing CSOs with financial, material and technical support and most are still dependent on the government for these resources. It is important to note, however, that as the numbers of CSOs increase and diversify their services, the provision and coordination of both financial and technical support to all of them is becoming a challenge to the government. The sharing of information on HIV and AIDS prevention and care and the support of programmatic issues between CSOs and the public sector both at national and implementation levels of the health sector response are weak. Additionally, public sector-CSOs collaboration linkages and patients referral systems are inadequate. This has implications on both the CSOs' and the government/public sector's accountability to the general public on quality of health services.

The above-mentioned capacity challenges experienced by the local organizations have attracted international organizations through various donor agencies' bilateral twinning programs, such as PEPFAR, United States Agency for International Development (USAID), Swedish International Development Cooperation Agency (SIDA), and BMS among others, to assist and strengthen the capacity of CSOs in Botswana. These international organizations come with both financial and technical expertise as well as pre-packaged options and ideas. For the health sector, both government ministries and CSOs, to maximize the benefits of these international NGOs' and donor agencies' support, there is a need to have formal mechanisms for communication, for example, on the sharing of information about the support they are able to give Botswana as well as what the public sector envisions, given the Botswana health sector's HIV/AIDS national priorities, objectives, policies, guidelines and challenges. This will enable NGOs and donor agencies to align their support with both local CSOs and the MOH to address the country's needs within the policy and legal framework, further strengthen the public sector -CSOs collaboration, and maximize the benefits of their financial and technical support to the country.

PEPFAR will support the position of a CSO Technical Advisor and Coordinator within the department of HIV/ AIDS Prevention and Care (DHAPC) at a government scale of D2 to enable the MOH to coordinate and strengthen links between CSOs and the public and private sectors.

10.C.CT10: Mullan - National Counseling and Testing Workshops - 110,000.00

Since FY08, Mullan & Associates has provided support to the Counseling and Testing (CT) program through logistics support, including organizing workshops, meetings, study tours, and trainings as well as printing technical materials.

In FY10, funds will provide logistics support to the following activities:

1. A study tour for six government and NGO/faith-based organization participants to a country in the region to share experience and learn more about child and adolescent CT service provision.

2. A workshop for 100 HTC providers to share best practices, receive technical updates, and discuss achievements and challenges.

3. A skills-building training for 30 lead HTC counselors on how to address the issue of repeat testing and what prevention messages to give different types of HTC clients

4. Two technical working group meetings for PEPFAR-funded HTC partners to review progress, discuss challenges and strategize for the attainment of set targets.

5. Printing of additional couples HIV counseling and testing (CHCT) training manuals and job-aids to support providers

- 500 participant manuals

- 200 cue cards

- 100 CHCT protocol charts

10.X.SS08: Mullan - IDM/Sustainable Management Development Program - 466,500.00

The SMDP was established in 2003 at the Institute of Development Management (IDM) with the assistance of CDC/BOTUSA. The program provides a local management course, adapted from the CDC Management of International Public Health (MIPH) Course. The aim is to strengthen management and leadership abilities of public health managers working in HIV/AIDS in both the public, NGO, CBO and Faith Based Organization (FBOs) sectors and improve the quality of service delivery and care. The program has been institutionalize at the IDM and a standardized curriculum developed. This standard curriculum is in modular form allowing for shorter training in specific sections of the curriculum. To date, more than 180 health managers have been trained.

In 2008 and 2009, the following activities were undertaken: 30 mid-level public health managers trained in SMDP Course I, 20 in SMDP Course II, 20 in SMDP Course III, 20 in Healthy Plan-It, 20 HIV and AIDS Civil Society Organizations in Leadership, Networking and Strategic Resource Development, the IDM program manager underwent advanced training in Quality Assurance course at Harvard School of Public Health ,and an alumni conference was convened to solicit experiences, challenges and feedback on course improvement. In addition, the program is expanding to include a cooperatives-based approach to spread and sustainability.

In 2010 Mullan & Associates will support the continuation of the training of another 110 mid-level public health managers and one IDM Senior Consultant in Management for International Public Health (MIPH) at CDC/Emory University in Atlanta during September-October 2009. The Alumni Conference will also be held, but with an attendance expected of at least 120 graduates.

10.T.PT04: Mullan - Early Infant Diagnosis Training - 100,000.00

With PEFPAR support over the past two years, Mullan & Associates have been able to support the training of clinicians in the implementation of Early Infant Diagnosis (EID) using DNA-PCR on dried blood spots (DBS). The trainings were undertaken by officials from the Ministry of Health, with Premiere providing logistical support. Trainings have not been rolled out as anticipated due to the shortage of ministry staff and challenges with coordination of the various health districts. Twelve training sessions have taken place thus far, but late in FY09, the Mullans scope of work was changed to a more intensive approach, such that Premiere now provides two teams of nurse trainers, thereby alleviating the demands on the ministry staff.

In FY10, these two teams will continue the roll out of training for 200 clinical and health care workers across Botswana in the implementation of EID by undertaking an intensive six-month training schedule. Training sessions will be conducted in each of the districts, as well as in individual clinics/health posts, as required by the Ministry of Health. Mullans will also provide vehicles, drivers, logistical support and supervision to enable the program to run effectively. The training by nurse trainers will be supervised by the MOH and CDC technical staff for purposes of quality assurance.

The target population for the trainings is clinical staff, but the focus of the program is the testing of 12,300 HIV-exposed infants from six weeks of age in FY10. During trainings, clinical staff will be required to demonstrate the newly learned procedures in a supervised environment.

10.P.PM06: Mullan - Impact of Infant Feeding Practices - 100,000.00

For several years, the Government of Botswana has supported infants born to HIV-infected mothers with infant formula for replacement feeding as part of the PMTCT program. As a result of the new WHO Infant Feeding Guidelines, the Ministry of Health will almost certainly adapt their guidelines, which will require additional training of health workers.

The goal of this activity is to evaluate the effect of training on actual infant feeding practices. With PEFPAR support over the past two years, Mullan has been able to support the capacity building and training of health care workers in the implementation of the Infant and Young Child Feeding (IYCF) guidelines. In FY08, training was provided to 112 healthcare workers, most of whom were nurses. In FY09 and FY10, following a change in the scope of work due to a delay in obtaining IRB clearances for the evaluation protocol, a total of 199 healthcare workers will be trained. Of this group, 49 will be lay counselors and 150 will be nurses in the Francistown and Tutume sub-districts. Training is scheduled to be complete by the end of February 2010.

In FY10, Mullan will focus on the implementation of the evaluation study. The evaluation is to take place four to six months after the completion of the capacity building and training phase. It consists of recruiting mothers and children from post-natal wards at hospitals and clinics in the Francistown, Tutume and Tonota health districts who will allow for a home visit once infants are between eight and 24 weeks old to ascertain the level of information that has been provided to mothers, check for compliance to the guidelines and identify any difficulties or challenges that exist.

The target population for the training is health care staff, but the focus of the program is on infants born to HIV-positive mothers and the impact of the infant feeding practices as it pertains to the PMTCT objectives.

10.T.LS11: Mullan lab position - 65,000.00

Mullens & Associates employs and seconds, under PEPFAR funding, a Laboratory Data Management Officer to the Ministry of Health. The National Tuberculosis Reference Laboratory requested this, due to the fact that their methods and operations at the laboratory generate very large volumes of data. This position is needed to assist with the clerical work in microscopy, culture and susceptibility testing, and specifically with the registration of specimens in the manual and electronic registers, the capture of results from the laboratory request forms to the manual registers and electronic database, the daily management of data on TB drug resistance, including 1st and 2nd line drug testing for MDR-TB and XDR-TB, the conveyance of results to clinicians, peripheral laboratories, and TB coordinators for quick interventions, and assistance to the laboratory technical staff in using databases.

A Laboratory Data Management Officer was employed by Mullens & Associates with FY08 PEPFAR funding with the employment and secondment commencing on 1 February 2009.

The Laboratory Data Management Officer works at the National Tuberculosis Reference Laboratory and liaises with clinicians and peripheral laboratories which geographically cover the whole of Botswana. Furthermore, this officer's involvement in the management and dissemination of data on TB drug resistance and the resulting interventions ensure that activities are aligned with the national policies and strategic plans. By virtue of being involved in data entry and management at the National TB Laboratory, this officer is also involved in the implementation of the M&E framework and tools.

In FY10, funding is requested to continue supporting this position.