Context

Building upon the strong national health infrastructure, the Government of Botswana (GOB) has initiated and sustained a multilevel, multi-sector response to HIV/AIDS.

The National HIV/AIDS response is embodied in the National Strategic Framework and involves several governmental bodies. These include the Ministry of Health (MOH), the Ministry of State President and the Ministry of Local Government (MLG).

Major Activities

The GOB supports national programs for prevention, care and treatment including behavior change communication, social marketing, HIV-testing services, Prevention of Mother to Child Transmission services, Orphans & Vulnerable Children, opportunistic infections, sexually transmitted diseases, ARV treatment and services.

The GOB supports surveillance, blood safety, and monitoring and evaluation (M&E) programs.

Making the Most of Other HIV Resources

The GOB leverages its own funds to provide a variety of programs to limit the spread of HIV/AIDS in Botswana, and to provide care and treatment to those affected by the disease.

Cross-Cutting Areas

As part of its HIV programs, the GOB supports the cross-cutting areas of gender, strategic information, human resources for health, and renovation.

Enhancing Sustainability

The GOB's strategies for creating a sustainable program, rooted in host-country ownership involve:

- Strengthening health systems within MOH and other relevant government ministries (MLG, National AIDS Coordinating Agency)

- Taking leadership in coordination of health-program goals and agendas among International Organizations and local nongovernmental organization, as well as with agencies such as UNICEF, UNFPA.

- Continued training of healthcare workers to add to Botswana's cadre of trained, local healthcare staff.

Monitoring and Evaluation

The GOB will use the program data it routinely collects to inform and shape ongoing project design and implementation. Its monitoring and evaluation plan will thus be programmatically relevant, based upon ongoing inputs utilizing staff expertise for data collection and data-driven interventions.

10.C.AC15: MOH - STI - 62,000.00

STI Program of Department of HIV/AIDS Prevention and Care of the Ministry of Health is aiming at collaborating with PEPFAR in strengthening the STI unit. The unit will conduct clinical mentoring training and site visits in the districts. STI Program continues building capacity of the centrally placed STI trainers through on-going technical assistance and professional development opportunities and workshops. Based upon the highly positive experience of the STI Unit staff in FY2008 and 2009, Funds will sponsor one additional Ministry of Health (MOH) employee to attend the University of Washington (UW) Principles of HIV/STD Research course in July, 2010.

STI national program will continue to support STI District TOTs and Mentors trained in 2009/2010 to implement a national program in clinical mentoring for high-quality STI syndromic management in Botswana. Specifically, the Program will provide support to the National STI Training and Research Center (NSTRC) master trainers to provide on-going clinical mentoring training and supervision in the 24 health districts. Two workshops will be conducted, one will be for four clinical mentoring trainings and one workshop for clinical mentors trained in previous years. Mater trainers will have follow-up visits with the clinical mentors to health facilities in the country. The program will support skill-building and professional development of Master Trainers by providing technical assistance to the Master Trainers in developing a plan for the scale-up, monitoring and evaluation of mentoring activities.

In FY2010, PEPFAR funds will support completion of clinical mentoring rollout that began in FY2007. Technical assistance will also be provided for developing an exit strategy for I-TECH to ensure that the STI Unit's capability of carrying out the on-going clinical mentoring activities is sustainable. The MOH, now having finalized the clinical mentoring guide and developed the mentoring and professional skills of the Master Trainers, MOH, is currently in the process of planning how to absorb the Master Trainers, and will be facilitated to do so. Ongoing clinical mentoring activities will be supported by the MOH.

Building Capacity and Systems Strengthening of the NSTRC

The NSTRC was founded in 2002 as a center of STI training and research in Botswana. The center currently houses an STI clinic and a small training hall, and hopes to expand to include laboratory facilities and a resource center. The NSTRC also plans to expand from its current training focus to include a counseling component and clinical and operations research.

10.C.AC17: MOH - MASA Opportunistic Infection Mgmt - 100,000.00

MOH has come up with an array of important interventions to reduce HIV related morbidity and mortality. Because of proven effectiveness in reducing mortality, as well as being cost effective, the provision of cotrimoxazole prophylaxis (CTX) continues to be a very high priority intervention. The Government of Botswana through MOH continues to provide other services to reduce mortality including recognition and management of tuberculosis, other opportunistic infections, screening and treatment for cervical disease/cancer and interventions to reduce the burden of cryptococcal disease as well as other common HIV co-morbidities.

Therefore treatment, care and support PEPFAR funds are specifically targeted for the improvement of HIV/AIDS clinical management including that of opportunistic infections. The annual updating and expansion of the HIV/AIDS and opportunistic infection Clinical Guidelines manual will be carried out in order to strengthen the quality of the overall provision of care and treatment. Regular supervisory site visits will be conducted to monitor inclusion of the latest clinical care updates in day to day service delivery. Also CME short courses and mentoring will be conducted with the aim of furthering clinical skills of health workers on the ground. ARV Nurse Task Shifting Initiative is planned to continue with two ARV Nurse Workshops. It is through these workshops that they will be sharing their experiences and lessons learnt from 3 years of this ARV Nurse Task Shifting Initiative. It will also allow ARV nurses an opportunity to share their challenges and successes with each other as well as inform Masa program directly on how the task shifting initiative could be further enhanced.

MOH will continue to work in collaboration with several private partners including PEPFAR to come up with a cost effective and sustainable care and treatment program.

10.C.OV03: MOH - Nutrition Rehabilitation for OVC - 685,378.00

The overall goal of this project is to ensure effective and comprehensive nutritional management of malnourished children affected and infected by HIV/AIDS. Specific objectives include the 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.

The MOH's nutrition program's aim is linked to the Partnership Framework Goal 4 with more focus on care and support services. Currently, the program is based in Gaborone (Princess Marina Hospital) and Francistown (Nyangabgwe Hospital) and targets malnourished children affected and infected by HIV and AIDS.

This activity is linked to C0802, C0811, C0812, and C0814. The USG funds will support the construction of a rehabilitation unit for malnourished children infected and affected by HIV/AIDS at PMH in Gaborone and NRH in Francistown. This activity was initially scheduled to start in FY05. Due to insufficient funds, the initiation of the renovation was deferred to FY07 and implementation will be shifted to USG's Regional Procurement Service Office in Frankfurt, Germany. The Rehabilitation Unit will serve several purposes: 1) malnourished children will be served at the Unit; 2) the Unit will serve as a training center for care givers of malnourished children; 3) NGOs, CBOs, and FBOs working with OVC will refer needy cases to the Unit; 4) the Unit will provide office space for the Program staff. This program is identical to the PMH Rehabilitation Unit that is being renovated using FY06 PEPFAR funds. Architectural drawings are available and soil testing has been done at both sites.

In FY10, the nutrition rehabilitation program will continue to enroll malnourished HIV-infected and affected children for treatment. The program continues to be implemented in Gaborone and Francistown, although referrals of children also come from districts surrounding the program sites. The training of heath workers, other service providers, caregivers and civil society organization staff serving OVCs continues, using curriculum and training manuals developed by the program. The shortage of adequate space for the program remains a major challenge.

Enrolment of malnourished children infected and affected by HIV/AIDS will continue, as well as capacity building of health workers and the community to support care of children. Needs assessments for other districts will also be undertaken. Renovation of the two Rehabilitation Units by RPSO will be completed.

In FY10 and FY11 the program will be evaluated to inform up-scaling to other districts during the PEPFAR 2 Partnership. Enrolment of malnourished children infected and affected by HIV and AIDS will continue as well as capacity building of health workers and the community to support care of children. Needs assessments of other districts will also be undertaken. Renovation of the two rehabilitation units by RPSO will be completed.

10.C.OV06: MLG - OVC Support - 1,024,169.00

Context

Led by the Department of Social Services (DSS) under the Ministry of Local Government (MLG), the Government of Botswana provides care and support to orphans and other vulnerable children (OVC) through the Short Term Plan of Action (STPA) 1999-2003.

The STPA serves as the normative framework for responding to the immediate needs of OVC.

The DSS coordinates the provision of services to OVC and mobilizes non-governmental organizations (NGOs), community-based organizations (CBOs), and faith-based organizations (FBOs) to participate in issues that affect OVC.

Major Activities

- MLG, through DSS in FY09, started the dissemination of national documents on OVC and will carry on the dissemination and monitoring of the implementation of these documents in FY10.

- DSS will cascade psychosocial support training in the remaining districts in FY10. Following passage of the Children's Act 2009 by parliament, DSS will focus on the dissemination and establishment of community structures set up in the Act to protect children including OVCs.

- DSS will strengthen its capacity at the district level to support, monitor and coordinate the implementation of OVC programs.

- DSS will disseminate national guidelines and frameworks formulated to improve the quality and type of services being provided to OVC.

- DSS will work with the Marang Childcare Network (Marang) to disseminate relevant legislation affecting OVC to different stakeholders.

- DSS will work with stakeholders to advocate implementation of guidelines and policy frameworks on OVC, and will solicit technical assistance from UNICEF on issues of child rights, advocacy of children's issues, and implementation of legislation relevant to OVC programming and child protection.

- DSS will coordinate the provision of services to OVC and mobilize NGOs, CBOs and FBOs to participate in issues that affect OVC.

- DSS will work with Marang and other stakeholders to strengthen coordinating-structures at national and district levels through in-service training of employees, and by enhancing linkages and partnerships with the NGO/CBO/FBOs providing care and support to OVC.

- DSS will build a partnership with the private sector.

- District forum teams comprised of the Department of Social and Community Development (S&CD) and NGOs will be strengthened.

- The National Children's Council and Village Child Committees will be established. These will not only be responsible for coordination, but will ensure that OVC are identified and have access to basic services.

- DSS will identify and train community caregivers.

- The 2007 Situational Analysis on OVC in Botswana revealed that a significant number of OVC are cared for by elderly, female-headed households with little or no income, or by young people who are unemployed and unable to provide basic needs to the OVC. To address this, DSS will use the Community Carers Model (CCM) and Family Care Model (FCM).

- DSS and S&CD, together with the CCM, will identify community carers who will monitor the delivery of government services to ensure they reach the intended OVC and their families.

- Community members will be trained on issues such as parenting skills and hygiene. Within the carers' network, supervisors will work directly with the social workers and provide monthly reports.

- The FCM will ensure that all members of families with OVC are catered for, and that their capacity to cope is strengthened by addressing their needs. Marang will assist DSS in monitoring the project and in documenting the processes in preparation for replication and mainstreaming into the DSS mandate.

- DSS will strengthen the OVC registration system in 16 districts. This will involve training staff on the use of the updated registration system.

- DSS will utilize PEPFAR resources to build the capacity of the NGO/CBO/FBOs it has been supporting. The support will include giving these organizations grants for OVC services, including support for psychosocial support and other basic needs.

Target Population

All OVC

Geographic coverage

Botswana

Integration and Linkage

The DSS OVC program's aim is linked to the Partnership Framework goal 4 with more focus on care and support services.

Monitoring and Evaluation (M&E)

DSS will take the lead in ensuring that OVC programs are adequately monitored and evaluated using the National M&E Framework for OVC.

DSS will facilitate and ensure that OVC-serving organizations provide at least three minimum essential services as defined by DSS.

DSS will collaborate with OVC-serving organizations to ensure provision of quality OVC services, monitor program results, and document best practices and lessons learned.

10.T.AT11: MOH - Airbourne Lifeline - 500,000.00

The Airborne Lifeline Foundation provides the first regularly scheduled preventative medical air service in Africa with its primary emphasis on HIV/AIDS treatment. It not only transports specialists from Princess Marina and Nyangabgwe hospitals to remote clinics on a scheduled basis, thereby allowing medical professionals to spend time both to treat patients, as well as train other health care providers, but also transports anti-retroviral (ARV) medications, other drugs, and medical equipment to these remote clinics in a secure and timely manner.

The needs for the service have been identified by key members of the Ministry of Health, and as these needs change, the service will adapt its schedule to these changes. It was demonstrated that although Botswana has upgraded its rural medical facilities, the facilities were not staffed with the necessary health care specialists to tend to the local population, as most of the health care specialists were living in Gaborone and Francistown. The need was identified for a timely and efficient transport system to convey these specialists to the rural areas, so as to cover the population of Botswana with medical services more effectively.

The Airborne Lifeline Foundation began its flight operations in Botswana in May 2007, initially funded by its founder, Johnathan Miller, and his wife, Elizabeth Thompson. Airborne has since signed a Memorandum of Understanding with the Ministry of Health in August 2006 and received its first PEPFAR grant in April 2008.

Airborne originally flew specialists from Gaborone to Hukuntsi, Tsabong, Ghanzi and Gumare on a regularly scheduled basis. Based on feedback from the MOH, the clinics and the health care professionals that utilized the service, the schedule was expanded and changed in July 2008. Airborne continues to fly from Gaborone to Ghanzi, Hukuntsi and Tsabong, but added service from Francistown to Kasane, Maun and Gumare in 2009.

It is anticipated that this recently expanded service will continue in FY10, and that additional flights to certain overstretched hospitals such as, Ghanzi, Maun and Kasane, will be scheduled. Furthermore, service to additional medical facilities, such as Shakawe, New Xade, Ncojane, and Lethlakane will be created, should funds become available. Airborne would utilize a second smaller aircraft for the more remote additional clinics that have smaller airfields and poor land transport.

10.C.CT02: MOH - Counseling and Testing Unit - 200,000.00

During COP 09, PEPFAR provided funding and technical assistance to the Ministry of Health (MOH) to support the goal of expanding access to quality HTC services. Services were targeted to the entire population of Botswana, with special emphasis on the sexually active population aged 15-49. PEPFAR support to MOH is largely for the provision of provider-initiated testing and counseling also referred to as routine HIV testing (RHT), in all government facilities. PEPFAR also supports MoH in training of providers in couples counseling and testing (CHCT), development of IEC materials and provision of VCT services by selected CBOs. In 2009, the following were achieved:

- National HTC guidelines published and disseminated

- Development of the national counselor supervision program commenced with the training of 15 Master Trainers

- HTC providers were trained in CHCT

- The daily HTC register was developed and piloted in two districts

- CHCT and RHT curricula adapted to Botswana context

In FY10, PEPFAR will support MoH to carry out the following activities:

- Review and print the counselor training curriculum

- National branding of HTC services

- Support and mentor HTC providers on site

- Training in counselor supervision and CHCT

- Develop national CHCT strategy

- Promote and conduct testing during the following national HIV/AIDS events: National Month of Youth Against AIDS, the National Month of Prayer (September)

- Produce promotional materials and media activities to create awareness of HTC and support services

- Roll out the national M & E tools to all health facilities (i.e. the HTC register)

- Support the creation and improvement of referral linkages through the development of directories, tracking tools and systems

10.X.SI20: MOH - Capacity Bldg Surveillance - 150,000.00

Overall goal: Build district capacity to collect, analyze, and present data, as well as use the information for planning and advocacy.

As in many countries around the world, Botswana has invested heavily the past decade in collecting information about the human immunodeficiency virus (HIV) and the behavior that spreads it. PEPFAR, the UN family and other partner organizations have supported this investment and the country has been using guidelines detailing the principles of what is now known as second generation HIV surveillance, developed by the World Health Organization (WHO). Second generation surveillance includes biological surveillance of HIV and other sexually transmitted infections (STIs), as well as systematic surveillance of the behavior that spreads them. It aims to use these data together to build up a comprehensive picture of the HIV/AIDS epidemic.

By tracking the past course of the HIV/AIDS epidemic, warning of possible future spread, and measuring changes in infection and behavior over time, second generation surveillance is designed to produce information that is useful in planning and evaluating HIV/AIDS prevention and care activities. This objective has been met in many countries where useful, high-quality data are now available.

Nevertheless, a gap remains between the collection of useful data and the actual use of these data to reduce people's exposure to HIV infection and improve the lives of those infected. More effort has been put into improving the quality of data collection than into ensuring the appropriate use of data.

Collecting high-quality data is an important prerequisite to using them well, but why are available data not used better? One reason is that surveillance systems are often fragmented. This means that many departments or groups are responsible for various aspects of data collection. Each considers its job done after it has held its own "dissemination workshop." No single entity is responsible for compiling, analyzing, and presenting all the data as a cohesive whole. Furthermore, very few countries budget adequately for analyzing, presenting and using data in terms of either financial or human resources. When financial resources are allocated, people often underestimate the skills and time required to use data well. Many surveillance officials simply do not know how to use the data. This is hardly surprising because most often the people responsible for surveillance systems are physicians and public health professionals who are good at interpreting trends in disease, but who have limited training in the different ways HIV surveillance data can be used to improve programming, measure the success of prevention, lobby for policy change and engage affected communities in the response.

Specific Objectives

This activity aims to provide guidance in the following major areas:

- Improve surveillance data quality and data analysis

- Use data for program planning, program monitoring and evaluation, and advocacy. The activity will concentrate on the mechanics of using data, not just what can be done with data, but how it can be done (analysis) as well.

- Package data for different audiences, i.e., information communication strategies, who should be involved in dissemination, and what makes a good press release, how to produce a district report, develop interesting and persuasive presentations and present data effectively.

Targets

The targets of this project are the public health officials at district level (public health specialists, matrons, district program officers, information management officers, district AIDS officers, and DAC officers). An anticipated total of 240 people are targeted by this activity.

Geographic coverage

The project will cover all of the 24 health districts in Botswana.

Leveraging HIV resources

This activity will build the capacity of the district officials to monitor the epidemic and use the data for better HIV response programming. This will contribute to less reliance on the national surveillance unit's annual surveys and minimize the cost of monitoring the epidemic in the country.

Enhancing sustainability

The end result of this activity is to build capacity for data use at the district level. Once this objective is attained, the districts will be able to conduct the own HIV surveillance to monitor the epidemic and avail the information to decision makers at the district level for a prompt response.

10.X.SI23: MOH - DHAPC Strategic Information Support (Data Warehouse) - 41,640.00

The DPPME recently awarded a tender to Meditech to (a) upgrade IPMS to the latest version; (b) add additional modules to the existing modules; and (c) implement IPMS in an additional three hospitals, namely Ghanzi, Mahalapye and Molepolole (Scottish Livingstone). The DHAPC's Data Warehouse currently extracts data from IPMS, but this will need to be substantially modified to cater for the new versions of the existing modules that will be coming on line. New data extracts must also be developed for the new modules, as well as for the continued automation that will result from system maturation. A Meditech consultant with detailed knowledge of the new IPMS system will be required to ensure that the development of these extracts happens in an efficient and timely manner.It will then be necessary to travel to IPMS sites to train staff in data capture, conduct rudimentary data quality audits, provide feedback regarding the outputs from the data warehouse, and train staff on interpretation and processing of the site manager's report (produced from the Data Warehouse). Site visits will also be necessary in order to reconcile the uptake of data from the old systems into the new version of IPMS and audit the statistics produced from IPMS after the new deployments. In order to keep the Data Warehouse software current, QlikView and Microsoft licenses must be renewed every year to get the latest upgrades and support.

10.X.SI24: MOH - DHAPC Strategic Information Support (PIMS 2) - 38,360.00

Masa, with PEPFAR support, deployed the upgraded patient information management system (PIMS II) and trained staff in its use in ARV clinics across Botswana in FY09 and will continue to do so in FY10. This upgrade has more robust functionality, integral operation audit logs, improved data security and confidentiality, and greater capacity than the previous Access-based version (PIMS).

It will be necessary to undertake site support visits to PIMS II facilities to maintain the efficient operation of the system. These visits are envisaged to integrate training, data quality audits, and IT support. Support visits will be particularly needed at facilities that are identified though data analysis and/or validation as having challenges with quality data. These activities are planning to ramp up within the government, as partner support to this project begins to decrease.

10.X.SS29: NACA - Support to UB FHS, includes SOM, SON and SPH - 400,000.00

During FY2010 the President's Emergency Plan for AIDS Relief (PEPFAR) will support the development of public health education in the University of Botswana Faculty of Health Science through:

- the completion and continuation of activities planned for, and begun in FY2009;

- employing an expert consultant to assist the School of Medicine in the planning and implementation of a public health residency; and

- provision of resources and logistical backing to the School of Nursing to enable the delivery of a program to teach HIV/AIDS prevention, education and control and integrate it into University of Botswana curricula.

In recognition of the need for national capacity-building to ensure sustainable combating of HIV/AIDS, FY2010 will also see PEPFAR give support to five School of Medicine (SoM) initiatives directed at establishing a credible and high quality Faculty of Health Sciences teaching health system[1], including:

- family medicine where two district hospitals will be piloted as Family Medicine/Community Health Learning Centres. PEPFAR funding will provide ICT infrastructure (hardware and software) and specialist assistance in the planning and assessment of the requirements for setting up Centres at Maun and Mahalapye district hospitals.

- trauma and emergency care for which is required a coordinator working with SoM Trauma and Emergency Department and School of Nursing on operational planning and priority setting for establishment of an integrated teaching health system- wide program for trauma and emergency care.

- quality improvement in-patient care and theatre technology and process assessment in the referral hospitals that will require (i) a doctor-nurse team to provide advanced life support training and certification and (ii) a coordinator/educator (likely with advanced nursing training) to assess, evaluate and improve the processes within the operating theatres.

- infant and maternal mortality requiring technical assistance for study of the 2001 to 2009 mortality statistics leading to introduction of a position with responsibility for "oversight of labour services in the teaching health system".

[1] Relationships and collaborative activities involving the Faculty and the entirety of the health services of Botswana can be considered as a teaching health system, in relation to which the Faculty would pursue education, research and service functions. In practical terms, undergraduates, graduate trainees and academic staff will be distributed through the health care system

10.X.SS31: MOH - Health Inspectorate Strategic Planning - 200,000.00

The provision of quality health care services has long been one of the main challenges faced by the health system in Botswana. Until recently capacity constraints within the government have limited the approach to issues of health regulation, monitoring and evaluation of health service delivery and quality improvement issues to pragmatic ad hoc activities driven by the need to respond to incidents and crises rather than being grounded in an organized structured system. In order to address this deficiency the Health Inspectorate was established in 2005 by the Ministry of Health during its restructuring process, to undertake statutory and inspection related functions with respect to health care regulation and quality improvement.

The main objective of the activities listed below are to build the capacity of the Health Inspectorate to carry out its mandate to safeguard the general public by promoting and driving improvements in the quality and safety of health care to assist it to eventually become autonomous from Government.

1. Strategic Plan

There is an urgent need to develop a robust and long-term strategic plan that will result in a series of activities that will keep the organization relevant and responsive to the needs of the health system and contributes to its stability and growth.

2. Staff Training

In view of the fact that the staff of the Health Inspectorate have been drawn from various clinical backgrounds and do not have a background in health regulation or quality improvement, there is an important need to provide explicit structured training in these areas:

Quality assurance and quality improvement processes

Clinical and quality audits

Inspection, assessment and evaluation processes and the differences between them

Evaluation and analysis of facility self-assessment audits

Accreditation processes

Implementation and monitoring of standards

Development and refinement of operational tools

Clinical governance in the context of facility management

Report writing

3. Guidance in the preparation and drafting of health regulatory legislation

The Health Inspectorate has been charged with preparing material for legislation to govern its operation and the powers with which it will be invested. Whilst the final drafting of this legislation will be the responsibility of the Attorney General's Chambers, the Inspectorate is expected to provide the drafting instructions.

4. Creation and implementation of an effective incident and complaints management system

Patient safety matters are paramount and so the accurate, reliable and diligent recording of incidents and complaints involving patients, health care workers and members of the public so that they can be correctly managed is an essential component of good practice. An effective incident and complaints management system will be developed and implemented in all health facilities.

5. Development of standardized clinical guidelines for common conditions

To ensure that patients will receive the most appropriate treatment for their condition wherever they might be in the country, it is important that standardized clinical guidelines are developed for all common conditions. If implemented correctly this will guarantee best practice based on current evidence and will also accommodate assessment of hospital performance and clinical outcomes. Such information can be used not only for quality improvement purposes but also to inform government health policy.

10.P.AB23: MOH Faith based initiative - mega coag - 75,000.00

According to the first Botswana National HIV/AIDS Strategic Framework (2003-2009), faith-based organizations (FBOs) were to play a central role in addressing HIV/AIDS. As such, a FBO national strategy was developed to ensure a comprehensive and cohesive response to the epidemic. FBO is defined as any charity or non-profit organization aligned to any one of the world's major religions. In Botswana, FBOs are extremely well placed to respond the HIV/AIDS epidemic because they: (a) are based in both rural and urban settings; (b) have large followings and gather communities; (c) promote ethics and provide counseling on health, compassion and care; and (d) are highly trusted and revered by their communities. Religious leaders are central in their teachings on abstinence from all sexual involvement until marriage and faithfulness within marriage, both of which are in-line with the national response.

In FY07, PEPFAR supported a study to assess the capacity of FBOs to implement HIV prevention activities, which was followed by the development of the Ministry of Health's (MOH) FBO Strategy. The MOH proceeded to hire a consultant to develop an implementation plan yet rollout has yet to occur.

In FY10, MOH will be funded to strengthen FBOs that have already begun initiatives within their communities. Some of these activities will include:

establishing abstinence clubs;

conducting a training of trainers on abstinence education and counseling;

increasing age of first sex by promoting abstinence and virginity through primary schools and churches;

developing and disseminating HIV prevention and behavioral change communication; and

mobilizing churches and schools to promote abstinence, avoidance of premarital sex among youth, and faithfulness among married couples.

10.P.PM01: MOH - PMTCT Program Support - 650,000.00

This activity is to directly support the PMTCT program within the Ministry of Health (MOH). The support complements the Government of Botswana's efforts to build human resource capacity to manage the PMTCT program both at the national and district level.

The MOH's PMTCT Unit continues to provide leadership and coordination to the national PMTCT program towards the goal of universal access to comprehensive integrated quality PMTCT services. In collaboration with the MOH's Nutrition and Food Control Division (NFCD) and the Sexual and Reproductive Health Division (SRHD), the PMTCT Unit will strengthen its regulatory and supervisory functions, including implementing quality assurance mechanisms to ensure delivery of comprehensive and integrated PMTCT services, which reflect current scientifically-proven interventions.

In FY10, PEPFAR funds will be used to support the establishment of systems and mechanisms for stronger linkages and coordination across related programs. Through the PMTCT Technical Working Group, the PMTCT program will guide the national roll out of comprehensive integrated PMTCT services in addressing all the four PMTCT prongs, with special emphasis on primary prevention, provision of family planning services and partner testing and counseling.

Other significant activities will include training on early infant diagnosis using DNA-PCR on dried blood spots, enhancing post-natal care including improved follow-up, printing of the revised Botswana Training Package (BTP) and PMTCT guidelines, updating workshops for health workers and strengthening the referral system for continuum of care.

The BTP and PMTCT guidelines have recently been harmonized with the 2008 revised ART guidelines to provide health workers with the latest evidence-based PMTCT information and recommendations to enable providers to deliver quality PMTCT services. The revisions necessitate on-going and regular in-service training on PMTCT at all levels. PEPFAR will support workshops for 300 lay counselors, 150 trainers and 24 focal persons.

10.P.PM04: MOH - Family planning - 100,000.00

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 maternal and child health (MCH) clinics, but these data suggest problems in the uptake of family planning services and that unintended pregnancies among HIV-positive women are common. Although condoms are freely available in most facilities offering HIV counseling and treatment services, there is a need to integrate family planning serviceswith an emphasis on dual contraceptionnot only in MCH facilities but at all places of contact with people living with HIV/AIDS (PLWHA), particularly ART clinics.

With support from PEPFAR, the Ministry of Health's Sexual and Reproductive Health (SRH) Division made major progress in FY09, which saw the revision and printing of 100 family planning manuals incorporating HIV issues and the training of 49 health workers on these new guidelines. In FY10, an additional 200 health providers will be trained on the manuals. PEPFAR is a strong supporter of linkages between HIV/AIDS and voluntary family planning and reproductive health programs.

The need for family planning services for HIV-positive women who desire to space or limit births is an important component of the preventive care package of services for PLWHA and for women accessing PMTCT services. In FY10, through PEPFAR support, the SRH Division will work to expand access to SRH and routine HIV testing and counseling (RHT) services by co-locating the two services whenever possible. Efforts will be made to ensure facilities provide confidential RHT at family planning sites.

Another area that remains of major concern is cervical cancer screening. PAP smear screening remains sub-optimal; for example, in 2009, 25,497 PAP smears were done compared to 30,777 PAP smears in 2008. The main reason for the reduced numbers is because of untrained staff and lack of equipment. In FY10, the SRH Division intends to scale up training of health workers in PAP smear screening by training 150 staff and will ensure equipment is available in all health facilities providing SRH services.

10.P.PM05: MOH - Infant Nutrition Support - 500,000.00

The Ministry of Health's Nutrition Unit has made significant progress in training its health workers on growth monitoring, nutrition, management of severe acute malnutrition and the infant and the infant and young child feeding (IYCF) guidelines. Through PEPFER support, the program has managed to procure anthropometric equipment, comprising of 700 scales, 420 infant beam type scales and 210 mother/child scales that have been distributed to the districts. Additional scales have been ordered and are expected to arrive by March 2010.

The current IYCF policy states that HIV-positive women will be counseled about the risks and benefits of breastfeeding and formula feeding, and guided to choose formula only if it is acceptable, feasible, affordable, sustainable, and safe to do so. The WHO has just announced new infant feeding guidelines that recommend breastfeeding with the use of antiretroviral therapy. It is anticipated that the Government of Botswana will in turn adjust its infant feeding recommendations and thus additional trainings will be needed to support any new policies. In FY10, there will be 60 health workers engaged in the training of trainers program and 400 other health care workers trained on the new integrated IYCF counseling course.

It has been noted that advice given to HIV-positive mothers recommending replacement feeding has spilled over to the HIV-negative population. In light of this and the anticipated revised national guidelines recommending breastfeeding with HAART, health workers providing maternity services at ten hospitals will be trained in the Baby Mother Friendly Hospital Initiative. This initiative is an effort recommended by WHO to ensure that all maternities, whether free standing or in hospital, become centers of breastfeeding support.

Severely malnourished children are still seen frequently and health worker skills for managing these children are inadequate. In FY10, PEPFAR will support the scale up of training for 150 health workers on growth monitoring as well as 120 health workers for hospital-based and community-based management of severe acute malnutrition. This program entails provision of ready to use therapeutic foods to identified acutely malnourished children at health facilities. To aid in the proficient training of health workers and women, other supplies to be purchased include sterilizing units, breast pumps, graduated cups and body mass index calculators.

To improve the effectiveness of the adapted WHO/UNICEF training course, the Ministry of Health's Nutrition, Food and Control Division will print course materials, purchase teaching aids and produce IEC materials for mothers through PEPFAR support. PEPFAR will also support the printing and dissemination of child welfare cards that include HIV, PMTCT and nutrition information as well as the trainings of health workers to ensure appropriate distribution of such materials.

10.T.LS01: MOH - Laboratory Support - 338,175.00

In FY10, funds are requested to continue some of the activities of FY09 as follows.

1. Laboratory Information Management System (LIMS) Support

In FY09, a new laboratory-based Laboratory Information System (LIS) was piloted at four sites. In FY10, funds are requested to help roll out the LIS to six additional sites. The funds will be used for site assessments and for the procurement of scanners and printers for the sites.

2. HIV Rapid Test Support

In FY09, PEPFAR funds were used to support the evaluation of new rapid HIV test kits and revise the HIV training manual. In FY10, funds are requested to support the training of trainers (TOT) on the new testing algorithm.

3. Salary Support

FY10 funds are requested to continue support for the positions at the Institute of Health Sciences and the MOH laboratories.

4. Quality Assurance Support

In FY07, six laboratories were enrolled for the accreditation process with the South African National Accreditation System (SANAS), and two of these labs are now at the stage of applying for accreditation with SANAS. Progress, however, has been hampered by the lack of calibration and certification of equipment, including biosafety cabinets, centrifuges, balances, pipettes and timers. This has been a major setback in the accreditation process. Biosafety cabinets need to be validated annually. FY10 funding is, therefore, requested to assist the GOB in calibrating and certifying biosafety cabinets, pipettes, centrifuges, thermometers, timers and balances for the laboratories enrolled in the accreditation process.

5. The Upgrading of Laboratory Space

PEPFAR supported the construction of five pre-fabricated laboratories for Athlone Hospital, Princess Marina Hospital microbiology laboratory, the National Quality Assurance Laboratory, and the Letlhakane and Tutume primary hospital laboratories. The funds allocated for the construction of the laboratories, however, could not cover the costs of cabinet and storage space, basic laboratory furniture, and safety features, such as fire extinguishers and smoke detectors, in the laboratories. In FY10, funding is requested to upgrade the safety features in these laboratories.

10.T.AD01: MOH - Central Medical Stores Support - 6,712,500.00

Central Medical Stores (CMS) is a government entity, under the Department of Clinical Services in the Ministry of Health, responsible for managing the supply chain for all drugs, medical supplies, and essential health commodities used in the public sector.

There are currently 126 operational ART sites in Botswana, serving more than 93,000 patients, as of December 2008. CMS provides monthly ARV distribution services to all hospitals and District Health Teams, combined with the distribution of other medicines and health products.

ARV Procurement

CMS intends to use the majority of its funding (US$ 6,400,000) to procure ARVs for the public health system. A list of the ARVs that this funding will cover is included on the overleaf.

The total funding envelope for ARV procurement in the public sector includes the following streams:

- The PEPFAR budget, administered through NACA and implemented by CMS.

- The NACA budget (DDF), which is the government budget for ARV procurement.

- Donations for specific products or groups of products from the Clinton Foundation and ACHAP.

The PEPFAR budget used by CMS to procure ARVs since 2007/8 is as follows:

2007/8: USD 21,504,228

2008/9: USD 13,582,633

2009/10: USD 6,599,520

The total estimated cost of ARVs to be procured in 2010/11 is USD 44,983,291. The proposed figure for the CMS budget, therefore, represents 14.2% of the total need. The majority of the rest of the funding will come from the Government of Botswana's (GOB) budget through NACA.

Some breaks in the supply of ARVs were experienced in the last year, mainly due to long procurement processes, poor performance of suppliers, and changing demand patterns. The new management team at CMS (funded by PEPFAR through the SCMS project) is addressing these problems through the development of a new procurement strategy. The new strategy will involve framework contracts with suppliers, which will lead to a smoother flow of supplies and less reactive emergency tendering.

CMS will use ARV stock availability at CMS as the performance indicator for the use of this year's PEPFAR funding. The target will be 100% availability throughout the funding period.

Systems Strengthening

CMS proposes to use USD 312,500 to support two strategic projects during this funding period:

- IT systems transformation: this project is designed to transform the IT environment at CMS to support the CMS core operations more effectively. In particular, this project will address the interfaces between the finance, procurement and warehouse management systems in use, which have been identified as key bottlenecks to the improvement of CMS's performance.

- Security Systems Improvement: this project is designed to enhance the effectiveness of the security systems and procedures currently in use at CMS.

10.C.TB01: MOH - TB/HIV & IPT Support - 500,000.00

FY10 funds will support collaborative activities, notably integrated clinical management, treatment and strategic information, for both the Botswana National TB Program (BNTP) and the Department of HIV/AIDS Prevention and Control (DHAPC). Specifically, the budget provides salary support for all of the existing program personnel who are now positioned within the DHAPC. Funds for additional computers and related equipment reflect the urgent need to update old hardware systems that are no longer able to deliver reliable data on TB/HIV indicators. Laptops and personal data assistants (PDAs) will be used for training and improved data collection mechanisms, respectively.

As part of a new TB/HIV integrated approach, revision of current IPT policy and clinical guidelines will require printing, training seminars, and improved clinical monitoring. Efforts to launch the initial ten "Enhanced TB/HIV Sites" are reflected in the ten supervisory visits scheduled by DHAPC. Additionally, information, education and communication (IEC) material will be developed. The support and supervision for other TB/HIV activities will be focused in the other 19 sites/districts.

Quarterly TB coordinators' meetings will ensure the continued strict monitoring and evaluation of the TB/HIV activities by the central level, and mentoring of the district staff. Patient and heath care worker education will also be emphasized. Improved TB/HIV collaborative activities will need proper documentation to demonstrate best practices. This will be achieved through the development of the TB/HIV collaborative website, which in turn will allow routine program monitoring to be shared across sites and districts. Results from operational research will be shared in local and international scientific meetings, hence the budget for international travel for BNTP and DHAPC staff.

10.C.TB20: GOB - Bonela - 100,000.00

FY10 funds will be requested to support the salaries of one FSN and one contractor, and the travel costs of the FSN for site visits and attendance at regional and international meetings. Funds will also be requested to support the printing of the national TB/HIV guidelines and IEC materials, the maintenance and development of the electronic TB register (ETR.Net), the pilot project on mobile telephone technology for TB data transmission, and the procurement of one laptop and printer for use by the TB/HIV program officers. Contingency funds will be requested for anticipated requests for emergency IC measures, e.g., ultraviolet light fittings, fans, and respirators in the MDR-TB sites and in selected Infectious Disease Care Clinics (IDCCs).

FY10 funds will be requested to provide TA from CDC Atlanta for the following activities: the assessment of treatment outcomes among TB patients with INH mono-resistance; a pilot project to intensify TB case finding in the health facilities in Francistown; an intervention project on TB infection control in the national prison network; and a project to assess the transmission of TB in outpatient care settings that serve persons with HIV-infection and evaluate measures to reduce TB transmission in these outpatient care settings.