Context

The International Training and Education Center for Health (I-TECH ) envisions a world in which all people have access to high quality, compassionate and equitable healthcare .

I-TECH was founded in 2002 by HRSA in collaboration with CDC. It is a global network that supports the development of a skilled health work force and well-organized national health delivery systems, in order to provide effective prevention, care, and treatment of infectious disease in the developing world. I-TECH works primarily on activities that contribute to the achievement of PEPFAR.

Goals and Objectives

To provide technical assistance to strengthen government health systems and to ensure that healthcare providers deliver high-quality care for HIV/AIDS patients.

I-TECH will support ongoing health-workforce capacity-development activities in the program areas of laboratory, TB/HIV, continuing medical education, Prevention of Mother to Child Transmission of HIV (PMTCT), strategic information and in-service training.

Male circumcision and the lay counselor evaluations will continue with 2009 carryover funds.

HIV-Specific Objectives

To improve HIV/AIDS training programs and build the capacity of physicians in treating HIV+ patients

To build the capacity of national HIV training and coordinating unit at the Ministry of Health to ensure standardized and coordinated healthcare worker training

To increase access to laboratory tests

To build the capacity of healthcare professionals in treating TB-HIV co-infection

To improve quality of data relating to PMTCT through building human resources and organizational capacity to collect data

To directly reduce risk in HIV-negative males and, indirectly, reduce HIV in females through building capacity to scale up safe male circumcision (SMS) services; set standards and quality systems for long-term HIV prevention; and monitor and evaluate acceptance, performance, coverage, safety and impact of SMC services

To improve use of data for HIV policy decision-making through mentoring of 44 Information Management Officers (IMOs), providing technical assistance for two IMO supervisors, expanding the utilization of the District Health Information System and supporting two government-seconded staff

Geographic Coverage

All 28 districts throughout Botswana

Target Populations

Healthcare workers, both at the national and district levels.

Leveraging HIV Resources

I-TECH will work in partnership with other organizations to effectively support the Ministry of Health (MOH).

I-TECH has embarked upon a strategic plan to diversify funding through identification and securing additional funding from new donors.

I-TECH will establish legal and operational capacity for diversification by completing its registration as a local NGO in keeping with its plan to localize its staffing for sustainability of its programs.

Cross-Cutting Areas & Priority Areas

In collaboration with CDC, Global AIDS Program, the MOH, the Ministry of Local Government (MLG), and the University of Botswana (UB), I-TECH builds human and institutional capacity in training, strategic information, quality improvement, and program evaluation.

I-TECH supports the Botswana National Tuberculosis Program (BNTP) to provide training to various healthcare worker cadres on TB care and treatment.

Enhancing Sustainability

I-TECH's approach to partnership with MOH, MLG, and UB serves to enhance the Government of Botswana (GOB)'s capacity to provide high quality HIV/AIDS services to the people of Botswana. I-TECH's approach to sustainable programs is as follows:

I-TECH supports health systems strengthening in Botswana through development and strengthening of data collection and training systems, and the provision of technical assistance in operations research.

I-TECH will continue to develop capacity of MOH staff to deliver national health programs through assignment of 13 staff members to the Department of Policy, Planning, Monitoring & Evaluation; the KITSO Training and Coordinating Unit; BNTP; the PMTCT Unit; National Quality Assurance Laboratory; and Botswana Harvard HIV Reference Laboratory.

I-TECH will utilize its strengths in curriculum development, training, systems-strengthening, quality-improvement, and monitoring and evaluation to meet Botswana's HIV prevention strategy through rollout of SMC.

Monitoring and Evaluation

I-TECH Botswana will ensure appropriate monitoring of activities in each program area through quarterly reports documenting targets achieved, progress toward objectives, lessons learned and best practices. Reporting on activities conducted will be through existing reporting mechanisms, and will be submitted to BOTUSA. Progress and other requested reports will be provided as needed to BOTUSA.

10.C.AC20: I-TECH - STI Unit Staff - 138,000.00

Since 2004, the International Training and Education Center on HIV (I-TECH) has successfully collaborated with the Ministry of Health's National STI Training and Research Center (NSTRC) to improve management of Sexually Transmitted Infections (STI) in primary care settings nationwide. A national STI prevalence study conducted in 2000 found a high burden of STI, particularly genital ulcer disease (GUD), in Botswana. Given concerns about the synergistic relationship between HIV and other STIs, it has been a priority of the MOH to reinforce STI management using a syndromic management approach, including the introduction of acyclovir for treatment of symptomatic genital ulcer disease. I-TECH has assisted the NSTRC to roll-out a proven training package on the revised national STI syndromic management guidelines, including routine HIV testing (RHT) of clients as well as risk reduction counseling. I-TECH has also supported the NSTRC to strengthen supportive supervision and monitoring and evaluation of STI services, through training of district trainers in these areas and through support to the implementation of a routine facility checklist related to quality of STI care. In 2007, I-TECH began supporting the NSTRC to implement clinical mentoring among their district trainers and health care providers. Over 60 STI clinical mentors have been trained and will continue to support improvement of STI quality of care.

In COP 2010, I-TECH requests funds to support two positions, Principal Health office 1 and Principal health officer II in the National STI Control Programme of the Ministry of Health. These officers will function as focal persons for STI/HIV contact tracing and Most at Risk Population projects/initiatives.

These officers will build on the STI training, clinical mentoring and capacity building work supported by I-TECH in previous COPs.

MoH will provide transport and subsistence for district support visits of these officers.

10.T.AT02: I-TECH Continuing Medical Education courses - 100,000.00

Botswana was one of the first countries in Africa to establish a national ART program for the provision of free treatment. The ART program has contributed to HIV infection becoming a chronic condition. With more and more people surviving the HIV infection and with ongoing research into providing care for PLWHA, the medical field is rapidly changing to meet these challenges. In response to this challenge, the MOH and the Botswana-Harvard AIDS Initiative Partnership developed the KITSO training program that uses a five-day basic course and a three-day abbreviated course to train providers. Continuing medical education opportunities to ensure that private practitioners who are trained in the provision of ART keep abreast of the rapidly changing world of HIV prevention, treatment and care remain critical. I-TECH, through its CME sessions, aims to complement the KITSO training program and the other in-service training programs that are available. I-TECH began conducting annual CME sessions in 2005, providing critical updates and exploring in-depth scientific perspectives on advanced issues in HIV care. I-TECH collaborates with the Associated Fund Administrators (AFA) to identify private and public practitioners for these CME sessions. I-TECH requests funding to conduct quarterly CME sessions on advanced HIV treatment and care topics for both public and private sector medical providers at each of the three sites. Continuing Medical Education This activity continues to complement the Botswana national KITSO training program by providing a series of didactic and skill-building workshops to medical providers, including physicians, pharmacists, and nurses, on six advanced HIV/AIDS topics. I-TECH will offer CME workshops on two topics in Gaborone, Francistown and Maun. For each topic, a local or regional clinical expert will conduct interactive workshops, present recent clinical research findings and optimal care practices, including relevant Botswana national treatment guidelines, and utilize cases that demonstrate relevant clinical decision-making. The trainer will also facilitate discussion of actual Botswana cases brought to the workshops by participants. I-TECH staff will ensure that each CME session is grounded in specific, relevant learning objectives, is clinically accurate, and applies the best practices on interactive teaching and learning. I-TECH will also evaluate all CME sessions to inform improvements as each topic is repeated and as the CME series continues over time. The resources required to sustain the CME series include staff time and logistical costs for the sessions (staff travel, venue rental, refreshments, and printing of materials).

10.X.SI10: I-TECH - M&E Support - 400,000.00

I-TECH will continue its activity in the area of strategic information during FY10 at a scaled down rate as compared to preceding years. This activity will focus on three main project areas that include supporting one senior technical position at the DHAPC in the MOH, strengthening capacity at the MLG level for continued training and mentoring of information management officers (IMO), and supporting the enhanced deployment of district health information management systems (DHIS). FY10 funds will be used to finalize activities related to training and mentoring of IMOs with the focus on ensuring that materials and systems are in place for the MLG to takeover the full responsibility. I-TECH will develop self-directed learning modules that can be completed independently by newly hired officers as a first level of standardized, non-resource intensive training. Two additional sets of self-directed learning modules will also be developed for on-the-job training after the officers have been posted. I-TECH will develop a basic orientation and training curriculum and four more editions of the 'M & E Focus' newsletter. Additionally, I-TECH will work with the MLG and other partners to develop a minimum package of data management, use, and analysis activities that should be completed by the M & E Officers on a periodic basis. I-TECH will work collaboratively with their partners to conduct a process evaluation of the M & E Officer placement at the district level. The evaluation will provide systematic data on lessons learned, opportunities missed, and future directions. To share this innovative project with national and international organizations, a video documenting the process will be developed. Finally, through the secondment of a senior epidemiologist at the DHAPC, I-TECH will help strengthen surveillance systems and build local technical skills.

10.X.SI15: I-TECH - HMIS Middleware - 250,000.00

The GOB currently has numerous separate health information systems being utilized throughout the HIV response. Although these systems contain vast amounts of data, there is no mechanism that allows the systems to share relevant and synonymous data. This poses challenges for staff working with patient records and all other systemic data that reside on multiple systems which need to be harmonized. As time progresses, the rising costs of service delivery create a need for the more effective and efficient use of resources through integrated service delivery models. Integrated health systems are widely considered to provide superior performance in terms of quality and safety as a result of effective communication and standardized protocols. PCI, through a partnership with BAPL, proposes the creation of a health data messaging service that could be viewed as a 'post office' where each health information system could communicate via a standardized interface. The plan would allow all participating information systems to deliver specific records to the 'post office' that other systems would then access and programmatically use to update associated relevant records on their own systems. This interface would use the HL7 health system interfacing language. This system would facilitate system-wide coordination of all clinical data. This solution, utilizing open source technology (Mirth HL7 messaging software), is a cost effective mechanism of achieving the desired functionality. In the upcoming year, BAPL will integrate the new patient information management system (PIMS II) with an SMS messaging platform, BOTS 1.2, to show that mobile network and SMS technology can be used to connect different systems and facilitate seamless communication between them. This would allow the patient level tool to utilize the specialized libraries of the SMS tool to send SMS reminders as required, without needing significant redevelopment of the large and complex PIMS system. From there, the way forward would involve linking in the new laboratory information management system, blood banking software, and other patient level tools, the aggregate level tools and the TB tools with an aim of creating a single network, instead of the siloing that currently exists.

10.X.SI16: I-TECH - DHIS Support - 200,000.00

I-TECH will continue its activity in the area of strategic information during FY10 at a scaled down rate as compared to preceding years. This activity will focus on three main project areas that include supporting one senior technical position at the DHAPC in the MOH, strengthening capacity at the MLG level for continued training and mentoring of information management officers (IMO), and supporting the enhanced deployment of district health information management systems (DHIS). The DHIS system has been fully deployed to the health district level, but is currently experiencing problems with a lack of use. With this funding, I-TECH will support increased utilization of the DHIS software. This will include meeting with the DHIS TWG, conducting a rapid assessment, and working with the TWG to develop and assist in implementing an operational plan to increase the programmatic use of DHIS. STTA may also be required to customize the output reports and plan for more effective use of the data. I-TECH will leverage the IMOs and the IMO training plan extensively in this process as well.

10.X.SI22: I-TECH - Financial Manager & IT - 150,000.00

10.X.SS16: I-TECH - In-service Training Technical Assistance - 300,000.00

This is a continuing activity that aims to build the capacity of the training unit in the Department of HIV/AIDS Prevention and Care in the Ministry of Health (MOH). Funding and support for three training unit staff seconded to MOH, development and dissemination of national training standards and tools and the maintenance of the Resource Center will continue. Since the beginning of the epidemic, the Government of Botswana has responded proactively and rapidly to the HIV/AIDS epidemic by training health care professionals to provide HIV/AIDS prevention, treatment and care services. A wide range of trainings and training materials were developed by various partners involved in HIV prevention, care and support. The KITSO training coordination unit (KTCU) of the Ministry of Health was established to coordinate all in-service HIV trainings. I-TECH has been supporting the KTCU since 2007. Systems Barriers Despite the creation of coordination unit, human resources to support this unit have remained a challenge. I-TECH support for three positions in this unit has been in an effort to support this challenge. I-TECH supports a training assistant, a resource center coordinator and a data manager for the training information system. In an effort to ensure comprehensive, standardized, coordinated HIV/ AIDS training, I-TECH collaborated with KTCU to develop national training standards. These standards were finalized in FY09. The training standards provide minimum requirements for the provision of HIV/AIDS in-service trainings for health care providers in Botswana to ensure quality, effectiveness, harmonization and standardization of training. These standards cover the entire spectrum of the provision of in-service training -Assessment, Design, Development, Implementation and Evaluation of training programs and events (ADDIE). I-TECH will continue to work with KTCU to develop and disseminate tools for monitoring the training standards. The training standards and any curricula that meet these training standards will be posted on the DHAPC website. I-TECH will continue to support the Training Information Management System (TIMS) through salary support of the data manager. LinkagesKTCU will explore how TIMS could be linked to the iHRIS being developed by DPPME. The HRIS has individual health worker information; by linking this information with TIMS, district management will at a glance be able to identify which individuals have attended specific trainings. The resource center will continue to link with all other units in DPHAC as a way of sharing existing documents, including approved curricula both within department and with the general public.

10.X.SS35: I-TECH: PPP - NIIT SI Positions in Districts - 360,000.00

At district-level and facility-level, there are a numerous health information systems in place to collect and use patient-level data as well as electronic systems focusing on aggregate-level data to monitor the national response addressing HIV/AIDS. These electronic data systems are serving a critical need in terms of patient care as well as monitoring and evaluation. However, the shortage of qualified IT personnel at the district-level is an impediment to the efficient and effective use of the IT systems in place throughout the country. IT is a scarce skill in Botswana, making it a challenge to find suitably qualified personnel at the district level who can provide much needed IT support so that systems operate as intended. Moreover, the mobility of personnel with these skills is very high and so there is a retention problem as well. I-TECH proposes to work with NIIT (a tertiary education college offering certificate, diploma and degree programmes in IT) as part of a Public Private Partnership to help ensure that sufficient IT support is available for the District Health Team (DHT) and the Districts Aids Councils (DAC), the major players in the implementation of the various HIV initiatives. Specifically, I-TECH will work with NIIT and GOB to develop and implement a one-year district-level IT internship program for NIIT graduates. I-TECH will provide strategic and technical guidance in the development of the implementation and monitoring plan for the project. I-TECH will also pass-funds through to NIIT for the implementation of the project. NIIT will be responsible for overall administration, implementation, and monitoring of the project. NIIT will contract graduates for a year-long assignment as district IT Interns. These graduates will be guided and supervised by senior personnel from NIIT in addition to the administrative support that will be provided to the project. The NIIT supervisors will also assess the performance and development needs of these graduates and provide them with relevant additional training, if required. NIIT will provide I-TECH and the funding agency with quarterly reports of the relevant activities at the various districts.

10.C.TB15: I-TECH - Co-morbidity of HIV - 300,000.00

Tuberculosis is a serious public health problem in Botswana. In 2007, the case notification rate was 477 per100 000. The 2006 and 2007 HIV surveillance data estimate the TB/HIV co-infection rate to be between 60% and 86%. In response to this public health challenge, I-TECH has supported the Botswana National TB Program (BNTP) through the development of TB training and mentoring materials based on the National TB Program manual. To support the training rollout, I-TECH seconded two master trainers to the MOH/BNTP. The role of the two trainers is to develop the capacity of health care workers to provide care for TB/HIV co-infected patients using the training of trainers (TOT) model. Trainers are trained in every district and they in turn are to conduct cascade trainings within their own districts. As of October 2009, over 600 health care workers had been trained. Despite the large numbers of health care workers trained, the quality of the management of TB/HIV co-infected individuals has remained poor. To complement the training program, in FY09, I-TECH recruited two clinical mentors to help bridge the gap between the training and the clinical practice. While many of the shortcomings identified were policy and structural issues, most can be addressed through training and support. In FY10, I-TECH will continue to support both the training and the clinical mentoring programs. The Government of Botswana will fund the costs of the training, while I-TECH will support the per diem and lodging costs for the trainers. Major FY10 activities for which I-TECH is requesting funding include: (1) support for the salaries, benefits and professional development of four BNTP staff; (2) two district TOT workshops with 20 participants per training, as a response to the high attrition rate, with the master trainers supporting the district cascade trainings; (3) a TB clinical mentoring program where two mentors will spend at least two weeks in each of the eight districts selected for mentoring.

10.P.PM08: I-TECH - PMTCT Data Quality Improvement - 500,000.00

This is a continuing activity that aims to build the capacity of the PMTCT Unit in data collection, management and analysis. In FY10, I-TECH will support the roll out of the PMTCT data collection tool and seven registers, both of which were piloted in FY09. District health care workers (HCWs) will be trained to accurately use the new tools. I-TECH will collaborate with the PMTCT Unit to develop Standard Operating Procedures (SOPs), which will guide the district HCWs in using the new registers. FY10 funds will be used to cover conference facility costs for 39 workshops for training district health care workers (lay counselors, site facilitators, data clerks, midwives and nurses), in the country-wide roll out. In order to ensure high-quality structured and standardized trainings, the trainers will undergo a five-day training-of-trainers course before embarking on district trainings. I-TECH will support salaries, per diem and lodging for the six training officers, who will conduct training (two months) and support visits (three months) to mentor HCWs and carry out data audits during the roll out. To ensure sustainability upon completion of the roll out, the district PMTCT focal person and both the District AIDS Coordinating Office (DAC) and District Health Team (DHT) M & E Officers will also be trained and will form part of the teams that will conduct the trainings and support visits in the districts. I-TECH will also continue to support the secondment of a Data Manager to the PMTCT Unit.

I-TECH will provide support to the PMTCT Unit and the Data Manager in ensuring that ongoing data audits are performed to ensure quality and completeness of data. The Data Manager will elaborate protocols for quality control. I-TECH's PMTCT Officer will provide support to the Data Manager to identify strengths and weaknesses in the data and to problem-solve systems-related solutions to ensure utility. I-TECH will also ensure the new data collection tools are integrated into existing mentorship and support of the M & E Officers and their work with HIV Program Officers. Funding will also continue to support the subcontract with Data Management Systems (DMS) to input early infant diagnosis (EID) data to help clear the backlog.

10.T.LS03: I-TECH - Laboratory Positions Support - 140,000.00

In order to strengthen the capacity for laboratory management, quality assurance of laboratory testing, and access to pediatric HIV diagnosis, funding is requested to support the following activities: Human Resources: -Salary support and professional development for three positions at NQA Laboratory. - Support for training of laboratory scientists at the CDC/NICD training center in South Africa - Salary support and professional development for a laboratory scientist position at BHHRL. -Salary support and professional development for the Head of the Department of the Medical Laboratory Sciences. -Professional development opportunities for laboratory scientists and technicians. Development of Training Modules: Technicians admitted into the B.Sc. (Medical Laboratory Sciences) program are weak in the areas of research methodology, biostatistics, and protocol design. This has handicapped their ability to cope with some of the most important required courses, including their research projects and genetics. I-TECH is requesting funding to support curriculum development of a two-week intensive, modular-based course in research methodology for the students. The support will be for the development of three modules (Research Methods, Introduction to Biostatistics, and Protocol Design). Training will be conducted by lecturers at the University of Botswana.