I-TECH is a collaboration between the University of Washington (UW) and the University of California, San Francisco (UCSF). I-TECHs mission emphasizes working with local partners to develop skilled healthcare workers, strengthening national health systems, and ensuring sustainability by promoting local ownership. I-TECHs strengths lie in the areas of health system strengthening, health workforce development, operations research and evaluation, and prevention, care and treatment of infectious diseases. Since 2004, I-TECH's overall goal in Botswana is to provide technical assistance to strengthen government health systems and to ensure that health care providers across the public and private sectors deliver high-quality care for HIV/AIDS patients in Botswana. I-TECH works in collaboration with the Centers for Disease Control and Prevention Global AIDS Program in Botswana, the Botswana Ministry of Health, the Ministry of Local Government, and the University of Botswana in the areas of health service delivery, human resources for health, and research.

I-TECH has also established strong linkages with other partner organizations such as the African Comprehensive HIV/AIDS Partnership (ACHAP), Botswana Harvard Partnership (BHP), Population Services International (PSI), Johns Hopkins program for international education in gynecology and obstetrics (jhpiego),Botswana University of Pennsylvania (UPENN) Partnership (BUP), and Associated Fund Administrators (AFA) in the private sector. I-TECH Botswana supports programs in care and support, prevention of mother to child transmission (PMTCT), tuberculosis (TB/HIV), laboratory infrastructure (LAB), strategic information (SI), and other health systems strengthening (OHSS).

I-TECH has successfully collaborated with the MOHs National Sexually Transmitted Infections (STI) Training and Research Center (NSTRC) to improve management of STI in primary care settings in Botswana. I-TECH assisted the NSTRC in designing and implementing a training package on the revised national STI syndromic management guidelines and the STI training curriculum. I-TECH also helped train more than 5,000 HCW using the STI curriculum and strengthened the NSTRCs supportive supervision and monitoring and evaluation capabilities by training district trainers. In 2007 I-TECH began supporting the NTSRC to implement clinical mentoring among their district trainers and healthcare providers. I-TECH also supported the STI unit to develop useful training materials including the STI Trigger video, and the Sensitive Pelvic Examination video. The STI program illustrates the two core principles of GHI namely building sustainability through health system strengthening and encouraging country ownership and investing in country led plans. In FY 2010, I-TECH supported salaries for an STI Regional Coordinator and Principal Health Officer working with most at risk populations (MARPS). In FY 2011, I-TECH supported the salary for the STI Principal Health Officer (PHO). With I-TECH providing technical assistance, the STI unit developed guidelines for sexual partner tracing (SPT) and distributed SPT slips to 29 districts. Through I-TECH support, an operational plan for MARPS was developed and 20 health care workers (HCW) and 10 peer educators were trained to provide services to MARPS. Sex workers in Gaborone and Tlokweng were screened to establish baseline information. In FY 2012, salary support will be provided to the STI PHO. The PHO will assist with the coordination and implementation of STI activities including supportive supervision, clinical mentoring, HIV/STI surveillance, support of the NTSRC, and monitoring and evaluation of STI programs. In FY 2012, I-TECH will second a womens health program manager (WHPM) to the Department of Public Health at the MOH to scale up cervical cancer see and treat implementation. The scale up was recently sanctioned by the MOH after a successful pilot conducted by the Botswana UPenn Partnership proved that see and treat is a viable option for Botswana. The WHPM will conduct a needs assessment, develop a comprehensive operational plan together with other stakeholders, and oversee implementation and coordination of activities related to the scale up. There are no direct PEFPFAR targets for these seconded positions. I-TECH successfully transitioned and integrated the STI activities it supported into the STI unit at the MOH. I-TECH will ensure a transition plan is developed for the absorption of the seconded STI PHO. I-TECH will ensure the cervical cancer see and treat operational plan has key stakeholder buy- in.

Tuberculosis (TB) remains a major public health problem in Botswana. The 2009 prevalence rate according to the World Health Organization was 694 per 100,000 while the co-infection rate with HIV was 66%. Multi-drug resistant TB (MDRTB) is also on the rise with an estimated 220 and 150 cases among new and retreatment patients respectively. Results from MDRTB studies indicate that Mycobacteria other than tuberculosis (MOTT) contribute to a number of pulmonary infections and are treated with ineffective TB treatment regimes. I-TECH supports the Botswana National Tuberculosis Program (BNTP) in line with the GHI core principles of building sustainability through health system strengthening, promoting learning and accountability through monitoring and evaluation (M&E), and accelerating results through research. In 2007, I-TECH helped develop a TB training curriculum for healthcare workers (HCW) in collaboration with several partners. Over 3,000 HCWs have since been trained using the curriculum. In subsequent years, I-TECH has supported clinical mentoring in four districts and improved clinical outcomes for patients with TB. I-TECHs M&E support has improved data quality and strengthened national systems. TB data is currently utilized to make programmatic decisions in all districts in Botswana. I-TECH is currently conducting research on MOTT to better understand the epidemiology of the disease and associated risk factors in Botswana as well as to provide appropriate treatment options. In FY 2012, I-TECH will continue to support five seconded positions at the BNTP, namely physician trainer, physician mentor, nurse trainer/mentor, M&E specialist, and M&E understudy. I-TECH will conduct four national TB clinical case management trainings for 100 HCW, two TB/HIV training of trainers for 50 HCWs, and four MDRTB clinical seminars for 100 TB clinicians. Mentoring support will expand to 13 districts. M&E systems will continue to be strengthened both at the national and district level through regular data audits and feedback. I-TECH will conclude the MOTT study during FY 2012. I-TECH will develop and finalize plans for transitioning seconded positions and programs to the MOH consistent with PEPFAR II and GHI goals. The PEPFAR indicator relevant to these activities is H2.3.D number of HCW trained who successfully completed an in-service training program. I-TECH has established strong linkages with other organizations that play important roles in supporting BNTP activities including the African Comprehensive HIV/AIDS Partnership (ACHAP), Botswana UPENN Partnership, and the Global Fund. BNTP leads all TB programs thus ensuring local ownership and sustainability. I-TECH will work with BNTP to ensure that the MOH absorbs seconded staff and that appropriate capacity is built within the unit.

The HIV/AIDS epidemic in Botswana has resulted in a need for highly skilled laboratory personnel who have specialized diagnostic and management skills. The MOH has made training and placement of medical laboratory scientists a top priority. I-TECH has utilized its extensive global experience in strengthening laboratory services to support MOH and the University of Botswana (UB) in addressing this need. I-TECHs support for laboratory infrastructure is in line with GHI core principles of building sustainability through health systems strengthening and encouraging country ownership and investing in country-led plans. In 2007, I-TECH seconded a laboratory scientist to the Botswana Harvard HIV Reference Laboratory (BHHRL) to build capacity through training and to perform DNA PCR testing for HIV-exposed infants. In 2008, in collaboration with the UB and MOH, I-TECH supported the establishment of a Bachelor of Science (BSc) degree in medical laboratory sciences (BSc MLS). Quality assurance and quality control (QA/QC) are critical components of good laboratory practice. Since 2008, I-TECH has collaborated with the national quality assurance laboratory (NQAL) to strengthen QA/QC activities in Botswana by seconding key staff to the NQAL. Three seconded laboratory scientists perform QA/QC activities and build capacity of laboratory and non-laboratory based health care workers (HCW) in testing and good laboratory practice. I-TECH has achieved several notable accomplishments. Since the onset of support, DNA PCR turnaround times at the BHHRL have dropped from six weeks to one week. DNA PCR specimen rejection rates have dropped from 6% to 2% due to rigorous training of HCW. I-TECH staff at the NQAL has trained over 1,800 laboratory and non-laboratory based HCWs in rapid HIV testing. All public laboratories in Botswana participate in proficiency testing and QA/QC pass rates for laboratories have increased from 49% to 98 %. Three public laboratories in Botswana are now accredited; a number of others are working towards accreditation. At UB, I-TECH seconded three key personnel who have developed and supported a one-year bridging program which aims to upgrade laboratory technicians to laboratory scientists. A total of 29 laboratory scientists have graduated from two intakes so far. A third intake of laboratory technicians has recently joined UB and will graduate in 2012. Meanwhile a four-year BSc MLS curriculum has been developed at UB through I-TECH support in order to further augment the bridging course and produce more laboratory scientists. The first intake for this program will commence in August 2012. In FY 2012, I-TECH will support salaries, travel, and professional development of three laboratory scientists at NQAL, one laboratory scientist at BHHRL, and the program coordinator at UB. There are no direct PEPFAR indicators for I-TECH seconded positions. I-TECH has strong linkages with other stakeholders in laboratory programs such as the Institute of Health Sciences and the American Society of Microbiology. I-TECHs laboratory programs strive toward sustainability. Through pre-service training and other capacity building activities, Botswana will have a skilled workforce that will support laboratory systems into the future. I-TECH will work closely with the MOH and UB to develop a transition plan for seconded positions and programs.

Health data is critical for ensuring accountability, appropriate policy formulation, program improvement, and appropriate resource allocation. However, in Botswana, monitoring and evaluation (M&E) is a relatively new field and health information systems are not well harmonized. Strengthening strategic information systems within the Ministry of Health (MOH) will benefit not only HIV/AIDS programs but also other public health programs targeted by the Global Health Initiative (GHI). I-TECH is well-positioned to support strategic information (SI) activities due to its achievements in support of national surveillance systems, national M&E systems, and national Health Information Management Systems (HIMS).

Since 2007, I-TECH played a key role in developing a new M&E cadre: district M&E Officers. I-TECH successfully transitioned this project to the Government of Botswana in FY2010. Since 2008, I-TECH has provided technical assistance to the MOH through the secondment of a Senior Epidemiologist and M&E Specialist. In 2009, I-TECH also conducted a national Data Quality and Data Flow Assessment to inform SI needs. I-TECH has worked with the MOH to upgrade the District Health Information Systems (DHIS) software to a web-based version. Additionally, in 2010, I-TECH collaborated and subcontracted to a local partner, the Botswana Association for Positive Living (BAPL), in the creation of a health data messaging service to improve HIMS interoperability.

FY 2012 funds will continue to support national surveillance, M&E, and HIMS activities which are in-line with the GHI philosophy of helping to build on and expand existing country-owned platforms.

To strengthen surveillance systems and build local technical skills, funds will be used to continue seconding a Senior Epidemiologist to the Department of HIV/AIDS Prevention and Care as well as an M&E Specialist to the Department of Health Policy, Planning, Monitoring, and Evaluation (DHPDME). Plans to fully transition these positions to the MOH will be finalized. Additional support to DHPDME will include building the M&E capacity of the District Health Management Teams; increasing the use of the DHIS; and improving the timeliness of national morbidity and mortality statistics.

I-TECH has built strong partnerships with multiple organizations working to strengthen strategic information (SI) systems in Botswana and will continue to utilize these resources to build support for the implementation of SI activities. I-TECHs experience with district M&E systems will be utilized to support activities related to strengthening DHPDME.

There are no relevant PEPFAR indicators for these activities.

Transition plans will be finalized for the MOH to absorb or graduate seconded staff positions. Country ownership will be promoted by aligning activities with country-owned plans and objectives related to SI. The implementation of new technologies related to HIMS is in-line with the GHI philosophy of innovate for results.

The Ministry of health like many other government entities faces serious project implementation challenges. Among the worst affected have been donor funded projects which in most cases have lacked internal oversight and leadership to ensure that they are delivered on time and on budget. In light of this, in 2009, MOH established a project management office (PMO) to help plan, manage and coordinate MOH projects. In 2011 the PMO evolved into an office of strategy management (OSM) which is expected to provide a comprehensive solution to the problems of project management and operational strategy. The success of the OSM is dependent on strong leadership and project management expertise.

I-TECH continues to meet the GHI goal of collaborating for impact by supporting strategic secondments at MOH.

Since FY 2011, I-TECH has seconded the manager in the OSM to oversee MOH strategy development and implementation of critical initiatives through project management and performance improvement measures. In addition, I-TECH has seconded a Finance Advisor to the MOH department of HIV/AIDS prevention and care (DHAPC) to monitor and strengthen systems for effective utilization of PEPFAR funds.

In FY 2011, I-TECH provided technical assistance to begin building the capacity of the MOH OSM and PMO to lead strategic planning and develop a country-owned plan that improves coordination among the Government of Botswana, donors, and partners. In addition, priority MOH projects were scoped with MOH department and project leads and the management of these key projects commenced. In the same fiscal year, I-TECH built the MOH DHAPC capacity to effectively budget, monitor, and report on PEPFAR expenditures, with a goal of improving programmatic implementation and fiscal management.

FY 2012 funds will be used to continue to second the manager of OSM to oversee MOH strategy development and implementation and to second the DHAPC Finance Advisor to monitor PEPFAR expenditures and strengthen systems for effective utilization of funds. Linkages with MOH departments, PEPFAR and other donors have been established as a result of OSM activities. The Finance advisor has forged partnerships with the National AIDS Coordinating Agency (NACA) and MOH constituents receiving PEPFAR funds.

Secondment of the OSM manager is a key investment in a country-owned and coordinated health plan for long-term sustainability. Secondment of the Finance Advisor builds DHAPCs capacity to manage funding for effective program implementation.

I-TECH will work closely with the MOH on a transition plan for these secondments in FY 2012.

In 2007, the MOH introduced a PEPFAR-supported wellness programme to ensure the wellness of healthcare workers and improve employee morale and productivity. It is anticipated that the wellness program through its productive employees will meet the goals of the OSM. In keeping with the GHI philosophy of innovate for results, it is important to evaluate this approach to improving the effectiveness and sustainability of the healthcare system. I-TECH is well-positioned to conduct this evaluation, having completed several other national evaluations in Botswana. In FY 2012, I-TECH will conduct an evaluation of the Wellness Program to document the outcomes and achievements, identify areas for program improvement in Botswana, and provide guidance for other countries implementing similar programs.

There are no PEPFAR targets relevant for these activities.

Prevention of Mother to Child Transmission (PMTCT) coverage and effectiveness is a PEPFAR program priority for FY 2012. Through support from PEPFAR, the Government of Botswana and other partners, Botswana boasts a very robust PMTCT program, with uptake reported at 94% in 2010. In line with the Global Health Initiative philosophy of do more of what works, it is important to continue to support the PMTCT program. To maintain the gains on this investment, it is critical to ensure that national, district, and clinical site levels have the capacity to routinely collect high-quality data and use this data to monitor the quality of PMTCT services. Since FY 2008, I-TECH has been involved in a number of activities to support improvements in PMTCT data quality, management, and utilization.

I-TECH has supported the PMTCT Data Manager position at the Ministry of Health (MOH) since October 2008. This includes supporting the Data Manager to provide training and supportive supervision in the field. I-TECH also supported the revision of the national PMTCT data collection tools and registers to ensure that these instruments were relevant and in-line with revised treatment guidelines. Additionally, I-TECH has supported the rollout of an electronic medical records system to improve capture of patient-level PMTCT data. To improve data use, I-TECH provided training for national PMTCT staff on the use of statistical analysis software. Finally, I-TECH has engaged Document Management System (DMS) to conduct ongoing entry of data related to early infant diagnosis. In FY 2010, I-TECH began the process of transitioning this activity to the MOH.

In FY 2012, funds will support the secondment of the Data Manager to the PMTCT Unit. Funds will also support the Data Managers quarterly travel to the field to conduct data audits and provide training and support to the districts and facilities. Funds will continue to support a vendor agreement with DMS for entry of early infant diagnosis data.

I-TECH will ensure that initiatives to improve PMTCT data quality and use are integrated into Strategic Information activities through work at the national-level with the Department of Policy, Planning, Monitoring, and Evaluation and through work at the district-level with Monitoring and Evaluation (M&E) Officers.

The PEPFAR indicator relevant for these activities is H2.3.D: Number of health care workers who successfully completed an in-service training program (PMTCT). The target will be 60 health care workers trained by the Data Manager on activities related to data quality and data use to ensure implementation of quality PMTCT service provision.

To promote sustainability, FY 2012 activities will include transitioning activities conducted by the Data Manager and by DMS to MOH by the end of the year. During the year, the PMTCT Data Manager will continue to provide training and build the capacity of health care workers in the districts and at the facilities to be able to effectively utilize the data systems. This will strengthen the PMTCT program further.