Mother to Mother (M2M) Training and Supervision Support

In FY 07, JHPIEGO will establish Mothers to Mothers (M2M) referral linkages between hospitals delivering PMTCT services and M2M Support Groups supported by IntraHealth (10633) in the community. In addition to establishing referral linkages with community based M2M services, JHPIEGO will support IntraHealth's activities through training and supportive supervision. JHPIEGO will also form M2M Support Groups, based on IntraHealth's existing program, in Networks where IntraHealth is not currently working.

The M2M groups are primarily established by IntraHealth as referrals from the PMTCT services both at hospital and health center level: mothers who are found HIV+ join a support group with other mothers. The support group will have from 8 to 12 HIV+ pregnant women as members. Each support group will have regular meeting at least once every 2 weeks and will focus on key aspects of HIV care and other related available services for HIV+ pregnant women and infants in the facility and in the family. The support groups will be led by Mothers who are both educators and counselors and will have the flexibility to fit specific facility circumstances and will be linked to other programs. JHPIEGO will assign points of contacts and will establish referral linkages at 15 Networks where IntraHealth is not working. That will enable facilities to effectively refer and link HIV+ mothers to M2M services in the community.

Using recent experience training lay counselors for C and T, JHPIEGO will assist IntraHealth in providing courses in opt out counseling and health education for all mothers even before testing. JHPIEGO will also ensure that M2M support groups create a link to PLWHA associations especially those dealing with women to strengthen the second prong of comprehensive PMTCT. The support group will also address some of the challenges PMTCT programs suffer, lost to follow up. The group will promote follow up of mother baby pairs, for all relevant clinical service through education and support for transportation of HIV+ mothers and their babies coming form distant areas. The group, led by the mentor mother, will develop a directory of care and support services outside of hospitals. JHPIEGO will support the training of M2M support group members in collaboration with IntraHealth.

Nationally, JHPIEGO plans to facilitate the development and revision of a directory of organizations involved in Nutritional support to HIV+ pregnant women during pregnancy and up to six months post delivery as well as to HIV exposed infants whose mothers opt to exclusively formula feed. JHPIEGO will help members of the support group access nutritional support by developing a M2M nutritional referral system.

Added July 2007 Reprogramming: Accelerated Roll out of Opt-out Counseling and Testing and Collection and implementation of PMTCT best practices in selected pilot sites. In COP07, JHPIEGO-Ethiopia in collaboration with PMTCT partners will undertake accelerated roll out of the use of opt out testing for PMTCT with the following objectives: 1. To orient national PMTCT trainers and PMTCT advisors of PEPFAR partners and others on the use of opt out testing 2. Standardize training incorporating opt out testing for PMTCT 3. To document the findings of using opt out implementation and TC tools for subsequent evaluation of the approach and tools.

In COP07, JHPIEGO supported activities include: 1. To orient national PMTCT trainers and PMTCT advisors of PEPFAR partners and others on the use of opt out testing a. Communicate with CDC Ethiopia and Atlanta and conduct a two days orientation on the use of PMTCT TC tools b. Conduct three days workshop on opt out testing and use of tools for trainers from all USG PMTCT partners supported regions. 2. Standardize training incorporating opt out testing for PMTCT a. TA to CDC partners implementing PMTCT while they are conducting offsite and onsite training and mentoring on PMTCT focusing on the Counseling and Testing b. Prepare a CD room on the use of the TC tools and samples for easy duplication by partners, regions and facilities to use it in need of regional expansion 3. To document the findings of using opt out implementation and TC tools for subsequent

evaluation of the approach and tools. a. Work with university partners to come up with standardized recording and reporting of the implementation of opt out testing and use of TC tools b. Communicate with CDC Ethiopia and CDC Atlanta on preparation of evaluation of the use of TC tools following the preliminary data acquired from sites

In COP07, JHPIEGO will implement the following activities: a. Preparation of PMTCT best practices booklet for Ethiopia on the following areas: i. Counseling and Testing of women and partners ii. Testing during labor and delivery iii. Linkages to ART clinic and Pediatric follow up inside the facility and outside the facility iv. Improved FP services in MCH v. Strengthened M2M activities vi. Increased motivation for follow up and support vii. Support for infant feeding viii. Safe obstetric practices, with an emphasis on using partograph, AMTSL and appropriate management of complications ix. Infection prevention b. Implementation of the best practices on selected pilot sites

Qualitative Assessment of Women's Attitudes, Perceptions, and Fears Related to PMTCT and Related HIV/AIDS Services

This assessment utilizing qualitative methods will seek to better understand pregnant and recently delivered women's attitudes and concerns regarding HIV testing in the context of ANC services, issues surrounding spousal consent, testing of older children, disclosure of HIV status, fears or opportunities regarding the prophylaxis and/or ART treatment offered, concerns about infant feeding and follow up and expressed willingness to access follow up services for themselves and their children. The results will inform interventions to improve ANC services, increase PMTCT service uptake, encourage male involvement in PMTCT, partner notification, couples counseling, and family-centered care.

The methodology will include focus group discussions (FGD) of 6-8 women, either currently pregnant or recently delivered. Women will be recruited from ANC clinic records at selected hospitals as well as linked rural health centers. Hospitals from which to draw FGD participants will be randomly selected from among 1st, 2nd, 3rd cohort sites so as to maximize the chances that participants will have experienced PMTCT services. Two groups, one urban and one rural, will be formed in each region, excluding Addis Ababa and Dire Dawa, where only urban groups will be included, but there will be an attempt to target underserved neighborhoods in the catchments of the selected hospital.

FGD facilitators will be recruited and trained in consultation with the Department of Community/Public Health of selected Ethiopian universities. Fluency in the local language of the target population will be a criterion for selection of facilitators. In addition, MPH students will be recruited and trained to provide additional support. FGDs will both be tape-recorded and notes will be taken. The tapes will be transcribed and then translated into a common language, probably English, for analysis. Analysis will be carried out using qualitative methods.

The population of interest is pregnant women or women who have delivered in past six months. Women will be invited to participate through a non-random selection from ANC clinic registers based on usable residence information. MPH students from major Ethiopian universities will be recruited to visit the hospitals and spend time to locate participants and invite them to the FGD locations. They will also provide assistance to tape record and take notes during the FGD.

The proposed budget will be used to conduct the evaluation and to organize dissemination meetings.

National Infection Prevention

PEPFAR Ethiopia has funded JHPIEGO to support the MOH in improving the infection prevention practices at the hospitals in public sector as a means of reducing medical transmission of HIV and other infections among patients and healthcare workers. The support includes training of healthcare providers, developing guidelines for infection prevention, and providing onsite support to improve IP practices.

In COP05 JHPIEGO trained 332 people from 56 sites in all regions. During FY06, JHPIEGO completed site assessment for 33 new hospitals for infection prevention, in close collaboration with the US University partners. By the end of FY06 800 providers would be trained from 89 sites. During FY07 JHPIEGO will make use of the findings and recommendations in implementing IP practices and use to improve the program. In the proposal for FY07, JHPIEGO is planning to train 770 providers in 127 sites.

In order to address high turn over of hospital-based staff and challenges in changing provider behaviors in infection prevention, JHPIEGO adopted a new onsite training approach in FY06 and trained 75 people in group based workshop from 56 sites of 1st and 2nd Cohort and train up to 15 providers at each site with onsite training (Approx: 495 providers) from 3rd Cohort. In addition 30 providers were trained to be IP trainers. 8 onsite IP orientations for up to 200 providers from 1st and 2nd cohort sites were conducted. JHPIEGO utilized the services of in country pool of trainers to conduct onsite training which we found to be the most cost effective one.

During FY06 JHPIEGO continued to support 1st and 2nd cohort hospitals by training 110 providers and providing follow up site visits. During FY07 JHPIEGO will continue to support 1st, 2nd and 3rd cohort hospitals to ensure adequate IP trained staff available at the hospitals. (Replacement training to address high turnover of trained staff - assumes that will need 10% more funding to cover 2 providers from each of 89 sites)

Towards the end of FY05, JHPIEGO trained 7 advanced IP trainers in JHPIEGO and utilized them in IP training during FY06. JHPIEGO also trained 23 additional providers as IP trainers during FY06. In FY07, JHPIEGO will train additional 20 IP trainers.

During FY06 JHPIEGO developed draft performance standards for infection prevention in Ethiopia consistent with the National Infection Prevention Guidelines. During FY07 JHPIEGO will work with MOH/FHAPCO, RHB, US University partners, Global Fund, JSI and other partners to implement IP performance standards at selected hospitals. At the same time, JHPIEGO will continue to monitor the implementation of the guidelines and standards and make any adjustments that are deemed necessary.

Experience from follow up visits and SBM-R implementation indicates that hospitals have difficulties applying IP guidelines for lack of adequate IP supplies at all the hospitals. The proposed mechanism is working with Global Fund to purchase and distribute supplies to the places where the gap is there.

JHPIEGO also proposes to develop, test and print IP print materials, such as job aids for providers or patient/caretaker education materials on good hygiene and infection prevention practices in home-based care of AIDS-affected individuals. These materials will be developed in consultation with JSI/MMIS not to duplicate efforts and through JHU/CCP TA.

I. National HIV counseling and testing support (COP ID 5627) This is a continuing activity from FY05, FY06. This COP 07 addresses three merged activities and is linked to new activity 1073 and 1074 in policy and system strengthening As of April 06 date, JHPIEGO received 100 % of FY06 funds and is on track according to the original targets and workplan. We have increased funding based on the achievements from FY05 and partially FY06. During FY06, JHPIEGO worked with the MOH/HAPCO, RHB and CDC to build human capacity for providing high quality HIV counseling and testing services at 89 hospitals. Interventions included training of service providers, training of trainers, developing and updating training materials. VCT training is well established in Ethiopia under PEPFAR support. Training materials exist; trainers are competent and active in conducting VCT courses. In FY07 for innovations in HCT, JHPIEGO will: (1) Support the national effort to improve HCT training program through adaptation/development of training materials (Couple counseling, Ongoing supportive counseling, burnout management) and guidelines and work with National VCT Working Group to update the VCT implementation manual and advocate for partner notification protocol. (2) Support US universities to implement VCT and PIHCT trainings within their regions by training additional HCT trainers including training 20 non health professional counselors' trainers to build capacity for training non health professional counselors. (3) Train 30 counselors from sites with couple counseling needs and 40 supervisors to strengthen supervisory skills. (4) Work in collaboration with the US Universities in selected first ART cohort hospitals to implement and support establishment of post-test clubs and development of draft guidelines for these clubs. (5) In collaboration with US Universities, JHPIEGO will establish and support 3-4 regional Counselors Associations. This will include support for establishing offices, identifying other support and organizing launching meetings and the yearly meeting of members. (6) Use of SBM-R to improve the quality of counseling and testing services is proposed in the funding request for SBM-R (under system strengthening). JHPIEGO will introduce VCT performance standards.

During FY06, from selected regions, 40 lay counselors where trained and deployed in the hospitals. During FY07, in collaboration with the US Universities and other partners JHPIEGO will document the effectiveness of lay counselors in providing VCT services. The areas of documentation will include: (1) Lay counselors knowledge and skills in using protocols. (2) Client satisfaction with lay counselors (3) Lay counselors skills in performing HIV rapid tests under the supervision of trained lab technician. (4) Quality of recordkeeping carried out by lay counselors. Data will be collected on routine follow up visits in collaboration with US universities and tools to gather information on client satisfaction will be developed in collaboration with other partners involved in lay counselors training, deployment and technical assistance.

II. This is on going activity COP ID # 5647 (8.3.2). In FY06, through the support of PEPFAR Ethiopia two regional demonstration sites were established in Oromyia and Amhara Regions, aimed at acting a demonstration site for HCT trainings to improve the delivery of quality HIV counseling and testing services in the regions. The sites serve as venue for regional practical attachment as part of VCT training. These model sites are envisioned to strengthen the network between local VCT sites. JHPIEGO proposes to continue to support and further strengthen the existing sites established in Oromyia and Amhara regions and establish similar facilities in SNNPR and Tigray Regions. Proposed Activities for FY07 include: (1) Establishment of 2 regional demonstration sites for counseling and testing in SNNPR and Tigray regional states. To the extent that CDC/PEPFAR guidance allows, this includes renovation of service buildings and conference rooms as well as procurement of necessary furniture for the buildings. (2) Support continued implementation of VCT services at the first two and the two new demonstration sites. (3) Support the 4 demonstration sites to regularly document best practices that can be transferred to other VCT centers in the regions

III. This is a new activity for FY 07 to support local NGO to strengthen VCT service delivery. Knowing HIV status has been shown to have a greater impact on the use of preventive measures than counseling alone. The Family Guidance Association of Ethiopia (FGAE) is a national organization with significant experience in the delivery of VCT, PMTCT, HBC and FP services. FGAE's program activities and services cover a large part of the country creating a network of branches and offices that span from the region to the community level including workplace, youth centers and outreach and marketplace activities. During 2005, FGAE provided VCT services to 40,692 clients. FGAE is requesting for funding and hence, JHPIEGO proposes to provide financial and technical support to FGAE to continue and expand past efforts of VCT and PMTCT program in 34 clinics and youth centers. During FY07, JHPIEGO will: (1) Train FGAE trainers in VCT and PIHCT (2) Provide support to deliver VCT services at the 34 sites (3) Cover costs to train and support 340 volunteer providers to carry out outreach VCT services (4) Support activity costs to integrate VCT services for FGAE6 youth centers and 8 standalone VCT clinics (5) Support procurement of test kits and medical supplies, if these cannot be leveraged from GFTAM-funded sources. (6) In addition, JHPIEGO will continue dialogue with FGAE to identify other specific areas where JHPIEGO can provide TA and work together with FGAE.

PLUS UP FUNDING: PEPFAR will support the GOE plan to expand the successful pilot of Community Counselors for HCT provision under the broad framework of task shifting in HIV/AIDS prevention, care and treatment activities. The introduction of community counselors (lay counselors) into public health facilities in September 2006 boosted VCT uptake and decreased the burden on health care workers; the counselors also conducted large numbers of HIV rapid tests. The pilot was a great success and the Federal HIV/AIDS Prevention and Control Office (FHAPCO) plans to deploy an additional 700 community counselors in hospitals and health centers in the next few months. The government secured funds for recruitment of 743 lay counselors (including the existing 43). PEPFAR support through the plus up will used for 6-week training courses for 700 lay counselors, logistics, training follow-up and evaluation of the community counselors' performance. The project will be implemented jointly through JHPIEGO and FHI.

Pre-service Education in Medical and Nursing Schools

During COP06, CDC funded JHPIEGO to initiate a process of strengthening quality and content of HIV/AIDS education for physicians and nurses at three Ethiopian universities, namely Addis Ababa, Gondar and Jimma. As medical and nursing schools are separate faculties, the total number of university-based schools reached is six. At the time of writing, the process to undertake detailed needs assessment and implementation plan has just begun. It is anticipated that, in FY06, a core group of faculty from each of the six schools will be given training to update their HIV/AIDS knowledge and will be taught effective teaching skills. Core competencies in HIV/AIDS for nurses and general practitioners will be defined and curriculum teams established. A process for introducing/strengthening the content provided to students will be initiated. Teaching equipment needs will be assessed and some essential equipment provided.

Among PEPFAR partners, JHPIEGO is taking the lead on pre-service education, and university partners are supporting the effort, through their established relationships with each university as well as in contributing technical expertise in the HIV context. Each US university has a different mode of operation with their Ethiopian counterparts, so it in not yet clear how uniform the experience will be in each setting. JHPIEGO's role will be to provide an element of standardization so that similar results can be achieved across schools as well as to provide a forum to exchange ideas across the group. By the end of FY06, these mechanisms will be formalized and guide FY07 work. It is expected that each regional partner will either work hand-in-hand with JHPIEGO to follow-up and strengthen the HIV clinical content of teaching, perhaps even providing complementary teaching to what the universities offer, while JHPIEGO's expertise will focus on strengthening the skills in high quality teaching and structuring pre-service education to focus on skills acquisition.

In FY07, the activity will continue with the development or adaptation of teaching materials and teaching methods for use in the pre-service context, supporting the core group of faculty to develop plans for and train their colleagues in essential teaching skills, strengthening the practical learning opportunities for students and ensuring effective clinical mentoring and feedback systems from practice/clinical instructors to classroom where evaluation and assessment methodologies monitor students' performance in HIV knowledge and skills acquisition over their educational careers.

Depending on interest and infrastructure available, JHPIEGO will also explore the feasibility of using innovative information technology tools to expand student and faculty access to updated information and resources in HIV/AIDS, such as internet-based tools, computers, PDA, or other technologies. Such efforts may link with the JHU School of Medicine, Center for Clinical Global Health Education, should resources be sufficient (this will probably require an increase in funding).

Universities in any countries have an organizational structure and culture of their own. Smaller universities are likely to have a multi-disciplinary faculty who provide teaching in several schools (Jimma seems to fit that model in Ethiopia), while other, perhaps larger universities) have very compartmentalized schools and faculties who rarely interact with each other unless there is a special project or initiative. Depending on progress of activities and a better sense of the linkages within a given Ethiopian university between faculties of various health disciplines, JHPIEGO will organize seminars to explore opportunities for expanding activities within universities to affect the teaching of certain disciplines, such as laboratory and pharmacy cadres. This model has been used in Egypt where a core group of educators took on responsibility of upgrading the teaching skills of their colleagues. The difference in this case would be to make this collaboration extend across faculties rather than only within. We must recognize the possibility that the medical/nursing faculties may already be overburdened and teachers understaffed and unable to take on additional efforts and responsibilities. In any case, JHPIEGO will also explore opportunities of working with new partners with content expertise in laboratory services for a more structured approach to strengthening pre-service education of new cadres in FY08.

Several technical assistance visits from Ethiopia staff and international experts will be conducted to schools to provide ongoing support and targeted assistance where it is most needed. These external visitors will observe teaching in practice as well as review student

performance measures. This is in addition to supporting focal persons for each university.

*Note regarding targets of individual trained in HIV/AIDS content - these are gross estimates of medical and nursing students in a single academic year (as it is not yet known which year has the most ART specific content) and is dependent on the number of students enrolled in target schools, thus is not a reflection of funding allocated for this activity.

Plus ups: JHPIEGO-E, in collaboration with the US universities and the federal Ministries of Health and Education, conducted institutional needs assessment for strengthening pre-service HIV/AIDS education in three Ethiopian Universities (Gondar, Jimma, and AAU). Based on the findings and discussions with deans and faculty instructors, the critical factors limiting effective teaching emerged as lack of qualified staff, lack of teaching materials and audiovisual aids, and large numbers of students in the classroom and during clinical skills trainings. The key recommendations from the seven targeted medical faculties, nursing and midwifery schools in the three universities were: technical and material assistance to develop simulated environments to enable large numbers of students to develop skill competence before practice on patients, audiovisual aids to enable large numbers of students to watch video counseling sessions, minor operations and procedures recorded from the actual service provision with informed consent. A dermatologist faculty from AAU said, " I had a lot of patients with classical skin manifestations of HIV but I use very obsolete slides and pictures to teach my students due to lack of modern recording equipment. If I had a digital or even an analog video camera, I could have shown my students a classic skin manifestation on local people, which they can understand better". Concerning problems related to large classes in lecture halls lacking sound amplification, another faculty member from Gondar University said, "I teach 300 students in a lecture hall; however loudly I speak, students in the middle and at the back cannot hear what I say. If we had good sound, which a wireless microphone would provide, I could give better lessons." Therefore additional funds for activity 10611 in COP07, dealing with HIV/AIDS knowledge update and effective teaching skills, trainings, supply of educational materials and equipment like LCD projectors, procurement and supply of critical teaching aids like anatomical manikins, cameras and sound system equipment directly to faculties and nursing schools will assist universities to improve the quality of teaching and learning.

None provided.

Table 3.3.11:

In the last few years, the HIV/AIDS program has markedly expanded to a large number of sites and patients. The pace has accelerated while it has exerted huge burden on the health system especially in relation to human resources. Retention of trained staff in the HIV/AIDS services is a serious issue as this affects the expansion and quality of the program in general. Recently the country has embarked in a campaign to expand the program substantially to achieve the highly ambitious targets. The human resource issue is a big challenge as the scale up builds momentum and it needs to be addressed using multiple innovative approaches. One of the major factors for trained human capacity attrition is very low remuneration in the government health sector. To support sites retain their trained human capacity, PEPFAR Ethiopia will support retention schemes including supporting through remuneration for weekends, holidays and duty hours services linked with HIV/AIDS program scale up. The number of health workers to be trained and how they would be supported will be determined with each implementing partner. Other innovative ways of human resource retention are needed and should be adapted to regional/local situations. Thus, the plus up funds will be used to support ART sites to retain trained staff and continue providing quality service ensuring the rapid expansion of the program.

Table 3.3.12: Program Planning Overview Program Area: Laboratory Infrastructure Budget Code: HLAB Program Area Code: 12 Total Planned Funding for Program Area: $ 18,884,494.00

Program Area Context:

The organizational and physical infrastructure, procurement systems, supply availability, equipment, and trained staff are critical for the implementation of PEPFAR Ethiopia's plan. To improve the quality of services and achieve the targets, there is a need to strengthen the laboratory infrastructure from national to regional, district to health center laboratories.

PEPFAR Ethiopia in collaboration with MOH is working to strengthen the regional and hospital laboratories to support HIV/AIDS prevention, care, and treatment programs. Comprehensive renovation at national, regional and hospital laboratories are being supported.

During COP05 and COP06, standardized curricula for in-service training on chemistry, hematology, CD4, laboratory management, and quality systems were developed. More than 800 laboratory technicians, technologists, supervisors, and directors were trained in HIV, TB, STI, laboratory quality systems, and laboratory monitoring (chemistry, hematology and CD4 count) of ART. The trainings were conducted at national, regional and site levels.

Essential laboratory equipments including automated clinical chemistry analyzers, automated hematology analyzers, BD FACS-Count machine, Gene Amp PCR machines, and other basic equipments for supporting diagnosis and Antiretroviral treatment (ART) monitoring were purchased and distributed to regional and hospital laboratories. In addition, PEPFAR Ethiopia provided technical and logistic support for transportation and installation of GF/MOH purchased medical equipments for 62 ART hospitals.

PEPFAR Ethiopia is supporting laboratory-based targeted evaluation of laboratory diagnosis and disease monitoring including biotyping, HIV drug resistance threshold surveys, and validation of diagnostic tools. Laboratory requisition, documentation, and reporting forms were standardized. Early infant diagnosis of HIV was established at the National HIV Reference Laboratory. Procedures for HIV pro-viral DNA PCR detection from dried blood spots has been validated and piloted at selected ART sites. Preparations are underway to set up testing at six regional Reference laboratories and scale up of diagnostic services to all regions.

In COP07, PEPFAR Ethiopia will continue supporting the implementation of quality assurance program, complex diagnosis including drug resistance monitoring, and laboratory management and information system. Tiered, quality-assured laboratory network will be strengthened. Policies and strategic planning developed at national level will be implemented across the network. Integrated laboratory services, referral linkages will be implemented from heath centers to district hospitals, district hospitals to regional hospitals/regional laboratories from regional laboratories to National reference laboratory. This network will provide an efficient mechanism for providing integrated services to expand ART programs.

In COP07, PEPFAR Ethiopia will continue the support and coordinate all laboratory trainings, external quality assessment (EQA) and site supervision at all 131 ART health networks (131 hospitals and 240 health centers). More than 800 laboratory professionals will be trained on HIV rapid testing, diagnosis of tuberculosis, opportunistic infections, laboratory monitoring of ART and laboratory quality, information, and management systems. The national "TOT based" trainings will be conducted by EHNRI in collaboration with CDC, ASCP, and APHL. Regional laboratories and US universities will be involved in regional and site level trainings. ASCP and APHL will assist in developing, customizing, and standardizing different training modules.

PEPFAR Ethiopia will support the implementation of the National Mater Plan for laboratory services and logistic management. Logistics support for transportation and distribution of all laboratory commodities (test kits, reagents, other lab supplies, and equipments) to all 131 ART hospital networks will be provided through Supply Chain Management System (SCMS). Reagent management needs, inventory and

forecasting of supplies will be coordinated.

The Ethiopian Health and Nutrition Research Institute (EHNRI) with the support of CDC, will provide the national leadership in strategic planning, laboratory policies, guidelines, integrated services and testing, and ensure the implementation of laboratory standards. With the support of EHNRI, Regional reference laboratories will also be involved in coordinating activities including regional training, reference testing, and EQA services. The Association of Public Health Laboratories (APHL) and American Society for Pathology (ASCP) will provide technical assistance to support quality improvement, networking, referral linkages, developing and standardizing training modules, lab policy, guidelines, accreditation, and certification of clinical laboratory services.

For provision of standard clinical laboratory services for HIV/AIDS prevention, care and treatment programs at regional levels, the regional laboratories will work closely with US universities involved in site level support. US universities will provide technical assistance (site level training, laboratory management, and follow up of implementation of standardized laboratory services) within their respective regions and health networks (hospitals and health centers). University partners will also be involved in coordinating referral linkages between hospital and health centers including, specimen management and transport, sample tracking, recording and reporting systems.

By the end of COP07, diagnosis of HIV/TB/OI, and laboratory monitoring services (hematology, biochemical, and CD4 profiles) will be provided to more than 300,000 pre-ART patients on care and 138,300 patients on ART as per the "National Guidelines for use of ARV drugs". The revised National rapid HIV testing algorithm and QA/QC program will be operational at all Voluntary Counseling and Testing (VCT) sites. DNA-PCR based early virologic tests will be provided to about 13,800 infants. All major regional specialized referral hospitals and regional laboratories will be networked and the laboratory information system will be operational for effective implementation of QA, monitoring and evaluation of services.

With PEPFAR Ethiopia partners, CDC Ethiopia will coordinate and follow up of laboratory related services for HIV/AIDS care, treatment, and prevention activities. The services will also be coordinated with GF/MOH including providing technical and logistic support.

As part of the local capacity development and sustainability, ASCP and APHL will work closely with the local organizations including the National Reference and regional laboratories. APHL will support the Ethiopian Public Health Laboratory Association (EPHLA) and regional reference laboratories. ASCP will work with the Ethiopian Medical Laboratory Association (EMLA). PSCMS will also work closely work with the national supply chain management system and ensure the local capacity is developed to take over the services.

Program Area Target: Number of tests performed at USG-supported laboratories during the 907,983 reporting period: 1) HIV testing, 2) TB diagnostics, 3) syphilis testing, and 4) HIV disease monitoring Number of laboratories with capacity to perform 1) HIV tests and 2) CD4 tests 371 and/or lymphocyte tests Number of individuals trained in the provision of laboratory-related activities 854

Table 3.3.12:

Production of HIV care, treatment & prevention related electronic materials

This is a new activity for FY07. This activity is linked various capacity building activities (5714, 5611) and HIV care, treatment and prevention activities of PEPFAR Ethiopia. With PEPFAR Ethiopia, Global Fund, and other international funding, HIV/AIDS services are rapidly expanding in Ethiopia. In order to achieve the targets of PEPFAR Ethiopia, the Ministry of Health is engaged in strengthening and expanding HIV/AIDS related services including HIV Counseling and Testing (CT), ART and PMTCT at healthcare facilities throughout Ethiopia. Training of healthcare providers in all HIV/AIDS services has been a major focus of this intervention. Beyond the direct cost of training, pulling healthcare providers out for training affects the continuity of services at already understaffed health facilities. The situation is further affected by high staff turnover of trained physicians and nurses within government health facilities. The result is a seemingly endless need for training in order to ensure a critical numb er of quality HIV/AIDS service providers. Because information related to ART, PMTCT, and CT constantly changes, refresher trainings are required, further complicating the situation.

With over a decade of experience addressing these challenges through innovative applications of education technology, JHPIEGO continues to adapt its approaches to the changing environment of healthcare and technological advances. Following is a list of examples of JHPIEGO's accomplishments. In 1999, JHPIEGO developed the ModCAL™ CTS, a self-paced computerized clinical training skills learning package that prepares clinical trainers to conduct skills training for providers. Created as a cost-effective workshop alternative with minimal technological requirements, ModCAL CTS includes interactive audio and video presentations with knowledge assessments. Participants complete the modules and assessment on their own and must bring their results to the complementary skills training. Reducing training time by almost 50%, ModCAL has been used in several countries in the Caribbean and Africa.

In 2001, with funding from the Health Resources and Service Administration of HHS, JHPIEGO developed a series of tutorials on the clinical care of women with HIV. These tutorials include presentation graphics to support audio presentations and a knowledge assessment questionnaire.

In 2002, JHPIEGO developed a 14 week e-mail course, Meeting the Family Planning and Reproductive Health (FP/RH) Needs of Clients with HIV/AIDS in Low-Resource Settings, to help providers better meet the needs of clients with HIV/AIDS. It focused on practical solutions based on current scientific knowledge. 37 healthcare professionals participated in the first course, which resulted in a 30% increase in their knowledge as compared to the baseline.

To address challenges faced by Ethiopia and to quickly address the need for increasing the number of trained healthcare providers to support HIV/AIDS services, the following activities will be implemented in FY07.

Learning Platform. Making use of state-of-the-industry MS Windows® compatible technology appropriate to low resource settings, JHPIEGO will adapt and use a free and open-source Learning Management System (LMS), such as Moodle (Modular Object Oriented Dynamic Learning Environment), as a framework to manage and deliver learning materials related to specified competencies. This virtual classroom will support a community of users by providing concurrent access to multiple computer workstations delivered by the LMS located on the hospital server. The LMS will ensure consistent access to emerging evidence-based knowledge, skills and practice consistent with training materials approved by the MOH. The LMS will also facilitate educational collaboration by the users within each hospital. The proposed system is scalable to allow growth in the number of users accessing the content and is replicable to multiple facilities in the absence of Internet connectivity. The locally-hosted LMS will also support distribution of stand-alone learning activities and job aids to various mediums, such as CD/DVD, print-based tools, mobile MP3 players, PDA or mobile phones to support off-line learning and sharing. Using a LMS format will permit more flexibility for adding content topics and modifying specific learning tools as needed and determined locally.

Though the LMS is not an Internet-based tool, Internet connectivity will be desirable to

extend the reach of the LMS, provide additional means to connect healthcare experts and learners in different facilities, and to provide additional means to distribute new or updated curriculum content. The LMS will thus be designed to function in a facility LAN environment, with consideration to having limited or no Internet connectivity.

Initially, the LMS will be installed at hospitals attached to Gondar, Jimma, and Addis Ababa Universities. These three sites have been identified based upon their involvement in the strengthening of preservice education efforts under PEPFAR Ethiopia.

Content development and Learning Activities. In order to standardize training within the country, MOH has played a key role in overseeing and approving training materials developed and adapted for national use. Such training packages include ART, PMTCT, VCT, PIHCT, Infection Prevention, and several others. Using the approved training materials, a variety of innovative e-learning activities supporting the development of knowledge, skills and clinical decision-making important to several areas based upon priorities set by the MOH and key stakeholders will be embedded within the LMS. Pod casts, narrated presentations and study questions will be used to promote mastery of knowledge objectives.

Monitoring and Evaluation: The LMS will monitor the number of providers accessing the learning modules, completing the learning activities and demonstrating mastery of HIV/AIDS competencies. Competency for each module will be measured using electronic quizzes and gaming activities. Feedback will be gathered and used to adapt the LMS as needed to improve its supportive capabilities and also to expand curriculum content. Based upon the feedback received from the users during the first year, appropriate revisions will be made in the LMS.

Scale Up: The revised and updated LMS will be installed in all first cohort hospitals by the end of the project year.

Effectiveness of Training under PEPFAR Ethiopia

This evaluation will provide feedback to PEPFAR Ethiopia regarding the effectiveness and cost of investments to train health care workers at facilities. It will include a descriptive review of training processes and methodologies utilized by PEPFAR implementing partners, a review of costs per trained provider, and the cost of re-training providers due to attrition. A quasi-experimental data collection methodology will also assess the performance of providers (either on the job or in a simulation) on specific knowledge and skills included in the in-service training they receive. Additionally, the evaluation will measure the attrition rates and reasons for attrition.

There are seven evaluation questions. (1) What proportion of health care workers who have attended at least one training event funded under PEPFAR are still in the post they were in at the time of training? (2) If trained providers are not at the post they were in at the time of training, where did they go and what was the average time from training to the absence of post? (3) If still on the job, do health care workers report using the knowledge and skills received during training. If they report not using this knowledge and skills, what are the causes and constraints they report? How have they sought to overcome these constraints and what support is needed to improve the skills? (4) How effectively are health care workers performing on specific skills imparted during training, as measured through observation or simulation? (5) What was the average cost per trainee of the training, by category of knowledge and skills of the training event (specifically, laboratory, infection prevention, voluntary counseling and testing, provider-initiated HIV counseling and testing, prevention of mother to child transmission, ART clinical skills, pediatric ART, and others to be determined) and what is the anticipated cost for re-training providers because of attrition. (i.e. money spent on providers that leave and the cost projection for training more replacement individuals)? (6) How are the PEPFAR trainers being used within the program and how many training events have they conducted? Additionally, how comfortable are these trainers in conducting training? (7) What is the perceived risk of HIV infection in providers trained versus providers not trained in providing HIV services? (8) What are the implications of the analysis of the findings in the above questions on future directions in training for PEPFAR Ethiopia?

JHPIEGO will review PEPFAR Ethiopia's Training Information Management Information System (TIMS) for data on providers trained in HIV services to identify the population of health care workers trained in all areas of HIV prevention, care and treatment at hospitals. The study will employ a quasi-experimental design which matches a randomly selected percentage of trained workers to a randomly selected group of untrained workers by gender, age, cadre, work setting, level of professional experience, and type of training and educational preparation.

Assessors will evaluate the skills of trained providers by comparing skills that providers are expected to have post-training versus skills that are displayed at the time of assessment using standardized skills assessment tools. These tools will be developed or gathered from partners who conducted the first training of providers in each particular HIV service area.

Surveys will be distributed to PEPFAR Ethiopia's university partners to determine the methods and costs of training. Questionnaires will be distributed to all trainers trained under PEPFAR to see the extent of their involvement in training providers. The cost elements will include a comparison of the cost of training and forecasting training needs based on attrition across course types given.

The population of interest includes service providers -- doctors, nurses, midwives, pharmacists, lab technicians -- trained to provide HIV services under the PEPFAR Ethiopia program and service providers at the same hospitals not trained to provide HIV services. Thus, the sample will be selected from the 89 hospitals that have PEPFAR trained staff and will be determined to be a statistically significant representation from different levels of hospitals (district, referral, zonal, etc) and regions as well as an appropriate urban-rural sample.

Training Information Monitoring System (TIMS) and Strategies for Human Resources for Health

This is continuation of FY06 activity.

PEPFAR Ethiopia is aware that it is essential to have a training information system in order to make intelligent management decisions regarding the type of professionals to train, in what technical area, and in which geographical region. During COP05, PEPFAR Ethiopia established the Training Information Monitoring System (TIMS), with the purpose of collecting information from all PEPFAR partners supporting trainings for program monitoring. The focus of FY05 was to start the process and sensitize the partners about the database, and reporting into the database.

During FY06, JHPIEGO refined the TIMS program to include more information on evaluation of PEPFAR trainings by using a follow up evaluation format to track trained providers post training activities to determine attrition and forecast future training needs. The evaluation format also captures information on the competence of trained providers, although the format is not yet comprehensive nor is competence clearly defined for technical areas. During FY06, JHPIEGO pilot tested the formats and data collection process for the evaluation component of TIMS. JHPIEGO also expanded the types of reports available for utilization of training information for PEPFAR Ethiopia and MOH program planning. In addition, JHPIEGO assumed management of TIMS for PEPFAR Ethiopia and is currently responsible for data entry and management for all partners, along with running regular reports for PEPFAR Ethiopia and MOH.

During FY07, JHPIEGO will continue to manage TIMS for PEPFAR Ethiopia and will expand the program to conduct further analyses of training and evaluation of data to assist program planning, monitoring and decision making for national prevention, care and treatment working groups and MOH/HAPCO. The program will include data entry and management for all PEPFAR Ethiopia partners, running reports for partners, and performing any software upgrades. JHPIEGO will continue to expand the use of the evaluation format for post-training to expand the competency component. JHPIEGO will conduct a technical review of the methods training partners use to evaluate competency of providers during training and the frequency of monitoring competency during different time intervals after training interventions. JHPIEGO will then craft guidance on various technical areas on how to assess competency, develop formats with partners and suggest systems to ensure that providers trained are actually competent to provide HIV/AIDS services.

JHPIEGO will continually orient staff of new PEPFAR Ethiopia partners on TIMS, the use of the forms and options for specialized reports and revise the formats based on partner comments. JHPIEGO will also begin dialogue with MOH and RHB about managing data regarding training. Although the current system does not allow for data entry from multiple points, there is a need to institutionalize training data management systems with government counterparts. JHPIEGO will develop proposals and options for doing so, at the same time sharing lessons learned from other countries.

Using lessons learned during previous fiscal years, JHPIEGO will also perform additional analyses of TIMS data. JHPIEGO will produce reports regarding the geographic/facility frequencies of providers trained in specific technical areas to national TWGs for PEPFAR program monitoring and planning. Additionally analysis will look specifically at issues of deployment of trained professionals by facilities, regions and topics trained, attrition and estimations and projections of trained manpower needs in relation to PEPFAR Ethiopia and national health goals. With three years of data and figures from other sources on health manpower, JHPIEGO will issue policy briefs on the gaps and potential opportunities for addressing the human resource crisis facing the Ethiopian health system.

Should these policy briefs generate sufficient interest from high-level policy makers, JHPIEGO will be prepared to work closely with other HRH implementing partners to expand its work, by developing specific strategies for human resources planning, production and retention. The areas of engagement include:

(1) Analysis of gaps in HIV/AIDS training provision in specific technical areas and cadres.

With various international partners that are taking leads in specific areas, TIMS can help generate a master list of courses to clarify understanding the comprehensiveness of training by topic and ensuring appropriate geographical coverage. This information will be sent to the various donors and implementing partners to ensure comprehensiveness of the overall PEPFAR and HIV/AIDS program. This strategy will also increase interventions transparency and stimulate need based training, reducing redundancy among partners.

(2) Planning for increasing numbers of trained professionals. This might involve estimating total numbers of health care workers needed at health care facilities, potential for supporting salary levels for additional staff, factoring in attrition, public/private mix and absorption capacity, housing and other staff needs at a worksite. Also, this may involve refining recruitment strategies for pre-service training that emphasizes recruitment of students from under-served geographical areas so as to increase likelihood of deployment to those areas. JHPIEGO could provide estimates of numbers of schools, tutors and other faculty that would need to meet increased health manpower production goals.

(3) Retention of health care workers. Low salaries and benefits mandated for the entire civil service are very difficult to change for one sector and would be beyond the capacity of JHPIEGO to act upon. Depending on interest to advocate for piloting alternative retention strategies, JHPIEGO could work with other partners in this area to propose efforts such as improving workplace conditions, piloting monetary and non-monetary incentives as a means of encouraging deployment to underserved area and increasing retention in those areas. Some examples include: housing for health care workers within or near hospitals, education benefits for school age children in locations where schools are not available, special hardship allowances, provision of medicines for workers and families, workplace safety programs that include a package of immunization, post exposure prophylaxis, protective equipment and supplies (linked with infection prevention activities), reinsertion to the workplace or an alternative career path after an occupational illness.

(4) In-service training will always be a necessity for updating existing providers in new evidence-based guidelines and content. JHPIEGO is working on national training guidelines in FY06. JHPIEGO has advocated and implemented a competency-based approach to in-service training, which emphasized mastery learning for the acquisition of skills and immediate transfer and application of these skills to the work setting. To expand on these activities in FY07, JHPIEGO could work to analyze the number and regional distribution of HIV-specific trainers as well as advanced trainers (i.e. trainers who can develop the training skills of providers) to meet PEPFAR Ethiopia goals and further improve the sustainability of the HIV/AIDS program in the country.

Standards Based Management and Recognition (SBM-R)

SBM-R is a practical management approach for improving health service which, as demonstrated in other countries, can increase service uptake to reach PEPFAR targets and improve patient treatment adherence. SBM-R systematically uses performance standards by onsite health care staff teams as the foundational for improving service organization and provision.

After introducing performance standards at a healthcare facility, teams conduct baseline service assessments, which are repeated after two or three months. Using performance standards, the team again measures the service performance. Improvements are measured by the difference in the number and percentage of standards achieved from baseline to internal assessment.

SBM-R follows four basic steps: (1) setting performance standards, (2) implementing those standards through streamlined and systematic methodology, (3) measuring progress to guide improvements to achieve these standards, and (4) recognizing standards achievement..

Performance standards are assessment tools used mainly to assess service delivery but can also be used for self, peer, internal and external assessments in different contexts. Performance standards implementationleads to the identification of performance gaps, which need to be reduced or eliminated. Local health managers and providers can then analyze the causes of the gaps and implement appropriate corrective interventions. Local teams are encouraged to focus on action and begin with simple interventions to achieve early results, create momentum for change, and gradually acquire management skills to tackle more complex gaps. Facilities achieving compliance with standards are acknowledged through recognition involving institutional authorities and the community.

Given the large number of sites in Ethiopia, JHPIEGO used a three-module workshop approach to SBM-R in FY06, rather than focusing on extensive site visits. Hospitals selected teams to participate in the workshops, which taught how to apply the methodology to their sites, assure buy-in and address performance gaps. Internal assessments are then applied by participants to their workplaces in between workshops. Subsequent workshops allow for extensive exchange of results, lessons learned and best practices, as well as resolution of more difficult problems in care quality. Key field staff from IntraHealth (a PEPFAR Ethiopia partner working at health centers and in communities) and PEPFAR Ethiopia university partners at hospitals were also trained in SBM-R modules during FY06.

Standards were developed for PMTCT in FY04 and have been implemented in 55 first and second cohort hospitals. The generic PMTCT performance standards developed by JHPIEGO were adapted during a meeting of stakeholders, including all PEPFAR partners, hospitals and health centers. These standards were later approved by the MOH. By the end of FY06, in close collaboration with the MOH and PEPFAR Ethiopia partners, JHPIEGO adapted standards for ART, HCT and IP services. This created a comprehensive HIV performance standards document that can be used by facilities to improve all HIV service performance. HIV performance standards (including ART, HCT, and IP) are designed to be uniform, yet not overly burdensome to implement. JHPIEGO has applied the SBM-R approach to HIV and other health services in many countries and has demonstrated its ability to improve performance and quality dramatically and long-lastingly within a short period. The implementation of the PMTCT performance standards in Ethiopia has also succeeded in improving performance and quality of those services.

In FY06, national PMTCT performance standards were introduced into 55 first and second cohort hospitals. All first cohort sites will complete all stages and be ready to validate internal assessments through external assessments to verify improvements in service delivery, and will be in the recognition phase. The second cohort sites will pass half way through the process and will work on closing performance gaps based on assessments. In order to streamline the process of service standards implementation, it is critical that sites implement HIV services for a period of at least six to eight months. Thus, JHPIEGO will introduce overall HIV services performance standards at 3rd cohort hospitals in the beginning of FY07.

The national Ethiopian monitoring and evaluation system is functional and new initiatives are in place to strengthen the quality of reporting and analysis of HIV service delivery data. HIVQUAL is the one initiative to improve the quality of individual client care at the facility level and improve the reporting and monitoring systems for HIV services. SBM-R is geared towards improving the quality of overall service delivery, while HIVQUAL is focused on individual client services, thus no overlap is expected. In FY06, JHPIEGO will work with Tulane to harmonize the SBM-R and HIVQUAL approaches at facility, regional and national levels. This collaboration will reduce effort duplication and complement existing monitoring and evaluation systems. In FY07, JHPIEGO will continue to work with PEPFAR partners to harmonize the SBM-R and HIVQUAL initiatives at sites -- both public and private -- providing HIV/AIDS services supported by PEPFAR Ethiopia.

In FY 07, JHPIEGO will accomplish the following for SBM-R: (1) orient first and second cohort sites to the new HIV standards for expansion from PMTCT only to IP, HCT and ART services; (2) conduct workshops for the second cohort sites to finalize implementing PMTCT performance standards and implementing the overall HIV standards (module 3); (3) introduce the SBM-R process and work with PEPFAR Ethiopia partners to implement the comprehensive HIV performance standards for third cohort hospitals and network of health centers (conduct modules one and two out of 3); (4) work closely with PEPFAR Ethiopia partners to ensure the implementation of standards at facilities by orienting staff to the approaches of coaching service providers and to implement standards and close identified gaps identified; (5) continue support to quality assurance body, working closely with the national monitoring and evaluation system and HIVQUAL initiatives, for external verification of standards, including external assessors training and some costs for external assessments; and (6) support the recognition of facilities through coordination of recognition events and items (plaques, certificates, etc.).