Community Mobilization Under the Care and Support Contract

This is a continuing activity. As of August 2006, 100% of funds were obligated to the USG - Ethiopia Strategic Objective Agreement (SOAG) to support programming in this mechanism when awarded in December 2006/January 2007.

This is a comprehensive ABC activity. This activity is linked to the 10647 (Care and Support) contract (formally BERHAN) RFP to be awarded in 2006 found in CT, PC, TB/HIV and ART. In addition, this activity is linked to activity PEPFAR Ethiopia's support of MOH/Health Extension Workers (10435).

Given the low urbanization rates, a significant proportion of HIV/AIDS cases remain in rural areas. ANC surveillance in many peri-urban health centers indicate a high HIV/AIDS case burden where limited services are available. Furthermore, DHS reveals limited reach of mass media including radios. In response, this activity prioritizes the deployment of Case Managers and Outreach Volunteers to the peri-urban fringe and rural areas in/around ART health networks to conduct face-to-face community outreach, and supports Government of Ethiopia efforts to deploy Health Extension Workers to these areas.

The activity has several components. One component utilizes non-medical Case Managers in health centers to support consistent HIV prevention ABC communications with people living with HIV/AIDS or most at risk groups appearing. These brief counseling periods, anticipated after a closer relationship is formed with Case Managers, represents efforts to integrate and mainstream brief motivational interventions alongside clinical IMAI training among the clinical care team.

The second component of this activity includes providing technical assistance to Zonal and District Health Offices to support the HIV prevention activities of Health Extension Workers. Technical assistance will encompass engagement by the TBD contractor to ensure adequate in-service training, support to ensure referrals of most at risk populations and counseling in the community and at a health post level of the ART health network. This new cadre of health worker is placed at the community level to serve several villages (i.e. Kebele) in peri-urban fringe and rural areas. In total, 30,000 Health Extension Workers (HEW) will be deployed by 2010. The HEW is the first point of contact at the community level for the formal health care system. The HEW reports to public health officers at the health center and is responsible for a full range of primary and preventive services at the community level. They function as a significant and new link in the referral system and will be able to, through community counseling and mobilization, move vulnerable and underserved populations into the formal health system. During FY07 HEWs will function as the lead position at the health post and the community level to provide social mobilization activities in HIV prevention.

The third component of this activity includes, in partnership with local authorities, identifying, training and deploying outreach volunteers to support and facilitate the role of community outreach by Health Extension Workers. Through this activity, outreach volunteers will provide technical support to the Regional HIV/AIDS Prevention and Control activities in communities through community conversations and outreach counseling at the household level. In addition, outreach volunteers will support Case Managers in tracking and counseling those who drop from appointments for clinical care. Outreach volunteers, as local individuals, will use culturally appropriate approaches in discussing HIV/AIDS, primary ABC and secondary prevention. This will include identifying misconceptions, sitgma reduction, highlighting the gender and HIV burden for young women in Ethiopia and negative social and cultural norms.

This activity will strongly support regional government prevention efforts through social mobilization. The Care and Support Contract's coverage is anchored in predominantly peri-urban settings reaching out from health centers to health posts through Outreach Volunteers in coordination with Health Extension Workers, Peace Corps and other community agents for social mobilization activities. Case managers will refer HIV-positive clients to VCT and lay counselors for prevention for positive counseling. Outreach volunteers, in coordination with Health Extension Workers, will be responsive to local needs, distinctive social and cultural patterns. They will coordinate and assist in the implementation of HIV prevention efforts of local governments by supporting the provision

of accurate information about correct and consistent condom use and supporting access to condoms for those most at risk of transmitting or becoming affected with HIV.

Outreach Volunteers will play an active role in broader community and family-based counseling including the distribution of Government of Ethiopia and PEPFAR Ethiopia IEC BCC materials. Both Case Managers and Outreach Volunteers will support the provision of counseling interventions with abstinence and fidelity messaging, and improve client knowledge and understanding of discordance. The Care and Support Contract will collaborate with existing prevention partners so as not to duplicate ongoing PEPFAR Ethiopia and Government of Ethiopia activities.

This activity will consolidate the delivery of prevention messages to clients of MTCT, VCT, FP, TB and STI services, and PLWHA and ART clients to capture programming synergies and cost efficiencies. Case managers and Outreach Volunteers will utilize interpersonal approaches to behavior change on topics including VCT, substance abuse, abstinence, faithfulness, correct and consistent use of condoms, STI referral, targeted condom promotion and distribution and other risk reduction education.

Community Mobilization through Care and Support Contractor (CSC) Outreach Workers

This is a continuing activity. As of August 2006, 100% of funds were obligated to the SOAg to support programming in this mechanism when awarded in December 2006 or January 2007.

This is a comprehensive ABC activity, linked to the care and support contract (Pallative 10647,TB/HIV 10400, ART 10399, 10604 CT)TBD/CSC (RFP) to be awarded in 2006 found in CT, PC, TB/HIV and ART. In addition, this activity is linked to activity 5768, PEPFAR Ethiopia's support of MOH/Health Extension Workers.

Recent ANC and EDHS indicate greater concentrations of HIV infection in urban and peri-urban areas. Given the low urbanization rates, a significant proportion of HIV/AIDS cases remain in rural areas. In response, this activity prioritizes the deployment of case managers and outreach volunteers to the peri-urban fringe and rural areas in/around ART health networks, and supports Government of Ethiopia efforts to deploy Health Extension Workers to these areas.

The activity has several components.

One component utilizes non-medical case managers in health centers to support consistent ABC communications with PLWHA or most at risk groups appearing. These brief counseling periods, anticipated after a closer relationship is formed with case managers, represent efforts to integrate and mainstream brief motivational interventions alongside clinical IMAI training among the clinical care team.

The second component of this activity is technical assistance to Zonal and District Health Offices to support HIV prevention activities of Health Extension Workers. Technical assistance will encompass engagement by the TBD contractor to ensure adequate in-service training, referral support for most at risk populations, and counseling at community and at health post levels. This new cadre of community health worker is to serve several villages (i.e. kebele) in peri-urban fringe and rural areas. An anticipated 30,000 HEW will be deployed by 2010. The HEW is the first point of contact at community level with the formal health care system. The HEW reports to public health officers at the health center and is responsible for a full range of primary and preventive services. They function as a significant and new link in the referral system and will be able to move, through community counseling and mobilization, vulnerable and underserved populations into the formal health system. During COP07 HEW will function as the lead position at health post and community levels to provide social mobilization activities. .

The third component of this activity includes, in partnership with local authorities, identification, training and deployment of outreach volunteers to support and facilitate the role HEW. Through this activity, outreach volunteers will provide technical support to the Regional HIV/AIDS Prevention and Control activities in communities through community conversations and outreach counseling at the household level. In addition, outreach volunteers will support case managers in tracking and counseling those who miss clinical appointments. Outreach volunteers, as local individuals, will grasp culturally appropriate manners in discussing HIV/AIDS primary ABC and secondary prevention. This will include mitigating misconceptions, sitgma reduction, highlighting the gender and HIV burden for young women and negative social and cultural norms.

The USG anticipates that this activity will strongly support regional government prevention efforts through social mobilization.

CSC coverage is anchored in predominantly peri-urban settings reaching from health centers to health posts through outreach volunteers in coordination with HEW and other community agents for social mobilization. Case managers will refer HIV+ clients to VCT and lay counselors for prevention, for positives counseling. COOWS, in coordination with Health Extension Workers, will be responsive to local needs, distinctive social and cultural patterns. They will coordinate and assist implementation of local government HIV prevention efforts correct consistent condom use education and access to condoms where needed.

Outreach volunteers will play an active role in broader community and family-based counseling, including distribution of Government of Ethiopia and PEPFAR Ethiopia IEC BCC materials. Both case managers and outreach volunteers will support provision of counseling interventions with AB messaging, improve client knowledge and understanding of discordance. CSC will collaborate with existing prevention partners to avoid duplication of ongoing PEPFAR Ethiopia and Government of Ethiopia activities.

This activity will consolidate the delivery of prevention messages to clients of MTCT, VCT, FP, TB and STI services, and PLWHA and ART clients to capture programming synergies and cost efficiencies. Case managers and outreach volunteers will utilize interpersonal approaches to behavior change on topics including VCT, substance abuse, abstinence, faithfulness, correct consistent condom use, STI referral, targeted condom promotion and distribution and other risk reduction education.

Care and Support Contract- Palliative Care (CSC-PC). [NB: This TBD activity was previously named, Building Ethiopia's Response for HIV/AIDS Network (BERHAN) Palliative Care].

This activity will provide integrated prevention, care and support services and is described in the program areas of Prevention AB (5760), Prevention OP (5791), Care and Support Contract- HCT (5654), Care and Support Contract TB/HIV(5749), Treatment services and linked to JHU (5618), ITECH (5767), UCSD (5770)CU (5772) palliative care activities. This is a follow on of FHI/IMPACT activity. Proposals for the follow-on project have been reviewed and a new project will be awarded in early FY07. An end of project evaluation indicated that the IMPACT project contributed substantially to the rapid augmentation of HIV services. These included: expansion of HIV/ CT services in 469 government and private facilities; establishment of TB/HIV and chronic care services at health center level; establishment of HCBC programs and mobilization of communities to engage in AIDS care and support, community-level ART and TB treatment adherence support; and development of multi-sectoral referral networks at community level and between community, health center and hospital services. As of March 2006, IMPACT supported 469 counseling and testing sites, where 436,885 individuals were tested and received results. The activity also supported 198 TB/HIV sites in different parts of the country, and provided TB/HIV services to 26,447 patients. Hospital-centered delivery of care and support services is near capacity. A recent assessment conducted by JHU indicates that hospital providers on average spend only seven minutes with each ART patient. In addition, the Government of Ethiopia has accelerated decentralization of care and treatment to health centers. To complement this strategy, PEPFAR Ethiopia will continue to expand the delivery of palliative services throughout the health network. The CSC-PC will continue to work in health centers and health posts, the facilities that deliver most preventive and curative services throughout Ethiopia. As part of the ART health network, CSC-PC will link with ART hospitals for referrals and work with clients and their families in the community.

During COP07, this activity will continue to support a massive scale-up of care and support services that began in COP06 in line with the MOH decentralization of HIV/AIDS care at health centers. Activities include implementation of enhanced palliative care services in 393 selected health centers nationwide. Health centers that are geographically and functionally linked to ART health networks will be included in this category.

At these selected health centers, PEPFAR Ethiopia will provide technical assistance to support asymptomatic and symptomatic care including: (1) developing and updating semi-annual HIV/AIDS prevention, care and service plans jointly with Woreda health offices, health center administrators and clinical care teams; (2) implementing personalized and family-focused care plans; (3) providing clinical care services based on Integrated Management of Adult and Adolescent Illnesses (IMAI) and treating opportunistic infections; (4) establishing, standardizing and/or strengthening chronic care clinics and clinical care teams including terms of reference for health providers, supportive supervision and cross-training opportunities; (5) working closely with Tulane University and other PEPFAR partners to achieve effective patient tracking and identification, and data measures to ensure that PLWHA receiving palliative care services at different levels will be reported only once; (6) delivering clinic-based elements of the Preventive Care Package including Long Lasting Insecticide Treated Nets (LLITN) in malaria endemic areas, Cotrimoxazole Preventive Therapy (CPT), prevention for positives, screening for active TB among HIV+ clients, and nutrition counseling in collaboration with the GFATM and World Bank; (7) educating on safe water and personal hygiene and linking to community-based safe water initiatives; (8) integrating nutrition assessment and monitoring in the health center based HIV care settings, and referring severely malnourished PLWHA to food-by-prescription and later to Title II food or livelihood support initiatives. (Food-by-prescription will be initiated at least 25 health centers providing ART services); (9) improving quality of laboratory services including complete blood count, acid fast bacilli microscopy, stool for ova and parasites, malaria smear, pregnancy test and serology for HIV and syphilis; and routine quality assurance and control of laboratory practices with CDC support; (10) implementing standardized paper records management including procurement in coordination with the US universities and RHB.

This activity will also strengthen pediatric palliative services by increasing detection of pediatric HIV cases through family centered, PMTCT,OVC, TB/HIV, adult palliative care

and home based care programs and improved pediatric diagnosis. In addition to provision of elements mentioned under the adult preventive care package, pediatric clients will receive regular nutrition and growth monitoring, safe infant feeding, therapeutic and supplementary feeding through facility level food by prescription in selected health centers, and referral to community-based WFP food and nutrition outlets. Moreover, infants and children will benefit from existing non-PEPFAR child survival interventions. While rapidly expanding palliative care services, this activity will ensure provision of quality services through use of standard guidelines.

This mechanism will continue to provide technical assistance to RHB, zonal and Woreda health offices to deploy case managers in 393 health centers providing enhanced palliative care. Support includes the cost of the case managers' training, deployment, supportive supervision, and salary.

The activity continues to support major elements of the health network model including case managers based at health centers. These key staff will continue to collaborate with Health Extension Workers, Community Health Agents, and Traditional Birth Attendants to support and link patients with community-based services. These include the promotion of adherence, referral to RH/FP and child survival services, delivery of elements of the preventive care package, and referrals to spiritual counseling.

These efforts will continue to promote effective referrals within health centers, to and from hospitals for specialized care, and to and from community and faith-based organizations. A data tracking system supporting case management will link hospitals, health centers and community services through Tulane University strategic information support.

To create additional linkages between the health network, communities and families, PEPFAR Ethiopia will continue to provide technical assistance to selected Kebele HIV/AIDS desks and health posts to deploy, at a minimum, five volunteer outreach workers supporting Health Extension Workers in their community outreach activities. The outreach workers will collaborate closely with existing community health promotion volunteers and reproductive health agents. In addition, CSC-PC will work closely with FHI's Community-level Responses to Palliative and preventive care activities to further strengthen local ownership and capacity development of indigenous partners. Finally, the CSC-PC works closely with PEPFAR Ethiopia university partners and WHO to provide clinical mentoring at health centers.

Care and Support Contract (CSC) (TB/HIV)

This activity is linked to Care and Support Contract TB/HIV (5749) Care and Support Contract Palliative Care (5616), Care and Support Contract counseling and testing (5654), and ART Service Expansion at Health Center.

This is a continuing activity from FY05 and FY06 currently being run by Family Health International. As of March 2006, FHI IMPACT established 198 TB/HIV sites in different parts of the country and provided TB/HIV services to 26,447 patients. To date, the partner has received 100% of FY06 funds and is on track according to the original targets and workplan.

Forty to 60 percent of TB patients are co-infected with HIV. Health center and community outreach activities are major venues for case detection, diagnosis, care and treatment in Ethiopia where TB/HIV services are highly decentralized. The government policy of decentralization demands that all health centers serve as providers of TB diagnosis and treatment,

This activity will continue to strengthen health centers and health posts, the facilities that deliver most preventive and curative health services throughout Ethiopia. As part of the ART health network, (CSC-TB/HIV) will link with network hospitals for referrals and work with clients and their families in the community. It is anticipated that health centers continue receiving TB referrals from hospitals. Complex TB cases will be referred to hospitals. By September 2008, CSC-TB/HIV will be established in 500 health centers linked to the 131 ART hospitals. Many of these sites overlap with existing additional CT services including the preventive care package and ARV.

The CSC-TB/HIV approach conforms with the PEPFAR Ethiopia Five-Year Strategy of building up the public health sector and of promoting a set of TB/HIV interventions appropriate to specific partners in the ART health network.

During COP06, much experience has been gained from health center based TB/HIV activities. Family Health International's support to decrease the burden of TB in PLWHA continues to be achieved through TB screening, in health centers, HIV clinical, home, and community-based care settings. HIV counseling and testing has been decreasing the HIV burden in tuberculosis patients. CPT was provided by FHI and the Global Fund for PLWHA TB patients, and the patient referral system was improved.

Gaps still exist: integration between CT and TB services requires continued support. Important lessons learned include: (1) the need to strengthen patient referral systems, (2) the need for a case manager for HIV+ patients to ensure that services required by individual patients were accessed, recorded and monitored, and (3) the need to facilitate the referral of patients "up the line" for ARV treatment centers in hospitals, and conversely referral of patients for follow-up services at health center and community levels.

In COP07, CSC-TB/HIV will continue to coordinate with RHB and USG partners including the World Health Organization to provide regionally-distributed trainings to support TB/HIV service provision including OI counseling, bi-directional referral systems between TB, VCT, OI, FP, and STI services through a case manager, data management, customer service, performance standards and ethics using nationally accepted curricula to public health providers including VCT counselors and laboratory technicians.

TB/HIV interventions are a key component of the preventive care package. Health centers provide TB diagnosis and treatment through the DOTS strategy and VCT services. In COP07, the TB clinics will conduct the following (1) all TB patients will be given provider initiated counseling and testing (opt-out), (2) co-infected patients will receive ongoing counseling along with their TB drugs, (3) after the intensive phase of TB treatment, patients will be referred formally to the ART treatment center for ARV evaluation (4) co-infected patients will be provided with the preventive care package at the health center and community levels, (5) VCT clients will receive TB screening and formal referral to the TB clinic for diagnosis and treatment if necessary. The issue of provision of IPT at health center level needs further consultation. Its feasibility can be assessed in selected number of health facilities to guide future policy decisions.

In COP07, CSC-TB/HIV will support 500 health centers to diagnose and treat 60,000 TB patients of which, 34,000 (57%) will receive HIV counseling and testing. Of the 220,000 HIV+ clients expected to receive palliative care services at health centers, 100,000 (45%) will receive routine TB screening at least once. Screening is based on sign/symptom review and AFB smear microscopy for patients with a history of productive cough of more than two weeks.

The results of TB screening among HIV+ clients receiving palliative care will be recorded in the pre-ART and ART registers at health centers. Program performance will be monitored every quarter, under leadership of the Woreda Health Office and RHB. Supportive supervision will be provided by the RHB staff and experts from implementing partners. National and Regional TB/HIV Review Meetings will be held on regular basis.

Increasing case detection by providers at health center and within the community, specifically family-oriented case detection, is critical. Social mobilization activities will be supported through outreach workers who will establish relationships at health posts with Health Extension Workers (HEW). They will provide community groups and households with CT referral, adherence support and TB/HIV IE/BCC messages. CSC-TB/HIV interventions will have outreach workers and HEW who will screen PLWHA for TB based on symptoms and refer suspected cases to health centers for diagnosis, counsel TB/HIV patients to adhere to TB treatments, and confirm that TB/HIV patients receive CT and CPT.

Care and Support Contract - Counseling and Testing (CSC-CT)

This activity is linked to community-level counseling and testing service support in Ethiopia; the High Risk Corridor Initiative (5719), Care and Support Contract in Palliative Care (5616), and ART Service Expansion at Health Center Level.

The Care and Support Contract is a comprehensive prevention, care and support activity and is described in the program areas of Prevention AB, Prevention OP, Care and Support CT, TB/HIV, Palliative Care and Other/Policy. The Care and Support Contract (CSC) will work in health centers and health posts, the facilities that deliver most preventive and curative health services throughout Ethiopia. As part of the ART health network, the CSC will link with ART hospitals for referrals and work with clients and their families in the community.

PEPFAR Ethiopia supports the scaling up of CT services to enable Ethiopia to reach its targets for prevention, care and treatment. PEPFAR Ethiopia currently assists VCT centers based in hospitals, health centers, workplace and stand alone sites. The CSC provides rapid expansion of health services among three progressively more comprehensive tiers. The first tier, at 500 health centers, offers basic services including TB/HIV and VCT. The second, at 393 health centers, offers TB/HIV, VCT and palliative care services. The third tier, at 240 health centers, offers ART as well as the above services (see the Annex- for more details).

Rapid expansion of HIV/AIDS care and treatment services has prompted a significant increase in VCT nationwide through PEPFAR-funded activities, such as FHI's IMPACT project, Save the Children Federation/US (Save/US) along the Addis Ababa- Djibouti High Risk Corridor and US university partners supported hospitals. This support has encompassed assessment of existing services and implementation with respective RHB. The numbers of VCT centers continues to increase with the MOH plan to have at least one VCT center per health center and per hospital.

The National Counseling and Testing Guidelines are being revised to include provider initiated counseling and testing, engagement of non-medical counselors and other important issues, such as the maximum age requiring parental consent. PEPFAR Ethiopia will support health centers to implement the new Government of Ethiopia guidelines to maintain support to existing health center VCT services and scale-up CT services through provider initiated counseling and involvement of non-medical counselors. Moreover, all VCT services supported by this project will be linked to a specific, functioning referral system, through case managers, to ensure that HIV+ clients are linked to care and treatment services.

During FY07, PEPFAR Ethiopia will provide technical assistance to 500 health centers nationwide through the CSC mechanism. The technical assistance includes provision of support for HIV VCT by medical and non-medical counselors, and provider initiated counseling and testing (PICT) services; quality assurance of counselor performance including in-service performance improvement; screening for active TB among VCT/PICT clients; outreach services to target most-at-risk populations in surrounding areas; quality HIV tests including implementation of simpler techniques, such as finger pricking instead of using venous puncture to collect samples ( once approved by national authorities); and routine quality assurance and quality control of laboratory services mechanisms.

This activity will also build local capacity in a sustainable manner through TOT programs for regional, zonal and Woreda level master trainers on HIV testing and counseling. Other technical support activities will include: training of five counselors per health center, followed by refresher training and site level cross training to facilitate knowledge transfer and sustainability; ensuring consistent availability of HCT services at the health centers by advocating availability of full time medical or non-medical counselors; ensuring availability of standard registration books and client intake forms ; supporting site level data analysis, utilization and timely reporting to public health authorities; strengthening regular supportive supervision by regions, zones and Woredas; regional and national review meetings to discuss best practices, strengths, weaknesses, challenges and the way forward to establish sustainable VCT services; partnering with RPM+ and SCMS to support facilities, Woredas, zones, and regions to ensure consistent supply of HIV test kits; and

supporting regular quality control of HIV tests in partnership with national, regional and sub regional laboratories.

This activity will also work to improve the quality of HIV/AIDS counseling services through integration of standard self-reflection and peer supervision tools in all health centers supported by this mechanism.

This activity will also support the linkage of VCT services with HIV/AIDS prevention, care and treatment services with strong emphasis on "prevention for positives| counseling and strong linkages with community-based HIV/AIDS services through case managers, health extension workers and outreach workers.

Strengthening Pharmacy Capacity: Improving Pharmacy Infrastructure and QA of ARV

This is a continuing activity from FY06. To date, the partner has received 100% of FY06 funds and is on track according to the original targets and work plan. It has provided technical support in ARV and related commodities supply management in 109 hospitals and 23 health centers. This support includes training 236 staff on ARV management and Drug and Logistics Management Information Systems; technical support in the developing the national health commodities logistics and pharmaceutical master plans; and technical support in the establishment of antimicrobial resistance(AMR) committees, and drug and therapeutic information centers (DIC and DTC). This activity is linked to Prevention, Care and Support, ART, renovation and laboratory services. All activities listed below will be carried out under the directionof the Pharmaceuticals and Medical Supplies Import and Wholesale Enterprise (PHARMID).

Ethiopia's 2006 decision to decentralize ART services to the primary health care unit demands intensive support at site level to reach the national ART targets. To address this situation, in FY 2007 PEPFAR Ethiopia will support the provision of HIV commodities at through RPM+, with a primary focus on site level activities supporting effective pharmaceutical management. During this transitional year, as the Supply Chain Management System Project (PSCMS) becomes fully operational, some resources will be utilized in a phased transition with the new project, transferring critical procurement and supply chain management functions currently supported by RPM+ to PSCMS. The two projects will be co-located; and joint work planning is underway, supporting a seamless transition characterized by close coordination, including co-sponsoring of some activities. The activity will focus on the following areas:

1. Dispensing and Site-level Inventory Management: RPM+ will collaborate with PSCMS and other stakeholders, under PHARMID's direction, in implementing rational drug dispensing and commodity use practices at service delivery level for antiretroviral (ARV), Opportunistic Infection (OI) and Sexually Transmitted Infection (STI) drugs, Prevention of Mother-to-Child Transmission (PMTCT) commodities, laboratory reagents and test kits. This support will be focused at site level, with PSCMS handling other levels.

RPM+ will assist the Ministry of Health's Pharmaceutical Supplies and Logistics Department (PSLD), as it transitions to the Ethiopia National Drugs Program (ENDP) Unit, in the development of a mechanism for product exchange between sites, optimizing stock levels and preventing stock outs and expiry of drugs. It will also support PHARMID in quantification exercises and site level implementation of a new ordering system. RPM+ will work closely with relevant institutions such as PSCMS, supporting PHARMID in transitioning to the new system, through training and retraining of pharmacy personnel. PSCMS will assume this role after this transitional year.

RPM+ will assist pharmacy and treatment adherence support personnel in conducting ARV use counseling and patient follow-up to ensure adherence, compliance and proper ARV drug handling.

2. Strengthening Human Resource Capacity at Pharmacy Level: With the Ethiopian Pharmaceutical Association and the Addis Ababa University School of Pharmacy, , staff from ART sites will be trained in supply management, pharmaceutical care, Rational Drug Use (RDU) and computer skills. Training will be followed by supportive supervision and mentoring, in collaboration with relevant stakeholders and partners. RPM+ will continue donating technical materials and organizing partner exchanges

3. Improving Quality Assurance of ARV and Related Commodities: RPM+ will continue to provide technical assistance to the Drug Administration and Control Authority (DACA), primarily through staff seconded to DACA's Quality Control (QC) Laboratory, ensuring the quality, safety and efficacy of ARV, anti-tuberculosis (TB) and anti-malaria drugs. The project will continue building the capacity of DACA's drug QC laboratory, improving lab conditions, promoting proper storage of reagents and proper record keeping, and providing reference books and standards, computers and accessories. RPM+ will continue to provide TA in the development of standard operating procedures (SOP) for the pharmaceutical and logistics systems, and in development of an electronic data base and reporting system for the laboratory. Finally, RPM+ will support establishment of six

regional QC mini-labs.

In collaboration with PSCMS, RPM+ will support the efforts of DACA and the PHARMID in post-marketing surveillance of HIV/AIDS, TB and malaria drugs.

4. Strengthening Site-Level Drug and Laboratory Logistics Information Management: RPM+, in a phased transition with PSCMS, will support distribution of ARV drugs and related products from regional stores and at individual sites. Under COP07, PSCMS will strengthen PHARMID at national and regional levels, taking over all USG procurement and supply chain management support by the end of COP 07.

RPM+ will build on experience acquired to date to support improvements in inventory and pharmacy data management, and to operationalize the ART SOP and pharmacy forms and registers at supported sites. Existing manual drug inventory and patient pharmacy data tools will be fully computerized at target facilities, per availability of electrical supply. Supportive supervision and monitoring and evaluation of ARV drug management and use will be supported, to ensure effective programs. As an interim measure where facilities have a critical shortage of personnel to handle information, RPM+ will provide data clerks.

RPM+, in collaboration with PSCMS, the Ethiopian Health and Nutrition Research Institute (EHNRI) and other stakeholders, will assist in the review of existing operating procedures for laboratory commodity management and will develop SOPs for this function. In transition with PSCMS and other partners, RPM+ will finalize ongoing work to implement an electronic laboratory commodity information management tool.

5. Provision of TA including Coordination: In a phased transition with PSCMS to avoid shortages during this transitional year, RPM+ will continue to provide TA in Drug Supply Management (DSM), focusing at the health facility. This joint TA will include stock level and expiry monitoring, data collection and reporting. Site-level TA and coordination efforts will focus on facility-level ART and laboratory supply management; promoting rational drug use (RDU) of ARV; pharmaceutical care; drug efficacy and toxicity monitoring; Adverse Drug Reaction (ADR) monitoring; ARV adherence support; and approaches to contain AMR. Other activities will promote collaboration between programs (HIV/AIDS, TB and Malaria) and conducting drug-related operational research. RPM+, in collaboration with PSCMS, DACA and PSLD, will provide TA to establish or strengthen DIC and DTC at health facilities.

6. Improve Pharmacy Infrastructure and Equipment: RPM+ has engaged in renovation of hospitals and health centers as part of the GOE's ART service expansion, focusing on storage areas, dispensing pharmacies and adherence counseling areas. As of June 2006, RPM+ has renovated 23 hospitals and nine health centers. An additional eleven hospitals and 73 health centers are to be renovated with COP06 funding in close coordination with the GOE, Crown Agents and RPSO. During FY 2007, the project will continue conducting small-scale renovation, in collaboration with these partners.

Data Use at Health Centers for Programmatic Improvement

This is a new activity. It also relates to the Care and Support Contract (CSC) Palliative Care (5616), CSC (TB/HIV) (5749), CSC counseling and testing (5654), ART Service Expansion at Health Center Level, PMTCT/Health Centers and Communities (5586), National Monitoring and Evaluation System Strengthening and Capacity-Building (5582, 1090, 1094, 5714), activities. This activity will also be strengthening the implementation of the national HMIS.

Under PEPFAR Ethiopia, access to free ART has markedly increased to become a major component of HIV/AIDS services in addition to the prevention and care efforts. This increase has important implications for data collection and use within and among health networks. PEPFAR Ethiopia is planning to expand provision of comprehensive HIV/AIDS services to 131 health networks in COP07. Despite the rapid expansion of HIV/AIDS services all over the country, very little attention was given to systematically collect, analyze, document and share the resulting health service information by and with stakeholders at all levels (i.e. health care personnel at facilities and health managers at zonal and regional levels). As a result, only limited data are available on the quality of services and barriers to utilization of services. It is, in turn, difficult to document best practices in PMTCT, VCT, PIHCT, TB/HIV, palliative care and ART services.

Besides the logistics, infrastructural and human resource inputs, the availability of appropriate information at these sites is essential for the success of the ART scale up and other HIV/AIDS care services. A huge amount of patient data are generated that need to be reported to various levels through appropriate channels. Most importantly, these data are required in order to improve and maintain quality of service at the health centers. Ensuring data capture and the capacity to effectively use these data at the health center level is a major priority.

In COP07, this activity will provide training to appropriate health center staff on data entry, data cleaning, and data analysis techniques. A recent assessment of health centers for ART readiness revealed that most facilities don't have computer trained data clerks. Hands on training will be provided on basic computer packages for capturing and analyzing patient data. This activity will include training on report writing and data presentation technique to ensure staff are able to successfully communicate accurate and practical status reports that reveal both problems and success stories.

Information should be used for decision making at the point of source. Staff will be trained on how data are used to improve program and service delivery, and how to measure program effects (e.g. service utilization and behavioral outcomes). Data quality issues will also be addressed to ensure the validity and reliability of data coming from the facilities.

Health facility staff will be trained to use the national HIV/AIDS monitoring and evaluation framework, and the associated data capturing and reporting formats. Facilities staff will also be trained to develop their own monitoring and evaluation plans, which will ensure effective communication of information within and outside of the health centers.

Computers, printers and related information communication technology (ICT) equipment will be supplied to the facilities as appropriate for local conditions based assessment findings on existing gaps.

This activity will focus primarily on health centers that are undertaking HIV/AIDS interventions including VCT, ART, and PMTCT. It will work within existing systems, such as the national monitoring and evaluation framework, and link with other health facilities in the network model with the aim of enhancing information sharing for program improvement. District health bureaus will also be supported to build their capacity in data management.