Integrated Service Strengthening

This is a continuing activity from FY 2007. This activity relates to activities in Prevention, Care, and Support,

ARV Drugs, ART and laboratory services.

Currently the Government of Ethiopia (GOE) is scaling-up the decentralization of the ART services to health

centers ,and to date 139 health centers have started to deliver ART services in the country. To support this

scale-up, the World Health Organization (WHO) has conducted trainings on Integrated Management of

Adult and Adolescent Illness (IMAI) for 1,384 health professionals from 10 of the 11 regions using USAID,

Italian, and Canadian funds.

Critical shortage of human resources, particularly physicians and health officers, is being observed at the

health centers. Capable nurses are present in relatively larger numbers, though more personnel of all types

are needed. In response to this situation, the Ministry of Health (MOH) has revised the national guideline

supporting the nurse-centered HIV/AIDS services, featuring task-shifting, particularly in the area of ART

services. The MOH HIV/AIDS Prevention and Control Office (MOH/HAPCO) is working with relevant

stakeholders including PEPFAR Ethiopia and WHO on how task-shifting is implemented during ART

services expansion to the health-center level without compromising the quality of services.

As part of WHO "Treat, Train and Retain" initiative to address shortage of health workers and the response

to AIDS, WHO, with PEPFAR Ethiopia partners, is assisting the Government of Ethiopia on standardization

of task shifting and HIV treatment, prevention, care, support services for health workers. On this line, WHO

will continue to provide technical assistance to MOH on the implementation phase of the "Treat, Train and

Retain".

As per the request of MOH/HAPCO, WHO, with relevant PEPFAR Ethiopia partners, will support creating a

national electronic health workforce database (HRIS) which will provide more reliable information on

workforce demographics, training needs, migration patterns and workforce capacity. Information such as the

number of healthcare workers by cadre, credentials, workforce location, training, and age demographics

can assist the country to more accurately assess workforce needs.

This activity will provide technical assistance to the health centers and community-based delivery sites to

have more sustainable as well as improved quality of HIV prevention, care, and treatment services. The

capacity of healthcare providers working at the first level health facilities and HIV/ART program at region,

zonal, and district levels will be strengthen based on the IMCI/IMAI service delivery approach.

Activities will include: adaptation, standardization and dissemination of the IMAI training materials to

address tuberculosis care with TB-HIV co-management, PMTCT, reproductive health (RH) and family

planning (FP), in partnership with the MOH and other relevant PEPFAR partners. The integrated

management approaches to health system using IMAI will improve the case management of HIV and

tuberculosis co-management, STI management, improved management of pediatrics ART, improved

maternal health services through the expansion of an integrated approach to PMTCT, and RH/FP. This will

ensure that Ethiopia continues to benefit from innovative technical approaches supporting the integrated

health services across the care continuum for patients.

WHO will work with other key PEPFAR Ethiopia partners, notably the MSH Care and Support Contract, at

the health-center and community level on trainings based on service delivery approach. The IMAI clinical

training will target the clinical team at the health center (physicians/health officers, nurses, pharmacy

technicians, and case managers); Expert Patient Trainers (EPT); data clerks and health extension workers.

WHO will closely work with the RHB, local universities and regional nursing colleges to create a pool of

trainers in all 11 regions. Intensified training of trainers (TOT) will be conducted for the potential trainers

selected from regional health facilities, public, and private local universities/colleges. These will be resource

trainers both in pre-service as well as the in-service IMAI trainings in each region. As sustainability of the

decentralized ART program is very crucial, WHO in partnership with PEPFAR Ethiopia, regional health

bureaus (RHB) and local universities/colleges will focus on the pre-service training. Through this activity, a

cumulative total of 450 health center will provide ART services and 650 health centers implementing

enhanced palliative care services.

WHO is taking a leading role in development of national clinical mentoring guideline and training materials.

With key PEPFAR Ethiopia partners, WHO will continue in supporting the RHB at different levels in

development of regional implementation plan for clinical mentoring, building regional capacity to facilitate

clinical mentoring and train clinical mentors. Potential mentors will be selected from experienced practicing

HIV/ART clinicians (doctors, health officers and nurse-practitioners). Priority will be given to proficient

clinicians who are already treating HIV patients.

WHO will work in improving the quality of the HIV prevention, care, and treatment services at the health

center and community level. This will be done by increasing the capacity of the regional, zonal and district

HIV program teams on integrated health service management. WHO with relevant PEPFAR Ethiopia

partners will link the internationally reputable "Health Service Management and Leadership" short courses

with the local universities in order to capacitate the 11 RHB management team at different levels. This will

assist to have a sustainable indigenous institutional capacity to sustain public health approaches at these

key levels of health system in Ethiopia.

Furthermore, WHO will keep on providing one week HIV program management training to increase the

supervisory capacity of zonal and district management teams. In the context of improving the quality of HIV

care and treatment services, WHO with key partners will continue providing the necessary technical and

logistic support for RHB at different levels to conduct a regular supervisory site visits (at least six times per

year) and organize a quarterly review meeting among healthcare providers working at the first-level health

facilities and HIV program teams at zonal and district level. The IMAI tools for district HIV coordinators

include standardized case management observation and exit interviews that will be included as part of the

routine reports submitted by district HIV coordinators to regional and national offices.

As Health Network Model is crucial for effective HIV prevention, care, and treatment, WHO with relevant

PEPFAR partners will closely work on the continuum of care between the health facilities and the

Activity Narrative: community. By appropriate training of the health extension workers (HEW) and community

promoters/volunteers, the tracking of ART defaulter cases as well as the referral/back referral linkage

between the first level health facilities and community will be improved. With this activity, WHO with relevant

PEPFAR partners will provide in-service as well as pre-service (22 out of the total 36 Technical and

Vocational Education Training Centers) community IMAI training for Health Extension Workers.

Analysis and routine quality assurance for health center and community work: in order to ensure quality of

services, the following activities will be continued. Certification and licensing of the health workers providing

HIV care and ART; analysis of the routine use of IMAI acute care guideline module; treatment validation

studies of acute care guideline; identification, follow-up and management of HIV-exposed and -positive

children through IMCI-HIV approach; opportunistic infection prevention and management for persons with

HIV (including routine screening for tuberculosis); and integration of HIV prevention in care and treatment

services.

As to the quality of data on patient monitoring, data clerks at the facility level will be trained and the district

HIV coordinators will be supported to fulfill their role to aggregate data from several facilities and to

supervise health workers in the use of this system. Strengthening of the non-ART data on-site and establish

coordinated linkage of HIV related activities (HCT, OI management, TB management and etc.) is very

crucial. This will be done through regular site visits, during which review of recording and reporting forms

will take place.

Support to the Global Fund Country Coordinating Mechanism

The Government of Ethiopia has secured $713,053,234 from the Global Fund for AIDS, Malaria, and

Tuberculosis (GFATM) for five years to address HIV/AIDS (66%), malaria (26%), and tuberculosis (TB-9%).

In order to oversee, facilitate, support, and monitor these funds, a Country Coordinating Mechanism (CCM)

was established in early 2002. The 17 CCM members include: Ministry of Health (4 members, including the

Chair); HIV/AIDS Prevention and Control Office (1); Ethiopian Health and Nutrition Research Institute (1);

the World Health Organization (WHO, 1); the Joint United Nations Program on HIV/AIDS (UNAIDS, 1);

Health, Population and Nutrition Donors' Group (2); PEPFAR Ethiopia (1); Department for International

Development (1); Christian Relief and Development Association (1); Dawn of Hope (Vice Chair, 1);

Ethiopian Employers' Federation (representing the private sector) (1); Ethiopian Public Health Association

(1); and the Ethiopia Inter-Faith Forum for Development Dialog for Action (1).

PEPFAR Ethiopia has made major contributions towards implementation of the GFATM. Some examples of

the depth and scope of PEPFAR's involvement include: active membership on the CCM since its inception,

technical assistance for proposal development, support of the Secretariat since November 2003, and

chairing the sub-committee responsible for preparing the mechanism's Terms of Reference (TOR).

The CCM Secretariat carries out the administrative activities that allow the CCM to function smoothly,

organizing meetings, ensuring that relevant documents are available, and supporting CCM members in

serving on sub-committees with various functions. The Secretariat also supports key proposal-development

processes and funding-approval processes. Without the Secretariat, successful management of Ethiopia's

grants, the largest total to any country in the world, would be extremely problematic.

During FY05, FY06, and FY07, PEPFAR provided modest funds to support the CCM Secretariat. This USG

contribution leveraged funds from UNAIDS and the Royal Netherlands Embassy, and has been managed

through the WHO Ethiopia Country Office. PEPFAR Ethiopia proposes to continue this modest funding in

FY08 to assure the successful management of Ethiopia's grants for HIV/AIDS, malaria, and TB.

The performance of the four GFATM grants is of concern within the donor community. Recognizing the

GFATM's operating principle of performance, the CCM's TOR state that it is to submit high-quality

proposals and provide oversight of the proper use of the GFATM through regular monitoring. The TOR

explicitly states: "…the CCM/E will provide a monitoring report on fund status, including its progress, results,

and organizations with approved funding and their expected total level of funding." The report will be made

available through a wide variety of communication channels.