Mother to Mother (M2M) Training and Supervision Support

This is a continuing activity from FY07. In FY07, JHPIEGO held responsibility for mother support groups at

15 hospitals. In FY08, JHPIEGO will implement the mother support groups at 20 additional hospitals and

five community support groups.

In FY07, JHPIEGO started working with the National Network of Positive Women Ethiopia (NPWE) by

inviting network members from the regions to be active participants and coordinators of some of the mother

support groups (MSG) sites at the hospital level. In FY08, JHPIEGO will continue strong collaboration with

NPWE and IntraHealth, another PEPFAR partner, to establish MSG at 20 new hospitals and five community

sites. The community MSG will largely be run by the NPWE, with technical assistance from partners

involved in MSG. This community support group will be a basis to start programs which will bolster male

involvement in the prevention, care, and treatment of women.

As part of the continuation of the MSG, JHPIEGO will also facilitate the strengthening of prevention, care,

and treatment to women using the "mothers' voice" initiative. This is a warm-line which will have access to

women coming to health facilities through their mentors and site coordinators, as well as to pregnant and

postpartum women at home who have the desire to learn the many facts about PMTCT, ART, and infant

feeding in the context of HIV. JHPIEGO will facilitate the implementation of the warm-line in collaboration

with the AIDS Resource Center (ARC).

Parallel to the expansion of PMTCT services; JHPIEGO will also conduct a targeted evaluation on a

comparative basis among facilities with and without such MSG to determine effects of participation in the

group on subsequent use of PMTCT, prevention, care, and treatment services.

JHPIEGO will provide technical assistance to NPWE, as a local, institutional-capacity development activity.

In collaboration with PEPFAR partners and NPWE, JHPIEGO will facilitate linkages to income-generating

activities for HIV-positive mothers in the community. JHPIEGO will also facilitate institution of the Food by

Prescription initiative at hospital-based MSG.

Expansion of PMTCT Services at Family Guidance Association of Ethiopia Clinics

This is a continuing activity from FY07. To date, PMTCT services in Ethiopia have largely been

concentrated in public health facilities and limited private institutions. In FY08, JHPIEGO proposes scaling

up PMTCT services to local nongovernmental, as well as charity maternal-child health (MCH) clinics. In

FY08, JHPIEGO will do this in collaboration with the Family Guidance Association of Ethiopia (FGAE), an

established organization, which provided support to JHPIEGO to deliver VCT services at 35 sites in FY07.

The FGAE is a national organization with significant experience in family planning and other reproductive

health 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 regional to the community level. In FGAE clinics which

already offer MCH services, JHPIEGO plans to establish counseling and testing for PMTCT, with referral

linkages to public facilities in the vicinity for labor and delivery (L&D).

JHPIEGO will provide training, mentoring, and supportive supervision to initiate PMTCT services at ten

FGAE clinics. JHPIEGO will facilitate the delivery of combined ARV prophylaxis to be dispensed at FGAE

clinics and ensure referral of eligible HIV-positive mothers for ART. JHPIEGO will also take advantage of

FGAE's existing outreach service to promote testing and counseling and referral to PMTCT sites for

mothers who are not coming to health facilities.

In addition, in FY08, JHPIEGO will assist FGAE to establish labor and delivery services at two sites

selected based on client load and distance from an obstetric facility. After identifying where there is existing

need, JHPIEGO will support the initiation of L&D services by providing necessary equipment and materials.

If there is a need in these facilities to prepare rooms, JHPIEGO will work with FGAE to support minor

renovations. This support to FGAE will be the beginning of establishing comprehensive PMTCT services, as

well as maternal diagnosis and treatment in coming years.

Establishing a viable and comprehensive PMTCT service within FGAE will be a continuous process which

will need significant follow-up and advocacy. In the meantime, JHPIEGO, in consultation with FGAE, will

establish a referral linkage between FGAE sites and existing public sites for ongoing prevention, care, and

support. This linkage will be strengthened until FGAE has its own L&D capacity, as well as laboratory

capacity to do diagnosis and staging.

In a related FY06 PMTCT activity, JHPIEGO adapted the testing and counseling tools for accelerated opt-

out testing. This activity arose as a result of a recommendation from a PEPFAR technical assistance

consultation, and was funded from the PMTCT reprogramming fund. This activity is helping to scale up

PMTCT testing and counseling for opt-out testing, using standard tools and training materials. In FY07,

JHPIEGO supported US-based university partners to adapt the tools for Ethiopian settings. In FY08,

JHPIEGO will translate the tools into local languages and continue supporting US-based universities to

adapt the tools. JHPIEGO will also conduct a review and document the results of opt-out testing from a sub-

sample of sites.

Building on FY07 activities to orient regional and district level managers, JHPIEGO will continue to adapt

and review the PMTCT orientation package in FY08.

In FY08, JHPIEGO also proposes to pilot test the use of lay counselors in MCH settings for the purpose of

task shifting and increasing the uptake of PMTCT services.

National Infection Prevention

In FY07 and previous years, JHPIEGO supported Ethiopian governmental hospitals to properly implement

recommended infection prevention (IP) practices and processes. In FY08, JHPIEGO plans to give in-service

infection-prevention training courses for private hospitals and clinics. This is in response to specific requests

from many private facilities, including the Family Guidance Association of Ethiopia. Together with the

trainings for private facilities, JHPIEGO will support university partners with replacement IP trainings for

sites with high staff attrition.

Proper infection prevention in health facilities is largely dependent on support staff: housekeeping, laundry,

and kitchen. JHPIEGO proposes to develop a simplified training package, translated into local languages,

for use in training these hospital workers. JHPIEGO will also work with stakeholders to identify the most

cost-effective way of delivering the training to these supporting staffs.

The JHPIEGO infection-prevention team will also support other activities, including pre-service education

(COP ID 10611) and the development of electronic learning modules/materials (COP ID 10482) for use by

hospitals. JHPIEGO will also continue and strengthen support to professional associations such as the

Ethiopian Medical Association, the Ethiopian Public Health Association, the Ethiopian Nurse Midwives

Association, and the Ethiopian Nurses Association in FY07.

Another bottleneck in the implementation of proper infection-prevention practices has been lack of supplies,

especially personal protective equipment (PPE), antiseptic hand rubs and aprons, as well as lack of

maintenance of sterilizers and autoclaves. In FY08, JHPIEGO proposes to develop low-cost, locally

customized basic IP supplies. JHPIEGO intends to support two local Technical and Vocation Education and

Training institutions (TVET) to produce IP supplies, such as aprons, goggles, antiseptic hand rubs, sharps

and waste containers. The first pilot production will include 20 selected hospitals, with an emphasis on

teaching hospitals supported by PEPFAR.

For maintenance of sterilizers, autoclaves, and other relevant IP equipment, JHPIEGO proposes to

collaborate with a local contractor/partner, such as Departments of Technology at Addis Ababa University,

the Ethiopian Health and Nutrition Research Institute, Ethiopian Science and Technology Commission and

private biomedical engineering firms to design and deliver a generic training course on the maintenance of

laundry machines and autoclaves.

Maintaining and expanding current gains in infection prevention will require a coordinating body or group at

both the national and regional levels in the years to come. FY08 will be an opportunity to strengthen the

national infection-prevention/control working group and regional offices. JHPIEGO is setting aside some

funds to support the activities of this group with consultant assignments, workshops, printing, etc.

Strengthening Male Circumcision in Gambella and Southern Nations, Nationalities, and Peoples Region

(SNNPR)

This request for $50,000 in early funding will allow this important new activity to begin as soon as possible.

This is a new activity to provide comprehensive male circumcision service in Gambella.

Circumcision of men is widely practiced in different regions of Ethiopia and often serves as a rite of passage

to adulthood. According to the 2005 Demographic Health Survey (DHS), 93% of Ethiopian men aged 15-59

are circumcised. Circumcision was highest among men aged 40-44 and lowest among those aged 15-19.

Currently married men are slightly more likely to be circumcised than formerly married men. Men who have

never married were least likely to be circumcised. Circumcision was highest among Orthodox Christians

and Muslims and lowest among men of non-Christian and non-Muslim religions. With the exception of men

in Gambella and Southern Nations, Nationalities, and Peoples Region (SNNPR), circumcision is nearly

universal among men in the other regions. Fewer than one in two men living in Gambella (46%) are

circumcised, while three in four men living in SNNPR (79.6%) are circumcised.

The effect of male circumcision on the risk of HIV infection, and the impact of the practice in the spread of

HIV in different population groups has been a subject of interest. Many studies indicate that circumcised

men are less likely to become infected with HIV than uncircumcised men. There is substantial evidence that

circumcision protects males from penile carcinoma, urinary tract infections, and ulcerative sexually

transmitted infections (STI). There is also considerable evidence supporting association between the

presence of a foreskin and susceptibility to STI. Foreskin provides a warm, moist environment for the

growth of bacteria and viruses and is susceptible to scratches and tears during intercourse, which are

possible sources of viral entry. Lack of circumcision also increases the chances of infection with other STI,

which have been shown to enhance transmission of HIV. If lack of male circumcision is indeed an important

risk factor for HIV infection, then it merits some consideration as a possible intervention in HIV infection

control. Since circumcision is usually linked to cultural or religious practices, it has been argued that the

apparent protective effect of the procedure is not related to foreskin removal but to the behaviors prevalent

in the ethnic or religious groups in which male circumcision is performed.

Data from a range of observational epidemiological studies, conducted since the mid-1980s, show that

circumcised men have a lower prevalence of HIV infection than uncircumcised men. Three randomized,

controlled trials have made it possible to separate a direct, protective effect of male circumcision from

behavioral or social factors that may be associated with both circumcision status and risk of HIV infection.

These trials have been conducted in Orange Farm, South Africa; Kisumu, Kenya; and Rakai District,

Uganda. The results of these trials showed that following circumcision, the incidence of HIV infection was

reduced in men by more than half.

Male circumcision has been associated with a lower risk for HIV infection in international observational

studies and in three randomized, controlled clinical trials. Male circumcision could also reduce male-to-

female transmission of HIV to a lesser extent. It has also been associated with a number of other health

benefits. Based on the above evidence, in March 2007, the World Health Organization (WHO) has

considered male circumcision to be one element of a comprehensive HIV-prevention package that includes

the correct and consistent use of condoms, reductions in the number of sexual partners, delay in the onset

of sexual relations, avoidance of penetrative sex, and testing and counseling to know one's HIV serostatus.

From the DHS 2005 Ethiopian figure, the relation between HIV and male circumcision conforms to the

expected pattern of higher rates among uncircumcised men (1.1%) than circumcised men (0.9%).

Uncircumcised men in Gambella had the highest HIV prevalence rate (9.8%)—as compared to the HIV

prevalence rate (2.3%) among circumcised men in Gambella. The prevalence of HIV among uncircumcised

men in SNNPR was 0.7% which is higher than 0.3% among circumcised men. Therefore, it is a timely

intervention to plan and conduct male circumcision service in those regions in Ethiopia.

Because of its long years of experience with strengthening male circumcision services in other African

countries, and technical expertise in that area, JHPIEGO will conduct formative assessment, training, and

male circumcision services in Gambella and SNNPR regions in FY08

The following activities will be included:

1) JHPIEGO will work in community and clinic settings to conduct formative assessments on social and

cultural considerations and on integration of the service with other reproductive health services. The

assessment will be based on the WHO Assessment Tool Kit.

2) Training of trainers on safe male circumcision service and training of 50 healthcare providers in the two

regions using the WHO/JHPIEGO male-circumcision training manual. Instructors from Gambella Health

Sciences College will be trained to support pre-service education on male circumcision.

3) Producing information, education, and communications materials to provide information on the

importance, safety, and quality of male circumcision services

4) Initiating circumcision services in 12 healthcare facilities (four in Gambella and eight in SNNPR) as part

of the comprehensive package of prevention services. That package includes: provider-initiated HIV

counseling and testing; active exclusion of symptomatic STI and syndromic treatment when required;

counseling on behavior change, including a gender component that addresses male norms and behaviors;

provision of condoms and counseling on correct and consistent use; reduction of the number and

concurrency of sexual partners; and delaying the debut of, or abstaining from, sexual activity (ABC).

In FY08, the service will be provided to adolescents and adults, and this activity will look for opportunities to

provide the services for infants with integration with other reproductive health care services in subsequent

years. The service will be supported with intense communication and advocacy campaigns and will provide

patient education materials. JHPIEGO will procure all the necessary medical equipment and commodities to

run the service in 12 facilities.

National HIV Counseling and Testing Support

This activity describes three components of FY08 activities.

I. Building Human Capacity

During FY07, JHPIEGO worked with the Federal Ministry of Health (MOH), the national HIV/AIDS

Prevention and Control Office (HAPCO), regional health bureaus (RHB) and CDC to build human capacity

for providing high-quality HIV counseling and testing (HCT) services at 131 hospitals. Interventions included

training, updating materials, and training new community counselors following the successful pilot.

JHPIEGO started work with Addis Ababa Counselors Support Association (AACSA) to establish new

regional counselors associations and post-test clubs.

In FY08, JHPIEGO will:

1) Support the scale-up of HCT training by training a total of 60 new trainers in voluntary counseling and

testing (VCT), provider-initiated counseling and testing (PICT), and couples' HIV counseling and testing

(CHCT). JHPIEGO will also complete HCT training packages through the National HIV Counseling and

Testing Working Group (HCT TWG) and support printing of the materials.

2) Provide technical assistance to PEPFAR partners in conducting VCT training for community counselors

3) Work with AACSA through sub-agreement to further strengthen its capacity and train 120 counselors in

CHCT and burnout management. AACSA will provide supportive follow-up to these counselors. JHPIEGO

will also work with AACSA and other regional counselors' associations to support the establishment of 3-4

more regional associations networked into a National Counselors Association. Building on FY07

experiences, AACSA will explore the feasibility of establishing post-test clubs for couples at selected sites.

4) Complement Standards Based Management and Recognition (SBM-R) for HCT, as proposed in

application for SBM-R (under system strengthening)

5) Work closely with implementing partners to strengthen counselors' burnout-management program

II. Supporting the Expansion of Regional VCT Demonstration And Training Centers

By the end of FY07, PEPFAR will complete the renovation of four regional demonstration sites in Amhara,

Oromiya, Southern Nations, Nationalities, and Peoples Regions (SNNPR), and Tigray regions. JHPIEGO is

instituting model systems, including furniture, staff training, documenting best practices and use as a

practice site for trainees. In FY08, JHPIEGO proposes to further strengthen existing sites and establish two

similar facilities in the eastern and western parts of the country in consultation with partners.

Proposed activities for FY08 include:

1) Establishing two new regional CT demonstration sites, with the assumption that the Regional

Procurement Support Office will conduct renovations of service buildings and conference rooms

2) Support for implementing VCT services at all six demonstration sites

3) Support for the six sites to document best practices that can be transferred to other VCT centers in the

regions

III. Strengthen Local Nongovernmental Organizations (NGO) to Expand HCT

The Family Guidance Association of Ethiopia (FGAE) is a local NGO delivering sexual and reproductive

health services in an integrated fashion. These include: family planning services, cervical cancer diagnosis,

care for rape victims, management of sexually transmitted infections (STI), and HIV services (e.g., VCT,

condom promotion and distribution, treatment of opportunistic infections). FGAE's programs and services

cover many parts of the country through branches in regions, sites in workplaces, youth centers, and

outreach and marketplace activities. In FY07, JHPIEGO signed a sub-agreement with FGAE to strengthen

VCT and introduce PICT in 32 clinics and youth centers. Outreach workers were trained to provide

education and referral for HCT services. Sample collection through finger prick was piloted at some sites.

For FY08, JHPIEGO proposes to continue providing financial and technical support to FGAE to expand

current activities:

1) Training of FGAE trainers in VCT, CHCT, and PICT

2) Training 100 providers in PITC and training 100 VCT counselors (including community counselors) and

70 FGAE counselors in CHCT and burnout management

3) Supporting VCT, CHCT and PITC services at 35 sites

4) Train and support 400 volunteers to perform CT outreach activities, including provision of HCT in the

community

5) Document HCT best practices

6) Procure test kits and medical supplies, if these cannot be leveraged from sources funded through the

Global Fund for AIDS, Malaria, and Tuberculosis

7) Support FGAE to provide outreach CT programs at the market place and during community mobilization

Ethiopia's goals for expanding access to HIV/AIDS prevention, care, and treatment services consistently

face common and recurring challenges, particularly when dealing with human resources. These include

absolute shortages in terms of numbers, an inadequate knowledge and skills base which require extensive

and expensive in-service training, and the poor distribution and low motivation of those healthcare workers

in the system. The crisis in human resources for health is most severe in emerging regions, where vacancy

and attrition rates are nearly double the national average.

In FY06 and FY07, JHPIEGO worked with seven health professional schools of three major universities

(Addis Ababa University, Gondar University, and Jimma University) to integrate and strengthen the teaching

of HIV/AIDS in pre service education. Efforts included: consensus-building workshops with stakeholders; an

in-depth needs assessment; faculty updates in HIV/AIDS content areas, effective teaching skills, infection

prevention, etc.; and the development of educational standards specific to this program and linked with the

Higher Education Relevance and Quality Agency (HERQA) standards. Last, but not least, JHPIEGO worked

with instructors to develop relevant teaching materials for HIV/AIDS and supported individual departments

and schools in introducing these into relevant sections of the curriculum. JHPIEGO also procured teaching

equipment, including computers, LCD projectors, screens, TVs and VCRs, printers, overhead projectors,

clinical models, teaching charts, DVDs, videos, etc. for distribution to each school. As of July 2007, 87

faculty attended training workshops (with many attending a series involving both HIV/AIDS updates and

effective teaching skills), and 349 students received pre-placement training prior to graduation. The effective

teaching skills component, in particular, has led faculties to re-think and re-design how they deploy students

to clinical practice sites (e.g., Jimma), and to adopt the use of clinical preceptors as a way to maximize

mentoring of students in clinical areas.

For FY08, JHPIEGO proposes to consolidate its efforts in the three universities and expand to new cadres

within the university. These cadres will include laboratory technicians, pharmacists and others. JHPIEGO

proposes to work with PEPFAR partners—Strengthening Pharmaceutical Systems (SPS) and a CDC

laboratory partner. The partners will work to update faculty knowledge and skills and revise curricula, and

JHPIEGO will provide effective teaching-skills training and teaching equipment. JHPIEGO will also apply the

Standards Based Education Management and Recognition (SBEM-R) approach for strengthening the

quality of the training.

In addition, JHPIEGO proposes to apply the lessons learned in university settings to a regional health

college for diploma-level nursing education. According to the new calibration, Gambella is a high HIV/AIDS

prevalence region (2.4% in 2007); it was also found in a follow-up analysis of the Training Information

Management System to have the highest attrition of trained staff (64.9% of trained providers were no longer

at the facility at the time of the follow-up visit). Benishangul Gumuz, which is adjacent, has an estimated

2007 prevalence of 1.8% and attrition of 48.3%; thus, the college in Pawe could also be targeted if funding

allows. With the assumption that nurses recruited from and trained in Gambella are more likely to stay in

Gambella for a longer proportion of their career (with the similar assumption for Benishangul), JHPIEGO

proposes to strengthen the school and prepare it to accept larger intakes of students. The focus will be on

HIV/AIDS content, but the strengthening will include equipping classrooms and clinical skills labs, ensuring

good scheduling of clinical attachments so that students learn by doing, upgrading faculty skills, etc, and

testing whether the SBEM-R methodology can be effectively applied in such a setting.

Core groups of faculty/tutors will also receive training in effective teaching skills and HIV/AIDS content

support, working with PEPFAR partners to carry out the latter as appropriate. Educational development

centers will be established in large universities and in all participating schools. JHPIEGO will establish a

core team of "Educational Mentors for Health" in an effort to build capacity for internal development of

instructors and to overcome the problem of teacher turnover. JHPIEGO will continue to support the

development of printed materials, tools (question banks, learning resource packages for faculty, clinical

attachment logbooks for students, etc.) and support for other resources, such as teaching

supplies/equipment, models, and other supplies for clinical skills labs, as the curriculum development

evolves. Where these exist (and we understand that Addis Ababa University is exploring a master's

program in medical education), JHPIEGO also proposes to support institutions that have programs to

develop educators in the health area. These types of programs are recommended in the draft human

resources for health strategy.

Where feasible, JHPIEGO will share other resources that are available to school faculties and leadership,

such as the virtual/distance leadership course established by the Leadership and Management Support

project, which is funded by the US Agency for International Development.

Production of HIV care, treatment & prevention related electronic materials

In FY07, JHPIEGO was supported to develop and implement an HIV/AIDS-specific, electronic learning

management system (LMS) for three universities in Ethiopia (i.e., Addis Ababa, Gondar, and Jimma). The

LMS was developed in three HIV/AIDS technical areas, based on the established national HIV/AIDS training

packages. The goal was to use an electronic learning platform to provide in-service training on HIV/AIDS

services. This project was designed in FY07 in the context of the rapid expansion of HIV/AIDS services in

Ethiopia, high attrition rates of providers with HIV/AIDS training, and little available time for more providers

and students to learn essential HIV/AIDS services. JHPIEGO, in close collaboration with CDC Ethiopia,

assessed, designed, and implemented the LMS for three HIV/AIDS technical focus areas for use in three

major Ethiopian universities.

A needs assessment of the three universities and affiliated hospitals yielded important findings that tailored

the subsequent implementation of the LMS. First, the findings suggested that program efforts focus on pre-

service education rather than in-service training. Thus, the project implemented the LMS at the universities

so that teaching faculty can use it as a resource for teaching students, rather than installing the LMS at the

hospital level to support providers already working. Support for the decision to focus on pre-service training

included the reality that a larger pre-service education project is concurrently underway to strengthen

HIV/AIDS teaching for medical, nursing, and midwifery students, as well as the imminent need for students

to graduate with basic knowledge of HIV/AIDS in order to expedite the provision of HIV/AIDS services with

minimal in-service training.

The needs assessment findings also indicated that a large number of students have access to mobile

phones and other handheld devices such as MP3 players. These types of tools can easily be used for

mobile learning. Other assessments conducted by JHPIEGO in the pre-service education program noted a

shortage of time during medical, nursing, and midwifery training to incorporate comprehensive HIV/AIDS

teaching. Thus, innovative strategies to allow for a variety of HIV/AIDS learning opportunities for students

outside of the classroom were recommended to be employed for HIV/AIDS teaching.

In response to the e-learning needs assessment findings, a non-Internet-based LMS in HIV/AIDS content

was developed using a variety of learning methodologies, including case studies, lectures, videos and

pictures. The LMS was field-tested and installed at the three universities. Faculty members at those

universities were selected as core champions of the program, and were trained on using the LMS for

HIV/AIDS learning and teaching.

In FY07, in order to ensure the functionality and appropriate implementation of the LMS at the universities,

JHPIEGO and CDC procured minimal but essential information technology (IT) equipment and provided IT-

specific technical assistance needed to maintain the LMS at the universities. However, the IT support to the

universities was not adequate to ensure that a critical mass of students could access the materials. Addis

Ababa and Gondar Universities were noted to have fairly poor access to computers, not allowing many

users to access the LMS at one time.

Also during FY07, JHPIEGO liaised with the TheraSim advanced ART project to learn from their experience

with e-learning uptake in Ethiopia. In addition, under the e-learning project, JHPIEGO collected information

on end-user comfort in using electronic materials for teaching and learning.

During FY08, JHPIEGO proposes to document the practices of instructors incorporating the HIV/AIDS LMS

into their HIV/AIDS teaching practices, their interest in expanding electronic learning for HIV/AIDS teaching,

and the use of the LMS by students. In addition, JHPIEGO will analyze scores obtained by the students

using the LMS as well as other reporting indicators that were embedded in the LMS during FY07.

In FY08, JHPIEGO will increase the opportunities for students and service providers to access the LMS via

different mechanisms, as well as expand the project to involve mobile learning for students and integration

of mobile and eLearning into skills labs. First, in order to increase the access to the LMS at the current

program universities, JHPIEGO proposes to do the following:

1) Continue supporting and strengthening the use of LMS at Addis Ababa, Gondar, and Jimma universities

for pre-service teaching, as well as explore possibilities of expanding the LMS into the university-affiliated

teaching hospitals

2) Procure and upgrade the computer labs by increasing the IT capacity at the universities through

hardware, software, and networking to allow for more students to have access to a computer and the LMS

3) Work with staff and students to improve their comfort level in teaching and learning via electronic tools

4) Develop downloadable lectures for students to save lectures on MP3 players to allow learning outside of

the computer lab, allowing more students to access lectures when they have available time

5) Procure MP3 players for students and personal digital assistants (PDA) for faculty to use for the e-

learning project

6) Work with staff to integrate e-learning into skills labs, including equipping the skills labs with computers,

models, and MP3-based learning. Support integrating mobile and e-learning into competency-based skills

training for students when they use the skills lab.

7) Provide instructors and key faculty with an e-learning toolkit that includes various technology materials

that can be used for instructional design purposes. Such equipment can include software and hardware,

digital cameras, and digital video cameras.

8) Continue to upgrade and troubleshoot the HIV/AIDS LMS developed in FY07

9) Provide instructional design courses for key faculty at the universities

Based on lessons learned in FY07, JHPIEGO will also expand the e-learning project in FY08. The project

will be expanded to two other major health teaching universities. JHPIEGO will support HIV/AIDS pre-

service education strengthening by conducting needs assessments, procuring minimal but essential IT

equipment, installing the LMS, and training faculty on the use of LMS. JHPIEGO will also train faculty in

instructional design and provide them with a toolkit. JHPIEGO also plans to pilot the installation and

implementation of the HIV/AIDS LMS in two ART hospitals (one urban and one rural) and assess the use,

uptake, and effectiveness of the LMS in the clinical in-service environment.

In addition to providing an HIV/AIDS LMS for faculty to use as an additional HIV/AIDS teaching aid for

students and allowing interested service providers to access HIV/AIDS training in their workplace/hospital,

Activity Narrative: there is also merit in providing up-to-date HIV/AIDS evidence and the latest best practices to provide

opportunities to continually update knowledge in HIV/AIDS. In FY07, Johns Hopkins University Center for

Communications Programs (CCP) initiated a talkline for HIV/AIDS service providers in Ethiopia. In FY08,

JHPIEGO will support this talkline by using telephone and mobile technology to provide up-to-date

HIV/AIDS information, the latest international and national HIV/AIDS events/news and conferences, as well

as allowing for providers to request technical advice for their specific HIV/AIDS work area. JHPIEGO will

support a touchtone answering system, in collaboration with CCP and with support from appropriate

partners.

Strengthening Pre-Service Education in Private Health Colleges

Ethiopia faces numerous challenges related to human resources for health (HRH), including an overall

shortage of health professionals. Various stakeholders are actively engaged in analyzing human resource

needs. For example, a business process re-engineering effort is ongoing throughout the government and, in

the health sector, the human resources issue is one of the seven core processes being analyzed with a

view to aligning production needs with new health-facility staffing patterns and the goals of the Health

Sector Development Plan III (HSDP-III). Similarly, a task force headed by the Federal HIV/AIDS Prevention

and Control Office (HAPCO) and facilitated by the World Health Organization (WHO) is guiding a series of

studies and assessments dealing with task-shifting and the WHO global Treat, Train, Retain initiative. One

task force member, the Clinton Foundation, has begun time and motion analyses for HIV treatment services

and will enter the data into the SIMCLIN model, a decision-support software tool. SIMCLIN will run

projections of staffing needs, including projections related to decisions to shift selected tasks from one

group of healthcare providers to another (i.e., from physicians/health officers to nurses, from health

professionals to health extension workers, people living with HIV/AIDS (PLWH), community counselors, or

peer educators, etc.).

As the Federal Ministry of Health (MOH) has pressured nursing, medical, and other related educational

institutions to increase enrollments, PEPFAR has also invested resources in improving the quality of pre-

service education at the university level and ensuring that the content related to HIV/AIDS core

competencies is effectively integrated in the curriculum. In FY06 and FY07, JHPIEGO worked with seven

medical, nursing, and midwifery schools in three government universities. After conducting a needs

assessment, JHPIEGO has: worked with faculty of these schools to update and standardize their

knowledge of HIV/AIDS-related services; shared national guidelines and in-service training materials for

HIV/AIDS; provided workshops on effective teaching skills; developed and gained consensus on

educational standards; and conducted instructional-design workshops to assist faculty in integrating

HIV/AIDS content into their teaching. In FY07, JHPIEGO will test new strategies in government schools,

including: facilitating the use of standards-based education management and recognition approaches and

tools; and addressing the gaps identified in school self-assessments. In a separate activity (COP ID 10482),

JHPIEGO is using electronic media to develop self-directed learning materials on HIV/AIDS. For FY08,

JHPIEGO also proposes to expand this work to other health professional schools within the three

universities, as well as selected public-sector health colleges in regions hardest hit by the human resource

challenges.

At the same time, private health-training colleges are multiplying at a rapid rate. Some observers, including

the Ethiopian Nurses Association, have expressed concerns about the quality of the education in these

private institutions. The MOH, however, sees that the private sector is an important partner in meeting the

human resource needs of the country. In the 2005-2006 academic year, private institutions graduated 476

health professionals out of a total of 3,011 at diploma level and above, or 16% of the total output for the

year (Planning and Programming Department, MOH, 1998 Ethiopian Calendar Health and Health-related

Indicators). By investing in strengthening the quality of the education provided to private-school graduates

and ensuring that HIV/AIDS knowledge and skills are included as part of the curriculum, PEPFAR can

provide a huge contribution to meeting the human resource challenges in Ethiopia.

JHPIEGO proposes a two-pronged approach to the issue. One set of activities would involve supporting the

new provisional Human Resources Department (pHRD) at the MOH to work with the Federal Ministry of

Education (MOE) and the Higher Education Relevance and Quality Assurance (HERQA) agency to

strengthen the oversight and accreditation process for private health colleges. As part of this component,

JHPIEGO would also review the licensing process for graduates of private health colleges, linking with the

relevant professional associations, including the Association of Private Higher Learning Institutions, and

working with other efforts under the HRH strategy. Another would be to select a number of schools, assess

the existing quality of their training, sign memoranda of understanding (MOU), and work with them to

improve teaching, along the same lines as the work ongoing in public-sector institutions. The MOH's pHRD

will work with JHPIEGO to establish selection criteria and approach the schools to participate in this

initiative. Assuming this request is fully funded, and that this is not a one-year activity, we expect to include

4-5 schools in the first year, of which 2-3 would be in Addis Ababa and the remaining in the regions.

JHPIEGO's role will be to update faculty on HIV/AIDS topics, share tools and materials for the work with the

government universities, and encourage private colleges to promote and support student-centered and self-

directed learning. The use of competency-based learning and assessment tools, together with the use of

anatomic models as described above, will help remedy the HRH crisis by markedly decreasing the time

needed for competency and by increasing the quality of training through using a mastery learning approach.

As part of signing the MOU, JHPIEGO and the respective schools would agree on roles and responsibilities,

as well as specify resources to be contributed by each partner. For example, schools would have to agree

to conduct periodic self assessments using the standards-based education management and recognition

tools as a benchmarking of their efforts to improve teaching quality and integration of HIV/AIDS content.

The standards-based education management approach and tools espoused also cover areas of school

administration and management, which may need more emphasis and follow-up in working with private

health colleges. JHPIEGO would also expect private colleges to contribute some of their own resources to

the project in exchange for materials not easily available in Ethiopia, such as anatomical models for clinical

skills labs and/or electronic learning materials in HIV/AIDS developed under COP ID 10482.

Title of Study: Public Health Evaluation of Training of Health Providers in Health PEPFAR funded health

centers in Ethiopia

Time and Money Summary:

The evaluation will be conducted from April 2008 to March 2009, pending clearance of the revised protocol,

and is expected to cost $150,000 for Year 2.

Local Co-Investigator: Marion McNabb, Mesrak Nadew, Yassir Abduljewad, Anne Pfitzer, Dr Anteneh

Worku, Petros Faltamo

Project Description

The availability of trained and competent service providers in delivering quality HIV/AIDS services is of

utmost importance in the Ethiopian context. Ethiopia's single point HIV prevalence is 2.1%, which translates

into a target of 350,000 eligible for ART in order to obtain the universal access for ART by 2010. The

Ministry of Health's 2005-06 publication "Health and Health Related Indicators" reported that there is one

physician for every 35,493 people and one nurse for every 4,207 people in Ethiopia. The numbers are

significantly below the WHO international standards for physicians with the standards set at one physician

for 10,000 people and near to the nurse ratio of one nurse for every 5,000 people making access to regular

healthcare services by skilled

There have been multiple reports of high attrition of health care providers in Ethiopia. The resources and

efforts put into PEPFAR training have been enormous. It is important to provide measurable information and

assess training effectiveness periodically. In the context of the Ethiopian scale up of ART services, health

centers were recently added as service provision sites. COP08 will be an opportune time to review the

effectiveness of training programs at this health facility-level to refine strategies for the future.

Status of study/progress to date

In FY07, JHPIEGO was funded to conduct an evaluation that will provide feedback to PEPFAR Ethiopia

regarding the effectiveness and cost of investments to train health care workers at facilities. The evaluation

included descriptive review of training processes and methodologies utilized by PEPFAR implementing

partners employing a quasi-experimental data collection methods to assess the performance of trained and

untrained providers(either on the job or in a simulation) on specific knowledge and skills included in the in-

service training they received. Additionally, the evaluation measured the attrition rates and reasons for

attrition.

The main evaluation questions were:

1) What proportion of health care workers who have attended training funded under PEPFAR are still in the

post they were in at the time of training?

2)Where are the providers that left the facilities?

3)How effectively are health care workers performing on specific skills for which they were trained?

4)What was the average training cost per trainee, by category of knowledge and skills of the training event?

What is the anticipated cost for re-training providers?

5)How are the PEPFAR trainers being used within the program and how many training events have they

conducted?

6)What is the perceived risk of HIV infection in providers trained versus providers not trained in providing

HIV services?

JHPIEGO reviewed PEPFAR Ethiopia's Training Information Management Information System (TIMS) for

data on providers trained in HIV/AIDS services to identify the population of health care workers trained by

PEPFAR in all areas of prevention, care and treatment at hospitals. Accordingly, data were collected from

selected but representative cohort hospitals in Ethiopia. Due to funding limitations in COP 07 the sample

only included hospitals.

The skills of trained providers were evaluated by comparing skills that providers are expected to have post-

training versus skills that are displayed at the time of assessment using standardized case study

assessment tools which were developed using competencies agreed upon in Ethiopia and all PEPFAR

Ethiopia Training Partners reviewed and approved the tools.

Surveys were distributed to PEPFAR Ethiopia's university partners to determine the costs of training. The

protocol was finalized and submitted for the CDC Institutional Review Board approval.

Planned FY08 Activities:

In COP08, JHPIEGO proposes another Training Evaluation with a similar study design and the same

objectives, but with a protocol targeting staff at health centers. The evaluation will assess similar elements

as the hospital version collected: including trainers, cost, and competency of providers and attrition rates of

providers at the health center level. The selection of health centers will be confined to those networked to

hospitals. JHPIEGO will work closely and collaborate with implementing partners that have trained staff at

health center level in refining the protocol and evaluation tools, including US agencies and

international/local partners. The evaluation of training effectiveness will provide useful information across all

PEPFAR funded training programs; working closely with PEPFAR partners on the evaluation will bring

greater impact. The availability of trained and competent service providers in delivering quality HIV/AIDS

services is of utmost importance in the Ethiopian context. Ethiopia's single point HIV prevalence is 2.1%

which translates into a target of 350,000 eligible for ART in order to obtain the universal access for ART by

2010. In 2005/06 the Ministry of Health document "Health and Health Related Indicators" that there is one

physician for every 35,493 people and one nurse for every 4,207 people in Ethiopia. The numbers are

significantly below the WHO international standards for physicians with the standards set at one physician

for 10,000 people and near to the nurse ratio of one nurse for every 5,000 people making access to regular

healthcare services by skilled providers limited for a significant proportion of Ethiopians.

Information Dissemination Plan:

The findings can be used by HAPCO and the Human Resource Department of Ministry of Health, Regional

Health Bureaus, and PEPFAR partners that invest in in-service training for capacity building. The study will

also inform retention strategies with a specific focus on the needs of health centers

Activity Narrative: Budget Justification for FY08 monies:

Given experience to date and the breadth of the proposed FY08 scope of work, the study is budgeted at

$150,000 in COP08. The funding will be used for protocol development, recruitment of data collectors,

training of data collectors, data collection and supervision, data cleaning, entry and analysis, dissemination,

salaries of staff, other direct costs and Johns Hopkins University financial and administration costs.

This is a continuing activity in COP 08 originally planned with JHPIEGO-E as Prime Partner. It was

erroneously entered in the databasewith JHU -Bloomberg as prime partner. The activity is to conduct a

targeted evaluation on the effectiveness of Training for staff at Health Centers under PEPFAR -E. The

findings of the evaluation will provide useful information across all PEPFAR funded training programs ,

partners and stakeholders to identify the retention and attrition status of trained health care providers.

JHPIEGO-E is a prime partner which has a strong potential in conducting targeted evaluation. CDC-E will

provide guidance and follow up of the targeted evaluation.

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

This is an ongoing activity. The FY07 human resources for health (HRH) component of this project has

been removed from FY08 activities since a new COP ID and activity 12231 was created to support HRH

staff-retention activities.

PEPFAR Ethiopia has actively supported the collection and synthesis of PEPFAR-funded training

information in order to make program management decisions. During FY05, PEPFAR Ethiopia established

the Training Information Monitoring System (TIMS), with the goal of collecting information from all PEPFAR-

supported trainings. TIMS reporting forms collect pertinent training information from PEPFAR Ethiopia

partners. All in-country and international training partners supported under PEPFAR Ethiopia provide

training information for analysis. New guidance on the definition of training was agreed upon and

implemented in FY07. JHPIEGO provides data entry for all PEPFAR TIMS forms submitted to JHPIEGO

through USAID and CDC. As of July 2007, 39 PEPFAR-supported organizations have shared data on 1,171

trainings and 32,825 trainees. In FY07, the number of TIMS partners increased to 50, therefore FY08

should produce commensurate growth in the number of training events and participants tracked. In FY07,

JHPIEGO also organized partner meetings for both existing and new partners to familiarize them with TIMS

features. Innovations also included the posting of TIMS reports on the AIDS Resource Center (ARC) partner

website.

Beginning with FY07 resources and continuing into FY08, JHPIEGO plans a redesign of TIMS to expand its

functionality, including a web data-entry application and improved ability to manage large amounts of data.

In FY08, JHPIEGO will transfer existing data into the new version as well as continue TIMS database

management activities, such as data entry, analysis, cleaning, and reporting. JHPIEGO will also conduct

one workshop to orient new PEPFAR partners to the new TIMS program features and reporting, and

prepare for a FY09 transition when partners will begin to enter their own data. The new version will also be

designed to link into existing Human Resources Information System (HRIS) systems.

Training information is shared monthly with the federal Ministry of Health (MOH) and quarterly with the

regional health bureaus (RHB) to inform their planning activities. Following a TIMS stakeholders' meeting in

February 2007, the partners agreed to share a set of regular reports. These regular monthly general training

reports are shared with partners via the ARC website. This method was chosen for ease of download for all

partners, as well as accessibility for people who are browsing that website. The TIMS program is also

working with partners to respond to requests for individual training reports. While the requests for these

reports are still fairly low, the TIMS program is ready and able to support all partners. JHPIEGO also

developed reports specific to the PEPFAR technical working group that were shared quarterly with PEPFAR

agencies and partners. In FY07, JHPIEGO also incorporated the production and reporting of GIS maps that

graphically show training concentrations in regions, as well as training focus areas. Samples of these maps

were generated, and the list of routine maps to be reported was developed and implemented. Key needed

and partner-requested data reports were also programmed into the TIMS database for ease of use during

FY07. Reporting of the data found in TIMS will be expanded in FY08.

In FY08, JHPIEGO will expand reporting capabilities further to include: people who attend multiple training

events, compared to specializations; trends in HIV/AIDS training offered from quarter to quarter; user-

friendly electronic training reports for partners to manipulate their own training data; and other reports to be

identified during stakeholder meetings.

In order to ensure the quality and accuracy of data entered into TIMS, JHPIEGO invited all partners to go

through their reports in detail to ensure data quality and completeness. In addition, weekly data receipt

reports are shared with partners to confirm receipt of TIMS forms for data entry. This activity will continue in

FY08.

To expand the usefulness of the TIMS program and data that is found in the database, JHPIEGO, CDC,

and USAID prepared a pilot project to collect post-training follow-up information on trained providers.

PEPFAR implementing partners agree there is anecdotal evidence of large attrition rates of HIV/AIDS-

trained providers, causing serious service interruptions at the site level. This pilot project was designed to

provide quantitative data about the actual working status of trained individuals in order for PEPFAR

implementing partners to plan effectively for training and service coverage. The pilot project was a great

success with eight selected partners who collected key HIV/AIDS working status information on trained

providers from 98 PEPFAR-supported hospitals and health centers. Data from 2,545 HIV/AIDS-trained

providers revealed that 43.5% of those providers are not providing the HIV/AIDS services for which they

trained. At the time of data collection, 34.4% of all trained providers were no longer at the designated

facility, with 5% having relocated to another public health sector facility. Of those still at the facility, 9.1% of

trained providers were not providing the HIV services for which they trained. All participating partners of the

project agreed that this type of data collection was very important for monitoring HIV/AIDS services and

agreed to conduct it in the future. Half of the partners suggested the data be collected semiannually. The

findings of the pilot project were prepared and disseminated to all PEPFAR partners, MOH,and the

HIV/AIDS Prevention and Control Office (HAPCO), and RHB via implementing partners and other key HRH

stakeholders. Based on the findings of the pilot project, key follow-up data collection forms were

programmed into the TIMS database for regular use.

In FY08, this type of data collection will be expanded beyond the eight pilot partners to all PEPFAR training

partners submitting training forms for TIMS. The data will be collected and analyzed on a semiannual basis,

and reports on working status and attrition trends of HIV/AIDS-trained service providers will be reported to

all PEPFAR partners and interested stakeholders. GIS maps of working rates will also be prepared and

included in routine reports to partners. Other analysis of this type of training data will be identified.

With TIMS funding in FY07, JHPIEGO supported the situational analysis and business process re-

engineering (BPR) for human resources at the MOH. As a result of this exercise, JHPIEGO learned that

information systems for managing human resources are decentralized down to the district level, and not

organized in a consistent manner from region to region. Most regions used paper-based systems and

manually tabulate information to send to the central Planning and Programming Department. This results in

errors and inconsistent data. As a result, the new HRH strategy includes a goal of establishing an HRIS

database. JHPIEGO will ensure that the updated version of TIMS can link to the HRIS.

Activity Narrative:

In FY07, JHPIEGO was tasked with working with MOH and two regions to install TIMS for their use. While

the results of this pilot is not yet clear, the Ethiopian Health and Nutrition Institute (EHNRI) has expressed

interest in installing TIMS in order to track all staff training, including that not funded under PEPFAR.

JHPIEGO and CDC decided the best way to demonstrate to government counterparts the usefulness of

TIMS was to start supporting EHNRI to maintain a TIMS database, document the implementation, and use

lessons learned to assess the feasibility and interest of other regions or government offices to implement

TIMS. In FY08, JHPIEGO will assess the challenges and successes of working with the Ethiopian Health

and Nutrition Research Institute and provide recommendations for further expansion to other government

offices.

In addition, certain professional associations are actively providing continuing education to their members. A

consortium of professional associations has even been formed to address HIV/AIDS issues. JHPIEGO will

first involve these associations in providing input to the new version of TIMS, and then explore the feasibility

of their using TIMS to track their membership and continuing education efforts, with a view to potentially

using TIMS in the future for re-licensing of health professionals.

In FY08, in order to increase the usability of both training and follow-up information, JHPIEGO will also

organize semiannual meetings with key PEPFAR stakeholders to present trends and comparisons of

service providers trained on HIV/AIDS and follow-up information. The PEPFAR Ethiopia TIMS database and

the use of training data to monitor service-provider working status has been a great success story in

Ethiopia. JHPIEGO will document this success and share with key PEPFAR stakeholders in order to

disseminate success stories in training, capturing training data, and monitoring HIV/AIDS working status to

other PEPFAR countries. If desired, JHPIEGO will support travel to conferences and/or other PEPFAR

countries to present the successes of the Ethiopia TIMS program. In addition, in FY08, if feasible and

desired, JHPIEGO will support key PEPFAR Ethiopia representatives to develop a PEPFAR Ethiopia

training strategy for planning, monitoring, and reporting on PEPFAR Ethiopia-supported training to support

implementation of the Office of the Global AIDS Coordinator's guidance on human capacity development for

HIV/AIDS.

The partners targeted for training include international organizations, local PEPFAR-supported

organizations, professional associations, and government agencies.

Standards Based Management and Recognition for HIV/AIDS Service Performance

Standards Based Management and Recognition (SBM-R) is a practical management approach for

improving the performance and quality of health services. As proven by experience in other countries, SBM-

R can increase the uptake of services to reach PEPFAR targets and improve patient treatment adherence.

SBM-R is the systematic use of performance standards by on-site health care staff teams as the basis for

improving the organization and provision of services. After introducing performance standards at a

healthcare facility, the team conducts a baseline assessment of services. After two to three months of

implementing performance standards, the team again measures the performance of services during an

internal assessment. Improvements in performance are measured by the difference in the number, as well

as percent of standards achieved, from baseline to internal assessment. The achievement of standards is

recognized. In Zambia, such recognition was shown to lead to improved healthcare worker satisfaction,

which can lead to improved retention of health staff.

In FY07, JHPIEGO implemented SBM-R for a comprehensive set of HIV/AIDS performance standards.

Operationally, performance standards are assessment tools that are mainly used for assessing the

performance of service delivery, but can also be used for self, peer, internal, and external assessments at

the facility level. Hospitals elect teams to participate in three short workshops, learning how to apply the

methodology at their sites, gain buy-in, and address performance gaps. These team members and their

colleagues then perform facility-based internal assessments in between workshops. Subsequent workshops

allow for extensive exchange of assessment results, lessons learned, and best practices, as well as the

resolution of more difficult problems in quality of care. In FY07, JHPIEGO deployed six SBM-R coaches to

selected regional health bureaus (RHB) to facilitate support to hospitals. In addition, the SBM-R Advisor

was temporarily seconded to the Federal HIV/AIDS Prevention and Control (HAPCO) Quality Team,

working to institutionalize SBM-R oversight in that unit.

By the end of FY07, JHPIEGO expects to have:

1) Assisted all first, second, and third cohort hospitals (except for HIV-Quality pilot sites) to complete

baseline assessments and develop action plans

2) Assisted at least half of these hospitals to conduct a second internal assessment and new action plan

3) Worked with the HAPCO Quality Team and implementing partners to recognize any hospital achieving a

set level of standards

At each facility, SBM-R coaches and facilitators work with one core team representing the hospital. That

team is made up of the medical director and/or administrator and other representatives as selected by the

hospital. In addition, for the initial orientation, a team of 2-3 people from each unit with HIV/AIDS services

(e.g., ART, out-patient departments, maternal/child health (including antenatal clinics and labor and

delivery), central supply and sterilization, record-keeping, pharmacy, and laboratory) is invited to the on-site

training and given help to conduct the baseline assessment. The teams are composed of physicians,

nurses, laboratory technicians, pharmacists, data clerks, and administrators.

JHPIEGO is working closely with PEPFAR partners, including US-based university partners, to ensure that

staff are oriented to the coaching approach so that service providers and facilities implement standards and

close any identified gaps.

In FY08, JHPIEGO will continue to support the first 100 hospitals in achieving recognition status, as well as

preparing high-achieving hospitals to implement HIV-QUAL. While doing so, JHPIEGO will work on

harmonized quality management, through a large-group consultation and discussion with CDC and HAPCO.

JHPIEGO will also introduce the process in the remaining fourth cohort hospitals and additional health

centers supported by CDC partners. To accomplish this, JHPIEGO will recruit additional SBM-R coaches

deployed in RHB. Another important activity will be to decentralize the external verification process for sites

to attain recognition to the regional level; this will reduce cost and increase sustainability. Also, SBM-R

activities and processes will be further linked to Human Resource Management systems at the regional

level, in order to maximize its role in improving retention of HIV/AIDS trained staff.

In FY08, JHPIEGO will use Health Management Information System (HMIS) data to perform an analysis

exploring the correlation between HIV/AIDS patient outcomes and SBM-R assessment results from the

second internal assessment. We hope that this analysis will demonstrate the link between performance

standards, which measure how services are delivered and support functions carried out, to improved

outcomes—thus convincing stakeholders to absorb the SBM-R coaches into the RHB staff in their next

budget cycle and sustain activities beyond PEPFAR.

In FY07, a significant amount of carry-forward funds (approximately $200,000) was applied to the SBM-R

funding to supplement the FY07 funding of $400,000. This budget included no US salaries or technical

assistance; however, JHPIEGO will require some US technical assistance in FY08 to facilitate the analysis

of SBM-R results with HMIS outcome data. We therefore request that the total FY07 budget (including the

carry forward applied) of $600,000 be considered as the base for FY07 to justify the increase in the FY08

funding request.

Retention of Trained Healthcare Workers

In general, retention of trained staff and healthcare workers has posed challenges worldwide, and Ethiopia's

human resources for health (HRH) situation is one of the worst, with 51,597 technical healthcare workers in

2006 (including 8,901 Health Extension Workers) for a population of over 70 million, resulting in one of the

lowest healthcare-worker-to-population ratios in the world. The number of doctors is also rapidly decreasing

since 2001, with physician attrition outpacing the graduation of new doctors. Furthermore, health workers

are poorly distributed with many concentrated in urban areas. The government's Health Extension Program

seeks to address this imbalance; by the end of 2007, 24,453 health extension workers (HEWs) will be

deployed in rural wards. However, there is fear that the HEWs are given a large load of preventive activities

and unable to meet the demand for curative services. Other health professional cadres are urgently needed

to meet Ethiopia's goal of achieving universal access to ART by 2010. While production of healthcare

workers is addressed elsewhere, interventions are needed to address the high attrition rates and are the

focus of this activity.

In FY07, PEPFAR Ethiopia funded JHPIEGO for two HRH activities. The first (activity 10383) linked with the

TIMS© project involved analyses of the existing HRH situation and the development of a policy agenda for

HRH using TIMS© data and other sources, as well as piloting some new retention schemes, such as job

sharing. The Retention of Trained Staff program, which is the second activity, led to exploring new

interventions to improve retention of healthcare workers trained and deployed in HIV/AIDS-related services.

With the TIMS funding, JHPIEGO and PEPFAR Ethiopia were able to assist the Federal Ministry of Health

(MOH) with a broad situational analysis of the HRH situation in country, as well as with the development of

an ambitious and radical new HRH strategy. Part of JHPIEGO's input was the support of a local health

economist to cost out the strategy. JHPIEGO is also currently working on a concept note for an HR

inventory specific to the HIV/AIDS workforce, as requested by the Federal HIV/AIDS Prevention and Control

Office. The JHPIEGO involvement in these efforts has opened the door for working hand-in-hand with

government counterparts on testing and documenting various retention efforts.

For the Retention of Trained Staff program in FY07, proposed activities included a survey of potential

retention schemes, followed by consultative meetings. This led to the implementation of several

performance-based retention schemes to improve workers' morale and motivation, which will be continued

and potentially expanded in FY08. US university partners are offering overtime/duty pay, but the regional

health bureaus (RHB) and hospitals are not generally accessing these funds. These initiatives will continue,

to be scaled up and monitored to assess whether they have a positive impact. USG funding precludes

attempting other schemes, such as constructing housing for healthcare workers in remote sites or providing

bank loans; however, JHPIEGO may look to work with other donors and partners to leverage those that can

work in this area.

In order to monitor the impact of various efforts, it will be necessary to develop a Human Resource

Information System (HRIS). The Health and Health-related Indicators which regularly publishes HR

information is thought to be fraught with data errors and is not considered reliable. JHPIEGO's work in

TIMS© has also highlighted some of the constraints in terms of tracking human-resource data, including the

lack of unique identifiers for Ethiopian healthcare workers. A World Bank consultant has proposed working

with JHPIEGO and other partners to test a new HRIS in one region.

Linked to information systems, but with its own distinct issues, is the set of procedures for licensing and

registration of healthcare workers. In collaboration with universities, the MOH has been overseeing the

licensing of healthcare workers with a bachelor's degree or above, but has recently delegated the task of

registration and licensing of healthcare workers with diplomas (and those below diploma level) to RHB. The

MOH has suggested to JHPIEGO that strengthening that system across regions and ensuring some

standardization might be an important and useful task. This would include the registration of lay healthcare

workers who provide HIV/AIDS services.

Another aspect of the HR strategy that is critical to retention, but difficult to achieve, is the area of Human

Resource Management (HRM) after deployment. There is little understanding currently in MOH circles

about the role of supervision in promoting and sustaining quality staff performance. In FY08, there will be a

continuing need to build the capacity of the MOH's Human Resources Department, including with seconding

of technical advisors. JHPIEGO has developed HIV/AIDS-specific performance standards. Achievement of

those standards can be linked to recognition and financial or other rewards. In Zambia, non-financial

rewards, coupled with recognition and celebration of quantifiable achievements by health center teams,

were more powerful than financial rewards without community recognition. JHPIEGO will explore working

with new partners, such as Initiatives, Inc. and/or Liverpool Associates in Tropical Health (LATH), who may

have additional expertise in this area.

Initiatives, Inc. has assisted governments to conduct workforce-planning exercises and prepare strategies

for providing adequate numbers of appropriately trained healthcare personnel. In recent years, for the

governments of Zambia and Rwanda, they have taken a close look at the use of the workforce to provide

HIV/AIDS prevention and care services in the context of a diminishing supply of qualified workers. They

have looked at retention through the lens of both financial and non-financial incentives and promotion of

bonding schemes.

For over ten years, LATH has been involved in supporting HRH in many countries and in helping to develop

good human resources management and development (HRM/D) practices to improve health sector

performance. LATH has a full time HR Management and Development Specialist based in Uganda. In

addition, LATH consultants have advised Ministries of Health in many developing countries on HRM/D

issues, including: human resource planning, assessing and identifying HRM/D practices such as

recruitment, deployment and retention, training and development systems, performance management

systems, and HR information systems. LATH has worked with JHPIEGO in Malawi in HRIS and HR

planning areas.

A significantly increased budget is requested in order to allow procuring the additional expertise of LATH

and Initiatives, Inc. to complement JHPIEGO efforts and to staff the HR Department and JHPIEGO to

coordinate inputs. Also, in FY07, it is anticipated that piloting of retention schemes will only begin, but will

significantly expand in FY08, with additional regions requesting assistance and also more time in the year to

Activity Narrative: implement the activities (given that funding for FY07 was delayed).