PEPFAR's annual planning process is done either at the country (COP) or regional level (ROP).
PEPFAR's programs are implemented through implementing partners who apply for funding based on PEPFAR's published Requests for Applications.
Since 2010, PEPFAR COPs have grouped implementing partners according to an organizational type. We have retroactively applied these classifications to earlier years in the database as well.
Also called "Strategic Areas", these are general areas of HIV programming. Each program area has several corresponding budget codes.
Specific areas of HIV programming. Budget Codes are the lowest level of spending data available.
Expenditure Program Areas track general areas of PEPFAR expenditure.
Subdivisions of Program Areas, these track general higher level sub-classifications of expenditure.
Subdivisions of Major categories, these are the most detailed expenditure data.
Cross-cutting attributions are areas of PEPFAR programming that contribute across several program areas. They contain limited indicative information related to aspects such as human resources, health infrastructure, or key populations programming. However, they represent only a small proportion of the total funds that PEPFAR allocates through the COP process. Additionally, they have changed significantly over the years. As such, analysis and interpretation of these data should be approached carefully. Learn more
PEPFAR sets targets using the Monitoring, Evaluation, and Reporting (MER) System - documentation for which can be found on PEPFAR's website at https://www.pepfar.gov/reports/guidance/. As with most data on this website, the targets here have been extracted from the COP documents. Targets are for the fiscal year following each COP year, such that selecting 2016 will access targets for FY2017. This feature is currently experimental and should be used for exploratory purposes only at present.
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
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
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
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
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
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-
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
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
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
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
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
6)What is the perceived risk of HIV infection in providers trained versus providers not trained in providing
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
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
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
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
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.
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
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
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
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
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
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).