This is a continuation of FY07 activity.

The World Health Organization (WHO) supports rapid scale-up of activities in Ethiopia for the establishment

of a sustainable, nationally coordinated Blood Transfusion Service. This project began in FY04 with an

assessment of existing blood transfusion services to determine their capacity for rapid strengthening into

the Blood Transfusion Service infrastructure and program. WHO, assisted by the Federal Ministry of Health

(MOH), developed a five-year strategic plan in collaboration with all key stakeholders for strengthening and

restructuring the blood supply system through the regionalization of key services, including testing and

processing. WHO has provided support in training and development of instruments to improve blood donor

recruitment, blood testing, and the clinical interface, as well as establishment of quality systems in the

national blood supply system. This marked the initiation phase of the program.

In FY06, WHO provided technical support for implementation of the five-year strategic plan. WHO, in

collaboration with the MOH, completed assessments of strategies in blood donor recruitment as well as

quality systems. Following the assessments, roadmaps to address the identified gaps in blood donor

recruitment and quality were developed, and the implementation of these roadmaps is on course. National

Guidelines for Appropriate Clinical Use of Blood were developed and distributed. WHO supported the

initiation of hospital-level transfusion committees and one of them, at Black Lion Hospital, became a pilot

site for the strengthening of aspects of the clinical interface. To date, WHO has trained 306 individuals

involved in blood transfusion services, and four technical staff members have been out-posted in other

countries to gain experience and further professional development.

In FY07, WHO continued to support strengthening of the national blood program by following the roadmaps

developed in FY06. In collaboration with regional health bureaus (RHB) and the Ethiopia Red Cross

Society, WHO worked to build capacity and develop partner engagement mechanisms through forums

focusing on equity and quality issues in service provision. WHO also collaborated on development of draft

legislation for the blood transfusion service legal framework and a human resource development plan. Since

the inception of the project, internationally renowned consultants in blood transfusion have been recruited to

support activities in their areas of expertise.

In FY08, WHO will continue to provide technical assistance to expand and consolidate the blood safety

program. The technical assistance will result in the establishment of efficient, sustainable, national blood

transfusion services that can assure the accessibility, quality, safety and adequacy of blood and blood

products to meet the needs of all patients requiring transfusion in Ethiopia. This will be achieved through the

following activities:

1) WHO will offer pre-service training and continuing medical education to 350 individuals involved in

providing vein-to-vein blood transfusion services. International placements and training of technical staff will

be coordinated.

2) WHO will support enhanced blood donor recruitment to meet the national requirements for a safe blood

supply. Community mobilization and improved communication methods will lead to an expanded, stable,

base of regular, voluntary, non-remunerated blood donors. WHO will support the training of journalists,

community mobilizers, and staff for improved communication.

3) Cost-effective quality testing and processing will be achieved by establishing and strengthening blood

bank laboratory functions, particularly in the regions. This will include scale-up of component production and

cold chain maintenance.

4) WHO will support the reduction of unnecessary transfusions in order to prevent adverse transfusion

events and reactions by training staff at the clinical interface on appropriate clinical use of blood and safe

bedside practices. WHO will support the requisite training tools, as well as continue supporting Hospital

Transfusion Committees.

5) WHO will strengthen systems for regular monitoring, evaluation, review, and re-planning through training.

WHO will also support improved mechanisms for data collection and management, including the use of

appropriate indicators.

6) WHO will support the regionalization/centralization of blood bank functions to enhance cost-effective

service provision while preserving quality service.

7) WHO will support strengthening of quality systems through training as part of the roadmap developed in

FY06. Through these trainings, establishment of all quality elements in blood transfusion services is

foreseen.

In FY08, WHO will put particular emphasis on scale-up of services in the regions through human resource

development, mentoring, and regular supportive supervision. Due to inadequate capacity in the country,

both local and international expertise will be engaged in some of the activities.

Strengthening Human Resources, MDR-TB control, and TB Infection Control

I. Strengthening of Human Resource Capacity:

The human resource crisis in the health system is one major rate-limiting problem in Ethiopia. TB/HIV

collaborative activities have faced high staff turnover, which has affected scale-up of collaborative activities

implementation. Plus-up funding from FY07 was used by the World Health Organization (WHO) to provide

additional staff at the Federal Ministry of Health (MOH) and the regional health bureaus (RHB).

Activities for FY08 will include:

1) Providing training to mid-level staff in MOH to develop their skills, so that they can eventually fill higher-

level positions

2) Assessment of the impact of additional staff added in FY07

3) In underperforming regions, staff may be added according to need at RHB

II. MDR-TB:

The TB program in Ethiopia has not yet started managing multi-drug-resistant TB (MDR-TB) cases.

However, plus-up funding from FY07 was allocated to support MOH in the initiation of MDR-TB treatment.

WHO will continue this support in FY08 by providing ongoing MDR-TB training to additional clinicians in St.

Peter's Hospital, the TB specialty hospital in Addis Ababa. This activity will synergize well with support from

the Global Fund for AIDS, Malaria, and Tuberculosis, which will support the cost of second-line drugs for

MDR-TB treatment. WHO will facilitate these activities by closely working with MOH and the HIV/AIDS

Prevention and Control Office (HAPCO).

III. TB Infection Control:

The country urgently needs a TB infection-control strategy. Plus-up funding from FY07 was allocated to do

a baseline assessment of current infection-control practices, to support the national program in developing

national infection-control guidelines, and to implement appropriate infection-control measures in selected

hospitals, including St. Peter's. Activities for FY08 will build on these activities by:

1) Supporting technical assistance from external consultants to improve infection control practices and to

guide implementation

2) Procuring necessary supplies for infection control in hospitals.

WHO will take the lead in assisting the MOH in these activities, in collaboration with relevant stakeholders

and partners. WHO will also organize a review mission to evaluate the status of implementation of the TB

and TB/HIV programs in Ethiopia.

Integrated Service Strengthening

This is a continuing activity from FY07. This is a hospital-level activity related to strengthening integrated

services at health centers. Integrated health service strengthening—which builds capacity for decentralized

HIV services, including chronic disease management, ART, and prevention—requires good coordination of

clinical care within the health network model and appropriate back-up from zonal, regional, and university

hospitals. The health network model consists of hospitals, health centers, health posts, and community-

based health workers. Health center scale-up of HIV prevention, care, and ART is proceeding very rapidly,

along with efforts to link hospitals and health centers through clinical mentoring programs.

Doctors and health officers at hospital level need preparation for their mentoring role with compatible

training materials, and continued support through an ongoing learning program.

Scaling up HIV care and ART requires decentralization and active strengthening of the health network

model, establishment of a consultative referral and back-referral system between community health center

and hospital, and a system of supportive supervision and clinical mentoring. This requires consistent

support and understanding of the planned interventions and the simplified, operationalized, Ethiopia-

adapted guidelines for integrated management of adolescent and adult illness (IMAI) and training materials

used at hospital, health center, and community levels. Inconsistencies in approaches will confuse and

undermine attempts to extend HIV prevention, care, and ART. Doctors and health officers will also need

empowering to introduce any new guidelines or interventions, as HIV global normative guidelines and

national policies change.

The World Health Organization's (WHO) IMAI/ Integrated Management of Childhood Illness (IMCI) Second

Level HIV Clinical Learning Program consists of an introductory training course and materials to support

follow-up learning, supporting individual progressive expertise while accommodating new updates.

In this activity WHO will: 1) Continue providing technical assistance (TA) to work with Ethiopian and US

universities to support the IMAI/IMCI Second Level HIV Clinical Learning Program by supporting adaptation

and further development of training programs. 2) Continue working with Ethiopia and US universities on

training of trainers, pre-service and in-service training of IMCI/IMAI Second Level HIV Clinical Learning

Program and clinical mentoring. WHO will focus on building the capacity of the local institutions to have a

big role in both pre-service and in-service training. 3) Provide TA with career development, including

continuing medical education, certification and licensing, and non-financial schemes for retention of clinical

mentors. 4) Continue development and update of clinical videos to support improved initial and ongoing

learning. 5) Provide TA for supervision of the clinical mentoring program to assure quality development of

functional health network models. Standardized, periodic on-site supportive supervision and regular clinical

mentoring program reviews will be an integral part of this activity. 6) Develop a case library of actual cases

from hospitals and health centers for the training and ongoing learning process. 7) Provide in-depth

opportunities for professional exchanges fro government and university senior clinician mentors, in

collaboration with other WHO programs in Africa and elsewhere.

The learning program begins with the second-level in-service course, as well as pre-service training, based

on initial IMAI basic course training. The program then covers material designed specifically for district

doctors. The initial training will be in ART and opportunistic infections (OI), through an interactive approach

with expert patient trainers and hospital and health center visits. The second-level course does not produce

HIV expert physicians or pediatricians, but doctors and medical officers competent at handling first- and

second-line ART, OI, and tuberculosis/HIV co-infection in adults and children, and their common

complications. The course focuses on the most common conditions requiring management at district-

hospital level.

The second-level learning program is framed in the public health approach for scaling up access to high-

quality HIV care and treatment. There are already more than 30 organizations and 15 countries involved in

the interactive development process, including the US universities working at hospitals in Ethiopia (e.g.,

Washington University/I-TECH, Johns Hopkins University, Columbia University, and the University of

California, San Diego.

Mentoring and follow-up training are integral to the IMAI approach in doctor training. WHO will work with

HIV/AIDS Prevention and Control Offices to standardize the mentoring activity according to

recommendations from the Ethiopian Ministry of Health. Other components of the learning program include

follow-up short courses, preparation for clinical mentoring, ongoing support for mentors, clinical casebook

exercises, and video case presentations. These support doctors to further develop their HIV care skills and

expand their knowledge. The follow-up courses help to solidify existing experience and training, as well as

to expand knowledge about a particular topic, such as pediatric ART or TB/HIV. This will harmonize with the

national approach to training, with substantial benefits for the zonal/district network and the speed and

efficiency of scale-up. This will lead to wider access to higher quality, sustainable HIV care.

Each potential mentor will undergo training on: effective mentoring; adult participatory education skills

(communication skills, active listening, giving nonjudgmental feedback); and effective case review and care

by the clinical team. They will also receive a set of standardized mentoring tools, including reporting forms

and log books. Mentors will be expected to participate in the two-week basic IMAI clinical course in order to

become completely familiar with the clinical and operational protocols used at district hospital and health-

center level. Mentors will be trained to use the standardized patient monitoring system (ART follow-up form,

ART, and pre-ART registers) to find and review interesting cases, and to calculate simple indicators which

can be collected easily by the clinic staff or a clinical mentor during an on-site visit in order to identify,

change, and improve inefficient or ineffective clinical practices.

In light of the emphasis on accelerated, decentralized HIV care and ART, the HIV care and treatment scale-

up in Ethiopia will follow the guiding principle of "high impact and high yield." For FY08, WHO will increase

TA to a total of 100 hospitals and 450 health centers, found in all 11 regions of the country. The TA will

focus on referral/back-referral linkages, on-going learning programs through clinical mentoring, and routine

on-site supportive supervision based on the existing health network model. As care and treatment programs

expand, and the number of patients on treatment increases, attention must be given to the quality of the

ART services being provided. WHO will work with other relevant PEPFAR Ethiopia partners to strengthen

Activity Narrative: the zonal and district health networks' abilities to monitor and evaluate programs using the standardized

program indicators.