Strengthening HIV Infrastructure to Increase Service Delivery Access

This is a new activity that relates to the Renovation of ART Hospitals (10410), the Renovations - Health

Facility ART (10485) activity, as well as to two new activities, Renovations to Strengthen Quality of

ANC/PMTCT Services (at hospitals and health centers, respectively).

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Health service utilization in Ethiopia is a low 36%, and 50% of the population live more than 10 kilometers

from a health center. In response to the lack of access to services, the Government of Ethiopia (GOE) has

launched an ambitious program, the Health Service Delivery Program III (HSDP III) to provide universal

primary healthcare to the population by 2010. The plan is also being supported through the Ministry of

Health's Road Map 2007-2008: Accelerated Access to HIV/AIDS Prevention, care, and Treatment in

Ethiopia, an ambitious plan to bring the population universal access to HIV services, also by 2010.

While PEPFAR is unable to support the very large resources required to reach the targets of these

ambitious plans, it will provide, in support of these important efforts, financial resources to support

infrastructure development alleviating a portion of the serious access gaps that the population currently

suffers. PEPFAR will provide $18 million to the Federal Government of Ethiopia through the Fixed Amount

Reimbursement method for local cost financing, pursuant to the USAID Automated Directives System 317,

and the pertinent Supplemental Reference, "Use of Fixed Amount Reimbursement Method for Local Cost

Financing".

PEPFAR is currently supporting two other construction activities with the Regional Procurement Service

Organization (RPSO) and with Crown Agents. These activities support services at the tertiary care level,

improving hospital infrastructure, and at the health-center level, supporting safe, quality services and

helping preserve existing infrastructure, currently at risk due to lack of preventive maintenance and budget

to support this critical function.

This activity would extend PEPFAR's efforts to bring HIV services to at risk groups in Ethiopia. Up to 95

health stations (existing facilities smaller than health centers) would be renovated, expanded and equipped

at a cost of approximately $178,000 each. The sites would be selected to focus on areas with high HIV

prevalence and potentially high patient volume. Extension of the financing to additional sites will be

contingent on the GOE demonstrating that sites are fully staffed and fully functional, a concern given the

serious human resource crisis facing Ethiopia.

Additionally, up to $1 million of the funds may be used by the GOE to construct housing for physicians and

other pertinent staff at hospitals, particularly in the city of Addis Ababa where housing costs and the

resulting shortage, particularly for low paid public sector employees, is one of the factors resulting in high

personnel turnover and shortages.

This activity will complement the almost $19 million PEPFAR plans to spend supporting improvement of

existing health infrastructure under FY08, and will support a major GOE priority, increasing access to all

services for the Ethiopian population.

Based on COP08 approval funds for renovations of health centers in high prevalence areas along the high

risk corridors funding levels were restored to initial COP08 levels after discussion with OGAC.

This is a continuing activity from FY07.

This activity supports the Ministry of Health's (MOH) Health Extension Program (HEP) and represents a

bilateral capacity-building activity between the MOH and PEPFAR Ethiopia through an existing Strategic

Objective Agreement (SOAg) between USAID and the Ethiopian Ministry of Finance and Economic

Development (MoFED). This activity leverages other USG child survival and health resources.

The HEP, as indicated in the MOH's Health Sector Development Plan III (HSDP III) 2006-2010, will train

30,000 health extension workers (HEW) for assignment in 15,000 rural wards where they will serve a

population of approximately 5,000 per ward or village. A total of 17,000 HEW were deployed to communities

in most of the regions in the country by June 2007. An additional 14,000 HEW are expected to be trained

and deployed through 2010. The HEW is the first point of contact to the community for the formal healthcare

system. The HEW report to public health officers at the health center and district health office and are

responsible for a full range of primary and preventive services to the community, including implementation

of basic communicable disease prevention and control activities.

HEW function as a significant link in the health network model. Through community counseling and

mobilization, HEW will be able to move vulnerable and underserved populations into the formal health

system. HEW promote essential interventions and services by encouraging community education and

dialogue around health issues, and participation in healthcare at the community and household level. During

FY07, HEW functioned as the lead at health posts and in the community to provide social mobilization

activities for HIV prevention. HEW were instrumental in the two rounds of the Millennium AIDS Campaign

(MAC-E), mobilizing people for voluntary counseling and testing, and other HIV/AIDS services.

HEW will provide preventive services to community members. This activity will continue to support pre-

service and in-service training of HEW on: key HIV/AIDS messages and information; providing counseling

to community members on issues like stigma; symptomatic screening of patients with opportunistic

infections (including active TB) for referral to health facilities for further diagnostic work-up and

management; and adherence counseling for ART and/or TB treatment. In addition, the activities will further

expand several models of HEW provision of PMTCT services and HIV counseling and testing services at

the health post level to facilitate the referral of clients to inpatient facilities and to community care services.

HEW will also be trained and supported to facilitate the referral and linkage process for various services,

and to participate in social mobilization activities for HIV prevention, care, and treatment services. Under

the direct supervision of the Ward Health Team, HEW oversees all community-level health interventions,

including the coordination of efforts with other voluntary community health workers. This activity will support

HEW to build their capacity in joint planning and program implementation.

The urban health extension program has been started in some parts of the country, and will be expanded

further to include more urban and semi-urban areas in FY07/08. This offers an excellent opportunity to link

urban HIV/AIDS activities with the HEW.