Private Sector Program (Prevention AB)

This is a continuing activity.

The Private Sector Program (PSP) led by Abt Associates works with large workplaces and private clinics to

improve access to HIV prevention, care, and treatment services for the general population and employees

and dependents. PSP focuses on developing abstinence, being faithful, and correct and consistent condom

use (ABC) programs which reflect the needs and demands of private and parastatal business firms. The

project seeks to establish management and labor ownership of its workplace ABC activities and encourages

companies to share a significant part of ABC program costs. As of 2007, the project provided routine

support and supervision for 75 workplace sites for both AB and ABC (10374) activities in seven regions of

Ethiopia.

In workplaces, PSP conducts a rapid assessment of HIV services, knowledge, and behavior. Based on the

assessment, the project conducts an orientation session with senior management to reach agreement on a

memorandum of understanding regarding activities and the contributions made by PSP and the company.

PSP trains a cadre of peer educators over a two-to-five-day period on a variety of HIV topics, including

prevention, TB, and stigma. Peer educators also learn skills to support effective counseling and

communication with family and community members. Ideally the project trains one peer educator for every

20 to 30 workers. In turn, the peer educators conduct eight to 16 sessions which focus on increasing

knowledge and fostering behavioral change. The sessions require 30 minutes to one hour of staff time

which the company provides during working hours. The monthly education sessions use peer interpersonal

communication to teach positive behaviors , including correct, consistent, condom use, seeking sexually

transmitted infection (STI) treatment, and accessing counseling and testing services. Sessions also address

stigma and self-risk perception of males engaging in cross-generational, coercive, or transactional sex.

PSP sponsors "family days" to recognize the employer/employee commitment to workplace peer education.

The project engages PLWH associations to deliver messages on HIV prevention. The project also supports

companies to design and complete HIV/AIDS workplace policies and strengthens the capacity of company

health and anti-HIV committees. In 2006, PSP leveraged resources from the International Labor

Organization to expand HIV-prevention programs in ten additional workplaces throughout the country.

In FY07, PSP prepared and enabled large Ethiopian companies to conduct peer-education programs with

ABC and TB/HIV messages by providing training for peer educators, supportive supervision, and

consultation with company senior management. PSP integrated materials on ABC, cross-generational and

transactional sex, TB and HIV, gender norms and the HIV burden on women. Utilizing cross-generational

sex study results, PSP developed three video spots focusing on male behaviors which will be used in the

program component on stigma and discrimination.

In FY08, PSP implementing partners will continue implementation of the peer-education program in the

existing 75 medium to large workplaces. The project intends to propose some innovations in its

peereducation program after completing a review of the 40 workplaces which have not yet begun to train

peer educators. Many of these 40 companies assert that their economic circumstances make them unable

to enter the longer-term commitment to an eight-month peer-education program. The PSP rapid review will

assess the opportunity to offer a new option to companies that are reluctant to embark on the eight-month

peer-education program. PSP will assess whether these companies would be willing to participate in ABC

and TB/HIV information sessions which compress key messages into a half-day format delivered by

professional educators. If the target companies indicate an interest in the half-day event format, the project

will seek opportunities to connect these half-day sessions with PSP's mobile counseling and testing (CT)

activities in order to give staff the opportunity to be counseled and tested. PSP experience in January and

February 2007 during the Millennium AIDS campaign indicates that there is strong demand in workplaces

for mobile or external CT services.

PSP will test the acceptability of a half-day interpersonal communications (IPC) program of ABC and

TB/HIV messages with existing workplaces. If the results are positive, the project will look actively for

opportunities to implement the half-day program with agricultural, industrial, and service sector workplaces

along the four corridors where PSP is implementing mobile CT activities. This activity will focus on

identifying and targeting at-risk populations in the workforce. PSP will also provide assistance to the

Agriculture and Trade Expansion Program (ATEP) which will begin introducing HIV-prevention activities with

their existing private sector clients and companies. PSP will share their IEC materials and best practices to

support ATEP in replicating successful HIV-prevention workplace programs.

PSP's existing, intensive eight-month workplace peer education program, and the possible new half-day

IPC program, are expected to reinforce positive behavioral norms and build more accurate self-perception

of risk among workers. PSP will provide peer educators with follow-up training and supportive supervision to

ensure the consistency of message delivery and support their motivation. In workplace and private clinics,

PSP provides technical assistance to support counseling on prevention for positives, which uses existing

materials. PSP emphasizes prevention for urban males of high educational and socioeconomic status

based on Ethiopia Demographic and Health Survey (EDHS) data which indicates that this group has a large

number of sexual partners. Self-reported condom use among urban males is 48% (EDHS 2005) and there

is an opportunity for increased HIV-prevention programming. This activity will collaborate with HIV-

prevention partners to use or adapt pre-existing audio and print materials to address issues surrounding

male social norms and low self-risk perception.

This workplace program involves sectors such as tourism, transportation, plantation and seasonal

agriculture which employ workers with a higher risk of HIV/AIDS infection. The modified half-day program

approach should allow more transportation, agriculture, and service sector employees to participate in

workplace communication activities. It will also enable PSP to reach out to new enterprises along the major

transportation corridors whose employees are at risk because of their contact with the mobile population

along the corridor.

The PSP program is complementary to AB programs implemented with public sector, government partners,

and affords significantly more reach for PEPFAR than would the public sector alone. PSP reaches the

Activity Narrative: employees and dependents in the general population through its workplace and private clinic programs. It

also reaches at-risk populations through the workplace program by selecting a majority of its intervention

sites in companies whose employees are thought to have one or more risk factors. The target enterprises

include transportation companies (trucking, airline, and railway), agricultural and floricultural enterprises,

tourism, and manufacturing. Through the workplace, PSP reaches men in their sexually active years who

also earn a regular income. At the management level, PSP reaches males of higher educational and

socioeconomic status, who the EDHS indicates are at risk due to their high number of sexual partners and

low reported condom use.

Workplace Peer Education Program

This is a continuing activity. This activity is a comprehensive HIV-prevention activity with both HVAB and

HVOP funding.

Private Sector Program (PSP) reaches at-risk populations through the workplace program by selecting a

majority of its intervention sites in companies whose employees are thought to have one or more risk

factors. The target enterprises include transportation companies, (trucking, airline, and railway) agricultural

and floricultural enterprises, tourism, and manufacturing. Through the workplace, PSP reaches men in their

sexually active years who also earn a regular income. At the management level, PSP reaches males of

higher educational and socioeconomic status. The Ethiopian Demographic and Health Survey has indicated

that members of this group are at risk due to their high number of sexual partners and low reported condom

use.

PSP works with large workplaces and private clinics to improve access to HIV-prevention, care, and

treatment services for the general population, employees, and dependents. PSP focuses on developing

abstinence, being faithful, and correct and consistent condom use (ABC) programs which reflect the needs

and demands of private and parastatal business firms. The project seeks to establish management and

labor ownership of workplace ABC activities and encourages companies to share a significant part of ABC

program costs. As of 2007, the project provided technical assistance in interpersonal HIV-prevention

activities and clinical services in 75 large workplaces. A majority of workplaces have over 500 employees, of

which a subset has several thousand employees in several sectors of the economy including tourism,

transportation, and plantation and seasonal agriculture which employ workers with a higher risk of HIV/AIDS

infection. Many workplaces currently are located adjacent to major transportation corridors whose

employees are at risk because of their contact with the mobile population along the corridor.

In workplaces, PSP conducts a package of interpersonal and interactive HIV-prevention activities, as well

as clinical services strengthening. PSP works closely with company management to outline a package of

services per company requirements. This accentuates company interest and increases the leveraging of

private non-USG resources.

PSP trains a cadre of peer educators over a two- to five-day period on HIV prevention and tuberculosis

(TB)/HIV services. Peer educators also learn skills to support effective counseling and communication with

family and community members. Ideally the project trains one peer educator for every 20 to 30 workers. In

turn, the peer educators conduct eight to 16 structured sessions focused on increasing knowledge and

fostering risk-reduction. Sessions use peer interpersonal communication to teach positive behaviors,

including correct consistent condom use, seeking sexually transmitted infection (STI) treatment, accessing

HIV counseling and testing (CT) services, stigma, and self-risk perception of males engaging in cross-

generational, coercive or transactional sex. One major effort in FY07 was to increase participants'

knowledge of the HIV epidemic using recent Ethiopian Demographic and Health Survey (EDHS) and

antenatal care (ANC) information, specifically the estimated prevalence rates and the burden and

vulnerability on women.

PSP sponsors "Family Days" to recognize the employer/employee commitment to workplace peer education

and to address communities at risk. Family days engage associations for people living with HIV/AIDS

(PLWH) to deliver messages on HIV prevention. The project also supports companies to design and

complete HIV/AIDS workplace policies and strengthens the capacity of company health and anti-HIV

committees. In late 2006, PSP leveraged resources from the International Labor Organization to expand

standard HIV-prevention programs to additional workplaces throughout the country.

In FY07, PSP supported 75large Ethiopian companies train peer educators to reach individuals with

repeated HIV-prevention and risk-reduction sessions. PSP integrated materials on ABC, cross-generational

and transactional sex, TB and HIV, gender norms, and the current HIV burden on women for these

sessions. Using a FY05 cross-generational sex study, three video spots focusing on male behaviors were

used to initiate dialogue on stigma and discrimination.

In FY08, PSP will continue implementation of the peer education program in up to 75 large workplaces.

Several workplaces involved in FY05 will be graduated and provided minimal technical assistance to

facilitate more intensive interventions for recent entrants. The project will innovate peer-education activities

after completing a review of the 40 workplaces. PSP will provide several new options to facilitate access to

HIV-prevention activities among as many employees as possible. Specifically, PSP will implement frequent,

interactive HIV-prevention and CT events in parallel to modified peer-education sessions. This will be

coupled with the delivery of mobile HIV CT services to accommodate employees, family members, and

community members and their families.

PSP experience in January and February 2007 during the Millennium AIDS campaign indicates that there is

strong demand in workplaces for mobile or external CT services. The project will look actively for

opportunities to implement the half-day program with agricultural, industrial, and service sector workplaces

along the four corridors where PSP is implementing mobile CT activities. This activity will focus on

identifying and targeting at-risk populations in the workforce. PSP's intensive eight-month, workplace peer-

education and half-day interactive program seeks to reinforce positive behavioral norms and build more

accurate self-perception of risk among the most-at-risk population groups. PSP will provide peer educators

with follow-up training and supportive supervision to ensure the consistency of message delivery and

support their motivation.

To build up a knowledge based for workplace HIV-prevention programming, PSP will conduct a structured

internal evaluation to determine the effectiveness of the HIV-prevention program in FY08.

In workplace and private clinics, PSP provides technical assistance to support the integration of HIV-

prevention counseling and prevention with positives into workplace clinical settings using pre-existing

materials and leveraging other USG implementing partner's expertise.

PSP's expanding engagement with private clinics offers an opportunity to integrate HIV-prevention

counseling in private, voluntary, CT and TB clinics.

Each workplace program encourages the public distribution of condoms. To support sustainable

programming, PSP does not procure condoms but helps track expiry of condoms in workplaces.

Activity Narrative: Workplace Peer Education Program

Private Sector Program

Building on FY05-FY07 activities, the Private Sector Program (PSP) led by Abt Associates will continue

interventions in large (1000+ employees) and medium-sized companies (500+ employees) in seven regions

to improve access to quality tuberculosis (TB) and TB/HIV clinical services for employees, their dependants,

and surrounding communities.

PSP will also expand integrated TB/HIV services in 100 additional private health facilities. In FY08, the

project will providing continuing supportive supervision for clinical programs in up to 60 workplaces and 120

private clinics. In the same period, the project will begin to work with 100 additional private clinics to

introduce quality HIV and TB services, including TB/HIV prevention, TB detection, TB diagnosis, and

directly observed, short-course therapy (DOTS).

The process of engaging 100 new private facilities consists of ten key steps. To engage stakeholders in the

planning process, PSP will work with the regional health bureaus (RHB) to convene meetings that build

consensus and sensitize stakeholders to the regions' needs for the expansion of TB/HIV services to include

private-sector clinics.

PSP will assist the regions in developing and applying transparent criteria to select up to 100 additional

private facilities to provide TB/HIV services. The project will work with the RHB to conduct a rapid

assessment of the private health facilities identified as potential TB/HIV service providers, in order to

examine their resources and the needs of the facility.

After identifying the most qualified private facilities, PSP will work with the RHB and the private facilities to

establish a Memorandum of Understanding (MOU) between the bureau and the clinics. The MOU

establishes a formal relationship and clearly articulates the roles and responsibilities of the RHB, the district

health office, and the private health facility.

To maintain quality in implementation, healthcare providers must be appropriately trained to provide the

best level of service. PSP will continue to adapt existing training materials for health providers to better fit

the needs of private providers. The training will address the integration of counseling and testing (CT), TB,

TB/HIV, provider-initiated counseling and testing (PICT). PSP will strengthen the facilities' skills in reporting

and recording, internal quality assurance, monitoring and evaluation, and basic finance and management

skills to support service delivery and sustainability.

PSP will help to strengthen a referral network between the private and public sector which ensures

continuity of care, is able to track patient progress, and gets patients the care that they need. The project

will work with the RHB to build a shared understanding of how the referral links between the public and the

private sectors should function, to map the geographic links between the facilities, and to build and

strengthen the links between facilities.

Community awareness can help reduce the barriers to TB/HIV prevention, diagnosis, and treatment. PSP

will encourage the RHB to support community awareness through mass media campaigns, information

leaflets, and posters. PSP will also work actively to promote media coverage of TB and HIV services in the

private sector.

Supervision ensures national guidelines are implemented for provision of care, laboratory and pharmacy

services, and overall facility maintenance, including record-keeping and reporting. PSP will work with the

RHB, and potentially with professional associations, to promote an approach to supervision which goes

beyond a checklist and involves careful direct observation of infrastructure, data entry in registers, and all

other reporting formats, referral tracking, reporting on defaulters, and TB drug supplies, expiry dates, and

requisitions for new stocks.

PSP will assist the RHB and district health offices to develop reliable logistics systems to supply anti-TB

drugs. Depending on the agreements set out in the MOU, there is the potential to include HIV rapid-test kits,

as well. The project will build the capacity of the facility to properly store, manage, and requisition required

stocks of TB drugs.

PSP will assist the RHB in establishing a monitoring and evaluation system which ensures appropriate use

of resources, assure quality, and generates data for decision-making. Monitoring and evaluation of

implementation activities will help to evaluate the outcomes achieved, while measuring both short- and long-

term impact.

This activity will increase access to TB and HIV services through private-sector facilities. The activity will

add 100 new facilities which can identify and treat TB infections and provide HIV counseling and testing

services which are integrated and coordinated. The project will also provide continuing supportive

supervision to 60 existing workplace sites and 100 FY07 private-sector clinics which offer TB/HIV services.

PSP-Ethiopia will closely integrate its TB/HIV activities with the other PSP activity for Mobile and Private

Sector Counseling and Testing Services (10538). In addition, the project will coordinate with other related

projects by sharing its strategies, tools, and ‘lessons learned' with the related contracts. It will request the

same level of information sharing from the related PEPFAR partner programs. The key programs for

information sharing and coordination are the Care and Support Program for TB/HIV, Palliative Care, and

Counseling and Testing (10399, 10400, and 10647), and Community-Level Counseling and Testing Service

Support (10588).

This initiative focuses on the general population which uses private-sector health facilities for care and

treatment. PSP will build the capacity of the RHB and district health offices to integrate the private-sector

facilities into delivery of the key TB and HIV public health services. PSP will assist the Ethiopian Ministry of

Health with facility selection, logistics, supportive supervision, reporting, and monitoring and evaluation.

PSP will build the private-sector facilities' capacity for clinical services, referral, reporting, internal quality

assurance, and general management.

Mobile, Private Sector, and Workplace Counseling and Testing Services

This is a continuing activity. This activity implements activities to support mobile HIV counseling and testing

(HCT), private sector HCT, and workplace HCT.

The Private Sector Program (PSP) led by Abt Associates works with large workplaces and private clinics to

improve access to HIV prevention, care, and treatment services for employees, their dependents, and the

general population. The project seeks to establish management and labor ownership of workplace activities

and encourages companies to share a significant part of program costs.

In FY08, PSP and its local subcontractors will complement ongoing efforts in workplaces and private clinics

with expanded, high-quality, mobile HCT services designed for adult populations in higher prevalence urban

and peri-urban areas. The project will also leverage activities under several existing PEPFAR programs that

provide HIV-prevention and facility-based counseling and testing (CT) and tuberculosis (TB) services.

Access to, and use of, of high-quality, facility-based voluntary counseling and testing (VCT) services by at-

risk populations remains problematic along major transportation corridors (i.e., Addis-Djibouti; Addis-

Adigrat; Addis-Metema; and Modjo-Dilla). Private CT services, although promising, are not yet sufficiently

supervised to assure that they comply with national guidelines to provide quality laboratory services and

comprehensive referrals. The activity will expand mobile CT services in parallel to expanding long-term,

facility-based CT services in workplaces and private for-profit clinics along the corridors.

Each component is described below. It is important to note that the intermittent nature of mobile CT services

poses a challenge to providing sustained improvements to CT services. In response to this, PSP is ensuring

that private, for-profit clinics are identified and CT services are installed or strengthened in areas of mobile

CT. Furthermore, using basic subcontracting, PSP is working with large, indigenous, commercial and civil

society CT providers to support mobile CT services. These subcontracts are improving the capacity of these

partners to perform services and compete in future USG activities.

1) Support for Mobile CT Services:

During FY08, PSP will operate four, low-cost, mobile counseling and testing units along four transportation

corridors focusing on high prevalence and high demand areas. The mobile units will:

- Target adult populations, commercial sex workers, mobile workers, and other risk groups for CT in urban

and peri-urban areas

- Employ highly visible promotion teams to prime demand and offer multiday CT events in high-prevalence

areas within the ART health network

- Receive training and supervision to ensure that services meet national guidelines, including quality

assurance/quality control, use of finger-prick techniques with dried-blood-spot or parallel testing

- Make comprehensive referrals for care and treatment. The program will follow up to monitor success in

connecting seropositive individuals with appropriate care.

- Standardize reporting to appropriate levels of the Ethiopian Ministry of Health and conduct joint analyses

of client demographics and findings with regional health bureaus (RHB) and USG partners.

This activity will support targeted community mobilization to promote use of CT services along

transportation corridors, in markets, workplaces, public gatherings, and particularly in places identified as

sites where high-risk populations live and work.

Each quarter, PSP will select four different groups of 10-20 towns along the major transportation corridors

where the project will provide mobile CT services. Program staff will complement CT services with targeted

mobilization activities to increase uptake of such services among adult populations and MARPs. By

vigorously promoting the CT services, PSP will help to make the teams efficient and productive. The

program will target 15 tests per counselor per day on a five-day-per-week activity schedule. CT service

capacity ranges from 5-15 counselors per day, depending on the findings of service-demand assessments.

The mobile services will contribute to the national strategy to rapidly scale up CT services to reach

underserved and marginalized populations. Current services are predominantly based in static centers in

government health centers and hospitals. Ethiopia's July 2007 national CT guidelines clearly indicate the

need for outreach and mobile CT service delivery.

2) Support for CT Services in Private Health Clinics:

In FY08, PSP will work closely with RHB and town health offices to strengthen a minimum of 200 private

clinics with high client volume to provide CT services. PSP will also develop innovative models to refer at-

risk clients visiting pharmacies to appropriate TB or HIV clinical services. While working with private health

facilities, PSP will:

- Strengthen the capacity of Ethiopian nongovernmental organizations (NGO) and private sector partners to

provide CT and TB diagnosis and treatment

- Provide facilities with training, supervision, and assistance to improve service quality, productivity, and

management. This will support better quality counseling and testing services.

- Promote extended VCT hours to facilitate access

- Strengthen referral linkages to community and facility-based HIV/AIDS prevention, care, and treatment

services

By increasing the use of the private sector to provide CT services, this program will reduce the strain on

already overburdened public health providers and build the competence of local organizations to provide

high-quality, sustainable CT services where international organizations may now be filling that role.

3) Support for Workplace CT Services and Referral:

PSP will continue implementation in large (1000+ employees) and medium-sized companies (500+

employees) in seven regions to ensure improved access to counseling and testing. By September 2008,

this activity will operate in up to 75 workplaces and private health facilities across Ethiopia and will ensure

the presence or improved access to quality services, including counseling and testing.

Activity Narrative: As part of an integrated workplace program for HIV/AIDS prevention, care, and treatment, PSP will continue

to support intensive, workplace peer-education programs, which support greater uptake of TB and HIV

services. PSP promotes a "Know Your Status" interpersonal communication program to reinforce positive

behavioral norms. The peer education program will increase numbers of employees and dependants

choosing VCT and needing subsequent clinical care and treatment.

PSP will support CT services in the workplace by providing supportive supervision for those clinics which

offer on-site CT services or refer clients to external CT providers through provider-initiated counseling and

testing (PICT) or voucher programs. The project will also link workplaces whose employees fall into the high

-risk groups with mobile CT services.

This activity will educate the workforce and families about basic facts and the importance of CT in 75

workplaces and will reach families and the surrounding community with similar messages during mass

educational events. The peer-education component educates staff through eight modules on TB and

HIV/AIDS which are delivered in small-group discussions during the work day. This activity works with

employers to establish HIV policies to protect HIV-positive employees from stigma and discrimination.

PSP will work closely with Medical Association of Physicians in Private Practice (MAPPP) and other

professional associations in collaboration with RHB to initiate and sustain private-sector CT services. This

activity will focus on reaching MARPs along the four high-risk corridors in urban and peri-urban settings. It

will increase access to quality, integrated HIV and TB services for urban populations by engaging new

private-sector clinics in delivering services.

PSP targets MARPs by conducting thorough rapid assessments before deploying mobile CT teams or

selecting private-sector clinics. The assessments gathers information on who the MARPs are in a

community, where they live or work, and what messages might persuade them to accept CT services. The

assessment identifies the most-at-risk groups in a community through key informant interviews with staff

from RHB and district health offices, as well as local NGO and faith based organizations which provide care,

treatment, and support services. It also uses focus-group discussions and individual interviews with

individuals from the risk groups to ascertain where these groups can be reached with CT services and what

messages might prompt them to seek CT.

PSP reaches at-risk populations through the workplace program by selecting a majority of its intervention

sites from companies whose employees are thought to have one or more risk factors. The target enterprises

include transportation companies, (trucking, airline, and railway), agricultural and floricultural enterprises,

tourism, and manufacturing. Through the workplace, PSP reaches men in their sexually active years that

have disposable income. At the management level, PSP reaches males of higher educational and

socioeconomic status whom the 2005 Ethiopia Demographic and Health Survey indicates are at-risk due to

their high number of sexual partners and low reported condom use.

PSP will use national systems for implementation, monitoring and evaluation, and intensive supportive

supervision to strengthen CT services in areas of operation.

Private Clinic ART integrated with PMTCT

The Private Sector Program (PSP) led by Abt Associates works with large workplaces and private clinics to

improve access to HIV prevention, care, and treatment services for the general population and employees

and dependents.

As Ethiopia has increased the number of people on ART, hospital-bases services have become increasingly

congested. While hospitals which provide ART are overcrowded, the related services in those facilities such

as counseling and testing (CT), PMTCT and TB are frequently underused. This activity is designed to assist

in identifying and treating HIV-positive adults with specific focus on pregnant women in peri-urban

communities who are not served by other entry points to care. Despite greater access to HIV/AIDS services

in urban and peri-urban areas, efforts to prevent pediatric HIV infection have been hampered by low

PMTCT uptake, clients' perception of poor quality public sector ANC services, low utilization of antenatal

care (ANC) services, and lack of awareness of PMTCT and ART services.

Based on recommendations from the USG private sector technical assistance visit of August 2006,

PEPFAR Ethiopia expanded its approach to target private sector facilities which may identify HIV-positive

persons and link them to ART.

According to the Ethiopia Demographic and Health Survey (EDHS) 2005, approximately 11% of deliveries

in Addis Ababa occur in the private sector. Furthermore, 17% of all women (urban and rural) receive family

planning services from the private sector. It is likely that this number comes primarily from urban and peri-

urban areas. PSP will work in regional capitals and large towns such as Addis Ababa, Bahir Dar, Dessie,

and Nazareth to expand the ART health network through private clinics and pharmacies to identify and treat

those living with HIV/AIDS who do not attend public facilities.

This activity will build on linkages between health centers and hospitals supported in the FY07 activities.

The following activities are proposed:

1) Improve awareness of HIV services among pregnant women and address client perceptions of service

quality to increase uptake. The contractor will work with private sector providers to: strengthen their

awareness and involvement in HIV/AIDS care for pregnant women; increase counseling and testing for

adults and specifically pregnant women receiving CT; improve the quality of care and support for HIV-

positive women; strengthen referral linkages for HIV-positive adults specifically pregnant women; strengthen

the public-private partnerships to bring HIV-positive adults, specifically pregnant women into the ART

network; and integrate HIV/AIDS and TB services, specifically ART clinical management of stable patients

into private sector clinics in selected high client flow private facilities.

2) Ensure that private facilities which provide integrated TB and HIV services target pregnant women for

service. The contractor will prioritize assistance to facilities that reach this audience, such as antenatal care

and family planning providers.

3) Support outreach to raise community awareness of HIV/AIDS counseling and testing, care during and

after pregnancy, and of assisted delivery. Several pre-existing materials were developed with past PEPFAR

Ethiopia investments. Low-level mobilization, (i.e. road shows during market days) will be conducted where

mass media has little penetration.

4) The activity will prioritize identification and enrollment of pregnant women for ART in selected high-

volume private facilities.

5) This activity will improve data management, supportive supervision, quality assurance and stewardship in

the Regional Health Bureau (RHB) and District Health Offices' (DHO) interaction with the private sector. It

will accelerate rollout of PMTCT and ART in private facilities, and generate community demand for PMTCT

and ART services.

6) Work with the Ministry of Health and Regional Health Bureaus to revise national Public Private Mix

guidelines for HIV/AIDS services.

This activity is integrated with several Private Sector Program activities proposed for FY08 funding. The

activity will be implemented in full collaboration with US government implementing partners at Health Center

and Hospitals as well as Pharmacy specific expertise of RPM Plus.

It will also draw strategies, material, and tools from the following activities: IntraHealth International for

PMTCT/Health Centers and Communities (104615), JHPIEGO Qualitative Assessment of Women's

Attitudes related to PMTCT (10650), the ART treatment activities of US universities which provide technical

support for ART scale-up [Johns Hopkins University (10430) Columbia University (10436), and University of

Washington (10439)], Johns Hopkins University, Clinically Focused Record Systems (10598), Family Health

International ART Service Expansion at Health Center Level (10604), Johns Hopkins University, User

Support Center for ART Service Outlets (10606), US Centers for Disease Control and Prevention, Public

Awareness on ART (10623).

This initiative targets adults and HIV positive adults who use private sector pharmacies and health facilities

for care and treatment services or products. It will reach pregnant women and those planning pregnancy by

strengthening and PMTCT counseling services, training, and communication material within those facilities.

PSP will build the capacity of the Regional Health Bureaus, District Health Offices and Town Health Offices

to supervise private sector providers through systems-oriented technical assistance and secondment.

The result of this activity is expected to build the private sector facilities' capacity for clinical services,

referral, reporting, internal quality assurance, and general management.

The Private Sector Program (PSP), led by Abt Associates, works with private clinics to improve access to

HIV prevention, care, and treatment services for the general population, and works with large workplaces to

improve access for employees and their dependents.

This activity leverages proposed funding from USG Ethiopia's bilateral Tuberculosis ($600,000).

This activity began in FY07 to 1) strengthen host country policies toward private-sector engagement and 2)

establish an information base on sustainable HIV/AIDS financing for private and civil service employers

through AIDS Solidarity Funds. In FY07, successful public-private mix activities in Addis Ababa in

tuberculosis (TB) directly observed therapy - short course (TB DOTS) and HIV counseling and testing

accounted for approximately 11% of TB case notification and approximately 10% of total HIV counseling

and testing sessions. Progress was made in structuring and advancing public policy dialogue with the

Ministry of Health (MOH) and regional health bureaus (RHB) in the areas of TB/HIV service delivery by the

private sector and cost recovery. Cost recovery and sustainable financing mechanisms will be further

analyzed in the remainder of FY07.

To date, donor and government efforts have focused on building the capacity of public-sector provision of

counseling and testing, ART, and TB DOTS, with support from PEPFAR and the Global Fund for AIDS,

Malaria, and Tuberculosis (GFATM). While these efforts have achieved tangible gains and greatly increased

access to quality HIV/AIDS/TB services, there are limits to the absorptive capacity of the public sector,

which is not always the best channel to reach high-risk groups that may be reluctant to attend public-sector

clinics and may keep hours that are incompatible with public-sector clinic times. Finally, the private sector's

need to charge fees is not necessarily a barrier to service provision.

There are three components to this activity:

In FY08, this activity will use $400,000 in PEPFAR resources to continue: 1) building an evidence base for

the sustainable financing of HIV/AIDS services through private, parastatal, and civil service employers; 2)

structuring policy dialogues with federal and regional authorities to support continued expansion of private

service delivery of quality HIV/AIDS and TB services; and 3) continuing to analyze and build an information

base of HIV/AIDS service delivery in the private sector for future programming.

In FY08, this activity will provide technical assistance to implement a Development Credit Authority (DCA)

between the USG and two private banks. This DCA will facilitate private financing of private-sector activities

valued at $500,000 in PEPFAR resources, for a total DCA of $850,000 of USG resources. The DCA

mechanism will support the financing of private hospitals, higher clinics, and private health colleges to

expand capacity to address private-service delivery of HIV/AIDS and TB services and human resource

development of health officers, nurses, laboratory technologists, and pharmacist technicians. Analysis by

the USG identified that an Ethiopia-based DCA would achieve a 12:1 leverage of private capital (i.e., a

$1,000,000 DCA would enable the banking sector to mobilize $12,000,000 in private non-USG resources to

use for financing private-sector health projects as agreed to by the USG and the bank participants). The

DCA is a proven model to expand private-sector capacity through increased financing opportunities and will

provide tangible incentives to expand sustainable HIV/AIDS programs, including ART services at hospitals

and higher clinics throughout Ethiopia. Funds for the DCA were incorrectly assigned to Abt Associates and

are being reprogrammed in Apr'08 to a USAID mechanism.

In FY08, approximately $300,000 in PEPFAR funds and $200,000 in non-PEPFAR USG Population funds

will provide technical assistance to private-sector participants, including bank employees and private health

practitioners, to support business and loan training. Training initiatives would target private hospitals and

clinics to expand management and administrative capacity, which will further strengthen the delivery of

HIV/AIDS and TB services.

In FY07, this activity provided policy expertise to work with the government, the PSP Ethiopia project, and

the private sector to address such issues and build consensus for solutions. In addition, this activity

provided technical assistance to the MOH and selected RHB to draft appropriate public policies expanding

the physical and economic access of Ethiopians to private-sector HIV/AIDS and TB services. Substantial

analysis of private-sector delivery, quality, and financing of ART will be completed in FY07.

In Ethiopia, many private providers are already offering priority public health services and are interested in

expanding these services. Most of these providers are seeing a significant demand for priority public health

services such as HIV counseling and testing, TB diagnosis and treatment, reproductive health services

(including long-term methods), and ART. Unfortunately, due to the mismatch between bank lending terms

and private providers' investment needs, many are not able to access financing to expand their capacity to

delivery public health services.

Despite the constraints, there is broad interest from private providers in accessing financing. Providers are

interested in using financing for a variety of purposes, including renovating and constructing facilities and

purchasing equipment and drug stocks. Financing needs are quite diverse, we envision median

requirements to range from $8,000 to $35,000 in order to support care and treatment services. The highest

levels of interest are from higher clinics, private hospitals, laboratories, and private health colleges.

Health sector lending is limited, but USG analyses have found that several banks are interested in entering

the market. A recent assessment revealed that, currently, financial institutions are not lending to the health

sector in a significant way mainly because collateral requirements and short loan terms are constraints. The

DCA, however, has induced three banks to reduce loan collateral requirements by 50%.

Recommendations:

Based on these findings, PEPFAR Ethiopia believes that, by engaging the private health sector we have the

opportunity to shape the development of the sector to deliver public health services including HIV

counseling and testing, TB diagnosis and treatment, and ART. Interventions to provide business training to

private providers and work with financial institutions to expand health sector lending will greatly strengthen

HIV/AIDS service delivery in the private sector. The USG assessment recommends that the DCA address

the health sector by providing approximately $15 million to assist banks to enter the healthcare market. The

DCA funds will reduce risk and addresse some of the banks' collateral constraints. The Office of

Development Credit estimates that the total subsidy cost of a $15 million guarantee would range from

Activity Narrative: $1,798,500 to $1,818,000.

This activity will provide the MOH and several RHB with technical support to identify and address the gaps

and obstacles in policy and requirements which may limit the willingness and ability of the private sector to

provide TB or HIV services. This activity will provide support to the overall strategy to decentralize HIV/AIDS

services in urban and peri-urban areas and further multiply entry points for HIV/AIDS care and treatment by

utilizing private-sector clinics.

This activity is linked to activities addressing private-sector providers, including hospitals, higher and

medium clinics, laboratories, and pharmacies. In addition, there is a link between the technical assistance

being provided through "training" partners who are addressing pre-service curriculum adaptation and private

health colleges.

The activity will reach a range of stakeholders in the private sector, including private healthcare providers,

professional associations (e.g., the Medical Association of Physicians in Private Practice-Ethiopia),

business leaders, private-sector medical schools, and training institutes. Strategies to reach these different

groups vary depending on the stakeholder. The primary strategy to reach these stakeholders will be the

creation and facilitation of a working group focusing on private-sector issues related to the provision of

HIV/AIDS and TB services (quality improvement, training, access to commodities, data reporting, financing

mechanisms, etc).

The activity will provide in-service training to host-country government workers and health providers. The

training will focus on policy advocacy and policy experiences with private-sector health service delivery.

This activity will address workplaces by analyzing existing financing mechanisms used for HIV/AIDS

prevention, care, and treatment activities at those sites.

The public-private partnership component of this activity will leverage approximately $10,002,000 in private,

non-USG resources. Furthermore, this activity will receive funding from the USG's non-PEPFAR bilateral

TB and population and reproductive health programs.