Targeted Promotion and Community Mobilization for Antenatal Care

This is a continuing activity from FY07. This program is a wraparound activity with the Presidential Malaria

Initiative (PMI) to mobilize women to attend antenatal care (ANC) in support of joint goals, enrollment in

ANC/PMTCT services, and provision of a long-lasting insecticide-treated net. The activity will leverage

$900,000 in PMI funding. This activity is implemented in urban and peri-urban areas of Amhara and

Oromiya. This activity reaches women ages 15-45 years old.

Ethiopia's 2005 Demographic and Health Survey found that low ANC attendance and assisted delivery

remain major impediments to progress on PMTCT targets. Fifty-six percent of urban women delivered in

their homes, and 30% of urban women did not receive delivery assistance from a health provider or

traditional birthing attendant. Women who attend ANC are on average 4.2 months along in their pregnancy.

Eighty-eight percent of urban-based pregnant women expressed several factors affecting their decision to

attend ANC or assisted delivery:

1) Concern there may not be a health provider (71%)

2) Concern there may be no one to complete household chores (57%)

3) Getting money for treatment (53%)

The goal of this activity is to increase total ANC enrollment through interpersonal and interactive

communications. As total ANC enrollment increases, the number of unique pregnant women using PMTCT

services will increase throughout selected hospitals and health centers in Amhara and Oromiya. In FY07,

the activity operated in 55 hospitals, health centers, and nongovernmental organization (NGO) clinics in

Amhara and Oromiya regions where the USG has installed PMTCT and ART services.

The activity's objective is to reach pregnant women in communities through interpersonal and mass media

campaigns promoting routine ANC attendance. Mass media activities are in the form of interactive radio

dramas which are coupled with discussion papers distributed to community groups. Interpersonal

approaches focus on community groups where women congregate.

Using USG partner's pre-existing communications platform regarding ANC attendance (i.e., umbrella media

campaigns, low-level road shows, interactive attendance at community group meetings, and household-

level promotion) in regional capitals and towns, the activity will promote ANC attendance and assisted

delivery.

The activity focuses on reaching households and community groups where women congregate in

communities where HIV prevalence remains highest, yet where ANC attendance and assisted delivery

statistics are low. It is anticipated that 50% of Amhara and Oromiya's urban population will be covered. If

this leads to an additional 20% of pregnant women attending ANC or assisted delivery within the health

network, public facilities would increase ANC attendance by approximately 24,600 pregnant women.

Since 2004, NetMark has used USG Malaria funding for communications campaigns to increase knowledge

about and use of insecticide-treated nets (ITN). In addition, NetMark participated in several activities with

the Ethiopian Ministry of Health (MOH) and Amhara regional health bureau (RHB) to improve maternal and

child health (MCH) uptake through targeted subsidy of ITN. NetMark facilitated, through a public private

partnership, several commercial distributors to import, brand, and distribute ITN to improve accessibility.

NetMark provided extensive support to the Amhara and Oromiya RHB and the MOH's Health Education

Center to improve communication materials on ANC attendance and ITN use.

PEPFAR Ethiopia's investment in this activity represents a leveraging of USAID's child survival/malaria

resources. NetMark's activities use interactive and interpersonal communications at the grassroots to

increase demand for ANC services among adult women. Mass media, interactive and interpersonal

communications is anticipated to increase patient flow at ANC clinics.

NetMark's first program component includes targeted promotion through a focus on social organizations,

women's groups, and community-based organizations with household-level activities and interactive

community activities, including road shows. The proposed targeted promotion activity aims to increase

uptake of facility-based maternal health services, which would increase PMTCT service uptake. Targeted

promotion activities reach women and families, educate communities, and improve understanding of

maternal health services, by emphasizing the advantages of ANC and assisted delivery

(ANC/PMTCT/pediatric care services including treatment).

To support this component the following strategies will be used:

1) Leverage existing messages through a multichannel, comprehensive program using mass-media road

shows and community-level and household-level communications to mobilize ANC attendance in/around

selected hospitals and health centers in Oromiya and Amhara

2) Mobilize marketing agents in the community to participate in the communications campaign to increase

ANC service uptake (e.g., district action committees, ward action committees, community malaria agents,

community-based reproductive health agents, health promoters, and traditional birthing attendants)

3) Emphasize household-level and interpersonal communication, dramas, community groups/meetings,

community activations, social mobilization and ANC counseling at health centers. This will also include

training and educational materials for the various expected audiences.

NetMark's second program component includes the targeted subsidy of ITN to ANC attendees. This

component, funded by the PMI, provides a targeted subsidy to ANC attendees to obtain a commercial ITN

product in the nearby community. This is completed through a voucher system distributed by the ANC

provider to pregnant women during routine health-education counseling which includes malaria

transmission and HIV prevention. This is supported by non-PEPFAR resources. To support this component,

ANC providers and commercial sales agents require training, distribution of information-education-

communication (IEC) materials and subsidy vouchers to ANC clinics.

In coordination with regional authorities, this activity will target outreach campaigns that promote services to

audiences in peri-urban areas. The partner will coordinate with USG implementing partners to address

capacity issues within ANC clinics and to prepare for increases in ANC attendance. The partner will

Activity Narrative: collaborate with IntraHealth and US universities to increase the number of women entering the ANC

system.

This activity contributes to the PMTCT program area by providing targeted mass media, interactive and

interpersonal communications campaigns to increase ANC attendance. The use of structured

communication campaigns to attend ANC services in facilities will target urban and peri-urban areas where

HIV prevalence is high. The outcome of this activity is expected to increase the total number of pregnant

women attending ANC services, including PMTCT, in Amhara and Oromiya. This program does not provide

PMTCT services such as the provision of HIV counseling or testing or ART prophylaxis to clients.

This activity is linked to implementing partners providing clinical PMTCT services at the hospital, health-

center, and health-post/community level.

This activity leverages PMI funding for ITN utilization and ITN distribution to vulnerable populations through

ANC service clinics at hospitals and health centers.

Food and Nets for OVC

This is a new activity in COP08. The activity will pilot the leveraging of resources from PEPFAR, the

Presidential Malaria Initiative (PMI), education sector (Basic Education Services at USAID), and World Food

Program (WFP) to improve food security, malaria prevention and detection, and the health status of

students and their families.

The activity will be focused in urban and per-urban areas of the Oromiya region where, according to the

2005-2006 Ethiopia Demographic and Health Survey (EDHS), the HIV prevalence rate is 1.4%. The activity

is piloted in the Oromiya region because this region is the focus region of the new PMI activity.

According to the PMI Malaria Operational Plan, malaria is considered to be the most important

communicable disease in Oromiya. Three quarters of the region, 242 of 261 districts and 3932 of 6107

wards are considered malarious, accounting for over 17 million persons at risk of infection. There are 1.5 to

2 million clinical cases per year, with malaria 20-35% of outpatient consultations, and 16.2% of hospital

admissions. Malaria is also the leading cause of hospital deaths accounting for 18-30% of all hospital

deaths.

Families affected by HIV/AIDS are more vulnerable to the consequences of malaria and persons with

malaria are more susceptible to contracting HIV. Coordination of care will maximize resources and reach of

PEPFAR and PMI.

Malaria is ranked as the leading communicable disease in Ethiopia. About 75% of the country is malarious

with about 68% (50 million) of the total population of 73 million living in areas at risk of malaria (MOH,

2006). About 9.5 million cases of malaria were reported annually between 2001-2005, with an annual

average of 487,984 confirmed cases. In Ethiopia, malaria is the cause of about 70,000 deaths each year.

The 2005-2006 EDHS showed that only about 6% of the 15,000 households surveyed owned at least one

mosquito net whether treated or untreated.

Food insecurity further exacerbates the affects of HIV and malaria. Ethiopia has one of the highest rates of

malnutrition in Africa—47% of children-under-five are stunted and 24% are severely stunted, according to

the EDHS. Oromiya represents a region in Ethiopia where there is convergence of high rates of HIV

prevalence, malaria, and food insecurity in urban and peri-urban sites.

Schools offer a primary entry point for service provision in communities. Several OVC programs and WFP

work closely with schools. The USG PMI program encourages increasing malaria prevention and detection

services through schools. This pilot activity will aim to demonstrate the delivery of coordinated care to OVC

and their families through school-based coordination of care.

PEPFAR funds will be used to support a health counselor (or nurse if possible) at the schools and partially

support community health fairs twice per year in collaboration with UNICEF and PMI. The health counselor

will be trained in nutritional assessments and education, basic child health, special needs of children

affected by HIV/AIDS, and malaria education. The health counselors would be responsible for nutritional

education and counseling and providing psychosocial support to OVC. In addition, these counselors

(possibly nurses) will strengthen the diagnostic capacity for malaria case detection, prevention and

treatment. Outreach to students' families will be a critical responsibility of the health counselor who will work

collaboratively with community health workers, school PTA, teachers and providers of OVC and palliative

care services.

Local education and health and school officials will be asked to make their facilities available for broader

community outreach in exchange for having a health counselor provided.

PMI resources will be leveraged through case detection services and the provision of insecticide-treated

bednets (ITN) and anti-malarial prophylaxis. PMI will also contribute to the community health fairs.

To address food insecurity, this pilot activity aims to coordinate with WFP to provide a school feeding

program. Food insecurity is a large problem in many parts of Ethiopia and affects many schools. Lack of

food prevents many children from attending or staying in school, especially OVC. Student concentration and

productivity are impeded by hunger.

WFP has applied for a McGovern-Dole grant where one component is the support of school feeding

programs in selected schools in Ethiopia. The long-term objective of the Food For Education (FFE) program

is to enable households in food insecure areas to invest in the education of children, especially girls. If WFP

is successful in receiving this grant, USG would exert a strong effort to ensure that this activity is linked to

WFP food support.

For this activity the OVC partner will work collaboratively with PMI and WFP partners to:

1) Identify schools in urban and peri-urban areas in Oromiya region hardest hit by HIV/AIDS and malaria in

consultation with regional and local education and health offices. The partner will identify primary schools in

communities most affected by HIV/AIDS, are in a malarial region and have a need for food and nutritional

support in consultation with regional and local education and health offices.

2) Identify and train health counselors and/or nurses. The partner will hire a nurse/counselor/community

worker for a cluster of 2-3 of the identified schools. These individuals will be responsible for the provision of

coordinated care with assistance from school staff and local health institution to include: nutritional

assessment, education and counseling; malaria case detection and treatment; and service referrals for

OVC. The nurse will be responsible for growth monitoring and for collecting and reporting results and

maintaining student records. The nurse will also provide counseling and referrals to OVC.

3) Provide ITN to the children and malaria education. The partner will provide PMI nets to students and

their families during health fairs or during other events. The provision of ITN will be accompanied on malaria

education and proper usage of the nets.

Activity Narrative: 4) Integrate malaria and HIV/AIDS education into school activities. The partner will integrate education on

malaria and HIV/AIDS into school teaching learning activities such as organizing anti-malaria clubs,

development of IEC materials and others as required. The partner will also integrate nutrition into school

activities.

5) Logistics. The partner will link with WFP to assure that the food security needs are met through a school

feeding program and will ensure that nurses have appropriate and adequate training and information-

education-communications materials. The partner will also ensure that school has the necessary stock of

antimalarial drugs in collaboration with local health institution.

6) Develop the capacity of local education and health including PTA, teachers and school OVC committees.

The partner will build the capacity of the PTAs to support the nurse/counselor at the schools and provide

additional support such as assist with community health fairs to be held at the schools. Members of the PTA

will be encouraged to support OVC mentoring and tutoring services for especially vulnerable children.

This PEPFAR activity is a wraparound with the PMI program and leverages resources from WFP. The

activity is targeted to OVC who are affected or infected by HIV/AIDS and living in Oromiya region. The

activity will also be linked to the USG basic education program.

Children and families affected by HIV/AIDS living in Oromiya region will be the focus for this pilot program.

The project will be based in primary schools in areas most affected by HIV/AIDS and malaria. Target

population will be reached through school and local education and health and community leaders. Children

and families affected by HIV/AIDS and malaria will be involved in decision-making processes.