Addition: 10/7/08

The FY08 country specific PHE activity on "assessment of the perception/knowledge and attitudes of

women, men, and health care providers regarding PMTCT service and program" has not been approved by

OGAC to be implemented in FY08. Therefore, this reprogramming request is to remove the activity and

reprogram the fund 200,000 to RIPSO activity renovation of 15 addditional PMTCT sites (activity number

18843). The total number of facilities to be rennovated will reach 115.

The remaining 25,000 is reprogrammed to multicountry PHE entitled "Evaluation of Interventions to Reduce

Early Mortality among Adults Initiating ART in Emergency Plan Countries" activity ID 18807.

The rest of the narrative section for activity number 18843.08 will be kept as it is.

Ethiopia's national PMTCT coverage is very low and currently estimated at 2%. A major limiting factor to

PMTCT uptake is believed to be poor antenatal care (ANC) and delivery coverage in health facilities. The

2005 Ethiopian Demographic and Health Survey (EDHS) report indicates that ANC coverage is as low as

28%, with only a 1% increase from the 2000 EDHS. Skilled attendance at birth is only 6% (EDHS 2005)

showing no change whatsoever from the 2000 level. Even in urban areas only 44.6% had skilled

attendance at delivery. Given this limited coverage, it is estimated that only about one-quarter of HIV-

positive women attend at least one ANC visit. Consequently, only a small group of women have access to

the available PMTCT services. Among those women who initiate PMTCT, significant numbers do not

complete the full course due to poor quality of ANC and delivery services in the facilities.

The ultimate goal of PMTCT is to improve overall maternal and child survival, maximizing the number of

AIDS-free children. To reach this goal, it is imperative that as many women as possible access antenatal

care, delivery and postnatal care services. These services provide an important "gateway" for pregnant

women, infants and families to access HIV prevention, care and treatment programs. Among the many

ways to encourage more women to use ANC and PMTCT services, improving and ensuring the quality of

the services are key. Quality services are also essential to strengthen national systems for sustainable

PMTCT scale-up.

There are a number of reasons why women do not want to attend ANC and/or to deliver in health facilities.

Ethiopia's National Reproductive Health Strategy lists poor access, weak referral systems, limited human

resources, and shortages of supplies and equipment as major problems. In addition to these problems,

women do not want to come to health facilities because of the quality of care they receive in these

institutions. The majority of the health facilities do not meet minimum standards of quality. It is quite

common to see shabby delivery rooms which are open and lack the privacy of even a screen, blood-soaked

mattresses and plastic sheets, delivery coaches splattered by old dried blood, and/or no running water in

the room and no place to wash or otherwise clean up for the mother who has delivered. There is also

shortage of supplies and equipment needed for obstetric care and infection prevention

One of the strategies to improve PMTCT uptake is to improve quality of labor and delivery services, in order

to increase the number of facility-based deliveries. Minor renovation of health facilities in a manner that

ensures privacy, availability of running water, proper toilet and wash room facilities, etc., will create sense of

security among women, encouraging them to come for the service. The health facilities need support in

supplies and equipment that are needed for obstetric care and infection prevention such as mattresses,

proper plastic sheeting, gloves, gowns, detergents and other infection prevention supplies, etc.

As part of HIV/AIDS treatment, care and prevention, PEPFAR Ethiopia has supported infrastructure

development of health facilities including renovations of laboratories, clinics, VCT sites, and pharmacy

services. For scale up of PMTCT and achieving PEPFAR PMTCT targets, extensive renovations for ANC

and delivery services are still required in most hospitals and health centers. Nationally, up to 20 hospitals

and 80 health centers will be selected based on their potential for a high yield of HIV-positive mothers, and

their ANC and labor and delivery sections renovated. The Regional Procurement Support Office (RPSO)

will be responsible for the procurement and renovations in the hospitals and Crown Agents will handle

renovations in the health centers. Actual numbers of sites renovated will depend on costs for needed

repairs.

In selecting the sites for renovations, RPSO will collaborate with Crown Agents, the Government of

Ethiopia (GOE), and PEPFAR Ethiopia to select health networks in higher prevalence areas. PEPFAR

Ethiopia will provide technical assistance including follow up and regular supervision of renovation activities;

and coordinate with regional heath bureaus, US universities and other PEPFAR partners in selecting and

determining the need and type of renovation. Renovation plans will also be linked and coordinated with the

Global Fund for AIDS, Tuberculosis and Malaria-supported renovations. All renovated sites will also be

supported for supplies and equipment related to obstetric care and infection prevention. The expected

increase in PMTCT clients will be documented by the partners supporting the PMTCT program in the

facility.

This activity will contribute to the PMTCT program area by improving the quality of services and thereby

attracting more women to attend ANC and deliver in health facilities.

Renovation of ART hospitals

As part of HIV/AIDS treatment, care, and prevention, PEPFAR Ethiopia has supported infrastructure

development of health facilities, including major construction and minor renovation works for laboratory,

clinic, voluntary counseling and testing (VCT), and pharmacy services. CDC Ethiopia has supported

renovation of the National HIV Laboratory at the Ethiopian Health and Nutrition Research Institute (EHNRI),

hospital laboratories, and VCT, PMTCT and ART clinics through the Regional Procurement Support Office

(RPSO). RPSO has more than three years of experience with renovations in Ethiopia and has fostered links

with a national architectural and engineering firm (A/E firm) and other local construction companies. RPSO,

as a parastatal of the State Department, understands US renovation and construction regulations.

In FY07 and FY06, PEPFAR Ethiopia strengthened the clinical and public health laboratories to increase

capability and capacity for care and treatment and ART scale-up. Renovation and furnishing were

accomplished in 45 hospitals and three regional reference laboratories. The renovations include major

and/or minor constructions that increase work spaces for clinical and laboratory services. Hospital

renovations will be comprehensive, to accommodate VCT, ART, PMTCT, pharmacy and laboratory

services.

For rapid scale-up of ART and to achieve targets, extensive renovations are still required in most hospitals.

The infrastructure for VCT, antenatal clinics (ANC)/PMTCT and ART services is also limited and does not

allow rapid expansion of ART. In FY08, major construction and minor renovation works will still be

continued. ART hospitals in which construction/renovation works were started will be completed. Additional

construction/renovation works will also be initiated at 40 ART hospitals and selected health centers in the

emerging regions. RPSO will work at hospital levels in the five major regions (Addis Ababa, Oromiya,

Amhara, Tigray, SNNRP), and will be responsible for renovation and construction activities at both health

centers and hospitals in emerging regions and uniformed services. All renovated sites will also be fully

furnished with required furniture and fixtures. RPSO will be working with Crown Agents and PPD in the

national coordination and tracking system for renovation and construction. Together with these partners, it

will develop the national renovation guidelines.

Accelerated renovation using simple construction materials (prefabricated materials) will be implemented for

construction of ART clinics, VCT, PMTCT and laboratories to expedite ART scale-up at some sites. Such

constructions are expected to be completed quickly and available for services in less than a year. CDC

Ethiopia will provide technical assistance including follow up and regular supervision of

renovation/construction activities; and will coordinate with regional health bureaus and US universities in

selecting and determining the need for and the types of renovation. Renovation plans will also be linked and

coordinated with the renovations supported by the Global Fund for AIDS, Malaria, and Tuberculosis.

Adding $2,682,925 in unallocated funding to this activity to raise it to its original level, following the removal

of COP08 yellow lights. In additon, added $356,114, the total amount of money that the PECO office

borrowed from CDC. Subtracted $1,300,000 from this activity to fund Tulane HRH.

Prime partner entered in COPRS as TBD and should be in RPSO.

Management and Staffing (HVMS) Renovation of Office Building

This activity includes the renovation of building to expand the current collaboration with the Federal Ministry

of Health. Half of CDC staff is presently in the process of moving into a facility located within Ethiopian

Health and Nutrition Research Institute (EHNRI) compound that was renovated in collaboration with the

Institute. The other half of CDC staff will remain at our current location within a leased private facility. Since

CDC Ethiopia's programs and number of staff have and will continue to expand, both buildings are unable

to accommodate our staffing size, even in the present. Thus, newly renovated building will enable all CDC

staff to be located in one building and further expand on collaboration with MOH.