PEPFAR's annual planning process is done either at the country (COP) or regional level (ROP).
PEPFAR's programs are implemented through implementing partners who apply for funding based on PEPFAR's published Requests for Applications.
Since 2010, PEPFAR COPs have grouped implementing partners according to an organizational type. We have retroactively applied these classifications to earlier years in the database as well.
Also called "Strategic Areas", these are general areas of HIV programming. Each program area has several corresponding budget codes.
Specific areas of HIV programming. Budget Codes are the lowest level of spending data available.
Expenditure Program Areas track general areas of PEPFAR expenditure.
Expenditure Sub-Program Areas track more specific PEPFAR expenditures.
Object classes provide highly specific ways that implementing partners are spending PEPFAR funds on programming.
Cross-cutting attributions are areas of PEPFAR programming that contribute across several program areas. They contain limited indicative information related to aspects such as human resources, health infrastructure, or key populations programming. However, they represent only a small proportion of the total funds that PEPFAR allocates through the COP process. Additionally, they have changed significantly over the years. As such, analysis and interpretation of these data should be approached carefully. Learn more
Beneficiary Expenditure data identify how PEPFAR programming is targeted at reaching different populations.
Sub-Beneficiary Expenditure data highlight more specific populations targeted for HIV prevention and treatment interventions.
PEPFAR sets targets using the Monitoring, Evaluation, and Reporting (MER) System - documentation for which can be found on PEPFAR's website at https://www.pepfar.gov/reports/guidance/. As with most data on this website, the targets here have been extracted from the COP documents. Targets are for the fiscal year following each COP year, such that selecting 2016 will access targets for FY2017. This feature is currently experimental and should be used for exploratory purposes only at present.
Years of mechanism: 2008 2009
Standards Based Management and Recognition (SBM-R) for HIV/AIDS Service Performance
ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS:
This is a continuing activity from FY08. In FY09, TBD partner will continue to expand the SBM-R services in
health facilities, including health centers in the emerging regions and other sites where there is no program
for quality. It will strengthen the recognition activities in the health facilities currently implementing the
program and expand the services to six private hospitals in different regions.
Building on experiences, TBD partner will work towards institutionalization and sustainability of the quality
improvement and measurement of HIV/AIDS services in the country. TBD partner will support the
establishment of a separate office for quality improvement of HIV/AIDS services which will be accountable
for the MOH, in close collaboration and consultation with FHAPCO, health service department of FMOH and
RHBs.
TBD partner will conduct four SBM-R experience sharing workshops, advocacy workshop on the
establishment of an independent quality assurance and regulatory system at national level, and host one
regional forum for sharing experience on the implementation of SBM-R.
Furthermore, TBD partner will support the strengthening of the pre-service education on health service
quality improvement at the masters' level education for public health and hospital administration studies in
Ethiopia.
Standards Based Management and Recognition (SBM-R) is a practical management approach for
improving the performance and quality of health services. As proven by experience in other countries,
SBMR can increase the uptake of services to reach PEPFAR targets and improve patient treatment
adherence. SBM-R is the systematic use of performance standards by on-site health care staff teams as the
basis for improving the organization and provision of services. After introducing performance standards at a
healthcare facility, the team conducts a baseline assessment of services. After two to three months of
implementing performance standards, the team again measures the performance of services during an
internal assessment. Improvements in performance are measured by the difference in the number, as well
as percent of standards achieved, from baseline to internal assessment. The achievement of standards is
recognized. In Zambia, such recognition was shown to lead to improved healthcare worker satisfaction,
which can lead to improved retention of health staff.
In FY07, JHPIEGO implemented SBM-R for a comprehensive set of HIV/AIDS performance standards.
Operationally, performance standards are assessment tools that are mainly used for assessing the
performance of service delivery, but can also be used for self, peer, internal, and external assessments at
the facility level. Hospitals elect teams to participate in three short workshops, learning how to apply the
methodology at their sites, gain buy-in, and address performance gaps. These team members and their
colleagues then perform facility-based internal assessments in between workshops. Subsequent workshops
allow for extensive exchange of assessment results, lessons learned, and best practices, as well as the
resolution of more difficult problems in quality of care. In FY07, JHPIEGO deployed six SBM-R coaches to
selected regional health bureaus (RHB) to facilitate support to hospitals. In addition, the SBM-R Advisor
was temporarily seconded to the Federal HIV/AIDS Prevention and Control (HAPCO) Quality Team,
working to institutionalize SBM-R oversight in that unit.
By the end of FY07, JHPIEGO expects to have:
1) Assisted all first, second, and third cohort hospitals (except for HIV-Quality pilot sites) to complete
baseline assessments and develop action plans 2) Assisted at least half of these hospitals to conduct a
second internal assessment and new action plan 3) Worked with the HAPCO Quality Team and
implementing partners to recognize any hospital achieving a set level of standards At each facility, SBM-R
coaches and facilitators work with one core team representing the hospital. That team is made up of the
medical director and/or administrator and other representatives as selected by the hospital. In addition, for
the initial orientation, a team of 2-3 people from each unit with HIV/AIDS services
(e.g., ART, out-patient departments, maternal/child health (including antenatal clinics and labor and
delivery), central supply and sterilization, record-keeping, pharmacy, and laboratory) is invited to the on-site
training and given help to conduct the baseline assessment. The teams are composed of physicians,
nurses, laboratory technicians, pharmacists, data clerks, and administrators.
JHPIEGO is working closely with PEPFAR partners, including US-based university partners, to ensure that
staffs are oriented to the coaching approach so that service providers and facilities implement standards
and close any identified gaps.
In FY08, JHPIEGO will continue to support the first 100 hospitals in achieving recognition status, as well as
preparing high-achieving hospitals to implement HIV-QUAL. While doing so, JHPIEGO will work on
harmonized quality management, through a large-group consultation and discussion with CDC and HAPCO.
JHPIEGO will also introduce the process in the remaining fourth cohort hospitals and additional health
centers supported by CDC partners. To accomplish this, JHPIEGO will recruit additional SBM-R coaches
deployed in RHB. Another important activity will be to decentralize the external verification process for sites
to attain recognition to the regional level; this will reduce cost and increase sustainability. Also, SBM-R
activities and processes will be further linked to Human Resource Management systems at the regional
level, in order to maximize its role in improving retention of HIV/AIDS trained staff.
In FY08, JHPIEGO will use Health Management Information System (HMIS) data to perform an analysis
Activity Narrative: exploring the correlation between HIV/AIDS patient outcomes and SBM-R assessment results from the
second internal assessment. We hope that this analysis will demonstrate the link between performance
standards, which measure how services are delivered and support functions carried out, to improved
outcomes—thus convincing stakeholders to absorb the SBM-R coaches into the RHB staff in their next
budget cycle and sustain activities beyond PEPFAR.
In FY07, a significant amount of carry-forward funds (approximately $200,000) was applied to the SBM-R
funding to supplement the FY07 funding of $400,000. This budget included no US salaries or technical
assistance; however, JHPIEGO will require some US technical assistance in FY08 to facilitate the analysis
of SBM-R results with HMIS outcome data. We therefore request that the total FY07 budget (including the
carry forward applied) of $600,000 be considered as the base for FY07 to justify the increase in the FY08
funding request.
exploring the correlation between HIV/AIDS patient outcomes and SBM-R assessment results from the
New/Continuing Activity: Continuing Activity
Continuing Activity: 16572
Continued Associated Activity Information
Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds
System ID System ID
16572 5569.08 HHS/Centers for JHPIEGO 7473 3746.08 University $500,000
Disease Control & Technical
Prevention Assistance
Projects in
Support of the
Global AIDS
Program
10480 5569.07 HHS/Centers for JHPIEGO 5468 3746.07 $1,055,000
Disease Control &
Prevention
5569 5569.06 HHS/Centers for JHPIEGO 3746 3746.06 $860,000
Emphasis Areas
Gender
* Increasing gender equity in HIV/AIDS programs
Health-related Wraparound Programs
* Child Survival Activities
* Family Planning
* Malaria (PMI)
* Safe Motherhood
Human Capacity Development
Public Health Evaluation
Food and Nutrition: Policy, Tools, and Service Delivery
Food and Nutrition: Commodities
Economic Strengthening
Education
Water
Table 3.3.01:
Expansion of PMTCT Services at Family Guidance Association of Ethiopia Clinics
This is a continuing activity from FY08. In FY 09, TBD partner will build on FY 08 activities and continue
strengthening the PMTCT program at a national level and FGAE clinics. In FY 09 TBD partner will scale up
the PMTCT program in addition to the FY 08 planned activities by including the following:
1)Support the transitioning of the national PMTCT program from Federal HAPCO to the Family Health
Department (FHD) of the Federal MOH through active participation in the national PMTCT TWG
2)TBD partner will focus on supporting strategic directions and programmatic gaps such as: PMTCT
program management support for managers at central and regional level and integration of PMTCT with
MNCH services. Program management training and supportive supervision for managers at different levels
will be expanded. TBD partner will use expertise namely MNCH and HIV/AIDS to help the FHD and HAPCO
to integrate PMTCT with MNCH services
3)Promote the Testing and Counseling Support tools for PMTCT at all PMTCT sites
4)As part of its sustainability and exit strategy, TBD partner will strengthen its support for FGAE in the
provision of comprehensive PMTCT/MNCH and HIV care and treatment for women coming to FGAE clinics
as well as through outreach program which FGAE is implementing. It will continue supporting the PMTCT
services at FGAE clinics selected in FY 08 and support establishment of labor and delivery services at eight
of these health facilities. Furthermore, the PMTCT services will be expanded to additional 12 sites.
5)JHPIEGO has been supporting MSG in FY 07 and FY 08. In FY 09, however, TBD partner will facilitate
smooth transfer of the MSG sites to the respective university partners, as the university partners are well
positioned to implement these programs.
6)Assist to strengthen the PMTCT M&E system: TBD partner will assist the national PMTCT program to
improve data collection and reporting on key PMTCT indicators
COP08 ACTIVITY NARRATIVE
This is a continuing activity from FY07. To date, PMTCT services in Ethiopia have largely been
concentrated in public health facilities and limited private institutions. In FY08, JHPIEGO proposes scaling
up PMTCT services to local nongovernmental, as well as charity maternal-child health (MCH) clinics. In
FY08, JHPIEGO will do this in collaboration with the Family Guidance Association of Ethiopia (FGAE), an
established organization, which provided support to JHPIEGO to deliver VCT services at 35 sites in FY07.
The FGAE is a national organization with significant experience in family planning and other reproductive
health services. FGAE's program activities and services cover a large part of the country, creating a
network of branches and offices that span from the regional to the community level. In FGAE clinics which
already offer MCH services, JHPIEGO plans to establish counseling and testing for PMTCT, with referral
linkages to public facilities in the vicinity for labor and delivery (L&D).
JHPIEGO will provide training, mentoring, and supportive supervision to initiate PMTCT services at ten
FGAE clinics. JHPIEGO will facilitate the delivery of combined ARV prophylaxis to be dispensed at FGAE
clinics and ensure referral of eligible HIV-positive mothers for ART. JHPIEGO will also take advantage of
FGAE's existing outreach service to promote testing and counseling and referral to PMTCT sites for
mothers who are not coming to health facilities.
In addition, in FY08, JHPIEGO will assist FGAE to establish labor and delivery services at two sites
selected based on client load and distance from an obstetric facility. After identifying where there is existing
need, JHPIEGO will support the initiation of L&D services by providing necessary equipment and materials.
If there is a need in these facilities to prepare rooms, JHPIEGO will work with FGAE to support minor
renovations. This support to FGAE will be the beginning of establishing comprehensive PMTCT services, as
well as maternal diagnosis and treatment in coming years.
Establishing a viable and comprehensive PMTCT service within FGAE will be a continuous process which
will need significant follow-up and advocacy. In the meantime, JHPIEGO, in consultation with FGAE, will
establish a referral linkage between FGAE sites and existing public sites for ongoing prevention, care, and
support. This linkage will be strengthened until FGAE has its own L&D capacity, as well as laboratory
capacity to do diagnosis and staging.
In a related FY06 PMTCT activity, JHPIEGO adapted the testing and counseling tools for accelerated opt-
out testing. This activity arose as a result of a recommendation from a PEPFAR technical assistance
consultation, and was funded from the PMTCT reprogramming fund. This activity is helping to scale up
PMTCT testing and counseling for opt-out testing, using standard tools and training materials. In FY07,
JHPIEGO supported US-based university partners to adapt the tools for Ethiopian settings. In FY08,
JHPIEGO will translate the tools into local languages and continue supporting US-based universities to
adapt the tools. JHPIEGO will also conduct a review and document the results of opt-out testing from a sub-
sample of sites.
Building on FY07 activities to orient regional and district level managers, JHPIEGO will continue to adapt
and review the PMTCT orientation package in FY08.
In FY08, JHPIEGO also proposes to pilot test the use of lay counselors in MCH settings for the purpose of
task shifting and increasing the uptake of PMTCT services.
Continuing Activity: 16625
16625 11161.08 HHS/Centers for JHPIEGO 7473 3746.08 University $500,000
11161 11161.07 HHS/Centers for To Be Determined 5483 5483.07 TBD/CDC
Estimated amount of funding that is planned for Human Capacity Development
APRIL 2009 REPROGRAMMING
Prevention for MARPs in Hotspots in Amhara region identified in the 2008 Amhara MARPs study.
B-focused AB.
A study conducted in the Amhara region in 2008 has identified commercial sex workers (CSWs), daily
laborers, mobile merchants, students, and long distance drivers as Most at Risk Populations (MARPs) -
given that HIV prevalence among these populations is much higher than the rest of the general population
in Ethiopia. The study documented HIV prevalence rates in the range of 11.6% to 37% in these populations,
rates that are 5-18 times higher compared to the national single-point HIV prevalence estimate of 2.1%;
and 2 to 7 times higher than the 5.5% HIV prevalence documented for urban Ethiopia in the 2005 DHS.
Consistent with high HIV prevalence, the study also documented high rates of partner change and
concurrent sexual partnerships, high prevalence of sexually transmitted infections (STIs), and low and
inconsistent rates of condom use. The study has also identified HIV hotspots, defined as a Woreda (district)
or an intersection of Woredas where there is a high concentration of population groups/sub-populations
with an elevated risk for HIV/AIDS or an area where well-defined high-risk groups (such as sex workers,
long distance truck drivers) are congregated, in the region.
The purpose of this program is to increase access to high quality HIV prevention, care and treatment
services for MARPs and their partners, particularly in identified rural and urban hotspots in selected
Woredas and Zones of the Amhara region. The intervention will provide a range of prevention activities with
a particular focus on providing a minimum package of prevention services to affected MARPs with the
ultimate goal of reducing HIV transmission among these populations. A minimum package of services
includes peer education and outreach, condom distribution and promotion, STI screening and treatment,
HIV counseling and testing (HCT), and referral to HIV care and treatment for persons who test positive.
Models that are innovative, evidence based and that emphasize increased access to services, and that can
be scaled up, are a priority. Innovative models for delivery of HCT to MARPs should be included, including
rapid and mobile testing as appropriate to the local context. A coordinated strategy for behavior change
communication (BCC) activities will support implementation of the minimum package and promote sexual
risk reduction, including correct and consistent condom use, and referral to HCT, STI, and HIV care and
treatment services. Implementation of prevention with positives is also a critical component. The program
should include training for service providers who interact with MARPs to reduce stigma and discrimination,
particularly for service providers who work with sex workers. This activity will be linked with regional AIDS
Resource Center outreach activities, which include training and interpersonal communication activities
through facilitated small group discussions. The AIDS Resource centers reach older youth and other
vulnerable groups; in addition, the strategies are being crafted to reach the MARPs.
Specific objectives include:
• Reaching MARPs in identified hotspots of the Amhara region with a coordinated and intensive behavior
change strategy targeted at reducing sexual risk behaviors and increasing the number of MARPs who
access HIV prevention, care, and treatment services.
• Developing and implementing models for efficient delivery of a minimum package of services to identified
MARPs.
• Establishing national and regional (Amhara Region) MARPS Task Forces to take the lead to roll out and
implement this program.
• Supporting the Government of Ethiopia (GOE) in developing a comprehensive national strategy for most-
at-risk populations based on the current knowledge of the epidemic.
• Training and mentoring major stakeholders to build capacity for delivering services to MARPs, including
planning, implementation. monitoring and evaluation of programs.
Measurable outcomes of the program will be in alignment with the following performance goal(s) for the
Emergency Plan:
Measureable outcomes of the program will be in alignment with the goals of PEPFAR and the Ethiopia
national AIDS plan. Additionally there will be indicators that monitor program quality and specific service
elements. Applicants will develop a plan for reaching objectives for the full project period; however,
applicants should include a work plan with associated targets for the first year of implementation:
• 80% of targeted MARPS and their partners receive comprehensive information and education on how to
reduce risk, through a multi-level and coordinated BCC strategy that includes training of appropriate agents
(e.g. peers, community health extension workers, agricultural extension agents, and women and youth
associations) as peer educators.
• Condoms and lubricants are available to targeted MARPs in a timely and sustainable way.
• 40% of targeted MARPS receive HCT through a mix of CT options.
• 50% of targeted MARPS and their partners receive STI services.
• 20% of HIV-positive MARPS receive HIV care and treatment services.
• 30% of government and civil society organizations who deliver services to MARPs receive training in
delivery of a minimum package of services to MARPs, including training that addresses reduction of stigma
and discrimination.
New/Continuing Activity: New Activity
Continuing Activity:
Table 3.3.02:
Demand Creation and Promotion for STIs including genital ulcer and discharge.
As a result of the Prevention Portfolio Review, we have determined this activity to have 10% AB component
from the previous 100% OP activity.
This is a continuing activity. The aim is to increase demand for quality HIV and sexually transmitted
infections (STI) prevention services in Ethiopia through social marketing of STI treatment services that are
linked to HIV counseling and testing. The intervention includes intense service-promotion and demand-
creation activities for STIs. In FY06, FY07, PSI produced 60,000 STI (urethral discharge) treatment kits to
STI patients. These kits contained STI drugs, promotional materials, partner-notification cards, condoms,
HIV testing information, and vouchers to access free HIV tests. The HIV-testing voucher system increased
HIV test uptake. In addition, 137 health workers in the private facilities were trained on STI syndromic
management, based on the national guidelines. Kit distribution was accompanied by intense promotion
activities to generate demand for quality HIV/STI services, including HIV testing and treatment services and
increased service uptake. Two radio and TV spots created advertisements with a generic message on STI
and health-seeking behaviors were placed, and 5,000 posters and point-of-sale materials were distributed.
A recent study by CDC/EPHA in selected urban and rural areas identified a number of barriers that limit the
utilization of STI services in the country, operating at individual, community, health facility, and
policy/program levels. These include: at facility level space problems, shortage of basic functioning
diagnostic equipment, failure to implement syndromic management guidelines, lack of BCC/IEC materials,
poor recordkeeping, lack of confidentiality. At provider level lack of training; health workers lack basic
patient counseling and education skills; health workers are judgmental to patients with STDs. At patient
level urban patients buy STI drugs to treat their disease without consulting health care; government facilities
seen as the last resort; fear of stigma, judgmental clinic staff, breach of confidentiality, long waiting times
seen as barriers to attending clinics. In FY09, the following major activities in collaboration with the Federal
Ministry of Health (MOH) and regional health bureaus (RHB): 1) Distribution of 200, 000 STI treatment kits
through private and public facilities, ART clinics, and high risk corridor centers. The kit is used for the
treatment of urethral discharge, genital ulcer, and recurrent genital ulcer diseases. It is an essential tool for
service providers, as it prescribes the correct medication in correct doses, and provides supporting
information, education and communication (IEC) materials and other items (e.g., condoms). 2) Linkage of
STI treatment services to HIV counseling and testing 3) Improvement of service providers in syndromic
management through professional training. Emphasis will be on training identified private-sector providers,
though public partners will also be trained. 4) Increased awareness of, and demand for, optimum STI
syndromic management services. This will focus on promotion of good STI services and pre-packaged STI
treatment kits. 5) Strengthening and improving STI recording and reporting 6) Strengthening STI partner
notification and management. 7) Expansion of coverage areas to other major towns in the country.
Activity Title: - Community outreach and Social Mobilization for Prevention of sexual transmission and
integrating sexual prevention in Care and treatment setting.
As a result of the Prevention Portfolio Review, we have determined this activity to have 20% AB component
Activity Description: - Creating awareness and comprehensive knowledge in communities throughout
Ethiopia is key for successful HIV/AIDS prevention, treatment, care, and support interventions. The recent
demographic and health survey (DHS 2005) indicated that only 16% of women and 29% of men have
comprehensive knowledge about HIV transmission routes and prevention methods, and that they are
subject to common misconceptions.
Social/community mobilization and outreach programs in the context of the HIV/AIDS response is an
intervention aimed at creating community involvement and ownership to address problems related to
HIV/AIDS prevention, control, treatment, care and support. It focuses on the participation of all possible
sectors and the community in the mobilization of local resources, the use of indigenous knowledge and
enhancement of people's creativity and productivity through mass campaigns. The concept has an
extremely positive significance, since real change can be accelerated through joint efforts against the
HIV/AIDS epidemic. The targeted and synchronized grassroots social/community mobilization and outreach
interventions can promote skills and knowledge development to combat HIV/AIDS, community
empowerment and ownership and ultimately lead to increased utilization of prevention, care, support and
treatment services.
Intensifying community mobilization and outreach enables individuals, families and communities to make
informed decisions on how to avoid HIV infection, and seek treatment and provide care and support to
people infected or affected by HIV/AIDS. Reports have indicated that increased utilization of services was
registered with intensified social mobilization and community outreach interventions, particularly since the
Millennium AIDS Campaign-Ethiopia began in late 2006. This clearly indicates that social/community
mobilization and community outreach programs linked with specific services are key to intensifying the
response against HIV/AIDS. As community mobilization and outreach program is a cross-cutting strategic
intervention in the fight against HIV/AIDS, it should be scaled in such a way to augment the scale up of
programmatic activities to achieve Ethiopian Government universal access targets.
The purpose of this activity is to invite potential partners to design and implement social and community
mobilization HIV/AIDS prevention interventions to intensify the comprehensive nationwide response to
HIV/AIDS by increased knowledge, a shared sense of urgency, increased community ownership and
involvement at the community level, and increased utilization of HIV/AIDS prevention, treatment, care and
support services. The interventions should focus on strategies that 1) promote behavioral changes that
reduce the risk of HIV infection and transmission; 2) encourage communities to use services [e.g., voluntary
counseling and testing (VCT) and ART]; 3) encourage health care providers to routinely offer HIV
prevention and treatment services for target populations (pregnant women, TB and STI patients); 4)
address problems related to stigma and discrimination towards PLWHA; 5) encourage communities to care
for people living with HIV/AIDS (PLWHA) and children orphaned by the epidemic; 6) promote consistent and
correct condom use, 7) promote early treatment of sexually transmitted infections (STI); and 8) promote
ART adherence and prevention messages for HIV positive persons.
A secondary purpose of the activity is to also strengthen the leadership on HIV prevention at the Federal
and Regional levels through advocacy, communication and social mobilization. The program will need to
provide technical assistance to Health Extension and Education Center (HEEC) and HIV/AIDS Prevention
and Control Offices (HAPCO) of the Federal Ministry of Health. The grantee will collaborate with HEEC on
planning, developing, and implementing multi-media communication materials and mainstreaming
information, education, and communication (IEC) and behavior change communication (BCC) programs.
Overall the program the strategies will be guided by PEPFAR's Abstinence, Faithfulness, and Correct and
Consistent condom use (ABC) strategy, including the reduction of concurrent sexual partnerships. The
social, community mobilization, and outreach programs will be implemented in Dire Dawa, Somalia,
Gambella, Benishangul Gumuz, and Afar.
Demand Creation and Promotion for Quality
ACTIVITY MODIFIED IN THE FOLLOWING WAYS
creation activities for STIs.
In FY06, FY07, PSI produced 60,000 STI (urethral discharge) treatment kits to STI patients These kits
contained STI drugs, promotional materials, partner-notification cards, condoms, HIV testing information,
and vouchers to access free HIV tests. The HIV-testing voucher system increased HIV test uptake. In
addition, 137 health workers in the private facilities were trained on STI syndromic management, based on
the national guidelines..
Kit distribution was accompanied by intense promotion activities to generate demand for quality HIV/STI
services, including HIV testing and treatment services and increased service uptake. Two radio and TV
spots were created advertisements with a generic message on STI and health-seeking behaviors were
placed, and 5,000 posters and point-of-sale materials were distributed.
A recent study by CDC/EPHAin selected urban and rural areas identified a number of barriers that limit the
policy/program levels. These include: at faclility level space problems, shortage of basic functioning
seen as barriers to attending clinics.
In FY09, the following major activities in collaboration with the Federal Ministry of Health (MOH) and
regional health bureaus (RHB):
1) Distribution of 200, 000 STI treatment kits through private and public facilities, ART clinics, and high risk
corridor centers. The kit is used for the treatment of urethral discharge, genital ulcer, and recurrent genital
ulcer diseases. It is an essential tool for service providers, as it prescribes the correct medication in correct
doses, and provides supporting information, education and communication (IEC) materials and other items
(e.g., condoms).
2) Linkage of STI treatment services to HIV counseling and testing
3) Improvement of service providers in syndromic management through professional training. Emphasis will
be on training identified private-sector providers, though public partners will also be trained.
4) Increased awareness of, and demand for, optimum STI syndromic management services. This will focus
on promotion of good STI services and pre-packaged STI treatment kits.
5) Strengthening and improving STI recording and reporting
6) Strengthening STI partner notification and management.
7) Expansion of coverage areas to other major towns in the country
Continuing Activity: 16724
16724 10654.08 HHS/Centers for Population 7525 5551.08 Increasing $500,000
Disease Control & Services demand and
Prevention International promotion for
quality STI
services in
FDRE
10654 10654.07 HHS/Centers for Population 5551 5551.07 psi-cdc $310,000
Disease Control & Services
Prevention International
* Addressing male norms and behaviors
Table 3.3.03:
Prevention of Urban-Rural Transmission
ACTIVITY MODIFIED IN THE FOLLOWING WAYS:
This is a continuing activity from FY08 which was supplemented to Addis Ababa University (AAU). This
program is designed to interrupt urban-rural HIV transmission, and was planned to be piloted in late FY07
but this didn't happen because of the delay from the Amhara MARPs study and then supplemented to AAU
to outreach activities by university students in their original regions. Though this is a continuing activity, a
TBD partner needs to implement a standardized program to curb the epidemic in the region.
According to the 2005 Antenatal Care (ANC) National Surveillance on HIV/AIDS, the urban HIV prevalence
was 10.5% compared with 1.9% in rural areas. The study indicated that national rural HIV prevalence has
stabilized, while urban prevalence is declining. Most prevention activities have focused on urban and peri-
urban settings. Educational materials and methods developed for mainly urban audiences no doubt
contribute to the declining trend in towns and cities.
However, the HIV/AIDS prevalence in rural Amhara is worse than in any other region; it has the highest
numbers of people living with HIV (PLWH) (444,600; 34% of the total), of new HIV infections (39,140; 31%
of the total), and the highest rural prevalence (3.2%) in Ethiopia. The ANC-based surveillance results show
that more focus is needed on certain populations, especially women and girls in Amhara region. The social
and administrative infrastructure at the local rural level (district-level HIV/AIDS Administrations and
Secretariats, health extension workers, agricultural extension agents, women's and youth associations, and
leaders of local faith-based associations) will provide the most likely points of entry to formal systems for
rural individuals.
A preliminary report of the study conducted on MARPs in Amhara region has identified that CSWs, Daily
Laborers, Mobile merchants, Students and long distance drivers as MARPs. The HIV prevalence among
these targets is much higher than the rest of the population. The study has also identified the Hotspots in
the region through a muti-faceted approach.
The objective of this project is to adequately respond to this complicated set of circumstances through
systematically and continuously understanding the dynamics of urban-rural transmission, providing relevant
information, laying the ground for service provision in isolated regions, and fully implementing a prevention
program to curb the spread of HIV/AIDS from urban to rural settings. In FY08, CDC conducted buy-in
meetings, consensus building and identification, and selection of hotspots in rural areas. Building on this
foundation, AAU has planned to reach 100,000 MARPs through a community outreach pilot program in
FY08, promoting HIV/AIDS prevention through other behavior change beyond abstinence and/or being
faithful (Other Prevention/OP) and providing condoms in 25 MARPs targeted condom outlets. This
intervention includes behavior change communication (BCC) activities to promote safer sexual practices
using interpersonal communication. This activity also is planned to be linked with AIDS Resource Center
outreach activities.
In FY09, the project will scale up activities piloted by AAU and will focus on CSWs, Daily Laborers, Mobile
merchants and Students as the main target populations based on the evidences MARPs evidence. The
following activities will be implemented:
1) Sensitization workshop for stakeholders about project goals and activities.
2) Training for peer educators within the MARPs groups, community health extension workers, agricultural
extension agents and women's and youth associations to promote ABC and early treatment of STI.
3) Development and distribution of intervention BCC materials.
4) Creation of accessibility and availability of condoms.
5) Organization of various interactive forums and entertainment education on risk reduction, correct and
consistent condom use, drug and alcohol addiction, early treatment of STI, etc.
Continuing Activity: 16627
16627 10639.08 HHS/Centers for To Be Determined 7484 5483.08 TBD/CDC
10639 10639.07 HHS/Centers for To Be Determined 5483 5483.07 TBD/CDC
Confidential STI Clinics for MARPs
In FY09 the following major activities will be undertaken to realize the project objectives:
1) Identification of clinic sites and implementing partners and renovation and construction of the model
clinics
2) Development of training curricula, procurement of audio-visual educational equipment, training of clinic
health and support staff
3) Procurement and provision of condoms
4) Provision of STI medicines
5) Design of referral linkages
6) Promotion of clinics emphasizing their low cost/free services, confidentiality, and quality of service
(including hospitality)
FY 2008 ACTIVITY NARRATIVE
This is a continuation activity. The main objectives of this activity are to establish comprehensive most-at-
risk population (MARP)-friendly sexually transmitted infections (STI) services and to link confidential clinics
with other services like mobile counseling and testing, ART, PMTCT, the Wegen Talkline, and ABC
comprehensive prevention messages.
In FY07, three confidential STI clinics were to be renovated/constructed in Addis Ababa, Bahir Dar, and
Nazareth to provide comprehensive STI services. In FY08, four more clinics will be renovated /constructed
to provide comprehensive STI services, including reproductive health and post-exposure prophylaxis
services for rape survivors.
Evidence suggests that STI are spreading widely in Ethiopia, particularly among MARPs, which include
commercial sex workers and their clients, long-distance truck drivers, low-income women, substance
abusers, street people, migrant workers, bar owners, and urban men with money, among others. MARPs
have the highest partner rates and are therefore critical targets for comprehensive STI prevention and
control. They are often socially marginalized, discriminated against and the last reached by traditional health
services. In recent years, increasing poverty in Ethiopia has lead to large-scale unemployment and
homelessness, which coupled with widespread commercial sex work, has increased STI prevalence. HIV
has spread between Ethiopian cities following the main trading routes.
The sixth report on "AIDS in Ethiopia" indicates that the 2005 HIV prevalence was 3.5% (urban 10.5%, rural
1.9%), and indicated the national prevalence had stabilized. However prevalence remains high in MARPs
and in rural Amhara. The 2005 STI regional report indicated 13,768 and 14,322 cases of urethral and
vaginal discharge respectively; and 5,582 cases of genital ulcer. The 2005 antenatal care survey indicated a
general 2.7% syphilis prevalence and a 4.9% prevalence of syphilis among HIV-positive clients, with higher
incidence in rural areas. Rates were higher in all settings than they were in 2003. Although it is widely
acknowledged that STI are rampant across the country, the number of cases seen at formal health service
points is low. The treatment-seeking behavior of STI patients, especially of MARPs with STI, remains poorly
understood. They tend to seek treatment from alternative sources, such as drug vendors, traditional
healers, and open marketplaces. Services provided there are inferior in terms of provider knowledge,
availability of other services like condom supply and voluntary counseling and testing (VCT), provision of
promotional/educational materials, etc. Among commercial sex workers, there is lack of knowledge of early
STI symptoms and thus lack of early care and treatment seeking; most commercial sex workers also lack
the skills to negotiate safer sex with their clients. Most MARPs do not seek STI treatment until it interferes
with their routine life, mainly due to stigma and lack of accessible affordable health services. There is also a
lack of staff trained in managing such marginalized populations. Therefore, confidential clinics, particularly
for MARPs, are essential to reach them.
Strategies for this intervention will include:
1) Rapid assessment to decide sites and services for the confidential MARPs clinics
2) Integration of MARPs clinics with partners' clinics
3) STI diagnosis and treatment, including drug provision, condom promotion and provision, establishment of
peer-support groups, STI education and counseling, and referral linkages to VCT, ART and PMTCT
4) Clients will receive messages and educational materials through linking clinics with AIDS Resource
Centers
5) Communications skill training will be provided to clinic staff to improve service delivery and to make user-
friendly
The following major activities will be undertaken to realize the project objectives:
1) Communication/consultation with other PEPFAR partners on implementation of the clinic service
2) Identification of clinic sites and implementing partners and renovation and construction of the model
3) Development of training curricula, procurement of audio-visual educational equipment, training of clinic
4) Procurement and provision of condoms
5) Provision of STI medicines
6) Design of referral linkages
7) Promotion of clinics emphasizing their low cost/free services, confidentiality, and quality of service
Continuing Activity: 16628
16628 10636.08 HHS/Centers for To Be Determined 7484 5483.08 TBD/CDC
10636 10636.07 HHS/Centers for To Be Determined 5483 5483.07 TBD/CDC
Construction/Renovation
* Reducing violence and coercion
Strengthening Higher Learning Institutions' Clinics to Provide HIV Prevention and Friendly STI Services
In FY09, based on the experience gained from this activity, expansion of the service to six other Universities
will be done with the following similar activities
1) Assess the HIV/STI and reproductive health messages and prevention activities in six selected
Universities.
2) Strengthen university campus clinics to provide comprehensive HIV/STI and reproductive health
services, including voluntary counseling and testing services, to students and staff of the universities
3) Train 24 health workers from the institutional clinics in HIV/STI syndromic management and counseling
and testing
4) Adapt available HIV/STI information, education, and communication materials for use in the three
universities
5) Recruit one additional health worker to support the HIV prevention services in the clinics
6) Strengthen campus anti-AIDS clubs, university anti-AIDS committees, and gender offices to provide
youth-friendly STI and reproductive health information to their members
7) Support making AIDS Resource Center materials available to students at the three university campuses
COP 08 NARRATIVE:
This is a continuation activity to provide HIV-prevention messages and friendly services to address sexually
transmitted infections (STI ) in Universities.
Students in higher learning institutions are considered to be fully aware of HIV/AIDS risks and preventive
mechanisms. As a result, they are often neglected by HIV/STI interventions. However, on arrival at
university, many students encounter new ways of life, with relative independence and freedom as they are
away from the immediate control and influence of their parents. Students coming from rural villages and
semi-urban areas in particular have difficulty adapting to the new urban environment and group social life.
The influence of peers is significant, and there is a high level of desire for new experience. The widely
acknowledged attitude that ‘you can't be in campus without a girl/boyfriend' causes them to engage in
sexual activity that puts them at risk for HIV and STI.
Transactional sex is one of the most evident social dynamics around the university campus. For most
female students, particularly those from poorer backgrounds, having sex with men who are often older and
wealthier is the quickest and easiest way to secure the material goods and lifestyles exemplified by their
wealthier peers. The fact that many parents/guardians are not able to support students financially due to
economic hardships creates a further financial strain on students. These factors, added to a high level of
sexual networking and high HIV prevalence in the cities where the higher institutions are located, put
university students at high risk for HIV exposure.
The recent UNAIDS report indicates that the percentage of Ethiopian young people aged 15 to 24 who used
a condom last time they had sex with a casual partner was only 36.2% among males and 14.6% among
females. In the past 12 months, 37.8% males and 34% female adolescents had had casual sex in the past
12 months.
All Ethiopian universities have clinics that are supposed to provide comprehensive, primary-level healthcare
service to all registered students. But because of the nature of the diverse students enrolled and the limited
capacity of the clinics, the clinics are not well-utilized and are not providing standard and quality HIV/STI
prevention services.
PEPFAR currently supports few interventions in HIV prevention at Ethiopian universities, because most
PEPFAR activities are concentrated in the capital and the universities outside Addis Ababa. Therefore, this
activity will be conducted in three universities where the prevalence of HIV among students and the
surrounding community is high. It will strengthen university clinics to provide HIV prevention and friendly STI
services to reduce the occurrence of new infections and break the cycle of HIV/STI infections.
In FY08 the following activities are planned;
1) Assess the HIV/STI and reproductive health messaging and prevention activities in three universities:
Gondar, Halemaya and Addis Abeba Universities.
3) Train 12 health workers from the institutional clinics in HIV/STI syndromic management and counseling
youth-friendly STI and reproductive health information to their members.
Continuing Activity: 18710
18710 18710.08 HHS/Centers for To Be Determined 7484 5483.08 TBD/CDC
Strengthening Behavior Change Initiatives at Care and Treatment Setting
This is a new activity in COP09.
No one thought, 25 years ago, that HIV prevention would be as difficult as it has proven to be. Despite
efforts, UNAIDS now estimates that 33 million people are living with HIV, and 2•5 million new infections
arise every year. We must do better and the question is how. We have learned that no simplistic or even
simple solutions exist for HIV prevention. We need to remain humble as we approach the issue of how to
keep the virus from moving from one person to another. Base on the Single-point estimates: HIV
prevalence in Ethiopia among adults ages 15-49 is 2.2% nationally. The urban being 7.7% and the rural
0.9%. These new estimates reflect a consistent pattern observed in both the ANC surveillance and the
EDHS of a many-fold higher HIV prevalence in urban settings than in rural settings. In fact, the single-point
exercise estimates HIV prevalence among adults in urban settings to be almost nine times higher than that
among adults in rural settings. A fundamental goal of HIV prevention is to change the behavior that
puts individuals at risk of infection. For the past two and a half decades, HIV prevention has been
dominated by individual-level behavioral interventions that seek to influence knowledge, attitudes, and
behaviors, such as promotion of condom use, or sexual-health education, and education of injecting drug
users about the dangers of sharing equipment. Causal pathways link so-called structural factors—social,
economic, political, and environmental factors—and risk of HIV. Using the existing resources and structure
to address the HIV prevention issue in a comprehensive manner is vital.
Advances in scaling up antiretroviral treatment in resource-poor countries, the benefits of male circumcision
and the hoped for promise of pre-exposure prophylaxis and microbicides do not render behavioral
strategies obsolete. If anything, behavioral strategies need to become more sophisticated, combined with
advances in the biomedical field, and scaled up. But that task is not easy. The varieties of sexual
expression are infinitely greater than is acknowledged or sanctioned by most societies' defined legal and
moral systems. Ironically, most societies—either openly or clandestinely—provide opportunities for varied
sexual expression, often within the context of substance use, even if the defined legal and moral systems
seem somewhat rigid. Sexual behavior typically does not occur in public, making it difficult to motivate
protection when potential transmission occurs, and making it almost impossible to verify reports of what
people say they have or have not done. Substance use to the point of intoxication is not only allowed, but is
central to many countries' economies, and attempts to control the distribution and sale of illegal
substances—and especially drugs that are injected—have met with little success.
The US University partners are operating in all the regions including emerging regions where the vertical
HIV Network Model is being implemented. The university partners mainly focus on Hospital level care and
treatment activities and some prevention activities like STIs and PMTCT. There is little (if at all there is) or
no activity on sexual prevention of HIV though HIV prevalence is higher in the areas these partners operate.
In COP08, some budget was reprogrammed to initiate mainstreaming activities on sexual prevention and
IEC/BCC. This funding will be used to strengthen the existing prevention intervention by University partners.
Mainly the program will focus on mainstreaming IEC and Behavioral Change Communication programs with
care and treatment programs. The Universities implement the sexual prevention activities in collaboration
with federal and regional states. Prevention with positives was also among the key activities that were
reprogrammed for these partners. The activities mentioned will strengthen the leadership at the federal and
regional levels through advocacy, communication and social mobilization.
In COP09, a TBD partner will strengthen the already existing initiatives at care and treatment settings and
design a behavior-change communications (BCC) strategy that promotes behavioral changes that reduce
the risk of HIV infection and transmission, and encourages communities to use services (e.g., voluntary
counseling and testing (VCT) and ART), to care for people living with HIV (PLWH) and children orphaned by
the epidemic; work on sexual prevention activities focusing on promotes consistent and correct condom
use; promotes early treatment of sexually transmitted infections (STI); addresses problems related to stigma
and discrimination towards PLWH. If the US University partners deliver results with their reprogrammed
funds in COP08, it will be again supplemented to these partners. PEPFAR/CDC will further workout better
mechanism to implement this activity.
ITECH is having a lead in Prevention with positives in terms of curriculum adaptation and training of training
to have a pool of regional trainers; further scale up and implementation of sexual prevention activities at the
care and treatment settings will be implemented in Dire Dawa, Somalia, Amhara, Gambella, Benishangul
Gumuz and Afar in collaboration with Care and Treatment TWG.
This partner will provide technical assistance to Health Extension and Education Center (HEEC) of the
Federal Ministry of Health. Health Extension and Education Center (HEEC) is one of the departments with
in the Federal Ministry of Health which is responsible to coordinate, monitor, evaluate, and play a leading
role in the implementation of Health Education/promotion activities including harmonization of messages at
the national level through, the development of Health Communication Strategies, standard and
implementation guideline; and to design, develop, distribute and disseminate research based health
learning materials and message; to bring behavioral change. HEEC has not been able to play its leadership
role at the national level due to technical and financial constraints. There were reprogramming in COP08 to
initiate this activity through EPHA. Based on results in COP08, either a TBD partner will be selected based
on FOA or will be supplemented to the previous partner.
This program will build the capacity of HEEC in researching, planning, developing and implementing multi-
media communication materials and evaluation on sexual prevention of HIV/AIDS so that HEEC will play a
leading role in leading and standardizing the national health communication programs particularly HIV/AIDS
communication interventions in a sustainable manner. The activity will also include capacity building for the
HEEC through mentoring, trainings, personnel secondment, technical assistance, and also equipment.
Families Matter
This is a new activity for COP09.
Youth need to receive HIV prevention information and skills as a baseline to change HIV risk behaviors.
Parents and other family members are in a unique position to educate adolescents about the negative
health outcomes associated with sexual risk-taking and related risk behaviors and to foster responsible
sexual decision-making skills.
HIV prevention efforts which embrace the cultural values and strengths of the community may enhance the
efficacy of prevention interventions. Parents already play a critical role in the promotion of healthy behaviors
in their children and have the opportunity to deliver age appropriate health messages to their children over
time. Because it is critical to reach youth early with effective HIV prevention messages, intervening with
parents may be one of the most viable, yet underutilized prevention methods available to reduce adolescent
sexual risk behaviors. The Families Matter! Program further addresses the unique HIV prevention needs of
youth by aiming to increase family involvement in abstinence and behavior change.
Parents are also a viable and potent venue for delivering accurate HIV prevention information to youth at
much younger ages than youth typically are exposed to unsafe sexual behaviors. Unfortunately, many
parents do not discuss sexuality or sexual risk with their children, and when parents do talk to their children,
research has found that it is often later rather than sooner. Studies with pre-teens conducted in US by the
Kaiser Family Foundation have documented that pre-teens want, yet do not typically receive, sexuality and
HIV information from their parents.
The purpose of this activity is to support the adaptation and implementation of a parent focused HIV sexual
preventive intervention piloted in main HIV hotspot cities and towns of three major regions of Ethiopia: Addis
Ababa, SNNPR and Amhara. Families Matter is an evidence-based intervention designed to promote
positive parenting and effective parent-child communication about abstinence, sexuality, and decision-
making and sexual risk reduction for parents or guardians. It is designed to give parents and caregiver's
specific information about ways that they can reduce their children's risk of becoming infected with HIV and
other sexually transmitted infections, or getting pregnant. The ultimate goal of this community-based, family
prevention program is to support sexual abstinence and reduce sexual risk behaviors among adolescents,
including delayed onset of sexual debut, by giving parents tools to deliver primary prevention to their
younger and older children. For those older youth groups who are sexually active and their family members
condom promotion activities and referrals we be implemented. The Families Matter intervention recognizes
that many parents and guardians may need support to effectively convey values and expectations about
sexual behavior and communicate important HIV, STI, and pregnancy prevention messages to their
children. As a result, these tools aim to enhance protective parenting practices, overcome communication
barriers and promote parent-child discussions about sexuality and sexual risk reduction.
The Families Matter intervention is an adaptation of the Parents Matter curriculum, which the Centers for
Disease Control and Prevention (CDC) implemented and evaluated in the United States. The Parents
Matter evaluation found that the intervention produced positive behavioral and health outcomes among
participants. Similarly, a preliminary analysis of Families Matter, which was conducted 15 months post-
intervention in Kisumu, Kenya, found a sustained positive effect in terms of parenting and communication
skills reported by participants and their children separately. The activities that are complementary to this
activity include: Support religious leaders and teachers in the implementation of a complementary Families
Matter! program; that targets parents and development of a monitoring and evaluation to facilitate ongoing
updating, improvement and expansion of these and related programs.
Families and guardians of current high school students and university students will be identified through
school's parents committees and the school administration. Once the training and other program materials
are adapted, facilitators will be trained and identify parents of primary, secondary and tertiary school
students where life planning skills are being supported. The intervention curriculum need to focuses on:
raising awareness about the sexual risks many youth face; encouraging general parenting practices (e.g.,
relationship building, monitoring) that increase the likelihood that children will not engage in risky sexual
behaviors; and improving parents' ability to effectively communicate with their children about abstinence,
sexuality, sexual risk reduction, and delaying sexual debut. Facilitators engage parents of youth as
educators on sexuality and HIV prevention through a mixture of structured learning experiences, discussion,
audiotapes, role plays, and group exercises.
In FY 09 the Families matter activities include:
•Adopt print and distribute the curriculum of Families matter for training purposes
•From selected secondary and tertiary schools in Addis Ababa, SNNP and Amhara train and support
Parents committee in the implementation of a school-based youth abstinence and behavior change
program.
•Support religious leaders and teachers in the implementation of a complementary Families Matter!
Program that targets parents;
•Develop a monitoring and evaluation tool to facilitate ongoing updating, improvement, and expansion of
these and related programs.
National Infection Prevention
IN 08 THIS ACTIVITY WAS JHPIEGO PRIME PARTNER WITH MECHANSIM # 5483
In FY08 and previous years, JHPIEGO supported Ethiopian governmental hospitals to properly implement
recommended infection prevention (IP) practices and processes. In FY09, the new partenr plans to give in-
service infection-prevention training courses for private hospitals and clinics. This is in response to specific
requests from many private facilities, including the Family Guidance Association of Ethiopia. Together with
the trainings for private facilities, the new partner will support university partners with replacement IP
trainings for sites with high staff attrition.
Proper infection prevention in health facilities is largely dependent on support staff: housekeeping, laundry,
and kitchen. The new partner will develop a simplified training package, translated into local languages, for
use in training these hospital workers. The new partner will also work with stakeholders to identify the most
cost-effective way of delivering the raining to these supporting staffs.
The new partner's infection-prevention team will also support other activities, including pre-service
education (COP ID 10611) and the development of electronic learning modules/materials (COP ID 10482)
for use by hospitals.The partner will also continue and strengthen support to professional associations such
as the Ethiopian Medical Association, the Ethiopian Public Health Association, the Ethiopian Nurse
Midwives Association, and the Ethiopian Nurses Association in FY07.
Another bottleneck in the implementation of proper infection-prevention practices has been lack of supplies,
especially personal protective equipment (PPE), antiseptic hand rubs and aprons, as well as lack of
maintenance of sterilizers and autoclaves. In FY08, the new partner will develop low-cost, locally
customized basic IP supplies.The parnter intends to support two local Technical and Vocation Education
and Training institutions (TVET) to produce IP supplies, such as aprons, goggles, antiseptic hand rubs,
sharps and waste containers. The first pilot production will include 20 selected hospitals, with an emphasis
on teaching hospitals supported by PEPFAR.
For maintenance of sterilizers, autoclaves, and other relevant IP equipment, the new partenr will collaborate
with a local contractor/partner, such as Departments of Technology at Addis Ababa University, the
Ethiopian Health and Nutrition Research Institute, Ethiopian Science and Technology Commission and
private biomedical engineering firms to design and deliver a generic training course on the maintenance of
laundry machines and autoclaves.
Maintaining and expanding current gains in infection prevention will require a coordinating body or group at
both the national and regional levels in the years to come. FY09 will be an opportunity to strengthen the
national infection-prevention/control working group and regional offices. The new partener will set aside
some funds to support the activities of this group with consultant assignments, workshops, printing, etc.
In FY08, JHPIEGO conducted on-site IP trainings for 30 hospitals, trained 430 health workers, assisted
university partners in conducting IP training, provided IP training and demonstration materials, and
technically supported IP activities at different levels.
Furthermore, JHPIEGO has contributed in the development of the National Healthcare Waste Management
Guidelines; reviewing the National HIV/AIDS Policy, with an emphasis on the IP components; supported
and advocated for the establishment of national infection prevention technical working group.
In FY09, TBD PArtner will conduct on-site and off-site IP trainings for healthcare providers and support staff
in private, public and NGO clinics. Local Technical and Vocation Education and Training institutions (TVET)
will be supported to produce some selected IP supplies for healthcare facilities. TBD Partner will also
conduct autoclave and laundry machine operations and maintenance trainings. It will also support national
MDR/X-MDR TB prevention efforts.
TBD Partner will conduct advocacy workshops for national IP program, and to ensure availability of IP
supplies at facilities. It will strengthen supportive supervision to facilities to ensure proper IP practices
through technical assistance. TBD Partner will also support US university partners in identifying and filling
gaps in areas where there is high staff attrition rate. On the other hand, it will work to strengthen the national
coordination of IP program.
Continuing Activity: 16573
16573 5759.08 HHS/Centers for JHPIEGO 7473 3746.08 University $500,000
10384 5759.07 HHS/Centers for JHPIEGO 5468 3746.07 $353,500
5759 5759.06 HHS/Centers for JHPIEGO 3746 3746.06 $300,000
Table 3.3.05:
Strengthening Male Circumcision in Gambella and Southern Nations, Nationalities, and Peoples Region
(SNNPR)
In FY09, TBD Partner will continue the following activities:
1) Support training of heath care workers in MC services in the context of HIV/AIDS prevention.
2) Integration of MC core competencies in pre-service education in the context of HIV/AIDS prevention.
3) Support three sites in Gambella to provide safe MC services.
4) Adapt and field test MC quality and standards practice.
5) Support Surgical Society of Ethiopia to carry out male circumcision activities nation-wide.
6) Support development of pocket guides, job aids, and video materials on safe clinical MC services.
This is a continuation activity by Prime Partner JHPIGO, Activity Number 18237, Mechanism ID 5483 to
provide comprehensive male circumcision service in Gambella.
In addition to successfully implementing Male Circumcision (MC) services in Zambia, Jhpiego has played a
lead role in developing the international WHO/UNAIDS/Jhpiego MC training materials, developing quality
standards, tools for conducting situational analysis, and operational guidelines for scaling-up MC services.
In collaboration with the WHO, Jhpiego has conducted several regional trainings for MC and situational
analyses in numerous countries.
Preliminary findings before the situational analysis conducted by Jhpiego in Gambella indicate that there is
a clear unmet need for male circumcision, despite overwhelming responses from interviews with RHBs,
religious leaders, NGOs, and youth stating the importance and need of MC in the region. Jhpiego will
continue to assess the cultural context of circumcision not only in Gambella but among other societies with
limited circumcision practices including areas in SNNPR and around the Rayya community in Tigray
Region.
To develop local capacity, TBD partner, through direct training and technical assistance, will work with the
Ethiopia Surgical Society in establishing comprehensive MC services as an intervention that promotes
gender equity as well as prevention of HIV transmission. This will include providers with updated
knowledge, appropriate attitudes and surgical competencies, sufficient equipment and supplies, informed
consent, group education, pre- and post-operative assessment and care, and risk-reduction counseling,
partner counseling that promotes gender equality and communication, quality assurance and record-
keeping and reporting. The TBD Partner will also provide leadership in the adaptation of the WHO
standards for quality MC services; appropriate job aids, and will conduct or participate in a multi-center
assessment of MC services. Based on the situational analysis conducted in FY08, TBD partner proposes an
in depth study of MC in the three selected regions, the results of which will inform the anthropologic and
social factors to improve the provision of MC services.
In FY08, JHPIEGO planned to perform the following activities.
1) Conduct formative assessments on social and cultural considerations and on integration of the service
with other reproductive health services. The assessment will be based on the WHO Assessment Tool Kit
2) Training of trainers on safe male circumcision service and training of 50 healthcare providers in the two
regions using the WHO/Jhpiego male-circumcision training manual. Instructors from Gambella Health
Sciences College will be trained to support pre-service education on male circumcision
3) Producing information, education, and communications materials to provide information on the
Importance, safety, and quality of male circumcision service
4) Initiating circumcision services in 12 healthcare facilities (four in Gambella and eight in SNNPR) as part
of the comprehensive package of prevention services. That package includes: provider-initiated HIV
counseling and testing; active exclusion of symptomatic STI and syndromic treatment when required;
counseling on behavior change, including a gender component that addresses male norms and behaviors;
provision of condoms and counseling on correct and consistent use; reduction of the number and
concurrency of sexual partners; and delaying the debut of, or abstaining from, sexual activity (ABC)
Continuing Activity: 18237
18237 18237.08 HHS/Centers for JHPIEGO 7473 3746.08 University $200,000
Table 3.3.07:
Integration of Water, Sanitation and Hygiene in the National HIV/AIDS Program
THIA IS A NEW ACTIVITY FOR FY09;
This is a new activity linked to the previous efforts of PEPFAR Ethiopia in provision of safe water and
sanitation services to PLWH and their families. In FY08 and FY07, there were similar efforts to give these
services.
In FY08, PEPFAR Ethiopia worked with national nutritional task forces to ensure that safe water and
hygiene issues were addressed in the national guidelines on Nutrition and HIV/AIDS. But the challenge was
that there are no clear guidelines in certain programs about safe water and hygiene.
In FY09, PEPFAR Ethiopia will support Government and other partners to review the current HIV/AIDS
implementation guidelines on PMTCT, ART, TB/HIV and OI guidelines for evidence-based water, sanitation
and hygiene strategies. The process will identify gaps and develop, revise, and the national guidelines and
training manuals for HIV/AIDS-related services to ensure that essential technical information on WASH is
adequately addressed. All relevant policies and guidelines will be evidence-based, relevant, appropriate
and responsive to meet the demands for appropriate services to address the current epidemic in Ethiopia
and to ensure the achievement of the program goals. During policy development, the program will conduct
wide consultation with national and international experts and local stakeholders, service providers, non-
governmental organizations, community-based organizations, other sectors whose activities impact on the
program and, most importantly with the intended users of the services, persons infected with and affected
by HIV, and their families. Emphasis will be placed on safe water treatment options and safe storage, hand
washing with soap by providers, safe feces management and the promotion of a hygienic latrine, and food,
personal and household hygiene. The guideline development process will include country-specific
estimates for water consumption for HIV-affected households and recommendations for improved point-of-
use water quality and access and mainstreaming WASH planning in the health and HIV/AIDS sector.
Activities will be aimed at preventing mother-to-child HIV transmission (effective maternal nutrition and safe
infant feeding), extending and optimizing quality of life throughout the continuum of illness for HIV-infected
adults and children, and improving the lives of orphans and other vulnerable children affected by HIV/AIDS.
PEPFAR Ethiopia care and treatment facility partners will also be supported to place drinking water and
hand washing stations with soap in HIV care and treatment, antenatal /MCH clinics, pediatric wards, TB/HIV
clinics, etc. Installing the system at the antenatal /MCH clinics, pediatric wards, TB/HIV clinics may help a
lot with stigma issues.
The interventions are a part of the program's delivery of the preventive care package for all HIV-positive
clients. The approach will include providing commodities for safe drinking water at the point of use (water
treatment with bleach/hypochlorite, storage vessels) for HIV-positive clients placing hand washing stations
(soap, jerry cans, small bottles for tipsy-tap construction in water-scarce areas, and buckets with taps in
areas with adequate water supplies).
Coupled with product distribution, TBD partner will support evidence-based behavior change activities and
technical assistance, including: an in-service training curricula on hand washing behavior for physicians,
nurses, community volunteers that is locally adapted, translated and implemented; a behavior change
communications poster and electronic media materials for ART waiting rooms on priority water, sanitation
and hygiene actions for PLWHA; and drinking water and tipsy-tap hand washing stations placed in the ART
facility. Ongoing technical support and training will be provided to ART providers and PLWHA on improved
hygiene behavior practices, with an emphasis on treating and storing water at the point of use and washing
hands with soap at critical times and with proper technique. Logistics support will also address the
appropriate use, storage and replenishment of commodities. Funding will primarily be used to train
providers, develop BCC materials and procure commodities needed for treating and safely storing drinking
water and hand washing stations, monitoring program implementation; and evaluating program outcomes.
Table 3.3.08:
Prevention of Cervical Cancer in HIV Positive Women
THIS IS A NEW ACTIVITY FOR FY09:
This is a new activity in FY09. This is a prevention of cervical cancer in HIV positive women in selected 20
sites providing care and support activities. This activity will form the basis for further rollout of cervical
cancer prevention in HIV positive women on a wider scale in Ethiopia.
Current estimates anticipate 7,619 Ethiopian women will be diagnosed with cervical cancer every year and
6,018 will die of the disease. Cervical cancer is the leading cause of cancer among Ethiopian women
between 15 and 44 years of age.
In FY09, PEPFAR Ethiopia TBD Partner will introduces a prevention approach that uses visual inspection of
the cervix using dilute acetic acid or vinegar (VIA) to detect pre-cancerous lesions and treatment of detected
lesions with cryotherapy during the same visit in some 20 sites offering care and support activities. The
approach is simple enough to be used by trained nurses in lower level facilities, such as health centers.
In Ethiopia, The Federal Ministry of Health, through its Family Health Department, has already recognized
the importance of cervical cancer as a public health issue and included its prevention as part of the National
Reproductive Health Strategy. It has also funded a feasibility study, in collaboration with the Addis Ababa
University Department of Obstetrics and Gynecology, for establishing screening programs including VIA in
the national Addis Ababa teaching hospital and 7 referral hospitals throughout Ethiopia. The following
issues are identified as limitations: the current lack of a key component of the single visit approach, the
treatment of pre-cancerous lesions, and thus are limited by the lack of options once a case has been
detected. In addition, there is only one radiotherapy unit in the country. As a result, while providers were
trained in VIA, screening services may not have started. This pilot activity will build on resources already
committed to this problem.
In selecting sites for this pilot program hospitals where providers were trained in visual inspection with
acetic acid are prioritized. This activity would support only the screening and treatment of pre-cancerous
lesions among HIV positive women. Inevitably, more advanced stages of cervical cancer will be detected
and the TBD partner will help sites to establish a site-specific referral process. The TBD partner will also
spearhead advocacy strategy for the MOH to invest in strengthening their capacity to manage advanced
cases as well as offer palliative care for far-advanced cases detected during the screening program.
Important stakeholders include Ministry of Health Family Health Department, the local and USG universities
partners, Ethiopian Society of Gynecologist and Obstetrics (ESOG) etc. The TBD partner will establish the
feasibility of the single visit approach with minimal resources to ensure the integration in ART clinics.
This activity will ensure the following activities:
1.Briefing of national stakeholders including the Family Health Department (FHD) about HPV infection,
cervical cancer and HIV/AIDS; and the application of the single visit approach for prevention
2.Establishing a National Technical Working Group under national palliative care task force for cervical
cancer prevention representing all the important stakeholders including FHD, HAPCO, CDC, NAPWE,
ESOG, ENA, other women's groups etc.
3.Identifying possible donors or charitable organizations interested in cervical cancer prevention and able to
contribute to a national program
4.Selecting twenty sites for implementation of the cervical cancer prevention activities
5.Procuring 20 cryotherapy units for the hospitals already implementing VIA and identifying sources of
carbon dioxide to run the cryotherapy units
6.Promote policy consensus and adoption for providing cervical cancer prevention to HIV positive women
by sponsoring a consensus building workshop to present the evidence to date and discuss integration with
HIV/AIDS-related services. Such a meeting would also decide what category of nurses and other health
professional can carry out screening and treatment in a single visit format, as well as to whether services
are integrated into MCH units and HIV positive women linked to the care there or integrated within pre-ART
and ART settings.
7.Reproduce training materials (flash cards, atlas, DVDs and manuals) for local use. Train a core team of
trainers and rolling out trainings; Develop educational materials for women to be displayed in target sites
(brochures, posters) to inform them of the availability of services, translate into local languages and print
materials; Provide training in the single visit approach (one week) for 20 to 40 providers. The exact number
will depend on funding---at least 2 providers per potential service point.
8.Work with facility based PEPFAR Ethiopia Care and Support partners to train clinical staff in the roll out
and application of the single visit approach and give site level mentorship and supervision to the trained
providers.
An evaluation report on the community counselors' program has been compiled and shared with
stakeholders.
Retention of Health Care Workers
ACTIVITY UNCHANGED FROM FY2008
This is a continuing activity from COP07 (through plus-up funds) and COP08.
In general, retention of trained staff and health care workers has posed challenges worldwide, and
Ethiopia's human resources for health (HRH) situation is one of the worst, with 51 597 technical health care
workers in 2006 (including at the time 8,901 Health Extension Workers) for a population of over 70 million,
resulting in one of the lowest health care worker to population ratios in the world. The number of doctors is
also rapidly decreasing since 2001, with graduation of new doctors not keeping up with attrition.
Furthermore, health workers are poorly distributed with many concentrated in urban areas. The
government's Health Extension Program seeks to address this imbalance and by the end of 2007, 24 453
health extension workers (HEWs) will be deployed in rural wards. However, there is fear that the HEWs are
given a large load of preventive activities and unable to meet the demand for curative services. Other health
professional cadres are urgently needed to meet Ethiopia's goal of achieving universal access to
antiretroviral therapy by 2010. While production of health care workers is addressed elsewhere,
interventions are needed to address the high attrition rates and are the focus of this activity.
In FY07, PEPFAR Ethiopia funded for two HRH activities. The first (activity ID 10383) linked with the TIMS©
project involved analyses of the existing HRH situation and the development of a policy agenda for HRH
using TIMS© data and other sources, as well as piloting some new retention schemes, such as job sharing.
The Retention of Trained Staff program, which is the second activity, led to exploring new interventions to
improve retention of health care workers trained and deployed in HIV/AIDS-related services. With the TIMS
funding, a PEPFAR partner and PEPFAR Ethiopia were able to assist the Federal Ministry of Health
(FMOH) with a broad situational analysis of the HRH situation in country as well as with the development of
an ambitious and radical new HRH strategy. Part of the partner's input was the support of a local health
economist to cost out the strategy. The partner is currently working on a concept note for an HR inventory
specific to the HIV/AIDS workforce, as requested by the Federal HAPCO office. The partner's involvement
in these efforts has opened the door for working hand in hand with government counterpart on testing and
documenting various retention efforts.
For the Retention of Trained Staff program in FY07, proposed activities were a survey of potential retentions
schemes, followed by consultative meetings, and putting in place several performance-based retention
schemes to improve workers' morale and motivation, to be continued and potentially expanded in FY08. US
university partners are offering overtime/duty pay, but the regional health bureaus and hospitals are not
generally accessing these funds. These initiatives will continue, to be scaled up and monitored to assess
whether they have a positive impact. USG funding precludes attempting other schemes, such as
constructing housing for health care workers in remote sites or providing bank loans; however, the partner
may look to work with other donors and partners to leverage those that can work in this area.
One aspect of HRH that has been proposed is the need to monitor the impact of various efforts is to
develop a Human Resource Information System (HRIS). The Health and Health-related Indicators which
regularly publishes HR information is thought to be fraught with data errors and is thus not very reliable. The
PEPFAR partner's work in TIMS© has also highlighted some of the constraints in terms of tracking human
resource data, including the lack of unique identifiers for Ethiopian health care workers. A World Bank
consultant has proposed working with this implementing partner and other partners to test a new HRIS in
one region.
Linked to information systems, but with its own distinct issues is the set of procedures for licensing and
registration of health care workers. The FMOH is currently overseeing the licensing of bachelor degree-level
health care workers and above in collaboration with universities, but has recently delegated the task of
registration and licensing of diploma and those below diploma level health care workers to regional health
bureaus. The FMOH has suggested to this partner that strengthening that system across regions and
ensuring some standardization might be an important and useful task that could be undertaken. This would
include the registration of lay health care workers who provide HIV/AIDS services.
Another aspect of the HR strategy that is critical to retention but yet difficult to achieve is the area of Human
Resource Management (HRM) after deployment. There is little understanding currently in MOH circles
about the role of supervision in promoting and sustaining quality staff performance. Continuing in FY08 will
be the need to build the capacity of the FMOH's Human Resources Department, including seconding of
technical advisors. The partner has developed HIV/AIDS-specific performance standards. Achievement of
those standards can be linked to recognition and financial or non financial rewards. In Zambia, non
financial rewards coupled with recognition and celebration of quantifiable achievements by health center
teams were more powerful than financial rewards without community recognition. PEPFAR partner will
explore working with new partners, such as Initiatives Inc. and/or Liverpool Associates in Tropical Health
(LATH), who may have additional expertise in this area.
Initiatives has assisted governments to conduct workforce planning exercises and prepare strategies for
providing adequate numbers of appropriately trained personnel to provide heath services. In recent years,
for the governments of Zambia and Rwanda, they have taken a close look at the use of workforce to provide
HIV/AIDS prevention and care services in the context of a diminishing supply of qualified workers. They
have looked at retention through the lens of both financial and non financial incentives and promotion of
bonding schemes.
For over ten years, LATH has been involved in supporting human resources for health in many countries
and helped to develop good human resources management and development (HRM/D) practices to
improve health sector performance. LATH has a full time HR Management and Development Specialist
based in Uganda. In addition, LATH consultants have advised Ministries of Health in many developing
countries on human resource management and development issues, including: human resource planning,
Activity Narrative: assessing and identifying HRM/D practices such as recruitment, deployment and retention, training and
development systems, performance management systems, HR information systems. LATH has worked with
PEPFAR partner in Malawi in HRIS and HR planning areas.
A significantly increased budget is requested so as to allow for the procurement of additional expertise from
LATH and Initiatives to complement the partner's efforts and to staff the HR Department and the partner to
coordinate inputs. Piloting of retention schemes began in FY07 and was significantly expanded in FY08
after additional regions requested assistance and more time in the year to implement the activities (given
that funding for FY07 was released late).
Table 3.3.09:
Expansion of HIV/AIDS Pre-Service Education
To date, over 250 faculties participated in educational strengthening activities and HIV care competencies
have been integrated in the course syllabi of all participating schools.
To ensure sustainability, PEPFAR's pre-service education strengthening activities, including e-learning,
have supported, through sub agreements, Academic Development and Resource Centers (ADRCs) and IT
departments at each institution, consistent with their own vision to build their internal capacity in curricula
design and educational strengthening. At the policy level, PEPFAR has supported the Ministry of Education
and its affiliate, the Higher Education Relevance and Quality Assurance Agency (HERQA), in their endeavor
to standardize higher education for health and will continue to do so by strengthening policies, protocols and
standards and establishing accreditation and licensing processes. In light of PEPFAR II suggestions and the
GoE plan to increase the output of health education institutions, PEPFAR partner will conduct a thorough
need-assessment and feasibility study for supporting long term training programs for other cadres and for
strengthening TB and malaria education by the higher institutions. To assess impact for the future
programming, the partner proposes to conduct mid term and project end evaluation.
In FY09, PEPFAR partner will continue with the following activities:
•Academic Development and Resource Centers (also known as educational development centers)
established and strengthened at three target universities and colleges
•Three skills laboratories strengthened
•Competency-based education to be promoted and strengthened at three target public universities, two
private colleges and two regional colleges
•Educational quality is improved based on the increment in achievement of performance standards through
standards-based educational management and recognition
•100 instructors will be trained on effective teaching skills
•100 instructors will be trained on Instructional Design (ID)
•100 instructors will be trained on student's performance assessment teaching and student performance
assessment will be improved.
•In collaboration with the Ministry of Education, Ministry of Health, the Higher Education Relevance and
Quality Agency, and professional associations, accreditation and licensure processes will be developed and
implemented
•Pre-service HIV/AIDS education strengthening support is expanded to other health science disciplines and
•Practical training sites and their linkages with teaching institutions are strengthened; through training of
preceptors and strengthening the support to practical sites.
FY08 ACTIVITY NARRATIVE
Ethiopia's goals for expanding access to HIV/AIDS prevention, care, and treatment services consistently
face common and recurring challenges, particularly when dealing with human resources. These include
absolute shortages in terms of numbers, an inadequate knowledge and skills base which require extensive
and expensive in-service training, and poor distribution and low motivation of those healthcare workers in
the system. The crisis in human resources for health is most severe in emerging regions, where vacancy
and attrition rates are nearly double the national average.
In FY06 and FY07, PEPFAR partner worked with seven health professional schools of three major
universities (Addis Ababa University, Gondar University, and Jimma University) to integrate and strengthen
the teaching of HIV/AIDS in pre-service education. Efforts included: consensus-building workshops with
stakeholders; an in-depth needs assessment; faculty updates in HIV/AIDS content areas, effective teaching
skills, infection prevention, etc.; and the development of educational standards specific to this program and
linked with the Higher Education Relevance and Quality Agency (HERQA) standards. Also, PEPFAR
partner worked with instructors to develop relevant teaching materials for HIV/AIDS and supported
individual departments and schools in introducing these into relevant sections of the curriculum. The
PEPFAR partner also procured teaching equipment, including computers, LCD projectors, screens, TVs
and VCRs, printers, overhead projectors, clinical models, teaching charts, DVDs, videos, etc. for distribution
to each school. As of July 2007, 87 faculty attended training workshops (with many attending a series
involving both HIV/AIDS updates and effective teaching skills), and 349 students received pre-placement
training prior to graduation. The effective teaching skills component, in particular, has led faculties to re-
think and re-design how they deploy students to clinical practice sites (e.g., Jimma), and to adopt the use of
clinical preceptors as a way of maximizing mentoring of students in clinical areas.
For FY08, the PEPFAR partner proposes to consolidate its efforts in the three universities and expand to
new cadres within the university. These cadres will include laboratory technicians, pharmacists and others.
The partner proposes to work with PEPFAR partners—Strengthening Pharmaceutical Systems (SPS) and a
CDC laboratory partner. The partners will work to update faculty knowledge and skills and revise curricula,
and will provide effective teaching-skills training and teaching equipment. This partner will also apply the
Standards Based Education Management and Recognition (SBEM-R) approach for strengthening the
quality of the pre- service education.
In addition, the partner proposes to apply the lessons learned in university settings to a regional health
college for diploma-level nursing education. According to the new calibration, Gambella is a high HIV/AIDS
prevalence region (2.4% in 2007); it was also found in a follow-up analysis of the Training Information
Management System to have the highest attrition of trained staff (64.9% of trained providers were no longer
at the facility at the time of the follow-up visit). Benishangul Gumuz, which is adjacent, has an estimated
2007 prevalence of 1.8% and attrition of 48.3%; thus, the college in Pawe could also be targeted if funding
allows. With the assumption that nurses recruited from and trained in Gambella are more likely to stay in
Activity Narrative: Gambella for a longer proportion of their career (with the similar assumption for Benishangul), PEPFAR
partner proposes to strengthen the school and prepare it to accept larger intakes of students. The focus will
be on HIV/AIDS content, but the strengthening will include equipping classrooms and clinical skills labs,
ensuring good scheduling of clinical attachments/internships so that students learn by doing, upgrading
faculty skills, etc, and testing whether the SBEM-R methodology can be effectively applied in such a setting.
Core groups of faculty/tutors will also receive training in effective teaching skills and HIV/AIDS content
support, working with PEPFAR partners to carry out the latter as appropriate. Educational development
centers will be established in large universities and in all participating schools. The partner will establish a
core team of "Educational Mentors for Health" in an effort to build capacity for internal development of
instructors and to overcome the problem of teacher turnover. The PEPFAR partner will continue to support
the development of printed materials, tools (question banks, learning resource packages for faculty, clinical
attachment logbooks for students, etc.) and support for other resources, such as teaching
supplies/equipment, models, and other supplies for clinical skills labs, as the curriculum development
evolves. Where these exist (and we understand that Addis Ababa University is exploring a master's
program in medical education), it also proposes to support institutions that have programs to develop
educators in the health area. These types of programs are recommended in the draft human resources for
health strategy.
Where feasible, the partner will share other resources that are available to school faculties and leadership,
such as the virtual/distance leadership course established by the Leadership and Management Support
project, which is funded by the US Agency for International Development.
ACTIVITY WITH ONLY MINOR CHANGES FROM FY2008
In FY08, Partner successfully adopted and integrated the Smart Care EMR System into the Ethiopian
context in close collaboration with CDC-Zambia and the Federal Ministry of Health (FMOH). Partner has
established strong regional collaboration with CDC Zambia EMR developer's team using an online Team
Foundation Server (TFS) source controls system to update and share source codes to facilitate
collaborative programming between SmartCare Zambia and SmartCare Ethiopia.
Initially, the EMR/SmartCare system was designed for 85 ART clinics usage only where 2-3 computers
were to be installed with workgroup network topology. But in the same year the Ethiopian HMIS information
scene had changed. The new HMIS that is speared headed by FMOH changed and standardized the
clinical patient information format at facility level by introduced individual folder/patient chart at medical
record/card room. This had a great impact on the ART information system and its roll out as it means all
patient information of the individual are to be integrated in a folder and kept at the medical record room.
Thus, The FMOH wanted the rollout of new EMR to be hand in hand with the new HMIS paper system scale
up and for it to be customized not only to include ART modules but all the new HMIS information. Partner
has been working to modify EMR/SmartCare to include all the modules of the new HMIS. Thus, the EMR is
being redesigned to incorporate all major departments' services in health facilities, to become a fully blown
EMR system. Currently the system is being implemented at one of the health network model where the new
HMIS is rolled out. For the EMR implementation, Partner has also purchased IT Equipments, performed
hardware configurations, LAN infrastructure installations and EMR (SmartCare) installation at these facilities
and user training is underway. This has dramatically increased the IT equipment investment at facility level.
In FY09, Partner will continue to implement and maintain the Electronic Medical Records (EMR) system at
85 sites that have implemented the new HMIS. Partner will also continue to develop and deploy data
warehouse system for MOH and eleven RHB linked to the National HMIS; and will continue to support
human resource capacity building, hardware acquisition, and software licensing and application
development to strengthen the data warehouse, GIS, EMR and related activities to MOH and agencies,
CSA, RHB and health institutions. In FY09, Partner will continue building technical capacity at FMOH to
manage and lead the implementation and expansion of these systems to all health facilities and institutions.
Partner will also support all information and communication technology activities at national, regional and
facility level through continued trainings as well as seconding staffs as part of capacity building. Mapping
and unique identification of all health institutions will be also supported.
FY08 Activity Narrative:
In FY06, the National Computer Resources Mapping Survey mapped the districts where the Government of
Ethiopia's (GOE) high-speed communications network (funded by the World Bank) exists, their human
resource capacity, hardware, and software resources. The information gathered has identified available
information and communication technology (ICT) infrastructure and resources for the implementation of the
data warehouse and electronic medical records (EMR).
In FY07, there were two sub-activities:
1) The development of an EMR system to support HIV/AIDS care and treatment. In FY07, this was
expanded to include other activities at health facilities, including health management information systems
(HMIS).
2) The Design and development of a data warehouse for the Ethiopian Federal Ministry of Health (MOH)
and regional health bureaus (RHB) that included strengthening the geographic information system (GIS)
and spatial analysis in health.
The MOH is expanding ART services rapidly and needs a robust patient information system that improves
care and programming. The MOH, facing the challenge of improving the quality of ART services while also
rapidly scaling up capacity, is trying to ensure that ART patients are not lost to follow-up and their medical
information is not lost as they visit various clinics over time and distance. In FY07/08, Partner has
successfully adopted and integrated CDC-Zambian Smart Care (EMR) system into the Ethiopian context in
close regional collaboration with CDC-Zambia and CDC-Ethiopia. The relatively new technology of EMR is
a complement to the national HMIS, which can record and track the provision of quality medical service at
the individual client level. Using EMR, it becomes possible to record and track each individual's care, as
well as collective or aggregate patient information for HMIS purposes. For clinics using an EMR system,
many HMIS indicators can be produced automatically, without further burden to staff. The system is needed
to assure continuity of patient care over time and place, and across types of service and levels of care. It
enables: standardization and collection of health information data for decision-making; timely data capture
at a point of care; and data access and reuse at a subsequent point of service, hence improving care quality
and reducing costs of repeated tests. Furthermore, it can report in "real-time" indicators such as patient
count by sex and age categories, geographic distributions, longitudinal cohort data, health demographics,
and adherence and cost statistics, which are accurate, valid, reliable, and timely. It also helps in preventing
duplication of patient counts and linking of patient information to currently separate ‘vertical' paper systems
such as tuberculosis (TB), HIV/ART, antenatal clinics (ANC), PMTCT, voluntary counseling and testing
(VCT), and sexually transmitted infections (STI)—thus improving the efficiency of decision-making.
Electronic data reduces human error and the burden of manual aggregation for HMIS reporting.
In FY07, EMR implementation began in 35 ART networks; in FY08, it expanded to include 50 networks. The
system covers all patients enrolled in comprehensive ART services, as well as mothers attending ANC and
receiving PMTCT, and spouses seeking VCT. The inclusion of ANC services is to reduce the possible
stigmatization of the smart card that might occur if EMR is used only for those patients who are taking ART.
Further TB, family planning, outpatient departments, laboratory departments, in-patient department modules
also included. The program expansion required investment in hardware, including: computers and monitors;
uninterruptible power supplies; printers (for all 50 networks); and consumables, including paper, toner, and
cards. Adaptation of the software has also continued by drawing technical assistance (TA) from other
Activity Narrative: countries implementing such a system. Related costs include: recruitment and salaries for new software
programmers, salaries for data clerks; training on use of the system, and a series of staff sensitization
interventions at facilities selected for implementation. The data flow between the EMR system at facilities
and the HMIS system at the facility, district, and regional levels also implemented. Ongoing support
continued to all sites including seconding staff to MOH as well as capacity building at MOH for development
and expansion of EMR in the country.
The data warehouse is a central data repository that collects, integrates, and stores national data with the
aim of producing accurate and timely health information which will support evidence-informed data analysis
and reporting on HIV/AIDS care, treatment, and prevention. Relevant sources for the data warehouse
include the national monitoring and evaluation (M&E) program reports, population-based surveys, non
identifiable aggregated data from EMR, and data from routine national HMIS reporting.
In FY07, a data warehouse architecture system study was completed and assistance was provided to
redesign the MOH website that links to the data warehouse for data mining, analysis, and reporting. This
activity was also extended to regional health bureaus (RHB). MOH and RHB staffs were trained to maintain
the website. In FY08, MOH and RHBl continued to receive technical assistance on the development of
electronic data warehouse systems, using the latest technology available and integrating HMIS, including
the HIV/AIDS information system, surveillance, surveys and other related data sources. This system also
includes routine and survey information on HIV/AIDS and other related diseases from various government
organizations, nongovernmental organizations, research institutions, and the private health sector. This
activity also includes integrating the national information and communication technology resource-mapping
database, CostET, and district-based planning application database with the MOH intranet. In FY08,
support was provided to include human resource capacity building, hardware acquisition, and software
licensing and application development to strengthen the data warehouse. In support of this activity, mapping
and unique identification of all health institutions were conducted as outlined in "The Signature Domain and
Geographic Coordinates: A Standardized Approach for Uniquely Identifying a Health Facility" in
collaboration with the MOH, the Ethiopian Central Statistical Agency, and the National Mapping Authority.
The support includes strengthening GIS capacity through human resource capacity building, hardware
acquisition, and software licensing. In FY08, all information and communication technologies activities had
continued trainings as part of capacity building.
April 2009 Reprogramming:
Project title: Integrating pediatric HIV psychosocial support with the existing pediatric HIV care and
treatment services at national level
This is a new activity to integrate psychosocial care and support services for HIV infected and exposed
children at national level. Psychosocial care in HIV infected children is an ongoing process of meeting the
social, mental and spiritual needs, which are considered essential elements for positive human
development. Child centered and family focused Psychosocial support is the integral component of the
holistic approach to caring an HIV infected children .The provision of psychosocial support services for HIV
infected children has to be an important part of care at both institutional and community level. Moreover,
there is a need to deliver comprehensive pediatric care and treatment services with optimal quality of care.
Issues related to Psychosocial support of HIV infected and exposed children encompass ,Effective
communication, Special issues of counseling and testing, disclosure of HIV status, dealing with chronic
health conditions, bereavement and its consequences, Supporting siblings and others. Psychosocial
assessments that identify each families vulnerabilities are essential components of the comprehensive care
of an HIV infected child. The current national guideline and training materials for pediatric HIV services are
deficient in addressing psychosocial support issues at health facilities. Basic psychosocial support services
are not properly incorporated into the care provided to HIV exposed and infected infants in hospitals and
health centers.CU/ ICAP will develop developing guidelines and training materials adapted to the Ethiopian
situation for psychosocial care of HIV infected children. CU will involve multiple professional disciplines
other than health sector (psychologist, sociologists) to provision of the service at health facilities. Eventually
this activity will contribute to the initiation and establishment the psychosocial support services at health
facilities providing care and support for HIV exposed and infected children. Additionally it supplements to
the positive impact of psychosocial care for HIV infected children on treatment outcome and quality of life
improvement
Table 3.3.10:
Strengthening Clinical Laboratory Workforce
The clinical laboratory workforce plays a vital role in the health care system. Accurate, reliable and
repeatable clinical laboratory testing remains a central component of the public health approach to disease
management in resource-limited settings. Results generated from the laboratory are essential for service
providers to accurately assess the status of a patient's health, make accurate diagnoses, design treatment
plans and monitor the effectiveness of a given treatment. The accuracy of laboratory results is critical as it
impacts the patient's life as well as the quality and credibility of a program, including those related to
TB/HIV/AIDS.
For laboratories to be able to provide accurate, repeatable and timely results, a few components must be in
place. First, there must be a safe and suitable physical environment with uninterrupted power and high
quality functioning equipments. Second, there must be an effective management of quality systems to
ensure the laboratory is functioning at the highest quality standards with appropriate documentation and
measures of quality implemented. Third, there must be available human capacity (laboratory technologists)
that have been properly trained and certified competent. By competent, we refer to the ability of a laboratory
technologist to perform an assay with associated equipment unsupervised. Over the past 3 years PEPFAR
Ethiopia has registered some strides in laboratory infrastructure improvement. To name a few, PEPFAR
supported the complete renovation of the national HIV reference laboratory as well as the renovation of 6
regional laboratories that are currently doing early infant diagnoses. Also major equipments have been
bought for monitoring patients on ART. PEPFAR Ethiopia has assisted laboratories to enroll into external
quality assurance programs for HIV monitoring, TB diagnosis as well as ensuring standard operating
procedures, provided trainings and developed standard operating procedures. Laboratory technologists
constitute a key component of the health work force and yet they remain a very weak area in terms of the
number of personnel as well as the quality of the staff trained.
A recent WHO report indicated there was a global crisis of the health workforce that was expressed by
acute shortages, poor quality, and maldistribution of staff especially in Sub-Saharan Africa
(http://www.who.int/hrh/en/). In Ethiopia there is a shortage of laboratory technicians among other health
workers. In the 2002/2003 Health and Health-related indicators report [by the Planning and programming
department of the Ministry of Health] only 249, 223 and 302 laboratory technicians graduated from five
universities with medical laboratory training in 2001, 2002 and 2003, respectively. These are relatively small
numbers to cover the tiered laboratory network across the large population and vast expanse of Ethiopia
that is made up of 9 regions. A 2005 Ethiopia health sector development report projected a decrease of
laboratory technicians by 2007. Several reasons may be contributing to the shortage and quality of
laboratory technicians including recruitment, retention, and migration. Another factor that may be
contributing to poor quality is that laboratory technologists complete their entire training program with little or
no practical exposure to equipment routinely used in public health laboratories. Graduating laboratory
technologists are ill-equipped simply because the training schools lack these instruments. The disadvantage
with the current system is that when students graduate from training schools and gain employment into
public health laboratories, as new employees, they are required to spend at least six months in orientation
and familiarization with the equipment in their work place. This is valuable time lost, which otherwise, would
have been dedicated to specimen management and testing and/or other laboratory activities. Furthermore,
these newly-trained but inexperienced staff risk disrupting the normal flow of laboratory activities when the
lab is compelled to now train them and risk misuse of expensive equipment. Also there is poor access to
literature by the training school due to lack of computers. Access to literature is a valuable source of
material or knowledge for laboratory technicians in training schools for use to improve and hone their skills.
There is the need to address these problems to avoid the negative impact it will have on health care
systems if unqualified technicians are left to staff the laboratories. In Ethiopia, five universities have medical
laboratory training colleges and have a total student population for laboratory technologists of 2,486; with
Jimma University having (n=700 students), Haramaya University (n=325), Hawassa (n=430), Addis Ababa
University (n=620), and Gonder University (n=411). These universities constitute a valuable source for
producing laboratory technicians for use in the health sector and between them they graduate about 500-
600 laboratory technicians a year. If 600 graduates have to spend an additional 6 months post-graduate to
learn and have hands on experience on the equipment, that is 3,600 months or 30 person-years that would
be returned to the workforce by equipping the schools so that they are competent upon graduation. To
improve the quality of student laboratory technicians and expand the number of graduates who have
sufficient exposure to equipments in routine clinical laboratories, PEPFAR Ethiopia will support and ensure
procurement of laboratory equipment to pilot in 3 Universities' medical laboratory technologist training
programs and this will be rolled out in subsequent years. A detailed assessment will be done among the
Universities to select 3 for the pilot phase. Some of the selection criteria will be the ability for the University
to demonstrate uninterrupted supply of reagents for use with equipment, proper maintenance, laboratory
space and quality supervision. This is critical in addressing the acute shortage of qualified clinical laboratory
technicians. This involves procurement of biosafety cabinets (for protection of personnel and environment
while processing specimens), clinical chemistry, hematology, advanced sero-diagnostic equipment (ELISA
washers and readers), CD4 machines and computers. These equipments will be installed with appropriate
trainings on their use as well as performing preventive maintenance. Additionally, there will be development
and provision of courses on laboratory management. By providing equipment to training colleges, laboratory
technologists will train on them, hone their skills and be certified competent on the use of the equipment
while still in school. Instead of unnecessary delays, upon graduating, PEPFAR support will allow the staff to
be highly skilled, confident, and capable of immediately filling the critical shortage of clinical laboratory
technologists for delivering quality laboratory services.
Table 3.3.12:
Infrastructure Development and Rapid baseline surveillance for XDR TB
ACTIVITY UNCHANGED FROM FY 2008 (no Update needed)
Even though there are not many reports of extensively drug-resistant tuberculosis (XDR TB) in Ethiopia, it
has recently emerged as a global public health threat. In South Africa, XDR TB among HIV-infected persons
killed 52 of 53 persons diagnosed with the disease, many of whom were on antiretroviral therapy (ART).
The World Health Organization (WHO) recommends surveillance for XDR TB among high-risk patients,
which would include "re-treatment patients," or those previously treated for tuberculosis. EHNRI proposes
to conduct XDR TB surveillance in collaboration with St. Peter's Specialized TB Hospital in Addis Ababa,
the largest TB hospital in the country. The hospital sees a large number of TB patients with a previous
history of TB treatment, many of whom have drug-resistant TB. All re-treatment patients have their sputum
sent to the national reference laboratory for first-line drug susceptibility testing.
Evaluation Question: The evaluation question is whether XDR TB exists among HIV co-infected persons in
Programmatic Importance: The study is important to establish presence, or lack thereof, of XDR TB in
Ethiopia and to develop local capacity at EHNRI to screen for XDR TB.
Methods: USG will support surveillance for second-line TB drug-resistance (and thus XDR TB) by having
sputum specimens for all re-treatment cases at St. Peter's for a 3-6 month interval sent to the national
reference laboratory as usual for first-line drug-susceptibility testing. All such specimens will be stored in a
freezer at EHNRI and then will be shipped in 1-3 batches to either one of the WHO International Union
against Tuberculosis and Lung Disease (IUATLD) Supranational Reference Laboratories (SRL) or to CDC-
Atlanta for second-line drug-susceptibility testing. To build the capacity of EHNRI, second-line testing will
also be done there.
Activities will include, purchase of second line testing reagents, purchase and maintenance of equipments,
training in second line testing for EHNRI staff, shipment of specimens to supra national lab, supplying
second line testing to a destination laboratory (WHO IUATLD SRL). In addition, the EHNRI TB laboratory
will be strengthened to be able do XDR TB testing in future.
Information Dissemination Plan: Stakeholders include the HIV-TB Technical Working Group members,
selected TB diagnostic centers in Ethiopia, the Federal Ministry of Health (MOH), Addis Ababa Regional
Health Bureau, health care providers, PEPFAR and other entities involved in HIV-TB care and support.
XDR surveillance reports will be disseminated in a review meeting for the region and findings will be shared
with PEPFAR partners.
* TB
Management and Staffing
Based on an assessment of program priorities, the direct hire position, TB/HIV Advisor has been abolished.
These responsibilities will be covered by the Associate Director for Care and Treatment. The TB/HIV
Advisor position has been redefined as Associate Director for Prevention.
FY 2008 ACTIVITY NARRATIVE:
This activity represents the direct technical assistance which is provided to partners by CDC Staff. The
amount represents the salary cost for CDC Ethiopia direct hire technical staff. Detailed narrative of CDC -
Ethiopia management and Staffing is included in program Area 15-Management and Staffing HVMS.
Program Budget Code: 13 - HKID Care: OVC
Total Planned Funding for Program Budget Code: $34,062,269
Total Planned Funding for Program Budget Code: $0
Program Area Narrative:
"Know Your Epidemic" is paramount to the success of the PEPFAR/Ethiopia Team. The 2007 estimate indicates a low-level
generalized epidemic for Ethiopia with an overall HIV prevalence of 2.1%. This prevalence estimate does not, however, tell the full
story of the epidemic here where the majority of infections occur in urban settings. The 2007 single point prevalence study
estimates urban prevalence is 7.7% (602,740 persons living with HIV and AIDS (PLWH)) and rural prevalence is 0.9% (374,654
PLWH).
The Government of Ethiopia's single point estimate issued in 2007 states Ethiopia should now have almost 5.5 million orphans; 16
percent of whom are due to AIDS. This includes 640,802 maternal orphans, 550,300 paternal orphans, and 304,282 dual orphans
due to AIDS. The majority of orphans due to HIV/AIDS are in Amhara (39%), Oromia (22.4%) and SNNPR (14.1%).
The remaining causes of orphaning are due to food insecurity, conflict, natural disasters, malaria, and infectious diseases. Only
65.2 percent of 10 to 14 year olds, and 52% of children 15-17, live with both parents, according to the 2005 Demographic and
Health Survey. Lack of parental care and support exposes children to increasing vulnerability, such as food insecurity and chronic
malnutrition; lack of protection, shelter, and education; and physical and sexual abuse. These children also face the increased
burden of caring for ill parents along with stigma and discrimination. This vulnerability can increase children's risk for exposure to
HIV.
The rising cost of food has intensified the vulnerability of children and requires that PEPFAR Ethiopia, intensify our focus on food
and nutrition security. Support to the primary food and nutrition partners' interventions, World Food Program and Food by
Prescription, will expand in response to this growing food crisis. Through these programs, food access has improved for over
15,000 households and 40,000 OVC in FY08.
FY08 target achievements are on track for the OVC program with over 550 community partnerships providing support to 400,000
OVC as of March 2008. Successful approaches highlighted in the May 2008 evaluation of the PC3 program include working with
existing local structures and increasing their capacity to mobilize resources and prioritize interventions. These efforts will be
expanded in FY09 through the newly awarded FY08 APS recipients and the focus on family-centered care and support. The FY09
APS and the PC3 follow-on activity will further expand the application community networks engaged in providing comprehensive
care and support to families affected by HIV.
Increased support to education sector activities will improve the reach of school feeding programs. Approximately 12 percent of
any elementary student body is considered OVC. OVC targets for all food and nutrition activities of PEPFAR Ethiopia will increase
in FY09. USAID convened PEPFAR OVC stakeholders in September 2008 to begin mapping revised strategic approaches for
improving food and nutrition security. Consensus is being reached on the critical minimum results for all PEPFAR Ethiopia OVC
partners. This will likely include access to safe water, hygiene and nutrition education, and household economic strengthening.
Mapping data generated in FY07 and expanded in FY08 is being used to increase coordinated care at community level, especially
relating to food and education access and referrals to clinical care. Challenges relating to HIV and AIDS stigma and access to
quality health facilities remain the primary barriers to increasing referrals to counseling and testing, PMTCT, palliative care, and
ART. A focus on family-centered care and support through improved community networks will tackle these challenges by
identifying most promising practices and supporting community exchanges. The OVC National and Regional Platforms will
facilitate these exchanges and support documentation for broader reach.
Data and results from the May 2008 evaluation of the Positive Change: Children, Communities, and Care (PC3) program have
prompted a design change in the PEPFAR Ethiopia OVC program. Therefore, family-centered care and support is now needed to
improve the quality of life for the greatest number of OVC, including children living with HIV. The intent is to keep surviving
parents alive and economically viable and children free from HIV. Interdependent networks of local stakeholders will be supported
to meet the needs of vulnerable families and to identify and assist families or households prior to the point of extreme vulnerability.
In COP 09, emerging regions such as Gambella and semi urban towns are included. Local and indigenous implementing agencies
such as OSSA are encouraged to run OVC programs through direct relation with PEPFAR Ethiopia.
Stakeholder consensus will be reached on defining, measuring and improving community capacity to deliver on family-centered
care and support. A barometer or index will be used to measure compliance with standards for improving community capacity
response. Top performing communities will serve as technical resource hubs for other communities seeking to meet standards for
the provision of care and support to families affected by HIV/AIDS. Priority technical areas to be demonstrated by these technical
hubs include: directly improved community capacity response especially in the areas of food and nutritional security, education for
OVC, household economic strengthening, and functioning referral system or case management of family-centered care.
Given Ethiopia's low and urban concentrated HIV prevalence, a major emphasis for family-centered care and support will be
improved linkages between community and clinical care services to improve uptake in: counseling and testing, PMTCT, adult and
pediatric ART, care and support. Ties to USG partners in reproductive health, child survival, education, economic strengthening,
and malaria prevention will be strengthened to provide a continuum of care for vulnerable families. For example, one successful
approach that will be continued is reaching adolescent, pregnant girls though clinic-based support groups ("Mothers to Mothers"
program) to encourage HIV testing and follow up as well as provide child care training. The coordination between home-based
care and OVC programming will be expanded to ensure a continuum of care for families living with HIV/AIDS. Additionally, Child
Centeredness an approach that will focus on children's participation and engagement before, during and after program
implementation will enable considering the voices of children and make the support meaning full and need based. This will also
help to ensure that we work with our partners to provide the appropriate resources and support necessary to get to universal
access to prevention, treatment, care and support for the children of Ethiopia.
The gender of a vulnerable child and of his or her caretaker has a major impact on access to essential services and on the
structure of programs that provide these services. PL 109-95(President Bush recently signed into law Public Law-109-95, the
"Assistance for Orphans and Other Vulnerable Children (OVC) in Developing Countries Act of 2005) acknowledges the
importance of gender, with special emphasis on gender differences in land, property and inheritance rights. Access to education,
ability to travel to health care sources, availability of credit, range of employment opportunities, and vulnerability to trafficking and
the sex trade are common areas where gender differentials are large. USG programs will continue to be designed to recognize
the many ways in which gender affects access to services and will program funds to address gender differentials.
PEPFAR Ethiopia will continue to support two seconded positions to Federal HAPCO and one to the Ministry of Women's Affairs
to strengthen stakeholder coordination, policy reform, resource mobilization, and data demand and use. Leadership at the
national level has improved in FY08 directly due to the inputs from these PEPFAR seconded positions. For example, agreement
was reached to use Global Fund monies to support a national OVC situation analysis. PEPFAR partners will continue to support
regional and community networks to strengthen government and civil society partnerships. These existing structures will be
tapped to review local data, set community-wide targets, prioritize interventions, and determine best use of resources for provision
of family care and support that mitigates the impacts of HIV and AIDS.
Drafting and piloting the Ethiopian Standards of Services for OVC has strengthened the partnership between government and civil
society entities to improve the wellbeing of vulnerable children in a more united way. This success will be expanded to develop
community capacity standards. The rollout of service standards and the focus on quality improvement have been a joint effort of
USAID and Peace Corps in Ethiopia. Discussions are underway to formalize and expand this multi-agency partnership.
PEPFAR/Ethiopia will intensify efforts in small business development and other livelihood options to increase the asset base of
households caring for OVC; this includes a focus on youth livelihoods for the older OVC. Larger programs designed to address
household capacity in 2009 include the Urban Gardens follow on and the Civil Society program, both of which will address food
security and income generation.
PEPFAR Ethiopia support to Population Council will be increased to expand integrated approaches to reducing gender-based
violence and impacts of early marriage. Activities will include sharing best practices and providing technical assistance based on
piloting approaches to protecting children from harmful gender-based practices and assisting children who have been affected.
The community data management system implemented under the PC3 program will be expanded through new FY2008 and
FY2009 OVC partners. This system allows for the rapid collection, organizing, and reporting of data among community
stakeholders. The implementation of both service and capacity standards will inform data demand and use. Outcomes in child and
family wellbeing are part of each standard and are determined based on what is realistic and meaningful to community
stakeholders, especially community and clinical care service providers. For example, these local providers will meet periodically to
discuss progress in meeting outcomes and determine any needed improvements in activities. Both short and long-term outcomes
may be needed to prioritize actions across stakeholders. Special studies may be undertaken to provide evidence on promising
practices especially in priority areas of household economic strengthening, education for OVC, and food and nutrition security.
Workforce development within GOE will continue to be supported through increasing available urban Health Extension Workers
(HEW). Sustainability of these human resources is more likely given they are government positions. Human resource capacity for
family-centered care and support increased in FY08 for USG.
A slight funding decrease in the PEPFAR OVC portfolio and an increase in quality improvement of services require the COP09
targets for OVC to remain consistent with COP08.
Table 3.3.13:
Home Based Voluntary Counseling and Testing in the rural Community - Hot spot
VCT serves as an entry point to prevention, care, treatment and support, programs and enables people to
confidently understand their HIV status and learn about supportive behaviors for protecting themselves and
preventing further spread of HIV. Knowledge of HIV status has been promoted as a prerequisite for access
to support and care including treatment.
Voluntary counseling and testing (VCT) remains the most widely accepted approach for promoting
knowledge of HIV status. WHO promotes initiatives to increase access to innovative, ethical and practical
models of HIV testing and counseling.
A number of counseling and testing (CT) service delivery models are being used to expand entry points to
HIV testing and to promote testing as a more routine practice. Expanding the number of models will help
more people learn their HIV status and benefit from prevention, care and treatment services. The models
are designed to reach different target groups and achieve different goals.
Home-based CT (HBVCT) is relatively new and is still being piloted. It is similar to the mobile model in that
CT is offered within the home to family members, including children, where appropriate. For this reason, it is
sometimes referred to as the family-based model.
In a number of African countries HBVCT is implemented to create better access HIV testing services for the
rural community. Qualitative DHS+ in Uganda showed that homes were perceived by almost all the
respondents who participated in the blood draw as spaces where they could receive their test results in
privacy and with confidentiality.
The major advantages of the HBVCT are; reaching of couples or families at once, hence prevention can be
more effective and the strategy facilitates disclosure. However, some of the challenges of HBVCT include
the cost of the service, disclosure consequences and social acceptance.
In FY08 HBVCT was introduced by community counselors as a pilot in urban setting of Addis Ababa.
There is little information on the cost effectiveness and social acceptance of HBVCT in Ethiopia particularly
in the rural community.
The Millennium AIDS Campaign 2007/8 indicated that 10% of the population accessed HIV testing through
the campaign. Most of the reports were from the health facilities which mostly concentrated in urban areas.
Access to services such as VCT and care and treatment including ART are limited in rural communities.
The VCT site should be located close to the people it serves. If people have to pay for transportation or if it
takes too long to get to a site, they may not be able or willing to come for testing. Experience in other
countries has shown that mobile and home to home VCT are effective strategies to reach rural populations.
This activity is intended to pilot HBVCT in a rural setting with high prevalence. The service will be closely
linked with the health post, a primary health unit which is close to community.
Activities will include;
1.Selection of sites rural area with high prevalence (DHS+ and ANC surveillance);
2.Conducting rapid need assessment of the community;
3.Mapping of referral linkage for care and support services;
4.Establishing data recording and reporting mechanism;
5.Launching of HBVCT service;
6.Closely monitoring the service and identify main issues; and
7.Documenting best practices and lesson learned for future replication.
HBVT service will serve to meet Ethiopian ART Road PEPFAR care and treatment targets.
Table 3.3.14:
Family Guidance Association of Ethiopia, Addis Ababa Counselors Support Association
ACTIVITY MINOR CHANGE FROM FY2008
COP 08 ACTIVITY NARRATIVE:
Activity Narrative: National HIV Counseling and Testing Support
This activity describes four components of FY09 activities.
I. Building Human Capacity
During FY08, JHPIEGO worked with the Federal Ministry of Health (MOH), the national HIV/AIDS
Prevention and Control Office (HAPCO), Regional Health Bureaus (RHB) and CDC to build human capacity
for providing high-quality HIV counseling and testing (HCT) services at ART hospitals. Interventions
included training, updating materials, and training new community counselors following a successful pilot.
JHPIEGO started work with Addis Ababa Counselors Support Association (AACSA) to transform to national
association and established new regional counselors associations and post-test clubs and two regional VCT
demonstration sites equipped to serve as regional training centers.
In FY09 JHPIEGO will continue to support FHAPCO in updating national guidelines and training packages
for HCT, with specific focus on needs of vulnerable or underserved populations, including guidelines for
pediatric disclosure, counseling for youth, families and the disabled. JHPIEGO will do so using on-site
training and appropriate learning technologies to minimize disruptions in service delivery. Finally, JHPIEGO
will continue to build human capacity by expanding the pool of HCT trainers through the competency-based
trainer development pathway; working with the CDC and Regional Procurement and Supplies Office
(RPSO) to establish additional regional VCT Demonstration Sites, and continuing to build the capacity of
two local organizations, (FGAE) and Ethiopia HIV/AIDS Counseling Association (EHACA) to effectively
conduct training and implement HCT independently.
1) Support the scale-up of HCT training by training a total of 60 new trainers in voluntary counseling and
testing (VCT), provider-initiated testing and counseling (PITC), and couples' HIV counseling and testing
(CHCT). JHPIEGO will also complete HCT training packages through the National HIV Counseling and
Testing Working Group (HCT TWG) and support printing of the materials.
2) Provide technical assistance to PEPFAR partners in conducting VCT training for community counselors
3) Work with AACSA through sub-agreement to further strengthen its capacity and train 120 counselors in
CHCT and burnout management. AACSA will provide supportive follow-up to these counselors. JHPIEGO
will also work with AACSA and other regional counselors' associations to support the establishment of three
or four more regional associations networked into a National Counselors Association. Building on FY07
experiences, AACSA will explore the feasibility of establishing post-test clubs for couples at selected sites.
4) Complement Standards Based Management and Recognition (SBM-R) for HCT, as proposed in
application for SBM-R (under system strengthening)
5) Work closely with implementing partners to strengthen counselors' burnout-management program
II. Supporting the Expansion of Regional VCT Demonstration and Training Centers
By the end of FY08, PEPFAR will complete the renovation of four regional demonstration sites in Amhara,
Oromiya, Southern Nations, Nationalities, and Peoples Regions (SNNPR), and Tigray regions. JHPIEGO is
instituting model systems, including furniture, staff training, documenting best practices and use as a
practice site for trainees. In FY08, JHPIEGO proposes to further strengthen existing sites and establish two
similar facilities in the eastern and western parts of the country in consultation with partners.
Proposed activities for FY09 include:
1) Establishing two new regional CT demonstration sites, with the assumption that the Regional
Procurement Support Office will conduct renovations of service buildings and conference rooms
2) Support for implementing VCT services at all six demonstration sites
3) Support for the six sites to document best practices that can be transferred to other VCT centers in the
regions
III. Strengthen Local Nongovernmental Organizations (NGO) to Expand HCT
The Family Guidance Association of Ethiopia (FGAE) is a local NGO delivering sexual and reproductive
health services in an integrated fashion. These include: family planning services, cervical cancer diagnosis,
care for rape victims, management of sexually transmitted infections (STI), and HIV services (e.g., VCT,
condom promotion and distribution, treatment of opportunistic infections). FGAE's programs and services
cover many parts of the country through branches in regions, sites in workplaces, youth centers, and
outreach and marketplace activities.
Signed a sub-agreement with Family Guidance Association of Ethiopia in 07 to strengthen VCT and
introduce PITC in 34 clinics and youth centers. Outreach workers were trained to provide education and
referral for HCT services. Sample collection through finger prick was piloted at some sites
For FY08, JHPIEGO proposes to continue providing financial and technical support to FGAE to expand
current activities:
1) Training of FGAE trainers in VCT, CHCT, and PICT
2) Training 100 providers in PITC and training 100 VCT counselors (including community counselors) and
70 FGAE counselors in CHCT and burnout management
3) Supporting VCT, CHCT and PITC services at 35 sites
4) Train and support 400 volunteers to perform CT outreach activities, including provision of HCT in the
community
5) Document HCT best practices
6) Procure test kits and medical supplies, if these cannot be leveraged from sources funded through the
Global Fund for AIDS, Malaria, and Tuberculosis
7) Support FGAE to provide outreach CT programs at the market place and during community mobilization
Activity Narrative: Expansion of VCT to market vendors (pilot program)
JHPIEGO planned to pilot HIV counseling and testing and STI testing in the market place in close
collaboration with AIDS Healthcare Foundation-Uganda.. Market communities, which comprise a significant
proportion of the informal work sector in many African countries, are particularly vulnerable to HIV/AIDS.
Market vendors, the majority of whom are women, are a high-risk group for HIV infection due to a number of
contributing factors that include: little knowledge of the dynamics of HIV transmission, infection and
prevention; promiscuity; substance abuse; unsafe sex; congestion; long work hours; and poverty.
Exacerbating this problem is the fact that, traditionally, market vendors do not access HIV/AIDS services,
even when available, for fear of losing valuable time and money.
In Uganda, AIDS Healthcare Foundation (AHF) partnered with Development Initiatives International (DII) in
2005 to develop a comprehensive and integrated HIV/AIDS service package of prevention, care, support,
and free antiretroviral therapy (ART) specifically designed for market populations and communities.
Studies have shown that for populations with low rates of HIV prevalence overall (like in Ethiopia), it is most
effective to target high-risk groups with programs that emphasize counseling, testing, and treatment
services. Therefore, implementation of an innovative model designed to accommodate the lifestyles and
needs of market vendors is appropriate and necessary. JHPIEGO will pilot the program in Addis Ababa and
based on the lessons gained will replicate the services in other towns.
Continuing Activity: 16574
16574 5627.08 HHS/Centers for JHPIEGO 7473 3746.08 University $2,486,448
10382 5627.07 HHS/Centers for JHPIEGO 5468 3746.07 $2,642,000
5627 5627.06 HHS/Centers for JHPIEGO 3746 3746.06 $750,000
Involvement of selected regional, hospital and health center laboratories in a WHO step-wise accreditation
process
Laboratory services are essential components in the diagnosis and treatment of persons infected with the
human immunodeficiency virus (HIV), and other related diseases of public health significance including
malaria and mycobacterium tuberculosis. A lot has been done in Ethiopia to improve laboratory
infrastructure for HIV, malaria and TB diagnosis. Seven molecular laboratories for DNA PCR have been
established in regional and national reference laboratories for expansion of early infant diagnosis services
and all of these laboratories are linked with quality assurance program at CDC Atlanta, International
Laboratory Branch. Biosafety level III laboratory has been established at St. Peter tuberculosis specialized
hospital for TB culture and drug resistance detection. Similar laboratories will be established at regional
laboratories. More than 200 laboratories have been equipped with automated anti-retroviral monitoring
(ART) machines.
Despite all the achievements, the laboratory infrastructure remains poor in many facilities and therefore,
there is an urgent need to strengthen the laboratory. The establishment of accreditation systems will help
countries to improve, and to strengthen the capacity of their laboratories. Accreditation provides
documentation that the laboratory has the capability and the capacity to detect, identify, and promptly report
all diseases of public health significance that may be present in clinical and Research specimens. The
accreditation process further provides a learning opportunity, a pathway for continuous improvement, a
mechanism for identifying resource and training needs, and a measure of progress.
Ethiopia does not have any national accreditation system or accrediting board or agency for the laboratory
services. There are no well defined standards or bench marks to be attained for all laboratories at different
levels. However, more and more laboratories are being involved in international EQA programs. Based on
EQA results, laboratories are undergoing continuous process improvement. This will be more effective if
supported by some sort of national accreditation system. Accreditation has been initiated for the National
Reference Laboratory (NRL) using Joint Commission International (JCI) standards. American Society for
Clinical Pathology (ASCP) has been providing technical support for the full accreditation of the NRL. Even
though much of the accreditation process has been achieved, the process took more than three years. The
laboratory is not yet fully accredited and the requirements are very stringent.
Accreditation of all levels of laboratories through international accrediting agencies and international
standards is quite expensive, time consuming and un-realistic especially for district hospital and health
center laboratories. Cognizant of the challenges, WHO has come up with feasible and step-by-step
accreditation system. Enrollment of laboratories in the step-wise accreditation system will be important for
the quality of laboratory test results and credibility of laboratory in health services. At the end, laboratories
will benefit from the process and WHO will involve the laboratories in this system in EQA program.
Accreditation of laboratories is reviewed annually by the WHO Regional Office and is based on laboratory
performance during the immediately proceeding 12 months relying on complete data, usually from the past
1-13 months to one month prior to evaluation and accreditation is given for the upcoming calendar year.
CDC-Ethiopia, in collaboration with Ethiopian Health and Nutrition Research Institute (EHNRI) and
implementing partners will pilot the WHO accreditation process in nine selected regional and hospital
laboratories. Selected laboratories will be enrolled in this process and this requires document preparation,
training, improvement of the work flow and providing technical assistance for the selected laboratories to
implement all internal quality assurance measures in preparation for step-by-step accreditation. With this
budget, some 50 laboratory personnel will be trained on quality systems management, documentation,
recording and reporting. The lessons from the pilot process will be helpful for the establishment and
strengthening of the national accreditation system in Ethiopia.
Table 3.3.16:
Strengthening STIs and OIs laboratory diagnosis as part of comprehensive and integrated laboratory
services
Laboratory testing for HIV and related opportunistic infections plays a critical role in the effective
implementation of prevention, care and treatment programs with regard to disease screening, clinical
diagnosis, staging of disease, therapeutic monitoring, blood safety and surveillance. Because of this pivotal
role, the overall goal of the laboratory program in a developing country should be to ensure sustainable,
integrated laboratory capacity that can provide quality, rapid, accurate, affordable and reliable diagnostic
tests for the effective implementation of lifesaving treatment and prevention programs. There are many
opportunities, if utilized wisely that will be helpful to strengthen laboratory infrastructure.
Ethiopia has moved one step forward in this regard. Under strong commitment and leadership from the
government, and concerted effort of partner agencies' available funds for HIV/AIDS services have been
utilized to strengthen laboratory infrastructure. Physical infrastructure of many laboratories have been
upgraded and equipped with anti-retroviral treatment (ART) monitoring machines, laboratory personnel
have been trained not only in HIV related laboratory services but also in tuberculosis, malaria and other
disease diagnosis. The initial laboratory strategic plan which focuses on HIV laboratory services has been
revised to address laboratory services for integrated diseases prevention, care and treatment. The national
quality assurance program has expanded to involve tuberculosis and malaria in addition to well-established
systems for CD4, chemistry, hematology and HIV tests.
However, laboratory support services for diagnosis of STIs and OIs remains weak nationwide and even the
available resources are not well utilized to address these important diseases in HIV prevention and control
program. Therefore, strengthening of the laboratory capacity for STI and OIs diagnosis as part of integrated
laboratory services will be important for HIV/AIDS, TB, STIs and OIs prevention, care and treatment
activities. Even though STIs are treated based on syndromic management, tests like RPR, VDRL, gram
stain, culture and sensitivity, KOH mount and other are being done. Strengthen those tests and addition of
other feasible and simple OI and STIs diagnostic techniques will be critical. Strengthening laboratory
capacity for OI and STI diagnosis has also been reflected in EHNRI's national laboratory strategic plan.
CDC-Ethiopia in collaboration with EHNRI and implementing partners will work to strengthen laboratories to
support STI and OI diagnosis. The budget will be allocated for baseline assessment, training of laboratory
personnel (40 individuals who will be training lab personnel at facilities) on simple and quality diagnostic
techniques, documentation of work (SOPs, protocols, training package), technical assistance for the
laboratories to implement internal quality assurance measures and involvement in external quality
assessment.
Production of HIV care, treatment & prevention related electronic materials
In COP 09, Partner will continue to maintain and provide technical assistance to the existing Learning
Management System (LMS) sites as well as expand the LMS to four ART hospitals (two university and two
rural hospitals). Partner will also introduce the use of cell casting for training of health extension workers on
maternal and neonatal health; utilize the existing laboratory information system for educational purpose, and
support Higher Education Relevance and Quality Assurance (HERQA) in adapting e-learning course
development standards.
In FY 08 this activity was being implemented by JHPEIGO under Mechanism ID: 3746 and Activity ID:
10482. In FY 09 the implementing partner is TBD.
FY 08 ACTIVITY NARRATIVE:
In FY07, Jhpeigo was supported to develop and implement an HIV/AIDS-specific, electronic learning
management system (LMS) for three universities in Ethiopia (i.e. Addis Ababa, Gondar, and Jimma). The
LMS was developed in three HIV/AIDS technical areas, based on the established national HIV/AIDS training
packages. The goal was to use an electronic learning platform to provide in-service training on HIV/AIDS
services. This project was designed in FY07 in the context of the rapid expansion of HIV/AIDS services in
Ethiopia, high attrition rates of providers with HIV/AIDS training, and little available time for more providers
and students to learn essential HIV/AIDS services. Jhpeigo, in close collaboration with CDC Ethiopia,
assessed, designed, and implemented the LMS for three HIV/AIDS technical focus areas for use in three
major Ethiopian universities.
A needs assessment of the three universities and affiliated hospitals yielded important findings that tailored
the subsequent implementation of the LMS. First, the findings suggested that program efforts focus on pre-
service education rather than in-service training. Thus, the project implemented the LMS at the universities
so that teaching faculty can use it as a resource for teaching students, rather than installing the LMS at the
hospital level to support providers already working. Support for the decision to focus on pre-service training
included the reality that a larger pre-service education project is concurrently underway to strengthen
HIV/AIDS teaching for medical, nursing, and midwifery students, as well as the imminent need for students
to graduate with basic knowledge of HIV/AIDS in order to expedite the provision of HIV/AIDS services with
minimal in-service training.
The needs assessment findings also indicated that a large number of health science students have access
to mobile phones and other handheld devices such as MP3 players. These types of tools can easily be
used for mobile learning. Other assessments conducted by Jhpeigo in the pre-service education program
noted a shortage of time during medical, nursing, and midwifery training to incorporate comprehensive
HIV/AIDS teaching. Thus, innovative strategies to allow for a variety of HIV/AIDS learning opportunities for
students outside of the classroom were recommended to be employed for HIV/AIDS teaching.
In response to the e-learning needs assessment findings, a non-Internet-based LMS in HIV/AIDS content
was developed using a variety of learning methodologies, including case studies, lectures, videos and
pictures. The LMS was field-tested and installed at the three universities. Faculty members at those
universities were selected as core champions of the program, and were trained on using the LMS for
HIV/AIDS learning and teaching.
In FY07, in order to ensure the functionality and appropriate implementation of the LMS at the universities,
Jhpeigo procured minimal but essential information technology (IT) equipment and provided IT specific
technical assistance needed to maintain the LMS at the universities. However, the IT support to the
universities was not adequate to ensure that a critical mass of students could access the materials. Addis
Ababa and Gondar Universities were noted to have fairly poor access to computers, not allowing many
users to access the LMS at one time.
Also during FY07, Jhpeigo liaised with the TheraSim advanced ART project to learn from their experience
with e-learning uptake in Ethiopia. In addition, under the e-learning project, Jhpeigo collected information on
end-user comfort in using electronic materials for teaching and learning.
During FY08, Jhpeigo proposes to document the practices of instructors incorporating the HIV/AIDS LMS
into their HIV/AIDS teaching practices, their interest in expanding electronic learning for HIV/AIDS teaching,
and the use of the LMS by students. In addition, Jhpeigo is analyzing scores obtained by the students using
the LMS as well as other reporting indicators that were embedded in the LMS during FY07.
In FY08, Jhpeigo increased the opportunities for students and service providers to access the LMS via
different mechanisms, as well as expand the project to involve mobile learning for students and integration
of mobile and eLearning into skills labs. First, in order to increase the access to the LMS at the current
program universities, Jhpeigo implemented the following activities:
1) Continued supporting and strengthening the use of LMS at Addis Ababa, Gondar, and Jimma universities
for pre-service teaching, as well as explored possibilities of expanding the LMS into the university-affiliated
teaching hospitals
2) Procured and upgraded the computer labs by increasing the IT capacity at the universities through
hardware, software, and networking to allow for more students to have access to a computer and the LMS
3) Worked with staff and students to improve their comfort level in teaching and learning via electronic tools
4) Developed downloadable lectures for students to save lectures on MP3 players to allow learning outside
Activity Narrative: of the computer lab, allowing more students to access lectures when they have available time
5) Procured MP3 players for students and personal digital assistants (PDA) for faculty to use for the e-
learning project
6) Worked with staff to integrate e-learning into skills labs, including equipping the skills labs with
computers, models, and MP3-based learning. Support integrating mobile and e-learning into competency-
based skills training for students when they use the skills lab.
7) Provided instructors and key faculty with an e-learning toolkit that includes various technology materials
that can be used for instructional design purposes. Such equipment can include software and hardware,
digital cameras, and digital video cameras.
8) Continued to upgrade and troubleshoot the HIV/AIDS LMS developed in FY07
9) Provided instructional design courses for key faculty at the universities
Based on lessons learned in FY07, Jhpeigo expanded the e-learning project in FY08 to two other major
health teaching universities as well as two ART hospitals (one urban and one rural) and assessed the use.
Jhpeigo also supported HIV/AIDS pre-service education strengthening by conducting needs assessments,
procuring minimal but essential IT equipment, installing the LMS, and training faculty on the use of LMS.
Jhpeigo also trained faculty in Instructional design and provided them with a toolkit. In addition to providing
an HIV/AIDS LMS for faculty to use as an additional HIV/AIDS teaching aid for students and allowing
interested service providers to access HIV/AIDS training in their workplace/hospital, there is also merit in
providing up-to-date HIV/AIDS evidence and the latest best practices to provide opportunities to continually
update knowledge in HIV/AIDS.
In FY07, Johns Hopkins University Center for Communications Programs (CCP) initiated a talk line for
HIV/AIDS service providers in Ethiopia. In FY08, Jhpeigo supported this talk line by using telephone and
mobile technology to provide up-to-date HIV/AIDS information, the latest international and national
HIV/AIDS events/news and conferences, as well as allowing for providers to request technical advice for
their specific HIV/AIDS work area. Jhpeigo also supported a touchtone answering system, in collaboration
with CCP and with support from appropriate Jhpeigo.
Table 3.3.17:
National Monitoring and Evaluation System Strengthening and Capacity-Building
This activity is a continued activity from FY08, Prime Partner University of Tulane (TUTAPE), under Activity
Number 5582, and Mechanism Number 487.
In FY08 PEPFAR/CDC through its partner provided comprehensive support to FMOH through technical and
logistic assistance in implementing the new M&E/HMIS and building M&E capacity through short-term
trainings, pre-service trainings, institutional capacity building for Jimma University, integrated supportive
supervision, and seconding of staff to MOH, HAPCO and other institutions.
•The partner linked HIVQUAL and the integrated supportive supervision (ISS) as part of the HMIS reform
and implemented the package in 100 ART networks.
•The partner has expanded the MOH costing tool into a Woreda planning tool which will be integrated in the
HMIS.
•As part of the government's initiative to deploy 8,000 new Health Information Technicians (HIT) by 2010,
Tulane University has been designated as the lead international development partner by Federal Ministry of
Health (FMOH) for the roll out the new Health Management Information system (HMIS). The partner
developed a HMIS pre-service training curriculum and renovated 11 technical educational and vocational
training schools (TEVTs) so that they can serve as multi-functional training institutions. The partner has
been tasked with the training of all 45,000 health and support personnel nationwide. The partner has plans
to contract 200 master mentors then train and deploy them to different health facilities for a period of 1-1½
years. The master mentors will undergo 3-4 weeks training before they are deployed to different facilities.
To date, the partner has trained 5,000 of the 45,000 staff and successfully completed pilot testing of the
new HMIS in Dire Dawa. Of the 200 planned mentors, 24 have been trained and deployed. A total of 500
Health Information Technicians of the 8,000 planned have been trained and Regional Health Offices have
signed a MoU with FMOH to employ them as civil servants, thereby ensuring sustainability.
•The partner will train 1000 HITs and 200 HMIS mentors and will roll out the electronic HMIS to 80 sites. as
planned.
•The partner continued support to Jimma University's master's program in M&E by providing teachers and
training, and supporting course coordinators, and administrative staff. Forty students were enrolled in FY08.
Jimma University also accepted four paying international students from Tanzania. The partner has designed
a training course for biostatisticians.
•The partner provided TA to EHNRI to complete field data collection for the 2007 health facility survey.
Analysis is currently under way.
In FY09 PEPFAR/CDC through its partner will:
1.Maintain support for the HMIS in the 100 ART networks through supervision, quality assurance, providing
training materials, and facilitating communication and collaboration with other partners working at the site
level
2.Support the training of an additional 1,000 HITs. PEPFAR partners will begin to migrate to the new HMIS
at the HIV/AIDS service delivery level and non-PEPFAR USG health funds will be leveraged to support the
HMIS at the primary health care level where there is less HIV/AIDS.
3.Plan, coordinate and provide technical assistance to the FMOH in developing guidelines for integrated
supportive supervision (ISS)
4.Continue seconding staff to EHNRI and higher learning institutions to build the capacity of these
institutions to utilize health data for decision-making.
5.Maintain support for Jimma University, with a focus on phasing out support and developing a mechanism
to transfer this initiative wholly to the university and linking it to the university's other programs. The partner
will facilitate the enrollment of 10 students in the new pre-service biostatistics course that it has developed
6.Collaborate with EPHA in implementing short term training programs and scientific writing workshops.
7.Continue support for the Woreda planning tool
8.Update the intervention mapping component of the National AIDS Spending Assessment (NASA) and
upload to the MOH intranet
9.Continue to support MOH/HAPCO in the production of HIV M&E/HMIS updates and reports and include
reports on TB/HIV and other HIV related areas
10.Conduct a process evaluation of the HMIS
11.Support EHNRI to become a center for evaluation
12.Provide TA to HAPCO for its community information system
13.Provide TA to MOH-PPD for the HMIS in-service training
COP08 NARRATIVE
Development of Ethiopia's National HIV/AIDS Monitoring and Evaluation (M&E) system is a sub-set of the
comprehensive Health Management Information System (HMIS) strategy and master plan being developed
by the Federal Ministry of Health (MOH). M&E is an increasingly important subject in present-day Ethiopia,
as it has made great strides in implementing the Third One—One National M&E System with the support of
Tulane University Technical Assistance Program Ethiopia (TUTAPE). To this end, Ethiopia has redesigned
its M&E/HMIS system, which includes all HIV/AIDS indicators.
In the past, Ethiopia suffered from a poorly functioning, manual data collection and reporting system that
lacked standardized indicators and formats. Reports were untimely and often incomplete. While efforts to
improve this are ongoing within the MOH, the need for technical assistance and support for the new HMIS
and M&E system is evident. PEPFAR Ethiopia recognizes this need and supports in its five-year plan the
goal of the Third One—One National M&E System.
The new national HMIS, which is currently in the piloting phase, standardizes, integrates data
collection/reporting, and harmonizes the information needs of all HMIS consumers. In FY07, TUTAPE's
technical assistance to MOH extended to successfully integrating the National HIV/AIDS M&E system into
the newly developed national HMIS, leading toward national harmonization and sustainability. TUTAPE
assisted MOH to identify core health indicators, including those for HIV/AIDS and TB/HIV, for HMIS
Activity Narrative: reporting and to improve capacity to collect patient information and use the information generated to
enhance decision-making at the local level. With MOH and partners, TUTAPE revised HIV/AIDS and related
disease-reporting formats. Support also included technical assistance to the national HIV/AIDS Prevention
and Control Office (HAPCO) to develop M&E training modules for the grassroots level. This will help
HAPCO to expand comprehensive HIV/AIDS patient monitoring services to the district health centers.
In FY07, based on the design of the MOH, TUTAPE is supporting the new HMIS by developing website and
intranet tools to access data collected from several sources: HIV/AIDS service delivery, finance, human
resources, and logistics, including information from other governmental organizations and the private
sectors. HMIS data will also be harmonized with health-related and multisectoral data collected by other
organizations, such as vital-events registration, census, survey, etc. The HMIS will also establish common
data definitions and understanding on how to interpret the information.
The new M&E/HMIS reforms are directed toward ensuring data quality to strengthen local action-oriented
performance monitoring. To that end, MOH is putting into place trainings to improve M&E/HMIS tools and
methodologies, including the use of information for data and service quality improvement and evidence-
informed decision-making. In FY07, TUTAPE developed the training modules and conducted training in a
cascaded manner for the national HMIS, including data-quality assurance for decision-making associated
with performance monitoring. TUTAPE assisted the MOH in the national rollout of HMIS to 35 ART
networks and will expand that rollout to 100 in FY08. This enhances the HIV/AIDS M&E by introducing and
reinforcing structure and methods for data quality and use and performance monitoring.
In FY07, TUTAPE also introduced HIVQUAL, a service-quality improvement system for MOH and the
HIV/AIDS Prevention and Control Office (HAPCO). At the request of MOH, TUTAPE supported the initial
exchange of experiences on HIVQUAL between Ethiopia, New York, and Thailand. HIVQUAL enables the
data generated by the HMIS to be used for improvement in data and service quality. In FY07, HIVQUAL
was implemented in 35 HIV networks; in FY08, it will expand to include 100 networks. TUTAPE provides
training-of-trainers on HIVQUAL.
The MOH recognizes the need to institutionalize M&E/HMIS responsibilities in the staffing structure at all
levels. In FY07, the MOH endorsed the training of new HMIS cadres. TUTAPE will continue to support
participants from local partners for the pre-service HMIS training program to build a sustainable M&E
system that will support the newly designed HMIS. The MOH plans to train more than 2,000 HMIS cadres in
FY08. TUTAPE will expand its HMIS pre-service training from 100 in FY07 to 500 new cadres by using
technical educational and vocational training schools (TEVT) around the country. TUTAPE will renovate the
institutions as state-of-the-art, multifunctional training institutions for HMIS and other allied health
professionals.
The MOH program links integrated supportive supervision (ISS) as part and parcel of the M&E/HMIS
reform. In FY07, to strengthen the new M&E/HMIS, TUTAPE provided technical support for ISS strategy
development. This activity will continue through FY08 for concurrent implementation of ISS with HMIS in
100 districts.
In FY07, TUTAPE supported HAPCO management to bring the information monitoring and evaluation to
department level. In FY07, TUTAPE's short- and long-term consultancies, fellows, and M&E specialists
were seconded to the HAPCO M&E department and quality team. In FY07 and FY08, TUTAPE will work to
improve organizational structures by seconding staff within the Ethiopian Health and Nutrition Research
Institute (EHNRI), local hospitals, and higher learning institutions.
TUTAPE continues to provide technical support for human capacity building for M&E at the national, sub-
national, and service-delivery levels. TUTAPE, in collaboration with Jimma University (JU), launched the
first postgraduate degree in health M&E and postgraduate diploma program in Africa. The first group of 31
students started in February 2006 and will graduate in FY07. Graduates will form the first Ethiopian M&E
network, a forum for sharing ideas and experiences, and mentor RHB, nongovernmental organizations
(NGO), faith-based organizations (FBO), and other local stakeholders. In January 2007, the second class of
38, including candidates from NGO and organizations for people living with HIV (PLWH) were enrolled. A
third cohort of 40 is expected to enroll in FY08. In FY08, institutional support to JU will continue, including
joint appointments of academics and technical assistance to create a sustainable integrated master's
program at JU. That technical assistance will support course coordinators, administrative staff, and other
aspects of the program. In addition, in FY08, JU will receive support to enroll paying international students
(including other PEPFAR countries) and host international short-courses in M&E.
In FY07 a summer institute for faculty for training and sharing experiences will be established. As JU has a
critical shortage of teaching staff, lecturers amongst the first M&E cohorts will be recruited as part of a staff-
retention mechanism. In FY08, this support will continue.
In FY08, a fellowship will be initiated for PLWH who will be trained in multi-sector HIV/AIDS program design,
implementation, and M&E. This will be linked to all activities at JU and All Africa Leprosy Rehabilitation and
Training Center (ALERT), with credit counted towards an advanced certificate/ degree. In addition, to
support the national HMIS and health systems, biostatisticians will be trained. These efforts will provide
didactic, as well as practical, experience for further career enhancement.
In FY07, short-term training programs (e.g., M&E for program improvement and use of data for decision-
making, program improvement and other related trainings) were provided to MOH/HAPCO, the Drug
Administration and Control Authority, EHNRI, RHB, the Christian Relief And Development Association, the
PLWH network, and the Central Statistical Agency to improve M&E knowledge and skills at national and
regional levels. Scientific writing workshops will be offered to larger audiences and will expand from 30
people in FY07 to include 100 in FY08. Participants will continue to be supported to publish their work in
peer-reviewed journals. In FY08 the short-term trainings, including M&E/HMIS, program, and HR
management and data use/quality, will be extended to cover regions.
Activity Narrative: In FY08, in order to reach a much larger audience of government, NGO/FBO, and community participants,
teaching materials from JU will continue to be converted into e-materials to support e-learning.
TUTAPE will conduct process evaluations of the HMIS reform, the data-quality system, the HIV/AIDS
committee at health facility, and other program evaluations as it becomes necessary in the course of
program implementation. TUTAPE continues to provide technical assistance to EHNRI for heath facility
survey, national -level surveys and health-impact evaluations.
HAPCO conducted the first round National AIDS Spending Assessment (NASA) in FY07 and TUTAPE
supported the intervention mapping component. In FY08 the intervention mapping would be updated for the
MOH/HAPCO and uploaded on to the MOH intranet TUTAPE is establishing in FY07.
In FY08, support will be provided to the Federal Ministry of Health, Program and Planning Department
(MOH/PPD), and HAPCO in costing programs, for use in program planning as well as in development of
funding proposals. Support will also be provided to finalize the inputs needed for the costing tool developed
in FY07.
TUTAPE, in FY06 and 07, provided technical assistance to MOH/HAPCO in producing the first and second
Annual HIV/AIDS M&E Reports. In FY08, technical and financial assistance will be given to MOH/HAPCO to
produce monthly, quarterly and annual M&E/HMIS updates and reports.
Continuing Activity: 16563
16563 5582.08 HHS/Centers for Tulane University 7470 487.08 University $5,265,000
10371 5582.07 HHS/Centers for Tulane University 5463 487.07 $4,175,000
5582 5582.06 HHS/Centers for Tulane University 3754 487.06 $1,000,000
Local Institutional Capacity Building for Evidence-based Informed Decision and Dissemination of Scientific
Information
THIS IS A NEW ACTIVITY
PEPFAR Programs are guided by Public Health Evaluation (PHE), Basic Program Evaluation (BPE),
surveillance and other survey studies. These studies conducted by the different implementing agencies and
partners, focus across different PEPFAR programs areas, assess the impact of the programs or the trend of
the problem among individuals and communities infected and affected by HIV.
In order to successfully interpret and conduct evidence-based HIV/AIDS projects, public health workers,
program managers and policymakers must understand basic research/ study methods related to
surveillance, program monitoring, targeted evaluations, and similar efforts.
CDC Ethiopia has been supporting local institutional capacity through scientific writing skill and oral
communication trainings for the last five years. In FY08, 20 public health professionals from different CDC
partner institutions are being trained on Ethical issue in studies involving Human subjects, and scientific
writing skills.
Among the many CDC Ethiopia local Institutional partners only three of them have established Institutional
Review Board (IRB) having Federal Wide Assurance (FWA); thus only the three local partners could review
protocols from their own the remaining partners have difficulty to get their protocols cleared with out delay.
Therefore, CDC will be supporting the establishment of seven Local IRB with FWA in the Seven Ethiopian
In FY09, CDC will provide training for 40 Public health professionals from Implementing agency and
partners in research methodology, successful scientific writing skill and effective oral communication
including dissemination of scientific studies and ethical issue in Human subject researches.
The development and publication of 200 copies of research methodology and ethical guideline with in CDC
handbooks will be covered.
Strengthening Pre-Service Training for Medical Doctors
This is a new activity in response to the critical need and one of the highest priorities of the Ethiopian
Federal Ministry of Health (FMOH) to scale up the training of medical doctors. Due to the low production of
physicians and a high attrition rate both internally and externally, Ethiopia is one of the sub-Saharan
countries that is severely affected from the shortage of medical doctors.
Problem statement
Recent assessments suggest that the shortage of medical doctors and other health professionals, poor
performance, inequitable distribution of the available health workforce among regions and health facilities
are root causes for poor service delivery of health care.
Ethiopia is committed to the global initiative of Universal Access to HIV/AIDS by 2010 and the reach the
Millennium Development Goals (MDG) by 2015. To meet these targets, the Ethiopian FMOH is currently
implementing a massive ART scale up of which the most prominent challenge is the human resource
shortage
The physician-to-population ratio has worsened over the last two decades due to an increase in the annual
attrition rate of medical doctors, fast population growth, governmental and nongovernmental health
institution expansion, and low production of doctors.
The densities of health workers in particular medical doctors per population remain among the lowest in the
world, and are by far inadequate to reach the goals of Ethiopia's Health Sector Strategic Plan. With 0.3
physicians (and 2.05 nurses) per 10,000 population, Ethiopia ranks in the lowest HRH (Human Resources
for Health) density quintile of African nations and far below the World Health Organization estimate of 2.1
minimum workforce required per 10,000 population.
The Ethiopian FMOH, the Ministry of Education and medical schools have limited technical capacity to
coordinate, supervise and evaluate basic health training programs resulting in poor quality of training for
medical doctors. Furthermore, medical education curricula are not aligned with current and future health
system needs and health policy. There is a lack of standardized accreditation and national examination for
licensing. This is compounded by poor planning, coordination and quality of in-service training programs
(mostly donor driven training activities).
The FMOH intends to scale up preservice training of doctors is in over 20 medical schools and transition
from a six-year to a four-year curriculum. PEPFAR implementing partners who will be working with medical
schools in the scale up will be challenged if they fail to effectively coordinate their activities.
The FMOH recognizes that with the existing levels of outputs of medical doctors and other medical
professionals it will have difficulties reaching its MDGs by 2020.
Recognizing the shortcoming of the system the FMOH has embarked on a Civil Service reform to overhaul
the health system. This is pursued along seven interrelated core themes: access and quality, financial
utilization, health management information system, logistics, emergency response and human resources for
health (HRH).
While the FMOH recognizes the rapid need of medical specialties, it stated that the existing level of output
for health extension workers, health officers, nurses, pharmacists and paramedics is sufficient and thus no
major scale up is required.
In summary, high annual attrition rate of medical doctors, fast population growth, rapid expansion of
governmental and nongovernmental health institutions, and low production of MDs have contributed to an
extremely low physician-to-population ratio in Ethiopia. Retention as a strategy and scale up of the
production of medical doctors' as a program are seen as viable long term solutions by the Government of
Ethiopia. The goal, as stated in the HRH strategy, is to achieve physician-to-population ratios of 1:10,000
and 1:5,000 by the year 2015 and 2020, respectively, thus meeting WHO's recommended ratio of 1:10,000.
What does the FMOH intend to do?
The FMOH recognizes that with the existing levels of outputs from medical schools of medical doctors,
surgical specialists, anesthesia professionals, midwives, dentists and mental health professionals it will
have difficulties reaching the MDGs by 2020.
The FMOH intends to scale up the number of medical doctors from the current 1,806 to 9,000 doctors in
public service thru a number of ambitious interventions. These are as follows:
1. To expand medical training by increasing the number of medical schools to twenty-one. Up to five
teaching facilities such as hospitals or other medical teaching centers will be attached to each new medical
school. Each of these teaching facilities will have an annual intake of 100 students. Thus, each new
medical school is expected to have an annual intake of up to 500 new students.
2. To introduce a 4 year medical training program (for BSc holders) in addition to the existing six year
program without compromising quality.
3. To identify hospitals with adequate patient flow to be upgraded as teaching centers.
Activity Narrative: 4. Utilize appropriate Information Communication and Technology (ICT) to enhance the quality and
efficiency of medical education.
Why is PEPFAR Ethiopia assisting the FMOH?
The MOH has repeatedly requested, both informally and formally, PEPFAR Ethiopia's assistance to scale
up the training of medical doctors. The scale up of medical doctor training is an important part of the FMOH
strategy to meet the MDGs. PEPFAR II, as part of the US/UK Partnership to strengthen human resources in
health, intends to invest over 1.2 billion USD over a period of 5 years. Ethiopia is one out of four countries
besides Kenya, Mozambique, and Zambia as part of this PEPFAR and USG-funded initiative. PEPFAR has
been involved since FY07 in assisting the Ethiopian FMOH to address HRH issues, in particular supporting
the FMOH to develop the HRD strategy and the implementation plan up to 2020. Tulane University has
been a central partner with the FMOH on development of the HRH plan and distance learning methods.
Tulane University has also provided an experienced technical advisor to the FMOH to coordinate the
implementation of the four-year medical school curriculum and approach.
Objective #1:
To strengthen the institutional capacity of Ethiopian public and private medical education institutions to
deliver comprehensive quality and broad pre-service medical education whilst specifically integrating HIV,
TB and Malaria modules originating from national and international guidelines into the national syllabi and
curricular materials.
Objective #2:
To increase the capacity of medical students to provide comprehensive, secondary and tertiary level clinical
services with particular emphasis on HIV/AIDS, reproductive health, TB and Malaria co-infection
management through knowledge and skills gained from didactic and practical attachments.
Objective #3:
To strengthen educational planning, coordination and management roles of the FMOH, Federal Ministry of
Education- Higher Education Department, Higher Education Relevance and Quality Agency (HERQA),
Universities, National Medical Curriculum Review Panel etc. in the process of curriculum
development/review, subject benchmarks development, school management, student assessment,
licensure and accreditation activities.
Objective #4:
To expose faculty at Ethiopian public and private medical education institutions to different models of
delivery of medical doctors' training.
Objective #5:
To assist and support the FMOH to meet its HRH requirements for medical doctors as articulated in the
HRH strategy and the HRH implementation plan and the new FMOH BPR documents.
FY09 major activities to meet these objectives are:
The following US-based universities (implementing partners) are currently working on PEPFAR-funded
projects in most regions of Ethiopia where medical schools already are or will be located:
1.I-TECH (International Training & Education Center on HIV, University of Washington)
2.ICAP (Information Center for AIDS Care and Treatment Programs, Mailman School of Public Health at
Columbia University)
3.JHPIEGO
4.John Hopkins University (JHU)
5.University of California -San Diego
6.Tulane University (TUTAPE)
These implementing partners will:
A:- On regional level in collaboration with medical schools:
•Conduct needs assessment of Ethiopian public and private medical education institutions for implementing
the accelerated medical doctors training program.
•Provide technical, material and financial support to the FMOH, MOE, HERQA, and Universities in teaching
materials development, review, publication and distribution activities as well as in supply of essential
teaching/training materials for medical education, in licensure and accreditation procedures.
•Provide limited support where feasible to infrastructure development based on needs assessment.
•Monitor and evaluate the progress in the implementation of the medical doctors' education/training
programs.
•Assist in the development, adaptation and review of curricular/training materials and modules for pre-
service education.
•Provide technical, material and financial support to the training of medical doctors.
•Assist faculty and program managers in teaching and research, coordination, communication and
networking for medical education in the existing and new public/private universities providing medical
Activity Narrative: education in Ethiopia.
•Assist Ethiopian medical education institutions in the development and effective application of different
models of education and training, including community-based team training and information technology for
distance learning-assisted approaches, standards-based education management and recognition, student
assessment and evaluation procedures, faculty development, establishment and/or reinforcement of
academic development centers in the universities/faculties.
•Will coordinate their activities with all PEPFAR implementing partners on regional and central levels
including FMOH and HAPCO.
B:- On central level a lead partner in collaboration with the FMOH and FHAPCO will:
•Provide technical assistance to the FMOH and FMOE in various aspects of human resources development
including experts in health policy, law, costing, workforce forecasting, management and medical education.
•Coordinate other PEPFAR partners working on training for medical doctors with Ethiopian medical schools.
•Support development of ICT infrastructure for facilities and training centers where feasible.
Other activities are:
•Support activities will include the institutionalization of the estimation of detailed densities of health
workforce to the woreda level.
•Support the activities of the FMOH in education, training and skill development of health professionals
including curriculum review and development and development and dissemination of manuals and
guidelines (CME/CPD, registration and licensing and other legal documents).
•Analyze policy, legal and financial frameworks necessary to implement the HRH strategy and conduct an
assessment of the feasibility of different possible reform options and assess the sequencing of investment
options in HRH and develop monitoring and evaluation activities needed to support the above areas.
•Develop human resource management capacity of the FMOH by seconding experts, training as well as
develop the necessary tools including software and other applications.
•Support the FMOH to deploy the designed Human Resource Information System (HRIS) at the FMOH and
other federal agencies including FHAPCO, EHNRI, DACA etc. Support will include training; ICT
infrastructure linked to other funded activities for maximum leverage and may include secondment of short
term and long term technical experts were feasible.
•Assist updating the HRH data base.
Table 3.3.18:
Training Information Management System
This was an activity previously conducted by JHPIEGO under activity number 5735 and Mechanism
Number 5483
COP 08 ACTIVITY NARRATIVE
This is a continuation of activity from FY08. PEPFAR Ethiopia has actively supported the collection and
synthesis of PEPFAR-funded training information in order to make program management decisions. During
FY05, PEPFAR Ethiopia established the Training Information Monitoring System (TIMS), with the goal of
collecting information from all PEPFAR-supported trainings. TIMS reporting forms collect pertinent training
information from PEPFAR Ethiopia partners. All in-country and international training partners supported
under PEPFAR Ethiopia provide training information for analysis. New guidance on the definition of training
was agreed upon and implemented in FY07. JHPIEGO provides data entry for all PEPFAR TIMS forms
submitted to JHPIEGO through USAID and CDC. As of September 2008, 39 PEPFAR-supported
organizations have shared data on 2276 training events and 69,074 trainees.
Beginning with FY07 resources and continuing into FY08, JHPIEGO is working on a redesigning of TIMS to
expand its functionality, including a web data-entry application and improved ability to manage large
amounts of data. In FY08, JHPIEGO transferred existing data into the new version as well as continue TIMS
database management activities, such as data entry, analysis, cleaning, and reporting. JHPIEGO will also
conduct one workshop to orient new PEPFAR partners to the new TIMS program features and reporting,
and prepare for a FY09 transition when partners will begin to enter their own data. The new version will also
be designed to link into existing Human Resources Information System (HRIS) depending on progress in
this area.
Training information is shared monthly with the Federal Ministry of Health (MOH) and quarterly with the
regional health bureaus (RHB) to inform their planning activities. These regular monthly general training
reports are shared with partners via the ARC website. This method was chosen for ease of download for all
partners, as well as accessibility for people who are browsing that website. The TIMS program is also
working with partners to respond to requests for individual training reports.
In FY08, JHPIEGO will expand reporting capabilities further to include: people who attend multiple training
events, compared to specializations; trends in HIV/AIDS training offered from quarter to quarter; user-
friendly electronic training reports for partners to manipulate their own training data; and other reports to be
identified during stakeholder meetings.
In order to ensure the quality and accuracy of data entered into TIMS, JHPIEGO regularly invites all
partners to go through their reports in detail to ensure data quality and completeness. In addition, weekly
data receipt reports are shared with partners to confirm receipt of TIMS forms for data entry. This activity
will continue in FY09.
To expand the usefulness of the TIMS program and data that is found in the database, JHPIEGO, CDC,
and USAID prepared a pilot project to collect post-training follow-up information on trained providers.
PEPFAR implementing partners agree there is anecdotal evidence of large attrition rates of HIV/AIDS-
trained providers, causing serious service interruptions at the site level. This pilot project was designed to
provide quantitative data about the actual working status of trained individuals in order for PEPFAR
implementing partners to plan effectively for training and service coverage. The pilot project was a great
success with eight selected partners who collected key HIV/AIDS working status information on trained
providers from 98 PEPFAR-supported hospitals and health centers. All participating partners of the project
agreed that this type of data collection was very important for monitoring HIV/AIDS services and agreed to
conduct it in the future. Half of the partners suggested the data be collected semi-annually. The findings of
the pilot project were prepared and disseminated to all PEPFAR partners, MOH, and the HIV/AIDS
Prevention and Control Office (HAPCO), and RHB via implementing partners and other key HRH
stakeholders. Based on the findings of the pilot project, key follow-up data collection forms were
programmed into the TIMS database for regular use. In FY08, this type of data collection will be expanded
beyond the eight pilot partners to all PEPFAR service delivery partners submitting training forms for TIMS.
The data will be collected and analyzed on a semi-annual basis, and reports on working status and attrition
trends of HIV/AIDS-trained service providers will be reported to all PEPFAR partners and interested
stakeholders. Geographic information System (GIS) maps of working rates will also be prepared and
included in routine reports to partners. Other analysis of this type of training data will be identified.
In FY07, JHPIEGO was tasked with working with MOH and two regions to install TIMS for their use. While
the results of this pilot is not yet clear, the Ethiopian Health and Nutrition Institute (EHNRI) has expressed
interest in installing TIMS in order to track all staff training, including that not funded under PEPFAR.
JHPIEGO and CDC decided the best way to demonstrate to government counterparts the usefulness of
TIMS was to start supporting EHNRI to maintain a TIMS database, document the implementation, and use
lessons learned to assess the feasibility and interest of other regions or government offices to implement
TIMS. However, given the slow pace and lack of availability of EHNRI staff, the plan is to wait for the re-
designed TIMS before proceeding further. JHPIEGO will continue to support existing partners and host
government institutions including RHB and regional HAPCOs to develop their own TIMS.
Discussions have been held with FHAPCO at their request where the Monitoring and Evaluation unit has
expressed the desire for the data management of TIMS to be co-located at FHAPCO. As part of the
implementation of the re-designed TIMS, JHPIEGO will explore collocation of its TIMS team with FHAPCO
and gradually building capacity for FHAPCO to both use the TIMS data for decision-making and perhaps
take over oversight of TIMS. In a web-designed format where implementing partner enter their own reports,
the data entry component of the program would be reduced, but the oversight, monitoring and technical
capacity needed to continually improve the software side of the system will grow. In this regard, discussions
with FHAPCO will continue to strengthen the system.
Activity Narrative: In addition, certain professional associations are actively providing continuing education to their members. A
consortium of professional associations has even been formed to address HIV/AIDS issues. JHPIEGO will
first involve these associations in providing input to the new version of TIMS, and then explore the feasibility
of their using TIMS to track their membership and continuing education efforts, with a view to potentially
using TIMS in the future for re-licensing of health professionals.
As in previous years, JHPIEGO will also organize periodic meetings with key PEPFAR stakeholders to
discuss TIMS and present trends and comparisons of service providers trained on HIV/AIDS and follow-up
information. JHPIEGO will support travel to conferences and/or other PEPFAR countries to present the
successes of the Ethiopia TIMS program If need arises. In FY08, at the initiative of FHAPCO, JHPIEGO
has been one of the partners supporting the development of a National Training Implementation and
Coordination Guidelines. In FY09, JHPIEGO will continue to support the process not only through its
finalization, but monitor its implementation.
The partners targeted for training include international organizations, local PEPFAR-supported
organizations, professional associations, and government agencies.
Strengthening Pre-Service Training for Medical Doctors This is a new activity in response to the critical
need and one of the highest priorities of the Ethiopian Federal Ministry of Health (FMOH) to scale up the
training of medical doctors. Problem statement Recent assessments suggest that the shortage of medical
doctors and other health professionals, poor performance, inequitable distribution of the available health
workforce among regions and health facilities are root causes for poor service delivery of health care. The
FMOH recognizes that with the existing levels of outputs from medical schools of medical doctors, surgical
specialists, anesthesia professionals, midwives, dentists and mental health professionals it will have
difficulties reaching the MDGs by 2020. While the FMOH recognizes the rapid need of medical specialties,
it stated that the existing level of output for health extension workers, health officers, nurses, pharmacists
and paramedics is sufficient and thus no major scale up is required.
public service thru a number of ambitious interventions. These are as follows: 1. To expand medical
training by increasing the number of medical schools from currently seven to twenty-one. Up to five teaching
facilities such as hospitals or other medical teaching centers will be attached to each new medical school.
Each of these teaching facilities will have an annual intake of 100 students. Thus, each new medical school
is expected to have an annual intake of up to 500 new students. 2. To introduce a 4 year medical training
program (for BSc holders) in addition to the existing six year program without compromising quality. 3. To
identify hospitals with adequate patient flow to be upgraded as teaching centers. 4. Utilize appropriate
Information Communication and Technology (ICT) to enhance the quality and efficiency of medical
education.
The FMOH has repeatedly requested PEPFAR Ethiopia, both informally and formally, to assist, thru US-
based universities, to scale up the training of medical doctors.
The scale up of medical doctor training is an important part of the FMOH strategy to meet the MDGs.
PEPFAR II, as part of the US/UK Partnership to strengthen human resources in health, intends to invest
over 1.2 billion USD over a period of 5 years. Ethiopia is one out of four countries besides Kenya,
Mozambique, and Zambia as part of this PEPFAR and USG-funded initiative. PEPFAR has been involved
since FY07 in assisting the Ethiopian FMOH to address HRH issues, in particular supporting the FMOH to
develop the HRD strategy and the implementation plan up to 2020. Tulane University has been a central
partner with the FMOH on development of the HRH plan and distance learning methods. Tulane University
has also provided an experienced technical advisor to the FMOH to coordinate the implementation of the
four-year medical school curriculum and approach. Objective #1: To strengthen the institutional capacity
of Ethiopian public and private medical education institutions to deliver comprehensive quality and broad
pre-service medical education whilst specifically integrating HIV, TB and Malaria modules originating from
national and international guidelines into the national syllabi and curricular materials. Objective #2: To
increase the capacity of medical students to provide comprehensive, secondary and tertiary level clinical
management through knowledge and skills gained from didactic and practical attachments. Objective #3:
licensure and accreditation activities. Objective #4: To expose faculty at Ethiopian public and private
medical education institutions to different models of delivery of medical doctors' training. Objective #5: To
assist and support the FMOH to meet its HRH requirements for medical doctors as articulated in the HRH
strategy and the HRH implementation plan and the new FMOH BPR documents. FY09 major activities for
Tulane University to meet these objectives are:
Tulane University is a major US-based university partner for PEPFAR-Ethiopia.
Thus, in FY09, major activities for Tulane University are to: Provide technical assistance at the national
level to the FMOH and FMOE in various aspects of human resources development including experts in
health policy, education, costing, workforce forecasting, management and retention.
• From the national level, coordinate with other PEPFAR partners and other donors working on training for
medical doctors with Ethiopian medical schools.
• Monitor and evaluate the progress in the national implementation of the medical doctors'
education/training programs.
• Support development of ICT infrastructure for facilities and training centers where feasible.
• Coordinate all activities with all PEPFAR implementing partners on regional and central levels including
FMOH and HAPCO thru established mechanisms.
• Other activities for Tulane:
• Support activities will include the institutionalization of the estimation of detailed densities of health
• Support the activities of the FMOH in education, training and skill development of health professionals
including national curriculum review and development and development and dissemination of manuals and
• Analyze policy, legal and financial frameworks necessary to implement the HRH strategy and conduct an
• Develop human resource management capacity of the FMOH by seconding experts, training as well as
• Support the FMOH to deploy the designed Human Resource Information System (HRIS) at the FMOH and
• Assist in the development, adaptation and review of curricular/training materials and modules for pre-
service education, especially as is related to medical education.
• Assist updating the HRH data base.
