Strengthening HIV Infrastructure to Increase Service Delivery Access and Quality

ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS:

This is a continuing activity from COP08. Funding is reduced from COP08 levels based on the likelihood

that Ministry of Health (MOH) efforts to utilize the COP08 funding will be substantially delayed, as the

Project Management Unit (PMU) overseeing these activities has been established only recently, and

systems for implementing the construction activities are not yet fully in place.

An initial pilot phase while MOH systems are in the development phase is envisioned, with a relatively small

number of facilities being converted or constructed, followed by a larger second phase once the pilot is

completed.

A recent engineering assessment from USAID/Washington's Infrastructure and Engineering (I&E) Team

reviewing MOH capacity to plan, implement and monitor this activity indicated that most sites will involve

essentially new construction, since many of the existing health stations are not suitable for conversion to

new structures.

The assessment also indicated the requirement that maintenance systems to be in place to ensure that

newly converted or constructed health centers will remain as fully functional health care delivery points.

The importance of this requirement is highlighted in Ethiopia, where the COP08 PEPFAR health center

renovation implementing partner found that 68 of 100 existing health centers had non-functional running

water systems, thus affecting their ability to provide safe, quality services. These problems were largely

caused by lack of routine maintenance. As a result of these findings, this activity will include a clear focus

on consistent availability of water supplies at facilities converted or constructed, as well as routine

maintenance of all systems, to ensure that services are maximally effective.

A second USAID/I&E assessment of energy availability and quality for health facilities, in April 2008,

revealed the absence of maintenance and quality standards in wiring and other electrical installations as a

major constraint at existing facilities. The importance of quality in this area, particularly for delicate

laboratory equipment, is not only critical for maintaining the ability of this and other equipment to support

facility services, but also potentially impacts patient and staff safety, and can result in destruction of facilities

when fires occur.

Unit cost estimates for Nucleus B Health Centers have increased to $188,000, for construction only not

including cement and structural steel, which will be provided through a quota provided for this purpose by

the Ministry of Works and Urban Development. The unit costs range higher for less accessible sites. This

unit cost estimate is increased from the $138,000 unit cost estimate under COP08, supplemented by

approximately $40,000 to equip the facilities.

At this unit cost, and assuming no additional price hikes for needed inputs, approximately 21 sites can be

constructed or converted using COP09 funding. This is in addition to the up to 70 sites supported under

COP08 (reduced from the 95 estimated in COP08 as a result of the 36% cost hike this year. Based on this

experience, it is important to note that additional major price changes for needed inputs could affect the final

number of facilities constructed or converted.

Renovation/construction efforts will include development of functional water supply for facilities, critical

given the importance of abundant, clean water in providing safe, high quality care.

PEPFAR's new COP09 Construction Technical Assistance activity will support the MOH/PPD's PMU in

establishing the systems needed to effectively and rapidly utilize these funds, and as favorable results are

achieved, other PEPFAR resources for construction/renovation may be channeled directly to the MOH and

RHBs.

The new PEPFAR Construction Inspection/Oversight activity will work closely with the MOH, assisting in the

initial specifications for facilities, inspecting sites as they are completed, and working closely with the

Construction TA activity to ensure that any issues revealed during inspections are addressed effectively by

MOH and RHB engineers, leading to continuous quality improvement.

As confirmed in discussions with the Office of the Global AIDS Coordinator during the COP08 approval

process, selected sites will be in high HIV prevalence areas along the high risk corridors. This is in support

of PEPFAR's focus on urban and periurban areas with high HIV prevalence, as well as rural "hotspots", and

is critical given the limited resources available to support construction/renovation, coupled with the highly

dispersed rural population and the low HIV prevalence in those areas. This strategy will allow PEPFAR

efforts to maximally support efforts to address HIV in Ethiopia.

COP08 Narrative

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

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

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

.

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

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

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

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

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

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

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

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

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

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

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

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

Financing".

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

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

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

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

to support this critical function.

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

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

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

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

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

serious human resource crisis facing Ethiopia.

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

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

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

personnel turnover and shortages.

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

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

services for the Ethiopian population.

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

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

New/Continuing Activity: Continuing Activity

Continuing Activity: 17715

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

17715 17715.08 U.S. Agency for To Be Determined 7603 7603.08

International

Development

Emphasis Areas

Human Capacity Development

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Estimated amount of funding that is planned for Water $500,000

Table 3.3.09: