Detailed Mechanism Funding and Narrative

Years of mechanism: 2008 2009

Details for Mechanism ID: 7609
Country/Region: Ethiopia
Year: 2009
Main Partner: Management Sciences for Health
Main Partner Program: NA
Organizational Type: NGO
Funding Agency: USAID
Total Funding: $18,794,400

Funding for Biomedical Prevention: Prevention of Mother to Child Transmission (MTCT): $1,500,000

Support for Integrated ANC/PMTCT Services

ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS:

This is a continuing activity from COP 08. The activities and narrative remain similar for COP09 with the

exception of targets. Health center service outlets will be increased to 550. There will be a greater

emphasis on community-based PMTCT services and integration with ANC/ PMTCT services. This activity is

linked with the overall PMTCT activities at hospitals, health centers, and at the community level, as well as

with pediatric care and treatment services at facility levels. This activity is also linked with OVC, food and

nutrition support services and maternal and child health wrap-around programs. Emphasis will be given to

scaling-up PMTCT services at both the facility and community levels using mother support groups (MSG's)

and integration of PMTCT services with ANC and Family Planning.

COP08 ACTIVITY NARRATIVE

The Care and Support Program (CSP) is a three-year effort to focus on HIV/AIDS at health centers and

communities in partnership with PEPFAR Ethiopia partners and the Government of Ethiopia (GOE). CSP is

PEPFAR's lead health network care-and-support activity in Ethiopia at the primary healthcare-unit level and

at health centers and satellite health posts. CSP provides coverage nationwide. This program will support

the GOE to provide HIV/AIDS prevention, care, and treatment services at health centers and at the

community and household levels through technical assistance, training in strengthening of systems and

services, and expansion of best practice HIV prevention interventions. The lead partner is Management

Sciences for Health (MSH).

This is a continuing activity begun in FY06 and previously conducted by IntraHealth International.

IntraHealth has coordinated the introduction of PMTCT services in over 250 health centers and trained a

substantial number of health professionals. While IntraHealth will continue to introduce and integrate

PMTCT into antenatal care (ANC) services in new sites in 2008, MSH/CSP will systematically transfer the

responsibility for maintaining quality PMTCT services at their current sites to the CSP. The GOE and

PEPFAR remain committed to implementing HIV prevention, care, and treatment services that include

moving PMTCT services into an integrated comprehensive HIV/AIDS treatment and care program. Without

adequate investment in operational readiness, however, the quality of PMTCT services will be

compromised. This activity addresses PMTCT services at health centers by increasing their operational

capacity including integration into ART services and the health network. MSH/CSP will support PMTCT

services in 240 sites under FY07 and 150 additional sites in FY08 with the activities below.

1) Supportive Supervision, Mentoring, and Training of Health Workers: Human resources will be

strengthened through training in multiple program areas and supportive supervision in conjunction with GOE

personnel. The activity will facilitate training on PMTCT using current PMTCT Guidelines that include

multiple drug therapy. Updates and refresher training will be carried out for health workers previously

trained on the single drug therapy regimen using Nevirapine and on PMTCT/ART integration. In close

collaboration with regional health bureaus (RHB) and district health offices, standard operating procedures

(SOP) and care protocols will be implemented with other relevant stakeholders and partners. To strengthen

the provision of PMTCT services in the ART health networks, mentoring of health workers and monitoring of

PMTCT clients with experienced hospital and private-sector clinicians will be organized. This will help build

provider capacity to manage clients and improve client care. The mentoring activity will be jointly carried out

by the ART mentors, who will be trained to mentor health workers providing the comprehensive continuum

of HIV/AIDS care and treatment.

2) Strengthening the Referral System and Community Outreach: This component will be linked with multiple

services in health centers and health posts to support the integration of PMTCT, ANC, TB, reproductive

health (RH), and ART services. The existing community outreach activities begun under IntraHealth will be

supplemented with new CSP outreach activities, including the introduction of community-oriented outreach

workers (COOW). MSH/CSP will identify, train, deploy, and support 6,350 COOW over the next three years.

The COOW will ultimately work with health extension workers (HEW), community groups, local leaders, and

government health institutions to strengthen support to communities and households impacted by

HIV/AIDS. CSP will support the training and capacity-building of the COOW in: basic HIV and symptom

management for adults and children (e.g., integrated management of adult and adolescent illness(IMAI) and

integrated management of childhood illness(IMCI)); appropriate and timely referrals to health centers for

ART therapy for clinically eligible pregnant women; and pediatrics HIV case detection and referral. The

program will reinforce provider-initiated counseling and testing (PICT) on an opt-out basis for ANC clients;

cotrimoxazole prophylaxis for HIV-exposed infants; and systematic tracking, follow-up and support of

mother-infant pairs emphasizing clear links with well-child services and the existing and expanded network

of community services coordinated through the health posts and COOW.

HIV-exposed infants will be traced through mothers who access PMTCT and identification of infants at

routine immunizations and community-based health and nutrition services (e.g., growth monitoring). The

COOW will provide oversight for the Mothers' Support Groups (MSG). MSG provide educational, emotional,

and psychosocial support to women living with HIV and their families during and after pregnancy. In addition

to empowering the women, the MSG provide links to other services. The COOW will also focus their

activities on families affected by HIV/AIDS and ensure increased partner involvement in HIV/AIDS treatment

care and support activities.

By the end of COP08, CSP will be supporting an integrated package of HIV/AIDS services including

PMTCT in 390 health facilities and the communities around them. The program will support all links in the

PMTCT/ART and care-network continuum, from client and household to community and health center, with

a focus on the delivery of PMTCT/ART services at the health center and community level.

New/Continuing Activity: Continuing Activity

Continuing Activity: 18562

Continued Associated Activity Information

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

System ID System ID

18562 18562.08 U.S. Agency for Management 7609 7609.08 Care and $500,000

International Sciences for Support Project

Development Health

Emphasis Areas

Gender

* Increasing gender equity in HIV/AIDS programs

* Increasing women's access to income and productive resources

Health-related Wraparound Programs

* Child Survival Activities

* Family Planning

* Malaria (PMI)

* Safe Motherhood

* TB

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:

Funding for Sexual Prevention: Abstinence/Be Faithful (HVAB): $164,000

The Care and Support Program (CSP)

ACTIVITY UNCHANGED FROM FY2008

This activity will continue in COP09 as is described below without budget and target changes.

The Care and Support Program (CSP) is a three year effort to focus on HIV/AIDS at health centers and

communities in partnership with PEPFAR Ethiopia partners and the Government of Ethiopia (GoE). CSP is

PEPFAR's lead health network care and support activity in Ethiopia at Primary Health Care Unit, health

center and satellite health stations, and provides coverage nationwide. This project will support the GoE to

provide HIV/AIDS prevention, care and treatment services at health centers and at the community and

household levels through provision of technical assistance, training in strengthening of systems and

services, and expansion of best practice HIV prevention interventions.

Given the low urbanization rates, a significant proportion of HIV/AIDS cases remain in rural areas. Antenatal

care (ANC) surveillance in many peri-urban health centers indicates a high HIV/AIDS case burden where

limited services are available. Furthermore, Demographic and Health Survey (DHS) reveals limited reach of

mass media including radios. In response, this activity prioritizes the deployment of case managers and

outreach volunteers to the peri-urban fringe and rural areas in/around ART health networks to conduct face-

to-face community outreach, and supports Government of Ethiopia (GoE) efforts to deploy health extension

workers (HEW) to these areas. The activity has several components.

1) The first component utilizes non-medical case managers in health centers to support consistent HIV

prevention abstinence, be faithful and consistent and correct condom use (ABC) communications with

people living with HIV/AIDS or most at risk groups appearing. These brief counseling periods, anticipated

after a closer relationship is formed with case managers, represents efforts to integrate and mainstream

brief motivational interventions alongside clinical integrated management of adult illness (IMAI) training

among the clinical care team.

2) The second component of this activity includes providing technical assistance to zonal and district health

offices to support the HIV prevention activities of HEW. Technical assistance will encompass engagement

by Management Sciences for Health (MSH) and its partners to ensure adequate in-service training support

to ensure referrals of most at risk populations and counseling in the community and at a health post level of

the ART health network. This new cadre of health worker is placed at the community level to serve several

villages in peri-urban fringe and rural areas. In total, 30,000 HEW will be deployed by 2010. The HEW is the

first point of contact at the community level for the formal health care system. The HEW reports to public

health officers at the health center and is responsible for a full range of primary and preventive services at

the community level. They function as a significant and new link in the referral system and will be able to,

through community counseling and mobilization, move vulnerable and underserved populations into the

formal health system. During FY08 HEW will function as the lead position at the health post and the

community level to provide social mobilization activities in HIV prevention.

3) The third component of this activity includes, in partnership with local authorities, identifying, training and

deploying outreach volunteers to support and facilitate the role of community outreach by HEW. Through

this activity, outreach volunteers will provide technical support to the Regional HIV/AIDS Prevention and

Control (HAPCO) activities in communities through community conversations and outreach counseling at

the household level. In addition, outreach volunteers will support case managers in tracking and counseling

those who drop from appointments for clinical care. Outreach volunteers, as local individuals, will use

culturally appropriate approaches in discussing HIV/AIDS, primary ABC and secondary prevention. This will

include identifying misconceptions, stigma reduction, highlighting the gender and HIV burden for young

women in Ethiopia and negative social and cultural norms.

This activity will strongly support regional government prevention efforts through social mobilization. The

HIV Care and Support Project's coverage is anchored in predominantly peri-urban settings reaching out

from health centers to health posts through outreach volunteers in coordination with HEW and other

community agents for social mobilization activities. Case managers will refer HIV-positive clients to

voluntary counseling and testing (VCT) and lay counselors for prevention for positive counseling. Outreach

volunteers, in coordination with HEW, will be responsive to local needs, distinctive social and cultural

patterns. They will coordinate and assist in the implementation of HIV prevention efforts of local

governments by supporting the provision of accurate information about correct and consistent condom use

and supporting access to condoms for those most at risk of transmitting or becoming affected with HIV.

Outreach volunteers will play an active role in broader community and family-based counseling including the

distribution of GoE and PEPFAR Ethiopia information education and communication (IEC) behavior change

communication (BCC) materials. Both case managers and outreach volunteers will support the provision of

counseling interventions with abstinence and fidelity messaging, and improve client knowledge and

understanding of discordance.

The Care and Support Program will collaborate with existing prevention partners so as not to duplicate

ongoing PEPFAR Ethiopia and GoE activities. This activity will consolidate the delivery of prevention

messages to clients of MTCT, VCT, family planning (FP), TB and sexually transmitted infections (STI)

services, and PLWHA and ART clients to capture programming synergies and cost efficiencies. Case

managers and outreach volunteers will utilize interpersonal approaches to behavior change on topics

including VCT, substance abuse, abstinence, faithfulness, correct and consistent use of condoms, STI

referral, targeted condom promotion and distribution and other risk reduction education.

Ethiopian Orthodox Church Comprehensive HIV/AIDS activity (10512), Muslim Faith-based HIV prevention

(10520), HIV prevention for MARPS (10594), ROADS transport corridor (10593). This activity will strongly

support regional government prevention efforts through social mobilization. The Care and Support

Program's coverage is anchored in predominantly peri-urban settings reaching out from health centers to

health posts through outreach volunteers in coordination with HEW, Peace Corps and other community

Activity Narrative: agents for social mobilization activities.

Community members will be reached through the outreach volunteers, who are already members of and

accepted within the community, as well as through HEW. The use of HEW and outreach volunteers also

helps to ensure that relevant messages appropriate for the audience are disseminated.

Training and building of local capacity will be achieved through the collaboration with regional and district

health bureaus and the participation of HEW and outreach volunteers in the activity.

New/Continuing Activity: Continuing Activity

Continuing Activity: 16598

Continued Associated Activity Information

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

System ID System ID

16598 5749.08 U.S. Agency for Management 7609 7609.08 Care and $1,534,500

International Sciences for Support Project

Development Health

10400 5749.07 U.S. Agency for Management 5516 3798.07 $1,374,000

International Sciences for

Development Health

5749 5749.06 U.S. Agency for Management 3798 3798.06 $737,000

International Sciences for

Development Health

Emphasis Areas

Gender

* Increasing gender equity in HIV/AIDS programs

* Increasing women's access to income and productive resources

Health-related Wraparound Programs

* Child Survival Activities

* Family Planning

* Malaria (PMI)

* Safe Motherhood

* TB

Human Capacity Development

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.02:

Funding for Sexual Prevention: Other Sexual Prevention (HVOP): $656,000

HIV and Care and Support Program

ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS:

The Activity Narrative continues as is described below but with budget and target increases. The activity

will focus on urban, peri-urban and "hot spots" where the HIV prevalence is high in the country.

FY 08 ACTIVITY NARRATIVE

The Care and Support Program (CSP) is a three-year effort to focus on HIV/AIDS at health centers and

communities in partnership with PEPFAR Ethiopia partners and the Government of Ethiopia (GOE). CSP is

PEPFAR's lead health-network care and support activity in Ethiopia at Primary Healthcare Unit, health

center and satellite health post, and provides coverage nationwide. This project will support the GOE to

provide HIV/AIDS prevention, care, and treatment services at health centers and at the community and

household levels through provision of technical assistance, training in strengthening of systems and

services, and expansion of best-practice HIV-prevention interventions.

This is a continuing activity for Other Prevention and Condoms under the broader CSP project that builds on

PEPFAR Ethiopia's support of Ministry of Health (MOH)/Health Extension Workers (HEW). Recent

antenatal clinic (ANC) and Ethiopian Demographic and Health Survey (EDHS) indicate greater

concentrations of HIV infection in urban and peri-urban areas. Given the low urbanization rates, a significant

proportion of HIV/AIDS cases remain in rural areas. In response, this activity prioritizes the deployment of

case managers and outreach volunteers to the peri-urban fringe and rural areas in/around ART health

networks, and supports GOE efforts to deploy health extension workers (HEW) to these areas. The activity

has several components.

1) The first component uses non-medical case managers in health centers to support consistent ABC

communications with people living with HIV/AIDS (PLWH) or most-at-risk groups. These brief counseling

periods, anticipated after a closer relationship is formed with case managers, represent efforts to integrate

and mainstream brief motivational interventions alongside clinical Integrated Management of Adult Illnesses

(IMAI) training among the clinical care team.

2) The second component of this activity is technical assistance to zonal and district health offices to

support HIV-prevention activities of HEW. Technical assistance will encompass engagement by

Management Sciences for Health (MSH) and its partners to ensure adequate in-service training, referral

support for most-at-risk populations (MARPs), and counseling at community and at health-post levels. This

new cadre of community health workers is to serve several villages in peri-urban fringe and rural areas. An

anticipated 30,000 HEW will be deployed by 2010. The HEW is the first point of contact at community level

with the formal healthcare system. The HEW reports to public health officers at the health center and is

responsible for a full range of primary and preventive services. They function as a significant and new link in

the referral system, and using community counseling and mobilization, they will be able to move vulnerable

and underserved populations into the formal health system. During FY08, HEW will function as the lead

position at health-post and community levels to provide social mobilization activities.

3) The third component of this activity includes, in partnership with local authorities, identification, training,

and deployment of outreach volunteers to support and facilitate the role of HEW. Through this activity,

outreach volunteers will provide technical support to the regional HIV/AIDS Prevention and Control

(HAPCO) activities in communities through community conversations and outreach counseling at the

household level. In addition, outreach volunteers will support case managers in tracking and counseling

those who miss clinical appointments. Outreach volunteers, as local individuals, will grasp culturally

appropriate manners in discussing HIV/AIDS primary ABC and secondary prevention. This will include

mitigating misconceptions, stigma reduction, highlighting the gender and HIV burden for young women, and

negative social and cultural norms.

The USG anticipates that this activity will strongly support regional government prevention efforts through

social mobilization. CSP coverage is anchored in predominantly peri-urban settings reaching from health

centers to health posts through outreach volunteers in coordination with HEW and other community agents

for social mobilization. Case managers will refer HIV-positive clients for prevention-for-positives counseling.

Community-outreach-oriented workers (COOW), in coordination with HEW, will be responsive to local

needs and distinctive social and cultural patterns. They will coordinate and assist implementation of local

government HIV-prevention efforts, education on correct, consistent condom use, and access to condoms

where needed.

Outreach volunteers will play an active role in broader community and family-based counseling, including

distribution of GOE and PEPFAR Ethiopia information-education-communication/behavior-change

communication (IEC/BCC) materials. Both case managers and outreach volunteers will support provision of

counseling interventions with AB messaging that improve client knowledge and understanding of

discordance.

CSP will collaborate with existing prevention partners to avoid duplication of ongoing PEPFAR Ethiopia and

GOE activities. This activity will consolidate the delivery of prevention messages to clients of PMTCT,

voluntary counseling and testing (VCT), family planning, tuberculosis, and sexually transmitted infection

(STI) services, as well as to PLWH and ART clients, to capture programming synergies and cost

efficiencies. Case managers and outreach volunteers will use interpersonal approaches to behavior change

on topics including: VCT; substance abuse; abstinence; faithfulness; correct, consistent condom use; STI

referral; targeted condom promotion and distribution; and other risk-reduction education.

The target populations of MARPs will be reached through expansion of available facilities. In addition, social

mobilization activities conducted by the HEW will allow for greater reach within the community. The target

includes commercial sex workers, mobile people with disposable income, and people engaged in

Activity Narrative: transactional sex.

Local organization capacity will be built through the training of health facility staff and the support of health

centers for improvement of health systems, data collection, and patient service. The Performance Based

Management approach will be the key strategy to work with partners and stakeholders, including regional

health bureaus, zonal health offices, and district health offices. This is believed to strengthen the capacity of

the institutions in taking over responsibilities in due course.

New/Continuing Activity: Continuing Activity

Continuing Activity: 16593

Continued Associated Activity Information

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

System ID System ID

16593 5791.08 U.S. Agency for Management 7609 7609.08 Care and $240,000

International Sciences for Support Project

Development Health

10403 5791.07 U.S. Agency for Management 5516 3798.07 $200,000

International Sciences for

Development Health

5791 5791.06 U.S. Agency for Management 3798 3798.06 $725,000

International Sciences for

Development Health

Table 3.3.03:

Funding for Care: Adult Care and Support (HBHC): $2,278,240

HIV Care and Support Program

ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS:

This activity will continue as is described in COP 08, except for the targets receiving care and support

services to reach 280,500 beneficiaries in COP 09. MSH will leverage resources from the Food for Peace

program to provide food and nutrition for PLWHA, with an emphasis to involve facility and community

service care providers to focus on providing preventative services to HIV positive cases in urban and

periurban areas. The adult care and support will be closely linked to pediatric care and support activities,

counseling and testing, PMTCT activities and comprehensive ART services. MSH care and support will also

focus on strengthening the linkages to provide comprehensive services at both health center and

community levels also, strengthening the linkages with hospital level care and support services.

COP 08 Narrative:

The Care and Support Program (CSP) is a three year effort to focus on HIV/AIDS at health centers and

communities in partnership with PEPFAR Ethiopia partners and the Government of Ethiopia (GOE). CSP is

PEPFAR's lead health network care and support activity in Ethiopia at Primary Health Care Unit level,

health center and satellite health posts, and provides coverage nationwide. This program will support the

GOE to provide HIV/AIDS prevention, care and treatment services at health centers and at the community

and household levels through provision of technical assistance, training in strengthening of systems and

services, and expansion of best practice HIV prevention interventions.

This is a continuing activity from FY05 and FY06 implemented by Family Health International IMPACT

project and launched in FY07 by Management Sciences for Health as part of the Care and Support

Program. The Palliative Care Activity within the CSP is focused on health centers. Hospital-centered

delivery of care and support services is near capacity. JHU recently conducted an assessment that

indicates that hospital providers on average spend only seven minutes with each ART patient. The

Government of Ethiopia has accelerated decentralization of care and treatment to health centers. To

complement this strategy, PEPFAR Ethiopia will continue to expand the delivery of palliative services

throughout the health network. The MSH CSP will continue to work in health centers and health posts, the

facilities that deliver most preventive and curative services throughout Ethiopia. As part of the ART health

network, CSP will link with ART hospitals for referrals and work with clients and their families in the

community.

During FY08, this activity will continue to support a massive scale-up of care and support services that

began in FY06 in line with the MOH decentralization of HIV/AIDS care at health centers. Activities include

implementation of enhanced palliative care services in 393 selected health centers nationwide. Health

centers that are geographically and functionally linked to ART health networks will be included in this

category.

At these selected health centers, CSP will provide technical assistance to support asymptomatic and

symptomatic care in several main areas. CSP will expand the reach of care services on multiple levels

through developing and updating semi-annual HIV/AIDS prevention, care and service plans jointly with

district health offices, health center administrators and clinical care teams; and by implementing

personalized and family-focused care plans.

The program will strengthen health centers and management systems by improving clinical care services

based on Integrated Management of Adult and Adolescent Illnesses (IMAI) and treating opportunistic

infections; establishing, standardizing and/or strengthening chronic care clinics and clinical care teams

including terms of reference for health providers, supportive supervision and cross-training opportunities;

working closely with Tulane University and other PEPFAR partners to achieve effective patient tracking and

identification, and data measures to ensure that PLWHA receiving palliative care services at different levels

will be reported only once; and delivering clinic-based elements of the Preventive Care Package including

Long Lasting Insecticide Treated Nets (LLITN) in malaria endemic areas, Cotrimoxazole Preventive

Therapy (CPT), prevention for positives, screening for active TB among HIV-positive clients, and nutrition

counseling in collaboration with the GFATM and World Bank.

CSP-PC will increase the scope of palliative care by educating on safe water and personal hygiene and

linking to community-based safe water initiatives and integrating nutrition assessment and monitoring in the

health center based HIV care settings, and referring severely malnourished PLWHA to food-by-prescription

and later to Title II food or livelihood support initiatives. (Food-by-prescription will be initiated at least 25

health centers providing ART services).

Laboratory services will be improved including the areas of complete blood count, acid fast bacilli

microscopy, stool for ova and parasites, malaria smear, pregnancy test and serology for HIV and syphilis;

and routine quality assurance and control of laboratory practices with CDC support. Along with improved

laboratory services, CSP will be implementing standardized paper records management including

procurement in coordination with the US universities and regional health bureaus (RHB).

Ensuring quality of palliative care services at health center and community levels will be a critical element of

the program. The program will build on the catchment area and regional meetings pioneered by FHI, to the

skill and knowledge of managerial and technical staff.

This activity will also strengthen pediatric palliative services by increasing detection of pediatric HIV cases

through family centered, PMTCT,OVC, TB/HIV, adult palliative care and home based care programs and

improved pediatric diagnosis. In addition to provision of elements mentioned under the adult preventive care

package, pediatric clients will receive regular nutrition and growth monitoring, safe infant feeding,

therapeutic and supplementary feeding through facility level food by prescription in selected health centers,

and referral to community-based WFP food and nutrition outlets. Moreover, infants and children will benefit

from existing non-PEPFAR child survival interventions. While rapidly expanding palliative care services, this

Activity Narrative: activity will ensure provision of quality services through use of standard guidelines. This mechanism will

continue to provide technical assistance to RHB, zonal and District health offices to deploy case managers

in 393 health centers providing enhanced palliative care. Support includes the cost of the case managers'

training, deployment, supportive supervision, and salary.

The activity continues to support major elements of the health network model including case managers

based at health centers. These key staff will continue to collaborate with Health Extension Workers,

Community Health Agents, and Traditional Birth Attendants to support and link patients with community-

based services. These include the promotion of adherence, referral to RH/FP and child survival services,

delivery of elements of the preventive care package, and referrals to spiritual counseling. These efforts will

continue to promote effective referrals within health centers, to and from hospitals for specialized care, and

to and from community and faith-based organizations. A data tracking system supporting case management

will link hospitals, health centers and community services through Tulane University strategic information

support.

To create additional linkages between the health network, communities and families, PEPFAR Ethiopia will

continue to provide technical assistance to selected Ward HIV/AIDS desks and health posts to deploy, at a

minimum, five volunteer outreach workers supporting Health Extension Workers in their community

outreach activities. The outreach workers will collaborate closely with existing community health promotion

volunteers and reproductive health agents. In addition, CSP-PC will work closely with FHI's Community-

level Responses to Palliative and preventive care activities to further strengthen local ownership and

capacity development of indigenous partners. Finally, the CSP-PC works closely with PEPFAR Ethiopia

university partners and WHO to provide clinical mentoring at health centers.

The greater expansion of ART services through 240 health clinics throughout Ethiopia will allow for greater

access to care and services for PLWHA, including most at risk populations. Program linkages through

palliative care and other activities will enable a reach into 500 health centers. The program will rely on

Health Extension Workers at health posts to provide information, referrals, and counseling. The community-

based HEW are key to identifying, referring and counseling most at risk populations. For example, HEW

form the bridge between health facilities and prisons, to assure that counseling and appropriate care are

provided to incarcerated populations. HEW and Community Outreach Oriented Workers provide out-of-

facility counseling and care to discordant couples. As community members, they know, develop

relationships with, and can refer street youth and persons who engage in transactional sex. They also are

adept at identifying and referring mobile populations - transport workers, traders -- to health facilities and/or

support groups. In certain areas and/or during times of drought, HEW work at gathering points such as for

internally displaced persons (e.g. food distributions) to provide messages, counseling and referrals.

Expansion of facilities for service provision will allow the activity to reach a greater population and thus

provide testing, treatment, care, and prevention messages to the larger population and enabling more

persons to access treatment. All HIV positive clients on pre-ART and ART service are potential targets of

the services.

Local organization capacity will be built through the training of health facility staff and the support of health

centers for improvement of health systems, data collection and patient service. There will be close

collaboration with HAPCO/MOH, WHO, CDC and US university partners in standardizing and updating

HBHC related training materials and modules.

The implementation of Performance Based Contracting strategy under CSP, a novel approach in Ethiopia,

is believed to strengthen the capacity of partner organizations and, in particular, government stakeholders,

including RHB, Zonal Health Departments (ZHD) and District Health Offices (DHO).The managerial capacity

of RHB, ZHD and DHO is the key to the success of the program.

New/Continuing Activity: Continuing Activity

Continuing Activity: 16596

Continued Associated Activity Information

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

System ID System ID

16596 10647.08 U.S. Agency for Management 7609 7609.08 Care and $890,411

International Sciences for Support Project

Development Health

10647 10647.07 U.S. Agency for Management 5516 3798.07 $3,306,820

International Sciences for

Development Health

Emphasis Areas

Gender

* Increasing gender equity in HIV/AIDS programs

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $1,000,000

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.08:

Funding for Treatment: Adult Treatment (HTXS): $7,875,000

ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS:

This is a continuing activity from COP08. There is no change to the activity narrative, except activities

relating to Pediatric treatment, which will be shown under the new COP 2009 Pediatric treatment section.

There will be an incremental increase of adult treatment facility targets which will increase to 350 sites, and

80,700 individuals of ever receiving treatment (cumulative). These targets reflect the new emphasis to reach

HIV positive individuals under treatment, strengthening linkages with communities to decrease the lost-to-

follow-up. A further focus of linking clients on ART services with facility case managers and community

outreach volunteer workers will be strengthened. MSH will also reinforce each catchment area management

and technical meetings at the woreda and zonal level to improve linkages with USG university partners and

local community services.

COP 08 Narrative:

The Care and Support Program (CSP) is a three year effort to focus on HIV/AIDS at health centers and

communities in partnership with PEPFAR Ethiopia partners and the Government of Ethiopia (GoE). CSP is

PEPFAR's lead health network care and support activity at primary health care unit level, health center and

satellite health post, in Ethiopia and provides coverage nationwide. This project will support the GoE to

provide HIV/AIDS prevention, care and treatment services at health centers and at the community and

household levels through provision of technical assistance, training in strengthening of systems and

services, and expansion of best practice HIV prevention interventions.

This is a continuing activity from FY07 previously conducted by FHI. It continues the expansion of

antiretroviral therapy (ART) decentralization to health centers. FHI coordinated the assessment of 120

health centers for site ART readiness and trained 402 health professionals in seven regions, in close

collaboration with World Health Organization (WHO). This activity is linked to care and support, ARV

Services and Technical Support for ART Scale-up, allowing PEPFAR Ethiopia to meet ART targets and to

ensure quality of care through fully functional HIV service networks. The fund increase from COP 07 funding

is owing to the gross underestimate for the activity in COP07 and the further decentralization of ART

services to 120 additional health centers in FY08. Experience from FHI ART decentralization service

support revealed that coordination of services at facility level, organizing regional and catchment meetings,

capacity building, refurbishing facilities to provide the minimum clinical services, and coordinating clinical

mentoring and supportive supervision cost much more than originally planned.

The GoE recently rapidly expanded access to ART at health centers. A site readiness assessment was

carried out by the USG at 120 health centers. Human resources consisted, on average, of one health

officer, one lab technician and a few nurses at each site. Health center ART readiness is hampered by basic

infrastructure inadequacies in, human resources, and by administrative capacity of district health offices and

regional health bureaus (RHB).

The GoE remains committed to implementing HIV care and treatment services including ART at health

centers. Without adequate investment in operational readiness, the quality of ART care for patients will be

compromised. This activity increases operational capacity to manage ART services, including integration

into the health network. ART services will be supported with the following activities: operational site

readiness; commodities; health management information system (HMIS); refurbishment of facilities and

provision of equipment; network implementation; and support to nurse-centered ART service delivery at the

health center level.

Operational site readiness will increase through human resource development. Human resources will be

strengthened through training in multiple program areas and supportive supervision in conjunction with

Government of Ethiopia personnel. The activity will facilitate training on HIV disease management and ART

services, including adherence counseling, nutrition, case management, laboratory and pharmacy services.

In close collaboration with RHB and district health offices, standard operating procedures will be

implemented with other relevant stakeholders and partners. To strengthen clinical management in the ART

health network, mentoring and monitoring of ART patients with experienced will be organized based on the

national clinical mentoring guidelines, helping build provider capacity to manage patients and improving

patient care.

The activity will complement the focused activities of USG partners in supply chain and pharmacy

management, collaborating with RPM Plus and PSCMS to ensure that their interventions achieve maximum

impact at site level. The project will work with relevant PEPFAR Ethiopia partners and key stakeholders

such as the HIV/AIDS Prevention and Control Office (HAPCO), implementer of the Global Fund to Fight

AIDS, Tuberculosis (TB) and Malaria (GFATM) grants, complementing their efforts to strengthen laboratory

services at 240 ART sites.

Site level ART patient monitoring will be enhanced through collaboration with Tulane University's health

center-level Health Management Information System (HMIS) activities supporting an ART patient tracking

system, with data clerks trained in this paper-based system by Tulane. Community networks supporting

adherence, follow-up and new patient intake will be strengthened. This activity will also support community-

based organizations to strengthen monitoring for ART adherence and follow-up. This will facilitate multi-

agency referral channels for clinical and non-clinical services to reinforce the existing continuum of care and

treatment.

Infrastructure and equipment need to be available and adequately maintained. This activity will assess and

prioritize renovation needs at health centers in collaboration with Crown Agents, to ensure a synchronized

scale-up of ART service capacity in high client flow sites. There will a needs assessment to look at what

basic medical equipment is required to support delivery of a minimum ART service package. Additionally,

procurement coordination with district health offices and USG partners will leverage GFATM resources.

Network implementation will be a patient-centered approach. This activity will be linked with multiple

Activity Narrative: services in health centers and hospitals to support integrated ART services. Furthermore, this will be

integrated with the CSP activities, linking households and community members to the health networks

through outreach efforts by USG and GoE supported community outreach workers, community based

organizations, private providers and case managers.

This activity will support ART services at 240 health centers. By the end of FY08, through linked activities

within palliative care, services will be extended to support 500 health centers and community-based care.

The CSP provides rapid expansion of health services among three progressively more comprehensive tiers.

The first tier, 500 health centers, offers basic services including TB/HIV and voluntary counseling and

testing (VCT). The second, with 393 health centers, offers TB/HIV, VCT and palliative care services. The

third tier, at 240 health centers, offers ART as well as the above services (see the Annex- for more details).

This activity will support all links in the ART and care network continuum, from patient and household to

community, health center and hospital, with a focus on the delivery of ART services at the health center and

community level. This activity will facilitate patient receipt of critical lab results. By leveraging previous

PEPFAR investments at the hospital level, laboratory linkages to hospitals will be maximized to ensure that

patients who present with complicated diagnoses will receive further laboratory services, with specialized

equipment at hospitals functioning optimally through effective health network implementation.

This activity also provides support to nurse-centered ART service delivery at health center level through I-

TECH, University of Washington and Hadassah University, Jerusalem. FHI's ART site readiness

assessment showed that highly capable nurses are present in larger numbers at the health centers

assessed, though more personnel of all types are needed. The MOH is supporting the initiation of nurse-

centered HIV/AIDS services, featuring task-shifting, particularly in the area of ART services. The Hadassah

University AIDS Center (HAC), supported ART service delivery at the hospital level for the last two years in

collaboration with I-TECH, has implemented training of trainer (TOT) courses in integrated HIV/AIDS patient

care. Forty Ethiopian physicians, nurses and laboratory staff have been trained in Israel. To support the

decentralization of ART services, MSH will collaborate with the HAC, WHO, and the four US universities

supported by PEPFAR Ethiopia. MSH will support Hadassah in identifying nurses to be trainers supporting

nurse-initiated ART, and will coordinate with these personnel to support follow-up activities in Ethiopia. MSH

may also collaborate with Hadassah in designing and implementing the evaluation of the nurse-centered

ART model, focusing on programmatic factors that may affect ART effectiveness.

The CSP will collaborate with existing treatment partners so as not to duplicate ongoing PEPFAR Ethiopia

and Government of Ethiopia activities. This activity will expand on the delivery of treatment services, access

to care and human resource development.

The expansion of ART services through 240 health clinics throughout Ethiopia will allow for greater access

to care and services for PLWHA. Project linkages through other program activities will enable a reach into

500 health centers. Expansion of facilities for service provision will allow the activity to provide testing,

treatment, care, and prevention messages to the larger population.

The emphasis on in-service training, task-shifting, and a greater retention strategy is integral to this activity.

These areas will be addressed through provision of training for health care workers and the strengthening of

systems and infrastructure at the health center level.

New/Continuing Activity: Continuing Activity

Continuing Activity: 18703

Continued Associated Activity Information

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

System ID System ID

18703 18703.08 U.S. Agency for Management 7609 7609.08 Care and $9,500,000

International Sciences for Support Project

Development Health

Emphasis Areas

Gender

* Increasing gender equity in HIV/AIDS programs

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $2,000,000

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.09:

Funding for Care: Pediatric Care and Support (PDCS): $596,160

HIV Care and Support Program

ACTIVITY IS REPLACED ENTIRELY AS FOLLOWS:

The Care and Support Program (CSP) is a three year effort to focus on HIV/AIDS at health centers and

communities in partnership with PEPFAR Ethiopia partners and the Government of Ethiopia (GOE). CSP is

PEPFAR's lead health network care and support activity in Ethiopia at primary health care level, and

provides coverage nationwide. This program started in FY07 and supports the GOE to provide HIV/AIDS

prevention, care and treatment services at health centers and at the community and household levels

through provision of technical assistance, training in strengthening of systems and services, and expansion

of best practice HIV/AIDS care and support interventions.

The uptake of pediatric HIV care and support is still low in Ethiopia. MSH has been supporting the GOE in

initiation and scaling of pediatric care and support services at health level in line with the government's

service decentralization policy. Currently, MSH is supporting 105 health centers to provide care and support

services to HIV-exposed/infected children.

The need to increase scale up and uptake of HIV/AIDS pediatric care and support services in Ethiopia

cannot be over-emphasized. To achieve its objectives, MSH will employ the following strategies in FY 09:

By supporting the availability of pediatric care and support services at health center level, MSH will reduce

the physical accessibility barrier for pediatric care and support services.

MSH will increase demand for pediatric care and support services through sensitization of communities on

the benefits of pediatric HIV diagnosis and enrolment into care. MSH will do this in conjunction with

community volunteers, Community Oriented Outreach Workers (COOW), People Living with HIV (PLWH),

Mothers' Support Groups (MSG) and other relevant community groups/members.

To increase pediatric HIV case detection, Provider Initiated-Testing and Counseling (PITC) will be adopted

in all selected health facilities. Entry points including: PMTCT programs; routine immunization; nutritional

rehabilitation units; TB clinics; out-patient clinics and in-patient departments. In addition, MSH will continue

to promote the family-centered model to enhance the HIV case detection and enrolment into care. MSH will

work with the African Network for Care of Children Affected by HIV//AIDS (ANECCA) to sensitize health

care providers on the benefits of early HIV diagnosis and enrolment into care.

Of critical importance will be the strengthening of the Early Infant Diagnosis (with DNA-PCR) program.

Making use of the current 6 regional and 1 national laboratory with DNA-PCR machines, MSH will work with

Ethiopia Health and Nutrition Research Center (EHNRI) to strengthen the laboratory health network with the

selected health centers linked to respective regional laboratories. Furthermore, laboratory staff from the

selected health centers will be trained in DBS sample collection, storage and transportation.

MSH will support the selected health centers to provide comprehensive and quality pediatric HIV care and

support services. The standard of care model - whereby pediatric care and support are provided as a

package - will be consolidated. The service package includes: early infant diagnosis (EID); routine

immunization; Cotrimoxazole Preventive Therapy (CPT); treatment of common infections; tuberculosis risk

assessment; and use of Insecticide Treated Nets (ITNs). Other components of the package include: growth

and developmental assessment; nutritional support; counseling on infant feeding; education on safe water

and personal hygiene; and psychosocial support to the child and family. MSH will work with other partners

including ANECCA, WHO and UNICEF to conduct didactic training and mentorship for health care providers

in the provision of comprehensive and quality pediatric care. Furthermore, health workers will be provided

with pediatric care and support job aids and other resource materials to enhance their capacity.

Laboratory services for diagnosis and monitoring of common and opportunistic infections will be

strengthened. The tests include: complete blood count; acid fast bacilli microscopy; stool for ova and

parasites; malaria smear; pregnancy test; and serology for HIV and syphilis. MSH will work with Ethiopia

Health and Nutrition and Research Institute (EHNRI) to conduct routine quality assurance and control of

laboratory practices. Along with improved laboratory services, CSP will be implementing standardized paper

records management including procurement in coordination with the US universities and regional health

bureaus.

To ensure continuum of care and support, MSH will continue to employ the personalized care approach at

all the selected health centers. The use of case managers - an initiative pioneered by MSH in Ethiopia -

has been instrumental in minimizing loss to follow-up for the clients enrolled into care and support services.

MSH will also continue to promote functional linkages between health centers and community groups

especially organizations that are involved in provision orphans and vulnerable children (OVC) services such

as the ‘Save the Children'. Children under care will also be linked to organizations involved in nutritional

support such as the Food by Prescription and Urban HIV programs.

Furthermore, efforts will continue to promote effective referrals within health centers, to and from hospitals

for specialized care, and to and from community and faith-based organizations. A data tracking system

supporting case management will link hospitals, health centers and community services through Tulane

University strategic information support. In addition, MSH will work with Regional, Zonal and Woreda Health

bureaus to revitalize the area catchment area meetings with the aim of strengthening inter-facility referrals.

MSH will continue to support major elements of the health network model including case managers based

at health centers. These key staff will continue to collaborate with Health Extension Workers, Community

Health Agents, and Traditional Birth Attendants to support and link patients with community-based services.

These include the promotion of adherence, child survival services, delivery of elements of the preventive

care package, and referrals to spiritual counseling. The program will rely on Health Extension Workers at

health posts to provide information, referrals, and counseling. The community-based HEW will remain key

to identifying, referring and counseling children exposed or living with HIV and their families.

To create additional linkages between the health network, communities and families, PEPFAR Ethiopia will

continue to provide technical assistance to selected Ward HIV/AIDS desks and health posts to deploy, at a

minimum, five volunteer outreach workers supporting Health Extension Workers in their community

outreach activities. The outreach workers will collaborate closely with existing community health promotion

volunteers.

Activity Narrative: Local organization capacity will be built through the training of health facility staff and the support of health

centers for improvement of health systems, data collection and patient service. There will be close

collaboration with HAPCO/MOH, WHO, CDC and US university partners in standardizing and updating

HBHC related training materials and modules.

HSP will continue to support and scale up the implementation of Performance Based Contracting (PBC)

strategy. This novel approach in Ethiopia has proved to strengthen the capacity of partner organizations

and, in particular, government stakeholders, including RHB, Zonal Health Departments (ZHD) and District

Health Offices (DHO). The managerial capacity of RHB, ZHD and DHO is the key to the success of the

program.

New/Continuing Activity: Continuing Activity

Continuing Activity: 16596

Continued Associated Activity Information

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

System ID System ID

16596 10647.08 U.S. Agency for Management 7609 7609.08 Care and $890,411

International Sciences for Support Project

Development Health

10647 10647.07 U.S. Agency for Management 5516 3798.07 $3,306,820

International Sciences for

Development Health

Emphasis Areas

Health-related Wraparound Programs

* Child Survival Activities

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $181,848

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.10:

Funding for Treatment: Pediatric Treatment (PDTX): $1,425,000

Care and Support Program

ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS

This is a new narrative per COP 2009 requirements for pediatric treatment. The Care and Support Program

(CSP) is a three year effort to focus on HIV/AIDS at health centers and communities in partnership with

PEPFAR Ethiopia partners and the Government of Ethiopia (GOE). CSP is PEPFAR's lead health network

care and support activity at primary health care unit level provides coverage nationwide. This project started

in FY07 and is supporting the GOE to provide HIV/AIDS prevention, care and treatment services at health

centers and at the community and household levels through provision of technical assistance, training in

strengthening of systems and services, and expansion of best practice HIV prevention interventions.

MSH is currently supporting the provision of adult ART services. By the end of June 2008, 21,000,000

adults were under treatment the 240 MSH-supported health centers. By the end of FY08, MSH will have

scaled-up adult ART services in 260 health centers.

However, MSH's support for pediatric ART has been limited treatment with most of the children receiving

treatment at hospital level. Currently, MSH is supported 25 health centers with only 57 children under ART.

The need to scale up pediatric ART services in the MSH-supported health centers cannot therefore be over-

emphasized.

MSH will continue with scaling pediatric HIV treatment services at health center level. In FY09, MSH targets

to scale the services in at least 80 health centers in the regions of Addis Ababa; Oromiya; Southern Nations

and Nationalities Peoples (SNNP); Amhara and Tigray. MSH will be working jointly with the African Network

for Care of Children affected buy HIV/AIDS (ANECCA). The latter (ANECCA) will provide technical support.

The scale-up process for pediatric ART services will include: strengthening the already existing pediatric

ART sites; identification of the new sites; conducting needs assessment; sites preparation; implementation;

monitoring/support supervision; and periodic monitoring with re-planning.

Strengthening of services in the health centers that are already providing pediatric ART will be done after a

gap analysis. A plan on how to address the identified weakness will then be developed in participatory

manner - together with the relevant service managers and providers. MSH will then taking a leading role in

handling the weaknesses in a systematic manner.

Identification of the new sites will be determined based on selected criteria including: potentially high

volume health centers based on the area HIV prevalence rates and the number of adult clients on

treatment; distance from the nearest pediatric service point; readiness of the health center; the degree of

health administrative support; among others.

Site preparation will include sensitization of health managers and providers on the benefits of early pediatric

HIV diagnosis. This will help in soliciting support and commitment from relevant stakeholders in scaling up

pediatric ART services. Furthermore, it will promote ownership and enhance sustainability of the ART

programs.

Operational site readiness will increase through human resource development. Human resources will be

strengthened through training in multiple pediatric program areas and supportive supervision in conjunction

with Government of Ethiopia personnel. The activity will facilitate training on pediatric HIV disease

management and ART services, including adherence counseling, nutrition, case management, laboratory

and pharmacy services. In close collaboration with RHB and district health offices, standard operating

procedures will be implemented with other relevant stakeholders and partners. To strengthen clinical

management in the pediatric ART health network, mentoring and monitoring of ART patients with

experienced will be organized based on the national clinical mentoring guidelines, helping build provider

capacity to manage patients and improving patient care.

In an effort to minimize loss to follow-up, MSH adopted the personalized treatment, approach using case

managers. The case managers are based at the health center and get particular clients on ART. Case

managers provide psychosocial support to the respective clients and ensure their close follow-up. As a best

practice, this approach will be consolidated and extended to the HIV-infected children under treatment. .

The activity will complement the focused activities of USG partners in supply chain and pharmacy

management, collaborating with RPM Plus and PSCMS to ensure that their interventions achieve maximum

impact at site level. The project will work with relevant PEPFAR Ethiopia partners and key stakeholders

such as the HIV/AIDS Prevention and Control Office (HAPCO), implementer of the Global Fund to Fight

AIDS, Tuberculosis (TB) and Malaria (GFATM) grants, Clinton HIV/AIDS Initiative (CHAI) complementing

their efforts to strengthen laboratory services at 80 pediatric ART sites.

Site level ART patient monitoring will be enhanced through collaboration with Tulane University's health

center-level Health Management Information System (HMIS) activities supporting an ART patient tracking

system, with data clerks trained in this paper-based system by Tulane. Community networks supporting

adherence, follow-up and new patient intake will be strengthened. This activity will also support community-

based organizations to strengthen monitoring for ART adherence and follow-up. This will facilitate multi-

agency referral channels for clinical and non-clinical services to reinforce the existing continuum of care and

treatment.

Infrastructure and equipment need to be available and adequately maintained. This activity will assess and

prioritize renovation needs at health centers in collaboration with the Federal Ministry of Health, to ensure a

synchronized scale-up of ART service capacity in the selected sites. There will a needs assessment to look

at what basic medical equipment is required to support delivery of a minimum pediatric ART service

package. Additionally, procurement coordination with district health offices and USG partners will leverage

Activity Narrative: GFATM and CHAI resources.

Network implementation will be a patient-centered approach. This activity will be linked with multiple

services in health centers and hospitals to support integrated pediatric ART services. Furthermore, this will

be integrated with the CSP activities, linking households and community members to the health networks

through outreach efforts by USG and GOE supported community outreach workers, community based

organizations, private providers and case managers.

This activity will support all links in the pediatric ART and care network continuum, from patient and

household to community, health center and hospital, with a focus on the delivery of ART services at the

health center and community level. This activity will facilitate patient receipt of critical laboratory results. By

leveraging previous PEPFAR investments at the hospital level, laboratory linkages to hospitals will be

maximized to ensure that patients who present with complicated diagnoses will receive further laboratory

services, with specialized equipment at hospitals functioning optimally through effective health network

implementation.

The CSP will collaborate with existing treatment partners so as not to duplicate ongoing PEPFAR Ethiopia

and GOE activities. This activity will expand on the delivery of treatment services, access to care and

human resource development. The expansion of pediatric ART services through health clinics throughout

Ethiopia will allow for greater access to treatment for children living with HIV. The emphasis on in-service

training, task-shifting, and a greater retention strategy is integral to this activity. These areas will be

addressed through provision of training for health care workers and the strengthening of systems and

infrastructure at the health center level.

New/Continuing Activity: Continuing Activity

Continuing Activity: 18703

Continued Associated Activity Information

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

System ID System ID

18703 18703.08 U.S. Agency for Management 7609 7609.08 Care and $9,500,000

International Sciences for Support Project

Development Health

Emphasis Areas

Health-related Wraparound Programs

* Child Survival Activities

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $400,000

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.11:

Funding for Care: TB/HIV (HVTB): $1,000,000

Expansion on TB/HIV Sites

ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS:

The activity will continue in COP 09 to scale-up TB/HIV sites reaching 550 health centers, despite the

decrease of budget. This activity will be linked with University partners' TB/HIV activities at hospitals,

strengthening referral systems and laboratory TB screening and diagnosis. This activity will be

implemented in conjunction with PEPFAR and NON-PEPFAR TBCAP activities by the three in-country

partners KNCV, WHO and MSH to improve MDR-TB treatment and TB infection control activities.

FY 08 ACTIVITY NARRATIVE

The Care and Support Program (CSP) is a three-year effort to focus on HIV/AIDS at health centers and

communities in partnership with PEPFAR Ethiopia partners and the Government of Ethiopia (GOE). CSP is

PEPFAR's lead health network care-and-support activity at primary healthcare units, health centers, and

satellite health stations in Ethiopia and provides coverage nationwide. This project will support the GOE to

provide HIV/AIDS prevention, care, and treatment services at health centers and at the community and

household levels by providing technical assistance, training in strengthening of systems and services, and

expansion of best practice HIV-prevention interventions.

This is a continuing activity from FY05 and FY06; it was previously implemented by Family Health

International (FHI) and launched in FY07 by Management Sciences for Health (MSH) as part of the CSP.

As of March 2007, FHI established 198 TB/HIV sites in the four major regions. FHI trained 40 health

workers in the management of dual TB/HIV infection. A total of 5,266 HIV-positive clients received treatment

for active TB in the 196 facilities. This figure is believed to be a gross underestimate as the National TB

monitoring and evaluation (M&E) system is currently functioning poorly.

According to the World Health Organization's (WHO) 2007 Global TB Control Report, the national estimate

of adult TB cases infected with HIV is 11%. Health-center and community-outreach activities are major

venues for case detection, diagnosis, care, and treatment in Ethiopia, where TB/HIV services are highly

decentralized. The government policy of decentralization demands that all health centers serve as providers

of TB diagnosis and treatment. This activity will continue to strengthen health centers and health posts—the

facilities that deliver most preventive and curative health services throughout Ethiopia. As part of the ART

health network, CSP-TB/HIV will link with network hospitals for referrals and work with clients and their

families in the community. It is anticipated that health centers will continue receiving TB referrals from

hospitals. Complex TB cases will be referred to hospitals. By September 2009, CSP-TB/HIV will be

established in 500 health centers linked to the 131 ART hospitals. Many of these sites overlap with existing

additional HIV counseling and testing (HCT) services, including the preventive-care package and ARV.

During FY06 and FY07, much experience was gained from health-center based TB/HIV activities. HCT has

been decreasing the HIV burden in tuberculosis patients. Cotrimoxazole preventive therapy (CPT) was

provided by FHI and the Global Fund to Fight AIDS, Malaria, and Tuberculosis (Global Fund) for TB

patients who are co-infected with HIV, and the patient referral system was improved. Gaps still exist:

integration between HCT and TB services requires continued support. Important lessons learned include:

(1) the need to strengthen patient referral systems; (2) the need for a case manager for HIV-positive

patients, to ensure that services required by individual patients were accessed, recorded, and monitored;

and (3) the need to facilitate the referral of patients "up the line" for ARV treatment centers in hospitals—as

well as referral of patients for follow-up services at health-center and community levels.

In FY08, CSP-TB/HIV will continue to coordinate with regional health bureaus (RHB) and USG partners

(including WHO) to provide regionally distributed trainings on providing TB/HIV services, including:

opportunistic infection (OI) counseling; bi-directional referral systems between TB, voluntary counseling and

testing (VCT), OI, family planning (FP), and sexually transmitted infections (STI) services through a case

manager; data management; and customer service, performance standards, and ethics. These trainings will

use using nationally accepted curricula and will be offered to public health providers, including VCT

counselors and laboratory technicians. TB/HIV interventions are a key component of the preventive-care

package. Health centers provide TB diagnosis and treatment through the Directly Observed Therapy - short

course (DOTS) strategy and VCT services.

In FY08, PEPFAR-supported TB clinics will conduct the following: (1) all TB patients will be offered provider-

initiated counseling and testing (PICT), using an opt-out strategy; (2) co-infected patients will receive

ongoing counseling along with their TB drugs; (3) after the intensive phase of TB treatment, patients will be

referred formally to the ART treatment center for ARV evaluation; (4) co-infected patients will be provided

with preventive-care services at the health-center and community levels; and (5) VCT clients will receive TB

screening and formal referral to the TB clinic for diagnosis and treatment if necessary. The issue of

provision of isoniazid prophylactic therapy (IPT) at health-center levels needs further consultation. Its

feasibility can be assessed in a selected number of health facilities to guide future policy decisions.

In FY08, CSP-TB/HIV will support 500 health centers to diagnose and treat 36, 000 TB patients, 94% of

whom will receive HIV counseling and testing services. Of the 220,000 HIV-positive clients expected to

receive palliative care services at health centers, 100% will receive routine, symptomatic TB screening.

Screening is based on sign/symptom review and acid fast bacilli (AFB) smear microscopy for patients with a

history of productive cough of more than two weeks. Patients with signs and symptoms suggestive of active

TB will undergo proper diagnostic workup. TB patients who test positive for HIV will be immediately linked to

pre-ART and ART services, as appropriate.

The results of TB screening among HIV-positive clients receiving palliative care will be recorded in the pre-

ART and ART registers at health centers. The results of HIV screening among active TB patients will also

be captured in the quarterly TB reports. Program performance will be monitored every quarter, under

leadership of the district health office and RHB. Supportive supervision will be provided by the RHB staff

Activity Narrative: and experts from implementing partners. National and regional TB/HIV review meetings will be held on

regular basis. Increasing case detection by providers at health centers and within the community

(specifically family-oriented case detection) is critical. Social mobilization activities will be supported through

outreach workers who will establish relationships at health posts with health extension workers (HEW).

They will provide community groups and households with HCT referral, adherence support, and TB/HIV

information-education-communication/behavior-change communication (IEC/BCC) messages. CSP-TB/HIV

interventions will have outreach workers and HEW who will screen people living with HIV/AIDS (PLWH) for

TB based on symptoms and refer suspected cases to health centers for diagnosis. They will also counsel

TB/HIV patients to adhere to TB treatments, and confirm that TB/HIV patients receive HCT and CPT.

The CSP-TB/HIV approach conforms to the PEPFAR Ethiopia five-year strategy of building up the public

health sector and of promoting a set of internationally accepted TB/HIV interventions in the ART health

network.

The activity is linked to PSP/Abt program, WHO, and US university TB/HIV activities, as well as with other

activities within the CSP project to extend service delivery of counseling, testing, diagnosis, and treatments

to underserved community members. The activity also links with the Ethiopian Ministry of Health, RHB, and

PEPFAR Ethiopia.

The target populations of most-at-risk populations will be reached through expansion of available facilities.

In addition, social mobilization activities conducted by the HEW will allow for greater reach within the

community.

Local organization capacity will be built through the training of health facility staff and the support of health

centers for improvement of health systems, data collection, and patient services.

New/Continuing Activity: Continuing Activity

Continuing Activity: 16598

Continued Associated Activity Information

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

System ID System ID

16598 5749.08 U.S. Agency for Management 7609 7609.08 Care and $1,534,500

International Sciences for Support Project

Development Health

10400 5749.07 U.S. Agency for Management 5516 3798.07 $1,374,000

International Sciences for

Development Health

5749 5749.06 U.S. Agency for Management 3798 3798.06 $737,000

International Sciences for

Development Health

Emphasis Areas

Health-related Wraparound Programs

* Child Survival Activities

* TB

Human Capacity Development

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.12:

Funding for Prevention: HIV Testing and Counseling (HVCT): $1,000,000

Care and Support Program

ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS:

Urban and periurban areas are at the center for Counseling and Testing services to beneficiaries in the

Care and Support program, reaching sites with the highest prevalence and the largest concentration of

potential beneficiaries. To assist the government of Ethiopia's ambitious goal for universal access of

services USAID/Ethiopia will focus HCT support in urban and periurban areas and a few periurban and

maybe some rural "hot-spots". The counseling and testing services will focus on increasing the linkages to

the care and support and treatment services at facilities and with community-based services. Activity

narrative continues as is described below with decreased budget and increased targets for COP 09.

COP 08 Narrative:

The Care and Support Program (CSP) is a three year effort to focus on HIV/AIDS at health centers and

communities in partnership with PEPFAR Ethiopia partners and the Government of Ethiopia (GoE). CSP is

PEPFAR's lead health network care and support activity in Ethiopia and provides coverage nationwide. This

program will support the GoE to provide HIV/AIDS prevention, care and treatment services at health centers

and at the community and household levels through provision of technical assistance, training in

strengthening of systems and services, and expansion of best practice HIV prevention interventions. The

program is implemented by Management Sciences for Health (MSH) and several partners.

PEPFAR Ethiopia supports the scaling up of CT services to enable Ethiopia to reach its targets for

prevention, care and treatment. PEPFAR Ethiopia currently assists voluntary counseling and testing (VCT)

centers based in hospitals, health centers, workplace and stand alone sites. The CSP provides rapid

expansion of health services among three progressively more comprehensive tiers. The first tier, at 500

health centers, offers basic services including TB/HIV and VCT. The second, at 393 health centers, offers

TB/HIV, VCT and palliative care services. The third tier, at 240 health centers, offers ART as well as the

above services.

Rapid expansion of HIV/AIDS care and treatment services has prompted a significant increase in VCT

nationwide through PEPFAR-funded activities, such as Family Health International's IMPACT project, Save

the Children Federation/US (Save/US) along the Addis Ababa- Djibouti High Risk Corridor and US

university partners supported hospitals. This support has encompassed assessment of existing services

and implementation with respective regional health bureaus (RHB). The numbers of VCT centers continues

to increase with the Ministry of Health (MoH) plan to have at least one VCT center per health center and per

hospital. The National Counseling and Testing Guidelines are being revised to include provider initiated

counseling and testing, engagement of non-medical counselors and other important issues, such as the

maximum age requiring parental consent.

PEPFAR Ethiopia will support health centers to implement the new Government of Ethiopia guidelines to

maintain support to existing health center VCT services and scale-up CT services through provider initiated

counseling and involvement of non-medical counselors. Moreover, all VCT services supported by this

program will be linked to a specific, functioning referral system, through case managers, to ensure that HIV-

positive clients are linked to care and treatment services.

In FY 07, PEPFAR Ethiopia provided technical assistance to 500 health centers nationwide through the

previous mechanism. The technical assistance included provision of support for HIV VCT by medical and

non-medical counselors, and provider initiated counseling and testing (PICT) services; quality assurance of

counselor performance including in-service performance improvement; screening for active TB among

VCT/PICT clients; outreach services to target most-at-risk populations in surrounding areas; quality HIV

tests including implementation of simpler techniques, such as finger pricking instead of using venous

puncture to collect samples (once approved by national authorities); and routine quality assurance and

quality control of laboratory services mechanisms.

This activity will also build local capacity and continue to improve upon CT services in a sustainable manner

through training of trainers (TOT) programs for regional, zonal and district level master trainers on HIV

testing and counseling. Human resource capacity building technical assistance will include the training of

five counselors per health center, followed by refresher training and site level cross training to facilitate

knowledge transfer and sustainability. CSP will also help to ensure the consistent availability of HCT

services at the health centers by advocating availability of full time medical or non-medical counselors.

The data collection and maintenance will be enhanced through the ensuring the availability of standard

registration books and client intake forms; supporting site level data analysis, utilization and timely reporting

to public health authorities; strengthening regular supportive supervision by regions, zones and districts;

and conducting regional and national review meetings to discuss best practices, strengths, weaknesses,

challenges and the way forward to establish sustainable VCT services.

CSP will partner with PEPFAR commodity logistics programs implemented by Rational Pharmaceutical

Management Plus (ID 10534) and Partnership for Supply Chain Management (ID 10532) to support

facilities, districts, zones, and regions to ensure consistent supply of HIV test kits as well as support regular

quality control of HIV tests in partnership with national, regional and sub regional laboratories. This activity

will also work to improve the quality of HIV/AIDS counseling services through integration of standard self-

reflection and peer supervision tools in all health centers supported by this mechanism.

The strengthening and expansion of CT service delivery through a greater number of health centers will

enable the program to extend its reach into the community. The TOT will assist in the creation of a larger

cadre of qualified health facility workers and continue to increase the capacity of the program as a whole.

This activity will also support the linkage of VCT services with HIV/AIDS prevention, care and treatment

Activity Narrative: services with strong emphasis on "prevention for positives" counseling and strong linkages with community-

based HIV/AIDS services through case managers, health extension workers and outreach workers.

Youth and adults will be reached by this activity through the increase of quality services available in a

greater range of communities through a variety of health care facilities. The health center level services,

being available at a more localized level, will enable a greater percentage of the community to access care

and support. . The program will rely on health extension workers (HEW) at health centers to provide

information, referrals, and counseling. The community-based HEWs are key to identifying, referring and

counseling most at risk populations. For example, HEW form the bridge between health facilities and

prisons, to assure that counseling and appropriate care are provided to incarcerated populations. HEW and

community outreach-oriented workers provide out-of-facility counseling and care to discordant couples. As

community members, they know, develop relationships with, and can refer street youth and persons who

engage in transactional sex. They also are adept at identifying and referring mobile populations - transport

workers, traders -- to health facilities and/or support groups. In certain areas and/or during times of drought,

HEW work at gathering points such as for internally displaced persons (e.g. food distributions) to provide

messages, counseling and referrals.

The activity will build significant local organizational capacity through the training of health facility staff and

the support of health centers for improvement of health systems, data collection and patient service.

New/Continuing Activity: Continuing Activity

Continuing Activity: 16602

Continued Associated Activity Information

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

System ID System ID

16602 5654.08 U.S. Agency for Management 7609 7609.08 Care and $1,000,000

International Sciences for Support Project

Development Health

10399 5654.07 U.S. Agency for Management 5516 3798.07 $2,100,000

International Sciences for

Development Health

5654 5654.06 U.S. Agency for Family Health 4136 4136.06 Family Health $1,732,000

International International International

Development

Emphasis Areas

Gender

* Addressing male norms and behaviors

* Increasing gender equity in HIV/AIDS programs

* Reducing violence and coercion

Human Capacity Development

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.14:

Funding for Laboratory Infrastructure (HLAB): $1,700,000

HIV Care and Support Project

ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS:

The activity narrative will not be changed for COP09 and the activity will focus on pediatric laboratory

services and early infant diagnosis (EID) at health center level and basic laboratory services at 240 health

centers. This activity will be linked with the laboratory services at the hospital level and will provide back-

stop support at the health center level including the specimen transport from health center to the testing

sites.

COP08 ACTIVITY NARRATIVE

The HIV Care and Support Project (CSP) is a three year effort to focus on HIV/AIDS at health centers and

communities in partnership with PEPFAR Ethiopia partners and the Government of Ethiopia (GoE). CSP is

PEPFAR's lead health network care and support activity in Ethiopia at Primary Health Care Unit level,

health center and satellite health posts, and provides coverage nationwide. This program will support the

GOE to provide HIV/AIDS prevention, care and treatment services at health centers and at the community

and household levels through provision of technical assistance, training in strengthening of systems and

services, and expansion of best practice HIV prevention interventions.

The CSP laboratory component will involve site-level laboratory support in 240 health centers. The program

complements other PEPFAR/Ethiopia efforts to strengthen laboratory capacity nationally working through

the Ethiopian Health and Nutrition Research Institute (EHNRI). The focus of PEPFAR/Ethiopia activities has

been to strengthen central and regional laboratories and implement an external quality assurance (EQA)

program. There are encouraging results in some regions in institutionalizing EQA and efforts should be

strengthened to expand the program at health center level. The proposed CSP laboratory component at the

240 health centers in which CSP is also providing comprehensive HIV/AIDS services, including ART, is

designed to complement and strengthen the national EQA work with respective Regional Reference

Laboratories (RRL) and EHNRI.

The facility level comprehensive laboratory support activities include organizing training for lab staff at

health center level in collaboration with EHNRI, RRL, Centers for Disease Control (CDC) and US

universities on laboratory diagnosis of integrated diseases including common OI and STI diagnosis using

the centrally developed and standardized training modules; making standard operational plans (SOPs)

available at individual labs and providing the necessary mentorship and supportive supervision that staff

abide by the SOPs; working with EHNRI, RRL, PfSCM and RPM Plus to have an uninterrupted supply of

laboratory commodities including rapid test kits, reagents and equipment; work with EHNRI, RRL and

relevant partners to have a functional recording and reporting system including establishing/strengthening

tracking system for samples and results; facilitate at site the collection of samples for transport through

RRL/EHNRI funding for tests at higher level; and ensuring that results of samples sent to higher level are

received on time. MSH/CSP is also expected to be engaged (with EHNRI and regional laboratories) in

improving laboratory layout, work flow, gap identification and system strengthening.

MSH/CSP will facilitate the renovation of health center laboratories to expand the uptake and improve

quality of the services. As stated above, MSH/CSP will also support integration of OI and STI diagnosis

including improvement of TB microscopy.

The CSP laboratory component is part of CSP's overall health systems strengthening component. CSP will

support the national strategic plan developed by EHNRI for integrated diseases and covers the tiered

laboratory network in the country will be implemented and adhered to. Additionally, CSP will work with

EHNRI and PEPFAR/Ethiopia to implement the "Maputo Declaration on strengthening laboratory systems"

appropriate for level I or health center level laboratories. The CSP implementing partner, Management

Sciences for Health (MSH) will recruit and hire a lab strengthening advisor with intimate knowledge and

experience within the Ethiopian health system and with an advanced degree in laboratory services. The

advisor's primary responsibility will be to coordinate and supervise all laboratory strengthening activities at

the health centers. Working together with the PEPFAR/Ethiopia and EHNRI staff, this advisor will take

existing laboratory standards for regional labs and adapt them to meet the situation of the health center labs

(if these standards already exist, CSP will use those). The laboratory standards will be incorporated into

CSP's standards-based management performance quality improvement tool (SBM-PQI) for health centers

called the Fully Functional Service Delivery Point (FFSDP). The FFSDP contains nine standards in various

functions critical for high quality health center services with appropriate criteria for each. The new health

center lab standards will be incorporated into the FFSDP as one of the critical standards.

During FY08, MSH/CSP will train regional health bureau (RHB) and district health office (DHO) staff in the

application of this tool to the health centers selected to provide ART. In collaboration with RHB and WHB

staff, CSP will undertake an FFSDP baseline evaluation which will identify any laboratory deficiencies for

the health center. CSP will then collaborate with those staff to develop an intervention plan to address the

deficiencies. The FFSDP will be applied twice more over a 12 month period to assist the health center to

improve standards compliance and to assist the RHB/WHB personnel to monitor progress.

CSP will use performance-based contracting to provide technical assistance and support to assist the

laboratories to meet the standards. CSP plans to use a competitive process to outsource laboratory training

and support to a local organization with the capacity to train lab staff, help implement the EQA programs,

develop preventive maintenance and replacement programs for lab equipment, and assist with the supply of

reagents and other supplies locally. Once in place, the contract with this local organization will support the

health centers to achieve 80% or greater of the lab standards. That will be the performance standard

included in the contract. CSP will award another set of performance-based contracts to the RHB and DHO

to improve health center adherence to the standards. Through the contracts, the RHB and DHO will have

the responsibility, and the resources, to improve health center operating conditions, be they staff shortages,

renovations, equipment, or other structural issues.

Activity Narrative: CSP will use existing sample referral documents for laboratory specimen handling in the facilities in which it

works, for safe transport to the regional referral labs for tests not available in the health centers, such as

CD4 counts and viral load. Specimen transport is currently the responsibility of the university PEPFAR

partners. CSP plans to work closely with these PEPFAR partners to ensure health centers adhere to the

appropriate standards for specimen preparation and transfer.

Through application of the FFSEP standards at the health center level, coupled with performance based

contracting with both private and public local organizations and collaboration with other PEPFAR partners

(such as EHNRI, PfSCM, SPS, and universities), CSP expects to show and measure significant

improvement in health center laboratory capabilities over time. This high quality laboratory support to the

health centers is essential to the provision of high quality comprehensive HIV/AIDS services, including ART,

throughout the health network.

New/Continuing Activity: Continuing Activity

Continuing Activity: 18099

Continued Associated Activity Information

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

System ID System ID

18099 18099.08 U.S. Agency for Management 7609 7609.08 Care and $2,000,000

International Sciences for Support Project

Development Health

Emphasis Areas

Health-related Wraparound Programs

* Malaria (PMI)

* TB

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $1,000,000

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.16:

Funding for Strategic Information (HVSI): $600,000

Care and Support Program

THE ACTIVITY HAS BEEN UPDATED IN THE FOLLOWING WAYS

Activity unchanged from FY2008 and this narrative will not be changed in COP 09. Since the HMIS rollout is

expected to have progressed significantly by the beginning of FY2010, this activity will focus on data use in

the context of the new HMIS. This program will provide technical support to enhance the successful

implementation of the HMIS' data use processes including building health professional skills in data

processing and presentation, data quality assessment (accuracy, completeness and timeliness), and the

conduct of regular performance review. It will be linked with other SI activities providing support to the

rollout of the HMIS.

In FY08, this activity provided orientation to health center staff on data collection, compilation, analysis and

use for decision making in the regions where the program operates. Two hundred twenty eight data clerks

were trained and deployed at health centers. HCSP is working towards incorporating HMIS data analysis

and use into regular HIV/AIDS coordinating committee meetings at all levels through HCSP regional M & E

advisors and clinical mentors.

COP08 NARRATIVE

The Care and Support Program (CSP) is a three-year effort to focus on HIV/AIDS at health centers and

communities in partnership with PEPFAR Ethiopia partners and the Government of Ethiopia (GOE). CSP is

PEPFAR's lead health network care-and-support activity in Ethiopia and provides coverage nationwide. This

program will support the GOE to provide HIV/AIDS prevention, care, and treatment services at health

centers and at the community and household levels through technical assistance, training in strengthening

of systems and services, and expansion of best-practice HIV-prevention interventions. The program is

implemented by Management Sciences for Health (MSH) and several partners.

This is a continuing activity from FY07. This strategic information activity will strengthen implementation of

the national Health Management Information System (HMIS) and the use of data at the site level for

programmatic improvement.

In FY07, MSH/CSP will conduct an assessment to determine the status of data use at health centers and

district health offices. The assessment will help to clarify the existing situation in relation to data use and

identify constraints as well as best practices. The assessment will look at human resource issues in terms

of: availability and skill levels, organizational policies and structures, and existing infrastructure for data

management. The findings will aid MSH/CSP to design an effective and focused intervention to improve the

data management skills of health center and district health office staff. The program will begin

implementation in FY07 and will serve 267 health centers that are providing voluntary counseling and

testing (VCT), PMTCT and tuberculosis (TB)/HIV services.

This activity will focus primarily on health centers that are undertaking HIV/AIDS interventions including

VCT, ART, and PMTCT. It will work within existing systems, such as the national monitoring and evaluation

framework, and link with other health facilities in the network model with the aim of enhancing information-

sharing for program improvement. District health bureaus will also be supported to build their capacity in

data management.

In FY08, MSH/CSP will provide training to appropriate health-center staff on data entry, data cleaning, and

data analysis techniques of HMIS and the national HIV/AIDS Monitoring and Evaluation system. Hands-on

training will be provided on basic computer packages for capturing and analyzing patient data. Where

computers are not available or feasible, effective use of manual systems will be promoted. This activity will

include training on report writing and data presentation techniques to ensure staff are able to successfully

communicate accurate and practical status reports that reveal both problems and success stories.

Information should be used for decision-making at the point of source. To that effect, staff will be trained on

how data are used to improve program and service delivery, and how to measure progress of programs.

Sites will receive technical assistance to conduct routine data quality assessments to ensure the validity and

reliability of data coming from the facilities. Data use at the point of origin will foster data quality,as it will be

easier for staff to identify errors and make appropriate corrections.

Health facility staff will be trained to use the national HIV/AIDS monitoring and evaluation framework, and

the associated data capturing and reporting formats. Once the new HMIS starts full operation, this activity

will coordinate with the HMIS reform to facilitate adoption of the new tools. Facility staff will also be trained

to develop their own monitoring and evaluation plans, which will promote effective communication and

utilization of information within and outside of the health centers. Regular data review meetings at different

levels will be promoted and supported, including training in dynamic and participative methodologies for

presenting and analyzing information for decision-making.

Computers, printers, and related information-communication technology equipment will be supplied to the

facilities, as appropriate, for local conditions based on assessment findings on existing gaps. Protective

measures such as voltage regulators, surge protectors, grounded electrical lines, and antivirus software, will

be included in all cases.

The program will enable staff at health facility and regional/zonal/district health office levels to properly use

and manage data. Sites will be further enabled to appropriately tabulate and visualize their data so that they

will be capable of making sense of the data they generate and be able, in the long run, to make evidence-

informed decisions supporting all facets of the HIV/AIDS program. This strategy fits with the GOE plan to

improve monitoring and evaluation (M&E) and HMIS in Ethiopia. It will also be instrumental in the

implementation of the performance-based contracting scheme of MSH at health centers and regional/district

health offices.

Activity Narrative: This activity will build on best practices modeled from the national HMIS support activity (10413). In

addition, it will collaborate with and expand on the site level data support by US universities (ID 10427, ID

10433, ID 10437, ID 10440) and the Global Fund for AIDS, Malaria, and Tuberculosis. This activity is in line

with the National HMIS rollout plan led by MOH.

Local organization capacity building will be improved through training of staff, provision of needed material

inputs such as computers, and support for activities such as supportive supervision and catchment area

meetings. Strategic Information will be supported in the same ways. The program will target 300 health

centers and 100 district health offices with two individuals being drawn from each organization to participate

in the trainings.

New/Continuing Activity: Continuing Activity

Continuing Activity: 16604

Continued Associated Activity Information

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

System ID System ID

16604 10442.08 U.S. Agency for Management 7609 7609.08 Care and $800,000

International Sciences for Support Project

Development Health

10442 10442.07 U.S. Agency for Management 5516 3798.07 $500,000

International Sciences for

Development Health

Program Budget Code: 18 - OHSS Health Systems Strengthening

Total Planned Funding for Program Budget Code: $17,022,710

Total Planned Funding for Program Budget Code: $0

Program Area Narrative:

Health System Strengthening 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%. 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). PEPFAR Ethiopia focuses on urban and peri-urban programming for HIV/AIDS

prevention, care and treatment activities. In addition PEPFAR invests in several key health system platforms on a national scale.

Health system strengthening is an important foundation for ensuring the sustainability of health services and other interventions.

Ethiopia's Third Health Sector Development Program outlines Ministry of Health priorities related to health service coverage,

expansion and human resource targets. PEPFAR works as one of many bilateral/multilateral donors to Ethiopia's health sector.

With this recognition PEPFAR support aligns itself within national programs and leverages non-PEPFAR and non-USG resources

to achieve more with less. Activities include 1) assistance to the host country on policy reform and national strategic planning; 2)

investments in critical health system platforms such as the Human Resources for Health Strategy, Health Sector Finance Reform,

Health Management Information System, National Logistics and Pharmaceutical Master Plan, Tiered Laboratory Structure,

Federal Project Management Unit for Construction and Renovation and Public Private Mix Framework for TB/HIV; and 3)

strengthening governmental and non-governmental capacity to do financial and program management.

Strengthening the capacity of host government institutions to implement national HIV/AIDS and health programs

In COP04 PEPFAR initiated support to the Ministry of Health, the HIV/AIDS Prevention and Control Office, the Ethiopian Health

and Nutrition Research Institute, the Drug Administration and Control Authority and the Pharmaceutical Administration and Supply

Service to address policy and standards, clinical and laboratory service delivery, pharmaceutical and logistics management and

information systems. Since COP07 PEPFAR supported Ethiopia's Federal Parliament to improve their understanding and

advocacy of HIV/AIDS policies. This work continues and supports correct and consistent messaging and advocacy by

parliamentarians.

In COP08, recognizing the growing complexity of PEPFAR and GFATM interactions the USG team initiated activities to 1) provide

technical assistance to the RHBs in GFATM implementation and 2) supported greater integration of PEPFAR partners into District

planning cycles led by local authorities. PEPFAR is actively engaging the MOH and RHBs in addressing capacity gaps and will

continue to strengthen key offices and systems to support the MOH and RHBs manage the Health Sector Development Program

III and the national HIV/AIDS response.

Strengthening the capacity of local non-governmental organizations and the private sector

Current programs engage local non-governmental organizations including civil society and faith-based organizations to implement

HIV/AIDS programs at the grass-roots. Over 600 local groups oversee community orphan care programs. In addition partners

provided key capacity building initiatives to the Ethiopian Supreme Islamic Council, the Ethiopian Orthodox Church and Mekane

Yesus Church. The US Embassy's Small Grants Program remains an important facility for proposals received requesting under

$30,000. A Grants, Solicitation and Management mechanism is established for local NGOs to access fund with and provide

organizational capacity development. Professional associations such as the Ethiopian Public Health Association (EPHA), the

Ethiopian Nurse Midwife Association, the Ethiopian Pharmaceuticals Association and the Ethiopian Medical Association receive

support through PEPFAR partners to improve professional practices and standards. These partners are receiving valuable

technical assistance from international partners such as JHPIEGO/ACCESS. EPHA, a direct recipient of PEPFAR funds, sub

grants on behalf of CDC to local and international partners given the capacity built since PEPFAR's inception.

"The Government of Ethiopia has pending legislation governing the registration and operation of Civil Society Organizations

(CSO) which is expected to pass in 2008. This legislation will restrict CSO activities in a number of areas, but the full impact of its

implementation on PEPFAR-related activities remains unclear. In any case, the USG must continue to support multi-sectoral

HIV/AIDS programming which promotes country ownership by engaging both civil society and governmental institutions in the

national response. In COP09, the USG proposes to increase support to local civil society programs in Orphans and Vulnerable

Children, as well as Care and Support services, by increasing both the number of local partners receiving direct funding and the

level of technical and organizational capacity development provided, to promote sound and efficient utilization of USG and non-

USG foreign assistance for HIV/AIDS.

Address gender disparities and reduce stigma and discrimination of persons living with HIV/AIDS

Since COP06 the USG supported activities including Men as Partners and Preventing Early Marriage in Amhara to address social

norms that contributed to the vulnerability of girls and women. In COP09 the USG proposes to support the Network of Ethiopian

Women's Associations to build organizational capacity to effectively address gender equity and access to primary health care

including HIV/AIDS and education, discussing gender-based violence and coercion. In addition several other key USG programs

including Small Scale Dairy program, Accelerated Trade and Export program and the Urban Gardens program will mainstream

gender to improve access of women to income and productive resources. Additional mainstreaming work will be conducted with

the Ethiopian Orthodox Church to address social norms and behaviors.

Improve donor coordination and strengthen Global Fund for AIDS, Tuberculosis and Malaria management structures

The USG was actively involved in the Donor Assistance Group preceding PEPFAR which allowed US agencies to communicate

and align donor programs to address key public health needs. In COP05 PEPFAR Ethiopia and the GOE signed a Memorandum

of Understanding (MOU) establishing a division of labor between GFATM and PEPFAR resources. This effectively focused

PEPFAR on technical assistance to address clinical requirements of the ART program and utilized GFATM resources to address

commodity and capacity building needs. In addition PEPFAR supported UNICEF to accelerate PMTCT expansion. In COP06

and COP07 the GOE continued to revise the MOU to reflect the growing GFATM grant resources available. The Clinton

HIV/AIDS Initiative and PEPFAR Ethiopia initiated coordination on Pediatric and Second Line Antiretroviral Therapy and

Therapeutic Feeding for HIV exposed children.

Responding to multiple requests for technical assistance the USG in COP08 allocated funds to strengthen GOE and regional

government capacity to manage and implement GFATM resources. Through the Leadership, Management and Sustainability

global mechanism the USG placed management specialists in the Federal HAPCO and Regional Health Bureaus to better

facilitate utilization of GFATM resources. In FY2009 the USG and UK/DFID will collaborate on Human Resources for Health

initiatives.

Support to Health System Platforms

Health Management Information Systems

In 2006 the HPN Donor group, including the USG, supported JSI to design and pilot tested a Health Management Information

System. In 2007 the HMIS system was evaluated by the Ministry of Health and PEPFAR invested in Tulane University to

implement the revised system. In 2008 there was limited ability to scale up HMIS due to financial constraints of the Ministry of

Health - at a costed price of over $100,000,000 - donors were unable to adequately fill the resource gap. Several gaps were

identified during USG planning sessions related to HMIS implementation including the limited capacity of federal and regional

authorities to scale up HMIS and the requirement of USG to provide additional system and site level HMIS support to health

facilities and administrative offices throughout the country. Community-based information such as OVC and palliative care

performance remain unaddressed by the GOE or PEPFAR. In FY2009 the USG will support HMIS with limited investments in

technical assistance and training.

Human Resources for Health

The USG has long supported several pre-service training initiatives in Ethiopia including 1) Health Extension Program; 2) Health

Officer Training; and 3) M&E Postgraduate training. In addition the USG supported in-service trainings for key health providers to

initiate HIV/AIDS and TB services in public and private health facilities throughout Ethiopia.

In FY2009 the USG proposes several pre-service training activities to support the implementation of the Urban Health Extension

Program, the scale up of production of Medical Doctors, Nutritionists and Social Workers as well as a continuation of support to

Health Officer and Nurse training. Additional assistance is required to support regional health bureaus adequately plan and

manage workforce.

Construction and Renovation

Starting in COP06 and continuing in COP07 PEPFAR Ethiopia initiated the renovation of hospitals and health centers through the

Regional Procurement and Supply Office (RPSO) and Crown Agents USA with approximately $16,525,064. Approximately 47

Health Centers were partially renovated to support both basic and chronic care services. PEPFAR supported standardization and

synchronization of renovations at health centers throughout the country.

In COP08 PEPFAR committed approximately $19,000,000 to hospital, regional laboratory and health center renovations and the

conversion of health stations to health centers in peri-urban areas of high HIV prevalence. Key assessments and evaluations

were conducted: Energy systems, FMOH construction management capabilities and an evaluation of health center renovation

supported USG programming decisions.

In FY2009 proposes to continue renovation worth approximately $14,450,000 for existing hospitals, regional labs and health

centers while scaling back support of the national conversion of health stations to $5,000,000 given ongoing capacity issues and

constraints on materials, equipment and human resources to support the operation of these facilities. Programming structures,

including Fixed Acquisition Reimbursement and technical assistance in Architectural and Engineering services will ensure

progress in health center construction activities.

Health Sector Finance Reform (HSFR)

The USG and PEPFAR support Health Sector Finance Reform (HSFR) program started by the Ministry of Health and USAID in

1998. The program supports the revision of government financing policies at the Federal and Regional level to support revenue

retention, management and utilization at health facilities throughout the country. In COP08 PEPFAR initiated support to the HSFR

program and supported activities to develop a Framework for Performance Based Contracting (PBC) by Ministry of Health to

structure pay for performance agreements signed between the Federal, Regional, Districts. Current PBC designs incorporate all

primary health care services but firmly address and build incentives to support quality service delivery of HIV/AIDS related

services throughout Ethiopia.

In FY2009 HSFR and PBC will continue to be supported in addition to a pilot implementation of Social Health Insurance and

Community Based Health Insurance following on from successful experiences in other PEPFAR Focus Countries including

Rwanda.

National Pharmaceutical Logistics Master Plan (PLMP)

PEPFAR continues its efforts to strengthen national logistics systems for HIV commodities, with major investments in support of

the Pharmaceutical Logistics Master Plan. Support to date has included technical staff, training, vehicles, distribution system

design, and procurement training. These efforts will be strengthened in FY2009, with design of the logistics management

information system and the roll-out of the critical inventory control system as major elements of the nascent system. Training and

TA at all levels, from national to facilities, will be emphasized. Development of effective procurement capacity will be a major

benchmark, as reduced PEPFAR funds mean the MOH must be able to procure effectively using GFATM monies.

Public Private Mix Framework

The local private sector, maintaining over 3,000 private clinics nationwide, attracts 40 percent of total health expenditure. A

majority of urban clinical sessions occur in private sector clinics despite ongoing problems with quality and affordability. The

majority of private clinics and pharmacies are highly accessible to urban and peri-urban populations. Given the nature of

Ethiopia's HIV epidemic the USG engaged 180 private health clinics and 13 private hospitals to expand access to safer health

services including HIV/AIDS and TB. In addition the USG supported management, accounting and human resource training

workshops for over 100 clinic owners to improve the management routines of clinics. Building on a viable local commercial sector

the USG subcontracted mobile HCT activities to three local private companies to expand their role in the national HIV /AIDS

response and to grow the competitive market. Because of market forces the price of mobile HCT to the USG decreased from

$7.50 to $3.00 per HCT session with sustained quality and additional competent implementing partners.

Table 3.3.18:

Subpartners Total: $0
IntraHealth International, Inc.: NA
Save the Children: NA
Dawn of Hope Ethiopia Association: NA
Ethiopian Inter Faith forum for Development Dialogue and Action: NA
Cross Cutting Budget Categories and Known Amounts Total: $4,581,848
Human Resources for Health $1,000,000
Human Resources for Health $2,000,000
Human Resources for Health $181,848
Human Resources for Health $400,000
Human Resources for Health $1,000,000