PEPFAR's annual planning process is done either at the country (COP) or regional level (ROP).
PEPFAR's programs are implemented through implementing partners who apply for funding based on PEPFAR's published Requests for Applications.
Since 2010, PEPFAR COPs have grouped implementing partners according to an organizational type. We have retroactively applied these classifications to earlier years in the database as well.
Also called "Strategic Areas", these are general areas of HIV programming. Each program area has several corresponding budget codes.
Specific areas of HIV programming. Budget Codes are the lowest level of spending data available.
Expenditure Program Areas track general areas of PEPFAR expenditure.
Expenditure Sub-Program Areas track more specific PEPFAR expenditures.
Object classes provide highly specific ways that implementing partners are spending PEPFAR funds on programming.
Cross-cutting attributions are areas of PEPFAR programming that contribute across several program areas. They contain limited indicative information related to aspects such as human resources, health infrastructure, or key populations programming. However, they represent only a small proportion of the total funds that PEPFAR allocates through the COP process. Additionally, they have changed significantly over the years. As such, analysis and interpretation of these data should be approached carefully. Learn more
Beneficiary Expenditure data identify how PEPFAR programming is targeted at reaching different populations.
Sub-Beneficiary Expenditure data highlight more specific populations targeted for HIV prevention and treatment interventions.
PEPFAR sets targets using the Monitoring, Evaluation, and Reporting (MER) System - documentation for which can be found on PEPFAR's website at https://www.pepfar.gov/reports/guidance/. As with most data on this website, the targets here have been extracted from the COP documents. Targets are for the fiscal year following each COP year, such that selecting 2016 will access targets for FY2017. This feature is currently experimental and should be used for exploratory purposes only at present.
Years of mechanism: 2008 2009
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:
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.
Continuing Activity: 16598
16598 5749.08 U.S. Agency for Management 7609 7609.08 Care and $1,534,500
10400 5749.07 U.S. Agency for Management 5516 3798.07 $1,374,000
International Sciences for
5749 5749.06 U.S. Agency for Management 3798 3798.06 $737,000
Table 3.3.02:
HIV and Care and Support Program
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
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
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.
Continuing Activity: 16593
16593 5791.08 U.S. Agency for Management 7609 7609.08 Care and $240,000
10403 5791.07 U.S. Agency for Management 5516 3798.07 $200,000
5791 5791.06 U.S. Agency for Management 3798 3798.06 $725,000
Table 3.3.03:
HIV Care and Support Program
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:
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
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.
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.
Continuing Activity: 16596
16596 10647.08 U.S. Agency for Management 7609 7609.08 Care and $890,411
10647 10647.07 U.S. Agency for Management 5516 3798.07 $3,306,820
Estimated amount of funding that is planned for Human Capacity Development $1,000,000
Table 3.3.08:
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.
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
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.
Continuing Activity: 18703
18703 18703.08 U.S. Agency for Management 7609 7609.08 Care and $9,500,000
Estimated amount of funding that is planned for Human Capacity Development $2,000,000
Table 3.3.09:
ACTIVITY IS REPLACED ENTIRELY AS FOLLOWS:
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.
volunteers.
Activity Narrative: Local organization capacity will be built through the training of health facility staff and the support of health
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.
Estimated amount of funding that is planned for Human Capacity Development $181,848
Table 3.3.10:
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.
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. .
AIDS, Tuberculosis (TB) and Malaria (GFATM) grants, Clinton HIV/AIDS Initiative (CHAI) complementing
their efforts to strengthen laboratory services at 80 pediatric ART sites.
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.
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
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.
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.
Estimated amount of funding that is planned for Human Capacity Development $400,000
Table 3.3.11:
Expansion on TB/HIV Sites
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.
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
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
centers for improvement of health systems, data collection, and patient services.
Table 3.3.12:
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.
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.
Continuing Activity: 16602
16602 5654.08 U.S. Agency for Management 7609 7609.08 Care and $1,000,000
10399 5654.07 U.S. Agency for Management 5516 3798.07 $2,100,000
5654 5654.06 U.S. Agency for Family Health 4136 4136.06 Family Health $1,732,000
International International International
Development
* Addressing male norms and behaviors
* Reducing violence and coercion
Table 3.3.14:
HIV Care and Support Project
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.
The HIV Care and Support Project (CSP) is a three year effort to focus on HIV/AIDS at health centers and
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.
Continuing Activity: 18099
18099 18099.08 U.S. Agency for Management 7609 7609.08 Care and $2,000,000
Table 3.3.16:
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
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.
Continuing Activity: 16604
16604 10442.08 U.S. Agency for Management 7609 7609.08 Care and $800,000
10442 10442.07 U.S. Agency for Management 5516 3798.07 $500,000
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:
