Renovation: Enabling quality PMTCT services at hospitals

ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS:

Construction costs have risen dramatically recently, reaching a five-time increase from 2006 to the present

in Ethiopia. Global market forces including oil price increases, shipping cost acceleration, and increased

demand for Portland Concrete Cement (PCC) and rebar have all contributed to this reality. Internal factors

include a rapidly growing foreign exchange shortage, especially in available US dollars, and rampant

restrictions on imported concrete for non-Government of Ethiopia (GoE) partnered entities are also

contributory factors. Furthermore, the GoE is importing 1.4 million metric tons of PCC for low-income

housing construction which highlights other internal constraints.

The harsh realities of the clinical space for pregnant women are an obstacle to quality PMTCT programs.

Poorly ventilated, foul smelling, labor & delivery and postpartum facilities are a deterrent to women seeking

care and contribute to low morale amongst health personnel. In addition to poor PMTCT coverage,

inadequate and low quality health infrastructure contributes to Ethiopia's high maternal mortality rate, one of

the highest in the world.

To advance PMTCT success in areas of higher HIV-prevalence, efforts will be focused on interventions that

were previously viewed as non-critical to PMTCT achievement. The entire MCH suite will undergo a much-

needed transformation, including labor and delivery (L&D), pre- and post-partum, operation rooms (ORs),

and any other spaces pertinent to safe maternal care and delivery. Coupling an appropriate clinical

infrastructure with a welcoming environment (inclusive of healing gardens & art), maternity wards will no

longer be viewed as a place for the last and least health resort.

Creating a welcoming, caring and nurturing environment is paramount for any effort that seeks behavioral

change. Privacy (both visual & hearing) will be addressed through semi-private and private spaces, buffered

by sound retarding walling & flooring systems. Concurrent to aesthetic improvements will be an appropriate

overhaul of plumbing and sanitary systems, electrical wiring, and waste management controls. The

establishment of optimized clinical and patient flow, proper lighting and ventilation, fire protection and water

purification systems will comprehensively rehabilitate the clinical space for this gateway program.

Staff retention rates and recruitment efforts will be positively impacted through the same mechanisms of art

& healing gardens being used for patient perspective change. Such activities, along with comprehensive

renovations, will enable PMTCT at these facilities to become centers of excellence for safe and quality

healthcare through innovative & effective practices. This is a requirement for image enhancement within the

community and the catchment area of these facilities. Once complete, exemplary quality healthcare will

become the norm as such facilities will become leaders in their regions and beyond. Again, all activities lend

themselves towards the creation of a safe, comfortable and welcoming environment that empowers patients

and staff alike.

Coordination efforts between and among donor partners (e.g. - the Global Fund and Packard Foundation)

are slowly gaining momentum. Furniture, fixtures, and equipment that are not being covered within this

activity are expected to be supported through synchronized efforts with the aforementioned donor entities.

Acquisition of environmentally-friendly finishes (No VOC), solid surface furniture, seamless flooring requiring

no edging, inverter battery systems for ORs, and sensor-operated fixtures will be covered. Assessment of

equipment stockpiles within a facility will also be conducted, determining the actual need of a facility in

which new equipment purchases are required.

The rehabilitation of MCH spaces is ultimately coordinated with other ART and HIV-related rehabilitative

work for seamless construction and/or renovation work at hospitals, health centers, and regional labs.

Subsequently, acceptance of US/International building practices is slowly becoming standardized amongst

the major donor groups. This is vital as the GoE continues to show nascent interest in superior and long-

established building practices. And with the issue of maintenance, which is generally non-existent at all

health facilities, it is expected that all procured equipment & furnishings will be backed by service contracts

supported by manufacturer-designated business entities. And whenever possible, cost savings to the

rehabilitated facility will be directed towards establishing a maintenance department in-house, continuing

existing service contracts, or engaging in new third-party contracted services.

The rehabilitation pipeline for PMTCT is $400,000. This amount along with the COP09 funding request will

support comprehensive work at about 5-8 hospitals. The flat-line budget scenario for PEPFAR in 2009 will

impact the ability of PEPFAR partners to provide ancillary support to this specific activity. Additionally,

changing priorities and mandates and interests of other donor partners is another important factor to take

into consideration. A weighted-scoring system (Current ART population, HCT quarterly population, HCT

prevalence (regional), Pregnant women attending ANC) has been used to prioritize all of Ethiopia's public &

uniformed hospitals. Consideration of infrastructure condition is included in the overall prioritization as well.

For 2008, only one (1) hospital is undergoing rehabilitation per this novel strategy for high-impact PMTCT

success.

COP08 ACTIVITY NARRATIVE

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

PMTCT scale-up.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

repairs.

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

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

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

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

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

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

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

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

facility.

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

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

New/Continuing Activity: Continuing Activity

Continuing Activity: 18843

Continued Associated Activity Information

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

System ID System ID

18843 18843.08 Department of Regional 8275 8275.08 RPSO $600,000

State / African Procurement

Affairs Support

Office/Frankfurt

Emphasis Areas

Construction/Renovation

Health-related Wraparound Programs

* Child Survival Activities

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:

Renovation of ART hospitals

ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS:

Global price escalation for food and oil has placed an unexpected burden on localized populations. A trickle-

down effect in increased shipping costs worldwide acutely impacts landlocked nations like Ethiopia. Yet,

BRICIT (Brazil, Russia, India, China, Indonesia, Turkey) nations particularly have developed an insatiable

demand for raw materials as their markets develop and expand. Thus global demand for construction

components - Portland Concrete Cement (PCC) and Rebar, has increased the premier on which such

commodities are acquired. In conjunction with these external factors as well as those internal to Ethiopia,

concrete prices have risen from ETB 60 ($6.19) to ETB 290 ($29.93) per 100kg, a nearly five-time increase.

Rebar has seen an equivalent markup from ETB 6 to 7 ($0.62) to ETB 24 to 35 ($3.62), a nearly six-fold

increase.

Construction and renovation efforts underpin PEPFAR's sustainability goal by providing much needed

health systems strengthening support in Ethiopia. Together, they also represent cross-cutting activities that

impact nearly all programmatic theaters from Lab to Palliative Care of Care & Support. Facility-level

rehabilitation is targeted to PMTCT/ANC & all MCH services, Lab, Pharmacy, ART (adult & pediatric), HCT,

TB/HIV and Palliative Care. To-date, approximately 54 hospitals and 2 regional labs have undergone some

form of renovation. With the removal of codicil and rider constraints, the scope of rehabilitative work

needed for long-term sustainability can now be fully realized. Thus, another two (2) regional labs and one

(1) hospital are underway via this novel comprehensive rehabilitative policy.

Deficiencies at these facilities are many - examples include (but are not limited to), foundation settlement,

rampant crack & fracture prorogation, waste not properly segregated or disposed, pregnant women utilizing

bathing and drinking water out of toxic drums. These facilities are failing to serve their constituents with safe

and quality health care. Thus, system-level changes are required to implement waste management and

wastewater control, fire alarm & protection, and upgrade of public works and electrical wirings, water

purification, infection control, lighting are core and key requirements. The establishment of privacy (hearing,

visual), wayfinding, safety, and maintenance programs and landscaping are other key features to be

undertaken additionally. The clinician-patient relationship will be radically changed in which medical

personnel will move between rooms instead of the patient navigating a multitude of spaces and locations.

With the inclusion of art, healing gardens, and daylighting, such facilities will effectively communicate that

they are welcoming healing centers of quality health care. Together, all of these activities represent a critical

and fundamental perceptual shift for both patient and health worker experiences - real and tangible quality

health care delivery.

Green/clean technology implementation will be provided through such mechanisms as:

•Bio-gas generation - recycles human and organic waste into fuel. Byproducts include nutrient-enriched

fertilizers and increased sanitary waste disposal options.

•Solar energy extraction - co-generation (heating, electricity) and hot water heating

•Daylight harvesting and energy-efficient electrical lighting

•Waterless urinals and sensor, touch-free fixtures

•Low, no, zero VOC paints and finishes

•Reflective metal cool roofing

•Rainwater collection

These are vital for optimized use of scarce water resources and unsupported electricity needs. Again, all

activities lend themselves towards the creation of a safe, comfortable and welcoming environment that

empowers patients and staffers alike.

US-based universities will continue to be relied upon for minor to intermediate renovation efforts, as well as

furniture and equipment installations. The University programs, in tandem with GoE efforts, (MOH, RHBs)

have contributed significantly to the prioritization process of most critically-needed hospitals. Support gaps

that could arise in furniture and equipment procurements are expected to be filled by these same

stakeholders.

Collaboration continues with MOH, MOH/PPD, and EHNRI. A prototypical design for regional laboratories

has been successfully generated, standardizing operational layouts and services, which, going forward, will

be used throughout Ethiopia. Crown Agents continues to be a collaborator and partner in assessing and

enhancing health center-level facilities. Information and resource sharing is best highlighted via the national

coordination and tracking system, well-tracking, how, when and by whom work is being accomplished.

Guidelines established through Crown Agents will direct efforts for emerging region health center

rehabilitation additionally.

Coordination and standardization of construction practices have commenced between the Global Fund, the

Clinton Foundation, ands other donors. US/IBC (International Building Code) is becoming de factor for

USG and donor-led entities alike. A parallel effort has been demonstrated within Ethiopia at the facility-level,

and continues to gain traction.

COP08 Narrative:Renovation of ART hospitals

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

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

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

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

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

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

links with a national architecture and engineering firm (A/E firm) and are familiar with construction

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

Activity Narrative: regulations.

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

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

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

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

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

services.

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

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

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

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

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

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

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

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

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

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

develop the national renovation guidelines.

Accelerated renovation using simple construction materials (Prefabricated materials) will be implemented

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

Such constructions are expected to be completed quickly and made available for services in less than a

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

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

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

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

New/Continuing Activity: Continuing Activity

Continuing Activity: 16610

Continued Associated Activity Information

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

System ID System ID

16610 6456.08 Department of Regional 8275 8275.08 RPSO $7,686,191

State / African Procurement

Affairs Support

Office/Frankfurt

10410 6456.07 Department of US Department of 5476 116.07 $0

State / African State

Affairs

6456 6456.06 Department of US Department of 3747 116.06 $0

State / African State

Affairs

Table 3.3.09:

Collaborative Office Building Renovation for Management & Staffing

ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS:

Global price escalation of food and oil, as well as shipping costs, has placed an unexpected burden on

localized populations. Global demand for construction components - Portland Concrete Cement (PCC) and

rebar, has increased the premia for such commodities. In conjunction with these external factors, internal

forces have driven Ethiopian concrete prices and rebar prices higher, five and six times respectively over

the past 18-24 months. Also, the rapidly growing foreign exchange shortage, especially US dollars, is also a

contributory factor. And the importation of 1.4 million metric tons of PCC by the GoE highlights other internal

constraints.

EHNRI continues to play a pivotal role in health systems strengthening activities within Ethiopia. Appropriate

investment in infrastructure in which organizations empower its people to action for quality and effective

health care delivery cannot be underestimated. Thus, the Collaborative Office building renovation will

continue knowledge-transfer and systems strengthening needed for sustainability throughout Ethiopia.

FY 08 ACTIVITY NARRATIVE

Management and Staffing (HVMS) Renovation of Office Building

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

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

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

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

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

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

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

New/Continuing Activity:Continuing Activity

New/Continuing Activity: Continuing Activity

Continuing Activity: 19567

Continued Associated Activity Information

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

System ID System ID

19567 19567.08 Department of Regional 8275 8275.08 RPSO $2,066,700

State / African Procurement

Affairs Support

Office/Frankfurt

Emphasis Areas

Construction/Renovation

Human Capacity Development

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.19: