The purpose of the project is to expand the competencies of individual nurses and the capacity of nursing schools and professional nursing organizations so that they are able to intervene appropriately to the demand of task shifting.

The ICAP Nurse Capacity Initiative will address the political, professional, and legal/regulatory barriers to the evolution of nursing roles and responsibilities that will be required to achieve PEPFAR goals and strengthen weak health systems in line with partnership frame work goals.

The proposed ICAP Nurse Capacity Initiative (INCI) draws upon the strengths of Columbia/ICAP Ethiopia's deep knowledge of capacity-building and nurse workforce training and is complemented by their robust experience in supporting Federal HIV/ AIDS Prevention and Control Office at national level and in implementing multidisciplinary HIV programs in Oromia, the biggest region of Ethiopia and also in Somali; Harari regions and Dire Dawa City Administration. INCI will be implemented by CU/ICAP Ethiopia at national level .

The INCI is designed to maximize local capacity-building while strengthening and expanding the role of nurses in the delivery of HIV prevention, care, and treatment services. Rapid start-up can be achieved by leveraging ICAP's existing offices, programs, and partnerships with the government of Ethiopia. ICAP partners with Ministries of Health (MoH) to support national HIV/AIDS programs and to implement HIV services from rural health centers to tertiary referral hospitals, creating and enhancing effective linkages between communities, programs, and facilities. ICAP works closely with local partners and colleagues, including non-governmental organizations, faith-based organizations, community-based organizations, associations of people living with HIV/AIDS (PLWHA), professional organizations and universities. Strengthening indigenous partners and health systems is an ICAP priority, and the organization routinely provides support and hands-on technical assistance for training mentoring, strategic planning, management, finance, administration, and development.

The program will address the overwhelming challenges that nurses face following their pre-service training. Severe human resource shortages result in long lines of patients with not enough providers to see them. In addition, nurses often face high stress, unhygienic an unsafe working environments, outdated equipment, long shifts, and poor remuneration. These poor working conditions have contributed to the low motivation of nurses in the country . In order to respond to the high demand for health care workers, many facilities and programs have informally relied upon task shifting which has attracted considerable interest. However experts note the need for cautious application of such innovations to ensure that lower level workers are not simply loaded with new tasks. A systematic and carefully evaluated plan is required to augment human resources for health and to remedy in adequate public health services. Task-shifting requires additional training and supervision and, often, changes in laws, regulations, and professional policies which limit nurses from expanding their roles within the health care system. Existing ICAP training and nursing initiatives in Ethiopia include establishment of a regionally based mentorship program for nurses, which included, but was not restricted to, the field follow-up for I-TECH's HANS Nurse Training Course. In this mentorship initiative, a trained nurse mentor coordinates and conducts clinical system mentorship (CSM) activities focusing on nursing in different HIV-related service areas within the region. ICAP-Ethiopia has supported the attendance of nurses to in-service trainings on CSM and in pediatric HIV care and treatment. In addition, ICAP-Ethiopia supports pre-service training in nursing schools in ICAP-supported regions by facilitating training for instructors. Finally ICAP-Ethiopia has developed a human resource database to track the number and cadre of health professionals trained in different HIV/AIDS related services areas at all ICAP-supported health facilities and Regional Health Bureaus in Ethiopia.

ICAP has built substantial local capacity to implement successful monitoring and evaluation: Many of the goals and objectives of the nurse mentoring program aim to impact on national systems. This impact will be measured using program-specific reporting forms and a simple database to track indicators such as trainings and revisions to curricula and national guidelines over time. ICAP will develop a new Human Resources database to track retention of nurses and other clinical staff in facilities where nurses have been trained which will be standardized and implemented across all regions in the country . Additional National level evaluation will be done via the repeated needs assessment process, which will give insight into the changes in nursing roles, policies, organizational capacity, and expansion of nurse leadership.

The use of monitoring and evaluation (M&E) data at the local level i.e., at service delivery sites is critical for effective program planning and the design of real-time interventions to improve programs and patient outcomes. All of the data described above will be analyzed so that information can be used to feed back into programming and allow early recognition of, and intervention into, program challenges. It is anticipated that data analysis will occur on a quarterly basis.

Fundamental to ICAP's work is a commitment to sustainability. Solid in-country partnerships-with national ministries of health (MOH), provincial and district health teams, local universities and research organizations, community groups, organizations of people living with HIV/AIDS, and others-raise the quality of and capacity for prevention, care, and treatment in a way that facilitates the transfer of skills and ensures new programs/ longevity. ICAP uses the innovative approach called Clinical Systems Mentorship (CSM) to build programmatic capacity and solidify infrastructure. This methodology applies to the facility level, as well as to the level of local and national government agencies, where ICAP routinely contributes to the strategic planning of national HIV programs and to the drafting of national guidelines and processes relating to HIV care. In all of these multilevel efforts, CSM provides an integrated, data-driven, systematic framework for quality assessment and improvement as well as health-systems strengthening.

ICAP's systems have three principal aims to make the program cost efficient: (1) to assure that ICAP is in compliance with all relevant financial and grants management regulations of the CDC, and of the Federal government more generally; (2) to assure that the funding provided to in-country institutions is effectively managed for maximum programmatic benefit; and (3) to help develop local institutional capacity to effectively and independently manage health programs in the future.

This is a new activity in COP10.There is now widespread recognition that physician-based models of care are not sufficient to address the HIV crisis in developing countries. Attention has turned now to nurses to deliver HIV care and treatment, a promising task shifting activity to sustain HIV care and treatment programs. However, nurses have not been adequately educated, trained, supported, or empowered to perform the critical and demanding tasks of organizing and providing care and treatment for patients. In direct response to these challenges, the International Center for AIDS Care and Treatment Programs (ICAP) of Columbia University proposes to collaborate with the Federal Ministry of Health (FMOH), Regional Health Bureaus (RHBs), Ethiopian Nurse Association (ENA), and other stakeholders to initiate a capacity building program for nurses. This program will implement an innovative, integrated, sustainable approach to improving nurse led HIV/AIDS services, nurse retention in the public workforce, and institutional capacity building of nursing organizations through creating the ICAP Ethiopia Nurse Capacity building Initiative (I-ENCI).

ICAP-E with unlimited technical assistance from ICAP-NY, especially for its clinical unit, will bring extensive experience in program implementation, training, monitoring and evaluation, and continuous data-driven quality improvement.

Activities will include:

1. In collaboration with the FMOH of Ethiopia, RHBs and PEPFAR implementing partners, train 24 senior nurse mentors as mentor trainers. These mentor trainers will in turn train 125 nurse mentors all over the country, and the project shall support the deployment of these nurse mentors.

2. In collaboration with ENA, advocate for enhanced nursing support to improve retention, and practical work toward policy change.

3. Implement mechanisms to closely monitor and evaluate the program.

To foster sustainability, the project is carried out in close collaboration with FMOH, RHB and ENA and works to build the capacity of these local institutes to enable them to support the program fully by the end of the project period. The partner being within PEPFAR will play its part in Global Health Initiative (GHI).