During COP09, RPSO provided contracting services Renovation and Construction (Ren/Con) activities recommended by CDC. On December 18, 2009, CDC-E received formal guidance from HHS/CDC that new PEPFAR Ren/Con activities may no longer be procured through RPSO based on requests from CDC. At this point, all new Ren/Con activities must therefore be implemented using non-RPSO mechanisms, ie, CDC-Atlanta issued grants or cooperative agreements, or another PEPFAR implementing agency (USAID or DoD). The new TBD partner will continue to provide existing contracting services required to guarantee the delivery of high quality Outpatient Department Annexes and Regional Laboratories that are, or will be, designed using international standards of acceptance with the goal of improving the standard of health care for HIV/AIDs patients.

In addition to being an important diplomacy tool of PEPFAR, this improvement of infrastructure is essential for the improvement of health care delivery and will directly lead to the Partnership Framework's goal of reducing HIV incidence and AIDS-related mortality while building the health system in a sustainable manner. New comprehensive facilities will reduce the stigma that currently follows HIV patients reluctant to enter "HIV" centers. Providing new outpatient departments (OPDs) in existing hospital settings greatly increase the chance of providing a facility where health care workers and equipment are already available. Existing buildings that will become vacant can be used for storage centers which are also lacking in existing health care facilities. Designing and constructing health facilities according to international design standards will provide longer lasting facilities that Health Workers will be proud to work in, thus reducing maintenance costs while increasing the retention of health care workers.

The mechanism will provide an increased standard of health care quality to areas where concentration of ART patients is the highest. Assessments indicate that the construction of OPDs and Regional Labs for 40 identified government hospitals will provide a new standard of care to the vast majority of all ART patients throughout every region in Ethiopia. These new integrated facilities will also be instrumental in providing greater comprehensive and quality ANC, PMTCT, and TB services.

Although the renovation of some facilities may be possible, most renovation projects are not cost effective with many unforeseen challenges. In light of the many aging and decrepit health facilities in Ethiopia, renovations are only temporary band-aids that have been applied multiple times to the same wound. Renovating one or two building systems may still not provide a safe, hygienic, health facility. One of the main responsibilities of the partners in this IM is to review the assessments already being performed on the existing hospitals and determine the most cost effective means of improving the infrastructure. The TBD partner will be required to follow CDC's technical advice and procure contracts that will provide the greatest improvement within the allowable budget.

This narrative is submitted for review because it includes new construction. Out of the total budget requested for renovation and construction (RenCon) of comprehensive outpatient departments (OPD), 70% has been attributed to adult treatment. Currently 40 outpatient departments in high-volume hospital outpatient departments have been assessed and prioritized for RenCon. These 40 sites currently account for 80% of all the ART patients being managed at hospital outpatient departments, which account for 69% of all patients on ART in Ethiopia. Several of these sites have in excess of 10,000 patients in pre-ART care and are operating under difficult conditions and inadequate infrastructure. Appropriate infrastructure improvement will contribute to the delivery of quality care and improve staff morale and patient retention. The TBD RenCon partner will be supported with technical assistance from two qualified engineers on the CDC-Ethiopia team. Three sites are nearly completed and work is commencing on three others. Other PEPFAR partners will continue to carry out minor to moderate renovationsI in other sites needing infrastructure improvements.

OPD annexes exemplify integrative health service delivery. Ideal-sized exam spaces will promote efficient workflow and staff/patient comfort. Internal furnishings, when necessary, will be procured through other funding resources. Integration of HIV services, specifically family-centered treatment in this case, is more challenging for large hospital sites. Substantially more investment is needed at these sites, given their size and complexity.

A shift from disease-focus to patient-focus is particularly essential for pediatric ART patients. Immunization services have been co-located with other services including MCH/RH with Pediatrics whenever OPD annexes are optimal. Otherwise, services are regrouped within existing buildings to the extent possible.

The unique needs of smaller-sized patients are being incorporated into appropriately designed clinical spaces that bring ease and comfort in an otherwise fearful experience. Dedicated exam rooms for pediatric patients are being provided, as such medical spaces are routinely absent. Other additions include a kid's play area to reduce the intimidation factor commonly associated with youthful patients in medical settings.

All 40 prioritized hospitals could sufficiently provide pediatric-friendly examination room furnishings could be provided to these same sites. Ideally, such furnishings would supplement US university partner efforts whenever shortfalls may occur. Seamless flooring can be provided in more locations, specifically for Peds than normally could be done otherwise to help advance infection prevention controls.

Regional laboratories will also be supported under this Infrastructure Improvement project. Existing regional labs are 200-400 m2 with a compendium of single-story chaotically placed buildings. The two-story prototypical design ensures commonality throughout Ethiopia as well as support accreditation efforts where BSL-3 TB culture compliance is met for instance. Each floor, approximately 750 m2, has been designed to optimize workflow patterns between and among lab sections. Dedicated conference and general lab training spaces allow for expeditious scale-up of additional laboratorians to enter the workforce at all health facilities. Single-point consolidation of all laboratory services, in line with MOH/EHNRI directives, at hospitals will be supported as funding availability will be a major determinant.

Due to limited budget resources, both wastewater and medical waste systems implementation will become cost prohibitive at all regional lab sites, thus requiring their prioritization. Furthermore, any wastewater and medical waste solution rollout at large ART patient hospitals will not be possible for those outside of the clustered model. An expanded clustered model to incorporate nearby health centers may be possible, however logistics management of waste streams from multiple sites to a single treatment location present several challenges including transportation when other sites are many kilometers away

Because this activity is construction, it will be included with the streamlined COP10 submission. Infrastructural investment in PMTCT represents 30% of the overall renovation and construction (RenCon) budget in COP10. RenCon efforts support integrative health services and PMTCT integration into MCH/Reproductive Health services in the clinical setting. The rehabilitation of MCH spaces is ultimately coordinated with other ART and HIV-related RenCon work for seamless execution and completion. Partners supporting newly upgraded sites will monitor and document the expected increase in PMTCT and ANC clients, among other patient uptakes.

Sadly, pregnant mothers can be often found sitting in crowded, unhygienic settings or struggling to navigate large campuses to disparate MCH services that lack privacy. Hospital deliveries can put both the mother and newborn in jeopardy when there is only one or insufficient operating rooms available on-site.

Continuation of last year's RenCon strategy focuses on safe and hygienic comprehensive maternal, antenatal, perinatal, and postnatal care in the continuum of PMTCT. This includes labor and delivery, family planning, ANC, Ob/Gyn, surgical, recovery, and partum suites. The most advantageous integration of these services with other HIV services is best-suited for OPD annexes, which is determined from robust site assessments for each location. Hospitals with large delivery and related emergency surgical needs require the largest and most immediate investment.

A shift from disease-focus to patient-focus is particularly essential for pediatric ART patients. Immunization services have been co-located with other services including MCH/RH with Pediatrics whenever OPD annexes are optimal. Otherwise, services are regrouped within existing buildings to the extent possible.

The unique needs of smaller-sized patients are being incorporated into appropriately designed clinical spaces that bring ease and comfort in an otherwise fearful experience. Dedicated exam rooms for pediatric patients are being provided, as such medical spaces are routinely absent. Other additions include a kid's play area to reduce the intimidation factor commonly associated with youthful patients in medical settings.

All 40 prioritized hospitals could sufficiently provide pediatric-friendly examination room furnishings could be provided to these same sites. Ideally, such furnishings would supplement US university partner efforts whenever shortfalls may occur. Seamless flooring can be provided in more locations, specifically for Peds than normally could be done otherwise to help advance infection prevention controls.

Regional laboratories will also be supported under this Infrastructure Improvement project. Existing regional labs are 200-400 m2 with a compendium of single-story chaotically placed buildings. The two-story prototypical design ensures commonality throughout Ethiopia as well as support accreditation efforts where BSL-3 TB culture compliance is met for instance. Each floor, approximately 750 m2, has been designed to optimize workflow patterns between and among lab sections. Dedicated conference and general lab training spaces allow for expeditious scale-up of additional laboratorians to enter the workforce at all health facilities. Single-point consolidation of all laboratory services, in line with MOH/EHNRI directives, at hospitals will be supported as funding availability will be a major determinant.

Due to limited budget resources, both wastewater and medical waste systems implementation will become cost prohibitive at all regional lab sites, thus requiring their prioritization. Furthermore, any wastewater and medical waste solution rollout at large ART patient hospitals will not be possible for those outside of the clustered model. An expanded clustered model to incorporate nearby health centers may be possible, however logistics management of waste streams from multiple sites to a single treatment location present several challenges including transportation when other sites are many kilometers away