This is a continued activity aiming at expanding ART service at private higher clinics. Despite a delay in the initiation of ART through private clinics, the Private Health Sector Program (PHSP) during FY 2009 overcame many of the policy issues that were barriers for the expansion of ART services at private sector run clinics. PSP is now on track to expand to an initial 16 private higher clinics in Addis Ababa with the vision to expand to 60 private clinics in major urban centers during succeeding years. Better quality and confidentiality offered at private clinics will provide an option for ART clients who are economically better off who may opt to follow treatment at private clinics.

PHSP will finalize minor policy issues related to the expansion of ART at private clinics, especially the provision of ART drug dispensing. It will also provide refresher and continued comprehensive clinical training for professionals at 50 private clinics and evaluate clinical outcomes, both on individuals and as a cohort, using CD4, weight and functional status as monitoring parameters. Adherence to treatment will be facilitated through counseling by ART nurses and linkages with community health workers supported by partner organizations. At initial stage, implementation will be aimed at 8 selected higher clinics after joint assessment and selection process with AA regional health bureau.

PHSP will also work to improve the quality of laboratory services through supportive supervision and the use of QA and QC tools and build the capacity of RHBs, District and City health offices to supervise private sector providers. PHSP aims to increase the demand for health services at private clinics through awareness creation. The program will prioritize identification and enrollment of pregnant women for ART in selected high-volume private clinics. The activity will ensure that private facilities which provide integrated TB and HIV services will have strong functional linkages between TB and HIV services.

This is a continued activity. PHSP will implement activities in support of expanding access to and demand for HIV counseling and testing services. The type of activity for HCT services will be mainly client-initiated testing and a mobile outreach activity. The mobile HCT will target MARPS and vulnerable groups such as CSWs, daily laborers, truck drivers, university students and women. The geographic coverage of the mobile HCT activity will be on urban centers and small towns along the high-risk transportation corridors. In providing mobile HCT, PHSP will use the national testing algorithm.

The activity will expand mobile HCT services in parallel with expanding long-term, facility-based CT services in the workplace and for-profit private clinics. The program takes into consideration the challenges posed by the intermittent nature of mobile CT services, especially the linking and channeling of demand created by social mobilization for the mobile HCT towards facility-based CT services.

Supervision of the mobile HCT activity will be done jointly with Regional HAPCO offices and PHSP mobile HCT field officers, using nationally approved supervision tools. In order to ensure quality of service, aside from field supervision, PHSP will ensure that HCT services are provided only by qualified health workers. After every round of services, selected test results will be sent to regional labs for quality control. The test results will be recorded using nationally approved HCT formats and forwarded to city health offices.

PHSP understands the importance of linking HIV-positive clients to treatment facilities; providing care and support services is key to implementing successful mobile HCT services. PHSP will continue to strengthen referrals and linkages so that clients who receive HCT will be efficiently referred to treatment and care providing facilities.

This activity comprises seperate entities: (1) The absence of a comprehensive accreditation manual for health facilities and a proactive monitoring tool to help facilities improve their services is a critical barrier for quality delivery of health services. Poor state of health education in the country and the lack of appropriate screening mechanisms to ensure that training graduates have learned the essential materials of a training program are major barriers that impact on the quality of health services. There is also a push to increase the number of health professionals being graduated. While this might address the current shortage of manpower, if they are not well trained, they may deliver substandard services which impact negatively on the quality of the program. The following core activities in the quality assurance program are aimed at addressing these barriers.

Medical services: The implementing partner will support the production of comprehensive licensing and accreditation manuals for different health care providers, under the leadership of DACA. The implementing partner will engage different professional bodies to get their buy-in for the accreditation program. Capacity building of DACA and Regional Health Bureaus: The implementing partner will work to build the capacity of DACA and regional health bureau staff to implement comprehensive licensing and accreditation manuals and implementation of practice of the incentive based monitoring exercise through supportive supervision. The implementing partner will work with the central DACA office and the five regional health bureaus in Addis Ababa, Oromia, SNNPR, Amhara, and Tigray. The QA activities will be linked to other health system activities supporting pre-service training programs. The following are key indicators for the QA program: national dissemination of the accreditation and licensing manual, number of staff trained on the implementation of incentive based supportive supervision in DACA and the five regional health bureaus. (2) The activity provides specialized technical assistance to financial and micro credit institutions to improve lending practices. By working with local financial institutions to promote the health sector and lending to microcredit institutions, including bank training, loan product development, market assistance and close lending to microcredit institutions, including bank training, loan product development, market assistance and close collaboration with USAID's Development Credit Authority (DCA) program the technical assistance has the ability to improve the credit-readiness among recipients. Training and technical assistance also addresses skills to improve business skills, access loans and implement on-going financial management. Additionally, the technical assistance provider will build market linkages for private providers or micro credit institutions, financial institutions and other business support providers.

In FY 2010 this activity will provide technical assistance to private sector participants including bank employees, private health practitioners and microcredit/finance providers to support business and loan training to improve access commercial credit activities by private health providers and microcredit providers. Training initiatives would target commercial banking staff to catalyze lending to private health and microcredit institutions. In addition basic networking activities between banks, insurance companies and the private health sector will occur.

This activity is linked to activities addressing private sector providers including hospitals, higher and medium clinics, laboratories, pharmacies and private medical teaching institutions. In addition, there is a link between the technical assistance being provided through training? partners who are addressing pre-service curriculum adaptation and private health colleges. (3) 'The activity provides specialized technical assistance to financial and micro credit institutions to improve lending practices. By working with local financial institutions to promote the health sector and lending to microcredit institutions, including bank training, loan product development, market assistance and close lending to microcredit institutions, including bank training, loan product development, market assistance and close collaboration with USAID's Development Credit Authority (DCA) program the technical assistance has the ability to improve the credit-readiness among recipients. Training and technical assistance also addresses skills to improve business skills, access loans and implement on-going financial management. Additionally, the technical assistance provider will build market linkages for private providers or micro credit institutions, financial institutions and other business support providers. In FY 2010 this activity will provide technical assistance to private sector participants including bank employees, private health practitioners and microcredit/finance providers to support business and loan training to improve access commercial credit activities by private health providers and microcredit providers. Training initiatives would target commercial banking staff to catalyze lending to private health and microcredit institutions. In addition basic networking activities between banks, insurance companies and the private health sector will occur.

This activity is linked to activities addressing private sector providers including hospitals, higher and medium clinics, laboratories, pharmacies and private medical teaching institutions. In addition, there is a link between the technical assistance being provided through training? partners who are addressing pre-service curriculum adaptation and private health colleges. (4) 'This is a continuing activity. This activity supports implementation of the Development Credit Authority funded in FY2008 on health sector by PEPFAR and will provide support to a COP09 Development Credit Authority with the aim of increasing access to commercial credit for private health institutions who wish to improve quality of service by upgrading the technical and managerial capacity. The program will be collaborating with local private banks to increase their confidence so that loan portfolio to the health sector increase so more and more private health institutions will have access to credit. Currently the commercial credit is largely given out to the construction sector. Due to high collateral, small private clinics and retail drug stores are unable to access credit from private banks. The PEPFAR DCA fund will be used to establish a risk sharing mechanism with selected private banks for loans provided to private health clinics. PEPFAR DCA fund will be used to guarantee a portion of potential lose due to defaulting private clinics or retail drug stores. It is expected that the banks will lower their collateral in their loans to private health institutions as a result of PEPFAR DCA guarantee. The decrease in collateral for private health sector is expected to increase demand for credit loan products among the private health sector institutions.

The program will work both from the supply side to improve lending practice and work on the demand side to promote awareness among the private health institutions. The program will be implemented in towns and cities with high HIV prevalence including Addis, Amhara region, Oromia Region, SNNPR, and the emerging regions like Gambella, Afar. The target beneficiaries are small and medium level clinics that provide largely outpatient care, small drug stores and vendors, private laboratories and medical teaching institutions.

The HVOP program is linked to other component programs implemented by PHSP, including the mobile HCT services and facility-based STI, TB and HIV services at private clinics. PHSP will work to satisfy the demand created as a result of social mobilization for HIV testing activities. PHSP will promote the proper and consistent use of condoms among high-risk and vulnerable groups, such as commercial sex workers, daily laborers, truck drivers, university students, women and other vulnerable groups.

Barriers to condom use and attitudes and knowledge on condom use in the context of HIV and family planning (FP) will be assessed through a meta-analysis of existing research. Health information-education-communication packages will be disseminated at large and medium-size companies and private health facilities along the high-risk corridor where the mobile HCT is provided. The geographic coverage of the program will be largely in the urban centers and towns along three high-risk corridors (Addis Metema; Addis- Dijibuti; Addis-Moyale routes). The health IEC package will feature other common health problems, including malaria, TB, FP, and diabetes which will maximize benefits from costs associated with developing and disseminating these materials. The packaging of HIV-related messages with other messages will have cost savings and increase listener attentiveness.

PHSP will have field officers that will be trained to teach negotiation skills for women to use and demand the use of condoms during sexual encounters. The quality of the promotion activity will be monitored with field technical officers who will ensure that condoms are distributed to vulnerable groups and that high-risk individuals receive information on the benefits of correct and persistent condom use.

In addition, performance-based contracts will be outsourced to local private institutions to promote early treatment seeking for STIs, create awareness of the link between STIs and HIV, and distribute STI drugs to private and company based clinics. This activity will also engage pharmacies and druggists to refer STI cases to facilities and will train and build the capacity of private company clinics for STI management and condom use.

This program supports selected private clinical laboratories in Addis Ababa where a significant amount of HIV and TB related laboratory services are provided through the private sector. Anecdotal data suggest that 50% of HIV counseling and testing and 20% of TB diagnosis in Addis Ababa occurs in the private sector. Due to the variability of service quality and the limited capacity of the government to regulate the sector, it is necessary to provide laboratory technical assistance to the private sector.

The activities to be carried out, through technical assistance and collaboration with EHNRI, will work to strengthen the capacity of five private laboratories to provide services to private clients. The project will collaborate with EHNRI to support the national laboratory strategic plan with a focus on improving quality laboratory services; develop a mechanism for branding laboratory services that meets standards set through a central accreditation process; improve the monitoring and quality control of private clinics through supportive supervision; and, advance private-public partnership in resource sharing through qualified referrals for selected services, training and shared manuals.

Facility-level activities include organizing training for laboratory staff, in collaboration with EHNRI, on lab diagnosis of communicable diseases and other conditions relevant to HIV, STIs and OIs, using a centrally developed training manual, as well as training on proper documentation of lab results to facilitate accurate forecasting, planning and budgeting; developing standard operating procedures for individual labs and providing related mentorships; collaborating with EHNRI /DACA offices to develop standard accreditation and supportive supervision tools; establishing a functional recording and reporting system that is in compliance with national recording and reporting requirements; implementing appropriate quality control and quality assurance measures to ensure an acceptable level of accuracy and precision in lab test results; and creating a functional linkage with other laboratory services for effective and efficient service continuity.

Private Health Sector Program (PHSP) will provide technical support to 94 private clinics providing TB services in four administrative regions (Amhara, Oromia, SNNPR, and Tigray) and two cities (Addis Ababa, Dire Dawa). The program will be engaged in the various core activities in implementing support for TB/HIV services at for-profit and large and medium company clinics.

The program will link TB service provision at private clinics with national TB policy by collaborating with the Regional Health Bureaus (RHBs) in selecting private clinics eligible to provide TB/HIV services, by ensuring the use of national TB formats for patient registration and ensuring that TB drugs are provided for free, in accordance with national policy. The program will coordinate with other partners through the national TB technical working group. In the face of high attrition among health personnel, the program will support training in participating health facilities in order to ensure sustainability of high-quality services in the private clinics.

PSHP will implement a monitoring and evaluation activity that includes supportive supervision, conducted jointly with RHBs. Further, it will support external quality control activities to ensure high quality laboratory diagnosis.

The establishment of a public-private referral network, the initiation of TB services in more than 50 new facilities, and the use of a supportive supervision tool to standardize monitoring and evaluation are key achievements upon which the program will build in the COP 2010. A tracking mechanism for TB defaulters at the facility level and connecting activities at private clinics to community level activities remains a challenge. PHSP will collaborate with partners working at the community level to help establish a tracking mechanism for TB patients at private clinics.

PHSP will provide technical support for the integration of HIV prevention and counseling activities into workplace clinical settings, using existing materials. Also, the project will conduct an internal evaluation to assess the effectiveness of the HIV prevention program in FY2010.