This is a continuing activity. Harari Regional State is located in eastern Ethiopia with a total population of approximately 183,344. ANC HIV prevalence in 2009 was 3.7%. The Harari Regional Health Bureau (HRHB) directly funded by PEPFAR to implement HIV program activities for preventing new HIV infections, scaling-up and strengthening ART, providing care and support to PLHIV and affected populations, improving the quality of service delivery, and effective M&E of the HIV program. It works to strengthen the health network model and the health system in the region. It will build the human resources for health and infra-structure of the health facilities providing care and treatment services.

HRHB oversees all health facilities in the region. The population served is predominantly urban, but also includes rural population around the town of Harar and neighboring region of Oromia. HRHB will maximize efficiency by leveraging resources from various sources. It will strengthen the linkage between services and facilities, including community level services, to ensure the continuum of care for the PLHIV. The HRHB program supports the goals of the GOE's National Strategic Plan (SPMII) and is aligned with the goals of the GOE and USG HIV/AIDS Partnership Framework and Global Health Initiative. HRHB will continue to work with CU ICAP to build the capacity of the RHB and transition specific program activities to ensure sustainability and strengthen local ownership. HRHB will purchase one vehicle in COP2012 at a cost of USD$55,000. The vehicles will be used to support implementation and monitoring of the program activities in the region and distribution of supplies to the health facilities. The total number of vehicles for the life of this mechanism is two.

The HRHB will recruit or assign a care and support focal person who will oversee the implementation of care and support related activities and will take over the adult care and support activities currently being implemented by the CU-ICAP. In COP 2013, the HRHB will undertake the following activities:

Strengthen the intra-facility and two way referrals and linkages between health facilities and the community.

Coordinate and harmonize work with community-based organizations (CBOs) working on HIV/AIDS care and support services, and facilitate their involvement in health facilities multi-disciplinary team and catchment area meetings; use CBOs and urban health extension workers to trace and link lost to follow-up PLHIV.

Intensify prescription of co-trimoxazole prophylactic therapy (CPT) for eligible PLHIV; consider CPT as one of the quality monitoring indicators and review its performance regularly.

Provide nutritional assessment and counseling services, and provide nutritional support to malnourished PLHIV in collaboration with partners working on nutritional support.

Integrate mental health services into the chronic care unit or link PLHIV who need mental health service to psychiatric clinics.

Strengthen PwP prevention messages and services

Strengthen pain assessment and management services for PLHIV, and improve access to pain medication for PLHIV, including morphine.

Ensure training, distribution and utilization of basic preventive care package components.

Refer and link HIV positive women for cervical cancer prevention services

In COP 2013, the HRHB will strengthen its capacity to support and monitor the TB/HIV program and integration of services in a sustainable manner through training, integrated mentorship activities, and ensuring quality of TB/HIV care.

In COP 2013, the HRHB will:

Develop a costed strategic plan for TB/HIV program support as part of the comprehensive HIV/AIDS program plan.

Strengthen TB and HIV control program coordination and integration at regional and sub-regional health care structure levels.

Undertake assessment of the TB and TB/HIV program to identify key program gaps and focus areas for the regional TB control program.

Strengthen TB program management and human resource capacity at regional and sub-regional levels through training of TB and TB/HIV control program staff.

Undertake regular supportive supervision and review meetings to monitor the TB/HIV programs.

Organize a pool of core trainer teams for comprehensive TB-Leprosy, TB/HIV and MDR-TB training at the regional level.

Organize regional TOTs and in-service trainings on comprehensive TB, TB/HIV TOTs in collaboration with local universities and partners.

Organize mentorship teams composed of RHB, health facility, local university staff, and partners to undertake mentorship of the comprehensive TB and TB/HIV control programs in health facilities in the region

Undertake TB and TB/HIV related program evaluations.

Strengthen TB diagnostic services and EQA in collaboration with EHNRI, regional laboratories, and partners.

Strengthen patient referral networks across TB/HIV delivery sites; print and distribute TB/HIV guidance documents and job aids. Support TB and TB/HIV Advocacy Communication and Social Mobilization (ACSM) activities.

In COP 2013, the core activities of the HRHB will be to build its managerial and technical capacity to take over the pediatric care and treatment program in preparation for a full transition of the support by 2015. In COP 2013, the HRHB will support implementation of pediatric care and support services in the region, in collaboration with CU ICAP. In COP 2013, the HRHB will expand its management experience in order to completely take over r the site level support in 2015. In COP 2013, the HRHB will:

Support the development of guidelines, training curricula and standard operating procedures at the national level.

Strengthen EID service delivery as well as the intra-facility linkages required to test and identify HIV positive children, and expand the service to all PMTCT sites.

Ensure all HIV exposed and infected children/adolescents receive caring and consistent psychosocial support services, including HIV status disclosure, adherence counseling and bereavement care.

Provide on-site implementation assistance, including staff support, implementation of referral systems, and support for monthly pediatric HIV/AIDS team meetings.

Provide training in pediatric care and pediatric preventive care package support.

Provide clinical mentoring and supervision to work towards a multidisciplinary approach for care of HIV exposed and infected children, and improve quality of care.

Develop and distribute pediatric health care provider job aids and patient education materials related to pediatric care and support.

Integrate child survival interventions such as immunization, safe water and hygiene, micronutrient supplement, growth monitoring, and improved infant and young child feeding.

Support nutrition assessments and counseling as a routine clinical activity and coordinate with USG and other partners for provision of food products.

Promote interventions to ensure provision of appropriate pain management for infants and children.

Link families with community-based resources after discharge.

Coordinate with other partners to support safe water interventions like point of use water treatment by disinfectant and general personal and environmental hygiene.

In COP 2013, HRHB/ Regional laboratory will work closely with ICAP-Ethiopia to facilitate the transition of laboratory program activities in the region. The HRHB/Regional laboratory will:

Conduct baseline assessment of laboratories to be enrolled in SLIPTA, participate in SLIPTA training, and mentor participating laboratories.

Procure ancillary laboratory equipment and safety materials to support laboratory accreditation through SLIPTA.

Collaborate with Haramaya University and ICAP-Ethiopia to conduct training on laboratory quality management systems, laboratory management, HIV rapid testing, laboratory safety, and ART monitoring.

Establish central equipment maintenance capacity through employment of equipment maintenance engineers, training of the maintenance engineers and procurement of preventive maintenance tool kits and calibration equipment. The workshop will have the capacity to maintain ancillary equipments, conduct calibration, and provide preventive maintenance for larger equipment.

Strengthen the Regional EQAS program and increase coverage of facilities in the region. The Regional Laboratory will implement process improvement informed by REQAS performance. The rRegional laboratory will procure equipments and supplies required for regional EQAS.

The Regional Laboratory will organize regional laboratory program review meetings.

The Regional Laboratory will collaborate with EHNRI to establish data management capacity (Data base) for major laboratory program areas such as training, sample referral networks, EQA, SLIPTA and equipment maintenance.

Closely work with EHNRI, the postal service and ICAP-Ethiopia to strengthen sample referral networks. The Harari Regional Laboratory will train laboratory personnel on sample referral networks, and monitor network performance. The Regional Laboratory will procure sample transportation and storage materials to strengthen the sample referral network.

Will strengthen the microbiology laboratory service at the regional laboratory to support referral testing, disease surveillance, and outbreak investigation in the region.

Strengthen laboratory monitoring of patients including sample referrals.

Starting in COP 2013, in the SI program area, the HRHB will support and strengthen monitoring and evaluation of the HIV program activities in order to be able to report on PEPFAR indicators for the region, and to utilize data at site level and regional level to inform evidence-based planning and quality improvement. The HRHB will manage the smooth transition of key technical and managerial activities from CU ICAP to the Regional Health Bureau (RHB). Technical and management support includes, but is not limited to, on-site mentoring and supportive supervision, coordination of in-service training through collaboration with local universities, and implementation of a monitoring system that will result in capacity to report on PEPFAR performance indicators. In COP 2013, the HRHB will:

Effectively transition key technical and managerial activities to the RHB.

Assign M&E/HMIS staff and HIT/Data clerks that will be trained in HMIS and HIV/AIDS data management and take over full responsibilities from the existing international TA partner working on this.

Use site level performance data for informed decision making.

Work together with the international TA partner to take over the reporting on PEPFAR performance indicators.

Document its activities, share best practice, undertake monitoring and evaluation of the program, and provide site supportive supervision.

Conduct regular regional review meetings.

Collaborate with the international TA partner and local universities to strengthen the M&E unit of the RHB through SI specific in-service trainings.

This is a new activity to be implemented by the HRHB.

Health system strengthening remains a priority for the Government of Ethiopia (GOE) and all stakeholders in the health sector as weaknesses in the health system are critical barriers to achieving country capacity to sustain the response to HIV/AIDS over time. The goal of this program is to build the technical and managerial capacity of the HRHB to successfully transition technical and management support for the implementation of comprehensive HIV prevention, care, and treatment services. In particular, this program will be geared toward supporting the implementation of strategic objective 5 (improve quality of health care), strategic objective 6 (enhance harmonization and alignment), and strategic objective 13 (improve human capital and leadership) of the GOEs Health Sector Development Program IV (HSDP IV).

In COP 2013, the HRHB will work closely with local universities to coordinate the implementation of pre- and in-service training, support the deployment and implementation of human resources information system (HRIS), support and coordinate the implementation of hospital reform and quality improvement programs, conduct regional joint supportive supervision with implementing partners, support regular health sector review meetings, disseminate policy documents, implementation guidelines, best practices, and evaluation findings. The HRHB will work closely with the USG and other partners to avoid programmatic duplication and to synergize activities for optimal use of resources.

The HRHB blood safety program will implement the following activities in COP 2013:

The HRHB will manage and coordinate collection and testing of blood from voluntary non remunerated donors through a stationary collection site and a mobile outreach team. One mobile team will be established under the regional blood bank. The Harari Regional Health Bureau will assist the blood bank in setting up mechanisms for pre and post donation counseling, donors test result notification for transfusions, transmissible infections (TTIs), and referral to health facilities for those who require clinical care. To meet the need for safe blood in the rapidly expanding health care facilities in the region, the HRHB has set a target of collecting, testing and distributing 4000 units of blood in COP 2013.

The HRHB will coordinate and facilitate training of hospital clinical staff on appropriate clinical use of blood to ensure the safety of the recipients and reduce poor transfusion practices. At least one clinician from each transfusion hospital will receive a TOT training on the clinical use of blood from WHO to cascade the training to clinical staff working in each transfusion hospital in the region. To build the capacity of the HRHB on blood safety, approximately 20 professionals drawn from the HRHB and the blood bank will be trained on blood bank management, donor recruitment, blood testing, and processing by WHO and the FMOH/NBTS.

Recruitment of blood donors is an important component of transfusion services. Therefore, HRHB will assist the blood bank in the region to create public awareness around blood donation and community mobilization, development, dissemination, and utilization of communication materials. This will include the use of different communication channels such as print and electronic media for blood donor education, mobilization, recruitment, and retention. It will also assist with the establishment of community blood donors clubs with the support of the existing regional blood bank.

In collaboration with WHO the HRHB will roll out quality management systems to blood banks in the region and assist the blood bank and hospitals in setting up a mechanism and systems for M&E of the regional blood safety program.

The HRHB will also assist the blood bank and hospitals to set up and maintain a cold chain system for proper storage and transportation of blood and blood products. The HRHB will therefore assist with the effort to furnish the blood bank and hospitals with appropriate cold chain equipment to ensure correct temperatures for the storage and transportation of blood.

The HRHB will support the establishment of blood bank hospital linkages by mapping all facilities within a 100 kilometer radius that are eligible to provide blood transfusion services and will assist the blood banks and hospitals in the region to establish haemovigilance and a review system, in addition to supporting the establishment of transfusion committees in all transfusion hospitals in the region.

Medical Injection/Infection Prevention (IP) procedures are important components for providing quality health care services and to prevent the transmission of HIV and other diseases. The international TA partner has been implementing various activities in health facilities under the management of the HRHB, which includes technical support through training, provision of basic IP/personal safety equipment, ISS, and clinical mentoring..

In COP 2013, some of the IP and patient safety activities will be transitioned to the HRHB, to support health facilities focusing on building IP management capacity through providing trainings, printing and distribution of IPPS guidelines, integrating injection safety and waste management practices into all OPD/IPDs in the facilities, and procuring and distributing selected standard IP commodities.

The HRHB will work closely with the health facilities under its management, other implementing agencies, and the IP committee in all health facilities, to build capacity through mentoring of clinical staff and waste handlers, ISS, and providing IP support materials. This support will include assistance with planning for cost effective, appropriate, and environmentally friendly waste management techniques at the facility level. The HRHB will assist the health facilities to continue work on ventilation of TB wards and complete the MDR/XDR TB prevention activities. It will also assist with implementation of a continuous quality improvement assessment on the injection safety activities and closely monitor infection prevention and waste management activities at the facility level to identify and close gaps in collaboration with the IP committees at health facilities.

In the past, ICAP has been supported HIV testing and counseling (HTC) services in health facilities of the Harari Region. In COP 2013, in collaboration with the USG international TA partner, some of the HCT program activities will be transitioned to the Harari RHB. In COP 2013, the Harari RHBs HCT program will:

Support the implementation of VCT services including couples/partner and family testing and counseling, and routine HIV testing at point-of-care (POC) in all health care facilities where the service is provided.

Strengthen pediatric PITC in all entry points at all health facilities including in pediatric inpatient facilities, under five outpatient departments, therapeutic feeding units, and immunization outlets.

Work with partners to implement index case testing in hospitals and health centers.

Build human resource capacity through onsite training of health care workers on couples and individual HTC and PITC.

Strengthen systems through regular mentorship and supportive supervision to ensure quality HTC service delivery.

Support HIV rapid testing and quality assurance through regular supervision of laboratories.

Develop SOPs for HTC activities.

Establish stronger HTC related partnerships at national and regional levels and provide technical and logistic support to sites implementing HTC services.

Work in close collaboration with the USG international TA partner.

Since 2005, CU ICAP has been supporting the HRHB to strengthen STI services and program activities in all the hospitals in the Region.

In COP 2013, the following STI program support activities will be transitioned to the HRHB to ensure sustainability and local ownership of the STI/HIV program by the region.:

Strengthening the capacity of HCWs in HRHB to diagnose and treat STIs/HIV. Health care providers from public health hospitals and health will be trained on syndromic management of STIs.

Improving the linkage of STI/HIV / AIDS services through provision of PITC for STI clients at public hospitals and health centers. At least 80 percent of STI patients will be tested for HIV and get linked to care and treatment services.

Strengthen STI screening for PLWHAs at ART clinics, and provide HCT , family planning, and ANC services in public hospitals and health centers .

Strengthen condom demonstrations and access at the public health facilities in the region, particularly for STI patients and PLWHAs at the ART clinics.

Strengthen risk reduction counseling and health education for STI patients at the public health facilities in the region.

Support the capacity of public health facilities to print and distribute STI job aid materials, (national STI guidelines, wall charts, and flipcharts) and IEC/BCC materials on STI/HIV prevention.

Improve access to prepackaged STI treatment kits in the public health hospitals and health centers in collaboration with other partners (PFSA &PSI).

The HRHB will work closely with the respective HHS/CDC international TA partner to build its capacity, and will gradually transition PMTCT activities i to strengthen local ownership and ensure sustainability of the program. It will enhance capacity of Zonal/Woreda Health Offices to support the effective transition of PMTCT services.

In COP13, HRHB will:

Support the transition of PMTCT services to public hospitals and health centers in the region.

Support the roll out of Option B+ through training and mentoring of health care providers at facilities providing PMTCT services.

Conduct site supportive supervision, use site level performance data, and implement quality improvement approaches to improve retention of HIV+ mothers and HEIs in care services

Strengthen the capacity of Case Managers and MSGs to improve retention of HIV+ women and family members in care and treatment services.

Support implementation of the updated PMTCT monitoring system in line with the Option B+ strategy.

Support training on safe pregnancy and FP counseling, and promote integration of FP and HIV services.

Support integration of TB screening with PMTCT programs.

Scale-up couples counseling and partner testing, facilitate male friendly services, and establish a monitoring system related to these services.

Support minor renovations, refurbishment, and repairs of ANC, labor and delivery rooms, and maternity wards.

Improve the referral system to ensure continuum of PMTCT care.

Support the catchment area meetings and conduct regular regional review meetings.

HRHB currently manages eight ART sites and >2,500 patients on ART. HIV/AIDS activities initially implemented through a sub-grant with Columbia University ICAP are now continuing under the primary direction of the HRHB. Under COP2012, Columbia University ICAP will continue to provide technical assistance as the HRHB assumes the lead implementer role. HRHB will work with CU ICAP in coordinating and supporting in-service training of different cadres of health providers. It will support and strengthen the clinical mentorship program in the health facilities providing care and treatment services in the region. It will strengthen quality improvement activities in all health facilities and laboratories, and promote use of site level data. HRHB will support and strengthen the health network and referral system in the region in order to ensure the provision of efficient, quality care and treatment services for PLHIV and other persons affected by HIV. It will support and facilitate catchment area meetings in the region. It will strengthen the health facility Multi-Disciplinary ART Teams for site level monitoring of care and treatment program activities, coordination and efficient delivery of available services. The RHB will also conduct regular supportive supervision site-visits to the care and treatment facilities in the region in order to monitor the progress of planned HIV program activities, identify challenges and implementation gaps, and support the sites to improve their performance. The HRHB will work closely with NEP+ in implementing case management to improve ART adherence and retention of HIV patients in care and treatment services, as well as strengthen linkages among facilities and with community-based organization efforts related to HIV/AIDS care and support.

In COP 2013, the core activities to be undertaken by the HRHB will be to build its managerial and technical capacity to take over the pediatric care and treatment program in preparation for a full transition of the support by 2015. In COP 2013, the HRHB will collaborate with CU ICAP to support implementation of pediatric care and treatment services at existing facilities and to initiate the service at all sites providing adult ART services.

In COP 2013, the HRHB will:

Provide technical support in the areas of family-centered HIV care and treatment, and work with the national ART Program to strengthen the growing Ethiopian pediatric HIV program.

Conduct integrated regular mentoring, supportive supervision and review meetings with stakeholders.

Use IEC/BCC materials in local languages to enhance public awareness of pediatric HIV care and treatment services.

Provide technical support with an emphasis on integrating pediatric HIV with child survival interventions, family-centered HIV care and treatment, and strengthen appropriate retention mechanisms.

Emphasize increased pediatric ART service uptake at all sites through improved entry points for children.

Expand its experience in assessing and improving quality of service to all supported facilities in collaboration with CU-ICAP.

Expand case management services to pre-ART and pediatric wards to decrease dropout rates.

Provide on-site assistance to improve medical record keeping, referral linkages, and patient follow-up.

Provide ART training in collaboration with local universities based on national guidelines.

Strengthen linkages with community support services, particularly for OVC.