The goal of USAID/UHEP is to support the scale-up, implementation and monitoring of the GOEs Urban Health Extension Program (UHEP). Currently, the program provides TA to strengthen the GOE's capacity. The organizing principle of the UHEP is provision of household-centered services with strong referral linkages to public sector health facilities to improve access and demand for health services in an increasingly urbanized country. Urban HEWs will be placed in the health centers to bridge households, communities and the facilities. Community mobilization, BCC for disease prevention, health promotion and risk reduction will be key to increasing demand for public health services and improved health seeking behavior by communities, more specifically targeted towards at-risk populations such as PLHIV in urban areas. The TA provides support for pre-service and in-service training of UHEW to strengthen their capacity to work with and engage their community especially vulnerable individuals, provide tailored training on data collection, use of data in planning, training for supervisors and adaption and development of tools to promote timely supportive supervision. With COP 12 funds, the program will scale-up TA to more cities implementing UHEP as well as consolidate existing support with focus on further integrating the UHEP within the health system. This includes strengthening community documentation and reporting, establishment of well-defined national targets based on epidemiological evidence; standardization of core competencies for UHE professionals and efforts to create a career path for health professionals. This supports the PF goal 2 and the GHI strategy to improve access to healthcare services with community linkages to facilities. Estimate 4 new vehicles.

This follow-on program will scale-up and consolidate successes of the first UHEP. Currently the program provides technical support for UHEP in 19 cities nationwide and the follow on program will scale-up coverage to reach an additional 20 urban centers. The focus of the follow on program will be consolidating lessons learned made so far, scale-up coverage for UHEP technical support and strengthen the capacity of GOE regional and woreda level offices to enhance ownership and ensure sustainability of technical and administrative management beyond the life of the project. The program will also advocate for inclusion of public health priorities that are have not received attention in the current health service package under UHEP. The follow-on program will advocate for the inclusion of mental illness as one priority area and will redirect its focus on finding community base and business solutions for sanitation. In FY 2012 the program will continue to provide TA to more cities implementing UHEP as well as address major barriers such as: referral linkages, community level health information management and mainstreaming health professionals with facility level care services. Activities to address major barriers include: strengthening a documentation and reporting system for community level interventions through training and standardizing reporting formats; improving referral linkage through distribution of referral directories and stakeholders meetings; establishing well -defined national targets based on epidemiological evidence; refining /standardizing core competencies for UHE professionals; strengthening functional linkage with facility level activities; participating in national level efforts to create a career path for health professionals; and instituting instruments for quality assurance for community level activities. The program will work collaborate with range of stakeholders to maximize efficiency and expand the resource base. UHEP will establish a communication framework for collaboration including creating terms of engagement and institutionalizing joint meetings and a central information resource center for UHEP activities.

Health Extension Professionals and the volunteers they supervise provide vital entry points for HIV prevention messaging and behavior change. The urban Health extension workers will also help to identify household level HIV vulnerability and risks. Each household visited by an extension professional will have a health folder to track livelihood, HIV status, ART adherence, and discussions on condom use and partner reduction. UHE workers , working at household level ,will help to reach at-risk populations who otherwise will have access to HIV prevention services , including wives of truck drivers, house maids , undocumented migrant workers . one-on-one approach at house hold level reinforces activities by other projects that focus on mass media or small group discussions. Persons engaged in high risk behaviors such as transactional sex or sex works at household level which are not covered by other establishment based MARPs programs in urban areas will be reached by this mechanism. The pre-service training includes HIV prevention knowledge, attitudes, and practices, including issues like stigma reduction, improving utilization of HIV preventive biomedical services and overall health-seeking behaviors. Extension workers are instructed to prioritize most-at-risk households in terms of HIV status and need for HIV prevention. The Urban HEWs are already providing home based testing in many of the cities where home base counseling has been a standard practice . In cities such as Addis and Hrari where home based HTC has yet to be approved , HEW play a key role in linking high risk individuals to facilities for testing after a propoer counseling .Urban HEWs also provide referral confirmation and documentation of community level HIV testing referrals and USAID UHEP has done some operational study to identify barrrier to referral linkages. For HIV discordant couples, extension workers are able to engage couple testing and practicing consistent and correct condom use.

Despite PMTCT programs scale up, attrition and loss to follow-up (LTF) are high, threatening the effectiveness of PMTCT intervention. Improving PMTCT profile is one of the a top priority for the government of Ethiopia and there has been innovative interventions along PMTCT cascade to address the challenges surrounding PMTCT , retention of mothers under care , increasing complete ANC uptake, enhancing intuitional delivery and improve ARV adherence. Health extension workers will be playing a vital role by creating demand for facility level health services to improve the ANC uptake and institutional delivery. Urban HEWs already are making siginificant contribution by identifying pregnant mother in the community , providing home base HTC and referring mother to facility for a follow on care and defaulter tracing from key public health services including ANC , PMTCT and vaccination. The follow on UHEP will build on these promising engagment of the HEW and intensify key PMTCT activities including couple testing, improved referral linkages to facility services , index case tracing and HIV exposed infant identification. The UHEP will be working in 40 cities in close collaboration with city health offices to deliver household level public health services including activities targeting pregnant women. The follow on UHEP will have valuable contribution to creating bi directional referral linkage between community level efforts and facility level interventions including tracing loss to follow up patients.