PAHO will strengthen TB/HIV collaborative activities within the National Tuberculosis Program. As a part of their regional health model, which decentralizes health services to the regional level, tuberculosis nurses at all MOH regional hospitals and health centers with outpatient TB clinics will be trained in TB/HIV co-management. Training will be based on the IMAI "TB Care with TB/HIV Co-management" module, which was developed by the WHO's StopTB Department and has been adapted by Guyana's National Tuberculosis Control Program. TB nurses will be trained to offer HIV testing to all TB patients and suspected patients, offer cotrimoxazole prophylaxis, counsel patients on prevention, assess clinical stages for TB/HIV co-infected patients, and refer patients for ART when necessary.

Regional TB coordinators will be included in IMAI training for regional HIV coordinators and will receive training and funding for site visits to facilities with out-patient TB clinics. During these visits, regional TB coordinators will offer support to TB nurses, monitor progress, and assess the need for supplementary trainings. These activities will strengthen linkages between TB and HIV treatment systems, enhance co-infection services in outer regions, and help integrate TB/HIV management into the greater healthcare system for maximum sustainability.

CDC will be the technical lead for this activity and funding will be administered through USAID to PAHO.

Supervision of HIV program activities becomes more important as HIV services are decentralized. In the regional health model, the regional coordinator has a crucial role in ensuring smooth functioning of public health programs such as HIV and TB. The regional HIV coordinator is most often an administrator with previous clinical training (as a doctor, clinical officer or nurse) who has the responsibility of coordinating all HIV program activities in the region.

A regional HIV coordinator with clinical training is necessary to supervise HIV clinical services at health facilities in the region. Regions without such a position will be provided with funds for one. All regional HIV coordinators will be trained for 1 week in HIV program management, including: planning for scale-up, coordinating region-level training, recording and reporting using the national patient monitoring system, performing site visits and identifying/solving facility-level problems. This training will precede IMAI clinical training for clinical teams in the region. UNV physicians supported by PEPFAR will be included in the trainings and will also serve as a support system to mentor the MOH regional coordinators in the field.

Regional coordinators will be expected to participate in the 2-week basic IMAI clinical course in order to become completely familiar with the clinical and operational protocols used at regional hospital and health centre level. Supervisory site visits will start immediately after IMAI clinical training, and will continue monthly for 3-6 months, after which the frequency will shift to quarterly. This activity covers funds for transportation to health facilities within the region and communication via phone, radio or mobile phone with facilities and regional offices.

This activity includes a component of targeted evaluation. The IMAI tools for regional HIV coordination include standardized case management observation and exit interviews that will be included as part of the routine reports submitted by regional HIV coordinators to regional and national offices. Quantification of this data in a subset of regions will be done as part of an evaluation of the quality of care during scale-up of integrated HIV services in those regions.

At regional level, the HIV management team should be strengthened by additional staff whose major responsibility will be coordinating support supervision activities at the regional level: communicating with region HIV coordinators, reviewing reports, solving regional-level problems, and coordinating support for regional coordinators. Coordinators at all levels will be trained in reporting via the standardized patient monitoring system (covered in the Patient Monitoring concept paper).

This activity also covers the cost of meetings that will be held quarterly in each region, to allow regional coordinators to exchange experiences with each other.

USG will fund technical assistance and ongoing support to the implementation of the modified WHO format national patient tracking and monitoring system. After final approval from a committee of all stakeholders, this system will become the national monitoring system for all HIV/AIDS care in country. PAHO will support the MOH Surveillance Unit in training data entry and clinical staff on use of the system, roll out of the system in all HIV/AIDS treatment sites, and ongoing technical support. The PAHO Surveillance Office will work closely with CDC,(the technical lead for the USG team), USAID, and other partners to coordinate activities in support of the MOH Surveillance Unit including funding and training for backfilling of registries, mentorship for Surveillance Unit staff and technical assistance for data analysis and reporting. Site visits for ongoing monitoring will coincide with visits for monitoring other programs such as the malaria initiative. This coordination will assist in the integration of HIV care into the overall health system. Early funding is requested for this activity to initiate training and data entry as soon as possible.

In FY06 PAHO focused on strengthening the capacity of the National AIDS Program Secretariat since a 2004 assessment that had been conducted by the Caribbean Health Research Council (CHRC) noted that the program was affected by insufficient human and technical ability as well as inadequate emphasis on its mandate of coordination and management the National response to HIV/AIDS. Currently, PAHO continues to assist the Ministry of Health in strengthening NAPS to take the lead in implementing all health-related aspects of the National HIV/AIDS Strategic Plan, including the implementation of the GFATM project.

A considerable amount of work was undertaken in the past to analyze workforce issues and develop a National Health Plan 2003-2007. This Plan released in March 2003, contains important recommendations on Health Services and Workforce Development Strategies. In FY07, PAHO will dedicate more level of effort to the MOH and its human resource unit with a primary focus on fields most relied upon by the HIV/AIDS program. PAHO will support the MOH to establish a Human Resources Planning and Development Unit (HRDU) with the following functions: • Steer the development of an integrated Human Resources for Health Plan which matches population health needs, service delivery mandates with skills needed, appropriately budgeted levels for supplies, equipment and pharmaceuticals; • Provide directions to the existing training department (Dept of Health Sciences Education) with the aim to achieve synchrony between the identified service needs and the training activities. • Collect and systematize a database of stock, trends, and qualitative data on human resources that allows to forecasts needs and track the impact of interventions; • Build a consensus mechanism involving education, finance, donors, public service and local governments in order to address this issue through a comprehensive and coordinated approach.

Given the environment of out-migration, internal migration, PAHO will play a proactive role in the understanding and resonding to the main contributing factors by: • Conducting studies on the main flows of different types of professionals and the consequences of these flows in the health services and in the priority programs. • Implement and reinforce an "exit interview" procedure. • Facilitate international dialogues between major partner recipient countries of Guyana health staff and the Guyana health services to provide more specific support to Guyana service needs development based on staff losses. • Develop and pass regulation of contracting policies in the health sector as a way of balancing the availability of critical human resources in the MoH and the other health providers and programs. • Determine critical path to scale up the main training programs and the establishment of an inter-sectoral task force to devise a short term plan to address the ill effects of the identified bottlenecks. • Achieving consensus among development partners on incentive structures across the various priority health and education programs they support. The main issues of concern for the MOH with recruitment and retention are the inefficient procedure for filling new and vacant positions is considered time-consuming and inefficient to guarantee adequate levels of staffing and lead to losses of good candidates, the lack of career prospects (flat pay structure, poor working conditions), insufficient incentives through the current pay system, and insufficient access to continuing and post-graduate education. Hence, PAHO will develop a coherent set of interventions addressing the main factors identified: • Design alternatives to build career paths adapted to the public health sector, rewarding performance, acquired skills and experience. • Strengthen the continuing education system so it is linked to opportunities for career advancement. • Establish a dialogue with Ministry of Finance and Public Service Ministry to discuss ways for appropriate salary grid and/or benefits packages and streamlining the appointment process. • Staff category specific needs should be responded to in consultation with the partner community, particularly in the area of incentives which do not demand immediate remuneration issues. • In 2004, a proposal detailed the existing and required staffing needs at the regional level and by categories. There is a need to validate and update these findings and use

them as a basis to propose incremental budget changes for the next budgetary period. • A cabinet approved Human Resources for Health Plan should be taken as the basis for staffing needs and authorization to fill positions to avoid delays. • Staffing levels should be determined by workload indicators of staffing needs which should form an integral part of the Human Resources for Health Plan.

Deliverables/Additional targets: •Multi-stakeholder coordinating committee established to address human resource needs; quarterly meetings held •Regulation of contracting policies developed •Standardized incentive structure developed as collaborative process among development partners in health and education •Human resource unit developed in planning department of MOH with approved staffing and authority structures