Background

Pan-American Health organization has received USG support to strengthen the quality of the Ministry of Health's treatment, care and support programs since 2008, specifically working in the areas of ART services, palliative care of TB/HIV, Strategic Information and Health systems strengthening. Notable achievements realized through PAHO's work include sustained technical support and other resources (stationery, facilitation of transportation for out of town validation visits etc.) to the Ministry of Health supportive supervision team for the Patient Monitoring System which has facilitated the generation of high quality and reliable HIV care and treatment data. Through PAHO, the Ministry of Health conducted a gap analysis to determine the availability of Human resources for Health (HRH) and to make projections of the growth in human resource needs during the development of the Ministry of Health's Package of Publicly Guaranteed Health Services (PPGHS). Additionally, staff within the MoH Human Resource Unit attended advanced HR skills training programs abroad while training was also conducted with health care workers in Regions 4 and 6 on the Integrated Management of Adolescent and Adult Illnesses (IMAI) strategy. PAHO intends to continue the work in these program areas further strengthening the Ministry of Health's program utilizing FY2010 funds.

Overall goals and objectives and contribution to HSS

During FY2010, PAHO will provide technical assistance to the Ministry of Health to accelerate the incorporation of HIV/AIDS treatment, care and support and TB/HIV palliative care into the primary health care service, a central aspect of ensuring sustainability of parallel HIV/AIDS and TB programs. PAHO will continue to provide technical assistance to the Ministry of Health to improve quality of service of the Treatment, Care and Support program, as well as support for TB/HIV Palliative Care, Strategic Information and Health System Strengthening. Program activities will impact the skills and resources available to TB health care workers who are already working in HIV/AIDS treatment, care and support as well as the health care workers and social workers providing other services such maternal and child health care, TB-DOTS treatment and laboratory services. It will also impact persons recruited as data clerks.

Guyana has adopted IMAI as a pertinent strategy to effectively decentralize the provision of care, treatment and support for HIV and AIDS. Technical assistance to the Ministry of Health will enhance their ability to roll-out the IMAI Strategy and associated activities in targeted regions; train and support IMAI supervisors, doctors and other target health care workers and finalize the integration of IMAI processes into pre-service training curricula for health professionals. PAHO will support the national TB program through the provision of support for TB/HIV co-management activities through the rolling out of the IMAI strategy for the decentralization of TB services. Strategic information support to the MoH will be focused on implementation of the HIV drug resistance (HIVDR) monitoring protocol in order to enhance the ministry's capacity to monitor HIV drug resistance as well as report on the WHO early warning indicators for drug resistance. Support to the Patient Monitoring System (PMS) will also continue in order to ensure high quality care and treatment data is generated for program management, planning and reporting. Health Systems Strengthening support will focus on providing continued support to the Ministry of Health's Human Resources Unit in order to deal with issues of health worker retention and health care worker capacity building.

PAHO's PEPFAR supported program will be monitored to determine the timeliness of program implementation and the appropriate use of funding. This will be facilitated through regular quarterly program meetings and reports, both financial and programmatic that address activities and budgets outlined in the program proposal.

The roll out of the IMAI strategy will compensate for health workers turnover and expand the number of facilities providing integrated HIV services. Limited human resources in the health sector is the greatest threat to sustainable HIV services in Guyana. The regional health model and IMAI initiative will shift tasks involved in HIV care into the overall health care system. This shift will better integrate HIV care into primary care and ease the need for specialist physicians who are in critically short supply in Guyana. Since IMAI has been earmarked for national expansion, a continuing training program for facilitators (TOT) and health care professionals has been established as one of the main priorities for collaboration between PAHO and the MOH.

Technical assistance to the Ministry of Health will enhance their ability to roll-out the IMAI Strategy and associated activities in targeted regions; train and support IMAI supervisors, doctors and other target health care workers and finalize the integration of IMAI processes into pre-service training curricula for health professionals. Training in the IMAI strategy will be rolled out to additional regions, it is expected that personnel from at least 75 health facilities will be trained. In order to expand IMAI to all regions, a central coordination and administrative function will be to continue to support the MOH to facilitate the roll out of the strategy to all regions and provide oversight and supervision to ensure the IMAI strategy is fully and functionally integrated into the public health care system. Supervision visits will be conducted to health facilities where staff have been already trained in the IMAI strategy to examine how well the strategy is being utilized, provide on the job mentoring and address issues of quality of care.

Even though some doctors have been trained on the IMAI strategy, it is acknowledged that there is a need to have a more targeted training exercise for additional doctors in health facilities, since they play a vital leadership role in clinical settings. This not only refers to the care and treatment of clients but also their capacity to guide other staff of the health team. Since other critical members of clinical teams need to be also trained, medex social workers and other health providers will be trained in IMAI. To promote sustainability, IMAI will also be integrated into pre-service curricula for different cadres of health care workers.

In FY07, PAHO served as the lead technical agency to assist the Ministry of Health to adapt the WHO format national patient tracking and monitoring system to the Guyana context. In FY08 and FY09 they provided sustained technical support and other resources (stationery, facilitation of transportation for out of town validation visits etc.) to the Ministry of Health's supportive supervision team for the Patient Monitoring System which has facilitated the generation of high quality and reliable HIV care and treatment data. The system is being used in all sixteen existing ARV treatment sites and is now the national monitoring system for all HIV/AIDS care in country. The Patient Monltorrng System (PMS) is being recognized as a Best Practice to adequately and easily capture all relevant information making use of patient charts to track the patient in pre-ART care and on treatment. PAHO will continue to support PMS in the 16 ART sites across the country and support and monitor the work of contract data entry clerks and clinic staff working on the roll out of the patient monitoring system (PMS).

PAHO will also provide technical assistance for the TB/HIV reporting system as described in the TB/HIV program description narrative and will continue to work closely with CDC, USAID, and other partners to coordinate activities In support of the MOH surveillance unit including funding, training and mentorship of surveillance unit staff. In order to be cost-effective ongoing monitoring and supervision of staff will coincide with visits for monitoring other programs. PAHO Will continue to provide technical assistance on preventing the spread of HIV drug resistance through support for HIV drug resistance (HIVDR) monitoring through the implementation of the HIVDR Monitoring Protocol as well as data collection for Early Warning Indicator (EWls) for HIVDR which have already been established.

The health system in Guyana faces structural and operational problems that hinder their performance and prevent full and comprehensive access to health services by the general public. In FY09, PAHO has been able to make significant strides in the development of a human resource unit within the Ministry of Health, including key training for staff and the conduct of a gap analysis.

In FY2010, PAHO will dedicate more 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 strengthening of the MoH Human Resources Planning and Development Unit (HRDU). In support of health systems strengthening, PAHO will continue support to the Human Resources Unit of the Ministry of Health to address health care worker recruitment and retention issues and human resource management issues. Building on work within this area over the past years, PAHO will enhance the MOH capacity to roll-out IMAI and support priority health programs in targeted regions. PAHO will also prepare training materials and supportive supervision tools for use to support quality of service. Also a priority will be ensuring the integration of appropriate training into training curricula for medex, nurses and other cadres of health care workers.

Training schools are essential to enhancing the quality of services provided by new and veteran health care workers. Nursing training schools will also receive technical support to enhance the skills of trainers and the resources available for teaching. Curricula will be upgraded to ensure that critical and priority health care program skills are taught such as the IMAI strategy and management concepts and skills. Also strengthening the local management abilities will ensure decentralization and promote sustainability.

Decentralization of the National Tuberculosis Program is critical to ensuring that TB/HIV services are incorporated into primary health care systems. Support from PAHO to the National program will ensure that the decentralization process is conducted so that TB/HIV services are made more accessible to the general population. Specifically, PAHO will support TB/HIV co-management activities through the roll-out of the IMAI

strategy for the decentralization of TB services, train and support TB regional supervisors, MEDEX, nurses etc, to improve their management and leadership skills, support the expansion of VCT services In TB clinics and strengthen TB Monltoring, Evaluation and surveillance system for decision making while also providing technical assistance for the implementation of Round 8 Global fund activities.

The strategy for TB treatment adopted in Guyana is the WHO-recommended, Directly Observed Treatment Short Course (DOTS) which ensures adherence to effective Therapy. For this strategy to be successful in Guyana it requires further integration into the primary health care services and the participation of families and community members. The IMAI will be the vehicle through which TB/HIV services are further integrated into the primary care setting. The Integrated Management Adolescent and Adult Illnesses (IMAI) is presently being rolled out in primary health care facilities and is supporting TB/HIV co-management, therefore the new TB/HIV module of the IMAI strategy will continue to be implemented in new targeted health centers to expand the decentralization of services for the National TB Program.

Voluntary Counseling and Testing (VCT) skills continue to be a challenge within the

TB/HIV service settings, therefore in order to enhance and expand the TB/HIV program

into all regions, staff will be trained in HIV counseling and testing particularly where permanent VCT sites are not established and existing TB staff can conduct testing. Technical support for Counseling and Testing within TB treatment facilities will also include support for monitoring and evaluation and surveillance to enhance the data collection and reporting processes within the TB program. To this end, the clinic monthly report will be assessed and revised where necessary and registers will be printed in order to document critical TB/HIV information and enhance program planning and management as well as reporting.

The National TB program has received funding under the Round eight Global Fund grant and implementation will begin in January 2010, and PAHO will continue to provide support for implementation.