SUMMARY

The Public Health Management Institute (PHMI) will provide technical and managerial consultants to NACO

to strengthen the national ART program during a time of rapid expansion. The PHMI consultants will focus

on a number of systems level additions such as ART accreditation (for NACO ART centers and for private

institutions), mechanisms for referral down the system, state-level ART field supervision and monitoring,

regional technical reviews, an ART clinical hotline, and new public-private partnerships.

BACKGROUND

Mediciti SHARE India (SHARE India) is a not-for-profit organization working in rural communities outside

Hyderabad, Andhra Pradesh, reaching out to about 300,000 persons in the rural population with services

ranging from maternal and child health, reproductive health, HIV/AIDS and nutrition programs, coordinated

through the SHARE India medical college and hospital located nearby.

In 2006, through a cooperative agreement with PEPFAR/CDC, SHARE India established PHMI as a

technical assistance and training organization. PHMI's main objective is to provide human resource capacity

building and systems strengthening within the public health infrastructure of Andhra Pradesh (AP). The

current focus is on developing innovative quality improvement mechanisms such as accreditation systems

and on the job training programs. Its technical focus is currently on HIV but PHMI envisions a broader role

for the Institute in building public health systems in AP.

ACTIVITIES AND EXPECTED RESULTS

PHMI will work closely with the National AIDS Control Organization (NACO) to provide focused technical

assistance to strengthen the ART delivery systems throughout India. This includes supporting: Full time

NACO ART consultants (2); Regional technical consultants (5) at State AIDS Control Societies (SACS);

international consultants and contractors; and direct technical assistance from the CDC India team and

CDC Atlanta. Overall PHMI will work closely with NACO/SACS in strengthening and developing systems

that would help India operationalize their ART guidelines consistently across all the 200-plus ART centers

expected to be functioning in FY08 under NACP3. In FY08, the above mentioned technical support and

manpower will be used to provide the following activities:

ACTIVITY 1: Accreditation of ART Treatment and Care Centers

PHMI consultants and contractors will work with NACO to develop an accreditation process for all NACO-

supported ART centers in India. The newly created operational guidelines for ART centers will be used to

create an accreditation checklist. The technical assistance effort will have to focus on developing a scoring

system based on the checklist that takes into account NACO priorities and functional realities. A system will

also have to be established for objectively evaluating the center. A team of accreditors will have to be

identified, trained, and closely supervised and a quality control mechanism will be required.

Early in the process, PHMI consultants will review existing ART accreditation systems in other countries:

this may require exposure visits to other countries. One challenge will be what to do about sites that

repeatedly score poorly and cannot meet accreditation standards. This is especially important given that

over 100 ART centers are already established and providing ongoing ART to PLHAs and so de-recognizing

sites as NACO ART Centers will be difficult both politically and administratively in terms of the continuity of

treatment and care for PLHA.

NACO and PHMI hope to have the accreditation system developed and piloted in one or more states. In

FY09-10, the accreditation system will be expanded to all states and all 250 planned centers.

ACTIVITY 2: Decentralized ART Service Delivery through a Downward Referral System

PHMI consultants and contractors, with mentoring from CDC, will work with NACO in developing

mechanism and systems that allow stable ART patients to receive their monthly ART drugs and counseling

services closer to home through drug delivery/distribution centers called ART link centers. These ART link

centers will most likely be placed at NACO-supported community care centers. PHMI envisions pilot testing

this system at some of the better functioning community care centers in FY08. If successful, this model

may be expanded to include all 350 plus proposed community care centers in India. The goal of

establishing ART link centers is to provide quality services closer to patients' homes and yet maintain a

strong link to the nearest ART center for medical consultations, supervision, laboratory tests, etc. In FY08,

PHMI consultants and staff will initially review existing ART downward referral systems in other countries

and propose a specific model and guidelines for the system in India. An evaluation of the pilot system will

also be supported by PHMI.

ACTIVITY 3: Strengthen and Improve State Level ART Management and Delivery Systems

PHMI consultants and contractors, with mentoring from CDC, will work with various State AIDS Control

Societies to strengthen ART delivery services by providing management and policy support and conducting

periodic field supervisory and monitoring visits. These consultants, in close collaboration with SACS and

CDC staff, will examine and improve the critical ART service delivery components including pre-registration

systems, CD4 testing, treatment initiation protocols, adherence counseling and monitoring, and

mechanisms to follow up quickly on defaulters. The consultants will also develop and implement schemes to

improve the efficiency of CD4 testing (where and when required based on formal assessments of current

efficiency at the state and local level) using incentives and/or continuous quality improvement processes.

ACTIVITY 4: ART Technical Hotline

This program envisages developing a technical hotline that ART medical officers or other health care

providers involved in ART care can call and get immediate technical advice related to patient management.

ITECH with USG funding will likely take the lead in developing and manning this hotline. PHMI consultants

and staff will play a supportive and collaborative role in the process. PHMI may support an evaluation of the

hotline system once established.

Activity Narrative:

ACTIVITY 5: Regional Technical Review Meetings and Refresher Trainings

PHMI will also support and organize, in close collaboration with NACO/SACS, experience-sharing technical

review meetings of ART medical officers and nodal officers by region. These meetings are likely to be for 2-

3 days and to focus on updating the clinical skills of the ART medical officers and nodal officers. If

successful, these reviews will be held bi-annually for each region. PHMI will support at least two of these

regional review meetings. PHMI will also work with ITECH on the content and teaching methodology.

Activity 6: Create Well-Informed Government Leaders in Care and Treatment

PHMI will support and help organize future South-to-South sharing and exposure visits to other countries

where ART scale up is happening. Technical exposure visits are expected to be very useful for NACO

leaders/technical staff and leaders/technical staff at the state level (such as SACS project directors, State

health ministers/secretaries, Directors of Medical Education, state ART program officers). This was the case

with the recent India delegation to South Africa focused on ART roll out organized and led by CDC India

staff. In FY08, one or two of these South-to-South exposure visits will be organized for up to 10

state/national leaders and technical staff.

ACTIVITY 7: Provide Technical Assistance in Establishing New ART Centers of Excellence.

PHMI staff and consultants will assist NACO in developing ART/HIV centers for training, research, and

advanced care. The specific areas that PHMI will assist in will be decided jointly as the operational plans for

each center of excellence evolve. Some possible areas of support may include assistance with: a)

infrastructure design (such as modifying blueprints from GHTM's ART center built by CDC); b) staff capacity

development; c) training skills and training strategies (in collaboration with ITECH); d) patient information

systems (or other clinical databases); and e) laboratory improvements (including assistance with viral load

testing, rapid tuberculosis culturing systems, CD4 testing, and quality assurance systems).

ACTIVITY 8: Private Sector ART Initiatives:

PHMI will lead an effort to develop a HIV specific clinical accreditation process for private sector clinics and

hospitals. This is a major undertaking and will be developed in collaboration with the USG technical team,

other USG partners, technical consultants, NACO/SACS, and WHO India. A clinical accreditation system is

required to standardize HIV care and treatment services, empower consumers, and address the reality that

medical care in India remains highly unregulated. PHMI and its collaborators will develop basic standards of

HIV care, an accreditation checklist, and procedures to assess HIV care practices periodically. In FY08, this

will be pilot tested in one state (AP) and revised based on the experience and feedback from key

stakeholders. This accreditation system may be closely tied into APAIDSCON's plans to develop a low-cost

ART package of services. For example, low-cost ART packages may only be made available to clinics and

hospitals that successfully complete the accreditation process.

NACO is considering allowing select private sector hospitals and clinics to receive free government supplied

first line ART for their patients. Once selected, these care centers will likely need to maintain some form of

accreditation. PHMI will advocate for this form of public-private partnership and assist NACO in creating an

accreditation system and monitoring system for these private care centers.

SUMMARY

The important objectives of program activities in 2008-09 are to: 1) partner with the Andhra Pradesh State

AIDS Control Society (APSACS), to provide technical assistance (TA) through a Surveillance/Monitoring

and Evaluation (M&E) consultant to the state's HIV interventions, specifically for building organizational

capacity to: 1) effectively monitor and evaluate programs, conduct program reviews, collect and analyze

program data for informed-planning, and strengthen program evaluation tools; and 2) take the lead on

behalf of APSACS in developing and conducting skills-based trainings for the staff the District AIDS

Prevention and Control Units (DAPCUs), established as part of the decentralization of HIV/AIDS

management under the third National AIDS Control Program (NACP-3), in order to build their data

generation, collection, collation, analysis and dissemination capabilities.

BACKGROUND

Mediciti SHARE India is a not-for-profit organization working in rural communities outside Hyderabad,

Andhra Pradesh specifically reaching out to about 300,000 of the rural population with services ranging from

maternal and child health, immunization, population control, cancer detection, HIV/AIDS and nutrition

programs, coordinated through their medical college and hospital. SHARE India is also recognized as a

research foundation by the Department of Science and Technology, Government of India.

In 2006, through a cooperative agreement with PEPFAR/CDC, SHARE India established the Public Health

Management Institute (PHMI) as a technical assistance and training organization. PHMI's main objective is

to provide human resource capacity building and systems strengthening within the public health

infrastructure of Andhra Pradesh (AP). The current focus is on developing innovative quality improvement

mechanisms such as accreditation systems and on the job training programs. PHMI's technical focus is

currently on HIV but it envisions a broader role in building public health systems in AP. PHMI advocates for

and develops better strategic information systems to support public health programs and interventions.

ACTIVITIES AND EXPECTED RESULTS

ACTIVITY 1: Partnership with the State Government to Provide Technical Assistance (TA)

This is an ongoing activity, to provide TA to local and state government HIV agencies. PHMI has provided

three full-time technical experts to APSACS to support HIV activities. The consultants are in the areas of

Surveillance/Monitoring and Evaluation Consultant, management of Integrated Counseling and Testing

Centers (ICTCT), and training. Their role in FY08 will be to provide technical support to the state's HIV/AIDS

interventions and program officers, many of whom have little experience and limited technical backgrounds

in the areas that they have been tasked with. Consultants are placed under the APSACS Project Director

and mentored by CDC and PHMI staff. They are responsible for strengthening systems in their specific

areas of expertise: building organizational capacity to effectively monitor and evaluate programs; creating

minimum standards for all training programs; establishing procedures for routine program reviews;

advocating and developing better systems of program supervision, field evaluations, supplies and

equipments maintenance; and developing tools and processes for collecting, consolidating and analyzing

data at the state and district level.

Specific strategic information activities for these consultants in FY08 will include: 1) building interest in

evidence-based program planning among APSACS staff and district leaders; 2) reviewing counseling and

testing (CT) data with APSACS staff, NGOs involved in testing, and district government staff; 3) integrating

TB/HIV, ART, and sexually transmitted infection (STI) program data into the ICTC-web-based management

information system (WMIS) and establishing linkages between NACO CMIS and APSACS ICTC-WMIS; 4)

expanding the web-based reporting system beyond the pilot districts; 5) developing evaluation tools for

specific types of APSACS-funded training programs; 6) strengthening current statewide sentinel

surveillance systems conducted annually in antenatal clinics, STI clinics, TB centers, and among high risk

populations; 7) disseminating and explaining sentinel surveillance and the National Health and Family

Survey (NHFS) findings for Andhra Pradesh to opinion leaders and program managers; and 8) advocating

for and piloting innovative surveillance strategies (biologic and behavioral) among potential bridge

populations and most at-risk populations. The ICTC consultant will also develop a Positive ANC tracking

tool to improve the PPTCT program's Nevirapine administration rates in the State. This will be

accomplished through a paper-based system of positive ANC line-listing that will track and document all HIV

-positive mothers from the time of diagnosis till the time of delivery and subsequently follow up the child till

s/he is 18 months old.

ACTIVITY 2: Training of District AIDS Prevention and Control Units (DAPCUs).

Under NACP-3, DAPCUs will be formed in all districts in the high prevalence states. The objective of

establishing the DAPCUs is to decentralize program implementation and management down to the district

level (population: 2-2.5 million). Specific activities of the DAPCU will include: 1) ICTC supervision; 2) field-

level staff training and mentoring; 3) technical support to district government officials in charge of health and

social programming; 4) establishment of linkage systems between prevention programs, ICTCs, and ART

centers; 5) coordination of all district level partners and activities; 6) technical inputs into communication

and condom social marketing campaigns; and 7) monitoring and evaluation of all district level HIV services.

The process of recruiting and then training DAPCU staff is a tremendous challenge and opportunity. USG

and its partners already have experience in district capacity building. USG supported the establishment of

district HIV management teams in ten districts in Andhra Pradesh, and CDC and its partners were given the

responsibility to develop and conduct skills-based trainings for these district staff. PHMI has been identified

as CDC's lead partner in DAPCU trainings and capacity building and will seek inputs from other USG

partners in conducting DAPCU trainings.

In FY08, PHMI will play a technical role in training DAPCU staff on basic public health principles, field

management skills, HIV prevention strategies, HIV care and treatment operational guidelines, and

monitoring and evaluation skills. A strong focus will be on building the capacity of the DAPCU staff to use

data for decision-making and to learn to provide timely feedback to field staff regarding their monthly

monitoring reports. The exact training calendar will be determined in collaboration with each State AIDS

Control Society, each technical support unit, and other technical agencies.

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