Summary

These planned activities are linked to EGPAF's Emergency Plan (EP) - funded PMTCT program at Bwaila

hospital and the Lighthouse CT program that will be expanded to all ANC sites in Lilongwe district. Through

EP funding in FY 2008, Lighthouse will establish a referral network with over 10 PMTCT sites around

Lilongwe, including the largest PMTCT site in the country, and will initiate HAART within the ante-natal

period for over 70% of eligible HIV positive antenatal mothers reaching its ART site.

Background

Beginning in 2003, USG has supported Lighthouse to provide a continuum of quality care and support to

people infected with HIV in a comprehensive model program operating within Malawi's National Health care

system. Lighthouse has evolved to become a center of excellence combining comprehensive HIV services

with training and operational research that continuously inform national response to HIV in the areas of CT,

ART, TB/HIV and monitoring and evaluation (M and E). Since PMTCT plays a critical role in prevention of

pediatric HIV and care services to families, Lighthouse already supported the Ministry of Health (MoH) to

improve core PMTCT interventions to enhance quality and uptake of services.

USG support in FY 2006 helped to strengthen Lighthouse as an institution, funding senior staff and building

organizational capacity to manage cross-cutting issues in HIV programming especially in M and E. This

support has enabled Lighthouse to work closely with the MoH and develop a new system and tools for

monitoring the National PMTCT program.

Previous USG funding has enabled Lighthouse to assist the MoH closely monitor and evaluate PMTCT

services in Malawi, and develop and test innovative approaches that have influenced policy on the basis of

evidence. Using FY 2008 EP funds, PMTCT activities at Lighthouse will be expanded and additional

resources leveraged from other donors including UNICEF and the Rose Project to support the development

of protocols for referral of eligible HIV-positive pregnant mothers identified at PMTCT sites in Lilongwe city,

and its surrounding areas, for ART services. Lighthouse will use EP funds to review its ART program to fast

track initiation of triple therapy for eligible pregnant mothers identified at a co-located PMTCT outlet

operated by University of North Carolina with USG support. Similar support will be extended to other

satellite PMTCT sites around Lilongwe City, and Lighthouse will work with MoH to develop a mechanism for

tracking cross referrals between PMTCT and ART.

Activity 1: Develop a Protocol for Referral of all HIV-positive Antenatal Mothers for ART

Lighthouse operates a comprehensive HIV care clinic in close proximity to the largest PMTCT site in

Malawi. The site performs CD4 cell counts on all HIV-positive antenatal mothers, and continuously identifies

20 patients per month of those eligible for ART. Lighthouse will use FY 2008 EP funds to develop protocols

for referral, and promote practices that prioritize HIV-positive antenatal mothers for initiation of HAART.

Lighthouse also will use EP funding to establish a program of referral of HIV-positive antenatal mothers

from 10 satellite PMTCT sites around Lilongwe that have no CD4 testing capabilities or ART services to its

comprehensive care centre.

Activity 2: Restructure ART Clinic at Lighthouse to Ensure Prompt Initiation of HAART for Eligible HIV-

Positive Antenatal Mothers

The Lighthouse ART clinic is one of the largest ART sites in Malawi and already operates at full capacity.

Lighthouse faces challenges in its service delivery capacity to address the urgent ART needs of eligible HIV

-positive mothers identified at nearby PMTCT sites. FY 2008 EP funds will be used to reorganize operations

at the ART clinic to ensure that all eligible antenatal mothers are initiated on HAART promptly, and followed

up in a schedule that is synchronized with their PMTCT visits.

Summary

In response to severe congestion in the medical wards resulting from large numbers of HIV/AIDS patients

being admitted at Kamuzu referral Hospital in Lilongwe, Lighthouse was established in 1997 to provide care

for discharged patients unable to receive appropriate ongoing care in a home environment. Lighthouse

started as a non-traditional hospice (i.e. a HBC referral network) but with support from USG and other

partners, it has grown to become the leading comprehensive HIV care center in Malawi providing CT, ART,

TB care, and Home-Based care services including facility-based stabilization day care for severely ill

patients that do not require admission.

Background

The new Lighthouse Martin Preuss Centre at Bwaila Hospital, the old wing of Kamuzu Central Hospital

(KCH), opened in December 2006 to provide on-going care to about 3,000 PLWHA. The center was

refurbished with Emergency Plan (EP) funding. The new center focuses on supporting HIV care and routine

ART, whilst Lighthouse's main clinic will continue to manage more problematic cases including patients on

second line and alternative first line regimens. Enrollment into the new center will be primarily from the TB

Registry via Lighthouse counseling and testing (both TB and CT will co-locate) and from PMTCT services

also on the same site. EP FY 2007 funds will support these activities.

Lighthouse runs a nurse-led community CHBC program, funded by the USG through Pact within its

comprehensive care and treatment model. The program has four full-time nurses working with 16 CBOs and

more than 300 active volunteers, who collectively extend care services to homes of over 150 severely ill

patients and provide support to their family members as well. In FY 2008 Lighthouse will use EP funding to

train new community volunteers on Palliative care; initiate focused HIV prevention activities for ART patients

served at its clinic and collaborate with PSI to introduce the use of Water Guard for home based care clients

as a strategy to reduce incidence of diarrhea.

Lighthouse Palliative care activities funded through Pact are described under the Pact activity narrative for

Home Based Care.

USG Malawi's cooperative agreement with Lighthouse supports Lighthouse as an institution. These funds

make Lighthouse exceptional. Support through Pact will pay for direct services by Lighthouse.

Activity 1: USG-funded Water Guard for HBC

Lighthouse will collaborate with PSI in FY 2008 to pilot Water Guard water purification technology in a HBC

setting to improve access to safe water. It is envisaged that this will reduce incidence of diarrhea diseases

in immuno-compromised patients in the home based care program. Initial phase of this activity will be

limited to evaluating patient acceptability, led by PSI. Lighthouse personnel will collect qualitative data on

acceptability of Water Guard among HBC patients and their family members. If it is well accepted then it will

be scaled up during the third quarter of FY 2008 and beyond.

Activity 2: Prevention for Positives

Lighthouse comprehensive care centre houses one of the busiest ART clinics in Malawi registering over

4000 contacts with HIV positive patients on ART each month. This clinic presents an opportunity where HIV

preventive interventions will be delivered routinely to ART patients at each visit. Lighthouse has an existing

patient education and counseling program into which prevention messages for positives will be

incorporated. The ITECH - supported training officer will work with HBC and clinic staff to develop focused

messages targeting individuals with HIV. The messages will be delivered through group education sessions,

one-on-one counseling, and IEC materials. The primary focus will be on assisting HIV infected individuals to

disclose their HIV status to partners, reduce their risk of transmitting HIV, and reduce the risk of primary STI

infection or HIV re-infection.

Activity 3: Training Community Volunteers for the HBC Program

As a pioneer in delivery of Palliative Care services in Malawi, Lighthouse continues to chair the Palliative

Care Association of Malawi (PACAM), and plays a leading role in the development of palliative care policies

and services. In 2007 Lighthouse made significant technical inputs in the development of Malawi's national

curriculum for training on Palliative care. Lighthouse will use FY 2008 EP funding to train 15 health care

workers in from Lilongwe District on Palliative Care. Lighthouse will use FY 2008 funds to support facilitation

costs for training volunteers and health care workers from other institutions and partners providing palliative

care services in Lilongwe. Beneficiaries of the USG supported facilitation services by Lighthouse will

however pay for other associated costs.

With previous USG funding, Lighthouse provided leadership for the Palliative Care Association of Malawi

and supported national policy and training curriculum development for palliative care. Through USG

funding in FY 2008, Lighthouse will introduce a much needed program of prevention for positives in its

comprehensive HIV care clinic and provide training in palliative care for health care workers and community

volunteers in Lilongwe.

Summary

Lighthouse was registered as a trust in 2000 and has since functioned as an integral part of Malawi's public

health system with independent funding from USG and other sources including Global Fund monies

administered by National AIDS Commission (NAC). Since 2003, Lighthouse has provided antiretroviral

treatment and care including TB treatment within a comprehensive HIV service model that primarily targets

people with HIV/AIDS in Lilongwe city and neighboring areas. USG Emergency Plan (EP) funds have

supported the organizational development of Lighthouse which delivered these services with non-USG

funds.

In 2006 and with support from USG and other Partners, Lighthouse worked with the Ministry of Health

(MoH) to integrate HIV counseling and testing (HCT) and ART services at Martin Preuss Center (MPC)

which is the largest TB registration facility In Malawi. This center has pioneered successfully a program that

integrates CT as a standard part of Care for all TB patients and uses a register that captures HIV

information on each TB patient. These collaborative TB/HIV activities will be rolled out nationally in FY

2008. To intensify and expand HCT for HIV in TB settings, Lighthouse will use FY 2008 funds to expand its

program of testing for HIV to cover all TB suspects served at MPC.

These planned activities will contribute to a broader national TB/HIV plan that includes the contribution of a

TBD partner (Activity ID# 15410) that will support coordination at national level, and TBCAP (Activity ID#

17384) that will strengthen national systems for TB/HIV services while supporting direct service provision in

two focus districts.

Activity 1: Support National roll out of New TB/HIV Register

As a member of the National TB/HIV coordinating body, Lighthouse is part of the task force developing a

new 5-year National TB/HIV plan for Malawi that will be completed by the end of 2007. The new TB/HIV

plan emphasizes integrating HIV information in the National TB register and incorporating TB information in

the ART register. With USG support, Lighthouse has piloted a program that integrates HCT as a standard

package of care for all TB patients and captures HIV information on each TB patient in one register. The

National TB/HIV coordinating body will work with Lighthouse to roll out this new register nationally.

Lighthouse will use FY 2008 EP funds to support on-site training of TB officers on the use of new register

and to monitor their ongoing recording and reporting practices through a program of joint supervision with

the MoH staff.

Activity 2: Train TB Officers on collaborative TB/HIV activities

As part of the process of implementing a model pilot program integrating TB and HIV activities, Lighthouse

adapted the WHO/CDC generic DTC training guidelines to the Malawian context, and used it to provide a

two-day training to TB officers. Collectively, the trained TB officers (TBOs) have done well in the field and

increased HIV testing rate for TB patients to over 93% within their clinics. About 40% of people reaching the

TB registry actually had tested positive prior to arrival at the Lighthouse, but that was not being

systematically captured in the registers.

Working in collaboration with the National TB/HIV coordinating body, Lighthouse will use FY 2008 EP funds

to finalize the draft training package and apply the final version to train 15 TBO's as trainers. USG FY 2008

funds will be used to run a ToT for approximately 20 people (central unit and zonal officers). Lighthouse will

then support (but not pay for) the roll-out through trainings in four referral hospitals and five zones, a total

estimated 250 people. Lighthouse plans to focus on new Monitoring and Evaluation (M&E) system tools;

integration of HCT, especially in Referral hospital (50% of registrations); and co-management of TB

treatment and ART combined from 2 months.

Activity 3: Counseling and Testing for TB Suspects (New activity)

Studies in Malawi have shown that HIV prevalence in TB suspects submitting sputum for AFB microscopy is

about 60% and compares closely with the rate in TB patients (70%). HIV screening of TB suspects

therefore offers an opportunity for early identification of HIV as an underlying cause of symptoms in TB

suspects. Lighthouse will use FY08 funds to introduce a program of routine HIV testing for all TB suspects

presenting for investigation at the Martin Preuss Center (MPC), the largest TB registration site in Malawi.

EP funding will support minor alterations specifically required to introduce patient movement patterns that

will facilitate routine HIV testing for all TB suspects without increasing risk of TB transmission within the care

facility.

The planned activities will result in improved TB/HIV services for hopefully over 4000 people. This figure is

difficult to predict but Lighthouse is working hard to persuade the National TB program (NTP) to

decentralize registration. Only about 35% of the TB patients registered at the MPC are actually managed

there. However if registration is decentralized, a significant proportion of MPC registrations will be lost and

Lighthouse will have to consider how to support its health centers in Lilongwe and other referring sites and

how to get TB patients onto ART.

A new TB/HIV register developed in collaboration with NTP and the HIV/AIDS unit will facilitate better

recording and reporting of TB/HIV services. The number of TB patients starting anti-TB treatment with

known HIV status at MPC could increase to 95% through the routine offering of HCT as a standard package

of care by trained TBOs. This is ambitious since people sometimes avoid testing. Implementation of

improved M&E systems to monitor TB patients getting onto ART will lead to better understanding of the

issues involved in referral and guide further improvement of linkages in future.

Summary

The services provided by Lighthouse include HIV counseling and testing (HCT), free anti-retroviral therapy,

clinical outpatient and daycare, community home based care, and training services especially in HCT and

ART. HCT services are provided through a network of seven sites, three of which offer traditional VCT while

the remaining four sites offer provider-initiated HCT in medical settings. The VCT sites provide outreach

HCT services to neighboring communities and one prison within Lilongwe city. Being a center of excellence

in comprehensive HIV services, Lighthouse has been certified as a national center for training and

mentoring in HCT and ART.

Background

Lighthouse is a Malawian Public Trust established in 2001 to provide comprehensive HIV services

including, HCT, treatment, and home based care for people living with HIV. Since 2003, with USG support,

Lighthouse has been providing integrated HIV services and training providers for the central region of

Malawi. Lighthouse also serves as the largest anti-retroviral program in Malawi and operates a HCT

program providing services to an average of 2500 clients every month. Provider initiated HCT services

provided by Lighthouse are offered within a comprehensive care model that integrates testing in a TB

treatment center, an antenatal clinic, children's ward and adult medical wards. Direct HCT service provision

at Lighthouse is supported by a combination of EJAF and CAFORD (pays staff salaries and direct operation

costs), and Emergency Plan (EP) funds. USG supports overall institutional development at Lighthouse

including HCT Training and mentoring activities both through direct funding to Lighthouse, funding through

ITECH, as well as funding for monitoring and evaluation through Baobab.

EP funding in FY 2006 and FY 2007 have been used to strengthen the Lighthouse as an institution, funding

senior staff, organizational capacity building, and cross-cutting activities. This allowed Lighthouse to

monitor and evaluate HCT services closely and to lead the development and piloting a new national HCT

register that has been approved for use by all sites in the country. FY 2008 funds will enable Lighthouse to

continue its support to MOH in national supervision of HCT services and to manage additional supervision,

training and mentoring activities for transitioning from parallel to serial testing strategy.

Activity 1: Supervision of MoH HCT Services

Lighthouse has an ongoing close working relationship with MoH which enables it to support national level

HCT policy development, training, supervision, and piloting HCT innovations before they are rolled out

nationally. Support to national supervision of HCT remains a high priority to Lighthouse because it helps to

maintain service quality nationally and to provide a comprehensive picture of HCT services as they evolve.

This support fills an important gap since the capacity at MoH to conduct routine supervision is limited as

other priorities compete and funding for supervision is inadequate. Lighthouse senior counselors and HCT

providers complement MoH HCT personnel and cover half of the country during quarterly supervision field

visits. Using 2006 PEPFAR funds, Lighthouse, with USG support, directly funded two rounds of quarterly

supervision. In FY 2008 Lighthouse will continue to support quarterly national supervision of HCT by the

MoH. USG funding will also support the revision of the existing tools used in supervision and provide

training to Lighthouse counselors and other national supervisors to impart supervision and mentoring skills.

Activity 2: Mentoring MoH HCT Service Providers

This activity includes a mentoring system in which protégés become mentors and support program roll out.

As a certified center for training HCT counselors in the central region of Malawi, Lighthouse maintains a

close link with the network of HCT counselors within its training target areas and has piloted a program of

district-wide mentoring for HCT counselors to improve quality of counseling through observed practice and

feedback. With FY 2008 funds, Lighthouse will work with the District HCT Officer in Lilongwe to consolidate

the mentoring program based on experiences from the pilot phase. Lighthouse will target 16 counselors in

eight health centers, visiting each of them once a month. Progress of each counselor will be evaluated

based on a set of predetermined criteria and when they meet the desired performance level, then each will

take on the mentoring of another two counselors, with periodic support from Lighthouse. By the end of FY

2009, Lighthouse will have reached and trained 100 counselors.

Recognizing the importance of building the esteem and identity of counselors, Lighthouse will work to

strengthen its existing link with counselors and establish a Central Region Counselors' Network using USG

funding. The network will institute regular meetings of practicing counselors and initiate a mechanism to

reward those who primarily focus on counseling and use this incentive as a means to promote identity of

counselors.

Activity 3: Support National Transition from Parallel to Serial Testing Strategy

MoH plans to roll-out serial whole-blood rapid HIV testing in 2008. Lighthouse works with the USG funded

technical assistant that sits in the MOH and is heading this effort. Lighthouse has already provided

technical support to the MOH by designing a package to train counselors in new HIV testing protocols and

will provide training to more than 1,000 counselors during transition from parallel to serial testing in the last

quarter of CY 2007. Lighthouse will use FY 2008 funds to support enhanced supervision and mentoring of

HCT counselors trained in the new HIV testing strategy. This pilot of best practice will set the standard and

provide input to MOH for action. Lighthouse will use the supervision contacts with HCT counselors to

provide on job orientation on new monitoring and evaluation tools and concepts including routine screening

of all HIV positive HCT clients for TB.

Summary

This USG support strengthens the Lighthouse as an institution, funding senior staff, building organizational

capacity, and supporting cross-cutting activities. Even though funding for actual HIV/AIDS service delivery

is from other sources, this USG funding to Lighthouse allows us to monitor and evaluate these services

closely, identify challenges, and to develop and test innovative solutions. It also allows Lighthouse to

maintain her close working relationship with the Ministry of Health (MoH) and to influence policy on the

basis of data and experience derived from the institution. This USG funding afford Lighthouse the flexibility

of piloting innovative approaches to service delivery at a much faster pace than the MoH could and the MoH

looks to Lighthouse to carry out these interventions on its behalf. The quality of their work has made

Lighthouse become the driver of policy in the MOH. Finally, this USG support allows Lighthouse to play an

important capacity building role that translates these policies into practice nationwide.

Background

The Lighthouse Trust manages one of the largest ARV clinics in Malawi, and the new Martin Preuss Center

which was inaugurated this year and partly funded by the USG, has doubled her capacity to provide

HIV/AIDS services. The Lighthouse provides treatment services on behalf of the MoH. Approximately 5,000

patients are currently on treatment at Lighthouse facilities, and the number is expected to reach 7,000 by

the end of 2008. As a designated Center-of-Excellence for HIV/AIDS service delivery by the MoH, the Trust

is not only one of the largest treatment service providers in the country, but it is also a major learning and

training center for the country. A component of USG funded support to the Lighthouse Trust is in the critical

areas of placement and support of key staff, development and adaptation of important and innovative

training models, and exploring new ways of service delivery that are responsive to the ever increasing

workload of patient care.

The ART-related activities specific to USG funding focus on task shifting, decentralization, and community

involvement in services in order to facilitate the management of large numbers of patients within an

overstretched Health System.

This USG funding to Lighthouse is closely linked with and complementary to other USG support received by

Lighthouse through the provision of M&E and training advisors. These activities also link closely to HTC,

PMTCT, TB-related work, and to SI and systems strengthening. All Lighthouse work is designed for

National scale-up in collaboration with the MoH.

Activity 1: Task Shifting

The success of the ART scale-up in Malawi brings with it many challenges, not least will be the burden on

the health sector of managing a steadily increasing number of ART patients. By shifting routine tasks to

less qualified staff, Lighthouse hopes to free up nurses and clinicians to prioritize patients who are

experiencing problems on ART.

A pilot is under way in which specially trained HSAs (ART Assistants or ARTAs) evaluate patients against a

standardized form. USG supports these HSAs through a pilot program that emphasizes their technical

development through training and mentoring. Through this HSA-led review, the ARTAs identify stable,

adherent patients who would be eligible to receive ART directly from the HSA. Each patient then sees a

clinician, and results are compared to evaluate the performance of the HSA. Results from this pilot are

expected early in 2008. If these results are encouraging, a second phase that evaluates HSAs competence

in dispensing medicine and correctly recording their work will be done. Based on results this effort may be

broadened to include a review of training methodologies and roll out to less well supervised settings.

Because of the sensitivity of this issue and the need to further engage the MOH, DHOs, and regulatory

institutions, the primary focus of this activity will be to provide adequate quality data that will inform any final

decision. More than 2000 additional HSAs earmarked for recruitment by the GFATM would benefit

tremendously from the results of this activity.

Activity 2: Health Centre ART

In partnership with District Medical Officers, the Lighthouse decentralization program will identify two health

centers in which to support HIV care and treatment services. Although no additional staff are planned for

these centers, Lighthouse through funding from USG will provide minor refurbishment of rooms, furniture,

and equipment; will support and train staff; and will provide on-site supervision. Ultimately, these sites will

become satellite ART clinics of the Lighthouse. The Health Center support program will give Lighthouse a

greater insight into some of the challenges facing the ART scale-up and integrated services in settings with

very few staff. The sites will be selected in consultation with the MOH and the DHOs.

Activity 3: Roll-out of the ART EDS

This activity directly supports treatment services and could be under SI. Because of the ever growing

burden of managing large number of patients at treatment sites, the paper-based system of registering and

tracking patients is becoming inadequate to meet the program needs. The USG intends to support the

transition from a paper-based tracking system to an electronic system. Lighthouse currently uses a USG

funded touch screen system for CT services. A similar system has been adapted for patient registration. In

FY 2008, Lighthouse will work with another USG Emergency Plan (EP) partner, Baobab Health Partnership,

to pilot and improve innovations in the software and hardware for the new electronic data system (EDS).

In 2008 Lighthouse will replace the old touch screen system at Lighthouse with the EDS currently working at

the Martin Preuss Center. Lighthouse will help design algorithms for the second version of the EDS,

including options for more pediatric functionality and more integration of CD4 testing. Lighthouse will offer

their facilities as beta testing sites for Baobab as they develop new modules for TB treatment, and for

referral between ANC, PMTCT, and ART services.

Activity 4: Ndife Amodzi (Pact funded)

Activity Narrative: The Ndife Amodzi program is a USAID-Pact funded effort aimed at exploring effective ways to involve the

community in the support of ART patients by using Community Volunteers to promote adherence, early

referral, and positive living, and to support the monitoring of ART patients. The Lighthouse hopes to have

city-wide coverage in Lilongwe of Ndife Amodzi, and 1,000 patients enrolled, by the end of 2007, through

collaboration with other Home Based Care providers and their CBOs. If valid information is derived through

Ndife Amodzi, Lighthouse would use the program to reduce the frequency of visits of community-supported

patients to formal services.

Through HHS/CDC-supported senior staff and HHS/HRSA technical assistance staff, Lighthouse aims to

establish Ndife Amodzi as an effective and appropriate ‘minimum standard' of HBC and an effective

reporting mechanism for HBC nationally, working in partnership with donors, other NGOs and the MoH.

Activity 5: ART Training Attachments

Traditionally, Lighthouse has provided two-week clinical attachments for over 75% of all clinical officers and

nurses trained to provide ART services in Malawi. As the next round of expansion of ART sites approaches

by the end of 2007, Lighthouse will again be the major venue for in-service attachments for staff

establishing new ART sites. In FY2008 an additional 60 staff will be offered this clinical attachment. The

expertise of Lighthouse clinical staff will be complemented by the training team to ensure the maximum

impact of the two-week attachments.

Summary

The CDC- Lighthouse cooperative agreement differentiates the Lighthouse from other service-delivery

NGOs, allowing Lighthouse to have national (and international) relevance and impact.

Background

USG support through CDC strengthens the Lighthouse as an institution, funding senior staff, organizational

capacity building and cross-cutting activities. USG does not fund Lighthouse HIV/AIDS services directly,

but Emergency Plan (EP) support allows Lighthouse to closely monitor and evaluate these services, to

identify (and sometimes anticipate) challenges, and to develop and test innovative approaches. EP also

allows Lighthouse to maintain its close working relationship with the Ministry of Health (MoH) and influence

policy on the basis of experience. EP support also allows us to play an important capacity building role and

put these policies into practice nationwide.

The I-TECH supported M and E technical advisor takes a lead in Strategic Information for the Lighthouse,

and has produced a separate document detailing this work (see ID#5983). The TA is embedded within the

Lighthouse, works under the management of the Lighthouse director, and with a team of Lighthouse staff.

EP provides specific funds to support operational research efforts as they emerge, and also to conduct

annual surveys of Lighthouse clients to monitor service quality and identify issues that need attention.

I-TECH support is central to this activity. Lighthouse also provides significant direct support in Strategic

Information to the MoH HIV/AIDS Unit.

Activity 1: Evaluation of Task-Shifting Project

USG funds a broad SI budget line that covers costs of recruiting external enumerators, data entry staff, or

others to support many small studies. This enables Lighthouse to be flexible and responsive to emerging

issues. The budget currently supports mainly the ART task shifting pilot described in Treatment (ID#5970).

If initial results are encouraging, Phase 2 of this pilot should move forward in FY 2008. If Lighthouse can

demonstrate that the trained health service assistants HSA's can accurately identify stable, adherent

patients, in Phase 2 they will be evaluated dispensing drugs and completing the necessary records pending

MoH approval. Phase 3 will then roll out the program to other centers around Lilongwe, again under close

monitoring and evaluation from the Lighthouse team. The HIV Unit at MoH has taken a key interest in this

study, and results are likely to have significant impact on the evolution of national policy.

Other areas where Lighthouse plans to conduct monitoring and evaluation activities in FY 2008 include the

planned roll-out of HIV testing and counseling (HTC) to health center ANCs, through which Lighthouse will

pilot new PMTCT M and E tools. Lighthouse will also conduct further investigation into the referral of TB

patients and eligible PMTCT mothers to ART at the Martin Preusse Center, and review the effectiveness of

improved monitoring protocols for our Ndife Amodzi Community ART Support program. The details of these

investigations will be developed through the year, and timing will largely depend on the capacity and

priorities for our M and E department.

Activity 2: Client Surveys

Lighthouse conducts annual surveys of HTC clients, HBC and clinic patients. The client surveys use

standardized questionnaires, and samples of 50-150 clients / patients are interviewed on leaving Lighthouse

clinics (or in their homes for HBC). Lighthouse uses external interviewed to try to avoid bias, and USG

funds their costs. The surveys give invaluable insight into service quality and have significant impact on the

development of services - the Ndife Amodzi program, for example, grew directly from findings of HBC

surveys. Lighthouse has found absolute measures of client satisfaction to be of limited usefulness, but

each survey will be in its third repeat in 2008 using essentially the same tools, and giving the opportunity to

identify trends in the quality of service provision. Hard indicators and factual questions embedded in the

surveys also highlight areas for improvement.