PEPFAR's annual planning process is done either at the country (COP) or regional level (ROP).
PEPFAR's programs are implemented through implementing partners who apply for funding based on PEPFAR's published Requests for Applications.
Since 2010, PEPFAR COPs have grouped implementing partners according to an organizational type. We have retroactively applied these classifications to earlier years in the database as well.
Also called "Strategic Areas", these are general areas of HIV programming. Each program area has several corresponding budget codes.
Specific areas of HIV programming. Budget Codes are the lowest level of spending data available.
Expenditure Program Areas track general areas of PEPFAR expenditure.
Expenditure Sub-Program Areas track more specific PEPFAR expenditures.
Object classes provide highly specific ways that implementing partners are spending PEPFAR funds on programming.
Cross-cutting attributions are areas of PEPFAR programming that contribute across several program areas. They contain limited indicative information related to aspects such as human resources, health infrastructure, or key populations programming. However, they represent only a small proportion of the total funds that PEPFAR allocates through the COP process. Additionally, they have changed significantly over the years. As such, analysis and interpretation of these data should be approached carefully. Learn more
Beneficiary Expenditure data identify how PEPFAR programming is targeted at reaching different populations.
Sub-Beneficiary Expenditure data highlight more specific populations targeted for HIV prevention and treatment interventions.
PEPFAR sets targets using the Monitoring, Evaluation, and Reporting (MER) System - documentation for which can be found on PEPFAR's website at https://www.pepfar.gov/reports/guidance/. As with most data on this website, the targets here have been extracted from the COP documents. Targets are for the fiscal year following each COP year, such that selecting 2016 will access targets for FY2017. This feature is currently experimental and should be used for exploratory purposes only at present.
Years of mechanism: 2008 2009
NOTICE - Per the recommendation from OGAC that Malawi as an FY2008 Compact Country, submit a mini
-COP (i.e. program area level narratives only), this activity level narrative has not been updated prior to the
submission of the FY09 Full COP. The Malawi country team anticipates updating narratives upon
completion and final approval of the negotiated 5-year Compact between the United States Government
and the Government of Malawi.
Summary
In FY 2008, Lighthouse plans to continue its work on building the capacity of clinicians, nurses, and others
in ART management. Special emphasis will be placed on training key Lighthouse staff and trainers on
training curriculum development and dissemination for care givers. The initial beneficiaries will be students
of the clinical attachment program and new Lighthouse staff. Lighthouse will expand the curriculum to
include pediatric treatment and care as well as the management of TB/HIV co-infection.
Background
Since 2005, I-TECH using USG resources has provided a full-time Training Advisor to the Lighthouse Trust
to support ARV scale-up and increase capacity of clinical staff in the provision of HIV services. In
collaboration with the Lighthouse staff and the I-TECH M&E Advisor, the Training Advisor has played an
important role in building capacity for HIV treatment care and support. Training of Lighthouse healthcare
workers (HCW) has included various strategies ranging from formal classroom training to learner-driven
mentoring. In previous years, the Training Advisor provided direct support to the training attachment
program for ART management. After formal training of nurses and clinical officers, graduates were sent to
Lighthouse on a clinical attachment. For a period of 2 weeks nurses and clinical officers from different parts
of the country work with, and are mentored by Lighthouse staff who have experience managing AIDS
patients. This program was developed at the Lighthouse and rolled out nationwide. It emphasized the
importance of management of OIs especially TB in parallel with building skills in ART delivery.
In the new role of Lighthouse as an MoH designated Center-of-Excellence for AIDS patient management it
was important that staff acquire the skills of scientific information dissemination. This involved developing
staff skills at distilling complex scientific information into communication messages for academics, clinical
and nursing staff, and the general public. In 2006/7, the Training Advisor worked with the Lighthouse nurses
to write and submit 4 abstracts centering on findings associated with the various departments of Lighthouse,
including Home Based Care, Day Care Ward, the Nursing Empowerment Project, and Adherence to the
National Conference for the Association of Nurses in AIDS Care.
The priority activities for FY 2008 will include :
Activity 1: Human Capacity Development in ART Management and Distribution (Continuation Activity and
Expansion).
This training activity will support the implementation of the revised ART guidelines and efforts to increase
pediatric treatment. In FY 2008, Lighthouse will continue its work to build the capacity of clinicians, nurses,
and others in ART management and distribution. The Training Advisor will assist in planning and support
for the ART mentoring program for both newly recruited Lighthouse staff and staff sent on attachment
programs to Lighthouse. The training advisor will design, pilot, and evaluate training of healthcare workers
in the treatment of HIV/AIDS. The Training Advisor will contribute to the appropriate design and
implementation of new programs that are intended to scale up the provision of HIV treatment services at the
Lighthouse. Capacity development in this area includes effective communication and dissemination of
information and best practices to other Health Care Workers (HCWs), the MoH, and the public. Also,
ongoing support is provided to build capacity of the nurses and counselors at Lighthouse to provide high
quality ART for adults and children.
If funds are available, opportunities will be sought for Lighthouse staff to share their knowledge and
expertise in ART delivery as well as learn new skills from their peers through participation in international
and domestic meetings and conferences.
Activity 2: National Capacity Development: HIV/TB (Expansion Activity)
This activity is to develop ways to harmonize TB and HIV services for co-infected clients at Lighthouse
clinics for treatment. The I-TECH Training Advisor will work with other Lighthouse staff to assist the MoH in
integrating training strategies as they develop a national TB/HIV 5-year scale-up plan. This should include
classroom training, attachments, mentoring, and supervision as appropriate. The Lighthouse will provide the
venue for piloting this effort.
New/Continuing Activity: Continuing Activity
Continuing Activity: 15438
Continued Associated Activity Information
Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds
System ID System ID
15438 6168.08 HHS/Health University of 7141 3899.08 I-TECH $50,000
Resources Washington
Services
Administration
9995 6168.07 HHS/Health University of 5360 3899.07 I-TECH $39,251
6168 6168.06 HHS/Centers for University of 3899 3899.06 $26,000
Disease Control & Washington
Prevention
Table 3.3.09:
In FY 2008, the USG proposes to fully fund a new clinical support team to assist the HIV Unit of the MoH
with the expansion of HIV/AIDS treatment services in the country. The team will comprise of an expatriate
Senior Technical Assistant (TA) and two Malawian Staff Fellows as counterparts. The team will be housed
at the MoH. The Staff Fellowship program is intended to attract Malawians into a mentorship program to
help address concerns of the MoH regarding sustainability of this very successful HIV/AIDS treatment
program. The new team will directly support the MoH's aspiration of expanding ARV treatment services
from the current 114,375 patients started on ARV treatment as of June 2007 to 250,000 patients by 2010.
Specifically, their functions will involve, but not be limited to coordinating: provider-initiated HIV counseling
and testing in the context of care; ARV treatment for adults, pregnant women, and children; adverse drug
effects monitoring; drug regimen changes and switching to second line drugs; management of TB/HIV co-
infection; OI management (including prophylaxis); palliative care (including home-based care); and
monitoring and evaluation (M&E) of the clinical outcomes of care and treatment. Additional details of the
new model in terms of the duration of support and remuneration of the Staff Fellows is being negotiated.
The new clinical team will be working very closely with the USG Medical Officer (HTXS ID# 15422) to
ensure appropriate and timely support from the EP team.
Over the past four years, the USG recruited and placed a Senior Technical Assistant (TA) within the HIV
Unit of the Ministry of Health (MoH). This TA has overseen the expansion of HIV/AIDS treatment services
from a mere 4000 patients at nine sites in December 2003 to more than 114,375 patients ever started on
ART in 146 public and private sector facilities by June 2007. Currently, 69.4% of the patients who ever
started treatment are alive and continuing their treatment. The TA has coordinated the training of service
providers in all treatment sites, led a team of on-site supervisors on a regular quarterly basis, collated data
from all the sites, and produced a comprehensive report of progress every three months. This is a
remarkable achievement considering that patient identification was based on WHO clinical staging and
patient monitoring was based on clinical presentation. In spite of these successes, the MoH has expressed
some concerns about the lack of adequate complementary Malawian staff in leadership roles to ensure
sustainability of this effort. The current contract for the TA expires in March 2008 and a new model for
providing assistance is being considered.
Activity 1. Recruitment and placement of an Expatriate Senior Technical Assistant to assist the MoH with
the expansion of ART Services
USG will work with MoH and HHS/HRSA/I-TECH to identify a suitable candidate for the senior Technical
Advisor position. This Senior Technical Assistant will be placed within the HIV Unit of the MoH and report
directly to the HIV Unit Director. The responsibilities of the Senior Technical Assistant will be divided equally
between oversight for the expansion of ART services and training, supervision, as well as mentoring the
senior leadership team of the HIV Unit including the Malawian Staff Fellow counterparts.
Activity 2. Recruitment and Placement of Malawian Staff Fellow Counterparts
USG will work with MoH to identify two suitably qualified Malawian counterparts that will be recruited under
a newly proposed Staff Fellowship program and placed in the HIV Unit of the MoH. The Staff Fellows will be
supervised by the Senior Technical Assistant under the overall leadership and direction of the HIV Unit
Director. The plan is for these positions to transition into MoH permanent staff within two years. The
Ministry anticipates that length of time is needed to obtain permanent positions for the fellows.
Activity 3. Resource and on-site Support Supervision
This new clinical team will bring additional technical expertise and expand the capabilities of the HIV Unit.
Additionally, they will be a resource to all other ARV service providers through training and on-site support
supervision. They will oversee the collection and collation of valuable data on the expansion of ARV
services and ensure the quality of the services as programs expand. The team will work with others in the
HIV Unit to prepare long-term plans, annual work-plans, 6-monthly reports, and other ad hoc reports on the
state of scaling up and performance of the ART support services and operations research. The Unit will
ensure timely dissemination of reports and updated guidance.
Continuing Activity: 16528
16528 16528.08 HHS/Health University of 7141 3899.08 I-TECH $300,000
Program Budget Code: 10 - PDCS Care: Pediatric Care and Support
Total Planned Funding for Program Budget Code: $610,000
Total Planned Funding for Program Budget Code: $0
Program Area Narrative:
Overview
The number of children living with HIV in Malawi is estimated to be 101,939, which accounts for about 1.5% of the total population
of children less than fifteen years of age in the country. Of these children about 32,500 are thought to require treatment now, but
only slightly more than 9,000 are currently on ART, representing 28% coverage of the estimated need for pediatric treatment, and
9% of all patients presently on ART. Malawi has set a target of 15% of patients on ART being children by 2010, which would
double the current proportion, and translate into a numerical target of 36,750 children. The median age of children being initiated
into treatment is 7, with very few infants currently on ART, in part due to lack of access at most health facilities to Early Infant
Diagnosis (EID). While 15,400 children were ever started on ART, 6,400 of these are no longer on treatment, indicating a great
need to improve the quality of the program, and retain children in care. Unfortunately, national data is not currently available to
indicate how many of these 6,400 children have died, were lost to follow-up, or were transferred out.
The number of children being enrolled on ART has accelerated in the last year with 95% of national ART sites reporting that they
have ever started a child on treatment. However, most of these sites are still enrolling very few children in proportion to the
number of adults being initiated on treatment. Although there are large numbers of children being enrolled in care at non-public
sector or international partner sites (i.e. Baylor and MSF), a specialty pediatric treatment model of care is prioritized rather than a
family-centered model in which mothers and children can receive their care at the same time and in the same facility. In order to
more rapidly expand the number of children on treatment at ART sites in the country it will be necessary to implement a more
mainstreamed and decentralized approach to pediatric treatment.
The national ART guidelines were recently updated to recommend immediate treatment for all HIV-infected children less than one
year of age, but little has been done to orient providers on this change or to develop plans of how to implement it nationally.
Monitoring and evaluation for pediatric HIV in Malawi has also received inadequate attention, as is evidenced by the fact that a
recent country-wide survey of HIV services made no mention of pediatric HIV. The ART card, which is the main source of pediatric
patient records, does not have a space for CD4%, and the standard child health passport has not yet been updated to include HIV
-specific information, although plans are in process to address the deficiencies in both of these tools.
The vast majority of HIV-positive children on ART are receiving an adult FDC (d4t/3TC/NVP) split into smaller dosages using pill-
cutters. Pediatric FDCs such as pedimmune are now being procured and are expected to become more available in country in
FY09. While there have been no reported stock-outs of ARVs, shortages of cotrimoxazole have been frequent. This is due in part
to the fact that cotrimoxazole is supplied through the inconsistent Central Medical Stores (CMS) system. ARVs are supported
through a parallel system operated by a private company. Both drugs are procured with Global fund for AIDS, TB and Malaria
(GFATM).
Commodities for the pediatric cohort including ARVs, OI drugs, EID reagents, Ready-to-use therapeutic foods (RUTF) (i.e.
"plumpy-nut"), and other supplies are largely provided with GFATM resources. UNITAID, UNICEF, and Clinton Foundation (CHAI)
have committed to support until the end of 2010 at which time all pediatric ARVS will be purchased with GFATM resources.
Previous USG Support
FY08, USG support for pediatric HIV activities in Malawi focused primarily on two priorities: 1) expanding access to early infant
diagnosis (EID); and 2) strengthening basic care for HIV-exposed and infected children. In expanding EID, USG and its partner
Howard, along with other collaborators such as Baylor and CHAI, supported the Ministry of Health (MOH) in implementing a
successful EID pilot in all three regions of the country. Over 70 lab staff have now been trained in EID, 4,000 dried blood spot
(DBS) samples tested, and the country is in the process of developing a national EID scale-up plan, having set ambitious targets
of DBS testing 80% of known HIV-exposed infants at 6 weeks by the end of 2010.
With regard to the second priority of improving pediatric care, USG has been working to support the implementation of
comprehensive child survival interventions through Basic Support for Institutionalizing Child Survival (BASICS) in eight priority
districts which account for almost 30% of Malawi's population HIV. BASICS provides HIV-related support to district health
management teams, health facilities, and communities to improve postpartum follow-up of HIV-exposed infants and increase
access to pediatric HIV diagnosis, care, and treatment services for HIV-infected and exposed infants, including improving CPT
utilization, management of OI's, nutrition and organizational aspects of pediatric care delivery. During FY08, Year One of the
project, a baseline survey took place which characterized the current status of pediatric HIV implementation in eight districts and
indicated that cotrimoxazole preventive therapy (CPT) services remain limited, with only 47% of sites providing CPT to HIV-
exposed and positive children, and only 60% of staff having been oriented to CPT guidelines and the implementation process.
Additionally, an orientation module was developed which will be used to orient staff in the districts on the most important aspects
of PMTCT and pediatric HIV.
FY09 USG Support
With FY09 funding, USG will continue to deepen its support for the two priority areas of EID and pediatric care, while also
expanding support to include activities that will increase provider initiated testing and counseling (PITC) of children and improve
monitoring and evaluation of pediatric HIV.
i. Laboratory and technical support for scale-up of early infant diagnosis services
With FY09 funding, Howard University will continue to provide support for the scale-up of EID, providing direct on-site technical
assistance and commodities as needed to high three high-volume zonal hospital labs to ensure EID samples are processed and
transported efficiently and accurately. Howard will also provide support for quality assured CD4 testing at 17 zonal and district
hospital labs, including CD4% which is needed for staging of children. To complement the direct on-site assistance provided by
Howard, USG staff will work with other stakeholders at the national level to provide technical assistance to the MOH to complete
the EID pilot data evaluation and develop a comprehensive and detailed national EID scale-up implementation plan based upon
the results of the pilot. See lab section for more information.
ii. Improving quality of pediatric HIV care
With FY09 funding, BASICS will support District Health Management Teams (DHMT) to strengthen the implementation of CPT
and monitor progress at facilities in these districts on number of infants receiving CPT. BASICS will train Trainers of Trainers in all
8 districts who in turn will train clinicians at a total of 80 facilities, utilizing a CPT training package developed by the HIV Unit of the
MOH. Additionally, BASICS will train lower-level health workers who would not normally be able to access specialized HIV
training. Despite the fact that low-level health workers such as HSA's do not directly provide PMTCT services, they are active in
Maternal and Child Health (MCH) units where these services are provided, and are able to enhance key aspects of HIV service
delivery during interactions with clients. The orientation module emphasizes enquiring about a child's HIV exposure status at
routine under-5 clinics, assessing HIV-exposed and infected children, enquiring about CPT, and referring children for clinical
assessment, testing, and treatment when needed. The orientation process will also emphasize practical issues such as
appropriate patient flow pathways which prevent missed opportunities, regular examination of health passports, and the
development of mechanisms which limit the drop out of children from PMTCT care. Program support will consist of on-site training
activities, district level technical assistance, the development of supportive supervision for service provision, and use of job aids to
facilitate improved quality of care.
To complement these efforts on the facility level, the USG will continue to support 170 community-based Mother-Father Support
groups (MFSG's) that were established by BASICS in FY08 in 2 districts, and will scale-up these MSFG's to more districts with
FY09 funding pending an evaluation of them in mid-2009. MFSG's promote maternal and neonatal health and child health, with a
strong emphasis the maintenance of exclusive breast feeding and the introduction of complementary feeding. During FY09 key
aspects of pediatric care will be integrated into activities provided through the MFSG's, including support for Mother-Infant pair
follow up, advocating for CPT in HIV-affected children, and appropriate referral of children who may be affected by OI's.
BASICS is also receiving non-PEPFAR USG Child Survival funding to provide technical assistance to support the MOH in rolling-
out its Pediatric Hospital Initiative and Integrated Management of Childhood Illnesses (IMCI) interventions which are aimed at
improving the quality of care provided to ill children at community and facility levels. BASICS will help ensure that HIV Positive
children who present with common childhood illnesses (pneumonia, diarrhea, fever) are managed effectively, and conversely that
children presenting with common illnesses are tested for HIV. These initiatives build on work done by the earlier BASICS bilateral
project in incorporating key HIV components into IMCI materials. With 2009 funding, TB-CAP will also work closely with BASICS
in the 8 districts where BASICS provides support to improve the quality of HIV/TB services provided to HIV-exposed children
identified in MCH, using a family-centered approach that targets all household members.
iii. Supporting expansion of PITC for children
FY09 funds will be used to provide reliable and regular HCT services through continuing support of 16 lay counselors at 8 district
hospitals, and to pilot deployment of 30 counselors to lower-level health facilities in 2 of these districts. FY09 funding these
counselors will increasingly focus on EID and active-case finding among children in the pediatric wards in district hospitals and
large MCH clinics. Monthly meetings will be held for counselors in the 8 USG supported districts in which counselors will follow an
in-service training program and meet to discuss problem areas related to HIV testing in children such as issues of consent, client
rights, and disclosure related to pediatric HIV and effecting proper referrals of children following testing. Additionally, building on
the findings of its FY08 baseline assessment in the eight districts where it is working, BASICS will provide technical assistance to
CBOS providing OVC services to strengthen the capacity of these CBOs to actively refer HIV-exposed and infected children for
testing and other HIV care as indicated. BASICS will further contribute to PITC by ensuring that the community therapeutic care
nutrition activities it is supporting are actively linked with HIV testing and counseling services.
vi. Strengthening monitoring and evaluation of pediatric HIV
USG staff will work within the national PMTCT/peds subgroup and HIV technical working group to strengthen M&E for pediatric
HIV through: 1) supporting revision of the child health passport to include HIV-specific information and modification of clinical
cards to include CD4%; 2) advocating for inclusion of pediatric-specific indicators within national HIV program and for
reorganization of medical records at the site level to allow for separate records for pediatrics and adults; and 3) supporting
inclusion of pediatric components in future national program evaluations and reviews. Based upon the recommendations of a
recent TA visit from the PEPFAR PMTCT/peds TWG, if adequate technical and financial support could be provided from
headquarters USG would also consider involvement in multi-country PHE projects such as the Pediatric HIV Monitoring and
Outcomes Project.
Compact Funding Program Plans
GOM and PEPFAR have discussed a framework under which a new partnership agreement will be developed using FY08 and
FY09 Compact funds. In September 2008, a Concept note was submitted to OGAC, and the country team was given approval to
begin developing a partnership compact with the GOM. Pediatric care and treatment is a priority area under consideration.
GOM has a goal of enrolling 36,750 children on HIV treatment by 2010. If approved under the Compact, USG would explore
developing a public-private partnership with Baylor and the Clinton Foundation to increase the number of children enrolled on
treatment throughout the country and improve the quality of pediatric care. Baylor has developed and implemented successful
approaches in the Malawi context to link children and families in longitudinal care maximize PITC and linkages to long-term care
in high-volume facilities, strengthen community-based systems to improve retention of children in clinical care, and provide on-site
mentoring and training of staff in pediatric treatment. Given its medical expertise in ART, Baylor appears well-positioned to
complement the work that BASICS is doing at the facilities and communities and to help develop service outreach models which
would allow pediatric ART to be decentralized to lower-level health centers.
Compact funds would also be prioritized to help scale-up the national EID program, as current resources under the GFATM are
not sufficient to reach the national goal of testing 80% of exposed children by the end of 2010. Funds would also be used to re-
establish a 3rd EID lab in the Northern Region, which was closed in early 2008 after the departure of the Taiwanese Medical
Mission. Additionally, to complement the performance based financing (PBF) to be proposed under the Compact for PMTCT
indicators, indicators such as infants tested, and numbers of infants and numbers initiated on ART, could be used for PBF.
Table 3.3.10:
With FY 2008 funding, the International Training and Education Center on HIV (I-TECH) Technical Advisor
for Training, in collaboration with Lighthouse (LH), will play a key role in the development of systems of
training, supervision, and mentoring of CT staff at both Lighthouse and Ministry of Health (MoH). Activities
of the Training Advisor also relate to activities in PMTCT, Other Health Policy/Systems Strengthening, and
HIV Treatment/ARV services. Activities are identified and driven by the Lighthouse Trust and in
collaboration with the MoH. I-TECH provides technical assistance (TA) to Lighthouse through the placement
of the Technical Advisor for Training.
In 2007, the I-TECH Training Advisor played a major role in revising a 5-week HIV Counseling and Testing
training to a 3-week training on behalf of the MoH. The training advisor was responsible for leading a Work
Group through this intensive process, including pilot testing and evaluation of the revised CT curriculum. In
2008, monitoring and evaluation (M and E) of this curriculum will continue using FY 2007 Emergency Plan
funds. Minor updates are also expected before the curriculum is finalized in early 2008. The curriculum
includes key components of TB screening for HIV+ individuals and PMTCT protocols and referral. The
primary target populations are nurses, counselors, home-based care nurses, and other health care staff.
The I-TECH Training Advisor provides TA to Lighthouse nurses, counselors, home-based care nurses, and
other health care staff assisting them to improve group education skills. The Advisor also responds to the
training needs of the MoH and provides training and curriculum revision on behalf of the MoH. Activities
include: mentoring, training, curriculum revision, quality improvement, and supportive supervision.
In 2007, Lighthouse and the I-TECH Training Advisor were charged with the task of leading the revision of
Malawi's national counseling and testing curriculum alongside the Ministry of Health. The central
accomplishments were facilitating a successful curriculum re-design workshop in February and re-designing
the curriculum in preparation for the pilot in March. The positive feedback from MoH, participants in the
workshop suggested that the workshop and subsequent revisions were successful. These two outputs
were accomplished within 4 weeks time. In early April, results from the pilot training were compiled and
revisions to the curriculum were made based on feedback from: participants, facilitators, observers, and
outcome indicators (i.e. pre and post test). Revisions were completed in May and a 2.5 day TOT workshop
was conducted with 60 HTC trainers (30 in Lilongwe and 30 in Blantyre). I-TECH Training Advisor planned
and facilitated the TOT in Lilongwe.
Activity 1: Human Capacity Development in Training for Counseling and Testing
In collaboration with Lighthouse, the I-TECH training advisor will contribute to the development and revision
of sustainable systems and materials to improve national HIV Testing and Counseling (HTC) mentoring and
supervision at 300 HTC sites throughout Malawi. The I-TECH Training Advisor works with Lighthouse staff
to build overall training capacity of the institution. Therefore, when projects are implemented, it is difficult to
separate Lighthouse contributions from I-TECH's contributions, as the Advisor coaches, encourages and
supports Lighthouse counterparts to build the capacity of other Lighthouse and MoH staff.
This will include the development of a mentoring skills curriculum, review of monitoring systems, and focus
on outputs of the mentoring. In 2008, the I-TECH Training Advisor and Lighthouse counterparts will make
significant improvements to the "cascade" approach, where LH mentors outstanding site counselors how to
mentor others at their site. The Training Advisor also contributes to planning and scale-up through a
National-level HTC mentoring Work Group. LH will build the understanding that sharing counseling skills
and experience through observed practice and mentorship is a natural and essential part of a counseling
service. Both mentoring and supervision programs will focus on 1) developing capacity for provider initiated
counseling and testing; 2) working with TB Officers and clinicians to ensure that appropriate routine referrals
for CT are made; and 3) refining counseling protocols to improve consistency of message and efficiency.
Mentoring/training may include curriculum update and revision, training of HCT trainers, and leading and
evaluating training of trainers (TOT's) workshops. The primary target populations are nurses, counselors,
home-based care nurses, and other health care staff. The outcome of this activity will be of benefit and
relevance to both men and women in the general population.
Continuing Activity: 15437
15437 10715.08 HHS/Health University of 7141 3899.08 I-TECH $50,000
10715 10715.07 HHS/Health University of 5360 3899.07 I-TECH $13,084
Table 3.3.14:
This activity will support national Monitoring and Evaluation efforts through the recruitment, placement, and
training of an M and E Unit within the Ministry of Health's HIV and AIDS Unit. The proposed M and E Unit
will comprise a senior M and E Technical Advisor and two local counterparts.
HIV services are rapidly scaling up in Malawi and with the scale-up in services, the need for strong
monitoring and evaluation of the response is critical. Data are needed to monitor site performance, guide
policy development, and for quantification and forecasting of drug and commodity needs.
Though the Health Management Information Unit (HMIU) has the overall mandate for monitoring of the
SWAp and Program of Work within MoH, the HIV/AIDS Unit currently has considerable M and E needs that
the HMIU does not have capacity in place to support.
Placement of additional staff and resources for M and E within the Ministry of Health would greatly
strengthen coordination and leadership for M and E within the HIV/AIDS Unit as well as HMIU to more
actively work with implementing partners on M and E issues. The team would have the capacity to take on
limited but focused M and E implementation roles, e.g. routine data collection and reporting, monitoring HIV-
related training programs in the Unit, and drug and commodity quantification and forecasting.
Key M and E related needs were identified through discussions with various programs within the Ministry of
Health. Placement of additional M and E resources within the various Units could begin to address the
following:
• Provide overall leadership and coordination to M and E activities
• Development and Revision of M and E Tools (e.g. registers)
• Data Management and Reporting of Routine Service Delivery Data
• Supervision of Service Delivery Sites (Data Collection and Quality Assurance)
• Data Management of Routine Training Data
• Quantification and Forecasting of drugs and other commodities
• Design, Conduct and/or Disseminate Operational Research
• Informatics/Serve as internal point person for the ART EDS.
• Liaise with programs within MoH and provide technical assistance on M and E and operations research
activities
• Serve as the point person on M and E issues for the Unit for other Units within MoH (HMIU), NAC, and
external technical and development partners
Activity 1: National Monitoring and Evaluation of HIV Services
I-TECH will support national monitoring and evaluation of HIV services by providing technical assistance to
the Ministry of Health through the recruitment and placement of a senior M and E Technical Advisor and two
locally recruited M and E Officers at the HIV/AIDS Unit at the MoH. This is a new activity for 2008. Although
the Health Management Information Unit (HMIU) has the overall mandate for monitoring of the SWAp
(Health Sector Wide Approach) and Program of Work within MoH, the HIV/AIDS Unit currently has
considerable M and E needs that the HMIU does not have capacity in place to support. This newly formed
Unit will be responsible for monitoring site performance, and disseminating information relevant to policy
development, quantification and forecasting of drug and commodity needs, and other areas. The team will
support limited and focused M and E implementation roles, e.g. routine data collection and reporting,
monitoring HIV-related training programs in the Unit, operational research and drug and commodity
quantification and forecasting. I-TECH will collaborate with other implementing partners, including the LH,
to continue to support the MoH, but with greater coordination and leadership provided from the Unit.
I-TECH is prepared to provide the necessary support, professional development opportunities, and IT-
related operations and infrastructure for routine data collection. Resources will be offered including
networking, database development, long-distance consultation, and other necessary resources such as
computers, software, communication technologies, sponsorship of the senior Technical Advisor and his/her
local counterparts at major conferences and meetings, and a vehicle for meetings and quarterly ARV site
supervision. As part of I-TECH's global team of M and E Technical Advisors, the MoH M and E Advisor will
have extensive tested resources to draw from in heath services monitoring and quality improvement.
Continuing Activity: 16527
16527 16527.08 HHS/Health University of 7141 3899.08 I-TECH $400,000
Table 3.3.17:
I-TECH will work in Human Capacity Development in Monitoring and Evaluation (M and E) of Clinical
Services by placing a Technical Advisor at the Lighthouse Clinic. I-TECH will work at developing an
effective referral system for HIV-positive TB patients and pregnant women with low CD4-counts to ART, and
will provide mentoring support in M and E to 104 ARV clinics. I-TECH will provide technical expertise to the
Electronic Data System Task Force on the development and launch of a pilot electronic data system for
monitoring the national ART program, and will provide technical assistance in establishing M and E
functions in the MoH's HIV/AIDS Unit.
Since 2005, I-TECH has supported M and E activities of Lighthouse clinical services through technical
assistance, human capacity development, and systems strengthening. Lighthouse has assumed a unique
role in Malawi as the model centre for integrated HIV-care in the public sector. To fully realize this potential,
the M and E Technical Advisor will further strengthen the Lighthouse in-house capacity to conduct
operational research and to disseminate findings that are expected to influence national policy and
practices.
Within the past year, with guidance and technical assistance from the I-TECH M and E Technical Advisor,
Lighthouse has built a robust M and E unit including, 2 M and E officers, 3 IT officers and 4 data clerks. In
2008, the M and E Technical Advisor will continue to build the capacity of this 9-member team to carry out
M and E of Lighthouse clinical services. Technical assistance is provided to ensure that Lighthouse has the
means to effectively evaluate its work, to better inform national and international policy, and to
collaboratively collect, validate and compile national data along with the Ministry of Health (MoH).
Additionally, I-TECH will support the national M and E efforts through the recruitment, placement, and
training of a senior M and E Technical Advisor and two local M and E counterparts within the MoH. The
primary target populations are clinical (doctors, medical officers, nurses) and technical (IT, administrative,
and other support staff) healthcare workers.
I-TECH supports the Lighthouse Clinic's capacity development goals in Monitoring and Evaluation (M and
E) of its clinical services and ART program. In 2008, I-TECH proposes to provide technical assistance in
systems strengthening and capacity building of the Ministry of Health (MoH) M and E Unit. Activities include:
human capacity development, systems strengthening, operational research, dissemination of information,
and M and E of PMTCT activities.
Activity 1: Human Capacity Development in Monitoring and Evaluation of Clinical Services
In 2008, I-TECH will continue supporting an M and E Technical Advisor at the Lighthouse (Lighthouse)
Clinic. This activity focuses on the development of human capacity and program sustainability through
continued on-the-job training of the Lighthouse Monitoring and Evaluation team. It covers work begun in FY
2006, which is consolidated and expanded for continuation in FY 2008. The I-TECH M and E Technical
Advisor will continue to develop monitoring and evaluation systems with the Lighthouse M and E team to
provide strategic information on the expanding HIV-services offered at Lighthouse and its new Centre. The
core services now include: HIV testing and counseling, family-centered ARV clinic, integrated TB/HIV
management, integration of PMTCT, home based care, community support group for PLWHA, therapeutic
feeding, and training centre
Activity 2: System Strengthening and Quality Assurance
This is a continuing activity in Systems Strengthening and Quality Assurance. Lighthouse opened the new
‘Martin-Preuss-Centre (MPC) Tithandizane-Clinic' on the Bwaila-Hospital campus in Lilongwe in December
2006. This clinic is Malawi's first center dedicated to the integration of TB and ARV services. In 2007, the I-
TECH M and E Technical Advisor assisted with the design and implementation of aspects of the clinic
operations (patient registration, patient flow, filing system for clinical records, management of lab-samples
and results, referral protocols, etc.). In 2008, the M and E Technical Advisor will continue to guide the
Lighthouse M and E team in the refinement of tools for routine data collection at the new centre. The
effective referral of HIV-positive TB patients and pregnant women with low CD4-counts to ART has been
identified as a new key challenge. The M and E team will continue to develop systems for monitoring of
referrals and conduct research into the causes for failed referrals.
Activity 3: Local Organization Capacity Building
This is a continuing activity in Local Organization Capacity Building. In the past two years, the Lighthouse
M and E team has assumed a growing role in providing services directly to the Ministry of Health, such as
designing tools for M and E, national surveys, data entry and analysis, writing of reports. The I-TECH M
and E Technical Advisor supports the HIV Unit directly through participation in the quarterly supervision and
clinical mentoring of the 104 ARV clinics currently in the public sector. The model of direct provision of M
and E services to the MoH has proven very successful and in 2008 the M and E team will continue their
collaboration with the MoH. Activities will include: revision of the HIV Counseling and Testing Register and
revision of the reporting of indicators from the approximately 360 HTC-sites; review of the national PMTCT
activities and assistance with the HIV Unit in revising PMTCT M and E methods; conducting the 2008-round
of the National Situation Analysis of HIV and TB Services with the teams from HIV Unit and CDC Malawi,
and providing other technical assistance to the MoH.
Activity Narrative: Activity 4: HMIS, Survey/Surveillance, Reporting
Through his technical expertise and in-country clinical experience, the I-TECH M and E Technical Advisor
has been able to make a significant contribution to the development of an electronic data system for the M
and E of the national ART program (implemented by Baobab Health Partnership and Taiwanese Medical
Mission in Mzuzu). The MoH has recognized this project as a key for the sustainability of the national M and
E system for ART. A pilot of this system will be launched at 4 public ART clinics in July 2007 and the I-
TECH M and E Technical Advisor will continue to support this project in the evaluation process and through
technical support in FY 2008.
Continuing Activity: 15439
15439 5983.08 HHS/Health University of 7141 3899.08 I-TECH $200,000
10714 5983.07 HHS/Health University of 5360 3899.07 I-TECH $128,273
5983 5983.06 HHS/Health University of 3900 3900.06 $130,000
I-TECH in Malawi supports the ongoing development of healthcare worker training systems that are locally-
determined, optimally resourced, highly responsive and self-sustaining. The activity described here
supports the activities of the Lighthouse. The targets are ascribed to Lighthouse, and not the training
advisor who supports the implementation of services and the training done by Lighthouse.
Since 2005, I-TECH has partnered with the Lighthouse Trust to increase the capacity of the Lighthouse
Training Department, including the Lighthouse Training Officer, to conduct training for Lighthouse staff and
select other participants. The Training Department provides oversight to the design and dissemination of
information, education and communication (IEC) materials by the Ministry of Health (MoH) to the Districts,
monitors and evaluates clinical and training services, and provides trainings on behalf of the MoH. In the
next two years, Lighthouse plans to formally transition the training department and establish Lighthouse as
a general training institution. This will lend support to the larger human resources issues being addressed
with the GFATM Round 5 Health Systems Strengthening (HSS) Grant to the MoH implemented through the
larger Sector Wide Approach (SWAp) in Health.
In 2007, I-TECH sponsored the training team to attend the Monitoring and Evaluation of Training Programs
Workshop—an intensive weeklong workshop in Seattle, Washington. Participants were able to adapt and
integrate the newly gained evaluation methodologies and tools from this workshop into their training
activities at the Lighthouse and elsewhere. In 2008, I-TECH will continue to provide a full-time Training
Advisor to Lighthouse, with the primary goal of developing a sustainable, quality-driven Training Department
within the institution.
The International Training and Education Center on HIV (I-TECH) will continue to support Lighthouse's
goals in national capacity development and program sustainability through training of healthcare workers in
Malawi. Activities include clinical training, mentoring, quality assurance, quality improvement, and
supportive supervision with the aim of supporting the expansion of HIV and AIDS, TB and STI care and
treatment in Lilongwe. These services are provided to MoH and CHAM (private hospitals) staff and will
involve 2000 health care workers trained in the classroom, with about 450 ART and VCT sites receiving
quality assurance visits. The primary target populations are nurses, counselors, home-based care nurses,
and other health care staff.
The I-TECH Training Advisor provides technical assistance (TA) to the Lighthouse implementing partners,
to improve the quality of the training programs conducted. In 2007, Lighthouse created 3 new positions
(known as "lead facilitators") and began to monitor all training sessions, focusing on the Training Officer and
Advisor giving regular improvement feedback to facilitators. Lighthouse Departments appointed lead
facilitators, and a formal orientation for the lead facilitators was conducted in April. The benifits of this
structural change include: decreased workload for coordinators, improved monitoring of trainings (as one
person will be clearly responsible for paperwork and other pre-training preparations), and more focused
attention from the training office (Lighthouse advisors coach the 3 lead facilitators on how to train other
facilitators at Lighthouse. Currently the Lighthouse Training Officer and I-TECH Training Advisor coach
around 25 facilitators).
This activity also relates to activities in Strategic Information, Counseling and Testing, and Palliative
Care/TB/HIV. Activities are linked to those at the Lighthouse Clinic.
Activity 1: Capacity Development in Training
In 2008, the I-TECH Training Advisor will continue to provide mentorship to the Lighthouse Training Officer
in training methodologies, curriculum design and revision, and training evaluation. This activity, which
focuses on the development of human capacity and program sustainability, is a continuation of work started
in 2005, and an expansion on the activities implemented in 2007. The Training Advisor will continue to build
the capacity of the Lighthouse training department to conduct new trainings and deliver refresher courses to
Lighthouse staff, to integrate HIV/AIDS-related content into standardized curricula, and to utilize
standardized evaluation tools and processes based upon mastery of key competencies. The training team
will provide technical assistance to key trainers in each Lighthouse department: Clinic, CT and Home based
Care. In 2008, the Training Advisor will work with the Training Officer to conduct a needs assessment and
quarterly skills update trainings in the departments of Lighthouse and continue to train HBC volunteers.
The I-TECH Training Advisor will also strengthen the capacity of the MoH to provide health worker training
programs related to HIV. In collaboration with staff at Lighthouse, the Training Advisor will assist in the
revision and development of key national HIV trainings, as these needs are identified by MoH.
Activity 2: Training Program Development
In line with the Lighthouse vision for a multi-year HIV training program, the I-TECH Training Advisor and
Lighthouse will develop a strategic training plan consistent with MoH goals, to meet the growing demand for
quality HIV training that support the MoH HSS goals. In 2007, the Training Advisor participated in the
Lighthouse strategic planning retreats and contributed to ideas for expansion of training through the
Lighthouse Training Department. In 2008, the Training Advisor will assess how an organization like
Lighthouse can better meet national training needs while supporting MoH, and involve appropriate partners,
Activity Narrative: both in-country and internationally.
New FY 2008 funding will support the continuation of human capacity development in training programs at
the Lighthouse. Activities are expected to lead to improved training and improved care clinic-wide.
Continuing Activity: 15440
15440 6174.08 HHS/Health University of 7141 3899.08 I-TECH $100,000
10717 6174.07 HHS/Health University of 5360 3899.07 I-TECH $66,587
6174 6174.06 HHS/Centers for University of 3899 3899.06 $133,141
Table 3.3.18:
This activity is funded through an IAA to CDC from USAID Child Survial and Health HIV/AIDS funds.
One of the critical success factors for the national ARV treatment program in Malawi is the central
coordination of all services. This coordination has led to the development and adoption of national policies
with very impressive timelines. It has also led to the standardized approach to service delivery using
nationally accredited guidelines. Because HIV/AIDS care and treatment interventions are dynamic, these
standards, policies, and guidelines need to be constantly updated. Currently there is only one individual
within the HIV Unit with responsibility for coordinating the scale-up of treatment services nationally. With the
increasing number of patients on treatment and the growing complexity of the management of AIDS as a
chronic disease, having a single individual take responsibility is becoming untenable. This is further
compounded by the concerns about ARV drug resistance, treatment in pregnant women, TB/HIV co-
infection, and treatment of children.
In FY 2008, the USG plans to fund a clinical team comprising of a Senior Technical Advisor and two Staff
Fellows to assist the HIV Unit (see ARV Services activity# 26527). A part of the team's responsibility will be
to assist with the coordination of the ARV treatment scale-up plan, updating policies, standards, and
guidelines, and ensuring that treatment targets are met while maintaining the quality of the service.
Activities associated with this program area include:
Activity 1: Expansion of Treatment Services
USG will support the newly formed clinical team of the HIV/AIDS Unit to strengthen the Ministry's
coordination role in the implementation of health services that make up the continuum of care. The team will
work with all stakeholders to facilitate standardized training for the implementation of provider-initiated
counseling and testing services, management of opportunistic infections, ARV delivery, palliative care,
home care, and caring for careers.
In conjunction with expansion of treatment services is the need to monitor and track patients. The clinical
team will work with others in the HIV Unit to establish and maintain a monitoring system that tracks,
documents and disseminates key data on operations research and health service delivery at intervention,
service and program levels.
The HIV Unit will facilitate the development and implementation of management systems and standards for
technical support services on such aspects as drug security and safety, laboratory support, referral
systems, facility and equipment specifications and monitoring and evaluation.
Activity 2: HIV Policy and Systems Strengthening
As scale-up activities continue, policies need to be developed or constantly updated. The clinical care team
will work with others in the HIV Unit to develop and implement HIV/AIDS care and support policies,
guidelines, and standards that are responsive to the changing HIV/AIDS service environment in the country.
The clinical team will ensure that policies, guidelines, and standards are sensitive to critical issues such as
gender and equity. The clinical team will work very closely with the HIV team and others within and outside
the MoH to develop the capacity of the staff to design, and implement operations research to address
critical problems encountered in the delivery of ARV services. They will be trained and mentored to evaluate
such projects, write reports and disseminate findings which may have an impact on relevant aspects of
HIV/AIDS care and support activities in Malawi.
In FY 2008, the USG will support the HIV Unit to work effectively with all stakeholders, at policy and
implementation level, within and outside the MoH, and within and outside Malawi. Through information
sharing, the team would strengthen the MoH and her contribution to inter-sectoral, regional, international
policies, and guidelines for HIV/AIDS treatment and care.
Continuing Activity: 16529
16529 16529.08 HHS/Health University of 7141 3899.08 I-TECH $100,000
