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.

Related to activity #1738, this is the PHE on MDR-TB surveillance. Funding level will follow.

Activity 6: MDR Survey Sub-Contract

Using FY 2007 funds, TBCAP will sub-contract the sample collection, data entry, and analysis aspects of

the MDR survey to a dedicated Malawian research team. This team will work with the NTP for at least three

months. TBCAP through Reach, NTP, and LSTM will engage the following research personnel: five

dedicated logistics and sample collection officers, one data manager, and two data entry clerks.

Administrative, transport, and logistic support will also be provided.

New/Continuing Activity: Continuing Activity

Continuing Activity: 19176

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

19176 19176.08 U.S. Agency for KNCV TB 7740 7740.08 KNCV/MSH TB- $0

International Foundation CAP

Development

Table 3.3.12:

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

Previously the USG has provided technical assistance (TA) and support for TB/HIV through the MSH-TB

Control Assistance Program (TBCAP) with child health funding. The activities are focused on ensuring

quality of TB and HIV diagnosis and treatment at the Central TB Reference Laboratory (CRL) and local

laboratory sites in Zomba and Mangochi districts. The overall objective of the project is to strengthen

management and technical systems for the delivery of TB/HIV services in Malawi. This wrap around activity

is part of a larger USAID-funded TB program. In recognition of the needs of the National TB Program (NTP)

in Malawi, USG will also provide direct support to the NTP in FY 2008 (see narrative HVTB ID# 15410).

Background

The National TB Program (NTP) in Malawi has attempted, and failed, to conduct an MDR-survey since

2001. The central obstacle to successful completion of this survey is the non-functional Central TB

Reference Laboratory (CRL), particularly the lack of competent leaders and managers within the laboratory.

Additional difficulties in the health system around sample collection and case detection though important,

are non functional in some local labs.

USG Emergency Plan (EP) funds and other wrap around funding will be used to rebuild and strengthen the

capacity of CRL and selected local labs to implement the MDR-TB survey. The proposed key activities to

be funded with EP funds by TBCAP will include the complete refurbishment of CRL and selected local labs

in Zomba and Mangochi districts, improving the management and technical capacity of CRL staff through

international TA and sub-contracting of sample collection, data entry, and analysis aspects of the MDR

survey by a dedicated Malawian research team to work with the NTP. In addition, a basic "TB/HIV

package" will be implemented in selected health facilities that will help build capacity for joint TB/HIV

planning, monitoring and evaluation (M and E), and surveillance of HIV prevalence in TB patients in Zomba

and Mangochi districts. Malawi recently applied for a $35million TB Grant through the Global Fund Round 7

call for proposals. Should additional resources become available, this effort by TBCAP could be expanded

into more districts beyond Zomba and Mangochi.

Key previous achievements using USG support have included

• Drafting the Terms of Reference (TOR's) defining the working relationship between TBCAP and the

National TB Program (NTP)

• Drafting the TOR's defining the working relationship between TBCAP, REACH Trust, and the Liverpool

School of Tropical Medicine (LSTM)

• Conducting the baseline survey in Zomba and Mangochi from the 22nd to 27th May 2007

• Conducting orientation meetings of 400 Health Center health workers on the role and function of TBCAP

TBCAP started activities in April 2007. During the three months start-up period, the project team focused on

organizing the administrative and logistics support as well as providing orientation to the MoH district teams.

Now they are shifting focus to technical activities.

Activity 1: Build Capacity for TB/HIV Control

The following activities will be implemented with FY 2007 EP funds:

i) TBCAP will organize collaborative national meetings between NTP and the HIV/AIDS unit; the Zonal

Health Management Team (ZHMT) in selected zones, districts, health centers, and communities in an effort

to implement the model of care for TB and HIV.

ii) TBCAP will identify/set up/support district and community level committees with broad representation, to

guide and monitor TB/HIV activities.

iii) TBCAP will assist the NTP and the MoH's ART program to organize stakeholders to fine tune,

implement, and scale up the model for the "continuum of integrated TB/HIV care" in a step-wise approach in

selected districts in the South East Zone.

iv) Using current norms and guidelines of the TB and ART programs, TBCAP will adapt the roles and

responsibilities for integrated TB/HIV services at each level and document in the form of SOPs.

v) TBCAP will develop/adapt training and reference materials for community health workers, home-based

care workers, and HSA's.

vi). TBCAP will mobilize the communities to become engaged in TB and HIV integrated care.

Activity 2: Consolidate Model of Integrated TB/HIV Care from Zones to Home Model.

TBCAP will support the implementation and scaling-up of community sputum collection sites and use EP

funds to assist the District Health Officer (DHO) implement and monitor the integrated model of care at the

district level.

To improve case detection on TB/HIV cases and quality of care the project will design and implement a

"TB/HIV kit" in line with the Essential Health Package (EHP) on selected health facilities in Zomba and

Activity Narrative: Mangochi districts. The EHP is the minimal set of services offered to every Malawian through the Sector

Wide Approach (SWAp) plan. USG EP funding will support minor refurbishment of treatment areas for TB

and TB/HIV patients in selected health facilities in both districts.

Activity 3: Complete Refurbishment of CRL and Local Labs in Zomba and Mangochi Districts.

With previous USG support, TBCAP initiated refurbishment of CRL. With FY 2008 EP funds, TBCAP will

complete the refurbishment of the CRL, ensuring that basic working and biosafety conditions are in place.

Once the refurbishment is completed, the MDR survey will be conducted finally.

Activity 4: Provide Technical Assistance to the CRL

Technical assistance to the CRL is an identified need. With FY 2008 EP funds, TBCAP will hire an external

consultant detailed to the CRL through REACH Trust, NTP, and the LSTM tasked with training the CRL

team, including the transfer of knowledge and skills to assist effectively the implementation of MDR survey

activities. The Consultant will be in hired for 6 months.

Activity 5: Improve Management and Technical Capacity of CRL staff.

Using FY 2008 EP funds, TBCAP will review the position descriptions of the 2 laboratory technicians

currently employed by the CRL to ensure the staff are capable of doing the necessary laboratory work in

microbiology, run quality assurance, and link the latter with the external quality control measures provided

by the supra-regional laboratory in South Africa for the MDR survey. The lab technicians will be provided

with the necessary training to ensure they are technically capable of providing reliable data for the survey.

This is a new activity.

Activity 6: MDR Survey Sub-Contract

Using FY 2007 funds, TBCAP will sub-contract the sample collection, data entry, and analysis aspects of

the MDR survey to a dedicated Malawian research team. This team will work with the NTP for at least three

months. TBCAP through Reach, NTP, and LSTM will engage the following research personnel: five

dedicated logistics and sample collection officers, one data manager, and two data entry clerks.

Administrative, transport, and logistic support will also be provided.

New/Continuing Activity: Continuing Activity

Continuing Activity: 17384

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

17384 17384.08 U.S. Agency for KNCV TB 7740 7740.08 KNCV/MSH TB- $400,000

International Foundation CAP

Development

Emphasis Areas

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $400,000

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Program Budget Code: 13 - HKID Care: OVC

Total Planned Funding for Program Budget Code: $3,863,575

Total Planned Funding for Program Budget Code: $0

Program Area Narrative:

Context

The devastating effect of HIV/AIDS in Malawi is nowhere better captured than in the number of children orphaned or made

vulnerable as a result of the epidemic. In Malawi's National Plan of Action (NPA) for OVC (2005 - 2009), the Government of

Malawi (GOM) reported that of its stunning 1,008,000 orphans (or 14 percent of all children) in 2005, nearly half were a direct

result of AIDS. Beyond these, many more children are vulnerable due to factors which impact their physical and psychosocial

development, health and protection, and access to education, food, and other essential services. Of the 924,248 persons living

with HIV/AIDS in Malawi 101,939 are children (0-14). Eight percent of all persons ever started on antiretroviral therapy are

children. While there are very few child-headed households in Malawi (two-thirds of one percent, DHS 2004), this issue warrants

attention. Currently, one third of all Malawian households and 50% of female-headed households are reported to care for at least

one orphan.

In 2004 the Ministry of Women and Child Development (MOWCD), with support from PEPFAR, UNICEF and other key partners

including the Global Fund for AIDS, TB and Malaria (GFATM), developed the NPA. Notable progress in the national OVC

response include the development and inclusion of district OVC action plans into district implementation plans in all 28 districts;

the development of an M&E plan by the MOWCD; nationwide registration of OVC in rural areas; provision of school bursaries to

about 15,000 children nationwide (albeit a far cry from the numbers of children who need education support) and social cash

transfers to 7800 ultra poor households in five districts.

Despite these successes, the just concluded mid-term review of the NPA outlines key areas that still require attention. These are

limited access of OVC to essential services, especially those in peri-urban and very rural areas; the poor quality of existing

services; lack of basic data on OVC and mechanisms for collecting data; un-coordinated OVC reporting systems and limited OVC

operational research to inform programming; limited capacity, leadership and coordination by the ministry; lack of collaboration

and synergy among partners in implementing the NPA; and limited advocacy and enabling environment on OVC issues. Limited

MOWCD capacity to utilize the GFATM resources also remains a major challenge due to difficulties between the MOWCD (sub-

recipient) and National AIDS Commission (NAC, principal-recipient).

There are two coordinating bodies for OVC programs in Malawi, the National OVC Steering Committee (NSC) housed at the NAC,

and the National OVC Technical Working Group at the MOWCD. USG participates in both groups and is therefore effectively

involved in strategic leadership on OVC and supports national-level efforts such as development of materials, implementation of

the NPA, and advocacy for OVC.

Previous USG Support

FY08 marked the transition in USG Malawi's OVC programming, as the large FHI and Save the Children Umoyo projects

concluded in FY07. These programs and services were continued with Pact Malawi. Through an annual program statement

competition in 2007, Pact selected six organizations serving OVC in 8 districts, followed by 4 new organizations in 2008 to

increase coverage and scale up quality of OVC programming in an additional 3 districts. By September 2008, a total of 41,833

OVC out of a target of 39,150, were reached with primary and supplemental direct services. Pact partners built capacity through

staff and volunteer training in OVC care and support, monitoring and evaluation, and reporting. PEPFAR funding increased age-

appropriate and gender sensitive services for OVC such as food and nutrition, education and vocational training, shelter and care,

health services, protection, psychosocial support, and economic strengthening and improved referrals for prevention, CT, PMTCT,

ART and other HIV/AIDS related services to OVC identified by local communities. USG also supported community based child

care centers where children under five (U5) participated in early childhood development activities, received food, growth

monitoring and immunization. USG provided educational support in the form of facilitating enrolment into schools, scholastic

materials, school fees and uniforms to help children stay in school, as well as strengthen access to health care and social support

services for OVC. Meals were provided for children in food constrained homes through community feeding centers as well as

food rations to child-headed households. Play, recreation and life skills were other key services provided to children. All Pact

partners supported households to establish home gardens.

USG, in partnership with UNICEF, supported the MOWCD in conducting a human resources assessment and gap analysis in the

ministry that will support the on-going decentralization of government services to districts by building the skills of frontline district

staff to lead and coordinate OVC response. USG also supported the participation of MOWCD staff in a regional training on

Quality in OVC Programming, in order to advance the national process of improving OVC interventions and follow-on with specific

quality and standards for the Malawi context.

FY09 USG Support

The PEPFAR OVC program plans to complement the GFATM Round 5 HIV/AIDS grant for OVC. In FY09, USG will focus on

addressing some key areas identified in the NPA midterm review. This includes expanding and strengthening integrated

community-based platforms for direct OVC service delivery to children, especially in hard to reach communities; improving quality

of OVC services through the child status index (CSI) initiative; continuing support to build MOWCD through an HR implementation

plan, and upgrading of Magemero Institute, the school that trains social welfare workers. To this end, PEPFAR will explore

GFATM Technical Support for MOWCD, and partner with MOWCD and NAC to strengthen the national OVC M&E system and

support OVC operations research. USG will also maintain its strategic role in addressing the bottlenecks to accessing GFATM

resources from NAC by beneficiaries. The PEPFAR Gender Initiative that aims to prevent HIV infection among 13-19 year old

girls will also continue.

i. Focus on scale-up

10 OVC partners under Pact will continue to increase the scope of services and numbers of children and households affected by

HIV/AIDS they reach. Other scale-up plans include integration with the current Food for Peace program and its follow-on which

currently reaches over 60,000 vulnerable households with targeted food and agriculture support and microfinance in seven

districts. Through integration with the USAID/Malawi Education Decentralization Support Activity, PEPFAR funds will complement

GFATM education bursaries to OVC (which between 2005 - 2007 supported only 15,000 children in secondary schools), by

reaching additional children in primary and secondary schools with education bursaries, school material, prevention and

psychosocial support (including in-school children living with HIV/AIDS whose needs are not adequately addressed by current

programs in Malawi) in order to improve school attendance, retention and performance. Pact partners will also work with Peace

Corps to strengthen capacity at district assemblies, and also facilitate OVC access to GFATM school bursaries and social cash

transfers. Public private partnerships are also planned with Land-O-Lakes to provide milk and HIV prevention services to

households with vulnerable children, and with Project Peanut Butter, for increased production of ready-to-use therapeutic foods to

malnourished children.

ii. Improve quality

In 2007 PEPFAR funds supported three MOWCD and one partner staff to attend the quality improvement training in Tanzania.

PEPFAR will partner with MOWCD, Pact partners and other stakeholders to implement the CSI initiative - a tool for assessing

OVC well being and therefore the quality and outcome of OVC programs. National quality standards and service outcomes will be

adapted and piloted in the PEPFAR funded programs. The Funders Collaborative for Children (FCFC) - a consortium of four UK-

based foundations and major donor - is currently piloting the use of the CSI in two districts. Lessons from these pilots will inform

the PEPFAR quality improvement initiative. The USG Community Care and Support and Nutrition Advisors will also provide

program mentoring to Pact and other PEPFAR supported programs.

iii. Coordinate Care, Referrals and Linkages

A key focus for USG in FY09 is to strengthen referral and feedback systems that will facilitate access to continuum of HIV/AIDS

prevention, care, and treatment and related services to all PEPFAR program beneficiaries. Proposed activities - in collaboration

with other PEPFAR treatment, care and support programs - will include a mapping of existing services such as CT, PMTCT, ART,

food and nutrition, education, maternal neonatal and child health, President's Malaria Initiative (PMI), Sustainable Economic

Growth, Malawi's P.L. 480 Title II food aid program; Ambassador Girls Grants, FAO, UNICEF protection services; GFATM social

cash transfers; and developing referral directories and simple referral and feedback tools. Existing referral models in Malawi will

be identified and adapted for phased national scale up. Linkages with the proposed GOM universal access for insecticide treated

nets (ITNs) will ensure malaria prevention services to OVC older than five years and non-pregnant HIV positive parents or

caregivers who currently cannot receive ITNs through PMI and the National Malaria Program.

iv. Reach especially vulnerable children

Current and planned programs will adopt the developmental, life cycle approach to ensure that program activities are age-

appropriate and gender sensitive for children under 2, 2 -4, 5 - 11, and 12 - 17 years. Especially vulnerable children who will be

reached in FY09 will include U5 girls who are maternal orphans; HIV positive children in schools; and children who are carers of

chronically ill parents. Data emerging from the UNICEF funded secondary data analyses of the MICS 2006 and DHS 2004 show

that U5 girls who are maternal orphans are not accessing immunization and other child health services at rates that are markedly

lower than U5 boys. USG will collaborate with UNICEF to further understand this and other noteworthy phenomena and program

appropriately to address these gaps.

v. Strengthen Capacity

The 2008 Human Resource Gap Analysis of the MOWCD supported by USG and UNICEF, revealed significant areas requiring

restructuring in order for the Ministry to carry out its duties as well as succeed in decentralizing the response to districts. The

developed HR capacity building plan includes support to MOWCD to strengthen the pre-service training for District Social Welfare

Officers who are the duty bearers for OVC at the district, by revising and upgrading the training curriculum at Magamero Institute

so the institute can award diplomas and degrees (instead of the current certificate); and train the lecturers to upgrade their skills.

Twinning with the Catholic University, Mzuzu University, and other institutions in the SADC region are also being explored. USG

is working closely with UNICEF, MOWCD and the Regional HIV/AIDS program (RHAP) in South Africa to implement this plan, as

this is critical to sustainability. Other capacity building activities will support the MOWCD to resolve its internal bottle-necks, which

hopefully will assist in removing the barriers to the ministry's ability to draw on much needed GFATM for OVC programs. Peace

Corps activities will also support MOWCD district efforts.

vi. Build knowledge

Planning for OVC programs is greatly limited by the lack of basic data for programming. The situation analysis that was planned

in the NPA has not happened. PEPFAR funds will support the collection of basic OVC data possibly through over-sampling the

2009 DHS to help programs understand the scope, dimensions and intensity of vulnerability in Malawi, and inform strategic

decision-making for OVC programming. The planned OVC strategic information mapping will also support better targeting of USG

services with needs on ground by identifying areas of high vulnerability and potential linkages with other programs. Formative

research on the needs of HIV positive children in schools will provide important information for this critical group of OVC. Through

continued partnership and information sharing of best practices and lessons learned with other agencies - UNICEF, FCFC,

NGOs, MOWCD - PEPFAR programs will ensure increased access to OVC data and information. Training and capacity building

at all levels will also contribute to building knowledge. PEPFAR funds will also support USG partners to strengthen and

harmonize data collection tools and ensure alignment with the national M&E tools.

vii. Policy

MOWCD with funding from the GFATM is working on several laws in Malawi. These include The Adoption Act; Child Care,

Protection & Justice Bill; The Wills and Inheritance Act; Human Trafficking Act; Gender Equality Act; Domestic Violence Act; and,

the HIV and AIDS Legislation. USG will collaborate with MOWCD, UNICEF, NAC and other stakeholders to ensure the speedy

enactment of these laws through the TWGs. As already described elsewhere, USG will, in close partnership with UNICEF and

MOWCD, continue to support the restructuring and decentralization of the ministry functions, upgrading of Magemero Institute in

order to strengthen the ministry's capacity at national and district level to provide, and supervise and coordinate support to OVC,

their households and communities.

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. OVC is a priority area for the Compact.

In collaboration with the GOM, USG will propose a scale up of the OVC response through a new RFA for activities that mobilize

and support community response; increase meaningful child participation; strengthen household, community and national capacity

to respond; and ensure equitable access of boys and girls to quality services. Key focus will be on initiatives that channel the

most services directly to vulnerable children and their households; promote integration and wraparounds with food/nutrition,

education, child health, and household economic strengthening; and ensure each child receives the right mix of quality services

that translate to real improvements in child well being.

Table 3.3.13: