Detailed Mechanism Funding and Narrative

Years of mechanism: 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

Details for Mechanism ID: 12131
Country/Region: Malawi
Year: 2010
Main Partner: Christian Health Association of Malawi
Main Partner Program: NA
Organizational Type: FBO
Funding Agency: HHS/CDC
Total Funding: $1,195,000

The Christian Health Association of Malawi (CHAM) is an ecumenical, not for profit non-governmental umbrella organization of Christian owned health facilities which provide health care to approximately 40% of the population in Malawi. CHAM will play a key role in the implementation of the Partnership Framework between the United States Government (USG) and the Government of Malawi (GOM) in Malawi, and the PEPFAR-supported CHAM activities will serve to further strengthen the broader health sector.

CHAM was established in 1966 by Malawi Council of Churches (MCC) and the Episcopal Conference of Malawi (ECM) to facilitate and coordinate the provision of health services by church based health facilities registered under ECM and MCC. As at the end of 2008, CHAM had 173 member health units across the country. Out of these health facilities 20 are main hospitals, 19 community hospitals, 1 mental hospital and 132 health centers. 90% of these health facilities are located in the rural hard-to-reach settings of the country. CHAM also has 10 training colleges, a college of health sciences and a mental health college, all of which are attached to CHAM hospitals. CHAM produces about 77% of the nursing personnel in Malawi.

CHAM has been very instrumental in the health sector by participating in all reforms being implemented by Ministry of Health (MOH). The reforms include Essential Health Package (EHP). CHAM is also a signatory to the Sector Wide Approach (SWAp), an overarching strategy that is used in implementation of the EHP. The Ministry of Health (MOH) outsource the provision of EHP to CHAM through signing of Service Level Agreements (SLAs), as they are unable to meet the national healthcare needs of the country especially in hard-to-reach areas where most CHAM facilities are located.

While the number of church-based health facilities operating under CHAM has increased, provision of health care in such health facilities has been greatly affected by lack of adequate staffing. In addition, CHAM Secretariat (headquarters), has also suffered from poor funding to effectively coordinate implementation of health care policies including the national response to HIV and AIDS. While attempts have been made to mobilize resources for HIV and AIDS interventions for church-based health facilities, very little has been allocated to strengthen the capacity of the secretariat to effectively monitor, supervise, train and document good practices that can be replicated in other CHAM health facilities (particularly in the areas of ART provision and scale up, adherence, Prevention of Mother-To-Child Transmission of HIV (PMTCT), Monitoring and Evaluation). To date only 35 health facilities provide comprehensive HIV Counseling and Testing (HCT), Antiretroviral Therapy (ART), and PMTCT services, 84 provide PMTCT only and 9 Pediatric ART. The Secretariat has only one employee dedicated to implementing of HIV programs for all member units. Therefore, through this project, CHAM envisages that CDC will work with its member units to increase access to high quality HIV services, strengthen linkages between HIV

services, and improve laboratory services and training programs for all health workers.

Monitoring of HIV services at member health facilities is not standardized at the site level, although standardized checklists are used during routine supervision visits by the secretariat. Monitoring and Evaluation, including surveillance and health information systems, are high priorities in the revised Malawi National Action Framework (NAF) and equally high priorities in CDC supported programs. This partnership will have a focus on strengthening the M & E activities at CHAM's member health facilities and their secretariat. CHAM also oversees 10 training colleges which provide health care workers for both public and private health facilities in Malawi. These training colleges graduate about 450 health care workers from all cadres each year; approximately 60% are deployed to work for MOH, and 40% for CHAM. In 2008, the MOH asked CHAM to rapidly scale up their training programs, and to double their intake of new students within one year. The effort to scale up training so rapidly has put additional strain on the limited capacity of the secretariat, and the U.S Government (USG) will work with CHAM to creatively solve the challenges in this area.

To ensure effective coordination and implementation of the program, CHAM has the Director of Health Programs who oversees implementation of programs activities. She is supported by the HIV Manager who is responsible for managing all HIV and AIDS Activities in CHAM. The Executive Director, Director of Finance, Internal Audit Manager and Finance Manager and the Training Manager will all play a role to ensure that that all proposed activities are effectively implemented. Given that these members of staff are already involved in a number of activities, CHAM will further recruit additional staff who will be working fulltime to facilitate program implementation. These will include: the HIV Manager, Project Coordinator; Grants Management Officer, Laboratory Services Program Officer and M & E Officer. The Executive Director will provide overall leadership of the project implementation.

Budget Summary PFIP Year 1 Funding - $770,000.00 PFIP Year 2 Funding - $770,000.00

Funding for Care: Adult Care and Support (HBHC): $170,000

III. Budget Code: HBHC ($170,000) CHAM will work with MOH in developing and implementing the new national Pre-ART program. This will include the following activities:

With PFIP Year 1 funds:

Activity 1: The National ART program is working to decentralize ART to lower level health facilities as well as to develop a pre-ART program, and will need extensive support to succeed. A formalized pre-ART program is needed in order to minimize patients 'lost-to-follow-up' between HCT and ART clinics, and to follow HIV-positive individuals closely enough to ensure timely initiation of ART and minimize early mortality.

CHAM will use part of PFIP Year 1 funds to support the national ART program efforts by working with the Ministry of Health in developing and piloting the pre-ART program at selected health facilities. Activities include but are not limited to:

Implementing a pre-ART package which includes Prevention with Positives (PwP) strategies in collaboration with Ministry of Health is a core activity during FY10. It is critical to actively involve HIV- positive individuals in prevention activities in order to avert further infections. CHAM will participate in trainings on the guidelines and modules for the pre-ART package. The pre-ART model/package will also be pilot tested in selected CHAM health sites that have CD4 facilities along with Ministry of Health facilities. Trainings will be conducted at the pilot sites for health care workers on the minimum package and M & E tools. CHAM will implement PwP interventions to reduce the spread of HIV infections by

focusing prevention efforts on HIV-positive individuals who receive care services in its health facilities. A roll-out of treatment programs will provide an important opportunity to cater to the prevention requirements of the HIV-positive people.

PwP participants will receive risk reduction counseling and case management services, and learn skills to help them adopt safer behaviors to both help them stem the spread of HIV and prevent secondary infections. The interventions will include activities but not limited to: encouraging and counseling HIV- positive persons to prevent. Through PwP, CHAM will ensure that participating health facilities have the tools and training they need to maintain comprehensive and holistic client participation in the interventions. CHAM realize that a prevention response that does not recognize the needs and desires of people living with HIV cannot succeed hence community involvement strategies will be employed since it has been shown that it boosts the health care system, helps to tackle stigma and discrimination in the clinic set up and improves adherence in those that are on treatment.

PFIP Year 2 Funds ($170,000)

CHAM will continue the same activities described in year 1.

Funding for Testing: HIV Testing and Counseling (HVCT): $200,000

IV. Budget Code- HVCT -($200,000) With PFIP Year 1 Funds CHAM will:

Activity 1: Expand confidential HIV counseling and testing programs to reduce sexual transmission of HIV, and strengthen linkages between HTC and other services. Activities include but are not limited to: In a bid to expand HCT services, CHAM will embark on training HCT service providers who will undergo three weeks of the national certified training curricula. Efforts will be made to expanding confidential counseling and testing capacity to respond to demand and identify HIV positive individuals who require care, as well as to improve prevention services to those attending HCT services. Couple counseling will be emphasized to cater for PMTCT clients. CHAM intends to put more effort on expanding HCT services to cover TB, STI and ANC clients to avoid missing out on eligible clients. Strong referral systems will be worked out within the health facilities to maximize opportunities that arise when one consults to seek medical help for other related conditions.

CHAM will be working with Ministry of Health in designing a pre-ART package which will be strongly linked to HCT as part of strengthening linkages between HIV services. CHAM envisage that by working with Ministry of Health to pilot a new confidential referral system for HCT service, access to counseling and testing services for the general population will be improved. Counseling and Testing will be linked to other HIV services thereby establishing a functional referral system that will ably link potential clients to prevention, care and treatment services. The linkage will facilitate implementation of PwP interventions in the health facilities.

With PFIP Year 2 Funds, CHAM will:

Activity 1: CHAM will expand confidential counseling and testing capacity to respond to demand and identify HIV positive individuals who require services

CHAM will continue to assess capacity needs of HTC services in new and old implementing health facilities and trainings for service providers shall be organized based on the need. In addition, CHAM will facilitate renovation of user-friendly HTC infrastructures including equipping and furnishing where there are infrastructure gaps.

CHAM will facilitate training of health care workers and lay counselors in HCT following the approved national curricula. In addition, quarterly supervision of trained HTC counselors will be conducted to ensure that quality control is adhered to in service delivery. CHAM will roll out and institutionalize Provider Initiative Counseling and testing (PITC) in-patient settings, ANC, STI and TB clinics to ensure integration of services and leverage of available resources. Linkage of different interventions will be established and promoted between HCT, PMTCT, ART, TB, and community support groups to ensure that no client is lost in the process.

CHAM will also facilitate establishment/improvement of HCT sites and train adequate personnel to cope with the expected increased uptake of HCT clients. Patients presenting with TB, STI or other common Opportunistic Infections will need a diagnostic HIV test to determine the medical care need. These patients do not need full VCT with a risk assessment and risk reduction plan. Given the current structure of services, it is not feasible for the TB clinician or the outpatient clinician to provide this lengthy intervention. The current procedure requiring full VCT for sick patients overloads the VCT service and reduces the availability of VCT to self referred clients. As a result, many TB, STI and other OI patients are not tested for HIV. CHAM endeavors to structure its services to allow implementation of PITC in its implementing sites.

Funding for Strategic Information (HVSI): $50,000

V. Budget Code- HVSI - ($50,000)

With PFIP Year 1 Funds CHAM will: Activity 1: Strengthen its capacity in collection of HIV prevention data to use for informing national level programming and for informing decision-making for HIV/AIDS care and treatment programs. Activities will include but are not limited to: CHAM will use part of the PFIP Year 1 funds to review its existing monitoring and evaluation tools and checklists to ensure that they capture all the project and PEFPAR indicators. This will strengthen the capacity of the CHAM secretariat to develop and implement a standardized M & E system for the health facilities.

A standardized monitoring system for member health units will be created and strengthened to ensure accurate data collection, analyses and utilization for information driven decision making. An electronic information management system will be established and implemented across the participating facilities and an office will be designated for this exercise. All program staff will be trained in data recording, analysis and utilization and also to provide maintenance and trouble shooting at facility level. Quarterly, bi-annual and annual reviews will be conducted in order to assess progress, draw lessons, identify challenges and refine or adjust the implementation plan as and when need arises.

With PFIP Year 2 Funds, CHAM will

Activity 1: Expand capacity in collection of HIV prevention data to use for informing national level programming and for informing decision-making for HIV/AIDS care and treatment programs ($50,000)

Through PEPFAR Year 2 funds, CHAM will continue to enhance its capacity in routine data collection, usage and management of HIV and AIDS programs. This will be done by expanding HIV/STI/TB surveillance programs and strengthening laboratory surveillance, diagnosis, treatment, disease monitoring and HIV screening for blood safety. The capacity of CHAM secretariat and health facilities to collect, analyze and use data generated will be strengthened to ensure that the data is essential for planning and evaluating prevention and care activities and for assessing impact of the interventions that will be initiated.

CHAM will continue to improve its established monitoring and evaluation systems to ensure that they reliably capture all the project and PEFPAR indicators. A standardized monitoring system for member

health units will be sustained and strengthened to ensure accurate data collection, analyses and utilization for information driven decision making. An electronic information management system will be implemented across the participating facilities. All program staff will undergo refresher training in data recording, analysis and utilization. Quarterly, bi-annual and annual reviews will be conducted in order to assess progress, draw lessons, identify challenges and refine or adjust the implementation plan as and when need arises.

Funding for Biomedical Prevention: Injection Safety (HMIN): $75,000

CHAM will receive 1-time injection safety funds to strengthen pre-service training curricula and activities

for nurses and other health providers to incorporate a stronger component on injection safety and PEP in

all training facilities participating in the HRH initiative. (see OHSS narrative)

Funding for Sexual Prevention: Other Sexual Prevention (HVOP): $250,000

II. Budget Code: HVOP ($250,000)

With PFIP Year 1 Funds CHAM will conduct the following activities:

Activity 1: CHAM will improve the ability to collect standardized data on HIV prevention in their partner health facilities, including: CHAM will also scale up the prevention activities conducted in non-HIV services including Tuberculosis (TB), Sexually Transmitted Infections (STI) and Antenatal Clinic (ANC). The interventions will include but not limited to HIV screening to which these service areas should make certain its clients have access, as well as services that the HIV program offer.

In order to decrease the burden of HIV in TB patients, the following activities will be undertaken; provision of HIV counseling and testing, Cotrimoxazole preventive therapy (CPT), ensure accessibility and availability of comprehensive HIV/AIDS care and support services. The HIV/ TB or STI or ANC collaborative approach will reduce number of eligible clients who get lost within service areas. -Developing a standardized monitoring and evaluation system for CHAM facilities to support data collection -Implementing the new M & E system, including the collection, analysis and reporting of HIV data to sites and relevant partners

-Working with Ministry of Health to pilot a new confidential referral system for those who test positive to ensure they are linked into care early, thus ensuring their exposure to Prevention messaging and timely initiation of ART, reducing the likelihood of transmission of HIV.

With PFIP Year 2 Funds, CHAM will:

Activity 1: Improve care and treatment of HIV/AIDS, opportunistic infection, sexually transmitted infections (STIs) and related opportunistic infections by improving STI management; enhancing the care and treatment of opportunistic infections, including tuberculosis (TB); and initiating programs to provide anti-retroviral therapy

CHAM will assess the laboratory capacity of all the Health facilities participating in the project, develop and implement standard operating procedures aligned with national standards. CHAM will work with district health offices and Ministry of Health, to ensure that laboratories are adequately staffed and equipped to carry out their activities effectively. More laboratory personnel will be trained and diagnostic equipment procured and distributed in order to strengthen laboratory services.

Training of health workers will be provided to improve technical skills and ensure that quality services are expanded and improved in the areas of PMTCT, HCT, ART (adult and pediatric), TB, STI laboratory and early infant diagnosis.

Funding for Biomedical Prevention: Prevention of Mother to Child Transmission (MTCT): $450,000

I. Budget Code: PMTCT ($450,000)

With PFIP Year 1 funds, CHAM will conduct the following activities:

Activity 1: CHAM will increase access to PMTCT services ($100,000): CHAM will work with the Ministry of Health to roll-out and scale up PMTCT services in order to improve availability and accessibility of the service to eligible pregnant women. CHAM is considering strengthening integration of PMTCT in MCH settings with a goal to alleviate overall maternal and infant morbidity and mortality. CHAM will implement activities including training of counseling and testing service providers so that they are able to address all aspects of HIV counseling and testing, including the reduction of the risks of sexual and postnatal transmission of HIV, contraception options and prevention of HIV sexual transmission appropriate to HIV status. Availability of counseling and testing services for

pregnant women will facilitate early presentation of HIV-positive pregnant women to benefit from a complete course of antiretroviral prophylaxis and early infant diagnosis interventions.

Under this component, CHAM will also undertake renovations of PMTCT service sites to make them male-friendly and ideal for services that are offered in PMTCT programs. CHAM will also increase and strengthen linkages between PMTCT interventions with ART and other health programs and creating a better system for monitoring and reporting. With these services, CHAM will implement interventions that will include identifying the HIV status of women and infants, providing ART to HIV-positive pregnant women within MCH, follow-up treatment for all babies exposed to HIV and follow-up for all mother enrolled in PMTCT programs to minimize loss to follow-up issues.

With PFIP Year 2 Funds, CHAM will continue increasing access to PMTCT nationally, and will also engage in the following additional activities:

Activity 1: CHAM will strengthen quality of PMTCT services its health facilities to reduce Mother to Child Transmission of HIV

CHAM will work with the Ministry of Health to roll-out and scale up PMTCT services in order to improve availability and accessibility of the service to eligible pregnant women. CHAM is considering strengthening integration of PMTCT in MCH settings with a goal to alleviate overall maternal and infant morbidity and mortality. CHAM will implement activities including training of counseling and testing service providers so that they are able to address all aspects of HIV counseling and testing, including the reduction of the risks of sexual and postnatal transmission of HIV, contraception options and prevention of HIV sexual transmission appropriate to HIV status. Availability of counseling and testing services for pregnant women will facilitate early presentation of HIV-positive pregnant women to benefit from a complete course of ART and early infant diagnosis interventions.

CHAM will also undertake renovations of MTCT service sites to make them male-friendly and ideal for services that are offered in PMTCT programs. CHAM will also increase and strengthen linkages between MTCT interventions with ART and other health programs and creating a better system for monitoring and reporting. With these services, CHAM will implement interventions that will include identifying the HIV status of women and infants, providing ART to HIV-positive pregnant women within MCH, follow-up treatment for all babies exposed to HIV and follow-up for all mother enrolled in PMTCT programs to minimize loss to follow-up issues.

Activity 2: CHAM will scale up lay cadres and/or expert patient approaches

CHAM would strengthen Mothers-to-Mothers (M2M) approaches where they exist and initiate where they do not exist. HIV-positive mothers and HIV exposed infants that are confirmed positive will be followed up in order to identify those eligible for ART as early as possible as well as for care and support services. Eligible HIV positive pregnant women and infants will be enrolled for ART initiation under the project.

Activity 3: Prevention of sexual transmission with a focus on discordant couples CHAM will continue the provision of integrated, comprehensive PMTCT services in an effort to scale up male involvement in PMTCT, particularly in the area of men accessing HTC with their wives at the first Antenatal visit. CHAM shall endeavor to provide a male friendly environment in the Antenatal clinics by facilitating renovation of some Antenatal Clinic infrastructures in selected health facilities where this need arise. CHAM will endeavor to scale up evidence-based prevention efforts. This will entail strengthening support services for discordant couples, provision of quality Prevention-with-Positives counseling, improve support structures for the intervention therefore and community mobilization for male involvement initiatives. CHAM envisages that these interventions will facilitate HIV prevention for HIV- infected individuals during pre-ART and post-ART initiation.

Cross Cutting Budget Categories and Known Amounts Total: $122,122
Human Resources for Health $122,122
Key Issues Identified in Mechanism
Addressing male norms and behaviors