The Support for Service Delivery Excellence (SSD-E) project will reach 6.5 million Malawians with Essential Health Package (EHP) services, including PMTCT and other HIV services. SSD-E will implement an integrated service delivery program that will ensure expansion and improved quality of priority EHP services at the community and referral (health centers and district hospitals) levels. All actors in the household-to-facility continuum of care (i.e., women, men, youth, community leaders, HSAs, clinical providers, and district managers)will be empowered to play their part in increasing access, utilization, quality, and demand for health services. SSD-Es strategy will reach the un-reached by tracking individuals along the life cycle to ensure continuity of care, and other strategies such as engaging in catchment area mapping to enlist target households. Specific HIV interventions will include PMTCT, HCT, infection prevention, parent-infant pair follow-up for HIV-positive mothers and/or fathers and exposed infants, nutrition and HIV care support groups.

The project activities will be implemented in 11 out of 28 districts and will contribute to the PFIP goals of reducing new HIV infections, improving quality of care and strengthening health systems. The projects M&E will enable effective tracking of project implementation and results. SSD-E will strengthen the capacity of its local partners with the aims of fostering a sustainable HIV response. Some examples of capacity building efforts include clinical skill transfer through mentoring, infrastructure improvement, monthly supportive supervision to health facilities and districts for M&E, and sub-granting to community-based organizations along with technical support on financial management.

This project will support a wide array of HIV/AIDS care and support services in six districts of Malawi. The projects interventions will primarily be facility-based and target people living with HIV. The project will aim to increase availability of key services and improve the quality of service delivery. Based on the package of services defined in the national clinical care guideline and the program components outlined in the COP technical considerations, the key areas of focus will include diagnosis and management of opportunistic infections, provision of CPT, family planning, adherence counseling, and assessment of and linkage to ART. In order to improve the quality of services, the project will support the implementation of the national clinical mentorship program in the six districts and provide technical and financial support for the training/re-training of health providers. In COP 13, SSDI-services will collaborate with the District Health Office and community-based partners to strengthen the community-health facility continuum. This will involve establishing support groups, strengthening bidirectional referral systems, tracing of defaulters, etc. The project will also seek to enhance access to non-clinical care and support services by creating/updating service directories (food support, IGA, etc.), working closely with stakeholders outside of the health sector (e.g. food security activities), and implementing efficient referral mechanisms. The project will monitor the effectiveness of its interventions by tracking key indicators such as CPT coverage, CD4 monitoring of pre-ART patients, completeness of referrals and LTFU rate. The project will implement Performance Quality Improvement (PQI) methods to help health facilities learn from their implementation and improve their performance continuously. The project will undertake operations research in order to understand specific patient- and program-level challenges that may influence attainment of project goals and desired health outcomes.

In COP13, SSDI-services will implement priority TB/HIV interventions in six districts of Malawi. These interventions are in line with the national TB strategy and MOHs HIV/AIDS guideline. The project will coordinate its activities with the national TB program and other key partners including the USG funded TBCARE II project.

At the health facility level, SSDI-services will provide in-service training and mentorship to TB and HIV service providers with a focus on regular screening of TB patients for HIV and vice versa, timely initiation of co-infected patients on ART, provision of IPT, and appropriate implementation of DOTS. Based on need and availability of resources, the project will undertake renovation of TB and HIV clinics, as well as in-patient wards, to minimize the risk of TB transmission within the clinical setting and create space for a one-stop shop TB/HIV services. Depending on need (e.g. staff turnover, programmatic changes), SSDI will train/re-train additional staff to make sure they possess the knowledge and clinical competence they need to fully implement TB/HIV services.

In Malawi, provision of IPT is still in its early stages. The first (large scale) distribution of isoniazid and pyridoxine for the HIV programs reached ART sites during July 2012. In the last quarter of FY12, 27% of pre-ART patients were on IPT. A further increase in IPT implementation is expected in the coming months and year. SSDI will support health facilities and providers in the roll out of the IPT program. SSDIs support will include training, mentorship, supportive supervision and provision of job aids.

At the community level, the project will establish sputum collection points and facilitate the transportation of samples and results to and from diagnostic labs. . The project will identify community volunteers and train them to ensure they have the required skill to manage a sputum collection site and a sample/result transportation network. The project will also implement effective referral mechanisms and link TB patients to health facilities for further work up and treatment. Through its Community-based family planning Distribution Agents, which also conduct door-to-door HIV testing, the project will avail HIV counseling and testing services to individuals suspected of TB.

SSDI will strengthen the provision of key pediatric HIV services including early infant diagnosis, prevention and management of OIs, and timely initiation of ART. As an integrated platform (i.e. HIV and other health programs including MCH), the project is well positioned to influence a broad range of basic child health services that will synergize with the work done through PEPFAR. Nutritional counseling, assessment and support interventions will be integrated into pre-ART and ART clinics through in-service training, mentoring, provision of job aids, etc. HIV-exposed and infected children with malnutrition will be linked to nutritional rehabilitation units and their caregivers referred to community-based nutrition/food security programs.

To enable timely identification of HIV positive children and enrollment into care, SSDI will support collection and transportation of EID samples/results, provide training, procure EID kits, and develop SOPs for sample and result transportation. Additionally, health providers in under-five clinics, in-patient wards, and nutritional rehabilitation units will be trained on provider-initiated testing counseling, and linkage to other HIV and MCH services. The project will support the Ministry of Health to develop a 5 year EID scale up plan.

The project will coordinate with OVC programs to establish effective linkages that meet the health and HIV needs of OVC, as well as the social, economic, legal, and educational needs of HIV-exposed and infected children and adolescents. Health Surveillance Assistants will serve as the critical link between health facility services and community-based programs. Additionally, the project will help establish facility and community-based support groups for exposed infants, HIV infected children, adolescents, and their families.

In targeted facilities, SSDI-services will strengthen the diagnostic capacity of laboratories to conduct key clinical laboratory tests. This will be accomplished through procurement of CD4 machines, development and/or operationalization of QA/QC systems, mentorship of laboratory technicians, etc. A recent HTC review revealed gaps in the quality of HIV testing. One of the major priorities for this year will be improving the quality of HIV testing conducted at various points within the health facility. Additionally, SSDI-services will support the collection and transportation of samples (sputum, EID, CD4 and VL) as well as timely return of results. The project will collaborate with MOH and USG lab partners to align its support with the national strategy for sample transportation. The project will also explore/adopt innovative technologies that will shorten the turnaround time for lab results such as CD4 and DNA PCR. PEPFAR standard indicators will be used for the regular monitoring of project interventions and measure progress the labs are making. SSDI-services will work with USG lab partners on accreditation of labs through the SLMTA process.

SSDI-services will train and mentor health providers and data clerks on the national monitoring and evaluation tools (registers, reporting forms). The project will ensure regular availability of registers and reporting forms. The project will also facilitate monthly performance reviews that will enable managers and service providers to reflect on their achievements, identify bottlenecks and implement corrective actions.

SSDI-services will provide financial support for the deployment of the electronic data system (EDS) in high volume sites. EDS will support patient care and facilitate routine data management for monitoring and evaluation.

In order to enhance the quality of data generated at the health facility, SSDI-services will assist health facilities and district health offices to implement data quality assurance mechanisms, and conduct periodic data quality assessments.

Most health facilities in Malawi face numerous health systems challenges (poor infrastructure, shortage of skilled HRH, etc.) that affect the effective delivery of HIV/AIDS services. In FY14, SSDI-services will undertake renovation in selected health facilities. These renovations will improve the quality of service delivery by facilitating patient flow, creating a good working environment for providers, reducing risks of nosocomial infection (such as TB), and creating secure spaces for key commodities such as ARVs and test kits. Through in-service training and regular clinical mentoring, SSDI-services will facilitate the appropriate implementation of the national HIV/AIDS guidelines. The project will also assist health facilities develop and implement tools that will enable regular monitoring of key commodities such as rapid test kits and ARVs. Standard Operating Procedures will be developed that will guide linkage between various service delivery points within a health facility.

HIV testing and counseling is a key HIV prevention tool and an entry point to HIV/AIDS care and treatment services. In order to expand access to HTC, SSD will train and mentor HCWs on HIV counseling and testing. In addition to health facility HTC, the project will implement door-to-door HTC that is integrated with counseling on and provision of family planning commodities. In total, its expected that SSD will facilitate the counseling and testing of 149,400 individuals including pregnant women.

SSD will also strengthen provider-initiated testing and counseling in multiple points within the health facility, including immunization clinics, cervical cancer screening programs, STI and post-abortion care clinics.

SSD will maximize the benefit of increasing access to HTC by establishing effective referral systems for HIV positive individuals both in health facilities and communities. The program will also promote couples counseling and testing and improve healthcare worker skills in couples counseling.

SSD, in collaboration with USG lab partners, will assist District Health Offices (DHOs) and health facilities to establish an External Quality Assurance (EQA) for HIV tests.

The project has established a robust monitoring and evaluation system that will enable effective tracking of HTC activities and results including number tested, test result, couples testing, client-initiated/provider-initiated HTC, etc.

SSD will support implementation of the national PMTCT program through both facility- and community-based approaches to establish ART/PMTCT mentoring programs in 50% of health facilities in 11 districts and will ascertain the HIV status of 124,500 pregnant women. At the facility level, SSD will assist the Ministry of Health (MOH) and districts to improve access to and quality of PMTCT services by training health workers, supporting integrated clinical mentoring, and improvement of infrastructure. These interventions will aid successful application of Malawis new integrated ART/PMTCT guidelines adopted in July 2011. Through its life-cycle approach, SSD will foster provision of integrated services for HIV positive pregnant and breastfeeding women including FP, MCH, and ART. In order to promote continuous quality improvement in service delivery, SSD will implement Performance and Quality Improvement (PQI) initiatives using its Standards Based Management and Reward (SBM-R) approach. SSD will work with District Health Management Teams (DHMTs) and communities during action planning to identify areas where dilapidated or insufficient infrastructure creates barriers to effective integration and might be remedied through a simple intervention (e.g., modifying a health facility structure through the construction of a wall enclosure that create conditions for counseling to take place with privacy and confidentiality). SSD will establish mother-infant pair (MIP) follow-up programs in the facilities and communities it targets. The MIP follow up will improve adherence to ART, early access to EID and linkage to pediatric care and treatment services. As part of its community MNCH package, SSD will deploy community health workers who will engage the community with the aim of increasing utilization of key health services including HTC, ANC early in pregnancy, and institutional delivery. Its community volunteers will provide door-to-door HIV testing and counseling and link HIV positive individuals with facilities for pre-ART or ART services. The program will champion male involvement in PMTCT and other health needs of the community. Finally, SSD will work with HPSS to strengthen district and health center leadership capacity.

COP 13 is the first time this project is implementing HIV treatment services (i.e. outside of the PMTCT context). SSDI-services will facilitate in-service training and clinical mentoring, and support DHMTs to conduct supportive supervisions in Kasungu, Nkhotakota, Dowa, Salima, Chikwawa, Nsanje. These interventions aim to build the clinical skills of ART providers, and ensure proper application of the current national guideline. Some key services provided at the ART clinic include: family planning, screening for TB, cotrimoxazole prophylaxis, and viral load monitoring. The project will also work with the health facilities and district health offices (DHO) to identify the closest, or most logical, viral load center, and develop a sample transportation system around it.

The project will establish support groups at the health facility level where ART clients will receive, among many other services, adherence and risk reduction counseling, and support for disclosure. SSDI-services will strengthen the coordination between ART providers and Health Surveillance Assistants to foster effective defaulter tracing within communities.

In each of these 6 districts, the project will assess current distribution of ART sites, and analyze the accessibility of these sites to the community. If significant gaps exist, the project will assist MOH and DHOs to open new ART sites; which may involve training of staff, renovation, and provision of basic equipment and furniture.

The project will use key indicators such as new enrollment, 12 month survival, early mortality, loss to follow up rate, etc., to measure program performance. The project will implement Performance Quality Improvement (PQI) methods to help health facilities learn from their implementation and improve their performance continuously.

COP 13 is the first time this project is implementing ART activities. Pediatric ART will be one of the major areas of support to the national program beginning FY14. The current national guideline stipulates universal ART for HIV-positive children less than 2 years, and HIV-exposed infants with Presumed Severe HIV Disease. The project will use clinical mentorship, supportive supervision, and in-service training to build the skills of health providers in Pediatric ART, including timely initiation, provision of appropriate regimen and dosage, clinical and lab monitoring of ART, and caregiver counseling. Currently, children make up only 9% of PLHIV that are alive and on treatment. In COP 13 SSDI-services will aim to increase the pediatric coverage by expanding pediatric care and treatment interventions including EID.

In addition to improving the quality of pediatric ART services, the project will focus on optimizing the identification of HIV-infected children, and facilitate their enrollment and retention in care/treatment. The project will help establish facility and community-based support groups for exposed infants, HIV-infected children, adolescents, and their families. Facilitators of the health facility support groups will play a key role in making sure HIV-exposed infants are enrolled into the EID program (immediately after birth) and liaise with HSAs and/or community support group facilitators for the tracing of exposed infants who miss their EID schedules. See PDCS for activities related to expansion of PITC capacity in health facilities. SSDI-services will support District Health Offices to conduct regular supportive supervision and quarterly program reviews. The project will also implement Performance Quality Improvement (PQI) methods to help health facilities learn from their implementation and improve their performance continuously.