Detailed Mechanism Funding and Narrative

Details for Mechanism ID: 4867
Country/Region: Mozambique
Year: 2007
Main Partner: U.S. Centers for Disease Control and Prevention
Main Partner Program: NA
Organizational Type: Own Agency
Funding Agency: HHS/CDC
Total Funding: $2,770,772

Funding for Biomedical Prevention: Prevention of Mother to Child Transmission (MTCT): $345,000

This activity is linked to 8588, 8567, 8605, 8617, and 8571 activity sheets.

FY07 funding is requested to support the USG PMTCT program in the following areas:

1) Travel expenditures for the CDC PMTCT Technical Advisor facilitating regional and provincial PMTCT trainings and participating in PMTCT site supervision and quality assurance, in particular to 2007 focus provinces- Sofala and Zambezia; CDC technical staff visits to the PMTCT reference center and satellite units in Nampula Province; and participation in PMTCT program evaluation activities.

2) Participation in international and/or regional continuing education events relevant to PMTCT program policy development and management for five people, to be selected in discussion with the Ministry of Health (MoH) Community Health, Reproductive Health and PMTCT programs and National AIDS Council (NAC).

3) Exchange visits for approximately 5 PMTCT staff to be selected in discussion with MoH PMTCT program and NAC) to countries within the African region to learn from experiences in integration of PMTCT services in maternity settings, infant and child follow-up, integration of Counseling and Testing, and male partner involvement.

4) Finalization of the assessment of clinical staging performed by PMTCT personnel with comparison to CD4 & TLC (total lymphocyte count) to determine eligibility for antiretroviral therapy, and dissemination of findings through presentation of findings to MOH and stakeholders in-country, reproduction and dissemination of the final report. Please see the Public Health Evaluation Background sheet for more information.

Funding for Care: Adult Care and Support (HBHC): $430,000

Additional funds available through the plus-up will be used in collaboration with CDC Atlanta and the Mozambique Ministry of Health, department of clinical laboratory services and the Mozambique Institute of Health, to develop and implement surveillance of Cryptococcus disease amongst persons infected with HIV. This will contribute to improved treatment and management of Cryptococcosis including Cryptococcus meningitis amongst PLWHA.

This activity is linked to activity sheets 8587, 8570 and 8631 in relation to HIV-STI integration.

Funding under this activity will support the following HIV-STI integration activities: (a) provision of technical assistance for the development/review of routine monitoring and data collection for HIV and STI patients at outpatient consultations and HIV/AIDS treatment service sites; (b) reproduction and distribution of revised HIV/STI registers, data collection tools and job aids; and (c) finalization of the assessment of integration of STI diagnosis, treatment and improved partner services into routine HIV outpatient clinical care.

In addition this activity will fund the following HBC program support activities: (a) travel for Home-Based Care (HBC) Technical Advisor and FSN; (b) participation in exchange visits and continuing education events for professional growth for the multisectoral team working on the development of Integrated Care and Support systems, both for MOH (Ministry of Health) and MMAS (Ministry of Social Welfare) staff.

Funding for Care: TB/HIV (HVTB): $572,000

Plus-up: These funds requested for CDC will be used to support TB/HIV activities that could not be implemented due to limited funding in FY07 COP. The Main activities include 1) the implementation of feasibility assessment of Isoniazid preventive therapy (IPT) program. key activities will include;- convening meetings; hiring a consultant to develop a protocol and phased implementation starting at 2 or 3 sites; 2) Support the rapid evaluation of MDR and XDR TB to compliment the National drug resistance survey that is underway and in accordance with new WHO guidelines.

These funds requested for CDC will be used to support TB/HIV activities that could not be implemented due to limited funding in FY07 COP. The Main activities include 1) the implementation of feasibility assessment of Isoniazid preventive therapy (IPT) program. key activities will include;- convening meetings; hiring a consultant to develop a protocol and phased implementation starting at 2 or 3 sites; 2) Support the rapid evaluation of MDR and XDR TB to compliment the National drug resistance survey that is underway and in accordance with new WHO guidelines.

Original COP: The link between HIV and TB has been well-documented. In Mozambique, the Ministry of Health (MoH) has been taking steps to improve the collaboration between the TB and HIV Programs to better identify and serve dually infected patients. For example, TB registers have been modified and revised to incorporate recording of HIV at the facility-level.

During FY07, the USG will provide technical assistance and support to the MoH in the development and implementation of an electronic TB and HIV recording and reporting systems. The MOH is in the process of computers for all provincial TB supervisors which will help to facilitate implementation of the ETR. Implementation will be done in two phases; Phase one: Initiate at provincial level in the priority provinces of Sofala, Zambezia and Nampula and expanding to all provincial TB sites. Phase two: The second phase will be to pilot implementation in 3-4 districts in the priority provinces. Software developed by the South African CDC regional office has been translated into Portuguese and will be presented to MoH TB program managers to identify necessary changes before roll-out to the field. Once these changes have been made, the software and hardware will be installed on end-user computers in pilot, and then later at all TB clinics offering HIV testing. Training of end users in use of the software is planned (15-20) as well as the provision of technical and maintenance support needed to operate the software program, including data transfer and data analysis. Funding will be used to support travel of technical support persons from the regional office to help with planning and start-up of the program. There-after the country office staff will work with local MOH staff to provide on-going support.

This activity will contribute to improved data management with respect to routine reporting and analysis of TB/HIV co-infection and will be linked with and integrated with National health information system involving close collaboration with MOH Health information management unit.

Funding for Prevention: HIV Testing and Counseling (HVCT): $305,000

Plus-up:This activity will support the translation, adaptation and piloting of guidelines and training materials for counseling and testing (CT) of children in Mozambique. Funding will go towards provision of technical assistance to the Ministry of Health (MOH) CT staff for adaptation of the materials, facilitation of first pilot trainings and implementation at first selected sites. Special attention will be paid to providing guidance for CT for children in a variety of settings such as at community level as part of home-to-home CT services and in clinical settings such as pediatric consultations and childrens' wards. Health care workers and counselors will be trained to provide counseling to parents and caretakers as well as on ways to counsel, disclose HIV status and support older children undergoing HIV-testing.

Original COP: This activity is linked to 8597, 8608, and 8568 activity sheets.

Please also see linkage to the CDC's Public Health Evaluation of oral fluid-based HIV testing.

Funds for FY07 are requested to support a number of key activities required to ensure CT program staff at CDC and in the Ministry of Health's (MoH) are sharing and learning lessons from program implementation. Funding requested will cover: 1) Travel expenditures for the CDC CT Technical Advisor to participate in regional and provincial coordination meetings and trainings, for the CDC M&E Advisor to participate in regional and provincial CT data management and supervision visits, and for the CDC Senior Prevention Advisor to participate in quality assurance and supervision visits; in particular to 2007 focus provinces Sofala and Zambezia. 2) Travel and registration fees for international and/or regional continuing education events relevant to CT program policy development and management for three people, to be selected in discussion with the MoH CT program and National AIDS Council (NAC). 3) Exchange visits (around 5 CT staff to be selected in discussion with MoH CT program and NAC) to countries within the African region to learn from experiences in integration of CT in clinical settings, implementation of community-based CT (e.g. Kenya, Uganda) and integration of lay counselors into the public health care system (e.g. Zimbabwe). 4) Finalization of the evaluation of oral fluid HIV testing in Mozambique and dissemination of findings through presentation of findings to MOH and stakeholders in-country, reproduction and dissemination of the final report. See the Public Health Evaluation sheet for additional information.

Funding for Treatment: Adult Treatment (HTXS): $300,000

CARE will work in Vilankulos district, Inhambane Province to strengthen the technical capacity of the district level government health facilities to effectively scale up ART services and support Community Service Organizations to provide continuum of care for people living with HIV and AIDS through sub-grants.

The main objectives of the program are to Increase the capacity of the MOH to strengthen and scale up ART services in Inhambane province, Increase access of ART services for eligible PMTCT and TB clients through improved linkages and , strengthen community response to ensure linkages between community resources and clinical HIV services.

Funding for Strategic Information (HVSI): $467,000

This activity is linked to 8632 (National ART Evaluation) and the PHEs describing the National ART Evaluation, the Costing Evaluation, and the Cost-Effectiveness of ART in Mozambique. In addition, funding will be requested in Activity ID 8799 to cover the costs of one PI who will also complete his PhD through USG-supported long-term training. This FY07 funding request is for 3 Public Health Evaluations (PHEs):

1) Malaria and HIV (75,000) Funding for FY07 will be used to evaluate whether children taking daily cotrimoxazole for opportunistic infections prophylaxis who become febrile should be treated presumptively with an antimalarial drug, as recommended under current guidelines, or should have a diagnostic test for malaria (rapid diagnostic test for malaria (RDT) or blood smear), and further investigation for cause of fever if the results of that diagnostic test are negative.

This study will support improved diagnosis of malaria in HIV clinics, look for risk factors for malaria in children with fever at HIV clinics, and specifically evaluate whether daily cotrimoxazole protects children from malaria illness. This evaluation will provide essential programmatic information to improve treatment guidelines for HIV infected and exposed febrile children receiving daily cotrimoxazole.

Requested funds will hire support staff to carry out this activity including a clinician, a community health worker to explain the study, consent guardians, and follow-up the few children who may have a false negative RDT and require antimalarial treatment, as well as a laboratory technician who will read blood slides to compare to RDT results. Funding for a driver, an administrative assistant, a data manager and a data entry clerk is also requested. Other costs are for specimen collection and processing, RDTs, medications for sick children, fuel and maintenance, administrative support, administrative supplies and training costs.

2) Public health evaluation on the cost of HIV treatment to support resource planning (292,000)

This PHE is also linked to the National ART Evaluation described in 8632.

In FY07, the USG proposes to address one of the Ministry of Health (MoH) key priorities: to describe the costs of delivering HIV treatment in Mozambique. A full assessment of the cost of ART will contribute to resource planning and allocation for program scale-up.

This activity proposes a public health evaluation to measure the costs of selected ART programs and to evaluate the cost-effectiveness of these programs when combined with data from the national ART evaluation. The specific objectives of the analysis are 1) to estimate the average annual per-person cost of providing quality comprehensive ART for eligible adult and pediatric clients; 2) to evaluate the range of ART costs across settings; 3) to assess the effects of program scale-up and maturity on resource needs; 4) to inform resource planning to meet the targets of the Emergency Plan; 5) to inform planning for long-term sustainability of ART in country; 6) to assess the relative cost-effectiveness of the differing program types and program delivery systems.

Accurate estimation of comprehensive ART costs in a range of settings will serve a number of purposes. First, the PHE will deliver robust estimates of per-patient treatment costs in representative programs. Second, comparative analyses across settings will identify institutional and contextual factors that affect ART provision costs. Third, by estimating the program costs under a particular set of circumstances, the project will inform resource planning as programs expand to meet ambitious treatment goals and guide long-term sustainability planning. The evaluation will identify and value the discrete cost components that comprise the cost of comprehensive HIV treatment within country, assist USG and country partners in assessing the potential reach of ART programs given available financial resources, inform the choice of approach used for provision of treatment services, and assist the programs in identifying those areas where potential efficiency gains could free-up resources to expand service provision.

A sample of 9-11 HIV treatment facilities will be selected by the MoH, the USG and other appropriate stakeholders. Retrospective costing data will be collected to capture costs over a full year's period, with opportunities to go back to service delivery point in some

locations. Comprehensive treatment costs will be estimated based on facility-level program operations costs. The source of support for each cost component will also be tracked. In 1 to 2 facilities, other costs related to in-patient and out-patient HIV care will be collected to better compare the cost-effectiveness of ART in Mozambique as compared to care alone (see below).

Requested funds will be used to support staff needed to carry out this activity, such as a project support officer to manage travel logistics to participating sites, a data manager, and data entry clerks. Other costs are for materials reproduction of new forms or logbooks as needed, supervisory visits and travel to the selected two sites.

3) Cost-effectiveness of in-patient, out-patient care of patients not on ART as compared to patients on ART in Mozambique (100,000)

This PHE will capture the use of inpatient and outpatient hospital services for HIV infected individuals on ART in Mozambique compared with those who are being cared for in inpatient and outpatient services but not on ART. Direct and indirect cost data will be collected as part of the previously described PHE. Currently, costs and therefore outcomes associated with patient care in inpatient and outpatient facilities beyond day hospitals are not captured and linked to day hospital records. Thus, this PHE will enable policy-makers to assess the full use and costs of services and link this to outcomes at the individual level. This will also enable stakeholders at hospital level information to evaluate the effectiveness, efficiency, equity and acceptability of HIV services. When combined with relevant impact information (population HIV prevalence and incidence) and programmatic costs, this study will be able to provide policymakers with strategic information in order to guide the current scale-up of HIV treatment and care services in Mozambique as well as predict future requirements.

To conduct the evaluation, a prospective study of HIV infected individuals being managed at two sites and their catchement areas will be identified. One site will be a hospital where HIV infected people have been started on HAART, which will be compared with a hospital where HIV-infected people are being managed but do not yet have access to HAART. The use of inpatient and outpatient services in both sites will be collected prospectively and these will be combined with relevant unit costs to calculate the cost of services used by HIV infected people at different WHO or clinical staging of HIV infection. Cost data will than be linked to outcome data. Instruments for follow -up of the use of inpatient and outpatient services will be drawn up and may include both self-completed diaries, regular face-to-face interviews and collecting relevant information from case-notes.

Requested funds will be used to support staff needed to carry out this activity, such as a project support officer to manage day to day study operations, a data manager, and data entry clerks. Other costs are for materials reproduction of study instruments, training materials, supervisory visits and travel to the selected two sites.

Funding for Health Systems Strengthening (OHSS): $125,000

As a result of the 2004 elections, there have been many changes in the leadership and management of the Ministry of Health (MoH). A significant number of staff who have been moved into management, especially at the provincial level, have not received training in the needed skills. In addition, there is a push to decentralize decision-making and financial management to the provinces. With the move toward decentralization, the deputy permanent secretaries (senior MoH staff) at the provincial level have been given more responsibility and a new coordinating position was instituted, provincial HIV/AIDS, TB and Malaria Coordinator. These coordinators typically are clinicians who continue to carry some clinical responsibilities while also playing a coordination role.

The Human Resources director at the MoH has requested that the USG fund management training at the district level. In other conversations at the MoH, management training for HIV/AIDS, TB and malaria provincial coordinators and training institution administrators have been identified as areas of need.

Management training will occur via a constellation of activities receiving PEPFAR funding in FY07. Specifically, I-TECH will work with last year's graduate from the Sustainable Management Development Program (SMDP) to assess and provide training for the leadership of a select number of training institutions, especially in the USG-focus province of Sofala (Linked to 8802). CDC's training staff are discussing with other implementing partners and donors to see if a common set of management principles could be developed for guiding all management training activities. FY 06 funds supported sending 2 MoH staff to the 6 week Management in Public Health course sponsored by SMDP and to support their initial activities upon return. This spring, one of the 06 SMDP course graduate began to work with I-TECH on doing an assessment of the management training needs for training institution administrators. Currently, data are being analyzed and will be used to guide the design of the management training activities. One of the training institutions being considered for management training is located in Sofala (Linked with 8806).

In FY 07, funds will support sending 2 participants to the 07 SMDP course in Atlanta, to support their initial management training activities in Mozambique upon completion of the course and to support travel for Atlanta-based SMDP technical assistance staff. In addition, I-TECH has been asked to provide technical assistance to these course graduates through supporting the management training for leadership staff of training institutions, district health managers and provincial HIV/AIDS, TB and malaria coordinators. NASTAD (US National Alliance of State and Territorial AIDS Directors) will be providing technical assistance for management training activities for district health managers (Linked with 8802).

FY07 funds will also be used to strengthen systems to reach health care workers and minimize/mitigate the impact of HIV/AIDS on their personal and professional lives. (This activity is a continuation of one funded in FY 06 5245 ($50,000) and linked to activities CDC_OHPS_TBD, CDC_OHPS_MoH and CDC_SI_TBD.) One of the key objectives of the MoH Strategic Plan to Combat STIs, HIV, and AIDS is to reduce the impact of HIV/AIDS on health care workers. To date, there are few activities existing that support health workers in dealing with HIV/AIDS. It is unknown how many health workers themselves have undergone testing and counseling. According to anecdotal information, confidentiality of information and fears of discrimination within one's work environment are concerns of health care workers when considering whether to access counseling and testing services. These concerns represent barriers to accessing services, seeking accurate information and examining the risk associated with their personal and professional behaviors. It is unlikely that HIV risk among health workers can be overcome without significant changes to attitudes and behaviors.

In FY05 and FY06, USG funding has been supporting the development of an assessment of health workers' current behaviors, attitudes, norms and knowledge around primary prevention of HIV and uptake of counseling and testing services, to determine how to better design interventions promoting structured opportunities for educating and assisting health workers to better deal with HIV/AIDS in their work and home environment. The assessment is currently undergoing Ministry of Health human subjects' clearance approval. It will then be sent to CDC for human subjects' clearance approval.

FY 07 funds are being requested to support: (a) technical assistance from the CDC behavior change communication specialists in Atlanta; (b) in-country CDC staff travel for technical personnel (CDC Senior Prevention Advisor, BCC Prevention Program Support Officer and CDC M&E Advisor) providing technical assistance and working with MOH counterparts on piloting and implementation of first interventions at health facilities and training institutes; and (c) a visit to health worker support programs developed and implemented by MOH staff and nursing associations in Zambia, to allow the Mozambique MOH and CDC team to learn from lessons learned and experiences of these more advanced projects.

Funding for Management and Operations (HVMS): $226,772

The CDC Mozambique Management and Staffing program is divided among four different mechanisms - 4864, 4865, 4866, 4867. The four activities that contain costs associated with this program are 8512, 8611, 8624, and 8634. The Management and Staffing program supports all administrative costs associated with running the robust portfolio of technical programs, including administrative staff salaries, office costs as well as direct program support through staff and other costs to manage grants and advise program staff on administrative issues.

The CDC office currently has 26 positions under various mechanisms - including four direct hires, 13 locally employed staff and nine contracted staff (COMFORCE, PSC). Three positions are currently vacant, but will be filled in the near future. Each of these positions existed when COP 2006 was submitted with the exception of one administrative assistant which was a proposed position in 2006 and since been filled. We had proposed an additional seven positions at that time, but due to various hiring difficulties - lack of available hiring mechanisms, visa issues with the local government and severe shortage of local human resources, only the administrative assistant position was filled. CDC is currently dealing with these issues on various fronts and hopes that a sound resolution will be found.

In addition to the approved positions from the 2006 COP, CDC Mozambique is proposing 12 technical and administrative positions that will manage the significant increase in activities for 2007 and beyond. They are discussed in the Staffing Matrix as well the individual program activities that will fund these positions.

CDC's office space is currently full with existing staff. In order to accommodate the expected growth in staffing, CDC received approval in the 2006 COP to expand the office to the adjacent space in our existing building. We are in the final stages of the OBO approval process and rehabilitation should begin in the coming months. Funding for rehabilitation was budgeted in 2006.

This activity contains funding for the following administrative costs:

- Office rent - Existing space ($10,014.06*12) + Expansion ($8,883.64*12) (Total of $226,772). We are requesting the full amount of this activity via the early funding mechanism as rental payments are made early in the fiscal year. If we are unable to pay in a timely manner, we may lose the opportunity to acquire the adjacent office space.

Table 3.3.15: