This activity is linked to activities 8579, 8572 and 8633. Through this activity JHPIEGO will support the Mozambique Ministry of Health (MOH) PMTCT and CT programs to gather existing regional or international screening tools and materials that can be used for the identification of women that access HIV testing services and as a result are at risk of sexual and/or domestic violence. Simple tool(s) will be translated and adapted for use in the Mozambican context, and piloted at selected PMTCT sites. In-country staff as well as qualified experts with experience in the clinical and behavior areas working with the MOH PMTCT and CT programs will be involved in this effort.

This activity is also linked with 8582, 8575 and 8574.

This activity will support JHPIEGO to continue to provide technical assistance to the Ministry of Health (MoH) with standards-based management and expansion of biosafety or Infection Prevention and Control (IPC) interventions to a total of 33 major MoH hospitals in all 11 provinces. JHPIEGO will also work with other partners such as international and local NGOs that are working in the area of IPC and are part of the National IPC Task Force. In 2007, plans include the expansion to at least one Military Hospital in Maputo City that provides HIV/AIDS services to both military and civilian populations, and currently has a large number of patients on anti-retroviral treatment.

Main goals for FY07 will be to: 1) Implement and monitor the five-year national operational plan for IPC 2) Continue the implementation and follow-up of the Standards-Based Management and Recognition (SBMR) initiative to improve IPC practices in 23 hospitals and expand the initiative to 10 new hospitals. Provide ongoing support of a recognition system to reward hospitals that are complying with IPC standards, to enhance motivation and sustainability and to reinforce regulation 3) Continue the strengthening of the central and provincial levels to expand and institutionalize the SBMR process, including the development and implementation of a database system to monitor the SBMR/IPC data 4) Continue to strengthen local capacity to provide training and technical assistance in IPC for current health care providers by creating and strengthening trainers and training sites at the provincial level 5) Organize and coordinate a national IPC conference to disseminate the IPC initiative, to recognize best performing hospitals, and to promote the institutionalization of the IPC initiative

Activities proposed to achieve these goals for FY07 include: 1) Hold SBMR Training and meetings for coaches from the participating hospitals: Two 4-day Module 1 workshops (new 10 hospitals, 3rd expansion); two 2-day Module 2 workshops (new 10 hospitals, 3rd expansion); four 2-day Module 3 workshops (10 hospitals, 2nd and 3rd expansion) 2) Conduct Baseline assessments (10 hospitals), internal monitoring assessments (around 33 hospitals), and verification visits by the external assessors in 10 hospitals 3) Hold benchmarking visits among hospitals (exchange of best practices) and lend technical assistance to the hospitals (on-the job training and follow-up visits) 4) Coordinate meetings with the National IPC Task-Force and other stakeholders 5) Implement a recognition process (IPC logo, internal campaign, external recognition procedures) 6) Recognize ceremonies in at least five hospitals 7) Develop and implement of a database system to collect and analyze the IPC/SBMR data 8) Equip 3 provincial training centers with IPC training materials and supplies including the IPC stations for students' practice 9) Hold four 5-day IPC training courses for healthcare providers and tutors, one 2-week training of trainers in IPC, and one 2-day National IPC Conference for 100 participants

Expected results for FY07 will be as follows: 1) SBMR initiative fully implemented in 23 hospitals and expanded to 10 new hospitals 2) Compliance with IPC performance standards in the initial 13 hospitals improved by at least three-fold, and by at least two-fold to the 2nd expansion group of ten hospitals, as compared with their baseline assessment results 3) Baseline assessments conducted, operational action plans developed, and implementation started in 10 new hospitals 4) Strengthened central, provincial and local infrastructure to support the SBMR initiative: national IPC task force, provincial IPC liaison, and hospital-based SBMR coaches 5) External assessments to verify hospitals compliance with the IPC standards conducted in at least 10 hospitals 6) Compliance with 80% or more of all IPC standards at least in five hospitals 7) Simple database system developed and implemented to capture and analyze the IPC/SBMR results 8) 3 provincial training centers strengthened in IPC (IPC training, stations and materials) 9) 100 hospital health care providers with knowledge and skills updated in IPC

10) 20-25 health care providers trained as trainers in IPC 11) 1st National IPC conference conducted to exchange best practices

In the 2007 SIDA Gender Relations Update, it is estimated that 1 in 4 women are victims of gender-based violence. This activity will explore the possibility of piloting the provision of Post Exposure Prophylaxis (PEP) for women who are victims of sexual violence in Sofala and Zambezia provinces. Funds would support the development of PEP kits, provision of training for health care staff to assess who are victims and to provide them with treatment and to develop protocols that will undergird these health care delivery activities in coordination with the Ministry of Health. JHPIEGO has been selected as the implementing partner for this activity based on their work with the Ministry of Health around national guidelines for PEP for health care workers.

Plus Up funding will complement existing funding for male circumcision interventions as follows: 1. Support to the MOH and NAC to design MC policy, service delivery guidelines, strategy and plans to implement MC services, based on assessment results and the MOH and NAC preferences: a. Facilitate stakeholder meetings at various levels (central, provincial, district, facility and community level) to educate stakeholders on MC, disseminate assessment results and discuss service delivery strategies ($50,000) b. Translate/adapt and print IEC materials on MC for healthcare facility providers, users and potential users ($30,000)

2. Support implementation, M&E, and plan for expansion of MC services: a. Provide necessary site strengthening, equipment and commodity support including MIS/record keeping materials, counseling and IEC materials ($100,000)

This activity is linked to 8579 and 8633. This activity will support JHPIEGO to continue to provide technical assistance to the Ministry of Health (MoH) and the National AIDS Council to expand Counseling and Testing (CT) services within clinical and community-based settings. JHPIEGO will work with MoH structures at various levels, including the central, provincial, and facility levels, and with other partners such as international and local NGOs that are working at facility and community based levels. CT activities at community level, in particular, will include volunteers and staff from CBOs, FBOs and traditional and religious leaders who are part of these organizations or networks at community level where CCT activities will be implemented.

The main two goals for this activity will be: 1) Provide integrated Counseling and Testing in the Community (CCT): a) Monitor the pilot implementation of the CCT strategy b) Develop and adapt job aids (e.g. flip charts) to facilitate implementation of the CCT strategy c) Evaluate the pilot phase and make adjustments for expansion of CCT, considering acceptability and effectiveness of the piloted models d) Build local capacity for CCT expansion: train and support community CT trainers and strengthen training sites or centers in a decentralized context (at provincial level) e) Implement and monitor the expansion strategy To achieve this goal, activities proposed for 2007 for Integrated Counseling and Testing in the Community will include: a) Development and printing of job aids (e.g. flip charts) b) Evaluation of the pilot implementation comparing acceptability and effectiveness of the different models (number of people counseled and tested, referrals, etc.) c) One 10-day training of trainers (30 participants) d) Six 10-day CCT training (25 participants each).

e) Supervision to the initial and new sites to monitor implementation (around 20 new sites) f) Two 2-day meetings with trainers and supervisors to assess implementation and additional needs Expected results for Integrated Counseling and Testing in the Community at the end of FY07 will be: a) Job aids developed and printed (e.g. flip charts) b) Pilot phase evaluated and adjusted for expansion, considering acceptability and effectiveness of the piloted models c) 30 new trainers/counselors trained as trainers for the integrated CCT d) 150 new counselors trained in integrated CCT e) At least 20 new sites/areas providing integrated CCT (to be determined after the pilot evaluation) 2) Ensure the availability and integration of Counseling and Testing in clinical settings: a) Develop and adapt job aids (e.g. flip charts) to facilitate implementation of the integrated clinical CT strategy b) Continue the implementation of the integrated CT in clinical settings.

To achieve this goal, activities proposed for 2007 for Integrated Counseling and Testing in Clinical Settings will include: a) Development and printing of job aids (e.g. flip charts) b) One 10-day training of trainers (20 participants) c) Five 5-day CCT training (25 participants each) d) Supervision to the initial and new sites to monitor implementation (around 50 new sites) e) Two 2-day meetings with trainers and supervisors to assess implementation and additional needs Expected results for integrated Counseling and Testing in clinical settings at the end of FY07 will be: a) Job aids developed and printed (e.g. flip charts) b) 20 new trainers/counselors trained as trainers for the integrated CT in clinical sites c) 125 healthcare workers trained in integrated CT d) Up to 50 sites or services (e.g. different departments in the same facility).

With Plus Up funding proposed, JHPIEGO will assist the Mozambique MOH CT staff to carefully assess and monitor quality of counseling and testing services in PMTCT and other clinical settings, as challenges associated with workload of clinical providers, time for counseling, ability to successfully communicate potentially sensitive issues such as disclosure, discordance, and adherence to follow-up and treatment for those identified as HIV-infected are anticipated. Technical assistance including development of practical assessment tools, supervision procedures, and job aids, will be provided to resolve or reduce potential problems encountered and ensure quality of CT services in this context.

This activity is linked to activity sheet 8516.

This activity is linked to the MOH's and USG partners overall efforts to expand quality anti-retroviral treatment (ART) services thourghout the country. The MOH, under guidance from the new Minister appointed in early 2005, considers appropriate prevention of medical transmission, and in particular appropriate waste disposal, part of the prerequisites or service package required for adequate provision of ART services. Funding proposed under this activity will support the rehabilitation of the waste management systems (incinerators) in eight USG supported treatment healthcare facilities and central sterilization services at two USG-supported treatment healthcare facilities that are providing ART services to large numbers of HIV-infected patients and in addition are operating as referral sites for treatment and other services in Mozambique.

The rehabilitation of the waste management system and central sterilization services will not only reduce the risk of HIV medical transmission at those facilities where larger number of HIV-positive clients are expected to receive services and large quantities of contaminated waste are likely to be handlel and eliminated, and will contribute to ensure safety and high quality services being available at these USG supported treatment sites.

Main goal of the activity is to:

Strengthen up to 10 USG supported ART service delivery sites through the rehabilitation of waste management (8) and central sterilization services (2)

Anticipated results include:

(a) List of eligible healthcare facilities to receive the support described (b) Final selection of the healthcare facilities (c) Vendors/contractors selected for each area utilizing current technical specifications (d) Healthcare facility staff trained on operation and maintenance of each system (e) Monitoring plan developed and implemented (f) 8 USG ART sites with incinerators installed and working (g) 2 USG ART sites with improved central sterilization services in place (h) 10 hospitals' staff trained in operation and maintenance of installed equipment

Specific activities include:

(1) Identification and selection of of USG supported ART healthcare facilities that need improvement in line with this activity (2) Review of documentation related to status of each USG ART site in the areas included in the Scope of Work (3) Interviews with site directors to verify/update needs (4) Visits to selected sites to finalize needs assessment (5) Identification of the final sites to be supported and specific areas for implementation (6) Competitive selection of vendors/contractors utilizing current technical specifications (7) Development of specific implementation plans for each hospital (8) Implementation of the plans (9) Training of hospital staff on operation and maintenance of each system (10) Monitoring of operation of systems to ensure proper functioning

Plus Up funding will complement existing funding for male circumcision interventions as follows: 1. Support to the MOH and NAC to design MC policy, service delivery guidelines, strategy and plans to implement MC services, based on assessment results and the MOH and NAC preferences: a. Translate/adapt and print the WHO/UNAIDS guidance document ($10,000) b. Develop and pilot test performance standards, M&E and supervision/quality assurance tools for MC services based on the policy recommendations and service delivery guidelines consistent with above WHO/UNAIDS/JHPIEGO materials ($50,000) 2. Support implementation, M&E, and plan for expansion of MC services: Develop a costed national plan for scaling up MC services ($30,000)

Reprogramming October 2007: Additional activity component - This activity component is a continuation of activity 5245 funded in FY06, and is linked with 8577, 8516, and 8639. The focus is on strengthening systems to reach health care workers and minimize/mitigate the impact of HIV/AIDS on their personal and professional lives. One of the key objectives of the Ministry of Health (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 in place 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, the 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. 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. While the assessment protocol and tools are undergoing clearance, the MoH human resources, training and community health departments have expressed their desire and requested assistance for urgent start-up of interventions that will target and support health workers, facilitating behavior change and improved primary prevention, as well as increased HIV counseling and testing (CT) and anti-retroviral treatment (ART) up-take among health workers and their partners. FY07 funds will be used to identify a technical assistance provider who will identify appropriate methods for facilitating behavior change among health workers and their partners, develop an action plan for conducting appropriate interventions to support health workers in reducing risk behaviors, pilot and design interventions, explore use of community radio to reach rural workers and create an environment conducive and supportive to changes of health worker behaviors and attitudes. In addition, interventions to reduce barriers to use of CT and ART services among health workers such as for example mobile units for counseling and testing will be explored and piloted. Finally, the technical assistance provider will work with teachers and students at MoH training institutions to design and pilot interventions at pre-service training institutions where young doctors, technicians and nurses are currently undergoing training.

Plus-up: The Ministry of Health, through its health reform, is undergoing major transformations throughout its care delivery system. One of the challenges with this expansion is how to rapidly expand a competent workforce in order to increase access to health care. With the lack of physicians, tecnicos de medicina and nurses are being called on to perform more tasks. Changes in education will need to occur both at the pre-service and in-service levels for basic and mid-level nurses. It is also critically important to lessen the number of nurses who become HIV+. The purpose of this situation analysis, to be conducted by JHPIEGO, is to examine the actual and planned demands made on the nursing profession, identify the cadres available to perform these tasks and the key competencies needed, and identify how to improve the production of the nurses required to deliver competent and cost effective health care. This analysis will include activities such as interviews, observations and document review with the goal of providing critical information to policy-makers in order to align the scopes of practice of different categories of nurses in accordance with health care delivery needs and streamline and improve pre-service education and in-service training of nurses in terms of outputs and cost-effectiveness.

Original COP: JHPIEGO/JHU is working with the Ministry of Health (MoH) and in collaboration with other partners, to improve infection prevention and control (IPC) practices to decrease the risk of infection transmission in health facilities. This program aims, over a five-year period, to protect clients, providers, and the community through three main strategies: 1) ensuring the adoption of IPC practices in 30 hospitals of the country using a hands-on standards-based management and recognition approach (SBMR) for quality and performance improvement, 2) strengthening/developing a continuous education system for key cadres of service providers in IPC to ensure continuous compliance with IPC evidence-based practices, and 3) strengthening the pre-service education in IPC at teaching institutions.

During 2005, JHPIEGO/JHU started providing technical assistance to the MoH and the National AIDS Commission (NAC) in two new areas: 1) development/adaptation of a training information and monitoring system for in-service training (TIMS©), and 2) development of a national strategy for Community HIV/AIDS Counseling and Testing/CCT (originally customization/translation of a group education reference manual and learning package to train lay educators in HIV/AIDS).

In 2006, JHPIEGO/JHU started the second expansion of the IPC initiative to 10 new hospitals, totaling 23 facilities using the SBMR approach for improving IPC practices. As part of the IPC initiative, JHPIEGO/JHU also started working on the workplace safety policy (WPS) including post-exposure prophylaxis (PEP) for HIV/AIDS, and developing training modules and job aids for ancillary workers. The web-based TIMS© is under development and will be piloted in Maputo City and Zambezia Province. During the current year, JHPIEGO/JHU is also finalizing the training materials and starting the training activities for the integrated HIV/counseling and testing in the community and in clinical settings. Under treatment, JHPIEGO/JHU is starting to provide technical assistance to improving infrastructure of selected USG ART treatment sites in the areas of waste management systems (incinerators) and central sterilization departments.

In the OPHS section of the FY 07 COP, JHPIEGO activities that will be continued to be funded through the OPHS section are: training information and monitoring system for in-service, workplace and developing training modules and job aids for ancillary workers. In FY 07 improving the quality of pre-service education at training institutions with emphasis on HIV/AIDS prevention and care will be added. Each activity is described below:

Training Information Management Systems (TIMS) ($400,000) (Linked to 8577) In FY 07, TIMS activities include: an evaluation of the pilot implementation of the web-based system and support for any adjustment/modification; printing of training forms and materials; purchase of 7computers; support of internet connectivity, support for maintenance of web-based system, support for regional workshops and supervision visits to each province to monitor web-based TIMS implementation. Deliverables: 10 provinces using web-based TIMS, 70 % of training activities captured by TIMS

Workplace safety policy (WPS) ($140,000) (Linked to 8577) In FY 07 will continue and focus on developing IEC and training materials, forms and job aids for the implementation of the WPS policy, train supervisors and providers on how to implement the policy and protocols, implement WPS policy including post exposure prophylaxis in selected health care facilities and monitor the implementation of the WPS policy. Deliverables: At least 10 healthcare facilities offering PEP, 20 supervisors trained in PEP

Infection prevention and control (IPC) ($139,000): IPC for ancillary workers activities will focus on development and printing of training materials/job aids for ancillary workers in IPV, waste management, HIV/AIDS, and basic nursing; training of trainers course; and week long course for ancillary staff. Deliverables: 20 new trainers, 60 auxiliary workers trained with new curriculum

Quality Assurance in Training Institutions ($450,000): At the request of the Human Resources Department in the Ministry of Health, JHPIEGO will work with 2 training institutions, one in Sofala and the other yet to be decided, on quality assurance elements of a training institution on quality improvement. (Linked with 8577). Goals for this work include: creating a workgroup with representation among key stakeholders, conducting an assessment in both training institutions that train 2 cadres (nurses, medical technicians, or lab), review/define core competencies of selected two cadres, develop educational standards using the standards based management and recognition (SBMR) methodology, train coaches based at each training institution to implement the SBMR tools and the baseline results and develop improvement plans. Deliverables: 100% of baseline assessments conducted, 20 coaches trained, 100% of improvement plans developed

The Ministry of Health, through its health reform, is undergoing major transformations throughout its care delivery system. One of the challenges with this expansion is how to rapidly expand a competent workforce in order to increase access to health care. With the lack of physicians, tecnicos de medicina and nurses are being called on to perform more tasks. Changes in education will need to occur both at the pre-service and in-service levels for basic and mid-level nurses. It is also critically important to lessen the number of nurses who become HIV+. The purpose of this situation analysis, to be conducted by JHPIEGO, is to examine the actual and planned demands made on the nursing profession, identify the cadres available to perform these tasks and the key competencies needed, and identify how to improve the production of the nurses required to deliver competent and cost effective health care. This analysis will include activities such as interviews, observations and document review with the goal of providing critical information to policy-makers in order to align the scopes of practice of different categories of nurses in accordance with health care delivery needs and streamline and improve pre-service education and in-service training of nurses in terms of outputs and cost-effectiveness. 2. Support implementation, M&E, and plan for expansion of MC services: a. Develop a national plan to train and certify providers with above WHO/UNAIDS/JHPIEGO materials, including facility-level orientations for management buy-in and understanding ($20,000) b. Train MC providers using the international WHO/UNAIDS/JHPIEGO materials and MC counselors using WHO/UNAIDS/JHPIEGO plus supplemental counseling training materials ($100,000) c. Provide supportive supervision using performance standards and a standards based management and recognition approach ($10,000)