Reprogramming October 2007 - Treatment partners in Mozambique have scaled up quite rapidly by increasing the number of sites and the access of populations to those sites. Treatment partners have acknowledged that one of the key areas for improvement in the provision of treatment services is the standardization of a comprehensive package of services, based both in the clinics and in the community. The difference between the number of PLWHA who are currently benefiting from care services relative to the number of those in treatment is substantial and pre-occupying. PLWHA are staged initially, however, if they aren't immediately put onto treatment, the vast majority are lost. A good portion of the USG portfolio over the coming year is to close this gap and "catch" missed opportunities to get people back to the clinics. In fact when representatives from CDC and USAID headquarters visited the large gap between the two numbers was the basis of one of their recommendations; namely that the USG in Mozambique standardize a minimum care package and ensure that those who are HIV-positive are offered a range of options and services, including CTX prophylaxis and a system to ensure that they return to the clinic to establish their eligibility. A consultant will assist the USG to create systems and processes that enable USG treatment partners, and the Government of Mozambique, to capitalize and consolidate on progress made in the area of connecting the dots between clinical services as well as those linking clinical services to community-based care and support.

Table 3.3.12: Program Planning Overview Program Area: Laboratory Infrastructure Budget Code: HLAB Program Area Code: 12 Total Planned Funding for Program Area: $ 9,607,123.00

Program Area Context:

The Mozambique laboratory network is comprised of all clinical laboratories which fall under the responsibility of the National Health Services in the MOH. The HIV, viral diseases and malaria reference laboratories fall under the National Institute of Health while the TB reference laboratory falls directly within the TB program. The public health laboratory system faces multiple deficiencies that include inadequate numbers and skills of existing laboratory personnel, deficient physical infrastructure and sub-optimal coordination between laboratory and clinical services. The MOH has taken the important step of developing a Laboratory Strategic Plan that will help define the organizational structure of the laboratory network from central MOH to the district level as well as describing the referral network, services to be offered at each level of health service provision and to standardize laboratory equipment being procured for the country to ensure efficiency in maintenance and procurement of laboratory reagents.

The USG in Mozambique seeks to support the MOH to improve and expand the clinical laboratory capacity for the safe and effective provision of HIV prevention, care and treatment services within the Integrated Health Network. The approach has focused on supporting infrastructure renovations, procurement of equipment and reagents, building human resource capacity through provision of technical assistance and supporting training of clinical laboratory personnel.

The Emergency Plan provides funding to several organizations to support laboratory services in Mozambique; these include the Association of Public Health Laboratories (equipment and reagents), Federal University of Rio de Janeiro (training) and the Ministry of Health (National Institute of Health) for quality control and quality assurance. Other groups that have contributed widely to laboratory infrastructure and capacity building include all the Emergency Plan treatment partners. These partners have been responsible for undertaking the renovation and rehabilitation of laboratory infrastructure needed to house the new lab equipment that is being procured by APHL.

The achievements of the combined efforts of all these partners to date include: 1) Completion of two high tier laboratory renovations situated at Mavalane Hospital in Maputo City and Xai-Xai-Provincial Hospital. Due to the lengthy process involved in renovating infrastructure in Mozambique, temporary renovations or installation of temporary containers (pre-fabricated structures) has been undertaken. Four temporary laboratories have been renovated, and 2 temporary containers have been procured. 2) Equipment and reagents for the determination of CD4, haematology and biochemistry tests has been distributed to 5 laboratories. Distribution will continue to be expanded as and when laboratory infrastructure is completed in conformity with MOH recommendations and approval. 3) More than 70,000 CD4 test have been performed which is expected to increase to 150,000 by the end of FY06; DNA PCR testing for the paediatric treatment program remains low at approximately 100 tests per month for 6 provinces. 4) Mozambique participates in an external quality assurance testing for CD4, which is conducted 3 times a year. During FY06 funding it is anticipated that serology proficiency testing will be initiated to start with in 50 testing points and ultimately service all testing points. 5) An early assessment of the requirements for the implementation of a laboratory information system has been conducted with the aim of initiating the program during the FY06 funding period. This will provide laboratory consumption information needed for forecasting laboratory reagent needs. 6) Initial trainings have been conducted for laboratory staff in the use of CD4, haematology and Biochemistry equipments. Plans are still underway to initiate the in-service training and mentorship program for clinical laboratory personnel to enhance their practical laboratory skills.

Areas that continue to require strengthening include finalization of the national strategic plan, decentralization and building provincial level capacity to provide oversight for serology quality assurance, improvement of the specimen referral system needed for paediatric and adult HIV program

implementation, development of an integrated logistics management system for all laboratory commodities to support the expanding laboratory network and avoid stock-outs and improvement of coordination between the laboratory with HIV, malaria and TB program.

FY07 funding will continue to support the strengthening and expansion of the laboratory network in the following areas: (1) Strategic planning for laboratory services: APHL has been identified to work with the USG partners and country representatives to develop a strategic plan for each tier of laboratory that describes minimal requirements needed to effectively support programs. Support will include provision of technical assistance to the MOH for the development of a strategic plan that incorporates the national objectives and strategies and defines what and how activities will be implemented to develop a national laboratory network. Senior laboratory directors will also work with the MOH to support national planning and implementation activities.

(2) Support of laboratory networks through: a) implementation of laboratory information system for 20 ART support laboratories which will include purchase of hardware, installation of LIS software and training of users; b) plan and develop a national specimen referral transport system that incorporates existing ARV treatment partner transport systems, standardizes specimen identification, tracks specimens, provides timely delivery of specimens to referral laboratory services, and provides access to testing to all levels of the health care system; c) hire and train additional staff for scale-up of DNA PCR testing for paediatric HIV diagnosis; d) provide start-up technical assistance to 10 new laboratory sites to assure rapid initiation of quality testing, identify training needs and assure communication link to technical assistance; and e) develop capacity and procure commodities necessary for resistance monitoring.

(3) Implementation of laboratory quality assurance through; a) training of 6 Mozambican technical staff at the National immunology reference laboratory and HIV serology reference laboratory to oversee and provide supervision of the CD4 T cell and HIV serology quality assurance programs respectively; b) procurement and distribution of proficiency panels for the quality assurance programs; c) provision of continuous training of laboratory staff in participating laboratories; and d) provide technical assistance to strengthen the TB and microbiology laboratories in support of diagnosis of opportunistic infections

(4) Provide training support that includes: technical assistance to the MOH for planning and development of laboratory training centres and pre- and in-service training of laboratory technicians

(5) Support commodities management through a)maintenance of reagent rentals for supply of lab testing equipment and reagents; b) provision of technical assistance to the MOH through SCMS to integrate the management of laboratory reagents and consumable supplies into the existing integrated drug management system (SIGM); and c) train Staff from Laboratory Sector, Central Medical Stores (CMAM), Provincial Warehouses and Hospitals to manage laboratory reagents and consumable supplies using the SIGM system.

Other support to Ministry of Health is from the World Bank for HIV test kit procurement, the NGO Sant' Egidio, which procured CD4 machines for 3 laboratories, and Italian Cooperation for microbiology and biochemistry equipment and reagent requirements. USAID, through TB-CAP, is providing assistance for TB lab strengthening.

Program Area Target: Number of tests performed at USG-supported laboratories during the 1,152,822 reporting period: 1) HIV testing, 2) TB diagnostics, 3) syphilis testing, and 4) HIV disease monitoring Number of laboratories with capacity to perform 1) HIV tests and 2) CD4 tests 29 and/or lymphocyte tests Number of individuals trained in the provision of laboratory-related activities 365

Table 3.3.12:

Reprogramming October 2007 - In an effort to assure quality of services in care, this activity will evaluate systems in place to deliver comprehensive and integrated care and treatment services in Mozambique. The results this assessment will inform programming and planning for FY08. Based on the results of this assessment, a standardized, minimum package of care will be developed by the USG Team in Mozambique.

Coverage Areas: National

Table 3.3.13: