Continuing Activity - Replacement Narrative:

Since the formal establishment of the Ministry of Health (MOH) PMTCT program coordination office in 2003,

the USG has supported the development of national PMTCT program guidelines and training materials, as

well as the geographical expansion of PMTCT services, including the training of PMTCT program trainers

and PMTCT service providers. In 2005-2006 MOH was reorganized to include PMTCT within the

reproductive health section of the community health department. USG continues to support central-level

PMTCT efforts within this framework.

FY08 funding proposed under this activity will contribute to and support the following activities:

1) PMTCT training: Support for PMTCT training at sites that do not currently have USG partner support.

Funding for FY08 will support the training of 60 new PMTCT program trainers and 60 existing PMTCT

program trainers, using the new/revised PMTCT program curricula, incorporating counseling and testing

(CT) in ante/postnatal and maternity settings, couples counseling and support for discordant couples as well

as a revised overall counseling contents. These trainers will in turn conduct training for PMTCT service

providers at existing and newly established PMTCT service sites in FY08. Whenever possible, training

activities will incorporate evaluation and validation activities.

2) PMTCT supportive supervision: Funding in FY08 will support supervision team visits from central level to

PMTCT sites. Six provincial visits will occur during FY08. Central to provincial support for PMTCT will be

coordinated through the MOH reproductive health department.

3) PMTCT service provision: Funding in FY08 will support service delivery at selected sites that do not

currently have USG support, including supplies, travel, specimen transport, and other needs such as

renovation projects and durable goods such as refrigerators.

4) Production and distribution of 1,000 PMTCT kits for PMTCT trainers and providers: These kits contain

key PMTCT program materials such as the PMTCT operational guidelines, the PMTCT training manual, the

PMTCT providers' pocket guide, and other job aids and educational materials that have been developed by

the PMTCT program over the past two years.

5) Community PMTCT activities: In FY07 support for MOH included community mobilization and

development of facility-community linkages around PMTCT services. FY08 activities will build on this

foundation, as well as incorporate materials developed by USG partners, specifically on mother support

groups in the PMTCT setting.

Mother support group activities will be scaled up with MOH central level guidance, in collaboration with USG

partners who have been tasked to inventory current practices and develop an optimal standardized

approach. In FY08, two districts will be identified in Gaza province for a rapid cycle (6 months) pilot.

As a follow-on to FY07 activities, MOH will continue to support training for community health agents,

including ongoing training of PMTCT trainers dedicated to working with community health agents. FY08

support can include additional training of these trainers (20) and funding for training activities (materials,

venues, transportation, etc.). Whenever possible, training activities will incorporate evaluation and validation

activities. In keeping with MOH guidance from a national meeting on community involvement, these training

activities will be pursued as a near-term solution while long-term approaches are developed; specifically,

the development of a holistic approach for health facility interaction with communities, incorporating multiple

health service areas.

These community-focused activities will be designed to help community health agents (traditional birth

attendants, peer educators, other laypersons involved in PMTCT activities) to focus on PMTCT service

promotion, PMTCT-related behavior change, promotion of adherence to ante/postnatal care consultations

and institutional births in general as well as adherence to ARV prophylaxis or treatment where applicable,

and support to HIV infected pregnant women, mothers and families at community level.

MOH activities in FY08 will include coordination with USG partners who are currently working on PMTCT

PHE's that will inform central-level policy and practice.

USG funding for these activities will complement funding for PMTCT program expansion and training

support provided by other agencies such as WHO, UNICEF, and the Global Fund Initiative.

The Mozambican Ministry of Health (MOH), within its Medical Assistance Department and closely linked to

the National Nursing Department, has a National Infection Prevention and Control (IPC) Program under

which all activities related to the prevention of medical transmission are coordinated, implemented and

supervised.

Funding support provided directly to the MOH biosafety program has been used and will continue to enable

the MOH biosafety program staff to roll out training activities to health facilities where no external partners

are present. This enhances the MOH staff's capacity to utilize training materials developed with assistance

from JHPIEGO and JSI, and to implement activities on their own, strengthening their confidence and

implementation experience in the absence of outside support, which in turn will contribute to long-term

sustainability and continuation of the program activities.

The goal of activities proposed for 2008 is to continue the strengthening the role of the MOH IPC program,

in particular the nursing department, in the expansion and institutionalization of the IPC efforts in health

facilities throughout the country.

Main activities proposed are to:

(a) Conduct three IPC training courses for 60 mid and basic level nurses from general and rural hospitals

(b) Conduct three IPC training courses for 60 ancillary workers from general and rural hospitals

(c) Conduct three IPC training courses for 60 mid and basic level nurses and other technicians from

emergency services from general and rural hospitals

(d) Support and monitor IPC committees and training activities in general and rural hospitals though

supervision visits

(e) Purchase selected Personal protective equipment (PPE) for 10 hospitals

(f) Print training materials and job aids to support the implementation of IPC activities

Proposed budget amount can be broken down into funding for each activity as follows:

(a) IPC Training Activities: $150,000

(b) Purchase of PPE: $50,000

(c) Supervision Visits: $30,000

(d) Printing of Materials and Job Aids: $20,000

Continuing activity - FY08 Narrative: The goal of this activity is to support the Mental Department of the

MoH to improve alcohol and other substances abuse interventions. USG is currently supporting the MoH to

formally assess alcohol and substance abuse of vulnerable populations in Mozambique, through

implementation an I-RARE (International Rapid Assessment, Response and Evaluation) study among drug

users and sex workers. It is expected that as a result of I-RARE, awareness will be raised among alcohol

and substance abusing populations, increasing the demand for health services for treatment and support.

As a starting point for a comprehensive support to MoH in this area, the proposed activities for FY08 are to

support the MoH to: (a) develop and disseminate a Mental Health Strategy that includes alcohol and

substance abuse; and (b) revise, improve and disseminate the MOH M&E tools and data base for

monitoring admissions related alcohol and drug use.

This activity sheet describes funding and support to the Mozambique Ministry of Health (MOH) for three

components divided into Home-Based Care (HBC), Sexually Transmitted Infections (STI)/HIV, and

Opportunistic Infections (OIs) prevention and control.

Continue USG support for MOH Home Based Care and Traditional Medicine Program program activities

($250,000) as described below:

HBC Program

1. Refresher training for the Provincial HBC Focal Points in conjunction with ANEMO (Mozambican Nurses

Association).

2. Monitoring and Evaluation: Creation of materials and supervision to improve quality and assure

integration with the MOH Health Information System Database. This includes a workshop with implementing

NGO partners to orient them to the MOH electronic database for direct integration to improve quality and

timely collection of information.

3. Update and revision of guidelines, training materials and job aids to include integration with treatment

sites and other changes as needed.

4. Routine supervision of the provinces by the 3 technical staff in the MOH to improve the quality of HBC

and M&E activities and assure integration of community HBC with Treatment sites. At the Central level,

HBC supervision will be integrated with Treatment supervision during this period.

Traditional Medicine Program

This will support activities already in progress based in the National Institute of Health and as start-up

monies for the Institute of Traditional Medicine planned to start in 2008. It will encompass such as activities

as:

1. Training of Trainers at the Provincial level addressing: referrals to the National Health System through

raising awareness in both Traditional Medical Practitioners and Health Personnel about the importance of

their positive interaction, the modification of harmful beliefs and practices in the areas of health, legal issues

such as inheritance rights, gender based violence and others which Traditional Medical Practitioners have

substantial influence over in the community.

2. Integration of effective approaches to traditional practices in other areas, such as: pre-service training

and continuing education for doctors, nurses and the planned Community Health Worker program, various

existing MOH programs such as STI, TB/leprosy, nutrition for adults and children, malaria and chronic

diseases, OMM (Organization of Mozambican Women) activities, Integrated Care and Support Systems

activities with MMAS (Ministry of Social Action) providing social support for those with chronic diseases and

affected family members such as orphans and vulnerable children (OVC).

3. Supervision of provincial activities

Continue USG support for MOH STI/HIV program activities ($368,000) as described below:

1. Integration of STI screening and treatment in clinical and Anti-Retroviral Treatment (ART) settings as well

as Prevention of Mother-To-Child (PMTCT)/Antenatal Care (ANC) services ($310,000). This activity will

build on the results of the assessment of STI diagnosis and treatment in ART settings supported by USG

FY06/07 funds. The assessment provides information on the prevalence of STIs in HIV-infected patients

followed at ART service sites and integration of STI prevention, diagnosis, and treatment in routine

outpatient HIV care and treatment settings. The proposed activities for FY08 include:

(a) Revision and adaptation of current guidelines, training materials and development of job aids on

management of STIs for HIV-infected patients and their partners, attending ART services;

(b) Development of guidelines, revision of training materials and job aids, to address the specific context of

pregnancy, to ensure that pregnant women and their partners, attending ANC/PMTCT services are routinely

screened and correctly treated for STIs in accordance with their status;

(c) Reproduction and dissemination of integrated STI/HIV tools for ART and ANC/PMTCT service sites,

including outpatient and Mother and Child Health Care (MCH) settings;

(d) Performance of refresher trainings for health workers from both ART and PMTCT service sites (one

course per province, therefore a total of 11 refresher trainings for approximately 275 health workers to be re

-trained);

(e) Supervision visits for monitoring of implementation of the above described activities (at least one central

level visit per province per year).

2. Finalization of the development of an algorithm on sexual abuse in children, and performance of a

dissemination and advocacy workshop ($50,000). Sexual abuse of children is an important problem among

families, where family members, friends, teachers, and others are often identified as the abuse perpetuators

therefore creating an environment facilitating repeated abuse and psychosocial problems for the victims. To

-date the MOH STI/HIV program has developed an algorithm addressing sexual abuse in adults. Funding

under this activity will support the finalization and dissemination of an algorithm for sexual abuse in children.

Existing algorithms for sexual abuse tend to mainly address clinical management of victims and lack other

aspects such as reference to and management of psychosocial and other aspects arising from the abuse.

The advocacy workshop will facilitate dissemination of the algorithms and at the same time assist the MOH

to work with other line ministries and stakeholders in developing a plan for improved referral mechanisms

and linkages.

3. As in previous years, USG proposes to continue general STI/HIV office and program support ($8,000) for

routine program functions (office supplies, communication expenses, etc).

Continue USG support for MOH OI program activities ($200,000) as described below:

Improvement of diagnosis and management of OIs. The main activities are: policy development and

revision, training of various cadres of health workers, acquisition of equipment and supplies, strengthening

M& E, and joint supervisions. This year's activities will also include the implementation of OI surveillance.

The first component of this activity ($200,000) complements and continues TB/HIV activities that were

funded during FY07. Funds or this activity will be used to scale up collaborative TB/HIV activities with the

main objective to 1) decrease the burden of HIV/AIDS in tuberculosis patients and 2) decrease the burden

of TB in people living with HIV/AIDS through key interventions that include: scaling up TB screening for all

HIV patients at the different sites offering HIV services, and HIV testing in all TB patients and suspects.

In addition the national TB program will be funded to coordinate and take the lead in the following activities:

1) Strengthening the provision of cotrimoxazole prophylaxis for TB/HIV co-infected patients

2) Intensified case finding and provision of INH for adults HIV+ patients and under 5 children with household

contact after ruling out Tb active disease.

3) Expansion and strengthening of the implementation of infection control measures in health facilities by

education of patients and health workers, training of personnel and provision of equipment and

establishment of appropriate infrastructure guided by international standards.

4) Support the improvement of the diagnosis of Pulmonary TB (smear positive and smear negative) and

Extra Pulmonary TB by training and setting up a referral path for further evaluation and treatment

.5) Provide Initial and refresher training to TB supervisors and provincial coordinator on MDR-TB

management as well as adapt training modules for "técnicos de medicina" (physicians assistants) and

nurses who follow TB patients MDR-TB.

6) Expansion and strengthening of M & E including activities related to MDR-TB, including expansion of the

electronic TB register (ETR) to additional provinces and districts, and support supervisory visits.

A complementary activity is the secondment of an M& E Specialist using resources from the Global Fund to

support efforts for program monitoring.

The second component of this activity ($150,000) is a new addition and will fund the salary and benefits

package for a full-time MOH CT trainer/supervisor position in the MOH TB/HIV program that will provide

significant support to the Counseling and Testing program. The trainer will assist with planning and

supervising of CT training roll-out for TB providers as well as accompany activities that look at improved

screening for TB at CT service sites and successful referral mechanisms. This person will participate in

monitoring and evaluation activities to assess and monitor linkages between CT and TB program activities.

Funding will be provided to the Mozambique National TB program of the Ministry of health (MOH) to

support the following specific activities 1) Strengthen infection control at health facilities to prevent

nosocomial transmission of TB and drug-resistant (MDR, XDR) TB through the procurement of equipment

(respirators, fans, etc.) 2) Strengthen monitoring and evaluation of TB/HIV activities through the rolled out

implementation of the Electronic Tuberculosis Register (ETR) including supervision and training activities.

and 3) Support renovation of the National TB reference laboratory, establishment of supervised quality

assurance programs and specialised TB training for 4 biologist in the area of TB laboratory management

Continuing activity: In March 2005, the Ministry of Health (MOH) started a process of redefining and revising

national policies and program directions for counseling and testing (CT) services. Since then the national

CT expansion strategy has undergone some major changes which aside from greater emphasis on

expansion of Provider Initiated CT (PICT) in clinical settings, introduced the "Counseling and Testing in

Health" (CTH) approach extensively promoted by the Health Minister as a way to implement health

promotion and prevention activities aiming at enhancing the number of people that access health and HIV

services. This health and HIV promotion package proposes continuation and expansion of HIV counseling

and testing as well as the inclusion of TB, Sexually Transmitted Diseases (STD) and hypertension

screening and referrals where necessary, counseling on malaria prevention, environmental health

education, and sexual reproductive health orientation - especially in relation to early pregnancy diagnosis

and institutional delivery. Community-based CT is being piloted and will be expanded in FY08.

The proposed funding will contribute to and support the following activities:

(a) Reproduction of CT program materials: Support the revision of the National CT Training Manual; printing

and disseminating revised guidelines and training materials for CT in clinical settings, CT in Health and

community-based CT.

(b) CTH training for trainers: CT training course to provide CT in Health providers knowledge and skills in

areas of TB, Sexually Transmitted Diseases (STD) and hypertension screening, counseling on malaria

prevention, environmental health education, and sexual reproductive health orientation. Proposed FY08

funds will support 2 training courses for trainers that will help to establish a pool of 50 CT trainers for roll-out

of CT training for CTH sites. Following the training-of-trainers, participants will return to conduct trainings for

counselors within their respective provinces. Funds proposed will support training courses for 200

counselors.

(c) Improvement of CT program management through Monitoring and Evaluation (M&E): In line with new CT

program directions, the existing computerized CT database needs to be updated and improved to

incorporate CT data collected in clinical and community settings. The revisions and modifications will also

help simplify and improve the management of individual client records from CTH centers and Youth-Friendly

Health Centers. Funds will be utilized for the procurement of computer equipment for provincial level data

entry and analysis as well as for a course to train 30 key MoH and NGO personnel involved in managing CT

program data.

(d) Support for CT program supervision: Funding proposed for FY08 will continue to support travel of the

central level CT staff, and provincial CT trainers and supervisors for supervision of training activities. These

supervisors will monitor the quality of training activities, accredit newly trained CT trainers, and give

feedback to staff at existing and newly opened CT service sites to help to improve services.

(e) Support for provincial counselors' meetings: Funding will support 3 regional CT meetings (25 health

workers/counselors per meeting) to exchange experiences and lessons learned on the expansion of CTH

approach, and to help prevent burn-out by coping with the emotional and psychological burden associated

with the work conducted. These meetings will also contribute to the dissemination of revised role and job

description of staff providing counseling services in light of the new CT policies.

FY07: This activity is linked to Activity ID Numbers: 8568, 8572, 8620, and 8633.

Early in 2006, the Ministry of Health (MoH) started a process of redefining and revising national policies and

program directions for counseling and testing (CT) services. Where CT services have traditionally been

provided through Voluntary CT (VCT) centers co-located at health facilities, the MoH is moving toward a

system of routine counseling and testing that is integrated into a package of existing health services (e.g.

tuberculosis, antenatal care, hospital, youth-friendly, and sexually transmitted infections). Existing VCT

services will continue, however, their scope will be broadened to include other diseases and health

promotion areas. Community-based CT is being piloted and will be expanded in FY07.

The requested funds will contribute to and support the following activities:

(a) Reproduction of CT program materials: Support the transition of traditional VCT services to routine CT in

health facilities: Print and disseminate revised guidelines and training materials for CT in clinical settings

and community based CT.

(b) CT training for trainers and health workers: Health workers will undergo a basic CT training course to

provide CT in their respective health services. This will include a 24 hour classroom training and 20 hours

in-service training under supervision. Proposed FY07 funds will support 4 training courses for trainers that

will help to establish a pool of 100 CT trainers for roll-out of CT training for health workers in clinical

settings. Following the training-of-trainers, participants will return to conduct trainings for health workers

within their respective provinces. Funds proposed will support 11 training courses (1 in each of

Mozambique's 11 provinces) for 275 health workers located in tuberculosis (TB), inpatient-hospital,

maternity settings, youth-friendly health clinics (YFHC) and outpatient consultations.

(c) CT service promotion and communication: There is an urgent need to increase public awareness about

the importance of CT in the general public as well as in specific populations (couples, young people, rural

population, vulnerable populations etc.). Communication campaigns are planned in coordination with the

National AIDS Council Communications Unit and the MoH health education department as well as NGOs

that work in the field of social communication. Radio spots and written materials (leaflets) will be designed.

These efforts will address issues of gender, discordant couples, and young people. Additionally, materials

directed to health workers about the importance of CT will be produced.

(d) Improvement of basic CT management practices through Monitoring and Evaluation (M&E) training: In

line with new CT program directions, the existing computerized CT database needs to be updated and

improved to incorporate aggregate CT data collected in clinical and community settings. This improvement

will also help simplify and improve the management of individual client records from VCT centers and Youth

Activity Narrative: -Friendly Health Centers. Funds will be utilized for the procurement of computer equipment for provincial

level data entry and analysis as well as for 2 courses to train 30 key MoH and NGO personnel involved in

managing CT program data.

(e) Procurement of a vehicle for central level CT Program personnel for supervision visits to CT sites

located in the Southern region, i.e. Maputo City, Maputo Province, Gaza and Inhambane Provinces where

sites can be accessed by road.

(f) Support for CT program supervision: Funding proposed for FY07 will continue to support travel of the

central level CT staff and provincial CT trainers and supervisors for supervision of training activities. These

supervisors will monitor the quality of service provider training and accreditation of newly trained CT

trainers, and give feedback to staff at existing and newly opened CT service sites to help to improve

services.

(g) Support for provincial counselors' meetings: Funding will support 11 provincial level CT meetings (one

meeting per province, 25 health workers/counselors per meeting) for health workers and counselors from

selected sites to exchange experiences and lessons learned, and to help prevent burn-out by coping with

the emotional and psychological burden associated with the work conducted. These meetings will also

contribute to the dissemination of revised role and job description of staff providing counseling services in

light of the new CT policies and roll-out of integrated services.

Continuing activity: The Mozambican National Health System is leading the scale-up of comprehensive HIV

Care and ART throughout the country. By June 2007 there were 193 treatment sites providing ART in all

districts for 65,296 people in need of treatment-(this number has already increasd to 202 in July 2007). The

National Directorate of Medical Assistance (DNAM) is responsible for overseeing HIV care and ART

expansion. This funding will assist the MOH in providing quality ART services via the development of strong

systems to ensure the availability of necessary supplies, materials, and human resources for the adult and

pediatric ART program. Currently the team at the MOH conducts 2-week supervision visits in each province

annually. The visits involve in-depth analyses of the health system infrastructure, human resource

allocation, coordination between related programs, review of patient charts and data bases as available,

logistics, specific review of pediatric ART provision, etc. On average 80% of health facilities with ART in the

province are assessed during the 2 week visits. In addition DNAM coordinates weekly ART management

committee meetings designed to coordinate expansion of the program, as well as ensure quality of care

provision. Funding will support the completion of these activities and specifically assist in the following

activities:

1. ART-related training in the following areas—ART service provision, nurse training in PCR / infant

diagnosis, and monitoring and evaluation

2. Provincial supervision for ART service delivery for MOH staff including non-NGO supported ART facilities

implementing the HIVQUAL program;

3. Reproduction and dissemination of materials and guidelines for doctors, nurses and physician assistants

(técnicos de medicina) related to adult and pediatric HIV care and ART service provision

4. Revision, reproduction and dissemination of ART reports, M&E forms and site supervision tools

5. Training of health workers, provincial and district program managers in the use of the revised M&E forms

and supervision tools

Continuing Activity: This activity is a continuation of activities initiated in FY06 to support the Ministry of

health (MOH) in the development of the network of public health laboratories in Mozambique.

The MOH's overall objective for laboratory services is to improve the capacity, access to and the quality of

diagnostic laboratory services in Mozambique to support health care.

FY08 funding will continue to support this broad objective through implementation of the following activities:

1. Support to carry out supervision visits to assess laboratory operations, institute corrective action where

necessary and therefore ensure improvement and maintenance of laboratory quality standards.

2. Purchase of laboratory reagents for hematology, biochemistry and CD4 to support HIV care and

treatment. This activity aims at assuring availability of continuous testing services.

FY07:

This activity is related to activity 8532, and 8540 and is a continuation of activities initiated in FY06 for

support to the Ministry of Health (MoH) in the development of the network of public health laboratories in

Mozambique.

The MoH's overall objective for laboratory services is to strengthen and provide state-of-the-art technology

to ensure the quality of services provided to complement and support health care services. The main areas

that the MoH aims to improve include: expansion of access to quality serological HIV diagnosis, provision of

appropriate technical laboratory support needed for quality ART including in peripheral zones; creation of

sustainable and effective specimen referral and laboratory logistics systems in order to establish locally an

internationally accredited quality laboratory diagnostics.

Funding during FY07 will continue to support these broad objectives through implementation of the following

activities:

1) Planning and coordination of trainings for all laboratory personnel in the country including participation in

international meetings and conferences

2) Development and updating standard laboratory operating procedures and guidelines and undertake

supportive supervision

3) Procurement of laboratory units including supplies and equipment for five to-be-defined district health

centers.

In addition to these activities, these funds will be used to help maintain and support skilled expatriate staff

needed to develop the referral network through strengthening laboratory support at provincial level.

This existing activity is comprised of several sub-activities designed to build and strengthen MOH capacity

in strategic information. Subactivities include:

1) Provide IT infrastructure and TA support to help formalize, disseminate, and implement MOH

"infrastructure architecture" plan in collaboration w/ WHO

2) Monitoring of early warning indicators by MOH, including CDC field support to contract survey teams

3) Support resistance monitoring in ART patients at one MOH site

4) Expansion of informatics infrastructure in the Provinces of Manica and Tete; similar support for 2

hospitals in Maputo City (Mavalane and Jose Macamo)

5) pilot the implementation of a national mortality system in the country

6) create, train and strengthen a group within the MoH to define standard definitions for medical procedures

and related systems at the Health Information Department of the MoH

7) strengthen the linkages between public laboratories and epidemiological surveillance activities

8) continue support for activities linked to the health facilities inventory, including the creation and

maintenance of a national registry of health facilities

1) Provide hardware, equipment, and TA support to help formalize, disseminate, and implement MOH

"infrastructure architecture" plan $275,000

FY08 funds will be used to support DIS/MISAU in project management activities with regards to the Hospital

Information System. Technical expertise will be provided to DIS in the assessment, development, adoption,

and upgrading of existing health information systems. Funds will also support DIS/MISAU to design, testing

and deployment of the others national health information systems, such as mandatory disease notification,

National Immunization Database, and other epidemiologic surveillance systems (specific programs such as

Malaria, TB, AIDS and others), construction of the national health data warehouse strategy, national

registries of birth and deaths. Funds will also be used to procure hardware and other needed informatics

equipment.

2) Monitoring of early warning indicators by MOH, including CDC field support to contract survey teams

$80,000

Monitoring and controlling the emergence of drug resistance in Mozambique is important in order to be able

to ensure the quality of the ART program and to rationally plan national treatment regimens. MOH has

assigned responsibility for ART drug resistance monitoring to the ART monitoring committee of the MOH.

The committee, in consultation with CDC and WHO has developed a plan to monitor the emergence of drug

resistance. The plan calls for a) monitoring of routinely-collected Early Warning Indicators (EWI) from

treatment sites, b) monitoring of treatment failure, adherence and drug resistance in cohorts at a sample of

treatment sites, and c) threshold surveillance of transmitted drug resistance during sentinel surveillance.

This activity will support the MOH coordination and setup of these activities. The committee will appoint a

coordinator for drug resistance monitoring activities, and will produce an annual drug resistance report

combining data from all three resistance monitoring activities. If necessary, this activity will provide salary

support for the coordinator.

For EWI monitoring, this activity will support development and implementation of a set of indicators adapted

from the WHO recommended list of EWI indicators. The Committee will adapt and translate data

abstraction forms and data entry programs for local use. The Coordinator will oversee data abstraction

teams that will be responsible for abstracting data at sentinel sites on a rotating basis. Funds will cover

development of data entry programs, abstraction forms, and salaries and travel costs for the coordinator

and data abstraction teams. This activity will provide technical assistance to the MOH and will train 2

persons in M&E. This activity is related to activity 12267.08.

3) Support resistance monitoring in ART patients at one MOH site $35,000

For ART monitoring one MOH-supported treatment site will be selected to pilot drug resistance monitoring

in a pediatric or adult cohort. Expected sample size is 100 patients, for whom baseline data will be

collected. Routinely-collected blood samples will be used for preparing baseline and 12 month genotyping

and viral load samples. Funds will cover development of data entry programs, abstraction forms, and

salaries and travel costs for the coordinator, and sample collection. Threshold surveillance is implemented

and funded through sentinel surveillance. This activity is related to activity 15916.08.

4) Expansion of informatics infrastructure in the Provinces of Manica and Tete; similar support for 2

hospitals in Maputo City $225,000

Currently, limited informatics infrastructure exists at isolated health care facilities throughout Mozambique.

Funds will be provided through a contractor for the acquisition of informatics hardware to link and network

existing hardware and equipment in two provinces as well as at 2 hospitals in Maputo City, including

establishing a contract with an ISP.

5) Establish a national mortality system in the country $50,000

FY08 funds will be used to establish a new integrated system for mortality surveillance in the country,

comprising all data generated at health facilities and elsewhere, so that a unique consolidated database can

be generated and managed by DIS, after appropriate processing, revision and correction. Currently, the

Department of Health Information (DIS), along with the National Directorate for Medical Assistance (DNAM),

hospitals and the Ministry of Justice plan to revise the death certificate requirements/procedures. In

calendar year 2008 DIS will develop, pilot, and implement an information system for mortality data

generated through the new system. The national database on Mortality will be publicly available, through

various mechanisms, i.e., published reports or web access.

6) Establishment of a group to define standard definitions for medical procedures and related systems at the

DIS $50,000

FY08 funds will be used to establish communication standards to facilitate interoperability among systems.

A key final product of this activity will be a Mozambican implementation guide describing different national

health communication standards, such as disease reporting, immunization, referral and counter-referral,

discharge summary and death and birth registration.

7) Strengthen the linkages between public laboratories and epidemiological surveillance activities $50,000

Support will be provided to strengthen the laboratory network as it relates to epidemiological surveillance,

referral systems, laboratory confirmation of clinical cases, monitoring of pathogens resistance and reporting

Activity Narrative: of cases to the central level. To achieve this goal, DIS will develop or revise guidelines, procure equipment,

strengthen the quality control procedures at all levels.

8) Creation and maintenance of a national registry of health facilities $100,000

This activity plans to support the development of an online database, in collaboration with the Provincial

Directorates of Health, which will provide information of health facilities - an online registry. This is a follow

up activity of the national inventory of health facilities which was just carried out by the Ministry of Health.

PHE: The Ministry of Health, with technical assistance (TA) from the Centers for Disease Control and

Prevention (CDC), is currently preparing the implementation of the following qualitative study in

Mozambique:

Title: "Assessment of acceptability and feasibility of intervention strategies that address HIV prevention,

testing, care, and treatment among the Public Sector Health Care Workforce in Mozambique" (COP07 ID:

10211)

This activity is linked and will build on findings from the quantitative survey, entitled "Survey of HIV/AIDS

Knowledge, Attitudes, and Practices (KAP) among health workers in Mozambique" (COP07 ID: 8639).

While the results of the KAP survey completed at the end of FY07, will allow to establish nationally

representative baseline data and describe knowledge, attitudes and behaviors among health workers and

students, the proposed qualitative assessment will complement information obtained from the KAP survey,

and inform the design and development of first interventions to be started at selected Ministry of Health

(MOH) facilities and training institutes.

Funding requested and approved for this activity in FY07, i.e. $75,000, will suffice for completion of this

activity, and therefore now new funds are required for this activity in FY08.

Local Principal Investigator: Dr Francisco Mbofana, Researcher of the National Health Institute,

Mozambique Ministry of Health

Local Co-Investigator: Felisbela Gaspar, MOH STI Program Director, and Adjunct HIV/AIDS Program

Director

Project Description:

Evidence reveals high HIV prevalence rates among health workers in Africa. In Mozambique, a study

conducted in Sofia (1997-2001) found an increase in annual mortality from 1.5-2.4% among medical staff

and 1.4-2% among support staff. In 2004, of 1558 health workers accessing counseling and testing, 23%

tested HIV-positive. It is estimated that 15% of Mozambique's health professionals will die of AIDS in the

coming decade. Health workers are an extremely valuable resource, especially in Mozambique. This study

will assess the acceptability and feasibility of intervention strategies that address HIV prevention, care, and

treatment with recommendations to guide the development of effective interventions to reduce risk and

increase service uptake among health workers.

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, concerns around 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.

Evaluation Question: This qualitative research consists of two components: focus group discussions (FGDs)

with health workers and interviews with key stakeholders. These qualitative data will be used to examine

barriers and facilitators health care workers face with regard to HIV prevention, testing, care, and treatment;

to assess acceptability and feasibility of various intervention strategies; and to provide recommendations for

intervention development. Programmatic importance: The specific objectives of this study are to:

A) Assess the feasibility and acceptability of HIV workplace interventions

B) Assess health workers' risk perception related to workplace and personal exposures

C) Identify strategies and methods to reduce high risk sexual behaviors among health workers

D) Identify strategies and methods to reduce high risk workplace practices

E) Identify social norms surrounding fidelity, partner reduction, and condom use

F) Identify barriers and facilitators to VCT and ART uptake among health workers to provide

recommendations for intervention development.

Methodology: FGDs and interviews will be conducted by two-person fieldwork teams trained in facilitation,

interview, and note-taking techniques. FGD participants will be selected from selected health facilities in 2

provinces and be separated by sex and cadre. Eight focus groups will be conducted in each province,

separated by sex and cadre (including medical and non-medical cadres).

Key stakeholder interviews will be conducted among leaders of labor, medical, and nursing associations

who represent health workers in the 2 selected provinces. In addition, interviews will be conducted with key

MOH staff, such as Directors from the Human Resource and Information Education and Communication

departments.

Population of Interest: The population to be studied is health workers, including both medical and non-

medical staff in MOH facilities. Medical cadres consist of doctors, medical technicians, and nurses. Non-

medical cadres consist of support staff, such as administrative staff, laboratory staff, and janitorial staff.

Status of the Study:

A working group composed of MOH staff from various departments, including the human resources,

training, health education departments, and the HIV/AIDS program, has been established, including CDC

technical assistance providers for strategic information, human capacity development/training and

prevention.

Visits to health facilities, including facilities with HIV/AIDS and ART services and facilities without such

services, informal discussions with health workers, and discussions with selected PLWHA groups have

informed the contents of the assessment protocol and FGD guide.

Activity Narrative: The assessment protocol and tools have been submitted and approved by the Mozambique Bioethics

Committee. The translation of all documents to English has been completed, and documentation is

prepared for submission to appropriate bodies in the US for approval prior to end of September 2007.

Implementation of the study will start as soon as approval from the US has been obtained.

Lessons Learned:

(a) High level MoH commitment (MoH Human Resources Director and the National Health Institute Director

are Principal Investigators) is key to move these activities forward successfully.

(b) Frequent changes and transfers of MoH personnel require constant re-briefing of new working group

members from a variety of backgrounds and programs.

(c) While the use of a very participatory approach allowing for staff from various departments and programs

to participate, as well as providers and PLWHA being able to provide inputs, may make this process

lengthier and slow, it enhances MOH ownership and contributes to highly relevant and appropriate tools

being developed.

Information Dissemination Plan:

Findings will be shared with participants, study sites and provinces involved through sharing of the final

study report. The Ministry of Health investigators will also present findings at a dissemination workshop

where key Ministry of Health Program and Department Directors and Coordinators, as well as stakeholders

will be invited to attend. Follow-up discussions with Heads of selected departments involved in activities that

will occur as a result of the assessment, such as Human Resources, training etc. will take place. Results will

be submitted for publication in an appropriate peer reviewed journal.

Planned activities are as described under the status report above: As soon as approval from the US has

been obtained, implementation of the assessment, i.e. 16 FGDs and 29 in-depth interviews will be

conducted in the two provinces selected.

Budget Justification:

No new funds will be required for FY08. FY07 funds will be used for implementation of this study as follows:

Salaries for short-term consultancies - data collection, analysis: $30,000

Supplies: $4,900

Transcriptions: $11,000

Transport: Flights $3,350; Car rental & fuel: $6,800

Per diems for staff travel: $7,700

Training: $8,050

Other: $3,200

Total: $75,000

In line with MOH policies, no incentives are being issued to study participants.

Continuing activity:

FY08 Narratives: The Training Department of the Ministry of Health has been implementing an Accelerating

Training Plan in order to increase the number of human resources and facilitate the scaling up HIV services.

Teaching quality at the health training institutions has been identified as a big concern, in particular when

more faculty board is being integrated. CDC will support the quality improvement program developed by the

MOH. ($734,200)

Objectives

Support in-service training in HIV for faculty board from the training institutions

Support training institutions with books for libraries and medical items to facilitate practical sessions for

students.

Activities and expected outcomes

Activity 1: Provide HIV courses in ART, counseling and testing for in-service training faculty. Those trainings

are coordinated with programs responsible. 4 courses in 2008. Deliverable: 90-100 persons trained.

Course curriculum already existed.

Activity 2: Purchase of technical books already listed by the MOH. Deliverables: 500 books are given to

training institutions in 2008

Activity 3: Purchase of medical items already listed by the MOH. Deliverables: 50 kits are given to training

institutions.

Activity 4: Reprint pamphlets for training institutions. Deliverables: 2000 pamphlets

Activity 5: Provide funds for health workers continuing their studies at the Health Science Superior Institute.

Deliverables: 4-6 health workers with scholarships

Expand TIMS to all provinces, support for supervisory visits, faculty development support, purchase of

books, HIV tool kits, computers and equipment for training department staff, printing materials, scholarships

for students at ISCISA.

This second component of this activity sheet also contributes to capacity building of MoH staff from various

departments, including Human Resources, Training, Health Education Departments and the HIV/AIDS

Program ($80,000):

All behavior change and informational activities relating to the MoH's desire to support health workers are

lead by the MoH working group composed of staff from departments listed above. With funding from

previous year quantitative and qualitative assessments looking at prevention behaviors, access to

counseling and testing, and ARV services among MoH health workers and students at MoH training

institutes have been conducted. As the key stakeholder, MOH staff will proceed analyzing the data from the

assessments, and design and pilot interventions stemming from those analyses. FY08 funding will permit

the MoH to realize the design and implementation of informational and behavioral interventions.

Activities supported in FY08 will include to: (a) Review and adapt existing BCC materials to the

Mozambican context; (b) sponsor and participate in trainings which involve data analysis; (c) participate in

capacity-building trainings in areas of qualitative and quantitative analysis, behavioral intervention design,

and intervention evaluation; and (d) work alongside partners in piloting new behavioral and informational

intervention groups.

Deliverables/benchmarks:

• HIV courses in ART, counseling and testing for in-service faculty.

• Technical books for libraries in training institutions, medical kits to for training institutions to be used for

clinical practicums, and reprint educational pamphlets for training institutions

• Scholarships for health workers to continue their higher education studies

Deliverables/benchmarks:

• Adapt BCC materials for use in Mozambique

• Capacity development in qualitative and quantitative analysis, behavioral intervention design and

intervention evaluation

• Pilot new behavioral and informational intervention groups