PEPFAR's annual planning process is done either at the country (COP) or regional level (ROP).
PEPFAR's programs are implemented through implementing partners who apply for funding based on PEPFAR's published Requests for Applications.
Since 2010, PEPFAR COPs have grouped implementing partners according to an organizational type. We have retroactively applied these classifications to earlier years in the database as well.
Also called "Strategic Areas", these are general areas of HIV programming. Each program area has several corresponding budget codes.
Specific areas of HIV programming. Budget Codes are the lowest level of spending data available.
Expenditure Program Areas track general areas of PEPFAR expenditure.
Expenditure Sub-Program Areas track more specific PEPFAR expenditures.
Object classes provide highly specific ways that implementing partners are spending PEPFAR funds on programming.
Cross-cutting attributions are areas of PEPFAR programming that contribute across several program areas. They contain limited indicative information related to aspects such as human resources, health infrastructure, or key populations programming. However, they represent only a small proportion of the total funds that PEPFAR allocates through the COP process. Additionally, they have changed significantly over the years. As such, analysis and interpretation of these data should be approached carefully. Learn more
Beneficiary Expenditure data identify how PEPFAR programming is targeted at reaching different populations.
Sub-Beneficiary Expenditure data highlight more specific populations targeted for HIV prevention and treatment interventions.
PEPFAR sets targets using the Monitoring, Evaluation, and Reporting (MER) System - documentation for which can be found on PEPFAR's website at https://www.pepfar.gov/reports/guidance/. As with most data on this website, the targets here have been extracted from the COP documents. Targets are for the fiscal year following each COP year, such that selecting 2016 will access targets for FY2017. This feature is currently experimental and should be used for exploratory purposes only at present.
Years of mechanism: 2008 2009
SUMMARY and BACKGROUND
I-TECH's FY09 PMTCT program consists of providing technical support to MISAU in four activities: 1)
support for the on-going clinical mentoring program for PMTCT nurses; 2) the finalization and dissemination
of an Operational Guide and training package for mothers' support groups; 3) the selection and adaptation
of an internationally-approved curriculum for PMTCT to replace the current in-service course; and 4) the
provision of technical assistance for the insertion of PMTCT content into key pre-service courses, with a
particular focus on the pre-service course for the tecnicos de medicina (TM). Additionally, I-TECH will
continue to provide technical assistance to MISAU's PMTCT technical working group and its sub-groups, as
requested by the MOH.
ACTIVITIES
ACTIVITY 1: Clinical Mentoring of PMTCT Nurses ($180,000)
I-TECH has been working with MOH in developing a mentor's training curriculum and set of clinical
mentoring tools for PMTCT nurses in order to strengthen the national expansion of PMTCT services. I-
TECH has been collaborating with two PEPFAR partners, Columbia University/ICAP and EGPAF, to
develop and pilot two different clinical mentoring models. The ICAP-supported model consists of the
provision of nurses' training via two-week rotations through a PMTCT model center, followed by on-site
mentoring. The EGPAF model consists of mentor training and subsequent mentoring for PMTCT nurses at
their "home facility" sites. The primary objectives of the program are to increase and reinforce PMTCT-
related knowledge and aptitude of nurses working in the nation's pre-natal, delivery, and post-partum
facilities, and to address some of the barriers to providing a basic PMTCT package of services for women of
reproductive age in Mozambique.
I-TECH's collaboration with ICAP in the development of a mentors' training and nurse rotation materials
dates back to 2007. In June 2008, the two organizations conducted the first training of 20 PMTCT nurse
mentors followed by the initiation of rotations in the Nampula model center. The training materials
developed for the first course consisted of a Facilitator's Manual, a Reference Manual for mentors, a Clinical
Rotation Guide, a set of technical lectures with accompanying notes for mentors and set of checklists for
mentors to use to measure mentee progress during clinical rotations and during subsequent on-site
mentoring. A key finding of the initial mentor's training was lack of a strong clinical knowledge base on the
part of the selected mentors, an issue that will need to be addressed by the program implementers prior to
conducting mentor trainings. Based on the evaluation of the first mentor training and rotations, the
materials have been refined for the subsequent training at the model center in Maputo province, scheduled
for October 2008.
The materials developed in FY08 will be used to inform development of a national approach for PMTCT
clinical mentoring, led by MOH, in FY09. While the Ministry has approved the use of model centers (ICAP)
for training PMTCT nurses, it is the decentralized mentoring model being developed with EGPAF that they
believe will be most appropriate for national expansion. I-TECH is presently working with EGPAF to
develop tools to conduct a baseline assessment of the knowledge level and clinical skills of possible
mentors. The results of the assessment will provide enough of an evidence base to gauge the technical
knowledge and skills of PMTCT nurses in general and to draft training materials to upgrade both the theory
and clinical practice of potential mentors before they are expected to work with their mentees. The same
assessment tools may be helpful to MOH in other facilities.
In FY09, 15 mentors at ICAP-supported sites in Maputo will be trained, 10 EGPAF-supported tutors will be
trained, and 10 MOH mentors, including provincial and district supervisors in Gaza, will be trained. An
evaluation of the decentralized model's materials will be conducted following the initial training and the
materials will be revised accordingly. Following revisions, the final products will be submitted to MOH for
their approval as official MOH documents and made available to all partners and Ministry-supported sites
conducting PMTCT activities.
ACTIVITY 2: Framework for Mother Support Groups ($130,000)
I-TECH completed an inventory of PMTCT mother support groups in Mozambique in February 2008, which
was complemented by a regional desk review conducted by UNICEF. Following the release of the report, I-
TECH supported MOH in conducting a series of workshops to help steer the development of a Mothers for
Mothers (Maes para Maes, or MpM) Operational Guide. The aim of the Operational Guide is to provide
simple, standardized guidance on how to start and successfully run a support group for HIV positive
pregnant women or women who have recently delivered. The Guide will ensure that MOH-approved
policies and best practices are followed wherever the groups are formed, and that groups are linked with the
national health service. The Guide will not only be an important tool for health facility nurses and mothers,
but also will encourage male participation in this important prevention service. This activity will be ongoing
in FY09; completion in FY08 was not possible due to replacement of key MOH personnel who were acting
as counterparts on this project. The MpM Operational Guide will be submitted to MOH for approval before
the end of November 2008. Once MOH has approved the Guide, I-TECH will use FY09 funds to develop a
comprehensive training package to accompany the Guide. It will include materials for nurses and mothers
who play lead coordination and training roles in the support groups. I-TECH will conduct a pilot and an
evaluation of the training materials for 10 nurses with a PEPFAR-supported NGO partner and finalize the
materials based on the evaluation. A training-of-trainers will then be offered to an approximate total of 20
nurses from MOH and other implementing partners. Given the close linkage between training PMTCT
nurse mentors and the creation of mother support groups that are based in PMTCT services, the
Operational Guide and accompanying training package will also be shared with the PMTCT nurses who are
trained in the mentoring program.
ACTIVITY 3: PMTCT In-Service Course Revision ($70,000)
The present national PMTCT in-service course is out-dated and requires revisions. To that end, in FY09 I-
TECH will work closely with MOH and its PMTCT technical working group on selecting an appropriate
internationally-approved PMTCT course to be adapted for Mozambique. The Ministry will be encouraged to
choose either the WHO IMAI/IMPAC Clinical Training Course for Integrated PMTCT Interventions or the
CDC 2008 generic training package for adaptation. Within the context of the MOH PMTCT working group, I
-TECH will provide technical assistance to the Ministry and help guide the decision making process such
Activity Narrative: that I-TECH can initiate course adaptation and updates. The deliverable for this activity is an improved,
updated, and printable PMTCT curriculum by the end of FY09.
ACTIVITY 4: PMTCT Content Developed for Pre-Service Courses ($20,000)
The current pre-service courses for TM, nurses and other health worker cadres do not include any
information on PMTCT services. I-TECH will support the MOH training department in reviewing and
inserting PMTCT content in pre-service curricula where appropriate. I-TECH is presently technically
supporting an MOH working group in revising the TM pre-service course for HIV care and treatment, and
will ensure that appropriate PMTCT content is included in this new curriculum.
New/Continuing Activity: Continuing Activity
Continuing Activity: 13217
Continued Associated Activity Information
Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds
System ID System ID
13217 8798.08 HHS/Health University of 6417 3583.08 I-TECH $500,050
Resources Washington
Services
Administration
8798 8798.07 HHS/Health University of 4941 3583.07 I-TECH $450,000
Emphasis Areas
Human Capacity Development
Estimated amount of funding that is planned for Human Capacity Development $270,000
Public Health Evaluation
Food and Nutrition: Policy, Tools, and Service Delivery
Food and Nutrition: Commodities
Economic Strengthening
Education
Water
Table 3.3.01:
ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS:
One of the key objectives of the Ministry of Health (MOH) Strategic Plan to Combat HIV/AIDS and STIs, for
2004-2008 is to reduce the impact of HIV/AIDS on health care workers. As a primary means of prevention,
behaviors associated with HIV transmission must be addressed, especially those sexual behaviors that put
individuals (and their partners) at greater risk of infection. To date, there are few existing activities that
support health workers in dealing with HIV/AIDS risk behaviors and address issues of abstinence, delay of
sexual debut, and faithfulness to one's partners.
CDC has been assisting the Mozambican Ministry of Health (MOH) in identifying these gaps, through the
BANK (Behavior Attitudes, Norms and Knowledge) quantitative and qualitative survey. Using the BANK
findings, recommendations, and other qualitative research results has further the understanding of the
barriers and facilitators of change and the media through which such change can happen. In
addition,exchange visits to health worker specific programs in Botswana and Tanzania by CDC/MoH teams
has also deepened the appreciation for practical and sustainable interventions in Mozambique. In particular,
these visits illustrated the need to consider ways reduce stigma in the health workplace.
The focus of this activity is to promote safe behaviors and reduce sexual risk behavior by promoting
abstinence and faithfulness (A/B). FY 08 funds were used to support the University of Washington partner
Global Health Communications (GHC) in the development and evaluation of Behavior Change
Communication (BCC) interventions. Activities GHC conducted in Mozambique included:
(a) Identified informational and educational gaps and adapted existing A/B materials to the in-country
context. Some of these materials may be circulating in parts of Mozambique, but the partner was
encouraged to also identify materials from other countries in the region that may be translated into
Portuguese and other local idioms as well as materials from other Portuguese speaking countries (e.g.,
Angola, Brazil, Cabo Verde, Guinea Bissau) that may be modified to address the Mozambican context;
(b) Created new A/B informational/educational materials where materials do not exist;
(c) Developed and piloted behavioral and educational interventions focused on issues of abstinence and
faithfulness;
(d) Evaluated pilot interventions to assess their personal life effectiveness, and;
(e) Trained and on-the-job mentored the MOH staff from human resources, training, health education
departments, and HIV/AIDS/STI program in evaluation of A/B behavior change and educational
interventions.
FY 09 funds are being requested to support existing partners with activities that include:
(a) Behavior change trainings with groups of health workers and students at health training institutes that
specifically address abstinence and faithfulness (A/B).
(b) Using the Behaviors, Attitudes, Norms and Knowledge (BANK) study findings and other research that
identified informational and educational gaps develop and/or adapt existing A/B materials .
(c) Create new A/B informational/educational materials where existing materials do not exist;
(d) Provide technical assistance in the implementation, monitoring and evaluation of FY08-FY09 activities
that MOH has piloted in the areas of A/B and develop and pilot additional behavioral and educational
interventions focused on issues of abstinence and faithfulness as recommended by MoH and key
stakeholders;
(e) Drawing from the experience of the Breaking the Silence project in Tanzania, role-model stories used in
Ethiopia, and the PANOS participatory video project in Madagascar to create a series of biographical videos
highlighting challenges -including that regarding abstinence and faithfulness—from the perspective of
health workers themselves;
(f) Design a set of discussion guides that can be used in conjunction with health worker videos that
encourage small groups of health workers to examine unsafe norms surrounding abstinence and
faithfulness issues in their own lives;
(g) Establish teams of "focal persons" within health centers to assist the staff at neighboring centers to
undertake stigma reduction activities using the videos and discussion guides. These focal persons may
include HIV+ health workers (peer educators);
(h) Continue on-the-job mentoring of MOH staff from human resources, training, health education
departments and HIV/AIDS/STI program in evaluation of behavior change and educational interventions,
with the emphasis on interpersonal communication, encouraging testing and disclosure and A/B practices.
Deliverables and Products
1. The workshop/training curricula in which BANK and qualitative study findings are introduced to MISAU
and other stakeholders and a written report of the AB intervention design outputs created as a result of
these meetings. Roster of participants will be submitted.
2. Workshop reports on a series of trainings conducted with health workers and students in which they are
led to understand the behavioral barriers and facilitators associated with AB outcomes and then helped to
identify personal and small-group activities that might address these barriers. Rosters of all participants will
be submitted
Activity Narrative: 3. All workplans and reports on the piloting of activities that arise out of health worker and student
workshops described in #1 and #2 above.
4. A complete catalogue of relevent lusophone materials used in other countries that can be adapted for
MISAU along with recommendations for their use. This collection of materials will focus on
Abstinence/Delay of Sexual Initiation and Fidelity.
5. Print-ready materials addressing gaps in AB informational/educational materials where existing local,
regional or lusophone materials do not exist. Inforamal obsevations of how current materials are circulating
in the health centers, and how that can be improved, will also be provided.
6. A set of short (5-8 minute) videos developed using participatory approaches that show how HIV+
healthworkers and students deal with problems relating to abstinence and fidelity.
7. A set of training materials that complement the videos listed in #7. These will take the form of discussion
group guides and activities that can be conducted in small groups and focus healthworkers' attention on
norms relating to abstinence and fidelity in their lives and that of their family.
8. Rosters of health workers and students volunteers who have been trained to use the materials describes
in #6 and #7 above as well as the rosters of participants at these discussion groups.
9. Rosters of MOH staff requesting and receiving support in their supervision of behavior change activities
and their assessment. Materials developed and used in this support will also be submitted.
FY08: One of the key objectives of the Ministry of Health (MOH) Strategic Plan to Combat STIs, HIV, and
AIDS for 2004-2008 is to reduce the impact of HIV/AIDS on health care workers. As a primary means of
prevention, behaviors associated with HIV transmission must be addressed, especially those sexual
behaviors that put individuals at greatest risk of infection. To date, there are few existing activities that
support health workers in dealing with HIV/AIDS risk behaviors and that address issues of abstinence, delay
of sexual debut, and faithfulness to one's partners. The focus of this activity is to promote these behaviors
and strengthening the norms that support them. FY 08 funds are being requested to support the University
of Washington through its partner Global Health Communications (GHC), a partner with experience in the
successful development and evaluation of Behavior Change Communication (BCC) interventions in the
African context. Activities that this partner will support in Mozambique include:
(a) Building on the results of quantitative and qualitative assessments conducted with funding support from
FY06/07, to identify informational and educational gaps that might be quickly and efficiently addressed by
adapting existing A/B materials. Most of these may be print-based, but there may be radio PSAs that can be
identified. Some of these materials may be circulating in parts of Mozambique, but the partner will be
encouraged to identify materials from other countries in the region that may be translated into Portuguese
and other local idioms as well as material from other lusophone countries (e.g., Angola, Brazil, Cabo Verde,
Guinea Bissau) that may be modified to address the Mozambican context;
(b) Creating new A/B informational/educational materials where existing regional or lusophone materials do
not exist;
(c) Developing and piloting behavioral and educational interventions focused on issues of abstinence and
(d) Evaluating pilot interventions to assess their personal life effectiveness, and;
(e) Training and on-the-job mentoring of MOH staff from human resources, training, health education
Continuing Activity: 15798
15798 15798.08 HHS/Health University of 6417 3583.08 I-TECH $300,000
Table 3.3.02:
Activity has been modified from year 2008:
Two priorities of the Mozambican Ministry of Health (MOH) are to minimize the impact of HIV on health
workers and to design interventions that will contribute to the prevention of STIs and HIV among vulnerable
and Most at Risk Populations (MARPs). With these priorities in mind, the University of Washington's partner
Global Health Communications (GHC) will use FY 09 funds ($425,000) to develop and evaluate Behavior
Change Communication (BCC) interventions for these important target groups.
A. Health Workers and Trainees of MOH Health Institutions ($200,000)
One of the key objectives of the MOH Strategic Plan to Combat HIV/AIDS and STIs for 2004-2008 is to
address HIV/AIDS prevention for health care workers. In this document, MOH declared that reducing the
impact of HIV/AIDS among health workers (including support and administrative staff in addition to students
currently enrolled in health institutes) is one of their highest priorities. To date, there are few existing
activities that support health workers in dealing with HIV/AIDS risk behaviors and that address issues of
abstinence, delay of sexual debut, and faithfulness to one's partners. For this component of the BCC
interventions activity in FY09 GHC will:
(a) Implement recommendations from stakeholders and MOH formulated in FY08; implement Post
Exposure Prophylaxis (PEP) standards/policies and develop promotional and educational materials
regarding condom-use.
(b) Create a series of videos highlighting challenges regarding condoms use and other preventive behaviors
from the perspective of health workers themselves to be used for the purpose of stigma reduction, based
upon the experience of the Let's Breaking the Silence project in Tanzania, role-model stories used in
Ethiopia, and the PANOS participatory video project in Madagascar.
(c) Design a set of discussion guides to supplement the videos described above and focus on the lives of
health workers discussing condom usage and other prevention issues. These guides will be used by trained
teams of health workers from neighboring health centers to encourage small groups of health workers to
examine condom usage and other prevention practices as they relate to their own lives to stimulate open
discussion and reduce stigma.
(d) Conduct behavior change trainings with groups of health workers and students to address PEP access
standards and policies and the appropriate use of condom.
(e) Provide technical assistance in the implementation, monitoring and evaluation of activities piloted in
FY08 and develop and pilot additional behavioral and educational interventions focused on PEP, condom
use and other prevention priorities as recommended by MOH and key stakeholders.
(f) Continue on-the-job mentoring of MOH staff from human resources, training, health education
departments and HIV/AIDS/STI program in evaluation of behavior change and educational interventions.
B. Most at Risk Populations ($225,000)
Mozambique's International Rapid Assessment Response and Evaluation (I-RARE) was designed to better
understand, assess, and make recommendations for how to respond to rapidly changing sexual risk and
drug using patterns that increase vulnerability to HIV infection among sex workers and drug users in three
cities in Mozambique, Maputo, Beira, and Nacala Porto. The assessment explored the presence of drug
and alcohol use and high risk sexual behavior in sex workers and injection and non-injection drug users.
The potential for overlapping risk behaviors, sexual mixing among these populations, and bridging to the
general population exists, and may be contributing to the rapid spread of HIV in the country. Using specific
findings from the I-RARE survey, the partner will continue to develop targeted approaches and appropriate
public health interventions for these populations and pilot specific activities.
Globally, male-to-male sex is increasingly recognized as a high risk behavior in need of targeted prevention,
care and treatment interventions. A number of country-specific surveys have been carried out and have
provided valuable information on HIV prevalence and risk behaviors among men who have sex with men
(MSM); however, no data are available on MSM in Mozambique. It is vital to have an accurate description of
the extent of this issue in Mozambique before designing specific interventions to address MSM.
FY 09 funds are being requested to support continued development, implementation and evaluation of
prevention activities relating to MARPs. Specific activities will include:
(a) Developing outreach programs for most at risk populations, as refined by I-RARE findings including the
use of narrative strategies that elicit ideas for interventions with sex workers and drug users;
(b) Training organizations in basic organizational capacity with particular reference to behavioral and
outreach activities relating to condoms and other prevention;
(c) Developing venue-based interventions, such as bar-based outreach that 1) deliver HIV prevention
information, particularly information, education and/or skills based training on sexual risk reduction,
especially as related to HIV risk in the context of drinking alcohol, 2) distribute condoms in formal and
informal drinking venues, 3) refer patrons to alcohol treatment and/or social services as appropriate, such
as HIV/AIDS care and treatment, and 4) provide information on prevention for positives on the relationship
between alcohol and adherence to ARVs.
(d) Acting as liaison between CDC GAP, DHAP and stakeholders in Mozambique to facilitate technical
assistance for the implementation of an assessment or study of MSM, including HIV prevalence and related
Activity Narrative: risk behaviors
(e) Adapting and piloting other outreach activities for sex workers and enhancing the capacity of NGOs
based on models provided by the I-RARE-based experience of countries such as South Africa.
(f) Ensuring ongoing advocacy work and promoting collaboration among stakeholders, including MoH, and
other USG partners.
(g) Establishing a bar owner's association, encouraging them see the value in keeping their patrons healthy
(setting up condom vending machines on site, allowing outreach workers to operate there, etc.)
As implementation moves forward for MARPs, there will be regular, ongoing coordination with organizations
already working in these areas to ensure that no overlap of project activities will occur.
Continuing Activity: 15799
15799 15799.08 HHS/Health University of 6417 3583.08 I-TECH $250,000
Table 3.3.03:
This activity has been receiving funds from Adult Treatment Program Area and for 2009 will receive funds
from Sexual Prevention Program Area as well.
Now, there is a change of funding mechanism, from AIHA to I-TECH
Activity unchanged from FY08. Instead of AIHA, I-TECH through its technical partner UCSF, will continue to
implement
Positive Prevention (PP) programs in the Maputo, Sofala and Zambezia Provinces in Mozambique. In
2006, AIHA developed and initiated a partnership between the University of California, San Francisco
(UCSF) and two HIV/AIDS service sites in the Maputo Province: Namaacha Health Center and Esperanca-
Beluluane VCT Center. Since 2006, partners have joined efforts to conduct and develop programs and
interventions, specifically targeting the clientele at each site. Working under the assumption that the
patientprovider
relationship contains vast opportunities to carry-out HIV transmission interventions, partners
developed provider and patient specific goals and objectives to track behavior changes in both populations.
The goals of the intervention are the same: both the health care providers from Namaacha Health Center,
and community based workers and PLWHA support group members fromBeluluane-Esperanca VCT Center
develop skills to address the prevention needs of HIV-infected individuals accessing their services or
participating in PLWHA support group activities. This includes discussions about:
HIV risk behavior (risk reduction techniques)
Encourage partner testing
Counseling and support
How to disclose HIV to partners and family members
How to produce or maintain healthy families
Individualized prevention plans and risk reduction techniques
Currently this program is in the scale up phase to provide healthcare workers at the facility-based sites and
PLWHA and counselors at the community-based sites with competencies, comfort, and skills to discuss risk
behavior, risk reduction techniques and prevention needs, thereby decreasing HIV transmission, and
encourage HIV testing (including partner testing). During FY07, in collaboration with MOH, Provincial Health
Directorate, and other stakeholders, CDC and UCSF staff identified additional sites to expand the
intervention to two provinces with high prevalence, Sofala and Zambezia.
In FY08, the partnership focused on the completion (including piloting) of training materials and developing
an intervention package (including a toolkit) designed and developed through the work at the above sites, to
make these materials available for other sites and partners in Mozambique to develop Positive Prevention
(PP) programs.
During FY08 the technical partner organized a pilot training using PP curriculum developed to be used by
the partners to train various providers and counselors to develop their own individual PP programs and
prevention messages tailored to the specific site. The PP curriculum was piloted to obtain input from health
care workers, including counselors and the materials were revised to include the feedback from the pilot.
The materials are used by partners to train other organizations in Mozambique.
With FY09 funds the project will expand the Positive Prevention activities, by conducting a TOT training for
trainers, counselors, program managers and staff for 22 community-based prevention staff (2
staff/province); dissemination of materials to organizations participating (i.e. training materials, PP toolkit,
job aids, flip charts, IEC materials etc.), and disseminate the materials to organizations participating (i.e.
training materials, PP toolkit, job aids, flip charts, IEC materials etc.)
In addition, FY09 funds will be used for expansion of FY08 Twinning Partnership and capacity building for
Mozambican PLWHA and Women's Rights Organizations (Starting with one organization in FY08, adding 1-
2 in COP09)-Previously under treatment, but moved to prevention with broader scope, in line with team
discussions - Southern Prevention Initiative to strengthen the partnership with the International organization,
Women Organized to Respond to Life-Threatening Diseases (WORLD) and the identified Mozambican
Women Association/women support group, to assist prevention projects targeting women and women
empowerment opportunities (through either small subgrants and/or procurement of items needed and
identified by the group seeds, T-shirts, transport funds to the ARV Treatment Centers).
Measurable project outcomes consist in tracking behavior changes in WLWHA and direct service providers
and implementing and managing M&E systems and tools to monitor outcomes. It is anticipated that 75
individuals (both service providers
and women) will receive PP training and support.
Goals
The initial focus areas, include the following: (a)To increase the knowledge and skills of WLWHA,
counselors and
peer educators/activists to address prevention counseling, adherence counseling, disclosure of HIV status,
partner notification and risk reduction techniques; and (b)To increase the capacity of support group
participants to organize group discussion, meetings, facilitate groups, address specific issues such as
stigma and discrimination, positive living, encourage partner testing.
Deliverables and Products:
Number of Twinning Partnership and capacity building with Mozambican PLWHA and Women's Rights
Organizations buided
Number of PP Facility Based Program Managers, Trainers, Counselors and Staff trained, including
provision of a kit of PP toolkit for the community-based prevention staff
New/Continuing Activity: New Activity
Continuing Activity:
ACTIVITY UNCHANGED FROM FY2008
According to a WHO working paper (Key Elements in HIV/AIDS Care and Support,2002) major barriers to
implementing the key components of palliative care and treatment often stem from systemic, organizational
or policy shortcomings. These include: Low priority of HIV care within national health budgets; lack of
investments in building infrastructure; insufficient remuneration and support for care professionals; loss of
staff due to high HIV-related mortality and morbidity; shortages of relevant HIV information and HIV training
opportunities; irregular and inadequate supplies of drugs, reagents, and equipment; and lack of essential
drug lists and drug procurement not adapted to needs of people with HIV/AIDS.
USG policy suggests that addressing the needs of the infected-including treatment of sexually transmitted
infections and opportunistic infections-should be a fully integrated component in any care system that
emphasizes patients' quality of life by ensuring symptom control and supportive therapies combined, when
possible, with disease-specific therapies. (Foley, Aulino, & Stjernsward, 2003).
Yet there are many barriers to providing sex workers and drug users with needed diagnosis and treatment
of STIs and other opportunistic infections. These barriers range from serious financial limitations of both the
government and of families to stigma and social barriers associated with HIV/AIDS and the behaviors of
these populations. Since treating STIs and opportunistic infections are a crucial component of every
comprehensive AIDS strategy, results from a qualitative assessment (I-RARE) supported by USG FY06/07
funds, will be used to determine how at-risk or infected sex workers and drug users access to services
providing HIV and STI screening and treatment can be improved.
FY08 funds are being requested to support the University of Washington and its partner Global Health
Communications (GHC) to work with local civil and governmental stakeholders to consider Mozambique's
capacity to provide STI and HIV screening, early diagnosis and treatment to sex workers and drug users.
Activities proposed for support in Mozambique include:
(a) Directing the analysis of I-RARE data to address STI and OI needs among sex workers and drug users;
(b) Supplementing I-RARE findings with other government and NGO/CBO information about referral to, and
access and uptake of, screening and treatment services within Mozambique's sex worker and drug using
populations;
(c) Coordinating a review of successful practices in other countries in the region that have dealt with the
particular challenges specific to
hard-to-reach populations such as sex workers and drug users in creating and sustaining access to STI and
OI testing and treatment; and
(d) Organizing and facilitating a workshop in which Ministry of Health (MOH), other Mozambican
stakeholders and technical assistance from USG and elsewhere develop recommendations, guidance, and
activities that promote the referral, screening and treatment of STIs and OI among sex workers and drug
users.
Continuing Activity: 15804
15804 15804.08 HHS/Health University of 6417 3583.08 I-TECH $75,000
Table 3.3.08:
The reprogrammed funds ($757,520) wil be spend through new funding mechanism, pass-through I-TECH
I-TECH through its technical partner UCSF, will continue to implement Positive Prevention (PP) programs in
the Maputo, Sofala and Zambezia Provinces in Mozambique. In 2006, AIHA developed and initiated a
partnership between the University of California, San Francisco and two HIV/AIDS service sites in the
Maputo Province: Namaacha Health Center and Esperanca-Beluluane VCT Center. Since 2006, partners
have joined efforts to conduct and develop programs and interventions, specifically targeting the clientele at
each site. Working under the assumption that the patient-provider relationship contains vast opportunities to
carry-out HIV transmission interventions, partners developed provider and patient specific goals and
objectives to track behavior changes in both populations. The goals of the intervention are the same: both
the health care providers from Namaacha Health Center, and community based workers and PLWHA
support group members from Beluluane-Esperanca VCT Center develop skills to address the prevention
needs of HIV-infected individuals accessing their services or participating in PLWHA support group
activities. This includes discussions about: HIV risk behavior (risk reduction techniques)
Currently this program is in the scale up phase to provide healthcare workers at the facilty-based sites and
make these materials available for other sites and partners in Mozambique to develop PP programs.
prevention messages tailored to the specific site. In addition, project implementers developed partner
opportunities with the International organization, "Women Organized to Respond to Life-Threatening
Diseases" (WORLD) and a TBD Mozambican Women Association to create prevention projects targeting
women and women empowerment opportunities. Partners explored the collaboration opportunities with a
nascent Mozambican treatment literacy organization (MATRAM) to incorporate PP messages into their
activities. This initial exploration is expected to lead to strengthening of partnership in the subsequent year
(FY09).
In FY09, as a continuation of activities, additional PP activities will include disseminations of the PP
curriculum, train master trainers, conduct ToTs for facility based care and treatment program managers and
staff including the provision of PP toolkits to staff and participating organizations; a PP ToT for community
based care and treatment program managers and staff targeting national NGOs and CBOs -1 Training for
18 staff from Clinical Care & Treatment partners (3 staff/agency) and 1 Training for 18 staff from
HBC/community care partners (10 ANEMO trainers, 3 Ministry trainers, 5 staff from bigger international
Home Based Care Partners); and an exchange study tour for PP implementers in-country to visit other PP
sites to establish close collaboration among all sites. Partners will continue to support existing PLWHA
groups through either small sub-grants and/or procurement of items needed by the group (e.g. seeds,
Tshirts,
transport funds for treatment follow up, etc).
Partners will continue the collaboration and supporting opportunities with the Mozambican treatment literacy
organization (MATRAM) to incorporate PP messages into their activities at the community level.
Measurable project outcomes consist in tracking behavior changes in PLWHA and direct service providers
and implementing and managing M&E systems and tools to monitor outcomes. It is anticipated that 195
individuals (both service providers and individuals) will receive prevention with positives training.
Although continued specific partnership objectives are jointly developed by both partners with input from
MOH, and CDC Mozambique initial focus areas, based on the technical partner (UCSF) experience so far,
will include the following: (a)To increase the knowledge and skills of healthcare workers, counselors and
PLWHA peer educators to address prevention counseling, adherence counseling, disclosure of HIV status,
partner notification and risk reduction techniques among PLWHA; (b)To increase the capacity of staff and
PLWHA peer educators at the PP program sites to monitor and evaluate PP activities; and (c) To increase
the level of PLWHA patient monitoring/surveillance in conjunction with PP activities.
In FY09, continuation of support and activities for the selected sites in Maputo, Sofala and Zambezia
Provinces including support for the PLWHA support groups, through either small subgrants and/or
procurement of items needed and identified by the groups (seeds, T-shirts, transport funds to the ARV
Treatment Centers). In FY09 continuation and scale up of PP ToT trainings for the clinical care partners
staff, home based care and community care partners, Mozambican PLWHA organizations or groups;
and implementing and managing M&E systems and tools to monitor outcomes. It is anticipated that 130
individuals (both service providers and individuals) will receive PP training.
Activity Narrative: Deliverables and Products
Number of sites supported and activities developed in the demonstration sites (Maputo, Zambézia and
Sofala Provinces) and number of existing PLWHA groups supported
Number of staff trained from Clinical Care & Treatment partners
Number of staff from HBC/community Care partners ( ANEMO trainers, MOH trainers, staff from bigger
international HBC partners)
Number of staff from Mozambican PLWHA Organizations or groups trained and received some mentorship
on PP with these organizations
M&E for scale -up of PP activities: (1) Routine monitoring of basic process indicators (e.g. # partners
involved, # sites, # staff trained); (2) Program evaluations (TBD, possibly annually)
Collaboration with MATRAM, by integrating PP messages in the treatment education/literacy activities
Number of exchange visits between PP sites in Mozambique
Table 3.3.09:
ACTIVITY UNCHANGED FROM FY2008 - NO NEW FUNDING IN FY09
Summary:
I-TECH has been committed to providing technical assistance to the Ministry of Health in support of their
ambitious HIV program expansion plans. ($1,686,000)
In 2008, in partnership with MISAU, I-TECH will establish a training center in one of the MISAU / PEPFAR
focal provinces (Sofala, Zambezia or Nampula, TBD), linked with one of the Ministry's pre-service training
centers. The new training center will offer a range of training support services to the Mozambique and will
establish a link between pre- and in-service trainings.
In COP 08, I-TECH will continue its support to MISAU through the provision of technical assistance and
training to conduct a number of critical HIV-related initiatives, including the rollout of a Pediatric ART course,
country-wide; validation research related to opportunistic infections; and the development of a pre-service
curriculum for TdM, including, for the first time, HIV-related topics in the course.
I-TECH's COP 08 objectives are as follows:
Objective 1: Provide training and support to mid-level health workers in the provision of ART and PMTCT
services
Objective 2: Increase the capacity of mid-level practitioners to provide pediatric ART services
Objective 3: Provide support for OI validation research
Objective 4: Provide technical support to MISAU in the development of the TdM pre-service curriculum
services. In 08, I-TECH will establish a training center in one of the priority provinces (Sofala, Zambezia or
Nampula) in order to better support a range of training services in the region.
Activity 1.1. In a selected province, work with the training institute, provincial training unit, NGO partners,
clinics and hospitals to establish a training center with a regional focus, which would offer a range of training
services, for example, refresher courses for clinicians; trainings for trainers and mentors on a range of HIV-
related topics; and workshops on curriculum development and training methodology. The center would link
pre-service and in-service activities, and didactic and hands-on training.
Activity 1.2. Provide individualized capacity building assistance to training partners in assessing, planning,
organizing, implementing and evaluating HIV-related training activities through assistance from specialists
based at the center.
Objective 2: Increase the capacity of mid-level practitioners to provide pediatric ART services. In 2008, I-
TECH will assist MISAU in rolling out the pediatric ART in-service course for mid-level providers country-
wide.
Activity 2.1. Revise the pediatric ART curriculum and training materials based on the pilot course evaluation.
Activity 2.2. Plan, coordinate and facilitate the national roll-out of the Pediatric ART training: conduct two
national Training of Facilitators courses for MISAU trainers (2 facilitators per province); facilitate one training
per province (x 11 provinces) with MISAU trainers. Conduct training evaluations; adapt materials as
appropriate.
Objective 3: Provide support for OI validation research through the development of a validation proposal,
and pilot of the OI component of the Basic Course on HIV.
Activity 3.1. Serve a supportive role (TBD) in the implementation of 07 proposal for validation research
related to the opportunistic infection (OI) guidelines.
Objective 4: Provide technical support to MISAU in the development of the TdM pre-service curriculum. In
2008, I-TECH will provide technical assistance to MISAU to support them in the management of the phased
development of the TdM pre-service curriculum, envisioned to be a multi-year project.
Activity 1: I-TECH will assist MISAU's Training Unit and Technical Working Group to lead and manage a
phased approach to expanding the course outline by developing the content of the TdM pre-service course,
first prioritizing prerequisites needed for HIV and related courses. I-TECH will collaborate and/or
subcontract with international or regional training institutions to develop the course content. The amount of
course material able to be developed will depend on depth/complexity of a standard module (TBD).
Funding may include related costs of the working group.
.
This activity sheet also proposes funding ($50,000) for the following activities: The MoH currently provides
its workers with free ARV treatment and, according to the MoH, as of May, 2007 ARVs were available in
146 sites covering all 128 districts of Mozambique (and all ARV service sites are integrated with counseling
and testing services). As with accessing other HIV-related services, however, it is unclear that among HIV-
infected and eligible health workers uptake of, and adherence to, ARVs is at an optimal level and what
could be done to improve this situation. 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 treatment. These concerns present significant barriers for
health workers to accessing ARVs but it is unlikely that increased access to ARV services can occur without
both a clearer understanding of service-seeking behavior and subsequent efforts to address informational
and behavioral gaps. This understanding will be based on the quantitative and the qualitative health
workers studies currently being undertaken and supported through FY06/07 funds. FY08 funds are being
requested to support the University of Washington and its partner Global Health Communications (GHC)
with experience in the successful development and evaluation of Behavior Change Communication (BCC)
interventions in the African context. Activities that this partner will support in Mozambique include:
Activity Narrative: (a) Providing technical assistance to MoH in applying quantitative and qualitative assessments to the task of
BCC intervention design with the goals of improving access to ARVs, facilitating uptake of ARV services,
and promoting adherence to ARV regimes;(b) Guiding the development and piloting behavioral and
educational interventions focused on issues of ARV access and adherence; and (c) Assisting MoH in
evaluating pilot interventions relating to ARV access and adherence.
(b) Guiding the development and piloting behavioral and educational interventions focused on issues of
ARV access and adherence; and
(c) Assisting MoH in evaluating pilot interventions relating to ARV access and adherence
Continuing Activity: 13218
13218 8806.08 HHS/Health University of 6417 3583.08 I-TECH $1,736,000
8806 8806.07 HHS/Health University of 4941 3583.07 I-TECH $680,000
Activity unchanged from FY08:
This narrative describes Counseling and Testing (CT) actvities related to two areas, namely the support to
the Ministry of Health (MoH) to develop CT activities for health workers ($40,000) and the most at risk
populations (MAPRS) ($60,000).
FY08 funds were used for the following activities:
(a) MOH: Support development of materials and interventions targeting health workers to increase
Counseling and Testing (CT) uptake and partners counseling among health workers. 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.
One area that the MoH has singled out for special attention is that of counseling and testing (CT).
Considered a "gateway" behavior, CT and determination of serostatus is prerequisite to many other
behavioral efforts. Mozambique currently offers free counseling and testing services available at 334
centers throughout the country. Although it is presently unknown how many health workers themselves
have undergone testing and counseling, analysis of data gathered as part of a quantitative survey in 2007
will provide a much clearer picture. 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.
FY08 funds are being used to support Global Health Communications (GHC) to assist the MoH team to
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 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 mobile units for counseling and testing are being piloted. The
technical assistance provider is working 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
training.
A priority area singled out by MOH for special focus is counseling and testing (CT) FY 09. As perhaps the
most significant "gateway" behavior, CT and determination of serostatus is prerequisite to many other
behavioral and educational efforts. Mozambique currently offers free counseling and testing services
available at 334 health centers throughout the country and free testing is, technically, available to all health
workers. The BANK (Behavior, Attitudes, Norms and Knowledge) study and other data gathering has
provided greater insight into relatively low testing uptake. Similar to what was found in FY08 visits to
Tanzania and Botswana, the confidentiality of information and fears of discrimination within one's work
environment are major concerns for health care workers wanting 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 changing both attitudes towards HIV status and creation of a system in
which health workers can seek confidential testing and counseling away from their workplace.
FY09 funds will be used to identify in collaboration with MOH, appropriate methods to increase CT uptake
among health workers and their partners, assist in reducing risk behaviors, and design and pilot
interventions in line with the MOH/Stakeholder/CDC sponsored meeting in late FY08. It would also be
desirable to create an HIV+ network of health workers who can offer peer support at workplace. Finally, the
partners will assess whether materials/teaching aids, provide multi-faceted narratives that encourage health
workers to identify and overcome barriers to counseling and testing. Activities to be supported in FY09
include:
(a) Conduct of an in-depth review of workplace counseling and testing programs in Botswana and Tanzania
and possibly other countries in the region to analyze activities currently undertaken in those countries with
an eye towards how successful elements can be recombined and applied to the Mozambican context. Initial
visits in FY08 have provided the foundation for these more targeted visits;
(b) Continue to provide technical assistance to MoH in applying BANK survey findings and the
accompanying qualitative assessment to the task of designing behavioral and informational interventions
with the aim of increasing counseling and testing uptake;
(c) Develop behavioral and educational interventions focused on counseling and testing issues, using ideas
drawn from small groups of health workers and health institute students who will be trained in prevention
strategies and simultaneously encouraged to identify means to improve the uptake of counseling and
testing;
(d) Create and support a network of HIV+ health workers to lead and facilitate discussion groups, offer
personal stories regarding the importance of Counseling and Testing (CT), establish peer support to help
people through the entire CT process seeking to counter stigma.
(e) Train local organizations and stakeholders to implement MoH recommendations for counseling and
testing.
Deliverables:
1. A detailed structural review proposing how elements of regional CT programs for health workers can be
applied to Mozambique. The report will examine the intrastructural, policy, and financial cost of these
elements and anticipate problems with adapting them to the Mozambican context.
2. A set of reports suggesting how the BANK (Behavior, Attitudes, Norms and Knowledge) study and
subsequent qualitative research might shape MoH CT priorities.
Activity Narrative: 3. The workshop/training curricula in which BANK and qualitative study findings are introduced to MoH and
other stakeholders and a written report of the CT intervention design outputs created as a result of these
meetings. Outputs will include activities to establish a system whereby individuals can priority test at
neighboring clinics rather than their home clinics. Rosters of all training participants will be submitted.
4. All workplans and reports on the piloting of activities that arise out of MoH workshops described in #3
above.
5. Roster and organizational chart of a network of self-identified HIV+ health workers willing to be trained to
participate in health center activities (e.g., buddy systems, discussion groups using health worker videos,
etc.) and advocate CT uptake.
6. The curriculum and materials used to train HIV+ health workers to perform the role indicated in #5 above
along with the roster of trained health workers.
(b) MARPS:
Sex work in Mozambique is driven largely by the lack of employment opportunities, and facilitated by the
demand of migrant and mobile laborers, as well as members of the general population (World Vision, 2005).
Young women are at particular risk; the age of sexual debut in Mozambique is low (15.4 years) and the
mean age for women entering sex work is 17.8, with an age range of 9-28 years (World Vision 2005). While
the extent of drug use among sex workers is not known, a 2004 survey reported that 13% (15/111) of
female sex workers used drugs, including cocaine, up from 7.4% in 2002 (World Vision 2005). Another
study has documented drug dealers as frequent clients of sex workers in the Maputo corridor area (Wilson
2001). These factors indicate that the potential for increasing drug use among sex workers and mixing of
sex worker and drug using populations exists, and may serve to spread HIV further into the general
population. In response to this situation, Mozambique's International Rapid Assessment Response and
Evaluation (I-RARE) has been designed to better understand, assess, and make recommendations for how
to respond to rapidly changing sexual risk and drug using patterns that increase vulnerability to HIV
infection among sex workers and drug users in three cities in Mozambique, Maputo, Beira, and Nacala
Porto, Mozambique. One of the foci of this assessment is the identification and description of the range of
available counseling and testing (CT) services for sex workers and drug users as well as the understanding
of the personal, social, and environmental barriers that sex workers and drug users perceive as inhibiting
access to CT services. Service providers' perspectives on CT availability and access are also important,
and this activity is aimed at assisting them in making CT services more desirable and convenient. FY 09
funds are being requested to continue to undertake the development, implementation and evaluation of
prevention activities relating to at risk populations. Activities that this partner will support in Mozambique
(a) Supporting local partner in developing outreach programs and possibly bar and other drinking venues
where alcohol consumption and sexual mixing may present opportunities for targeted CT interventions. In
addition to CT, such interventions may deliver a range of informational and behavioral content. This activity
may also include reviewing models of CT processes and procedures based on the South African rapid
assessment experience;
(b) Developing outreach programs for most at risk populations including the use of narrative strategies that
elicit ideas for interventions with sex workers and drug users. Subsequently, the piloting of CT-related
activities that NGOs/CBOs deem to be sustainable.
Continuing Activity: 15800
15800 15800.08 HHS/Health University of 6417 3583.08 I-TECH $125,000
Table 3.3.14:
USG Mozambique works closely with the Mozambican Ministry of Health (MOH) to support Health
Information Systems. The current system, Modulo Basico, requires upgrading but due to key staffing
vacancies at MOH, there is inadequate technical input and no clear strategic plan for upgrading or replacing
this system. The University of Washington through ITECH completed an assessment of the status of
Modulo Basico with PEPFAR funding and technical oversight from from CDC in 2008. The MOH has
requested continued assistance on this issue as they determine the way forward for the national health
information system. This activity is consistent with the priorities of the USG Strategic Information Technical
Working Group and with the Mozambican Ministry of Health. Activities will include technical assistance to
MOH in determining system and programmatic needs, selection of appropriate contractors for design and
implementation of an upgraded system, and integration of existing program-specific information systems
and databases into the national system.
Table 3.3.17:
ACTIVITY UNCHANGED FROM FY2008 (No new funds for FY09)
This PHE activity, "Assessment of integration of graduates from Health Training Institutes into the national
health system", was approved for inclusion in the COP. The PHE tracking ID associated with this activity is
MZ.08.0092.
PARTNER: I-TECH/University of Washington
NEW PHE: CDC and the Mozambican Ministry of Health (MOH) support an evaluation of graduates of
Health Training Institutes who were hired and those who were not hired through the national health system.
Title: Assessment of integration of graduates from Health Training Institutes into the national health system.
It is anticipated that this assessment will take 9 months total with a budget of $200,000.
Local co-investigator: Dr. Martinho Dgedge, National Human Resource Director for Training of the Ministry
of Health. Dr. Dgedge will collaborate in designing questionnaire and sampling framework, and supervising
the assessment
Project Description: The problem that the public health care system is facing is an insufficient number of
health care workers entering the health care system. To address the acute need for trained health workers
to respond to the HIV epidemic, an Accelerated Training Plan was developed in 2006 by the MOH Training
Department and is being implemented by Health Training Institutions in all provinces. It is expected that, as
a result of the plan, by 2010, there will be 8,106 graduates at the basic and middle levels. As the number of
new health workers are available for hire will dramatically increase, it is important that other measures are
taken at national and provincial level in order to ensure that those graduates (as well as existing workers
who have upgraded their skills) are able to be absorbed by the national health system.
Evaluation questions:
Primary question of this assessment is: What percentage of recently graduated students are incorporated
into the national health system?
Secondary questions are:
• Were all the graduating students from the IdF assigned from the central level to provincial health
directorates?
• Of those students assigned to the provincial level, what percentage accepted these positions and reported
for work?
• What factors influence the assignment and hiring processes at central and provincial levels?
Methodology: The assessment will consist of two parts: 1) a compilation of data regarding the number of
graduates (from the last two years) who were assigned to provincial positions by the National Human
Resource Directorate, and a comparison of this data with employment data from the Human Resource
Departments at the provincial level; and 2) interviews with a sample of health workers who have graduated
and started to work in the last two years (as well as those who chose not to accept their assignments);
interviews with key staff from Human Resources at the central and provincial levels. A structured
questionnaire will be prepared with closed and open-ended questions. Questionnaire data and participation
will be confidential. The assessment period will take place over approximately 6 months. A purposive
sample of graduates will be generated using the list of recently graduated students and by consulting with
provincial and local health authorities where the graduates work. One province per region (three total) will
be sampled so that results will be more generalizable. Informed consent will be obtained from all
participants: graduates, Human Resources staff and other key provincial authorities.
Population of interest: The primary population of interest is health workers who have completed their studies
at the Health Training Institutions during the previous two years.
Information dissemination plan: Assessment results will be presented to the Ministery of Health by meeting
with key individuals from the following directorates: Human Resources, Planning and Cooperation, Medical
Assistance authorities, as well meeting with provincial health leadership. Results of the evaluation will
contribute towards the design of new strategies and interventions related to the assignment and hiring of
recent graduates.
Budget justification
The main cost of the assessment will be for:
Salaries/fringe benefits: $100,000 for public health evaluation staff including: consultant, logistician, data
collector, data entry staff and interviewers
Training and supplies: $10,000 data collectors, interviewers, data entry clerks
Material: $10,000 questionnaires, items for interviewers
Travel: $44,000 US/Mozambique and Mozambique internal travel to the provinces, MIE, lodging
Other: $36,000
Total: $200,000
Deliverables/benchmarks:
• Reasons why all newly graduated health workers are not being absorbed into the health care system
identified
Continuing Activity: 15803
15803 15803.08 Department of To Be Determined 8865 8865.08 New PHEs
State / Office of
the U.S. Global
AIDS Coordinator
Table 3.3.18:
During the FY09 COP activity period, I-TECH will implement a number of activities which are natural
progressions from the previous COP years, and which are predominantly national in scope. The overall
goal of all of the activities is to strengthen the training capacities of the Ministry of Health at the national and
provincial levels so that the country's training institutions can graduate an increased number of, and more
competent, health care workers.
The primary target population in this program area is Mozambique's mid-level health worker, or tecnico de
medicina (TM), although nurses, Mozambican physicians, and agentes are also targeted in some activities.
The following paragraphs provide brief summaries of the planned activities, all of which have a particular
focus on strengthening the national capacity to ensure more accessible health care, while decreasing the
country's dependency on external resources. Although all of these activities fall into the Systems
Strengthening program area, each activity also intersects with other PEPFAR program areas and thus will
be explained by each PEPFAR program area.
ACTIVITIES and EXPECTED RESULTS
ACTIVITY 1: Adult Care & Support - OI Course Revision: over the past 6 months, I-TECH has been
working with the Ministry of Health and partner organizations to develop a clinical mentoring program for
TM, wchich includes new OI algorithms and training content. The content was approved by the MISAU
Therapeutic Committee in September 2008 and is scheduled to be pilot in Zambezia province in November.
After the material has undergone final revision, I-TECH will adapt it for Nurses and Agentes de Medician
and insert it into the Basic Course on HIV. I-TECH will work with a partner organization to conduct a pilot
training for 15 nurses or agentes, do a final revision of the material, and submit it to MOH for approval.
Once the curriculum has been approved, I-TECH will conduct a Training of Trainers for a minimum of 10
MISAU-selected trainers.
ACTIVITY 2: Adult Treatment - Clinical Mentoring of TM on Adult ART: In partnership with the Ministry of
Health's National Directorate for Medical Assistance (DNAM), I-TECH will roll out a clinical mentoring
program for TM in Zambezia and possibly one or two other provinces (TBD), likely Sofala and Cabo
Delgado. The program will initially be piloted in Zambezia, where Vanderbilt University's Friends in Global
Health Program, Columbia University's ICAP, and I-TECH are partnering on the pilot and subsequent roll-
out of the provincial program. In Sofala, the primary implementing partner is being recompeted via a RFA
by USAID. The objective of the mentoring program is to provide ongoing on-site technical assistance to the
TM to improve their technical knowledge and clinical capacity to provide adult ART. The first step in the
process is a five-day course to train ART-experienced physicians (both expatriate and Mozambican), TM,
and selected pre-service health training institute teachers, as mentors. Subsequently, a two-week intensive
HIV course for TM will be conducted, which is based on the clinical gaps documented in the 2007 clinical
evaluation of TM. The training will introduce the clinical algorithms developed by I-TECH and approved by
the National Therapeutic Committee. The TM course will include classroom training as well as mentored
rotations in the provincial hospital. Upon completion, TMs will return to their sites where they will be
mentored by one of the program-trained mentors for one week per month for a minimum of six months. The
Zambezia pilot will provide the basis for any revisions of the training materials. The program will be closely
monitored as it is being implemented An anticipated 24 mentors and 48 TM will be trained and mentored
over the year. I-TECH has placed an experienced Clinical Advisor in DNAM to provide specific TA on
implementing and monitoring the CM program.
ACTIVITY 3: Adult Treatment- ATOMM (AIDS, TB, OIs, Malaria, Malnutrition) short course: In 2007, I-
TECH developed a course focused on AIDS, TB, Opportunistic Infections, Malaria, & Malnutrition
(ATOMM) that was intended to provide HIV content for newly graduated TM. Course implementation had
been stalled due to the lengthy MISAU approvals process, but it appears that the content has been recently
approved. The ATOMM course will be competency based, and developed from a combination of the
original ATOMM content submitted to MISAU in 2007, the materials developed in the Adult CM program,
and some content from the original Adult ART course. In 2009, the course will target newly graduating TMs
from the provincial health training institutes (ICS)), while being incorporated into the TM 30-month pre-
service course. I-TECH anticipates training 150 TM with this new curriculum, which will be evaluated and
revised, based on the first ‘pilot' roll-out of the course. An important second component of this activity is the
training and coaching of ICS teachers (docentes) to slowly assume teaching of the ATOMM course. A
small number (5) will be trained in the first year by attending the first ATOMM trainings; by conducting a
training of trainers to review the main objectives, content, and teaching approach of the course; and by
having the selected docentes gradually assume responsibility for teaching the course in preparation for the
next phase, when the content will be fully integrated into the revised pre-service curriculum.
ACTVITY 4: Adult Treatment - Integrated Provincial Support in Zambezia: In coordination with Vanderbilt
and pending funding availability, I-TECH may place a trainer and a technical advisor in the province to
provide technical support to the provincial pre-service health training institutes and in-service training
partners, the model practicum site in the district of Ile, and the on-going CM program, all with a focus on
strengthening TM knowledg
Continuing Activity: 13219
13219 5241.08 HHS/Health University of 6417 3583.08 I-TECH $1,580,000
8802 5241.07 HHS/Health University of 4941 3583.07 I-TECH $1,457,485
5241 5241.06 HHS/Health University of 3583 3583.06 I-TECH $400,000
Estimated amount of funding that is planned for Human Capacity Development $717,000
Estimated amount of funding that is planned for Education $717,000
FY07 COP activity number linked to PHE project : 8802
Title: Targeted Evaluation of ARV Training Course in Mozambique.
Time and money summary: this is a 07 COP activity, expected to be complete in early 2008; original budget
request in 07 COP was $88,000; we now estimate that $100,000 will be expended on the actual evaluation.
No funds are requested in 08 COP for the evaluation, but rather follow-on activities, to include the revision
of the TARV course (see below).
Local Co-investigator: several individuals at the MOH's National Department of Medical Assistance are
involved in this project, headed by Dr. Americo Assan
Project description: CDC and the Mozambican Ministry of Health (MoH) supported a new course to teach
Mozambican mid-level health practicioners (tecnicos de medicina) to prescribe and manage active
anetiretorviral therapy (ART) for HIV patients. The two-week course includes classroom and practical
components. The primary purpose of the evaluation in 2007 is to assess to what extent course graduates
adhere to the guidelines taught in the course once they return to their work sites. Secondary questions are:
Do course guidelines address the clinical questions most commonly encountered by the graduates? Are
the guidelines learned by the graduates consistent with other guidelines currently in force in their work
sites? Are the course graduates' working conditions conducive to guideline adherence? The anticipated
outcome is a series of recommendations for revision or updating of the course curriculum, clinical
guidelines, and/or post-course support and supervision systems. The study design will incorporate
structured observation of course graduates as they attend patients in their usual work sites. The study will
use two instruments, one for HIV-infected patients not yet on HAART and one for patients already on
HAART. The structured observations will be supplemented by brief semi-structured interviews with course
graduates and site supervisors. A convenience sample of course graduates will be generated using training
lists and by consulting with provincial and local health authorities where the course graduates work. We will
aim for a sample of 40-50 graduates and will plan to observe one new HIV patient and one patient already
on HAART for each graduate.
Status of study/progress to date: Protocol was initially presented to MOH in November 2006 and approved
by MOH bioethics committee in early July 2007. CDC Atlanta is in the process of reviewing protocol. The
evaluation scheduled to take place in October-November 2007. Data analysis and reporting should be
completed by January 2008. The follow-on activity to this evaluation is the revision of the ARV course based
on the evaluation results, and the design and implementation of two training of trainer courses to roll it out.
The revision of the course was originally included in COP 07, but will likely be carried into COP08 due to
time constraints.
Lessons Learned: to be included in final report
Information Dissemination Plan: The primary audience for the evaluation results is comprised of the
Mozambican Ministry of Health and the institutional partners currently assisting the Ministry in
implementation of public-sector AIDS-related training and patient-care programs. This audience is internal.
However, should the evaluation yield results that might be of interest to other Ministries of Health or
PEPFAR implementers, we would consider presenting them orally (at professional meetings) and/or in
writing (through peer-reviewed scientific journals), depending on the specific nature of the findings.
Planned FY08 activities: Build the capacity of MOH staff and provide them with technical guidance to adapt
and relaunch the TARV course based on the results of the evaluation. The course will be principally used as
in-service refresher trainings for TdMs, their supervisors, and other mid-level practitioners. Conduct 2 TOTs
for implementing agencies to roll out the course.
Budget Justification for FY08 monies (please use US dollars):
Salaries/fringe benefits: $30,000
Equipment: $0
Supplies: $5,000
Travel: $18,000
Other: $12,000
Total: $65,000.
• Final report on ARV Training Course in Mozambique
• Discussion around results and implications for national policy and procedures
Continuing Activity: 15802
15802 15802.08 HHS/Health University of 6417 3583.08 I-TECH $0
In October 2008, the Ministry of Health launched their strategy for Human Resources for Health. While pre-
service is a noted priority, they also are emphasizing strengthening and coordinating in-service activities
nationally. Per request from Ministry of Health Department of Training, ITECH is being requested to support
the development of a National In-Service Training Strategy in conjunction with JHPIEGO. Terms of
reference have been drafted and approved by the Ministry of Health to guide this work.
