The overall goal of I-TECH is to develop a global network that supports the development of a skilled health work force and well-organized national health delivery systems, in order to provide effective prevention, care, and treatment of infectious disease in the developing world. Their focus areas are: health systems strengthening; human resources for health; operational research and evaluation; and prevention, care and treatment of infectious diseases.

In Mozambique, I-TECH works in the areas of in-service and pre-service curriculum design (emphasis on competency based participatory educational methods), strategic planning for health worker education, task shifting, faculty development, clinical mentoring, and information systems. Their activities align with the Partnership Framework goal of strengthening the Mozambican health system including human resources for health and social welfare in key areas to support HIV prevention, care and treatment. The benchmark is number of new health worker graduates by cadre. The geographic coverage is national with emphasis on select pre-service institutions for faculty development activities. The target audiences are government health workers, pre-service students and faculty and implementing partners.

The key contributions to the health system are: continue developing clinical mentoring for maternal child health nurses by evaluating the effectiveness of the program existing; continue working with maternal child health nurses to pilot and evaluate training materials for Mothers' Support Groups and submit finalized training materials to the MOH; complete development of the basic course on opportunistic infections and submit finalized course to MOH followed by 3 regional training of trainers for implementing partner and MOH trainers; continue to conduct combined adult and pediatric clinical mentoring trainings for clinical officers by doing training in remaining 6 provinces followed by intensive on-site support to the mentors; scale up faculty development work by placing 3 staff at 6 pre-service institutions each with the goal of rolling out a new teacher training course and development of pedagogic nuclei per institution; and complete course materials and pilot the new 30 month clinical officer course at 8 pre-service institutions; and conducting 4 week HIV, TB, opportunistic infections, malaria, and malnutrition course for 12 graduating clinical officer cohorts. I-TECH has two sub-partners working on prevention activities funded out of FY 2009 prevention funds, University of California at San Francisco (UCSF) and Global Health Communications (GHC). UCSF is working on prevention with positives and GHC is working on behavior change communication with most-at-risk populations (MAPRs) specifically sex workers, drug users and MSM. Both of these sub partners will be phased out in 2010. This implementing mechanism was funded in 2008 for a PHE on factors affecting recruitment and retention of new graduates from pre-service institutions. In FY 2009, once all human subject approvals were granted, work began on this MOH priority issue. Given the strong emphasis on pre-service education the cross-cutting program is human resources for health. The implementing partner works closely with the MOH's Training Department as they develop national products (i.e. curricula) and systems (i.e. clinical mentoring). The MOH views clinical mentoring as a primary means for maintaining quality assurance and continuing training for clinical officers and nurses so that their skills are up to standard. All of the activities of this implementing partner are ones that will be handed over to the MOH and clinical implementing partners upon completion. In terms of organizational staffing, this implementing partner has developed a timeline for mentoring Mozambican staff to move into each position that is currently held by an expatriate.

M & E plans are a required component of each I-TECH activity and include process (i.e., draft curriculum piloted), output (i.e., numbers trained), and outcome indicators (i.e., measureable improvement in quality of HIV care provided by clinical officers). Prior to any training program, each curriculum undergoes a rigorous evaluation that consists of an external clinical review (by a pre-tested Portuguese-speaking clinical expert) followed by a review of language and cultural appropriateness, and finally a pilot training using the draft curriculum. The pilot process consists of a pre- and post-training knowledge test, focus group sessions with participants, daily evaluations by participants, and daily facilitator meetings. Each pilot is evaluated by a minimum of one Quality Improvement Specialist who reports specific changes needed to the curricula, teaching methodology, presentation of material, and points to stress in a Training of Trainers (TOT) to facilitate the teaching of the material. Follow-up tools such as clinical checklists are often piloted along with the curriculum. All facilitators, participants, and training topics are entered into TrainSmart, a ''next generation'' database

developed by I-TECH headquarters. From this system, I-TECH can easily generate reports of training activities by PEPFAR category, and the cadres trained. TrainSmart can also track the activities of each trainer and note any training specialties that they may have.

I-TECH is the lead training USG partner supporting the MOH in the development of training material in

opportunistic infections (OI) which is a key component in the provision of HIV health care services by

health providers. Other components of the program are carried out by other USG implementing partners.

OI training materials will be finalized and the implementing partner in coordination with the MOH staff will

conduct three trainings of trainers, and provide training technical assistance in six sites and evaluate

training results in three sites. This support will be coordinated with other USG implementing partner

supporting the Provincial/District Health Directorates. Training material content includes various areas

such as management of OI, referral criteria, OI prophylaxis, adherence and ART issues.

On-going activity. I-TECH has been working with the National Directorate for Medical Assistance and

other USG programs and other USG implementing partner to revise the Basic Course on HIV integrating

the opportunistic infections for nurses and medical agents. In 2010, the implementing partner will finalize

the training materials and pilot the material in one site; and will adjust them based on the result of piloting

and submit for MOH approval. It is planned to carry out three regional training of trainers; technical

assistance in 6 sites and evaluate the results of training in 3 sites.

I-TECH supports MOH's priorities as outlined in Human Resources National Development Plan (2008- 2015) in coordination with other USG implementing partners, other donors and bilateral agencies. Specifically activities will be implemented focused on teaching quality and strengthening the training capacities of the MOH at the national and provincial levels to increase the number and overall level of competence of health care workers. This links with service delivery and human resources. These are spillover activities since having better trained clinical officers will benefit overall health outcomes.

One of areas is the development of a new competency based curriculum for clinical officer Tecnico de Medicina (TM) based on the revised scope of practice that includes HIV care and treatment. The new 30 month pre-service course for TMs will be used in government based health training institutions. I-TECH will continue to conduct 4-week course in HIV, TB, OIs, malaria, malnutrition (ATOMM) for an expanded number of graduating clinical officers (TM) from health training institutions in the different provinces. This effort will ensure that graduating TMs are prepared to provide HIV services while the new curriculum is being developed.

Although the need to expand pre-service education is known, there is not enough faculty to support expansion and there is question as to the quality of education provided by faculty who may not have had any preparation for teaching. I-TECH will significantly scale up faculty development efforts to 6 health training institutions and will place staff in each of 4 largest health training institutions and two smaller ones to support the development of more classroom faculty and practicum mentors who can provide education.

I-TECH, with the MOH's National Directorate for Medical Assistance (DNAM) and USG clinical partners, will continue to support the clinical mentoring program provincially. A combined adult and pediatric ART clinical mentoring training will be conducted in six provinces that consists of a 2-week training for mentors and a training in Adult and Pediatric ART to clinical officers. Following training, TMs are mentored at their health facilities and I-TECH clinicians provide 1 week of intensive support to mentors on-site followed up by a visit 3-6 months later.

I-TECH PMTCT activities will be aligned with FY 2010 priorities, focusing on coordination with MOH and scale up of PMTCT services within an integrated MCH system. Objectives include improved quality; access to a comprehensive package including psychosocial support; and expanded training through a clinical mentoring approach.

Key activities for FY 2010 include: 1) PMTCT clinical mentoring for PMTCT nurses: 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. Objectives of the program are to increase and reinforce PMTCT-related knowledge and aptitude of nurses working in the nation's maternal and child health facilities. I-TECH has been collaborating with two USG partners to develop and pilot two different clinical mentoring models. One model consists of the provision of nurses' training via two-week rotations through a PMTCT model center followed by on-site mentoring, while the other model consists of mentor training and subsequent mentoring at "home facility" sites. It is this decentralized model that is likely to be most appropriate for national expansion. I-TECH is presently conducting a baseline assessment to inform revision of training materials supporting theory and clinical practice for potential mentors before they are expected to work with their mentees. In FY 2010, following revisions, the final products will be submitted to MOH for their approval as official MOH documents and made available to all partners and MOH supported sites conducting PMTCT activities.

2) Support groups (Maes para Maes): I-TECH is supporting the national framework and development of an operational guide to provide standardized guidance on how to start and successfully run a support group for HIV positive pregnant women and mothers. 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, and will also encourage community involvement and male participation in HIV prevention services. FY 2010 activities will focus on finalization, approval, and dissemination and roll out of this approach.