The GOM has assigned overall responsibility to the MOH to provide all clinical and medical services for the prevention, care and treatment of HIV and other opportunistic infections. However, physical infrastructure and human resources are severely constrained in the country. In spite of these limitations, the national response to the HIV epidemic has been substantial in recent years and treatment services are now available in every district in the country. Nevertheless, support is still required to maintain these achievements and expand HIV-related services and program quality. While donor support through USG and other agencies provides resources to many partners in Mozambique, the MOH has a unique responsibility for providing basic clinical services for its entire population. Direct support to the public health sector helps to strengthen health systems and promote sustainability. This cooperative agreement offers a framework to provide comprehensive support to the scale-up of HIV prevention, care and treatment services. The scope of this collaboration is thus national in scale. The goals of the HIV response in Mozambique are to increase HIV prevention; improve service quality (i.e. counseling and testing, diagnostics, staging of disease, etc) to then support further expansion; promote all aspects of counseling and testing (community and PICT); engage Health Care Workers (HCWs) by supporting their educational development through a variety of pre- and in-service trainings, encouraging counseling and testing, and providing adequate services; and by further integrating health services to provide a more holistic approach to health. Through these identified priorities, the MOH intends to reach 189,717 patients by the end of 2010.

The purpose of this program is to progressively build an indigenous, sustainable approach to the national HIV epidemic through the rapid expansion of innovative, culturally appropriate, high-quality HIV prevention, care and treatment interventions, and improve linkages and coordination between the national (central) and provincial response to HIV counseling and testing, HIV treatment and care services targeting rural and other underserved populations, and addressing (developing and strengthening) the shortage of human resources.

The USG, through this cooperative agreement, will continue to support the MOH in the areas of PMTCT, other prevention (STIs), Injection Safety, Adult Care and Support, Adult Treatment, TB/HIV and other opportunistic infections, Counseling and Testing, Pediatric Treatment, Laboratory Services, Strategic Information, and Health System Strengthening. The activities included in this CoAg will directly contribute to the five goals of the Partnership Framework: Goal 1: Reduce new HIV infections in Mozambique by getting to know the HIV status and expanding access to confidential HIV counseling and testing; Goal 2: Strengthen the multisectorial HIV response in Mozambique; Goal 3: Strengthen the Mozambican health system, including human resources for health and social welfare in key areas to support HIV prevention, care and treatment goals; Goal 4: Improve access to quality HIV treatment services for adults and children; Goal 5: Ensure care and support for pregnant women, adults, and children infected or affected by HIV in communities and health and social welfare systems.

This activity also addresses wrap around issues such as gender and workplace interventions. As examples, a gender strategy was approved by the Minister, focal points in every directorate were identified and a IEC component is being implemented. Additionally, the USG supported MOH to perform a study on behavior, attitudes and knowledge among health workers regarding prevention, care and HIV treatment that was recently disseminated to provincial health directorates. One of the key finding in the study was stigma and discrimination as key barriers for both health service delivery by health providers and to seek health care by community members and health providers themselves. MOH in conjunction with USG and other donors have created a working group (including participation of MOH:HR, Medical Assistance Directorates, and other donors such as CDC and GTZ. GTZ hired a national coordinator for the Workplace program (WPP) based at the HR Directorate to coordinate activities in this area. A working plan was developed and approved by the MOH. Activities planned address stigma and discrimination, and is looking at gaps regarding to knowledge of HIV related information and bio safety including PEP.

The MOH will continue to work towards development of policies and defining standards of training curricula in order to build the capacity to implement a comprehensive care package which includes prevention and improvement of diagnosis and management of OI screening and treatment of STIs and other HIV related activities.

At central level the MOH, with technical assistance from USG, will continue working towards identification of a suitable organization to strengthen the Mozambican Organization for Palliative Care Association (MOPCA) capacity to implement the palliative care strategy. Also, the MOH in collaboration with USG partners will conduct training, mentoring and supervision at central and provincial levels.

In 2008 USG supported the MOH in Collaboration with MMAS and ANEMO (National Nurses Association) to develop guidelines/tools for HBC activities, such as: operational, supervision and M&E forms, Entry and exit criteria to HBC services, "Where There is no Doctor Manual", revised HBC Manual, and standardized training materials. In FY 2010, the USG will continue supporting the integration of affectivity approach in training of the HBC activist, distribution and supervising the used of these tools.

In 2008 the MOH, in collaboration with the USG, FHI and ANEMO, conducted a HBC quality survey, which shows that HBC programs caregivers are poorly educated women (80%), three fourths of them do not have any income and two-thirds suffered a reduction in household income due to chronic illness. Their main barriers to adherence to ART were found to be: lack of food, motivation, transport, and medicines side effects. Thus, USG will continue to support the MOH in policy revision to improve access quality services as defined by the MOH.

The USG will continue supporting the traditional Medicine Program, after being shifted from National Institute of Health and now become Institute of Traditional Medicine.

The National Directorate of Medical Assistance (DNAM) in the MOH continues to be responsible for monitoring implementation of the HIV treatment program. By August 2009 there were 215 treatment sites providing ART to 157,190 HIV infected adults. During FY 2010, funding provided to the MOH will continue to assist and support 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 ART program. In addition, as part of the Track1.0 transition activity, funds will be earmarked for 4 to 5 provinces to directly implement HIV treatment related activities. A rapid assessment will be conducted to determine which provinces are best suited to begin receiving direct funds.

Central level activities that will be financed with these funds include: Development of tools and guidelines for continuation of ART service integration and decentralization; supervision visits to provincial sites for: ART service delivery, integration and decentralization process, and implementation of the HIVQUAL program; supervision of clinical mentoring activities to assure quality of ART services; dissemination of materials and guidelines for doctors, nurses and physician assistants related to adult service provision; dissemination of ART reports, M&E forms and site supervision tools; training of health workers, provincial and district program managers in the use of M&E forms and supervision tools and ART; participation in exchange visits and conferences for key staff in the DNAM, for clinical fellowship activities, ART program management and quality assurance of clinical and treatment programs.

At provincial level, funds will be used to support the following: in-service training; routine supervision; procurement of fuel, supplies and vehicles maintenance; reproduction and distribution of training materials, monitoring tools, job aides and clinical guidelines; program M&E activities; hiring of staff; minor infrastructure repairs at clinical sites.

Since March 2005, 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 Minister of Health 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, STIs, 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. The same comprehensive approach was adopted in Community-based CT and has been widely promoted and expanded.

FY 2010 funds are planned to support the continuation supervision visits to monitor progress on activities related to the expansion of PICT in clinical settings, community-based CT and the CTH. Special attention will be given to the minimum standards for CT in all modalities and strengthening of activities related to quality of testing and counseling procedures.

MOH is committed to implementing the revised national ART pediatric guidelines, continue to scale-up care and treatment services, and decentralize these services to peripheral health centers, in an effort to improve accessibility and equitability of HIV service delivery, whether at provincial or district level.

Based on MOH August 2009 data, the number of children receiving antiretroviral treatment is still low, 12,204 (7, 2%) of the 169,339 individuals receiving treatment in the country.

The decentralization of HIV care and treatment services will be based on the development of a clear plan for decentralization and integration of HIV services and preservation of specialized centers for complicated cases of HIV. The successful implementation of these activities will be complemented by training of different cadres of health workers, reproduction of materials like guidelines, training manuals and job aids.

The national pediatric technical working group will define the profile of the health facility staff team that will receive and guide the referred HIV infected patients within the exiting patient flow of the health facility to reduce lost of patients.

The MOH will also carry out provincial supportive supervisions to monitor the effectiveness of the HIV program as well as the decentralization process to offer the necessary support. The national pediatric technical working group will define indicators and develop national monitoring and evaluation tools to support these activities. All these will be aimed at improving and maintaining the service quality, ensuring equitable service delivery and retention of patients in care and treatment.

This existing activity reflects a general strategy designed to build and strengthen MOH capacity in strategic information. The MOH has specifically requested USG assistance with surveillance, M&E, information systems, and human capacity development.

Activities will be funded through a combination of Partnership Framework FY 2009 funds (as part of the overarching strategy of strengthening capacity and systems in the MOH in strategic information) as well as FY 2010 funds.

Planned activities will be implemented through several departments within the MOH including the Department of Health Information (DIS), the National Institute for Health (INS) and the National Directorate for Medical Assistance (DNAM); each of these have distinct responsibilities for different strategic information activities.

Areas of emphasis include:

1) Support to the Department of Health Information a. Information systems and standards development b. Strengthen mortality surveillance systems c. Support standards development by supporting the National Standard Commission and its related activities. d. Help formalize, disseminate, and implement MOH "infrastructure architecture" by providing hardware, equipment, and TA support e. Revision of the national data aggregation system (Modulo Basico) and evolution in a national data repository for all the information produced at the local level f. Implementation of the Health Information System for the Hospitals with aggregated data using CID-10 reduced list of morbidity and mortality g. Strengthening Human Resources in Information Systems

2) Support to the National Institutes of Health include training and technical support for antenatal care sentinel surveillance

3) Support to the National Directorate for Medical Assistance includes the implementation of ARV Drug Resistance Monitoring

The USG supports MOH priorities in accordance with the Human Resource Development Plan. This is done in coordination with other USG implementing partners and other donors. The implementing partners will directly contribute to the human resource for health, information system and health service delivery and will ensure that health workers acquire competencies needed to provide high-quality services upon graduation from pre-service institutions.

In 2010, MOH in collaboration with the USG will contribute to the implementation of the quality assurance program for pre-service institutions that will strengthen training capacity of pre-service level. Emphasis will be given to an incentive system for recognition of the best teachers; training faculty from pre-service institutions to increase knowledge and skills in new interventions of the health programs including HIV, STI, Malaria, TB and pedagogic issues and scholarships to get superior level and Master degree for teachers. This will increase faculty motivation and retention at the pre-service institutions.

MOH will continue to support salaries for hired staff who supports the implementation of the information and monitoring system for in-service training as well as pre-service information system while their integration to the national health services takes place. Supervision visits to pre-service institutions and provincial level, and office supplies are supported.

Funds are available for the implementation of the Mozambique Field Epidemiology and Laboratory Training Program (M-FELTP) with major emphasis on trainings, technical assistance and logistic support

Additionally, MOH will focus on the HIV prevention for health care workers activities including faculty and students at the pre-service institutions at the central, provincial and district level. Emphasis is given to trainings, developing and reproduction of training materials for health care workers, IEC materials, supervision and promotion of events for sensitization of HIV prevention, etc.

The goal of the injection safety program is to reduce the risk of transmission of HIV and other blood borne pathogens among health care personnel at health facilities in Mozambique. The National Directorate of Medical Assistance (DNAM) of the MOH closely linked to the National Nursing Department has been implementing a nationwide Infection Prevention and Control (IPC) program that coordinate,

implement and supervise the prevention of medical transmission activities in the country.

USG resources have been utilized to implement the IPC program and will continue to support the MOH staff to roll out training to health workers of health units where there is no partner. This enhances the MOH staff's capacity to utilize training materials developed with assistance from USG supported partners, 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.

In FY 2010 the goal is to continue to strengthen 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.

Key activities include 1) training, including provincial level, for health workers and ancillary staff, reproduction and dissemination of materials, including job aids; 2) supportive supervision and monitoring; 3) procurement and distribution of selected personal protective equipment (PPE); e.g. respirators, non- sterile exam gloves, face shields, surgical masks, eye protection, aprons, etc.

MOH will support three distinct areas within the sexual prevention (other prevention) portfolio support.

FY 2010 funds for the STI program will continue supporting the program goal to reduce the prevalence and incidence of HIV and STIs in the general population as well as PLHIV through improved counseling activities, management of STIs, and monitoring and evaluation of STI prevention and control. Funds will support training; IEC materials; integration of the STI activities in the different services and increase their link to other relevant areas; and supervision visits for provincial and district staff involved in the implementation of the STI program.

FY 2010 funds will continue support for the Mental Health Department to improve alcohol and substance abuse interventions, as well as dissemination of M&E tools and database for monitoring admissions related to alcohol and drug use. Funds will be used for training; community interventions; IEC materials; collection of surveillance data on alcohol and other drugs; and publication of Surveillance Bulletin on alcohol and other drugs. Options for improved substance abuse substitution therapy will be explored.

In coordination with the USG and other donors (notably GTZ), MOH is developing a comprehensive workplace program (WPP) approach for health personal at all levels. Activities will build on available data from a previously completed situational analysis and the BANK study that examined Behaviors, Attitudes, Norms, and Knowledge among health workers. Activities will include development/adaptation of teaching material and IEC material; identification of focal persons at all levels; training; and planning workshops with stakeholders to generate agreement on standardized approach of the WPP. WPP content will include: 1) Prevention (BCC, condom availability, CT access); 2) Health care and support including access confidential counseling and testing, care and treatment, psychosocial support, and home based care; 3) Impact mitigation including benefit scheme (support to orphans, widows/widowers); 4) Human resource management including HIV policy.

The USG has supported the development of national PMTCT program guidelines and training materials, as well as the geographic expansion of PMTCT services beginning in 2003. In 2005-2006 MOH 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.

Priorities in FY 2010 focus on scale up of PMTCT services within an integrated MCH system. Objectives include improved quality; access to a comprehensive package including psychosocial support; and improved nutrition support for reduced vertical transmission, including emphasis on safe infant nutrition and exclusive breast feeding.

The GOM/MOH will be supported by USG implementing partners through a district-based approach and collaboration at provincial level, including subcontracts or grants from partners to provincial and district public health departments. This will increase partner responsiveness, including support for overall systems strengthening and positioning for transition, in line with the goal of 80% PMTCT coverage by 2013.

MOH will receive direct support from USG in FY 2010. Key activities will include: 1) Integrated MCH / PMTCT training, including support for the revision, finalization, and dissemination of training materials; 2) PMTCT supportive supervision, including team visits from central level to PMTCT sites, support for

provincial supervisory teams. Central-to-provincial support for PMTCT will be coordinated through the MOH reproductive health department; 3) With coordination at DPS level, support for PMTCT service provision at selected sites that are not currently supported by a USG implementing partner; supplies, travel, specimen transport, and other needs such as renovation projects and durable goods such as refrigerators; 4) Community PMTCT activities will also be supported, including finalization of support group materials and policy at national level, with subsequent dissemination and rollout; 5) PMTCT clinical mentoring materials will be finalized and disseminated.

USG funding for these activivities will complement funding for PMTCT program expansion and training support provided by other agencies such as WHO, UNICEF, and the Global Fund.

In an effort to build local capacity for MOH to utilize donor funds and manage their laboratory network, USG funding is provided to MOH through a cooperative agreement.

Funding will be utilized to expand and improve laboratory services in Mozambique. The priority for 2010 is quality improvement through implementation of a National Quality Assurance (QA) Program. To accomplish this, MOH has named a QA Officer to oversee QA implementation with the goal of leading the Central and Provincial Hospital Laboratories to ISO accreditation.

USG funds will be used to implement and manage the National Laboratory QA Program and will support site supervision and training visits by the QA officer and his provincial counterparts (present in all provinces). The team will conduct assessments of the quality systems and make recommendations for corrective action where required to ensure compliance to quality standards developed for the Lab Network. Funds will be allocated to production of materials required by the QA Program.

FY 2010 funds will purchase commodities and reagents required for laboratory operations (hematology, biochemistry and microbiology) to ensure uninterrupted testing in the network.

Funding will also support activities that are managed by the National Insitute of Health (INS) Department of Immunology. These activities include: quality assurance programs for CD4 and HIV Rapid Testing, HIV DNA PCR for infant diagnosis of HIV, HIV DNA and viral load testing and monitoring genotypic resistance to ARV drugs.

Funding will be directed to training and supervision for the CD4 network, the purchase and distribution of proficiency testing panels for CD4 and HIV rapid test EQA programs.

MOH wishes to initiate routine viral load testing in selected patient groups. Three laboratories will offer this service in 2010, and the INS will provide EQA and technical assistance to the testing process.

As the number of patients under treatment increases, it has become crucial that resistance to ARV drugs be monitored. In 2009 capacity building for resistance testing was initiated at the Department of Immunology. In 2010, the lab capacity will continue to be developed and testing for selected surveys will commence at INS.

In joint collaboration with partners. the MOH will strengthen the implementation of the TB/HIV collaborative. . The MOH priorities for 2010 are: 1) Increase TB case detection and cure rate: a. TheAmerican International Health Alliance (AIHA) and Mozambican Red Cross will increase education campaigns on TB and HIV/TB literacy, empower patients and affected communities to seek timely diagnosis and treatment; b. Engage TB patients to implement preventive measure to reduce TB transmission in their community c. Develop and implement a two way referral system between community and health facilities; d. Formalize the Mozambican STOP TB Partnership.

2) Strengthen lab diagnostic services by: a. training nurses in smear prep at health posts with no laboratory for referral; b. supporting lab partners in training of trainers TB Smear microscopy; c. training in proficiency panel preparation, TB culture training; d. implementing rapid rifampicin resistance testing; e. TB bio-safety training and mentorship program.

3) Strengthen TB/HIV collaborative interventions, expand PICT to all TB patients, promote HIV testing to all suspect TB positive patients and to contacts of known TB patients: a. train and retrain TB nurses working at the TB sites; b. revise the recording and reporting on contact tracing.

4) Implement the 3 "Is": Intensified case finding , Isoniazid preventive treatment (IPT) and Infection control a. increase the number of HIV patients screened for TB and the provision of IPT to those without TB active disease by training, revising recording and reporting; b. train health workers on Infection Control in sites not covered by partners; c. conduct joint supervision with HIV and Infection Control Program.

5) Conduct training and refresher training for clinicians and nurses on management of TB including MDR- XDR/TB, training on the use of the MDR-TB reporting forms and linkages with ART services using the adults and new pediatric guidelines.

6) Other activities include: adapt and disseminate educational materials on TB in prisons; strengthen procurement and supply of TB medicines and other commodities; and improve communication between Nampula, Beira and Maputo laboratories and the TB National Reference laboratory by setting phone/fax and internet lines.