The American International Health Alliance's (Twinning Center) goal is to advance global health by helping communities and nations with limited resources to build sustainable institutional and human resource capacity. Through twinning partnerships and other programs, it provides technical assistance using the knowledge and skills of experienced physicians, nurses, administrators, educators, allied health professionals, and civic leaders. This partner focuses on the creation of peer-to-peer, voluntary relationships between health institutions. Twinning Center's programs address critical issues such as HIV and other infectious diseases, maternal and child health, primary care, emergency and disaster preparedness, and health professions education and development. Twinning Center partnerships and programs often rely on the commitment of professionals' time and energy provided by volunteers on both sides. Most of their programs are based on peer-to-peer relationships among healthcare providers and policymakers who collaborate to find solutions to health services delivery issues that are technologically and economically sustainable in the host country. Twinning Center's technical assistance model provides an underlying structure that supports health reform, offering counsel and guidance based on five key pillars that serve as the basic framework for their programmatic work: introducing new models of care and services; mobilizing communities for change; building sustainable capacity among healthcare practitioners; furthering the development of health-related professions and expanding knowledge through effective dissemination of successful programs.

Twinning Center's activities most closely align with the third goal of the Partnership Framework to strengthen the Mozambican health system, including human resources for health and social welfare in key areas to support the HIV prevention, treatment and care goals and the second goal to reduce new infections in Mozambique. The geographic coverage for Twinning Center activities is defined by the partnership. For the TB/HIV partnership, the coverage is national and the target population is community organizations. For Catholic University of Mozambique (UCM), geographic coverage is Sofala and target populations are medical students, nursing students, and current health workers. For ANEMO (National Nursing Association), coverage is national for nurses. There are two continuing activities that will not receive any FY 2010 funds: lay counselors and scholarships for individuals.

The key contributions to health systems strengthening are in the areas of developing institutional capacity administratively and technically. The focus of the partnership with ANEMO is on association building. With the partnership at UCM the emphasis has been on increasing technical capacity of medical students and health workers via the development of a clinical practicum training clinic on the university campus. TB/HIV partnership is supporting the National Tuberculosis Program in implementation of TB/HIV literacy activities through partnership with the Mozambican Red Cross. For all partnerships, the cross cutting program is human resources for health.

One of the issues that this implementing mechanism will need to address in FY 2010 is its strategy for becoming more cost efficient over time. None of the partnerships with the exception of UCM, have increased their request for funds since FY 2008. While these partnerships are stabilized at a set level of support, it is unclear whether they are planning for a time when these funds are no longer available. Through the workplan development process, the Twinning Center puts great emphasis on the development of a clear and comprehensive monitoring and evaluation plan. The partners are working together to identify specific indicators which will assess improvements made in human resources for health as a result of their activities. Twinning Center assists the partners in the collection of PEPFAR relevant indicators to inform programmatic direction. M&E tools include pre- and post-test evaluations during trainings. Further, as activities roll out, partners will conduct assessments of program outcomes, using a range of evaluation methods and tools, based on outcome indicators and focused on sustainable outcomes. Examples of evaluations types: surveys of knowledge/attitudes/practices of providers, client satisfaction; organizational capacity assessments; benchmarking; and structured observation studies and interviews

The Twinning Center's evaluation framework focuses on M&E efforts on three levels; individual partnership, cross-partnership, and program wide. Progress toward the overall Twinning Center project goals and objectives will be measured periodically using the specified indicators and a variety of data collection approaches across the three levels. At the individual partnership level the focus will be on monitoring the successful achievement of the measurable objectives and activities as outlined in the partnership workplans. Cross-partnership evaluation will focus on identifying outcomes across partnerships working in similar technical areas. Finally, the program-wide evaluation will focus on the broader outcomes of the partnerships and the impact of the Twinning Center as it relates to sustained human and organizational change to enhance service delivery.

Funds are supporting an individual scholarship, national nursing organization), clinical practicum clinic at a private medical school and a TBD partner working with Eduardo Mondlane or Lurio University on medical curricula. Since 2007, funds from the laboratory have been supporting an individual studying clinical pathology in Brazil. Upon return, he will be the only clinical pathologist here. The current mechanism used is being re-competed so the funding for the final year of support will go through the Twinning Center. Other activities supported are association building activities within ANEMO and supporting the clinical practicum training activities supported by Catholic University of Mozambique.

In FY 2009, ANEMO gained a new partner, St. Luke's School of Nursing. This partnership is addressing the need for a viable nursing organization in Mozambique. In FY 2010, ANEMO's activities focus on continuing their training of home based care trainers accreditation program, providing field supervision for trainers and ensuring a functional referral system between health centers and home based care partners. Although the MOH chose ANEMO to scale up home based care, ANEMO lacks permanent staff, financial resources and proper infrastructure. Through association building, ANEMO could gain access to resources through funds gained from training activities and via association membership activities. ANEMO also receives organizational capacity building support and funds via another USG partner, AED.

Although the use of field based clinical practicums is commonly employed, they are not uniform in their approach or content. The opening of the community health clinical practicum-training clinic at Catholic University of Mozambique, in partnership with University of Pittsburg, is addressing this issue through offering technically sound clinical community health practicum opportunities for medical students and health workers. This activity has spillover effects since the funds are supporting a small aspect of medical education. Catholic University has other university partners who provide technical assistance to the clinical practicum clinic and program in general.

Funds to support the UEM and UCLA collaboration around pediatrics including HIV/AIDS. This support may also include bringing educational experts to UEM to support the transition to a problem based learning curriculum for medical school.

The Twinning Center will continue to support the National Tuberculosis Program in implementation of the TB/HIV literacy activities through partnership with the Mozambican Red Cross, a national NGO. The Red Cross not only provides services in emergency situations but also in disease prevention, control and mitigation namely malaria, cholera, TB and HIV. Currently, steps have been made in identifying a Brazilian NGO for a south to south partnership with the Mozambican Red Cross.

Activity will continue in FY 11 although there will not be any FY11 funding as there is sufficient pipeline.