The Capacity Project is continuing from FY09. In COP09, this IM funded activities under MTCT, HVAB, HVOP, CIRC, HBHC, HTXS, PDCS, PDTX, HVTB, HVCT, HVSI, and OHSS. In COP10, HVSI is no longer being funded.

The overall objectives under the award are to: 1) build the capacity of indigenous organizations to respond to and implement HIV programs, leading to an increased number of Namibians who know their HIV status, and 2) improve access to high quality HIV prevention, care and support, and treatment services for people affected and infected with HIV.

Since 2006, IntraHealth has been supporting the Government of the Republic of Namibia (GRN) and its partners to reduce the spread and impact of HIV/AIDS through building the capacity of indigenous organizations. Currently, the project has sub-awards with nine local organizations with plans to transition Anglican Medical Services to a tenth sub-award recipient. In addition, IntraHealth supports the activities of two professional organizations, the HIV Clinician's Society and The Pharmaceutical Society of Namibia.

Intermediate award objectives will be met by providing technical support in HIV clinical services, and prevention and capacity building to the indigenous organizations in partnership with the GRN, stakeholders, private providers and other implementing partners in Namibia. The key intermediate results (IRs) are as follows: 1. Increased capacity of indigenous organizations to respond to the epidemic and to implement HIV/AIDS- related programs, 2. Strengthened capacity of local organizations to provide high quality, age-appropriate HIV/AIDS prevention programs and referrals at the health facility and community levels, 3. Improved opportunities for Namibians to know their HIV status by improving local organizations' ability

to provide quality HIV/AIDS counseling and testing services at medical facilities and in communities, 4. Strengthened capacity of local organizations to provide HIV/AIDS care and treatment services for both adults and children, and 5. Increased capacity of the Ministry of Health and Social Services (MOHSS) to manage human resources for health (HRH) through support to the development and implementation of a human resources information system (HRIS).

IntraHealth and its partners are working to achieve the objectives while contributing substantially to the goals of the GRN and PEPFAR program, specifically the Partnership Framework (PF). In an effort to ensure sustainability, IntraHealth supports the GRN in building the capacity of the HR department in the MOHSS through the development of an HRIS, as well as strengthening the capacity of indigenous NGOs and faith-based organizations (FBOs) working in remote areas. Specifically, IntraHealth is helping organizations strengthen financial, human resources, compliance and other management systems so that these institutions will be ready for transition to direct support. IntraHealth is concurrently strengthening partners technical expertise to help them provide quality HIV prevention, care and treatment services. The five IRs are closely linked to the National Strategic Framework and the PF, targeting prevention, treatment, care and support.

The program targets Namibians of all ages and gender, with specific emphasis on at-risk populations. IntraHealth works with indigenous organizations covering rural, semi-rural and urban areas in 11 of Namibia's 13 regions.

Human Resources for Health (HRH) are fundamental to the sustainability of HIV programming. IntraHealth is making significant progress with the MOHSS to strengthen its capacity to manage HRH with health workforce data nearly completed. MOHSS staff has also participated in key capacity building activities on the use of data for decision making. The program will continue to build the capacity of MOHSS and will extend the pilot of the HRIS to all regions in Namibia.

The focus of IR1 is to increase the cost effectiveness of the program by helping build the capacity, beginning with the larger, more developed organizations, and gradually assisting the smaller organizations, to implement HIV programs. Over time, this will enable IntraHealth to have a reduced presence, shifting to a more supportive role to provide targeted technical assistance. IntraHealth will also work with the local organizations to continue seeking economies of scale as their HIV care and treatment programs expand. One example is the development of an electronic patient management system. As a cornerstone of long term care to PLHIVs, this system not only supports quality care and treatment, it also enables clinics to schedule patients more easily and assist with defaulter tracing.

Monitoring and evaluation is fundamental to the success of the program and is a critically important mechanism for strengthening partner capacity. Through a system of data collection, analysis, reporting and feedback, IntraHealth will work closely with its partners, USAID, and MOHSS to ensure the program is on track, while helping to build partners' capacity to monitor and evaluate HIV programs. IntraHealth is committed to ensuring that information produced is timely, valid, precise, accurate and reliable, and will routinely monitor the quality of the information generated, conducting data quality audits with staff from partner organizations to improve this information.

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This is a substantially changed continuing activity from FY2009.

This continued activity has six main components: 1) Access to counseling and testing (CT), 2) referral system, 3) enhancing the quality and consistency of CT services, 4) offering comprehensive support in CT sites, 5) increasing capacity of local organization to run CT services, and 6) collaborating with the MoHSS.

During COP10, IntraHealth will continue to support NewStart (NS) network. This consists of six integrated (facility-based) and 12 standalone (community-based) sites in ten out of thirteen regions. However, based on the CT portfolio review recommendations, given the high cost per client in the New Start franchise, there will be a reduction in the number of sites supported by USG, especially in areas where mobile and facility based services are readily accessible. This will be done after careful consultation with all stakeholders. Integrated sites will support Provider-Initiated Testing and Counseling (PITC) in the clinical setting in accordance with national guidelines and improve access for HIV positive individuals to care and treatment services, while community-based sites will focus on self referral clients. Provision of CT for sexual partners and other family members will continue to be provided. Support for the HIV status disclosure will be strengthened during counseling sessions. IntraHealth will continue to support counseling and HIV negative individuals to keep their HIV status negative. Link with NawaLife Trust in an advisory capacity will ensure aggressive demand creation campaign for HIV testing. This partnership will increase testing numbers at both NS and MoHSS testing sites. The recruitment of community mobilizers in most sites will also enhance this demand creation activity. Also, extending business hours to open on Saturdays and during week days will accommodate individuals who would not have access to HIV CT, and increase demand.

IntraHealth will continue the support for an effective bidirectional referral system between standalone sites, health facilities and CBO/FBO at the community level. The system is comprised of a focal person, HIV/AIDS service directory, a register, forms and referral committee in every site to manage referral in

and out. Continuous evaluation will be conducted.

IntraHealth and its partners are using HIV rapid testing according to the national algorithm. The effective and uninterrupted supply of rapid tests and medical consumables will be accomplished through a continued partnership with SCMS for the standalone and through the Central Medical Stores for the facility-based sites. IntraHealth will continue partnership with the Namibian Institute of Pathology who will provide quality assurance oversight at all regional training sites. IntraHealth will enforce quality of CT provision and services through consolidating and updating the training and supervision of counselors. The two regional VCT Coordinators in the North will continue to support the sites in these remote areas and ensure consistent quality assurance for counseling and site supervision. IntraHealth will conduct supportive supervision visits and performance improvement sessions with all staff at the NS sites using an assessment checklist and scoring system along with analysis of client exit interviews, suggestion boxes and focus group discussions. Comprehensive support in CT sites will continue through integration of other activities such as screening for TB, alcohol abuse and male circumcision (MC). In COP10, IntraHealth will pilot screening for gender- based violence. The success of these services depends on the reliable and efficient referral system from CT to other relevant service providers. IntraHealth will use its specially designed software to monitor these new activities and the referral.

As a member of the CT Technical Working Group, IntraHealth will continue working closely with the MOHSS, providing expertise on both clinical and counseling issues, and joint supervisory visits. This collaboration also covers training, national testing day events and M&E activities. Since COP 2008, IntraHealth brought the CT training program in line with the minimum standards for training required by the MOHSS. IntraHealth will continue to work with the MOHSS and the training agency to complete training for counselors in the NS network with special emphasis on window period streamline information, TB referral, referral for brief motivational intervention, MC, couple counseling, child counseling, family-based counseling, gender-based violence screening and referral, and male-friendly services.

To improve quality of health services, Intrahealth, the host government and faith-based counterparts, will conduct regular joint supportive supervision visits. Efforts to address the highest-priority problems, including: logistics, commodities, staff turnover, and other pertinent issues will be followed.

As part of the transition and sustainability plan, IntraHealth will work with its partners to assess financial capacity in the provision of community services for CT beyond PEPFAR funding. Building the capacity of local partners will be a primary function, in addition, resource mobilization and exploration of other more cost effective models for community CT services will be undertaken. IntraHealth will ensure that

communities where sites might be reduced will continue to have access to CT services through existing mobile or facility based outlets.

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This is a substantially changed continuing activity. In COP10, IntraHealth will support the MOHSS (which is where the HRIS is housed) to create linkages and harmonization of HRH information, embark on HRH data use, working with the Stakeholder Leadership Group (SLG) to link the HRIS with existing systems, such as the private sector NAMAF system, TB registry, I-Tech's in-service training database, Health Professionals Council system, and public sector systems such as Ministry of Finance and the OPM. IntraHealth will ensure the SLG continues to function well with strong participation and support from all key members and stakeholders.

In COP10, IntraHealth will also continue to strengthen and build on the foundation phase by focusing on: (i) ensuring the SLG retains its vitality and continues as a functional group; (ii) finalizing the essential HRH indicators for the MOHSS as a first step, and then identifying additional indicators for all the key owners, producers and consumers of HRH information as a second step; (iii) establishing automated interfaces enabling the sharing of common information between the M)HSS and key stakeholders;(iv) providing advanced information technology (IT) training to MOHSS IT staff to manage their enhanced IT infrastructure and HRIS environment; (v) providing advanced computer literacy and system training to MOHSS HR personnel to ensure data completeness and accuracy; and, (vi) ensuring sustainability by training on the effective use of data in developing policy and informing management decisions. PEPFAR technical experts will be available to provide supervision and provide technical input as required by the GRN.

Training on data use not only supports the utility, data quality, and continued strength of HRIS systems but also provides support for many key cross-cutting areas, including identification of gender issues, looking for incentive and retention trends and examination of distribution of staff with specific areas of specialty. The training will also contribute towards the sustainability of the HRIS and enhance the capacity of the health system.

This is a substantially changed continuing activity from FY2009.

This continuing activity has 3 main components: (1) communication, education and advocacy on male circumcision; (2) training; and (3) scale up of male circumcision service delivery.

1. Communication, Education and Advocacy on Male Circumcision: IntraHealth will continue to engage opinion leaders, political leaders and traditional authorities, as well as the community at large, in order to communicate the benefits of including male circumcision (MC) as part of a multi-faceted, robust prevention approach. Critical to the success of MC is an appropriate, affordable and culturally sensitive communication strategy and demand creation tailored to the service availability. IntraHealth will work with the USG lead communication partner (TBD) and other stakeholders to expand education and communications (IEC) materials to ensure MC information is provided to the community. The communication programming will align within Namibian National Strategic framework and the forthcoming National Namibian HIV prevention strategy. As part of the integration of MC into counseling and testing services (CT), CT sites will continue to provide information, education and referral, as appropriate, and help clients consider MC as part of their overall risk reduction strategy. In addition, policy makers and community leaders will become familiar with the international and local evidence on MC and the cost saving related to infections averted. IntraHealth will continue to engage the national leadership at all levels, disseminate findings of the situational analysis and provide opportunities to build a strong political commitment and obtain buy-in from decision makers.

2. Training: After successfully organizing the first MC skills building training in Namibia in collaboration with JHPIEGO, the MoHSS, the MC task force and other USG partners, IntraHealth will continue to provide support and technical assistance in skill building for safe MC under local anesthesia during COP10. The success of the first training will be translated in pilot sites delivering MC services, to be followed by a national roll out. Trainings will ensure that providers acquire clinical and counseling skills that conform to

the international standards of quality, including follow up care and management of complications.

3. Scale up of male Circumcision Service Delivery: Currently, all IntraHealth supported district hospitals are providing male circumcision. In many hospitals there is a waiting-list for MC services due to the lack of trained personnel. IntraHealth will bring to scale safe MC in the 6 supported FBO health facilities by allocating staff time and salaries, supplies (consumables), equipment, and sharing facilities. Beyond COP 2010, MC related costs will rely heavily on public sectoring financing. Additionally, in COP 2010, Intrahealth will deploy a catch-up strategy that will partner with WHO and USG/HQ to deploy JHPIEGO to enhance the current host-country expertise. JHPIEGO will provide critical international technical assistance to run MC clinics. The supply of commodities will acquired through the government's CMS with support from SCMS, taking into account cost minimization. The service delivery model will adopt the WHO recommended minimum package of prevention services that combine MC with: (1) provider-initiated testing and counseling (PITC) and comprehensive post-test counseling; (2) STI screening and treatment; (3) counseling on risk reduction behaviors with a focus on partner reduction and abstinence; and, (4) condom promotion and provision and appropriate referrals to other sexual and reproductive health services. This package will include strict post operative care with regards to wound care instructions and six week abstinence from sexual activities. It is also imperative to engage traditional MC providers as key community gatekeepers; more than 52% of men currently circumcised in Namibia have been through traditional providers. IntraHealth will provide opportunity for open dialogue. This support will include areas such as registration and regulation, training on hygiene and infection control, competency building on HIV issues and documentation of adverse events and referral linkages to medical providers.

Supportive Supervision & Quality Assurance: IntraHealth will use the WHO quality assessment tool as adopted by the MC task force. This tool assesses quality of services through monitoring supply chain management, adherence to the prevention minimum package, counseling services, competence of staff performing the procedure, follow-up care and management of complications, and record keeping. In addition, client satisfaction will be sought through interviews with clients using the services. A quality improvement team will be formed and will conduct regular support supervision visits at each site.

Sustainability: To ensure long term sustainability and cultivate MC awareness in Namibia, IntraHealth will continue to work through the task force to advocate for the inclusion of neonatal circumcision in all districts. This will entail contribution to policy finalization, training of providers (mid-wives) and education and social mobilization campaigns.

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