This is a new implementing mechanism which is a follow-on to Project Hope, whose Track 1 award ends in June, 2010. Project Hope has been working directly with guardians and parents of orphans and vulnerable children (OVC), providing them with small loans and business training through its Village Health Fund Microcredit Methodology. Under this approach, solidarity groups are formed, and micro- financing is accompanied by a health and parenting course. Since the beginning of the project in 2005,

2,251 caregivers have been trained, and 8,164 OVC have been served.

The new mechanism will target OVC through their caregivers, combining economic strengthening with health education and targeted interventions for TB prevention and management. The program design will utilize the structures of village health funds established by Project Hope, including field workers, and build linkages to local partners and the health system.

1. The new mechanism will focus on mitigating the impact of HIV/AIDS on OVC and OVC caregivers, addressing both economic needs and health aspects of HIV and TB. It has three comprehensive goals and objectives: 1) sustainable economic strengthening of families of OVC through microfinance and business skills training, and 2) building capacity of caregivers to address the emotional, physical and health needs of children in their care and 3) increasing TB awareness and case management.

2. The mechanism is in line with USG commitments of the Partnership Framework in its response to the draft National Strategic Plan on HIV AIDS, both in regard to impact mitigation (improving sustainable livelihoods for households with vulnerable person) as well as care (management of TB/HIV co-infection).

3. The geographic coverage will be six political regions (Oshana, Omusati, Ohangwena, Oshikoto, Kavango, and Caprivi). Target populations will be: a) caregivers of OVC, including elderly and junior heads of households, b) OVC in their care, and c) TB patients and patients co-infected by TB and HIV.

4. The mechanism will be linked to USG support for systems' strengthening of the Ministry of Gender Equality and Child Welfare (MGECW) human resource system and the administration of welfare grants. OVC caregivers will be educated on eligibility and processes for access to OVC grants, and strengthening the MGECW Community Development Directorate will broaden its capacity to support community projects for OVC caregivers. The TB activities will strengthen health systems delivery for DOTS through strengthening linkages and communication between clinics and communities.

5. The mechanism will increase women's access to income and productive resources, and thereby address unequal gender relations and gender-based violence. The proposed mechanism will reach predominantly women since, due to culture and social norms, the majority of OVC caregivers are female. Providing women and the children under their care with the opportunity to generate income through small businesses will contribute towards addressing the prevailing imbalances in power relations between male and female household members.

6. The mechanism will aspire towards long term cost-effectiveness and sustainability by linking operations to an emerging local micro-finance bank, Koshi-Yomuti. The TB activities will utilize and feed into the

national TB control program and existing community structures.

7. An M&E plan will be developed, and outcomes will be measured at the household (household assets) and child (care, health, education) levels. For TB case management, the activities will utilize the government's recording and reporting system and report to the health system.

This new activity is follow-on to Project Hope, whose Track 1 award ends in June 2010.This activity compliments the church-based income generating activity by focusing on households instead of institutions. It will have the following three components: 1) economic strengthening of caregivers of OVC, 2) training of OVC caregivers on parenting skills, and 3) collecting socioeconomic data on caregivers and OVC through member profile and parenting maps.

1. Economic strengthening of caregivers of OVC. OVC caregivers will be supported with business skills training and with micro-credit enabling them to engage in small businesses. The best performing micro- credit clients from Village Health Funds established under Project Hope's Track 1.0 program will be selected for continued access to graduated levels of credit and continued business skills training. These

caregivers will be groomed for graduation into the clientele of commercial micro finance bank Koshi Yomuti.

2. Training of OVC caregivers on parenting skills. Linked to the economic strengthening activities, participating caregivers will undergo a health and parenting course, and caregivers will be provided with continued support to improve the well-being of the OVC in their household through a care plan. This care plan will be actionable through referrals to partner organizations, direct service provision via payment for procuring birth certificates and hospital fees, and targeted refresher trainings on topics from the Parenting Training curriculum.

3. Collecting socioeconomic data on caregivers and OVC through member profile and parenting maps. When enrolling caregivers into the program, baseline member profiles will be collected and an assessment of parenting practices conducted. The same data will then be re-collected at periodic intervals.

As with Project Hope, the micro-credit activity will be monitored through accounting systems administered by field officers to help credit recipients manage their payments. Extensive controls will be put in place to ensure the cash payments involved in the process are subject to transparency and the possibility of fraud is minimized. The health education activities delivered by field workers will be monitored by a health coordinator.

Supportive supervision will be included in project activities for field officers. Quality assurance will include a participatory monitoring and feedback system in which outcomes for children are assessed according to the national OVC service standards.

This new activity has 2 main components: 1) to improve TB case management, and 2) to reduce TB defaulter rates in Oshikoto, Oshana and Kavango regions.

1. To improve TB case management This activity will focus on strengthening existing health delivery systems in the above three regions, identifying gaps in service delivery and targeting the TB clinics with high caseloads and treatment default rates. The program will implement a strategy that educates TB patients and their supporters at the hospital, health centers, clinics, and households through information and education sessions to equip

them with the needed knowledge on treatment regimen, importance of adherence, and follow-up schedule. The activity will also strengthen the linkages between the households, TB patients, hospitals, and their assigned clinics by placing project staff at each level to ensure continuous communication and coverage.

2) Reduce TB defaulter rate in Oshikoto, Oshana and Kavango regions This activity will continue to support the engagement of existing community health workers (Field Promoters) and "recharge" them to provide strong and consistent support to TB patients and their supporters in their catchment areas; mobilize them with weekly household visits; and provide community education outreach sessions. Where feasible, it will conduct mapping exercises using the GIS system to produce maps of caseloads and defaulters per catchment area. The mapping exercise will serve as a replicable model for controlling TB in rural and hard-to-reach areas.

The implementing partner will conduct supervisory support visits to the health facilities as a way of strengthening inter-workings of project staff with the government/Ministry officers. Most of the MOHSS staff consulted expressed their appreciation toward the field promoters presence that are assisting the overburdened nursing staff with TB and TB/HIV care in the community and health facilities.

Quality assurance will be addressed through regular meetings with MOHSS to review field promoters' performance and training needs. Regularly updated caseload mapping will serve as a monitoring and quality assurance tool.

Data verification will be done during the project supervisory support visits to the health facilities. Other non clinical TB care community activities are collected as additional information. Field staff will be trained on the MOHSS TB program tools for M&E.

Sustainability and Transition 1) The National TB Control Program initiated a coordination and collaboration partners' meeting for all partners in the two North-western regions represented by the Red Cross, Project Hope and Total Control of the Epidemic (TCE 2) to ensure: a clear understanding of all NGO's program activities, reporting systems, sharing of field experiences, and reduction in overlaps. 2) The project will subscribe to the Ministerial national TB control program recording and reporting system, avoiding duplicative or misaligned monitoring and evaluation systems, and enable transition to the to the Ministry upon project completion. 3) The project will conduct focus group discussions between the key district teams to assist the project team in understanding the deeply in-grained community beliefs regarding the spread of TB (how TB is 'inherited' and TB/HIV related misconceptions) which in turn assists in creating better guided and tailored

TB and TB/HIV messages for the household and clinic levels. This coordination with local government promotes ownership and sustainability of the interventions and reduces the use of contracted, and often expensive, external consultants. 4) The project will build the TB component on existing community based interventions, resulting in leveraging of existing activities and resources to reduce overall costs.