This mechanism supports USG and GRN contributions in the PF and GHI strategy. The MOHSS has a mandate to manage and coordinate the national HIV/AIDS response in accordance with the strategies outlined in the 2010 NSF. Direct funding to this partner, a government institution, emphasizes strengthening GRN capacity and ownership of the HIV response. This mechanism is designed to support activities with a national scope. Support to the MOHSS is designed to contribute to systems strengthening and human capacity development throughout the public health care sector. This support in turn benefits Namibians who access care nationwide. Direct support strengthens MOHSSs ability to plan, implement, monitor and evaluate strategies within and beyond the national HIV/AIDS response. Over time, MOHSS will identify activities that may be absorbed completely by the GRN, that require continuing technical assistance from the USG, or that could be terminated, e.g., in COP12 the USG will cease funding for ARV drugs. The transition of other commodities is also under discussion. Within the public healthcare system, services are increasingly coordinated and integrated at the facility level. This mechanism contributes to efforts to improve the capacity of MOHSS to recruit and retain Namibian staff. USG support for training supports a sustainable pool of healthcare workers; point-of-care testing and other new lab technologies will reduce per-test costs and reduce the Ministrys dependence on NIP for bio-clinical monitoring. The MOHSSs work plan is based on PEPFAR indicators and targets in the NSF and PF. National M&E systems are used to generate data for PEPFAR, GF and national reporting requirements.

Global Fund / Programmatic Engagement Questions

1. Is the Prime Partner of this mechanism also a Global Fund principal or sub-recipient, and/or does this mechanism support Global Fund grant implementation? Yes2. Is this partner also a Global Fund principal or sub-recipient? Principal Recipient3. What activities does this partner undertake to support global fund implementation or governance?

Budget Code Recipient(s) of Support Approximate Budget Brief Description of ActivitiesCIRC MOHSS 200000 Salary support for key technical staff (e.g., MC and National Prevention Coordinators) helps improve communication between MOHSS departments that receive funding from USG and GF.HVSI Response M&E Unit 100000 Revision and updating the National Strategic Framework for HIV/AIDS will improve coordinated planning between USG and GF by providing harmonized indicators and targets.

Funding under this activity supports the procurement of equipment for HIV-related clinical care, including tools to improve clinical monitoring. To address barriers to proper care of HIV-infected women, equipment has, and will continue to be, procured to improve gynecological screening and care of HIV-positive women to more adequately address HIV-related conditions such as cervical dysplasia and reproductive tract infections.

Funds will be used to replace outdated equipment (e.g, scales, and exam tables) in existing Integrated Management of Adolescent and Adult Illnesses (IMAI) sites and procure new equipment for new sites in the IMAI network. Funding will also support printing of IMAI patient cards and files.

The procurement of new equipment will also support the national task-shifting initiative, which is central to the success of the IMAI strategy. Taking on tasks previously provided by physicians, nurses will increasingly provide palliative care, including screening and treatment for minor OI, Nutrition assessments and management. Nurses will also manage pre-ART and stable ART clients who have completed their first six months of ART without incident. They will provide appropriate referrals and linkages with community-based Health Care (CBHC) organizations.

The 2010 HIV treatment guidelines recommend baseline and routine annual cervical cancer screening for all HIV infected adult women. With the scale up of this activity facilities will need to be equipped with the tools such as speculums, slides, lamps, cervico-brushes, and other equipment necessary for pap smears. Onsite training will train providers in pap smear specimen collection, preservation and logistics for transport to the laboratory for analysis. The referral system for management of patients found to have abnormal results will also be refined. An implementation plan for the national roll out of this initiative will be supported. The capacity to deal with abnormal pap smear results will also be strengthened. In COP12, PEPFAR support to the MOHSS for cervical cancer prevention and treatment within HIV programs will include support for an assessment of the countrys needs and readiness for a broader cervical cancer prevention program and treatment program. The activities will also focus on refinement of policies and protocols, IEC materials, printing and distribution of these tools for the scale up of cervical cancer prevention activities among HIV infected women.Continued support to MOHSS for cervical cancer screening is another example of PEPFAR Namibias support for the integration of HIV/AIDS services with the primary healthcare system. This funding will contribute to the access objectives described in the Namibia GHI strategy.

Community Counselors: Funding for the Community Counselor (CC) program is distributed among six activity areas: Other Prevention (20%), Counseling and Testing (45%), Preventing Mother to Child Transmission (15%), and Adult Treatment (10%). Facility-based CC provide HIV counseling and testing (HCT); adherence, prevention, and male circumcision counseling; and provide referral services.Procurement of HIV Test Kits and Supplies for TB patients and suspects: The Ministry of Health and Social Services (MOHSS) will continue to purchase Determine and Unigold HIV test kits (using a parallel testing algorithm) for approximately 50,000 TB patients and suspects at 250 MOHSS facilities; ELISA or a MOHSS-approved rapid test device for tie-breaker re-testing in cases of discordance; HIV rapid test starter packs to launch new testing sites, and rapid HIV test supplies for training CC. These kits and supplies will be procured and distributed by the MOHSS Central Medical Stores.Support TBHIV program contribution to bio-clinical monitoring costs.Support for the programmatic management of Drug Resistance TB: including intensified DR TB case findings, contact tracing, strengthening specimens collection and referral systems, There are over 372 cases of drug resistant TB cases in Namibia, including 23 Extensively Drug Resistant (XDR) TB. Namibia Institute of Pathology (NIP) will continue to provide diagnostic support to MOHSS for aggressive DR TB case finding through C/DST and rapid molecular test of all at risk patients including (HIV positive patients, previously treated patients and DR contacts).Support the Electronic TB Register (ETR) and TB Surveillance Systems: MOHSS will expand TB surveillance system with technical assistance from CDC .Support to the TB program midterm review as well as support infection control and support to the Community TB care and community TB promoters is integrated into COP12.Development and implementation for integrated service delivery model for TB HIV: USG will support development, implementation and evaluation of a service integration model for TB HIV services. Funding will cover TA, baseline assessment, tools development, training of HCW.

The estimated ART coverage among the pediatric population is close to 100%. As the PMTCT program effectiveness increases, more pediatric infections will be averted and fewer children will be born HIV infected. The program budget for care and support is shared with HBHC, with approximately 85% supporting adult services and 15% supporting pediatrics through PDCS. Activities supported in this budget code include;

Clinical Equipment and Supplies: Funding under this activity supports procurement of equipment necessary to provide essential HIV-related clinical care, including tools to improve clinical monitoring and care for children. Emphasis will focus on tools to monitor growth and nutritional status in pre-ART sites and maternal and child clinics. Job aides and patient education materials will be produced, printed and disseminated. PEPFAR has supported basic essential clinical equipment since 2004. In line with the PEPFAR Namibia transition strategy; this budget line item will continue to decline over the next few years as the GRN takes on this responsibility.

HIV DNA PCR testing for early infant diagnosis. PEPFAR funds will continue to support a portion of DNA PCR testing for the Early Infant Diagnosis (EID) program. Support is reduced from COP11 levels as the MOHSS assumes increased responsibility for EID costs.

Assessment of the EID program: PEPFAR funds will support a comprehensive assessment of the EID program with a specific focus on HCW compliance with guidelines and timeliness of processing and return of lab as part of an effort to improve the program for early identification of HIV+ infants.

Improving mother baby follow up: MOHSS, in collaboration with partners, has been piloting follow up of HIV exposed infants. PEPFAR funds will support rolling out mother-baby follow up nationwide, including support for revision, printing and distribution of tools and registers for mother-baby follow up including child health passports, postnatal registers and patient clinic booking cards and job aids. Patient unique numbers will facilitate linking of mothers and their HIV exposed infants during postnatal period and to address double counting concerns. Funds will also be used for training health workers and data clerks, supervision (national, regional, district), phones for facilities and airtime for SMS/calls to remind patients of follow-up clinic visits, M&E, and review meetings.

CDC will continue to work with the MOHSS sustainability task force to ensure that the essential services that are currently supported by PEPFAR will be included in coming years budget motivations. CDC will also work closely with MOHSS and other USG agency partners to support costing exercises for essential services.

The MOHSS is responsible for HIV surveillance, M&E, and HMIS activities related to the national HIV/AIDS response. In COP12, strengthening the capacity of the RM&E unit will continue while new activities for drug resistance monitoring, ANC sentinel surveillance /PMTCT data comparison, and more comprehensive M&E activities will be priorities. In line with transition of activities, funds for logistical support such as printing and purchasing of computer equipment will now be supported by MOHSS. Capacity building through training and mentorship activities will promote autonomy within the MOHSS and reduce the need for future external assistance. In line with GHI principles, operational research activities will be a focus and capacity building activities will include several Directorates across the MOHSS, including Primary Health Care. All activities will support the Multi-Sectoral M&E Plan, the indicators included in the National Strategic Framework (NSF) and the National HIV Research Agenda.

Building research and monitoring capacity will allow the MOHSS to do more with fewer resources. Documenting and understanding process, outcome and impact indicators will promote evidence-based programming and the identification of non-performing or low-impact activities.

Key activities include: 1) Support for the MOHSS Response Monitoring & Evaluation (RM&E) unit and the Health Research Unit for essential responsibilities and functions including supportive supervisory visits and trainings for current M&E, surveillance and research methods including ethical review standards; 2) Strengthen TB/HIV surveillance. Currently, M&E systems do not effectively capture TB/HIV information; data from TB systems and HIV systems are currently interpreted together to gain an understanding of the TB burden with HIV infected persons, however better linkages among systems and TB and HIV programs is urgently needed; 3) Implementation of a TB MDR survey. The last TB MDR survey was conducted in 2008 and a new survey is needed to understand the current situation of drug resistant TB; 4) Support for an ANC sentinel surveillance /PMTCT data comparison exercise. This exercise will determine if PMTCT data can be utilized for HIV surveillance and potentially replace the need for conducting bi-annual ANC sentinel surveys; 5) Implement HIV drug resistance monitoring. Drug resistance monitoring is one component of the Namibia HIV drug resistance strategy which includes the use of early warning indicators and a drug resistance threshold survey. In conjunction with WHO, MOHSS is piloting new methods for monitoring drug resistance and these funds will be used for a national survey; and 6) Implement an M&E system for male circumcision scale-up. An M&E system needs to be developed with the roll out of the male circumcision program. Efforts will include aligning needed indicators into existing M&E systems for routine data and also conducting process evaluations.

Inadequate human resource capacity is among the leading obstacles to the development and sustainability of HIV/AIDS-related health services in Namibia. The USG has recognized pre-service training as instrumental in scaling up and sustaining the national HIV/AIDS response, and to strengthening the overall healthcare system.Critical human resource gaps exist at all levels of the healthcare system, from the national administration to local facilities. The lack of pre-service training institutions for doctors and pharmacists in Namibia, coupled with limited local training opportunities for other allied health professionals, has contributed to a chronic shortage of health professionals.

COP12 will support bursaries for Namibian students with demonstrated financial needs and educational qualifications to train as doctors, pharmacists, pharmacy assistants, nurses, enrolled nurses, laboratory technologists, social workers, public health administrators, epidemiologists, and nutritionists in Namibia, South Africa, Kenya, and elsewhere. Students awarded bursaries through this program will be bonded to serve the MOHSS upon completion of their studies. To assess whether bursary recipients are remaining within the Namibian health workforce, the USG will work with the MoHSS to track the employment status of previous, current and future bursary recipients. USG technical advisors will also facilitate the flow of information about the bursary program between MOHSS program managers and MOHSS leadership. In COP12 USG will also raise the issue of linking individuals who benefit from other USG-funded capacity building projects (e.g, those that help vulnerable students) to the bursary program. This kind of direct linkage between USG projects and the bursary program has not been attempted in the past. Historically (and continuing in COP12), busary opportunities are widely publicized; and applicants are selected base on merit and need. This facilitation will include, where relevant, support for the collection, analysis and dissemination of information captured in human resource information systems.

As the demand for male circumcision (MC) increases in Namibia, PEPFAR will support the Ministry of Health and Social Services (MOHSS) to ensure that appropriate supplies, equipment, and commodities are available. These supplies and commodities may include, but will not be limited to, surgical equipment, sterile equipment, local anesthetic, patient education materials, training curricula, and circumcision devices. In addition, supplies such as surgical beds, lights, privacy screens, tents, and other materials needed to roll out MC are included. Where possible, existing GRN procurement services will be used, specifically the MOHSS Central Medical Stores to order, stock, and distribute the appropriate supplies, commodities, and equipment. A distribution plan will be aligned with the National MC Implementation Plan. Travel to and from targeted regions is an essential to the success of this program; funds allocated for this purpose may be used by MOHSS national and regional staff, as well as MC service providers. In COP12, while continuing to provide MC services through the current integrated service model in all the regions, the MOHSS also intends to specifically target 3 to 4 regions to ramp up the scale of MC services through sustained intense MC campaign models in those few regions. The regions will be selected by the MOHSS through the MC TWG guided by the MC implementation plan (which is currently in draft form), once it is finalized and adopted. This will require extensive travel for coordination and management of the campaigns through the national and regional health managers.

Support for equipment, materials and logistics will support MOHSS efforts to increase access to MC services in high-need areas of Namibia. A successful rapid roll-out of MC services will also accelerate the transition of the MC program from a time-limited program focused on adult males to an MOHSS-led routine program focused on neonatal MC.

Community Counselors (CC): Namibia introduced the CC program in 2004 as part of the national task-shifting initiative. Facility-based lay CC provide a range of counseling services. Under HVCT, focus will be on couples counseling, provider-initiated counseling and testing (PICT), and outreach HCT services (e.g., mobile). Continued support with funding for approximately 45% of the facility-based lay-Community Counselors program is distributed among five activity areas: Other Prevention (20%), Prevention of Mother to Child Transmission (15%), Adult Treatment (10%), and HIV/TB (10%). This includes salaries for 650 CC who are deployed in public health sites to work on activities such as HCT, ARV, TB, PMTCT, as well as correctional facilities; training implemented by MOHSS with support from ITECH; supervisory support visits by MOHSS staff persons who provide supervision and support to the CC, and support for planning meetings and an annual retreat for CCs.CDC will continue to work with the USG-GRN HRH TWG to develop and implement a rational transition plan for Community Counselors and other lay facility- or community-based health care workers.

CDC continues to transition responsibility for the procurement of HIV Test Kits and Supplies to MOHSS, which will procure a greater number of test kits with its own funds in COP12. The COP12 budget for this line item represents a nearly 50% reduction compared to COP11. Kits will be procured and distributed by the MOHSS Central Medical Stores. MOHSS will also continue a feasibility assessment for implementing oral fluid rapid HIV testing in specific settings, including outreach and correctional settings as well as related quality assurance support.

Promotion of HCT through an Annual National HIV Testing Event: Funding will support promotional activities in all 13 regions, including drama presentations, radio announcements, other educational events, and production and distribution of print materials. Outreach-based HIV counseling and testing services will be provided during the National Testing Day event.

Continued support for approximately 20% of the facility-based lay-Community Counselors (CC) program = $656,212. Procurement of approximately 4.5 million male and female condoms = $0. Supporting the Ministry of Health and Social Services (MOHSS), Department of Social Welfare Services for alcohol/HIV prevention activities = $120,000. Support for MOHSS Prevention staff to conduct e program support visits and to attend capacity building trainings and conferences = $50,335. Support for Condom Logistics Officers at district hospitals to facilitate local supply and distribution of condoms to health facilities and PEPFAR-funded nongovernmental organizations (NGO) and faith-based organizations (FBO) who distribute condoms to high-risk people = $87,699.

Community Counselors (CC): Continued support for approximately 20% of the facility-based lay-Community Counselors (CC) program will be given in COP12, which is distributed among five activity areas: Other Prevention (20%), counseling and Testing (45%), Prevention of Mother to Child Transmission (15%), Adult Treatment (10%), and HIV/TB (10%). This includes salaries for 650 CC who are deployed in public health sites to work on activities such as HCT, ARV, TB, PMTCT, as well as correctional facilities; training implemented by MOHSS through ITECH, supervisory support visits, and; support for planning meetings and an annual retreat for CCs.Under HVOP, facility-based lay CC work will focus on condom distribution, HIV prevention counseling, and outreach to people living with HIV and AIDS (PLWHA) to reduce high-risk behaviors through faithfulness to one partner. CC address cultural norms that factor into HIV transmission, including lack of health care seeking behavior by men, multiple sex partners, transactional and trans-generational sex, power inequities between men and women, and alcohol abuse. Funding is also used to support refresher training workshops on HCT related topics such as male circumcision, prevention for PLWHA, and alcohol abuse.

Condom Procurement: The budget for this activity was zeroed and moved to a USAID central mechanism. In COP12 support for Condom Logistics Officers at district hospitals is given, to facilitate local supply and distribution of condoms to health facilities and PEPFAR-funded nongovernmental organizations (NGO) and faith-based organizations (FBO) who distribute condoms to high-risk people.

Alcohol/HIS Prevention: USG funds will continue to support the MOHSS Coalition on Responsible Drinking (CORD). CORD incorporates media messaging and works with community, business, and health partners, as well as shebeens and breweries to reduce alcohol abuse, a major driver of the HIV epidemic in Namibia. CORD exists in all 13 regions of Namibia. Funds will educate business owners and the general public about the association between alcohol consumption, high-risk sexual behavior, and HIV transmission.

Community Counselors (CC): MTCT support will focus on HIV counseling and testing (HCT); adherence, prevention, and referral services in PMTCT and ANC settings. Funds will also support refresher training workshops. In COP12, CDC will continue to work through the USG-GRN HRH TWG to develop a transition plan for this cadre of lay healthcare workers.

Procurement of supplies and equipment, including hemoglobin meters for monitoring anemia, weighing scales, furniture, lockable cabinets and equipment.Training for Traditional Birth Attendants (TBA): TBA will be trained on PMTCT, HIV prevention, reproductive health, and referrals. In addition funds will be used for TBA kits and supervisory visits. Support for an IEC campaign promoting PMTCT. Activities will include development, production, and dissemination of PMTCT IEC materials for use in clinical and community settings.Funds will support revision, printing and distribution of tools and registers for improved mother-baby follow-up.Implementation of the new PMTCT guidelines: Funds will support the roll-out of revised PMTCT guidelines including printing and distribution, curriculum review, and review of user tools for PMTCT (registers summary reporting forms, job aids and IEC materials).Capacity building of health workers to implement new guidelines: MOHSS will roll out training at regional level to complement limited numbers of health workers trained by ITECH and NHTC.Development and implementation of service integration model for PMTCT, ART, TB/HIV and pediatric ART. Funds will support the development and implementation of a service integration model for PMTCT, ART, FP and ANC services, technical assistance, baseline assessment, tools development, training of providers, supervision, monitoring, evaluation and roll out of service integration model.eMTCT coordination. Funds will support MOHSS coordination efforts between the Directorate of Special Programs and Primary Health Care.

Routine bio-clinical monitoring tests: Funding will support bio-clinical monitoring of ART patients.Support for CD4 Point of Care (POC): In COP12, this technology will be rolled out to remote health facilities to increase access to testing, decrease lab costs and increase quality of care.Community Counselors (CC): CC provide HCT, ART adherence, prevention, and MC counseling; and make use of referral services.Nutrition support for PLWHA: Implementation of the nutrition assessment, counseling and support (NACS) program as it expands to every district over the next two years. See PDTX for additional details.Basic clinical equipment: Reduced support for commodities procurement for ART services in primary care clinics.Mobile HIV Services: Ongoing implementation of mobile service units to deliver prevention counseling, HCT, MC, ART and other PHC services to remote areas.HR administration: Funds will support operational costs, internet access, IT support within the HR unit.Renovations: Funds will supplement MOHSS and Global Fund resources to renovate existing public health facilities for expanded HIV, PMTCT, and TB services.HIV quality improvement (HIVQUAL) program: In COP12, partial funding for this activity will be directly funded through the MOHSS to support QI mentoring, conference participation and training.Regional ART trainings: In COP12 the USG will increase direct support to the MOHSS to conduct localized trainings through the regional health training network to address the individual training needs of the regions.Adherence promotion: MOHSS will pilot evidence-based ART adherence support interventions such as SMS technologies (baseline and follow assessments).Service integration: USG will support development, implementation and evaluation of a service integration model for PMTCT, ART, FP and ANC services (TA, baseline assessment, tools development, training of HCW).

Routine bio-clinical monitoring tests: Funding will support routine bio-clinical monitoring tests for pediatric patients at MOHSS facilities. These tests will be performed by the Namibia Institute of Pathology (NIP). Funding will also support CD4 monitoring of non-ART patients enrolled in pre-ART care. The MOHSS will also link clinical and laboratory data systems to reduce turn-around time and improve data quality.

Point of care testing: The NIPs system for specimen referral ensures countrywide coverage for laboratory services. However, the referral system faces the challenges of specimen collection, transportation from health facilities to the laboratories, and long turn-around times for test results. The cost of laboratory testing has also increased and seems not to be sustainable. To address these challenges, MOHSS and USG piloted a CD4 POC in 2011. In COP12, this technology will be rolled out to remote health facilities. This will increase access to testing, decrease cost of laboratory testing and increase quality of care and support services.

Nutrition support for PLWHA on ART, including children: PEPFAR will support MOHSS to strengthen the nutrition assessment, counseling and support (NACS) program as it expands from 15 to 34 districts over the next two years. This activity is linked to the USAID FANTA III project and ITECHs support for building capacity of health care workers in ART, MCH and PHC clinics. Funds will procure and deliver reduced quantities of food supplements as USG transitions out of food procurement and logistics. This activity will include support for regional and national supportive supervision, oversight and program monitoring in coordination with other USG partners.