ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS:

JHPIEGO's ART2Scale project activities in the FY 2009 COP will separate HIV and AIDS treatment work

from systems strengthening. The policy and systems strengthening work on building consensus, and

stakeholder buy-in for both accreditation and Nurse-Initiated and Managed (NIM) antiretroviral therapy

(ART) policy development, which were dealt with under the treatment section in the FY 2007 and 2008

COPs, will move to systems strengthening. FY 2009 COP activities will be modified as follows:

ACTIVITY 1: Performance Standards

JHPIEGO proposes a model that will link accreditation to standards-based management and recognition

(SBM-R), whereby facilities are accredited in order to ensure high quality ART service provision, and the

SBM-R approach is used to sustain quality post accreditation. To strengthen TB/HIV integration, JHPIEGO

will work with the National Department of Health (NDOH) to develop a specific SBM-R standard focused on

improving TB case finding, TB preventive therapy and TB management in accordance with the national TB

infection control guidelines. Also, with the NDOH, JHPIEGO will also explore the development of SBM-R for

TB service delivery, which would include HIV testing of TB patients.

The SBM-R model will be introduced to five primary health care (PHC) facilities that were assisted by

JHPIEGO to get accredited in FY 2007. Building on the FY 2008 COP, during which JHPIEGO would have

initiated ART SBM-R in five sites within a district in Limpopo province; JHPIEGO proposes to expand to four

facilities with FY 2009 funding, and to strengthen the capacity of district and facility teams to implement the

program. This will be achieved through training, on-site technical support, involving different stakeholders

and sharing SBM-R results widely with provincial, district and facility staff. Together with the provincial

Quality Assurance and HIV and AIDS managers, JHPIEGO plans to establish provincial, district and facility

teams in order to institutionalize SBM-R. The SBM-R teams and staff at implementing sites will be trained

on the SBM-R approach and tools. The following activities will be undertaken to strengthen SBM-R:

conducting baseline assessments of actual performance at targeted sites, conducting root cause analysis

and design of interventions, implementing interventions to improve quality of services, supporting

continuous measurement of actual performance, and working with the provincial and district management to

establish criteria for recognition and rewarding best performing sites. As a result of these interventions,

sites are anticipated to achieve a minimum score of 85% on the ART SBM-R standards.

ACTIVITY 2: Strengthening Nurse-Managed Antiretroviral Therapy and Comprehensive HIV and AIDS

Services

With FY 2007 funding, JHPIEGO provided technical support to the development of the national NIM ART

framework, and conducted a situational analysis to assess capabilities and readiness of NIM ART within

comprehensive HIV and AIDS services. It is expected that the focus in the implementation of the FY 2008

COP will be the dissemination of NIM ART results, and further collaboration with DOH in the development

and finalization of NIM ART policy. JHPIEGO will further collaborate with nursing institutions and

associations on the development of training curricula and strategies for pre-service and in-service nurses. In

the FY 2009 COP period, JHPIEGO proposes pre-service and in-service workforce development for nurses

in line with the NIM ART framework, which will address the role of nurses and task-shifting in clinical

management of ART. JHPIEGO will work with nurse-training institutions to strengthen and align training

curricula to NIM ART, and strengthen linkages between the training institutions and provincial departments

of health. To improve nursing skills on TB/HIV integration, JHPIEGO will ensure that all aspects of TB/HIV

management will be included in the curriculum (e.g. systematically offering counseling and testing to all TB

patients and providing insulin potentiation therapy (IPT) to eligible people living with HIV (PLHIV)).

Task shifting will broaden the range of health workers to manage ART services and increase access overall.

JHPIEGO proposes a competency-based in-service training for nurses on ART and comprehensive HIV and

AIDS management, advanced ART course for ART specialization, development of nursing job aides for

ART services, as well as on-site support and supervision to trained providers in selected sites in order to

strengthen the management of ART clients by nurses including TB/HIV integration. Competency-based

training is a methodology that relies on the learner demonstrating the ability to put the lessons into practice

before moving on with other areas of learning. As a result of this intervention, it is expected that 460 nurses

will be trained on NIM ART nationally.

ACTIVITY 3: Expand Capacity for Accreditation, Site-Readiness and TB/HIV integration

In the FY 2007 COP period JHPIEGO began conducting national accreditation capacity building workshops

for provincial teams. JHPIEGO will focus on district and facility-based trainings in supported provinces and

upon provincial request in the FY 2008 COP period. With FY 2009 funding, the accreditation technical

support will be expanded from two provinces to four provinces: Limpopo, Northern Cape, Eastern Cape and

North West. JHPIEGO will continue to strengthen and expand accreditation through capacity building for the

provincial, district and facility accreditation teams. JHPIEGO will conduct district-based accreditation

workshops to capacitate the accreditation teams and service providers on site readiness, the accreditation

tool and the process, conducting self-appraisal and development of action plans to fill performance gaps.

JHPIEGO will assist the department of health prepare twenty-four sites to get accredited. The national

accreditation tool will be used as framework to prepare facilities for accreditation, identify gaps and develop

action plan, and provide technical support until facility is accredited. The accreditation of primary health

care (PHC) sites will strengthen down referral by ensuring that there is capacity at PHC for hospitals to refer

ART patients close to where they live. During accreditation on-site support JHPIEGO will assist facilities to

strengthen referral systems with other facilities within a service point; and assist them identify and

strengthen links with community-based support organization that provide counseling, home-based and other

relevant services within the catchment population.

JHPIEGO will ensure the training of staff on infection prevention and control. In collaboration with the

Foundation for Professional Development (FPD) and other PEPFAR partners, JHPIEGO will provide

Activity Narrative: continuing education on TB/HIV strengthening using FPD's standardized, certified modules. JHPIEGO will

create or strengthen TB/HIV integration models. Patient education will be enhanced through the distribution

of TB information, education, and communication (IEC) materials to enable PLWHA to recognize TB

symptoms, to protect themselves and others from exposure to TB. JHPIEGO will provide technical

assistance on proper ventilation in accordance with the national TB infection and control guidelines. If and

when a need arises, JHPIEGO will assist with the procurement of ultraviolet germicide radiation lights in ten

of the primary health care clinics or community health care clinics in four provinces (Limpopo, Northern

cape, Eastern Cape and North West provinces).

--------------------------------

SUMMARY:

JHPIEGO's activities support efforts by the National Department of Health (NDOH) and public sector

antiretroviral therapy (ART) sites in Gauteng to ensure access to and quality of ART services. The

emphasis areas include human capacity and development (including task shifting for nurse managed ART

services), and local organization capacity building. Specific target groups include people living with HIV

(PLHIV).

BACKGROUND:

JHPIEGO has been working with the NDOH since FY 2004 to improve institutional capacity through training

and dissemination of national HIV and ART guidelines and through support of a treatment technical advisor

to the NDOH. In FY 06 and FY07, JHPIEGO partnered with the Foundation for Professional Development

(FPD) (a PEPFAR-funded partner) to initiate a standards-based management and recognition approach for

improving ART services. In FY 2008, JHPIEGO will continue to implement these interventions, aimed at

improving access to and quality of HIV and AIDS service delivery. In FY 2007 JHPIEGO supported

implementation of the NDOH's model for nurse-initiated and managed ART through an approach that will

encourage a healthcare culture supportive of nurse-initiated and managed ART; a policy environment that

will ensure that these frontline nurses have the training, funding, and ongoing support they require; and

ensure that South African training institutions are strong partners in the efforts to achieve the ambitious

targets set in the HIV & AIDS and STI Strategic Plan for South Africa, 2007-2011 for increasing the

proportion of adults and children started on ART by nurses. These activities will continue in FY 2008.

ACTIVITIES AND EXPECTED RESULTS:

ACTIVITY 1: Performance Standards

Standards-based Management and Recognition (SBM-R) is a practical management approach for

improving the performance, efficiency and quality of health services. It consists of the systematic utilization

of performance standards as the basis for the implementing organization and related service delivery.

Compliance with standards is recognized through formal mechanisms and is in line with NDOH standards

and guidelines. In FY 2005 and FY 2006, JHPIEGO developed detailed performance standards for ART and

introduced this process at four FPD-supported ART sites. Performance standards focused on twelve

different areas of ART service delivery including pre-treatment, treatment commencement, and

management of complications for both children and adults; pharmacy services; laboratory services;

information, education and communication; health information systems; infrastructure; and human

resources.

Based on the initial work by the South African Government in FY 2007, JHPIEGO will support scale-up of

this process to other NDOH sites in the Northern Cape, especially those where ART will be integrated into

primary healthcare services. JHPIEGO will coordinate with other PEPFAR treatment partners in the

accreditation process. JHPIEGO will support scale-up of SBM-R for ART in the Gauteng province, or other

provinces as requested by the NDOH. As a result of these interventions, access to and quality of ART

services will improve for both children and adults.

ACTIVITY 2: Strengthening Nurse-Managed Antiretroviral Therapy and Comprehensive HIV and AIDS

Services

In FY 2008, JHPIEGO will continue to support implementation of the NDOH's model for nurse-initiated and

managed ART through an approach that will encourage a healthcare culture supportive of nurse-initiated

and managed ART; a policy environment that will ensure that these frontline nurses have the training,

funding, and ongoing support they require; and ensure that South African training institutions are strong

partners in the efforts to achieve the ambitious targets set in the HIV & AIDS and STI Strategic Plan for

South Africa, 2007-2011 for increasing the proportion of adults and children started on ART by nurses.

JHPIEGO proposes strengthening both in-service and pre-service education with a focus on training nurses

and providing on-going support to ensure their competency in day-to-day management of patients on ART

and identification and referral of treatment complications from the health center to district hospital level.

This will relieve the heavy client burden on tertiary ART institutions resulting in improved access for current

clients and more clients getting on ART.

ACTIVITY 3: Expand Provincial and District Capacity of Accreditation and Site Readiness

In FY 2008, JHPIEGO will continue to work with the National Department of Health to build the capacity of

the national, provincial and district teams to accredit sites. Activities will include adaptation of the

accreditation tools for primary health care level, training and onsite mentoring of teams. JHPIEGO will also

work with the sub-district level teams by providing support for implementation of site readiness plans and

work with other USAID treatment partners to assist them in receiving ART accreditation for their sites.

These activities will indirectly contribute to the overall PEPFAR objectives by ensuring sustainability and

Activity Narrative: quality of ART services. Technical experts working with NDOH will indirectly contribute to increased access

to treatment services through site accreditation, and standards-based management of services will indirectly

increase access due to improved quality of service. These activities contribute the PEPFAR goal of putting

two million people on treatment, and support the USG/SA Five-Year Strategy by building capacity for ART

service delivery.

New/Continuing Activity: New Activity

Continuing Activity:

Emphasis Areas

Construction/Renovation

Gender

* Addressing male norms and behaviors

* Increasing gender equity in HIV/AIDS programs

* Increasing women's legal rights

Health-related Wraparound Programs

* Family Planning

* Safe Motherhood

* TB

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $800,000

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.09:

SUMMARY:

Jhpiego's activities support efforts by the national Department of Health (NDOH) to expand the

Comprehensive HIV and AIDS Care, Management, and Treatment (CCMT) plan to ensure increased

access to services in antiretroviral therapy (ART) and other forms of care. Jhpiego has provided technical

assistance to the NDOH in increasing access to ART services through task shifting efforts focusing on

Nurse Initiated and Managed ART (NIM-ART).

BACKGROUND:

Jhpiego has been working with the NDOH since 2004 to improve institutional capacity for implementation of

the CCMT program through training and dissemination of national HIV and ART guidelines and through the

placement of a Care & Treatment Technical Advisor to the NDOH. Through a separate funding mechanism,

Jhpiego partnered with the Foundation for Professional Development (FPD), to initiate a Standards-Based

Management and Recognition (SBM-R) approach for improving ART services. Under COP 2007, Jhpiego

has supported the development of a practice directive of nurse initiated ART in public health facilities, an

approach that will encourage a health care culture supportive of nurse-initiated and managed ART; a policy

environment that will ensure that these front-line nurses have the training, funding, and ongoing support

they require; and a strategy that ensures South African training institutions are strong partners in the efforts

to achieve the targets set in the HIV & AIDS and STI Strategic Plan for South Africa, 2007-2011 (NSP). The

NSP aims to increase the proportion of adults and children started on ART by nurses. Jhpiego will continue

to implement these interventions aimed at improving access to quality HIV and AIDS service delivery.

ACTIVITIES AND EXPECTED RESULTS:

Jhpiego will carry out these three separate activities in this program area.

ACTIVITY 1: Continued support for the development of a policy framework and guidelines for NIM-ART

centering on the dissemination of the NIM-ART policy guidelines to managers at national, provincial and

district levels.

The dissemination entails detailed orientation to the guidelines and training on issues of SBM-R, an

approach that ensures quality, efficiency and proficiency of service delivery. The ART SBM-R

comprehensive tool has a total of 165 standards in ART Treatment Readiness in Adults; ART Treatment

Commencement in Adults; Follow-up and Management of ART Complications in Adults; ART Treatment

Readiness in Children; ART Treatment Commencement in Children; Follow-up and Management of

Complications in Children; Laboratory; Pharmacy; Marketing; Information Education and Communication

(IEC); Community Participation; Medical Records and Information Systems; Human and Physical

Resources; Management System. ART SBM-R enhances the quality of ART management through assisting

the facilities in setting their performance standards from the onset.

ACTIVITY 2: Implementation of NIM-ART

Jhpiego is currently piloting the SBM-R approach in five FPD-run facilities in Gauteng and North West

provinces. With NDOH approval, Jhpiego will integrate SBM-R into NIM-ART roll-out to ensure adherence

to treatment protocols, infection control measures and pharmacology vigilance. Jhpiego is already working

with Limpopo, Northern Cape, North West, Eastern Cape and NDOH on site-readiness for accreditation of

Primary Health Care (PHC) facilities. It is in the accredited facilities that NIM-ART will be implemented.

Jhpiego will conduct two-day workshops for nursing schools; the Nursing Council; managers at national,

provincial and district levels; and other key stakeholders in the implementation of a nurse-driven model for

ART services. At the workshops the managers will gain more insight into task shifting and will outline the

strategies they plan to use in the deployment of staff, especially given the enhanced role of nurses in

initiating ART.

ACTIVITY 3: Technical Assistance in Institutional Capacity Building

Jhpiego will conduct more intense follow-up sessions with fourteen institutions to assist in a more strategic

focus, such as line item budget development and developing plans for integrating NIM-ART guidelines into

their specific organizational infrastructure. The plans would focus more on staff training and task re-

orientation, drug procurement and budgetary issues critical to the implementation of the program. This

activity will target institutions providing ART services, including provincial Departments of Health (PDOHs),

the Department of Defense (DOD), correctional institutions and non-governmental organizations (NGOs).

Jhpiego will work in consultation with NDOH in prioritizing the organizations for institutional capacity

building. It is anticipated that Jhpiego's technical staff will be able to respond to requests at national and

provincial levels to interpret and unpack the policy guidelines disseminated. For cost-effectiveness, Jhpiego

will link this activity with the other components of ART2Scale up given that the activities target the same

providers and managers.

New/Continuing Activity: New Activity

Continuing Activity:

Emphasis Areas

Gender

* Increasing gender equity in HIV/AIDS programs

Military Populations

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $11,558

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Program Budget Code: 19 - HVMS Management and Staffing

Total Planned Funding for Program Budget Code: $28,537,626

Total Planned Funding for Program Budget Code: $0

Program Area Narrative:

HIV and AIDS continue to be the number one priority for the US Mission in South Africa. Managing and coordinating the

implementation of the PEPFAR program in South Africa is the responsibility of an Interagency USG PEPFAR Team that includes

representation from the Department of Health and Human Services (HHS), the Centers for Disease Control and Prevention

(HHS/CDC), the United States Agency for International Development (USAID), the Department of Defense (DOD), Peace Corps,

and the Department of State. These represent all relevant USG Agencies present in South Africa working on global health. The

primary objectives of the PEPFAR Team are to: 1) advise the Ambassador and other US Embassy leadership on all matters

related to HIV and AIDS in South Africa; 2) plan the overall USG response to HIV and AIDS in South Africa; 3) coordinate USG-

supported HIV and AIDS prevention, treatment and care activities with the South African government (SAG); and 4) ensure that

USG activities are consistent with guidance from the Office of the Global AIDS Coordinator (OGAC).

Central features of the South African PEPFAR management and staffing plan are: 1) an effective Interagency PEPFAR team that

meets monthly to guide the U.S. Mission in developing and implementing a coordinated USG HIV and AIDS program; 2) a

Secretariat that facilitates the communication, coordination, and planning necessary for effective PEPFAR Team deliberations and

actions, which in turn helps assure successful, uniform messaging to all stakeholders; and 3) an Interagency Management

Committee that meets on a regular basis to give policy direction, approve new partner selection, and review budget and staffing

decisions regarding USG HIV and AIDS activities in South Africa. Its members are the DCM (Chair), senior leadership of USAID

and CDC, representatives of Peace Corps and DOD, and the Health Attaché.

PEPFAR in South Africa will continue to operate as a single, integrated USG program, taking advantage of each Agency's

individual comparative strengths, and promoting a culture of Interagency collaboration. When an Agency possesses technical

expertise it will take the lead, but in consultation with other Agencies through the local Technical Teams that has been established

by the PEPFAR Team. For example, USAID has technical staff with extensive experience in working with partners in the area of

Orphans and Vulnerable Children (OVC). CDC, Peace Corps, DOD, and DOS also have assigned staff to assist in the OVC area.

CDC has technical expertise in Lab work and is bringing together local stakeholders to work with NDOH to improve quality lab

services. In other technical areas, such as treatment and prevention, which are the largest portfolios, the responsibilities are

shared by both CDC and USAID, and technical guidance is coordinated through the technical pairs, who serve also as chairs of

Technical Teams. Ad hoc committees are also formed in response to needs. One example of this is the government and

provincial coordination Ad Hoc Committee, that was established to work closely with SAG to align PEPFAR activities with those of

the SAG and the priorities of the HIV & AIDS and STI Strategic Plan for South Africa, 2007-2011. Membership on the Technical

teams and ad hoc committees is always representative of multiple Agencies. Furthermore, several members of the PEPFAR

Team in South Africa participate in the OGAC TWGs and liaise with Washington. This provides OGAC with input from the field,

and also provides the SA program with input from central expertise.

The interagency team implemented a Staffing for Results exercise in July 2007 and is in the process of recruiting this staff. New

positions were approved in last year's COP. The management committee is responsible for reviewing and addressing on-going

staffing issues. Although the South Africa budget is likely to decrease over the next five years, staff needs will not diminish for a

number of years, given the overall size of the portfolio. Historically, PEFPAR South Africa has very low administrative costs, with a

ratio of management and staffing to overall country budget of 4%. This year, however, funds have provisionally been set aside by

USAID and CDC for the purpose of obtaining new office space given critical building constraints, raising the ratio to 7% for the first

time.

In FY 2008 the Country Team conducted the PEPFAR South Africa Interagency Partner Evaluation. Interagency panels reviewed

the accomplishments to date and FY 2009 plans of all partners grouped by Program Area. Panel members included

representatives of USG agencies, the South African government and headquarters-based technical working groups (in some

cases by DVC and in other cases in person). For the sake of objectivity, activity managers did not participate in reviews of their

own partners, except to answer questions. The PEPFAR team jointly drafted technical program considerations against which

partners' plans were evaluated to ensure that proposed activities were aligned with USG and SAG priorities. The panels'

recommendations led to significant modifications in the budget, and provided the basis to make the cuts needed for this year's

overall country reduction. This was a highly successful activity and will be repeated in future years with a few minor modifications.

The South Africa PEPFAR Team has created management efficiencies through use of several interagency mechanisms. A major

accomplishment in FY 2008 was the award of a contract for the monitoring and assessment of activities of PEPFAR sites

throughout the country, in every technical area. This contract, in the process of being finalized, is managed by CDC, and will

provide services to both CDC and USAID, and potentially other agencies working on PEFPAR. The end result will be improved

quality at PEPFAR sites. Another efficient mechanism are the umbrella grants to organizations that provide grants management,

and financial and technical assistance to local grantees, thereby reducing the government cost of additional employee salaries.

Both CDC and USAID have developed these mechanisms.

State 00112759 requested missions to report best practices for interagency coordination. The PEPFAR South Africa Team

considers itself to be overall a best practice in terms of interagency collaboration. All of the practices mentioned above contribute

to our successful interagency collaboration. Other best practices include several joint interagency processes listed below. An

interagency Annual Program Statement (APS) is used to select partners. To date, PEPFAR SA has conducted four solicitations

for new partners through the USAID-let Annual Program Statement (APS). The CDC Procurements and Grants Office has agreed

that this competitive solicitation can be used to also make awards for CDC. The announcement is developed and agreed upon by

both agencies, applications are reviewed by all USG agencies and new awardees are selected and allocated to the most

appropriate agency. This reduces the burden on USG staff to conduct multiple solicitations for new partners and ensures that new

partners allocations are agreed upon by all USG agencies.

All PEPFAR partners report on the same indicators and in the same format on a quarterly, semi-annual and annual basis via a

single web-based reporting system (Data Warehouse). USG staff have access to all partner reports. With over 130 partners

reporting and more than 500 sites reporting ART data, this facilitates timely reporting of data and enables aggregated data

analysis for program decision making.

In January 2008, the USG Strategic Information and Treatment teams conducted a joint assessment of ART patient monitoring

systems (Interagency HMIS review). The objectives were to gain a better understanding of USG-funded systems, provide

guidance to partners on issues such as system interoperability, and gather technical assistance needs from partners. A

dissemination meeting was held in April 2008 to provide feedback to all USG partners on the results and recommendations from

the assessment and to provide a forum for sharing of tools between all USG ART partners.

Every year, the USG PEPFAR team conducts joint Data Quality Assessments (DQA) on 12-14 PEPFAR partners to ensure that

the data that are reported are valid and reliable. An external contractor, guided by the USG team, conducts these audits and uses

standard tools and methods across all partners.

Finally, personal commitment on the part of all agency staff contributes to the well-functioning South African interagency process.

Table 3.3.19: