The South African National Strategic Plan (NSP, 2007-2011) for HIV/AIDS and STIs notes that a reduction of new HIV infections by 50% by 2012 (within 5 years) is an ambitious target that requires a supportive policy framework. Therefore, the Department of Health seeks to expand the primary model (VCT) to include provider-initiated counseling and testing (PICT).

In partnership with the National Department of Health (NDOH) and Provincial Department of Health in Eastern Cape, Limpopo and KwaZulu-Natal, AMREF aims to strengthen counseling and testing services in Amathole, Umkhanyakude, and Sekhukhune districts, respectively. The project will build the capacity of health providers to provide HIV testing to people attending health facilities within the South African counseling and testing model and build on the initiative by the Department of Health and other service providers, on provider - initiated counseling and testing (PICT). This will be done through through on site (clinic facility) mentoring and coaching. The target population includes health professionals working in

HIV and TB services, including lay councilors and/or DOTS supporters. AMREF will strengthen Counseling and Testing services and collaboration with TB services, and will strengthen referral systems between HIV and TB services as means to increasing access to quality VCT and TB services.

The project comprises a series of coordinated interventions that aim to achieve the following outcomes: (1) increased capacity of the selected VCT sites in the three provinces; (2) improved integration and coordination of HIV and TB services in selected facilities in the same areas. (3) a sound data management strategy in place that supports the DHIS at facility level, (4) improved management of the facilities that AMREF is currently supporting. AMREF will work in partnership with the provincial, district and municipality levels of the Department of Health to improve the quality of HIV counselling, testing, support and care services and to ensure that effective referral is taking place between HIV and TB and other PHC services. AMREF will achieve this through: (a) comprehensive training programs; (b) continuous mentoring of trainees (health workers); (c) developing and strengthening sustainable systems for quality VCT services, referral, and VCT and TB co- ordination; (d) strengthening data management at facility and local service area level. AMREF will focus its attention on Human Capacity Development. Specifically, AMREF will conduct training in VCT, VCT-TB, and data management. AMREF will also provide mentoring support to health workers on VCT and VCT- TB integration and monitor the referral system for HIV and TB clients. Four main outcomes (results) are expected: (1) Increased number of healthcare providers trained and applying acceptable standards in counseling and testing; (2) Increased number of people counseled and tested for HIV and TB and receiving their results. (3) a sound data management strategy in place that supports the DHIS at facility level, (4) improved management of the facilities that AMREF is currently supporting. Activity 1: Capacity Building The human capacity building activities are in line with South African National Strategic Plan for HIV/AIDS, and STIs (2007 to 2011). Specifically, AMREF will continue to support 180 health facilities in the project areas. AMREF has provided initial training and continuing support to these facilities. In the coming year we will carry out the following activities.

1. Because of high staff turnover in the areas, staff members who have been hired recently will not have received the initial training. AMREF will train recently hired healthcare providers from 180 facilities in counseling and testing, integration of TB and HIV, and data management, according to national and international standards.

Training programs will be on VCT (10 days), VCT-TB integration (3 days), and data management (3 days). This intervention is aimed at improving the overall quality of service provision for Counseling and

Testing by addressing human resources capacity gaps and critical weaknesses as identified by the needs assessment and district/provincial DOH. Training will also strengthen data collection, management, and organizational systems, including the referral system.

2. We will continue to provide mentoring support to health providers to ensure that VCT and TB service providers are applying the knowledge and skills by the have learned. The mentor will visit facilities at least once a month and will be available for consultation between visits. AMREF will support health providers to apply policy guidelines for both routine and provider-initiated counseling and testing to increase access to counseling and testing services. We will put Standard Operating Procedures (SOPs) for client services in place to support the facility staff. AMREF will also do onsite training as part of regular support supervision visits.

AMREF will identify the gaps between the training done and the implementation of the training, and will monitor the health workers to ensure that the mentoring is having an impact. AMREF will also identify facilities that have been supported by the program for three years and are doing well, and will reduce the number of visits with the goal of phasing out support for those capable of standing on their own.

ACTIVITY 2: DATA MANAGEMENT Khulisa Management Services conducted a Data Quality Audit at the health facilities in 2008. They examined six data quality criteria: validity, reliability, integrity, precision, timeliness, and completeness. Some strengths and deficiencies were noted especially on the total risk scores (TRS) during the clinic audit (8 out of 16 for precision/accuracy) and office audit (validity (9/16 TRS); reliability (9/16 TRS); precision/accuracy (12/16 TRS); completeness (9/16 TRS). Khulisa recommended that AMREF improve reliability and precision of data collection and collation by developing standard operating procedures (SOP) with clear quality control steps and data collation tools. They further recommended that we monitor transcription at critical points in the DMS, maintain an error log to record all data errors found, and ensure that all data management documents are dated accurately. AMREF is implementing these recommendations.

In the third year of the grant, AMREF will strengthen M&E and referral systems to improve data management and institutional systems for VCT and TB data collection, management, reporting and use. This will involve analyzing DMS at facility level, conducting data audits and quality assurance, developing tools and manuals for data management, collection and collation, and technical assistance to the Department of Health (especially at LSA level) on DHIS. AMREF will conduct strategic meetings and training workshops with key stakeholders such as Information Officers, Programme Managers, and local HAST committees (where they exist) to strengthen the quality of data inputs from facilities into the District Health Information System (DHIS).

AMREF has embarked on a threefold data management system that includes immediate, intermediate, and advanced intervention. The immediate intervention aims to address the immediate data need of the facility. Therefore, AMREF will assess which tools are being used within the facility and the logic of the use of the tools in relation to the information flow of the facility. Based on the assessment, we will facilitate a training to ensure that the facilities are using the paper-based data collection system correctly. The training will include ensuring that the HF staff understand how the data they collect is passed on to LSA and then to the District, where it is entered into an electronic data system (DHIS).

The M&E Officer and provincial mentors provide follow-up support. The final aspect of this process is for the mentors to take the information to the district for data input into the DHIS System. This information is then verified and the figures are fed back to the facility. The facility then plots the figures on a graph so that they can measure their progress and use the information to identify problems and implement changes to address them. In this way, the facilities own their data and learn to value it.

Activity 3: Referral Systems In FY2007, AMREF refined the Eastern Cape Department of Health's referral protocol for VCT and TB patients. In FY2010 AMREF will roll out and/or institutionalize the use of a referral system (and tools) for VCT and/or TB services in all three provinces. This will be done through a consultative approach with the Department of Health in the provinces. An external consultant will be used to carry out this specialized activity.

AMREF will work in collaboration with service providers to monitor the referral system. In line with the mentoring support strategy, we will check the use of the referral tools and track access to services for referred clients. This will enable accurate data and monitoring of the number of HIV infected clients that are undergoing screening for TB. AMREF will also conduct on-site training for health providers who were not previously trained on the referral system. If use of the tool indicates that it should be refined, AMREF will refine the tool in line with the needs of the relevant stakeholders. The tool will then be implemented again and monitored.

Activity 4: Quality Assurance AMREF has identified the link between quality of services offered to clients and uptake of voluntary counseling and testing. If clients feel that they are treated kindly and competently and with respect, they are willing to seek care, but if they do not like the way they are treated, they will not use the facility. Hence, AMREF has embarked on an initiative that will improve the quality of service and measure client satisfaction. We will develop a quality management tool that measures customer care, quality assurance in general, clinic/ facility audit and clinic/facility staff practices. WE will then train staff on all the above

issues. Facilities will implement the tool and be measured on a quarterly or ad hoc basis and the facility that scores the highest in terms of quality assurance will be rewarded with a motivational token (for example a trophy).

Activity 5: Community Involvement To increase uptake of services, it is important for AMREF to reach beyond the facilities into the communities to disseminate messages that encourage people to know their HIV status. However, the project does not have the resources for an extensive community motivation intervention. Therefore in year 3, when project staff visit facilities, they will not only check on how the referral tool is working, and if the data management system is in place, but will ask what community efforts are under way and how AMREF can work with the communities, with CBOs and FBOs to support the project goals.

Activity 6. Monitoring, Evaluation, and Documentation AMREF will document outcomes and lessons learned on approaches and strategies that are shown to improve access to VCT services and cross-referrals between VCT and TB services. HAST committees are charged with monitoring and evaluating the performance of the health facilities, but are not doing it. We feel that documenting lessons learned will be an important step in increasing the understanding of HAST committees and district authorities of how good data can be used to improve quality and to increase access to services, and therefore gain their commitment to maintaining and using the HMIS. This is crucial to the sustainability of the project, because if the committees and districts do not take over the responsibility for the system, it will cease to function when the project has ended. AMREF will convene strategic meetings with policymakers (Department of Health) and HAST committees and other key civil society bodies to demonstrate the importance of a high quality HMIS for identifying problems and setting priorities.

The Programme Manager (based in AMREF's Pretoria office) works with the Country Director, Deputy Director, and Finance Manager to develop the project work plan and budget, and directs its implementation. She supervises the project staff and reports to the Deputy Country Director. She is responsible for establishing and maintaining the project's relationships with the Department of Health and with the CDC. She is responsible for preparing project reports.

The project employs four Project Managers, one each in Limpopo and KZN and two in Eastern Cape. They provide project management and implementation oversight in each province, supervise and support the Project Officers, communicates and coordinates with the provincial and district departments of health on implementation, and write progress reports. They report to the Programme Manager.

There are three Project Officers, one in each province. They assist the Project Managers with all aspects of the project in their district. These are key technical staff members responsible for supporting all project activities, especially health worker training and mentoring, and reporting.

Two Project Assistants are assigned to Limpopo and KZN, due to the workload and the geographic spread of the sites supported. The PAs will support project activity, strategy development, and implementation; and will provide administrative support to the Project Officers and Project Managers.

The M&E Officer deals with data collection, analysis, and use of data for planning within the project areas as well as all levels of the health system. The M&E Officer works closely with the Programme Manager to improve data management and quality, including analyzing DMS at facility level, conducting data audits and quality assurance, and developing tools and manuals for data management, collection and collation. The Officer provides technical assistance to the Department of Health (especially at LSA level) on DHIS.

The Quality Assurance Manager focuses on: (1) monitoring client service at facility level, insuring that the service offered is of good quality, in terms of the actual information parted to the client; (2) data quality management at facility level, especially on areas concerning data management strategy and the M&E strategy; (3) keep facilities motivated on quality management systems and tools so as to improve quality and information use.

AMREF SA management and administrative staff (Country Director, Deputy Country Director, Finance Manager, Human Resources Manager, and Administrative Assistant) will all provide programmatic, financial, and administration leadership and support to the project team.

AMREF USA, as the grantee, maintains oversight of the project's finance and administration, provides some support on technical issues, and serves as the liaison between the project and CDC's Procurement and Grants Office. AMREF USA's Director, Institutional Giving, Finance Manager, and Technical Advisor are budgeted at daily rates based on their salaries.

The Director of Institutional Giving, is the point person at AMREF USA responsible for this grant. He helps produce the annual continuing application and reviews interim reports and deals with most administrative issues concerning the grant. The Finance Manager, reviews quarterly financial reports, draws down and transfers grant funds to AMREF for the project. He reviews annual financial reports and prepares the annual FSR 269. He conducts an on-site review of the financial management of the grant by AMREF South Africa. Cudjoe Bennett, MPH, is AMREF USA's technical advisor and is available to the project for advice technical issues related to public health and monitoring and evaluation.

AMREF will require Local and international travel for project staff and Directors. Travel will cover vehicle running and maintenance costs, insurance, and fuel costs for the vehicles used for the project, and air tickets and accommodation for senior management during technical support and technical backstopping visits, participation in management meetings and periodic technical meetings and quarterly programme reviews, and meetings with strategic alliances like national or provincial government departments. Travel costs include per-diem (for accommodation and meals and incidentals) at the country-approved rate, air- ticket and (where applicable car hire).

International travel by AMREF USA for financial and programme technical backstopping and help prepare the interim report and continuing application. The AMREF USA Finance Manger also does an on-site review of each U.S. government grant's financial records, procedures, and internal controls. The Finance Manager will conduct such a review in this project year. International Air Fares are shared with other projects, and are budgeted at less than full cost. Lodging and per diems are included at 7 days per trip at current State Department rates. AMREF USA reimburses employees for actual expenses however, which are generally lower than the allowable rates.

Supplies Fuel costs are calculated based mostly on travel for quarterly management meetings and routine fieldwork.

Office supplies and stationery costs for meetings and other office work is calculated per participant (or workstation) per day and aggregated to participant-month. This total cost covers books, pens, folders, marker pens, production of learning materials and other supplies such as training props/aids (i.e., flipchart stands) and project promotion items (t-shirts, caps, etc).

Project Activities Data Management, Capacity Building(clinical Training refresher, mentoring and coaching, quality assurance), M&E and Documentation of Best Practices, Referral System Strengthening are key planned activities Administrative Local project offices will incur costs such as rent, utilities, water, maintenance and insurance for office space in the Eastern Cape, KZN and Limpopo. All associated communication costs and other miscellaneous costs (including mobile and land telephones, fax, e-mail, internet, courier and postage) are budgeted under this category. Other monthly expenses include insurance for project computers and vehicle and photocopying and printing services. Other expenses include bank fees for project bank account, and maintenance of project vehicle. Project funds will also cover a small proportion of running costs of the national office.