Anova Health Institute (Anova) will provide Technical Assistance (TA) and Health Systems Strengthening support within the Partnership Framework, and South African Governments (SAG) National Strategic Plan (NSP). Anova will work in close partnership with the Department of Health (DOH) in 3 provinces: Limpopo, Gauteng and Western Cape, encompassing over 5 million people (10% of the population). Target populations include: women, children, groups with highest HIV prevalence, least access to health care, and key populations such as men who have sex with men and sex workers.

Interventions include: Consolidating current quality service provision; TA to health facilities and community groups for adult and pediatric care, support and treatment, TB and prevention of mother to child transmission; Strengthening health systems financial and project planning, management, leadership, health information systems, workforce planning, and service delivery; Supporting health care reengineering and outreach teams; and Supporting SAG policy, guideline and standards development and implementation.

Anova will facilitate well-capacitated and managed district health management teams and systems, delivering sustainable high quality patient care. The strategy will provide intensive cost-effective support for 2-3 year and then scale down to a mentoring role to ensure full managerial and financial responsibility by DOH.

The M&E plan includes baseline and end of project evaluations, and quarterly collection of process and output indicators, such as health workers trained and facility TA activities. Annual assessments will use District Health Information System data for outcome, impact and NSP target indicators, and feedback dashboard mechanisms will monitor health service coverage and quality.

Anova Health Institute (Anova) will continue to support adult HIV care and support (HBHC) in South African Department of Health (DOH) facilities in Limpopo, Gauteng and Western Cape. This reaches a catchment population of over 5 million people. The target population is all adults, with a focus on younger adults and adolescents, women, and most at risk populations including sex workers, men who have sex with men (MSM) and migrant workers.

Anova-supported HBHC services test around half a million people annually with 72,000 testing HIV-positive. The majority receive CD4 tests and are screened for TB. Nearly 40,000 HIV-positive people are in pre-ART care and around 48,000 initiated on antiretroviral treatment (ART) annually.

Anova will support HBHC by providing technical assistance and health systems strengthening, moving away from direct service delivery. The major cost of the program will be borne by the DOH.

The main objective of HBHC is to ensure provision of an appropriate comprehensive package of HIV-related care prior to the need for ART, to strengthen community linkages to health facilities and to mitigate structural impediments outside the domain of the health systems. The program will foster improved early diagnosis of HIV, TB and STIs and improved access to speedy treatment, appropriate and gender-sensitive treatment services with bidirectional referral systems. HIV-related mental health issues are common and Anova will work with specialists to integrate mental health diagnosis and treatment into HIV services at a PHC level.

Anova will leverage community expertise to create a supportive environment for HIV/AIDS care and support and reduce HIV-related stigma and discrimination, addressing social challenges, including residence in informal settlements or rural and hard-to-reach areas, migration and mobility, and alcohol and substance abuse. Anova and HIVSA will work on health and development interventions that are coordinated with facilities, local community and districts.

Key facility-level interventions are training to ensure capacity for and retention in pre-ART care, adherence counselor training and empowering patient literacy groups. Health workers are sensitized and trained(in-service) on the specific needs of special groups such as adolescents, and MSM to ensure that service is available without prejudice. PICT and linkages to other services such as family planning, mother and child health and support groups will be strengthened.

At a community level, PHC outreach teams, community health workers, home-based and palliative care workers will be trained and supported, and patient-support groups facilitated. At a district level, linkages between community groups and health facilities will be strengthened through social mobilization and health promotion.

Anovas strategy, in close partnership with the DOH, will provide intensive cost-effective support for 2-3 years and then scale down to a mentoring role to ensure full managerial and financial responsibility by DOH.

The M&E plan includes baseline and end of project evaluations, and quarterly collection of process and output indicators. Singizi will conduct annual implementation assessments. Annual assessments for outcome, impact and NSP target indicators will use District Health Information System data, and feedback dashboard mechanisms will monitor health service coverage and quality.

Anova Health Institute (Anova) will scale up TB/HIV integration programs, in line with the South African National Strategic Plan, in Mopani district (Limpopo), City of Johannesburg (Gauteng) and Cape Winelands (Western Cape), to reduce the number of new TB infections, as well as deaths from TB by 50% by 2016.

Combination prevention approaches to reduce TB Infection and disease will be employed. Anovas focus, guided by the NSP, is to prevent new infections, to effect early diagnosis and rapid enrolment into treatment, to integrate HIV and TB care within an efficient chronic care delivery system, and to improve patient adherence and defaulter tracing through community outreach teams. Anova will provide technical assistance and health systems strengthening, moving away from direct service delivery. The major cost of the program will continue to be borne by the DOH.

Baseline assessments followed by annual facility audits will be conducted at all supported facilities on the status of the TB/HIV program, focusing on TB/HIV integration and implementation of IPT and infection control activities

At facility level, Anova will provide technical assistance through mentorship and supportive supervision by experienced TB mentors. Key interventions will include a) Intensified TB case finding through universal screening for TB and contact-tracing, b) TB infection control through training, mentorship and establishing facility-based infection control committees; c) Scale-up of IPT through training and data collection to enable effective outcomes and eliminate or reduce frequency of drug stock outs; d) Management of drug resistant TB through training, mentoring and improving time between diagnosis, follow-up and tracing and; e) Overall health systems strengthening to improve management and costing of TB programs.

At district level, Anova will work with the District Health Management Teams to develop comprehensive and progressive TB/HIV work plans, budget forecasting and coordination and harmonization of activities across vertical program areas.

At community level, Anova and HIVSA will work with established community groups to link to facilities and conduct mass media and local campaigns, promoting a culture of cough hygiene and household infection control. Community health workers and outreach teams will assist in engaging with the household contacts of index cases, conducting household door-to-door visits and enhancing community follow up of MDR-TB cases. Anova supports the integration of screening activities across program areas for early identification of most at risk populations including children and informal settlement dwellers.

Anova is evaluating the use of GeneXpert technology on a test and treat basis in clinics in Mopani. Outcomes of this evaluation will inform scalable and sustainable TB interventions.

Anovas strategy, in close partnership with the DOH, will provide intensive cost-effective support for 2-3 years and then scale down to a mentoring role to ensure full managerial and financial responsibility by DOH.

The M&E plan includes baseline and end of project evaluations, and quarterly collection of process and output indicators. Singizi will conduct annual implementation assessments. Assessments for outcome, impact and NSP target indicators will use District Health Information System data, and feedback dashboard mechanisms will monitor health service coverage and quality.

Anova Health Institute (Anova) currently supports (through an ending mechanism) around 850 children aged (0-15) in care, 11,000 children on antiretroviral treatment and newly enrolls around 500 each quarter onto treatment. Less than 300 are identified as HIV positive through HCT outside of PMTCT programs.

While pediatric care and support predominantly takes place in primary care facilities, community expertise can be leveraged to promote greater involvement in MCH to work towards achievement of NSP and Millennium Development Goals (MDGs) 4, 5 and 6. The involvement of both women and men living with HIV (and affected by HIV) in programs can create a more supportive environment for infant care and reducing HIV-related stigma and discrimination.

Anova will provide technical assistance and health systems strengthening, moving away from direct service delivery. The major cost of the program will be borne by the DOH. All activities follow South African guidelines for pediatric care and treatment.

Key facility interventions include PHC Reengineering, NIMART and Palsa+ training for and supporting comprehensive HIV-related care for infants, supporting and promoting the Expanded Program of Immunization (EPI), linking it to accessing HIV care, training counselors on pediatric adherence counseling and support, and providing training and material support to counselors and service providers on nutritional assessments (NACS) and identification of at-risk children, including infant feeding practices. Integration of HIV pediatric services into MCH will contribute towards efforts to scale up early infant diagnosis, provider initiated and voluntary counseling and testing, monitoring and retention in care.

In addition, the special needs of adolescents will be addressed through the training (in-servoce) and mentoring of health workers on the needs and risks that adolescents face regarding HIV prevention, care and treatment and addressing adolescent sexuality. Anova has developed age appropriate counseling and support training manuals for people working with adolescents. This allows HIV positive and negative adolescents to explore their sexuality in a non-judgmental environment.

At the community level Anova and HIVSA will strengthen community linkages by working with community groups and social sector government clusters to ensure the continuum of care that extends to social and structural support mechanisms for affected mother-baby pairs, children and adolescents.

The quality of the program will be monitored regularly to ensure that issues such as adherence, loss to follow up, linkages to other services and pharmaceutical supply are addressed. Anova will support government in expanding access to 2nd and 3rd line regimens and monitor, through a case study approach on all treatment failures. These activities will improve long-term outcomes.

Anovas strategy, in close partnership with the DOH, will provide intensive cost-effective support for 2-3 years and then scale down to a mentoring role to ensure full managerial and financial responsibility by DOH.

The M&E plan includes baseline and end of project evaluations, and quarterly collection of process and output indicators. Singizi will conduct annual implementation assessments. Annual assessments for outcome, impact and NSP target indicators will use District Health Information System data, and feedback dashboard mechanisms will monitor health service coverage and quality.

The Anova Health Institute (Anova) supports the South African Government (SAG) efforts to strengthen health systems to improve capacity and enhance performance. In line with the SAGs 10-point plan, PHC Re-engineering and the National Strategic Plan (NSP), Anovas emphasis areas are capacity building on strategic use of health information, human capacity development, quality service delivery and improved governance and management structures of health systems.

Anovas approach is to view health systems holistically emphasizing strengthening referral structures and the relationships between different levels of health systems. Each district is engaged in a Project Planning approach to determine specific role delineation between Anova and the Department of Health (DOH). Anova is included as a member in the standard district health management team meetings. Technical assistance is provided to ensure coordinated, multi-level systems strengthening at the scale and intensity required to build capacity to design, implement, monitor and evaluate effective and scalable interventions.

Interventions aimed at improving the quality, efficiency and sustainability of services will cover 7 broad areas as follows:

Health Service Delivery Innovation: In line with National Core Standards, Anova is implementing the Quality Improvement methodology of Plan, Do, Check and Act (PDCA) iterative cycles to improve quality of service delivery at supported facilities. This is aimed at reducing waiting times and improving quality of outcomes.

Human Resources for Health: Regional Training Centers will be strengthened to enhance human capacity development by increasing training throughput and improving the quality of healthcare worker (HCW) training. Support covers improved monitoring of training activities, material development and implementation of task-shifting activities.

Healthcare Financing: Anova facilitates and coordinates district business and strategic planning processes. This includes leading the gathering and documentation of essential information that informs the budget and planning processes.

Strengthening Governance: Anova is part of the Leadership and Management Partners Forum, supporting DOH efforts to strengthen HCW and managers competency through the development of an educational framework. Anova will provide in-service skills development to HCW, managers and team leaders in the districts, sub-district and facilities.

Strategic Information Use: Anova is partnering with DHMTs to improve data collection, analysis and reporting through improved quality and utilization of data. Anova is also supporting the districts to roll out the ART Tiered M&E Strategy.

Procurement: Anova provides on-site mentorship of HCW on forecasting pharmaceutical needs, timely ordering and maintaining appropriate inventory levels, and supports the DHMTs with forecasting, budgeting and planning for pharmaceutical needs. Quality improvement and option analysis aimed at eliminating bottlenecks in the supply chain process is being undertaken.

Medical Products: Anova is evaluating the impact of use of GeneXpert technology in test-and-treat for tuberculosis in Mopani District. This evaluation will inform national solutions to improve the early identification and treatment for TB.

The M&E plan for this work includes baseline and end of project evaluations, Annual assessments for outcome, impact and NSP target indicators will use District Health Information System data.

Anova Health Institute (Anova) has been at the forefront of innovative PMTCT solutions and will scale up access to PMTCT programs in Mopani district (Limpopo), City of Johannesburg (Gauteng) and Cape Winelands (Western Cape).

The Anova supported PMTCT program, guided by the South African National Strategic Plan (NSP), reaches 90,000 pregnant women annually with HIV prevalence of 16.5%, giving close to 15,000 HIV positive mothers. In the next 2 years Anova aims to ensure quality PMTCT services are maintained in 100% of facilities, over 95% of mothers are tested and more than 67% of HIV exposed infants are tested at 6 weeks, with HIV prevalence remaining below 2%. Anova will investigate reasons for the current low uptake of 18 month infant testing, and implement improvement strategies.. These targets are measured and reviewed quarterly.

Anova will support PMTCT by providing technical assistance (TA) and health systems strengthening, moving away from direct service delivery. The major cost of the program will be borne by the DOH.

Anova will strengthen clinical services, and co-ordination, and leadership of programs, facilitating integration with other primary health services, including TB screening in PMTCT programs and activities to eliminate neonatal syphilis. Anovas support for the Action framework for no child born with HIV by 2015, will focus on expanding primary prevention services, ensuring PICT is offered to all women, ensuring appropriate postpartum prophylaxis and care, and strengthening family planning (FP) services.

At a national level Anova will contribute to South African Government guidelines, implementation plans and program monitoring and evaluation.

At a facility level Anova will support development of facility and district managers and mentorship for all service providers to ensure adoption of best practices. Operational support will be provided to improve early booking systems for pregnant women for optimal PMTCT services, and strengthen referral linkages between antenatal care, appropriate HIV and social services, and linked FP services.

At a district level Anova will provide ongoing TA for PMTCT operational challenges, identifying and responding to key bottlenecks. Anova will work with DHMTs to develop operational plans and facilitate workshops using strategic information on maternal and child health (MCH) in order to strengthen early infant diagnosis and linkages between PMTCT and Pediatric HIV care.

At a community level Anova will work with HIVSA to empower communities to establish linkages between social mobilization, health promotion, and facility PMTCT services. HIVSA will train community groups, PHC outreach and health promotion teams to track and trace infants and children, and institute appropriate referrals. Pregnant women will be supported through the Hi4Life mobile phone program, developed by HIVSA in partnership with Anova,

Anovas strategy, in close partnership with the DOH, will provide intensive cost-effective support for 2-3 years and then scale down to a mentoring role to ensure full managerial and financial responsibility by DOH.

The M&E plan includes baseline and end of project evaluations, and quarterly collection of process and output indicators. Singizi will conduct annual implementation assessments. Assessments for outcome, impact and NSP target indicators will use District Health Information System data, and feedback dashboard mechanisms will monitor health service coverage and quality.

Anova Health Institute (Anova) will continue to support adult HIV treatment services (HTXS) in South African Department of Health (DOH) facilities in Mopani district (Limpopo), City of Johannesburg (Gauteng) and Cape Winelands (Western Cape). The target population is all people with HIV who are eligible for treatment according to the South African DOH guidelines, including younger adults and adolescents, women, and most at risk populations including commercial sex workers, men who have sex with men and migrant workers.

The Anova supported HTXS programs have around 155,000 people on ART with around 48,000 newly enrolled annually. Anova will support HTXS by providing technical assistance and health systems strengthening, moving away from direct service delivery. The major cost of the program will be borne by the DOH.

In alignment with the NSP Anova will strive to ensure that people who are started on antiretroviral treatment remain within the health care system, are adherent to treatment and maintain optimal health standards.

Key facility level interventions are in-service training, mentorship and supportive on-site supervision of healthcare providers on DOH guidelines, to enhance knowledge transfer and clinical excellence, and continuous skills development on current policies and treatment protocols. Access to health services is fundamental and innovative solutions will be sought for program efficiencies, such as improved patient follow-up systems, modifying working hours and redesigning patient triaging. Integration of services will be strengthened including HIV, TB, MCH and FP. At a district level Nurse Initiated Management of ART (NIMART) training will be prioritized to build skills, competencies and confidence of healthcare workers to provide quality comprehensive services without discrimination or gender biases. Task shifting and training support will be strengthened to address health worker shortages and to increase service coverage through HIVSAs Health and Welfare Sector Education and Training Authority (SETA)-accredited training. Pharmaco-vigilance and resistance monitoring will be supported through training and strengthening referral linkages. Post-exposure prophylaxis (PEP) will be enhanced through counselor training on the management of victims of sexual violence; occupational exposure and non-occupational exposure, with linkages to the justice system through the Thuthuzela care centers for sexual violence survivors. Ongoing training and support will be provided to Community Health Workers and PHC Outreach Teams on HIV and TB treatment policies, guidelines and tools to promote transition to treatment, retention and adherence. All clinical program areas will be supported further by community information access through links to HIVSA's hi4LIFE mobile phone project, an eHealth application that enables rapid access to public health information.

Anovas strategy, in close partnership with the DOH, will provide intensive cost-effective support for 2-3 years and then scale down to a mentoring role to ensure full managerial and financial responsibility by DOH.

The M&E plan includes baseline and end of project evaluations, and quarterly collection of process and output indicators. Singizi will conduct annual implementation assessments. Annual assessments will use District Health Information System data for outcome, impact and NSP target indicators, and feedback dashboard mechanisms will monitor health service coverage and quality.

Anova Health Institute (Anova) currently supports around 850 children aged (0-15) in care, 11,000 children on antiretroviral treatment and enrolls 500 each quarter onto treatment. Anova will continue to support children in 3 provinces: Gauteng, Limpopo and Western Cape.

Anova's program will support an integrated approach to maternal and child health, provide capacity building, training, and health systems strengthening to support scale-up, improve quality of care, measure patient outcomes and build the capacity of facilities and health care providers to treat children and adolescents. The needs of adolescents will be included in all training. Special attention will be given to improving early infant diagnosis, reducing loss to follow up by tracking and tracing mother-baby pairs and ensuring good quality care and treatment from birth to 24 months.

Anova will provide technical assistance and health systems strengthening, moving away from direct service delivery. The major cost of the program will be borne by the DOH. All activities follow South African guidelines for pediatric care and treatment.

Key interventions at a facility level will include the integration of pediatric treatment through training, mentoring and on-site supervisory support for healthcare workers to improve long-term outcomes. Routine provider initiated counseling and testing (PICT) of all children will be encouraged to promote early identification and rapid treatment initiation. Scaling up PCR and CD4 follow-up testing and the prevention of TB in children through screening and provision of IPT will be implemented. Regular monitoring will address issues such as adherence, linkages to other services and pharmaceutical supply. Anova will support government in expanding access to 2nd and 3rd line regimens and monitor, through a case study approach, all treatment failures.

The special needs of adolescents will be addressed by facilitating integrated comprehensive counseling, testing and care services that are youth-friendly. Anovas age appropriate adolescent counseling and support training manuals will be used to allow them to explore their sexuality in a non-judgmental environment and to empower them to make informed and responsible healthcare choices, including a choice to abstain and delay sexual debut.

At a district level Anova will work with the DHMT and Regional Training Centers (RTC) to expand pediatric training to all facilities by conducting regular clinical forums on pediatric HIV/TB and will facilitate the establishment of Pediatric High Quality training sites under the guidance of experienced clinicians.

Anova and HIVSA will strengthen community linkages by working with community groups and social sector government clusters to ensure the continuum of care that extends to social and structural support mechanisms for affected mother-baby pairs, children and adolescents.

Anovas strategy, in close partnership with the DOH, will provide intensive cost-effective support for 2-3 years and then scale down to a mentoring role to ensure full managerial and financial responsibility by DOH.

The M&E plan includes baseline and end of project evaluations, and quarterly collection of process and output indicators. Singizi will conduct annual implementation assessments. Assessments will use District Health Information System data for outcome, impact and NSP target indicators, and feedback dashboard mechanisms will monitor health service coverage and quality.