The goal of the Foundation for Professional Development (FPD)s Systems Strengthening TA model is to foster a public sector management culture that is based on effective leadership by professional managers committed to: providing integrated quality services based on SAG policy in partnership with civil society; using strategic information to guide decision making; and improving service quality and outcomes. In partnership with SAG, FPD will: i) develop and inform strategies to help Districts realize the 10 Point Plan, including NSP on HIV/AIDS, PHC Re-Engineering Strategy, NHI and the Minister of Healths NSDA in line with the PIPF; ii) support district management to draft, implement and monitor progress against District Health Plans, related plans and expenditure reviews; iii) support districts to achieve and maintain targeted levels of performance for PEPFARs priority areas, in particular TB/HIV. Target population includes district management teams (DMT), facility managers, staff in Tshwane/Metsweding (GP), Nkangala (MP), Capricorn and Vhembe (LP)and the uninsured public (est. 5,122,683) especially PLWHAs. Primary investment will be strengthening systems related to routine management with scale-back of TA investment and energy once processes are adopted and ingrained. FPD will ensure successful transition to SAG by: involving DMT in the conceptualization, planning and implementation of SS TA within the districts, and negotiating roles and responsibilities regarding program milestones, sustainability measures and transition timelines. Key outcomes include: increased district management capacity; improved district health expenditure in line with approved budget; increased health systems efficiency and effectiveness; and improved program performance.

Problem statement: Deviations from guidelines, disjointed packages of care and uncertainty regarding accountability result in breaks in continuity of care and incomplete provision of health services. Key gaps in quality of services related to: underutilization of PHC services, in particular cervical cancer screening, mental health screening and treatment, gender-based violence (GBV), and psycho-social and client support groups; Goal: PHC clinics provide integrated, comprehensive health service provision focused on prevention, early diagnosis and continuum of care. Key Activities in partnership with DOH include: provide expert programmatic TA to DMT to inform strategies, evidence-based interventions and best practice and compliance with national policy; TA to DMT to ensure appropriate planning for HAST programs in district strategic and operational planning, target setting and budgeting processes; support HAST programs to formulate and implement work plans, targets and budgets in line with population needs, district priority areas and NDOH policy and clinical guidelines; TA to PHC re-engineering strategies to strengthen early access to services, referral and retention; map HIV care services and reported performance against estimated need, to identify service gaps and inform district HIV strategies and related work plans; engage district stakeholders to ensure comprehensive support linked to health services (NGO, CBO, DSD); TA referral networks to improve community to clinic to hospital referral and tracing strategies; undertake formative evaluation and baseline assessment of HIV care related activities in each district; engage community organizations in communication and behavior change strategies to address stigma and discrimination; support RTC to develop training plan; train TB/HIV/STI, GBV, cervical cancer, mental health, IACT, tier, CHW. Through roving mentor teams: provide supportive supervision to facility based staff and ensure continuity of training to mentorship to competency in HIV related programs; mentor staff to integrate (NIM)ART, TB/STI/PICT, nutrition, ANC, MCH, GBV, psychosocial, mental health; TA systems to monitor & retain high CD4 counts & fast track; increase detection of cryptococcal meningitis; improve cervical cancer screening, cotrimox, TB screening and Rx, INH in line with guidelines; support HCW soft skills, debriefing and coping skills; mentor support group facilitators to establish IACT support groups to bridge HIV+ clients from HIV testing into HIV care; TA to improve dispensing and stock control; strengthen M&E of loss to initiation and retention in care for QI; promote family/male/ gogo/youth friendly HIV services; strengthen recording, reporting and data use of HIS (Tier and DHIS) and related data management tools (e.g. clinical stationery); facilitate use of innovative SI tools to facilitate program review and decision making; undertake operational research to explore, test, document and disseminate streamlined and/or best practice care modalities; strengthen referral and patient tracing between and within health services; support CHW to support HIV care and integrate patient tracing into PHC outreach activities; Intended outputs include: # trained (500); cervical cancer screening coverage (80%); comprehensive HIV care and support strategies in place; # IACT support groups established (20 p/d); IACT retention rate (70%); Intended outcomes include: increased CD4 at ART initiation.

Problem statement: SA has high incidence of TB (993/100 000), low cure rate (70%) and high TB/HIV co-infection (65%). Goal: to improve TB/HIV patient outcomes. Key activities in partnership with DOH include: provide expert programmatic TB/HIV TA to NDOH around implementation of policy and guidelines; provide TB/HIV TA to DMT to inform strategies, evidence-based interventions and best practice and compliance with national policy; TA to DMT to ensure appropriate planning for TB/HIV in DHP, target setting and budgeting processes incl. DOTS; TA to strengthen SCM for TB/HIV; support strengthening of PPP with stakeholders (incl. mines, correctional services, military and SAPS); undertake formative evaluation and baseline assessment of TB/HIV related activities in each district; map TB/HIV services and reported performance against estimated need, to identify service gaps; train on TB/HIV; support DMTs to organize campaigns, provide supportive supervision to facility based staff and ensure continuity of training to mentorship to competency in TB/HIV, improve compliance with the five Is at all health facilities and promoting early detection and diagnosis of TB suspects through: intensified case finding, regular TB symptom screening for all clients [especially PLWHA] during clinic visits; mentoring nurses on INH prophylaxis to ensure compliance with policy; providing targeted infrastructure and administrative TA to improve and ensure compliance with infection prevention and control standards; mentoring clinical staff on early Initiation on ART; TA to facilities and program managers to maximize TB/HIV service integration [with key focus on PICT, MCH, NIMART]; TA to integrate TB/HIV care with nutritional gardens, patient education and psychological support to both health care givers and receivers (FPDs 2012, Co-Adherence study documented 90% adherence levels amongst patients receiving concurrent TB treatment); TA around QI and compliance with guidelines; link champions and roving mentor teams with district specialist teams to prioritize TB/HIV service integration for ANC and pediatric services; TA to improve bacteriological coverage by using standardized TB diagnostic algorithms; strengthen recording, reporting and data use of TB/HIV in HIS (DHIS and etr.net) and related data management tools through training, mentoring, supportive supervision and structured performance reviews using national TB and HIV M&E framework and targets; TA to district and program managers on data use and analysis of TB/HIV indicators to strengthen TB/HIV service integration and improve patient outcomes; TA to strengthen clinic-laboratory interface to improve turnaround times (TATs); TA to plan, cost and implement novel technology (e.g. Gene Xpert) to maximize availability of diagnostic tests and results at the point of service; undertake operational research to explore, test, document and disseminate streamlined and/or best practice TB and HIV care and treatment modalities; strengthen referral and patient tracing between and within health services; support CHW to integrate TB/HIV awareness and mobilization, defaulter and contact tracing as part of PHC outreach activities. Intended results include: initiate TB Rx in 100% with + lab/clinical test for TB; increase INH initiation (10%); # diagnosed TB patients started ART (5000, 10 %+); train (300). Intended outcomes include: improved TB cure rate; decreased TB defaulter rate (<8%), increased TB cure rate (5% increase)

Problem statement: Deviations from guidelines, disjointed packages of care and uncertainty regarding accountability result in breaks in continuity of care and incomplete provision of health services. With exception of PMTCT, PICT is not routine for children resulting in inadequate referral of and late presentation and low treatment uptake of HIV-infected children to ART services. Goal: Improved early diagnosis of HIV-infected children and linkages to HIV care and treatment. Key Activities in partnership with DOH include: provide expert programmatic (pediatric) HIV and NIMART TA to DMT to inform strategies, evidence-based interventions and best practice and compliance with national policy; TA to DMT to ensure appropriate planning for pediatric and adolescent HIV programs in district strategic and operational planning, target setting and budgeting processes; support HAST programs to formulate and implement work plans, targets and budgets in line with population needs, district priority areas and NDOH policy and clinical guidelines; map paed. services and reported performance against estimated need, to identify service gaps and inform district HIV strategies and related work plans; TA to strengthen planning and coordination between health facilities, DSD, DOE, schools, and OVC organizations to ensure comprehensive support to HIV positive children; engage community organizations in implementing communication and behavior change strategies to address stigma and discrimination; engage with stakeholders to undertake campaigns and mobilize around pediatric HIV testing, care and treatment; support RTC to develop pediatric (NIM)ART training plan; train IMCI, pediatric TB/HIV/STI, mental health, IACT, tier. Through roving mentor teams: provide supportive supervision to facility based staff and ensure continuity of training to mentorship to competency in pediatric HIV related programs; mentor staff to integrate (NIM)ART, adherence, TB/HIV/STI, PICT, TB, ANC, MCH, GBV and mental health services and implement according to policy; promote sibling and grandchildren testing; TA systems to trace and fast track children; mentor doctors and nurses in pediatric care; support family-friendly and youth-friendly clinics; identify and establish model child ART sites for benchmarking; TA support group formulation for children, adolescence and guardians; strengthen program monitoring using clinical stationery and tier cohort data to speed to initiation and retention in care; promote total quality assurance and compliance with guidelines; strengthen recording, reporting and data use of HIS (Tier and DHIS) and related data management tools (e.g. clinical stationery); undertake operational research to explore, test, document and disseminate streamlined and/or best practice pediatric HIV modalities; strengthen referral and patient tracing between and within health services; support CHW to baby, child and adolescent HIV testing uptake, integrate patient tracing and adherence into PHC outreach activities.

Intended outputs include: # trained (300); # children tested (60,000); # child support groups established (1 p/d); Intended outcomes: Increased access to HIV services.

Barriers: Lack of management competencies inhibits translating good policy into strategies with associated work plans, budgets and appropriate HR allocation. Historical-based budgeting and weak HR planning/management inhibit plan implementation. Goals: DHPs and related plans are linked to strategy, budgets, HR, realistic targets and appropriate activities; Expenditure and HR align to needs and plan. Working in partnership with SAG TA will build capacity of the DMT to plan, manage, implement and finance DHS, including HIV/TB programs. Activities (by area) are: (LE) provide expert TA in line with HSS technical areas, NDOH policies, NHI preparation, TB/HIV programs, DHP priorities and district needs with aim to build capacity of district structures and persons focused on systems, evidence base, plans/budgets and organizational culture; TA aimed at strategic and ops planning, budgeting, and review processes (from provincial to facility level); train/mentor/coach managers on core management competencies, quality and QI methodologies; (co)facilitate meetings to communicate and manage policy updates, plans, related activities and performance to stakeholders & role players; (establish and) strengthen governance structures including clinic committees, hospital boards and district AIDS councils; engage with PPL and other partners to ensure district donor coordination; strengthen QI team to implement and monitor progress against the NCS; support district to systematically strengthen and improve program efficiency and quality and disseminate and lessons learned/recommendations. (FI) provide expert TA in support of budgeting, expenditure review and costing analyses; (co-) submit proposals for funding and/or leverage. (HR) strengthen and streamline HR dept.s recruitment, retention, performance management, and HR information systems; TA workforce planning, HR strategy and training plan formulation; recruit skilled HCW into funded posts (thru AHP); strategically transition skilled FPD staff into DOH in line with vacancies and plans; train (with RTC) in line with plans, policy and district priority areas. (PR) TA systems of forecasting, timely ordering and storage of essential medicines; TA pharmaceutical management information systems, Pharmacy and Therapeutics Committees and Pharmacovigilance activities; train on dispensing, SCM and (through HSA) PBPA; TA infrastructure and equipment planning (including maintenance) and budgeting in coordination with Public Works; TA clinic-lab interface to reduce turnaround time and minimize useless expenditure. Intended outputs include: # (%) Dist. managers trained, by level (Exec. DMT, sub-district, facility) & type (course/coaching) & dist. (10 p/d); # plans TA-ed, by level [DHP, Ops, Strat.] & pillar & dist. (2 p/d); # (%) governance structures operating accord. to std, by dist & level. (TBD); # (%) districts with costed health workforce plan in place, by dist. (1 p/d); # HCW recruited and placed, by dist. & cadre & foreign/SA (50); # FPD staff transferred into DOH staff complement, by district & cadre (0); # trained, by course & cadre & pillar & dist (310); # interventions conducted based on needs, by pillar & prog & dist (1 p/d); # (%) facilities, by accreditation rating (based on std: NCS) & by dist (TBD). Outcomes: Improved- HS efficiency; management capacity; financial management, cross functional area improvement, leverage via increased partner contribution, training tenders, funding from other donors

Circumcision rates in South Africa [range 20-80% according to WHO] are too low constitute a population-level HIV prevention strategy. The goal is to scale up medical male circumcision in line with NSP targets in supported districts and nationally. Key activities in partnership with National Department of Health (NDOH) include: 1) Training activities in partnership with CHAPS provided to SAG staff and CDC PEPFAR partners around clinical skills to provide high quality MMC including emergency preparedness and training of facility managers around setting up and managing a high volume MMC site. Training and on-going mentorship to DOH service providers will ensure sufficient, skilled human resources in MMC service delivery facilities to support PEPFAR-supported facilities as well as publicly funded facilities providing MMC services. Specialized training teams will also maintain contact with clinicians trained to provide TA to ensure that training translates into increased VMMC service delivery post training. Training may be updated to accommodate task shifting to nurses as well as the introduction of Prepex or other VMMC devices approved by WHO and PEPFAR. In addition, services may be provided to districts and provinces to sustain PEPFAR-supported MMC facilities through SAG support once plus up funds expire. 2)Technical assistance: TA to DMT to integrate MMC into district planning, target setting and budgeting processes; TA to community mobilization and awareness campaigns to increase community demand for MMC; TA to support facility management around infrastructure and equipment management and maintenance to establish and maintain MMC sites; TA to strengthen SCM for MMC related equipment and sundries; support to the DMT and district-based MMC partners to scale up services, referrals and demand; mentoring and TA to management and facility staff to implement and maintain MMC sites; strengthen referral networks between community structures and NGOs and facilities linked to HCT and MMC; support CHW to integrate MMC awareness and mobilization as part of PHC outreach activities. Intended outputs include: # MMC sites per district (4 p/d); # trained (800). Intended outcomes include: increased male circumcision rates and reduced adverse events

Problem statement: South Africa is not on target to meet MGDs relating to maternal and child mortality; HIV still contributes to about 40% of maternal and child deaths in South Africa. Goal: to eliminate pediatric HIV infections and decrease burden of HIV in pregnant and lactating women

Key activities in partnership with DOH: provide expert programmatic MCH and PMTCT TA to NDOH to input in development and implementation of new policy and guidelines, as required; provide expert programmatic MCH TA to DMT to inform strategies, evidence-based interventions and best practice and compliance with national policy; TA to DMT to ensure appropriate planning for CARMMA, MCH and PMTCT programs in district strategic and operational planning, target setting and budgeting processes; support MCH (and PMTCT) programs to formulate and implement work plans, targets and budgets in line with population needs, district priority areas and NDOH policy and clinical guidelines; map MCH services and reported performance against estimated need, to identify service gaps and inform district MCH strategies and related work plans; undertake formative evaluation and baseline assessment of MCH (and PMTCT) related activities in each district; support MCH management and coordinators to organize campaigns. Involve community organizations in implementing communication and behavior change strategies to improve maternal and child health services. Provide supportive supervision to facility based staff and ensure continuity of training to mentorship to competency in MCH programs with focus on PMTCT and TB/HIV; train on IMCI, MCH and PMTCT; through roving mentor teams and MCH champions improve: integration of TB/HIV services into EPI, ANC and SRH/FP services and other prevention services ; early booking; exclusive breast feeding; nutrition; HIV testing (couples, 1st visit, 32 wk re-test, 6 wk PCR, 18 mo test); CD4, AZT and HAART uptake in ANC, strengthening obstetric practices which reduces MTCT, scaling up and improving quality of care and Increasing couple protection rate. Increasing postnatal follow up of mother baby pair; promote total quality assurance and compliance with guidelines in line with MCH programs; link program champions and roving mentor teams with district specialist teams to support MCH; work closely with other partners to understand social determinants of health and develop interventions to reduce HIV infections, strengthen recording, reporting and data use of MCH in HIS (ANC register, ART register) and related data management tools (e.g. tally sheets); facilitate use of innovative SI tools to facilitate program review and decision making; undertake operational research to explore, test, document and disseminate streamlined and/or best practice MCH and PMTCT care modalities; strengthen referral and patient tracing between and within health services; support CHW to integrate ANC early booking, PMTCT programs, breast is best, nutrition, male involvement, and ANC and pediatric HIV testing awareness and mobilization into PHC outreach activities. Intended results include: # trained (400); # PF initiated HAART (8000); # initiated AZT (25000); HIV 1st test rate (100,000; 95%); HIV 32 week re-test rate (55%); PCR uptake rate (90%); Intended outcomes include: PCR positivity rate (<3%).

Problem statement: due to massive burden of HIV, DOH introduced Nurse Initiated and Managed ART (NIMART) ART which requires that ART be integrated into a PHC setting.

Goal: i) NIMART model is fully deployed providing integrated HIV/TA care for adults, adolescents and children; ii) model (NIM)ART sties established that meet the highest national standard. Key Activities in partnership with DOH include: provide expert programmatic HIV and NIMART TA to DMT to inform strategies, evidence-based interventions and best practice and compliance with national policy; TA to DMT to ensure appropriate planning for NIMART and ART programs in district strategic and operational planning, target setting and budgeting processes; support HAST programs to formulate and implement work plans, targets and budgets in line with population needs, district priority areas and NDOH policy and clinical guidelines; map ART services and reported performance against estimated need, to identify service gaps and inform district HIV strategies and related work plans; undertake formative evaluation and baseline assessment of (NIM)ART related activities in each district; engage community organizations in communication and behavior change strategies to address stigma and discrimination; support RTC to develop (NIM)ART training plan; train NIMART, mentorship, ART, TB/HIV/STI, tier. Through roving mentor teams: provide supportive supervision to facility based staff and ensure continuity of training to mentorship to competency in NIMART and related programs; mentor staff to integrate (NIM)ART, adherence, TB/HIV/STI, PICT, TB, ANC, MCH, GBV and mental health services and implement according to policy; TA systems to fast track low CD4 counts, pregnant females and TB patients onto ART; support NIMART certification of nurses; identify and establish model NIMART sites for benchmarking; strengthen hospital-based ART clinics for complicated case referral; increase detection of cryptococcal meningitis; improve cervical cancer screening, cotrimox, TB screening and treatment, INH in line with guidelines; improve viral load and drug resistance monitoring and appropriateness of regimens; support adherence counseling and adherence improvement initiatives; support HCW soft skills, debriefing and coping skills; TA to improve dispensing and stock control; strengthen program monitoring using clinical stationery and tier cohort data; promote total quality assurance and compliance with guidelines; promote family/male/gogo/youth friendly HIV services; link roving mentor teams with district specialist teams to support complicated HIV; strengthen recording, reporting and data use of HIS (Tier and DHIS) and related data management tools (e.g. clinical stationery); facilitate use of innovative SI tools to facilitate program review and decision making; undertake operational research to explore, test, document and disseminate streamlined and/or best practice NIMART modalities; strengthen referral and patient tracing between and within health services; support CHW to integrate patient tracing and adherence into PHC outreach activities. Intended outputs: # trained (100); # patients (% facilities) initiating ART (45,000), by dist. & age group & TB/Preg; # total remaining on ART, by dist. & age gr (150,000). Intended outcomes: Increased ART coverage rate, by age group & district, Increased baseline CD4 at initiation, Increased viral load suppression rate, Improved ART patient retention rate

Problem statement: due to massive burden of pediatric HIV, DOH introduced Nurse Initiated and Managed ART (NIMART) ART which requires that ART be integrated into a PHC setting. Goal: i) NIMART model is fully deployed providing integrated HIV/TA care for adolescents and children; ii) model (NIM)ART sties established that meet the highest national standard. Key Activities in partnership with DOH include: provide expert programmatic (pediatric) HIV and NIMART TA to DMT to inform strategies, evidence-based interventions and best practice and compliance with national policy; TA to DMT to ensure appropriate planning for pediatric and adolescent ART programs in district strategic and operational planning, target setting and budgeting processes; support reviews using cohort data; support HAST programs to formulate and implement work plans, targets and budgets in line with population needs, district priority areas and NDOH policy and clinical guidelines; map ART services and reported performance against estimated need, to identify service gaps and inform district HIV strategies and related work plans; undertake formative evaluation and baseline assessment of pediatric ART related activities in each district; engage community organizations in implementing communication and behavior change strategies to address stigma and discrimination; engage with stakeholders to undertake campaigns and mobilize around pediatric HIV testing and treatment; support RTC to develop pediatric (NIM)ART training plan; train IMCI, NIMART, mentorship, ART, pediatric ART, PMTCT, TB/HIV/STI, tier. Through roving mentor teams: provide supportive supervision to facility based staff and ensure continuity of training to mentorship to competency in pediatric ART related programs; mentor staff to integrate (NIM)ART, adherence, TB/HIV/STI, PICT, TB, ANC, nutrition, MCH, GBV and mental health services and implement according to policy; TA systems to fast track children; mentor doctors and nurses in pediatric ART; support NIMART certification of nurses; support family-friendly and youth-friendly clinics; identify and establish model NIMART sites for benchmarking; strengthen hospital-based ART clinics for complicated case referral; support adherence counseling and adherence improvement initiatives with target for babies, children, adolescence and guardians; TA to improve dispensing and stock control of pads drugs; promote total QI linked to treatment outcomes & cohort data; link with district specialist teams to support complicated HIV and MCH; strengthen recording, reporting and data use of HIS (Tier and DHIS) and related data management tools (e.g. clinical stationery); facilitate use of innovative SI tools to facilitate program review and decision making; undertake operational research to explore, test, document and disseminate streamlined and/or best practice pediatric ART modalities; strengthen referral and patient tracing between and within health services; support CHW to baby, child and adolescent HIV testing uptake, integrate patient tracing and adherence into PHC outreach activities. Intended outputs: # trained (100); # children (% facilities) initiating ART (4,000), by dist; # total remaining on ART, by dist. & age gr (10,000). Intended outcomes: Increased pediatric ART coverage rate, by district, Increased baseline CD4 at initiation, Increased viral load suppression rate, Improved ART patient retention rate.