Plan to move entire TB-HIV actiities for National Health Laboratory Services from HLAB and add NHLS to

the HVTB budget category with narrative.

New/Continuing Activity: New Activity

Continuing Activity:

Table 3.3.12:

SUMMARY:

Activities will be carried out to address laboratory-specific unmet needs that impede full implementation of

national laboratory programs. Activities will increase national coverage of HIV and TB diagnostics and

treatment monitoring capabilities; ensure uniform quality assurance measures among laboratories;

strengthen laboratory reporting systems; promote efforts to synchronize infection control activities in

collaboration with the National Institute of Occupation Health (NIOH); and to expand upon the regional

support and collaboration with other PEPFAR-funded countries.

BACKGROUND:

The NHLS is accountable to the National Department of Health (NDOH) through its Executive Board and is

responsible for public sector laboratory services. The NHLS also governs activities and provides funding to

the National Institute of Communicable Diseases (NICD) to provide surveillance, research and

programmatic operations, as well as funding to the NIOH for policy development activities related to

occupational health.

ACTIVITY 1: HIV testing at point of care

HIV testing at point of care settings using HIV rapid tests is set to increase in terms of the National strategic

plan developed by the NDOH. Project Goals and Objectives: (1) Assess rapid HIV kits performance at a

laboratory level; (2) routine monitoring of new lots/batches prior to release to testing sites and (3) produce

training materials for HIV QMS, external quality assurance (PT) and internal quality controls (IQC) for

testing sites for quality assurance purposes. The target would be 200 sites in 5 provinces over a year period

to determine feasibility of the program. This will include piloting of dried plasma PT panels. Project Outputs:

The objective of HIV assessment at field level allows for rational decision making in terms of algorithm

setting and alternatives to current tests. Post marketing surveillance permits early warning systems to

become operative. IQC usage will allow for program managers to become aware of any problems that could

be site-specific or systematic. The EQA/PT program will assess overall program performance.

ACTIVITY 2: HIV Rapid kit Quality Management Training

As part of the National Strategic Plan to reduce infections by 50% by 2011 there is a need to expanded

services for counselling and testing. Project Strategy: To continue QMS training implemented in 2008 and to

provide direct support to the Provinces in terms of a train the trainer-type approach or direct training as

needed. The current time spent per training is 2-3 months per province at the trainer level. The outcome will

be that at least 5 provinces will be trained by the third quarter of 2009. The training will be integrated with

implementation of EQA and IQC programs as well as M&E programs. Project Goals and Objectives: (1)

Training of trainers in 9 Provinces in HIV rapid Test QMS and implementation of training at provincial level.

(2) Integration of QMS training with implementation of EQA and IQC programs in at least 6 provinces. (3)

Implementation of an M&E program that integrates with provincial- level monitoring of HIV rapid testing.

Project Outputs: Monitoring of numbers trained: trainers and direct technical assistance, provincial

coverage, IQC coverage and EQA scores, M&E evaluation scores in terms of numbers of sites trained and

implementation of QMS program.

ACTIVITY 3: HIV-1 NAT EQA

External Quality Assessment (EQA) and IQC will be an integral part of the laboratory quality management

system (QMS) that will detect weak spots in performance as well as improve on the reliability and

confidence when performing HIV-1 NAT. Project Strategy - Description and Methodologies: The NICD will

source local material as well as characterize materials in collaboration with QCMD for HIV viral load and

subtyping PT and IQC. NICD will make the program available to 25-30 participating laboratories for two

distributions: first and last quarters of 2009. Data will collated by an independent secretariat that includes

the NICD and QCMD for data analysis. For the IQC program software development allows for web-based

submission of data with real time analysis and trend analysis. A positive standard has been selected

(subtype C, 5000 copies/ml) and characterized for this purpose. The program will be introduced in the first

quarter of 2009. The NICD intends to introduce IQC program for HIV DNA testing on DBS in the second

quarter of 2009 to 11 participating laboratories. Project Outcomes: (1) The implementation of an EQA

program that will monitor laboratory performance related to the ART program. (2) Capacity development of

the NICD to perform as a molecular EQA provider. (3) The development of an IQC program for HIV viral

load testing and infant diagnosis that can provide real time monitoring (4) The use of locally relevant

materials to be characterized and included in panels.

ACTIVITY 4: Early Infant Diagnosis

Project Goals and Objectives: (1) To develop a clinical and laboratory infrastructure that supports early

testing and HIV diagnosis in infants. (2) To assess the most appropriate method for early and accurate

diagnosis of HIV infection in infants. The primary objective is to utilize the DBS HIV DNA PCR as a tool for

diagnostic purposes in a setting with approximately 6000 infants over a 12 month period from the second

quarter of 2009. The objectives would be the identification of processes that will ensure high throughput that

will allow for access to diagnostics, care and follow-up as required. Project Outputs: The primary outcome

will be the establishment of technologies that can be applied in the public health setting for the early

diagnosis of HIV infected infants as well as monitoring antiretroviral therapy. An algorithm of cost-effective

testing will be a primary accomplishment. The application will be at an operational level to ensure that

clinical sites that do not have easy access to diagnostic services benefit.

ACTIVITY 5: Increased access of TB culture and referral services

In light of the significant increase in MDR and XTR-TB cases within South Africa, and recognizing that there

is a significant lack of laboratory capacity to capture and report suspect TB cases, it has been determined

Activity Narrative: that an immediate expansion of TB culture and referral services are required. TB culture facilities have been

established in all provinces but to make a significant impact quickly, it has been proposed that a further 3

TB laboratories be renovated to meet current demands during this funding period, in Mpumalanga, the

Western Cape, and KZN. The selected sites would provide a responsive and regional impact in respect to

TB culture services and the overall ability to capture possible MDR and XTR-TB cases. The proposed sites

would provide relief to the existing laboratory services and improve overall performance and TB diagnostic

capacity within the entire region. Proposed funding would be used to provide equipment purchases and

renovations for the proposed sites.

ACTIVITY 6: Approaches to increase TB laboratory throughput

With the current number of sputum samples submitted for laboratory smear microscopy and culture already

at an all time high and continuing to increase, it is recognized that one of the most significant rate

determining factors directly impacting laboratory through-put is that of the NALC decontamination process,

a labor intensive processes of sputum concentration and decontamination. In order to streamline this

process and to increase overall laboratory through-put of sputum specimens to meet the increased demand

and lack of available staff to process such specimens, alternate or automated measures should be

investigated. Currently, NICD has vested time in investigating possible automated methods that could

significantly reduce and provide standardized decontamination processes. The currently proposed funds

would be used, in partnership and through co-funding with NHLS, for the development of automated NALC

decontamination instrumentation and technologies. The project with full details and project plan has been

submitted. There is strict adherence to the time lines in the project plan and budget. Completion date of

project will be January 2010.

ACTIVITY 7: National TB Quality Programs

Proficiency testing: Second line DST EQA for culture laboratories is a priority and will be developed during

this funding period, as there is NO PT for second line anti-TB drugs in the NHLS. Description and

Methodology: Simulated specimens for DTS testing will be prepared and distributed to all culture facilities

within the NHLS. The resistance profile among the organisms will vary from organism to organism and

measure the proficiency of the laboratories to correctly identify resistance to second line drugs amikacin or

kanamycin, ethionamide and ofloxacin. Capreomycin. Objectives of the program include: (1) capacity

building, (2) improvement of quality (3) institution of corrective actions where deficiencies are detected and

follow up, as well as (4) providing support to peripheral laboratories. Outputs: Second line DST is

performed by MGIT liquid culture in the following NHLS Laboratories: Green Point, Port Elizabeth, Umtata,

Albert Luthuli, Braamfontein. All these laboratories will be required to participate in the PT.

ACTIVITY 8: Rechecking program

A blind rechecking program is in the process of being rolled out in the NHLS. Goals and objective: (1)

Blanket approach of rechecking random selected slides from the laboratory register is inadequate. (2)

Selection of sample size is based on implementation and sustainability, rather than rigorous analytical

methods. (3) The recommended sample size provides relative information on the sensitivity of microscopy.

(4) Sample size is based on annual laboratory volume and the proportion of positive smears. (5) Positive

slides are included to achieve blinding, but numbers are insufficient to determine specificity. (6) Guidelines

to interpret Discrepancies.

ACTIVITY 9: Line Probes

Project Strategy: 20 NHLS regional laboratories will be identified for roll out of the line probe over the next

24 months. This entails (1) Identify additional space for PCR laboratories (2) Renovate the space for PCR

laboratories to an acceptable standard (3) Purchasing of equipment (4) Training newly employed scientists

(5) Validation of the assays (6) Institute quality systems for the ongoing monitoring of performance. A

partnership will be established with Davies Diagnostics, the local supplier of the Hain line probe, for

technical assistance in the training and roll out of the assay. Project Goals and Objectives: The overall goal

is the establishment of line probe assays in 20 regional laboratories throughout South Africa for the early

identification, isolation and treatment of new MDR-TB cases to improve outcomes in these patients. Project

Outputs: PCR Laboratory space would have been identified and renovated, capital equipment put in place

and scientists trained to perform the assay. Quality systems will be in place. These laboratories would be

confident in performing routine diagnostic PCR investigation on smear positive sputa for the identification of

MDR-TB patients.

ACTIVITY 10: National Tuberculosis Reference Laboratory

Molecular Biology: Goals and objectives: (1) With an emphasis on the MDR-TB and XDR-TB strains

isolated nationally, molecular characterization of sensitive and resistant M tuberculosis will be commenced

on the collection of MDR and XDR organisms from all provinces in South Africa. (2) Molecular investigations

into outbreaks will be performed and unique mycobacterial strains and NTM species encountered will be

identified and characterized by conventional, molecular and HPLC technology. (3) Molecular genotyping on

a sample of the isolates obtained from drug resistance survey (about 14,000 strains) to accurately reflect

the genotypic epidemiology of M tuberculosis in South Africa. Outcomes expected: (1) Characterizing

general circulating M tuberculosis strains, MDR-TB strains and longitudinal characterization of repeat

isolates from MDR-TB patients (2) Sequencing the resistance genes of M tuberculosis MDR-TB strains and

promoters,(3) Molecular investigations into outbreaks (4) Characterizing general circulating M tuberculosis

strains, MDR-TB strains and longitudinal characterization of repeat isolates from MDR-TB patients. Assays

planned to be performed in the NTBRL include RFLP, spoligotyping, sequencing of drug resistance loci.

ACTIVITY 11: ACILT - African Centre for Integrated Laboratory Training

Objective: Recent reviews of TB and HIV laboratory practices throughout Africa have affirmed the principle

Activity Narrative: that accurate laboratory results are not only based on the number of people employed in laboratories, but

on the quality of their work. This is chiefly a matter of better training, motivation and management according

to good laboratory practices. The primary objective is to train technical staff from across Africa in current

technologies and methodologies for TB and HIV. Strategy: It is proposed that a Technical Advisory

Committee be formed which would provide technical expertise to the Centre management on issues related

to management, laboratory curriculum development and training programs, review the training centre's

training priorities and strategies so that they are in line with the regional requirements and targets, and give

support to the faculty. Outputs: courses to be focused on in the short-term are: (1) TB culture/DST and

molecular diagnostics. (2) Early Infant Diagnosis PCR (3) Laboratory management (4) Quality management

systems (QMS) (5) Commodity management (quantification).

ACTIVITY 12: CDC Management & Administration

The NHLS/NICD has implemented financial and administrative processes to ensure improved focus and

oversight of the funding of this Cooperative Agreement. These processes are broadly divided into two,

being 1) processes around the budget development and the funding needs affecting the application, and 2)

financial controls for project finances. Budget development and funding needs affecting the previous

application were addressed by having a centralized budget development function. All the budgets and carry-

forward requests are consolidated in conjunction with individual PIs, the Cooperate Services Manager of the

NICD, the NHLS Cooperate Services and the PI managing the CDC grant overall. Secondly, financial

controls affecting funds have been investigated and are currently being implemented in alignment with

NHLS policies and procedures. The processes followed for committing expenditure and the treatment

thereof have been documented. This forms the basis for the implementation of financial controls, including

monthly reporting of expenditure, and the review of these expenditures by the relevant PIs.

New/Continuing Activity: Continuing Activity

Continuing Activity: 14328

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

14328 14328.08 HHS/Centers for National Health 6777 6777.08 $12,000,000

Disease Control & Laboratory

Prevention Services

Emphasis Areas

Construction/Renovation

Health-related Wraparound Programs

* TB

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $2,177,049

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.16:

SUMMARY:

Activities will be carried out to address laboratory-specific unmet needs that impede full implementation of

national laboratory programs. Activities will increase national coverage of HIV and TB diagnostics and

treatment monitoring capabilities; ensure uniform quality assurance measures among laboratories;

strengthen laboratory reporting systems; promote efforts to synchronize infection control activities in

collaboration with the National Institute of Occupation Health (NIOH); and to expand upon the regional

support and collaboration with other PEPFAR-funded countries.

BACKGROUND:

National Health Laboratory Services (NHLS) is accountable to the National Department of Health (NDOH)

through its Executive Board and is responsible for public sector laboratory services. The NHLS also governs

activities and provides funding to the National Institute of Communicable Diseases (NICD) to provide

surveillance, research and programmatic operations, as well as funding to the NIOH for policy development

activities related to occupational health.

ACTIVITY 1: Point of care testing

HIV testing at point of care settings using HIV rapid tests is set to increase in terms of the National strategic

plan developed by the NDOH. Project Goals and Objectives: (1) Assess rapid HIV kits performance at a

laboratory level; (2) routine monitoring of new lots/batches prior to release to testing sites and (3) produce

training materials for HIV QMS, external quality assurance (PT) and internal quality controls (IQC) for

testing sites for quality assurance purposes. The target would be 200 sites in 5 provinces over a year period

to determine feasibility of the program. This will include piloting of dried plasma PT panels. Project Outputs:

The objective of HIV assessment at field level allows for rational decision making in terms of algorithm

setting and alternatives to current tests. Post marketing surveillance permits early warning systems to

become operative. IQC usage will allow for program managers to become aware of any problems that could

be site-specific or systematic. The EQA/PT program will assess overall program performance.

ACTIVITY 2: HIV Rapid kit Quality Management Training

As part of the National Strategic Plan to reduce infections by 50% by 2011 there is a need to expanded

services for counseling and testing. Project Strategy: To continue QMS training implemented in 2008 and to

provide direct support to the Provinces in terms of a train the trainer-type approach or direct training as

needed. The current time spent per training is 2-3 months per province at the trainer level. The outcome will

be that at least 5 provinces will be trained by the third quarter of 2009. The training will be integrated with

implementation of External Quality Assessment (EQA) and IQC programs as well as M&E programs.

Project Goals and Objectives: (1) Training of trainers in 9 Provinces in HIV rapid Test QMS and

implementation of training at provincial level. (2) Integration of QMS training with implementation of EQA

and IQC programs in at least 6 provinces. (3) Implementation of an M&E program that integrates with

provincial- level monitoring of HIV rapid testing. Project Outputs: Monitoring of numbers trained: trainers and

direct technical assistance, provincial coverage, IQC coverage and EQA scores, M&E evaluation scores in

terms of numbers of sites trained and implementation of QMS program.

ACTIVITY 3: HIV-1 NAT EQA and IQC

HIV-1 NAT EQA and IQC will be an integral part of the laboratory quality management system (QMS) that

will detect weak spots in performance as well as improve on the reliability and confidence when performing

HIV-1 NAT. Project Strategy - Description and Methodologies: The NICD will source local material as well

as characterize materials in collaboration with QCMD for HIV viral load and subtyping PT and IQC. NICD

will make the program available to 25-30 participating laboratories for two distributions: first and last

quarters of 2009. Data will collated by an independent secretariat that includes the NICD and QCMD for

data analysis. For the IQC program software development allows for web-based submission of data with

real time analysis and trend analysis. A positive standard has been selected (subtype C, 5000 copies/ml)

and characterized for this purpose. The program will be introduced in the first quarter of 2009. The NICD

intends to introduce IQC program for HIV DNA testing on DBS in the second quarter of 2009 to 11

participating laboratories. Project Outcomes: (1) The implementation of an EQA program that will monitor

laboratory performance related to the ART program. (2) Capacity development of the NICD to perform as a

molecular EQA provider. (3) The development of an IQC program for HIV viral load testing and infant

diagnosis that can provide real time monitoring (4) The use of locally relevant materials to be characterized

and included in panels.

ACTIVITY 4: Early Infant Diagnosis

Project Goals and Objectives: (1) To develop a clinical and laboratory infrastructure that supports early

testing and HIV diagnosis in infants. (2) To assess the most appropriate method for early and accurate

diagnosis of HIV infection in infants. The primary objective is to utilize the DBS HIV DNA PCR as a tool for

diagnostic purposes in a setting with approximately 6000 infants over a 12 month period from the second

quarter of 2009. The objectives would be the identification of processes that will ensure high throughput that

will allow for access to diagnostics, care and follow-up as required. Project Outputs: The primary outcome

will be the establishment of technologies that can be applied in the public health setting for the early

diagnosis of HIV infected infants as well as monitoring antiretroviral therapy. An algorithm of cost-effective

testing will be a primary accomplishment. The application will be at an operational level to ensure that

clinical sites that do not have easy access to diagnostic services benefit.

ACTIVITY 5: Increased access of TB culture and referral services

In light of the significant increase in MDR and XTR-TB cases within South Africa, and recognizing that there

is a significant lack of laboratory capacity to capture and report suspect TB cases, it has been determined

Activity Narrative: that an immediate expansion of TB culture and referral services are required. TB culture facilities have been

established in all provinces but to make a significant impact quickly, it has been proposed that a further

three TB laboratories be renovated to meet current demands during this funding period, in Mpumalanga, the

Western Cape, and KZN. The selected sites would provide a responsive and regional impact in respect to

TB culture services and the overall ability to capture possible MDR and XTR-TB cases. The proposed sites

would provide relief to the existing laboratory services and improve overall performance and TB diagnostic

capacity within the entire region. Proposed funding would be used to provide equipment purchases and

renovations for the proposed sites.

ACTIVITY 6: Approaches to increase TB laboratory throughput

With the current number of sputum samples submitted for laboratory smear microscopy and culture already

at an all time high and continuing to increase, it is recognized that one of the most significant rate

determining factors directly impacting laboratory through-put is that of the NALC decontamination process,

a labor intensive processes of sputum concentration and decontamination. In order to streamline this

process and to increase overall laboratory through-put of sputum specimens to meet the increased demand

and lack of available staff to process such specimens, alternate or automated measures should be

investigated. Currently, NICD has vested time in investigating possible automated methods that could

significantly reduce and provide standardized decontamination processes. The currently proposed funds

would be used, in partnership and through co-funding with NHLS, for the development of automated NALC

decontamination instrumentation and technologies. The project with full details and project plan has been

submitted. There is strict adherence to the time lines in the project plan and budget. Completion date of

project will be January 2010.

ACTIVITY 7: National TB Quality Programs

Proficiency testing: Second line DST EQA for culture laboratories is a priority and will be developed during

this funding period, as there is NO PT for second line anti-TB drugs in the NHLS. Description and

Methodology: Simulated specimens for DTS testing will be prepared and distributed to all culture facilities

within the NHLS. The resistance profile among the organisms will vary from organism to organism and

measure the proficiency of the laboratories to correctly identify resistance to second line drugs amikacin or

kanamycin, ethionamide and ofloxacin. Capreomycin. Objectives of the program include: (1) capacity

building, (2) improvement of quality (3) institution of corrective actions where deficiencies are detected and

follow up, as well as (4) providing support to peripheral laboratories. Outputs: Second line DST is

performed by MGIT liquid culture in the following NHLS Laboratories: Green Point, Port Elizabeth, Umtata,

Albert Luthuli, Braamfontein. All these laboratories will be required to participate in the PT.

ACTIVITY 8: Rechecking program

A blind rechecking program is in the process of being rolled out in the NHLS. Goals and objective: (1)

Blanket approach of rechecking random selected slides from the laboratory register is inadequate. (2)

Selection of sample size is based on implementation and sustainability, rather than rigorous analytical

methods. (3) The recommended sample size provides relative information on the sensitivity of microscopy.

(4) Sample size is based on annual laboratory volume and the proportion of positive smears. (5) Positive

slides are included to achieve blinding, but numbers are insufficient to determine specificity. (6) Guidelines

to interpret Discrepancies.

ACTIVITY 9: Line Probes

20 NHLS regional laboratories will be identified for rollout of the line probe over the next 24 months. This

entails (1) Identify additional space for PCR laboratories (2) Renovate the space for PCR laboratories to an

acceptable standard (3) Purchasing of equipment (4) Training newly employed scientists (5) Validation of

the assays (6) Institute quality systems for the ongoing monitoring of performance. A partnership will be

established with Davies Diagnostics, the local supplier of the Hain line probe, for technical assistance in the

training and roll out of the assay. The overall goal is the establishment of line probe assays in 20 regional

laboratories throughout South Africa for the early identification, isolation and treatment of new MDR-TB

cases to improve outcomes in these patients. PCR Laboratory space would have been identified and

renovated, capital equipment put in place and scientists trained to perform the assay. Quality systems will

be in place. These laboratories would be confident in performing routine diagnostic PCR investigation on

smear positive sputa for the identification of MDR-TB patients.

ACTIVITY 10: National Tuberculosis Reference Laboratory

Molecular Biology: Goals and objectives: (1) With an emphasis on the MDR-TB and XDR-TB strains

isolated nationally, molecular characterization of sensitive and resistant M tuberculosis will be commenced

on the collection of MDR and XDR organisms from all provinces in South Africa. (2) Molecular investigations

into outbreaks will be performed and unique mycobacterial strains and NTM species encountered will be

identified and characterized by conventional, molecular and HPLC technology. (3) Molecular genotyping on

a sample of the isolates obtained from drug resistance survey (about 14,000 strains) to accurately reflect

the genotypic epidemiology of M tuberculosis in South Africa. Outcomes expected: (1) Characterizing

general circulating M tuberculosis strains, MDR-TB strains and longitudinal characterization of repeat

isolates from MDR-TB patients (2) Sequencing the resistance genes of M tuberculosis MDR-TB strains and

promoters,(3) Molecular investigations into outbreaks (4) Characterizing general circulating M tuberculosis

strains, MDR-TB strains and longitudinal characterization of repeat isolates from MDR-TB patients. Assays

planned to be performed in the NTBRL include RFLP, spoligotyping, sequencing of drug resistance loci.

ACTIVITY 11: ACILT - African Centre for Integrated Laboratory Training

Objective: Recent reviews of TB and HIV laboratory practices throughout Africa have affirmed the principle

that accurate laboratory results are not only based on the number of people employed in laboratories, but

Activity Narrative: on the quality of their work. This is chiefly a matter of better training, motivation and management according

to good laboratory practices. The primary objective is to train technical staff from across Africa in current

technologies and methodologies for TB and HIV. It is proposed that a Technical Advisory Committee be

formed which would provide technical expertise to the Centre management on issues related to

management, laboratory curriculum development and training programs, review the training centre's training

priorities and strategies so that they are in line with the regional requirements and targets, and give support

to the faculty. Courses to be focused on in the short-term are: (1) TB culture/DST and molecular

diagnostics. (2) Early Infant Diagnosis PCR (3) Laboratory management (4) Quality management systems

(QMS) (5) Commodity management (quantification).

ACTIVITY 12: CDC Management & Administration

The NHLS/NICD has implemented financial and administrative processes to ensure improved focus and

oversight of the funding of this Cooperative Agreement. These processes are broadly divided into two,

being 1) processes around the budget development and the funding needs affecting the application, and 2)

financial controls for project finances. Budget development and funding needs affecting the previous

application were addressed by having a centralized budget development function. All the budgets and carry-

forward requests are consolidated in conjunction with individual PIs, the Cooperate Services Manager of the

NICD, the NHLS Cooperate Services and the PI managing the CDC grant overall. Secondly, financial

controls affecting funds have been investigated and are currently being implemented in alignment with

NHLS policies and procedures. The processes followed for committing expenditure have been documented.

This forms the basis for the implementation of financial controls, including monthly reporting of expenditure,

and the review of these expenditures.

New/Continuing Activity: New Activity

Continuing Activity:

Emphasis Areas

Health-related Wraparound Programs

* TB

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $1,260,192

Public Health Evaluation

Estimated amount of funding that is planned for Public Health Evaluation $0

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.17: