A senior level international TB expert with both management and technical expertise in all levels of mycobacteriology is requested to augment the existing MoH leadership in order to secure and sustain accreditation for the Chest Diseases National TB Laboratory. This person will work full time onsite in the National TB Laboratory for one year working with MoH, USG and other TB laboratory partners to maximize efficiency in training efficiency and human resources. A strong internal and external quality assurance program in all areas of TB laboratory activities will be developed for TB smear microscopy, culture, isolate identification and drug susceptibility testing which include both first and second line testing to detect multiple drug resistant (MDR) and XDR tuberculosis. The person will work with MoH to strengthen operational and administrative systems. Support will be provided to the national TB national quality assurance technologist on sample transport for data management, documentation, test result feedback and customer services in smear microscopy, rapid culture, drug susceptibility testing and health and safety issues in providing services from rural and urban health care centers to sustain international accreditation standards for the national laboratory.

Table 3.3.08: Program Planning Overview Program Area: Orphans and Vulnerable Children Budget Code: HKID Program Area Code: 08 Total Planned Funding for Program Area: $ 14,902,338.00

Program Area Context:

In Zambia, despite the scale of the orphans and vulnerable children (OVC) problem, the Government of Zambia (GRZ) and USG are making progress in OVC policy and programming. As per the USG/Zambia Five-Year Strategy, Zambia is achieving annual targets and continues to rapidly scaling up OVC services. The USG has been instrumental in strengthening the capacity of the government, local organizations, communities, schools, workplaces, and families to provide care and support to OVCs, facilitating policy changes, and leveraging non-PEPFAR donor and private sector resources.

The GRZ estimates there are 1.2 million orphans, of which 801,000 are AIDS orphans. Most OVC support in Zambia comes from NGOs and FBOs. The 2004 OVC Situation Analysis identified 428 OVC support organizations. Unfortunately, government coordination of OVC support and care services remains an issue. Support to OVC is implemented and managed across several sectors through numerous government agencies, including: the National HIV/AIDS/STI/TB Council (NAC); Ministry of Education (MOE); Ministry of Sports, Youth and Child Development (MSYCD); Ministry of Health (MOH); and the Ministry of Community Development and Social Services (MCDSS).

To coordinate OVC efforts, the GRZ has established a multisectoral National OVC Steering Committee (NOSC), NAC implements an OVC Technical Working Group, and the MCDSS is initiating a Social Protection Team. The NOSC chaired by the MYSCD is represents GRZ ministries, Central Statistics Office, NAC, NGOs, UN agencies, traditional leaders, donors, and FBOs and is tasked with addressing high level policy, social service, and M&E matters. The NAC OVC Technical Working Group is tasked with technical oversight. In FY 2006, the NOSC updated and costed the OVC Mid-Term Action Plan and approved the National Child Policy, which includes an OVC chapter. The GRZ has integrated the Mid-Term Action Plan and budget into the National Development Plan for 2006-2010. While there has been impressive progress on the policy and strategy front, the OVC support and care efforts at the district and community level are still not well coordinated and leadership for the OVC response remains unclear. The joint HIV/AIDS Cooperating Partner (donor) group considers OVC coordination a key issue for FY 2007.

FBOs provide the most organized institutional response to the orphan crisis. There are a number of umbrella organizations and networks that fund and build capacity of local OVC programs. However, the limited supervision and training of OVC caregivers provided through small community-based organizations puts into question the quality and completeness of care being provided to OVC. Two areas need more attention: refuge camps and the Zambia Defense Force. Only two out of six refugee camps in Zambia have quality OVC services despite the risk of children being abused and neglected or having had traumatic experiences. The OVC problem is growing in the Zambian Defense Force as the impact of the AIDS epidemic increases. In addition, many military families take in AIDS orphans though they lack sufficient resources. Low military salaries and the high costs of school fees, books, and uniforms limit the number of children families can send to school.

The USG is the largest contributor to OVC support in Zambia. Other donors that support OVC include: The Development Corporation of Ireland, DFID, UNICEF, SIDA, GTZ and the World Bank's small grant mechanism. In FY 2006, the USG assisted in the dissemination, training, and implementation of the National Child Policy and placed an OVC technical advisor in the Ministry of Community Development and Social Services.

By mid-FY 2006, the USG reached 168,268 OVC with essential services and trained 6145 caregivers in 53 of 72 districts, representing 74% national coverage. All USG activities are coordinated through the USG OVC Forum to avoid overlapping and duplication. The forum meets on a monthly basis and is a platform for partners and USG staff to share information, PEPFAR guidance, and best practices, and to map activities. In FY 2005, this forum developed a Zambia USG OVC Strategy which is in line with the PEPFAR OVC guidelines.

In FY 2007, the USG will further scale up support to OVC throughout the nine provinces, implement the USG/Zambia OVC Strategy and action plan, and link all OVC activities more closely to the GRZ OVC framework. As a result, the USG will reach 321,240 AIDS-affected OVC and train 11,512 caregivers. The USG/Zambia team will ensure that all OVC programs are implemented in accordance with the OGAC OVC guidance. In FY 2007, the USG will put emphasis on: (1) expanding OVC care and support geographically in the areas with the most OVC; (2) integrating OVC support into home-based and hospice care, ART, and in military, refugee, and workplace programs; (3) increasing CT access for OVC and linking children living with HIV to ART; and (4) improving the quality and comprehensiveness of OVC services. The USG will continue to coordinate all OVC activities to maximize program coverage, avoid overlaps and duplicative efforts, and ensure quality care and support.

In FY 2006, USG will support 16 OVC activities, including 8 Track 1.0 OVC projects, and a small grants program through the State Department in Zambia. The USG OVC Forum will continue to carefully coordinate and map OVC activities and provide a platform for OVC partners to share good practices, lessons learned, materials, and M&E tools and strategies. The USG will continue to support Zambia's unique education and OVC wraparound approach that works with the Ministry of Education to produce interactive radio instruction broadcasts for OVC who are unable to access formal education, and leverages AEI funds for scholarships to non-AIDS orphans. USG partners will provide education support to OVC in preschool and grades 1-9, and scholarships to at least 4,000 orphans in grades 10-12 who have lost one or both parents to AIDS or who are HIV positive. The USG will continue to leverage Food for Peace and World Food Program food assistance for malnourished and food insecure OVC. USG will further leverage private resources for OVC support through U.S. and Zambian public-private partnerships. In order to serve the most vulnerable OVC, USG partners will focus on providing support to OVC from child-headed and grandparent-headed households. All OVC efforts will ensure that the essential needs of each child are met in accordance with OGAC guidance either through direct support and linkages to needed services.

To ensure sustained OVC interventions, the USG will use a three-pronged approach. The first approach will focus on strengthening the national OVC coordination and policy formulation and implementation. The USG will work with the National OVC Steering Committee, NAC, and other ministries to establish a coordinated OVC action plan, and will work with the MSYCD, MOE, and MCDSS to build their capacities to provide district and community OVC social services. Second, USG will put more emphasis on increasing the capacity of local partners to implement quality OVC programs. And third, the USG will strengthen the capacity of OVC families and caregivers, including child-headed households, to meet the needs of OVC at household level. At national level, the USG will work with the Central Statistics Office and NAC to strengthen the national M&E system to enable it to track OVC inputs, outputs, and outcomes, and to use GIS technology to map OVC programs and services. At project level, USG will further strengthen OVC partner M&E systems. The USG through the OVC forum has developed OVC database which is being adopted by all OVC partners. The database has helped OVC partners to avoid double counting.

Program Area Target: Number of OVC served by OVC programs 323,390 Number of providers/caregivers trained in caring for OVC 11,712

Table 3.3.08:

This activity allows laboratory experts from Atlanta to come and spend varying periods of time in Zambia working side by side with the Zambia nationals to transfer laboratory technical skills instead of sending laboratory technicians to the US for training. By having experts here, they are able to interact with a larger number of local lab technicians hence transferring skills to more people compared to if we send one or two Zambians to the US for training. Also, by having experts come to Zambia, they are able to see, work in, and transfer skills relevant to the environment the lab technicians work in. They are able to work with the Zambia to identify and implement practical solutions and not just transferring western lab techniques to Zambia.

In fiscal year 2006 this activity allowed two international laboratory experts to come and spend about four months each in Zambia. Two laboratory technical experts worked in country with the USG Chief of Laboratory Infrastructure and Zambian public health laboratory technologists to strengthen national sustainability for good laboratory practices, planning and quality assurance on a daily basis for care and treatment support. The first expert focused on TB laboratory procedures with special attention to the quality assurance, fluorescent microscopy, and culture techniques. On-the-job training was provided to staff working in the Chest Disease Laboratory and Maina Soko Military Hospital. The second expert focused on haematology and biochemistry procedures, providing on-the-job training to laboratory staff. Since these experts focus on skill transfer to build the national laboratory system, while in country, they work with Ministry of Health, Department of Defense, and private facilities.

In FY 2007 this activity will support laboratory experts to work side by side with the CDC Zambian public health laboratory staff recently hired in 2006 to strengthening their skills and expand the national quality assurance program for automated and non-automated laboratory testing procedures. Technical assistance will provided training on molecular technology procedures for, dried blood spot (DBS) analysis, infant HIV PCR and HIV resistance testing as well as hematology, CD4 and chemistry quality assurance for monitoring care and treatment support to persons on ARV and TB therapy. Support will also be provided to implement the national laboratory information system to improve accuracy of patient laboratory test data collection for care and treatment, reagent procurement and other laboratory management support. In addition, in FY 2007 this activity will extend technical assistance to all Department of Defense laboratory sites. This activity provides support for lodging, consultant fees, travel, training costs, needed supplies and other costs related to work with the national HIV/TB program in Zambia. Trainings and target data collection for this activity will be done in consultation with CDC-Zambia or other organizations. This kind of technical support brings international expertise to provide solutions for local issues with local staff and personnel, while building capacity the long-term skill of the local staff to take leadership in addressing those issues in the future. A third technical expert will provide support to the national TB laboratory program for rapid detection and identification of multiple and extreme drug resistant Mycobacterium tuberculosis using automated liquid culture systems for first and second line TB drug resistance testing and molecular techniques. This senior level expert will work with a supranational laboratory and assist the national laboratory program in achieving international accreditation.

This activity relates to EGPAF SI (#9001), JHPIEGO SI (#9034), AIDSRelief - Catholic Relief Services (CRS) (#8828), Ministry of Health (MOH) (#9008), and Technical Assistance/Centers for Disease Control and Prevention (CDC) (#9023) and Zambia National Blood Transfusion Service (ZNBTS) (5251).

To support the transition of software upgrades and development in 2007 to in-country talent, United States Government (USG) will hire a ‘lead' professional programmer/developer to work closely with the integrated Continuity of Care and Patient Tracking System (CCPTS) team on-location in Zambia to finish bringing skill levels of the Zambian team up to the level required to maintain and adapt the software in the future. In addition to this lead staff (probably an American), the Centers for Disease Control and Prevention (CDC) strategic information (SI) section will identify a national hire as an understudy. The purpose of having these two SI staff in-house is for closer monitoring and evaluation of their capability and contribution, and to make it easier to provide close guidance for the next phase of the project as the Ministry of Health (MOH) transitions into leadership in a new technical area.

(Please see the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF) SI narrative for more details about the Continuity of Care project, which involves a wide collaboration for national deployment of the system presently called CCPTS - Continuity of Care and Patient Tracking System.)

The intent for the ‘national hire' developer is to provide an option for a longer term and lower cost technical bridge between the US-based technical expertise that jump-started the project, and the locally sustainable ownership of the technology. This provides CDC an alternative method of placing essential software talent at the disposal of the ministry; this is particularly crucial due to the year long difficult period of Ministry reorganization as the Central Board of Health is absorbed by the MOH.

The high end technical professional will possess experience in developing clinical software applications, including electronic medical records (EMR), and will be employed no more than two years. Experience with deployment and capacity building for such systems will also be requisite for this person. This lead professional will work daily with Zambian colleagues to ensure transparent and shared engineering of the system.

This activity provides a critical 1-2 year bridging capacity, while the US based developers who gave the project its initial jump start, are tapered down to small contributions and backup roles for what is becoming the Zambian EMR. August 31, 2006, the Ministry held a high level meeting to announce to all the Cooperating Partners the plan to deploy this partially complete EMR nationwide. They were able to announce that the latest consensus revision of the ART software ‘forms' were entirely developed in Zambia. However there remain some challenging technical areas yet to be mastered by the in-country team, despite the tremendous success of the project concept at a political level and deployment level.