PEPFAR's annual planning process is done either at the country (COP) or regional level (ROP).
PEPFAR's programs are implemented through implementing partners who apply for funding based on PEPFAR's published Requests for Applications.
Since 2010, PEPFAR COPs have grouped implementing partners according to an organizational type. We have retroactively applied these classifications to earlier years in the database as well.
Also called "Strategic Areas", these are general areas of HIV programming. Each program area has several corresponding budget codes.
Specific areas of HIV programming. Budget Codes are the lowest level of spending data available.
Expenditure Program Areas track general areas of PEPFAR expenditure.
Expenditure Sub-Program Areas track more specific PEPFAR expenditures.
Object classes provide highly specific ways that implementing partners are spending PEPFAR funds on programming.
Cross-cutting attributions are areas of PEPFAR programming that contribute across several program areas. They contain limited indicative information related to aspects such as human resources, health infrastructure, or key populations programming. However, they represent only a small proportion of the total funds that PEPFAR allocates through the COP process. Additionally, they have changed significantly over the years. As such, analysis and interpretation of these data should be approached carefully. Learn more
Beneficiary Expenditure data identify how PEPFAR programming is targeted at reaching different populations.
Sub-Beneficiary Expenditure data highlight more specific populations targeted for HIV prevention and treatment interventions.
PEPFAR sets targets using the Monitoring, Evaluation, and Reporting (MER) System - documentation for which can be found on PEPFAR's website at https://www.pepfar.gov/reports/guidance/. As with most data on this website, the targets here have been extracted from the COP documents. Targets are for the fiscal year following each COP year, such that selecting 2016 will access targets for FY2017. This feature is currently experimental and should be used for exploratory purposes only at present.
April 2009 Reprogramming: Updated Mechanism and Prime Partner from TBD
Zambia is currently one of the countries leading in integrating Male Circumcision (MC) as part of HIV/AIDS
prevention activities. JHPIEGO has been supporting the male circumcision program in Zambia for several
years, beginning in 2004 when they teamed up with the Government of the Republic Zambia (GRZ) to begin
work on small scale efforts to strengthen existing male circumcision services in order to meet existing
demand. This early work in Zambia has informed the international efforts of the World Health Organization
(WHO) and Joint United Nations Agency UNAIDS, and the training package that JHPIEGO developed with
the Ministry of Health (MOH) in Zambia formed much of the basis for the new international
WHO/UNAIDS/JJHPIEGO training package. Likewise, assessment tools used in Zambia also provided
background for the WHO toolkit. The GRZ has established an MC Task Force under the MOH and the
Prevention Technical Working Group of the National AIDS Council, of which JHPIEGO plays a key role.
In FY 2009, TBD will continue to support these groups and facilitate the hosting of an annual consultative
and update workshop for all stakeholders involved in MC activities.
This activity has four components: 1) Development of local capacity to provide quality MC services, 2)
Promotion of abstinence, being faithful, and condom usage (ABC) messaging, 3) counseling for prevention
and testing integrated in MC services, and 4) creating a favorable policy environment for the expansion of
MC services.
Development of local capacity to provide quality MC services
In FY 2009, TBD will support the sites developed in FY 2007 and FY 2008 with the aim of consolidating
their MC services and ensuring that clients receive high quality, comprehensive services. Services should
include standardized counseling, safe and efficient procedure, and client follow-up. Emphasis will be placed
on developing provincial level training centers with capacity to train new service providers in the
comprehensive approach to MC service provision within this framework. TBD will work to strengthen these
provincial centers and continue to improve the environment for scaling-up MC services. These training
centers will be used to guide other expansion sites for FY 2009.
In FY 2007, JHPIEGO worked with four model sites (three sites in Lusaka, one in Livingstone) to ensure
that they met the minimum standards to provide quality MC services, and trained 50 clinicians (10-14 per
site) to provide MC services, and 50 counselors (10-14 per site) to provide comprehensive counseling on
circumcision services and male reproductive health. Sites were supported to provide integrated services,
strengthening links to STI and family planning programs, provision of routine opt-out HIV counseling and
testing, and strong components of HIV prevention counseling and services. In FY 2009, TBD will continue
to provide ongoing support to these sites, to ensure that they provide high quality, comprehensive MC
services, through supportive supervision using a standard-based management and recognition approach.
In addition, TBD will also continue to monitor changes in the sexual risk behavior of clients post-procedure,
to ensure that adequate, effective counseling and HIV/AIDS prevention measures are in place and well
integrated with the new MC services.
In FY 2008, JHPIEGO expanded to five additional sites in Ndola, Kitwe, Solwezi, Chipata, and Kasama,
based on demand for maximization of service coverage. Sites trained included MOH, Zambian Defense
Forces (ZDF) and Churches Health Association of Zambia (CHAZ) affiliated institutions. Sixty MC providers
and 60 counselors were trained following the same training curriculum as in FY 2007, 12 providers and 12
counselors per site. Twenty of these providers, four from each site, were later trained as clinical trainers as
part of JHPIEGO's efforts to increase the local training capacity in MC.
To ensure that trained providers can actually start providing services, the project conducts detailed initial
assessment, evaluating the site infrastructure, level of administrative support, providers' readiness to
engage in the new service, as well as demand for MC services in the catchment area. Only sites that meet
the criteria for a project site are involved in the training.
In FY 2009, TBD will expand MC skills training to six additional sites as follows: three provincial sites in
Central, Luapula, and Western Provinces, and three large district sites; locations will be identified in
consultation with CDC and District Health Management Teams (DHMTs). Working in these sites, JHPIEGO
will prepare 72 additional MC providers and 60 counselors, 12 clinicians, and 10 counselors per site. Later,
24 of these providers will be trained as clinical trainers, four trainers per site. This will produce 132
individuals (72 clinicians and 60 counselors) trained to promote HIV/AIDS prevention through other
behaviour change.
Development of local capacity and decentralization of training and supervisory responsibilities is one of the
cross-cutting objectives in JHPIEGO's work in Zambia. During FY 2009, the emphasis will be placed on
establishing training teams and supporting local providers to coordinate MC activities at provincial level.
The established network of trainers will be tasked with identification of additional training sites, providing
training and conducting supervisory visits to sites. TBD will continue overseeing all these activities and will
supervise training and follow up activities.
In this way, management and supervision of MC work will gradually be transferred to local establishments
under MOH to ensure ownership and sustainability of services.
As part of the support, JHPIEGO provides the project sites with standardized list of commodities to 1) start
the MC services, and to 2) sustain them. The initial commodities include MC surgical equipment identified
during the initial assessment visit. After training, the sites are provided with additional supplies as required.
As part of national scale-up efforts, TBD will continue providing all sites with start-up surgical equipment and
supplies, and will periodically replenish the supplies as required. The itemized list of standardized MC
equipment is available on request.
As result of TBD support, it is expected that at least 7,000 clients will receive quality MC services, including
counseling, at the new sites through the end of FY 2009, assuming that each of these new sites is providing
Activity Narrative: at least 140 procedures a month within three months after training.
Promotion of ABC usage message
In FY 2008, working with the MOH in the development of ABC strategies and messages, JHPIEGO reached
6,000 individuals with AB messages delivered through various communications media that ensured the
most coverage possible. By providing the MOH with the framework with which to develop new messages
and initiatives JHPIEGO ensured that there will be continuity and sustainability in prevention message
development and dissemination.
In FY 2009, TBD will work with the MOH and other partners to build a strong message focused on
abstinence for youth, including the delay of sexual debut and abstinence until marriage, being faithful in
marriage and maintaining monogamous relationships; and correct and consistent usage of condoms (ABC
message) as part of the MC service package, which includes the development and dissemination of
counseling guidelines for men undergoing MC. ABC messages will play a key role in the pre- and post-
circumcision counseling that is part of the comprehensive MC services package. TBD will additionally focus
on including messages that specifically target female partners of circumcised men. Apart from encouraging
female participation in decision making regarding sexual intercourse, dangers of early intercourse before
the wound completely heals will be addressed. TBD will work with the MOH to design culturally appropriate
messages and disseminate them through already established channels. In addition, TBD will work to
strengthen community involvement in promoting MC and preventing HIV transmission, and will engage
community leaders in disseminating these messages.
Specifically, FY 2009 funds will be used to: (1) support the development and testing of additional messages
and implementing the effective messages as part of the national prevention strategy; (2) develop take home
brochures, radio, and TV spots emphasizing ABC as integral part of MC education; and (3) support the
development of counseling protocols that include ABC messages during MC service delivery, and train
counselors on the importance of delivering ABC messages with this service; (4) develop materials
specifically targeting female partners of circumcised men, stressing the importance of abstinence before the
wound fully heals.
Counseling and testing integrated in MC services
The WHO recommends that MC be promoted primarily to HIV-negative males in areas of high HIV
prevalence. Since knowing one's HIV statues is critical to making informed decisions regarding MC and
other sexual health needs it is critical that counseling and testing be integrated into all aspects of MC
service provision. In FY 2009, TBD will continue integrating CT at all expansion sites and will expand MC
service delivery while offering CT to all men who seek MC services and are above the legal age of CT in
Zambia. It is expected that approximately 3,000 men will be reached through MC services.
To work toward the sustainability of quality MC services and the associated CT, JHPIEGO conducted
clinical training skills for 20 providers within the model institutions developed in FY 2007 and FY 2008.
These workshops provided the trainers with teaching skills and methodologies as well as reinforcing their
knowledge and skills in comprehensive MC service provision. The trainers will form the core for the
standardization and expansion of MC services in Zambia. Over 60 providers were trained through the
second-generation MC workshops conducted by these new trainers with JHPIEGO's support and
supervision.
FY 2009 funds will be used specifically to: (1) strengthen the CT component developed earlier to support
the MC services; (2) ensure that CT remains an integral part of MC services; and (3) training additional VCT
counseling and clinicians.
Creating a favorable policy environment for MC services
In FY 2007 in FY 2008, JHPIEGO spearheaded and supported the development of national guidelines on
MC, strategic planning and implementation of scale-up efforts, including development and dissemination of
materials to ensure clarity and consistence in the application of MC policy nationwide. In FY 2009, TBD will
continue to work with MOH, NAC and other stakeholders to update and consolidate the contents of the MC
guidelines/policy documents to ensure that they are thorough and clear for providers to follow.
This initiative will contribute to sustainability by supporting the GRZ and MOH to develop national
guidelines and putting in place a framework that will allow for the further update of this document by
following a standard stepwise process that can be replicated in the future.
In FY 2009, TBD work in policy and systems strengthening will focus on: (1) disseminating the MC
guidelines using a variety of media appropriate for service providers as well as clients; (2) collaborating with
the MOH and other partners in the development of information, education, and communication materials; (3)
continuing to monitor performance standards for MC, developed in FY 2007 to standardize and enhance
performance and quality improvement and supervision of MC services; and (4) hold annual
consultative/update workshops in order to obtain consensus and updates regarding new developments in
the MC arena.
New/Continuing Activity: New Activity
Continuing Activity:
Emphasis Areas
Gender
* Addressing male norms and behaviors
Human Capacity Development
Estimated amount of funding that is planned for Human Capacity Development $1,390,000
Public Health Evaluation
Food and Nutrition: Policy, Tools, and Service Delivery
Food and Nutrition: Commodities
Economic Strengthening
Education
Water
Table 3.3.07:
ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS: Work with pre-service institutions has been
added to improve educational process and further quality of services, and support sustainability of the
program.
Activity Narrative
This activity has several components: 1) revision of clinical care guidelines and corresponding updates for
service providers, 2) provision of national leadership in the area of capacity building and performance
improvement through implementation of continuing education opportunities for HIVAIDS clinical staff at
antiretroviral therapy (ART) centers, and 3) adaptation and integration of new performance improvement
tools into ART service provision. Efforts to ensure sustainability of the program through development and
using appropriate technologies and working in close collaboration with the MOH and national institutions cut
across all components.
Revision of clinical care guidelines and corresponding updates for service providers. In FY 2006,
JHPIEGO assisted the Ministry of Health (MOH) and National HIV/AIDS/STI/TB Council (NAC) to update
clinical training materials and trainers to be consistent with the recently revised clinical care guidelines. In
FY 2007, JHPIEGO assisted the government, particularly the MOH and NAC, to adapt the revised clinical
care guidelines and training materials to more useful electronic formats accessible to providers through a
variety of appropriate technologies (e.g., CD-ROM, web-based, handheld technologies). This was done in
close collaboration with other implementing partners and technical specialists working on ART programs,
and ensured consistency and standardization of materials, messages, and approaches to maximize the
efficiency and success of HIV/AIDS clinical care and ART scale-up activities in Zambia. In FY 2008,
JHPIEGO with expertise of the Johns Hopkins Point of Care Information Technology (POC-IT) Center
worked with MOH and other collaborating partners to develop and test different technologies (CD-ROMs
and handheld technologies such as Palm handheld or smartphone) to make the clinical guidelines and
resources available and accessible for HIV/AIDS care and treatment to providers. In FY 2009, three
hundred (300) more CD ROMs and handheld devices will be purchased, loaded with HIV/AIDS clinical
guidelines, and disseminated to the healthcare providers working at ART sites nationwide.
Provision of national leadership in the area of capacity building and performance improvement for HIV/AIDS
care and treatment providers is an important component to address gaps identified in ART service delivery
programs. This support is critical to ensure that HIV/AIDS care and treatment services maintain an
acceptable level of quality, which will help to ensure not only that new clients are encouraged to enter care
but also that existing clients remain under care. To achieve this, JHPIEGO will continue to support the
implementation of continuing education opportunities for HIVAIDS clinical staff at ART centers, reinforcing
their basic skills and expanding their knowledge in specific areas. In previous years, JHPIEGO assisted
the GRZ to develop and pilot continuing education programs for ART service providers and facility teams.
These programs included a combination of distance education programs for use in low technology settings
as well as internet and e-mail based education program developed by the Johns Hopkins University Center
for Clinical Global Health Education. Through the end of FY 2008, initial programs had trained 250 ART
providers, including staff from hospital- and large urban clinic-based ART sites. JHPIEGO supported these
programs to reach additional clinical caregivers, while developing additional content to fill identified gaps.
One such gap addressed was strengthening the use of highly active antiretroviral therapy (HAART) in
pregnant women for their own health (as well as to further reduce mother to child transmission of HIV), a
high priority for training in FY 2008 consistent with national PMTCT and ART guidelines in Zambia. In FY
2008, JHPIEGO developed new modules in prevention of mother to child HIV transmission (PMTCT) and
Pediatric ART according to the national guidelines and disseminated to service providers who finished the
initial update course.
In FY 2009, the initial and new modules will be further disseminated to 450 healthcare providers and 10 pre
service education institutions nationwide, to support educational process of medical and nursing students.
TBD's blended learning approach—one that combines electronic and face-to-face learning—will ensure that
frontline providers and students alike are given the knowledge and the skills that they need to provide
quality service. We will continue to increase gender equity in provision of ART services, by imparting this
knowledge and skills to equal proportions of males and females in all our programs.
Adaptation and integration of new performance improvement tools into ART service provision. TBD will
work with the Ministry of Health (MOH), University of Zambia and the University Teaching Hospital (UTH)
partnership and the Medical Council of Zambia to adapt and integrate additional tools for performance
improvement into ART service provision programs such as those of Elizabeth Glaser Pediatric AIDS
Foundation and Zambia HIV/AIDS Prevention, Care, and Treatment Partnership, as well as TBD's work with
the Zambian Defense Forces. These tools and approaches will not only help to support the quality of
HIV/AIDS care and treatment services, but enhance the sustainability of technical support. Further efforts
will focus on maximizing the use of tools that can be delivered onsite to reduce the need for ongoing
external technical assistance and additional manpower (e.g., trainers and supervisors). One such tool is
TheraSim™'s case-base simulation program, a computer-based interactive tool which allows providers to
go through a series of HIV care cases and receive feedback on their clinical decision making skills. This is
a tool which can be used both for advanced training as well as for monitoring performance.
To ensure sustainability of the program, TBD will continue working in close collaboration with the MOH,
NAC, Medical and Nursing Councils, and the University of Zambia Medical School/UTH, to build the local
capacity to design, develop, and implement educational programs to support quality ART services.
Materials developed in these programs are ‘owned' by the national program and these institutions, and are
designed to be implemented through existing systems (e.g., by involving the Provincial Clinical Care
specialists to monitor and follow-up the distance education programs). By using appropriate technology,
implementation and support cost are reduced comparing to other, more traditional approaches. The
program focus to develop tools that can be delivered on site, require less movement by clinical staff,
Activity Narrative: eliminate costs of travel and lodging will ensure less disruption of services and improve the ‘immediacy' of
applying new skills and knowledge at the workplace. Likewise, electronic versions of guidelines and
continuing education material can be updated, reproduced, and disseminated at much less cost than print-
based material. Using these approaches and tools, the national program and local partner institutions will
be able to continue supporting these programs with minimal levels of investment, as compared to the cost
of traditional group-based in-service training. Furthermore, smartphones or other handheld devices will be
used both as a source of latest HIV/AIDS clinical guidelines by providers and as a supervisory tool by
trainers and supervisors.
New/Continuing Activity: Continuing Activity
Continuing Activity: 15531
Continued Associated Activity Information
Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds
System ID System ID
15531 3689.08 HHS/Centers for JHPIEGO 7173 3017.08 UTAP - $500,000
Disease Control & U62/CCU32242
Prevention 8 / JHPIEGO
9033 3689.07 HHS/Centers for JHPIEGO 5019 3017.07 UTAP - $500,000
3689 3689.06 HHS/Centers for JHPIEGO 3017 3017.06 Technical $250,000
Disease Control & Assistance/JHPI
Prevention EGO
Estimated amount of funding that is planned for Human Capacity Development $500,000
Table 3.3.09:
The scope of work and funding level for this activity in FY 2009 will remain the same as in FY 2008. Only
minor narrative updates have been made to highlight progress and achievements.
As outlined below, funding for this activity will provide support to continue implementation of standardized
quality improvement interventions to enhance quality of service delivery across United States Government
(USG) sponsored Antiretroviral Therapy (ART) programs. Of critical importance will be use of findings from
the special quality studies to improve quality of services and close gaps in ART service provision.
The national ART implementation evaluation published in April 2006 revealed numerous areas in need to
improve the implementation of services in Zambia. For example, 84%of institutions visited, reported not
having seen the national ART implementation plan with many sites having never received key policy
documents and guidelines. One can proximally assume then that quality improvement and monitoring
activities were few. Moreover, this evaluation did not include in-depth investigation of care quality as part
of its mandate. It is clear that as ART continues to be rolled-out at a rapid pace in Zambia, quality must be
assured to promote the sustainability of these services in the future. In cooperation with JHPIEGO, USG
through Centers for Disease Control and Prevention (CDC)/Zambia began support for a joint program
assessment of ART technical and financial support in Zambia in 2006 that revealed key areas for quality
improvement interventions. This evaluation activity is now an ongoing process of data collection and
feedback. It is therefore critical for funding in FY 2009 to implement sustainable activities that will aim to
close performance gaps identified in the ongoing evaluation process.
In FY 2007, CDC-Zambia entered into a collaborative partnership with JHPIEGO to implement the Zambia
Antiretroviral Quality Improvement Project (A-QIP). Under this project, in FY 2008, JHPIEGO implemented
standardized quality improvement interventions to enhance quality of service delivery, finalized special
quality studies, and trained facility-based program managers on utilization of quality indicators to improve
service delivery.
A-QIP consists of four inter-related components designed to facilitate quality improvement among the
Government of the Republic of Zambia (GRZ) and cooperating partners (CPs) in Zambia. JHPIEGO's
overall work in capacity development and performance improvement is closely linked with this initiative, and
is integrated in some of the components, such as implementation of SmartCare software at ART sites
nationwide to improve quality of services and JHPIEGO's ongoing work in development and implementation
of continuing education courses for ART providers at sites throughout the country.
Below are the descriptions of TBDs activities within the frame of each component for the FY 2009.
1.Collective and Routine Monitoring of Quality
Evaluation activities with participation across ART service providers in Zambia will bring together the
Ministry of Health (MOH), major private sector companies, and CPs, including Elizabeth Glaser Pediatric
AIDS Foundation (EGPAF), Centre for Infectious Disease Research in Zambia (CIDRZ), Zambia
Prevention, Care, and Treatment (ZPCT), AIDSRelief/ Catholic Relief Services (CRS), University Teaching
Hospital Pediatrics/Columbia University, John Snow Incorporated/DELIVER, and JHPIEGO. MOH and
CPs will be convened to identify critical and common questions and develop a shared evaluation strategy to
evaluate care quality, service delivery and coverage, and continuity of care from a sample of sites. The
process will require regular meetings of project directors, monitoring and evaluation (M&E) staff, and clinical
experts to identify indicators, collect and share information, and further inform policy development and
service delivery in Zambia. This process will also incorporate existing standard quality indicators (such as
HIV-QUAL indicators) into the evaluation process. As a result of these activities, a set of core indicators for
quality monitoring will be developed, and ultimately integrated into the SmartCare system to ensure
standardized, comprehensive and sustainable data for quality of care. In addition to tracking a common set
of quality indicators, a special study will be supported in the area identified by the group.
2.Data Use for Improved Care
The SmartCare system has been deployed in more than 100 sites between 2005 and 2007. It is
anticipated that the system will continue to be deployed where feasible in GRZ locations throughout the
country in 2008. SmartCare provides critical individual level data on health services as well as numerous
opportunities to query facility-based and eventually district and provincial data. Data use from the system,
in cooperation with other facility-based aggregation systems (e.g., ARTIS) and what will be a redesigned
health management information system for Ministry of Health (MOH), must be maximized to inform quality
improvement activities. This is a key feature and task of the A-QIP project and will include all sites with
SmartCare deployment. JHPIEGO has been involved in the development, piloting, and implementation of
SmartCare from its inception, and will continue providing technical assistance in the areas of training and
supervision. This activity is closely linked with JHPIEGO's activity under strategic information in this COP.
3.Coordinated Quality Improvement Assistance
Based on findings from routine monitoring and evaluation, key interventions for quality improvement will be
elaborated and delivered to sites identified most in need of support. In close collaboration with the MOH,
the group will identify an organization that will map out and help to coordinate technical support activities
delivered through GRZ and CPs. It's important that this organization will have capacity to actively introduce
quality assurance and facilitation services to improve individual and facility-level performance by providing
on-the-job training (OJT) for quality improvement. JHPIEGO's ongoing work in performance improvement
and capacity building through development and implementation of performance improvement tools and OJT
training of providers is deeply integrated in this component, and will help build the basis for sustainable
quality assurance.
4.Creating International Networks for Learning
Distance learning will be used to reinforce a response to findings from routine monitoring and assessment.
In cooperation with MOH facilities, distance learning will be combined with OJT opportunities and organized
Activity Narrative: in a specific set of course work and informal sharing focused on adult and pediatric ART. We will continue
to increase gender equity in provision of ART services, by providing distance learning opportunities to equal
proportions of males and females in all the programs. Lectures from Zambia and international experts will
be recorded and used in these educational sessions. In close collaboration with the MOH, the group will
identify an organization to take responsibility to moderate and facilitate ongoing learning through session
design and execution. JHPIEGO's ongoing work in development of continuing education opportunities for
service providers via distance learning is integrated within this component and will further progress in close
collaboration with A-QIP activities.
Continuing Activity: 15529
15529 9745.08 HHS/Centers for JHPIEGO 7173 3017.08 UTAP - $400,000
9745 9745.07 HHS/Centers for JHPIEGO 5019 3017.07 UTAP - $300,000
Estimated amount of funding that is planned for Human Capacity Development $400,000
The funding for this activity in FY 2009 will remain the same as in FY 2008.
ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS: Work with pre-service institutions has
been added to improve educational process and further quality of services, and support sustainability of the
This activity relates to activities in counseling and testing, laboratory infrastructure, palliative care, and basic
health support activities.
This activity is closely linked to Jhpiego's other work in Zambia, focused on strengthening integrated HIV
prevention, care, and treatment services, including counseling and testing (CT) and palliative care, as well
as Jhpiego's work on integrating diagnostic CT into TB and STI services. It also linked with cross-cutting
Jhpiego's work to promote task shifting through training lay workers in counseling and testing skills. It also
incorporates work under Jhpiego's ART program in development of distance learning opportunities for
providers of HIV prevention, care and treatment.
In Zambia, rates of HIV and TB co-infection are more than 70% and TB is one of the leading causes of
death among PLWHA. To ensure appropriate care for TB patients, HIV counseling and testing should be
integrated into TB programs.
Jhpiego is working to strengthen the integration of HIV/AIDS and TB care and treatment services in
Southern, Western, and Eastern Provinces through: 1) Training for Provider Initiated HIV counseling and
testing (PICT); 2) On-the-job training (OJT) for diagnosis and management of opportunistic infections; 3)
Training of community counselors and treatment supporters; 4) Supportive supervision in clinical training
skills; and 5) Building provincial and district team capacity in TB infection control
In FY 2009, TBD will continue strengthening and expanding the capacity at the provincial level in training
skills, supervision and monitoring, continue with the TB infection control activity, and expand OJT activities
to improve providers' skills in diagnosis and treatment of opportunistic infections without taking them away
from their workplaces.
TB patients must be effectively counseled and tested for HIV, and, if found positive, referred to HIV care
and treatment services in a timely manner. Based on successful approaches in integrating CT into
antenatal care for PMTCT, in FY 2005, Jhpiego adapted Centers for Disease Control and Prevention's
(CDC) counseling protocols and training materials to incorporate DCT into TB services more effectively. In
FY 2005, Jhpiego trained 63 health care providers in DCT from 14 sites in three districts (Livingstone,
Mazabuka and Mongu) of Southern and Western Provinces, who then provided counseling and testing to
1,300 clients during that year. Also, Jhpiego provided technical assistance to the Ministry of Health (MOH),
CDC, World Health Organization (WHO), Tuberculosis Control Assistance Program (TBCAP), Churches
Health Association of Zambia (CHAZ), and Center for Infectious Diseases Research in Zambia (CIDRZ), to
further build capacity in DCT clinical training skills by training 50 MOH TB focal point persons from all the
nine provinces of Zambia and staff from other implementing partners' programs.
In FY 2006-2007, Jhpiego continued to work with the Southern and Western Provincial Health Offices
(PHOs) to support integration of HIV counseling and testing into TB services. Working with the local
provincial trainers in FY 2006 and FY 2007, 125 health care providers from ten new sites were trained in
DCT, in addition to the provinces' own programs of training. To ensure that these programs are
sustainable, in FY 2009, Jhpiego will strengthen and expand the capacity at the provincial level in training
skills in all the provinces, and supervision and monitoring, through joint training and supervision activities in
Southern, Western and Eastern Provinces. In FY 2007, Jhpiego used plus-up funds to train a total of 216
trainers in DCT from all the 72 districts of Zambia and developed the training capacity of the Zambia
Defense Forces by holding a DCT clinical training skills workshop for 12 ZDF trainers who later trained 80
service providers. In FY 2008, JHIEGO worked with these trainers to conduct additional DCT workshops
targeting 100 ZDF service providers from sites nationwide. This number was in addition to the 80 ZDF
health care providers who were trained in TB diagnosis and management under the DOD-Jhpiego TB/HIV
activity #9090.
In FY 2009, TBD will continue FY 2007 plus-up and FY 2008 funding initiatives to develop district level DCT
clinical training skills by ensuring that new trainers receive support in their first trainings by co-training with
experienced trainers who will provide support and feedback on their training skills. In FY 09, Jhpiego will
train 100 new trainers national wide to account for the attrition of trainers in the districts.
In FY 2009, TBD will also continue with the TB infection control activity started in FY 2007 and FY 2008
when the guidelines were developed and disseminated at the central level and to all PHOs. TBD will work
to build capacity of provincial teams and later will support them to conduct orientation and oversee the
implementation of TB infection control activities at the district/facility level. TBD will also provide support to
the local teams in conducting supportive supervision.
Providers of HIV care and treatment services need significant strengthening in the recognition, diagnosis
and management of TB and other opportunistic infections (OIs). Because of the complexities of
presentation and manifestation of TB and other OIs, and the limited diagnostic capacities of providers and
facilities, initial basic training in OI management is only the tip of the iceberg. Experience from Jhpiego's
work in past years shows that significant effort in hands-on mentoring and on-the-job training can
dramatically improve care and treatment for HIV patients.
Structured on-the-job training (OJT) is a non-traditional, intensive approach to in-service training that
involves a highly experienced clinician spending extended period of time at a service outlet working with a
Activity Narrative: team of providers in their environment. OJT includes daily rounds together with structured mentoring, case
study reviews, and working with the teams of providers through diagnosis, clinical decision-making, and
management of TB and other OIs, using the national guidelines and training materials. Between FY 2005
and FY 2008, with assistance of clinical experts from the University of Zambia (UNZA) and University
Teaching Hospital (UTH), Jhpiego provided OJT to 150 health care providers, including nurses, clinical
officers and doctors, from Livingstone General Hospital, Lewanika General Hospital, Chipata General and
Mazabuka District Hospitals along with selected staff from hospital-affiliated health centers (HAHC). In FY
2009, an additional 95 service providers will receive OJT in 10 additional district hospitals in Eastern,
Southern, and Western Provinces. Relevant performance standards were drafted and implemented in FY
2006 and FY 2007. This should improve the quality of care by providing sites with standards they can
implement and monitor as well as tools for supervisors to use in monitoring and supporting clinical services.
In FY 2006, Jhpiego formalized an arrangement with UNZA and UTH to use the pool of clinical experts from
the institutions for this training program as a step towards building the capacity of those key national
institutions. In addition, in FY 2008, Jhpiego increasingly involved the Clinical Care Specialists from the
Provincial Health Offices and the experienced clinicians from the Provincial Hospitals and other larger
facilities, to build local capacity to support and expand this program from the Provincial level. In FY 2009,
the respective Provincial Health Offices will increasingly carry out supervision and monitoring of the training
and quality of services with the support of TBD and the UNZA/UTH clinical experts as needed.
Based on the TB DOTS model of community treatment support programs, HIV treatment programs are
similarly developing community treatment and adherence support programs. With the high rates of TB-HIV
co-infection, tremendous opportunities exist to increase the synergies in these programs and ensure that TB
treatment supporters are able to refer for and support HIV services, and vice-versa. There are no gender
disparities in the provision and access to TB/HIV diagnosis and treatment in Zambia.
To strengthen TB/HIV collaborative activities, between FY 2005 and FY 2008, Jhpiego trained 285
community counselors/treatment supporters (CCTSs) in Livingstone, Mazabuka, Monze, Kazungula, Itezhi-
tezhi, Sesheke, and Mongu districts in support of the sites where DCT and OJT activities were conducted.
The CCTS are involved in providing HIV/TB education, TB treatment support and ART treatment adherence
support at community level and referral for TB and HIV services. In FY 2009, TBD will draw upon earlier-
trained CCTSs and local NGO staff, building local capacity to expand and support these programs. In order
to ensure sustainability of the program, local trainers will increasingly take the lead in training and
supervision activities, supported by TBD and our local partners (Kara Counseling and Community-Based TB
Organization [CBTO]) as needed. The aim in FY 2009 is to support the training of 120 CCTSs in 10 districts
of Southern, Western and Eastern provinces. The focus will also be on strengthening supportive
supervision and exploring an integrated system that includes HIV/TB/PMTCT/Malaria. Home visit diaries
will be provided to the CCTSs to enhance record keeping. To ensure that community counselors have
necessary set of skills to provide services needed in the community, TBD will also build their capacity in
counseling and testing using finger prick under the Jhpiego's HVCT program. It is expected that local
trainers will conduct roll-out training activities using resources from the MOH, Global Fund and other
sources, thus further expanding the pool of community resources in order to attain geographical coverage of
the services.
TBD will also support the pre-service education institutions in strengthening their TB/HIV curricular
component through access to the continuing education programs with the latest evidence-based
information. These programs include a combination of distance education programs for use in low
technology settings developed by Jhpiego in collaboration with the MOH, as well as internet and e-mail
based education program developed by the Johns Hopkins University Center for Clinical Global Health
Education for service providers. In FY 2009, the initial and new educational modules will be provided to 10
pre-service education institutions nationwide, to support educational process of medical and nursing
students. Jhpiego's blended learning approach—one that combines electronic and face-to-face learning—
will ensure that frontline providers and students alike are given the knowledge and the skills that they need
to provide quality service.
To ensure sustainability, these activities are enshrined in the Ministry of Health District Plans.
Health-related Wraparound Programs
* TB
Estimated amount of funding that is planned for Human Capacity Development $650,000
Table 3.3.12:
ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS:
•Update on current activities
•Plans for 2009
•Increased training targets.
This activity is closely linked JHPIEGO's other work in Zambia, focused on strengthening integrated HIV
prevention (MC #12519.08, #12524.08, #12530.08, New PMTCT), care and treatment services (including
counseling and testing (CT) and palliative care - #DOD) , as well as JHPIEGO's work on integrating
diagnostic CT into TB and STI services (#3644.08). It also linked with cross-cutting JHPIEGO's work to
promote task shifting through training lay workers in counseling skills.
This activity has two components: 1) training lay workers in HIV counseling and testing using finger prick,
and 2) ensuring that trained lay counselors provide quality services and meet the demand for HIV
counseling and testing, both in service delivery sites and in the community. Promotion of shifting the task of
HIV counseling and testing to lay workers, and strengthening of local training and supervisory capacity are
cross-cutting objectives in this activity.
Counseling and testing (CT) is an essential intervention in all HIV/AIDS programs, serving as a key link
between prevention, care and treatment efforts. Those who test HIV negative have the opportunity to
change their behavior in order to prevent acquisition of the virus in the future. Those who test positive have
the opportunity to change their behavior to prevent transmission to their partner(s) and to make informed
decisions about seeking appropriate care and treatment including prevention of mother to child transmission
(PMTCT), prevention and management of opportunistic infections (including TB and STIs) and, when
clinically indicated, antiretroviral therapy (ART).
One of the most devastating impacts of the HIV/AIDS epidemic has been its effect on the healthcare sector.
As the need for skilled healthcare workers has increased exponentially due to the burden of disease caused
by HIV, TB and other infections diseases, the number of healthcare workers becoming ill as well as the
brain drain have increasingly pulled trained personnel away from the health sector at precisely the time that
they are most needed.
The acute shortage of nurses and other skilled healthcare workers has resulted in woefully insufficient
number of trained counselors for HIV or psychosocial counseling to meet the demand (or potential demand)
for counseling and testing.
In light of this acute shortage, JHPIEGO in collaboration with the Provincial Health Offices (PHOs), District
Health Offices (DHOs), and other partners, is promoting "task-shifting" wherever possible. Task shifting
means that tasks that are commonly conducted by higher-level healthcare workers (e.g., nurses) should be
shifted to lower-level providers and even lay people if these cadres can competently conduct them. HIV
counseling is a prime example. Lay counselors can provide high quality HIV counseling, provided that they
are properly trained and supervised, freeing up professional nurses to perform the clinical skills for which
they were trained.
The community (lay) counselors are a link between the community and health care services and are
involved in providing group education and counseling and testing both at the community and facility levels.
Task-shifting strategy and making greater use of lay counselors is another way of ensuring continuous
availability of trained counselors at the service delivery sites.
JHPIEGO works to build local capacity in supporting and expanding CT services. In FY 2008, in order to
expand services and strengthen the community outreach around the target facilities, improve the continuity
of care and uptake of services, JHPIEGO conducted counseling and testing (using finger prick) training for
120 lay counselors from selected districts of Southern (Livingstone, Monze, Mazabuka,), Western (Mongu
and Senanga), and Eastern (Chipata) Provinces.
JHPIEGO worked with the existing management and supervisory teams of PHOs and DHOs to provide
supportive supervision and on-the-job training to at least 100 community (lay) counsellors who were trained
in FY 2007, as well as quality assurance to programs strengthened during previous years. Quality
assurance exercises are focused on the two key components: quality of counseling and quality of testing.
The project uses a variety of methodologies to evaluate the quality of counseling, such as client exit
interview, mystery client, and chart review. To assure the quality of finger prick testing, internal and external
quality control systems were used.
In FY 2009, TBD will continue training of new lay counselors in counseling and testing using finger prick in
Southern, Western and Eastern Provinces, in the six districts mentioned above and four additional districts
to be selected in coordination with the PHOs, and will train at least 160 community (lay) counselors ( 16 per
district). These lay counselors will provide services in the communities and at the clinics, allowing qualified
medical personnel to attend to clinical care duties.
Taking in consideration the number of local and international agencies working to strengthen CT services in
Zambia, location of trainings and distribution of trainees will be discussed and closely coordinated with the
PHOs and DHOs to ensure that TBD's training activities fit in the local strategy and avoid overlap of efforts.
In addition to training of new lay counselors, JHPIEGO works to ensure that previously trained lay
counselors have ample opportunity to apply their new skills and that they provide quality services to the
community. With this purpose, in FY 2009, TBD will continue providing supportive supervision and on-site
updates, working with 120 community counselors trained in FY 2008. To strengthen local supervisory
capacity, TBD will work closely with the PHOs and DHOs to ensure that they are capable to further
Activity Narrative: strengthen the monitoring of the quality of services.
To ensure that community counselors have necessary set of skills to provide services needed in the
community, TBD, in addition to the CT skills, will also build their capacity in TB/HIV integration activities
under the TBD's TB/HIV program. This program will include training in TB/HIV group education, TB
treatment support and ART adherence support at the community level. The districts will be selected in
consultation with the PHOs.
These activities will be complimented by the CT and supervision trainings conducted by the provinces
themselves; TBD will work in close collaboration with Community-Based TB Organization and Kara
Counseling to strengthen their capacity and support the provinces in conducting these trainings. Provinces
will further report the number of people reached with counseling and testing through this activity thus it will
not be included here to avoid duplication.
TBD will continue providing support to the local management and supervisory teams to ensure that they will
soon take the lead in both training and supervision activities and will work to enhance their ability to sustain
and expand these programs.
Continuing Activity: 15527
15527 4527.08 HHS/Centers for JHPIEGO 7173 3017.08 UTAP - $200,000
9035 4527.07 HHS/Centers for JHPIEGO 5019 3017.07 UTAP - $235,000
4527 4527.06 HHS/Centers for JHPIEGO 3017 3017.06 Technical $235,000
Estimated amount of funding that is planned for Human Capacity Development $200,000
Table 3.3.14:
ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS: Per CDC-Zambia request, work with
nursing schools to improve pre-service nursing education will be initiated. The rest of the activity is
unchanged from FY 2008.
This activity also relates to Ministry of Health (# 3713.08), EGPAF (#3709.08), COMFORCE (#9692.08),
CDC-TA (#3714.08).
Building upon FY 2008 activities, TBD will continue to support the scale-up and deployment of electronic
patient monitoring and data management tools to enhance continuity of care. This will be provided by a)
training and b) supporting the project sites during the early implementation and use of the growing number
of modules in the SmartCare software (formerly called the Continuity of Care and Patient Tracking System
[CCPTS]). Within the scope of a cooperative agreement with CDC, TBD will continue to collaborate with
the broad consortium of organizations involved in the development and deployment of the SmartCare
System nationwide. These organizations include the Ministry of Health (MOH), the CDC-Zambia, Provincial
Health Offices (PHO), District Health Management Teams (DHMT), the Elizabeth Glaser Pediatric AIDS
Foundation (EGPAF), Centre for Infections Disease Research in Zambia (CIDRZ), AIDSRelief, and the
Zambia Prevention, Care and Treatment Program (ZPCT), among others.
In FY 2005 and FY 2006, JHPIEGO supported the early development of the SmartCare software and its
pilot and scale-up in Kafue District. Starting in FY 2007, JHPIEGO supported the transition of the
SmartCare project from the pilot phase in Kafue District to the nationwide deployment of the system.
Working with MOH and CDC-Zambia and in collaboration with other implementing partners, JHPIEGO
supported the training of over 500 managers, supervisors and service providers, including District Health
Information Officers (DHIOs) and district Maternal and Child Health (MCH) coordinators, district level focal
person in ART, PMTCT and TB, as well as all nine Provincial Data Management Specialists (PDMSs). In
addition, JHPIEGO has supported staff involved in all phases of deployment of SmartCare, including pre-
deployment, orientation, training, and post-deployment supervision of the SmartCare system. Also,
JHPIEGO has supported the training of service providers at "independent" service outlets which are service
outlets that do not have an implementing partner committed to directly support the deployment of
SmartCare and the training of service providers in the use of SmartCare.
In FY 2009, TBD will continue to support the implementation of SmartCare through training, post-
deployment supportive supervision visits conducted jointly with provincial, district and other SmartCare
implementing partners, provision of logistical support for the deployment, and limited site readiness
preparation. TBD deployment staff will work closely with the MOH, CDC-Zambia and other implementing
partners to prioritize activities focused on pre- and post-deployment to ensure that there is a synergy of
efforts as the nationwide deployment continues. TBD will take a leadership role in the development and
implementation of post-deployment supervision methodologies and tools that guide managers and
supervisors at all levels to measure gaps between actual and ideal usage of the SmartCare System. These
tools not only measure the gaps, but also provide managers and supervisors with the information necessary
to guide service providers on how to close the gaps and why it is important.
TBD training and implementation staff will also support training of 250 service providers in the provinces
and districts targeted during the scale-up. They will co-train with the provincial and district trainers and work
in conjunction with all the partners supporting the scale up of the system such as MOH, CDC-Zambia,
EGPAF/CIDRZ, ZPCT, CRS, and other implementing partners. They will make sure that the quality of
training is maintained from the PHOs in the districts and collaborate with the SmartCare team in the update
and revision of training materials as the system matures.
Increasingly, the MOH is taking the lead in SmartCare collaboration, deployment authority, and field
support, and has solicited commitments for infrastructure from all major implementers. The MOH, through
collaboration and in close consultation with CDC-Zambia and other implementing partners, developed a
very aggressive deployment plan that includes a) training provincial level Trainers of Trainers centrally, b)
sending provincial technical leadership back to province to replicate training for district leadership with
SmartCare team support, and c) tasking the trained providers with implementation at their districts. So even
before the FY 2009 activity period, the efforts of the initial three SmartCare collaborators will be joined by
efforts of all other HIV/AIDS care and treatment partners in Zambia, including CRS-AIDSRelief, ZPCT,
JHPIEGO, Health and System Strengthening Project (HSSP), and EGPAF.
In building this collaboration around the SmartCare solution, it is clear that the MOH is comfortable taking
the initiative on this effort. TBD, in coordination with CDC's future developments and other CDC
partnerships, will leverage its long-term good relationship with the MOH and established ‘trainer' role.
JHPIEGO's strong technical staff will continue to support the rapid national deployments and most of this
activity will be focused on the training and post-deployment supervision. While Zambian electronic medical
records (EMR) system now provides services to more than 90,000 patients, with the additional partners
starting deployment before the end of October, the rate of growth may increase non-linearly along with the
number of electronic clinics, provided there are no supply limitations.
The methodologies employed by JHPIEGO and the SmartCare team as a whole are designed with the
express interest in developing a system that can be sustained by the Ministry of Health. By empowering all
levels of the Zambian Ministry of Health system with the knowledge and skills to deploy and manage the
SmartCare system, from the pre-deployment preparation through post-deployment supervision, it will be
within the scope of the MOH and Government of the Republic of Zambia to sustain the SmartCare system
as an essential tool in the provision of continuous, quality health care service in years going forward.
In FY 2009, per request from CDC-Zambia, JHPIEGO will start identifying opportunities to improve the
Activity Narrative: nursing pre-service education. It will include identification of gaps in the curriculum content, especially in
presentation of evidence-based information and particularly in the area of HIV/AIDS. At the same time, a
needs assessment will be conducted to identify gaps in current training methodologies, including
development of competencies to manage EMR.
JHPIEGO will work with nursing schools in the development of a learning management system framed
around EMR. It will also include the potential development of E-learning materials to enhance the transfer
of knowledge, skills and attitudes related to the target competencies (such as TB, STI, OIs, and provider-
initiated counseling and testing [PICT]) while simultaneously preparing future providers to work with the
EMR as part of the SmartCare approach.
Estimated amount of funding that is planned for Human Capacity Development $75,000
Table 3.3.17:
