The University of Zambia is the only institution in Zambia that offers higher level medical training hence the Government of the Republic of Zambia's (GRZ) vision of training 100 doctors per year dating as far back as 1970 has not been realized. The School of Medicine's (SOM) first admissions were in 1966 when Zambia's population was about 4 million which has since increased to 12 million. The School has been operating below levels required to produce adequate health manpower to satisfy the health workforce needs for Zambia or to deliver optimal health care in combating HIV/AIDS/TB/STI/Malaria and other health needs. In the last 40 years, there has been no corresponding growth and development in particular support areas such as laboratories, lecture rooms, and other physical structures in spite of the introduction of post graduate programs in 1983 and more recently, the undergraduate programs in pharmacy, physiotherapy, biomedical sciences, environmental health and HIV residency diploma courses, that tripled the number of students. The lack of capacity for adequate health workforce production is basically owing to four factors namely: 1) lack of teaching facilities, lecture rooms and laboratories, 2) lack of adequately trained faculty, 3) poor conditions of service, and 4) lack of adequate student and staff accommodation. The School of Medicine development master plan aims at increasing the number of graduating doctors to 150 per year by 201; currently only 80 doctors are admitted into the school per year. To achieve this goal, the SOM has identified the need to increase its teaching space that includes lecture theatres, tutorial rooms, laboratory space and equipment.

In this regard, the overall institutional objectives under this funding mechanism for the School of Medicine, in FY 2010 are as follows: (1) Continue to strengthen the quality and scope of the graduate programs in the Master of Public Health degree (2) Continue strengthening the quality and scope of the laboratory equipment, infrastructure and biomedical training for both undergraduate and graduate courses; and (3) Rehabilitate the teaching space infrastructure that includes lecture theatre, tutorial rooms, the anatomy and physiology laboratories at Ridgeway Campus and the public health laboratory in the Department of Community Medicine; (4) Participate in enhancing effective sexual risk reduction through selected and specific known interventions to community health centers throughout Zambia; (5) Develop and implement circumcision programs in Zambia as part of comprehensive care, treatment and support critical in HIV prevention; (6) Continue the development, implementation, and evaluation of a Certificate Program that prepares nurses in Zambia to provide comprehensive care, treatment and support, including initiation of antiretroviral therapy (ART) for patients with HIV/AIDS. In the second phase of this program, the main focus is to intensify training of nurses in all provinces and expand their roles so that they are able to meet the challenges of HIV/AIDS care and support programs; and (7) Maintain support of visiting lecturers to enhance the quality of the teaching in disciplines identify by the dean's committee as requiring such support.

The strengthened school in FY 2010, is expected to increase the output of public health graduates being supported from 10 to 20, increase the number of biomedical scientists and doctors through improvement of current infrastructure in order to cater for high enrolment demands, and improve on linkages with other preventative programs. As a result, this will benefit the whole country at large in that there will be an increase in the number of graduates, improved quality of education, improved research, and participation in actual health education and health promotion from labs to community level.

A number of cross-cutting programs and key issues for cost efficiency surface mainly in training. Funds for certain basic core courses in Master in Public Health and Master in Clinical Medicine that might be duplicated will be offered in a coordinated manner in FY 2010. Other strategies that will be considered for more cost efficiency will involve increasing the number of enrolled students as this does not directly affect fixed costs, yet impacts immensely in output as average costs are varied but maintained on the efficient production frontier.

Monitoring and evaluation plans for health systems strengthening in the School, have differential frameworks. The M&E for the Master in Public Health program includes internal evaluation frameworks where evaluation is performed by students and faculty. In this case, students provide personal feedback on learning materials received during program. Other programs under this funding mechanism utilize external evaluation framework, which make use of an external person against the set targets. In the HVOP program, the monitoring and evaluation plan will follow and rely on the RE-AIM (Reach, Efficacy/Effectiveness, Adoption, Implementation and Maintenance) strategy. As for the male circumcision program, the stipulations of inputs, outputs, outcomes and expected impacts will allow for monitoring and evaluation. The internal M&E mechanism constitutes project director, site manager as well as the Dean of the School of Medicine. The National MC task force will have a quality assurance subcommittee which will provide the external M&E to all sites through the National MC coordinator.

During FY 2010, the School of Medicine (SOM) aims to support the nursing certificate program to strengthen nurses' training for effective care and support for HIV/AIDS in Zambia. We aim at developing, implementing, and evaluating a certificate program to prepare nurses to provide comprehensive care, treatment and support, including initiation of antiretroviral therapy (ART) for patients with HIV/AIDS. This is based on the realization that to address the health workforce shortage and increase access to and quality of HIV services, the redistribution of tasks among health workforce teams is necessary. Therefore, there is need to develop mechanisms for clinical training, mentoring and supervision of workers who assume expanded roles, and for developing financial and/or non-financial incentives in order to retain and enhance the performance of these health workers.

The second component is to support short term visiting lecturers from within and outside the region to provide lectures and clinical skills in disciplines with limited available expertise as determined by the Deans' advisory committee of the SOM. Due to the shortage of human resources, training programs in the school are generally grossly understaffed. Through this support the School will pay for the visiting professor's travel and upkeep to provide a block of lectures and clinical skills training. There will be a deliberate effort to identify and bring in experts from within the region as it is cost effective. Where regional expertise is not available, experts will be identified from outside the region.

Additionally, in FY 2010, UNZA will strengthen and build local human laboratory capacity by continuing renovation and upgrading of training laboratories, and revise curricula for biomedical science students. UNZA will support revision of curricula for biomedical students, biomedical training and renovation of laboratories in other departments within the School of Medicine (such as the public health laboratory in the Department of community Medicine). UNZA will hire one Zambian biomedical expert to coordinate both undergraduate and graduate biomedical training, mentorship and building capacity in this field in collaboration with University of Nebraska.

In FY 2010, USG funds will continue to support the Master of Public Health (MPH) program. The SOM plans to continue strengthening the quality and scope of the MPH program for effective imparting of skills for care and support services in HIV/AIDS. Additionally, the SOM continues to emphasize and promote the need for requisite tools necessary for the training of health professionals. The above stated program to be implemented in FY 2010 broadly aims to achieve this objective for development of a health workforce with necessary skills to combat HIV/AIDS/TB/STI/Malaria. Given that the School of Medicine at the University of Zambia is the only medical school in Zambia, this is critically important and will impact immensely in the provision of health care in the country.

USG Zambia will additionally help build a lecture that would accommodate 180 students. This project will greatly increase and improve students learning environment leading to better quality of graduates who will be leaders in provision of HIV/AIDS/TB/STI/Malaria prevention, treatment and care services in Zambia. This undertaking is a response to addressing one of the four factors preventing the school from producing adequate numbers of health workers to alleviate the health workforce shortage.

The University Teaching Hospital (UTH) Urology section has run a Male Circumcision (MC) and Male Reproductive Health service since August 2004, with over 2000 procedures having been performed. The complication rate of 3% non permanent adverse events is close to that achieved at research sites in the region. The site began providing counseling and testing (CT), MC, and Neonatal MC services in November 2008. One full time counselor, two MC providers, one neonatal MC coordinator and one data entry operator have been seconded to the site. To date the site has conducted two trainings of 25 MC providers, and it has conducted 430 adult and 103 Neonatal comprehensive MC. It is anticipated that in FY 2009, the center will have provided training to 100 providers and offered MC services to 600 clients. In addition, the center is expected to conduct approximately 120 Neonatal MC and provide CT to 300 clients.

During FY 2010, we hope to continue the MC program and support services as carried out in 2008 and 2009. It is anticipated that by the end of FY 2010, the center will provide training to 100 providers and provide MC services to 600 clients. The site intends to train 50 MC counselors from among the staff of the UTH. To establish a sustainable program, and thereby have a large pool of trained staff within the Hospital, the site intends to train an additional 50 MC counselors from 5 provinces in Zambia where organizations providing MC will need trained MC providers. These organizations include Churches Health Association of Zambia, Family Health International and the Zambia Police Service. SOM will work with existing clinical facilities and non-governmental organization to strengthen their capacity in providing high quality MC services. The SOM's' goal is to establish a high quality comprehensive MC training and service to effectively scale-up into provinces that includes a package of testing and counseling, condom use, couple counseling and involvement of women, linkages to antiretroviral therapy, screening and treating for sexually transmitted infections, family planning services and infection control with strict adherence to national guidelines. SOM will also develop its oversight and technical assistance capacity in MC.

This program was designed to train Community Health Center (CHC) staff in the implementation of an evidence-based sexual risk reduction intervention among HIV seropositive and discordant couples. The intervention builds on the outcomes of several NIH funded studies carried out in Zambia at the UNZA-School of Medicine (SOM) and in the US at University of Miami (UM). Using cognitive behavioral strategies, this sexual risk reduction intervention focuses upon increasing HIV knowledge, skill-building to increase sexual barrier use, sexual negotiation and communication. This intervention utilizes gender concordant groups to allow men and women to discuss gender specific concerns and develop gender specific strategies for sexual risk reduction while addressing information critical to reducing HIV/STI transmission. In FY 2010, we plan to continue implementing these activities as a build up to what has already occurred. In the first three months, one group led by CHC staff with provincial health office (PHO) staff as co-leader will be trained, the SOM and UM consultants will provide an overview of the project to PHO leadership; and existing PHO staff from those trained previously among the four PHOs will select two additional CHCs from each of selected three districts to receive training in the project. The SOM, UM & PHO staff will develop program evaluation strategies & finalize project materials for new PHO. In the period from the fourth to eighth month, the third and fourth groups will be led by CHC staff members and PHO staff previously trained will provide supervision to CHC staff conducting the program. The new PHO staff will receive training as well as the new selected CHCs' staff. During the 9th to 12th months, the SOM Trainers & PHO staff at new PHO will provide training to selected CHC staff in each province over 2 days. During Y2, PHO staff and CHC staff will conduct groups 1 & 2. The first intervention group will be led by PHO senior trainer with CHC staff as co-leader while the second intervention group will be led by CHC staff. The SOM, UM & PHO staff will conduct program evaluation, analyze the evaluation and assess program implementation as well as plan for expansions to remaining PHOs.