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.
Years of mechanism: 2008
Private Sector Program (Prevention AB)
This is a continuing activity.
The Private Sector Program (PSP) led by Abt Associates works with large workplaces and private clinics to
improve access to HIV prevention, care, and treatment services for the general population and employees
and dependents. PSP focuses on developing abstinence, being faithful, and correct and consistent condom
use (ABC) programs which reflect the needs and demands of private and parastatal business firms. The
project seeks to establish management and labor ownership of its workplace ABC activities and encourages
companies to share a significant part of ABC program costs. As of 2007, the project provided routine
support and supervision for 75 workplace sites for both AB and ABC (10374) activities in seven regions of
In workplaces, PSP conducts a rapid assessment of HIV services, knowledge, and behavior. Based on the
assessment, the project conducts an orientation session with senior management to reach agreement on a
memorandum of understanding regarding activities and the contributions made by PSP and the company.
PSP trains a cadre of peer educators over a two-to-five-day period on a variety of HIV topics, including
prevention, TB, and stigma. Peer educators also learn skills to support effective counseling and
communication with family and community members. Ideally the project trains one peer educator for every
20 to 30 workers. In turn, the peer educators conduct eight to 16 sessions which focus on increasing
knowledge and fostering behavioral change. The sessions require 30 minutes to one hour of staff time
which the company provides during working hours. The monthly education sessions use peer interpersonal
communication to teach positive behaviors , including correct, consistent, condom use, seeking sexually
transmitted infection (STI) treatment, and accessing counseling and testing services. Sessions also address
stigma and self-risk perception of males engaging in cross-generational, coercive, or transactional sex.
PSP sponsors "family days" to recognize the employer/employee commitment to workplace peer education.
The project engages PLWH associations to deliver messages on HIV prevention. The project also supports
companies to design and complete HIV/AIDS workplace policies and strengthens the capacity of company
health and anti-HIV committees. In 2006, PSP leveraged resources from the International Labor
Organization to expand HIV-prevention programs in ten additional workplaces throughout the country.
In FY07, PSP prepared and enabled large Ethiopian companies to conduct peer-education programs with
ABC and TB/HIV messages by providing training for peer educators, supportive supervision, and
consultation with company senior management. PSP integrated materials on ABC, cross-generational and
transactional sex, TB and HIV, gender norms and the HIV burden on women. Utilizing cross-generational
sex study results, PSP developed three video spots focusing on male behaviors which will be used in the
program component on stigma and discrimination.
In FY08, PSP implementing partners will continue implementation of the peer-education program in the
existing 75 medium to large workplaces. The project intends to propose some innovations in its
peereducation program after completing a review of the 40 workplaces which have not yet begun to train
peer educators. Many of these 40 companies assert that their economic circumstances make them unable
to enter the longer-term commitment to an eight-month peer-education program. The PSP rapid review will
assess the opportunity to offer a new option to companies that are reluctant to embark on the eight-month
peer-education program. PSP will assess whether these companies would be willing to participate in ABC
and TB/HIV information sessions which compress key messages into a half-day format delivered by
professional educators. If the target companies indicate an interest in the half-day event format, the project
will seek opportunities to connect these half-day sessions with PSP's mobile counseling and testing (CT)
activities in order to give staff the opportunity to be counseled and tested. PSP experience in January and
February 2007 during the Millennium AIDS campaign indicates that there is strong demand in workplaces
for mobile or external CT services.
PSP will test the acceptability of a half-day interpersonal communications (IPC) program of ABC and
TB/HIV messages with existing workplaces. If the results are positive, the project will look actively for
opportunities to implement the half-day program with agricultural, industrial, and service sector workplaces
along the four corridors where PSP is implementing mobile CT activities. This activity will focus on
identifying and targeting at-risk populations in the workforce. PSP will also provide assistance to the
Agriculture and Trade Expansion Program (ATEP) which will begin introducing HIV-prevention activities with
their existing private sector clients and companies. PSP will share their IEC materials and best practices to
support ATEP in replicating successful HIV-prevention workplace programs.
PSP's existing, intensive eight-month workplace peer education program, and the possible new half-day
IPC program, are expected to reinforce positive behavioral norms and build more accurate self-perception
of risk among workers. PSP will provide peer educators with follow-up training and supportive supervision to
ensure the consistency of message delivery and support their motivation. In workplace and private clinics,
PSP provides technical assistance to support counseling on prevention for positives, which uses existing
materials. PSP emphasizes prevention for urban males of high educational and socioeconomic status
based on Ethiopia Demographic and Health Survey (EDHS) data which indicates that this group has a large
number of sexual partners. Self-reported condom use among urban males is 48% (EDHS 2005) and there
is an opportunity for increased HIV-prevention programming. This activity will collaborate with HIV-
prevention partners to use or adapt pre-existing audio and print materials to address issues surrounding
male social norms and low self-risk perception.
This workplace program involves sectors such as tourism, transportation, plantation and seasonal
agriculture which employ workers with a higher risk of HIV/AIDS infection. The modified half-day program
approach should allow more transportation, agriculture, and service sector employees to participate in
workplace communication activities. It will also enable PSP to reach out to new enterprises along the major
transportation corridors whose employees are at risk because of their contact with the mobile population
along the corridor.
The PSP program is complementary to AB programs implemented with public sector, government partners,
and affords significantly more reach for PEPFAR than would the public sector alone. PSP reaches the
Activity Narrative: employees and dependents in the general population through its workplace and private clinic programs. It
also reaches at-risk populations through the workplace program by selecting a majority of its intervention
sites in companies whose employees are thought to have one or more risk factors. The target enterprises
include transportation companies (trucking, airline, and railway), agricultural and floricultural enterprises,
tourism, and manufacturing. Through the workplace, PSP reaches men in their sexually active years who
also earn a regular income. At the management level, PSP reaches males of higher educational and
socioeconomic status, who the EDHS indicates are at risk due to their high number of sexual partners and
low reported condom use.
Workplace Peer Education Program
This is a continuing activity. This activity is a comprehensive HIV-prevention activity with both HVAB and
Private Sector Program (PSP) reaches at-risk populations through the workplace program by selecting a
majority of its intervention sites in companies whose employees are thought to have one or more risk
factors. The target enterprises include transportation companies, (trucking, airline, and railway) agricultural
and floricultural enterprises, tourism, and manufacturing. Through the workplace, PSP reaches men in their
sexually active years who also earn a regular income. At the management level, PSP reaches males of
higher educational and socioeconomic status. The Ethiopian Demographic and Health Survey has indicated
that members of this group are at risk due to their high number of sexual partners and low reported condom
PSP works with large workplaces and private clinics to improve access to HIV-prevention, care, and
treatment services for the general population, employees, and dependents. PSP focuses on developing
abstinence, being faithful, and correct and consistent condom use (ABC) programs which reflect the needs
and demands of private and parastatal business firms. The project seeks to establish management and
labor ownership of workplace ABC activities and encourages companies to share a significant part of ABC
program costs. As of 2007, the project provided technical assistance in interpersonal HIV-prevention
activities and clinical services in 75 large workplaces. A majority of workplaces have over 500 employees, of
which a subset has several thousand employees in several sectors of the economy including tourism,
transportation, and plantation and seasonal agriculture which employ workers with a higher risk of HIV/AIDS
infection. Many workplaces currently are located adjacent to major transportation corridors whose
employees are at risk because of their contact with the mobile population along the corridor.
In workplaces, PSP conducts a package of interpersonal and interactive HIV-prevention activities, as well
as clinical services strengthening. PSP works closely with company management to outline a package of
services per company requirements. This accentuates company interest and increases the leveraging of
private non-USG resources.
PSP trains a cadre of peer educators over a two- to five-day period on HIV prevention and tuberculosis
(TB)/HIV services. Peer educators also learn skills to support effective counseling and communication with
family and community members. Ideally the project trains one peer educator for every 20 to 30 workers. In
turn, the peer educators conduct eight to 16 structured sessions focused on increasing knowledge and
fostering risk-reduction. Sessions use peer interpersonal communication to teach positive behaviors,
including correct consistent condom use, seeking sexually transmitted infection (STI) treatment, accessing
HIV counseling and testing (CT) services, stigma, and self-risk perception of males engaging in cross-
generational, coercive or transactional sex. One major effort in FY07 was to increase participants'
knowledge of the HIV epidemic using recent Ethiopian Demographic and Health Survey (EDHS) and
antenatal care (ANC) information, specifically the estimated prevalence rates and the burden and
vulnerability on women.
PSP sponsors "Family Days" to recognize the employer/employee commitment to workplace peer education
and to address communities at risk. Family days engage associations for people living with HIV/AIDS
(PLWH) to deliver messages on HIV prevention. The project also supports companies to design and
complete HIV/AIDS workplace policies and strengthens the capacity of company health and anti-HIV
committees. In late 2006, PSP leveraged resources from the International Labor Organization to expand
standard HIV-prevention programs to additional workplaces throughout the country.
In FY07, PSP supported 75large Ethiopian companies train peer educators to reach individuals with
repeated HIV-prevention and risk-reduction sessions. PSP integrated materials on ABC, cross-generational
and transactional sex, TB and HIV, gender norms, and the current HIV burden on women for these
sessions. Using a FY05 cross-generational sex study, three video spots focusing on male behaviors were
used to initiate dialogue on stigma and discrimination.
In FY08, PSP will continue implementation of the peer education program in up to 75 large workplaces.
Several workplaces involved in FY05 will be graduated and provided minimal technical assistance to
facilitate more intensive interventions for recent entrants. The project will innovate peer-education activities
after completing a review of the 40 workplaces. PSP will provide several new options to facilitate access to
HIV-prevention activities among as many employees as possible. Specifically, PSP will implement frequent,
interactive HIV-prevention and CT events in parallel to modified peer-education sessions. This will be
coupled with the delivery of mobile HIV CT services to accommodate employees, family members, and
community members and their families.
PSP experience in January and February 2007 during the Millennium AIDS campaign indicates that there is
strong demand in workplaces for mobile or external CT services. The project will look actively for
identifying and targeting at-risk populations in the workforce. PSP's intensive eight-month, workplace peer-
education and half-day interactive program seeks to reinforce positive behavioral norms and build more
accurate self-perception of risk among the most-at-risk population groups. PSP will provide peer educators
with follow-up training and supportive supervision to ensure the consistency of message delivery and
support their motivation.
To build up a knowledge based for workplace HIV-prevention programming, PSP will conduct a structured
internal evaluation to determine the effectiveness of the HIV-prevention program in FY08.
In workplace and private clinics, PSP provides technical assistance to support the integration of HIV-
prevention counseling and prevention with positives into workplace clinical settings using pre-existing
materials and leveraging other USG implementing partner's expertise.
PSP's expanding engagement with private clinics offers an opportunity to integrate HIV-prevention
counseling in private, voluntary, CT and TB clinics.
Each workplace program encourages the public distribution of condoms. To support sustainable
programming, PSP does not procure condoms but helps track expiry of condoms in workplaces.
Activity Narrative: Workplace Peer Education Program
Private Sector Program
Building on FY05-FY07 activities, the Private Sector Program (PSP) led by Abt Associates will continue
interventions in large (1000+ employees) and medium-sized companies (500+ employees) in seven regions
to improve access to quality tuberculosis (TB) and TB/HIV clinical services for employees, their dependants,
and surrounding communities.
PSP will also expand integrated TB/HIV services in 100 additional private health facilities. In FY08, the
project will providing continuing supportive supervision for clinical programs in up to 60 workplaces and 120
private clinics. In the same period, the project will begin to work with 100 additional private clinics to
introduce quality HIV and TB services, including TB/HIV prevention, TB detection, TB diagnosis, and
directly observed, short-course therapy (DOTS).
The process of engaging 100 new private facilities consists of ten key steps. To engage stakeholders in the
planning process, PSP will work with the regional health bureaus (RHB) to convene meetings that build
consensus and sensitize stakeholders to the regions' needs for the expansion of TB/HIV services to include
PSP will assist the regions in developing and applying transparent criteria to select up to 100 additional
private facilities to provide TB/HIV services. The project will work with the RHB to conduct a rapid
assessment of the private health facilities identified as potential TB/HIV service providers, in order to
examine their resources and the needs of the facility.
After identifying the most qualified private facilities, PSP will work with the RHB and the private facilities to
establish a Memorandum of Understanding (MOU) between the bureau and the clinics. The MOU
establishes a formal relationship and clearly articulates the roles and responsibilities of the RHB, the district
health office, and the private health facility.
To maintain quality in implementation, healthcare providers must be appropriately trained to provide the
best level of service. PSP will continue to adapt existing training materials for health providers to better fit
the needs of private providers. The training will address the integration of counseling and testing (CT), TB,
TB/HIV, provider-initiated counseling and testing (PICT). PSP will strengthen the facilities' skills in reporting
and recording, internal quality assurance, monitoring and evaluation, and basic finance and management
skills to support service delivery and sustainability.
PSP will help to strengthen a referral network between the private and public sector which ensures
continuity of care, is able to track patient progress, and gets patients the care that they need. The project
will work with the RHB to build a shared understanding of how the referral links between the public and the
private sectors should function, to map the geographic links between the facilities, and to build and
strengthen the links between facilities.
Community awareness can help reduce the barriers to TB/HIV prevention, diagnosis, and treatment. PSP
will encourage the RHB to support community awareness through mass media campaigns, information
leaflets, and posters. PSP will also work actively to promote media coverage of TB and HIV services in the
Supervision ensures national guidelines are implemented for provision of care, laboratory and pharmacy
services, and overall facility maintenance, including record-keeping and reporting. PSP will work with the
RHB, and potentially with professional associations, to promote an approach to supervision which goes
beyond a checklist and involves careful direct observation of infrastructure, data entry in registers, and all
other reporting formats, referral tracking, reporting on defaulters, and TB drug supplies, expiry dates, and
requisitions for new stocks.
PSP will assist the RHB and district health offices to develop reliable logistics systems to supply anti-TB
drugs. Depending on the agreements set out in the MOU, there is the potential to include HIV rapid-test kits,
as well. The project will build the capacity of the facility to properly store, manage, and requisition required
stocks of TB drugs.
PSP will assist the RHB in establishing a monitoring and evaluation system which ensures appropriate use
of resources, assure quality, and generates data for decision-making. Monitoring and evaluation of
implementation activities will help to evaluate the outcomes achieved, while measuring both short- and long-
This activity will increase access to TB and HIV services through private-sector facilities. The activity will
add 100 new facilities which can identify and treat TB infections and provide HIV counseling and testing
services which are integrated and coordinated. The project will also provide continuing supportive
supervision to 60 existing workplace sites and 100 FY07 private-sector clinics which offer TB/HIV services.
PSP-Ethiopia will closely integrate its TB/HIV activities with the other PSP activity for Mobile and Private
Sector Counseling and Testing Services (10538). In addition, the project will coordinate with other related
projects by sharing its strategies, tools, and ‘lessons learned' with the related contracts. It will request the
same level of information sharing from the related PEPFAR partner programs. The key programs for
information sharing and coordination are the Care and Support Program for TB/HIV, Palliative Care, and
Counseling and Testing (10399, 10400, and 10647), and Community-Level Counseling and Testing Service
This initiative focuses on the general population which uses private-sector health facilities for care and
treatment. PSP will build the capacity of the RHB and district health offices to integrate the private-sector
facilities into delivery of the key TB and HIV public health services. PSP will assist the Ethiopian Ministry of
Health with facility selection, logistics, supportive supervision, reporting, and monitoring and evaluation.
PSP will build the private-sector facilities' capacity for clinical services, referral, reporting, internal quality
assurance, and general management.
Mobile, Private Sector, and Workplace Counseling and Testing Services
This is a continuing activity. This activity implements activities to support mobile HIV counseling and testing
(HCT), private sector HCT, and workplace HCT.
The Private Sector Program (PSP) led by Abt Associates works with large workplaces and private clinics to
improve access to HIV prevention, care, and treatment services for employees, their dependents, and the
general population. The project seeks to establish management and labor ownership of workplace activities
and encourages companies to share a significant part of program costs.
In FY08, PSP and its local subcontractors will complement ongoing efforts in workplaces and private clinics
with expanded, high-quality, mobile HCT services designed for adult populations in higher prevalence urban
and peri-urban areas. The project will also leverage activities under several existing PEPFAR programs that
provide HIV-prevention and facility-based counseling and testing (CT) and tuberculosis (TB) services.
Access to, and use of, of high-quality, facility-based voluntary counseling and testing (VCT) services by at-
risk populations remains problematic along major transportation corridors (i.e., Addis-Djibouti; Addis-
Adigrat; Addis-Metema; and Modjo-Dilla). Private CT services, although promising, are not yet sufficiently
supervised to assure that they comply with national guidelines to provide quality laboratory services and
comprehensive referrals. The activity will expand mobile CT services in parallel to expanding long-term,
facility-based CT services in workplaces and private for-profit clinics along the corridors.
Each component is described below. It is important to note that the intermittent nature of mobile CT services
poses a challenge to providing sustained improvements to CT services. In response to this, PSP is ensuring
that private, for-profit clinics are identified and CT services are installed or strengthened in areas of mobile
CT. Furthermore, using basic subcontracting, PSP is working with large, indigenous, commercial and civil
society CT providers to support mobile CT services. These subcontracts are improving the capacity of these
partners to perform services and compete in future USG activities.
1) Support for Mobile CT Services:
During FY08, PSP will operate four, low-cost, mobile counseling and testing units along four transportation
corridors focusing on high prevalence and high demand areas. The mobile units will:
- Target adult populations, commercial sex workers, mobile workers, and other risk groups for CT in urban
and peri-urban areas
- Employ highly visible promotion teams to prime demand and offer multiday CT events in high-prevalence
areas within the ART health network
- Receive training and supervision to ensure that services meet national guidelines, including quality
assurance/quality control, use of finger-prick techniques with dried-blood-spot or parallel testing
- Make comprehensive referrals for care and treatment. The program will follow up to monitor success in
connecting seropositive individuals with appropriate care.
- Standardize reporting to appropriate levels of the Ethiopian Ministry of Health and conduct joint analyses
of client demographics and findings with regional health bureaus (RHB) and USG partners.
This activity will support targeted community mobilization to promote use of CT services along
transportation corridors, in markets, workplaces, public gatherings, and particularly in places identified as
sites where high-risk populations live and work.
Each quarter, PSP will select four different groups of 10-20 towns along the major transportation corridors
where the project will provide mobile CT services. Program staff will complement CT services with targeted
mobilization activities to increase uptake of such services among adult populations and MARPs. By
vigorously promoting the CT services, PSP will help to make the teams efficient and productive. The
program will target 15 tests per counselor per day on a five-day-per-week activity schedule. CT service
capacity ranges from 5-15 counselors per day, depending on the findings of service-demand assessments.
The mobile services will contribute to the national strategy to rapidly scale up CT services to reach
underserved and marginalized populations. Current services are predominantly based in static centers in
government health centers and hospitals. Ethiopia's July 2007 national CT guidelines clearly indicate the
need for outreach and mobile CT service delivery.
2) Support for CT Services in Private Health Clinics:
In FY08, PSP will work closely with RHB and town health offices to strengthen a minimum of 200 private
clinics with high client volume to provide CT services. PSP will also develop innovative models to refer at-
risk clients visiting pharmacies to appropriate TB or HIV clinical services. While working with private health
facilities, PSP will:
- Strengthen the capacity of Ethiopian nongovernmental organizations (NGO) and private sector partners to
provide CT and TB diagnosis and treatment
- Provide facilities with training, supervision, and assistance to improve service quality, productivity, and
management. This will support better quality counseling and testing services.
- Promote extended VCT hours to facilitate access
- Strengthen referral linkages to community and facility-based HIV/AIDS prevention, care, and treatment
By increasing the use of the private sector to provide CT services, this program will reduce the strain on
already overburdened public health providers and build the competence of local organizations to provide
high-quality, sustainable CT services where international organizations may now be filling that role.
3) Support for Workplace CT Services and Referral:
PSP will continue implementation in large (1000+ employees) and medium-sized companies (500+
employees) in seven regions to ensure improved access to counseling and testing. By September 2008,
this activity will operate in up to 75 workplaces and private health facilities across Ethiopia and will ensure
the presence or improved access to quality services, including counseling and testing.
Activity Narrative: As part of an integrated workplace program for HIV/AIDS prevention, care, and treatment, PSP will continue
to support intensive, workplace peer-education programs, which support greater uptake of TB and HIV
services. PSP promotes a "Know Your Status" interpersonal communication program to reinforce positive
behavioral norms. The peer education program will increase numbers of employees and dependants
choosing VCT and needing subsequent clinical care and treatment.
PSP will support CT services in the workplace by providing supportive supervision for those clinics which
offer on-site CT services or refer clients to external CT providers through provider-initiated counseling and
testing (PICT) or voucher programs. The project will also link workplaces whose employees fall into the high
-risk groups with mobile CT services.
This activity will educate the workforce and families about basic facts and the importance of CT in 75
workplaces and will reach families and the surrounding community with similar messages during mass
educational events. The peer-education component educates staff through eight modules on TB and
HIV/AIDS which are delivered in small-group discussions during the work day. This activity works with
employers to establish HIV policies to protect HIV-positive employees from stigma and discrimination.
PSP will work closely with Medical Association of Physicians in Private Practice (MAPPP) and other
professional associations in collaboration with RHB to initiate and sustain private-sector CT services. This
activity will focus on reaching MARPs along the four high-risk corridors in urban and peri-urban settings. It
will increase access to quality, integrated HIV and TB services for urban populations by engaging new
private-sector clinics in delivering services.
PSP targets MARPs by conducting thorough rapid assessments before deploying mobile CT teams or
selecting private-sector clinics. The assessments gathers information on who the MARPs are in a
community, where they live or work, and what messages might persuade them to accept CT services. The
assessment identifies the most-at-risk groups in a community through key informant interviews with staff
from RHB and district health offices, as well as local NGO and faith based organizations which provide care,
treatment, and support services. It also uses focus-group discussions and individual interviews with
individuals from the risk groups to ascertain where these groups can be reached with CT services and what
messages might prompt them to seek CT.
PSP reaches at-risk populations through the workplace program by selecting a majority of its intervention
sites from companies whose employees are thought to have one or more risk factors. The target enterprises
include transportation companies, (trucking, airline, and railway), agricultural and floricultural enterprises,
tourism, and manufacturing. Through the workplace, PSP reaches men in their sexually active years that
have disposable income. At the management level, PSP reaches males of higher educational and
socioeconomic status whom the 2005 Ethiopia Demographic and Health Survey indicates are at-risk due to
their high number of sexual partners and low reported condom use.
PSP will use national systems for implementation, monitoring and evaluation, and intensive supportive
supervision to strengthen CT services in areas of operation.
Private Clinic ART integrated with PMTCT
The Private Sector Program (PSP) led by Abt Associates works with large workplaces and private clinics to
improve access to HIV prevention, care, and treatment services for the general population and employees
As Ethiopia has increased the number of people on ART, hospital-bases services have become increasingly
congested. While hospitals which provide ART are overcrowded, the related services in those facilities such
as counseling and testing (CT), PMTCT and TB are frequently underused. This activity is designed to assist
in identifying and treating HIV-positive adults with specific focus on pregnant women in peri-urban
communities who are not served by other entry points to care. Despite greater access to HIV/AIDS services
in urban and peri-urban areas, efforts to prevent pediatric HIV infection have been hampered by low
PMTCT uptake, clients' perception of poor quality public sector ANC services, low utilization of antenatal
care (ANC) services, and lack of awareness of PMTCT and ART services.
Based on recommendations from the USG private sector technical assistance visit of August 2006,
PEPFAR Ethiopia expanded its approach to target private sector facilities which may identify HIV-positive
persons and link them to ART.
According to the Ethiopia Demographic and Health Survey (EDHS) 2005, approximately 11% of deliveries
in Addis Ababa occur in the private sector. Furthermore, 17% of all women (urban and rural) receive family
planning services from the private sector. It is likely that this number comes primarily from urban and peri-
urban areas. PSP will work in regional capitals and large towns such as Addis Ababa, Bahir Dar, Dessie,
and Nazareth to expand the ART health network through private clinics and pharmacies to identify and treat
those living with HIV/AIDS who do not attend public facilities.
This activity will build on linkages between health centers and hospitals supported in the FY07 activities.
The following activities are proposed:
1) Improve awareness of HIV services among pregnant women and address client perceptions of service
quality to increase uptake. The contractor will work with private sector providers to: strengthen their
awareness and involvement in HIV/AIDS care for pregnant women; increase counseling and testing for
adults and specifically pregnant women receiving CT; improve the quality of care and support for HIV-
positive women; strengthen referral linkages for HIV-positive adults specifically pregnant women; strengthen
the public-private partnerships to bring HIV-positive adults, specifically pregnant women into the ART
network; and integrate HIV/AIDS and TB services, specifically ART clinical management of stable patients
into private sector clinics in selected high client flow private facilities.
2) Ensure that private facilities which provide integrated TB and HIV services target pregnant women for
service. The contractor will prioritize assistance to facilities that reach this audience, such as antenatal care
and family planning providers.
3) Support outreach to raise community awareness of HIV/AIDS counseling and testing, care during and
after pregnancy, and of assisted delivery. Several pre-existing materials were developed with past PEPFAR
Ethiopia investments. Low-level mobilization, (i.e. road shows during market days) will be conducted where
mass media has little penetration.
4) The activity will prioritize identification and enrollment of pregnant women for ART in selected high-
volume private facilities.
5) This activity will improve data management, supportive supervision, quality assurance and stewardship in
the Regional Health Bureau (RHB) and District Health Offices' (DHO) interaction with the private sector. It
will accelerate rollout of PMTCT and ART in private facilities, and generate community demand for PMTCT
and ART services.
6) Work with the Ministry of Health and Regional Health Bureaus to revise national Public Private Mix
guidelines for HIV/AIDS services.
This activity is integrated with several Private Sector Program activities proposed for FY08 funding. The
activity will be implemented in full collaboration with US government implementing partners at Health Center
and Hospitals as well as Pharmacy specific expertise of RPM Plus.
It will also draw strategies, material, and tools from the following activities: IntraHealth International for
PMTCT/Health Centers and Communities (104615), JHPIEGO Qualitative Assessment of Women's
Attitudes related to PMTCT (10650), the ART treatment activities of US universities which provide technical
support for ART scale-up [Johns Hopkins University (10430) Columbia University (10436), and University of
Washington (10439)], Johns Hopkins University, Clinically Focused Record Systems (10598), Family Health
International ART Service Expansion at Health Center Level (10604), Johns Hopkins University, User
Support Center for ART Service Outlets (10606), US Centers for Disease Control and Prevention, Public
Awareness on ART (10623).
This initiative targets adults and HIV positive adults who use private sector pharmacies and health facilities
for care and treatment services or products. It will reach pregnant women and those planning pregnancy by
strengthening and PMTCT counseling services, training, and communication material within those facilities.
PSP will build the capacity of the Regional Health Bureaus, District Health Offices and Town Health Offices
to supervise private sector providers through systems-oriented technical assistance and secondment.
The result of this activity is expected to build the private sector facilities' capacity for clinical services,
referral, reporting, internal quality assurance, and general management.
The Private Sector Program (PSP), led by Abt Associates, works with private clinics to improve access to
HIV prevention, care, and treatment services for the general population, and works with large workplaces to
improve access for employees and their dependents.
This activity leverages proposed funding from USG Ethiopia's bilateral Tuberculosis ($600,000).
This activity began in FY07 to 1) strengthen host country policies toward private-sector engagement and 2)
establish an information base on sustainable HIV/AIDS financing for private and civil service employers
through AIDS Solidarity Funds. In FY07, successful public-private mix activities in Addis Ababa in
tuberculosis (TB) directly observed therapy - short course (TB DOTS) and HIV counseling and testing
accounted for approximately 11% of TB case notification and approximately 10% of total HIV counseling
and testing sessions. Progress was made in structuring and advancing public policy dialogue with the
Ministry of Health (MOH) and regional health bureaus (RHB) in the areas of TB/HIV service delivery by the
private sector and cost recovery. Cost recovery and sustainable financing mechanisms will be further
analyzed in the remainder of FY07.
To date, donor and government efforts have focused on building the capacity of public-sector provision of
counseling and testing, ART, and TB DOTS, with support from PEPFAR and the Global Fund for AIDS,
Malaria, and Tuberculosis (GFATM). While these efforts have achieved tangible gains and greatly increased
access to quality HIV/AIDS/TB services, there are limits to the absorptive capacity of the public sector,
which is not always the best channel to reach high-risk groups that may be reluctant to attend public-sector
clinics and may keep hours that are incompatible with public-sector clinic times. Finally, the private sector's
need to charge fees is not necessarily a barrier to service provision.
There are three components to this activity:
In FY08, this activity will use $400,000 in PEPFAR resources to continue: 1) building an evidence base for
the sustainable financing of HIV/AIDS services through private, parastatal, and civil service employers; 2)
structuring policy dialogues with federal and regional authorities to support continued expansion of private
service delivery of quality HIV/AIDS and TB services; and 3) continuing to analyze and build an information
base of HIV/AIDS service delivery in the private sector for future programming.
In FY08, this activity will provide technical assistance to implement a Development Credit Authority (DCA)
between the USG and two private banks. This DCA will facilitate private financing of private-sector activities
valued at $500,000 in PEPFAR resources, for a total DCA of $850,000 of USG resources. The DCA
mechanism will support the financing of private hospitals, higher clinics, and private health colleges to
expand capacity to address private-service delivery of HIV/AIDS and TB services and human resource
development of health officers, nurses, laboratory technologists, and pharmacist technicians. Analysis by
the USG identified that an Ethiopia-based DCA would achieve a 12:1 leverage of private capital (i.e., a
$1,000,000 DCA would enable the banking sector to mobilize $12,000,000 in private non-USG resources to
use for financing private-sector health projects as agreed to by the USG and the bank participants). The
DCA is a proven model to expand private-sector capacity through increased financing opportunities and will
provide tangible incentives to expand sustainable HIV/AIDS programs, including ART services at hospitals
and higher clinics throughout Ethiopia. Funds for the DCA were incorrectly assigned to Abt Associates and
are being reprogrammed in Apr'08 to a USAID mechanism.
In FY08, approximately $300,000 in PEPFAR funds and $200,000 in non-PEPFAR USG Population funds
will provide technical assistance to private-sector participants, including bank employees and private health
practitioners, to support business and loan training. Training initiatives would target private hospitals and
clinics to expand management and administrative capacity, which will further strengthen the delivery of
HIV/AIDS and TB services.
In FY07, this activity provided policy expertise to work with the government, the PSP Ethiopia project, and
the private sector to address such issues and build consensus for solutions. In addition, this activity
provided technical assistance to the MOH and selected RHB to draft appropriate public policies expanding
the physical and economic access of Ethiopians to private-sector HIV/AIDS and TB services. Substantial
analysis of private-sector delivery, quality, and financing of ART will be completed in FY07.
In Ethiopia, many private providers are already offering priority public health services and are interested in
expanding these services. Most of these providers are seeing a significant demand for priority public health
services such as HIV counseling and testing, TB diagnosis and treatment, reproductive health services
(including long-term methods), and ART. Unfortunately, due to the mismatch between bank lending terms
and private providers' investment needs, many are not able to access financing to expand their capacity to
delivery public health services.
Despite the constraints, there is broad interest from private providers in accessing financing. Providers are
interested in using financing for a variety of purposes, including renovating and constructing facilities and
purchasing equipment and drug stocks. Financing needs are quite diverse, we envision median
requirements to range from $8,000 to $35,000 in order to support care and treatment services. The highest
levels of interest are from higher clinics, private hospitals, laboratories, and private health colleges.
Health sector lending is limited, but USG analyses have found that several banks are interested in entering
the market. A recent assessment revealed that, currently, financial institutions are not lending to the health
sector in a significant way mainly because collateral requirements and short loan terms are constraints. The
DCA, however, has induced three banks to reduce loan collateral requirements by 50%.
Based on these findings, PEPFAR Ethiopia believes that, by engaging the private health sector we have the
opportunity to shape the development of the sector to deliver public health services including HIV
counseling and testing, TB diagnosis and treatment, and ART. Interventions to provide business training to
private providers and work with financial institutions to expand health sector lending will greatly strengthen
HIV/AIDS service delivery in the private sector. The USG assessment recommends that the DCA address
the health sector by providing approximately $15 million to assist banks to enter the healthcare market. The
DCA funds will reduce risk and addresse some of the banks' collateral constraints. The Office of
Development Credit estimates that the total subsidy cost of a $15 million guarantee would range from
Activity Narrative: $1,798,500 to $1,818,000.
This activity will provide the MOH and several RHB with technical support to identify and address the gaps
and obstacles in policy and requirements which may limit the willingness and ability of the private sector to
provide TB or HIV services. This activity will provide support to the overall strategy to decentralize HIV/AIDS
services in urban and peri-urban areas and further multiply entry points for HIV/AIDS care and treatment by
utilizing private-sector clinics.
This activity is linked to activities addressing private-sector providers, including hospitals, higher and
medium clinics, laboratories, and pharmacies. In addition, there is a link between the technical assistance
being provided through "training" partners who are addressing pre-service curriculum adaptation and private
The activity will reach a range of stakeholders in the private sector, including private healthcare providers,
professional associations (e.g., the Medical Association of Physicians in Private Practice-Ethiopia),
business leaders, private-sector medical schools, and training institutes. Strategies to reach these different
groups vary depending on the stakeholder. The primary strategy to reach these stakeholders will be the
creation and facilitation of a working group focusing on private-sector issues related to the provision of
HIV/AIDS and TB services (quality improvement, training, access to commodities, data reporting, financing
The activity will provide in-service training to host-country government workers and health providers. The
training will focus on policy advocacy and policy experiences with private-sector health service delivery.
This activity will address workplaces by analyzing existing financing mechanisms used for HIV/AIDS
prevention, care, and treatment activities at those sites.
The public-private partnership component of this activity will leverage approximately $10,002,000 in private,
non-USG resources. Furthermore, this activity will receive funding from the USG's non-PEPFAR bilateral
TB and population and reproductive health programs.