Detailed Mechanism Funding and Narrative

Years of mechanism: 2008 2009

Details for Mechanism ID: 3978
Country/Region: India
Year: 2009
Main Partner: Science Health Allied Research Education Foundation
Main Partner Program: MediCiti
Organizational Type: NGO
Funding Agency: HHS/CDC
Total Funding: $521,000

Funding for Biomedical Prevention: Prevention of Mother to Child Transmission (MTCT): $5,000

CONTINUING ACTIVITY - NEW ACTIVITY NARRATIVE

SUMMARY

PHMI will provide ongoing support to the Andhra Pradesh State AIDS Control Society (APSACS) for the

management of the Integrated Counseling and Testing Center (ICTC) system, which is a key piece of the

prevention of mother to child transmission (PMTCT) program in Andhra Pradesh/India. In AP as well as

elsewhere in India, the PMTCT program is relatively new and the public health systems to monitor and

follow-up antenatal women are generally weak. Therefore, it is not surprising that a large number of

pregnant women who test positive are lost to follow up. In 2006, over 4,000 pregnant women in AP were

found to be positive in the government sector (tested at ICTCs). Of these, approximately 42% were

documented as having received Nevirapine prophylaxis. This percentage appears to have increased to 60%

in select USG focus districts in 2007.

BACKGROUND

This ongoing support will place a senior ICTC consultant at APSACS. Secondary support will come from

two other PHMI-supported APSACS consultants who focus on monitoring and evaluation and trainings.

PHMI will also support PMTCT by advocating for new policy initiatives, conducting management and system

strengthening training workshops (especially for district staff), and assisting with field-level assessments.

Most of the budget to support the APSACS consultants is provided under Policy and Systems

Strengthening; however there will be substantial results (particularly indirect results) in this program area as

a consequence of the consultants' activities.

ACTIVITIES AND EXPECTED RESULTS

ACTIVITY 1: Strengthening the Quality of PMTCT Services and Supportive Linkages

The ICTC consultant will play a leadership role in establishing stronger linkages between antenatal outreach

services and ICTCs where HIV testing is routinely performed. New strategies for reaching antenatal women

and promoting routine HIV testing will be developed in FY09. One possible strategy is to send ICTC teams

to remote primary health centers or sub-centers on select antenatal service days (perhaps once a month).

Another strategy is for APSACS to develop closer relationships with private testing centers to ensure quality

testing, counseling, and patient follow up.

The consultant will ensure that newly-released ICTC operational guidelines (developed by NACO) are

adopted by the state and are made available in all centers, with a goal of standardizing counseling and

testing services. Further the consultant will ensure that the recently created follow-up counseling toolkit is

distributed to all centers and counselors are adequately trained in how to use this important teaching aid for

those testing positive.

PHMI, mostly through the ICTC consultant, will continue to work on ways to improve the rate of Nevirapine

administration to pregnant women identified as HIV positive. Other agencies and APSACS staff are

primarily responsible for this important activity. However, PHMI staff and consultants will remain engaged in

this issue and provide technical support and inputs as required.

ACTIVITY 2: Development of a Positive ANC Tracking Tool

Through another consultant to APSACS, who provides support for data management systems, PHMI will

develop a Positive ANC tracking tool to improve Nevirapine administration rates in the State. This will be

done initially as a paper-based system of positive ANC line-listing that will track and document all positive

mothers from the time of diagnosis till the time of delivery and subsequently follow up the child till s/he is 18

months of age. This will be a very useful tool for counselors, nurses and outreach workers in the field. It can

be used to link women to private providers and 24-hour PHCs.

ACTIVITY 3: Development of Mother-Baby Card

A mother-baby card, in line with NACP-III guidelines on the District AIDS Control Unit, will be developed and

piloted in the state for better follow-up and ease of providers in giving comprehensive services in

collaboration with NRHM, RCH.

ACTIVITY 4: Support to District-Level Teams

The ICTC Consultant will support the district-level teams and government officials who will, in turn, monitor

all HIV CT centers in their respective districts. The ICTC consultant will help develop monthly site visit

checklists, reporting formats, training calendars, review meeting agendas, testing targets, and budget

requirement, for each district team. The consultant will periodically join district team members in their

monitoring visits. He/she may visit the best and worst performing ICTCs in the district to better understand

the factors that directly impact program performance and find solutions to problems.

To support APSACS, PHMI will also work with the district teams on ways to improve the rate of Nevirapine

administration to pregnant women identified as HIV positive. This may include mentorship to the district

teams and other field managers on how to maximize outreach efficiency, track positive antenatal women,

encourage positive deliveries by medical staff, provide infant testing and care protocols, and ensure that

family planning services are made available post-delivery. PHMI will also support the evaluation and review

of PMTCT-related policies and procedures.

New/Continuing Activity: New Activity

Continuing Activity:

Program Budget Code: 02 - HVAB Sexual Prevention: AB

Total Planned Funding for Program Budget Code: $1,476,497

Total Planned Funding for Program Budget Code: $0

Program Area Narrative:

Overview: India, with an estimated 2.47 million people infected with HIV/AIDS, has the third largest epidemic in the world. Despite

the large number of infections, India continues to be a concentrated epidemic with a 0.36% national adult prevalence. Prevalence

among most-at-risk populations (MARPs) continues to be high. It is estimated that nearly 5% of female sex workers (FSWs) and

6% of men having sex with men (MSMs) are infected by HIV (NACO report, 2006). HIV prevalence among MARPs in the six high

prevalence states is still higher, being almost double the national average for MARPs. The National AIDS Control Organization

(NACO) has also prioritized truckers and migrants as bridge populations needing HIV/AIDS interventions: HIV prevalence among

long distance truckers is estimated as 2.4%.

In the last two years, NACO has initiated many efforts to streamline HIV/AIDS interventions for MARPs and bridge populations.

Significant achievements include: a) development and dissemination of NGO/Community Based Organizations (CBOs) guidelines

for interventions among MARPs, b) establishing 16 Technical Support Units (TSUs) to support the State AIDS Control Societies

(SACS) for effective roll-out of interventions, c) country-wide mapping of MARPs and migrants, d) introducing a new cadre of link-

workers to reach MARPs in rural areas, e) targeting short-stay single male migrants and long-distance truck drivers and working

with the relevant ministries to integrate HIV/AIDS into their programs, f) contracting a national condom social marketing (CSM)

organization, and g) expanding access to STI treatment by social franchising of STI services through private health care

providers.

NACO is also coordinating with the Ministry of Education and Ministry of Women and Child Development to mainstream HIV/AIDS

programs for interventions among youth and women. The PEPFAR review team visited India this year and endorsed this as an

important strategy for a concentrated epidemic country. The team suggested USG/India shift from supporting direct interventions

amongst women and youth, to working closely with the SACS to mainstream these programs. In response, USG has transitioned

much of its funding for these groups to the relevant ministries, retaining a small supervisory role to ensure the long-term

sustainability of these investments. In 2008, USG also transitioned over 20 NGO projects supporting bridge population

interventions.

Coordination and Other Donor Support: USG programs support and complement NACO's interventions for MARPs and bridge

populations. At the national level, USG coordinates with NACO, multilateral agencies and other international donors to influence

policy, and provide strategic direction and technical assistance. At the state level, USG partners coordinate with the SACS and

other developmental agencies to share data and best practices and support joint initiatives.

The USG and the Bill and Melinda Gates Foundation are the two major agencies supporting programs among MARPs and bridge

populations. UNICEF, UNDP and GTZ support programs on HIV/AIDS among youth and industrial workers and address human

trafficking issues. USG programs continue to leverage millions of dollars for condoms, STI drugs and HIV test kits from the state

governments for its programs. USG-supported prime partners have collaborated with private companies to establish STI clinics

along national highways. They also coordinate with local ministries to link MARPs with various social and development schemes

offered by the state and central government.

Current USG Support: USG programs include field-based interventions and support for policy change. At the policy level, USG

was instrumental in developing the national guidelines for NGO/CBOs engaged in MARPs and bridge population interventions.

They provide a comprehensive understanding of the process of identifying, contracting, capacity building and monitoring of

MARPs and bridge population interventions. USG also provided critical inputs to shaping the national CSM program and finalizing

the strategies and organizations for social franchising of STI clinics. The USG team participates in joint implementation reviews

organized by NACO that assess and strategize on the performance of states.

In line with NACP-III's priorities, USG's role has changed to a mixture of demonstration projects and building the capacity of the

SACS to manage NGO interventions with MARPs, among other programs. This function is carried out by Technical Support Units

(TSUs) set up by NACO to provide strategic support, timely roll-out of programs, coordination, and adherence to national

guidelines and standards; and develop and monitor state and district annual action plans. USG supports TSUs in six states and

thus has a major role in developing strategies and operational plans and streamlining capacity-building initiatives in the state.

In selected districts of Tamil Nadu (TN), Maharashtra and Karnataka, USG supports 80 projects reaching approximately 25% of

MARPs, including demonstration models covering the prevention-to-care continuum. This furthers the national and state mandate

to saturate coverage of MARPs and bridge populations. USG also supports state-level capacity-building initiatives to enhance the

quality of interventions, including mapping MARPs in TN and Karnataka, and migrants in TN. USG also supports mapping of

private healthcare providers who can be contracted to deliver STI services. As noted above, in TN and Maharashtra, USG is also

working with the SACS to transition several interventions to SACS-supported NGOs and government ministries.

Several USG innovations have been adopted for use nationally or by other projects. In Karnataka, USG has pioneered the

concept of reaching rural MARPs through link workers, a model recognized by NACO and used as a learning site for other states.

A USG partner in Andhra Pradesh (AP) developed a risk-assessment tool for prioritizing industries for HIV/AIDS programs, which

is now being used by other USG projects. In TN and AP, USG prime partners are engaging the private medical sector to provide

STI and HIV treatment to MARPs and bridge populations. In Maharashtra, a USG prime partner is taking the lead in migrant

interventions and has been requested by NACO to provide technical support on this approach.

USG programs have also developed communication materials specific to MARPs and bridge populations that have been adapted

by SACS and NACO. In TN, NACO has suggested that a USG prime partner pilot the concept of a unique identity card for MARPs

(using either biomarkers or smart cards). This is being tried primarily to estimate the number of MARPs accessing different

prevention and care services, follow-up MARPs who do not regularly access the services, understand MARPs' mobility patterns,

and avoid double-counting.

Many challenges still persist:

a) Coverage of MARPs, particularly MSMs, is way below the goal of 85%. Only 43% of FSWs (estimated at 1.2 million) and 20%

of MSMs (estimated at 2.35 million) are reached through interventions. Coverage of MARPs in the southern states is slightly

better. However, the changing dynamics of sex work have affected intervention programs. Patterns of client solicitation have

changed. More MARPs operate from streets and homes rather than brothels, and are accessed through mobile phones and

internet. The legal status of sexwork has also affected interventions. The Government of India has recently amended the Immoral

Trafficking (Prevention) Act to penalize clients of sex workers. Similarly Section 377 of the Indian Penal Code continues to

consider homosexuality a criminal offence. These laws have been greatly debated and are the subject of intense lobbying by civil

society. They contribute to the complexity of designing interventions and messages for MARPs, and the need to work closely with

law enforcement agencies and policy makers.

b) The quality of interventions with MARPs and bridge populations and the provision of comprehensive services to them are still

issues. The 2006 Behavior Surveillance Survey among MARPs indicates that only 38% of FSWs have correct knowledge of HIV,

and 50% of FSWs contracted STIs in the last 12 months. With regard to MSMs, correct knowledge of HIV varies from 16% to 75%

across the states and the number of MSMs reporting STIs ranges from 2% to 21%. Timely treatment-seeking behavior and

consistent condom use among MARPs are concerns. Current interventions with MARPs primarily focus on condom promotion,

although other risk reduction options include reduction of the number of sexual partners and promoting periodic medical check-

ups. Similarly, integrating messages on alcohol use and its influence on safe sex, working with children of FSWs to prevent

second-generation sex work and offering alternate livelihood options for FSWs are critical in prevention programs but not given

the required emphasis.

c) Linkages to counselling and testing (CT), care and support, and treatment services for HIV- infected MARPs and bridge

populations are limited. The BSS 2006 reports indicate that less than 40% of female sex workers ever had a HIV test. In the case

of MSMs, this varies from 3% to 69% across states. There is little data on the number of MARPs availing care, support and

treatment and on the quality of services provided to them. This is critical as MARPs are stigmatized populations and HIV-positive

MARPs can be further stigmatized and denied services.

d) Mainstreaming and greater engagement of the community in programs continues to be a challenge. NACO has set an

ambitious plan to support 50% of the planned MARP interventions through CBOs. Response from NGOs and CBOs has not been

encouraging and needs more attention. Similarly, mainstreaming with the different Ministries and Associations will require

considerable handholding for them to own and run the program effectively.

USG FY09 Support: USG will work with the SACS and NACO to address the gaps in interventions and improve the quality and

scale of programs. In FY09, USG will give more emphasis to providing technical and strategic support to NACO and the SACS.

1. Support to National and State TSUs: NACO plans to establish a national-level TSU to provide strategic support to NACO

officers for the effective roll-out of prevention programs. It will coordinate with state TSUs to ensure that interventions are rolled-

out on time, are of high quality, and adhere to national guidelines. USG will support key positions in the national TSU; and will

consolidate important lessons learned from USG programs for dissemination and adaptation. USG will also continue to support

the six state TSUs. They will work with SACS to address the major gaps and challenges in MARPs and bridge population

interventions, evolve appropriate strategies to address these issues; and build the capacity of SACS officers and the District AIDS

Prevention Control Units on effective supervision and capacity-building of NGOs and CBOs, including their capacity to implement

Targeted Interventions.

2. Technical support for project reviews, policies and guidelines: USG will participate in Joint Implementation Reviews and provide

technical and strategic inputs to NACO and SACS to improve prevention and care programs. USG and its prime partners will also

participate in policy and procurement meetings and assist NACO and SACS in evolving appropriate policies, guidelines and

systems. A USG prime partner is the vice-chair for the national Technical Resource Group on interventions among MARPs and

bridge populations which provides strategic oversight to NACO and SACS.

3. Learning sites and documenting best practices: USG will identify potential organizations/projects that have demonstrated high-

quality interventions among MARPs and bridge populations and build their capacity to function as learning sites for the

state/country. USG will also identify best practices and disseminate these experiences across SACS, TSUs and NACO for wider

recognition and adaptability.

4. Human capacity development: There are many gaps in current training programs for sexual prevention and a need to go

beyond training to strengthen capacity. Areas such as gender, project management, CBO formation and management, data

quality assurance, advocacy, community mobilization, provision of balanced ABC messages, and supply chain management need

to be incorporated in a comprehensive approach to sexual prevention. USG will prioritize and support specific training programs to

address these gaps.

5. Mainstreaming models: USG will continue to work with the Ministry of Education, the Ministry of Women and Child

Development, the Ministry of Surface Transport, and the Ministry of Labor to mainstream the Red Ribbon Club, Self Help Group

and public sector workforce interventions. In FY09, there will be an evaluation of the Women's Self-Help Groups program, and the

results can help mainstream the program in other USG focus states.

6. Demonstration programs for MARPs and migrants: In selected high-prevalence districts, USG will continue to support

demonstration models of the prevention-to-care continuum. The models will saturate coverage, offer comprehensive services,

establish strong linkages and follow-up for MARPs to access CT and care, support and treatment services, and demonstrate the

advantage of reaching FSWs and MSM with a composite intervention supported by a single agency. In Maharashtra, USG will

support demonstration models for male migrant interventions, strengthened by technical assistance at the national level. The

experience of piloting a unique ID for MARPs will also be distributed nationally. The USG will also address underlying structural

issues through working with TNSACS to establish a mechanism for dealing with human trafficking issues and supporting the

women lawyers' network to protect human rights abuse of MARPs.

7. CSM: USG will support the national CSM program's efforts to increase access to male and female condoms for MARPs and

bridge populations, including determining the reasons for inconsistent condom use and modifying programs to address these

issues. USG will develop prototypes for CSM communication materials specific to MARPs and bridge populations, and work with

social franchising organizations to ensure private health care providers in the intervention areas are supported.

Table 3.3.02:

Funding for Testing: HIV Testing and Counseling (HVCT): $20,000

CONTINUING ACTIVITY - NEW ACTIVITY NARRATIVE

SUMMARY

Andhra Pradesh State AIDS Control Society (APSACS), the state's nodal agency for HIV control, has

scaled up counseling and testing (CT) services to both rural and urban populations, unlike in other states

where the services are primarily urban and peri-urban. The 677 integrated counseling and testing centers

(ICTCs) offer PMTCT services, CT services and TB-HIV linkages. APSACS also encourages provider

initiated testing by closely linking outpatient clinics and inpatient wards to the ICTC, usually located within

the same building. APSACS has started initiatives to scale up ICTC services in 24 hour primary health

centers, including working with private sector ICTC as a public-private partnership model. In accordance

with NACP-III, efforts have been made by APSACS to decentralize the management process to district

level. Activities are carried out to support expansion of comprehensive CT services through placement of

qualified manpower to support the state CT program.

The Public Health Management Institute (PHMI) will provide ongoing support to APSACS for the

management of the ICTC Program. This support will continue to focus on the placement of a senior ICTC

consultant at APSACS. Secondary support will come from two other PHMI-supported APSACS consultants

who focus on Monitoring and Evaluation (M&E) and training. PHMI will also support counseling and testing

by advocating for new policy initiatives, conducting management and systems strengthening, training

workshops (especially for district staff), and assisting with field-level training needs assessments.

BACKGROUND

Mediciti SHARE India (SHARE India) is a not-for-profit organization that works in rural communities outside

Hyderabad, Andhra Pradesh, reaching out to about 300,000 rural residents with services including maternal

and child health, immunization, population control, cancer detection and treatment, HIV/AIDS and nutrition

programs. Implementation is coordinated through the SHARE India medical college and hospital located

nearby. SHARE India is also recognized as a research foundation by the Department of Science and

Technology, Government of India.

In 2006, with support from USG, SHARE India established PHMI as a technical assistance and training

organization. PHMI's main objective is to build human resource capacity and strengthen systems for the

public health infrastructure of Andhra Pradesh (AP). This is achieved by developing innovative quality

improvement mechanisms such as accreditation systems and on-the-job training programs. While the

current technical focus is on HIV, in the longer term PHMI envisions a broader role encompassing additional

public health priority areas in AP.

The ICTC concept was developed in 2005 by the Tamil Nadu State AIDS Control Society (TNSACS) with

USG support during a period of rapid scale up of testing services by Tamil Nadu. APSACS went through a

similar scale up and re-structuring process in 2006 and early 2007, with the help of CDC and its partners,

LEPRA, CHAI, and PHMI. These APSACS-funded ICTCs are performing over 1.5 million tests per year, of

which 600,000 are among antenatal women with a positivity rate of 1.25 to 2.5%, and 900,000 are among

walk-in clients and non-antenatal patients (provider-initiated) with a positivity rate of 8-14%. NACO has set

a target of ~2.5 million tests for FY08-09 for Andhra Pradesh, of which 1.5 million tests are to be performed

on non-antenatal populations. This does not include the large number of tests being done in the private

sector (except those few testing sites funded by APSACS such as the APAIDSCON network of private

medical colleges) since those numbers are not reported to APSACS currently.

Almost all ICTCs are located in government medical care facilities (medical colleges, district and sub-district

hospitals, primary health centers) and are therefore designed to link clients to support services, facility-

based palliative care, and ART screening and treatment. The location also encourages provider-initiated

testing by closely linking outpatient clinics and inpatient wards to the ICTC, which is usually located within

the same building.

ACTIVITIES AND EXPECTED RESULTS

The state's CT systems are currently managed directly by the USG/PHMI-funded ICTC consultant under the

guidance of the APSACS Project Director and Associate Project Director. The ICTC management systems

have evolved over the past 2-3 years. APSACS has recently placed district-level counseling supervisors in

all 23 districts. USG-supported district management teams (placed in the 10 highest prevalence districts

eight months ago) are providing management support to the ICTCs as an important part of their job

responsibilities. Decentralization of the management to the district level has strengthened the system by

streamlining reporting, quality field supervision, regular review meetings and on-the-job trainings. In FY09,

PHMI will continue to provide support to APSACS for the management of the ICTC Program through the

placement of a senior state-level ICTC consultant.

ACTIVITY 1: Management of the AP State ICTC System

The APSACS-based consultant will continue to play a leadership role in managing the ICTC system and

develop strategies to continuously improve the program structure. This includes: a) strengthening training

programs for counselors, laboratory technicians, and nurse practitioners; b) ensuring annual refresher

trainings are conducted for all field staff; c) improving the supervision skills and procedures for district-level

counseling supervisors and district project managers; d) strengthening supply chain management systems

for HIV test kits; e) using the web-based monitoring system to analyze data and provide ongoing, timely

feedback to district teams and individual ICTCs; f) creating better human resource management systems

including annual performance reviews for all ICTC staff and g) taking steps to mainstream ICTCs into the

general health care delivery system at the district level.

The consultant will also ensure that newly released ICTC operational guidelines (developed by NACO) are

adopted by the state and are made available at all centers, with a goal of standardizing counseling and

testing services. Further the consultant will ensure that the recently created follow-up counseling toolkit is

distributed to all centers and that counselors are adequately trained in correct use of this important teaching

aid for those testing positive.

Activity Narrative: ACTIVITY 2: Establishing Stronger Linkages between Care Providers and ICTCs

The consultant will play a leadership role in establishing stronger linkages between care providers and

ICTCs, with a continued focus on strong referral systems for patients with active TB or STI. He/she will also

strengthen the referral linkages between ICTCs and community care centers, positive networks, ART

centers, and other PLHA services available in the district. A system to monitor and evaluate these referral

linkages will be developed and pilot tested in FY 09.

ACTIVITY 3: District Level Monitoring and Supervision

District level officers will be supported by the PHMI consultant, who will monitor services at all ICTCs to

provide supervision, technical input and feedback. District level counseling review meetings will be

organized monthly by the district managers in consultation with the consultant.

ACTIVITY 4: Promoting Routine External Quality Assurance

PHMI, mostly through the work of the state-level consultant with oversight from USG, will ensure that

external quality assurance of laboratory HIV testing, as required by NACO guidelines, is routinely conducted

at all ICTCs. The consultant will provide feedback to APSACS on identified and recommend corrective

actions for specific ICTCs in the state.

ACTIVITY 5: Expand HIV Counseling and Testing to High-Risk Populations

PHMI, mostly through the work of the state-level consultant with oversight from USG, will support the

expansion of HIV CT to additional at-risk and high-risk populations (select migrant laborers, commercial sex

-workers and clients, and prison inmates). The consultant will guide the expansion and implementation,

which will be carried out through mobile testing facilities, in line with the NACP-III strategy. These high-risk

populations have traditionally had limited access to HIV CT services specific to their unique needs (such as

extended hours of operation, staff trained to meet their specific needs). PHMI will partner with LEPRA

(another USG partner) in this effort since LEPRA is currently conducting a demonstration project for the

state on mobile testing. The consultant will provide oversight to the expansion of HIV counseling and

testing into primary health centers supported by National Rural Health Mission (NRHM) and private sector

nursing homes, hospital, and industrial hospitals.

ACTIVITY 6: Integration and Sustainabilty

The PHMI CT program and consultant will look for opportunities to link CT services with public-private

partnerships and mainstreamed into other services. State-level planning for scale-up of services in the

private sector is complete. The consultant will also further the goal of integration of CT services with the

National Rural Health System (NRHM), which started with the training of 95 Primary Health Centers that are

part of NRHM. The ICTC consultant has played a vital role in strengthening the quality of services through

training and supportive supervision.

New/Continuing Activity: Continuing Activity

Continuing Activity: 14590

Continued Associated Activity Information

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

System ID System ID

14590 11505.08 HHS/Centers for Share Mediciti 6880 3978.08 PHMI $15,000

Disease Control & (Umbrella)

Prevention

11505 11505.07 HHS/Centers for Share Mediciti 5622 3978.07 $25,000

Disease Control & (Umbrella)

Prevention

Emphasis Areas

Gender

* Increasing gender equity in HIV/AIDS programs

Human Capacity Development

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.14:

Funding for Strategic Information (HVSI): $150,000

CONTINUING ACTIVITY - NEW ACTIVITY NARRATIVE

SUMMARY

The important objectives of program activities are to: 1) partner with the Andhra Pradesh State AIDS

Control Society (APSACS) to provide technical assistance (TA) through placing a Surveillance/Monitoring

and Evaluation (M&E) consultant for the state's HIV interventions at APSACS. The consultant will build

organizational capacity to effectively monitor and evaluate programs, conduct program reviews, collect and

analyze program data for informed planning, and strengthen program evaluation tools; 2) take the lead on

behalf of APSACS in developing and conducting skills-based trainings for the staff of District AIDS

Prevention and Control Units (DAPCUs) established as part of the decentralization of HIV/AIDS

management under the third National AIDS Control Plan (NACP-III). This is expected to build the state's

capacity in improved data generation, collection, collation, analysis and dissemination; and 3) initiate a

human resource information systems strengthening process designed to foster better understanding of the

current health workforce picture in the state of Andhra Pradesh. This will assist decision makers to

effectively plan for recruitment and training.

BACKGROUND

Mediciti SHARE India (SHARE India) is a not-for-profit organization working in rural communities outside

Hyderabad, Andhra Pradesh, reaching out to about 300,000 rural residents with services including maternal

and child health, immunization, population control, cancer detection and treatment, HIV/AIDS and nutrition

programs. Implementation is coordinated through the SHARE India medical college and hospital located

nearby. SHARE India is also recognized as a research foundation by the Department of Science and

Technology, Government of India.

In 2006, through a cooperative agreement with CDC, SHARE India established the Public Health

Management Institute (PHMI) as a technical assistance and training organization. PHMI's main objective is

to build human resource capacity and strengthen systems for the public health infrastructure of Andhra

Pradesh (AP) state. This is achieved by developing innovative quality improvement mechanisms such as

accreditation systems and on-the-job training programs. While the current technical focus is on HIV, in the

longer term PHMI envisions a broader role encompassing additional public health priority areas in AP.

ACTIVITIES AND EXPECTED RESULTS

Strategic Information (SI) support is a component of PHMI's efforts to strengthen HIV programs in the state

of Andhra Pradesh. The SI activities are oriented towards strengthening the government information

system by supporting technical manpower, conducting a review of existing health systems for better

training, manpower and logistics planning, dissemination of scientific information, building capacity of the

state and district-level staff on information management, and assisting local government and non-

government agencies in building their capacity in data management and systems. Consultants are placed

in APSACS, reporting to the APSACS Project Director and mentored by USG and PHMI staff.

The activities have been modified from those in the FY08 COP. The modifications include deletion of three

activities (recorded under the PHMI FY08 COP narrative for use of GHAI funds for SI): Activity 1: Support

for a Patient Information System, specifically support for the T/HIS system at the Government Hospital of

Thoracic Medicine in Tambaram, Chennai; Activity 2: Capacity Development for SI through the Public

Health Field Leaders Fellowship; and Activity 3: Dissemination of HIV-Related Information of Strategic

Importance through workshops. Three new activities have been added: a) Data for Decision Making

(DDM), a structured long- term training program for district level decision makers; b) Human Resource

Information Systems Strengthening; and c)Review of Public Health Trainings and Implemented Programs.

As this is a new activity narrative that combines the GHAI and GAP narratives from FY08, note that all

activities have been renumbered.

ACTIVITY 1: Partnership with Government to Provide Technical Assistance

This is an ongoing activity providing TA to local and state government HIV agencies. PHMI has provided

three full-time technical experts to APSACS to support HIV activities. The consultants are in the areas of

Surveillance/Monitoring and Evaluation, management of Integrated Counseling and Testing Centers

(ICTCT), and training. Their role in FY09-FY10 will be to provide technical and managerial support to the

state's HIV/AIDS interventions and program officers, under the APSACS Project Director and mentored by

USG and PHMI staff. They are responsible for strengthening systems in their specific areas of expertise:

building organizational capacity to effectively monitor and evaluate programs; creating minimum standards

for all training programs; establishing procedures for routine program reviews; advocating and developing

better systems of program supervision, field evaluations, supplies and equipments maintenance; and

developing tools and processes for collecting, consolidating and analyzing data at the state and district

level.

Specific SI activities for these consultants include: 1) building interest in evidence-based program planning

among APSACS staff and district leaders; 2) reviewing counseling and testing (CT) data with APSACS staff,

relevant NGOs, and district government staff; 3) integrating TB/HIV, ART, and sexually transmitted infection

(STI) program data into the ICTC-web-based management information system (WMIS) and linking NACO

and APSACS web-based data; 4) helping APSACS expand the web-based reporting system beyond the

current pilot districts to all the 23 districts; 5) developing evaluation tools for select APSACS-funded training

programs; 6) strengthening ongoing sentinel surveillance in antenatal clinics, STI clinics, TB centers, and

among high risk populations; 7) disseminating and explaining sentinel surveillance and the National Health

and Family Survey (NHFS) findings to Andhra Pradesh to opinion leaders and program managers.

ACTIVITY 2: Training of District AIDS Prevention and Control Units (DAPCUs) Staff

Under NACP-III, DAPCUs are being formed in all districts in the high-prevalence states with the objective of

decentralizing program implementation and management to the district (population: 2-2.5 million). Specific

activities of the DAPCUs will include: 1) ICTC supervision; 2) field-level staff training and mentoring; 3)

technical support to district government officials in charge of health and social programming; 4)

establishment of links between prevention programs, ICTCs, and ART centers; 5) coordination of all district

Activity Narrative: level partners and activities; 6) technical input to communication and condom social marketing campaigns;

and 7) monitoring and evaluation of all district level HIV services.

Recruiting and training DAPCU staff is a tremendous challenge and opportunity. USG and its partners are

experienced in district-level capacity building. USG supported the establishment of district HIV

management teams in 10 districts in AP after which USG and its partners conducted skills-based trainings

for them. PHMI has been USG/CDC's lead partner in DAPCU trainings and will partner with other USG

agencies to implement this activity.

In FY09, PHMI will support training of DAPCU staff on basic public health principles, field management

skills, HIV prevention strategies, HIV care and treatment operational guidelines, and monitoring and

evaluation skills. A strong focus will be on building the DAPCU staff capacity to use local data for decision-

making and to provide timely feedback to field staff on their monthly monitoring reports. The exact training

calendar will be determined in collaboration with each State AIDS Control Society, each technical support

unit, and other technical agencies.

ACTIVITY 3: Training of District Level Managers on "Data for Decision Making"

PHMI initiated a Data for Decision Making (DDM) training program in early FY08. Built on past USG

experience, this new activity will strengthen systems at district level. This will support the planned

decentralization of decision making and management to district level by the National AIDS Control

Origination (NACO) and the National Rural Health Mission (NRHM). Using FY09 funds, PHMI will continue

to improve the quality of the DDM training program curriculum and structure.

PHMI will identify the decision makers and data handlers at the district level and enhance their capacities to

use data effectively in planning, implementing, monitoring, and evaluating health programs in AP state.

Using target audience analysis, PHMI will identify the different cadre of officials at district level, who are

involved in the process of using data for decision making, including those who make decisions, analyze

data and collect data. A decision maker can make sound decisions only if they are supported by valid and

relevant data.

This is an on the job-training program that minimizes the time a participant spends away from his/her job

and produces tangible results to improve existing programs and conditions. The project consists of six core

areas (surveillance; M&E; data collection; data analysis and interpretation; data presentation; decision

making). Each theme area has a basic and an advanced course. The basic course provides conceptual

knowledge and understanding of the subject. The advanced course gives additional hands-on training and

practical experience. Once the target audience matrix is developed, a needs review of the target group is

conducted. The capabilities of the selected target group are then measured to determine trainee needs and

to define the course structure and training methods.

Initially, there will be approximately 25 trainees per course. Each course will be conducted in six contact

workshops. Background reading material will be sent in advance to develop conceptual clarity on the

subject to be addressed and aid in completing the home assignments. The quality of the reading material

will be monitored. Collection of homework, homework review and feedback will be done between the

workshops. The course will have lecture sessions and class room-based group exercises. The duration and

nature of the sessions will be influenced by the needs review. In FY09, 25 fellows and 25 staff will be

trained in DDM through short term trainings.

ACTIVITY 4: Human Resource Information Systems (HRIS)

PHMI and other USG partners conduct regular training programs to build human capacity to fight the

HIV/AIDS epidemic. However, it is difficult to ensure that the right health care providers are receiving the

right training because the HR needs of the work force are not being monitored. A strong HRIS will allow

program leaders and managers to quickly assess key training gaps and redundancies.

The HRIS strengthening process is designed to foster better understanding of the current health workforce

picture in the state of Andhra Pradesh. This will prepare decision makers to effectively plan for recruitment,

training and retention and replacement of health professionals. This system will supplement the current

process of collecting collated data by gathering healthcare workforce data (e.g. demographics, basic

qualification, years of experience, training type and dates) from all staff working in HIV and linking it to the

job description of the person and the training needs.

Proposed systems improvements are based on a thorough technical assessment and consider low-cost

solutions that can rapidly but significantly enhance existing systems and processes in collaboration with the

state government and the local NGOs. This initiative will improve and expand existing systems rather than

replace what is already working at present. Where there is a paper-based system, an electronic register

can be implemented. Where an electronic register is already in place, a simple database can be built.

Where there is a simple database, that database can be progressively strengthened or expanded to meet

the needs of the state.

ACTIVITY 5: Review of Public Health Trainings and Implemented Programs

PHMI will provide technical assistance in review of Public Health Trainings and of implemented programs by

facilitating/participating such reviews for programs funded by USG or GOI.

New/Continuing Activity: Continuing Activity

Continuing Activity: 14593

Continued Associated Activity Information

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

System ID System ID

14593 10121.08 HHS/Centers for Share Mediciti 6880 3978.08 PHMI $100,296

Disease Control & (Umbrella)

Prevention

10931 10121.07 HHS/Centers for Share Mediciti 5622 3978.07 $300,000

Disease Control & (Umbrella)

Prevention

10121 10121.06 HHS/Centers for Share Mediciti 5399 5399.06 $300,000

Disease Control & (Umbrella)

Prevention

Emphasis Areas

Gender

* Increasing gender equity in HIV/AIDS programs

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $150,000

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.17:

Funding for Health Systems Strengthening (OHSS): $346,000

CONTINUING ACTIVITY - NEW ACTIVITY NARRATIVE

SUMMARY

The Public Health Management Institute (PHMI) was established in 2006 as a means of developing human

resource capacity and systems strengthening within the public health infrastructure of Andhra Pradesh (AP).

The current focus is on developing structured curricula, trainings, mentoring and providing long-term

learning opportunities for the public health workforce, primarily in the area of HIV/AIDS. The main activities

are: in-service training of state level public health managers, district level managers (DLM), District AIDS

Prevention and Control Units (DAPCUs), and other public health personnel (short-term trainings), providing

on-line learning opportunities through virtual learning systems, and opportunities to work in collaboration

with other institutions (South-to-South collaboration). Additional activities include conducting networking and

short-term trainings highlighting activities in the Southern states, providing technical assistance to

mainstream HIV activities into National Rural Health Mission (NRHM) services, and providing technical

assistance as needed to the APSACS Technical Support Unit (TSU).

BACKGROUND

Mediciti SHARE India (SHARE India) is a not-for-profit organization working in rural communities outside

Hyderabad, Andhra Pradesh, reaching about 300,000 rural residents with services including maternal and

child health, immunization, population control, cancer detection and treatment, HIV/AIDS and nutrition

programs. Implementation is coordinated through the SHARE India medical college and hospital located

nearby. SHARE India is also recognized as a research foundation by the Department of Science and

Technology, Government of India.

In 2006, through a cooperative agreement with CDC, SHARE India established the Public Health

Management Institute (PHMI) as a technical assistance and training organization. PHMI's main objectives

are to build human resource capacity and strengthen systems for the public health infrastructure of Andhra

Pradesh state (AP). This is achieved by developing innovative quality improvement mechanisms such as

accreditation systems and on the job training programs. While the current technical focus is on HIV, in the

longer term PHMI envisions a broader role encompassing additional public health priority areas in AP.

ACTIVITIES AND EXPECTED RESULTS

The activities have been modified from those in the FY08 COP. Modifications include deletion of three

activities listed in FY08: Activity 4, HIV Laboratory Accreditation Program; Activity 5, Clinical Accreditation

Program; and Activity 6, AP HIV Consortium. Activity 1: Human Resource Capacity Development through

Public Health Field Leaders Fellowship has been modified. There are six new activities, listed below.

ACTIVITY 1: Human Resource Capacity Development through Public Health Field Leaders Fellowship

The Public Health Field Leaders Fellowship Program (PHFLFP) began in early FY07. It is a one year on-the

-job training program for approximately 25 mid-career NGO and government personnel responsible for

developing or managing HIV related field interventions. It addresses the need for on-the-job public health

trainings for mid-career professionals with limited options for formal courses. The curriculum consists of six

weeks of group contact sessions combined with distance learning modules and field mentorship provided by

PHMI. Significant attention is given to project management skills development, science-based intervention

design, and evidence-based planning. FY08 funds will be used to refine the curriculum, conduct a needs

assessment of the fellows and conduct audience analysis to restructure the fellowship. With FY09 funds,

PHMI will continue the fellowship and collaborate with local institutions to improve the quality of the

curriculum and structure. It also may expand its support of the fellowship to more than one batch per year.

ACTIVITY 2: Partnership with AP Government to Provide Technical Support

This is an ongoing activity providing 3 full-time technical experts to APSACS to support statewide HIV

activities. The consultants support surveillance/monitoring and evaluation, integrated counseling and

testing, and training. They are placed under the APSACS Project Director and mentored by USG/CDC and

PHMI staff. In FY09, the consultants will provide technical support to the State HIV/AIDS interventions and

program officers, many of whom have limited experience. They are responsible for strengthening systems in

their specific areas of expertise: building organizational capacity to effectively monitor and evaluate

programs; creating minimum standards for all training programs; establishing procedures for routine

program reviews; advocating and developing better systems of program supervision, field evaluations,

supplies and equipments maintenance; and developing tools and processes for collecting, consolidating

and analyzing data at the state and district level.

PHMI will work closely with the future AP Technical Support Unit (TSU) for HIV programming (to be

identified and funded by the Bill and Melinda Gates Foundation). Since Gates Foundation programs focus

on high risk prevention only, USG support via PHMI and others will continue to play an essential role in

building HIV prevention and care systems in the state under this new TSU system. As an additional

example, PHMI will coordinate inter-state learning exposure visits for SACS staff/officers.

ACTIVITY 3: Support to NACO

PHMI will work closely with NACO to strengthen the ART delivery systems throughout India. This will

include appointing 2 full -NACO ART consultants, 5 Regional technical consultants at the SACS level,

periodic international consultants and in-country contractors to work on specific ART-related deliverables.

Direct TA will also be provided by CDC/India and CDC/Atlanta. This program will be used by NACO to

establish an ART center accreditation system, a down referral system, and an improved human resource

management system. The ART support package will also be used to assist NACO to establish 10 ART

centers of excellence in care, training, and operational research and to create models for private sector

involvement in ART delivery.

FY08 ACTIVITIES 4, 5, and 6 have been deleted

ACTIVITY 7: Training and TA Support to DAPCUs

Under NACP-III, DAPCUs will be formed in all districts in the high-prevalence states. The objective of

Activity Narrative: building DAPCU capacity is to ensure high-quality performance as program implementation and

management is decentralized to the district level. DAPCU activities will include: 1) ICTC supervision; 2) field

-level staff training and mentoring; 3) technical support to district government officials in charge of health

and social programming; 4) establishment of linkage systems among prevention programs, ICTCs, and the

ART center; 5) coordination of district level partners and activities; 6) technical inputs into communication

and condom social marketing campaigns; and 7) M&E of all district-level HIV services.

Recruiting and training DAPCU staff is a tremendous challenge and opportunity. USG and its partners are

experienced in district-level capacity building. USG supported the establishment of district HIV management

teams in 10 districts in AP and conducted skills-based trainings for them. PHMI has been identified as a

lead partner in DAPCU trainings and capacity building, working closely with the TSU, SACS, and other USG

partners and local agencies.

In FY09, PHMI will support training of DAPCU staff on basic public health principles, field management

skills, HIV prevention strategies, HIV care and treatment operational guidelines, and monitoring and

evaluation skills. A strong focus will be on building the DAPCU staff capacity to use local data for decision-

making and to provide timely feedback to field staff on their monthly monitoring reports. PHMI will seek

inputs from other USG partners in designing and conducting DAPCU trainings. The training curriculum and

calendar will be determined in collaboration with APSACS, TSU, and other technical agencies.

ACTIVITY 8: District Level Managers' Training on Data for Decision Making

PHMI initiated the Data for Decision Making (DDM) training program in early FY08 to support systems

strengthening at district level. The DDM training will increase the capacities of district level managers, data

users, and program officials to use program data scientifically and effectively in planning, implementing,

monitoring, and evaluating HIV and health programs in the state of Andhra Pradesh.

This is a on the job-training program consisting of six core areas (surveillance; M&E; data interpretation,

collection and reporting; analysis and Interpretation; presentation skills and decision making). Each theme

area has a basic and an advanced course. Target audience analysis will identify the cadres of officials at

district level (public and private), who are involved in decision making process. The capabilities of the target

groups will be reviewed to help define the course structure and training methods. In FY09 25 fellows and 25

staff will be trained in DDM.

The course modules will be developed by PHMI staff in collaboration with technical support from CDC GAP-

India and each course will be given in 5-6 workshops.

ACTIVITY 9: Strengthening Local Government Institutions

A technical consultant will be placed in the National Rural Health Mission (NRHM) to work with APSACS.

The focus areas for the consultant are: collaborate with APSACS, DAPCUs, RCH, RNTCP and other health

programs on HIV issues at the state and district levels, generate awareness of HIV services, generate

awareness of HIV/STD linkages, increase access to condoms, generate awareness about safe blood,

generate referrals for pregnant women for PMTCT services, and address access issues for routine

opportunistic infections.

ACTIVITY 10: Technical Support to the State Level Supply Chain System

Providing TA to improve and sustain an effective supply chain system for HIV services is an activity that

started at the request of APSACS. The goal is to develop an efficient decentralized supply chain and

logistics system that can ensure a continuous and uninterrupted supply of commodities. Strong

procurement and logistics management from manufacturer to center is thus essential.

The system in use is an on-call/fax/indent system that is random and reactive in nature, with multiplicity in

calling for requests, multiple points of control and confusion in the system. Call charges are not reimbursed;

counselors personally deliver kits to the centers from headquarters. The proposed pull-system would

enhance APSACS's performance in the systematic supply of logistics. PHMI will undertake a review of the

current health sector logistics systems in the state and partner with local logistics management institutes to

look for alternate solutions.

ACTIVITY 11: Technical Workshops

In general, HIV information related to programs and policy is not available to state, district and field staff. In

FY09, PHMI will organize workshops to disseminate timely and important HIV-related reports and

operational research findings from India and especially from AP. The workshops will be run in collaboration

with APSACS and other key agencies and institutions in AP.

PHMI will conduct periodic workshops for stakeholders to share, analyze, and process operational research

findings, surveillance reports, and scientific studies. This will provide a forum for sharing experiences, new

findings from the field, and operational/ technical guidelines. PHMI will advocate with State level policy

makers and program implementers for more and better use of quality strategic information in AP.

ACTIVITY 12: Virtual Platform for Information

Creation of a virtual platform for information and knowledge sharing encourages faculties and trainees to

work collaboratively and learn from each other. The PHFLFP program demonstrated the value of creating a

virtual resource library to build relationship between and among faculty and trainees and provide a platform

for collaboration, exchange, and capacity-building. Developing a virtual platform will provide a lower-cost

option to assist the PHMI faculty to reach trainees, since the faculty is geographically dispersed. A web-

based learning program using UNESCO-recommended free software will be developed and will be

managed by a point person from PHMI. All training material will be posted on the web for the trainees.

Assignments, submissions, and a discussion forum can also be supported through the virtual platform.

ACTIVITY 10: Twinning/South-to-South Collaboration

South-to-South partnerships and peer relationships can create an effective framework for building

sustainable institutional and human-resource capacity through the open exchange of knowledge,

Activity Narrative: information, and professional experience. PHMI will assist state and national level public health workforces

to learn from international field experience - preferably with USG partners in the South - in the areas of HIV

prevention, care, strategic information and systems strengthening components. PHMI will assist health

officers and partners to reflect on their own work, share best practices with others and help replicate

successful models. PHMI will promote faculties' and students' exchange programs between India and other

global South countries and will encourage public health experts to go for study tours, meetings,

conferences, and short-term trainings. It is expected that 4 Indian experts and 4 from Southern countries

would be supported for exchange visits.

New/Continuing Activity: Continuing Activity

Continuing Activity: 14594

Continued Associated Activity Information

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

System ID System ID

14594 10116.08 HHS/Centers for Share Mediciti 6880 3978.08 PHMI $250,000

Disease Control & (Umbrella)

Prevention

10909 10116.07 HHS/Centers for Share Mediciti 5622 3978.07 $45,000

Disease Control & (Umbrella)

Prevention

10116 10116.06 HHS/Centers for Share Mediciti 3978 3978.06 $45,000

Disease Control & (Umbrella)

Prevention

Emphasis Areas

Gender

* Increasing gender equity in HIV/AIDS programs

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $346,000

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.18:

Cross Cutting Budget Categories and Known Amounts Total: $496,000
Human Resources for Health $150,000
Human Resources for Health $346,000