FPD is implementing the Comprehensive District Health Team Support (CDHTS) TA model. The goal is to foster a public sector management culture that is based on effective leadership by professional managers who are committed to: providing integrated high quality services based on SAG policy; working in partnership with civil society; using strategic information to guide decision making; and improving the quality of services and patient outcomes. In partnership with SAG, FPD will: i) develop and inform strategies to help Districts realise the 10 Point Plan, including NSP on HIV/AIDS, PHC Re-Engineering Strategy, NHI and the Minister of Healths NSDA in line with the PIPF; ii) support district management to draft, implement and monitor progress against District Health Plans, related plans and expenditure reviews; and iii) support districts to achieve and maintain targeted levels of performance for PEPFARs priority areas, in particular TB/HIV. The target population includes district management teams (DMT) in Gr. Sekhukune (LP), Cacadu, NMM, Amatole and Buffalo City (EC) over est. pop of 3,678,244. Primary investment will be strengthening systems related to routine management with scale-back of TA investment and energy once processes are adopted and ingrained. 4. FPDs CDHTS TA will ensure successful transition to SAG by: involving DMT in the conceptualization, planning and implementation of SS TA within the districts, and negotiating roles and responsibilities regarding program milestones, sustainability measures and transition timelines. Key outcomes include: increased district management capacity; improved district expenditure in line with approved budget; increased health systems efficiency and effectiveness; and improved program performance for key indicators

Problem statement: Deviations from guidelines, disjointed packages of care and uncertainty regarding accountability result in breaks in continuity of care and incomplete provision of health services. Key gaps in quality of services related to: under utilisation of PHC services, in particular cervical cancer screening, mental health screening and treatment, gender-based violence (GBV), and psycho-social and client support groups; Goal: PHC clinics provide integrated, comprehensive health service provision focused on prevention, early diagnosis and continum of care. Key Activities in partnership with DOH and CDC partner include: provide expert programmatic TA to DMT to inform strategies, evidence-based interventions and best practice and compliance with national policy; TA to DMT to ensure appropriate planning for HAST programs in district strategic and operational planning, target setting and budgeting processes; support HAST programs to formulate and implement work plans, targets and budgets in line with population needs, district priority areas and NDOH policy and clinical guidelines; TA to PHC re-engineering strategies to strengthen early access to services, referral and retention; map HIV care services and reported performance against estimated need, to identify service gaps and inform district HIV strategies and related work plans; engage district stakeholders to ensure comprehensive support linked to heath services (NGO, CBO, DSD); TA referral networks to improve community to clinic to hospital referral and tracing strategies; undertake formative evaluation and baseline assessment of HIV care related activities in each district; engage community organisations in communication and behaviour change strategies to address stigma and discrimination; support RTC to develop training plan; train TB/HIV/STI, GBV, cervical cancer, mental health, IACT, tier, CHW. Support CDC-funded partner to align supportive supervision and mentorship to district priorities, including (NIM)ART, TB/STI/PICT, nutrition, ANC, MCH, GBV, psychosocial, mental health; TA systems to monitor & retain high CD4 counts & fast track; TA to increase detection of cryptococcal meningitis and cervical cancer screening in line with guidelines; support CDC to train and establish IACT support group facilitators to bridge HIV+ clients from HIV testing into HIV care; TA to improve dispensing and stock control; strengthen M&E of loss to initiation and retention in care for QI; TA family/male/ gogo/youth friendly HIV services; strengthen recording, reporting and data use of HIS (Tier and DHIS) and related data management tools (e.g. clinical stationery); facilitate use of innovative SI tools to facilitate program review and decision making; undertake operational research to explore, test, document and disseminate streamlined and/or best practice care modalities; strengthen referral and patient tracing between and within health services; support CHW to support HIV care and integrate patient tracing into PHC outreach activities; Intended outputs include: # trained (50); cervical cancer screening coverage (80%); comprehensive HIV care and support strategies in place; # IACT support groups established (10 p/d); IACT retention rate (70%); Intended outcomes include: increased CD4 at ART initiation.

Problem statement: SA has high incidence of TB (993/100 000), low cure rate (70%) and high TB/HIV co-infection (65%). Goal: to improve TB/HIV patient outcomes. Key activities in partnership with DOH and CDC partner include: provide expert programmatic TB/HIV TA to NDOH around implementation of policy and guidelines; provide TB/HIV TA to DMT to inform strategies, evidence-based interventions and best practice and compliance with national policy; TA to DMT to ensure appropriate planning for TB/HIV in DHP, target setting and budgeting processes incl. DOTS; TA to strengthen SCM for TB/HIV; support strengthening of PPP with stakeholders (incl mines, correctional services, military and SAPS); undertake formative evaluation and baseline assessment of TB/HIV related activities in each district; map TB/HIV services and reported performance against est need, to identify service gaps; train on TB/HIV; support DMTs to organise campaigns and engage with CDC-funded partner to provide supportive supervision and mentorship to facility based staffto increase competency in TB/HIV and improve compliance with the five Is at all health facilities and promoting early detection and diagnosis of TB suspects through: intensified case finding, regular TB symptom screening for all clients [especially PLWHA] during clinic visits; mentoring nurses on INH prophylaxis to ensure compliance with policy; providing targeted infrastructure and administrative TA to improve and ensure compliance with infection prevention and control standards; mentoring clinical staff on early Initiation on ART; TA to program managers to maximise TB/HIV service integration [with key focus on PICT, MCH, NIMART]; TA strategies to integrate TB/HIV care with nutritional gardens, patient education and psychological support to both health care givers and receivers (FPDs 2012, Co-Adherence study documented 90% adherence levels amongst patients receiving concurrent TB treatment); TA around QI and compliance with guidelines; link CDC-funded partner to district specialist teams to prioritize TB/HIV service integration for ANC and paediatric services; TA to improve bacteriological coverage by using standardised TB diagnostic algorithms; strengthen recording, reporting and data use of TB/HIV in HIS (DHIS and etr.net) and related data management tools through training, supportive supervision and structured performance reviews using national TB and HIV M&E framework and targets; TA to district and program managers on data use and analysis of TB/HIV indicators to strengthen TB/HIV service integration and improve patient outcomes; TA to strengthen clinic-laboratory interface to improve turnaround times (TATs); TA to plan, cost and implement novel technology (e.g. Gene Xpert) to maximise availability of diagnostic tests and results at the point of service; undertake operational research to explore, test, document and disseminate streamlined and/or best practice TB and HIV care and treatment modalities; strengthen referral and patient tracing between and within health services; support CHW to integrate TB/HIV awareness and mobilisation, defaulter and contact tracing as part of PHC outreach activities. Intended results include: initiate TB Rx in 100% with + lab/clinical test for TB; increase INH initiation (10%); # diagnosed TB patients started ART (5000, 10%+); train (220). Intended outcomes include: improved TB cure rate; decreased TB defaulter rate (<8%), increased TB cure rate (5% increase)

Problem statement: Deviations from guidelines, disjointed packages of care and uncertainty regarding accountability result in breaks in continuity of care and incomplete provision of health services. With exception of PMTCT, PICT is not routine for children resulting in inadequate referral of and late presentation and low treatment uptake of HIV-infected children to ART services. Goal: Improved early diagnosis of HIV-infected children and linkages to HIV care and treatment. Key Activities in partnership with DOH and CDC-partner include: provide expert programmatic (paediatric) HIV and NIMART TA to DMT to inform strategies, evidence-based interventions and best practice and compliance with national policy; TA to DMT to ensure appropriate planning for paediatric and adolescent HIV programs in district strategic and operational planning, target setting and budgeting processes; support HAST programs to formulate and implement work plans, targets and budgets in line with population needs, district priority areas and NDOH policy and clinical guidelines; map paed. services and reported performance against estimated need, to identify service gaps and inform district HIV strategies and related work plans; TA to strengthen planning and coordination between health facilities, DSD, DOE, schools, and OVC organisations to ensure comprehensive support to HIV positive children; engage community organisations in implementing communication and behaviour change strategies to address stigma and discrimination; engage with stakeholders to undertake campaigns and mobilise around paediatric HIV testing, care and treatment; support RTC to develop paediatric (NIM)ART training plan; train IMCI, paediatric TB/HIV/STI, mental health, IACT, tier. Engage with CDC-funded partner to provide supportive supervision and mentorship to facility based staff to ensure quality and integrate (NIM)ART, adherence, TB/HIV/STI, PICT, TB, ANC, MCH, GBV and mental health services and implement according to policy; promote sibling and grandchildren testing; TA systems to trace and fast track children; support family-friendly and youth-friendly clinics; (with CDC partner) identify and establish model child ART sites for benchmarking; TA support group formulation for children, adolescence and guardians; strengthen program monitoring using clinical stationery and tier cohort data to speed to initiation and retention in care; promote total quality assurance and compliance with guidelines; strengthen recording, reporting and data use of HIS (Tier and DHIS) and related data management tools (e.g. clinical stationery); undertake operational research to explore, test, document and disseminate streamlined and/or best practice paediatric HIV modalities; strengthen referral and patient tracing between and within health services; support CHW to baby, child and adolescent HIV testing uptake, integrate patient tracing and adherence into PHC outreach activities. Intended outputs include: # trained (100); # children tested (30,000); # child support groups established (1 p/d); Intended outcomes: Increased access to HIV services

Barriers: Lack of management competencies inhibits translating good policy into strategies with associated work plans, budgets and appropriate HR allocation. Historical-based budgeting and weak HR planning/management inhibit plan implementation. Goals: DHPs and related plans are linked to strategy, budgets, HR, realistic targets and appropriate activities; Expenditure and HR align to needs and plan. Working in partnership with SAG TA will build capacity of the DMT to plan, manage, implement and finance DHS, including HIV/TB programs. Activities (by area) are: (LE) provide expert TA in line with technical areas, policies, NHI preparation, TB/HIV programs, DHP priorities and district needs with aim to build capacity of district structures and persons focussed on systems, evidence base, plans/budgets and organizational culture; TA aimed at strategic and ops planning, budgeting, and review processes (from provincial to facility level); train/mentor/coach managers on core management competencies, quality and QI methodologies; (co)facilitate meetings to communicate and manage policy updates, plans, related activities and performance to stakeholders & role players; (establish and) strengthen governance structures including clinic committees, hospital boards and district AIDS councils; engage with PPL and other partners to ensure district donor coordination; strengthen QI team to implement and monitor progress against the NCS; support district to systematically strengthen and improve program efficiency and quality and disseminate and lessons learned/recommendations. (FI) provide expert TA in support of budgeting, expenditure review and costing analyses; (co-) submit proposals for funding and/or leverage. (HR) strengthen and streamline HR depts recruitment, retention, performance management, and HR information systems; TA workforce planning, HR strategy and training plan formulation; recruit skilled HCW into funded posts (thru AHP); strategically transition skilled FPD staff into DOH in line with vacancies and plans; train (with RTC) in line with plans, policy and district priority areas. (PR) TA systems of forecasting, timely ordering and storage of essential medicines; TA pharmaceutical management information systems, Pharmacy and Therapeutics Committees and Pharmacovigilance activities; train on dispensing, SCM and (through HSA) PBPA; TA infrastructure and equipment planning (including maintenance) and budgeting in coordination with Public Works; TA clinic-lab interface to reduce turnaround time and minimise useless expenditure. Intended outputs include: # (%) Dist. managers trained, by level (Exec. DMT, sub-district, facility) & type (course/coaching) & dist. (10 p/d); # plans TA-ed, by level [DHP, Ops, Strat.] & pillar & dist. (2 p/d); #(%) governance structures operating accord. to std, by dist & level. (TBD); # (%) districts with costed health workforce plan in place, by dist. (1 p/d); # HCW recruited and placed, by dist. & cadre & foreign/SA (50); # FPD staff transferred into DOH staff complement, by district & cadre (0); # trained, by course & cadre & pillar & dist (600); # interventions conducted based on needs, by pillar & prog & dist (1 p/d); # (%) facilities, by accreditation rating (based on std: NCS) & by dist (TBD). Outcomes: Improved- HS efficiency; management capacity; financial management, cross functional area improvement, leverage via increased partner contribution, training tenders, funding from other donors

Problem statement: South Africa is not on target to meet MGDs relating to maternal and child mortality; HIV still contributes to about 40% of maternal and child deaths in South Africa. Goal: to eliminate paediatric HIV infections and decrease burden of HIV in pregnant and lactating women. Key activities in partnership with DOH and CDC partner: provide expert programmatic MCH and PMTCT TA to NDOH to input in development and implementation of new policy and guidelines, as required; provide expert programmatic MCH TA to DMT to inform strategies, evidence-based interventions and best practice and compliance with national policy; TA to DMT to ensure appropriate planning for CARMMA, MCH and PMTCT programs in district strategic and operational planning, target setting and budgeting processes; support MCH (and PMTCT) programs to formulate and implement work plans, targets and budgets in line with population needs, district priority areas and NDOH policy and clinical guidelines; map MCH services and reported performance against estimated need, to identify service gaps and inform district MCH strategies and related work plans; undertake formative evaluation and baseline assessment of MCH (and PMTCT) related activities in each district; support MCH management and coordinators to organise campaigns; engage stakeholders in implementing communication and behaviour change strategies to improve maternal and child health services; support with CDC-funded partner align to plans and ensure supportive supervision and mentorship of facility based staff to ensure competency in and integration of MCH programs with focus on PMTCT and TB/HIV; train on IMCI, MCH and PMTCT; promote total quality assurance and compliance with guidelines in line with MCH programs; link CDC-funded partner teams with district specialist teams to support MCH; work closely with other partners to understand social determinants of health and develop interventions to reduce HIV infections, strengthen recording, reporting and data use of MCH in HIS (ANC register, ART register) and related data management tools (e.g. tally sheets) through DQ monitoring, data feedback and data use forums; facilitate use of innovative SI tools to facilitate program review and decision making; undertake operational research to explore, test, document and disseminate streamlined and/or best practice MCH and PMTCT care modalities; strengthen referral and patient tracing between and within health services; support CHW to integrate ANC early booking, ANC/PNC, PMTCT, breast is best, nutrition, male involvement, and ANC and paediatric HIV testing awareness and mobilisation into PHC outreach activities.

Intended results include: # trained (55); # PF initiated HAART (4000); # initiated AZT (14000); HIV 1st test rate (100,000; 95%); HIV 32 week re-test rate (55%); PCR uptake rate (90%); Intended outcomes include: PCR positivity rate (<3%)

Problem statement: due to massive burden of HIV, DOH introduced Nurse Initiated and Managed ART (NIMART) ART which requires that ART be integrated into a PHC setting.

Goal: i) NIMART model is fully deployed providing integrated HIV/TA care for adults, adolescents and children; ii) model (NIM)ART sties established that meet the highest national standard. Key Activities in partnership with DOH and CDC-partner include: provide expert programmatic HIV and NIMART TA to DMT to inform strategies, evidence-based interventions and best practice and compliance with national policy; TA to DMT to ensure appropriate planning for NIMART and ART programs in district strategic and operational planning, target setting and budgeting processes; support HAST programs to formulate and implement work plans, targets and budgets in line with population needs, district priority areas and NDOH policy and clinical guidelines; map ART services and reported performance against estimated need, to identify service gaps and inform district HIV strategies and related work plans; undertake formative evaluation and baseline assessment of (NIM)ART related activities in each district; engage community organisations in communication and behaviour change strategies to address stigma and discrimination; support RTC to develop (NIM)ART training plan; train NIMART, mentorship, ART, TB/HIV/STI, tier. Through roving mentor teams: provide supportive supervision to facility based staff and ensure continuity of training to mentorship to competency in NIMART and related programs; support CDC-partner to integrate (NIM)ART, adherence, TB/HIV/STI, PICT, TB, ANC, MCH, GBV and mental health services and implement according to policy; TA systems to fast track low CD4 counts, pregnant females and TB patients onto ART; identify and establish model NIMART sites for benchmarking; strengthen hospital-based ART clinics for complicated case referral; increase detection of cryptococcal meningitis; improve cervical cancer screening, cotrimox, TB screening and treatment, INH in line with guidelines; improve viral load and drug resistence monitoring and appropriateness of regimens; support adherence counselling and adherence improvement initiatives; support HCW soft skills, debriefing and coping skills; TA to improve dispensing and stock control; strengthen program monitoring using clinical stationery and tier cohort data; promote total quality assurance and compliance with guidelines; promote family/male/gogo/youth friendly HIV services; link CDC partner with district specialist teams to support complicated HIV; strengthen recording, reporting and data use of HIS (Tier and DHIS) and related data management tools (e.g. clinical stationery); facilitate use of innovative SI tools to facilitate program review and decision making; undertake operational research to explore, test, document and disseminate streamlined and/or best practice NIMART modalities; strengthen referral and patient tracing between and within health services; support CHW to integrate patient tracing and adherence into PHC outreach activities. Intended outputs: # trained (200); # patients (% facilities) initiating ART (80,000), by dist. & age group & TB/Preg; # total remaining on ART, by dist. & age gr (300,000). Intended outcomes: Increased ART coverage rate, by age group & district, Increased baseline CD4 at initiation, Increased viral load suppression rate, Improved ART patient retention rate

Problem statement: due to massive burden of paediatric HIV, DOH introduced Nurse Initiated and Managed ART (NIMART) ART which requires that ART be integrated into a PHC setting. Goal: i) NIMART model is fully deployed providing integrated HIV/TA care for adolescents and children; ii) model (NIM)ART sties established that meet the highest national standard. Key Activities in partnership with DOH include: provide expert programmatic (paediatric) HIV and NIMART TA to DMT to inform strategies, evidence-based interventions and best practice and compliance with national policy; TA to DMT to ensure appropriate planning for paediatric and adolescent ART programs in district strategic and operational planning, target setting and budgeting processes; support reviews using cohort data; support HAST programs to formulate and implement work plans, targets and budgets in line with population needs, district priority areas and NDOH policy and clinical guidelines; map ART services and reported performance against estimated need, to identify service gaps and inform district HIV strategies and related work plans; undertake formative evaluation and baseline assessment of paediatric ART related activities in each district; engage community organisations in implementing communication and behaviour change strategies to address stigma and discrimination; engage with stakeholders to undertake campaigns and mobilise around paediatric HIV testing and treatment; support RTC to develop paediatric (NIM)ART training plan; train IMCI, NIMART, mentorship, ART, paediatric ART, PMTCT, TB/HIV/STI, tier. Through roving mentor teams: provide supportive supervision to facility based staff and ensure continuity of training to mentorship to competency in paediatric ART related programs; mentor staff to integrate (NIM)ART, adherence, TB/HIV/STI, PICT, TB, ANC, nutrition, MCH, GBV and mental health services and implement according to policy; TA systems to fast track children; mentor doctors and nurses in paediatric ART; support NIMART certification of nurses; support family-friendly and youth-friendly clinics; identify and establish model NIMART sites for benchmarking; strengthen hospital-based ART clinics for complicated case referral; support adherence counselling and adherence improvement initiatives with target for babies, children, adolescence and guardians; TA to improve dispensing and stock control of paeds drugs; spromote total QI linked to treatment outcomes & cohort data; link with district specialist teams to support complicated HIV and MCH; strengthen recording, reporting and data use of HIS (Tier and DHIS) and related data management tools (e.g. clinical stationery); facilitate use of innovative SI tools to facilitate program review and decision making; undertake operational research to explore, test, document and disseminate streamlined and/or best practice paediatric ART modalities; strengthen referral and patient tracing between and within health services; support CHW to baby, child and adolescent HIV testing uptake, integrate patient tracing and adherence into PHC outreach activities. Intended outputs: # trained (300); # children (% facilities) initiating ART (5,000), by dist; # total remaining on ART, by dist. & age gr (18,000). Intended outcomes: Increased paediatric ART coverage rate, by district, Increased baseline CD4 at initiation, Increased viral load suppression rate, Improved ART patient retention rate