Executive Summary
Like any resource-constrained settings; Ethiopia have made little progress in scaling up services for the prevention of mother-to-child transmission, and current achievements fall far short of achieving the targets set globally.
This project is designed for scaling up the demand for PMTCT service & for the provision & improvement of better services to HIV positive pregnant women & their children.
Major strategies of involving community volunteers & HIV positive people through strategic linkages of community actors & health facilities will be sought highly. Through HIV positive mother support groups established at Health center setting, it is expected to address the unmet psychological, social, medical and even economic needs of HIV positive pregnant women. In addition, these groups are encouraged to reach out to their communities to provide prevention education, decrease stigma and refer pregnant women for ANC and PMTCT services which is one of the observed challenges in implementing PMTCT programs.
The issue of improving the services provided at health facilities through capacity building activities and the provision of care and support activities for HIV positive people will be other components of this project. With the involvement of more community volunteers, different activities will be also implemented to aware the larger community. Major sensitization options are also sought.
In this project 20 health centers found in the region which are eligible for PMTCT service provision are selected from 4 zones and one city administration.
PART ONE: The rationale
Currently in Ethiopia the implementation of PMTCT is found at its very low status & it has also poor performance in the southern region where this proposal is intended to work. The reality is still HIV positive women are not benefiting as such from the PMTCT services and are giving birth to an HIV positive child.
As national reports by Federal HIV/AIDS prevention and control office in Ethiopia for the year 2010 indicate, although the number of mothers who received HIV testing under the PMTCT service has shown increment, it is still under low level. Among the mothers who were found HIV positive, from those accessing ANC service, only 6,990 (53%) have taken the ARV prophylaxis. This achievement shows that 47% of the identified HIV positive mothers haven’t received the ARV prophylaxis. Compared to the estimated 84,149 positive mothers who need PMTCT in 2009 (single point prevalence estimate), only 6,990 (8%) were able to access it at national level. In the southern region of Ethiopia, in year 2010, out of 7,952 pregnant women only 796 (10%) were able to access it.
As HIV/AIDS and the Health-related Millennium Development Goals review in Ethiopia highlights; many of the barriers to increasing PMTCT coverage compared to other core HIV-related services include systemic challenges that require improvements to both ANC services, as well as more focus on the continuum of care at the community level. PMTCT sensitization efforts can also contribute to broader gains for the health sector. Challenges related with cultural factors, fear & distrust, stigma & discrimination & lack of care & support activities to HIV positive mothers & their children should be tackled.
Ethiopia has specially started to improve it health coverage & register significant progress in the sector, after implementing its policy of strengthen the health system to provide universal primary health care and institutionalize community-based services. National reports also reveal highly the importance & contribution of the Health Extension Workers in national health coverage, who conduct social mobilization and thereby provide education to the community regarding PMTCT.
Moreover, this time the high interest of different actors to work in collaboration with community volunteers, & with the involvement of HIV positive people has shown significant change. It is in recognition of these opportunities that we desired to involve in this task.
In association’s experience, it is our first time to intervene with activities directly related with PMTCT. Before this; we have been funded different projects, which have significance mainly in creating general awareness on HIV and AIDS to the public which resulted mainly in reduction of stigma & discrimination with some contributions in improvement in health service seeking behavior.
The global guidance supports the implementation of all four components of the United Nations comprehensive approach and which is also core areas of PACF areas of work. In this proposal community intervention is given priority for promoting community awareness to address lost to follow up in PMTCT, prevents unintended pregnancy, community intervention to keep HIV negative women negative, addressing early infant diagnosis & provision of care & support services to HIV positive mothers & their children.
For this specific project 4 zone & one city administration are selected as project catchment areas in Southern Nations & Nationalities & Peoples Region. Health centres found at Gediwo, Kembata Tembaro, Wolaita & Sidama zones including the regional capital Awasa town are selected based on their accessibility to the association, our previous experience to work with them, and with the absence & minimal interventions in the area.
The Southern Nations, Nationalities and People’s Region is located in the southern and south western part of Ethiopia. The region has 14 Zones and 8 special Woredas. The population of the region is estimated to be 15,780,630. The focus site of this project will be Health centres which have started to provide ART and lacking data clerks. In the catchment sites 20 Health Centres will be selected which accounts for about 6% of eligible health centres for PMTCT.
PART TWO: Working to achieve results
AIM:
Contribute towards the virtual elimination of Mother to Child Transmission of HIV & alleviate the impacts of HIV and AIDS on women & children’s health
OBJECTIVE
Improve the regional PMTCT service coverage through community interventions & Greater and Meaningful involvement of People Living with HIV and AIDS.
PROJECT APPROACH/ STRATEGIES
Creative strategies are needed to ensure that HIV-positive mothers receive psychosocial and emotional support and are able to navigate the health care system to access antenatal care (ANC) and PMTCT services.
The establishment of Health center-based peer support mother groups for mothers-to-be and mothers living with HIV will be the core one with the deployment of community mobilizers & volunteers for community outreach activities & with the assignment of data clerk at health facility level so as to strengthen the quality of the service, create linkage & data tracking of PMTCT service.
The human capacity building relevant for the project, PMTCT sanitization effort & implementation of IEC/BCC are also additional approaches to be implemented.
PROJECT TARGETS
The primary targets for this project are women on child bearing age found to be in the catchment areas. Based on 90 % regional target set for ANC testing & estimated prevalence of 2% among pregnant women, it is expected for 52,110 pregnant women to visit ANC sites & 1,042 HIV positive women to take ARV prophylaxis by the end of 2014 in the catchment areas alone.
80 Mother Support Group mentors, 10 testimony providers & 25 beneficiaries of positive living training & 40 positive women supported through economic empowerment totally 165 who are all HIV positive women are also direct beneficiaries of this project. 100 community volunteers &15 community mobilizers are also the direct beneficiaries.
Indirectly a total of 200,000 people is expected to attend the education provided by testimony providers which is provided during waiting time at the health centre. They are also benefited through the IEC/BCC material production.
PROJECT OUTPUTS
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- 20 HCs supported through human capacity building & material support
- 20 health professionals trained on PMTCT service & start their service delivery
- 20 Mother Support groups established at each HC
- 80 Mother Support Group (MSG) mentors trained & assigned at 20 health centers
- 20 data clerks trained & assigned in 20 selected HCs
- 15 community mobilizers selected from the community & trained
- 100 volunteer women selected from catchment areas & trained
- 40 woreda health office officers sensitized
- 100 influential community members selected from different CBOs, FBOs, GO/NGOs & attended advocacy workshop
- 25 HIV positive members who are found in the catchment areas trained on positive living & infant feeding
- 52,110 pregnant women visited ANC sites & 1,042 HIV positive women taken ARV prophylaxis
- 40 members of MSG benefited from small seed money provided as economic support
- 200,000 people addressed by member’s testimonial service
OUTCOMES
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- Strong and organized ANC/PMTCT service will be established.
- Demand for ANC/PMTCT service will rise
- Stigma & discrimination towards HIV positive people will reduce
- HIV positive women will be empowered economically & psychologically
- Linkage of HIV positive pregnant women to chronic care and MSG will be increased.
IMPACT
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- Number of HIV free children will increase
- Improved quality of life of HIV positive women.
- Number of disclosures increased.
- Number of Facility delivery will be increased.
- Follow up of HIV exposed infant will be established.
MAJOR PROJECT ACTIVITIES
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- Establishment of Mother Support Group (MSG) at 20 health centers selected in the region:
The MSG is designed to reach women from the beginning of pregnancy through the first year of motherhood. Mothers-to-be and mothers may join a mothers’ support group following their first HIV counselling and testing visit at a health centre, after any repeat ANC visit, following labour and delivery, or postpartum. The MSG program is health centre-based and closely integrated with the clinic-based PMTCT programs.
In each health center the MSG program will link with the available ANC/PMTCT unit head and counselor & case manager assigned in the health center. This linkage help the mentor mothers; identify, recruit, and enroll mothers-to-be and mothers to participate in the support groups; and ensure that the support groups are taking place smoothly. MSG mentors follow pregnant women till delivery and follow the child till 18 months.
The mentor mothers are the linchpin of the MSG program. These mother mentors are recruited from each health center at the catchment area who themselves are HIV-positive. The mentor mothers are selected based on their willingness to be a mentor, willingness to disclose HIV status with peers, firsthand experience with PMTCT services & ability to read and write (8th grade completed).
There are four mentor mothers per site, and two mentor mothers work on any given day. Mentor mothers must be willing and committed to spend at least two full days per week supporting HIV-positive mothers at the health centre. The two days-a week schedule allows the four mentors to cover an entire month of working days with two mentors per shift. They have additional assignment also in the community to give their life testimony.
Five-day training for mentor mothers on basic topics of HIV transmission and infection, HIV and pregnancy, psychosocial issues, self-care, antiretroviral therapy, ANC, labor and delivery and infant care will be provided. Once trained, the mentor mothers facilitate separate support group meetings for mothers-to-be and mothers through traditional media of Coffee ceremony.
On occasion, a postpartum mother may be invited to attend a group meeting of mothers-to-be to discuss topics such as partner disclosure. The support group meetings provide a safe and open space for discussion of a variety of topics. The mentor mothers also refer support group members for care such as PMTCT and family planning services. They provide also their life testimony to establish male involvement. The MSG has coffee ceremony every two week and an individual who attended 8 sessions considered he/she had got full information and will graduate from the program, but still serve in the community outreach services as volunteers.
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- Training and hiring of community volunteer and community mobilizer to create demand for PMTCT service.
100 volunteer women selected from catchment areas will be trained & engaged in community home to home education approach for the creation of demand & tracing loss. Community volunteers are selected from each woreda (district) by their kebele (divisions within woreda) with and health office responsible persons.
15 community mobilizers will be selected from the community & trained so as to facilitate the link between the community, volunteer & Urban Health Extension (UHE) workers. Community mobilizers are selected by woreda health office with some criteria having influential power & trustworthy by the community. They are responsible to mobilize community & to manage volunteers. They establish good relationship between woreda health office, health center, Volunteers and with urban health extension workers.
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- Provision of life testimony:
Using life testimony of members of the association will be an integral part of creating awareness and will support ANC/PMTCT unit and MSGs. The testimonial sites will be the same health centers selected and 2,880 sessions will be conducted within the three years period and a total of 200,000 people are expected to attend the education which is provided during waiting time at the health center.
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- Awareness creation through sensitization workshops & IEC/BCC intervention
To utilize the influential people who are mostly gate keepers at community level & to raise the awareness level of the service provider; sensitization workshops will be provided and the development of appropriate health communication materials are included so as to facilitate male involvement in the program and create awareness to reduce stigma and discrimination and harmful cultural practices.
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- Provision of different trainings:
The provision of different trainings at the outset of the program intervention is planned to be one of the major activities. The trainings have the purpose of capacitating the professionals at health sector who are relevant to the program & in providing basic skill to the community volunteers, mobilizers, and mother support group mentors. Positive living training is also provided for selected 25 positive women coming to be members of the MSG group and also to others ready to disclose their status to the public or their peers.
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- Economic empowerment of HIV positive women:
As part of empowering some of the economically weak members of the MSG members and to sustain the activities implemented at community level, 40 members will be provided startup capital which leads them to start their own business.
In implementing this project, the main challenge will be HIV related stigma and discrimination, harmful traditional practices and lack of male involvement which need to be overcome. As one method of tackling the challenge and creating meaningful changes; the involvement of Positive people especially members of the association as testimony providers & others as Mother support group mentors & community mobilizers in health facilities will be major entry points.
Since we have planned to reach more HIV positive women through the life time of this project; expansion of positive living training will be vital especially for the new comers. The association needs to find other funding sources so as to accommodate the high demand coming to it with this implementation of the project.
Different HIV positive associations, organization working on HIV, Government offices and Health bureaus in the region, CBOs, FBOs & Health Centers will be our major stakeholders. Tilla has Advisory board members who are selected from different government and non government offices will also provide the technical guidance & the leadership role.
Tilla as pioneering association has been implementing different relevant projects related to HIV and AIDS and has been also benefiting & being benefited from its stakeholders. With our available networks we will work together to achieve the best and at the same time it will benefit others through the initiation we taking in this new area of work.
Government policies & approaches existing currently are also very much supportive of this type of interventions. Community mobilization, with a particular emphasis on engaging women’s associations for mobilizing increased uptake of maternal and child health services is one of the focus of national plan. In this regard major government bodies & implementing partners are also aware of the project and have their say in the plan.
PART THREE: Management and capacity
Project management Plan & organizational structure
At the top of the association structure is the General Assembly which consists of all members of the Association. Next to that, there is Board of Directors comprised of individuals from government offices and NGO’s.
In operational matters the Association is led by Executive Director and the Executive Director is accountable to the Board of Directors. Under the Executive Director, there is deputy Director who is responsible to manage Finance Administration Head, Monitoring and Evaluation Officer, Member’s Development Officer, different project coordinators, Branch Office Coordinators and Junior Counsellor.
A project management team comprising the deputy director, project coordinator, finance officer and monitoring and evaluation officer will be formed. The project coordinator who will going to be assigned for this specific task is in charge of the project directly.
The project coordinator, Monitoring & evaluation officer will be fully responsible and engage in managing the project. The Deputy Director & Administration and Finance Head will endow their partial time for smooth implementation of the project.
Institutional Capacity
Tilla was established in April 2003 by five HIV positive women who were prepared to declare their status to the public in order to make people more aware of HIV and AIDS and reduce the stigma associated with being infected with the virus. Since then it has been engaged in HIV/AIDS prevention and control activities. Tilla is prominent in its testimonial activities which has made people to give attention to HIV/AIDS and its impacts. Currently, 400 women living with HIV are members of the Association. Tilla has an organizational structure with sound programmatic, administrative and financial system and has 27 employees.
The Association has shown its demonstrated capacity in managing different projects. The program management committee consists of the executive director, Deputy Director, project officers, monitoring and evaluation officer, Finance and Administration head of the association and provides overall guidance to projects implementation.
Financial management will be handled in accordance with the terms of contractual agreement and basic standards. The Finance and Administration Head and the Accountant will control the budget and review expenditure specifications against the allowable budget category and line items. Financial reports will be submitted using the standard forms that would be provided by the donor. Each year, the Association uses certified external auditors to audit its finance. External audit for the year 2010 had already carried out.
Organizationally the Association has established strong linkage and relationship with both governmental line offices and NGO’s such as Woreda, Zonal and Regional Councils, Bureau of Finance & Economic Development, HIV/AIDS Prevention and Control Secretariats, and other concerned stakeholders
Tilla will exercise a participatory project management and link the project to the local government institutions at grassroots level. As the Association has the experience of participating in networks of similar activities and closely works with the respective government structures, there will be continuum of support and supervision after project phase out.
PART FOUR: Monitoring, evaluation, research and reporting
Since most of the activities in this project have direct linkages with health centres, the major strategy implemented in generating the basic information from the heath system will be the utilization of Health Management Information System (HMIS) system practiced in the facilities. The trained & deployed data clerks by this project will help in implementing the standard patient monitoring system.
Supportive supervision and strong mentorship at each health Center will be conducted on monthly basis by the project coordinator who will going to have a clinical mentorship skill. The Monitoring and Evaluation Officer of the Association will be responsible for coordinating monitoring and evaluation activities of the project.
While the monitoring of the activity is done in a participatory manner with all stakeholders, regular quarterly, half year and annual physical and financial reports will be prepared by Monitoring & Evaluation officer and Finance officer of the Association for submission to the donor and concerned government parts.
Besides the monthly field visit & monitoring conducted from the office level, community mobilizers, volunteers & case managers are expected to meet on monthly bases to discuss on the performances at health facilities. Biannual review meeting of all implementing bodies will be also part of this monitoring & evaluation task.
Different strategies will be sought to hare lessons gained from this project. Communications made through published materials, local FM radio, website blogs, workshops & reports are the major ones.
The effort made in enhancing the service at Health center level through capacity building element & the high engagement of community volunteers having basic skills will put a base for this project sustainability. Of course, the demand for PMTCT service & tracing loss to follow-up initiative will continue to rise with the fact that there is a presence of responsive community members & sensitized influential community members & concerned stakeholders.
