Operational Plan Report


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Sensitive but Unclassified

USG Only

Operational Plan Report
FY 2011

Operating Unit Overview
OU Executive Summary


COP 2011 comes when there is a nexus of opportune events spanning the next five years: the Government of Ethiopia’s (GOE) Growth and Transformation Plan, 4th Health Sector Development Plan (HSDP IV) and 2nd Strategic Plan for Intensifying the Multisectoral HIV and AIDS (SPM II) response, the designation of Ethiopia as a Global Health Initiative (GHI) Plus country and the imminent signing of a Partnership Framework. These generate positive momentum towards country ownership and leadership, achieving Millennium Development Goals and significant gains in addressing HIV/AIDS. The extraordinary reach of USG-supported programs across Ethiopia as well as close engagement with the Ministry of Health (MOH), non-governmental organizations (NGOs) and the private sector provides a unique and promising opportunity not only to continue to demonstrate success in addressing HIV/AIDS, but also to reduce maternal, neonatal, and child mortality in a way that is fully country-owned. PEPFAR/E has identified priority focus areas in COP 2011 that support HSDP IV and SPM II, and align with the Partnership Framework and GHI strategy. These include expanding sexual prevention and PMTCT services, strengthening TB/HIV and pediatric HIV/AIDS services, human resources, and better SI. With another 3% budget cut, the team paid particular attention to a more strategic program and increasing efficiencies, including consideration of duplicative activities and partner pipelines to inform budget allocations.

With a population of 80 million1, Ethiopia is the second most populous country in Sub-Saharan Africa. It is low-income with a real per capita income of US $2322 and 39% of the population living below the international poverty line of $1.25/day.3 It is also one of the least urbanized countries with 84% of the population living in rural areas. Ethiopia’s HIV/AIDS epidemic has placed substantial demand on the country’s already strained resources. Although the 2009 HIV point prevalence estimate of 2.3% is lower than many other Sub-Saharan countries, there are still over 1.1 million people living with HIV in Ethiopia, the third highest number of PLHIV in East Africa. Ethiopia’s low-level generalized epidemic has wide urban:rural differences in prevalence (7.7% vs. 0.9%, respectively), thought to be driven primarily by most at risk populations (MARPs). The high urban prevalence results in 60% of PLHIV living in cities/towns.4 Prevalence is significantly higher in women than in men (2.8% and 1.8%, respectively). Of Ethiopia’s estimated 5.4 million orphans, 855,720 were orphaned due to AIDS. As new information from DHS+ 2010, the TB prevalence survey and other ongoing surveys becomes available, forthcoming strategies will need to consider new epidemiologic evidence. A National Prevention Summit held in April 2009 refocused national efforts to target MARPs and highly vulnerable populations, including commercial sex workers (CSWs), migrant workers, long-distance drivers, uniformed services, men who have sex with men, and discordant couples. Common settings for MARPS include construction sites, urban areas, small market towns, and transport corridors.5 There are also a number of potentially highly vulnerable groups including clients of CSWs and high school and university students who migrate to towns.

With PEPFAR support, the GOE has demonstrated strong leadership and commitment resulting in increased social mobilization, expansion of health facilities and services, improved access to antiretroviral treatment (ART), and innovative efforts to build human capacity. Facilities offering counseling and testing nearly tripled from 658 in 2005 to 1596 in 2009. As a result of provider initiated counseling and testing (PICT) in health facilities and community mobilization, the number of people tested for HIV increased from 436,854 (2004/5) to 5,800,248 (2008/09). In the first half of FY 2010, 2,952,039 people alone were tested and received their results6. The number of hospitals and health centers quadrupled from 645 in 2004 to 2,884 by 2009; over the same period the number of health posts increased almost five-fold. In 2005, only 3 facilities were offering ART; these services are now available in 511 facilities7. From a baseline of 8,226 persons ever started on ART in 2005, over 241,250 had been started on ART by 2009 (62% of estimated need).8 As of March 2010, 186,154 PLHIV remained on ART9, the difference including patients that died, stopped treatment, and the 7% who are “true” lost to follow-up”. High lost to follow up among pre-ART patients will be addressed by focusing on effective retention models and networks at the facility and community level.

PEPFAR provides significant support for health systems strengthening (HSS), including implementation of Ethiopia’s Pharmaceutical Logistic Master Plan, the Laboratory Master Plan, the Health Management Information Reform Scale-up, Public Health Emergency Management, Health Sector Financing Reform and Health Insurance, Hospital Reform Implementation Guidelines, and the Human Resource for Health (HRH) strategy. The private healthcare sector is expanding and will be an important complement to the public arena.

Significant challenges remain to addressing PMTCT and maternal mortality. Ethiopia has one of the highest rates of maternal mortality in the world at 673/100,000 live births. Over 90% of women in need of a caesarian section cannot access one; 19,000 women die from childbirth-related causes every year and an estimated 50,000 women experience obstetric fistula. Despite a three-fold increase in the number of sites providing PMTCT, only 8.2% of the estimated eligible number of HIV-infected pregnant women received prophylaxis. The main reason for this is limited uptake and access to quality ANC and maternity services. An assessment of Emergency Obstetric and Neonatal Care standards (EmONC) showed 11% of health facilities met standards.10 The challenges with PMTCT have been acknowledged by the GOE, partners and donors alike. It is hoped that the 30,000 Health Extension Workers will increase demand for ANC and facility delivery at the community level, coupled with performance improvement at the facility level, will be effective in improving PMTCT coverage and reducing maternal mortality.

Sustainability and Country Ownership

The Partnership Framework (PF) was signed on October 27, 2010 and reflects the respective contributions of the GOE, USG and other partners to collaboratively expand and sustain an effective response to the HIV/AIDS epidemic in Ethiopia.. The PF consolidates the gains achieved through partnerships in the first five years and increases focus on country ownership and leadership, while strengthening health systems that integrate HIV prevention, care and treatment services. PF goals and objectives are consistent with the GOE’s SPM II and HSDP IV and also seek to ensure that USG contributions complement and leverage those of other stakeholders. COP 2011 reflects the priorities, goals and objectives outlined in the PF that will be detailed within the Partnership Framework Implementation Plan (PFIP).

Through the signing of the PF, the USG and the GOE acknowledge a shared desire and responsibility to strengthen their relationship, and increase the effectiveness, efficiency and sustainability of the national response to the HIV/AIDS epidemic in Ethiopia. The PF supports the GOE’s unique leadership role in coordinating and mainstreaming efforts among many sectors to create an efficient, effective and sustainable response to HIV/AIDS in Ethiopia. The Framework is guided by the vision that systems and services related to HIV/AIDS should be equitable, move towards universal access, be of high quality, and support a family and community based approach. The PF will work in close collaboration with other Ethiopian collaborative arrangements such as the International Health Partnership (IHP+) and other multilateral and bilateral relationships and encourage working with multiple government sectors, private sector, civil society, faith-based organizations, donor organizations, PLHIV, and communities at large. Gender inequalities should be addressed by all sectors to ensure more effective HIV/AIDS prevention care, treatment and mitigation programs and should also take into account and work towards ensuring that all people with disabilities receive equitable and accessible standard quality services. While the USG’s main modality of delivering development assistance is project support, USG investments in Ethiopia going forward should be based on a joint plan, include country leadership in decision-making on where investments are made, be transparent and support the principles of the “Three Ones”. The HIV/AIDS response should be guided by planning that results in implementing programs that are data driven, rigorously monitored and evaluated and based on the most strategic investment of available resources in order to maximize program impact.

In addition to the above Principles, the two Governments affirm the importance of financial principles including prioritization given limited resources, recognition that reaching goals require resources beyond those of any one partner, and that funding constraints could lead to a review and revision of priorities, GOE contributions will meet cost sharing requirements under U.S. foreign assistance programs and progressively cover recurrent expenditures, expectation of transparency in resource allocation and expenditures, collaboration with other stakeholders to reduce redundancies and inefficiencies in allocation of resources for HIV/AIDS interventions and support of full and open competition in the funding of non-governmental implementing partners.

Activities supported through COP 2011 aim to fulfill the USG commitments in the PF, which include the following GOE goals to be achieved by 2014:

  1. Reducing national HIV incidence by 50% by focusing prevention efforts on MARPS and PMTCT services as well as increasing comprehensive HIV knowledge and behavior change among the adult population;

  2. Reducing morbidity and mortality and improving the quality of life for PLHIV by expanding access to quality care and support and treatment for both adults and children;

  3. Supporting functional health systems necessary for universal access including adequate human resources for health; expanded and improved physical infrastructure; increased capacity for planning, management, and finance of programs, especially at regional levels; functioning systems for health management information, laboratories, surveillance, and other sources of data, all supported by adequate systems to ensure un-interrupted procurement and supply of essential HIV/AIDS commodities; and,

  4. Strengthening leadership to ensure coordination and implementation of one multisectoral and strategic national response including intensified involvement of civil society and the private sector.

Additionally the USG and GOE will promote greater country ownership of programs and activities by the GOE, local organizations and other stakeholders through jointly agreeing upon indicators that characterize ownership and increasing the number and amount of PEPFAR resources going to local partners, including but not limited to the GOE.

Integration across the USG

Ethiopia has been among the top recipients of USG health resources in the world with total FY 2010 funding of $400 million including PEPFAR, the President’s Malaria Initiative (PMI), Maternal and Child Health (MCH), family planning, tuberculosis, food and nutrition, pandemic influenza, immunization, and water and sanitation programs. COP 2011 feeds into the GHI/Ethiopia strategy, which articulates all USG investments in the health sector, and aims to contribute to reduced maternal, neonatal and child mortality by identifying specific contributions across the continuum of prevention, care, treatment and support, underpinned by broader HSS efforts. Specific examples include integration across TB programs to develop one USG TB plan, improving ANC, labor and delivery services through PMTCT, and complementary activities with PMI to increase the availability of insecticide treated nets and malaria treatment.

The USG also brings other sector development programs including education, food security and livelihoods to address the underlying causes of poor health. The USG has had a strong history of “wrap-around” programs linking food assistance with OVC, HIV/AIDS treatment and care programs, as well as linking education with HIV/AIDS, water/sanitation, micronutrient supplementation and education for behavior change. Plans are underway to link several Feed the Future agricultural and pastoralists programs with the provision of health services in the most food insecure regions.
The Staffing for Results review (see below) and move to the new embassy building are further examples of improved integration.
Health Systems Strengthening and Human Resources for Health

Ethiopia is one of 57 countries recognized by WHO as having a health workforce crisis, marked by chronic under-production of trained personnel, especially at high and mid-levels, and low retention related to poorly motivated and underpaid staff. In addition, there are major rural:urban distribution disparities with health worker density ranging from 0.24 to 2.7 per 1,000 population, respectively. There are 2,151 physicians in the country, a ratio of 1 to 36,710 people, far below WHO standards.11 Ethiopia has been visionary in task-shifting HIV/AIDS services to nurses and other cadres in order to compensate for the severe shortage of high and mid-level trained health workers.

The USG invests significant resources in HSS by contributing to the MOH’s commodity logistics and supply chain management, public health emergency management, health management, laboratory and human resources information systems, building health facility and laboratory infrastructure, and strengthening MOH capacity in management, leadership and governance. Long standing USG investments in health financing reforms have resulted in new approaches for health facility retention of fees, national health accounts surveys and current piloting of community and social insurance. The USG builds the capacity of educational institutions to deliver quality pre-service education by supporting curriculum and faculty development and renovation and equipping of educational institutions, labs and field sites. The USG also supports extensive in-service education for health professionals including medical doctors, health officers, nurses, lab and pharmacy technicians, case managers, and kebele-oriented outreach workers. The USG has engaged the private health sector in provision of CT, TB and PMTCT services; is strengthening the capacity of private sector representative bodies; and is working towards establishing a licensing and accreditation process for private providers based on clinical and management quality standards.

Coordination with Other Donors and the Private Sector

Ethiopia is the largest recipient of grants from the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) which, with PEPFAR resources, provided 90% of donor support for HIV/AIDS in 2009. Other donors include the UN Joint Program, World Bank, UNITAID, and other bilateral donors. The FHAPCO has the mandate for coordination of the HIV/AIDS donor response. Ethiopia was one of the first signatories to the International Health Partnership (IHP+). Currently the USG and GOE have a Memorandum of Understanding (MOU) which delineates the complementary roles of Global Fund and PEPFAR resources. As an essential step in the development of the PFIP, the GOE and PEPFAR will review and harmonize their investments within a revised MOU outlining coordination modalities. The USG is a member of the Country Coordinating Mechanism (CCM) of the GFATM, and co-chairs both the Health Population and Nutrition Donors Group and the HIV Donors Forum. Technical assistance is provided to the GOE to develop GFATM proposals for HIV, malaria and TB.

Programmatic Focus

PEPFAR/E has incorporated recommendations from prior COP reviews in COP 2011 by discontinuing the contingency fund for ARVs, completing a staffing for results (SFR) exercise, evaluating the MARCH program, developing a strategy for regional support, and focusing on MARPS and PMTCT. Ongoing costing of programs and discussions with the GOE on the prioritization of high-impact interventions within the available resource envelope remains important, including the potential costs and feasibility of adopting WHO’s new guidelines for PMTCT and ART. New findings from DHS 2010, MARPS, and other surveys and reports will be used in 2011 to further inform strategic planning. All PEPFAR technical working groups contributed this year to assumptions around national commodity requirements to improve the accuracy of projected needs and to clearly document PEPFAR’s contribution.

PEPFAR/E’s SFR exercise is submitted as an Annex to COP 2011. Recommendations from this include agency review of job descriptions to ensure adequate staff coverage for focus program areas. Based on the request from the COP 2010 review, a regional strategic plan is also included as an Annex. This outlines plans for direct support to regions through embedded staff and supports both increasing capacity at regional level and greater country ownership. All of the following programmatic areas will contribute towards worldwide PEPFAR 4-12-12 goals:
Prevention: ($80,720,554) The prevention portfolio in COP 2011 focuses on comprehensive prevention among most at-risk groups and other highly vulnerable populations where most new infections occur in this largely concentrated epidemic. Emphasis will be placed on Scale up and coverage of proven behavioral and biomedical interventions to reach at least 60 percent of MARPS. Support for comprehensive PMTCT and PwP services remains important to reduce vertical transmission and transmission in discordant couples. With improved support for local evaluation, plans for large-scale studies and the roll-out of New Generation Indicators, we hope to increase demand and use for up-to-date surveillance, monitoring and evaluation data to guide programming and foster programming

COP 2011 improves on previous prevention programming in several ways. Top priority is to scale up proven interventions among MARPS and other highly vulnerable populations (e.g., persons engaged in transactional sex), including access to male and female condoms, promoting correct and consistent condom use, STI testing and treatment, individual and couple HIV testing, and strengthening referral linkages for ART treatment when eligible. Across programs, emphasis will be placed on linking interventions to ensure continuity of prevention and care from the client perspective. Ability to identify and enumerate most at-risk and highly vulnerable populations and target interventions appropriately will be enhanced by large-scale surveys and size estimation exercises. Previously underserved areas such as Addis Ababa, estimated to account for 20% of new infections, will be targeted with intensive prevention programming. Standardizing of services and innovative strategies will be introduced or expanded, including confidential clinics for sex workers, mapping of sexual networks for peer outreach, improved continuity of prevention and care for persons living with HIV, and engagement with private sector (e.g. private clinics, hotel and bar owners) to create enabling environments for sustainable prevention. A study to determine the extent of MSM in Addis is underway and subsequent outreach efforts will be informed by expertise from similar African settings.

For prevention in the general population, partner reduction, fidelity, delaying sexual debut and decreasing gender-based violence will be promoted with a mixture of mass media, school-based and small group interventions. Broader structural risk factors that exacerbate vulnerability to HIV in Ethiopia particularly for women and girls such as early marriage and sexual coercion also cannot be ignored. At the same time, strong commitment and ownership by the GOE and religious groups of AB programs indicate that the USG should focus efforts on advocacy and the incorporation of minimum standards for such programs into community conversations, school curriculum, and religious outreach with a transition of activities to local partners.
Although circumcision is widespread in Ethiopia, an estimated 800,000 men nationwide remain uncircumcised and hence at higher risk of HIV infection. Over the past year, results exceeded expectations with the new program that rolled out in Gambella, the highest prevalence region outside Addis, and amongst uniformed services. In COP 2011 an accelerated campaign will aim to circumcise 28,000 adult men by 2012 in Gambella and Southern Nations and Nationalities regions where need is greatest, as well as selected MARPs and vulnerable male populations across the country.
In line with the GHI focus on decreasing maternal mortality, specific efforts will be made to strengthen and expand the availability of safe blood. The program has been hampered with serious management issues within the Red Cross. Now being taken over by the MOH, and with increased TA provided through this COP, it is hoped that good progress will now be achieved.

Ongoing efforts to increase PMTCT uptake remain a major priority for COP2011. Although there is at 25% increase in the first half of FY 2010 compared to a similar period in FY 2009, with 5,398 pregnant women receiving PMTCT prophylaxis, this still falls far well short of the estimated 79,000 women needing these services nationwide. It is essential to encourage women to attend ANC, to decrease missed opportunities to reach women within the health system and to strengthen outreach programs. PEPFAR will focus on supporting the GOE to provide integrated services and to prioritize high-yield facilities in areas of high HIV prevalence, building upon the opportunity provided through the deployment of over 6,000 urban HEWs. Referral linkages within facilities and between facilities and surrounding communities need to be strengthened to insure effective, fully integrated service delivery. Barriers to ANC and institutional delivery, including inadequate clinical infrastructure, will be addressed in conjunction with creating demand at the community level. HIV-positive pregnant and post-partum women will receive nutritional support and be linked to care and treatment services. In support of GHI priorities, PEPFAR will support GOE efforts to expand the health workforce, including emergency obstetrics masters-level training for clinical officers, midwifery training, and support for HEWS to provide clean and safe delivery at community level. Wraparound PMI and FP activities will all contribute towards decreasing maternal and neonatal mortality.

Care and Support: ($84,814,235) Rapid expansion of care and treatment services has changed the focus from home-based and palliative care to ensuring retention of pre-ART patients in the continuum of care. In the first half of FY 2010, 944,497 adults and children were provided with at least one care service. COP 2011 will focus on strengthening retention of pre-ART patients within the health system, ensuring they receive cotrimoxazole prophylaxis, are screened for TB and other OIs, receive the basic care package and are assessed earlier for ART to prevent early mortality. In support of integrated services and GHI principles, there will be expanded collaboration with partners in reproductive health, child survival, FP, malaria, TB, and improved child rearing practices. These programs also provide a neutral entry point from a stigma perspective for providing a continuum of care from health facilities to communities.
Food remains a major priority given the high levels of malnutrition and food insecurity among PLHIV and OVC, as well as the negative effects of malnutrition on ART adherence. The introduction of the Food by Prescription (FBP) program in FY 2010 and ongoing supplementary feeding programs reached 18,445 patients, but it will be important to both increase coverage and further streamline transition from FBP to supplementary feeding. Across all programs, nutritional assessment and counseling will be strengthened. With USG resources for nutritional care through FBP and by leveraging food resources from PL 480 and the World Food Program, COP 2011 will support 66,093 malnourished PLHIV with FBP and supplementary feeding.

Despite progress in improved screening for TB/HIV co-infection, treatment, and M&E, the proportion of PLHIV started on TB treatment remains only 5%. With an estimated 20-25% HIV prevalence in TB patients, TB/HIV remains a priority area for improvement in COP 2011. PEPFAR supports several facets of the TB program including the deployment of TB advisors to regions, development of a new national strategic plan, improved infrastructure such as a new TB ward in Gondar Hospital, co-infection screening, better laboratory smear and culture diagnostic capacity, and ensuring treatment completion. The 2010-11 national TB prevalence study being conducted by WHO and EHNRI will provide better epidemiological data. There has been good progress in expanding the number of HIV diagnostic and treatment sites to over 800 with greater participation of the private sector. Five new regional TB labs will have the ability to perform TB culture and drug sensitivity testing by early 2011. Although the prevalence of MDR-TB remains relatively low at 1.5% of new cases, there are still large numbers of patients who have not been identified or adequately treated. PEPFAR will complement GFATM resources being used to improve MDR treatment facilities, to support the further roll out of MDR guidelines, train staff and improve lab infrastructure and diagnostic capabilities. This will include supporting all components of the “Three I’s” as well as better monitoring of service provision. In line with improved efficiencies and effectiveness, the USG will unite its PEPFAR and non-PEPFAR funded programs to develop a “one USG plan” for TB supporting Ethiopia.

Ethiopia has a substantial burden of OVC estimated at 12% of students in all schools including PEPFAR-supported schools. To address this, a new OVC RFA was released in August 2010 to build on the successes of previous programs. The USG will also support the dissemination and implementation of recently released OVC Standard Service Delivery Guidelines for care and support as a basis for ensuring program quality. Efforts to strengthen GOE institutions responsible for OVC programs, typically much weaker institutionally than the MOH, will continue. Building on the President’s Initiative for Expanding Education, PEPFAR will strengthen partnerships with parent-teacher associations (PTAs), Girls’ Advisory Committees and teacher training institutes to support children to complete their primary education and remain HIV free. Communities, churches and local governments are being supported to address the needs of OVC in the community with both local and PEPFAR resources.

The national momentum for VCT continued with almost 3 million people receiving these services between October 2009 and March 2010 in over 1,000 sites. USG support will emphasize higher-yield testing strategies including intensified efforts among MARPS and hot spot areas, PICT, couple testing to address discordance, task shifting to lay counselors, and the appropriate involvement of HEWs. In order to identify more HIV-positive children, aggressive efforts will be made to maximize all opportunities to test children, taking into account any ethical concerns. Rapid test kits are procured by the GOE using GFATM resources. Reports of interrupted supplies of test kits seem to be caused by poor distribution planning rather than a shortage of the kits themselves. Efforts to strengthen the system through technical assistance to the GOE’s Procurement Funding and Supply Agency (PFSA) will benefit the overall procurement and logistic system.

3. Treatment: ($84,049,560) As of March 2010, there were 186,154 PLHIV on ART. In FY 2011, 49,027 new patients will be enrolled in ART reaching 252,509 by September 2011 and 300,150 by September 2012. Although PEPFAR support extends nationwide, these PEPFAR targets form a subset of the national universal access target and reflect a more realistic scale-up and retention scenario. Support for improved adherence through case managers, many of whom are PLHIV themselves, to track patients on ART remains important. COP 2011 will begin the transition of major Track 1 care and treatment partners to local partners for the first time in Ethiopia.

Aggressive attempts will be made to increase the number of children on treatment above the current 5.5% of total number on treatment. This requires better detection and retention of HIV-positive children, more health workers trained in pediatric services, making pediatric formulations available and the provision of psychosocial support. Pediatric ART will be available at all ART sites and supported by early infant diagnosis and linkages with PMTCT and MCH services.

ARVs and drugs for opportunistic infections (OIs) are primarily procured by the GFATM. As indicated above, greater efforts will be made to harmonize GFATM and PEPFAR-supported activities, especially ARV forecasting. PEPFAR plans to purchase second-line ARVs and pediatric formulations to cover an anticipated gap between the end of Clinton Health Access Initiative (CHAI) support in 2011 and the start of GFATM Rolling Continuation Channel funds. There are ongoing efforts to clearly forecast the national ARV needs, taking into account available GFATM resources and seeking to influence Ethiopia’s plans decision whether to adopt the new WHO treatment and PMTCT guidelines. The USG supports a monthly National Commodity Committee that reviews ARVs and other essential drugs and commodities.

There continues to be steady progress on strengthening laboratory services. PEPFAR provides considerable support to the national laboratory system, including procurement of all reagents and supplies for ART monitoring. Working primarily with the Ethiopian Health and Nutrition Research Institute (EHNRI), PEPFAR provides physical infrastructure improvements and equipment, TA, quality assurance, and site supervision to the National Reference Laboratory, nine regional laboratories, and all hospital and health center labs. This includes more than 400 sites participating in Dried Tube Specimen EQA for rapid HIV testing, 120 sites in ART monitoring, 100 sites in TB, and 7 early infant diagnosis (EID) laboratories linked with CDC-Atlanta’s proficiency testing (PT) program. Over the past year, there was 100% concordance with PT test results. The focus of laboratory support in 2011 will emphasize system strengthening as a whole, also incorporating other USG inputs such as PMI lab support, the regional lab network, supporting the establishment of comprehensive equipment maintenance with initiation of postgraduate masters training, Strengthening Laboratory Management towards Accreditation, establishing national standards and a national accreditation body, more involvement of regional laboratories for expansion of EQA programs (on TB, HIV rapid test and malaria), and expansion of the Laboratory Information System. As with other programmatic areas, PEPFAR will strengthen involvement in pre-service training through working with the GOE on curriculum standardization.

Particular emphasis will be put on improving health center laboratories where infrastructure is particularly poor, improving country capacity for microbiology, as well as providing support for the private sector in quality control. Sample referrals especially for TB and EID will continue to be strengthened using the Ethiopian postal system. PEPFAR will also support implementation of the National Master Plans for Laboratory Services and Logistics Management. PSCM will work to develop the capacity of PFSA to strengthen its central and regional hub capacity to handle the special logistics needs for lab supplies, including cold chain requirements. As the HIV epidemic matures, there is an increased likelihood of treatment failure for ART patients taking first line regimens, hence, an estimated 5% of patients are targeted for viral load measurements. Continued support will be given for viral resistance surveillance using WHO guidelines. The USG will review how to efficiently strengthen integration of overall laboratory functions, especially HIV, OI detection, malaria, and TB. PEPFAR-Ethiopia will support joint planning and annual review meetings for harmonization and better resource alignment of laboratory support activities across stakeholders.

4. Woman and Girl-Centered Approaches: This area is well articulated within the GHI/E strategy through which the Ethiopia program takes a more comprehensive life cycle approach to addressing women’s health. Utilization of ANC and PMTCT programs will be increased by improving quality of services, infrastructure and community mobilization. The quality and utilization of labor and delivery services will be increased through pre-service training of midwives and emergency surgery officers, improving facilities and blood supply and ensuring that needed commodities and equipment are in place. Other prevention efforts target CSWs as a specific intervention group, as well as girls in high schools and universities. FP/RH services will be expanded and integrated into HCT, PMTCT and HIV care and treatment programs. Wraparound resources such as PMI and Feed the Future also focus on women.

5. Other Programs: ($51,080,844) PEPFAR continues to support local institutions such as EHNRI to strengthen available strategic information. This includes roll out of the MOH’s HMIS system, expansion of electronic medical registers, and the support for a central data warehouse, all with significant support from PEPFAR. There will be ongoing efforts to align the NGI and HMIS indicators, the majority of which are available within registers but are not necessarily all reported up to the regional and national level. PEPFAR also supports the development of a community management information system to better capture multisectoral activities. COP 2011 will see the completion of the MARPS survey and quantification which will provide important information, as well as the 2010 DHS+. PEPFAR will continue to support EHNRI for ongoing surveillance in STI, TB/HIV and ANC and strengthen data quality and triangulation. PEPFAR, together with other donors, will encourage the GOE to release surveillance and other information in a timely manner.

PEPFAR/E has been successful in supporting HSS. In line with identified priorities for GHI, PEPFAR will continue to focus on the following activities: HRH, health sector finance reform, logistics and capacity supply chain management, infrastructure, and capacity building of government and local NGOs with a focus on better governance, planning, leadership and management, and expanding the role for the private sector. Significant effort will be put into strengthening the health workforce ranging from pre-service training of critical cadres to a rationalization and improved coordination of in-service training with a focus on improving the quality of health education by increasing the capacity of instructors, matching job skills to curricula, making greater use of information technology, and standardizing curricula and materials nationwide. In addition, the USG is expanding the scope of its HRH efforts to include improving human resource planning, development and management, including effective health workforce deployment and retention at the national and regional level. The USG is also building the MOH capacity in management, leadership and governance, including organizational sustainability, financial management, planning, policy development and implementation, health care finance reform, licensing and certification of health professionals, accreditation of facilities and laboratories, and quality improvement. Strengthening of local professional associations are also important components of increasing country capacities.

The proposed placement of USG staff at regional level is a critical strategy in COP 2011. This is further expanded upon in the COP Annex on the regional strategic plan. Additional new COP11 foci include expanding public-private partnerships, building the capacity of the GOE for the costing of plans and programs, increased support for the Ethiopian National Defense Force for hospital and health systems administration, and support for roll out of national health insurance.

New Procurements:


Program Contact: Carmela Green-Abate, PEPFAR Coordinator (Green-AbateCR@state.gov)
Time Frame: October 2011 to September 2012
Population and HIV Statistics

Population and HIV Statistics

Additional Sources







Adults 15+ living with HIV

Adults 15-49 HIV Prevalence Rate



UNAIDS Report on the global AIDS Epidemic 2010. This mid-point estimate is calculated based on the range provided in the report.

Children 0-14 living with HIV

Deaths due to HIV/AIDS

Estimated new HIV infections among adults

Estimated new HIV infections among adults and children

Estimated number of pregnant women in the last 12 months



UNICEF State of the World's Children 2009. Used "Annual number of births (thousands) as a proxy for number of pregnant women.

Estimated number of pregnant women living with HIV needing ART for PMTCT



Towards Universal Access. Scaling up priority HIV/AIDS Intervention in the health sector. Progress Report, 2010. This mid-point estimate is calculated based on the range provided in the report.

Number of people living with HIV/AIDS



UNAIDS Report on the global AIDS Epidemic 2010. This is a mid-point estimate calculated based on the range provided in the report.

Orphans 0-17 due to HIV/AIDS

The estimated number of adults and children with advanced HIV infection (in need of ART)



Towards Universal Access. Scaling up priority HIV/AIDS Intervention in the health sector. Progress Report, 2010. This mid-point estimate is calculated based on the range provided in the report.

Women 15+ living with HIV

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