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USAID

Agenda. Mid May participated in virtual' portfolio review of USAID partner's including limited discussions with partners. Review of prior consultant reports. June 11 Arrival June 11 18 In-country meetings with partners (PACT, APCA, SCMS, Nawa Life, ITECH), USAID staff, and MOHSS staff (PH

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USAID

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    1. USAID/Namibia Care and Support TDY John GH Palen, PhD, MPH, PA Senior Tech Advisor, Palliative Care USAID/HQ June 11 – 25, 2008

    2. Agenda Mid May – participated in ‘virtual’ portfolio review of USAID partner’s including limited discussions with partners. Review of prior consultant reports. June 11 – Arrival June 11 – 18 – In-country meetings with partners (PACT, APCA, SCMS, Nawa Life, ITECH), USAID staff, and MOHSS staff (PHC) and participation in COP 09 planning retreat June 19 – 20 – Additional meeting with partners (PACT, CAA), and MOHSS (DSP) and CDC staff. June 22 – 23 – Trip to Anamulenge to visit CAA’s HBC program (home visits and volunteer staff) and linkage/relation to Outapi District Hospital. June 24 – Final wrap-up meetings with USAID staff June 25 – Debrief and depart … continued TA

    3. General Observations Functional, comprehensive facility-based care system within cities and towns; however, challenges exist in rural areas regarding availability of service sites and providers and, in general, the provision of home-based care services. Centralized (MOHSS) authority in setting standards and in delivering care services. MOHSS commitment to expanding access to HIV and primary care in communities; however, challenges exist in MOHSS regarding staff shortages, training and experience in community/HBC, and the administrative separation of DSP and PHC. Small number of highly committed USG partners; however, mixed experience and skill levels in providing community/HBC services and commodities.

    4. Areas of consideration in preparing COP 09 SI informing policy and program decisions Implementation of HBC Guidelines HCW cadre and training Increases access to services in rural areas Linkages and referrals between facilities and HBC programs Basic Care Package and HBC kits Pediatric C&S and treatment Other issues – TB, Alcohol related services, cervical CA Post retreat follow up….

    5. Is strategic information informing the planning for PEPFAR C&S services? Continue (and formalize) mapping exercise initiated at COP 09 planning retreat for PEPFAR supported facility-based ART and non-ART care facilities. Quantify level of service demand within facilities – ART and non-ART clinical services. Identify other PEPFAR supported facility, community, HBC clinical and support sites within vicinity – facility and community/HBC. Describe linkages between ART and non-ART facilities and other facility and community/HBC sites. Assess if current ART and non-ART facilities are capable of providing the full range of C&S services at the facility and C/HBC level and role of other PEPFAR funded C/HBC providers to provide such services. Identify service and provider (types) gaps.

    6. How can USG assist the MOHSS in implementing HBC ? Work with MOHSS to establish ‘pilot’ scale-up projects (PACT/consultant) Embed (PT) new USG/USAID clinically trained staff (RN) with community/HBC experience within MOHSS (PHC) to assist in implementing project. Identify with MOHSS and stakeholders (PACT, CAA, ITECH) ‘priority’ set of services (refer to following CHW slide/s) Develop core curriculum base on ‘priority’ areas. Integrate ‘pilot’ into existing service sites and link facility and HBC programs (MOHSS/PACT/CAA) Incorporate QA/QI system during scale-up (MOHSS/CDC) within facilities.

    7. What should be considered in developing and training a HCW cadre? Work with MOHSS to determine feasibility of establishing new cadre (with core competencies) or expanding the role (and training) of existing cadre. Recommended standard set of core competencies for new (or existing) cadre: HIV education & counseling, and VCT referrals Symptom assessment, management and referral (IMAI/IMCI) TB case finding and referral Use of and adherence to medications (ART, TB, others) Nutrition assessment, counseling and referrals ADL/basic nursing Brief psychosocial assessment and referral (including ETOH) Prevention with PLWHAs – condom provision; counseling and testing of partners, children, other family members; ART adherence counseling

    8. HCW cadre and training? Budget as HCD activities for COP 09 and describe: (PACT/MOHSS): Standard eligibility and training requirements Certification examination and retraining Registration via NGO or regional govt office Supervisory requirements Salaries/retention/incentives Professional development opportunities HBC/BCP kits – access and use (including distribution of or referrals for CTX, ITN, IPT, safe water vessels, etc) and integration with PWP

    9. Expanding services HIV care services in rural communities? Consider ‘pilot’ mobile clinics staffed by nurses for providing basic HIV care and treatment within local communities (CAA has initial stages completed and will expand) Equip nurses with necessary transportation, equipment and medications Stethoscope, BP cuff, thermometer, etc CTX, INH, analgesics (all levels), symptom management (diarrhea, N/V, etch) Vehicles Cell phone

    10. Expanding services to rural areas? Assure access of ‘opioids’ (oral) at Level B health centers and equip mobile nurses with oral morphine (and other analgesics) for use during community visits (District hospitals, APCA, PACT, CAA) Establish specific procedures and protocols for: providing direct care within communities and supervisory relations with MO/RN facility care providers (PACT) Role and responsibilities with overseeing CHWs and volunteers (PACT)

    11. Any other innovative ideas in expanding in rural areas? Explore the use of existing technologies to expand access to C&S services in hard-to-reach areas, including: Cell phones – SMS/direct calls – between HBC nurses and CHW/volunteers and facility and HBC staff. DVC links between ‘new’ and ‘highly qualified’ facilities in training, CME, consulting, and supervision/reporting. (e.g., cervical CA screening and treatment program to support nurses) Data reporting via cell phones

    12. Improving linkages and referrals between facilities and HBC programs? Support MOHSS in convening a meeting of key stakeholders to identify best practices and implementation strategies or methods, including: bi-directional reporting/registry system case manager roles and responsibilities inventory of available C&S services within community for referral purposes Identify roles of volunteers or PLWHAs to provide follow-up and retention support.

    13. Basic Care Package and HBC kits What is the status of the distribution of BCP interventions? (CTX px, INH px, ITN, safe water vessels/water guard) – no apparent collective effort or systematic process for delivering interventions. Capacity of SCMS regarding mapping for HBC kits and distribution and re-stocking kits. Distribution of kits to volunteers versus CHW or RN. Can BCP be integrated into efforts to develop and distribute standard HBC kits to HBC program staff?

    14. Will need to present pediatric care and support program COP 09? Establish pediatric ITT to describe the availability of existing pediatric care and treatment services among existing partners and sites for HIV+ children. (MOHSS PHC and DSP, all USG and IPs). Recommend a pediatric TDY (USAID, CDC) Assess the barriers of these HIV+ children to gain and retrain access to ART and non-ART services. (MOHSS, query all IPs) Integrate pediatric components in HBC guidelines and implementation strategy. (PACT) Establish mechanisms to link HIV+ children with existing OVC services such as the use of pediatric case managers to link clients to OVC and other services. (CAA)

    15. TB Integrate TB case finding as a standard component of HBC services. Support of MOHSS (CDC/USAID) to include TB identification within HBC guidelines and activities Training HBC providers (nurses and others) on TB identification Adopting standard list of TB questions to be used by HBC staff and volunteers Assessing availability of referral relations (and laboratory capacity) between HBC programs and facilities for follow up assessment/screening and treatment.

    16. Alcohol and Cervical CA screening Alcohol – prevention and recovery Cervical cancer screening and treatment Discussion with MOHSS to adopt strategy based on existing national guidelines and standards Determine modality based on existing resources Establish protocols and procedures regarding: Selection of modality Training of staff Biosafety Quality assurance

    17. Post-retreat Follow-up What next?

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