Strengthening Angolan Systems for Health (SASH)

Angola Final Report

October 1, 2011– April 30, 2017 Submitted: June 30, 2017

Produced for review by: United States Agency for International Development, USAID Cooperative Agreement No. AID-654-A-11-00001

Prepared by: Jhpiego in collaboration with Management Sciences for Health

This report is made possible by the generous support of the American people through the United States Agency for International Development (USAID). The contents are the responsibility of Jhpiego Corporation or the Angola SASH program and do not necessarily reflect the views of USAID or the United States Government.

Table of Contents

Abbreviations and Acronyms ...... iv Acknowledgements ...... vii Executive Summary ...... ix Major Accomplishments ...... x Background and Approach ...... 1 Key Changes in SASH’s SOW ...... 2 Geographic Focus ...... 4 Guiding Principles ...... 4 Description of Results...... 5 Health Information Systems ...... 5 Municipal Planning ...... 10 AOP Budgeting ...... 13 HIV/AIDS ...... 16 Family Planning ...... 26 Malaria ...... 32 Challenges & Solutions ...... 35 Lessons Learned & Recommendations ...... 42

Angola SASH: Final Report, June 2017 iii Abbreviations and Acronyms

AOP Annual Operational Plan ANC Antenatal Care ART Antiretroviral Treatment CCM Continuum of Care Model DHIS District Health Information Software DNSP Direção Nacional de Saúde Pública (National Public Health Directorate) DPS Direção Provincial de Saúde (Provincial Health Directorate) EPHS Essential Package of Health Services FP Family Planning FPOM Ferramenta de Planificação e Orcamentação Municipal, Municipal Planning and Budgeting Tool GEPE Gabinete de Estudos, Planeamento, e Estatística (Department of Studies, Planning, and Statistics at the Ministry of Health) GTI Gabinete de Tecnologias de Informação (Department of Information Technology at the Ministry of Health) GoA Government of Angola GPSL Gabinete Provincial de Saúde de Luanda (Luanda Health Provincial Cabinet, formerly the DPS in Luanda) HTC HIV Testing and Counseling HF Health Facility HIS Health Information System HSS Health Systems Strengthening HRH Human Resources for Health HRM Human Resources Management HTS HIV Testing Services IC Index Case INLS Instituto Nacional de Luta Contra SIDA (National Institute in the Fight against AIDS) IP Implementing Partner IPTp Intermittent Preventive Treatment in pregnancy IUD Intrauterine Contraceptive Device LARC Long-acting reversible contraceptive LTFU Loss to Follow-Up

iv Angola SASH: Final Report, June 2017 LOP Life of Project MIP Malaria in Pregnancy M&E Monitoring and evaluation MoH Ministry of Health MSH Management Sciences for Health NMCP Programa Nacional de Controlo da Malária (National Malaria Control Program) NS National Secretariat PAC Post-Abortion Care PAF Patient Assistant Facilitators PASS II Professional Acquisition Support Services (PASS II) PDDS Planos Distritais de Desenvlvimento Sanitario (District Health Development Plans) PEPFAR President’s Emergency Plan for AIDS Relief PESIS Plano Estratégico do Sistema de Informação Sanitária (Health Information System Strategic Plan) PITC Provider-Initiated Testing and Counseling PLHIV People Living with HIV PMDS Plano Municipal de Desenvolvimento Sanitário (Municipal Health Development Plan) PMI President’s Malaria Initiative PMTCT Prevention of Mother-to-Child Transmission of HIV PNDS Plano Nacional de Desenvolvimento Sanitário (National Health Development Plan) PNSR/PF Programa Nacional de Saúde Reprodutiva/Planificação Familiar (National Reproductive Health/Family Planning Program) PPDS Plano Provincial de Desenvolvimento Sanitário (Provincial Health Development Plan) PPIUD Postpartum Intrauterine Contraceptive Device PPFP Postpartum Family Planning QI Quality Improvement RDT Rapid Diagnostic Test (Malaria) RMHSS Revitalization of Municipal Health Services Strategy RMS Repartição Municipal de Saúde (Municipal Health Department) SASH Strengthening Angolan Systems for Health SBM-R Standards Based Management and Recognition SOP Standard Operating Procedure

Angola SASH: Final Report, June 2017 v SOW Scope of Work TOT Training of Trainers TWG Technical Working Group UNAIDS Joint United Nations Programme on HIV/AIDS UNFPA United Nations Fund for Population Activities USAID United States Agency for International Development USG United States Government VCT Voluntary Counseling and Testing WHO World Health Organization

vi Angola SASH: Final Report, June 2017 Acknowledgements

The Fortalecimento do Sistema Angolano de Saúde (ForçaSaúde) project, or the Strengthening Angolan Systems for Health (SASH) project, has been the United States Agency for International Development’s (USAID) flagship health program in Angola. Designed to increase the availability and use of quality public health services through Technical Assistance (TA) and training at the national, sub-national and health facility (HF) levels, SASH supported programming in the areas of Family Planning (FP), Malaria, and HIV/AIDS to work towards Health Systems Strengthening (HSS). In addition, SASH strongly encouraged opportunities for integration within HSS; cross- cutting technical areas included: building managerial and technical capacities; improving service delivery, human resources, municipal decentralization, and health management information systems; and ensuring women and young girls receive equitable, ethical, effective, and efficient health interventions, as well as addressing gender-based violence.

This program and report were made possible by the generous support of the American people through USAID, under the terms of the Cooperative Agreement AID-654-A-11-00001. The contents of this report are the responsibility of the SASH project and do not necessarily reflect the views of USAID or the United States Government (USG).

The success of a large-scale project, like that of SASH, depends on the joint efforts of many people. It is impossible to thank everyone individually for his or her generous and invaluable support, however, our team would like to take a moment to express special gratitude to key collaborators whose support was instrumental to the project’s success. The SASH team would especially like to thank the Angolan Ministry of Health (MoH)— specifically the Direção Nacional de Saúde Pública (DNSP) (National Public Health Directorate), the Instituto Nacional de Luta Contra SIDA (INLS) (National Institute for the Fight Against AIDS), the Programa Nacional de Controlo da Malária (NMCP) National Malaria Control Program,and the Programa Nacional de Saúde Reprodutiva/Planificação Familiar (PNSR/PF) (National Reproductive Health/Family Planning Program). In addition, we’d like to thank all Provincial, Municipal, and District Level Health Directors, all HF Directors and Clinical Directors, all Health Service Providers and Technical Focal Points, all Patient Assistant Facilitators (PAFs), and all Community Activists and Leaders, with whom we worked in both the Luanda and Huambo provinces throughout the project’s implementation. Their mission gave shape to our mission as a project. Their collaborative spirit, and their openness to new ideas, spurred our own efforts in support of our shared goal to improve the technical quality of health services, promote the practice of respectful care for Angolan women and their families, and engage in Quality Improvement (QI) and health promotion efforts.

In particular, SASH is appreciative of support provided by: Dr. Luis Sambo, Minister of Health and his predecessor, Dr. José Días Van Dúnem; Dr. Constantina Furtado, Vice Minister of Health; Dr. Miguel de Oliveira, National Director of Public Health, and his predecessor, Dr. Adelaide de Carvalho; Dr. Lucia Furtado, Director of the INLS and her predecessor, Dr. Ducelina Serrano; Dr. Filomeno de Jesus Fortes, Director of the NMCP; Dr. Henda Vasconcelos, head of the Reproductive Health National Program; Eng. Rosario Lemos, Director of the Gabinete de Tecnologias de Informação (GTI) (Department of Information Technology) at the MoH; Dr. Hipólito Amoroso, Director of the Gabinete de Estudos, Planeamento e Estatística (GEPE) (Department of Studies, Planning and Statistics) at the MoH; Dra. Georgina Marques Panzo, Head of the Statistics Department of the MoH and her predecessor, Dr. Belarmino João; Dr. Nobre Miguel, head of Studies and Projects of the MoH; Dr. Frederico João Carlos Juliana, Provincial Health Director of Huambo; Dr. Rosa Bessa, Director of the Gabinete Provincial de Saúde de Luanda (GPSL) (Luanda Health Provincial Cabinet); and Dr. Regina António, Head of the Public Health Department in Luanda. Special thanks to Dr. Isilda Neves, former head of the Direção Nacional de Saúde Pública (DPS) (Provincial Health Directorate), Luanda province; and Dr. Vita

Angola SASH: Final Report, June 2017 vii Vemba, former Luanda Provincial Health Director who later joined the SASH team to continue working for the improvement of health in both Luanda and Huambo. Without them, the project’s results could not have been achieved.

These same results were made possible through the leadership, participation, coordination and collaboration of numerous international and local development partners, including: Management Sciences for Health (MSH), Linkages, UNICEF, United Nations Fund for Population Activities (UNFPA), World Health Organization (WHO), EU Professional Acquisition Support Services (PASS II), Centers for Disease Control and Prevention (CDC) implementing mechanisms , Africare, The World Bank, the Rede Angolana das Sociedades de Serviços de Sida (ANASO) (Angolan Network of AIDS Service Societies), members of the Associação Angolana de Luta contra SIDA (AALSIDA) (Angolan Association for the Fight Against AIDS), Associação dos Amigos Seropositivos (AAS) (Association of Seropostive Friends), Luta Pela Vida (LPV) (Fight for Life), Ajuda de Desenvolvimento de Povo para Povo (ADPP) (Development Aid from People to People), and the Malaria National and Huambo Provincial Forums (World Learning, Abt, Exxon, Chevron, Mentor). The collective wisdom of the staff from each of these partners, and the lessons learned from one another, contributed significantly to the success of the field-supported phase of the SASH project.

Last, but not least, we would also like to thank US Ambassador, Helen Meagher La Lime (appointed May 2014), for her leadership and support to the SASH project, and her role in promoting closer relationships with government counterparts and the private sector. In addition, we’d like to thank the USAID Directors and Acting Directors who supported the team throughout the SASH project’s implementation, as well as our Agreement Officer Representatives for their daily support and advice.

viii Angola SASH: Final Report, June 2017 Executive Summary

The United States Agency for International Development (USAID) Fortalecimento do Sistema Angolano de Saúde (ForçaSaúde), or Strengthening Angolan Systems for Health (SASH), was envisioned as a 5-year multi-faceted health project designed to support the Government of Angola (GoA) to increase the availability and use of high-quality HIV, Family Planning (FP), and Malaria services in the provinces of Luanda and Huambo.

From 2011 to 2017, Jhpiego, an international non-governmental organization affiliated with the Johns Hopkins University, in collaboration with Management Sciences for Health (MSH), led the SASH project. The project supported the Angolan Ministry of Health (MoH) and the provincial governments of Luanda and Huambo to strengthen the Angolan health system, working to improve the well-being of the Angolan population. During the life of the project (LOP), SASH focused on strengthening the National Health Information System (HIS), providing support to the Municipal Decentralization Process—building district and provincial capacity to develop their own five-year and annual plans and budgets, and supporting the expansion of the public sector’s HIV, FP, and Malaria services.

Due to the evolutionary nature of SASH’s Scope of Work (SOW), the project can be divided into two distinct phases, as described here and in additional detail per the Background and Approach section of this report.

Phase 1: October 2011–June 2015 SASH’s Phase 1 corresponds roughly to the first three and a half years of project implementation, in which SASH’s SOW responded directly to the original project objectives as outlined and agreed upon by USAID and Jhpiego in award documentation at the time of project inception (2011). The only exception was a revision to the malaria component in project year three (PY3), at which time the USAID/President’s Malaria Initiative (PMI) decided to focus SASH’s geographic malaria scope to solely Luanda. All other technical components continued to be implemented in both Luanda and Huambo provinces.

Phase 2: July 2015–March 2017 SASH’s Phase 2 corresponds to the final quarter of project year four (PY4), as well as project years five and six (PY5 and PY6), during which time SASH’s work plans and activities were revised to meet a new mandate established by USAID and the President’s Emergency Plan for AIDS Relief (PEPFAR). The new mandate indicated that SASH’s HIV component should undergo major shifts: i.) Geographic Focus—ending all HIV activities in Huambo and concentrating efforts in Luanda; ii.) A Reduction in the Number of Targeted HFs to only 9 Luanda facilities, and iii.) A shift in HIV strategy—moving away from Prevention of Mother- To-Child Transmission of HIV (PMTCT) to focus on the development of an integrated care and treatment model for People Living with HIV (PLHIV) designed for scale-up at the national level. All other project components continued activity implementation in accordance with the approved annual work plans. The HIV component during the extension on Y6 became the primary focus.

A summary of SASH’s major accomplishments are detailed below:

Angola SASH: Final Report, June 2017 ix Major Accomplishments

SASH supported the GoA to institutionalize new and updated national health policies, protocols, manuals, tools, and job aids in the areas of HIS, Municipal Planning, HIV, FP, and Malaria1.

 HIS: 1 District Health Information Software Two (DHIS2) user manual and 1 correlating technical manual

 HIV: 4 QI standards, 3 protocols, 5 manuals and 11 training modules

 FP: 7 sets of QI standards

 Malaria: 1 national policy, 1 manual, and 3 sets of QI standards

SASH improved the quality, collection, and use of HIS data to inform decision-making at all levels (Central to Facility).

Central Level Achievements:

 Established a centralized web-based database using a DHIS2 platform for the Angolan MoH. DHIS2 system is now operational and ready for national level scale-up.

 Worked collaboratively with the World Bank and the Cuban Cooperation to complete a review of all 409 health indicators monitored by the MoH and Gabinete de Estudos, Planeamento e Estatística (GEPE) (Department of Studies, Planning and Statistics) the list to 125 indicators.

Municipal, District, and HF Level Achievements:

 In Huambo, empowered 52 HFs and the Direção Provincial de Saúde (DPS) (Provincial Health Directorate) to utilize the SASH-tailored Excel Tool to produce digital monthly statistical reports, resulting in the reduction of mathematical and reporting errors, and improving data quality.

 In Luanda, reduced the percentage of errors in HIV registry reporting from 9.05% to 1.58% at the 9 targeted HFs implementing HIV interventions in PY5 and PY6.

 A cadre of FP municipal/district focal points improved the timely submission of monthly reports, increasing report compliance from 40% to 92%.

SASH spearheaded capacity-building efforts to empower municipal, district and HF managers to use data to develop municipal health plans and budgets.

 In Huambo, supported the completion of a 5-year Provincial Health Plan, as well as 11 Municipal Health Plans, receiving MoH review and approval. Nationally, Huambo was the first province to develop health plans for all of its municipalities.

 In Huambo, supported the development of 8 municipal Annual Operational Plans (AOPs) and budgets.

 In Luanda, supported the completion of 2 Municipal level (1) and District level (1) AOPs.

 Worked closely with the MoH and other partners to develop a national-level monitoring tool for AOPs and corresponding municipal budgets.

1 See Annex 1 for Detailed Index of National Level Policies supported by SASH x Angola SASH: Final Report, June 2017

SASH established an effective standardized QI approach for HIV, FP, and Malaria services based on national protocols, norms and international guidelines.

 Developed 15 QI standards and tools for HIV, FP and Malaria services in collaboration with national counterparts, using the Jhpiego designed Standards-Based Management and Recognition (SBM-R) approach, receiving MoH approval for the use of these QI tools at SASH-supported facilities.

 Provided technical support to HF’s municipal and district level supervisors, to conduct baseline assessments and at least one follow-up assessment in 50 FP services, 85 Malaria services, and 9 HIV Testing Services (HTS). Of these facilities, 98% demonstrated improved compliance to standards in FP services, 93% in Malaria services and 89% in HIV services.

SASH expanded access to and utilization of HIV and FP services in both Luanda and Huambo Provinces.

Established New Services:

 HIV:  Established 117 new PMTCT services (Luanda 49 HF , Huambo 68) out of 158 supported;  Established 177 new Provider-Initiated Testing and Counseling (PITC) services (Luanda 49 HF, Huambo 128 HF) out of 207 supported;  Established 117 new Adult services (Luanda 49 HF, Huambo 68);  Established 13 new Pediatric services in Huambo;

 FP:

 Created 149 new FP services (80 in Luanda, 69 in Huambo);

 Created 40 Postpartum Family Planning (PPFP) services (32 in Luanda and 8 in Huambo); Outcome:

 During the LOP, 314,524 pregnant women were tested for HIV and knew their status, (of 6,686 who were HIV-positive, or equivalent of 2.1%) and 632,184 individuals were tested for HIV in Luanda and Huambo (of whom 36,645 were HIV+, or equivalent of 5.8%);

 In Luanda, 4,321 women received Postpartum Intrauterine Devices (PPIUDs) at 32 maternity wards from October 2015 to September 2016;

 In Luanda, there was a 167% increase in new FP users over the LOP;

SASH improved the capacity of health providers to offer high-quality HIV, FP, and Malaria Services through In-Service and On-the-Job trainings and continual mentorship.

 HIV:  201 Trainers trained in Prevention of Mother to Child Transmission (PMTCT) & Adult ART, resulting in a 79% increase in the number of HIV+ positive pregnant women diagnosed (2,304 tested in 2012 to 4,128 tested in 2015). In addition, the number of pregnant women living with HIV who received ARVs to prevent transmission of HIV to their babies doubled from 1,152 to 2,687 from 2012 to 2015.

Angola SASH: Final Report, June 2017 xi  2,244 health professionals trained in HIV services (481 trained in HTC, 1,300 trained in PMTCT, and 463 trained on ART). Of those, 1,731 were nurses trained to provide and manage ART patients. Of the 463 trained in ART, 121 physicians, nurses and PAFs were trained in adherence counseling.

 FP:  Trained 366 trainers on FP methods  Trained 784 health professionals in FP, including:  Trained 291 health professionals in Long-Acting Reversible Contraceptive methods (LARCs), (e.g.—implants and intrauterine contraceptive devices [IUDs]).  Trained 198 health professionals in non-LARC Contraceptive methods.  Trained 295 delivery room midwives in PPIUD.  426 health professionals received in-service trainings contributing to improved skillsets in Balanced Counseling Approaches, Infection Prevention and Control, Post- Abortion Care (PAC), LARCs, and PPFP methods.

 Malaria:  931 health service providers were trained in i.) Malaria Case Management with the use of artemisinin-based combination therapy (ACTs), ii.) Malaria Laboratory Diagnostics (RDTs or microscopy) and iii.) Intermittent Preventive Treatment in Pregnancy (IPTp), in Luanda and Huambo throughout the LOP  604 health service providers received on-the-job trainings contributing to strengthened skillsets in malaria case management and diagnosis

The main objective of this report is to document and share SASH’s programmatic approach, accomplishments, and lessons learned during the past five years, while also providing recommendations for future implementation.

xii Angola SASH: Final Report, June 2017 Background and Approach

At the time of the SASH project’s inception, following decades of civil war, Angola had begun the process of leveraging its rapid economic growth to put the country on the path to prosperity, productivity, and improved health. The MoH, through its malaria and reproductive health programs, and in collaboration with the INLS, made significant progress addressing Angola’s most pressing health concerns. For example, the under-five mortality rate dropped from 118 per 1,000 live births in the period 2001-2006 to 91 per 1,000 live births in the period 2006-2011. Parasitemia among children under-five declined from 21% nationally in 2006 to 14% in 2011 (from 26% to 15% in both Huambo and Luanda provinces), and the HIV mother-to-child transmission rate reduced from 37.5% in 2012 to 25.2% in 2014. 1

Despite these achievements, Angola still faced Angola’s Health Context tremendous health challenges (see Angola’s HIV Health Context2). The GoA struggled to • HIV prevalence (adults aged 15–49): 2.41%* achieve increased ART coverage, facing low • Number of PLHIV: 285,368 uptake of HTS, poor linkages to and retention • ART coverage, adults (age 15–49): 29%, 75,775 in care, and inadequate M&E systems. As of adults 2011, 46% of women whose last pregnancy was • ART coverage, children (0–14): 24%, 6,032 children unwanted did not use any form of • HIV deaths: 9,228 (adults and children) contraceptive; 57% of women who did not plan • Mother to Child Transmission rate: 25% their pregnancy also indicated they did not use any form of contraceptive, demonstrating a Malaria need for an effective FP strategy. Additionally, • Malaria cases: 3,254,270 (confirmed and in 2011, there was only 18% coverage of IPTp2 suspected) for women who gave birth two years prior. • Malaria deaths: 10,851 (January–July 2016) While this did present an increase in IPTp2 from 2% in 2006–2007, a significant gap in FP 1 coverage remained, especially in rural areas. • Infant mortality: 96 per 1,000 live births • Child mortality: 157 per 1,000 deaths The GoA recognizing the need for continued • Maternal mortality rate: 477 women deaths per 100,000 health progress, committed to the rapid live births reduction of maternal and infant mortality, • Total fertility rate: 6.1 children per woman implementing initiatives to tackle these issues • Modern contraceptive prevalence rate: 12.6% 1 head-on. The Municipalização Policy Sources (Municipal Decentralization Policy) which decentralized government services, including management of health services, to the municipal level, and the MoH created the Revitalization of Municipal Health Services Strategy (RMHSS) as a “road map” toward reducing maternal and infant mortality. This strategy was designed to help municipal administrators ensure that the Essential Package of Health Services (EPHS) was, and is, offered in every HF around the country. With this Municipal Decentralization Policy in place, the GoA and the MoH began to decentralize health services, including the allocation of local budgets and management of health services at the municipal level.

The SASH project was created by USAID/Angola to support the MoH’s decentralization process, with the specific goal of increasing the use and availability of high-quality FP, HIV, and Malaria services in the provinces of Luanda and Huambo. SASH’s results framework illustrated the

2 Sources: Angola Malaria Indicator Survey 2011; Inquérito Integrado sobre o Bem-Estar da População (Integrated Survey on Welfare of the Population), 2011; National Institute for the Fight against AIDS (INLS) National Report 2015; Joint United Nations Programme on HIV/AIDS [UNAIDS] SPECTRUM 2015; National HIV and AIDS Strategic Plan, 2015–2018; National HIV and AIDS Strategic Plan, 2015–2018; UNAIDS SPECTRUM 2015; UNAIDS Global Report 2015, National Malaria Control Program [NMCP], 2015); NMCP, 2016; World Bank, 2015; and the UN Population Division, 2015.

Angola SASH: Final Report, June 2017 1 project’s focus on two intermediate results: (1) improved management of the health system through implementation of the RMHSS, and (2) the implementation of a routine QI approach. Together, these would support reaching more Angolans with high impact FP, HIV and Malaria interventions. This results framework remained in effect for the first 3 years of project implementation.

In 2014, with USAID’s shift toward an increased emphasis on HIV treatment in alignment with the Joint United Nations Programme on HIV/AIDS (UNAIDS) 90-90-90 goals3, it was necessary for SASH to pivot interventions to focus on HIV care and treatment services. The timeline below Figure 1 depicts the various revisions to SASH’s SOW from 2011–2017.

Key Changes in SASH’s SOW

 In PY2, USAID requested that SASH’s Malaria activities in Huambo end, shifting geographic focus to Luanda only.

 In PY2 and PY3, USAID requested that SASH’s FP activities concentrate primarily on LARC training. As such, SASH reintroduced the use of implants and IUDs at the facility level, and introduced the use of PPIUDs to Angola.

 In PY4, USAID requested that SASH’s HIV activities shift from the expansion of HIV services (HTC and PMTCT) and task shifting, to the creation and implementation of a new HIV Continuum of Care Model (CCM), including HIV Care and Treatment through direct support for site-level service delivery. SASH supported HIV activities promoting the new CCM model in 9 HFs in Luanda. These changes influenced the SASH project’s implementation strategy, shifting away from the prioritized goal of “graduating” 14 municipalities, to a focus on: the creation of an HIV-centered approach; the expansion of FP services; and the improvement of malaria case management; Angolan HISs; and the municipal planning and budgeting processes.

 In PY4, SASH’s HIS strategy also shifted to adapt to USAID’s revised HIV mandate. HIS focus during PY4-PY5 placed emphasis on the improvement of HIV statistical registries in the 9 targeted HFs.

 In PY5, on June 30, 2016, all implementation in Huambo province ended.

 In PY6, on February 28, 2017 all SASH technical interventions terminated, allowing for project closure and operational shutdown throughout March 2017.

3 The 90-90-90 are: By 2020, 90% of all PLHIV will know their status; 90% of all people with diagnosed HIV infection will receive sustained ART; and 90% of all people receiving ART will have viral suppression.

2 Angola SASH: Final Report, June 2017 Figure 1. Timeline of Major Revisions to SASH’s SOW 2011–2017

3 Angola SASH: Final Report, June 2017 Geographic Focus

During Phase 1, SASH worked in Luanda and Huambo provinces, covering all 7 municipalities and 5 districts in Luanda and all 11 municipalities in Huambo. Starting in PY3, SASH stopped supporting malaria interventions in Huambo province at the request of USAID/PMI. During Phase 2, SASH continued to support interventions in both provinces in all technical areas except for malaria. However, beginning in PY4, SASH limited the project’s HIV interventions to nine HFs in Luanda province, as listed in Table 1. Figure 2. Map of Angola* Table 1. HFs Supported by SASH in Luanda Province, Oct 2015-Feb 2017 Health Facility Municipality/District Cajueiros Municipal Cazenga Hospital Kilamba Kiaxi Municipal Kilamba Kiaxi Hospital Divina Providencia Kilamba Kiaxi Hospital Sanatorio Hospital Kilamba Kiaxi Pediatric Hospital Dr. Maianga David Bernardino TB Dispensario Maianga Esperança Hospital Rangel Rangel Health Center Rangel Ana Paula (Viana 1) Viana Health Center

In addition to supporting facility, district and provincial level activities, SASH also provided TA to the central level, working closely with counterparts in GEPE, the national programs for FP and Malaria, and INLS to develop policies, protocols, training materials and job aids that aim to strengthen the delivery of HIV, FP and Malaria services throughout the country.

Guiding Principles SASH applied the following guiding principles to all interventions throughout the duration of the project:

 Aligned all program interventions (including alignment with the MoH’s National Strategic Plans4) to ensure that lives were saved through an increase in quality health care services.

 Endorsed a “No Missed Opportunities” for the delivery of health services.

 Encouraged an “Enabling by Mentoring” approach, rather than a “doing” approach.

 Promoted Sustainability through supporting capacity-building activities.

 Maintained an active Environmental Mitigation and Monitoring plan.

4 MoH’s National Health Development Plan (PNDS) 2013–2025; HIS Strategic Plan 2011–2015; National HIV and AIDS Strategic Plan 2015-2019; Strategic Plan for Controlling Malaria, 2012-2015; and The Municipal Health Development Plans (PMDS). *Malaria Indicator Survey (MIS) 2011

4 Angola SASH: Final Report, June 2017 Description of Results

Health Information Systems Results Summary

• Facility Level: SASH, in coordination with GEPE, GTI, and the Huambo DPS and RMS, developed an Excel tool to produce monthly statistical reports. SASH provided training and supervision on the tool in 52 Huambo HFs, to promote the collection and production of quality information.

• Central Level: GEPE entrusted SASH with the responsibility to lead the structuring of an Angolan HIS platform using DHIS2. In structuring the platform, the Malaria, HIV/AIDS, Reproductive Health, and Epidemiological Surveillance Programs were included in order to optimize the reception and use of the platform and its information for decision-making.

• Municipal Level: With support and TA from SASH, a team composed of GEPE, GTI, INLS and DNSP technicians led the implementation of a pilot DHIS2 experience in three municipalities of Huambo. The MoH decided to expand DHIS2 to the national level based on the pilot experience. Other partners, such as UNAIDS, Global Fund and EU Pass II have already designated funds to support the expansion and scale-up of the system, beginning February 2017.

• PEPFAR-supported HFs: SASH provided TA to HIV testing providers to improve the HIV testing registries, achieving a significant reduction in errors (9.05% to 1.58%).

SASH supported HIS activities at the Central level—where all requirements for national, regional, and municipal HIS standards, procedures, and instruments are defined— helping to disseminate updated HIS information to the lower level institutions (municipal directorates, HFs). SASH also provided support to HIS on-site activities at the HF level—where all services are provided and routine health information is generated. SASH provided direct TAto GEPE in the implementation of the Plano Estratégico do Sistema de Informação Sanitária (PESIS), HIS Strategic Plan main objectives:

Improved HIS Coordination Throughout the duration of the project, SASH supported coordination meetings between GEPE, the MoH national programs, and interested partners. As a result of these meetings, partners formed a Technical Working Group (TWG) to jointly support PESIS implementation. One of the initiatives supported by the TWG included the pilot DHIS2 system.

Established a basic list of essential indicators SASH collaborated with the MoH, GEPE, World Bank, and Cuban Cooperation to review and synthesize a list of more than 400 HIS indicators. By December 2013, the list was narrowed to 125 defined national-level HIS indicators.

Promoted information-based decision-making by broadening the coding and standardization of data and technical terms In PY2 and PY3, SASH supported the MoH with training Angolan statisticians in the WHO’s 10th revision of International Classification of Diseases (ICD-10). SASH, MoH, with financial

Angola SASH: Final Report, June 2017 5 support from MEASURE, organized two training courses on ICD-10 coding, reaching over 91 participants from various national level institutions (i.e.—MoH, GEPE, Armed Forces, Ministry of Justice, Ministry of Territorial Administration, Faculties of Medicine and Nursing, DPSs of Luanda, Huambo, Bie, Benguela and Huila).

Established a standardized and routine HIS information system In response to gaps identified in the Angolan HIS system, SASH collaborated with GEPE to design an Electronic Excel Tool to input data from registry books and generate monthly statistical reports.

Figure 3. Example of the Electronic Tool’s Logbooks

This tool uses criteria and validation lists to guarantee the use of standardized data and formulas to perform counts and sums automatically, without the need for the statistician to perform calculations. The tool’s logbooks use the same structure as printed registry books, and the statistical reports are identical to those requested by the national programs (See Figure 3 above). It includes seven types of registry books and thirteen types of monthly statistical reports. The tool is configurable per data lists used (e.g., codes of registration books, list of health personnel, list of services and rooms, neighborhoods of origin).

The tool records the historical data of the HF in an electronic format to maintain quality control; to work optimally, data must be entered exactly as it is written in the registry books. The tool also allows for the reproduction of additional utility reports per facility, such as productivity reports (number of services provided by each employee per month), geography of demand (using patients’ neighborhood data to inform) amidst others. Another benefit of the tool is that it empowers the statistician to review all data registered by health personnel. As a result, overall data quality is improved. In Huambo province, 11 municipalities and 52 HFs were trained on the electronic tool and continue to use it to improve timeliness of reporting, data quality, and use of data for decision-making.

Established a system that integrates various HIS databases In July 2016, SASH responded to a request from GEPE and the MoH to support the identification and set-up of a standardized HIS database using DHIS2. SASH paved the way for the introduction, use, and scale-up of the DHIS2 platform (currently referred to as SIS-Angola, https://sisangola.org).

From July-December 2016, SASH provided TA through an expert consultant to develop and implement SIS-Angola in three municipalities with collaboration from GTI; the MoH’s Malaria, HIV/AIDS, Reproductive Health, and Epidemiological Surveillance programs; and the Huambo DPS. During the first phase of SIS-Angola’s rollout, the aforementioned national programs were tasked with developing data entry forms to correspond to the national programs’ monthly statistical reports (see Figures 4 and 5).

6 Angola SASH: Final Report, June 2017 Figure 4. Example of SIS-Angola Epidemiological Surveillance Data Input Form

Figure 5. Example of SIS-Angola Generated Statistical Reports

From there, a central-level technical team comprised of national program technicians was formed and led by GEPE-GTI. This team provided a source of sustainability for SIS-Angola. In the second stage of pilot implementation, SASH coordinated with PMI and the Provincial Health Director of Huambo to select three municipalities (Londuimbali, Bailundo and Mungo) where the system would be tested. Trainings were conducted for health care providers (specifically, a statistician and a municipal focal point) on data entry and analysis for each municipality in the DHIS2 system. Procedures for supervision and quality control were also defined and carried out by the central MoH team. Another key component of the pilot test was incorporating all statistical reports from 2015 and 2016 into SIS-Angola. Upon SASH closeout, the MoH was left well- equipped for future HIS expansion and advancement, utilizing SIS-Angola.

Improved the quality of HIV data In October 2015, USAID’s focus shifted to the prioritization of HIV record keeping. As such, SASH concentrated on QI of HIV services and records in HFs supported by PEPFAR, prioritizing HIV Testing and Counseling (HTC) services in nine HFs.

Angola SASH: Final Report, June 2017 7 To support this effort, SASH recognized the need for collaboration between PEPFAR partners. SASH identified incorrect data input within HIV registry books, especially related to HTC and clinical records. The most common errors included missing data (e.g., incomplete records, missing indictors such as age, sex, and test results). It is important to note that registry entries with errors or insufficient information could not be included in the PEPFAR DATIM report, therefore, these data were lost, or inconsistent with INLS data from these same facilities. To address this problem, SASH used the electronic tool (described above) to support the HTC registry book and data input. Therefore, the disaggregated HIV data were entered into the tool, to produce high quality reports and accurate DATIM indicator calculations. SASH supported providers in the targeted HFs to routinely review all HTC data entries in the HIV registries. As a result, errors in the data decreased by 7.5% from October 2015 to February 2017 (see Figure 6 below).

Figure 6. Registries with Errors at the Nine Targeted HFs Oct 2015–Feb 2017

Note: The graph does not include registries from Divina Providencia Hospital for Y5Q1 to Y5Q3 and from Pediatric Hospital for Y5Q1 and Y5Q2.

Improved Data Analysis to inform the improvement of HIV services Improved data input into HIV registries and disaggregation of indicators by HF allowed for the quick production of statistical reports in the form of tables, charts, and graphs. This easy data visualization technique allowed for health providers to quickly identify service gaps and facilitate informed decision-making based on real-time results, ultimately improving services. Figure 7 is an example of a chart developed with the information gathered by SASH through electronic tools. This chart demonstrates the number of new HIV cases diagnosed in Hotel Esperança during the second quarter of 2016. The chart has disaggregated patient results by CD4 count and correlating WHO stage (two of the criteria used to determine if a patient should begin ART treatment or not), and ART enrollment status according to the current national protocol. This chart allows a supervisor to identify gaps in patient treatment and work together with service providers to improve these gaps. These types of graphics were produced for all HFs and were shared at quarterly meetings with both HIV service providers and HF Directors. This type of access to quality information encouraged the improvement of services and data reporting.

8 Angola SASH: Final Report, June 2017 Figure 7. Example of a Chart produced by SASH E -tool

Angola SASH: Final Report, June 2017 9 Municipal Planning

Results Summary

• Supported the Huambo DPS to elaborate 11 Municipal Plans (PMDSs) for the period of 2013 – 2017, which were approved by the MoH.

• Supported the Huambo DPS to elaborate their Plano Provincial de Desenvolvimento Sanitário (PPDS) (Provincial Health Development Plan) for the period of 2013 – 2017, which was approved by the MoH.

• Supported the Luanda DPS to create 6 Planos Municipais de Desenvolvimento Sanitário (PMDSs), (Municipal Health Development Plans) and 5 Planos Distritais de Desenvolvimento Sanitário (PDDs) (District Health Development Plans) for the period of 2013 – 2017.

• Collaborated with Huambo Municipal Teams to complete 8 Municipal Annual Operational Plans (AOPs) and corresponding Budgets, presenting them to their respective Municipal Authorities.

• Supported the monitoring of Annual Municipal Budget Plans in 4 municipalities of Huambo Province using the Ferramenta de Planificação e Orcamentação Municipal (FPOM), or Municipal Planning and Budgeting Tool. In Luanda, 2 municipalities teamed up with SASH and GEPE to use the FPOM tool for planning and budgeting purposes.

• Implemented strategies to improve Human Resource (HR) capacities, focusing on the enhancement of management skills for staff in 46 HFs in Luanda Province, with special emphasis on the 9 HFs targeted by SASH HIV interventions. These HR interventions included: rapid needs assessments, the development of action plans to improve gaps in HR capacities, the elaboration of job descriptions, the organization of personnel files, the development of continuing education plans, and the provision of staff training/orientation sessions regarding the stigma and discrimination encountered by PLHIV.

Throughout the LOP, SASH adapted its HSS strategy to respond to the demands of the Angolan context as well as to USAID’s priorities. Although the MoH considered the municipal decentralization process a key strategy, not all municipalities were aware of its importance nor the amount of work it demanded. Therefore, before implementation, SASH requested support from MoH authorities to promote and advocate for the municipal/provincial level health planning processes. This advocacy ensured that all staff would actively participate and remain engaged in all facets of the planning processes from inception to completion. HSS activities focused on encouraging municipal ownership of plans, and incorporated involvement at all levels (national, provincial and municipal). HSS key activities included: advocacy of the systematic planning and budgeting processes; trainings on the use of all planning tools; dissemination of SASH mapping results; and compilation and organization of health data from each municipality/district to inform their respective epidemiological profiles, health priorities, and proposed interventions including a review of basic service costs for each plan.

Prior to SASH’s interventions, Angolan municipalities prepared their budgets without conferring with their technical and clinical teams, which led to the allocation of funds to non-priority health issues. Under SASH’s leadership, the municipal planning process became an inclusive and

10 Angola SASH: Final Report, June 2017 multisector process—including participation from other sectors (e.g., Education, Agriculture, Youth and Sports, and Religious organizations, etc.) as well as involvement from key municipal, technical, administrative, and finance staff. Through this collective approach, SASH encouraged the streamlining of priorities, allowing for collaboration across sectors, shared/saved funding, and ensured efficacy in planning and implementation.

Conducted a Comprehensive Readiness Assessment and Mapping Study of HIV, Malaria and FP services at the Targeted HFs SASH collected information from 342 HFs in the provinces of Luanda (140 of 154) and Huambo (202 of 221) as the first step in the municipal planning and budgeting process. SASH also provided TA to recover and consolidate health data from the past 5 years in each municipality, as data were not easily available, or were stored in various places.

Supported development of the MoH’s Municipal Health Planning and Monitoring Guidelines and Implementation in select municipalities In 2010, before SASH’s inception, the GoA’s budgetary process consisted of assigning a gross amount of approximately 2 million USD (at the time) per municipality to each provincial government. This allocation of funding for health was a great first step in prioritizing health interventions; however, without the appropriate planning processes in place, municipalities were spending the funds without prioritizing interventions. As such, SASH first collaborated with the MoH to develop a set of guidelines for municipal health planning and budgeting processes, which were included in their Plano Nacional de Desenvolvimento Sanitário (PNDS) (National Health Development Plan). After the PNDS and the corresponding MoH Planning tool kit was released, SASH helped each targeted municipality to implement these tools per the detailed explanation below:

Pre-PNDS stage: One of the first steps in establishing a standardized health planning process includes a review of existing resources. In previous years, the MoH had developed several policies and tools to support health planning processes; however, the tools were complex and directed at the provincial level versus the municipal level. At the time of SASH implementation, the MoH did not have a PNDS or a tool kit developed. Therefore, SASH began a process to develop a set of guidelines, and correlating methodology to support the planning and creation of Municipal Health Plans.

Guidelines for Drafting Municipal Health Plans

 Elaborate a mapping and readiness tool to carry out an assessment to determine if operating facilities have the necessary staff, medications, equipment, and transportation to “get the job done.”

 Determine each Repartição Municipal de Saúde (RMS’s) Municipal Health Department’s,) geographic catchment area and population

 Apply a methodology and tool to identify essential functions of the RMSs

 Organize existing public health and clinical service data, and analyze service coverage data

 Organize HF profiles and human resource data

This methodology was implemented in all municipalities of Luanda and Huambo prior to the introduction of the MoH official toolkit (see below), with all health data/information being compiled to later serve as the baseline for elaborating the Municipal Plans.

Post-PNDS Stage:

Angola SASH: Final Report, June 2017 11 In 2013, at the MoH’s annual meeting, the MoH announced the finalization and approval of their official municipal planning tool kit. Guidance provided by the MoH also indicated that all provincial and municipal health targets should align and contribute to the overarching goals outlined in the MoH PNDS. To meet this goal of aligned approaches, SASH adopted the MoH tool kit to elaborate the PMDS.

Prompted by the MoH’s release of this tool kit, Huambo’s Provincial Director requested SASH’s TA to complete the municipal planning process with all 11 provincial municipalities. Each municipality used Photo: Technical staff from Ucuma Municipality review their municipality’s health data to prioritize the tool kit to update their municipal profiles, health interventions for the coming years. including revised data on: municipal population estimates, purview of each health facility, services offered by the EPHS/per facility, critical equipment needs, Human Resources (HR) /staffing numbers, and identification of health indicators (prioritizing the 20 most critical health problems affecting their municipality).

Supported the completion of PMDSs in Huambo and Luanda Provinces Huambo: To support Huambo’s efforts to complete the municipal planning process, SASH collaborated with the Director of “The PPDS and the PMDS are the DPS and each municipality to draft the plans. After now the "Bible" for health several months of intense work, SASH also helped conduct planning and development in a workshop for all municipal planning teams. The Huambo Province, thanks to our workshop was attended by 263 participants, including partners SASH and USAID.” members of community and civil society groups, traditional leaders and authorities, and related sectors (e.g.— – Dr. Frederico João Carlos Agriculture, Education, Youth, Sports NGOs, Religious Juliana, organizations), Huambo’s DPS, and Provincial Health Director the PNDS Secretariat. In preparation for the workshop, Huambo SASH coordinated with the DPS Director to identify strategic goals, interventions, and indicators needed to support the completion of the PMDSs. Huambo’s 11 municipalities successfully submitted their PMDSs to the MoH. This was the first time in Angola’s history that a province had all of its municipalities submit their plans. As a side effort, SASH supported the Huambo DPS in the creation of digital maps which highlighted topographical and geographical data, and demarcated key institutions including school and HF locations. These maps allowed Huambo province to better visualize and serve their communities.

Photo: Participants of the Municipal Planning Workshop on PMDS, June 2014, Huambo Province.

12 Angola SASH: Final Report, June 2017 Luanda: In Luanda province, SASH followed the same implementation strategy to complete the development of PMDS plans, assisting 6 municipalities—Cacuaco, Viana, Belas, Icolo & Bengo, Quiçama and Cazenga in the completion of their PMDSs.

Supported the Development of Huambo’s Plano Provincial de Desenvolvimento Sanitário (Provincial Health Development Plan) (PPDS) After SASH’s successful support of the PMDS development in Huambo’s municipalities, the MoH’s National Secretariat asked for TA in the development of Huambo province’s PPDS. The same process was followed for the PPDS development—a workshop was held where attendees included the MoH National Secretariat, the Huambo PDS and 87 other participants comprised of municipal and local authorities in the health, government, and related sectors—resulting in successful development of the PPDS. At the closing ceremony of the planning workshop, the Vice Governor of Huambo recognized and thanked SASH for their critical role and support throughout this process.

Photo: Provincial Health Development Plan (PPDS) Workshop, September 2015 Huambo Province. Presided by Vice Governor of Huambo, Dr. Guilherme Tuluca; Huambo Provincial Health Director, Dr. Frederico Carlos Juliana; and the head of the National Secretariat, Dr. Tânia Lourenço.

Led the Development of Municipal AOPs and Budgets The second step in support of systematized Municipal Health Planning in Angola, was the development of Municipal Annual Operating Plans (AOPs) and corresponding budgets to ensure efficient implementation of health interventions throughout the year. In Huambo, SASH supported eight municipalities—Cachiungo, Chicala-Cholohanga, Chinjenje, Ecunha, Londuimbali, Longonjo, Mungo and Ucuma—to draft their AOPs. After presentation of the PMDS to the Municipal Authorities, municipal administrators (as the budget holders) provided feedback and provision of funds to each municipality. In Luanda, SASH supported two municipalities— Viana and Kilamba Kiaxi—to develop their AOPs.

AOP Budgeting Obtaining health commodities in Angola is difficult. Prices of materials and supplies nationally are often significantly more expensive than if purchased internationally. In addition, the supply chain management nationally needs to be restructured and become more efficient. As a result, municipalities often used their annual funding to independently purchase needed supplies, instead of for actual health interventions. Before SASH’s interventions, health care service costs had never been calculated.

Angola SASH: Final Report, June 2017 13 To improve the situation, SASH, with TA from MSH, developed a Health Services Costing Model. The Model was based on a costing analysis completed for services provided under the EPHS at the HF level. In addition, to improve efficacy of the budgeting processes, the MoH collaborated with GEPE, and Implementing Partners (IPs), to develop a single standardized Municipal Planning and Budgeting Tool or Ferramenta de Planificação e Orcamentação Municipal (FPOM). The SASH team helped implement the use of this tool in 8 Huambo municipalities and two Luanda municipalities. (See Annex 2. Completed Budget Sample Cover Page).

The FPOM tool allowed teams to: “Prior to being trained by SASH,  Identify goals, results, activities and indicators linked to we didn’t have a tool that municipal health programs and their PMDS projects, allowed us to optimize our prioritizing health programs and diseases to monitor: financial resources in health. malaria, HIV and AIDS, TB, diarrheal and respiratory Now, the PMDS will be our guide diseases among others; and for the future, allowing us to negotiate our budgets and  Assess the level of achieved progress, results, possible prioritize activities.” delays and gaps between planned and achieved results. SASH also trained municipal teams to monitor –Mr. Jose Muetunda, Head of their AOPs and budgets, through simulated the RMS of Londuimbali expenditure analysis exercises.

The development of AOPs succeeded in allowing municipal teams to:

 Strengthen the management capacity of the municipal teams;

 Negotiate with the provincial and national government (re: budget and needs);

 Budget estimates based on real needs;

 Identify needs to improve technical capabilities of municipal health staff;

 Identify needs to create a provincial technical team to support municipal teams to manage their plans and budgets;

 Adjust plans and budgets according to availability of funds;

 Give visibility of municipal contributions to the Provincial and National Health Development Plans as part of a national effort to improve the delivery of health services.

Strengthened Municipal Team’s Human Resources Management (HRM) Skills in Luanda during PY5 To assess the HRM systems and practices in place within Luanda province, an HRM Rapid Assessment Workshop was carried out in January 2016, including participation from 9 HF facility teams representing the 9 HFs where SASH was implementing the HIV Continuum of Care Service model. During the workshop, each HR team completed an HRM assessment using MSH’s “Human Resource Management Rapid Assessment Tool for Health Organizations” to identify the strengths and weaknesses of their HRM system. Key findings of these assessments included:

 Existing HR staff have limited technical skills and experience in HRM;

 Limited, or non-existent budget dedicated to HRM activities (e.g.— staff trainings, or operational activities);

 HR policies and procedures are not consolidated into a HR manual and are not accessible to staff;

 There are No orientation session or materials for new staff;

 HIV/ AIDS program is not fully implemented or understood by all staff in the HF;

14 Angola SASH: Final Report, June 2017  HRIS is not fully functional, huge data backlog and a critical shortage of computers;

 Three are no staff dedicated to the HRM role;

 Supervision is usually ad hoc;

As a result of this HRM assessment, SASH followed up by organizing Continuing Education Plan workshops, which would allow for the development of action plans to address these identified HRM gaps.

Photo: Participants at the HRH Workshop January 2016 in Luanda Province. The workshop included the completion of the HRH Rapid Assessment and Action Plans to improve the HR management in 9 HFs.

Although the findings in all facility assessments and corresponding action plans were not identical, they shared many commonalities (e.g.,—identified gaps included a lack of: job descriptions, work planning, performance reviews, employee/staff files, digitalization of data, policy manuals, and HIV/AIDS workplace prevention programs). In addition, all of the plans indicated the need for designated technical and financial staff to facilitate hiring, procurement and operational tasks. After the workshop, SASH held advocacy meetings with the Directors of the 9 HFs, requesting support for the implementation of their HRM action plans.

One important HR task that showed significant improvement, included the organization and creation of HR files. In PY5, SASH completed the final supervision of the 9 targeted HFs, at which time the facilities had completed 69% of personnel files. In addition, the overall result achieved in 46 HFs in Luanda was similar with 71% (3,999 files /5,627 workers) of personnel files completed. A very committed provincial and municipal HR team now has the challenge of continuing this process until they reach 100% of their personnel files. After four supervisions conducted between August 2015 and April 2016, the results demonstrated an ongoing increase in the creation of personnel files.

Angola SASH: Final Report, June 2017 15 HIV/AIDS

Results Summary

• In 2011, SASH supported the INLS to roll out the Provider-Initiated Testing and Counseling (PITC) strategy. SASH increased access to PITC by expanding the number of facilities offering these services from 21 to 207 locations during the life of the project.

• In 2012, the GoA adopted the strategy for the "Elimination of HIV Transmission from Mother to Child until 2015.” This strategy was spearheaded by SASH’s roll-out of task- shifting, or the transfer of skills (e.g.—management of ART) from physicians to Nurses. SASH trained 2,244 health professionals on HIV Testing and Counseling Services (HTC), initiation and management of ART, as well as 201 Trainers on implementation of skills transfer, mentoring, and supervision. This strategy had a positive impact: increasing access to ART and reducing Mother to Child HIV Transmission from 37% in 2012 to 25% in 2014, as indicated by the UNAIDS 2015 Progress Report on the Global Plan towards the elimination of new HIV infections among children and keeping their mothers alive.

• In 2012, SASH introduced the role of Patient Assistance Facilitators (PAFs) to support adherence to HIV treatment and retention in care, contributing to 78% retention of pregnant women in PMTCT services after 12 months in supported HFs. In addition, from October 2016 to February 2017, PAFs helped track 98% of individuals who missed appointments, successfully reintegrating 79% back into care.

• From 2012 to 2015, SASH supported the expansion of PMTCT services from 21 in 2012 to 158 in 2015. SASH also supported the INLS to roll out PMTCT option B+ in Luanda and Huambo contributing to an increase in the number of HIV positive pregnant women receiving ARV in order to reduce HIV transmission to their newborn babies from 422 in 2012 to a cumulative total of 4,715 in 2015 in SASH supported HFs.

• In July 2015, SASH began implementing the HIV Continuum of Care Model (CCM) in coordination with other PEPFAR partners at 9 targeted HFs in Luanda. SASH supported the HFs to offer high quality services through early identification of HIV-positive clients, immediate linkage to care, and timely ART initiation as per national recommendations, as well as continued adherence and support for sustained viral suppression. By the end of the project, 14,757 HIV positive individuals newly enrolled into care and 10,652 initiated ART in the 9 targeted HFs.

• In October 2016, SASH piloted the Index Case (IC) approach as a strategy to achieve the first of UNAIDS’ 90-90-90 targets. This approach was more effective in identifying HIV positive individuals compared to Voluntary Counseling and Testing (VCT) and PITC in Angola, which has a generalized low HIV prevalence, with a positivity rate that was over five times higher than rates achieved with VCT and PITC.

Over the course of the project, SASH’s work in HIV evolved to respond directly to new HIV implementation strategies and changes in mandate from PEPFAR and USAID/Angola. The first three years of the project, or Phase 1, focused on the expansion of HIV services (HTC and PMTCT) and task shifting. During the fourth year of the project, USAID and other USG agencies, at PEPFAR’s instruction, worked to sharpen their focus on curbing the HIV epidemic in Angola. After a period of deliberations of approximately six months, SASH’s PY4 work plan was revised and approved midway into the year to include activities supporting the full HIV CCM, from

16 Angola SASH: Final Report, June 2017 testing and counseling to adult and pediatric care and treatment, including adherence and retention, as well as activities to strengthen the HIV information system. This shift marked the second phase, or Phase 2, of the project, and SASH pivoted from implementing HSS approaches to a direct site-level service delivery support approach. This approach was concentrated in nine- targeted HFs in Luanda, where the newly defined HIV CCM was implemented. Direct, daily site- level support and monitoring was achieved with the embedding of clinical mentors at each of the HFs.

For SASH’s fifth year of implementation, the project’s HIV scope shifted again, with a focus now on components related to HTC, linkage of newly diagnosed HIV positive individuals to care, and adherence and retention in care at the nine HFs.

In this context, the following sections provide descriptions of SASH’s main accomplishments in HIV from project inception to completion.

New or updated guidelines, protocols, manuals, job aids and supervisory tools related to HTC and PMTCT implementation SASH technical experts were routinely called upon by INLS, DPS/GPLS, RMS and HFs to help develop or revise guidelines, protocols, training manuals, job aids and supervisory tools to guide the provision of HTC and PMTCT services. National documents that were developed or revised with SASH support included the following:

5 Manuals:

 HIV Testing and Counseling Reference Manual (2014)

 HIV Testing and Counseling Trainer’s Manual and Participant’s Manual (2014)

 PMTCT Manual for Nurses, Trainer’s Manual and Participant’s Manual (2016)

4 Sets of Standards:

 HIV Testing and Counseling standards (2012)

 PMTCT standards (2012)

 HIV Care standards (2015) – drafted

 HIV Treatment standards (2015) – drafted

3 Protocols and Norms:

 Protocol for the Evaluation and Follow-Up of Nurses of HIV+ Patients (2014) – drafted

 Antiretroviral Treatment Norms (2015)

 HIV Testing and Counseling Protocol (2016) – drafted

Angola SASH: Final Report, June 2017 17 More than 2,000 health professionals with increased capacity to offer quality HTC and PMTCT services Committed to the principle of creating an “enabling” environment, SASH’s approach to capacity building centered on mentoring and providing direct and enhanced TA to ensure a focus on the gradual building of local capacity, rather than on direct implementation. SASH worked alongside INLS, DPS and HIV focal points at the municipal and HF levels to conduct formative supervision and on-the-job trainings. Quality improvement tools, based in the SBM-R methodology, were used during formative supervision and mentoring Photo: SASH HIV activists promoting HTC in Huambo. visits to enable health workers to assess their own performance and progress over time.

This collaborative effort in mentoring and on-site support was complemented as needed by group- based trainings, aligned with INLS training plans. During the first phase of the SASH project, 2,244 health professionals were trained in HTC, PMTCT, and ART including 1,731 nurses trained to initiate and manage ART (task shifting). SASH also helped to create a cadre of over 200 health professionals as HIV trainers who can continue to build the capacity of HIV health workers in the years to come.

Expanded access to high quality HTC, PMTCT and ART services During the first four years of the project, in alignment with the INLS’ priorities for the expansion of HIV services, SASH increased the total number of sites receiving project support (ensuring all sites offered quality HTC, PMTCT and ART services) in both Luanda and Huambo provinces, as illustrated in the graph below. The number of new services established with SASH support from 2012 to 2015 include:

 117 new PMTCT services (Luanda 49, Huambo 68)

 177 new PITC services (Luanda 49, Huambo 128)

 117 new Adult ART services (Luanda 49, Huambo 68)

 13 new Pediatric ART services in Huambo

18 Angola SASH: Final Report, June 2017 Chart 1: Number of PITC, PMTCT, and Adult and Pediatric ART services in Luanda and Huambo Provinces supported by SASH, 2012–2015 . 250

207 200 177 150 158

100

50 31 0 Y1 (2012) Y4 (2015)

PITC PMTCT Adult ART Pediatric ART

Increased care and treatment for HIV- positive Pregnant Women Through the increased availability of, and access to HIV services with skilled providers, SASH was able to support a significant increase in the number of pregnant women tested for HIV between 2011 and 2015, as well as in the number of pregnant women with a positive HIV diagnosis who initiated ART. At the end of PY1, 36,768 pregnant women were tested in SASH- supported HFs as compared to a cumulative 314,524 tested by the end of PY4, a 755% increase. As show in Figure 15 below, of the total Photo: An advertisement sponsored by SASH, 6,886 pregnant women and breastfeeding encouraging pregnant women to test for HIV. It was mothers diagnosed with HIV by 2015, 4,715 placed in all waiting areas of all facilities in Luanda and Huambo where PMTCT services were offered. (68%) had received ARVs. At the end of PY1, only 51% of HIV+ pregnant women received ARVs.

Angola SASH: Final Report, June 2017 19 Chart 2: Number of HIV+ pregnant women diagnosed and who received ARVs at SASH- supported Health Facilities: 2012–2015 Y1 (2012) Y4 (2015) 8,000 6,886

6,000 4,715

4,000

2,000 833 422 0 Diagnosed HIV+ Received ARVs

More than 600,000 people tested and know their HIV status HTC remained a pillar of SASH’s work throughout the LOP. SASH supported HFs and provincial and district level teams to improve forecasting and distribution of rapid HIV tests and other consumables needed for HIV testing. SASH also provided constant mentoring and formative supervisions to strengthen counseling and testing skills, applying QI tools to assess counseling competencies in HTC, and to reinforce the correct completion of the HIV registry books and reporting forms.

SASH’s efforts enabled the targeted HFs to significantly increase the number of people who know their HIV status in Luanda and Huambo provinces. At the end of PY1, 59,698 people were tested for HIV at SASH-supported facilities. By the end of the project, a total of 632,185 individuals were tested and knew their HIV status over the period of five and a half years.

Higher HIV positivity rates gained through Index Case Contact Tracing In Phase 2, SASH focused on reaching more vulnerable populations, including pregnant women and breastfeeding mothers, as well as sick or malnourished children, hospitalized adults and/or people with TB. SASH also began to pilot the Index Case (IC) approach in one HF, Viana I Health Center, in an effort to identify individuals at high risk of HIV infection. The IC approach is a strategy in which index cases (ICs), or HIV positive patients newly diagnosed, or recently admitted into HIV care, are counseled about the importance of testing their contacts, who could include sexual partners or family members. When ICs provide information to reach their contacts and consent to tracking, contacts are reached via phone or home visits, and offered HIV testing services.

20 Angola SASH: Final Report, June 2017 Chart 3: HIV Continuum of Care for HIV+ Contacts of Index Cases, Oct-Dec 2016, Viana 1 Health Center Adults Children 140 131 120

100

80

60 50 43 40 30 20

0 Tested Diagnosed Linked to Care Initiated ART

During the IC pilot from October to December 2016, 60 index cases were enrolled, 80% of whom were between the ages of 25-49 years; and 67% were female. Of the 131 contacts identified, 64 were sexual partners (37 primary partners), 48 were children, 2 were parents of child/adolescent index cases, and 17 were other family members. Fifty contacts, or 38%, were tested and diagnosed with HIV; of these, 84% were linked to HIV care and treatment services and 60% initiated ART. This HIV positivity rate is more than five times greater than the 6% positivity rate achieved through VCT and PITC approaches in Luanda and Huambo from 2011-2017 (of the 632,185 tested, 36,645 received a HIV positive diagnosis).

PITC integrated into more service areas at 9 targeted HFs To increase the number of people who know their HIV status, SASH supported the integration of PITC into existing services, such as Antenatal Care (ANC), labor and delivery, TB, and pediatric and adult admission wards, to capture those at risk of HIV infection. The graph below shows the increase in the number of service areas that offer HIV testing across the nine-targeted HFs.

Angola SASH: Final Report, June 2017 21 Chart 4: Number of SASH-supported Health Facilities offering PITC in various service areas, October 2015–February 2017

DENTAL UNIT SURGERY NUTRITION PEDIATRIC WARD MEDICAL WARD PEDIATRIC OUTPATIENT MEDICAL OUTPATIENT LABORATORY Oct-15 BLOOD BANK Feb-17 MATERNITY EMRGENCY DEPT TB ANC FP HTS

0 1 2 3 4 5 6 7 8 9 10

Strengthened Linkages to Care In Phase 2, SASH first began to support components along the full HIV CCM, including linking newly diagnosed individuals immediately to care. Linking HIV positive clients to care on the same day as diagnosis is the vital first step necessary for successful patient retention outcomes. To reinforce immediate linkages, SASH implemented the following activities:

 Developed a tracking tool for diagnosed HIV positive patients

 Trained PAFs and nurses on how to use the tracking tool

 Developed Standard Operating Procedures (SOPs) and patient flow charts tailored to each facility

 Established same day diagnosis and reception/consultation for HIV positive patients

 Deployed PAFs to accompany patients to their first medical consultation (to ensure a clinical record is opened) for HIV care and treatment

 Conducted constant mentoring and formative supervision for health providers

 Audited tracking tools for HIV positive patients and conducted cross-checks with HIV register books to ensure data quality

By the end of December 2016, at the 9 project-supported HFs, 14,757 HIV-positive individuals were newly linked to care and 10,652 initiated ART. The graph below depicts the HIV continuum of care cascade for a 15-month period by quarter, and illustrates that the proportion of HIV-positive people enrolled in care who initiated ART increased over time, from 77% to 99%.

22 Angola SASH: Final Report, June 2017 Chart 5: HIV Continuum of Care Cascade in PERFAR-Supported Health Facilities October 2015– December 2016

Tested Diagnosed Enrolled in Care Initiated ART

%Diagnosed/Tested % Care/Diagnosed %TX/Care

25,000 120%

100% 20,000

80% 15,000

60%

10,000 40%

5,000 20%

0 0% Oct-Dec15 Jan-Mar16 Apr-Jun16 Jul-Sep16 Oct-Dec16

The data provided in Chart 5 above represent the total numbers of individuals tested, diagnosed and newly enrolled in care and treatment, which includes information on those who may have received their HIV positive diagnosis before October 2015 or those who were tested elsewhere but enrolled in care at one of the nine HFs during the 15-month period of analysis. Some individuals may have received their diagnosis at these sites, but then decided to seek care at a different facility. In an effort to better monitor immediate linkages to care, SASH began to track individuals who were enrolled in care and treatment services on the same day of receiving their diagnosis. In January and February 2017, 904 (51%) of the 1,779 individuals diagnosed with HIV were immediately linked to care with support from PAFs (an additional 61 people were linked to care without PAFs).

Increased the proportion of HIV+ individuals who initiated ART from 51% to 61% The second of UNAIDS 90-90-90 goals is that 90% of all people with diagnosed HIV infection will receive sustained ART. In SASH-supported HFs in Luanda, the percentage of those who initiated ART increased from 51% in December 2015 to 61% in December 2016, as shown in the graph below. This is an accomplishment; however, there is still more work to be done to improve adherence to treatment and retention in care in order to reach the 90% goal.

Angola SASH: Final Report, June 2017 23 Chart 6: HIV Continuum of Care Cascade, comparing Y5 Q1 and Y6 Q1

Diagnosed Enrolled in Care Initiated ART 2500

2000

61% 61% 1500 66% 51% 2324 1000 1672 1428 1420 500 1111 854

0 Y5 Q1 Y6 Q1

Improved 12-month Retention Rates In addition to strengthening same day linkages to care, SASH worked to improve adherence to ART and retention to care and treatment services with the aim to achieve the second of UNAIDS’ 90-90-90 targets. With mentoring and formative supervision visits following targeted trainings on adherence counseling skills, SASH helped health providers to integrate adherence counseling into routine HIV care consultations at the nine target HFs. SASH-supported PAFs, along with health providers, used the SOPs and tracking tools to follow up with patients Lost To Follow-Up (LTFU) or those who had missed appointments and reintegrate them back into care.

Because retention data are not routinely collected within the national HIS, SASH conducted an assessment to determine retention and LTFU rates 12 months after initial enrollment in care. The assessment was conducted at six HFs (Cajueiros Hospital, Divina Providencia Hospital, Kilamba Kiaxi Hospital, Viana Health Center, Luanda Sanatorio Hospital, Rangel Health Center) and compared 12-month retention rates and LTFU rates between the 146 patients enrolled in care from October to December 2014, and the 182 patients enrolled in from October to December 2015. The data on patients enrolled in the 2014 period served as a baseline because SASH interventions did not begin until October 2015. As illustrated in the graph below (Figure 20), t retention rates increased and LTFU rates decreased in all HFs except one (Divina Providencia Hospital). The average increase in retention rates was 5%, and the average decrease in LTFU rates was 8%.

24 Angola SASH: Final Report, June 2017 Chart 7: 12-month Retention and LTFU Rates among 2104 vs 2015 analysis groups in 6 Health Facilities

Alive Abandoned Transferred Deceased 100%

22% 22% 23% 24% 28% 28% 34% 80% 42% 28% 39% 48% 29%

60%

40% 76% 76% 75% 72% 70% 70% 64% 66% 58% 58% 61% 51% 20%

0% 2014 2015 2014 2015 2014 2015 2014 2015 2014 2015 2014 2015 Cajueiros Div. Provid. Kil. Kiaxi Viana Sanatório Rangel

Reduced Rates of Loss-to-Follow Up (LTFU) PAFs, in collaboration with HIV clinical supervisors, helped to reduce LTFU by actively tracking and reintegrating back into care those HIV clients who missed clinical appointments and/or were lost to follow up. As shown in the graph below, from October 2016 to February 2017, 4,442 clients missed appointments in the nine SASH targeted HFs. During this same time period, PAFs helped to successfully track and identify 4,371 (98.4%) of clients, and 3,516 patients (or 79%) were recovered back into care and treatment.

Chart 8: Number of patients who missed an appointment, were found, and returned to care, October 2016–February 2017

5,000 98% 98%

4,000 79%

3,000

4,442 4,371 2,000 3,516

1,000

0 Missed appointment Were found Returned to care

Angola SASH: Final Report, June 2017 25 Family Planning

Results Summary

• Increased access to high-quality FP services by establishing 149 new FP service locations (49 in Luanda and 89 in Huambo)

• Trained a total of 784 health professionals on FP methodologies:

− 291 health professionals trained on Long-Acting Reversible Contraceptive methods (LARCs), e.g.—Implants and IUDs

− 198 health professionals trained on non-LARC Contraceptive methods

− 295 delivery room midwives trained on PPFP and Post-Partum IUD insertion

• 426 health professionals received in-service trainings contributing to improved skillsets in Balanced Counseling Approaches, Infection Prevention and Control, Post-Abortion Care (PAC), LARCs, and PPFP methods.

• Introduced the use of Post-Partum Family Planning (PPFP) Services in 40 maternity wards (32 in Luanda and 8 in Huambo)

• Strengthened and trained a cadre of 24 FP municipal focal points in Luanda and Huambo

• Developed 7 sets of Quality Improvement (QI) tools for the evaluation of FP provider’s skills, resulting in improved compliance of FP standards & service delivery

Throughout the LOP, SASH’s Family Planning interventions were implemented in both Luanda and Huambo provinces. SASH’s FP strategy evolved to respond directly to the country’s priorities and USAID’s mandates. In the first three project years, SASH focused on the expansion of FP services at all levels including Health Posts, and the introduction of Long Acting Reversible Contraceptives (LARCs) into the FP method mix. SASH also supported the National Reproductive Health/Family Planning (PNSR/PF) Program by strengthening Post-Abortion Care (PAC) services and reinforcing the integration of PAC and FP counseling. In PY4, SASH’s FP approach focused on the integration of FP, ANC, and HIV services through series of trainings. PY4 activities centered around the training of FP, HIV, and ANC providers on FP skillsets, while also continuing to support long-term methods (e.g.—implants, or IUDs) and post-partum methods. Throughout implementation, SASH utilized the SBM-R approach to guide its FP work, developing tools to evaluate the quality of FP service providers’ performance. At the time of SASH’s closure, the Angolan PNSR/PF was in the process of institutionalizing all FP training packages, supervision tools, and job aids, which SASH developed for the introduction of long-term FP methods.

New or Updated guidelines, protocols, job aids, and supervisory tools related to RH & FP implementation SASH technical experts were routinely called upon by the National Public Health Directorate, the PNSR/FP, the DPS/GPLS, RMS, and HFs to help develop or revise guidelines, protocols, training materials, job aids, and supervisory tools in order to guide the quality provision of RH & FP services. National documents that were developed or revised with SASH Support include the following:

26 Angola SASH: Final Report, June 2017

7 Sets of QI Standards: Standards for Evaluating Provider Performance regarding: . Client First consultation . FP Client follow-up visit(s) . Insertion and removal of implants and interval IUDs . Postpartum IUD insertion (PPIUD) . Uncomplicated incomplete abortion care . Evaluation of Women with incomplete abortion . FP Infection Control and Prevention

1 Guideline: . Maternal Perinatal Clinical Record (Finalized)

More than 2,000 health professionals with increased capacity to offer quality RH and FP services SASH’s strategy to improve RH and FP capacities focused on the provision of direct and enhanced TA and mentorship, to ensure future sustainability through knowledgeable local health providers. SASH collaborated with the National Public Health Directorate, the PNSR/PF, the DPS, GPLS, RMS, and HFs to expand knowledge and skillsets related to:

Balanced FP Counseling SASH adapted and implemented the use of the “Balanced Counseling Strategy” (BCS) toolkit, a series of cards (one FP method per card) designed to support a client centered counseling approach. SASH updated the BCS toolkit to include WHO’s 2015 recommendations on FP, and implemented the toolkit in both Luanda and Huambo, training over 1,568 FP service providers on its use. The toolkit served as an effective way to assist providers and clients in discussing FP methods, while also helping the client to make an informed decision. SASH encouraged the Photo: A provider uses FP Balanced use of individual balanced counseling during client’s first FP Counseling cards during a one on one appointments, as well as with returning clients. individual counseling session.

Long Acting Reversible Contraceptives (LARCs) SASH re-introduced in 2012 Long-acting reversible contraceptives (LARC) in Angola. These (implants and IUDs) are methods of birth control that are the most effective reversible methods of contraception because they do not depend on patient compliance and have a failure rate of less than 1%. In general physicians and nurses were not trained on FP use, and counseling. During a qualitative study conducted by SASH and the Johns Hopkins Bloomberg School of Public Health (JHSPH), it was noted that not trained physicians, were one of the reasons that a patient decided to remove a FP implant. As such, SASH coordinated with the DPS to develop a training for physicians on the provision of LARCs (e.g.—implants and IUDs). This training was one of the steps taken by the project to have physicians supporting women to maintain their IUDs or implants. SASH supported the reintroduction of implants and IUDs, by training providers on its use, and insertion as well as counseling, inserting over 16,266 implants in Luanda and Huambo provinces.

Angola SASH: Final Report, June 2017 27 Chart 9. 489 professionals from Luanda (291) and Huambo (198) trained on FP, including LARCs Women Men

Luanda 282 9 291 TOTAL

Huamb 187 11 198 TOTAL o

0 50 100 150 200 250 300 350

Postpartum Family Planning (PPFP) From 2015-2016, SASH supported the continued promotion of PPFP activities, including the use of Postpartum-IUD insertion (PPIUD). Due to SASH’s success with PPIUD, the PNSR requested SASH’s PPFP/PPIUD educational materials in order to replicate this effort in additional provinces. In addition, 40 delivery rooms providing PPIUD services were established by SASH, resulting in 4,391 PPIUDs being inserted by 295 midwifes/nurses trained by SASH. SASH’s promotion of PPFP, and specifically PPIUD use, was innovative in Angola, never having been Photo: US Ambassador La Lime views a FP demonstration at the SASH implemented by the GoA/MoH prior. achievements ceremony. Post-Abortion Care Services (PAC) In response to a request from the PNSR for help strengthening PAC services, SASH supported the training of 45 service providers from 13 HFs in Luanda and Huambo on PAC services (25 Luanda and 20 Huambo). This training package was later replicated by the PNSR in four other provinces (Benguela, Huila, Cabinda and Uige) to train an additional 80 service providers in PAC.

Expanded access to high quality FP services SASH supported the creation of 80 new FP service locations in the province of Luanda and 69 new locations in Huambo, for a total of 149 new FP services. Prior to SASH interventions, the majority of facilities in Huambo did not offer FP services, as most were rural health posts.

28 Angola SASH: Final Report, June 2017 Chart 10. New FP Services Established

Number of FP Services, 2011 Number of New FP Services Established with SASH Support, 2011-2016

Haumbo 46 80 126 TOTAL

Luanda 30 69 99 TOTAL

0 20 40 60 80 100 120 140

Established a Cadre of 24 FP Focal points SASH provided support to the PNSR/FP, the DPS and RMS, to identify and train national, provincial and municipal Family Planning Focal Points, or health facilitators trained to serve as leaders regarding FP/RH interventions. At the time of SASH’s inception, FP work at the municipal level was not a priority in Angola. Few municipalities had a FP supervisor at each municipal health directorate (RMS). Some supervisors had not been trained and very few supervision activities were carried out. As a result, few HFs offered FP methods; there were often stock outs of FP materials, and poor FP statistical information available at all levels. To resolve this issue, at the beginning of the project, SASH met with the DPSs and RMSs of both Luanda and Huambo provinces to propose the designation of a FP focal point at each municipality. Each focal point would be responsible for training service providers and improving FP program performance. SASH provided TA through training, mentorship, and monthly meetings with municipal and head facilities’ FP focal points. Similarly, quarterly supervision visits to evaluate providers’ performance, identify areas for improvement, and draft QI action plans were completed. By having engaged, committed and trained health staff to supervise and provide mentoring to others in the areas of FP and RH, SASH ensures sustainability well into the future. The PNSR is currently using some of the Municipal Focal Points trained by SASH as National Trainers. By the end of the project municipal supervisors also were identifying health facility focal points to help supervise each unit.

FP Service Providers trained on QI Methodologies SASH utilized an SBM-R strategy throughout the life of the project. Two FP tools were created and utilized from PY1 through PY5: (i) Standards to evaluate FP service providers’ performance at clients’ first FP consultations; and (ii) Standards to evaluate FP service providers’ performance during client follow-up visits. During the project’s final three years, additional sets of standards were developed to assess the performance of FP providers on: (i) insertion and removal of implants; (ii) insertion and removal of IUDs; (iii) insertion of PPIUDs; (iv) infection prevention in FP; (v) uncomplicated incomplete abortion care and post-abortion FP, and (vi) FP counseling in women with uncomplicated incomplete abortion. All of these tools were transferred to the PNSR/FP and the DPS for their continued implementation. In addition, during the LOP 13 municipal focal points and 3 provincial coordinators were trained in Luanda on the QI tools, while 11 municipal focal points and 2 provincial coordinators were trained on these tools in Huambo.

Angola SASH: Final Report, June 2017 29

Chart 11: FP SBM-R Percentage of HFs that achieved 80% of Quality Standards Luanda, 2015–2016

Baseline Final 100% 90% 80% 70% 60%

50% 96% 100% 40% 78% 30% 60% 20% 10% 0% First consulting Follow-up consulting

More than doubled the number of New FP users in Luanda Through SASH’s FP interventions—including the establishment of FP municipal focal points, capacity building of FP service providers, and the endorsement of comprehensive FP methods including LARCS—SASH contributed to doubling the number of new FP users in Luanda, increasing from 40,053 (accounting for 8% of new users nationally) in 2011 to 106,781 (accounting for 23% of new users nationally) in 2015. Figure 27 demonstrates the increase in new FP users from 2011–2015.

Chart 12. Proportion of Total New FP Users (National) in Luanda 2011–2015

Number of New FP Users in Luanda

Percent of RH Clients who are new FP users (National) 150,000 100%

115,755 120,000 106,781 75% 90,736 90,000 50% 57,002 60,000 40,053 25% 21% 23% 25% 30,000 10% 8% - 0% 2011 2012 2013 2014 2015

Conducted a Qualitative Study on FP Implant Use in Luanda and Huambo Provinces During HF supervision visits, SASH observed that some women were requesting the removal of implants well in advance of the implant’s expiration date. To investigate the cause, SASH requested support from the Global Health Established Field Placement (GHEFP) program, a joint

30 Angola SASH: Final Report, June 2017 program between Jhpiego and the Johns Hopkins School of Public Health (JHSPH). Mary Qui, a JHSPH graduate student, conducted a qualitative study on Implant Use in Angola, with technical support from Professor Peter Winch (JHSPH, Primary Investigator), the SASH team, and the MoH. The study sought to understand the reasons why women were requesting the premature removal of implants. Findings from the study showed that the main reasons for implant discontinuation were: side effects, such as: prolonged bleeding, headaches, dizziness, weight gain, and fatigue; husband/spouse dissatisfaction or disapproval; the desire to get pregnant; false information re: implant use from friends; stigma or lack of information; religious opposition. As a result of these findings, SASH strengthened efforts, including trainings, to improve FP provider’s skills on individual/couples counseling, and FP comprehensive method mix (including LARCs). The results of the study were shared with USAID and the DNSP, and FP monitoring tools and training packages were reviewed and updated to incorporate principle findings and recommendations.

Formed Public-Private Partnership for “Low Dose High Frequency” Training via SMS SASH approached UNITEL (Angolan mobile phone and service provider) with a proposal for the use of mobile technology as a “low dose, high frequency” FP training strategy. The strategy, which would be implemented via SMS messaging, would allow for free SMS messaging of key FP intervention messages to 30-50 health providers. These messages might address stock-outs of medical supplies, integrated services, and facilitate communication for FP referrals and counter- referrals. UNITEL accepted the proposal committing to a 5-year period of performance; however, they only notified SASH of their approval at the time of the project’s close (early 2017). As a result, SASH shared this proposal with the USAID follow-on project, introducing USAID to UNITEL, with the hope that together they will explore the possibility of collaboratively implementing this mobile strategy under the new project.

Angola SASH: Final Report, June 2017 31 Malaria

Results Summary

• Supported the NMCP to develop the document, "Guidelines and Standards of Conduct for the Diagnosis and Treatment of Malaria"

• Supported the NMCP to create the "Manual for the Diagnosis and Treatment of Malaria in Pregnant Women", in accordance with WHO-2013 recommendations

• Participated in the development of the "National Strategic Plan for Malaria Control 2016-2020, in Angola," which included the national standards for diagnosis and treatment of Malaria

• Designed and implemented the use of a job aide, a Malaria Flip Chart, or Album Seriado de Malaria, for service providers to use when discussing malaria symptoms, care, and treatment with patients.

• Supported the provincial government of Huambo in the creation of a Malaria Pre- Elimination Study and Action Plan

• 931 health service providers trained in i.) Malaria Case Management with the use of artemisinin-based combination therapy (ACTs), ii.) Malaria Laboratory Diagnostics (RDTs or microscopy) and iii.) Intermittent Preventive Treatment in Pregnancy (IPTp), in Luanda and Huambo throughout the LOP

• 604 health service providers received on-the-job trainings contributing to strengthened skillsets in malaria case management and diagnosis

• Of the 85 targeted HFs in Luanda (2016), 93% of facilities obtained a rating of 80% or higher in performance of malaria QI standards during the LOP

• SASH participated as an active member of the Angolan National Forum of Malaria Partners, having assumed the Presidency of the Provincial Forum in Huambo throughout the five years of the project

Throughout the duration of the SASH project, the Malaria SOW evolved to respond directly to both the country’s priorities, as well as PMI/USAID’s mandates. During PY1, SASH focused its malaria efforts in both Luanda and Huambo provinces. In Huambo, the Health Directorate (DPS) prioritized reducing the number of deaths due to malaria. During PY1, SASH formed a team of malaria specialists to train all service providers in the targeted municipalities of Huambo (Londuimbali and Mungo) and Luanda (Cacuaco and Viana) all of which were among the municipalities with the highest incidence of malaria cases and deaths within Huambo and Luanda provinces. SASH focused training efforts on case management, rapid diagnosis testing, and lab skills. A key shift in implementation occurred during PY2 at which time USAID requested SASH change its malaria SOW and geographic focus, ending activities in Huambo and prioritizing malaria activities solely in Luanda province.

32 Angola SASH: Final Report, June 2017

For the remainder of the SASH project (PY2-PY5), malaria efforts were centralized in Luanda province and SASH’s SOW was designed to address gaps in malaria services as identified by the NMCP and DPSs. The main gap identified was the need to improve malaria provider’s skills in Malaria Care and Treatment. As such, SASH supported all municipalities of Luanda—Cacuaco, Luanda, Belas, Cazenga, Icolo e Bengo, Quiçama and Viana—working with appointed Malaria Municipal Focal Points and Provincial Coordinators to train 604 providers via on the job trainings in the HFs. These trainings covered topics such as: clinical diagnosis, laboratory diagnosis (RDT and malaria microscopy), differential diagnosis (simple vs complicated cases), as well as malaria treatment. A specific training module was developed to address prevention and treatment of Malaria in Pregnancy (MIP) (e.g.—using Fansidar and delivery of mosquito nets) based on the updated MIP Manual. SASH’s malaria work in Luanda set the bar for the NMCP’s activities at the national level.

Served as the President of the National Malaria Forum 2012-2016, Improving Stakeholder Participation & Collaboration in Malaria Activities SASH participated as an active member of the Angolan National Forum of Malaria Partners, having assumed the Presidency of the Provincial Forum in Huambo throughout the five years of the project. Despite SASH’s reduction in malaria activities during PY2, all forum partners voted unanimously that SASH should continue in the forum’s presidential role. As President of the Provincial Forum, SASH coordinated with all partners to collaborate and support the Provincial Health Director’s local strategy in the fight against malaria. SASH also incorporated support from other key stakeholders, including NGOs, members of the private sector, civil society, police and military, to participate in malaria prevention activities. For example, participation in malaria testing and treatment campaigns in rural communities at weekly health fairs organized by the DPS in Huambo. As a result of SASH’s efforts, Huambo province demonstrated a significant decrease in malaria deaths, reducing from 171 deaths in 2011 to 36 deaths in 2015.

Supported Huambo Provincial Health Directorate in Completing a Malaria Pre- Elimination Study & Action Plan In September 2015, the SASH project completed a malaria pre-elimination study in Huambo province. SASH, supported by Jhpiego’s Senior Malaria Advisor, Bill Brieger, led an analysis of HMIS data on malaria testing in Huambo for a three-year period (2012-2015). Using data results from RDT, a Test Positivity Rate (TPR) was calculated for each municipality. The assessment found that there was a distinct difference between the northern and southern parts of the province, with some areas in the south approaching pre-elimination status, and some areas in the north still in need of the scale-up of malaria control measures. Using this data as a baseline, four municipalities—Mungo, Bailundo (north); Longonjo, Cachiungo (south)—were selected to participate in an additional assessment geared at identifying the needs of municipal and frontline health providers in order to begin working towards a provincial pre-elimination malaria status. The assessment proposal and tools were shared and discussed with the DPS and the Director of the NMCP, prior to implementation. The assessment concluded that most health providers had solid knowledge, skills and experience in the areas of malaria prevention and treatment measures, and RDT use. Areas for improvement included: response to outbreaks, monitoring and evaluation (M&E), large scale drug administration, and microscopy. These results were shared with the NMCP, and a draft action plan was designed by stakeholders from Huambo’s health and social sectors to identify the necessary actions and resources needed for follow-up.

Angola SASH: Final Report, June 2017 33 Prioritized the Improved Quality & Collection of Malaria Data through Use of the DHIS2 System in Huambo During PY5-6 of the project a standardized, HIS platform, DHIS2, was piloted in three municipalities of Huambo. As part of the pilot, it was determined that existing malaria data from 2015 to 2016 should be input into the DHIS2 system. Through the project’s and GEPE-GTI’s collaborative efforts, SASH trained staff from the 3 municipalities provided basic equipment and access to internet and an average of 89% of malaria data reports from 2015-2016 were introduced by the three municipalities in Huambo province: Bailundo, Londuimbali and Mungo.

Strengthened Service Provider Competencies in Malaria Diagnosis, Treatment, and Care in Targeted HFs in Luanda During the project, SASH supported the NMCP, DPS, and RMS to implement malaria control activities in Luanda and Huambo provinces in accordance with USAID’s mandates. This support included the active training and scale-up of malaria municipal focal points on the updated Malaria norms and recommendations per WHO standards, as well as differential diagnosis. Through the capacity building of malaria municipal focal points and service providers at the HF, this work aimed to improve competencies to provide appropriate diagnosis, treatment, and care for both adults and children. Having a focal point in each HF allowed for improved quality of malaria services. During the LOP, 931 health workers were trained in Malaria Case Management with the use of artemisinin-based combination therapy (ACTs); 926 health workers were trained in Malaria Laboratory Diagnostics (RDTs, or microscopy); and 931 health workers were trained in IPTp. In addition, municipal and provincial malaria supervisors were trained on the utilization of a supervision tool to ensure adequate service provision and standardization of services. SASH also worked to develop and distribute malaria protocols and job aids.

Improved Quality of Malaria Services in Targeted HF’s in Luanda

In PY4 and PY5 malaria efforts focused on Case Management and QI of Malaria Services, specifically regarding MIP. At the end of Y5, an SBMR assessment was conducted in 85 Luanda HFs, in which 93% achieved successful implementation of 80% or more of the MIP standards.

Chart 13. Malaria Luanda 2013–2015

Positive Malaria Cases Treated SASH 2013-2015 1,200,000

1,000,000

800,000

600,000

Axis Title Axis 400,000

200,000

0 2013 2014 2015 Total # Malaria Cases in 1,072,112 822,634 901,791 Luanda Total # Positive 651,479 544,215 685,182 Total # Positive Treated 396,138 397,302 497,225

34 Angola SASH: Final Report, June 2017 Challenges & Solutions

Throughout the SASH project, certain challenges arose in the implementation of all technical activities. The following chart describes these challenges and provides examples of how SASH was able to overcome these barriers, as well as detailing valuable lessons learned.

SASH Implementation Challenges Challenge/Barrier Solution

HIS Challenges

1. Limited Qualified Personnel to Implement HIS Limited qualified personnel to lead SASH provided support/TA: partners on the most practical and efficient way to initiate and lead • For GEPE-GTI to coordinate and lead all HIS interventions to strengthen the HIS. interventions in this component and make decisions collaboratively with IPs (e.g.— implementation of the DHIS2 platform, reviewing national indicators, etc.). • Designing and implementing low-cost high- impact interventions, focusing on a friendly user approach, e.g.—developing a system which quickly and easily produced results.

2. Poor Quality Health Data/Information Reported The quality of health information/data SASH provided support /TA: reported at the central level has been poor, often strife with • At the HF level to improve the quality of inconsistencies/errors. information generated. Training health service provider’s use of the e-tool to improve accuracy of data was a key element of this TA and overall QI. • To prioritize the development and implantation of tools, which served as the axis around which all HIS interventions were concentrated, therefore producing a clear change and HIS process improvement. 3. Limited Number of Trained Staff re: HIS skillset Lack of trained statisticians at all levels of SASH provided support to: the MoH. • Train staff working as statisticians on registry and elaboration of monthly reports; • Trained HIS supervisory teams at the provincial and municipal level; • Coordinated with GEPE a Capacity-Plus activity (a consultant) to prepare Statistician curricula to

Angola SASH: Final Report, June 2017 35 be used in technical health schools pre-service training. 4. Insufficient HIS Equipment at the Facility Level Insufficient conditions for using the excel SASH: tool and improve data collection. • Advocated with the Provincial Director, the Municipal Directors and Administrators to budget for in their annual plans, and provide basic equipment (e.g.—internet access, computers) to all facilities. • Provided basic equipment, such as computers and printers to 20 HFs in Huambo and 10 in Luanda. • Created an IT and mentoring team to help supervise and provide IT support to all HFs using the excel tool Municipal Planning Challenges

1. Staff New to Provincial and Municipal/District Level Planning Process This was the first National Strategic Plan SASH: prepared by the MoH and health staff at the provincial and municipal levels. • Worked at all levels to integrate municipal Municipalities were already receiving a teams, accompany them through the process of fixed amount of funds and saw no mapping, prioritizing, collecting and analyzing immediate need for planning and data, identification of indicators and budgeting, Staff had little or no interventions. experience in planning and budgeting. • SASH worked at all levels to support the need and importance for planning and budgeting No experience in Implementing and • Worked with GEPE and other partners in monitoring the Plans developing and field test the FPOM that would be user friendly and easy to use by the municipal teams. • Helped edited and published all Huambo Provincial and Municipal Plans to distribute them to all Huambo municipalities and HFs to use as a reference and be able to implement and monitor interventions. • Trained 4 municipal teams to monitor budgets and plans

HIV Challenges

1. Continual Changes to the HIV Mandate throughout LOP

36 Angola SASH: Final Report, June 2017 As detailed in the aforementioned SASH: sections, the SASH HIV mandate was • continuously and drastically changed Made every possible effort to respond and adapt quickly to these changes, immediately during implementation in order to reflect communicating with the MoH and other IPs, revised PEPFAR recommendations. working to coordinate joint and collaborate efforts in sites where multiple partners were working in the same HF. • Reviewed every time SOW for the project and staff to respond to the new mandates • Made every effort to train health staff to continue activities to provide sustainability; • Actively asked other PEPFAR partners to hold coordination meetings on a regular basis. 2. Delays in Approval of HIV Norms and Tools Development and approval of norms and SASH: tools by the INLS is a lengthy process. • Advocated for approval but parallel requested authorization for field-testing and use of developed norms, tools, and manuals in the selected HFs while pending final INLS official approval. 3. Physician centered service provision to PLHIV PMTCT care and treatment in Angola was SASH: provided solely by physicians. • Unfortunately there are limited number of Supported the introduction of task shifting and training of Nurses to initiate PMTCT care and physicians and demand high, causing a treatment and ART services. gap in coverage for all HFs.

4. Identify 90% of PLHIV Less than 50% of PLHIV know their HIV Status SASH: in Angola. • Introduced implementation of IC contact tracing approach. • Integrated PITC in key services to target patients most vulnerable for acquiring HIV and reduce lost opportunities. • Strengthened PITC in existing services. Some Service providers less motivated to SASH: provide services • Motivated staff through recognition incentives, mentoring and continuous supervision HIV testing outlets with constant stock outs of SASH: rapid tests and other infection prevention • materials Supported on site rapid tests forecasting and quantification

Angola SASH: Final Report, June 2017 37 • Supported the transportation and distributed of rapid tests, provided infection prevention supplies and materials to ensure provision of quality services in all the HIV testing outlets

5. Linkage of HIV patients to Care and Treatment Services Many HIV positive individuals not linked to SASH: care and treatment services and lost to follow up including HIV Exposed • Developed a tool to track HIV positive individual and trained service providers, Nurses, and PAFs on its use • Introduced PAFs (Patients Assistant Facilitators who provided adherence counseling, tracking patients within 24 hours of missing appointments. • Created an environment (or a space) for the PAFs to welcome the patients after HIV positive diagnosis and provide first adherence counseling session. SASH donated furniture and computers for this space. • Take the patients the same day to the first clinical HIV consult to open their clinical records. • Developed tracking tools, Standard Operating Procedures (SOPs). 6. Adherence to ART and retention ART services Low adherence to ART and retention to SASH: care and treatment services • Developed adherence counseling package, SOPs and patient flow • Introduced appointment system to decrease congestion • Trained service providers including PAFS on adherence • PAFs started tracking patients who miss appointments within 24 hours 7. Addressing Stigma and discrimination for PLHIV Stigma and discrimination from : As a result, SASH

a. Service providers • Provided training to service providers and HFs b. Family and communities on stigma and discrimination prevention of c. Auto stigmatization PLWHIV and Key populations, • Supported PAFs to provide talks and testimonies about stigma and discrimination to communities, patients and staff • Supported PAFs to conduct home visits to provide couple and family counseling and

38 Angola SASH: Final Report, June 2017 address domestic violence issues following stigma and discrimination • Carried out workshops with patients and service providers to work together on addressing issues identified by patients.

8. Weak HIS Statistics personnel poorly trained As a result, SASH:

• Provided training, mentoring and constant supervision to service providers on data collection, processing analysis and reporting. • Provided constant mentoring on filling out registry books. • Provided basic equipment such as computers, printers and other material as well as advocated with local authorities to provide the same to at least high volume HFs. HIS not computerized mostly paper based, As a result, SASH: poorly organized, incorrect information, • registers poorly filled and with many errors, Organized medical records and registers, provided archives and files to store medical data not accurate. registers, computerized HIS in some HFs FP Challenges

1. Lack of access to FP materials and methods Stock outs of FP methods due to poor As a result, SASH: procurement planning and distribution, • and reduced funding from the GoA and Collaborated with the GPSL and DPSH as well as the RMS to submit reports to the National partners Program on a timely manner for them to authorize re supply to avoid stock outs of FP method; • Provided support to prepare distribution plans in both provinces as well as transportation when needed. 2. Lack of Trained FP Health Providers Few HFs offered FP services. Health As a result, SASH: Providers competencies not adequate or • updated Completed and updated FP training modules • Trained FP providers on how to provide quality friendly services • Strengthened counseling techniques.

Angola SASH: Final Report, June 2017 39 • Helped expand and established new FP services in both provinces

3. Need for Integrated Services There were little or no integrated health As a result, SASH: services offered for clients. • Worked to integrate FP with HIV, ANC and Delivery services.

Malaria Challenges

1. Frequent Stock out of Malaria Medical Supplies Frequent stock-outs of malaria medication As a result, SASH: and testing supplies occurred due to poor • Encouraged and mentored municipal and HF procurement planning and reduced focal points to supervise stocks and request re- funding from the GoA and partners. supply of RDTs, ITNs & ACTs in a timely manner. • Coordinate with USAID supply management IP to contribute to correctly forecast supply needs in order to avoid Stock-Out • Advocate at all levels to authorize distribution of supplies to the provinces and the HFs in a timely manner • Provide transportation to bring supplies to the HFs;

2. Outdated National Malaria Norms and Protocols

Delays in NMCP’s communication re: SASH: updated Malaria protocols or norms. In • Contributed to update norms, protocols and addition, malaria-related curriculums and manuals as well as training modules; resources are outdated in training schools. • Provided training to last year nursing students on the updated norms • With the NMCP provided case management refresher trainings to service providers (physicians and nurses) 3. Frequent Misdiagnosis Frequent malaria misdiagnosis occurs due As such, SASH provided: to health providers not having the • Training, mentoring and supervision of technical expertise to make differential diagnosis staff in the use of RDTs to improve confidence in when the patient presents fever symptoms. their results. • In-service trainings, mentorship, formative supervision, performance evaluations-re: case management including treatment of uncomplicated and severe malaria, MIP were

40 Angola SASH: Final Report, June 2017 implemented to improve overall quality of malaria services.

Health providers need to improve their As a result, SASH technical know-how to use RDTs • Provided trainings and promoted the increased use of RDTs in diagnosis in all facilities at the different levels. 4. Poor Malaria Data Quality The data/information collection and As such, SASH provided: processing system of the NMCP is weak. • In-service trainings focused on the correct filling Data reporting is poor at all levels. out of registry books, or monthly reports to provide accurate and complete malaria data. • Implemented the use of the DHIS2 Platform as a functional health information reporting system.

Angola SASH: Final Report, June 2017 41 Lessons Learned & Recommendations

The success of a large-scale project, like that of SASH/Angola, depends on the joint efforts of many people, institutions, and stakeholders. It involves a detailed understanding of the country’s needs, the local government’s vision for the future, and the Angolan culture at large. It will take time to learn processes and maneuver the health landscape, which can prove both fruitful and challenging. Following this line of thought, and considering both the USAID/Angola follow-on project and future potential health implementers in Angola, SASH will use this section of the report to provide recommendations for future programming. With this final note, SASH bids adieu to Angola, wishing them much success and fruitful results in the months and years to come.

Throughout the duration of the SASH project, the team learned that in order to obtain optimal results in health implementation efforts in Angola, the following recommendations should be reinforced:

SASH Recommendations In order to achieve optimal results in the areas of HIS, Municipal Planning, HIV, FP, and Malaria, it is important to:

1. Foster Leadership & Sustainability • Promote participation and engagement of project beneficiaries, such as national and community level organizations, as well as local authorities, in the design and implementation of all technical interventions and activities, in order to bring greater “ownership” and accountability to the project, ensuring sustainability into the future. • Work with leaders to respond to Angola’s identified and prioritized needs. • Future projects should not reinvent the wheel, but should aim to learn about past efforts (both successes and failures) in order to ensure a seamless transition of current health systems.

2. Encourage Pre-planning and Forecasting • Emphasize pre-planning with all implementing partners, specifically budgeting, and making funds available for the implementation of low-cost high-impact interventions in the area of HIS. Include budget for basic equipment (computers, printers, internet and if possible generators) • Provide follow-up with health staff to encourage forecasting to avoid stock outs of vital health supplies • Promote Decision Making based on evidence. Future projects should continue to hold regular check-ins with health staff at the facility, municipal, and provincial levels, as well as with the national-level programs, to discuss quarterly achievements, and to brainstorm what’s working/not working, and possible solutions for improvement. These types of discussions help health professionals to understand the logic behind norms and protocols and the importance of following SOPs.

3. Standardize Systematic Processes • Update national level policies, procedures, and curriculums, ensuring dissemination of all updates in order to provide standardized daily operational procedures and the delivery of safe and cost-effective quality health services.

42 Angola SASH: Final Report, June 2017 • Help health teams to design SOPs and patient flowcharts, mentoring staff on their use. Review efficacy of plans, pros/cons and brainstorm solutions for SOP improvement as necessary • Continue collaborative efforts between the MoH, GEPE, USAID, and other implementing partners to continue implementing and advocating for the use of the DHIS2 platform at all levels (i.e.—central, provincial, municipal and HF levels). In addition, future projects should work to establish DHIS supervision and IT support teams.

4. Implement Monitoring, Evaluation, and Feedback Processes • Provide continual monitoring to project activities in “real time” in order to improve upon project design, function, and efficacy throughout the implementation process. Cyclical M&E processes are effective ways to: provide continual feedback on whether or not a project is achieving its goals, identify potential problems at an early stage, and propose possible solutions.

5. Strengthen Human Resources in Health • Support the MoH to strengthen national-level programs through continued investment in cadres of trained health professionals and service providers, as some programs have limited qualified staff or no staff available to guide the implementation of policies and protocols. • Health Staff should continue to provide active supervision, mentoring, on-the-job trainings, and application of QI tools on a regular basis. Monthly and quarterly meetings led by municipal focal points and projects/partners should accompany this process to ensure sustainability. • Include updated FP, HIV, and Malaria curriculums in all pre-service trainings for health professionals.

6. Implement Interventions at All Levels • Encourage integrated activities across all implementing levels (Central, Municipal, District, Provincial, and Facility Levels)

Angola SASH: Final Report, June 2017 43 ANNEX I Index of All SASH supported National Level Health Policies

SASH SUPPORTED NATIONAL LEVEL HEALTH POLICIES

Title English Translation (as applicable) HIS Policies Manuals: DHIS2 User Manual and technical documentation HIV Policies Protocols: Normas de Tratamento Antiretroviral Antiretroviral Treatment Guidelines (2015) (2015) Serviços de Testagem para o VIH: HIV Testing Services: Protocol (2014) Protocolo (2014) Protocolo para Avaliação e Protocol for Evaluation and Follow-up of Seguimento Nursing for HIV + Patients de Enfermagem aos Pacientes VIH+ Manuals: Aconselhamento e Testagem para o HIV Counseling and Testing: Reference VIH: Manual de Referência (2013) Manual (2013) Aconselhamento e Testagem para o HIV Counseling and Testing: Trainer's Manual VIH: Manual do Formador (2013) (2013)

Manual De Prevenção Da Manual of Prevention of Vertical Transmissão Vertical Do VIH para Transmission of HIV for Nurses: Participant Enfermeiros : Manual de Manual (PMTCT 2016) Participante (PMTCT 2016) Manual de Prevenção de Manual of Prevention of Vertical Transmissão Vertical do VIH para Transmission of Enfermeiros : Manual de Formador HIV for Nurses: tranieners Manual (PMTCT, (PMTCT 2016) 2016) Training Curso de formação de assessores Training module for Case Managers in HIV Modules: clínicos em tratamento e care and treatment seguimento de Adultos, gestantes e crianças VIH Módulos de Formação em Training module in Counseling and testing Aconselhamento e testagem para for lay counselors conselheiros leigos

Módulos de Formação de Activistas Training module for Activists in HIV Index em busca de contactos de caso case contact tracing índice (BACCI) Módulos de Formação de Training module for Couple counseling and conselheiros em aconselhamento e testing for HIV testagem do VIH para Casais Módulos de Formação de Training module for trainers in competency formadores em habilidades de based training of CT service providers ensino baseada em competência Módulos de Formação de Training module for service Providers in Post prestadores em profilaxia pós Exposure Prophylaxis exposição

Módulo de formação para adesão Training module for adherence in ART ao TARV

Módulo de formação para adesão Training module for Enhanced adherence reforçada ao TARV em caso de counselling in case of detectable viral load Carga viral detectável

Modulo de formação para activistas Training module for Activists in gender em violência baseada em Género based violence Modulo de formação para PAFs em Training module for PAFs in health dignity aconselhamento em vida positiva e and prevention and retention counselling retenção em serviço de cuidado e of tratamento anti-retrovirai PLWHIV

Instrumento para Avaliação do Standards to evaluate the competencies in Desempenho dos Profissionais que the provision of HIV counselling and testing Fazem conselhamento e Testagem services para o VI

QI standards Instrumento de Supervisão do Standards to evaluate the competencies in (SBMR): Desempenho dos Profissionais que provision of PMTCT services Fazem Prevenção da Transmissão Vertical de VIH

Instrumento para Avaliação do Standards to evaluate the competencies in Desempenho dos Profissionais que provision of care and treatment services first prestam serviços de tratamento e visit seguimento de pessoas vivendo com VIH Primeira Consulta Instrumento para Avaliação do Standards to evaluate the competencies in Desempenho dos Profissionais que provision of care and treatment services prestam serviços de tratamento e follow up visits seguimento de pessoas vivendo com VIH Consulta de Seguimento

Instrumento para Avaliação do Standards to evaluate the competencies in Desempenho dos Profissionais que provision of care and treatment services prestam serviços de tratamento e follow up visits seguimento de pessoas vivendo com VIH Consulta de Seguimento

Malaria Policies National Estratégia Nacional Malaria 2016- Updated National Malaria Strategy 2016- Strategy: 2020 2020

Protocols: Protocolo e Normas para Review and Update Malaria in Pregnancy Diagnostico e Tratamento da protocol and norms according to WHO Malária (2013) Aprovado 2017 2012 rommendations (2013). Approved in 2017. Manuals: Malaria in Pregnancy Manual (2015)

QI standards Ferramenta para supervisão dos Tool for supervision of services and provider (SBMR): serviços e do Desempenho dos Performance (Malaria in pregnancy, provedores (Incluídos padrões de children and adults/SBMR) desempenho)

Ferramenta para supervisão dos Tool for supervision of services and provider serviços e do Desempenho dos performance provedores.

FP Policies: QI standards Padrões para avaliar desempenho Standards for evaluating provider (SBMR): dos provedores na consulta de performance at FP follow-up visit seguimento em PF

Padrões para avaliar desempenho Standards for evaluating provider

dos provedores na primeira consulta performance at first consultation

Padrões para avaliar desempenho Standards for evaluating provider

dos provedores na inserção e retiro performance on insertion and removal of de implantes e DIU de intervalo implants and interval IUDs

Padrões para avaliar inserção de Standards for evaluating postpartum IUD DIU pós-parto insertion

Padrões para avaliar Standards for evaluating provider aconselhamento nas mulheres com performance in uncomplicated incomplete aborto incompleto abortion care

Padrões para avaliar desempenho Standards for evaluating counseling of dos provedores no atendimento do women with incomplete abortion aborto Incompleto não Complicado

Padrões para avaliar desempenho Standards for evaluating provider dos provedores no Controlo e performance in FP Infection Control and Prevenção de infecções em PF Prevention

ANNEX II Municipal Planning Documentation

The figure below provides an example of the first and last pages of a Municipal AOP with a budget developed using the Municipal Budgeting Tool, Huambo Province. República de Angola GOVERNO DA PROVÍNCIA DE HUAMBO ADMINISTRAÇÃO MUNICIPAL DE KATCHIUNGO REPARTIÇÃO MUNICIPAL DE SAÚDE DE KATCHIUNGO Plano Operacional Anual 2016 Tabela 1: Informação Básica Ano Planificado: 2016

1. Nome da PROVÍNCIA: Huambo 2. Nome do MUNICÍPIO: Cachiungo 3. UO básica: 2 4. População do Município: 121,713 5. Câmbio Kwanzas/USD: 140

Rede Sanitária e População estimada por US

Hospitais e Unidades Sanitárias com Orçamento (Od) Nº Nome da US População HM1 Hospital Municipal Cachiungo 35,235 Rede Primária Dependente do Orçamento da Repartição Municipal de Saúde (RMS) Nº Nome da US População US1 CMI Cachiungo 11,335 US2 CS Chinhama 8,240 US3 CS Chiumbo 15,493 US4 PS Calunda 2,898 US5 PS Dondi 3,361 US6 PS Cachilengue 4,300 US7 PS Alto Chiumbo 8,745 US8 PS Ombala Moma 4,675 US9 PS Nondolo 4,635 US10 PS Savitangayala 5,023 US11 PS Sahemba 5,740 US12 PS Chiquengue 3,489 US13 PS Upunda 3,120 US14 PS Soma Ndumbo 3,150 US15 PS Etunda Moma 2,274

Tabela 2: Resumo de necessidade orçamental municipal de bens e serviços Cód Rubricas Hospital US RMS RMS Total Total igo Municipal Dependente Actividades RMS Município Cachiungo s da RMS Programadas 3.3 Bens e 125.885.81 46.176.166 641.41 7.963.820 54.781.398 180.667.212 Serviços 3 3 3.3.1 Bens 67.666.023 38.688.926 173.363 1.205.820 40.068.108 107.734.131 3.3.2 Serviços 58.219.791 7.487.240 468.050 6.758.000 14.713.290 72.933.081

Table 2. Results Summary of Municipal Planning Products Developed Province Huambo* Luanda Totals

Municipalities Belas Viana Caala Mungo Ukuma Ekunha Luanda Chicala Huambo Bailundo Cazenga Longonjo Chinjenje Cacuaco Quissama Cachiungo Choloanga Londuimbali Icolo e Bengo Icolo

PMDS elaborated 1 1 1 1 5 1 1 12 pending MoH approval PMDS 2013-17 approved by 1 1 1 1 1 1 1 1 1 1 1 11 MoH

AOPs 1 1 1 1 1 1 1 1 1 1 10

# of AOPs 1 1 1 1 4 monitored Budgets 1 1 1 1 1 1 1 1 8 elaborated Budgets monitored with 1 1 1 1 4 FPOM *And one PPDS completed by Huambo Province

ANNEX III Index of All Reports and Informational Materials Produced Under SASH

Index of Reports & Informational Materials Developed during SASH LOP 2011-2017 Title Authors Date Quarterly Reports Angola SASH Quarterly Reports FY12 Q1-Q4 Jhpiego, MSH FY12 Angola SASH Quarterly Reports FY13 Q1-Q4 Jhpiego, MSH FY13 Angola SASH Quarterly Reports FY14 Q1-Q4 Jhpiego. MSH FY14 Angola SASH Quarterly Reports FY15 Q1-Q4 Jhpiego, MSH FY15 Angola SASH Quarterly Reports FY16 Q1-Q4 Jhpiego, MSH FY16 Angola SASH Quarterly Reports FY17 Q1 & Q2 Jhpiego FY17 Annual Work Plans Angola SASH Annual Work Plan FY12 Jhpiego, MSH FY12 Angola SASH Annual Work Plan FY13 Jhpiego, MSH FY13 Angola SASH Annual Work Plan FY14 Jhpiego, MSH FY14 Angola SASH Annual Work Plan FY15 Jhpiego, MSH FY15 Angola SASH Annual Work Plan FY16 Jhpiego, MSH FY16 Conference Abstracts, Presentations, & Posters HIV “Referral Helps, Escorting Patients Helps More, but Integration Is Best: Providing Jhpiego: Jhony Juarez, Margarita Gurdian, Samson HIV testing and counseling in a TB clinic increases testing uptake from 15 to 97 Ngonyani 2011 percent in Huambo province, Angola” (Plenary); International Conference on AIDS & STIS in Africa (ICASA) “Angola and HIV” (Poster); 2nd East And Southern Africa Regional EMTCT Jhpiego: Samson Ngonyani 2014 Global Plan Stock-Taking Meeting “Task shifting ARV Prescription to Nurses Increases Uptake of Prevention of Jhpiego: Samson Ngonyani, Kelly Curran, Margarita Mother to Child Transmission (PMTCT) Services Among HIV+ Pregnant Women Gurdian, Jhony Juarez; INLS: D. Serrano, J. Simões, M. 2015 in Luanda, Angola” (Plenary); International Federation of Gynecology and Nunes; Obstetrics (FIGO) Africa Regional Conference “Supporting Angola’s Acceleration Process Towards the Elimination of New Jhpiego: Jhony Juarez HIV Infections Among Children and Keeping Their Mothers Alive” (Plenary); 2016 21st International AIDS Conference 2016; 18-22 July 2016 Family Planning “Family Planning: A Powerful Tool for Reducing Maternal Death” (Plenary); Jhpiego: Jhony Juarez, Margarita Gurdian, Anaisia de American Public Health Association (APHA) Melo Octavio, Samson Ngonyani; MoH: Adelaide de 2013 Carvalho, Isilda Neves “Meeting the Unsatisfied Demand for Family Planning Services in Peri-Urban Jhpiego: Jhony Juarez, Margarita Gurdián, Samson Setting in Angola” (Plenary); International Conference on Family Planning Ngonayni, Anaisia de Melo Octavio; MSH: Ana Díaz; 2013 (ICFP) MoH: Isilda Neves, Elsa Coelho, Maria da Conceição André Malaria “Malaria in Pregnancy Program Implementation: Key Elements & Materials” Jhpiego: Jhony Juarez 2012 (Plenary); Central African Regional Network (CARN) “Working Together: The Key To Success in Controlling Malaria in the Province Jhpiego: Jhony Juarez; MoH: Frederico João Carlos 2015 of Huambo, Angola” (Poster); American Public Health Association (APHA) Juliana, Amandio Natito, Lelo Zola “Winning the Fight against Malaria in Huambo Province, Angola” (Plenary, Jhpiego: Jhony Juarez, William Brieger; MoH: Poster); American Society of Tropical Medicine & Hygiene (ASTMH) Frederico João Carlos F. Juliana, Clementino 2015 Sacanombo “Readiness for Malaria Elimination: Using HMIS Data to Map Malaria Test Jhpiego: William R. Brieger, Jhony Juarez, Connie Lee, Positivity in Huambo Province, Angola” (Plenary, Poster); American Society of Clementino Sacanombo; MoH: Frederico João Carlos 2015 Tropical Medicine & Hygiene (ASTMH) F. Juliana “The Challenge of Reducing Malaria in Angola” (Poster); American Society of Jhpiego: Margarita Gurdian, Jhony Juarez, Julio 2016 Tropical Medicine & Hygiene (ASTMH) Bonilla, William Brieger Studies Completed HIV HIV Testing and Counseling Index Case Study, Luanda, Angola Jhpiego: Marcia Ueda, Jhony Juarez, Samson 2016 Ngonyani, Vita Vemba, Thiago Costa, Julio Bonilla HIV Retention Study, Luanda, Angola Jhpiego: Marcia Ueda, Jhony Juarez, Samson 2016 Ngonyani, Vita Vemba, Thiago Costa, Julio Bonilla; INLS: Isabel Fortes, Felicina Alberto Family Planning “Evaluation of Long-Acting Contraceptive (Implant) Acceptance, Utilization, Johns Hopkins University Bloomberg School of Public 2016 and Discontinuation in Huambo & Luanda, Angola” Health: Mary Qiu, Peter Winch; Jhpiego: Jhony Juarez; MSH: Vita Vemba MoH: Adelaide de Carvalho, Frederico Joao Carlos Juliana, Lucas Nyambe, Islda Neves, Ligia Alves Abreu Pecamena Malaria “Malaria Elimination Planning for Huambo Province Angola” Jhpiego: Margarita Gurdian, Gilberto Jolomba, 2015 Adolfo Sampaio, William Brieger Norms and Protocols

HIV HIV Counseling & Testing Services: Protocol (2014) Jhpiego: Samson Ngonyani; INLS Team 2014 Antiretroviral Treatment Guidelines (2015) Jhpiego: Samson Ngonyani; INLS Team 2015 Jhpiego: Amelia Kaufman, Samson Ngonyani; INLS Protocol for Evaluation and Follow-up of Nursing for HIV + Patients 2016 Team Malaria Updated National Malaria Strategy 2016-2020 Jhpiego, NCMP, MoH 2016 MANUALS HIS DHIS2 User Manual and technical documentation Jhpiego, MoH, GEPE, GTI 2016 HIV HIV Counseling and Testing: Reference Manual (2013) Jhpiego: Amelia Kaufmann, Maria do Rosario Nunes; UNICEF: Alfredo Francisco; INLS: Isabel Fortes de 2013 Carvalho, Julieta da Cunha Simões

HIV Counseling and Testing: Trainer's Manual (2013) Jhpiego: Amelia Kaufmann, Maria do Rosario Nunes; 2013 UNICEF: Alfredo Francisco; INLS: Isabel Fortes de Carvalho, Julieta da Cunha Simões

Manual of Prevention of Vertical Transmission of HIV for Nurses: Participant Jhpiego: Samson Ngonyani; INLS Team 2016 Manual (PMTCT 2016) Manual of Prevention of Vertical Transmission of HIV for Nurses: Trainers Jhpiego: Samson Ngonyani; INLS Team 2016 Manual (PMTCT, 2016) Malaria Malaria in Pregnancy Manual (2015) Jhpiego: Adolfo Sampaio, Jhony Juarez; MOH; NMCP; 2015 INLS; PMI/USAID; PMI/CDC; UNICEF; World Learning Training Materials, Job Aides, & Tools HIV Training module in Counseling and testing for lay counselors Jhpiego: Samson Ngonyani; INLS Team 2014

Training module for Case Managers in HIV care and treatment Jhpiego: Samson Ngonyani; INLS Team 2015

Training module for PAFs in health dignity and prevention and retention Jhpiego: Samson Ngonyani; INLS Team 2015 counselling of PLWHIV Training module for Couple counseling and testing for HIV Jhpiego: Samson Ngonyani; INLS Team 2015 Training module for trainers in competency Jhpiego: Samson Ngonyani; INLS Team 2016 based training of CT service providers

Training module for service Providers in Post Exposure Prophylaxis Jhpiego: Samson Ngonyani; INLS Team 2016 Training module for adherence in ART Jhpiego: Samson Ngonyani; INLS Team 2016 Training module for Enhanced adherence counselling in case of detectable Jhpiego: Samson Ngonyani; INLS Team 2016 viral load Training module for Activists in Gender Based Violence (GBV) Jhpiego: Samson Ngonyani; INLS Team; PSI: Valentina 2016 Rossi Training module for Activists in HIV Index case contact tracing Jhpiego: Samson Ngonyani; INLS Team 2016

Job Aide: Standard Operating Procedures (SOPs) HIV Clinical Records Jhpiego: Samson Ngonyani, Thiago Costa; INLS Team; 2016 Pediatric HIV/AIDS Hospital Hospital Pediatrico Team Job Aide: HIV Patient Flow Charts Jhpiego: Samson Ngonyani, Thiago Costa; INLS Team 2016 Malaria Job Aide: Malaria Album Seriado Jhpiego: Adolfo Sampaio, Jhony Juarez; MoH 2016

Quality Improvement Standards, Tools, & Job Aides HIV Standards to evaluate the competencies in provision of PMTCT services Jhpiego: Samson Ngonyani; INLS Team 2012 Standards to evaluate the competencies in provision of care and treatment Jhpiego: Samson Ngonyani; INLS Team 2015 services first visit Standards to evaluate the competencies in provision of care and treatment Jhpiego: Samson Ngonyani; INLS Team 2015 services follow up visits Standards to evaluate the competencies in the provision of HIV counseling Jhpiego: Samson Ngonyani; INLS Team 2012 and testing services Family Planning Standards for evaluating provider performance in uncomplicated incomplete Jhpiego: Jhony Juarez; Anaisia de Melo Octavio 2014 abortion care Standards for evaluating counseling of women with incomplete abortion Jhpiego: Jhony Juarez; Anaisia de Melo Octavio 2014 Standards for evaluating provider performance at FP follow-up visit Jhpiego: Jhony Juarez; Anaisia de Melo Octavio 2015 Standards for evaluating provider performance at first consultation Jhpiego: Jhony Juarez; Anaisia de Melo Octavio 2015 Standards for evaluating provider performance on insertion and removal of Jhpiego: Jhony Juarez; Anaisia de Melo Octavio 2015 implants and interval IUDs Standards for evaluating postpartum IUD insertion Jhpiego: Jhony Juarez; Anaisia de Melo Octavio 2015 Standards for evaluating provider performance in FP Infection Control and Jhpiego: Jhony Juarez; Anaisia de Melo Octavio 2015 Prevention Malaria Standards for Diagnosis and Treatment of Malaria Jhpiego: Adolfo Sampaio, Jhony Juarez; MOH; NMCP 2015

Plano de Pre Eliminacao da Malaria na Provincia de Huambo Jhpiego: Bill Brieger, Adolfo Sampaio, Vita Vemba, 2015 Gilberto Jolomba; NMCP, DPS Huambo Municipal Strategic Plans Huambo Strategic Municipal Development Plans 2013-2017 Huambo Municipal Teams from: Bailundo, Caala, 2013 Cahiungo, Chicala, Chinjenje, Ecunha, Huambo, Londuimbali, Longonjo, Mungo, Ucuma Luanda Strategic Municipal Development Plans 2013-2017 Luanda Municipal Teams: Belas, Cacuaco, 2013 Cazengaa, Icolo Bengo, Quicama, Viana Luanda Strategic District Development Plans 2013-2017 Luanda District Teams: Mainga, Rangel, Sambizanga 2013 Videos Informational Video: SASH PMTCT Work in Angola Jhpiego: SASH Team, Charles Wanga, Ann Lolordo, 2016 “ SASH: Reaching Angolan Mothers and Babies through HIV Testing and Silvia Kelbert, Cole Bingham, Kara Breen, Michelle Treatment” (English Version); and “ForçaSaúde: Alcançando as mamães e os Goshen bebés angolanos através de testagem e tratamento para o VIH” (Portuguese Version)

ANNEX IV

KEY PERFORMANCE INDICATORS FOR Y1 TO Y6

Goal Goal Level Indicators Summary TARGET RESULT

HIV 89% (HTC) 2 Increased quality of FP: 98% Percentage of HFs achieving Analysis will include disaggregation by (FP 1st Evaluation: 96% 3 HIV/AIDS, FP and malaria 1 50% 80% of quality standards technical area 4 services FP Return: 100% ) MIP 93% 5 1. Indicator measured between Y4 to Y6. 2. 9 HFs evaluated. 3. 49 HFs evaluated. 4. 50 HFs evaluated. 5. 85 HFs evaluated.

Output IR # Key Performance Indicators Summary TARGET RESULT # An “HMIS guideline” signifies a written set of recommended procedures for health data management Number of HMIS tools and 1 including (but not limited to) data collection, storage, 5 5 2 guidelines developed or updated 1 cleaning, quality control, analysis, validation and presentation for target audiences Number and percentage of RMS units demonstrating Number of RMS units that use IR. core competencies in quality collection, analysis, 1.1 2a information for planning and 4 20 4 1 dissemination, and use of health information for health management 3 planning and management. SASH is working with GEPE to develop a tool that the Number of RMS using SASH 2b “above-site” facilities use for reproductive health data 2 3 6 supported information tools 5 collection, aggregation, analysis and visualization HIS coordination group formed 3 1 1 7 and functioning 1. First three years KPI name was: "Number of National HIS guidelines, tools and/or indicators developed/ updated and disseminated" 2. Results: - Mapping and Readiness tool - Excel tool for elaborate reports in HFs (version 1, 2 and 3), with several tools integrated in one: malaria, reproductive health (FP, antenatal care, deliveries), epidemiological surveillance, HIV, laboratory, outpatients, health posts and centers reports and others. This tool is the first one developed specifically for health low complexity HFs, and it has improved the data quality, facilitated the production of reports and allowed the HFs managers to use information for decision-making with a minimum cost because it uses electronically the same information that the HF staff register in its daily registry books. By example, productivity information (how many health consultation are done by each health technician). - Angolan SIS in DHIS2 3. Indicator measured for Y1 to Y3. 4. 11 municipalities in Huambo and 5 municipalities (Cacuaco, Viana, Belas, Icolo & Bengo, Quissama) and 4 districts (Samba, Rangel, Sambizanga, Maianga) in Luanda 5. Indicator measured for Y4 to Y5. 6. Angolan HIS in DHIS2 used in Bailundo, Londuimbali, Mungo 7. During Y3, GEPE started hosting meetings of the HIS TWG composed of representatives from GEPE, SASH-USAID, Cuban Cooperation, PRSMS - World Bank, EU PASS II and an Advisor of the Minister. This TWG prepared a Work Plan and implemented many activities in coordination with the partners. During Y5 and Y6, GEPE and GTI conformed a DHIS2 TWG with SASH, national programs of DNSP and INLS in order to develop and implement the HIS Angola in DHIS2, and a DHIS2 coordination group with other partners: SASH, USAID, PRSMS - World Bank, EU PASS II, Global Fund, UNAIDS, WHO in order to elaborate a plan for the deployment of DHIS2 to another provinces and the addition of more national programs to the platform. IR Output # # Key Performance Indicators Summary TARGET RESULT

Municipal Annual Health Planning and Elaboration and implementation of a Guide to carry out 1a monitoring guideline updated and in 1 1 2 AOPs and monitor the implementation at municipal level use 1 An operational plan is an instrument that includes the municipality priorities to be developed in the current year. Number of supported RMS units with 1b In this way the allocation of financial and other resources 4 8 4 AOPs 3 must be directly related to these specific priority health problems Number of RMS units with budgets Elaboration of budgets based on annual health plans at 2a 4 6 5 1.2 linked to their annual health plans 1 municipal level The monitoring capacities strengthened at municipal level Number of municipalities with 2b will bring decision makers capabilities to track their AOP 4 4 6 monitoring capacity strengthened 3 and manage their priorities through basic M&E tools. IR. 1 Number of national health norms and SASH is working with RMS to operationalize national 3 regulations adopted at the municipal norms and regulations at the municipal level 6 158 level 7 (HIV: norms for HTC; Malaria: MIP; FP). Number of municipal health staff Municipal health staff who attend SASH training on 4 trained on budget or pharmaceutical 12 50 budget management. management 7 Number of RMS units with current Elaboration of HRH plans to improve their management 1 human resource plans incorporated capacities and incorporate to the annual health plans at 9 20 into their annual health plans 1 municipal level 1.3 Number of DPS, RMS, HF managers with HR responsibility who have Based on HRH management plans identify improvement 2 13 48 increased their competency to carry at local level. Baseline established out their HR role 1 1. Indicator measured for Y1 to Y3. 2. During Y2, SASH used the tool developed during Y1 and during Y3 SASH provided TA through one national guide provided by PNDS NS. 3. Indicator measured for Y4 to Y5. 4. Municipalities of Huambo: Catchiungo, Tchicala-Tcholohanga, Chindjenje, Ekunha, Londuimbali, Longonjo, Mungo, Ucuma 5. Municipalities of Cachiungo, Ecunha, Londuimbali and Ucuma in Huambo, and Viana municipality and Kilamba Kiaxi district in Luanda. 6. SASH used the MPBT in the municipalities of Cachiungo, Ecunha, Londuimbali and Ucuma in Huambo. 7. Indicator measured during Y5. 8. Regulations: HTC (1), PMTCT (1), HIV Care and Treatment (2), Malaria (3): Pregnancy, Adults and Children, FP (8): 1st consultation, follow up consultation, PPIUD, IPC, intra uterine device insertion, implant insertion, incomplete abortion care, incomplete abortion counselling Out TAR RESULTS IR put # Key Performance Indicators Summary GET # HIV FP MAL HIS TOT Standards for quality service provision in FP, 1 Number of quality standards in use 1 22 4 8 6 21 2 malaria, and HIV developed/adapted HF staff trained through TOTs (disaggregated by 2 Number of trainers trained 3,4 248 201 366 259 34 808 training topic (SBMR, HIV, Malaria, SIS, FP) 2.1 Municipal or district area teams that conduct Number of municipal QI teams supervision visits according to a quarterly IR.2 3 20 6 13 5 6 4 27 6 functioning supervision plan, and are using the standard supervision tools Average increase in the score of all standards Average net increase over baseline in applied in a HF, compared to the average 2.2 1 50% 76% 10% 63% 50% achievement of quality standards 7 achievement of these standards from the baseline assessments 1. First three years KPI name was: "Number of standards finalized and approved" 2. Quality Standards developed/adapted (each quality standard can have more than one versions): o HIV: . Standards to evaluate the competencies in the provision of HIV counselling and testing services . Standards to evaluate the competencies in provision of PMTCT services . Standards to evaluate the competencies in provision of care and treatment services first visit . Standards to evaluate the competencies in provision of care and treatment services follow up visits o Malaria . Pediatric Treatment (2 versions) . Treatment of MIP (2 versions) . Care for Severe Malaria in Adults (2 versions) . Each malaria quality standard was updated in order to respond to WHO guidelines recommendations. o FP . Initial FP Consultations . Follow-up FP Consultations . PPIUD . IPC . IUD insertion . Implant insertion . Incomplete abortion care . Incomplete abortion counselling 3. First three years this KPI was disaggregated in two: - "Number of people reached with TOTs and on-site training on SBM-R approach (Disaggregated by quarter)"; and - "Number of Trainers trained disaggregated by technical area" 4. For the target and for each technical area we use the maximum value of the six years because TOTs could be repeated. 5. Municipalities of Cazenga, Cacuaco, Viana, Belas and Quisama and District of Kilamba Kiaxi, Sambizanga, Samba and Ingombota in Luanda, and the municipalities of Huambo sede, Bailundo, Londuimbali and Ucuma in Huambo. 6. Total is more than the total of municipalities in Luanda and Huambo because one municipality can have more than one team considering technical areas 7. First three years KPI name was: "Increase over baseline in achievement of quality standards"

Outp TAR RESULTS IR # Key Performance Indicators Summary ut # GET HIV FP MAL HIS TOT Number of training modules adapted to reflect national norms, protocols 1 8 14 2 26 3 14 41 disaggregated by technical area (FP, Malaria and HIV and AIDS) 1 HFs to which the project has visited on a quarterly basis, provided job aids and other Number of HFs receiving substantive materials and assessed using the SBM-R 2 330 215 169 144 60 451 support 4,5 methodology. Disaggregated by technical IR.2 2.3 area and Province. Target is the same as the highest number. Number of health care workers who HF staff who have attended in-service 3 successfully completed an in-service training. Disaggregated by sex, technical area 684 2244 426 604 785 2951 training program 6 and Province HFs using GEPE/SASH developed tool for Number of HFs using SASH supported 4 reproductive health data collection, 4 8 52 52 52 60 7 information tools aggregation and analysis 1. Indicator measured between Y1 to Y3. 2. HIV training modules: • HIV Counseling and Testing: Reference Manual (2013) • HIV Counseling and Testing: Trainer's Manual (2013) • Manual of Prevention of Vertical Transmission of HIV for Nurses: Participant Manual (PMTCT, 2016) • Manual of Prevention of Vertical Transmission of HIV for Nurses: Trainers Manual (PMTCT, 2016) • Training module for training of case managers in care and treatment • Training module in Counselling attesting for lay counsellors • Training module for Activists in HIV Index case contact tracing contact tracing • Training module for Couple counseling and testing for HIV • Training module for trainers in competency based training of CT service providers • Training module for service Providers in Post Exposure Prophylaxis • Training module for adherence in ART • Training module for Enhanced adherence counselling in case of detectable viral load • Training module for Activists in gender based violence • Training module for PAFs in Positive health dignity and prevention and retention counselling of PLWHIV 3. SASH developed more than one module for each method. 4. First three years KPI name was: "Number of HFs receiving job aids and guidelines" 5. For the target and for each technical area we use the maximum value of the six years because the HFs could be repeated. 6. For the target and for each technical area we use the maximum value of the six years because the trained could be repeated. 7. 52 HFs in Huambo and 8 HFs in Luanda (PEPFAR selected HFs).

Prog # KPI Summary TARGET RESULT ram Number of individuals who received HIV Testing and Counselling (HTC) services 1 HTC_TEST 581,609 632,184 for HIV and received their test results 1 Number of HIV-positive adults and children newly enrolled in clinical care during 2 CARE_NEW the reporting period who received at least one of the following at enrollment: 17,864 3 14,757 clinical assessment (WHO staging) OR CD4 count 2 Number of HIV-positive adults and children who received at least one of the 3 CARE_CURR following during the reporting period: clinical assessment (WHO staging) OR CD4 66,903 5 20,959 count OR viral load 4 4 TX_NEW Number of adults and children newly enrolled on ART 2 8,406 6 10,652 5 TX_CURR Number of adults and children currently receiving ART 2 22,080 7 20,847 HIV Number of HIV-positive pregnant women who received antiretrovirals to reduce 6 PMTCT_ARV 9,021 6 4,715 risk of mother-to-child-transmission (MTCT) during pregnancy and delivery 8 Percentage of HIV-positive pregnant women who received antiretrovirals to 7 reduce risk for mother-to-child-transmission (MTCT) during pregnancy and 69% 76% delivery (NGI) 9 Number of pregnant women with known HIV status (includes women who were 8 PMTCT_STAT 294,452 314,074 tested for HIV and received their results) 8 9 SITE_SUPP Number of unique sites supported by PEPFAR 10 58 230 Number of HFs providing ANC services that provide both HIV testing and ARVs 10 110 158 for PMTCT on site 9 1. Indicator measured between Y3 to Y6. 2. Indicator measured between Y4 to Y6. 3. There is no target for Y6. 4. Indicator measured between Y4 to Y5. 5. There is no target for Y4 and Y6, and annual target for Y5 was not set accurately. 6. There is no target for Y4. 7. There is no target for Y4 and Y6. 8. Indicator measured between Y3 to Y4. 9. Indicator measured during Y3. 10. Indicator measured during Y4.

Program # Key Performance Indicators Summary TARGET RESULT

Stock out rate of contraceptive The team will routinely check for reported stock-outs (those 1 commodities at FP service delivery that happen at the beginning or end of the month) for 10% 12% 2 points 1 selected tracer commodities. CYP is the estimated protection provided by FP services Couple Years Protection (CYP) in during a one-year period, based upon the volume of all FP 2 80,615 137,627 3 USG supported projects 1 contraceptives sold or distributed free of charge to clients during that period To determine the role of USG support in the national FP 82% Luanda Percent of FP services receiving response, this indicator looks at the number of FP services 3 30% 39% USG assistance 1 that offer counseling on FP relative to all of the FP services Huambo 4 in the supported provinces 1. Indicator measured for Y4 to Y5. 2. Indicator measured as average for results achieved in Y4 and Y5. Stock out was a permanent problem during the entire project, despite the frequent coordination at all levels because the problem was at national level. 3. Indicator measured for Y4 and Y5. 4. Between 2011 and 2016, the number of HFs with FP services in Luanda and Huambo increased due to the support of SASH Project. No other Project worked on this, only SASH.

Program # Key Performance Indicators Indicator TARGET RESULT

Number of health workers trained in case management with Trained in malaria case 1 artemisinin-based combination therapy (ACTs) with USG 94 2 931 management 1 funds Malaria Trained in malaria laboratory Number of health workers trained in malaria laboratory 2 94 2 926 diagnostics 1 diagnostics (RDTs or microscopy) with USG funds 3 Trained in malaria IPTp 1 Number of health workers trained in IPTp with USG funds 94 2 931 1. Indicator measured between Y4 to Y6. 2. Annual targets were low related to the numbers needed to achieve the objectives of the Project.

ANNEX V: SASH Staff and Consultant List

IN-COUNTRY STAFF FULL NAME TITLE ORGANIZATION PROJECT YEAR KEY PERSONNEL Margarita Chief of Party Jhpiego 2011-2017 Gurdian Jhony Juarez Deputy Chief of Jhpiego 2011-2017 Party/Technical Director Julio Bonilla Senior HIS Advisor Jhpiego 2012-2017 Samson Ngonyani HIV Team Lead Jhpiego 2011-2017 Andrea Diarte M&E Health Informatics Jhpiego 2012-2013 Advisor Scott Merritt M&E Health Informatics Jhpiego 2013-2014 Advisor Julia Perri Senior Operations Manager Jhpiego 2016-2017 Ana Diaz Result I Team Lead MSH 2011-2014 Vita Vemba Strengthening Health MSH 2011-2017 Systems Senior Advisor Luis Bolanos Result 1 Team Lead MSH 2014-2016 Adelina Nobre HRM Advisor MSH 2014-2016 PERSONNEL Ndoza Luwawa Municipal Decentralization MSH 2012-2014 Advisor Adolfo Sampaio Provincial Malaria Jhpiego 2012-2016 Coordinator Gilberto Jolomba Municipal Coordinator- Jhpiego 2011-2017 Huambo Anaisia Octavio Provincial Family Planning Jhpiego 2011-2017 Coordinator - Luanda Cecilia Dembei Provincial Family Planning 2014-2017 Coordinator - Huambo Cecilia de Jesus Provincial Family Planning Jhpiego 2012-2014 Catumbela Coordinator- Huambo Maria Graca PAFs Coordinator Jhpiego 2011-2017 Baptista Maria do Rosario Provincial HIV Coordinator - Jhpiego 2011- 2015 Nunes Luanda Domingas Manuel Assistant to HIV Team Lead Jhpiego 2015-2017 Filipina Manuel HIV case manager Jhpiego 2015-2016 Maria de Fatima HIV case manager Jhpiego 2015-2016 Afonso Baptista Luiana Gaspar HIV case manager Jhpiego 2015-2016 Tonduangu HIV case manager Jhpiego 2015-2016 Matias Sara Domingos HIV case manager Jhpiego 2015-2016 Pires Joana Aguinalda HIV case manager Jhpiego 2015-2016 Maria Isabel Bartolomeu HIV Case Manager Jhpiego 2015 Augusta HIV Provincial Coordinator Jhpiego 2014 Chicumbo Ivandro Martinho HIV case manager Jhpiego 2015-2016 de Pepeka Lisdalia Abraao HIV case manager Jhpiego 2015-2016 Rafael A. Pedro Finance Manager Jhpiego 2011-2017 Jorge Ngaca Financial Analyst Jhpiego 2012-2017 Rosa Pedro Financial Analyst Jhpiego 2013-2017 Francisco Wanda Financial/Administrative Jhpiego 2012-2017 Coordinator in Huambo Province Mali Jamba Administrative Assistant Jhpiego 2013-2017 Elisa Andre Administration Manager & Jhpiego 2011-2017 HR coordinator Josefa M. Sona Administrative Assistant Jhpiego 2012-2017 Alberto Pedro Logistic Assistant Jhpiego 2016-2017 Zua Prata Manuel Senior driver Jhpiego 2011-2017 Domingos Driver Jhpiego 2011-2017 Caetano Jaze Agostinho Driver Jhpiego 2014-2017 Kissanga Maria Elena Joao janitor Jhpiego 2011-2017 Belita Joao Janitor Jhpiego 2011-2017 Nilton E. Sebastiao Jr. M&E Analyst Jhpiego 2014-2017 Fadeusa Praia M&E digital clerk Jhpiego 2014-2017 Joao Junior M&E digital clerk Jhpiego 2015-2017 Osvaldo M&E digital clerk Jhpiego 2015-2017 Fernando Silveira Manuel Luemba M&E digital clerk Jhpiego 2016-2017 Tati Alberto F. M&E Jr. Analyst- Huambo Jhpiego 2012-2017 Goncalves Juscelino Melves M&E digital clerk Jhpiego 2015-2016 Alberto Waldemar M&E digital clerk- Huambo Jhpiego 2014-2017 Gandara Anastacia Janitor-Huambo Jhpiego 2015-2017 Chingonguela Cipriano Mendes Driver - Huambo Jhpiego 2012-2017 Chiumbo Anibal Andrade Driver - Huambo Jhpiego 2015-2016

HEADQUARTERS STAFF FULL NAME TITLE ORGANIZATION PROJECT YEAR Connie Lee M&E Advisor Jhpiego 2015-2017 Senior Program Officer 2011-2015 Bernice Pelea Senior Program Officer Jhpiego 2015 Michelle Goshen Program Officer I Jhpiego 2015-2017 Senior Program Coordinator 2012-2014 Kara Breen Senior Program Coordinator Jhpiego 2015-2017 Ricardo Bonner Finance Team Lead Jhpiego 2011-2014 Rachel Kopajtic Finance Team Lead Jhpiego 2014-2017 Rebecca Fielding Finance Administrator Jhpiego 2013-2017 Senior Program Coordinator 2011-2012 Silvia Kelbert Technical Advisor, HIV Jhpiego 2015-2017 Prevention, Care, and Treatment Ricky Lu Director, FP/RH Jhpiego 2011-2017 Veronica Reis Senior Technical Advisor, Jhpiego 2011-2015 MNH/RH Bill Brieger Senior Malaria Specialist Jhpiego 2011-2016 Bruno Benavides Senior Advisor Jhpiego 2011-2014 Health Systems Development

CONSULTANT STAFF FULL NAME TITLE ORGANIZATION Thiago Martins Consultant, HIV/AIDS Jhpiego Zeferino Saugene Consultant, DHIS2 Jhpiego Amelia Kaufman Consultant, HIV/AIDS Jhpiego Marcia Ueda Consultant, HIV QI Monitor Jhpiego Vita Vemba Consultant, Technical Advisor Jhpiego Almudena Gonzalez Consultant Jhpiego Steve Sapiri Consultant MSH Jacqueline Lemlin Consultant MSH Eliana Monteforte Consultant MSH Hector Colindres Consultant MSH Lia Junqueiro HRH COnsultant MSH

ANNEX VI Success Story

The Singing Nurses!—Music facilitates Antiretroviral Treatment Learning in Huambo, Angola

In 2014, the INLS developed an acceleration plan to expand PMTCT option B plus all over the country to ensure pregnant women living with HIV have access to ART. According to the plan, as soon as a woman is diagnosed with HIV, her health care provider will prescribe her a combination regimen of three antiretroviral drugs, which she will continue to take for life. The treatment plan seems to be straightforward, but Nurse Trainer Helena Cumbelembe soon realized that carrying this out in a remote health center, 40km from the nearest municipal hospital, would not be simple. The SASH project, financed by USAID, trained Helena so she could in turn teach and train the six nurses working Photo: In Mungo, a remote area of Huambo at Chorinde Health Center to take care of HIV province, Helen Cumbelembe, a 42-year-old patients in their small town in southeastern Angola, SASH-trained nurse, found a creative and effective way to train her peers at Chorinde 120 kilometers from Angola’s second city, Huambo, Health Facility to provide ART to pregnant where Helena is based. The six nurses are eager to women living with HIV, so their babies will be help, but as with many health care workers in rural born free of the virus. Angola, they lack all but the most basic training in nursing, have not received any medical refresher trainings in years, and only completed limited primary education. Helena explained, “…The learning is slow and they could not pronounce well the names of the ARVs drugs, let alone to remember the combination of the drugs.” Helena asked herself what she could do, and with her fellow nurse trainer came up with new lyrics to the well- known children’s nursery rhyme, Frere Jacques. “Ah it was quick and easy. The nurses sang and danced, the names stuck and they could remember the combination very well. Even when we went back for supervision they recited the ARVS correctly.” Helena’s struggle to successfully train these nurses, and they in turn to provide high- quality medical care to PLHIV, reflects the reality of rural Angola. After years of war, many of the educated nurses have immigrated to cities, leaving the rural areas with less educated health professionals who are motivated to work but lack the skills and support. Many rural nurses worked to provide much-needed first aid during the civil war, and now are integrated into the formal health system in the post-war era. Through the SASH project, Jhpiego and partner MSH have trained health care workers like Nurse Helena and her colleagues to provide HIV testing, ARVT, malaria treatment and FP counselling. Without the work of these nurses, many pregnant women living with HIV will never start treatment, or abandon treatment after beginning it. The benefit of strengthening the capacity of nurses is clear: two-thirds of the 524 HIV-positive pregnant women in Huambo received ARVT in 2014, compared to only 13% in 2013. Thanks to nurses like Helena, many HIV pregnant women have now have access to ART. Brava, Helena!