FundingModel TBAndHIVConceptNote Final Ethiopia Oct15 2014

The single concept note details the applicant’s request for Global Fund
resources for a disease component for a three-year period. The concept

note should articulate an ambitious, strategically focused and technically
sound investment, informed by the national health strategy and the national
disease strategic plan. It should represent a prioritized, full expression of
demand for resources, and it should be designed and implemented in a way
that maximizes the strategic impact of the investment. The single concept
note for TB and HIV details the CCM’s request for countries with high co-
TB AND HIV
infection rates for the two diseases based on data from the World Health
Organization.
CONCEPT NOTE
Investing for impact against tuberculosis and HIV
Countries with overlapping high burden of tuberculosis (TB) and HIV must submit a
single concept note that presents each specific program in addition to any integrated and
joint programming for the two diseases.
In requiring that the funding requests be presented together in a single concept note, the
Global Fund aims at maximizing the impact of its investments to make an even greater
contribution towards the vision of a world free of the burden of TB and HIV. Enhanced
joint HIV and TB programming will allow to better target resources, to scale-up services
and to increase their effectiveness and efficiency, quality and sustainability.
All concept notes should articulate an ambitious, strategically focused and technically
sound investment, informed by the national health strategy and the national disease
strategic plans (NSPs).
The concept note for TB and HIV is divided into the following sections:
Section 1: The description of the country’s epidemiological and health systems context
including barriers to access, the national response to date, country processes for
reviewing and revising the response, and plans for further alignment of the NSPs,
policies and interventions for both diseases.
Section 2: Information on the national funding landscape, additionality and sustainability
Section 3: The funding request to the Global Fund, including a programmatic gap
analysis, rationale and description of the funding request, as presented in the modular
template.
Section 4: Implementation arrangements and risk assessment.
TB and HIV Concept Note: Ethiopia 15 October 2014│ 1

SUMMARY NOTE:
IMPORTANT INFORMATION
Applicants should refer to the TB and HIV Concept Note Instructions
to complete this template.
Applicant Information
Country ETHIOPIA
Funding Request Funding Request December 2017
July 2015
Start Date End Date
Principle
Ministry of Health and HAPCO
Recipient(s)
If the programs are to be managed as separate grants:
Funding Request Funding Request December 2017
July 2015
Start Date for HIV End Date for HIV
Principal
Recipient(s) for HAPCO
HIV
Funding Request Funding Request
July 2015 December 2017
Start Date for TB End Date for TB
Principal
Recipient(s) for Ministry of Health
TB
FUNDING REQUEST SUMMARY TABLE
A funding request summary table will be automatically generated in the online

grant management platform based on the information presented in the
programmatic gap table and modular templates.

SECTION 1: COUNTRY CONTEXT
This section requests information on the country context, including descriptions of

the TB and HIV disease epidemiology and their overlaps, the health systems and
community systems setting, and the human rights situation.
1.1 Country Disease, Health Systems and Community Systems Context
With reference to the latest available epidemiological information for TB and HIV,
and in addition to the portfolio analysis provided by the Global Fund, highlight:
a. The current and evolving epidemiology of the two diseases, including trends
and any significant geographic variations in incidence or prevalence of TB
and HIV. Include information on the prevalence of HIV among TB patients
and TB incidence among people living with HIV/AIDS.
b. Key populations that may have disproportionately low access to prevention,
treatment, care and support services, and the contributing factors to this
inequity.
c. Key human rights barriers and gender inequalities that may impede access to
health services.
d. The health systems and community systems context in the country, including
any constraints relevant to effective implementation of the national TB and
HIV programs including joint areas of both programs.
Back ground : General
Ethiopia is a country with a population of 88 Million 1. The annual population growth

rate is 2.6% and average size of a household is 4.7 persons. According to the 2007
census, the country is among the least urbanized nations in the world with 83.6%
living in rural areas while only 16.4% is living in urban areas. Nearly 11% of the
Ethiopian population are living in hot lowlands area mainly pastoralist community.
The Federal Democratic Republic of Ethiopia is composed of nine Regional States
and two City Administrations councils, which are further sub divided into 840
administrative Woredas (districts) and the Woredas, further divided into about
17,000 Kebeles, which are the smallest administrative unit in the governance.2
Major progress registered in improvement of the health status of the Ethiopian
population in the last two decades. However, there are high rates of morbidity and
mortality from common causes of ill health. Preventable communicable diseases
and nutritional disorders continue to be the major health problems affecting the
majority of the population. Health indicators from 2011 DHS show a life expectancy
of 54 years (53.4 years for male and 55.4 for female) at birth, infant mortality rate
(IMR) of 59/1000 and under-five mortality rate of 88/1000. More than 90% of child
deaths are due to pneumonia, diarrhoea, malaria, neonatal problems, malnutrition
and HIV/AIDS, and often a combination of these conditions.
1 Central Statistical Agency: Population projection of Ethiopia for all regions at Woreda level 2014-
2017, August 2013, Addis Ababa
2 HSDP VI

Process of the CN preparation
The CN was developed in a participatory approach. The following processes were
undertaken. A) A media call was made for country dialogue ( Annex 1) B) a
country dialogue meeting was conducted on 15 August 2014 whereby 134
participants drawn from different sectors participated ( Annex 2) C) Group
discussions with Female sex workers ( Annex 3 ) and PLHIV ( Annex 4) were
conducted on 27 and 29 August 2014( key population respectively D)
Establishment of CN writing team E) Developed a focus area based on the
country dialogue, group discussion and gap analysis and presented to CCM (
Annex 5). CCM discussed in detail on 25 September and endorsed as the focus
areas for the CN. F) the draft CN was shared to different partners and received
inputs. G) CCM discussed again on the draft concept note on 9 October 2014 and
endorsed with the incorporation of the inputs of the partners and CCM members.
The inputs received were incorporated and shared again to CCM members.
1.1 Country Disease, health system and country systems context
A. Epidemiology
HIV/AIDS
The HIV epidemic in the country is a mixed type with variation by sex, age,
demographic characteristics and geographic areas. According to DHS 2011, the
national HIV prevalence among the general population aged 15-49 years was 1.5%,
with 1.9 % in women and 0.9% in men. The HIV prevalence among people aged
15-24 years is lower (men= 0.09 % and women=0.5 %) than that of people aged 25-
49 years. The HIV prevalence increases with age from 0.2% at 15-19 age groups
to 3.7% at 30-34 in women and from 0% at 15-19 to 3% at 35-39 in men. After the
peaking of the prevalence for women at age 30-34 and men at 35-39, the
prevalence drops thereafter, but remains higher than that of 15-24 years age group
(Figure 1&2).
Figure 1: HIV Prevalence rates by age group in women and men (Source: EDHS
2011 and Epidemiologic synthesis 2013 edition)
4
3.5 3.7
3 2.9 3
2.5
2 2.1
1.9 1.8 Women
1.5 1.4
1 0.9 0.9 1 Men
0.5
0 0.2 0.2
0
15-19 20-24 25-29 30-34 35-39 40-44 45-49
Age (yr)

Figure 2: HIV prevalence by sex and year (EHNRI: HIV related estimates and
projections for Ethiopia-2012 and EPHI, 2014 Spectrum estimation)
5.0%
5%
4.6%
Female Male
4.2%
4%
3.7%
3.3%
3.0% 2.9%
3%
2.6% 2.6%
2.4%
2.3%
2.1% 2.1%
2% 1.8% 1.9% 1.8%
1.6% 1.6%
1.5%
1.4%
1.3%
1.1%
1.0% 1.0% 0.9% 0.9%
1%
0%
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
HIV prevalence, by sex and year
The DHS 2011 also shows that there is an HIV prevalence variation by marital
status. The prevalence is 0.3% (0.5% in women& 0.3% in men) among never
married; 1.5% (1.5% in women & 1.3% in men) among married/living together;
5.2% (5% in women & 5.9% in men) among divorced/ separated and 12.2%(12% in
women & 14.5% in men) among widowed aged 15-49 years. The HIV prevalence
among remarried was disproportionally higher (4.3% in females & 2.6% in males)
than that of married once (1.7 % in females & 1 % in males).
Figure 3: HIV prevalence among remarried adults, by the per cent remarried in each
age group (Epidemiologic synthesis 2013 edition & EDHS 2011)

7.0
6.0
HIV prevalence (%)
5.0
4.0
3.0
2.0
1.0
0.0
male female
<= 1 marriage 1.0 1.7
>1 marriage 2.6 4.3
All rounds of HIV sentinel surveillances among ANC pregnant women conducted in
the country, and the 2005 and 2011 DHS demonstrated difference in HIV
prevalence between urban and rural areas. The recent DHS shows that the HIV
prevalence is 4.2% in urban and 0.6% in rural areas. There are also differences
based on distance from an asphalt road (<5km has 4X the prevalence compared to
>5 km). The HIV prevalence in regions ranges from less than one percent in the
Southern Nations, Nationalities and People region (with a population size of 15
Million) to 6.5% in Gambela (with a population size of 350,000).
summarizes HIV prevalence rate per region according to the recent three nationally
representative data sources.
Table 1. HIV prevalence, TB/HIV co infection and TB CNR data per region
Region TB case
HIV Prevalence (%) TB/HIV co Notification
infection /100,000
(%) population
DHS ANC ANC 2012 2013 HMIS data
2011 2009 2012 HMIS
Tigray 1.8 2.2 1.9 15 156
Afar 1.8 4.5 2.7 11 259
Amhara 1.6 3 2.7 14 149
Oromia 1 1.7 1.2 7 155
Somali 1.1 3.5 4.4 2 87
Benishangul 1.3 2.9 1.5 6
G. 90
SNNPR 0.9 1.4 1.6 4 142
Gambela 6.5 5.4 3.1 22 247
Harari 2.8 3.7 4.6 18 612
Addis Ababa 5.2 5.3 4.4 31 234
Dire Dawa 4 4.9 3 17 293

A national MARPs survey focusing on female sex workers and truck drivers was
done in 2013. The HIV prevalence is 23% among female sex workers and 4.9%
among truck drivers. Rapid assessment of HIV situation in prison settings was
conducted in 2013 and found that the HIV prevalence among prison inmates to be
4.2% (4.3% in males & 3.8% in females). Baseline survey among daily labourers
in building and road construction sites conducted by the Transaction project in 2010
showed 9-12% reported STD prevalence in six months3.
Table 2: Size estimation and HIV prevalence among FSWs, truck drivers and daily
Labourers
Key population Size estimation HIV Source

in 2013 prevalence
FSWs 120,000- 23% National MARPS survey ,2013, EPHI

160,000
Truck drivers 15,000 4.9% National MAPS survey, 2013, EPHI
Daily /seasonal 1,000,000 NA

labourers and
prisoners 112,361 4.2% Rapid assessment of HIV situation in

prison settings. December 2013.
UNODC, UNAIDS, Ethiopian Federal
Prison Administration – draft
According to the ANC based HIV sentinel surveillance the HIV prevalence among
15-24 year-old has declined from 12.4% in 2001 to 2.1% in 2012. Furthermore, a
spectrum modelling to estimate and project the HIV related parameters (
prevalence, incidence, death, ART need etc ) with the use of the 1989 to 2012 ANC
based HIV sentinel surveillance and DHS 2011 results was conducted in 2014.
This has shown that the adult HIV incidence has decreased by 90% 4 from 0.28% in
2005 to 0.03% in 2013. The total number of newly HIV-infected persons has
decreased from 140,000 at the peak of the epidemic in 2000 to 21,500 in 2013, of
whom 13,200 are adults and 8,300 are children. Of the estimated total number of
new HIV infection by 2013, 11,700 (54.4%) and 9,800 (45.6%) had occurred in
urban and rural areas respectively. Overall, there is a decreasing trend of HIV
prevalence and new infections as shown in the figures below5. In fact, Ethiopia has
reached the ‘HIV Tipping Point,’ in which number newly initiated on ART exceeds
the number newly infected.
Figure 4: Trends in HIV prevalence among pregnant women age 15-49 yr by
3 Baseline report by Transaction,2010

4 UNAIDS 2012, Global AIDS report
5 2012 ANC surveillance report and HIV investment case 2015-2020

location (Source: ANC 2012)
16
14 14.3
12.8
12 12
10 9.6 Urban
8
Rural
6 5.8 5.7 6.2
5.3 Total
4.9 4.4
4 4 4.1 3.7 3.3
2.5 2.2 2.5 2.6 2.3
2 1.9 1.8
0
2001 2002 2003 2005 2007 2009 2012
Figure 5: Trends in HIV Prevalence by age group (Source: ANC 2012)
Figure 6: Trends of New HIV infection by sex (Source: 2012 HIV related estimates&
projections and 2014 Spectrum estimation)

80
Female (x 1,000)
70
Male (x 1,000)
60
50
40
30
20
10
0
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
New HIV infections, by sex and year
Empirical data from the AIDS Mortality Surveillance study in Addis Ababa showed
steady decline in AIDS related mortality from 2001 to 2009. HIV-related deaths
among men declined from 41% (2001) to 11% (2009); and from 51% (2001) to 14%
(2009) among women6. An ART implementation status and outcome study for the
September 2005 to May 2010 treatment cohorts in Ethiopia also showed that 78%
of the cohort survived five years.
Figure 7: AIDS and AIDS related death by year (EHNRI: AIDS related estimates
and projections and EPHI, 2014 Spectrum estimation)
6Reniers,G.A;T.Davey,G; Nagelkerke,N;Berhane, Y;Coutinho R; Sanders,EJ (2009), “ Steep

declines in Population level AIDS mortality following the introduction of Antiretroviral therapy in Addis
Ababa, Ethiopia” AIDS 23(4):511-518

140
Number of…
120
100
80
60
40
20
0
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
AIDS and HIV-related illness deaths, by year…
Based on the recent Spectrum modelling, the estimated number of PLHIV in 2014 is
769,600 of whom 591,100 (76.8%) are adults and 178,500 (23.2%) are children
under 15. Of the total estimated adult population living with HIV in the country,
369,800 (62.6%) and 221,300 (37.4%) are females and males respectively. About
sixty-seven percent of PLHIV live in urban areas and thirty three percent in rural
areas.
In general, the epidemic has declined markedly, but the type remains
heterogeneous with largely affecting women, urban dwellers people with marital
disruption or remarriage and at risk population such as female sex workers and
truck drivers. The existing behavioural data and field observations also exhibit that
migrant workers in the various development schemes and mega projects in the
country are at risk for HIV as many have risky sexual practices.
In addition to the Mode of transmission studies conducted in three regions in the
last four years, an epidemiologic synthesis also conducted in 2013. The driving
factors for the epidemic in the country include
A) the Mother to child transmission of HIV, which accounts for a third of the new
infections
B) presence of high discordance ( two third of the positive cohabiting couples)
particularly in urban areas , remarriage( serial partnership)
C) risky sexual behaviours among urban residents, STI ( HIV prevalence among
respondents in DHS 2011 with symptom of STI was 4.7%) and
D) low consistent condom use with non regular partners among at risk population
such as waitresses ( 53.2%) and daily labourer ( 35.9%).
Cognizant of these changes in context, the country in collaboration with

development partners refocused the HIV prevention with a balanced approach of
targeting the identified at risk population (female sex workers, truckers,
seasonal/daily labourers in development schemes, extensive and mechanized

farms) and the general population since the development and implementation of the
HIV Strategic plan 2010-2014. Furthermore, this was refined and a more targeted
and focused strategy was developed as described in the 2015-2020 HIV Investment
Case.
Tuberculosis
Ethiopia is the ninth high-TB burden country in the world, with an estimated 230,000
new cases of TB (incidence rate 247 per 100,000 populations) reported in 2012.
Compared to the 1990 baseline, there has been a major decline the prevalence,
incidence, and TB associated death rates in the country as shown in Figure 8
below. The prevalence rate for all forms of TB has declined from 425/100,100 in
1990 to 224/100,000 populations in 2012 (47% reduction). Similarly, the TB
incidence rate has dropped from 367 in 1990 to 247/100,000 population in 2012
(32% reduction), after peaking to 421/100,000 in 2000. The TB related mortality rate
has also declined from 49/100,000 in 1990 to 18/100,000 in 2012 (63% reduction
from 1990 level). The country is therefore on track in achieving the TB related MDG
targets.
Figure 8. Trends in TB prevalence, incidence and mortality rates 1990-2012
600
Prevalence
Rate/100,000
500 populations
400
Mortality
300
Rate/100000
populations
200
Incidence
100 Rate/100,000
populations
0
Source: Global TB Reports 1991-2013

Further examination of the available data suggests wide variations in the local TB
epidemiology. According to the 2010/11 national TB prevalence survey, for
example, smear positive and bacteriologically confirmed TB was more prevalent
among 15-34 years old population groups and in pastoralist settings (Table 3). The
prevalence of bacteriologically confirmed TB cases was found to be comparable in
rural and urban areas, whereas, the prevalence of smear positive TB cases was
higher in pastoralist and rural areas.7 Given the higher TB case notification rates
from urban regions compared to rural settings over the years and better access to
TB diagnostic and treatment services in the urban settings, it appears that the
historic prevalence of TB in urban settings was actually higher than the prevalence
in rural settings.
7 National TB Prevalence Survey Report, 2011

Table 3. Prevalence of smear positive and bacteriologically confirmed pulmonary
TB (per 100 000 population, > 15)
Prevalence of smear positive
pulmonary TB Prevalence of bacteriologically
Setting
(per 100 000 population), % confirmed pulmonary TB (per 100
(95% CI) 000 population), % (95% CI)
Urban 68 (22-157) 230 (134-368)
Rural 101 (70-141) 235 (187–292)
Pastoral 166 (67-342) 290 (150–506)
Source: Ethiopia TB prevalence survey 2010/11
Despite the extensive expansion of DOTS services in the country and the massive
expansion of TB prevention and control activities at the grass-root level, the case
notification rate (CNR) for all forms of TB remains low compared with the estimated
incidence. However, over the last four years, the gap in the estimates for TB
incidence and case notification rates (CNR) has been widening; namely, there has
been significant decline (over 8% decline per year) in the number of notified TB
cases since 2011 (Figure 9).
Figure 9. Trends of TB incidence rate vs CNR per 100,000 populations in Ethiopia:
1999-2014
450 428 421 408 395

400 379 Incidence/100k
359
342
350 324
308
293 CNR/100K
Rate/100K Pop
300 280 269 258 247 247

250
175 179 179 185
200 157 161 170 168 160 164 165
134 137 145
150 116
100
50
0
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Source: Global TB Reports 2000-2013, National TB Report 1999-2013

There is wide geographic variation in the number of notified TB cases at local level.
Figure 10 shows that TB case notification rate per 100,000 populations has been
consistently higher in urban regions compared to rural and pastoralist settings.

Figure 10: TB cases notification arte by major agrarian, pastoralist and
urban regions: 2008-2013
1000
CNR Urban
case per 100,000 popn
800 Region
600
CNR
Pastoralist
400 Region
200 CNR
Agrarian
Region
0
2008 2009 2010 2011 2012 2013
Source: National TB Data

Detailed analysis of TB CNR data by regions also shows that there is a consistent
decline in TB case notification rates from all major agrarian regions and urban
settings over the last 4 years. However, the CNR in some of the pastoralist regions
has shown an increasing trend as shown in the following figure.
Figure 11: TB Case Notification trends by regions in Ethiopia: 2008 - 2013

Source: National TB Data
The recent decline in TB CNR appears to be due to many factors. Under reporting
of detected cases through the national HMIS, sub-optimal implementation of
community based TB activities in most of the regions and under planning in high-
burden settings and at local level are among the main reasons contributing to the
declining trends. Under-reporting of TB cases has been identified in the recent
national HMIS Routine DQA conducted at national level. The assessment revealed
that 22% of registered TB cases were not reported to HMIS. The under-reporting is
mainly related with the recent shift from vertical paper based TB program reporting
to more horizontal HMIS reporting of TB cases in 2011. Results from two regions
which maintained both the vertical TB program reporting system and the HMIS
confirm underreporting by the HMIS - in Addis Ababa, for example, the HMIS was
able to capture only 50% of what was reported through the vertical reporting

system.8 Besides the under-reporting, the decline is also related to sub-optimal
implementation of community based TB case finding activities in all regions. Data
from regions that implemented comprehensive community TB care activities has
shown an increasing TB CNR trends during the same trend.9 The decline in TB
CNR also followed the release of the result of TB prevalence survey conducted in
2010/11, which revealed a lower TB prevalence and incidence estimate as
compared to the WHO estimates leading resulting in attainment of the 70% TB
CDR. This has created a sense of satisfaction and under-planning for TB case
finding targets in regions and localities. This is particularly the case in areas where
the prevalence of the disease is higher than the national level prevalence and
incidence level estimates. In such settings, the use of national level Incidence
estimate to set targets for TB case detection at regional and local level will lead to
under-planning, as targets for CDR could be easily attained without much effort due
to higher burden of TB. Further studies to establish the main deriving factors for the
acute decline in TB case notification are also required.
It has also been identified that certain geographic areas within the regions have
been consistently notifying high number of TB cases over the last years. For
instance, HEAL TB, a USAID Supported project operating in the two major regions
of the country (Oromia and Amhara) has reviewed TB case notification data by
zones and districts and identified high burden reporting zones and districts in
Oromia and Amhara regions, as shown in the following figures underscoring
differential geographical disease burden and possibly limited performance of health
services in the sites identified.10,11
Ethiopia has a very high proportion of EPTB cases, which has been in a range of
32-36% of all notified TB cases over the last decade.12 In 2013, the highest number
of EPTB cases per 100,000 populations were notified in the following three major
cities: Harari (228), Dire Dawa (118), and Addis Ababa (90), followed by Afar (68),
Tigray (64), and Amhara (62) regions.
9TB REACH Report, SNNPR

10Belaineh Girma, et.al; Wide variations in tuberculosis case notification rates across districts
suggest the need for shaping our strategies toward targeted interventions. National TB research
conference , Ethiopia .March,2014
11 B. Girma et.al. Heterogeneous TB Case Notification Rates in Ethiopia: What is the implication for
TB control? International Union TB and Lung Disease, Paris 2014.
12 National TB surveillance data 2000-2013

TB case notification rate also varies by gender and age group.13 For all forms of TB
combined and for smear positive TB, notification rates are higher for males than for
females, but for both sexes, they peak at the 25-34 year age band. For smear
positive cases, the rates for males remain high from the younger age group of 15-24
all the way up to 55-64 year old but with a clear progressive increase in rates
among the aging with subsequent years. This is particularly obvious from the age
group 45-54 years. A similar distribution is seen among females even though the
rates are lower than in males (Figures 3.4a & 3.4b). This picture is pointing to a shift
to the right in the epidemiology of overall as well as new smear positive TB in the
country. Since just over a decade and half ago, the country seems to have had an
HIV driven TB epidemic with higher incidences among the young and sexually
active, peaking much earlier in females than in males. As new HIV infections begin
to decline significantly, an epidemic driven by background infections and other
factors other than HIV seems to be emerging. This is therefore indicative of double
TB epidemics; a continuing epidemic from background community transmission in
the younger age groups; and an emerging reactivation epidemic among the elderly
as more and more people begin to live longer. Further studies are also indicated to
fully understand the social determinants that might be at play in the Ethiopia
context.
Figure 13: TB notification rates by age group and gender for TB of all forms in
Ethiopia 2001-2011
Figure 3.4b: TB notification rates by age group and gender for new smear positive
TB cases in Ethiopia 2001-2011
13 Ref: NTP Review report

In 2013, pediatric TB cases accounted for 17.0% (6,588) of all new smear positive
PTB notified cases, for 16.9% (7,151) of all new smear negative PTB cases, and for
19.5% (7,549) of all new EPTB cases (Table 4).14
Table 4. New smear positive PTB, new smear negative PTB, and new EPTB cases
by age group notified in 2013
New Smear New smear
Age New EPTB
Positive Negative
Total cases notified*** 38,716 42,214 38,735
0-4 years 2,367 2,107 2,168
5_14 years 4,221 5,044 5,381
Total pediatric cases 6,588 7,151 7,549
Proportion of total pediatric
cases 17.0% 16.9% 19.5%
*** Age disaggregated data for children were available for only for 119,665 cases
Source; national HMIS data of 2013
MDR-TB Epidemiology: Ethiopia is also among the 27 high-MDR TB burden

countries. The prevalence of MDR TB increased from a baseline rate of 1.6%
among new smear positive TB cases in 2005 to current level of 2.3% in 2014;
similarly, the rate has increased from 11.8% to 17.8% among previously treated
smear positive TB cases.15 Higher rate of MDR –TB cases were observed among
females compared with males (cOR = 1.6, P = 0.04); the survey results showed that
age group did not have association with MDR TB; HIV positive individuals were
three times higher than non HIV positives to have MDR TB (cOR =3.07, P=0.043).16
The available evidences indicates clear geographic variations with the highest MDR
TB prevalence among new TB cases in major urban settings, namely, Addis Ababa
(7.1%) and Harari (6.8%).17 XDR-TB burden in Ethiopia is not known.
Despite steady progress in MDR-TB case finding very recently, it remains very low.
In 2013, only 25% of estimated MDR-TB cases among notified TB cases were
detected.
Figure14 : Trend of MDR-TB case notification TB Cases in Ethiopia: 2009 -2013
Trend of MDR-TB Case finding and estimates among notified TB

cases in Ethipiopia: 2009 -2012
3000
Estimated MDR TB
Number
2000
cases among notified
1000 TB cases
MDR TB cases Detected
0
2009 2010 2011 2012 2013
Years
TB- HIV co infection
15 DRS report 204

16
DRS report 2014
17 DRS report 2014

The 2013 HMIS and Global TB report showed that the TB-HIV co infection was 11
% with variation by region. The TB/HIV co-infection rate variation is similar to the
HIV prevalence variation by regions and residential areas. It is high in urban areas,
while TB is more prevalent in pastoralist areas. Full package of TB/HIV services are
provided in all ART sites (1047) while HIV testing and TB screening services as
well as referral are provided in 3447 public and private HFs. According to the
TB/HIV sentinel report for the period June 2012-June 2013 ( in 79 sites):
 93.1% of TB patients were tested for HIV and more than 96.7 % of newly
enrolled HIV patients were symptom screened for TB in the most recent
visit.
 TB incidence among HIV positives newly enrolled in care was 4.5%. It went
down from 10.4% in 2010.
 HIV prevalence among TB patients was 17.9%, but this may be an
overestimate as the sentinel sites were primarily urban and hospital based,
where sick patients would be seen.
 CPT uptake among co infected patients was 78.4%
 53.9% of co-infected patients were provided with ART. This varies by region
ranging from 43% to 69.4% with the exception of Somali region (11.1%).
 Only 5.5% of the newly enrolled patients in HIV care received IPT during the
surveillance report. This was partly explained by the shortage of INH.
However, a National TB- HIV and DOT assessment done in 2014, after
addressing the supply issue, showed the uptake had improved to 14% 18.
B. Key population: access to prevention, treatment, care and support

services.
Socio-cultural, economic, and geographic factors act as critical barriers to HIV and
TB services. Among socio-cultural barriers to accessing care, stigma and
discrimination continue to be critical challenges. Although there has been a decline
in discriminatory attitudes toward PLHIV compared to the 2005 values, people
expressing accepting attitudes toward PLHIV remained low at 17%. Similarly,
people with TB and their families face stigma and discrimination, with over a half of
TB patients reporting perceived stigma in one report19. The growing threat of MDR-
TB and widespread misconceptions among the community are likely to contribute to
worsening of stigma and discrimination against people contracting TB and their
families. While HIV and TB share similar socio-cultural and economic barriers, there
are specific key populations for each of the diseases.
B 1. HIV
As summarized in Table 2 above, Ethiopia identified the following as key

populations within the context of the Ethiopian HIV epidemiology: Female sex
workers, truck drivers , seasonal /migrant labourers , discordant couples and
18 FMHO/EPHI. TB/HIV and DOTS assessment. Preliminary report presented at the Annual TB Program review meeting
19 Abebe G, Deribew A, Apers L, et al. Knowledge, Health Seeking Behavior and Perceived Stigma towards Tuberculosis
among Tuberculosis Suspects in a Rural Community in Southwest Ethiopia. PLoS ONE 5(10): e13339.
doi:10.1371/journal.pone.0013339

dwellers of hot spot areas. As planned in SPM II, MARPs survey focusing on female
sex workers and truck drivers was conducted and estimated the HIV prevalence at
24.7% in female sex workers and 4.9% in heavy truck drivers. The STI prevalence
among the FSWs was high ( 11.5% among those who had had a vaginal discharge
while 7.9% among those genital ulcer). The 2013 HIV epidemiologic synthesis
confirmed the aforementioned groups as key populations. Further, the HIV
prevalence among prison inmates is 4.2% (4.3% among men & 3.8% among) as
per the 2013 rapid assessment of HIV in the prison settings. .
HIV prevention, treatment and care services are accessible to the majority of the
target population as there are many service providing sites ( 3447 HIV testing sites,
2495 PMTCT sites and 1047 ART) , the services are provided free ,and there is no
legal barrier that hinders access to services. Furthermore, there are community
based and work site based HIV services that avail some of the services and
facilitate the utilization of these services by the key population. PLHIV and female
sex workers have been engaged as treatment adherence educators, tracers of
those lost to follow and peer educators which have also improved the service
uptake among the key population.
However, there are a substantial proportion of FSWs, truck drivers and

migrant/daily laborers that have not fully reached due to limited capacity of the
service delivery system and also there are a segment of these groups that have
not accessed and discontinued service uptake due to stigma and discrimination,
lack of comprehensive knowledge, lack of trust on the service, fear of side effects,
food or nutrition related issues and lack of social support.20 The national stigma
index conducted in 2010 showed that 69% of the participants experienced stigma in
the form of gossip while nearly 11% of the PLHIV reported that they were physically
assaulted at least once in the 12months preceding the survey. The same study
showed that 56% of men and 49% of women experienced internalized (self) stigma
and one quarter of the participants isolated themselves because of their HIV status
from their families.
As part of the development process of the concept note group discussion among
PLHIV and Female sex workers living in Addis Ababa was conducted and they
pointed out the following as reasons for not accessing or discontinuing services.
These include:
 Still there are many FSWs unreached with HIV education through the peer
educators as owners of drinking establishment and house owners do not
allow any volunteer to go and provide education in their establishment .
 They do not have trust in symptom based STI treatment and do not take the
medicines as prescribed.
 Some patients discontinued ART claiming they are healed by divine
intervention or being fed up taking medications every day
20 NEP+. The People Living With HIV Stigma Index: Ethiopia. Summary of Findings Report. 2011

 Poor counselling quality by adherence counsellors.
 Lack of food or nutrition support
 Orphan children growing up with their grandparents or other guardians have
lower chance of undertaking HIV test and know their HIV status due to lack of
knowledge among the care giver or fear of stigma and discrimination .
B2. TB
Prisoners, refugees, migrant population and pastoralist population are identified as
key population affected by TB. According to CSA/UNHCR report, there are 112,361
estimated numbers of prisoners in Ethiopia; the pastoralist population is estimated
to be 10,284,343 which account 11% of the total population (CSA), evidence show
that the risk of TB among this group of population is higher compared to general
population. According to the current national assessment finding the estimated TB
prevalence among prisoner was 3381 per 100,000popn which is nearly 14 times
higher. Similarly, Ethiopia TB prevalence survey revealed that prevalence of TB
among pastoralist population is found to 277/100,000. Limited diagnostic capacity of
the Health facilities, geographic inaccessibility for TB/HIV services, low
socioeconomic status and highly mobile living style of the population are among key
barriers to TB prevention, treatment and support services in those population
groups. All the risk factors for TB transmission as well as disease development are
believed to be prevalent in such marginalized communities. Adherence to TB
treatment is also another major challenge in these settings and the generic DOT
which is the main treatment adherence strategy for TB lacks patient-centeredness
and not convenient for a highly mobile population with limited access to health
services.
Ethiopia is in fast economic growth and huge development projects are flourishing in
different parts of the country. This undertaking has created huge population mobility
into the mega development projects to meet the HR need. Thousands of people
have been mobilized to the project sites from almost all over the country and this will
continue at a higher scale in the future as more and more mega projects start. The
health needs of these transiently settled populations in the project sites will be
immense. There are nearly one million mobile workers who are working in a mega
projects (mining, sugar plantation and dam and roads and railways construction)
and large scale working sites. Access to health services in general and to TB control
services will be limited under such circumstances since the NTP never considers
these settings in the annual plans. The risk of TB therefore, could be similar to the
risk among migrant populations if TB control strategies are not in place. According
to UNHCR report, there are about 630,000 estimated refugees in Ethiopia, most of
the refugee camps are found in the very remote part of the country and
programmatic condition and access to general health services is very much limited.

Table 5: Description of key affected population
Key population Population size Estimated TB Estimated MDR-

group Prevalence TB Prevalence
Prisoners 112,361 21 1.5% among

annually reported
3,381/100,000 22
TB patients23
Refugees 629,718 24 368/100,000 25 No data available
Seasonal Migrant 1,000,000 247/100,000 2.3% among new

Workers in Mega and 17.8% among
Projects previously treated
TB
Pastoralist 10,284,343 26 277/100,000 2.3% among new

population and 17.8% among
previously treated
TB
Urban poor/ 4,854,622 27 247/100,000

urban slums
C. Human right barriers and gender inequalities that impede access to health
services
The Government of Ethiopia formulated the National policy on Women in 1993 to

address gender inequality in social, economic and political areas, and to devise
major strategies to address gender issues in the country. In 1994 the government
also created supportive constitutional provisions to establish women’s equality with
men. Since then significant policy, legal, institutional and social measures have
been taken to address gender inequalities in all spheres. The major ones are
a) The Development and Social welfare policy formulated in 1996 puts special
emphasis on gender issues including elimination of all forms of discrimination
against women with respect to technical training, formal sector employment, and
working conditions, as well as access to healthcare services.
21 WPPL 10th edition

22 National TB/HIV Assessment Preliminary report, 2014
23
National TB/HIV Assessment Preliminary report, 2014
24 UNHCR Operation in Ethiopia, July 2014
25 Report of IOM Activities, 2011
26
CSA and mini DHS
27
CSA and mini DHS

b) The development of the National Reproductive Health strategy and launching of
the Health Extension Program which largely focuses on community based
provision of services to women and children in more than 15,000 villages.
c) The revisions of the family law, penal code and Civil servants’ proclamation.
The revised family law raised the marriage eligible age for girls from 15 to 18 years,
making it equal with that of boys and promulgated that marriage should be
concluded by consent. Harmful traditional practices such as female genital
mutilation, abduction, early marriage and rape, which hamper the human and
health rights of women, became punishable by the revised penal code. With the
extensive public education, community mobilization efforts through religious
leaders, local leaders, women’s association & media, and the effecting of the
revised law had reduced the aforementioned harmful traditional practices in the
community. Similarly, the revised Civil Servants’ Proclamation ensured women’s
right to affirmative action and the creation of violence free working environment
including free from sexual violence.
d) Initiation of the Women centered Health development army in the rural and
urban areas which aims at demand creation and utilization of primary health
care services among the communities, particularly women.
e) Improved service uptake among women, and girls and boys. For example,
women accounted for 53% of last year’s HIV tests
In conclusion there is no policy, legal frame or institutional norm that creates

gender inequalities and which in turn impedes access to health services. However,
there are still society beliefs and practices in pastoralist communities and certain
localities that affect the health of women and also impede access to health services.
Examples: intergenerational sex, female genital mutilation and wife inheritance.
There are women (31.5%, DHS 2011) who believe that a wife should not propose
condom use if her husband has STI.
Overall there is an enabling environment for all population segments in the country
to access health services including PLHIV, female sex workers, prison inmates
and other vulnerable populations. For instance, prison inmates received ART and
TB care in the health facilities of the prison establishment as well as any other
public health facilities free of charge. However, stigma and discrimination remains
high though notable improvement was observed. According to DHS 2011,
prevalence of discriminatory attitudes toward PLHIV declined between 2005 and
2011. A group discussion held with FSWs on 27 August 2014 as part of the
concept note development process mentioned that hotel owners where the FSWs
are working and sometimes house owners who rented their houses to FSWs are not
willing to let the FSWs get the peer education. They also pointed out that some
stopped ART because of stigma, especially those who live in rented houses and
when they feel they would be stigmatized if they found taking the medication.
D. Health and community system
Ethiopia has a three-tier health care delivery system: a Woreda/district health care

tier comprising a primary hospital (covering 60,000-100,000 population), health
centers ([HC] covering 15,000-25,000 population) and their satellite health posts
(HP) located in each Kebele/village (covering 3,000-5,000 population) connected to
health center by a referral system, all taken together constituting primary health care
unit (PHCU). A General and Specialized Hospitals are next tiers covering a
population of 1-1.5 and 3.5-5 million, respectively. Starting from 1996/97,
Government of Ethiopia (GOE) has formulated and implemented four consecutive
Health Sector Development Plans (HSDPs), with the latest plan covering 2010/11 -
2014/2015, which outlines key strategic areas and sets targets for health sector
development.28 In 2005, Ethiopia launched a new Health Extension Package (HEP)
aimed at achieving universal primary health care (PHC) coverage and
institutionalization of the community health services at health post level. Since 2005,
there has been significant increase from 2,800 trained and deployed female HEWs,
to current 32,500 community-HEWs deployed in 16,599 Kebele/village HPs
(approximately two HEWs per HP) throughout the country.
Service delivery
There has been massive expansion of health facilities over the last decade. As of
2014, there are a total of 156 public hospitals (including 26 university and referral
hospitals), 3,335 health centres and 16,251health posts providing health services in
2013/14. A number of new constructions of health facilities are going on including
123 hospitals, 211 health centers and 203 health posts Private health facilities have
significantly been contributing in increasing access to health services. Engaging
private health facilities in the provision of TB DOTS and TB/HIV services began in
2006 following the development of national PPM-DOTS Implementation guideline,29
first as USG-supported pilot project and subsequently been expanded. Currently
there 276 private-for-profit HFs engaged in PPM-DOTS services, with plan for
further expansion as indicated in the NSP.30 Furthermore, there are civil society
organizations (CSOs)/faith based organizations (FBOs) backing up the care and
support through community based systems supporting continuity of care.
In line with expansion of health facilities over the last decade, TB and HIV services
were also scaled up. The scale up and expansion of TB and HIV Services is as
shown in the following figure.
Figure 15: Trend of HCT, PMTC, AFB Microscopy and TB DOTS services
expansion in Ethiopia: 2010 -2014
28 Health Sector Development Program IV 2010/11 – 2014/15, 2010

29
???
30 NSP, page ??

Trends of TB and HIV Diagnostic and treatment Services
Expansion 2010-2014
4000
3500
3000
2010
2500
2011
2000
1500 2012
1000 2013
500 2014
0
HCT PMTCT ART AFB TB DOTS(RX
Microscopy only)
In 2009, the FMOH of Ethiopia in collaboration with partners developed national TB

infection control (IC) guidelines, training materials, various job aids and provider
support tools adopted based on the international guidance. National, regional as
well as health facility level sensitization workshops and trainings has been
delivered. However, the implementation of minimum package of TB IC interventions
has not uniformly implemented in health facilities in the country.
The health care system in Ethiopia relies upon a tiered network of laboratories and
reference laboratories, with an increasing degree of specialization at each tier. As
part of this design, specialized equipment and test systems have been placed at
various laboratories throughout the country, including automated analysers for
haematology, chemistry, CD4 testing; molecular diagnostics like DNA-PCR; culture
systems, TB liquid culture, and additional molecular diagnostic techniques. There is
one national reference laboratory for TB, HIV, Malaria and other laboratory services
with more than 10 high-profile regional reference laboratories with TB Culture and
DST as well as viral load testing capacities. Sample transport system through postal
courier has been established for transportation of sputum samples for TB culture
and DST, HIV Viral load testing and DBS. However, the coverage is inadequate
and utilization is sub-optimal. These gaps will be addressed through interventions
included in the HSS concept note for sample referral and lab networking.
Human Resources for Health
Staffing remains an issue with relatively high turnover and low number of skilled
staff at mid and high levels of the health system. The total health workforce
currently in service in the country is 66,314 persons (including HEWs). In the
Ethiopia health system context, the health extension worker is the pillar of the
community system; it is an innovative approach aimed at promoting health,
disease prevention( HIV, TB, Malaria, Diarrhea, etc ) and providing of family
health services and selected curative health services at the community level. In
every village where there are 3000 to 5000 populations, there is one health posted
staffed with two women health extension workers. To further strengthen this and
intensify the involvement of the community in the primary health care, a new

initiative called Health development army has been introduced at the community
level. With the lead of a role model household head, a team with five members is
organized and engaged in demand creation, strengthening community and health
center linkage and improving primary health service utilization including TB and HIV.
The Health extension worker and health development army has contributed
significantly to the high uptake of HIV testing, the improvement in PMTCT and
MNCH services, TB community care and malaria control.
PSM
To address the need for un-interrupted supply of pharmaceuticals and health

commodities, the government has established the Ethiopian Pharmaceutical Fund
and Supply Agency (PFSA) in 2007. Since its establishment, the agency has
designed a new Integrated Supply Management System (IPLS) and, to make the
system work efficiently. A number of new and modern warehouses were
constructed and the old ones renovated to increase storage capacity. There are
also huge renovation investments at facility levels to improve the storage capacities
of pharmaceutical stores.
PFSA has designed an automated Health Commodity Management Information

System (HCMIS), implemented at Central PFSA hubs, and selected health facilities.
Using the same system, communication and information exchange between central
PFSA and hubs has improved greatly. Some health facilities have also started using
the system although the numbers are few and communication with the hubs using
the system is yet to be established. Based on the design of the new system, direct
delivery of health commodities to health facilities has started to minimize the levels
of pipeline and subsequently reducing the number of warehouses and minimizing
the time required for supplies to reach service delivery points to minimize/avoid
shortages and stock outs of the necessary pharmaceuticals.
Even though there is a significant improvement in the overall PSM, a continued

need remains for capacity building to strengthen the procurement and supply of
drugs and commodities. Some of the major gaps include long procurement lead-
time, resulting in frequent stock outs and emergency procurements, inadequate
storage and distribution capacity, and inadequate logistics management information
system. Although the integrated direct delivery system through Integrated
Pharmaceuticals and Logistics Supply (IPLS) has been progressively expanding, all
ART, PMTCT, and other sites are not fully covered yet. The distribution of
HIV/AIDS, TB and malaria commodities from districts to the health centers and to
health posts is weak mainly due to limited capacity for bulk logistics transport at
national level. At central level, PFSA has a shortage of transportation resources to
deliver commodities from the central warehouses to the primary and secondary
warehouses in the country. The HSS concept note will substantially address the
transport gaps linking central, regional and district levels particularly for integrated
supervision activities and timely delivery of commodities. The FMOH and partners
will also share the cost of building of transport networks. This activity will strengthen
PFSA by providing trucks to facilitate the transportation of HIV/AIDS, TB and

malaria supplies and commodities from central level to regions as well as sustain
their distribution.
Food, Medicines and Health Care Control Authority (FMHACA) is a responsible

authority to undertake inspection and quality control of health and health related
products including ARVs and TB drugs. FMHACA QC laboratory is accredited in
accordance with ISO 170125 with the assistance of USP/PQM (USAID). All the
product quality control tests are being carried out in this laboratory. FMHACA has
also been conducting post-market surveillance of essential pharmaceutical
products. The key constraints in product quality control include attrition/poor
retention of skilled and experienced professionals; poor supportive supervision and
feedback system; inadequate integration and collaboration with regions and other
stakeholders; weak collaboration between FMHACA and national programs as
impediment to smooth operations related to product importation and clearance.
Interventions to improve product quality control and regulatory system are covered
through MDG pool fund and with the support of other development partners.
HMIS
GOE has invested a lot to improve HMIS and routine health service data quality.
Shift from paper-based HMIS to electronic HMIS (e-HMIS) and electronic medical
record (EMR) systems has been started as a pilot and there is a need for rapid
scale up nationwide. The number of facilities implementing e-HMIS increased to
2,345 in June 2014. In addition, e-HMIS has been upgraded to reflect the changes
in the revised list of priority indicators - the pre-ART/ART registers and e-HMIS have
recently been revised to include all globally recommended as well as nationally
relevant TB, TB/HIV, MDR-TB, and HIV/AIDS indicators. There is also a national
sentinel surveillance system for TB and HIV. The major gaps in scaling up HMIS
include health care workers training on revised HMIS, health information technicians
training and deployment, HMIS data quality issues with particular focus on under-
reporting, incompleteness, and inconsistency of data. Interventions to improve
HMIS operations and data quality are included in the HSS concept note.
Program management and M&E
Recently conducted HSDP IV annual performance assessment documented

weaknesses of the existing health system with regard to evidence-based planning,
monitoring, evaluation, policy formulation and implementation, also limited capacity
to provide on time supportive supervision and monitoring at each level as well as
limited capacity in data collection and analysis and in information use for decision
making purposes. The HSS concept note considers supporting activities aimed at
improving coordination between programs at different levels as well as improving
financial management capacity of public health programs, and scaling up the
Integrated Financial Management Information System (IFMIS) that is one of the
major financial reform programs in the public sector.
TB and HIV specific Health and community system constraints
HIV Testing and counselling, PMTCT, ART and TB diagnostic & treatment are
available in 3447; 2495; 1047 and 3258 public and private health facilities
respectively. Private health facilities have significantly been contributing in
increasing access to TB/HIV care and treatment services. Furthermore, there are
CSOs/FBOs backing up the care and support through community based systems
supporting continuity of care. Despite these remarkable improvements in HSS and
TB/HIV services delivery, there are still some constraints that need to be addressed
so as to better improve the outcomes. The main health system and community
constraints relate to HIV and TB services include:
 ART service is not available in all health facilities providing TB diagnostic and
treatment services. Less than third of HCs with TB treatment sites currently
provide ART. Only 73% of HCs provide AFB microscopy, and only 38% of
HPs are implementing DOTS through community TB care (CTBC) approach.
 Weak referral system and follow up
 Frequent disruption of laboratory services particularly CD4 testing and AFB
microscopy.
 Weak laboratory equipment maintenance capacity, networking, sample
transfer and lab information system.
 Limited access to and under utilization of facilities for early infant diagnosis,
viral load testing and TB culture and DST as well as long laboratory results
turn-around-time.
 The pharmaceutical and logistics management system is not optimal to
generate timely information on consumption, stock status and stock
inventory.
 Low utilization of HIV testing data at the local level; limited implementation of
the HMIS and incomplete or in adequate data on TB and HIV service uptake.
Though the implementation has not yet started, the indicators in the HMIS
were revised recently to address the existing challenges and track the
performance adequately.
 Weak QC and EQA systems for TB and HIV lab services.
 Gaps in implementation of TB IC measures in health facilities and prison
settings as confirmed by recent National TB/HIV and DOTS assessment.
Only 20% and 30% of facilities have written IC plan and implement cough
triage, respectively.
 Gaps in knowledge, attitude and practices among healthcare providers with
regard to TB transmission risks and TB IC measures.

1.2 National Disease Strategic Plans
With clear references to the current TB and HIV national disease strategic plan(s)
and supporting documentation (including the name of the annexed documents and
specific page reference), briefly summarize:
a. The key goals, objectives and priority program areas under each of the TB
and HIV programs including those that address joint areas.
b. Implementation to date, including the main outcomes and impact achieved
under the HIV and TB programs. In your response, also include the current
implementation of TB/HIV collaborative activities under the national
programs.
c. Limitations to implementation and any lessons learned that will inform future
implementation. In particular, highlight how the inequalities and key
constraints and barriers described in question 1.1 are currently being
addressed.
d. The main areas of linkage with the national health strategy, including how
implementation of this strategy impacts the relevant disease outcomes.
e. Country processes for reviewing and revising the national disease strategic
plan(s). Explain the process and timeline for the development of a new plan
and describe how key populations will be meaningfully engaged.
Note : A chronological order of the HIV sections has been modified so as to

fit in to the country context of sequential flow of the matter.
I. HIV
A. Implementation of the previous HIV/AIDS strategic plan and
achievements
The previous strategic plan to intensify the multi-sectoral HIV response (SPM II) in
the country was for the period of the 2010 to 2014. It has been implemented
across all parts of the country and remarkable achievements were registered.
Programmatic achievements: coverage, outcome and impact
HIV Prevention
 Community based HIV programs have been implemented in 75-80% of the
communities through the health extension workers and health
development army initiative.
 Comprehensive HIV prevention program targeting female sex workers
have been implemented in 169 towns and reached 50,000 to 60,000 which
accounted for 50% coverage of the estimated 120-160, 000 FSWs in the
country. This has contributed to improve condom use, access STI
treatment, increase HIV testing uptake and adherence to ART among the
FSWs in these towns. 31
 HIV Prevention interventions targeting mobile or seasonal labourers or
migrant workers and other work forces in mega projects or development
31 HIV Investment case 2015-2020

schemes, mechanized farms and in 92 work places have been
implemented and have reached about 20% of the estimated population.
 In addition to the curriculum based HIV education in all primary and
secondary schools, Life skill HIV education has been implemented in
about 56% of the schools.
 The accessibility of HIV testing and counselling has significantly
increased and currently there are 3447 testing and counselling service
delivery points which makes a ratio of one site for about 25, 000
population. Ten to eleven million people were counselled and tested
annually.
 PMTCT B+ plus is implemented in 2542 public health facilities and 153
private health facilities.
 69% of estimated number of HIV infected pregnant women received ARVs
to prevent mother to child transmission by March 2013.32
Care and treatment
ART was decentralized to health centers which had improved the

accessibility of the service; currently the service is available in 1047
health facilities (hospitals, health centers and private clinics).
 Implementation of the 2013 WHO HIV treatment guidelines was started in
early 2014 . The adopted elements of A) Enrolling all adult PLHIV whose
CD4 is 500 or less by time of HIV diagnosis. B) Enrolling all HIV positive TB
cases, all HIV positive children under 5 and C) HIV positive pregnant
women irrespective of CD4 count by the time of diagnosis. the guidelines
were
 343, 511 PLHIV are currently on ART; among these 322 ,213 are adults
and 21298 are children which accounts for 54.5%% of the adult and
12% of under fifteen children living with the HIV respectively.
 The percentage of PLHIV who are alive and still on treatment 12 months
after initiation of ART is 85.6% by 2013.
Outcome and impact
 Condom use at most recent sexual act with non-regular clients among
female sex workers has reached 98.4%.33
 90% reduction in new HIV infection rate was noted as the incidence
reduced from 0.28% in 2009 to 0.03% in 2013. 34
 AIDS related death was reduced by 53%.
B. Limitation to the implementation of the previous HIV/AIDS strategic plan
(2010-2014)
As described above there was a successful implementation of the programs with
remarkable achievements in HIV incidence and death reduction. However, there
were constraints and gaps in some of the programs as elaborated below.
 Of the estimated 120, 000 female sex workers and one million migrant
/daily/ seasonal labourers in mega projects, farms, flower plantation and
mining areas 50% of the former and 80% of the latter were not reached
32FY2013 PEPFAR report
332013 MARPS survey, EPHI
34 UNAIDS, Global AIDS report 2012..

with behaviour change communications provided through a group or one to
one education. Furthermore, the capacity of the implementers of HIV
programs in the development schemes or mega projects is not optimal to
provide the required services.
 The Education sector has HIV specific strategic plan, but it did not fully
implement it and introduce performance measurement indicators in to the
Management information system of the Education sector.
 HIV testing and counselling was not adequately targeted and the system
does not differentiate new and repeated testers in the year. The yield
among provider initiated testing and counsel ling clients was 1.2% while
that of VCT was 2.7% in 2013. That positivity rate higher among VCT
compared to those for whom test was ordered by provider based may have
been due to indiscriminate testing of all patients visiting health facilities
or repeated testing of VCT clients to confirm a previously positive results
be
 Child testing and counselling was low due to low parent HIV status
disclosure, weak counselling capacity of service providers and weak family
based or index case testing.
 PMTCT service coverage has not reached the level to ensure elimination
of Mother to child transmission of HIV by 2015.
 Based on the CD4 500 cut off treatment eligibility, 45.5 % of adult PLHIV
have not yet enrolled for ART; paediatric ART coverage is far lower with
88% of the estimated paediatric population not yet on treatment.
 The accessibility of laboratory services is not adequate due to due to lack
of maintenance capacity, stock outs of reagents and supplies, inefficiencies
in utilization of existing machines and the limited number of functioning
machines in only selective ART sites and regional laboratories.
 The existing M&E/HMIS system did not fully track new and repeated tests
for HIV and etiological vs Syndromic STI case management.
The HIV investment case , which was developed recently , addresses these
limitations through appropriate strategies , refocusing and targeting , and
strengthening the health system with particular emphasis to improving HMIS,
decentralizing equipment maintenance , improving laboratory services and
strengthening pharmaceutical and health products management
C. The 2015-2020 HIV Investment case: goals, objectives and Priority areas
Recently the Federal HIV/AIDS Prevention and Control Office in collaboration
with national stakeholders and development partners had developed the 2015-
2020 National HIV strategic plans in an Investment case approach.
Goals: The 2015-2020 HIV investment case has two main goals. These are:
1. To prevent 70,000 to 80,000 new HIV infections.
2. To save 500,000 - 560,000 lives
Strategic objectives: The 2015-2020 HIV investment case four strategic

objectives. These are:
1. Implement high impact and targeted prevention program
2. Intensify targeted HIV testing and counselling services.
3. Attain virtual elimination of MTCT of HIV

4. Optimize and sustain quality care and treatment.
In addition to the four strategic objectives, the investment case has identified four
critical enablers. These include strengthening health system, increasing domestic
resources, effective partnership and gender equality and equity in accessing
services.
Priority program areas: The 2015-2020 HIV investment case identifies six
priority program areas. These are:
1. Behaviour change communication for most at risk population& vulnerable
groups, young people and communities. The four major strategies to
implement this priority program are :
A. Intensifying Behaviour change communication targeting at risk population
and priority geographical areas. This includes FSWs, truck drivers,
migrant/seasonal/daily labourers), urban and hot spot area dwellers, work
forces in mega projects and surrounding communities, uniformed forces,
prisoners, PLHIV and sero-discordant couples. In terms of areas the focus
will be in development schemes, hydroelectric dams, extensive &
mechanized farms, flower plantation, mining areas, urban and hot spot
areas, transport corridors, road constructions, prisons and cross border
areas.
B. Strengthening School HIV education: sustain the low HIV prevalence among
youth in school.
C. Strengthening community based HIV BCC through health extension and

Health development army: Empower communities and sustain the gains
D. Intensify media HIV Behaviour change communication using the

local/regional, and public & private FM and school media across the
country.
2. Condom distribution and use:

The main focus of this is to ensure the sustainable and equitable access to quality
condom; and promote correct and consistent use of condom for prevention of
HIV/STI and unplanned pregnancies among the sexually active population, with a
special emphasis on most at risk population and vulnerable groups. The two main
strategies at the moment are a) Social marketing b) availing free condom for most
at risk population through increasing peripheral outlets. So as to sustain this in
the future the approach will evolve to total market approach.
3. Prevention and control of STI
The focus of the next six years is to reduce the incidence of the common
sexually transmitted infections among the population, with a special emphasis
to most at risk and vulnerable population groups and intensify appropriate
diagnosis and treatment of STI through overhauling Syndromic case
management with revising the existing guidelines and implementing at all
service delivery points

4. HIV testing and counselling
The focus of this program is to identify the majority of the infections through
targeted testing of prioritized population segments and link to care and
treatment, and to respond to the created demand in the community and ensure
the rights of people to know their HIV status through co sharing or price
segmentation. Furthermore, focus will be given to optimize identification of
HIV infected children through focused testing of paediatric inpatients,
paediatric TB patients, children seen for malnutrition service, children of adult
index case and AIDS orphan. Overall the targets are identified and in clued the
following: Couples who will get married or remarried; Pregnant women;
Widowed; Most at risk population (Female sex workers, daily labourers, truck
drivers); TB patients; STI cases; Discordant couples; Orphans and vulnerable
children; children of family index cases, prisoners, uniformed forces and adults
or adolescent with medical indications or suggestive signs & symptoms of HIV.
5. PMTCT.
The women centred health development army , health extension program ,
community structures ( women’s Association & youth association) and
involvement of CSOs will be used to intensify the primary HIV prevention
among the adults, particularly women in child bearing age and strengthen the
HIV and RMNCH integration. The rolling out of the implementation of the
integrated FP and HIV services, reaching 98 % ANC coverage and testing of
at least 90% pregnant women and expanding the PMTCT B + are the key
strategies under implementation to ensure the elimination of MTCT. The main
strategies outlined in the HIV investment case to attain virtual elimination of
MTCT of HIV include
 Expanding behaviour change communication focusing on Sexual
reproductive health and HIV to all 15-49 years people through Health
extension, health development army, schools, youth and Women’s
Association and CSOs engaged in providing youth friendly HIV services.
 Increasing ANC coverage and Identification of the unreached HIV positive
pregnant women through increasing testing uptake.
 Promoting male partner testing
 Addressing missed opportunities through strengthening the integration,
linkage and improving tracking system.
 Improving the provision of family planning services to HIV positive women
through integrating the Family planning services and PMTCT.
 Improving the adherence and retention in care.
 Ensuring the availability of Early Infant diagnosis supplies and required
commodities for PMTCT and RMNCH.
 Strengthen the involvement of private and FBOs/nongovernmental health
facilities in providing PMTCT services.
6. Care and treatment: ART

The focuses of this priority program area are
a) Increasing enrolment for ART through
 increasing HIV testing coverage especially among MARPs and children
at high risk and linking to care and treatment
 Maximizing the utilization of the capacities of the existing service
delivery points and expanding the ART sites based on HIV prevalence
or HTC data to other health centres
 Strengthening TB –HIV integration
 Providing ART as prevention for sero discordant couples
 Ensuring the availability of EID supplies and ARV drugs
b) Improving adherence and retention in care through improving the quality
of counselling, involving PLHIV and FBOS in providing adherence
education and strengthening the Lost to Follow up tracing mechanism.
c) Strengthening the capacity of detection of treatment failure and
strengthening ART monitoring
d) Strengthening health system for successful care and treatment (
Laboratory services, pharmaceutical and health products management,
HMIS and service delivery)
D. Linkage of HIV Investment Case with the National Health Strategy
The 2015-2020 HIV investment case is an integral component of the 2015-2020
Health sector Transformation plan which is under preparation. Both strategic plans
consider Health Extension Program and Health Development Army initiative as the
primary strategy for demand creation and maximizing the utilization of primary
health care services and HIV services. To further enhance and reposition the HIV
prevention component in to the Health Development Army initiative adequately the
HIV investment case includes interventions to strengthen the implementation
based on the local epidemiological evidences such as HIV testing data and
contextual risk in the areas. Furthermore, the improved health and HIV outcomes
will largely depend on a strong health system, both strategic plans emphasize
strengthening the health system and the integration of health services Overall
the programs in the HIV investment case complement the strategies in the health
sector and the investment in either of the strategic plan will improve the expected
outcome of these national strategic plans.
E. Country process for developing the current HIV investment case and
future revisions
The preparation for developing the HIV investment case was started in December
2013 and the final and costed document was produced in July 2014. In the
development process,
 Stakeholders’ consultation was conducted to create a common
understanding on the concept of HIV investment case and on the process
how to develop it.
 A core team drawn from government sectors, bilateral, multi-lateral , FBOs,
CSOs , Association of PLHIV and private sectors was establish to collect
the required epidemiological data and identify priority areas.
 FHAPCO conducted in depth discussion with the different Technical
working groups ( HIV counselling and testing, PMTCT, TB, Care and

Treatment, Prevention advisory group, Procurement and supply
management coordination committee ) to get in puts on the current
response and gaps and identify priority areas for the 2015-2020.
 Based on the data collected by the core team, findings of the discussion
with the various technical working groups organized by MOH and FHAPCO
and the core team and the extensive document review. FHAPCO drafted
the 2015-2020 HIV investment case and shared to relevant stakeholders
and development partners.
 FHAPCO conveyed a discussion on the draft document at different
partnership forum and consultation sessions, namely government sub
forum, CSO meeting organized by AMREF, HIV donors Group, High level
consultation of Health sector Transformation plan and annual Joint
stakeholders HIV planning session.
 With the inputs received from the different partners and the various
consultation, FHAPCO enriched the document and developed the second
draft,
 FHAPCO presented the document to the Executive committee of the
health sector, Ministry of Finance and Economic Development and Planning
Commission and conducted discussion on the draft HIV Investment case.
The executive committee of the Health sector discussed on the draft
document and endorsed with the incorporation of the comments given by
the members.
 With the incorporation of the inputs of the Executive committee of the health
sector and the responsible persons from the Planning Commission and
Ministry of Finance and Economic Development, FHAPCO developed the
third draft of the investment case and shared to all relevant stakeholders
and development partners.
 A validation workshop was conducted on the costed HIV investment case
2015-2020; the participants of the validation workshop were from
government sectors, bilateral, multi laterals, FBOs, CSOs, Association of
PLHIV and private sectors and discussed on the document by group and in
a plenary session. FHAPCO incorporated the inputs of the validation
workshop and developed the final draft of the 2015-2020 HIV investment
case.
The midterm review of the HIV investment case will be done by end of 2017
through joint and participatory approach as done in the development process. If
the findings of the midterm review come with a recommendation for revision of the
investment case, likewise it will be done jointly.
II. Revised National TB Strategic Plan: 2013/14-2020
The development of the revised National TB Strategic plan 2013 - 202035 has been
informed by extensive mid-term external review of the precedent strategic plan
from August –September 2013,36 epidemiologic analysis,37 and highly participatory
consultations with a wide range of stakeholders. Representatives from all regional
health bureaus, agencies, regional laboratories, health care providers, and experts
from partners have reviewed the major challenges, recommendations and strategic
interventions of the draft strategic plan.
The revised TB NSP has an overall goal of ending the TB epidemic with three
35 Revised National TB Strategic plan 2013 -2020
36
Comprehensive Mid-term External NTP review report, 2013
37 Epi-analysis report of Ethiopia, 2013

major targets of reduction of TB prevalence, incidence and mortality rates by 30%,
35% and 45% by 2020, respectively compared to the 2013 levels.
The nine strategic objectives of the current TB NSP grouped under four
perspectives are:
 Improve access to TB, TB/HIV, MDR TB and Leprosy services;
 Improve community ownership on prevention & control of TB, TB/HIV Co-
infection, MDR TB and Leprosy;
 Maximize resource mobilization & utilization for the prevention and control
of TB, TB/HIV Co-infection, MDR TB and Leprosy;
 Improve quality TB, TB/HIV, MDR TB and Leprosy Service delivery;
 Enhance harmonization & alignment;
 Improve TB, TB/HIV, MDR TB and Leprosy Control pharmaceutical supply
system;
 Improve evidence based decision making in the prevention and control of
TB, TB/HIV Co-infection, MDR TB and Leprosy;
 Improve Human capital and leadership for the Prevention & control of TB,
TB/HIV Co-infection, MDR TB and Leprosy; and
 Improve health infrastructure for the prevention and control of TB, TB/HIV
Co-infection, MDR TB and Leprosy.
Strategic objective 1 - Improve access to TB, TB/HIV, MDR TB and Leprosy
services
This strategic objective is focused primarily on improving access to standard TB,
TB/HIV, MDR TB and Leprosy services. It is aimed to expand TB, TB/HIV, MDR-
TB and Leprosy diagnostic and treatment services to public, private health facilities
and prison settings. Four main initiatives under this objective will guide the service
expansion in public HFs, private HFs, community, and prison settings. These four
initiatives are in line with overall health service expansion as per the health sector’s
plan. The main targets under this strategic plan include expansion of AFB
microscopy services in all health centers, LED FM microscopy services expansion
to 400 new public health facilities, expansion of GeneXpert MTB/RIF Assay in 126
hospitals, TB culture and DST services expansion to additional 4 sites,
decentralization of FNAC services to all public primary hospitals.
Encouraging progress has been made in the implementation of the initiatives under
this objective through increasing government’s commitment and with the support of
development partners and the GFATM. The major achievements in this regard
include:
 TB/DR-TB diagnostic capacity has been improved and rapid molecular
diagnostics (such as Xpert MTB/RIF assay and LPA) are successfully
introduced and scaled up. GeneXpert machines have been placed in total of
28 primary hospitals, with additional 72 machines to be placed in the
remaining hospitals in few months.
 TB culture and DST centers are opened in six regional reference labs
(Adama, Jimma, Bahir Dar, Mekele, Jimma and Hawassa) in addition to the
culture and DST centers at NRL and St Peter Hospital laboratories.
 LED FM service has been introduced and being expanded to high-volume
public health facilities.
 Development of national PMDT scale up plan and effective decentralization
of MDR-TB treatment services to reach current level of has been initiated
and total of 32 MDR-TB treatment initiating sites were opened in six of the
regions (Addis Ababa, Oromia, Tigray, Amhara, SNNPR and Dire Dawa).

 PPM-DOTS service expanded to more than 260 HFs
 TB/HIV services are scaled up successfully
 Due attention has also been given to improve access to TB and TB/HIV
services for high risk and vulnerable groups including prison settings. With
the support from GF grant and TB REACH projects, TB diagnostic and
treatment services have been initiated in Federal and regional prison health
facilities.
 FNAC services are also being introduced in regional hospitals to improve
EPTB diagnostic capacity
The gaps in implementation of the initiatives under this objective:
 Slow community TB DOTS expansion
 Significant proportion of health centers still do not have microscopy services
 Inadequate TB culture and DST services coverage,
 National targets of MDR-TB treatment services expansion has not been
achieved
 Expansion targets for new diagnostics (Xpert MTB/RIF assay, LED
microscopy), diagnostics to improve EPTB case detection (e.g. NFAC
services) are still not met.
 Limited availability of TB DOTS services in most of the prisons in the
country.
Strategic objective 2 - Improve community ownership on prevention & control of
TB, TB/HIV, MDR TB and Leprosy
This objective aims to ensure the involvement, engagement and empowerment of
the community via the implementation of comprehensive community based TB and
Leprosy interventions through the Health Extension Program (HEP) and Health
Development Army (HDA). The main focus of the initiatives of this objective is
expansion and implementation of community based TB care through HEWs and
HDA and targeted TBL ACSM initiatives. It also focuses on engaging CSOs and
NGOs on TB prevention and care. The main target is expansion of community TB
DOTS to 100% health posts.
Key achievements of the strategic objective include:
 Strong political, policy and program commitment to CBTC
 Development of CTBC Implementation guidelines with well-defined
Community TB Care packages and the expected roles of HEWs.38 The core
community TB care packages are community based TB awareness
creation, identification and referral of presumptive TB cases, community
based TB treatment adherence support, community based directly observed
treatment [DOT], retrieval of lost to follow up TB cases and contact
tracing,).
 In addition to HEWs, engagement of HDA/WDA in TB control activities is
evident in some areas.
 Development of CTBC training manuals as part of Integrated Refresher
Training curriculum for HEWs and most rural HEWs have been trained on
TB/HIV modules of IRT
 Full package of CTBC is being implemented in 38% of HPs in the country.
The key challenges in implementation of the initiatives in this objective are:
38 Community TB Care Implementation Guideline, 2nd Edition, 2014, FMOH

 Weak CBTC in pastoral settings
 Weak referral linkages between HPs and HCs,
 Poor urban HEWs engagement in refresher training,
 Inadequate engagement of HDAs in CBTC,
 High staff turnover (especially HEWs) in some settings,
 Delayed decentralization of community based DOT to HPs
 Lack of effective system to track and document the contribution of CBTC to
the performance of the overall TB control program. The contribution of the
CTBC to the overall case notification has not been as high as expected in
most regions.
 Untargeted case findings to all agro-ecological regions, and poorly
functional monitoring and evaluation in the implementation of the CTBC.
The first year performance review found evidence of successfully implemented
partner support pilot projects on CBTC such as those supported by GLRA, TBCAP,
WHO and TB REACH. The TB REACH project implemented in SNNPR has
demonstrated a significant increase in total and smear positive cases identified by
involving HEWs in implementing the full package of CBTC including sputum
collection, smear preparation and fixing (slide referral), DOT, conducting absentee
retrieval, contact and defaulter tracing.39 In addition, the HEWs provided IPT to
under-five year children. By the time of the NTP review, the TB REACH project in
collaboration with the SNNP Regional Health Bureau had scaled up the
interventions to five zones in the region. Lessons learned from such best practices
in CTBC implementation are used for scale up to prioritized high-burden regions.
The revised community TB care implementation guideline also recommends the
wider use of innovative TB case finding strategies and CTBC packages, including
sputum smear preparation, fixing and transportation at health posts level by trained
HEWs to improve TB case detection for specific population groups and settings
building on the lessons learned.
Furthermore, innovative CTBC strategies using mobile TB/HIV service model
(Mobile TB/HIV Van) will be implemented as per the initiatives under this strategic
objective. The mobile TB/HIV service model is through use of mobile TB/HIV vans
well equipped with digital X-ray, LED FM microscopy, GeneXpert machine and HIV
test kits, AIR Conditioner and generator for power source. The mobile clinic will be
run by team of health care providers (Medical Doctor or Health Officer, Clinical
Nurse, Laboratory technologist, X-Ray technician, and driver) and will be linked
with local public hospital or health centre. The mobile clinic will receive all the
required supplies from the linked public health facility. The mobile TB/HIV van will
be mobilized on weekly basis with the team to defined areas accessible to most
pastoralist communities to provide the following package of services: TB diagnostic
services using LED FM, GeneXpert MTB/RIF assay as per the national TB
diagnostic algorithms, X-Ray services for bacteriologically negative presumptive
TB cases, HIV testing and counseling services, TB treatment initiation, adherence
counselling and monitoring of treatment as per the national guidelines, Referral
linkage for RR-TB cases to MDR-TB TICs, Referral linkage to ART sites for HIV
infected patients for comprehensive HIV care services and Contact Screening and
investigation for confirmed TB/DR-TB cases. Standard NTP Recording and
39 Innovative Community-Based Approaches, Yassin et.al, 2013, PLoS ONE 8(5):

Reporting tools will be used in the mobile clinic. Community mobilization and
demand creation for integrated mobile TB/HIV services are made through
engagement of community leaders. Community/clan and religious leaders will be
oriented and sensitized on TB, TB/HIV and MDR-TB prior to initiation of the mobile
clinic service. The community leaders will be oriented specifically to identify and
refer any presumptive TB cases among the members of their community to the
mobile clinic on scheduled weekly dates. HEWs will also be oriented on the model
and will lead the community mobilization activities. The following figure highlights
the service model.
Mobile Van for Integrated TB/HIV Services in pastoralist Settings in Ethiopia
Diagnostics HR: Supplies:
 ILED Microscope  Medical Doctor, Clinical  FLDs (TB PKs), INH

Nurses, Health Officers
 GeneXpert  CPT
 Lab technician, Radiographer,
 Portable Digital X-Ray  NTP R&R forms
 Driver
 HIV Test Kit
Laboratory Services
TB Treatment Unit
Specimen collection unit

Clinical Evaluation Unit
Reception
Waiting Area/Tent
Community Mobilization and Referral
Strategic objective 3 - Maximize Financial Resource Mobilization &Utilization for

the prevention and control of TB, TB/HIV Co-infection and MDR TB.
This strategic objective sets out a proactive approach to the mobilization of
resources from domestic and international sources for sustained TBL Prevention
and Control. It builds on fostering partnerships, resource mapping and enhanced
grant and financial resources management capacity at all levels. In line with and
derived from the health sector’s resource mobilization and utilization objective, it
includes enhancing pool funding; effective and efficient use of resources; sound
financial management and performance-based financing; as well as equitable and
evidence-based allocation of resources to priority interventions. The ultimate
outcomes of this strategic objective are ensuring that adequate resources are
mobilized & available for financing TB prevention and control; that there is
equitable resource allocation; significant improvements in resource absorptive
capacity & decreased wastage of resources; ensuring financial protection of the
citizens.
Funding for health services in Ethiopia derives from a number of sources: Central
government, bilateral and multilateral donor partners, regionally generated funds,
out of pocket funds and Insurance schemes. When these finances are mobilized,
TB and other control programs benefit. In addition, the Ministry of Health has also

benefited from a “Technical Assistance Pooled Fund” created in 2005 by selected
donor partners to fill critical funding gaps; and “The MDG Performance Fund” that
started working in 2007 with funds for health systems strengthening especially in
the thematic areas Health extension program, MCH Service delivery, and Public
health commodity procurement. In a mainstreamed health delivery system, the TB
control activities have benefited from all these channels of funding. Allocation has
been based on compilation of Woreda administrative level plans.
Good progress has been observed in mobilizing and utilizing more resources for
the health sector from various sources. Major achievements include:
 Establishment of grant management units at national level to enhance
timely utilization of funds
 Very good and progressively improving TB GF grant performance and
financial utilization40
Despite these achievements in resource mobilization and utilization for TB
prevention and control, there are issues that needs to be addressed;
 TB financing is hugely donor dependent, with a high out-of-pocket
expenditure recorded in NHAs
 Heavy donor dependence for TB financing, including for core activities such
as procurement of first line anti-TB drugs and laboratory reagents for direct
microscopy
 An increasing demand for resources, to realize universal coverage and
access to TB services, including universal roll-out of community DOTS,
scale-up of domiciliary treatment of drug resistant TB and scale-up of
TB/HIV services (with policy shift to treat all TB/HIV co-infected with anti-TB
and ART treatment).
 Delayed submission of financial statements (un-liquidated advances to
regions) and audit reports.
Strategic objective 4: Improve quality TB, TB/HIV and MDR TB Service delivery
The expected outcome is a health system that satisfies the community’s health
care needs through the delivery of relevant, safe and optimum quality TB, TB/HIV,
MDR TB and Leprosy services in an integrated and user-friendly manner. The
interventions under this strategic objective focus on early case finding and
treatment of TB/DR-TB cases, patient centered treatment strategies; quality
assured diagnostic services and standardized patient care.
Progress made so far and lessons learned:
 TB/DR-TB and TB/HIV national guidelines and training curriculums are
updated and in line with latest global recommendations
 High TB treatment success rate for consecutive years.
 Progressively improving EQA program for AFB smear microscopy
 Very good MDR-TB Treatment outcome registered.
 There are examples of wide-scale implementation of TB contacts
investigation from two regions of Ethiopia with high yield.
 Steady progress was made in decentralization of MDR-TB treatment
services to regional hospitals using ambulatory model of care with shift from
obligate admission to outpatient level MDR-TB case management. Rate of
40 Portfolio Analysis Report, TB Round 10 SSF TB grant, The Global Fund

enrollment has been improved with decentralization of MDR-TB treatment
services to regional hospitals from obligate admission to ambulatory model
of care.
 Sample transport for DST using postal system is working well in urban and
some rural settings but operational challenges were observed in the rest.
 The need for psycho-social and economic support to MDR-TB patients on
care and their families has been recognized
Major gaps in implementation of the initiatives under this objective;
 Unavailability of standardized tools for contact registration and follow-up
was the key challenge to the implementation of contact investigation.
 The progress in MDR-TB case detection is very low compared to the
estimated MDR-TB cases; MDR-TB contact investigation and management
is not being practiced regularly.
 Early and systematic TB case finding among high-risk groups such as
contacts, individuals with chronic medical illnesses is weak and needs
improvement. Lack of timely culture and DST results for both diagnosis and
follow up examinations, treatment waiting list and very low cure rate.
 Quality of TB DOTS and TB/HIV services as measured by adherence to
national guidelines is not adequate. Quality improvement packages for TB
services in health facilities is not defined and not implemented.
These gaps has been identified during annual performance review and
interventions to address these prevailing constraints have been included in
national TB program control program improvement plan, which is developed to
rapidly reverse the declining program performance.41
Strategic objective 5: Enhance harmonization & alignment for TBL Control.
This strategic objective is primarily aimed to ensure that all actors in the sector
working on TBL prevention and control work together to harmonize and align their
plans and resources with that of the NTP. Key achievements include:
 There is strong Stewardship by the FMOH, ensuring complementarity of
donor support to TB control program
 Establishment of annual resources mapping mechanisms with donor
partners to map by activity and geographical area their projected
contributions in line with HSDP and NSP strategic objectives.
 Joint mechanisms for review of annual plans with partners for alignment
with FMOH program priorities
Strategic objective 6- Improve TB, TB/HIV, MDR TB and Leprosy Control

pharmaceuticals &logistic supplies system.
The intended outcome of the initiatives under this strategic objective will be
adequate availability of the right TBL pharmaceuticals and supplies at the right
place the right time in the right condition and used properly by patients and clients.
PFSA is working towards achieving a direct delivery system of pharmaceuticals to
all health facilities within 175 to 300 KM radius from a given PFSA hub. PFSA is
following a phased approach or strategy in implementing the direct delivery of
pharmaceuticals to health facilities, where ART sites are phase I sites, PMTCT
41 NTP Improvement plan, 2014

sites are phase II sites and TB treatment only sites are included in the phase III.
PFSA hubs are responsible for delivery of program drugs including anti-TB FLDs to
health facilities (for ART and PMTCT sites) and to zones and/or Woredas (for non-
ART and non PMTCT sites). PFSA distribution is mainly through pull system which
relies on requests from facilities. An IPLS is in place to aid tracking and stock
management.
Key achievements include:
 Regional PFSA hubs have been set up and are functional bringing supplies
closer to regions and Woredas across the country; distribution of anti-TB
FLDs are integrated with other program drugs as per IPLS;
 Good supply of anti-TB FLDs in facilities, especially where the IPLS was
operational;
 Anti-TB patient kit which is expected to improve supply chain besides its
advantage in increasing drug availability and adherence is being procured
and implemented in major regions and zones;
 Well-functioning manual and computerized inventory management system
is in place in all PFSA hubs to enable both central PFSA and PFSA hubs to
check stock status at any time;
 Construction of modern and standard warehouses at different locations
based on geographical proximity in all the regions in line with the Growth
and Transformation plan of the country, as a result of this initiative, 10
primary and seven secondary warehouses are constructed across the
nation which are expected to improve and expand the service.
Key challenges/gaps in TBL PSM include:
 Long procurement lead time, repeated supplies interruptions of TBL
commodities (FLDs, reagents) leading to emergency procurements, expiry
of pharmaceuticals;
 Weak logistic management information system;
 Integration of anti-TB FLDs distribution through IPLS is also only limited to
ART sites in some regions,
 Inadequate support and limited engagement of Regional Health Bureaus
(RHBs), Zonal Health Departments, and Woreda Health Offices & Health
Facility management in most regions on IPLS.
To address the challenges/gaps in pharmaceuticals supply management system,
specific interventions are included under both HSS and this concept note.
Interventions to improve pharmaceuticals supply information system Enterprise
Resource Planning Software will be installed and scaled up to regions. The storage
and distribution capacity of PFSA will also be improved through procurement of
trucks and investments on ware houses as indicated in HSS concept note.
Strategic Objective 7: Improve evidence based decision making in the prevention
and control of TB, TB/HIV Co-infection, MDR TB and Leprosy
This strategic objective is aimed to support improved evidence-based decision
making on TBL prevention and control through enhanced TBL data flow, improved
TBL data quality, promoting TBL Operations research and improved program
performance monitoring, supervision and review mechanism at all levels. It will
comprehensively address identification of TBL prevention and control bottlenecks;
research; HMIS; performance monitoring; quality improvement; surveillance; use of
TBL information for policy formulation, planning, and resource allocation.
Progress made so far;

 Currently, much focus has been given to improve TBL information flow
through HMIS. All essential program indicators including TB/HIV and MDR-
TB related indicators have been incorporated into HMIS.
 Scale up of e-HMIS
 Repeated DQA were made, joint review mechanisms were established.
Major gaps;
 Serious data quality issues including incompleteness of recording and
reporting, inconsistencies of data, under-reporting and
 Limited collaboration between HMIS and program are among the key gaps
that needs urgent attention. These issues are addressed in both the HSS
and this concept notes.
Strategic Objective 8: Improve Human capital and leadership for the
Prevention & control of TB, TB/HIV Co-infection, MDR TB and Leprosy
The expected outcome of the strategic objective is adequate availability of skilled
and motivated health staff working on TBL prevention and control as well as
committed to work and stay in a well-managed sector.
Progress made to date;
 Appropriate structural arrangement at national level.
 Recruitment and deployment of TB program officers and advisors at
national and regional levels with the support of GF, partners and
governments contributions
 Capacity building of program officers and managers at national and regional
levels has been improving.
 Standardized training curriculums on TB, TB/HIV and PMDT have been
prepared and health care workers are being trained.
Challenges/gaps;
 High-attrition of trained human resource at all levels.
 Available resources are insufficient to cover training needs and lack of
adequate skill mix in service delivery points. This concept note considers
these gaps by including support to TB, TB/HIV, PMDT trainings in the
funding request.
Strategic Objective 9: Improve health infrastructure for the prevention and control
of TB, TB/HIV Co-infection, MDR TB and Leprosy
Enhancing health infrastructure for optimal TB services is the main aim of this
strategic objective and this entails investments in renovations, medical, laboratory
and other diagnostics installation and maintenance.
Progress made so far:
 Renovations and construction of new TB/MDR-TB wards to improve
airborne infection control
 Procurement and installation of advanced diagnostics and TB culture and
DST laboratory equipment
However, the current equipment maintenance system is inadequate. Only
biosafety cabinets are currently maintained. Due to limited local capacity, an
external service provider is required to provide equipment maintenance and
support. This will be addressed through MDG PF support.

1.3 Joint planning and alignment of TB and HIV Strategies, Policies and
Interventions
In order to understand the future plans for joint TB and HIV planning and
programming, briefly describe:
a. Plans for further alignment of the TB and HIV strategies, policies and
interventions at different levels of the health systems and community
systems. This should include a description of i) steps for the improvement of
coverage and quality of services, ii) opportunities for joint implementation of
cross-cutting activities, and iii) expected efficiencies that will result from this
joint implementation.
b. The barriers that need to be addressed in this alignment process.

Alignment of policies, strategies and interventions
Ethiopia has a health policy which focuses on democratization and decentralization

of the health care delivery, health promotion and prevention of communicable
diseases and provision of curative health services. Following the endorsement of
the health policy, the sector had developed and implemented 20-years sector plan.
Recently, the health sector developed the next 20 years visioning document and
2015-2020 health sector transformation plan (HSTP-5). The TB NSP and HIV
investment case are an integral part of the HSTP. Both plans are implemented by
the three health tier systems and by and health development armies of the
community. Overall, both programs are guided by the same health policy and
health sector plan. There is a platform for annual joint planning of all health
programs and joint health sector performance review including TB and HIV
programs. In addition to this, there is also a program specific joint review whereby
stakeholders of both programs participate.
While alignment of policies, strategies and interventions has been achieved, actual
integration of services for the two diseases has been challenging. Some of the
challenges include:
 Uncoordinated supply management system for HIV and TB;

 HIV programs have been supported through intensive clinical mentoring
system while TB did not have such a system
 No joint supportive supervision for TB and HIV
 Lack of adherence support and strong patient counselling tools for TB while
this has been a standard practice in ART clinical care
 Limited ART delivery sites compared to the DOTS sites
 Uncoordinated sample transportation and results notification system
 Different standards for care and support package
 Separate trainings for the two diseases
 Community based TB care is not coordinated with community based HIV

services
As clearly outlined in the strategic plans for TB and HIV, the following strategies will
be employed to address the above challenges:
 Integrated supply management: FMOH will work through the PFSA to

ensure the coordinated supply of both HIV and TB commodities including
SLDs for MDR-TB
 Coordinated clinical mentoring: Uniform and coordinated clinical mentoring
approaches will be followed both for TB and HIV using unified mentoring
checklists
 Integrated supportive supervision: Single supportive supervision checklists
and schedules will be developed both for TB and HIV
 Patient counselling and adherence support: the existing HIV adherence
support and patient counselling scheme will be expanded to include TB and
MDR TB patients
 ART in TB clinics: ART provision in TB treatment units in prioritized health
facilities with high TB/HIV co-infection rates
 Integrated sample transport and results delivery system: The existing
courier-based sample transportation system being used for MDR TB and
EID will be expanded to include all forms of samples both for HIV and TB
 Patient support and care: the existing standard operating procedures for
nutritional care and support for ART and MDR-TB patients will be expanded
to include nutritional care and support for TB patients as per the recent
WHO guidelines. 42
 Integrated training approaches: FMOH is currently revising all in-service
training curricula to make them more integrated and cost-efficient. Some
components of TB and HIV topics already exist both in the comprehensive
TB and HIV training curricula. However, further steps will be taken to fully
integrate the trainings through the blended learning approach which is now
being piloted in some regions.
 Integrated community based TB and HIV care: The HEP platform including
the HDA networks will be mobilized to implement an integrated demand
creation, patient referral, and support both for TB and HIV patients
Opportunities for joint implementation of cross-cutting activities

 Having a health policy and health sector development plan that guide the
integrated implementation of all health programs including TB and HIV
 Availability of many health facilities (eg. More than 3500 HCs) that can
provide TB and HIV services
 Having an innovative community based program (Health Extension
Program) which implements 16 health package s. This gives more emphasis
to MNCH, Hygiene and Sanitation, HIV/AIDS, TB, and Malaria.
42World Health Organization: Guideline: Nutritional Care and Support for Patients with Tuberculosis.
2013

 Having an integrated refresher training for health extension workers which
allows training on all packages to be given at the same time .
 The recent initiative of Women-centred Health Development Army
 Presence of technical and financial support from partners such as USG, GF
ATM, UN,
 Existence of good public private partnership.
Expected efficiencies that will result from this joint implementation:

The community mobilization efforts for TB and HIV will be done by community
structures at the same time. This allows ensuring the complementarities of the
messages, saves the times of the communities and enables to reach many with
low costs. The training to the health extension workers is given in an integrated
with contribution of resources from partners based on their comparative advantage;
some may cover expenses for daily allowance and transport; other may provide
trainers or covering cost of training materials. This avoids the frequent call of
HEWS for training by different programs. The utilization of laboratory and
treatment services will be optimized as both services will be provided in an
integrated approach. It also reduces the costs of the clients and time lost in the
process for getting services. As the supervision and reviews will be done jointly, all
these will reduce the cost and save time and resources that can be used to support
others.
Beyond the financial savings, the implementation of the joint program will enable to
increase the percentage of TB screening among HIV, HIV testing among TB, ART
enrolment of TB- HIV co infection, improvement of IPT coverage and improvement
in quality of services. This will contribute to the achievement of the mortality
reduction goals of the TB NSP and HIV investment case.

SECTION 2: FUNDING LANDSCAPE, ADDITIONALITY AND SUSTAINABILITY
To achieve lasting impact against the diseases, financial commitments from
domestic sources must play a key role in a national strategy. Global Fund
allocates resources that are insufficient to address the full cost of a technically
sound program. It is therefore critical to assess how the funding requested fits
within the overall funding landscape and how the national government plans to
commit increased resources to the national disease program and health sector
each year.
2.1 Overall Funding Landscape for Upcoming Implementation Period
In order to understand the overall funding landscape of the TB and HIV national
programs and how this funding request fits within these, briefly describe:
a. The availability of funds for each program area and the source of such
funding (government and/or donor). Highlight any program areas that are
adequately resourced (and are therefore not included in the request to the
Global Fund).
b. How the proposed Global Fund investment has leveraged other donor
resources.
c. For program areas that have significant funding gaps, planned actions to
address these gaps.
I. HIV/AIDS
A. Available resources for programs by source and existing gaps
The 2015 -2020 HIV investment case of the country requires US$ 1.65 Billion. Out
of this, US$ 767 million is for the first three years (2015 -2017), which coincides
with the concept note period.
Resource mapping was done for the priority programs or main strategies of the
2015-2020 HIV investment case recently. Over 20 government sectors, the four big
regions, Addis Ababa city administration, UN agencies and bilateral (PEPFAR,
DFID USG) provided us the available resource for the 2015 HIV response. Some
provide the anticipated fund for three years till 2017. Based on the overall trend
of annual government budget increment and the expectation of covering the cost
of certain interventions in the priority sectors with local resources, the domestic
resources for the coming three years were estimated to be US$ 57.5 Million. Out
of this 42.2%, 8.3%, 26% and 23% will be prevention programs( Behaviour change
communication, condom, HIV testing and counselling); care and treatment ( OI
drugs and related services); support to OVC and PLHIV and program management
respectively. Without including the Human resources in the various service
delivery points, the Government contribution to the HIV program in the coming
three years will be 14% of the overall needs for the program. If all the staffs
involved in the provision of PMTCT in 2695 HFS and ART in 1047 HFS , the
contribution of the government will be twice of the figure mentioned above.
According to the information received from UN agencies the amount anticipated

the for the three years is US$ 4,790,734 of which US$ 2,038,335 is for the
condom procurement ; 1,328,0022 for behaviour change communication programs
targeting risk population and communities; US$ 325,377 for strengthening school
HIV programs and US$ 1,093,000 for PMTCT and strengthening of PMTCT and
MNCH integration. The US$ 7 million support from DFID indicated in the financial
gap analysis is for the condom distribution and use.
Through the COP 14 USG/PEPFAR has indicated that they have submitted a
request to the US Congress for US$ 203 Million to support the implementation of
the various HIV programs, construction of health centres and blood banks as well
as social health insurance during FY2015. While doing the financial gap analysis
the resources related to construction and social health insurance were not included
as these intervention were not included in the HIV investment case, but this part of
the USG/PEPFAR support is vital to improve the overall health service outcome
including HIV and will be captured in the HSS Concept Note. With this assumption
the support of US$ 178 Million for the various HIV programs in 2015 was taken in
to the envelope of the financial gap analysis. According to the guidance from the
Country PEPFAR coordinator office for estimating future years’ resource using the
FY2015, it has been indicated that the following program changes and spending
declines are expected over the next 1-3 years.
 Over the next one year, PEPFAR will phase out spending on activities that
do not directly support the core of its program, which is focused on most at
risk populations and areas most heavily burdened by HIV. Thus, spending
on general /low risk population prevention activities will end by FY 2016.
 PEPFAR expenditures on construction activities will gradually decline over
the next three years and will cease by end of FY2018.
 Over the next 2-3 years , PEPFAR spending will phase out for those
activities which have become ready to transition to GOE or other local
entities( including VMMC, blood safety, community/peer support, private
sector TA)
Although PEPFAR funding levels cannot be confirmed until annual approval by the
US Congress, taking into account the aforementioned guidance, we estimate the
PEPFAR support for the 2016 and 2017 could be US$ 169.7 M and US$ 159.6 M
respectively. Based on the FY2015 PEPFAR funding proposal and estimation of
2016 and 2017 according to the guidance note mentioned above, the total
PEPFAR anticipated funding for the different HIV programs during the entire
period of the concept note implementation (January 2015 – December 2017) is
estimated as follows.
1. Behaviour change communication primarily directed at most at risk

populations with limited focus on strengthening school HIV education and
communities: US$ 22.8
2. Prevention and control of sexually transmitted infections.
 US$ 47.8 M for Education and program management and US$ 1.86 M
for drugs

3. Condom distribution and use: US$ 6.6 M
4. Targeted HIV testing and counselling
 US$ 7.5 M for promotion and training of service providers & 1.44 M for
procurement of RTKs
5. PMTCT
 US$ 34.2 M Promotion, training and strengthening of integration with
MNCH
 US$ 8.3 M for M&E
6. ART
 US$ 89 M for facility based capacity building and support to seven
regional health bureaus and US$ 7.8 M for adherence education and
retention
 US$ 25 M for strengthening laboratory system and commodities (
CD4, viral load, haematology, chemistry, EID supplies )
 US$ 22 M for Non ARV treatment and supplies
 US$ 14.3 for monitoring and evaluation
7. Care and support program OI management
 US$ 42.6 M for health care worker training, site level support , OI
management, nutritional assessment & counselling and US$ 2.5 M for
drugs
8. Blood safety: US$ 3. 6 M
9 Support to strengthen health system
 US$ 28 M for Support to strengthen pharmaceuticals and health
products management
 US$ 14.8 M for Support to strengthen HIV related laboratory services
 US$ 6.7 M for Support to program and grant management
 US$ 21.9 M for Support to HMIS, national level surveys and surveillance
 US$ 9.6 M for HSS for RHBs and professional associations
 US$ 6.5 M for Other HSS ( local organizations capacity building, private
sector TA, nutrition)
10. VMMC: US$ 2.1 M
11. TB/HIV: US$ 15.9 M for providing site level support for DOT implementation;
MDR –TB implementation, strengthening TB laboratory and management of
TB commodities.
12. OVC; US$ 47 M: for psychological, social, educational, linkage to care and
treatment and strengthen community support system.
As described above and seen in the financial gap analysis table, the financial
need for 2015 to 2017 is US$ 767 Million while the available or anticipated
resources from domestic, bilateral, multilateral and remaining RCC HIV grant
included in the no cost extension is about US$ 616.9 M. This leaves a gap of
US$ 150 million with a theoretical assumption of the available fund with partners
can be redistributed to areas where there is gap. However, this is not a practical
one because of different reasons. When the financial gap analysis is done by the
key interventions of a priority program the actual financial gap becomes US$ 263

Million. On the basis of the in depth gap analysis for each priority program in
the HIV investment case, the following have financial gaps to reach the set targets
for the period of 2015-2017.
 HIV package services for FSWs and vulnerable populations ( Labourers in

large scale work sites)
 BCC community based HIV programs
 School HIV programs
 HIV testing and counselling: commodities
 Care and treatment & PMTCT : ARV drugs , OI drugs and laboratory
commodities
B. Leveraging other donor resources
The health sector and partners in country had a discussion on how the support
from partners can fill the gaps that will not be covered with the GF and domestic
resources. Furthermore, the health sector conveyed a discussion with the in
country USG team to see if there is a possibility for PEPFAR to cover some of
the components such as Laboratory reagents and STI. Overall the increased
involvement and engagement of partners in the development process and
decision making on the prioritization of high impact interventions for the concept
note creates the opportunity to know the existing gaps and to look possibilities
on how to narrow the gap while developing the next annual plan or
commitment. It has also influenced the Health sector and the AIDS
coordinating Authority to intensify its dialogue with government sectors and
Ministry of Finance and Economic development to increase the allocation of
domestic resources for HIV programs.
C. Planned actions to address the gaps
To address the existing gaps the following actions will be undertaken.
 Use resources from the MDG fund to cover some of the critical gaps
through having a discussion with the partners of the MDG fund and
including in the joint annual plan
 Maximizing the community involvement and utilization of community
resources to implement some of the strategies
 Conducting further dialogue and continued discussion with PEPFAR while
developing COP 15 and COP 16 to cover the critical gaps.
 Strengthening public private partnership and engaging the private sectors to
sourcing some of the HIV prevention programs.
 Strengthening the integrated Health-HIV financing.
 Increasing domestic resources for the HIV prevention, particularly for the
priority sectors.

II. Tuberculosis Funding Landscape
Based on revised National TB strategic plan at total of $587 Million is required for
the period July 2014 to 2020. The required budget for TB NSP is increasing over
the period of six years because of increasing investment on expansion of rapid TB
diagnostic tool and treatment cost for Drug resistance TB cases across the country.
Procurement of TB commodities laboratory supplies and other new diagnostic
equipment take big share of the total cost, which is nearly 80% of the total cost
required for the specified period.
About $246 million is required for implementation of TB interventions in TB NSP

for period of 2015 to 2017. Interventions under MDR-TB care and prevention
module require $94 million (38% of the total cost) whereas interventions under TB
care and prevention module require $87 million (35% of total cost), and TB/HIV
interventions $19.5 million (8.3%), the remaining 19% account for intervention
under TB HSS module.
FMoH conducted resource mapping in order to establish the financial commitment

from government, Partners and other relevant stakeholders for national
Tuberculosis strategic plan. Accordingly, the collected commitment data has
showed that nearly $72 million is committed from government and partners for the
period 2015 to 2017, which is 29% of the NSP total cost required for three years.
According to commitment, data collected for in responses to TB NSP in Ethiopia
continues to fall considerably short of what is required to implement the levels of
service necessary to bring an impact on the spread of the epidemic as put forward
in the National Tuberculosis Strategic Plan.
Summary of Funding gap by major TB modules for period 2015-2017

100%
Gaps
80%
60% Partner
contribution
40%
Government
20% contribution
0%
MDR-TB total TB care & prevention TB/HIV total
total
Figure 16: Funding landscape for of NSP by major module from 2015 to 2017
The overall government contribution is $28 million for three years which mainly
covers investment for infrastructures, staffing of TB, TB/HIV and MDR-TB program
at all levels, Prevention activities, ACSM, program management and planning cost
required for the implementation of the program
The partner contribution is $44 million over a period three years (2015 to 2017), of

which 95% is from USG, the remaining is from GLRA, Bill and Melinda Gates
foundation, TB REACH and UNITAID. From the total anticipated partner
contribution for TB for period 2015 to 2017, about $11million will partially cover
costs for program management, M&E and training of HCWs. Similarly, about $15
million is for MDR-TB case detection and diagnosis, $10.3 million is for TB case
diagnosis, Treatment and improving quality of services, and $2.9 for TB/HIV
interventions. Partners’ contribution for CTBC activities and TB interventions to
address the key affected population are the least funded areas.
The overall TB funding gaps for the concept note period is $75million, $42 million
and $12 million for implementation of major activities under MDR-TB module, TB
care & prevention module and TB/HIV modules, respectively. The detail funding
landscape shown in table figure 17.
Summary of funding landscape for TB by diffrent intervention areeas 20015_2017

100%
90%
80% Gaps
70%
60%
50%
40% Partner
contribution
30%
20%
10%
0% Government
contribution
Figure17: summary of TB funding landscape for the period 2015-2017
MDR-TB care and prevention module: Cost of Procurement of SLDs and ancillary
medicines will be covered through GF. Similarly, chemicals and consumable for TB
culture and DST costs will be covered largely by GF with modest contribution from
partners (USG, UNITAID). Capacity building for general health care workers on
MDR-TB case detection and treatment is covered by partners as well as by global
fund.
Under the TB/HIV module there is $10 million funding gap, mainly for procurements
of INH and GeneXpert Cartridges for TB diagnosis among HIV infected.

Leveraging other donor resources through Global Fund’s Investment on TB
The established mechanism for plan alignment and harmonization between the
NTP and development partners has created a conducive environment to enhance
complementarity of funding for TB through different mechanisms and channels.
The development of the NSP has been made through consultation of broader
stakeholders including donors, government agencies, implementing partners and
CSOs. The national priority areas jointly identified and resources mobilized
accordingly. The NTP uses the GF resources mainly for procurement of FLDs,
SLDs and laboratory supplies in addition to program management and capacity
building activities. The resources from other sources are used for other high priority
interventions not covered through the GF grants. Furthermore, the previous GF
grants has helped the government to build the overall health systems, apart from
the direct support on live saving drugs and other lab supplies procurement, in turn
leveraging resources from other donors to invest on programmatic interventions.
The intervention proposed in this concept note considers the lessons learned in
this regard and the funding request thus takes into account these principles.
2.2 Counterpart Financing Requirements
Complete the Financial Gap Analysis and Counterpart Financing Table (Table
1). The counterpart financing requirements are set forth in the Global Fund
Eligibility and Counterpart Financing Policy.
a. For TB and HIV, indicate below whether the counterpart financing
requirements have been met. If not, provide a justification that includes
actions planned during implementation to reach compliance.
If not, provide a brief

Counterpart Financing
Compliant? justification and
Requirements
planned actions
i. Availability of reliable
data to assess X☐Yes ☐ No
compliance
ii. Minimum threshold

government
contribution to disease
program (low income-
5%, lower lower-middle X☐Yes ☐ No
income-20%, upper
lower-middle income-
40%, upper middle
income-60%)
iii. Increasing government X☐Yes ☐ No

contribution to disease

program
b. Compared to previous years, what additional government investments are

committed to the national programs in the next implementation period that
counts towards accessing the willingness-to-pay allocation from the Global
Fund. Clearly specify the interventions or activities that are expected to be
financed by the additional government resources and indicate how
realization of these commitments will be tracked and reported.
c. Provide an assessment of the completeness and reliability of financial data
reported, including any assumptions and caveats associated with the
figures.
I. HIV
Increasing domestic resources for the national HIV response is one of the four
critical enablers stipulated in the 2015-2020 HIV investment case. It has also
identified the strategies and the main interventions that will be implemented with
the domestic resources. These include: 1) Behaviour change communication and
work place interventions in targeted and prioritized government sectors and large
scale development sites. Government sectors such as Ministry of Mining, Ministry
of women, children &youth, Ethiopian Electric power, Sugar corporation are
allocating program based budget annually. 2) school HIV program : Ministry of
Education and regional bureau of education are allocating resources for HIV
prevention programs
3) Work place intervention, social mobilization and care and support for orphan:
Regional government are also budgeting for these interventions annually. Some of
the regions have a separate HIV sub account and others decided to allocate 2% to
HIV programs from a sub account of services and utilities. 4) Integrated heath –
HIV financing. The health extension program and the expansion of heath
infrastructure are instrumental for the improved outcome of Health and HIV
services. These are largely covered by domestic resources. 5) Provision of HIV
services in public health facilities, uniformed forces and prison administration. The
human resource in these health facilities are covered by government of which a
share of their time is for provision of HIV services. Overall there will be an
increasing of domestic resource allocation to HIV programs as many sectors have
started to allocate resources on program based budget.
II. Governments contribution to TB control program
The government’s contribution for TB control program has been increasing over the
past years and the same trend will continue over the concept note period (Table --).
The investments from the government on TB Control are expected to count
towards the willingness to pay allocation from the Global Fund to be utilized
amongst others for the purposes of TB prevention and community’s awareness
activities through use of HEP, Health Development Army initiatives and mass
media, investments on health infrastructure, human resources for health, health
system leadership and maintenance interventions.

SECTION 3: FUNDING REQUEST TO THE GLOBAL FUND
This section details the request for funding and outlines how the investment is
strategically targeted to achieve greater impact on the diseases and health
systems. While the investments for both the HIV and TB programs should be
described, the applicant should also provide information on the expected impact
and efficiencies achieved from planned joint programming for the two diseases
including cross-cutting health systems strengthening as relevant.
3.1 Programmatic Gap Analysis
A programmatic gap analysis should be conducted for the six to twelve

priority modules within the applicant’s funding request. These modules
should appropriately reflect the two separate disease programs in addition to
cross-cutting modules for both programs such as Health System and
Community Systems Strengthening.
Complete a programmatic gap table (Table 2) for the quantifiable priority modules
within the applicant’s funding request. Ensure that the coverage levels for the
priority modules selected are consistent with the coverage targets in section D of
the modular template (Table 3).
For any selected priority modules that are difficult to quantify (i.e. not service
delivery modules), explain the gaps, the types of activities in place, the populations
or groups involved, and the current funding sources and gaps in the narrative
section below.
The programmatic gap analysis is summarized by component as follows.
A. HIV
Module 1; Prevention for FSWs and clients.
Of the estimated 160,000 population of FSWs, the HIV Investment case 2015-
2020 plans to reach 84% of FSWs with a package of HIV prevention programs
by 2017. With the domestic and ongoing PEPFAR supported program, 57% of
the estimated population will be reached and this leaves a gap of 43%. In the
concept note, a support for covering 18% of the estimated population in need in
2015,; 21% in 2016 and 23% in 2017 is requested . This will raise the program
coverage to 80% by 2017. Thus, it leaves a gap of 20% compared to the total
estimated population and a gap of 4% against the set target in the HIV
Investment Cased for the period.
Module 2; Prevention program; Other venerable population
The Population group targeted for this module are laborers in the Development
schemes, Mega projects and large scale work sites in the country whose sizes are
estimated to be about one million. Of the one million laborers in the different
development schemes/ mega projects and large scale work sites, the 2015-2020
HIV investment Cases sets a target to reach 84% by 2017. The domestic resources
and the support from PEPFAR through the ongoing work site prevention program
will enable to reach 79% of the estimated population by 2017 leaving a gap of 21%.
This Concept note focuses on 15 large work sites with about 50,000 laborers and

will cover 5% of the estimated population in each year. This will raise the
program coverage to 84% by 2017 and able to achieve the set targets in the HIV
investment case. .
Module 3; Prevention : HIV testing and counseling
There is a plan to offer HIV testing to 13.5 Million to 14.3 Million people on
annual basis. Thirty seven of these will get the service on fee basis with the
provision of startup fund for revolving fund. By PFSA. Thus, it leaves a gap of 8.5
Million against the annual target. This has been included to be filed with this
request and hence, the set target in the HIV investment case will be met.
Module 4; PMTCT
The 2015-2020 HIV Investment Case envisages raise the PMTCT coverage from
the current coverage of 69% to 92% by 2017. The committed or anticipated
resources from domestic and development partners are for prong 1&2 while the
support from this request will cover the major component of Prong 3& 4 (testing,
viroligical testing, ARVs).. This, it will enable to achieve the set target of 92% and
leaving a gap of 8%.
Module 5; Treatment, care and Support
Among all adults and children living with HIV 45% of adults and children are
currently on ART by June 2014. The 2015-2020 HIV Investment Case envisages
providing ART to 78% of PLHIV by 2017. The support from partners is largely
focusing on site level support to build capacity and improve implementation,
Laboratory commodity, and nutrition, drugs for STI and selective OI and system
strengthening. The major gaps are in ARV drugs and viral load testing supplies.
Hence, we are still depending on the Global Fund resources to cover the ARV
needs. With the support of the GF resources, 61% of PLHIV in 2015; 68% in 2016
and 76% in 2017 will be on ART. This leaves a gap of 39% in 2015; 32% in 2016
and 24% in 2017. The 2015 need for ARV drugs ( 61%) will be covered with
available and the no cost extension of the HIV RCC grant and as .a result it is not
included in this request. Overall with the support of this request the ART coverage
will reach 76% by 2017.Thus it leaves a gap of 4% against the target in the national
target.
B. TB
Prior to this TB/HIV concept note, Round 10 SSF Tuberculosis Phase 2 grant
program was funded at $56m for July 2014 – December 2016 (2.5 years). Out of
this amount, $22m was disbursed in early 2014 to procure FLDs and SLDs as well
to support programmatic activities starting from July 2014 onward. With evolving of
the joint TB/HIV concept note opportunity, and per TGF requirement the country
had to reprogram Phase 2 funding to achieve aligned start date (July 2015) for
activities from the consolidated concept note. As Phase 2 grant was consolidated
with NFM, actual implementation period comprised 3.5 years (July 2014 –
December 2017) with TB component funded at $59.5million as per the country
program split allocation. This created additional budgetary constraint for TB/HIV
concept note, which necessitated prioritization of previously approved Phase 2
interventions as well as revision of the concept note TB specific targets to make
sure the set targets are reached given the available budget. The below table shows
the Phase 2 grant approved targets (with major implications to implementation
costs) as well as the reduced targets within the allocation amount request and
within allocation plus above allocation amount request. The NSP targets for TB

case notification is based on the latest TB incidence estimate of 247/100,000
populations as per the 2013 Global TB report and also considers the targets and
milestones set for post 2015 TB control strategy. The declining TB incidence
estimate has been taken into consideration to set the absolute number of TB cases
to be notified as per the NSP targets for Case Detection Rate set for the 2015 -
2017 (77%, 79% and 81% for 2015, 2016 and 2017, respectively).
Table 7 Summary of TB targets set for allocation and above allocation
Target
under Target
Indicator Period Round 10 Target with
Estimated SSF TB allocation Above
TB cases Phase 2 amount allocation
July14 to June15 2385 1578 1578 1578
July15 to June16 2333 1928 1172 1716
July16 to
MDR-TB
June17(6months) 2327 1142 1289 1902
case
July 17 to Dec17
notification
(6months) 1195 715 998
Average cases/
year 2,354 1,859 1,358 1,770
July14 to June15 207,774 161,960 161,960 161,960
July15 to June16 204,731 175,404 143,312 165,943
July16 to
TB case June17(6months) 201,421 94,717 147,037 165,943
notification July 17 to Dec17
83,696
(6months) 98,901 74,175
Average No of
cases /year 203,665 172,832 150,424 165,012
Average annual Fund available $22.4 mill $15 mill
Major programmatic gaps were identified based on NSP targets and the projected
progress that can be made on these targets through domestic & donor funding
available for 2014-2017 in light of the country’s current TB epidemiological and
HSS/CSS context. Interventions were prioritized with the aim of selecting those
with best potential for filling the identified gaps given the consolidated concept
budget and timeframes. Details on these gaps and respective priority interventions
are included in five Programmatic Gap Tables, with a brief summary presented in
the table below.

Priority Interventions Interventions requested to be covered
module & requested to be from above allocation amount
Selected covered from allocation
coverage amount
indicator
Programmatic AFB microscopy and - Intensified community case finding

gap table: #1 Xpert MTB/RIF testing through active engagement of HEWs
to identify cases in and HDAs by Phase based scaling
Priority
2015-17 up of high-impact interventions
module: TB
demonstrated in TB REACH project
Care and Lab personnel training
in four bigger regions, 35 zones, and
Prevention on AFB/LED
350 districts over concept note
microscopy, and EQA
Coverage period.
indicator: Comprehensive - Phased Introduction and scale up of
Number of integrated TB/HIV and mobile TB diagnostic and treatment
notified all PMDT training for services in highly mobile and
forms of TB healthcare providers underserviced pastoralist
cases from new hospitals, communities. The mobile TB/HIV
HCs, PPM-DOTS sites service model is through use of
Improving diagnosis of mobile TB/HIV vans well equipped
Child hood TB by using with digital X-ray, LED FM
Gene Xpert as per the microscopy, GeneXpert machine and
WHO recommended HIV test kits, AIR Conditioner and
diagnostic tool. generator for power source. The
Procurement of mobile clinic will be run by team of
cartridge for screening health care providers and will be
of 56,000 children with linked with local public HFs.
presumptive TB which Integrated TB/HIV diagnostic
is 50% of the total services, TB treatment services
need (Mobile clinic based DOTS), HCT for
TB cases, referral linkage for HIV
care and contact investigation will be
provided using the mobile model.
- Orientations for health care
providers, HEWs, and community
leaders on the mobile service,
- Training of the mobile clinic HCWs
on new diagnostic tools, and
national algorithms will be conducted
- With successful implementation of all
the interventions indicated under
above allocation amount, additional
49,956 TB cases will be detected and
treated over the concept note period.
FLDs to treat - Provision of FLDs to additional

376,524( 364,524 new 49,956 patients identified through
and 12,000 innovative CTBC and mobile TB
retreatment ) TB diagnostic services in pastoralist and
patients identified from high TB burden communities
July 2015 to Dec 2017 - Phase based Implementation TB

services quality improvement
Packages in all DOTS sites
Programmatic Xpert MTB/RIF testing - Phased introduction of FLD DST (at

gap table: #2 and conventional DST least Rif-Resistance testing using
to diagnose and Xpert MTB/RIF) among
Priority
monitor 2831 MDR-TB bacteriologically confirmed new TB
module:
patients identified in cases in major urban areas and scale
MDR-TB
2015-17, procurement up to major regional towns with high
prevention
of chemicals and TB burden. This is to improve MDR-
and care
consumables, TB detection among new TB cases
Coverage Procurement of Gene as the majority of MDR-TB cases are
indicator: Xpert Cartridges will among new cases due to the high
Number of also be further proportion of new TB cases notified.
cases with supported by UNITAID This is one of the strategies included
DR TB (RR- and USG in addition to in the NSP to improve MDR-TB case
TB and/or GF. detection. During first year it will be
MDR TB) that implemented in all Major regional
Training of lab
began towns and three urban regions.
second line specialists on culture Gradually expanding in Zonal and
and DST
treatment woreda towns based on analysis of
HSS CN grant will also annual notification of DR-TB
cover costs for MDR- caseloads in 2nd and 3rd year.
TB sample referral and - Further expansion of GeneXpert
laboratory networking. services in additional 50 hospitals
and other heavy load health centers,
- Implementation of Active contact
screening activities for all notified
MDR-TB cases in all TICs and TFCs.
- adequate training for health care
workers on MDR TB specimen
collection and referral and additional
currier in place where postal services
not reached
SLDs ancillary drugs to - SLDs and ancillary medicine to

treat 3177 MDR-TB treat 1440 MDR-TB patients
patients identified in additionally identified with
2015-17 intervention using above allocation,
nutritional support,
Psycho-social and
economic support to - Expansion of MDR - TB treatment
initiating center to 50 hospitals,
MDR-TB patients on
additional cost will be required for
care and their families
renovation, MDR-TB program
management, TB infection control
Programmatic Xpert MTB/RIF testing - To screen for TB Additional 30% of

gap table: #3 to screen PLHIV with the target (88,000PLHIV) using
presumptive TB for GeneXpert, with presumptive TB,
Priority
207,963 HIV positive as the remaining need will be
module:
TB cases in 2015-17,

TB/HIV this will cover only 41% covered by partners
of the total need
Coverage
indicator: %
of HIV
positive INH to provide IPT to - Accelerated uptake of IPT,
patients who HIV positive 196,009 massive sensitization for all care
were adults and 12,909 providers specially from ART Sites
screened for children in 2015-17. health care worker,
TB in HIV - Mass media communication
care through spot message to improve
treatment the awareness of health care
settings worker and patients on use of IPT
Programmatic HIV test kits to provide - This is for screening of 49,956 TB

gap table: #4 HCT to 364,524 TB cases who will be detected and
cases detected by through above allocation request
Priority
allocation request in for 2015-17.
module:
2015-17 - Cost for HCT will be covered using
TB/HIV
HIV component within allocation
Coverage amount
indicator: %
of TB patients
who had an
HIV test
result
recorded in
the TB
register
Programmatic ART to 43,655 TB/HIV - ART for 5,495 TB/HIV co-infected

gap table: #5 co-infected patients in cases detected through TB case
2015-2017 finding interventions under above
Priority
allocation.
module:
TB/HIV
Coverage
indicator: %
of HIV-
positive
registered TB
patients given
anti-retroviral
therapy
during TB
treatment
TB Care and Prevention

The first major programmatic gap that has been identified in TB care and
Prevention module is reaching the NSP targeted number of notified cases (all forms
of TB -bacteriologically confirmed plus clinically diagnosed, new and relapses). The
gap is mainly related to ensuring the provision of the required quantities of

laboratory reagents, consumables and supplies for AFB microscopy services as
well as Xpert MTB/RIF test cartridges for TB diagnosis among Children using
molecular diagnosis as per the recent global and national recommendations over
the concept note period.
Though there is support from development partners, mainly from UNITAID and
USG, the available resource from the partners will only cover 21% of the total need
for cartridges for two and half years. Nearly 650,000 cartridges are required for
screening of HIV infected patients and children with presumptive TB cases. There is
no gap for year one for MDR-TB screening. There is huge need for training of
laboratory personnel in AFB/LED microscopy and EQA activities. Even though
trainings will be mainly covered by partners, the gap will remain high in some
regions where there is no partner support. Comprehensive integrated TBL, TB/HIV
and PMD Training for healthcare providers in these regions without direct partners
support will be supported through the GF allocation amount. To fill this gap, CCM
requests the appropriate amount of funding from the allocation amount, which
together with available domestic/donor funding will allow to detect 364,524 TB
cases over 2.5 years, i.e. reaching 70%, 73%, and 75% of the national targets for
the grant Y1, Y2, and Y3, respectively. However, these targets are below of the
NSP targets (77%, 79%, and 81% for Y1, Y2, and Y3, respectively).
In order to fill the remaining gap in case detection, CCM requests additional
funding from the above allocation amount, to be used for implementation of
innovative high impact CTBC interventions (based on the results of successful TB
REACH CTBC models) focusing on intensified case finding among pastoralists
communities and other 4 major regions with high TB burden. Besides, the CCM-
Ethiopia requests above allocation funding for implementation of innovative mobile
TB/HIV clinic model described below in hard to reach pastoralist communities to
improve TB case finding in among these population groups. Implementation of the
aforementioned CTBC intervention and mobile TB diagnostic and treatment in
major pastoralist regions will allow the country in detecting 49,956 additional TB
cases over two and half period. The requested above allocation amount will allow
reaching the national targets for the number of all notified cases over 2015-2017.
The other major gap that has been identified is provision of first line treatment to all
TB cases that will be identified over the next three years, as no procurement of
FLDs is planned through domestic/donor funding for the concept note period. To fill
this gap, CCM requests the funds from the allocated amount that will be used for
procuring FLDs for the projected 364,524 TB cases that will be identified in 2015-
2017. Should the requested funding for implementing the aforementioned
innovative CTBC activities be available, it would require additional amount of
funding to cover the need in first line treatment for additional 49,956 TB case.
MDR-TB
Within the framework of previous GF grants and other donor supported programs,
the country has made significant progress with building TB molecular diagnosis
capacity. In total, by July 2015 there will be 99 GeneXpert functioning sites across
the country. TB molecular diagnosis among targeted groups within the scope of
MDR-TB priority module, given that the major gap in provision of Xpert MTB/RIF
test cartridges is filled. Hence, CCM is requesting appropriate amount of funding
from the allocation amount for provision of MTB/RIF test cartridges to make sure
that the national targets on MDR-TB case identification are met.
By July 2015, there will be total of 14 functional TB culture and DST labs including

one national reference laboratory in the country, allowing regional coverage with
culture and conventional DST in the presence of well functional lab specimen
transportation network (support lab network strengthening interventions is included
in the HSS concept note request). Again, the major gap remains in the provision of
culture and conventional DST materials, which is requested to be covered from the
allocation amount accordingly. A gap is also identified with regard to training of lab
specialists on culture/DST and Xpert methods. Overall, the requested funding from
the allocated amount will allow provision of Xpert MTB/RIF testing and conventional
culture/DST to diagnose/monitor 3,177 MDR-TB patients in 2015-17 and near to
32,320 tests for MDR TB suspects and MDR-TB contacts.
The other major gap in the MDR-TB priority module is the provision of second line
treatment to the NSP targeted number of MDR-TB patients. The domestic & donor
funding available for 2015-2017 envisages mainly for support including capacity
building, training, and mentorship with no budget for the procurement of SLDs and
ancillary drugs. Hence, CCM requests financial support from the allocation amount,
which together with available domestic/donor funding will allow covering the need in
second line treatment of 3177 MDR-TB patients in 2015-2017. Considering the total
estimated population in need, this will result in accomplishment of 49%, 53%, and
58% MDR-TB Case detection rates for Y1, Y2, and Y3, respectively.
To further increase the coverage with MDR-TB treatment, CCM requests
appropriate amount of funding from the above allocation amount to start Xpert
MTB/RIF testing among bacteriologically confirmed new TB cases in major big
cities like Addis Ababa, Dire Dawa Harari, and major cities and towns in regions
with highest drug resistance prevalence among resident population and to provide
second line treatment to the MDR-TB cases that will be identified through this effort.
The amount of requested funding from the above allocation amount is defined to
allow us for gradual scale up to some cities and towns, and followed by major
regional cities and zonal capital towns with high TB burden. Additional 1440 MDR-
TB patients over 2 and half year will be detected by implementation of activities
listed under above allocation amount.
TB/HIV
Within the framework of TB/HIV collaborative activities, the major gaps identified
include TB screening and IPT among PLHIV (mainly related to procurement of
Xpert MTB/RIF test cartridges as well as INH for adult and pediatric TB
prophylaxes), HCT among TB patients (mainly related to procurement of HIV test
kits), ART/CPT among TB/HIV co-infected patients (mainly related to procurement
of ARVs and CTX). Hence, CCM is requesting financial support from the allocation
amount for provision of Xpert MTB/RIF testing for 207,963 presumptive HIV positive
TB cases, IPT to HIV positive 196,009 adults and 12,909 children, HCT to TB
cases, and ART to 43,655 TB/HIV co-infected patients in 2015-2017. In line with
above allocation request for TB cases finding, additional fund under above
allocation is required to provide ART for 5495 TB patients, HIV testing for 49,956
TB patients and 88,000 GeneXpert testing for HIV positive presumptive TB cases
during same period(July 2015- Dec 2017).
Program management and M&E
There is a considerable gap in supporting program management and M&E activities
facilitating provision of quality services to targeted population groups within the
scope of TB Care and Prevention, MDR-TB, and TB/HIV modules TB/HIV priority
modules. To fill this gap, CCM requests funding from the allocation amount to
support selected key activities including TB and HIV joint program performance

reviews, M&E, supportive supervision, mentorship Which are highly to ensure
satisfactory performance within all priority modules at all levels (e.g., keep TB
treatment and cure rates high, improve performance indicators on collaborative
TB/HIV activities). Relevant interventions are planned budgeted within the scope of
all three priority modules with more details given in respective modular tables. All
these interventions to be funded from the allocated amount are planned so that to
have major focuses on key populations (e.g., more frequent supervisory visits in
pastoralists’ communities, prisons, and urban slum areas). To further improve
performance of TB and HIV programs, CCM requests additional funding from the
above allocation amount to support innovative intervention to design and implement
national quality improvement (QI) system for TB and HIV programs, which will have
major focus on improving quality of TB and HIV services and care.
3.2 Applicant Funding Request
Provide a strategic overview of the applicant’s funding request for TB and HIV,
including both the proposed investment of the allocation amount and the request
above this amount. Include the specific elements related to joint programming
such as health systems and community systems strengthening. Describe how the
request addresses the gaps and constraints described in sections 1, 2 and 3.1. If
the Global Fund is supporting existing programs, explain how they will be adapted
to maximize impact.
A. HIV
The basis for the request was the priority interventions of the 2015-2020 HIV
investment case, the outputs of the country dialogue, group discussion with key
population such as female sex workers and PLHIV and the programmatic and
financial gap analysis. Accordingly, the focuses of the funding request are:
1. Module 1; Enhancing HIV prevention programs targeting female sex
workers and clients (US$ 4,901,573).
A package of services includes behavior change communication, condom
distribution, STI screening and treatment and HIV testing and counseling will
be implemented in 100-150 towns with high sizes of FSWs, of hot spots
nature or near mega projects/ development schemes which are not covered
either by the on-going projects or supports. The existing domestic and other
partners support will cover 57 % of the estimated population leaving a gap of
43% in each year. Through this Concept note, 18-23% of the estimated
population in need will be reached and will raise the overall coverage to 80%
by 2017. It complements the on-going prevention program in 200 towns with
the support of PEPFAR and will raise town coverage from 200 to 300-350 and
contribute to raise program target coverage from 50% in 2014 to 80% by 2017.
The sites will be selected by the nine regions based on the
aforementioned criteria. The BCC component of the package will be
conducted through small group sessions of 5-6 sessions each with 1 to 2
hours and maintained through one to one session. As part of the package,
tailored education to improve treatment seeking behaviour and accessing STI
screening, getting HIV testing , community referral and linkage with nearby

health facilities will be strengthened. With the consideration of the 2013
MARPs Survey findings of reported prevalence of vaginal discharge ( 11.5.%
) and genital ulcer ( 7.5%) and service data of STI in the catmint area, STI
drugs will be avail in the nearby health centres where the FSWs get service
for STI screening and treatment including the periodic health check-up. FSWs
are among the priority target groups for HIV testing and the required
commodities for testing will be avail for all towns including the 200 sites
supported with PEPFAR and the additional 100-150 towns included in this
request. Community based organizations and Civil society organizations along
with the district health office, health facilities and local administration will
implement the program through outreach education, peer education, providing
Condom, promoting HIV testing, availing drugs for STI and linking with the
Health development army initiatives in the areas. They will implement it
based on the national guidelines and building on the current lessons learnt
from the PEPFAR supported prevention project implemented in 169 towns by
PSI. Training related to designing of programs, management , monitoring and
evaluation and documentation of the lessons as well as good practices will be
given to the implementers as part of building the capacity to implement the
program effectively , track the progress and improve accordingly. In general
five to six sessions are considered while implementing this program and at
minimum an individual should attend three fourth of the sessions so as to be
considered as reached with this prevention intervention.
2. Module 2: Enhancing HIV Prevention program for vulnerable
population: US$ 1,149,444.
The HIV investment 2015-2020 aims to expand the prevention program for
vulnerable population and reach about one million laborers in large scale work
sites with a package of HIV services ( BCC, condom, STI and HIV testing and
counseling) as per the national guidelines. Currently World Learning with the
support of PEPFAR funding is implementing work site HIV prevention
programs in 92 large work sites and will expand to reach 100 sites by 2017,
end of the project and reach 75% of the estimated population. In addition to
this, the sectors or the work sites are also implementing prevention programs
by their own resources, but not fully covered or not at the required scale. Both
the domestic resources and the PEPFAR support will cover 79% of the needy
population by 2017 and this leaves a gap of 21%. The Sugar Development
schemes and the Mega projects, particularly the hydroelectric plantation are
among the large work sites which have no adequate program coverage or no
support from other partners and also difficult to access by other partners.
This module focuses to fill the gaps and complement the program targeting
daily laborers in 13-15 Sugar development schemes and mega projects such
as hydroelectric plantations which have high works forces, low program
coverage and at risk of HIV because of risk sexual practices and influx of high
number of FSWS to the area as witnessed by field visit observations and local
authorities. It covers 5% of the overall estimated population of the laborers in
all large scale work sites and will complement and intensify the efforts of
the Ethiopia sugar corporation, Ministry of water, Irrigation and Energy, and
the Ethiopian Electric power against HIV in the mega project sites and enable
them to reach additional 50,000 labourers every year. The implementation
approach will be through peer education model complemented with community
wide events , mini media , behavioural change communication materials, and
supporting or building the capacity of the district health office and local mass
associations such as youth association, women's association etc. As part of the
service package, this priority modules also aims to improving the
availability of condom though increasing fixed condom outlets around work
sites, availing STI kits either in development scheme clinics or nearby
health facilities , increasing HIV testing uptake through intensifying of
provider initiated testing counselling and voluntary counselling in the health
facilities of the development schemes or community base testing and
strengthening the linkage with surrounding health facilities .
This module will be implemented by the Sugar Corporation and Ethiopian
Electric Power with the involvement of regional health bureaus, local authorities
& health district offices in the projects sites and community structures in the
work sites. With this the linkage of the HIV prevention programs in the
development schemes/ mega projects and surrounding communities will be
strengthened.
As indicated above the PEPFAR support and the allocation of resources by
the development schemes or mega projects will be the largest source to
implement the program and achieve the set targets for 2017; however this
priority model or request also contributes about 5% focusing on reaching
50,000 laborers per year among the selected work sites which will help to
increase the work site coverage from 100 to 115 and to contribute to the
achievement of the set target of reaching vulnerable population with HIV
prevention packages by 84% in 2017.
3. Module 3; Prevention; general
3.1. HIV testing and counseling : US$ 22,100,000

The 2015-2020 HIV investment case identifies two groups of target for HIV
testing and counseling based on risk/high yield and rights of people to know
their HIV status. The first one is targeted HIV testing and counseling aimed at
identifying most HIV infections and linking to care and treatment. These include
couples (marriage and remarriage), TB patients, STI cases, Risk population
(FSWs, truck drivers, daily laborers), uniformed forces, prison inmates ,
widowed , discordant couples, orphan and vulnerable children and pregnant
women. As indicated in the HIV Investment Case (page 56), the primary
delivery channel will be heath facility based while in the development schemes
it will be backed with community based testing. The second one is general
population testing based on fee. With the revolving fund PFAS will procure
and gets reimbursed from regional health bureaus.
The funding request in this concept is to implement the targeted HIV testing
through provider initiated testing and counseling and voluntary counseling and
testing for the identified target groups. The requested fund will be largely used
for the procurement of rapid test kits and a part for the demand creation,
promotion of targeted HIV testing and counseling and provision of community
based HIV testing in development schemes or large mega projects which do
not have a clinic with adequate capacity. Over all the request fund for this is
US$ 22,100,000 and will enable testing of 8.5 Million new clients and
400,000 repeat tests (FSWs, other at risk) per annum for the period of 2016-
2017. This will help to identify the infections, increase the proportion of PLHIV
who know their status, achieve the annual ART enrollment target of 46,000 to

50,000 and overall enhance the effective implementation of the 2013 WHO HIV
treatment guidelines which Ethiopia has been implementing since January
2014.
3.2. Orphan and Children package :US$ 5,931,650
This request is to complete the transition support started with the Transition
Funding mechanism (TFM) that has been implemented by the Ethiopian Inter
faith Forum for Development and Dialogue in Action (EIFDDA) and to support
the continuum of care and creating a sustainable mechanism of OVC support
through strengthening the community based support approach. In addition to
this, the support will be used to increase HIV testing among OVC through
approaching the families or guardians and linking to care and treatment. This
will contribute to increase pediatric ART enrolment. EIFDDA will implement
this program at large and US$ 5,531.650 will be directed to it. It has also a
capacity building component of Civil society organization so as to strengthen
the community system for OVC support. The latter will be implemented by the
Consortium of Christian Relief and Development Association.
4. Module 4: PMTCT: US$ 2,758,750

Improvement in PMTCT coverage has been noted In regions or areas where
there is a strong Women Centered Health Development Army initiative , high
engagement of political leadership from region to districts, active
engagement of Women’s Association and Health extension workers in
registering all pregnant women in the community , good coverage of focused
ANC coverage through referral of ANC attendants in health posts to health
centers and in health facilities with entertaining the traditional norms of the
locality in providing delivery services. Furthermore, the significant rollout of
PMTCT B+ to health centers with the support of partners through providing
technical and financial support for training and mentoring has supported to
improve the PMTCT coverage. Building on this the following will be
implemented with community and domestic resources and partners’ support.
a) Expanding behaviour change communication focusing on Sexual
reproductive health and HIV to all 15-49 years people through Health
extension, health development army, schools, youth and Women’s
Association and CSOs engaged in providing youth friendly HIV services.
b) Increasing ANC coverage and HIV testing uptake among pregnant women
c) Strengthening the integration, linkage and improving tracking system.
d) Improving the provision of family planning services to HIV positive women
through integrating the Family planning services and PMTCT.
e) Availing required commodities for early infant diagnosis, PMTCT and
MNCH.
F) Strengthen linkage of ART with PMTCT/RMNCH.
Continued building capacities of Health Development Army to ensure
individual, families and communities involvement and participation in
sustaining e-MTCT of HIV.
f) Strengthen the involvement of private and FBOs/nongovernmental health

facilities in providing PMTCT services.
g) Improving the quality of the integrated MNCH services through
strengthening the platform and implementing continuous national quality
improvement.
h) Strengthen the Monitoring and Evaluation framework for e-MTCT of HIV.
The request in this Concept note is to support the implementation of the plan
for elimination of MTCT and the strategies of the HIV Investment Case
focusing on a) providing support to the implementation of primary HIV
prevention among adult population, particularly women of child bearing age b)
availing rapid test kits to test 2.9 million pregnant women each in 2016 and
2017 c) conducting virological testing within two months in 92% of infants
born to HIV positive women and d) availing ARV drugs for 92% of HIV
positive pregnant and lactating women by 2017. With this support the PMTCT
program coverage will raise from 69% in 2014 to 92% in 2017, the proportion
of HIV positive infants born to HIV positive women will reduce from 12.8% in
2014 to 5.4% in 2017 and the overall HIV incidence will significantly reduce.
The overall requested fund for PMTCT ( prong 1, prong 3 and prong 4 ) is
US$ 16,573,947 ; however the need for prong 3 ( testing and ARV drugs )
are indicated in the testing and care and treatment component. The request
for prong one and four is US$ 2,758,750 which is indicated in the PMTCT
module.
5. Module 5: Treatment, care and support : US$ 172,238,205
The annual new ART enrollment per year over the last four years was in the
range of 45,756 to 64,500 patients per year. From July 2013 to June 2014, 53,
721 adult and children living with HIV were enrolled for ART and 40,138
(75%) % these were enrolled in the first half of 2014. Since January 2014 the
country has been implementing the 2013 WHO HIV treatment guidelines with the
support of Global Fund and PEPFAR. Besides, adopting and implementing the
guidelines, additional 423; 341 and 134 Health facilities started to provide HIV
testing and counseling, PMTCT and ART services during the last 12 months
respectively. Following the implementation of the guidelines, rolling out of PMTCT
+ and the expansion of the sites, the monthly enrollment has improved
remarkably and the current average monthly enrollment is about 4480 new
patients per month. By June 2014, there are 344,344 PLHIV who are currently on
ART, which accounts for 45% of all estimated PLHIV by the December 2014.
Over the years survival rate 12 months after initiation of ART has been improving;
it increased from 82.4% in 2010 to 85.6% in 2013. Overall there are currently
1047 ART and 2695 PMTC + providing sites and there is a plan to increase 51
ART sites by June 2015 and thereafter in a similar trend based on HIV testing
and counseling data.
In addition to the rapid roll out of PMTCT +, the health sector had revised the HIV
testing and counseling guidelines with the aim to improve child counseling and
testing, adopted the policy of testing and treating of all under 15 children living
with HIV and developed a pediatric ART acceleration plan to address the low
pediatric ART coverage. Preparation has been started to increase the
availability of early infant diagnosis service (PCR) from 11 in June 2014 to 18 by
December 2014 and theater to expand on evidences and additional needs.
Improving adherence and retention in care is one of the priority areas of the

care and treatment strategic objective of the 2015-2020 HIV investment case. To
this effect the following interventions will be implemented: a) Provision of
education and counselling to patients through one to one or peer supporters b)
providing Nutrition support c) Building the capacity of Association of PLHIV and
Faith based organizations and involve in providing adherence education. D)
Strengthen family role in care and treatment. E) strengthening tracing mechanisms
through the case managers and volunteers f) Improving the availability of OI drugs
and management of OI and concomitant illness.
As described in the 2015-2020 HIV investment case there is a plan to use viral
load testing as ART t monitoring. Recently the Ethiopian Public Health Institute
with the involvement of partners had developed the guideline and plan for rolling
out of viral load testing; preparation for implementation has been started. Based
on the plan 25%; 65% and 85% of patients on ART will have viral testing at 12
months by 2015, 2016 and 2017 respectively. To realize this a) the testing centre
for viral load will increase from the current 11 to 18 by December 2014; b) training
will be given to health care providers c) sample transfer and result turn about time
will be improved through strengthening the network .
With this request it is envisaged to provide ART for 507,000 patients
( 465,000 adults & 42,000 <15 children ) in 2016 and for 553,000 ( 505,00 adults
& 48,000 < 15 children) in 2017. 51, 000 and 46,000 new cases will be
enrolled in 2016 and 2017. 92% and 8% of all the patients in ART will be adults
and under 15 children living with the virus respectively. Currently 1.7% of
patients are on second line. With the rolling out of the viral load testing it is
expected that the capacity of treatment failure detection will be improved. With
this improvement in detection capacity and maturity of the ART program, the
proportion of patients on second line regimen are expected to will increase and
assumed to be 2% for the coming two years based expert opinion.
The request with the allocation is primarily to ensure the availability of ARV
drugs for the currently on ART and increasing enrollment; improving adherence
and retention in care through expanding the community based adherence
education by association of PLHIV, rolling out of viral load testing as ART
monitoring and provision of OI prophylaxis,. The overall request for this is
US$ 172,238,205. The category of this need is A) US$ 151,364,800 (86%) for
the procurement of ARV drugs. Out of this US$ 145,471,200 is for first line ARV
drugs. B) US$ 7, 765, 600 is for the procurement of viral load testing for ART
monitoring. C) US$ 5,207,805 is for procurement of drugs for OI prophylaxis and
treatment. D) US$ 7,900,000 will be for community based Treatment adherence
education through the Association of PLHIV. The Network of Networks of
Ethiopian HIV positives (NEP+) along with member associations will implement
this across the country focusing on high volume catchments and in
complementarities with the current health facility based Adherence education in
616 Health facilities with the support of PEPFAR.
With the allocation fund included in this request the overall ART coverage will
increase from 45% in June 2014 to 76% in 2017. To achieve this the health
sector is now focusing on targeted testing, maximizing the utilization of the
available ART and PMTCT sites, expand ART sites based on HIV prevalence and
burden or HTC data in districts, expanding Early Infant diagnosis service ( PCR) ,
viral load testing , improving laboratory services and sample transfer ,
strengthening TB- HIV integration , strengthening the health system particularly
pharmaceutical and logistics management and HMIS, ensuring the availability of

uninterrupted HIV commodities and enhancing partnership with different
development partners.
PEPFAR is providing a substantial and critical support to the implementation of
care and treatment program through a) providing facility based support & capacity
building (training, mentoring, and provision of job aid supportive supervision) and
support to seven regional health bureaus. b) strengthening the laboratory system
and provision of commodities for hematology, chemistry, CD4 and viral load
testing d) providing facility based support and commodity management
strengthening for TB/HIV interventions e) Providing support to OVC in a way to
strengthen HIV testing and linking to care and treatment f) support to health
system strengthening, particularly pharmaceutical and logistics management and
HMIS . These supports will significantly help to achieve the set targets. In
addition to these there are other opportunities on the ground or in the communities
that will help to increase ART enrollment and retention in care. These include: the
Health extension program , Health development army , the ongoing construction
of hospitals , further decentralization of ART in to Health centers, presence of
Association of PLHIV in different regions which have active involvement in
Adherence education and tracing of Lost to Follow up and the engagement of
Religious leaders in ART adherence education.
In general, with the implementation of the preventions and care &treatment
strategies articulated in the HIV investment case, the support from partners,
particularly PEPFAR and optimum utilization of the existing opportunities, the
proposed targets in this request can be achieved and significantly contribute to the
realization of the 2015-2020 HIV investment case goals, namely, reduction of
70,000-80,000 new infections and save 500,000 -550,000 lives.
6. Program management : US$ 4,950,000
To have an effective program and sub recipients management, PSM
management , financial management and monitoring and evaluation , critical and
limited staff that have experienced and demonstrated capacity will be retained the
Global Fund t resource. In addition, a support for program management including
monitoring and evaluation is included. Overall the fund for this module is
US$ 4,950,000.
Overall the requested fund for the six modules described above is US$ 214,074,
622. All is from the allocation.
. Implementation of other priority areas of the HIV investment case, but not
include in the CN.
Among the priority programs or strategies of the 2015-2020 HIV investment case
there are some which are not addressed by this request despite their strategic
importance. The reasons are a) they can be addressed with community
resources, domestic or other partners support b) they can be addressed by
integrating with other interventions c) the available resource in the allocation is
not adequate to cover all and thus requires to prioritizing among the priorities.
Some of these are
A. Health and community system strengthening

The proposed interventions, particularly the care and treatment in this
concept note will be largely implemented by the health sector and this
requires strengthening of the health system. The support for strengthening
HMIS, pharmaceutical and logistics management, financial management
and overall strengthening of laboratory system will be presented in the HSS
concept note
B. HIV prevention in school Youth: Though the HIV prevalence among

these groups is very low, the need for strengthening school HIV program is
one of the strategies in the HIV investment cases because of the need to
sustain the low HIV prevalence, enhance the protection of risk sexual
practices and the size of its population (a quarter of the country population).
The recently revised curriculum, the commitment of the Education sector to
increase domestic resources and implement the program in an integrated
approach with other school activities, optimizing the use of school
resources and existing support from partners will enable Ministry of
Education to expand the implementation of the strategy/program.
Resource mobilization will be intensified to find resources for the some of
the critical areas such as training on life education and media education
that will have a catalyzing effect on the program.
C. RMNCH linkage and gender based violence

The women centered health development army, health extension program
and over the health sector development plan put the health of women as the
epicenter of the community and health care delivery system. Because of this a
number of programs to improve adolescent and maternal health including
RMNCH/ SRH are implemented by the health facilities, the communities,
particularly women’s Association and health development army and civil
society organizations. To realize this and achieve MDG 5, the government of
Ethiopia has allocated a budget for RMNCH. In addition to this the Health
sector received a huge support from DFID to implement this program through
involving CSO implementers. Besides the existing of GBV protecting legal
frameworks in the country, an intensified community mobilization against GBV
is an ongoing effort through the involvement of religious leaders, community
leaders, women’s Association, Ministry of women, children and Youth Affairs,
regional& local administrations and media. There are also bilateral, such as
the Embassy of the Netherlands that provide resources for sexual and
reproductive health which is implemented through civil society organizations.
Because of these reasons the RMNCH linkage and gender based violence was
not included as standalone intervention in this concept. But it will be
implemented as an integral component of the primary HIV prevention (prong 1)
among child bearing age women.
D. Community based HIV BCC program: This will be implemented largely by
the healthy development army and the health extension package. The
community and domestic resources will be used to reposition HIV
prevention in the health development army adequately. Due to this and the
shortage and prioritization of the allocation resources to care and treatment,
the community based HIV BCC component was not included in this request.

B. TB Funding Request
Summary of Fund for available for NFM

Description of Funds Fund in USD
Total allocation as of Jan 1 2014 $59,542,335
2014 amount disbursed to date $5,781,338
Expected disbarment from commitment ( excluding march $13,698,561
2015 scheduled transferred to roll-over as saving)
Fund available for the NFM concept note period July 2015 $40,062,436
–Dec 2017
TB care and prevention module: $19 million from allocation amount

High priority has been given for improving TB case detection and treatment in the
revised TB Control NSP. Furthermore, to rapidly reverse the recent decline in TB
case notification rates and to address critical gaps in the control program, NTP
improvement plan has been developed and endorsed. The commitment of the
health leadership to improve overall TB program performance in general and TB
case finding in particular has been heightened. This has created great opportunity
and huge momentum in the health sector to enhance the implementation of
interventions to improve TB cases detection over the coming three years. Some of
the key interventions that are planned to be implemented in this regard are
intensified TB cases finding activities at health facility level (adult OPD, less than
five OPD and HIV clinic) and regular TB contact screening both at health facilities
and health posts level. Furthermore, TB case finding will be enhanced by
implementing intensified community based presumptive TB identification and
referral through HEWs. As a result, more than half million TB cases are planned
to be detected and put on treatment during July 2015 to December 2017. Most of
these activities will be supported from government sources but need additional
resource to enhance the interventions.
To improve the quality of X-ray result interpretation, training for heath care
provider X-ray reading will be provided and services will available in the
hospitals, this activities is mainly supported by USG through COP 15, and 16.
Similarly, to improve diagnosis of Extra pulmonary, TB task shifting on FNAc
services will be made by decentralizing the services into the peripheral hospitals
and health care workers will be trained on FNAc and the activities will supported
by USG through COP
Access to TB diagnosis and treatment services further improved in existing and
newly opened public health facilities and more private and prison health facilities
will be engaged in TB diagnosis and treatment services. This will be supported
through GF from allocation amount. Similarly Children with presumptive TB will be
screened using GeneXpert and it will be supported from allocation amount.
For implementation of key interventions under TB care and prevention module,
CCM-E requests a total of $19 million from allocation amount for two and half year.
Of this $4.5million for TB case finding and diagnosis, $9.72 million for TB
treatment, $2.59 million for program management and M&E, $1.22 million for

engaging all care providers and the rest $0.78 million and $0.23million will be for
technical support and prevention activities respectively.
TB case detection and diagnosis: Nearly $4.5 million is allocated TB case
finding and diagnosis, $1.7million for procurement of reagent for AFB & LED
microscopy services, $1.1million to support partially the in-services training for
laboratory personnel on AFB, LED microscopy, GeneXpert MTB/RIF to fill gaps in
regions where partner support does not exist (like all pastoralist regions, and the
three urban regions and two agrarian regions). $0.8million improving diagnosis of
TB among children mainly used for is for procurement of cartridges for diagnosis
of childhood TB, and $0.82 million will be used to support partially the
implementation of EQA decentralization (onsite support, blind rechecking and
further decentralization of services to hospitals), there is also modest support from
USG for EQA activities in the project areas.
TB Treatment and care: $9.72 million is allocated for TB treatment intervention
which is mainly used for procurement of first line anti TB drugs including
associated PSM cost, for two and half year (Y1 $3.45million, Y2 $4.14 million, Y3
$2.14million) for treating 376,524 (including 12,000 other previously treated) TB
patients detected with allocation amount over two and half year. Printing of
standardized provided support tool packages which help care providers to improve
quality of services will be supported USG mechanism.
Engaging all care providers: About $1.18 million is allocated for implementation
of two major activities. Expansion of TB diagnostic and treatment services in new
private and prison health facilities to address prisoners and other population from
urban slum will be supported partially from allocated amount. Training of health
care worker on comprehensive TB/HIV and PMDT will supported with $0.86
million. The training is to address the high turnover of trained staff, fill the gap for
newly opened health facilities from regions where there is limited partner support.
Relevant capacity building training will be provided for health cases workers from
newly opened health facilities. The country has planned to shift from hotel based
training to institution based training strategies using customized training materials
developed to address both comprehensive TB/HIV and PMDT components
through blended 6-day duration course. Using these new training strategies one
health worker from every selected public DOTS site, prison health facility and
private health facility will receive the training. The remaining $ 0.22 million will be
used for baseline assessment, sensitization and launching of PPM-DOTs services
in those health facilities the expansion of TB diagnostic and treatment services in
those health facilities will be integrated with basic HIV services (HIV counseling
and testing services). Program management training for all woreda office will be
addressed in HSS concept as district level management and leadership training
which help to strengthen the district level TB program management capacity.
TB program management and HR: CCM-E request the global fund for 3.7
million from allocation amount ($2.6 for M&E and $0.8million for Human resource
for 11 regional health bureaus) to strengthen TB program implementation and
monitoring mechanism at all levels. TB program specific supportive supervision
and program performance review will be made at national, regional, and zone
levels every quarter. Though regional and Zonal level supportive supervision and
review meetings are conducted on quarterly basis, the current grant will support
only bi annual review and program specific supportive supervision. The remaining
two will be supported from partners especially for two big regions with USG
project site. TB program review and supervision will mainly focus on key

challenges, tracking performance indicators, improving the data quality, and
program management at all levels. There will be stronger effort made in the
pastoralist regions and regions with limited program support from partners, i.e.,
adequate support will be provided to conduct more frequent review meetings and
supervisory visits. To effectively implement and monitor the TB control program
nationwide, CCM-E requests the global fund $2.6million support program
monitoring and performance review activities at national, regional and zonal
levels for two and half years ($0.94 million for supportive supervision and routine
data quality assessment, and $1.6 for program review).
To address the gap in the implementation capacity and M&E activities at all
levels, the country will needs to maintain human resource at national and regional
health bureau that is being supported under the current R 10 TB grant. The
MDR-TB, TB/HIV and M&E consultants are supporting national and regional TB
program by providing technical support, building the capacity of program officers
and transferring adequate knowledge and skills to other and ultimately contribute
for the improvement of the program. Under current 22 TB/HIV and MDR-TB
program consultants for region (three for each of four big regions, 2 for each of
three urban regions, and one for each of four pastoralist regions) will be
maintained. These 22 consultants will support the implementation of regional TB
program with special focus on implementation of global fund support activities
and M&E as well. Total of $0.8million is requested for salary supports of regional
level the consultants for two and half years. In the long run, government will take
over in filling the gap by maintaining adequate number of manpower for
successfully implementation of program at all levels. On the top of this, three
senior technical advisors (one PMDT advisor, one TB/HIV advisors, and one
ACSM advisor) will be maintained under the current concept note.
TB prevention: INH for under five children with close contact of bacteriologically
confirmed TB cases will be procured for 46,539 children in two and half years
which $220,925 which will be from country allocation for TB but procurement of
INH for HIV positive eligible population will be from HIV country allocation for HIV.
Above allocation: TB care and prevention
1. Implementation of innovative community TB cares interventions:
Additional 8.4million is requested for three years to detect and treat 32,352
additional TB cases. In Ethiopia HEWs of the HEP in the community currently
identify and refer presumptive cases to diagnostic units. The country target is for
the HEWs to increase the referral of presumptive TB cases to more than 50% of
cases attending diagnostic centres. In the new approaches, HEWs will be more
actively involved in the diagnosis and treatment of the cases in the community.
This activity will be additional to the conventional DOT centre activities and will
serve as a backbone to increase the number of cases detected. It is expected that
engaging HEWs in community-based TB prevention and control efforts would
increase their contribution to smear-positive case notification rate of 65%43. The
43 Mohammed A. Yassin1,2*, Daniel G. Datiko2,3, Olivia Tulloch2, Paulos Markos3, Melkamsew

Aschalew4,Estifanos B. Shargie1, Mesay H. Dangisso3, Ryuichi Komatsu1, Suvanand Sahu5, Lucie Blok6,Luis
E. Cuevas2, Sally Theobald Innovative Community-Based Approaches Doubled Tuberculosis Case Notification
and Improve Treatment Outcome in Southern Ethiopia. PLoS ONE 8(5): e63174.
doi:10.1371/journal.pone.0063174

community HEWs will provide services for 65% of smear positive cases notified.
This would mainly contribute to increasing case finding and reverse the declining
trend in TB case detection.
The TB REACH project implemented in southern Ethiopia had a high impact on TB
case finding by addressing the main barriers to seeking diagnosis and making the
services accessible to the community. In this application, the country targeted
increasing case finding through strengthening the existing health system and
implementing high impact intervention such as the interventions illustrated by the
TB REACH project in phased manner. The country therefore, plans to scale up the
TB REACH CTBC intervention packages in four major regions (SNNPR, Oromia,
Amhara and Tigray) of the country. These regions are of predominantly rural
population, high burden of TB and a declining case finding. Additional funding is
required to implement the community-based approach and enhance case finding in
these high burden areas. The interventions will require; strengthening the health
centre-health post links; improve the community awareness of TB and of the
service and the implementation of the interventions by actively engaging HEWs and
the health development army. This would require budget additional budget amount
$8.4 million with community-based approaches and selected interventions will be
implemented in a phased manner. In the first phase of the grant, NTP will continue
to sustain and expand the interventions already implemented in the Southern
Region of Ethiopia (to better characterize and document the TB epidemic in the
whole Region), learn from the interventions and monitor its impact) and scale up
the interventions to at least 10 zones. In the second phase, and based on the
lesson learned during the initial implementation of the interventions, the approach
will be further scaled up in the regions selected, to include 25 new zones and to
consider expanding to the remaining regions of the country. The key interventions
include strengthening the basic packages implemented by the NTP. Under this
concept note period, the CCM-E request $8.4million request for implementation of
the above innovative community TB case interventions of which $1.62million used
for familiarization and training of HCWs $1.62 million, $1.49 million for
implementation cost (district level program review, air time for Key ACSM
activities),$2 procurement of Non - medical items( Motorbikes, reagents, fuel and
maintenance),$3.3 million for procurement of medical items like cartridges, ILED
microscopes, experts). With this approach over all additional 32,352 TB cases will
be detected and put on treatment.
2. Phased introduction and scale up of mobile TB diagnostic and
treatment services highly mobile pastoralist community
Ethiopia has the highest number of highly mobile (nomadic) pastoralist population
in East Africa. Notably, two of the nine regional states in Ethiopia (Afar and Somali
Regional States) contribute to the largest number of pastoralist communities.
There are also largely pastoralist communities in Oromia region (most of
population of Borena, Guji Zones), SNNPR (South Omo Zone), Gambella and
Benishangul Gumuz regions. An enhanced and intensified TB case finding
interventions along with expansion of TB diagnostic and treatment health facilities
are required to rapidly reduce the huge burden of TB in pastoralist communities in
the country. While the expansion and enhancement of TB diagnostic and
treatment services within the existing health facilities in pastoralist regions is
essential, additional TB/HIV intervention packages suitable for the highly mobile

living style of pastoralist communities needs to be implemented in these settings to
enhance TB case finding and improve treatment outcome. In line with this,
innovative mobile TB/HIV service model in pastoralist regions of Ethiopia
described above (section 1.2 of the concept note) will be implemented. This
approach will be implanted in Somali, Afar and Oromia (Borena and Guji Zones)
regions. One mobile TB/HIV Clinic (Van) will be deployed in each of the selected
areas during the concept note period. Total of 17,604 additional TB cases will be
detected and treated with full implementation of the mobile TB/HIV interventions
which costs $2.4 million. Out these, $792,000 will be used for procurement of
medical items (GeneXpert machines, ILED Microscopes, mobile digital X-Ray and
FLDs ). Procurement of non-medical items (4 Vans, portable generators and air
conditioners ) will require $264,000. The remaining $1.34 million will be used for
the implementation of the interventions (maintenance cost, consumables, HR,
community mobilization and GHWs orientations) in the selected pastoralist areas.
DOT is decentralized to the community of Ethiopia and treatment and Continuity of
care will be further facilitated by engaging HEWs and treatment support within the
community. The NTP targeted to achieve a treatment success rate above >90% by
making a financial contribution for drug procurement through global fund. The
increased number of cases that will be detected by the innovative approaches
described above will require more drugs and supplies for additional patients.
Additional funding is required to ensure uninterrupted supply of quality-assured
drugs and the purchase of microscopes for the increased laboratory workload for
the diagnosis and follow up of patients. There is however a funding gap for
training, mentoring and supervision and cluster level regular review meeting on the
activities of the case holding for the additional effort required ensuring patient
friendly service and treatment success in the community using the existing links
including HEWs and HDA as treatment supporters
MDR-TB care and prevention Module: $18.64 million from allocation amount
Under this concept note, the CCM–E request GF a total $18.64 million from
allocated amount for key interventions under MDR-TB prevention and care module
which will enable the country to detect and treat 3,177 RR/MDR-TB cases over
two and half years. About $13.6million is allocated for MDR-TB treatment
(procurement of SLDs and ancillary drugs, nutritional support for MDR-TB
patients) and followed by $2.08 MDR-TB detection and diagnosis ($1.91million is
procurement of chemicals and consumable for culture and DST for 14 regional
culture and DST laboratories,$0.16million for training of laboratory culture and
DST test), $1.58million is requested for procurement of N-95 respirators for MDR-
TB treatment centers and TFCs for two and half years. To improve and monitor
the quality of MDR-TB service being provided at MDR-TB treatment centers $1.38
million support mentoring visit and regular catchment area meeting from
Treatment centre to TFCs for two and half years.
The TB laboratory networking and sample transportation system will be
strengthened and supported through the HSS grant with a total cost $ 2.41million
for two and half year. The support is mainly for procurement of triple package,
deep freezer, specimen transportation and training on specimen referral for health
care workers post office which is completely integrated with HIV sample
transportation (viral load and DBS).
To strengthen the human resource capacity of the regional and national culture
and DST centers in the country and improve the implementation of EQA activities,

CCM-E requests the GF for salary support to maintain 18 TB lab advisors which is
$0.8million USD for Two and half years(three for national reference laboratory,
and 15 for regional reference laboratories).
MDR-TB care and prevention Above allocation request: Phased
Introduction of DST for FLDs among New TB Cases from urban settings:
With allocation amount the country can only achieve 49%, 53% and 58% MDR-TB
case detection among estimated cases in Y1, Y2 and Y3 of the concept note
period, respectively. To fill the remaining gap, total of $7.9million is required to
scale up 1st line DST for bacteriologically confirmed new TB cases identified in
high MDR-TB burden areas, besides ensuring DST for all previously treated TB
cases in the same areas. During 1st year, major urban settings with high MDR-TB
burden will be considered, in the second year it will be scaled up in major regional
cities. Having this intervention funded from the above allocation amount for
intensifying routine MDR-TB screening among all new bacteriologically confirmed
TB cases as well as previously treated TB cases, the country would be able to
achieve 23% additional annual increase in MDR-TB case enrolment each year.
Total of 1440 additional MDR-TB cases will be diagnosed and treated using the
above mentioned strategies over the next two and half years. For this purpose, the
CCM-E requests the GF to allot $7.9 million from the above allocation of which
$5.93 million is will be used to treat 1440 additional cases, 50 additional treatment
initiating center will be established and equipped with appropriate TB-IC settings
which will cost $1.04milion, $ 420,000 for additional 20 GeneXpert machines,
chemicals and consumables for Culture and DST; $240,000 for catchment area
meeting and mentoring support. In summary, with additional 6.16 million funding
from above allocation, the country will be able to diagnose and treated 1440
additional MDR-TB cases in the two and half years.
TB/HIV modules: $2.4 million for allocation amount

As per the national guideline and diagnostic algorithm for GeneXpert, all HIV
positive clients with presumptive TB need to be screened for TB using the new
molecular diagnostic tool. Under this concept note, the CCM-E request the GF to
allot $2.4million from the allocation amount for procurement of cartridges which will
be used for routine screening of HIV positive patients with presumptive TB in 99
hospitals with GeneXpert services.
Above allocation for TB/HIV Module: To meet the national target to screen all
HIV positive patients with presumptive TB, the country request additional funding
of $1.15million to improve TB/HIV interventions of which $0.8million for
procurement cartridges for screening additional 80,000 HIV positive presumptive
TB cases using GeneXpert testing and $0.35 million health worker sensitization of
the new diagnostic tool to increase awareness and utilization of molecular test as
per the national guidelines.
The summary of overall funding request by prioritized intervention areas under the
three modules is depicted in the figure below.

100% TB_DOTS Prevention
80% Human Resounce(MDR-TB,

TB lab and TB/HIV)
Engaging all Care providers
60%
MDR-TB Program mgt and
40% M&E
MDR-TB Prevention
20% MDR-TB cases Findings and

Dx
TB/HIV
0%
proportion
Figure 18: Summary of funding request by each intervention under three

modules from July 2015- Dec 2017
Table 9: Summary of TB funding request by modules for period July 15

to Dec 17
From Above allocation
Key Interventions allocation
TB DOTS: TB Case Findings and
Diagnosis $4,496,137 $1,857,739
TB Treatment $9,725,992 $7,438,405
Engaging all Care providers $1,181,674 -

TB DOTS: Program management
(Program M& E ) $3,368,685 -
TB_DOTS Prevention $226,543 -

1Total TB Prevention and care
Module $18,999,031 $9,296,144
MDR-TB cases Findings $2,078,381 $1,414,000
MDR-TB Rx $13,604,964 $5,927,040
MDR-TB Prevention $1,575,600 $292,500
MDR-TB HR $796,043
MDR-TB Program Management and
M&E $584,300 $240,000
2.Total MDR-TB Module $18,639,288 $7,873,540
3.TB/HIV $2,424,117 $1,150,000
Grand Total $40,062,436 $18,319,684

3.3 Modular Template
Complete the modular template (Table 3). Note that the template allows access
to modules that are specifically relevant to TB and HIV components, in addition to
modules that are cross-cutting for both diseases.
To accompany the modular template, for both the allocation
amount and the request above this amount, explain:
a. The rationale for the selection and prioritization of modules and
interventions for TB and HIV, including those that are cross-cutting for both
diseases.
b. The expected impact and outcomes of the interventions being proposed.
Highlight the additional gains expected from the funding requested above
the allocation amount.
3-4 PAGES SUGGESTED

I. HIV/AIDS Modules
Module 1: prevention program for Female sex workers and their clients
According to the country HIV investment case , the three target population
groups for HIV prevention programs are most at risk population ( FSWs &
laborers in development schemes, mega projects and large scale work sites) ,
youth in schools and communities. Among these FSWs and laborers in the
mentioned work sites were prioritized for this request. The reasons for selecting &
prioritizing the prevention program for FSWs and their clients are:
A) the prevalence of HIV among FSWs is very high ( 23%) which is 15 times
more than the national adult HIV prevalence and 12 times more than the national
HIV prevalence among women.
B) The prevalence of STI among FSWs was higher (genital ulcer,7.5%& vaginal
discharge:11.5%) than that of ANC attendants women ( syphilis:1%) .
C) FSWs’ and clients focused intervention with a defined package of services is
implemented currently only in 169 towns and reaching about 50 % of the
population. The PEPFAR support will expand to 200 towns and expected to reach
80% the FSWs in these sites. . Due to this there is a need to expand the ongoing
program to another 100-150 towns with high population size of female sex
workers, hot spot nature and high overall HIV prevalence in the area to reach
the remaining 50% and also maintain the intervention. This was also proposed by
the FSWs who participated in the group discussion conducted for getting inputs
and addressing the needs of this key population in the concept note.
D) the evidence generated from the 2013 epidemiological synthesis also supports
the need to focus on FSWs
E) The effect and impact of the intervention is high as demonstrated by the
PEPFAR supported program which has achieved significant incremental
improvements in HIV testing, ART enrollment and retention among FSWs and
initiatives for alternative sources for income generation for this key population..
This calls for expansion of the program to other towns.
Outcome and impact: It will contribute to increase the use of condom, reduce
STI and improve treatment seeking behavior, treatment retention at 12 months,
reduce new HIV infections and death due to HIV. The modeling done with the

support of Futures Institute while we were developing the 2015-2020 HIV
investment case showed that reaching FSWs with the proposed interventions in
the investment case will reduce 3450 new infections by the end of the investment
period.
Module 2: Prevention programs for vulnerable population (seasonal/daily
laborers in development schemes, mega projects, extensive & mechanized
farms, flower plantation, mining and/ or large scale work sites).
As mentioned above this segment of the population was targeted for HIV
prevention programs including HIV testing and counseling during the
implementation of the 2015-2020 HIV investment case. This module is selected
for the support with this funding request because of
A ) the size of the seasonal /daily laborers is larger ( about one million ) than
other vulnerable groups in the country.
B) The presence of high sexual risk practices and sexual networks, and being
clients of FSWs . Baseline survey conducted in 2010 among laborers in building
and road construction showed that 19% of male daily laborers had had sex with
commercial sex workers and 21% had two or more partners in the previous year.
C) The development schemes and the mega projects demand separation of the
laborers from families and home environment which increase the vulnerability of
the group to STI and HIV.
D) Most of the laborers are young productive and in the reproductive age group.
E) Presence of large development schemes and mega projects with inadequate
intervention coverage; overall about 80% of the laborers are not currently reached
and a major of these was because of operational difficulty. The PEPFAR
supported work site prevention program is now implemented in 92 sites and with a
plan to expand to 100 sites by 2017 and reach 75% of the laborers through
focusing on the hard to reach (seasonal labors in Humara and Metema area).
F) High mobility and influx of female sex workers to these work sites resulting in
development “ hot spots”. With the observation of this mobility and sexual
practices in these areas , there is a fear of resurgence of the epidemic in the
country if these population groups are not reached with high impact interventions
in a a timely fashion accompanied by strengthen the collaboration and linkage of
the intervention with the responses in the surrounding community.
Outcome and Impact: The implementation of this module will contribute to
improved utilization of HIV testing, condom use and reduction of new HIV
infection, particularly among 15-24 years old.
Module 3: Prevention programs for general population. This module largely
focuses on targeted HIV testing and counseling, and to some extent on orphan
and vulnerable children package. The primary reasons for selecting HIV and
testing for this request and overall prioritizing this intervention in the investment
case are :
A) The success of the PMTCT and ART enrollment is largely depending on
having high HIV testing up take and coverage
B) There are a good percentage of PLHIV (30-35%) who do not know their HIV
status and particularly among children case identification is extremely low
.Because of this they are not linked to care and treatment.
C) Testing strategy is to focus on high risk and vulnerable population, where
yield is likely to be highest and link identified PLHIV to care and treatment.

D) The prevention effect of having HIV testing and knowing status and adopting
safe sexual behaviors. The Goal modeling done with the support of the
Futures institute while we developed the 2015-2020 HIV investment showed
that 5640 new HIV infections can be averted by 2020 with reaching the
population groups targeted for HIV testing and the set coverage targets of HIV
testing in the strategic document.
The orphan and vulnerable package was also selected as part of this module
because a) OVC are targeted for HIV testing through linking with the orphan
support package and approaching guardians or relatives. This will help to increase
the percentage of children living with HIV who know their status and pediatric ART
enrollment.
b) to complete the transition started with the support of Transition Funding
mechanism of the GF whereby the Ethiopian Inter Faith Forum for Development
and Dialogue in Action has been implementing.
c) to ensure continuum of care through supporting the community based care and
support program for OVC.
Outcome and Impact of the selected module

 Increased percentage of PLHIV who know their HIV status and are linked
to care and treatment, resulting in earlier initiation of ART and increased
ART enrollment
 Contributed to the reduction of new HIV infections and achievement of the
70,000-80,000 infection reduction goal of the country by 2020.
 Will contribute to death reduction goal of the country by serving as the
entry point to care and treatment.
4) Module 4: PMTCT
PMTCT is one of the top priorities of the 2015-2020 HIV investment case .
Because of this and the existing programmatic and financial gaps it is prioritized
for the funding request in the concept note. More specifically it is selected
because
A) A third of the current new annual infections are the results of MTCT.
B) the effectiveness of the intervention. The Goal modeling at the time of
developing the investment case showed that 12,960 new HIV infections can be
averted with reaching the coverage target and implementing the interventions in
the strategic document.
C) presence of 31% programmatic gap and
D) Financial gaps for prong 3&4.
Outcome and impact
 Improved PMTCT service utilization
 Contributed to the reduction of new HIV infection and death reduction,
particularly to the achievement of the national goal of 70,000-80,000 new
infections averted by 2020.
 Reduced the percentage of HIV infants to born to HIV positive women from
12.8% in 2014 to 5.4% in 2017.
5) Module 5: Treatment , care and support
The first priority of the Ethiopia 2015-2020 HIV investment case is to assure the

provision of Antiretroviral therapy (ART) as 45% of infections averted and 89% of
death reduction will result from expanded and sustained treatment, care and
support that results in achieving the set targets of 90% enrollment by 2020.
Hence, the treatment, care and support module was prioritized for the request in
the allocation fund . Additional reasons for prioritizing this module include:
A) the resource needs for implementing this program are huge
B) there is no financial resource committeemen from domestic resources or any
development partners for ARV drugs. ARV drugs have been covered with Global
Fund resources.
C) the need to ensure continuity of services( ART).
Outcome and impact
 Increased the percentage of adults and children with HIV known to be on
treatment 12 months after ART initiation from 85.6% to 90 % by 2017.
 Contributed significantly to the new HIV infection reduction and
achievement of the 57% incidence reduction (taking the current base line
of 0.03%) by 2017.
 Reduced death from the current level to 4,625/ 100,000 in 2014 to 2,093/
100,000 in 2017.
6) Module 6: Program management

The grant management requires experienced professionals in program and sub
recipients management, pharmaceutical and health product management, financial
management and monitoring and evaluation of the program and grant
implementation. Because of this there is a need to retain the critical positions
for grant management in the PR and the nine regional and two city administration
health bureau / regional HIV/AIDS coordinating authorities Grant fund will be
utilized to recruit and fill these critical human resources.
Outcome and impact
 Improved timely and effective implementation of program/grant.
 Improved the financial management of grant
II. TB Modules
Module 1: TB Prevention and Care Module
Detection and successful treatment of TB cases is among the top priorities for the
national TB control program. High-impact interventions to detect and treat TB
cases are included under this module. The first programmatic gap that has been
identified as a priority is reaching the NSP targeted number of notified cases (all
forms of TB - bacteriologically confirmed plus clinically diagnosed, new and
relapses). This is mainly related to insufficient amount of available domestic/donor
funding for the next three years to ensure provision of necessary quantity of
laboratory reagents, consumables and supplies for AFB microscopy as well as
Xpert MTB/RIF test cartridges for TB molecular diagnosis among children.
Similarly, a gap is identified with regard to training of laboratory personnel in
AFB/LED microscopy and EQA, comprehensive integrated (TB DOTS, TB/HIV, IC,
PMDT) training of healthcare providers, and selected ASCM activities for
increasing awareness on TB among general communities and KAP. To fill these
gaps, the CCM requests the appropriate amount of funding from the allocation

amount, which together with available domestic/donor funding will allow
identification of 364,524 TB cases over 2.5 years, i.e. reaching 70%, 73%, and
75% of the national targets for the grant Y1, Y2, and Y3, respectively. However,
these targets are below of the NSP targets (77%, 79%, and 81% for Y1, Y2, and
Y3, respectively). In order to fill the remaining gap, CCM requests additional
funding from the above allocation amount, to be used for implementation of
innovative high impact CTBC interventions including phased scale up of TB
REACH demonstrated CTBC packages and mobile TB/HIV Clinics using mobile
vans. Implementation of the aforementioned CTBC intervention through the
requested above allocated amount will allow reaching the national targets for the
number of all notified cases over 2015-2017.
The other major gap that has been identified is provision of first line treatment to all
TB cases that will be identified over the next three years, as no procurement of
FLDs is planned through domestic/donor funding for the said period. To fill this
gap, CCM requests the funds from the allocated amount that will be used for
procuring FLDs for the projected 364,524 TB cases that will be identified in 2015-
2017. Should the requested funding for implementing the aforementioned
innovative CTBC activities be available, it would require additional amount of
funding to cover the need in first line treatment for additional 49,963cases.
Outcome and Impact of the module:
 Improve TB case detection from 62% baseline to 72% with allocation
amount and attaining the NSP targets of 81% with above allocation by 2017
 TB treatment success rate will be maintained at or above 90%
 This will contribute to reduction of TB transmission, TB morbidity and
mortality
Module 2: MDR-TB Prevention and Care

The prevention and control of DR-TB is also one of the priority initiatives in the
NSP. Within the framework of previous GF grants and other donor supported
programs, the country has made significant progress with building TB molecular
diagnosis capacity. There will be 99 GeneXpert functioning sites across the
country, which will allow achieving sufficient coverage with TB molecular diagnosis
among targeted groups within the scope of MDR-TB priority module, given that the
major gap in provision of Gene Xpert MTB/RIF test cartridges is filled. Hence, CCM
is requesting appropriate amount of funding from the allocation amount for
provision of MTB/RIF test cartridges to make sure that the national targets on
MDR-TB case identification are met. By July 2015, there will be total of 14
functional labs including one NRL in the country, allowing sufficient coverage with
culture and conventional DST in the presence of well functional lab specimen
transportation network (support lab network strengthening interventions is included
in the HSS concept note request). Again, the major gap remains in the provision of
culture and conventional DST materials, which is requested to be covered from the
allocation amount accordingly. A gap is also identified with regard to training of lab
specialists on culture/DST and Xpert methods as well as implementation of ACSM
activities for increasing awareness on MDR-TB among general communities and
KAP. Overall, the requested funding from the allocated amount will allow provision
of Xpert MTB/RIF testing and conventional culture/DST to diagnose/monitor 3176
MDR-TB patients in 2015-17.
The other major gap in the MDR-TB priority module is the provision of second line
treatment to the NSP targeted number of MDR-TB patients. The domestic & donor
funding available for 2015-2017 envisages mainly PMDT support including
capacity building, training, and mentorship, with no budget for the procurement of
SLDs and ancillary drugs. Hence, CCM requests financial support from the
allocation amount, which together with available domestic/donor funding will allow
covering the need in second line treatment of 3176 MDR-TB patients in 2015-
2017.
To further increase the coverage with MDR-TB treatment, CCM requests
appropriate amount of funding from the above allocation amount to start Xpert
MTB/RIF testing among bacteriologically confirmed new TB cases in major urban
settings with higher drug resistance prevalence among new TB cases and to
provide second line treatment to the MDR-TB cases that will be identified through
this effort. The amount of requested funding from the above allocation amount is
anticipated to result in accomplishing the NSP targets by enrollment into second
line treatment total of 1440 additional MDR-TB patients in 2015-17.
Impact and outcome of this module:
 MDR-TB Case detection among notified TB cases will reach 58% with
allocation amount and attaining NSP target of 81% with above allocation
amount.
 This will contribute towards substantial reductions in DR-TB transmission,
morbidity and mortality.
Module 3: TB Program management and M&E
There is a considerable gap in supporting program management and M&E
activities facilitating provision of quality services to targeted population groups
within the scope of TB Care and Prevention, MDR-TB, and TB/HIV modules
TB/HIV priority modules. To fill this gap, CCM requests funding from the allocation
amount to support selected key activities including TB and HIV joint program
performance reviews, M&E, supportive supervision, mentorship, etc., which are
critically important to ensure satisfactory performance within all priority modules at
all levels (e.g., keep TB treatment and cure rates high, improve performance
indicators on collaborative TB/HIV activities). Relevant interventions are planned/
budgeted within the scope of all three priority modules with more details given in
respective modular tables. All these interventions to be funded from the allocated
amount are planned to have major focus on key populations (e.g., more frequent
supervisory visits in pastoralists’ communities, prisons, urban slum areas). To
further improve performance of TB and HIV programs, CCM requests additional
funding from the above allocation amount to support innovative interventions to
design and implement national quality improvement (QI) system for TB and HIV
programs, which will have major focus on improving quality of TB and HIV services
and care.
Anticipated Impact and outcome:
 Strengthened TB/DR-TB Program management
 Improved Quality of TB services
III. TB/HIV Module

This module focuses to strengthen the TB/HIV Collaborative activities building on
the gains made so far in HIV testing, TB Screening & ART enrollment; improving
TB diagnosis among HIV infected patients and IPT coverage. Module 3 and
Module 5 of the HIV component fully addresses the HIV testing, ARV, and CPT

need for TB/HIV Collaborative intervention. While the TB component of the
concept note includes the needs for IPT, TB IC, and improving diagnosis of TB
among HIV infected (particularly cost of GeneXpert cartridges). With the request in
the TB component, 312,938 presumptive HIV positive TB cases and 241,083 HIV
positive adults &children will have Xpert MTB/RIF testing and IPT, respectively in
the concept note period. The TB/HIV interventions are fully integrated at the
community level as the services are provided by the HEWs and the health
development army. Similarly, TB/HIV services are provided in the same health
facility, but there are health facilities providing HIV testing and TB diagnosis&
treatment but not ART. The focus is to make ART available in all health facilities
providing TB diagnostic &treatment, strengthening intra- and inter-facility referral
system and joint planning. Hence, this will be implemented as articulated in the TB
NSP and HIV investment case through the integrated health and TB/HIV financing.
Impact and outcome
 Universal access to core TB/HIV interventions will be attained
3.4 Focus on Key Populations and/or Highest Impact Interventions
This question is not applicable for Low Income Countries.
For TB and HIV, describe whether the focus of the funding request meets the
Global Fund’s Eligibility and Counterpart Financing Policy requirements as listed
below:
a. If the applicant is a lower-middle income country, describe how the funding
request focuses at least 50% of the budget on underserved and most-at-risk
populations and/or highest-impact interventions.
b. If the applicant is an upper-middle income country, describe how the funding
request focuses 100% of the budget on underserved and most-at-risk
populations and/or highest-impact interventions.
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SECTION 4: IMPLEMENTATION ARRANGEMENTS AND RISK ASSESSMENT
This section requests information regarding the proposed implementation

arrangements for this funding request. Defining the implementation arrangements
for the program including the nominated Principle Recipients (PRs) and other key
implementers is essential to ensure the success of the programs and service
delivery. For the concept note for TB and HIV, the Country Coordinating
Mechanism (CCM) can nominate one or more PRs, as appropriate given the
country context.
4.1 Overview of Implementation Arrangements
For TB and HIV (including HSS if relevant), provide an overview of the proposed
implementation arrangements for the funding request. In the response, describe:
a. If applicable, the reason why the proposed implementation arrangement
does not reflect a dual-track financing arrangement (i.e. both government
and non-government sector PRs).
b. If more than one PR is nominated, how co-ordination will occur between
PR(s) for the same disease and across the two diseases and cross-cutting
HSS as relevant.
c. The type of sub-recipient management arrangements likely to be put into
place and whether sub-recipient(s) have been identified.
d. How coordination will occur between each nominated PR and its respective
sub-recipient(s).
e. How representatives of women’s organizations, people living with the two
diseases and other key populations will actively participate in the
implementation of this funding request.
The implementation of the HIV and TB interventions are guided by the Health
sector development plan and the disease specific strategic plans. Overall the
Ministry of health will lead and guide the implementation of the programs along
with the five agencies under it and the nine regional and two city administration
health bureaus. In the implementation different government sectors, FBOs, CSOs
and Associations of PLHIV will be involved. There are two principal recipients
which will coordinate and lead the implementation of the TB –HIV concept. Both
are government organizations ( MOH & HIV/AIDS prevention and control Office)..
There are many Civil society organizations that will be Sub recipients for selected
interventions. For example, EIFDDA is the SR for OVC support while NEP + is the
SR for ART adherence education. Others such as Consortium of Christian Relief
and Development Association will be SRS for prevention program, support for
OVC and capacity building component of CSOs. As the Health sector is looking
for Results based funding , the CCM decided MOH and HAPCO ( government
sectors ) to continue as PR while the previous CSO PRS to be SRs.
HIV component of the CN: The PR for this component is the HIV/AIDS
prevention and Control office ( HAPCO). .
1. HAPCO : US$ 214,074,622,
HAPCO, the national AIDS coordinating Authority, will be the PR for most of
the Modules and will coordinate and lead the implementation of these

interventions across all parts of the country. It was the PR for HIV Round two,
Round 4 and Round 7 and also PR for the current active RCC HIV grant. It has
grant management guidelines that outlines the management of the grant, the
fund flow, SR selection and management including capacity assessment and
project appraisal mechanisms. Based on the decentralized system of the
country, mandate of the organizations and comparative advantage of the
organizations in relation to the priority modules, most of the sub recipients are
pre identified. These include :
A) All the nine regional and two city administration health bureaus or regional
AIDS coordinating authorities, Districts/ town administrations, health
facilities ( HFs), Health extension and Women centered Health
development army in all the communities.
B) Pharmaceutical Fund Supply Agency: It will procure all pharmaceuticals
and health products include in this concept note and distribute to health
facilities through 17 hubs.
C) Federal hospitals, Uniformed forces hospitals and Prison Administration-
like any other public HFs they will implement module 3, 4 and 5 of the HIV
component and TB diagnosis and treatment
D) FBO and private HFS involved in the implementation of HIV testing, PMTCT
and ART
E) Sugar corporation and Ethiopian Electric Power will implement Module
2( HIV prevention programs for laborers in development schemes and
Mega projects with adequate linkage with interventions in the surrounding
Communities.
F) Civil society organizations operating at the center, regions and district
level. Some are already identified and includes the Consortium of Christian
Reliefs and Development Association, women’s Association and Youth
Association in the different regions. Other CSOs will be involved in the
implementation of the preventions components based on open media call
as per the grant management guideline.
In the implementation of Module 1 (Prevention programs for FSWs and clients )
and Module 2 ( prevention program for other vulnerable population), the FSWs
and laborers will be involved as peer educators who will reach the target
population through one to one and small group sessions in the 100-150 towns and
15 development schemes/d mega projects respectively . In addition to this they will
be involved in joint planning and review of these programs in the towns or work
places. Likewise the women association’s in regions and town administration will
be the sub- sub recipients for the HIV prevention programs for FSWs & clients,
General prevention ( HIV testing and counseling ) and PMTCT, particularly prong
1.
EIFDDA will be the sub recipient ( : US$ ) the OVC package of module three
while NEP + will be the lead SR for ART adherence education of US$ 7.9
Million. NEP+.. . It will implement this through involving 102 associations of
People living with HIV in the different regions and city administrations..
As indicated above HAPCO is not only a PR, but it a national AIDS coordinating
Authority which coordinates and leads the implementation of the 2015-2020 HIV
investment case. Hence, it will coordinate all HIV actors as part of its mission
through the annual joint planning , semiannual joint supervision and semiannual

joint review platforms as well as through the joint Technical working groups.
TB component
The Ministry of Health will be the PR for the TB components. It is PR for the
current active Round 10 phase 2 TB grant ( US$ 56 M ) which was signed in July
2014. During the allocation new 3 M million was added with eligible for incentive
funding. As most of the interventions are biomedical or procurement related, a
substantial part of the resource is from the phase 2 and overall mandate , MOH
will continue as PR for the TB component. It will implement through the regional
health bureaus , district health offices and community structures..
4.2 Ensuring Implementation Efficiencies
Complete this question only if the CCM is overseeing other Global Fund
grants.
From a program management perspective, describe how the funding requested

links to any existing Global Fund grants, or other funding requests being submitted
by the CCM at a different time. In particular, explain how this request complements
(and does not duplicate) any human resources, training, monitoring and
evaluation, and supervision activities.
Currently there is an active HIV RCC grant which is implemented by HAPCO. No

cost extension was requested for six months and will end by June 2015. While the
starting period of this concept note is July 2015. There is no overlap. The ARV
drugs that will be procured with the no cost extension and the six months buffer
and other pharmaceuticals that will be procured at early 2015 with available grant
resources in country will cover the needs of 2015. Because of this we did not
include these for 2015. Similarly, funding request for human resources and
monitoring and evaluation was done only for two and half years considering the
first half of 2015 will be covered with existing resource. CCM- E requested cost
extension of one year (July 2014-June 2015 ) from the allocation for NEP+ to
ensure the continuity of the services it has been providing. This was considered in
this CN and the support request for NEP+ is for two and half years aiming at
continuing the Treatment adherence education. In general the request was made
based on the programmatic and financial gap analysis and the
complementarities of the support by different partners as well as domestic
resources.
There are two current GF grants being managed by FMOH as a PR; Round 10
SSF Round 10 TB grant and Round 9 HSS TB grant both of which will be
consolidated into NFM starting from July 2015.
The priority interventions under the modules in this concept note were built on the
interventions under these grants. For example, all the priority interventions under
the TB component of the concept note allocation amount are extensions of already
prioritized TB interventions under phase II round 10 SSF TB grant avoiding any

duplications. In fact, since all existing grants are consolidated into NFM starting
from 2015, there will not be any risk for duplications. Complementarity of
interventions between disease specific programs and the different grants on HR,
training, M&E and supervision activities are ensured through an already
established system of joint planning, integrated supportive supervisions and
through use of one HMIS to inform performance. Besides, the request under HSS
concept note addresses priority health system gaps and the interventions under
TB/HIV concept note are focused on programmatic issues. This will ensure
efficiency in implementation of the planned interventions.
4.3 Minimum Standards for Principal Recipient (PR) and Program Delivery
For both TB and HIV complete the table below for each nominated PR. For
more information on Minimum Standards refer to the Concept Note
Instructions.
PR 1 Name MOH Sector Government
PR 2 Name HAPCO Sector Government
Does this PR currently manage a

Global Fund grant(s) for this X☐Yes All the selected PRs are now
disease component or a stand- implementing GF grants. ☐No
alone cross-cutting HSS grant(s)?
Minimum Standards CCM assessment
HAPCO: It is structured with eight

directorates and one section. These are : Plan
and M&E; Multi sectoral response
Coordination; projects and grant management
Coordination; Finance and Procurement,;
Human resources and Property administration;
Audit and Inspection; Women and Youth
Affairs; Public Relation and Communication
and Legal section . Overall it is led by Director
General and has ten executive management
1. The Principal Recipient team members who are responsible for the
demonstrates effective management of the organizations. It has a
management structures and planning and M&E directorate who coordinates
planning the planning and M&E through the different
teams and the existing joint platform of
planning with all stakeholders.
FMOH: FMOH demonstrates effective
management structures and rigorous planning
process. Since GF Round 1, FMOH has been
PR for 7 GF grants and has had no major
issues regarding management of GF grants.

HAPCO: has the experience of managing R2,
R4, R7 and RCC HIV grants as well as other
projects the World Bank supported HIV
projects. It has a designated directorate
responsible for coordinating and leading the
management of the different and projects
along with the Finance and procurement
directorates and Audit and Inspection. It is
staffed with experienced professions of
different discipline mixes. It has a grant
management guidelines which outlines SR
capacity assessment , SR management, flow
of reports and over sighting mechanism .To
ensure the accountability , guide the time
implementation of the grant and track the
performance of each SR and SSR there is a
grant agreement that the PR enters with SRs
2. The Principal Recipient has the and also SR with SSRs that shows the
capacity and systems for responsibility and obligation of each, the work
effective management and plan and budget, performance measurement
oversight of Sub-Recipients and expected results, reporting periods and
(and relevant Sub-Sub- duration and overall time framework for the
Recipients) implementation.
FMOH: There is a long-standing, internal
system for effective management and
oversight in the FMOH, including sub-
recipients. The current strategy relies on the
structure of the Ministry extending down to the
regions and beyond (see accompanying
implementation structure). The structure
demonstrates clear lines of authority and
establishes organizational responsibilities for
implementation at all levels. Each level is
effectively held accountable for commitments
to internal and external partners. While
administrative authority is decentralized for
efficiency, technical coordination remains with
the FMOH to assure coordinated action.
.
HAPCO has an Audit and Inspection

directorate which audits and inspects the PR
every six months and annually the SRs based
on risk assessment. It checks the internal
3. The internal control system of
control system and they are implementing the
the Principal Recipient is
grant in compliance with the grant agreement,
effective to prevent and detect
procedures and operating manuals of the
misuse or fraud
Government financial and procurement
guidelines e assures .
FMOH: There is a strong internal control
system to prevent and detect any misuse or

fraud at all levels of the health system. FMOH
conducts internal and external audits annually
down to the regional level and subsidiary
levels are audited down the reporting
structure. The system has proven to be
effective in detecting and avoiding misuse or
fraud.
HAPCO:
Ministry of Finance and Economic
Development is now rolling out the
implementation of the Integrated financial
management Information system (IFMIS ) in
the country. Likewise the Health sector and
HAPCO have started the preparation to
implement this. Until now HAPCO is using
Peachtree complete accounting software
supported with the financial manual for
managing Global Fund grants. The Finance
and procurement directorate is organized
under three teams , namely, budget control,
disbursement and Liquidation; general
accounts and procurement . In addition to this
it has a system for verification of expenditures
and fix assess. In general the PR has a well
functioning financial management system
which has developed based on the cumulative
4. The financial management experiences of managing Global Fund and
system of the Principal World Bank HIV projects as well as support
Recipient is effective and of UN agencies.
accurate FMOH designed a new grant management
system and established a grant management
unit at federal and regional levels. The new
grant management system has been working
to improve the coordination and
implementation of grant between different
departments at federal and regional levels. In
addition, FMOH has started to scale up
Integrated Financial Management System
(IFMIS). The system provides multiple
advantages for performance improvement –
 Timely, accurate and consistent data for
management and budget decision-making.
 Information for budget planning, analysis

and government-wide reporting.
 Facilitates reporting and auditing.
Closer linkages between FMOH, Regions and

implementing partners.
.
PFSA is the agency which is responsible for

the quantification, procurement, storage and
distribution of all pharmaceuticals and health
products for t he public health facilities in the
country. Currently, it has a central ware
house of 50,200 Metric cube capacity and six
functioning regional hubs of 170,075 Metric
Cube. There are other four main hubs of 96
712 Meter cube and six secondary hubs of
45,318 meter cube which are under
construction. Which will make the overall
number of hubs be 17 and the capacity of
dry store to be 362,305 meter cube. In
5. Central warehousing and
addition to the dry, PFSA has 16 cold chains
regional warehouse have
with a storage capacity of 2, 000 meter cube.
capacity, and are aligned with
The ware houses are:
good storage practices to
ensure adequate condition, -clean and have adequate storage capacity
integrity and security of health -well-lit, well- ventilated storeroom – out of
products direct sunlight
-Protected from water penetration
-have maintained cold storage and cold chains
-authorized only for working personnel and
controlled substances are locked
-integrity of products are maintained by
stacking cartons 10cm away from the floor and
30 cm away from the wall and no more than
2.5m high.
-unusable or expired pharmaceutical products
are kept separately
The current distribution system has three
levels, from the central PFSA to regional Hubs
6. The distribution systems and and regional hubs to Health facilities. The
transportation arrangements distribution is integrated with Integrated
are efficient to ensure pharmaceutical logistic system (IPLS) . Direct
continued and secured supply delivery distribution is done to more than 1047
of health products to end users ART sites and more than 2000 PMTCT sites
to avoid treatment / program
(direct or pass through woreda health office)
disruptions
It has 124 of different sizes of trucks, ranging
from a heavy truck that can carry 25 tons to

small truck of 3 tones carrying capacity. The
overall distribution capacity at a time is 990
tons. As the need is increasing along with the
expansion of the health facilities and the need
to delivery HIV commodities to the health
facility level, PFSA is now procuring additional
46 vehicles of 322 tons of carrying capacity.
All PFSA warehouses are now strategically

placed within reasonable radius of all locations
in the country for assuring timely distribution of
health products and eliminating stock outs and
avoiding treatment/program disruptions.
There is a health management information

system (HMIS) and a logistics management
information system (LMIS). The HMIS and
LMIS provide some data and reports that are
valuable for monitoring malaria program
performance. The Public Health Emergency
Management (PHEM) Directorate at Ethiopian
Public Health Institute (EPHI) assures the
availability of data-collection capacity and
tools. It is within the responsibility of PHEM to
provide surveillance data and emergency
response, for which it must assure on-going
monitoring of program performance.
The HMIS indicators were revised recently. In
the revised HMIS, a number of HIV indicators,
7. Data-collection capacity and which were not in the previous one, were
tools are in place to monitor included that enable to track the program
program performance performance. Example :number of infants born
to HIV positive mothers who received ARV
prophylaxis, number of infants born to HIV
positive women received virological testing
within two months of delivery ; HIV positive
women who receive family planning services
etc. Training on the revised HMIS was given.
The formats were printed and distributed to all.
With these revisions and the continuous
support there is a ground for having the
capacity for data collection and reporting. In
addition to HMIS there is multi sectoral
response information system ( MRIS) which
tracks non health response data..
8. A functional routine reporting There is a functioning HMIS. Recently the

system with reasonable indicators were revised and training was given

coverage is in place to report to professionals. The implementation of this
program performance timely has started recently and is expected to provide
and accurately an accurate and timely report with a
continuous support for improvement.
The Ethiopian Food, Medicine, and Health

Administration and Control Authority
(FMHACA), quality control laboratory has been
re-accredited for ISO/IEC 17025:2005.
The regulatory authority establishes which
medicines submitted during the drug
registration process conform to their claimed
9. Implementers have capacity to specifications. The laboratory validates test
comply with quality methods and specifications submitted as part
requirements and to monitor of the drug application dossiers and tests
product quality throughout the samples of medicines submitted prior to
in-country supply chain FMHACA granting the manufacturer marketing
authorization. It also carries out inspection of
manufacturers’ quality control laboratories,
monitoring the quality of marketed medicines
through post-marketing surveillance programs.
The laboratory also provides testing services
to medicine procurement agencies and
medicine manufacturers that lack the
necessary internal quality control system.
4.4 Current or Anticipated Risks to Program Delivery and PR(s) Performance

a. With reference to the portfolio analysis, describe any major risks in the country
and implementation environment that might negatively affect the performance
of the proposed interventions including external risks, PR(s) and key
implementers’ capacity, past and current performance issues.
b. Describe the proposed risk mitigation measures (including technical
assistance) included in the funding request.
1-2 PAGES SUGGESTED

Major risks in the country and implementation environment that might negatively
affect the performance of the proposed interventions categorized as programmatic
risks, fiduciary and financial risks, pharmaceutical and health products risk and
grant administration & oversight risks and risks related with monitoring and
evaluation.
Programmatic risks include not achieving targets (PMTCT targets) this is because
of low delivery at health facilities, inadequate service integration and inadequate
service linkages between health post and health centre services and STI
prevention program also has less attention and it is not the area of focus .Fiduciary

and financial risks include funds or other resources not disbursed timely, not being
used efficiently, or not being properly recorded. Pharmaceutical and health product
risks are related with Stock out of products caused by delayance of fund
disbursement; unplanned program change; long lead time; poor supplier
performance; unpredictable or limited sources of supply or sole supplier; Small
volume procurement for paediatric ARV drugs; unpredictable sole supplier for
supplies; poor supplier performance. Grant administration & oversight risks are
related to poor grant administration in terms of speed and efficiency, governance
and oversight, or compliance with grant agreement and conditions. Monitoring and
evaluation risks include delay & completeness of reports this is caused by staff
turnover & limited number of M&E staff and inadequate data verification.
To mitigate the probability of programmatic risks actions will focus on achieving

grant performance targets and program impact, Strengthening demand for
institutional delivery through the Health Development Army in all the communities,
building capacity to provide services, enhancing integration of MNCH services with
HIV, and strengthening service linkages between health extension program and
health centers. To mitigate fiduciary & financial Risks; financial management
strengthening ; filling the gap of qualified staff to recruit qualified professionals;
following and monitoring SRs on financial management; undertaking SoE
verification and speeding-up settlement of advances. Sending PUDR timely to the
Global Fund secretariat requesting fund release, similarly informing SRs to speed-
up fund disbursement to SSRs fulfilling the necessary pre-requisites in advance;
quickly closing any backlog issues; conducting timely inventory and tagging all
items timely. To mitigate Grant administration & oversight risks; undertaking pre-
grant capacity assessment of SRs and giving feedbacks of the assessment
findings to respective SRs (regions) so as to enable them take the necessary
actions. Undertaking supportive supervisions regularly, during supportive
supervisions technical support on program implementation and financial
management will be provided. To reduce risks related to monitoring and
evaluation; recruiting & maintaining additional M&E staffs and undertaking regular
data verification. To reduce risk associated with PHP especially with stock out of
products; timely fund disbursement; avoiding dalliance by closely following the
supplier status; integrating program changes with logistics; periodic review of stock
& procurement status of products which is conducted every month as PSM
coordination committee meeting which comprises all partners who are actively
engaged in the supply issues. Early initiation of the procurement for small volume
purchases; giving priority for efficient supplier and penalize the poor supplier and
strengthening hub/facility communications.
CORE TABLES, CCM ELIGIBILITY AND ENDORSEMENT OF THE CONCEPT

NOTE
Before submitting the concept note, ensure that all the core tables, CCM eligibility
and endorsement of the concept note shown below have been filled in using the

online grant management platform or, in exceptional cases, attached to the
application using the offline templates provided. These documents can only be
submitted by email if the applicant receives Secretariat permission to do so.
x☐ Table 1: Financial Gap Analysis and Counterpart Financing Table
x☐ Table 2: Programmatic Gap Table(s)
x☐ Table 3: Modular Template
x☐ Table 4: List of Abbreviations and Attachments
x☐ CCM Eligibility Requirements
x☐ CCM Endorsement of Concept Note

FundingModel TBAndHIVConceptNote Final Ethiopia Oct15 2014

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FundingModel TBAndHIVConceptNote Final Ethiopia Oct15 2014

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The single concept note details the applicant’s request for Global Fund

resources for a disease component for a three-year period. The concept

Investing for impact against tuberculosis and HIV

TB and HIV Concept Note: Ethiopia 15 October 2014│ 1

FUNDING REQUEST SUMMARY TABLE

A funding request summary table will be automatically generated in the online

TB and HIV Concept Note: Ethiopia 15 October 2014│ 2

This section requests information on the country context, including descriptions of

1.1 Country Disease, Health Systems and Community Systems Context

Back ground : General

Ethiopia is a country with a population of 88 Million 1. The annual population growth

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1.1 Country Disease, health system and country systems context

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HIV prevalence, by sex and year

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Key population Size estimation HIV Source

FSWs 120,000- 23% National MARPS survey ,2013, EPHI

Truck drivers 15,000 4.9% National MAPS survey, 2013, EPHI

Daily /seasonal 1,000,000 NA

prisoners 112,361 4.2% Rapid assessment of HIV situation in

Figure 4: Trends in HIV prevalence among pregnant women age 15-49 yr by

3 Baseline report by Transaction,2010

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Figure 5: Trends in HIV Prevalence by age group (Source: ANC 2012)

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6Reniers,G.A;T.Davey,G; Nagelkerke,N;Berhane, Y;Coutinho R; Sanders,EJ (2009), “ Steep

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AIDS and HIV-related illness deaths, by year…

Cognizant of these changes in context, the country in collaboration with

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Figure 8. Trends in TB prevalence, incidence and mortality rates 1990-2012

Source: Global TB Reports 1991-2013

7 National TB Prevalence Survey Report, 2011

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450 428 421 408 395

300 280 269 258 247 247

Source: Global TB Reports 2000-2013, National TB Report 1999-2013

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Source: National TB Data

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9TB REACH Report, SNNPR

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13 Ref: NTP Review report

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MDR-TB Epidemiology: Ethiopia is also among the 27 high-MDR TB burden

Trend of MDR-TB Case finding and estimates among notified TB

TB- HIV co infection

15 DRS report 204

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B. Key population: access to prevention, treatment, care and support

As summarized in Table 2 above, Ethiopia identified the following as key

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However, there are a substantial proportion of FSWs, truck drivers and

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Key population Population size Estimated TB Estimated MDR-

Prisoners 112,361 21 1.5% among

Refugees 629,718 24 368/100,000 25 No data available

Seasonal Migrant 1,000,000 247/100,000 2.3% among new