The Goal of the national PMTCT programme is to expand PMTCT services in order to reduce the risk of transmission of HIV infection from infected mothers to their babies during pregnancy, child birth and during breastfeeding through integration of PMTCT services in routine reproductive and Child health services in all 21 regions. Since the national PMTCT program inception in 2000, PMTCT services roll-out has accelerated significantly. Currently 544 sites (10%) out of 5,379 in all districts are providing the core elements of PMTCT services including testing and counselling (TC), antiretroviral prophylaxis, and infant feeding counselling integrated in reproductive and child health services. This 10% coverage is low and as a result, by the end of 2005 only 11,435 (9%) of the estimated 122,000 HIV positive pregnant women were receiving Nevirapine prophylaxis. The USG funds several partners who provide PMTCT services in several sites to meet these challenges. In accordance with the current policy of PMTCT regionalization, USG partners are assigned specific regions (rather than choosing individual sites) within which they support the provision of PMTCT services to selected facilities within that region, by working with regional and district government authorities. Deloitte/FHI is the Partner for HIV Care and Treatment activities in Morogoro, Singida and Iringa and has been asked to be the MTCT partner in these regions. In these regions, FHI/Deloitte supports sites with HIV care and treatment services and as well communities with HBC and OVC services. Deloitte/FHI will use the plus up funds to add PMTCT services to the program and this will support the delivery of comprehensive HIV services that are linked across a continuum of care. Deloitte/FHI will work with the MOHSW and Local Governments in expanding PMTCT services to all 17 districts in the three regions, through a combination of sub-grants and site support to district councils and their respective facilities, so that more pregnant women access the services. Similarly, support will be provided to relevant community organizations involved in care and reproductive health. The approach will be a comprehensive system strengthening approach through involvement of local authorities and stakeholders. Implementation will include: sensitization and orientation, participatory assessments to determine needs, followed by capacity building. supportive supervision, renovations where required and service delivery improvement. Services provided will include opt out counselling and testing of HIV to all pregnant women, offering a combination of single dose NVP and more efficacious regimen based on facility capacity, post natal follow-up and providing nutritional counselling and support to infants and the lactating mothers. Since the uptake of NVP is very much dependent on facility based delivery, selected facilities will receive additional support to set up maternal homes, improve obstetric, labour and postnatal wards infrastructure, equipment, commodities and services to entice more women to give birth in these facilities and for those HIV+, access NVP. Special/additional orientation training to midwives handling both HIV+ and HIV exposed (mother/child pair) will be made to improve providers' attitudes and perinatal caring skills towards clients. TBAs will be engaged to work from the community side as their health promotion role is respected and significant. TBAs will be supported to promote early access of Antenatal Care service including HIV testing, facility delivery, convince pregnant women to get tested and access NVP and other anti-retroviral drugs and services. Appropriate infant feeding and nutritional support will be promoted based on MOHSW guidelines. In general PMTCT will be integrated into HIV care for infants and Paediatric AIDS.

The targets set by Deloitte/FHI will follow those of the MoHSW: is to scale up PMTCT by opening at least 5 new sites in every district by end of 2007. Therefore in the three regions, it is expected that in all the 17 districts, (Iringa 8, Morogoro 6, Singida 3) 85 new sites will be opened. Prioritization will be given to those sites which are transitioning over from a partner to Deloitte/FHI.

Targets

Target Target Value Not Applicable Number of service outlets providing the minimum package of 62  PMTCT services according to national and international standards Number of pregnant women who received HIV counseling and 10,560  testing for PMTCT and received their test results Number of HIV-infected pregnant women who received 996  antiretroviral prophylaxis for PMTCT in a PMTCT setting Number of health workers trained in the provision of PMTCT 460  services according to national and international standards

Table 3.3.01:

This activity also relates to activities in OVC (#8866) and ART (#7701). The program will also link with the Peace Corps (#7581), the RPM activity (#8694), the Palliative Care Association (#8704) and the National AIDS Control Programme coordinating activity (#8692).

This is a newly competed and awarded mechanism that will absorb all of the home-based care services previously funded under CARE/Tumaini. Beginning in FY 07, a consortium led by Deloitte Touche Tohmatsu, called Tunajali ("We Care") will continue to provide home-based palliative care through 23 community. A key component of the activity is the ensuring comprehensive care across the continuum of care to people living with HIV/AIDS, and will be linked with OVC services provided under the same mechanism, and treatment under a separate mechanism with the same major implementing partners. The CARE/Tumaini activity, which has been active since early 2004, was successful in establishing functional linkages with programs and services that address the various needs of PLWHA through the 23 CSOs/subgrantees. In addition, it has provided technical assistance to each of the sub-grantees to strengthen their ability to provide quality and sustainable services. These services will continue with the new mechanism.

The activity operates in Mwanza, Dodoma, Iringa, Coast, and Arusha regions. It has recently expanded to Zanzibar. The new Tunajali activity will work in Dodoma, Iringa, Morogoro, Mwanza, and Zanzibar, and will focus on four critical priorities: 1) quality service delivery through sub-grants to support the national scale up of home-based palliative care in; 2) identifying and integrating components of service to provide a continuum of care; 3) strengthening local coordinating bodies to ensure the availability of quality, integrated services to PLWHA, and 4) ensuring the application of a national framework, standards, guidelines, curricula, and systems.

Previous experience with anti-retroviral treatment (ART) sites in Iringa and Mwanza will help to inform the approach for enhancing services and linkages for comprehensive care. This experience has demonstrated that services to PLWHA across a continuum has been accepted and embraced by clinicians, nurses, local government officials and civil society. Health care facilities, government institutions, civil society organizations, communities, and PLWHA will be engaged in the activity to work together to build a continuum of care that spans from health facility to household and vice versa. With this new activity, simple protocols will be developed to further assist sub-grantee CSOs in establishing functional referral systems and networks. Tools to enhance adherence to ART are already in development and will be applied through training, simple visuals, and supervision.

A key priority for the FY07-funded activity will be enhancing home-based palliative care to strengthen nursing supervision, and to include provision of cotrimoxozole, improved supervision of volunteers, and strengthened preventive services. In addition, the program will strengthen linkages with ART, clinic-based management of patients as appropriate, pediatric AIDS services, PMTCT, prevention, and OVC programs in Dodoma, Iringa, Morogoro, Mwanza, and Zanzibar. The number of CSOs in these five regions will increase from 23 to 35. Emphasis will be placed on enhancing coordination and effectiveness. Targets for this activity will increase for PLWHA to 35,000.

Using new guidance from the USG and WHO, programs will also be enhanced with FY07 funds to include safe water kits and vouchers for Insecticide Treated BedNets in HBC kits. The activity will also review the procurement and distribution of HBC kits in the most efficient way to ensure timely and continuous availability of drugs and other essentials to patients at household level. Further reviews and adaptations of training materials will be conducted with NACP.

The continuum of care will be strengthened with the reassignment of regions in the ART site regionalization. Deloitte/FHI has been assigned Dodoma, Iringa, and Morogoro for ART, and with this new award they will be responsible for home-based care and OVC in the same regions, as well. Since the regionalization approach includes strengthened planning and budgeting with the Regional and District Health Management Teams for care and treatment services, it will help to maximize the integration of care and services. Sub-awards from the Deloitte/FHI mechanism will link Catholic Relief Services (CRS) in Mwanza with CRS ART sites, further strengthening the continuum of care. Previous CARE/Tumaini sub-grantees in Arusha Region either have been "graduated" to direct

support from the USG or have been reallocated to Pathfinder, which works in Arusha. This alignment should help to increase coordination and decrease transaction costs inherent in working with different service providers.

Achievement of this anticipated increase in targets will require that considerable additional human resources be trained, deployed, and supervised, involving district level home-based care coordinators from the District Medical Office. The regionalization approach will help to make the linkages with local government to increase staff and training for technical monitoring and supervision. It is crucial that volunteers and CSO staff be trained in recording numbers and events and proper reporting. By bringing activity monitoring to the service delivery level and by including the District Medical Office staff in monitoring, the activity will be able to improve service and data quality.

Presently, female clients outnumber male clients in HBC programs and the same applies to use of VCT and ART services. Also, family care providers, volunteers, and HBC coordinators are mostly women. In addition to this gender imbalance, there is considerable stigma that serves as a barrier to seeking services. In coordination with Muhimbili University College of Health Sciences and the International Centre for Research on Women, FHI will pilot innovative interventions, such as community-based educational tools, deploying male PLWHA on treatment in community programs, using local radio chat shows, promoting male family caregivers through peers, etc., to increase the uptake of services. These interventions will be aimed at both HBC and Care and Treatment programs.

Tunajali will identify opportunities for wraparound programs that will provide for income generating activities and nutritional support. The program has already initiated discussions to pilot programs that would leverage resources from the USAID Economic Growth Sector through local implementing partners.

The Deloitte oversight of the sub-granting process will help to ensure the sustainability of CSO organizations who will provide essential services, assessing and strengthening their programmatic and fiscal accountability on a routine basis.

Additional funding will be used to: a) increase the number of CSOs supported; b) initiate scale up of home-based care services in their newly assigned region of Singida (This funding will be used to provide grants to two civil society organizations to launch home-based care services for PLWHA that will link with treatment services that Deloitte will initiate with other FY2007 Plus Up funding requested under ARV Services); c) initiate home-based counseling and testing, using lay providers, including the hiring of a full-time counsellor to manage the initiative and train field staff (including approximately 100 volunteers and approximately 15 supervisors); and d) extend the Permaculture and Bio-intensive Micro Farming project to care and treatment clinics in Dodoma, Iringa, Morogoro, and Singida.

This activity is related to requests for funds for the RFE under Orphans and Vulnerable Children (OVC) (#7700), and Other Policy and Systems Strengthening (#8979).

The Rapid Funding Envelope (RFE) has been evaluated as an effective mechanism to get funding to small community-based organizations (CBOs) for urgent and innovative projects. The RFE is supported by ten donors, including the Bernard van Leer Foundation, Canadian International Development Agency, Development Cooperation Ireland, Embassy of Finland, Royal Danish Embassy, Royal Netherlands Embassy, Royal Norwegian Embassy, Swiss Agency for Development and Cooperation, and United Kingdom's Department for International Development. USG support, which is not pooled with the other donors, is used instead to support the management of the RFE program. During both FY05 and FY06, over $3.6 million of other donor support was distributed each year to 23 small organizations through the RFE.

FY07 funds are requested to cover management costs for the RFE activities covering OVC, palliative care, and stigma programs. These funds leverage nearly $6 million each year in contributions from the other donors to address the HIV/AIDS situation, especially in under-served areas of Tanzania.

At least once each year, there are rounds of grantsmaking supported by the RFE where grants of up to $200,000 are given to CBO or FBO sub-grantees. This coordinated mechanism has helped to ensure a consistent approach to link donors, CBO, and FBO organizations with the programs and policies of the Government of Tanzania (GOT). The RFE also helps to link diffuse and disjointed community programs with decentralized management of HIV/AIDS programs, where otherwise the CBO or FBO might have worked independent of the GOT infrastructure or other available resources. For example, those organizations who are funded to do home-based palliative care or other community services for people living with HIV/AIDS (PLWHA) are requested to link locally with the Council Multi-sectoral AIDS Committees (CMACS) to maximize the resources available locally and to integrate all available programs to improve comprehensiveness of programs. The work with the CMACS will enhance the sustainability. These local projects will also be requested to coordinate closely with anti-retroviral treatment centres in the community to foster a continuum of care.

Deloitte provides important technical assistance in proposal review, pre-award assessment, and awards; technical assistance to grantees in implementation and reporting; and grants management in terms of financial management and monitoring. The technical assistance for small grantees provided by the RFE will complement the several palliative care and impact mitigation activities that were initiated in FY05 and FY06. The RFE allows for the rapid "piloting" and evaluation of innovative interventions, as well as sharing of lessons learned, that then can be shared with and used by USG implementing partners, as well as smaller programs. For example, RFE support for a Heifer Project income generating project (goat husbandry) provided both nutritional support for PLWHAs and their families, and the wherewithall to build sustainable livlihoods. Present and future priority activities include a continued collaboration with civil society to find innovative and effective ways to meet the complex and comprehensive needs of PLWHA and minimize caregiver burnout.

NOTE: Targets are primarily upstream (indirect), since the actual funds for the sub-grants come from other donors. RFE funds are primarily for management of the sub-grants.

The MOHSW has successfully adopted the STOP-TB TB/HIV Collaborative approach and through the National Tuberculosis and Leprosy Program, is currently scaling-up TB/HIV activities in the country after successfully piloting in three districts. The goal of the country's TB/HIV program is to reach all health facilities in 21 region. However the program is still short of covering the entire country. Deloitte &Touche Tohmatsu through plus up funding, intends to contribute to this coverage gap by engaging TB/HIV activities in Morogoro, Iringa, Singida and Dodoma regions. Based on previous funding and work, Deloitte supports care and treatment in the regions of Morogoro, Iringa and Dodoma, and soon the support will be extended to Singida. This is in accordance to the strategy of Care and treatment regionalization whereby USG supported partners has been assigned regions that they should cover and support. Deloitte has adopted a comprehensive continuum of care approach that covers both clinical and social needs of the individuals accessing HIV services. HIV service delivery is addressed across a continuum of care, from home based care to the care and treatment clinic. Similarly, the referral system within the hospital has been elaborated in all Deloitte supported sites to make sure no opportunity is missed in capturing would be beneficiaries of HIV Care and ART.

Deloitte intends to use the plus up funds to add and support TB/HIV service, a move that will enhance the services to become more comprehensive in scope and breath. To implement TB/HIV, Deloitte will include the following strategies that are aimed at decreasing TB infection among HIV patients and manage HIV infection among TB patients: improve the diagnosis of TB in all clients attending CTC through better screening (at least 80% of HIV Care and treatment clients to be screened using TB screening checklist as part of clinical assessment), enquiring on history of contact with suspects TB patient etc. Support for TB diagnosis will be aided by chest x-ray where facilities are available and microscopic examination of sputum to identify AFB.

Prophylactic preventative therapy and DOTS will be instituted as per national guidelines.On the other side, TB client will undergo diagnostic counseling and testing to determine if they are HIV infected, infected clients will be staged and initiated on ART as appropriate. Where ART services can be provided under one roof, this will be supported and in other situations referral mechanisms will be strengthened. We propose to increase the collaboration between the CTC and TB clinics and staffs so as to maintain a good working relationship service to clients.Health care providers will be trained in TB-HIV co-management and importance of team work emphasized. Monitoring of PLHA and TB patients through community based and home based care programs will ensure follow-up and completion of treatment.

This activity is related to requests for funds for the RFE under Palliative Care (#8707) and Other Policy and Systems Strengthening (#8979). In addition, all OVC awards made with other donor funds managed by this multi-donor pool will be linked with the PACT Coordinating Implementing Partner Group network for OVC (#7783) and the FHI OVC data management system (#7715).

The Rapid Funding Envelope (RFE) has been evaluated as an effective mechanism to get funding to small community-based organizations (CBOs) for urgent and innovative projects. The RFE is supported by ten donors, including the Bernard van Leer Foundation, Canadian International Development Agency, Development Cooperation Ireland, Embassy of Finland, Royal Danish Embassy, Royal Netherlands Embassy, Royal Norwegian Embassy, Swiss Agency for Development and Cooperation, and United Kingdom's Department for International Development. USG support, which is not pooled with the other donors, is used instead to support the management of the RFE program and where there are special program needs, such as grants focused on orphans and vulnerable children (OVC). During both FY05 and FY06, over $3.6 million of other donor support was distributed each year to 23 small organizations through the RFE.

FY07 funds are requested to cover management costs for the RFE activities covering OVC, palliative care, and stigma programs. These funds leverage nearly $6 million each year in contributions from the other donors to address the HIV/AIDS situation, especially in under-served areas of Tanzania. USG funds will focus on managing projects funded by the other donors to address community-based OVC and related impact mitigation among those infected with or affected by HIV/AIDS. In addition, as funds permit, Deloitte will make up to four special awards to NGOs and FBOs funded exclusively by the USG that will build community capacity to respond to OVC needs and train and prepare adolescent OVC for a profession.

Deloitte will help develop the local response to OVC needs by linking sub-grantees with both the newly formed Council Multisectoral AIDS Committee. In addition, sub-grantees will be linked with Most Vulnerable Children Committees (MVCCs) on the local level to ensure the utilization of the national MVC identification process, implementation of the National Plan of Action for OVC, and to strengthen the local response.

The sub-grantees will assist adolescent OVC to complete vocational training programs certified by the national Vocational Education Training Authority (VETA). This assistance will be aimed at enabling the adolescents to gain financial security and independence through suitable careers. This program will be of particular importance to OVC adolescents who are heads of households because it will provide training that will enable them to support their siblings with jobs that do not put them at risk.

Deloitte provides important technical assistance in proposal review and awards, technical assistance to grantees in implementation and reporting, and grants management in terms of financial management and monitoring. The technical assistance for small grantees provided by the RFE will complement the several OVC activities that were initiated in FY05 and FY06. The RFE allows for the rapid "piloting" and evaluation of innovative interventions, for example, one subgrantee supported youth vocational skills and marketing training. As they graduated, these young people were given basic tools to initiate their own businesses. Creativity and sustainability are key criteria for selection and approval of funding. In addition, Deloitte promotes the sharing of lessons learned by sugrantees by publishing success stories in the quarterly newsletter,, that then can be shared with and used by other OVC USG implementing partners and smaller programs.

Present and future priority activities include a continued collaboration with civil society to find sustainable alternatives to institutional care and support for OVC; increasing the level of support and funding for impact mitigation projects, including life skills education and vocational training activities; and reaching a greater number of OVC affected by HIV/AIDS through the RFE mechanism.

This is a newly awarded mechanism that is related to the Tunajali home-based care program (#7816) and the Peace Corps Orphan and Vulnerable Childrens (OVC) program (#7850). As an OVC partner, this activity will also link with the PACT coordinating implementing partner group network for OVC (#7783) and the FHI OVC data management system (#7715).

Since early 1994, the Care/Tumaini Alliance has provided OVC services and home-based palliative care in 5 regions of Tanzania. This activity has been re-competed, and the new implementing partner, a consortium headed by Deloitte Touche Tohmatsu, will absorb the beneficiaries previously served by Care/Tumaini.

Arusha will no longer be a target region for Tunajali since Selian, the implementer of the major OVC program, has "graduated" from being a sub-grantee to an implementing partner directly funded by USG. Morogoro will be the new region for the activity. Current regions for the program include: Coast, Dodoma, Iringa, Morogoro, Mwanza, and Zanzibar. In particular, OVC services will be closely aligned with care and treatment referral services in Dodoma, Iringa, and Morogoro, where Deloitte will also be implementing care and treatment programs, and in Mwanza, where Catholic Relief services, a member of the Tunajali consortium, is the main care and treatment partner.

With FY07 funding, Tunajali work in 35 districts in a total of six regions, and will serve 45,000 OVC. A hallmark of the Tunajali Program is the integrated approach to home-based palliative care and OVC services, an approach based on the previous experience of consortia members Family Health International, Catholic Relief Services, and Africare.

FY07 funds will primarily be dedicated to service delivery through Deloitte's rapid sub-granting mechanism, which will issue and manage sub-grants. With FY07 funds, Tunajali will be expanding services to OVC to ensure the provision of comprehensive services. The array of age-specific services that will be available, based on need, include: health care, nutritional education and targeted support, psychosocial support, child protection, educational support, housing and shelter, prevention of HIV/AIDS, and access to life-skills training and income-generating activities. Tunajali will seek opportunities for linking and leveraging activities of other USG-supported activities for children and youth, such as Peace Corps' income-generating IGA activities. In addition, there will be efforts to reduce stigma through volunteers working in homes and in the community.

In particular, for children under 12, Tunajali volunteers will work with the local Most Vulnerable Children's Committee (MVCC) and the sub-grantee OVC supervisor to ensure that OVC needs are being met. For in-school and out-of school children 12 years and older, volunteers and sub-grantee OVC supervisors will facilitate the formation of youth clubs. To avoid stigma, the youth clubs will be open to other children. Based on experience in Mwanza, volunteers will also encourage caregivers, parents, and guardians of OVC (who are not necessarily people living with HIV/AIDS--PLWHA) to join PLWHA support groups. These groups meet regularly and will help provide psychosocial support to strengthen extended families and encourage disclosure for those who are HIV positive.

Tunajali will seek to minimize volunteer burnout with performance-based incentives, developed based on results from a recent volunteer motivation stud conducted by FHI in Tanzania. While the incentives include reimbursement of travel-related expenses and access to income generating activities, they also include non-monetary incentives such as awards and farm-work assistance to volunteers through the community.

Tunajali will participate in coordination activities with other national implementing organizations under the direction of the Department of Social Welfare, sharing tools, materials, effective practices, and lessons learned, as well as ensuring that duplication of effort is minimized. Tunajali will provide ongoing support and training to MVCCs at both the district and village levels in the program districts.

As with all USG-funded implementing partners, Tunajali will support the implementation of the national Data Management System, and will use that system for their own Monitoring and Evaluation system. They will ensure that information regarding MVC/OVC identified at the local level not only feeds into the national system, but is also available to MVCCs at the

local level for planning, decision making, and monitoring.

The requested Plus Up funds will be used to scale up support to the MVCC in an additional 10 districts, to accompany Tunajali's scale up in services. Tunajali will also step up efforts to roll out the national DMS to go along with the increase of the coverage for effective MVCC, to ensure that vulnerable children are fully identified and most importantly they will receive well coordinated support and care. The Plus Up funding will also support the purchase of 15 computers to provide for the collection of data on OVC and OVC services in 15 additional districts and train 200 additional caretakers.

This activity relates to other activities under PMTCT (#7760), HBHC (#s 8706, 7716, 7702, and 7851), HKID (#7817), HVCT (#7670), HTXS (#7771), and OHPS (#s 7703 and 7704).

The activity is designed to support priority needs for the Tanzania HIV/AIDS Care and Treatment Programme. It is a newly competed mechanism awarded to Deloitte and their key technical partner, FHI.

Presently Deloitte/FHI's program in Tanzania has approximately 5,000 patients under treatment. By the end of FY2007, the 33 sites in three regions are expected to have over 20,000 receiving general HIV clinical care and support, 9,764 of which will be on ART. This will expand to 38 sites and 60 health centres by the end of FY2008, when over 28,000 will be on receiving general HIV clinical care and 17,400 on ART.

The activity will focus on the important priority of rapidly increasing and sustaining the number of Tanzanians receiving HIV clinical care and anti-retroviral therapy (ART) in the three regions that were assigned by NACP. The program will be focused on scale up to all facilities (33) in these three regions, and will expand to one additional neighboring region, Singida, with an additional five facilities. The prioritization of particular sites in the regions will be selected in cooperation with the Regional Health Management Team (RHMT) and the District Health Management Team (DHMT).

The new regionalization approach will engage RHMTs and DHMTs in the planning for and funding of sites, identifying possible sources such as Global Fund of other donors, or district level "basket funds," to support key aspects of the scale up. The activity will specifically outline a comprehensive approach to bridge the communication gap between programs related to care and treatment and the planning and budget of local government. This approach should result in greater synergy and collaboration at the local level and promises to increase sustainability. Although it will likely yield fewer patients served per facility, it will result in more patients being served overall. The cascade down to district hospitals and health centres is particularly critical for getting services to the 80% of the Tanzanian population who reside in rural areas.

Program components are based on a comprehensive systems approach to build capacity across a continuum of care. The activity uses national standards and guidelines to achieve quality of care and sustainability.

The ART sites will be funded through sub-grants through this activity, complemented by technical assistance, training, and supervision/mentoring/precepting. Quality service provision will be supported with the development and strengthening of linkages between entry points to care and treatment services (i.e. TB clinics, PMTCT services, and counseling and testing) and care and treatment clinics (CTCs). Two-way referral mechanisms will be established and tracing of those lost to follow up will be overseen by district level health authorities. If necessary, specific staff to handle referrals will be placed in facilities.

Deloitte/FHI will support the implementation of diagnostic counseling and testing at inpatient ward facilities and outpatient departments, especially pediatrics and TB. Data from other facilities indicate that this approach will yield high numbers of positive patients who otherwise would be of unknown status.

To build demand for services, the program will pilot modes of community preparation and involvement to ensure functional referrals with community-care programs across a continuum of care; and developing low literacy patient educational materials for adherence, nutrition, etc. It will link with the new STRADCOM Program to ensure that messages from STRADCOM are reinforced through the clinical services. It will integrate with other activities providing home-based palliative care, counseling and testing, PMTCT, TB, preventive counseling, and family planning services. Focus will be placed on pediatric uptake of services, improving case finding and referrals from lower level facilities and maternal child health clinics, and monitoring and reporting. It will link with services in the community that will support the involvement of PLWHAs and the media to highlight and promote services and educational messages.

To ensure quality of services, specific quality improvement measures will be established so that facilities themselves can track key indicators of quality of care, rather than only to depend on intermittent supportive supervision. In addition, Deloitte/FHI will work closely with the RHMT and DHMT offices to develop a local program for supportive supervision.

Two important issues will receive specific attention during FY2007, including sensitization of providers to the issues of stigma to reduce the negative impact of stigma on service uptake or compliance. Also, staff will be trained to promote prevention messages with those who are HIV positive, so as to reduce the potential for further transmission.

One important barrier that precludes more effective use of facilities is the lack of manpower. This limits the hours/days that CTCs can serve patients, and the efficiency of the clinical personnel. Efforts are underway to hire retired nurses to complement staff, to reorganize the work at the clinic to depend more or administrative staff for non-clinical tasks, and to hire and train any staff that might be assigned to CTCs from the Emergency Hiring Plan that will be organized in FY2007 using reprogrammed Global Fund monies.

An important component of the program is the grant management services provided by Deloitte to ensure fiscal and programmatic accountability by carrying out budget reviews of treatment sites, perform pre-award assessments, and ensure that all the necessary financial controls and systems are in place before grants are awarded to the facilities. To ensure sustainability, capacity building provided by the contractor will prepare the regions and districts to plan appropriately for ART and related services, and will enable ART sites to work independently over time. Vehicles and lab equipment may be procured, if necessary, until centralized procurement services are in place.

During FY2007, additional records will be kept to track referrals so that problems with referrals can be remedied locally through routine review of referral data. A regional monitoring and evaluation officer will be hired to monitor the completeness and accuracy of data collected.

Plus up funding will provide an initial increment directed at attracting larger employers - those with in-house clinic facilities - to leverage our Treatment program, gaining access to the technical assistance, materials, and providing the guidance they need to move along the road towards certification as CTCs.

In addition, plus-up funds will be used to initiate expansion into a fourth region, Singida. With these plus-up funds, Deloitte/FHI will be able to provide significant technical assistance for scale up of treatment, and improve the quality of services provided. Deloitte's one year ART target for the region is to ensure standardized quality services to at least 200 patients on ART in each district hospital and 800 at SRH. This requires significant training, as well as infrastructure and programmatic improvements. It is critical to establish a small, but strong, Deloitte/FHI team in Singida with adequate means of transport and reliable communication. This technical assistance team will consist of one clinician, a monitoring and evaluation officer, a home-based care and community officer and an accountant. The team will require 2 vehicles. Office space will be provided from the Singida regional authorities. Deloitte/FHI will continue to use a comprehensive systems approach in each region to build capacity across a continuum of care services.

This activity relates to OPSS activity #7743.

The Rapid Funding Envelope (RFE) has been evaluated as an effective mechanism to get funding to small community-based organizations (CBOs) for urgent and innovative projects. The funds used for RFE are provided by ten donors. The USG support is largely focused on the management of the RFE program and on special program needs (such an orphans and vulnerable children or on particular geographic areas that are under-represented). During FY 2006, over $3.6 million dollars were distributed to small organizations through the RFE. In FY 2007, funds will need to be available to manage grants for OVC, palliative care, and stigma programs. The funds used to support the management of the RFE will leverage significant resources from other donors to address the HIV/AIDS situation, especially in under-served areas of Tanzania. These particular funds will focus on managing projects that address stigma among those infected with or affected by HIV/AIDS.

At least once each year, there are rounds of grantsmaking supported by the RFE where grants of up to $200,000 are given to CBO or FBO sub-grantees. This coordinated mechanism has helped to ensure a consistent approach to link CBO and FBO organizations with the programs and policies of the Government of Tanzania (GOT). It also helps to link diffuse and disjointed community programs with decentralized management of HIV/AIDS programs, where otherwise the CBO or FBO might have worked independent of the GOT infrastructure. For example, those organizations who are funded to address stigma and discrimination or other community services for people living with HIV/AIDS (PLWHA) are requested to link locally with the Council Multi-sectoral AIDS Committees (CMACS) to maximize the resources available locally and to increase the potential impact of programs. The work with the CMACS will enhance the sustainability and broader sensitization to the fact that stigma is such a significant barrier to accessing testing, care, and treatment for HIV/AIDS. These local projects will also be requested to coordinate closely with anti-retroviral treatment centres in the community to foster informed approaches to minimizing stigma in and out of clinical settings.

Deloitte provides important technical assistance in proposal review, pre-award assessment, and awards; technical assistance to grantees in implementation and reporting; and grants management in terms of financial management and monitoring. The technical assistance for small grantees provided by the RFE will complement the several palliative care and impact mitigation activities that were initiated in FY 2005 and FY 2006. The RFE allows for the rapid "piloting" and evaluation of innovative interventions, as well as sharing of lessons learned, that then can be shared with and used by USG implementing partners, as well as smaller programs.

Present and future priority activities include a continued collaboration with civil society to find innovative and effective ways to minimize stigma and discrimination.

NOTE: Targets are primarily upstream (indirect), since the actual funds for the sub-grants come from other donors. RFE funds are primarily for management of the sub-grants.