This activity will link with all the USG-funded Orphan and Vulnerable Children (OVC) Implementing Partner Group (IPG) network for OVC (#7783), PACT (#7783), Salvation Army (#7801), Africare (#7674), CRS(#7691), AIHA (#7677), and Deloitte Touche Tohmatsu (#8866).

Since 2004, FHI has been providing technical support for service implementation of care and support programs for Orphans and Vulnerable Children. FHI provides technical support and direction to the OVC implementing partners through provision of direct technical support to the Department of Social Welfare (DSW) in the development of the national OVC guidelines, National OVC Plan of Action, and policy on care and support for OVC. This technical assistance is key to providing direction for the OVC National IPG, which represents the majority of interventions (USG and non-USG) for OVC in Tanzania. In addition, FHI technically supports other implementing partners, such as PACT, with whom they have a tripartite Memorandum of Understanding (MOU) with the DSW, to ensure that the programs being implemented are appropriately in line with the Tanzanian National Plan of Action. In FY06, FHI facilitated the development and initial implementation of the National Data Management System for tracking OVC and OVC services in collaboration with Data Vision.

With FY 07 funds, FHI will provide technical support to the DSW to advise and support the finalization and implementation of the OVC National Plan of Action. In support of the consistent roll out the implementation of the OVC National Plan of Action, FHI will assist partners in troubleshooting the implementation of a standard care package and roll out the national Data Management System. This system will be initiated in all 71 USG-funded districts, as well as those implemented with Global Fund monies. All USG prime partners and sub-grantees will utilize this system in FY07. FHI will train the M&E officers of each of these partners, and at the national level, on data entry, processing and analysis for the new system.

FHI will collaborate with the MVC IPG in the areas of monitoring, completing annual training work plans, updating standards of care, documenting best practices, developing and standardizing OVC training materials. When necessary, FHI will conduct assessments of specified components of service delivery to better inform practices of the IPG. FHI will provide technical direction for the capacity building of the social workers in the USG-funded sites. FHI will also collaborate with AIHA through the Twinning Partnership with the Institute of Social Welfare (ISW) for curriculum development of the pre- and in service social workers.

Directing technical assistance in the field will require updated information on the needs and services available in the community. FHI will continue to provide assistance at the district and community level to implement and learn from the findings of the National Data Management System as it becomes a management tool both at the local and the national level. These data will serve as an effective planning tool for the District Social Welfare office and the local organizations.

Since this is a quality assurance measure linked with FHI's role at the national level for systems strengthening, there are no direct targets.

Targets

Target Target Value Not Applicable Number of local organizations provided with technical assistance for
stratetgic information activities Number of local organiztions
Number of OVC served by OVC programs
Number of providers/caregivers trained in caring for OVC

Target Populations: Community leaders Street youth HIV/AIDS-affected families Infants Orphans and vulnerable children People living with HIV/AIDS Program managers USG in-country staff Volunteers Children and youth (non-OVC) Caregivers (of OVC and PLWHAs) Out-of-school youth Other MOH staff (excluding NACP staff and health care workers described below) Implementing organizations (not listed above) HIV positive infants (0-4 years) HIV positive children (5 - 14 years)

Coverage Areas: National

Table 3.3.08:

Public health evaluation of community anti-stigma intervention

This activity is a follow-up on the 2-year stigma-reduction activity that was approved in the FY 2005 COP. Funds allocated in FY 2005 were to cover activities for the first year. FY 2006 funds were for the final phase of the study which will be completed in FY 2007.

Stigma and discrimination is a barrier to effective HIV programs, including uptake of VCT, PMTCT, ARV and opportunistic infection treatment, adherence to treatment, care and support for PLWHA and OVC, as well as behavior change. Reducing stigma and discrimination is essential to meeting the goals of the President's Emergency Plan. It will help create an environment that will support people to increase the uptake of services, such as seeking HIV testing, disclose HIV sero status, access treatment, adhere to drug regimens, and ensure care and support for PLWHA and OVC. The need to address HIV-stigma and discrimination has now been clearly recognized in Tanzania and by the President's Emergency Plan, and is a key cross-cutting issue that runs through all HIV/AIDS programming. For the past four years the International Center for Research on Women (ICRW) and Muhimbili University College of the Health Sciences (MUCHS) have been working together to collect data to inform the design of stigma-reduction programs, develop practical tools, adapt and translate these tools into Swahili and begin to develop a standard set of HIV stigma and discrimination indicators for measuring program success. In addition, they have worked closely with Kimara Peer Educators and Health Promoters Training Trust (Kimara Peers) during the data collection phase, in developing intervention tools and also in developing a community stigma reduction program. Building on the foundational work done by ICRW and MUCHS in Tanzania, Kimara Peers has just completed implementing a pilot model community-based stigma reduction program, through a grant from the REACH project. Intervention activities ended in April 2006. It is critical that this first-of-its-kind model program be systematically evaluated to examine whether it has had the intended impact in both the short-term (immediate effect) and longer-term (sustained effect), as well as to capture and document lessons learned to allow for feasible replication and scale-up of stigma-reduction.

The evaluation incorporates both quantitative and qualitative methods. With FY 2005 funding, ICRW, MUCHS and Kimara Peers through FHI, conducted the first phase of a targeted program evaluation of the ongoing Kimara Peers community stigma reduction program to assess short-term, immediate impact. In FY 2006, a second phase of evaluation was initiated to examine the longer-term impact and whether the intervention has had lasting, sustainable effects. The second phase of the evaluation will continue in FY 2007. The evaluation examined whether there was a change in stigma and resulting discrimination at the population level within the communities that receive Kimara's enhanced stigma reduction programs. A pre/post survey was designed and triangulated with qualitative data collection. This design measured the change in stigma and discrimination at the community level over 20 months of implementation of the enhanced Kimara project (i.e., with the integration of stigma-reduction components into ongoing HIV and AIDS activities). A baseline survey on stigma (n=978) was conducted in Kinondoni as part of a project to develop and test indicators for stigma and discrimination. The qualitative data focus on documenting, from the perspective of PLWHA, their families, project staff and key community leaders, whether, and how, stigma may be changing over the course of the intervention and the role of the intervention (as opposed to other confounding factors) in any change that might be occurring. Specific methods used to answer the four main research questions were: 1) Analysis of baseline survey data (data collected as part of stigma indicators development project). 2) Qualitative data collection: In-depth interviews with PLWHA, affected family members, program staff and community leaders to collect information on their experience with stigma in the community, and perspectives going back to before the start of the intervention. 3) End-line survey: The analysis will be to test and validate indicators for stigma and discrimination (through HORIZONS), and to evaluate the impact of the stigma-reduction program. Process indicators being collected by Kimara Peer Educators will also be included in the analysis.

Initial anecdotal evidence from the program indicates that it is having significant impact. Kimara Peers have seen a significant increase in people using VCT since the activities began, an increase in PLWHA joining group counseling sessions, and community demand for expansion of the stigma-reduction programming. However, without targeted program evaluation, it will be difficult to distinguish whether these increases are all, or partly, due

to the stigma activities, rather than to other possible confounding factors, like the expectation of ARV availability or media campaigns. In addition to assessing whether these immediate impacts are due fully or in part to the intervention, it is also important to examine whether there are lasting impacts and whether behavior change is sustained once the intervention ends. Kimara's program is the first of its kind in Tanzania, and is already being looked to as a model stigma reduction program. This is a unique and important opportunity to thoroughly evaluate what impact this program is having, both in the short and longer-term, and to learn vital lessons for successful scaling up of stigma-reduction programs. Kimara Peers is also the recipient of funding from the Foundation for Civil Society to support AIDS affected children through psychosocial interventions and IEC materials.

This activity links to numbers #8981, #7677, and #8868.

The first component of this activity is to strengthen the coordination and management capacity of the NACP Care and Treatment Unit (CTU) and the Counseling and Social Service Unit (CSSU). This support stretches out to the Partners as well.

In FY 2007 FHI will support NACP to stimulate further regionalization of all HIV prevention, care, treatment and support activities for which the MOHSW is responsible to the relevant regional partners. FHI will also provide technical assistance towards the decentralization of supportive supervision by involving zonal and regional facilities. FHI will continue to strengthen the formal coordination mechanism among the about 17 organizations directly implementing care and treatment programs in the country.

As co-chair of the recently-established national subcommittee on HBC, FHI will play a key role in developing and shaping relevant policies for home based care and strengthening the coordination of all organizations providing home based care in Tanzania. The support for coordination will begin with Dar es Salaam and eventually be expanded to include all regions. Under the umbrella of the "Three Ones" approach, FHI will strengthen the mechanisms to harmonize the variety of approaches, ideas, and plans. Formal and informal methods will be used to maintain this coordination, technical information sharing, and harmonization. FHI will support planners, implementers, and partners to use the Continuum of Care approach presented by the MOHSW in Durban and Toronto. FHI will continue to support NACP to develop mechanisms to ensure quality and uniformity in the provision and reporting of HBC services through Zonal Coordination meetings, advocacy, joint partner revisions of materials, and planning to minimize HBC volunteer "burnout" and increase retention. These activities will reach all 204 current CTC sites, an increasingly number of health centres, and all USG-funded HBC programs. FHI will also implement concrete approaches to address the human resource crisis through piloting innovative approaches such as hiring retired nurses, utilizing student nurses/clinicians during their clinical practicum, and providing incentive packages.

FHI will also support I-TECH and the MOHSW to integrate HIV care and treatment training curricula and materials in pre- and in-service training programs in national, zonal, and regional health and medical training institutions. Support to the National Palliative Care Association will lead to a tool set of standards to be used in hospitals and home based care programs. In-service training will be part of this to improve the quality of palliative care service delivery. FHI will continue to support regular review and revision of training materials for the national care and treatment and palliative care courses for both public and the private medical sectors, refresher courses, and patient and provider learning materials. FHI will assist in finalization, distribution, and use of the national Standard Operating Procedures for care and treatment and the pocket guide for clinicians and nurses.

Finally, based on the recommendations of a management consultant to NACP, FHI will work with NACP to improve internal communication and decision making processes.

The second component of this activity is to build critically-needed capacity in the Department of Social Welfare (DSW) to respond to the needs of orphans and most vulnerable children (OVC/MVC). With FHI support, DSW will further guide the implementation of the National OVC/MVC Plan of Action, develops systems to decentralize its implementation, and translate the standards and policies set by the plan into practical support. The frailty of the DSW is being addressed by FHI in close collaboration with PACT to provide the coordinating and technical human resource and communication technology at the DSW central office. FHI will further support the training and refresher training at the Institute for Social Work which will be charged with the welfare of OVC/MVC at the district level together with America International Health Alliance Twinning Center. Building functional health and welfare systems will depend on good information on needs and services available. In FY 2006, the data management systems developed with support of FHI by a national data company has been approved and adapted by all partners for implementation in districts. FHI will continue to provide assistance at national, district and community level to implement and learn from this OVC/MVC mapping of needs and service provision. It will serve as an effective planning tool at the national and local level. In this way technical integrity of programs, sharing of tools, materials, best practices, and lessons

learned will be ensured

FHI technical support to the NACP and DSW of MOHSW will serve as an important overall coordination, integration, and quality control measure for all organizations involved in HIV Care and Treatment, HBC and OVC services, and will contribute to both quality and quantity of the goals set by the Government of Tanzania and USG. It will also have a positive quality impact on all hospitals, HBC, and OVC programs in the country.