This activity is linked to other activities in Injection Safety (# 7732, 7759), and to activities in Policy and Systems Strengthening. Transmission of infection continues to be a major problem in Tanzanian health care settings, affecting both the users of health services as well as health care workers. Improper infection prevention and control practices, including unsafe use of injections, continue to be a route for HIV transmission. Infection also remains one of the top five direct causes of maternal death in Tanzania. The Ministry of Health and other stakeholders in health sector acknowledge that infection prevention is one of the pre-requisites for ensuring safe health care delivery as well as protecting the population from infectious diseases, including HIV/AIDS. It is also essential to protecting the health workforce. This infection prevention (IP) activity is a follow-on effort implemented by JHPIEGO (a Johns Hopkins Affiliate) in partnership and with the leadership of the Ministry of Health under the ACCESS program. (ACCESS to Clinical and Community Maternal, Neonatal And Women's Health Services is a 5-year, USAID-sponsored global program aimed at reducing maternal and newborn deaths and improving the health of mothers and their newborns). In FY2006, JHPIEGO/ ACCESS, with support of FY 05 PEPFAR funding has produced a pocket guide containing the National Guidelines on Infection Prevention. This is a simplified National guidelines book translated into Swahili. However, due to delays in funding, printing, and dissemination of the simplified Kiswahili guidelines will be carried over to ACCESS FY2007 work-plan. The purpose of the pocket guides is to provide all healthcare service providers with basic infection prevention guidelines and safety precautions applicable in their day-to-day activities. Updates on injection safety will be one of the important components of the pocket guide. Additional activity components for FY2007 include developing, printing and disseminating an orientation package on infection prevention which will assist district supervisors, trainers and other resource people in their efforts to orient policy makers at the district level and health providers to the IP guidelines. The orientation package aims at facilitating the updates on infection prevention Standard Precaution practices at district and other levels of health care system. To benefit health workers at health centers and dispensaries in Tanzania, the orientation package will be translated into Swahili. Sufficient copies will be produced so that it is available in every district, as well as one per large health facility including FBO facilities. The pocket guide will be distributed widely so that peripheral health facilities as well as some Village Health Management Committees will be reached. Two trainers from 37 districts where ACCESS in collaboration with the MOH introduced focused ANC in FY2006 will be given an update on IP and Injection Safety and oriented on the use of the Swahili Infection Prevention Orientation Package. This training session will also equip trainers with advocacy skills for them to advocate for infection prevention among Council Health Management Teams (CHMTs). Advocacy training will include advocating for the allocation of resources to conduct orientation sessions on infection prevention and injection safety as well as to ensure that standard precautions feature in Council Comprehensive Health Plans. In turn trainers will conduct orientation of service providers in their own districts to complete the training cascade, resulting in over four hundred and seventy individuals being trained in infection prevention and injection safety. ACCESS together with the MOHSW will follow up with trainers to support them as they carry out these orientations. It is expected that over 2000 providers will be reached with the Swahili pocket guide on Infection Prevention in at least 37 districts. A follow-up tool will be developed for use by the supervisors.

With additional funding, JHPIEIGO through the ACESS program will support the MOHSW in initiating the process of adopting training tools for the pre-service schools (Nurse and Nurse mid-wife certificate and diploma schools) so that IS-IPC can be part of the mainstream training curriculum of these institutions. This will ensure that capacity building in IPC-IS is implemented In Tanzania in a more cost effective and sustainable manner. They will work with over 20 such schools who have over 500 graduates a year. Health Care Providers from these schools form the bulk of providers in Health centers and dispensaries throughout Tanzania.

This project will build on past and current work JHPIEGO/ACCESS is implementing in the certificate-level Nurse Midwifery pre-service institutions, including curriculum updates on Focused ANC and other key maternal and newborn health care areas, along with quality improvement efforts in teaching. Pivotal to the success of the project will be the already established relationships JHPIEGO has built with the institutions during the Maternal Neonatal Health (MNH) and ACCESS programs in addition to the work now underway from JHPIEGO's FY2006 Plus Up award to begin this activity. Altogether, there are 22 schools Certificate-level schools, 13 Government and 9 FBO, which will be the target of JHPIEGO/ACCESS's two-year intervention. The process of strengthening the Nursing and Midwifery schools will start with advocacy and planning meetings with the administrators of the schools and affiliated clinical health facilities. The meetings will inform them of the proposed interventions and gather their feedback and buy-in. This participatory planning will strengthen and assist in ensuring that activities are complimentary, not duplicated and gaps in PMTCT training system are filled. The next step in improving the teaching and learning environment will be to develop performance standards for PMTCT in collaboration with partners and key stakeholders. In Tanzania, JHPIEGO/ACCESS has previous experience in developing such performance standards in other topic areas with pre-service institutions such as Focused ANC and teaching. Outside of Tanzania, JHPIEGO/ACCESS has developed performance standards for PMTCT in Ethiopia. Once performance standards are set and agreed upon, they can be adapted into useful management tools, or specifically, a PMTCT Quality Improvement tool. This tool will be pre-tested and vetted by national MOHSW partners in order to gain recognition. JHPIEGO/ACCESS will then train tutors, preceptors and PMTCT supervisors including RCH Coordinators, facility in-charges and NACP/PMTCT staff in the use of this quality improvement tool. Training typically takes 3-4 days, during which tutors, preceptors and supervisors are fully acquainted to the quality improvement process and are given a chance to practice using the tools and completing assessments. Tutors, preceptors and supervisors will then be supported to return to their institutions and affiliated clinical sites to implement the quality improvement process and begin conducting assessments and analysis. Furthermore, tutors will also complement this process by integrating the previously developed tools for quality improvement in teaching. Finally, JHPIEGO/ACCESS will further strengthen pre-service schools through the procurement and orientation to state of the art training equipment and supplies (e.g. anatomical models, BP machines, weighing scales, examination couches, screens, HIV test kits). The final list of materials to be provided to schools will be based on the outcome of a needs assessment on PMTCT for pre-service that is being completed in FY07. Following the delivery of such equipment, tutors and preceptors will be trained on their proper use for improving pre-service education. A total of 22 schools will receive support, with expected output for these funds including: 22 schools supported for improvements and equipment, and 22 prepared practicum sites.

Targets

Target Target Value Not Applicable Number of local organizations provided with technical assistance for
HIV-related policy development Number of local organizations provided with technical assistance for 22  HIV-related institutional capacity building Number of individuals trained in HIV-related policy development
Number of individuals trained in HIV-related institutional capacity
building Number of individuals trained in HIV-related stigma and
discrimination reduction Number of individuals trained in HIV-related community
mobilization for prevention, care and/or treatment

Table 3.3.15: Program Planning Overview Program Area: Management and Staffing Budget Code: HVMS Program Area Code: 15 Total Planned Funding for Program Area: $ 9,361,644.00

Program Area Context:

The past year was one of continued integration, as our agencies moved beyond détente into a period of true teamwork and cooperation. This year, the team is poised to further the collaborative environment through even greater levels of agency partnership, as described below.

Management Approach: Ambassador Michael Retzer is responsible for the overall leadership of the President's Emergency Plan for AIDS Relief (PEPFAR)/Tanzania program. He is supported by the Deputy Chief of Mission (DCM) and Heads of Agency from the Departments of Health and Human Services/Centers for Disease Control and Prevention (HHS/CDC), Department of Defense (DoD), and Department of State (DoS), Peace Corps, and the United States Agency for International Development (USAID). The DCM and Agency Heads jointly comprise the Interagency HIV/AIDS Coordinating Committee (IHCC) - an interagency policy making body. The PEPFAR Country Coordinator is responsible for implementing the direction set by the IHCC and accomplishes this by working through the newly-constituted PEPFAR Management Council (PMC) and the 15 Thematic Groups (TGs).

The PMC, a new coordinating mechanism this year, is an outgrowth of the fiscal year (FY) 2007 Country Operational Plan (COP) Steering Committee, a senior PMC advisor from each agency acts as the primary day-to-day point of contact on operation issues between the Agencies and the Country Coordinator. The PMC assists the Coordinator in implementing the direction set by the IHCC, addresses longer-term programmatic and operational issues, and filters requests for direction to the IHCC.

Currently, most TGs are the primary units for program planning and reporting. However, over the coming year, the model of the HIV/AIDS Treatment TG (ongoing interagency collaboration and coordination to implement the treatment program along with program planning and reporting responsibilities) will be expanded as the model for all TGs. Where possible, TGs are comprised of representatives from the various agencies who bring both personal and agency expertise to the table. For example, the treatment thematic group includes an off-shore hire physician who brings U.S. treatment experience; a Tanzanian physician who is able to contribute first hand local experience in developing services and treating individuals; a PhD health systems specialist; and an off-shore physician with extensive research experience.

Each TG is led, or co-led, by a Thematic Group Leader (TGL). Thematic Group Leaders also represent a mix of skills. In some cases, the TGL contributes predominant capability in the technical area. In other cases, the lead is selected because of the focus of their work, the level of effort that they contribute, and/or their ability to the coordinate the activities of the group. In addition, some groups are co-led to facilitate burden sharing and to create complementary leadership.

In FY 2007, the USG/Tanzania will review the composition of the thematic groups as well as leadership to ensure the best mix of skills and technical leadership.

Staffing Rationale: Our current compliment of 40 full-time technical staff, blustered by our seven planned technical new hires, reflects the core capabilities and the multi-faceted nature of our approach to the AIDS emergency in Tanzania. On the one hand, we address the near-term demands through our time-tested development assistance approach while strengthening the government and other local health service organizations through the institutional capacity building efforts of all the USG agencies.

Peace Corps and USAID both leverage their long-term relationships - with the rural communities of Tanzania, in the one case, and with local implementing partners in the other - to rapidly and cost-effectively mobilize critical resources. Their long-term presences and time-honed approaches offer them notable economies of scale. These agencies represent our smallest staff-sizes and lowest costs. In

the case of USAID, many of the costs associated with the program are directly contracted allocations, others are shared across a broader array of the agency's development activities, and some are covered at the Agency-level.

CDC and DoD's in-country approaches pair them closely with the Government of Tanzania as an implementing partner - in the first case, Ministry of Health and Social Welfare, and in the second, the Ministry of Defense. In these capacities, both agencies provide a significant percentage of their overall staffing in direct technical support. Both agencies are in-country primarily in support of their PEPFAR roles. As a result, the full costs of program implementation, along with all associated staff, is PEPFAR-funded.

While significant effort has been put into staffing and integrating operational components to leverage economies of scale, this year we will be looking at right-sizing staff, whether that entails adding people, shifting between agencies, out-sourcing services, or eliminating duplicative roles. In addition, our Mission is undergoing a review for overall integration of services across agencies. These activities dovetail well with the ‘core competencies' approach of OGAC. We are adapting both sets of program directions as we revisit our delivery structure to ensure the best blend of non-duplicative services.

In the first six months of the coming year, we will embark on - and complete - the discussions and activities needed to maximize the best blend of USG agency efforts under PEPFAR. By the next COP season, we expect to have built upon this year's integrated management structure and complimentary teams to create a fully blended program that gets the best from the best, accomplishing ‘stretch targets' at the lowest possible cost.

It is important to note that the new level of integration has placed additional work requirements on an already very thinly-stretched management and implementation team. As further discussed in the attached agency-specific narratives, in certain incidences, (like CDC) we have recently begun to fill long-term gaps and, in others, such as USAID, we propose innovative approaches to resolve the impact of impediments to staffing such as critical limitations on available space. Currently, the Chief of Mission has instituted a Mission-wide hiring freeze while the Mission right-sizing review occurs. For PEPFAR in FY 2007, we anticipate being able to fill technical positions but potentially no administrative and/or program support positions. All in all, this year's staffing plan defines measured staff adjustments during a year of stock-taking and load-balancing and proposes a general ‘way forward' for FY 2007 and FY 2008.

We have also undertaken several new initiatives which draw upon unique agency capabilities and promote greater levels of integration. These initiatives range from the provisions of multi-agency services from a single source to the cross-agency sharing of personnel. For example, USAID is providing two unique contracting mechanisms designed to centralize the procurement of key materials and services required across the entire team. We are also seeing an expansion in the cross-agency sharing of individuals whose skill sets are in high demand or whose job functions are required by multiple agencies on less than a full-time basis.

In summary, the groundwork has been done: the lines of communication and management are agreed upon, cross-agency in nature, and well understood. Staffing is currently adequate, and we are actively engaged in improving the situation through the selective addition of key staff. We have also found innovative ways to leverage agency resources to assist members across the full spectrum of our team. We strongly believe that the strength of our shared vision, the capabilities of the team, and our creative solutions will ensure we have a highly productive and successful year.

Table 3.3.15: