This activity will be related to the newly awarded program for Basic Care and Support that will be implemented by a consortium led by Deloitte Touche Tohmatsu (#8706), and also the AED T-Marc Social Marketing Program (#7667).

The duka la dawa baridis (DLDBs) outlets provide an essential service in Tanzania. They are small outlets, originally set up to provide non-prescription drugs in the private sector. DLDBs constitute the largest network of licensed retail outlets for basic essential drugs in Tanzania. They are found in all districts in the country. For many common medical problems, such as diarrhea, fungal infections, malaria, etc., a variety of factors encourage people to self-diagnose and medicate before going to a health facility. Because nearly 80% of the population of Tanzania is rural, DLDBs are often the most convenient retail outlet from which to buy drugs.

Evidence has demonstrated that DLDBs are not operating as had been originally intended. Prescription drugs that are prohibited for sale by the Tanzania Food and Drug Authority (TFDA) are invariably for sale, quality cannot be assured, and the majority of dispensing staff lack basic qualifications, training, and skills. Regulation and supervision are also poor. To address this, Management Sciences for Health (MSH) initiated a program (originally funded under the Gates funded SEAM program) to build the skills of the DLDBs and transform them into Accredited Drug Dispensing Outlets (ADDOs).

In the past two years, MSH's Rational Pharmaceutical Plus program has laid the groundwork in Morogoro to develop ADDOs and prepare them to support palliative care programs for HIV/AIDS. Elements of their work to date have included accreditation based on Ministry of Health and Social Welfare/TFDA-instituted standards and regulations governing ADDOs; business skills training, pharmaceutical training, education, and supervision; commercial assistance; marketing and public education; and regulation and inspection.

The work done to date has been primarily focused on ensuring accreditation, but has not yet been linked with home-based care activities. Beginning in FY07, the ADDO work will be linked with the newly awarded Tunajali home-basesd care/orphan and vulnerable children activity in Morogoro, Iringa, and Dodoma. ADDOs, in collaboration with community-based organizations and NGOs, may provide HBC services to remote and rural areas through the provision of HBC kits and services that might no otherwise be available in rural areas. Selected ADDOs would be assigned a catchment area where they could provide HBC services to volunteers and possibly HIV patients identified by local NGOs and/or clinical facilities. If this linkage works well, the USG would propose the expansion of the network of ADDOS to another region covered by Tunajali, e.g., Iringa. The ADDOS could also support referrals of patients for counseling/testing and for clinical services at the closest HIV/AIDS Care and Treatment Clinic.

The proposed role of ADDOs in community-based HIV/AIDS prevention and care would also include dissemination of HIV/AIDS information whereby ADDOs would become centers for providing basic HIV/AIDS information to the public. This way, information on HIV prevention, treatment, and the fight against stigma can be provided using available IEC materials and social marketing techniques in collaboration with other partners (e.g. PSI, T-Marc) would reach groups and areas that might not otherwise be reached.

It is expected that through this program, additional beficiaries will be reached, but the first focus will be on providing quality and accessible goods to existing NGOs whose beneficiaries are counted under the Tunajali program. In future years, the program could reach more persons in remote areas who are unduplicated. Consequently, no targets are set.

This activity links to all activities under antiretroviral treatment with the goal of improving the accessibility to affordable, quality and effective essential medicines and pharmaceutical services to populations in rural and peri-urban areas through assistance to the Ministry of Health and Social Welfare (MOHSW) and the Tanzanian Food and Drugs Authority (TFDA) to expand the number of accredited drug dispensing outlets (ADDOs). The ADDO effort transforms duka la dawa baridi (DLDBs) outlets, low-level, private sector vendors of drugs and commodities, into a regulated service and health education provider. The major feature of the ADDO shops is that in most cases they are the nearest service in a community offering standardized health services of an assured quality. It has been found that about 41% of the population makes their first contact at the drug outlets before going to a health facility. Major ADDO program elements include: accreditation based upon MOHSW/TFDA-instituted standards and regulations governing ADDOs; business skills training; pharmaceutical training (including dispensing practices); basics of common diseases symptoms and treatment; health communication skills,; essentials of HIV/AIDS; and regulation and inspection. Once DLDBs have been accredited, RPM Plus will work with National AIDS Control Programme (NACP), other PEPFAR partners, district authorities to link prevention, care and treatment activities into the ADDO program in order to leverage resources, create referral linkages and collaborate to provide integrated HIV/AIDS care and support at the community level. The strategy will support both Government of Tanzania (GoT) and PEPFAR plans to scale up HIV/AIDS services.

ADDOs outlets offer avenues for providing appropriate community health interventions. Conceivably, they may be used to reinforce compliance to drugs for chronically ill patients, provide medicine refills for these conditions, provide storage of basic medicines and drugs for treating opportunistic diseases for patients living with HIV/AIDS, and provide general health information. In addition, the number of trained dispensers could play a role in recognizing serious conditions for referral and provide one-on-one counseling and advice. Once established, integrated HIV/AIDS prevention, care and treatment activities and other major public health interventions such as malaria, TB and Integrated Management of Childhood Illness will be integrated into the ADDO menu of essential pharmaceutical services.

In 2005 RPM Plus carried out a rapid situation analysis of home-based care services in Morogoro region in order to be able to understand the existing gaps and to explore feasible options for integrating HIV/AIDS interventions into the ADDO program. A concept paper detailing the ADDO-HIV/AIDS model has been finalized and is being shared with major stakeholders for input. The strategy was later presented and approved by both TFDA management and MOHSW senior management team. In addition, in 2006, RPM Plus provided technical support to TFDA to finalize joint work plans to implement ADDO roll out activities at national, regional and district levels. Implementing the first phases of the basic elements of the ADDO model (accreditation) RPM Plus transformed and TFDA accredited 177 ADDOs in two districts of Morogoro region. Owners were trained on dispensing, common disease conditions, communications skills and HIV/AIDS.

In FY 2007 the RPM+ effort will focus on Iringa region and complement the treatment and care activities of Family Health International, a major USG partner. Iringa is located in the southern highlands of Tanzania. The region is divided into eight districts, has a population of 1,495,333, and 801 villages. There are 712 registered DLDB outlets however, experiences have shown that the registered DLDBs are only 50% of the existing DLDBs in the districts and the numbers tend to be higher than the existing information at the regional pharmacist's office.

Through the ADDOs, public education on HIV/AIDS campaigns related to availability of voluntary counseling and testing (VCT) for HIV/AIDS, and ARV treatment facilities, and information on prevention fight against stigma using available Information, Education, and Communication materials and social marketing techniques in collaboration with other partners (e.g. PSI, T-Mark) will reach groups and areas that might not otherwise be reached. In addition ADDOs, in collaboration with community-based organizations/NGOs, could provide home-based care (HBC) services to remote and rural areas through extension services that would be able to take the HBC kits and services into underserved and remote areas. In addition, ADDOs could be a source for replacement of kit supplies. The MOHSW/NACP guideline for HBC places emphasis on the continuum of care that links the relevant elements of comprehensive care to the relevant health and other sectors that

will ensure the needs of clients and their families are met through timely and effective intervention. The patient receiving care must have access to all three levels: facility, community and home. ADDOs are well-positioned to be part of a functional referral link to other HIV/AIDS services such as HBC, VCT, PMTCT and ART. A referral system will be developed that will assist clients with information on where to access those services. RPM Plus will link with PEPFAR's Care and treatment partners in Iringa and Morogoro to pilot the use of ADDOs as an adjunct to proposed interventions.

The current scope of work for Partnership for Supply Chain Management Services (SCMS) includes procurement and delivery of HIV pharmaceuticals and related products to target countries, coupled with technical assistance in supply chain management as required ensuring their timely delivery to health facilities. SCMS does not address issues of pharmaceutical or clinical services such as diagnostic, prescribing or dispensing practices, public education or other issues related to medication use. In those countries where both SCMS and RPM Plus are supporting the country PEPFAR programs this division of technical responsibility is the agreed upon approach based on the comparative strengths, skill sets and competencies of each activity.

Expected results will include: increased access to essential drugs and basic pharmaceutical services for rural communities through a sustainable public-private collaborative model that; improved dissemination and distribution of HIV/AIDS products and services to rural populations, increased awareness on HIV/AIDS available services and referral linkages to VCT, STI, PMTCT and other public health interventions; six million contacts per year; and documented results and outcomes of this innovative public-private model for supporting HIV/AIDS prevention, care and treatment activities in resource-limited setting.