This activity also relates to Pathfinder activities in Other-Policy and Systems Strengthening (#8978). It also relates to other Palliative Care Services under activities by the National AIDS Control Programme (#8692) and the National Palliatie Care Association (#8704).

The Pathfinder activity supports the development of community home-based care (HBC) services across Tanzania. Over the last two years, the activity reached over 8,000 people living with HIV/AIDS (PLWHA) in 12 districts across 4 regions of the country. The activity provides care for clients and supports other members of those clients' households.

With FY07 funds, Pathfinder, along with other HBC providers, will focus on strengthening the quality and comprehensiveness of HBC services, as well as expanding coverage to 22,000 recipients.

The first component of the activity will be to ensure provision of high-quality HBC services through a cadre of trained community HBC providers. All activities are in accordance with the Tanzanian Ministry of Health/NACP guidelines on HBC services. Activities will include but are not limited to: identification of vulnerable households and PLWHA; providing basic nursing care; training caregivers; providing adherence counseling, providing recommended prophylaxis and treatment for HIV opportunistic infections (such as Cotrimoxazole, and Isoniazid) and direct observations of anti-tuberculosis treatment for TB patients; referral to facilities for complicated opportunistic infection (OI) treatment and ART; conducting health education to prevent new HIV infections in the community and in-client households; promoting HIV testing and counseling of family members and other contacts; and offering psychosocial support to clients and household members.

The second component of the work to be done with FY07 funds includes support to district level Council Multisectoral AIDS Committees (CMACS) to strengthen Ward AIDS Committees and District Health Committees to better coordinate community HBC efforts. Emphasis will be placed on increasing participation of PLWHA in these bodies, strengthening the continuum of care and choosing and monitoring the community HBC providers. Attention will be given to helping the community establish an integrated network of community services available for PLWHA and their families.

A third component of the activity is to provide support to PLWHA, and especially ARV recipients in project areas. The FY07 funding will go toward instituting a system where Care and Treatment Clinics (CTCs) refer ARV patients for community services, assuring patient confidentiality. The CTCs will identify liaisons between the community and the facility, who will ensure that patients receive appropriate facility-based services and are then referred back to the community HBC providers. The activity will focus on strengthening and reinforcing linkages between the HBC services and other local resources or programs and CTCs to ensure there is a highly functional two-way referral system (community HBC to health facility and health facility to community HBC programs).

A fourth component of this activity will focus on continuing to build the institutional capacity of community- and faith-based organizations to play a key role in service delivery to households affected by HIV/AIDS. This will increase the number of people who benefit from quality, sustainable services that meet national standards. This funding will target local partners and tailor training to build capacity for skills needed to deliver quality services, sustain capacity, and attract future donors to diversify funding. Training will also cover developing proposals and administrative systems and procedures for program management. This will be done to extend coverage through qualified sub-grantees.

A fifth component of this activity is support for the procurement of goods for HBC kits. Providers receive community HBC kits, which contain essential supplies for their work. Cotrimoxazole will be purchased centrally through the Supply Chain Management (SCMS) Project , and other items such as ITNs and WaterGuard units and supplies will also be procured centrally. However, until SCMS is prepared to provide complete and assembled kits, it will still be necessary to procure other components locally through the activity. Resources from the activity will also cover transportation and distribution of the kits to the selected project areas. While the Ministry of Health and Social Welfare will be responsible for storage and re-supply, the activity will use existing logistics systems to trace all supplies, so as to ensure availability of resources to the beneficiaries. Procedures for requesting and issuing kit contents will ensure the replenishment of HBC supplies is

consistent and sustainable.

Finally, in FY07, the activity will add new training components for continuing HBC education. The availability of anti-retroviral treatment and Directly Observed Therapy (DOTS) are resulting in patients living longer, resulting in a need to focus on keeping clients healthy. New trainings will include prevention of malaria and water-borne diseases, use of cotrimoxazole to prevent OIs, and proper use of nets and water treatment equipment. The new HBC components will also be included in refresher trainings for trainers.

The activity will encourage community participation in HIV/AIDS activities. Creative avenues will be used to pass traditional HIV/AIDS prevention messages and introduce new topics (i.e., importance of safe water and treated bed nets). Behavior change communication materials will be produced with messages about community HBC, prevention for positives, and positive living. Finally, funding will be used to work with PLWHAs, HBC providers, caregivers, clients, and supervisors to determine how to best facilitate PLWHAs' participation in HBC activities.

Funds for FY07 will also be used to strengthen and revise Monitoring and Evaluation data collection tool and its analysis. Routine monitoring and supervision of HBC activities will be strengthened to ensure activities are implemented according to work plans and that project targets are met, and to improve the data that flows to the National AIDS Control Programme.

With plus up funds, Pathfinder will expand home-based care services to Manyara region. Funds will be used to ensure provision of high-quality CHBC services in the region by conducting the following activities: Conducting community sensitization on the need for CHBC;Train 12 CHBC Supervisors,train CHBC volunteers, identifying vulnerable households and people living with HIV/AIDS (PLWHA); and procure one vehicle to facilitate transport for supervision in the region. The program will increase the number of sites from 66 to 73, increase the number of individual provided with palliative care from 22,000 to 22,300 and increase the number of individual trained from 920 to 980. As the project expands, Pathfinder will continue cultivating the good relationships they have forged at the national, district, and ward levels. Pathfinder will work with Council Multisectoral AIDS Committees (CMACS) to train 15 Ward AIDS Committee and District Health Committees in coordinating CHBC efforts. Pathfinder emphasizes the need to increase participation by PLWHA.

In addition, due to rapid scale up of home-based care services and the necessity to track and analyze quality of service data that has been collected since the beginning of the program, Pathfinder is now in need of a computerized monitoring database system to evaluate already collected information and facilitate future collections and analysis. This new database system will be developed in consultation with Deloitte/Family Health International's (FHI) - Tunajali HBC program and through the HBC Working Group, and will help inform the NACP with its future HBC monitoring system plans.

This activity also relates to activity numbers 7711, 7835, 7776, 8661, 8663, 8672, & 9085 (CT); 7781 & 7791 (TB/HIV); 7757, 7771, 7683 & 8839 (ARV).

Pathfinder International implements the Tutunzane ("Lets take care of each other") community home-based care (CHBC) program in 12 districts in 4 regions: Dar es Salaam (3 districts), Arusha (4 districts), Kilimanjaro (3 districts), and Tanga (2 districts). Pathfinder selects districts in cooperation with the National AIDS Control Program (NACP) and USG/CDC, with an aim to maximize national CHBC coverage and avoid duplication of efforts. In the last two years, the Tutunzane program has cared for nearly 8,000 people. The program community home-based care providers (CHBCP) each provide care to 2 - 20 clients and support members of those clients' households.

Pathfinder will continue to ensure the provision of high-quality CHBC services through a cadre of trained CHBCPs. Activities include but are not limited to: identification of vulnerable households and people living with HIV/AIDS (PLWHA); providing basic nursing care; training caregivers; providing recommended prophylaxis and treatment for HIV opportunistic infections such as Cotrimoxazole, and Isoniazid, and direct observation of anti-tuberculosis treatment for TB patients; referral to facilities for complicated OI treatment and ART; conducting health education to prevent new HIV infections in the community and in client households; promoting HIV testing and counseling of family members and other contacts; and offering psychosocial support to clients and household members. All activities are in accordance with the Tanzanian Ministry of Health/NACP guidelines on home-based care services.

In FY 2007, Pathfinder plans to expand its services by using the CHBC infrastructure to provide CT services in home settings to family members of index patients. This home-based CT approach has a comparative advantage because it uses the existing infrastructure of the Tutunzane CHBC program and brings services closer to the family members of the index patient getting home-based care services. Pathfinder will incorporate CT services into existing Tutunzane CHBC programs in Tanga, Kilimanjaro and Dar es Salaam regions. Pathfinder will work with other USG partners to build their capacity to implement home-based CT and care programs.

Consistent with Pathfinder's CHBC services, this activity will use the existing core CHBCPs to provide CT services for the family members of index patients. These supervisors and providers, who have medical backgrounds, will be equipped with counseling and testing skills using MOHSW/NACP developed training materials. Trainings for CHBCPs will be conducted by nationally supported trainers according to NACP guidelines. Family members of patients cared for by the Tutunzane CHBC program who consent will be tested using the national rapid test algorithm and results will be provided according to the national guidelines on VCT. In the implementation of CT services for family members, Pathfinder CHBCPs will provide family counseling (pre-test and post-test counseling) adhering to the 3C's (i.e., Counseling, Confidentiality and Consent). Pathfinder will adapt standardized preventive messages (prevention with positives interventions, education materials on positive living and prevention) developed in collaboration with MOHSW/NACP and USG/CDC technical assistance team. CHBCPs will be trained on these preventive messages and they will be communicated to and shared with clients during counseling sessions.

In FY 2007, 60 CHBCPs will be trained as volunteer counselors in Dar es Salaam, Tanga and Moshi Urban. Pathfinder expects to provide care to 6,700 index patients and provide CT services to approximately 30,000 family members in the home settings.

In order to ensure the quality of test results provided, Pathfinder has established internal quality assurance procedures. These procedures will require every tenth test, both positive and negative, to be sent to the laboratory for quality assurance. Linkages between the existing Tutunzane program and laboratory services in health facilities will be strengthened to incorporate this quality assurance activity. Laboratory personnel in health facilities will also play a role in conducting regular supportive supervision to CHBCPs providing CT to make sure that test results provided are of high quality. Pathfinder will use the existing Medical Stores Department (MSD) and local government logistics system to procure and distribute HIV test kits and reagents.

In an effort to provide a continuum of care, Pathfinder will work with MOHSW/NACP to

develop integrated referral systems for chronically ill patients. Pathfinder will build on the existing strong linkages between the Tutunzane CHBC program and health facilities, local NGOs, and FBOs in program areas. This linkage strategy and coordination effort will ensure that family members tested at home get necessary referrals in order to meet their needs. It also will facilitate early referral to care, treatment and support services for the HIV infected individuals. Pathfinder will ensure that PLWHAS are referred to established district level networks close to their homes for on going support and follow up. The program will conduct quarterly meetings with health facilities, FBOs, and local NGOs in order to share experiences and challenges regarding referral systems. This is aimed at strengthening linkages between program and referral facilities.

Program sensitization meetings will be conducted at different levels in order to create awareness of and advocate for home-based CT. At the national level, this will involve working with the Ministry of Health and Social Welfare (MOHSW)/National AIDS Control Programme (NACP), TRCS, NGOs, CBOs and other stakeholders implementing traditional HBC. At the regional and district levels, Council Health Management Teams (CHMTs), Council Multisectoral AIDS Coordinators, Regional/District AIDS Control Coordinators (R/DACCs) will be contacted to assist with strengthening the use of home-based CT. Finally, community sensitization about home based CT will be conducted at different levels by CHBCPs.

The program will review/adopt and or develop appropriate Management Information System (MIS) tools for the purpose of monitoring the progress of the program. The program will undertake quarterly monitoring/supervisory visits, mid term review and final program evaluation.

Using plus up funding, Pathfinder will incorporate CT services into existing Tutunzane Home based care program. In achieving the set targets for FY07 Pathfinder will employ more staff for program implementation. Activities proposed include, promoting HIV testing and counseling, training of existing HBC supervisors, conducting supportive supervision for quality assurance and providing CT services in home settings to family members of index patients. The project will purchase one vehicle and eight motorcycles to be used solely by teams that visits homes in respective wards. Additional funds will be used for salaries, fuel, maintenance, spare parts and insurance for the motorcycles and the vehicle.

This activity relates to OPSS activity #7714.

Public sector institutions in Tanzania, such as the National AIDS Control Programme (NACP), referral hospitals, National Institute for Medical Research (NIMR), city, district and ward councils, and district health management teams, have increasingly become an integral part in HIV/AIDS programming, either by provision of direct prevention, care, and treatment services or by formulating policies and providing technical direction. However, the effectiveness of these organizations is often compromised because of the variability of their institutional capacity, which in turn affects the quality and outreach of their programs and services. Because Tanzania's success in the fight against HIV/AIDS depends heavily on these institutions, Pathfinder is committed to strengthening their capacity to mount the strongest possible response to the epidemic.

In FY 2007, Pathfinder will strengthen the institutional capacities of CDC's public sector grantees, including NACP, ZACP, NIMR, and Bugando Hospital. Pathfinder's institutional capacity building (ICB) approach begins with a thorough participatory needs assessment using a tailored version of Pact's organizational capacity assessment tool (OCAT) modified to fit the needs and realities of public sector institutions. This assessment will focus on seven major components of organizational effectiveness: governance; management practices; human resources; financial resources; services delivery; external relations; and sustainability. Pathfinder will assess management & systems capabilities, current services, practitioner skills and competence, information management and data systems, and the potential for existing systems to handle scaling up of existing activities. Throughout the initial assessment process, Pathfinder will cultivate a close working partnership with the senior management of these public institutions to facilitate a favorable environment for organizational change.

Based on assessment findings and recommendations, Pathfinder will work with the partners to develop organization-specific technical assistance (TA) plans. The TA plans will include training, on-site support, supportive follow-up visits and interim assessments. Anticipated training services include: results-oriented project management; financial management; operational planning; resource mobilization and proposal development; and development of management information systems. With regards to financial management, a strong government financial management system already exists, but implementers often lack the sustained training, governance systems, and accountability structures to ensure that such systems are used appropriately. The training will be complemented with intense one-on-one coaching and mentoring to ensure that the learning is institutionalized.

Expected outcomes of the activity include substantially higher managerial and institutional performance and accountability of USG public sector partners with regards to PEPFAR and in general, and greater likelihood of program ownership and sustainability. It is also envisaged that as these USG-funded public institutions grow stronger in institutional capacity, they will be in a position to provide mentoring to emerging organizations.

Deliverables include reports for each of the institutional capacity assessments; work plans for ICB of each organization; and quarterly and annual progress reports.