To support the rapid strengthening of the National blood transfusion services in Tanzania, three more centers have been renovated in Zanzibar, Mtwara and Tabora increasing the service outlets to seven as planned in FY06. CDC has completed the renovation of the three sites through a RPSO contractual agreements. Equipment for the facilities was initially procured through the RPSO mechanism. However the funding calculated during FY06 catered for some of the equipment in anticipation for complete procurement in FY07 utilising Post Held Funds. In FY07 no funds were allocated to post for blood safety equipment procurement. The equipment to be procured is necessary for the centers to be functional.

Table 3.3.04: Program Planning Overview Program Area: Medical Transmission/Injection Safety Budget Code: HMIN Program Area Code: 04 Total Planned Funding for Program Area: $ 1,055,000.00

Program Area Context:

In Tanzania, as in most developing countries, the World Health Organization (WHO) estimates that at least 5% of new HIV infections per year are attributable to unsafe injections. To assess current medical injection practices and extent of risk, USG supported the Infection Prevention and Control-Injection Safety (IPC-IS) program's cross-sectional assessment of five medical injection safety pilots at referral and consultant hospitals in 2004. The study evaluated infection control and safe injection practices among prescribers, health providers, patients and community members. The study found that unsafe injection practices occurred in 47% of instances, with high numbers of needle stick injuries among health workers, inadequate disposal procedures (89%), and a large number of unnecessary injections (e.g., injectable vitamins and antibiotics). Furthermore, post-exposure prophylaxis (PEP) is neither widely used nor consistently available. The most important factors contributing to unsafe practices which can result in needle stick injuries to health staff are the lack of safe disposal facilities, improper disposal procedures, and disposal of hazardous waste in open and unguarded rubbish areas.

The Government of Tanzania (GOT) and USG remain committed to ensuring safe, quality health care services to Tanzanians through the implementation of IPC-IS. USG supports the Ministry of Health and Social Welfare's (MOHSW) overall responsibility for achieving the three-step strategy recommended by WHO and the Safe Injection Global Network (SIGN) that includes supporting behavior change for healthcare workers and patients to ensure safe injection practices, ensuring availability of equipment and supplies, and introducing safe management procedures for disposal of medical waste. The objectives of the program are to: strengthen the national capacity to establish policies for safe and appropriate use of injections; ensure industry standards and the quality and safety of injection devices; guarantee the availability and affordability of injection devices; ensure appropriate and cost-effective use of injections during percutaneous or per mucosal procedures performed in medical and other settings; ensure safe and appropriate health care waste and sharps management in all health care facilities; implement PEP for HIV exposure; and vaccinate all health workers at risk of Hepatitis B infection.

Since 2004, MOHSW, through USG support, has worked with partners to develop the Infection Prevention (IPC) policy, the IPC training manual and job aids. Four sets of additional policies are in draft form: Healthcare Waste Management (HCWM) national policy guidelines; Standard Operating Procedures (SOP); IPC-IS pocket guides; and HCWM training modules. MOHSW has functioned as the coordinator for IPC-IS implementation by organizing stakeholders through Infection Prevention Control Committees and Health Care Waste Management Committees at both the Ministry level and facility levels. Through these bodies, the program ensures that the MOHSW goal for all healthcare providers to practice universal safety precautions across such services as Blood safety, Laboratory, Counseling and Testing, and Prevention of Mother to Child Transmission of HIV services is achieved. The program has established an environment where healthcare workers and patients are better protected from transmission of HIV and other blood-borne pathogens via medical practices.

In FY 2006, MOHSW, through USG technical and financial support, has initiated a Universal Safe Precaution and Injection Safety program in five referral hospitals and 60 district facilities. Under this program, MOHSW developed, printed, and disseminated over 5,000 copies of National IPC-IS guidelines in these facilities. In addition, a total of 2,762 health workers were trained in general IPC-IS, quantification/management of safety injection supplies and proper waste handling. This was augmented by direct USG support in procurement of safety equipment (personal protective gear) and safety boxes. MOHSW and the private sector are currently examining possibilities for local production of safe disposal boxes and injection devices as an alternative to reliance on imported commodities.

Rolling out the program has been possible through a clear division of tasks between the three USG partners, namely MOHSW, John Snow Inc. and Johns Hopkins Health Program for International Education

in Gynecology and Obstetrics (JHPIEGO) and other key actors in this area. The decentralization of the training to the zonal level has served to speed the implementation of the program especially in the area of training health workers. Other donors such as German Technical Cooperation (GTZ) and WHO have supported the initiation of the universal safe precautions program in Tanzania. Danish International Development Agency (DANIDA) through the Health Sector Program Support (HSPS III) provided funding for training of tutors on IPC-IS, quality improvement and supportive supervision for quality health care. It is believed that it will take the combined experience and long-term commitment of these donors, MOHSW and USG to build the significant capacity required to achieve the MOHSW goal. Key challenges include the need to further develop and implement the PEP policy and guidelines for healthcare workers, ensure continued quality training for healthcare workers in IPC-IS, and procurement of injection equipment with safety features, safety boxes for health facilities, and protective gear for waste handlers.

USG support in FY 2007 will focus on scaling up the IPC-IS program in Tanzania. Under the Emergency Plan, USG will provide ongoing technical assistance and funding to MOHSW for the continued expansion of IPC-IS to10 new regions, reaching 76 sites. USG efforts have been coordinated with the MOHSW and other donors to maximize both geographic and programmatic coverage. Capacity strengthening of referral hospitals and zonal training centers in the application of and education in standard safety precautions, including waste management, will be a critical component of USG's activities fostering long-term sustainability. This will include the implementation of targeted advocacy and behavior change strategies. Critical priorities will be to continue decentralizing training to zonal training centers, developing a strategy for local production of injection equipment with safety features, finalizing the PEP policy and guidelines for healthcare workers, lobbying for vaccination of healthcare workers at risk of Hepatitis-B infection with Hepatitis-B vaccines, training of tutors in health training institutions on IPC-IS, integrating IPC-IS trainings into the existing training curriculum for health training institutions, and advocating for inclusion of IPC-IS activities in Medium Term Expenditure Framework (MTEF) for sustainability. In FY 2007, this will be achieved through three USG partners working in collaboration with other key actors to strengthen existing programs and to emphasize stronger linkages with other programs.

Program Area Target: Number of individuals trained in medical injection safety 11,896

Table 3.3.04:

This activity links to activity number 7781 TB/HIV services (NTLP).

Proposed physical infrastructure improvements include upgrades of existing building space in TB clinics provided for patient examination areas, laboratory spaces, medical dispensaries, counseling and patient waiting rooms in order to improve patient flow, ensure confidential adherence counseling, hygienic laboratory conditions to contribute to quality patient care and enhance delivery of TB/HIV services in the 10 TB Clinic sites.

Consolidating infrastructure improvements will take away administrative and management burden from partners to allow a single country contact to oversee and coordinate the process for all RPSO procurements across program areas in Tanzania. The added benefit will ensure quality and consistency of products and services and ideally lead to cost efficiency with bulk purchasing. The in-country requisitioner will work with identified technical leads to assist RPSO in their contracting responsibilities. Funding for the representative is covered under the CDC management and staffing portion of the COP. RPSO has previously assisted CDC Tanzania with laboratory improvements and equipment purchases. The Government of Tanzania has mandated that the National Tuberculosis and Leprosy Program (NTLP) coordinate and implement TB/HIV activities in collaboration with the National AIDS Control Program (NACP) and other stakeholders. In the FY 2007 COP, NTLP, through the Regional Procurement Support Office/Frankfurt (RPSO), proposed physical infrastructure improvements that included the upgrade of existing space in TB clinics. This space included areas for patient examination, laboratory spaces, medical dispensaries, counseling and patient waiting rooms. These upgrades will improve patient flow, ensure confidential adherence counseling and hygienic laboratory conditions. These changes will ultimately improve the quality of patient care and enhance delivery of TB/HIV services in 10 TB Clinic sites. The funds initially allocated in the 2007 COP were insufficient for the proposed renovations. Therefore, plus-up funds are being requested to cover the gaps. These gaps include procurement of furniture for patient comfort and building confidential storage systems for patient records.

This activity links to activities under Counseling and Testing Ministry of Health/National AIDS Control Program activity #7776.

Proposed physical infrastructure improvements include upgrades of existing building space for counseling rooms in order to improve client flow and ensure confidential counseling in 25 NACP-funded, CT sites.

Consolidating infrastructure improvements will take away administrative and management burden from partners to allow a single country contact to oversee and coordinate the process for all RPSO procurements across program areas in Tanzania. The added benefit will ensure quality and consistency of products and services and ideally lead to cost efficiency with bulk purchasing. The in-country requisitioner will work with identified technical leads to assist RPSO in their contracting responsibilities. Funding for the representative is covered under the CDC management and staffing portion of the COP. RPSO has previously assisted CDC Tanzania with laboratory improvements and equipment purchases.

Targets

Target Target Value Not Applicable Number of service outlets providing counseling and testing
according to national and international standards Number of individuals who received counseling and testing for HIV
and received their test results (including TB) Number of individuals trained in counseling and testing according to
national and international standards

Target Populations: USG in-country staff

Table 3.3.09:

This activity links to activities under Counseling and Testing Ministry of Health/Zanzibar AIDS Control Program activity #8690.

Proposed physical infrastructure improvements include upgrades of existing building space for counseling rooms in order to improve client flow and ensure confidential counseling in 10 ZACP-funded, CT sites.

Consolidating infrastructure improvements will take away administrative and management burden from partners to allow a single country contact to oversee and coordinate the process for all RPSO procurements across program areas in Tanzania. The added benefit will ensure quality and consistency of products and services and ideally lead to cost efficiency with bulk purchasing. The in-country requisitioner will work with identified technical leads to assist RPSO in their contracting responsibilities. Funding for the representative is covered under the CDC management and staffing portion of the COP. RPSO has previously assisted CDC Tanzania with laboratory improvements and equipment purchases.

Targets

Target Target Value Not Applicable Number of service outlets providing counseling and testing
according to national and international standards Number of individuals who received counseling and testing for HIV
and received their test results (including TB) Number of individuals trained in counseling and testing according to
national and international standards

Target Populations: USG in-country staff

Table 3.3.09:

Infrastructure improvements in facilities and laboratory This activity links to activities under ART Services (AIDS Relief, Harvard, EGPAF). Proposed physical infrastructure improvements include upgrades of existing building space provided for patient examination areas, laboratory spaces, medical dispensaries, counseling and patient waiting rooms in order to improve patient flow, ensure confidential adherence counseling, hygienic laboratory conditions to contribute to quality patient care and enhance delivery of services in USG supported treatment sites. Consolidating infrastructure improvements will remove the administrative and management burden from partners to allow a single country contact to oversee and coordinate the process for all RPSO procurements across program areas in Tanzania. The added benefit will ensure quality and consistency of products and services and ideally lead to cost efficiency with bulk purchasing. The in-country requisitioner will work with identified technical leads to assist RPSO in their contracting responsibilities. Funding for the representative is covered under the CDC management and staffing portion of the COP. RPSO has assisted CDC Tanzania with laboratory improvements and equipment purchases in the past and we anticipate that this partnership will continue to be successful.

Plus up funding will be used for the construction/renovation needs of AIDSrelief partner facilities. This includes: Musoma Regional Hospital $80,000; Sengerema DDH $65,000; Ukerewe District Hospital $40,000; Magu District hospital $27,000; and Sekou Toure Regional Hospital (Mwanza) $24,000.

In Musoma, the proposed addition will allow a self-contained CTC including a covered waiting area, triage, registration, records, clinicians' office, examining rooms, phlebotomy, private counseling area, and a dispensary. The estimated surface area to be added is 150 sq. meters comprising 5 additional rooms. In Sengerema, a new 3 room facility is being built for STI and mental health, but the CTC will occupy that area while waiting for its own facility to be built. The staff is extremely motivated and hard-working and they are producing quality work, but the space situation is dire. We are in possession of a diagram and a budget. The addition will be about 27 x 10 meters and it will house an indoor waiting area, registration/triage, lab, dispensary, 2 examining rooms, an office and a classroom.

In Ukerewe, the CTC is operating out of one room. There is very little privacy and no waiting area. All CTC stations are crammed into the room. The hospital administration has agreed to allocate an additional 5 rooms, which will require extensive renovation. In Magu, the proposed addition will allow a self-contained CTC including a covered waiting area, triage, registration, records, clinicians' office, examining rooms, phlebotomy, private counseling area, and a dispensary. The estimated surface area to be added is 85 sq. meters comprising 4 additional rooms. Sekou Toure Regional Hospital in Mwanza town, is a large government hospital that appears to be doing excellent work. They have between 2000 and 3000 patients under care and they receive as many as 100 patients per day. The CTC facility is basically adequate with the important exceptions of space for medical records and the waiting area. The pharmaceutical stores are also inadequate - the space limitations are severe and this makes it impossible to stock medicines properly. The ARVs, being a recent addition to the array of medicines stored there, are not properly stored. Accessing meds in the stores often requires climbing over and around cartons that obstruct passage. The area to be renovated totals about 80 sq meters in 2 separate locations.

Finally, the additional funds will be used to renovate additional 10 laboratories in these sites to facilitate laboratory services in support of diagnosis, care and treatment for HIV / AIDS.

This activity links to activities HLAB MOHSW 7758, 7779 NIMR, CDCBase 7834, CLSI 7696, APHL7682, AIHA7676, ASCP 7681, AMREF 7672, BMC 7685, ZACP 8224, DoD 7746; Track 1 ART CU7697/7698, EGPAF 7705/7706, HARVARD7719/7722, AIDSRelief 7692/7694, DoD7747, Blood Safety; CT NACP 7776, TB/HIV 7781, PMI, SCMS 8233, FHI 7712; SI NACP 7773, MOHSW 7761.

Quantities and specifications of equipment and reagents required to support the National Care and Treatment plan for treating patients are detailed in the National Laboratory Operational Plan for HIV/AIDS. In this plan, a number of facility renovation, equipment and reagent procurement principles are recommended. In FY 2004, the Regional Support and Procurement Office (RPSO) assisted USG with the contractual process for the preparations for renovation of the National Quality Assurance and Training Centre. In FY 2005, RPSO recruited the contractor who started the actual renovation process which will be completed in 2007 December. RPSO has also assisted USG with the contractual process for the purchase of high volume CD4, Chemistry and Haematology equipment for the Zonal Hospitals. In FY 2007, RPSO will assist in the procurement process for the equipment for the National Quality assurance and Training Center. The contractual processes include service contracts, delivery and training of users and maintenace staff prior to commissioning of the equipment.

When completed, equipped, and staffed, the Center support MOHSW in the development and implimentation of HIV/AIDS laboratory quality systems in Tanzania. IT will function to conduct quality assessment of HIV/AIDS testing at Referral, Regional and District laboratories, develop HIV laboratory training materials, train trainers in HIV/AIDS related testing and testing specific quality assurance, establish a central area for receiving and delivering distance-based training, and provide technical assistance for external quality assessment (proficiency testing) programs. In FY 2007, RPSO will continue to render procurement and renovation contractual services to the USG in support of MOHSW in its efforts to combat HIV/AIDS and to attain the PEPFAR goals.