URC through the Quality Assurance and Workforce Development Project (QAP) is working closely at national and district level to improve the quality of health services and outcomes in the national prevention, care and treatment of HIV/AIDS program by focusing on human capacity development. URC use systems strengthening strategies and Quality Improvement methods including Collaborative, mentoring and coaching activities to ensure provider compliance with national guidelines and standards of care.

In the program area of prevention of mother to child transmission, in FY 2005 and FY 2006, URC, working with Tanzania Food Nutrition Center (TFNC), COUNSENUTH and other stakeholders, focused on efforts to strengthen infant feeding counseling as an integral part of PMTCT programs. Evaluations of PMTCT programs in Tanzania show that infant feeding counseling is a weak component of PMTCT service delivery. In collaboration with national partners and USG funded organizations and other donors, URC has strengthened infant feeding counseling in PMTCT service delivery by contributing to formation of national PMTCT policy guidelines; developing a whole facility training curricula, and training more than 600 health workers in over 300 sites who are now able to counsel HIV positive mothers in optimal infant feeding practices. URC also developed job aids on infant feeding in the context of HIV which have now been taken up by MOHSW to become national materials. These materials and effort contribute to the improved health and well being of mothers and infants by reducing pediatric AIDS from HIV transmission through breast feeding by increasing the proportion of women who practice safer feeding: exclusive breast feeding, reduction in mixed feeding and use of appropriate complementary foods.

In FY 2007 URC will engage and work directly with MOHSW, USG PMTCT partners and other partners on overall quality improvement activities to enhance the efficiency and effectiveness of PMTCT service delivery. As PMTCT services become widely accessible throughout Tanzania, it has been noted that the quality of service provision varies considerably.

PMTCT program managers have noted three challenges to achieving program delivery targets. Firstly, the uptake of counseling and testing at labor and delivery wards is very low; this also indicates that there are a high number of pregnant women with unknown HIV status who are not being reached with PMTCT services in the prenatal period. Secondly, the uptake of NVP by HIV positive pregnant women has been extremely low ranging from 25 to 40% in some sites, due a variety of reasons including prenatal visit patterns, delivery patterns, and use of the drug. Documentation of case management and in-facility data are largely unavailable for these key aspects of service delivery. Thirdly, the follow up care of mothers and their HIV exposed children needs improvement - linking mothers to care and treatment programs; infant care - NVP dose, Cotrimoxazole prophylaxis, infant feeding counseling, testing at 15 months and palliative care for positive children. If these challenges were addressed by effective strategies for continuous quality improvement, this would lead to significant quality of service changes and enhanced ability to meet PEPFAR targets.

URC aims to increase the uptake of PMTCT services at existing sites, particularly uptake and use of ARV prophylaxis, prophylaxis and improve the quality of PMTCT services overall. To fulfill these goals and address the challenges, URC will develop a quality improvement model that would be beneficial to a large number of sites in a short time. This model would be easy, manageable at facility level and have potential for scale up to entire health system. URC will work with the MOHSW, partners and facilities to adopt and improve systems and procedures that health workers can use to undertake regular quality audits and assessment to identify service gaps, related to PMTCT. The tools would be simple job aids and algorithms and form part of the MOHSW supervision tools. URC/QAP will use experience gained from South Africa, Rwanda and Uganda with PEPFAR support to support the MOHSW and USG partners to improve the supervision and Quality Improvement system for PMTCT. URC will adapt the quality of care model and tools for Tanzania. URC work in these other settings has shown that the approach of monthly self-monitoring of key indicators has lead to enhanced internal management and developed greater consciousness among health workers of impact of daily activities.

The specific activities would be identifying and prioritizing quality gaps, organizing improvement teams, developing and implementing improvement plans, training staff in QI methods specific to PMTCT, chart audits with onsite data analysis to ensure accuracy and

completeness of PMTCT records, and mentoring and support of staff.

URC/QAP would meet with facility team on a monthly basis so that systemic quality issues are identified and appropriate interventions developed to close the gaps. We would train the facility staff to conduct health card audits and patient surveys to see if the newly introduced changes are producing desired outcomes. As a facility improves its quality, the intensity of mentoring visits becomes less and QA staff would move on to other facilities within the district.

Initially we propose to work on developing the improvement model in direct collaboration with EGPAF supported sites in Kilimanjaro and Mtwara Regions with the aim of rapidly moving the model to other USG partner sites. In this role, URC would supplement technical expertise in quality of care for USG partners engaged in pMTCT service delivery.

In FY 2007, URC will also scale up capacity building in infant feeding counseling in PMTCT services to several new regions in direct collaboration with MOHSW, EGPAF and Columbia in these areas: Arusha, Mtwara, Tabora, Singida, Dodoma, Zanzibar, Mwanza and Coast. The scale up strategy URC has been using in the regions is centered on the district health referral system. Scaling up to these 8 regions through training roll-out by USG partners would result in an additional 320 service outlets providing the required package of PMTCT services and close to 3,000 more health workers trained in infant feeding counseling.

For infant feeding, URC will place a facility-driven monitoring and evaluation plan that will be two-fold to 1) develop a recurrent monitoring system to empower local managers to collect, use and analyze data to manage their own program and 2) provide information on quality and coverage of program at different levels including: health worker perceptions of the training program; health worker competencies: knowledge and skills; health worker performance and quality of counseling. URC will also assist client outcomes: mother's knowledge and practice; health systems improvements; and facility - community linkages.

This activity is related to all treatment activities, including the ART monitoring activity (#8840) that will measure quality of outcomes in ART sites.

Since anti-retroviral drugs became available free to all Tanzanian citizens approximately 18 months ago, there has been significant effort directed toward rapidly ensuring access to and scaling up of treatment services. As more people are put on treatment, it is important to place additional emphasis on quality and instituting a systematic mechanism for ensuring quality of services provided. Each of the USG/Tanzania (USG/T) implementing partners has instituted some form of supportive supervision and monitoring of quality, but in FY 2007, the USG/T would like to harmonize and apply a uniform approach to quality improvement and institutionalizing quality assurance. The USG/T believes such an activity could contribute to the Government of Tanzania's (GOT's) plans for decentralized supportive supervision.

The proposed plan would be implemented by the University Research Council's Quality Assurance Project (URC/QAP), using their proven Quality Improvement Collaborative methodology. The Quality Improvement Collaborative is an approach for rapidly improving the quality and efficiency of healthcare. A Collaborative focused on specific components of HIV treatment identifies existing knowledge or best practices related to HIV treatment or services, and initiates systematic improvement efforts with a large number of teams. A Collaboratives is a time-limited improvement strategy, usually lasting from 12 to 24 months. Collaboratives are designed to achieve dramatic improvements in the quality and outcomes of care by fostering active learning among improvement teams, regularly tracking and communicating results of the improvement efforts. Teams within a Collaborative use a common set of core measurement indicators that relate to the desired outcomes of the Collaborative. Teams focus client needs, models of service delivery systems and processes, measurement, and how teamwork can improve each. Each team collects indicator data and reports monthly to the other teams. Frequent monitoring and sharing of results helps to spur the pace of improvements, creating a sense of friendly competition among teams to achieve the best results. The network of shared learning results in rapid development and testing of innovations and solutions to problems, rapid dissemination of effective changes, and rapid development of effective models of care.

The QAP has successfully implemented Collaboratives focused on ART in Rwanda and on pediatric AIDS, pediatric hospital care, and family planning in Tanzania. In other countries URC/QAP focuses on various aspects of reproductive health, HIV, and improving tuberculosis case management. In FY 2006, URC/QAP was funded to strengthen the pediatric HIV/AIDS care and support through an Improvement Collaborative in six referral facilities (three in Dar es Salaam, one in each of Morogoro, Kilimanjaro and Coast Regions) focusing on two main areas. The first was increasing the number of children diagnosed with HIV infection and referred to Care and Treatment Clinics (CTC) for ART and cotrimoxazole prophylaxis. The second area was to improve case management of HIV and HIV-related conditions such as malnutrition, pneumonia, and malaria in children admitted to these referral facilities. In addition, the program worked to strengthen referral linkages within hospital facilities as well as linkages with the community to improve the continuum of care.

By the end of FY 2006, a total of 3,086 children were suspected to have HIV infection among children admitted in six hospitals using the WHO testing algorithm. Of these 2,093 were tested, 1,048 were found to be HIV positive and 943 (90%) were referred to USG-funded CTC for ART and cotrimoxazole prophylaxis, if eligible.

In FY 2007, the QAP Pediatric AIDS Improvement Collaborative will broaden the entry points for administration of the WHO clinical screening algorithm and train ward-based HIV counselors in the catchment facilities so that they are readily available to counsel children with suspected HIV infection. Apart from the inpatient, the new entry points will include the outpatient clinics and under-five clinics. This activity will be preceded by training of health workers (on site) on the use of the WHO algorithm for clinical screening of children for HIV as well as data collection on suspected cases.

Starting in FY 2007, URC/QAP will work closely with the National AIDS Control Programme (NACP) and USG partners to expand the Pediatric AIDS Quality Improvement Collaborative

program to other facilities funded by the USG. The first priorities will be with Harvard, EGPAF, and recently "graduated" facilities in Dar es Salaam (PASADA) and Arusha (Selian). URC/QAP will work with NACP and the USG treatment partners to prioritize other sites for Improvement Collaborative interventions, moving to up to 12 new sites in FY 2007. URC/QAP will also work with NACP and the USG treatment partners to prioritize other components of ART services that require harmonization among partners and Improvement Collaborative intervention. A new nationwide initiative to monitor quality of ART services will be put into place in FY 2007, and the QAP will complement this program at the facility level by taking quality issues that are identified, analyze the problems and contributing factors, develop interventions, and test/implement improvement actions. Special focus is placed on the Institutionalization of improvements so they become an integral/sustainable part of an organization.

In addition, there is a significant gap in the referrals between Community-based Organizations (CBO) that serve people living with HIV/AIDS and the CTCs. It is for this reason that in FY 2007, URC/QAP will work consultation with NACP and USG-funded treatment partners to pilot a quality-designed model that attempts to involve communities and families in the identification of needs of HIV-infected children and families, including orphans. The design will include identification and implementation of interventions that lead to strengthened linkages between facility and community care and incorporate quality assurance approaches to improve HIV/AIDS services. The model will also try to: 1) identify and enroll children born at home by HIV-positive mothers, 2) establish strong working Collaborative relationships with CBOs, health facilities, and other stake holders and 3) establish a two-way referral network between community and health facility. This program will involve testing defined coordination mechanisms, referral, and counter referral tools. URC/QAP will work with NACP and the USG-funded partners to identify the best location to pilot this program.

Because this is a quality enhancement of existing treatment sites, there are no direct targets from this activity.