TITLE: Expanding and Integrating TB/HIV activities at Mbeya Referral Hospital (MRH)

NEED and COMPARATIVE ADVANTAGE: According to the National Tuberculosis and leprosy Program

(NTLP), TB /HIV dual infection contributes to 17.5 % of the total disease burden in Tanzania (Ministry of

Health and Social Welfare (MOHSW), Manual of National Tuberculosis and Leprosy Program in Tanzania,

Fifth Edition, 2006). Currently, MRH provides TB services to patients in the counseling and testing centers

(CTC) and has embarked on an integrated approach to further strengthen collaboration between TB care

and HIV/AIDS care, reducing the burden of TB among PLWHA, and reducing the burden of HIV among TB

patients, resulting in more effective control of TB among HIV-infected people.

The MRH is one of five zonal hospitals in Tanzania. Its function in the Southern Highlands is to offer direct

clinical services, to provide training, to coordinate and oversee the quality of treatment in the zone.

ACCOMPLISHMENTS: MRH began full recruitment of patients in January 2005, and now boasts a patient-

load of over 2,499 on ART and another 5,269 on care. It will reach its September 2008 ART targets of

5,420, enrolling over 200 new patients each month.

The MRH will continue to strengthen the monitoring of HIV patients who are on TB care. Monitoring TB

patients through the use of clinical forms with TB screening questions has been key to ensuring the

screening and referral of all HIV and TB patients. Patients referred both ways have been well documented

in the care and treatment clinics. Integration of HIV care and treatment and the TB diagnosis, as well as

treatment and follow up will be strengthened further in FY 2008.

ACTIVITIES: Though all hospitals in the Mbeya Region, under the Mbeya Regional Medical Office (MRMO

under separate submission), now support ART, identification of a majority of patients is still through the

MRH. Here, they undergo their initial evaluation after which they are referred down to the regional and

district hospital for management. It is believed this is due to the higher quality of services and better

infrastructure at MRH, including its large inpatient wards.

1) All HIV infected patients receiving HIV care and treatment will be screened for TB disease routinely and

those suspected will access TB diagnostic services Those found positive for TB will be immediately referred

to the TB clinic to initiate an uninterrupted treatment using Directly Observed Therapy (DOT). 1a) Support

making of the clinical forms with TB screening tool. 1b) Clinicians at each site will be trained on TB/HIV

collaborative activities including use of modified clinical forms to routinely identify underlying TB signs and

symptoms for all clients attending at CTC. 1c) Develop a referral system for access of HIV-infected TB

suspects to laboratory diagnosis and treatment for TB.

2) TB infection control practices will be implemented in the care and treatment clinics to prevent

transmission of TB among PLWHA as well as health providers. 2a) CTC staff at each site will be trained on

TB infection control practices. Ensure ventilation in Care and Treatment clinics.

3) Strengthen existing laboratory services needed to implement TB/HIV program activities. 3a) Supplement

supply of X-ray films.

4) Support outreach ART services to remote TB clinic in the regions.

LINKAGES: This activity is linked to activities under this facility in treatment and palliative care as well as

those of the regions in this zone (Mbeya, Rukwa and Ruvuma). It is also linked to the DOD submission

under SI other USG treatment partner submissions providing expertise in areas of pediatric care and TB

infection control.

The MRH will continue to promote outreach services from the facilities to the communities. It has a list of

NGO's, CBOs and HBC providers involved in HIV/AIDS support, indicating geographical coverage and

types of services offered. This list is displayed in the CTCs and other clinics/wards so health staff can refer

clients to those organizations as necessary. These referrals, as well as referrals from community

organizations to the facility, will be further strengthened through a facility social worker serving as the point

of contact (POC) for the community organizations.

CHECK BOXES: The areas of emphasis will include: initial and refresher training of staff in TB/HIV co-

management, infection control, provision supplies and medications, and capacity building. Community

Health Management Teams (CHMTs) will be supported in planning and incorporating TB/HIV activities in

Council Comprehensive Plan (CCHPs).

M&E: The MRH is the central hub for the zonal electronic medical record system (EMRS) supported with

direct technical assistance (TA) from DOD. This EMRS is critical for patient management and program

monitoring in support of ART in the Southern Highlands.

All efforts will be made to capture all the HIV care and treatment related data from both the CTCs and TB

clinics using NTLP data collection, recording, and reporting tools. Data at the CTC is collected using

standardized forms based on NACP and facility data needs. It is entered into the electronic medical record

system (EMRS) and synthesized, generating NACP and USG reports as well as providing feedback to CTC

teams for use in-patient management.

SUSTAINABILITY: The MRH is accomplishing this through capacity building of other health care facilities

and its staff, sensitization of community members, and advocacy through influential leaders. This is also

being accomplished by strengthening "systems", such as the zonal supportive supervisory team and the

zonal weekly ART meetings as part of already existing zonal support functions.

TITLE: Expanding Care and Treatment Services in the Southern Highlands Zone

NEED and COMPARATIVE ADVANTAGE:

The Mbeya Referral Hospital (MRH) is one of five zonal hospitals in Tanzania. Its function in the Southern

Highlands is to offer direct clinical services, to provide training, to coordinate and oversee the quality of

treatment in the zone, and to establish health service referral systems among four regions (Mbeya, Iringa,

Rukwa and Ruvuma) serving a catchment population of over six million people. Initiated in late 2004, under

PEPFAR funding and multiple donor support, an infectious disease medicine clinic and training facility with

a referral level laboratory has been under development and is scheduled to be fully functional by January

2008. It is anticipated this center will support continued expansion of ART and clinical care needs at this

facility as well as provide classrooms and a fully functional clinic and lab for improved practical training in

HIV services.

ACCOMPLISHMENTS:

The MRH began full recruitment of patients in January 2005 and now boasts a patient-load of over 2,499 on

ART and another 5,269 on care. It will reach its September 2008 ART targets of 5,420, enrolling over 200

new patients each month. The MRH also provides technical supervision to the hospitals in the Mbeya,

Rukwa and Ruvuma Regions through out the zone, contributing to quality services to a total patient

population in the Southern Highlands of over 10,000 on ART and another 26,000 with care. In collaboration

with the NACP, the MRH has also supported the direct training of over 475 health providers through the

Southern Highlands in ART services (numbers per region indicated in separate activity submissions).

ACTIVITIES:

Though all hospitals in the Mbeya Region, under the Mbeya Regional Medical Office (MRMO under

separate submission), now support ART, identification of a majority of patients is still through the MRH.

Here they undergo their initial evaluation after which they are referred down to the regional and district

hospital for management. It is believed this is due to the higher quality of services and better infrastructure

at MRH, including its large inpatient wards. This serves as a bottle neck in increasing enrolment of patients

and also means the MRH bears the brunt of the cost of bringing on new patients in the region. As part of FY

2007 and FY 2008 activities, the DOD and MRH will work with the MRMO in developing strategies beyond

provider initiated testing and counseling (PITC) to decentralize identification/enrollment of patients to

increase up take of services. This will be a key component of the overall improvement of services through

out the region, including expansion to health centers.

Within the MRH, activities will include:

1. Provision of ART to patients, both in main MRH CTC and at satellite/health centers.

1a. In coordination with the Mbeya Regional Medical Office, directly support satellite health centers within

the municipality in providing ART to decongest the MRH CTC

1b. Provide ongoing mentoring to MRH and satellite health center CTC staff

1c. Continue to senstize hospital staff and clients in provider initiated counseling and testing (PICT) as a

regular part of all out patient services, including the TB clinic.

1d. Reinforce PICT sensitization through rotation of staff from the HIV CTCs to assist regular hospital staff

in patient identification and provision of this service.

1e. Reinforce patient record/data collection, working with DOD and facility staff to collect, record and

analyze data to inform improvement of services

1f. Strengthen prevention for positives counseling as a critical aspect of all HIV services within the facility

from CT, TB and the CTC

1g. Continue to provide evaluation for malnutrition and nutritional counseling to all HIV+ clients as part of

both care and treatment

1h. Procure commodities for services and patient monitoring when not available through central mechanism

2. Provide support to zonal facilities to ensure quality services

2a. Strengthen and reinforce implementation of SOP for clinical services, laboratory monitoring and

maintenance of patient records

2b. Bi-monthly visits to facilities in the zone by supportive supervisory teams consisting of a medical officer,

clinical officer and nurse

2c. Observe service provision and provide direct technical and material support to health facilities in the

zone

2d. Mentor RMO development and/or strengthening of regional supportive supervisory teams

2e. Conduct weekly zonal ART meetings with the Mbeya, Rukwa and Ruvuma Regional Medical Offices to

discuss treatment roll out, identify areas of need, determine solutions and coordinate resolution

3. Function as the zonal training center in HIV related services for the Southern Highlands in support of

NACP

3a. In collaboration with the NACP, conduct initial and refresher training in ART, TB/HIV co-management,

and PICT for the regions of Mbeya, Rukwa and Ruvuma

3b. Provide practical portion of training with MRH CTC staff to reinforce class room lectures

3c. Work with RMO to continually evaluate training needs in the zone and meet those need through both

formal and informal mechanisms/approaches

4. Increase enrollment of women and children in ART services.

4a. Promote routine counseling and testing of mothers and their children at all contact points in the health

facility, including the maternal child health (MCH) center (Meta), labor and delivery wards, immunization

clinics, and female and pediatric inpatient wards

4b. Continue to strengthen co-management of HIV+ mothers identified in the MCH with the CTC for

evaluation and follow up for treatment

4c. Develop capability for infant diagnosis. The MRH will receive equipment from the Clinton Foundation

and technical assistance from USG lab partners to conduct infant diagnosis for the entire Southern

Highlands.

4d. Train MCH and CTC staff in the collection of DBS for infant diagnosis.

4e. Ensure all HIV exposed and infected children are initiated on cotrimoxazole prophylaxis as appropriate.

5. Strengthen of referral system between HIV services points at the MRH.

5a. Use site coordinator to conduct daily checks on registers in outpatient clinics, in-patient wards, MCH

Activity Narrative: and the TB clinic to keep track of patients referred to the CTC.

5b. Strengthen and formalize referrals to and from CBO, NGO and FBO serving patients in their

communities through facility social workers.

LINKAGES:

This activity is linked to activities under this facility in TB/HIV and palliative care as well as those of the

regions in this zone (Mbeya, Rukwa and Ruvuma). It is also linked to the DOD submission under SI other

USG treatment partner submissions providing expertise in areas of pediatric care and TB infection control.

The MRH will continue to promote outreach services from the facilities to the communities. It has a list of

NGO's, CBOs and HBC providers involved in HIV/AIDS support, indicating geographical coverage and

types of services offered. This list is displayed in the CTCs and other clinics/wards so health staff can refer

clients to those organizations as necessary. These referrals, as well as referrals from community

organizations to the facility, will be further strengthened through a facility social worker serving as the POC

for the community organizations.

CHECK BOXES:

The areas of emphasis will include initial and refresher training, commodity procurement, strengthening

linkages with MCH and TB/HIV services and community organizations.

M&E:

The MRH is the central hub for the zonal electronic medical record system (EMRS) supported with direct TA

from DOD. This EMRS is critical for patient management and program monitoring in support of ART in the

Southern Highlands. The system currently supports 9 sites in Mbeya region and 3 sites each for Rukwa and

Ruvuma regions. The EMRS is linked to the National CTC2 and CTC3 databases and is capable of

producing national reports and identifier stripped data for national analyses. Patient records at the Referral

Hospital CTC are entered at the clinic immediately upon completion of the patient visit and electronically

transferred to the data centre where data is synthesized and fed back to the CTC team for use in patient

management. SI Targets: In FY 2008, the DoD SI team will train 60 HCW in M&E and provide TA to 53

CTCs and three regions

SUSTAINABILITY:

The MRH is accomplishing this through capacity building of other health care facilities and its staff,

sensitization of community members and advocacy through influential leaders. This is also being

accomplished by strengthening "systems", such as the zonal supportive supervisory team and the zonal

weekly ART meetings as part of already existing zonal support functions.

TITLE: Management and Staffing for DoD

NEED and COMPARATIVE ADVANTAGE: The Department of Defense's (DOD's) management and

staffing costs for laboratory will support one laboratory engineer and five laboratory technicians. These

laboratory officers will provide technical assistance to Referral, Regional, District hospitals in the Southern

Highlands of Tanzania. This support is centrally housed at the Mbeya Referral Hospital (MRH) and covers

the Mbeya, Rukwa and Ruvuma regions.

Presently in Mbeya, Rukwa and Ruvuma there are 25,455 patients under care and 13,638 patients on ART

served in over 28 hospitals. The MRH is working with all levels of health facilities in these regions to

develop lab capacity through training and supervision and ensure lab samples are being analyzed and

results reported accurately through the establishment of a lab quality system that monitors district, regional

and zonal hospital lab performance.

ACCOMPLISHMENTS: In FY 2006 and FY 2007 DOD and the MRH have made tremendous strides in lab

infrastructure in Mbeya, Rukwa and Ruvuma. This includes the two laboratory trainings of over 64

laboratory personnel at a total of 16 district and regional hospitals in these regions in equipment use,

maintenance and QA/QC procedures. A total of 13 labs have been renovated and equipped. In addition, the

MRH has established both an internal and zonal QA/QC system, a supportive supervisory team for direct

monitoring and assistance to sites as well as the "Quality District by District" program using a team

approach with regional lab managers to determine zonal training, maintenance and ordering needs.

ACTIVITIES: The Department of Defense's (DOD's) management and staffing costs for laboratory will

support one laboratory engineer and four laboratory technicians. These laboratory officers will provide

technical assistance to referral, regional, and district hospitals in the Southern Highlands of Tanzania. This

support is centrally housed at the Mbeya Referral Hospital (MRH) and covers the Mbeya, Rukwa and

Ruvuma regions.

Currently four laboratory personnel provide lab services to support to DOD's treatment efforts in achieving

Country Operational Plan (COP) targets. FY 2008 funding will continue to support lab technicians at MRH

and also support and monitor performance of HIV/AIDS related laboratory testing services through the

development of supportive supervision teams from the MRH.

To date we have been able to establish a well functioning laboratory team that provides technical

assistance to all three regions (Mbeya, Rukwa and Ruvuma) in maintaining and implementing standard

operating procedures and Quality Assurance/Quality Control programs and assuring that all district and

regional laboratories contribute to our treatment goals in the Southern Highlands of Tanzania.

LINKAGES: This program is linked directly to ART, PMTCT and CT services at these same hospitals

through out the zone. The development of lab capacity is integrated into the zonal expansion plan for the

strengthening of the quality of the overall HIV services of these hospitals. The in-service and Center of

excellence (COE) training activities are coordinated with and implemented as part of a national roll out with

the MOHSW, Muhimbili National Referral Hospital and other USG lab efforts.

CHECK BOXES: The areas of emphasis will include local organization capacity building, pre-service and in

service training, infrastructure improvement to support care and treatment in the Southern Highlands of

Tanzania.

MONITORING AND EVALUATION: Through supportive supervision the Laboratory team travels to sites to

provide technical support. As part of the QA/QC activity, developing capacity of the labs in the zone, the

Zonal QA/QC team and Zonal Engineer monitor control documentation, sample processing and reporting,

corrective and preventive actions taken, and reagent accounting sheets of each lab during supportive

supervisory visits. This information is used as a site-monitoring tool with immediate feed back from the

supervisory team provided.

SUSTAINABILITY: All aspects of management and implementation are conducted by MOHSW staff at the

MRH, and regional and district hospitals. The Zonal QA/QC, the Zonal engineer, lab staff and, regional lab

technologists are MOHSW staff or local contract hires based on existing open MOHSW positions. The

"Quality District by District" program provides a locally developed mechanism within the MOHSW supported

framework to disseminate best practices to ensure the capacity for quality monitoring and services,

forecasting and equipment maintenance is transferred and constantly reinforced. This program strengthens

not only the national role of the MRH but the local level facility participation in ensuring overall service

development and delivery.