TITLE: Strengthening the National and Regional Use of the Wide Area Network (WAN)

NEED and COMPARATIVE ADVANTAGE: The fight against pandemic diseases such as HIV/AIDS can be

made more effective when complete, accurate and timely data and information is available. Information and

Communication Technologies (ICTs), particularly Wide Area Network (WAN), can be used as a tool to

enhance the collection, processing, dissemination and availability of such information. This could be through

e-mails, file sharing, access to the World Wide Web, publishing information on the web and speedy delivery

of data via web-enabled data collection tools from upcountry to the ministry headquarters. This project is

therefore a timely initiative to modernize how health workers and policy makers collect, process,

communicate, disseminate and share information.

ACCOMPLISHMENTS: Implemented Local Area Networks (LAN) in seven regional medical

offices/hospitals and 1 referral hospital namely: Mbeya, Iringa, Lindi, Mtwara, Dodoma, Arusha, Mwanza

and Mbeya Referral Hospital; provided Internet connectivity for the above regional medical offices; recruited

two system administrators to manage the WAN and provide end user support; provided LAN and WAN for

two NIMR sites (Mwanza and Tabora); provided training to end users on e-mail use and internet surfing;

maintained all LAN and WAN equipment in 6 Dar es salaam sites and seven regional sites in good working

condition.

ACTIVITIES: Maintain and strengthen the existing LANs and WAN including connectivity, hardware, and

software updates through continued technical support to the 16 sites in seven regions

1. Conduct quarterly supportive supervisory visits to the existing 16 sites in seven regions

2. Train Health workers in seven regions on computer applications and training them about email and

internet use at the sub-national levels to ensure proper use of the technologies and timely data transfer.

3. Perform maintenance of the WAN system to the existing 16 sites in seven regions to ensure systems are

operating and address any issues. The sites under maintenance will include: Headquarters of the Ministry of

Health and Social Welfare (MOHSW), National AIDS Control Program (NACP), Prevention of Mother to

Child Transmission (PMTCT), Mbeya Referral Hospital, Regional Medical Offices/Regional Hospitals of

Mtwara, Lindi, Mbeya, Iringa, Arusha, Mwanza, Dodoma, NIMR Headquarters, Tukuyu, Muhimbili, Mwanza

and Tabora.

4. Maintain Annual Internet subscription fee for shared bandwidth for all 16 sites

5. Awareness and dissemination through websites and electronic newsletters

LINKAGES: NIMR collaborates closely with MOHSW and particularly with HMIS unit and NACP in

implementation and management of LAN/WAN at Dar-es-salaam and upcountry sites. In FY 2005 the

assessment of ICT needs for regional connectivities was carried out from July to September 2005. The

assessment team was composed of three officials from the MOHSW's Policy and Planning Department, two

from CDC, one from NIMR and two from a private company, AFSAT. The MOHSW team was headed by the

Head of HMIS Unit. Planning meetings involved stakeholders from CDC, NIMR, MOHSW HQ and NACP

who formed a task force that implemented LAN/WAN to Dar-es-salaam and regional sites. The senior

ministry officials (Permanent Secretary and Director of Policy and Planning) launched the MOHSW

LAN/WAN and website that was developed.

Regionally, the project involved the Regional HMIS Focal persons in implementing and managing the

LAN/WAN. This collaboration has always been done when LAN was implemented and VSAT based-

Internet was provided for the following regional hospitals (Regional Medical Offices) of Mtwara, Lindi,

Mbeya, Iringa, Arusha, Mwanza, Dodoma and Mbeya Referral Hospital. Also, upcountry NIMR's IT officers

were also involved during connecting NIMR sites of Mwanza and Tabora which also received LAN and

VSAT connectivity.

CHECK BOXES: Conduct In-service training to health workers in seven regions on computer applications

and train them on email and internet use at the sub-national levels to ensure proper use of the technologies

and timely data transfer.

M&E: 1. Conduct quarterly supportive supervisory visits to all 16 sites to ensure that the systems are

operating and address any issues.

2. Review the usage of official e-mails on MOH.GO.TZ, NACPTZ.ORG and NIMR.OR.TZ domains. Review

will answer question about how many users are properly using the system, what are the gaps/limitations

and recommendation on improvements will be outlined.

SUSTAINABILITY: 1. The program staff will collaborate with the Ministry's HMIS staff to conduct basic

computer training, including basic troubleshooting of the systems to HMIS Focal person of the seven

regions where the regional and/or referral hospitals are connected.

2. Conduct end-users training and follow up for all sites. This will specifically involve conducting training to

end-users about email and internet use at the sub-national levels to ensure proper use of the technologies

and timely data transfer.

TITLE: National Institute of Medical Research (NIMR), Build Capacity and Implement Health Workforce

Research and Evaluation for Policy Change in Tanzania

NEED AND COMPARATIVE ADVANTAGE

A strong workforce in the health sector is a critical component in meeting the challenges of the HIV/AID

crisis. In Tanzania there is a need to urgently increase health manpower as well as the performance and

productivity of health workers. Improvements in human resources for health (HRH) require policies that are

informed by evidence based research about Tanzania's unique problems and issues. There is the need to

build the capacity for this research, perform the evaluations and use the results to inform and improve the

system and policies relating to human resources for health.

National Institute of Medical Research (NIMR) has played a critical role in supporting the Ministry of Health

and Social Welfare (MOHSW) to address human resource crisis through operational research and

evaluations related to HRH. NIMR has experience in research in the fields of epidemiology, biomedical,

and general public health and began work on the HRH issue in 2004. The presence of NIMR offices

throughout the country and the availability of a network of researchers are added advantages. NIMR, which

is part of the MOHSW under the Policy and Planning Department, is in a key position to advocate for major

policy decisions based on the results of their evaluations. In addition NIMR as a member of the HRH

Working Group of the MOHSW is strategically placed to give input, advocate and advise MOHSW on

changes in HRH policies and systems.

ACCOMPLISHMENTS

Since 2004 NIMR has made strides in performing evaluations and assessments in the area of HRH,

advocating for policy changes in HRH and building capacity through support of Tanzanians in the Field

Epidemiology and Laboratory Training Program (FELTP) in Kenya. More specifically, operational research

centered on workload and productivity was conducted. These studies were important in informing policy

makers and local/district leaders on productivity and the means to improving it. After analysis, triangulation

of data, and through discussions with health care workers root causes and possible solutions that could be

applied were identified. As a result, at the national level the MOHSW and NIMR are redefining staffing for

health facilities and are developing activity standards and workload indicators. A major finding from the

workload study was that retaining health workers in rural areas is a major challenge. Therefore a retention

study was undertaken. Analysis and dissemination is ongoing and is expected to inform policy decisions on

which cost-effective retention schemes to embark on at the national and district levels.

Another component of NIMR work involves capacity development. In FY 2006-07, through the Kenyan Field

Epidemiology and Laboratory Training Program (FELTEP) program, two graduates completed masters'

degrees. These two graduates will strengthen both communicable and non-communicable units of the

MOHSW. Additional residents have been recruited, one for strengthening the Zanzibar AIDS Control

Program of Zanzibar and the other for Laboratory Diagnostic Unit of the MOHSW on Mainland. The FELTP

graduates and students are beginning to play a major role in outbreak investigation (measles, rift valley

fever and malaria), in studying the epidemiology of HIV/AIDS and have prepared epidemiological bulletins

and materials for short course for laboratory workers. One current student is conducting a study on

antiretroviral (ARV) drug resistance in patients starting ARV treatment.

MAJOR ACTIVITIES

Major activities for NIMR for COP 2008 include: continued work on HRH related issues; strengthening the

capacity of Tanzanians to undertake public health evaluations (PHEs); building capacity for GIS; and

continued support for Tanzanians in the FELTP program.

1) Operational research will continue, with a greater emphasis on capacity building at NIMR zonal/district

levels to decentralize the research. As a follow up to previous work, a job description assessment will be

completed to measure the effect of providing clear job descriptions and job aides on improving performance

of health workers. In addition NIMR, with additional funds for one PHE, will conduct an evaluation of the

feasibility of task shifting of health workers in health facilities and its acceptability among consumers and

communities. Results from these two activities will be translated into policy changes for improving HRH in

Tanzania. In addition, NIMR will continue to disseminate information and build health worker capacity

through production of the quarterly NIMR HRH newsletter and through membership of the MOHSW HRH

working group. Lastly, in collaboration with the Capacity Project, a retention scheme intervention at district

level will be implemented and evaluated.

2) FY 2008 funding will also support strengthening Tanzanian capacity to undertake public health

evaluations. By strengthening this capacity NIMR will be a strong local partner to serve as co-investigator in

public health evaluations. They will be able to offer services such as protocol and tools development, field

data collectors, data entrants/analysts and report writers. Databases will be established of research

assistants who would assist in fieldwork and data entry. Funds will also be used to purchase equipment to

assist in easy data collection and transfer such as PDAs. In addition NIMR will provide assistance in data

analysis and validation of the SAVI (social assets and vulnerabilities indicators) database.

3) With FY 2008 funds, NIMR will support two students to complete their studies in the Kenyan Field

Epidemiology and Laboratory Training Program (FELTP) which will build capacity in Tanzania to address

the current shortages in these fields. As part of the MOHSW Epidemiology Unit activity plans are

underway to establish a Tanzania FELTP program and these two students who will graduate in 2008 will

play a key role in this future program.

4) NIMR will use FY 2008 funds to build its capacity to complete GIS mapping through close collaboration

with the MEASURE project. As part of this activity GIS experts will work closely with NIMR to build in-

country capacity and use. Although GIS mapping is widely applied in health data, efforts have not been

coordinated resulting in duplication. Given, the existence of GIS experts in NIMR and NIMR's position as a

national research institute, coordination also falls under its mandate. In addition, NIMR will coordinate the

GIS group, through; routine meetings and updates, sharing of information among the group, organizing and

offering coordinated support to PEPFAR activities and linking GIS data sets.

LINKAGES

In order to achieve the FY 2008 objective NIMR will link with a number of other key partners. NIMR will

Activity Narrative: work with the Capacity Project and the Health Policy Initiative for research and advocacy on HRH. Kenyan

FELTP students and graduates program will be linked with PMI, AFENET, Muhumbili University and the

new Tanzania FELTP program. NIMR will collaborate with institutions that have research experience for

implementation of the PHE component. For the GIS activities linkages will be developed MEASURE

Evaluation, University College of Lands and Architectural Studies and the National Bureau of Statistics.

M&E

NIMR has a strong focus on M&E and will employ the following M&E strategies: feedback from readers;

quality assurance plans for data collection; and visits to districts and respective zones to review use and

implementation of operational research after training. NIMR will strictly adhere to the PEPFAR reporting

and planning requirements.

All NIMR activities will be initiated in a participatory manner from both national and local level. Key

stakeholders will be involved through a bottom up approach to get their input into specific activities. Such

stakeholders include: ministries; NGOs; district leaders; and community representatives. Where possible,

additional funds will be leveraged to create a wider ownership and to ensure sustainability. Most of the

NIMR activities will include a capacity building component to build the necessary skills to sustain activities in

the future.

Title of Study: Evaluation of the feasibility of existing task shifting of health workers at health facility levels

and its acceptability among consumers and communities in Tanzania.

Expected Timeframe of Study: Phase One of the study is expected to take a total of 12 months. The

timeline is:

April-May: protocol and tools development

June-July: Pilot study, analysis of pilot data and tools rectification

August-October: Data collection

November-March 2009: Data entry, cleaning and processing, report writing and dissemination.

The Phase Two timetable will be developed during Phase One for implementation in year two.

Local Co-investigators: National Institute for Medical Research (NIMR); Tanzania Ministry of Health and

Social Welfare; Policy Analysis partner to be identified during phase one.

Project Description: A strong workforce in the health sector is a critical component in meeting the

challenges of the HIV/AID crisis. In Tanzania there is a need to urgently increase health manpower as well

as the performance and productivity of health workers. This proposal builds on existing evaluations that

investigated workload, productivity and retention schemes. The first phase evaluates the feasibility and

acceptability of task shifting among health workers based on both current informal task-shifting and within

sites where limited formal task-shifting has begun. Phase two will involve a pilot of new formal task-shifting

approaches within government facilities. Evaluation includes triangulating methods of cross-sectional

survey, discreet choice analysis and qualitative methods. Policy analysis for both phase one and two will

assess barriers to implementation of task-shifting and identify mechanisms to change policy. NIMR will be

working closely with MOHSW particularly in Phase Two to identify which task shifting to evaluate and refine

protocols.

Evaluation Question: Phase One

The primary question is: What is the feasibility of task shifting (informal and limited formal) by health

workers at health facility level and its acceptability among health workers, consumers, communities and

policymakers in Tanzania?

Secondary questions:

1. What are tasks of the various cadres of health workers in different types of health facilities?

2. How dissimilar are the tasks of the health workers compared to their training and capacity?

3. What kind of task shifting, given current pre-service and in service training in Tanzania, can be done in

the various cadres of health workers in the health facilities?

4. What is the perception and acceptance of task shifting among health workers, patients, the community at

large and policy makers?

5. How do these findings differ in facilities where limited formal task-shifting is already ongoing?

6. What are the barriers within policy preventing formal task shifting initiatives and how can these be

addressed?

Phase 2 (To be further refined depending on policy analysis and progress and in consultation with MOHSW)

The primary question is as follows: in selected health services and in selected health cadres where formal

task shifting, approved by MOHSW, is being piloted, what is the success as measured in ability to perform

tasks and feasibility and acceptability among health care workers, consumers and policy makers in

Tanzania?

Methods: Phase one

The study will employ both qualitative and quantitative methods:

1. Quantitative methods will involve; a questionnaire surveying healthcare workers from health facilities that

are practicing task shifting either informally or formally. Informal task shifting is when health workers are

performing tasks they were not formally trained for and/or tasks not in their job descriptions. Formal task-

shifting is where a health worker has been formally trained to perform an additional task and where the

Ministry has sanctioned the particular task shifting to that cadre. Currently only limited formal task shifting is

occurring involving lay counselors performing HIV pre-counseling but not being able to perform the HIV

tests. In phase two it is hoped the MOHSW will authorize piloting of more comprehensive task shifting.

Variables of interest include performance, job satisfaction, and perceptions and acceptability of task-shifting.

In addition health workers will be asked to make choices of different groups of tasks that they would like to

be assigned using discrete choice experiment techniques

2. Qualitative methods will include: in-depth interviews and focus group discussions with health workers,

and other stakeholders including patients and communities.

Quantitative data will be double entered into a database and later analyzed using both Epi-info and Stata 8.

All qualitative data will be tape-recorded, transcribed and then using software, e.g. MAXQDA, grounded

theory analysis will be undertaken. Sub analysis will involve comparing the main variables of interest

between informal and limited formal task-shifting facilities. Further analysis will distinguish variables of

interest between the different cadres, areas, level of facility, and according to numbers of health workers in

the particular health facility.

Methodology for Policy Analysis will be developed early in the protocol development phase in conjunction

with a partner experienced in this area of research.

Phase Two

This phase is to be developed during phase one. The aim would be to pilot MOHSW approved models of

task-shifting. Since the task-shifting model is yet to be decided it is not possible to elucidate the outcome

measures or research methodology at this point.

Activity Narrative:

Population of Interest: The population of interest will be: health workers and stakeholders such as Council

health Management Team (CHMTs), leaders, councilors, patients and communities.

Using the existing four geographical zones, at least one district per zone will be chosen randomly. In each

district-- all District hospitals, 50% of health facilities, and 10% of Dispensaries will be selected. Fifty percent

of all health workers will be recruited from the selected facilities for the survey. Exit interviews will be

carried out with patients in the same health facilities on the day of the survey. In each district at least three

Focused Group Discussions (FGDs) will be carried out with members of the community from catchments

area of the health facilities, making a total of 24 FGDs. These FGDs will involve women, men, leaders and

youths. All stakeholders will be identified through a snowball technique and will be involved in the in-depth

interviews.

It is hoped that data will also be collected from sites purposively selected as examples of limited formal task

-shifting (e.g. where lay counselors are working).

In phase two, similar data approaches will be used but the study sites will be clinics implementing new

models of formal task-shifting developed in collaboration with MOHSW.

Information Dissemination Plan: A workshop will be organized prior to the study to solicit information from

important stakeholders such as the Director of Human Resources of MOHSW, Human Resources for Health

Working Group, private facilities, and civil societies on key issues to be considered in the study. Once the

study is finalized and report produced, it will be disseminated according to well-set dissemination plan

including workshops, conferences, newsletters, policy briefs and distribution of report.

Budget Justification: Salary/fringe benefits: $50,000

Equipment: None

Supplies: $15,000

Travel: $40,000

Participant Incentives: None

Laboratory testing: None

Other: $25,000

Total: $130,000