TITLE: Strengthening HIV/AIDS Theory and Clinical Practice Components in Pre-service Medical Education

COMPARATIVE ADVANTAGE: National medical institutions and university teaching hospitals play a critical

role in the training and development of new health workers. Such sites are often used for clinical training

aspects of many health worker cadres, not just medical students. Furthermore, medical institutions and

physicians hold a great deal of influence in Tanzania. To this end, it is critical that such institutions and their

personnel exhibit and support quality care for HIV/AIDS according to evidence-based best practices as a

model for the entire country.

ACCESS is USAID's global program to improve maternal and newborn health, and is being implemented by

JHPIEGO. JHPIEGO/ACCESS works to expand key maternal and newborn health services, including the

prevention and treatment of HIV/AIDS, mainly through training and supportive follow-up of providers.

JHPIEGO/ACCESS uses a competency-based approach to training in order to improve the skills and

knowledge of health care providers in evidence-based best practices. Examples of areas where

JHPIEGO/ACCESS has trained extensively include focused antenatal care, safe labor and delivery, and

PMTCT. JHPIEGO/ACCESS has been active not only in in-service training, but also in strengthening pre-

service education of nurse/midwives.

ACCOMPLISHMENTS: With USAID/TZ funding, JHPIEGO/ACCESS has been working to improve teaching

of PMTCT in pre-service nurse/midwifery schools, at both certificate, and diploma levels. This work built on

previously-established relationships with pre-service schools for integrating focused antenatal care (FANC)

into their curricula. In FY 2008, JHPIEGO/ACCESS plans to expand the FANC work to medical schools

with funding from the Presidential Malaria Initiative. This will enable JHPIEGO/ACCESS to develop a strong

relationship with medical schools that will allow for successful expansion into subsequent strengthening of

HIV teaching.

JHPIEGO has experience working on HIV/AIDS in pre-service education in many countries. For example,

currently, JHPIEGO is implementing a large PEPFAR-funded project in Ethiopia with a focus on introducing

PICT (provider-initiated counseling and testing) to pre-service schools.

ACTIVITIES: JHPIEGO/ACCESS will provide technical assistance to the MOHSW, including the

Reproductive and Child Health Section, the National AIDS Control Program and the Human Resources

Development Directorate, to strengthen the theory and clinical practice content for comprehensive HIV care

in the pre-service curriculum of training institutions such as Muhimbili University College of Health Sciences

(MUCHS), Kilimanjaro Christian Medical College (KCMC), and others. Content for Comprehensive HIV care

will include: PMTCT, PICT, ART basics, selected Opportunistic Infections (OIs) and management of the

TB/HIV co-infected patient.

JHPIEGO/ACCESS will work with the MOHSW to implement the following activities:

1) Conduct a needs assessment and curriculum review of current medical institution curricula and teaching

practices. The needs assessment will build on assessments previously completed and will use tools

developed by WHO in collaboration with JHPIEGO. The purpose of the assessment will be to determine

the status of each school in teaching updated, evidence-based and competency-based practices related to

comprehensive HIV care, the structure and suitability of the clinical practice component, any

faculty/preceptor training needs, any teaching or clinical practice equipment needs, etc.

2) Stakeholders meeting to disseminate reports on needs assessment findings to USAID/TZ and MOHSW.

Participants at the stakeholders' meeting will include key members of the MOHSW, Administrators from the

medical institutions and representatives from professional associations. The stakeholders' meeting will not

only serve to present results of the assessment, but also to introduce plans for strengthening

comprehensive HIV education at the targeted schools.

3) Support the development of a Learning Resource Package (including faculty teaching guide, student

handbook, classroom presentations for faculty, clinical practice guide, etc.) on Comprehensive HIV services

with MOHSW partners and medical education professionals. JHPIEGO has many examples of such

packages from neighboring East African countries, like Ethiopia. Upon completion, the Learning Resource

Package will be: 3a) printed and 3b) delivered to all medical schools.

4) Training instructors from medical institutions and clinical preceptors from affiliated clinical sites on

comprehensive HIV content, including infection prevention (infection prevention training modules have been

previously developed by JHPIEGO with PEPFAR funding). JHPIEGO/ACCESS will use a competency-

based approach to training where instructors and providers are assessed on their both knowledge and

clinical skills before being declared competent in the subject area. At least 25 instructors and 25 clinical

preceptors will be trained from a variety of institutions.

5) Develop and implement standards for quality pre-service teaching (i.e, the standards for a good

educational program - teaching skills, clinical practice components, equipment and materials, etc.) in order

to strengthen the capacity of medical school instructors to ensure a strong educational experience for

medical students. Using a standards-based approach, JHPIEGO/ACCESS, MOHSW and representatives

from medical institutions will develop performance standards for teaching. The standards will be adapted

into tools that will allow instructors to conduct self-assessments leading to improved teaching skills. A

similar tool has already been developed for nurse/midwifery schools which can be adapted for the medical

training setting.

6) Supply equipment for state-of-the-art teaching. JHPIEGO will supply at least five schools with

educational equipment such as LCD projectors and laptop computers in order to aid them in delivering high

quality lectures and lessons. Representatives from recipient institutions will also be trained on the use of

such equipment.

LINKAGES: JHPIEGO/ACCESS will collaborate closely with other organizations, local partners and health

care providers currently working with medical institutions and national teaching hospitals. JHPIEGO will

also ensure synergies between its own pre-service activities to build on previous experience. For

developing content areas of the HIV curriculum, JHPIEGO will collaborate with other organizations for their

technical expertise such as JSI on medical injection safety and EGPAF and ACQUIRE on PMTCT.

The area of emphasis for this program is Human Capacity Development through pre-service training for

medical professionals and educators.

The target populations are adolescent and adult men and women who are HIV+ and require a wide array of

comprehensive HIV treatment services.

Activity Narrative:

M& E: The knowledge and competencies of medical school educators regarding comprehensive HIV

services will be assessed and evaluated during training. JHPIEGO will use the training information

management system (TIMS) database to capture names and numbers of persons trained. Furthermore,

results from quality improvement assessments will evaluate the level of teaching skills of physician

educators on HIV prevention and treatment. M&E will account for 5% of the total budget.

SUSTAINABILITY: The sustainability of all pre-service programs is long-term in that, by ensuring that new

graduates have updated skills in evidence-based best practices, there is less need for in-service training.

Furthermore, this program will develop strong trainers who will have the capacity to scale up comprehensive

HIV education to all medical institutions and affiliated clinical teaching sites. This will ensure that new

providers graduate with the necessary skills to provide adequate care to HIV+ women.

TITLE: Strengthening Infection Prevention and Control (IPC) Injection Safety (IS) in Tanzania

Transmission of infection is a major problem in Tanzanian health care settings. Improper IPC practices,

including unsafe use of injections, continue to serve as a route for HIV transmission. The Ministry of Health

and Social Welfare (MOHSW) and other stakeholders in the health sector acknowledge that IPC-IS is one

of the pre-requisites for ensuring safe health care delivery as well as protecting the population from

infectious diseases including HIV/AIDS. Injection safety is essential to protecting the health workforce.

JHPIEGO is an international leader in implementing evidence-based IPC practices that protect both the

client and the health care worker and has developed successful IPC-IS initiatives through focused antenatal

care (FANC) and Reproductive and Child Health Services (RCHS) in over 40 countries.

ACCOMPLISHMENTS: This IPC-IS program builds upon efforts already being implemented by JHPIEGO in

partnership with the MOHSW health services inspectorate unit (HSIU), under the ACCESS program and

John Snow International, Inc (JSI). Utilizing FY 2005 PEPFAR funding, JHPIEGO/ACCESS assisted the

HSIU in developing national guidelines on IPC. During FY 2006, the guidelines were adapted into a

simplified pocket guide for health care providers, translated into Kiswahili, printed, and widely disseminated

to frontline health care workers. Currently, in FY 2007, JHPIEGO/ACCESS is assisting the HSIU in

developing an IPC orientation package for use in orienting district-level policymakers and training

institutions to the IPC guidelines. Approximately 60 tutors will be updated on IPC-IS and use of the

orientation package for updating others in the pre-service training institutions. These trainers will receive

support to implement the IPC-IS training. In addition, the IPC orientation package will serve as a tool for

advocacy with Council Health Management Teams (CHMT) to ensure that standard precautions are

featured in Council Comprehensive Health Plans (CCHP).

With FY 2008 funding, JHPIEGO/ACCESS will collaborate with the MOHSW/HSIU to develop and introduce

a formal quality improvement (QI) initiative at individual health facilities. JHPIEGO/ACCESS, JSI, and HSIU

will develop nationally standardized performance standards for IPC-IS and will adapt these standards into

checklists for both external assessments and internal QI work. This work has been discussed and solidified

by all key stakeholders, and suggested target districts have already been identified with HSIU input.

ACTIVITIES: JHPIEGO/ACCESS will introduce IPC-IS performance standards and a QI approach to 26

hospitals previously identified and trained on IPC-IS best practices by the MOHSW/HSIU and JSI.

JHPIEGO/ACCESS will work with 13 of these hospitals under the FY 2007 plus up funding to introduce the

IPC performance standards and the QI approach. This initiative will come to fruition when FY 2008 funding

becomes available for program introduction to the remaining 13 hospitals.

The program will include assembling advocacy meetings with regional and district health teams in the areas

where selected hospitals are located in order to introduce the program to local authorities and advocate for

IPC-IS training and equipment to be entered into council health plans. Additionally, up to five IPC-IS focal

persons from each facility will be trained on IPC QI process and tools through a modular approach.

Selected focal persons were chosen by the HSIU, updated on IPC best practices, and will form the core of

QI teams within the IPC-IS committee at their facilities. Furthermore, 13 hospitals will receive support to

conduct baseline assessments on IPC-IS. The QI team will subsequently review results, identify gaps, and

develop action plans to address these gaps.

The 13 hospitals will receive additional support in order to conduct quarterly follow up assessments on IPC-

IS, conduct onsite analysis, and share results with hospital staff and HSIU. Roughly three months following

baseline analysis, the first follow up assessment will be conducted by the QI team to evaluate progress and

identify larger gaps and arising issues. Results will feed into module two training where progress and

challenges will be shared. A subsequent follow up assessment will be conducted at a similar interval, with

results shared during module three training. Lessons learned at these trainings will allow QI teams to make

greater improvements in their facilities. After identifying gaps through the assessments, limited support will

be in place to address those shortcomings. These disparities could include support for onsite training,

technical assistance visits, and benchmarking visits.

Two national IPC quality improvement-sharing meetings will be supported by JHPIEGO. Following QI

modular training, program stakeholders from national, regional and district level, as well as facility

management, will convene bi-annually to review results to date, discuss common gaps, and suggest

solutions. Participation in these meetings will assist in advocacy with district and regional policymakers and

support for sustainability of the program.

Additionally, JHPIEGO will facilitate the development of a recognition mechanism/plan for high

scoring/achieving facilities to encourage productivity. JHPIEGO/ACCESS will collaborate with facilities and

the HSIU to develop a formal system of recognition for facilities who achieve at least 80% of standards.

This is a critical element in order to sustain motivation and maintain the QI process at the facilities.

JHPIEGO/ACCESS and HSIU will work with districts to develop local systems for recognizing staff and

funding them through their council health plans based on experiences with other QI work in UIanga District.

LINKAGES: JHPIEGO/ACCESS will collaborate with other organizations and local partners currently

working on IPC-IS. JHPIEGO/ACCESS has already established close working relationships with

MOHSW/HSIU and JSI/Making Medical Injections Safer as part of the IPC-IS thematic group. JHPIEGO

will also link the IPC programs with ongoing work in antenatal care (ANC), ensuring that FANC providers

are also implementing quality IPC-IS practices.

CHECK BOXES: The area of emphasis for this program is human capacity development through pre-

service training institutions and health workers at selected hospitals. The target population is the general

population who access health services at hospitals. Health care workers will also benefit from reduced

instances of nosocomial infections, such as transmission of HIV.

M&E: JHPIEGO will collaborate with HSIU, district health management teams, and other partners working in

IPC-IS in all data collection, evaluations, assessments, supervision tool development and quality

improvement initiatives undertaken as part of IS programs. The supervision and follow up tools that were

developed with FY 2007 funds in collaboration with the MOHSW will be used in the quality improvement

initiative form.

QI assessment results will provide a set of quantitative data for measuring facilities' improvements over time

in implementing infection prevention practices to standard guidelines. All work on the QI in the 26 facilities

Activity Narrative: will be closely coordinated with MOHSW and documented to ensure replication capability in other facilities

in future years. As part of the QI JHPIEGO will collect key service statistics from a sampling of sites to

evaluate translation of improved IPC-IS practices to reduced instances of infection transmission. PEPFAR

training indicators will be reported and other indicators adapted to assist MOHSW to better measure the

progress and potential impact of IS programs.

SUSTAINABILITY: As previously discussed, QI teams will be actively involved in advocacy efforts with all

districts. District allocation of resources to conduct orientation sessions on IPC and IS will ensure greater

coverage and effectiveness. Integrating recognition mechanisms into the program is another way to ensure

sustainability as facilities continuously strive to achieve at least 80% of standards or to maintain this level.

Finally, IPC focal persons will have the training and facilitation skills necessary to replicate this initiative in

other facilities.

TITLE: Strengthening Pre-service Education for Medical Institutions

NEED and COMPARATIVE ADVANTAGE:

National medical institutions and university teaching hospitals play a critical role in the training and

development of new health workers. Such sites are often used for clinical training aspects of many health

worker cadres, not just medical students. Furthermore, medical institutions and physicians hold a great deal

of influence in Tanzania. To this end, it is critical that such institutions and their personnel exhibit and

support quality care for HIV/AIDS according to evidence-based best practices as a model for the entire

country.

ACCOMPLISHMENTS:

JHPIEGO has a long history to working with pre-service educational institutions throughout the world. With

USAID funding, JHPIEGO/ACCESS has been working to improve teaching of PMTCT in pre-service nurse-

midwifery schools, both certificate and diploma levels. This work was building on previously-established

relationships with pre-service schools for integrating focused antenatal care (FANC) into their curricula. In

FY 2008, ACCESS plans to expand the FANC work to medical schools with funding from the Presidential

Malaria Initiative. This will enable ACCESS to develop a strong relationship with medical schools.

ACTIVITIES:

ACCESS will work with the MOHSW of Tanzania, the National AIDS Control Program (NACP), and the

Human Resources Development Directorate, to strengthen medical training institutions such as Muhimbili

University College of Health Sciences (MUHAS), Kilimanjaro Christian Medical College (KCMC), and

others. Specifically, ACCESS will supply equipment for state-of-the-art teaching. ACCESS will supply at

least five schools with educational equipment such as LCD projectors and laptop computers in order to aid

them in delivering high quality lectures and lessons. Representatives from recipient institutions will also be

trained on the use of such equipment.

LINKAGES:

JHPIEGO/ACCESS will collaborate closely with other organizations, local partners and health care

providers currently working with medical institutions and national teaching hospitals. JHPIEGO will also

ensure synergies between its own pre-service activities to avoid re-inventing the wheel.

CHECK BOXES:

The area of emphasis for this program is Human Capacity Development through pre-service training for

medical professionals and educators.

M&E:

JHPIEGO will use the TIMS database to capture names and numbers of persons trained. M&E will account

for five percent of the total budget.

SUSTAINAIBLITY: The sustainability of all pre-service programs is long-term in that by ensuring that new

graduates have updated skills in evidence-based best practices, there is less need for in-service training.

Furthermore, this program will improve pre-service facilities and this will allow more students to enter to

training and will ensure that new providers graduate with the necessary skills to provide adequate care to

HIV+ women.