TITLE: Ensuring health care workers receive adequate in-service TB/HIV training

NEED and COMPARATIVE ADVANTAGE: The National TB and Leprosy Program (NTLP) sought

assistance in the development of policy guidelines, improvement of coordination between the TB and HIV

programs, and for support for TB/HIV training. I-TECH responded to this need in FY 2007 by working

closely with the NTLP in these areas. However, the need for expanded in-service training and supportive

supervision has emerged as key to the scale-up of TB/HIV care and forms the basis for this application. In

addition, through capacity building of the Zonal Training Centers (ZTC), I-TECH will support the

coordination of TB/HIV collaborative activities at district and facility levels. Through its ongoing work with the

ZTCs and HIV/AIDS related training in Tanzania, I-TECH is well suited to support these needs.

ACCOMPLISHMENTS: By the end of FY 2007, I-TECH will have finalized the national TB/HIV policy in

collaboration with the NTLP and other stakeholders, developed an operational manual for implementation of

TB/HIV activities, and enhanced the TB/HIV in-service curriculum, including the incorporation of the

International Standards for TB Care. The TB/HIV in-service training and training of trainers course will have

been standardized and piloted.

ACTIVITIES: 1. Collaborate with the Zonal Training Centers (ZTCs) to promote, coordinate, and implement

TB/HIV training. This will contribute to efforts to decentralize training through Government of Tanzania

(GOT) institutions and will increase the quality of TB/HIV care and treatment. 1a) Through the ZTCs,

support TB/HIV in-service trainings to health care workers in each zone. 1b) Develop the capacity of the

ZTCs to coordinate TB/HIV activities by developing a cadre of master trainers and mentors through clinical

and classroom teaching skill development. 1c) Maintain an on-site inventory of learning and teaching tools,

curricula, educational materials, and presentations of various TB/HIV related topics at each ZTC.

1d). Provide support to the NTLP technical working group on TB.

2. Monitor and evaluate the effectiveness and quality of the TB/HIV in-service training. This is important to

ensure high utilization of the knowledge acquired during the training and provide information about

improving the quality of training materials and approach. 2a) Development of a process and timeline for a

quality improvement of the TB/HIV in-service training through regular feedback, training observations and

analysis of training reports and pre- and post-test evaluations. 2b) Monitor the training, delivery, and

transfer of learning, including on-site visits by district and regional partners to clinical sites.

LINKAGES: I-TECH works very closely with the Ministry of Health and Social Welfare (MOHSW), CDC and

other USG and non-USG partners. As in FY 2007, I-TECH will continue to work closely with Program for

Appropriate Technology in Health (PATH) which is supporting TB/HIV collaborative activities, particularly to

enhance public-private partnerships. In addition, I-TECH will continue to work with the Curry TB Center's

International Standards for Tuberculosis Care (ISTC) medical school project and Integrated Management of

Adolescent and Adult Illness (IMAI), with the aim of harmonizing materials and minimizing duplication. This

will be enhanced through I-TECH's attendance of the monthly USG meetings and regular TB technical

working group sessions in order to share work updates and materials. I-TECH documents meeting

proceedings with the aim of improving collaboration.

CHECK BOXES: Human Capacity Development/In-service training: This activity addresses the in-service

training needs of HIV and TB care and treatment providers. Local organization Capacity Development: In

combination with projects funded by OPSS, this activity will strengthen the capacity of the ZTCs to rollout

HIV related trainings.

M&E: Activity managers use a results-based framework and M&E plan for each activity that includes

benchmarks and indicators. Progress towards objectives is entered and reviewed quarterly via a progress

database. Each activity will also have a data-flow map to identify roles of implementing partners in data

collection and use. Tools and relevant methods are used to assess training participants' knowledge and

practice, facilitator skills, curricula products, and training program design. Data quality assurance and

support will be provided where relevant. Timely stakeholder review meetings will be held to ensure that data

collected is useful to program management and oversight. Approximately six percent of the I-TECH budget

supports M&E.

SUSTAINABILITY: By supporting decentralization of training to ZTCs, local capacity will be enhanced and

sustainability promoted. I-TECH also plans to develop a cadre of skilled trainers in each zone who will be

able to train on all health-related topics, including TB/HIV. With the additional focus of incorporation of

HIV/AIDS and TB education into pre-service medical and allied health school curricula, a stage will be set

for sustaining quality, state-of-the-art HIV/AIDS and TB care through development of a workforce well-

grounded in this area.

TITLE: Rollout of Provider-Initiated Testing and Counseling (PITC) Training through the Zonal Training

Centres

NEED AND COMPARATIVE ADVANTAGE: GOT recognizes that access to HIV testing solely through VCT

centers is limited; therefore, the National AIDS Control Program (NACP) has begun to implement provider-

initiated testing and counseling (PITC) to increase the number of Tanzanians who know their HIV

serostatus. In addition to scaling up HIV testing, PITC will help ensure that affected individuals access

prevention, care, treatment, and support services as early as possible. I-TECH is a collaborating partner in

this national effort, and has worked with CDC, NACP, IntraHealth, AMREF, Bugando Medical Center and

Muhimbili Health Information Center to finalize PITC training materials. I-TECH was also identified to be an

implementing partner for the PITC training rollout. PITC training coordinated by I-TECH will be done by

zonal training teams that comprise zonal training center (ZTC) faculty, clinical trainers from hospitals and

trainers in other pre-service institutions.

ACCOMPLISHMENTS: In addition to its existing relationship with CDC, NACP, and the ZTCs, by the end of

FY 2007, I-TECH will have developed partnerships with IntraHealth, AMREF, BMC and MHIC to roll out

PITC training. During this period, I-TECH will have built the capacity of Central and Southern Highland

ZTCs to provide PITC trainings to 200 healthcare providers using the cascade approach through training

Master Trainers and trainers/training of trainers (TOTs) with the new algorithm on HIV testing. I-TECH, in

collaboration with NACP, CDC, AMREF, MHIC and BMC, will have developed standard tools for monitoring

the quality of PITC trainings including quality of services.

ACTIVITIES:

I-TECH, using FY 2008 funds, will:

1. Empower zonal training teams to become master trainers, who will in turn train trainers in PITC at the

hospital level. These hospital level trainers will train healthcare providers in regional and district hospitals

using the new algorithm on HIV testing and approved national curriculum. This activity will enable

healthcare providers to provide quality HIV testing and counseling services in clinical settings. Specific

activities include: a) Developing a training plan in collaboration with PITC partners. b) Conducting

sensitization meetings for Regional Health Management Teams (RHMTs), Council Health Management

Teams (CHMTs), principals of health training institutions, and NGOs in Central and Southern Highland

zones. c) Producing adequate PITC training materials including job aids in collaboration with other PITC

partners. d) Conducting TOTs for ZTC faculty, and facilitators from hospitals and health training institutions

in order to form zonal training teams. e) Integrating PITC content into the ZTC and pre-service curricula. f)

Conducting whole site training in regional and district hospitals for 200 healthcare providers (100 per zone).

Training will be given to hospital staff in outpatient and inpatient departments, reproductive health/PMTCT

clinics, STI clinics, and TB clinics. Training will cover all healthcare providers (e.g. doctors, assistant

medical officers, nurses, pharmacists and laboratory technicians) in order to provide appropriate care and

referral services to HIV affected clients.

2. Provide refresher trainings for trainers and hospital staff who receive PITC trainings. This activity will

ensure that tutors and healthcare providers receive updated information on PITC and provide an opportunity

for them to learn best practices. Specific activities include: a) Conducting refresher workshops for PITC

trainers in order to share best practices, and to update them on new developments. Prior to conducting the

workshops, a needs assessment will be done to determine areas which require emphasis during refresher

trainings. This will be followed by development or adaptation of the materials for the trainings. 2b)

Conducting refresher trainings for PITC health care workers in order to strengthen their knowledge and

skills, and share best practices.

3. Monitor and evaluate PITC trainings. This activity will ensure that the healthcare providers' record and

report PITC data accurately and timely, provide quality care by using correct testing procedures and by

providing proper counseling and referral services. This will be accomplished by working with regional,

district hospital management and partners to monitor the performance of healthcare providers in order to

determine how well they are able to apply the knowledge and skills learned.

LINKAGES: I-TECH will work closely with NACP, CDC, ZTCs, FHI, IntraHealth, MHIC, BMC and AMREF in

the enhancement of PITC training materials. I-TECH will also collaborate with the partners in rolling out the

services. The teams will also ensure a functional referral system within the facility departments, and from

one facility to another. Referral of clients from health facilities to community support groups, where they

exist, will be established or enhanced.

CHECK BOXES: Human Capacity Development/in-service training: this activity addresses in-service needs

of PITC training for healthcare providers. Local Organization Capacity Development: These activities will

build the capacity of ZTCs to provide and coordinate PITC trainings. They will also strengthen the capacity

of ZTCs to monitor and evaluate PITC trainings. Strategic Information: these activities will strengthen

MOHSW and ZTC capacity to build the training database. The M&E activities will help to determine the

effectiveness of PITC trainings and help revise the materials or the design of future courses.

M&E: Emphasis will be placed on monitoring and evaluating the trainings during the actual training and

when healthcare workers return to their duty stations. M&E tools will be used to collect systematic

information, and use it to determine the quality and effectiveness of the training. The outcome of the M&E

will inform the need to improve training materials and/or the training approach. M&E will ensure that quality

PITC services are provided. PITC focal persons will be identified at each ZTC and in each of the

implementing hospitals. All the 200 healthcare providers will be trained in data-collection using the national

tools, reporting, and utilization. Approximately 25% of the budget for this project will be spent on M&E.

SUSTAINABILITY: I-TECH's strategy is to strengthen the capacity of ZTCs so that they can continue to

organize and deliver PITC trainings with minimal support from central level. The capacity of Ministry of

Health and Social Welfare (MOHSW) at regional and district levels, and local organizations will also be built

in terms of ability to review and revise training materials, as well as to conduct monitoring and evaluation of

PITC trainings.

TITLE: Ensure new pre-service institution graduates can provide adequate HIV care and treatment.

NEED and COMPARATIVE ADVANTAGE:

The lack of comprehensive integration of HIV/AIDS prevention, care, and treatment in the pre-service

curricula of most cadres of health care workers is a significant obstacle to rapid scale-up and sustainability

of quality programs. Throughout FY 2006 and FY 2007, I-TECH has been working with the MOHSW to

incorporate HIV/AIDS and TB into the pre-service curricula for Clinical Officers (CO), Assistant Medical

Officers (AMO), and Pharmacy Technicians. I-TECH has worked in close collaboration with UCSF and the

HIV/AIDS Twinning Center, two technical partners involved in pre-service work in Tanzania. I-TECH is also

strategically decentralizing curriculum development capacity to country offices, health ministries, and other

in-country partners to allow for continuous improvement to pre-service curricula over time.

ACCOMPLISHMENTS:

By the end of FY 2007, I-TECH will have completed the following activities related to HIV/AIDS and TB

integration into pre-service for CO, AMO and pharmacy technicians: needs assessment; convened technical

working group to address the full integration of HIV/AIDS related content into the teaching programs;

gathered content from existing curricula; designed interactive and participatory learning activities; and

produced

training materials to support teaching.

ACTIVITIES:

1. Enhance HIV/AIDS and TB components of the pre-service curricula for Clinical Officers, Assistant

Medical Officers, and Pharmacy Technicians to ensure new graduates provide quality of HIV care and

treatment $300,000. 1a) Pilot test and revise new HIV/AIDS and TB pre-service modules developed in

FY07. 1b) Implement faculty development training package to improve teaching skills of pre-service

institution faculty (include Zanzibar College of Health Sciences). 1c) Train the faculty on HIV/AIDS and TB

clinical content.

2. Enhance the HIV and HIV/TB related pre-service curricula of the Medical and Pharmacy Schools in

collaboration with the Curry TB Center, Harvard University and RPM+. $200,000. 2a) The Curry TB Center

is currently enhancing the Medical School curricula to include TB. I-TECH will work with them to expand this

enhancement to also include HIV/AIDS. 2b) I-TECH will build on work done by Harvard related to pharmacy

school pre-service curricula to ensure the incorporation of HIV/AIDS and TB training content.

3. Strengthen capacity of the ZTCs to support national HIV/AIDS and TB/HIV trainings in pre-service

training institutions. $325,000. 3a) Conduct pre-service faculty development courses in teaching

methodology and adult learning.3b) Equip pre-service training institutions with basic training equipment and

materials so they can provide quality HIV/AIDS and TB/HIV trainings. 3c) Equip ZTCs with necessary

staffing and basic training equipment/materials, so they can provide services to pre-service institutions.

4. Monitor and evaluate pre-service training related to HIV/AIDS and TB. This activity will improve the

quality of HIV-related training. This activity will focus on two components: Increased capacity of pre-service

faculty to deliver pre-service HIV/AIDS and TB training, and student increase in knowledge and

preparedness to provide HIV care and treatment. $325,000. 4a) Develop and implement standardized

student knowledge and skills assessments 4b) Conduct a baseline assessment of skills in practice among

recent graduates. 4c) During the implementation of the new HIV content in the curriculum, monitor the

changes made to methods, materials, and content and use lessons learned to improve pre-service curricula

and teaching.

5. Develop a National Training Center to serve as a resource to ZTCs, a training venue, a distance learning

center, and a center for curriculum development in the new CDC/NIMR building. This supports the

institutionalization of training through GOT systems. $200,000. 5a) Hire essential staff for national training

center. 5b) Develop a business plan to ensure the centre becomes sustainable. 5c) Implement the business

plan.

LINKAGES:

I-TECH plans to coordinate with the UCSF Curry TB Centre to ensure integration of TB and with the

François-Xavier Bagnoud Center (FXB) to ensure integration of PMTCT content. I-TECH will also work

closely with the MOHSW, the NACP, the NTLP, RPM+ and with all pre-service institutions. In addition, by

leveraging the work of the I-TECH global pre-service working group, I-TECH's framework for developing

and/or revising pre-service training will assist in standardizing approaches in Tanzania. I-TECH will also

leverage its work with the Zonal Training Centers to strengthen the capacity of pre-service institutions.

CHECK BOXES:

Human Capacity Development/pre-service training: This activity addresses the pre-service training needs of

health care workers entering the workforce. Local Organization Capacity Development: This activity will

strengthen the teaching capacity of faculty at pre-service institutions throughout Tanzania. These activities

aim to improve teaching skills as well as update HIV/AIDS and TB technical knowledge.

M&E: As described above in activity four, I-TECH will focus on the monitoring and evaluation of two

components: Increased capacity of pre-service faculty to deliver pre-service HIV/AIDS training, and student

increase in knowledge and preparedness to provide HIV care and treatment. In addition, each cohort of

students will be assessed using the standardized exam as they complete their year of learning. Student

exam results will be compared over time, and will be triangulated with process evaluation data on

implementation of the curriculum. Roughly 10% of activity funds will be spent on M&E of this activity.

SUSTAINAIBLITY:

I-TECH is strategically decentralizing curriculum development capacity to country offices, health ministries,

and other in-country partners to allow for continuous improvement to pre-service curricula over time. I-

TECH hopes that by including the MOHSW and pre-service institutions in the curriculum revision process,

updates can be done on a regular basis without outside assistance. In addition, by ensuring new graduates

are adequately trained in HIV/AIDS and TB, this activity will ensure that the health workforce is better

prepared to implement large scale HIV care and treatment programs.

TITLE: Strengthening Zonal Training Center's (ZTCs) Capacity to Decentralize HIV/AIDS Training.

NEED and COMPARATIVE ADVANTAGE: The Ministry of Health and Social Welfare (MOHSW) requested

technical assistance to strengthen the Zonal Traingin Center's (ZTC) network's capacity to coordinate,

implement, monitor and evaluate HIV/AIDS training. Spread throughout the country, the ZTCs are well

positioned to provide maximum access to quality training for healthcare professionals and to monitor

training within each zone. While the eight ZTCs differ in their current capacity, all will benefit from faculty,

resource, and organizational development. I-TECH has developed similar training systems in Namibia and

the Caribbean, and will leverage those experiences and lessons learned in working with the ZTCs. I-TECH

has also developed international experience in M&E including a five-day workshop for the evaluation of

training programs.

ACCOMPLISHMENTS: By the end of FY 2007, I-TECH will have built collaborative relationships with the

MOHSW and the ZTCs. I-TECH will have sponsored a study tour to learn from Namibia's national training

network. I-TECH will also have completed a national evaluation of the approach to ART training and used

the results to improve the curriculum and develop a quality assurance plan for ART trainings. I-TECH will

have developed new training methods, tools, and materials and implemented a training of trainer (TOT)

series.

ACTIVITIES:

1. Work with the MOHSW to strengthen capacity of the ZTCs to support national HIV/AIDS trainings. This

supports the institutionalization of in-service training through GOT systems. 1a) Continue in-service faculty

development courses in teaching methodology and adult learning. 1b) Develop and roll-out HIV/AIDS

training materials including the production of stand-alone media to meet identified program needs (e.g. a

stigma and discrimination documentary targeting the general population in Zanzibar; case studies for in-

service training). The documentary will be accompanied by supporting curriculum and training materials. 1c)

Equip selected under-resourced ZTCs with necessary staffing and basic training equipment/materials, so

they can provide services as needed. 1d) Work with District and Regional Medical Teams to ensure that

training supports task shifting and decentralization of HIV services. 1e) Work with referral and district

hospitals to maximize the use of I-TECH Tanzania's documentary on stigma and discrimination, including

providing technical assistance to create support groups and workplace programs for HIV+ health care

workers.

2. Strengthen ZTC capacity to monitor and evaluate HIV/AIDS training programs. A stronger culture for data

demand and use and a strengthened monitoring and evaluation system for training will enable MOH and

health care facilities to more readily identify training success, gaps, and redundancy. 2a) Work with

MOHSW, Capacity Project and other partners to adopt a training information management system. Train

partners in data demand, data use, and data quality assurance. 2b) Work with the ZTCs to conduct pilot

evaluations of new or revised curricula including PITC, ART, lab, blood safety, IMAI and others. 2c) Work

with MOHSW, ZTCs and USG partners to develop and implement a quality improvement plan to enhance

HIV/AIDS training. Plan will include monitoring of training delivery and transfer of learning, and involve on-

site visits by district and regional partners (using PDAs to collect and report data).

3. Undertake activities to examine feasibility of distance learning in Tanzania and if feasible, design a

program which builds upon and complements existing programs.

LINKAGES: To accomplish all of the activities listed above, I-TECH will work closely with the MOHSW and

the ZTCs. For activity one, I-TECH will collaborate with USG training partners that are working in each zone

as well as with IntraHealth, the UCSF ASPIRE project, and the Capacity Project.. For activity two I-TECH

will work with the Capacity Project and with USG training partners.

CHECK BOXES: Human Capacity Development/In-service training: These activities address the in-service

training needs of HIV and TB care and treatment providers.

Local Organization Capacity Development: These activities strengthen the ZTCs capacity to support

HIV/AIDS training and training on operational research.

Strategic Information: These activities will enhance the local infrastructure to collect and analyze accurate

and timely data on trainings. They will also facilitate the use of data in improving the design, quality and cost

-effectiveness of training.

M&E: Activity managers use a results based framework and M&E plan for each activity that includes

benchmarks and indicators. Progress towards objectives is reviewed quarterly via a progress database.

Tools and relevant methods are used to assess training participants' knowledge and practice, facilitator

skills, curricula products, and training program design. Data quality assurance and support will be provided

where relevant. Timely stakeholder review meetings will be held to ensure that data collected is useful to

program management and oversight. Approximately six percent of the I-TECH budget supports M&E.

SUSTAINAIBLITY: I-TECH's sustainability plan is to strengthen the capacity of the ZTCs, the institutions

designated by the MOHSW, to coordinate, manage, monitor and evaluate HIV/AIDS trainings throughout

Tanzania. The existing capacity of ZTCs is variable and so working with MOHSW and NACP, I-TECH will

simultaneously work to develop and implement training quality assurance plans as it works to strengthen

ZTC capacity to take the lead in this role for their zones. As individual ZTC capacity increases, they will

assume greater leadership and responsibility, and TA will move to strengthen other ZTCs.