TITLE: Scaling Quality Home-based Palliative Care Services in Six Regions

NEED and COMPARATIVE ADVANTAGE: By September 2007, Tunajali (Kiswahili for "we care") will have

reached 35,000 PLWHA (4.5%) of the estimated 782,783 in need of palliative care with home-based care

(HBC) services in their six assigned regions. There remains a huge unmet need requiring targeted

expansion of services. Deloitte Consulting and their technical partners, Family Health International (FHI),

are best positioned to respond quickly to this enormous challenge because of their established partnerships

with government structures in the regions they serve with HBC services. Deloitte/FHI is also the treatment

partners for most of those regions. Tunajali has staff in all the regions to provide timely technical assistance

and supportive supervision. Tunajali already supports 28 local subgrantees and 32 district councils to plan,

implement, and monitor quality home-based palliative care interventions. Tunajali's collective strengths

include a thorough understanding of the local health care environment, and a sound and practical technical

approach.

ACCOMPLISHMENTS: Tunajali has established a network of over 2,200 trained community volunteers who

are providing quality home-based palliative care services to about 30,000 people living with HIV/AIDS

(PLWHA) as of June, 2007. Effective referral networks have been developed, with nearly 40% of these

patients linked to care and treatment services, who are also receiving facility-based palliative care. The

basic package of services in being expanded to include Insecticide-treated nets (ITNs) for malaria

protection, and the use of cotrimoxazole is being expanded. In addition, Tunajali is implementing a pilot to

develop a community-based prevention with positives package with Columbia University. Tools developed

for quality improvement and supportive supervision are being now in use.

ACTIVITIES:

The primary purpose of the Tunajali Program is to increase the number of HIV+ adults and children on

palliative care in Dodoma, Iringa, Morogoro, Coast, and Mwanza. Coverage will be increased in all districts,

including expansion into a new region, Singida (three new districts). Service outlets will be increased from

the current 398 wards to 731 wards. About 19,000 new PLWHA will be identified and supported to reach

the cumulative total of 54,000 patients on palliative care. Efforts will be made to include more children under

care through linkages with Care and Treatment Clinics, and also improving casefinding for exposed children

in the homes of PLWHA. An additional 1,267 volunteers will be identified, trained, and motivated

(bicycles/recognition) to provide community palliative care and support. Grants will be provided to 28

existing subgrantees and four new subgrantees will be identified in the new districts. Stigma reduction

interventions will be conducted in all communities to enhance voluntary counseling and testing.

During FY 2008, focus will be placed on improving the quality of palliative care provided to PLWHA.

Tunajali's core package of care aims to address health care, nutritional, spiritual and psychological, socio-

economic, and legal rights needs from the time one is confirmed as HIV+ through all stages of disease

progression to end of life. All new volunteers will undergo comprehensive training courses in HBC, using the

Ministry of Health and Social Welfare (MOHSW) curriculum, and will understand the referral process for

orphans/vulnerable children. Ongoing volunteers will undergo a one-week refresher training/update.

Subgrantee and district HBC staff will be trained in supportive supervision skills and updates of palliative

care, including the expansion of the preventive care package (provision of insecticide treated nets-ITNs--for

malaria control, water-guard for water safety, and cotrimoxazole prophylaxis). In addition, a plan for

introducing prevention with positives measures will be introduced: adherence counseling, encouragement

for disclosure, availability of family planning counseling/referrals and condoms, etc. Regular supportive

supervision will be conducted by Tunajali central and regional staff, subgrantee supervisors and the

MOHSW District HBC Coordinators. Tools for assessing nutritional status will be adopted and used by

volunteers to assess and timely refer malnourished patients. HBC kits will be procured and distributed for

pain and other symptoms management. Best practices for wider replication and for informing future policy

and technical guidance will be identified, documented, and disseminated. Tunajali has also received

permission to pilot the use of lay counselors and testers in the household to improve casefinding.

Tunajali will build the capacity of local civil society organizations and district public units to effectively

network and coordinate the provision of comprehensive care for PLWHA. The program will regularly

monitor and review referral systems at community/districts levels. It will also conduct regular mapping and

updates of organizations providing essential services and wraparound programs to enhance comprehensive

care in areas of prevention, nursing and medical care, spiritual and psychological support, food and

nutrition, income generation, legal and human rights. Tunajali will build the capacity of PLWHA support

groups to play an active role in interventions at the household, community, and health care facility levels. A

critical role Tunajali will play is to help support district coordination teams to meet, plan, and monitor the

provision of comprehensive services across a continuum of care at community/district levels.

A critical aspect of the Tunajali program is to increase the technical and organizational capacity of civil

society organizations (CSOs) to deliver comprehensive care and support to PLWHA. Deloitte will focus on

fiscal accountability, ensuring that financial controls and reporting are in place. In addition, Deloitte and FHI

will assist with program accountability so that the services to be provided are, indeed, provided with high

quality and consistency.

LINKAGES: To address the variety of needs related to palliative care and HBC services, TUNAJALI will

assist (CSOs) and districts to identify institutions that can support priority PLWHA needs such as food and

income generation. Tunajali shall advocate for creation of local food reserves for the sick through

contributions by villagers as a strategy to enhance the traditional "caring" spirit. Tunajali will link with Peace

Corps of Tanzania to scale up permaculture gardening initiatives, training core CSO staff and ward

agricultural extension workers as trainers and they will train HBC volunteers. The volunteers will develop

demonstration vegetable gardens to be replicated by members of households served. Tunajali shall link

with MSH to increase accessibility of HBC kits through Accredited Drugs Dispensing Outlets in Morogoro

region. In addition, Tunajali shall link with STRADCOM for to build demand for HBC services. In the

regionalization process, Deloitte/FHI's palliative care and related OVC initiatives are linked with another

Deloitte/FHI mechanism for anti-retroviral treatment and prevention of mother-to-child transmission. At the

national level, it is also linked with all other palliative care providers who fall under the coordination of the

National AIDS Control Programme. Tunajali will make a bulk purchase of HBC kits to be distributed through

the Medical Stores Department to all implementing partners requesting them.

Activity Narrative: CHECK BOXES: Volunteers will be trained to provide quality palliative care services, with attention paid to

retention issues (through non-cash incentives). They will train at least two members per household to

provide palliative care. CSOs will be strengthened to enable them scale up sustainable quality palliative

care. PLWHA are the main focus of this program, though it will work in a holistic way with the household,

both finding potentially exposed family members. It will link adolescent boys to male circumcision

interventions in order to reduce HIV transmission.

M&E: Tunajali will participate in the development and will use the national HBC systems for recording,

storage, retrieval, and reporting field service data to ensure standardization at all levels. Data will be

collected by trained volunteers, who will submit monthly reports to their CSO where it will be reviewed and

aggregated before it is sent to our regional offices through the district channels. At each level the data will

be verified using data quality checklists to ensure reliability. Tunajali shall routinely improve the capacity of

CSOs to manage data. To disentangle the overlap of HBC and facility-based care patients, Tunajali will

keep records of those HBC who are served at the Care and Treatment Clinic. Reports will l be shared

quarterly with MOHSW authorities to inform future plans.

SUSTAINAIBLITY: Tunajali will play a facilitative role to ensure the incorporation of CSO work plans,

budgets and reports in the district response plans as a sustainability measure. At household level family

members will be mentored to adopt caring roles. With the support of district and community leaders

strategies will be developed to leverage local food production to create community reserves for the sick.

Community members will be encouraged to contribute to a "community food reserve" earmarked for the

chronically sick. Tunajali supported CSOs will be offered training in project proposal development so as to

open other grant opportunities.

TITLE: Scaling Quality Care and Support of Orphans and Vulnerable Children in 6 Regions and Zanzibar

NEED and COMPARATIVE ADVANTAGE: In Tanzania, 6% of all children are estimated to be orphaned by

HIV/AIDS. Community responses are already overstretched and resources have been exhausted. As more

people in productive ages die of AIDS, the burden of caring for orphans and vulnerable children (OVC) is

growing dramatically. It has particularly shifted to the elderly, especially the grandparents. The Tunajali

(Kiswahili for "we care") team is best positioned to respond to the OVC needs and their elderly care givers

through its established partnerships with government structures and systems in the regions. Staff are

located in all regions to provide timely technical assistance and supportive supervision. In addition, 28 sub

grantees and 32 district authorities are currently supported to plan, implement, and monitor quality OVC

care and support interventions. Employees of Tunajali possess numerous strengths including a thorough

understanding of local OVC care environment and a sound and practical technical approach.

ACCOMPLISHMENTS: As of June 2007, Tunajali, through a network of over 2,200 community volunteers,

supported over 50,000 OVC in various areas such as education, health, psychology, and Income

Generation Activities (IGAs). By September 2007, 317 Most Vulnerable Children Committees (MVCCs)

were established in five districts to ensure community participation and ownership in OVC identification,

care, and support.

ACTIVITIES: Key activities will:1) Assist Civil Society Organizations in 35 districts to identify and enroll

OVC through the national identification process. Program activities will be expanded to increase coverage

in all districts, including three new districts in Singida region. Service outlets will increase from the current

1,164 villages in 398 wards to 2,560 villages in 574 wards. In collaboration with national facilitators from the

Ministry of Health and Social Welfare (MOHSW), 1,267 new volunteers will be trained and 2,209 retrained in

OVC care and support. A total of 800 MVCCs will be established in 15 districts, 250 of which will be

strengthened through training in order to provide consistent information pertaining to specific roles and

responsibilities.

2) Provide services to 62,000 OVC in 35 districts. All OVC under both primary and secondary support will

receive psychosocial support through activities such as development of memory books and education of

caregivers to learn positive parenting skills. Upon completion of a needs assessment which will prioritize

interventions, issues will be addressed regarding support for education, nutrition, basic health management,

and access/referral to health services, shelter, and economic strengthening of house holds by linking to IGA

such as the Peace Corps permaculture program. Through 32 sub grantees, 52,700 OVC will receive

primary support while 9,300 will receive supplementary support. TUNAJALI will build referral networks in 35

districts for referring OVC to services not already provided. The program will provide incentives (e.g., the

provision of bicycles) to 3,476 volunteers to ensure retention and quality service. In collaboration with the

Regional Psychosocial Initiative (REPSSI), Tunajali will ensure OVC access to psychosocial care in 35

districts by training of trainers on psychosocial skills, and parents/guardians on positive parenting skills. In

collaboration with identified micro-finance entities, Tunajali will facilitate 3,500 older OVC access to services

regarding IGAs.

3) Provide support to 5,167 elderly OVC caregivers. More than 50% of OVC caregivers are elderly, at an

average of three OVC per household. During FY 2008, Tunajali will support 10,333 elderly caregivers.

About half of these individuals will benefit from support groups or some other possible method of

strengthening their efforts and support networks. In collaboration with STRADCOM, public awareness will

be raised on the vulnerability of elderly care givers and the need to focus on the importance of these

individuals as a conduit of services to orphans. Tunajali will facilitate the formation of elderly caregiver

support groups. These will provide opportunities for caregivers to experience understanding and empathy,

gain some respite, and share their challenges in caring for OVC. The program will also provide primary

caregivers with knowledge and skills to effectively care for sick OVC as well as training in identification of

HIV related illnesses for proper care and referral to facilities for HIV testing of the child.

4) Build the capacity of 32 local community service organizations (CSO) and district public units to

effectively network and coordinate the provision of comprehensive quality care and support to OVC.

Tunajali will regularly monitor and review referral systems at community and district levels. It will conduct

regular mapping and updates of organizations providing essential services and wraparound programs to

enhance comprehensive care in areas of medical care, spiritual support, psychosocial support, food and

nutrition, IGA, and legal and human rights. Tunajali will support district coordination teams to meet, plan,

and monitor the provision of comprehensive services across a continuum of care at community and district

levels. Overall, Tunajali will increase the technical and organizational capacity of CSOs to deliver

comprehensive care and support to OVC. In addition, it will train district and project staff in 35 districts on

National OVC Data Management System (DMS) and ensure adoption of the same.

5) Build wraparound programs as often as possible. OVC needs include education, shelter, healthcare,

spiritual, psychosocial, legal rights, and economic resources. To address these needs, Tunajali will assist

sub grantees and districts to identify institutions that can support OVC priority needs that are not directly

covered by the program such as food, nutrition, and IGA. Local food reserves will be strengthened through

contributions by community members to support child and elderly headed OVC households. Tunajali will

link with Peace Corps of Tanzania to scale up permaculture initiatives. A team of CSO staff and ward

agricultural extension workers will be trained by the Peace Corps program and these will in turn train

volunteers to ensure sustainability. Volunteers will be required to have demonstrated proficiency in building

vegetable gardens which can be replicated in OVC households. These can also be emulated by older OVC

as IGA. Tunajali will link CSOs with STRADCOM for sensitization of communities on supporting elderly

care givers, and REPSSI in training community TOTs on psychosocial support so that they may train

volunteers who will provide the same to OVC and their caregivers.

6) Build capacity of NGOs. Through Deloitte, NGOs will be assessed and receive technical assistance to

ensure that financial controls and systems are in place to ensure fiscal accountability.

LINKAGES: This activity will contribute to the implementation of the OVC National Plan of Action. It is

linked to PMI and/or direct USG procurement of bulk insecticide-treated nets for OVC, with a priority for

those under five years of age. Tunajali is closely aligned with the technical assistance provided by Family

Health International to the DSW with USG funding. In addition, Tunajali will link with other OVC partners

Activity Narrative: through the monthly meeting of the Implementing Partners Group. The program will attempt to maximize

linkages for wraparound programs, as indicated above.

CHECK BOXES: Volunteers will be trained and motivated so that they can provide quality OVC care and

support services. They will also train 5,167 elderly caregivers on OVC care and support. Sub grantees will

be strengthened to enable scale up in sustainable quality for OVC care and support.

M&E: Tunajali will monitor OVC care services using the national DMS for tracking OVC and OVC services,

as well as the storage and reporting system, and will monitor the use of data for decision making.

Volunteers will work with MVCC to register OVC at the community level. CSOs will use service providers'

register and referral forms to track services provided to OVC and they will enter the data in their database

and export it to the district. CSOs will analyze and report data to the regional office according to services

provided, age, and sex. The regional office will report to the head office on a quarterly basis. Tunajali will

build the capacity of sub grantees on data collection, use, and reporting. Duplication in counting OVC will be

avoided to the extent possible. All reports will be shared with relevant authorities for decision making and

planning. 6% of the budget will be used for M&E.

SUSTAINAIBLITY: Tunajali will play a facilitative role to ensure the incorporation of CSO work plans,

budgets, and reports in the overall district response plans as a sustainability measure. At the household

level, family members will be mentored to adopt caring roles. With the support of district leaders, MVCC,

and community leaders, strategies will be developed to leverage local food production to create community

reserves for the child and elderly headed households. TUNAJALI supported CSO will be offered training in

project proposal development in order to allow for other grant opportunities.

TITLE: Scaling-Up Home Based Counselling And Testing Services In Seventeen Districts

NEED and COMPARATIVE ADVANTAGE: Only 15% of people in Tanzania know their HIV status. In order

to reach the estimated 400,000 PLHIV with ART services, enormous efforts must be done to scale-up

testing and counseling services. The Tunajali ("we care" in Kiswahili) program has initiated home-based

counseling and testing services in index households where PLHIV are receiving palliative care in selected

wards of two districts. Index household members have a high probability of being HIV+ and we think they

should be a target group. The Tunajali team is best positioned to undertake this activity because it has the

lessons learned that will support a quick scale-up. Tunajali has qualified staff to plan, implement, and

monitor field activities and has built strong partnerships with local institutions and district councils in the

Tunajali regions.

ACCOMPLISHMENTS: Five HBC focal persons have been trained and qualified as counselors and 25

community volunteers from two districts of Kilolo (Iringa) and Mvomero (Morogoro) have also undergone

training in home-based counseling and testing skills using a pilot curriculum. Communities and districts

have been sensitized in readiness to expand services to three additional districts in which 10 HBC

counselors and 221 volunteers will be trained. We estimate to counsel and test about 10,000 household

members within the FY 2007 plans. The GOT has approved this activity and has issued a waiver to enable

the program to use lay counselors to expand service availability.

ACTIVITIES:

1.Scale-up home counseling and testing services in seventeen districts of Dodoma Urban, Mkuranga,

Bagamoyo, Morogoro Rural, Morogoro Urban, Mvomero, Iringa Rural, Iringa Urban, Kilolo, Njombe,

Mufindi, Makete, Geita, Magu, Ilemela, Nyamagana, and Misungwi. The focus will be in high prevalence

and high transmission areas for better yields. 1a) Train 50 HBC focal persons and health facility staff on

VCT. 1b) Train approximately 2,080 community volunteers on home-based counseling and testing (HBCT).

1c) Train approximately 30 district level health staff to monitor and support HBCT services.

2) Conduct home-based counseling and testing to index patient households. 2a) Liaise with the district

medical office (DMO) for accessibility and availability of test kits, with the aim of receiving reagents and

supplies from the National AIDS Control Program (NACP) to supplement those bought directly by Tunajali.

2b) Provide the HBC focal person with transport and means of communication. 2c) Provide community

volunteers with means of communication with the HBC focal persons. Volunteers will be responsible for

initial counseling of individuals in the households and informing the HBC focal persons who will do

additional counseling before actual testing because existing national guidelines do not allow the non-health

workers to test. 2d) Establish registers for clients tested. 2e) Procure equipment and supplies necessary for

home-based counseling and testing. 2f) Refer all diagnosed HIV+ individuals to CTC services and other

support services; where indicated provide transport.

3. Conduct community sensitization campaigns to increase demand and uptake of testing. This activity will

allow the scale-up of our counseling and testing services to the wider community beyond the index

households. 3a) Sensitize local and influential leaders on HIV transmission, the harmful impact of stigma,

the importance of testing, and the availability of services. 3b) Hold sensitization meetings with community

members. 3c) Prepare and distribute information, education, communication (IEC) materials including

posters, leaflets, billboards, local drama groups performance, and TV and radio broadcasting.

4. Link with NETWO and MUCHS for promotion of stigma reduction and disclosure, as this will promote

HIV testing to community members.

5. Conduct supportive supervision in collaboration with the council health management team (CHMT) to

ensure quality HBCT is provided to clients. 5a) Develop a checklist for supportive supervision for HBC focal

persons. 5b) Link with the district HIV counseling and testing supervisor to conduct supervisory visits in

partnership.

LINKAGES: Tunajali works closely with the NACP, particularly the care and social support unit which is

responsible for counseling and testing services, the DMO's office and health facilities. This will ensure

availability of test kits as well as joint supportive supervision and good coordination of the services. Local

community service organizations (CSOs) which Tunajali works with have strong links to care and treatment

clinics (CTCs) and this will facilitate effective referrals of people diagnosed as HIV+ to CTC services for

further assessments and management. The program will collaborate with Pathfinder and if appropriate will

adopt this USG partner's QA system for home-based care.

CHECK BOXES: Human capacity development and training; our community volunteers will undergo training

on home counseling and testing. HBC focal persons and government health staff will undergo training on

voluntary counseling and testing. If HIV affected children are identified through the community-based

activity the volunteers will discuss testing with the parents and will link these individuals with appropriate

service sites.

M&E: Tunajali will adapt counseling and testing national data collection and monitoring tools. Community

volunteers will be trained on how to use tools to collect and report the data. Referral forms will be used to

refer patients diagnosed with the virus to CTC and other support services in the community. During

supportive supervision visits HBC focal persons will use checklist to address the quality of the collected

data. The data will be disaggregated by sex, age group and serostatus. Data will be aggregated and

reported monthly by CSOs to the regional office and quarterly to the head office by the regional office.

Regional M&E will routinely support CSOs to address data quality issues. The quarterly reports will be

shared with GoT authorities for future planning. M&E will use 6% of the total budget.

SUSTAINABILITY: Training of community volunteers, HBC focal persons at the community level, and

health staff will ensure continuity of the services. Collaboration of the program with the local authority and

community leaders is also a step towards sustainability of the service as the program/service will be part

and parcel of the districts plans.