TITLE: A Comprehensive Community Approach to Integrated PMTCT/FANC/PNC Services

NEED AND COMPARATIVE ADVANTAGE: This proposal addresses the need to support both HIV and

broader Reproductive health needs of HIV positive mothers and their children, and provides an example of

a wraparound program. The program supports PMTCT services through ensuring a more comprehensive

and integrated Maternal Neonatal and Child Health (MNCH) services for HIV+ pregnant women and their

infants. It covers unique needs from the antenatal care (ANC) period, through labor and delivery and post-

partum period through a community approach.

JHPIEGO will mobilize and work with the community through community health workers (CHW) and

Community Own Resource Persons (CORPS) to mobilize moms and their family support units to create

demand and access to comprehensive reproductive health services that strengthens both PMTCT and

Reproductive health services at the community level.

ACCOMPLISHMENTS: Based on JHPIEGO's previous work in Tanzania in Focused antenatal care, Safe

Motherhood initiative in emergency obstetric care, and more recently Malaria through community health

workers , JHPIEGO intends to use the experience gained to strengthen community mobilization and

demand creation so that more women access PMTCT and RH services.

ACTIVITIES: In the proposed program, the strategy is to ensure that HIV+ pregnant women are linked to a

continuum of comprehensive MNCH care services through an integrated community/facility approach. This

proposed program will build on the CDC-funded community mobilization project and tools as well as the

USAID-funded FANC/PMTCT service provider orientation tools. JHPIEGO will train CHWs to transmit key

messages among pregnant women regarding PMTCT, FANC, preventing malaria, post natal care (PNC)

services, family planning (FP), and cervical cancer prevention. Using their FANC orientation package, the

program will complement and strengthen the skills of low-level providers working in health centers and

dispensaries serving as care and treatment centers refills/outreach sites. Providers will offer quality RH and

HIV services to women in their communities and ensure follow-up as indicated. The community component

will create demand for quality integrated health services, and will therefore complement HIV and RH

services at the health facility level to strengthen service provision.

Up to four districts that have the need/capacity for strengthening community outreach will be selected to

pilot this initiative, with a scale-up planned for subsequent years based on lessons learned.

ACTIVITIES: 1) Carry out advocacy and sensitization meetings: at national, regional, district and ward

levels with a focus on CHWs leadership to create awareness and to facilitate buy-in from stakeholders.

2) Initiate active FANC/PMTCT program for mothers and infants in the target districts through CHW: with

messages to improve ANC care, HIV screening, ARV prophylaxis, follow-up of infants and mothers, uptake

of intermittent presumptive therapy/prevention (IPTp), use of long-lasting ITNs (based on national PMTCT

and malarial guidelines), exclusive breastfeeding (AFASS as appropriate), transition to complementary

feeding, cotrimoxazole prophylaxis for infants, cervical cancer prevention and FP. 2a) Conduct assessment

of existing RH/PMTCT/FANC/PNC services. 2b) Develop strategic approach to support PMTCT/FANC and

PNC follow-up using assessment findings.

3) Improve PNC/safe delivery/cervical cancer prevention/FP services, including postpartum FP at up to four

district hospitals (that are also serving as care and treatment centers) and up to eight selected health

centers (two per district), where FANC/PMTCT services have already been established to improve

availability of quality, comprehensive RH/MNCH services for mothers and infants. 3a) Ensure training as

appropriate in PNC, safe delivery, cervical cancer prevention and/or FP for providers, based on existing

training materials and national standards. 3b)Conduct supervision quarterly.

4) Community mobilization for RH/FANC/PMTCT/PNC and follow-up through the first year: to support

norms for routine RH/FANC/PMTCT/PNC and follow-up of mothers and infants. CHWs will sensitize fellow

community members on the importance of ANC, PMTCT and other RH services for HIV+ pregnant women;

refer pregnant women in their communities to ANC and PMTCT services; refer women who recently

delivered for postpartum and newborn care; refer women for cervical cancer prevention and FP services;

and refer infants for treatment with cotrimoxazole. 4a) Identify needs in RH/FANC/PMTCT/PNC and

develop an action plan, including messages and information education and communication (IEC) materials

supportive of RH/FANC/PMTCT/PNC and follow-up care through the 1st year postpartum. 4b) Carry out

local sensitization meetings for community leaders in the importance of RH/FANC/PMTCT/PNC for women

and infants. 4c) Adapt previously developed training materials for CHW trainers, CHW supervisors, village

health committees (VHCs) and volunteers in RH/FANC/PMTCT/PNC. We will work with stakeholders to

revise the current FANC community mobilization training materials to include additional information on

PMTCT, HIV prevention and care, MIP, safe delivery, PNC, cervical cancer prevention, FP and other key

MNH areas that are not currently covered through existing community mobilization efforts and will ensure

that these are appropriate for the local context. 4d) Two trainers from each district will be oriented on

training and supervision manuals and reference guides for community mobilization for integrated

RH/PMTCT/FANC/PNC services

4e) In each ward, four service providers will be selected and trained to provide supportive supervision to

CHWs. 4f) In each district, two CHWs will be trained from approximately four to six villages on how to

transmit key messages, conduct individual and group counseling and develop action plans. 4g) Support

CHWs, VHCs, and other advocates to carry out household visits to women in their communities and refer

for RH/FANC/PMTCT/PNC.

LINKAGES: We activities will be linked with existing RH, PMTCT, FANC and other MNCH services

implemented by the MOHSW and local partners at both the facility and community level. We will work with

the Ministry of Community Development, Gender and Children, and international NGOs training service

providers and CHWs on all topics to integrate RH/PMTCT/FANC/PNC messages. At the facility, we will

work in coordination with ACQUIRE, EGPAF and URC for PMTCT, with ACQUIRE and other partners for

FP, with national MOHSW initiatives for improving maternity care and current FANC activities. We will

collaborate closely with those organizations currently working to support CTCs. For example, our partner,

international medical association (IMA) World Health, has relationships with many such CTCs. In addition,

We will bring in new partners who are working in areas such as cervical cancer (from Ocean Road Cancer

Activity Narrative: Institute) to work with regional JHPIEGO experts on cervical cancer prevention training and service delivery.

CHECK BOXES: The program emphasizes a wraparound approach because activities will include

promotion of FANC (a malaria and child survival-focused activity), safe delivery, cervical cancer prevention

and PNC services including FP with special consideration for HIV+ women. We will work closely with the

RCHS to develop and implement this program.

Pregnant women, adult women, adolescent girls, and men were selected as target populations. Because

the median age at first birth in Tanzania is 19-years old, many female adolescents are pregnant and

subsequently may use PMTCT services. It is anticipated that the VCT and ARV FP counseling activities will

reach women who may be interested in becoming pregnant. Group education within the community will

focus on male involvement in MNCH.

M&E: Monitoring of community activities will be done mainly by immediate supervisors through monthly

meetings with CHWs and joint home visits to follow up clients. Immediate supervisors will compile the

reports and forward them to the district level where they will be sent to the RCHS and ACCESS-FP. RCHS

and ACCESS-FP, accompanied by district staff, will complete monitoring visits to selected sites once a

year. We will also evaluate increased use of RH/PMTCT/FANC/PNC services in the target facilities by

examining service statistics on PMTCT counseling and testing, early booking at ANC, intermittent

presumptive therapy (IPT) 1 & 2, attendance at PNC, uptake of post-partum FP, and cervical cancer

screening and treatment statistics. JHPIEGO uses an electronic system to monitor number of people trained

and ensure no duplication of training. M&E will account for 8% of the total budget.

SUSTAINABILITY: We will work closely with district health management teams and national level MOH

partners, including RCHS and NACP, to ensure sustainability. During advocacy meetings, We will support

district health teams to plan for continuation of facility support as well as CHW training and support by

including the program in Council Health Plans. Integrating with other ongoing service provider and CHW

training programs will also increase longevity of support for the program. In FY 2009, JHPIEGO/ACCESS-

FP will also introduce a strategy of recognition of high-achieving facilities and CHWs as a further incentive

for continued work.