THIS IS AN ONGOING ACTIVITY FROM FY 2008. ACTIVITIES LISTED HAVE BEEN INITIATED AND

WILL PROCEED DURING FY 2009 AS IN THE PREVIOUS YEAR. ACCOMPLISHMENTS WILL BE

REPORTED IN THE FY 2008 APR. PLEASE NOTE THAT THE ACTIVITY NARRATIVE REMAINS

UNCHANGED FROM FY 2008.

The funding for this activity has changed from 800,000 to 600,000.

*END ACTIVITY MODIFICATION*

TITLE: URC QUALITY IMPROVEMENT in PMTCT SERVICE DELIVERY

NEED AND COMPARATIVE ADVANTAGE: The Government of Tanzania (GoT) and the United States

Government (USG) have collectively identified a need to improve the very low coverage and quality of

PMTCT services throughout Tanzania. University Research Company/Quality Assurance Project

(URC/QAP) has proven successful in preventing mother to child transmission (PMTCT), identifying and

testing children potentially infected with HIV, and referring individuals to care and treatment centers (CTC)

for follow up care including PCP prophylaxis and antiretroviral treatment (ART). During 2007, URC

partnered with the Ministry of Health and Social Welfare (MOHSW), the National AIDS Control Program

(NACP), and other USG partners to strengthen access and quality of comprehensive PMTCT services.

ACCOMPLISHMENTS: During the last two years, URC/QAP pediatric AIDS collaborative trained 362 health

workers in HIV case management; assessed quality improvement (QI) and collaborative methods;

established, trained and mentored QI teams in 17 referral facilities; provided technical guidelines, job aids,

and self assessment tools; assisted with reorganization of patient flow and provision of emergency pediatric

care. In addition, the program improved monitoring of emergency drugs, supplies and equipment. The

program supported initiatives stemming from. NACP and partners to develop nationally endorsed whole

facility training curricula on infant feeding (IF) counseling in the context of HIV/AIDS. Close collaboration

with GoT organizations has facilitated the creation of a necessary infrastructure for future successful

initiatives in FY 2008.

ACTIVITIES: URC/QAP will utilize lessons learned from best practices in other countries (e.g., Uganda and

Rwanda) to implement quality improvement measures using a collaborative approach. Core activities will

include: improving quality of ART services for adults and children; linking PMTCT to pediatric AIDS care;

and improving rates of TB testing among ART clients. To ensure synergy and success, URC will continue

to develop innovative methods linking lower level facilities and communities for improved follow up and

comprehensive management of PLWHA. URC will strengthen essential linkages between PMTCT, infant

diagnosis and follow-up in addition to linking PMTCT with overall HIV/AIDS care and treatment services to

increase numbers of exposed infants who benefit from services, (e.g., nevirapine, staging and

Cotrimoxazole prophylaxis).

URC/QAP will focus on building and strengthening quality improvement (QI) capacity within MOHSW and

USG partners in order to set up and maintain a standard adequate PMTCT quality of service system using a

collaborative approach. This includes developing a continuous QI system for PMTCT that is linked to care

and treatment while building on quality improvement collaborative work, current experience, and best

practices. URC/QAP will expand capacity through collaboration with GoT and USG partners for continuous

QI in PMTCT services; monitor progress; develop PMTCT QI framework; train and support regional and

district QI teams in developing coaching and mentoring skills; and document and share experiences in

learning sessions. URC will train regional and district teams on roll-out procedures and use of tools in

addition to coordinating national training coinciding with PMTCT quarterly meetings to share experiences,

monitor progress, and train future trainers to ensure sustainability. Adoption of QI methods and service

tools nation-wide to improve quality of PMTCT services is necessary to provide sustainable and effective

services. Therefore, URC/QAP will identify and address key systems barriers to quality PMTCT services for

pregnant women and their partners. Furthermore, URC will incorporate do, study, act (PDSA) cycles to test

improvement changes in anti-retroviral therapy (ART), PMTCT and IF.

Results from a networking and continuum of care pilot will be available by COP 2008 implementation, and

URC/QAP will disseminate information gathered from the pilot regarding best practices, quality of services,

interventions, and management procedures to regions designated by GoT to ensure a continuum of care.

Best practices identified by the pilot will be put into practice nationwide. Emphasis will be placed on building

ways to sustain the model of care and linkages between facilities and communities such as using Network

Support Agents.

Activities will include identifying members of the PMTCT service to be included in the HIV QI team at each

facility; developing procedures for networking and referral between PMTCT, Well Child clinics and ART

service areas at facility levels and with Community Based Organization (CBO's) at the community level;

identification of exposed infants born at home for referral within 72 hours for nevirapine and essential

newborn care and establishing indicators for PMTCT quality performance as part of the overall HIV/AIDS

prevention, care and treatment Program. In addition, URC/QAP will work with MOHSW and USG PMTCT

partners to roll-out QI monitoring in sites integrating PMTCT and RH services, including maternal and child

survival activities practices, to manage and prevent HIV transmission.

LINKAGES: URC/QAP will continue to work closely with the PMTCT and ART units within the NAC, the

inspectorate unit of MOHSW, the Tanzania Food and Nutrition Centre, and all USG supported PMTCT

partners. URC will also work with other related units such as Counseling and Testing, OVC, HBC, RCHS,

NMCP, etc to ensure that the quality framework and related tools and methodology are in keeping with the

programs and necessary adoptions are made.

CHECK BOXES: This activity addresses the in-service training needs of PMTCT counselors and other

health workers to counsel on infant feeding and gain competencies in QI to improve quality of PMTCT

services. Local Capacity: RHMTs and CHMTs will be strengthened in their ability to supervise and monitor

Activity Narrative: QI activities.

URC has developed pre/post test assessments for IF training participants, training evaluation, job aids

evaluation and supportive supervision tools. We have developed M&E tools for IF counseling performance:

facility checklist, counselor observation checklist, and client exit interviews.

We use QI improvement tools that capture patient data for use and analysis at site level. Run charts will be

produced monthly and quarterly to highlight programmatic strengths, weaknesses and QI changes.

SUSTAINAIBLITY: By involving the RHMTs and CHMTs, quality improvement activities will be included in

the Council Comprehensive Health Plans (continued education, peer coaching, continued sharing of

outcomes, continuous monitoring quality improvement, data collection and management). We will

collaborate with partners at National, Regional and District levels in line with the organization of national

health care system. Using QI methodologies we will empower the facility QI teams to use PDSA cycles to

identify, test and adopt quality care improvements in PMTCT services. Based on successful best practices,

URC/QAP will utilize peer coaches and mentors across QI Teams to ensure sustainability.

New/Continuing Activity: Continuing Activity

Continuing Activity: 13602

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

13602 3510.08 U.S. Agency for University 6565 1199.08 $800,000

International Research

Development Corporation, LLC

7827 3510.07 U.S. Agency for University 4600 1199.07 $650,000

International Research

Development Corporation, LLC

3510 3510.06 U.S. Agency for University 2900 1199.06 $575,000

International Research

Development Corporation, LLC

Emphasis Areas

Health-related Wraparound Programs

* Child Survival Activities

* Family Planning

* Malaria (PMI)

* Safe Motherhood

* TB

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $30,000

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Estimated amount of funding that is planned for Food and Nutrition: Policy, Tools $20,000

and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.01:

ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS:

The funding for this activity has decreased from $800,000 to $600,000.

*END MODIFICATION*

TITLE: URC Quality Improvement for HIV/AIDS Care and Treatment in Tanzania

NEED AND COMPARATIVE ADVANTAGE:

The GOT and the USG have identified a major gap in the quality and coverage of HIV/AIDS care including

provision of ART. The need to harmonize quality improvement (QI) and quality assurance (QA) approaches

and monitoring of quality of HIV/AIDS services nationwide has been recognized.

Recognizing URC's experience in QI and in providing TA to HIV QI in Tanzania, Rwanda, Uganda and

Russia, the USG/T and the GOT have assigned responsibility to URC to take the lead in harmonizing and

applying a uniform approach to the institutionalization of QI. URC will assist the GOT and its partners in

implementing QI (including the improvement collaborative approach), developing systems for monitoring

quality of services, and linking services to lower levels of the health system and to the communities.

ACCOMPLISHMENTS:

In the last two years, URC/QAP pediatric AIDS collaborative trained 362 health workers in case

management, QI and collaborative methods. Specifically, URC/QAP:

1) Established, trained and mentored QI teams in 17 referral facilities

2) Provided technical guidelines, job aids, and self assessment tools

3) Assisted reorganization of patient flow and provision of emergency pediatric care.

4) Improved monitoring of emergency drugs, supplies and equipment

Key results:

1) In FY 2006, 3,086 hospitalized children were screened for HIV, 2094 were tested, 50%were found

positive, and 90% of these were referred to CTC

2) In FY 2007, 1000 children have been screened

3) Compliance to HIV care guideline improved from 30% at baseline to 90% in 2007

ACTIVITIES:

I. Build QI capacity of the Ministry of Health and Social Welfare (MOHSW) system and partners in HIV/AIDS

care and ART using the collaborative approach.

URC, MOHSW and partners will build an ART quality improvement system that is linked to PMTCT using

the QI collaborative approach. They will build on current experience and be guided by the revised ART

guidelines, and QI framework developed by the inspectorate unit of MOHSW. The quality of the ART

framework and simplified tools to rapidly assess quality and coverage at the national level will be adopted

by partners.

The collaborative will train trainers who will in turn train QI teams in self-assessment, use of data, and

plando-

study-act (PDSA) cycles to test improvement changes in ART, PMTC,T and infant feeding. Based on the

approaches designed in FY 2007-2008 URC will work with MOHSW, the National AIDS Control Program

(NACP) and partners to expand capacities for continuous QI in ART services, monitor progress, and

document and share experiences in learning sessions. The mechanism to guide the QI process for HIV care

and ART will be built within the national ART sub-committee. URC will help train and support regional and

district QI teams in coaching and mentoring to roll out continuous quality improvement (CQI) at the

servicelevel.

II. Facilitate adoption of Quality Improvement (QI) methods and service tools by the MOHSW and partners

to improve quality of ART services.

Various mechanisms will be used to review best practices, identify, and address key systems barriers to

quality ART services for both adult and child PLWHA. URC will help build partner consensus for the

collaborative model through advocacy to spread throughout the health system.

III. Work with MOHSW and USG ART partners to roll-out QI monitoring in sites integrating ART and RH

services including PMTCT and infant feeding practices to prevent HIV transmission.

Through the cascade of training described above institutionalize the training of QI among ART and PMTCT

partners and initiate the roll-out training in QI of ART at the regional, district, and lower level facilities in the

regions supported by The Elizabeth Glaser Pediatric AIDS Foundation (EGPAF), Columbia, Harvard, Family

Health International (FHI) and AIDS relief and other partners. Best practices emerging from the ongoing roll

out of the ART program will be documented and shared.

IV. Spread the experiences from the networking and the continuum of care pilot undertaken in COP 2007

(FY 2007-2008) to regions designated by the MOHSW and the Mission.

By COP 2008 implementation, the pilot will have been completed and results documented giving

organization, quality of services interventions, management procedures, and communication channels for

continuum of care. URC and partners will expand the pilot's best practices and models to other parts of the

country by spreading implementation of the model, and building capacity of CBOs and primary-level

providers to implement best practices developed by the pilot. In addition, URC and partners will train staff in

QI monitoring, documentation, reporting, using simple tools, and building ways to sustain the model of care

and linkages between facilities and communities such as using network support agents and use of simple

tools to monitor in the spread districts.

V. Facilitate development and implementation of a framework for monitoring quality of ART services at the

service site within and outside the collaborative.

With MOHSW and partners develop key quality improvement objectives and processes, facilitate use of well

defined indicators and tools to monitor processes and compliance with standards of care, methods of

Activity Narrative: recording the data, analysis, sharing, and use. URC will facilitate training of trainers (TOTs) who will in turn

train QI teams in self-assessment, use of the data, and use of PDSA cycles to test improvement changes.

Vi. Based on COP 2007 (FY 2007-2008) experiences, URC will strengthen linkages between PMTCT and

overall HIV/AIDS care and treatment services to increase numbers of exposed infants who benefit from

services (e.g. nevirapine, testing, and cotrimoxazole prophylaxis).

Activities will include identifying members of the PMTCT service to be included in the HIV QI team at each

facility; developing procedures for networking and referral between PMTCT, well child clinics and ART

service areas at facility levels and with CB's at the community level; identification of exposed infants born at

home for referral within 72 hours for nevirapine and essential newborn care and establishing indicators for

PMTCT quality performance as part of the overall HIV/AIDS prevention, care and treatment program.

LINKAGES:

1) URC/QAP will hold a consultative meeting with key partners to explain the task assigned to URC by the

mission.

2) URC/QAP shall work closely with the MoHSW, NACP and USG partners to identify and prioritize

objectives, indicators of performance and monitoring frameworks.

3) URC/QAP shall work closely with the MoHSW, NACP and USG partners to build a national level capacity

to implement continuous quality improvement in HIV/AIDS care and ART (including using collaborative

approach).

4) URC/QAP will assist in the dissemination of networking best practices learned in the pilot area

5) URC will work with partners to strengthen inter-facility and intra-facility network.

6) URC process will strengthen peer mentoring and peer-coaching.

M&E

URC will work with the national core team, the MOHSW and all USG partner in setting up, adopting and

rolling out the Quality Improvement (QI) system. The system will have a QI framework, tools with

appropriate indicators and will be linked to the ongoing quality improvement initiative in reproductive health,

ART monitoring and evaluation tools and commodity logistics management (LMIS) tools. It will support

regional and district teams to collect and report quality related ART information on the agreed national

protocol, and provide feedback on tool performance. URC will work with these key institutions to document

the process and strengthen the implementation of ART quality framework by providing regular supervision.

SUSTAINABILITY:

1) By involving the RHMTs & CHMTs, quality improvement activities will be included in the council

comprehensive health plans (continuing education, peer coaching, continuous sharing of results, continuous

monitoring of quality improvement activities, data collection, and management)

2) Collaborating with partners at the national, regional, and district levels will improve networking.

3) Using collaborative methodologies empowers the hospital QI teams to use PDSA cycles to improve care.

4) Promoting the use of peer coaches and mentors among the QI Teams.

The implementation of the program will involve all of the partners with guidance of the MoHSW/Quality

Improvement Unit using the Tanzania QI framework. The core QI team, which involves members from all

the parties, will institutionalize the best practices.

New/Continuing Activity: Continuing Activity

Continuing Activity: 13603

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

13603 3511.08 U.S. Agency for University 6565 1199.08 $800,000

International Research

Development Corporation, LLC

7828 3511.07 U.S. Agency for University 4600 1199.07 $600,000

International Research

Development Corporation, LLC

3511 3511.06 U.S. Agency for University 2900 1199.06 $500,000

International Research

Development Corporation, LLC

Table 3.3.09:

THIS IS A NEW ACTIVITY

TITLE: Improving Quality Care for Orphans and Vulnerable Children (OVC)

NEED and COMPARATIVE ADVANTAGE: A lack of consistency across services being provided to orphans

and vulnerable children (OVC) prompted the Government of Tanzania (GOT), through the Department of

Social Welfare (DSW) and other stakeholders, to invest in drafting and piloting standards for each service

area within the National Costed Plan of Action (NCPA) for Most Vulnerable Children. The application of

validated standards will assist USG implementing partners to measure and improve quality of care with

outcomes in program performance, client satisfaction, and child wellbeing. Both OVC services and data

quality for the national Data Management System (DMS) will improve as more partners meet the service

standards and report results accordingly. Better data will provide an important resource for monitoring the

impact of Quality Improvement (QI) on the services being provided. To ensure effective implementation of

these approaches, a coordination partner is needed to facilitate and harmonize the QI activities within all

OVC partner programs.

University Research Co. (URC) is well-placed to support these QI activities because of their coordination of

regionally-placed experts in QI and OVC programming. URC, through the Health Care Improvement (HCI)

Project, is a leading organization providing technical assistance in several PEPFAR countries on quality

improvement of OVC services. URC experts have provided technical inputs to the Tanzanian OVC partners

throughout 2007 and 2008. URC has been contracted by USAID/Washington to serve as the technical hub

for the USG QI Initiative for OVC Programming. Lessons learned, tools, materials, and processes from

other countries will be provided to inform adaptation of activities to the Tanzanian context. Mentoring to

build sustainable capacity in QI is a major component in the URC approach to support defining, measuring,

and improving quality in programs for OVC.

ACCOMPLISHMENTS: This will be a new activity supported by USG/Tanzania. However, OVC partners

have already been working together with the GOT to draft service standards and support the piloting of

these standards. Through Pact, and in close collaboration with the DSW, the services standards have been

piloted and validated in two regions. OVC partners have formalized collaboration by establishing a national

task force, in which the DSW is represented. The role of the task force is to maintain QI momentum, avoid

duplication, and advise on the technical integrity of the work.

ACTIVITIES: In FY 2009, Tanzania will have results and lessons learned from the piloting of OVC service

standards ready for dissemination countrywide. The primary focus will be placed on helping OVC partners

meet the standards through QI methods and to measure outcomes in program performance, client

satisfaction, and child wellbeing. QI will be focused on: improvements in structural areas (e.g., provider

knowledge and skills, service environment, etc.) and processes; and the actual provision of services

according to national standards. QI technical support will remain integrated within the national response

under the leadership of the DSW within the Ministry of Health and Social Welfare. URC, in partnership with

other OVC partners and DSW, will undertake the following activities and seek the following related results:

1. Assess individual partners and develop a QI Plan to improve their performance in service provision,

including key milestones.

2. Support countrywide dissemination of the validated service standards and guidance on implementation in

alignment with the NCPA. This will include in-person and electronic technical assistance to OVC partners in

USG priority regions to achieve systemic action on improving quality of care.

3. Develop a measurement framework to track improvements leading to outcomes for each standard; the

framework will be used to document and report progress in complying with the standards and achieving

outcomes. The national DMS and existing tools such as the Child Status Index will inform the framework

development and implementation of the tracking system.

4. Provide mentoring and technical supervision to expand and support a cadre of Tanzanian QI facilitators

(working for implementing partners, but providing technical support to the local government) equipped to

guide OVC programs on using QI methods. This includes developing and implementing a mentoring or

"buddy" system that promotes achievement of core competencies that can continue beyond the life of the

URC activity.

5. Reinforce a harmonized approach to improving the quality of care for OVC and their families. URC will

work closely with the Implementing Partners Group (IPG) forum, chaired by the GOT, and the QI task force.

Coordination will be reflected in annual work plans especially between URC and the district strengthening

activity to build local management capacity to implement the NCPA locally. The approach will also be

reflected in the pre- and in-service training of social workers and paraprofessional social workers.

6. Facilitate learning exchanges among frontline service providers to scale up best practices in meeting

service standards and measuring improvements. Exchange forums include site visits, written and electronic

communications, and regional workshops.

7. Bridge Tanzanian experiences with the larger regional and global QI initiatives by documenting and

promoting emerging best practices through the GOT and regional QI website.

8. Support Tanzania as a technical hub that demonstrates how standards-based QI can increase the

efficiency, effectiveness, equity, and reach of care and support services to children affected by HIV/AIDS.

LINKAGES: URC will be tasked to work with all USG OVC partners and in close collaboration with the QI

task force which is a sub-group of the IPG. In this way, URC will be linking and associating their activities

across OVC partners. In addition, URC will link with the AIHA Twinning partnership to ensure that QI

approaches are included in training curricula. Also, URC will link with FANTA on the development of QI

Activity Narrative: indicators for OVC nutritional support. URC is also engaged in global work on quality service indicators for

HIV/AIDS programming, and serves as a bridge between these efforts and work underway in Tanzania. In

addition, because of the integrated approach between OVC services and home-based care (HBC) by many

partners, URC will facilitate the expansion of the OVC QI methods and measuring techniques into HBC.

Both program areas share a vision for improving the wellbeing of children and the family's capacity to care

for them.

M&E: The OVC partners will be assisted with conducting self assessments in relation to meeting the service

standards. These assessments will inform changes needed to comply with the standards. URC and the

cadre of Tanzanian QI facilitators will provide support to local service providers on tracking and reporting

improvements and determining if their efforts are on-track for achieving outcomes in program performance,

client satisfaction, and child wellbeing. A regionally-placed QI M&E consultant will be periodically engaged

to provide technical inputs based on tools and processes used by other countries, including mentoring of

the OVC partners' M&E staffs. URC will have access to this consultant via their regional QI activities

contracted by USAID/Washington. QI monitoring efforts will complement the national DMS tracking and

reporting procedures.

SUSTAINABILITY: The primary function of URC will be to support the work of OVC partners as they seek to

be in compliance with service standards, and to document results in child wellbeing. This will require close

coordination with OVC partners in government and civil society, as well as being aligned with the NCPA.

Success in mentoring and building capacity of the Tanzanian cadre of QI M&E staffs who will transfer skills

at the local level will be an indicator of this collaboration. Emphasis will also be placed on expanding and

promoting the capacity of Tanzanian entities, including increased competency in resource mobilization.

New/Continuing Activity: New Activity

Continuing Activity:

Table 3.3.13: