THIS IS A NEW ACTIVITY

TITLE: Strengthening Capacity of District-Level Government Structures

In FY 2009, PEPFAR/Tanzania will award a Task Order under AIDSTAR II to support the strengthening of

district-level government structures in Tanzania. In Tanzania's FY 2008 COP, two separate entries were

included to support systems strengthening activities: one a TBD under antiretroviral (ARV) services to

strengthen districts in management and accountability, and one in Other Policy/Systems Strengthening to

strengthen key Government of Tanzania organizations. Given the complementary nature of these activities,

funds from multiple sources will be programmed through a single Task Order. With the greater focus on

sustainability in FY 2009, a new component of district strengthening included in the Task Order will focus on

the district-level government's ability to support programs and services for orphans and vulnerable children

(OVC). The details of this component follow:

NEED and COMPARATIVE ADVANTAGE: Tanzania has been actively pursuing decentralization through

devolution of responsibility and accountability for programs that were formerly the responsibility of central

government to local government authorities (LGAs). Although LGAs in Tanzania have started to play a

significant role in the delivery of key health and community services, the degree to which local responsibility

has developed varies by sector. The social welfare services branch of central government has been

particularly slow to release resources and power to LGAs, in spite of the mandate LGAs have to provide

services. The social welfare services have not been formally integrated into local government

administrative functions and by default the responsibility has continued under the central government. This

ambiguity has slowed the ability of LGAs to accept responsibility and accountability for services; particularly

for OVC. Consequently, the strengthening of LGAs is hindered, as most of the local government councils

are still depending on the central government technical and capacity support, and are slow to embrace their

new responsibility. One critical problem is the fact that until the district is clearly charged with responsibility

and accountability for social welfare services, they do not include them in their annual plans or budgets.

Other key challenges that affect the decentralization by devolution of central government activities to LGAs

are the shortage of skilled human resources; lack of basic management and coordination skills, as well as

financial management skills; and the inability to access and use updated socio-economic data and

information for the purpose of informing district development plans and priorities. For the sake of

sustainability, it is essential that LGAs have the ability to plan for and manage funds and programs

effectively. It is also critical that they be skilled at leveraging resources and services in the communities.

Based on the critical role that the local government should play, it is important that these structures be

strengthened so as to be to be more efficient, equitable, and transparent in resource allocations within the

community development plans. This strengthening is essential for all districts, even those where the USG is

not providing services, to lay the groundwork for sustainable OVC programs and services as Tanzania rolls

out the National Costed Plan of Action for Most Vulnerable Children.

ACTIVITIES: In response to these significant challenges and to ensure sustainable OVC support, the

USG/Tanzania program intends to provide strengthening to the Council Multi-sectoral AIDS Committee

(CMACS), particularly the Council HIV/AIDS Coordinator (CHACS) and the District Executive Director

(DED), as well as the council management team. The program will provide critical support to develop an

effective approach to identify and serve vulnerable children with a continuum of services in the community.

The program would focus on essential skills such as: ability to assess need, good planning and budgeting

of resources, supportive supervision, monitoring for action and decision making, linking with health facilities

and community/outreach services, and accountability for results. The DED and the council management

team, in particular, will be trained to appropriately plan for, recruit, and retain social workers and allied staff.

To date, the OVC implementing partners have worked to ignite a cohesive program with the CMACS, the

subsidiary Most Vulnerable Children's Committees, and the CHACS, but the need for further intervention is

apparent. TBD, under AIDSTAR, would work initially with six pilot districts to assess needs, then to

prepare a standard package and tools for strengthening the district council functionaries. TBD would also

visit the "learning districts" set up as model districts by implementing partners to understand what makes

them work well. The pilot would be modified as necessary, and then scaled up in 40 districts in FY 2009.

The expectation is that after the strengthening, the CMACS will be able to set their own priorities, based on

need, and translate those priorities into good decisions in terms of financial and human resources, and

achieve the desired results. They will also be able to coordinate programs funded by different donors in the

districts, reduce gaps in services, and minimize duplication of services in some areas.

In addition to the critical elements described above, the model will include the establishment of a meaningful

referral system; linkages with the community and, especially, faith-based networks; skills to advocate for

resources; OVC information sharing; and coverage of OVC needs through the integration of para

professional social workers for appropriate task shifting. It will include training the councils on the use of

data, including from the OVC data management system for planning, management and resource

mobilization, and decision making. It will help the councils recognize priority elements of OVC support,

including manpower and accessible (e.g., distance-based learning) training needs. TBD will also ensure

that districts are equipped with basic working tools, support such as computers, information boards, etc. to

facilitate their work.

A critical initial step has been achieved to set the stage for the formal transfer of power, authority, and

resources to the LGAs. A memorandum of understanding has been signed between one of the USG

partners handling national OVC system's strengthening (FHI--Family Health International) and the Prime

Minister's Office, Regional Administration and Local Government (PMORALG--which has mandate to

oversee all the local government councils) to initiate their oversight of the LGA strengthening. FHI has been

working with the Department of Social Welfare (DSW) at the Ministry of Health and Social Welfare on the

National Costed Plan of Action for Most Vulnerable Children, and on the plan for rolling out the National

Costed Plan of Action. FHI will continue their strengthening of DSW to develop their normative and

regulatory role and with PMORALG for oversight of the rollout of the National Costed Plan of Action through

effective local government programs. TBD, under AIDSTAR, will be responsible for translating this

transformation of responsibility into results-oriented programs at the district level.

Activity Narrative: LINKAGES: TBD, under AIDSTAR will provide critical technical expertise to strengthen the local councils.

They will link with all the USG OVC implementing partners and their programs' councils and the PMORALG

through FHI to ensure national policy support for the work. In addition; AIDSTAR will work with other

stakeholders and donor partners who will be supporting the district councils to ensure their work

complements other ongoing work or plans.

M&E: A primary challenge in system strengthening is measuring and attributing the benefits of the work to

the intended OVC. The common indicator used is the number of people trained to support OVC.

AIDSTAR, as any other USG OVC implementing partners, will use the national Data Management System

(DMS) for Most Vulnerable Children for reporting and monitoring of results in those districts that have been

strengthened. They will report on the number of district officers trained. For program monitoring, specific

indicators to be monitored will include number of district that have integrated OVC in their budget;

availability of OVC data to the district councils; number of district councils replicating the IPG coordinating

meeting; number of local councils' system development plans that include the improvement of the working

environment for social workers; and availability of data for decision making.

SUSTAINABILITY: AIDSTAR will work in collaboration with the Council Health Management Teams, the

DED and PMORALG to ensure sustainability of LGA strengthening for OVC care. Success of the program

will be attained when all the district councils start planning for paraprofessional social workers' salaries and

capacity development in their staff development plans and OVC DMS activities into their budgets.

New/Continuing Activity: New Activity

Continuing Activity:

Table 3.3.13:

5/27/09 Deleted due to duplicate entry

---------------------------------

Funds to be reprogrammed to support the construction of a warehouse in Mwanza to increase storage

capacity of MSD. Solicitation will be local.

New/Continuing Activity: New Activity

Continuing Activity:

Table 3.3.18:

ACTIVITY HAS BEEN REVISED SIGNIFICANTLY FROM FY2008COP

This narrative combines activities 16994.08 and 16475.08 into one narrative for Government Infrastructure

Strengthening. The funding for activity 16475.08 has changed from ART Treatment (HTXS) to Health

Systems Strengthening (OHSS). As a result the targets have also changed to reflect their contribution to

OHSS targets. Note: In FY 20008 activity 16475.08 did not contribute to HTXS targets.

TITLE: Strengthening Capacity of at District Health Management Teams and Key Central Government of

Tanzania (GOT) Organizations

ADVANTAGE: NEED and COMPARATIVE:

As the USG/Tanzania team moves forward with planning for a potential Partnership Compact, strengthening

the management infrastructure of the Government of Tanzania (GOT) at key operational levels is of

paramount importance. In the coming years, USG/Tanzania will strive toward achieving a long-term

"sustainability model" whereby key functions of planning for and operating prevention, care, and treatment

programs would transfer to the GOT. In this intervening period, the strengthening and mentoring described

below will help lay the groundwork for this important transition.

The Ministry of Health and Social Welfare has been implementing health sector reform for more than ten

years. One of the main challenges of the reform is decentralization, as most actions critical to the scale up

of HIV/AIDS care and treatment occur at the district level. Decentralization of budgets and administrative

control has left local government in control, but without the appropriate capacity. District health

management teams are ill equipped to plan, manage, budget, and implement programs that are

comprehensive and integrated. Both the Japanese International Cooperation Agency (JICA) and

Gesellshaft fur Technische Zusammenabeit (GTZ) have worked in several districts in Tanzania to

strengthen the ability of district governments to manage. Most recently, Pharm Access International (PAI)

has started working with district governments. The PAI plan actually creates service-level agreements with

districts that are based on performance.

At the same time is it imperative that central level GOT organizations are able to carry out their policy and

supervisory functions. The funding for HIV/AIDS in Tanzania has grown tremendously

over the last five years. With this funding has come increased responsibility for GOT organizations charged

with coordination and management of efforts to address the HIV/AIDS epidemic. Many of these GOT

organizations lack the capacity to meet the increased demands placed upon them.

The AIDSTAR Sector II indefinite quantity contract (IQC) has recently been awarded to help countries

address these needs. This IQC will provide state-of-the-art technical expertise to enhance management and

leadership skills of

national GOT partners. To be determined (TBD) will be a competitively chosen organization with a track

record in strengthening local and national government entities to be accountable for managing resources

effectively to meet the needs of the population; particularly providing integrated, sustainable HIV/AIDS

services at scale.

ACTIVITIES:

The program would build on a successful model of working with the District Health Management Teams

(DHMT) called "reaching every district." It would focus on five components: supportive supervision,

monitoring for action, good planning and adequate resources (financial and goods) management, and

linkages between various programs for a continuum of care, including the link between health facilities and

community/outreach services. Since the DHMT is the group charged with addressing health needs at the

district level, the program would have the objective of improving the managerial capacity and fiscal

accountability systems of the entire DHMT. Priority would be given to tools that would enable the DHMT to

analyze and solve the priority health issues in the district; to gather, tabulate, and use data for decision

making and program improvement; and to monitor achievement of results. In addition, it would train the

DHMT in health planning, monitoring, and program evaluation. For example, many districts do not have a

well developed district network model for upward referral or downward support or supervision. Also, vertical

programs at the local level are not well integrated, such as HIV services and programs for sexually

transmitted infections, malaria, or tuberculosis (TB). Districts do not normally plan with all the resources

available to them to achieve one vision of a functioning health system, but rather have separate plans for

one vertical program or another, and one donor program or another. The USG would like to assist districts

to develop comprehensive plans, building synergies and making greatest use of multiple sources of funds.

Since there is little attention paid to performance and accountability, the district strengthening approach to

be used will likely be performance based. Experience in other countries and in an array of programs (e.g.,

immunization, TB) has demonstrated remarkable improvements in key health indicators achieved through

performance-based programs. A formal memorandum of understanding will be developed with the district

government laying out the key performance indicators and targets, quality measures, and all aspects of

monitoring and reporting. This will be a new activity that will identify districts that have not yet had

strengthening in management, planning, budgeting, etc. It will be designed taking into consideration the

experience in districts of Tanzania, as well as experiences in other countries of Africa, Latin America, and

the Caribbean. It will assist the treatment partners to achieve the collaboration needed under regionalization

and to lay the groundwork for a sustainability model under a Partnership Compact. The full range of

financial and material incentives will be assessed with the aim of inspiring changes in behavior among

public and non-state sector institutions, managers, and health workers that ultimately result in improved and

efficient performance. The program will also help to foster the critical role the regional government should

play in overseeing and supervising work at the district level.

At the central level the program will enhance the capacity of key GOT organizations so they can effectively

and efficiently implement and manage programs to address the HIV/AIDS crisis in Tanzania. TBD will work

with local Tanzanian firms to assess the needs of GOT partners and to provide focused technical

assistance to address the areas of greatest need. Depending on the specific requirements of each

Activity Narrative: organization work could potentially include: building competence to develop strategic plans; strengthening

project management skills; increasing ability to design and monitor effective programs; enhancing capability

to mobilize resources; developing organizational and staffing vision, policies, and procedures; enhancing

ability to monitor and evaluate implementation; increasing ability to document, synthesize, and disseminate

lessons learned; strengthen partnerships across service delivery organizations and between the public and

private sectors; and general administrative system strengthening. In particular, TBD would help central

level government authorities embrace their role under decentralization as normative and quality monitoring

bodies, transitioning from their previous role as implementers.

LINKAGES:

The program would build upon the experiences of JICA, GTZ, and PAI, as well as the needs identified by

USG treatment partners based on their experience of working with the districts in the regionalization

process. It will also be linked in the same IQC to the orphans and vulnerable children (OVC) district

strengthening activity, as well as to the program being implemented by the Capacity Project to strengthen

districts in the area of managing and retaining human resources. In addition, it would be linked with the

planned GOT performance-based systems soon to be launched throughout the country related to specific

Millennium Development Goals. The program will also need to have very strong linkages with the Ministry of

Finance and the Prime Minister's Office for Regional and Local Government.

This activity will also closely collaborate with the Management Sciences for Health Leadership,

Management, and Sustainability activity, which is undertaking similar activities with the Global Fund for

HIV/AIDS, Tuberculosis and Malaria (GFATM) and civil society organizations. Any relevant tools and

materials developed will be shared and utilized as appropriate with the different target groups. AIDSTAR

Sector II will also coordinate with the CDC TBD auditing activity which will work to ensure GOT

organizations are fiscally accountable and transparent in managing PEPFAR funding.

M&E: This activity would be closely monitored to determine that the incentives and disincentives are aligned

with the desired performance/results. Not only will the capacity building activities be monitored, but the

specific indicators for performance will be monitored to assess the success of a performance-based

scheme. AIDSTAR will develop a monitoring and evaluation plan to track impact of activities on each GOT

organization.

SUSTAINAIBLITY:

Ultimately, it is the responsibility of the GOT to manage the country's response to the HIV/AIDS epidemic.

Currently many of these organizations both at the national and district level need new skills to effectively

plan for, budget for, and manage HIV/AIDS interventions. AIDSTAR will build the capacity of GOT

institutions, thus ensuring the long-term sustainability of HIV/AIDS activities. This activity will provide the

skills that will enable a decentralized government, over the long term, to plan and budget for comprehensive

programs, monitor them appropriately, and be accountable for achieving results.

Apr reprogramming: $ 100,000 to be reprogrammed from district strengthening activity to leadership and

management capacity for PEPFAR partners (MSH-LMS), such that this TBD partner (AIDSTAR) will focus

exclusively on district strengthening. TBD AIDSTAR's targets will be reprogrammed once the partner is

identified and the workplan is finalized.

New/Continuing Activity: Continuing Activity

Continuing Activity: 16994

Continued Associated Activity Information

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

System ID System ID

16994 16994.08 U.S. Agency for To Be Determined 7930 7930.08 AIDSTAR II

International

Development

Table 3.3.18: