ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS:

In FY 2008, Tunajali identified and trained over 1,200 new community volunteers, making an established

network of over 3,418 trained community volunteers who are providing quality HBC services to over 51,000

PLWHA. Effective referral networks have been developed, with 63% of patients linked to care and

treatment services and receiving facility-based palliative care. Over 300 PLWHA support groups with over

6,500 members were formed and strengthened. Local government officials have been sensitized to support

Tunajali activities to enhance sustainability. Thirty District Continuum of Care Coordinating Committees

(DCoCCCs) have been established in the mainland and two in Zanzibar. These DCoCCCs are supported

by Tunajali to meet quarterly to review progress and plan ways in which to enhance and monitor program

performance. The program is starting to reap evidence of sustainability, with three district councils

allocating about $25,000 to Tunajali for HBC services, and about seven more have promised to do the

same. Service outlets have increased from 398 to over 500 wards in the mainland and ten districts in

Zanzibar.

In FY 2009, there will be increased emphasis on provision of prevention with positives (PWP) services for

People Living with HIV/AIDS (PLWHA). All sexually active PLWHA will be provided with condoms and

linked with sexually transmitted infection treatment services and counseling to reduce high-risk behaviors.

Referrals will be made for family planning, if appropriate. Service providers will discuss with PLWHA

specific strategies for disclosing one's HIV status to sexual partners, and offer confidential HIV testing to the

partners of and children born to all PLWHA in their coverage areas.

In addition, Tunajali will strengthen its basic prevention package. PLWHA will be provided with counseling,

and linked to support groups or peer-led interventions through the HBC system. There will be increased

involvement of PLWHA in the communities in service provision as HBC providers. PLWHA will be provided

with information about ways they can protect their own health, prevent common illnesses, and improve

access to safe water and hygiene practices. Tunajali will ensure that interventions address the

comprehensive needs in an environment free from stigma and discrimination. Tunajali will support

procurement and/or distribution of insecticide-treated bed nets to PLWHA, and promotion on their correct

usage. Tunajali will ensure that all PLWHA are receiving Cotrimoxazole for prevention of opportunistic

infections. PLWHA will also be provided with water treating tablets and water vessels in provision of safe

drinking water. Tunajali will train HBC providers on screening for TB and linking the clients to services.

HBC volunteers will also be addressing and monitoring adherence to TB treatment.

The importance of nutrition in determining clinical outcomes for people on ART is becoming increasingly

more apparent. In FY 2009, USG/Tanzania will put more emphasis on addressing food and nutrition needs

of clients receiving care and support. In home visits, Tunajali will conduct nutritional counseling and refer

patients to the CTC facility for nutritional assessments, which will help to inform the clinical management of

PLWHA, pregnant women under PMTCT programs, as well as HIV-exposed infants and children receiving

care and support.

M&E: Tunajali will roll out the newly developed paper-based national HBC reporting and recording system.

All Tunajali regional and sub-grantee staff and volunteers will be trained on the system, as well as the HBC

electronic data management system. To disentangle the overlap of HBC and facility-based care patients,

the new recording and reporting system will enable tracking the records of those HBC clients served at

CTCs. Tunajali will provide technical support to sub-grantees in data assurance through trainings and

supportive supervision. Reports will be shared quarterly with other HBC stakeholders including the

MOHSW authorities to inform future plans.

*END ACTIVITY MODIFICATION*

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

NEED and COMPARATIVE ADVANTAGE: By September 2008, Tunajali (Kiswahili for "we care") will have

reached 35,000 people living with HIV/AIDS (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 sub-grantees and 32

district councils to plan, implement, and monitor quality HBC interventions. Tunajali's collective strengths

include a thorough understanding of the local healthcare 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 HBC services to about 30,000 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 being expanded includes insecticide-

treated bed nets (ITNs) for malaria protection, and the use of cotrimoxazole. In addition, Tunajali is

implementing a pilot to develop a community-based positive prevention package with support from the FHI

system strengthening project. Tools developed for quality improvement and supportive supervision are now

in use.

ACTIVITIES: The primary purpose of the Tunajali program is to increase the number of HIV-positive adults

and children on palliative care in Dodoma, Iringa, Morogoro, Coast, and Mwanza regions. 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 a 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 centers (CTCs), and

Activity Narrative: improve case finding for HIV-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 sub-grantees, and four new sub-grantees will be identified in the new

districts. The program will conduct stigma reduction interventions in all communities to enhance voluntary

counseling and testing.

During FY 2009, Tunajali will focus on improving the quality of palliative care provided to PLWHA.

Tunajali's core package of care aims to address healthcare, nutritional, spiritual, psychological and

socioeconomic support, and legal rights from the time one is confirmed HIV-positive 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 and vulnerable children (OVC). Ongoing volunteers will undergo a one-week refresher

training. Sub-grantee 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 ITNs for malaria control,

Waterguard 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, condoms, etc. Regular supportive supervision will be

conducted by Tunajali central and regional staff, sub-grantee supervisors and the MOHSW District HBC

Coordinators. Tools for assessing nutritional status will be adopted and used by volunteers to assess and

refer malnourished patients. HBC kits will be procured and distributed for management of pain and other

symptoms. Tunajali will identify, document, and disseminate best practices for replication and informing

future policy and technical guidance. Tunajali has also received permission to pilot the use of lay

counselors and testers in the household to improve case finding.

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/district levels. It will also conduct regular mapping and

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

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

nutrition, income generation, and 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 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 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 the US Peace Corps to

scale-up Permaculture gardening initiatives, training core CSO staff and ward agricultural extension workers

as trainers who will train HBC volunteers. The volunteers will develop demonstration vegetable gardens to

be replicated by members of households served. Tunajali shall link with Management Sciences for Health

to increase accessibility of HBC kits through Accredited Drugs Dispensing Outlets in the Morogoro region.

In addition, Tunajali will 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.

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

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

provide palliative care. CSOs will be strengthened to enable them to 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 HIV-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 use of 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 CSOs, who will review and

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

be verified using data quality checklists to ensure reliability. Tunajali will 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 CTCs. Reports will 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 the 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.

New/Continuing Activity: Continuing Activity

Continuing Activity: 13462

Continued Associated Activity Information

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

System ID System ID

13462 8706.08 U.S. Agency for Deloitte Consulting 8030 8030.08 Community $4,570,000

International Limited Services

Development

8706 8706.07 U.S. Agency for Deloitte Touche 4532 1197.07 $4,225,000

International Tohmatsu

Development

Emphasis Areas

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $20,000

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

Estimated amount of funding that is planned for Food and Nutrition: Commodities $100,000

Economic Strengthening

Education

Water

Table 3.3.08: