The goal of the Health Care Improvement Project (HCI) is to support the Ministry of Health and Social Welfare (MOHSW) and implementing partners (IP) to achieve and sustain delivery of quality HIV/AIDS care through capacity building by applying and adapting modern quality improvement (QI) approaches to care delivery practices.

In FY 2011, six ART/PMTCT demonstration QI collaboratives were established in six regions, resulting in innovations that have been spread to six other regions. In addition to scaling up to new regions in FY 2012, the technical scope of the interventions will be enhanced to test applications of modern QI methods to new program areas. These will include testing the application of QI approaches to enhance provider performance in Mtwara, adapt HBC Standard Operating Procedures in Tanga and Morogoro, test the feasibility of patient self-management in ART in Morogoro, and assess the modalities of improving management capacities of Council Health Management Teams (CHMTs). The program will also work to strengthen district health management performances. HCI will assist MOHSW with the roll out, benchmark, and improve the quality of OVC while assessing the impact of integrated PMTCT and RCH services in the Manyara region.

HCIs program approach encompasses many of the priorities within the PF and GHI strategy, mainly that of mainstreaming gender into activities, while partnering and leveraging resources from other stakeholders to harmonize work and maximize outcomes. Building capacity of MOHSW structures will help to ensure sustained practices. Strengthening MOHSW's knowledge management system will improve monitoring practices to track progress and outcomes of the work plan, thereby promoting learning and accountability as prioritized in GHI.

In collaboration with MOHSW and HBC IPs, HCI is currently in the process of developing Standard Operating Procedures (SOPs) for HBC services. As part of the SOP development, prototyping of the SOPs in Morogoro and Tanga regions aim to demonstrate and model how the application of HBC SOPs improve practice. Documentation of associated effectiveness using routine M&E tools, however, is an on-going process. The completion of this endeavor will be followed by introduction and application of the SOPs in the countrys routine service delivery, thus helping to strengthen the quality of care within the HBC system.

Expanding on previous years work, HCI will continue to support MOHSW and the IPs in FY 2012 to introduce SOPs in service delivery while documenting resultant care outcomes. This support will provide a formal, standardized mechanism for linking existing non-HIV community-based programs, such as family planning, community IMCI, immunization, and nutrition. Furthermore, to strengthen the M&E system, HCI will support the National AIDS Control Program (NACP), IPs, and council staff on using the HBC/UWANYU database, as well as provide training on how to link routine M&E indicators with client-level program performance measures. The SOP for HBC provides detailed descriptions of steps and procedures to be followed by providers in performing specific tasks, including referral management, adherence to treatment, linking clients to PLHIV support groups, IGA, family planning, and TB clinics. Implementation of the SOP is expected to result in harmonized HBC practices across councils and IPs, improved coordination among services, increased efficiencies in program monitoring and evaluation, and better health and social outcomes for PLHIV and their families.

Training on the HBC/UWANYU database will be coordinated through the NACPs M&E department, HBC IPs, and the UDSM computing centre. All 25 regional and 130 district HBC coordinators (totaling 155 staff) in Mainland Tanzania will be trained on how to use the database.

The SOP for HBC is based on eight priority programmatic areas, which are directly linked with HBC M&E indicators. Since adherence to standards of care delivery is associated with better care outcomes, HCI plans to build the capacity of MOHSW, IPs, and councils to be able to measure key HBC outcomes using routine M&E tools.

HCI and IPs will orient national, regional, and district HBC trainers to the SOPs as part of the formal roll out in FY 2012. The trainers will in turn orient HBC supervisors and providers. This intervention is planned to cover 10 out of 23 regions in which eight trainers from each region will be oriented on the SOPs (total of 80 trained); each region will then train 20 district trainers (total of 200 trained). In FY 2013, HCI intends to support SOP trainings to national and regional HBC coordinators and trainers from the government and IPs from the remaining 13 regions using a cascade model, allowing the national team to train regional teams which in turn will train district teams and, subsequently, HBC service providers and supervisors. This approach creates ownership and sustainability of the program across levels of care and allows for transition of responsibilities from the central government to local authorities. A total of 406 staff will be trained on SOP usage.

HCIs goal in supporting OVCs in Tanzania is to strengthen the capacity of MOHSW, IPs, and local structures to provide quality of care, support, and protection to orphans and vulnerable children. In FY 2011, HCI will support scale up of OVC QI activities to Arusha, Tanga, Rukwa, and Shinyanga regions. Continuing activities in FY 2012, efforts will be directed to sharing lessons learned from Bagamoyo to the whole Pwani region while rolling out QI training activities to the rest of the country.

HCI will provide TA to the national level to support scaling up and utilization of QI job aides by local structures. As part of PEPFARs OVC goals and priorities to address the severe human resource shortage, efforts will be directed to skills building for social welfare officers, para-social workers, and other key staff at local government authorities (LGAs) to facilitate effective implementation of national QI guidelines at the service delivery level. Furthering GHIs strategy of promoting learning and accountability through M&E, improvements to data collection and usage from MVC registers for planning and decision-making will be a prioritized capacity building activity.

Support to local multi-sectoral structures, such as the Most Vulnerable Children Coordinator (MVCC), child protection teams, and local CBOs, is key to sustainability to not only ensure mobilization of resources in providing direct social services, but also to identify and address various issues related to child protection, including violence, abuse, exploitation, and neglect. Through these interventions, HCI will support teams to identify, plan, and implement different changes in accordance to standards, norms, and structures that are in the best interest of the children.

National PEPFAR OVC goals of integration are addressed as HCI will support teams to enhance utilization of available resources in integration and linkages of OVC services with other HIV programs, such as PMTCT, care and treatment, and HBC to improve retention. This will help to explore opportunities in other sectors to strengthening the economic capacity of families in caring and supporting OVCs, creating an ability to meet other basic household needs.

HCI will support gathering evidence and documentation of QI processes focused on the impact, efficiency of QI models, and best practices through mentoring and coaching to local partners and LGA, leveraging of resources to avoid duplication of efforts, and scaling up in other areas applicable to the context. This will facilitate local structures ability to harmonize and utilize tools in documentation of implementation of OVC standards at service delivery level. Exchange visits will be conducted across local stakeholders to facilitate in sharing best practices and challenges in implementing service standards.

HCI will continue working with IPs, RHMTs, and CHMTs to facilitate regional scale up of PMTCT quality improvement to all regions in mainland Tanzania. At the national level, HCI will support the NACP to finalize updates to the infant feeding counseling training package, print copies for HCI QI supported sites, develop job aides, and continue to provide TA to infant feeding counseling trainings and refresher courses.

In all new regions, the sequence of events will include PMTCT quality gap analysis, consensus building on priorities, testing changes to close the gaps, and benchmarking outcomes using selected indicators. QI teams will be identified in all sites and go through modular cause of didactic training in QI, followed by coaching and mentoring. HCI will harmonize efforts with IPs and build capacities of RHMTs and CHMTs in quality improvement to ensure sustainable implementation. HCI is testing the role of on-site QI Preceptors in Iringa, which after positive evaluations has the potential for expansion. In general, COP 2012 will focus on scaling down regional trainings in favor of conducting district on-site trainings.

HCI will also work with MOHSW, local government structures, and IPs to support an assessment of the level, impact, and quality of integrated PMTCT/RCH services in Manyara region. The aim is to strengthen local government ownership of the programs, increase the coverage of quality PMTCT and RCH services, increase program sustainability, strengthen the health system, and improve MNCHs outcomes. Baseline assessments were conducted during FY 2011 and a synthesis of the findings will guide future development of PMTCT/RCH integration service packages, as well as help to identify current quality gaps. Integrated services will produce best results where functional management is optimal. HCI will apply QI methods to improve management performance of the Manyara RHMT and CHMTs through capacity building on strategic planning, program management, monitoring, and coordination. Learning from the experiences in Manyara, expansion efforts will be made to Shinyanga, Mwanza, Dodoma, and Mbeya for COP 2013.

Improvements to the district health information systems will provide quality data for monitoring PMTCT/RCH service integration and impact. RRCHCOs and RCHCOs will be trained. Integration will also promote the scale up of more efficacious regimen for PMTCT by providing technical support to district supervisors and mentors. Additional benefits of PMTCT/RCH integration will address retention and adherence challenges of motherinfant pair, improve linkages and referrals to treatment, care and support services, and implement local strategies to promote male involvement in PMTCT/RCH services. Furthering a comprehensive approach, integration will also include detection and management of chronic illnesses, such as hypertension and diabetes.

Periodic review against the national policy and guidelines of the developed minimum package for PMTCT/RCH integration will take place over time. These will be done in QI learning sessions within the five regions. HCI will document and share with other partners best practices of the PMTCT/RCH integration. HCI will also assist CHMTs to take responsibility for monitoring the quality of PMTCT services, through support of improved data recording, data verification and periodic analysis, and relevant responses to findings.

In FY 2011, HCI supported MOHSW to finalize the National QI Guideline for HIV/AIDS services and corresponding training curricula to harmonize training and practice procedures. Currently, HCI is working with MOHSW and other partners in training of National Trainers of Trainers (TOT) in QI with coverage in 12 regions.

In FY 2012, HCI will support MOHSW and IPs to sustainably scale up ART services QI into six new regions of Shinyanga, Dodoma, Arusha, Kilimanjaro, Tabora, and Mbeya regions. Subsequently, HCI will cover the rest of the country in FY 2013. Within the new regions, baseline assessments of the quality of HIV services will be determined to provide initial learning on quality gaps to be addressed. This will be followed by identification of QI teams in each facility providing ART in all districts. The team will then prioritize initial challenges from the quality gap analysis they will like to address and agree on indicators to benchmark progress and outcomes in line with MOHSW and PF priorities.

HCI will train the teams on the use of QI techniques that will provide optimal improvement of ART services. The guiding principle is that good ART services will ensure that all patients in need of ART receive the services, are retained in services, and experience good outcomes from the treatment. All teams will go through modular courses of three learning sessions that alternate with coaching and mentoring. During the learning sessions, there will be sharing of the experience observed in each facility in the QI efforts. RHMTs and CHMTs in each region will be trained to be program mentors and coaches as they facilitate some aspects of the learning sessions and coaching visits in preparation for the transition. It is envisaged that their involvement will increase QI program sustainability and some of the skills learned will also help improve other programs under each of the management teams jurisdiction.

In selected regions, HCI will apply implementation science to explore options of carrying the improvement agenda to other levels. Work started in FY 2011 of testing modalities of improving ART providers engagement and productivity in Mtwara will be finalized and lessons learned will be applied in all on-going ART improvement collaboratives. Likewise, learning from the ongoing feasibility test of patient self-management as an additional option of improving ART in Morogoro will be applied to other ART programs countrywide. Since functionality of CHMTs is central to quality ART, HCI will support the RHMT in Lindi to apply QI techniques to improve management performance of the CHMTs and share the lessons learned with other improvement collaboratives.