The Tanzania Ministry of Health is scaling up a new Integrated Community-Facility Maternal Newborn and Child Health service package designed to ensure that HIV-positive pregnant women are linked to comprehensive MNCH services through an integrated approach implemented through community health workers (CHWs) and facility-based providers. Evidence-based approaches are needed to support the development and implementation of effective strategies for the roll-out and national scale-up of the approved package. Johns Hopkins University/HRCI will support implementation and evaluation research to identify policy and program strategies to maximize the programs effectiveness at improving continuity of care for HIV-positive and negative women. The objectives are:

1. To identify priority questions for effective scale up of the integrated package and design studies to answer those questions;

2. To provide technical assistance to partner organizations on the development of data collection instruments, protocols, and data analysis;

3. To disseminate project findings and promote the incorporation of recommendations into implementation strategies and policies.

In alignment with the Partnership Framework, this activity will enable the use of relevant and comprehensive evidence for planning and decision making. It is inherently designed to improve cost effectiveness of the Integrated Program over time by identifying strategies for enhancing program outcomes. Through key partner workshops, study findings will be translated into relevant program and policy guidelines transitioning the effort to local stakeholders, particularly the Ministry of Health. This effort will complement ongoing monitoring and evaluation activities within partner programs.

The Ministry of Health and Social Welfare (MOHSW) of Tanzania has approved a national community health worker (CHW) program that will enable community-facility linkages and promote maternal and newborn health services for HIV-positive and HIV-negative women, including PMTCT, postnatal care, and postpartum family planning. The CHW package involves the recruitment and training of a new cadre of CHWs who will conduct home visits to pregnant and postpartum women, provide health education and promote facility-based services. In-service training will be provided to clinicians at health centers to improve integration of HIV and MNH services and improve the quality of postnatal care.

The JHU/HRCI will conduct implementation and evaluation research in support of the national scale up of Tanzanias Integrated Community-Facility Maternal Newborn and Child Health package (Integrated Package). Through stakeholder engagement and working with key partners in country, JHU-IIP will work with PEPFAR partners to actively translate the study results into recommendations for effective policy, planning and financial approaches that will support the ongoing development of appropriate strategies for the phased introduction and sustained national scale-up of the Integrated Package within the context of the existing health system. Additionally, research findings will also inform the multi-stakeholder National CHW task force discussions. The National CHW task force has been convened by the Department of Preventive Services within the MOHSW and has been charged to review and bring together lessons learned, as well as consolidate current status of implementation of community health worker related activities and guidelines in country. Key implementation and scale-up challenges that may be addressed include:

1. The development of sustainable systems for CHWs, with a focus on supportive supervision and reasonable incentives.;

2. A need to formalize and standardize the CHW cadre, including recruitment criteria, training, and service packages;

3. Effective creation of sustained demand for services and referral by strengthening CHW program;

4. Definition of a cost and financing model for scale-up of the Integrated Program.

5. Weaknesses of existing platforms and the related impact on the coverage and quality that may be achieved through the Integrated Program.

6. Existing and projected program and financial constraints at the primary, periphery and tertiary level.

The Johns Hopkins Institute for International Programs (JHU-IIP) will support implementation and evaluation research on the national scale up of Tanzanias Integrated Community-Facility Maternal Newborn and Child Health package (Integrated Package). PMTCT and HIV/AIDS treatment services have been largely facility-based whereby PMTCT has been integrated with ANC and delivery services. The Ministry of Health and Social Welfare (MOHSW) of Tanzania has approved a community health worker (CHW) program that will enable community-facility linkages and promote maternal and newborn health services for HIV-positive and HIV-negative women, including PMTCT, postnatal care, and postpartum family planning. The CHW package will recruit and train a new cadre of CHWs who will conduct home visits to pregnant and postpartum women as well asprovide health education and promote facility-based services. In-service training will be provided to clinicians at health centers to improve integration of HIV and MNH services and improve the quality of postnatal care. Comprehensive evidence is needed to inform the roll out and support strategies for the national scale-up. By using evidence to evaluate and further develop its strategies, the Integrated Program will be better positioned to reduce loss to follow up from routine MNH services, and from PMTCT and long-term HIV treatment for HIV-positive women.

JHU-IIP will provide TA to implementing partners and the MOHSW to conduct implementation research and evaluation studies as the scale up goes forward. Specifically, JHU-IIP will work with PEPFAR-funded partners who are supporting the scale-up of the integrated program, including the CDC and EGPAF, the MOHSW and USAID, to identify priority operational research questions that will inform the strategies of the integrated program. JHU-IIP will collaborate with partners to design three to four operational research studies that address priority questions, develop protocols and measurement instruments, and secure ethical approval. This approach will maximize efficient use of resources and uptake of research results by relying on partner infrastructure and management to conduct data collection. In some cases, more than one partner may contribute to the same study, by testing different implementation strategies and comparing outcomes. JHU-IIP will work with implementing partners to analyze data and disseminate results to stakeholders for incorporation into policy. Results from each study will be feed back into the program. Design and analysis workshops will be held annually in order to engage all stakeholders in the research and improve the policy uptake of results.

Knowledge gaps and scale-up barriers that the proposed implementation research may address include:

- In what way can health facilities communicate with CHWs to follow up with women who miss appointments?

- What are the most effective approaches for training and supervising CHWs? What role can the dispensary play, and what other strategies can be employed?

- What is the realistic scope of activities that CHWs can effectively complete? Can CHWs scope be increased over time without a decrease in the quality/coverage?

- Are there conditions under which CHWs i Tanzania can provide integrated community case management?

By answering the above or other questions, this project will play an important role in the development of effective policies for a sustainable and successful CHW program in Tanz