TITLE: Technical Assistance to the National AIDS Control Programme for Strengthening Palliative Care and

Developing/Implementing a National Palliative Care Monitoring/Evaluation System for HIV/AIDS

NEED and COMPARATIVE ADVANTAGE: The National AIDS Control Programme (NACP) has been

successful in rolling out the care and treatment program. However, in order to reach the majority of those

who need care and treatment effectively, there must be stronger coordination and integration of available

services, and strengthening of planning and monitoring for program scale up and quality enhancement. The

Counseling and Social Services Unit (CSSU) of NACP, charged with the responsibility for palliative care, is

severely understaffed. This has contributed to inadequate guidance, coordination, and monitoring. Service

providers' noncompliance to set operating procedures continues to be a problem, resulting in poor quality of

services. FHI has played a systems strengthening role with NACP for several years, and is well positioned

to be a catalyst to strengthen the vulnerabilities in this program, and help orchestrate the scale up of

services throughout the country. FHI has considerable expertise in the Tanzanian health system, which has

been shown to build trust, technical reliability, and respect with the NACP, regional, and district-level

authorities, and with other USG partners. This also positions FHI to help "raise the bar" on expectations at

the NACP.

ACCOMPLISHMENTS: FHI successfully assisted the Ministry of Health and Social Welfare (MOHSW) to:

develop home-based palliative care guidelines and training materials for NACP and Zanzibar AIDS Control

Programme (ZACP), and standard operating procedures (SOP) for care and treatment; and effectively

regionalize services and decentralize supportive supervision. FHI provided extensive technical assistance

to the Health Sector Strategy for HIV/AIDS (2008-2012) development focusing on care, treatment, and

support. FHI was instrumental in updating national guidance with regard to d4T toxicities, and will be

leading the community pilot for prevention for positives interventions. In addition, FHI has developed the

monitoring system for OVC, with many lessons learned for the development/implementation of a palliative

care monitoring system.

ACTIVITIES:The program will focus on strengthening quality of services and the CSSU at NACP in four key

ways:

1. FHI will work closely with other USG-funded programs that will contribute to the quality of palliative care

services, such as the African and Tanzanian Palliative Care Associations and Ocean Road Cancer Institute.

In addition, there is a New Partner Initiative program with the Foundations for Hospice in Sub-Saharan

Africa (working with the Evangelical Lutheran Church—ELCT), and a twinning partnership with the Iowa

Synod of the ELCT. These programs all pledge to bring additional expertise to the table for the

review/update of the national guidelines for palliative care, including the strengthening of pain management

and end-of-life care. These guidelines will feed into the soon-to-be-initiated accreditation process for

service providers.

2. FHI will assist the CSSU in developing a coordinating mechanism, since palliative care has been an area

without strong direction and leadership from NACP in the past. FHI will contract a qualified health-planning

expert to the care and treatment unit (CTU) to plan the expansion of care and treatment activities. The

planner will help the CSSU plan and operationalize the rollout of the HIV/AIDS care component of the

Health Sector Strategy for HIV/AIDS (2008-2012). FHI will facilitate the regionalization of home-based care

(HBC) providers, and help to strengthen the linkages with Care and Treatment Clinics (CTC), PMTCT, and

TB/HIV activities.

3. There will be a component of the program to enhance the package of services available for patients,

including the basic preventive package initiated in FY 2007. In addition, FHI aims to promote integration of

prevention messaging and interventions, adherence counseling, and home counseling and testing. The

home counseling and testing by lay providers will require advocacy for policy change. Because FHI will

assist in adapting the CDC/WHO operational guidelines to implement care and treatment at health

centre/dispensary level, they will help to integrate the local health center into the palliative care services

provided to PLWHA.

4. FHI will convene all stakeholders to develop and plan the implementation of a palliative care monitoring

system to include standardized reporting tools and data management system. This system is regarded as a

tool on at the national level, as well as at the local level for planning, budgeting, management, and decision-

making. A key component will be to pilot the system and its application, and to organize a phased

implementation plan to involve all palliative care partners to catalyze the process. FHI will develop training

materials and conduct training of trainers in anticipation of the rollout. A data manager will be contracted to

the CSSU to manage the database and rollout of HBC monitoring. FHI will also organize a team of systems

implementation specialists for an effective and smooth rollout.

Because the accomplishments in this activity will be to strengthen the system and provide appropriate tools,

standards, and systems for palliative care, there are no targets associated with the work. There should be

over 100 individuals trained in and five organizations provided with institutional capacity building in the

system strengthening area at time of reporting.

LINKAGES: FHI works closely with NACP, specifically with the CTU, the CSSU, and the technical

subcommittees. It is a member of the national advisory committee and the following subcommittees:

clinical care; training and human resource; and care and support services. Through membership in these

committees, FHI is able to collaborate with key partners and decision-makers in the MOHSW and national

health institutions. It also works with treatment partners directly to ensure synergy in activities; national-

level work is informed by on-the-ground experience; and compliance to national guidelines. In updating the

guidelines/curricula, FHI will work with the African and Tanzanian Palliative Care Associations, Mildmay, the

Foundations for Hospice in Sub-Saharan Africa, the AIHA Iowa Synod partnership, Columbia

University/Ocean Road Cancer Institute, and all palliative care implementing partners. Similarly, the

conceptualization and development of a monitoring system will arise from collaborative efforts for

improvement in palliative care. In addition, FHI will collaborate with the I-TECH, and Capacity Project

programs, as well as medical officers, assistant medical officers, clinical officers, and nursing training

schools to enhance pre-service training. FHI partners with regional and district health authorities,

department of training in the MOHSW, Muhimbili University College of Health Sciences School of Public

Health, Department of Social Welfare, and the private medical sector to advance the concept of

comprehensive care across a continuum.

Activity Narrative:

CHECK BOXES: Project activities focus on strengthening capacity with NACP, especially the CSSU, and

pre-service training institutions. NACP staff will be trained in continuous quality improvement, planning,

coordination, and monitoring of standards for care and treatment. Pre-service practical training at care and

treatment clinics will be implemented nationwide. FHI will also emphasize piloting and rollout of innovative

task-shifting and retention strategies. The project targets the NACP staff members, particularly the CTU

and CSSU staff, and pre-service training institutions. Support also extends to implementing organizations.

M&E: A key need is to develop a national monitoring system that can provide more data about palliative

care services, the quality of those services, and the impact of those services. The system will ensure that

quality and completeness of data can be assessed through regular data audits and feedback from staff.

FHI will also develop standardized monitoring tools to capture data and report routinely on progress and

quality of proposed national level activities. In order to facilitate effective program monitoring, and develop

M&E capacity for full scale up, a variety of methods will be used to build NACP M&E capacity, including

training and on-the-job mentoring.

SUSTAINAIBLITY:FHI's technical support to NACP is designed to build human and institutional capacity

leading to the sustainability of national level coordination, monitoring, and standards development. FHI will

work as a partner with NACP to provide training, mentoring, and building capacity for systemic planning.

The focus is on innovative mechanisms to increase and retain qualified staff at all levels. Emphasizing

decentralization and sourcing out of activity areas will free time for NACP to focus on normative functions.

In addition, FHI will enhance local capacity and encourage sustainable, quality services by ensuring that

implementing partners work within existing public and private systems, and use national guidelines,

standards, and monitoring system instead of creating a parallel system.

TITLE: Strengthening National Systems for OVC Services

NEED and COMPARATIVE ADVANTAGE: Tanzania has an estimated 2.5 million orphans and vulnerable

children (OVC). Out of this number, 1.1 million are classified as most vulnerable children (MVC). The

challenges of meeting the needs of these children require strategic leadership, an efficient and effective

Department of Social Welfare (DSW) to coordinate and monitor the roll out of the National Plan of Action

(NPA) and the Data Management System (DMS), and a strong phased plan and on-the-ground readiness

for the rollout. In addition, though implementing partners are undertaking OVC identification processes,

they still require assistance in the NPA and DMS implementation at the district level. FHI has worked

closely with the DSW in the development of both the NPA and DMS, and thus, it is in a strategic position to

support the rollout of the OVC national system.

ACCOMPLISHMENTS: With FHI's technical support and leadership: the NPA has been finalized; the DMS

is in place tracking MVC and service providers; 72 social welfare /community development officers and

M&E officers from implementing partners have been trained in the DMS. The use of the DMS has been

launched in 17 districts. FHI collaborates with local partners to ensure quality of data and the ability to use

the data for decision making at the national and local level. FHI is also updating the OVC standard of

quality care tools, and developing a manual for integrating OVC care and support within home-based

palliative care, which includes case finding for HIV exposed children.

ACTIVITIES: The most critical function of FHI's work is to support the Ministry of Health and Social Welfare

(MOHSW) and their Department of Social Welfare (DSW) to orchestrate the implementation of OVC

national policies, strategies, and plans in an effective way. This will strengthen capacity of the MOHSW

staff to scale up quality and sustainable services to reach more OVC with needed care and support. To

date, this has been a daunting task because of many challenges within the DSW that do not lend

themselves to effective implementation. FHI will hire a strategist to collaborate with the DSW to develop

and rollout a phased implementation of the NPA. A critical part of the rollout is to support the piloting and

integration of newly developed OVC standards of quality care. As a normal function of their ongoing

relationship with DSW, FHI will continue to support DSW to develop and disseminate national OVC policies,

standards, and guidelines (including printing and distribution). In the immediate future, however, FHI will

take bold measures to turn this low performing department into a high performing unit, focusing on a

strategic perspective and strengthened leadership, and catalyzing effective coordination of national rollout

of OVC programs. A key step will be for FHI to ensure that the National Steering Committee for OVC is re-

energized and that it meets on a regular basis. This will provide the backbone for the national Implementing

Partners Group, who comprise the national Technical Coordinating Committee. FHI will provide technical

assistance to the effective functioning of all of these important groups, though they are led by the

government of Tanzania (GOT).

The infrastructure for the rollout of the NPA has not yet been finalized. While on paper there are council

multi-sectoral AIDS committees and MVCCs, these entities are not well integrated into the local government

structure. To facilitate their effective functioning, FHI will work closely with the Prime Minister's Office for

Regional and Local Government (PMORALG) to operationalize the devolution of responsibility for OVC

care. FHI will ensure the smooth undertaking of the local government's roles and responsibilities, and the

respective implementing partner will actually handle the day-to-day management of the OVC response.

One key component is for FHI to support capacity building of the new district social welfare officers recently

hired by PMORALG and the overall devolution of the social workers in the local government system. An

important function of FHI is to assist in advocating for increased funding allocation for OVC support in the

central and local government budgets to ensure the ability to achieve the NPA rollout.

FHI will play an important role in providing technical expertise to other OVC implementing partners. A

useful venue to achieve this is to discuss technical issues together at the Implementing Partners Group

(IPG) and supporting national OVC guidelines and policies. FHI will also develop mechanisms to ensure

inputs from implementing partners, local communities, MVCC, and children clubs regularly inform policy and

planning. To ensure that critical technical issues are discussed and that practices are evaluated for scale

up, FHI will sponsor periodic inter-regional learning sessions to share and disseminate OVC care and

support best practices. A component of this will be to disseminate the findings of an assessment of

nutritional needs for OVC and to collaborate with other partners to develop an effective approach for

nutritional support of OVC. Another important need for OVC care includes a resource manual to support

elderly caregivers. To address the need for improved case finding of OVC, FHI will assess and document

the cost-effectiveness of integrating OVC care and support within home-based palliative care.

A key strategic piece of an effective OVC program is the ability for the GOT to monitor services and OVC on

a routine basis. Though the national DMS is developed, it is in the early stages of implementation and is

being piloted in five districts. A comprehensive rollout plan is in development, and will require a special unit

developed for a successful full implementation. USG-funded implementing partners are responsible for

ensuring the data is collected in the DMS and that the local MVCCs are supported to use it. FHI will need to

contract with a firm experienced in systems implementation and information technology support to ensure

that the DMS rolls out to an additional 83 districts in a phased timeframe, and that data recording and

reporting for OVC are operational at all levels. A key piece of that plan is to ensure that every district clearly

understands the data can be used for managing programs, planning, and decision-making. The same is

true at the national level. Both levels will need to have their capacity strengthened through hands-on

sessions to understand what the data can do to make their jobs easier and more effective. Other trainings

may need to occur for individuals who may use the data as a case management tool. FHI will also provide

information technology support to DSW, including provision of computers for key staff members. FHI will

also work with the DSW for data quality review systems.

One significant limitation is that the DSW is presently located in a large block building with limited power, no

internet connectivity, and even a poorly equipped office. This office needs to be relocated, and funds will be

made available for renovation of their working facility and ensuring that they have internet connectivity and

the ability to link up the server for the national Data Management System.

Lastly, FHI will work with the DSW and the Capacity Project on strategic human capacity issues. That

includes a plan to address the shortfall of social workers. A critical piece is to have at least short-term needs

addressed so that there is some infrastructure in place for the rollout of the NPA. Specifically, FHI will work

Activity Narrative: with the Capacity Project on the full integration of the para-professional social workers at the district level,

and the DSW and the Institute of Social Welfare to organize students' internship opportunities.

LINKAGES:This activity will link with the OVC Implementing Partner Group network; i.e. PACT, Salvation

Army, Africare, CRS, AIHA, Pathfinder International, Pharm Access, Deloitte Consulting, and Peace Corps.

FHI will collaborate with the DSW and GOT Ministries on issues of local government, education, vocational

training, food security and nutrition, and legal support. FHI will work with the National Bureau of Statistics to

integrate the DMS into their system and TACAIDS to coordinate OVC HIV/AIDS multi-sectoral framework.

FHI will also work very close with the PMORALG to facilitate the devolution of the social workers and

integration of the OVC support.

CHECK BOXES: The main thrust of this project is to increase the capacity of local organizations to plan,

implement, and monitor OVC care and support activities. M&E is also a focus area. Since this is a quality

assurance activity linked with FHI's role at national level for systems strengthening, there are no direct

targets.

M&E: The program will support national DMS as the M&E system for tracking OVC and service providers

and its rollout including training, data quality, and use. FHI will assist all OVC USG- funded implementing

partners to adopt the system and DSW national M&E data analysis and dissemination activities to provide

feedback to frontline data collectors and inform policy makers on progress achieved.

SUSTAINAIBLITY: All activities are designed to build the capacity of DSW, local GOT structures, and other

partners for sustainability. FHI staff will be identified for DMS and will mentor DSW staff. Through the

proposed strategy of decentralization of OVC identification, DMS, NPA and supportive supervision, and

local government authorities will gradually take off and include OVC issues into their annual plans and

budgets to ensure sustainable quality care. Through capacity building, systems strengthening, and policy

environment improvements, DSW will be in a stronger position to scale up and monitor quality OVC

services in the country.

TITLE: Technical Assistance to the NACP Care and Treatment Unit to Build Strategic Planning and

Management Capacity

NEED and COMPARATIVE ADVANTAGE:

The National AIDS Control Programme (NACP) has made some successes in rolling out the National Care

and Treatment Program; however it is critical to strengthen its capacity to plan, orchestrate implementation,

and monitor national, regional, and district-level activities in order to reach the majority of those who need

care and treatment most effectively. Family Health International (FHI) is well-positioned to provide national-

level support because of its health systems and HIV care and treatment expertise. It has successfully

collaborated with the NACP in Tanzania for several years. Its approach of working "through" government

has allowed FHI to gain the trust and respect of the NACP, which has resulted in FHI being often called

upon to provide feedback and technical guidance to the NACP.

ACCOMPLISHMENTS:

FHI's work with NACP has led to the development of national Standard Operating Procedures (SOPs) for

care and treatment. It was instrumental in conceiving the regionalization of treatment activities, the

decentralization of supportive supervision, and the development of supportive supervision tools. FHI

provided technical assistance and to the Ministry of Health and Social Welfare in the development of the

Health Sector Strategy for HIV/AIDS-2008-2012, leading a team experts in the components focused on care

and treatment. FHI has conducted an analysis of NACP management capacity, followed by a teambuilding

retreat to strengthen effective management and communication. FHI facilitates convening of important

technical meetings, including the national care and treatment subcommittee. This includes fostering good

policy and practices by facilitating discussions and providing technical state of the art inputs. For example,

this has led to the updating of national guidance with regard to d4T toxicities and phasing out stocks of d4T

40.

ACTIVITIES:

NACP is severely understaffed, which leads to an inability to effectively orchestrate the rollout of care and

treatment services, and provide adequate monitoring and supervision of established standards and

operating procedures. Its highly bureaucratic procedures delay implementation. To address this, FHI will

identify and proceed with appropriate ways to build coordination, planning, and management capacity of the

NACP Care and Treatment Unit (CTU). FHI will continue skills building in planning, implementation

(translating plans into phased action) through secondment of a senior-level health planner, who will assist

the head of the CTU. The seconded staff will facilitate the development, implementation, and monitoring of

the unit's work plans and budgets according to MOH and donor priorities. This includes required assistance

in mobilizing other donor funds, e.g., Global Fund. FHI will draw on expert consultancies as necessary to

ensure that NACP rolls out their work plan in a timely and coordinated fashion, as well as NACP's

implementation of the 2008-2012 HIV/AIDS health sector strategy with regard to care and treatment. As

follow-on to the management retreat conducted last year, FHI will support biannual retreats and workshops

for NACP staff to further improve management and coordination skills focusing on areas identified during

the previous retreat. FHI will ensure regular meetings are conducted for the national technical

subcommittee on care and treatment. FHI will guide the CTU in translating recommendations into policies

and guidelines through: contributing to setting the agenda for the subcommittee meetings; ensuring state of

the art information feed into discussions; facilitating development of clear action points; and ensuring action

points are carried out. FHI will provide technical and financial support in development/updating and printing

of national policy and strategic guidelines, such as the development of guidelines for:

(1) implementing the continuum of care approach

(2) integrating HIV services into general health service delivery

(3) implementing "prevention for positives" package.

It will also support the printing of the recently revised national treatment guidelines.

FHI will assist the NACP in planning linkages between treatment the regionalization of other HIV-related

services, in particular palliative care (HBC), PMTCT and TB/HIV activities as agreed with USG and other

partners. FHI will ensure technical consistency between the hospital level SOPs and the health

centre/dispensary level operational guidelines, which is currently being developed through the support of

CDC/WHO. FHI will drive the agenda to ensure that state of the art information and lessons learned inform

decision makers and those developing training materials. In the area of human resources, FHI will

document its success with the "retired but not tired" health worker recruitment, and work with NACP and the

MOHSW to bring that intervention to scale. It will also look for other best practices in maximizing health

manpower (e.g. task shifting), and work with the Government of Tanzania and the Capacity Project to bring

those interventions to scale.

Though there are no direct targets for treatment, there will be individuals trained and capacity built with local

organizations, which will be reported in the semi-annual and annual reports.

LINKAGES:

FHI works closely with the NACP, specifically with the CTU, and the National HIV Care Advisory Committee

and national technical care and treatment subcommittee. FHI also works closely with the other USG

treatment partners directly to ensure national-level work is informed by on-the-ground experience,

complementarity of activities, and compliance to national guidelines. It partners with regional and district

health and medical authorities, Muhimbili University College of Health Science, and various clinical training

institutions for nurses and clinicians and as well the private medical sector to advance the concept of

comprehensive care across a continuum with sound clinical and referral components.

CHECK BOXES:

Project activities focus on technical and managerial capacity building for better strategic planning and

technical skills NACP staff will be trained in planning, coordination, management, and monitoring of

standards for better rollout of a decentralized implementation of care and treatment following national

standards. This activity area targets the NACP staff members, particularly the CTU and affiliates in other

units, the ministry and partners.

M&E:

To assess progress systematically and provide timely information for making mid-course adjustments, FHI

will use standardized monitoring tools to routinely capture data and report on progress and quality of

proposed national level activities. The quality of data will be ensured by regular data audits and feedback

Activity Narrative: from staff. FHI will use approximately 7% of its budget for M&E activities.

SUSTAINAIBLITY:

FHI technical support to NACP is designed to build human and institutional capacity leading to the

sustainability of national level coordination, planning, monitoring, and standards development. FHI will work

"through" more than "with" NACP through training, mentoring, and building capacity for systemic planning.

Its focus on innovative mechanisms to increase and retain qualified staff at all levels. Emphasizing

decentralization and outsourcing of activity areas will free time for NACP to focus on normative functions. In

addition, facilitating and ensuring implementing partners work within existing public and private systems,

and use national guidelines, standards, and monitoring system, instead of creating a parallel system, will

ensure enhanced local capacity. Lastly, FHI will work with the private sector to provide technical inputs in

the training on care and treatment to private providers in major urban centers, in collaboration with the

Muhimbili University of Health and Allied Sciences Public Health department and the Private Physicians

Association. Though there are no direct targets related to treatment in this activity, FHI will provide capacity

building to one organization and a minimum of five individuals with this funding.