TANZANIA FOUNDATION-SUPPORTED PMTCT PROGRAM EVALUATION 2010

Transcription

1 TANZANIA FOUNDATION-SUPPORTED PMTCT PROGRAM EVALUATION 2010

2 Table of Contents Acknowledgments... Error! Bookmark not defined. Acronym List... 6 Executive Summary... 7 Background... 7 Evaluation Methodology... 7 Findings... 8 PMTCT Program Effectiveness... 9 Introduction Section 1: Background Tanzania Demographic Overview Population and HIV Prevalence Administrative Structure Maternal Health Indicators PMTCT in Tanzania The Foundations s Program in Tanzania Section 2: The Foundation-Supported Tanzania PMTCT Services Coverage District Approach to Scale-Up PMTCT Services Capacity Building and Support to Districts and Partners: Technical Programming Capacity Building and Support to District Partners: Contracts and Grants Section 3: Methodology Evaluation Design Goal of Evaluation Objectives of Evaluation Sampling Method PMTCT Evaluation Team Quantitative Data Collection Qualitative Data Collection Data Analysis Limitations of the Evaluation

3 Section 4: Findings Coverage of PMTCT Services in the Five Regions Tanzania PMTCT Program Counseling and Testing Coverage, PMTCT Service Coverage by Region Shinyanga and Tabora Regions, Arusha Region, Kilimanjaro Region, Mtwara Region, Antiretroviral Prophylaxis Uptake by Mothers and Infants Regimens for PMTCT Prophylaxis in ANC Antiretroviral Uptake in Labor and Delivery in PMTCT Access to Infant ARVs Antiretroviral Treatment of HIV-Positive Pregnant Women Use of Existing Systems to Implement PMTCT Programs Program Integration Referral Systems Male Partner Involvement Facilities Supplies and Procurement System Policies and Guidelines Partnerships Monitoring and Evaluation Systems for PMTCT Clinic Performance Gap analysis Section 5: PMTCT Program Effectiveness Methods Used Results of Analysis Section 6: Key Successes and Challenges, Recommendations and Conclusion Key Successes and Challenges Recommendations Recommendation 1: Increase early uptake of maternal prophylaxis by providing antiretrovirals (ARVs) to HIV-positive pregnant women at the time of diagnosis, as early as the 14th week of gestation

4 Recommendation 2: Increase uptake of infant ARV prophylaxis by dispensing to women in ANC, preferably at the time of diagnosis of HIV infection, for them to take home in case they are not able to deliver in a facility Recommendation 3: Increase uptake of MER by allowing personnel in ANC to dispense combination ARV prophylaxis to pregnant women, and training them to do so Recommendation 4: Increase the proportion of pregnant women receiving ART by improving CD4 count availability, and consider task sharing or shifting to enable more staff members to prescribe and dispense ARV treatment Recommendation 5: Continue roll-out of early infant diagnosis at all RCH facilities with well-child care clinics Recommendation 6: Develop mechanisms to increase the number of children on ART Recommendation 7: Standardize the systematic availability and use of the new infant records card, including discarding all outdated cards in stock Recommendation 8: Increase human resources for health Recommendation 9: Integrate health services provided through RCH, PMTCT, and C&T Recommendation 10: Reduce the proportion of home deliveries Recommendation 11: Make national guidelines, monitoring and evaluation tools, and job aids available in local languages (i.e., Kiswahili) and in formats that can be utilized by local health-care workers Recommendation 12: Construct and renovate health facilities to meet the needs created by population increase and the addition of HIV/AIDS services Recommendation 13: Identify innovative interventions used in other developing countries Recommendation 14: Strengthen the commodity management system to reduce stock-outs Recommendation 15: Strengthen the monitoring and evaluation system for accrued benefits to MoHSW, partners, and stakeholders Conclusion Appendix 1: References Appendix 2: The Foundation-Supported Tanzania Program Organizational Charts Appendix 3: Site List: Evaluation Sites Appendix 4: The Foundation s Program in Tanzania Appendix 5: Capacity Building and Support to District Partners: Contracts and Grants Appendix 6: Data Flow from Facility to National and Global Levels Appendix 7: Site List: Foundation-Supported Sites in 2009 with Validated Data Appendix 8: List of Interviewees Appendix 9: Program Coverage Maps

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6 Acronym List 3TC lamivudine ANC antenatal care ART antiretroviral therapy ARV antiretroviral AZT zidovudine C&G Contracts and Grants (Department) C&T care and treatment CDC U.S. Centers for Disease Control and Prevention CHMT council health management team CTA Call to Action CTC care and treatment clinic DACC district AIDS control committee DED district executive director DBS-PCR dried blood spot real-time polymerase chain reaction DMO district medical officer DRCHCo district RCH coordinator EID early infant diagnosis the Foundation The Elizabeth Glaser Pediatric AIDS Foundation GLASER Global AIDS System for Evaluation and Reporting HCW health-care worker HEART Help Expand Antiretroviral Therapy KCMC Kilimanjaro Christian Medical Center L&D labor and delivery MC male circumcision M&E monitoring and evaluation MER more efficacious regimens (of ARV drugs) MoHSW Tanzanian Ministry of Health and Social Welfare MSD Medical Stores Department MTCT mother-to-child transmission MTUHA health management information system (Swahili acronym) NACP National AIDS Control Programme NBS National Bureau of Statistics NVP nevirapine PCR polymerase chain reaction PEPFAR U.S. President s Emergency Plan for AIDS Relief PITC provider-initiated testing and counseling PMTCT prevention of mother-to-child transmission RACC regional AIDS control committee RCH reproductive and child health RHMT regional health management team RRCHCo regional RCH coordinator sdnvp single-dose nevirapine TBA traditional birth attendant THMIS Tanzania HIV/AIDS and Malaria Indicator Survey USAID United States Agency for International Development USG U.S. government WHO World Health Organization 6

7 Executive Summary BACKGROUND The Tanzanian Ministry of Health and Social Welfare (MoHSW) introduced prevention of mother-to-child transmission (PMTCT) of HIV services in Tanzania in In 2003, the Elizabeth Glaser Pediatric AIDS Foundation (the Foundation) began to support PMTCT services in collaboration with MoHSW under a fiveyear global cooperative agreement with the U.S. Agency for International Development (USAID). As of December 2009, The Foundation supported 962 sites in 33 districts in five regions (Arusha, Kilimanjaro, Mtwara, Shinyanga, and Tabora) in the provision of PMTCT services to pregnant women, their children, and their families. Subsequent to the Foundation s supporting PMTCT in Tanzania, Project HEART (Help Expand Antiretroviral Therapy), funded by the U.S. Centers for Disease Control and Prevention (CDC), was initiated in March As of December 2009, Project HEART was supporting care and treatment (C&T) activities in 47 hospitals and 118 primary health facilities in Arusha, Kilimanjaro, Lindi, Shinyanga, and Tabora regions. The goal of this evaluation is to determine whether the Foundation s support has increased access to quality PMTCT services, including linking to C&T for women, children, and their families, in Tanzania. This evaluation report explores PMTCT coverage in Tanzania, presents data from the past eight years to quantify uptake of PMTCT services, and synthesizes the findings of 50 health facility assessments in an effort to understand variations in the quality of services supported by the Foundation in Tanzania. EVALUATION METHODOLOGY During the period from April to June 2010, the evaluation team reviewed quantitative data submitted electronically to the Global AIDS System for Evaluation and Reporting (GLASER), an online data warehouse developed by the Foundation to store PMTCT and C&T data. A review of available gray literature was carried out to assess program progress and to examine information on program inputs, activities, achievements, challenges, and lessons learned. Qualitative information was obtained through (1) in-depth interviews with policymakers, service providers, and regional and council health management teams, and (2) direct observation of facility services using an observation checklist. Qualitative data were entered into an Excel spreadsheet and coded by themes. Content analysis was then carried out by theme. Through triangulation in order to validate data collected by the different methods, a final evaluation report was developed. The main objectives of this evaluation were as follows: To describe the current status of PMTCT program implementation in the Foundation s program in Tanzania, facility and population coverage in five regions (by number of districts and PMTCT sites), and contribution of the program to overall national PMTCT program coverage To assess and describe increase of access to PMTCT in the Foundation-supported regions, looking at the following indicators and comparing data over the period : PMTCT coverage and accessibility; Coverage is defined as the proportion of pregnant women accessing PMTCT services. 7

8 PMTCT cascade (women eligible, counseled, tested, and received results); maternal and infant antiretroviral access, including single-dose nevirapine (sdnvp), more efficacious regimens (MER), and antiretroviral therapy; increase in deliveries at facility; infant infection as measured by early infant diagnosis data; and male partner testing Facilities in the five regions where the Foundation provides PMTCT services were sampled using stratified and purposive sampling. The evaluation team comprised 2 senior external consultants, 12 research assistants, and 3 data entry clerks (combination of Foundation employees, external consultants, and district staff), working under the supervision of district PMTCT coordinators. Due to limited time available to conduct this evaluation and to apply for ethical approval in accordance with national and international requirements, clients perception of quality of services was not explored. To address this limitation, service providers were asked about their perception of patient satisfaction. FINDINGS The Foundation s Tanzania program goal of providing access to PMTCT services to 80 percent of pregnant women has been exceeded; access ranges between 89 percent and 99 percent. The cumulative data from Foundation-supported sites, over the past eight years, show 1.27 million eligible women, of whom 1.15 million (98.3 percent) were counseled and 1.1 million (96 percent) tested for HIV at Foundation-supported sites in Tanzania. Of these, 1.1 million (99.6 percent) received their results. Cumulatively over eight years, 87 percent of all eligible women in Tanzania (in Foundation-supported and non-foundation-supported sites) were counseled, were tested, and received test results. A cumulative total of 39,961 HIV-positive pregnant women (84 percent) have received antiretroviral prophylaxis, but only 16,987 exposed infants (36 percent) received prophylaxis. Because women attending antenatal care do not receive infant antiretroviral drugs (ARVs) to take home due to national policy, and only approximately 40 percent of infants are delivered in a facility, as many as 60 percent of infants born to HIV-positive mothers may receive no ARVs in Tanzania. Thus, the combined effects of delivery at home and the restriction of dispensing infant ARVs only in facilities has resulted in lower-than-desired infant uptake. It should be noted, however, that the weakest part of service delivery is the uptake of ARVs by mothers. Pregnant women are now more educated on how to prevent HIV infection in their children during pregnancy, delivery, and feeding. Integration of PMTCT into reproductive and child health (RCH) services has succeeded in increasing awareness of HIV, improving staff knowledge, and reducing stigma, but it still has some challenges, including staff shortages, high workload, staff burnout, limited working space for conducting PMTCT services, low male involvement, and lack of privacy due to shortage of space. By the end of 2009, the 61 trainers trained and supervised by the Foundation had trained 3,295 service providers at all health facility levels. This group of trainers has assisted in the establishment and continued provision of PMTCT services in five regions of the country. The Foundation s officers assist districts with PMTCT supervision and mentorship; sharing of knowledge and experience; organizing community activities; and building capacity in monitoring and evaluation, supply chain management, and laboratory services. The Foundation has also helped district partners with contracts and grants by both building capacity and providing support. The perceptions of the respondents interviewed for the evaluation were that the Foundation s PMTCT program in Tanzania reaches the intended beneficiaries, who have increased in number over the years of the program. According to the respondents, PMTCT is also integrated into facilities offering RCH in the five regions where the Foundation offers PMTCT services. 8

9 PMTCT PROGRAM EFFECTIVENESS Different studies show that if no intervention were available and transmission rates to infants are estimated to be 25 percent, 1,2 in a population of 13,000 infected pregnant women, 3,250 infected infants would be born each year. If sdnvp were given to all HIV-positive pregnant women in this group, the transmission rate could potentially be reduced to 12 percent 3, and the number of infected infants born to the 13,000 infected mothers would be reduced to 1,560. Under this same scenario, if all HIV-positive women received MER of ARV drugs, the transmission rate could be reduced even further, to 2 6 percent. 4 The total number of HIVinfected infants would be reduced to Using current program assumptions, 372 cases of pediatric HIV are averted each year. However, the program data indicate that fewer than 2 percent of HIV-positive women attending PMTCT clinics who qualify for antiretroviral therapy (ART) in the five Foundation-supported regions in Tanzania are receiving it. If 90 percent of treatment-eligible women were to receive ART, it is estimated that an additional 671 infant infections would be averted per year. If the necessary requirements, including education of staff, supply chain provision, availability of CD4 counts, and permission to dispense infant ARVs, could be extended to all RCH facilities providing PMTCT services, the number and proportion of immunocompromised women receiving appropriate therapy, and thus of infant infections averted, could be increased. The Foundation s PMTCT program reaches more than 90 percent of pregnant women in the five regions where it operates, and it has been very successful in using the district approach to build capacity within MoHSW structures and to expand access to and uptake of PMTCT interventions. The program has been able to demonstrate consistency with national government policies and guidelines; to provide customized support within the local setting; to integrate services from the outset into existing RCH services at the district and facility level; and to promote interaction among stakeholders within the districts, who include service providers, clients, communities, and district supervisors. The Foundation also has excellent relationships with donors, partners, and MoHSW to implement its programs. Despite these successes, the program is held back by some policy constraints and challenges in service delivery, such as lack of human resources and poorly functioning commodity systems. Recommendations based on these factors will be used by the Tanzania country program to enhance its implementation and contribute to reaching the Foundation s mission of eliminating pediatric HIV. The findings and recommendations from this report can also be used by MoHSW, donors, and other implementing partners to strengthen national, regional, and district PMTCT and C&T services in Tanzania. Recommendations for improvement are also included in this report. 9

10 Introduction This evaluation report will explore coverage of prevention of mother-to-child transmission (PMTCT) of HIV services in Tanzania, compare selected PMTCT indicators used by Foundation-supported sites in Tanzania with indicators used in other Foundation country programs, present data from the past eight years to quantify uptake of PMTCT services, and synthesize the findings of 50 health facility assessments in an effort to understand differences in the quality of services provided. Section 1: Background 1.1 TANZANIA DEMOGRAPHIC OVERVIEW POPULATION AND HIV PREVALENCE Tanzania had an estimated population of million people in 2010, with the population growing at about 2 percent annually. 5 An estimated 1.4 million people in Tanzania were living with HIV in 2008, 140,000 of whom were children under age Among adults ages 15 49, the national prevalence of HIV is 5.7 percent. 7 However, women in this age category are at higher risk, with a prevalence of 6.6 percent, compared with prevalence among men of about 4.6 percent. Urban areas also have a higher prevalence (8.7 percent) than rural areas (4.7 percent). 8 It is estimated that 86,000 newborn infants are at risk of acquiring HIV every year, either during pregnancy, labor, and delivery, or through breastfeeding ADMINISTRATIVE STRUCTURE Tanzania is a large country in East Africa, comprising 26 regions that are subdivided into 127 districts. Each district contains several divisions, which are subdivided into wards, each consisting of five to seven villages. As part of an overall health management system overseen by the Ministry of Health and Social Welfare (MoHSW), regional health management teams coordinate implementation of reproductive and child health (RCH) activities and provide linkages between governance at national, regional, secretariat, and council levels. Within each region, the several districts, or councils, are the important administrative unit for public health planning and implementation, and are thus the focal points for health service development. The council health management team in each district is the body primarily responsible for the implementation, monitoring, and evaluation of health sector based, district-level HIV/AIDS activities. 10

11 1.1.3 MATERNAL HEALTH INDICATORS The total fertility rate for Tanzania is 5.6 births per woman; the crude birth rate (annual number of live births) is 42 births per 1,000 population. 10 Tanzania estimates there are approximately 1.4 million births annually. 11 According to data from the National Bureau of Statistics of Tanzania, it is estimated that 94 percent of women attend antenatal care (ANC) at least once during each pregnancy and 62 percent attend the recommended four visits. In 2005, only 47 percent of deliveries occurred in a health facility in Tanzania PREVENTION OF MOTHER-TO-CHILD TRANSMISSION IN TANZANIA Services for prevention of mother-to-child transmission (PMTCT) of HIV were introduced in Tanzania in 2000 when MoHSW established a pilot program at five health facilities (one regional and four referral hospitals). The main recommendation of the pilot program evaluation was to scale up PMTCT to all regions of the country through a phased approach. As of early 2007, only 10 percent of health facilities in Tanzania were providing the core components of PMTCT, and an estimated 12 percent of HIV-positive pregnant women were receiving antiretroviral (ARV) prophylaxis. In response to the need for greater access to these services, the government of Tanzania included a goal in its Health Sector HIV and AIDS Strategic Plan to increase the percentage of HIV-positive pregnant women who receive ARV prophylaxis to at least 80 percent by The government also set a target of providing comprehensive PMTCT services to at least 80 percent of pregnant women, their infants, and their families by MoHSW reports that as of 2009, 3,626 facilities out of 4,047 (78.6 percent) that provide ANC also provide at least some PMTCT services. In Tanzania, the department responsible for PMTCT at MoHSW is that of RCH. Components of RCH services provided by MoHSW include but are not limited to care before, during, and after childbirth; newborn care; male involvement in reproductive health; family planning; infant feeding practices; immunization; HIV counseling and testing; integrated management of childhood illnesses; and adolescent sexual and reproductive health. The PMTCT program has successfully been integrated into the department as an integral part of RCH services. The national strategy for interventions to prevent mother-to-child transmission of HIV in Tanzania is guided by four elements of a comprehensive approach to preventing HIV infection in infants and young children: 1. Prevention of primary HIV infection 2. Prevention of unintended pregnancies among women infected with HIV 3. Prevention of HIV transmission from women infected with HIV to their infants 4. Provision of treatment, care, and support to women infected with HIV, their infants, and their families According to the 2007 Tanzanian national PMTCT guidelines, 14 PMTCT services include routine HIV testing and counseling, ARV treatment and prophylaxis for mothers and children, safer delivery practices, counseling and support for safer infant feeding practices, long-term follow-up care for mother and child, and family planning services. The guidelines further stipulate that all women of reproductive age should receive HIV counseling and testing as a routine procedure when accessing RCH services, and that all pregnant women should receive pre HIV test information at their first antenatal visit and or as soon as possible thereafter. The diagnosis of HIV 11

12 infection in adults is established by detecting HIV antibodies using simple rapid tests according to the national HIV rapid testing algorithm. PMTCT services were implemented to provide the following benefits: 15 PMTCT of HIV through the use of ARV therapy (ART) and ARV prophylaxis for HIV-positive women and HIV-exposed infants Strengthened antenatal care, safe delivery practices, and counseling and support for safer infant feeding practices Linkage of mothers (and other household members) living with HIV to care, treatment, and support services, prolonging their lives and enhancing the survival of their children Follow-up of HIV-exposed infants to monitor their health and HIV status; provide prophylaxis, treatment, or both for opportunistic infections; and link them to care, support, and treatment Establishment of a nonstigmatizing entry point for HIV and AIDS information (i.e., primary prevention), as well as counseling and testing for women and their partners, families, and communities Establishment of an entry point for family planning services to help women and men living with HIV make informed reproductive choices 1.3 THE FOUNDATION S PROGRAM IN TANZANIA The Elizabeth Glaser Pediatric AIDS Foundation (the Foundation) began to support PMTCT services in designated Tanzanian facilities in 2002 under a five-year global cooperative agreement with the U.S. Agency for International Development (USAID) named the Call to Action (CTA). In collaboration with MoHSW, the Foundation-supported Tanzania program initiated PMTCT activities through CTA beginning in Currently, the Foundation supports 33 districts in five regions (Arusha, Kilimanjaro, Mtwara, Shinyanga, and Tabora) in the provision of PMTCT services to pregnant women, their children, and their families, through 37 sub-grantees. By December 2009 the Foundation was able to support 960 health facilities to initiate PMTCT services in the five regions. These activities are implemented with the goal of reaching all RCH facilities with PMTCT services, including hospitals, health centers, and dispensaries. In 2009, there were an estimated 409,470 pregnancies in the five regions of Tanzania supported by the Foundation, 16 representing more than 29 percent of total births in Tanzania. The Foundation reported 393,000 pregnant women eligible for services 17 attending RCH facilities for ANC. The number of eligible women seen in the Tanzania program constituted about one-sixth of the Foundation s global program in The Foundation-supported Tanzania program has evolved to be one of the Foundation s four largest country programs. In March 2004, subsequent to the start of the Foundation s PMTCT program in Tanzania, Project HEART (Help Expand Antiretroviral Therapy), funded by the U.S. Centers for Disease Control and Prevention (CDC), was initiated. Project HEART has maintained a focus on integrating care and treatment with PMTCT services in order to provide a family-centered model of care that includes access to ART for HIV-infected pregnant mothers, HIV testing and care for partners and families, and screening and treatment for TB and other opportunistic infections. Please see Appendix 4 for more information. 12

13 sdnvp = single-dose nevirapine; MER = more efficacious regimens; EID = early infant diagnosis; C&T = care and treatment Figure 1. Map of Tanzania with Foundation-supported regions 13

14 Section 2: Foundation-Supported Tanzania PMTCT Services 2.1 COVERAGE The number and type of health facilities in the five regions supported by the Foundation in 2009 are shown in Table 1. The Foundation-supported Tanzania program has worked toward providing services for prevention of mother-to-child transmission (PMTCT) of HIV in all public-sector and faith-based reproductive and child health (RCH) facilities in its geographic regions. Table 1. Number and Type of Facilities Supported by the Foundation to Provide PMTCT Services in 2009 Region Number of Foundation-supported facilities Hospitals Health centers Dispensaries Total Number of regional RCH health facilities* % of facilities supported by the Foundation Arusha % Kilimanjaro % Mtwara % Shinyanga % Tabora % Total ,086 88% *Numbers from district RCH coordinators Figure 2 shows the expansion of the Foundation s PMTCT program in Tanzania; the program has grown dramatically since its inception. It supported fewer than 50 facilities in the first year, rising to almost 1,000 by The number of women accessing antenatal care (ANC) for the first time climbed from fewer than 5,000 in 2004 to almost 400,000 in This is both a remarkable growth in facilities and a great increase in the number of women provided with access to PMTCT services. 14

15 Figure 2. Number of women attending first ANC in Foundation-supported facilities and number of facilities, DISTRICT APPROACH TO SCALE-UP OF PMTCT SERVICES The Foundation-supported Tanzania program has come to utilize a decentralized, or district, approach in accordance with the country s decentralization policy, in which districts are to become the focal point for health service development. Decentralization is at the core of local government reform in Tanzania, with the goal being to move resources, decision making, and program implementation to the districts. The Foundation defines the district approach as working with the regional authorities through the districts. It involves building district-level capacity to plan, implement, and monitor PMTCT activities. 18 The district approach strengthens the speed and quality of the scale-up process and promotes the long-term sustainability of services through integration of PMTCT activities into existing structures and systems. The Foundation s Tanzania program has worked closely with Tanzanian Ministry of Health and Social Welfare (MoHSW) regional health management teams (RHMTs) and district council health management teams (CHMTs) to scale up PMTCT services in the five regions where MoHSW implements PMTCT programs, in accordance with the Foundation s supportive role. This role includes providing technical support to districts for effective planning and implementation of integrated health programs, for training and mentoring, and for ensuring the quality of health services through supportive supervision. It also includes coordinating, monitoring, and supervising health activities in each region, as well as supporting districts in their analysis and utilization of program data. RHMTs have the responsibility of reporting to MoHSW at the national level. Specifically, the Foundation works with the regions in conducting initial assessments, planning PMTCT programs with the districts, providing training and supervision, and holding meetings to discuss program progress. The Foundation works in close collaboration with the district throughout the scale-up process. For example, from the outset, the district combines its resources with those of the Foundation to provide PMTCT services. The financial contribution of the Foundation, as well as that of the district, is clarified in the program budget, which is developed collaboratively. PMTCT funds are then channeled directly to the district rather than through another nongovernmental organization or individual health facility, in order to ensure district 15

16 ownership. The district is held accountable for all expenditures made in association with the approved plan and for timely reporting. Where supplies are included in the plan and budget, the district handles procurement in accordance with local guidelines. The approach aims to ensure that district PMTCT activities achieve financial sustainability. Therefore, the Foundation stresses the importance of including PMTCT activities in comprehensive council health plans from the start so that all stakeholders are conscious of the financial implications of the program. The success of this approach depends on the involvement and collaboration of a range of district personnel, including those serving in non-health-related capacities. This strategy has evolved over time as the Foundation realized the importance of involving stakeholders from outside the local health authorities. Initially, the Foundation worked closely with the key district-level health administrators, such as the district medical officer, the district AIDS control coordinator, and officers of the CHMT. However, it was later discovered that other top-level district government officials, such as the district executive director and district treasurer, also needed to be involved in planning and decision making in accordance with local policies and procedures. As a result, the district approach now involves all program partners (district authorities, the CHMT, service providers at facilities, and the Foundation) working together to plan, manage, and implement the scale-up of services. Key characteristics of the district approach: There are several characteristics of the district approach that distinguish it from other more conventional methodologies for health services expansion: A focus on building technical capacity at the district level to provide sustainability and rapid service expansion from the inception of planning the services An emphasis on financial sustainability so that activities are included in district budgets and do not indefinitely rely on support from an implementation partner Mechanisms for ongoing supportive supervision and monitoring to ensure the quality of services and to address challenges as they arise Sequential steps to implementing the district approach: 1. Conduct an initial assessment with district staff members. 2. Engage the district administration, including professionals outside the health field such as the district executive director and the district treasurer. 3. Involve community leaders to promote PMTCT services. 4. Establish PMTCT training capacity in the district. 5. Link PMTCT training with the establishment of new health facilities. Helping newly trained PMTCT service providers to establish services at their facility is one of the district PMTCT trainers responsibilities. 6. Integrate supportive supervision into the district routine. 7. Facilitate the exchange of experiences between districts to build awareness of successful programmatic approaches. 8. Involve district stakeholders in monitoring and evaluation. District-level capacity must be developed so that district personnel can use the data collected for program improvement and local, decentralized decision making. These data can also be used to advocate for program support. 16

17 9. Make cost sharing explicit. The respective contributions of the supporting organization and the district or facility should be clarified from the outset to help the district plan for sustainability. 10. Help build district leadership. 11. Ensure linkages to all elements of care. The capacity of the existing local referral network must be assessed at the outset and reinforced throughout the process as needed. 12. Build the district s financial management capacity through staff training and regular supervisory visits by compliance officers. 13. Facilitate modification of the approach within the context of national guidelines. 14. Encourage team building. 15. Establish district control over the budget. 16. Establish district control over procurement of equipment and supplies CAPACITY BUILDING AND SUPPORT TO DISTRICTS AND PARTNERS: TECHNICAL PROGRAMMING Developing PMTCT Proposals In order to identify appropriate sub-grantees, the Foundation solicited proposals in the regions that MoHSW identified as having priority. Requests for applications were sent to government institutions, district councils, and faith-based organizations, inviting them to submit a letter of intent. Representatives from selected institutions and organizations were invited to participate in a workshop to further develop their proposals. Prior to proposal writing, the Foundation assisted districts in conducting initial assessments that helped them to develop their funding proposals. A key aim of this approach was to build technical capacity, including writing of proposals, at the district level. More districts in Foundation-supported regions were included in the program year by year until all the districts were covered. Year by year, as the institutions capacity to write proposals gradually improved, development of renewal proposals took less time. District personnel became increasingly focused on setting targets and prioritizing activities; their understanding of integrating PMTCT into RCH services increased, and more health facilities were included in the program year after year. Building Training Capacity Crucial to the successful scale-up of PMTCT under the district approach is the Foundation s strategy to train PMTCT district trainers and to link the training of service providers to the establishment of new PMTCT services. District trainers receive supportive supervision from the Foundation during their first training, but they train service providers independently thereafter. The Foundation helped districts identify staff members who would become PMTCT district trainers, according to set criteria. The Foundation then conducted interviews to assess whether the selected candidates had the essential knowledge and skills to become trainers. Using national PMTCT trainers and the national curriculum, a two-week training-of-trainers course was conducted for selected service providers and supervisors. Similar trainings were conducted as necessary to fulfill program expansion requirements. District and regional trainers served as a useful resource in training service providers. They have facilitated rapid scale-up of PMTCT services in Foundation-supported regions. 17

18 This novel approach to training has significantly strengthened local capacity and makes it possible to support districts in direct response to the needs of the population being served. In 2004, the Foundation trained and provided supportive supervision to 24 trainers of trainers. These 24 trainers then trained 252 facility-based health-care workers (HCWs). In 2006, the Foundation trained 17 additional trainers, for a total of 41 trainers, who in turn trained another 407 HCWs, bringing the total to 659 trained service providers. In 2008, an additional 20 trainers were trained. By the end of 2009, the 61 trainers trained and supervised by the Foundation had trained 3,295 service providers at all health facility levels. This group of trainers has assisted in the establishment and continued provision of PMTCT services in five regions of the country. Assisting Districts in PMTCT Supervision During the first three months of establishing services, the Foundation officers accompany the district teams during their monthly supportive supervision visits to recently trained PMTCT providers at newly established health facilities. These accompanied visits are reduced to quarterly, then semiannually, and eventually only as needed. The regions supported are large geographically, and the supervision of this extensive program has been managed through field visits. It is intended that health facilities receive mentoring in PMTCT and care and treatment (C&T) once per quarter. The approximately 800 PMTCT-only health facilities are visited relatively infrequently due to the size of the program and available resources. The district approach allows the Foundation to provide resources and technical assistance to the CHMTs to build their own capacity and take ownership of performing the necessary supervision to these more rural, smaller health facilities. The frequency and quality of these visits are variable and depend upon local leadership and resources. The Foundation also funds quarterly coordination meetings in each district to maximize use of available resources to support PMTCT-only health facilities. At these meetings, health facilities can address various challenges, and health-care providers share their registers to verify data and improve its quality. Mentoring PMTCT Facilities The Foundation trained two or three PMTCT district mentors per district to enhance the skills of service providers in PMTCT service provision. The district mentors conduct monthly mentorship visits to facilities. Since the number of facilities is large, the mentors identify potential facilities to visit, such as those with low performance in the previous quarter, those with newly trained staff, and those that have recently established PMTCT services. Sharing of Knowledge and Experience Service providers, the people who are working at the facility level, are in the best position to make positive changes in service provision, policies, and guidelines by sharing what they experience in their day-to-day work. Most of the time, they are not given the opportunity to share their experiences to improve performance and maintain a high quality of care. Having realized the importance of experience sharing for service providers, the Foundation encourages districts to have quarterly providers meetings. The Foundation has developed a guide to help districts plan meetings and provides support in conducting them. During the meetings service providers discuss problems and experiences, share site-specific quarterly data, update their PMTCT knowledge, set ways forward for improving PMTCT services, and so forth. Supporting Community Activities The Foundation has one community linkages officer in each of its field offices and two in the Dar es Salaam country office. These officers provide technical assistance to the districts using districts community structures to sensitize community members to PMTCT, pediatric HIV and AIDS, and follow-up of exposed infants. Using the community sensitization guide developed by MoHSW in collaboration with the 18

19 Foundation, the districts are able to give key messages to the community on HIV. This goes along with advocacy activities that the Foundation uses at the district, regional, and national levels to advocate for utilization of established HIV services. Building Capacity for Monitoring and Evaluation The Foundation recognizes the importance of high-quality monitoring and evaluation (M&E) systems for real-time measurement of program performance and for program improvement through systematic and regular feedback. The Foundation continuously assists districts in strengthening M&E at the clinic and district levels through training health-care providers and supervisors, introducing data quality checklists, giving feedback, and providing regular supportive supervision. In addition, the Foundation has facilitated the availability and use of Kiswahili-language guidelines. Whenever necessary, the Foundation has supported printing of additional M&E tools to be used at the facility level. Managing the Supply Chain In order to have access to a continuous supply of antiretroviral therapy commodities, PMTCT commodity management at the service provider level needs to be strengthened. The supply should respond adequately to constant changes in the program. The Foundation has therefore been providing technical support to help service providers correctly forecast the needs of PMTCT sites. The Foundation has also helped build the capacity of service providers and RCH coordinators to maintain inventory systems, including those of safety stocks, so that commodities are used before they expire. In addition, the Foundation has trained personnel in the proper use of logistics management information system tools. The Foundation has also been working with other stakeholders to disseminate information regarding changes of regimens and new commodities available, to receive and distribute donations from other partners of test kits and nevirapine, and to procure hemoglobin reagents for sites when there are shortages from the national supplier. Ensuring Quality of Laboratory Services The Foundation utilizes resources from both the U.S. Centers for Disease Control and Prevention (CDC) and the United States Agency for International Development (USAID) to assist districts in ensuring that laboratory tests at all levels, including lower-level health facilities, are conducted according to national standards. In addition to procuring lab equipment, including CD4 and HemoCue machines, the Foundation conducts trainings and provides technical assistance in the use of standard operating procedures for HIV testing and attends to quality assurance issues as necessary. Continuing capacity building is achieved through supportive supervision and mentorship, thus improving access to C&T for HIV-positive pregnant women CAPACITY BUILDING AND SUPPORT TO DISTRICT PARTNERS: CONTRACTS AND GRANTS The Foundation s Tanzania program s Contracts and Grants (C&G) Department has launched several initiatives aimed at enhancing support to sub-awardees in order to assist with building the capacity of partners to manage finances and accounting in accordance with U.S. government (USG) rules and regulations, and to ensure that the funds awarded to partners are properly safeguarded and utilized. Initiatives include the following (and more information is provided in Appendix 5): Pre-award assessment: Assesses the capacity of potential partners to implement an award, documenting the findings and discussing them with the prospective sub-awardee Training: Offered on USG rules and regulations 19

20 Hands-on assistance: A partnering relationship that emphasizes capacity building and effectively addresses any questions, concerns, or issues partners may have Monthly financial reports: Required from each sub-awardee to forecast cash requests for a period from two to three months. This practice has resulted in a 30 percent to 50 percent increase in the burn rate of sub-agreements. Sub-awardee handbook: A 60-page handbook for sub-awardees to explain the nature of the program and organization they are partnering with, the administrative intricacies of the agreement, and the ways in which the Foundation will be supporting them Audits: An audit checklist and reporting template, in order to conduct a semiannual audit of each partner. The semiannual audits have had the following results: - Recovery of funds not used in accordance with required policies and procedures - Proper documentation of expenses - Verification of controls to safeguard funds - Building of partner capacity through knowledge of best practices that benefit management and implementation of other activities Renewal transition improvement: An annual plan for renewing sub-agreements in order to address the gaps that have previously occurred when partners were renewing their awards Risk management: Assigns a risk level to each partner and monitors the ways in which these risk levels may change over time Joint facility visits: By the C&G team and the technical team, to provide standard and consistent feedback to partners in a more holistic fashion Section 3: Methodology 3.1 EVALUATION DESIGN Conducted from April to June 2010, the evaluation of the Foundation s Tanzania program for prevention of mother-to-child transmission (PMTCT) of HIV employs both quantitative and qualitative methods of data collection and analysis. It collates information from policymaker, provider, and community perspectives. Methods used to collect data include interviews to obtain qualitative information; review of data from different documents, including monitoring and evaluation (M&E) tools; and observation using a structured checklist filled in at each health facility. 3.2 GOAL OF EVALUATION The goal of this evaluation was to determine whether the Foundation, with support from the United States Agency for International Development (USAID), has increased access to quality services for PMTCT, including linking to care and treatment (C&T) for women, children, and their families, in Tanzania. 3.3 OBJECTIVES OF EVALUATION 20

21 To describe the current status of PMTCT program implementation in the Foundation program in Tanzania, facility and population coverage in five regions (by number of districts and PMTCT sites), and contribution of the program to overall national PMTCT program coverage To assess and describe increase of access to PMTCT in Foundation-supported regions, looking at the following indicators and comparing data over the period : PMTCT coverage and accessibility; PMTCT cascade (women eligible, counseled, tested, and received results); maternal and infant antiretroviral access, including single-dose nevirapine (sdnvp), more efficacious regimens (MER), and antiretroviral therapy; increase in deliveries at facility; infant infection as measured by early infant diagnosis (EID) data; and male partner testing To assess the quality of Foundation-supported PMTCT services with focus on the following areas: - The Foundation contribution to national PMTCT programs - PMTCT integration within antenatal care (ANC) and maternity; with C&T, provider-initiated testing and counseling, and/or EID; and with other non-hiv required care such as syphilis screening and testing, infant growth monitoring, immunization, and malarial prophylaxis for mothers - Strategies for and integration of PMTCT into existing reproductive and child health (RCH) services and health systems, and strategies for involving the community, including male partners - Service acceptance frequency (quality of services according to the national PMTCT guidelines assessed by, e.g., client satisfaction tools and interviews with care providers) - M&E and data management (number of PMTCT data collection tools and the language of each, understanding by service providers and supervisors, reporting system, quality of data, etc.) - Partnerships with the Ministry of Health and Social Welfare (MoHSW), donors, and partner organizations To evaluate the practicality and impact of the district approach model and the degree to which the program can be replicated To evaluate the impact of the Foundation s capacity development activities focusing on supportive supervision, training, and improving skills of care providers To assess the cost-effectiveness and sustainability of the program To evaluate supply chain management and procurement systems in order to analyze stock-outs of diagnostics, drugs, or equipment To review existing Tanzanian national policies and guidelines, particularly with regard to up-to-date, evidence-based information and potential barriers to optimal implementation To identify main program challenges and provide recommendations for improvement 3.4 SAMPLING METHOD For the purposes of this evaluation, our sample of facilities was drawn from the five regions where the Foundation provides PMTCT services Arusha, Kilimanjaro, Mtwara, Shinyanga, and Tabora selecting districts within these regions that were performing well and those that were below the expected standard. The sampling technique was stratified and purposive in order to make sure all criteria were met. 21

22 Criteria for the health facilities selected for the sample were as follows: At least 1 health facility from each of the 5 regions At least 50 health facilities for PMTCT (to be representative of 1,000 health facilities) Of these 50, at least 25 having MER provision Catchment area (health facilities with highest population reach) Type of facility (a balance of hospitals, health facilities, and dispensaries) Inclusion of health facilities that provide sdnvp Inclusion of 60 percent facilities that cover all services (PMTCT, EID, C&T, lab, CD4) Inclusion of 20 percent facilities that provide sdnvp without C&T Inclusion of 20 percent facilities that provide MER without EID Inclusion of facilities with both the highest and the lowest proportion of facility deliveries 3.5 PMTCT EVALUATION TEAM The evaluation team comprised 2 senior consultants, 12 research assistants, and 3 data entry clerks working under the supervision of district PMTCT coordinators. The Foundation recruited research assistants and trained them for three days before they commenced fieldwork. The aim of the training was to familiarize the research assistants with the Foundation s scope of work, to explain the goal and specific objectives of the evaluation, and to familiarize them with the evaluation tools. This also presented an opportunity to remind research assistants of research ethics and the expected code of conduct in the field. The training program included role playing the interviewing techniques and translating the tools into Kiswahili for easy administration of the interview guide and communication with target respondents. The tools were then revised and finalized based on input from this process. Three teams were created to visit the five regions. One team visited Mtwara, the second team went to Shinyanga and Tabora, and the last team covered Arusha and Kilimanjaro. PMTCT coordinators of the districts supervised the teams to ensure quality control in areas such as completeness of interviews and selection of respondents. 3.6 QUANTITATIVE DATA COLLECTION Each facility records patient data in both ANC and labor and delivery settings. Data about counseling, testing, HIV status, and antiretroviral prophylaxis, as well as other process indicators, can usually be obtained from the daily patient registers, and every effort is made to promote standardized definitions of key program indicators related to PMTCT services. These data, which are collected at the facility level, represent program results among the population of women attending RCH clinics. The data are submitted to the Foundation s Tanzania M&E staff members, who review and submit the data electronically to the Foundation s global headquarters on a quarterly basis for entry into the Global AIDS System for Evaluation and Reporting (GLASER), an online data warehouse developed in 2007, in which the Foundation stores the data on its PMTCT and C&T programs. The indicators are standardized across all Foundation programs and are 22

23 consistent with standards of the national monitoring program in each country. Data are reviewed for inconsistencies, trends over time, and health facility variability to facilitate discussion of challenges and improvements. The data also undergo a series of hard and soft checks of quality designed to bring attention to any apparent gross data entry errors or programmatic situations that cause the data to appear substantially different from what one would expect. Queries are sent to in-country staff for appropriate corrections. This evaluation utilized the GLASER database to create graphs and charts that describe the program. Comparisons of the overall Foundation program, the 2009 calendar year for the Tanzania program, and the cumulative eight years of the Tanzania program provide a description of the accomplishments in Tanzania and the challenges to be addressed. In addition, with the assistance of MoHSW data, including the Tanzania HIV/AIDS and Malaria Indicator Survey, an effort was made to assess the coverage obtained by the program in the five regions. The evaluation used available estimates of the number of pregnancies by district and region provided by MoHSW. Available literature, including program reports, published articles, and Tanzanian MoHSW documents, was reviewed to assess program progress and to examine information on program inputs, activities, achievements, challenges, and lessons learned. 3.7 QUALITATIVE DATA COLLECTION Qualitative methods used for data collection included (1) in-depth interviews with policymakers, service providers, and regional and council health management teams, and (2) direct observation of facility services using an observation checklist. The in-depth interview guide and the observation checklist were adapted from the Family Health International/Foundation 2003 baseline assessment tools for PMTCT 19 and the rapid health facility assessment manual developed by MEASURE Evaluation, ICF Macro, and USAID. 20 The respondents for the in-depth interview guide included the regional authorities (regional medical officer, regional RCH coordinator, and regional AIDS control coordinator), the district management (district medical officer, district RCH coordinator, district AIDS control program coordinator, and district executive director), and service providers from selected facilities. All staff members in the regional and district coordination areas were eligible for interview. In-depth interviews were also held with key informants such as personnel from USAID, Foundation technical experts in charge of coordinating PMTCT activities, Foundation partners (International Center for AIDS Care and Treatment Programs, AIDS Relief, Family Health International, and the Clinton Health Access Initiative), and MoHSW staff members coordinating PMTCT. Qualitative data were collected in a total of 60 selected sites, with a total of 119 key informants reached. The research team visited sites and interviewed people from the regional, district, and facility levels in the following numbers per region: Arusha, 12 facilities and 31 individuals; Kilimanjaro, 11 facilities and 35 individuals; Mtwara, 12 facilities and 39 individuals; Shinyanga, 14 facilities and 37 individuals; Tabora, 11 facilities and 38 individuals. The research team also conducted physical site visits and walk-throughs to assess each facility s ANC area, voluntary counseling and testing services and space, maternity services, laboratory, and pharmacy supplies and services. This gave the evaluation team an opportunity for direct observation of the space, commodities, and equipment of each facility. A total of 48 health facilities were assessed using the observation checklist. 3.8 DATA ANALYSIS 23

24 Appropriate techniques were used to analyze the data. The quantitative data from the GLASER database were analyzed through cross tabulations, frequency distributions, graphs, and charts to describe the Foundation s Tanzania PMTCT program over time. Qualitative data collected from the study were entered into an Excel spreadsheet and coded by theme. Content analysis was then carried out by theme. Through triangulation in order to validate data from the different methods of collection, a final evaluation report was developed. 3.9 LIMITATIONS OF THE EVALUATION Due to limited time available to conduct this evaluation and to obtain ethical approval in accordance with national and international requirements, the perception of clients of quality of services was not explored. Service providers shared information regarding their perception of patients satisfaction. However, in the future it would be optimal to develop a new evaluation to determine patient satisfaction with PMTCT services. Other limitations of the evaluation include challenges with data reliability, measure and analysis, and sample size. These are explained in more detail below: Reliability of data: Data sources often used as a denominator for calculations came from the Tanzania National Bureau of Statistics (NBS) and thus cannot be confirmed, creating a possible limitation. One possible caveat to the NBS data is that these are projected estimates and, for example, may have underestimated the population of the Shinyanga urban area, Shinyanga being known to have high levels of urban migration. Measure and analysis of data: The Foundation does not use cohorts of pregnant mother / exposed infant pairs, allowing lag time of up to multiple quarters between pregnant mother data collection and exposed infant data collection, thus causing artificial spikes and shortfalls in the data. Other instances of artificial spikes and shortfalls would be seen during periods when policy has recently changed. For example, when the policy changed to allow all newly diagnosed patients to receive ARV immediately, administration to patients who had not received it under the old policy caused a spike. Sample size: A possible limitation exists when including sites with low coverage rates, which may cause high sample bias. For example, some sites reported higher percentages for no prophylaxis and sdnvp than what was reported for the overall population, a situation that may seem incongruent. But in reality, no prophylaxis is expected since these clients are less often identified for services. Section 4: Findings Section 4 presents the main findings of the evaluation of the Foundation s Tanzania program for prevention of mother-to-child transmission (PMTCT) of HIV being implemented in five regions Arusha, Kilimanjaro, Mtwara, Shinyanga, and Tabora. The main areas discussed in this section include coverage of PMTCT services in the regions served, a view of the Tanzania program within the broader context of the Foundation s global work, program coverage at the regional level, antiretroviral (ARV) prophylaxis uptake by mothers and infants, regimens for PMTCT prophylaxis in antenatal care (ANC), ARV uptake in labor and delivery (L&D), access to infant ARVs, ARV treatment of HIV-positive pregnant women, use of existing systems to implement the PMTCT program, and gap analysis. 4.1 COVERAGE OF PMTCT SERVICES IN THE FIVE REGIONS 24

25 The Foundation has supported the initiation of PMTCT programs in the public sector and in facilities of faith-based organizations in five regions in Tanzania for eight years; however, most of the expansion has occurred in the last few years. By 2009, all 33 districts in these five regions were providing PMTCT services to pregnant women, their children, and their families. This portion of the PMTCT evaluation seeks to describe PMTCT services in terms of population coverage of pregnant women. For purposes of this evaluation, coverage is best defined as access to PMTCT facilities, since PMTCT services are not provided at all facilities that provide ANC. The Foundation s Tanzania program was supporting 88 percent of all reproductive and child health (RCH) facilities in the five regions served at the time of the evaluation (as reported in Table 1), indicating that PMTCT is available to most pregnant women who accessed ANC, making coverage a strong feature of the Tanzania program that deserves attention in this evaluation. The Foundation s PMTCT coverage of facilities has been reviewed in this evaluation through December In Table 2, the expected number of pregnancies per district and region, as estimated by the National Bureau of Statistics (NBS) of Tanzania, 21 is used as the denominator to capture the theoretical number of women in need of PMTCT services. The number of pregnant women reported to the Foundation as having been provided with services in an RCH setting (ANC, maternity, or Expanded Program on Immunization) that is, the number of women actually receiving those services is designated as the numerator. The proportion thus calculated is the population coverage. 25

26 Table 2. PMTCT Coverage Region NBS-projected number of pregnancies Number of pregnant women with access to PMTCT services* Percentage of pregnant women with access to PMTCT services Arusha 55,351 51,281 93% Kilimanjaro 42,332 38,773 92% Mtwara 44,537 40,287 90% Shinyanga 175, ,518 89% Tabora 107, , % Total 424, ,888 93% * Pregnant women with access to PMTCT services is defined as those who access PMTCT services for the first time during the current pregnancy (usually the first ANC visit). Source: NBS data and Foundation data The percentage of pregnant women reported as having used Foundation-supported health facilities in these five regions varies from 89 percent to more than 100 percent. In Tabora region, the number of women seen in Foundation-supported facilities exceeds the number of pregnancies projected by NBS; this could be the result of projection errors or a change in fertility rate because the last time Tanzania undertook a census was TANZANIA PMTCT PROGRAM COUNSELING AND TESTING COVERAGE, 2009 The overall coverage of pregnant women for the entire Tanzania program for 2009 is displayed in Figure 3. The first bar is the estimated number of total pregnancies provided by NBS. 22 The Foundation cascade does not usually include the first column, so it typically calculates the percentage of women counseled, tested, and receiving results based on the number of women who came to a clinic. However, not all pregnant women come to a clinic. Thus, in the present evaluation, when we calculate uptake based on total expected pregnancies, we include the women who receive no services at all because they do not attend clinic or attend one without PMTCT services. 26

27 Note: All percentages are calculated as percentage of NBS-projected pregnancies. Source: NBS data and Foundation data Figure 3. PMTCT coverage in Foundation-supported regions of Tanzania, 2009 Evaluation of the overall program reveals a high level of coverage: Using the NBS projection for all pregnant women as the denominator, 91 percent of all pregnant women were counseled, 87 percent were tested, and 86 percent received the results of their testing. Another way to look at coverage is to examine the number of women who arrive in L&D with unknown HIV status. These women either previously refused testing, were not offered testing in ANC, or did not attend ANC at all. During 2009 and the first quarter of 2010, 458,783 first ANC visits were reported by all Foundation-supported facilities in Tanzania, and 28,655 women with unknown HIV status delivered in a facility. Thus only 7 percent of women who had attended ANC in Foundation-supported facilities in these regions arrived for delivery with unknown status. Because only about half of women deliver in a facility, these women of unknown status derive from half the pregnant population. However, it is very impressive that the rate of women not reached by testing at Foundation-supported facilities is only 6 percent. As Figure 4 shows, the proportion of women arriving at delivery with unknown HIV status has been dropping rapidly for several years. During the fourth quarter of 2009 and the first quarter of 2010, fewer than 4,000 women came to all delivery facilities in the Foundation-served regions of Tanzania with unknown HIV status. This speaks to the extremely high coverage of PMTCT services in these five regions. The vast majority of women in these regions are attending ANC and being provided with PMTCT services. 27

28 Figure 4. Percentage of women delivering in a facility who have unknown status, he goal of providing access to PMTCT services to 80 percent of pregnant women has been more than realized in the Foundation programs in the five regions, where access lies somewhere between 89 percent and 101 percent. This remarkably large program has efficiently scaled up and delivered services to almost all women attending RCH clinics. 4.3 PMTCT SERVICE COVERAGE BY REGION Figure 5 shows expected heterogeneity in PMTCT service coverage by region. Recognition of these differences permits further evaluation to describe lower-performing regions and districts. This information at the facility level guided the site selection for field visits. Overall coverage in Arusha, Kilimanjaro, and Mtwara regions appears higher than coverage in Shinyanga and Tabora. Source: NBS data and Foundation data Figure 5. Foundation Tanzania PMTCT coverage by region,

29 4.3.1 SHINYANGA AND TABORA REGIONS, 2009 Shinyanga region has eight districts, and Tabora region has six districts, shown in Table 3. Shinyanga rural and Bukombe districts (in Shinyanga region) did not achieve the same high level of counseling, testing, or provision of results as other districts; the reported stock-out of SD Bioline HIV test kits, which was attributed to problems in procurement between Shinyanga districts and the Tanzania Medical Stores Department, may have contributed. Figure 6 shows overall coverage in both regions. 29

30 Table 3. Uptake as a Proportion of Estimated Pregnancies, in Foundation-Supported Shinyanga and Tabora Regions, 2009 Region/District NBS-estimated number of pregnancies Number of pregnant women with access to PMTCT services Number counseled Number tested Number who received results n (%) n (%) n (%) n (%) Shinyanga region Bariadi 40,421 36,038 (89) 35,236 (87) 34,292 (85) 34,194 (85) Bukombe 28,194 18,518 (66) 15,877 (56) 14,114 (50) 14,114 (50) Kahama 35,009 35,637 (102) 31,893 (91) 28,763 (82) 28,637 (82) Kishapu 13,728 11,299 (82) 11,282 (82) 11,088 (81) 11,041 (80) Maswa 19,538 14,829 (76) 14,851 (76) 14,085 (72) 14,217 (73) Meatu 15,412 12,955 (84) 12,775 (83) 12,622 (82) 12,620 (82) Shinyanga rural 16,551 13,184 (80) 12,418 (75) 11,057 (67) 11,925 (72) Shinyanga urban 6,871 14,058 (204) 13,629 (198) 12,939 (188) 12,939 (188) Total 175, ,518 (89) 147,961 (84) 138,960 (89) 139,687 (80) Tabora region Igunga 19,926 18,991 (95) 19,135 (96) 17,396 (87) 17,080 (86) Nzega 24,433 27,365 (112) 24,530 (100) 20,860 (85) 20,822 (85) Sikonge 8,899 8,603 (97) 8,810 (99) 8,372 (94) 8,372 (94) Tabora urban 12,953 10,714 (83) 10,818 (84) 10,573 (82) 10,306 (80) Urambo 23,137 24,961 (108) 22,887 (99) 22,498 (97) 22,147 (96) Uyui 17,675 17,395 (98) 16,910 (96) 15,625 (88) 15,625 (88) Total 10, ,029 (101) 103,090 (96) 95,324 (89) 94,352 (88) Note: All percentages are calculated as percentage of NBS-projected pregnancies. 30

31 Source: NBS data and Foundation data Figure 6. PMTCT coverage of Foundation-supported Shinyanga and Tabora regions, ARUSHA REGION, 2009 Arusha region has five districts, and the data for each in 2009 are listed in Table 4. Arumeru district, which includes Arusha municipal, has the highest coverage, even though Arusha municipal recorded the lowest. Ngorongoro, Monduli/Longido, and Karatu districts have population coverage of 89 percent, 93 percent, and 93 percent, respectively. Of particular interest is the high level of uptake in all parameters of coverage after women access services. 31

32 Table 4. Uptake as a Proportion of Estimated Pregnancies, Arusha Region, 2009 Region/District NBS-estimated number of pregnancies Number of pregnant women with access to PMTCT services Number counseled Number tested Number who received results n (%) n (%) n (%) n (%) Arusha region Arumeru (includes Arusha municipal) 32,680 30,438 34,147 33,891 33,883 Karatu 7,893 7,375 (93) 7,349 (93) 7,281 (92) 7,281 (92) Monduli/ Longido 9,050 8,376 (93) 8,594 (95) 8,406 (93) 8,396 (93) Ngorongoro 5,728 5,092 (89) 4,900 (86) 4,777 (83) 4,477 (78) Total 55,351 51,281 (93) 54,990 (99) 54,355 (98) 54,037 (98) Note: All percentages are calculated as percentage of NBS-projected pregnancies. Source: NBS data and Foundation data Source: NBS data and Foundation data Figure 7. PMTCT coverage in Arumeru district, Arusha municipal district, and Arusha region,

33 It seems the main weakness in Arusha is effectively providing access to PMTCT services to all pregnant women. Once pregnant women reach RCH, almost all are counseled, tested, and provided with their results. Improving access to PMTCT services for pregnant women in Arusha is necessary. To some extent the gap may be diminished by adding PMTCT services to additional RCH facilities. Arumeru district has succeeded in providing high coverage of pregnant women in spite of several factors, including the distance of patients from a facility, overall attendance at ANC, seasonal and local conditions such as flooding that have an impact on transportation, and sociocultural factors that may pose barriers to care KILIMANJARO REGION, 2009 Kilimanjaro region, with its six districts, is providing coverage at about the same level as Arusha region (see Table 5). 33

34 Table 5. Uptake as a Proportion of Estimated Pregnancies, Kilimanjaro Region, 2009 Region/District NBS-estimated number of pregnancies Number of pregnant women with access to PMTCT services Number counseled Number tested Number who received results n (%) n (%) n (%) n (%) Kilimanjaro region Hai 7,955 7,613 (96) 7,192 (90) 6,981 (88) 6,964 (88) Moshi urban/ Moshi rural 15,184 14,720 (97) 14,529 (96) 14,311 (94) 14,266 (94) Mwanga 3,634 3,364 (93) 3,382 (93) 3,320 (91) 3,320 (91) Rombo 7,955 7,395 (93) 7,397 (93) 7,000 (88) 7,000 (88) Same 7,604 5,681 (75) 5,684 (75) 5,684 (75) 5,684 (75) Total 42,332 38,773 (92) 38,184 (90) 37,296 (88) 37,234 (88) Note: All percentages are calculated as percentage of NBS-projected pregnancies. Source: NBS data and Foundation data

35 Source: NBS data and Foundation data Figure 8. Kilimanjaro region and Moshi district coverage, 2009 Although Moshi is administratively divided into two districts, Moshi urban and Moshi rural, it is combined in Figure 8 as one district because many of the clinics from both administrative districts are selected by clients for geographic proximity. For the catchment population, then, there are not two defined sets of facilities separated by a significant distance but in effect a single district. Overall, regional PMTCT services achieve 92 percent coverage of the projected number of pregnancies MTWARA REGION, 2009 Mtwara region is the fifth region provided support by Foundation. It now has six districts, but the 2009 data displayed in Table 6 combine the recently divided Masasi and Nanyumbu districts into the former single Masasi district. 35

36 Table 6: Uptake as a Proportion of Estimated Pregnancies, Mtwara Region, 2009 Region/District NBS-estimated number of pregnancies Number of pregnant women with access to PMTCT services Number counseled Number tested Number who received results n (%) n (%) n (%) n (%) Mtwara region Masasi/ Nanyumbu 17,554 15,594 (89) 15,841 (90) 15,702 (89) 15,702 (89) Mtwara rural 8,220 9,167 (112) 9,057 (110) 8,796 (107) 8,769 (107) Mtwara urban 3,464 3,515 (102) 3,570 (103) 3,568 (103) 3,568 (103) Newala 6,954 5,427 (78) 6,290 (91) 6,209 (89) 6,182 (89) Tandahimba 8,345 6,584 (79) 6,927 (83) 6,743 (81) 6,743 (81) Total 44,537 40,287 (91) 41,685 (94) 41,018 (92) 40,964 (92) Note: All percentages are calculated as percentage of NBS-projected pregnancies. Source: NBS data and Foundation data Newala district has the lowest coverage in the region, Mtwara rural the highest. Again, the only significant bottleneck in coverage is access to PMTCT services, as delineated above. The proportion of women counseled, tested, and receiving results is more than 80 percent of women who access services in all districts. 36

37 Source: NBS data and Foundation data Figure 9. PMTCT coverage in Mtwara rural district, Newala district, and Mtwara region, 2009 As the foregoing discussion reveals, the Foundation has achieved excellent coverage of RCH facilities at 88 percent in five regions, varying from 75 percent in Arusha to 95 percent in Tabora. Using the NBS-projected number of pregnancies as a denominator, 93 percent of pregnant women have accessed ANC and obtained PMTCT services in the regions supported by the Foundation. 4.4 ANTIRETROVIRAL PROPHYLAXIS UPTAKE BY MOTHERS AND INFANTS Since the Foundation began PMTCT work in Tanzania in 2003, a cumulative total of 44,243 women have tested HIV-positive (adding to 3,115 who were known to be HIV-positive) overall, 47,358 HIV-positive women were reported to have attended Foundation-supported antenatal clinics. The cumulative rate of those who tested HIV-positive is 4 percent. During this time, 39,961 HIV-positive pregnant women (84 percent) have received ARV prophylaxis, but only 16,987 exposed infants (36 percent) received it. In all, 16 percent of HIV-positive mothers and 64 percent of exposed infants did not receive, or were not recorded to have received, ARV prophylaxis. In 2009, the Foundation s Tanzania program reported that 12,621 women tested HIV-positive (adding to 1,738 who were known to be HIV-positive), and the total number of HIV-positive women seen at the clinics was 14,359. The proportion of pregnant women testing HIV-positive was 3.4 percent. As a result, 11,140 HIV-positive pregnant women (78 percent) received ARV prophylaxis and 5,641 exposed infants (39 percent) received ARV prophylaxis. In 2009, 22 percent of HIV-positive mothers and 61 percent of HIV-exposed infants were reported to receive no ARV prophylaxis. This drop in women receiving prophylaxis was caused by a change in policy to start ARV prophylaxis at point of diagnosis (based on a successful pilot and draft guidelines from the Ministry of Health and Social Welfare). However, the ministry (MoHSW) called back this draft, and policy reverted to ARV prophylaxis after 28 weeks of gestation, which reduced uptake. 37

38 Uptake of ARV prophylaxis by pregnant women and infants in the Foundation s Tanzania program is impaired in part by policy barriers. At the MoHSW level, infant ARVs for prophylaxis are not dispensed in ANC clinics REGIMENS FOR PMTCT PROPHYLAXIS IN ANC Considerable effort has been invested in training staff and educating facility workers about the use of more efficacious regimens (MER) of prophylactic ARV. Tanzanian PMTCT guidelines are evolving to mirror those of the WHO, which recommend that zidovudine (AZT) plus single-dose nevirapine (sdnvp) should be used for pregnant women whose CD4 counts are higher than 350. The guidelines also advise that lamivudine (3TC) plus AZT be given during and after labor to diminish the virus resistance created by nevirapine (NVP). The facilities supported by the Foundation in Tanzania by 2009 reported that between 35 percent and 40 percent of eligible women identified as HIV-positive in ANC received no prophylactic ARVs in ANC (this figure does not include the women receiving ARVs in L&D wards). However, 43 percent of HIV-positive women in ANC receive sdnvp during PMTCT staging, making Tanzania one of eight Foundation country programs with a high proportion of sdnvp provision in ANC. In Tanzania, this reliance on sdnvp in ANC is due to a delay in review and adoption of the WHO 2010 PMTCT guidelines 19 that include MER, which has delayed the wide use of MER in the country. Likewise, Tanzania adopted the 2006 WHO guidelines in 2007 by issuing revised national guidelines. However, implementation was delayed and did not actively begin until early In addition, Tanzania does not dispense infant prophylactic drugs to mothers during ANC. This practice is stipulated by MoHSW for the following reasons: Safety and storage: MoHSW is concerned with whether pregnant women could safely keep the drugs to remain usable by the time they deliver. This takes into account the socioeconomic and cultural background of most of the population. Reliability of administration (of drugs): MoHSW is concerned with ensuring that infants receive the drug and those taking the drugs are reported into MoHSW databases from the facility reports. In the five regions of Tanzania where the Foundation works, all facilities that provide care and treatment (C&T) services (46 hospitals and 74 health centers) also provide PMTCT. Of these facilities, all hospitals provide C&T and PMTCT using MER. Additionally, 43 dispensaries, scattered through all five regions, provide MER without being able to provide C&T, and a few dispensaries also provide C&T. Of the health centers, 29 provide only sdnvp, without C&T or early infant diagnosis (EID), and 15 provide C&T and EID but not MER, relying only on sdnvp services for PMTCT. Usually all HIV-positive pregnant women receive NVP during labor and delivery and are dispensed a tail of AZT plus 3TC postpartum. In summary, the rapid expansion has maintained consistent services, with only a few identified disparities. All facilities providing C&T (except the listed health centers) provide MER. All hospitals in these regions provide C&T as well as PMTCT, dispensing MER. Twenty-nine health centers have yet to incorporate MER into their PMTCT programs; in addition to sdnvp, a few health centers also provide C&T ANTIRETROVIRAL UPTAKE IN LABOR AND DELIVERY IN PMTCT It is important to assess dispensing regimens in L&D as well as in ANC. PMTCT services need to be accessible at each possible entry point for the patient. It is essential that a woman who is HIV-positive be identified when she comes to deliver her infant. When she presents at L&D, her HIV status should be 38

39 ascertained if unknown and appropriate medications dispensed if she has not yet received medication or has not taken it. The ARV regimen for HIV-positive pregnant women in the L&D ward should include the following: A combination regimen for use at all health facilities that have the capacity to initiate ARV treatment and have the ARV medications available; and A minimum single-drug regimen that can be used at sites that do not have capacity to initiate ARV drugs. Women testing HIV-positive during ANC who are not eligible for ARV treatment: Pregnant women who do not need ARV treatment for their own health should be given combination ARV prophylaxis starting in ANC. During ANC: Start AZT 300 mg BD from 28 weeks or anytime thereafter. During labor: Give sdnvp 200 mg at the onset of labor. Give AZT 300 mg and 3TC 150 mg at the onset of labor. Continue AZT every 3 hours and 3TC every 12 hours until delivery. During the postpartum period: Continue AZT 300 mg BD and 3TC 150 mg BD for 7 days. All infants receive sdnvp 2 mg/kg as soon as possible after delivery and AZT syrup 4 mg/kg BD for 4 weeks, or 1 week (7 days) if a mother received at least 4 weeks of AZT during ANC. Pregnant women presenting during labor who test HIV-positive: During labor: Give sdnvp 200 mg at the onset of labor. Give AZT 300 mg and 3TC 150 mg at the onset of labor. Continue AZT every 3 hours and 3TC every 12 hours until delivery. During the postpartum period: Continue AZT 300 mg BD and 3TC 150 mg BD for 7 days. All infants should receive sdnvp 2 mg/kg as soon as possible after delivery and AZT syrup 4 mg/kg BD for 4 weeks. Mothers who test HIV-positive after delivery: All infants should receive sdnvp 2 mg/kg immediately after birth and AZT syrup 4 mg/kg BD for 4 weeks. Only those infants born to identified HIV-positive mothers and delivered in a facility are receiving ARVs in Tanzania. More than 90 percent of HIV-exposed infants born in a facility received ARV prophylaxis in Tanzania only 8 percent of HIV-exposed infants born in a facility were not given any drug. Of those who received ARVs, 38 percent received NVP only and 53 percent received MER. 39

40 4.4.3 ACCESS TO INFANT ARVS % facility deliveries - general population % facility deliveries - HIV+ population Source: Global AIDS System for Evaluation and Reporting (GLASER) data. Figure 10. Reported deliveries as proportion of women attending ANC in all five Foundation-supported regions of Tanzania With 93 percent of HIV-positive women attending ANC but not receiving infant ARVs at ANC, and only approximately 40 percent of infants being delivered in a facility, 60 percent of infants born to HIV-positive mothers do not receive ARV drugs in Tanzania. Figure 10 compares the proportion of deliveries in a facility occurring in the general population with the proportion of facility deliveries among HIV-positive women. The proportion of HIV-positive women who delivered in a facility has not demonstrably risen over the three years depicted. Thus, the combined effects of delivery at home and restriction from dispensing infant ARVs for use outside facilities has resulted in lower-than-desired infant uptake. The failure to give both mother and infant access to PMTCT interventions means mother-to-child transmission of HIV will not be reduced. For optimal effectiveness, both maternal and infant medications should be given. Maternal ARVs alone or infant ARVs alone will be less effective than the combination. For the national program to achieve desired effectiveness, mothers and infants must both receive ARV prophylaxis. If maternal and infant access to ARVs were improved, the effectiveness of the PMTCT program in Tanzania would be greatly enhanced. 4.4 ANTIRETROVIRAL TREATMENT OF HIV-POSITIVE PREGNANT WOMEN ARV treatment should be provided to all HIV-positive pregnant women who meet the country eligibility criteria. The population of women with CD4 counts of less than 350 is known to be responsible for more than 76 percent of mother-to-child transmission of HIV. 23 Therefore, identification of the women in need of ARV therapy is essential for their health, and it will simultaneously prevent vertical transmission of HIV. 4.5 USE OF EXISTING SYSTEMS TO IMPLEMENT PMTCT PROGRAMS This evaluation looked at the Foundation s Tanzania PMTCT program in terms of its integration with other services as well as its use of existing guidelines, data management practices, and partnerships. PMTCT is 40

41 integrated into facilities offering RCH in the five regions where the Foundation works. The facilities are owned varyingly by government, nongovernmental organizations, and the private sector. Following are the findings in these areas PROGRAM INTEGRATION Integration of PMTCT services in RCH clinics has given more pregnant women the opportunity to be tested for HIV, and for those testing positive to receive prophylaxis. Pregnant women are educated on how to prevent HIV infection in their children during pregnancy, delivery, and feeding. They are counseled and tested through provider-initiated testing and counseling (PITC). Clients identified as in need of HIV care and treatment are referred to care and treatment clinics (CTCs) for treatment of opportunistic infections, receipt of ARVs, and any related services. Integration of these services has reduced stigma because clients are attended to by one service provider. Even though some clients may be lost in the referral chain as discussed below, integration has reduced the number of such losses, especially where services are in one location. Integration of PMTCT into RCH services has succeeded in increasing awareness of HIV, improving staff knowledge, and reducing stigma, but it still has some challenges that need immediate redress. These include staff shortages, high workload, staff burnout, limited working space for conducting PMTCT services, low male involvement, and lack of privacy due to shortages of space. Most supported districts have successfully initiated PMTCT services into most of their RCH facilities. In Arusha region, Meru district, 34 out of 53 health facilities have integrated RCH and PMTCT. Out of these 34 health facilities, 6 also offer C&T. Rombo district in Kilimanjaro region has 41 facilities, with 32 of them offering PMTCT in RCH settings. With all pregnant women screened for HIV at the first visit to a health facility, Rombo district s coverage is about 98 percent. Some districts have achieved PMTCT provision in all their RCH facilities, including Nanyumbu district in Mtwara, Maswa district in Shinyanga, and Nzega district in Tabora. It is reported that about 80 percent to 95 percent of women in RCH facilities in Mtwara region are willing to receive HIV counseling and testing on their first and follow-up visits. Community mobilization has helped to raise awareness in the community about HIV, PMTCT, and male participation. It is reported that the community is accepting of the services, and women may even specifically request the services, called damukubwa, or big blood, when they are referred for an HIV test. All districts noted that community outreach activities have had a positive impact on clinic attendance. Outreach has increased community awareness of HIV and AIDS, which in turn has increased clinic attendance (especially for pregnant women), increased the number of clients who come for checkups, and increased the number of men participating in the PMTCT program, even though the number of men is still not very significant. However, community outreach efforts may lack adequate privacy for clients. It was suggested that changing MoHSW confidentiality policies to allow couples to be counseled and tested together would improve efficiency of services in RCH. It was also suggested that the District AIDS Control Programme and the district RCH coordinator should work better together for more effective program implementation REFERRAL SYSTEMS Most health centers and dispensaries need to refer clients to a higher-level facility for CD4 counts, hemoglobin checks, and prescribing of ARV drugs. Some of the problems identified with the referral system include failure of the service provider to file the referral form and inability of the provider to follow up on the client. Women often do not complete the referral by attending the higher-level facility, citing transportation costs and long distances as the main reasons. The discrepancy between the very large number of RCH facilities with integrated PMTCT and the smaller number of CTC health facilities has resulted in the 41

42 expressed wish to have all PMTCT health facilities offer C&T. If women identified as in need of treatment are not successfully referred, they do not receive appropriate therapy. During the discussion on referrals, it was noted that most clients are referred for CD4 count and for hemoglobin check. Health facilities with equipment to conduct these tests are limited. There is only one reported CD4 machine in Bukombe district in Shinyanga, while all districts reported a shortage of hemoglobin machines. Results from the observation checklist revealed that hemoglobin testing was available in 64 percent of facilities in Mtwara, 88 percent in Arusha, 64 percent in Kilimanjaro, 55 percent in Tabora, and 57 percent in Shinyanga, for an average of 65 percent availability across the five regions MALE PARTNER INVOLVEMENT Districts have used various innovative methods to encourage men to participate in PMTCT services. These have included organizing community mobilization efforts, giving a letter to the pregnant woman that invites her male partner to visit the RCH clinic on his partner s next visit, and assigning a number that the man can bring to the center to be counseled and tested. Districts are using influential people such as religious and political leaders to encourage participation of men in RCH/PMTCT services. Yet despite all the efforts put in place, only small increases have been observed in male involvement. Only about 36,000 male partners of pregnant women were tested for HIV in 2009, with 1,515 testing positive. When asked why male involvement in PMTCT is poor, respondents reported that male partners feel that PMTCT is the woman s responsibility and that, as head of household, they do not need to listen to their wives regarding HIV testing. Disclosure of HIV-positive status by the wife is generally not common, respondents reported, and there is a misconception that the man s status will be the same as that of his partner. Workers in Shinyanga region pointed out that when health facility space is very limited, bringing males into the ANC clinic means not enough seats for all, and perhaps that is also a discouragement. To address the gap in male involvement, community health education measures aim to teach men about the services available in RCH and the importance of participating in the care of their infants. As an incentive for men to participate in RCH services, women who bring their partners are given priority in some clinics FACILITIES Despite the fact that facilities generally have limited space to serve their entire catchment area, which has increased over the years, the Foundation s Tanzania program has reached about two-thirds of the pregnant women in Kilimanjaro region and three-quarters in Arusha region. Based on MoHSW pregnancy estimates, more than 90 percent of pregnant women accounted for in the Tanzania HIV/AIDS and Malaria Indicator Survey (THMIS) are seen in ANC clinics supported by the Foundation. When women attend an RCH facility with both PMTCT and C&T services, almost all learn their HIV status and receive C&T. PMTCT services add a disproportionate need for space in the RCH because each patient needs private time with the healthcare worker (HCW), often on at least two occasions: for post-test counseling and for examination. Long waiting times are noted. All five regions have high numbers of home deliveries. Most pregnant women (53 percent) deliver at home with traditional birth attendants (TBAs), even those who may have attended ANC. 24 The primary reason given by respondents was that facilities are often far away from where some of the community members live. The community still believes very much in the ability of TBAs to provide a safe birth, despite counseling received at ANC visits. Many respondents reported that the facilities are located at a distance from homes of patients without reliable or affordable transportation, and that the physical infrastructure of the facilities is perceived as not as comfortable as home, where a familiar TBA can be present. 42

43 Another shortcoming in the program is that CD4 counts are not available at all facilities providing PMTCT services. When the blood sample must be sent to another facility, delays are likely to occur. Drawing blood for CD4 counts may be limited to a specific day or days of the week, and the specimen must often be transported to the laboratory of another facility, usually within the district. This necessitates that the woman return to the RCH clinic for the blood draw if she has not attended on the correct day, and return once more for the results. Because repeat trips are not always possible, she may fail to learn of her low CD4 count and thus fail to receive therapy. Collection tubes providing greater stability to white blood cells are available and may help alleviate the problem of drawing blood only on specific days. Point-of-care CD4 counts are under development and would help to improve the routine drawing of blood for CD4 counts. The Foundation s Tanzania PMTCT program is viewed as one of the initiatives that can contribute to a decline in maternal and child mortality. The program is strong in building the capacity of service providers, and those interviewed for this evaluation felt the quality of overall services had improved. The RCH integration of PMTCT has provided excellent coverage and important entry points (ANC, maternity, wellchild clinic) for HIV-positive mothers and HIV-exposed or -infected children, as well as other family members such as siblings and male partners. The interviewed staff felt that HCWs are working together and have embraced PMTCT services as part of the routine services to be available to all in the community. The knowledge level of all women about HIV has improved, and providers cite a decrease in HIV prevalence in pregnant women as a possible result SUPPLIES AND PROCUREMENT SYSTEM The MoHSW Medical Stores Department (MSD) uses an integrated logistics system to replenish PMTCT commodities at RCH facilities. The system requires that the service facility complete a report and a request form for any supplies and commodities that are running low, which is then submitted to the district pharmacist. The district pharmacist then orders the commodities from MSD or any other supplier within three months. This logistics system is working, but it needs to be strengthened to ensure an effective supply chain for HIV products. There have been problems over time in terms of stock-outs or low supplies of test kits, ARVs, and reagents. Districts do not use data to quantify their needs, even though they are trained on commodity supply chain management. Through the U.S. President s Emergency Plan for AIDS Relief (PEPFAR), the U.S. government brought in the Supply Chain Management System, which has already begun to address these issues. Trainings have already been held, including ones on PMTCT and C&T commodity management. During fieldwork, the research team inquired about possible stock-outs of PMTCT commodities such as reagents, test kits for HIV, test kits for syphilis, drugs for prophylaxis, or ARVs. At the facilities visited in 2009, there were no stock-outs reported in Arusha, but Kilimanjaro s Rombo district reported a one-month stock-out of reagents due to delivery delays from MSD. The other three districts also noted stock-outs. In Shinyanga, Bariadi district highlighted running out of gloves; Bukombe and Kahama districts noted stockouts of SD Bioline and dried blood spot real-time polymerase chain reaction (DBS-PCR) test kits. In Mtwara, although stock-outs were generally infrequent, Masasi district reported a cotrimoxazole syrup stock-out; in Newala, a Determine test kit stock-out was cited, and Nanyumbu reported a stock-out of NVP syrup. Tabora region experienced frequent stock-outs, with Urombo and Tabora municipal districts short of NVP syrup and borrowing from other facilities. Igunga district had stock-outs of HIV test kits and DBS-PCR test kits. These stock-outs were attributed to poor recording and forecasting, which contributed to delays in procurement. It has been documented that MSD has distributed commodities nearing their expiration date, 43

44 leading to outdated stocks and the need for replacement. Karatu district, for example, noted that test kits received were outdated POLICIES AND GUIDELINES Government of Tanzania PMTCT guidelines limit the distribution of ARV drugs to women who are at least in the 28th week of gestation, 14 thus not permitting women who come for their first ANC visit prior to 28 weeks to receive ARVs. In Tanzania, as previously noted, 94 percent of women attend ANC at least once, and 62 percent attend four times. About half (47 percent) of women deliver with a skilled birth attendant in a facility. 17 If the first antenatal visit is before 28 weeks and the mother does not return, she receives no ARVs. If she returns after 28 weeks, it must be possible for providers to know she needs ARVs and then to record her receipt of medication when given. With knowledge and agreement by MoHSW, the Foundation conducted a pilot study in 2006 of the consequences of removing the 28-week restriction on the dispensing of ARV medications to pregnant women. The study was conducted in 73 health facilities providing PMTCT services, including 5 hospitals, 11 health centers, and 57 dispensaries. All participating service providers started giving sdnvp tablets at the time of diagnosis (at that time, Tanzania was using only sdnvp), usually the first ANC visit. No extra training was conducted for the providers, but the supply of sdnvp tablets was increased to these health facilities to meet increased demand. The results, covering July through September 2006, show a near doubling of provision of ARV prophylaxis when provided at the time of diagnosis (see Table 7). 44

45 Table 7. Distribution of ARV Doses at 28 Weeks or Later (April June 2006),* Compared with Distribution at Time of Diagnosis (July September 2006) Nzega Igunga Sikonge 28 weeks or later Distribution at diagnosis 28 weeks or later Distribution at diagnosis 28 weeks or later Distribution at diagnosis Pregnant women tested for HIV Women identified as HIV-positive 4,898 5,556 3,426 4,292 2,349 2, Women provided with sdnvp tablets 116 (42.9%) 340 (94.9%) 96 (54.8%) 242 (102.9%)** 80 (66.6%) 152 (102%)** * Based on WHO PMTCT Guidelines, 2006 ** A result of more than 100% was due to two factors: (1) women in labor received ARV/sdNVP after they had forgotten the tablet at home or did not take it at the onset of labor, and (2) women identified at ANC before 28 weeks in earlier months received ARV/sdNVP at follow-up visits during the study period. A closer look at one district is shown in Table 8. Sikonge district demonstrated a sequential improvement with time as providers distributed sdnvp to women at the time of HIV diagnosis. Table 8. Distribution of ARV Doses at 28 Weeks or Later (April June 2006), Compared with Distribution at Time of Diagnosis (July September 2006) Sikonge district April May June July August September Pregnant women tested for HIV Women identified as HIV-positive Women provided with sdnvp tablets 5 (13.8%) 13 (25.5%) 21 (42.9%) 40 (85%) 50 (102%)* 40 (100%) * A result of more than 100% was due to two factors (which also may contribute to inflated percentages elsewhere): (1) women in labor received ARV/sdNVP after they had forgotten the tablet at home or did not take it at the onset of labor, and (2) women identified at ANC before 28 weeks in earlier months received ARV/sdNVP at follow-up visits during the study period. Providers reported appreciating the ease of providing the drug upon diagnosis rather than asking women to return for it, and they said the women were grateful to receive it. There is no guarantee that the patient will swallow the tablet, but if she has never received it, she cannot take it unless she delivers in a facility where sdnvp is available PARTNERSHIPS 45

46 With a niche in pediatric care, the Foundation works with a number of partners in convening the Tanzania Pediatric Association conference. The Foundation contributes significantly to MoHSW development of various materials that include policy and strategic documents; guidelines; data collection tools; and materials for information, education, and communication. MoHSW developed its first PMTCT guidelines, curriculum, and monitoring and evaluation (M&E) system in partnership with a technical working group that included the Foundation. Other partners include the International Center for AIDS Care and Treatment Programs, the Clinton Health Access Initiative, Family Health International, AIDS Relief International, University Research Co., Abbott Fund, various faith-based organizations, and private hospitals. In addition, the Foundation works with development partners at the national level through MoHSW technical working groups to discuss policies, strategies, guidelines, and curricula. However, there is a need for more regular meetings for experience sharing. The districts have described their partnership with the Foundation as positive, and the Foundation is viewed as supportive, with a spirit of teamwork. In the Arusha region, district personnel added that the communication channel between the Foundation, the districts, and the region is always open. Districts also have other partners that they work with in the implementation of HIV and AIDS interventions, such as home-based care, family planning, lab renovation, condom distribution, vaccination, and adolescent health, to name a few. All these partners work together with the Foundation to improve the health of women and children. People living with HIV are involved in HIV and AIDS programming as expert patients in the community. They participate in education in communities and at facilities, emphasizing the importance of RCH clinic care for women and children. With support from Pathfinder (in Arusha region), people living with HIV are involved as volunteers in home-based care and participate in HIV and AIDS commemoration. Some have formed support groups for psychosocial support, such as UMATU in Karatu district. The support groups could be strengthened through funding for income-generating projects. In Shinyanga region, there is less involvement of people living with HIV, although some have formed clubs in Shinyanga municipal district, and some assist with mobilizing people for testing and counseling for drug adherence. People living with HIV are also working with the CTC in Kahama, assisting with filing client records, giving health education, and weighing clients. The Foundation needs to continue to find innovative ways of involving people living with HIV in PMTCT. Meaningful involvement has been found to reduce stigma and discrimination. Even though the Foundation is the only partner providing PMTCT services, there is a pool of other partners in the five regions implementing an array of interventions. Synergies can be drawn among partners for improved service provision, since they all serve the same population MONITORING AND EVALUATION SYSTEMS FOR PMTCT In accordance with MoHSW policies and guidelines, the Foundation s PMTCT program follows the MoHSW M&E system. RCH staff members manage the data, and providers must complete six registers (ANC, care, treatment, mother follow-up, child follow-up, and L&D). Service providers compile summary reports every month, submitting four such reports at the district level, and there are additional reports for THMIS. Due to the workload and complexity of these registers, the reports are often not of high quality. District RCH coordinators (DRCHCos) do not acknowledge receipt of the reports or give feedback on facility performance, nor do they use the reports for planning their supervision; hence the data are not used to improve service provision. In some districts, however, DRCHCos 46

47 have started to sign a dispatch form as a record of report submission in response to the Foundation s advocacy for proper documentation, quality improvement, and use of the data to improve services. As part of the funding sub-agreements that each district has with the Foundation under U.S. government funded awards, districts report quarterly to the Foundation. Usually the reports have to be physically collected because there is no other standard way of submitting them due to poor infrastructure around most health facilities. Occasionally phones are used to send reports to the district from health facilities through voice calls or short message service. At the Foundation, the data are uploaded to the Global AIDS System for Evaluation and Reporting (GLASER). At the national level, MoHSW data are still managed in a paper-based system, but a computerized national database has been developed and will soon be rolled out. Due to work overload, lack of constructive feedback, and lack of ownership of these data, site-to-district reporting is often not timely and not complete. Lots of follow-up is often needed before a report is submitted. At Foundation-supported sites, nearly 100 percent of reports reach the district and regional levels, but only about 60 percent of these reports reach the MoHSW central office. The major bottleneck is from regional to national level, which lacks a systematic way for reports to be submitted. The entire data flow is represented in Appendix 6. The Foundation has developed the reporting capacity of district PMTCT coordinators through training. These coordinators submit the quarterly reports to the Foundation via . The field office checks the data submitted, uploads them into the database, and forwards the database to the Foundation s headquarters. After validation of data, the Foundation produces a simplified report that is sent to the field office and then to the district as feedback on performance. The districts hold quarterly data review meetings, and information is used for planning the next quarter s activities. These reports are sometimes also discussed with district health management teams and personnel at the health facilities, depending on identified gaps. One weakness observed in the PMTCT national program is that HIV M&E systems are not integrated in the normal THMIS system. Service providers reported that the number of registers is large and that recording data is time consuming. To ensure that MoHSW and Foundation data are the same, the districts complete the Foundation template first and then copy relevant data from it into the MoHSW template. Reports are reviewed by the DRCHCo before submission to the region. The regions have not experienced many stockouts of MoHSW PMTCT data collection tools; only in a few instances have districts reported stock-outs of some forms and registers. Districts participate in quarterly performance feedback meetings, which are useful in assessing facility performance, identifying problems, and finding areas for improvement. The process motivates service providers to prepare even better reports and institute programmatic adjustments CLINIC PERFORMANCE In this evaluation, the authors observed that the better-performing clinics are likely to have more staff, committed HCWs, and all RCH services in one facility. Teamwork in these better-performing facilities is apparent. These clinics have less frequent transfer of staff and better-trained staff. Seeking services like treatment or CD4 count within such a facility is easier logistically than traveling to another facility. Clients appreciate easy access to the facility. The clinics having more challenges with services are likely to have fewer staff and higher turnover, or have untrained staff. In some clinics this leads to unqualified staff providing suboptimal services, or in some cases leads to forced closure due to lack of qualified staff. Private clinics charge clients for services, affecting access. 4.6 GAP ANALYSIS 47

48 To summarize the findings of the evaluation of the Foundation s Tanzania PMTCT program, the authors performed a gap analysis to identify some gaps in the program that should be addressed. Table 9 indicates the identified gaps by area of focus. A checkmark in one of the last three columns indicates that program staff members at district level, within MoHSW and its partners, or in the Foundation were aware of the identified gap. Table 9. Gap Analysis Area Identified gaps District staff members aware MoHSW/ partners aware The Foundation aware PMTCT program Infrequent evidence basis for interventions Low quality of PMTCT services (tracking of HIVpositive pregnant women and exposed infants, initiation on C&T, number of defaulters) Vertical programming of PMTCT No measurement of transmission rate or survival Numerous and different partners for PMTCT, PITC, C&T, EID (Mtwara) Low percentages of women delivering at facilities Low uptake of exclusive breastfeeding Challenges in bureaucracy in the districts, causing delays in disbursement of funds Poor identification and treatment of women who are immunocompromised Low implementation rates of MER Poor rate of identifying HIV-infected infants and initiating them on ART Male involvement Low level of male involvement High levels of stigma and discrimination Staffing Inadequate human resources for health Frequent turnover, redeployment, and rotation of trained HCWs 48

49 High workload Capacity building Low number of trained service providers Low capacity in C&T at RCH; many providers lacking capacity in EID, infant feeding Insufficient training for pharmacy and laboratory workers in PMTCT Facilities Lack of adequate space in RCH facilities Lack of furniture and audiovisual presentations for clients in waiting areas Commodities and equipment Frequent commodity stock-outs Regular transportation and communication problems Guidelines Few CD4 count machines Few hemoglobin machines National guidelines in English, not user friendly for all providers Slow adoption of WHO guidelines Lack of job aids M&E Weak M&E system with too many tools, indicators No single national M&E system 49

50 Section 5: PMTCT Program Effectiveness The data from the Foundation-developed Global AIDS System for Evaluation and Reporting (GLASER), the calculations of coverage, and the observed infection rate in infants (ascertained by analyzing data from polymerase chain reaction [PCR] HIV testing of infants) have been used here to attempt an assessment of the effectiveness of the Foundation s Tanzania program for the prevention of mother-to-child transmission (PMTCT) of HIV. The Pierre Barker model from the November 2008 meeting of the World Health Organization (WHO) 25 has been used. For all tables and figures, the values obtained in previous portions of this evaluation have been used. 5.1 METHODS USED In 2009, the reported rate of counseling across all five regions was 98 percent, and the reported rate of testing was 95 percent of women at antenatal care (ANC). Therefore, the calculated counseled-and-tested rate is 93 percent. The reported rate of uptake of maternal antiretrovirals (ARVs) for prophylaxis and treatment is 78 percent. GLASER analysis tells us that in ANC, the proportion of HIV-positive mothers receiving no ARV is 37 percent, the proportion of mothers receiving single-dose nevirapine (sdnvp) is 44 percent, the proportion receiving more efficacious regimens (MER) is 17 percent, and the proportion receiving antiretroviral therapy (ART) is 2 percent. The Pierre Barker model requires conversion of the percentages by using the total women receiving any ARV as denominator. Out of those who received any ARV, 70 percent of HIV-positive women received sdnvp, 27 percent of HIV-positive women received MER, and 3 percent of HIV-positive women were put on ART. Data on infants were gathered from the registers at sites performing early infant diagnosis (EID). Currently in Tanzania, performance of EID is restricted to sites providing care and treatment. Infants are tested at routine well-child visits at approximately six weeks of age. This study includes all infants who had dried blood spot polymerase chain reaction (DBS-PCR) tests done and results reported. The authors visited 25 clinics and examined their registers. Out of 25 facilities, 18 reported performing a DBS-PCR test on at least 95 percent of HIV-exposed infants; 2 clinics reported doing none; 2 clinics performed testing on 25 percent to 30 percent of exposed infants; and 3 clinics reported testing, respectively, 55 percent, 70 percent, and 85 percent of HIV-exposed infants. Thus a total of 1,500 infants were tested at 23 clinics and had their results reported. While this is an incomplete sample, it nevertheless represents all PCRs done at these clinics, and results are reported as test positivity rate, not as transmission rates. 50

51 Table 10. Observed Infection Rate in Infants Having PCR Done at About Six Weeks of Age, by Mother s Regimen Mother s regimen Number of infections Number tested % infected Nothing % sdnvp % MER % ART % Total 123 1, % 5.2 RESULTS OF ANALYSIS The observed infection rate in infants having their virological status ascertained is as follows (see Table 10): Of the infants whose mothers received no ART, 15 percent were infected (44 of 294), 9.2 percent of the infants whose mothers received sdnvp were infected (65 of 709), 3.4 percent of infants whose mothers received MER were infected (13 of 387), and 0.9 percent of the infants born to mothers receiving ART were infected (1 of 110). The results of this observed infection rate are illustrated in Figure 11, below. 51

52 PMTCT = prevention of mother-to-child transmission; ANC = antenatal care; ARV = antiretroviral; SdNVP = single-dose nevirapine; MER = more efficacious regimens; ART = antiretroviral therapy; MTCT = mother-to-child transmission Figure 11. Estimated transmission rate when attendance at ANC is 93 percent (per calculations of overall population coverage and reported attendance) Source: Barker 25. Using the assumptions that 91 percent attend ANC and 93 percent estimate of population coverage, now a total of 34 ( ) women do not get an intervention, and 5.1 of their infants are infected per 100 HIVpositive women. Some 4.3 infections occur in the infants born to the 70 percent of women who receive sdnvp, 0.61 infections in the infants of the 27 percent of women who receive MER, and.02 infections in the infants of the 3 percent who receive ART. The total infection rate is percent. It is important to know the true proportion of women attending ANC at least once. More than 90 percent of the reproductive and child health clinics in the five regions have PMTCT services provided by the Foundation. Thus the weakest part of service delivery is the uptake of ARV drugs by mothers. It should be expected that the increased use of MER and the increased number of eligible women accessing ANC will continue to expand and thus further reduce transmission. This exercise in estimating effectiveness demonstrates the benefits of coverage of the entire population as well as the current deficiency in pregnant women s receipt of ARV drugs. The policy changes suggested in the 52

53 recommendations section could have a measurable beneficial impact on the effectiveness of PMTCT programs. Section 6: Key Successes and Challenges, Recommendations, and Conclusion 6.1 KEY SUCCESSES AND CHALLENGES It is evident that the district approach has facilitated quick scale-up of services for the prevention of motherto-child transmission (PMTCT) of HIV in Foundation-supported regions. Keys to this success include consistency with national government policies and guidelines; customized support in the local setting; integration of services from the outset into existing reproductive and child health (RCH) services at the district and facility levels; and continuing interaction among players within the districts, including service providers, clients, communities, and district supervisors. Regardless of the observed successes, implementing the district approach is not without challenges. Some key challenges include these: Multiple constraints within the HIV/AIDS sector: Common constraints include staffing shortages, service bottlenecks, and social and cultural limitations that cannot be directly addressed by the program. Less direct control over program outcomes: The district approach has demonstrated great potential for PMTCT scale-up, but it also provides less direct control over program outcomes than traditional support strategies, such as working directly with individual facilities. Therefore, the quality and rate of expansion of PMTCT services largely depend on district leadership and the level of capacity at baseline. This must be understood and accepted by the Foundation and program donors. Inadequate financial management capacity: Initially, districts faced difficulties in reporting monthly expenditures and requesting funds for the subsequent two months, and sub-grantees reported only when money was spent and then submitted a new request. In some instances, little money was spent because of these bureaucratic constraints, which often delayed implementation of planned activities at the beginning of a partnership. As explained earlier, the Foundation initiated several strategies for dealing with these challenges. Rapid expansion of the program: With an ever-growing number of PMTCT sites in several regions, quality assurance through mentorship and supportive supervision required additional personnel in the Foundation-supported Tanzania program. Coordination and communication between sub-grantees and the Foundation became complicated at times because of the increasing number of sub-grantees and health facilities. The establishment of field offices has relieved this pressure and improved communication and coordination. Difficulty determining district readiness to operate independently: The Foundation provides initial funding, training, and mentorship, and then supportive supervision, until districts are ready to operate on their own. However, the appropriate time for graduation is difficult to determine. There is a continuing need for the Foundation to guide programmatic changes taking place within the district PMTCT programs, including ongoing integration of PMTCT with care and treatment (C&T) services. Nonetheless, increasing independence can be observed in a number of districts. A similar challenge exists with respect to financial sustainability. The Foundation goal is for districts to achieve financial 53

54 sustainability by including PMTCT in their comprehensive council health plans and by looking for alternative sources of funding. This is another instance where the cutoff point for Foundation support is difficult to determine. The Foundation has had, and continues to have, excellent relationships with donors, partners, and the Ministry of Health and Social Welfare (MoHSW) to implement its programs. The Foundation continues to make improvements to develop the financial management capacity of its partners and eventually hopes to be able to document ways in which it has reduced overall risk and enhanced the skills of its partners to manage budgets and implement programs. The Foundation s partners compare favorably with other program operators in Tanzania in the areas of financial management, sharing of skills, and overall management of their hospitals or programs. However, it is difficult to imagine the partners independently managing U.S. government funds without the Foundation s continued support or the significant involvement and ownership of these responsibilities by MoHSW. 6.2 RECOMMENDATIONS The Foundation has analyzed the data and challenges listed above and has developed the following set of recommendations to support MoHSW in implementing its programs. In implementing these recommendations, the Foundation will facilitate positive changes, for example advocate for policy change, build capacity to roll out early infant diagnosis (EID), increase uptake of CD4 testing, and so on. Fifteen detailed recommendations follow. RECOMMENDATION 1: INCREASE EARLY UPTAKE OF MATERNAL PROPHYLAXIS BY PROVIDING ANTIRETROVIRALS (ARVS) TO HIV-POSITIVE PREGNANT WOMEN AT THE TIME OF DIAGNOSIS, AS EARLY AS THE 14TH WEEK OF GESTATION. As more efficacious regimens (MER) are introduced, the World Health Organization (WHO) has recommended that HIV-positive pregnant women begin taking zidovudine (AZT) as early as 14 weeks of gestation, and optimally no later than 28 weeks, in order to achieve maximum effect. 26 There is no observed increase in viral resistance, nor is there any increase in anemia or other possible side effects, when AZT is initiated as early as 14 weeks. If a woman requires antiretroviral therapy (ART) because her CD4 count is lower than 350, other drugs of recommended first-line regimens can be safely added after initiating AZT, with no reduction of the effect of the combination regimen. Removing the prohibition on distributing these medicines in antenatal care (ANC) prior to 28 weeks has been shown in Tanzania and elsewhere to increase the proportion of women who receive medication to more than 90 percent. RECOMMENDATION 2: INCREASE UPTAKE OF INFANT ARV PROPHYLAXIS BY DISPENSING TO WOMEN IN ANC, PREFERABLY AT THE TIME OF DIAGNOSIS OF HIV INFECTION, FOR THEM TO TAKE HOME IN CASE THEY ARE NOT ABLE TO DELIVER IN A FACILITY. For optimal effectiveness of ARV prophylactic regimens, both the mother and the infant must receive the medication in the immediate neonatal period (within 72 hours of birth). In 2009 in Tanzania, only 39 percent of HIV-exposed infants (5,641) received ARVs, meaning that 61 percent of exposed infants failed to receive medication. Unfortunately, the Foundation s Tanzania program has the lowest infant uptake of ARVs of the four largest Foundation-supported programs. In Tanzania it is reported that approximately half of deliveries (47 percent) occur in a facility with a skilled birth attendant present. Infant ARVs are dispensed only in labor and delivery (L&D), and therefore infants 54

55 born at home receive no medication unless they are brought back to a facility within 72 hours after delivery. It has been demonstrated that dispensing infant medication to the mother at the time of HIV diagnosis improves infant access to the drugs in locations where the rates of delivery in a facility are low. 27 Of HIVexposed infants delivered in a facility, 92 percent receive antiretroviral medication. About half the infants get single-dose nevirapine (sdnvp) and half receive combination drugs for prophylaxis. This proportion is evolving and provides evidence that the programs are incorporating combination drugs. L&D providers are doing a good job of dispensing prophylaxis, but facility delivery will have to improve in order to increase maternal and infant uptake. RECOMMENDATION 3: INCREASE UPTAKE OF MER BY ALLOWING PERSONNEL IN ANC TO DISPENSE COMBINATION ARV PROPHYLAXIS TO PREGNANT WOMEN, AND TRAINING THEM TO DO SO. In Tanzania, the Foundation program provides C&T and PMTCT in five regions. The PMTCT services are integrated into existing RCH services. Facilities at all levels provide ANC and deliver infants, and the Foundation has supported the initiation and continuation of PMTCT services in 988 facilities (46 hospitals, 116 health centers, and 826 dispensaries). Depending upon the region, coverage of RCH facilities providing ANC varies from 75 percent to 95 percent. The Foundation has tried to provide maximal coverage of the pregnant population by supporting PMTCT at all health facilities that provide ANC or L&D services in all five regions where it works. Remarkable coverage of 89 percent of the population of pregnant women has been accomplished. Existing Tanzanian guidelines allow only medical doctors, medical officers, and assistant medical officers to dispense essential ARVs not the nurses and nurse-midwives who provide counseling, testing, and sdnvp. 28 bonly clinical officers and doctors can prescribe these medications, so additional medications are dispensed only to the extent that one of these authorized prescribers can participate in the PMTCT services of a facility. However, the availability of these prescribing professionals is far from optimal. The women identified at RCH clinics as HIV-positive have insufficient and inconsistent access to ART, since they must access a care and treatment clinic (CTC). These policies limit the ability of facilities to provide MER for both women and their infants. Trained personnel, such as nurses and nurse-midwives, could safely deliver ARVs while providing increased access to combination prophylactic regimens and to treatment. Nurses and nurse-midwives are already responsible for dispensing prophylactic sdnvp for PMTCT. They are trained to provide more efficacious combination regimens of ARV drugs for prophylaxis, but are not permitted to prescribe these medications. Task shifting to the trained personnel (nurses and nurse-midwives in RCH) will allow expanded prescription of combination ARV. RECOMMENDATION 4: INCREASE THE PROPORTION OF PREGNANT WOMEN RECEIVING ART BY IMPROVING CD4 COUNT AVAILABILITY, AND CONSIDER TASK SHARING OR SHIFTING TO ENABLE MORE STAFF MEMBERS TO PRESCRIBE AND DISPENSE ARV TREATMENT. For the same reasons described above in Recommendation 3, the number of HIV-positive pregnant women receiving ART could be increased through the strategic use of task shifting in Tanzania. There are too few health-care providers, including nurses, nurse-midwives, and doctors, available to optimally provide necessary C&T services, such as prescribing ART. 55

56 Data have accumulated demonstrating that increased viral load correlates with maternal transmission of the virus to the infant. In the absence of routine availability of viral load measurements, CD4 count is used to indicate maternal immunocompromise. Of the reported 12,600 infections diagnosed in 2009 in facilities supported by the Foundation s Tanzania PMTCT program, only 59 percent were screened and staged, 43 percent were enrolled in C&T, and only 4 percent received ART. The administration of appropriate ART depends upon the screening and staging of women and upon their CD4 count. There are probable deficiencies in clinical staging of women, compounded by the logistical problems of obtaining CD4 counts and by the lack of eligible prescribers who can give therapy to these immunocompromised women. Giving therapy during pregnancy is safe and prevents the emergence of nevirapine resistance, which can be incurred by administration of nevirapine alone. It is therefore desirable to focus on getting appropriate therapy to the immunocompromised women by using task shifting to allow a broader base of health-care providers to prescribe both ART and ARV prophylaxis. RECOMMENDATION 5: CONTINUE ROLL-OUT OF EARLY INFANT DIAGNOSIS AT ALL RCH FACILITIES WITH WELL-CHILD CARE CLINICS. The identification and provision of services to HIV-exposed infants has lagged behind the provision of interventions to prevent mother-to-child transmission and needs to be routinely integrated into the program in all facilities. EID should be expanded to all facilities providing well-child care. The procurement of the blood sample is simple, but the transport of the sample and the return of results will continue to pose logistical problems. RECOMMENDATION 6: DEVELOP MECHANISMS TO INCREASE THE NUMBER OF CHILDREN ON ART. Tanzania follows WHO guidelines in recommending ART for infected infants younger than one year old. This recommendation was extended in 2010 to all infected infants younger than two years old. However, it is clear from the number of infants on therapy in Tanzania that there are barriers to initiating ARVs in children there. The logistics of diagnosing infection, obtaining results, and successfully getting the infants to a CTC have not yet been optimally incorporated into the routine care of children. To overcome these obstacles, the Foundation suggests rolling out EID in all RCH clinics, making EID routine at all clinics for children under the age of five, linking EID to the Expanded Program on Immunization, and ensuring provider-initiated testing and counseling is done for children at all entry points, including pediatric wards. RECOMMENDATION 7: STANDARDIZE THE SYSTEMATIC AVAILABILITY AND USE OF THE NEW INFANT RECORDS CARD, INCLUDING DISCARDING ALL OUTDATED CARDS IN STOCK. Tanzania has created a new infant records card that displays maternal information relevant to care of the infant. The deployment of the card needs to be systematized so that it is universally employed in all PMTCT clinics. Many outdated cards still exist in the Medical Stores Department and are preferentially disseminated before new cards. The identification of HIV-exposed infants is essential for EID, and using only the updated infant record cards is an important step in that direction. RECOMMENDATION 8: INCREASE HUMAN RESOURCES FOR HEALTH. Tanzania faces a critical shortage of human resources for health. To address this shortage in the long term, more direct investment in the training and support of health-care workers is needed. The Ministry of Health 56

57 and Social Welfare (MoHSW) may need to develop a motivation plan with a human resource recruitment and retention strategy that takes into account the social and economic needs of health-care workers. In the short term, MoHSW may need to reassess its staff deployment and rotation strategy to ensure that rather than creating unnecessary staffing gaps, the system works toward getting the optimum benefit out of the available staff members. This can be complemented by task shifting for full use of the staff members skill sets, as described above. Currently, the district RCH coordinator is the person responsible for coordinating many RCH programs. This lack of adequate staff may hinder proper planning, implementation, and supervision of all the RCH components that are implemented in the district. The systematic planning and implementation of PMTCT services would be enhanced by adding personnel, who would become assistants to the coordinator. RECOMMENDATION 9: INTEGRATE HEALTH SERVICES PROVIDED THROUGH RCH, PMTCT, AND C&T. Integration of health services on the RCH platform should continue, with the possibility of adding on C&T services to health facilities already providing PMTCT. This will help address the gaps identified in the current referral system, whereby clients are lost to services and follow-up. Many women who are in need of ART are going without the treatment they need, and PMTCT programs present an excellent opportunity for the provision of this vital service to women before they get sick. RECOMMENDATION 10: REDUCE THE PROPORTION OF HOME DELIVERIES. For many women in Tanzania, the primary obstacle to delivering in a facility is the distance of these facilities from their homes. While it may be difficult to build more delivery facilities in strategic locations, the establishment of waiting shelters for mothers could increase their access to facilities where deliveries can be performed. In addition, transportation systems should be developed to assist women in reaching facilities in time to deliver their infants. Health workers in ANC should conduct birth preparedness planning with women and assist them in finding ways to overcome their personal obstacles to delivery in a facility. While this evaluation did not specifically assess maternity facilities, minor upgrades to facilities could potentially attract more women to deliver there. Community mobilization around the importance of facility delivery and involvement of men in this area could also have an impact. Other creative strategies are being considered in other Foundation-supported country programs as well. Efforts should be made to create strategies to work with traditional birth attendants to increase their participation in service delivery and to encourage them to refer clients to health facilities for delivery. RECOMMENDATION 11: MAKE NATIONAL GUIDELINES, MONITORING AND EVALUATION TOOLS, AND JOB AIDS AVAILABLE IN LOCAL LANGUAGES (I.E., KISWAHILI) AND IN FORMATS THAT CAN BE UTILIZED BY LOCAL HEALTH-CARE WORKERS. Most RCH facilities have copies of national guidelines, but health workers have indicated that they do not or cannot use them because they are not comfortable reading in English and are better able to read and understand Kiswahili. Providing translations of these important documents would make them more widely accessible to the health-care workers for whom they are intended. In addition, there is some confusion by some staff members over use of record cards and registers, and as these tools change over time, continuing education for health-care workers is needed. If the registers were in Kiswahili, a broader cross-section of staff members could use them effectively. 57

58 RECOMMENDATION 12: CONSTRUCT AND RENOVATE HEALTH FACILITIES TO MEET THE NEEDS CREATED BY POPULATION INCREASE AND THE ADDITION OF HIV/AIDS SERVICES. Working with its development partners, MoHSW needs to construct new buildings and renovate existing ones in order to accommodate the increased demands of larger numbers of clients receiving more services, such as PMTCT, at RCH facilities. Adding structures may ease congestion in the corridors and consulting rooms as well as increase privacy for patients. Sheds may be useful as waiting areas, and waiting shelters to increase space at facility deliveries may help to ensure consumption of PMTCT prophylaxis by both mother and child, as well as increase the likelihood of delivering at a facility. RECOMMENDATION 13: IDENTIFY INNOVATIVE INTERVENTIONS USED IN OTHER DEVELOPING COUNTRIES. Adequately addressing the challenges of HIV stigma and discrimination can improve uptake of HIV/AIDS services by the community. In addition to the activities that districts in Tanzania are initiating for community mobilization and increased male involvement, it is recommended that Tanzania learn from other developing countries through information exchange and experience sharing. RECOMMENDATION 14: STRENGTHEN THE COMMODITY MANAGEMENT SYSTEM TO REDUCE STOCK-OUTS. This recommendation could be achieved through capacity building of cadres in the logistics supply chain for improved procurement of supplies and commodities. These cadres, including pharmacy and laboratory staff members, could also be trained in forecasting, ordering, tracking, and inventory management, fostering appreciation of the program and the importance of their contribution to it. RECOMMENDATION 15: STRENGTHEN THE MONITORING AND EVALUATION SYSTEM FOR ACCRUED BENEFITS TO MOHSW, PARTNERS, AND STAKEHOLDERS. Consolidated data collection tools with essential indicators should be developed for the Foundation s PMTCT program, for partners, and for MoHSW under the Health Management Information System. This need stems from the fact that more than 300 indicators are currently collected at site level. The Foundation collects about 120 indicators but utilizes only about 20 percent of them. Findings and recommendations of this evaluation and those from the indicator mapping exercise of 2009 are a basis for the revisions. There is a need to include PMTCT quality indicators that allow for tracking of HIV-positive pregnant women, exposed infants, and HIV-positive pregnant women referred for C&T. With quality indicators included, the rates of transmission and of infant survival could more successfully be measured. Additionally, the great variance between reported numbers of pregnant women attending ANC at least once in Tanzania should be investigated. The official national statistic is 94 percent, whereas the WHO/UNICEF statistic is 76 percent. 6.3 CONCLUSION The evaluation findings suggest that access to quality PMTCT services, including linking to C&T for women, children, and their families, has increased as a result of the Foundation s support in Tanzania. The Foundation program goal of providing access to PMTCT services to 80 percent of pregnant women has been exceeded, with access at Foundation-supported sites ranging between 89 percent and 99 percent. The Foundation has also been very successful in using the district approach to build capacity within MoHSW structures and to expand access to, and uptake of, PMTCT interventions. The Foundation program has been able to demonstrate consistency with national government policies and guidelines; to provide customized 58

59 support within the local setting; to integrate services from the outset into existing RCH services at the district and facility level; and to promote interaction among stakeholders within the districts, who include service providers, clients, communities, and district supervisors. Specifically, integration of PMTCT into RCH services has succeeded in increasing awareness of HIV, improving staff knowledge, and reducing stigma. Pregnant women are educated on how to prevent HIV infection in their children during pregnancy, delivery, and feeding. The Foundation also has excellent relationships with donors, partners, and MoHSW to implement its programs. Despite these successes, the Foundation program has faced some challenges that include staff shortages, high workload, staff burnout, limited working space for conducting PMTCT services, low male involvement, and lack of privacy due to shortages of space. Structural constraints and challenges in service delivery, such as lack of human resources and poorly functioning commodity systems, also exist. It should be noted that the weakest part of service delivery in the Foundation s program is the uptake of ARVs by mothers. Additional challenges that the Foundation has faced include a weak health system with multiple constraints, lack of direct control over program outcomes, inadequate financial management capacity, rapid expansion of the program, and difficulty in determining district readiness to operate independently. The 15 recommendations made in this report are based on the findings of the evaluation and the experiences of the eight years that the Foundation s program has existed. These recommendations will be used by the Foundation program to enhance implementation and contribute to reaching the Foundation s mission of eliminating pediatric HIV. The findings and recommendations from this report can also be used by MoHSW, donors, and other implementing partners to strengthen national, regional, and district PMTCT and C&T services in Tanzania. 59

60 Appendix 1: References 1. Guay LA, Musoke P, Fleming T, et al. Intrapartum and neonatal single-dose nevirapine compared with zidovudine for prevention of mother-to-child transmission of HIV-1 in Kampala, Uganda: HIVNET 012 randomised trial. Lancet. 1999;354(9181): Jourdain G, Ngo-Giang-Huong N, Le Coeur S, et al. Intrapartum exposure to nevirapine and subsequent maternal responses to nevirapine-based antiretroviral therapy. N Engl J Med. 2004;351(3): Dabis F, Ekouevi DK, Bequet L, et al. A short course of zidovudine + peripartum nevirapine is highly efficacious in preventing mother-to-child transmission of HIV-1: The ARNS 1201 DITRAME Plus study. Paper presented at: 10th conference on Retrovirus and Opportunistic Infections; February 2003; Boston, MA. Abstract Lallemant M, Jourdain G, Le Coeur S, et al. Single-dose perinatal nevirapine plus standard zidovudine to prevent mother-to-child transmission of HIV-1 in Thailand. N Engl J Med. 2004;351(3): CIA world factbook: Tanzania. Central Intelligence Agency Web site. Accessed May 1, Tanzania HIV/AIDS health profile. USAID Web site. Accessed May 1, Tanzania Commission for AIDS (TACAIDS), Zanzibar AIDS Commission (ZAC), National Bureau of Statistics (NBS), Office of the Chief Government Statistician (OCGS), and Macro International Inc. Tanzania HIV/AIDS and malaria indicator survey (THMIS) Dar es Salaam, Tanzania: TACAIDS, ZAC, NBS, OCGS, and Macro International Inc.; Accessed May 1, Ibid. 9. Tanzania Ministry of Health and Social Welfare (MoHSW). Health sector HIV and AIDS strategic plan (HSHS) pdf. Published June 24, Accessed May 1, Tanzania, United Republic of: Statistics. UNICEF Web site. Updated March 2, Accessed May 1, MoHSW (Ministry of Health and Social Welfare) Prevention of mother-to-child transmission of HIV (PMTCT) national guidelines. Dar es Salaam: MoHSW. (accessed May 1, 2010) 12. National Bureau of Statistics (NBS) and ORC Macro. Tanzania demographic and health survey (DHS) Dar es Salaam, Tanzania: NBS and ORC Macro; Accessed May 1,

61 13. Tanzania Ministry of Health and Social Welfare (MoHSW). Health sector HIV and AIDS strategic plan (HSHS) pdf. Published June 24, Accessed May 1, MoHSW (Ministry of Health and Social Welfare) Prevention of mother-to-child transmission of HIV (PMTCT) national guidelines. Dar es Salaam: MoHSW. (accessed May 1, 2010) 15. MoHSW. National road map strategic plan to accelerate reduction of maternal, newborn and child deaths in Tanzania Dar es Salaam: MoHSW; Tanzania Commission for AIDS (TACAIDS), Zanzibar AIDS Commission (ZAC), National Bureau of Statistics (NBS), Office of the Chief Government Statistician (OCGS), and Macro International Inc. Tanzania HIV/AIDS and malaria indicator survey (THMIS) Dar es Salaam, Tanzania: TACAIDS, ZAC, NBS, OCGS, and Macro International Inc.; Accessed May 1, GLASER database. Washington, DC: Elizabeth Glaser Pediatric AIDS Foundation. Accessed May 1, 2010.Elizabeth Glaser Pediatric AIDS Foundation. Rapid scale-up of PMTCT service provision using a district approach: The Tanzania experience. Dar es Salaam, Tanzania: Elizabeth Glaser Pediatric AIDS Foundation; Family Health International Institute for HIV/AIDS and Elizabeth Glaser Pediatric AIDS Foundation. Baseline assessment tools for preventing mother-to-child transmission (PMTCT) of HIV. Arlington, VA: Family Health International Institute for HIV/AIDS; MEASURE Evaluation, ICF Macro, and USAID. Manual, rapid health facility assessment: A tool to enhance quality and access at the primary health care level. Chapel Hill, NC: MEASURE Evaluation; Tanzania socio-economic database. Dar es Salaam: National Bureau of Statistics. Accessed May 1, Ibid. 22. Kuhn L, Aldrovandi GM, Sinkala M, et al. Differential effects of early weaning for HIV-free survival of children born to HIV-infected mothers by severity of maternal disease: Zambia exclusive breastfeeding study. PLoS One. 2009;4(6):e National Bureau of Statistics (NBS) and ORC Macro. Tanzania demographic and health survey (DHS) Dar es Salaam, Tanzania: NBS and ORC Macro; Accessed May 1, Barker P. Health systems performance and consideration for implementing PMTCT AR prophylaxis interventions. Paper presented at: WHO Expert Consultation on New and Emerging Evidence on Use of ARV Drugs for PMTCT of HIV; November 2008; Geneva, Switzerland. 61

62 25. WHO Rapid advice: Use of antiretroviral drugs for treating pregnant women and preventing HIV infection in infants. Version 2. Geneva, Switzerland: WHO; Accessed May 1, Sripipatana T, Spensley A, Miller A, et al. Site-specific interventions to improve prevention of mother-tochild transmission of human immunodeficiency virus programs in less developed settings. Am J Obstet Gynecol 2007;197(3):S107-S National AIDS Control Programme (Tanzania). National guidelines for the management of HIV and AIDS. 3rd ed. cedv2pbtefowrvd65o/natlguidemgmthivtzfnl2008.pdf. Published Accessed May 1,

63 Appendix 2: The Foundation-supported Tanzania Program Organizational Charts Tanzania Country Director Program Coordinator Communication & Outreach Executive Assistant Program Officer, C &O Technical Director Associate Director of Operations Associate Director, Field Programs Associate Technical Director Senior Technical Advisor, Research & Strategic Information Procurement & Logistics Manager Finance Manager HR Manager Contracts and Grants Manager Dar Office & Admin Manager Mtwara Sub Office Field Office Program Coordinator Program Coordinator EPI/Pediatric Aids Program Officer EID Services Program Coordinator, Laboratory Services Program Coordinator LSCM Program Coordinator, Data Management Program Coordinator, Quality Improvement Program Officer Quality Improvement Technical Advisor, M&E Procurement & Logistics Assistant Procurement & Logistics Assistant Sr. Accountant Accountant Finance Assistant Senior Payroll & Sub-grant Accountant HR Assistant HR Assistant IT Manager IT Assistant Contracts & Grants Assistant Manager Contracts and Grants Assistant Admin Assist/Receptionist Driver Driver Driver Tabora Sub Office Field Office Program Coordinator Moshi Sub Office Zonal Field Office Program Coordinator Technical Advisor, C&T Program Officer, M & E, C & T Accountant Office Attendant Program Officer, C &T Program Officer, M & E, C & T Day Guard/Receptionist Program Coordinator TB/HIV Collaborative Activities Program Officer, M&E /PMTCT Office Attendant Program Coordinator, Community Linkages Program Officer M & E,/PMTCT Program Officer Community Linkages Data Assistant, M &E Pediatric AIDS Advisor Program Officer, PHE Technical Advisor, Training & Capacity Building Program Officer, Training & Capacity Building Technical Advisor, PMTCT Program Officer, PMTCT Program Assistant 63

64 Mtwara, Shinyanga, Tabora Sub-Offices Mtwara Sub-Office Shinyanga Sub-Office Tabora Sub-Office Field Office Program Coordinator Field Office Program Coordinator Gastor Njau Field Office Program Coordinator Regional Tech Team Lead Compliance Administrator Regional Tech Team Lead Compliance Administrator Regional Tech Team Lead Compliance Administrator Program Officer PMTCT and C & T Program Officer PMTCT and C&T Program Officer PMTCT and C & T Program Officer PMTCT and C &T Program Officer PMTCT and C & T Program Officer Lab Services Program Officer Community Linkages Compliance Administrator Field Operations Officer Administrative/IT Assistant Office Attendant Driver Driver Program Officer PMTCT and C & T Program Officer PMTCT and C & T Program Officer PMTCT and C&T Program Officer Community Linkages Program Officer Lab Services Program Officer M & E Program Officer Training & Capacity Building Compliance Administrator Field Operations Officer Administrative Assistant Office Attendant Gardener/ Day Guard Driver Driver Program Officer PMTCT and C&T Program Officer PMTCT and C&T Program Officer PMTCT and C&T/TBHIV Program Officer Community Linkages Program Officer Lab Services Program Officer M & E Regional Data Assistant Compliance Administrator Field Operations Officer Administrative Assistant Office Attendant Day Guard IT Assistant Driver Program Officer M & E Program Officer Training & Capacity Building Regional Data Assistant Driver Driver Regional Data Assistant Regional Data Assistant Driver Driver Regional Data Assistant Driver Driver Regional Data Assistant Program Officer PMTCT and C&T 64

65 Moshi Sub-Office Zonal Field Office Program Coordinator Regional Technical Team Lead Moshi Field Operations Officer Program Officer Training & Capacity Building Senior Compliance Administrator Regional Technical Team Lead Arusha Program Officer PMTCT & C&T Finance Assistant Compliance Administrator Program Officer PMTCT & C&T Program Officer PMTCT & C&T IT Assistant Compliance Administrator Program Officer PMTCT & C&T Program Officer PMTCT & C&T Program Officer M & E Program Officer Community Linkages Office Manager Office Attendant Office Gardener/ Day Guard Compliance Administrator Program Officer PMTCT & C&T Program Officer M&E Program Officer Laboratory Service Driver Program Officer Community Linkages Regional Data Assistant Driver Program Officer Laboratory Services Regional Data Manager Driver Regional Data Assistant Driver Regional Data Assistant Driver Driver 65

66 Appendix 3: Site List Evaluation Sites Facilities with PMTCT, C&T, MER, and EID Facilities with PMTCT, C&T, MER, and EID With good performance With less performance Shinyanga Tabora Arusha Kilimanjaro Mtwara Shinyanga Tabora Arusha Kilimanjaro Mtwara Kahama District Hospital (Kahama DC) Sikonge Designated District Hospital (Sikonge DC) Monduli District Hospital (Monduli DC) Kilimanjaro Christian Medical Centre Referral Hospital (Moshi mun.) Ligula Hospital (Mtwara mun.) Shinyanga Regional Hospital (Shinyanga mun.) Ndala Hospital (Nzega DC) Mt. Meru Regional Hospital (Arusha mun.) Tanzania Plantation Company Ltd. Hospital (Moshi rural DC) Kitere Health Centre (Mtwara DC) Bariadi District Hospital (Bariadi DC) Upuge Rural Health Centre (Uyui DC) Ngarenaro Health Centre (Arusha mun.) Mawenzi Regional Hospital (Moshi mun.) Newala Hospital (Newala DC) Uyovu Health Centre (Bukombe DC) Nzega District Hospital (Nzega DC) Enduleni Hospital (Ngorongoro DC) Pasua Health Centre (Moshi mun.) Chiwale Rural Health Centre (Masasi DC) Maswa District Hospital (Maswa DC) Choma Health Centre (Igunga DC) Karatu Designated District Hospital (Karatu DC) Huruma Designated District Hospital (Rombo DC) Luagala Health Centre (Tandahimba DC) Masumbwe Health Centre (Bukombe DC) Kaliua Health Centre (Urambo DC) Kaloleni Health Centre (Arusha mun.) Mkomaindo Hospital (Masasi DC) PMTCT = prevention of mother-to-child transmission; C&T = care and treatment; MER = more efficacious regimens; EID = early infant diagnosis 66

67 PMTCT Facilities Providing SdNVP without C&T Facilities Providing SdNVP without C&T With good performance With less performance Shinyanga Tabora Arusha Kilimanjaro Mtwara Shinyanga Tabora Arusha Kilimanjaro Mtwara Kagongwa Dispensary (Kahama DC) Mwaisela Health Centre (Nzega DC) Oldeani Health Centre (Karatu DC) Mashati Roman Catholic (Rombo DC) Tawala Dispensary (Newala DC) Replaced during fieldwork with Mkunya Health Centre Bwelwa Dispensary (Bukombe DC) Isanzu Dispensary (Nzega DC) Baraa Dispensary (Arusha mun.) Maore Dispensary (Same DC) Lukuledi Dispensary (Masasi DC) Halawa Dispensary (Bariadi DC) Mazinge Health Centre (Sikonge DC) Karansi Dispensary (Siha DC) Ntobo Dispensary Kahama (Kahama DC) sdnvp = single-dose nevirapine; C&T = care and treatment 67

68 PMTCT Facilities Providing MER without EID PMTCT Facilities Providing MER without EID With good performance With less performance Shinyanga Tabora Arusha Kilimanjaro Mtwara Shinyanga Tabora Arusha Kilimanjaro Mtwara Chamaguha Dispensary (Shinyanga mun.) Town Clinic Dispensary (Tabora mun.) Mangola Health Centre (Karatu DC) Kiruavunjo Rural Health Centre (Moshi Rural DC) Mangaka Rural Health Centre (Nanyumbu DC) Mpera Health Centre (Kahama DC) Kaliua Health Centre (Urambo DC) Mkonoo Health Centre (Arusha mun.) Ngarenairobi Health Centre (Siha DC) Kitere Health Centre (Mtwara DC) Mwasayi Health Centre (Maswa DC) Mbuguni Health Centre (Meru DC) Mahurunga Health Centre (Mtwara DC) Kitunda Health Centre (Sikonge DC) Sanya Juu Health Centre (Siha DC) Lupaso Rural Health Centre (Masasi DC) Bulungwa Health Centre (Kahama DC) Karatu Health Centre (Karatu DC) Ndanda Hospital (Mwanga DC) MER = more efficacious regimens; EID = early infant diagnosis 68

69 Appendix 4: The Foundation s Program in Tanzania The Elizabeth Glaser Pediatric AIDS Foundation (the Foundation) began to support services for the prevention of mother-to-child transmission (PMTCT) of HIV in designated Tanzanian facilities in 2002 under a five-year global cooperative agreement with the U.S. Agency for International Development (USAID) named the Call to Action (CTA). In collaboration with the Tanzanian Ministry of Health and Social Welfare, the Foundation-supported Tanzania program initiated PMTCT activities through CTA beginning in The Foundation initially sub-contracted to three international nongovernmental organizations EngenderHealth, Axios International, and the Anglican Church of Tanzania which were charged with establishing PMTCT services within individual health facilities in the regions. EngenderHealth worked in the Arusha region; Axios worked in three districts in Kilimanjaro and Morogoro regions; and in 2006 the Anglican Church of Tanzania received support to work in three hospitals and four health centers in Tanga region, one hospital in Dodoma region, and one hospital in Singida region. In the same year, more districts from Mtwara and Tabora received support from CTA as well. In September 2003, USAID/Tanzania s vision and commitment to PMTCT service expansion led it toward a separate bilateral agreement with the Foundation specifically for PMTCT program support in Tanzania. The agreement was renewed in 2005 for an additional three years through September 2008 and then extended twice for one-year periods. It expired in September Currently, the Foundation supports 33 districts in five regions (Arusha, Kilimanjaro, Mtwara, Shinyanga, and Tabora) in the provision of PMTCT services to pregnant women, their children, and their families, through 37 sub-grantees. By December 2009 the Foundation was able to support 960 health facilities to initiate PMTCT services in the five regions. These activities are implemented with the goal of reaching all reproductive and child health (RCH) facilities with PMTCT services, including hospitals, health centers, and dispensaries. In 2009, there were an estimated 409,470 pregnancies in the five regions of Tanzania supported by the Foundation, 11 representing more than 29 percent of total births in Tanzania. The Foundation reported 393,000 pregnant women eligible for services attending RCH facilities for antenatal care. In March 2004, subsequent to the start of the Foundation s PMTCT program in Tanzania, Project HEART (Help Expand Antiretroviral Therapy), funded by the U.S. Centers for Disease Control and Prevention (CDC), was initiated. Project HEART has maintained a focus on integrating care and treatment (C&T) with PMTCT services in order to provide a family-centered model of care that includes access to antiretroviral therapy (ART) for HIV-infected pregnant mothers, HIV testing and care for partners and families, and screening and treatment for TB and other opportunistic infections. Project HEART/Tanzania supports and operates within Tanzania s national care and treatment plan and the national health system; all supported sites are nationally designated ART sites. The project reflects national goals and objectives and supports only those activities that are in line with the national guidelines for C&T. It is currently supporting C&T activities in 47 hospitals and 118 primary health facilities in Arusha, Kilimanjaro, Shinyanga, and Tabora regions in accordance with the regionalization policy of the government of Tanzania, and it has expanded to Lindi region as well in partnership with the Clinton Health Access Initiative. The Foundation s core goals have guided all of its Project HEART activities, and the project has already exceeded its initial five-year goal of having initiated 19,578 patients on ART. 69

70 The Foundation-supported Tanzania office was established in Dar es Salaam in Currently, the Foundation has five offices throughout Tanzania, located in Moshi (covering Arusha and Kilimanjaro), Mtwara (covering Mtwara and Lindi), Shinyanga, Tabora, and Dar es Salaam. Staff has grown to more than 140, with 97 percent of the personnel being Tanzanian nationals. The staff includes physicians; nurses; and persons trained in public health, finance, compliance, and monitoring and evaluation. 70

71 Appendix 5: Capacity Building and Support to District Partners: Contracts and Grants In 2004, with the opening of the first Foundation office in Tanzania, two staff members took responsibility for contracts and grants management. They assessed new sub-awardees, looking at strengths and weaknesses including capacity for financial management, and developed a support plan for each sub-grantee. Potential partners received training before receipt of funds, and supervision and financial reporting mechanisms were put in place. However, the rapid expansion of the program greatly increased the need for financial management and compliance with U.S. government (USG) regulations. The need to train other appropriate local governmental authorities in the regions where the Foundation was active also became apparent. The Contracts and Grants (C&G) Department has therefore expanded since 2004 to meet the needs of this very large program. Since 2008, the Foundation s Tanzania C&G Department has launched several initiatives aimed at enhancing support to sub-awardees in order to assist with building the capacity of partners to manage finances and accounting in accordance with USG rules and regulations, and to ensure that the funds awarded to partners are properly safeguarded and utilized. These initiatives include the following: Pre-award assessments The C&G Department assesses the capacity of potential partners to implement an award, documenting the findings and discussing them with the candidates. This has proven to be an effective way to clarify areas of needed improvement from the beginning in order to ensure that both the Foundation and the sub-awardee begin the partnership with common understandings and expectations. Training The Foundation provides training to all new partners on USG rules and regulations and the operational aspects of implementing their awards in accordance with approved policies and procedures. There is also an annual refresher training to review USG rules and regulations, as well as to discuss and troubleshoot existing trends in the implementation and management of partners agreements. These trainings have been a useful and effective way to revisit some important principles regarding the implementation of these awards and to re-energize partners commitment to working with the Foundation to implement these life-saving programs. Hands-on assistance The Foundation C&G Department has striven to provide one-on-one assistance to partners and has focused on building a relationship that emphasizes a partnership approach. Currently one compliance administrator is assigned to six partners in order to efficiently and effectively address any questions, concerns, or issues partners may have. In addition, the C&G managers and the director of operations regularly visit the field and interact with partners. This attention to building a positive and effective relationship with partners, and on working with them to address their concerns and questions in a timely and effective manner, has been crucial for the successful implementation of awards. 71

72 Monthly financial reports Beginning in 2008, the Foundation began to require monthly financial reports from each sub-awardee. Previously, these reports had been submitted on an ad hoc basis, mainly as sub-awardees required cash. This practice resulted in frequent outages of cash to fund activities, irregular burn rates, and interruptions in program implementation. Requiring these financial reports monthly and extending the available forecasting period from two to three months has resulted in a 30 percent to 50 percent increase in the burn rate of sub-agreements since early Sub-awardee handbook In 2008, the C&G team developed a 60-page handbook for sub-awardees to explain the nature of the program and organization they were partnering with, the administrative intricacies of the agreement, and the ways in which the Foundation would be supporting them. A copy of this handbook was provided to key personnel of each sub-awardee and has been useful in communicating major concepts to partners, as well as serving as a basis for ongoing discussions regarding performance and compliance. Audits Beginning in 2009, the C&G team also developed a standard operating procedure on audits, including an audit checklist and reporting template, in order to conduct a semiannual audit of each partner. The team documents findings and discusses them with partners, requiring written responses to explain the resolution of material findings. Tests are conducted in more than 20 functional areas, and in most cases, 75 percent to 100 percent of the transactions for the period under review are checked. In order to assist the team with conducting these audits, professional auditors are hired to provide annual audit training to C&G staff. The semiannual audits have had the following results: - Recovery of funds not used in accordance with required policies and procedures - Proper documentation of expenses - Verification of controls to safeguard funds - Building of partner capacity through knowledge of best practices that benefit management and implementation of other activities Renewal transition improvement In 2009, the Foundation developed an annual plan for renewing sub-agreements in order to address the gaps that have previously occurred when partners were renewing their awards. As a result of this plan, gaps between awards have been greatly reduced (and in most cases completely removed), helping to significantly improve implementation of these agreements as well as improving partners overall level of comfort in their collaboration with the Foundation. Risk management Beginning in 2010, the Foundation began to assign a risk level to each partner and to monitor the ways in which these risk levels may change over time. This process is helping the Foundation gauge the quality of the intervention and support, in addition to identifying best practices that could be replicated in other health facilities. 72

73 Joint facility visits Beginning in 2010, members of the C&G team and the technical team have begun making joint visits to health facilities. These visits help the Foundation provide standard and consistent feedback to partners, and make possible a complete review of the way each award is implemented. 73

74 Appendix 6: Data Flow EGPAF System National System NACP PMTCT DEPT Region Monthly reports RRCHCo is responsible USAID HQ USA USAID TZ EGPAF COUNTRY OFFICE EGPAF field office EGPAF HQ USA District level DRCHCo compiles district monthly reports for Antenatal Clinic, Care, Labour Delivery and Mother Child follow up and Quarterly for EGPAF. Site in Charge compile monthly reports and send to district level SITE PMTCT ANC Monthly report SITE PMTCT Care Monthly report SITE PMTCT L&D Monthly report SITE PMTCT MC Monthly report HCWs trained to provided PMTCT services compile site monthly report by using Checklist and guidelines on how to summarise monthly report from PMTCT registers PMTCT ANC Register and MTUHA Book 6 PMTCT Care Register PMTCT L&D Register and MTUHA Book 12 PMTCT MC Register There are guidelines on every first page of each registers on how to fill in registers (English form) 74

75 NACP = National AIDS Control Programme; PMTCT = prevention of mother-to-child transmission; USAID = U.S. Agency for International Development; RRCHCo = regional reproductive and child health (RCH) coordinator; DRCHCo = district RCH coordinator; ANC = antenatal care; L&D = labor and delivery; MC = male circumcision; HCW = health-care worker; MTUHA = health management information system (Swahili acronym) 75

76 Appendix 7: Site List: Foundation-Supported Sites in 2009 with Validated Data* *29 sites did not have validated data Available upon request. 76

77 Appendix 8: List of Interviewees Name Organization / Region / District Title Dr. Patrick R. Swai Dr. Yahya Ipuge Dr. Eric van Praag Dr. Redempta Mbatia U.S. Agency for Int l. Development Clinton Health Access Initiative Family Health Int l. Int l. Ctr. for AIDS Care and Treatment Programs AIDS Relief Contracting officer technical representative Country director Country director Acting country director Dr. Sekela Mwakyusa Dr. Anja Giphart Dr. Jeroen Van t pad Bosch Dr. Aisa Muya Dr. Werner Schimana Illuminata Ndile Chrispine Kimario Joseph Yuda Msoffe Dr. Neema Dr. Angela Ramadhani Dr. Michael Msangi Dr. Mary Azayo Dr. Koheleth Winani Dr. Josiah Dr. Salash Toure Christopher Mremi Liliani Msofe The Foundation Tanzania Ministry of Health & Social Welfare Nat l. AIDS Control Programme Arusha region Country medical director Country director Technical director Associate technical director Regional pediatric advisor Technical director, capacity building Technical advisor, care and treatment Technical advisor, monitoring & evaluation Deputy director in charge of reproductive and child health (RCH) services Head, prevention of mother-to-child transmission (PMTCT) unit Training coordinator Child health coordinator National coordinator for safe motherhood Head, care and treatment Regional medical officer Regional AIDS control committee (RACC) Regional RCH coordinator (RRCHCo) 77

78 Dr. Faustine Shapo Mponija Rose Moshi Babila Shilogela Nganga Silivia Mushi Bundala Joseph Digna Mwanga Esther Masawe Sikolastika Makale Eliana Mhalu John Peter Makundi Epiphania Masawe Dr. Aminieli Msemo Emiliani Muroo Martha Ngifira Elizabeth Deemay Iveta Damiano Anna Baran Dr. Abdalah Mvungi Janet Pallagyo John Babu Asha Mjiku Dr. Kenedy Israel Mathaka Kisaka Herieth Monah Dr. M. Mwako Eliotha Kaale Mosile Arusha municipal Monduli district Karatu district Meru district Ngorongoro Kilimanjaro region District medical officer (DMO) District RCH coordinator (DRCHCo) District AIDS control committee (DACC) Public health nurse Public health nurse Midwifery nurse Public health nurse Public health nurse DRCHCo DACC Public Health Nurse Acting DMO DACC Nurse in charge Public health nurse Public health nurse Nurse in charge Acting DMO DRCHCo DACC Public health nurse Acting DMO DRCHCo Public health nurse Regional medical officer RRCHCo RACC 78

79 Dr. Mtakaya Christopher Elivasta Mshana Paul Mauki Zawadieli Hillu Ademas Tairo Tea G. Macha Candida Mafoi E. Kiwia Annah Joram Mwahalende Judith Ngowi Veronica Mrema Selina Mushi Dr. Criston Nkya Lyaruu Sprian Oliva Moshi Kandida Chrispine Mroso Lydia Jengo Dr. Waziri Juma Semarundo Halima Omary Thomas Masawe Nzaniwe Mdingi Margret Mmari Timothy Shuma Dr. Joseph Tesha Dr. Lalashowi Kweka Mary Mmary Anna Woiso Dr. John Gurisha Sr. Vivian Kilimba Humpredas K. Kitundu Moshi urban Moshi DC Rombo DC Same DC Siha DC Mtwara region DMO DRCHCo DACC PMTCT coordinator, Kilimanjaro Christian Medical Centre (KCMC) RCH in charge Nurse officer Labor in charge Nurse officer, KCMC District executive officer Acting district RCH coordinator Assistant district RCH coordinator Midwives nurse DMO DACC RCH in charge Public health nurse Registered nurse DMO DRCHCo DACC Public health nurse Assistant DRCHCo DACC Acting DMO DED Assistant, labor ward RCH in charge Regional medical officer Regional RCH coordinator Regional HIV/AIDS control coordinator 79

80 Asumpta Mbawala Dr. Eligius Ndunguru Mohamed Ngwilima Nassoro Hemedi Lilian Winna Sulpis Likande Dr. John Papalika Florida Mlaponi Judethadaus Mboya Dr. Festo Masay Jennifer Mkata Dr. Ignas Mlowe Christa Swalehe Rose Alphonce Titus Yustus Mtwara municipal Mtwara DC Nanyumbu Newala DC Masasi DC Tandahimba DC DRCHCo DMO District executive director (DED) For DMO DRCHCo DED DMO DRCHCo DED DMO DRCHCo DMO DRCHCo DRCHCo For DMO Antonia Mago Shinyanga region RRCHCo Shinyanga municipal Dr. Mremi Paulina Masanja Elizabeth Kitundu Bertha Wagala Dr. Edith Kwezi Fredrick Mlekwa Joyce Kandoro Dalison Elesailen Janeth Pole Bakiriley Pamela Charles Dr. John Assey Maswa district Shinyanga municipal Bariadi DMO DRCHCo DED Service provider Acting DMO In-charge Shinyanga Regional Hospital Assistant DRCHCo Service provider DRCHCo DED DRCHCo Acting DMO 80

81 Rehema Kantabula Edna Mushi Esther Matondo Dr. Leonard Subi Penina Rwegasira Dr. Rwezaura Daniel Martin Sinda Alfreda Kato Kahama Bukombe DRCHCo Service provider Service provider DMO Service provider DMO Assistant DRCHCo Service provider Antonia Mbago Tabora region RRCHCo Tabora Hildergard Chafwila Violet Lusesa Edson Maziku Dr. Revocatus Elizabeth Luewa Zub eda Hussein Makwaya Leila Maxifongo Robert Mgeta Dr. Joseph Kisala Emelda Mnubi Paula Zakayo Mary Dickson Jane Makiya Amina Ysuph Dr. Yudes Ndungile Benadeta Chimalilo Mary Dickson Prisca Mwebuge Joyce Rufo Urambo district Tabora municipal Igunga Nzega Uyui DRCHCo Service provider DACC DMO Service provider Tabora municipal DACC Tabora municipal Assistant DRCHCo Tabora municipal DED DMO Assistant DRCHCo Service provider Service provider DRCHCo Service provider Assistant DMO Service provider Service provider DRCHCo Service provider 81

82 Paul Manganisi Dr. John Buselwu Rosemary Sijaona Gaspar Mihayo Sikonge Service provider Acting DMO DRCHCo DACC 82

83 Appendix 9: Program Coverage Maps PMTCT = prevention of mother-to-child transmission; sdnvp = single-dose nevirapine; MER = more efficacious regimens; EID = early infant diagnosis; C&T = care and treatment 83

84 PMTCT = prevention of mother-to-child transmission; sdnvp = single-dose nevirapine; MER = more efficacious regimens; EID = early infant diagnosis; C&T = care and treatment 84

85 PMTCT = prevention of mother-to-child transmission; sdnvp = single-dose nevirapine; MER = more efficacious regimens; EID = early infant diagnosis; C&T = care and treatment 85