ACCOMPLISHMENTS AND CHALLENGES IN TANZANIA

1. ACCOMPLISHMENTS AND CHALLENGES IN TANZANIA Dr Mark Hawken Dr Boniphace Idindili 6 March 2006

2. Presentation Outline Background Accomplishments The NACP perspective Challenges Conclusions

3. Background PEPFAR goals are to support treatment for 2 million people, prevent 7 million infections, support care for 10 million The national Tanzania HIV Care and Treatment Program began in July 2004 with pilot at Muhimbili National Hospital The Tanzanian program aims to enroll 500,000 people on ART by 2008 By the end of February 2005, 96 health facilities have established care and treatment program and there are plans for a further 104 sites 59,000 on care and 25,000 on ART by January 2006 PEPFAR goals are to ...PEPFAR goals are to ...

4. Columbia Supported Sites CU started supporting PMTCT sites in February 2004 and C&T since July 2004 Currently there 13 Care and Treatment sites and 38 PMTCT sites at zonal, regional, district, health center and dispensary level

5. CU-Supported Sites Year 1 Zonal Muhimbili Bugando Medical Centre Mnanzi Mmoja Hospital Regional Sekou Toure Regional Hospital Kagera Regional Hospital Chake Chake Hospital District Huruma (and 11 peripheral PMTCT sites) Same (and 17 peripheral PMTCT sites) Year 2 Specialist Ocean Road Cancer Institute District Bagamoyo Biharamulo Nyakahanga Murgwanza Chato

7. Presentation Outline Background Accomplishments The NACP perspective Challenges Conclusions

8. Accomplishments Building trust national partners Establishing a team Establishment of sites Establishment of infant diagnosis program

9. Building Trust Key elements have included: Demonstrating the ability to deliver Establishing steady reliable cash flow Public relations Supporting NACP Building a degree of trust between CU and the national program has been a major accomplishment which has taken the full 18 months that we have worked here in Tanzania. Factors necessary to do this are the ability to show that we can deliver, establishment of a steady cash flow to project sites, a considerable amount of public relations to inform the national program of our activities and demonstrating to NACP we are willing to support them on their terms. Building a degree of trust between CU and the national program has been a major accomplishment which has taken the full 18 months that we have worked here in Tanzania. Factors necessary to do this are the ability to show that we can deliver, establishment of a steady cash flow to project sites, a considerable amount of public relations to inform the national program of our activities and demonstrating to NACP we are willing to support them on their terms.

10. Establishing a Team Establishing program and support team Fostering team spirit Recognition of a multidisciplinary approach Establishing a team of appropriately qualified personnel (both programmatic and support) has been a major accomplishment and remains a challenge. Human resource is scarse in Tanzania and many advertisements for SPO, PO and lab technicians have produced few suitable applicants. Fostering a rteam spirirt by weekly staff meetings, social occasions, recognition of performance,and has been an important activity. Two members of a multidisciplinary which have played and particularly important role are the logistician (who is responsible for ordering, selection and delivery of equipment and consumables) and a consultant quantity surveyor (who is responsible for overseeing renovations at our sites).Establishing a team of appropriately qualified personnel (both programmatic and support) has been a major accomplishment and remains a challenge. Human resource is scarse in Tanzania and many advertisements for SPO, PO and lab technicians have produced few suitable applicants. Fostering a rteam spirirt by weekly staff meetings, social occasions, recognition of performance,and has been an important activity. Two members of a multidisciplinary which have played and particularly important role are the logistician (who is responsible for ordering, selection and delivery of equipment and consumables) and a consultant quantity surveyor (who is responsible for overseeing renovations at our sites).

11. Establishment of Sites 8 sites established within first year Further 6 sites established in the last 4 months Baseline needs assessment Writing of SOW and budget Gaining consensus NY processing Wiring funds Training in ART Establishing preceptorships Planning renovations Ordering lab machines In the first 1 2 months we established 8 operational sites delivering PMTCT+ and Care and Treatment. In the last 6 months , 6 new sites which have begun delivering care and treatment at various degrees of infancy. This involves performing baseline assesments at 10 sites, writing SOW and budgets, gaining consensus from our partners, the NY sub agreement compilation, delivery of funds, training and establishing preceptorships, planning renovations and initiating strengthening of the labs. In the first 1 2 months we established 8 operational sites delivering PMTCT+ and Care and Treatment. In the last 6 months , 6 new sites which have begun delivering care and treatment at various degrees of infancy. This involves performing baseline assesments at 10 sites, writing SOW and budgets, gaining consensus from our partners, the NY sub agreement compilation, delivery of funds, training and establishing preceptorships, planning renovations and initiating strengthening of the labs.

12. 5927 patients were enrolled in HIV care by the end of December 2005. There were 631 children enrolled on care. 5927 patients were enrolled in HIV care by the end of December 2005. There were 631 children enrolled on care.

13. 3390 persons were initiated on ART by the end of December 2005. There were 293 children (9%) initiated on ART. 3390 persons were initiated on ART by the end of December 2005. There were 293 children (9%) initiated on ART.

14. Site Highlights Rombo/Same demonstration sites for pMTCT-Plus Community mobilization Ocean Road Cancer Institute Precepting on co-management of HIV and malignancies Computerization of care and treatment monitoring systems at 5 site programs, including focused computer training of health care workers

15. Establishment of Infant Diagnosis Program CU has taken a lead in establishing early infant diagnosis in Tanzania Collaboration with ICAP Rwanda and ICAP regional laboratory specialists In the first year planned to have dried blood spots (DBS) collected at 5 pilot sites with expansion to serve the Lake Zone Case-finding among HIV-exposed infants at 6 week immunization visit and symptomatic infants

16. DBS collection to start by April 2006 Bugando laboratory renovation is underway PCR laboratory equipment and reagents have been delivered to laboratory Technician from BMC has received training on PCR at the Rwanda NRL. Second technician to be trained in April ID coordinator employed to coordinate the logistics Four clinicians have been sent to Kenya for pediatric ART training Study visit to the Rwanda ID program by Tanzania National Diagnostic Services Establishment of Infant Diagnosis Program

17. Presentation Outline Background Accomplishments The NACP perspective Professor Tabasamu Kicheko Challenges Conclusions

18. NACP Organogram

19. NACP Targets National Care and Treatment activities began in May 2004 at 91 sites The target was to initiate 44,000 patients on ART in the first year By the end of December 2005, 25,000 people were initiated on ART

20. Funding to Tanzania (USD) As of June 2005 Global Fund 11m PEPFAR 5m SIDA 4m World Bank 2m Clinton 1m NORAD 0.5m I would like to take this opportunity to thank President Bush for his 5 million $ contribution towards the HIV scourge in Tanzania. We are grateful to the International community for their support. I would like to take this opportunity to thank President Bush for his 5 million $ contribution towards the HIV scourge in Tanzania. We are grateful to the International community for their support.

21. A Conditional Invitation One agreed AIDS action framework that provides the basis for coordinating the work of all partners One national authority with a broad based multi-sectoral mandate One agreed country-level monitoring and evaluation system The principle of three ones is applicable in our current situation with many implementing partners with various administrative regulations. However the three ones principle as proposed by World Bank have been adopted by NACP to harmonize operations.The principle of three ones is applicable in our current situation with many implementing partners with various administrative regulations. However the three ones principle as proposed by World Bank have been adopted by NACP to harmonize operations.

22. Capacity Building vs Expatriate Expertise Expatriate expertise is recognized but is not sustainable Enormous salary differentials create strain and low morale Alternative allowances are possible We appreciate the need for expatriate expertise but it should not be at the expense of building local capacity. Expatriate expertise is not sustainable and the program should be ble to run once expats have left the country. In addition, from our perpective, enormous salary differentials create strained working reltionships and low morale in local staff. Alternative methods should be employed such as large housing allowances to bring local salaries closer to expat salaries. We appreciate the need for expatriate expertise but it should not be at the expense of building local capacity. Expatriate expertise is not sustainable and the program should be ble to run once expats have left the country. In addition, from our perpective, enormous salary differentials create strained working reltionships and low morale in local staff. Alternative methods should be employed such as large housing allowances to bring local salaries closer to expat salaries.

23. Publication of National Data Publication is a way of sharing information National data belongs to the nation Publication should recognize all partners involved Publication without permission has occurred in research All publications must be cleared with the relevant ministry Publicatoion is a way of sharing information. However� As in any counrty data generated by a national system belongs to that country and should only be disseminated with the approval of that country. One of fears is that our supporting partners will publish data without our knowledge and approval. This has been abused in the research setting and has caused embarrassment to the country. Fortunately Columbia has obtained permission on two abstracts for the Toronto AIDS meeting. We trust all groups will follow their good example. Publicatoion is a way of sharing information. However� As in any counrty data generated by a national system belongs to that country and should only be disseminated with the approval of that country. One of fears is that our supporting partners will publish data without our knowledge and approval. This has been abused in the research setting and has caused embarrassment to the country. Fortunately Columbia has obtained permission on two abstracts for the Toronto AIDS meeting. We trust all groups will follow their good example.

24. Presentation Outline Background Accomplishments The NACP perspective Challenges Conclusions

25. Challenges Maintenance of a supportive environment for implementation Strengthening of the team/recruitment Addressing quality of care despite the obsession with targets

26. Maintaining Supportive Environment for Effective Implementation Critical players include MOH, NACP, CDC, USAID Slow response and closed door policy unhelpful Regionalization enforced strictly by USG Team has not helpful Co-funding of single sites leads to competition Continual advocacy and updating required to maintain supportive environment for implementation Maintaining a supportive environment for effective implementation is a major challenge. Critical players include the MOH, NACP, CDC, USAID. The MOH have been slow in affirming their support for CU. This has been demonstrated in their reluctance to respond to requests for an MOU and work permits. NACP have shown passive resistance to several activities such as training and generally have a closed door policy. Last year in an attempt to get a more even distribution of partners throughout the country and avoid duplication, USG partners were given regions in which to work. While this is a good trend it means we are having to leave some of our established sites who will be transferred to new partners. While NACP were happy for us to keep old sites and regionalise in new sites USG has enforced a strict interpretation of this trend and this is not helpful. Instead of opposing our activities we feel this should be done in a spirit of support. In several places where we are working CDC have decided to dual fund the same site with an additional coagreement in similar areas of focus. This creates an environment of competition rather than cooperation and is agaain counterproductive. Continual advocacy and updating of progress are required with our national partner s Maintaining a supportive environment for effective implementation is a major challenge. Critical players include the MOH, NACP, CDC, USAID. The MOH have been slow in affirming their support for CU. This has been demonstrated in their reluctance to respond to requests for an MOU and work permits. NACP have shown passive resistance to several activities such as training and generally have a closed door policy. Last year in an attempt to get a more even distribution of partners throughout the country and avoid duplication, USG partners were given regions in which to work. While this is a good trend it means we are having to leave some of our established sites who will be transferred to new partners. While NACP were happy for us to keep old sites and regionalise in new sites USG has enforced a strict interpretation of this trend and this is not helpful. Instead of opposing our activities we feel this should be done in a spirit of support. In several places where we are working CDC have decided to dual fund the same site with an additional coagreement in similar areas of focus. This creates an environment of competition rather than cooperation and is agaain counterproductive. Continual advocacy and updating of progress are required with our national partner s

27. Human Resource Constraint Lack of qualified professionals due to braindrain Low salaries for local staff creates strained relationships Repatriation of Tanzanian nationals on higher salaries a possible solution

28. Obsession with Targets PEPFAR programme indicators focus on ART enrollment Jeopardises quality of services provided to patients Congests outpatient departments and compromises services in other departments Creates competition among implementing partners

29. Obsession with Targets (2) Necesitates crash course training of HCW, resulting in poor quality training with training becoming an income-generating activity for HCW and facilitators Sustainability not addressed Detracts attention from ensuring equity of services

30. Presentation Outline Background Accomplishments The NACP perspective Challenges Conclusions

31. Conclusions Continue building supportive environment with continuous communication, updating NACP to foster trust and cooperation Continue to recognise NACP as national authority and respect their coordinating role USG team and NACP need to harmonize their coordination role to avoid conflicting directives Increase staff capacity with continuing efforts to recruit Tanzanian nationals Need to address quality of care and sustainability at all sites

32. Acknowledgements CU New York NACP/MOH CDC USAID Partners