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Utilizing the District Approach for Scale-Up:

The Tanzania Model

Allison Spensley MPH, MSW

Elizabeth Glaser Pediatric AIDS Foundation

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Presentation Overview • Background

• Description of the District Approach- Value added

- Steps for implementation

• Program Results

• Challenges

• Lessons Learned

• Conclusion

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Background: EGPAF Tanzania Program

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EGPAF Tanzania Program

• PMTCT support started in 2003 through CTA project; now supported through USAID bilateral

• C&T support started in 2004 through CDC Track 1 funding

• National partner for HIV services in 6 regions (5 PMTCT, 5 C&T)– Arusha, Kilimanjaro, Tabora, Shinyanga, Lindi,

Mtwara

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EGPAF Work in Tanzania

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PMTCT Program Goal and Key Principles

• Program Goal: Increase access to quality PMTCT services including the linkage to care and treatment for women, children and their families in Tanzania

• Work within MOHSW plans for scale up of services

• Integration of PMTCT into RCH services

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Description of the District Approach

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The District Approach • EGPAF defines district approach as working

through the district

• Working with the District Health Management Teams (DHMTs) to plan, implement, manage, and monitor all aspects of the PMTCT program

• Building the capacity of the DHMTs for them to lead with the support of EGPAF

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The Value of the District Approach

• Building local capacity for PMTCT programming while fostering greater ownership and sustainability

• Enabling rapid scale-up of PMTCT services through integration with existing structures and systems

• Facilitating health system strengthening and supporting quality

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Steps for Implementation:Laying the Foundation

• Ensure plans are consistent with national policy/guidelines

• Engage the district administration and help build leadership: work with technical, administrative & operational staff

• Conduct an initial assessment with district & region staff

• Involve community leaders to increase awareness and promote PMTCT services

• The human factor

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Steps for Implementation:Getting Started

• Letters of Intent→ Proposal → Annual Work Plan– Including targets, budget, outlined activities and timeline

with responsible parties

• Operational issues:– Cost sharing, district control over budget, procurement/

supply chain management

• Establish PMTCT training capacity in the district and synchronize training with the establishment of new sites

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Steps for Implementation:Now What?

• Encourage team building

• Facilitate the exchange of experiences between districts

• Integrate supportive supervision into the district routine

• Involve district stakeholders in M&E

• Facilitate modification of approaches

• Constant follow-up

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Program Results

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Program Expansion: 2003-2009

2003 2004 2005 2006 2007 2008 20090

200

400

600

800

1000

1200

0

50,000

100,000

150,000

200,000

250,000

300,000

350,000

400,000

450,000

Eligible Women Total Sites

Site

s

Eligible Wom

en

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PMTCT Service Coverage: June 2010

Region # of districts

# of health facilities per

regionTotal # of RCH sites

Total # of PMTCT sites

(%) RCH sites with

PMTCT

Arusha 7 279 192 163 85%

Kilimanjaro 7 369 257 248 96%

Mtwara 6 183 161 158 98%

Shinyanga 8 293 279 275 99%

Tabora 7 244 217 216 99%

Total 35 1,368 1,106 1060 96%

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Number of Women Receiving Services: 2003-2009

2003 2004 2005 2006 2007 2008 20090

50,000

100,000

150,000

200,000

250,000

300,000

350,000

400,000

EligibleCounseledTestedResults

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Program Quality: Uptake of Services Over Time

Counseled Tested Results Women ARV Infant ARV Percentage

20%

30%

40%

50%

60%

70%

80%

90%

100%

110%

2003

2004

2005

2006

2007

2008

2009

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Challenges, Lessons Learned & Conclusions

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Key Challenges

• Multiple constraints within the HIV/AIDS sector

• Less direct control over program outcomes: balance priorities between EGPAF and districts

• Rapid expansion of the program; little means to supervise sites, not able to provide direct support that would be ideal

• Balance of focus on quantity vs. quality

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Lessons Learned: Opportunities

• Need for 360 degree support: lack of financial management and administrative capacity in some districts

• Weak data quality/systems

• Ensure links to other services: most sites do not offer HIV care/treatment or delivery services

• Difficult determining when the districts are ready to operate independently

• Importance of assessing program performance by district/site

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Varied Program Performance by District

District A District B District C District D0%

20%

40%

60%

80%

100%

48%

99%

33%

96%

Counseled

Tested

Results

Women ARV

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How to Work Better

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Conclusions• The district approach is responsible for

the successful rapid scale-up of PMTCT in EGPAF supported regions in Tanzania

• This approach is not without challenges

• Districts are assisted to strengthen their health systems to meet the long-term health needs of women and children

• National leadership through MOHSW played key role in this approach

• Strong approach for sustainable services

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Thank you• Clients that we serve

• All District Health Management Teams

• Anja Giphart

• Jeroen Van’t Pad Bosch

• Agatha Haule

• Betty Muze

• Adam Silver

• Patrick Swai

DISCLAIMER: This program was made possible through support provided by the Office of HIV/AIDS, Global Bureau Center for Population, Health and Nutrition, of the United States Agency for International Development (USAID), through the President’s Emergency Plan for AIDS Relief, as part of the Elizabeth Glaser Pediatric AIDS Foundation's International Family AIDS Initiatives (“Call To Action Project”/ Cooperative Agreement No. GPH-A-00-02-00011-00). Private donors also supported costs of activities in many countries. The opinions expressed herein are those of the authors and do not necessarily reflect the views of USAID.