ACCOMPLISHMENTS AND CHALLENGES IN TANZANIA

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ACCOMPLISHMENTS AND CHALLENGES IN TANZANIA
International Center for AIDS Care and Treatment
Programs Annual Meeting, March 2006 Dar es
Salaam, Tanzania

• Dr Mark Hawken
• Dr Boniphace Idindili
• 6 March 2006

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Presentation Outline

• Background
• Accomplishments
• The NACP perspective
• Challenges
• Conclusions

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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

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Columbia Supported Sites

• CU started supporting PMTCT sites in February
  2004 and CT since July 2004
• Currently there 13 Care and Treatment sites and
  38 PMTCT sites at zonal, regional, district,
  health center and dispensary level

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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

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Presentation Outline

• Background
• Accomplishments
• The NACP perspective
• Challenges
• Conclusions

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Accomplishments

• Building trust national partners
• Establishing a team
• Establishment of sites
• Establishment of infant diagnosis program

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Building Trust

• Key elements have included
• Demonstrating the ability to deliver
• Establishing steady reliable cash flow
• Public relations
• Supporting NACP

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Establishing a Team

• Establishing program and support team
• Fostering team spirit
• Recognition of a multidisciplinary approach

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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

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Enrolled in HIV Care by December 2005
(non-ART/ART)
8 sites
5 sites
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Initiated on ART by December 2005
8 sites
5 sites
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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

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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

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Establishment of Infant Diagnosis Program

• 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

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Presentation Outline

• Background
• Accomplishments
• The NACP perspective
• Professor Tabasamu Kicheko
• Challenges
• Conclusions

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NACP Organogram
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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

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Funding to Tanzania (USD)

• As of June 2005
• Global Fund 11m
• PEPFAR 5m
• SIDA 4m
• World Bank 2m
• Clinton 1m
• NORAD 0.5m

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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

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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

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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

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Presentation Outline

• Background
• Accomplishments
• The NACP perspective
• Challenges
• Conclusions

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Challenges

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

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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

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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

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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

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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

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Presentation Outline

• Background
• Accomplishments
• The NACP perspective
• Challenges
• Conclusions

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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

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Acknowledgements

• CU New York
• NACP/MOH
• CDC
• USAID
• Partners