The District Mentorship Initiative in Tanzania Track 1.0 Annual Meeting Redempta Mbatia ICAP Tanzania August 10 th 2010

ICAP Tanzania Program ICAP TZ has assisted implementation of prevention, care and treatment services in 127 sites, and PMTCT services in 408 sites with a focus on quality services in 4 mainland regions (Pwani, Kagera, Kigoma) and Zanzibar. As of June 2010: 61,807 clients enrolled in care and 30,346 (49%) initiated on ART. 458,728 pregnant women were tested, counseled with 44,120 provided ARV prophylaxis Important innovations have been initiated e.g. prevention with positives, male circumcision, prevention and programs for IDUs, FSWs and MSM Partnerships have been established with 25 CHMT, 3 RHMT, and 39 NGOs/FBOs

National (GoT) Context Chronic shortage of Human Resources (HR) The current GoT supervision approach is largely aimed at improving staff performance, supply chain, HR & training gaps and logistics using checklists rather than providing mentorship and ensuring quality Six MOHSW indicators for quality improvement in HIV prevention, care and treatment have been defined National Supportive Supervision and Mentoring Guidelines developed by MOHSW, ICAP other IPs and now finalized and being adopted ICAP TZ experience expected to inform national roll out of mentorship

MoHSW MNH Referral Hospitals (4) Regional Hospitals (RHMT) District Hospitals (CHMT) Dispensaries/Health Centre Community and Health Post Tertiary Secondary Primary Ministry of Health and Social Welfare (MoHSW) Policy Development and National Strategy Muhimbili National Hospital (MNH) Translation and Coordination of Policy Implementation and Supportive Supervision Tanzanian Health System

ICAP-Tanzania District Mentorship Initiative (DMI) Goal: Ensure sustainability and ownership of HIV prevention, care and treatment within Tanzania’s existing decentralized health system Build a network of mentors at the District and Regional level to support lower level centres Improve quality through introducing a quality improvement approach using standards of care (SOCs)

District Mentoring Initiative GOAL Growth, Quality and Sustainability OBJECTIVES Implementing a Model of Care Improving Quality of Care Building Capacity/Strength ening Systems NATIONAL RESOURCE MATERIALS National Quality Improvement Framework (TQIF) for quality improvement in health service provision National QI Guidelines for HIV and AIDS Services National Clinical Mentoring manual for HIV/AIDS service National Clinical Mentoring training curriculum for HIV/AIDS service ICAP TANZANIA RESOURCE MATERIAL District Mentoring Initiative (DMI) Proposal (in line with national guidelines/manuals) The DMI is fully integrated into the existing health system; Regional and District Health Management Teams are responsible for site selection for mentoring activities, to coordinate DMI and to select the regional and district mentors

Principles of DMI Mentorship will not replace traditional ‘support supervision’ currently being implemented by regional & district health teams District Mentors will not be a new cadre within the health system RHMT and CHMT are the key ‘players’ in the existing system and must be supported. –Their role is to coordinate and oversee implementation of DMI in collaboration with ICAP Mentors must meet certain criteria Clinical competence (macro skills) and experience General mentorship skills (micro/soft skills) Willingness and commitment

Methodology Orientation to RHMT/CHMTs in the region(s) Selection of district mentors by CHMTs based on set criteria Selection by RHMT/CHMTs of sites to receive mentorship Assessment of mentors’ skills (ICAP TZ) In-depth training of mentors- (6 days) Pre-mentorship site activities: sensitization of sites, staff, and site assessments of the model of care. Implementation with ICAP TZ close monitoring Assessment at 3-months followed by 6 month evaluation

DMI : The Process 1) DMI implementation started at 2 CTC and 2 PMTCT sites in each district 2) Next step DMI evaluation after 3 months pilot period (between July-Nov 2010): Assessment on Model of Care (MOC), Standard of Care (SOC), Routine HIV/AIDS indicators, DMs reports, mentees and mentors self-assessment reports 6 days training for district mentors (DMs) focusing on mentorship skills and methodologies Kagera February mentors (8 districts) Kigoma June mentors (4 districts) Pwani August mentors (7 districts) 2 day workshop to orient RHMT/CHMT and endorsement of the proposal followed by Mentors Self Assessment Kagera October 2009Kigoma May 2010 Pwani July 2010 CMS Training of Core ICAP Staff in Uganda Review MOC and agree on key SOC/indicators Adapt i-TECH-NACP Training Materials After DMI evaluation: roll out DMI in all facilities in each district. Internal Processes External Processes

Selection criteria Mentor Expertise and experience in a specific HIV intervention area Approachable and accessible with good communication skills Actively providing HIV/AIDS interventions Been through at least one of the relevant HIV-related intervention course Understands the country/district’s health systems Willing and committed Site High volume site New site with high volume Low CD4 testing High number of Loss to Follow up (LTFU) Poor documentation Poor enrolment of patients who are eligible for ART/ or poor linkage/referral of PMTCT clients to C&T

Quality Indicators for Tanzania*…. All pregnant HIV+ women should be enrolled into CTC within one month of first ANC visit. All HIV-exposed infants should be started on CTX prophylaxis at one month of age. All patients on ART should return to clinic for follow-up within one month of starting ART. All pre-ART and ART patients should have CD4 testing every six months. All ART and pre-ART patients should be assesses for TB disease at every visit. All ART patient should be assessed for adherence at every visit. * Quality indicators basis for the SOCs being measured by mentors before and after mentorship

Next steps Quarterly review, assessment, feedback to region and MOHSW and evaluation of program at six months Sharing of progress to date in annual stakeholder meetings in Kigoma and Kagera (August 2010) Incorporation of DMI into the district council health comprehensive plans (with funding) Increased focus on quality with measurable results(SOCs) Growing network of mentors focusing on micro/macro skills in HIV Care, ART, PMTCT (and potentially beyond) In light of transition, pool of mentors to be gradually increased under RHMT/CHMT management.

Thank you!