Tanzania National Community Based Health Program Proposed model for Program Design Helen Semu AD HPS Ministry of Health and Social Welfare Thank you for inviting me to this meeting. My name is Colin Baynes. I am the Program Manager for the Connect Project, a randomized cluster controlled trial of the introduction of a paid, professionalized CHW cadre that implements an integrated MNCH work package in rural Tanzania. It is great to be here to present the evaluation of the community health worker intervention which Ineke has just presented. As Ineke has said, our project, called Connect, conducted a practically identical recruitment, selection, training and implementation process as the SolidarMed Project. Therefore, during this presentation, I will highlight very briefly the intervention itself and move on to present pieces of the program evaluation. I should also, acknowledge the Connect Team at the Ifakara Health Institute, Columbia University and the Tanzanian Training Center for International Health who partnered to conduct this project.

Essential pre-conditions (GoT driven, partner support) 1.       By Nov 2015, MOHSW completes the generic Program Design and launch the program 2.       By November 2015, MoF commits to prioritize salary for at least 2000 CHW per year from 2016/7 3.       By December 2015, POPSM commits to prioritize positions for at least 2000 CHW per year from 2016/7. 4.       By December 2015, PMO-RALG commits to prioritize training of at least 2500 CHW per year from 2016/17 . 5.       By December 2015 LGAs in RMNCH-BRN Regions commit to prioritize absorption of at least 80% of the required CHW per year and establish district-led CBHP. 6.       By April 2016, partners and GoT achieve a CHW-cost sharing agreement. 7. By Dec 2015 Strategize and deploy partners to work with LGAs BRN-RMNCH regions to achieve the strategic goals  

The components of Program Design Identified and approved by the community, village GoT Recruitment by LGA (WDC) Training by National curriculum, HTI/setellites Employed by LGA, NGOs, Private sector Service delivery Standardized remuneration for existing CHWs to deliver a minimum package of RMNCAH mostly health promotion, disease prevention and referral (economic analysis proposed) Salaried – comprehensive and integrated package (health promotion, preventive and referral, basic curative, rehabilitative, disease surveillance, reporting vital statistics) Deployment and management by the LGA Nearby facility staff Village government To quickly recap what Ineke just presented, the intervention comprised the holistic introduction of CHW into the local health system – recruitment and selection of CHW by way of enabling initiative of communities to develop job description and scopes of work for CHW, village government and community selection processes; a nine-month training program for CHW that was optimized for eligibility for the national scheme of service and adoption of the program by national government, and imparted on CHW competencies to perform an integrated maternal, newborn and child health service package, which includes case management for malaria, pneumonia and diarrhea for under-fives. The intervention was managed by the district health systems, but this was backstopped by enabling activities of the project to ensure essential system supports to the CHW.

CBHP Policy Guidelines “Essential health services cannot be provided by people working on a voluntary basis if they are to be sustainable and accountable. While volunteers can make a valuable contribution on a short-term or part-time basis, trained health workers should receive adequate wages and/or other appropriate and commensurate incentives”. Task shifting: rational redistribution of tasks among health workforce teams [Global recommendations and guidelines, recommendation 14]. Geneva: World Health Organization; 2008. task shifting guideline, MOHSW, 2015 In March 2014, MOHSW approved CBHP Policy Guidelines which calls for a Community Health Worker cadre that: Is chosen by their community and reports to their community; Is formally trained according to government standards, paid and employed by the government and enrolled in a scheme of service Provides an integrated and comprehensive package of interventions to include RMNCAH services Connects people across the household to facility continuum and engages health promotion, preventive, basic curative, rehabilitative services and surveillance.

National CBHP Strategic Plan 2015-2020 From 2015 to 2020… Operationalize the CBHP country wide: Start scale up in “BRN – RMNCH regions (5) Finalize tools to guide the program implementation - ongoing Assess the capacity of HTI/Setellites – partly done Equip to enable training – plans underway Start training Build sustainable systems for national. replication and scale up Five strategic objectives: Strengthen management and coordination mechanism of CBHP at all levels. Formalize CHW cadre Strengthen institutional capacity to mobilize and manage resources for CBHP Strengthen advocacy, communication and social mobilization Strengthen support systems for effective planning and implementation of CBHP services at all levels.

Status of progress: 40% mostly national level Strategic goal 1: By June 2020, in at least 75% of LGAs, increased capacity to manage and coordinate the CBHP Partners: USAID, MUHAS, JSI, JhPiego, BMAF, BMGF, CHAI, IRISH AID, UNICEF, WB, DANIDA, WHO Status of progress: 40% mostly national level Next steps: solicit partners collaboration, financial and technical support - MoU Outcome1.1:Strengthened the capacity of existing structures by 75% from the baseline by 2020 Outcome 1.2: By 2020, 100% of partners planned activities for CBHP are integrated into national and councils plans Outcome 1.3: Mult sectoral collaboration for implementing CBHP established in 75% of LGAs by 2020

Strategic Goal 2: By June 2020, at least 1/3 of required CHWs trained with the national curriculum be employed and deployed by the GoT Outcome 2.1: By Dec 2015, roles and responsibilities of CHWs be adopted in the SoS for MA Partners: WHO, DDCF, THET, Columbia, Comic Relief, IHI, *, BMGF, CHAI, UNICEF, USAID, JhPiego, Solidamed, SDC Status of progress: 55% accomplished mostly national level Next steps: Solicit collaboration, technical and financial support for program design, implementation in BRN regions, knowledge management and roll out Outcome 2.2: The National curriculum for training CHWs in use in 80% of the HTI/satellites by June 2020, Outcome 2.3: 1/3 of trained CHW’s are deployed by public and NGO’s implementing CBHP Outcome 2.4: By 2020, t least 80% of existing CHWs volunteers have capacity to delivery a minimum package of RMNCAH Outcome 2.5: 80% of deployed CHWs are retained in service by 2020

Strategic goal 3: By 2020, 80% of LGAs sustain CBHP Outcome 3.1: By 2020 80% of LGAs have increased the capacity to mobilize resources for CBHP Potential partners: 1mCHWs Campaign, BMGF, CHAI, USAID, JSI, Comic Relief, THET, WHO, UNICEF, JhPiego, UNFPA, Status of progress: 10% Next steps: Develop strategies, toolkits for advocacy and capacity building on resource management at national and LGA level. Outcome 3.2: By 2020, 80% of LGAs have increased capacity to manage CBHP Outcome 3.3: By 2020, 75% of existing structures increase accountability on resource management

Strategic goal 4: By 2020, 80% of LGAs will have the capacity to advocate, communicate and social mobilization for CBHP. Outcome 4.1 : By 2020, 80% of legislations and by-laws for improved community health will be enforced Outcome 4.2: by 2020, 75% of community structures are accountable for CBHP services (social mob) Outcome 4.3: By 2020, 90% of care takers of children aged 5 years and below improved early health care seeking behavour (ASBCC) Strengthen support systems for effective planning and implementation of CBHP services at all levels. Partners: UNICEF, WHO have provided support which somehow touches the CBHP components Status of progress: 20% a lot of in country programs/ projects to learn from and use for CBHP Next steps: to determine partners to support the interventions.

Strategic goal 5: 80% of support systems for planning and implementation of CBHP at all levels strengthend Partners: Columbia/IHI, MUHAS/JHU, BMG/CHAI, USAID/JSI Status of progress: 15% - BRN, is strengthening logistics scheme and supervision systems, etc. M&E, research: Lessons learned from pilot work conducted by partners. Next steps: program design which will involve knowledge management, operational research and M&E plan for CBHP. Outcome 5.1: By 2020, community-based health component of HMIS established and functional Outcome 5.2: Build capacity for effective and applied M&E and Operations Research of CBHP Outcome 5.3: by 2020, 80% of CHWs work plan are successful implemented (supportive supervision) Outcome 5.4: At least 80% of CHWs experience an uninterrupted supplies each year

Asanteni sana