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THE RESPOND TANZANIA
PROJECT FINAL REPORT
TH ST 30 NOVEMBER 2012 – 31 OCTOBER 2017
AID-621-LA-13-00001 Reference LWA No GPO-A-00-08-00007-000
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Our Mission Catalyzing the value of women and girls by harnessing the power of sexual and reproductive rights and health
Our Vision A world where sexual and reproductive rights are respected as human rights and women and girls have the freedom to reach their full potential.
The RESPOND Tanzania Project Associate Cooperative Agreement No. AID-621-LA-13-00001 Managing partner: EngenderHealth, Inc. Associated partners: Meridian Group International, the Population Council
For inquiries, please contact: EngenderHealth Country Office Plot #254, Mwai Kibaki Road/Kiko Avenue - Mikocheni P.O. Box 78167 Dar es Salaam, Tanzania +255 22 277-2263 / 277-2365 Fax: +255 22 277-2262 www.engenderhealth.org
® © 2018 EngenderHealth. COPE , Supply-Enabling Environment-Demand, and the SEED™ Model are trademarks of EngenderHealth Photo credits: S.Lewis/EngenderHealth, M. Tuschman/EngenderHealth, Staff/EngenderHealth. (RTP)
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CONTENTS
CONTENTS...... 3 FOREWORD ...... 4 ACRONYMS AND ABBREVIATIONS ...... 5 ACKNOWLEDGMENTS ...... 7 EXECUTIVE SUMMARY ...... 9 BACKGROUND ...... 13 Maternal Mortality and Family Planning ...... 13 The Respond Tanzania Project (RTP) ...... 13 Project Implementation Strategy ...... 13 RESULT 1: ACCESS TO QUALITY LA/PM AND RH SERVICES (HIV AND AIDS AND GBV) INCREASED...... 15 Capacity building for service providers ...... 15 Access to and Use of FP and LARCs/PMs ...... 17 FP method mix ...... 17 Proportion of FP-LARC/PM clients attributable to RTP interventions ...... 18 Estimated impact from provision of FP services ...... 19 Uptake of LARCs among youths ...... 19 PMTCT ...... 20 GBV and VAC ...... 21 Task sharing of FP service provision ...... 23 Postpartum FP ...... 23 Comprehensive postabortion care ...... 24 Improved contraceptive commodity security ...... 25 RESULT 2: QUALITY FP-LARC/PM AND RH INTEGRATED SERVICES DEMONSTRATED, EVALUATED, AND SCALED UP ...... 26 FP integration at workplaces ...... 27 RESULT 3: HEALTH SYSTEMS MANAGEMENT AND MONITORING AND EVALUATION STRENGTHENED FOR INTEGRATED FP- LARC/PM AND RH SERVICES...... 28 Health systems strengthened ...... 28 RTP research activities ...... 29 Safety of minilaparatomy provided by trained clinical officers and assistant medical officers ...... 29 Access to RH and HIV services among young mothers in Tanzania ...... 30 Operations research on the optimal package and process of integrated health care ...... 31 Monitoring and evaluation ...... 32 RESULT 4: COMMUNITIES MOBILIZED TO INCREASE USE OF FP-LARCS/PMS AND RH SERVICES THROUGH THE FOLLOWING INTERVENTIONS ...... 33 Community mobilization for outreach and FP weeks ...... 33 Community engagement and mobilization through “site walk throughs ...... 33 Legacy products ...... 34 CONCLUSION ...... 35 REFERENCES ...... 36 APPENDIX 1: PERFORMANCE MANAGEMENT PLAN (PMP) ...... 37 APPENDIX 2: FUNDING OBLIGATIONS ...... 44 APPENDIX 3: RTP RESULTS FRAMEWORK ...... 45
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FOREWORD
EngenderHealth has been the primary family planning and in contributing to its efforts to eliminate preventable reproductive health (FP/RH) partner to the Ministry of Health, maternal and child deaths and reach the national goal of Community Development, Gender, Elderly and Children achieving a contraceptive prevalence of 45% by 2020. (MOHCDGEC), Mainland, and the Ministry of Health, There has been a growing realization that up to one-third Zanzibar, for over a decade. In the past five years of all maternal deaths and illnesses could be prevented if EngenderHealth, through the RESPOND Tanzania Project women had access to contraception. Over the duration of (RTP), partnered with the two Ministries (Mainland and the project, LARCs/ PMs were provided to more than 4.5 Zanzibar) to scale up and strengthen the delivery of FP million women. This is estimated to have resulted in services, with an emphasis on long-acting reversible 16,000 fewer maternal deaths, 2 million fewer unsafe contraceptives (LARCs) and permanent methods of abortions, 133,000 fewer newborn deaths, and a 93% contraception (PMs), and also worked in comprehensive reduction in mother-to-child transmission of HIV. postabortion care (cPAC) and prevention of mother-to-child transmission of HIV (PMTCT) and prevention of gender- RTP was a very successful project, and its implementation based violence (GBV) and violence against children (VAC). has produced useful lessons and observations. The
The Tanzania Demographic and Health Survey 2015–2016 closeout of the project ensured that the achievements documented the progress made in increasing the national were shared with all of the regions and the 110 districts contraceptive prevalence rate from 27% in 2010 to 32% in where the project was implemented and with the partners, 2015/16. The report indicates that the contraceptive method including the three USAID Boresha Afya projects, through mix now includes more use of LARCs/PMs, which increased regional and national dissemination meetings in the from 6.5% in 2010 to 11.2% in 2015–2016), and reflects the mainland and Zanzibar. fact that more women and couples are achieving their reproductive intentions, including spacing births and The capacity building of public service providers and the meeting their family size desires. approach that was used to work directly with government through the districts and health facilities aimed to promote However, much remains to be done to address the high the sustainability of services and approaches even after unmet need for FP (22%) among currently married women. the project ended. These women want to space or limit births but are not currently using contraception. EngenderHealth has Feddy Mwanga continued to support the Tanzanian government in meeting RTP, Chief of Party its Family Planning2020 country commitment and
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CRONYMS AND ABBREVIATIONS
AGOTA Association of Gynecologists and Obstetricians of Tanzania AMO Assistant Medical Officer ANC Antenatal Care ART Antiretroviral Therapy ATP ACQUIRE Tanzania Project CHAMPION Channeling Men’s Positive Involvement in the National HIV/AIDS Response CCHP Comprehensive Council Health Plan CO Clinical Officer COPE Client-Oriented, Provider Efficient CCBRT Comprehensive Community Based Rehabilitation in Tanzania CCHP Comprehensive Council Health Plan CHMT Council Health Management Team cPAC comprehensive Post Abortion Care CTC Counseling and Testing Centre CYP Couple-Years of Protection DBS Dried Blood Spot DMO District Medical Officer DRCHCO District Reproductive and Child Health Coordinator EID Early Infant Diagnosis FP Family Planning GHI Global Health Initiative HIV Human Immunodeficiency Virus IRB Institutional Review Board IUD Intrauterine Device JHU/CCP Johns Hopkins University/Center for Communication Programs LARC Long-Acting Reversible Contraceptive M&E Monitoring and Evaluation MAP® Men as Partners MOHCDGEC Ministry of Health, Community Development, Gender, Elderly, and Children MOHSW Ministry of Health and Social Welfare MTUHA Mfumo wa Taarifa za Uendeshaji wa Huduma za Afya (Kiswahili acronym for Health Management Information System) MVA Manual Vacuum Aspiration NFPCIP National Family Planning Costed Implementation Program NIMR National Institute of Medical Research NOGI National Operational Guidelines on Integration of HIV and MNCH NSV No-Scalpel Vasectomy OJT On-the-Job Training OPD Outpatient Department PM Permanent Method (of contraception) PMP Performance Management Plan PMTCT Prevention of Mother-to-Child Transmission of HIV PNC Postnatal Care PO Program Officer
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ACRONYMS AND ABBREVIATIONS
RCH Reproductive and Child Health RCHS Reproductive and Child Health Section RH Reproductive Health RMNCH Reproductive, Maternal, Neonatal, And Child Health SEED Supply–Enabling Environment–Demand [Programming Model SMS Short Message Service SRH Sexual and Reproductive Health STI Sexually Transmitted Infection TA Technical Assistance TAHA Tanzania Horticultural Association TANAPA Tanzania National Park Association TAMA Tanzania Midwives Association TDHS Tanzania Demographic and Health Survey TOT Training Of Trainers TWG Technical Working Group UMATI Chama cha Uzazi na Malezi Bora Tanzania USAID United States Agency for International Development WAMA Wanawake na Maendeleo WHO World Health Organization WRA Women of Reproductive Age
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ACKNOWLEDGMENTS
Accomplishments of the RESPOND Tanzania Project provided continued guidance and support throughout the (RTP) were achieved through the contributions of many project implementation. partners, stakeholders, and colleagues within the project RTP has greatly benefited from the continued technical and from the health ministries of Tanzania Mainland and support of EngenderHealth New York and Washington staff Zanzibar. in all areas of the project, and from the efforts of the field
managers (in Arusha, Coastal, Iringa, and Mwanza regions), RTP is greatly honored to have worked with and benefited program officers, and other staff who worked tirelessly to from the support and guidance of the Prime Minister’s Office– ensure that the project achieved its goals and objectives. Regional Administration and Local Government and of the
Ministry of Health, Community Development, Gender Elderly We express our sincere gratitude to USAID technical team of and Children (MOHCDGEC) at the national, regional, district, Michael Mushi, Jane Schueller, Jennifer Erie, Raz and facility levels.The teams’ work in organizing, Stevenson, Selina Mathias, Patrick Swai, Erasmo Malekela, implementing, and monitoring the interventions were the main and Eric Mlanga, for their technical support and guidance ingredients toward the recorded achievements of the project. during the planning and implementation of the project. We are RTP also expresses its deep gratitude to the American also grateful to Laurel Fain, Health Office Director, and People, who made implementation of the project possible Ananthy Thambinayagam, Deputy Director Health Office, for through the financial support received from the United States their overall support. Furthermore, we thank Patrice Lopez, Agency for International Development (USAID) and the Sheila Bumpass, Esteban Estevez, and Nya Kwai Bwakye, technical support received from the USAID Mission at the Ruby Tawonezvi and Ayana Angulo from the USAID country level.We are also grateful for the strong collaboration Agreements Office, for their guidance and support. and partnership that we have had with other family planning
(FP), HIV, and maternal and child health implementing partners. Sincere appreciation goes to the following persons from the MOHCDGEC: The Hon. Minister, Ummy Mwalimu (Member of Parliament); Dr. Ulisubisya Mpoki, Permanent Secretary; Dr. Neema Rusibamayila, Director of Preventive Services (who was also the Assistant Director for Reproductive and Child Health Services during the beginning of the project); Dr. Georgina Msemo, the acting Assistant Director for Reproductive and Child Health Services for most of RTP implementation period; Mr. Maurice Hiza, Family Planning Program Manager during the first three years of the project; Mrs. Zuhura Mbuguni, the Current Acting FP National Coordinator; Dr. Grace Mallya, National Gender-Based Violence Coordinator; and Dr. Angela Ramadhani, National Coordinator for Prevention of Mother-to-Child Transmission of HIV. These colleagues, along with their teams, have
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EXECUTIVE SUMMARY
The RESPOND Tanzania Project (RTP) was a five-year The specific scope of RTP was to: project (2012–2017) led by EngenderHealth and supported • Improve the uptake of LARCs/PMs in 110 districts of by the U.S. Agency for International Development (USAID). mainland Tanzania In close partnership with Meridian Group International, Inc.,1 • Decentralize postabortion care (PAC) to lower level health the Population Council,2 local community-based partners,3 facilities in 21 districts of Mwanza, Geita, Simiyu, and and national, regional, and district-level health authorities, Shinyanga regions RTP supported Tanzania’s Ministry of Health, Community
Development, Gender, Elderly, and Children (MOHCDGEC) • Scale up comprehensive services for the prevention of to advance the use of family planning (FP) and reproductive mother-to-child transmission of HIV (PMTCT) to all sites health (RH) services, with a focus on the informed and providing reproductive and child health (RCH) services in voluntary use of long-acting reversible contraceptives (LARCs) and permanent methods (PMs). Building on the Manyara Region, with a focus on strengthening the FP successes and lessons learned from the two previous USAID- component within PMTCT and other HIV services -unded FP flagship projects implemented by EngenderHealth—the ACQUIRE Project (2003–2007) and • Expand and strengthen clinical care and treatment for the ACQUIRE Tanzania Project (ATP) (2007–2012)—RTP survivors of gender-based violence (GBV) and violence applied a mix of strategies and approaches designed to against children (VAC) in Iringa and Njombe regions, while support the national commitments to FP and RH outlined in addressing the root causes of GBV through community- MOHCDGEC’s Reproductive Health and Maternal Newborn based prevention activities and Child Health (RHMNCH) Sharpened One Plan (2008–
2015), the Sharpened One Plan II (2016–2020), and the In addition, RTP served as the lead prevention and clinical National Family Planning Costed Implementation Program partner for all U.S. government-funded GBV programs (NFPCIP) for 2010–2015. and provided support to the Ministry of Health of Zanzibar to strengthen the provision of its FP services. RTP was structured around EngenderHealth’s holistic In the five years of project implementation, RTP, in programming approach, the Supply–Enabling Environment– collaboration with local and international partners (UMATI, Demand (SEED) Programming Model, for the design and Utu Mwanamke, WAMA, Zonal Health Resource Centers, implementation of activities and to inform the selection of Meridian Group International, Inc., and the Population activities within the results. Under this approach, RTP, in Council) made tremendous achievements toward its set collaboration with the MOHCDGEC, strengthened the goals and objectives. RTP’s implementation was guided provision of facility-based services at public facilities, trained by six overarching strategies that are discussed in detail service providers, and expanded and strengthened public- later in this report—using the targeted district approach; private collaboration (supply), and generated district and promoting “smart” integration; strengthening gender, community support for LARC/PMs (enabling environment rights, and equitable access to high-quality clinical and demand). services; strengthening service delivery through a holistic programming approach; building the capacity of districts to “own” their
1 Meridian Group International, Inc., supported the project through building public-private partnerships. religious bodies like the Tanzania Interfaith Partnership (TIP) and the Na-tional Muslim Council of 2 The Population Council supported the project to conduct operations research and special studies and Tanzania (Baraza Kuu la Waislamu Tanzania, BAKWATA) and with professional associations like through documentation. the Tanzania Midwives Association (TAMA) and the Association of Gynaecologists and 3 RTP’s local, community-based partners were Wanawake na Maendeleo (WAMA), Obstetricians of Tanzania (AGOTA). Chama cha Uzazi na Malezi Bora Tanzania (UMATI), and Comprehensive Community-Based Rehabilitation in Tanzania (CCBRT). RTP also collaborated with 9 9
FP/RH programs; and strengthening local capacity to forge decreased by 59%, and the number of districts with the alliances and partnerships with other stakeholders. As highest FP uptake increased by 68%. The method mix USAID/ Tanzania’s flagship FP/RH program, RTP played a also shifted: Prior to the approach’s implementation, key role in the following important achievements that have fewer than 12% of FP acceptors were using a LARC/PM, greatly advanced FP/RH services in Tanzania: but by 2017, 46% of FP users in the districts with the lowest FP uptake and one in four (24%) in the highest • The MOHCDGEC was supported to serve more than 4.5 uptake districts were using a LARC/PM as their FP million LARC/PM clients from Year I to Year 5 (October 2012– method of choice. September 2017), generating more than 18.7 million couple- years of contraceptive protection (123% of the benchmark of • Through RTP’s clinical and prevention efforts in GBV and 15.2 million) and covering 110 districts in all regions of VAC, more than 57,000 women, children, and men Tanzania. One-third of all LARC/PM clients in Tanzania were received clinical care or treatment for GBV at supported served during FP outreach events directly supported by RTP, sites, and community outreach activities reached more an approach which ensured that hard-to-reach communities than 205,000 men and women in Iringa and Mufindi with also received the services. messages around inequitable gender norms, violence, and clinical GBV services between 2014 and 2017. • This achievement in the voluntary use of LARCs/PMs averted millions of unintended pregnancies and prevented thousands • Between 2012 and 2016, access to comprehensive of deaths. Through RTP’s direct and indirect support, greater PMTCT services, inclusive of FP, was expanded to all use of FP is estimated to have averted 6.9 million unintended 167 RCH sites in Manyara Region. In addition, RTP pregnancies, 2 million unsafe abortions, and 16,000 maternal supported the MOHCDGEC to scale up the early infant deaths and to have saved more than $503 million in direct diagnosis (EID) program and offer Option B+ (the health care costs as per impact 2 calculator4 l (Figure 1). initiation of all HIV-positive pregnant and breastfeeding Focusing on districts with traditionally low FP uptake women on antiretroviral therapy [ART] for life) to all RCH contributed greatly toward these gains. Among the 110 sites. As a result, use of ART among HIV-positive supported districts, the mean uptake of FP per 10,000 women pregnant and breastfeeding women increased, and fewer of reproductive age (WRA) increased by 32%, from 3,037 to infants tested positive for HIV in Manyara. 3,996 clients per 10,000 between 2012 and 2017. By • Across 239 RTP-supported PAC sites, more than 24,000 September 2017, the number of targeted districts with the PAC clients received FP counseling, 19,000 of whom lowest FP uptake were discharged with an FP method of their choice. Annually, Figure 1: Estimated impact from provision of FP services
4 Source: MSI Impact 2 calculator
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the percentage of PAC clients at RTP-supported sites who received FP counseling and an FP method was between 71% and 84%, higher than the World Health Organization (WHO) standard for PAC clients accepting FP methods 60%).
• Service integration was among the strategies that were utilized to increase uptake of FP, and a total of 267,585 clients received FP through integrated services. The largest percentage were attending immunization/under-5 clinics (32%), while HIV care and treatment (22%), postnatal care (21%), and outpatient department (OPD)/sexually transmitted infection (STI) sites and inpatient department (25%) accounted for the balance.
• RTP conducted three studies intended to generate information that would enable the MOHCDGEC and implementing partners to strengthen provision and increase access and use of reproductive, maternal, neonatal, and child health (RMNCH) services, by increasing the range of cadres that are permitted to provide services. Such a strategy would be expected to minimize missed opportunities and ensure that services reach disadvantaged groups, including youth.
• The Integration Acceleration Operations Research study was intended to define a feasible package and process for integrated services at the health center level, considering such elements as cost/efficiency, human resources for health, financing, service delivery modes, and health management information systems (HMIS) requirements.
• The Safety of Minilaparotomy Provided by Trained Clinical Officers and Assistant Medical Officers study aimed to establish whether minilaparotomy can be provided as safely by trained clinical officers as by trained assistant medical officers (AMOs), as measured by rates of major adverse events among women undergoing minilaparotomy.
• The study Examining Access to RH and HIV Services among Young Mothers in Tanzania assessed the experiences of young mothers aged 12–19 in Tanzania regarding their access to RH and HIV services.
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BACKGROUND
Maternal Mortality and Family Planning The project was designed under four results: Maternal mortality is still unacceptably high in Tanzania because of early and frequent pregnancies, inadequate 1. Access to quality FP (LARCs/PMs) and RH services (HIV maternal health services, and a lack of skilled birth and AIDS and gender-based violence [GBV]) increased attendance—problems that are worse in poor communities 2. Quality FP (LARCs/PMs) and RH integrated services with less education level and among rural women. The demonstrated, evaluated, and scaled up 2015–2016 Tanzania Demographic and Health Survey and 3. Health systems strengthened for integrated FP and RH Malaria Indicator Survey (MOHCDGEC et al., 2016) services reported a maternal mortality ratio of 556 maternal deaths 4. Communities engaged in the promotion of FP (LARCs/ per 100,000 live births for the 10-year period before the PMs) and RH services survey, which was higher than the ratios reported in the 2010 Tanzania Demographic and Health Survey (454 per The Results Framework for RTP is included in the appendix. 100.000 live births) (NBS & ICF Macro, 2011). Project Implementation Strategy Modern contraceptive use among currently married women in Tanzania has steadily increased over the last decade, RTP’s work was grounded in the Supply–Enabling from 20% in 2004–2005 to 27% in 2010 and 32% in 2015– Environment–Demand (SEED) Programming Model (Figure 2016 (MOHCDGEC et al., 2016). It is well-known that family 2), a holistic framework developed by EngenderHealth and planning (FP) saves lives: If contraception were provided to based on the principle that RH programs will be more the 1 million women with an unmet need for FP, there would successful and sustainable if they comprehensively address be 660 fewer maternal deaths, 320,000 fewer unintended the multifaceted determinants of health. Interventions were pregnancies, 6,200 fewer newborn deaths, and a 93% designed to address the availability and quality of FP/RH reduction in mother-to-child transmission of HIV (Marie services (Supply) while generating awareness of, support Stopes International Impact 2 tool). However, while the for, and utilization of these services (Enabling Environment contraceptive prevalence rate (CPR) for any FP method and Demand). quadrupled in Tanzania between 1991 and 2016, from less than 8% to 38%, and long-acting reversible contraceptives Figure2: EngenderHealth’s Supply-Enable Environment-Demand (SEED) Programming Model (LARCs) or permanent methods (PMs) increased as a proportion of the method mix from 6.5% to 11.2%, only half of the existing total demand for FP is met with a modern method of contraception (MOHCDGEC et al., 2016).
The Respond Tanzania Project (RTP)
RTP was a five-year project that was awarded to EngenderHealth in October 2012 by the U.S. Agency for International Development (USAID) under Associate Cooperative Agreement No. AID-621-LA-13-00001. The project was designed to support the Ministry of Health, Community Development, Gender, Elderly, and Children (MOHCDGEC) to advance the use of family FP and reproductive health (RH) services, with a focus on the informed and voluntary use of LARCs/PMs and to support the Reproductive and Child Health Section (RCHS), as well 13 environment coupled with social as the Government of Tanzania in the implementation of the The National Road Map to Accelerate Reduction of 13 Maternal Newborn and Child Deaths 2008–2015 (referred to as the “One Plan”) and the National Family Planning Costed Implementation Program (NFPCIP) for 2010–2015.
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2. Promote “smart” integration In support of the Figure 3: The six overarching strategies that belief that every client has a right to FP, integration of FP into RH, HIV, and other services was strengthened using guided RTP implementation EngenderHealth’s integration framework and five-step
approach (identifying the level of integration that can be adopted, assessing a health facility’s capacity to support integration, building/strengthening that capacity, identifying resources needed to support integration, and
phasing in FP methods to expand method mix based on the facility’s capacity.
3. Strengthen gender, rights, and equitable access to high-quality clinical services. Using orientation and
training materials developed for local government officials, health managers, and service providers, along with evidence-based approaches like Men As Partners ® 5 6 (MAP ) and curricula like Couple Connect, RTP was to increase the quality, availability, and utilization of clinical RTP’s implementation was guided by six overarching GBV services in Iringa and Njombe regions while tackling strategies (Figure 3)—using the targeted district approach; the root causes that contribute to and normalize GBV. In 7 promoting“smart” integration; strengthening gender, rights, addition, these same gender-transformative approaches and equitable access to high-quality clinical services; were utilized to encourage greater male involvement in strengthening service delivery through a holistic programming FP/RH—both their partner’s and their own. approach; building the capacity of districts to “own” their FP/RH programs; and strengthening local capacity to forge 4. Strengthen service delivery through a holistic alliances and partnerships with other stakeholders (Figure 3). programming approach. Each of these strategies is described below: Activities worked synergistically through the SEED model, either with direct support from RTP or through
collaboration with other implementing partners. 1. Act at all levels through a targeted district approach. Districts with low FP uptake and high unmet need received 5. Transition and build the capacity of districts to varied packages of intensive programming, primarily focused “own” their FP/RH programs. RTP collaborated with on the informed and voluntary use of LARCs/PMs. FP uptake the RCHS of the MOHCDGEC, with district health per 10,000 WRA was calculated for the 110 districts, which councils, and with local organizations to build greater were then assigned to one of three levels based on FP uptake. local “ownership,” thereby improving the financial and Level 1 districts had the lowest uptake and received more programmatic sustainability of FP/RH programs. intensive programming. Level 2 districts received less- intensive interventions that emphasized collaboration among 6. Strengthen local capacity to forge alliances and service partners to strengthen and deliver FP services. For partnerships with other stakeholders. RTP worked with Level 3 districts, interventions focused on building districts’ regional health management teams (RHMTs) and council health management teams (CHMTs) to facilitate the capacity to take ownership of their FP/RH activities. This creation of partnerships to leverage resources and strategy is further described under the interventions and commitments to FP/RH services. achievement section of this report.
5 MAP® was developed by EngenderHealth in 1996 to work with men (and later expanded to include 7 Gender-transformative approaches encourage critical awareness among men and women of gender roles women) to play constructive roles in promoting gender equity and health in their families and and norms; promote the position of women; challenge the gender-based distribution of resources and communities. allocation of duties; and/or address power imbalances between women and others.
6 CoupleConnect is an innovative, interactive curriculum developed by EngenderHealth’s CHAMPION Project, designed to prevent HIV infection among Tanzanian couples in committed relations by improving couple communication and changing gender norms.
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14 INTERVENTION AND ACHIEVEMENTS
RTP operated through four field offices located in Arusha, The MOHCDGEC requires that each facility should have at Iringa, Mwanza, and Dar Es Salaam. The field offices were least two trained providers to offer a range of FP methods the implementation units of the project, in which they worked appropriate for the facility level and cadres available. To directly with the regions, districts, and facilities to support achieve this goal, RTP supported: the MOHCDGEC to train service delivery, training, supervision, and mentoring and national FP trainers, with special attention to strengthening to build the capacity of the districts to monitor the project provider capacity at lower-level health facilities; the national activities, including data management, and coordinate transition to Implanon NXT and development and review of partners and service provision. The field offices were led by different FP training curricula for trainers and service field managers, who were supported by program officers in providers. Realizing that traditional in-service trainings are such project areas as FP, GBV, or prevention of mother-to- costly and can disrupt routine services when providers are child transmission of HIV (PMTCT), monitoring and taken off-site, RTP promoted more cost-effective and evaluation (M&E) officers, and finance and operations and support staff, including drivers, secretaries, and office sustainable approaches to training of FP providers, attendants. Each field office was responsible for including on-the-job training (OJT), for which a national coordinating activities in an average of eight districts. The guideline was developed and rolled out starting in 2014. main responsibility of the RTP headquarters (in Dar es OJT has been widely and successfully adopted, and Salaam) was to engage with USAID, MOHCDGEC, and currently, more FP trainings are conducted through OJTs other partners at the national level and to supervise the field than by means of centralized off-site trainings. offices. In total, RTP had 55 staff. RTP also promoted the inclusion of FP in the pre-service RESULT 1: ACCESS TO QUALITY LA/PM AND RH SERVICES training curriculum for certificate and diploma nurses and (HIV AND AIDS AND GBV) INCREASED. midwives and the training of nurse tutors on short-acting FP and LARCs to build their capacity, with emphasis on
RTP was designed to support the government of Tanzania practical skills training. The project continued to support training of preservice assistant medical officers (AMOs) on to advance the use of FP/RH services, with a focus on the LARCs/PMs (which had started during ATP). In the past five informed and voluntary use of LARCs and PMs. To achieve years, a total of 4,833 service providers were trained on FP this goal, the project was developed around the SEED clinical skills through RTP support. holistic approach to programming. RTP’s interventions targeted the availability of quality LARCs/PMs (Supply) By September 2017, a total of 11,475 healthcare workers while generating awareness about and support for FP had been trained by RTP in various areas of RH/FP. RTP services (Enabling Environment and Demand). supported the training of 6,430 service providers in LARC/PM services, including FP counseling, through both During five years of implementation, RTP accomplished a central training and OJT approaches (Figure 4). Five number of achievements that will greatly advance access to hundred eighteen were trained in the integration of FP and utilization of quality FP/RH services in Tanzania. The services into other care, while 196 service providers interventions that helped to achieve the results are received training in comprehensive postabortion care described below: (cPAC) skills. A total of 661 providers received training on aspects of health systems strengthening, such as Capacity building for service providers orientation on the DHIS2 system (174) and on HMIS tools (487); 1,239 were trained in community mobilization (not shown), 442 on GBV care, and 3,889 on PMTCT. Some 372 Inadequate availability of trained service providers has providers attended other trainings, such as quality continued to be a bottleneck in the provision of health improvement, including COPE and supportive supervision services across all levels of health facilities. The Sharpened (not shown). One Plan to Accelerate Reduction of Maternal and Newborn Deaths in Tanzania (2008–2015), identified increasing the number of skilled FP providers as a priority intervention.
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Figure 4: RTP capacity building results, Project Year 1 to Project Year 5
8 Table 1: District geographic coverage and levels
DISTRICT REGIONS, GROUPED BY CPR
GEOGRAPHIC NO. AND % OF
TOTAL NO. OF COVERAGE TARGETED CATEGORY 1 CATEGORY 2 CATEGORY 3 DISTRICTS
LEVEL AND DISTRICTS REGIONS REGIONS REGIONS
MEASURE
CPR 10–29% CPR 30– 39% CPR 40–50%
40 (85%) Level 1 24 15 9 48
No. of districts
FP uptake/ 510–1,680 311–2,428 762–2,827
10,000 WRA
38 (82%) Level 2 24 14 8 46
No. of districts
FP uptake/ 1,686–2,567 2,653–4,219 3,012–4,310
10,000 WRA
32 (68%)*8 Level 3 23 15 9 47
No. of districts
FP uptake/ 2,671–9,134 4,392–11,191 4,793–9,939
10,000 WRA
110 Total 71 44 26 141
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8 RTP was providing minimal support to these 32 districts through national and regional support—for example, commodity security through RH/Zonal Commodity Security support and regional integrated facilitative supervision
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Access to and Use of FP and LARCs/PMs
benchmarks of 10%, 20%, and 30% of the districts for years Strategies such as focusing on districts with low FP uptake 2, 3, and 4, respectively. However, some districts did shift and high unmet need, integrating FP into other RH services, downward, with four of the 22 Level 3 districts moving down and strengthening the capacity of districts and local partners to Level 2 by the end of the project. to coordinate and support health system strengthening and service delivery helped guide project implementation. RTP reached 110 districts over the five-year project, focusing on The main service delivery approaches were outreach days, ,9 districts with a high unmet need for FP and lower FP uptake FP weeks, and special service days while routine services per 10,000 WRA (Table 1). in facilities with trained providers were strengthened through mentoring and supportive supervision.
To select target districts, RTP calculated FP uptake per During the project implementation period, RTP supported 10,000 WRA for each district, using data from the national the MOHCDGEC to serve a total of more than 4.5 million health management information system (HMIS), known as LARC/PM clients, generating more than 18.7 million couple- MTUHA. Based on this metric, districts were grouped into years of protection (CYP). One-third of these clients one of three levels. Districts in Level 1 had the lowest uptake received services during an FP outreach, special service of FP, while Level 3 districts had the highest. Based on the day, or FP week supported by RTP. Over the life of the analysis, 110 districts were selected for RTP programming project, progressively more women chose a LARC/PM between 2012 and 2017, 83% of which fell into Levels 1 and (Figure 6). RTP has consistently been able to achieve its
2. Level 1 districts had the lowest FP uptake and received annual benchmarks for LARC/PM provision throughout the the most intensive package of interventions. Activities duration of implementation (Figure 5). Benchmarks were set every year based on annual performance, but a strategic included capacity building for facilities and local health decision was made to have lower benchmarks for Year 5, authorities, in-service trainings, community mobilization, because of the shorter direct intervention period. In Year 5, and direct support to LARC/PM service delivery via direct interventions were reduced from 12 months to six outreach, FP weeks, and service days. Level 2 districts months, with the rest of the period used for project close- received a less intensive package of interventions, with out, including zonal and national meetings. greater emphasis on partner collaboration to strengthen and deliver FP services. Interventions for Level 3 districts Throughout the implementation of RTP, there has been a focused on building district capacity to take ownership of steady increase in the number of LARC/PM clients served their FP/RH activities. Determining the activities required to in each year. RTP has significantly contributed to a three- produce the greatest impact was guided by the National fold increase in the number of LARC/PM clients served Essential Package of FP Interventions, a MOHCDGEC between Year 1 and Year 5, from 444,616 into 1,291,331 document developed with technical assistance from (Figure 7). Among the LARC/PM methods, the uptake of EngenderHealth and designed to help districts plan and implants was the greatest, with a more than 3.4-fold budget for FP with district-managed resources, including increase during this period. In Year 5, due to fewer directly their own locally generated funding. supported FP events, the number of PM clients fell below other years. By the end of the project, the number of districts with the lowest FP uptake (Level 1) had decreased from 49% to FP method mix 20%, the number of districts with the highest FP uptake
(Level 3) had increased from 17% to 29%, and Level 2 While there is no right method mix or ideal method, there is districts had increased from 34% to 51% (Figure 5). Many a general agreement that providing access to a wide range districts at both Level 1 and Level 2 shifted to a higher level of contraceptives is an important principle of rights-based over time, with 56% of the 54 Level 1 districts graduating to FP, as well as a component of quality of care. In addition, Level 2 by Year 5 and 57% of the 37 Level 2 districts from a clinical perspective, some methods may be better becoming Level 3 districts. This transition exceeded the aligned with a client’s reproductive intentions than others. planned transition
9 A special service day is set once per month at a facility and is dedicated to FP services one day; outreach events are scheduled ei-ther monthly or quarterly, depending on demand. This (especially LARCs/PMs), to serve clients who might otherwise not been served through approach is coupled with community mobilization to create awareness about the availability of the routine services, either due to lack of a provider trained to offer a method or due to so services in terms of the facility and dates when they will be provided and. FP weeks are an extended many clients requiring other services. Outreach is a service delivery approach used form of outreach in which services are provided over a period of 5–6 days and involve many facilities, particularly in hard-to-reach areas, where lower-level health facilities lack trained with several teams that move from one facility to the next. providers and the capacity to offer services on a routine basis. In this approach, experts from higher level facilities move to a lower level facility to provide services, usually on
17 17
Data show that 39% of all FP clients Figure 5: Percentage distribution of facilities, by coverage level, served with modern methods in the according to year period October 2016 to September
100%
90% 17%
25% 2017 were using LARCs/PMs, compared 29% 29%
80% 38% 39% with 13% five years ago. A significant
70% increase was observed in clients who
34% 60% opted for implants (19 percentage points)
44% 50% and the intrauterine device (IUD) (five 51% 51%
40% 42% 42% percentage points). The proportion of
30% clients who opted for the injectable fell
49% 20% from 57% to 41% during the same period 32%
10% 20% 19% 20% 20% (Figure 8). This shows more women have
0% access to longer acting and effective FP Baseline FY1 FY2 FY3 FY4 FY5 (2012-13) (2013-14) (2014-15) (2015-16) (2016-17) methods, presumably reducing the risk of
Reporting Period unintended pregnancy, unsafe abortion,
and maternal and child deaths when
Level 1 Level 2 Level 3
compared with five years ago. These findings correlate with Tanzania Demographic and Health Survey findings indicating that the contraceptive Figure 6: Number of LARC/PM clients served, by project year, prevalence rate for LARCs/PMs increased October 2012–September 2017 (Source: National DHIS2) from 6.5% in 2010 (NBS & ICF Macro, 2011) to11.2% in 2015 (MOHCDGEC et
1,400,000 1,291,331 al.,2016).
1,200,000 1,200,024
clients 1,000,000 987,311
962,140 Proportion of FP-LARC/PM clients ofLAR C/PM
502,074 656,814
800,000 761,134 attributable to RTP interventions
665,743
636,383 600,000
Overall, 37% of clients adopting 400,000
Numbe r 444,616 LARCs/PMs during the period October
200,000 2012–September 2017 at MOHCDGEC
0 FY1 FY2 FY3 FY4 FY5 facilities did so as a direct result of RTP-
(2012-13) (2013-14) (2014-15) (2015-16) (2016-17) supported outreach events, FP weeks,
Reporting Period
and special service days (Figure 9). RTP’s
Achievement Benchmark
support had a greater contribution for
clients who accepted PMs through directly supported events: Among all women Figure 7: Number of LARC/PM clients, by method adopted, according to adopting minilaparotomy, 57% did so in project year, October 2012–September 2017 (Source: National DHIS2) connection with an RTP-supported activity; this was true for 37% of men choosing no-scalpel vasectomy (NSV)
Nu m be rof LA R C/ P M cli en ts
99,
64,486207,089 85, 461 357 ,03 6 85,410258,209100,99 7444,616 123,958398,646143,139 6 6 5 , 7 4 3 1 4 2 , 2 8 9 6 2 1 , 0 7 1 1 9 8 , 7 8 0 9 6 2 , 1 4 0 150,143796,6 20253,2611,2 00,024 122,9378 081269,3141 ,291,331
1,400,000 (37%), 34% of implant clients, and 31% of
1,200,000 IUD clients (Figure 9).
1,000,000
800,000
600,000
400,000
200,000
0
Baseline FY1 FY2 FY3 FY4 FY5 (2011-12) (2012-13) (2013-14) (2014-15) (2015-16) (2016-17)
Reporting Period
PMs Implants IUCD Total LARC/PM
18
18 18
However, the rise in the number of clients served through routine services Figure 8: Percentage distribution of FP method adopters, by method, can also be attributed in part to RTP’s project year 1 and project year 5 (Source: National DHIS2) activities, due to the increased capacity
of facilities to provide LARC and PM Year 1 Year 5 services as a result of RTP’s training and (October 2012–September 2013) (October 2016–September 2017)
mentoring of service providers,
Condom ML NSV IUCD Condom NSV ML 4% significant procurement and distribution IUCD 9% 2% 0% 3% Pills 9% 0% Implant 11% 8% of FP equipment, and support to districts Pills 8% 21% Implant to conduct supportive supervision. 27%
Furthermore, RTP built the capacity of Injectable Injectable
57% 41% the districts to coordinate services and partners, leading to equitable distribution of partner support and leveraging of resources to meet FP demand.
Estimated impact from provision of
FP services
Figure 9: Percentage distribution of LARC/PM adopters, by type of Based on impact estimates, the FP support received by facilities, according to method (Source: National services provided during the duration DHIS2 and project data) of RTP are estimated to have averted
100% 6.9 million unintended pregnancies,
90% 2 million abortions, 16,486 maternal
Contri bution 80% 43%
70% deaths, and 133,245 child deaths 63% 66% 69% 63% 60%
Pe rc en t 50% 30% 57% Uptake of LARCs among youths 40%
20%
37% 34% 31% 37%
During the period in which RTP was 10%
0% implemented, the number and ML NSV Implant IUCD Total FP Method percentage of adolescents using
LARCs has increased steadily. The RTP direct support Other IPs, Routine services, and RTP Indirect support
number of new FP clients aged 10–
14 years increased by 29%, from
1,600 in Year 2 to 2,063 in Year 5. Figure 10: Number of new FP clients aged 10–24 who were using Similarly, the numbers of new FP LARCs, by age, according to year (Source: National DHIS2) clients aged 15–19 and 20–24 rose more than two-fold (Figure 10). In
350,000 addition, the percentage of new FP 301,619
clients aged 10–24 who adopted 300,000 276,576 250,000
LARCs increased from nearly 25%
LARCc lie n ts 205,432
150,000 132,518 in Year 2 to 46% in Year 5 (Figure 200,000 11). Overall, the increase in uptake
of
of LARCs among youths has been 97,453 Num ber 86,103 35,875 100,000
steady, a reflection of international 63,895
clinical guidelines saying that 50,000
1,600 2,108 1,956 2,063
LARCs are appropriate methods for - FY2 FY3 FY4 FY5
youth, both married and unmarried. Reporting Period
Age 10-14 Age 15-19 Age 20-24
19
19 19
PMTCT Figure 11: Percentage of new FP clients ages 10–24
using LARCs, by project year (Source: National DHIS2) From November 2012 to September 2016, RTP supported MOHCDGEC to
50.00% 46.56% ensure that all 167 facilities in Manyara 45.00% Region with RCH services were 40.00% 34.78% equipped to provide PMTCT services, 35.00% 31.05% including FP; to strengthen the FP 30.00%
24.54% component within comprehensive
25.00% PMTCT and related HIV services; to 20.00% support the national roll-out of Option 15.00% 10 B+ ; to scale up early infant diagnosis 10.00% (EID) to all PMTCT sites throughout the 5.00% region; and to strengthen linkages
0.00%
FY2 FY3 FY4 FY5 between the facility and the community.
Reporting Period Between 2012 and 2014, RTP had supported the MOHCDGEC to scale up
the number of RCH sites providing
PMTCT from 145 to 167, to reach Figure 12: Number of PMTCT-related services provided at 100% of eligible RCH facilities to Manyara Region facilities, October 2012–September 2016. provide PMTCT services; by (Source: Project data and DHIS2) December 2014, Option B+ had been launched at all PMTCT sites.
With expanded PMTCT coverage,
between November 2012 and
September 2016, nearly 185,000 pregnant women in Manyara with
unknown HIV status were counseled and tested in antenatal and labor and
delivery units and received their test
results. The percentage of pregnant women with unknown HIV status who
received HIV counseling and testing increased from 81% between October Figure 13: Number of GBV/VAC survivors, by type of 2012 and September 2013 to 96% violence, according to year (source: National DHIS2) between October 2015 and June 2016,
exceeding the national commitment of 10,000 9,143
8,611 8,430
9,000 testing at least 90% of pregnant women
8,000 with unknown HIV status. The region
7,000 also was among the top 10 regions
clients 6,000 6,024
5,844
4,916 nationally, with the highest number of
of
5,000
Numb er 2,969 2,743 3,939 HIV-positive women who initiated ART.
4,000
3,000 RTP supported the MOHCDGEC to 2,000 1,288 expand the number of PMTCT sites 583 709 518 1,000 196 301 with an EID-trained provider from 81 at
-
FY1 FY2 FY3 FY4 FY5 the start of the project to 167 by
Reporting Period
Physical Violence Sexual Violence Emotional Violence
10 Option B+ is the World Health Organization (WHO) recommendation to health care providers in HIV-affected countries to place all HIV-positive pregnant and breastfeeding women on ART for life.
2020
September 2016, resulting in 100% EID coverage in HIV status were tested and received their results. Two Manyara. Overall, 2,688 PMTCT providers were trained on thousand, five hundred thirty-seven pregnant women were EID. RTP also supported the procurement and distribution identified as HIV-positive, and 92% of these (2,335) received of EID commodities and supplies, including dried blood spot ARVs to reduce the risk of mother-to-child HIV transmission. (DBS) and HIV test kits in times of critical shortages. To According to project data collected through RTP, 1,629 hasten the diagnosis process, RTP supported transport of infants had a virologic HIV test within 12 months of birth DBS specimens between facilities and the zonal laboratory during the reporting period, and 3.8% (62) infants attested and provided 30 EID sites with short message service positive for HIV (Figure 12). One hundred percent of HIV- (SMS) printers. A total of 1,629 HIV-exposed infants were positive infants were referred to a counseling and testing tested for HIV, and 73 who tested positive received care. center (CTC) for treatment. The percentage of infants who tested positive through the EID program in Manyara was also below the national target Innovative approaches to addressing human resource gaps to eliminate mother-to-child-transmission of HIV to less than included providing support allowances for 13 retired staff and 5% by 2015, with proportions of positive tests falling from volunteers and advocating for CHMTs to retain trained staff 5% for the period of 2011–2012 to 4% in 2012–2013, 3% in at health facilities for at least two years, to ensure that 2014–2015, and 2% in 2015–2016. knowledge transfer has helped support the achievement of full PMTCT coverage across all RCH sites. To link community- and facility-based care and improve community referrals for pregnant and breastfeeding women, GBV and VAC RTP collaborated with Africare to orient 248 of their existing home-based care providers in Manyara on Option B+, GBV and VAC are a serious health and human rights issue approaches for creating community awareness of this that undermines the well-being of individuals and service, links between gender and HIV, and how to communities worldwide and is widespread in Tanzania. GBV encourage male involvement in PMTCT and other RH affects all socioeconomic groups, and there are strong services. As a result of this initiative, districts reported the linkages between GBV and RH problems. More than half increased enrollment of HIV-exposed infants. As a result of (56%) of all ever-married Tanzanian women have RTP support, the PMTCT program in Manyara Region was experienced spousal violence—a reality that has remained consistently rated high on PMTCT scorecards11 among the unchanged over the past five years (MOHCDGEC et al., top such programs nationwide, and for two consecutive 2016). Additionally, 28% of girls and 13% of boys are quarters (July-September and October-December 2015), estimated to have experienced sexual violence by the age of the region ranked first out of the 26 regions in Tanzania. 18 (UNICEF, CDC, & Muhimbili University of Health and RTP’s support to the region through comprehensive Allied Sciences, 2011). GBV and sexual and reproductive PMTCT service training, trainee follow-up and mentorship, health (SRH) are strongly correlated, including increased risk the roll-out of Option B+, community engagement, for HIV acquisition, sexually transmitted infections (STIs), and commodity support, and improvement in DBS transportation compromised or denied use of contraceptive methods and and notification of results to mothers contributed to these other RH services. The use of violence, particularly intimate achievements. RTP support to PMTCT ended in September partner violence, is often rationalized or normalized as a 2016, and the program transitioned to another USAID result of harmful, inequitable social and gender norms. implementing partner who will continue providing support for PMTCT. Interventions targeting the prevention of and clinical care for GBV and VAC are relatively new in Tanzania. With recent During the period October 2012–September 2016, 100% of national and international investments galvanizing the the 167 RH facilities in Manyara Region were providing creation of a national GBV response, EngenderHealth—with PMTCT services, including Option B+. Among these sites, support from USAID—served as the lead clinical partner for 84 were supported by RTP, following the guidance from the all U.S. government-funded GBV programs between 2012 Office of the U.S. Global AIDS Coordinator that only high- and 2017 and as the lead prevention partner from 2014, after yield health facilities were eligible for support. A cumulative the conclusion of EngenderHealth’s CHAMPION Project. total of 184,427 women in Manyara Region with unknown
11 The PMTCT scorecard is a national tool providing real-time information on the status of facilities’ progress toward the goal of eliminating mother-to-child transmission of HIV. 21 21
Figure 14: Percentage distribution of GBV/VAC clients, by type of violence, according to sex (October 2012–September 2017)
FEMALE
MALE
Neglect FE
695
1% Neglect ME
603
Physical 5% Physical
Emotional Violence FE Violence ME
Emotional
Violence FE 20,699 6,025
Violence ME
21,702 46% 49%
5,482
48%
44%
Sexual Sexual
Violence FE Violence ME
2,089 218
5% 2%
In this critical role, RTP collaborated with the MOHCDGEC sexual violence, compared with 17% of all women ages 15–49 and other GBV clinical and prevention partners to increase nationwide (MOHCDGEC et al., 2016). Between project years the quality, availability, and utilization of clinical GBV 3 and 5, emotional violence was the most common form of services; address the root causes of GBV to reduce and violence (Figure 13). The number of clients reporting GBV and prevent further incidence of GBV; develop national VAC decreased between years 4 and 5 due to reduced project strategies to better respond to GBV and VAC; improve and strengthen existing GBV policies and the broader policy support, as RTP was in close-out mode and was transitioning environment; and improve the coordination of a multisector to USAID’s Boresha Afya project. GBV response at the national level. Through the project’s duration, roughly 5% of women receiving Following the introduction of services in 2012, a cumulative GBV care from RTP-supported clinical sites reported sexual total of 57,512 women, children, and men received clinical violence, compared with 17% of all women aged 15–49 care or treatment for GBV across 122 RTP-supported sites nationwide (MOHCDGEC et al., 2016), and 2% of all male GBV in Iringa and Njombe regions. Twenty-one percent of these survivors reported sexual violence. Emotional violence was the (12,327 out of 57,512) were men and 79% (45,185) were type of violence most often reported women. Seventeen percent (2,183) of the 12,327 males by females (48%), while physical violence was the most were children younger than 15 years old, as were 8% (3,769) of the 45,185 females. Generally, violence against commonly reported form of violence among males (49%). One- children under 18 years of age accounted for one-10th of all fifth of all GBV cases were referred for other services. Higher GBV and VAC cases reported at health facilities. Of those level health facility referrals were the most commonly reported who screened positive for GBV, survivors tended to be (44%). Among survivors of sexual violence, 40% received PEP women aged 25 years and older (44% of all GBV cases and 34% received EC. presented).
RTP used existing community structures in Iringa and Njombe Half of all female and male survivors (51% and 53%, regions to address the root causes that contribute to and respectively) reported experiencing physical violence, with normalize GBV and to encourage communities to access and injuries including fractures and burns. Roughly 4% of support clinical GBV services. RTP supported community women receiving GBV care from RTP-supported clinical action teams and community change clubs and worked sites reported alongside local groups like KIHAWAKI5 and Funguka—
22 2222
volunteer organizations comprising former perpetrators of postpartum IUD trainers from 14 regions and provide skills GBV—to create community awareness about inequitable training for 335 postpartum IUD service providers and gender and social norms, using gender-transformative refresher training for 20 more service providers, after a need approaches and materials. Community outreach activities for this, was identified through supportive supervision that directly supported by RTP reached more than 205,000 men included trainee follow-up and mentoring. Furthermore, the and women in Iringa and Njombe with messages around project procured and distributed 300 postpartum IUD kits at inequitable gender norms, violence, and clinical GBV the 118 supported sites. services between 2014 and 2017. During the period October 2015 to September 2017, more Task sharing of FP service provision than 11,000 clients received postpartum IUD services at the project-supported sites (Table 2). However, the number of
To further expand the pool of trained LARC/PM providers, postpartum IUD clients served in Year 5 of the project was less than in Year 4, due to revisions in medical eligibility RTP successfully advocated for medical attendants to criteria and the national training curriculum ensuring that both provide short-acting FP methods and implants and short-acting methods and LARCs/PMs are provided conducted a study to demonstrate the feasibility of task postpartum. As a result, clients had access to a wider range shifting and sharing of tubal ligation by minilaparotomy of contraceptives in the postpartum period than in the year under local anesthesia to trained clinical officers (COs) before. (discussed in detail under Result 3). The study revealed that minilaparotomy can be conducted safely and effectively by Table 2: Number of clients who received the IUD postpartum, trained COs, with no evidence of increased risk of major or project years 4 and 5 (October 2015–September 2017) minor adverse effects associated with the procedure, problems with performance of the procedure, or negative YEAR 4 YEAR 5 TOTAL effects on level of satisfaction among women undergoing the procedure, compared with when the procedure is conducted by an AMO. Following MOHCDGEC approval, Arusha 1,382 1,637 3,019 RTP supported the revision of the national FP training curriculum to include training of medical attendants on FP Coastal 1,992 1,767 3,759 (short-acting methods and implants) and development of trainee follow-up guidelines. As medical attendants Iringa 1,458 772 2,230 comprise the majority of service providers in Tanzania, expanding their eligibility to provide FP services was a huge Mwanza 1,153 971 2,124 step toward widening access to needed FP services. Total 5,985 5,147 11,132 Postpartum FP
Since Year 3, RTP introduced and scaled-up postpartum FP Reaching youth with SRH education and services services to 118 health facilities, including 16 regional hospitals, 58 district hospitals, 28 health centers, and 16 Between October 2014 and September 2015, RTP, in dispensaries. Of the 118 health facilities supported by RTP collaboration with the MOHCDGEC and respective districts, to provide the IUD postpartum, more were located in the organized youth FP/RH campaigns with the theme “My area covered by RTP’s Coastal field office (47) than in the Choice, My Future,” to empower youth with the knowledge, areas of the Arusha field office (–29), the Mwanza field skills, and confidence to make educated and responsible office (21), and the Iringa field office –(21). Introduction of decisions about their health and well-being, especially in these services involved orientation of a total of 1,011 staff regard to RH, and to help youth achieve their reproductive across all cadres and facility in-charges, including intentions. The campaigns took place at some of Tanzania’s administrators, doctors, nurses, and service providers. The largest institutions of higher learning, including Mbeya and orientation was aimed at ensuring that all staff were aware of postpartum FP service availability and supported the provision of the services. In addition, RTP supported the MOHCDGEC to train 44
23 23 23
Morogoro campuses of Mzumbe University, University of 3. Ensuring the provision of FP counseling and the Dodoma, and Butimba Teachers College in Mwanza. All four client’s adoption of her method of choice following the institutions enroll about 32,500 students and employ more procedure, including improving access to LARCs/PMs than 2,700 staff members. RTP trained 120 youth peer 4. Strengthening the referral system for linking clients educators and oriented 80 university staff members on youth- to other RH and social services friendly RH services. A total of 2,400 students received services, out of whom 1,316 received the contraceptive Counseling for FP method of their choice; 788 were tested for HIV, and 296
received breast cancer screening. Six students tested Data from RTP-supported sites suggest that greater positive for HIV, and two students were suspected to have breast cancer and were referred to nearby hospitals for decentralization placed comprehensive PAC services further investigation. In addition, 3,148 clients received FP closer to the communities most in need and increased services in neighboring health facilities during the campaign uptake of such services. In 2016, 61% of the 2,831 PAC week. During these events, 17,500 youth received FP/RH clients at RTP-supported sites had received PAC from a education, among which 4,464 received the FP method of lower level health facility. Before decentralization services their choice. HMIS data show that 39% of clients who by RTP, clients were referred from the lower level health accessed FP services between October 2014 and facilities because those facilities could not offer PAC September 2015 were youth aged 10–24 (about 1.7 million). services, mainly due to lack of trained providers and equipment. Mobilizing communities to recognize danger Comprehensive postabortion care signs during pregnancy and encouraging early health- seeking behavior and health service utilization are key Abortion complications contribute to Tanzania’s high components to reducing abortion-related deaths and maternal morbidity and mortality. According to MOHCDGEC, disabilities. 16% of maternal deaths are due to complications from abortion (MOHCDGEC, 2010). However, the majority of
abortion-related deaths are preventable, as are the Throughout RTP’s five years of implementation, a total of unintended pregnancies associated with abortion. Better 28,430 PAC clients were served at the 239 project- access to contraceptives and greater availability of supported health facilities. Half of these clients were comprehensive postabortion care (PAC) are critical to between the ages of 20 and 29. Following training and reducing maternal mortality and ensuring universal access to mentoring of service providers, between years 3 and 5, RH care. 84% of all PAC clients were counseled about FP, and 83% of those who were counseled chose and received modern Building on over a decade of PAC work by EngenderHealth contraceptives. Generally, across the RTP-supported in Tanzania, between 2012 and 2017, RTP collaborated with PAC sites, more than 24,000 PAC clients received FP national, regional, and local health authorities to improve and expand access to PAC services at 239 health facilities counseling, 19,357 of whom were discharged with the FP in 21 districts in Geita, Mwanza, Simiyu, and Shinyanga method of their choice (Figure 15). Annually, the regions in the Lake Zone. RTP’s interventions targeted the percentage of PAC clients at RTP-supported sites who decentralization of PAC services, focused on strengthening received FP counseling and an FP method was between FP provision in PAC. Programmatic activities concentrated 71% and 84%, higher than the WHO standard for PAC on five essential elements: clients accepting FP methods (60%).
1. Supporting local health authorities and leaders to Short-acting methods tended to be the method of choice raise community awareness and involvement in for a majority of PAC clients. However, as a result of addressing abortion complications and barriers to early project efforts to increase the capacity of PAC units and health care seeking and access to PAC providers to offer LARCs, in 2015–2016, 25% of the 3,232
PAC clients who adopted an FP method selected an 2. Equipping service providers and health facilities to offer emergency treatment of the medical complications implant, IUD, or PM. of abortion
3. Building the capacity of health care providers at lower level facilities to manage complications of abortion, including the use of manual vacuum aspiration (MVA) to remove retained products, counseling, and provision of FP methods after PAC care
2424
Improved contraceptive commodity security Contraceptive security exists when people are able to to assess the availability of contraceptives and build the choose, obtain, and use the contraceptive methods and capacity of districts to properly forecast, order, and stock services they want, so as to achieve their reproductive the commodities. intentions. For facilities to be capable of providing a full range of methods (short-acting, long-acting, and Through the efforts of the national Contraceptive Security permanent) to their clients, three basic elements are Committee, which includes the MOHCDGEC, USAID, the essential: the contraceptives themselves; the medical United Nations Population Fund, WHO, and FP equipment, instruments, and expendable supplies needed implementing partners, including RTP, the situation at the to provide the methods; and trained human resources national level has improved, and for the past two years capable of providing each method (Wickstrom & Jacobstein, (2016 and 2017), there have been no stockouts reported 2011). at the national level. However, logistics of distribution and ordering barriers have continued to constrain the Contraceptives and other commodities (including LARC/PM- availability of contraceptives in some facilities. RTP’s related equipment and supplies), MVA kits, and HIV test kits support of zonal contraceptive security meetings brought together relevant stakeholders who are involved in and reagents are essential for the delivery of priority services ordering supplies, compiling orders, and distributing FP supported by RTP. Contraceptive security has continued to commodities at the district level. These meetings were be a challenge that impedes the delivery of FP, cPAC, and valuable in determining shortages, facilitating transfers of PMTCT services. To address constraints at the national commodities between districts and facilities at times of level, RTP participated in national contraceptive security critical shortages, and improving forecasting, management meetings with other key stakeholders, while also building the of stocks, and equitable distribution of available stocks. capacity of zones, regions, districts, and facilities to have the commodities needed to make services available to clients/ RTP strengthened the quality of FP services through the users. Each RTP field office supported zonal and district support of 457 joint supportive supervision visits conducted contraceptive security meetings to promote transparency, by CHMTs. These joint supportive supervision visits mutual accountability, and sharing of best practices, and received
Figure 15: Number of PAC clients who were counseled for FP and received their method of choice (October 2012 to September 2017)
8,000
7,000 7,365
6,518 6,000 6,252
5,000
5,174
5,002 4,998 5,062
4,641 4,503
4,000 4,402 4,245
3,954
3,755
3,000 3,232 3,126
Number of PAC clients PAC of Number
2,000
1,000
0
FY1 FY2 FY3 FY4 FY5 Reporting Period
Number of PAC Clients Number of PAC Clients Counselled for FP Number of PAC Clients counseled and received FP method
25
25 25
Table 3: Number of contraceptive security meetings held and supportive supervision visits made, Year 1 (2012) to Year 5 (2017) (Source: Project database)
YEAR 1 YEAR 2 YEAR 3 YEAR 4 YEAR 5 TOTAL
Total contraceptive 11 10 10 10 5 46 security meetings
Joint supportive 50 57 55 52 24 238 supervision visits made (A)
Supportive 48 66 64 65 43 286 supervision visits, but not joint (B)
Total supportive 98 123 119 117 67 524 supervision visits made (A+B)
collaborative support from RTP team members and built the In 2012, RTP supported the Government of Tanzania to capacity of CHMTs to conduct effective supportive formulate the National Operational Guidelines for Integrating supervision. RTP also supported the 110 district councils to MNCH/HIV/AIDS Services, citing integration as vital to the improve contraceptive security by facilitating a total of 46 attainment of the national goal of a 45% CPR by 2020, a zonal contraceptive security meetings to address zonal, decline in maternal mortality, and a reduction of HIV regional, and district-level contraceptive security issues prevalence in the country (MOHCDGEC, 2014). RTP has during the past five years of implementation (Table 3). implemented multiple integration activities across the country, targeting clients with SRH needs with the intention of increasing access to and use of FP. RESULT 2: QUALITY FP-LARC/PM AND RH INTEGRATED SERVICES DEMONSTRATED, EVALUATED, AND SCALED UP Building on experience from Manyara Region, where EngenderHealth started integrating FP into HIV services
Service integration12 has taken an increasingly prominent during ATP (November 2007 to March 2013), FP has been role as a means to provide vital, client-focused health integrated with services including HIV in CTCs, cervical services, especially in hard-to-reach communities. cancer screening, immunization, tuberculosis care, the Integration offers opportunities to address people’s holistic outpatient department (OPD), STI care, in-patient health SRH needs, such as FP, to “facilitate the uptake of care, and services to address GBV and VAC. In addition, FP contraception by HIV-positive individuals, helping to has been strengthened in PMTCT and PAC services. Project maintain their health, plan safer pregnancies, and reduce interventions have included training, trainee follow-up and the rate of mother-to-child transmission of HIV” (Adamchak ongoing supportive supervision, mentorship, and coaching; et al., 2010) in a way that saves providers and clients time minor adjustments at facilities to improve client flow; and and resources. RTP has been supporting the MOHCDGEC purchase of equipment and supplies. By September 2017, to implement and scale up integrated services to increase 10,442 health care workers had been trained by RTP in access to FP and other services and minimize missed various areas of RH/FP integration. opportunities, using EngenderHealth’s “five-step” integration approach.13
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12 Integration is an approach in which health care providers use opportunities to engage the client in 13 The EngenderHealth five steps of integration include identification of the service that can be integrated, addressing broader health and social needs beyond those prompting the initial health care encounter facility capacity assessment, systems strengthening, partnership and networking, and monitoring and evaluation (EngenderHealth, 2014). (EngenderHealth, 2014).
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Data collected from the 114 health facilities that were strengthening FP services at worksites and referral linkages supported to provide integrated services show that among to nearby health facilities. A total of 164 peer educators the five service delivery points (CTCs; postnatal care [PNC]; provided staff with information on FP, HIV, and gender, and immunization/under 5 health care; OPD/STI services; and seven company medical staff were trained on LARC/PM inpatient pediatric and female/gynecological care), three of provision. By the end of Year 5, RTP had reached 21,330 them (immunization, CTC, and PNC) served 75% of all FP employees, their partners, and community members, clients served through integrated service delivery points including women’s groups and their friends. (figure 18). The capacity of these facilities to provide integrated services and their district managers that has Between 2014 and 2017, 20,485 staff of the companies been built will continue beyond the end of RTP. received health education through trained peer educators, and 11,108 clients received FP methods, either on-site or During project implementation, a total of 58,467 HIV- via a confirmed referral to a nearby health facility (Table 4). positive clients received the FP method of their choice at the In addition to the above integration activities, since Year 2 114 supported health facilities. The number of HIV clients of RTP, EngenderHealth worked with partners who were who received FP methods at CTC units increased from 456 implementing projects focused on economic development, in Year 1 to 24,270 in Year 4. Similar trends of increasing nutrition, and agriculture under the USAID Country Development Cooperation Strategy Development Objective numbers of clients choosing FP methods were observed in immunization services, cervical cancer screening, and 2 in Arusha and Iringa zones. In this context, RTP worked OPD/STI clinics. in close collaboration with three organizations—the Mwanzo Bora Project (a nutrition program), the Tanzania Wildlife Conservation Society and NAFAKA (an agriculture FP integration at workplaces program). Specific activities included:
RTP introduced FP/RH information and services into workplaces in the industrial, agricultureal, and tourism/ 1. FP education and communication for behavior change: conservation sectors through partnerships with eight private Provision of FP education to individuals and different companies (KiliFlora and SunFlag in Arusha, Shelys agriculture, nutrition, and economic development groups at the community levels, using community health workers, Pharmaceuticals and Chemicotex in DSM, Mufindi Tea agricultural extension workers, and community social Companies and Sao Hill Timber in Iringa, Nile Perch in welfare officers; Mwanza, and Tanzania Tobacco Processors Ltd. in 2. Integrated programming with the provision of FP Morogoro) and through organizations such as the Tanzania services: Through the Mwanzo Bora Project, RTP used the Horticultural Association (TAHA) and Tanzania National “the first Park Association (TANAPA). The main interventions were on-site peer education, training of company medical staff on FP, and
Figure 16: Number of clients receiving integrated services, by service area, project years 1–5
TB clinic 1
Cervical Cancer 12
IPD (Pediatric, Female/Gyn) 17
OPD/STI 36
Immunization/under 5 85
Postnatal 57
CTC 58
0 10 20 30 40 50 60 70 80 90
Number of clients (in 1000)
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14 1,000 days ” model to provide both nutrition and FP RESULT 3: HEALTH SYSTEMS MANAGEMENT AND education through the Mwanzo Bora Project community MONITORING AND EVALUATION STRENGTHENED FOR groups. INTEGRATED FP-LARC/PM AND RH SERVICES 3. FP outreach services to the agriculture and farmers community groups: Outreach services were organized to provide FP information and services to members of these Health systems strengthened groups; for methods such as the IUD and minilaparotomy, clients who chose these methods were referred with A health system strengthening approach helps create the facilitated referrals to ensure that they received the combination of factors needed to ensure the provision of services. high-quality, affordable health services at all levels. RTP actively coordinated with other advocacy initiatives and A total of 229 community health workers trained by groups to ensure that LARCs/PMs are included in existing these organizations were oriented on FP so they could and future enabling policies. RTP focused its efforts on include demand creation and community sensitization in district-level advocacy, with a special emphasis on building their work. Through this integration, 11,108 clients the capacity of districts in planning and budgeting for received FP services (634 minilaparotomy, 3,104 integrated FP/RH services, mobilizing district and regional implants, 802 the IUD, and 6,568 short-acting methods). champions, and strengthening coordination of partners and integrated FP/ RH services at the district level.
Table 4: Number of clients who received health education from a trained peer educator and who received FP services, by company, 2014–2017
NO. OF PEOPLE NO. OF CLIENTS SERVED, BY METHOD
TOTAL REACHED
COMPANY NO. OF BY PEER ML IUD IMPLANT INJECTABLE PILL EDUCATORS CONDOM DISTRICTS
KiliFlora 4,617 12 98 321 421 217 88 1,157
SunFlag 2,030 17 51 189 179 202 175 813
TTPL 2,949 25 22 126 381 107 739 1,400
Nile Perchl 1,820 9 19 52 45 29 1,700 1,854
Mufindi Tea Co. 2,500 26 21 139 121 337 46 690
Sao Hill 1,288 2 25 38 63 102 89 319
Shelys 86 0 0 0 0 0 0 0
Chemicotex 90 0 0 0 0 0 0 0
TANAPA 4,299 507 485 1951 577 288 291 4,099
TAHA 806 36 81 288 128 90 153 776
Total 20,485 634 802 3,104 1,915 1,372 3,281 11,108
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14 The first 1,000 days (the period from pregnancy to a child’s second birthday) has been recognized as a “window of opportunity” for reducing stunting, by ensuring that women and children receive proper nutrition during this period.
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district-level budget allocation, RTP has been tracking RTP research activities resource allocation for FP in the Comprehensive Council
Health Plans (CCHPs) of 110 supported districts since 2012. RTP carried out a research agenda that included three main Basket funding was the major source of funds for FP/RH in activities: the CCHP. The Global Fund was another source of support for FP interventions in CCHPs, which helped to increase Safety of minilaparatomy provided by trained clinical funds available for FP. This support, together with expanded officers and assistant medical officers funding for FP through multilateral and bilateral donors and In collaboration with the MOHCDGEC, RTP conducted districts’ own sources, increased the overall funding research in Arusha, Kilimanjaro, Singida, and Tanga regions to available for FP interventions at the district level. The total establish whether the safety of tubal occlusion by amount of funds allocated for FP in the tracked districts minilaparotomy provided by trained COs is “noninferior” to (i.e., increased from US$735,067.5 in FY 2012 to US$836,459.5 no less safe than) the safety of the procedure when provided 15 in 2016–2017, a 14% increase. The percent of districts by trained AMOs, as measured by rates of the occurrence of allocating resources in CCHP to support FP services major adverse effects. It was envisaged that the findings would increased from 46% in Year 1 to 83% in Year 5 (Figure 17); result in actionable evidence to advocate for policy change this positive trend can support sustainability of FP services allowing COs in Tanzania to perform minilaparotomy. Such a at the district level. change would increase access to permanent methods of
contraception for thousands of women across the country. The study was a randomized, controlled, open-label noninferiority Figure 17: Percentage of districts with an FP budget trial and included women who were aged 18 years and older; in their CCHP, by project year (n=110) who consented (in accordance with MOHCDGEC procedures) to tubal occlusion; who freely consented to participate in the
study and who signed a study informed consent form; who were
of sound mind, in good general health, and deemed suitable to 81% 83% undergo tubal occlusion by minilaparotomy, in accordance with 46% 48% 55% MOHCDGEC guidelines; who were able to understand the study procedures and the requirements of study participation; Y1 Y2 Y3 Y4 Y5 and who agreed to return to the study site for the full schedule Reporting Period of follow-up visits.
Given that COs are not allowed by MOHCDGEC regulations to perform minilaparotomy, all procedures conducted during the study period were under the supervision of a physician experienced with and qualified to perform minilaparotomy
(many of the trainers). RTP served as the Secretariat for the National Integration
Technical Working Group (TWG), the National FP TWG, To ensure that all providers had adequate skills to perform and the FP Training Coordination Committee, roles in which minilaparotomy and used standardized procedures, seven COs RTP team members made high-level inputs into the national and seven AMOs (none of whom had experience performing policy dialogue and information sharing and that greatly tubal occlusion by minilaparotomy) were trained to perform the improved the capacity of the MOHCDGEC to coordinate procedure. The 11-day competency-based training followed partners through mapping exercises and other means. MOHCDGEC guidelines and standards (MOHSW, 2010).
15 Converted from Tanzanian shillings at an exchange rate at http://tanzania.opendataforafrica.org/.
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The results showed that tubal occlusion by minilaparotomy The study was conducted in two districts—Temeke in can be conducted safely and effectively by trained COs, with Dar Salaam Region (an urban site) and Nachingwea in Lindi Region (a rural site) between October and no evidence of an increased risk of major or minor adverse November 2016. It involved structured face-to-face effects associated with the procedure, problems with the interviews with 802 young mothers aged 12–19; in-depth performance of the procedure, or negative effects on the interviews with 26 young mothers (a subset of those who level of satisfaction among women undergoing the participated in the structured interviews) with poor pregnancy experiences, including nonuse of services, procedure, compared with when the procedure is done by poor services, or poor outcomes); and in-depth an AMO. The research provided the evidence needed to interviews with 35 health care providers at facilities support policy change on task sharing at the national level serving populations in the study settings. in Tanzania, which will help the country meet the rising • Various vulnerabilities exposed the young mothers to demand for minilaparotomy among women who wish to limit early sexual debut and pregnancy including peer their childbearing and improve the FP method mix (Van Lith, pressure, poor socioeconomic conditions, unstable Yahner, & Bakamjian, 2013). The MOHCDGEC regulations family backgrounds, lack of information on preventive should be updated to allow trained COs to provide services, early marriage, and cultural rites of initiation for minilaparotomy, in line with the mission of the Government’s young girls, especially in the rural site. Task Sharing Policy Guidelines to redistribute and share • Use of a method to prevent pregnancy was higher during tasks among the available health and social welfare workers most recent sexual intercourse (46% in the urban site for effective and efficient delivery of quality health services and 62% in the rural site) than at the first sexual to the Tanzanian community (MOHCDGEC, 2016). The encounter (19% and 53%, respectively). However, use of a method to prevent HIV or other STIs remained low National Task Sharing Policy Guidelines should also be at first intercourse (21% and 37%) and at most recent updated to include minilaparotomy as a competency for intercourse (19% and 16%). COs. Likewise, the National Family Planning Curriculum for • The proportion of pregnancies that were unintended was Voluntary Surgical Contraception should be revised to higher in the urban sites (79%) than in the rural sites include COs among those who can be trained to perform (46%). Variations in unintended pregnancy between minilaparotomy. The study findings were disseminated to sites could partly reflect the circumstances in which the stakeholders, including the MOHCDGEC, representatives pregnancies occurred. Young mothers in the urban site from the regions, districts and facilities where the study was had become pregnant when they were living with conducted, FP and RH implementing partners, and the relatives (29%), single biological parents (24%), both USAID Mission. biological parents (22%), or husband/partner/boyfriend
(22%), while at the rural site, the majority (60%) of young The results have also been presented in the National Family mothers became pregnant when they were living with Planning TWG, and advocacy for policy change has started. their husband, partner, or boyfriend. In addition, steady The study report is available for sharing and distribution. boyfriends or fiancés were responsible for 51% of
pregnancies in the urban site, while husbands or live-in Access to RH and HIV services among young mothers in partners were responsible for 56% of pregnancies in the Tanzania rural site.
RTP conducted this study in collaboration with the • Utilization of RH and HIV services varied by type of care, Population Council, MOHCDGEC, and National Institute of with service-seeking high for antenatal care (84% urban Medical Research (NIMR). The overall objective of the study and 93% rural), health facility delivery (86% and 85%), was to generate evidence on access to RH and HIV services skilled delivery care (86% and 85%), delivery among young Tanzanian mothers aged 12–19 (those who complications (62% and 85%), and health check-ups for had ever been pregnant, regardless of the outcome) to the baby (93% and 82%). inform programming and actions to better meet their needs. • Factors affecting young mothers’ uptake of RH or HIV services included lack of information on available It specifically examined their experiences with accessing RH services, services (safe motherhood and contraception) and HIV care— testing and counseling, PMTCT, antiretroviral therapy (ART) and EID—as well as providers’ attitudes and practices toward the provision of these services to young mothers.
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the circumstances under which the pregnancy occurred Secondary Objectives: (such as forced sex or very young age), the requirement 3. To measure the effect of integration on provider workload at the facility to be accompanied by a partner, abrupt or and satisfaction early end of pregnancy (abortion, miscarriage, or 4. To measure the effect of integration on client satisfaction stillbirth occurring too soon after conception), and 5. To measure the effect of integration on quality of care of perceived poor treatment by healthcare providers. Other services that are integrated factors included a feeling of embarrassment, partner 6. To track and document the process of implementing refusal, delays in decision making to seek care, distance integrated services from a program implementation and to the facility (especially in the rural site), lack of supplies budgeting perspective or services at the facility, and not considering the health
condition a serious issue. Summary of findings: • A majority of young mothers (63% in the urban site and Most activities were implemented with high fidelity, with 67% in the rural site) reported experiencing intimate positive impacts on quality and satisfaction of integrated partner violence during pregnancy, although few sought service delivery by clients and providers. Consistent with help (37% in the urban site and 29% in the rural site). the literature on integration of services, lack of control over The most common sources for those who sought help clinic organization, staff turnover, external donor activities were family members, relatives, or in-laws (79% and and changes to national policies represented formidable 91%) and friends or neighbors (30% and 11%). challenges in studying the effects of integration, as was found in this process evaluation of the current study. Operations research on the optimal package and process of integrated healthcare Implementing the accelerated integration program requires an upfront investment in training, equipment, and supervision USAID/Tanzania supported EngenderHealth and its processes, plus upgrades to certain service delivery points
partners (MOHCDGEC, the Population Council, and Abt to ensure client privacy and confidentiality during FP Associates) to conduct intensive operations research to counseling and method provision. document and test different packages of health service Some identified challenges to service integration were integration. This research was intended to define a feasible largely around structural barriers, including the physical package and process of comprehensive integrated care by availability of amenities, equipment, FP commodities, examining several areas of health service operations, testing reagents, infection prevention supplies, and including cost/ efficiency, human resources for health, information, education, and communication materials. financing, service delivery modes, and HMIS changes needed to implement successful integration. This study Further, availability of trained staff and high staff turnover also tested efficiency indicators that would help understand were additional challenges encountered that likely impacted the benefits of integration from the perspective of costs to integrated service delivery. Cultural factors such as the healthcare system (i.e., labor, budget, etc.). customs and taboos were identified as potential barriers for FP uptake in some study communities. Social acceptance The overall aim of this operations research project is to of FP use in the extended postpartum period is reported to provide needed evidence to support decision-making, be lower among rural women than among urban women, programming, and budgeting related to RMNCH/HIV where, among rural women, it is reportedly a propagated service integration; shape integration programs and; belief that FP acceptors in this period seek contraception support integration policy. because they are engaged in sexual relationships outside
of their partnerships. Primary Objectives:
1. To assess the extent to which different packages of According to the study data, there was increased visit integrated service provision increase the range and volume at endline compared with the baseline at seven of uptake of selected RMNCH/HIV services. the FP service delivery points. In general, the number of 2. To assess the efficiency of delivering different types of visits at endline increased at study facilities where integrated services in terms of cost and human integration resources.
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was implemented in the antenatal care, labor and delivery/ 97% in Year 5 (Table 5). Similarly, the percentage PNC, and child health and immunization service delivery of health facilities submitting reports in a timely way points and in the OPD. On the other hand, several facilities increased from 54% to 94%. experienced severe drop-offs in visits at their PNC service
delivery points. Table 5: Percentage of health facilities reporting FP data in a timely way and in a complete way, However, integration varied widely among facilities as well as October 2013 to September 2017 among service delivery points within a given facility. In the
study, the highest ratios were recorded for service delivery points where HIV testing and counseling was integrated into YEAR the service delivery process. Almost 65% of women who YEAR 2 YEAR 3 YEAR 4 5 visited HIV care and treatment service delivery points received counseling on FP methods and other counseling Timeliness 54% 78% 87% 94% services at endline, while 31% received such services at Completenes baseline. s 78% 88% 93% 97%
The percentage of clients visiting facilities for FP services who
were screened for STIs rose from 2.6% at baseline to 11.6% Other initiatives to strengthen integrated strategic at endline; no FP clients were tested for STIs at baseline, information management under RTP included the following: compared with 4% at endline; and the proportion who were
asked about their HIV status rose from 35% at baseline to • Quarterly joint decision-making meetings were held 52% at endline, and the proportion who were tested for HIV between the RTP clinical and monitoring, evaluation, and went from 27% at baseline to 34% at endline. All these results research teams to select and discuss priority indicators to are attributed to the integration interventions conducted for a improve data quality and use of clinical data for decision period of a year at all 12 health facilities. Facilities making, as well as to facilitate effective cross-organizational implementing the PNC+HIV integration package had learning and sharing. This activity began in Year 4 and improvements in all indicators in the PNC service delivery continued into Year 5 of the project. Orientations on the use point. of the Train Tracker and Event SMART databases were implemented as part of internal capacity building. All RTP Estimates of unit and total costs of providing each type of visit field program officers and administrative assistants were for FP, CTC, child health and immunization, antenatal care, oriented on how to use and support MOHCDGEC and RTP labor and delivery/PNC, and OPD clients were calculated for headquarters to maintain the Train Tracker each site. For details please read the full report. and EventSMART databases, respectively. EventSMART maintained data related to all program trainings supported Monitoring and evaluation by RTP, including FP, cPAC, PMTCT, and GBV/VAC; Train Tracker is a national web-based FP database developed by During the past five years, RTP trained 174 regional and RCHS with support from RTP and other partners. The two district reproductive and child health coordinators (DRCHCOs) tools helped to avoid duplicate training of health care and HMIS focal persons on DHIS2 across seven regions and providers for the same skills. provided 24 computer sets to 24 district councils (Simiyu [7],
Katavi [4], Rukwa [4], Mbeya [1], Njombe [1], and Manyara [7]) • HMIS refresher training was conducted for facilities to be used by R/CHMTs. Provision of computers supported offering cPAC services, which helped to increase LARC national scale-up of the DHIS2, enhanced the timely entry of uptake during cPAC. The lessons learned informed scale- data into DHIS2, and contributed to improved FP reporting up of the intervention at other cPAC-supported sites. rates. Reporting rates (completeness) rose from 78% of health Challenges with low FP reporting for cPAC clients and facilities in Year 2 to poor cPAC data quality at the district level were addressed
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public announcements at village and sub villages, household through the orientation of health providers at the facility and visits, discussions with community and religious leaders, and district levels. cPAC documentation and reporting is now daily health talks at health facilities. Distribution of incorporated into the national DHIS2 reporting system. information, education, and communication materials to support outreach activities continued at public facilities and in • Other initiatives included providing modems and airtime the communities. Also, secondary and primary school to facilitate data entry on the DHIS2 database, which students were involved in informing their parents of the dates assisted DRCHCOs in timely report submission, data for upcoming activities. Traditional methods of conveying quality reviews, verification, and data entry in DHIS2; information, such as house-to-house, in meetings, via public supporting R/CHMTs to plan and conduct performance announcements, on posters, and in announcements in review meetings; and improving the use of facility data by churches and mosques were used to inform community R/CHMTs for decision making through data demand and members about dates and venues for outreach events, FP use meetings. RTP also initiated the use of FP weeks, and special service days. documentation and reporting, using tools developed by MTUHA, and supported CHMTs to orient service providers Community engagement and mobilization through “site on the HMIS tools. 16 walkthroughs”
RTP used various approaches to engage the community in RESULT 4: COMMUNITIES MOBILIZED TO INCREASE USE the implementation of the project’s goals. These included OF FP-LARCS/PMS AND RH SERVICES THROUGH THE orienting religious and community leaders in the mobilization FOLLOWING INTERVENTIONS and sensitization of the community for FP and other RH
services; developing tools (including booklets on FP in the To create demand and mobilize communities for FP-related Islamic and Christian contexts, to guide religious leaders); service events, RTP collaborated with various partners, training community health workers as FP mobilizers; and community groups, religious leaders, and champions, introducing “site walkthroughs.” EngenderHealth has used including communication-focused partners such as the Johns the “site walk through” approach as a strategy for bringing Hopkins University/Center for Communications Programs together health care providers and communities surrounding (JHU/CCP) and its Tanzania Capacity and Communications a particular health facility, to learn about services that Project (TCCP). The objective was to increase access to and are provided at the facility, to understand the challenges use of FP through providing correct knowledge about FP, hindering utilization of quality services, and to develop action particularly LARC/PMs, including their benefits and plans for increasing the utilization of services. This is done availability; addressing common myths and misconceptions through a one-day meeting that includes discussion about about FP methods; and promoting partner/couple service delivery and that uses facility data to create communication on matters regarding RH, including FP. awareness about how the community utilizes the facility and
Community mobilization for outreach and FP weeks service usage and community-facility relationship can be strengthened. This strategy has increased the utilization of FP services, as well as others, such as increased facility To enhance information on outreach and FP weeks, the deliveries. project used local radio to announce the availability of FP services, by telling the community where and when services RESPOND trained community health workers as community would be provided. RTP, in collaboration with CHMTs, FP mobilizers. Some community mobilizers received utilized FP community mobilizers, including community additional training and distributed condoms, cycle beads, and distributors, providers of home-based care, village health emergency contraceptive pills in the community. The project workers, and peer educators, to reach clients with worked with the MOHCDGEC to review a training package for comprehensive information on and referrals for FP community-based FP distributers and collaborated with services. Clients were also reached through public CHMTs to ensure that FP commodities were accessible to meetings and community distributors. Use of satisfied clients has been
16 A “site walk-through” is an open house for a health clinic, where local community obtain a community’s opinion about how they perceive available services and how service provision could leaders—men and women—are given the opportunity to walk through a health clinic and be improved/organized to attract their use. learn from the clinic staff firsthand about the FP/RH services and products available. It is both a learning experience and a way to publicize the benefits of FP/RH services and to
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very successful in mobilizing clients for FP services. Up to Overview brief September 2016, 110 satisfied clients from different districts
were trained on how to sensitize communities on FP This document is intended to work like an extended services (particularly LARCs/PMs). In collaboration with the brochure. In the form of a technical brief, it illustrates high- MOHCDGEC, districts, and institutions of higher learning, level program areas, the geographic scope of work, and RESPOND launched a youth campaign with a theme of “My RTP’s overall objectives. This brief summarizes the project choice, my future” at four universities in Tanzania in terms of what was proposed, what was implemented, and the achievements in each project area. It highlights
challenges and how they were addressed during the Legacy products implementation. This was the first brief to be produced, and it was widely distributed during national and regional A legacy product is an extremely important deliverable to project closeout meetings. illustrate the achievements and successes of a project like RTP and to demonstrate best practices to other implementing Technical briefs partners. Such a product is also intended to increase the
visibility of the project and leverage donor support for further In addition to the overview, nine technical briefs were funding through demonstrated areas of expertise. In addition, produced and are being distributed country-wide. These in- it is a way to disseminate learnings and recommendations to depth, detailed briefs focus on the progress and impact of the MOHCDGEC, as the main implementer of RTP activities. each of the program areas. They describe what was done and show trends in achievement over time in the specific The following section outlines some of RTP’s legacy products. program area. The briefs are to be distributed widely in Tanzania starting with the regional and national meetings.
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CONCLUSION
FP is considered a high-impact practice; if it is universally Service integration within RTP has been seen to reduce accessed by all WRA and their partners, it can reduce barriers that clients face in accessing FP services, expand the about 40% of maternal mortality. Demand for FP remains method mix to include LARCs/PMs, and therefore make these high in Tanzania. RTP’s work in collaboration with the services more widely available. With integration, clients can MOHCDGEC and other partners has revealed that well- receive relevant FP information without referrals, stigma, planned, well-implemented, properly monitored, and multiple visits, or loss to follow-up. Experience shows that appropriately coordinated interventions can improve there is no “one size fits all” approach to integration, as people’s access to and use of services such RH and guidance must be adapted to the facility context. LARCs/PMs. Implementation requires adaptation of a variety of approaches; in RTP’s case, exploring task Advocacy and capacity building to districts in the allocation shifting focusing on areas with low FP usage, adapting for FP and RH in CCHPs has produced impressive results, as service delivery approaches that will reach more clients evidenced by the increase in the number of districts allocating (particularly disadvantaged groups), building capacity, funds for FP in their CCHPs, as well as the amounts allocated promoting district coordination, ensuring the availability of both as part of donor funding and from districts’ own sources, commodities, and engaging in strategic monitoring have including from user fees, health insurance, local taxes, and all been shown to produce positive results. RTP’s the community health fund. Sustainability experience shows that innovative approaches to is guaranteed when districts allocate their own funds for addressing human resource constraints, such as task services, as opposed to depending on donor funding only. shifting and OJT, can increase the voluntary use of LARCs/PMs by expanding the pool of trained providers, Integrating FP into the workplace reaches clients who could particularly among people who are most in need. not have otherwise accessed services because of their work Participatory processes such as COPE improved the schedule, and it is an innovative model that integrates district- quality of facility-based services and fostered camaraderie level health officials directly into public-private partnerships. among staff. The use of this approach led to the Using peer educators to provide FP education and mobilize identification of contraceptive security concerns and other clients has proven to be effective. However, strong fundamental quality issues. Collaborative, coordinated management support from the company and from their health efforts were crucial to improving access to commodities at personnel is essential to the sustainability of information and the national level and reducing stockouts. services.
Working within a broader framework that included Innovative approaches to addressing human resource gaps, fostering an enabling environment for FP-seeking such as engaging retired staff and volunteers and advocating behavior and cultivating demand for services, RTP for CHMTs to retain trained staff transfer, ensures the interventions continued to advance the enormous FP achievement of full services such as PMTCT coverage across gains made in Tanzania over the past two decades. By all RCH sites. Preventing unintended pregnancies and strengthening the quality of comprehensive FP service mother-to-child transmission of HIV means that couples and provision, RTP enhanced access to a wider method mix, families are better positioned to lead healthy, productive lives. including LARCs/PMs, thereby supporting Tanzanian women and men to more effectively meet their reproductive intentions.
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OCGS, and ICF. RTP Synthesis Report, EngenderHealth Tanzania office, 2016 Ministry of Health and Social Welfare (MOHSW). 2010.
National Family Planning Costed Implementation World Health Organization (WHO). (2015). Maternal Program, 2010–2015. Dar es Salaam: Reproductive and mortality in 1990-2015. Retrieved from http://www.who.int/ Child Health Section, MOHSW gho/maternal_health/countries/tza.pdf
Ministry of Health, Community Development, Gender, United Nations Children’s Fund, U.S. Centers for Disease Elderly and Children (MOHCDGEC) [Tanzania Mainland], Control and Prevention (CDC), and Muhimbili University of Ministry of Health (MoH) [Zanzibar], National Bureau of Health and Allied Sciences. 2011. Violence against children Statistics (NBS), Office of the Chief Government in Tanzania: Findings from a national survey 2009. Dar es Statistician (OCGS), and ICF. 2016. Tanzania Salaam. Accessed at: https://www.unicef.org/media/ Demographic and Health Survey and Malaria Indicator files/VIOLENCE_AGAINST_CHILDREN_IN_TANZANIA_ Survey (TDHS-MIS) 2015–16. Dar es Salaam, Tanzania, REPORT.pdf. and Rockville, Maryland, USA.
Van Lith, L. M., Yahner, M., and Bakamjian, L. 2013. Ministry of Health Community Development Gender Women’s growing desire to limit births in sub-Saharan Elderly and Children. Task Sharing Policy Guidelines for Africa: meeting the challenge. Global Health: Science and Health Sector Services in Tanzania, January 2016. Practice 1(1):97– 107. doi: 10.9745/GHSP-D-12-00036.
Ministry of Health and Social Welfare (MOHSW) 2011, Wickstrom, J., and Jacobstein, R.J. 2011. Contraceptive National Management Guidelines for the Health Sector security: Incomplete without long-acting and permanent Response to and Prevention of Gender-Based Violence. methods of family planning. Studies in Family Planning Dar es Salaam. Accessed at: 42(2):291–298. www.healthpolicyplus.com/archive/ns/ pubs/hpi/1466_
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APPENDIX 1: PERFORMANCE MANAGEMENT PLAN (PMP)
OVERVIEW indicator list. In keeping with the GHI approach of adhering to This performance management plan (PMP) outlines the the ”three ones” strategy—one national plan, one national criteria that will be used to guide measurement of results of coordination mechanism, and one M&E system, we will the RTP Associate Award in Tanzania. This PMP is a draft measure use by tracking FP users at all project-supported that will be updated within the first 90 days of the award and sites, using the national HMIS (MTUHA), and will calculate CYPs based on these data. Our approach will include a annually thereafter. The monitoring, evaluation, and research thorough review of service statistics from the sites throughout (ME&R) strategy, like the overall program strategy, is the project, to improve the quality and use of these data at the informed by the U.S. Government GHI Strategy for Tanzania, sites, in collaboration with RCHS and other counterparts and in support of the MOHCDGEC Health Sector Strategic Plan stakeholders. (2009–2015), which includes monitoring, evaluation, and learning/knowledge management components.
MONITORING The USAID/Tanzania ME&R strategy is also informed by the USAID Forward Program, which is led by the Bureau of RTP will continue to collaborate with both the RCHS and the Policy, Planning, and Learning, and its Office of Strategic and MOHCDGEC Department of Policy and Planning, which Program Planning and Office of Learning and Research. oversees the MTUHA at the national level, to support rolling 17 USAID Evaluation Policy calls for each program to have a out the district health information system (DHIS2) in selected detailed PMP, which forms the basis of this document. All districts. (This activity is described in more detail under IR evaluation protocols and reports are subject to USAID 3.4.) technical review. In the case of Global Health, this means a review under the Bureau Operating Procedure (BOP 8) that Given the successful experience of ATP on improving the provides guidance for peer review in research managed by MTUHA system through implementation of the pilot data the Bureau for Global Health. EngenderHealth has a proven transmission initiatives, data sharing workshops, data quality track record in working with the Global Bureau on BOP8 and assessments, and building the capacity of selected CHMTs will apply this experience in collaborative reviews of study by using data for decision making, RTP will focus on protocols and reports with the Mission and with Tanzanian transitioning the training skills to national MTUHA and RCHS institutions. staff to oversee implementation of these activities at the regional, district, and facility levels. Moving forward, RTP Results Framework plans new initiatives that will further improve the MTUHA system. The new activities include:
The results framework for this project is outlined in Appendix 2. The indicators that will be used to track project results are 1. S upport roll-out of MTUHA electronic system called provided in Table A1 and include the Tanzania/GHI DHIS2. RTP will provide technical assistance (TA) to indicators pertinent to the specific RESPOND activities. The customize FP and PMTCT indicators into the national strategic objective of this project is Increased use of FP electronic database and supervise its implementation. services, with a focus on long-acting and permanent methods This activity will initially be introduced in Manyara Region, of contraception (LA/PMs), to meet the reproductive needs of and RTP will use the experience from Manyara to expand its Tanzanian men, women, and adolescents. Increased use will TA to cover all districts where HMIS or other partners have be measured by couple-years of protection (CYP), which will customized health interventions but excluded FP and serve as a proxy for the CPR. CPR can only be measured PMTCT. through a population-based survey such as the Demographic and Health Survey and is therefore not included in our
17. Evaluation: Learning from Experience, USAID Evaluation Policy (January 2011).
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2. RTP will work with partners such as I-TECH to build EVALUATION STUDIES the capacity of CHMTs and provide TA for CHMT
staff to perform online data entry for in-service RTP will conduct research and evaluation to produce quality trainings at the district level. The current practice is data to inform planning and programming decisions. Midterm that all training data is entered by ATP staff. Districts will and endline surveys will be implemented in collaboration with adapt the EventSMART online system, which will enable MOHCDGEC stakeholders at all levels to access online USAID and other partners to evaluate the project. RTP will data based on their unique access codes. This will also collaborate with the Population Council and local support improved assessment of training needs, research institutions, such as the NIMR and the Ifakara planning of training activities, and deployment of health Health Institute, to conduct operations research. Two to three service providers. special studies will be implemented to improve understanding of the most effective approaches to advance the use of 3. RTP will work with the MOHCDGEC to pilot test and LA/PMs, to study capacity-building approaches, and to scale up the use of mobile phones to submit FP and investigate the profile of users of LA/PMs. Full proposals will PMTCT monthly reports from health facilities to be developed for all evaluation and special studies and are districts directly into the DHIS2 system. This will subject to EngenderHealth’s ethical in-house review process require infrastructure building, staff training, and (termed the Evaluation and Research Standard Operating troubleshooting of the system before it is handed over to Procedures) and to BOP8 and a Tanzanian Institutional the CHMTs. The pilot has recently begun in Manyara Review Board (IRB), as required. In certain circumstances, Region, where RTP will focus most of its district- and proposals may require review by a U.S. IRB. Determination facility-level integration activities. Depending on the for U.S.-based IRB approval is based on the standards for the results, RTP will scale up the initiative to follow where the protection of human research, often referred to as the electronic MTUHA database (DHIS2) has been launched. Common Rule. Irrespective of the legal requirements, EngenderHealth vigorously protects the rights and welfare— 4. RTP will provide TA to national MTUHA and RCHS staff both physical and psychological—of people participating in on how to replicate the FP custom application for FP research and evaluation studies that we conduct or support, that has been developed in Manyara. RTP will assist and we adhere to all standards for the protection of human other regions and districts to add this application where the subjects outlined in the Common Rule. hardware and basic software for DHIS2 and the MTHUA have been contributed by the MOHCDGEC or other Program Evaluation partners, which will be very cost-effective and will be a
criterion for determining where this would be done. A baseline assessment will not be conducted, as stipulated by the RFA, and instead, RTP will use results of the ATP 5. RTP will provide computers to DRCHCOs in the pilot midterm review, which was conducted in 2010–2011, as part districts that will be implementing both MTUHA online of the baseline values for RTP. The data will be system and EventSMART in-service training complemented by national surveys such as the Demographic databases. Computers will facilitate and encourage and Health Survey and the Tanzania HIV/AIDS Indicator DRCHCOs to access data from the two systems and Survey and updated service statistics. These surveys provide provide quick feedback to system data managers in case baseline values and follow-up values. A midterm evaluation of any observed errors. Computers will support of RTP will be conducted after the first 2–3 years, to assess DRCHCOs to use electronic data for decision making progress and inform any needed adjustments in strategies after attending formal trainings. This initiative will be and interventions. USAID/Tanzania will determine the scope implemented of work for and mechanism for the midterm review. As with in Manyara Region, building upon the contribution of the midterm evaluation, the approach for a final evaluation of computers already provided to district data managers in RTP will be determined by USAID/Tanzania. Manyara Region. RTP will use this experience to RTP will also conduct a rapid assessment of district encourage other districts to plan and budget for computers coordination capacity and processes (Intermediate Result
and IT accessories for their DRCHCOs in their CCHPs as 3.2). A sample of eight districts from Level 3 (two from each a transitioning strategy. RTP zonal field office) will be assessed to document current guidance and practices related to district coordination and engagement and collaboration with partners. Guidance or performance gaps will be identified and will inform the development of capacity-building training and TA strategies.
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Better practices will also be identified. RTP will also build on Exploration of the changing profile of women seeking the experiences of ATP’s “district approach,” which has involved close partnership with both the MOHCDGEC and female sterilization services at public health facilities. the Prime Minister’s Office–Regional Administration and Local Government at the district level, as well as the Wajibika Project, led by Abt Associates. This activity will be In this study, RTP will work jointly with the Population completed by the end of Year 1 and lessons learned scaled Council to develop a protocol to examine the changing up from Year 3. profile of women of reproductive age who willingly want to limit their family size. Past experience gained from ATP Operations Research and Other Studies suggests that many of the women seeking minilaparotomy services were older than 35. Recently, the number of
To add to the knowledge base on LA/PM best practices, women seeking minilaparotomy services has declined, particularly in the Tanzanian context, RTP proposes to carry combined with a noted increase in the number of women out an operations research and special studies agenda, choosing long-acting methods. This study will help to including topics such as a comparison of alternative document the characteristics of these women and changes approaches for delivering LA/PM services and follow-up of in this profile over time, as well as establish determinants trainees. In light of resource constraints and the need to for the decrease in demand for permanent methods. The maximize the efficiency of interventions, attention will be results will guide efforts by RTP, MOHCDGEC, and other paid to the analysis of alternative service delivery and capacity-building approaches. Descriptions of anticipated partners to provide targeted communications and activities are listed below: interventions to the population segment(s) that are likely to use minilaparotomy services. Determining the most efficient LA/PM and other Urban FP mode integrated service delivery model(s)
To address the low CPR in Dar es Salaam, RTP will be ATP experience suggests that a large proportion of LA/PM designed and test an innovative “Urban FP Model” in the clients (more than 60%) are served during outreach days. Dar es Salaam region and then will replicate it in Arusha, As explained in the technical narrative, the outreach model Mbeya, and Mwanza in Year 3, subject to results from the demonstration model. The Urban FP Model will focus on will be continued in the next five years as a key LA/PM integrated services and foster strong public-private service delivery method, as it ensures the program’s ability partnerships in urban regions. In Year 1, RTP will to reach most people in rural settings. In addition, FP has collaborate with CCBRT to establish FP programs in the been provided at the health facilities during dedicated days, CCBRT Dar es Salaam hospital, based on the results of an whereby service providers do not provide any other services assessment now being completed through ATP. RTP will apart from FP (service days). ATP and the MOHCDGEC work with CCBRT and the MOHCDGEC to solicit funding introduced the FP week concept, whereby FP services are from donors to support FP integration in RMNCH programs in Dar es Salaam. This project will initially focus on 16 public publicized to be provided by skilled personnel during the health facilities with which CCBRT and ATP have been whole week. In all of these LA/PM service delivery models, working and the CCBRT hospital in Dar es Salaam and will a large number of clients turn out and get the service of their gradually expand to all public facilities by Year 3. RTP will choice. RTP, in collaboration with and leveraging inputs build the capacity of the RHMT and CHMTs in Dar es from other partners, will seek to establish and compare the Salaam to improve the coordination of local and costs and associated benefits of each of the models, international organizations supporting FP/RH in the region. including for FP-HIV integrated services, and will advise the MOHCDGEC and CHMTs based on the results, using the FP and disability model EngenderHealth Integration Framework and working with the Population Council. This pilot aims to increase FP/RH knowledge among the disabled population and caretakers of disabled children in Dar es Salaam.17 Proposed interventions include integrating FP services with fistula services and reaching caretakers of disabled children. RTP will partner with UTU Mwanamke, CCBRT, UMATI, and the MOHCDGEC.
17 Disabled persons represent 7.8% of the population overall, and 13.2% of Tanzanian households have at least one member with a disability (National Bureau of Statistics, 2010. Tanzania 2008 Disability Survey Report. Dar es Salaam).
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KNOWLEDGE MANAGEMENT NOWLEDGE MANAGEMENT conference abstracts and presentations and journal Knowledge management is a cornerstone of our strategic articles and using documentation and evidence from the approach. We will use evidence-based activities to build on special studies to contribute to USAID’s High Impact lessons learned in ATP, and RTP will document its Practices, the Implementing Best Practices initiative, and successes, results, best/better practices, and challenges, other GHI initiatives. including those anticipated with the public-private partnerships. The documentation will inform our ongoing RTP will systematically synthesize project progress in activities, allowing for the integration of best practices into reports to USAID and the MOHCDGEC. These will include our work. Resources that will be utilized as evidence to quarterly reports (due 45 days after the end of the quarter) inform activity design include the RESPOND library and ATP that will: a) summarize activities and results compared research and evaluation, as well as information from other with the work plan; b) include an explanation of why activities were not carried out or were delayed during the USAID implementing partners (e.g., K4Health, BEST and period, with corrective actions taken; and c) discuss PROGRESS Projects) and global sources such as World progress made toward indicator benchmarks. An annual Health Organization, the United Nations Population Fund, report will be submitted each year (due November 1) and and others. The latest Tanzania MOHCDGEC policies, will include a summary of information from the previous guidelines, and protocols, many of which EngenderHealth three quarterly reports and information for the fourth has helped develop, will also be a key guide. quarter, an assessment of yearly results, an explanation of why results were surpassed or not achieved, expenditures to date, and a description of all sub- Our growing knowledge base will add to the LA/PM agreements. A final end-of-project report will be Community of Practice, which was established in 2009 by completed in place of the annual report in Year 5 (due the RESPOND Project for collective learning and knowledge within 90 days of the expiration of award); this will include a description of cumulative results, an assessment of sharing in FP, with an emphasis on promoting LA/PMs. impact (including lessons learned and success stories), The RESPOND Project and EngenderHealth ME&R and research findings with recommendations, and a fiscal knowledge management staff will help RTP to access the report. Program reports will be disseminated to all program staff, project partners, and the MOHCDGEC. knowledge and resource base in the LA/PM Community of RTP will hold semi-annual progress review meetings, Practice and to finalize reports and other products so they where project results and lessons learned will be shared. may be disseminated globally to share the results and lessons learned from the project with as wide an audience as possible. This will include assisting the staff to develop
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INDICATOR BENCHMARK DATA ASSUMPTIONS/COMMENTS TYPE 2017 SOURCE
Mission Strategic Objectives Health: Health Status of Tanzanian families improved HIV/AIDS: Reduced transmission and impact of HIV/AIDS
PROGRAM STRATEGIC OBJECTIVE: Increased use of FP services, with a focus on LA/PMs, to meet the reproductive health intentions of Tanzanian men and women
Mission IR2: Family-level access to target services increased
Result 1: Access to quality FP-LA/PM and RH services (HIV and AIDS and GBV) increased
1.1 Improved capacity and performance of health service providers and facilities
FP-LA/PM services countrywide (110 districts)
1 CYPs, disaggregated by FP TBD RTP MTUHA Program database will provide service statistics for individual Mission method database LA/PM methods. Service data will be converted to CYPs using approved USAID conversion factors. The benchmark figure will be calculated by applying actual annual achievement figures to project targets for subsequent years during work plan preparation. 2 Percentage of women TBD MTUHA Program database will provide service statistics for individual accepting an LA/PM among LA/PMs. These will be used to calculate benchmarks during FP clients work plan preparation. 3 Number of service providers TBD EventSMART Routine analysis from the EventSMART database will provide Mission trained on FP -LA/PMs actual figures. Further, yearly RTP work plans will be the main (preservice and in-service), source of training projections. disaggregated by type, training method, and sex cPAC services in two regions and Zanzibar 4 Number of clients receiving TBD RTP MTUHA We assume the program will support cPAC services in 70% Mission/ cPAC services (disaggregate database of facilities in Mwanza, Shinyanga, and Zanzibar. Annual and GHI by type of facility and type of end-of-program benchmarks will be determined by estimating cPAC service) average number of cPAC clients per site per month, using the ATP/RTP database.
5 Number of service TBD EventSMART RTP yearly work plans will be the main source of the service providers trained in cPAC, provider Mission/ disaggregated by intervention, training projections. GHI training method, and sex Quality PMTCT services strengthened and scaled up in Manyara region 6 Number of facilities providing TBD RTP MTUHA the minimum package of database Assume program will work with all facilities providing antenatal PEPFAR PMTCT services according care and labor and delivery (L&D) services in Manyara Region. to national and international Annual benchmarks will be determined according to Country standards Operational Plan expansion guidance.
7 Number of pregnant women TBD RTP MTUHA GOT national PMTCT targets are to test at least 80% of PEPFAR with known HIV status database pregnant women. We will assume that at least 80% of new (includes women who were antenatal care clients and women attending L&D will be tested tested for HIV and received for HIV. The program will support 145 facilities in Manyara their results) Region, and current data will be used to estimate mean monthly attendance. ATP reports will be used to generate expected numbers of women with unknown status.
8 Number of HIV-positive TBD RTP MTUHA Program-level reports will be used to estimate HIV prevalence PEPFAR pregnant women who received database in women tested at antenatal care and L&D. This information antiretroviral l drugs to reduce plus the estimated number of women to be tested from above risk of mother-to-child- will be used to calculate numbers of HIV-positive pregnant transmission of HIV women.
9 Number of health workers TBD EventSMART RTP yearly work plans will be the main source of service provider PEPFAR trained in the provision of training projections. PMTCT services according to national and international standards, disaggregated by training method
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INDICATOR BENCHMARK DATA ASSUMPTIONS/COMMENTS TYPE 2017 SOURCE GBV services in Iringa and Njombe 10 Percentage of health facilities TBD RTP MTUHA RTP yearly work plans will be the main source of information for PEPFAR providing GBV clinical services database GBV service expansion in the districts. (Numerator: no. of health facilities reporting that they offer clinical GBV services; Denominator: total no. of health facilities in the intervention area) 11 Number of GBV service TBD RTP MTUHA RTP yearly annual reports will be the main source of service PEPFAR encounters at health facility, database achievements. Reporting will be disaggregated by type of GBV disaggregated by type of clinical services offered (e.g., STI/HIV testing, postexposure service, age, and sex prophylaxis, pregnancy testing, FP, etc.). RTP yearly work plans will be the main source of the service 12 Number of providers trained in TBD Quarterly provider PEPFAR GBV service delivery reports training projections. 13 Percentage of sexual violence TBD RTP MTUHA RTP annual work plans will provide an estimate based on the victims at RTP-supported database actual figures achieved on GBV service use. RTP health facilities who were counseled, tested, and received results for HIV 1.2 Strengthened supervision and quality improvement support for service delivery 14 Number of CHMTs conducting Quarterly RTP at least one integrated reports supportive supervision visit each quarter 15 Number of health facilities Quarterly RTP oriented on and using the reports COPE tool to improve/ strengthen service provision IR 1.3 Improved contraceptive/commodity security at the “last mile” 16 Number and percentage Quarterly RTP of facilities in targeted area reports using COPE-derived tool for contraceptive security, with and without outside facilitation Result 2: Quality FP-LA/PM and RH-integrated services demonstrated, evaluated, and scaled up 2.1 FP-LA/PMs integrated into HIV prevention, care, and treatment services 17 Number of HIV-positive TBD New tool to RTP yearly work plans will be the main source of service GHI/RTP women provided postpartum be developed provision projections. FP services 18 Number of HIV-positive TBD New tool to RTP yearly work plans will be the main source of service GHI/RTP pregnant women initiated be developed provision projections. on antiretroviral drugs at antenatal care visit 19 Number of facility-based staff TBD EventSMART RTP yearly work plans will be the main source of service provider GHI/RTP trained on integrating FP into training projections. HIV care and treatment and PMTCT services 20 Number of HIV-positive clients TBD New tool to RTP yearly work plans will be the main source of service RTP referred for FP counseling be developed provision projections. IR 2.2 FP-LA/PMs integrated into maternal and child health settings 21 Number of facilities providing TBD MTUHA RTP yearly work plans will be the main source of information for GHI/RTP postpartum FP services in database service expansion. maternal and child health settings 22 Number of clients referred for TBD MTUHA RTP yearly work plans will be the main source of information for FP services from maternal and database service expansion. child health clinics
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INDICATOR BENCHMARK DATA ASSUMPTIONS/COMMENTS TYPE 2017 SOURCE IR 2.3 Strengthen delivery of LA/PMs during cPAC services 23 Number of facility-based TBD EventSMART RTP yearly work plans will be the main source of service GHI/RTP providers trained on provider training projections. integrating FP into cPAC 24 Percentage of cPAC clients RTP MTUHA RTP quarterly reports will be the main source of service Mission/ counseled on FP database provision achievement. GHI
IR 2.4 FP-LA/PMs integrated into GBV services at facilities in targeted areas 25 Number of facility-based staff TBD EventSMART RTP quarterly reports will be the main source of service provider GHI/RTP trained on integrating FP into training projections. GBV service delivery 26 Number of clients receiving TBD RTP MTUHA RTP quarterly reports will be the main source of service GHI/RTP GBV services counseled on FP Database provision achievement. Program Mission IR3: Sustainability reinforced for target health programs Result 3 Health system management, monitoring, and evaluation strengthened for integrated FP-LA/PM and RH Services IR 3.1 FP and RH resource allocation in CCHP increased through capacity building and technical assistance 27 Number of districts allocating TBD Quarterly RTP quarterly reports will be the main source of service Mission/ FP budget in their CCHPs report provision achievement. GHI IR 3.2 Improved district coordination and partner collaboration 28 Number of partners TBD Quarterly RTP quarterly reports will be the main source of service RTP coordination meetings held at reports provision achievement. district level IR 3.3 National, regional and district level capacity built to support integrated services 29 Number of task-shifting Quarterly RTP initiatives implemented jointly reports with RH services
IR 3.4 Strengthened integrated strategic information management (through research or demonstration activities to inform policy change)
30 Percentage of facilities using TBD Quarterly RTP quarterly reports will be the main source of service RTP mobile phone technology report provision achievement. submitting monthly FP/HIV reports on time 31 Number of districts supported TBD Quarterly RTP quarterly reports will be the main source of service RTP by RTP to use DHIS2 national reports provision achievement. database to report FP-LA/PM, GBV, and PMTCT service use Mission IR 1: Communities empowered to practice key behaviors and use services for target health problems Result 4 Communities mobilized to increase use of FP-LA/PMs and RH services IR 4:1 Increased community engagement and action for accessing tailored FP and LA/PM services 32 Number of facilities using “site TBD Quarterly RTP walk-through” initiative to reports increase FP uptake 33 Number of satisfied clients TBD Quarterly RTP oriented to promote LA/PMs reports IR 4.2 Increased sensitization and acceptability of FP among targeted populations in selected areas 34 Number of individuals reached TBD Quarterly RTP with targeted FP messages, reports disaggregated by age and sex
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APPENDIX 2: FUNDING OBLIGATIONS
RTP received a combination of FP/RH funds and PMTCT PEPFAR funds over its five-year period of operation. Total funds obligated over the life of the project totaled $ 44,075,212.e project results and lessons learned will be shared.
Figure A2: RTP obligation, by year 2012 to 2017 (five years)
14,000,000
12,000,000
10,000,000
8,000,000
6,000,000
4,000,000
2,000,000
- Year 1 Year 2 Year 3 Year 4 Year 5
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APPENDIX 3: RTP RESULTS FRAMEWORK
Strategic Objective: Increased use of FP/RH services, with a focus on LARC/PMs, to meet the reproductive intentions of Tanzanian women, men, and adolescents
RESULT 1: RESULT 2: RESULT 3: RESULT 4: COMMUNITIES ACCESS TO QUALITY QUALITY FP- HEALTH SYSTEMS ENGAGED IN THE FP-LARC/PM AND RH LARC/PM AND RH STRENGTHENED FOR PROMOTION OF FP- SERVICES (HIV AND INTEGRATED SERVICES INTEGRATED FP-(LARC/ LARC/PM AND RH AIDS AND GENDER- DEMONSTRATED, PM AND RH SERVICES. SERVICES. BASED VIOLENCE EVALUATED, AND [GBV]) INCREASED. SCALED UP.
1.1 Improved capacity and 2.1 FP-LARC/PMs integrated into 3.1 FP/RH resource allocation in 4.1. Increased community performance of health service HIV prevention, care, and treatment Comprehensive Council Health engagement and action for providers and facilities services Plans (CCHPs) increased through accessing tailored FP- advocacy and capacity building LA/PM services 1.2 Strengthened supervision and 2.2 FP-LARC/PMs integrated into quality improvement support for maternal and child health settings 3.2 Improved district coordination 4.2. Improved knowledge and service delivery. and partner collaboration acceptability of FP services among 2.3 Strengthened delivery of LARC/ targeted populations (e.g., youth, 1.3 Improved contraceptive/ PMs during cPAC services 3.3. National, regional, and district males, urban) in selected areas commodity security at the “last level-capacity built to support mile”* 2.4 FP-LARC/PMs integrated into integrated services GBV services at facilities in targeted *Reaching health facilities and end areas 3.4 Strengthened integrated strategic users in the remote communities information management (including they serve. research or demonstration activities to inform policy change)
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