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U.S. PRESIDENT’S EMERGENCY PLAN FOR AIDS RELIEF (PEPFAR)

HEALTH RESOURCES AND SERVICES ADMINISTRATION (HRSA)

HIV/AIDS Bureau—Global HIV/AIDS Program

CLINICAL ASSESSMENT FOR SYSTEMS STRENGTHENING (CLASS)

ASSESSMENT REPORT

For

AIDSRelief-Tanzania

29 November -14 December 2010

AIDSRelief-Tanzania ClASS Report-December 2010

Table of Contents

Executive Summary ........................................................................................................................... 4

Acronyms & Abbreviations ............................................................................................................... 7

AIDSRelief -Tanzania ....................................................................................................................... 8

I. ADMINISTRATIVE REVIEW .............................................................................................. 8

II. CLINICAL REVIEW ........................................................................................................... 10

III. FINANCIAL MANAGEMENT REVIEW .......................................................................... 13

Christian Social Services Commission (CSSC)............................................................................... 17

I. ADMINISTRATIVE REVIEW ............................................................................................ 18

II. CLINICAL REVIEW ........................................................................................................... 22

III. FINANCIAL MANAGEMENT REVIEW .......................................................................... 26

Local Partner Treatment Facilities ................................................................................................... 31

AIDSRELIEF/ HYDOM LUTHERAN HOSPITAL ................................................................... 32

I. CLINICAL REVIEW .................................................................................................... 32

MBULU DISTRICT HOSPITAL ................................................................................................ 38

I. ADMINISTRATIVE REVIEW ..................................................................................... 38

II. CLINICAL REVIEW .................................................................................................... 39

III. FINANCIAL MANAGEMENT REVIEW ................................................................... 44

BUGANDO MEDICAL CENTER .............................................................................................. 46




SENGEREMA DESIGNATED DISTRICT HOSPITAL ............................................................ 56




NYAKALIRO HEALTH CENTER ............................................................................................ 64



III. CLINICAL REVIEW ................................................................................................... 65


SHIRATI DESIGNATED DISTRICT HOSPITAL .................................................................... 71

I. CLINICAL REVIEW .................................................................................................... 71

HRSA ClASS Visit Schedule .......................................................................................................... 76


Executive Summary

The Global HIV/AIDS Program of the Health Resources and Services Administration’s HIV/AIDS

Bureau provides funding under the President’s Emergency Plan for AIDS Relief (PEPFAR) to

AIDSRelief, a consortium in which Catholic Relief Services (CRS) is the lead agency. AIDSRelief

is funded under a PEPFAR program known as Track 1.0 created as a rapid response the tide of

deaths from HIV in 2003. The program leveraged US agencies already working in PEPFAR

focused countries that could quickly scale up to provide HIV care and treatment. The Track 1.0

program accounts for about a quarter of all PEPFAR activities.

AIDSRelief is one of four US agencies funded for care and treatment services under Track 1.0 and

currently manages programs in nine countries. The AIDSRelief Consortium consists of Catholic

Relief Services (CRS), the lead agency, which provides administrative and financial support, site

management in Mwanza and Tanga, as well as supply chain support for the pharmacy; the Institute

of Human Virology (IHV) at the University of Maryland, which provides clinical training, clinical

mentoring and laboratory support; and the Futures Group, which provides support for monitoring

and evaluation (M&E). In Tanzania, Interchurch Medical Assistance dba IMA World Health is

another international consortium member responsible for site management across four regions of

Mara, Tanga and Manyara.

At the end of the initial five-year project period there was concern that a full competition for these

awards would lead to disruption of services and also affect the rapid scale-up occurring at that

time. The US Department of Health and Human Services issued a waiver that granted an additional

three years to the initial award, with the condition that programs needed to be transitioned to

qualifying indigenous organizations within that period. Following transition these programs will

no longer be supported by HRSA, but will instead be managed by CDC in-country.

On March 4, 2010, the Government of the United Republic of Tanzania (URT) and the

Government of the United States of America (USG) signed a “Five-Year Partnership Framework

in Support of the Tanzanian National Response to HIV and AIDS, 2009 – 2013, (the Partnership

Framework). The Partnership Framework articulates the expected contributions of the two

Governments in response to the HIV and AIDS crisis in Tanzania. It also strives to ensure that

USG contributions to the national HIV and AIDS response complement and leverage those of

other stakeholders. USG and URT, with input of AIDSRelief-Tanzania and other international and

local organizations like CSSC helped develop the Partnership Framework and are carrying out

some of the strategies.

AIDSRelief-Tanzania submitted a transition plan to HRSA and CDC-Tanzania identifying

Christian Social Services Commission (CSSC) as the proposed prime local partner for both faith-

based and government managed health facilities. It is USG long-term vision that MOHSW will

provide technical and SI support to all facilities providing public health HIV services. In mid-

2010, CSSC responded to and won a CDC funding opportunity announcement for an organization

to become a new CDC-local care and treatment partner. CSSC will take over responsibility for 8

of the current AIDSRelief-Tanzania local partner treatment facilities located in the Mwanza and

Mara regions during the first year award.


In December 2010, after a courtesy visit to the MOHSW National AIDS Control Program

(NACP), a HRSA team visited AIDSRelief-Tanzania Consortium members, CSSC, three Regional

Health Management Teams (RHMT), some Council Health Management Teams (CHMT), and 6

LPTFs including 3 slated for transition to CSSC in FY11. CDC-Tanzania and representatives

from the Ministry of Health and Social Welfare (MoHSW) were included in the visits to the

LPTFs.

Purpose and Objectives

The purpose of the HRSA assessment was to determine the status of the AIDSRelief-Tanzania

transition plan, including the interest and organizational capacity of the proposed local partner, to

ensure that the transition plan is consistent with USG and national government plans, to provide

technical assistance during the visit as appropriate, and to begin the process of identifying other

technical assistance resources to support ongoing needs. HRSA’s Clinical Assessment for

Systems Strengthening (ClASS) framework was used to assess the capacity of CSSC, the status of

AIDSRelief transition planning efforts, and to review the timeline for preparation for sustainability

and transition to local ownership by the deadline of February 29, 2012. In addition, CDC-Tanzania

took advantage of the ClASS visit to perform its pre-award assessment of CSSC.

The objectives of the ClASS are as follows:

Assess the quality of services and care provided to patients; a reflection of the outcome of

AIDSRelief-Tanzania support to LPTFs and of their on-going needs.

Ensure that organizational systems, policies, and procedures are in place to accomplish

program goals and objectives.

Assess the organization’s capacity to provide the funded services and manage funding.

Identify organization as well as program strengths and areas for improvement and

provide appropriate consultation to enhance their capacity to support delivery of high

quality, cost competitive health care and services as part of systems strengthening.

Identify model programs or program components that can be replicated in other

communities or organizations.

The ClASS is comprised of the following modules:

CLINICAL: Assesses facility, clinical policies and procedures, project work plan,

continuous quality improvement/quality assurance, and review of medical records.

FINANCIAL: Assesses income and expenditures, charges and fees, billing and

collections, accounting system, accounts payable and cash flow, fixed assets, inventory and

purchasing, payroll, revenue, and cost allocation.

ADMINISTRATIVE: Assesses organization and structure, governance, strategic

planning, personnel policies and procedures, licenses and certifications, risk management,

networking, collaboration, linkages, and management information systems.

PARTNER: Assesses the organization’s capacity to train and mentor as well as to support

and monitor LPTFs to provide efficient, high quality HIV services, conduct site

management, and engage in identifying diverse funding.


The twelve-day assessment visit consisted of opening briefings, closing debriefings, two days and

one-day visits to six LPTFs.

Conclusions

Healthcare in Tanzania is delivered from dispensaries (lowest level of care), health centers, and

hospitals at district, regional and national referral levels. There remain serious healthcare shortages

in the country. AIDSRelief-Tanzania has done a tremendous amount of work with the 98 facilities

to which PEPFAR funding and support have increased access to and delivery of HIV services.

CSSC has a long history of working with diverse national, international, regional and zonal entities

in the country to ensure access to healthcare and education services. The organization structure at

the Dar es Salaam headquarters and at the five zonal offices should be reviewed to ensure timely

responsiveness to donor requests or requirements. The location of ART program positions across

multiple departments should also be reviewed. CSSC plans to house project staff in the Mwanza

zonal office. The current zonal office cannot accommodate this addition of program and financial

management project staffing. The coordination of information and reporting flow between the

zonal office, multiple departments and the ART Program Manager should be reviewed as well.

Presently the organization does not provide direct care services, but serves as an advocacy body

for faith-based health organizations. The organization offers capacity building and provides

linkages for the health facilities to other technical resources. Several of the CSSC member health

facilities serve as the country HIV care and treatment experts. CSSC must determine how to bring

similar expertise into the organization either through using some of these member staff as

consultants or sub-contracting with other local or international partners who bring such clinical

experience.

CSSC receives direct funding from several USG and European donors, including EED,

CORDAID, the GFATM, USAID, kfw, and DANIDA. CSSC is also a sub-recipient of PEPFAR

funds through AIDSRelief-Tanzania and IMA World Health. CSSC should investigate options to

maintain access to reserve funds when donor payments may be delayed or when other organization

improvements may be needed. As additional financial management staff is recruited, particularly

at the zonal offices, a plan for financial oversight of this staff will need to be developed. Currently

there is no financial management staff at the Mwanza zonal office.

HRSA will continue to work with AIDSRelief-Tanzania to revise the transition plan based on the

results of this assessment, including identifying who among AIDSRelief-Tanzania, CDC, and

HRSA can best meet CSSC technical assistance needs


Acronyms & Abbreviations

ART Antiretroviral Therapy

ARV Antiretroviral Drugs

CCT Christian Council of Tanzania

CDC Centers for Disease Control

CHMT Council Health Management Teams

CHW Community Health Worker

ClASS Clinical Assessment for Systems Strengthening

CRS Catholic Relief Services

CSSC Christian Social Services Commission

CTC Care and Treatment Clinic

GOT Government of Tanzania

GM General Manager

HCT HIV Counseling and Testing

HRSA Health Resources Services Administration

IHV University of Maryland School of Medicine – Institute of

Human Virology

IMA Interchurch Medical Assistance dba IMA World Health

LPTF Local Partner Treatment Facility

M&E Monitoring & Evaluation

MCH Mother-Child Health

MOHSW Ministry of Health and Social Welfare

OGAC Office of the Global AIDS Coordinator

OPD Outpatient Department

PEPFAR U.S. President’s Emergency Plan for AIDS Relief

PICT Provider-Initiated Testing and Counseling

PLWHA Persons Living With HIV/AIDS

PMTCT Prevention of Mother-to-Child Transmission of HIV

RHMT Regional Health Management Team

TB Tuberculosis

TEC Tanzania Episcopal Conference

USAID United States Agency for International Development

USG United States Government

TA Technical Assistance

VCT Voluntary Counseling and Testing


AIDSRelief -Tanzania

30 November 2010

BACKGROUND

AIDSRelief-Tanzania is a consortium of four organizations led by Catholic Relief Services (CRS),

Interchurch Medical Assistance (IMA), University of Maryland School of Medicine-Institute of

Human Virology (IHV), and Futures Group. Since the 2004 start of the ART program, ninety-

eight (98) treatment facilities are supported. In 2006, the organization adopted a regional approach

to support the provision of HIV care and treatment for government, faith-based and private health

facilities in the four regions of the country to include: Mwanza, Mara, Manyara and Tanga.

HRSA, CDC, and AIDSRelief-Tanzania agreed in 2010 that there would be an incremental

transitioning of LPTS to a local partner. AIDSRelief-Tanzania has been working with Christian

Social Services Commission (CSSC) for several years as the national organization for many of the

faith-based health facilities in the country. CSSC responded to a CDC request and was awarded

funds in mid-2010 to conduct site management for 8 ART facilities.

I. ADMINISTRATIVE REVIEW

Organization Structure and Management

The Chief of Party has come from within the global CRS pirograms and has extensive knowledge

and experience in various organization positions. Three Deputy Chiefs of Party provide day-to-

day oversight for country programs. A Sustainability Coordinator is taking the lead for transition

related activities. The AIDSRelief-Tanzania transition plan provided significant detail on the

processes completed to date and a specific plan for capacity building with CSSC and other local

partners.

Human Resources

The CRS Tanzania office has a total of 96 employees working on AIDSRelief-Tanzania and other

CRS projects in 14 regions of the country. Three (3) project officers and three(3) finance officers

work out of the Mwanza office with the area ART programs. The human resource policies and

procedures from the headquarters office in Baltimore cover the Tanzania office. Currently, the

human resources department is in the process of identifying software to manage personnel

information. The office continues to face challenges finding qualified with management styles and

experience compatible with the organization.

ART Program Management

CRS and IMA jointly provide site management for 98 LPTFs. IMA is responsible for site

management of 52 of the 98 local partner treatment facilities (LPTF). Each of the Project Officers

is responsible for 6-7 sites. Project and Finance Officers make all attempts possible to visit the

sites together. Schedules are developed on a quarterly basis to support this coordination. A

financial management site review tool is used by the finance staff and a general site management

tool is used by the Project Officer. Meetings are held with the site staff at the conclusion of the

review and findings are shared. The policy is for a copy of the site trip report to be sent to the site

after the review, but several of the sites visited had not been receiving these reports. Teams


visiting the sites may vary at each visit depending on the most current issues to be addressed. Any

of the Project Officers may be asked to review other areas while conducting their follow-up.

Clinical site visits are scheduled based on strategic information data. Discussions with the project

officers identified that there are no criteria to determine when monthly visits are no longer needed

at a site.

AIDSRelief-Tanzania has recently created a new department, Knowledge Management and

Quality, to review all of the site reports and begin to analyze information and communicate

additional needs for follow-up. This will be done manually since there is no current database or

electronic tracking system. AIDSRelief-Tanzania provided a 2-3 day new project officer

orientation for the CSSC-seconded staff person that mirrors that given to their own staff. There is

a project officer checklist that is developed based on the site workplan, budget, and previous year

unresolved problems. There are no written policies and procedures to support all of the processes

and activities carried out by the Project Officers. This is particularly important in ensuring that

local partners will experience seamless transitioning of sites.

Each site was requested in 2010 to identify a Nurse Coordinator to be responsible for the day–to-

day operations of the ART program and the primary point of contact for the Project Officers.

A. Administrative Strengths

Excellent detailed transition plan with a specific timeline for completion.

The development of the Knowledge Management and Quality Department is a great

addition.

The project officer is knowledgeable and skilled and very familiar with the sites.

The project officer has a reasonable number of sites for which he/she is responsible.

The Transition and Sustainability Coordinator has excellent relationships with the sites,

participates in management meetings, and has a good working relationship with the Zonal

Secretary in the Mwanza office.

There are flexible processes used to assess and support the sites.

The implementation of the Site Coordinator role at the LPTFs will facilitate project officer

access to information.

B. Administrative Areas for Improvement

1. Area for Improvement - Program Expectation: There are no written policies and

procedures to guide and standardize the site management processes. In preparation for

CSSC to assume oversight responsibility for the LPTFs, such a document will be key to

ensure consistency after transition. Recommendation: AIDSRelief-Tanzania should

determine if any of the existing processes should be revised. Develop a manual that can

be shared with CSSC or any other partners who may be assuming site management.


2. Area for Improvement - Program Expectation: The AIDSRelief-Tanzania clinical

review teams use the clinical indicator data to determine how often monitoring visits

should take place at an LPTF. This or a similar process is not used to determine the

interval of project officer or accountant visits to the same sites. Recommendation:

Assess the cost effectiveness of visiting sites at intervals that are not improving or

identifying ongoing or new issues related to program management or organization

administration or operations. AIDSRelief-Tanzania should outline what issues or

problems would constitute a change in the review schedule and who can approve such

changes.

3. Area for Improvement - Best Practice: There is not currently a single source database or

tracking system to consolidate all site-related trip reports, quarterly narrative site reports,

findings and recommendations, and the status of actions taken to resolve. This is critical

for AIDSRelief-Tanzania to be able to share with CSSC the last one year of reports and

action plans for each of the eight LPTFs. Recommendation: AIDSRelief-Tanzania

should identity a system to analyze trends within sites and across sites. It will also be

helpful to have copies of the checklists scanned for each site to be able to share as part of

the transition process.

C. Transition Preparation Recommendations for AIDSRelief-Tanzania

AIDSRelief-Tanzania should prepare a summary of total staff level of effort currently

needed to monitor (this should include IHV, Futures, and CRS management levels) the 8

sites to be transferred to CSSC. This would allow CSSC to clearly understand the

administrative burden associated with the program for their planning.

IMA, as the prime contractor for CSSC, should work to establish consultant agreements

and subcontractor language that will allow for support relationships to be used during the

first year of the CDC contract.

II. CLINICAL REVIEW

Overview

AIDSRelief-Tanzania provides clinical/technical support to MOH, FBOs and private health

facilities in Mwanza, Mara, Manyara, and Tanga regions. In 98 sites, AIDSRelief-Tanzania

supports comprehensive HIV care services (adult and pediatric care & treatment, HCT, HIV/TB,

PMTCT, and community-based care); in 538 additional sites and supports PMTCT-only sites as

part of a recent country-wide scale-up.

With GFATM funding support, the MOH is responsible for procurement of all ARVs, OI drugs,

and laboratory reagents; however, stock-outs are frequent. To minimize the negative impact of

such stock-outs on delivery of quality care, AIDSRelief-Tanzania purchases 15-20% of the

necessary OI drugs and lab reagents for its supported sites. It also supports the salary of 80

clinical/technical CTC staff.

Since 2004, AIDSRelief-Tanzania has supported HIV care to a cumulative number of 120,000

patients of whom 7% were infants and children; ART care to a cumulative of 60,000 PLWHA (7%

pediatric) of whom 35,000 are still actively on ART (8% pediatric).


AIDSRelief clinical/technical team includes 4 MDs, 2 Pediatricians, 1 Internist, 6 RNs, 5 lab

specialists, and 6 community-based treatment supporters. Areas of CTC support include training

and mentoring focused on the 36 large sites (mostly regional and district hospitals) and satellite

sites.

In addition, through Futures and its team of 23 staff (7 in Dar and 4 in each of the 4 regions),

AIDSRelief-Tanzania supports CTCs with their M&E / SI activities and data entry in the CTC2

MOH database. Futures also operates the IQTool which allows queries of the CTC2 database.

AIDSRelief-Tanzania also provides financial support to cover the salaries of CTC data entry

clerks. For 2/3rd

of the CTCs, data collection is computerized but for all the PMTCT sites data

collection is paper-based. AIDSRelief-Tanzania M&E team visits to assess, train, and mentor staff

at each CTC on average once every 2 months. That team is also responsible for the various

PEPFAR, CDC-Tanzania, and AIDSRelief reports as well as DQA.

A. Clinical Technical Strengths

1. Innovative chronic care model - AIDSRelief-Tanzania’s approach to HIV care and

treatment is comprehensive and uses the chronic care model with a focus on retention

through strong community linkages, intensive patient’s preparation for ART care (focus on

disclosure of HIV status, identification of a treatment buddy, multiple ART education visits

before initiation of ART), and in selection of an initial ART regimen that is highly effective

and preserves future treatment options.

2. Patient-level outcomes - Despite multiple challenges that the program is facing, a patient-

level outcome assessment of viral load (VL) limited to 3 highly performing sites

demonstrated a level of HIV VL suppression rate of 96%.

3. Clinical support to the sites - AIDSRelief-Tanzania has established 3 multidisciplinary

clinical teams that include a MD, a RN, as well as PMTCT, CQI, community-based

treatment, and laboratory specialists. Each of the clinical team focuses its support to the

HIV clinics and laboratories of hospitals and larges health centers which are visited from

once a quarter to once a year. The visit frequency is based on site requests, outcome of

previous supportive supervision visits, and SI data.

4. Knowledge Management and Quality department - This department analyses reports

and SI data and share this information with the clinical teams which in turn share that

information with the respective health facilities.

5. Task shifting and the use of community health volunteers - AIDSRelief has promoted

task shifting through the use of nurses, mid-level providers and community health

volunteers in different roles to alleviate staff shortages in the delivery of HIV care. Refill

nurses and CHVs have provided support on adherence to ART and retention into care.

B. Clinical/Technical Areas for Improvement and Recommendations

1. Area for Improvement - Technical support to lower level facilities: AIDSRelief-Tanzania

clinical/technical teams have provided limited direct technical support to small health

centers and dispensaries. The expectation is that training and mentoring to the hospitals

will trickle down to health centers and to dispensaries (ToT). Recommendation: Verify

that knowledge transferred to hospital staff is then accurately transferred to the health


center and dispensary staff and review the technical capacity needs of lower level health

facilities and how they could be better met.

2. Area for Improvement - TB screening: AIDSRelief-Tanzania reported that nearly all

patients are screened each quarter for TB but this was not validated during the clinical team

assessment of a sample of sites in Manyara, Mwanza, and Mara regions. Through

epidemiologic inferences, CDC-Tanzania expects that 4% of patients currently in HIV care

or treatment have active TB. Of its target of 4,000 TB cases, AIDSRelief-Tanzania

supported sites had so far only identified 1/3rd of that number. The visit to the sites

demonstrated that when TB symptoms screening occurs it is not rare that positive screening

do not result in sputum AFB request and collection. It was also observed that TB screening

forms did not consistently reflect clinician notes for the same patients. Recommendation:

Explore reasons why positive TB symptoms screenings do not always result in TB work-

up. Using a CQI approach, address the leading barriers.

3. Area for Improvement - Retention in care and on ART: Retention in ART care and in

HIV care has been so far a challenge especially in larger volume sites. However retention

efforts have often focused mostly on ART patients with no targets or specific efforts

developed for pre-ART patients. The AIDSRelief-Tanzania team expects that the recent

involvement of community liaison to trace defaulters will mitigate this problem.

Recommendation: Ensure that retention efforts are not limited to ART patients but also

address the needs of pre-ART patients.

4. Area for Improvement - HIV testing: There has been low uptake of PITC (≈10%) at

almost all health facilities. This has been in part because not all providers have been trained

but also limited access to HIV test kits, different interpretations of how the offer of testing

should be provided. There have also been not major attempts to track the numbers of

patients offered the test in busy outpatient settings. Recommendation: Even though AR-T

does not directly support PITC programmatically, it should help facilities address PITC.

Using a CQI approach supported facilities should, assess and address the causes of low

PITC uptake. Lessons could be drawn from PMTCT programs and inpatient wards that

have had successes in implementing PITC.

5. Area for Improvement - Pediatric enrolment: Pediatric enrolment has been relatively low.

On average 8% of the 35,000 patients currently on ART are children. There is variability in

pediatric enrolment across sites from as low as 2% to 10%. The target set by CDC is 15%.

Low pediatric enrolment may in part been related to providers’ lack of confidence and

competency in pediatric HIV but also due to poor linkages between MICH, ANC, and CTC

pediatric services. Recommendation: Using a CQI approach, assess and address the causes

of low pediatric HIV care and treatment enrolment. Even though the target set by CDC

may be too high, sites with higher proportions should share lessons with poor performing

sites as regards this indicator.

6. Area for Improvement - Laboratory: The quality of laboratory support has been affected

by poor access to CD4 reagents, HIV testing kits, and EID testing. Despite dual support of

labs by MOH (primary) and AIDSRelief (back-up), many laboratories have limited access

to needed CD4 reagents, HIV testing kits, and EID testing. Recommendation: Ensure that


CDC-Tanzania is made aware of reagents, drug or other supply stock-outs that directly

affect quality of HIV services.

7. Area for Improvement - Utility of data: Few people outside IHV staff know how to fully

utilize the IQTool. Aside AIDSRelief-lead CQI activities, CTCs are rarely analyzing their

own HIV data for management or CQI purposes. Recommendation: Expend CTC staff

training and mentoring on CQI approaches and utilization of the IQTool.

8. Area for Improvement - Data safety: Back-ups of the electronic patient-level database

collected by Futures staff are kept on laptops that are carried by staff to their homes. Even

though the present process decreases the risk of irreversible loss of the data, it increases the

risk that patient-level data could be accessible to people with no right to access it.

Recommendation: Ensure that patient-level electronic data files are backed-up regularly

and appropriately stored in a safe location.

III. FINANCIAL MANAGEMENT REVIEW

Financial Management and Oversight

The Finance Department at the Head Office in Dar Es Salaam includes three CPAs and is led by

the Finance Director who is also a CPA. The organization’s twenty finance staff positions

includes; ten in the Head Office, three in Arusha and seven in Mwanza. The turnover of

leadership at the Head Office has been challenging as stated in the most recent audit report and

evidenced by the less than one year time frame that the majority of the finance staff at the Head

Office has been with the organization. The organizational structure for the Finance Department

includes the Finance Director who reports to the Management Quality Coordinator who, in turns,

reports to the Country Director. Reporting to the Finance Director is the Deputy Finance

Manager/Project Accountant, who supervises four project accountants. A second Deputy of

Operations Accountant, will be starting soon and will be responsible for the four positions

supporting the day-to-day accounting operations. The finance organizational structure in the field

offices allows for financial oversight of LPTFs in the regions. Site assessments and trainings are

also conducted at LPTFs.

Financial policies and procedures

The financial policy guidance for AIDSRelief is provided by the “Tanzania Program, Procurement

Policies and Procedures Manual” dated November 2010. Finance guidance documents established

by CRS-Headquarters and used by the office include a pre-award assessment of partners, a training

for partners, a post-compliance questionnaire assessment, as well as a compliance guide. The

workbook developed by Headquarters is also geared to consortium members. Other documented

policies and procedures that were reviewed include: purchasing/procurement, travel and per-diem,

vehicle management, and fixed assets management.

Budget Management

CRS-Headquarters has developed a comprehensive budget development process and budget

management tools. The “budget workbook approach” is used for training partners as well as for

conducting compliance reviews. The comprehensive budget development process includes a

review of the program with the consortium members and partners evidenced by the most recent

review process in August 2010 that was attended by over 80 members for a three day period. This


forum provides the information necessary for budget development. LPTF budgets are submitted to

the Country Office, and based on the statement of work, the budgets are compiled by the Country

Team and sent to CDC and then to CRS-Headquarters.

Catholic Relief Services Consortium (AIDSRelief-Tanzania)

Period of Performance: March 1, 2010 – February 28, 2011

Year Seven Budget

Cost Category HRSA Central COP Year 7 Funding

Salaries 195,930 1,733,680 1,929,610

Fringe Benefits 118,526 534,423 652,949

Consultants 12,222 25,000 37,222

Equipment over

$5000

400,500 400,500

Supplies 130,841 1,297,812 1,428,653

ARVS

Equip. under

$5000

308,212

Other Supplies 989,600

Travel 37,571 483,655 521,226

Other Direct Cost 81,685 2,562,031 2,643,716

Contractual 9,741,255 9,741,255

Futures Group 1,911,120

Univ. of MD –

IHV

4,892,426

IMA 2,937,709

Total Direct Costs 977,275 16,377,856 17,355,131

Indirect Costs 86,517 920,490 1,007,007

TOTAL BUDGET 1,063,792 17,298,346 18,362,138

Chart of Accounts and Data Security

The tracking of expenses consists of the use of the SunSystem accounting package and Microsoft

Excel worksheets. The SunSystem has a data entry and report writing module. The financial

information is captured in SunSystem and transmitted to Headquarters monthly where it is

transferred to JD Edwards accounting software for reporting to the Donors. The chart of accounts

allows for the allocation of expenses by line item and grant source. The accounting system is

passcode protected and the passcodes are automatically rotated every three months. Each

employee has one month of training on the software application in a “demo environment” prior to

accessing the “live” software environment. After the training the employee is provided a

passcode. Routine backups are completed and monthly tape backups are performed.

Internal Control/Internal and External Audits

The most recent CRS/AIDSRelief internal audit was conducted for the budget period July 1, 2007

– February 28, 2009 and reported June 10, 2009. Prior to this audit an internal audit for the period

October 1, 2005 – April 30, 2007 was reported June 25, 2007. The most recent audit revealed that

the findings for prior audits have been closed. Most recent audit concluded that “internal controls


in general were adequate”; the fourteen findings included three classified as material weaknesses

and two as significant deficiencies. Audit findings ranged from financial transactions and

purchases not processed in accordance with CRS financial procedures, to weak internal controls,

and poor record keeping. Audits included review of LPTF sites, the Head Office, and regional

offices in Arusha, and Mwanza. At the time of the site assessment the finance team reported that

findings noted in the 2009 audit had been resolved. The next scheduled audit is 2011.

Bank reconciliations are performed monthly and payroll taxes are submitted by the 7th of each

month for the prior month. A quality report is printed monthly and is used in detecting posting

errors. The Country Office lacks an internal auditor or department to provide ongoing internal

audit support and independent reporting to the leadership.

CRS/AIDSRelief-Tanzania by Funding Source

Internal Audit Report June 10, 2009

Resource - USG

Agency

July 1, 2007-

Sept. 30, 2007

October 1, 2007

–Sept. 2008

October 1, 2008

– Feb. 28, 2009

Total Amount

($)

HRSA 2,957,737 11,268,016 5,669,372 19,895,126

USAID (GPO 61,257 971,891 460,342 1,493,491

USAID 621-A 110,470 28,484 28,367 167,322

USAID 623-A 45,674 91,466 (1) 137,139

USAID Sub-

Award Deloitte

66,511 321,593 54,592 442,696

Total USG Funds 3,241,650 12,681,450 6,212,672 22,135,773

Gen. Op. Funds 1,232 324,691 5,361 331,284

CRS Private

Funds

175,312 867,327 193,208 1,235,848

Other Private

Funds

56,870 231,708 16,369 304,947

Gates Foundation 321,616 392,272 713,888

Other Int. Org 165,070 461,125 138,596 764,791

Other Non US

Gov

Total Non US

Funds

399,683 2,229,188 825,671 3,454,542

Total 3,641,333 14,910,639 7,038,343 25,590,315

A. Financial Management Strengths

CRS performs comprehensive internal audits and there is a systematic approach to

resolving audit findings.

There is an experienced and capable finance team.

Comprehensive internal finance policies and procedures guide processes.


Systems are in place to provide LPTF’s with comprehensive financial management training

tools and workshops.

There is a well-developed finance organizational structure in place to support the LPTF’s

in the regions.

B. Financial Management Areas for Improvement

1. Area for Improvement - Internal Control/Audits: The internal audits that are provided by

CRS-Headquarters/Regional Office provide a comprehensive review of the financial

operations and include associated findings. However, the in-country organization does not

have an internal auditor or audit department. Recommendation: Consider establishing an

internal audit department or hiring an internal auditor who would be responsible for

ongoing internal reviews and would report directly to the Country Representative.

2. Area for Improvement – Site monitoring and evaluation: Site monitoring assessments are

conducted at the LPTFs, but there is a lack of formal written feedback that is provided to

the LPTFs. Recommendation: Ensure that formal written assessment reports are routinely

provided to the LPTFs.

3. Area for Improvement - Finance and management: The finance office turnover has

resulted in the hiring of new staff within the last twelve months. While this has provided an

opportunity for the organization to develop a new technically experienced team, the

retention of staff is important in order to provide continuity in financial operations.

Recommendation: Review and analyze retention rates for the organization, especially in

the finance department.


Christian Social Services Commission (CSSC)

1-2 December 2010

INTRODUCTION

AIDSRelief-Tanzania identified Christian Social Services Commission (CSSC) as one of the lead

agencies to serve as a local partner for the transition of its care and treatment program funded

through PEPFAR. CSSC applied directly in mid 2010 to a CDC-Tanzania (CDC) funding

opportunity announcement (FOA) and won a HIV Care and Treatment award that will allow it to

take on some of the responsibilities and activities for the AIDSRelief-Tanzania program. It has

been agreed by CDC, CSSC, and AIDSRelief that initially eight of the ART sites presently

supported by AIDSRelief in the Mara and Mwanza regions will be transitioned to CSSC by March

2011. AIDSRelief-Tanzania performed an assessment of the CSSC organization in April–May

2010; the findings of the CORAT report were shared with the HRSA assessment team before the

ClASS review and with CDC during the review. CDC agreed to do its required pre-award

assessment of CSSC in collaboration with HRSA using the ClASS framework.

The regions of Manyara, Mara, and Mwanza were visited during the ClASS assessment. Of the six

sites visited, three will transfer to CSSC under the new grant from CDC as of March 2011. These

three sites include two that are church-owned and government-supported as Council Designated

Hospitals (CDH) (Sengerema and Shirati) and a government-owned and supported health center

(Nyakaliro). References to administrative, clinical, and financial strengths as well as areas for

ongoing support of these three clinical sites will be made in this section as directly relevant to

CSSC’s capacity to take on responsibilities previously exercised by AIDSRelief.

BACKGROUND

CSSC was established in 1992 to coordinate social, health, and education services for the

Tanzanian Catholic and Protestant churches. It is an umbrella organization established and owned

jointly by the Christian Council of Tanzania (CCT) and the Tanzania Episcopal Conference (TEC).

CSSC promotes community access to health care services through its advocacy, capacity building

and other technical assistance support of over 900 health care facilities, including 90 hospitals, 88

health centers, and 731 dispensaries. Education is supported through a network of CCT- and TEC-

owned institutions (220 education facilities, 154 vocational institutions, and 402 teaching

institutions). CSSC does not directly run the individual facilities, nor directly supervise their

services in an official capacity, except where it is a prime for grants such as the Global Fund

against AIDS, TB, and Malaria (GF). CSSC’s representative role for these health care facilities has

given the organization a significant influence in the delivery of health care and educational

services nationally.

CSSC runs a semidecentralized structure with technical and administrative support provided

through five zones: the Northern Zone (Arusha, Kilimanjaro and Manyara regions), the Eastern

Zone (Dar es Salaam, Dodoma, Morogoro, Pwani, Zanzibar, and Tanga regions), the Southern

Zone (Iringa, Lindi, Mbeya, Mtwara, Ruvuma, and Rukwa regions), the Western Zone (Kigoma,


Tabora, and Singida regions), and the Lake Zone (Kagera, Mara, Mwanza, and Shinyanga

regions). Staffing at the zonal offices is limited to one full-time and a few part-time employees;

these teams rely on the Commission Headquarters/Secretariat for additional support.


The Secretariat Office of CSSC is located in Dar es Salaam and executes all activities of the

Commission. It further coordinates the efficient running of the activities of the departments and

units of the organization.

Governance

The CSSC Board of Trustees meets at the Annual General Meeting (AGM), usually in May each

year. The Board of Trustees is 100 percent Tanzanian and membership is composed of twelve

persons, six each representing the TEC and CCT. Representatives from the Ministries of

Education, Health, and Finance and other stakeholder organizations attend the AGM. The Board of

Trustees elects an Executive Council to manage the business of the organization. The Council

meets twice per year in May and November, the day before the trustee meetings. Three of the

committees of the Board of Trustees are the Technical Advisory Committee for Health, Policy and

General Management, and Finance and Programs. Detailed documentation of the AGM and the

committee meetings was reviewed. The committee and Council minutes are reviewed by the Chief

Executive Officer (CEO), but not by any of the committee or Council members before their

presentation at the next official meeting. It was suggested as a best practice for the Committee and

Council Chairs to review minutes as part of internal quality improvement processes.

The Technical Advisory Committee (TAC) for Health is made up of medical staff from different

government agencies, FBOs, and other health organizations. It was unclear from an interview with

a trustee member whether any of the TAC members have current experience delivering ART

services. Because the majority of the Board of Trustees are clergy, some members of the TAC for

Health should be experts with state-of-the-art information on HIV care and treatment. As CSSC

takes on more site management and may need to make organization policy decisions on the HIV

care standards to implement, this may be an area for further review.

The Finance Committee is composed of representatives of the member institutions, but not all are

specifically selected based on their level of financial experience. Financial information on specific

programs is not shared with the committee or the trustees unless there are problems. The

organization recently developed a five-year strategic plan that was approved by the Board of

Trustees on May 19, 2010.


The CEO is the person responsible for the day-to-day operations of the organization and is also a

member of many national organizations’ Boards of Directors and government committees. The

Deputy CEO position that the current CEO formerly held has not been filled due to cuts in

funding. Currently the Assistant Director of Programmes and the Assistant Director of Finance and

Administration jointly serve as the Deputy CEO.


CSSC has a few operations policies incorporated in its human resources and financial management

policies. There were no policies on maintenance of facilities, equipment, safety guidelines or

reporting, and security. There is no designated position responsible for the operations of the

organization. Some of the basic responsibilities for operations appear to be handled by the

Administrative Officer and the Assistant Director of Finance and Administration. Discussions with

staff have indicated that, in the absence of either a Manager of Operations or a full-time Deputy

CEO, there are often delays in decision making or timely actions if the CEO is away. CSSC should

determine how to address the operations management needs without overburdening the existing

staff members who are already filling multiple roles.

The CEO relies on the Department Managers to carry out the day-to-day activities of the

organization. These individuals meet as the Management Team biweekly. As a result of the

CORAT Africa assessment, CSSC added an additional level of meetings; the Heads of Units and

the Department Managers make up the Extended Management Team, which meets monthly. All-

staff meetings take place twice per year.

CSSC is in the process of reviewing the existing organogram and organization structure to better

reflect the management structure and lines of authority.

ART Program Management There were two CSSC departments/units working with the Local Partner Treatment Facilities

(LPTFs) at the time of the assessment, and one additional department that may be involved in the

future. The Transition Liaison Officer for the ART program is part of the Programmes Department

and has been designated as the Project Manager for the ART program. The current Senior Project

Officer of the ART program is under the Assistant Director of Planning, Monitoring, and

Evaluation, who has oversight for the zonal offices and Zonal Secretaries. The Senior Project

Officer has been working with AIDSRelief-Tanzania for the last ten months and has been working

out of the Mwanza AIDSRelief office. None of the Project Officer reporting documents submitted

to AIDSRelief had been shared with or requested by CSSC headquarters. Copies of the reports

were shared with the Transition Liaison Officer during the ClASS visit to the region. This raises a

concern about how much capacity building has taken place within CSSC beyond the one Senior

Project Officer position for site management.

There is a separate department of Information and Communication Technology, but it is unclear

whether the strategic information component of the ART program would be housed in this area. It

was also unclear at the time of the review what CSSC’s plan is for placing within its structure the

additional ART program staff who will soon be hired to oversee some of the ART program

functions, such as supply chain and laboratory. CSSC needs to determine where the ART program

will fit into the existing organization structure and whether it should cross multiple departments or

units. If it does cross multiple departments/units, how will coordination be expected to take place

and which project staff person will be responsible for ensuring such processes?

Human Resources

CSSC has a total of 55 staff persons. The Administrative Officer/Assistant carries out many of the

human resources functions, such as posting vacancy announcements, coordinating receipt of

applications, and handling staff issues and complaints. HR decisions have been made in the past by

either the CEO or the Deputy CEO. The new Assistant Director for Finance and Administration is


now responsible for many of the HR functions. All personnel information is maintained manually.

As the staff grows, CSSC should consider the CORAT recommendation to implement a human

resources management information system. CSSC should investigate whether the current financial

management system comes with an HR module.

The HR policies and procedures are currently under review and revision. Suggestions of policies to

consider adding were shared with the Assistant Director. The new Assistant Director has

developed a new performance management form and process to be implemented.

All employees work under contract with CSSC. Contract timeframes vary from one to two years

based on funding. Contracts viewed contained all expected sections in everyday language. Job

descriptions were reviewed for six positions. The Work Setting section of the job description

identifies the supervisory lines of authority, including those internal and external to the

organization. Due to the current CSSC organization structure, most staff positions were found to

be accountable to a minimum of four supervisors. This Work Setting section does not indicate

which positions have direct or primary supervisory authority and which may be allowed to assign

or review work. It is not clear who is expected to conduct the annual performance assessment, or

who should be contacted by the supervisor for contributions to the assessment. This section of the

job description should be reviewed and revised to reflect realistic lines of authority. For example,

the Senior Project Officer for the ART program has an immediate supervisor listed on the job

description of Regional Site Management Coordinator; as of the time of the review, there was no

such position on the CSSC staff listing.

Human resources support is the administrative area of greatest need identified for two of the three

sites visited that are transferring to CSSC (Sengerema and Nyakaliro). The HR functions for some

of these sites are handled by the District Health Office (DHO). The acting Sengerema District

Medical Officer (DMO) was very open to any assistance that can be provided. The Assistant

Director of Administration and Finance should begin working with the Project Director and Senior

Project Officer to determine how support can be provided in reviewing and updating job

descriptions and in identifying strategies to encourage completion of performance evaluations.

Zonal Offices

The zonal offices employ one full-time Zonal Secretary responsible for coordinating technical

support. There are four Zonal Coordinators, two for education and two for health. Some of these

individuals are staff of the diocese or part-time staff of CSSC. Zonal offices have their own

workplans and budgets. Zonal Secretaries provide monthly reports to the headquarters and face-to-

face meetings are held with headquarters twice per year. In the Mwanza office, the Zonal Secretary

is an MD with an interest in HIV. The Mwanza office expects to add an accountant position

funded from the new CDC grant.

The CORAT report raised a question about the location of the Zonal Secretaries in the CSSC

organogram under the Assistant Director of Planning, Monitoring, and Evaluation, suggesting that

they might be better positioned under the Programmes Department. This reviewer agrees with that

recommendation.



The governance body is very supportive of the Secretariat and relies on input from

technical advisors from the community to give guidance.

The zonal offices of CSSC offer an opportunity to decentralize the management of

programs.

CSSC leadership staff is open to technical assistance and has made many changes based on

the CORAT report.

The Manager of Finance and Administration is developing supplemental human resources

policies as well as policies for operations and administration.

B. Administrative Areas for Improvement and Recommendations

Top Transition Priority Areas—Before 1 March 2011

1. Area for Improvement—Administrative/Operating Systems: There is a lack of

documentation of processes and policies for how the organization operates. Many

processes are passed on verbally with no supporting official direction. There is no staff

directly responsible for the direction of operations. Recommendations: CSSC needs to

develop operations or administrative policies and procedures. The new Finance and

Administration Manager has begun to develop some new personnel policies, but more are

needed addressing the administrative functions. CSSC needs another management layer to

ensure efficient and timely compliance with the level of new project oversight

expectations. Processes appear to be driven by individuals rather than by documented

guidance.

Secondary Transition Priority Areas—Within the Next Six Months

2. Area for Improvement—Site Management Guidelines: AIDSRelief and IMA World

Health have no written policies and procedures to pass on to CSSC on how site

management is provided. Recommendation: CSSC should assess all site management

processes and tools and determine what changes will improve the site management process.

3. Area for Improvement—Site Management Checklist: The AR-T site management

checklist does not cover some key areas of oversight. Recommendation: Review the

checklist and consider adding the following sections:

Administration/Site Management Site communication, roles and responsibilities,

etc.

Financial Management Review Processes to minimize loss to follow-up

Staffing/Volunteers

4. Area for Improvement—Site Capacity Building: Two of the sites need support to review

and update job descriptions and encourage completion of performance evaluations.

Recommendation: As CSSC assumes responsibility for the eight sites, plans for capacity


building in HR should be considered; use expertise from sites doing well with HR to help

with support.

5. Area for Improvement—Reporting: The current reporting documents (trip reports and

quarterly reports) from the Project Officer site visits do not include details on what was

seen at each visit, but only the issues identified. Recommendation: CSSC should review

the reporting documents and determine whether additional information is needed to provide

a clear picture of site issues and the actions needed to address any issues identified.

Best Practice Areas

6. Area for Improvement—Human Resources Staffing: CSSC currently has 55 employees.

It is a best practice that organizations begin to consider having an experienced, dedicated

HR staff person when this number reaches 50 or above. There are several HR functions that

have not been addressed until recently.

a. Job descriptions have not been reviewed against current duties performed by staff.

Success factors should be combined with expected results. Current results do not

appear to be actual and should be revised. For example, the Project Officer is stated to

report to a position that does not exist in the organization chart. The Work Setting

section of the description identifies the supervisory relationships, but provides too

many positions. This section does not address how the external supervisors will

communicate with the internal and how input on the performance review is expected to

take place. Such a section should also be added to the revised human resources policies.

b. Performance reviews did not appear to have been completed for any of the five

personnel files reviewed.

Recommendation: CSSC should consider whether a human resources consultant would be

appropriate to support the Assistant Director, particularly with the job description review.

This may be a more cost-effective option for supporting the Assistant Director.

7. Area for Improvement—Governance: The Board of Trustees is supported by the Health

Technical Advisory Committee. These individuals represent the MOH and are mostly

clinicians. It is not clear whether any members currently deliver direct HIV care to patients.

Recommendation: The CSSC Board of Trustees with the Director should determine

whether there is a need for someone with such experience to be added to this committee.

II. CLINICAL REVIEW

Capacity within the FBO/CSSC Member Organizations

Significant capacity exists within the hospitals affiliated with CSSC, and several of them have

major roles within the Ministry of Health and Social Welfare (MOHSW) public health structure.

Two of the hospitals are among the four national consultant referral facilities; Kilimanjaro

Christian Medical Centre (KCMC), which serves the Northern Zone, and Bugando Medical Centre

(BMC), which serves the Western Zone. Both are also teaching hospitals for two affiliated medical

schools. Thirty-three of the hospitals belonging to the CSSC network have Council Designated


Hospital (CDH) status1 and receive some support from the government in terms of running costs

and staff.

CSSC’s constituent member organizations contribute significantly to both pre-service and in-

service training of health care workers at the health facilities and at 38 health training institutions.

The schools and health facilities provide training for nurses, clinical officers, laboratory

technicians, assistant medical officers, and physicians.

HIV/AIDS Capacity

CSSC has participated in rounds 3, 4, and 8 of the Global Fund as a lead subrecipient. CSSC has

provided oversight for the implementation of scale-up of voluntary counseling and testing (VCT),

provider-initiated testing and counseling (PITC), HIV care and treatment and support services, and

overall coordination. CSSC has used these grants to strengthen member institutions. However,

according to the CORAT assessment report, there were challenges in implementation and

monitoring of the various FBO Global Fund partner institutions. The report made several

recommendations to CSSC to strengthen strategic information (SI) and monitoring & evaluation

(M&E). As CSSC works with the initial eight transitioning sites, the lessons, best practices, and

other innovations it will learn will help the organization to assume successful oversight for more

sites in 2012.

Apart from some specific projects, such as the USAID-funded malaria work, the small technical

team at CSSC Headquarters provides no direct technical support or oversight to any of the sites in

the FBO network. The CSSC technical team has not been actively involved in the technical aspect

of the site ART programs supported through PEPFAR by Family Health International (FHI),

International Center for AIDS Care and Treatment Programs, Columbia University (ICAP),

Elizabeth Glaser Pediatric AIDS Foundation (EGPAF), and the Harvard School of Public Health

(HSPH). The HRSA ClASS visits to the clinical sites and the CORAT report found that there were

serious challenges in pharmaceutical/supplies/reagents distribution to health facilities, in

laboratory capacities, and possibly in overall quality of services. There were no major differences

between faith-based and government-owned sites in regard to the many challenges they face. From

the site visits, it is clear that many of the transitioning CTCs will require significant ongoing

clinical/technical support from CSSC.

Transition Planning and Readiness

In the process of identifying a local partner, AIDSRelief-Tanzania commissioned an assessment2

to determine the capacity of CSSC. The assessment identified areas where CSSC required

strengthening in order to support effective and efficient delivery of ART services; some of the

areas fall under strategic information and pharmaceutical service delivery. The CORAT report

concluded that the transition period was too brief to build CSSC’s capacity to fully manage all

transition components. The ClASS assessment identified additional areas for improvement as well

as several strengths discussed below.

1 CDH=Hospital that operates (mandated) on behalf of the GOT, in an area that has no other equivalent government or

public facility in the area. 2 CSSC CORAT Organizational Assessment Report, 2010.


A. Clinical Strengths

CSSC is an indigenous not-for-profit non-governmental organization representing the two

largest Christian health service networks (CCT and TEC) in Tanzania.

CSSC operates through a network of facilities covering the entire country, including

hospitals, health centers, dispensaries, and health training institutions.

CSSC has a nationwide network of facilities, including some of the eight for which HIV

care and treatment support will soon transfer from AIDSRelief-Tanzania.

Facilities owned by CSSC’s parent church organizations include two leading universities

and HIV Centers of Excellence (KCMC and BMC), which are also research and referral

centers. These two facilities have the potential to provide technical guidance on HIV care

to CSSC and their network providers; they already serve as specialist and teaching

hospitals and as such can mentor. It is, however, not clear whether they have sufficient

capacity to provide additional supervision and mentoring to the transitioning facilities that

lie in their respective catchment areas.

CSSC has had long-standing relationships with the GOT and the MOHSW at national,

regional, and district levels. These linkages will be helpful to support transitioning

government sites that are currently supported by AIDSRelief.

B. Clinical Areas for Improvement and Recommendations

Top Transition Priority Areas—Before 1 March 2011

1. Area for Improvement—Clinical Capacity for HIV Care and Treatment Program

Oversight and Support: The small clinical/technical team at HQs does not provide direct

HIV technical support or oversight to any of its affiliated sites, including some of the eight

that will soon transfer to CSSC. Most important, CSSC does not presently have the

capacity to take on this responsibility. Recommendation 1a: In order to provide clinical

oversight for a complex HIV care and treatment program, CSSC needs to develop technical

capacity in the following areas:

Supply chain (drugs and reagents) Clinical site management

Continuous quality improvement (CQI) Laboratory support

Monitoring and evaluation and strategic information Supportive supervision

Clinical training and mentoring HIV/TB

Pediatric HIV care & treatment

These areas reflect not only the crosscutting support needs of the sites but also those that

AIDSRelief-Tanzania has put together in its consortium. Since the CDC and CSSC plan is

for CSSC to have full responsibility for clinical/technical support to these eight sites by

March 2011, that capacity can be developed in-house in the period leading to the transition

through direct hire of experts, or be subcontracted in the short term, then gradually

developed over time at CSSC. Recommendation 1b: It would be best for some or all of the


clinical expertise in the nine areas referred to in 1a above to be based at the CSSC Mwanza

Zonal Health Office. This model best fits into the current CSSC program management

strategy of decentralization, as well as that of the GOT, which has emphasized

decentralization of technical services to regional and district levels. A technical team at the

Mwanza zonal level would be able to respond to facility needs in a timely fashion and

would replicate the AIDSRelief-Tanzania technical assistance team currently in place. This

arrangement would also suit a scenario where AIDSRelief-Tanzania regional team

members could eventually transition into identical CSSC structures in the different regions.

CSSC teams could also work with colleagues in AIDSRelief-Tanzania to improve skills.

When CSSC will have full discretion as to which organizations it will subcontract services

it has not been able to internalize by March 2011, transition disruption will likely be

minimized if, in the short term, it subcontracted back to some of the AIDSRelief

consortium members.

2. Area for Improvement—Capacity Building Plan: It is not clear how much internal clinical

capacity has been built or transferred through the CSSC seconded staff members working

with AIDSRelief-Tanzania. One of CSSC’s strategies for capacity building has been the

secondment of a few of its technical team members to relevant areas of the AIDSRelief-

Tanzania program. Recommendation: CSSC should review the benefits of this strategy for

capacity building. If this strategy is going to be used in future, there is a need for a detailed

plan with milestones, regular check-in at CSSC for the seconded staff, and a timetable for

gradual withdrawal of staff members. CSSC should also obtain a written description from

AIDSRelief-Tanzania on what site management and other technical roles will be acquired

at the end of the secondment.

3. Area for Improvement—New Relationships with Sites and Other Stakeholders: As of the

completion of the ClASS assessment (December 13), CSSC had not been officially

introduced to the transitioning sites or to the MOHSW/NACP at relevant district and

regional levels as a CDC ART local partner organization. Thus, CSSC has not been able to

actively establish new relationships at these levels, nor able to learn facility needs directly

from all eight of the ART sites. Recommendation: CSSC should urgently be introduced at

the relevant levels as a new care and treatment partner. This will enable CSSC to

strengthen existing relationships with all stakeholders and begin to develop relationships at

the facility level. Even though CSSC is well known at the faith-based facilities, for sites

that are not faith-based new relationships will be critical to the success of the transition. For

these sites, a plan for supportive supervision that fits with existing district and regional

structures will be required and discussions with regional teams should start or continue at a

fast pace.

Best Practice Areas

4. Area for Improvement—Clinical Technical Expertise: CSSC has not organized its clinical

technical capacity so as to take advantage of its member institutions’ expertise.

Recommendation: CSSC should identify key individuals with clinical and technical

experience from within its member institutions and organize them to support the CSSC

secretariat and regional offices. These individuals could be organized into a single

technical team that would provide management-level technical oversight and supervision

for the network of member institutions. Such a technical team (rather than individual


experts) would be better suited to advise the MOHSW on long standing problems such as

supply chain management, laboratory equipment, and national guideline changes.

5. Area for Improvement—Lesson Sharing, Best Practices, and Quality Improvement:

There are extensive variations in how different member institutions have dealt with similar

challenges. Best practices in different facilities have not been shared from the CSSC

headquarters level platform that could lead to quality improvements across the network.

Recommendation: CSSC should establish a clinical technical team representing member

organizations as described in (4) above to promote uniform or network-wide standards and

quality improvement. Regional technical meetings should be started to bring together

different organizations to facilitate the sharing of best practices. Such meetings may help

address challenges that are unique to FBOs.


CSSC has a wide range of funding sources, including bilateral and multilateral donor agencies

USAID, DANIDA, Church Development Service (EED), and Cordaid . CSSC has been a

subcontractor to AIDSRelief-Tanzania through IMA. The organization receives Global Funds and

was recently awarded an ART program management grant from the CDC-Tanzania.


The finance department is led by the Assistant Director of Finance and Administration, who has

been with the organization approximately three months. The Assistant Director reports to the

Director/CEO. He is a certified public accountant with over 12 years of accounting experience.

The finance department has eight additional accountants, including five project accountants and

three core accountants. The core accountants include the Senior Accountant, the Chief Accountant,

and the Cashier. The Assistant Director of Finance was hired after the CORAT assessment was

completed in 2010. He has already implemented a number of policies, including development of

procurement committee guidelines, and is working to formalize many of the processes in the

Finance Department. Additional financial oversight is rendered by the Finance Committee of the

Board, which reports to the Executive Council.

The five zonal offices provide the organization an excellent opportunity for expansion and

oversight in regions across the country. However, a lack of infrastructure exists at the zonal

offices, making financial oversight of programs and systems very challenging. The zonal offices

lack an appropriate backup system, such as check signatories, that could prevent delays of

operational support. There are two signatures required at the zonal offices; however, if the primary

signatory is not available, checks can be held up until the appropriate signature is obtained. The

process is very similar to that of the CSSC Head Office which was recently changed by the Board

to add an additional signatory on the bank accounts. There is limited staffing at the zonal offices,

making separation of duties and oversight of programs an ongoing concern.

Financial Policies and Procedures

The finance policies, procedures, and procurement manual is in place. The manual is

comprehensive and has been developed into a handbook for easy access of information. The

procurement/tender committee operations guidelines have been newly developed and


implemented. Compliance with policies and procedures can be assessed by examining appropriate

documentation. In particular, purchasing procedures are specific, addressing processes from

ordering of goods through receipt and payment of goods and services. All financial transactions

are reconciled monthly. Books are kept with supporting documents for all fiscal and personnel

transactions.

Budget Management

The organization has not established a reserve account. Revenues are generally tied to

grants/contracts. This model makes it difficult to manage cash shortfall, discretionary spending

needs, or other operational cost necessary for growth. Due to the pharmacy position vacancy, the

HIV program expenses have been lower than budgeted. For the 8 months (approximately 60% of

the budget period) that had expired, $63,153 of the $127,683 budget had been spent, or less than

50% of the grant dollars. The organization has submitted a revised budget for approval. Budgets

are sufficiently detailed to provide meaningful comparisons with actual YTD budget

reconciliation. The organization maintains over 40 bank accounts, with each account being

reconciled monthly.

Chart of Accounts and Data Security

The accounting package implemented in 2008 is Exact Globe. The system has a detailed chart of

accounts for tracking expenditures. However, for reporting and budget-to-actual comparisons,

information is downloaded into a MS Excel worksheet. The budget information for each

project/grant/contract is not loaded into the Exact system. The systems are password protected;

however, access is not tiered based on job functions. Computer backups are performed weekly,

both to a central system and to an external drive that is stored offsite.

Payroll/Employee Benefits

Employees’ time and effort is tracked using timesheets. Timesheets are completed, signed and

submitted by employees to their supervisors. Supervisors review the timesheets and sign for

approval.

Employees receive advance pay to travel for vacation leave. The amount of the compensation is

based on the cost of the bus fare for travel to the designated location. The funds are paid based on

the employee’s request. Therefore, if employees do not submit requests for payment for vacation

leave, they do not receive compensation. Actual travel is not verified. This practice currently

results in inequitable compensation to staff and should be reviewed.

Internal Control/Internal and External Audits

The organization has established internal audit functions by sourcing to a consultant. Each month

documents are taken offsite for review. The accountant reviews the previous month’s financial

transactions, including a full review of bank reconciliations. Findings resulting from the internal

audit are provided via a written report. The Assistant Director has developed a formal process for

tracking and resolving audit findings. The external audit for the year ending 31 December 2009

was performed by Organization and Efficiency Consultants (see below for the attached 2009

Income and Expenditure chart). In the opinion of the auditors, the financial statements of the

organization provide a true and fair view of the financial positions of the Commission and its

financial performance for the year 2009. The audit report was submitted June 2010. In addition to


the internal and external audits, a review was performed by CORAT Africa in June 2010 that was

commissioned by AIDSRelief-Tanzania.

Income and Expenditure Account (2008 and 2009)

(in Tanzania Shillings)

2009 TZS 2008 TZS

Income 4,016,744,928 5,001,093,286

Expenditure 4,894,577,396 4,397,772,154

Surplus/(Deficit)—excluding other

income (877,832,468) 603,321,132

Other Income 235,067,117 (795,544)

Surplus/(Deficit)—including other

income (642,765,351) 602,525,588

Prior Year Adjustment 17,012,786

Balance Brought Forward 2,146,642,525 1,544,116,937

Balance Brought Forward As

Restated 2,163,655,311

Surplus/(Deficit) Carried Forward 1,520,889,960 2,146,642,525


Monthly internal audits are performed and there is a systematic approach to resolving audit

finding. This process has been implemented within the last few months.

There is an experienced and capable finance team.

The procurement (tender) committee has a detailed policy. Minutes of procurement

committee meetings are in place.

The Finance Committee of the Board is active and reports to the Executive Council.

The chart of accounts is detailed and expenses for each project are tracked.


Transition Priority Areas

1. Area for Improvement—Grants Management: The organization lacks experience as a

prime contractor and lacks the systems and tools that support a comprehensive grants

management program. The current experience as a subgrantee for the Global Fund program

can provide a foundation that the organization can build upon. Recommendation: Continue

to build on the experience created by the execution and management of other subgrantee

awards. Analyze the infrastructure requirements both at headquarters and at the zonal

offices and develop a plan that describes the requirements and the plan of action

2. Area for Improvement—Budgeting: The grantee is not appropriately capturing and

recovering costs related to the management of the various PEPFAR and Global Fund


programs. Recommendation: Establish a direct cost recovery program to ensure that

program-related costs are covered as a direct cost in the various budgets.

3. Area for Improvement—Reserve Funds: The organization does not have reserve funds.

Revenues are predominately grant-related and restricted. Therefore the organization lacks

funds for cash shortfalls or revenues to cover costs necessary for growth and expansion.

Recommendation: Establish revenue-generating programs or secure other unrestricted

funds that can be used for discretionary spending and opportunities for growth and

expansion. Investigate options to secure lines of credit.

4. Area for Improvement—Employee Benefits/Travel: The organization’s practice allows for

employees to be paid to travel for vacation leave. The amount of the compensation is based

on the cost of the bus fare to travel to the designated location. The funds are paid in

advance to the employee based on employee’s request and verification of the cost of the

bus fare. If employees do not request bus fare for vacation leave, they do not receive

compensation. There is no process for verification of travel, which could result in

inequitable compensation to staff. Recommendation: The organization should examine the

policy to ensure that provisions are made for fair and equitable compensation. An example

might be to establish an equitable basis for compensation, such as a percentage of

employee salary or a fixed dollar amount per year. There should be a policy ensuring

equitable compensation and benefits for all employees.

Best Practice Areas

5. Area for Improvement—Accounting Software: The current accounting package appears to

be underutilized. This actually creates additional workload and inefficiencies that appear

very time-consuming. Recommendation: Increase the use of the current accounting

package. CSSC should seek additional training on the application to help staff members

better understand the full capabilities of the system.

6. Area for Improvement—Zonal Office Management and Oversight: A lack of

infrastructure exists at the zonal offices, making financial oversight of programs

challenging. The zonal offices lack an appropriate backup system such as check signatories

in order to prevent delays of operational support. Checks can be held up until the

appropriate signatures are obtained. Recommendation: Financial oversight must ensure

that financial operations at the zonal office can be performed. This oversight should include

site assessments and mentoring at the sites to be transitioned as well as proper oversight of

financial operations at the zonal offices. Additional staffing may be necessary. CSSC

should ensure that there are backup systems in place to alleviate delays in check signing.

This will allow for more efficient operations and service delivery.

7. Area for Improvement—Data Security: The accounting system is password-protected for

the various users of the system; however, there are no tiered levels of access based on job

responsibilities. Any employee with a password would be able to access the application at

all levels. The financial computer system is backed up weekly to a central server located in

the building; in addition, weekly tape backups are stored offsite. Recommendation:

Consider setting up a system of tiered passwords that would allow access depending on job

responsibility. The organization should consider daily backups of the accounting system. A


considerable amount of information would be lost in the event of a system crash. Daily

backups would minimize the risk exposure.

8. Area for Improvement—Accounts Payable: The organization does not book invoices at

the time of receipt; expenses are booked when invoices are paid and checks are cut.

Therefore, invoices could be lost or misplaced between receipt and the time of payment

and go unheeded until a vendor resubmits a bill. Recommendation: Invoices should be

routinely entered into the computer system immediately on receipt to ensure an accurate

accounting of accounts payable based on expenses.

9. Area for Improvement—Consultant/Vendor Agreements: Reconciliations are completed

monthly for each of the over 40 bank accounts. Original documents are taken offsite by the

Consultant Accountant/Internal Auditor. Recommendation: Consider releasing copies of

documents, rather than originals, to the consultant. CSSC should review the consulting

contract to determine if there are requirements related to confidentiality statements and the

organization’s code of ethics.


Local Partner

Treatment Facilities

Local Partner Treatment Facility Reports

Hydom Lutheran Hospital Serengema District Designated Hospital

Mbulu District Hospital Nyakaliro Health Center

Bugando Medical Center Shirati District Designated Hospital


AIDSRELIEF/ HYDOM LUTHERAN HOSPITAL

1 December 2010

BACKGROUND

Hydom Hospital is a large 400 bed hospital located in the rural Mbulu district in the Manyara

region. It also serves as a referral site for the neighboring districts Hanang, Iramba, Singida and

Meatu. It was established over 50 years ago and is one of the 23 hospitals owned and run by the

Evangelical Lutheran Church of Tanzania, a member institution of CSSC. The hospital has been

recognized for its services and recently designated as referral hospital by GoT. HIV services

started at the hospital in 2003 and it became a PEPFAR site in 2004. Services provided include

OVC/palliative care, VCT, PMTCT (supported by Engender Health and the Norwegian Embassy),

AB prevention (supported by the Norwegian Embassy).

The predominant health problems in the region are malaria, gastroenteritis, upper respiratory tract

infections, typhoid, and tuberculosis. Manyara region with a prevalence of 1.5%3 has one of the

lowest HIV prevalence estimates in Tanzania. Tuberculosis remains a big burden in this area

especially among HIV positive patients where 8.5%4 of those attending the hospital HIV clinic

were co-infected. The hospital provides a range of services under its nine departments including

technical, pharmacy, outreach, outpatients, medical, surgical, MCH and has a school of nursing. In

2008 there were over 16,000 hospital admissions and outpatient visits exceeded 60,000. The

hospital has extensive linkages and has used these connections to leverage resources, develop

research infrastructure and improve services.

A nursing and clinical officer training school is attached to hospital. Students rotate through the

CTC developing skills and also provide services in other departments of the hospitals. This is an

opportunity to integrate HIV training in pre-service education.

I. CLINICAL REVIEW

Facility

The CTC is facing space limitations. The waiting area is very small and both triage and morning

patient education takes place in the same location, making it difficult to ensure confidentiality.

Crowding in the waiting area, a poorly ventilated inner room is challenging efforts to minimize TB

transmission at the facility.

3 National Bureau of Statistics (NBS) and ORC Macro. 2008. Tanzania HIV and Malaria Indicator Survey 2007-8.

Dar es Salaam, Tanzania 4 Ngowi et al. BMC Public Health. 2008; 8: 341


HIV/AIDS Program

The Care and Treatment Clinic (CTC) is a division of the department of internal medicine. Even

though the clinic is housed in a separate building away from the outpatient, there is a high degree

of service integration through referrals, staff rotation, meetings, grand rounds and didactic

teachings, i.e. every Thursday morning there is a general hospital teaching. This is a good

opportunity for mentoring staff, medical interns and other team members on HIV care. It also

helps the CTC team to be introduced to patients before discharge minimizing potential loses of

patients between the ward and CTC.

There is good clinical leadership at the CTC in a supportive environment at the hospital as

exemplified in these best practices:

Staff is cross trained, dedicated to providing high quality care, thus building capacity and

creating a sense of shared ownership.

Team meetings are held every morning to discuss patient issues for those scheduled for the

day, those in inpatient wards, deaths and missed appointments.

Weekly multidisciplinary meetings are held at the CTC with clinicians, nurses,

pharmacy/dispensing and lab staff to discuss specific patient issues.

Monthly meetings are held for the entire facility where CTC issues are shared with the

other hospital departments.

Fifteen patients are currently on second line and all were switched after virological

confirmation done through collaboration with a Norwegian University.

HIV Care and Treatment

CTC services are available 5 days a week with 15-30 patients seen daily. One medical doctor, 2

clinical officers, 3 nurses and two data clerks are the regular staff at the clinic, but once staffs from

other departments attend ART training, they rotate through the clinic to acquire practical skills.

Most of the care is provided either by the clinical officers or the assistant medical officers who are

both mid-level providers. The CTC team also supports 3 affiliated health centers and they go to the

respective facilities to see patients and provide mentoring. The team comprises a clinician,

laboratory technician and a pharmacist or dispenser. No formal document was seen to see what

the achievements had been and how long this support would continue.

By the end of September 2010, the clinic had enrolled 1563 cumulative patients in care and just

under 1000 for ART, but only 431 are currently active on ART. As of September 2010 there was a

44% retention rate. Staff reported high rates of stigma, a semi nomadic lifestyle, food insecurity

and poor roads with irregular transportation as contributing to the high loss to follow up observed.

The staff also expressed other challenges such as a low number of doctors, inadequate resources,

and frequent breakdown of equipment i.e. the generator.

PICT has been introduced and staff in different departments trained about all potential entry points

(general OPD, ANC, Chronic care) they have not been maximized. TA for PITC is provided by

Intra health and Engender health. PITC has been successfully implemented in the inpatient wards

and the TB/DOTS clinic where almost all patients are tested and linked to HIV care before they


are discharged or leave the clinic respectively. However, similar success was not observed in the

general OPD and other clinics. A brief inspection of the logs at the OPD showed that only a small

fraction of the over 100-150 patients on average who attend daily were actually offered testing.

The way staff described the process did not clearly differentiate between PITC and VCT. Only one

provider or room was available for testing and on the day of the visit the assigned staff was not

present.

The HIV program faces several challenges that affect the delivery of quality care to patients:

1. Retention has been poor, especially for pre-ART patients. Some of the challenges

expressed by the staff include the unique location of the facility and the specific catchment

area for patients. It was reported that: 1) many patients have to travel long distances to seek

care with poor public transportation and 2) high stigma in the community leads to lack of

disclosure. While these were noted, the clinic did not seem to have a strong system for

tracking and following patients who miss appointments, especially those who miss

appointments. Guidelines on how frequently pre-ART patients should be seen are

controversial.

2. In several of the charts of reviewed patients had missed appointments after one or two

clinic visits but the charts did not have flags or documentation of efforts to reach the patient

early in their missing appointments.

3. Hydom is a referral facility and supports other lower level facilities; however there is

inconsistent and somewhat weak feedback to and from referral sites. There was no clear

understanding as to what support was being provided and for how long this support would

continue to health centers. In its new status as a referral hospital these activities should be

tracked. Poor documentation of referrals may lead to double counting and poor planning at

all sites involved.

4. Mortality was reported to be high apparently as a result of patients presenting late but also

those lost to care eventually returning with advanced disease. There is a general lack of

death ascertainment in the area and it is likely reasonable to assume that the bulk of

patients lost to follow up may have died.

Chart Review

Inspection of a few charts showed good general documentation, but also showed a few

inconsistencies between findings on the TB screening form (filled in at triage) and clinician’s

assessment and subsequent follow up of the patients. In some cases those identified as suspects did

not receive further assessment or sputum smears. If done, it was not documented in their medical

record. A number of patients have been screened with the majority having a negative assessment.

Also there was not a clear mechanism to follow how or when suspects delivered sputum smears.

Continuous Quality Improvement (CQI)

CQI has been introduced at the hospital and a hospital wide committee has been established. The

CTC clinical lead is a member. CQI has not been fully integrated within the CTC. As the first

steps to introducing it at the CTC level, one RN has been formally trained in CQI with the AIDS

Relief team, but has not shared the concepts formally with other staff nor initiated any projects to

date.


A. Clinical Strengths and Areas for Improvement

1. HLH is providing critically needed services in an underserved area.

2. The combination of good quality services and a consistent track record are reflected in the

number of referrals to the hospital even from hospitals outside the official catchment area.

3. There is a high degree of HIV service integration in the hospital with staff rotations; joint

medical rounds involving CTC staff and other ward staff are held whenever HIV infected

patients are admitted.

4. The hospital has extensive linkages and has used these connections to leverage resources,

develop research infrastructure and improve services.

5. There is good clinical leadership at the CTC in a supportive environment at the hospital.

6. There is a strong lab with both internal and external quality assurance and staffs are well

trained and competent.

7. Four expert patients (PLWHIV) work at the clinic to provide an opportunity for patient

input and also participate in the task shifting strategy.

B. Areas for Improvement and Recommendations

1. Area for Improvement-Facility: The CTC program has outgrown its current space. This

is making it difficult to ensure confidentiality increasing the risk TB transmission at the

facility. Recommendation: The clinic needs to identify a safe and convenient location for

triage and other services. An outside waiting area for patients would ease congestion and

allow the doctor to devote adequate amounts of time for each patient. Patients who are

waiting to see a clinician should be asked about cough and those identified should be fast

tracked through the process.

2. Area for Improvement-Documentation and processes: There are inconsistencies between

findings on the TB screening form (filled in at triage), clinician’s assessment and

subsequent follow up of the patients. Recommendation: There is need to review the entire

process of TB screening from how the screening form is administered to when and how

follow up actions are documented. Staff at triage may require re-orientation or training in

how to identify TB symptoms, how to accurately record the findings to eventual diagnosis

of or exclusion of TB. This should be taken up by the CQI committee and identify small

tests of change aiming at improving the process. Discrete activities that require

improvement include; administration of the questionnaire, referral of suspects, clinician

review of the assessment tool and further evaluation, and how sputum smears are

addressed. All components are shown in figure 1 below. The clinic should review and

sketch out the most efficient way to conduct TB screening as an infection control strategy

and to exclude active TB before initiation of other treatments. The CTC should work to

develop a plan to track all processes and clearly document for each patient file.


Figure 1: Potential steps involved in TB screening

3. Area for Improvement-Continuous Quality Improvement. CQI has not been fully

integrated within the CTC. The CQI designated RN for the program has not shared the CQI

information learned from trainings with other staff. No CQI projects have been initiated.

Recommendation: The clinic should embark on some CQI activities that will enable the

data collected to address local problems. A clinic based CQI committee should be

established with guidance from AIDSRelief and should work in collaboration with the

hospital wide committee.

4. Area for Improvement -HIV testing and entry into care: PICT has been introduced and

staff in different departments trained on all potential entry points (general OPD, ANC,

Chronic care), but they have not been maximized. Recommendation: The clinic should

maximize all opportunities for identification of HIV positive patients and apply PITC in a

way that ensures more numbers of individuals that visit the clinic are offered the test as part

of other routine investigations. A system should be put in place to ensure targets are set for

testing in the OPD and that those tested receive appropriate counseling and referral to the

CTC. A refresher training onsite for all OPD staff would help to ensure that all staff can

perform testing and backstop. General information sessions followed by individual offers

of testing by clinicians in the clinicians’ rooms could be a feasible option that would

improve uptake of testing rather than referral to a separate testing site at a distance. A

simple monitoring and evaluation process should be developed focusing on key indicators

available in Tanzania and WHO guidelines5. AR-T could let Intra health and Engender

health as well as CDC know of the status of PITC in some of the facilities where it is

working.

5 http://whqlibdoc.who.int/publications/2007/9789241595568_eng.pdf

Lab

Diagnosis of

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Educate

Take sputum

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Suspect

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Pati

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5. Area for Improvement- Laboratory and other equipment: In general the laboratory is

well equipped and staffed with very competent individuals but its functioning has been

affected by frequent breakdown of equipment and no effective backup systems. At the

time of the visit, the CD4 and generator had not been working for at least a month.

Additional issues in the lab include inadequate supply of reagents, using expired reagents

for both tests and controls, lack of servicing for safety cabinet and no controls for TB

smears. Recommendation: Accurate laboratory function should be reliant on maintaining

a cold chain in the lab, having an uninterrupted supply of reagents and preventive

maintenance of equipment. While solutions to some of these challenges may be beyond the

hospital and AIDSRelief, it is equally important that they be addressed or referred to

appropriate government officials.

6. Area for Improvement- Quality and continuity of care: The HIV program has no strategic

plan to address the key challenges facing staff regarding the quality of care patients receive

including: 1) patient retention and systems to track, conduct follow-up, and document

patient no shows for patients, 2) high stigma leading to lack of disclosure, 3)

Recommendations: Some of the following may offer potential solutions: (1) Strategies that

have been useful in follow up of ART patients should also be applied to pre-ART, i.e.

enrolling patients into support groups may be one of the ways of motivating them to attend

clinics. 2) Clear documentation and updating of charts with current status of the patients

could help accurately determine lost to follow up needed and lead to more effective plans

for reducing LTFU. (3) Improve tracking of referral forms for the charts. This will

contribute to the keeping of accurate records for patients. 4)Make the clinic visit

“enjoyable or worthwhile” by ensuring minimal waiting times, engaging and involving

patients in discussions about other life issues such as income generating activities are some

of the programs that maybe useful.. 4) Timely PITC, community initiatives including

education about HIV and the need for early testing, timely initiation of ART in addition to

good patient retention programs for those in care and on ART should be able to reduce

mortality.

7. Areas for Improvement-Supportive supervision: There are no written SOPs to identify

what support is provided at each level of referral facility (primary hospitals, health centers

and dispensaries). Recommendation: Assess what level of support is currently provided

to each facility and determine if it is meeting the sites’ needs. Establish Provide in-services

for all staff who participate in supportive supervisor as either givers or receivers. Consider

periodic peer reviews by clinicians (Hydom and all referral facilities) as a strategy to

reduce errors and improve overall quality of care.


MBULU DISTRICT HOSPITAL

3 December 2010

BACKGROUND

Mbulu District Hospital is run by the Ministry of Health and Social Welfare (MoHSW) and is

situated in northwest Manyara region. Built in 1954, Mbulu is a rural district south of the famous

Ngorongoro crater. The hospital provides services to a population of about 296,865, many of

whom are semi nomadic tribes of cattle keepers, the Iraqw, who move to ensure feeding for the

livestock. HIV/AIDS services (VCT, PMTCT, CTC, PEP and PITC) started in July 2005 and the

Hospital entered into partnership with AIDSRelief in 2006. AIDSRelief is providing financial

support covering a full-time date entry clerk and extra duty allowances for 7 staff.



Mbulu District Hospital also serves as the District Health Office for the MoHSW, thus most of the

key staff of the hospital fill at least two positions, one in the hospital and one of the district. There

is a management team which meets on a monthly basis while departments are expected to meet

every Friday. Staff acknowledged that due to the volume of work that the meeting intervals often

change. Staff did identify that meetings are opportunities for staff and managers to being issues

for improvement forward.

Human Resources

The hospital has a total of 169 staff with twice as many females than males filling the positions.

The national MoHSW develops a plan for the number of staff needed to provide services in the

district based on the previous year volume and district residency numbers. The District shuffles

staff in an attempt to meet these requirements. New funds often do not come to support any

expected staff increases. The supporting areas around the hospital are very small with no hotels to

allow tourism. There is also not sufficient housing for any staff that may need to move their

families to the area.

Fundraising/Sustainability

The hospital employs several strategies to cover costs. The community is required to provide a fee

from each house to the Community Health Fund that supports health services in the district. In

addition to cost-sharing payments from patients for services received, a District Health Board is

responsible for looking for other funding resources.

It was suggested that the hospital work more closely with any of the CSSC zonal offices that may

be near since they will be expected to begin conducting more local fund raising and increasing

their grant writing capability.


Facility

The hospital is composed of several buildings with the prime facility housing 10-12 rooms

including a waiting area for the clinic and examination rooms. Physicians and Clinical Officers

share an examination room due to space shortages. HIV care is well integrated within the hospital

services. There is a dental office with two chairs. There is now space for an eye clinic. The x-tray

department is able to also do sonograms as needed. A new theatre with 6 operating rooms was

recently added.


1. The management staff of the hospital who are also the staff of the District Office are very

competent, hard working, and exhibit great teamwork.

2. The Hospital Medical Director/District Health Officer is a great advocate for the HIV

program.

3. The hospital administrative systems are good including how staff has been encouraged to

look for quality improvements on a regular basis.

4. There are 91 community health workers supporting the HIV program.


1. Area for Improvement - Staff Recognition: Many staff are doing more than task shifting

and are taking on the responsibilities often of 3-4 positions due to staff and funding

shortages. Recommendation: When staff were asked what they needed to do their jobs

better, the overwhelming response was to be recognized for how hard they work.

Management should consider options to recognize staff such as a certificate ceremony, a

rotation of staff daily start times, treating staff to lunch, posting recognition information

within the clinic, or other creative options.

2. Area for Improvement – Grant/fundraising: The hospital has needs for staff housing and

vehicles to conduct supportive supervision within the district and a lack of funding to

support these areas. Recommendation: The hospital should determine what types of

fundraising activities are allowed by the MoHSW. Staff should work with CSSC to receive

grant writing training and team on grant writing efforts.

II. CLINICAL REVIEW

Overview

The main health problems in the area are malaria, pneumonia, diarrheal diseases, pregnancy

complications, peptic ulcers, acute respiratory illnesses, urinary tract infections, and typhoid. As a

typical rural district hospital, it offers both outpatient and inpatient services under the medical

(adult and pediatric), gynecology and surgery. Other support services such as lab and radiology

exist. The hospital is well staffed, but mostly with lower to mid level providers. On average about

28,000 patients are admitted and over 200,000 outpatients are served a year. The hospital has 150

bed capacity.


HIV clinic (CTC) has 365 cumulative patients enrolled in HIV care (ART and non ART) and 253

patients Cumulative on ART with 122 currently on ART, a retention rate of 48% (Sept 2010).

Voluntary Counseling and Testing (VCT), PMTCT and care and treatment started in 2005 when

the site became an AIDSRelief supported facility. The prevalence for HIV in this region is low

(less than 1% for the last year).

Facility

There is limited space to accommodate all patients without compromising infection control and

confidentiality. For example, triage and exit nurses share the same space. The TB waiting area and

the general clinic waiting areas are not separated. Staff also expressed the challenge of making the

facility child friendly and the general need to expand the waiting area. Current space is not

sufficient for support group meetings and for other patients such as pre-ART patients who do not

necessarily need to see health care workers, but would benefit from interactions at the facility.

Facility Staffing

The existing staff and skill mix for the hospital is not adequate for a district hospital. While the

entire hospital appears to be overstaffed in total with 169 full-time staff in excess of the 158

required. It was noted that workers with the right skills sets are few. For example there are only

two laboratory assistants running the hospital lab instead of laboratory technicians. Many

positions are staffed by mid to lower level health care workers such as medical attendants. This has

led to some staff being overworked because they are few. The staff and district/hospital leadership

acknowledges this. This imbalance in staff numbers and skills may not be enough to provide good

quality HIV care at the clinic. It is even more of a challenge for the hospital to provide appropriate

supportive supervision and oversight to the 4 satellite sites in the area.

HIV/AIDS Program

The CTC (HIV clinic) is located at the extreme end of the hospital premises offering

confidentiality. Even though separated from the general OPD, the hospital director, who is also the

district medical officer, is updated daily through meetings. Some of the CTC clinicians rotate in

the hospital and vice versa. At the time of the visit, the CTC clinical lead had just left for further

studies. Currently three clinical officers, 7 nurses, 2 nurse attendants and one data clerk are the

program staff. Hospital MDs can be consulted for difficult cases, but not all have been trained in

HIV/AIDS. The clinic operates three days a week (Tuesday, Thursday and Friday). One of the

days is dedicated to pediatric or family based care. The CTC team also supports 4 affiliated health

centers (Bashay, 40 km away, Nyoda 20 km away and two others on rotating Mondays or

Wednesdays monthly.

There is good leadership, collaboration and integration of the CTC with the rest of the hospital.

Examples of this integration are reflected in the way the TB patients are managed. Both clinics are

co-located and this facilitates referrals and improves TB/HIV management. In the inpatient wards

there is joint care with CTC and hospital ward staff improving linkage to care. Clinicians at the

CTC have opportunities to work in the hospital and vice versa and this encourages skills transfer

and sustainability.

Once identified as positive, patients from the PMTCT program are then referred to the CTC. By

the end of September 2010, the clinic had enrolled 365 cumulative patients in care, including 253


for ART. Only 122 were currently active (retention rate of 44%) on ART and of those active on

ART 14 (5.7%) were children (<14), much lower than the AIDSRelief or the Tanzania national

target. Staff identified stigma, a semi nomadic lifestyle practiced by the majority of the clients,

food insecurity, poor roads with irregular transportation, limited waiting area space, inadequate

funding for community activities and lack of adequately trained and skilled staff in the right

numbers are the main challenges affecting the clinic.

Continuous Quality Improvement

A hospital wide CQI team was formed one month prior to the assessment. One staff member was

also trained in quality improvement. The CQI committee consists of the CTC

coordinator/clinician. Overall CQI has not been extended to individual departments where

improvement projects would be initiated. No projects have been initiated and no mentoring on CQI

taken place.

Retention of patients on ART is low and that of pre-ART patients is not known since it is not

reported. Staff mentioned that the semi-nomadic lifestyle of patients in this area characterized by

frequent movements to stay with relatives might contribute to loss to follow up. For this reason

some patients self refer to get services closer to where their relatives live. Facilities do not seem to

have a way of minimizing such self referrals or to document and track them. The number of

patients who transfer in this way may account for the apparent number lost to follow up. The

number of children at the facility is also lower than national targets. The staffs indicated that the

clinic has no facilities from which to promote family centered care and are looking for support to

get a recreation area where child friendly services would be offered.

Home Based Care (HBC) and Community Health Workers (CHW)

All patients registered at the CTC are also registered with HBC regardless of being on ART or not

to allow for follow-up as needed. If maximized, this process will eventually reduce loss to follow

up of both ART and pre-ART patients. Africare, another USG partner is housed at the CTC and

supports home based through a group of community health workers (CHWs) or volunteers. An

HBC nurse and a program officer paid by AfriCare share an office and coordinate referrals.

Patients registered at the CTC are assigned to over 90 CHWs currently engaged by the program.

The CHWs have created a strong network that assigns each registered patient a CHW to visit them

weekly or monthly. Transport seems to be a challenge despite the bicycles that were recently

distributed. The CHWs distribute home care kits which include water, condoms and other small

products. The CHWs have focused on reducing loss to follow up and distributing other supplies.

TB/HIV

The TB and HIV clinics are co-located and share the same waiting area. TB screening is done at

triage by a nurse and any referrals are made to and from the TB clinic. The team was not able to

identify how many TB patients attended the clinic at any one time and if the TB clinic days

coincided with the CTC hours. Thus the team was unable to determine if this constituted a

significant risk for TB infection to general HIV patients.


Laboratory

The hospital laboratory serves the HIV clinic and the entire hospital. In its current state it does not

have the capacity to support a district hospital and does not provide sufficient support for delivery

of high quality HIV care because of the following reasons.

1. There is no laboratory technologist instead the team is made up of two lab assistants that

are not qualified to run a district lab. Other lab staffs were trained on the job.

2. There is inadequate space for all lab processes including PITC which is available but not

maximized because of work load and space limitations for actual testing and information

giving.

3. The CD4 machine is onsite but has not been installed, hence samples are still sent to

another site. It is unclear if sample processing in seamless.

4. CD4 percentages are not calculated even for pediatric patients affecting the interpretation

of immunological profiles and eventual decisions to initiate ART in children.

5. The chemistry machine is not working properly

6. Hematology machine has no controls for very low or high values

Post Exposure Prophylaxis

Most people who have received PEP have been victims of rape. The clinic management reported

PEP available for any staff that needed it, but the process described that requires those who get a

needle stick injury to be tested for HIV in the same facility (CTC) where they are known may

discourage reporting of exposures such as needle stick injuries for the fear of inadvertent

disclosure.


1. Service provision is well streamlined, with three service days, one of which is dedicated to

pediatric or family care.

2. The facility team supports care at 4 outreach sites in an attempt to bring care closer to those

who in need and maximize access to services and patient retention

3. There is good leadership, collaboration, integration and coordination of referrals of the

CTC with the rest of the hospital, particularly PMTCT and HBC.

4. PICT is actively being promoted by the hospital leadership and staff and many

opportunities exist for HIV testing. Testing has particularly been successful in the TB

clinic and in patient wards.

B. Clinical Areas for improvement and Recommendations

Priority Areas

1. Area for Improvement-Laboratory: The hospital laboratory is not adequately staffed and

does not have all needed working equipment. Staffing does not meet the minimum


requirements of a District hospital. Recommendation: AIDSRelief should work with the

hospital leadership to address the challenges to ensure that clinicians have access to the

HIV-related and other testing (CBC, LFT) to inform clinician decisions for initiation or

changing of treatment.

2. Area for Improvement-Patient records: Documentation in patient charts shows

inconsistence between TB screening questionnaire findings (administered at triage) and the

clinicians’ assessment. Follow up of identified TB suspects is not completed to either

diagnose or exclude TB. A few charts reviewed also showed some missing baseline and

repeat CD4. Recommendation: Chart reviews should be conducted as a means to improve

overall documentation and subsequently the quality of care.

3. Area for Improvement-Quality and Continuity of care: Retention of patients on ART is

low and that of pre-ART patients is not known. There is no plan to help minimize such self

referrals or to document and track them. The number of children at the facility is also lower

than national targets. Recommendation: There is need to improve monitoring the care and

follow up of pre-ART patients. Consider developing CQI projects focused on some of the

above issues and share solutions with all hospital staff.

4. Area for Improvement-Home/community based care. The large numbers of CHWs are not

receiving sufficient supervision and lack of transportation poses a challenge to conduct

outreach and visit patient homes. Recommendation: Maximize the use of volunteers to

improve loss to follow up through better supervision and monitoring of individual

volunteers. Setting targets, assigning geographically defined catchment areas and

reviewing visit logs or reports could improve the impact of the program. Patients should be

helped to join support groups where issues such as prevention with positives, nutritional

support and income generating activities can be discussed. AIDSRelief should discuss with

Africare to share and adapt experiences from elsewhere to maximize the synergies of both

organizations and improve HBC.

5. Area for Improvement-Continuous Quality Improvement. CQI information received to

date by the CTC designated CQI representative has not been shared with staff based on

interviews. Recommendation: Initiate CQI methodology at the CTC to reduce LTFU rates

and address unique site related challenges. Ensure documentation of all CQI efforts is

maintained.

Best Practices

6. Area for Improvement-Facility. There is limited space to accommodate all patients

without compromising infection control and confidentiality as well as support group

meetings. Recommendation: Consider construction of a waiting shade or identification of

other space that would also accommodate the additionally planned play and recreational

activities on family clinic days. This same space would provide meeting areas for support

group meetings. Explore if Africare would partner and support the development of this area

to foster more interaction between CHWs, staff and patients.

7. Area for Improvement-Staffing numbers and skills sets. There is insufficient staff with

the appropriate training to meet the MOHSW staff distribution requirements. This

imbalance in skills raises concerns about the quality of HIV care at the clinic in addition to


oversight at the 4 supported satellite sites. Recommendation: The facility should engage in

an exercise to document if and to what extent the staffing at the facility meets national

recommendations. For the HIV clinic, AIDSRelief should use its staffing tool to determine

needs and address any gaps with training or more FTEs. This assessment should also

establish whether the existing team at the clinic is able to supervise and mentor staff from

the satellites.

8. Area for Improvement-Post Exposure Prophylaxis: Most people who have received PEP

have been victims of rape. The management said it was available for any staff that needed

it but the process described that requires those who get a needle stick injury to be tested for

HIV in the same facility (CTC) where they are know may discourage reporting of

exposures such as needle stick injuries for the fear of inadvertent disclosure.

Recommendation: Staff should have an option of getting tested for HIV at a place of their

choice.


The financial management of the HIV program takes place at the District offices. The District

offices are “housed” in a separate building in close proximity to the Hospital. The program

accountant responsible for the financial management of the HIV program has been with the

organization since 2003. In addition to managing the accounts for the HIV program, the

accountant is also the Revenue accountant for the District. Financial operations for the District are

under the management of the District Treasurer who oversees expenditure accounts, final accounts,

and revenue accounts. Each area consists of one accountant. Although all staff work together to

ensure that all areas are covered, due to the minimal staffing, this can become problematic when

one person is out for a period of time.

Internal audits are performed on a quarterly basis and the most recent external audit was performed

by the National Audit Office for the period July 2009 - June 2010. The program accountant

performs bank reconciliations on a monthly basis. Timesheets for documenting time and effort

reporting have been implemented for the data clerk’s position.

Wire request are made quarterly by the District to AIDSRelief-Tanzania. The wire request is

accompanied by the budget, financial summary sheet of expenditures and cash flow document.

Funds are wired to the District. In the event there is a delay in receiving funds, the District has

advanced the monies until the funds are received from AIDSRelief. This prevents any disruption

of services.


1. The District has supported the HIV program when there has been a delay in receiving

funding.

2. Levels of oversight include quarterly internal audits and annual external audit reviews. The

external audit is performed by the National Audit Division.

3. AIDSRelief finance visits have been especially helpful according to staff interviews.


4. Procurement procedures are in good order.

5. The documentation for monthly bank reconciliations was detailed.

B. Financial Areas for Improvement and Recommendations

1. Area for Improvement-Management and Oversight. The financial operations are

performed by the District offices. However, the staffing is minimal and does not seem

commensurate with the workload. Recommendation: Evaluate the current staffing levels

to ensure there is sufficient manpower. Backup systems should be in place to ensure

proper coverage when persons are out for periods of time.


BUGANDO MEDICAL CENTER

6 December 2010

BACKGROUND

Bugando Medical Center (BMC) is a teaching hospital for the Lake and Western zones of

Tanzania. The 900 bed medical center is a referral facility for the 6 regions of Mwanza, Mara,

Kagera, Shinyanga, Tabora and Kigoma covering a catchment area of about 13 million. The

facility is also affiliated with a medical school on the campus and provides technical support to

other organizations and health centers. The hospital was opened in 1971 and in 1972 was

nationalized coming under the administration of the Government of Tanzania. In 1985 the

Tanzania Episcopal Conference of the Catholic Bishops of Tanzania became the owner and

developed a partnership agreement with the government. The HIV program began in 2005.

BMC serves as a referral site for the six regional hospitals along with the 46 district hospitals, 148

health centers and 1,398 dispensaries in the region. BMC provides pre-service and in-service

training for health care workers, onsite support and supportive supervision. It offers training for

general and specialists doctors and also offers diplomas in nursing, laboratory technology and

radiology. BMC and the medical school have extensive collaborations including the Weill Cornell

University and has implemented grants and programs funded through the African Medical and

Research Foundation (AMREF), The Touch Foundation, the Danish International Development

Agency (DANIDA), USAID and the US Embassy. It offers tertiary specialist care and is a center

of excellence in the region for cancer care and vesico-vaginal fistula repair.


Governance

The hospital’s Board of Trustees is a combination of church (6 members) and government (4

members) appointed representatives by the members of the Tanzania Episcopal Conference (TEC).

Minutes of meetings were reviewed and found develop to have sufficient detail to support

organization oversight. Strategic planning is conducted at three year intervals. Departments meet

their needs and send forward. An assessment of the status of the strategic plan is done annually.


The Director General runs the day to day operations of the hospital. An Executive Management

Committee (8 staff) meets on a weekly basis. Departments, directorates, and units are to meet on a

monthly basis. The Management Team which includes all of the department, directorate, and unit

heads meets twice a year. Written reports from the management team are provided to the

Executive Management Committee. Several staff indicated that communication within the

organization is good, but acknowledged that there is limited access to technology within the

facility. Managers identified the need for more training for staff. Staff turnover and the moving

of staff to areas with greater need create this continuous need.


The HIV Program was originally housed under the Department of Internal Medicine, but due to its

visibility and the need for ongoing linkages with the NACP, it has been moved under the Director

General oversight.

Human Resources

The hospital has 1200 employees with one human resources manager and no support staff. During

the 30 minute interview with the HR manager, there was a line of about 10 staff waiting to see him

about personnel issues during that time. All staff salaries are paid by the MoHSW. The hospital

uses several incentives to retain employees including housing allowances, soft loans, and backing

loan guarantees. Clinical staff are hired at the national level of MoHSW and all relevant hiring

information is kept by the hospital.

The HR manager identified that individual staff questions and concerns takes up all of his time and

therefore personnel files exist, but are not consistently current due to staff shortages. Staff

promotion was identified as a problem area. Many staff are due for promotion, but it may take the

MoHSW 2-3 years to make it happen.

Human resources policies and procedures used at the hospital are those of the MoHSW. The

hospital has developed a manual for managers with language distinguishing between requirements

versus options to consider in the policies. There is a new policy manual that is in the process of

being developed for hospital operations and also includes some financial management policies.

Performance assessments are expected to take place quarterly, semi-annually, and annually.

Reminders do go out to managers on the assessments. AIDSRelief-Tanzania provides salary

allowances for those employees who have full-time positions in the facility and who spend

additional time working the with HIV program.

Discussions with the HIV program identified that there were at least four (4) volunteers supporting

the program. The HR department had no knowledge of this, has no policies on volunteers.


There is a diverse membership of the Board of Trustees that includes MOH, practicing

clinicians, and community representatives.

The HIV program is now directly under the Director General to receive close attention and

oversight.

Linkages to the community for referrals and other support services are numerous.

Education and training testing is conducted with patients prior to starting ART.

The HIV program coordinator has been with the program since it started.

Finance and Administration functional areas have been separated for better oversight and

efficiency.



Priority Areas

1. Area for Improvement-Human Resources: There is only one staff person for 1200

employees of the hospital. This person has no consistent administrative support to address

employee issues or help maintain personnel files. Recommendation: The recommended

ratio of HR staff to employees is usually 50 staff to one HR representative. BMC should

determine how a part or full-time administrative officer can be assigned to work with HR.

2. Area for Improvement -Volunteers: The CTC program uses PLWHA volunteers to

conduct education with patients and conduct outreach for patients lost to follow-up. The

HR department had no knowledge of such persons. Recommendation: HR should

develop a policy on the use of volunteers along with ensuring that required documents are

signed HR should verify if any other departments or programs are also using volunteers.

At a minimum a file should be kept on each volunteer with a signed confidentiality

statement and code of ethics. Departments should provide a document with the

duties/tasks assigned. HR and the CTC should develop processes to communicate about

volunteers.

II. CLINICAL REVIEW

Overview

The clinical team at the Care and Treatment Clinic (CTC) is headed by a project director who is an

internist and university professor providing clinical oversight and mentoring to other providers.

The other team members include 7 MDs (2 of them 50% FTE), one senior nurse, 12 nurse

counselors, 2 PMTCT counselors, 1 phlebotomist, 3 laboratory technologists (on 50% FTE), 2 data

clerks and two pharmacists. The clinic runs 5 days of the week from 8:30 am to 5:00 pm. HIV

programs started in 2004 and have developed over the years with support from GoT, other

partners; CDC (Training), ICAP (supports Early Infant Diagnosis, EID), Baylor International

Pediatric Initiative (BIPAI), the Global Fund, Abbot (laboratory support) among others. BMC is a

high volume site with 10,261 cumulative patients enrolled in HIV care (ART and non ART) and

5,242 patients cumulative on ART with 2,759 currently active on ART and a retention rate of 53%

as of September 2010.

Clinical/Technical Capacity

BMC has considerable technical capacity in HIV and general medical care and clinical research

due to collaborations with several organizations. Some BMC staffs sit on several committees that

are involved in formulation of health policy. BMC is said to have been one of the sites that

pioneered provider initiated testing and counseling (PITC). It has been involved in community

outreach to the islands in the area to conduct HIV prevalence surveys. BMC is involved in male

circumcision and other programs targeting high risk populations in hard to reach areas, cervical

cancer screening, and voluntary counseling and testing. This track record of successful

implementation of USG and non USG grants make BMC a valuable local partner from a

clinical/technical standpoint and as a technical unit that can support and compliment CSSC or

other local organization.


BMC provides an extensive range of high quality services including food supplementation

provided to those who need it. The HBC coordinator is able to offer both Plumpy' Nut and High

Nutrition Packets for a two week supply.

HIV/AIDS Services

Between 2004 and the end of September 2010, over 10,000 patients have been enrolled in care, of

which about 5000 have initiated ART. Of those who ever started ART, about half were actively

receiving ART at the end of September 2010, a retention rate of 53%. Over two-thirds of those 15

and above who are currently on ART are female.

Pediatric care is supported by a pediatric center of excellence constructed at the hospital. This new

state of the art clinic was recently commissioned with support from PEPFAR to accommodate an

increasing number of patients. Baylor International Pediatric AIDS Initiative (BIPAI) supports

pediatric care through mentoring and direct patient care. This probably explains the clinic’s

success in enrolling children on ART. The proportion (10%) of children on ART is the highest

among the sites visited but is still lower than the national target (20%).

The mechanisms that the clinic has put in place to improve patient retention include:

A competent HBC coordinator who also doubles as the exit nurse.

A comprehensive referral system.

Adequate recording of demographic information including telephone numbers and use of

phone calls as the initial strategy to get patients who miss appointment

Patient retention placed on the agenda for the CQI team.

A systematic communication process with HBCs and HCWs with practices to close the

communication loop and follow up of patients.

There are definite indications that these efforts are paying off. For multiple registers and patient

lists exist and there is reported reduction in the loss to follow up rate within the last year. Death

and loss to follow up are some of the reasons for the low patient retention at BMC, but unknown

status continues to be identified for a large number of patients. In the period July-Sept 2010 of

those ever started on ART, 378 had died, 725 were lost to follow up, and 183 were not on ART for

unknown reasons.

Staff are well trained and committed as expressed by one nurse who stated “ I love working here

and I love what I do.” ART initiation is carefully implemented to ensure good adherence to the

lifelong medication.

There are dedicated ART initiation days (Monday and Thursday) enabling organized

treatment preparation

Treatment preparation is done though group education


An adherence quiz is administered to test knowledge and readiness to start ART.

Counseling is then further provided to address gaps for those who “fail” the quiz.

Laboratory services

BMC has a state of the art laboratory built with support from PEPFAR, Abbot Foundation, The

Global Fund, GoT and other donors. The review team was informed that the laboratory has

equipment to support many programs including PCR testing for the region supported by ICAP and

EGPAF for early infant diagnosis. Hematology, chemistry, microbiology and virology support the

hospital and surrounding facilities. The lab also houses the zonal TB lab.

Pharmacy

There have been stock outs of pediatric medications and the pharmacy has tried to address this by

compounding syrups from adult formulations. While pharmacies can compound other medications

such as cough syrups, ointments and lotions, there is a likelihood that children receiving locally

compounded medications may get suboptimal dosages and that such compounded syrups may

degrade in the home environment. There have also been challenges with other OI drugs,

specifically fluconazole, which was previously supplied from a Pfizer donation. There have also

been shortages of reagents for the laboratory, i.e. the viral load machine is not working optimally

due to limited reagents.

At the time of the visit, a computer in the pharmacy department was reported not to be working for

at least six months. Given the number of patients served, this may be adversely affecting

consumption reporting and quantification of ARVs.

Home-based Care

The clinic has put in place a strong HBC program and a concerted effort to monitor patients on

ART. The mechanisms put in place to improve patient retention include: 1) adequate recording

demographic information including telephone numbers, 2) using phone calls as the initial strategy

to get patients who miss appointment, 3) putting patient retention on the agenda for the CQI team,

and 4) a systematic communication process with Community HBC’s and health care workers with

closed loop communication and follow up of patients.


1. BMC is a Center of Excellence providing HIV training and mentoring and serves as a

referral site for the lake zone covering 6 regions.

2. The clinic provides the nearby medical, allied and nursing school schools with

opportunities to integrate HIV into the pre-service curriculum with students spending a

months at the CTC and PMTCT program.

3. PMTCT is well integrated with ANC and almost all women are tested for HIV.

4. The laboratory is very well equipped, professionally managed and has internal and external

controls. The lab is seeking ISO 9000 accreditation and provides early infant diagnosis

support to the lake region. TB QA on behalf of NTLP for Mwanza region and creates

several opportunities for training and mentoring.


5. Chart review shows longitudinal care, an indication of clinical care and consistent

screening of patients for TB at triage.

6. There is a strong CTC CQI team with documented monthly meetings, a designated clinical

leader who coordinates and facilitates meetings, and demonstrated improved outcomes:

reduction in waiting times, improvement in referral form return rates, and LTFU rates.

7. ART initiation is carefully implemented to ensure good adherence to the lifelong

medication.

a. There are dedicated ART initiation days (Monday and Thursday) enabling organized

treatment preparation

b. Treatment preparation is done though group education

c. An adherence quiz is administered to test knowledge and readiness to start ART.

Counseling is then further provided to address gaps for those who “fail” the quiz.


Priority Areas

1a. Area for Improvement-Pediatric ARVs, and OI drugs: The pharmacy has been

compounding syrups for children from adult formulations due to stockouts of several

ARVs which may result in children receiving suboptimal dosages and some of these may

degrade in the home environment. There have also been challenges with some OI drugs,

specifically fluconazole, which was previously supplied from a Pfizer donation.

Recommendation: The issue of pediatric ART is reportedly a national one with the supply

chain and will require higher level intervention at the USG and MoHSW. In the interim,

the clinic should not compound ARVs from adult preparations, but should use every

channel available to urgently address drug shortages. AIDSRelief should explore how the

supply of lab supplies and other drugs can be improved

1b. Lab reagents: There have also been some shortages of reagents for the laboratory, i.e. the

viral load machine is not working optimally due to limited reagents. Recommendation:

AIDSRelief-Tanzania should work to discover why there are repeated shortages of lab

supplies and what alternative options are available to ensure an uninterrupted supply chain.

1c. Pharmacy computer: At the time of the visit, a computer in the pharmacy department was

reported not to be working for at least six months. Given the number of patients served, this

may adversely affect consumption reporting quantification ARVs. AIDSRelief is aware of

this issue. Recommendation: The pharmacy computer should be repaired or replaced as

soon as possible to ease dispensing, reporting and quantification of ARVs.

2. Area for Improvement-Staffing: Many staffs are cross trained; however this has

inevitably led to multitasking. For example the HBC coordinator also works as the exit

nurse. Although the HBC and exit nurse functions are complementary, combining both

duties for an 8 hour period for a single individual is a burden and may lead to staff burn


out. Recommendation: These two important and complimentary functions should be

separated and performed by two different individuals

3. Area for Improvement-Adult and pediatric clinics: There is no clear operational plan to

guide adult or pediatric care when the clinic starts. The few unclear questions are (i) where

will adults who have infected children be seen? (ii) How will appointments be made

between adults and children to minimize patient delays? (iii) How will the new clinic affect

staffing for different cadres? Recommendation: BIPAI Tanzania and BMC should

urgently discuss and come up with a clear operational plan that will minimize patient flow

issues and functions of the two clinics.

4: Area for Improvement-Care for pre-ART patient: Lost to follow up has been high among

both ART and pre-ART patients, but there is no formal plan to conduct lost to follow-up

activities. Recommendation: There is need to improve monitoring specifically for pre-

ART patients to ensure that they remain in care. Interventions such as those described

above for follow up of ART patients could go a long way in addressing lost to follow up.

Peer review of charts as well as regular Morbidity and Mortality meetings should be

instituted as a strategy to improve the overall care of patients

5. Area for Improvement-PMTCT:. BMC is a high volume PMTCT site, however optimal

outcomes have not been achieved by the programs. For example it was noted from the lab

logs that among infants who get tested, about 10% test positive. This rate has not been

analyzed by ART regimen. It was also reported that many pregnant women who are

registered at the clinic get lost to follow up and potentially deliver from other sites. It is

also unclear if they or their newborns ever receive the intervention in a timely manner to

mitigate MTCT. Recommendation: The impact of the PMTCT program should be

established and the reasons for the high positivity rate determined .

Best Practices

6. Area for Improvement-Facility: A new facility was recently built to accommodate

increasing number of patients. However despite its size, at the time of the visit, the main

waiting areaswas still crowded. Recommendation: As a center of excellence, BMC can try

to implement better scheduling of patients to minimize waiting times, crowding and the

lack of privacy associated with the current sitting arrangement at the clinic.

7. Area for Improvement-Technical capacity. BMC has a lot of technical capacity to provide

HIV care, but staff could not identify their ongoing needs for additional TA from

AIDSRelief teams for clinical care. Is this a site that should graduate from TA?

Recommendation: AIDSRelief and BMC should discuss the need for ongoing TA.

Depending on how much capacity exists onsite for managing patients, the spacing of visits

by the clinical team, the agenda and format of TA should be refined to ensure that it still

benefits the institution. This assessment may also help determine how BMC could play a

bigger role in supportive supervision and mentoring sites in the lake region.

8. Area for Improvement-X-ray viewing screen: The HIV clinic currently has no equipment

to view the patient films and clinicians must go to the x-ray department to view patient

tests. Recommendation: AIDSRelief should purchase x-Ray viewers for the clinic.


9. Area for Improvement-CQI: There is no process to gather, document, and share best

practices and achievements from CQI activities with staff. Recommendation: within the

hospital, region and through abstracts to international QI journal/ conferences. This will

serve to motivate staff and promote CQI activities.


The organization has numerous collaborations and partnerships that include ICAP, Baylor, CSSC,

and AIDSRelief, just to name a few. The hospital has diverse funding streams that also include the

Vatican Children’s Hospital, Global AIDS Fund, Abbott Laboratories, Baylor University, and

others.

Financial management and oversight

The financial management for the PEPFAR program is supported by an accountant who works

full-time only for this project. The hospital has over 47 accountants/finance staff. The

AIDSRelief financial staff provides onsite assessments every two weeks. Annual training is also

provided by AIDSRelief. The most recent regional training was held June 2010. The program

accountant routinely communicates with the program by attending weekly program meetings.

Financial policies and procedures

The financial policies and procedures that support the PEPFAR program include the financial

policies of the Hospital but also include the financial training documents received at recent

AIDSRelief trainings.

Budget

The revenues are predominately grant related and restricted to service delivery. Therefore, the

organization lacks funds for cash shortfalls or revenues to cover expansion costs. The Hospital

was in agreement with the need for the additional discretionary funds. The project has a

comprehensive budget development process that takes place with AIDSRelief. BMC should

consider establishing a direct cost recovery program to ensure that as many program direct costs as

possible are recovered.

Internal and External Audits

The hospital’s internal audit department provides financial oversight. In addition an external audit

is completed, annually. AIDSRelief has recently completed an audit/review of the program.

Payroll

Employees paid by the PEPFAR program are required to complete timesheets to document the

hours worked. The employees are paid by the government, but receive allowances from the

PEPFAR funds for extra time and duties. Timesheets are completed by the employee and

submitted to the supervisor for approval. The accountant prepares a payroll report based on the

allocated time for each of the employees. The payroll report is prepared prior to the end of the

month and this is the basis for employee’s pay. Since the payroll report is completed prior to the

end of the month and before the timesheets are submitted at the end of the month; it was not clear

what the settlement process is ensure that salary amounts paid reflect the hours worked.


It was revealed during the assessment that the payroll taxes are not being paid for the employees

paid from the AIDSRelief funds. However, AIDSRelief is aware of the problem and has been

working with the organization to resolve this issue.

Chart of Accounts/Data Security

The financial information is maintained using the Microsoft excel application. The organization

has been in the process of evaluating the implementation of QuickBooks accounting software

application. This would increase the efficiency in tracking and reporting of expenses. Complete

backups to the accounting system are performed on a monthly basis. The Information Technology

department is responsible for the backups and storage of the backup data.


BMC has extensive experience with the management of contracts/grants to including those

from ICAP, Baylor Medical Center, CSSC, and AIDSRelief.

A strong partnership exists with the government.

The hospital provides in-kind support to the program which increases sustainability.

There is a dedicated project accountant who manages the finances. Hospital staffing

includes a network of 47 accounting/finance staff persons.

Additional oversight includes reviews by internal audit department as well as annual

external audits and internal audits by AIDSRelief.

Trainings are provided annually by AIDSRelief and on-site management is provided bi-

weekly.

The budget development process that occurs between the organization and AIDSRelief is

very comprehensive.


1. Area for Improvement Reserve Funds: The organization does not have a reserve fund

account. The revenues are predominately grant related and restricted to service delivery.

Therefore the organization lacks funds for cash shortfalls or revenues to cover expansion

costs. Recommendation: Establish revenue generating programs, lines of credit, or other

funds that can be used for discretionary spending and opportunities for growth and

expansion.

2. Area for Improvement – Payroll: Employees are paid with government funding and

receive allowances for work provided to the PEPFAR program. The payroll report is

prepared prior to the end of the month, although the timesheets are submitted at the end of

the month. It did not appear that there was due diligence to reconcile the payroll report

with the timesheets containing hours actually worked. In addition, it was discovered that

payroll taxes are not being paid for positions supported by AIDSRelief funds.

Recommendation: Ensure that a verification program is implemented to settle any

differences between the payroll reports and the timesheets. The organization should


continue to work toward a resolution to resolve the issue of unpaid payroll taxes.

AIDSRelief is currently in discussion to resolve this issue.

3. Area for Improvement - Chart of Accounts/Data Security: a. The organization is

planning to implement the QuickBooks accounting software package. However assistance

is needed in order to complete the implementation. b. Backups to the accounting system are

performed on a monthly basis. This infrequency of backups increases the risk exposure.

Recommendation: Implementation of the accounting application would provide greater

flexibility in reporting and efficiency in tracking and managing funds. AIDSRelief-

Tanzania can assist with the setup and implementation process. The organization should

consider daily back-ups of the accounting system.

4. Area for Improvement - Management and Oversight. a. The Director General is

responsible for information reported to the Governing Board. It was uncertain that the

level of financial detail reported to the Board is sufficient enough to assess the program. b.

The AIDSRelief staff provides on-site assessments. Reports are completed based on the

assessment; however, the formal reports are not shared with the Medical Center. Formal

written feedback from the site management process apparently is not being received.

Recommendation: BMC should ensure that the information provided to the Board is in

sufficient detail to adequately assess the performance of the program. The assessment

reports completed by AIDSRelief should be shared with the hospital’s finance and program

leadership to increase accountability. Reports can be used to measure resolutions to issues

identified.


SENGEREMA DESIGNATED DISTRICT HOSPITAL

7 December 2010

BACKGROUND

The Sengerema District Designated Hospital was founded by Sisters of Charity of St. Charles in

1959. In 1976 the hospital became a Designated District Hospital and also began to provide HIV

services. It is the only hospital for the 650,000 people living in nearby Districts.


Governance, Management and Oversight

The hospital is governed by a Board of Directors whose last meeting was held November 2010.

The Board is composed of members from the Diocese, the District Health Committee, and

MoHSW. The Diocese representatives include the Bishop, Secretary General, Parish priests, CEO,

and CNOs. The Board members meet quarterly. Sisters from the hospital report on the status of

operations and projects at each meeting.

There is also a management committee providing oversight for the 321 bed hospital. The Nursing

Officer and the Medical Officer conduct meetings monthly with the hospital and program staff.

Starting in 2011, the MO and NO will be meeting monthly with each of the wards to get first hand

information from staff. This came as a recommendation from staff feedback sessions held in 2010.

There is a management team representing all departments and units that meets on a monthly basis.

Human Resources

There are 189 staff employed by the hospital and 34 staff supporting the ART program. .

AIDSRelief supports 6 of these staff. The Acting DMO indicated that the MoHSW is in the

process of reviewing job descriptions and the Administrative Officer is working with them. The

current human resources policies manual was developed by CORAT of Africa in 1992.

The hospital Board recently voted to provide new retention incentives for employees.

Transportation is very poor in the district Small loans will now be approved for staff and the

hospital will provide collateral for these loans. There is a maximum loan amount of $300,000 Tsh.

Management also indicated that the MoHSW causes the most issues. Staffs are pulled from one

facility to help fill gaps in other facilities, often in the same district. Currently there is no

documentation in the personnel file that would indicate a staff person had completed specialty

training such as HIV or had worked in the HIV program for many years. Recommendations on

how to implement were discussed.

Performance review completion is a struggle for the District facilities. Personnel files were

reviewed for six (6) staff persons for a variety of positions of 2 Nurses, Watchman, Medical

Records Clerk, Accountant, and Data Clerk.


Linkages and Community Relationships

CSSC has a good working relationship with the district. CSSC provides advocacy support for the

hospital with the MoHSW and the NACP. MoHSW established new clinical indicators and CSSC

has helped with bench marking and there have been improvements in the hospital. An introduction

for the hospital into Information Communication Technology for the management team took place

in 2010.

CSSC coordinates trainings in Mwanza for staff in the zone and regions and are now offering

student scholarships for employee children.


There is a diverse membership of the Board of Trustees including the MOH and practicing

clinicians.

The management structure is designed to have a deputy for most management level

positions with the authority to make decisions in place of the prime employee.

There are regular reports provided to the Board sharing updates on hospital operations,

programs, and budgets.

Strong communication exists between the program staff.


1. Area for Improvement-Human Resources: Many of the staff do not have job descriptions

that are current and reflective of the duties fulfilled now. There is no consistent process for

completing performance assessments. Recommendation: Job descriptions are currently

under review for revision. Consider having the employee and the supervisor review the job

descriptions and share any suggested changes.

2. Area for Improvement- Communication: There is not consistently timely communication

with all of the partners and facilitators who can help access needed resources such as

medication and lab reagent stock-outs. Recommendation: The hospital should continue to

follow the NACP process as appropriate, but ensure that AIDSRelief and CSSC are

immediately aware of any issues.

II. CLINICAL REVIEW

Overview

As a district general hospital, it provides outpatient and inpatient services under the Medical,

Surgical, Pediatrics, Obstetrics and Gynecology departments. There is also a centralized pharmacy

and Laboratory. On average over 300 patients are seen in the outpatient department under different

clinics and in the last year over 70,000 outpatient visits took place. There is also a busy in patient

service with bed occupancy exceeding 90%. Among the challenges the hospital mentioned was the

inability of the zonal blood bank to meet what was described as “high rate of blood transfusion”.

This has led the hospital to prepare blood locally. The hospital has worked very good relationship


with CSSC. CSSC has also supported the district health leadership to reduce maternal mortality.

The hospital supports Nyakaliro health center with laboratory services and referral services. The

hospital provides a training site for the affiliated nursing school and clinical officer schools.

Facility

During peak service hours (mornings) the facility gets very crowded. Despite the increased space

created by the new clinic; it was very crowded at the time of the visit since all patients come at

almost the same time in the morning. The outer waiting shade which could help decongest the

triage area is not utilized and was empty at the time of the assessment when the triage and walk

ways were jammed. A few areas such as registration, triage and pharmacy serve as bottle necks to

patient flow. Because of the space limitations, triage/vital signs is conducted in the open waiting

area. In a separate room two clinicians share the same space. These space limitations create

challenges in ensuring confidentiality.

HIV/AIDS and Related Services

A new and well designed CTC has been built a few blocks from the main hospital, but within easy

reach of both the VCT where some of the patients come from and the main OPD. Currently 2

Assistant Medical Officers (AMO) and one clinical officer, two triage nurses, two pharmacy

assistants, a home based care coordinator, a lab technician, receptionist and data manager form the

core clinic staffing. The clinic is open between 7:30 am and 3:30 pm. Voluntary Counseling and

Testing (VCT) as a standalone service and PITC is offered in the outpatient and inpatient units. Six

staffs are trained in PITC. There is a TB clinic where the co-infected are also managed. Some

general hospital staffs have been trained in HIV and the hospital encourages regular rotations

within the departments including the CTC. PMTCT services are integrated within the RCH/ANC

clinics.

The team noted that the linkage between VCT and enrollment in care may not be strong enough to

enable many of those tested to enroll at the CTC. The PITC, which is offered in several sites in the

hospital, has not been maximized. Not all patients seen are offered the test and there is no clear

mechanism to track those who are offered. Test kits have been insufficient to meet testing needs.

In addition one staff interviewed did not seem to appreciate the distinct difference between PITC

and VCT. Some sort of screening was being done to identify those who would be offered the test.

The strategy used takes significant staff time reducing the main benefit of PITC over VCT. Even

though many staffs are trained, testing is only provided in two places due to inability to provide an

adequate number of test kits.

Both client (VCT) and provider initiated (PITC) testing strategies are utilized at the hospital. By

the end of September 2010, the clinic had enrolled 4,444 cumulative patients in care, including

1,418 on ART. Of those who ever initiated ART, more than a half, 828 were active and on ART at

the clinic. Children constitute 6.9% of those who were still on ART. Among adults almost two

thirds (272/771) were women. Deaths and transfers out were some of the reasons for the lower

number still at the center. Monthly hospital wide meetings are held and are one of the ways for

sharing updates. There is one centralized lab.

TB/HIV

Several weaknesses were noted in the process of TB screening and diagnosis. Patients are not

asked about cough at the first point of contact. The TB screening questionnaire is not


administered at all visits. When administered; there is inconsistence between the questionnaire

findings and the clinician assessment and often there is no clear and consistent follow up of

suspects. Protocols for sputum analysis are not followed consistently. For example, where the 1st

sputum is positive there is usually a follow up. If negative there are often no follow up samples

tested or documented. The TB clinic where co-infected patients also get care is at the entrance or

near the main hospital

Chart Review

Patients may not be getting the best possible quality of care at the site. First, from a few charts

reviewed, there was limited documentation to justify some of the treatment decisions that were

made. Limited documentation may reflect the limited patient-provider contact time, often due to

crowding that is compounded by an ineffective patient flow through the building. Retention of

patients, especially for those who are not yet eligible for ART, is poor. The mortality for those on

ART or in care is high. Many of these issues probably contribute to the high mortality.

There is lack of access to CD4 testing for many patients. Among the reasons is lack of consistent

supplies of reagents but also poor longitudinal follow up of patients. When done staff have not

interpreted trends consistently. For example a declining trend or unexpected results has not often

triggered questions, a discussion or an order to repeat by the clinician. CD4 percentages for

children have not been done making interpretation of absolute values difficult or inaccurate and

decisions to treat or monitor progress difficult.

Given the limited time available for clinical assessment, minimal documentation and the absence

of CD4 testing, there are virtually no objective measures of disease status possible in this setting is

a serious challenge

Community/Home Based Care

Two local organizations, Tunajali (funded through USAID) and Wamata work closely with the

hospital and clinic to provide community based care and related support services. They support

community based volunteers who visit patients, provide nutritional support; give micro loans and

support orphans and vulnerable children. The community health workers visit patients in their

respective catchment areas and report to the clinic once a month.

Laboratory

The lab has several limitations and challenges in supporting care for HIV patients at the clinic,

general patients in the hospital as well as for other health centers that are dependent on it. The

laboratory at Nyakaliro Health Center relies on the Sengerema DHH hospital lab for CD4s, sputum

microscopy and chemistry. It’s not clear whether other satellite clinics have similar needs to those

of Nyakaliro, nor what demands these place on reagent supplies for the hospital. Among the key

challenges noted in the lab are the following:

External and internal quality controls are week, or done inconsistently, i.e. the CD4

machine has not had EQA for at least 1 year,

Supply of reagents for CD4 and other tests are inadequate, and

The refrigerator is not on an emergency power back-up.



1. The facility offers a comprehensive range of well integrated services and works well with

MOHSW

2. Community involvement has been maximized at the facility with PLHIV involvement and

local organizations (Wamata and Tunajali)

3. The hospital/CTC supports three health centers which serve as satellite clinic

4. The new CTC is well designed to minimize TB transmission

5. There is a large pool of trained individuals who are and rotated every three months as a

capacity building strategy.

B. Clinical Areas for improvement and Recommendations

Priority Areas

1. Area for Improvement-Facility: During peak service hours (mornings) the facility gets

very crowded and all options to reduce crowding are not being used. Recommendation:

Consider either rearrangement of care days, times or effective scheduling so that patients

are seen during the whole day rather than only in the morning. More structured scheduling

may allow general information and education or treatment preparation to be given in

smaller groups. Additionally, scheduling stable patients at longer intervals, task shifting

their care to nurses may help decongest waiting lines for clinicians. The outer waiting

shade can be used as the main waiting area and only manageable batches of patients sent to

the main clinic.

2. Area for Improvement-Quality and continuity of care: Patients may not be getting the best

possible quality of care at the site. Some of the charts reviewed did not have sufficient

documentation to justify some of the treatment decisions that were made.

Recommendation: Initiating regular (peer) chart reviews to identify gaps and starting some

CQI activities based on initial results may help improve care. These chart reviews should

help identify patients who are eligible for ART but are not on it and those lost to follow up,

and those where critical clinical data to support decisions is insufficient. Improve linkages

with HBC to minimize lost to follow up especially among those who are not on ART.

Targets and definitions for lost to follow up for pre-ART patients should be agreed upon.

3. Area for Improvement-CD4 Testing: There is lack of access to and consistent

interpretation of results and a lack of consistent supplies of reagents to conduct the tests.

Recommendation: Access to timely CD4 testing should be addressed urgently and systems

put in place through CQI to increase the rate of repeat CD4s. Regular chart reviews could

help start the improvement process. Repeat CD4 orders could be filled at the exit nurse

station and appointments given so tests are conducted and results filed before the next

clinician visit.


4. Area for Improvement-Laboratory: The lab has several limitations and challenges in

supporting care for HIV patients at the clinic, general patients in the hospital as well as for

other health centers that are dependent on it. Recommendation: The lab capacity needs to

be strengthened in view of added and sometimes unpredictable needs of other facilities it

supports. Supply chain for reagents needs to be addressed and internal and external controls

set up.

5: Area for Improvement-HIV testing and linkage to care. PITC opportunities to offer

testing are not being maximized. Clear linkage of VCT to enrollment at CTC is not clearly

evident. Time spent on each patient tested through PITC is too long and removes the main

advantage of PITC over VCT. Recommendation: In order to improve testing for HIV the

supply of testing kits should be addressed, refreshers held for staff and testing locations

increased to remove potential obstacles to testing. Staff should consider offering group or

individual information rather than detailed pre-test counseling that takes staff time and

limits the number of test offered. Adequate time should be spent on post-test counseling;

referral and enrollment in care of those who test positive. The linkage between VCT and

the CTC could be strengthened by encouraging those who test to enroll at the CTC.

6. Area for Improvement-TB screening, diagnosis and treatment: Patients are not asked

about cough at the first point of contact and TB screening questionnaire is not administered

at all visits. There is inconsistency between the questionnaire findings and the clinician

assessment and inconsistent follow up of suspects. Protocols for sputum analysis are not

followed consistent. The TB clinic where co-infected patients also get care is at the

entrance near the main hospital. Recommendation: Given the large number of patients at

the clinic and hospital, and long waiting times TB infection control needs to be prioritized

to minimize the TB transmission.

Best Practices

7. Area for Improvement-Capacity to provide clinical oversight to other sites: In addition to

providing care at the CTC, the clinical team here is also responsible for providing oversight

to the three satellite clinics. From the assessment, the team had the impression that the

mentoring and supportive supervision provided to this site is insufficient to address the

needs of clinicians in providing care at the Sengerema CTC as well as those of sites to

whom they provide oversight. Recommendation: The team needs to be strengthened to

recognize and prevent problems rather than be reactive. The needs of supported health

centers should be documented and the capacity of the team to meet them while at the same

time providing primary care for patients at Sengerema DDH CTC. Following determination

of the need, realistic schedules and point persons for respective satellites can be drawn up

in a way that does not affect the quality of service provided as Sengerema DDH CTC.

8. Area for Improvement-Continuous Quality Improvement: CQI concepts and some

activities initiated but they have not been documented well enough to clearly demonstrate

improvement or shared with staff as best practices. Staff interviewed could not clearly

describe examples of improvement projects with targets and timelines. Recommendation:

Training and mentorship for staff should continue to equip them with skills that enable

them implement CQI activities, interpret and use data to address local and site specific

problems.


9. Area for Improvement- Pediatric care: The proportion of patients on ART (7%) is lower

than the national target. Recommendation: PITC for children should be scaled up,

especially for children born to HIV infected women. Training and mentoring of HCWS in

pediatric should be provided. Peer review of charts should be considered.


During the site assessment, the hospital management informed the team that a financial audit by

the government was taking place at the hospital and most financial documents were in the

possession of the auditors.

Financial management and oversight

The finance department reports to the Administrator who is accountable to the Board of Directors.

Finance reports are presented to the Board at the quarterly meetings. The program accountant is

full-time and responsible for managing the finances of the program. AIDSRelief provides on-site

management monthly. Program staff has access to financial training provided by the

AIDSRelief/CSSC team.

Payroll

Payroll reports are signed by the Administrator; however, the signature does not include the date

when the reports were signed. The support documentation starting from the payroll approval

process to the actual payment to employees is not sufficient. There should be a process to include

the validation and reconciliation between what is documented on the timesheet, the payroll report,

and actual payment to employee. The basis for the employee’s earnings was not clear. The

payment of allowances to employees on the PEPFAR program varies monthly and between

employees with no clear justification.


The financial information is maintained using the Microsoft excel computer application. The

organization has not implemented a more formal accounting software such as QuickBooks. The

implementation of a more formal accounting application could increase the efficiency in tracking

and reporting of expenses. The current reporting and tracking options are very limited.


1. Time and effort tracking on timesheets has been implemented for AIDSRelief funded

positions.

2. The hospital produces avery comprehensive annual report.

3. Trainings are provided by AIDSRelief and on-site management visits occur monthly.


1. Area for Improvement-Payroll: Payroll reports are signed by administration, however, the

signature does not include the date when the reports are signed. The backup

documentation from the payroll approval process, to the actual payment to employees, was


not sufficient. The basis for allowances to employees for work on the PEPFAR program

was not clear. Recommendation: Payroll reports should be approved with a signature and

date. There should be a clear documented process for the payroll process that includes the

validation and reconciliation between what is documented on the timesheet, the payroll

report and actual payment to employees.

2. Area for Improvement-Chart of Accounts/Data Security. The organization uses Microsoft

excel application for the tracking and reporting of finances. This limits the flexibility of

tracking and reporting and also is less efficient than a more formal accounting software

application. Recommendation: Consider the implementation of a more formal accounting

software application such as the QuickBooks accounting software application. Such an

accounting application would provide greater flexibility in reporting and increase

efficiency in the tracking and management of funds.

3. Area for Improvement-Management and Oversight: a. Quarterly reports are provided to

the Board; however, it was not clear that the level of detail of the reports is sufficient to

allow for an adequate assessment of the program. b. Reports for the monthly on-site

assessments are not shared with the hospital. Formal written feedback from the site

management process apparently is not being received. Recommendation: a. The

organization should ensure that the information provided to the Board is in enough detail to

adequately assess the spending of the program. b. The assessment reports completed by

AIDSRelief should be shared with the hospital’s finance and program leadership to

increase accountability. Reports can be used to measure resolutions to issues identified.


NYAKALIRO HEALTH CENTER

8 December 2010

BACKGROUND

The Nyakaliro Health Center is located in Sengerema District 45 km from Mwanza City. It is one

of four health centers in Sengerema district. The Health Center is owned by the Government of

Tanzania through Sengerema District Council. Nyakaliro Health Center was established in 1936 as

a dispensary and was upgraded to its current status in 1963. Currently it has more than 12 beds for

inpatient. The administrative and financial management oversight for the health center is provided

by the District Ministry Office in Sengerema.


Human resources functions for all of the health centers in the district are centralized from the

Ministry and carried out by an Administrative Officer. Supportive supervision for the health

centers is also provided from the District office in concert with the District hospitals on a quarterly

basis by the Regional Health Management Team (RHMT). The District is also responsible for

providing updates at the facilities in many clinical areas.

The District identified several challenges that impede their ability to do a better job of supporting

the district facilities: 1) lack of appropriate staffing at both the facilities and in the districts. The

MoHSW decides the staffing levels of each facility and the district office, but the funds to support

this come from a different department. Training versus seeing patients becomes an issue. 2)

Health centers cannot be closed for staff to attend trainings. 3) Transportation-there are only 2

vehicles for the district office. The islands for which the district is responsible are some 3-4 hours

road trip away and hard to reach.

Outreach is also a responsibility of the district office to show the community what is being given

to them and ask for their volunteering in return. 4) There is inadequate work space for the health

facilities and district offices and a lack of funding to support such infrastructure changes.

Personnel files were reviewed for five of the staff of the Nykaliro Health Center (2 clinical

officers, 2 nurses, and 1 medical attendant). Many of the previous facilities visited had raised

concerns about how staff members are rotated within districts and the criteria that were used. This

reviewer used this opportunity with the Acting DMO to learn the process. There is no information

maintained in the personnel files at this district office that would indicate the specialized training a

staff person had received to be considered when time for staff transfers. There is also no

information in the personnel file indicating the “real” contributions a staff person is making to the

facility that would affect a change in staffing.


1. The Acting DMO is very open to supporting HIV services and improving care and is very

knowledgeable of the facility challenges.


2. There is very detailed documentation of the oversight and monitoring efforts with the

district facilities.

3. New staff is being paired to provide more mentoring and ongoing training.


1. Area for Improvement-Supportive Supervision: There is currently no process to determine

the outcomes of supportive supervision. The Acting DMO identified that those responsible

for conducting supportive supervision may not bring the appropriate skills and training to

transfer their knowledge and skills to others. Recommendation: Consider developing a

scoring system or scale to decide how often supportive supervision visits should be made.

Consider having a technical team only for supportive supervision with no other

responsibilities. CSSC should be able to work to support this effort.

2. Area for Improvement-Transfer of Staff: The RMO makes decisions on the movement of

staff within the district, but there is not sufficient information available to make such

decisions. Recommendation: Consider asking staff for a skills/training status report as part

of the performance review process annually. The district could then use to help determine

staff rotations and transfers.

3. Area for Improvement-Staff Interviews: Interviews for non-clinical positions at the district

health facilities are conducted at the district offices, but management from the facility

where the employee is to work are not included in the interview process. Consider having

a member of the health facility management team participate in all staff interviews.

III. CLINICAL REVIEW

Overview

The Nyakaliro health center serves a rural clientele including some from hard to reach islands in

Lake Victoria. The health center offers outpatient services including general medical, antenatal

care, family planning and TB treatment. The health center relies on Sengerema DDH as the main

referral site but also for technical assistance and some laboratory services. There is a total of only

10 staff at the facility including two clinical officers and four nurses who are also primary care

providers. There were shortages of skilled staff and as a result staff multi-task. For example the

data entry is sometimes performed by a nurse.

The facility is not connected to the national electricity grid and there is no other reliable alternative

power. The computer for data entry for example is not working. There was also no running water.

At the time of the visit, the laboratory was not functioning because the staff member running it had

left for further studies.

HIV/AIDS Services

HIV and associated services are well integrated within other clinic services sharing the same

space, but are offered on different days. The HIV clinic (CTC) is open two days a week and on

those days there is a shortage of room to accommodate scheduled HIV clients and other general

unscheduled patients. VCT and PITC are offered at the facility and from January to November


2010, almost 700 patients were tested for HIV through PITC including 282 (40%) males and 417

females (60%). Of all those tested 169 (24%) were HIV positive. There is a robust maternity

service with about 40 deliveries per month. Almost all who attend ANC and those who give birth

at the facility get tested for HIV. Three percent (18/575) of pregnant women tested in 2009 were

HIV positive.

HIV care and treatment started in October 2008. Since then, 808 cumulative patients have been

enrolled in care including 228 who ever started ART. Of those who ever started ART, 172 (75%)

were still on ART as of September 2010. This retention rate is higher than other facilities visited

despite some of the patients served here coming from fishing communities in the islands who

reportedly move from place to place. Of those active on ART only 4 (2%) were children (<14).

Staff raised several challenges that affect the facility and these include patients who travel long

distances to seek care, frequent movement for some of the fishing communities, logistical

difficulties in conducting outreach, inadequate number of skilled staff, resistance to condom use,

alcohol abuse in some communities and inadequate space at the facility. There are only two HIV

providers who have received training in basic ART and TB/HIV, but have not received training in

pediatrics. This could partly explain the low number of children enrolled in care or on ART.

Chart Review

The level of documentation in medical charts does not reflect very good clinical care. Among

charts reviewed, staging was either inaccurate or inconsistent. While retention for patients on ART

is higher than in other sites visited, the staffs recognize it as an ongoing challenge especially

without resources for patient follow up. Chart review showed particularly inconsistent care with

high lost to follow up among those on pre-ART. The staffs have tried several activities such as the

use of volunteers, enrolling only those who show “commitment”, telephone calls and sometimes

“patients” themselves to follow up with their peers. Many patients have not had repeat CD4 tests.

In an additional attempt to reduce lost for pre-ART, staffs enroll patients 2 weeks after testing in

the assumption that those who are seen at two week time frames are more committed. This is not

an effective strategy.

Supportive Supervision

AIDSRelief does not provide direct clinical TA to health centers; instead staff from the health

center in this case receive supportive supervision visits from Sengerema DDH or are invited to the

district whenever the AIDSRelief team visits. Because of competing priorities the clinicians were

not able to attend at all times when they were invited. Even though the Mwanza region site

manager visits the health center, its unclear his visits focus on clinical or more programmatic and

systemic issues such as drug supplies. It is unclear how much supervision has been provided by

Sengerema DDH CTC staff to this health center. It is also not clear if this TA model for health

centers is effective. The team was unable to make this determination based on one health center

visit.

Home Based Care

Tunajali, a local partner supporting HBC serves this area and helps to track patients. Patients are

also used to track their fellow patients if they come from the same area.



1. Clinical services are integrated with general OPD maximizing the different staff capacities

and minimizing potential stigma associated with stand alone facilities. Only services days

on which different services are offered differ

2. The 4 staff running the HIV services are cross trained and multi task to alleviate staff

shortages

3. Stable patients are seen 2-monthly to minimize crowding during service days

4. There have been no stock-outs of drugs

5. Staff are very motivated and dedicated to their work


Priority Areas

1. Area for Improvement-Facility: There is not sufficient space to accommodate all patients

scheduled to attend the HIV clinic in addition to those with other general health problems.

This was evident on the day of the visit where patients were waiting in all places with

seemingly no clear flow. Some children were waiting in the same queues as adults. This

problem is more acute in the morning when patients all come. Recommendation: The

clinic needs to develop a clear patient flow to improve services on the days the CTC is

operational. It may be difficult to give exact appointment times to ensure that patients come

throughout the day, but patients who come from nearby should be reassured that the clinic

is open during the whole day and that they could opt to come in the afternoons. This would

leave mornings for patients who come from far and who have no control over the time they

arrive at the clinic. Consider increasing the number of CTC days from two to three to

accommodate needs.

2. Area for Improvement-Quality and continuity of care: The level of documentation in

medical charts does not reflect very good clinical care and staging was either inaccurate or

inconsistent. Chart review showed particularly inconsistent care with high lost to follow up

among those on pre-ART. Many patients have not had repeat CD4 tests.

Recommendation: Staff needs to be specifically trained to recognize problems such as

treatment failure adverse events. There is ongoing mentoring and supervision. Pre-ART

care should be prioritized with clear definitions and targets, improved linkage with HBC

teams supported by Tunajali and site service provision improvements that encourage

patients to come for follow up visits even though they are not on ART. Mortality meetings

and chart reviews may help identify additional areas for improvement.

3. Area for Improvement -Supportive Supervision and mentoring: It is not clear that the

supportive supervision received from the Sengerema DDH is sufficient to ensure that

quality care and treatment services are being provided to Nyakaliro patients.

Recommendation: There is need for ongoing mentoring and supervision to this HC and a

review/evaluation of the TA model used for HCs.


4. Area for Improvement-Laboratory. The lab was not functional at the time of the visit

because the single lab technician had just left for upgrade training. In the meantime patients

who need a TB diagnosis are sent to Sengerema DDH to give their sputum smears. The lab

has other ongoing challenges: 1) Access to CD4 is poor and dependent on the district

hospital which has its own challenges, and 2) there has been a regular stock out of reagents

and HIV test kits. Recommendation: Follow up with the district office is needed on the

filling of the lab technician position. Consider sending sputum samples to Sengerema

rather than asking patients to go individually.

5. Area for Improvement-Pediatric care. Of all patients active on ART, only 2% are children

(<14). This may reflect lack of testing of children or insufficient skills to identify and

manage HIV infected children. CD4 results for children do not reflect percentages.

Recommendation: Staff should be trained in pediatric care to replace those who have been

transfered. This should be followed by mentoring and specific initiatives undertaken to

ensure that children of index patients (esp. those <5 years) are offered testing, promptly

staged and prepared for ART. PITC should also be promoted in all general pediatric clinics.

Best Practices

6. Area for Improvement-Continuous Quality Improvement. CQI has not been implemented

at the site. There is no peer review of charts as a strategy to reduce errors and improve

quality. Recommendation: Initiate CQI methodology and encourage staff to implement

and document improvement strategies.

7. Area for Improvement-TB screening and diagnosis: TB screening and TB diagnosis has

several weaknesses at the site. The screening questionnaire is not administered at all visits,

and when administered there is inconsistency between the questionnaire and the clinician’s

assessment. There is clear follow up of suspects especially in the in the absence of sputum

examination at the site. Recommendation: Implement TB infection control strategies as

well as strengthening existing screening.


The fiscal review for Nyakaliro Health Center took place at the District Offices and included

interviews with the district and the project accountants.


The program financial records are maintained by the project accountant. The project accountant

reports to the district accountant who is responsible for the management of district expenses. The

district accountant, who has been with the district since 2003, has an advanced diploma in

accounting and reports directly to the district treasurer. There are currently eight accountants who

manage over 20 accounts for the district. Although the district has an internal audit department

and transaction audits are conducted monthly for programs; the PEPFAR program is not subjected

to these internal audits. The National Audit Office performs an annual external audit for all

programs. Completed audit reports are presented to the Council for review. The management team

meets to come up with the plan to resolve audit findings. The project accountant is included in

these CHMT meetings and efforts to resolve findings.


The AIDSRelief on-site management visits occur quarterly at the district level and monthly at the

site level. The site management staff is accompanied by the accountant from the district when

visits are made to the sites. Trainings for financial staff have been provided by AIDSRelief/CSSC

and others within the district have been invited to participate. For example, in a brief encounter

with the district planning director, the director informed this reviewer that he had attended the

AIDSRelief training and that “it was very informative”. AIDSRelief has recently completed its

own internal review of the program.

Payroll

The payroll is processed by the Ministry of Finance. Payroll reports are approved by the DMO, the

CO and the project accountant. Two health center staff is supported by the funds from AIDSRelief.

It was noted that there was a delay in the receipt of funds which delayed the payroll for the two

staff persons for the months of June and July 2010. (Funds were received on July 26 for the 2nd

quarter). It was unclear as to all the reasons for the delay. It was also revealed during the

assessment that the payroll taxes are not being paid for the AIDSRelief funded positions. It

appears that the problem is due to not having a vehicle such as the employer identification number.

Prior to leaving the district it appeared a potential solution had been put in place that would allow

the payroll taxes to be submitted.


The current accounting system for the PEPFAR program is a paper-based system where cash

books are maintained by the program accountant. However, the PEPFAR program is the only

program whereby the accounts are managed using a paper-based system. Other accounts are all

maintained using the EPICA system, an electronic accounting software application. Using EPICA

or another electronic accounting application would increase the efficiency in tracking and

reporting of expenses.


1. The District manages a comprehensive accounting software package known as EPICA.

2. The District accounting staff manages over 20 accounts and employs a total of eight (8)

accountants.

3. Trainings are provided annually by AIDSRelief/CSSC and on-site management is provided

quarterly at the district level and monthly at the site level.

B. Financial Management Areas for Improvement and Recommendations

Priority Areas

1. Area for Improvement-Payroll: a. There was a two month delay in payroll for the two staff

persons paid at the health center by AIDSRelief funds. Since funds were not received until

the end of July, the two staff persons waited for two months before being paid. b. The

AIDSRelief program has not been provided an employer identification number; therefore,

payroll taxes have not been paid since there has not been a vehicle in place to allow for the

transaction. Recommendation: a. AIDSRelief and the district should review the process


and the barriers that prevent the transfer of funds which created the delay in payroll for the

two staff persons. b. Prior to leaving the district a potential solution had been developed

for the payroll tax issue that would allow the district to submit the taxes using an existing

employer identification number. The program should follow through to ensure future

payroll taxes are paid.

2. Area for Improvement-Chart of Accounts/Data Security: The organization has a paper-

based accounting system that is maintained by the project accountant. The paper-based

system makes financial reporting very difficult and time consuming. Financial reports are

developed at the site level (health center) using Excel worksheets. Therefore there are

inefficiencies between the two systems. Recommendation: Since the district is financially

responsible and accountable for the funding, they should consider the implementation of

the accounting package that would provide greater flexibility in reporting and efficiency in

tracking and management of funds. Consider the EPICA accounting package which is used

by the district for the other programs or the QuickBooks accounting package.

3. Area for Improvement-Management and Oversight: The internal audit department of the

district performs monthly transaction reviews for programs within the district; however,

transaction reviews are not performed for the PEPFAR program. Recommendation:

Consider expanding the transaction review practice already in existence by the District to

the PEPFAR program. This would be an additional level of oversight that would be

beneficial to the program.


SHIRATI DESIGNATED DISTRICT HOSPITAL

9 December 2010

Background

Shirati Hospital is a 180 bed hospital belonging to the Mennonite Church of Tanzania located in

the newly created Rorya district in Mara region of northeastern Tanzania near the Kenya border. It

was initially constructed in the 1950s but underwent major renovations in 1972 increasing it to the

present capacity.

The hospital has recently been designated council or district status for the new Rorya district. Its

catchment area is about 300,000 people in the district although it also serves those from

surrounding districts.. The hospital also supports four health centers. With its new status as a

Council/District Designated Hospital, the facility is expected to receive additional support from the

GOT.

The hospital offers a range of outpatient and inpatient services as well a specialized clinic that

include that for HIV Care and Treatment, TB treatment, Burkitt’s lymphoma, leprosy treatment

and a rehabilitation center. Other outpatient clinics provide other primary health care services.

There are inpatient wards for children, adults (separate male and female) and a leprosy ward. All

diagnostic services include a centralized lab and radiological unit that provides x-rays and

ultrasound services. On average the hospital received 400 admissions and 270 new cases per

month in 2010.

I. CLINICAL REVIEW

HIV/AIDS Services

HIV is reported to be one of the major problems in the area in addition to malaria. In general Mara

region with an adult prevalence of 7.7%6 is one of the regions whose HIV prevalence increased

from its 2004 rate (3.5%)7 instead of decreasing as happened in other regions. At the hospital of

870 clients tested in the PMTCT program, 103 (11.8%) tested positive.

The hospital became an AIDSRelief/PEPFAR site in 2007. HIV related services at the clinic

include free standing VCT, PITC at almost all hospital departments, and HIV care and treatment at

the clinic’s 4 satellites. Mass screenings have been conducted in order to increase access to HIV

testing. By the end of September 2010, 2915 cumulative patients have been enrolled in care

including 1608 that had started ART. Of those who ever started ART, only 711 (44%) were still on

ART. This retention rate (44%) is much lower than other facilities visited. Some of those started

on ART had either transferred to other sites (37%) or died (27%) while 310 (35%) were

unaccounted for and were classified as lost to follow up. Of those active on ART only 4% (30)

were children (<14).

6 Tanzania HIV Indicator Survey 2007-2008

7 Tanzania HIV Indicator Survey 2003-2004


Other patients on ART were at the 4 satellite sites; Panyako (141), Nyamagaro (135), Changuge

(150) and Baraki (100). Some of these health centers were considered to have reached capacity to

run unsupported and instead two others at Nyirambo (Faith Based) and Bubumbi (Govt

dispensary) were to be taken on.

There are few staff at the clinic seeing a large number of patients. The large volume of patients

seen by each clinician cannot allow sufficient time and attention to ensure delivery of good clinical

care. Additionally some at the hospital staff have not been trained in HIV management i.e. many

of the doctors at the hospital whom CTC providers (clinical officers) turn to for consultation have

not received training. Staffs from other department are sometimes assigned to the CTC without

training or mentoring. A combination of these factors may affect the quality care patients receive.

Additionally, because of its elevation to District Designated Hospital status there will be increased

demands on existing staffs to provide more mentorship to lower facilities. It is unclear if the

existing staffing can currently meet this oversight function without adversely affecting HIV care at

the CTC.

Laboratory

The lab has several limitations and challenges in supporting HIV care. Several of these challenges

have been reported, but have not been resolved causing a lot of frustration for the staff.

Challenges include:

1. There is no machine to determine hemoglobin level. In light of the reported high

prevalence of anemia lack of testing for HB may lead inappropriate ART regimens being

started, i.e. Zidovudine.

2. The CBC machine has no controls.

3. The Chemistry machine has not been working for two years.

4. Supply of reagents for CD4 and for other tests are not consistently available.

5. CD4 machine, remaining from one of the research studies, has not been working for a long

time. Samples have had to be taken to Musoma, a journey that takes several hours by road

6. The Hood (biosafety cabinet) is not functioning.

7. There have been regular stock outs for Dry Blood Spots

There have been delays in getting results back. Of 64 tested between Jan –Nov 2010, only 28

results had been returned. Some of these samples may have been rejected or results were sitting

anywhere in the pathway (Shirati-Musoma-Bugando). The pathway was a recent recommendation

from the regional health office in Musoma that mandated sites to send samples to the region for

batching before relaying them to Bugando Medical Center for eventual DNA PCR (testing). A

similar pathway is reportedly used to receive results. According to staff this process led to longer

delays than when the hospital sent its samples directly.


PMTCT

PMTCT is well integrated within the ANC but the outcomes have not all been positive and not

well documented. Inspection of the HIV testing logs indicated that acceptance was only 34%. This

was likely because of how the test was offered and that room for patients to decline testing was

emphasized. Suggestions: Review the PITC protocol and ensure that staffs offer the test as

recommended. Conduct some exit interviews to find out why acceptance for testing is low and use

CQI methods to improve.

A. Strengths

1. There is very good management under the leadership of the medical director. Staff are also

very well motivated

2. Services are well integrated especially PMTCT where the program was well implemented

within the antenatal clinic. The PMTCT staffs were planning to collaborate with the CTC

to make ART available within the ANC both for prophylaxis and for those who needed

treatment.

3. The strategy whereby the hospital supports lower sites to start ART programs, supporting

them into independent sites is a good strategy in decentralizing care and probably is the

reason for some of the transfers out from the clinic.

4. Two of the 4 clinics originally supported were reported to have “graduated” and two new

ones were identified for additional support (see notes above)

5. The facility has provided several sites for PITC including in the OPD, in patient wards and

in phlebotomy.

6. All departments had staff trained in PITC and were providing testing with different

successes.

7. There has not been any stockouts of ARVs due to the good practices at the pharmacy

8. The clinic has initiated various CQI projects to address patients lost to follow up

B. Clinical Areas of Concern and Suggestions

Priority Areas

1. Concern-Facility. The CTC, which is housed in one of the old hospital buildings, cannot

accommodate all patients who come during clinic days. They fill the existing waiting area

and all walk ways. Suggestions: The clinic needs to urgently expand to enable staff to

work in a safe environment and for patients to have a sense of privacy. In the meantime,

staff should identify strategies to schedule patients and try different patient flow scenarios

to see which one alleviates the issue of patient flow. Groups of patients could be given

specific time slots in which they can be seen. A temporary shelter could be built to act as

the main waiting area from which a few patients enter the main clinic.


2. Concern-Staffing: The CTC specific staff providers at the clinic see large numbers of

patients, there is not sufficient time and attention given to ensure delivery of good clinical

care. The hospital staff who provide consultation to the CTC providers have not been

trained in HIV management. Staffs from other department are sometimes assigned to the

CTC without training or mentoring. With the new DDH status, there will be increased

demands on existing staffs to provide more mentorship to lower facilities. It is unclear if

the existing staffing currently meets this oversight function without adversely affecting

HIV care at the CTC. Suggestions: Provide more opportunities for HIV training to increase

the pool of providers.

3. Concern-Laboratory: The lab challenges are preventing appropriate information from

being available for the CTC and hospital staff to make appropriate care decisions.

Suggestions: AIDSRelief should work with the site to address some of the problems that

have been longstanding.

4. Concern-EID: Some EID samples are rejected yet no repeat samples are taken. Whenever

samples the feedback has not been received in a timely manner to allow taking additional

samples: Suggestions: Retraining of staff may minimize the number of samples rejected.

This is another area that CQI could be used to address.

5. Concern-Deliveries: A significant proportion of patients deliver at home or are lost to

follow up after testing in ANC and as such do not get the intervention: Suggestions:

Continued counseling should be provided to enable mothers to internalize the benefits and

timing of ART in prevention of infection to their unborn child. Strategies to minimize lost

to follow up and improve uptake could include: starting Mother Support Groups (MSGs)

which among other things identifies women who can motivate and influence their peers,

empowering pregnant women to counsel and support each other.

6. Concern-PMTCT: PMTCT is well integrated within the ANC but the outcomes have not

all been positive and not well documented. Inspection of the HIV testing logs indicated that

acceptance was only 34%. This was likely because of how the test was offered and that

room for patients to decline testing was emphasized. Suggestions: Review the PITC

protocol and ensure that staffs offer the test as recommended. Conduct some exit

interviews to find out why acceptance for testing is low and use CQI methods to improve.

7. Concern-Pathway testing: A new pathway (Shirati-Musoma-Bugando) was a recent

recommendation from the regional health office in Musoma that mandated sites to send

samples to the region for batching before relaying them to Bugando Medical Center for

eventual DNA PCR (testing). According to staff this process led to longer delays than

when the hospital sent its samples directly. Suggestions: AIDSRelief should facilitate a

discussion with regional health officials to find where the bottlenecks are in the process and

how they can be addressed. Explore whether it is possible to access Short Messaging

Printers for the site.

8. Concern- Continuity of care: Longitudinal care for patients remains poor. Review of

charts shows significant lost to follow up of pre-ART patients. Early mortality on ART

may reflect delay in initiation of ART, inadequate screening for different OIs, or just


patients lost to follow up coming back with more advanced disease. Suggestions: Regular

(peer) chart reviews, staff training, and study to clearly document loss to follow up.

9. Concern-Pediatric access to ART is low: Only 30 children (4% of patients ART) are

receiving ART. Suggestions: Clarify what strategy of testing is recommended by the

Tanzania PITC protocol; train staff on pediatric ART.

10. Concern-TB screening: Inspection of a few chats showed good documentation in general,

but also a few inconsistencies between findings on the TB screening form (filled in at

triage) and clinician’s assessment and subsequent follow up of the patients. Suggestions:

There is need to review the entire process of TB screening from how the screening form is

administered to when and how follow up actions are documented. Staff at triage may

require re-orientation or training in how to identify TB symptoms, how to accurately record

the findings


HRSA ClASS Visit Schedule

Monday, November 29th

– Monday, December 13th

, 2010

Team A: Juanita & Cheryl Team B: Moses & Philippe

Date Day Activity

Monday November 29th

, 2010 AM - Introduction Visit at CDC

AM - Introduction Visit at MOH

PM - Introduction Visit at AIDSRelief

PM - Introduction Visit at CSSC

Tuesday November 30th

, 2010 ClASS at AIDSRelief Tanzania Office

Wednesday December 1, 2010 ClASS Assessment at CSSC

Thursday December 2, 2010 Team A – ClASS Assessment at CSSC

Team B – Hydom Hospital – Manyara

Friday December 3, 2010 Mbulu District Hospital – Manyara

Saturday December 4, 2010 Weekend in Arusha Area

Sunday December 5, 2010 Weekend in Arusha Area – Fly to Mwanza in the afternoon

Monday December 6, 2010 Bugando Medical Center – Mwanza

Tuesday December 7, 2010 Sengerema District Designated Hospital (DDH)– Sengerema

Wednesday December 8, 2010 Nyakaliro Health Centre – Sengerema

Thursday December 9, 2010 PUBLIC HOLIDAY – Travel to Mara in the afternoon

Friday December 10, 2010 Shirati DDH – Mara

Saturday December 11, 2010 Travel from Mara to Mwanza. Fly from Mwanza to Dar.

Sunday December 12, 2010 Preparation of Debrief Presentations

Monday December 13, 2010 AM – Debrief to CDC Tanzania

AM – Visit to MOH Chiliade

PM - Debrief to AR TZ and then CSSC

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