Scale-Up Strategy for Essential Medicines for Child Health: Tanzania

Publication date: 2012

ESSENTIAL MEDICINES GLOBAL INITIATIVE – TANZANIA              THE UNITED REPUBLIC OF TANZANIA         MINISTRY OF HEALTH AND SOCIAL WELFARE SCALE-UP STRATEGY FOR ESSENTIAL MEDICINES FOR CHILD HEALTH DIARRHEA, MALARIA AND PNEUMONIA 2012-2015                March 2012  ESSENTIAL MEDICINES GLOBAL INITIATIVE – TANZANIA  Acronyms  1. Executive summary    2. Analysis & strategic context  2.1. Access to essential medicines  2.1.1. Sources of treatment – public and private sector landscape  2.1.2. Access to and rational use of diarrhea treatment   2.1.3. Access to and rational use of malaria treatment  2.1.4. Access to and rational use of pneumonia treatment  2.2. Assessment of key barriers to access and rational Use  2.2.1. Cross‐disease Barriers   2.2.1.1. Patient, caregiver, and service provider barriers 2.2.1.2. Supply Barriers  2.2.2. Diarrhea Barriers  2.2.2.1. Patient, caregiver, and service provider barriers  2.2.2.2. Supply Barriers  2.2.3. Malaria Barriers  2.2.3.1. Patient, caregiver, and service provider barriers  2.2.3.2. Supply Barriers  2.2.4. Pneumonia Barriers  2.2.4.1. Patient, caregiver, and service provider barriers  2.2.4.2. Supply Barriers    2.3. Current MoH/Partners’ Efforts and identification of priority areas    3. Proposed program of targeted interventions  3.1. Vision     3.2. Overview of key deliverables & outcome targets    3.3. Detailed description of targeted interventions  3.3.1. Intervention 1  3.3.2. Intervention 2  3.3.3. Intervention 3  3.3.4. Intervention 4  3.3.5. Intervention 5  3.3.6. Intervention 6  3.3.7. Intervention 7    4. Workplan & budget  4.1. High‐level Workplan  4.2. High‐level Budget, USD    5. Implementation arrangements  5.1. Monitoring & evaluation  5.2. Risk assessment    6. References    7. Annexes  7.1. Detailed workplan  7.2. Detailed budget, USD (without commodities)  7.3. M&E Log Frame  7.4. Results Framework  ESSENTIAL MEDICINES GLOBAL INITIATIVE – TANZANIA  ACRONYMS  ACT - Artemisinin-Combination Therapy ADDO – Accredited Drug Dispensing Outlets BCC – Behavior Change Communications c-HMIS – community Health Management Information System c-IMCI – community-Integrated Management of Childhood Illness C4D – Communication for Development CCAs – Community Change Agents CCHP – Comprehensive Council Health Plans CHA – Community Health Attendants CHMT – Counsel Health Management Team CHSB – Counsel Health Service Board CHW – Community Health Worker CORPS – Community Owned Resource Persons dIMCI - paper-based distance learning IMCI DHMT – District Health Management Team DLDB – Duka la Dawa Baridi = private drug shops EMI – Essential Medicines EMLc – Essential Medicines List for Children EPI – Expanded Programme of Immunization GMP – Good Manufacturing Practices GoT – Government of Tanzania HMIS – Health Management Information System, HRH – Human Resources for Health IEC – Information, Education and Communication iCCM – integrated Community Case Management IMCI – Integrated Management of Childhood Illness IPC – interpersonal communications ITN – Insecticide Treated Net LQAS - Lot Quality Assurance Sampling MDG – Millennium Development Goals MMAM – Primary Health Services Development Programme MNCH – Maternal, Neonatal and Child Health MOHSW – Ministry of Health and Social Welfare MSD – Medical Stores Department MSH – Management Sciences for Health MUHAS – Muhimbili University of Health and Allied Sciences NbCH – Newborn and Child Health Unit within the Reproductive and Child Health Section of the MOHSW NFSD - Novartis Foundation for Sustainable Development NIMR – National Institute for Medical Research NMCP – National Malaria Control Program NACP – National HIV/AIDS Control Program One Plan – National Road Map Strategic Plan to Accelerate Reduction of Maternal, Newborn and Child Deaths in Tanzania 2008-2015 ORS – Oral Rehydration Solution OTC – Over-the-Counter PHASTs - Participatory Hygiene and Sanitation Transformation POUZN/AED - USAID-funded Point-of-Use Water Disinfection and Zinc Treatment project won by AED RCHS – Reproductive and Child Health Section of the MOHSW RDT – Rapid Diagnostic Test RHMT – Region Health Management Team ROI – Return on Investment SMI – Safe Motherhood Initiative SP – Sulfadoxine - pyrimethamine TDHS – Tanzania National Demographic and Health Surveys TFDA – Tanzania Food and Drugs Administration UNICEF – United Nations Children’s Fund VHW – Village Health Worker WASH – Water, Sanitation and Hygiene WHO – World Health Organization ESSENTIAL MEDICINES GLOBAL INITIATIVE – TANZANIA  1 1. EXECUTIVE SUMMARY  Results from the Tanzania National Demographic and Health Surveys (TDHS) and other health surveys over the years suggest a significant drop in child and infant mortality 1. Comparing the baseline child mortality statistic of 191/1,000 births 2 to the TDHS 2010 statistic of 81/1,000 1 suggests a 58% drop in child mortality between 1990 and 2010. The surveys and analyses state that if the pace of decline in child mortality is sustained, Tanzania will be able to reach Millennium Development Goal 4 by 2015 1,2,3. To reach the Government of Tanzania’s (GoT) 2015 target of reducing child mortality to 54/1,000 births, as stated in the National Strategy for Growth and Reduction of Poverty II, 2010 4, however, an additional 33% reduction in child mortality is necessary.     The global Essential Medicines Initiative (EMI) proposes a focused goal on achieving universal coverage in ORS/zinc for diarrheal disease, ACTs for malaria, and dispersible amoxicillin for pneumonia by 2015 to help key countries like Tanzania reach MDG 4 by 2015. This focused approach is valuable for Tanzania where a rather low percentage of children under five access appropriate first-line treatments for diarrhea, malaria and pneumonia. While almost half of children sick with diarrhea receive a form of ORS for diarrhea treatment, sometimes with zinc included, only 4.7% receive zinc as a separate part of that treatment 1. 36.8% with fever received ACTs as treatment, but only 25.9% within the recommended 24 hour timeframe 1. The last official statistics collected for pneumonia from the TDHS 1991-92 show that only 22% of sick children received antibiotics 5. The fact that treatment statistics are not systematically collected for pneumonia and are over twenty years old underlines the lack of attention given to this main cause of under-five mortality and suggests that the treatment access challenge is probably similar twenty years later. On the positive side, the percent of caregivers seeking treatment for their children sick with diarrhea (53%), malaria (65%) or pneumonia (71%) is systematically higher than the percent accessing appropriate treatment 1. An immediate priority, therefore, is ensuring access to appropriate treatment and quality services for those already seeking care, which is well- aligned with the EMI. Furthermore, focusing on treatment availability and reduced stock-outs will also increase care- seeking, as stock-outs at public facilities are often cited as reasons for not seeking care 6, 7.    The EMI goal of universal coverage in ORS/Zinc for diarrhea, ACTs for malaria and dispersible amoxicillin for pneumonia requires a mix of interventions that respond to persistent bottlenecks and challenges across areas such as supply and service access, quality of services, and knowledge and demand in order to promote the rational use of services and treatments. Since care-seeking is above average in Tanzania, Tanzania presents a Strategy below that allows a comprehensive priority response to rational treatment, but in such a way that care-seeking will be promoted, as well. At the heart of the Strategy outlined in this document is a commitment to cost-effective, innovative solutions that play on the strengths of the public and private sector and support the important community-level efforts already taking place. The Strategy proposes 3 objectives and 7 interventions intended to contribute to the goal of universal coverage:  Objective 1: Improve availability and accessibility of essential medicines and commodities for pediatric care at the facility and community level through the public and private sectors by strengthening existing supply chain management systems It is supported by four interventions: (1) Expand TFDA registration fast-tracked Priority Products List and register key EMLc Drugs; (2) Roll-out of diarrheal treatment corners and launch of pre-packaged ORS/zinc through the public and private sector; (3) Adaptation and scale-up of proven mHealth monitoring system; (4) ADDO network access strengthening  Objective 2: Improve ability of health care providers to provide quality pediatric care services and promote rational use of pediatric diarrhea, malaria and pneumonia essential medicines by building health care provider capacity across the different sectors It is supported by one intervention: (5) Roll-out of ICATT IMCI training and alignment with a motivation/incentives system to active linkages  Objective 3: Increase informed demand for child health services by implementing comprehensive and integrated communication strategies promoting child health services, products and behavior change It is supported by two interventions: (6) Targeted advocacy campaign promoting the Strategy at all levels; (7) Targeted BCC campaign to promote rational diarrhea, malaria & pneumonia diagnosis and treatment The MOHSW is committed to improving access to rational diagnosis and treatment of diarrhea, malaria and pneumonia in order to reach universal coverage and continue on its path toward fulfilling MDG 4 by 2015. This Strategy and its vision are seen as essential to meeting these goals. ESSENTIAL MEDICINES GLOBAL INITIATIVE – TANZANIA  2   2. ANALYSIS & STRATEGIC CONTEXT    2.1 Child mortality and overall access to healthcare    Results from the Tanzania National Demographic and Health Surveys (TDHS) and other health surveys over the years suggest a significant drop in child and infant mortality (see Table 1 below) 1. Comparing the baseline child mortality statistic of 191/1,000 births 2 to the TDHS 2010 statistic of 81/1,000 1 suggests a 58% drop in child mortality between 1990 and 2010. Other analyses, such as the Child survival gains in Tanzania: analysis of data from demographic and health surveys regression analysis by Honorati Masanja, Don de Savigny, Paul Smithson, et al., also suggest reductions of up to 40% between 1990 and 2004 3. These surveys and analyses state that if the pace of decline in child mortality is sustained, Tanzania will be able to reach Millennium Development Goal 4 by 2015 1,2,3. Tanzania’s success is often attributed to its aggressive work to expand immunization, provide Vitamin A supplementation, control malaria, and introduce IMCI, as well as its health sector decentralization, basket-funding approach and increased public expenditures on health 3. To reach the Government of Tanzania’s (GoT) 2015 target of reducing child mortality to 54/1,000 births, as stated in the National Strategy for Growth and Reduction of Poverty II, 2010 4, an additional 33% reduction in child mortality is necessary. A focused and integrated response to major causes of child mortality, such as malaria (16%), pneumonia (13%) and diarrheal disease (11%) 51 is required with a special new focus on the most neglected of these three, pneumonia and diarrheal disease. This additional push will also require moving beyond current child survival interventions to respond to persistent bottlenecks and challenges across areas such as access to treatment and supply chain management, care-seeking and demand for services, and policy environment. Linkages across public, private and community levels will also need to be considered and potentially reinforced to promote efficiencies. As stated in the United Republic of Tanzania Ministry of Health and Social Welfare (MOHSW)’s Primary Health Services Development Programme – MMAM 2007-2017, “To be able to reach the MDG [Millennium Development Goal] 4 & MDG 5 targets by 2015 substantive efforts has to be made in strengthening the existing system and expand and decentralize further services, this implies a comprehensive approach is required to improve coverage within all districts with emphasis of reaching every child and woman and youth with essential effective interventions 6, pg.28.” Table 1: Context Snapshot General Information Under-five Mortality 1990 191/1,000 births (see graph) 2 Source: TDHS 2010 and PHDR 2009 2 Under-five Mortality TDHS 2004-5 112/1,000 births 1 Under-five Mortality TDHS 2010 81/1,000 births 1 Under-five Mortality 2015 Target MDG = 64/1,000 2 and GoT = 54/1,000 4 Diarrhea Malaria Pneumonia Prevalence (% in the two weeks preceding survey) 15% 1 23% 1 4% 1 Mortality 11% 51 16% 51 13% 51 Care-seeking Of the children under five who had symptoms in the two weeks preceding the survey, % taken to see a health care provider/facility 53% 1 65% (fever) 1 71% 1  Treatment Coverage Appropriate first-line treatment 44% (ORS or ORS/zinc) 1 36.8% (ACTs, at all) 25.9% (ACTs within 22% (antibiotics, per TDHS 1991-92) 5 1Mortality statistics in the Countdown to 2015 2010 Report, United Republic of Tanzania state the source as WHO/CHERG 2010 5  ESSENTIAL MEDICINES GLOBAL INITIATIVE – TANZANIA  3 4.7% (Zinc) 1 24hrs) 1 Dispersible Amoxicillin – n/a Primary Alternative Antibiotics 12% (Quinine) 1 Cotrimoxazole Other treatments (even if against policy) Pill/syrup (49.8%) 1 IV (0.5%) 1 Home Remedy/Other (6.8%) 1  Amodiaquine (7%) 1 SP/Fansidar (3%) 1 Chloroquine (0.1%) 1, others (1% or less each) 1 IV or Crystapen injection 7   The global Essential Medicines Initiative (EMI) proposes a focused goal on achieving universal coverage in ORS/zinc for diarrheal disease, ACTs for malaria, and dispersible amoxicillin for pneumonia by 2015 to help key countries like Tanzania reach MDG 4 by 2015. This focused approach is valuable for Tanzania where Table 1 above shows a rather low percentage of children under five accessing appropriate first-line treatments across diarrhea, malaria and pneumonia. While almost half of children sick with diarrhea receive a form of ORS for diarrhea treatment, sometimes with zinc included, only 4.7% receive zinc as a separate part of that treatment 1. Furthermore, 16.6% of children with diarrhea do not receive any form of treatment, and 40% were offered less fluid than usual or were given no fluids at all 1. Curtailing fluids is a dangerous practice and can exacerbate the diarrhea case 1. 36.8% with fever received ACTs as treatment, but only 25.9% within the recommended 24 hour timeframe 1. In terms of pneumonia, the last official statistics collected for pneumonia from the THDS 1991-92 show that only 22% of sick children received antibiotics 5. While these statistics suggest a challenge related to accessing appropriate pneumonia treatment, they are over twenty years old, and so the situation might have changed, but more recent statistics are not available to track the changes. The fact that treatment statistics are not systematically collected for pneumonia and are over twenty years old underlines the lack of attention given to this main cause of under-five mortality and suggests that the treatment access challenge still remains. On the positive side, the percent of caregivers seeking treatment for their children sick with diarrhea (53%), malaria (65%) or pneumonia (71%) is systematically higher than the percent accessing appropriate treatment 1. An immediate priority, therefore, is in fact ensuring access to appropriate treatment and quality services for those already seeking care, which is well-aligned with the EMI. Furthermore, focusing on treatment availability and reduced stock- outs will also increase care-seeking, as stock-outs at public facilities are often cited as reasons for not seeking care 6, 7. 2.1.1 Sources of treatment – public and private sector landscape Primary care is free at public facilities for children under five and pregnant women in Tanzania. Regardless of this incentive, limited accessibility to public health facilities, long lines and wait times, and frequent stock-outs of essential medicines often drive caregivers to seek care elsewhere, particularly in the private pharmacy sector 7. According to the USAID/BASICS Improving Child Health through the Accredited Drug Dispensing Outlet (ADDO) Program: Baseline Survey from the Five Districts in Tanzania, September 2006, it was estimated in 2006 that there were “more than 6,000 DLDBs [Duka la Dawa Baridi, private drug shops] across all districts in the country; over 50 percent more than all public health facilities and 11 percent higher than all public, voluntary, and religious facilities combined 7, pg.1.” As such, the country has embarked on the ADDO Program to establish a network of privately-owned, regulated and accredited DLDBs that provide non-prescription and a limited number of essential prescription medicines from trained, quality-assured dispensers in more remote areas without easy access to public facilities 7. The ADDO Program that started under USAID/BASICS is now being rolled-out nationwide by the TFDA supported by MSH and the Global Fund Round 7 for Malaria. All regions are expected to be covered in 2012. As expressed in the article by Edmund Rutta, Katie Senauer, Keith Johnson and Grace Adeya, Creating a New Class of Pharmaceutical Services Provider for Underserved Areas: The Tanzania Accredited Drug Dispensing Outlet Experience, the Program has been successful and has provided much needed treatment and service 8. There is an important opportunity to focus on reaching universal coverage through further strengthening ADDO network quality of services and treatment access. On the community-side, Tanzanian policy currently promotes c-IMCI and the distribution of ORS via 8 trained CORPS (Community-owned Resource Persons) per village plus two Community Health Workers, but does not allow the distribution of any other child survival treatments. The GoT has written policies against integrated Community Case Management (iCCM) given its experience ten years ago with Village Health Workers (VHW). VHWs were trained in the past in iCCM and provided with a health kit (ORS, cotrimoxazole, Chloroquine, eye ointment, etc.). The model, however, was unsustainable and required donor support. When donor support ran-out, medicine availability dropped and VHW motivation declined, causing a community backlash. Policy was then written against community distribution of drugs. Recently, the WHO and UNICEF are leading an effort to establish a Tanzania context- appropriate formalized cadre of CHWs, based on needs outlined in Tanzania’s Primary Health Services Development ESSENTIAL MEDICINES GLOBAL INITIATIVE – TANZANIA  4 Programme – MMAM 2007-2017. The team is working with the Ifakara Institute to establish the curriculum, job aides, selection criteria, and recruitment and training packets. Three pilot districts were deployed in July 2011 and the Ifakara Institute is conducting the assessment of the model. After review of the situation, both in terms of other country experience and the WHO/UNICEF CHW work, the MOHSW has decided to introduce a new cadre of health worker, called the Community Health Attendant (CHA), to replace the CORPS. As paid MOHSW personnel, the CHAs will be responsible for interpersonal communications and iCCM outreach from the public health facility to the village. The roll-out of the CHAs is a new development and has not begun yet. It is being prioritized and funded by the MOHSW and is expected to have an important positive impact on linking the community into the health system to help improve maternal and child health. Another important aspect of Tanzania’s treatment landscape is its very specific supply chain for medicines, and especially essential medicines (see Figure 1 below). All imported and locally manufactured medicine procurements must pass through the Medical Stores Department (MSD) of the MOHSW. The MSD was created in 1993 and is a non-for-profit, semi-autonomous single agency owned by the government and an independent department within the MOHSW 9. According to Nesia Satoki Mahenge’s 2010 analysis of the MSD’s July 2010 Stakeholder Meetings in her study Pharmaceutical supply chain and distribution network, Implications on access to medicine and quality health care: Critical analysis of the public pharmaceutical sector in Tanzania, 80% of the medicines are imported and 20% are procured locally 9. The MSD then manages storage and distribution to the public sector through nine zonal medical stores which are situated in nine different regions throughout Tanzania. The zonal medical stores then distribute to the health facilities. The MSD works in close collaboration with the Tanzania Food and Drugs Administration (TFDA), which is focused on drug regulation, quality control and assurance, and pharmaceutical public and private sector inspections. 9 For many years, starting in 1983, Tanzania’s health system drug procurement and distribution system was based on a kit system by which facilities receive essential drugs rationed out based on a predetermined quantity rather than demand 10. According to the Tanzania: Integrated Logistics System Pilot-Test Evaluation: Using the Logistics Indicator Assessment Tool, the indent system was introduced in the 1990s by the Pharmaceutical and Supplies Unit (PSU) “to transfer drug ordering from the central to the district level 10, pg.3.” The indent system has currently only been rolled-out to about half of the facilities, however 10, pg.5. The indent system is an important improvement in Tanzania’s procurement system, in that it allows a transition from the “push supply” of the kit system to a “pull supply” based on demand and health district needs, reducing waste and stock-outs. In 2002, the MOHSW approached JSI/DELIVER for technical assistance in integrating the logistics systems of many of its vertical programs into an Integrated Logistics Systems (ILS). The ILS was meant to take the improvements of the indent system “a step farther by including most or all vertical programs and the EDP in the same system. The ILS introduced routine reporting of data coupled with routine ordering of resupplies, which enhances accountability and provides the central level with data for decision- making, particularly forecasting 10, pg.3.” The ILS was initially piloted and Tanzania now has funding through 2013 to finalize the roll-out of the ILS to facilities nationwide. Electronic Logistics Management Information Systems (eLMIS) have been introduced in Tanzania to further strengthen the drug procurement and distribution system (please see Section 3, Intervention 3 for more information). ESSENTIAL MEDICINES GLOBAL INITIATIVE – TANZANIA  5 Figure 1 Pharmaceutical Supply Chain and Distribution Network in Tanzania 2.1.2 Access to and Rational Use of Diarrhea Treatment  Zinc and ORS were approved by the TFDA as Over-the-Counter (OTC) drugs in July 2009, thanks to a strong advocacy campaign led by the AED USAID-funded Point-of-Use Water Disinfection and Zinc Treatment (POUZN/AED) project 11. The GoT started to procure zinc from its own budget in 2009 11. There still seems to be low awareness of the fact that zinc is OTC, however, which has limited its distribution, especially through CORPS. There are, however, health facility and CORPS refresher trainings on diarrhea using the updated IMCI guidelines and national training curriculum that include zinc policy and treatment information. The IMCI Implementation in Tanzania: Experiences, Challenges and Lessons report suggest that only 14% of service providers are up-to-date on IMCI trainings 12. To bolster IMCI trainings, Diarrheal Treatment Corners have been reactivated at the peripheral level to promote diarrhea prevention and rational treatment. 20-30 wall charts have been provided per district, but more are needed. In the private sector, ORS sachets run about $0.08 and zinc costs between $0.40-$0.80/course. Overall, market penetration and coverage for zinc is low. The % of outlets with zinc ranges from 47%-65%, depending on the outlet type 13. The exception is pharmacies, as 80% carry zinc 13. Only 70% of the wards have at least one outlet with zinc 13. In terms of ORS, on the other hand, market penetration and coverage is better, with around 83% of the wards having at least one outlet with ORS, and 82% of facilities nationally with ORS 13. 2.1.3 Access to and Rational Use of Malaria Treatment  A significant portion of the MOHSW budget is committed to the control and prevention of malaria 1. District IMCI/malaria focal points are trained and deployed to follow malaria issues such as availability of ACTs, SP and ITN vouchers and case management quality in their district facilities. Multiple grants support malaria treatment with ACTs, Local Manufact Internatio nal 197 Registered Private Wholesalers External Procurem MS MSD pool of Essential Drugs MSD Procurement P MSD Procurem Essential Vertical Program Indent Stock Distri Hospital Primary Health 352 Registered Private Pharmacy 6000 Duka la Dawa baridi Essenti l Essent Patient Vertical Program Essentia l Drugs Source: Adapted from Euro Health Group: Tanzania Drug Tracking Study (2007) 9 ESSENTIAL MEDICINES GLOBAL INITIATIVE – TANZANIA  6 including multiple GFATM rounds and PMI work focused on ACT and RDT procurement and training in case management and diagnostics 14. ACTs are available at a subsidized price through the public sector, $0.60-$1.10 or full- price in the private sector at $6-$11. The MOHSW changed the treatment guidelines for malaria in the 1st quarter of 2010 from presumptive treatment of children under five to required parasitological diagnosis prior to treatment. The change was to be accompanied by a roll-out of RDT at peripheral health facilities, but the process has been slowed, leaving a lag between the policy change and the ability to implement the change. 2.1.4 Access to and Rational Use of Pneumonia Treatment  While pneumonia typically has not received much policy or intervention attention, there was a recent first-line treatment policy change in September 2011 from cotrimoxazole to dispersible amoxicillin. While TFDA regulations are changed, budgets are put in place, and stocks are obtained, it looks like the policy will accept both cotrimoxazole and dispersible amoxicillin as first-line treatments for the interim. In the meantime, Cotrimoxazole penetration is only at 66% of eligible outlets 13.   2.2 Assessment of key barriers to Access and Rational Use    The previous section hints at some important barriers related to access and rational use of treatment for three of the main causes of child mortality in Tanzania. Table 2 outlines key cross-cutting and disease-specific barriers to access and rational use of appropriate treatments related to patient demand and/or the public and private sector. Table 2: Barriers Across Diseases and Sectors    Patient  Public sector supply/provision (incl. community‐level)  Private sector supply/provision  Cross‐ disease   (a) Insufficient care‐seeking  behavior  (b) Outcome expectations that  syrups, antibiotics,  prescription drugs and IVs  are more effective  (c) Missed opportunity to raise  demand by raising child  health awareness among  fathers, traditional healers,  birth attendants and  mothers  (d) Misunderstanding the  importance of finishing a  full course of treatment  (e) Low consumer confidence  in certain drug quality  (a) Poor coordination and linkages  across the health sector (i.e.  between dispensaries, community‐ level CORPS and private sector  ADDOs).  (b) Drug, supply, equipment  procurement bottlenecks  (c) Limited reporting/supervision  associated with HMIS, and minimal  c‐HMIS  (d) Over‐prescription of non‐first‐line  treatments  (e) Insufficient/outdated public sector  training  (f) Need for updated iCCM policy  officially introducing CHAs   (g) HRH crisis  (h) Vertical health programming (NMCP  and NACP)  (i) Poor mainstreaming of child survival  interventions and Village Health  Committee plans into CCHP and  Overall Council Plans  (j) No comprehensive, in‐depth  assessment of child survival efforts  and needs  (k) Community agents work in silos  (l) Attrition of trained CORPS  (m) Poor coordination of partner work  at the community level  (a) ADDO Stock‐outs  (b) Slow scale‐up of the ADDO  project  (c) Drop‐out of trained ADDO drug  suppliers  (d) Irrational drug sale by  pharmacists/drug shops  (e) ACTs and antibiotics are not  OTC, limiting access    Diarrhea  (a) Low awareness of Zinc  among caregivers &  providers  (b) Insufficient/incorrect care‐ (a) Limited zinc awareness among  CHWs  (b) Public facility stock‐outs, despite  stock piles expiring  (a) Low zinc market penetration  and coverage  (b) Separation of ORS and zinc,  both in terms of packaging and  ESSENTIAL MEDICINES GLOBAL INITIATIVE – TANZANIA  7     2.2.1 Cross‐disease barriers    2.2.1.1 Patient, caregiver, and service provider barriers Ensuring availability of treatment alone will not ensure its proper and rational use or sustainable demand for its existence. In Tanzania, there are important barriers related to outcome expectations on both the caregiver and service provider sides that antibiotics, prescription drugs, injections and syrups are more effective than other types of treatment. There is a further resistance and skepticism on the caregiver-side that treatments that require self- preparation, such as ORS, do not “cure” 11. The preference leads to increased demand for prescription drugs, increasing their stock, and reduced demand for non-prescription drugs, such as ORS/zinc, reducing their stock. Using the case of pneumonia as an example, the USAID/BASICS Improving Child Health through the Accredited Drug Dispensing Outlet Program 2008 baseline qualitative survey found that mothers cited crystapen injection as the preferred treatment for pneumonia 7. The report also cited high rates of service providers prescribing IV/injections and antibiotics rather than the first-line treatment 7. As a further diarrhea example, of those who sought care for their children sick with diarrhea per the TDHS 2010, 50% received syrups/pills as treatment, compared to 44% ORS or ORS/zinc 1. The GoT and partners suggest that the drug budget is twice the expected amount (based on statistics) because providers are prescribing and ordering irrationally. As an additional rational use and demand barrier, the USAID/BASICS baseline qualitative survey also found that caregivers admitted to saving medicine by stopping treatment before all the medicine was used, especially when the medicine is in tablet or syrup form 7. In terms of service provision extension via community workers (IEC and ORS only), there is currently little collaboration of efforts at the community level, and as such, there has been a multiplication of vertical and sectorial seeking behavior (53%)1  (c) Outcome expectations  favor syrups and  antibiotics, rather than  ORS/zinc 11.  Resistance to  treatments that require  self‐preparation   (d) Continued and increasing  practice of curtailing fluid  intake when children have  diarrhea 1  (c) Slow dissemination of changed  policies regarding diarrhea  treatment  (d) Insufficient supervision, job aides  and wall charts in facilities  (e) Limited dissemination of policy  change that ORS and zinc have OTC  status has limited access    solution  (c) Private sector stocks less ORS  than is actually needed, given  low demand and ROI  (d) Stock expiration due to limited  purchase  (e) Limited dissemination of policy  change that ORS and zinc have  OTC status has limited access   Malaria  (a) Over‐diagnosis of malaria  creating excess demand for  a malaria response  (b) Use of ITNs less than  access  (c) Reduction in already  insufficient care‐seeking  (65%)1  (d) High ACT cost    (a) Service provider over‐diagnosis of  malaria  (b) Stock‐outs and irregular availability  of ACTs and RDTs at public health  facilities, especially in rural areas  (c) Inadequate public health facility  service provider training following  NMCP guidelines  (d) Inadequate public health facility  Supervision  (e) Questionable quality of  IMCI/malaria focal point services  (f) Missed opportunity to integrate  other training into CCAs for holistic  child health promotion  (a) Slow scale‐up and stock‐out of  the ADDO program  (b) ADDOs and pharmacies not  allowed to perform malaria  diagnosis using RDTs  (c) No local manufacturer  currently has WHO GMP status  to be able to produce and sell  ACTs to donors  (d) ACTs are not OTC, limiting  access  Pneumonia  (a) Misdiagnosis of pneumonia  as malaria  (b) Irrational drug use and  preference for crystapen  injections 7  (c) Insufficient care‐seeking  behavior (71%)1  (d) Limited easy, cost‐effective  prevention options for  pneumonia  (a) Lack of resources allocated to  pneumonia (treatment data not  collected since TDHS 1991‐92)  (b) Challenge of recent policy change to  dispersible amoxicillin  (c) Over‐prescription of non‐first‐line  treatments, especially IV/injections  and syrups  (d) Service provider misdiagnosis of  pneumonia as malaria  (a) Low private sector market  penetration  (b) Dispersible Amoxicillin is not  yet registered with the TFDA  (c) Antibiotics are not OTC,  limiting access    ESSENTIAL MEDICINES GLOBAL INITIATIVE – TANZANIA  8 efforts establishing parallel systems of community agents, such as Community Change Agents (CCA) for malaria, Community Based Distributors for family planning, PHASTs for WASH, CHW/IMCI agents for c-IMCI, and FastTrack for maternal health purposes. The multiplication of efforts is not only an inefficient use of already-limited resources, but has overwhelmed communities and created confusion in terms of care-seeking and treatment messages. The MOHSW feels strongly that this multiplication of effort is a waste and intends to introduce the new cadre of CHAs explained above in order to replace the CORPS and the multiple types of community agents. 2.2.1.2 Supply Barriers Break-downs in the Tanzania supply chain impact essential medicine availability. As cited by Nesia Satoki Mahenge, “the findings of that report [Mariacher, G.G., (2008); “Drug Donation in Tanzania: Stakeholders’ Perception and Knowledge”2] indicated that Tanzania has a 30% supply gap of essential medicines 9, pg. 50.” There are multiple reasons for this gap. The MSD cannot procure essential medicines without government funding, but insufficient funding, budget constraints and delays are common. If the MSD is stocked-out of an essential medicine, the process for facilities to get approval to procure elsewhere is cumbersome. As a result, facilities stock-up to avoid stock-outs, which can lead to drug expiration and waste 9. 9 Funding delays make it necessary to lengthen already long lead-times to procure internationally and then distribute the drugs to communities. Long lead-times require strict planning, and yet planning is one of the supply chain stumbling blocks. Given irregular reporting and use of the Health Management Information System (HMIS), errors in reporting, and inadequate HMIS training, the procurement data sent through the system is unreliable and often represents a mismatch between supply and demand. The Indent System described above, based on “pull” supply, has only been rolled-out in about 50% of the districts 10, pg.5 and the newly introduced Integrated Logistics System (ILS) will not finalize its roll-out until 2013. In areas where neither the Indent System nor the ILS have been rolled-out yet, facilities receive essential drugs rationed out based on a predetermined quantity (“push” supply) rather than demand. For those using the older “push” system, there is a regular mismatch between supply and demand. Capacity building in Logistics Management Information Systems (LMIS), HMIS, regular reporting supervision, and feedback loops is needed to help strengthen procurement planning, distribution and overall supply chain management. 9 In terms of the budget constraints, the AED USAID-funded Point-of-Use Water Disinfection and Zinc Treatment (POUZN/AED) project found that initial seed stocks of essential medicines provided by donors, such as zinc, complement messaging, IEC and BCC efforts by ensuring the initial supply to respond to increasing demand 11. Without this initial stock, procurement delays occur because the MSD is reluctant to take orders without proven demand, and the MOHSW is reluctant to promote IEC and BCC messaging throughout the system and to the community without a stock available 11. An initial donor stock can help overcome this obstacle. As the system starts to flow around a particular donor-provided drug, the GoT supply chain system will kick-in so that the GoT can take-over procurement. In the case of zinc, an initial stock was provided in 2007 by UNICEF, and the GoT took-over national procurement from its budget starting in 2009 11. 11   The Accredited Drug Dispensing Outlet (ADDO) Program that started under USAID/BASICS and is now being carried out by the TFDA supported by MSH and the Global Fund is a good complement to the public facility and supply circuit, helping to respond to some of its supply and service challenges. The Program has been successful and has provided much needed treatment and service, but its scale-up has been slower than expected 8. Roll-out was supposed to finish in 2011, but was not completed. The new expectation is that all regions will have functioning ADDOs in 2012.   2.2.2 Diarrhea barriers    2.2.2.1 Patient, caregiver, and service provider barriers Despite the fact that both ORS and zinc were approved by the TFDA as Over-the-Counter drugs in July 2009 11, there still seems to be low awareness of the fact that zinc is OTC, which has limited its distribution, especially through CORPS. There are, however, health facility and CORPS refresher training on diarrhea using the updated IMCI guidelines and national training curriculum that include zinc policy and treatment information. The problem is that only 14% of service providers are up-to-date on IMCI trainings 12.   2 Thesis Work. Available at: http://edoc.unibas.ch/858/1/DissB_8472.pdf. (Accessed on 29th June, 2010 at 5:30PM by Mahenge NS)  ESSENTIAL MEDICINES GLOBAL INITIATIVE – TANZANIA  9   In terms of challenges, Tanzania has one of the highest ORS awareness percentages (80%) in Africa, but its use as treatment is still low (44%) and zinc use is negligible 1. Besides the outcome expectations and skepticism related to treatments that require self-preparation described above in the cross-cutting section, the separate administration of ORS and zinc is a further barrier to its use. Research has found that Metronidazoles, such as Flagyl, anti-pyretics, and antibiotics are often cited as preferred treatment for diarrhea 7, 11. And according to the TDHS 2010, of those who sought care for their sick child, 50% received syrups/pills as treatment, compared to 44% ORS or ORS/zinc 1. USAID/BASICS research found that "Prescription practices for diarrhea treatment by both dispensaries and health professionals may be influenced by community expectations 7, pg.37." In addition, regular supervisions and the provision of job aides and wall charts at the facility-level that could facilitate and promote rational treatment of diarrheal disease are insufficient.   2.2.2.2 Supply Barriers A major challenge in the public sector is public facility stock-outs, despite stock piles expiring. Only 58% of public health facilities have non-expired zinc in-stock 13. There is limited awareness among service providers of the importance of zinc, so they do not restock, as they do not prioritize it. Only 70% of the wards have at least one outlet with zinc 13. UNICEF previously provided large stock piles, but found they were expiring and not being used. The priority barrier seems to be increasing demand for zinc among both caregivers and service providers, before focusing on increasing stock. With increased demand, service providers will order more stock and use it before it expires, and caregivers will demand stocks from private pharmacies, which will increase their order and stock of zinc.   2.2.3 Malaria barriers  2.2.3.1 Patient, caregiver, and service provider barriers Important challenges exist related to over-diagnosis of malaria 6, pg. 32 in terms of both over self-diagnosis and service provider over-diagnosis. The result is under-reporting of other fever-based illnesses, such as pneumonia, and over- reporting of malaria prevalence. Service providers often diagnose fever as malaria, with or without a lab confirmation. Even when lab testing does come out positive for malaria, service providers often treat for whatever comes-up as positive, as well as for malaria, increasing treatment costs and budget. Another important challenge to rational treatment is stock-outs and irregular availability of ACTs and RDTs at public health facilities, especially in rural areas.   2.2.3.2 Supply barriers There are important stock-outs and irregular availability of ACTs and RDTs at public health facilities, especially in rural areas. Given the recent policy change requiring parasitological diagnosis prior to treatment, these stock-outs and delays in rolling-out RDTs are an especially important barrier.   2.2.4 Pneumonia barriers  2.2.4.1 Patient, caregiver, and service provider barriers The important challenges related to rational use of pneumonia treatment are closely linked to malaria challenges. Pneumonia is often misdiagnosed as malaria until it develops into severe pneumonia. Irrational drug use is reinforced by caretaker’s resistance to treatments that require self-preparation, such as dispersible amoxicillin, and preference for crystapen injections and other antibiotics as treatment 7. Service providers further support this irrational drug use by over-prescribing non-first-line treatment options, as cited above.   2.2.4.2 Supply barriers The recent policy change in the first-line treatment of pneumonia from Cotrimoxazole to dispersible Amoxicillin brings with it several supply challenges. First of all, amoxicillin is more expensive than cotrimoxazole, which could cause both supply and demand barriers. Secondly, the GoT will probably not be able to buy it for the public sector until the next budget cycle (starting July 1, 2012), and yet the private sector is currently blocked from bringing in a supply of dispersible amoxicillin until it is registered with the TFDA. In the meantime, the MOHSW is currently keeping Cotrimoxazole as a first-line treatment option, but Cotrimoxazole penetration is only at 66% of eligible outlets 13.     2.3  Current MoH/Partners’ Efforts and identification of priority areas  In response to the MDGs in general, both initially and more recently, the Government of Tanzania (GoT) has been proactive in establishing a series of policies that are supportive of moving forward aggressively. As outlined in The ESSENTIAL MEDICINES GLOBAL INITIATIVE – TANZANIA  10 National Road Map Strategic Plan To Accelerate Reduction of Maternal, Newborn and Child Deaths in Tanzania 2008-2015 15, also known as the One Plan, Tanzania has been focused on improved maternal and child health services since 1974, and has introduced a series of policies, strategies and initiatives over the years, including the Expanded Programme of Immunization (EPI) in 1975, the Safe Motherhood Initiative (SMI) in 1989, the establishment of the Reproductive and Child Health Section (RCHS) within the MOHSW after the 1994 International Conference for Population and Development, and the adoption of the Integrated Management of Childhood Illness (IMCI) approach in 1996 15, pg.1-2. More recently, a Reproductive and Child Health Strategy was established (2005-2010), two National Road Map Strategic Plans were established (2006-2010 and 2008-2015), and maternal, neonatal and child health issues were integrated into the National Health Policy and the National Strategy for Growth and Reduction of Poverty II, 2010. The Ministry of Health and Social Work (MOHSW) work is also aligned with other enabling policies, such as the National Vision 2025, the Millennium Development Goals, Health Sector Reforms, the Local Government Reform Policy Paper, and the CCM Election Manifesto 2005 6, pg.4-7. Some of the key policies and strategies are outlined in the policy table below (Table 3). The GoT has also initiated current policy and strategy efforts to further child survival efforts, such as the Better Medicines for Children project to introduce an Essential Medicines List for Children (EMLc) led by the MOHSW Office of Chief Pharmacists with the MOHSW Newborn and Child Health Unit, and in partnership with UNICEF, WHO and others. The EMLc work provides an important initial advocacy and policy base to help facilitate scaling-up essential medicines in Tanzania. Another important current task force has been looking into models and strategies to introduce a formal Community Health Worker (CHW) cadre in Tanzania that would revise policy to allow integrated Community Case Management (iCCM). Following the GoT need expressed in the Primary Health Service Development Plan – MMAM 2007-2017 and in response to the health system human resource crisis in Tanzania, WHO and UNICEF are working with the Health Human Resource Department, the Health Promotion Unit and the RCHS, as well as consultative work with Ifakara Institute, to pilot a trial CHW model in two districts. The pilot was launched in July 2011. After review of the situation, both in terms of other country experience and the WHO/UNICEF CHW work, the MOHSW has decided to introduce a new cadre of health worker, called the Community Health Attendant (CHA), to replace the CORPS and to eliminate parallel community agent structures. As paid MOHSW personnel, the CHAs will be responsible for interpersonal communications and iCCM outreach from the public health facility to the village. The roll-out of the CHAs is a new development and has not begun yet. It is being prioritized and funded by the MOHSW and is expected to have an important positive impact on linking the community into the health system to help improve maternal and child health. The MOHSW’s important decision to introduce the CHAs should be supported and integrated into child survival efforts to strengthen the effectiveness of CHAs in forming the link between the community and the health system. The ADDO Program initially started by USAID/BASICS and now being carried-out by the TFDA with support from MSH and the Global Fund is another important initiative targeting vulnerable populations and rural communities. While nationwide roll-out is expected this year, further integration of the ADDOs into the health system overall, such as the MOHSW’s health monitoring and reporting systems, and responses to its stock-out challenges will help strengthen the ADDO network’s impact. Partners have also been working with the MOHSW on interesting and innovative mHealth and eLMIS solutions to important training and supply chain management challenges. JSI/DELIVER started working with the MOHSW in 2002 on an Integrated Logistics System (ILS) and is now working on introducing an SMS reporting tool into the ILS system through the ILS Gateway. Novartis introduced and led a public private partnership with the MOHSW, Roll Back Malaria Partnership, IBM, and Vodafone under a project called SMS for Life to introduce SMS reporting for malaria stock management. The Novartis Foundation for Sustainable Development (NFSD) and the World Health Organization partnered to develop an e-learning tool for IMCI called the IMCI Computerized Adaptation and Training Tool (ICATT) that was adapted for Tanzania in 2009. These efforts provide an important innovative technology base that should be considered for supported scale-up and strengthening, given the cost-effective and innovative approaches. Any new child survival effort or strategy will have to align with current GoT policies and strategies, as well as with other partner and project efforts to promote synergy, efficiency and country ownership. Main MNCH GoT policies and strategies are outlined in Table 3 below. ESSENTIAL MEDICINES GLOBAL INITIATIVE – TANZANIA  11 Table 3: Overview of Key GoT Policies and Strategies that Support MNCH United Republic of Tanzania Ministry of Health (2003). National Health Policy 2003 16 National Strategy for Growth and Reduction of Poverty II, 2010 4 Primary Health Services Development Programme – MMAM 2007-2017 6 The National Road Map Strategic Plan To Accelerate Reduction of Maternal, Newborn and Child Deaths in Tanzania 2008-2015 15 S u p p o r t i v e g o a l s , o b j e c t i v e s , t a r g e t s 2.4 Policy Objectives, especially 2.4.1: • Reduce the burden of disease, maternal and infant mortality and increase life expectancy through the provision of adequate and equitable maternal and child health services 2.5 Policy Strategies, especially 2.5.1: • From this Poverty Reduction Strategy, the Ministry of Health will use a greater proportion of the health budget to target cost effective interventions such as immunizations of children under 2 years of age, Reproductive and Child Health including Family Planning and control of Malaria, HIV/AIDS and TB and Leprosy Structure of Health Services in Tanzania 4.1.1 • The communities will have the mandate to choose their own community health worker who will be the main linkage between the community and the nearest health facility. The community health worker responsibilities will include, health education, and assisting in relevant public health interventions Goal 3: Improved survival, health, nutrition and well-being, especially for children, women and vulnerable groups Operational targets for addressing Infant and Child Health and Nutrition: i. Under-five mortality rate reduced from 81 per 1,000 live births (2010) to 54 per 1,000 live births by 2015. ii. Proportion of under-five underweight (weight for age) reduced from 21 percent (2010) to 14 percent by 2015. iii. Proportion of stunted under-fives (height for age) reduced from 35 percent (2010) to 22 percent by 2015. iv. Prevalence of exclusive breast- feeding in children under 6 months increased from 50 percent (2010) to 60 percent by 2015. Relevant Intervention proposals: ii. Addressing disparities in health outcomes and services delivery by socioeconomicgroups and by urban/rural and districts; Aim: the delivery of health services to ensure fair, equitable and quality services to the community. It “aims at empowering communities and involving them in health services provision 6, pg.8.” Objective: To accelerate provision of quality primary health care services to all by 2017. Some key Specific objectives: • To rehabilitate, upgrade and establish facilities at primary level to ensure equity and access of quality health care to all Tanzanians • To fast track capacity building, upgrading and on the job skills development for allied health workers. • To strengthen and maintain human resource database • To provide standardized medical equipment, instruments, pharmaceuticals and sundries to all primary health facilities • To ensure that the referral system is operational, and where necessary to establish teams of consultants to conduct mobile clinics and outreach services to support health facilities quality health care. • To increase financial allocation to the sector. Aim to attain the Abuja Call of 15% of annual budget. 3.2 Mission: To promote, facilitate and support in an integrated manner, the provision of comprehensive, high impact and cost-effective MNCH services, in order to accelerate reduction of maternal, newborn and child morbidity and mortality 3.3 Goal: To accelerate the reduction of maternal, newborn and childhood morbidity and mortality, in line with MDGs 4 and 5, by 2015. 3.4 Objectives 3.4.1. To reduce maternal mortality from 578 to 193 per 100,000 live births. 3.4.2. To reduce neonatal mortality from 32 to 19 per 1000 live births. 3.4.3. To reduce under-five mortality from 112 to 54 per 1000 live births. 3.5 Operational targets to be achieved by 2015: (relevant targets) 3. New EPI vaccines introduced (Hib, Pneumococcal, Human Papilloma Virus (HPV) and Rota Virus vaccines). 7. 90% of sick children seeking care at health facilities appropriately managed. ESSENTIAL MEDICINES GLOBAL INITIATIVE – TANZANIA  12 4.1.2: The Dispensary committee and Dispensary Management Teams will be established. Dispensaries shall provide comprehensive Primary Health Care services which will include the following (among others): Reproductive and Child Health Services, and Family Planning, Integrated Management of Childhood Illnesses (IMCI) viii. Improving access and quality of obstetric care; strengthening referral systems; and preventing malaria incidences; x. Strengthening community care and involvement in the health of expectingmothers to ensure accessibility to basic services; xi. Preventing chronic diseases (malaria, TB, HIV and AIDS) which are majorcauses of death); xii. Systematically build up the capacity for procurement and supplymanagement for timely and adequate provision of medical supplies andpharmaceuticals. Related Program Components: 5.1 Human resource for health is the first priority increasing output both in terms of quantity and quality. 5.2 District health service is the second priority component. Construction of 3,088 dispensaries, 19 district hospitals, 95 maternity waiting homes, 2,074 health centres. 250 dispensaries, 120 health centres and 54 district hospitals rehabilitated. 128 training institutions rehabilitated. Training provided to 15,000 youth peer eds and immunization outreach services to 8,000 villages. 5.3: Maternal, Newborn and Child Health: reduction of maternal and under five mortality from 578 and 175 per 100,000 live births and 112 to 45 per 1000 live births respectively. Increase coverage of births attended by skilled attendant up to 88 percent by 2017. 5.4 Malaria. Reduce the burden of Malaria by 80 percent by the end of 2017 5.9 Environmental Health Sanitation • Capacity building for environmental officers at district and ward level • Strengthen community participation 5.10 Health promotion and education. Capacity building of the communities and individuals 5.12 Traditional and Alternative Medicine, promotion and formulation of value added traditional medicine products and establishment and strengthening of registration of traditional health practitioners. 8. Increased coverage of under-fives sleeping under ITNs from 47% to 80% 9. 75% of villages have community health workers offering MNCH services at community level.   ESSENTIAL MEDICINES GLOBAL INITIATIVE – TANZANIA  13 Table 4 below combines the barriers described above in Section 2.2 and the current and ongoing efforts by the GoT and partners to respond to these barriers. Elements in yellow highlight the domains of insufficient or lacking current efforts where this project will prioritize its efforts. Table 4: Barriers and Efforts    Patient  Public sector supply/provision  (incl. community‐level)  Private sector supply/provision  Barriers  Current efforts  Barriers  Current efforts  Barriers  Current efforts  Cross‐ disease   (a) Insufficient care‐seeking  behavior  (b) Outcome expectations  that syrups, antibiotics,  prescription drugs and IVs  are more effective  (c) Missed opportunity to  raise demand by raising  child health awareness  among fathers, traditional  healers, birth attendants  and mothers  (d) Misunderstanding the  importance of finishing a  full course of treatment  (e) Low consumer confidence  in certain drug quality  (a) ADDO Program, PSI/Social  Marketing,   (b‐e) No specific action.    (a) Poor coordination and  linkages across the  health sector  (between  dispensaries,  community‐level  CORPS and private  sector ADDOs).  (b) Drug, supply,  equipment  procurement  bottlenecks  (c) Limited  reporting/supervision  associated with HMIS,  and minimal c‐HMIS  (d) Over‐prescription of  non‐first‐line  treatments  (e) Insufficient/outdated  public sector training  (f) Need for updated  iCCM policy officially  introducing CHAs   (g) HRH crisis  (h) Vertical health  programming (NMCP  and NACP)  (i) Poor mainstreaming  of child survival  (a) Presence of health  facility committee and  district boards, and  CHMT.  Formal links  have been outlined  between dispensaries  and CORPS and  dispensaries and  ADDOs, but not  formalized or  systematized.    (b) JSI and CHAI focused  on improving  commodity info  through scale‐up of  the ILS.  Adaptation  and scale‐up of  monitoring systems  linked to systems  needed  (c) National IMCI policy  links to HMIS. ICATT  IMCI Training could  link to HMIS.  JSI and  CHAI focused on  reporting.  (d & e) National IMCI                policy exists with a  National training  curriculum for clinical and  (a) ADDO Stock‐outs  (b) Slow scale‐up of  the ADDO project  (c) Drop‐out of trained  ADDO drug  suppliers  (d) Irrational drug sale  by  pharmacists/drug  shops  (e) ACTs and  antibiotics are not  OTC, limiting  access    (a) MSH currently  working with the  Ministry of  Agriculture to pilot  the establishment  of ADDO  Associations.  Stock  reporting and  monitoring support  is needed  (b) TFDA with MSH and  Global Fund  support is  expecting to finalize  roll‐out in 2012.  (c) No specific action  (d) TFDA created to  regulate, but there  are still gaps.  (e) No specific action.  ESSENTIAL MEDICINES GLOBAL INITIATIVE – TANZANIA  14 interventions and  Village Health  Committee plans into  CCHP and Overall  Council Plans  (j) No comprehensive, in‐ depth assessment of  child survival efforts  and needs  (k) Community agents  work in silos  (l) Attrition of trained  CHWs  (m) Poor coordination of  partner work at the  community level  community. Only 14% up‐ to‐date on training.  (f) WHO/UNICEF led  effort to establish a  context‐appropriate  formalized cadre of  CHWs, based on  MMAM, piloted in 3  districts. MOHSW  decision to introduce  CHAs will prioritize  updating policies  (g) ADDO project roll‐out,  MOHSW introduction  of CHAs.  (h‐j) No specific action.  (k, l, m) MOHSW decision  to introduce CHAs    Diarrhea  (a) Low awareness of Zinc  among caregivers &  providers  (b) Insufficient/incorrect  care‐seeking behavior  (53%) 1  (c) Outcome expectations  favor syrups and  antibiotics, rather than  ORS/zinc.  Resistance to  treatments that require  self‐preparation  (d) Continued and increasing  practice of curtailing fluid  intake when children have  diarrhea    (a‐c) POUZN/AED project ended  (2005‐2010), but a continued  comprehensive BCC campaign is  needed.  Assessment of  Community‐based Child Survival  Care and Treatment Dispensing in  Tanzania (PSI). 8 IMCI per village,  plus 2 original CHWs.  WHO,  MOHSW and MUHAS conducting  OR to see if zinc and ORS can be  distributed at grocery stores.   MOHSW is working with UNICEF,  WHO, and GAVI to add RotaVirus  to EPI.  MOHSW is working on  strengthening cold chain capacity  with support from CIDA and  UNICEF. Diarrheal treatment  corners have been re‐activated in  all but four regions.    (c) Pilot of pre‐packaged ORS/zinc  (a) Limited zinc  awareness among  community agents  (b) Public facility stock‐ outs, despite stock  piles expiring  (c) Slow dissemination of  changed policies  regarding diarrhea  treatment  (d) Insufficient  supervision, job aides  and wall charts in  facilities  (e) Limited dissemination  of policy change that  ORS and zinc have  OTC status has limited  access    (a) National Zinc Task  Force. 8 IMCI per  village, plus 2 original  CHWs.  Diarrheal  treatment corners  have been reactivated  in all but four regions.  (b) GoT started to  procure zinc from its  own budget in 2009 11.  Build on mHealth  approaches in malaria  (SMS for Life). Indent  System/ILS  (c) GoT updated IMCI  guidelines and  national training  curriculum in 2007  and revised EML in  Nov. 2007, but needs  to be rolled‐out.   (a) Low zinc market  penetration and  coverage  (b) Separation of ORS  and zinc, both in  terms of packaging  and solution  (c) Private sector  stocks less ORS  than is actually  needs, given low  demand and ROI  (d) Stock expiration  due to limited  purchase  (e) Limited  dissemination of  policy change that  ORS and zinc have  OTC status has  limited access  (a, c, d,) POUZN project  ended (2005‐2010).   Assessment of  Community‐based Child  Survival Care and  Treatment Dispensing in  Tanzania (PSI).  PedZinc  available from Shelys  since 2007.  Pilot of pre‐ packaged ORS/zinc  combination in 2  districts. Consider  mHealth approaches for  stock reporting and  management.    (b) Pilot of pre‐ packaged ORS/zinc  combination in 2  districts.  Shelys is  doing the  ESSENTIAL MEDICINES GLOBAL INITIATIVE – TANZANIA  15 combination in 2 districts.  Shelys  is doing the packaging.  ZENUFA  produces and sells zinc  suspension.      (d)No specific Action.  Consider ICATT IMCI (d) WHO response.  (e) POUZN/AED project  ended (2005‐2010).    Other: Strong WASH  initiatives:   SM of WaterGuard,  MOHSW grants linked to  national sanitations  campaigns, PHAST CORPS,  WaterGuard distribution  via CCAs.     Rotavirus vaccine as part of  EPI could prevent some  treatment.    packaging.   (e)No specific action.    Rotavirus vaccine as part  of EPI could prevent  some treatment.  Malaria  (a) Over‐diagnosis of malaria  creating excess demand  for a malaria response  (b) Use of ITNs less than  access  (c) Reduction in already  insufficient care‐seeking  (65%) 1  (d) High ACT cost    (a) Technical Working Group for  Malaria has reviewed the  national policy for RDT use  and developed a revised  draft that allows RDT use at  ADDOs.  Needs approval and  roll‐out.  CCAs introduced by  PSI.  A comprehensive  rational diagnosis and  treatment BCC campaign  needed  (b) Tanzania National Voucher  Scheme. Social marketing of  LLINs (PSI).  Zero taxing on  net and net materials policy.  Multiple rounds of GFATM  funding. Universal Coverage  Campaign. Community‐ based net distribution  initiatives.  (c) ADDO project.  PMI work on  strengthening the capacity  (a) Service provider over‐ diagnosis of malaria  (b) Stock‐outs and  irregular availability of  ACTs and RDTs at  public health facilities,  especially in rural  areas  (c) Inadequate public  health facility service  provider training  following NMCP  guidelines  (d) Inadequate public  health facility  Supervision  (e) Questionable quality  of IMCI/malaria focal  point services  (f) Missed opportunity to  integrate other  training into CCAs for  (a) Change from  presumptive  treatment to required  parasitological  diagnosis. RDT roll‐out  needed and a  comprehensive  rational diagnosis and  treatment BCC  campaign needed  (b) Build‐on mHealth  approaches for  Malaria ACT tracking  (SMS for Life). ILS  Gateway through JSI.  PMI focus on ACT and  RDT procurement,  training and  diagnostics.  CHAI and  JSI work on HMIS.  Indent System/ILS.  (c, d, e) PMI technical  (a) Slow scale‐up and  stock‐out of the  ADDO program  (b) ADDOs and  pharmacies not  allowed to perform  malaria diagnosis  using RDTs  (c) No local  manufacturer  currently has  WHO/UNICEF GMP  status to be able to  produce and sell  ACTs to donors  (d) ACTs are not OTC,  limiting access  (a) TFDA with MSH and  Global Fund  support is  expecting to finalize  roll‐out in 2012.   MSH currently  working with the  Ministry of  Agriculture to pilot  the establishment  of ADDO  Associations.  Stock  reporting and  monitoring support  is needed    (b) Technical working  group for malaria  has reviewed the  national policy for  RDT use and  developed a revised  ESSENTIAL MEDICINES GLOBAL INITIATIVE – TANZANIA  16 of the TFDA to develop a  monitoring and reporting  system for ADDOs. CCAs  introduced by PSI.  (d) Expansion of ACTs through  ADDOs under PMI.  Multiple  rounds of GFATM funding,  and supported by CHAI.  holistic child health  promotion  assistance to malaria  control program.  Further  training adaptation and  supervision linkages  needed    (f)No specific action.  draft that allows  RDT use at ADDOs.  (c) Shelys is close, but  needs final push.   May happen this  year.  (d) No specific action    Pneumonia  (a) Misdiagnosis of  pneumonia as malaria  (b) Irrational drug use and  preference for crystapen  injections 7  (c) Insufficient care‐seeking  behavior (71%)1  (d) Limited easy, cost‐ effective prevention  options for pneumonia  (a) Technical Working Group for  Malaria has reviewed the  national policy for RDT use  and developed a revised  draft that allows RDT use at  ADDOs.  A comprehensive  rational diagnosis and  treatment BCC campaign  needed    (b) Assessment of Community‐ based Child Survival Care and  Treatment Dispensing in Tanzania  (PSI).  Comprehensive BCC  campaign is needed    (c) ADDO Project scale‐up will be  finalized in 2012, but efforts to  further strengthen quality of care  and drug availability needed     (e) No specific action.  (a) Lack of resources  allocated to  pneumonia  (treatment data not  collected since TDHS  1991‐92)  (b) Challenge of recent  policy change to  dispersible amoxicillin  (c) Over‐prescription of  non‐first‐line  treatments, especially  IV/injections and  syrups  (d) Service provider  misdiagnosis of  pneumonia as malaria    (a) Pneumococcal vaccine  approved as part of  EPI.  The vaccines are  support by GAVI. May  reduce treatment  needs.  MOHSW is  working on  strengthening cold  chain capacity with  support from CIDA  and UNICEF.   (b) Policy change Sept  2011 to dispersible  amoxicillin. Interim,  accept both. National  IMCI policy exists with  a National training  curriculum for clinical  and community. Only  14% up‐to‐date on  training.  (c & d) Introduction of  RDTs. May not be sufficient  to change provider  behavior, so  comprehensive BCC  campaign needed.   Increased IMCI training  needed    (a) Low private sector  market penetration  (b) Dispersible  Amoxicillin is not  yet registered with  the TFDA  (c) Antibiotics are not  OTC, limiting  access    (a) Policy change  to dispersible  amoxicillin  may help here,  as will  extending  ADDO roll‐out.  (b) Specific action  is required to  push for rapid  registration.  (c) No specific  action.      ESSENTIAL MEDICINES GLOBAL INITIATIVE – TANZANIA  17 3. PROPOSED PROGRAM OF TARGETED INTERVENTIONS    3.1 Vision   Universal coverage in ORS/Zinc for diarrhea, ACTs for malaria and Dispersible Amoxicillin for Pneumonia requires a mix of interventions that respond to supply and service access, quality of services, and knowledge and demand in order to promote the rational use of services and treatments necessary for universal coverage. Since care-seeking is above average in Tanzania, focusing on the highlighted barriers in Table 4 above allows a comprehensive priority response to rational treatment, but in such a way that care-seeking will be promoted, as well. The barriers highlighted above are ones where either lessons learned have shown that there are successful solutions but that require supported scale-up and adaptation (diarrheal treatment corners, mHealth monitoring systems, ICATT IMCI)), or that there is a repeated, recurring gap (lack of supervision and coaching linkages at different levels, lack of coordination and confusion in messaging at the community level, lack of advocacy campaigns targeted at decision-makers, lack of response to consumer preferences in terms of medicine types), or that there is a cost-effective way to respond to several barriers with one solution (integrating the Community Health Fund into ADDOs, mHealth monitoring systems, ICATT IMCI). The proposed program vision and set of interventions are visually presented in the Results Framework in Annex 7.4 to show how they link back to rational treatment, universal treatment and, ultimately, MDG 4.   At the heart of this Strategy is a commitment to cost-effective, innovative solutions that play on the strengths of the public and private sector. One of the main strengths of the public sector in Tanzania is its established structure and design. The strategy is based on this structure and focuses on strengthening the internal training, monitoring, supervision, and linkages needed to improve service and drug delivery in innovative and cost-effective ways that move beyond traditional approaches. Tanzania has already proven its ability to harness the coverage and efficiency of the private sector for the good of the health sector through initiatives such as the ADDO project. This strategy applauds those efforts and looks to further many of Tanzania’s proven successful solutions that require support in either being adapted, strengthened, or scaled-up. Beyond the public and private sector, however, the community level must also be harnessed and linked into a triangle approach if universal coverage is the goal. Given the MOHSW’s important commitment to introducing CHAs and the current technical partners’ commitment to rolling-out the ADDOs, the Strategy aims to complement these efforts with a response to recognized gaps. In terms of ADDOs, the Strategy will focus on strengthening the network by responding to the stock issues they face and integrating the network into the Community Health Fund (CHF). In terms of CHAs, the Strategy will respond to the MOHSW’s request for communication skills support for the new cadre. Both the ADDOs and CHAs are meant to play an important role in linking the community to quality care and treatment to promote universal coverage, and this Strategy supports those efforts. Also at the heart of this Strategy is recognition that sustainability is required beyond initial financial partner support. Each intervention, therefore, kicks-off with a meeting to set a long-term financial roll-out plan that goes beyond donor funding to establish the vision for integration into Tanzania’s health system and budget. The MOHSW is committed to improving access to rational diagnosis and treatment in order to reach universal coverage and continue on its path toward fulfilling MDG 4 by 2015. This strategy and its vision are seen as essential to meeting these goals.         ESSENTIAL MEDICINES GLOBAL INITIATIVE – TANZANIA  18   3.2 Overview of key deliverables & outcome targets     Key interventions  Main deliverables   Outcome targets  Desired impact  1.Expand TFDA  registration Fast‐ Tracked Priority  Products List and  Register key EMLc  Drugs  * Decision with NIMR, MUHAS and WHO  regarding pneumonia first line treatment  (dispersible amoxicillin or alternative)  * The Ministry of Health and Social Welfare with  support from WHO through Better Medicine for  children initiative, developed essential pediatric  medicines list for Tanzania.  *  Registration granted for dispersible amoxicillin  and pre‐packaged ORS/zinc  * Initial stocks of dispersible amoxicillin and pre‐ packaged ORS/zinc (see Intervention 2) are  available in‐country for distribution.  *Essential medicines should be integrated in to  the current logistic supply chain for sustainability,  however, for new medicines e.g. dispersible  Amoxycilin, an initial push system for the first  year will help to introduce the medicine and  ensure accessibility.                          Increase in  Market  Penetration (%  of outlets  nationwide with  the drug):     Increase from  82%13 to 95%  for ORS   Increase from  56%13 to 80%  for zinc   Increase from  0% to 80% for  dispersible  amoxicillin   Increase from                          Improve  availability and  accessibility of  essential  medicines and  commodities  for pediatric  care at the  facility and  community  level through  the public and  private sector  by  strengthening  existing supply  chain  management  systems  2. Roll‐out of  diarrheal treatment  corners and launch  of prepackaged  ORS/zinc through  the public and  private sector  Diarrheal Treatment Corners  * Assessment and documentation of current  diarrheal corner situation  * Establishment of a long‐term financial roll‐out  plan, including integration of corners into GoT  budget  *Introduction of diarrheal treatment corners in  the four remaining regions  * Design, printing and dissemination of additional  job aides for diarrheal treatment corners  ORS/zinc pre‐packaging  * Establish a long‐term financial roll‐out plan,  including GoT budgeting for taking over  procurement  * ORS/zinc pre‐packaging consumer/market  research   *Identify most viable business plans among  pharmaceutical/manufacturing companies and  establish MOUs for production, promotion,  evaluation, etc.  * Initial and continued ORS/zinc production  * Prime the market and GoT supply system with  an initial procurement   * Pre‐packaged zinc/ORS available in public  health facilities  * Conduct market activations and other  marketing strategies  * Conduct promotion and demand creation  campaigns   * Social marketing of pre‐packaged ORS/zinc to  ADDOs    3.Adaptation and  scale‐up of proven  mHealth monitoring  systems (ILS  SMS for Life * Establish a long‐term financial roll‐out plan,  including integration into GoT systems and  budget  ESSENTIAL MEDICINES GLOBAL INITIATIVE – TANZANIA  19 Gateway & SMS for  Life)  *Integrate ORS/zinc, cotrimoxazole/dispersible  amoxicillin and any other agreed EMLc drugs into  SMS for Life tools and system  * Identify and carry‐out a cost‐effective way to  quickly disseminate the revised tool/additional  information   * Design an ADDO SMS for Life pilot  * Evaluate and disseminate pilot findings  * If successful, roll‐out the SMS for Life model to  as many ADDOs as interested    ILS Gateway and Interface  * Establish the long‐term financial roll‐out plan  for ILS Gateway and the Interface, including  integration into GoT systems and budget  * Technological design of an interface between  the SMS for Life and ILS Gateway systems  * Initial training‐of‐trainers and a core group of  system administrators   * Support to phased roll‐out of ILS Gateway and  Interface to districts  * Establishment of an ILS Gateway management  and supervision system  * Integration of ILS Gateway indicators into the  motivation/incentives system developed in  Intervention 5 below    66%13 to 80%  for  cotrimoxazole  (in interim  waiting for  dispersible  amoxicillin)   Increase from  x% to y% for  ACTs (use ACTWatch  Report when available)          Increase % of  CHF membership  to the 23% peak  reached in  199917  4.ADDO Network  access  strengthening (TFDA  list, CHF integration)  * Situation analysis of current CHF management  and fund use status   * TFDA revision/update of the approved drug list  for ADDOs  * Design of a revised CHF scheme that includes  ADDOs  * Establishment of a long‐term financial  plan/vision, including integration into GoT  systems and budget  * Signature of service agreements between  ADDOs and the CHF  * Design of a promotional campaign to sensitize  the population and market the new product  * Linked roll‐out of the integrated CHF product  and the promotional campaign    5.  Roll‐out of ICATT  IMCI training and  support mentoring  program and  incentives system to  activate linkages  (private and public)  ICATT  * ICATT was piloted both in pre‐service  institutions and in‐service by support from WHO,  evaluation was conducted in October 2010.  Experiences, lessons learnt and way forwards was  documented. ICATT was found to be more  feasible and applicable in pre‐service than in‐ service. Documentation is needed for the current  IMCI including producing an inventory of IMCI  facilitators and health care providers who are  already trained to avoid retraining. The Ministry  is proposing to roll out ICATT to pre‐service  institutions on experience and lessons learnt  from the pilot. The Ministry is also proposing to  conduct phased implementation of paper based  dIMCI together with Mentorship program for in‐ service health care providers and to assess the  introduction of ICATT into private facilities      Increase from 22%5 to  80% of children under  the age of 5 who had  symptoms of  ARI/pneumonia in the  preceding 2 weeks who  were given the  appropriate treatment  in accordance with  national guidelines     Increase from 44% 1 to  80% of children under      Improve ability of  health care  providers to provide  quality pediatric  care services and  promote rational  use of pediatric  diarrhea, malaria  and pneumonia  essential medicines  by building health  care provider  capacity across the  ESSENTIAL MEDICINES GLOBAL INITIATIVE – TANZANIA  20 however, introduction of ICATT to ADDO require  further discussions with TFDA.    * Establishment of a long‐term financial roll‐out  plan, including integration into GoT systems and  budget  * Technical work to update the ICATT tools   * Final roll‐out of ICATT to the pre service  institutions  * Refresher training public health facilities and  training pre‐service facilities        Incentives/Motivation System (such as PBF and  Mentorship Program)  Pre 2015:  * Operational research and field‐testing of  different PBF approaches, supporting a  Mentorship Program  * Selection of best approach  * Conduct mentorship to selected health facilities  within the operational research area  * Establishment of a budget and roll‐out plan,  including integration into GoT systems and  budgets  * Mapping of institutional embedding, and  identification of mechanisms for fund holding,  accountability and transparency, verification  efforts, community involvement, mentorship  structures, as necessary  * Capacity‐building of identified mechanisms in  phase one  * Negotiation and contracting of the price of  indicators and the allocation of incentives with  providers in phase one (more traditional PBF)  * Implementation of contracted activities and  performance‐based financing in phase one (more  traditional PBF)  * Research to compare the outputs and  outcomes in phase one areas to none  PBF/Mentorship Program areas  *Support roll out of existing P4P project, few  indicators need to be added to capture diarrhea  and pneumonia.  Most likely post 2015, but it depends on the  speed of roll‐out:  * Scale‐up PBF/Mentorship Program to remaining  phased areas    the age of 5 who had  diarrhea in the  preceding 2 weeks who  were given ORS  packets or ORS+zinc.     Increase from 25.9%1  to 80% of children  under the age of 5 with  fever who received  ACTs within 24 hours of  the onset of symptoms.       80% of targeted service  providers  correctly  managed diarrhea,  malaria and  pneumonia according  to national IMCI  guidelines    80% of targeted service  providers correctly  explain prevention  methods and rational  treatment of diarrhea,  malaria and  pneumonia according  to national IMCI  guidelines    different sectors   6.  Targeted  advocacy campaign  promoting the  strategy at all levels  * Message and action plan development  workshop with key stakeholders and partners  * Establish a long‐term financial roll‐out plan,  including integration into GoT systems and  budgets  * Advocacy meetings with key health decision‐ makers to promote the Strategy and ignite a  “spark” throughout the health pyramid  * Conduct district launch ceremonies  * Identification of and participation in key   stakeholder meetings        Increase from 22%5 to  80% of children under  the age of 5 who had  symptoms of ARI in the  preceding 2 weeks who  were given the  appropriate treatment      Increase informed  demand for child  health services by  implementing  comprehensive and  integrated  communication  ESSENTIAL MEDICINES GLOBAL INITIATIVE – TANZANIA  21   * Conduct site visits to model ADDOs and district  to highlight and emphasize the strategy impact.    in accordance with  national guidelines     Increase from 44% 1 to  80% of children under  the age of 5 who had  diarrhea in the  preceding 2 weeks who  were given ORS  packets or ORS+zinc.     Increase from 25.9%1  to 80% of children  under the age of 5 with  fever who received  ACTs within 24 hours of  the onset of symptoms.    Increase from 71%1 to  85% of children under  the age of 5 who had  symptoms of  ARI/pneumonia in the  last 2 weeks who were  taken to a health care  facility.    Increase from 52.6%1   to 80%  of children  under the age of 5 with  diarrhea for whom  advice or treatment  was sought from a  health facility or  provider (including  ADDOs)    Increase from 64%1 to  85% of children under  the age of 5 with fever  in the last 2 weeks for  whom advice or  treatment was sought  from a health facility or  provider     strategies  promoting child  health services,  products, and  behavior change  7. Targeted BCC  campaign to  promote rational  diarrhea, malaria  and pneumonia  diagnosis and  treatment  Communication Support to CHAs    * Identify IPC, community mobilization and  medium media best practices and lessons learned  in Tanzania  * Design communications training structure for  CHAs    * Train to the new CHA structure on  communication techniques, community  mobilization, and key messaging  * CHAs disseminating messaging through  interpersonal communication and medium media  channels    Village Health Days  * Identify any potential Public‐Private  partnerships possible in helping to fund village  health days  * Establish a long‐term financing plan, including  integration into GoT systems and budgets  * Mobilize and organize the communities for the  Village Health Days and establish district village  health day schedules  * Hold at least one village health day per quarter    High‐visibility mass media campaign  * Identification of popular icon to act as  spokesperson for the campaign  * Design mass media campaign by considering  events that transmit well over the radio, such as  song concerts and soap operas    * Conduct annual focus group discussions to help  identify and prioritize messaging  * Implementation of a high‐visibility mass media  campaign    ESSENTIAL MEDICINES GLOBAL INITIATIVE – TANZANIA  22   3.3 Detailed description of targeted interventions    1. Expand TFDA Registration Fast-tracked Priority Products List and Register key EMLc Drugs Rationale: As stated by Nesia Satoki Mahenge, “Regulation is a vital enabler of pharmaceutical supply chain 9, pg.21,” and in Tanzania, the TFDA plays a vital role in drug regulation, quality control and assurance, and pharmaceutical public and private sector inspections 9. According to the TFDA guidelines, “Section 22 of the Tanzania Food, Drugs and Cosmetic Act, 2003 prohibits manufacturing and import for sale, sell, offer or supply any medicine unless the medicine is registered 18, pg.1.” Given that timely product registration is part of the first stage of a healthy supply chain, slow product registration can be an important hindrance to activating the rest of the supply chain to ensure timely access to needed essential medicines and products. The TFDA has clear registration guidelines that allot twelve months for regular new product registration 18, but fast track priority products for registration within 3 months. Priority products currently include ARVs, antimalarials, and AntiTBs. Other medicines essential to child survival and already included in the Essential Medicines List, such as pediatric pneumonia antibiotic treatments, and pediatric/Over-the-Counter diarrhea treatments are not included in the Fast-tracked Priority Product List, however, slowing-down their registration and thus contributing to the supply chain challenges linked to facility access and stock challenges. As an example, Tanzania recently approved a policy shift from cotrimoxazole as the first line treatment for pneumonia among children under five to dispersible amoxicillin. Without the needed TFDA registration, however, no importation or local production of dispersible amoxicillin is allowed, leaving the country without a supply of the drugs to fulfill or even start to fulfill the policy change. As another example, pre-packaging of ORS/zinc has been proposed as a need by stakeholders and is proposed as part of intervention 2 below, but beyond the actual work of determining the best pre- packaging combination and producing the kits for registration submission, an additional year is necessary to pass it through the TFDA for registration before it can begin to reach the caregivers and children who need it. The purpose of this Intervention is to promote the timely registration of dispersible amoxicillin, new forms of ORS/zinc, and potentially other Essential Medicines List items in order to facilitate this stage in the supply chain and its role in ensuring availability and accessibility of essential medicines and commodities for pediatric care at the facility and community level through the public and private sector by strengthening existing supply chain management system. Approach: Advocacy is necessary to promote an update and expansion of the TFDA priority product list to include essential medicines from the EMLc, including, at a minimum, pediatric pneumonia antibiotics and pediatric/OTC diarrhea treatments. Just as POUZN/AED did with the policy change necessary to introduce and register zinc, the Strategy will seek “ways to jump-start the process and to carry out groundwork that [will] stimulate fast action once policies [are] in place 11, pg.4.” Once the fast-tracked registration is in process, the Strategy will work with those who submitted the registration applications (international and/or national manufacturers/pharmaceuticals, etc.) to pave the way for quick production and distribution once the registration green light is given. The RCHS will lead the advocacy and coordination effort with the TFDA. The RCHS will call on the EMLc working group to participate in initial list revision discussions to help determine which additional drugs to include in the expanded priority product list. Technical assistance will support overall coordination of the advocacy and registration efforts. Actions and Main Deliverables: (a) Stakeholder workshop, led by RCHS, to discuss the TFDA priority product list, EMLc drugs/products to include, and the next steps to take a. Action plan and long-term financing timeline (including integration into GoT systems and budget) identified b. Priority EMLc drugs/products to include identified (b) Coordinate with NIMR, MUHAS and WHO to explore alternative pediatric pneumonia first line treatments other than dispersible amoxicillin (c) Advocacy meetings with the TFDA to promote the importance of revising the priority product list (d) TFDA meetings/working groups to revise the priority product list, following the TFDA process (e) Jump-start meetings with international and local manufacturers/pharmaceutical companies to help facilitate production and distribution once registration is granted ESSENTIAL MEDICINES GLOBAL INITIATIVE – TANZANIA  23 (f) Registration granted for dispersible amoxicillin and pre-packaged ORS/zinc (g) Initial stocks of dispersible amoxicillin and pre-packaged ORS/zinc (see Intervention 2) are available in- country for distribution. 2. Roll-out of diarrheal treatment corners and launch of prepackaged ORS/Zinc through the public and private sectors Rationale: IMCI was introduced in Tanzania in 1996 and was accompanied by a number of important commitments by the GoT, including the establishment of an IMCI coordinator and a national IMCI budget line item 19, the introduction of pre- service IMCI training, and the establishment of 8 zonal training central to support district IMCI training. The IMCI Implementation in Tanzania: Experiences, Challenges and Lessons report states that the WHO 1999-2002 Multi- Country Evaluation (MCE), including Tanzania, found that “IMCI improved quality of care for children under 5 years of age, reduced child mortality by 13% and was cost-effective 12, pg.1.” Worldwide, however, IMCI has faced important challenges in scale-up and sustainability, and Tanzania faces similar challenges. The IMCI Implementation in Tanzania: Experiences, Challenges and Lessons report says that “the WHO recommends that at least 60% of health workers seeing sick children in health facilities are trained in IMCI. However, the research reveals that national coverage of trained health workers [in Tanzania] was estimated to be only 14% 12, pg.2.” The challenges that IMCI has faced in Tanzania include the high cost and approach to IMCI training, as well as poor adherence to IMCI protocol, including “poor supervision practices [and] reluctance to refer 12, pg.2-3.” Given the high cost and approach to IMCI training, it is expensive to consider updating the IMCI Guidelines and national training curriculum, and disseminating it through refresher trainings. Under the POUZN/AED project, zinc was introduced into Tanzania and “New diarrhea management guidelines were adopted in February 2009 and the list of essential medicines was revised to include lo- ORS and zinc the following month 11, pg.19.” The challenge, however, has been disseminating the updated diarrhea treatment policies and guidelines throughout the whole health system to promote rational prescription and use of ORS/zinc. The expectation is for the new guidelines to be integrated into an update of IMCI guidelines and the national training curriculum, but given how expensive the integration and roll-out of the refresher trainings is and how often IMCI guidelines are evolving in the face of new evidence and science, the refresher trainings tend to be delayed until a certain mass of updates is accumulated. The result is that there is an important lag between policy change and service provider uptake and implementation of revised guidelines. As a quicker solution, participants in the July 2008 annual IMCI malaria conference passed a resolution to revive “diarrheal treatment corners” in health facilities to promote diarrhea prevention and rational treatment 11. Given the fact that ORS and zinc are considered OTC treatments in Tanzania, updated policy information can be disseminated without the full, official IMCI refresher training package, and through easy to understand job aides instead. This intervention is a cost-effective, quick fix that can immediately be implemented while waiting for the more robust IMCI ICATT training roll-out proposed in Intervention 5 below. Quickly fulfilling the diarrheal treatment corner gap and informing service providers of changes in treatment guidelines is an important step in promoting rational diarrhea treatment and universal coverage of ORS/zinc. Another challenge linked to the IMCI service provision challenges, as well as overall consumer preference, is caregiver lack of compliance with revised guidelines. Tanzania has one of the highest ORS awareness percentages (80%) in Africa, but use of ORS for diarrhea treatment is still low (44%) and zinc use is negligible 1. Availability of ORS and zinc is not the major issue impacting rational treatment, however. The goal of the POUZN/AED project 2005-2010 was to “introduce zinc along with low osmolarity ORS nationwide 11, pg.3,” but despite reaching this goal in terms of geographical introduction, “challenges remain – particularly in improving caregiver acceptance of zinc treatment and ORT 11, pg.vi.” Research has found that Metronidazoles, such as Flagyl, anti-pyretics, and antibiotics are often cited as preferred treatment for diarrhea 7, 11. There is resistance and skepticism on the caregiver-side that treatments that require self-preparation, such as ORS, do not “cure” 11, and there is an outcome expectation that syrups are more effective than other types of treatment. According to the TDHS 2010, of those who sought care for their sick child, 50% received syrups/pills as treatment, compared to 44% ORS or ORS/zinc 1. The marketing department of the local pharmaceutical firm, ZENUFA, felt so strongly that syrup was the consumer preference among caregivers and children that they produced their TFDA-registered zinc product in syrup form in 2010, instead of the usual tablet form 11. Shelys, another major pharmaceutical firm in Tanzania, soon followed suit 11. The separate administration of ORS and ESSENTIAL MEDICINES GLOBAL INITIATIVE – TANZANIA  24 zinc is a further barrier to its use, as it further complicates the self-administration process already disliked by consumers. Consumer preference in Tanzania is clearly not in favor of the current, more-widely-available packaged forms of ORS and zinc on the market, and it is promoting irrational prescription and treatment practices. Qualitative research conducted by USAID/BASICS found that "Prescription practices for diarrhea treatment by both dispensaries and health professionals may be influenced by community expectations 7, pg.37." The GoT and partners suggest that the drug budget is twice the expected amount (based on statistics) because providers are prescribing and ordering irrationally. New research and efforts are needed to supply public sector health facilities, including diarrheal treatment corners, markets and ultimately consumers with alternative ORS/zinc treatment options in order to promote rational treatment. This Intervention proposes linking the scale-up and support of diarrheal treatment corners with the introduction of at least one type of pre-packaged ORS/zinc so that the diarrheal treatment corners can simultaneously respond to the IMCI training challenge lag, and respond to consumer preference to provide a double solution to promote rational prescription and compliance with diarrhea treatment guidelines. Approach: Diarrhea Treatment Corners are a quick, intermediary fix to promote rational diarrhea treatment which was previously successfully used in Tanzania, but enthusiasm and funding slowed with the growth of vertical programs focused on diseases other than diarrheal disease. Given the recognition that re-focused effort is needed in terms of MCH, and diarrheal disease especially, the corners have been revived in all but four regions (Mwanza, Mara, Kagera and Shinyanga), and basic job aides, such as 20-30 wall charts per district, have already been provided. Additional support is needed for the initial meetings and material dissemination needed to set-up the diarrheal corners in all health facilities, and to support additional wall chart and job aide dissemination to ensure at least 2 wall charts per facility per district. Research is needed to conduct consumer and market preference studies on the introduction of different types of pre- packaged ORS/zinc forms. The research should compare the introduction of the more traditional pre-packaged ORS sachet and zinc tablets as one form, pre-packaged ORS tetrapak and zinc tablets as a second form, pre-packaged ORS sachet and zinc syrup as a third form, and pre-packaged ORS tetrapak and zinc syrup as a fourth form. The research should analyze consumer preference for pre-packaging versus separate packaging, and preference among the four types of pre-packaging, as well as ability and willingness to pay. The ultimate goal of the research is to confirm whether or not pre-packaging will indeed improve consumer uptake, and if so, to identify which of the four types of pre-packaging are viable market options. Based on the research, this Strategy will introduce the appropriate pre-packaging on the market (assuming pre- packaging is indeed preferred), will prime the market and the government supply system with an initial stock, including ADDOs, and will conduct market activation and other marketing strategies. The option to supply the first procurement in order to prime the private and public sectors is based on the POUZN/AED project report finding that “slow public sector procurement can affect uptake in countries with a large public health sector 11, pg. vi.” The POUZN/AED project found that the MSD was reluctant to stock zinc without a proven demand for the product, and the MOHSW was reluctant to promote the use of zinc without a sure supply 11. POUZN/AED overcame this potential bottleneck by working with UNICEF to fund the initial procurement to be pushed out to public health facilities 11. The POUZN/AED report further suggests this approach as a lesson learned, and so this intervention will integrate this recommendation into its approach. Sustainability in ORS/zinc procurement will be ensured by establishing a long-term GoT financing plan, including work with RHMTs and CHMTs to ensure that ORS/zinc is budgeted for in the CHMT budget, which is responsible for drug budgets at local health facilities. This Strategy will promote production of the new ORS/zinc pre-packaged form(s) among local manufacturers, such as Shelys and ZENUFA. The POUZN/AED project 2005-2011 already proved that “African manufacturers can produce quality zinc treatment products for distribution both domestically and internationally 11, pg. vi” and so the idea is to build on the base and public private partnerships established under POUZN/AED to take ORS/zinc production to the next level, based on consumer preference and market viability. Work will be conducted with the appropriate departments of the MOHSW, including TFDA, MSD, the RCHS and the Newborn and Child Health Unit, PSU, RHMT/CHMTs, etc. As the overall Intervention lead, the RCHS will define ESSENTIAL MEDICINES GLOBAL INITIATIVE – TANZANIA  25 which of these departments, if not itself, should lead on this Intervention. Technical assistance will be necessary to conduct the consumer/market research, work with the private sector to develop viable business plans and design the appropriate pre-packaged forms, and test consumer uptake, as well as support coordination of the overall Intervention. Actions and Main Deliverables: Diarrheal Treatment Corners (a) Assessment and documentation of current diarrheal corner situation: which corners are operational and why/how have they succeeded?, best practices (b) Workshop with stakeholders in previous diarrheal treatment corner scale-up to review documentation, determine best roll-out plan for the four remaining regions, and any lessons learned from current situation a. Establishment of a long-term financial roll-out plan, including integration of corners into GoT budget b. Review and revise management guidelines and ordering protocols, as appropriate (c) District advocacy and promotion meetings to introduce idea of diarrheal treatment corners in four new regions, and the roll-out plan with key service providers and supervisors (d) Introduction of diarrheal treatment corners in the four remaining regions (e) Additional printing and dissemination of wall charts (at least 2 per facility per district) (f) Design, printing and dissemination of additional types of job aides for diarrheal treatment corners, based on lessons learned so far and need ORS/zinc pre-packaging (a) Conduct initial meetings with the MOHSW to discuss the Intervention, define the appropriate MOHSW lead, and define the plan of action a. Establish a long-term financial roll-out plan, including GoT budgeting for taking over procurement (b) Conduct consumer/market research to confirm whether or not pre-packaging ORS/zinc will improve consumer uptake, and if so, which pre-packaged form(s) should be marketed (c) Dissemination meeting to share and discuss research findings, including participants from the public sector (central, regional and district levels), the private sector and the community level (d) Meet with local pharmaceutical firms to further discuss findings and develop business plans (e) Identify most viable and agreeable business plans and establish MOUs with firms for production, promotion, evaluation, etc. (f) Production of initial stock of pre-packaged ORS/zinc (g) Visits to public and private sector providers to promote the new product, to be conducted by both GoT, technical partners and private sector partner (as part of MOU) (h) Prime the market and GoT supply system with an initial procurement (especially through public health facilities, including diarrheal treatment corners) (i) Continued production of pre-packaged ORS/zinc (j) Pre-packaged ORS/zinc available in public health facilities (k) Social marketing costs of pre-packaged therapy to ADDOs (including demand creation and market activations) (l) Evaluate consumer uptake (baseline and evaluation) 3. Adaptation and scale-up of proven mHealth monitoring systems (ILS Gateway & SMS for Life) Rationale: Break-downs in the Tanzania supply chain impact essential medicine availability. As cited by Nesia Satoki Mahenge, “the findings of that report [Mariacher, G.G., (2008); “Drug Donation in Tanzania: Stakeholders’ Perception and Knowledge”3] indicated that Tanzania has a 30% supply gap of essential medicines 9, pg. 50.” One of the reasons for the break-downs and bottlenecks has to do with the procurement and distribution system used. For many years, starting in 1983, Tanzania’s health system drug procurement and distribution system was based on a kit system by which facilities receive essential drugs rationed out based on a predetermined quantity rather than demand 10. Under this “push supply” system, there is a regular mismatch between supply and demand 9. 3 Thesis Work. Available at: http://edoc.unibas.ch/858/1/DissB_8472.pdf. (Accessed on 29th June, 2010 at 5:30PM by Mahenge NS)  ESSENTIAL MEDICINES GLOBAL INITIATIVE – TANZANIA  26 Tanzania has been taking important steps to pilot new systems to identify the best one to scale-up. According to the Tanzania: Integrated Logistics System Pilot-Test Evaluation: Using the Logistics Indicator Assessment Tool, the indent system was introduced in the 1990s by the Pharmaceutical and Supplies Unit (PSU) “to transfer drug ordering from the central to the district level 10, pg.3.” The indent system has currently only been rolled-out to about half of the facilities, however 10, pg.5. The indent system is an important improvement in Tanzania’s procurement system, in that it allows a transition from the “push supply” of the kit system to a “pull supply” based on demand and health district needs, reducing waste and stock-outs. In 2002, the MOHSW approached JSI/DELIVER for technical assistance in integrating the logistics systems of many of its vertical programs into an Integrated Logistics Systems (ILS). The ILS was meant to take the improvements of the indent system “a step farther by including most or all vertical programs and the EDP in the same system. The ILS introduced routine reporting of data coupled with routine ordering of resupplies, which enhances accountability and provides the central level with data for decision-making, particularly forecasting 10, pg.3.” From April-September 2005, the ILS was piloted in two regions, Dodoma and Iringa. Tanzania now has funding through 2013 to finalize the roll-out of the ILS to facilities nationwide. A complement to the ILS system and routine data reporting has been the SMS for Life project, a public private partnership initiated and led by Novartis in partnership with the MOHSW, Roll Back Malaria Partnership, IBM, and Vodafone meant to “tackle the current anti-malaria supply chain challenges and improve the in-country supply, planning and access to ACTs by harnessing everyday electronic communication tools and mapping technology to improve information exchange and to bring visibility to stock levels of ACTs in the public sector 20, pg. 5.” Using weekly reporting of stock levels by SMS, district visibility of stock levels increased dramatically, allowing for corrective redistributions between health facilities to avoid overstock in one and stock-out in another, emergency replenishment, and improved forecasting for regular ordering 20. The project started as a one year pilot in 2009, and by 2010 it had significantly reduced stock-out levels in the three pilot districts 20. As expressed by Tanzania’s Minister of Health, the Honorable David Mwakyusa, “the SMS for Life pilot project, designed to address this challenge, has been tried and tested in three districts of the country and, based on the results presented in this report, has showed remarkable success in keeping health facilities in those districts almost fully supplied with malaria treatments. The benefits for our health systems are potentially far reaching. Not only do we have the makings of a national stock management approach that can improve the availability of, and access to, lifesaving malaria drugs across the country, but we also have the possibility to apply this stock management approach to other essential health commodities 20, pg. intro.” Currently, SMS for Life funding is limited to scale-up in the domain of malaria and antimalarials. Additional funding and technical assistance is recommended to be able to adapt and “use the SMS for Life solution to track other medicines of priority 20, pg. 45,” such as other essential medicines for children, especially the other two treatments emphasized in this strategy (ORS/zinc and cotrimoxazole/dispersible amoxicillin), but also other essential medicines for children such as ARVs and HIV test kits, etc. Once the SMS for Life system and tools are adapted, stakeholders and health partners have suggested that SMS for Life could play an important role in ADDO supply, planning and access to approved essential medicines, helping to respond to ADDO stock challenges. As such, operational research is suggested to test the roll-out of SMS for Life in select ADDOs and compare results to non- SMS for Life ADDOs. Based on research results and ADDO buy-in to covering costs, SMS for Life could potentially be rolled-out to cover ADDOs, as well. Financial and technical assistance is needed to adapt SMS for Life, conduct the research, and support roll-out. For the public sector, the GoT and stakeholder recommendation is to actually switch from the SMS for Life model to the ILS Gateway, which is being developed and piloted by JSI, to allow for an SMS stock system linked to the whole ILS system. Financial and technical assistance is necessary to support the strategic roll-out vision for the ILS Gateway throughout the health public sector nationwide. As a final step, the aim is to create an interface between the private sector SMS for Life system and the public sector ILS Gateway system. The different systems are best suited to their specific sectors, but an interface will allow communication and stock visibility between the public and private sector to help the overall health sector monitor supply, planning and stock to ensure availability, whether through public or private facilities. Approach: According to the pilot report, “The SMS for Life pilot was designed so that health workers in Tanzania used their personal cell phone to send a weekly SMS stock-count message. The district management and National Malaria ESSENTIAL MEDICINES GLOBAL INITIATIVE – TANZANIA  27 Control Program management used any internet browser on any PC, or alternatively a Blackberry device, to access the data system information. Training materials were provided to both management staff and health care workers, with follow-up training and resources provided as needed 20, pg. 2.” This intervention will build-on the design and network established, the materials put in place and the lessons learned to integrate weekly SMS reporting of ORS/zinc, cotrimoxazole/dispersible amoxicillin and ACTs, if not all essential medicines for children required of facilities. A review of the current system and its tools will be conducted to determine how to integrate new drugs and commodities. Coordination meetings will take place to determine with the SMS for Life partners if revised training materials are necessary. In terms of ADDOs, a technical partner will be engaged to design a short research study to compare the impact of SMS for Life roll-out on ADDO stock-out versus control ADDOs. Based on pilot findings, a recommendation will be made regarding roll-out. Assuming positive impact, roll-out will be negotiated with ADDOs based on their willingness to contribute to implementation costs. The ILS Gateway roll-out approach will integrate the lessons learned from the pilot work begun by JSI. One lead from the GoT is needed to coordinate between the different departments and partners linked to the public and private sector approach. It is suggested that RCHS play the coordinating lead, and that PSU continue to technically lead the ILS Gateway roll-out, collaborating with the Chief Medical Officer, MSD, and TFDA, and that an appropriate technical lead be named for the SMS for Life component. Technical assistance is needed in terms of system adaptation, scale-up support, research/evaluation/documentation support, and coordination support. Actions and Main Deliverables: SMS for Life (a) Conduct initial coordination workshops with the SMS for Life partners, the MOHSW and other potential key child survival stakeholders to discuss SMS for Life’s current roll-out status, technical ideas for integration of additional medicines, and recommended next steps a. Establish a long-term financial roll-out plan, including integration into GoT systems and budget b. Review the current training curriculum to determine if new information is necessary, prompting refresher trainings (b) Meet with the partners working on the EMLc to determine whether the list is finalized, or whether a portion of it is finalized enough to be included in the SMS for Life tool. At the minimum, ORS/zinc and cotrimoxazole/dispersible amoxicillin should be included in the tool (ACTs are already included) (c) Establish the necessary partnerships and MOUs to revise the SMS for Life SMS data tool (d) If additional trainings are necessary, or additional information must be disseminated, identify a cost-effective way to quickly disseminate the additional information (through regional/district trainers, through district launch days, through regular supervision visits, etc.) (e) Design a pilot to determine whether or not SMS for Life roll-out to ADDOs is a cost-effective way to combat ADDO stock-out (f) Identify ADDOs willing to establish a public private partnership by which they cover their own costs to be involved in the study as an intervention area (use the SMS for Life public private partnership model to design these partnerships) (g) Conduct an intervention versus control area pilot (h) Evaluate and disseminate pilot findings (i) If successful, use pilot findings to promote and advocate for the mutual benefits to an ADDO, and identify ADDOs nationwide interested in participating in a roll-out at their own cost (j) Roll-out the SMS for Life model to as many ADDOs as interested (k) Evaluate uptake and determine if integration should be an obligation for (re)accreditation ILS Gateway and Interface (a) Planning workshop with JSI, relevant MOHSW representatives and financial and technical partners to discuss the status of the ILS Gateway technological development, the long-term financial roll-out plan for ILS Gateway (including integration into GoT systems and budget), and implementation steps (b) Technological design of an interface between the SMS for Life and ILS Gateway systems (c) Initial training-of-trainers and a core group of system administrators to build capacity in ILS Gateway and Interface technology, use, management and training (consider using the 8 Zonal training centers to act as the Trainers) (d) Support to phased roll-out of district training in ILS Gateway and Interface use and management (e) Establishment of an ILS Gateway management and supervision system ESSENTIAL MEDICINES GLOBAL INITIATIVE – TANZANIA  28 (f) Regular mentoring in and supervision of ILS Gateway use monthly in the first three months, and every three months thereafter (g) Integration of ILS Gateway indicators into the motivation/incentives system developed in Intervention 5 below   4. ADDO network access strengthening (TFDA list and Community Health Fund integration)    Rationale: According to the Tanzania MOHSW Primary Health Services Development Programme – MMAM 2007- 2017, the whole public health services system in Tanzania is suffering from a 67.9% shortage in staff, which comes to a shortage of 31,808 staff 6. “Governments that find themselves unable to address all their capacity shortfalls often look to the private sector to support the growth in demand 21, pg. 96,” and that is exactly the path that Tanzania has taken.   According to the USAID/BASICS Improving Child Health through the Accredited Drug Dispensing Outlet (ADDO) Program: Baseline Survey from the Five Districts in Tanzania, September 2006, it was estimated in 2006 that there were “more than 6,000 DLDBs [Duka la Dawa Baridi, private drug shops] across all districts in the country; over 50 percent more than all public health facilities and 11 percent higher than all public, voluntary, and religious facilities combined 7, pg.1,” and in addition, the Strategies for Enhancing Access to Medicines (SEAM) Program4 assessment in 2001 had shown that Tanzanians “frequently sought care from Duka la Dawa Baridi, which often had medicines in stock when public facilities did not 8, pg. 146.” As such, the country embarked on the ADDO Program to establish a network of privately-owned, regulated and accredited DLDBs that provide non-prescription and a limited number of essential prescription medicines from trained, quality-assured dispensers in more remote areas without easy access to public facilities 7. The complete national roll-out of the ADDO network is expected to take place this year under separate funding. To complement the effort put into establishing the ADDO network and reinforce its impact on furthering access to quality primary care services and quality treatment, continued strengthening of the existing network is needed. One of the issues ADDOs face is a limitation in the essential medicines they can distribute compared to the demand from caregivers, and another challenge is a fee-for-service and higher price structure than the public sector. Both create additional barriers to access. A child under five, pregnant women, and MCH services are entitled to free health care services at the public health facility under a statutory exemption, but distance, long wait times and frequent stock-outs are barriers to caregivers accessing such free care and treatment for their children, and so they often turn to ADDOs instead. As such, removing access barriers at the ADDO level is especially important to achieving universal coverage and health equity. Several activities have already been defined as necessary to further strengthen the ADDO network access, such as updating the TFDA list of drugs approved for distribution at ADDOs and integrating ADDOs into the Community Health Fund (CHF). The CHF scheme was started in 1996 by the MOHSW as a pilot and has since grown and scaled- up. As stated in the Gemini Mtei and Jo-Ann Mulligan document Community Health Funds in Tanzania: a Literature Review, “The CHF is a form of pre-payments scheme designed for rural people in Tanzania (Munishi 2001). It is based on the concept of risk sharing whereby members pay a small contribution on a regular basis to offset the risk of needing to pay a much larger amount in health care user fees if they fall sick 17, pg.3.” Revenue from different funding going into the CHF, the majority of which is member fees, is meant to finance a basic package of health services at health centers and dispensaries 17. The challenge is, however, that uptake has not been as high as the anticipated 30%17 and referral services (hospitals and secondary services) and private services are not or are only minimally included. One of the findings from the Mtei and Mulligan literature review cited above was that the limited benefits coverage caused by not including referral and private services reduced the attractiveness of membership and could be a cause for limited uptake 17. While “several studies have shown an improvement in the provision of and access to health care services after the introduction of CHF 17, pg.9,” challenges related to limited enrolment “could threaten the overall sustainability of the scheme 17, pg.7.” Given that “the CHF remains a crucial means for involving the community in health care financing and represents an important step toward universal coverage 17, pg.13,” it makes sense to focus efforts on aligning the benefits coverage with consumer preference for service delivery, such as integrating ADDOs into the scheme, in order to promote higher enrolment. 4 A Management Sciences for Health program funded by the Bill & Melinda Gates Foundation from 2000-2006.  ESSENTIAL MEDICINES GLOBAL INITIATIVE – TANZANIA  29 Approach: The overall approach will be to respond to these two pre-identified access strengthening needs. Advocacy work with the TFDA will begin immediately to review and update the approved drug list for ADDOs, taking into consideration all the experience from the last several years of ADDO roll-out, and the revisions taking place via the EMLc. In terms of the CHF, the focus will be on assessing the current status of CHF management and fund use at the district level to identify any major weaknesses that need to be addressed prior to integrating more benefits. Weaknesses in financial management and information systems have been identified in the past 17, and so the assessment will help to confirm whether or not and/or where these weaknesses still need attention. The next step will be to work with ADDOs to ensure a mutually beneficial service agreement between the ADDOs and the CHF, and to determine the logistics of how the integration will work in terms of membership, fund flow, management, etc. Finally, in case “the concept of insurance is [still] poorly understood among community members 17, pg. 4” and in order to promote the improved CHF benefits package, a sensitization and promotional campaign will be conducted to market the new product and find new members. The TFDA will continue to lead work associated with the ADDOs, including ADDO network access strengthening. The TFDA will coordinate with other stakeholders and MOHSW programs and departments for specific activities, such as the Counsel Health Services Boards, and ADDO representatives for the CHF ADDO integration activity. Technical assistance will be necessary to support the CHF situation analysis, technical and logistical integration of ADDOs into the CHFs, and to design a promotional sensitization and marketing campaign for the new product. Actions and Main Deliverables: (a) Situation analysis of current CHF management and fund use status at the district level (b) ADDO and CHF situation analysis workshop to discuss with stakeholders a. ADDO situation update (ADDO locations, capacity, gaps), and lessons learned, as they relate to ADDO access b. CHF management and fund use situation c. Areas for action prior to and in-line with integrating ADDOs into the CHF (c) RCHS-led advocacy meetings with the TFDA to discuss updating the ADDO drug list (d) TFDA-led workshop to revise the approved drug list for ADDOs (e) Design of a revised CHF scheme that includes ADDOs a. Including revision of existing manuals, logistical tools, management and fund use guidelines, training materials, and long-term financial plan/vision (including integration into GoT systems and budget) (f) Advocacy meetings with ADDOs at the district level to promote integration into the CHF (g) Development of mutually beneficial service agreements between ADDOs and the CHF/CHSB (h) Signature of service agreements between ADDOs and the CHF (i) Design of a promotional campaign to sensitize the population and market the new product (j) Linked roll-out of the integrated CHF product and the promotional campaign 5. Roll-out of ICATT IMCI training and alignment with a motivation/incentive system to activate linkages (public and private) Rationale: IMCI was introduced in Tanzania in 1996 and was accompanied by a number of important commitments by the GoT, including the establishment of an IMCI coordinator and a national IMCI budget line item 19, the introduction of pre- service IMCI training, and the establishment of 8 zonal training central to support district IMCI training. The IMCI Implementation in Tanzania: Experiences, Challenges and Lessons report states that the WHO 1999-2002 Multi- Country Evaluation (MCE), of which Tanzania was one of the countries, found that “IMCI improved quality of care for children under 5 years of age, reduced child mortality by 13% and was cost-effective 12, pg.1.” Worldwide, however, IMCI has faced important challenges in scale-up and sustainability, and Tanzania faces similar challenges. The IMCI Implementation in Tanzania: Experiences, Challenges and Lessons report says that “the WHO recommends that at least 60% of health workers seeing sick children in health facilities are trained in IMCI. However, the research reveals that national coverage of trained health workers [in Tanzania] was estimated to be only 14% 12, pg.2.” The challenges that IMCI has faced in Tanzania include the high cost and approach to IMCI training, as well as poor adherence to IMCI ESSENTIAL MEDICINES GLOBAL INITIATIVE – TANZANIA  30 protocol, including “poor supervision practices [and] reluctance to refer 12, pg.2-3.” Important training challenges include: o “The current 11-days IMCI training course [, which] places a big burden on the country's human resources keeping the workforce for a long time away from their respective facilities o The process of updating the IMCI training materials and clinical guidelines [, as it] is a cumbersome, expensive and time consuming [process]… o The availability of training materials [which] is a challenge for all institutions and districts carrying out IMCI training o The availability of appropriate reference materials at both national and district level… o …a great need for refresher training and follow-up with health workers who have already been trained in IMCI o …a need for building and sustaining a conducive environment for health workers trained in IMCI to practice IMCI routinely during their daily work 19.” In response to the training challenges faced by Tanzania and other countries, the Novartis Foundation for Sustainable Development (NFSD) and the World Health Organization partnered to develop an e-learning tool for IMCI called the IMCI Computerized Adaptation and Training Tool (ICATT). As defined in the Global guidance-local knowledge: ICATT for adaptable training in the Integrated Management of Childhood Illness brochure, “ICATT is an innovative computerized software application for IMCI. The tool makes it possible to adapt the IMCI guidelines at national and sub-national levels, and to develop ICATT-based training courses to support various training approaches 22, pg.1.” ICATT allows for flexibility in training and refresher training approaches, either through individual learning using a computer in in-service settings or in pre-service settings, group health worker classroom trainings with computers or a projector, distance learning using computers, computer/Internet or satellite-based facilitation, etc. 22. ICATT also facilitates and speeds-up the introduction of IMCI updates, as integration into the software is easy without the need for mass paper reproduction and dissemination. While ICATT is not a stand-alone training tool, as practical application training sessions are needed to assess actual application with patients, it is a great theoretical training tool. Tanzania was one of the first countries to adapt and introduce ICATT in 2009 19. Initial results founds that “ICATT courses proved to be more cost-effective because no print outs are necessary and the course can be done in a shorter period of time compared to traditional IMCI training. This also allows more time for clinical practice. The feedback from students was also very positive, reflecting the user-friendliness and flexibility of the tool compared to other e-learning programs 23.” The findings suggest that the ICATT is a cost-effective way to respond to the IMCI training challenges that Tanzania is facing, and there is room for potential innovation to expand ICATT beyond the public sector to cost- effectively link accredited private sector facilities, such as ADDOs, into the refresher training network. In terms of the challenges related to supervision and referral, they are not limited to poor adherence to IMCI protocol, but speak to a bigger weakness in linkages across the health system. Tanzania is considered to have one of the more stable and established health sector institutional architectures, compared to many developing countries. The structures in place have linkages defined on paper in terms of management, supervision, reporting and referral mechanisms. At the ward level, for example, the system has been set-up to link public sector dispensaries and ADDOs through referrals and supervision, and Dispensaries and CORPS through referrals and supervision. In practice, however, systematic implementation of supervision and referral is a challenge. Budget shortages, the health sector human resource crisis and demotivation have reduced the real operationalization of these linkages, impacting the quality of services provided. As stated in the IMCI Implementation in Tanzania: Experiences, Challenges and Lessons policy brief, “follow-up supervision is infrequent and doesn’t always come within the recommended time due to a shortage of facilitators and funds 12, pg.2-3.” And while accredited ADDOs have been recently added to the institutional architecture in certain regions, no clear link has been established between them and CORPS, despite the fact that both target the same rural, vulnerable populations. There is a missed opportunity here for additional message reinforcement and referral. An intervention focused on reinforced linkages should also establish this missing link. Unlike some countries, Tanzania’s issue is not so much putting in place a structure to establish linkages, but rather “activating,” motivating and facilitating the structures in place to dynamically fulfill their responsibilities. As stated in the document written by Ottar Maesard Rewarding Safe Motherhood: How can performance-based financing reduce maternal and newborn mortality in Tanzania?, “The Minister of Health in Tanzania has indicated that there is a need to motivate individual health workers to take increasing responsibility for improving the health services 24, pg. vii.” As such, the idea is to establish some kind of motivation/incentives system that facilitates activation of these linkages, either through a type of performance-based funding (PBF) system for the health sector or a Mentorship Program, in order to improve the “activation” of the supervision/coaching, reporting through the HMIS, and referral processes ESSENTIAL MEDICINES GLOBAL INITIATIVE – TANZANIA  31 required to ultimately improve the quality of service. As stated in the Jurien Toonen et al. document Learning Lessons from Implementing Performance Based Financing, From a Multi-Country Evaluation “PBF brings the attention to downstream accountability and transparency, to the operational level, where the results are focused on delivering more and better quality healthcare for the ultimate beneficiaries. So, PBF is about improving the performance at service delivery level 25, pg. xii.” PBF may be a good solution, but operational research and field-testing are needed to propose the appropriate design. If more traditional PBF approaches are not seen as the appropriate solution, then at the minimum, capacity needs to be built within the MOHSW structure to promote coaching and mentoring through a Mentorship Program. Approach: To-date, it is estimated that about two-thirds of Tanzania’s public sector facilities initially integrated ICATT use, but it is unclear whether it is being used to its full potential. Documentation of the current ICATT situation and lessons learned is needed. ICATT was initially piloted in Tanzania for use in pre and in-service training. Current lessons learned suggest that it is most effective in pre-service training, and not as much in in-service training. The documentation should speak to these concerns to make recommendations regarding the most effective use of ICATT in the public sector. Whether or not the lessons learned ICATT documentation recommends adaptations to the current Tanzania ICATT set-up for continued use in public sector in-service training or not, the MOHSW would like to compare these recommendations to potentially rolling-out a Mentorship Program based on the WHO’s paper-based distance learning IMCI (dIMCI) experience in South Africa 26. According to Dr. Lulu Muhe’s Paper-based Distance Learning IMCI – experiences from South Africa presentation, the model is a “primarily learner-driver model” with a “flexible self-study structure [that] saves time and travel, thus more healthcare providers can be trained in IMCI 26, pg.2.” The trainings are grouped into modules, allowing flexibility in blending the self-study with “face-to-face meetings with facilitators for orientation, review of study and practice,” “group study/group clinical practice,” “access to a mentor/tutor in person, or thru mobile,” “practicing IMCI skills in home facilities” 26, pg.3. It is meant to facilitate in- service training among health workers who cannot easily leave their facility for multiple-day off-site trainings. Materials include self-contained modules, a facilitator guide and logbook for progress assessment. The course is grouped into two self-study periods, with a suggested 4 weeks for the first section, and 6 weeks for the second session, accented by three mentor visits (an initial orientation meeting, a practice & review meeting between the two self-study periods, and a final synthesis meeting). The pilot findings in South Africa were that the approach was effective in terms of skills training (positive results in final exam skills recognition and IMCI multiple choice questions (although not as strong)) and affordable in that it was about three times less in Rand and HR costs than the traditional IMCI in- service training approach 26. Given the success of dIMCI in South Africa, the MOHSW proposes to introduce the approach into an overall Mentorship Program already started under Global Fund Round 7. Under Round 7, each RCHS Zonal Coordinator was named to oversee a group of mentors in his/her zone. Mentors included healthcare providers such as pediatricians and senior clinicians. Mentors have been trained in three zones, but funding is needed to finalize mentor training and support the costs of mentor supervision and coaching visits. During the ICATT documentation review workshop, areas where ICATT it is not being used efficiently or effectively should be discussed in order to determine an action plan to respond to these areas, the materials within ICATT should be updated, and the integration of RDT training should be considered. During this workshop, it will also be determined whether to test an updated/improved ICATT in-service training tool in the remaining facilities not yet using ICATT, or to test dIMCI within a Mentorship Program, or to test and compare both. Either way, in the remaining facilities, ICATT pre-service training will be rolled-out, and a test form of in-service training will be introduced. After roll-out to the remaining public sector facilities, the results from the in-service training approaches will be evaluated and a determination made as to what in-service training approach to continue using in the facilities nationwide. No matter what is recommended and chosen regarding in-service training, the Mentorship Program mentoring and coaching aspect is an important part of ensuring quality IMCI. Please see the paragraphs below regarding the motivation/incentive system proposal to see the suggestions regarding the Mentorship Program in terms of linkages. Beyond the final scale-up of ICATT IMCI in the public sector, operational research and field-testing should be conducted to assess the feasibility and cost-effectiveness of its roll-out to ADDOs and other appropriate private sector ESSENTIAL MEDICINES GLOBAL INITIATIVE – TANZANIA  32 facilities (about 700 facilities) to facilitate regular refresher trainings and updates. Given that the ICATT system allows for flexibility in terms of training materials for different sets of trainees, the trainings could be adapted to ADDO and private sector needs, and RDT trainings could be integrated if/when necessary. In terms of the private facilities with medical professionals, it is expected that adaptations to the current public sector ICATT IMCI tool and modules will be minor. In terms of the ADDOs, however, given that they are not run by medical professionals and that most do not have computers, a larger adaptation will be required to not only revise the modules to fit ADDO training requirements, but also to use more of the classroom-style setting with the facilitator using a computer to project the ICATT/ADDO trainings, rather than the other forms of training available under ICATT. Given ICATT’s flexible base, however, it is expected that adaptation will be possible to ensure a cost-effective roll-out to ADDOs. In terms of the motivation/incentive system to activate linkages, while studies show that PBF can be a promising approach 25, “introducing the PBF approach requires operational research and field-testing of different approaches to understand which one leads to the most sustainable and successful result 25, pg. xii.” Given Tanzania’s established institutional architecture, operational research and field-testing will help to define the best institutional embedding of mechanisms for fund holding, accountability and transparency, verification efforts, and community involvement 25, if PBF is chosen, or to define another motivation/incentive system. The research will also help to define whether it will be more effective to take an institutional or individual approach to incentives, and what intrinsic and/or extrinsic motivations to consider 24. The aim under this Strategy and by 2015 is to fulfill the research, identify the best PBF or motivation/incentives approach with buy-in from the national government, and begin to implement it in a phased approach. Based on the lessons presented in the Jurien Toonen et al. document Learning Lessons from Implementing Performance Based Financing, From a Multi-Country Evaluation, the GoT will “participate from the start in piloting the approach 25, pg. xii,” and establishing the proper phased approach for the context 25. If, during the process, a more traditional PBF approach is not determined to be the appropriate approach to activate linkages, then, at a minimum, a roll-out of the Mentorship Program should be considered to promote proper coaching and mentoring and the establishment of incentives. As described above, the MOHSW started to establish a Mentorship Program under Global Fund Round 7, and groups of mentors have been trained under the oversight of the RCHS Zonal Coordinator in three zones. If found to be more appropriate than PBF, the approach would focus on finalizing the capacity building of the zonal RCH Coordinators and the cadre of mentors to establish a mentorship framework in their zones, and to roll-out a mentorship coaching visit schedule and structure. The RCHS will take the lead for the GoT, working in close collaboration with different departments and groups within the MOHSW, including the RCHS/Newborn and Child Health Unit, and an identified technical partner to provide ICATT and PBF technical assistance. Documentation and adaptation of ICATT requires specific technical capacity, and PBF studies and lessons learned have shown that it relies heavily on financial support and technical support in the beginning, due to the need for PBF capacity building and creating “necessary precondition for scale up 25, pg. xi.” Financial and technical assistance is needed both in terms of documenting ICATT experience to-date and supporting any revisions before the final roll-out, designing the research and potential introduction of the ICATT in ADDOs and the rest of the private sector, and in PBF assessment, design and introduction. Actions and Main Deliverables: ICATT (a) Documentation is needed for the current IMCI including producing an inventory of IMCI facilitators and health care providers who are already trained to avoid retraining. Roll out ICATT to pre-service institutions on experience and lessons learnt from the pilot. Conduct phased implementation of paper based dIMCI together with Mentorship program for in-service health care providers and to assess the introduction of ICATT into private facilities however, introduction of ICATT to ADDO require further discussions with TFDA.  (b) Documentation dissemination workshop with key stakeholders to discuss lessons learned, recommendations, weaknesses and to determine: a. Long term financial roll-out plan, including integration into GoT systems and budget b. System updates, including a discussion on RDTs training integration c. Whether to introduce an adapted ICATT in-service training tool into the remaining public facilities, the dIMCI Mentorship Program for in-service training, or both for comparison purposes d. Whether or not to pilot it in ADDOs e. Whether or not to pilot it in private facilities (c) Technical work to update the ICATT tools ESSENTIAL MEDICINES GLOBAL INITIATIVE – TANZANIA  33 a. consider integrating communication training in how to use the C4D (Communication for Development) materials (d) Field visits to respond to areas with identified ICATT challenges (e) Final roll-out to remaining one-third of public sector facilities (f) Refresher training to all public health facilities already trained (g) Training to regional training facilities and pre-service facilities (h) Evaluation of adapted ICATT IMCI in-service training versus dIMCI and determination of best approach for continued public facility in-service training (i) Advocacy meetings with ADDOs and other private facilities to promote the integration of ICATT tools into their systems and to discuss their concerns and needed incentives (j) Adaptation of ICATT (modules and training format) for ADDOs, and design of roll-out to ADDOs (k) Roll-out of ICATT to established ADDOs (l) Adaptation of ICATT for the private sector facilities and design of roll-out to these facilities (m) Roll-out of ICATT to established private facilities Incentives/Motivation System (PBF or Mentorship Program) Pre 2015: (a) Operational research and field-testing of different PBF approaches, including a Mentorship Program (b) Engagement with all local and national level health management and providers to discuss and analyze research results (c) Selection of best approach (d) Communication and promotion of approach to health sector management and providers (e) Establishment of a long-term budget and roll-out plan, including integration into GoT systems and budget (f) Mapping of institutional embedding, and identification of mechanisms for fund holding, accountability and transparency, verification efforts, community involvement, mentorship structures, as necessary (g) Identification of general Maternal & Child Health indicators for PBF/Mentorship Program verification (h) Capacity-building of identified mechanisms in phase one (i) Negotiation and contracting of the price of indicators and the allocation of incentives with providers in phase one (more traditional PBF) (j) Implementation of contracted activities and performance-based financing in phase one (more traditional PBF) (k) Research to compare the outputs and outcomes in phase one PBF/Mentorship areas to control areas Most likely post 2015, but it depends on the speed of roll-out: (a) Assuming positive results from pre-2015 activities, scale-up PBF/Mentorship Program to remaining phased areas, following the long-term budget and roll-out plan 6. Targeted advocacy campaign promoting the Strategy at all levels   Rationale: A communication campaign to focus on promoting the overall Strategy and EMI approach to service providers, local government (especially CHMTs managing the local budget), parliamentarians, community decision-makers and private sector representatives is needed. Advocacy is needed to ensure buy-in to the overall Strategy by explaining its important contribution to Tanzania’s national policies outlined in Section 2.3, Table 3. Additional advocacy is needed to promote the public-private partnership approach so that the participation of other sectors, such as the private sector and community level, is seen as integrated into the health sector approach, and not as a separate competitor or something useless. One way actual buy-in will be measured is by the increase of money earmarked for IMCI and strategy activities in local budgets. Experience in Tanzania has shown that a communication campaign targeting decision-makers at different levels can help with the buy-in to new sector health approaches, but only if the decision- makers are involved from the beginning in the launch of the activities. PSI/Tanzania attributes one aspect of the success of its ITN work in Tanzania to the work it did to involve policy makers in the campaign from the beginning. Under PSI’s ITN work, net retreatment campaigns were held to launch the campaign with the Regional Commissioner as guest of honor. The launches were used to talk about the importance of nets to health and the proper use and treatment of nets. The members of the health sector under the Regional Commissioner came to the launch, since the Regional Commissioner was the guest of honor. Given the integration of officials from the top-down, it was easier for all levels to adopt and embrace the approach. The POUZN/AED project (2005-2010) also had a similar experience. ESSENTIAL MEDICINES GLOBAL INITIATIVE – TANZANIA  34 The POUZN/AED report states, “Advocacy with high level medical influencials in the very first months of the project provided the first sparks at the ‘top of the medical pyramid’ for a cascading process of awareness raising and support for zinc 11, pg. 9.” POUZN/AED worked with major professional associations at public and private hospitals, top medical professionals, and integrated POUZN/AED messages into high-level meetings that the upper-tier of health providers already attend, such as the annual IMCI malaria conference, Vitamin A supplementation meetings held at the zonal level, etc. 11. By achieving buy-in from the top-down, there is more overall buy-in and pressure is then put on CHMTs to budget for supporting activities to ensure their implementation. Approach: Building-off PSI/T’s experience and the POUZN/AED (2005-2010) project’s experience, the approach will be to target and integrate top-level decision-makers and service providers from the top down with the intension of ultimately achieving larger local budgets earmarked for IMCI and strategy activities. The expectation is that their involvement will promote buy-in to the strategic approach and a positive cascade of communication that starts with them and runs down through the health system. Launch events will be organized and developed with regional officials and the appropriate guest of honor to promote the EMI Initiative and this Strategy. Advocacy with high level health decision- makers will take place from the start of implementation in order to ignite the “sparks” described by POUZN/AED at the top of and throughout the health pyramid. The strategy coordinators will also look to identify key stakeholder meetings, including CHMT budgeting meetings, to help coordinate and to attend in order to integrate key communication messages about the Initiative, the Strategy and the approach. Finally, Intervention 6 will promote site visits to model ADDOs and districts to highlight and emphasize where the approach is having a strong impact. Actions and Main Deliverables: (a) Message and action plan development workshop with key stakeholders and partners a. Establish a long-term financial roll-out plan, including integration into GoT systems and budgets (b) Advocacy meetings with key health decision-makers, including Regional Coordinators, parliamentarians, and CHMT members, to promote the EMI Initiative and this Strategy, integrate any suggestions they have, and ignite a “spark” throughout the health pyramid (c) Establish district launch schedules, and line-up guests of honor, and speeches. Ensure CHMT attendance/involvement (d) Conduct district launch ceremonies (e) Identification of and participation in key stakeholder meetings (such as the annual IMCI malaria conference, Vitamin A supplementation meetings, CHMT budget meetings, etc.) (f) Conduct site visits to model ADDOs and districts to highlight and emphasize the strategy impact. 7. Comprehensive BCC campaign to promote rational diarrhea, malaria and pneumonia diagnosis and treatment Rationale: Ensuring availability of treatment alone will not ensure its proper and rational use or sustainable demand for its existence. Behavior change necessary to demand rational treatment is required at both the caregiver and provider level. In Tanzania, there are important barriers related to outcome expectations on both the caregiver and service provider sides that antibiotics, prescription drugs, IVs and syrups are more effective than other types of treatment. The preference leads to increased demand for certain prescription drugs, increasing their stock, and reduced demand for other prescription drugs and non-prescription drugs, such as ORS/zinc, reducing their stock. Using the case of pneumonia as an example, the USAID/BASICS Improving Child Health through the Accredited Drug Dispensing Outlet Program 2008 baseline qualitative survey found that mothers cited crystapen injection as the preferred treatment for pneumonia 7. The report also cited high rates of service providers prescribing IV/injections and antibiotics rather than the first-line treatment 7. In terms of malaria, the How can malaria rapid diagnostic tests achieve their potential? A qualitative study of a trial at health facilities in Ghana article by Clare IR Chandler, Christopher JM Whitty, and Evelyn K Ansah stated, “Peer and patient pressure were found to influence clinicians in their overdiagnosis of malaria in the face of microscopy results 27, pg. 11.” An assessment of dispensing practices in private pharmacies in Dar-es- Salaam, Tanzania conducted by Godeliver A.B. Kgashe, Omary Minzi and Lloyd Matowe found that “In Tanzania, an overwhelming proportion of medicines sold in pharmacies are dispensed without a prescription. The majority of medicines dispensed without a prescription are either requested by the client or recommended by the dispenser 28, pg. 30.” These findings suggest that consumer and provider preference play a huge role in what is diagnosed as the problem and ESSENTIAL MEDICINES GLOBAL INITIATIVE – TANZANIA  35 then prescribed and used as treatment, often overriding diagnosis and first line treatment policy regulations. The GoT and partners suggest that the drug budget is twice the expected amount (based on statistics) because providers are prescribing and ordering irrationally. Given the above reality regarding the influence of consumer and provider preference on rational treatment, the POUZN/AED Introducing Improved Treatment of Childhood Diarrhea with Zinc and ORT in Tanzania report found that “Sustained education and promotional efforts are required to ensure appropriate practices among prescribers, drug sellers, and caregivers 11, pg. vii.” Tanzania has a rich array of existing or previously existing communication platforms and campaigns to build-on in designing a comprehensive BCC campaign at all levels to promote rational use of child survival treatments. There are many vertical and sectorial efforts establishing parallel systems of community agents for the dissemination of IEC and BCC messages, the collection of community data, and sometimes, depending on the project, the distribution of a product. Tanzanian policy currently promotes c-IMCI and the distribution of ORS via 8 trained CORPS (Community- owned Resource Persons) per village plus two Community Health Workers, but does not allow the distribution of any other child survival treatments. Other parallel community agents include Community Change Agents (CCA) for malaria, Community Based Distributors for family planning, PHASTs for WASH, CHW/IMCI agents for c-IMCI, and FastTrack for maternal health purposes. The MOHSW has recognized that this multiplication of efforts is not only an inefficient use of already-limited resources, but has overwhelmed communities and created confusion in terms of care- seeking and treatment messages. The MOHSW has, therefore, decided to introduce a new cadre of health worker called the Community Health Attendant (CHA) to replace the CORPS and the parallel community agent structures. As paid MOHSW personnel, the CHAs will be responsible for interpersonal communications and iCCM outreach from the public health facility to the village. The roll-out of the CHAs is being prioritized and funded by the MOHSW, but there is a need for additional financial and technical assistance in providing practical communication training and tools to the new CHA cadre. An important element of Intervention 7, therefore, is communication support to the new CHA cadre. The previously successful village health days model should also be revived as a platform for communication dissemination, and the new ADDO network should not be left-out as a key message dissemination platform. As described in the Nutrition-Relevant Actions in Tanzania country case study by Festo P. Kavishe, village health days are “a concentrated event: colourful, packed with virtually all top district and regional leaders and functionaries, some visiting the village or being seen by the villagers for the first time - indeed, a mixture of serious business with pleasure (lectures, immunization and child-feeding on the one hand, and poetry, “ngonjera” and songs on the other). The presence of so many important people in the village shows the importance attached to the activity by the leaders and this, if reinforced, will have a long-lasting impact on the villages and their nutrition programmes (Mushi, 1988:25) 29, Chpt 8.” The new CHA cadre should be involved in helping to revive these village health days as key health message dissemination venues. Tanzania also has active Community-based and Faith-based Organizations which can be integrated into the work with the CHAs and village health days to further disseminate positive health messages. Approach: The communication campaign will be a multi-channel approach that segments the different population groups to identify the best communication approach for each segment. At the interpersonal level, the focus will be on providing practical communication training and tools to the new CHA cadre. For medium and mass media, the emphasis will be on reviving Village Health Days and use of the radio. In terms of the radio, the POUZN/AED project found, “The TDHS 2004 indicated 58 percent of families owned radios. The Tanzania All Media and Products Survey (Steadman 2005) indicated 95 percent of the population listened to radio at least once a week 11, pg. 14.” Intervention 7, therefore, will use the radio to launch a high-visibility mass media campaign featuring a key star or popular figure. Malaria No More’s experience in Senegal with the Surround Sound: Senegal campaign “activates key sectors of Senegalese society—including entertainment, sport, faith, local business and government—to encourage people to use mosquito nets, to recognize malaria symptoms and to seek treatment 30, pg. 15.” Inspired by this experience, a high-visibility song concert or soap opera or other type of edutainment campaign will be conducted over the radio to nationally disseminate key health messages and promote rational diagnosis, prescription and treatment of child survival medicines. RCHS and the Health Education Unit will lead the diagnosis and treatment BCC campaign, with support from other MOHSW departments and technical assistance. Technical assistance will initially support the design and development of the campaign, including message development using focus group discussions and communication channel assessment, communication support to the new CHA cadre and the long-term technical and financial roll-out plan. Since there does not seem to be much documentation of best communication practices in Tanzania, technical assistance will also help evaluate and document lessons learned and best practices. ESSENTIAL MEDICINES GLOBAL INITIATIVE – TANZANIA  36 Actions and Main Deliverables: (a) Stakeholder workshop to discuss past BCC campaign best practices and lessons learned and to establish a long-term financial roll-out plan, including integration into GoT systems and budgets Communication support to CHAs (a) Smaller stakeholder workshop to further discuss interpersonal communications (IPC), community mobilization and medium media best practices and lessons learned in Tanzania (b) Design of communications training structure for CHAs, including adaptation of existing IPC manuals, tools, procedures, and policies (c) Training to the new CHA structure on communication techniques (IPC and medium media), community mobilization, and key messaging (d) CHAs disseminating messaging through interpersonal communication and medium media channels Village Health Days (a) Conduct a stakeholder meeting to discuss village health day lessons learned from the past, and recommendations for the revival (b) Conduct outreach and advocacy meetings with potential private sector partners at the district level to identify any potential public private partnerships possible in helping to fund village health days (c) Establish district village health day schedules, and line-up high-level visitors, guests of honor and speeches (d) Work with CHAs to mobilize and organize the communities to prepare songs, dances, presentations, sports events, and other village health day activities (e) Hold at least one village health day per district per quarter High-visibility mass media campaign (a) Identification of popular celebrities, sports stars, officials or other pop culture icons that could act as spokesperson for a high-visibility mass media campaign (b) Design a mass media campaign by considering events that transmit well over the radio, such as song concerts and soap operas (c) Conduct annual focus group discussions to help identify and prioritize the most influential and impactful messaging to use in the campaign (initial focus groups will be held right after start-up so that the messaging is available to all campaign events, including CHAs, village health days and mass media) a. Coordinate and plan messaging with the Health Education Unit and the MOHSW vertical programs (d) Implementation of a high-visibility mass media campaign ESSENTIAL MEDICINES GLOBAL INITIATIVE – TANZANIA  37   4. WORKPLAN & BUDGET    4.1  High‐level workplan    Key Interventions  Year 1 Year 2  Year 3 Year 4 T1 T2 T3 T4 T1  T2  T3 T4 T1 T2 T3 T4 T1 T2 T3 T4 Expand TFDA Registration fast‐tracked priority products list and register key  EMLc Drugs                                  Updated TFDA Priority product list presented and disseminated  X                                Registration granted for dispersible amoxicillin & pre‐packaged ORS/zinc    X  X                            Initial stocks of dispersible amoxicillin & pre‐packaged ORS/zinc are  available in‐country        X                          Roll‐out of diarrheal treatment corners and launch of pre‐packaged ORS/zinc  through the public and private sector                                 Diarrheal Treatment Corners  X                                Assessment and documentation of current diarrheal corner situation  X  X                              Introduction of diarrheal treatment corners in the four remaining regions      X  X  X  X                      Additional printing and dissemination of wall charts      X  X  X  X                      Dissemination of additional types of job aides      X  X  X  X                      ORS/zinc pre‐packaging                                  consumer/market research   X  X                              ESSENTIAL MEDICINES GLOBAL INITIATIVE – TANZANIA  38 Identify viable business plans and establish MOUs with firms    X                              Prime the market with an initial procurement        X                          Pre‐packaged ORS/zinc available in public health facilities          X  X  X  X  X  X  X  X  X  X  X  X  Social marketing of pre‐packaged ORS/zinc          X  X  X  X  X  X  X  X  X  X  X  X  Evaluate consumer uptake (baseline and evaluation)        X              X            Adaptation and scale‐up of proven mHealth monitoring systems (ILS  Gateway & SMS for Life)                                 SMS for Life                                  Establish the necessary partnerships and MOUs to revise the SMS for Life  SMS data tool    X                              Design a SMS for Life ADDO pilot test          X                        Conduct pilot          X  X  X  X                  Roll‐out the SMS for Life model to as many ADDOs as interested                X  X  X  X  X  X  X  X  X  ILS Gateway and Interface                                  Technological  design  of  an  interface  between  the  SMS  for  Life  and  ILS  Gateway systems    X  X  X                          Support phased roll‐out of training of districts in ILS Gateway and Interface  use and management              X  X  X  X              Establishment of an ILS Gateway management and supervision system              X  X  X  X              Regular mentoring in and supervision of ILS Gateway use                  X  X  X  X  X  X  X  X  ESSENTIAL MEDICINES GLOBAL INITIATIVE – TANZANIA  39 Integration of ILS Gateway indicators into the motivation/incentives  system developed in Intervention 5 below                  X  X  X  X  X  X  X  X  ADDO network access strengthening (TFDA list, CHF integration)                                 Situation analysis of current CHF management and fund use status at the  district level  X  X                              Workshop to revise the approved drug list for ADDOs      X                            Design of a revised CHF scheme that includes ADDOs        X  X  X  X                    Signature of service agreements between ADDOs and the CHF                X  X  X              Linked  roll‐out  of  the  integrated  CHF  product  and  the  promotional  campaign                X  X  X  X  X  X  X  X  X  Roll‐out of ICATT IMCI training and alignment with a motivation/incentive  system to activate linkages                                 ICATT                                  Documentation  of  ICATT  situation,  coupled  with  research  to  assess introduction  of  adapted  ICATT  in‐service  training  compared  to  a  dIMCI  Mentorship Program, and to assess the  introduction of ICATT into ADDOs  and private facilities    X  X                            Technical work to update the ICATT tools          X  X  X                    Final roll‐out to remaining one‐third of public sector facilities                X  X  X  X  X          Refresher training to all public health facilities already trained                  X  X  X  X  X  X  X    Training to regional training facilities & pre‐service training facilities              X  X                  Adaptation of ICATT for ADDOs (modules and training format), and design  of roll‐out to ADDOs              X  X                  ESSENTIAL MEDICINES GLOBAL INITIATIVE – TANZANIA  40 Roll‐out of ICATT to established ADDOs                  X  X  X  X  X  X  X  X  Adaptation of ICATT for other private sector facilities and design roll‐out to  these facilities              X  X                  Roll‐out of ICATT to other private facilities                  X  X  X  X          Incentives/Motivation System (such as PBF or Mentorship Program)                                  Operational  research  and  field‐testing  of  different  PBF  approaches,  including a Mentorship Program          X  X  X                    Selection of best approach                  X                Establishment of a budget and roll‐out plan                  X  X              Mapping of institutional embedding, and identification of mechanisms for  fund holding, accountability and transparency, verification efforts,  community involvement, mentorship structures, as necessary                  X  X  X            Identification of general MCH indicators for PBF/Mentorship Program  verification                  X  X  X            Capacity‐building of identified mechanisms in phase one                      X  X          Implementation of contracted activities and performance‐based financing  in phase one (more traditional PBF)                          X  X  X  X  Research to compare the outputs and outcomes in phase one  PBF/Mentorship Program areas to control areas                                 X  Targeted advocacy campaign promoting the Strategy at all levels                                 Advocacy meetings with key decision makers         X  X  X  X  X        X      X    Conduct district launch ceremonies        X  X  X  X  X  X  X  X  X          ESSENTIAL MEDICINES GLOBAL INITIATIVE – TANZANIA  41     Identification of and participation in key stakeholder meetings      X    X    X    X    X    X    X    Conduct site visits to model ADDOs and districts to highlight and  emphasize the strategy impact              X  X  X  X  X  X  X  X  X  X  Targeted BCC campaign to promote rational diarrhea, malaria and  pneumonia diagnosis and treatment                                 Communication Support to CHAs                                  Design of communications training structure for CHAs, including  adaptation of existing IPC manuals, tools, procedures, and policies        X  X                        Training to the new CHA structure on communication techniques (IPC and  medium media), community mobilization, and key messaging            X  X  X  X  X  X  X  X  X  X  X  CHAs disseminating messaging through interpersonal communication and  medium media channels            X  X  X  X  X  X  X  X  X  X  X  Village Health Days                                  Work with CHAs to mobilize and organize the communities              X  X  X  X  X  X  X  X  X  X  Hold at least one village health day per district per quarter                X  X  X  X  X  X  X  X  X  High‐visibility Mass Media Campaign                                  Design mass media campaign (radio)      X  X                          Conduct annual focus group discussions to help identify and prioritize  influential and impactful messaging         X      X        X        X    Implementation of mass media campaign            X  X  X  X  X  X  X  X  X  X  X  ESSENTIAL MEDICINES GLOBAL INITIATIVE – TANZANIA  42   4.2  High‐level budget, USD    2012 2013 2014 2015 TOTAL TOTAL 1,828,673         19,698,206         24,077,838         37,625,988         83,230,704         Administration Support Costs (15%) 238,523            2,569,331           3,140,588           4,907,738           10,856,179         TOTAL before administration support costs 1,590,150         17,128,875         20,937,250         32,718,250         72,374,525         27,300               5,250                   ‐                        ‐                        32,550                 586,425            8,169,000           7,901,250           7,875,000           24,531,675         85,050               2,493,750           1,632,750           682,500               4,894,050           SMS for Life 56,000               295,000               305,000               450,000               1,106,000           ILS Gateway and Interface 25,000               2,080,000           1,250,000           200,000               3,555,000           89,250               525,000               1,055,250           1,050,000           2,719,500           36,750               1,779,750           6,531,000           19,078,500         27,426,000         ICATT  35,000               1,475,000           6,140,000           6,020,000           13,670,000         Incentives/Motivation System (such as PBF) ‐                     220,000               80,000                 12,150,000         12,450,000         456,750            241,500               199,500               105,000               1,002,750           233,625            3,824,625           3,517,500           3,827,250           11,403,000         Communication support to CHAs 27,500               312,500               550,000               550,000               1,440,000           Village Health Day  70,000               310,000               780,000               1,075,000           2,235,000           High‐visibility mass media campaign 125,000            3,020,000           2,020,000           2,020,000           7,185,000           75,000               90,000                 100,000               100,000               365,000               2012 2013 2014 2015 TOTAL Commodities 8,696,596         24,695,106         45,188,711         46,262,635         124,843,047      ACT ‐                     8,069,171           16,138,343         16,138,343         40,345,856         RDT 160,000            6,843,968           14,813,228         14,813,228         36,630,424         Zinc 3,163,302         3,785,583           6,413,735           7,079,777           20,442,397         ORS 1,969,155         2,356,525           3,992,550           4,407,161           12,725,392         Amoxycillin 3,329,138         3,639,858           3,730,855           3,824,126           14,523,977         Breathing counters 75,000               ‐                        100,000               ‐                        175,000               Procurement support costs (5%) 434,830            1,234,755           2,259,436           2,313,132           6,242,152           TOTAL Commodities with Support Costs 9,131,426         25,929,862         47,448,146         48,575,766         131,085,200      Cross‐cutting: Monitoring and Evaluation Intervention 7: Comprehensive BCC campaign to promote rational diarrhea,  malaria and pneumonia diagnosis and treatment Intervention 1: Expand TFDA Registration Fast‐tracked Priority Products List and  Register key EMLc Drugs Intervention 2: Roll‐out of diarrheal treatment corners and launch of  prepackaged ORS/Zinc through the public and private sectors Intervention 3: Adaptation and scale‐up of proven mHealth monitoring systems  (ILS Gateway  & SMS for Life) Intervention 4: ADDO Network access strengthening (TFDA list, CHF integration) Intervention 5: Roll‐out of ICATT IMCI training and alignment with a  motivation/incentive system to activate linkages (public and private) Intervention 6: Targeted advocacy campaign promoting the Strategy at all levels        ESSENTIAL MEDICINES GLOBAL INITIATIVE – TANZANIA  43   5.  IMPLEMENTATION ARRANGEMENTS    5.1   Monitoring & evaluation    Monitoring and evaluation will be participatory in nature, and will include key stakeholders across the health system in the collection, analysis and utilization of data. The comprehensive monitoring and evaluation structure will 1) plot progress in meeting workplan deliverables and milestones, 2) measure the quality of intervention implementation and outputs, and 3) track progress against the achievement of stated objectives and outcomes. Performance monitoring data will be collected through monitoring reports, MOH reporting and statistics through the HMIS and other means, healthcare service provider reporting and statistics, evaluations, and other appropriate means.   To reduce the cost normally associated with the collection and analysis of changes in knowledge, attitudes and practices, Lot Quality Assurance Sampling (LQAS) will be used where appropriate. Countries like DRC have already documented positive experience integrating LQAS into the regular supervision and management capacity of their Health Zone structure for collection at the community level 31 and Tanzania has been testing and piloting cHMIS solutions more recently. Given the Interventions outlined above focused on mHealth and electronic Logistics Management Information Systems (eLMIS), such as ILS Gateway and SMS for Life, and given the work with ICATT IMCI, the idea is to see if any of these tools can be aligned with LQAS and the HMIS review and monitoring system to further simplify the LQAS approach and HMIS data collection. At a minimum, LQAS indicators can be collected during regular routine supervision and integrated into the HMIS. Outcome indicator analysis will rely mostly on the TDHS, using 2010 as the baseline and 2015 as the evaluation. Data analysis and evidence-based decision-making will take place at each level of the health structure, from the CHMT and district level, up through the Regional and Central level. Performance review meetings will be used to disseminate data analysis findings, gather service provider and implementer feedback and discuss recommendations. Meeting outcomes and recommendations will be grouped into reports sent to the next health structure level where they will be further compiled until one final report reaches the Chief Medical Officer. Those responsible for compiling certain level reports will also be responsible for ensuring dissemination of implementation change or modification decisions back down through the system. Given that there are ten EMI countries globally, the documentation and dissemination of best practices and lessons learned among the countries will boost effective and efficient responses to common challenges faced. The strategy proposes an annual international lessons learned meeting in a different EMI country each time to share experiences, discuss challenges, and recommend international solutions.   5.2  Risk assessment     The strategy developed in this document is meant to contribute to universal coverage in ORS/zinc, ACTs and dispersible amoxicillin, but it not a global strategy, such as the Primary Health Services Development Programme – MMAM or National Health Policy. The Strategy will contribute to reaching the National Health Policy, the National Strategy for Growth, and Reduction of Poverty II, the MMAM and the One Plan objectives, and it will contribute to universal coverage in ORS/zinc, ACTs and dispersible amoxicillin/cotrimoxazole, but the expectation is that the MOHSW and other technical and financial partners, as well as the private sector, will continue to work toward filling remaining gaps and weaknesses in the health system that are not covered by this Strategy but that have an impact on the goal of universal coverage. The Strategy, therefore, makes certain assumptions regarding risks and the current situation. This section reviews the main assumptions required for the success of the Strategy, as well as an assessment of potential risks and potential responses to those risks. Main Assumptions:  Stability in Tanzania  GoT prioritizes budgeting for comprehensive IMCI and the EMLc, overcoming the HRH crisis and rolling-out the new CHAs, responding to HMIS challenges, ensuring minimum ESSENTIAL MEDICINES GLOBAL INITIATIVE – TANZANIA  44 stock levels at the MSD, and continued increased financial allocations to the health sector toward the goal of 15% of the annual budget  GoT assumes and ensures Strategy leadership, coordination and sustainability, as well as coordination with the different financial and technical partners  Financial partners are ready to support the GoT in its endeavor to fulfill the Strategy objectives  GoT takes responsibility for ensuring good governance and transparency in its practices Key Risks :    Cross-disease risks o The Strategy is not a stand-alone strategy that can alone ensure the system strengthening and overcome all the bottlenecks necessary to ensure universal coverage  Response: Tanzania already has global health strategies, such as the MMAM and National Health Policy that outline a complete approach to system strengthening. This Strategy is meant to complement these larger strategies with cost-effective approaches between now and 2015. In addition to implementing the Strategy outlined here, a focus on financing and completely implementing the global strategies is necessary to achieve universal coverage. o HRH crisis  Response: While the Strategy does not specifically respond with an Intervention focused on increasing human resources, it includes specific Interventions that promote current MOHSW and partner initiatives to respond to the HRH crisis, such as Intervention 7 and support to the CHAs, and Intervention 4 to strengthen the ADDO network. o The BCC aspects at the community-level depend on MOHSW roll-out of CHAs. If the CHA roll-out is not done in a timely manner, it will impact the Strategy’s ability to launch a comprehensive BCC campaign  Response: The MOHSW led the Strategy development and underlined the importance of the CHA approach. The MOHSW is fully committed to rolling-out the CHAs and the EMI Strategy. Given the MOHSW’s leadership over both initiatives, collaboration for efficiency and effectiveness will be facilitated. o The Strategy includes minimum direct intervention at the community level, given MOHSW’s CHA intervention  Response: The Strategy complements the MOHSW’s focus on the CHAs by focusing on ADDOs and their link to communities as a proven and effective support to the public sector in reaching universal coverage. It is expected that coupling the CHA and ADDO approach will help to cover the needs of communities. Collaboration and linkages with the CHAs are built into the Strategy to promote a link between the strategy and the direct community. o Increase in poor quality / counterfeit drugs. The Strategy focus is on responding to stock-outs and supply chain management challenges, and not as much on drug quality.  Response: TFDA involvement is integrated throughout the Strategy and so the TFDA will benefit from its involvement in capacity building efforts.  Response: The Strategy supports linkages and coordination with other financial and technical partners focusing on drug quality and registration/monitoring procedures o Stock-outs at the central level (MSD)  Response: Negotiations between the GoT and financial partners will be necessary to determine the most sustainable procurement support. Initial support may be provided to spark availability in the country with GoT procurement take-over thereafter. The GoT and financial partners will discuss need and come-up with the most viable procurement plan. o CHF current low enrollment and implementation challenges threaten the success of ADDO integration into the CHF ESSENTIAL MEDICINES GLOBAL INITIATIVE – TANZANIA  45  Response: A situation analysis is proposed as the first part of the CHF integration under Intervention 4. The findings will be disseminated to discuss recommended solutions to challenges. One of the previous identified challenges was the limited benefits coverage. The addition of ADDOs to the CHF will help to respond to this challenge and will give reason to newly promote the product. The extended benefits coverage and additional promotion is meant to boost enrollment. o High cost of drugs and non-sustainability of subsidization  Response: Boosting enrolment in the CHF is meant to help lower the cost of health care and drugs for vulnerable populations. Tanzania’s promotion of local production of drugs is another cost-cutting initiative that this Strategy will promote both in terms of the production of pre-packaged ORS/zinc to be introduced into the country and potentially dispersible amoxicillin. The Strategy will also collaborate with other cost-cutting efforts. o Low uptake of interventions in remote areas, poor communities, vulnerable populations, especially in terms of uptake of rational treatment and changes in caregiver preference to align with guidelines  Response: Intervention 7 is meant to target the important issues surrounding rational prescription and treatment, and compliance with treatment guidelines. The intervention is meant to respond to both caregiver and service provider challenges. Integrating the CHAs into the Strategy in Intervention 7 is meant to create a direct link with communities to ensure message dissemination to even the most remote communities. o Slow implementation of interventions  Response: Considerable time and effort has been put into ensuring GoT buy- in from the start, and GoT ownership over the Strategy design. It is expected that the GoT will prioritize the roll-out of the Interventions, once funded, as intended. o Creation of parallel eLMIS or HMIS systems  Response: Intervention 3 specifically aims to not only support the adaptation and scale-up of ILS Gateway and SMS for Life, but to ensure an interface that links both of them into the GoT ILS system. Intervention 5 builds on the ICATT IMCI training model already integrated into the GoT system. These technological systems are meant to facilitate upload of data into the central HMIS system, promoting use of that system and not the creation of parallel systems. o Caregivers not completing a full-course of treatment once symptoms are gone, in order to save extra medicine for future illness  Response: Intervention 7 is meant to target the important issues surrounding rational prescription and treatment, and compliance with treatment guidelines. The intervention is meant to respond to both caregiver and service provider challenges. Integrating the CHAs into the Strategy in Intervention 7 is meant to create a direct link with communities to ensure message dissemination to even the most remote communities.  Diarrhea o Lack of demand for Zinc & ORS  Response: Intervention 2 is specifically designed to promote ORS/zinc and rational treatment through diarrheal treatment corners and respond to caregiver preference with a pre-packaged ORS/zinc kit. Intervention 7 will also further support demand creation through BCC. o Pre-packaged ORS/zinc may not solve caregiver preference for antibiotics  Response: The pre-packaged kit will help to make it easier for caregivers to rationally treat diarrhea, even if they still may prefer antibiotics. Also, the potential inclusion of ORS tetrapak and zinc syrup is meant to respond to the preference for syrups, which are preferred and tend to be thought of as antibiotics. Intervention 7 is meant to target the important issues surrounding rational prescription and treatment, and compliance with treatment guidelines. The intervention is meant to respond to both caregiver and service provider challenges. Integrating the CHAs into the Strategy in ESSENTIAL MEDICINES GLOBAL INITIATIVE – TANZANIA  46 Intervention 7 is meant to create a direct link with communities to ensure message dissemination to even the most remote communities. o Use of zinc for less than the proposed 10 days  Response: Intervention 7 is meant to target the important issues surrounding rational prescription and treatment, and compliance with treatment guidelines. The intervention is meant to respond to both caregiver and service provider challenges. Integrating the CHAs into the Strategy in Intervention 7 is meant to create a direct link with communities to ensure message dissemination to even the most remote communities.  Malaria: o High price levels of ACTs (incl. AMFm ACTs)  Response: Boosting enrolment in the CHF is meant to help lower the cost of health care and drugs for vulnerable populations. Tanzania’s promotion of local production of drugs is another cost-cutting initiative that this Strategy promotes both in terms of introducing pre-packaged ORS/zinc into the country and potentially dispersible amoxicillin. The Strategy will also collaborate with other cost-cutting efforts, such as those implemented by CHAI, and will advocate on behalf of ensuring at least one local manufacturer/pharmaceutical has WHO GMP status. o Lack of focus on strengthening RDT roll-out in the public sector and moving it to ADDOs  Response: While there is not a specific intervention focused on RDT roll-out described in the Strategy, Intervention 5 is meant to update and adapt ICATT IMCI training tools. As part of this Intervention, inclusion of RDT training updates are suggested, as is the consideration of including RDT trainings into the ADDO trainings, once GoT approval is secured. o Prescription of ACTs in addition to other treatments for a negative RDT instead of replacing ACTs  Response: Intervention 7 is meant to target the important issues surrounding rational prescription and treatment, and compliance with treatment guidelines. The intervention is meant to respond to both caregiver and service provider challenges. Integrating the CHAs into the Strategy in Intervention 7 is meant to create a direct link with communities to ensure message dissemination to even the most remote communities. o Malaria efforts and success decrease with a comprehensive approach instead of a vertical program approach  Response: The intension of a comprehensive approach is not to undermine the progress made on a specific disease, but rather to exponentially improve the overall progress made on that disease and related diseases. The Strategy will work closely with not only the integrated MOHSW departments, but also the vertical programs, to ensure mutually beneficial progress.  Pneumonia: o Slow registration of dispersible amoxicillin and lack of drug availability  Response: Intervention 1 is focused on trying to overcome this risk. An aggressive timeline is proposed to try to ensure dispersible amoxicillin in- country by the end of the first year of implementation. o Continued preference for crystapen injections  Response: Intervention 7 is meant to target the important issues surrounding rational prescription and treatment, and compliance with treatment guidelines. The intervention is meant to respond to both caregiver and service provider challenges. Integrating the CHAs into the Strategy in Intervention 7 is meant to create a direct link with communities to ensure message dissemination to even the most remote communities. o Lack of oxygen at referral level  Response: The MMAM and National Health Policy are meant to respond to the health system strengthening issue at the heart of this risk. The Strategy is meant to complement the efforts of these global efforts so that the global strategies can focus on issues such as lack of oxygen at referral level. ESSENTIAL MEDICINES GLOBAL INITIATIVE – TANZANIA  47 o Over use of antibiotics leading to drug resistance  Response: The strategy is focused on promoting rational prescription and treatment. Intervention 7 is meant to target the important issues surrounding rational prescription and treatment, and compliance with treatment guidelines. The intervention is meant to respond to both caregiver and service provider challenges. Integrating the CHAs into the Strategy in Intervention 7 is meant to create a direct link with communities to ensure message dissemination to even the most remote communities. o Still not enough focus on pneumonia  Response: the introduction of this Stategy is meant to further the focus on IMCI and to respond to specific bottlenecks across diarrhea, malaria and pneumonia. It is expected that a focus on implementing the Strategy will bring more awareness to the challenges faced in terms of pneumonia and will promote the integration of innovative and cost-effective solutions.           ESSENTIAL MEDICINES GLOBAL INITIATIVE – TANZANIA  48   6. REFERENCES  Key informant interviews were used as a major source of data collection. A literature review was also conducted. The working group that was formed and led by the MOHSW/RCHS with the support of PSI/Tanzania also served as an important source of information. The working group led by MOHSW/RCHS and coordinated by PSI was composed of other key stakeholders, including UNICEF, WHO, UNFPA, USAID, CHAI, JSI, and MSH. The group provided recommendations, commented upon draft documents and further completed the information provided by the key informant interviews and the literature review. The group met December 6th, January 6th, January 10th, and a mini working group met January 11th. The framework and activities proposed by the working group was presented to the Chief Medical Officer (CMO) on January 13th. The working group and CMO inputs were integrated into the January 15th draft strategy. The information above reflects key findings from the interviews, literature review, and working group. Literature review sources are numbered and cited throughout in superscript and the numbers correspond to the numbered list below: 1) Measure DHS. (2010). Tanzania National Demographic and Health Survey Report. http://www.measuredhs.com/pubs/pdf/FR243/FR243%5B24June2011%5D.pdf (1 Oct. 2011). 2) UNDP Tanzania 2010. (2010). Millennium Development Goals. http://www.tz.undp.org/mdgs_goal4.html (4 Oct. 2011). 3) Masanja H, de Savigny D, Smithson P, et al (2008). Child survival gains in Tanzania: analysis of data from demographic and health surveys. The Lancet; 371: 1276-83. 4) The United Republic of Tanzania Ministry of Finance and Economic Affairs (2010). National Strategy for Growth and Reduction of Poverty II NSGRP II. 5) Countdown to 2015 Maternal, Newborn and Child Survival. Countdown to 2015 2010 Report, United Republic of Tanzania. http://www.countdown2015mnch.org/documents/2010report/Profile-TanzaniaURep.pdf (1 Oct. 2011). 6) The United Republic of Tanzania Ministry of Health and Social Welfare (2007). Primary Health Services Development Programme – MMAM 2007-2017 7) Improving Child Health through the Accredited Drug Dispensing Outlet Program (2008). Arlington, Virginia, USA: Basic Support for Institutionalizing Child Survival (BASICS) and the Rational Pharmaceutical Management (RPM) Plus Program for the United States Agency for International Development (USAID). 8) Rutta E, Senauer K, Johnson K, Adeya G (2009). Creating a new class of pharmaceutical services provider for underserved areas: the Tanzania Accredited Drug Dispensing Outlet experience. Progress in Community Health Partnerships: Research, Education, and Action; 3(2): 145-153. 9) Mahenge NS (2010). Pharmaceutical supply chain and distribution network, Implications on access to medicine and quality health care: Critical analysis of the public pharmaceutical sector in Tanzania. Maastricht School of Management, Maastricht, The Netherlands. 10) Amenyah, Johnnie, Barry Chovitz, Erin Hasselberg, Ali Karim, Daniel Mmari, Ssanyu Nyinondi, and Timothy Rosche (2005). Tanzania: Integrated Logistics System Pilot-Test Evaluation: Using the Logistics Indicator Assessment Tool. Arlington, Va.: DELIVER, for the U.S. Agency for International Development. 11) POUZN Project (2010). Introducing Improved Treatment of Diarrhea with Zinc and ORT in Tanzania: A Public-Private Partnership Supported by the POUZN/AED Project. Washington, DC: Point-of-Use Water Disinfection and Zinc Treatment (POUZN) Project, AED. 12) Prosper H and Borghi J (2009). IMCI Implementation in Tanzania: Experiences, Challenges and Lessons. Presented to DFID by the Ifakara Health Institute, Tanzania. CREHS Policy Brief. http://www.crehs.lshtm.ac.uk/downloads/publications/Tanzania_IMCI_policy_brief.pdf (4 Jan. 2012). 13) Measuring Access – in Selected Outlets (2010). Dar es Salaam, Tanzania: PSI. 14) President’s Malaria Initiative (2009). FY10 Malaria Operational Plan (MOP) Tanzania. http://www.pmi.gov/countries/mops/fy10/tanzania_mop-fy10.pdf (4 Oct. 2011) ESSENTIAL MEDICINES GLOBAL INITIATIVE – TANZANIA  49 15) United Republic of Tanzania Ministry of Health and Social Welfare (2008). The National Road Map Strategic Plan to Accelerate Reduction of Maternal, Newborn and Child Deaths in Tanzania 2008-2015. 16) United Republic of Tanzania Ministry of Health (2003). National Health Policy 2003. 17) Mtei G and Mulligan J (2007). Community Health Funds in Tanzania: A Literature Review. Ifakara Health Research and Development Center. http://www.tgpsh.or.tz/uploads/media/CHF_DESK_STUDY_IFAKARA_RC_02.pdf (11 Jan. 2012) 18) Ministry of Health and Social Welfare Tanzania Food and Drugs Authority (2006). Registration of Medicinal Products in Tanzania. http://www.tfda.or.tz/public1/vipeperushi/2.%20REGIST.%20OF%20DRUGS.pdf (10 Jan. 2012) 19) WHO and Novartis Foundation for Sustainable Development (2007). ICATT Integrated Management of Childhood Illness Computerized Adaptation and Training Tool. http://www.icatt-training.org/Implementation/Tanzania/tabid/87/Default.aspx (11 Jan. 2012) 20) Barrington J, Wereko-Brobby O, Ziegler R, et al (2010). SMS for Life Tanzania Pilot Project Report. For RBM Secretariat Hosted by WHO and Novartis Pharma AG. http://www.rollbackmalaria.org/docs/SMSdetailReport.pdf (10 Jan. 2012) 21) International Finance Corporation World Bank Group. The Business of Health in Africa: Partnering with the Private Sector to Improve People’s Lives, pp.88-97. http://www.ifc.org/ifcext/healthinafrica.nsf/AttachmentsByTitle/IFC_HealthinAfrica_Fin al/$FILE/IFC_HealthinAfrica_Final.pdf (13 Dec. 2011) 22) World Health Organization, supported by Novartis Foundation for Sustainable Development. Global guidance – local knowledge: ICATT for adaptable training in the Integrated Management of Childhood Illness. http://www.icatt- training.org/LinkClick.aspx?fileticket=pvHQcruN0WM%3D&tabid=57&mid=378 (11 Jan. 2012) 23) Novartis Foundation for Sustainable Development (2012). ICATT – Computer-based learning program for health professionals in developing countries – Novartis Foundation for Sustainable Development. http://www.novartisfoundation.org/page/content/index.asp?MenuID=573&ID=1752&Me nu=3&Item=44.22 (11 Jan. 2012) 24) Maestad O (2007). Rewarding Safe Motherhood: How Can Performance-Based Funding Reduce Maternal and Newborn Mortality in Tanzania? For

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