By Dr. Subilaga K. Kaganda (TACAIDS) & Dr. Deborah Kajoka (MOHSW)

HIV CAPACITY BUILDING PARTNERS’S SUMMIT, Johannesburg, RSA

20th March 2013

Integrating HIV and SRH Services: Tanzania’s Progress

Introduction Overview of HIV/SRH integration Opportunities for Integration through PMTCT

& other HIV services Examples: Integration efforts in Tanzania Challenges Future Directions

National statistics, targets,

Statistics, 2010 &2012• Population : 44.9 Million• CPR: 20% (modern method)• Unmet Need: 22% • High fertility rates 5.7• MMR: 454/100,000• HIV: 5.7% (6.6% women, 4.6% men)

2007/08 THMIS • HIV (pregnant women): 6.9%

National Targets, 2007• Increase CPR to 60% by 2015• Reduce MMR to 193 by 2015• At least 80% of women living with

HIV and attending PMTCT receive FP by 20154

Tanzania

Sources: TDHS 2010; THMIS 2007/08; ANC sententinel

2007-08 THMIS: NBS, TACAIDS, and Macro International, Inc.

7.0-15.7%

0.3-3.0%

National Average: 5.7%

3.3%

1.6%1.9%

4.8%

5.1%3.8%

5.9%

15.7%9.2%

2.7%6.4%

4.9%

12%

7.4%

3.4% 5.6%7.7%

1.5%

6.7%Dar- 9.3%

3.6%

1.8%

Pemba 0.3%

Unguja 0.8%%Dodoma

Arusha

Kili.

Tanga

Pwani

Moro-goro

Lindi

MtwaraRuvuma

Iringa

SingidaTabora

Mbeya

Rukwa

Kigoma

Kagera

Mwanza

Mara

ManyaraShinyanga

3.1-6.9%Percent of women and men age 15-49 who are HIV-positive

2007-08 THMIS- NBS, TACAIDS, and Macro International

Age

2007-08 THMIS- NBS, TACAIDS, and Macro International

Percent HIV-positive women and men 15-24

Integrating Reproductive Health, HIV and AIDS policies, programs, and services has been considered essential for meeting International and National goals and targets (MDG 4,5 & 6 and MKUKUTA)

Tanzania developed the National Road Map Strategy (2008 – 2015) to accelerate the reduction of maternal, newborn and child deaths in Tanzania.

The MOHSW has also reviewed National HIV and RCH Policy Guidelines and strategies to lay down frameworks for integration of RH and HIV services.

Initial focus has been on integrating FP into various HIV services such as FP into PMTC, FP into VCT and FP into CTC.

Development of National Operations Guidelines for Integrating MNCH & HIV

National Multisectoral Strategic Framework III (2013-17) has highlighted the importance of integration

At the lower level of facilities such as dispensary and health centers, services like PMTCT, SRHs are provided under one roof and in dispensary it may be carried out by the same provider

At regional and district levels (Regional & Council Health Management Teams)

At national level RCH section and NACP are two separate institutions under one directorate (Preventive)

Policy, 2007

Gap:• Minimal integrated service delivery (passive)• Policy not translated into practice ; lack of “how to”

guidance Leading to missed opportunities

Policy review in 2007 : Several HIV and FP policies mandate integration (initial focus was on FP/HIV integration)

• HIV Policies: FP recognized as a core intervention for PMTCT; FP services to be offered to HIV clients

• Comprehensive STI case management /FP

• Focused Antenatal Care (FANC)-ANC/Syphilis/Malaria

• Integrated Logistic system- HIV/FP commodities, Condoms

• FP Policies: Universal access to HIV testing

Processes…

Stakeholders consultation meeting (2008) - key recommendations:

• The two MoHSW arms (NACP & RCHS) agreeing that integration has a mutual benefit to each of their program

• To Formulate the FP HIV Technical Working Group- DONE• To have evidence based programming- on going

• To develop the National Strategic Framework for integration- DONE

A processes…

Ensured an enabling policy environment Continued to do Evidence based programming

- conduct research to inform policy and service delivery (on going)

Continued strengthening health system to deliver effective integrated SRH & HIV services

Since 2008, Tanzania has

Enabling policy environment In 2009, the FPHIV TWG (Technical Working Group) was

established, co chaired by the NACP and RCHS unit of the MoHSW (secretariat – partner rotation).

Advocacy strengthenedOutcomes Integration one of the MoHSW priority Structural adjustment – PMTCT was reallocated from NACP to RCHs to

enhance integration Increase donor attention/support Resource mobilization- Tanzania National Coordinating Mechanism

(TNCM) endorsed inclusion of FP in the GF round 10 proposal Just finalized National Operational Guidelines for Integrating MNCH &

HIV (2012) ASRH and HIV integration on going through provision of YFS (youth

friendly services- slow scale up)

Evidence based programming - conduct research to inform policy & service delivery

Focusing on generating local evidence on feasible and effective service delivery models

FP/MCH

Counseling &

Testing

HBC

Care &

Treatment

PMTCT

Research Status (policy and practice)Global FP/HIV Indicator pilot, 2010

• Inform improvement in the HMIS

Rapid Assessment,2009

• Provided information on where we are with integration; • Showed existing linkages between SRH & HIV within Tanzanians

policy, systems & services; • Identified gaps in the policy and programmatic environment• Results greatly informed advocacy efforts

Site specific assessments

• SRH/HIV linkages seen in national RH and HIV policies & plans but integration guidelines not present

• At Facility level – HCWs supportive of integration but human resources and technical capacity remains a challenge

Evidence based programming - Conduct research to inform policy and service delivery

Research/project Status (policy and practice)

FP CTC studies2 studies looking at 2 different modalities; 2009/10

• Policy decision to scale up

• Modality decided: Provision of condoms, pills, injectables and implants at the CTC and referrals for other long acting and permanent methods

FP VCT study • Piloting the intervention, VCT service providers to provide pills and condoms

FP-HBC Project2 groups (HBC & FP methods and HBC & FP counseling)

• Community HBC provides FP counseling; non clinical FP methods and referrals for long acting and permanent methods

FP-PMTCT Project • Modalities of FP integration into ANC(PMTCT), PNC and HIV/STI units assessed in 12 health facilities

Evidence based programming - conduct research to inform policy & service delivery

FP into CTC: through facilitated referrals in Morogoro and Iringa

regions by FHI and through training of HCW in Pwani by ICAP. EFPAF- Tabora

FP in PMTCT: Training of HCW in Manyara and Iringa- Engenderhealth FP into facility and community PMTCT in Morogoro-

JHPIEGO; EGPAF-Tabora (+cervical cancer screening)PITC and FP in the framework of MNCH services in

Mwanza, Mara, Kigoma, Shinyanga, and Arusha by IntraHealth and Iringa, Tabora, Dodoma, Singida, Tanga, Mtwara, Manyara and Kilimanjaro by UHAI/JHPIEGO

FP in Home Based Care Programme by Path finder International In Arusha, Kilimanjaro and Dar es salaam

FP and VCT By AMREF and Marie StopesSRH in HIV& AIDS : Lindi,Tanga, Mbeya& Mtwara by GIZ

Limitations in scaling up due to vertical funding streams- District planning process – skewed to

HIV compared to SRH programming – limited linkages Operational guidelines have just been finalized and yet to be

disseminated Integration not comprehensive enough

Moving forward within the overburdened system Human resource shortage Coverage of trained providers in integrated service delivery are not

adequately trained. Inadequate funding for basic supplies and commodities

Challenges

Policy Maintaining advocacy at all levels

Importance of demonstrating mutual benefits of integration in both HIV and SRH programs.

Political commitment is critical

FPHIV TWG is vital in moving and sustain the SRH/HIV integration agenda

Health Systems & Service delivery It takes evidence to inform country to scale up

Different service delivery models-One size doesn’t fit all

Lessons learned

Policy Enhancing advocacy efforts

• Increase donors willingness to fund integration issues at country level • MoHSW and Partners ready to adopt and scale up models• Strengthen joint planning and implementation between SRH and HIV&AIDS at all

levels

Ensure conducive operational policies to effectively provide integrated services (NMSF III, Reviewed National HIV & AIDS Policy, Health sector RCH & HIV guidelines)

Health System/ service delivery Adopt studies findings into policy

Scale up integrated service delivery models nationwide

Finalize and put operational guidelines in use. Expand use of community based volunteers for FP/HIV /MNCH services

Future directions

delivered by Community Health Workers (CHW) approved by the Ministry of Health and Social Welfare at household level or health post and shall be predominantly promotional in nature.

These services can also be preventive and curative in nature:

Family planning, HIV Testing and Counseling, Maternal and Child Health, Post Rape Care, Tuberculosis, Cervical, breast, and prostate cancer screening

Preventive messages shall include: Benefits of knowing one’s HIV status, Safer sex

practices (i.e. abstinence, being faithful, Correct and consistent use of condoms,) Early initiation and exclusive breast feeding, Healthy timing and spacing of births) and Use of insecticide-treated nets (ITN).

CHW also will provide services at community level:• Contraceptive pills• Male and female Condoms• Informational materials• Referrals

Improved access to and uptake of key HIV and MNCH services.

Better access of PLHIV to MNCH services tailored to their needs

Reduction in HIV-related stigma and discrimination Improved coverage of underserved/vulnerable/key

populations Greater support for dual protection Improved quality of care Decreased duplication of efforts and competition for

resources and better utilization of Human Resources Enhanced programme effectiveness and efficiency Better understanding and protection of individuals’

rights Mutually reinforcing complementarities in legal and

policy frameworks

ASANTE SANA!THANK YOU!