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XVII Annual International AIDS Conference

Revitalizing Community-Based Health Care Systems in Tanzania: Integrated Prevention, Care And

Treatment Services

J. Killewo, School of Public Health and Social Sciences,

MUHASC. Maternowska,

UCSF/ICRH-KenyaM. Gross,

Pangaea Global AIDS Foundation


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Tanzania: the Public Health Context

• Lack of access to health care services:

– Weakened health care infrastructure– Dwindling health care workforce– Escalating HIV/AIDS epidemic – Generalized poverty


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Tanzania: the Public Health Context

• In most rural areas poor transportation infrastructure, and shortage of healthcare workers and medicines, limit health care access for most vulnerable


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Tanzania’s Public Health Challenge

• To provide innovative solutions to HIV/AIDS prevention, care and treatment that support the MOH’s strategic plans: – Integrating HIV/AIDS prevention and care within a

strengthened primary health care delivery system– Improving community-based prevention– Increasing ARV adherence and referrals– Decongesting high-level tertiary care – Upgrading the health care workforce– Investment at the community level to meet demands

of remote and rural populations


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Formative Research: Understanding the Challenge (2005-2007)

• Archival research: Community Healthcare Workers and stakeholder interviews

• Field-based research: Mifundi District, Iringa Region & Kyela District, Mbyea Region

– Workforce gap analysis: to identify revitalized CHW role

– Ethnographic study of PHC issues: to identify local community needs


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Findings: Archival Research

• CHWs faced numerous problems– Volunteer positions, inadequate village support– Low level training, not well integrated into the national

health care delivery system– Lack of supervision– Shortage of drugs– Lack of transport


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Findings: Workforce Gap Analysis

– Shortages of equipment and supplies

– High patient volumes overworked staff & poor quality care

– Unmet patient expectations

– Long distances to health facilities lead to poor adherence

– Poor coordination with multiple NGOs, CBOS, etc


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Findings: Ethnographic Study

• Access to health care facilities limited by costs (insurance system ineffective, transport, etc)

• Lack of medications

• Quality of care problematic: – no confidentiality/stigma– provider/client rapport generally poor– no linkages between community & hospital


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Developing Health Care Leadership: the Youth of Tanzania

Given the TZ health care crisis—human resource and infrastructure—how can we: *promote HIV Prevention/treatment?*revitalize the CHW cadre?*strengthen the health system? *reach the rural and remote?

A simple intervention placing young Tanzanian’s at the centre of improving community-based HIV prevention, care and treatment:

The Youth Health Corps


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YHC Programme

Operates on several levels:• Provides economic opportunities and HIV

prevention for YHC members• Improves access to prevention and treatment at

the community level• Strengthens the community level health

dispensary to provide quality health services


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Scope of Work for YHC

• Provide HIV prevention, education and support services within the context of integrated primary health care

• Provide rapid HIV testing and/or referrals to HIV VCT

• Offer coordinated referrals for treatment and community support services

• Link HIV positive participants with HIV care and treatment services at community health dispensaries and/or at district level as appropriate

• Serve as patient and community advocates


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Implementation of Youth Health Corps

• Selection criteria:– Young adults 18-26– Minimum Form IV– Locally identified and recommended

• Train/employ YHC as ‘paramedic’ CHWs

• Facility level inputs at health dispensary level – improved diagnostics, staff training, support for adequate drug coverage

• Supervise YHC by clinicians at local health facilities

• Establish a TAG: review findings, changes and guide the process (NACP, MOH, MUHAS, etc)


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Implementation and Evaluation of Youth Health Corps

• The proposed stages of implementing and testing YHC model will be evaluated in collaboration with the MOH:– Demonstration Project (PEPFAR-Funded, launch in

October 2008)– Large scale RCT at regional level– Develop scale-up plan and exit strategy and

handover to MOH

• Evaluation will include feasibility; impact on household/community, health system and youth corps members; cost-effectiveness


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Intended Impacts of Youth Health Corps

Community/household Impacts

Health Systems Impacts Youth Impacts

Improved PHC

Increased utilization of VCT and ART

Decreased MTCT and HIV/AIDS related-stigma

Reduced incidence of HIV, STIs, maternal mort, malaria, child diarrhead and TB

Increased efficiency, quality, coverage, and cost-effectiveness of healthcare (by shifting the burden of routine care to the community)

Strengthened current and future human resources for health and social welfare

Decreased vulnerability to HIV infection with increased knowledge, eco opportunities, and future aspirations

Decreased vulnerability to HIV infection among OVC served


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Youth Health Corps: Generating Future Healthcare Leaders

• YHC members will be nationally recognized and certified by IAHS/MUHAS

• YHC members will train and serve for 2 years maximum—making way for new YHC members

• At completion YHC members will be linked to employment & education in clinical medicine and the allied health sciences

• Successful YHC members will receive an incentive-based

cash bonus to allay educational costs


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Acknowledgements• Ministry of Health and Social Welfare • Curriculum Development Committee Members• National Institutes of Health (NICHD)

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