THE PRIME MINISTERS OFFICE

TANZANIA COMMISSION FOR HIV/AIDS

NATIONAL MULTI-SECTORAL STRATEGIC FRAMEWORK ON HIV/AIDS 2003 - 2007

Dar es Salaam January,2003

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TABLE OF CONTENTS
TABLE OF CONTENTS Abbreviations FOREWORD Executive Summary 1 1. 1.1 1.2 1.3 2. 2.1 2.2 2.3 3. ii iv V

INTRODUCTION..........................................................................................................10 BACKGROUND ...........................................................................................................10 THE PURPOSE OF THE NATIONAL MULTI-SECTORAL STRATEGIC FRAMEWORK ON HIV/AIDS ...............................................................................................................11 RELATIONSHIP TO OTHER NATIONAL PLANS .............................................................11 EPIDEMIOLOGICAL SITUATION OF HIV/AIDS...........................................................13 THE IMPACT OF HIV / AIDS.....................................................................................13 DETERMINANTS AND DYNAMICS OF THE EPIDEMIC ..................................................14

THE HIV/AIDS SITUATION ......................................................................................13

EXPERIENCES AND LESSONS LEARNED IN THE FIRST 16 YEARS OF HIV /AIDS PREVENTION AND CONTROL ...................................................................16 3.1 3.2. 3.3 PLANNING AND INSTITUTIONAL STRUCTURES...........................................................16 POLITICAL LEADERSHIP, NATIONAL DEVELOPMENT POLICIES AND RESOURCES ......16 GENERAL REVIEW OF MEDIUM TERM PLANS I III: LESSONS LEARNT ................17
17
18 19 20

3.3.1STRUCTURAL CONSTRAINTS 3.3.2 AREAS OF MAJOR ACHIEVEMENTS 3.3.3 SUCCESSES IN PREVENTION AND CONTROL OF HIV/AIDS 3.4 THE CHALLENGES OF THE FUTURE

4.

VISION, MISSION, APPROACHES, GUIDING PRINCIPLES AND GOALS ....22 4.1.1 4.2 4.3 4.4 4.5 INTRODUCTION .........................................................................................................22 THE VISION ...............................................................................................................22 THE MISSION ............................................................................................................22 THE APPROACHES AND GUIDING PRINCIPLES ...........................................................22 STRATEGIC GOALS AND TARGETS ............................................................................24 INTRODUCTION .........................................................................................................27 THEMATIC AREAS .....................................................................................................27 STRATEGIC OBJECTIVES AND CORE - STRATEGIES....................................................28

5.

THEMATIC AREAS, OBJECTIVES AND CORE - STRATEGIES ......................27 5.1 5.2 5.3

5.3.1THEMATIC AREA:CROSS CUTTING ISSUES RELATED TO ENTIRE NATIONAL RESPONSE29 5.3.2 THEMATIC AREA 2:PREVENTION INCLUDING GENDER 34 5.3.3 THEMATIC AREA 3 HIV/AIDS CARE AND SUPPORT 44 5.34 THEMATIC AREA FOUR:SOCIAL AND ECONOMIC IMPACT MITIGATION 47

6.

MONITORING AND EVALUATION FRAMEWORK ...........................................50 6.1 6.2 6.3 6.4 6.5 6.6 6.7. INTRODUCTION .........................................................................................................50 NATIONAL LEVEL MONITORING AND EVALUATION ..................................................51 MONITORING AT REGIONAL, DISTRICT AND COMMUNITY LEVELS ...........................55 PROGRESS REPORTING ..............................................................................................56 NATIONAL EVALUATION ...........................................................................................57 FINANCIAL MONITORING ..........................................................................................57 MONITORING IN THE FRAMEWORK OF THE DEVELOPMENT POLICIES ........................58 Page ii

25/04/2003 7. INSTITUTIONAL AND MANAGEMENT FRAMEWORK....................................59 7.1 7.2 COORDINATION AND MANAGEMENT PRINCIPLES......................................................59 FROM THE NATIONAL MULTI SECTORAL FRAMEWORK TO THE IMPLEMENTATION OF THE NATIONAL RESPONSE ........................................................................................60
60 61 61

7.2.1 ROLES AND FUNCTIONS AT THE NATIONAL LEVEL 7.2.2 THE ROLES AND FUNCTIONS AT THE REGIONAL LEVEL 7.2.3 THE ROLES AND FUNCTIONS AT THE DISTRICT AND VILLAGE LEVELS

7.3 7.4. 7.5 8. 8.1 8.2 8.3

CIVIL SOCIETY, PRIVATE SECTORS AND NETWORKS OF PERSONS LIVING WITH HIV / AIDS........................................................................................................................62 FACILITATING AGENCIES .........................................................................................63 RESEARCH ................................................................................................................63 INTRODUCTION .........................................................................................................64 FINANCIAL FRAMEWORK PRINCIPLES .......................................................................64 FINANCIAL MECHANISMS .........................................................................................64
64 65 66

FINANCIAL FRAMEWORK ......................................................................................64

8.3.1 GOVERNMENT BUDGETARY ALLOCATION 8.3.2 THE NATIONAL FUND FOR HIV/AIDS 8.4 DISBURSEMENT OF FUNDS

8.5 FINANCIAL MONITORING ..........................................................................................67 8.6 FINANCIAL ABSORPTION CAPACITY..........................................................................67 8.7 PROCUREMENT MANAGEMENT .................................................................................68 69 Annex I PROCESS USED TO PREPARE THE STRATEGIC FRAMEWORK
II: REFERENCES 70 III:MEMORANDUM OF UNDERSTANDING OF PARTNERS TO THE TANZANIA MULTI SECTORAL STRATEGIC FRAMEWORK ON HIV/AIDS INCLUDING THE GOVERNMENT OF TANZANIA 73

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25/04/2003 Abbreviations
AIDS ARV CBO CSF DF DHS GDP GFATM GPA/WHO HIV IEC ILO LGA M&E MoE MoF MoH MDG MTP NACP NGO NMSF OI PEP PER PLWHA PMTCT PORALG PRSP PSF STD / STI STP TACAIDS TB UNGASS VAC VCT Acquired Immunodeficiency Syndrome Anti-retroviral Community-based Organisation Civil Society Fund District Fund Demographic Health Survey Gross Domestic Product Global Fund To Fight AIDS, Tuberculosis and Malaria Global Programme on AIDS Human Immunodeficiency Virus Information, Education, Communication International Labour Organization Local Government Authority Monitoring and Evaluation Ministry of Education Ministry of Finance Ministry of Health Millenium Development Goal Medium-term Plan National AIDS Control Programme Non Governmental Organization National Multi-Sectoral Strategic Framework (on HIV / AIDS) Opportunistic infection Post Exposure Prophylaxis Public Expenditure Review Person living with HIV / AIDS Prevention of Mother to Child Transmission (of HIV) President Office Regional Administration and Local Government Poverty Reduction Strategy Paper Public Sector Fund Sexually transmitted disease / infection Short-term Plan Tanzania Commission for AIDS Tuberculosis United Nations General Assembly Special Session (on HIV / AIDS) Village AIDS Committee Voluntary Counselling and Testing

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FOREWORD

HIV/AIDS presents a disastrous threat to our nation. Since the first three cases of AIDS were reported in 1983, HIV infection has spread throughout the country and hundred thousands of people in all walks of life have lost their lives. Surveillance reports indicate a two fold increase of HIV prevalence from 7.2 to 13.3 percent among female blood donors during the last ten years (1990- 2000). This shows that the epidemic is still growing and, with no effective cure or vaccine in the near future, it will continue to grow unless serious and effective measures are taken by all of us, individually and collectively to curb the epidemic now. The devastating impact of HIV/AIDS epidemic is now being experienced throughout our society. AIDS is now the major cause of illness and death in all sectors and at all levels. It causes prolonged human suffering, depriving parents of their children and children of their parents, and destabilizing family structures. It is depriving families, communities and the entire nation of the young and productive people. It is for this reason that in December 1999, His Excellency President Benjamin William Mkapa declared HIV/AIDS a national disaster and impressed on the entire nation, including the Government, political, religious and civil leaders and non-government organizations, on the importance of taking new measures to put the nation on a war footing against the HIV/AIDS epidemic. We must now intensify the fight against the HIV/AIDS epidemic with everything we have got. It will be a deadly mistake to allow complacency in the war against the HIV/AIDS epidemic.
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The Strategic Framework is an important step in the national efforts to intensify the epidemic. It is intended to operationalise the National Policy on HIV/AIDS. It provides strategic guidance for developing and implementing HIV/AIDS interventions by various partners. It identifies priority logical set of goals, principles, objectives and strategies to guide multisectoral responses to ensure a strengthened, effective and coordinated national response to the epidemic. It puts strong emphasis on community-based response, that communities are fully empowered and involved in formulating and implementing own responses. It is closely linked with other national development initiatives including Vision 2025, Poverty Reduction Strategy Paper (PRSP) and Medium Term Expenditure Framework (MTEF). Each sector, public, private, non-governmental organizations, faith based organizations and communities in rural and urban areas, are required to plan and implement cost effective HIV/AIDS interventions according to their comparative advantage. Political and Government leaders at all levels must take leadership and ensure that the war against the epidemic is sustained. Local Government Authorities, as leaders of the various communities, are therefore in the forefront in the war against the epidemic As contained in the policy, it is the individuals responsibility to protect oneself from HIV infection. Despite the prevailing economic situation, poverty should never be taken as an excuse for contracting HIV infection or engaging in drug substance abuse. Individuals must seriously endeavor to fight these enemies simultaneously; poverty, HIV infection and Drug substance abuse for their own survival. The Government will continue to provide an enabling environment for strategic leadership in multisectoral
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including

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coordination, advocacy, resource mobilization, monitoring and evaluation and provision of the right information to the public. HIV/AIDS is preventable. Its prevention must start from us as individuals. We must discuss HIV/AIDS openly in our families, with our children, in schools, at workplaces and in all our various groups. It is possible, Play your part.!

Frederick T Sumaye, MP Prime Minister Dar es salaam January 2003

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EXECUTIVE SUMMARY
Tanzania is facing a major threat to the survival of its people and the development chances of the nation from a concentrated and generalised HIV /AIDS epidemic. More than two Million people are estimated to be living with HIV /AIDS in 2002. The President of Tanzania has declared the epidemic a National Disaster. The National Multi-Sectoral Strategic Framework (NMSF) on HIV / AIDS will translate the National Policy of HIV/AIDS by providing strategic guidance to the planning of programmes, projects and interventions by various stakeholders in the fight against HIV/AIDS. It spells out the basic approaches and principles which guide the National Response and identifies goals, objectives and strategies for the period 2003 2007. The NMSF will guide all future programmes and interventions by the different stakeholders. It also contains a Monitoring and Evaluation System to measure progress towards the goals as well as the institutional / coordination and financial frameworks of the National Response. The NMSF builds on two elements: the dynamics and determinants of the HIV / AIDS situation (Chapter 2) and the achievements of the past and experiences gained in fighting the epidemic in the last 16 years (Chapter 3). Despite substantial efforts by the Government of Tanzania and its Development Partners since 1986 when the National AIDS Control Programme ( NACP) and the first Short-term Plan against HIV /AIDS were established, HIV prevalence rates continue to rise in nearly all parts of the country. The epidemic is still mainly driven by (hetero-) sexual transmission of the virus. Young girls and women are especially vulnerable to HIV. The biological and cultural / economic vulnerability of girls and women in general limit their possibilities to defend themselves against male pressure sometimes even forceful or to resort to other than sexual survival strategies for themselves, their children and families. Poverty which is still widespread in the country reduces the possibilities of larger segments of the population to have access to correct and continuous information and education about sexual health matters and medical services for treatment of Sexually Transmitted Infections (STIs). At the same time, poor resources limit the capacity of the public sector to safeguard the health of the population and provide sufficient education and social services to its

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people. Poverty also limits the economic safety-nets, to provide support to individuals, families and communities hard hit by the impact of the epidemic. Although it is difficult to establish the impact of HIV / AIDS in different sectors of society, economy or for the overall development, there is sufficient evidence that the impact of AIDS is already felt in many if not most sectors of society. This is especially apparent in the health and education sectors, but also private and business enterprises feel the impact due to higher morbidity and mortality among their workforces. Due to the increase in child and adult mortality caused by AIDS, life expectancy at birth in 2010 is supposed to be nearly ten years lower than it would have been in the absence of AIDS1. The impact of the National Response to the epidemic in the last 16 years is difficult to assess. Although the different Short-term and Medium-term plans between 1986 and 2002 were guided by national experiences and internationally recommended prevention and control strategies, their combined efforts failed to reverse the trend of the epidemic at national level. Past efforts spearheaded by the Ministry of Health and its National AIDS Control Programme (NACP) were constrained by structural factors: low implementation rate; lack of human and financial resources; inadequate capacity of the implementing institutions; excessive bureaucracy and centralisation; insufficient coordination; and limited integration of development partner activities. In spite of this, important and valuable achievements have been made in nearly all areas of HIV /AIDS prevention and control providing as basis for the consolidation and expansion of the National Response. 2 Two major achievements of recent years need to be noted: The elaboration and approval of a National Policy on HIV / AIDS (November 2001), and The creation through an act of Parliament (2001) of the Tanzania Commission for AIDS (TACAIDS), a new body to lead the multi-sectoral National Response under the Prime Ministers Office.

The estimated life expectancy by year 2010 might change once the September, 2002 Population and Settlement Census results are out.
The document doesnt contain a detailed Response Analysis. Details are available in different documents by different stakeholders and will be summarized in a Reference Document by TACAIDS).

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Furthermore, past experiences at regional level have demonstrated that capacities exist to curtail the dynamic of the epidemic and, eventually to reverse the trend.
In Mbeya region (three Million inhabitants), overall HIV prevalence rates

(surveillance data of women attending ante-natal care facilities) continued to rise in urban and rural settings up to 1994 reaching 20 per cent (the second highest level in the country). Since then they started to fall, reaching 11 per cent in 2001. Although it is impossible to determine scientifically the reasons for this spectacular decline, there is strong evidence that this success is related to the performance of the HIV / AIDS programme in the region. A high percentage of strategies and interventions mapped out by the NACP in its successive MTPs were implemented in Mbeya. From 1988/89 in a continuous and systematic fashion major elements (STI control, health and condom promotion, counselling and care services etc.) consistently and systematically reached the majority of the people. The intensity, continuity and large coverage of quality services and interventions, including the mobilization of districts and communities under strong regional political leadership and an excellent coordination between NACP and its development partners in Mbeya are major elements in explaining the achievements. Based on analysis of past efforts, achievements and constraints and on the continuous rise of the epidemic, the challenges for the new National MultiSectoral Strategic Framework are multiple. Among them are: To install a sense of increased commitment and leadership among the National Authorities and the leaders at all levels; To bring in line the long-term development policies of poverty reduction with immediate programme efforts of HIV / AIDS prevention and control; To unite all efforts of national and external stakeholders around a broad multisectoral response; To combine coverage of large parts of the population with long-term commitment to the programmes; To make financial mechanisms at all levels more adaptable to the needs of the actors; To respond to the rising demand for expensive, high quality treatment of persons living with HIV / AIDS in a matter which safeguards the health needs of the entire population.

Chapter 4 outlines the Vision, Mission, Approaches and Guiding Principles as well as the Goals of the NMSF for the period 2003 - 2007.

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While eradication of HIV is beyond the technical reach of any programme, reducing the threat and the consequences of the virus so that life perspectives of the younger generations are no longer overshadowed by this threat is the Vision guiding all efforts. It includes at the same time the building of a tolerant and caring society for those, today and tomorrow, already infected or affected by HIV / AIDS. The National Response is based on some general Approaches and Guiding Principles which provide the broad orientation of all programmes, projects and interventions. These approaches and principles have to be taken into account by all stakeholders and orient their undertakings. They include: Openness and frankness to address all issues related to HIV / AIDS including the sensitive issues of sexuality and sexual relations; Concentrating on intensification and scaling up of already proven interventions and best practises to cover as soon as possible the entire population; Mobilising the competence of communities to develop their own responses; Enabling local government councils to facilitate the communities in planning effective responses and to be effective coordinators of activities; Making all programmes and interventions gender sensitive and Investing continuously in human capacity building and development. In addition, principles including respect of Human Rights of people living with HIV / AIDS, long-term orientation of all anti-AIDS programmes, basing all interventions on scientifically and ethically sound practices respecting the life-styles, values and cultures of different population groups and centring all efforts on people and their capacities guide the NMSF. The NMSF projects Nine Goals which should be reached in the period 2003 to 2007. These goals are in line with international commitments by the Government of Tanzania as incorporated in the Millennium Development Goals (2000) and the Declaration of Commitment of the United Nations General Assembly Special Session on HIV / AIDS (UNGASS) of June 2001. The Goals address overall impact of the National Response as well as achievements in different Thematic Areas like Prevention, Care and Support, and Mitigation of Socio Economic Impact. GOAL 1: GOAL 2: GOAL 3: Reduce the spread of HIV in the country. Reduce HIV transmission to infants. Political and government leaders consistently give high visibility to HIV /AIDS in their proceedings and public appearances.

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GOAL 4:

Political leaders, public and private programmes, projects and interventions address stigma and discrimination and take Human Rights of persons living with HIV /AIDS into account. HIV /AIDS concerns are fully integrated and prioritized in the National Poverty Reduction Strategy and Tanzania Assistance Strategy. Reduce the prevalence of STIs in the population. Increase the knowledge of HIV transmission in the population. Increase the number of Persons living with HIV /AIDS who have access to a continuum of Care and Support from Home / Community to Hospital levels. Reduce the adverse effects of HIV /AIDS on orphans.

GOAL 5:

GOAL 6: GOAL 7: GOAL 8:

GOAL 9:

Chapter 5 contains the Strategic Orientation of the NMSF by providing under four Thematic Areas a set of Strategic Objectives and Core-Strategies for each objective. Four Thematic Areas have been identified 1. Cross-cutting Issues including Enabling Environment 2. Prevention including Gender 3. Care and Support 4. Mitigation of Socio-economic Impact A total of 18 Strategic Objectives are retained under these four Thematic Areas. For each Strategic Objective the Rationale and Challenges, Core Strategies and the Expected Outcome are presented. It has to be underlined that the Strategic Orientation of the NMSF is comprehensive. All major elements of the National Response have to be in place if the response is likely to achieve its desired impact. The NMSF does not attempt to prioritize among those objectives or strategies. It insists on the comprehensiveness of the Response, knowing that due to preferences, experiences, resources available etc. priorities will have to be established in distinct areas once Operational Plans and Activities are developed. It is one of the most important tasks of TACAIDS as the main guardian of the National Response to ensure that all areas are covered and balances between the areas are maintained or (re-) established. Chapter 6 deals with Monitoring and Evaluation which are very important aspects of the NMSF. It is one of the key tasks of TACAIDS to coordinate so as to ensure that the proposed M&E framework will be adhered to and that in the process of

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establishing Operational Plans for Sectors and at District and Community Levels appropriate M&E systems will be established. The national M&E framework is closely related to the international recommendations of indicators and targets adapted to the opportunities and constraints of the national situation. For all the nine goals, indicators as well as instruments to measure them are outlined. For many of the nine goals targets for the year 2007 exist already, for others these targets will have to be decided. For some of the Strategic Objectives, Indicators and Targets are also available. However, as the Strategic Objectives will have to be translated into Operational Plans of Sectors or Geographic Areas (Districts, Municipalities, Wards, Villages) these overall indicators will have to be complemented by sets of specific output, outcome and impact indicators. These systems should be linked as much as possible to the already existing M&E systems for Local Government Authorities as well as information management systems in specific sectors (e.g. health). It is the task of TACAIDS to make sure that all subsequent M&E systems are complementary and additional to the National System. All stakeholders have expressed their interest in the Memorandum of Understanding3 to harmonise as much as possible their M&E (as well as planning-) systems. A major task and challenge is the monitoring of the flow of financial resources and expenditure flows. The existing Public Expenditure Review should be used to track HIV/AIDS financial flows and expenditure and to identify resource constraints and bottlenecks. Provisions for progress reports from the community / district levels to the national levels are in place and annual review and replanning exercises are programmed. It will be important to make full use of these annual meetings for strengthening strategic planning, adjusting priorities and responding to new challenges. Two major evaluation exercises at mid-term and close to the end of the Five-Year period are planned. TACAIDS will have the task of coordination so as to ensure that HIV /AIDS M&E will be fully incorporated into the existing national poverty monitoring master plan as well as linking the collection and dissemination of data with initiatives (Tanzania Socio Economic Database) and systems in place by the National Bureau of Statistics. Chapters 7 and 8 deal with institutional / coordination and financial frameworks and mechanisms of the NMSF. One of the biggest challenges for National Response is the progression from National Strategic Framework to the development of National Plans in major sectors and their implementation. Two main requirements are needed:
3

For full text, see Annex 3

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A process of developing an environment of cooperation and mutual trust between the major stakeholders (public sector, civil society, development partners, private sector, networks of persons living with HIV /AIDS) which creates the precondition for cooperation and synergy between programmes , projects and interventions, and A multitude of institutional arrangements which facilitate the process of operational planning, implementation, assessment and review inside and across sectors and traditional division of responsibilities. Lessons from the past have shown that too often stakeholders have only a narrow and limited view of the National Response directed to their own part without sufficient concerns for the overall picture. The Draft Memorandum of Understanding of Partners4 provides an excellent framework for all partners to join hands in a concerted manner.

The clarification of responsibilities in moving from the NMSF to operational plans and implementation is of utmost importance. TACAIDS has the overall task to assure that implementation based on operational planning is undertaken by major sectors. The immediate next step after the NMSF will be the identification of lead agencies / structures for the Thematic Areas and the Strategic Objectives for developing the specific operational plans and their implementation. In this context the Health Sector will be the single most important area as many of the Strategic Objectives have a close bearing on it be it in prevention (STI control, condoms, Prevention of Mother-to-Child transmission, VCT) or in care and treatment. TACAIDS needs to support the Ministry of Health and its partners in the private sector, the traditional medical sector and the respective development partners to respond to the enormous challenges to this sector. Other government ministries like the Ministry of Education for the work in schools will equally be key players. TACAIDS has to make sure that for cross-cutting issues (like advocacy, reduction of stigma and discrimination etc.) appropriate working groups and structure are created to bring together the experiences and potentials of diverse actors and players. While the overall coordination of the National Response has been assigned to TACAIDS, each sector has to find the coordination mechanism most appropriate to its task and the complexities of structures involved. While some of the stakeholders for example, the development partners have already created effective coordination mechanisms among themselves, others, especially the Civil Society, the Private Sector and the persons living with HIV /AIDS still lack internal organisation and representation to facilitate national and local coordination with other sectors and actors. TACAIDS needs to support their capacity of internal structuring.

See Annex 3

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The concrete organisation and the institutional structuring of the response to the epidemic at Local Government Authority level is still under review. Whatever the outcome will be, capacities for planning, implementation, monitoring and review need to be strengthened at district / municipality as well as village and community level for these tasks. Regional level structure will be basically confined to play an intermediate role, receiving information and reports from below and assisting technically the local levels in their planning and reporting tasks. While some of the instruments (reporting forms etc.) are still under development, others need to be brought in line and harmonized with already existing mechanisms of other sectors. Reporting and monitoring of HIV /AIDS activities, especially of the public sector and by Local Government Authorities should wherever possible be a routine procedure fully integrated into existing systems. It will be important to use the planned periodic reporting, review and assessment structures of the progress of the National Response in a coherent and strategic manner. It is necessary to use the periodic review be they at local or national level to assess critically the progress undertaken, identify constraints and bottlenecks, incorporate new challenges and make necessary adjustments of plans and orientations wherever necessary. The agenda and the modalities of Research related to HIV /AIDS issues have to be reviewed and coordinated as part of the National Response. Major achievements should be documented as best practices to enlighten the internal and international discussion. The lack of financial (and human) resources to implement responses to HIV /AIDS was the single most important obstacle in the past. With the increased availability of government and international resources, the allocation and channelling of these resources according to needs and opportunities become a major task. The financial support will come from three sides:

Government budgetary allocations which are in the medium- and long-term the preferred mechanism as they make best use of existing systems as well as integrating fully HIV /AIDS into the regular and consistent public sector planning, implementation and reporting; A distinct National Fund for HIV /AIDS to which development partners, private sector and others can contribute and out of which additional national, Civil Society or private sector activities will be funded. Mechanisms for such a fund, its disbursement and reporting / accounting rules still have to be put in place.

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The continuous support especially by (private) development partners (e.g. Religious institutions, International NGOs) to local entities along well-established lines.

It will be one of the key tasks of TACAIDS to assure the regular monitoring of financial flows and that funds are properly allocated and disbursed taking into account the overall balance of the different strategies of the national Response. The identification of shortfalls and mobilization of additional resources is closely connected to this task.

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CHAPTER ONE INTRODUCTION

1.1 Background5
With a population of about 33 million people and an annual growth rate of 2.8 per cent and HIV prevalence of about 12 per cent of the adult, sexually active population (15 to 49 years old), Tanzania is one of the countries facing a serious HIV/AIDS epidemic with already noticeable negative impact on the development of the country. Since the first three cases of HIV/AIDS were reported in 1983, the epidemic has spread among people in all walks of life. It is estimated that about two million people in Tanzania have been infected with HIV and thousands have already died of AIDS related diseases. On 31st December, 1999, President Benjamin W. Mkapa declared the HIV/AIDS epidemic as a National Disaster and called on the entire nation, including the Government, political, religious and civil leaders and nongovernmental organisations, on the importance of taking new measures to put the nation on a war-footing against HIV/AIDS.6 In responding to the Presidents call and the continuing spread of the virus, Tanzania, in collaboration with all partners, is intensifying its efforts in fighting the epidemic. To date, the HIV/AIDS epidemic ranks among the top priorities in Government plans. The approach being promoted by the Government is frankness and openness about HIV/AIDS, prevention through capacity building and empowering of communities, families and individuals to respond to the challenges and threats of the epidemic. This broad National Response will be guided and directed by a National Multi-Sectoral Strategic Framework (NMSF) on HIV / AIDS which itself is based on the National Policy on HIV / AIDS of November, 2001.

The document will be updated once the results of the September 2002 National Population and Settlement Census are out. New Year message to the Nation by President Mkapa, December 31 1999, Dar es Salaam

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An Act of Parliament7 established the Tanzania Commission for AIDS (TACAIDS) under the Prime Ministers Office in 2001 to facilitate and strengthen the expanded response to the epidemic. The commission provides strategic leadership and coordination, monitoring and evaluation of the national response. TACAIDS will be the main guardian of the NMSF.

1.2 The Purpose of the National Multi-Sectoral Strategic Framework on HIV/AIDS

Together we can and must win the war against HIV/AIDS. Our survival as a nation and as a people critically depends on this victory (B.M.Mkapa, President of the United Republic of Tanzania, Forward National Policy on HIV / AIDS) The NMSF translates the National Policy of HIV/AIDS by providing strategic guidance to the planning of programmes, projects and interventions by various stakeholders in the fight against HIV/AIDS. It spells out the basic approaches and principles which guide the National Response and identifies goals, objectives and strategies for the period of five years (2003 2007). The NMSF will guide all future programmes and interventions by the different stakeholders. It also contains a Monitoring and Evaluation System and the institutional, coordination and financial frameworks of the National Response. Stakeholders have the opportunity to focus on specific thematic areas, objectives, strategies in relation to their areas of comparative advantage and to develop appropriate programmes, projects and interventions. The NMSF will also serve as the general document to advocate on HIV/AIDS issues, monitor and evaluate the National Response with regard to progress against the established goals. This will include progress on the reduction of HIV prevalence, programme performances as well as financial flows.

1.3 Relationship to other National Plans

The National Multi-Sectoral HIV/AIDS Strategic Framework aims to contribute to the realisation of the national aspirations with respect to the Vision 20258. HIV / AIDS poses a serious threat to what has been achieved in reducing poverty and is an obstacle to the realisation of national goals. Poverty significantly influences the spread and impact of HIV/AIDS.
7 8

Tanzania Commission for Aids Act of 2001 URT, Planning Commission, The Tanzania Development Vision 2025, 1999.

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Therefore, the fight against HIV/AIDS is considered an integral part to the efforts aimed at poverty eradication as outlined in the Poverty Reduction Strategy Paper9. The on-going government reforms particularly those related to local government are critical vehicles for creating an enabling environment for the fight of the HIV/AIDS epidemic. The focus of the local government reforms is the co-ordinated decentralisation of decision-making powers and service delivery to the districts, leaving the central government with the role of creating an enabling legal and policy framework and integrated coordination, monitoring and control of development activities. In this vein, the districts and through them the communities are critical hubs for spearheading effective and efficient implementation of HIV/AIDS interventions. The Framework therefore accords great emphasis on the scaling up the District and Community Responses in consonant with the ongoing local government reforms. All tiers of government shall have their capacity strengthened to enable them to synergistically bring together actors, resources and strategies in responding to the salient HIV/AIDS response needs of the communities. As the Framework will guide the substantial involvement and participation of the development partners of Tanzania. It is equally important that HIV /AIDS issues and concerns are fully addressed in the Tanzania Assistance Strategy. The Framework is also expected to guide the government allocation of resources under the Medium Term Expenditure Framework (MTEF) to targeted HIV/AIDS interventions. TACAIDS will therefore liase with the Ministry of Finance in order to ensure that the Guidelines for the Preparation of Medium Term Plan and Budget Framework for year 2003/04 2005/06 require the Ministries, regions and local government authorities to include HIV/AIDS control activities in their MTEFs/budgets that are guided by the strategies in the NMSF.

URT, Poverty Reduction Strategy Paper, August 2001.

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CHAPTER TWO THE HIV/AIDS SITUATION

2.1 Epidemiological Situation of HIV/AIDS
In Tanzania, the first three AIDS cases were reported in 1983 in Kagera region. By 1986, all regions in Tanzania Mainland had reported AIDS cases. The epidemic has spread into the rural areas thereby increasing the previously low rural prevalence to more than 10 per cent in some areas. The HIV Situation: Based on surveillance data, it is estimated that in 2002: Probably two Million persons are living with HIV/AIDS in the country. 80 per cent of them are in the productive age group of 20-44 years. HIV prevalence in the sexually active adult population (15 49years) is estimated at about 12 per cent10. HIV prevalence among pregnant women attending antenatal clinic for the first time ranges from 4.2 32.1 per cent in selected sentinel-sites.

The AIDS Situation: Only about 150,000 AIDS cases have been reported officially since the discovery of the first case. AIDS cases are heavily underreported. However the Ministry of Health estimates that only one out of five cases get reported. It is generally assumed that it takes about 7-10 years for a person in Tanzania to progress from HIV infection to the development of AIDS related diseases and, eventually, die.

2.2 The Impact of HIV / AIDS

Demographic Impact11 Adult and Child Mortality: Adult mortality in Tanzania has increased considerably in recent years due to HIV/AIDS and it is estimated that AIDS is now the leading cause of death among adults. The modest child mortality decline during the eighties and early nineties have been reversed due to HIV/AIDS.

10 11

UNAIDS, WHO, European Commission Data MEASURE (2001): AIDS in Africa During the Nineties: Tanzania

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Orphans: There is rapidly increasing proportion of children under 15 years who are orphans; by 2000, 1.1 per cent had lost both parents, 6.4 per cent had no father and 3.5 per cent had no mother. Life Expectancy at birth: The World Banks estimates that by 2010 because of HIV/AIDS, life expectancy will be reduced to 47 years as opposed to the projected 56 years without AIDS. Health Sector Impact12 Up to 50 per cent of hospital beds are occupied by patients with HIV/AIDS related illness. There is huge demand for care and hospital supplies. TB cases are rapidly on the increase. Economic Impact13 The overall economic impact of HIV/AIDS is difficult to establish. The World Bank estimates a reduction of average real GDP growth rate in the period 1985-2010 from 3.9 per cent without AIDS to between 2.8 and 3.3 with AIDS.

2.3 Determinants and Dynamics of the Epidemic

Tanzania is faced with a generalized and concentrated HIV /AIDS epidemic which has reached over 10 per cent of the sexually active population and continues to rise in most parts of the country. HIV transmission is estimated to be about 80 per cent through heterosexual contacts; less than five per cent is attributed to mother to child transmission; less than one per cent related to blood transfusion. Other transmission routes like intravenous drug use, professional accidents or through traditional skin practices are rare. Although most people have heard about AIDS and know how HIV is transmitted, widespread gaps and uncertainties in peoples mind on HIV transmission continue to exist. Despite prevention efforts in the last 16 years, there is little sexual behavioral change. Although most people are personally affected in one way or other by HIV/AIDS, a large portion of the people do not feel the risk. In addition to programme issues which impact on the dynamics of the epidemic, the main factors determining and driving the spread of HIV in

12 13

ibid ibid

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Tanzania are the prevailing sexual relations especially involving young persons and underlying economic, social and cultural factors. Sexuality is still largely taboo in families, schools and in public education / information. The construction of sexual relations in the country and among different population groups is still poorly understood. Traditional male dominated gender relations and poor economic opportunities impact negatively on the capacities of girls and women to determine their sexual relations. Thus making them more vulnerable to HIV infection. Cultural practices in some ethnic groups compound these risks. Poverty in all its facets reduces the capacity of the public and private sectors to provide quality services in education, health and social security for responding to the threats of the epidemic. It also limits the capacities of individuals, families and communities to access existing services. The general climate of stigma and discrimination surrounding HIV /AIDS and the continued resistance by important segments of society (e.g. religious organisations) provide the background for the continued spread of the virus.

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CHAPTER THREE EXPERIENCES AND LESSONS LEARNED IN THE FIRST 16 YEARS OF HIV /AIDS PREVENTION AND CONTROL
The National Response to the HIV /AIDS epidemic in the last 16 years is summarized, briefly, and major achievements and challenges on which the National Strategic Framework is built are highlighted.

3.1 Planning and Institutional Structures

The Government of Tanzania first responded to the challenge of the HIV /AIDS epidemic in 1985. A National AIDS Control Programme (NACP) was created in the Ministry of Health (MOH) in 1985 and with the support of the Global Programme on AIDS of WHO, a First Short- Term Plan (STP) was elaborated. This was later followed by three Five Years Medium Term Plans (MTP I III 1987, 1992, 1998). The National AIDS Committee (NAC) and the National Advisory Board on AIDS (NABA) were formed in 1989 and 1999 respectively to support/complement the NACP efforts.

3.2. Political Leadership, National Development Policies and Resources

National Leadership: While the first decade of the fight against AIDS was characterized by insufficient national political commitment and leadership, there is today a strong political commitment and leadership from the highest level, aimed at fighting the HIV/AIDS pandemic. HIV/AIDS is now a top priority in the development agenda of Government. There is a need to replicate this high political commitment at district and community level. National Development Policies: While the Poverty Reduction Strategy Paper (PRSP) of October, 2000 incorporates issues related to HIV /AIDS, it fails to provide the general development policy framework for dealing respectively with the impact and challenges of the epidemic. The following opportunities are to ensure that the PRSP is improved to have a more direct impact of the poverty reduction programme in addressing the HIV/AIDS challenge:

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Reviewing the PRSP to include broader set of core strategies addressing HIV/AIDS concerns. Linking more closely and fully the monitoring and evaluation of HIV/AIDS with the M & E system established for the poverty reduction programme. Funding for the National Response: In the past and today, the National Response was/is hampered by insufficient public funds. Although, HIV/AIDS features high in the government budget, the Medium Term Expenditure Framework (MTEF), the PRSP and the Public Expenditure Review (PER), leading to allocations of US$ 8 million in 2001/2002 and US$ 19 million in 2002/2003, disbursements and availability of these funds were and are far less than satisfactory. The overwhelming majority of HIV/AIDS projects and interventions were financially shouldered by Tanzanias development partners. Approaches of the National Response: In the early years, 1985 to 1991, the response to HIV /AIDS was driven by interventions of the health sector. Since then, expansion has taken place to develop a more multisectoral approach. Projects and activities have started in sectors like education, labour, agriculture, in the private sector, and among the youth. Increasing numbers of NGOs, CBOs and Faith-Based Organizations (FBOs) support the National Response. At the same time, interventions and activities have been more and more strengthened at district, ward and community level. Persons living with HIV /AIDS (PLHA) also have started to play an active role.

3.3 General Review of Medium Term Plans I III: Lessons Learnt

3.3.1 Structural Constraints While the MTPs contained the best available wisdom in designing strategies to prevent HIV transmission and to control the epidemic based on experiences and international recommendations, the National Response in the first 16 years was severely hindered by a number of structural constraints: a. Although frameworks were developed and approved, operational plans to put them into action were not always worked out. b. Implementation of HIV/AIDS operational plans was, at the national level, not achieved as expected. c. Plans rarely took into account the availability of human and financial resources. In addition, especially in the public sector,

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resources allocated and promised often were withheld for a variety of reasons. d. Plans largely concentrated on provision and delivery of services by rather weak institutions and structures. Participatory approaches and mobilisation of communities rarely featured prominently in projects and interventions. e. Bureaucracy and heavy centralisation impacted negatively in developing capacities and interventions at district and community level. f. Despite advocacy efforts by the NACP, the National Response to the epidemic is yet to pick up a sufficient momentum. To a large extent things are still business as usual. g. Development partners often preferred to invent their own wheels and sidestepped their integration and coordination with the National Response. 3.3.2 Areas of Major Achievements Despite the structural and conceptual limitations indicated in 3.3.1 the National Response succeeded in implementing major elements of HIV /AIDS prevention and control strategies over the years. It is not possible to appreciate these efforts in a way to determine to what degree the dynamic of the epidemic was influenced and slowed down by these efforts. The more important ones are listed below. No attempt is made here to appreciate their strengths and weaknesses in the past.14: a. b. c. d. e. f. g. h. Epidemiological surveillance Laboratory capacity for HIV testing Security of blood transfusion Control and Management of Sexually Transmitted Infections Counselling Services Programmes for children and young people in and out of school Interventions for specific vulnerable groups like Commercial Sex Workers, long-distance truck drivers, policemen, etc. Production of Information, Education and Communication (IEC) materials for different settings and campaigns

14

TACAIDS will prepare a reference document containing a detailed analysis of progress made and constraints encountered in the different areas of the National Response in the past 16 years based on analysis already done in other drafts and documents.

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i. j.

Research in intervention strategies (Mwanza trials, etc.) For most of these areas, and others, guidelines, training and communication materials have been developed.

Two major milestones were achieved recently: A comprehensive and far reaching National Policy on HIV/AIDS was approved in 2001 providing an overall guiding framework for all issues related to HIV /AIDS in the country. An Act of Parliament15 established the Tanzania Commission for AIDS (TACAIDS) under the Prime Ministers Office in 2001 to facilitate and strengthen the expanded response to the epidemic. The commission provides strategic leadership and coordination and monitoring and evaluation of the national response. Functionally, TACAIDS is mandated to plan, regulate and control its affairs independently but within the government system. However, these efforts and achievements were insufficient to reverse the dynamic of the epidemic. HIV prevalence rates continue to rise in nearly all regions of the country. A critical analysis of the efforts of the past 16 years will probably show that in addition to the structural constraints noted above, these strategies and interventions had common limitations. They were: a. b. c. d. e. f. Limited in scope and coverage. Restricted to pilot areas or a few wards or districts. Infrequent Hampered by quality assurance problems. Insufficiently coordinated. Insufficiently documented and communicated.

3.3.3 Successes in Prevention and Control of HIV /AIDS The past 16 years have also shown that HIV prevention and control is possible beyond tightly restricted geographical areas and small population groups. There is documented evidence that HIV prevalence rates have been declining in two regions of the country, Kagera and Mbeya.

15

Tanzania Commission for Aids Act of 2001

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While in Kagera, HIV prevalence rates started declining already in the early 90s, the case of Mbeya is more typical for the dynamic of the epidemic seen in the country. Overall HIV prevalence rates (surveillance data of women attending ante-natal care facilities) continued to rise in the whole region in urban and rural settings up to 1994 reaching 20 per cent (the second highest level in the country), since then, in contrast to other regions, they started to fall, reaching 11per cent in 2001, a nearly 50 per cent reduction. Although it is impossible to determine scientifically the reasons for this spectacular decline, there is strong evidence that this success is related to the performance of the HIV/AIDS programme in the region. A high percentage of strategies and interventions mapped out by the NACP in its successive MTPs were implemented in Mbeya (a region with three Million population). From 1988/89 major elements (STD control, health promotion, condom promotion, counselling and care services etc.) consistently and systematically reached the majority of the people. The intensity, continuity and large coverage of quality services and interventions, including the mobilization of districts and communities under strong regional political leadership and supported by an excellent cooperation between the NACP and its development partners in Mbeya are major elements in explaining the achievements.

3.4. The Challenges of the Future

Based on the experiences and lessons learned in the first 16 years of HIV / AIDS prevention and control in Tanzania, the new National Strategic Framework must address a number of challenges: 1. The National Response to the epidemic is not business as usual! Strong and continuous leadership and commitment are needed by the highest political authorities. 2. Government and sector reforms have to be undertaken in a way that is conducive to HIV /AIDS prevention e.g. strengthen district and community responsibility, capacity and competence. 3. A broad multi sectoral framework engaging all national and external actors and partners must guide the Response. Strong government leadership is necessary to coordinate this response. 4. New financial mechanisms have to be established by the government to support the National Response at district and community levels as well as in central government ministries. 5. Interventions impacting directly on HIV dynamics as well as long-term programmes addressing the root causes and structural inequalities which fuel the epidemic need to be synchronised.

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6. All programmes and interventions need to be of high quality. 7. All programmes must intend to cover the whole population continuously and have a long-term perspective (sustainability). 8. As HIV is still overwhelmingly transmitted through (unequal) sexual contacts, it is necessary to make sexuality and sexual relations a stronger focus in public debate, education and information at all levels (family, schools, media). 9. The access to drugs including the provision of antiretroviral treatment for persons living with HIV /AIDS has to be addressed in a comprehensive manner respecting equity in the HIV/AIDS programmes and in medical services provided to the population. 10. Adequate nutrition is important to the welfare of people living with HIV/AIDS (PLHA)

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CHAPTER FOUR THE NATIONAL MULTI-SECTORAL STRATEGIC FRAMEWORK ON HIV / AIDS

4.1 VISION, MISSION, APPROACHES, GUIDING PRINCIPLES AND GOALS

4.1.1 Introduction

The National Multi-Sectoral HIV/AIDS Strategic Framework for 2003-2007 articulates a vision for Tanzania in line with the National Policy on HIV /AIDS of November 2001 and elaborates through a mission statement, guiding principles, goals and objectives, the direction of the National Response against the HIV/AIDS epidemic in the medium-term and beyond. All future development of national, sectoral, district and community plans by all stakeholders will refer to this strategic framework and will put into operation the goals and objectives through programmes, projects and activities.

4.2 The Vision

Tanzania free from the threat of HIV/AIDS and which cares for and supports all those who are infected and affected by HIV/AIDS.

4.3 The Mission

Guiding and safeguarding the intensification and expansion of HIV/AIDS prevention, care and support, and impact mitigation programmes and interventions within a framework of a well coordinated national multi-sectoral response programme led by the Central Government, anchored at the Local Government Councils, rooted in communities and actively supported by partnerships with all concerned stakeholders.

4.4 The Approaches and Guiding Principles

4.4.1 The Approaches 1. Frankness and openness about HIV /AIDS will be promoted at all levels. As HIV still is overwhelmingly transmitted in (unequal) sexual

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2.

3.

4.

5.

6.

relations and changes in sexual behaviour had only limited results in the past, the issues of sexuality and sexual relations will be addressed more strongly without shyness and in an appropriate way for the different age-groups concerned. Based on the accumulated knowledge and experiences of HIV /AIDS control and prevention in the country and on international best practises, the National Response will build on achievements in the fight against the epidemic in different parts of the country by different stakeholders and communities. It will concentrate on intensifying and scaling up these positive experiences to cover eventually the whole country and involve the entire population. Rapid increase of coverage and continuous and long-term commitment by all stakeholders will be cornerstones of the National Response. The fight against AIDS will last for many generations. The success of the National Response resides with the competence of communities to live up to the challenges and threats of the epidemic and develop appropriate responses. Therefore, the focus of all programmes and interventions will be the strengthening of communities to openly discuss the realities in HIV transmission and its consequences, and develop appropriate interventions in prevention of HIV and care and support to those affected by HIV/AIDS. The imaginative potential and the creative capacities of the communities will be encouraged. CBOs and NGOs will play an important role to assist the communities in realising their potentials. The community refers to people at workplaces and institutions and in various groups at ward and village levels. The Local Government Councils are the focal points for intensifying the war against the epidemic. The Councils will have the responsibilities to plan and to coordinate actors and to support the communities in the villages, workplaces and institutions in their localities. Women and men, boys and girls are differently affected by and exposed to the threats of the epidemic. Efforts have to be undertaken to take these gender differences into account in the approaches, programmes and interventions and develop gender-sensitive interventions. Human capacities and human resources are critical in all activities, be they related to planning, implementation or monitoring and evaluation. They are needed at national, regional and most of all at local levels. It is absolutely critical, that major efforts have to be undertaken to assure the continuous expansion and qualification of them.

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4.4.2 The Guiding Principles National Response initiatives against the HIV/AIDS epidemic are guided by the following general principles. These principles have to be taken into account and included in all plans, programmes and projects: 1. 2. 3. The protection of health is a basic Human Right of the people of Tanzania. Combating AIDS needs the involvement and participation of the entire society. Combating AIDS is a priority and an integral part of the development policy of the country and is supported by continuously strong political and government commitment at all levels. Success and synergies can only be achieved through multi-sectoral and multidisciplinary approaches necessitating effective coordination and partnerships of all actors under government leadership. The Human Rights of persons living with HIV / AIDS are respected and their active participation in programming and implementation are pursued. Interventions are based on scientifically and ethically sound approaches (best practices) respecting the dignity, values and cultural diversity of the people. Due attention will be given to cost-effective interventions. Programmes and interventions are people-centred assisting and empowering communities, families and individuals to develop their own responses (AIDS-competency) to the challenges and threats of HIV /AIDS and to learn from the experiences of others.

4.

5.

6.

7.

4.5 Strategic Goals and Targets

The Strategic Framework sets out to achieve the following goals during the period 2003 to 2007. 16 GOAL 1: [OVERALL IMPACT] Reduce the spread of HIV in the country. Indicator: Percentage of young people aged 15-24 yearswho are HIV infected Target: By 2007, reduction by 30 per cent GOAL 2:
16

(OVERALL IMPACT) Reduce HIV transmission to infants17

(Note: Not for all goals, indicators and targets have been set; Millenium Development Goals (MDG) and Goals of the UNGASS Declaration of Commitment of June 2001 are marked)

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Indicator: Percentage of HIV-infected infants born to HIV-infected Mothers. Target: By 2007, reduction by x per cent. GOAL 3: (ADVOCACY) Political and government leaders consistently give high visibility to HIV /AIDS in their proceedings and public appearances. Indicator: Amount of national funds spent by the government on HIV /AIDS GOAL 4: (STIGMA AND DISCRIMINATION) Political leaders, public and private programmes, projects and interventions address stigma and discrimination and promote the respect for the Human Rights of persons living with HIV /AIDS. Indicator: Number of high-level events and programmes, projects and interventions having anti-stigma and anti- discrimination measures included. GOAL 5: (DEVELOPMENT) HIV /AIDS concerns are fully integrated and prioritized in the National Poverty Reduction Strategy and Tanzania Assistance Strategy. Indicator: PRSP and TAS have fully incorporated the HIV / AIDS dimension in the long-term development strategy. GOAL 6: (PREVENTION) Reduce the prevalence of STIs in the population. Indicator: Percentage of patients with STI at health care facilities who are appropriately diagnosed, treated and counselled. Target: By 2007, 70 per cent of patients in 80 per cent of health facilities GOAL 7: (PREVENTION) Increase the knowledge of HIV transmission in the population. Indicator: Percentage of young people aged 15 24 years who both correctly identify ways of preventing the sexual transmission of HIV and who reject major misconceptions about HIV transmission.

17

Target will be established later when MOH has developed its Sector Plan and more experiences are available.

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Target: By 2007, 95 per cent. GOAL 8: (CARE AND SUPPORT) Increase the number of Persons living with HIV /AIDS who have access to a continuum of Care and Support from Home / Community to Hospital levels. Indicator: Percentage of health facilities with the capacity to deliver appropriate care for persons living with HIV / AIDS. GOAL 9: [IMPACT MITIGATION] Reduce the adverse effects of HIV /AIDS on orphans. Indicator: Ratio of current school attendance among orphans to that among non-orphans in the age-range 10-14 years.

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CHAPTER FIVE THEMATIC AREAS, OBJECTIVES AND CORE STRATEGIES

5.1 Introduction
This Chapter contains frame strategies to guide the various stakeholders in the National Response against HIV/AIDS in their planning and implementation of programmes, projects and interventions during the period 2003 - 2007. It identifies four Thematic Areas: Cross-Cutting areas, Enabling Environment, Prevention, Care and Support, and Impact Mitigation. For each of the Strategic Objectives to be pursued, the basic Rationale and the Challenge in the country are captured and the Core Strategies to realise the Objectives are enumerated. The stakeholders have then opportunity to identify specific thematic areas, objectives, and strategies to focus on in relation to their areas of comparative advantage and to develop appropriate programmes, projects and interventions.

5.2 Thematic Areas

Table 5.1 Thematic and Strategic Areas of the National Response
Goal (as per Section 4.5) Goals # 1 , 2 Thematic Areas Strategic Areas

Impact of the National Response on the Epidemic

Cross-Cutting Areas Goals #3, 4, 5 Cross-cutting Issues related to the entire National Response including Enabling Environment

1. 2. 3. 4. 5.

Advocacy Fighting Stigma and Discrimination District and Community Responses Mainstreaming HIV /AIDS HIV /AIDS and Development /Poverty Reduction Policies

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Goal (as per Thematic Areas Section 4.5) Areas specific to certain goals Goals # 6, 7 Prevention

Strategic Areas

6. 7.

(Gender)

8. 9. 10.

11. 12.

13. 14.

Goal # 8

Care and Support

15.

16. Goal # 9 Mitigation of Socio-Economic Impacts 17.

18.

STI Control and Case Management Condom Promotion and Distribution Voluntary HIV Counselling and Testing Prevention of Mother to Child Transmission Health Promotion for specific Population Groups: Children & Youth, Women and Girls, Men, Disabled People School-based Prevention for Primary and Secondary Level Vulnerable Population Groups Commercial Sex Workers Men who have sex with men Bar Maids Prisoners Policemen and Soldiers Mobile Populations Refugees Drug Users Workplace Interventions (Public, Private and the Informal Sector) Safety of Blood, Blood Products and Universal Precautions in Health Care and Non-Health Care Settings including Hospital Waste Management Treatment for common opportunistic Infections including ARV Home /Community based Care & Support Economic and Social Support for Persons, Families and Communities affected by AIDS Support to Orphans

5.3 Strategic Objectives and Core - Strategies

For each of the Thematic Areas (in Table 5.1), the Objectives to be achieved along with the requisite Core Strategies are described in this section.

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5.3.1

THEMATIC AREA: CROSS-CUTTING ISSUES RELATED TO ENTIRE NATIONAL RESPONSE

1.

Advocacy
Rationale and Challenge Rationale: Advocacy remains in all HIV /AIDS programmes a prominent task. Despite recent impressive mobilisation of politicians, government and opinion leaders in Tanzania, issues and concerns of HIV /AIDS still have to be promoted in the general public as well as among decision makers. This includes stigma and discrimination, Human Rights of persons living with HIV /AIDS but also leadership, participation, involvement and resources. To provide correct and sound information and to protect people from false rumours and misinformation is a special task. Continuous strong advocacy can reduce the social and cultural barriers in the fight against AIDS. Challenge: To maintain and strengthen public awareness, acceptance and compassion related to HIV /AIDS issues and people living with HIV /AIDS through continuous advocacy among leaders of society at all levels as well as through correct and un-sensational information and education by the Media. To limit false rumours and misinformation. Strategic Objectives

Make HIV /AIDS an issue which society accepts and openly discusses. People infected / affected by HIV / AIDS are met with tolerance and compassion. Strategies

1. Develop and implement with important public decision makers (politicians, government people, business and community leaders) continuous plans for advocacy including leadership roles and role models (personal responsibility of leaders to live what they preach). 2. Work with different media (print, Radio, TV) on responsible and appropriate information, reporting and education on HIV /AIDS issues of the population. 3. Include networks and individuals of Persons living with HIV /AIDS to take part in advocacy work. 4. Develop communication strategies for specific population groups. Expected Outcomes

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Sustained Leadership is provided by decision makers and core people at national and local level. AIDS remains a priority issue in the perception of the society.

2.

Fighting Stigma and Discrimination

Rationale and Challenge Rationale: Stigma of HIV /AIDS as a sexually transmitted disease and discrimination of persons with HIV /AIDS are among the strongest barriers for successful programmes and interventions. They prevent open and informed discussion of issues related to sexuality. They marginalise and exclude people from communities and inside families creating not only unnecessary suffering by those infected but also contributing to denial and irresponsibility by the population at large. Violations of Human Rights of persons living with HIV /AIDS are frequent. Countries which have been successful in containing the epidemic have undertaken great strides in reducing stigma and discrimination. Challenge: Although nearly everybody in Tanzania knows a person with HIV or one who has died of AIDS, stigma and discrimination are still very powerful barriers in dealing successfully with the epidemic. National laws and regulations need to be reviewed to adapt them to the Human Rights of PLWHA. Strategic Objective

Create wide spread positive attitudes towards people living with HIV/AIDS and safeguard their Human Rights.

Strategies 1. Ensure that HIV/AIDS plans and campaigns of stakeholders include measures to reduce stigma and discrimination. 2. Promote greater involvement of PLWHA and their networks in HIV/AIDS interventions and public promotion by political leaders. 3. Establish hotline for human rights violations and acts of discrimination. 4. Review national laws and regulations (inheritance rights, workplace regulations etc.) to protect the Human Rights of PLWHA. 5. Strengthen VCT facilities in reducing stigma and discrimination. Expected Outcomes

HIV / AIDS and related issues accepted and dealt with more understanding and tolerance in society.

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Attitudes and behaviours have changed in certain professional groups (e.g. health workers) with regard to the infection and disease and to people who are infected / affected by them. Laws and regulations have been reviewed and adapted.

3.

District and Community Responses

Rationale and Challenge Rationale: Effective responses to the epidemic are based on the capacities of people living in communities to assess their own vulnerability and plan their own responses. Community mobilisation, empowerment and support to communities to respond effectively are the key elements of the National Response. It is in the communities and at local level where the fight against AIDS will be decided. NGOs, CBOs and Faith-Based Organisations can make important contributions towards mobilisation of communities and need to be supported. Districts and Municipalities are the most appropriate level for planning, coordination and support for the implementation of HIV/AIDS interventions. It is in the wards and villages where services are needed for the population. The TACAIDS Act of Parliament includes creation of District and Village HIV/AIDS committees to lead the planning, resource mobilisation and coordination of local responses. New partnerships have to be established and strengthened. Challenge: While encouraging experiences exist in a limited number of districts and communities, scaling up these experiences to all districts faces severe constraints with regards to human resources and capacities for district planning and community mobilisation. New forms of partnership have to be created at community level. Strategic Objectives

Mobilise and support the community to develop their own responses to HIV /AIDS. District and Municipalities to establish new partnerships and effectively plan and coordinate the local responses to HIV / AIDS under the leadership of local government councils.

Strategies 1. Promote, facilitate and expand models of Community Mobilisation for HIV / AIDS in all districts of the country.

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2. Rely on the strength, creativity and determination of Communities to find own solutions to reduce their vulnerability to HIV / AIDS. 3. Strengthen and accelerate District Responses by: a. Promoting and improving the comprehensive planning including all sectors. b. Promoting and improving the coordination of the various actors under the anchor of the local government councils. c. Developing and promoting participatory Monitoring and Accounting systems . d. Improving mechanisms for disbursing funds to the civil society (NGOs, CBOs) and faith-based organisations through the councils . 4. Strengthen the capacities of dispensaries, health centres and hospitals (both private and public), which are close to communities to provide effective HIV/AIDS interventions in areas such as STI management, condom promotion and distribution, VCT, health care and supports. 5. Strengthen the involvement of Faith-Based Organisations leaders, CBOs, NGOs as well as political and community leaders in advocacy, implementation and mobilisation of communities. 6. Mobilise increased local financial resources to sustain activities. 7. Identify and address the needs for capacity building of the various actors in districts, municipalities and communities. 8. Attach special importance for including the informal sector, unemployed and rural poor in the activities. Expected Outcomes

The number of communities which are competent to develop their own responses to the epidemic. By 2007, 100 per cent of districts and municipalities in the country are developing and implementing their own comprehensive plans and contribute to the sustainability of the HIV/AIDS related programmes.

4.

Mainstreaming HIV /AIDS

Rationale and Challenge Rationale: All sectors of society are encouraged to develop their own HIV /AIDS strategies and activities in order to expand the National Response. All sectors will have to analyse what HIV /AIDS does to its performance and how the sector itself contributes, directly or indirectly to the dynamic of the epidemic. Mainstreaming HIV / AIDS issues mean two aspects: concerns about the wellbeing of the labour / workforce in that sector and issues of its core business. While government structures (line ministries) will take the lead in

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mainstreaming, the sector they represent comprises many more actors and stakeholders including private sector institutions, businesses, civil society institutions and organisations of development partners. They are all called upon to make HIV /AIDS concerns their business. Challenge: Although the ideas and concepts of mainstreaming have been around for some time in the country, few sectors have actually been responding constructively to the challenge. Lack of (professional) capacities and resources to undertake are among the main constraints which need to be overcome. Strategic Objective The National Response to HIV /AIDS will be expanded and intensified in major sectors of society through mainstreaming plans and implementation Strategies 1. Develop mainstreaming plans in health, education, agriculture, industry sectors among the uniformed services including partnerships between public, private and civil institutions. 2. Provide guidance to the sectors on how to mainstream, including prevention and care programmes for their own human resources as well as adjusting the technical components (core business) of the sector to the impact of AIDS. 3. Develop human capacity and resources to implement the mainstreaming plan. 4. Develop monitoring, evaluation systems and review strategies to follow up on achievements and improve performances. Expected Outcome HIV /AIDS responses have been expanded in public, private and other sectors.

5.

HIV / AIDS, Development and Poverty Reduction Policies

Rationale and Challenge Rationale: The impact of a major HIV / AIDS epidemic on the development perspectives of countries are disastrous. This is why the threat of the epidemic has been declared a National Emergency in most cases in Africa and in Tanzania. Achievements of years and decades of development are threatened to be reversed. Poverty in all its economic, social and human facets will be increased by the epidemic. In a heavily affected country like Tanzania, it gets more and more evident that poverty can only be successfully tackled if the epidemic is

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controlled, but also that epidemic control can only be achieved if poverty can be reduced substantially. Challenge: Efforts have started to factor in the HIV / AIDS issues in the development strategy of Tanzania. However, more analytical work, research and professional imagination are needed to fully address the impact of the epidemic on the countrys long-term development and assistance plans. Strategic Objective The countrys major long-term development plans and policies have fully incorporated and addressed the challenges of the HIV /AIDS epidemic. Strategies 1. Continuous assessment of the major country documents (PRSP, Assistance Strategy, Vision 2025 etc.) for their analysis of the HIV / AIDS impact and their development of concepts and policies to mitigate those effects and contribute successfully to the control of the epidemic. 2. Sensitize national planners (and their international advisers) on the need to address the long-term impact of the epidemic. 3. Build technical capacities for analysis and anti - AIDS policy formulation. Expected Outcome The long-term national development plans and policies are addressing the rootcauses and the social economic impact of the epidemic and providing the framework for long-term successful responses to AIDS.

5.3.2. THEMATIC AREA 2: GENDER 6. Sexually Transmitted Management

Rationale and Challenge

PREVENTION Infection (STI) Control

including and Case

Rationale: STI control and prevention has been proven to be one of the major promising strategies in reducing HIV transmission. The Mwanza trial of 1994 has convincingly demonstrated the contribution of STIs and their control to the dynamic of the epidemic. Experiences from other regions (Mbeya) and countries point into the same direction.

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Challenge: To expand comprehensive STI control and management to all districts in the country Strategic Objective Make quality STI services including counselling and condom promotion available at all districts in the country. Strategies 1. Expand the coverage of quality STI services to all of the districts of the county. 2. Improve and maintain the quality of STI services trough capacity building, training, supervision and quality circles. 3. Assure the continuous availability of essential STI drugs at all health facilities offering STI services. 4. Involve the private medical sector (hospitals, practitioners, pharmacists)in training and quality control. 5. Regular monitoring of drug resistance. 6. Make quality STI services available to specific vulnerable groups like Commercial Sex Workers, Military and Miners. Expected Outcome By, 2007, 70 per cent of patients with STIs at 80 per cent of health facilities are appropriately diagnosed, treated and counselled . (UNGASS Indicator National Programme and Behaviour No 3)

7.

Condom Promotion and Distribution

Rationale and Challenge Rationale: Male Condoms are one of the most effective and easy to use barriers preventing the sexual transmission of HIV. Condoms also are also effective in preventing the transmission of other STIs and for family planning (prevention of unwanted pregnancies). Female condoms have been introduced in many countries and are especially accepted by groups like female Commercial Sex workers. Challenge: Although male condoms are promoted through social marketing and free distribution in the country, their general acceptance and regular use

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is still very limited. Female condoms are still a widely unknown product. The references to Condoms in the National Policy on HIV /AIDS are not sufficient to counter resistance from many quarters. Strategic Objective

Increase the proportion of the sexually active population especially in the rural areas who use condoms consistently. Promote the introduction of the female condom as an alternative protection especially among groups of high vulnerability (e.g. female sex workers)

Strategies 1. Develop and promote a National Condom Policy. 2. Promote the knowledge about condoms (male and female) in the general public consistently and throughout the country through private and public channels and counter consistently misconceptions and misinformation. 3. Expand the availability and accessibility of quality condom to all corners of the country through private and public channels. 4. Address gender and other socio-cultural barriers to using condoms. 5. Address the need of correct and consistent condom use as only effective way of protection by condoms. 6. Strengthen the involvement of the private sector in condom procurement and distribution. 7. Make female condoms more accessible by reducing financial barriers. Expected Outcome Percentage of young people aged 15 24 years reporting the use of a condom during sexual intercourse with a non-regular sexual partner. (UNGASS Indicator National Programme and Behaviour No 8).

8.

Voluntary HIV Counselling and Testing (VCT)

Rationale and Challenge Rationale: VCT has proven to be a major element in dealing with the epidemic (Uganda) and acknowledged by international technical agencies as a potentially powerful intervention for the benefit of the large majority of still-uninfected persons as well as for the persons already infected with the virus. A user-friendly service in public or private settings which provide counselling, testing on site and diagnostic / treatment and / or referral services for people who want to

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know their HIV status. VCT services can be an entry point for the worried (confirmation of their status and advice to remain HIV free) as well as for those who are already infected by providing medical, psychological and social support. Challenge: Despite some initial efforts, there are still very few places in the country which provide the service; in addition, the general level of stigma and discrimination associated with HIV / AIDS is a barrier to the request for VCT. Strategic Objective To increase number of people in Tanzania who consult about their HIV status and adopt appropriate measures for a responsible self-and other people protecting sexual life-style Strategies 1. Revise and disseminate national guidelines on the provision and management of VCT services. 2. Promote VCT services through IEC measures, advocacy, social marketing etc. 3. Establish, link and expand VCT services to existing reproductive health and MCH services and HIV/AIDS prevention, care and support programmes in the respective communities Expected Outcome By 2007, six VCT facilities are established in each of the districts and 20 per cent of the sexually active population know their HIV status.

9.

Prevention of Mother to Child Transmission of HIV (PMTCT)

Rationale and Challenge Rationale: In recent years, studies have proven that medical intervention during and immediately after delivery can substantially reduce the risk to transmitting HIV from the mother to the child. Low cost or free medication has become available. As the infection rates of pregnant women are still high or even rising, reducing the risk of transmission will have very beneficial effects on the survival of babies and children. Challenge: Although medication to reduce the transmission risk is relatively easy to administer, there exist many ethical, social / cultural and operational issues and problems which need to be addressed before expanding the service to the majority of pregnant women.

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Strategic Objective Reduce the risk of mothers to transmit HIV to their children, during pregnancy, birth and / or breast-feeding Strategies 1. Establish a comprehensive National Policy on PMTCT addressing all sensitive ethical and social / cultural issues. 2. Build capacities among health and social workers to implement interventions. 3. Advocate and sensitise the public at all levels on PMTCT. 4. De-stigmatise HIV /AIDS and encourage partner involvement. 5. Link PMTCT interventions to Access to Drugs initiatives and other treatment programmes. 6. Monitor and evaluate PMTCT interventions and undertake research on longterm benefits of interventions. Expected Outcome Percentage of HIV-infected pregnant women receiving a complete course of antiretroviral prophylaxis to reduce risk of MTCT. (UNGASS Indicator National Programme and Behaviour No 4).

10.

Health Promotion for Specific Population Groups: Children and the Youth, Girls and Women, Men & Disabled People
Rationale and Challenge Rationale: Although many of the campaigns address the general public at large, experiences have shown, that segments of society need to be addressed with specific approaches. In Tanzania, like in most countries, much hope concentrates on the so-called window of hope children and young people who are not infected and who should be supported to remain HIV-free in their future. It is also evident that the needs of women, men and disabled persons and their respective contribution to the fight against the epidemic are quite distinct based on their economic, social, and cultural situation (Gender differences). Challenge: In many parts of the country and by many stakeholders, programmes and projects for specific population groups have already been introduced. Experiences need to be documented and reviewed. Approaches must also been reviewed to make these population groups the subject of the programmes (to develop programmes with and by and not for them!) through capacity building and empowerment.

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Strategic Objective Increase the proportion of children and youth, girls and women, men and the disabled who feel adequately empowered to protect themselves against HIV infection. Strategies 1. Increase the number of quality Adolescent Sexual and Reproductive Health information sources. 2. Intensify and expand competent youth centres providing friendly STI and VCT services and other interventions in the communities for out of school youth. 3. Promote and expand programmes against drugs and sub-stance abuse, especially excessive alcohol consumption. 4. Strengthen and expand comprehensive HIV/AIDS interventions for primary, secondary and tertiary education. 5. Promote open discussion and awareness about gender and culture related traditions and sexual behaviour that increase vulnerability of women/girls to HIV /AIDS . 6. Empower girls and women to negotiate safer sex through strengthening of their knowledge about the nature and impact of HIV-AIDS and how best to have effective control so as to protect themselves. 7. Initiate programmes with and by men to promote male responsible behaviour in sexual and family relations (reduce machismo, irresponsible parenthood, domestic violence) 8. Initiate programme with and by disabled people to promote effective HIV/AIDS transmission amongst this group. Expected Outcome Different sections of the population are competent to deal with the challenges of HIV / AIDS by delaying onset of sexual activities, reducing the number of sexual partners and / or adopting safer sex measures as well as increasing understanding of gender issues.

11.

School based Prevention for Primary and Secondary Level

Rationale and Challenge Rationale: Life-skills and AIDS / Sex- Education programmes have demonstrated their effectiveness to support young people in encouraging and

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maintaining sexual relations which reduce the risk of HIV transmission. Schools provide a setting where a high percentage of young peoples congregates consistently and are easy to reach and organise. Participatory teaching methods can easily be applied to Life Skills issues. Challenge: There are still many barriers among professional and parental circles to intensifying and scaling up educational activities related to sexual issues in schools. Appropriate curricula are missing as well as capacities by teachers to guide the young people. Strategic Objective Primary and Secondary Schools provide education and opportunities for young people to develop and maintain orientations, values, attitudes and activities which safeguard their sexual and reproductive health. Strategies 1. Develop, test, and integrate curricula related to sexual health matters of young people at primary and secondary school level into the training of teachers. 2. Train sufficient numbers of teachers to achieve national coverage. 3. Assure support of parents and parents association in dealing with reproductive and sexual health matters. 4. Encourage pupils to develop their own projects and interventions (school clubs, theatre groups, competitions etc.). 5. Promote peer-education and guardian-centred projects. Expected Outcome Increase the number of schools with teachers who have been trained in lifeskills based HIV /AIDS education and who taught it during the last academic year. (UNGASS Indicator National Programme and Behaviour No.1).

12.

Health Promotion for Vulnerable Population Groups

Rationale and Challenge Rationale: Vulnerability to HIV infection is substantially higher in specific population groups than in the general sexually active population. This is either related directly to their professional activities (Commercial sex workers), to their social and cultural marginalisation (Men who have sex with men), or associated

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to their professions bringing them either in frequent contact with places of sexual mixing (bar maids), necessitating longer periods of separation from families or stable relationships (prisoners, migrant workers including miners, military) or the complete breakdown of stable social environment (refugees, intravenous drug users). These groups need special attention. They are also important in the dynamics of the epidemic. Challenge: While for some of these special vulnerable groups projects already exist in the country, for others new approaches have to be developed. For some of the groups (e.g. Men who have sex with men) little or nothing at all is known about their situation and behaviours. Strategic Objective Increase sexual behaviour change and care and support and impact mitigation activities for specific vulnerable groups like Commercial Sex Workers, Men Who Have Sex with Men, Bar Maids, Prisoners, Policemen, Soldiers and Mobile Populations, Refugees, and intravenous drug users. Strategies 1. Develop in a participatory manner and promote increased access to services and interventions ( IEC, condom access, peer education, friendly VCT and STIs services, care and support, mitigation of impact) for the specific vulnerable groups. 2. Support NGOs, CBOs and other agencies working with these groups and stimulate documentation and exchange (learning) among the actors. 3. Study social-cultural milieus and determinants of specific groups and develop projects with them. 4. Decriminalise activities connected to sex work and change discriminatory attitudes of the public and security forces (police) to persons exercising these activities. Expected Outcome Specially vulnerable groups have increased capacities and competence to ascertain their own risks of HIV transmission and undertake appropriate measures to safeguard their well-being.

13.

Workplace Interventions (Public, Private & Informal Sectors)

Rationale and Challenge

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Rationale: Businesses and enterprises (including the informal sector operators) are equally hit by the consequences of the HIV / AIDS epidemic with substantial repercussions on their workforce and profitability. In their own interest but also as a contribution to the well-being of the society, workplace programmes can reach substantial numbers of people. Challenge: While a few (larger) private enterprises have started workplace programmes already, many leaders of public and private enterprises and the operators in the informal sector still need to be convinced of the necessity and desirability of such programmes. Strategic Objective Increase the proportion of public/private sector enterprises and informal sector operators developing and implementing workplace interventions against HIV/AIDS. Strategies 1. Promote the introduction and maintenance of adequate workplace interventions in the public and private sector focussed on the protection and care and support for employees and mainstreaming of HIV/AIDS activities in the core business of the respective establishments. 2. Develop and disseminate replicable models of interventions. 3. Review and ensure a legal environment (Protection of workers rights, ILO recommendations) that is conducive for promoting and facilitating effective workplace interventions. 4. Strengthen labour and employment policies and regulation to incorporate HIV/AIDS/STDs and to discourage misconducts. 5. Develop outreach programmes to include families and communities of the workers and employees in the activities. 6. Develop special HIV/AIDS prevention and control programmes designed to reach the operators in the informal sector. Expected Outcome The percentage of (large) enterprises / companies that have workplace policies and programmes have increased. The proportion of operators in the informal sector reached by HIV/AIDS prevention and control programmes. (UNGASS Indicator National Programme and Behaviour No 2)

14.

Safety of Blood, Blood - Products and Universal Precaution in Health Care and Non-Health Care Settings including Waste Management

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Rationale and Challenge Rationale: Although HIV transmission through blood-transfusion, contaminated blood-products and interventions / accidents happening in hospital settings as well as through traditional practises (skin piercing, genital mutilation etc.) account only for a relatively low percentage of the overall transmission, the reduction of transmission risks in these settings is of importance for the safeguard of the health of the population in general and of the health workers / professional in particular. Challenge: The development of a functioning and effective National Blood Transfusion system provides a formidable organisational and financial challenge. There is limited awareness about risks of HIV transmission in hospital settings through contaminated instruments or waste as well as through traditional practices. Strategic Objective Reduce the risk of blood borne, health care and non-health-care settings -induced HIV transmission by invasive procedures. Strategies 1. Develop a National Blood Transfusion System covering all regions and districts. 2. Provide quality screening for HIV anti-bodies, hepatitis and syphilis for people donating blood. 3. Make Post-exposure prophylaxis available to professional groups at risk. 4. Improve the supply and distribution of laboratory supplies for HIV/AIDS blood screening. 5. Strengthen and enforce national hospital waste management guidelines. 6. Intensify advocacy and sensitise health workers on issues related to HIV transmission risks through discharged instruments and waste and reinforce the proper use of sterilization guidelines. 7. Provide appropriate information to the public and the practitioners on the transmission risks through traditional practises like skin piercing. Expected Outcomes

The population in general and health workers in particular are better protected against HIV transmission when donating blood or undergoing medical procedures.

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Traditional practices containing increased risk of HIV transmission are diminished.

5.3.3 15.

THEMATIC AREA 3: HIV / AIDS Care and Support

Treatment for common opportunistic infections, including ARVs

Rationale and Challenge Rationale: The dimension of the epidemic and the rising demand by persons living with HIV /AIDS for quality medical care and treatment urges the health care system to respond to these demands. International developments (reduction of prices for ARV, Global Fund to fight AIDS, Tb and Malaria) have opened the possibility at least for a portion of patients to have access to life-prolonging treatment. Real access to treatment will strengthen overall HIV / AIDS programmes by adding credibility. Challenge: In resource poor countries like Tanzania, general medical care is very often limited. Persons with HIV and AIDS patients suffer from these limitations. However, the dimension of the epidemic, demand by networks of PLWHA and international developments make the provision of appropriate care including access to highly effected anti-retroviral treatment one of the cornerstones of every National Strategy. Successes in treating persons with HIV / AIDS will have very beneficial outcomes for HIV prevention and control, but also increase demands on the health system. Strong regulatory measures have to be developed to prevent abuse and illicit use of drugs in open markets. A balance has to be found not to neglect other aspects of ill-health in favour of AIDS as well as to balance prevention, mitigation, and other aspects of care and support with the drug issue in the National Response. Families and individuals have to be protected from ruining their financial abilities in order to provide treatment for infected members. Strategic Objective Increase the proportion of PLWHAs having access to the best available treatment and medical care including ARVs Strategies 1. Expand the availability and affordability of quality service for prophylaxis and treatment of opportunistic infections and AIDS conditions in the public and private sector.

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2. Strengthen the National TB Control programme and its linkage with the HIV /AIDS programme. 3. Develop a National Policy for Access to Drug in the context of the on-going health sector reform containing clear stipulations on eligibility, priority of access, financial support, equity in the overall health service provisions etc. . 4. Include the private medical sector (Hospitals, practitioners, pharmacies) in all aspects of policies, guidelines and training related to treatment issues. 5. Link Access to Drug programme to other programmes like PMTCT. 6. Provide appropriate public information and transparency in regard to equitable access to drugs for AIDS patients and equity in relation to other conditions of ill-health of the population. 7. Establish strong and effective regulatory measures to safeguard the health of the people against abuse and illicit use of drugs. 8. Develop financial safety nets (health insurance schemes, social security packages etc.) to prevent the financial ruin of families and individuals due to treatment costs. 9. Include the traditional medical healers and their organisations in developing appropriate guidelines and training for treatment and care, including the promotion of constructive use of traditional/home remedies that have proven the potential in the treatment of opportunistic infections. 10. Promote the application of new research findings on the clinical management of AIDS patients. 11. Collaborate with international and national institutions in the search for HIV vaccine. Expected Outcomes Percentage of Persons with HIV /AIDS having access to best available treatment and medical care. Percentage of people with advanced HIV infection receiving antiretroviral combination therapy. (UNGASS Indicator National Programme and Behaviour No 5)

16.

Home / Community-based Care & Support

Rationale and Challenge Rationale: The rising demand for care and support by persons living with HIV /AIDS increases the burden on the health-care system especially on hospital care.

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Experiences in Tanzania and elsewhere have demonstrated, that a certain proportion of these care needs can be organised and shouldered at home and community level. Different pilot experiences exist. Home / Community care and support is also an important element in mobilising communities and promoting compassion for those infected and affected by the epidemic. Challenge: Home / Community based care and support programmes are still in early and often experimental stages. Experiences have to be documented and discussed and networks of learning to be established. Stigma and discrimination of HIV /AIDS still erects barriers to expansion of programmes. Strategic Objective Increase the proportion of PLWHAs having access to adequate community-based care and support. Strategies 1. Develop guidelines on provision of Home / Community care and support. 2. Promote and expand community and home-based care programmes. 3. Support NGOs/CBOs and Faith-based organisations in care and support projects. 4. Strengthen referral systems for patients in need to ascertain continuum of care from home community to hospital level. 5. Increase advocacy and education in communities to make them receptive and responding to the needs of PLWAH and their families. 6. Promote greater involvement of PLWHA in planning and implementation of Home / Community care and Support.

Expected Outcome Appropriate and sustainable community approaches for caring and supporting persons living with HIV / AIDS and their families have been developed and are expanded in the country.

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5.3.4 THEMATIC AREA FOUR: Social and Economic Impact Mitigation18 17. Economic and Social Support for Persons, Families and Communities affected by AIDS
Rationale and Challenge Rationale: With the progress of the epidemic, there are many indications that communities, families, and individuals hardest hit by HIV /AIDS face enormous difficulties to secure their survival. Loss of breadwinners in the family, femaleand child-headed households are some of the consequences of the AIDS impact. In the overall context of poverty reduction, new regulations like adapted health insurance schemes, social security measures and even direct assistance including provision of food may in many cases be necessary. Challenge: In the general context of wide-spread poverty, communities, families and individuals hit by the AIDS epidemic might become recipients of special social and economic support programmes which need to be created and sustained. Strategic Objective To secure the basic livelihood of persons, families and communities which are hardest hit by the impact of the epidemic. Strategies 1. 2. 3. 4. 5. Study the quantitative and qualitative issues related to the basic livelihood conditions of the affected persons and communities. Develop a social and economic policy framework to address the needs of the affected persons and communities. Study the possibility of a creation of special health insurance and social security plans for PLWHAs. Promote and expand programmes in the communities supporting PLWHAs with legal, psychosocial, economic and material assistance. Promote and strengthen the protection of legal, employment, economic and social rights of PLWHAs.
18 Note: The growing impact the HIV /AIDS epidemic has on different sectors of the society and

economy in Tanzania as well as on its overall development perspectives needs to be addressed under the Thematic Area No.1 : Cross cutting Issues related to the Entire National Response, especially the Objectives related to Mainstreaming of HIV / AIDS and Development and Poverty Reduction Policies.

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6.

Develop and institutionalise a framework/system for continued monitoring and assessment of the social and economic needs of persons, families and communities hardest hit by the epidemic. 5. Provide support to NGOs, CBOs, Faith-based organisations and other agencies providing economic, social and spiritual support to affected persons and communities. Expected Outcome A social policy framework for assisting persons living with HIV /AIDS and their affected families and communities has been developed and programmes / projects are in place to secure the basic livelihood of those affected by the impact of the epidemic.

18. Supports to Orphans

Rationale and Challenge Rationale: Among the persons and groups heavily affected by the epidemic, the orphans are probably the most vulnerable group which are threatened in their survival and the development of life-perspectives. Traditional support structures (extended families etc.) may no longer be capable to absorb this challenge. Orphans unprotected may be extremely exposed to a variety of social / economic degradations ( street-children, delinquency, economic sexual survival activities, drugs etc.), including increased risks of HIV transmission. Challenge: Traditional family safety structures are insufficient to respond to the growing number of AIDS orphans. New social and charitable programmes have to be developed respecting also the needs of non-AIDS related causes of child survival problems. Strategic Objective Increase the proportion of AIDS orphans having access to adequate integrated, community-based support. Strategies 1. 2. 3. Study the extent of the issue under different scenarios. Develop policy guidelines and co-ordination of interventions for orphans. Strengthen and expand integrated and innovative programmes for orphans especially at the district and community level (education, health care, shelter, psychosocial counselling, life skills training, etc).

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4.

Support NGOs, CBOs and Faith-based organisations in developing and sustaining support activities where ever possible in close relation with existing traditional family and community systems. 5. Address stigma and discrimination against HIV/AIDS orphans. Expected Outcome AIDS related and other orphans have developed their capacities to lead a productive life and are guided by social policy measures.

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CHAPTER SIX MONITORING AND EVALUATION FRAMEWORK

6.1 Introduction
Monitoring and Evaluation (M&E) is a critical and integrated task of the National Response on HIV / AIDS. M&E will take place at all levels from the National Strategic Framework to District and Community plans and activities. Coordination of the M&E of the National Response is one of the main responsibilities of TACAIDS. TACAIDS will devote core resources to this task and collaborate with the different M&E units of Ministries and other organizations. To make M&E effective and efficient, resources and capacities have also to be strengthened at lower government levels, especially in the Local Councils and at district level. The M&E framework is important in order to: Determine the progress in implementing the NMSF. Continuously identify and resolve any problems arising on the course of the implementation of the National Response. Continuously track down the trends of the HIV/AIDS epidemic. Track outcomes of the National Response. Establish the impact of the National Response.

This Chapter provides some guidelines for establishing the framework of M&E system which: a. identifies the tasks at the National level and b. provides guidance to all subsequent M&E systems at regional, district and community levels.

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6.2 National Level Monitoring and Evaluation

The M&E system is directly linked to the goals, indicators and targets of the NMSF and the expected outcomes of its Strategic Objectives. These goals, indicators, targets and outcomes are closely related to the internationally agreed indicators which will measure the Declaration of Commitment of the UNGASS on HIV / AIDS of July 2001 at global level as well as the Millenium Development Goals. These international goals and targets have been adapted to the capacities and opportunities of the National Response in Tanzania. There is a need to bring the HIV / AIDS goals and indicators into the Poverty Monitoring system. The National Response will be monitored, assessed and evaluated by the progress made in reaching the Nine (9) Goals of the NMSF. Table 6.1 provides a summary of the Goals, Indicators and Targets and indicates how often and by what activities the progress will be measured. The approach behind the M&E system of the NMSF is the following: a. The system tries to be as close as possible to the internationally agreed recommended indicators as Tanzania is a member state of the UN and reports back its progress to the Secretary General of the UN. b. The M&E system of the NMSF provides only the framework for the overall National Goals. It will have to be complemented by a number of subsets of indicators and targets fixed for each Objective, Sector, Programme, Project or Intervention. The M&E systems of these levels will be the responsibility of the planners / implementers of the activities. The National M&E framework must be taken into consideration and referred to in subsequent M&E systems of lower levels, in stakeholder programmes and projects and by development partners.19 c. For some of the Strategic Objectives, Indicators have already been formulated as they respond to the internationally recommended set of UNGASS Indicators. However, those stakeholders who will take the lead in translating a Strategic Objective into an Operational Plan will have to decide on Indicators and Targets and the means to measure them for each Objective. (This leadership and core responsibility will come from TACAIDS for Objectives in the Thematic Area of Cross-Cutting Issues; from Line Ministries as for Objectives No 6 - 9, 14, 15 (MOH) or Objective No 11 (MOE); or from Working Groups of various stakeholders.)
19

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d. Like the entire NMSF, the M&E system is a dynamic tool, bound to be reviewed, amended and changed as the situation of the National Response and its parameters change. e. It is practical and pragmatic in trying to concentrate on fewer areas and in expanding its complexity as the National Response gets stronger and capacities and experiences increase. f. Wherever Targets have been formulated, they cover the entire 5 Year period of the NMSF. In the process of developing operational plans for the sectors, it will be possible and necessary to establish yearly or biennial targets.

Table 6.1: Goals, Indicators and Targets of the National Multi-Sectoral Strategic Framework on HIV /AIDS
Description of Goal / Indicator / Target Goal: 1: Reduce the spread of HIV in the country Indicator: Percentage of young people aged 15-24 who are HIV infected Target: By 2007, reduction by 30 % Goal 2: Reduce HIV Transmission to infants Indicator: Percentage of HIVinfected infants born to HIVinfected mothers Target: By 2007, reduction by x% Goal 3: Political and government leaders consistently give high visibility to HIV /AIDS in their proceedings and public appearances. Indicator: Amounts of national funds spent by government Relation to UNGASS Indicators UNGASS Impact Indicator No 1: Target: 25% reduction by 2005) Reporting Schedule Yearly Method of Data Collection / Comments Annual Sero Surveillance In place in 6 regions with 4 sites each

UNGASS Impact Indicator No 2 Target: 20 % reduction by 2005

UNGASS Indicator National Commitment and Action No 1

Yearly

Target will be established later when MOH has developed its Sector Plan and more experiences are available. In meantime, see Expected Outcome of Strategic Objective No 9 : PMTCT Public Expenditure Review (PER) at community, district, regional and national level

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Table 6.1: Goals, Indicators and Targets of the National Multi-Sectoral Strategic Framework on HIV /AIDS
Description of Goal / Indicator / Target Goal 4: Political leaders, public and private programmes, projects and interventions address stigma and discrimination and promote the respect for the Human Rights of persons living with HIV / AIDS Indicator: Number of highlevel events and programmes, projects and interventions having antistigma and antidiscrimination measures included Goal: 5: AIDS concerns are fully integrated and prioritised in the National Poverty Reduction Strategy and Tanzania Assistance Strategy. Indicator: PRSP and TAS have incorporated sufficiently HIV / AIDS dimension Goal 6: Reduce the prevalence of STIs Indicator: Percentage of patients with STI at health care facilities who are appropriately diagnosed, treated and counselled Target: By 2007, 70% of patients at 80 % of health care facilities Goal 7: Increase the knowledge of HIV transmission in the Relation to UNGASS Indicators UNGASS Indicator National Commitment and Action, National Composite Policy Index: Human Rights Reporting Schedule Yearly Method of Data Collection / Comments Data collected from Districts, Regions and National Level, and organisations. Indicator will be reviewed after first year.

(UNGASS Indicator National Composite Policy Index Strategy Development No 2)

Yearly

Continuous Assessment and Review

UNGASS Indicator National Programme and Behaviour No 3

Yearly

Health Care Facility surveys (on appropriate care) plus data from districts, municipalities etc. on coverage

UNGASS Indicator National Programme and

Yearly

Annual Behavioural Surveillance Monitoring

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Table 6.1: Goals, Indicators and Targets of the National Multi-Sectoral Strategic Framework on HIV /AIDS
Description of Goal / Indicator / Target population Indicator: Percentage of young people aged 15-24 who both correctly identify ways of preventing the sexual transmission and who reject major misconceptions about HIV transmission Target: By 2007, 95 % Goal 8: Increase the number of persons living with HIV /AIDS who have access to a continuum of care and support from home / community to hospital level. Indicator: Percentage of health care facilities with the capacity to deliver appropriate care to persons living with HIV /AIDS Goal 9: Reduce the adverse effects of HIV /AIDS on orphans Indicator: Ratio of current school attendance among orphans to that among nonorphans in the age-range 1014 years Relation to UNGASS Indicators Behaviour No 7 Reporting Schedule Method of Data Collection / Comments In place in six regions

UNGASS Indicator (Alternative) National programme and Behaviour No 5

Yearly

Data from districts, regions and national level. See also: Expected Outcomes of Objective 15 on Treatment for opportunistic infections including access to ARVs.

UNGASS Indicator National Programme and Behaviour No 9

Population based-surveys (DHS, UNICEF Multiple Cluster Indicator Survey).

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25.04.2003, National Multisectoral Framework - final Responsibility for M&E at National Level The overall responsibility of M&E at National Level rests with TACAIDS and its M&E Section. They have to make sure that data are collected, analysed and presented. For some Goals (No 3, 4, 5) TACAIDS will directly organise the collection of data relying on information to be collected at regional and district level. For Goals 1 and 7, TACAIDS will rely on different partners and institutions to undertake this work. Annual National Sero- and Behaviour Surveillance will come under the responsibility of the Ministry of Health and the National Bureau of Statistics (NBS). The usefulness of other established surveys (DHS, UNICEF Multiple Indicator Cluster Surveys (MICS)) in contributing to the generation of data as well as the establishment of new HIV Indicator surveys have to be reviewed and decided. Presentation of Results The results of the yearly Monitoring of Progress exercise will be presented as part of the Annual Performance Report of the National Response which TACAIDS has the responsibility to produce. (See below). TACAIDS will also provide the data and information which will be communicated to UNAIDS as part of the annually (or biennial) reporting by countries to the Secretary General of the UN.

6.3 Monitoring at Regional, District and Community Levels

As the implementation of the National Response will happen to a very large degree at district and community levels, these levels must develop their own M&E frameworks. As stated above, the National M&E framework will guide the development of the lower level systems. With the exception of the two national Surveillance Surveys (for Goal No 1: HIV prevalence and Goal No 7: Knowledge of HIV Transmission) all other goals have direct bearing on District and Community level and should therefore be included in their local M&E systems. These include: Availability of local funds (Indicator No 3), Events and projects / interventions which address stigma and discrimination (Goal No 3), integration in poverty reduction plans (Goal No 5); availability of treatment of STI patients (Goal No 6; for the quality aspect a distinct health facility survey must be used), availability of treatment and support for PLWHA (Goal No 8). The responsibilities for and the format of the M&E systems at community and district level and the role of synthesizing lower level results at regional level will Page 55

25.04.2003, National Multisectoral Framework - final have to be decided in the context of the development of the relevant structures and functions for these levels which is currently in process. (See also Chapter 7 on Institutional Framework and Coordination)

6.4 Progress Reporting

1. Quarterly and annual reports based on the work plans of the different levels and structures are the main management tool of monitoring progress of the National Response. Reporting formats and requirements will be decided by TACAIDS and the Stakeholders for the different levels (community, village, district, region) and structures (Ministries, External organizations and agencies). 2. TACAIDS will consolidate the progress reports into an Annual Performance Report to be discussed by a joint TACAIDS/Stakeholder Annual Technical Review. Participants in this review will be the Technical Staff / Focal Points of organisations and institutions involved in the National Response. Progress, achievements, constraints and opportunities of the National Response will be discussed and recommendations made. 3. Based on this Annual Technical Review a Summary Annual Report highlighting the main achievements and constraints will be elaborated by TACAIDS and presented to a joint TACAIDS /Stakeholder Annual Conference. In this conference, the Chiefs, Directors, Heads of Agencies and Organizations will discuss the recommendations and suggest appropriate actions for the next period. This Conference will be chaired by the highest political level of the country. The report will also be forwarded to the National Assembly through the office of the Prime Minister. 4. Districts will also organise an annual stakeholder / partnership meeting to review progress and to identify new directions and orientations based on the consolidated reports by villages and wards. 5. The reports and the meetings are the key instruments to take strategic decisions for the next period. Milestones will have to be reviewed and adopted, resources reallocated and new challenges be met. In addition to these key national events involving all stakeholders, separate reports and meetings on specific areas or strategies comprising a limited number of actors might be organised whenever need arises.

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6.5 National Evaluation20

In addition to the yearly Monitoring and Review exercises, in depth evaluation will be undertaken twice during the five-year period as follows: In mid 2005, a Mid-term evaluation will take place to look into the achievements of the National Response after two years. In mid 2007, the evaluation of the Five Year NMSF will be undertaken to assess the overall national progress and to guide the directions and milestones of the next Five Year Strategic Framework. In both evaluations, internal and external experts will participate. The detailed Terms of Reference as well as the identification of the evaluation team will be part of the TACAIDS / Stakeholder consultation meetings. Generically, the evaluation will Assess the reasons for success or failure of specific aspects of the national response. Assess, if the NMSF is achieving its intended goals and objectives. Assess, if the NMSF is still valid and appropriate to the challenges of the epidemic. Assess the adequacy of resources which had been available for the National Response. Assess the performance and adequacy of the institutional framework, especially the coordination mechanisms at national and local levels.

6.6 Financial Monitoring

As part of the monitoring of the National Response, the monitoring of financial aspects is a very important one and will be a key task of TACAIDS. The main instrument will be a yearly Public Expenditure Review (PER) for HIV / AIDS involving all major stakeholders (see Indicator on Goal 3). The tasks of financial monitoring include especially: a. the constant review and discussion of operational plans of sectors and major stakeholders with regard to its financial viability (are resources available in sufficient quantities to assure the realisation of plans?); b. identification of bottlenecks and resource constraints especially for district and community activities (do funds arrive where they are needed? Are the financial mechanisms in place working? If necessary collaborate with the appropriate
20 Evaluation exercises should be reserved for the national level. It should be aimed to reduce the necessity

of various evaluation exercises necessitated by requirements of various international stakeholders and donors and to combine them as much as possible into the regular National Evaluation Exercise.

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25.04.2003, National Multisectoral Framework - final institutions in adapting them to the needs.) (see also Chapter 8 on Financial Mechanisms); c. tracking and review externally available funds and if they are sufficiently synchronised with the priorities of the National Response; d. identification of shortfalls of national and / or external funds and undertake efforts in resource mobilisation at national and external level. e. Transparency and accountability of public funds as well as donor funds

6.7. Monitoring in the Framework of the Development Policies

TACAIDS also has the responsibility to assure that HIV /AIDS is fully integrated in the larger monitoring and evaluation systems of the National Development Plans, especially the PRSP reviews. (see Goal and Indicator No.5). The Poverty Monitoring Goals and Indictors will have to be enlarged by the Impact Indicators of the NMSF.

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CHAPTER SEVEN INSTITUTIONAL AND MANAGEMENT FRAMEWORK

7.1 Coordination and Management Principles
The institutional and management framework provides guidance on how the National Response will be organized and coordinated. Translating the general orientation of the NMSF into concrete and detailed plans, programmes, projects and interventions and to assure their effective implementation requires leadership at all levels and strong and well-coordinated multi-sectoral partnerships with the wide array of actors at national and local levels. The coordination and management of the National Response is confronted with three major challenges: a. To create conducive environment and willingness among all partners to work together on a common goal; b. To provide the organizational, institutional settings and mechanism for effective coordination and management;. c. To learn how to cooperate, gain experiences and built trust among all partners. Ad a. The Memorandum of Understanding (MOU)21 of the Partners of the Strategic framework provides an excellent starting point for the creation of such an environment. TACAIDS, as the main guardian, and the major stakeholders in the government as well as among development partners have to practice what they have put on paper to fill this MOU with life and reality. Ad b. A number of mechanisms and institutional arrangements have already been put in place or are under development which facilitates the coordination and management of the National Response. (see Chapter 6 on M&E). Others, especially at district and lower levels will have to be created. Ad c. Past experience not only in the field of AIDS but others too, has proven how difficult it is to establish effective coordination. The threat of AIDS requires coordination and working together much beyond the already complex arrangements in other areas of development. The urgency of the issue requires from all partners dramatic changes on how to do business and calls for innovative approaches, flexibility and modesty. All partners have to understand that the National Response is more than adding up all individual strengths and contributions, that each and
21

For full text of the Draft MOU see Annex 3

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25.04.2003, National Multisectoral Framework - final every actor needs to assume a responsibility for the entire National Response and not only for its own part. It is only when these three aspects come together ( i.e., a general environment and willingness to cooperate, appropriate structures and regulations, and a willingness to learn, experiment and change) that it can be hoped that the NMSF can be filled with action and dynamics.

7.2 From the National Multi Sectoral Framework to the Implementation of the National Response
A number of critical steps will have to be taken to move from the general planning framework to the implementation and activities of a National Response. 7.2.1 Roles and Functions of the National Level: 1) The NMSF has to be translated into a series of specific plans, programmes, projects and interventions. This process must be organized. TACAIDS has the main responsibility to initiate, pursue and support this process. 2) For all Thematic Areas and for each Strategic Objective the main partners and actors have to be identified, reunited and brought together to develop action plans to implement the core-strategies. This includes: a. the identification of the main responsible structure / organization to develop the operational plan and to take the lead in a specific area. b. TACAIDS will take the lead to organize appropriate structures and concentration for the national Cross-Cutting Issues. c. The Ministry of Health, its partners in the private and civil sectors and the development partners supporting these areas will have a prime responsibility as many of the Strategic Objectives, especially No 6 on STI, No 7 on Condoms, No 8 on VCT, No 9 on PMTCT, No 14 on Blood Safety and No 15 on Treatment will fall in its direct responsibility. d. For other Strategic Objectives, the Ministry of Education and partners (No 11 on Schools) or new coordination and working groups which have to be created will be the lead organization. e. All these sectoral or area plans need to be elaborated in detail, including specific indicators and targets, assessment of human and financial resources, training and equipment needs. These operational plans have to identify responsibilities, timelines and resources. Interventions and activities must be costed, and monitoring, supervision and quality assurance measures must be identified.

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25.04.2003, National Multisectoral Framework - final f. It will be necessary to develop a variety of coordinating structures most appropriated for the Thematic Area of specific Strategic Objectives. TACAIDS delegates this coordination responsibility to a variety of collaborating structures and institutions. It is the task of TACAIDS to assure that the balance and priorities of the National Response are guarded and covered. g. The mechanisms of followup, monitoring, progress reporting, assessment and evaluation which TACAIDS can rely on, are described in Chapter 6 on M&E. 7.2.2 The Roles and Functions at the Regional Level The Regional Level, the Regional Administration Secretariat (RAS) as well as Regional Technical entities which might be created will play an intermediate role in the planning, implementation, and monitoring activities. 1. They will compile district HIV/AIDS Operational Plans and reports and forward them to PORALG and to TACAIDS for further perusal. 2. They will provide technical assistance to districts and communities in developing their responses and plans. The Regions/RAS will be provided with a dedicated component in the Government Budget for the aforementioned roles. 3. The Regional Consultative Committee will be the forum for discussion progress and other issues related to the multi-sector HIV/AIDS responses at the regional level. 7.2.3 Roles and Functions at the District and Village Levels 1. PORALG and TACAIDS are in the process to develop clear orientations for Districts / Municipalities, Wards and Villages regarding the organizational structure and responsibilities for planning, implementing and monitoring HIV / AIDS responses. These guidelines will include procedures for appropriate financial support and accountability. (See Chapter 8 on Financial Framework). 2. Local Government Councils will bring together and coordinate all actors working on HIV/AIDS in the respective district. Attached to one of their Subcommittees, a special multi-sectoral HIV /AIDS Committee will be established consisting of representatives of all major government, civil society and private partners of the district. It is this Committee which will do the actual technical work. 3. At Village / Ward a similar HIV /AIDS Committee comprising of the important actors will be created and responsible for the planning and implementation of HIV /AIDS responses.

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4. NGOs, CBOs and Faith-based organizations will play an important role in supporting districts and villages in the elaboration and implementation of their plans and activities. New partnerships between public and private / civil sectors will have to be created. 5. District/Municipality and Village Councils will prepare HIV/AIDS Operational Plans. Communities (villages) at the grass root level will be involved conducting their own situation analysis and planning of key activities. NGOs, CBOs, faith based organizations and other actors of Civil Society present at that district / village level will play a major role in providing support and as implementing structures. Village Plans will be consolidated into District Plans keeping the Ward level informed. The LGAs will submit their HIV/AIDS Operation Plans to TACAIDS/PORALG for the release of funds. 6. In addition to the District / Municipalities / Village HIV /AIDS Committees, an annual partnership meeting will be organized by the Local Councils in which the achievements, constraints and future plans of the locality will be discussed based on the annual performance reports elaborated by the Councils. 7. Due attention will be paid to increase and maintain the capacities of the district / municipality, ward and village level to develop, plan and implement their own HIV /AIDS responses. Capacity development on a large scale is needed in planning and monitoring but also in technical/programmatic issues for HIV /AIDS work. 8. Facilitating Agencies at national, regional and district level will be identified and contracted to support the capacity building activities.

7.3

Civil Society, Private Sectors and Networks of Persons living with HIV / AIDS

TACAIDS will work towards a regular consultative forum with National and International NGOs involved with HIV/AIDS on mechanisms through which they can participate and support the district and community responses. TACAIDS in collaboration with PORALG will work towards strengthened coordination of Civil Society Organisations and the links between the Councils and the networks of CSOs. NGOs as well as the Private Sector (Chambers of Commerce, Business Councils) have to be supported to establish more efficient and better accepted representative structures for coordination.

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25.04.2003, National Multisectoral Framework - final Special attention is given to existing / emerging networks of PLWHA. Efforts will be made at national as well as at district and community levels to associate these networks and groups at all levels of planning, implementation and monitoring.

7.4. Facilitating Agencies

Facilitating Agencies will be used to support the Local Government Authorities (LGAs) and communities to build up the necessary organizational and technical capacities related to their effective development and implementation of HIV/AIDS activities. TACAIDS will be responsible for contracting National and Regional Facilitating Agencies that will support the Regional Administrative Secretariat and LGAs in such functions as sensitization of LGAs, coordination, planning and monitoring as well as financial management. Facilitating Agencies or Teams will also be needed for ward and villages. Moreover, In line with the National Policy on HIV /AIDS, TACAIDS and other stakeholders will make use of contracting-out services for monitoring and evaluation, distribution of condoms, development of high impact IEC activities, capacity building, etc.

7.5 Research
In line with the National Policy on HIV/AIDS22, the coordination of research activities related to HIV/AIDS will be part of the National Multi-Sectoral Strategic Framework. A National Research Agenda will be established which is in line with the Strategic Orientation of the National Response. Under the leadership of TACAIDS, a National Research and Ethics Committee for HIV /AIDS will be established involving all major stakeholders and actors. This Committee will elaborate guidelines for the National Research Agenda as well as for all procedural aspects. Mobilization of funds for research and the dissemination of research findings will equally be part of this Committee. Best Practise Documentation: Efforts will be made to research, document and disseminate substantial achievements in major areas of HIV /AIDS prevention, control and mitigation in different parts of the country. These documents will help learning processes in the country and will also enrich the international discussion on successful programmes against AIDS.

22

National Policy on HIV /AIDS, 2001, p. 30-31

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CHAPTER EIGHT FINANCIAL FRAMEWORK

8.1 Introduction
Financial management procedures and mechanisms need to be in place to facilitate and support the process from planning to implementation. This process requires mechanisms to identify financial resources, allocate and channel them without unduly delay to the implementing agencies and structures. Additionally, it requires mechanisms for ensuring transparent and efficient financial management at all levels. TACAIDS has drafted a comprehensive financial management system manual23. The design philosophy of the manual is on establishing a swift flow of funds at all levels, capacities that ensure swift turnaround time for funds to flow, and adequate arrangements for application, approval, processing and accountability of funds.

8.2 Financial Framework Principles

(1) Existing financial management mechanisms of the public sector will be used and adapted wherever possible. HIV /AIDS will progressively be included in the regular budget proposals by and allocations to government structures (ministries, regions, district). (2) Parallel financial mechanisms using facilities of special funds and allocations will be used as transitional arrangements to allow time for capacity building and improvement of the existing/approved mechanisms and to bridge critical gaps.

8.3 Financial Mechanisms

The following mechanisms for mobilizing, allocating, disbursing and monitoring of funds exist or are in the process of being created. 8.3.1 Government Budgetary Allocation 1. Based on the requirement of the National Policy for HIV /AIDS that every sector shall budget, raise funds and mobilize material and human resources for its own HIV/AIDS prevention and control activities24, TACAIDS together with the Sector Ministries, PORALG / the Councils
23 24

See the final draft on the Financial Management System Manual prepared by CORE Securities Ltd. National Policy on HIV / AIDS, 2001, p.32

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25.04.2003, National Multisectoral Framework - final and the Ministry of Finance (MoF) will develop guidelines and mobilize support to ensure the allocation of government funds for HIV/AIDS interventions to Sectors and Councils will be taken sufficiently into consideration. The preferred approach is to integrate money for HIV/AIDS in all specific votes of Sectors and Councils. 2. TACAIDS will work with the MoF, Sectors, PORALG, the Councils and other relevant stakeholders in ensuring that funds earmarked for HIV/AIDS are properly ring-fenced so that they are not diverted for other activities. 8.3.2 The National Fund for HIV/AIDS

In order to mobilize more resources and to assure the availability of funds at different levels, a new mechanism is presently under consideration which receives its inspiration from National Basket funding mechanisms for example in the Health Sector. Contributors to this new National Fund will be Development Partners (Donors) as well as the Private Sector (companies, foundations etc.). This Fund will be under TACAIDS control within the agreed rules between the stakeholders. Criteria for transfer to and disbursements of the Fund will be established between the partners along the lines of the Memorandum of Understanding. Flexibility, timeliness, and accountability need to be taken into considerations to ensure smooth implementation of the planned activities. The Fund will have four sub sections / levels: 1. National Level Plans and activities by the Sectoral Ministries which are not included in the National Budget will flow to a Public Sector Fund (PSF) under the management of TACAIDS. Funds will be disbursed from this account into respective Ministerial accounts for HIV/AIDS. These funds will be managed by the Ministerial Technical HIV/AIDS Committees and accounted for through the Office of the Permanent Secretary. The PSF funds disbursed to the line ministries are not for re-disbursement to the LGAs; they are strictly reserved for their own (ministries) HIV/AIDS activities. Plans and programmes by National NGOs, Facilitating Agencies or Private Sector initiatives can also be funded through this mechanism. 2. Local Government Authority Level Plans and activities planned by local government structures (districts, wards, villages can receive support in addition to the routine government allocations or during transitional phases before village and district plans are integrated into the budget cycle. Requests by the local structures will have to be made and TACAIDS will advice on allocation of funds. The fund will be provided to, and administered and controlled by Local Councils.

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25.04.2003, National Multisectoral Framework - final 3. The Civil Society Fund A component of this new National Fund will be reserved for Civil Society support at local levels. This is in line with the National Policy on HIV /AIDS which foresees the establishment of AIDS Trust Funds that will draw funds from the Government and other stakeholders and individuals for supporting community based interventions.25. Support will go to implementation of HIV/AIDS activities by communities and civil society organizations, including local facilitating Agencies. The fund will be under the overall responsibility of TACAIDS which will establish effective institutional arrangements for disbursements and accountability. The fund will be managed at the National and Local Government Councils in line with Government financial regulations. 4. The Programme Management of TACAIDS TACAIDS own managerial and programmatic budget beyond the level of government allocation will also be supported by this Fund. In addition to these two main financial resource mechanisms: the Government Budget Allocation and the New National Fund, other existing resource mechanisms will continue to be operational. They include the mechanisms by Development Partners including the International NGOs and Religious Institutions who may continue to channel direct support to constituencies or projects as done in the past. It is highly recommended that TACAIDS is routinely informed about these supports in order to allow full tracking and documentation of the resource flow. Global Fund Trust For the allocations regarding HIV /AIDS which Tanzania will receive as part of the Global Fund to fight AIDS, Tuberculosis and Malaria (GFATM) budget procedures are underway to establish a trust fund that will receive these funds based on requirements established by the GFATM. 8.4 Disbursements of Funds

With the current observation that funding disbursement rates are much faster for government funds as opposed to project funds (because of the extra authorization), the preferred approach for disbursements from the CSF, PSF and DF will in general be to use the normal government financial system for both government and donor funds. Through the government system, earmarked grants will be used to channel the needed resources from the CSF, PSF and DF down the system to the councils, sectors and civil society organizations.
25

ibid, p.33

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25.04.2003, National Multisectoral Framework - final TACAIDS will also consider to establish a kind of Memoranda of Understanding or performance contracts with the Sectors and Councils in order to ensure compliance and timely implementation of HIV /AIDS activities. District & Village Multi-Sectoral HIV/AIDS Accounts TACAIDS through PORALG will request the Ministry of Finance to open and operate multi-sectoral HIV/AIDS accounts for all districts. Councils will facilitate villages to open and operate Multi- Sectoral HIV/AIDS accounts to be managed by the Village AIDS Committee (VAC) for activities stipulate in their HIV/AIDS Operational Plans. Councils will disburse funds to village AIDS Accounts for implementation of the HIV/AIDS Operational Plans.

8.5 Financial Monitoring

TACAIDS has the overall role of tracking financial flows of the National Response (See Chapter 6 Monitoring and Evaluation Framework). It will work with all relevant stakeholders towards a regularly updated information base/system for allocation and disbursements for HIV/AIDS activities using as much as possible accounting and reporting structures of the government system. These efforts will include working through and innovating the existing mechanisms such as the Public Expenditure Reviews and the Platinum System for enhanced tracking of HIV/AIDS expenditures. TACAIDS will work with PORALG for an effective monitoring system for HIV/AIDS funds management at the District and Community levels. Effective sharing of information on financial aspects will constitute an important part of the monitoring strategy.

8.6 Financial Absorption Capacity

Problems have been observed in relation to the management and accounting of funds at the various levels. The financial capacities of Sectors, Local Government Authorities and Civil Society need to be analyzed and enhanced. This will already start at the planning stage when identification of financial and human resources is needed including costing of activities. The use of experienced and competent Facilitating Agencies to assist the Councils and Sectors in this process is envisaged. District Financial Capacity Building & Facilitating Agencies /Teams The financial capacities at the district and community levels will be enhanced. At the sometime transitional arrangements (i.e., the use of Facilitating Agencies / Teams) will be applied for districts and villages with inadequate capacity to rapidly get the financial resources to the implementing actors in the communities. The Facilitating

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25.04.2003, National Multisectoral Framework - final Teams will build capacities at district and village levels to plan, manage contracts and funds.

8.7 Procurement and Inventory Management

Regular and normal procurement of services and commodities for the National Response will be in accordance with the Public Finance and Procurement Act 2001. TACAIDS and the Ministry of Finance will work on special agreements for special procurements which might occur. Rapid and effective modalities for ensuring quality assurance of the procurements and inventory control will also be developed by TACAIDS.

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Annex: No1. The Process used to prepare the Strategic Framework

A Steering Committee to coordinate the Strategic Framework development was formed in June, 2002 and consists of PMO, TACAIDS, WB, USAID, UNDP, UNAIDS, and a strategic planning consultant as members. The process of developing the National Multisectoral HIV/AIDS Strategic Framework has so far included the following steps: Review of the draft National Multisectoral Strategy on HIV / AIDS of January 2002. Review of World-Bank Supported Studies: As part of the efforts to develop the Tanzania Multi-Sector AIDS Programme (TMAP), several consultancies mainly covering the main issues/areas such as comprehensive HIV/AIDS situation analysis, design of civil society fund, design of public fund, financial management, procurement planning and management, co-ordination, monitoring and evaluation, hospital waste management, social assessment were commissioned. The relevant findings and recommendations were used in the development of the Strategic Framework. Joint-Appraisal Meeting for TMAP: The reports of the WB supported studies formed an important input into the Joint-Appraisal Meeting for the Tanzania HIV/AIDS & TMAP from June 2002 . The workshop deliberations provided another rich source of ideas and guidance for the Strategic Framework development process. Comprehensive Literature Review: A review of documents, studies and reports by different stakeholders has been undertaken to guide the situation and response analysis. Stakeholder Consultations Workshop: A first draft of the NMSF was discussed at a one-day workshop involving stakeholders from the public and private organisations, civil society and individuals including PLWHAs. The workshop was held in Dar es Salaam on October 10, 2002. The Draft found large support by all stakeholders. Numerous suggestions were made for improvements and additions. A Second Draft was prepared by the Consultants. Technical working groups on the three remaining issues: Monitoring and Evaluation; Institutional and Implementation Framework and Financial Mechanisms were established. A 2nd Draft was circulated in the week of October 14 to all participants of the Stakeholder Meeting. Various Drafts of the remaining issues on M&E, Institutional Framework and Coordination and financial Framework were discussed in smaller groups. A Final 3rd Draft was prepared by the Consultants.

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Annex No 2: References
1. 2. 3. 4. 5. 6. URT, Planning Commission, The Tanzania Development Vision 2025, 1999. The United Republic of Tanzania, Prime Ministers Office, The National Policy on HIV/AIDS, November 2001. The Republic of Uganda; The National Strategic Framework for HIV/AIDS Activities in Uganda: 2000/01-2005/6 Goergen, R.; AIDS in Tanzania Dar es Salaam, November 2001, Unpublished AWEPA International Human Rights Conference, 27-29, November 2000, South Africa R.Goergen, A.Mohamed, E.Mhando C.Hunger, A. Mlay, Artisanal and Small Scale Mines (SSM): Ticking bombs that highly need workplace interventions in STD/HIV/AIDS Daniels, D., Basstanie, H., Njobvu, E. & Muhungutwa, M.A.; Report of Working Group on Monitoring and Evaluation; Tanzania Multi Sectoral HIV/AIDS Project (TMAP) Pre-Appraisal Mission, 1-12 October, 2001 Ministry of Health Tanzania; National AIDS Control Programme; Formulation of Heath Sector HIV/AIDS/STIs Framework: Summary of Situation Analysis, Dar es Salaam September, 2002. Barongo, L.R., Senkoro, K.P. & Boerma, J.T; HIV Infection and Sexual Behaviour in Four Fishing Villages on Lake Victoria, Tanzania. TANESA Working Paper No 2 June 1995 United Republic of Tanzania; Ministry of Health; National AIDS Control Programme; HIV/AIDS/STI Surveillance Report for January December, 2000; Report Number 15 TANESA: Tanzania-Netherlands project to Support AIDS Control in Mwanza Region Annual Report, 1997 The United Republic of Tanzania, Ministry of Health: NAPC Research priorities on human Immuno deficiency Virus infection and AIDS in Tanzania. December 1991. World Bank. Tanzania AIDS Assessment and Planning study. Washington, DC. December 1992. Isaack H, Kisesa A: Report of the Inventory of local institutions /NGOs and Human Resources of HIV/ AIDS/STDs Programmes in Tanzania. September 1997. United Republic of Tanzania: The impact of HIV and AIDS on Women and Children in Tanzania, November 1995. The United Republic of Tanzania, Ministry of Education and Culture: Guidelines for HIV/ AIDS/STDs preventive Education for schools Version 1.0 October 1996. Van-Praag E: The TANESA story, Evaluation of the Tanzania- Netherlands support on AIDS, Feb March 1998. Ngweshemi JZL, Boerma JT Barongo L, et al: Changes in Male Sexual Behaviour in response to the AIDS epidemic. 1. Quantitative Evidence from a Cohort Study in Urban Tanzania. TANESA working paper No. 6. December

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13. 14.

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25.04.2003, National Multisectoral Framework - final 1995. The United Republic of Tanzania, Ministry of health: Policy Implication of Adult Morbidity and Mortality. End of Phase one Report. August 1997. Ngweshemi JZL , Boema T, Jet al: HIV prevention AIDS Care in Africa . A District level approach. 1997. SAREC: Behavioural and Epidemiological Aspects of AIDS Research in Tanzania. Proceeding from a workshop held in Dar es salaam, Tanzania, 6-8 December 1989. Eds. JZJ Killewo , GK Lwihula , a sandstorms and l Dahlgren. The United Republic of Tanzania, Ministry of health, national AIDS. Control programme: ParProso-participatory Management in coping with AIDS 1994. Boris Renjifor, Beth Chaplin, Davis Mwakagile et al. Epidemic expansion of HIV type 1 subtype C and Recombinant Genotypes in Tanzania. AIDS Research and Human Retroviruses, 1998; 14(7): 635-638 . Mohamed Bakari , Eligius Lyamuya, Ferdinand Mugusi et al. The prevalence and incidence of HIV- 1 infection and syphilis in a cohort of police officers in Dar es salaam , Tanzania. A potential population for HIV vaccine trials. AIDS 2000;14 313-320. Gideon Kwesigabo. Trends of HIV infection in the Kagera region of Tanzania 1987-2000. Umea University medical Dissertations. New series No 710-ISSN 0346-6612 Sweat Michael, Gregorich Steven, Sangiwa Gloria, et al. Cost effectiveness of voluntary HIV Counselling and testing in reducing sexual transmission of HIV in Kenya and Tanzania. The lancet, 2000;36: 113-121 Badru, A.R (2002); A Qualitative Assessment Report on Peoples Values, Knowledge and Risk Perceptions in Relation to VCT Services: A Case of Dar es Salaam. TACAIDS (2002); Financial Management System Manual. Prepared by CORE Securities Limited TACAIDS (2002); Situation Analysis of the National Response Towards the HIV/AIDS Epidemic. Conducted by Hesoma TACAIDS (2002); A Proposed Monitoring and Evaluation System for the National Response Against the HIV/AIDS Epidemic. Prepare by the University of Dar es Salaam Consultancy Bureau. Makwaya, C.K. and Badru A.R, (2001) AMREF Baseline Survey on Voluntary Counselling and Testing European Union (2001); Voluntary Counselling and Testing (VCT) Lessons Learned Workshop; Harare, 5-7 December 2001 MEASURE (2001); AIDS in Africa During the Nineties: Tanzania Goergen, Regina & Mlay, Akwillina, (2001) Facts and Burning Issues on Young Peoples' Sexuality and Reproductive Health in Tanzania. GTZ Reproductive Health Project Reproductive Health Project, GTZ (2001); Change of knowledge and behaviour is possible: Experience with Peer Education and Action Days as extracurricular activities in Primary Schools in Lindi Region Maltzan, K. (2001); Drug and Substance Abuse among Youth in Tanzania, An Overview. GTZ Reproductive Health Project

19. 20. 21.

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25.04.2003, National Multisectoral Framework - final 37. Kilembe, M., Kajuna, A., & Kameraat, K. (2001); Knowledge of and attitude towards HIV/AIDS - A survey at Dar es Salaams primary schools, age 6 to 12 years 38. M.J. Kelly (2001), Challenging the Challenger Understanding and Expanding the Response of African Universities to HIV/AIDs Publisher: ADEA Working Group on Higher Education 39. Hyera, F. L.M (2000); Report on the Scaling up Community and Home-Based Care for People Living With HIV/AIDS In Tanzania 40. URT (2000); Tanzania Assistance Strategy:HIV/AIDS. TAS Working Paper 41. Pfander, B (2000); KAP Survey on ARH, Lindi 42. Mwateba, Rehema (2000); Adolescent Reproductive and Sexual Health in LindiRegion, The Paper slip method, MoH, Reproductive Health Project 43. Jaenisch, T. (1999) Overview of Health Situation in Tanzania (unpublished) email: [email protected], South Patterson Park Av., Apt. #1, Baltimore, MD, 21231 44. Bollinger, l., Stover, J. & Riwa, P; (1999); The Economic Impact of AIDS in Tanzania; The Futures Group International in collaboration with: Research Triangle Institute (RTI)The Centre for Development and Population Activities (CEDPA) 45. Malawi Ministry of Health and Population (1999); Malawi National HIV/AIDS Strategic Framework: 2000-2004 46. Konrad Adenauer Foundation (1990); Report on the Findings of the Research into the Practice of Female Genital Mutilation in Tanzania. Legal and Human Rights Centre, Dar es Salaam 47. Zimbabwe National HIV/AIDS Strategic Framework 2000-2004 48. Mnyika KS: Epidemiology of HIV Infection in Northern Tanzania, 1996. 49. TANESA: Planning of District HIV/AIDS Programmes, October, 1996 50. TANESA Project 1997, Mobilization of communities for social change through risk behaviour mapping by Schapink D, Nyonyo V and Nhweshemi J. Mwanza, Tanzania 51. United Nations Development Assistance Framework Tanzania 2002-2006 52. Tanzania Commission for Aids Act of 2001 53. Bekele, Aberra (February 2001); Progress Report on the Prevention of Mother To Child Transmission of HIV (PMTCT) UNICEF Dar Es Salaam 54. URT, Poverty Reduction Strategy Paper, August 2001. 55. Tanzania joint health technical review 2002 Final report on HV/AIDS 56. Jordan-Harder, B. et.al, 2000, Hope for Tanzania: lessons learned from a Decade of Comprehensive AIDS Control in Mbeya Region Part I : Experiences and Achievements Part II : Guide for HIV /AIDS Interventions in a District of Subsaharan Africa

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Annex 3: DRAFT: Memorandum of Understanding of Partners to the Tanzania National Multi-Sectoral Strategic Framework on HIV/AIDS including the Government of Tanzania
Preamble WHEREAS the present HIV/AIDS epidemic presents a critical challenge for the development of Tanzania, AND WHEREAS the Government of Tanzania has put in place a National Strategic Framework on HIV/AIDS under the Tanzania Commission on HIV/AIDS in order to respond to this challenge, AND WHEREAS the partners to this Memorandum recognize that challenges posed by the HIV/AIDS epidemic can only be addressed through joint action by all those concerned for the development of Tanzania, NOW THEREFORE all partners agree as follows: Interpretation This Memorandum of Understanding is not a legal document but reflects the commitment of all partners, who recognize it as guidelines in the implementation of the National Strategic Framework on HIV/AIDS. Objectives of the partnership The objective of the Tanzania partnership against HIV/AIDS is to implement the Tanzania Strategic Framework on HIV/AIDS through a common Program of Work for planning, management, resource mobilization and allocation, and monitoring and evaluation. Obligations of all partners Within the limits of obligations, all partners will: Synchronize their planning, review and monitoring processes as far as possible with those established to monitor the implementation of the Tanzania Strategic Framework on HIV/AIDS; Keep all partners informed of the intentions and future plans for support for HIV/AIDS activities; Aim at increasing annually the total funding by all parties to HIV/AIDS related interventions over the period of the Strategic Framework. Obligations of the Government of Tanzania The Government of Tanzania, through the Tanzania AIDS Commission, will: Take leadership in the organization of an annual Joint HIV/AIDS Program Review; Co-ordinate the monitoring and evaluation against the common Program of Work, consistent with the Strategic Framework and in accordance with the Joint M+E Framework; Ensure that the reporting of financial information takes place against the common Program of Work; Share and disseminate information with partners.

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25.04.2003, National Multisectoral Framework - final Obligations of Development Partners Development Partners will: Ensure that the Tanzania AIDS Commission is consulted for all new programs, projects and financing related to HIV/AIDS; Ensure that reporting of program and financial information takes place according to the common Program of Work; Ensure that all new commitments are consistent with the common Program of Work and the Government of Tanzanias Medium Term Expenditure Framework.

Other partners It is recognized that there are others who are all partners in the implementation of the Strategic Framework on HIV/AIDS, such as communities, Faith Based Organizations and other Non-Governmental Organizations and private enterprises. Co-operation among partners Strategy Partners accept ownership of the Strategic Framework on HIV/AIDS. Partners will allocate resources based on the priorities defined by the Strategic Framework and as defined in the common Program of Work. Planning Planning of stakeholder and partner programs / projects will be consistent with the Strategic Framework and common Program of Work and undertaken in dialogue with the TACAIDS Secretariat and relevant TACs in line ministries. Consultation with other relevant partners should be maximized. Monitoring and Review Partners will harmonize their monitoring and evaluation indicators, consistent with the Strategic Framework and common Program of Work, and within the context of a joint Monitoring and Evaluation Framework. A Joint HIV/AIDS Program Review of the Strategic Framework on HIV/AIDS will take place annually. All parties will agree on the timing, term of reference and composition of the review mission. In preparation for this review the Tanzania AIDS Commission will ensure the preparation of a report that will reflect the progress to date against the indicators set out for the Strategic Framework and common Program of Work and as specified in the joint M+E Framework. It is envisaged that the Joint Program Reviews will ultimately replace individual project reviews, therefore partners will seek to minimize individual project reviews. Finance and Reporting Partners will seek to allocate their resources in support of the implementation of the Strategic Framework on HIV/AIDS and in accordance with the common Program of Work. Page 74

25.04.2003, National Multisectoral Framework - final Partners accept to provide financial information according to the agreed upon common Program of Work. Partners will seek to harmonize all financial reporting to be consistent with this program and minimize duplication. Information Partners accept to share information on HIV/AIDS activities through the Tanzania AIDS Commission. The Commission will share and disseminate information on HIV/AIDS related activities according to the common Program of Work. Settlement of Disagreements and Conflicts The signatories will be guided by the principles of openness, transparency and consultation. Effective information flows and dialogue are crucial to building and sustaining confidence and trust. In the event of disagreement or conflict between the participants in this MoU, dialogue and consultation will be the first means of resolving the problem. Joint reviews of the HIV/AIDS program offer the opportunity to identify and address potential problems. Unilateral actions will be avoided. In the event of continuing disagreement a high level meeting will be arranged between all signatories to this memorandum within a 14 days notice. Amendment/Termination of the Memorandum of Understanding Any amendments to the terms, operational modalities and change of status of the memorandum may only be made through a written agreement between the partners who are signatories to the Memorandum of Understanding. Joint Program Reviews may propose amendments to this MoU as required subject to the full acceptance of all signatories. Termination of participation in this agreement may be effected by any signatory on giving 90 days notice and reasons for the termination to all partners in writing. Inclusion of New Partners Any new partner who wishes to join the partnership under the provision of this Memorandum of Understanding will be free to do so upon signing the document. Commencement Date This Memorandum of Understanding shall become effective upon signing by respective representatives of the partners, and will be effective for the period of the Tanzania Strategic Framework on HIV/AIDS. Annexes and Documents 1. The Tanzania Strategic Framework on HIV/AIDS 2. Code of Conduct 3. Other IN WITNESS WHEREOF the undersigned being duly authorized representatives of the parties hereto, have signed this Memorandum of Understanding on the day and year first above written.

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25.04.2003, National Multisectoral Framework - final Signed

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