The Regional Acceleration Strategy
You are here
Overview
Since 2004, the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF) has worked with regional and council health management teams (R/CHMTs) and local government authorities (LGAs) in Tanzania, building their organizational capacity to plan, budget, and manage HIV/TB programs, and promoting the path to country ownership of the HIV and AIDS response. EGPAF introduced the regional acceleration strategy (RAS) in 2019 while implementing the USAID Boresha Afya project (2016-2021) in Tanzania and continues to use the strategy in the current project USAID Afya Yangu Northern (2021-2026). The strategy was created were to:
RAS is built on stakeholder partnerships that include donors, like-minded implementing partners, government counterparts, civil society organizations (CSOs), health care workers, community members, and health care recipients. Project teams collaborate with R/CHMTs and health facilities to co-create joint work plans, including resource prioritization and use. The local government receives project funds through subawards. The project teams are co-facilitators and technical advisors seconded to the regional and district leadership team. Since the inception of the RAS, the project has efficiently and incrementally increased the number of people served as shown below, despite declining budgets. The vision of the RAS approach is to ensure sustainability of the HIV response by locally embedding the program with the LGAs.
Building capacity for data-driven case management support at the site level has made LGAs and service providers more accountable for performance in their regions, councils, and sites. Mobilizing resources to support service continuation beyond donor funding is important for sustaining the program’s gains.
Why the RAS – Operationalizing the Path to Local Ownership
The RAS was developed so that regions would have greater ownership of—and accountability for— program performance. It aims to build local capacity, support successful transition, and operationalize the path to sustainable local government ownership.
Building local capacity for transition of the PEPFAR Program
EGPAF has consistently used a country ownership approach, working with and through existing national systems to bolster the capacity of governments to respond to the health needs of their populations. EGPAF’s activities are guided by our institutional framework to advance sustained country ownership and capacity, which includes:
- Evidence-based health systems strengthening activities at all levels of the health system
- Comprehensive organizational development of government partners, CSOs, and providers
- Iterative capacity assessments to monitor progress and identify gaps
EGPAF works with governments and local organizations, providing hands-on technical assistance (TA) that is embedded within existing structures. EGPAF develops and evaluates improved models of service delivery and assists in scale-up of the models across supported project regions. Together, EGPAF, local governments, and non-government partners ensure that clients receive comprehensive HIV/TB services across a range of interventions while strengthening integration with other health services and ensuring community engagement.
Path to Country Ownership
The RAS is an approach that guides the transition to full-country ownership and sustainability. This approach is grounded in rapid, agile responsiveness to the diverse needs of each region and stakeholder. It offers high-quality support and grows ownership toward a locally-led response.
EGPAF’s guiding TA principles include:
- Capacity development support should translate to results and improved health outcomes
- Each region is unique and requires tailored support to meet its needs
- Effectiveness is achieved through comprehensive capacity development
- TA offers mutual learning opportunities
- It is a non-linear and continual process
Each region differs in meeting targets and progress to achieving epidemic control. Because of that, EGPAF’s process includes capacity assessments, targeted capacity building, transition of activities and domains, monitoring of progress, and reassessment until transition benchmarks are achieved across each region. The below graphic illustrates the approach for transitioning full technical and financial responsibility to the regions and councils. Throughout the course of the project, EGPAF provides a limited, demand-driven TA and quality assurance (QA) role, as needed, and incrementally transfers technical, management, and financial responsibility to the LGAs. The goal: To finalize the transition process by the end of the current project.
USAID Afya Yangu Northern project’s path to country ownership
What is the RAS– An Evolving Approach to Facilitate a Sustainable Transition
Since 2004, EGPAF has provided direct support to districts, in line with Tanzania’s national decentralization policies, to foster country ownership and long-term sustainability of HIV programming. Using a district approach, EGPAF initially supported the rapid expansion of prevention of mother-to-child transmission of HIV (PMTCT) services, enabling delivery at the lowest-level of health care facilities. The model provided a platform for building comprehensive managerial, clinical, and operational capacity of the district health system. EGPAF’s support included TA approaches, such as training, supportive supervision, mentorship, and the development of tools, resources, and service delivery packages for health care workers and managers.
In 2019, in its fourth year of the USAID Boresha Afya North/Central project, EGPAF introduced the RAS to respond to higher expectations for the implementation and scale-up of country operational plan (COP) surge priorities. This included an improved focus on the United Nations’ 95-95-95 targets to end the HIV epidemic, while acknowledging performance gaps and differing strategic solutions across regions. EGPAF focused on efficiency, including joint efforts for cross-functional case management teams, monitoring and evaluation, technical implementation, and operations management at all levels. It also strengthened internal accountability mechanisms for improved performance. Sustainability of this approach is centered on the LGAs and both facility and community stakeholder engagement.
The RAS was designed to:

programs, priorities and resources.

performance gaps in the region
A year after the introduction of the RAS, EGPAF conducted an evaluation among 122 EGPAF staff respondents to assess their perspectives. Seventy-eight percent believed that the RAS had improved the overall program performance. However, it was recommended that the RAS be decentralized to regions and ensure stronger engagement of R/CHMT.
When the USAID Afya Yangu Northern project was introduced in 2021, the RAS strategy evolved to create stronger engagement of the RHMT leadership who identify regional health priorities and oversee the development of council plans and budgets. Through the RAS, the project provides direct funding and targeted TA to R/CHMTs and the hospital management teams, with an aim to transition implementation over time.
With co-creation from the LGAs and EGPAF, the RAS teams identified gaps at the regional, council, and site levels and made plans to address them in alignment with National HIV Program indicators. RAS required all EGPAF-supported regions to use the strength, weakness, opportunity, and threat (SWOT) analysis to develop a RAS to speed up program implementation, respond to priorities identified during the regional SWOT with operational plans, and develop a budget that addressed regional priorities to improve program performance.
With the RAS approach, EGPAF teams are co-facilitators and technical advisors supporting regional leadership. They are not site-level implementers. The RAS teams focused on joint programming, typically working with R/CHMTs in planning and implementation including resource prioritization and use. The RAS teams, working with project-supported staff and interns, data clerks, and community volunteers, provide hands-on assistance to the visited sites.
USAID Boresha Afya North/Central Zone (2016–2021)
In Arusha, Dodoma, Kilimanjaro, Manyara, Singida, and Tabora regions the project was implemented in partnership with EngenderHealth and collaboratively with the Ministry of Health and President’s Office – Regional Administration and Local Government (PORALG) to support preventative and curative services for HIV, tuberculosis (TB), and family planning while using differentiated models of care to ensure equitable access to services for children, adolescents, women, and other vulnerable groups.
USAID Afya Yangu Northern (2021–2026)
The project is designed around client-centered approaches to address gaps in HIV, TB, and family planning service delivery. The project is implemented by EGPAF in collaboration with Engenderhealth, Amref Health Africa, Matchboxology and D-Tree. It’s also building and transferring capacity of local stakeholders for sustainable and country-led ownership through regional acceleration strategies in Arusha, Dodoma, Kilimanjaro, Manyara, Singida, and Tabora regions.
The RAS Setup – A Health System Strengthening Model
Organizational Structure
In 2019, the RAS was introduced alongside the “lift-shift” strategy, whereby several EGPAF staff were re-allocated from the Dar es Salaam office to regional offices. This ensured that they were closer to the implementation point at the region, district, and site level.
Each region established its own RAS team, with its own regional office, and each team comprises the following members:
Team lead who oversees the RAS planning, budgeting, implementation and monitoring
RHMT members led by the Regional Medical Officer (RMO) who is the co-lead of the RAS
CHMT members led by the District Medical Officer (DMO) who lead the RAS at council level
In-charges of facilities owned by faith-based organizations (FBO)
District mentors and champions who offer case management support
Project technical and operational staff based within the region who offer case management support
Project head office advisors, managers, and directors who are assigned to a RAS team and provide TA in their field of expertise
Other implementing partners in the regions (e.g. community, key and vulnerable populations, etc.)
Planning
The RAS joint-planning process considers the regional context including the geographic, infrastructural, sociodemographic parameters, economic, and sociocultural issues affecting health. Work plan development is locally proposed and considers supported services, performance progress of indicators and service gaps, building blocks to strengthen the health system, alignment with regional and/or council performance priorities, human resources for health care service delivery, and management capacity gaps. This joint-planning process ensures greater involvement of all relevant stakeholders and can be sustained by the health system for program transition and sustainability. These plans reflect the facility, council, and regional context and are well aligned with respective MOH service guidelines and PO-RALG implementation guidance.
Each region develops its own RAS plan, which is funded through a combination of a regional project-based RAS budget and sub awards/sub-grantees. The sub-grantees’ project activities are integrated into their plans, including the Comprehensive Council Health Plan (CCHP). Integrating activities and funding through sub-grants allow councils to plan and allocate resources where they are most needed and have the greatest impact on improving uptake and quality of services. Currently, the project has engaged a total of 50 sub-grantees, which include five RHMTs, 36 CHMTs, five regional hospitals, and one national TB hospital, and three faith-based organizations.
Stakeholder Engagement and Partnerships
Engagements among RAS stakeholders were facilitated through regular RAS meetings, continuous project implementation efforts (using performance feedback loops with scorecards), and various communication channels such as joint program data review meetings, Zoom calls with facility providers, and performance feedback letters to the regional medical officer.
Case Management for Health Facility Management
RAS case management is a dynamic process that RAS teams use to assess, plan, implement, coordinate, monitor, and evaluate health facility performance to improve patient outcomes, experiences, and value. The steps of case management are described in the figure below. This process aims to ensure timely and immediate responsiveness of quality performance. The RAS teams break down the project’s overall annual plans into quarterly performance-driven priority work plans. These are implemented, reviewed, and updated monthly and weekly; they focus on progress, emerging challenges, and/or performance gaps. Work plans are designed in a highly comprehensive and integrated manner with strong coordination of case management teams. The goal is to deliver efficient and high-quality client-centered health care.
Case management teams comprise of cross-functional teams depending on the need of each facility. The team involves key stakeholders at facility and community levels with both service-delivery and capacity-building components. EGPAF also developed an innovative planning and supervision digital tool named DISC App (data-informed supportive supervision and coaching application). Applications include coaching providers based on performance gaps as well as reporting and planning of follow-up actions. The data is exported into EGPAF’s Power Business Intelligence (Power BI) system. See the screenshot below of the DISC App and data exported in Power BI.
The diagram below demonstrates the case management team approach.
Monitoring and Evaluation
Monitoring and evaluation is an integral part of the RAS approach. A core set of performance indicators aligned with the project objectives are used to track progress toward targets in HIV clients’ identification, care and treatment service update, viral load suppression, family planning service uptake, TB notification, etc. The data are collected using standardized MOH-approved registers, the Care and Treatment Clinic 2 (CTC2) database, Unified Community System (UCS), District Health Information System 2 (DHIS2), and other approved national tools. The RAS teams support health care providers to collect, summarize, and upload routine data into national data management systems, including DHIS2, CTC3 database, CTC Analytics, and the Electronic TB and Leprosy System (ETL).
The RAS approach builds the capacity of R/CHMTs, facility, and community health providers on data collection and reporting systems, data verification processes, and data analysis and use for decision-making to ensure the data are of the highest quality. In addition, routine data quality assessments are conducted using the MOH-endorsed guidelines and tools.
The RAS implements weekly virtual data review meetings, called “Dawati la Takwimu” to allow near real-time performance data review for immediate course corrections. The RAS team, under the RHMT’s leadership, holds monthly data review meetings with CHMTs. The purpose: To discuss strategies and interventions to address poorly performing indicators and challenges hindering performance.
Budgeting and Financial Management
Each RAS team develops an annual implementation budget proposal. During the budget development process, RHMT leadership and CHMTs ensure the workplan and budget are aligned with government health priorities. Budget proposals are developed jointly with the regional and council health team, then reviewed and approved by the donor.
District HIV plans are developed through the CCHP planning process. The steps include:
- Program scope, priorities, and targets are shared during CCHP planning
- Indicative one-year budget ceiling is shared during the planning process
- After finalization, plan and budget are uploaded in Government of Tanzania systems
- Councils access funds through government systems
- EGPAF organizes quarterly/monthly/weekly meetings with R/CHMTs to discuss performance success and challenges, and provide performance feedback to the RAS team
- EGPAF conducts quarterly sub-recipient monitoring to review implementation of plan and budget
Impact
RAS has significantly improved EGPAF’s support to donor-funded health service delivery. While donor-funded projects are often implemented through vertical programs, the RAS acknowledged the need to fully integrate and embed these projects into the public health system. Creating ownership and accountability at the LGA level has eliminated these siloes and paves the way for sustainable transition to country ownership.
The RAS facilitated a seamless transition, introduction, and implementation between USAID projects (Boresha Afya North/Central to Afya Yangu Northern). Despite the funding gap between the two projects, which caused a drop in implementation support in the first quarter of the new project, the RAS approach enabled teams to efficiently and effectively address performance gaps. The new USAID Afya Yangu Northern project achieved first-year targets and is on track to achieve year-two performance as well.
Enablers
- The RAS approach stimulated increased ownership and accountability across all government and health facility levels as demonstrated by leadership engagement in various activities including planning, implementation, monitoring, and dissemination of performance results during scheduled progress review meetings.
- The RAS introduced and adopted the weekly virtual data review monitoring platform to facilitate data use for decision making at all levels.
- The project promotes the use of national M&E systems, using government-owned scorecards and dashboards to monitor progress. Where gaps existed, the project introduced new tools to be embedded within the national systems.
- The RAS approach introduced a bottom-up planning process that prioritized locally proposed solutions to address gaps based on regional context.
- The RAS approach consistently aligned project priorities with regional and councils’ priorities in the comprehensive council’s health plans (CCHP) to match with government fiscal years.
- The RAS approach promoted joint support supervision with R/CHMTs and EGPAF staff.
- RAS operationalization efficiency has been realized from the co-location of EGPAF staff in some Government of Tanzania premises.
- Through the RAS approach, the USAID Afya Yangu Northern project and EGPAF established a trusted partnership and collaboration.
Challenges
- RHMTs are taking over the RAS leadership at a slow pace. Moving forward, we advocate the RHMT to pursue greater ownership and sustainability beyond the project.
- Increases in fuel costs have inflated implementation operational costs. This was addressed by integrating and adopting virtual support modalities, including Zoom, to provide site-level support and technical assistance, such as coaching and mentorship.
- Slow adoption of innovative digital solutions (such as DISC App) to monitor and document implementation. Continuous capacity building was required to motivate and train RAS teams to use the DISC App in monitoring project implementation and quality of services.
- Allocation of financial resources within the LGAs budget beyond project funding is limited, affecting the ability to transition intervention to full-country ownership.
- Slow financial burn rate: delayed funding disbursement from the central government financial systems to the local governments’ CCHPs affects the execution of health activities. EGPAF had placed the grants management specialist at the council level to provide timely support.
- The current human resources of health gaps (current health care workers’ vacancy rate of 52%) limit the ability to transition activities to LGAs. For example, the project still depends fully on donor-funded clerks to reduce and collect data, and on volunteers for community outreach services.
Lessons
- The RAS office co-location at project level for all consortium partners’ staff, at regional level in the regional administrative blocks with RHMTs, and at the council level with CHMTs, provided stronger opportunities to be effective. The RAS teams in Manyara and Tabora region have even secured office spaces in their respective regional government offices. Similarly, RAS council-based results management coordinators secured office spaces within their respective CHMTs offices.
- Weekly review of work plans, which are guided by performance data, were used to inform site-level case management teams to address performance gaps in a timely manner. For example, the Manyara RAS team consistently improved its performance indicators, which were previously lagging due to socio-economic and cultural factors affecting health care. This called for different community outreach models compared to other regions.
Reflection on Future Direction
In the transition to sustainable country ownership, RAS supports the readiness and responsiveness of a government-owned and locally-led health care service delivery program. The following are key consideration points for sustainability:
Building buy-in
EGPAF has ensured that the project has the buy-ins of government structures from the top down, securing Memorandums of Understanding (MOUs) from the MOH and PO-RALG that outline our common understanding of the project implementation. Further buy-in is needed on how to shift accountability and grow responsibility of government structures. This will help implement our shared vision of an independent, well-resourced government leading service delivery, taking responsibility for meeting PEPFAR targets, with implementing partners playing a consultative role by project end.
Tailoring TA plans to meet the needs of each individual structure
Based on assessment results, EGPAF will engage LGAs, working collaboratively to develop tailored capacity building plans and timelines for transition. The plans will include identified gaps and challenges, indicators, actionable steps to address gaps, responsible persons, and specific TA solutions. EGPAF will engage LGAs, the MOH and PO-RALG to review council plans and set specific annual benchmarks, which will mark progress against competencies and capabilities, results, and ownership. TA plans will align with the timelines agreed upon by the project and USAID.
Shifting ownership of programmatic results, target achievement, and reporting
EGPAF has consistently used existing government systems for collecting data and monitoring progress. This strategic investment will benefit projects by allowing EGPAF to easily shift ownership of monitoring and reporting results to government structures, as R/CHMTS will be able to use the national database for reporting. Specific indicators will be shifted to R/CHMTs for reporting, starting with well-established MER (Monitoring, Evaluation, and Reporting) indicators that would come from government e-systems, such as PMTCT indicators, TX_NEW (the number of adults and children newly enrolled on ART), and TX_CURR (the number of adults and children currently receiving ART). Others will require further system development, such as HTS (HIV Testing Services) and GBV (gender-based violence) indicators. As additional interventions11 are introduced and brought to scale, such as PrEP, Social Network Strategy testing, and HIV self-testing, the project will support the responsibility shift, working with the MOH and PO-RALG leadership on national-level oversight of project activities.
Continual monitoring and quality assurance
USAID Afya Yangu Northern will ensure continual monitoring and quality-assurance assessments to allow for immediate course correction and to prevent backsliding. Biannual assessments will measure progress and quarterly supportive supervision visits will identify underperformance or the need for further evaluation (and re-assessment, if necessary). EGPAF will monitor transition readiness using tailor-made sustainability assessment tools, and in collaboration with PO-RALG develop a transition maturity model.
Transferrable Tools
The following are tools to operationalize the RAS approach:
- SWOT Analysis—Strength, Weakness, Opportunity, and Threats Analysis
- RACI Matrix—Responsible, Accountable, Consulted, and Informed Matrix
- Work Plan Tool—Template that enhances weekly prioritization of activities
- DISC App—Data Informed Supervision and Coaching application
- M&E tools—Scorecards and dashboards
- Monthly feedback letter to the Regional Medical Officer—Provides performance update on regional health indicators
Elizabeth Glaser Pediatric AIDS Foundation in partnership with USAID Tanzania
Tanzania
Capacity Building