APHFTA is an umbrella organization of the Private Health Facilities (PHFs) (Self Sustaining) in Tanzania and has engaged the Private Health Sector (PHS) in the delivery of public health services under the Ministry of Health, Community Development, Gender, Elderly and Children (MoHCDGEC), in improving the quality of care in health sector and in achieving the Sustainable Development Goals (SDGs)

APHFTA has been organizing and implementing several organizational programs in the expansion of membership and service delivery to its members and also in managing programs pertaining to a wide -range of health and social issues. 

Improvement of the quality of healthcare services is a central issue in Tanzania as it is, in the other countries in East Africa. Given the expansion of health services that has occurred, emergent of acute infectious diseases such as COVID-19, quality of care remains a major concern to the government, PHS and the public in general.

The Afya Steps Quality Improvement System is an innovative approach developed by APHFTA as a tool for quality improvement that promotes institutionalization of quality of health care at various levels of health care delivery system based on national interests and vision. The PHS (i.e., faith-based health facilities and self-sustaining health facilities), provides about 40% of the health services in Tanzania. Therefore, supporting this sector to ensure quality services is of paramount importance.

Project Goal, Purpose and Objectives

Project Goal

The project titled “Quality Improvement System (Afya Steps) for Infection Prevention and Control (IPC) Including COVID-19 for the PHS in East Africa” focused on designing a quality improvement system (Afya Steps) that will be used by the umbrella organization (APHFTA) in providing technical support to PHFs in Tanzania and East Africa as a whole to enable them to provide sustainable quality primary health care services including COVID-19 prevention.

Project Purpose (Outcome)

The expected project outcome is to improve the quality and continuity of primary health care services in PHS in Tanzania/East Africa beyond COVID – 19.

Project Objectives

The project objectives are:

  1. To increase adherence to health care standards and guidelines on Infection Prevention and Control (IPC) for all diseases, especially COVID-19.
  2. To expand access to safe, and high-quality services to all patients accessing healthcare services.

Methodology / Process

The project was implemented in the PHFs in three regions of Tanzania Mainland – Dar es Salaam, Arusha and Kilimanjaro. These regions were engaged because they were major cities with higher risk of COVID-19 infection among other factors.

Prior to the engagement of the PHFs from these regions, there were sensitization meetings with the PHF owners to instil ownership of the project activities. Following the sensitization meetings, baseline assessments were undertaken to identify PHFs’ quality of care challenges and opportunities for action during and beyond COVID-19. Onsite-structured mentorship and capacity building followed the baseline assessments to Private Health Providers (PHPs). For sustainability purposes, the project oriented the Regional and Council Health Management Teams (R/CHMTs) on the Afya Steps QI system and enrolled them to participate as assessors.

Baseline assessments were conducted using the Afya Steps Quality Improvement data collection tools developed by APHFTA to address quality of care issues in resource-constricted settings. The data collection tools were for three levels of care including Dispensary, Health Centre and hospital levels. In this project, Afya Steps QI system applied the standards set by the Tanzania Ministry of Health. Following these assessments, quality improvement plans (QIPs) were generated through the data analysis run by the system. The QIPs constituted the identified gaps in the provision of quality health care.

All PHFs were visited for dissemination of QIPs, which highlighted the gaps identified during the baseline assessments. The system generates reports that show the rates scored by the health facilities. These rates have been categorized into five steps whereby attainment of higher steps indicates the progress made by the health facility in addressing the quality improvement issues.

Follow up assessments were conducted after an interval of one months since the baseline assessment. The major aim of the follow up assessment was to determine the PHFs’ performance after the implementation of QIP and henceforth inform the assessors on the needed mentorship and supportive supervision support.

Project Achievements

Project Goal

The project goal was to design and develop a quality improvement system (Afya Steps) use it in providing technical support to the private health facilities in Tanzania.

The project outcomes

  1. 100 Private Health Facilities use to the Afya Steps quality improvement system.
  2. 100 Private Health Facilities have received baseline assessments, have documented quality improvement plans and received follow up assessment.
  3. 58 Trainer of Trainers were oriented on Afya steps Quality improvement tools (4 from APHFTA staff and 54 from Regional and Council Health Management Teams).

General Achievements

The table below summarizes the number and location of Regional and Council Health Management Team (R/CHMTs) members oriented on the Afya Steps Quality Improvement System.

Table 1 – R/CHMTs Oriented on AFYA STEPS Improvement System

Details of Achievements

  1. Four (4) Regional Health Management Teams (RHMT) from Dar es Salaam, Kilimanjaro, Mwanza and Mbeya were oriented on the Afya Steps QI system. The orientation in Dar es Salaam took place between February and March 2021. A total of 56 health care providers were oriented.
  2. Five Council Health Management Teams (CHMTs) from Ilala (Dar es Salaam), Moshi urban in Kilimanjaro, Ilemela, and Nyamagana (Mwanza) and Mbeya town in Mbeya councils were oriented on the system. The aim was to build joint teams comprising of staff from both APHFTA (representing the Private Health sector) and Regional and Council Health Management teams representing the Public Health Sector for sustainability of project activities beyond the project tenure.
  3. The project reached to a total of 100 PHFs (70 PHFs in Dar es Salaam and 17 PHFs in Arusha and 13 PHFs in Kilimanjaro) with baseline assessments on Infection Prevention and Control.
  4. Orientation of members of Technical working group from 4 regions of East Africa namely, Kenya, Rwanda, Burundi and Uganda.
  5. The project also conducted onsite-structured mentorship and monitoring on the QIP to 100 PHFs using the AFYA steps QI tools. View the Table below.

Gaps and Actions Taken

Below is the outline of the general gaps identified during Baseline Assessment and action taken to support PHFs during onsite -structured mentorship:

Table 2 – Gaps Identified During Baseline Assessment

Achievements by Objectives

Table 3 – Achievements by Objectives

Achievement of Outcome

Baseline Assessment Findings

Baseline Assessment using AFTYA STEPS were used to assess 100 APHFTA member Private Health Facilities (i.e., 77 Dispensaries, 18 Health Centres and 5 Hospitals) from the Dar Es Salaam (70), Kilimanjaro (17) and Arusha (13).

Summarized Baseline Assessment findings based on the Afya Steps ratings for the visited100 PHFs is as shown in the Figure 1 below. Out of the 100 assessed PHFs, Fifteen percent (15%) scored One (1) Step, 58% scored Two (2) Steps, 18% scored Three (3) Steps and 6 % scored Four (4) Steps, respectively. None scored Zero (0) Step or Five (5) Steps.

Figure 1 – AFYA STEPS Baseline Assessment Results

The three (3) steps rating is the minimum acceptable rating that all health facilities should achieve as the starting point.

The Afya Steps Quality Improvement System comprises of twelve service sections. These service sections are the basis of the Afya Steps ratings and they include the following:

  1. Legality and Licensing
  2. Health Facility Management
  3. Facility data
  4. Staff performance management
  5. Organization of Services
  6. Emergence services and Referral system
  7. Client focus
  8. Social accountability
  9. Facility infrastructure
  10. Infection Prevention and Control
  11. Clinical services
  12. Clinical support service

The average scores (in %age) from the assessment of these service sections determine the rating of a health facility. There are six (0) rating steps namely zero step, One Step, Two Steps, Three Steps, Four Steps and Five Steps. The Minimum required rating is Three Steps. Details of average scores for each of the steps are given below:

Only 27% of the assessed PHFs had acceptable Quality Improvement Rating. Further details on baseline results are given in the charts below;

Chart 1 shows that out of the seventy (70) assessed Private Health Facilities in Dar es Salaam, fifteen (21%) scored 3 Steps and among these 7 were dispensaries, 6 were health centres and 2 were Hospital.
Forty out of fifty-five (73%) assessed dispensaries scored 2-Steps Only 7 (13%) dispensaries scored 3 Steps. Six health centres out of eleven assessed health centres scored 3-Steps which is 55%. Two assessed hospitals scored 3-Steps which is 50% (2 hospitals).

Chart 1 – Afya Steps Ratings for the Seventy (70) assessed Private Health Facilities in Dar es Salaam.

Chart 2 shows that 15 out of the 22 (72%) assessed dispensaries in Kilimanjaro and Arusha scored 2 Steps, only two (6%) scored 3 Steps and only one (3%) of the dispensaries scored 4 Steps. Three out of seven (43%) assessed health centres scored 3-Steps. There was only one hospital which was assessed and scored 3 steps.

Chart 2 – Afya Steps Ratings for the Thirty (30) assessed Private Health Facilities in Kilimanjaro and Arusha

Baseline Ratings for PHFs’ Preparedness on IPC

Because of the Project’s focus on preparedness for COVID – 19, we undertook focused baselines assessment of PHFs’ preparedness on Infection Prevention Control (IPC). Results for Dar Es Salaam region indicated that Forty-eight (69%) of PHFs scored three (3) Steps and above in IPC (Figure 2).

Figure 2 – AFYA STEPS Ratings on IPC for Visited PHFs in Dar Es Salaam

Figure 3 below shows the findings of Afya steps on IPC in Kilimanjaro and Arusha. Only 6 (20%) of Private Health Facilities scored 3 steps in Infection Prevention and Control. Majority (63%) of the Private Health Facilities in Kilimanjaro and Arusha scored 2 Steps on Infection Prevention and Control.

Figure 3 – AFYA STEPS Ratings on IPC for Visited PHFs in Kilimanjaro and Arusha

More efforts are needed to institutionalize the quality improvement system in these health facilities. And this can be done through the regular onsite mentorship and supervision among other interventions.

End line Results (Results After Mentorship and Monitoring)

The results after mentorship and Monitoring will be drawn from the follow up assessments that are to take place three months from the time of baseline assessment. APHFTA will solicit resources to facilitate the follow up assessments to all 100 PHFs. The scores achieved will reflect the findings from follow up assessment and the ratings as per the criteria set in the Afya Steps Quality Improvement System.

Achievement of the Main Goal

The project goal that aimed at designing and developing Afya Steps Quality Improvement System has been achieved and the the Afya Steps Quality Improvement System is up and running.

Project Cost

A total of US$ 25,000.00 (TZS 57,725,000.00) have been spent on this project. However, only US$23,112.00 (TZS 53,365,608) have been received from AERC, APHFTA is still expecting the remaining US$1,888.00 to be disbursed upon finalization of the reviews.

There was some delay in disbursing the last instalment (i.e., US$ 8,122.00), which affected the activity plan to some extent. Given the importance of the project, APHFTA had to use funds from other sources while waiting for disbursement.

AERC Finance Team have been co-operative and very supportive, especially during review of expenditure.

Challenges and Lessons learnt.


The following are the challenges encountered during project implementation:

  1. Project implementation timeline was reduced to 5 months instead of 6 months. This has made some of activities (e.g., onsite structured mentorship) to be undertaken in parallel with baseline assessment. Ideally these two activities were to be done sequentially.
  2. Delay in disbursement of funds especially in the second instalment. This affected timely execution of some activities. It is envisaged that in future engagements there will be more timely.
  3. Due to the short project tenure, some of project outcomes cannot be drawn within the 5 months of implementation. For instance, we have not been able to ascertain the impact of the mentorship and monitoring activities given to the PHFs subsequent to the QIPs. However, there is assurance for sustainability of the project gains including the developed Afya Steps Quality Improvement System, which will continue to be used beyond the project tenure.

Lessons Learnt

The following are some of the lessons learnt from implementation of this Project:

  1. Quality Improvement is a continuous process and continued mentorship, and coaching is key for the private facilities to sustain high quality healthcare services.
  2. The project’s response to Covid-19 has resulted to overall quality improvement for the private health facilities supported by the project.
  3. The stepwise approach for quality improvement is paramount for private facilities in resource- restricted settings.
  4. Involvement of Regional and Council Health Management Team has the potential for sustainable use of the developed Afya Steps Quality Improvement System beyond the project tenure.
  5. There is potential to continue advancing the Afya Steps Quality Improvement System to be adopted and used by private health facilities within the East Africa Federations
  6. Delay in disbursement of funds have impacted to timely completion of the project activities.
  7. A great teamwork spirit has been demonstrated by the East African participants in this project. This attitude needs to sustained.

Future Strategies

  1. The project results have revealed that involvement of Regional and Council Health Management team (existing government structures) in rolling out quality improvement activities in the PHFs is sustainable approach that can be continuously utilized even beyond the project tenure.
  2. The innovation as implemented through the Afya Steps QI system could be one of the effective and efficient interventions towards addressing quality improvement gaps in the Private Health sector.
  3. Onsite structured mentorship visits to PHFs when planned and implemented on regular basis could facilitate a continued improvement in the service provision that will address clients’ expectations and meet clients’ satisfaction.

Future Opportunities

The system can be accessed as an application in mobile phones and tablets, this will reduce direct cost and time to upload raw data into the system, generate QIPs and assessment reports.

Download the full report here.
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