Development and upgrading of public primary healthcare facilities with essential surgical services infrastructure: a strategy towards achieving universal health coverage in Tanzania

Management of possible serious bacterial infections in young infants where referral is not possible in the context of existing health system structure in Mbeya, Tanzania: Experience and lessons from the end line assessment

Severe bacterial infections (SBIs) are a leading cause of neonatal deaths in low- and middle-income countries. World Health Organization's (WHO's) guideline for outpatient management of danger signs indicating possible serious bacterial infections (PSBI) when referral is not possible was adopted by three pilot district councils in Mbeya Region, in Tanzania (Busekelo, Kyela and Mbarali Districts) in 2018 (the PSBI project). This study documented changes in practice during the PSBI project, and lessons learned. A cross-sectional study was conducted using both qualitative and quantitative data collection methods between July 2021 and January 2022, post-implementation. The study participants comprised stakeholders, health workers, community health workers, and mothers/fathers/caregivers who had a young infant with PSBI. Study tools included record review, quantitative, in-depth, and key informant interviews. Quantitative data were analysed using STATA version 15 (STATACorp Inc., TX, USA), whereas qualitative data were analysed using a framework analysis approach. Our assessment showed that 2,228 young infants (0-59 days old) from the three districts were classified as having PSBI. The majority, 1,607 (72.1%) had fast breathing as the only danger sign, while 621 (27.9%) were classified as having severe illness. All 621 young infants with severe illness were counselled and offered referral to a higher-level health facility; however, only 174 of them (28%) accepted the referral. The remaining 447 severely ill infants, for whom referral was not possible, were treated at the primary health facilities with gentamicin injection and amoxicillin dispersible tablets (DT). When referral is not feasible, outpatient treatment for young infants with signs of PSBI is possible within existing health system in Tanzania, based on experience after this pilot project. However, successful scale-up of outpatient management for PSBI will require commitments from government and key stakeholders to strengthen healthcare systems.

The impact of direct health facility financing on MNCH service provision: results from a comparative, before-after study in Pwani Region, Tanzania

BACKGROUND

Pwani Regional Secretariat in Tanzania implemented the Maternal, Neonatal, and Child Health Project (2016-2022) through Direct Health Facility Financing (DHFF), which allocates funds directly to health facilities. This study assessed the impact of the six-year DHFF project in Pwani region.

METHODS

The study utilised District Health Information Software 2 data from 18 intervention health facilities in Pwani region. Control groups comprised an equal number of facilities from Pwani and Dodoma regions where the project was not implemented. Key indicators assessed included 'ANC 4 + Rate (%)', 'Percentage of Mothers tested for Anaemia during ANC', 'Caesarean Section Delivery Rate (%)', 'Percentage of Mothers and Newborns receiving PNC services within 48 hours', 'Delivery Complication Rate (%)', and 'SBA Delivery Rate (%)' which are associated with the project interventions. The impact of the project was analysed using a paired sample t-test comparing baseline and endline data. We evaluated the significance of the dependent variables using one-way ANOVA with control groups, with the Tukey-Kramer test for post hoc analysis. Chi-square test assessed the significance of Caesarean Section Delivery Rate and the relationship between variables and health facility conditions. Pearson correlation test was used for significance between funding size and the change of MNCH variables. Statistical significance at 0.05 was calculated.

RESULTS

The project showed limited positive impacts, only in the 'Percentage of Mothers tested for Anaemia during ANC' (****p < 0.0001), 'Percentage of Newborns receiving PNC within 48 hours' (**p = 0.0095), and 'SBA Delivery Rate' (***p = 0.0043). The health facility assessment identified positively influencing factors on service delivery, such as facility type (*p = 0.0347), distance to the facility (****p < 0.0001), and internet connectivity (*p = 0.0186). We found that the project did not improve most MNCH indicators, including the CEmONC coverage (χ2 = 2.82, p = 0.2448, df = 2), which was known to be the leading outcome.

CONCLUSION

The project had limited impacts on MNCH outcomes due to various factors. While the health facility assessment highlighted positive influences on service delivery, significant areas for improvement remain, including referral systems and infrastructure. Operational research findings indicate that the effectiveness of the DHFF could be enhanced by refining its management and governance structures.

Effectiveness of EHR systems on decision support in primary healthcare: a technology acceptance model 3 perspective

PURPOSE

This study aims to evaluate healthcare practitioners' perceptions of electronic health record (EHR) systems and their effectiveness in supporting clinical decision-making in Tanzanian Primary Healthcare (PHC) facilities.

DESIGN/METHODOLOGY/APPROACH

A mixed-methods approach was employed, combining quantitative data from structured questionnaires and qualitative insights from open-ended responses. The study was conducted in the Dodoma region of Tanzania, focusing on a diverse representation of PHC facilities, including district hospitals, health centres and dispensaries. Data were analysed using multiple linear regression for quantitative data, and thematic analysis was applied to qualitative responses.

FINDINGS

The results revealed that while EHR systems are widely used in Tanzanian PHC facilities, their impact on clinical decision-making remains limited. Only a moderate portion of practitioners perceived EHR systems as effective in decision support, and frequent system use was negatively correlated with user satisfaction. Challenges such as inadequate training and support, system crashes, slow performance and poor usability and integration into clinical workflows were significant barriers to effectively utilising EHR systems.

ORIGINALITY/VALUE

This study contributes to the limited literature on EHR system implementation in low-resource settings, specifically Tanzania, by focusing on decision-support features within EHR systems. The findings offer valuable insights for healthcare policymakers, system designers and practitioners to optimise EHR implementation and improve healthcare outcomes in resource-constrained environments.

Identifying optimal locations for the development of health facilities towards the attainment of universal health coverage using geospatial techniques in Kishapu district, Tanzania

Two hours of travel time specified by the World Health Organization (WHO) to access quality health services is among the most important criteria for the Universal Health Coverage. However, locations of health facilities (HF) in many developing countries fail to realise this target due to a lack of appropriate models considering the local environment. This work used the central-place theory to explore locations of HF in Kishapu and their accessibility status based on two means of transport in the AccessMod tool: walking only and the combination of walking-and-motor devices. The results of the walking scenario indicated that the travel times to the health centres and hospitals exceeded 2 h, and a direct relationship existed between the facility level and the travel time spent to access it. The combined transport (walking and motorized) showed that dispensaries are easily accessible (14.5 min) compared to health centres (42.8 min) and hospitals (67.3 min). To address the challenge, we have developed a model revealing optimal sites with quick access for HF construction and improvement using Multi-Criteria-Evaluation and Analytical-Hierarchy Process methods weighting five criteria including distance from settlements (44% weight), roads (26% weight), existing health facilities (16% weight), rivers (9% weight) and railway (5% weight). A test of the model with both means of transport shows that at all places proposed to be optimal allow patitents to travel in less than 2 h, indicating that the proposed model can effectively and efficiently solve the challenge of allocating HF in society.

Routine health data use for decision making and its associated factors among primary healthcare managers in dodoma region

BACKGROUND

Data demand and use culture have a tremendous impact on the proper allocation of scarce resources and evidence-based decision making. However, primary healthcare managers in the majority of Sub-Saharan African countries continue to struggle with using routine health data for decision-making.

PURPOSE/OBJECTIVE

This study aimed to assess routine health data use for decision making among primary healthcare managers in Dodoma region.

METHODS

Cross-sectional study design involved 188 primary healthcare managers from Dodoma City Council, Kondoa Town Council and Bahi District Council was conducted. A self-administered questionnaire adapted from the Performance of Routine Information System Management (PRISM) tools was used to collect the data. Data was analysed by using the Statistical Package for Social Science (SPSS) program. Principal Component Analysis was used to find the level of routine health data use, binary logistic regression analysis was used to determine factors associated with routine health data use for decision making among primary healthcare managers. The study was conducted from May to June, 2022.

RESULTS

The level of adequate routine health data use for decision making among healthcare managers was 63.30%. Factors associated with adequate routine health data use for decision making among healthcare managers were; respondents characteristics: years of working experience (OR = 1.955, 95% CI= [0.892,4.287]), district surveyed (OR = 4.760, 95%CI= [1.412,16.049]), level of health facility (OR = 3.867, 95%CI= [1.354,7.122]) and male gender (OR = 1.901, 95%CI= [1.027,3.521]). Individual factors: comparing data with strategic objectives (OR = 2.986, 95%CI= [1.233-7.229]), decision based on health needs (OR = 7.330, 95%CI= [1.968-27.295]) and decision based on detection of outbreak (OR = 3.769, 95%CI= [1.091-13.019]). Technical factors: ability to check data accuracy (OR = 3.120, 95%CI= [1.682-5.789]), ability to explain findings and its implication (OR = 2.443, 95%CI= [1.278-4.670]) and ability to use information to identity gaps and targets (OR = 2.621, 95%CI= [1.381-4.974]). Organizational factors: organizational support (OR = 3.530, CI= [1.397-8.919]), analyse data regularly (OR = 2.026, 95%CI= [1.075-3.820]) and displays information on key performance indicators (OR = 3.464, 95%CI= [1.525-7.870]).

CONCLUSION AND RECOMMENDATION

The level of routine health data use for decision making among primary healthcare managers was found to be modest. The level of data demand and use culture may increase more quickly if capacity building is strengthened and issues that de-motivate primary health care managers from using data are addressed.

Bayesian spatial-temporal analysis and determinants of cardiovascular diseases in Tanzania mainland

BACKGROUND

Cardiovascular Diseases (CVDs) are health-threatening conditions that account for high mortality in the world. Approximately 23.6 million deaths due to CVD is expected in the year 2030 worldwide. The CVD burden is more severe in developing countries, including Tanzania.

OBJECTIVES

This study analyzed the spatial-temporal trends and determinants of cardiovascular diseases in Tanzania from 2010 to 2019.

METHODS

Individual data were extracted from Jakaya Kikwete Cardiac Institute (JKCI), Mbeya Zonal Referral Hospital (MZRH), Kilimanjaro Christian Medical Centre (KCMC) and Bugando hospitals and the geographical data from TMA. The model containing spatial and temporal components was analyzed using the Bayesian hierarchical method implemented using Integrated Nested Laplace Approximation (INLA).

RESULTS

The results found that the incidence of CVD increased from 2010 to 2014 and decreased from 2015 to 2019. The southern highlands, lake, central and coastal zones were more likely to have CVD problems than others. It was also revealed that people aged 60-64 years OR = 1.49, females OR = 1.51, smokers OR = 1.76, alcohol drinkers OR = 1.48, and overweight OR = 1.89 were more likely to have CVD problems. Additionally, a 1oC increase in the average annual air maximum temperature was related to a 14% risk of developing CVD problems. The study revealed that the model, which included spatial and temporal random effects, was the best-predicting model.

CONCLUSION

The study shows a decreased CVD incidence rate from 2015 to 2019. The CVD incidences occurred more in Tanzania's coastal and lake areas between 2010 and 2019. The demographic, lifestyle and geographical risk factors were significantly associated with the CVD.

Unveiling barriers to EHR implementation for effective decision support in tanzanian primary healthcare: Insights from practitioners

This study investigates the barriers to implementing electronic health records (EHR) systems for decision support in Tanzanian primary healthcare (PHC) facilities and proposes strategies to address these challenges. A qualitative, inductive approach was used, guided by the Diffusion of Innovations (DOI) theory, the Technology Acceptance Model (TAM), and the Sociotechnical Systems theory. Using snowball sampling, data were collected from 14 participants through semi-structured interviews in Dodoma, Tanzania. Thematic analysis identified key barriers. Critical barriers to EHR implementation include lack of leadership support, poor network infrastructure, increased workload, and resistance to technology due to concerns over professional autonomy. Technical challenges, such as system downtime and lack of skilled personnel, hinder EHR use, resulting in inefficiencies and incomplete system adoption, negatively affecting patient outcomes. This study offers unique insights into barriers to EHR adoption in Tanzanian PHC facilities. Grounded in multiple theoretical frameworks, the findings contribute to health informatics discourse in low-resource settings and provide practical recommendations for improving EHR implementation. The study's implications are relevant for policymakers, healthcare leaders, and IT developers in similar contexts.

The influence of the perception, attitude, and level of trust on the uptake of COVID-19 vaccinations among pregnant women attending antenatal care clinic in mbeya urban, Tanzania

BACKGROUND

Coronavirus Disease 2019 (COVID-19) has been associated with adverse effects and death among people with low immunity, including pregnant women. Despite introducing the vaccine as the proper means to curb the spread of the pandemic, vaccine uptake is still low. This study assessed the influence of perception, attitude, and trust toward COVID-19 vaccine uptake among pregnant women attending Antenatal Care Clinics.

METHODS

A cross-sectional study design was used, utilizing a quantitative approach with a cross-sectional analytical design conducted in Mbeya urban, distribution of sample size during data collection based on client's volume at three government health facilities (one tertiary health facility, one secondary health facility, and one primary health facility) in Mbeya Urban, Tanzania. Data were collected from 333 pregnant women who attended ANC during the data collection period using a questionnaire with closed-ended questions administered to respondents face-to-face. Data cleaning and analysis were done using Excel and Stata/SE 14.1 software for bivariate and multivariate data; Pearson's chi-squire and Fisher's test were used to analyze the independent determinants of COVID-19 vaccine uptake.

RESULTS

The proportion of pregnant women vaccinated with the COVID-19 vaccine was 27%. There was a statistically significant association between the respondents' vaccine uptake with primary education and < 5 work experience to vaccine uptake P = 0.015 (AOR = 6.58; 95% CI; 1.45-29.85), and P = 0.046 (AOR = 2.45; 95% CI; 1.02-5.89) respectively. The association of attitude influence to COVID-19 vaccine uptake was statistically significant (acceptance of vaccine due to its availability, vaccine acceptance for protection against COVID-19 pandemic to respondent and her baby, experience from other vaccines) was statistically significant at P = 0.011 (AOR = 4.43; 95% CI; 1.41-13.93), P = 0.001 (AOR = 45.83; 95% CI; 18.6-112.89) respectively. The level of trust in the COVID-19 vaccine influenced respondents' association with vaccine uptake in the 2nd and 3rd trimesters of pregnancy (P = 0.633 (AOR = 1.23; 95% CI; 0.53-2.48), respectively.

CONCLUSION

Pregnant women's positive attitude and trust in the COVID-19 vaccine influenced them to uptake it; our conclusion supports the WHO guidelines that the COVID-19 vaccine should be administered to pregnant women since it is a safer means to curb COVID-19 pregnancy-related complications.

The distribution of cardiovascular diseases in Tanzania: a spatio-temporal investigation

Cardiovascular Disease (CVD) is currently the major challenge to people's health and the world's top cause of death. In Tanzania, deaths due to CVD account for about 13% of the total deaths caused by the non-communicable diseases. This study examined the spatio-temporal clustering of CVDs from 2010 to 2019 in Tanzania for retrospective spatio-temporal analysis using the Bernoulli probability model on data sampled from four selected hospitals. Spatial scan statistics was performed to identify CVD clusters and the effect of covariates on the CVD incidences was examined using multiple logistic regression. It was found that there was a comparatively high risk of CVD during 2011-2015 followed by a decline during 2015-2019. The spatio-temporal analysis detected two high-risk disease clusters in the coastal and lake zones from 2012 to 2016 (p<0.001), with similar results produced by purely spatial analysis. The multiple logistic model showed that sex, age, blood pressure, body mass index (BMI), alcohol intake and smoking were significant predictors of CVD incidence.

Readiness to provide comprehensive emergency obstetric and neonatal care: a cross-sectional study in 30 health facilities in Tanzania

BACKGROUND

Despite the global progress in bringing health services closer to the population, mothers and their newborns still receive substandard care leading to morbidity and mortality. Health facilities' capacity to deliver the service is a prerequisite for quality health care. This study aimed to assess health facilities' readiness to provide comprehensive emergency obstetric and newborn care (CEmONC), comprising of blood transfusion, caesarean section and basic services, and hence to inform improvement in the quality of care interventions in Tanzania.

METHODS

A cross-sectional assessment of 30 CEmONC health facilities implementing the Safer Births Bundle of Care package in five regions of Tanzania was carried out between December 2020 and January 2021. We adapted the World Health Organization's Service Availability and Readiness Assessment tool to assess amenities, equipment, trained staff, guidelines, medicines, and diagnostic facilities. Composite readiness scores were calculated for each category and results were compared at the health facility level. For categorical variables, we tested for differences by Fisher's exact test; for readiness scores, differences were tested by a linear mixed model analysis, taking into account dependencies within the regions. We used p < 0.05 as our level of significance.

RESULTS

The overall readiness to provide CEmONC was 69.0% and significantly higher for regional hospitals followed by district hospitals. Average readiness was 78.9% for basic amenities, 76.7% for medical equipment, 76.0% for diagnosis and treatment commodities, 63.6% for staffing and 50.0% for guidelines. There was a variation in the availability of items at the individual health facility level and across levels of facilities. We found a significant difference in the availability of basic amenities, equipment, staffing, and guidelines between regional, and district hospitals and health centres (p = 0.05). Regional hospitals had significantly higher scores of medical equipment than district hospitals and health centers (p = 0.02). There was no significant difference in the availability of commodities for diagnosis and treatment between different facility levels.

CONCLUSION

Facilities' readiness was inadequate and varied across different levels of the facility. There is room to improve the facilities' readiness to deliver quality maternal and newborn care. The responsible authorities should take immediate actions to address the observed deficiencies while carefully choosing the most effective and feasible interventions and monitoring progress in readiness.

Health research evidence: its current usage in health planning, determinants and readiness to use knowledge translation tools among health planning teams in Tanzania-an exploratory mixed-methods study protocol

INTRODUCTION

Achieving universal health coverage requires using research evidence to inform decision-making. However, little information is available on the use of research evidence in planning in lower middle-income countries, including Tanzania. This paper presents a protocol that aims to investigate the usage of research evidence in health planning, determinants and readiness of the planning team members to use knowledge translation tools in Tanzania.

METHODS AND ANALYSIS

This study will employ a sequential exploratory mixed-methods design, with participants selected from national, regional and council levels. Qualitative data will be collected through a maximum of 52 in-depth interviews and 12 focused group discussions until saturation. To collect quantitative data, a structured questionnaire will be used to survey 422 participants, and a document review will be conducted from health facilities. Qualitative data will be analysed using thematic analysis, while descriptive and inferential analyses will be employed for quantitative data.

ETHICS AND DISSEMINATION

The study participants will provide written informed consent, and all recorded data will be stored on a secured research server accessible only to the investigators. Ethical approval has been obtained from the University of Dodoma Research Ethics Committee (ref. MA.84/261/02/'A'/64/91). The findings of this study will inform policymakers, researchers and implementers in the country on the use of research evidence in decision-making. We will disseminate our findings through publications, conferences, workshops and interactive communication with national, regional, council and health facility planning teams.

Understanding the role of the Tanzania national health insurance fund in improving service coverage and quality of care

Health insurance is one of the main financing mechanisms currently being used in low and middle-income countries to improve access to quality services. Tanzania has been running its National Health Insurance Fund (NHIF) since 2001 and has recently undergone significant reforms. However, there is limited attention to the causal mechanisms through which NHIF improves service coverage and quality of care. This paper aims to use a system dynamics (qualitative) approach to understand NHIF causal pathways and feedback loops for improving service coverage and quality of care at the primary healthcare level in Tanzania. We used qualitative interviews with 32 stakeholders from national, regional, district, and health facility levels conducted between May to July 2021. Based on the main findings and themes generated from the interviews, causal mechanisms, and feedback loops were created. The majority of feedback loops in the CLDs were reinforcing cycles for improving service coverage among beneficiaries and the quality of care by providers, with different external factors affecting these two actions. Our main feedback loop shows that the NHIF plays a crucial role in providing additional financial resources to facilities to purchase essential medical commodities to deliver care. However, this cycle is often interrupted by reimbursement delays. Additionally, beneficiaries' perception that lower-level facilities have poorer quality of care has reinforced care seeking at higher-levels. This has decreased lower level facilities' ability to benefit from the insurance and improve their capacity to deliver quality care. Another key finding was that the NHIF funding has resulted in better services for insured populations compared to the uninsured. To increase quality of care, the NHIF may benefit from improving its reimbursement administrative processes, increasing the capacity of lower levels of care to benefit from the insurance and appropriately incentivizing providers for continuity of care.

Patients' and Care Providers' Reported Barriers and Suggestions for Improving HIV Viral Load Testing in Tanzania: A Qualitative Study in Dar es Salaam

The study explores barriers and suggestions for improving viral load testing (VLT) uptake in Tanzania, revealing that only 58% of patients receive VLT annually, contrary to the Tanzanian National Guidelines toward the 95-95-95 UNAIDS targets. Twelve individual interviews and three patient-focus groups were conducted as part of a qualitative study conducted in six human immunodeficiency virus (HIV) clinics in Dar es Salaam to identify potential suggestions for access enhancement, as well as barriers to VLT uptake. Using King's theory of goal attainment, we found that missing appointments was the primary individual barrier to VLT uptake, along with limited knowledge among individuals living with HIV. Participants also face system-level barriers, such as a lack of integrated care and evening service availability. The study suggests that, despite challenges, there is potential for improvement in the uptake and quality of VLT services in Tanzanian public health facilities through a holistic approach.

Quality of reporting and trends of emergency obstetric and neonatal care indicators: an analysis from Tanzania district health information system data between 2016 and 2020

BACKGROUND

Routine health facility data provides the opportunity to monitor progress in quality and uptake of health care continuously. Our study aimed to assess the reliability and usefulness of emergency obstetric care data including temporal and regional variations over the past five years in Tanzania Mainland.

METHODS

Data were compiled from the routine monthly district reports compiled as part of the health management information systems for 2016-2020. Key indicators for maternal and neonatal care coverage, emergency obstetric and neonatal complications, and interventions indicators were computed. Assessment on reliability and consistency of reports was conducted and compared with annual rates and proportions over time, across the 26 regions in of Tanzania Mainland and by institutional delivery coverage.

RESULTS

Facility reporting was near complete with 98% in 2018-2020. Estimated population coverage of institutional births increased by 10% points from 71.2% to 2016 to 81.7% in 2020 in Tanzania Mainland, driven by increased use of dispensaries and health centres compared to hospitals. This trend was more pronounced in regions with lower institutional birth rates. The Caesarean section rate remained stable at around 10% of institutional births. Trends in the occurrence of complications such as antepartum haemorrhage, premature rupture of membranes, pre-eclampsia, eclampsia or post-partum bleeding were consistent over time but at low levels (1% of institutional births). Prophylactic uterotonics were provided to nearly all births while curative uterotonics were reported to be used in less than 10% of post-partum bleeding and retained placenta cases.

CONCLUSION

Our results show a mixed picture in terms of usefulness of the District Health Information System(DHIS2) data. Key indicators of institutional delivery and Caesarean section rates were plausible and provide useful information on regional disparities and trends. However, obstetric complications and several interventions were underreported thus diminishing the usefulness of these data for monitoring. Further research is needed on why complications and interventions to address them are not documented reliably.

Predicting the drop out from the maternal, newborn and child healthcare continuum in three East African Community countries: application of machine learning models

BACKGROUND

For optimal health, the maternal, newborn, and child healthcare (MNCH) continuum necessitates that the mother/child receive the full package of antenatal, intrapartum, and postnatal care. In sub-Saharan Africa, dropping out from the MNCH continuum remains a challenge. Using machine learning, the study sought to forecast the MNCH continuum drop out and determine important predictors in three East African Community (EAC) countries.

METHODS

The study utilised Demographic Health Surveys data from the Democratic Republic of Congo (DRC) (2013/14), Kenya (2014) and Tanzania (2015/16). STATA 17 was used to perform the multivariate logistic regression. Python 3.0 was used to build five machine learning classification models namely the Logistic Regression, Random Forest, Decision Tree, Support Vector Machine and Artificial Neural Network. Performance of the models was assessed using Accuracy, Precision, Recall, Specificity, F1 score and area under the Receiver Operating Characteristics (AUROC).

RESULTS

The prevalence of the drop out from the MNCH continuum was 91.0% in the DRC, 72.4% in Kenya and 93.6% in Tanzania. Living in the rural areas significantly increased the odds of dropping out from the MNCH continuum in the DRC (AOR:1.76;95%CI:1.30-2.38), Kenya (AOR:1.23;95%CI:1.03-1.47) and Tanzania (AOR:1.41;95%CI:1.01-1.97). Lower maternal education also conferred a significant increase in the DRC (AOR:2.16;95%CI:1.67-2.79), Kenya (AOR:1.56;95%CI:1.30-1.84) and Tanzania (AOR:1.70;95%CI:1.24-2.34). Non exposure to mass media also conferred a significant positive influence in the DRC (AOR:1.49;95%CI:1.15-1.95), Kenya (AOR:1.46;95%CI:1.19-1.80) and Tanzania (AOR:1.65;95%CI:1.13-2.40). The Random Forest exhibited superior predictive accuracy (Accuracy = 75.7%, Precision = 79.1%, Recall = 92.1%, Specificity = 51.6%, F1 score = 85.1%, AUROC = 70%). The top four predictors with the greatest influence were household wealth, place of residence, maternal education and exposure to mass media.

CONCLUSIONS

The MNCH continuum dropout rate is very high in the EAC countries. Maternal education, place of residence, and mass media exposure were common contributing factors to the drop out from MNCH continuum. The Random Forest had the highest predictive accuracy. Household wealth, place of residence, maternal education and exposure to mass media were ranked among the top four features with significant influence. The findings of this study can be used to support evidence-based decisions in MNCH interventions and to develop web-based services to improve continuity of care retention.

Scale up of anaesthesia services in underserved rural Tanzania

BACKGROUND

Because of critical shortage of physician anaesthesiologists, the government of Tanzania adopted a task shifting strategy for provision of anaesthesia services. This paper describes the results of an operational study designed to increase the number of anaesthesia providers for emergency obstetric surgeries in order to reduce maternal and perinatal mortality in underserved rural Tanzania.

METHODS

In 2016 a before-after cohort study was conducted in seven health centres in rural Tanzania. Five health centres received an intervention and two were selected to track secular trends (control group). Ten associate clinicians, i.e. assistant medical officers, clinical officers, and nurse midwives, from five health centres were trained in anaesthesia skills for emergency obstetric surgeries for three months followed by quarterly supportive supervision, mentoring and teleconsultation to reinforce skills. Primary and secondary outcome measures included Caesarean delivery (CD) rate, quality and safety of anaesthesia, and uptake of the educational program for anaesthesia.

RESULTS

Out of the 2,179 CDs performed in the intervention facilities from 2016 to 2019, two women died from complications of anaesthesia. The risk of death from anaesthetic complications was 0.9 per 1000 CD (95% CI 0.1-3.3. The risk of death was not established in the control group because of inadequate documentation and records keeping. The proportion of CD performed under spinal anaesthesia in intervention facilities doubled from 28% (60/214 with 95% CI 22-35) at baseline (July 2014 - June 2016) to 57% (558/971 with 95% CI of 54-61) in year three (July 2018 - June 2019), while in the control group increased by only 40% from 19% (92/475 with 95% CI of 16-23) at baseline and 27% (68/251 with 95% CI of 22-33) in year three. In 2020I, this educational training program was then adopted by the government with minor content changes and increasing duration of training to six months.

CONCLUSIONS

This three month educational training program for associate clinicians in anaesthesia, complemented by supportive supervision, can increase the CD rate to one that fills the "unmet need" and the proportion of operations performed under spinal anaesthesia, the gold standard technique for CD. The program can be used to meet the urgent demand for anaesthesia services in other underserved areas in Africa.

Role of health facility governing committees in strengthening social accountability to improve the health system in Tanzania: protocol for a participatory action research study

INTRODUCTION

Social accountability is important for improving the delivery of health services and empowering citizens. The government of Tanzania has transferred authority to plan, budget and manage financial resources to the lower health facilities since 2017. Health facility governing committees (HFGCs) therefore play a pivotal role in ensuring social accountability. While HFGCs serve as bridges between health facilities and their communities, efforts need to be made to reinforce their capacity. This project therefore aims to understand whether, how and under what conditions informed and competent HFGCs improve social accountability.

METHODS AND ANALYSIS

This study adopts a participatory approach to realist evaluation, engaging members of the HFGCs, health managers and providers and community leaders to: (1) map the challenges and opportunities of the current reform, (2) develop an initial programme theory that proposes a plan to strengthen the role of the HFGCs, (3) test the programme theory by developing a plan of action, (4) refine the programme theory through multiple cycles of participatory learning and (5) propose a set of recommendations to guide processes to strengthen social accountability in the Tanzanian health system. This project is part of an ongoing strong collaboration between the University of Dar es Saalam (Tanzania), and Umeå University (Sweden), providing opportunities for action learning and close interactions between researchers, decision-makers and practitioners.

ETHICS AND DISSEMINATION

Ethical approval to conduct the study was obtained from the National Ethical Review Committee in Tanzania- National Institute for Medical Research (NIMR/HQ/R.8a/Vol.IX/3928). Permissions to conduct the study in the health facilities were given by the President's Office Regional Administration and Local Government and relevant regional and district authorities. The results will be published in open-access, peer-reviewed journals and presented at scientific conferences.

Re-engineering primary healthcare in Kerala

INTRODUCTION

In the backdrop of the Sustainable Development Goals (SDGs), the state of Kerala, India, revamped its existing primary health centres (PHCs) into people-friendly family health centres (FHCs) in order to provide comprehensive primary care as part of a mission-based ('Aardram') initiative. It was envisioned that the mission's implementation and operation would make use of decentralised governance. The present study explored how the decentralised governance influenced reorganisation of primary care.

METHODS

The study adopted an exploratory approach using qualitative methods: key informant interviews (n = 8), in-depth interviews (n = 20) and document reviews. Thematic analysis was done following deductive coding and the themes that emerged were organised under a schema.

RESULTS

The results could be summarised under five overarching themes. Strong political commitment, combined with bureaucratic competence, facilitated implementation and functioning of 'Aardram' primary care. The insights developed through multi-sectoral training helped local governments (LGs) get involve and engage with the health system as a team in order to plan and implement interventions. The decentralised governance structures enabled re-engineering of PHCs by mobilisation of financial resources, provision of human resources, infrastructure modification, and enhanced community participation at various levels. Non-uniformity of commitment, sub-optimal engagement of urban LGs and issues of sustainability and monitoring were the shortcomings observed.

CONCLUSION

Decentralised governance played a positive role in the re-engineering of PHCs, which was utilised as a platform to demonstrate best practices in health governance through a participatory approach. The importance of empowering LGs through capacity building to address challenges in achieving primary care SDGs is highlighted in this study.

Essential emergency and critical care as a health system response to critical illness and the COVID19 pandemic: what does it cost?

Essential Emergency and Critical Care (EECC) is a novel approach to the care of critically ill patients, focusing on first-tier, effective, low-cost, life-saving care and designed to be feasible even in low-resourced and low-staffed settings. This is distinct from advanced critical care, usually conducted in ICUs with specialised staff, facilities and technologies. This paper estimates the incremental cost of EECC and advanced critical care for the planning of care for critically ill patients in Tanzania and Kenya.The incremental costing took a health systems perspective. A normative approach based on the ingredients defined through the recently published global consensus on EECC was used. The setting was a district hospital in which the patient is provided with the definitive care typically provided at that level for their condition. Quantification of resource use was based on COVID-19 as a tracer condition using clinical expertise. Local prices were used where available, and all costs were converted to USD2020.The costs per patient day of EECC is estimated to be 1 USD, 11 USD and 33 USD in Tanzania and 2 USD, 14 USD and 37 USD in Kenya, for moderate, severe and critical COVID-19 patients respectively. The cost per patient day of advanced critical care is estimated to be 13 USD and 294 USD in Tanzania and USD 17 USD and 345 USD in Kenya for severe and critical COVID-19 patients, respectively.EECC is a novel approach for providing the essential care to all critically ill patients. The low costs and lower tech approach inherent in delivering EECC mean that EECC could be provided to many and suggests that prioritizing EECC over ACC may be a rational approach when resources are limited.

Towards an Understanding of Successes of the Psychiatric Nurses in Caring for Children with Mental Health Problems: An Appreciative Inquiry

INTRODUCTION

Psychiatric nurses have a specialized body of knowledge and skills in providing care to persons with mental health challenges. The literature provides scanty evidence on child psychiatric nursing practices. This paper explored the successes of psychiatric nurses in caring for children with mental health problems using appreciative inquiry (AI).

DESIGN

A qualitative exploratory and descriptive design was used to allow for new ideas that can fundamentally reshape the practice of child psychiatric nursing. Purposive sampling was used to select psychiatric nurses caring for children with mental health problems. Focus groups were used to generate data.

FINDINGS

The results indicate both positive and negative prospects for psychiatric nursing practice. The positive possibilities included commitment, passion and dedication of staff to the children. The negative aspects that need urgent attention include lack of specific, integrated child mental health within the mental health care services, shortage of resources and not-fit-for purpose infrastructure.

CONCLUSION

Appreciative inquiry verified the commitment of psychiatric nurses in caring for children with mental health problems and the potential for dedicated child psychiatric institutions in realizing the needs of such children. The needs of children with mental health problems must be addressed through positive care in the health system.

Strengthening financial management systems at primary health care: Performance assessment of the Facility Financial Accounting and Reporting System (FFARS) in Tanzania

Background

Universal coverage remains a challenging pursuit around the world, even among the highest-income countries. Strengthening financial management capacity is essential towards attaining the three universal health coverage (UHC) goals, namely, expanded coverage, quality service, and financial protection. In this regard, Tanzania introduced the Facility Financial Accounting and Reporting System (FFARS) in line with the introduction of the Direct Health Facility Financing (DHFF) initiative in primary health care (PHC) in 2017-2018. We aim to assess the functionality of the FFARS in management, accounting, and reporting funds received and disbursed in the stride forward strengthening public financial management in PHC facilities towards UHC.

Methods

The study applied implementation research using a concurrent convergent mixed-methods design to assess sources of revenue, expenditure priorities, and changes of revenues and to explore the usability and benefits of FFARS in improving facility finance and reporting systems in more than 5,000 PHC facilities in Tanzania. Quantitative methods assessed the changes in revenues and expenditure between the financial years (FYs) 2017-2018 and 2018-2019, while the qualitative part explored the usability and the benefits FFARS offers in improving facility finances and reporting systems. Data analysis involved a thematic and descriptive analysis for qualitative and quantitative data, respectively.

Results

Of the 5,473 PHC facilities, 88% were in rural areas; however, the annual average revenue was higher in urban facilities in FYs 2017-2018 and 2018-2019. Overall, district hospitals showed an increase whereas health centers reported a decline of more than 40% in revenue. The user fee was the predominant source of revenue, particularly in urban facilities, while revenue from health insurance was not among the top three highest sources of revenue. Expenditure priorities leaned more towards drugs and supplies (25%) followed by allowances and training (21%); these did not differ by facility geographies. In health centers, expenditure on facility infrastructure was predominant. Key Informant Interviews revealed an overall satisfaction and positive experiences related to the system.

Conclusion

The implementation of FFARS in Tanzania demonstrated its high potential in improving facility financial management, including its ability to track revenue and expenditure at PHC facilities. Staffing shortages, ICT infrastructure, and limited opportunities for capacity building could be the limiting factors to reaching the potential of the implementation of FFARS and the attainment of its full impact on Tanzania's pursuit for UHC.

Assessment of Strategic Healthcare Purchasing Arrangements and Functions Towards Universal Coverage in Tanzania

BACKGROUND

Strategic health purchasing in low- and middle-income countries has received substantial attention as countries aim to achieve universal health coverage (UHC), by ensuring equitable access to quality health services without the risk of financial hardship. There is little evidence published from Tanzania on purchasing arrangements and what is required for strategic purchasing. This study analyses three purchasing arrangements in Tanzania and gives recommendations to strengthen strategic purchasing in Tanzania.

METHODS

We used the multi-case qualitative study drawing on the National Health Insurance Fund (NHIF), Social Health Insurance Benefit (SHIB), and improved Community Health Fund (iCHF) to explore the three purchasing arrangements with a purchaser-provider split. Data were drawn from document reviews and results were validated with nine key informant (KI) interviews with a range of actors involved in strategic purchasing. A deductive and inductive approach was used to develop the themes and framework analysis to summarize the data.

RESULTS

The findings show that benefit selection for all three schemes was based on the standard treatment guidelines issued by the Ministry of Health. Selection-contracting of the private healthcare providers are based on the location of the provider, the range of services available as stipulated in the scheme guideline, and the willingness of the provider to be contracted. NHF uses fee-for-service to reimburse providers. While SHIB and iCHF use capitation. NHIF has an electronic system to monitor registration, verification, claims processing, and referrals. While SHIB monitoring is done through routine supportive supervision and for the iCHF provider performance is monitored through utilization rates.

CONCLUSION

Enforcing compliance with the contractual agreement between providers-purchasers is crucial for the provision of quality services in an efficient manner. Investment in a routine monitoring system, such as the use of the district health information system which allows effective tracking of healthcare service delivery, and broader population healthcare outcomes.

Availability and functionality of neonatal care units in healthcare facilities in Mtwara region, Tanzania: The quest for quality of in-patient care for small and sick newborns

BACKGROUND

Evidence shows that delivery of prompt and appropriate in-patient newborn care (IPNC) through health facility (HF)-based neonatal care and stabilization units (NCU/NSUs) reduce preventable newborn mortalities (NMs). This study investigated the HFs for availability and performance of NCU/NSUs in providing quality IPNC, and explored factors influencing the observed performance outcomes in Mtwara region, Tanzania.

METHODS

A cross-sectional study was conducted using a follow-up explanatory mixed-methods approach. HF-based records and characteristics allowing for delivery of quality IPNC were reviewed first to establish the overall HF performance. The review findings were clarified by healthcare staff and managers through in-depth interviews (IDIs) and focus group discussions (FGDs).

RESULTS

About 70.6% (12/17) of surveyed HFs had at least one NCU/NSU room dedicated for delivery of IPNC but none had a fully established NCUs/NSU, and 74.7% (3,600/4,819) of needy newborns were admitted/transferred in for management. Essential medicines such as tetracycline eye ointment were unavailable in 75% (3/4) of the district hospitals (DHs). A disparity existed between the availability and functioning of equipment including infant radiant warmers (92% vs 73%). Governance, support from implementing patterns (IPs), and access to healthcare commodities were identified from qualitative inquiries as factors influencing the establishment and running of NCUs/NSUs at the HFs in Mtwara region, Tanzania.

CONCLUSION

Despite the positive progress, the establishment and performance of NCUs/NSUs in providing quality IPNC in HFs in Mtwara region is lagging behind the Tanzania neonatal care guideline requirements, particularly after the IPs of newborn health interventions completed their terms in 2016. This study suggests additional improvement plans for Mtwara region and other comparable settings to optimize the provision of quality IPNC and lower avoidable NMs.

Impact of traffic congestion on spatial access to healthcare services in Nairobi

Background

Geographic accessibility is an important determinant of healthcare utilization and is critical for achievement of universal health coverage. Despite the high disease burden and severe traffic congestion in many African cities, few studies have assessed how traffic congestion impacts geographical access to healthcare facilities and to health professionals in these settings. In this study, we assessed the impact of traffic congestion on access to healthcare facilities, and to the healthcare professionals across the healthcare facilities.

Methods

Using data on health facilities obtained from the Ministry of Health in Kenya, we mapped 944 primary, 94 secondary and four tertiary healthcare facilities in Nairobi County. We then used traffic probe data to identify areas within a 15-, 30- and 45-min drive from each health facility during peak and off-peak hours and calculated the proportion of the population with access to healthcare in the County. We employed a 2-step floating catchment area model to calculate the ratio of healthcare and healthcare professionals to population during these times.

Results

During peak hours, <70% of Nairobi's 4.1 million population was within a 30-min drive from a health facility. This increased to >75% during off-peak hours. In 45 min, the majority of the population had an accessibility index of one health facility accessible to more than 100 people (<0.01) for primary health care facilities, one to 10,000 people for secondary facilities, and two health facilities per 100,000 people for tertiary health facilities. Of people with access to health facilities, a sub-optimal ratio of <4.45 healthcare professionals per 1,000 people was observed in facilities offering primary and secondary healthcare during peak and off-peak hours.

Conclusion

Our study shows access to healthcare being negatively impacted by traffic congestion, highlighting the need for multisectoral collaborations between urban planners, health sector and policymakers to optimize health access for the city residents. Additionally, growing availability of traffic probe data in African cities should enable similar analysis and understanding of healthcare access for city residents in other countries on the continent.

Availability of comprehensive emergency obstetric and neonatal care in developing regions in Ethiopia: lessons learned from the USAID transform health activity

BACKGROUND

In collaboration with its partners, the Ethiopian government has been implementing standard Emergency Obstetric and Neonatal Care Services (CEmONC) since 2010. However, limited studies documented the lessons learned from such programs on the availability of CEmONC signal functions. This study investigated the availability of CEmONC signal functions and described lessons learned from Transform Health support in Developing Regional State in Ethiopia.

METHOD

At baseline, we conducted a cross-sectional study covering 15 public hospitals in four developing regions of Ethiopia (Somali, Afar, Beneshangul Gumz, and Gambella). Then, clinical mentorship was introduced in ten selected hospitals. This was followed by reviewing the clinical mentorship program report implemented in all regions. We used the tool adapted from an Averting Maternal Death and Disability tools to collect data through face-to-face interviews. We also reviewed maternal and neonatal records. We then descriptively analyzed the data and presented the findings using text, tables, and graphs.

RESULT

At baseline, six out of the 15 hospitals performed all the nine CEmONC signal functions, and one-third of the signal functions were performed in all hospitals. Cesarean Section service was available in eleven hospitals, while blood transfusion was available in ten hospitals. The least performed signal functions were blood transfusion, Cesarean Section, manual removal of placenta, removal of retained product of conceptus, and parenteral anticonvulsants. After implementing the clinical mentorship program, all CEmONC signal functions were available in all hospitals selected for the mentorship program except for Abala Hospital; the number of Cesarean Sections increased by 7.25% at the last quarter of 2021compared to the third quarter of 20,219; and the number of women referred for blood transfusions and further management of obstetric complications decreased by 96.67% at the last quarter of 2021 compared to the third quarter of 20,219. However, the number of women with post-cesarean Section surgical site infection, obstetric complications, facility maternal deaths, neonatal deaths, and stillbirths have not been changed.

CONCLUSION

The availability of CEmONC signal functions in the supported hospitals did not change the occurrence of maternal death and stillbirth. This indicates the need for investigating underlying and proximal factors that contributed to maternal death and stillbirth in the Developing Regional State of Ethiopia. In addition, there is also the need to assess the quality of the CEmONC services in the supported hospitals, institutionalize reviews, surveillance, and response mechanism for maternal and perinatal or neonatal deaths and near misses.

Clients satisfaction at primary healthcare facilities and its association with implementation of client service charter in Tanzania

Background

Client service charter (CSC) provides information about what people can expect in a facility’s services; what is expected of clients and service providers. Tanzania implemented Star Rating Assessment (SRA) of primary health care (PHC) facilities in 2015/16 and 2017/18 using SRA tools with 12 service areas. This paper assesses the status of service area 7, namely client focus that checked if client was satisfied with services provided and implementation of CSC through three indicators–if: CSC was displayed; CSC was monitored; client feedback mechanism and complaints handling was in place.

Methods

We extracted and performed a cross-sectional secondary data analysis of data related to clients’ focus that are found in national SRA database of 2017/2018 using STATA version 15. Client satisfaction was regarded as dependent variable while facility characteristics plus three indicators of CSC as independent variables. Multivariate logistic regression with p-value of 5% and 95% confidence interval (CI) were applied.

Results

A total of 4,523 facilities met our inclusion criteria; 3,987 (88.2%) were dispensaries, 408 (9.0%) health centres and 128 (2.8%) hospitals. CSC was displayed in 69.1% facilities, monitored in 32.4% facilities, and 32.5% of the facilities had mechanisms for clients’ feedback and handling complaints. The overall prevalence of clients’ satisfaction was 72.8%. Clients’ satisfaction was strongly associated with all implementation indicators of CSC. Clients from urban-based facilities had 21% increased satisfaction compared rural-based facilities (AOR 1.21; 95%CI: 1.00–1.46); and clients from hospitals had 39% increased satisfaction compared to dispensaries (AOR 1.39; 95%CI: 1.10–1.77).

Conclusion

The implementation of CSC is low among Tanzanian PHC facilities. Clients are more satisfied if received healthcare services from facilities that display the charter, monitor its implementation, have mechanisms to obtain clients feedback and handle complaints. Clients’ satisfaction at PHC could be improved through adoption and implementation of CSC.

An equity analysis on the household costs of accessing and utilising maternal and child health care services in Tanzania

BACKGROUND

Direct and time costs of accessing and using health care may limit health care access, affect welfare loss, and lead to catastrophic spending especially among poorest households. To date, limited attention has been given to time and transport costs and how these costs are distributed across patients, facility and service types especially in poor settings. We aimed to fill this knowledge gap.

METHODS

We used data from 1407 patients in 150 facilities in Tanzania. Data were collected in January 2012 through patient exit-interviews. All costs were disaggregated across patients, facility and service types. Data were analysed descriptively by using means, medians and equity measures like equity gap, ratio and concentration index.

RESULTS

71% of patients, especially the poorest and rural patients, accessed care on foot. The average travel time and cost were 30 minutes and 0.41USD respectively. The average waiting time and consultation time were 47 min and 13 min respectively. The average medical cost was 0.23 USD but only18% of patients paid for health care. The poorest and rural patients faced substantial time burden to access health care (travel and waiting) but incurred less transport and medical costs compared to their counterparts. The consultation time was similar across patients. Patients spent more time travelling to public facilities and dispensaries while incurring less transport cost than accessing other facility types, but waiting and consultation time was similar across facility types. Patients paid less amount in public than in private facilities. Postnatal care and vaccination clients spent less waiting and consultation time and paid less medical cost than antenatal care clients.

CONCLUSIONS

Our findings reinforce the need for a greater investment in primary health care to reduce access barriers and cost burdens especially among the worse-offs. Facility's construction and renovation and increased supply of healthcare workers and medical commodities are potential initiatives to consider. Other initiatives may need a multi-sectoral collaboration.

Scale up and strengthening of comprehensive emergency obstetric and newborn care in Tanzania

Introduction

In Tanzania, inadequate access to comprehensive emergency obstetric and newborn care (CEmONC) services is the major bottleneck for perinatal care and results in high maternal and perinatal mortality. From 2015 to 2019, the Accessing Safe Deliveries in Tanzania project was implemented to study how to improve access to CEmONC services in underserved rural areas.

Methods

A five-year longitudinal cohort study was implemented in seven health centres (HCs) and 21 satellite dispensaries in Morogoro region. Five of the health centres received CEmONC interventions and two served as controls. Forty-two associate clinicians from the intervention HCs were trained in teams for three months in CEmONC and anaesthesia. Managers of 20 intervention facilities, members of the district and regional health management teams were trained in leadership and management. Regular supportive supervision was conducted.

Results

Interventions resulted in improved responsibility and accountability among managers. In intervention HCs, the mean monthly deliveries increased from 183 (95% CI 174–191) at baseline (July 2014 –June 2016) to 358 (95% CI 328–390) during the intervention period (July 2016 –June 2019). The referral rate to district hospitals in intervention HCs decreased from 6.0% (262/4,392) with 95% CI 5.3–6.7 at baseline to 4.0% (516/12,918) with 95% CI 3.7–4.3 during the intervention period while it increased in the control group from 0.8% (48/5,709) to 1.5% (168/11,233). The obstetric case fatality rate decreased slightly from 1.5% (95% CI 0.6–3.1) at baseline to 1.1% (95% CI 0.7–1.6) during the intervention period (not statistically significant). Active engagement strategies and training in leadership and management resulted in uptake and improvement of CEmONC and anaesthesia curricula, and contributed to scale up of CEmONC at health centre level in the country.

Conclusions

Integration of leadership and managerial capacity building, with CEmONC-specific interventions was associated with health systems strengthening and improved quality of services.

Economic Costs of Providing District- and Regional-Level Surgeries in Tanzania

BACKGROUND

Access to surgical care is poor in Tanzania. The country is at the implementation stage of its first National Surgical, Obstetric, and Anesthesia Plan (NSOAP; 2018-2025) aiming to scale up surgery. This study aimed to calculate the costs of providing surgical care at the district and regional hospitals.

METHODS

Two district hospitals (DHs) and the regional referral hospital (RH) in Arusha region were selected. All the staff, buildings, equipment, and medical and non-medical supplies deployed in running the hospitals over a 12 month period were identified and quantified from interviews and hospital records. Using a combination of step-down costing (SDC) and activity-based costing (ABC), all costs attributed to surgeries were established and then distributed over the individual types of surgeries. These costs were delineated into pre-operative, intra-operative, and post-operative components.

RESULTS

The total annual costs of running the clinical cost centres ranged from $567k at Oltrumet DH to $3453k at Mt Meru RH. The total costs of surgeries ranged from $79k to $813k; amounting to 12%-22% of the total costs of running the hospitals. At least 70% of the costs were salaries. Unit costs and relative shares of capital costs were generally higher at the DHs. Two-thirds of all the procedures incurred at least 60% of their costs in the theatre. Open reduction and internal fixation (ORIF) performed at the regional hospital was cheaper ($618) than surgical debridement (plus conservative treatment) due to prolonged post-operative inpatient care associated with the latter ($1177), but was performed infrequently due mostly to unavailability of implants.

CONCLUSION

Lower unit costs and shares of capital costs at the RH reflect an advantage of economies of scale and scope at the RH, and a possible underutilization of capacity at the DHs. Greater efficiencies make a case for concentration and scale-up of surgical services at the RHs, but there is a stronger case for scaling up district-level surgeries, not only for equitable access to services, but also to drive down unit costs there, and free up RH resources for more complex cases such as ORIF.

Investigating the Potential for Clinical Decision Support in Sub-Saharan Africa With AFYA (Artificial Intelligence-Based Assessment of Health Symptoms in Tanzania): Protocol for a Prospective, Observational Pilot Study

BACKGROUND

Low- and middle-income countries face difficulties in providing adequate health care. One of the reasons is a shortage of qualified health workers. Diagnostic decision support systems are designed to aid clinicians in their work and have the potential to mitigate pressure on health care systems.

OBJECTIVE

The Artificial Intelligence-Based Assessment of Health Symptoms in Tanzania (AFYA) study will evaluate the potential of an English-language artificial intelligence-based prototype diagnostic decision support system for mid-level health care practitioners in a low- or middle-income setting.

METHODS

This is an observational, prospective clinical study conducted in a busy Tanzanian district hospital. In addition to usual care visits, study participants will consult a mid-level health care practitioner, who will use a prototype diagnostic decision support system, and a study physician. The accuracy and comprehensiveness of the differential diagnosis provided by the diagnostic decision support system will be evaluated against a gold-standard differential diagnosis provided by an expert panel.

RESULTS

Patient recruitment started in October 2021. Participants were recruited directly in the waiting room of the outpatient clinic at the hospital. Data collection will conclude in May 2022. Data analysis is planned to be finished by the end of June 2022. The results will be published in a peer-reviewed journal.

CONCLUSIONS

Most diagnostic decision support systems have been developed and evaluated in high-income countries, but there is great potential for these systems to improve the delivery of health care in low- and middle-income countries. The findings of this real-patient study will provide insights based on the performance and usability of a prototype diagnostic decision support system in low- or middle-income countries.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04958577; http://clinicaltrials.gov/ct2/show/NCT04958577.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/34298.

Brucellosis testing patterns at health facilities in Arusha region, northern Tanzania

BACKGROUND

Brucellosis is listed as one of six priority zoonoses in Tanzania's One Health strategic plan which highlights gaps in data needed for the surveillance and estimation of human brucellosis burdens. This study collected data on current testing practices and test results for human brucellosis in Arusha region, northern Tanzania.

METHODS

Retrospective data were extracted from records at 24 health facilities in Arusha region for the period January 2012 to May 2018. Data were captured on: the test reagents used for brucellosis, procurement and testing protocols, the monthly number of patients tested for brucellosis and the monthly number testing positive. Generalised linear mixed models were used to evaluate relationships between health facility characteristics and the probability that brucellosis testing was conducted in a given month, and the proportion of individuals testing positive.

RESULTS

Four febrile Brucella agglutination tests were used widely. The probability of testing for brucellosis in a given month was significantly associated with an interaction between year of testing and facility ownership. Test probability increased over time with more pronounced increases in privately owned as compared to government facilities. The proportion of individuals testing positive for brucellosis was significantly associated with facility type and district, with individuals tested in hospitals in Meru, Monduli and Ngorongoro districts more likely to test positive.

CONCLUSIONS

Febrile Brucella agglutination tests, known for their poor performance, were the mainstay of brucellosis testing at health facilities in northern Tanzania. The study indicates that historical data on human brucellosis in Arusha and other regions are likely to provide an inaccurate measure of true disease burden due to poor performance of the tests used and variation in testing practices. Measures to address these identified shortcomings could greatly improve quality of testing and surveillance data on brucellosis and ultimately inform prevention and control of this priority disease.

Advances in training of the specialized human resources for health in Tanzania: the case of Muhimbili University of Health and Allied Sciences

BACKGROUND

Increasing the number of specialized human resources for health is paramount to attainment of the United Nations sustainable development goals. Higher learning institutions in low-and middle-income countries must address this necessity. Here, we describe the 5-years trends in accreditation of the clinical and non-clinical postgraduate (PG) programmes, student admission and graduation at the Muhimbili University of Health and Allied Sciences (MUHAS) in Tanzania, highlighting successes, challenges and opportunities for improvement.

METHODS

This was a retrospective longitudinal study describing trends in PG training at MUHAS between 2015 and 2016 and 2019-2020. Major interventions in the reporting period included university-wide short course training programme to faculty on curricula development and initiation of online application system. Data were collected through a review of secondary data from various university records and was analyzed descriptively. Primary outcomes were the number of accredited PG programmes, number of PG applicants as well as proportions of applicants selected, applicants registered (enrolled) and students graduated, with a focus on gender and internationalization (students who are not from Tanzania).

RESULTS

The number of PG programmes increased from 60 in 2015-2016 to 77 in 2019-2020, including programmes in rare fields such as cardiothoracic surgery, cardiothoracic anesthesia and critical care. The number of PG applications, selected applicants, registered applicants and PG students graduating at the university over the past five academic years had steadily increased by 79, 81, 50 and 79%, respectively. The average proportions of PG students who applied, were selected and registered as well as graduated at the university over the past five years by gender and internationalization has remained stably at 60% vs. 40% (male vs. female) and 90% vs. 10% (Tanzanian vs. international), respectively. In total, the university graduated 1348 specialized healthcare workers in the five years period, including 45 super-specialists in critical fields, through a steady increase from 200 graduates in 2015-2016 to 357 graduates in 2019-2020. Major challenges encountered include inadequate sponsorship, limited number of academic staff and limited physical infrastructure for teaching.

CONCLUSION

Despite challenges encountered, MUHAS has made significant advances over the past five years in training of specialized and super-specialized healthcare workforce by increasing the number of programmes, enrollment and graduates whilst maintaining a narrow gender gap and international relevance. MUHAS will continue to be the pillar in training of the specialized human resources for health and is thus poised to contribute to timely attainment of the health-related United Nations sustainable development goals in Tanzania and beyond, particularly within the Sub-Saharan Africa region.

Assessing the Quality of Care at Primary Health Care Level in Two Pilot Regions of Albania

The quality of care (QoC) of primary health care (PHC) services in Albania faces challenges on multiple levels including governance, access, infrastructure and health care workers. In addition, there is a lack of trust in the latter. The Health for All Project (HAP) funded by the Swiss Agency for Development and Cooperation therefore aimed at enhancing the population's health by improving PHC services and implementing health promotion activities following a multi-strategic health system strengthening approach. The objective of this article is to compare QoC before and after the 4 years of project implementation. A cross-sectional study was implemented at 38 PHC facilities in urban and rural locations in the Diber and Fier regions of Albania in 2015 and in 2018. A survey measured the infrastructure of the different facilities, provider–patient interactions through clinical observation and patient satisfaction. During clinical observations, special attention was given to diabetes and hypertensive patients. Infrastructure scores improved from base- to endline with significant changes seen on national level and for rural facilities (p < 0.01). Facility infrastructure and overall cleanliness, hygiene and basic/essential medical equipment and supplies improved at endline, while for public accountability/transparency and guidelines and materials no significant change was observed. The overall clinical observation score increased at endline overall, in both areas and in rural and urban setting. However, infection prevention and control procedures and diabetes treatment still experienced relatively low levels of performance at endline. Patient satisfaction on PHC services is generally high and higher yet at endline. The changes observed in the 38 PHC facilities in two regions in Albania between 2015 and 2018 were overall positive with improvements seen at all three levels assessed, e.g., infrastructure, service provision and patient satisfaction. However, to gain overall improvements in the QoC and move toward a more efficient and sustainable health system requires continuous investments in infrastructure alongside interventions at the provider and user level.

Strengthening the Health System as a Strategy to Achieving a Universal Health Coverage in Underprivileged Communities in Africa: A Scoping Review

Universal health coverage (UHC) is defined as people having access to quality healthcare services (e.g., treatment, rehabilitation, and palliative care) they need, irrespective of their financial status. Access to quality healthcare services continues to be a challenge for many people in low- and middle-income countries (LMICs). The aim of this study was to conduct a scoping review to map out the health system strengthening strategies that can be used to attain universal health coverage in Africa. We conducted a scoping review and qualitatively synthesized existing evidence from studies carried out in Africa. We included studies that reported interventions to strengthen the health system, e.g., financial support, increasing work force, improving leadership capacity in health facilities, and developing and upgrading infrastructure of primary healthcare facilities. Outcome measures included health facility infrastructures, access to medicines, and sources of financial support. A total of 34 studies conducted met our inclusion criteria. Health financing and developing health infrastructure were the most reported interventions toward achieving UHC. Our results suggest that strengthening the health system, namely, through health financing, developing, and improving the health infrastructure, can play an important role in reaching UHC in the African context.

Knowledge, attitude and practices of frontline health workers in relation to detection of brucellosis in rural settings of Tanzania: a cross-sectional study

BACKGROUND

Brucellosis an important zoonotic disease worldwide, which frequently presents as an undifferentiated febrile illness with otherwise varied and non-specific clinical manifestations. Despite its importance, there are few reports on its awareness among frontline health workers. This study aimed at assessing the baseline knowledge, attitude and practice (KAP) related to detection and management of brucellosis among frontline health workers (FHWs) namely; healthcare workers (HWs) and community health workers (CHWs).

METHODS

A cross-sectional study was conducted from December 2019 to January 2020 in Kilosa and Chalinze districts of Tanzania. Data on demographic characteristics, knowledge, attitude and practices regarding brucellosis were collected from the study participants using a structured questionnaire. Interviews were conducted with 32 HWs and 32 CHWs who were systematically selected in study districts. Chi square/fisher Exact was used to assess the association between sociodemographic variables and those related to knowledge, attitude and practices.

RESULTS

Overall, a total of 30 (93.8%) HWs and nine (28.1%) CHWs from the study districts heard about brucellosis, with (34.4%) of HWs having knowledge about the causative organism. Overall, knowledge showed almost half (46.9%) HWs and (28.1%) CHWs were aware of the symptoms, clinical signs, diagnosis and control regarding brucellosis. Knowledge difference was statistically significant with HWs' age (p = 0.016). Almost half (46.9%) HWs and less than quarter (12.5%) CHWs had good practices regarding brucellosis control. Almost three quarters (71.9%) of HWs and (21.9%) CHWs had positive attitude regarding brucellosis control; overall attitude was statistically significant with CHWs age (p = 0.028) and education level (p = 0.024). Lack of awareness and unavailability of diagnostic tools were the main challenges faced by FHWs in the two districts.

CONCLUSION

The majority of participants were not aware of human brucellosis. Moreover, their overall knowledge was inadequate and the common practices were diagnostic tools, and adequate knowledge to manage brucellosis cases. These findings highlight the need to strengthen frontline health workers knowledge, practices and diagnostic capacities related to brucellosis.

Acceptability of the Direct Health Facility Financing (DHFF) initiative in Tanzania: A mixed methods process evaluation of the moderating factors

Despite wide agreement that stakeholder acceptability plays a critical role in an intervention's effectiveness, gaps remain on understanding acceptability of complex health financing interventions. We aimed to understand the moderators of acceptability of the Direct Health Facility Financing (DHFF) initiative across primary health facilities in Tanzania. Employing a mixed methods approach and guided by the theoretical framework for acceptability (TFA), we collected data from implementers and their supervisors using a structured questionnaire and semi-structured interview guides. We analysed data using a chi square test, logistic regression, and thematic analysis. We recruited 238 participants, of whom 71% were females and 54% were below 37 years old. Acceptability was found to be 63% and received high rating in qualitative interviews. Moderators of acceptability included sex (AOR = 1.93, p = 006), work experience (AOR = 3.47, p = 0.001), knowledge (13.8, p = 0.00), supportive work environment (AOR = 2.28, p = 0.019), and capability to implement the programme (AOR = 0.12, p = 0.00). Moderators reported in qualitative interviews related to individual and contextual factors. This study suggests that the DHFF initiative is acceptable and influenced by factors operating at the individual level and beyond. Addressing moderators of acceptability as programs are designed and implemented is the holy grail of acceptability of complex interventions.

Evaluation of the Direct Health Facility Financing Program in Improving Maternal Health Services in Pangani District, Tanzania

BACKGROUND

Maternal morbidity and mortality remain significant public health concerns globally, with Tanzania reporting 398 deaths per 100,000 live births annually. While national level data provide some insights into the issue, a focus on sub-national levels is required because of differences in contexts such as rural-urban disparities in maternal mortality. This study examined Direct Health Facility Financing (DHFF) and its effects on the quality of maternal health services in Pangani, a rural district in Tanzania.

METHODS

This study was conducted in Pangani district of Tanga region in Tanzania. The study used both qualitative and quantitative methods, including 16 in-depth interviews with the council health management teams, facility in charges, maternity nurse in charge, and 5 focus group discussions with community health governing committee members. The number of deliveries that occurred in health facilities, as well as medical supplies, equipment, and reagents purchased by the facilities, were compared using descriptive statistics before and after the DHFF implementation.

RESULTS

Direct disbursement of funds from the central government through the Ministry of Finance and Planning to the primary health facilities reduced delays in procurement, improved community outreach services, and improved community leaders' engagements. Deliveries occurring at health facilities increased by 33.6% (p < 0.001) one year after the HDFF implementation. Various medicines, delivery kits, and some reagents increased significantly (p < 0.05). However, the lack of computers and poor internet connectivity, an insufficient supply of medical equipment and unstable stock of the Medical Stores Department increased the difficulty of obtaining the missed items from the selected prime vendor.

CONCLUSION

Overall, this study shows a positive impact of the DHFF on maternal health service delivery in Pangani district. Specifically, an increase in the number of medical supplies, equipment, and reagents necessary to provide maternal health services contributed to the observed increase in facility deliveries by 33.6%. Moreover, the system minimizes unnecessary delays in the procurement processes of required drugs, supplies, and other facility reagents. To maximize the impact of the HDFF system, lack of computers, unstable internet, limited knowledge of the staff about the system, and inadequate health workforce should be addressed. Therefore, strengthening the DHFF system and staff training in-service and on the job is essential for smooth implementation.

Health insurance and health system (un) responsiveness: a qualitative study with elderly in rural Tanzania

Background

Health insurance (HI) has increasingly been accepted as a mechanism to facilitate access to healthcare in low and middle-income countries. However, health insurance members, especially those in Sub-Saharan Africa, have reported a low responsiveness in health systems. This study aimed to explore the experiences and perceptions of healthcare services from the perspective of insured and uninsured elderly in rural Tanzania.

Method

An explanatory qualitative study was conducted in the rural districts of Igunga and Nzega, located in western-central Tanzania. Eight focus group discussions were carried out with 78 insured and uninsured elderly men and women who were purposely selected because they were 60 years of age or older and had utilised healthcare services in the past 12 months prior to the study. The interview questions were inspired by the domains of health systems’ responsiveness. Qualitative content analysis was used to analyse the data.

Results

Elderly participants appreciated that HI had facilitated the access to healthcare and protected them from certain costs. But they also complained that HI had failed to provide equitable access due to limited service benefits and restricted use of services within schemes. Although elderly perspectives varied widely across the domains of responsiveness, insured individuals generally expressed dissatisfaction with their healthcare.

Conclusions

The national health insurance policy should be revisited in order to improve its implementation and expand the scope of service coverage. Strategic decisions are required to improve the healthcare infrastructure, increase the number of healthcare workers, ensure the availability of medicines and testing facilities at healthcare centers, and reduce long administrative procedures related to HI. A continuous training plan for healthcare workers focused on patients´ communication skills and care rights is highly recommended.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07144-2.

Evaluating urban-rural access to pathology and laboratory medicine services in Tanzania

Placement of pathology and laboratory medicine (PALM) services requires balancing efficiency (maximizing test volume) with equitable urban-rural access. We compared the association between population density (proxy for efficiency) and travel time to the closest facility (proxy for equitable access) across levels of Tanzania's public sector health system. We linked geospatial data for Tanzania from multiple sources. Data on facility locations and other geographic measures were collected from government and non-governmental databases. We classified facilities assuming increasing PALM availability by tier: (1) dispensaries, (2) health centres, (3) district hospitals and (4) regional/referral hospitals. We used the AccessMod 5 algorithm to estimate travel time to the closest facility for each tier across Tanzania with 500-m resolution. District-level average population density and travel time to the closest facility were calculated and presented using medians and interquartile ranges. Spatial correlations between these variables were estimated using the global Moran's I and bivariate Local Indicator of Spatial Autocorrelation, specifying a queen's neighbourhood matrix. Spatial analysis was restricted to 171 contiguous districts. The study included 5406 dispensaries, 675 health centres, 186 district hospitals and 37 regional/referral hospitals. District-level travel times were shortest for Tier 1 (median: [IQR]: 45.4 min [30.0-74.7]) and longest for Tier 4 facilities (160.2 min [107.3-260.0]). There was a weak spatial autocorrelation across tiers (Tier 1: -0.289, Tier 2: -0.292, Tier 3: -0.271 and Tier 4: -0.258) and few districts were classified as significant spatial outliers. Across tiers, geographic patterns of populated districts surrounded by neighbours with short travel time and sparsely populated districts surrounded by neighbours with long travel time were observed. Similar spatial correlation measures across health system levels suggest that Tanzania's health system reflects equitable urban-rural access to different PALM services. Longer travel times to hospital-based care could be ameliorated by shifting specialized diagnostics to more accessible lower tiers.

First recourse for care-seeking and associated factors among rural populations in the eastern Democratic Republic of the Congo

BACKGROUND

Access to quality healthcare is a global fundamental human right. However, in the Democratic Republic of the Congo, several parameters affect the choices of health service users in fragile, rural contexts (zones). The overarching aim of this study was to identify the first recourse of healthcare-seeking and the determinants of utilization of health centers (primary health care structures) in the rural health zones of Katana and Walungu.

METHODS

A cross-sectional survey was conducted from June to September 2017. Consenting respondents comprised 1751 adults. Continuous data were summarized using means (standard deviation) and medians (interquartile range). We used Pearson's chi-square test and Fisher exact test to compare proportions. Logistic regression was run to assess socio-determinants of health center utilization.

RESULTS

The morbidity rate of the sample population for the previous month was 86.4% (n = 1501) of which 60% used health centers for their last morbid episode and 20% did not. 5.3% of the respondents patronized prayer rooms and 7.9% resorted to self-medication principally because the cost was low, or the services were fast. Being female (OR: 1.51; p = 0.005) and a higher level of education (OR: 1.79; p = 0.032) were determinants of the use of health centers in Walungu. Only the level of education was associated with the use of health centers in Katana (OR: 2.78; p = 0.045).

CONCLUSION

Our findings suggest that health centers are the first recourse for the majority of the population during an illness. However, a significant percentage of patients are still using traditional healers or prayer rooms because the cost is low. Our results suggest that future interventions to encourage integrated health service use should target those with lower levels of education.

Modified gastrostomy feeding tubes in patients with oesophageal cancer: our experience from Northern Tanzania

Surgeons in resource-limited settings have adapted to overcome the challenges of the limitations of resources using different available methods and inventions from the local environment. We report four cases of oesophageal cancer palliatively treated with improvised gastrostomy feeding tubes by using 24Fr urinary catheters, to optimize their nutritional status to withstand chemotherapy/radiotherapy. Two patients managed to begin chemo and radiotherapy, but only one out of the four survived. The aim of this report is to appraise the methods used by surgeons to overcome the challenges they face in clinical practice.

Applying the Exploration, Preparation, Implementation, Sustainment (EPIS) Framework to Safe Surgery 2020 Implementation in Tanzania's Lake Zone

BACKGROUND

Access to safe, high-quality surgical care in sub-Saharan Africa is a critical gap. Interventions to improve surgical quality have been developed, but research on their implementation is still at a nascent stage. We retrospectively applied the Exploration, Preparation, Implementation, Sustainment framework to characterize the implementation of Safe Surgery 2020, a multicomponent intervention to improve surgical quality.

METHODS

We used a longitudinal, qualitative research design to examine Safe Surgery 2020 in 10 health facilities in Tanzania's Lake Zone. We used documentation analysis with confirmatory key informant interviews (n = 6) to describe the exploration and preparation phases. We conducted interviews with health facility leaders and surgical team members at 1, 6, and 12 months (n = 101) post initiation to characterize the implementation phase. Data were analyzed using the constant comparison method.

RESULTS

In the exploration phase, research, expert consultation, and scoping activities revealed the need for a multicomponent intervention to improve surgical quality. In the preparation phase, onsite visits identified priorities and barriers to implementation to adapt the intervention components and curriculum. In the active implementation phase, 4 themes related to the inner organizational context-vision for safe surgery, existing surgical practices, leadership support, and resilience-and 3 themes related to the intervention-innovation-value fit, holistic approach, and buy-in-facilitated or hindered implementation. Interviewees perceived improvements in teamwork and communication and intra- and inter-facility learning, and their need to deliver safe surgery evolved during the implementation period.

CONCLUSIONS

Examining implementation through the exploration, preparation, implementation, and sustainment phases offers insights into the implementation of interventions to improve surgical quality and promote sustainability.