Assessment of health facility quality improvements,United Republic of Tanzania

ObjectiveTo identify contextual factors associated with quality improvements in primary health-care facilities in the United Republic of Tanzania between two star rating assessments, focusing on local district administration and proximity to other facilities.MethodsFacilities underwent star rating assessments in 2015 and between 2017 and 2018; quality was rated from zero to five stars. The consolidated framework for implementation research, adapted to a low-income context, was used to identify variables associated with star rating improvements between assessments. Facility data were obtained from several secondary sources. The proportion of the variance in facility improvement observed at facility and district levels and the influence of nearby facilities and district administration were estimated using multilevel regression models and a hierarchical spatial autoregressive model, respectively.FindingsStar ratings improved at 4028 of 5595 (72%) primary care facilities. Factors associated with improvement included: (i) star rating in 2015; (ii) facility type (e.g. hospital) and ownership (e.g. public); (iii) participation in, or eligibility for, a results-based financing programme; (iv) local population density; and (v) distance from a major road. Overall, 20% of the variance in facility improvement was associated with district administration. Geographical clustering indicated that improvement at a facility was also associated with improvements at nearby facilities.ConclusionAlthough the majority of facilities improved their star rating, there were substantial variations between facilities. Both district administration and proximity to high-performing facilities influenced improvements. Quality improvement interventions should take advantage of factors operating above the facility level, such as peer learning and peer pressure.     

Paperless registration during survey enumerations and large oral cholera mass vaccination in Zanzibar, the United Republic of Tanzania

Problem

Field trials require extensive data preparation and complex logistics. The use of personal digital assistants (PDAs) can bypass many of the traditional steps that are necessary in a paper-based data entry system.

Approach

We programmed, designed and supervised the use of PDAs for a large survey enumeration and mass vaccination campaign.

Local setting

The project was implemented in Zanzibar in the United Republic of Tanzania. Zanzibar is composed of two main islands, Unguja and Pemba, where outbreaks of cholera have been reported since the 1970s.

Relevant changes

PDAs allowed us to digitize information at the initial point of contact with the respondents. Immediate response by the system in case of error helped ensure the quality and reliability of the data. PDAs provided quick data summaries that allowed subsequent research activities to be implemented in a timely fashion.

Lessons learnt

Portability, immediate recording and linking of information enhanced structure data collection in our study. PDAs could be more useful than paper-based systems for data collection in the field, especially in impoverished settings in developing countries.     

Malaria in the United Republic of Tanzania: cultural considerations and health-seeking behaviour

Malaria is one of the biggest health problems in sub-Saharan Africa. Large amounts of resources have been invested to control and treat it. Few studies have recognized that local explanations for the symptoms of malaria may lead to the attribution of different causes for the disease and thus to the seeking of different treatments. This article illustrates the local nosology of Bondei society in the north-eastern part of the United Republic of Tanzania and shows how sociocultural context affects health-seeking behaviour. It shows how in this context therapy is best viewed as a process in which beliefs and actions are continuously debated and evaluated throughout the course of treatment.     

Structure and performance of infectious disease surveillance and response, United Republic of Tanzania, 1998

OBJECTIVE: To assess the structure and performance of and support for five infectious disease surveillance systems in the United Republic of Tanzania: Health Management Information System (HMIS); Infectious Disease Week Ending; Tuberculosis/Leprosy; Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome; and Acute Flaccid Paralysis/Poliomyelitis. METHODS: The systems were assessed by analysing the core activities of surveillance and response and support functions (provision of training, supervision, and resources). Data were collected using questionnaires that involved both interviews and observations at regional, district, and health facility levels in three of the 20 regions in the United Republic of Tanzania. FINDINGS: An HMIS was found at 26 of 32 health facilities (81%) surveyed and at all 14 regional and district medical offices. The four other surveillance systems were found at <20% of health facilities and <75% of medical offices. Standardized case definitions were used for only 3 of 21 infectious diseases. Nineteen (73%) health facilities with HMIS had adequate supplies of forms; 9 (35%) reported on time; and 11 (42%) received supervision or feedback. Four (29%) medical offices with HMIS had population denominators to use for data analyses; 12 (86%) were involved in outbreak investigations; and 11 (79%) had conducted community prevention activities. CONCLUSION: While HMIS could serve as the backbone for IDSR in the United Republic of Tanzania, this will require supervision, standardized case definitions, and improvements in the quality of reporting, analysis, and feedback.     

Improving TB case notification and treatment coverage through data use

BACKGROUND:This was a study on national TB data.OBJECTIVE:To assess improvement in TB case notification and treatment coverage through improved data use for action in NigeriaDESIGN:We analysed pre- and post-intervention secondary TB programme data comprising data on increased supervisory visits, incentives for health workers, DOTS expansion, outreaches and geo-code monitoring. Trend analysis was performed using Cochran-Armitage χ² test for linear trends.RESULTS:Case-finding increased from 104,904 cases in 2017 to 138,591 in 2020. There was an increase of 2.0% from 2017 to 2018, 13.0% in 2018 to 2019 and 15.0% in 2019 to 2020 (P < 0.001). Facility DOTS coverage increased from 7,389 facilities in 2017 to 17,699 in 2020. There was an increase of 30.0% in 2018, 31.0% in 2019 and 40.0% in 2020 (P < 0.001). The number of reporting facilities increased from 5,854 in 2017 to 12,775 in 2020. Compared with 2017, there were an increase of 20.0% in 2018, 38.0% in 2019 and 32.0% in 2020 (P < 0.001). Treatment coverage rate increased from 24% in 2018 to 27% in 2019 and 30% in 2020.CONCLUSION:TB service expansion, improved monitoring and the use of data for decision making are key in increasing TB treatment coverage.     

Community-based monitoring of safe motherhood in the United Republic of Tanzania

OBJECTIVE: To examine the progress made towards the Safe Motherhood Initiative goals in three areas of the United Republic of Tanzania during the 1990s. METHODS: Maternal mortality in the United Republic of Tanzania was monitored by sentinel demographic surveillance of more than 77,000 women of reproductive age, and by prospective monitoring of mortality in the following locations; an urban site; a wealthier rural district; and a poor rural district. The observation period for the rural districts was 1992-99 and 1993-99 for the urban site. FINDINGS: During the period of observation, the proportion of deaths of women of reproductive age (15-49 years) due to maternal causes (PMDF) compared with all causes was between 0.063 and 0.095. Maternal mortality ratios (MMRatios) were 591-1099 and maternal mortality rates (MMRates; maternal deaths per 100,000 women aged 15-49 years) were 43.1-123.0. MMRatios in surveillance areas were substantially higher than estimates from official, facility-based statistics. In all areas, the MMRates in 1999 were substantially lower than at the start of surveillance (1992 for rural districts, 1993 for the urban area), although trends during the period were statistically significant at the 90% level only in the urban site. At the community level, an additional year of education for household heads was associated with a 62% lower maternal death rate, after controlling for community-level variables such as the proportion of home births and occupational class. CONCLUSION: Educational level was a major predictor of declining MMRates. Even though rates may be decreasing, they remained high in the study areas. The use of sentinel registration areas may be a cost-effective and accurate way for developing countries to monitor mortality indicators and causes, including for maternal mortality.     

Trachoma: evaluation of a new grading scheme in the United Republic of Tanzania

A new simplified grading system for trachoma, which is based on the presence or absence of five selected key signs, has been assessed. The level of inter-observer variation and of variation for individual observers (intra-observer variation) showed that the system had good reproducibility following a training period that included interactive clinical teaching. The grading scheme was quickly learned by experienced ophthalmologists and auxiliary health personnel (ophthalmic nurses). The scheme should therefore be suitable for widespread application in field surveys of trachoma.     

Estimating cause-specific mortality from community- and facility-based data sources in the United Republic of Tanzania: options and implications for mortality burden estimates

OBJECTIVE: To compare mortality burden estimates based on direct measurement of levels and causes in communities with indirect estimates based on combining health facility cause-specific mortality structures with community measurement of mortality levels. METHODS: Data from sentinel vital registration (SVR) with verbal autopsy (VA) were used to determine the cause-specific mortality burden at the community level in two areas of the United Republic of Tanzania. Proportional cause-specific mortality structures from health facilities were applied to counts of deaths obtained by SVR to produce modelled estimates. The burden was expressed in years of life lost. FINDINGS: A total of 2884 deaths were recorded from health facilities and 2167 recorded from SVR/VAs. In the perinatal and neonatal age group cause-specific mortality rates were dominated by perinatal conditions and stillbirths in both the community and the facility data. The modelled estimates for chronic causes were very similar to those from SVR/VA. Acute febrile illnesses were coded more specifically in the facility data than in the VA. Injuries were more prevalent in the SVR/VA data than in that from the facilities. CONCLUSION: In this setting, improved International classification of diseases and health related problems, tenth revision (ICD-10) coding practices and applying facility-based cause structures to counts of deaths from communities, derived from SVR, appears to produce reasonable estimates of the cause-specific mortality burden in those aged 5 years and older determined directly from VA. For the perinatal and neonatal age group, VA appears to be required. Use of this approach in a nationally representative sample of facilities may produce reliable national estimates of the cause-specific mortality burden for leading causes of death in adults.     

A comparison of cardiovascular measurements in the Gambia, Jamaica, and the United Republic of Tanzania.

Epidemiological studies of the cardiovascular characteristics of three typically rural communities in the Gambia, Jamaica, and the United Republic of Tanzania were carried out by means of standardized methodology. This paper reports comparisons of arterial blood pressure distribution and electrocardiographic findings in relation to age, sex, and body build. Marked differences in blood pressure were found, with higher values in Jamaicans than in Tanzanians, who in turn had higher values than Gambians. These differences are not explicable in terms of body build. Heart rates and ECG amplitudes were also strikingly different, with higher values in Jamaicans than in Tanzanians and Gambians. The differences in ECG amplitudes cannot be explained by differences in body build, heart rate, or blood pressure. The findings agree with the hypothesis that some factor or factors associated with development contributes to the risk of cardiovascular disease in peoples of African origin.     

Birth weights in two rural hospitals in the United Republic of Tanzania

Low birth weight (less than 2500 gm) is considered a health indicator by the World Health Organization. Birth weight data are scarce in Africa; therefore, this study was made of 2319 births in Lugarawa hospital from 1976-79 and 4372 births at Mbozi hospital from 1980-83. Infants weighing less than 1000 gm were considered abortions and were not included. Of the 2319 live births at Lugarawa, 402 weighed less than 2500 gm, and of the 4372 live births at Mbozi 678 did. The mean weight of singleton births at Mbozi was 2946 gm. The infants of primiparas weighed less than did those of multiparas, and male infants weighed more than female infants, but the difference deceased with increasing parity. 13% of women taller than 150 cm, 26% of women shorter than 146 cm, and 18% of women between 146 and 150 cm had low-eight babies. Perinatal mortality of low birth weight infants in Mbozi was compared with that of a mixed-race population in Amsterdam. The risk of perinatal mortality was greater in Mbozi for all birth weights, but the highest relative risk was among infants in Mbozi who weighed more than 1500 gm. Mortality of infants weighing between 1500 and 1999 gm was almost the same in Mbozi as in Amsterdam, where there were facilities for prenatal care, which were nonexistent in Mbozi. The cause of the greater mortality of the heavier infants in Mbozi was cephalopelvic disproportion. Obstructed labor was the most frequent cause of perinatal mortality in Mbozi (26%), and 85% of these infants weighed more than 2500 gm. Thus, although providing dietary supplements to pregnant women who are nutritionally at risk will reduce perinatal mortality due to low birth weight, it may increase the risk of deaths due to prolonged and obstructed labor.     

Midterm review of national health plans: an example from the United Republic of Tanzania

In the health sector, planning and resource allocation at country level are mainly guided by national plans. For each such plan, a midterm review of progress is important for policy-makers since the review can inform the second half of the plan’s implementation and provide a situation analysis on which the subsequent plan can be based. The review should include a comprehensive analysis using recent data – from surveys, facility and administrative databases – and global health estimates. Any midterm analysis of progress is best conducted by a team comprising representatives of government agencies, independent national institutions and global health organizations. Here we present an example of such a review, done in 2013 in the United Republic of Tanzania. Compared to similar countries, the results of this midterm review showed good progress in all health indicators except skilled birth attendance.     

Mapping malaria risk and vulnerability in the United Republic of Tanzania: a spatial explicit model

Background

Outbreaks of vector-borne diseases (VBDs) impose a heavy burden on vulnerable populations. Despite recent progress in eradication and control, malaria remains the most prevalent VBD. Integrative approaches that take into account environmental, socioeconomic, demographic, biological, cultural, and political factors contributing to malaria risk and vulnerability are needed to effectively reduce malaria burden. Although the focus on malaria risk has increasingly gained ground, little emphasis has been given to develop quantitative methods for assessing malaria risk including malaria vulnerability in a spatial explicit manner.

Methods

Building on a conceptual risk and vulnerability framework, we propose a spatial explicit approach for modeling relative levels of malaria risk - as a function of hazard, exposure, and vulnerability - in the United Republic of Tanzania. A logistic regression model was employed to identify a final set of risk factors and their contribution to malaria endemicity based on multidisciplinary geospatial information. We utilized a Geographic Information System for the construction and visualization of a malaria vulnerability index and its integration into a spatially explicit malaria risk map.

Results

The spatial pattern of malaria risk was very heterogeneous across the country. Malaria risk was higher in Mainland areas than in Zanzibar, which is a result of differences in both malaria entomological inoculation rate and prevailing vulnerabilities. Areas of high malaria risk were identified in the southeastern part of the country, as well as in two distinct “hotspots” in the northwestern part of the country bordering Lake Victoria, while concentrations of high malaria vulnerability seem to occur in the northwestern, western, and southeastern parts of the mainland. Results were visualized using both 10×10 km² grids and subnational administrative units.

Conclusions

The presented approach makes an important contribution toward a decision support tool. By decomposing malaria risk into its components, the approach offers evidence on which factors could be targeted for reducing malaria risk and vulnerability to the disease. Ultimately, results offer relevant information for place-based intervention planning and more effective spatial allocation of resources.

Electronic supplementary material

The online version of this article (doi:10.1186/s12963-015-0036-2) contains supplementary material, which is available to authorized users.     

Bypassing primary care clinics for childbirth: a cross-sectional study in the Pwani region,United Republic of Tanzania

Objective

To measure the extent, determinants and results of bypassing local primary care clinics for childbirth among women in rural parts of the United Republic of Tanzania.

Methods

Women were selected in 2012 to complete a structured interview from a full census of all 30 076 households in clinic catchment areas in Pwani region. Eligibility was limited to those who had delivered between 6 weeks and 1 year before the interview, were at least 15 years old and lived within the catchment areas. Demographic and delivery care information and opinions on the quality of obstetric care were collected through interviews. Clinic characteristics were collected from staff via questionnaires. Determinants of bypassing (i.e. delivery of the youngest child at a health centre or hospital without provider referral) were analysed using multivariate logistic regression. Bypasser and non-bypasser birth experiences were compared in bivariate analyses.

Findings

Of 3019 eligible women interviewed (93% response rate), 71.0% (2144) delivered in a health facility; 41.8% (794) were bypassers. Bypassing likelihood increased with primiparity (odds ratio, OR: 2.5; 95% confidence interval, CI: 1.9–3.3) and perceived poor quality at clinics (OR: 1.3; 95% CI: 1.0–1.7) and decreased if clinics recently underwent renovations (OR: 0.39; 95% CI: 0.18–0.84) and/or performed ≥ 4 obstetric signal functions (OR: 0.19; 95% CI: 0.08–0.41). Bypassers reported better quality of care on six of seven quality of care measures.

Conclusion

Many pregnant women, especially first-time mothers, choose to bypass local primary care clinics for childbirth. Perceived poor quality of care at clinics was an important reason for bypassing. Primary care is failing to meet the obstetric needs of many women in this rural, low-income setting.     

Patterns of Nausea, Vomiting, Aversions, and Cravings during Pregnancy on Pemba Island, Zanzibar, Tanzania

The function(s) of nausea and vomiting in pregnancy (NVP) and its accompanying aversions and cravings remain unresolved. Neither of the two major adaptive hypotheses, "maternal/embryo protection" and "placental growth," have been tested using data from a low-income country. We examined NVP in a cross-sectional study of 427 pregnant women. The prevalence of NVP was comparable to resource-rich contexts: 69.6%, 55.5%, 70.0%, and 64.9% reported NVP, gustatory aversions, olfactory aversions, and cravings, respectively. The prevalence of all phenomena was highest in the first trimester. The timing and characteristics of NVP, aversions, and cravings were most consistent with the protection hypothesis.