How do countries regulate the health sector? Evidence from Tanzania and Zimbabwe

The health sectors in many low- and middle-income countries have been characterized in recent years by extensive private sector activity. This has been complemented by increasing public-private linkages, such as the contracting-out of selected services or facilities, development of new purchasing arrangements, franchising and the introduction of vouchers. Increasingly, however, experience with the private sector has indicated a number of problems with the quality, price and distribution of private health services, and thus led to a growing focus on the role of government in regulation. This paper presents the existing network of regulations governing private activity in the health sectors of Tanzania and Zimbabwe, and their appropriateness in the context of emerging market realities. It draws on a comparative mapping exercise reviewing the complexity of the variables currently being regulated, the level of the health system at which they apply, and the specific instruments being used. Findings indicate that much of the existing regulation occurs through legislation. There is still very much a focus on the 'social' rather than 'economic' aspects of regulation within the health sector. Recent changes have attempted to address aspects of private health provision, but some very key gaps remain. In particular, current regulations in Tanzania and Zimbabwe: (1) focus on individual inputs rather than health system organizations; (2) aim to control entry and quality rather than explicitly quantity, price or distribution; and (3) fail to address the market-level problems of anti-competitive practices and lack of patient rights. This highlights the need for additional measures to promote consumer protection and address the development of new private markets such as for health insurance or laboratory and other ancillary services.     

MAJOR FACTORS THAT IMPACT ON WOMEN’S HEALTH IN TANZANIA: THE WAY FORWARD

Tanzania’s health policy is to improve the health of all Tanzanians with a focus on those most at risk. One of the major objectives is to reduce infant and maternal morbidity and mortality and increase life expectancy. The life expectancy in Tanzania is 49 years for males and 53 years for females. Maternal mortality is recorded at 300–400 deaths per 100,000 women. The main causes are haemorrhage, sepsis, rupture of the uterus, anaemia, and others. The risk factors associated with the above causes include maternal height, age, child spacing, and number of births per woman; malaria and anaemia; imbalance of energy and food intake; HIV/AIDS; women’s workload; and female genital mutilation (FGM). To address issues of women’s health, the government has put in place many strategies, for example, a ministry to look after women’s issues, the safe motherhood initiatives, improvement of the knowledge and skill of health care providers, as well as collaboration with nongovernmental organizations (NGOs) and private agencies. The health sector reform is important because it has negatively affected women’s access to health care. To improve the health of women in Tanzania, health and health-related sectors should cooperate and collaborate in order to empower women in the areas of education, social status, and technology. Policies must also address poverty, nutrition, adolescent health, and violence and sexual abuse.     

Monitoring and evaluation of integrated disease surveillance and response in selected districts in Tanzania

Integrated Disease Surveillance and Response (IDSR) is a strategy developed by the World Health Organization Regional Office for Africa in 1998. The Ministry of Health, Tanzania has adopted this strategy for strengthening communicable diseases surveillance in the country. In order to improve the effectiveness of the implementation of IDSR monitoring and evaluating the performance of the surveillance system, identifying areas that require strengthening and taking action is important. This paper presents the findings of baseline data collection for the period October-December 2003 in 12 districts representing eight regions of Tanzania. The districts involved were Mbulu, Babati, Dodoma Rural, Mpwapwa, Igunga, Tabora Urban, Mwanza Urban, Muleba, Nkasi, Sumbawanga Rural, Tunduru and Masasi. Results are grouped into three key areas: surveillance reporting, use of surveillance data and management of the IDSR system. In general, reporting systems are weak, both in terms of receiving all reports from all facilities in a timely manner, and in managing those reports at the district level. Routine analysis of surveillance data is not being done at facility or district levels, and districts do not monitor the performance of their surveillance system. There was also good communication and coordination with other sectors in terms of sharing information and resources. It is important that districts' capacity on IDSR is strengthened to enable them monitor and evaluate their own performance using established indicators.     

Child malnutrition and development processes in two Tanzanian villages

Despite drastic changes in the agricultural, educational andhealth sectors, Tanzania still has a high rate of child malnutrition.The differences in malnutrition rates between nearby villagesare often very large - in fact larger than between regions. This study of child malnutrition in two villages in the Rukwaregion, is an attempt to explain some of the underlying factorsand processes leading to differences in the malnutrition rate.An attempt has also been made to link this to developmentalprocesses. The villages had undergone development in the same areas: agriculturalmodernization, market integration, mass education and the expansionof the health service. However, the data from this study indicatesthat the balance in emphasis between the various parts of thedevelopment package was different in the two villages, and thatthis had implications for the food and nutritional situationin the households.     

Essential drugs programmes in Africa

The essential drugs concept encompasses national drug policy, selection, quantification, quality assurance, procurement, inventory control and distribution, financing, rational drug use, and training. People from all sectors and levels were involved in developing Tanzania's national drug policy which was approved in 1991. The process developing a policy in Kenya continues. The policy will allow Kenya's Ministry of Health to implement various operational changes (e.g., improvements in hospital drug management). 40 sub-Saharan African (SSA) countries have a national essential drug list (EDL). A synergistic effect results when EDLs are merged with standard treatment guidelines (STGs) (e.g., in Tanzania and Zimbabwe) or constructed with STGs and a national formulary. The Federal Ministry of Health in Nigeria designated 209 drugs as essential drugs, while Nigerian states determined their own EDLs based on these 209 drugs. Spreadsheet models use morbidity patterns, past consumption, and population to help countries quantify drug needs which are then used to determine drug procurement. Various problems with quality assurance in regional and national quality control laboratories in SSA include staff turnover, limited equipment maintenance, and lack of reagents and laboratory standard solutions. A database, structured, flexible drug registration system allows countries (e.g., Zimbabwe) to monitor drug suppliers and agents. Drug procurement has improved in countries with established procurement systems. Computers help control and manage drug inventories. Kenya, Mozambique, Tanzania, and Uganda distribute ration kits of prepackaged drug selections. Cash and carry in Ghana, hospital fees in Kenya, and community insurance schemes in Guinea Bissau are some financing schemes in SSA. The International Network for the Rational Use of Drugs is operating in Ghana, Nigeria, the Sudan, and Tanzania. Training courses in drug supply management are held in Ghana, Tanzania, and Zimbabwe.     

Major factors that impact on women's health in Tanzania: the way forward

Tanzania's health policy is to improve the health of all Tanzanians with a focus on those most at risk. One of the major objectives is to reduce infant and maternal morbidity and mortality and increase life expectancy. The life expectancy in Tanzania is 49 years for males and 53 years for females. Maternal mortality is recorded at 300-400 deaths per 100,000 women. The main causes are haemorrhage, sepsis, rupture of the uterus, anaemia, and others. The risk factors associated with the above causes include maternal height, age, child spacing, and number of births per woman; malaria and anaemia; imbalance of energy and food intake; HIV/AIDS; women's workload; and female genital mutilation (FGM). To address issues of women's health, the government has put in place many strategies, for example, a ministry to look after women's issues, the safe motherhood initiatives, improvement of the knowledge and skill of health care providers, as well as collaboration with nongovernmental organizations (NGOs) and private agencies. The health sector reform is important because it has negatively affected women's access to health care. To improve the health of women in Tanzania, health and health-related sectors should cooperate and collaborate in order to empower women in the areas of education, social status, and technology. Policies must also address poverty, nutrition, adolescent health, and violence and sexual abuse.     

Present health situation in Tanzania

This article discusses the present health situation in Tanzania, however, health system before independence, the colonial health system, has been the foundation on which the present health services in Tanzania are built upon. The population growth in Tanzania is high (3.2% in 1986), and projected to be 3.7% by the year 2,000. This high growth explains why it is difficult to achieve health objectives on the long term basis. Compounded to this is the economical crisis in the country. Child population in Tanzania account for about 47% of the total population in 1986. Maternal and Child Health Care services (MCHC) are discussed, with much emphasis on the child health care problems, and different programmes involved in improving child health care in the country. Problems of poor environmental sanitation are discussed including possible solutions for Tanzania. Tanzania, in this article, is urged to strengthen the existing health services in terms of staff, drugs, other supplies and equipment in order to give adequate health care to its people. Tanzania should also balance the distribution of resources between urban and rural so as to comply with the objective of the national health policy of comprehensive basic health services equitably to all within the limited available resources and to be able to reach the ultimate goal of health for all the people in the country by the year 2,000.     

The determinants of infant and child mortality in Tanzania

This paper investigates the determinants of infant and child mortality in Tanzania using the 1991/92 Tanzania Demographic and Health Survey. A hazards model is used to assess the relative effect of the variables hypothesized to influence under-five mortality. Short birth intervals, teenage pregnancies and previous child deaths are associated with increased risk of death. The Government of the United Republic of Tanzania should therefore maintain its commitment to encouraging women to space their births at least two years apart and delay childbearing beyond the teenage years. Further, this study shows that there is a remarkable lack of infant and child mortality differentials by socioeconomic subgroups of the population, which may reflect post-independence health policy and development strategies. Whilst lack of socioeconomic differentials can be considered an achievement of government policies, mortality remains high so there is still a long way to go before Tanzania achieves its stated goal of 'Health for All'.     

Fatal harmful substances or environmental exposures in agriculture, 1992 to 1996.

Data from the Census of Fatal Occupational Injuries surveillance system from 1992 through 1996 were analyzed to allow a better understanding of exposures to harmful substances or environments that resulted in agricultural work fatalities. There were 357 fatalities as a result of these exposures in the agriculture production and agriculture services sectors, representing 10% of all work-related deaths that occurred in these industry sectors during this period. Contact with electric current represented 52.9% of these fatalities. Agricultural services reported 87 electrocutions, 50 of which occurred among tree trimmers. The events most likely to result in fatalities were contact with overhead power lines (26.3%) and drowning (17.1%). The overall fatality rate was 2.1 deaths per 100,000 workers. The development of appropriate hazard-awareness training for workers, such as that for electrical and drowning-related hazards, may help prevent future deaths in these industry sectors.     

The importance of injury as a cause of death in sub-Saharan Africa: results of a community-based study in Tanzania

This paper describes rates and causes of injury deaths among community members in three districts of the United Republic of Tanzania. A population-based study was carried out in two rural districts and one urban area in Tanzania. Deaths occurring in the study areas were monitored prospectively during a period of six years. Censuses were conducted annually in the rural areas and biannually in the urban area to determine the denominator populations. Cause-specific death rates and Years of Life Lost (YLL) due to injury were calculated for the three study areas. During a 6 year period (1992-1998), 5047 deaths were recorded in Dar es Salaam, 9339 in Hai District and 11 155 in Morogoro Rural District. Among all ages, deaths due to injuries accounted for 5% of all deaths in Dar es Salaam, 8% in Hai and 5% in Morogoro. The age-standardised injury death rates among men were approximately three times higher than among women in all study areas. Transport accidents were the commonest cause of mortality in all injury-related deaths in the three project areas, except for females in Hai District, where it ranked second after intentional self-harm. We conclude that injury deaths impose a considerable burden in Tanzania. Strategies should be strengthened in the prevention and control of avoidable premature deaths due to injuries.     

Cause-specific adult mortality: evidence from community-based surveillance--selected sites, Tanzania, 1992-1998

Mortality data are a standard information resource to guide public health action. Because Tanzania did not have a representative mortality surveillance system, in 1992 the Adult Morbidity and Mortality Project (AMMP) was established by the Muhimbili University College of Health Sciences, the Ministry of Health of Tanzania (MOH), and the University of Newcastle upon Tyne, United Kingdom. The purpose of the surveillance system is to provide cause-specific death rates among adults in three areas of Tanzania and to link community-based mortality surveillance to evidence-based planning for health care. This report describes the results of AMMP surveillance during 1992-1998, which indicated that human immunodeficiency virus infection/acquired immunodeficiency syndrome (HIV/AIDS) was the leading cause of death reported by decedents' relatives and caretakers for adults of both sexes in all study areas, and suggests that a range of other causes of death exist across the three surveillance sites.     

关于发展上海市民营医院的政策思考

作者在深入调查研究的基础上，对上海市民营医院在发展中遇到的困难与问题进行了实事求是的分析和讨论，并从政府和行业协会两个方面就促进民营医院可持续发展的相关问题提出了政策建议。重点在于设立准入标准，合理布局，创建与公立医院公平的竞争机制，剥离公立医院的“特需服务”，完善依法监督、行业协会及自身管理。     

Scaling up postabortion contraceptive service--results from a study conducted among women having unwanted pregnancies in urban and rural Tanzania

INTRODUCTION: It is well recognized that unwanted pregnancies and unsafe abortion are significant public health problems in sub-Saharan Africa. At the International Conference on Population and Development held in Cairo in 1994, postabortion care was prioritized as a means to reduce maternal morbidity and mortality associated with unsafe abortion. However, only a few postabortion care programs have been implemented and most of them have been confined to urban settings. The present study describes the magnitude of the problem of unwanted pregnancies among women with incomplete abortion in urban and rural Tanzania and evaluates the outcome of a postabortion care intervention. METHODS: Data were collected among 781 women admitted with incomplete abortion in Dar es Salaam region (urban Tanzania) and 575 women in Kagera region (rural Tanzania). RESULTS: Sixty-seven percent of the women in urban Tanzania and 42% in rural Tanzania stated that their pregnancy was unwanted. Contraceptive acceptance among women with unwanted pregnancies was high; 93% in urban Tanzania and 71% in rural Tanzania left with a contraceptive method. CONCLUSION: The high proportion of women with unwanted pregnancies in urban and rural Tanzania underlines the need of scaling up postabortion contraceptive service.     

Will primary health care efforts be allowed to succeed?

It is suggested that the consequence of following Primary Health Care (PHC) principles as guidelines for health care development must of necessity lead to socio-economic and political restructuring in most countries. We are well aware that health status is determined more by the social and economic situation of population groups than by curative health services. The holistic approach of primary health care includes a concern with such factors. PHC, if it is to succeed, must ultimately lead to a reduction in the greater benefit for the few to the greater benefit for the many. This will receive strong opposition.The situation of a PHC programme in Guatemala is presented as a case of PHC efforts which were succeeding being violently opposed. This is compared with PHC development efforts in Tanzania where, unlike Guatemala, there has been a conscious effort at restructuring the society and where national development policies are in tune with PHC principles. The future of PHC in Tanzania will depend more on whether or not the organization and management of selection, training and implementation processes, and the minimal available resources, will lead to success, than on whether or not it will be allowed to succeed.It is concluded that the situation in most countries comes closer to that of Guatemala than of Tanzania and that many people and institutions in hierarchical, non-egalitarian societies will spend a great deal of energy to prevent PHC programmes from succeeding. This forces us to consider the promotion of PHC in a much more serious manner than we might wish.     

The costs of climate change: a study of cholera in Tanzania

Increased temperatures and changes in rainfall patterns as a result of climate change are widely recognized to entail potentially serious consequences for human health, including an increased risk of diarrheal diseases. This study integrates historical data on temperature and rainfall with the burden of disease from cholera in Tanzania and uses socioeconomic data to control for the impacts of general development on the risk of cholera. The results show a significant relationship between temperature and the incidence of cholera. For a 1 degree Celsius temperature increase the initial relative risk of cholera increases by 15 to 29 percent. Based on the modeling results, we project the number and costs of additional cases of cholera that can be attributed to climate change by 2030 in Tanzania for a 1 and 2 degree increase in temperatures, respectively. The total costs of cholera attributable to climate change are shown to be in the range of 0.32 to 1.4 percent of GDP in Tanzania 2030. The results provide useful insights into national-level estimates of the implications of climate change on the health sector and offer information which can feed into both national and international debates on financing and planning adaptation.     

Health diplomacy and Adapting global health interventions to local needs: findings from project accept (HPTN 043), a community-based intervention to reduce HIV incidence in populations at risk in Sub-Saharan Africa and Thailand

ABSTRACT: BACKGROUND: Study-based HIV prevention interventions, especially those that are conducted on an international or multi-site basis, frequently require site-specific adaptations in order to (1) respond to socio-cultural differences in risk determinants, (2) to make interventions more relevant to target population needs, and (3) in recognition of 'public health diplomacy' issues. We report on the adaptations development, approval and implementation process and describe adaptations from the Project Accept voluntary counseling and testing, community mobilization and post-test support services intervention. METHODS: We reviewed all relevant documentation collected during the study intervention period (e.g. monthly progress reports; bi-annual steering committee presentations) and conducted a series of semi-structured interviews with project directors and between 12 and 23 field staff at each study site in South Africa, Zimbabwe, Thailand and Tanzania during 2009. Respondents were asked to describe (1) the adaptations development and approval process and (2) the most successful site-specific adaptations in terms of facilitating intervention implementation. RESULTS: Across sites, proposed adaptations were identified by field staff and submitted to project directors for review, on a formally planned basis. The cross-site intervention sub-committee then ensured fidelity to the study protocol before approving. Successfully-implemented adaptations included: intervention delivery adaptations (e.g. development of tailored counseling messages for immigrant labour groups in South Africa); environmental and infrastructural adaptations (e.g. use of local community centers as VCT venues in Zimbabwe); religious adaptations (e.g. dividing clients by gender in Muslim areas of Tanzania); economic adaptations (e.g. co-provision of income generating skills classes in Zimbabwe); epidemiological adaptations (e.g. provision of 'youth-friendly' services in South Africa, Zimbabwe and Tanzania), and social adaptations (e.g. modification of terminology to local dialects in Thailand; adjustment of service delivery schedules to suit seasonal and daily work schedules across sites). CONCLUSIONS: Adaptation selection, development and approval during multi-site HIV intervention research studies should be a planned process that maintains fidelity to the study protocol. The successful implementation of appropriate site-specific adaptations may have important implications for intervention implementation, from both a service uptake and a 'public health diplomacy' perspective.     

The Contributions of Business and Civil Society Sectors to Rural Capacity to Solve Local Health Issues

The new health movement, which has emerged over the last decade, focuses decision making for program designs, interventions and health policies at the local level. This movement assumes that rural communities have the capacity to deal with local health issues. Local problem-solving capacity is based in local leadership patterns, relationships among different community sectors and the ability to select critical but feasible goals. In this research, 159 community leaders in 16 rural counties were interviewed regarding local health priorities, organizational interactions, and leadership roles in county health issues. Analysis of variance was used to identify differences among community sectors. The business and industry sector was found to interact with other organizations around health issues significantly less than all other sectors. Further, 69 percent of the business and industry sector compared with 32 percent of all other sectors thought that the business sector was a source of local leadership. The civil society sector, when compared with all other sectors, was significantly more likely to give priority to health services such as primary, specialty and auxiliary care goals. These findings suggest that rural communities need to find ways to more actively involve the business and industry sector in local health problem solving. In addition, the civil society sector brings to community problem solving a set of priorities that are often different from other sectors of the community.     

The incidence of squamous and transitional cell carcinomas of the urinary bladder in northern Tanzania in areas of high and low levels of endemic Schistosoma haematobium infection

Squamous cell carcinoma is the commonest type of bladder malignancy in most areas of northern Tanzania. Of 172 cases of bladder cancer recorded in 9 years, 72% were squamous cell carcinomas. Of these, 46% had Schistosoma haematobium eggs in sections taken from tumour tissue. The geographical distribution of this tumour closely corresponded to the prevalence of S. haematobium infection. The Mt Kilimanjaro area is free of schistosomiasis and virtually lacks squamous cell carcinoma. Although transitional cell carcinoma is rare in all regions of northern Tanzania, the relative frequency of bladder cancer in the Mt Kilimanjaro area was only one-third of that seen in other regions; population-based incidence rates were also very low in this area.     

The decentralisation-centralisation dilemma: recruitment and distribution of health workers in remote districts of Tanzania

Background  

The implementation of decentralisation reforms in the health sector of Tanzania started in the 1980s. These reforms were intended to relinquish substantial powers and resources to districts to improve the development of the health sector. Little is known about the impact of decentralisation on recruitment and distribution of health workers at the district level. Reported difficulties in recruiting health workers to remote districts led the Government of Tanzania to partly re-instate central recruitment of health workers in 2006. The effects of this policy change are not yet documented. This study highlights the experiences and challenges associated with decentralisation and the partial re-centralisation in relation to the recruitment and distribution of health workers.