Integrating reproductive and child health and HIV services in Tanzania: Implication to policy, systems and services

In Tanzania, reproductive health and HIV services are coordinated by the Ministry of Health and Social Welfare in two separate units namely Reproductive and Child Health Section and the National AIDS Control Programme. The importance of integrating the two services that are vertically run is expected to improve access to and uptake of key essential services and extend coverage to underserved and vulnerable populations and thus minimizing missed opportunities. Experts around the world recognize the central role of Sexual and Reproductive Health (SRH) services in preventing HIV infection. Evidence suggests that improving access to contraception for women to prevent pregnancy is an important and cost-effective way to prevent HIV-positive births. Integrating SRH and HIV services therefore verifies its importance for improving maternal and child health as well as leading to prevention of HIV infection.  The primary objective of this review was to gain an understanding of the current linkages between SRH and HIV within Tanzania’s policies, programmes, systems and services. Policy documents, guidelines, national laws, and published reports on SRH and HIV were reviewed.  The majority of the reviewed documents mentioned fundamentals of integration between SRH and HIV. Majority of policies and guidelines both in family planning (FP) and HIV documents mandate bi-directional linkages. This review suggests that there are linkages between the two services and can be operationalised together. However, policies and guidelines only specify services to be integrated without due consideration of resources and structural orientation for linked services

The use of routine health facility data for micro-stratification of malaria risk in mainland Tanzania

BACKGROUND: Current efforts to estimate the spatially diverse malaria burden in malaria-endemic countries largely involve the use of epidemiological modelling methods for describing temporal and spatial heterogeneity using sparse interpolated prevalence data from periodic cross-sectional surveys. However, more malaria-endemic countries are beginning to consider local routine data for this purpose. Nevertheless, routine information from health facilities (HFs) remains widely under-utilized despite improved data quality, including increased access to diagnostic testing and the adoption of the electronic District Health Information System (DHIS2). This paper describes the process undertaken in mainland Tanzania using routine data to develop a high-resolution, micro-stratification risk map to guide future malaria control efforts. METHODS: Combinations of various routine malariometric indicators collected from 7098 HFs were assembled across 3065 wards of mainland Tanzania for the period 2017-2019. The reported council-level prevalence classification in school children aged 5-16 years (PfPR(5-16)) was used as a benchmark to define four malaria risk groups. These groups were subsequently used to derive cut-offs for the routine indicators by minimizing misclassifications and maximizing overall agreement. The derived-cutoffs were converted into numbered scores and summed across the three indicators to allocate wards into their overall risk stratum. RESULTS: Of 3065 wards, 353 were assigned to the very low strata (10.5% of the total ward population), 717 to the low strata (28.6% of the population), 525 to the moderate strata (16.2% of the population), and 1470 to the high strata (39.8% of the population). The resulting micro-stratification revealed malaria risk heterogeneity within 80 councils and identified wards that would benefit from community-level focal interventions, such as community-case management, indoor residual spraying and larviciding. CONCLUSION: The micro-stratification approach employed is simple and pragmatic, with potential to be easily adopted by the malaria programme in Tanzania. It makes use of available routine data that are rich in spatial resolution and that can be readily accessed allowing for a stratification of malaria risk below the council level. Such a framework is optimal for supporting evidence-based, decentralized malaria control planning, thereby improving the effectiveness and allocation efficiency of malaria control interventions

Experiences, Opportunities and Challenges of Implementing Task Shifting in Underserved Remote Settings: The Case of Kongwa District, Central Tanzania.

Tanzania is experiencing acute shortages of Health Workers (HWs), a situation which has forced health managers, especially in the underserved districts, to hastily cope with health workers' shortages by adopting task shifting. This has however been due to limited options for dealing with the crisis of health personnel. There are on-going discussions in the country on whether to scale up task shifting as one of the strategies for addressing health personnel crisis. However, these discussions are not backed up by rigorous scientific evidence. The aim of this paper is two-fold. Firstly, to describe the current situation of implementing task shifting in the context of acute shortages of health workers and, secondly, to provide a descriptive account of the potential opportunities or benefits and the likely challenges which might ensue as a result of implementing task shifting. We employed in-depth interviews with informants at the district level and supplemented the information with additional interviews with informants at the national level. Interviews focussed on the informants' practical experiences of implementing task shifting in their respective health facilities (district level) and their opinions regarding opportunities and challenges which might be associated with implementation of task shifting practices. At the national level, the main focus was on policy issues related to management of health personnel in the context of implementation of task shifting, in addition to seeking their opinions and perceptions regarding opportunities and challenges of implementing task shifting if formally adopted. Task shifting has been in practice for many years in Tanzania and has been perceived as an inevitable coping mechanism due to limited options for addressing health personnel shortages in the country. Majority of informants had the concern that quality of services is likely to be affected if appropriate policy infrastructures are not in place before formalising tasks shifting. There was also a perception that implementation of task shifting has ensured access to services especially in underserved remote areas. Professional discontent and challenges related to the management of health personnel policies were also perceived as important issues to consider when implementing task shifting practices. Additional resources for additional training and supervisory tasks were also considered important in the implementation of task shifting in order to make it deliver much the same way as it is for conventional modalities of delivering care. Task shifting implementation occurs as an ad hoc coping mechanism to the existing shortages of health workers in many undeserved areas of the country, not just in the study site whose findings are reported in this paper. It is recommended that the most important thing to do now is not to determine whether task shifting is possible or effective but to define the limits of task shifting so as to reach a consensus on where it can have the strongest and most sustainable impact in the delivery of quality health services. Any action towards this end needs to be evidence-based

Malaria elimination in Zanzibar: where next?

In 2018, Zanzibar developed a national malaria strategic plan IV (2018-2023) to guide elimination of malaria by 2023. We assessed progress in the implementation of malaria activities as part of the end-term review of the strategic plan. The review was done between August and October 2022 following the WHO guideline to assess progress made towards malaria elimination, effectiveness of the health systems in delivering malaria case management; and malaria financing. A desk review examined available malaria data, annual work plans and implementation reports for evidence of implemented malaria activities. This was complemented by field visits to selected health facilities and communities by external experts, and interviews with health management teams and inhabitants to authenticate desk review findings. A steady increase in the annual parasite incidence (API) was observed in Zanzibar, from 2.7 (2017) to 3.6 (2021) cases per 1,000 population with marked heterogeneity between areas. However, about 68% of the detected malaria cases were imported into Zanzibar. Malaria case follow-up and investigation increased from <70% in 2017 to 94% and 96% respectively, in 2021. The review noted a 3.7-fold increase of the health allocation in the country's budget, from 31.7 million USD (2017/18) to 117.3 million USD (2022/23) but malaria allocation remained low (<1%). The varying transmission levels in the islands suggest a need for strategic re-orientation of the elimination attempts from a national-wide to a sub-national agenda. We recommend increasing malaria allocation from the health budget to ensure sustainability of malaria elimination interventions

HIV treatment outcomes and their associated factors among adolescents and youth living with HIV in Tanzania

Introduction:&nbsp; Despite improvements in access to Ante-Retroviral therapy in Tanzania, low ART initiation rate, low retention rate, lower viral load suppression, high loss to follow up and death rate among adolescents and youth living with HIV remain a challenge.&nbsp; This study was conducted to identify factors affecting HIV treatment outcomes among adolescents and youths. Methods: A cross-sectional study was done in seven regions in Tanzania. A total of 1124 in and out of school ALYHIV were interviewed using a semi-structured questionnaire. Results: A total of 1120(99.6%) participants were on ART. Of those who were on ART, 606 (53.9%) participants had advanced HIV disease, 423(37.6 %) had switched to the second line of ART and 1761(7.7%) had a virological failure. After adjusting for confounders, death of both parents (APR= 1.3, 95%CI: 1.01-1.8); regions with high HIV prevalence (APR= 1.7, 95%CI: 1.2-2.3) and taking ARVs for three years and less (APR= 2.2, 95%CI: 1.4-3.6) were associated to have advanced HIV. Additionally, HIV regional prevalence level, level of perception, adherence status, ARV storage and supervision of ART use were independently associated with Virological failure. &nbsp;&nbsp; Conclusion: This study has shown that despite an almost universal utilization of ART among adolescents and youth living with HIV unfavourable clinical ART outcomes such as advanced HIV disease, virological failure and ART switch to the second line remain a challenge, particularly among males and adolescents. Various factors at individual, community and health facility levels contribute to unfavorable ART clinical outcomes among AYLHIV. Therefore, an all-inclusive multidimensional and multi- stakeholders’ approach is needed to ensure the availability of sustainable, effective and quality care and treatment services prioritizing AYLHIV.&nbsp

"Should We Take Them or Leave Them?" A Qualitative Study to Understand the Social, Cultural, and Ethical Issues Associated With the Lifecycle Management of Insecticide-Treated Nets in Tanzania

Background: Insecticide-treated nets (ITNs) are highly effective in reducing morbidity and mortality from malaria. However, it is widely accepted that ITNs – if not re-treated – lose their effectiveness with time and eventually need to be replaced. This study sought to determine the social, ethical, and cultural issues related to the lifecycle of ITNs, which includes net ownership, usage, maintenance, reuse, recycling, disposal, and replacement. &nbsp; Methods: In this qualitative study, conducted in the districts of Mtwara Rural, Kilombero, and Muheza, Tanzania, we collected information about bed nets, including usage habits, types, treatment status, materials used, brands, acquisition sources, and perceptions thereof. We conducted 23 key informant interviews and 20 focus group discussions with village leaders, other influential people in the community, and district health-care personnel. &nbsp; Results: ITNs were deemed acceptable and used by most community members in the participating communities. Alternative uses and disposal practices of used bed nets were also common among community members; however, participants had limited knowledge regarding the health and environmental risks associated with these practices. Most participants did not perceive bed net recycling as a sustainable option. Recycling was considered feasible, however, if effective infrastructure for collection and disposal could be established. Poverty was identified as a major driving force towards alternative uses of bed nets. Financial constraints also meant that not all household members were able to sleep under bed nets; pregnant mothers, children under 5 years old, and the elderly were prioritised. &nbsp; Conclusion: Our findings may inform the National Malaria Control Programme and other stakeholders as they develop country-specific and environmentally friendly bed net replacement strategies. Appropriate strategies will help ensure sustained protection of vulnerable populations against malaria, while considering local social, ethical, and cultural issues related to the recovery of bed nets

Reasons given for not taking the drugs among the interviewed adult study populations from the four study sites in Lindi and Morogoro Region who reported not to have taken the drugs (n = 1403).

<p>Reasons given for not taking the drugs among the interviewed adult study populations from the four study sites in Lindi and Morogoro Region who reported not to have taken the drugs (n = 1403).</p

Factors Influencing Drug Uptake during Mass Drug Administration for Control of Lymphatic Filariasis in Rural and Urban Tanzania

<div><p>Background</p><p>In most countries of Sub-Saharan Africa, control of lymphatic filariasis (LF) is based on annual mass drug administration (MDA) with a combination of ivermectin and albendazole. Treatment coverages are however often suboptimal for programmes to reach the goal of transmission interruption within reasonable time. The present study aimed to identify predictors and barriers to individual drug uptake during MDA implementation by the National LF Elimination Programme in Tanzania.</p><p>Methods</p><p>A questionnaire based cross sectional household survey was carried out in two rural and two urban districts in Lindi and Morogoro regions shortly after the 2011 MDA. 3279 adults (≥15 years) were interviewed about personal characteristics, socio-economic status, MDA drug uptake among themselves and their children, reasons for taking/not taking drugs, and participation in previous MDA activities for LF control.</p><p>Findings</p><p>The overall drug uptake rate was 55.1% (range of 44.5–75.6% between districts). There was no overall major difference between children (54.8%) and adults (55.2%) or between females (54.9%) and males (55.8%), but the role of these and other predictors varied to some extent between study sites. Major overall predictors of drug uptake among the interviewed adults were increasing age and history of previous drug uptake. Being absent from home during drug distribution was the main reason for not taking the drugs (50.2%) followed by clinical contraindications to treatment (10.8%), missing household visits of drug distributors (10.6%), and households not being informed about the distribution (9.0%).</p><p>Conclusion</p><p>Drug uptake relied more on easily modifiable provider-related factors than on individual perceptions and practices in the target population. Limited investments in appropriate timing, dissemination of accurate timing information to recipients and motivation of drug distributors to visit all households (repeatedly when residents are absent) are likely to have considerable potential for increasing drug uptake, in support of successful LF transmission elimination.</p></div

Map showing the location of the study sites in Lindi and Morogoro Region, Tanzania.

<p>Red  =  the two urban study districts; Green  =  the two rural study districts; Yellow  =  remaining parts of the two study regions; DSM  =  Dar es Salaam.</p

Integrating reproductive and child health and HIV services in Tanzania: Implication to policy, systems and services

In Tanzania, reproductive health and HIV services are coordinated by the Ministry of Health and Social Welfare in two separate units namely Reproductive and Child Health Section and the National AIDS Control Programme. The importance of integrating the two services that are vertically run is expected to improve access to and uptake of key essential services and extend coverage to underserved and vulnerable populations and thus minimizing missed opportunities. Experts around the world recognize the central role of Sexual and Reproductive Health (SRH) services in preventing HIV infection. Evidence suggests that improving access to contraception for women to prevent pregnancy is an important and cost-effective way to prevent HIV-positive births. Integrating SRH and HIV services therefore verifies its importance for improving maternal and child health as well as leading to prevention of HIV infection. The primary objective of this review was to gain an understanding of the current linkages between SRH and HIV within Tanzania’s policies, programmes, systems and services. Policy documents, guidelines, national laws, and published reports on SRH and HIV were reviewed. The majority of the reviewed documents mentioned fundamentals of integration between SRH and HIV. Majority of policies and guidelines both in family planning (FP) and HIV documents mandate bi-directional linkages. This review suggests that there are linkages between the two services and can be operationalised together. However, policies and guidelines only specify services to be integrated without due consideration of resources and structural orientation for linked services