Demographic Transition in Sub-Saharan Africa: From Grassroots to Ivory Towers

The concept of demographic transition has been evident to European, North American and Japanese population since the early 1960’s. It loosely followed natural patterns that were postulated as far back as 1795. However, scientists and policy makers, still erroneously consider demographic transition to be absent in sub-Saharan Africa. The aim of this chapter is to uncover the hidden truth behind population censa in sub-Sahara African countries using Statistical tools. The chapter analyses philosophical basis of sub-Saharan Africa demographic dividends from 1960 to 2000. It then cautiously highlights how demographic transition is emerging in sub-Saharan Africa. Specifically, it endeavours to highlight how different African countries are in different stages of demographic transition. The chapter also contrasts some of the prevalent misconceptions about Africans, especially the delusional idea of Africans as a homogenous population group on genetic basis. Lastly, it offers solution, to the current demographic chaos, and their relationship to future matured demographic transition in sub-Saharan Africa

Perceived barriers to access available health services among men who have sex with men in Dar es Salaam, Tanzania

Background: Men who have sex with men (MSM) continue to be highly affected with the HIV infection worldwide. Studies have shown that the organization of healthcare systems and how the MSM perceive it play a major role in granting or denying them access to healthcare services. Little is known in Tanzania regarding the barriers that MSM face while accessing health services within the country. The study was geared towards determining the proportion of MSM who accessed health care and disclose their sexual orientations to health care workers (HCW). It also intended to find out the anticipated barriers from HCW’s if they were to disclose their sexual orientations to them and consider the types of social networks used when facing various challenges.Methods: The study employed both quantitative and qualitative methods. Participants were enrolled in the study Respondent Driven Sampling. Quantitative data was entered and analysed using the Statistical Package for the Social Sciences v.20. Qualitative data was collected using in-depth interviews read and interpreted to identify themes and create categories. These were manually analysed and interpreted according to the study objectives.Results: The majority (87.7%) of MSM accessed healthcare services when sick, only a few (3.4%) did nothing due to lack of financial resources. Only a third of them had ever disclosed their sexual orientations to healthcare workers. This was due to lack of confidentiality, fear of stigma and discrimination, shame and mistreatment at the health facilities, and fear of the healthcare worker’s reaction after they disclosed their sexual orientation to them.Conclusion: MSM need to be empowered to overcome their perceived fears towards healthcare workers and health facilities. Efforts should be put into breaking the cycle of negative information and perceptions MSM have about healthcare workers and how they deal with same sex practices’ health related problems

Cost of installing and operating an electronic clinical decision support system for maternal health care: case of Tanzania rural primary health centres

Background: Poor quality of care is among the causes of high maternal and newborn disease burden in Tanzania. Potential reason for poor quality of care is the existence of a “know-do gap” where by health workers do not perform to the best of their knowledge. An electronic clinical decision support system (CDSS) for maternal health care was piloted in six rural primary health centers of Tanzania to improve performance of health workers by facilitating adherence to World Health Organization (WHO) guidelines and ultimately improve quality of maternal health care. This study aimed at assessing the cost of installing and operating the system in the health centers. Methods: This retrospective study was conducted in Lindi, Tanzania. Costs incurred by the project were analyzed using Ingredients approach. These costs broadly included vehicle, computers, furniture, facility, CDSS software, transport, personnel, training, supplies and communication. These were grouped into installation and operation cost; recurrent and capital cost; and fixed and variable cost. We assessed the CDSS in terms of its financial and economic cost implications. We also conducted a sensitivity analysis on the estimations. Results: Total financial cost of CDSS intervention amounted to 185,927.78 USD. 77% of these costs were incurred in the installation phase and included all the activities in preparation for the actual operation of the system for client care. Generally, training made the largest share of costs (33% of total cost and more than half of the recurrent cost) followed by CDSS software- 32% of total cost. There was a difference of 31.4% between the economic and financial costs. 92.5% of economic costs were fixed costs consisting of inputs whose costs do not vary with the volume of activity within a given range. Economic cost per CDSS contact was 52.7 USD but sensitive to discount rate, asset useful life and input cost variations. Conclusions: Our study presents financial and economic cost estimates of installing and operating an electronic CDSS for maternal health care in six rural health centres. From these findings one can understand exactly what goes into a similar investment and thus determine sorts of input modification needed to fit their context

Cost-effectiveness of an electronic clinical decision support system for improving quality of antenatal and childbirth care in rural Tanzania: an intervention study

Background: QUALMAT project aimed at improving quality of maternal and newborn care in selected health care facilities in three African countries. An electronic clinical decision support system was implemented to support providers comply with established standards in antenatal and childbirth care. Given that health care resources are limited and interventions differ in their potential impact on health and costs (efficiency), this study aimed at assessing cost-effectiveness of the system in Tanzania. Methods: This was a quantitative pre- and post- intervention study involving 6 health centres in rural Tanzania. Cost information was collected from health provider’s perspective. Outcome information was collected through observation of the process of maternal care. Incremental cost-effectiveness ratios for antenatal and childbirth care were calculated with testing of four models where the system was compared to the conventional paper-based approach to care. One-way sensitivity analysis was conducted to determine whether changes in process quality score and cost would impact on cost-effectiveness ratios. Results: Economic cost of implementation was 167,318 USD, equivalent to 27,886 USD per health center and 43 USD per contact. The system improved antenatal process quality by 4.5% and childbirth care process quality by 23.3% however these improvements were not statistically significant. Base-case incremental cost-effectiveness ratios of the system were 2469 USD and 338 USD per 1% change in process quality for antenatal and childbirth care respectively. Cost-effectiveness of the system was sensitive to assumptions made on costs and outcomes. Conclusions: Although the system managed to marginally improve individual process quality variables, it did not have significant improvement effect on the overall process quality of care in the short-term. A longer duration of usage of the electronic clinical decision support system and retention of staff are critical to the efficiency of the system and can reduce the invested resources. Realization of gains from the system requires effective implementation and an enabling healthcare system. Trial registration: Registered clinical trial at www.clinicaltrials.gov (NCT01409824). Registered May 2009

Nesting doctoral students in collaborative North-South partnerships for health systems research

Background: The European Union (EU) supports North-South Partnerships and collaborative research projects through its Framework Programmes and Horizon 2020. There is limited research on how such projects can be harnessed to provide a structured platform for doctoral level studies as a way of strengthening health system research capacity in sub-Saharan Africa (SSA). Objective: The aim of this study was to explore the challenges of, and facilitating factors for, 'nesting' doctoral students in North South collaborative research projects. The term nesting refers to the embedding of the processes of recruiting, supervising, and coordinating doctoral students in the overall research plan and processes. Design: This cross-sectional qualitative study was undertaken by the EU-funded QUALMAT Project. A questionnaire was implemented with doctoral students, supervisors, and country principal investigators (PIs), and content analysis was undertaken. Results: Completed questionnaires were received from nine doctoral students, six supervisors, and three country PIs (86% responses rate). The doctoral students from SSA described high expectations about the input they would receive (administrative support, equipment, training, supervision). This contrasted with the expectations of the supervisors for proactivity and self-management on the part of the students. The rationale for candidate selection, and understandings of the purpose of the doctoral students in the project were areas of considerable divergence. There were some challenges associated with the use of the country PIs as co-supervisors. Doctoral student progress was at times impeded by delays in the release of funding instalments from the EU. The paper provides a checklist of essential requirements and a set of recommendations for effective nesting of doctoral students in joint North-South projects. Conclusion: There are considerable challenges to the effective nesting of doctoral students within major collaborative research projects. However, ways can be found to overcome them. The nesting process ultimately helped the institutions involved in this example to take better advantage of the opportunities that collaborative projects offer to foster North-South partnerships as a contribution to the strengthening of local research capacity

Prevalence and predictors of human immunodeficiency virus and selected sexually transmitted infections among people who inject drugs in Dar es Salaam, Tanzania: A new focus to get to zero

Background: Previous studies in Tanzania indicated that human immunodeficiency virus (HIV) prevalence among people who inject drugs (PWIDs) could be as high as 40%. We aim to provide data on the prevalence of HIV and sexually transmitted infection among PWIDs to inform national plans to get to zero. Materials and Methods: Respondent-driven sampling was used to collect drug use, and sexual practices data among PWIDs aged 15 years and older. Blood samples were examined for HIV, herpes simplex virus type 2, syphilis, and hepatitis B. Results: A total of 620 PWIDs with a median age of 32 (interquartile range, 17–52) participated in the study. Their use of drugs had typically started during adolescence. The prevalence of HIV was found to be 15.5%, whereas that of herpes simplex type 2 was 43.3%. Associated with an increased likelihood of HIV infection was being a female (adjusted odds ratio [aOR], 2.3; 95% confidence interval [CI], 1.0–3.6), sharing of syringes (aOR, 2.4; 95% CI, 1.1–6.1), used syringes hidden in public places (aOR, 5.1; 95% CI, 1.3–10.2), and having had a genital ulcer during the last 12 months before this survey. On the other hand, being educated, use of noninjectable drugs, access (aOR, 0.5; 95% CI, 0.2–0.8), and use of clean syringes (aOR, 0.3; 95% CI, 0.1–0.6) were associated with decreased likelihood of HIV infection. Conclusions: The prevalence of HIV infection among PWIDs in Dar es Salaam is 3 times higher than that in the general population. Behavioral and biological risk factors contribute to HIV transmission and needs to be addressed to be able to get to zero. The final version of this research has been published in Sexually Transmitted Diseases. © 2017 Lippincott, Williams & Wilkin

Motivation and incentives for maternal and neonatal health workers: a cross-country analysis of policies and strategies in Burkina Faso, Ghana and Tanzania

Background: Motivation and incentives are critically important aspects for health workers’ efficiency particularly for those working in maternal and neonatal health services in developing countries.Objective: To analyse maternal and neonatal health workers’ motivation policies and strategies in Burkina Faso, Ghana and Tanzania.Methods: We conducted cross-sectional case studies using document review and key informant interviews in the three countries. Data analysis applied thematic content analysis.Results: HRH policy documents reviewed provided context of health worker motivation. Although policy documents have wealth of on-going initiatives in health workers’ motivation and incentives in the three countries, still, there are deficiencies in strategies on motivation and incentives for health workers. The main deficit was lack of concrete plans for implementation of incentives as well as enforcement mechanism.Conclusion: Motivation and incentives should be well defined and concrete plans for how to implement motivation and incentive policies need to be in place in the three countries.Keywords: health worker, motivation, incentive, polic

HIV and STIs among men who have sex with men in Dodoma municipality, Tanzania: a cross-sectional study

Objectives: To determine the seroprevalence of HIV, STI and related risks among men who have sex with men (MSM) in Dodoma municipality, Tanzania. Methods: A cross-sectional study using respondent-driven sampling was employed to recruit study participants aged 18 years and above. Data on sociodemographics, HIV/STI knowledge and sexual practices were collected. Blood samples were tested for HIV and selected STIs. Results: A total of 409 participants aged from 18 to 60 years took part in this study. The median age at first anal intercourse was 15 years. At last anal intercourse, 37.5% practiced receptive, 47.5% insertive and 15.0% both insertive and receptive anal intercourse. The seroprevalence of HIV, herpes simplex virus 2 (HSV-2), syphilis, hepatitis B virus and hepatitis C virus were 17.4%, 38.5%, 0.2%, 5.4% and 3.4%, respectively. A third of MSM perceived their risk for HIV to be low and this was associated with unprotected sex (adjusted OR (AOR), 4.8, 95% CI 1.8 to 10.2). HIV seropositivity was also associated with HSV-2 (AOR, 5.0, 95% CI 3.01 to 11.21); having lived outside Dodoma (AOR 1.7, 95% CI 1.1 to 6.7); age above 25 years; (AOR 2.1, 95% CI 1.7 to 3.7); sexual relationship with a woman (AOR 5.6, 95% CI 3.9 to 12.8); assuming a receptive (AOR 7.1, 95% CI 4.8 to 17.4) or receptive and insertive (AOR 4.5, 95% CI 1.9 to 11.4) position during last anal intercourse; engaging in group sex (AOR 3.1, 95% CI 1.2 to 6.1) and the use of alcohol (AOR 3.9, 95% CI 1.1 to 9.2). Conclusions: HIV prevalence among MSM is five times higher compared with men in the general population in Dodoma. Perceived risk for HIV infection was generally low and low risk perception was associated with unprotected sex. STI, bisexuality and other behavioural risk factors played an important part in HIV transmission. The findings underscore the need for intensified HIV prevention programming addressing and involving key populations in Tanzania

Hiv Prevalence and Associated Risk Factors Among Men Who Have Sex With Men in Dar Es Salaam, Tanzania

Introduction: Limited studies and differential risk behaviours among men who have sex with men (MSM) in Africa calls for population specific studies. We present results from the largest integrated bio-behavioural survey among MSM in Africa to inform programming. Methods: This was a cross-sectional study utilizing respondent driven sampling to recruit MSM aged 18 and above. Data on socio-demographic characteristics and HIV-related risks were collected and all participants were tested for HIV, Herpes Simplex Virus Type-2 (HSV2), Hepatitis-B Virus (HBV) and Syphilis. Results: A total of 753 MSM with a mean age of 26.5 years participated in the study and 646 (85.7%) gave blood for biological testing. The prevalence of HIV was 22.3%, HSV-2 40.9%, syphilis 1.1 %, and HBV 3.25%. Significant risk factors for HIV were age above 25, having no children (aOR), 2.4, 95% CI: 1.4-4.2), low HIV-risk perception (aOR, 2.6, 95% CI: 1.2- 5.3), receptive position (aOR, 8.7; 95% CI 1.2-5.3), and not using water-based lubricants (aOR, 2.6, 95% CI: 1.0-4.5) during last anal sex. Also associated with HIV infection was, having sexual relationships with women (aOR, 8.0, 95% CI: 4.1-15.6), engaging in group sex (aOR, 3.8, 95% CI: 1.6-8.4), HSV-2 seropositivity (aOR, 4.1, 95% CI: 2.6- 6.5) and history of genital ulcers (aOR, 4.1, 95% CI: 1.1-7.2). Conclusions: HIV infection and HSV-2 were highly prevalent among MSM. Low perceived HIV risk, practice of risk behaviours and infection with HSV-2 were significant predictors of HIV infection. Behavioural interventions, HSV-2 suppressive therapies and Pre-exposure Prophylaxis are highly needed. The final version of this research has been published in Journal of Acquired Immune Deficiency Syndromes. © 2018 Lippincott, Williams & Wilkin

Five different ways of reasoning: Tanzanian healthcare workers’ ideas about how to improve HIV prevention among same-sex attracted men

Abstract Background Same-sex attracted men in Tanzania and globally carry a disproportionate burden of HIV. Drawing on qualitative research, this article explores healthcare providers’ ideas and recommendations regarding how to improve HIV prevention among same-sex attracted men. Methods We carried out a qualitative study among healthcare workers in the cities of Dar es Salaam and Tanga in Tanzania between August 2018 and October 2019. Data were collected using qualitative methods of data collection, specifically in-depth interviews, focus group discussions, and participant observation. Study participants were recruited through a purposive sampling strategy that aimed to ensure variation in age, education, and work experience. Forty-eight interviews with 24 healthcare workers, six focus group discussions, and participant observation were conducted. A total of 64 persons participated in the study. Results This paper describes five different “ways of reasoning” that were identified among healthcare workers regarding how to strengthen HIV prevention among same-sex attracted men. One held that punitive measures should be taken to prevent HIV transmission, another that health services needed to become more friendly towards men who have sex with men, a third that healthcare workers should reach out to provide more education to this population, a fourth called for strengthened collaboration between healthcare providers and same-sex attracted men in healthcare delivery, and the fifth proposed that activistic efforts be taken to remove structural barriers for same-sex attracted men to access healthcare. Conclusion When reflecting on what is needed to strengthen HIV prevention among men who have sex with men, healthcare workers described six different ideas. One was that restrictive and punitive measures ought to be taken to prevent HIV transmission through same-sex sex. The remaining five promoted understanding of and support for same-sex attracted men. They prescribed more healthcare education, measures to improve attitudes among healthcare workers, healthcare delivery with user involvement, and political action to achieve law reform. Finally, some study participants raised concerns about the implementation of the national comprehensive package for key populations