Aggregate cost implications of selected Cost-Drivers \ud in the Tanzanian Health Sector\ud

\ud Health is an important aspect of life of which one of its determinants is healthcare which is consumed in order to restore back deteriorated health to optimal pre-illness levels. The consumption of healthcare however has cost implications and accounts for a large share of resources directed towards the health sector. In health sector financing, it is vital to identify major cost components and create awareness about the costs of decisions. It is thus vital to identify factors that can cause changes in the cost of identified activities. A number of costly programs have been initiated and some others are on the horizon. In order to create awareness about the financial consequences of these decisions and to draw attention to the financing needs of the health sector, it is considered necessary to analyze the major health sector programs and initiatives with regard to the changes in costs brought about by new strategies, guidelines and interventions (including the adoption of new technologies), and aggregate these costs. The main objective of this study was to identify cost-driving decisions in the health sector. The study methodology comprised of three independent but complementary methodologies and activities: (a) Desk review of literature and documents; (b) Interviews with officials from MOHSW, programs and agencies involved in setting and promoting standards at international level; (c) collection of primary data/information and subsequent analysis of the same. The study reviewed 11 plans, including summary plans like the Health Sector Strategic Plan III and the Primary Health Services Development Program 2007 -2017 and national disease control programme plans/strategies. However, not all of cost-driving decisions in these plans could be integrated into the analysis because the plans are undergoing reprogramming, as the previous cost estimates are regarded not to be realistic relative to achieving plan objectives. In addition the costs of some decisions in some plans/strategies HRH, infrastructure, health care financing strategy, mhealth, etc. are not established or are in the process of being costed or reviewed. It should also be noted that the consultants did not assess all plans/strategies and their associated costs as to their plausibility. This was neither task of the consultants, nor would the time allocated to the study have allowed such an in-depth review. The study reviewed a total of 11 multi-year plans/strategies and found four plans to be affected by costs of decisions. Such decisions are: the adaption of WHO recommendations on Anti-retroviral Treatment eligibility criteria; re-treatment of conventional nets; indoor residual spraying; sustaining availability of long lasting insecticide treated nets (LLINs); provision of delivery kits to pregnant women in public health facilities, and the potential future introduction of a malaria vaccine, human papilloma virus and pneumococcal vaccines, which affect the Health Sector HIV and AIDS Strategic Plan II (HSHSP II) 2008 – 2012, the Malaria Mid-Term Strategic Plan 2008 – 2013 (NMCP), the National Road Map Strategic Plan to Accelerate Reduction of Maternal, Newborn and Child Deaths in Tanzania 2008 – 2015 (the Road Map), and the Expanded Program on Immunization 2010 - 2015 Comprehensive Multi Year Plan (EPI), respectively. The study found that these decisions have a significant cost implication to a tune of US$706,688,405 over a five year period 2011- 2015. The initially estimated costs of programs that are currently being updated (HSHSP II, EPI, NMCP and the Road Map) is US$ 2,297,009,378 exclusive of the identified cost drivers. The estimated cost of decisions is about 8 % of the total costs for health sector in Tanzania (HSSP III estimate) and about 3.3% of the 2009 GDP and added nominal per capita health spending/cost of US$17.3 (2009 population estimate) for five year period (annual per capita cost of US$ 3.46). This expenditure will definitely boost per capita health spending (US$13.45 in 2008/9). However, concerted revenue effort is needed if we are to hit HSSP III target of US$ 26.6 in 2014/15. The National Strategy for Non-communicable Diseases 2009 – 2015 did not include estimates, while most parts of the National Road Map Strategic Plan to Accelerate Reduction of Maternal, Newborn and Child Deaths in Tanzania 2008 – 2015 are undergoing reprogramming, as the previous cost estimates are regarded not to be realistic relative to achieving plan objectives. The rest of the programs are not significantly affected by cost of decisions. However, the estimated cost is likely to be higher owing to the fact that costs of some decisions in MMAM components such as HRH, infrastructure, health care financing strategy, mhealth, etc. are not established or are in the process of being costed or reviewed. Prevention and treatment of illness are the major strategies used to maintain or improve the health status of a population. Allocation of health resources are usually skewed towards treatment probably because addressing existing illnesses seem a present and clear danger than addressing potential illnesses which is what prevention is all about. Prevention and health promotion however lead to greater benefits than treatment in the long run in the sense that it reduces future demand for treatment than treatment alone does and has stronger merit good characteristics than treatment of illness. Health planning should thus intensify focus on prevention through promoting lifestyle and behaviour changes as well as intensifying prevention and health promotion at community level. Most health sector multi-year plans are characterized by heavy resource dependence on development partners. Such levels of dependence tend to compromise control over some decisions especially those supported by financiers. That is, recipients may be tempted to accept a full funded activity even if there is an ongoing similar activity which ends up creating parallel rather than complementary activities with cost implications. Thus, the financiers and recipients should undertake thorough analysis of potential decisions based on their cost implications (direct and indirect) as well as the time parameters, while avoiding decisions that spin off similar activities rather than complementing the existing ones. This can be facilitated by coordinated analysis from the MOHSW by keeping and monitoring comprehensive cost driver table enriched by inputs from all health sector programs and plans. Continuous reviews of the plans enhance the capacity of programs to adequately identify cost drivers and therefore enhance the planning process. However, reviews are not always undertaken on time and as regular as possible due to lack of resources or transfer of resources set aside for review process to implement other pressing components of the plan. MOHSW should make costing part of the plan a compulsory exercise for approval by the management and should not endorse plans which have not been adequately costed. MOHSW should also consider making reviews of multi-year plans a prerequisite for release of fund for subsequent implementation. Moreover, the reviews should integrate all stakeholders and involve technical people who are knowledgeable in costing and planning. The fact that most of the multi-year plans had indicative budgets, while others are not costed at all, warrants the conclusion that the basic knowledge in costing such as collaboration, parameter assumptions, time, manpower, and resources is lacking. Emphasis should thus be placed on developing and improving costing capacity in the programs as well as the MOHSW in terms of acquiring costing tools and exposure. The MOHSW should ensure that the priority activities of the strategies/plans are funded. This could be done through lobbying the government and other stakeholders for more resources. Protocols such as Abuja Declaration 2001, in which African governments committed themselves to scale up health budget to 15% of the annual budget, could be useful in this end. Also the government and local authorities through laws/bylaws could establish and commit specific sources of resources for the health sector. This should be pursued by keeping a close eye on the ratio of available resources to required resources which can indicate opportunities which development partners can be of help as well as providing an indication of the realism of planning. A review of the plans found the ratio of available resources to required resources to be 76 and 84 percent, respectively, for the Health Sector Strategic Plan III and the Expanded Program on Immunization 2010 – 2015 Comprehensive Multi Year Plan. The Malaria Medium Term Strategic Plan 2008-2013 on the other hand had the lowest ratio of available resources to required resources of 35 percent.\u

Development Partner Group-Health Retreat

Following the publication of the draft Tanzanian Joint Assistance Strategy (JAS) in July 2005 which outlined a medium-term framework for enhancing aid effectiveness through the rationalisation and alignment of development partner approaches, a series of consultations on this draft strategy took place both within government agencies and among Development Partners. The Development Partner Group in Health (DPG-H) took this opportunity to hold a two-day workshop in late September with the first day devoted to discussing the implications of the JAS for Development Partners, Ministry of Health and President's Office Regional Administration and Local Government. The second day was used as a time to internally reflect on the present functioning of the DPG-H Group, identifying ways of enhancing the work of the group in response to the changing environment. Discussions on the first day of the Retreat were structured around the five key elements of the JAS, i.e., Sector Dialogue, Aid Modalities, TA and Capacity Building, Division of Labour and Monitoring & Evaluation. Presentations were made by Development Partners with input/comments and clarification given by the Ministry of Health, President's Office Regional Administration and Local Government; and Ministry of Finance. Group work was undertaken in the afternoon to further address pertinent issues that were raised from the plenary discussions in the morning session. This resulted in a number of recommendations that included the following: supporting an effective division of labour; harmonising support with government plans and priorities irrespective of the funding modality; complementarity and coordination enhanced between the various aid modalities; basket funding to continue as a transition towards General Budget Support (GBS); demand driven technical assistance; and over time developing an agreed competency/profile skills mix of health development partners. The second day was an opportunity for members of the DPG-H to come together and reflect on the work of the group - where it had come from, the current functioning of the group (strengths/challenges) and looking forward. A number of presentations were made that covered the background of the group; the history of the Sector Wide Approach (SWAp) and the role of development partners; the sector dialogue structures, the expectations and challenges with respect to communication; strengthening the ways of working as a group and the development of an activity plan for prioritising activities. During the plenary sessions a number of recommendations were agreed that included better structuring of the DPG-H meetings; regularity of meetings (once month but more frequently when required); enhancing the coherency and linkages with the overall Development Partner Group; developing and agreeing a work plan and communication strategy; re-visiting the division of labour in terms of roles and responsibilities; putting in place a fully staffed DPG-H Secretariat and organising a troika chairing structure for the group. Moreover, a number of critical suggestions and recommendations were made for further strengthening sector dialogue that centred around revising the structure of the SWAp. As they had implications beyond the mandate of the DPG-H, it was concluded that this would require further discussions, elaboration and agreement by the Ministry of Health/PORALG.\u

Health System Support for Childbirth care in Southern Tanzania: Results from a Health Facility Census.

Progress towards reaching Millennium Development Goals four (child health) and five (maternal health) is lagging behind, particularly in sub-Saharan Africa, despite increasing efforts to scale up high impact interventions. Increasing the proportion of birth attended by a skilled attendant is a main indicator of progress, but not much is known about the quality of childbirth care delivered by these skilled attendants. With a view to reducing maternal mortality through health systems improvement we describe the care routinely offered in childbirth offered at dispensaries, health centres and hospitals in five districts in rural Southern Tanzania. We use data from a health facility census assessing 159 facilities in five districts in early 2009. A structural and operational assessment was undertaken based on staff reports using a modular questionnaire assessing staffing, work load, equipment and supplies as well as interventions routinely implemented during childbirth. Health centres and dispensaries attended a median of eight and four deliveries every month respectively. Dispensaries had a median of 2.5 (IQR 2--3) health workers including auxiliary staff instead of the recommended four clinical officer and certified nurses. Only 28% of first-line facilities (dispensaries and health centres) reported offering active management in the third stage of labour (AMTSL). Essential childbirth care comprising eight interventions including AMTSL, infection prevention, partograph use including foetal monitoring and newborn care including early breastfeeding, thermal care at birth and prevention of ophthalmia neonatorum was offered by 5% of dispensaries, 38% of health centres and 50% of hospitals consistently. No first-line facility had provided all signal functions for emergency obstetric complications in the previous six months. Essential interventions for childbirth care are not routinely implemented in first-line facilities or hospitals. Dispensaries have both low staffing and low caseload which constraints the ability to provide high-quality childbirth care. Improvements in quality of care are essential so that women delivering in facility receive "skilled attendance" and adequate care for common obstetric complications such as post-partum haemorrhage

The use of antenatal and postnatal care: perspectives and experiences of women and health care providers in rural southern Tanzania

BACKGROUND\ud \ud Although antenatal care coverage in Tanzania is high, worrying gaps exist in terms of its quality and ability to prevent, diagnose or treat complications. Moreover, much less is known about the utilisation of postnatal care, by which we mean the care of mother and baby that begins one hour after the delivery until six weeks after childbirth. We describe the perspectives and experiences of women and health care providers on the use of antenatal and postnatal services.\ud \ud METHODS\ud \ud From March 2007 to January 2008, we conducted in-depth interviews with health care providers and village based informants in 8 villages of Lindi Rural and Tandahimba districts in southern Tanzania. Eight focus group discussions were also conducted with women who had babies younger than one year and pregnant women. The discussion guide included information about timing of antenatal and postnatal services, perceptions of the rationale and importance of antenatal and postnatal care, barriers to utilisation and suggestions for improvement.\ud \ud RESULTS\ud \ud Women were generally positive about both antenatal and postnatal care. Among common reasons mentioned for late initiation of antenatal care was to avoid having to make several visits to the clinic. Other concerns included fear of encountering wild animals on the way to the clinic as well as lack of money. Fear of caesarean section was reported as a factor hindering intrapartum care-seeking from hospitals. Despite the perceived benefits of postnatal care for children, there was a total lack of postnatal care for the mothers. Shortages of staff, equipment and supplies were common complaints in the community.\ud \ud CONCLUSION\ud \ud Efforts to improve antenatal and postnatal care should focus on addressing geographical and economic access while striving to make services more culturally sensitive. Antenatal and postnatal care can offer important opportunities for linking the health system and the community by encouraging women to deliver with a skilled attendant. Addressing staff shortages through expanding training opportunities and incentives to health care providers and developing postnatal care guidelines are key steps to improve maternal and newborn health

Review of the State of Health in Tanzania 2004

\ud The Ministry of Health has mandated an independent review of the State of Health in Tanzania for there the year 2004. The objective was to provide an overview on the health situation in Tanzania, to assess if have been improvements in public health service delivery, to comment on the Tanzanian’s perception of health services, discuss equity in accessing health care, to identify successes and challenges and to provide. The methodology was to utilise existing documented data and other available information. The suggestions for improvements. An international and a national consultant were assigned to undertake the review. list of documents consulted, not always quoted, is in the annexe. In terms of understanding changes in health status, there were few reliable and recent data available at national level. Consequently the consultants were left with data, most of which had already been used in the 2001 review. Main “new” data sources compared to the 2001 State of Health Review were the 2002 Census, data from National Sentinel Sites and recently an in-depth study has been undertaken in 10 districts of Tanzania, as well as the first representative sero-survey published by TACAIDS in 2004. To obtain additional qualitative information 51 interviews with stakeholders were conducted. Health has many determinants, and only a few of these are directly influenced by the health care delivery system. As for the underlying determinants of health, unfortunately many crucial factors in Tanzania have not changed for the better since the last review. Most importantly, poverty is still rampant. Also, the negative consequences of poor school enrolment of girls in the past are only becoming visible as now, as these girls have become women and poor female education is a known determinant of infant health. The fact that the HMIS reports a slight decline in of maternal deaths reported in hospitals does unfortunately not mean that there is really less mortality, because a large proportion of deliveries, particularly in rural areas do not take place in health facilities, and even there skilled assistance is not guaranteed. The close relationship between the density of skilled staff and maternal mortality and the absence of skilled staff in rural areas make it unlikely that the high maternal mortality figures have declined since 2001. The HIV/AIDS prevalence, which was published for the first time in a nationwide representative sample in 2004, is comforting in the sense that the results – a 7% prevalence in the reproductive age group – are lower than feared, on the basis of the surveillance of blood donors. Although 7% (with considerable variation within the country, age groups and sex) is still high and rates HIV/AIDS as a leading cause of mortality of adults for years to come. A widely neglected issue in this context is the increasing number of HIV/AIDS orphans, their number already getting close, if not above 1’000’000. Exact figures are not available. Although this is as much a social as a health problem, the potential negative impact on the health status of these children and adolescents is obvious. A number of health problems do receive only limited attention. A recent study revealed that in at least one of every ten households there is one case of disability. Non-communicable diseases are on the increase and epidemiological transition is most certainly a reality, at least in urban areas. Infant mortality is internationally used to compare the health and well-being of populations across and within countries. The 2002 census data show overall minimal changes for the better. In particular the wide range between Arusha (58/1’000 LB) and Lindi (217/1’000) has not changed. However, there are some encouraging improvements in national sentinel and project sites in terms of reduced IMR/CMR/U-5MR and even maternal mortality, it is at this point in time impossible to tell if the health status of Tanzanians has substantially improved since the last review and one will have to wait for the results of the DHS 2005 to see if the long-term trend of a declining IMR/CMR/U-5MR, which has started in 1978, has continued. The data availability is better as far as the health systems input situation is concerned, as annual reviews both for health sector performance as well as for the overarching goal of poverty reduction are taking place. There is a wide consensus amongst directly involved stakeholders and development partners that the performance of the health system has improved, although it is still a patchy progress. It is obvious that the funding situation has improved substantially, although it is still far away from the recommended figures by the Macroeconomic Commission on Health. The human resource crisis is becoming increasingly urgent, particularly in the context of starting scale-up of ARV treatment and also in terms of reaching skilled birth attendance targets, which will require a substantial increase in human resources for health. Little is known about the professional quality of care, but misdiagnosing of severe malaria seems to be common, and might be only the tip of the iceberg, possibly hiding a dark picture. Findings are not conclusive. A recent study in ten districts found very high positive approval, even though certain complaints were documented. These results are in stark contrast to other studies, which paint a rather bleak image of user-unfriendly health services, where corruption is not uncommon. Policies are in place to promote equity in accessing health care, but reality still has a long way to go before reaching the ambitious goals. Exemption schemes are far from being functional and there is evidence that the poor have difficulties in accessing health facilities. There is also ample evidence of gender imbalances, such as early childbearing, early onset of sexual activity and early marriages, Female Genital Mutilation is widespread, and despite being unlawful the practice to force pregnant girls out of school is frequent. There are numerous achievements of the health care delivery system. This review could not deliver a ranking of successes, but just highlight on the basis of stakeholders and development partners’ comments a few success stories: TB-control programme is a success, IMCI has shown impact and the potential for rapid gains in survival rates. In general terms the planning capacity of the various stakeholders, particularly at district level has improved and in particular the burden of disease focussed planning has shown impact, and contributed to the decrease of IMR/CMR/U-5MR in the NSS. The commitment of the GoT to health sector reform and the continued donor support to Tanzania is commendable Improving maternal, newborn and child health (MNCH) in all its facets is in spite of achievements through ICMI a challenge ahead. HIV/AIDS morbidity and mortality is and will be on the top of the agenda. However, in addition to these major challenges, “neglected” diseases and non-communicable health problems will require attention. This will be closely linked to the human resource crisis, which is already a reality today, for example in the field of obstetrical care, but which will be further aggravated through the human resource requirements of the treatment and care programmes. Quality of care needs improvement, and linked to it, is the strengthening of health information systems, including the maintenance of the NSS. Two challenges, for the present and the future, which need strong improvements, but which go beyond the health sector are good governance and equity. It is not conclusive if health has really improved in Tanzania since the last review. However, taking a positive attitude there have probably been improvements in infant mortality rates, even though it is not clear to what extent these improvements documented in the national sentinel sites reflect also the situation at national level. Even though shortcomings persist, the health care delivery system is in better shape than before. A drop of bitterness remains issues related to equity and gender balance, where there is still major room for improvement. The consultants do not claim to have obtained a comprehensive overview of the Tanzanian health system and suggest therefore only with modesty to focus on three areas: The human resource crisis in the health sector needs urgent attention and fast and concerted action. The human resource crisis is an example where joint action across sectors is necessary to find a solution. Without the necessary human resources not much progress in health service delivery will be achieved in the future and in particular in terms of achieving the “health” - MDGs. However, it is acknowledged that solving this problem goes beyond the MoH and the Ministry of Education, and includes a variety of governmental and non-governmental stakeholders The burden of disease approach in setting priorities should certainly be pursued, and it has been shown to be an impressive success in a number of districts. However, there are some health problems (non communicable diseases, neglected diseases) not fully covered by these exercises, and which should not be neglected and should receive more attention. Health status cannot be influenced without addressing basic questions of equity in access to health services. Improvements in the area of removing financial barriers are important, but equally important are gender-related barriers, and it is crucial that efforts should be strengthened to abolish these barriers If another “State of Health Review” should be anticipated in the future, it is strongly recommended to have it timed to the availability of a major new set of health information, such as a DHS or a \ud Census exercise

Timing of antenatal care for adolescent and adult pregnant women in south-eastern Tanzania

Early and frequent antenatal care attendance during pregnancy is important to identify and mitigate risk factors in pregnancy and to encourage women to have a skilled attendant at childbirth. However, many pregnant women in sub-Saharan Africa start antenatal care attendance late, particularly adolescent pregnant women. Therefore they do not fully benefit from its preventive and curative services. This study assesses the timing of adult and adolescent pregnant women's first antenatal care visit and identifies factors influencing early and late attendance.\ud The study was conducted in the Ulanga and Kilombero rural Demographic Surveillance area in south-eastern Tanzania in 2008. Qualitative exploratory studies informed the design of a structured questionnaire. A total of 440 women who attended antenatal care participated in exit interviews. Socio-demographic, social, perception- and service related factors were analysed for associations with timing of antenatal care initiation using regression analysis. The majority of pregnant women initiated antenatal care attendance with an average of 5 gestational months. Belonging to the Sukuma ethnic group compared to other ethnic groups such as the Pogoro, Mhehe, Mgindo and others, perceived poor quality of care, late recognition of pregnancy and not being supported by the husband or partner were identified as factors associated with a later antenatal care enrolment (p < 0.05). Primiparity and previous experience of a miscarriage or stillbirth were associated with an earlier antenatal care attendance (p < 0.05). Adolescent pregnant women started antenatal care no later than adult pregnant women despite being more likely to be single. Factors including poor quality of care, lack of awareness about the health benefit of antenatal care, late recognition of pregnancy, and social and economic factors may influence timing of antenatal care. Community-based interventions are needed that involve men, and need to be combined with interventions that target improving the quality, content and outreach of antenatal care services to enhance early antenatal care enrolment among pregnant women

Antenatal care in practice: an exploratory study in antenatal care clinics in the Kilombero Valley, south-eastern Tanzania

BACKGROUND: The potential of antenatal care for reducing maternal morbidity and improving newborn survival and health is widely acknowledged. Yet there are worrying gaps in knowledge of the quality of antenatal care provided in Tanzania. In particular, determinants of health workers' performance have not yet been fully understood. This paper uses ethnographic methods to document health workers' antenatal care practices with reference to the national Focused Antenatal Care guidelines and identifies factors influencing health workers' performance. Potential implications for improving antenatal care provision in Tanzania are discussed. METHODS: Combining different qualitative techniques, we studied health workers' antenatal care practices in four public antenatal care clinics in the Kilombero Valley, south-eastern Tanzania. A total of 36 antenatal care consultations were observed and compared with the Focused Antenatal Care guidelines. Participant observation, informal discussions and in-depth interviews with the staff helped to identify and explain health workers' practices and contextual factors influencing antenatal care provision. RESULTS: The delivery of antenatal care services to pregnant women at the selected antenatal care clinics varied widely. Some services that are recommended by the Focused Antenatal Care guidelines were given to all women while other services were not delivered at all. Factors influencing health workers' practices were poor implementation of the Focused Antenatal Care guidelines, lack of trained staff and absenteeism, supply shortages and use of working tools that are not consistent with the Focused Antenatal Care guidelines. Health workers react to difficult working conditions by developing informal practices as coping strategies or "street-level bureaucracy". CONCLUSIONS: Efforts to improve antenatal care should address shortages of trained staff through expanding training opportunities, including health worker cadres with little pre-service training. Attention should be paid to the identification of informal practices resulting from individual coping strategies and "street-level bureaucracy" in order to tackle problems before they become part of the organizational culture

Tanzania HIV/AIDS and Malaria Indicator Survey\ud 2007-08\ud

HIV/AIDS, Malaria, Tanzania, anti malaria, Treatmen