Efficiency of antenatal care and childbirth services in selected primary health care facilities in rural Tanzania : a cross-sectional study

Background: Cost studies are paramount for demonstrating how resources have been spent and identifying opportunities for more efficient use of resources. The main objective of this study was to assess the actual dimension and distribution of the costs of providing antenatal care (ANC) and childbirth services in selected rural primary health care facilities in Tanzania. In addition, the study analyzed determining factors of service provision efficiency in order to inform health policy and planning. Methods: This was a retrospective quantitative cross-sectional study conducted in 11 health centers and dispensaries in Lindi and Mtwara rural districts. Cost analysis was carried out using step down cost accounting technique. Unit costs reflected efficiency of service provision. Multivariate regression analysis on the drivers of observed relative efficiency in service provision between the study facilities was conducted. Reported personnel workload was also described. Results: The health facilities spent on average 7 USD per capita in 2009. As expected, fewer resources were spent for service provision at dispensaries than at health centers. Personnel costs contributed a high approximate 44% to total costs. ANC and childbirth consumed approximately 11% and 12% of total costs; and 8% and 10% of reported service provision time respectively. On average, unit costs were rather high, 16 USD per ANC visit and 79.4 USD per childbirth. The unit costs showed variation in relative efficiency in providing the services between the health facilities. The results showed that efficiency in ANC depended on the number of staff, structural quality of care, process quality of care and perceived quality of care. Population-staff ratio and structural quality of basic emergency obstetric care services highly influenced childbirth efficiency. Conclusions: Differences in the efficiency of service provision present an opportunity for efficiency improvement. Taking into consideration client heterogeneity, quality improvements are possible and necessary. This will stimulate utilization of ANC and childbirth services in resource-constrained health facilities. Efficiency analyses through simple techniques such as measurement of unit costs should be made standard in health care provision, health managers can then use the performance results to gauge progress and reward efficiency through performance based incentives

Scaling land and water technologies in Tanzania: Opportunities, challenges and policy implications

The scaling of land and water technologies has widely increased across different parts of the world; and is recognized as important for ecological systems. These technologies contribute to sustainable management of watersheds on which agriculture, food production and rural livelihoods for most developing communities depend upon. There are ongoing efforts designed to halt land degradation in the Western Usambara which have arisen from pressure on land resources mainly caused by demographic growth, deforestation and the abandoning of the traditional regenerative land use and farming systems. Socio-cultural and economic factors such as education level, age, gender, and land tenure, marital status and income earnings of smallholder farmers are factors considered important in the adoption of land and water management practices. Environmental factors were also identified as limiting factors to smallholder farmers in soil-water management practices. Such factors involved physical distance, slope, type of crops grown and farm sizes. Insecure land tenure especially among women limits their adoption of the technologies. Technological complexity of the technology (farmers prefer technology that are less complex and easier to use), preference for less labor intensive technology, required capital, land ownership (less adoption in new technology on hired/leased land), approach of introducing the technology (preference of participatory bottom up approach), and motivation and the involvement of farmers from conceptualization to implementation are factors that impact adoption of technologies between farmers. Unsustainable cultivation in catchments and destruction of water sources in Tanzania is limiting the flow of water on which some of water use technologies directly depend. In some areas where farmers and pastoralists co-exist, conflicts always arise from grazing on farmland, with destruction to water infrastructure. In recognition of the need for sustainable management of land and water, and the increasing conflicts over use of resources by different sectors, Tanzania has enacted several policies. The irrigation policy calls for the improvement of irrigation water use efficiency and effectiveness by promoting closed conduit systems and high efficiency methods such as drip irrigation and promotion of efficient water utilization technologies such as the System of Rice Intensification. There is need for harmonization and linkage of land and water management and the policies to avoid conflicts. Whereas for example the customary land law recognizes the right to land entailing some resources therewith, the water law does not recognize such customary right by granting the ownership right to water by the owner of land on which the water resource is found. There is need for adequate mechanisms for enforcing policies, regulations and by-laws. Local water governance institutions such as water user associations are important for sustainable scaling of land and water technologies. Horizontal and vertical scaling of the land and water technologies depends on factors such as facilitation of registration of water user associations and empowering them; implementing projects based on actual ground conditions for ease of adoption by communities; and involvement of the local government. Strengthening linkages between relevant institutions and their respective roles and responsibilities also require to be clearly defined. Promotion of land and water technologies should not be gender-blind but rather ensure participation of women and youth in the training and implementation. An integrated systems approach is needed to address the multi-faceted challenges in sustainable land and water management, and a focus on the entire value chain activities; from input supply to output market

Children in an Urban Tanzania

One in four children being born in today‟s Tanzania is likely to be growing up in an urban area. It is projected to be one in three in the short time span of one generation. Tanzania is more urban than it perceives itself and official figures disclose. Urban Tanzanians feel emotionally rooted in their villages of origin rather than in the cities and towns where one quarter of the total population lives. Urbanisation figures fail to account for extensive high density areas just because they are not officially classified as urban. Despite a persisting rural self-representation, Tanzania is one of the fastest urbanising countries in one of the world‟s fastest urbanising regions. The nearly half urban population aged 0-18 may well be the first truly urbanised generation in the history of the nation.\ud As urbanisation is rapidly transforming the physical, social and economic landscape of the country, how has Tanzania equipped itself to provide adequate water, sanitation, health care, education, protection services to meet the fundamental needs and rights of a swelling number of urban children and communities? National policy and programmatic frameworks still broadly target rural poverty, perceived as the nation‟s core development challenge. Urban poverty, growing alongside urban affluence, remains mainly unaccounted for and, as a result, unaddressed. The condition of poor and marginalised urban groups escapes official urban figures. Standard urban-rural disaggregation generates statistical averages that overshadow sub-municipal disparities. Also poverty lines tend to underestimate actual poverty. Based on mere consumption levels, they disregard living conditions, thus leaving unaccounted for several necessities that poor households are normally forced to acquire through cash purchases in a monetised urban economy. As a result, urban poverty is broadly overlooked and poor urban children, lost in skewed official estimates and tucked away in peripheral unplanned urban fringes, risk remaining invisible in development policy and investments. In-depth analysis based on sub-municipal data is urgently needed to accurately measure urban poverty in its multiple dimensions of income poverty, inadequate access to basic services and powerlessness.\ud The assumption underpinning the limited attention that has been paid to urban poverty is that of an urban advantage. Undoubtedly, cities enjoy an edge over rural areas. Urbanisation drives the development of a whole nation. High population concentration, economies of scale, proximity and agglomeration make cities engines of growth. They offer greater avenues for livelihood and education, and should be expected to afford children better opportunities for survival, growth and development than rural areas. Better economic resources and political visibility hold a potential to offer higher incomes and enhance the scope for the government and the private sector to fund services and infrastructure. Density, favouring economies of scale, promises to favour delivering of essential services.\ud Children, adolescents and youth are attracted to city life, aspiring to access better jobs, higher education and a richer cultural life. Urban areas are also hubs of technological innovation, social exchange and mass communication. Urban children can draw from resources that are denied to rural peers.\ud The urban advantage, however, is being eroded. Provision of social services and infrastructure is failing to keep pace with growing demand being generated by urbanisation.\ud  Availability of basic services, expected to be markedly higher in urban centres as compared to remote rural areas, has been declining. Decreasing urban access to improved sources of drinking water over the past decade epitomises this trend. The traditional urban – rural social sector performance gap has been narrowing against most indicators in the areas of education, health, nutrition, water and sanitation. In some cases gaps have been actually bridged and rural areas are even outperforming urban centres.\ud 7\ud  As urban social sector performance is declining, it is likely that it is the poor, underserviced communities to remain unreached. Although statistical averages prevent any level of sub-municipal analysis, limited data available on access to basic services and health and education outcomes in low-income urban communities suggests that the urban poor may be faring even worse than their rural counterparts.\ud  Urbanisation growth is projected to continue in the future. If the present scenarios are not going to be addressed now, they are likely to deteriorate further. As density increases and unplanned settlements become more congested, investments in social facilities and infrastructure can only be expected to become costlier, both financially and socially.\ud If not properly leveraged, the potential advantage that cities offer can turn into a disadvantage. A concentration of children in areas where services and infrastructure are lacking is a major disadvantage. Children residing in overcrowded and degraded settlements characterised by poorly managed sanitation systems, inadequate provision of safe water, inefficient solid waste management are faced with one of the most life-threatening environments possible – with climate change posed to increase vulnerability further. Such a disadvantage can be daunting in a situation where the overwhelming majority of urban dwellers reside in unplanned settlements, which in Tanzania‟s primate city, Dar es Salaam, are estimated to accommodate over 80 percent of the population, one of the highest proportions in Sub-Saharan Africa.\ud Availability and access are not synonymous. In most cities, availability of basic services does not translate necessarily into access. Higher quality and availability of services needs to be equally distributed across social classes and space to achieve equal access by all citizens. The difference between successfully exploiting the urban advantage and passively reeling under the urban disadvantage can be made by the way access to resources is managed. A competent, accountable and equitable system of local governance can make that difference. Good local governance can help overcome the disparities that still bar access by the poor to safe water and sanitation, quality education, adequate health care and nutrition, affordable transport, secure land tenure and decent housing. Accountable local authorities, proactive communities and enabled children are the key actors in a local governance process leading to the creation of cities friendly to children.\ud Young people are already participating in local governance processes. They are active in children‟s municipal councils, children‟s school councils and other similar institutions. Avenues for child participation needs to be strengthened and opened to all children, not only in institutional settings, but also in families and communities having primary responsibility for children‟s well being. Cities and communities provide the most relevant scale for genuine children‟s participation, where young people can effectively engage in addressing the problems that directly affect them.\ud Though universal human rights and global development goals are set at the international and national levels, it is ultimately in a myriad of local Tanzanian communities that they are expected to be fulfilled – in the family, the school, the ward and ultimately the city. The city government offers an ideal platform for converging a plethora of sectoral interventions independently targeting children and delivering them holistically, at the local level where children live. The horizon of children is local. Within the local dimension, children‟s goals and rights can be met and monitored by duty bearers who have primary responsibility for their fulfilment. If development goals and human rights are not implemented locally, they are likely to remain abstract declarations of intent and sterile. Local authorities, communities, families and children together can transform today‟s child unfriendly urban settings into child-friendly cities – as cities friendly to children are friendly to all

Improving Tanzanian childbirth service quality.

Purpose The purpose of this paper is to describe a quality improvement (QI) intervention in primary health facilities providing childbirth care in rural Southern Tanzania. Design/methodology/approach A QI collaborative model involving district managers and health facility staff was piloted for 6 months in 4 health facilities in Mtwara Rural district and implemented for 18 months in 23 primary health facilities in Ruangwa district. The model brings together healthcare providers from different health facilities in interactive workshops by: applying QI methods to generate and test change ideas in their own facilities; using local data to monitor improvement and decision making; and health facility supervision visits by project and district mentors. The topics for improving childbirth were deliveries and partographs. Findings Median monthly deliveries increased in 4 months from 38 (IQR 37-40) to 65 (IQR 53-71) in Mtwara Rural district, and in 17 months in Ruangwa district from 110 (IQR 103-125) to 161 (IQR 148-174). In Ruangwa health facilities, the women for whom partographs were used to monitor labour progress increased from 10 to 57 per cent in 17 months. Research limitations/implications The time for QI innovation, testing and implementation phases was limited, and the study only looked at trends. The outcomes were limited to process rather than health outcome measures. Originality/value Healthcare providers became confident in the QI method through engagement, generating and testing their own change ideas, and observing improvements. The findings suggest that implementing a QI initiative is feasible in rural, low-income settings

Emerging Opportunities For Income Growth At The University Of Dar-Es-Salaam: Private Public Partnership Development Projects

Tanzania in 1986 went through a reform programme of shifting from central planned to a marketeconomy in that, trade, exchange and interest rates were liberalized and more than half of the 400 parastatals were closed down and/or privatised. In the second round of reforms that took in 1996 included institutional and structural reforms, at this time further transformation to a market economy, public administration and investment in key development sectors (education, health, agriculture, water, roads) took place. Such transformations resulted in increased macroeconomic stability and growth levels averaging 6 percent last year. In line with national reform programme, the University of Dar es Salaam developed a Corporate Strategic Plan 1993-2008 (UDSM, 1994) and revised it in 2004 for the period 2004 to 2013 (UDSM, 2004). The Corporate Strategic Plan categorically states its intention to exploit all areas of strength and opportunities offered by the current institutional and national policies of liberalization. One such an area that both the national and UDSM Corporate Strategic Plan emphasis is the public private partnership (PPP) or public to public collaboration in investment ventures. The University identified five potential group areas of UDSM resources that are worthy of the investors‘ consideration (UDSM, 2001). Chungu (2002) found that land based investments and knowledge/professional skills investments have higher income returns to the UDSM. This paper therefore focuses on land based investments and attempts to demonstrate a successful PPP collaborative venture initiated in May 2002 and charts out its associated factors to such a success. The Mlimani City project is the case on hand while the project on Information Communication Technology Special Economic Zone (ICT-SEZ) is the second forceful coming project initiated in year 2005. These two projects have taken 116 acres of University out of 268 envisaged for investment. The impacts of these two projects to the University and its surrounding communities as well as the nation at large are discussed. The paper concludes with possible challenges that the University have learnt from the Mlimani City project and how those milestones could be useful lessons for ICT-SEZ, a project which is on its infant, and also, to other incoming PPP collaborative investments