\ud Tanzania Health Insurance Regulatory Framework Review\ud

Make sure that current policy objectives – achieving universal coverage, social health protection, good governance and cost-containment – are reflected in the relevant legislative documents, and provide the requisite legal tools, reflecting the chosen policy options and the institutional consequences of those options. Consider reducing the fragmentation of the health financing legislation which reflects the current fragmentation in health financing and in governance and oversight of the health financing and insurance systems. Develop an explicit policy on competition in health financing to close the current gaps in legislation and to prevent the possibly negative side effects for Tanzania citizens of such competition in the event that the Government of Tanzania (GOT) opts for a competition-based model of health financing. The model ultimately chosen will have consequences not only for health financing practise, but also for the relevant legislation. Consider the establishment of an independent accreditation body for external assessment and gradual improvement of the quality of care of all health services providers, regardless of their sources of financing. Plug the identified gaps in single enactments which can be done without embarking on any big policy changes. The latter can be included in the development of a planned National Health Financing Strategy. During this development process, it will be possible to focus on specific areas of interest and make detailed recommendations. After national adoption of the strategy, new legislation will have to be drawn up.\ud \u

Correlates of Out-of-Pocket and Catastrophic Health Expenditures in Tanzania: Results from a National Household Survey.

Inequality in health services access and utilization are influenced by out-of-pocket health expenditures in many low and middle-income countries (LMICs). Various antecedents such as social factors, poor health and economic factors are proposed to direct the choice of health care service use and incurring out-of-pocket payments. We investigated the association of these factors with out-of-pocket health expenditures among the adult and older population in the United Republic of Tanzania. We also investigated the prevalence and associated determinants contributing to household catastrophic health expenditures. We accessed the data of a multistage stratified random sample of 7279 adult participants, aged between 18 and 59 years, as well as 1018 participants aged above 60 years, from the first round of the Tanzania National Panel survey. We employed multiple generalized linear and logistic regression models to evaluate the correlates of out-of-pocket as well as catastrophic health expenditures, accounting for the complex sample design effects. Increasing age, female gender, obesity and functional disability increased the adults' out-of-pocket health expenditures significantly, while functional disability and visits to traditional healers increased the out-of-pocket health expenditures in older participants. Adult participants, who lacked formal education or worked as manual laborers earned significantly less (p < 0.001) and spent less on health (p < 0.001), despite having higher levels of disability. Large household size, household head's occupation as a manual laborer, household member with chronic illness, domestic violence against women and traditional healer's visits were significantly associated with high catastrophic health expenditures. We observed that the prevalence of inequalities in socioeconomic factors played a significant role in determining the nature of both out-of-pocket and catastrophic health expenditures. We propose that investment in social welfare programs and strengthening the social security mechanisms could reduce the financial burden in United Republic of Tanzania

‘Mind the Gap’: Reconnecting Local Actions and Multi-Level Policies to Bridge the Governance Gap. An Example of Soil Erosion Action from East Africa

Achieving change to address soil erosion has been a global yet elusive goal for decades. Efforts to implement effective solutions have often fallen short due to a lack of sustained, context-appropriate and multi-disciplinary engagement with the problem. Issues include prevalence of short-term funding for ‘quick-fix’ solutions; a lack of nuanced understandings of institutional, socio-economic or cultural drivers of erosion problems; little community engagement in design and testing solutions; and, critically, a lack of traction in integrating locally designed solutions into policy and institutional processes. This paper focusses on the latter issue of local action for policy integration, drawing on experiences from a Tanzanian context to highlight the practical and institutional disjuncts that exist; and the governance challenges that can hamper efforts to address and build resilience to soil erosion. By understanding context-specific governance processes, and joining them with realistic, locally designed actions, positive change has occurred, strengthening local-regional resilience to complex and seemingly intractable soil erosion challenges.</jats:p

Drivers of increased soil erosion in East Africa’s agro-pastoral systems: changing interactions between the social, economic and natural domains

This is the final version. Available on open access from Springer via the DOI in this recordIncreased soil erosion is one of the main drivers of land degradation in East Africa’s agricultural and pastoral landscapes. This wicked problem is rooted in historic disruptions to co-adapted agro-pastoral systems. Introduction of agricultural growth policies by centralised governance resulted in temporal and spatial scale mismatches with the complex and dynamic East African environment, which subsequently contributed to soil exhaustion, declining fertility and increased soil erosion. Coercive policies of land use, privatisation, sedentarisation, exclusion and marginalisation led to a gradual erosion of the indigenous social and economic structures. Combined with the inability of the new nation-states to provide many of the services necessary for (re)developing the social and economic domains, many communities are lacking key components enabling sustainable adaptation to changing internal and external shocks and pressures. Exemplary is the absence of growth in agricultural productivity and livelihood options outside of agriculture, which prohibits the absorption of an increasing population and pushes communities towards overexploitation of natural resources. This further increases social and economic pressures on ecosystems, locking agro-pastoral systems in a downward spiral of degradation. For the development and implementation of sustainable land management plans to be sustainable, authorities need to take the complex drivers of increased soil erosion into consideration. Examples from sustainable intensification responses to the demands of population increase, demonstrate that the integrity of locally adapted systems needs to be protected, but not isolated, from external pressures. Communities have to increase productivity and diversify their economy by building upon, not abandoning, existing linkages between the social, economic and natural domains. Locally adapted management practices need to be integrated in regional, national and supra-national institutions. A nested political and economic framework, wherein local communities are able to access agricultural technologies and state services, is a key prerequisite towards regional development of sustainable agro-pastoral systems that safeguard soil health, food and livelihood security.Natural Environment Research Council (NERC)British Academ

Soil erosion in East Africa: an interdisciplinary approach to realising pastoral land management change

This is the author accepted manuscript. The final version is available from IOP Publishing via the DOI in this record.Implementation of socially acceptable and environmentally desirable solutions to soil erosion challenges is often limited by (1) fundamental gaps between the evidence bases of different disciplines and (2) an implementation gap between science-based recommendations, policy makers and practitioners. We present an integrated, interdisciplinary approach to support co24 design of land management policy tailored to the needs of specific communities and places in degraded pastoral land in the East African Rift System. In a northern Tanzanian case study site, hydrological and sedimentary evidence shows that, over the past two decades, severe drought and increased livestock have reduced grass cover, leading to surface crusting, loss of soil aggregate stability, and lower infiltration capacity. Infiltration excess overland flow has driven (a) sheet wash erosion, (b) incision along convergence pathways and livestock tracks, and (c) gully development, leading to increased hydrological connectivity. Stakeholder interviews in associated sedenterising Maasai communities identified significant barriers to adoption of soil conservation measures, despite local awareness of problems. Barriers were rooted in specific pathways of vulnerability, such as a strong cattle-based cultural identity, weak governance structures, and a lack of resources and motivation for community action to protect shared land. At the same time, opportunities for overcoming such barriers exist, through openness to change and appetite for education and participatory decision-making. Guided by specialist knowledge from natural and social sciences, we used a participatory approach that enabled practitioners to start co-designing potential solutions, increasing their sense of efficacy and willingness to change practice. This approach, tested in East Africa, provides a valuable conceptual model around which other soil erosion challenges in the Global South might be addressed.The authors gratefully acknowledge funding from the Research Councils UK [now UK Research and Innovation] Global Challenges Research Fund (GCRF) grant NE/P015603/1, European Commission H2020-MSCA-RISE-2014 IMIXSED project (ID 644320) and UK Natural Environment Research Council Grant NE/R009309/1 and the support of Joint UN FAO/IAEA Coordinated Research Programme CRP D1.50.17

Patient and provider delay in tuberculosis suspects from communities with a high HIV prevalence in South Africa: A cross-sectional study

BACKGROUND: Delay in the diagnosis of tuberculosis (TB) results in excess morbidity and mortality, particularly among HIV-infected individuals. This study was conducted at a secondary level hospital serving communities with a high HIV prevalence in Cape Town, South Africa. The aim was to describe patient and provider delay in the diagnosis of TB in patients with suspected TB requiring admission, and to determine the risk factors for this delay and the consequences. METHODS: A cross-sectional study was conducted. Patients admitted who were TB suspects were interviewed using a structured questionnaire to assess history of their symptoms and health seeking behaviour. Data regarding TB diagnosis and outcome were obtained from the medical records. Bivariate associations were described using student's T-tests (for means), chi-square tests (for proportions), and Wilcoxon rank-sum tests (for medians). Linear regression models were used for multivariate analysis. RESULTS: One hundred twenty-five (125) patients were interviewed. In 104 TB was diagnosed and these were included in the analysis. Seventy of 83 (84%) tested were HIV-infected. Provider delay (median = 30 days, interquartile range (IQR) = 10.3-60) was double that of patient delay (median = 14 days, IQR = 7-30). Patients had a median of 3 contacts with formal health care services before referral. Factors independently associated with longer patient delay were male gender, cough and first health care visit being to public sector clinic (compared with private general practitioner). Patient delay [greater than or equal to] 14 days was associated with increased need for transfer to a TB hospital. Provider delay [greater than or equal to] 30 days was associated with increased mortality. CONCLUSION: Delay in TB diagnosis was more attributable to provider than patient delay, and provider delay was associated with increased mortality. Interventions to expedite TB diagnosis in primary care need to be developed and evaluated in this setting

Priority setting for the implementation of artemisinin-based combination therapy policy in Tanzania: evaluation against the accountability for reasonableness framework

\ud Priority setting for artemisinin-based antimalarial drugs has become an integral part of malaria treatment policy change in malaria-endemic countries. Although these drugs are more efficacious, they are also more costly than the failing drugs. When Tanzania changed its National Malaria Treatment Policy in 2006, priority setting was an inevitable challenge. Artemether-lumefantrine was prioritised as the first-line drug for the management of uncomplicated malaria to be available at a subsidized price at public and faith-based healthcare facilities. This paper describes the priority-setting process, which involved the selection of a new first-line antimalarial drug in the implementation of artemisinin-based combination therapy policy. These descriptions were further evaluated against the four conditions of the accountability for easonableness framework. According to this framework, fair decisions must satisfy a set of publicity, relevance, appeals, and revision and enforcement conditions.In-depth interviews were held with key informants using pretested interview guides, supplemented with a review of the treatment guideline. Purposeful sampling was used in order to explore the perceptions of people with different backgrounds and perspectives. The analysis followed an editing organising style. Publicity: The selection decision of artemether-lumefantrine but not the rationale behind it was publicised through radio, television, and newspaper channels in the national language, Swahili. Relevance: The decision was grounded on evidences of clinical efficacy, safety, affordability, and formulation profile. Stakeholders were not adequately involved. There was neither an appeals mechanism to challenge the decision nor enforcement mechanisms to guarantee fairness of the decision outcomes. The priority-setting decision to use artemether-lumefantrine as the first-line antimalarial drug failed to satisfy the four conditions of the accountability for reasonableness framework. In our understanding, this is the first study to evaluate priority-setting decisions for new drugs in Tanzania against the accountability for reasonableness framework. In addition to the demand for enhanced stakeholder involvement, publicity, and transparency, the study also calls for the institution of formal appeals, revision, and regulatory mechanisms in the future change of malaria treatment policies.\u