Stagnating maternal mortality in Tanzania: what went wrong and what can be done

Background: This paper presents and analyses the trend of maternal mortality ratio in Tanzania against major events, policy, economic and political decisions which may have influenced this trend. The impact of several initiatives related to Health Systems Strengthening are discussed and alternative strategies for effective maternal mortality reduction in Tanzania are proposed.Methods: We reviewed data and information published on maternal mortality and relevant political decisions, policies programmes and guidelines on maternal and new-born for Tanzania from 1990 to 2016. We examined the timeline of economic development, political decisions and other major events going back 5-10 years before the possible stagnation of maternal mortality decline.Results: This period coincides with the Health Sector Reforms which included among other things the introduction of user fees, reintroduction of private practice, staff retrenchment, widening inequalities and growing poverty. Health service factors include persistent low coverage and utilization of basic emergency obstetric care services. To address these gaps, we propose strengthening rights-based approaches in maternal health programming with political, financial and performance accountabilities at all levels. Introducing these will themselves help with improvement of the quality of care and address the issues of equity by reaching even the poorest households. We further propose application of process indicators to monitor maternal care services. Skilled care should be adopted as the single most important indicator for improving emergency obstetric care. There is need to review the legal and policy framework on task shifting to allow nurses to deliver the seven signal functions and Assistant Medical Officers to deliver Comprehensive Emergency Obstetric Care.Conclusion: We conclude that greater effort needs to be put in designing heath strengthening systems that address more the demand side of health systems strengthening as opposed to current efforts which are largely supply oriented

Sickle cell disease in pregnancy

Structural and quantitative changes at the polypeptide chains of haemoglobin lead to defective red blood cells with a life span 1/5th of the normal, a much smaller capacity of oxygen saturation, and a less pliable structure that easily deforms in situations of hypoxia, stress, acidosis, dehydration, cold and prolonged physical effort etc. Multi-organ vaso-occlusion and hypoxia ensues, causing severe bone pains, sequestration, infarction and anaemia. Increased physiologic demands of pregnancy, aggravate falciformation resulting to poor perfusion of the placenta predisposing to preterm pregnancy loss, intrauterine growth retardation, pre-eclampsia, severe anaemia and increased perinatal and maternal morbidity and mortality. Urinary tract, respiratory and bone infections, as well as cardiac and neurologic complications are common. Treatment is preventive and symptomatic. It aims at reducing high risk combinations, and a meticulous follow-up to prevent the woman from developing complications and not dying from these complications. Though vasso-occlusive pain crises and severe anaemia may be fatal they may be remedied by generous use of analgesics, adequate hydration and exchange transfusion. Sickle cell anaemia the most common of the three major haemoglobinopathies is more frequent with individuals of African descent, haemoglobin C is more predominant in the coast of Africa west of the river Niger while alpha thalassemia and beta thalassemia haemoglobin are frequent in the Mediterranean and Southeast Asian countries respectively. Keywords: sickle cell anaemia, haemoglobin S, haemoglobin, thalassemia haemoglobin, haemoglobinopathy, pregnancy, vaso-occlusion, bone pain crises, exchange transfusion Clinics in Mother and Child Health Vol. 1(1) 2004: 53-6

Modeling solutions to Tanzania's physician workforce challenge.

BACKGROUND:There is a great need for physicians in Tanzania. In 2012, there were approximately 0.31 physicians per 10,000 individuals nationwide, with a lower ratio in the rural areas, where the majority of the population resides. In response, universities across Tanzania have greatly increased the enrollment of medical students. Yet evidence suggests high attrition of medical graduates to other professions and emigration from rural areas where they are most needed. OBJECTIVE:To estimate the future number of physicians practicing in Tanzania and the potential impact of interventions to improve retention, we built a model that tracks medical students from enrollment through clinical practice, from 1990 to 2025. DESIGN:We designed a Markov process with 92 potential states capturing the movement of 25,000 medical students and physicians from medical training through employment. Work possibilities included clinical practice (divided into rural or urban, public or private), non-clinical work, and emigration. We populated and calibrated the model using a national 2005/2006 physician mapping survey, as well as graduation records, graduate tracking surveys, and other available data. RESULTS:The model projects massive losses to clinical practice between 2016 and 2025, especially in rural areas. Approximately 56% of all medical school students enrolled between 2011 and 2020 will not be practicing medicine in Tanzania in 2025. Even with these losses, the model forecasts an increase in the physician-to-population ratio to 1.4 per 10,000 by 2025. Increasing the absorption of recent graduates into the public sector and/or developing a rural training track would ameliorate physician attrition in the most underserved areas. CONCLUSIONS:Tanzania is making significant investments in the training of physicians. Without linking these doctors to employment and ensuring their retention, the majority of this investment in medical education will be jeopardized

Can training in advanced clinical skills in obstetrics, neonatal care and leadership, of non-physician clinicians in Malawi impact on clinical services improvements (the ETATMBA project) : a process evaluation

Objectives The ‘enhancing human resources and the use of appropriate technologies for maternal and perinatal survival in sub-Saharan Africa’ (ETATMBA) project is training emergency obstetric and new-born care (EmONC) non-physician clinicians (NPCs) as advanced clinical leaders. Our objectives were to evaluate the implementation and changes to practice. Design A mixed methods process evaluation with the predominate methodology being qualitative. Setting Rural and urban hospitals in 8 of the 14 districts of northern and central Malawi. Participants 54 EmONC NPCs with 3 years’ plus experience. Intervention Training designed and delivered by clinicians from the UK and Malawi; it is a 2-year plus package of training (classroom, mentorship and assignments). Results We conducted 79 trainee interviews over three time points during the training, as well as a convenience sample of 10 colleagues, 7 district officers and 2 UK obstetricians. Trainees worked in a context of substantial variation in the rates of maternal and neonatal deaths between districts. Training reached trainees working across the target regions. For 46 trainees (8 dropped out of the course), dose delivered in terms of attendance was high and all 46 spent time working alongside an obstetrician. In early interviews trainees recalled course content unprompted indicating training had been received. Colleagues and district officers reported cascading of knowledge and initial changes in practice indicating early implementation. By asking trainees to describe actual cases we found they had implemented new knowledge and skills. These included life-saving interventions for postpartum haemorrhage and eclampsia. Trainees identified the leadership training as enabling them to confidently change their own practice and initiate change in their health facility. Conclusions This process evaluation suggests that trainees have made positive changes in their practice. Clear impacts on maternal and perinatal mortality are yet to be elucidated

Modeling solutions to Tanzania's physician workforce challenge

Background: There is a great need for physicians in Tanzania. In 2012, there were approximately 0.31 physicians per 10,000 individuals nationwide, with a lower ratio in the rural areas, where the majority of the population resides. In response, universities across Tanzania have greatly increased the enrollment of medical students. Yet evidence suggests high attrition of medical graduates to other professions and emigration from rural areas where they are most needed. Objective: To estimate the future number of physicians practicing in Tanzania and the potential impact of interventions to improve retention, we built a model that tracks medical students from enrollment through clinical practice, from 1990 to 2025. Design: We designed a Markov process with 92 potential states capturing the movement of 25,000 medical students and physicians from medical training through employment. Work possibilities included clinical practice (divided into rural or urban, public or private), non-clinical work, and emigration. We populated and calibrated the model using a national 2005/2006 physician mapping survey, as well as graduation records, graduate tracking surveys, and other available data. Results: The model projects massive losses to clinical practice between 2016 and 2025, especially in rural areas. Approximately 56% of all medical school students enrolled between 2011 and 2020 will not be practicing medicine in Tanzania in 2025. Even with these losses, the model forecasts an increase in the physician-to-population ratio to 1.4 per 10,000 by 2025. Increasing the absorption of recent graduates into the public sector and/or developing a rural training track would ameliorate physician attrition in the most underserved areas. Conclusions: Tanzania is making significant investments in the training of physicians. Without linking these doctors to employment and ensuring their retention, the majority of this investment in medical education will be jeopardized

Variations of HIV and STI prevalences within communities neighbouring new goldmines in Tanzania: importance for intervention design.

OBJECTIVES: To measure the prevalence of HIV and other STIs in communities neighbouring new large scale gold mines in northern Tanzania in order to inform the design of a targeted HIV/STI intervention programme. METHODS: Cross sectional surveys were conducted in adults aged 16-54 years from different sectors of communities neighbouring two newly opened, large scale gold mines near Lake Victoria. Mine workers, men, women, and female food and recreational facility workers (FRFW) from the community were randomly selected for interview and HIV and STI testing. RESULTS: 207 male Tanzanian mine workers, 206 FRFW, 202 other male and 205 female community members were enrolled. Overall, 42% of FRFW were HIV positive, compared to 6% of male mine workers, and 16% and 18% of other community men and women respectively. HIV prevalence in FRFW was significantly associated with alcohol consumption (adjusted odds ratio (aOR) = 2.5, 95% confidence interval (CI) 1.1 to 5.5), past or present syphilis (TPPA+) (aOR = 2.7, 95% CI 1.4 to 5.1) and single status (aOR = 3.8, 95% CI 1.2 to 11.9). Among FRFW, 24% had active syphilis (RPR+, TPPA+), 9% Chlamydia trachomatis, and 4% Neisseria gonorrhoeae. Overall, 50% of FRFW and 50% of community men never used condoms during sex, and 55% mineworkers, 61% male, and 20% female community members reported receiving/giving payment for sex during the previous year. CONCLUSIONS: There is a high prevalence of HIV and other STIs in communities around new goldmines in Tanzania, especially in FRFW. HIV and STI prevalence in the mining workforce is still relatively low, but high risk sexual behaviour is reported by all adult subgroups surveyed in this study. Programmes focusing on HIV/STI prevention, with targeted interventions for high risk women such as FRFW, will be extremely important in such high transmission communities where there is substantial recent in-migration of men and women seeking work. Such programmes have recently been initiated by a private/public/NGO partnership