Understanding Stakeholders’ Roles in Health Sector Reform Process in Tanzania: The Case of Decentralizing the Immunization Program.

The current need and enthusiasm for health reforms open an important arena for deeper analysis of the policy process with a view to understanding the political determinants of reforms and strengthening implementation. The studies described in this thesis analyse positions of different actors in the reform process, their actions in support or opposition of the process, and their impact on the health sector reform process. Globally and especially in developing countries health sector reforms have been implemented over long periods. Although there have been improvements in health, the remaining burden of disease in many countries is still very high. Reasons for the high burden of disease have been classified into lack of resources and poor organizational and managerial capacity. Good stewardship was needed to facilitate improvement in the performance of health systems. Stakeholders’ alignment and support was one of the most important components of good stewardship. However, stakeholder analysis had not been a common undertaking in developing countries despite the reforms that were being implemented in most of them. It was the aim of this study to answer the question: What has been the role and importance of stakeholders in supporting or opposing the health sector reform process? The study was conducted in Tanzania as one of the poorest countries in Africa, using the decentralization of the Expanded Programme on Immunization (EPI) as a case reference. The study units were the Ministry of Health Headquarters, Medical Stores Department, Expanded Programme on Immunization, national archives, regions and districts. At district level the study units were District Council, Council Health Management Team, EPI managers at regional and district levels, ward and village authorities, health facility, facility providers and households. Qualitative and quantitative methods were used to collect data from January 2000 to June 2002. Relevant data collection instruments were prepared and pre-tested. The qualitative data collection methods included document review, in-depth interviews, key informants interviews and observations. Quantitative methods involved retrieval of secondary data, health facility survey and household surveys. Regular discussions with key informants and data collectors were held to verify the findings. Qualitative data was analysed manually. Quantitative data was captured and analysed using Epi Info version 6.1 and STATA version 6.0. The study involved answering five main questions. The first question was: Do reforms learn from history? Analysis of the waves of health reforms prior to the current reforms from 1926 was done to answer the question. The main stakeholders in the reforms were the political party in power, the government and donors who supported the reforms each time. Each wave of health sector reforms provided information on health provision, financing and resource generation. Due to the political contexts, information on failures of health financing did not provide lessons for succeeding reforms of the health sector. Stakeholders’ political interests opposed lessons that did not match the political ideology at the time i.e. free public services versus privatization and paying for social services. Lessons from previous health reforms were selective, and did not consider health-financing needs among others. The ongoing health reforms needed to use information from all functional aspects of the health system to provide lessons for improving the health system. The second question was: Who were the stakeholders in the current health reforms and what were their interests and reactions? The main stakeholders were donors, and the government. The two had a very high support for the reforms evidenced by their participation in problem identification, justification, reform design, planning and implementation. The health sector reforms thus had high political support at central level. In the implementation process, issues that triggered stakeholders’ reaction included sectoral versus local government decentralization. Another issue was the donor modality in financing the health sector and need for adopting new financial management systems. Among the donors there was hesitancy to join the common financing modalities that included a Sector Wide Approach (SWAp) and Basket Funding. As a result, there was delay in the process in order to reach better consensus. The third question was: What was the impact of stakeholders in the process of reforming a vertical programme like EPI? Health Sector Reforms in EPI included integration of generic functions, for example, vaccine procurement to medical stores department. Qualitative and quantitative data was collected and analysed from the Ministry of Health, EPI management unit. This again revealed that EPI reforms were well supported by the government and donors centrally. EPI managers at both district and regional levels opposed some of the EPI reforms. They argued that coverage was falling due to the reforms. However, there was no concrete evidence relating reforms in the EPI programme and falling coverage. The primary aim of certain actors was to make sure that they continued receiving extra income from EPI functions. One of the effects of stakeholders’ reaction was reversal of reforms (recentralization) and return to the status quo. The fourth question was: What was the immediate reaction of stakeholders to decentralization at district level and how might it have affected performance of EPI functions and the challenges? The immediate reaction of stakeholders was reduced cooperation between the Council Health Management Team (CHMT) and the District Council who were politically supreme in the district. Within the Council Health Management Team there was inadequate communication, which led to poor teamwork. The result of this was reduced supervisory visits to peripheral health facilities. The EPI coverage in the study district was 52.8 per cent, which was well below the previous national average (80 per cent). A logistic regression model for EPI service quality variables on children between 12 months and 23 months who had completed vaccination was applied. Certain EPI quality of service variables predicted significant changes in the odds ratio for completing vaccination. It was then suggested that strategies were needed to improve management skills among the CHMT and District Council members. Also there was a need of hastening the process of increasing remuneration and motivation of peripheral health workers. The fifth and final question was: What was the interest of the stakeholders and prospects of increasing EPI coverage at district level? Decentralization and integration of EPI functions were among the reforms at district level. The analysis revealed that active stakeholders at district level were the Ministry of Health, CHMT, EPI managers at district and regional levels and facility providers. The Ministry of Health opposed integration of EPI at district level by issuing the directive that DCCOs and MCHCOs (EPI manager at district level) should resume their tasks. However, the CHMT had no option but to comply. This action reversed some of the health reforms at district level. Analysis of the importance the community attached to EPI, using willingness to pay for EPI cold chain kerosene, was done. The support was low (48.7 per cent). EPI service quality variables were significantly negatively associated with odds ratio for willingness to pay for EPI input. Simulation with Policy Maker computer software predicted that an increased number of stakeholders through community participation would significantly improve the current low level of EPI coverage. It was then proposed to do a similar analysis in other vertical programmes and implement on a trial basis the results of the simulation. In conclusion, stakeholders were found to be active and influential in the health sectors of developing countries like Tanzania but poorly considered in implementation of reforms. Stakeholders are important since some strongly support while others oppose the reforms. The reaction of stakeholders is evident through deployment or non-deployment of information depending on interest and context. This would result in poor management leading to inefficiency in resource use, which would then be followed by poor quality of services, poor support by communities and consequently poor utilization of health services. It is suggested that stakeholder analysis be conducted in other vertical programmes in the process of integration. Promotion of stakeholder analysis and also Policy Maker as a tool to manage stakeholders will facilitate the management of reforms in the health sector

Food insecurity and coping strategies among people living with HIV in Dar es Salaam, Tanzania

Food insecurity and malnutrition seriously impedes efforts to control HIV/AIDS in resource poor countries. This study was carried out to assess food security, and coping strategies among people living with HIV/AIDS (PLHIV) attending Care and Treatment Centre (CTC) in Dar es Salaam, Tanzania. A structured questionnaire was used to interview randomly selected adults (≥18 years) who were HIV positive who have just been eligible for anti-retroviral treatment (ART) in a CTC or one who has started ART but not more than four weeks has elapsed. A total of 446 (females=67.9%; males= 32.1%) people living with HIV/AIDS attending CTC were interviewed. About three quarters (73.1%) of the respondents were 25-44 years old and most (43.9%) were married. Two thirds (66.7%) of the respondents had primary school education. Seventy percent reported to have a regular income and 63.7% with a monthly income of less than US$154. More than half (52.2$154) (OR=0.10; 95%CI, 0.01–0.67). Reporting two or less meals increased the likelihood of food insecurity (OR=4.2; 95% CI1.7-9.8). Low frequency of meals was significantly more prevalent (18.6%) among those ≥45 years than among 35–44 years old respondents (6.7%) (P=0.04). Borrowing money (55.8%) and taking less preferred foods (53.3%) were the most common coping strategies. In conclusion, food insecurity is a significant problem among people living with HIV in Dar es Salaam which might significantly affect compliance to care and support. The study suggests that counselling of PLHIV before anti-retroviral treatment programmes should devise special strategies targeting those with low education, low income and low frequency of meals

Trends in Immunization Completion and Disparities in the Context of Health Reforms: The case study of Tanzania

\ud Of global concern is the decline in under five children mortality which has reversed in some countries in sub Saharan Africa (SSA) since the early 1990 s which could be due to disparities in access to preventive services including immunization. This paper is aimed at determining the trend in disparities in completion of immunization using Tanzania Demographic and Health Surveys (DHS). DHS studies randomly selected representative households from all regions in Tanzania since 1980 s, is repeated every five years in the same enumeration areas. The last three data sets (1990, 1996 and 2004) were downloaded and analyzed using STATA 9.0. The analysis included all children of between 12-23 months who would have completed all vaccinations required at 12 months. Across the time periods 1990, 1996 to 2004/05 the percentage of children completing vaccination was similar (71.0% in 1990, 72.7% in 1996 and 72.3% in 2005). There was no disparity in completion of immunization with wealth strata in 1990 and 1996 (p > 0.05) but not 2004. In 2004/05 there was marked disparity as most poor experienced significant decline in immunization completion while the least poor had significant increase (p < 0.001). All three periods children from households whose head had low education were less likely to complete immunization (p < 0.01). Equity that existed in 1990 and more pronounced in 1996 regressed to inequity in 2005, thus though at national level immunization coverage did not change, but at sub-group there was significant disparity associated with the changing contexts and reforms. To address sub-group disparities in immunization it is recommended to adopt strategies focused at governance and health system to reach all population groups and most poor.\u

Pesticide safety practice and its determinants among small scale vegetables farmers in Eyasi area, Arusha region Tanzania

Background: Strategies to achieve the millennium agricultural development goals include increased use of pesticides to increase agricultural production in poor countries. However, the increased availability and use of such chemicals need to be paralleled with national and personal level practices to maximize safety for communities and environment.Aim and methods: The aim of this study was to determine the pesticide safety practices among rural farmers in Karatu District in Northern Tanzania. Farmers practicing horticulture farming in Mang’ola Division were interviewed about their practices during and after pesticides application.Results: The study included 148 farmers of whom 79.7% were male. A significantly high proportion (77.7%) of the farmers did not use protective gear while applying pesticides. A notable percentage ate while applying pesticides (17.6%), one out of five took fluids and about a quarter smoked cigarettes. Factors found to be significantly associated with those practices were education, marital status, reporting frequent household spraying, long duration since starting to apply pesticides and farm size (p&lt;0.05).Conclusions: Given the lack of protective behavior, it is then very important that farmers and farm workers are reminded of the hazardous nature of pesticides and the need to have their health monitored regularly. Special educational and information strategies have to focus on those with low education, who are unmarried, working on large farms and have a high frequency of applying pesticides. To enhance sustained education and supervisions, community level surveillance and supervisors could be introduced

Food insecurity and coping strategies among people living with HIV in Dar es Salaam, Tanzania

Food insecurity and malnutrition seriously impedes efforts to control HIV/AIDS in resource poor countries. This study was carried out to assess food security, and coping strategies among people living with HIV/AIDS (PLHIV) attending Care and Treatment Centre (CTC) in Dar es Salaam, Tanzania. A structured questionnaire was used to interview randomly selected adults (≥18 years) who were HIV positive who have just been eligible for anti-retroviral treatment (ART) in a CTC or one who has started ART but not more than four weeks has elapsed. A total of 446 (females=67.9%; males= 32.1%) people living with HIV/AIDS attending CTC were interviewed. About three quarters (73.1%) of the respondents were 25-44 years old and most (43.9%) were married. Two thirds (66.7%) of the respondents had primary school education. Seventy percent reported to have a regular income and 63.7% with a monthly income of less than US$154. More than half (52.2were food insecure. Food insecurity was similar in both males (54.6and females (51.2those who were single and highest (57.7level of food insecurity was associated with having completed primary education (Adjusted OR=0.27; 95(>US$154) (OR=0.10; 95%CI, 0.01–0.67). Reporting two or less meals increased the likelihood of food insecurity (OR=4.2; 95% CI1.7-9.8). Low frequency of meals was significantly more prevalent (18.6%) among those ≥45 years than among 35–44 years old respondents (6.7%) (P=0.04). Borrowing money (55.8%) and taking less preferred foods (53.3%) were the most common coping strategies. In conclusion, food insecurity is a significant problem among people living with HIV in Dar es Salaam which might significantly affect compliance to care and support. The study suggests that counselling of PLHIV before anti-retroviral treatment programmes should devise special strategies targeting those with low education, low income and low frequency of meals

Policy analysis for deciding on a malaria vaccine RTS,S in Tanzania

Traditionally, it has taken decades to introduce new interventions in low-income countries. Several factors account for these delays, one of which is the absence of a framework to facilitate comprehensive understanding of policy process to inform policy makers and stimulate the decision-making process. In the case of the proposed introduction of malaria vaccines in Tanzania, a specific framework for decision-making will speed up the administrative process and shorten the time until the vaccine is made available to the target population.; Qualitative research was used as a basis for developing the Policy Framework. Interviews were conducted with government officials, bilateral and multilateral partners and other stakeholders in Tanzania to assess malaria treatment policy changes and to draw lessons for malaria vaccine adoption.; The decision-making process for adopting malaria interventions and new vaccines in general takes years, involving several processes: meetings and presentations of scientific data from different studies with consistent results, packaging and disseminating evidence and getting approval for use by the Ministry of Health and Social Welfare (MOHSW). It is influenced by contextual factors; Promoting factors include; epidemiological and intervention characteristics, country experiences of malaria treatment policy change, presentation and dissemination of evidence, coordination and harmonization of the process, use of international scientific evidence. Barriers factors includes; financial sustainability, competing health and other priorities, political will and bureaucratic procedures, costs related to the adoption and implementations of interventions, supply and distribution and professional compliance with anti-malarial drugs.; The framework facilitates the synthesis of information in a coherent way, enabling a clearer understanding of the policy process, thereby speeding up the policy decision-making process and shortening the time for a malaria vaccine to become available

Understanding the Role of Accredited Drug Dispensing Outlets in Tanzania’s Health System

Introduction: People in many low-income countries access medicines from retail drug shops. In Tanzania, a public-private partnership launched in 2003 used an accreditation approach to improve access to quality medicines and pharmaceutical services in underserved areas. The government scaled up the accredited drug dispensing outlet (ADDO) program nationally, with over 9,000 shops now accredited. This study assessed the relationships between community members and their sources of health care and medicines, particularly antimicrobials, with a specific focus on the role ADDOs play in the health care system. Methods: Using mixed methods, we collected data in four regions. We surveyed 1,185 households and audited 96 ADDOs and 84 public/nongovernmental health facilities using a list of 17 tracer drugs. To determine practices in health facilities, we interviewed 1,365 exiting patients. To assess dispensing practices, mystery shoppers visited 306 ADDOs presenting one of three scenarios (102 each) about a child’s respiratory symptoms. Results and Discussion Of 614 household members with a recent acute illness, 73% sought outside care—30% at a public facility and 31% at an ADDO. However, people bought medicines more often at ADDOs no matter who recommended the treatment; of the 581 medicines that people had received, 49% came from an ADDO. Although health facilities and ADDOs had similar availability of antimicrobials, ADDOs had more pediatric formulations available (p<0.001). The common perception was that drugs from ADDOs are more expensive, but the difference in the median cost to treat pneumonia was relatively minimal (US$0.26 in a public facility and US$0.30 in an ADDO). Over 20% of households said they had someone with a chronic condition, with 93% taking medication, but ADDOs are allowed to sell very few chronic care-related medicines. ADDO dispensers are trained to refer complicated cases to a health facility, and notably, 99% of mystery shoppers presenting a pneumonia scenario received an antimicrobial (54%), a referral (90%), or both (45%), which are recommended practices for managing pediatric pneumonia. However, one-third of the dispensers needlessly sold antibiotics for cold symptoms, and 85% sold an antibiotic on request. In addition, the pneumonia scenario elicited more advice on handling the illness than the cold symptoms scenario (61% vs. 15%; p<0.0001), but overall, only 44% of the dispensers asked any of the shoppers about danger signs potentially associated with pneumonia in a child. Conclusion: ADDOs are the principal source of medicines in Tanzania and an important part of a multi-faceted health care system. Poor prescribing in health facilities, poor dispensing at ADDOs, and inappropriate patient demand continue to contribute to inappropriate medicines use. Therefore, while accreditation has attempted to address the quality of pharmaceutical services in private sector drug outlets, efforts to improve access to and use of medicines in Tanzania need to target ADDOs, public/nongovernmental health facilities, and the public to be effective

What roles do accredited drug dispensing outlets in Tanzania play in facilitating access to antimicrobials? Results of a multi-method analysis

Background: People in low-income countries purchase a high proportion of antimicrobials from retail drug shops, both with and without a prescription. Tanzania’s accredited drug dispensing outlet (ADDO) program includes dispenser training, enforcement of standards, and the legal right to sell selected antimicrobials. We assessed the role of ADDOs in facilitating access to antimicrobials. Methods: We purposively chose four regions, randomly selected three districts and five wards per district. Study methods included interviews at 1200 households regarding care-seeking for acute illness and knowledge about antimicrobials; mystery shoppers visiting 306 ADDOs posing as a caregiver of a child with 1) pneumonia, 2) mild acute respiratory infection (ARI), or 3) a runny nose and request for co-trimoxazole; and audits of antimicrobial availability and prices at 84 public health facilities (PHFs) and 96 ADDOs. Results: Four hundred sixty seven (76 %) members from 367 (77 %) households had recently sought care outside the home for acute illness; 128 had purchased antimicrobials, of which 61 % had been recommended by a doctor or nurse and 32 % by an ADDO dispenser. Only 29 % obtained the antimicrobial at a PHF, whereas, 48 % purchased them at an ADDO. Most thought that ADDOs are convenient place for care, usually have needed medicines, and have high quality services and products, contrasting with 66 % who reported dissatisfaction with PHF waiting times and 56 % with medicine availability. One-third (34 %) of mystery shoppers presenting the mild ARI scenario were inappropriately sold an antimicrobial and 85 % were sold one on request; encouragingly, 99 % presenting a case of pneumonia received either an antimicrobial, referral to a trained provider, or request to bring the child for examination. Overall, 63 and 60 % of the 15 tracer antimicrobials were in stock in ADDOs and PHFs, respectively; ADDOs had significantly more antimicrobial formulations for children available (83 vs. 51 %). Of 369 records of antimicrobial sales in 47 ADDOs, 63 % were dispensed on prescription. Conclusion: ADDOs have increased access to antimicrobials in Tanzania. Community members see them as integral to the health system. Antimicrobials are overused due to poor ADDO dispensing, poor PHF prescribing, and inappropriate public demand. Multi-pronged interventions are needed to address all determinants. Electronic supplementary material The online version of this article (doi:10.1186/s13756-015-0075-2) contains supplementary material, which is available to authorized users