Institute of Development Studies

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Promoting community participation through health facility governing committees to improve the performance of district health systems in Tanzania
(University of Dar es Salaam, 2023-03) Kamuzora, Peter; Maluka, Stephen; San Sebastian, Miguel; Mtasingwa, Lilian; Kapologwe, Ntuli; Hurtig, Anna-Karin
A research project entitled “Examining the effects of decision-making space and its practices on health systems performance in Tanzania” was conducted in twenty districts of Tanzania between 2020 and 2023. The main objective of this research was to better understand and evaluate how and if decentralised sub-national structures used the opportunities to improve the performance of health systems. Two universities: the University of Dar es Salaam, Tanzania and Umeå University, Sweden, collaborated in the implementation of this project. To understand the opportunities that Tanzania’s decentralization structure has to offer, this research focused on the decision-making space provided to officials at the local levels over the health system functions of planning, financing, human resources, service delivery, and governance. Tanzania’s decentralization policy allows Health Facility Governing Committees (HFGCs), on behalf of the communities, to participate in these health system functions. The HFGCs consisting of community members have become integral in the decentralization reforms which have been implemented since 1990s. The government expects health care providers to involve HFGCs in the management of health facilities, including making decisions that best serve the interests of the community. HFGCs should be involved in decisions such as approving all transactions that are made at the health facilities, inspecting health commodities procured by health facilities prior to dispensing, taking part in the making of plans and budgets of health facility and holding health care providers accountable for the performance of their health facilities. This policy brief synthesizes the key findings of the research conducted to assess how HFGCs participated in the implementation of functions that have been decentralized to the district level in Tanzania.
Autonomy without capacity: the role of health facility governing committees in planning and budgeting in Tanzania
(University of Dar es Salaam, 2023-03) Maluka, Stephen; Kamuzora, Peter; Hurtig, Anna-Karin; San Sebastian, Miguel; Mtasingwa, Lilian; Kapologwe, Ntuli
Since the inception of health-sector reforms in Tanzania in the 1990s, health planning and implementation was decentralised to the Council Health Management Teams (CHMTs) headed by the District Medical Officer (DMO). This arrangement centralised the autonomy for planning, budgeting and resource allocation at the district level with very limited autonomy and authority at the health facility and community level. Since 2017/2018, the government of Tanzania has further transferred the autonomy to plan, budget and manage financial resources to health facilities. Under the current arrangements, each health facility prepares its comprehensive annual health plan and budget, and funds for the implementation of the plans are transferred directly from the Ministry of Finance and Planning (MoFP) to health facilities; the policy known as Direct Health Facility Financing (DHFF). Each health facility is supposed to have a planning team responsible for preparing annual plans. The team is required to: (i) conduct a thorough assessment of the implementation of the previous year comprehensive health facility plans to guide preparation of subsequent annual plan; (ii) gather community opinions regarding priorities and challenges in accessing health care services to inform the planning process; (iii) conduct a robust situational analysis about the morbidity and mortality trends, underlying causes and health system bottlenecks hampering the delivery and uptake of interventions; (iv) prepare plans in accordance to existing guidelines; (v) provide feedback of the approved facility plan to Health Facility Governing Committee (HFGC), Village Development Committee (VDC) and Ward Development Committee (WDC); and (vi) ensure that the plans are responsive to local needs (facility and population). The central government issues guidelines that steer the planning process at the district and health facility levels. The CHMTs and health facilities need to abide by these guidelines when preparing their annual health plans. Similarly, the central government supplies the budget making guidelines, which stipulate the ‘budget ceilings’ that every district and health facility has to adhere to. All facility plans are at later stage consolidated into a Comprehensive Council Health Plan (CCHP) for the whole district. Similarly, the preparation of the CCHP is led by a guideline from the central government. The consolidation process is done by the CCHP planning team led by the District Medical Officers (DMOs). After endorsement at the Council level, the plan is submitted to the Regional Secretariat (RS) for assessment, approval and submission to the national level. At this level, the plan is assessed by assessors comprising members from the President’s Office-Regional Administration and Local Government (PORALG) – Health and MoH and recommended for funding.
An Assessment of the Implementation of the Re-structured Community Health Fund in Gairo District in Tanzania
(Tanzania Journal of Development Studies, 2020) Asantemungu, Raphael; Maluka, Stephen
While the government of Tanzania has been implementing community health fund (CHF) for more than two decades, the uptake of the scheme has been persistently low due to management and performance problems. As a response, from 2011 a new initiative was adopted that changed the overall structure, management and benefit packages of the CHF. This paper assesses the implementation of the newly re- structured CHF in Gairo District in Morogoro Region. This study employed a descriptive qualitative case study design using three types of data collection techniques, namely individual interviews (n=14), focus group discussions (n=4) and document review. A thematic approach was used to analyse the data. Findings show that the re-structured CHF has improved the pooling and provider payment mechanism compared to the old CHF. Benefit packages have been expanded to include referral services up to regional level. However, stakeholders, including community members, had negative perceptions of the restructured CHF owing to high annual premium rates, low incentive to enrolment officers, weak registration network and poor quality of health care services. In order to improve CHF performance and achieve universal health coverage, the central Government needs to invest more in the improvement of the quality of health care services, particularly the availability of drugs and medical supplies. Additionally, the government should make CHF scheme compulsory to all members of the community who do not have alternative health insurance.
"Milking the Cow Without Feeding It": Perceptions of Communities on Water User Fees for Smallholder Irrigation in Ruaha Sub-Basin, Tanzania.
(Tanzania Journal of Development Studies, 2020) Kahimba, Joseph; Maluka, Stephen; Dungumaro, Esther
Water-user fees in Tanzania, like in other low-income countries, have been introduced mainly as a response to neo-liberal thinking which, among other things, believes that water has an economic value and should be recognized as an economic good. The objective of this study was to understand perceptions on water-user fees among smallholder farmers in the Ruaha Sub-basin, Tanzania. It employed qualitative and quantitative tools, including in-depth interviews, focus group discussions, and questionnaires. Qualitative data were analysed using a thematic approach, while quantitative data were analysed using SPSS Version 20. The findings revealed that most smallholder irrigators were dissatisfied with the payment, amount, and the use of water fees. There were three major reasons for the high level of dissatisfaction. First, owners of private water-use permits did not see why they should pay for water that had no (physical) investment on it. Second, some owners of group water-use permits were unwilling to pay for water because they felt that they did not get adequate support from the government since all irrigation water-related operational costs, including the constructions and maintenance of irrigation canals, were undertaken by themselves. The lack of community participation in determining the amount of water-user fees and ad-hoc changes of the amount of the fees was another reason for the dissatisfaction. This paper proposes some recommendations for effective management of water resources at a community level.
Integration of community health workers into the health system in Tanzania: Examining the process and contextual factors
(International Journal of Health Planning and Management, 2021) Mgawe, Peter; Maluka, Stephen
Education (DUCE) & Institute of Development Studies (IDS), University of Dar s Salaam, Dar es Salaam, Tanzania Correspondence Stephen O. Maluka, Dar es Salaam University College of Education (DUCE) & Institute of Development Studies (IDS), University of Dar es Salaam, 2329 Dar es Salaam, Tanzania. Email: stephenmaluka@yahoo.co.uk Funding information Institute of Social Work Abstract Integration of community health workers (CHWs) into the health systems has become a global concern. Recently, the Government of Tanzania through the then Ministry of Health and Social Welfare initiated different strategies that aimed at integrating CHWs into the health system. This paper discusses the process and factors that influence the integration of CHWs into the health system in Tanzania. The study employed qualitative case study design using in‐ depth interviews (n à 37). In addition, various documents including health policies, Community‐based Health Policy, community health workers guideline and Community health workers training curriculum were reviewed. Data were analysed by using thematic analysis. The findings indicated that potential CHWs were selected based on the National Council for Technical Education standards that required an applicant to have four (4) passes in the ordinary level examination. None of the CHWs who had undergone training had been employed by the government. This differed from what was prescribed in the CHWs guidelines. Integration of CHWs into health system in Tanzania has not been optimal because of inadequate preparations in terms of stakeholders engagement, infrastructure, legal and policy frameworks, technical expertise and financial resources. Effective integration of CHWs into the health system requires working with different actors to communicate objectives, achieve, ownership of the stakeholders, manage conflict and cooperation, and sustain changes.
The Failure of Community-Based Health Insurance Schemes in Tanzania: Opening the Black Box of the Implementation Process
(BMC Health Services Research, 2021) Kigume, Ramadhani; Maluka, Stephen
Background: Globally, there is increased advocacy for community-based health insurance (CBHI) schemes. Like other low and middle-income countries (LMICs), Tanzania officially established the Community Health Fund (CHF) in 2001 for rural areas; and Tiba Kwa Kadi (TIKA) for urban population since 2009. This study investigated the implementation of TIKA scheme in urban districts of Tanzania. Methods: A descriptive qualitative case study was conducted in four urban districts in Tanzania in 2019. Data were collected using semi-structured interviews, focus group discussions and review of documents. A thematic approach was used to analyse the data. Results: While TIKA scheme was important in increasing access to health services for the poor and other disadvantaged groups, it faced many challenges which hindered its performance. The challenges included frequent stock-out of drugs and medical supplies, which frustrated TIKA members and hence contributed to non-renewal of membership. In addition, the scheme was affected by poor collections and management of the revenue collected from TIKA members, limited benefit packages and low awareness of the community. Conclusions: Similar to rural-based Community Health Fund, the TIKA scheme faced structural and operational challenges which subsequently resulted into low uptake of the schemes. In order to achieve universal health coverage, the government should consider integrating or merging Community-Based Health Insurance schemes into a single national pool with decentralised arms to win national support while also maintaining local accountability.
The Influence of Community Factors in the Implementation of Community-based Interventions to Improve Antenatal Care: A Qualitative Study Based on the IMCHA Programme in Tanzania.
(BMC Reproductive Health, 2021) Joseph, Chakupewa; Maluka, Stephen
Background: Efforts to improve antenatal care have been heightened to reduce global maternal deaths. In resource- limited settings, community-based interventions play a pivotal role in improving antenatal care services. However, effective implementation of community-based interventions is influenced by prevailing community-related factors. Drawing from the community-based interventions implemented in Iringa Region in Tanzania, this paper underscores how community factors influence implementation and ultimate improvement of antenatal care services. Methods: A qualitative case study design was employed using in-depth interviews, focus group discussions and document reviews. Data was collected in Kilolo and Mufindi districts in Iringa Region where community-based interventions were implemented. A total of one hundred and forty-six (146) participants were involved in the study. Eighty-six (86) participants were interviewed and sixty (n = 60) participated in focus group discussions. Data were ana- lysed thematically and manually by categorizing and coding emerging issues to facilitate analysis and interpretation. Results: Key factors that influenced the implementation of the community-based interventions were the commu- nity readiness to adopt the interventions and effective local administrative systems. Stakeholders’ engagement and local health system support were also pivotal for improving antenatal care services. However, the physical environ- ment, bullying of implementers of interventions and family-related challenges constrained the implementation of the interventions. Conclusion: This study has shown that the performance of community-based interventions is highly influenced by community-related factors. More specifically, inadequate community engagement may lead to community members’ reluctance to adopt implemented interventions. Therefore, in-depth understanding and adequate management of community engagement are important during the planning, development and implementation of community-based interventions.
Geostatistical linkage of national demographic and health survey data: a case study of Tanzania
(Population Health Metrics, 2021) Yoo, E; Palermo, T; Maluka, Stephen
Background: When Service Provision Assessment (SPA) surveys on primary health service delivery are combined with the nationally representative household survey—Demographic and Health Survey (DHS), they can provide key information on the access, utilization, and equity of health service availability in low- and middle-income countries. However, existing linkage methods have been established only at aggregate levels due to known limitations of the survey datasets. Methods: For the linkage of two data sets at a disaggregated level, we developed a geostatistical approach where SPA limitations are explicitly accounted for by identifying the sites where health facilities might be present but not included in SPA surveys. Using the knowledge gained from SPA surveys related to the contextual information around facilities and their spatial structure, we made an inference on the service environment of unsampled health facilities. The geostatistical linkage results on the availability of health service were validated using two criteria—prediction accuracy and classification error. We also assessed the effect of displacement of DHS clusters on the linkage results using simulation. Results: The performance evaluation of the geostatistical linkage method, demonstrated using information on the general service readiness of sampled health facilities in Tanzania, showed that the proposed methods exceeded the performance of the existing methods in terms of both prediction accuracy and classification error. We also found that the geostatistical linkage methods are more robust than existing methods with respect to the displacement of DHS clusters. Conclusions: The proposed geospatial approach minimizes the methodological issues and has potential to be used in various public health research applications where facility and population-based data need to be combined at fine spatial scale.
Factors Facilitating and Challenges Facing Community-based Interventions in Improving Antenatal Care in Rural Tanzania
(Journal of Education, Humanities and Sciences, 2021) Maluka, Stephen O; Joseph, Chakupewa
The improvement of antenatal care has remained a topical global concern as signalled by maternal deaths, which have remained unacceptably high, especially in low- and middle- income countries. In response to this concern, community-based interventions through women’s groups have been implemented to improve antenatal care; and have shown promising results in rural settings. However, factors contributing to the success or failure of these interventions vary across geographical settings, thereby necessitating area- specific considerations. This paper sets out to unveil significant facilitators and barriers to the implementation of women’s group interventions in Tanzania. A qualitative case study design was employed involving interviews, focus group discussions, and documentary review in Kilolo and Mufindi districts. Eighty-six participants were interviewed and six small focus group discussions were conducted. Findings show that several factors facilitated the implementation of community-based interventions. These included recruitment and selection of the women’s groups, readiness among the women’s groups, support of the local administrative systems, and inclusive monitoring and evaluation process. On the other hand, the implementation process was constrained by insufficient logistical supplies, multiple workloads, and the desire for allowances. It is concluded that increased uptake and sustainability of antenatal care can potentially be attained through an understanding of both facilitators and barriers during the planning, development and implementation of the interventions of women’s groups.
Effects of Male Engagement Interventions on Women’s Autonomy in Decision Making in Iringa Region, Tanzania
(Tanzania Journal of Development Studies, 2021) Japhet, Paul; Maluka, Stephen O
Maternal and neonatal mortality are largely caused by delays in attending to obstetric complications and this is attributed to limited women’s power in making decisions regarding household resources and utilisation of health care services. This requires effective implementation of male engagement interventions to improve women’s autonomy in making decisions and hence reduce delays in attending to obstetric complications. This study examines the contribution of male engagement interventions in promoting women’s autonomy in decision making within households and society. A structured questionnaire was used to collect data on socio-demographic and household characteristics, women’s practices concerning prenatal care, childbirth, postnatal care, and related decision-making power. Descriptive statistics and inferential analysis were used to analyse the data. The findings show a significant difference in decision making autonomy regarding family planning methods among respondents who had received male engagement education versus those who had not received such education (p-0.001<1%). Again, there was significant participation of women in household purchases for daily needs (p-0.057<10%) and in decisions to work out of homes (p-0.015<5%). This trend was noted among respondents who had received male engagement education as compared to those who had not received such education. There was also greater engagement of women in decision making concerning major household purchases and their health care, although their engagement was not statistically significant (p- 0.397>10% and p-0.293>10% respectively). Effective implementation of male engagement interventions may leverage men’s power within households and promote women’s autonomy in decision making, thereby improving healthcare- seeking behaviour.
The Effect of Elderly Exemption Policy on Access to and Utilization of Health Care Services in Tanzania
(Tanzania Journal of Development Studies, 2021) Edward, Joshua; Maluka, Stephen O
Exemption from and waiver of social service cost for elderly people have been implemented in Tanzania for the past three decades. In order to facilitate the exemption of the elderly from paying for health services, the then Ministry of Health directed all districts in Tanzania to issue identify cards (IDs) to the elderly in order to address the challenges already observed in the implementation of the exemption and waiver policy. Despite an increase in demand and popularity of the IDs among elderly people, it was not clear whether this new mechanism offered the elderly access to health services. This paper examines the implementation of this policy in Mbarali and Ubungo districts in Tanzania. The study adopted a mixed method approach using surveys (n=879) and semi-structured interviews (n=23). Quantitative data were analysed descriptively and qualitative data were analysed thematically. It was found that elderly identity cards have only improved physical access to health facilities through simplification of identification. Shortage of health care services, particularly medicines and medical supplies, long waiting time due to shortage of staff and the use of unfriendly language by the health care workers, have caused negative perceptions of the elderly towards the exemption policy. The use of elderly IDs has not solved the earlier observed challenges facing the exemption policy for the elderly population. It is recommended that the government needs to work more to improve the quality of health care services for the elderly in public health facilities.
The Effect of Elderly Exemption Policy on Access to and Utilization of Health Care Services in Tanzania
(Tanzania Journal of Development Studies, 2021) Edward, Joshua; Maluka, Stephen O
Exemption from and waiver of social service cost for elderly people have been implemented in Tanzania for the past three decades. In order to facilitate the exemption of the elderly from paying for health services, the then Ministry of Health directed all districts in Tanzania to issue identify cards (IDs) to the elderly in order to address the challenges already observed in the implementation of the exemption and waiver policy. Despite an increase in demand and popularity of the IDs among elderly people, it was not clear whether this new mechanism offered the elderly access to health services. This paper examines the implementation of this policy in Mbarali and Ubungo districts in Tanzania. The study adopted a mixed method approach using surveys (n=879) and semi-structured interviews (n=23). Quantitative data were analysed descriptively and qualitative data were analysed thematically. It was found that elderly identity cards have only improved physical access to health facilities through simplification of identification. Shortage of health care services, particularly medicines and medical supplies, long waiting time due to shortage of staff and the use of unfriendly language by the health care workers, have caused negative perceptions of the elderly towards the exemption policy. The use of elderly IDs has not solved the earlier observed challenges facing the exemption policy for the elderly population. It is recommended that the government needs to work more to improve the quality of health care services for the elderly in public health facilities.
Knowledge, Attitude and Practices on Non-Communicable Diseases among Students and Staff at the Dar es Salaam University College of Education in Tanzania.
(Journal of Humanities and Social Sciences, 2022) Maluka, Stephen O; Sangeti, Saningo
Non-Communicable Diseases (NCDs) are among the major public health problems facing the world today. Despite contributing to over half of all deaths worldwide, and being a major challenge in low- and middle-income countries, NCDs have received less attention. In Tanzania, studies focusing on the assessment of comprehensive knowledge of NCDs are lacking. This study aims to assess knowledge, attitudes and behaviour of the Dar es Salaam University College of Education (DUCE) community on selected NCDs. A cross- sectional study was conducted to assess knowledge, attitudes and practices on selected NCDs. The study involved both students and staff at the DUCE. A descriptive analysis was adopted for the quantitative data collected through structured questionnaires. The study findings show that the general knowledge of the DUCE community about some selected NCDs was generally high. However, there was a very low level of knowledge about risk factors, early symptoms and preventive measures. Regarding risk factors, a very small proportion of students (1.6%) and staff (3.1%) consumed tobacco products. Only 75 (13.1%) of students and 70 (36.5%) of staff consumed alcohol. The intake of fruits and vegetables among the community was insufficient. About 493 (86%) of the students and 135 (70.3%) of the staff added salt or salty sauce to their meals. As for physical activities, 234 (40.8%) of the students and 99 (51.6%) of the staff reported that they ran or participated in games and sports for at least one day in a week. The study concludes that while generally there is a high level of knowledge about NCDs, there is a very low level of knowledge about risk factors, early symptoms and preventive measures. The study underlines the need to increase the awareness of the DUCE population on risk factors associated with NCDs, early signs and preventive measures that people should take to prevent NCDs in the future. Keywords: higher education, public health, diseases, HIV/AIDS, Tanzania
A systems perspective on the importance of global health strategy developments for accomplishing today’s Sustainable Development Goals
(Oxford University Press, 2019-07-30) Byskov, Jens; Maluka, Stephen; Marchal, Bruno; Shayo, Elizabeth; Blystad, Astrid; Bukachi, Salome; Zulu, Joseph; Michelo, Charles; Hurtig, Anna-Karin; Bloch, Paul
Priority setting within health systems has not led to accountable, fair and sustainable solutions to improving population health. Providers, users and other stakeholders each have their own health and service priorities based on selected evidence, own values, expertise and preferences. Based on a historical account, this article analyses if contemporary health systems are appropriate to optimize population health within the framework of cross cutting targets of the Sustainable Development Goals (SDGs). We applied a scoping review approach to identify and review literature of scientific databases and other programmatic web and library-based documents on historical and contemporary health systems policies and strategies at the global level. Early literature supported the 1977 launching of the global target of Health for All by the year 2000. Reviewed literature was used to provide a historical overview of systems components of global health strategies through describing the conceptualizations of health determinants, user involvement and mechanisms of priority setting over time, and analysing the importance of historical developments on barriers and opportunities to accomplish the SDGs. Definitions, scope and application of health systems-associated priority setting fluctuated and main health determinants and user influence on global health systems and priority setting remained limited. In exploring reasons for the identified lack of SDG-associated health systems and priority setting processes, we discuss issues of accountability, vested interests, ethics and democratic legitimacy as conditional for future sustainability of population health. To accomplish the SDGs health systems must engage beyond their own sector boundary. New approaches to Health in All Policies and One Health may be conducive for scaling up more democratic and inclusive priority setting processes based on proper process guidelines from successful pilots. Sustainable development depends on population preferences supported by technical and managerial expertise.
Why do pregnant women in Iringa region in Tanzania start antenatal care late? A qualitative analysis
(Springer Nature, 2020-02-24) Maluka, Stephen Oswald; Joseph, Chakupewa; Fitzgerald, Sian; Salim, Robert; Kamuzora, Peter
Background: When started early in pregnancy and continued up till childbirth, antenatal care (ANC) can be effective in reducing adverse pregnancy outcomes. While the proportion of women who attend ANC at least once in low income countries is high, most pregnant women attend their first ANC late. In Tanzania, while over 51% of pregnant women complete ≥4 visits, only 24% start within the first trimester. This study aimed to understand the factors that lead to delay in seeking ANC services among pregnant women in Tanzania. Methods: This qualitative descriptive case study was conducted in two rural districts in Iringa Region in Tanzania. A total of 40 focus group discussions (FGDs) were conducted involving both male and female participants in 20 villages. In addition, 36 semi-structured interviews were carried out with health care workers, members of health facility committees and community health workers. Initial findings were further validated during 10 stakeholders’ meetings held at ward level in which 450 people participated. Data were analysed using thematic approach. Results: Key individual and social factors for late ANC attendance included lack of knowledge of the importance of early visiting ANC, previous birth with good outcome, traditional gender roles, fear of shame and stigma, and cultural beliefs about pregnancy. Main factors which inhibit early ANC attendance in Kilolo and Mufindi districts include spouse accompany policy, rude language of health personnel and shortage of health care providers. Conclusions: Traditional gender roles and cultural beliefs about pregnancy as well as health system factors continue to influence the timing of ANC attendance. Improving early ANC attendance, therefore, requires integrated interventions that address both community and health systems barriers. Health education on the timing and importance of early antenatal care should also be strengthened in the communities. Additionally, while spouse accompany policy is important, the implementation of this policy should not infringe women’s rights to access ANC services.
Uptake of community health fund: why is Mtwara District lagging behind?
(Korean Society of Global Health., 2019-12-04) Ndomba, Teoford
Background: Globally, there is an increased advocacy for community-based health insurance (CBHI) schemes. CBHI refers to voluntary, non-profit health insurance, normally organized at local level where formal health insurance does not provide protection against the cost of illness. The community health fund (CHF) is a type of CBHI scheme which is being implemented in Tanzania since 1996. Despite this seemingly noble initiative, there is a growing concern that this scheme has not achieved its intended objectives. At present, enrolment rate in CHF is still low and there is also high dropout of members from CHF. This study explored the socio-economic, political, and health system factors that contribute to the low uptake of the CHF in Mtwara Region. Methods: This study employed descriptive qualitative case study design. The study primarily relied on 2 data collection techniques, namely individual interviews (n = 49) and focus group discussions (n = 12). A thematic analysis approach was used to analyse the collected data. Results: The findings of the study indicate that the most important factors which hindered the uptake of the CHF were: low household income, lack of knowledge of the CHF scheme and poor quality of health care services. Conclusion: The study concludes that individual, community, and health systems factors contribute to the low enrolment in the CHF schemes. Therefore, increased enrollment in the CHF schemes requires collaborative efforts of community leaders, health providers and health system managers. This study underlines the need for continuous sensitization of communities. Therefore, local government authorities should make CHF a permanent agenda in community meetings. Likewise, the government needs to invest more in the health sector with a view to improving the quality of health care services, particularly availability of medicines, medical supplies and health care providers.
Factors for late initiation of antenatal care in Dar es Salaam, Tanzania: A qualitative study
(Springer Nature, 2019-11-12) Mgata, Saidi; Maluka, Stephen Oswald
Background: Antenatal care (ANC) provided by a trained health care provider is important for monitoring pregnancy thereby reducing potential risks for the mother and child during pregnancy and delivery. The World Health Organization (WHO) recommends at least four ANC visits to all pregnant women. While the proportion of women who attend at least one ANC in low-income countries is high, most pregnant women start their first ANC attendance very late. In Tanzania only 24% of pregnant women start their first ANC attendance before the fourth month of pregnancy. While factors for the utilization of antenatal care in general have been widely studied, there is paucity of studies on the factors affecting timing of the first ANC attendance. This study aimed to understand individual, community, and health system factors that lead to the delay in seeking ANC services among pregnant women in Ilala Municipal in Dar es Salaam region, Tanzania. Methods: A qualitative exploratory study, using in-depth interviews with 20 pregnant women and five health care workers was conducted in three different health facilities in Dar es Salaam Tanzania. Thematic analysis approach was used to analyse the data. Results: Individual perceptions of antenatal care, past experience with pregnancy, fear of pregnancy disclosure, and socio-cultural beliefs were the key individual and social factors for late ANC attendance. Shortage of trained health care workers, lack of spouse’s escort and health providers’ disrespect to pregnant women were the main health system barriers to early ANC attendance. Conclusions: This study concludes that community members should be sensitized about the importance of early ANC attendance. Additionally, while spouse’s escort policy is important for promoting PMTCT, the interpretation of the policy should not solely be left to the health providers. District and regional health officials should provide correct interpretation of this policy.
Leaving no one behind: using action research to promote male involvement in maternal and child health in Iringa region, Tanzania
(2020-10-02) Maluka, Stephen; Japhet, Paul; Fitzgerald, Sian; Begum, Khadija; May, Alexander; Kamuzora, Peter
Introduction Male involvement has been reported to improve maternal and child health (MCH) outcomes. However, most studies in low-income and middle-income countries have reported low participation of men in MCH-related programmes. While there is a growing interest in the involvement of men in MCH, little is known on how male involvement can be effectively promoted in settings where entrenched unequal gender roles, norms and relations constrain women from effectively inviting men to participate in MCH. Methods and analysis This paper reports participatory action research (PAR) aimed to promote male participation in pregnancy and childbirth in Iringa Region, Tanzania. As part of the Innovating for Maternal and Child Health in Africa project, PAR was conducted in 20 villages in two rural districts in Tanzania. Men and women were engaged separately to identify barriers to male involvement in antenatal care and during delivery; and then they were facilitated to design strategies to promote male participation in their communities. Along with the PAR intervention, researchers undertook a series of research activities. A thematic analysis was used to analyse the data. The common strategies designed were: engaging health facility committees; using male champions and male gatekeepers; and using female champions to sensitise and provide health education to women. These strategies were validated during stakeholders’ meetings, which were convened in each community. Discussion The use of participatory approach not only empowers communities to diagnose barriers to male involvement and develop culturally acceptable strategies but also increases sustainability of the interventions beyond the life span of the project. More lessons will be identified during the implementation of these strategies.
Integration of community health workers into the health system in Tanzania: Examining the process and contextual factors
(2021-01-15) Mgawe, Peter; Maluka, Stephen
Integration of community health workers (CHWs) into the health systems has become a global concern. Recently, the Government of Tanzania through the then Ministry of Health and Social Welfare initiated different strategies that aimed at integrating CHWs into the health system. This paper discusses the process and factors that influence the integration of CHWs into the health system in Tanzania. The study employed qualitative case study design using indepth interviews (n . 37). In addition, various documents including health policies, Community‐based Health Policy, community health workers guideline and Community health workers training curriculum were reviewed. Data were analysed by using thematic analysis. The findings indicated that potential CHWs were selected based on the National Council for Technical Education standards that required an applicant to have four (4) passes in the ordinary level examination. None of the CHWs who had undergone training had been employed by the government. This differed from what was prescribed in the CHWs guidelines. Integration of CHWs into health system in Tanzania has not been optimal because of inadequate preparations in terms of stakeholders engagement, infrastructure, legal and policy frameworks, technical expertise and financial resources. Effective integration of CHWs into the health system requires working with different actors to communicate objectives, achieveIntegration of community health workers (CHWs) into the health systems has become a global concern. Recently, the Government of Tanzania through the then Ministry of Health and Social Welfare initiated different strategies that aimed at integrating CHWs into the health system. This paper discusses the process and factors that influence the integration of CHWs into the health system in Tanzania. The study employed qualitative case study design using indepth interviews (n . 37). In addition, various documents including health policies, Community‐based Health Policy, community health workers guideline and Community health workers training curriculum were reviewed. Data were analysed by using thematic analysis. The findings indicated that potential CHWs were selected based on the National Council for Technical Education standards that required an applicant to have four (4) passes in the ordinary level examination. None of the CHWs who had undergone training had been employed by the government. This differed from what was prescribed in the CHWs guidelines. Integration of CHWs into health system in Tanzania has not been optimal because of inadequate preparations in terms of stakeholders engagement, infrastructure, legal and policy frameworks, technical expertise and financial resources. Effective integration of CHWs into the health system requires working with different actors to communicate objectives, achieve ownership of the stakeholders, manage conflict and cooperation, and sustain changes.
Bank accounts for public primary health care facilities: Reflections on implementation from three districts in Tanzania
(WILLEY & Sons, 2019-01) Kuwawenaruwa, August; Remme, M; Mtei, Gemini; Makawia, Suzan; Maluka, Stephen; Kapologwe, Ntuli; Borghi, Jo
Health care financing reforms are gaining popularity in a number of African countries to increase financial resources and promote financial autonomy, particularly at peripheral health care facilities. The paper explores the establishment of facility bank accounts at public primary facilities in Tanzania, with the intention of informing other countries embarking on such reform of the lessons learned from its implementation process. A case study approach was used, in which three district councils were purposively sampled. A total of 34 focus group discussions and 14 in‐depth interviews were conducted. Thematic content analysis was used during analysis. The study revealed that the main use of bank account revenue was for the purchase of drugs, medical supplies, and minor facility needs. To ensure accountability for funds, health care facilities had to submit monthly reports of expenditures incurred. District managers also undertook quality control of facility infrastructure, which had been renovated using facility resources and purchases of facility needs. Facility autonomy in the use of revenue retained in their accounts would improve the availability of drugs and service delivery. The experienced process of opening facility bank accounts, managing, and using the funds highlights the need to strengthen the capacity of staff and health‐governing committees.

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