Patient's willingness to pay for improved community health insurance in Tanzania.

Globally, achieving universal health coverage remains significant challenge. Health insurance coverage in low- and middle-income countries is still low with only a few African countries managed to reach 50% coverage. This study aimed to investigate the factors influencing patients' willingness to pay (WTP) for medication and various versions of the improved Community Health Insurance Fund (iCHF) in Tanzania. A facility-based cross-sectional study was conducted in all hospitals, health centres, and eight randomly sampled dispensaries, sampling participant from the queue, one out of every three patient based on their order of entry into consultation room, and interviewed 1,748 patients in Kilombero and Same districts in Tanzania. We used multi-stage Contingent Valuation Methods exploring data collected during client exit interviews. We employed a random utility model and estimated WTP through an ordered logit model. The independent variables were; patient's gender, age, marital status, education, employment status, Non-Communicable Disease (NCD) status, health insurance status, and the type of healthcare facility level. Our findings revealed that most patients exhibited a WTP of an amount equivalent to the current iCHF premiums and would also be willing to pay for an augmented iCHF premium inclusive of additional medication coverage. Upon adjusting for demographic characteristics, we observed that patients enrolled in an insurance program or benefiting from user fee waivers demonstrated a lower WTP for medication, while those with non-communicable diseases (NCDs) and seeking care in private facilities exhibited a higher WTP. Furthermore, patients with a secondary education level or above generally displayed higher WTP for premiums. Conversely, patients enrolled in private insurance and availing user fee waivers, along with those accessing care in public facilities, demonstrated a lowered WTP for iCHF premiums. These results highlight the need for targeted interventions to address systemic deficiencies and improve access to medicines. Our conclusions is that policies considering NCD status, education levels and income status are important when designing health insurance schemes for the informal sector in Tanzania, with the goal of increasing uptake of CHF.

Routine Immunization Status and Factors Associated with Immunization Coverage among Children Aged 12-23 Months in Tanzania.

Immunization has saved millions of lives globally from vaccine-preventable diseases. Childhood immunization is an effective public health strategy for decreasing morbidity and mortality among children in developing countries. Tanzania has one of the highest rates of coverage of routine child immunization among sub-Saharan African countries. However, obstacles to universal immunization still exist, particularly in rural areas of the country. Assessing routine immunization coverage is essential to inform vaccine policies and program implementation. This study aimed to assess routine immunization status and factors associated with its coverage among children aged 12-23 months. We conducted a cross-sectional, quantitative household survey in 31 regions with caretakers of children in Tanzania, where a total of 4,560 households were visited. Nationally, 85.5% of children aged 12-23 months had completed the full recommended course of vaccines. Overall, 14.5% of children aged 12-23 months did not complete routine immunization schedules in 2019. We found that factors associated with immunization coverage included having one to six family members, higher household wealth, the family's head engaging in subsistence farming, caretakers' age, children's age, educational level, children with clinic cards, and children receiving the diphtheria, pertussis, tetanus-3 vaccine. The country is about to reach the vaccination coverage target set by the WHO and the United Nations Children Fund. Improving existing vaccination coverage and optimizing the use of recommended interventions are required. We strongly advise using the periodic micro-planning tool and satellite image technology, particularly in areas where immunization coverage is less than 80%.

Healthcare Workers' Experiences and Challenges in Managing Gender-Based Violence Among HIV-Positive Women Living in Southern, Tanzania: A Qualitative Study.

Introduction: Healthcare workers (HCW) play an important role in managing women living with HIV (WLHIV) with gender-based violence (GBV) experience, but little is known about their experience in screening and managing GBV among WLHIV. This study explored the perceptions and experience of the HCWs on screening and managing GBV cases among WLHIV. Patients and Methods: We performed a descriptive phenomenological qualitative study to elicit the views and experience of HCW on GBV screening and management for WLHIV. The study was conducted in the semi-urban setting in Morogoro Region, Tanzania. Ten in-depth interviews (IDIs) were administered to HCW selected purposefully based on their roles at an HIV care and treatment center. Data were transcribed using patterns matching study aim and then merged into relevant themes for analysis and interpretation. NVIVO software version 12 was used for data coding and analysis. Results: We found that HCW experienced multiple challenges in GBV screening and management, including limited capacity for GBV screening and management; inadequate training on assessment and handling GBV cases, limited resources (time, GBV guidelines and screening tools), inadequate GBV referral and monitoring systems; referral forms for GBV survivors to social support centers and follow-up mechanisms to trace survivors, mental aspects; HCWs' fear of being stressed by listening to women's' GBV traumatic experiences, HCWs' fear of causing problems to the women's families and HCW biased notions on women disclosure of GBV; the believes that women will not report their GBV experiences. Conclusion: We identified context-specific challenges preventing HCW to deliver optimal services of GBV to WLHIV, stressing the necessity to strengthen HCW capacity and resources for GBV services and to integrate psychosocial services into HIV care. Policy and programs should be developed to support GBV screening and management for WLHIV.

Impact of the COVID-19 pandemic on type 2 diabetes care and factors associated with care disruption in Kenya and Tanzania.

BACKGROUND: The COVID-19 pandemic affected healthcare delivery globally, impacting care access and delivery of essential services. OBJECTIVES: We investigated the pandemic's impact on care for patients with type 2 diabetes and factors associated with care disruption in Kenya and Tanzania. METHODS: A cross-sectional study was conducted among adults diagnosed with diabetes pre-COVID-19. Data were collected in February-April 2022 reflecting experiences at two time-points, three months before and the three months most affected by the COVID-19 pandemic. A questionnaire captured data on blood glucose testing, changes in medication prescription and access, and healthcare provider access. RESULTS: We recruited 1000 participants (500/country). Diabetes care was disrupted in both countries, with 34.8% and 32.8% of the participants reporting change in place and frequency of testing in Kenya, respectively. In Tanzania, 12.4% and 17.8% reported changes in location and frequency of glucose testing, respectively. The number of health facility visits declined, 14.4% (p < 0.001) in Kenya and 5.6% (p = 0.001) in Tanzania. In Kenya, there was a higher likelihood of severe care disruption among insured patients (adjusted odds ratio [aOR] 1.56, 95% confidence interval [CI][1.05-2.34]; p = 0.029) and a lower likelihood among patients residing in rural areas (aOR, 0.35[95%CI, 0.22-0.58]; p < 0.001). Tanzania had a lower likelihood of severe disruption among insured patients (aOR, 0.51[95%CI, 0.33-0.79]; p = 0.003) but higher likelihood among patients with low economic status (aOR, 1.81[95%CI, 1.14-2.88]; p = 0.011). CONCLUSIONS: COVID-19 disrupted diabetes care more in Kenya than Tanzania. Health systems and emergency preparedness should be strengthened to ensure continuity of service provision for patients with diabetes.

Main findings: The COVID-19 pandemic disrupted diabetes care in Kenya and Tanzania resulting in changes in place and frequency of blood glucose testing, medication prescribed (less oral hypoglycaemics and more insulin), fewer health facility visits and more difficulty accessing healthcare providers.Added knowledge: This study quantifies the impact of the COVID-19 pandemic on diabetes care in Kenya and Tanzania, and describes the factors associated with care disruption in both countries.Global health impact for policy and action: Evidence on diabetes care disruption is useful in making plans and policies responsive to the needs of diabetes patients during pandemics or related emergency situations.

Policies for type 2 diabetes and non-communicable disease management during the COVID-19 pandemic in Kenya and Tanzania: a desk review and views of decision-makers.

BACKGROUND: The COVID-19 pandemic caused disruptions in care that adversely affected the management of non-communicable diseases (NCDs) globally. Countries have responded in various ways to support people with NCDs during the pandemic. This study aimed to identify policy gaps, if any, in the management of NCDs, particularly diabetes, during COVID-19 in Kenya and Tanzania to inform recommendations for priority actions for NCD management during any future similar crises. METHODS: We undertook a desk review of pre-existing and newly developed national frameworks, policy models and guidelines for addressing NCDs including type 2 diabetes. This was followed by 13 key informant interviews with stakeholders involved in NCD decision-making: six in Kenya and seven in Tanzania. Thematic analysis was used to analyse the documents. RESULTS: Seventeen guidance documents were identified (Kenya=10; Tanzania=7). These included pre-existing and/or updated policies/strategic plans, guidelines, a letter, a policy brief and a report. Neither country had comprehensive policies/guidelines to ensure continuity of NCD care before the COVID-19 pandemic. However, efforts were made to update pre-existing documents and several more were developed during the pandemic to guide NCD care. Some measures were put in place during the COVID-19 period to ensure continuity of care for patients with NCDs such as longer supply of medicines. Inadequate attention was given to monitoring and evaluation and implementation issues. CONCLUSION: Kenya and Tanzania developed and updated some policies/guidelines to include continuity of care in emergencies. However, there were gaps in the documents and between policy/guideline documents and practice. Health systems need to establish disaster preparedness plans that integrate attention to NCD care to enable them to better handle severe disruptions caused by emergencies such as pandemics. Such guidance needs to include contingency planning to enable adequate resources for NCD care and must also address evaluation of implementation effectiveness.

Understanding the role of the Tanzania national health insurance fund in improving service coverage and quality of care.

Health insurance is one of the main financing mechanisms currently being used in low and middle-income countries to improve access to quality services. Tanzania has been running its National Health Insurance Fund (NHIF) since 2001 and has recently undergone significant reforms. However, there is limited attention to the causal mechanisms through which NHIF improves service coverage and quality of care. This paper aims to use a system dynamics (qualitative) approach to understand NHIF causal pathways and feedback loops for improving service coverage and quality of care at the primary healthcare level in Tanzania. We used qualitative interviews with 32 stakeholders from national, regional, district, and health facility levels conducted between May to July 2021. Based on the main findings and themes generated from the interviews, causal mechanisms, and feedback loops were created. The majority of feedback loops in the CLDs were reinforcing cycles for improving service coverage among beneficiaries and the quality of care by providers, with different external factors affecting these two actions. Our main feedback loop shows that the NHIF plays a crucial role in providing additional financial resources to facilities to purchase essential medical commodities to deliver care. However, this cycle is often interrupted by reimbursement delays. Additionally, beneficiaries' perception that lower-level facilities have poorer quality of care has reinforced care seeking at higher-levels. This has decreased lower level facilities' ability to benefit from the insurance and improve their capacity to deliver quality care. Another key finding was that the NHIF funding has resulted in better services for insured populations compared to the uninsured. To increase quality of care, the NHIF may benefit from improving its reimbursement administrative processes, increasing the capacity of lower levels of care to benefit from the insurance and appropriately incentivizing providers for continuity of care.

The impacts of family planning and HIV service integration on contraceptive prevalence among HIV positive women in Tanzania: a comparative analysis from the 2016/17 Tanzania HIV impact survey.

BACKGROUND: Prevention of unplanned pregnancies through modern contraceptives among HIV-positive women is one of the essential strategies for reducing mother-to-child transmission of HIV. Family planning and HIV services integration is a national strategy designed to scale-up modern contraceptives among HIV-positive women. This study aims to evaluate the success of a service integration strategy by comparing the prevalence of modern contraceptive use among HIV-positive women receiving ART within integrated services and those not on integrated services (HIV-negative women and HIV-positive women unaware of their status). METHODS: We used data from the Tanzania HIV impact survey (THIS) of 2016/17. THIS provided HIV counselling and testing with a return of results in over 30,000 adults over 15 years of age. Women tested positive self reported their enrollment into ARV with further confirmation through laboratory analysis for any detectible ARV in their blood. All non-pregnant women reported their contraceptive use. Univariate and multivariate logistic regression was used to assess the effect of accessing integrated services controlling for potential confounders. RESULTS: A total of 14,986 women were included in the analysis; HIV-positive women were 1,066 and HIV-negative women were 13,830. Modern contraceptive use prevalence was 35% among HIV-positive women and 30% among HIV-negative women. Among HIV-positive women, those enrolled in integrated services (ART) had a higher prevalence of modern contraceptive (40%) compared to HIV-positive women unaware of their status (27%, p-value = 0.0014). The most common contraceptive methods in HIV-positive women were injectables (32%) and male condoms (31%), while in HIV-negative women, injectables (39%) and implants (30%, n = 1032) were the most preferred methods. Among HIV-positive women, enrolment into integrated services (currently on ART) demonstrated an increase in the odds of modern contraceptives by 85% (AOD = 1.85, 95%CI: 1.27-2.71). CONCLUSION: This study found relatively low modern contraceptive use among HIV-positive women in the general population despite the existance of service integration program and guidelines to guide its implementation.Our study therefore calls for the evaluation on the implementation of the integration programme to identify factors that constrain or facilitate programme effectiveness.

Healthcare workers' experiences with COVID-19-related prevention and control measures in Tanzania.

The ability of a health system to withstand shocks such as a pandemic depends largely on the availability and preparedness of health-care workers (HCWs), who are at the frontline of disease management and prevention. Despite the heavy burden placed on HCWs during the COVID-19 pandemic, little is known regarding their experiences in low-income countries. We conducted a web-based survey with HCWs in randomly selected districts of Tanzania to explore their experiences with COVID-19-related prevention and control measures. The survey assessed implementation of COVID-19 control guidelines in health facilities, HCW perceptions of safety, well-being and ability to provide COVID-19 care, and challenges faced by frontline workers during the pandemic. We used multivariate regression analysis to examine the association between HCW and health facility characteristics, a score of guideline implementation, and challenges faced by HCWs. 6,884 Tanzanian HCWs participated in the survey between December 2021 to March 2022. The majority of respondents were aware of the COVID-19 guidelines and reported implementing preventive measures, including masking of both HCWs and patients. However, HCWs faced several challenges during the pandemic, including increased stress, concerns about infection, and inadequate personal protective equipment. In particular, female HCWs were more likely to report exhaustion from wearing protective equipment and emotional distress, while physicians were more likely to experience all challenges. While most HCWs reported feeling supported by facility management, they also reported that their concerns about COVID-19 treatment were not fully addressed. Notably, perceptions of protection and well-being varied widely among different HCW cadres, highlighting the need for targeted interventions based on level of exposure. In addition, various factors such as HCW cadre, facility ownership and COVID-19 designation status influenced HCWs' opinions about the health system's response to COVID-19. These findings highlight the importance of consistent implementation of guidelines and social and emotional support for HCWs.

Factors associated with COVID-19 vaccine uptake among people with type 2 diabetes in Kenya and Tanzania: a mixed-methods study.

BACKGROUND: People with type 2 diabetes (T2D) are at increased risk of poor outcomes from COVID-19. Vaccination can improve outcomes, but vaccine hesitancy remains a major challenge. We examined factors influencing COVID-19 vaccine uptake among people with T2D in two sub-Saharan Africa countries that adopted different national approaches to combat COVID-19, Kenya and Tanzania. METHODS: A mixed-methods study was conducted in February-March 2022, involving a survey of 1000 adults with T2D (500 Kenya; 500 Tanzania) and 51 in-depth interviews (21 Kenya; 30 Tanzania). Determinants of COVID-19 vaccine uptake were identified using a multivariate logistic regression model, while thematic content analysis explored barriers and facilitators. RESULTS: COVID-19 vaccine uptake was lower in Tanzania (26%) than in Kenya (75%), which may reflect an initial political hesitancy about vaccines in Tanzania. People with college/university education were four times more likely to be vaccinated than those with no education (Kenya AOR=4.25 (95% CI 1.00 to 18.03), Tanzania AOR=4.07 (1.03 to 16.12)); and people with health insurance were almost twice as likely to be vaccinated than those without health insurance (Kenya AOR=1.70 (1.07 to 2.70), Tanzania AOR=1.81 (1.04 to 3.13)). Vaccine uptake was higher in older people in Kenya, and among those with more comorbidities and higher socioeconomic status in Tanzania. Interviewees reported that wanting protection from severe illness promoted vaccine uptake, while conflicting information, misinformation and fear of side-effects limited uptake. CONCLUSION: COVID-19 vaccine uptake among people with T2D was suboptimal, particularly in Tanzania, where initial political hesitancy had a negative impact. Policy-makers must develop strategies to reduce fear and misconceptions, especially among those who are less educated, uninsured and younger.

Process of developing the National Health in All Policies Framework to address social determinants of health in Tanzania Mainland: lessons learned, 2018 - 2022.

Introduction: social determinants of health (SDH) are the non-medical factors that contribute to various infectious and non-infectious diseases in Tanzania. Studies suggest that SDH account for 30-55% of health outcomes globally. Most SDH are outside the mandate of the health sector; hence, multi-sectoral collaboration through Health in All Policies (HiAP) is critical. Health in All Policies looks at public policies across sectors that consider health implications of decisions, seek synergies, use resources and avoid harmful health impacts to improve population health and health equity. This paper demonstrates lessons learned from the process of developing National HiAP Framework in Tanzania Mainland to address SDH. It is expected that countries will be able to learn and adopt what deems fit in their context as they address SDH to improve population health. Methods: different methods were used to promote multi-sectoral collaboration in addressing SDH through HiAP. They included consultations with Prime Minister's Office (PMO) as the coordinator of Government business for their buy-in. High-level advocacy meetings of Directors of Policy and Planning and Permanent Secretaries from sectoral ministries were conducted to move forward the HiAP agenda. Capacity building was provided for sectoral Ministries to understand HiAP concept and SDH. Interministerial collaboration meetings were convened to bring sectors together to identify SDH issues and key areas for inter-sectoral collaboration and develop National HiAP Framework to address SDH. Health in All Policies Secretariat coordinates the HiAP activities. Results: it has been noted that almost every sectoral ministry has a health component in its policy which contributes to the Tanzanian population's health. In this regard, every sectoral ministry has a role to play in addressing SDH for sustainable development. Political will is key in moving forward the HiAP agenda. The role of PMO is significant to ensure inter-sectoral collaboration. Achieving the national and Sustainable Development Goals require strong collaboration among sectors and stakeholder coordination at all levels through HiAP. Conclusion: implementing HiAP is a win-win situation. It enhances inter-sectoral collaboration, benefiting each sector to achieve its health-related strategic indicators and ultimately achieve national and global goals.

Catastrophic health care spending in managing type 2 diabetes before and during the COVID-19 pandemic in Tanzania.

COVID-19 disrupted health care provision and access and reduced household income. Households with chronically ill patients are more vulnerable to these effects as they access routine health care. Yet, a few studies have analysed the effect of COVID-19 on household income, health care access costs, and financial catastrophe due to health care among patients with type 2 diabetes (T2D), especially in developing countries. This study fills that knowledge gap. We used data from a cross-sectional survey of 500 people with T2D, who were adults diagnosed with T2D before COVID-19 in Tanzania (March 2020). Data were collected in February 2022, reflecting the experience before and during COVID-19. During COVID-19, household income decreased on average by 16.6%, while health care costs decreased by 0.8% and transport costs increased by 10.6%. The overall financing burden for health care and transport relative to household income increased by 32.1% and 45%, respectively. The incidences of catastrophic spending above 10% of household income increased by 10% (due to health care costs) and by 55% (due to transport costs). The incidences of catastrophic spending due to health care costs were higher than transport costs, but the relative increase was higher for transport than health care costs (10% vs. 55% change from pre-COVID-19). The likelihood of incurring catastrophic health spending was lower among better educated patients, with health insurance, and from better-off households. COVID-19 was associated with reduced household income, increased transport costs, increased financing burden and financial catastrophe among patients with T2D in Tanzania. Policymakers need to ensure financial risk protection by expanding health insurance coverage and removing user fees, particularly for people with chronic illnesses. Efforts are also needed to reduce transport costs by investing more in primary health facilities to offer quality services closer to the population and engaging multiple sectors, including infrastructure and transportation.

Social-political and vaccine related determinants of COVID-19 vaccine hesitancy in Tanzania: A qualitative inquiry.

Vaccines have played a critical role in the response to the COVID-19 pandemic globally, and Tanzania has made significant efforts to make them available to the public in addition to sensitizing them on its benefit. However, vaccine hesitancy remains a concern. It may prevent optimal uptake of this promising tool in many communities. This study aims to explore opinions and perceptions on vaccine hesitancy to better understand local attitudes towards vaccine hesitancy in both rural and urban Tanzania. The study employed cross-sectional semi-structured interviews with 42 participants. The data were collected in October 2021. Men and women aged between 18 and 70 years were purposefully sampled from Dar es Salaam and Tabora regions. Thematic content analysis was used to categorize data inductively and deductively. We found that COVID-19 vaccine hesitancy exists and is shaped by multiple socio-political and vaccine related factors. Vaccine related factors included worries over vaccine safety (e.g., death, infertility, and zombie), limited knowledge about the vaccines and fear of the vaccine's impact on pre-existing conditions. Participants also found it paradoxical that mask and hygiene mandates are expected even after vaccination, which further exacerbated their doubts about vaccine efficacy and their hesitancy. Participants possessed a range of questions regarding COVID-19 vaccines that they wanted answered by the government. Social factors included preference for traditional and home remedies and influence from others. Political factors included inconsistent messages on COVID-19 from the community and political leaders; and doubts about the existence of COVID-19 and the vaccine. Our findings suggest that the COVID-19 vaccine is beyond a medical intervention, it carries with it a variety of expectations and myths that need to be addressed in order to build trust and acceptance within communities. Health promotion messages need to respond to heterogeneous questions, misinformation, doubts, and concerns over safety issues. An understanding of country-specific perspectives toward COVID-19 vaccines can greatly inform the development of localized strategies for meaningful uptake in Tanzania.

Gender in public health research: Reflections on design and process across four research projects in low-and middle-income countries.

A growing body of work clearly documents the gendered inequalities in health. The COVID-19 pandemic further exposed these deep inequities: men appear to be more vulnerable to poorer outcomes, but most of the global health workforce is female who are at increased risk of exposure to hospital infection. However, researchers often fail to adequately embed gender as part of the public health research. This paper reports findings from a synthesis exercise that identified some of the challenges of integrating gender in the design and processes of research studies in four projects conducted in six low- and middle-income countries. Through a collective retrospective meta-synthesis process with researchers from each project, we identified two main themes; (i) we deep dive on two of the structural pillars of conducting public health research (design and process) and (ii) we describe some of the underlying opportunities and resistances to the integration of a gender perspective in these research projects. In conclusion, we suggest that public health funding bodies require researchers to integrate gender in public health research from early on as part of the design and to conduct gendered analysis, as part of the overall drive towards more equitable health systems delivery.

Impact evaluation of the TAMANI project to improve maternal and child health in Tanzania.

BACKGROUND: The Tabora Maternal and Newborn Health Initiative project was a multicomponent intervention to improve maternal and newborn health in the Tabora region of Tanzania. Components included training healthcare providers and community health workers, infrastructure upgrades, and improvements to health management. This study aimed to examine the impact of trainings on four key outcomes: skilled birth attendance, antenatal care, respectful maternity care and patient-provider communication. METHODS: Trainings were delivered sequentially at four time points between 2018 and 2019 in eight districts (two districts at a time). Cross-sectional surveys were administered to a random sample of households in all districts at baseline and after each training wave. Due to practical necessities, the original stepped wedge cluster randomised design of the evaluation was altered mid-programme. Therefore, a difference-in-differences for multiple groups in multiple periods was adopted to compare outcomes in treated districts to not yet treated districts. Risk differences were estimated for the overall average treatment effect on the treated and group/time dynamic effects. RESULTS: Respondents reported 3895 deliveries over the course of the study. The intervention was associated with a 12.9 percentage point increase in skilled birth attendance (95% CI 0.4 to 25.4), which began to increase 4 months after the end of training in each district. There was little evidence of impact on antenatal care visits, respectful treatment during delivery and patient-provider communication. CONCLUSION: Interventions to train local healthcare workers in basic and comprehensive emergency obstetric and newborn care increased skilled birth attendance but had limited impact on other pregnancy-related outcomes.

Informal Support Networks of Tanzanians With Chronic Diseases: Predictors of Support Provision and Treatment Adherence.

Objectives: To examine the role of NCD patients' social ties as informal caregivers and whether receiving their support is associated with engagement in care. Methods: NCD outpatients (N2 = 100) in rural Tanzania completed a cross-sectional questionnaire to characterize the support role of their social ties (N1 = 304). Bivariate analyses explored predictors of social support and whether social support is associated with engagement in care. Results: This study found that 87% of participants had health insurance, yet 25% received financial support for financing healthcare. Patient gender, age and marital status were found to be important predictors of social support, with NCD-related disability and disease severity being predictive to a lesser degree. Monthly receipt of both material and non-material support were associated with increased odds of adherence to prescribed medications. Conclusion: These findings indicate that patients' social ties play an important role in filling the gaps in formal social health protection and incur substantial costs by doing so. The instrumental role of even non-material social support in promoting engagement in care deserves greater attention when developing policies for improving this population's engagement in care.

Care cascades for hypertension and diabetes: Cross-sectional evaluation of rural districts in Tanzania.

BACKGROUND: Noncommunicable diseases (NCDs), especially hypertension and diabetes, are rapidly rising in sub-Saharan Africa, necessitating health systems transformations. In Tanzania, current policies aim to improve control of hypertension and diabetes, but information is still needed to assess the gaps in treatment. METHODS AND FINDINGS: We conducted a cross-sectional household survey of 784 adults in two districts in Tanzania from December 2020 to January 2021, capturing the cascade-of-care for hypertension and diabetes. The ages of the respondents ranged from 18 to 89 years. Of those screened positive for these conditions, we measured the proportion in each step of the cascades: awareness, care engagement, treatment, and control. We conducted multivariable logistic regression analyses for all four steps along the hypertension care cascade with the independent variables of social health protection schemes, and prior diagnosis of comorbid diabetes, and demographic information. In our sample, of the 771 who had their blood pressure measured, 41% (95% confidence interval (CI): 38% to 44%) were screened positive for hypertension, and of the 707 who had their blood sugar measured, 6% (95% CI: 4% to 8%) were screened positive for diabetes. Of those with hypertension, 43% (95% CI: 38% to 49%) had a prior diagnosis, 25% (95% CI: 21% to 31%) were engaged in care, 21% (95% CI: 3% to 25%) were on treatment, and 11% (95% CI: 8% to 15%) were controlled. Of the 42 respondents with diabetes, 80% (95% CI: 69% to 93%) had a prior diagnosis. The diabetes care cascade had much less drop-off, so 66% of those with diabetes (95% CI: 52% to 82%) were engaged in care and on treatment, and 48% (95% CI: 32% to 63%) had their diabetes controlled at the point of testing. Healthcare fee exemptions were independently associated with higher odds of being previously diagnosed (OR 5.81; 95% CI [1.98 to 17.10] p < 0.005), engaged in care (OR 4.71; 95% CI [1.59 to 13.90] p 0.005), and retained in treatment (OR 2.93; 95% CI [1.03 to 8.35] p < 0.05). Prior diagnosis of comorbid diabetes was highly associated with higher odds of being engaged in care for hypertension (OR 3.26; 95% CI [1.39 to 7.63] p < 0.005). The two primary limitations of this study were reliance on screening at a single time point only of people available at the village at the time of the sample and dependence on self-report for to inform the three cascade steps of prior diagnosis, healthcare visits for engagement in care, and treatment use. CONCLUSIONS: The high burden of hypertension and low levels of control in our study underscores the importance of improving the awareness and treatment of hypertension. The differences in the care cascades for hypertension and diabetes demonstrates that chronic NCD treatment is possible in this setting, but efforts will be needed across the entire care cascade to improve hypertension control.

Multimorbidity.

Multimorbidity (two or more coexisting conditions in an individual) is a growing global challenge with substantial effects on individuals, carers and society. Multimorbidity occurs a decade earlier in socioeconomically deprived communities and is associated with premature death, poorer function and quality of life and increased health-care utilization. Mechanisms underlying the development of multimorbidity are complex, interrelated and multilevel, but are related to ageing and underlying biological mechanisms and broader determinants of health such as socioeconomic deprivation. Little is known about prevention of multimorbidity, but focusing on psychosocial and behavioural factors, particularly population level interventions and structural changes, is likely to be beneficial. Most clinical practice guidelines and health-care training and delivery focus on single diseases, leading to care that is sometimes inadequate and potentially harmful. Multimorbidity requires person-centred care, prioritizing what matters most to the individual and the individual's carers, ensuring care that is effectively coordinated and minimally disruptive, and aligns with the patient's values. Interventions are likely to be complex and multifaceted. Although an increasing number of studies have examined multimorbidity interventions, there is still limited evidence to support any approach. Greater investment in multimorbidity research and training along with reconfiguration of health care supporting the management of multimorbidity is urgently needed.

"I see salt everywhere": A qualitative examination of the utility of arts-based participatory workshops to study noncommunicable diseases in Tanzania and Malawi.

The burden of noncommunicable diseases (NCDs) including hypertension, diabetes, and cancer, is rising in Sub-Saharan African countries like Tanzania and Malawi. This increase reflects complex interactions between diverse social, environmental, biological, and political factors. To intervene successfully, new approaches are therefore needed to understand how local knowledges and attitudes towards common NCDs influence health behaviours. This study compares the utility of using a novel arts-based participatory method and more traditional focus groups to generate new understandings of local knowledges, attitudes, and behaviours towards NCDs and their risk factors. Single-gender arts-based participatory workshops and focus group discussions were conducted with local communities in Tanzania and Malawi. Thematic analysis compared workshop and focus group transcripts for depth of content and researcher-participant hierarchies. In addition, semiotic analysis examined the contribution of photographs of workshop activities to understanding participants' experiences and beliefs about NCD risk factors. The arts-based participatory workshops produced in-depth, vivid, emotive narratives of participants' beliefs about NCDs and their impact (e.g., "… it spreads all over your body and kills you-snake's poison is similar to diabetes poison"), while the focus groups provided more basic accounts (e.g., "diabetes is a fast killer"). The workshops also empowered participants to navigate activities with autonomy, revealing their almost overwhelmingly negative beliefs about NCDs. However, enabling participants to direct the focus of workshop activities led to challenges, including the perpetuation of stigma (e.g., comparing smells associated with diabetes symptoms with sewage). Semiotic analysis of workshop photographs provided little additional insight beyond that gained from the transcripts. Arts-based participatory workshops are promising as a novel method to inform development of culturally relevant approaches to NCD prevention in Tanzania and Malawi. Future research should incorporate more structured opportunities for participant reflection during the workshops to minimise harm from any emerging stigma.

Factors affecting non-coverage of measles-rubella vaccination among children aged 9-59 months in Tanzania.

Globally, measles remains a major cause of child mortality, and rubella is the leading cause of birth defects among all infectious diseases. In 2012, the World Health Assembly endorsed the Global Vaccine Action Plan that set a target to eliminate Measles-Rubella (MR) in five of the six World Health Organization (WHO) regions by 2020. This was cross-sectional study employed both quantitative and qualitative research methods. The sample size was calculated to provide overall, age- and sex-specific coverage estimates for MR vaccine among children aged between 9 and 59 months at the national level. Using desired precision of ±5% with an expected coverage of 95%, a total of 15,235 households were required. The age of children, a child who had received the MR vaccine before the campaign, household wealth quintile, the age of caregivers, and their marital status were associated with non-coverage of MR vaccination among children aged 9-59 months in Tanzania. Nationally, an estimated 88.2% (95% CI: 87.3-89%) of children aged 9-59 months received the MR campaign dose, as assessed by caregivers' recall. These estimates revealed slightly higher coverage in Zanzibar 89.6% (95% CI: 84.7-93%) compared to Mainland Tanzania 88.1% (95% CI 87.2-88.9%). These associated factors revealed causes of unvaccinated children and may be some of the reasons for Tanzania's failure to meet the MR campaign target of 95 percent vaccination coverage. Thus, vaccine development must increase programmatic oversight in order to improve immunization activities and communication strategies in Tanzanian areas with low MR coverage.

Governance factors that affect the implementation of health financing reforms in Tanzania: an exploratory study of stakeholders' perspectives.

The development of effective and inclusive health financing reforms is crucial for the progressive realisation of universal health coverage in low-income and middle-income countries. Tanzania has been reforming health financing policies to expand health insurance coverage and achieve better access to quality healthcare for all. Recent reforms have included improved community health funds (iCHFs), and others are underway to implement a mandatory national health insurance scheme in order to expand access to services and improve financial risk protection. Governance is a crucial structural determinant for the successful implementation of health financing reforms, however there is little understanding of the governance elements that hinder the implementation of health financing reforms such as the iCHF in Tanzania. Therefore, this study used the perspectives of health sector stakeholders to explore governance factors that influence the implementation of health financing reforms in Tanzania. We interviewed 36 stakeholders including implementers of health financing reforms, policymakers and health insurance beneficiaries in the regions of Dodoma, Dar es Salaam and Kilimanjaro. Normalisation process theory and governance elements guided the structure of the in-depth interviews and analysis. Governance factors that emerged from participants as facilitators included a shared strategic vision for a single mandatory health insurance, community engagement and collaboration with diverse stakeholders in the implementation of health financing policies and enhanced monitoring of iCHF enrolment due to digitisation of registration process. Governance factors that emerged as barriers to the implementation were a lack of transparency, limited involvement of the private sector in service delivery, weak accountability for revenues generated from community level and limited resources due to iCHF design. If stakeholders do not address the governance factors that hinder the implementation of health financing reforms, then current efforts to expand health insurance coverage are unlikely to succeed on their own.