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.

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 analysed 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 community 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 environment, 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.

Increasing uptake of antenatal care services is crucial for improving maternal and child health. One of the strategies that has been found to be relevant for improving uptake of antenatal care services in resource constrained countries especially in rural communities is implementation of community based initiatives. This study focused on the project that was implemented in Iringa region, Tanzania under the Innovating for Maternal and Child Health in Africa (IMCHA) program, which was implemented through community based initiatives.In order to understand community contextual factors that facilitated or constrained implementation of the IMCHA project, a participatory approach was applied to seek views from women groups as key project implementers and other stakeholders such as community leaders, male champions' religious leaders, health care providers and health facility governing committees. A total of one hundred forty six people were engaged in interviews and focused group discussions.Community readiness to adopt the interventions emerged as a determining factor for success of the project. Stakeholder engagement also enabled participatory implementation. The major constraining factors were the physical environment that made navigation through the villages difficult as well as negative feedback from family members.This study concludes that community readiness and participatory approaches can be enhanced by various aspects integrated in the initial designing of project activities. This strengthens the project support system critical for sustainability.

Why do pregnant women in Iringa region in Tanzania start antenatal care late? A qualitative analysis.

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.

Do Management and Leadership Practices in the Context of Decentralisation Influence Performance of Community Health Fund? Evidence From Iramba and Iringa Districts in Tanzania.

BACKGROUND: In early 1990s, Tanzania like other African countries, adopted health sector reform (HSR). The most strongly held centralisation system that informed the nature of services provision including health was, thus, disintegrated giving rise to decentralisation system. It was within the realm of HSR process, user fees were introduced in the health sector. Along with user fees, various types of health insurances, including the Community Health Fund (CHF), were introduced. While the country's level of enrolment in the CHF is low, there are marked variations among districts. This paper highlights the role of decentralised health management and leadership practices in the uptake of the CHF in Tanzania. METHODS: A comparative exploratory case study of high and low performing districts was carried out. In-depth interviews were conducted with the members of the Council Health Service Board (CHSB), Council Health Management Team (CHMT), Health Facility Committees (HFCs), in-charges of health facilities, healthcare providers, and Community Development Officers (CDOs). Minutes of the meetings of the committees and district annual health plans and district annual implementation reports were also used to verify and triangulate the data. Thematic analysis was adopted to analyse the collected data. We employed both inductive and deductive (mixed coding) to arrive to the themes. RESULTS: There were no differences in the level of education and experience of the district health managers in the two study districts. Almost all district health managers responsible for the management of the CHF had attended some training on management and leadership. However, there were variations in the personal initiatives of the top-district health leaders, particularly the district health managers, the council health services board and local government officials. Similarly, there were differences in the supervision mechanisms, and incentives available for the health providers, HFCs and board members in the two study districts. CONCLUSION: This paper adds to the stock of knowledge on CHFs functioning in Tanzania. By comparing the best practices with the worst practices, the paper contributes valuable insights on how CHF can be scaled up and maintained. The study clearly indicates that the performance of the community-based health financing largely depends on the personal initiatives of the top-district health leaders, particularly the district health managers and local government officials. This implies that the regional health management team (RHMT) and the Ministry of Health and Social Welfare (MoHSW) should strengthen supportive supervision mechanisms to the district health managers and health facilities. More important, there is need for the MoHSW to provide opportunities for the well performing districts to share good practices to other districts in order to increase uptake of the community-based health insurance.