Cost analysis for initiating an integrated package of essential non-communicable disease interventions (PEN-Plus) in Kondoa District Hospital, Tanzania: a time-driven activity-based costing (TDABC) study protocol.

INTRODUCTION: Non-communicable diseases (NCDs) constitute approximately 74% of global mortality, with 77% of these deaths occurring in low-income and middle-income countries. Tanzania exemplifies this situation, as the percentage of total disability-adjusted life years attributed to NCDs has doubled over the past 30 years, from 18% to 36%. To mitigate the escalating burden of severe NCDs, the Tanzanian government, in collaboration with local and international partners, seeks to extend the integrated package of essential interventions for severe NCDs (PEN-Plus) to district-level facilities, thereby improving accessibility. This study aims to estimate the cost of initiating PEN-Plus for rheumatic heart disease, sickle cell disease and type 1 diabetes at Kondoa district hospital in Tanzania. METHODS AND ANALYSIS: We will employ time-driven activity-based costing (TDABC) to quantify the capacity cost rates (CCR), and capital and recurrent costs associated with the implementation of PEN-Plus. Data on resource consumption will be collected through direct observations and interviews with nurses, the medical officer in charge and the heads of laboratory and pharmacy units/departments. Data on contact times for targeted NCDs will be collected by observing a sample of patients as they move through the care delivery pathway. Data cleaning and analysis will be done using Microsoft Excel. ETHICS AND DISSEMINATION: Ethical approval to conduct the study has been waived by the Norwegian Regional Ethics Committee and was granted by the Tanzanian National Health Research Ethics Committee NIMR/HQ/R.8a/Vol.IX/4475. A written informed consent will be provided to the study participants. This protocol has been disseminated in the Bergen Centre for Ethics and Priority Setting International Symposium, Norway and the 11th Muhimbili University of Health and Allied Sciences Scientific Conference, Tanzania in 2023. The findings will be published in peer-reviewed journals for use by the academic community, researchers and health practitioners.

HIV burden and the global fast-track targets progress among pregnant women in Tanzania calls for intensified case finding: Analysis of 2020 antenatal clinics HIV sentinel site surveillance.

BACKGROUND: For successful HIV response, updated information on the burden and progress toward HIV elimination targets are required to guide programmatic interventions. We used data from the 2020 HIV sentinel surveillance to update on the burden and factors associated with HIV infection, HIV status awareness, and ART coverage among pregnant women in Tanzania mainland. METHODOLOGY: We conducted the surveillance in 159 antenatal clinics (ANC) from all 26 regions of Tanzania's mainland from September to December 2020. This cross-sectional study included all pregnant women (≥15 years) on their first ANC visit in the current pregnancy during the survey period. Routine HIV counselling and testing were done at the facility. A multivariable logistic regression model accounting for the survey design was used to examine factors associated with HIV infections. RESULTS: 38,783 pregnant women were enrolled (median age (IQR) = 25 (21-30) years). HIV prevalence was 5.9% (95%CI: 5.3% - 6.6%), ranging from 1.9% in the Manyara region to 16.4% in the Njombe region. Older age, lower and no education, not being in a marital union, and living in urban or semi-urban areas were associated with higher odds of HIV infection. HIV status awareness among women who tested positive was 70.9% (95% CI: 67.5%- 74.0%). ART coverage among those aware of their status was 91.6% (86.5%- 94.9%). Overall, 66.6% (95% CI: 62.4%- 70.6%) of all pregnant women who tested positive for HIV knew their HIV status and were on ART. CONCLUSION: HIV is increasingly prevalent among pregnant women in Tanzania mainland especially among older, those with lower or no formal education, those outside marital union, and pregnant women living in urban and semi-urban areas. Behind the global fast-target to end HIV/ AIDS, about a third of pregnant women living with HIV initiating ANC were not on ART. Interventions to increase HIV testing and linkage to care among women of reproductive age should be intensified.

Epidemiology of syphilis infections among pregnant women in Tanzania: Analysis of the 2020 national representative sentinel surveillance.

BACKGROUND: Syphilis has detrimental effects on the health of the mother and that of both fetuses and newborns exposed in utero or at delivery. Understanding its local epidemiology is essential for policies, planning, and implementation of targeted preventive interventions. Using data from the 2020 National Sentinel Surveillance of pregnant women attending antenatal clinics (ANCs) in Tanzania we determined the prevalence and determinants of syphilis among pregnant women in Tanzania mainland. METHODOLOGY: The ANC surveillance was conducted in 159 ANC sites from all 26 regions of Tanzania's mainland from September to December 2020. It included all pregnant women 15 years and above on their first ANC visit in the current pregnancy during the survey period. Counseling for syphilis was done using standard guidelines at the ANC and testing was done using rapid SD Bioline HIV/Syphilis Duo test kits. Analysis was done using both descriptive statistics to determine the prevalence and characteristics of syphilis, whereas, logistic regressions were used to examine the independent association between syphilis and dependent variables. RESULTS: A total of 38,783 women [median age (Interquartile range (IQR)) = 25 (21-30) years] participated in the surveillance. Of them, 582 (1.4%) tested positive for syphilis. A wide regional variation was observed with the highest burden in Kagera (4.5%) to the lowest burden in Kigoma (0.3%). The odds of syphilis infections were higher among older women and those with no formal education. Compared with primigravids, women with 1-2, those with 3-4 and those with more than four previous pregnancies had 1.8 (aOR = 1.8, 95% CI: 1.2-2.5), 2.1 (aOR = 2.1, 95% CI: 1.4-3.1) and 2.6 (aOR = 2.6, 95% CI: 1.7-3.9) higher odds of syphilis infection respectively. CONCLUSION: Syphilis is still prevalent among pregnant women in Tanzania with a wide regional disparity. Efforts to prevent new infections, screen pregnant women, and treat those infected should be strategized to include all regions and renewed emphasis on regions with high burden, and importantly among women who are multipara, with a low level of education, and advanced age.

Understanding the implication of direct health facility financing on health commodities availability in Tanzania.

The Government of Tanzania (GoT) has in the last decade made progress in strengthening the health system financing with progress towards Universal Health Coverage (UHC). The major reforms includes development of the health financing strategy, reforming the Community Health Fund (CHF) and introduction of the Direct Health Facility Financing (DHFF). DHFF was introduced in all district councils in the 2017/18 financial year. One of the anticipated goals of DHFF is to improve availability of health commodities. The objective of this study is to assess the effect of DHFF in improving the availability of health commodities in primary health care facilities. This study employed cross sectional study design, using quantitative techniques to analyze data related to expenditures and availability of health commodities at the primary health care facilities in Tanzania mainland. Secondary data was extracted from Electronic Logistics Management Information System (eLMIS) and Facility Financial Accounting and Reporting System (FFARS). Descriptive analysis was used to summarize the data using Microsoft Excel (2021) and inferential analysis was done using Stata SE 16.1. There has been an increase in allocation of funds for health commodities over the past three years. The Health Basket Funds (HBFs) accounted for an average of 50% of all health commodities expenditures. The complimentary funds (user fees and insurance) contributed about 20%, which is less than the 50% required by the cost sharing guideline. There is potentiality in DHFF improving visibility and tracking of health commodities funding. Implementation of DHFF has increased the amount of funding for health commodities at health facilities. The visibility and tracking of health commodity funding has improved. There is a scope of increasing health commodity funds at health facilities since the expenditures on health commodities is lower than what is indicated in the cost sharing collection and use guideline.

National Evaluation of HIV Service Resource Allocation in Tanzania.

Using time-driven activity-based costing (TDABC), we examined resource allocation and costs for HIV services throughout Tanzania at patient and facility levels. This national, cross-sectional analysis of 22 health facilities quantified costs and resources associated with 886 patients receiving care for five HIV services: antiretroviral therapy, prevention of mother-to-child transmission, HIV testing and counseling, voluntary medical male circumcision, and pre-exposure prophylaxis. We also documented total provider-patient interaction time, the cost of services with and without inclusion of consumables, and conducted fixed-effects multivariable regression analyses to examine patient- and facility-level correlates of costs and provider-patient time. Findings showed that resources and costs for HIV care varied significantly throughout Tanzania, including as a function of patient- and facility-level characteristics. While some variation may be preferable (e.g., needier patients received more resources), other areas suggested a lack of equity (e.g., wealthier patients received more provider time) and presented opportunities to optimize care delivery protocols.

HIV virologic response, patterns of drug resistance mutations and correlates among adolescents and young adults: A cross-sectional study in Tanzania.

BACKGROUND: The emergence of HIV drug resistance mutations (DRMs) is of significant threat to achieving viral suppression (VS) in the quest to achieve global elimination targets. We hereby report virologic outcomes and patterns of acquired DRMs and its associated factors among adolescents and young adults (AYA) from a broader HIV drug resistance surveillance conducted in Tanzania. METHODS: Data of AYA was extracted from a cross-sectional study conducted in 36 selected facilities using a two-stage cluster sampling design. Dried blood spot (DBS) samples were collected and samples with a viral load (VL) ≥1000 copies/mL underwent genotyping for the HIV-1 pol gene. Stanford HIV database algorithm predicted acquired DRMs, Fisher's exact test and multivariable logistic regression assessed factors associated with DRMs and VS, respectively. FINDINGS: We analyzed data of 578 AYA on antiretroviral therapy (ART) for 9-15 and ≥ 36 months; among them, 91.5% and 88.2% had VS (VL<1000copies/mL) at early and late time points, respectively. Genotyping of 64 participants (11.2%) who had VL ≥1000 copies/ml detected 71.9% of any DRM. Clinically relevant DRMs were K103N, M184V, M41L, T215Y/F, L210W/L, K70R, D67N, L89V/T, G118R, E138K, T66A, T97A and unexpectedly absent K65R. Participants on a protease inhibitor (PI) based regimen were twice as likely to not achieve VS compared to those on integrase strand transfer inhibitors (INSTI). The initial VL done 6 months after ART initiation of ≥1000copies/mL was the primary factor associated with detecting DRMs (p = .019). CONCLUSIONS: VS amongst AYA is lower than the third UNAIDs target. Additionally, a high prevalence of ADR and high levels of circulating clinically relevant DRMs may compromise the long-term VS in AYA. Furthermore, the first VL result of ≥1000copies/ml after ART initiation is a significant risk factor for developing DRMs. Thus, strict VL monitoring for early identification of treatment failure and genotypic testing during any ART switch is recommended to improve treatment outcomes for AYA.

Emerging integrase strand transfer inhibitor drug resistance mutations among children and adults on ART in Tanzania: findings from a national representative HIV drug resistance survey.

BACKGROUND: Despite the scale-up of ART and the rollout in Tanzania of dolutegravir, an integrase strand transfer inhibitor (INSTI), treatment success has not been fully realized. HIV drug resistance (HIVDR), including dolutegravir resistance, could be implicated in the notable suboptimal viral load (VL) suppression among HIV patients. OBJECTIVES: To determine the prevalence and patterns of acquired drug resistance mutations (DRMs) among children and adults in Tanzania. METHODS: A national cross-sectional HIVDR survey was conducted among 866 children and 1173 adults. Genotyping was done on dried blood spot and/or plasma of participants with high HIV VL (≥1000 copies/mL). HIV genes (reverse transcriptase, protease and integrase) were amplified by PCR and directly sequenced. The Stanford HIVDR Database was used for HIVDR interpretation. RESULTS: HIVDR genotyping was performed on blood samples from 137 participants (92 children and 45 adults) with VL ≥ 1000 copies/mL. The overall prevalence of HIV DRMs was 71.5%, with DRMs present in 78.3% of children and 57.8% of adults. Importantly, 5.8% of participants had INSTI DRMs including major DRMs: Q148K, E138K, G118R, G140A, T66A and R263K. NNRTI, NRTI and PI DRMs were also detected in 62.8%, 44.5% and 8% of participants, respectively. All the participants with major INSTI DRMs harboured DRMs targeting NRTI backbone drugs. CONCLUSIONS: More than 7 in 10 patients with high HIV viraemia in Tanzania have DRMs. The early emergence of dolutegravir resistance is of concern for the efficacy of the Tanzanian ART programme.

Perceived performance of health facility governing committees in overseeing healthcare services delivery in primary health care facilities in Tanzania.

Health Facility Governing Committees (HFGCs) play a vital role in overseeing health services delivery in the primary health care system. However, despite their existence in Tanzania hiccups remain reported on the quality of health services delivered in primary health care facilities. The latter poses a question on the performance of HFGCs in overseeing the services delivery at the primary health facilities. This study sought to assess the perceived performance of the HFGCs and the associated factors in overseeing the healthcare services delivery at the primary health facilities in Tanzania. A cross-sectional study was conducted in five regions of Tanzania: Mwanza, Dar Es Salaam, Kilimanjaro, Pwani, and Arusha. A self-administered questionnaire containing structured questions was used to gather information from randomly selected 574 HFGC members. Data were analyzed descriptively and the binary logistic regression model was used to determine factors associated with the perceived performance. Half (50.52%) of the HFGCs members perceived themselves to have good performance. Furthermore, only 51.05% of all the participants had received any form of health management and governance training whereby about two-thirds had received training for only 1 day. The main factors associated with the perceived low performance of the HFGCs members were age, level of education and duration served in the HFGC. A low level of education was associated with the poor perceived performance of the HFGC (AOR 0.36 [CI: 0.23-0.55]). Similarly with increasing age, the odds of good-perceived performance lowered (AOR 0.26 [CI: 0.13, 0.55]). Serving as a HFGC member for less than 1 year was associated with poor perceived performance (AOR 0.40 [CI: 0.17, 0.95]). From these findings, it is recommended that the criteria for recruitment of HFGC members should be revisited. Furthermore, a qualitative study to explore contextual factors influencing the perforce of HFGCs is recommended.

Estimating the cost and efficiency gain of rolling out a multi-month dispensing programme for antiretroviral treatment in Tanzania.

Background: Globally, efforts to curtail the HIV pandemic are growing. The Joint United Nations Programme on HIV and AIDS (UNAIDS) and partners set the 95-95-95 targets to be achieved by 2025. Tanzania's ongoing transition from single-month ARV to longer multi-month dispensing (MMD) involves significant planning and shifts in existing resources, including health commodities, clinical staff and storage space. This study aimed at evaluating the costs and efficiency gains of rolling out MMD compared to the prior monthly dispending (MD) standard of care before the new guidelines.Methods: The analysis employed a health provider perspective utilising prior costing data collected to estimate cost of treatment for HIV/AIDS, including salaries, laboratory costs, antiretroviral drugs, other supplies and overhead costs. The projections were run from 2018 to 2030 using the Spectrum package for Tanzania.Results: Our model estimated that total treatment cost without MMD (including salaries, laboratory costs, antiretroviral drugs, other supplies, and overhead costs) is estimated to rise from USD 189 million in 2018 to USD 244 million in 2030. The introduction of a six-month MMD would lead to the total annual facility-based treatment costs being reduced to USD 205 million in 2030. When comparing MD to a six-month MMD, the total savings over the 13-year period would be USD 425 million. The introduction of six-month MMD for stable patients would reduce the average cost from USD 180 to USD 156 per patient per year if stable patients were only required to make six-monthly visit.Conclusions: The introduction of differentiated service delivery models (DSDMs) and MMD is already contributing to significant cost savings for Tanzania and will continue to do so as the country puts more stable patients on MMD. The potential gains from MMD implantation could further be harnessed if retention of treatment and viral suppression monitoring are prioritised.

Strengthening financial management systems at primary health care: Performance assessment of the Facility Financial Accounting and Reporting System (FFARS) in Tanzania.

Background: Universal coverage remains a challenging pursuit around the world, even among the highest-income countries. Strengthening financial management capacity is essential towards attaining the three universal health coverage (UHC) goals, namely, expanded coverage, quality service, and financial protection. In this regard, Tanzania introduced the Facility Financial Accounting and Reporting System (FFARS) in line with the introduction of the Direct Health Facility Financing (DHFF) initiative in primary health care (PHC) in 2017-2018. We aim to assess the functionality of the FFARS in management, accounting, and reporting funds received and disbursed in the stride forward strengthening public financial management in PHC facilities towards UHC. Methods: The study applied implementation research using a concurrent convergent mixed-methods design to assess sources of revenue, expenditure priorities, and changes of revenues and to explore the usability and benefits of FFARS in improving facility finance and reporting systems in more than 5,000 PHC facilities in Tanzania. Quantitative methods assessed the changes in revenues and expenditure between the financial years (FYs) 2017-2018 and 2018-2019, while the qualitative part explored the usability and the benefits FFARS offers in improving facility finances and reporting systems. Data analysis involved a thematic and descriptive analysis for qualitative and quantitative data, respectively. Results: Of the 5,473 PHC facilities, 88% were in rural areas; however, the annual average revenue was higher in urban facilities in FYs 2017-2018 and 2018-2019. Overall, district hospitals showed an increase whereas health centers reported a decline of more than 40% in revenue. The user fee was the predominant source of revenue, particularly in urban facilities, while revenue from health insurance was not among the top three highest sources of revenue. Expenditure priorities leaned more towards drugs and supplies (25%) followed by allowances and training (21%); these did not differ by facility geographies. In health centers, expenditure on facility infrastructure was predominant. Key Informant Interviews revealed an overall satisfaction and positive experiences related to the system. Conclusion: The implementation of FFARS in Tanzania demonstrated its high potential in improving facility financial management, including its ability to track revenue and expenditure at PHC facilities. Staffing shortages, ICT infrastructure, and limited opportunities for capacity building could be the limiting factors to reaching the potential of the implementation of FFARS and the attainment of its full impact on Tanzania's pursuit for UHC.

The public health sector supply chain costs in Tanzania.

Tanzania's supply chain system is a complicated web of integrated and vertical systems, covering essential and vertical programs health commodities, laboratory and diagnostics, equipment, and supplies. Despite significant improvement in the supply chain over the decades, the availability of medicines has remained uneven. Therefore, identifying the cost of operating the supply chain is vital to facilitate allocation of adequate finances to run the supply chain. We adopted a three-step approach to costing, which included i) identification, ii) measurement, and (iii) valuation of the resource use. Two levels of the Tanzanian supply chain system were examined to determine the cost of running the supply chain by function. These included first the Medical Stores Department (MSD) central and zonal level, secondly the health service delivery level that include National, Zonal and regional hospitals and the Primary Health Care (District Hospital, health center and Dispensary). The review adopted the health system perspective, whereby all resources consumed in delivering health commodities were considered, resource use was then classified as financial and economic costs. The costing period was an average of two financial years, 2015/16 and 2016/17. The cost data were exchanged from Tanzania Shillings to 2017 US$ and then adjusted for inflation to 2020 US$. The study used the total sales reported in audited financial accounts for throughput value. The average annual costs of running the supply chain at the central MSD was estimated at USD$ 15.5 million and US$ 4.1 million at the four sampled MSD Zonal branches. There is a wide variation in annual running costs among MSD zonal branches; the supply chain's unit cost was highest in the Dodoma zone and lowest in the Mwanza zone at 26% and 8%, respectively. When examined on a cost-per-unit basis, supply chain systems operate at sub-optimal levels at health facilities at a unit cost of 37% per unit of commodity throughput value. There are inefficiencies in supply chain financing in Tanzania. Storage costs are higher than distribution costs, this may imply some efficiency gains. MSD should employ a "just in time" inventory model, reducing the inventory holding costs, including the high-expired commodities holding charge, this could be improved by increasing the order fill rate.

Acquired HIV drug resistance among children and adults receiving antiretroviral therapy in Tanzania: a national representative survey protocol.

INTRODUCTION: Tanzania is making an enormous effort in scaling-up of antiretroviral therapy (ART). However, people living with HIV (PLHIV) continue to succumb to the challenge of drug resistance. Evidence on drug resistance for a national survey is unavailable in Tanzania. Therefore, we sought to assess viral suppression (vs) rates and magnitude of acquired drug resistance (ADR) among PLHIV. METHODS AND ANALYSIS: A national survey will be conducted from 26 July to 29 October 2021 in 22 regions, recruiting 2160 participants. These will include adults on ART for 9-15 months and ≥48 months and children on ART for 9-15 months and ≥36 months. A standardised questionnaire will capture participants' demographic and clinical data. Plasma and dried blood spot will be prepared for viral load testing and drug resistance genotyping. Statistical analyses to determine the burden of ADR, characteristics and factors associated therewith will be done using STATA V.15. ETHICS AND DISSEMINATION: Ethical approval has been obtained from the National Health Research Ethics Committee of Tanzania (NIMR/HQ/R.8a/Vol.IX/3432). Appropriate participant informed consent or parental consent and assent will be obtained. Dissemination will include a survey report, conference presentations, policy briefs and peer-reviewed publications.

The health system costs of post abortion care in Tanzania.

BACKGROUND: Unsafe abortion is common in Tanzania. Currently, postabortion care (PAC) is legally provided, but there is little information on the national cost. We estimated the health system costs of offering PAC in Tanzania in 2018, at existing levels of care and when hypothetically expanded to meet all need. METHODS: We employed a bottom-up costing methodology. Between October 2018 and February 2019, face-to-face interviews were conducted with facility administrators and PAC providers in a sample of 40 health facilities located across seven mainland regions and Zanzibar. We collected data on the direct and indirect cost of care, fees charged to patients, and costs incurred by patients for PAC supplies. Sensitivity analysis was used to explore the impact of uncertainty in the analysis. RESULTS: Overall, 3850 women received PAC at the study facilities in 2018. At the national level, 77,814 women received PAC, and the cost per patient was $58. The national health system cost for PAC provision at current levels totaled nearly $4.5 million. Meeting all need for PAC would increase costs to over $11 million. Public facilities bore the majority of PAC costs, and facilities recovered just 1% of costs through charges to patients. On average PAC patients incurred $7 in costs ($6.17 for fees plus $1.35 in supplies). CONCLUSIONS: Resources for health care are limited. While working to scale up access to PAC services to meet women's needs, Tanzanian policymakers should consider increasing access to contraception to prevent unintended pregnancies.

Cost-Efficiency Analysis of the Improved Web-Based Planning, Budgeting, and Reporting System (PlanRep) in Tanzania.

Background: Information systems offer unlimited potential for innovation and digitalization of management functions to facilitate citizen participation and improve accountability, transparency, and efficiency in government operations and service delivery. In line with this, for more than one decade, Tanzania implemented an integrated planning, budgeting, and reporting system (PlanRep) that was used to prepare plans and budgets at the local government authorities (LGAs) using a desktop application. In 2017, PlanRep was upgraded to a Web-based system to address several challenges, including poor coordination and high cost involved in the preparation of plans and budgets. However, operational evidence regarding the cost-efficiencies and benefits of shifting to Web-based PlanRep has not been explored. This study aims to address this gap by assessing efficiency gains (in terms of cost and time) of shifting to a Web-based PlanRep system as a tool for the preparation of LGA plans and budgets. Methods: The study applied a retrospective before-and-after study design whereby quantitative data was used to assess the amount of time and the cost incurred by LGAs when preparing their budget 1 year before the introduction of PlanRep and 1 year after. Parallelly, qualitative data were collected through key informant interviews with selected LGA officials, Regional Secretariats (RSs), President's Office Regional Administration and Local Government (PORALG), and system end-users such as heads of health facilities and schools (primary and secondary). Secondary data was analyzed by comparing time and cost used before and after Web-based PlanRep, while thematic analysis was employed for qualitative data. Results: The analysis showed a 53% reduction (from USD 3.8 million in 2017/18 to USD 1.8 million in 2018/19) in the total costs LGAs incurred during planning and budgeting after introducing the Web-based PlanRep. The main efficiency gain was related to per diem costs. The analysis also showed significant time saving from an average of 87 days in 2017/18 to only 8 days in 2018/19. PlanRep system end-users also acknowledged that the introduction of Web-based PlanRep has significantly saved their time and costs in preparation of LGA plans and budget. Conclusion: The introduction of the Web-based planning, budgeting, and reporting systems has resulted in tremendous cost reduction, time savings, transparency, accountability, and workload reduction. The findings offer operational evidence to guide the implementation and scale up of similar systems in countries that share equivalent circumstances like Tanzania.

Cost-effectiveness analysis of population-based tobacco control strategies in the prevention of cardiovascular diseases in Tanzania.

BACKGROUND: Tobacco consumption contributes significantly to the global burden of disease. The prevalence of smoking is estimated to be increasing in many low-income countries, including Tanzania, especially among women and youth. Even so, the implementation of tobacco control measures has been discouraging in the country. Efforts to foster investment in tobacco control are hindered by lack of evidence on what works and at what cost. AIMS: We aim to estimate the cost and cost-effectiveness of population-based tobacco control strategies in the prevention of cardiovascular diseases (CVD) in Tanzania. MATERIALS AND METHODS: A cost-effectiveness analysis was performed using an Excel-based Markov model, from a governmental perspective. We employed an ingredient approach and step-down methodologies in the costing exercise following a government perspective. Epidemiological data and efficacy inputs were derived from the literature. We used disability-adjusted life years (DALYs) averted as the outcome measure. A probabilistic sensitivity analysis was carried out with Ersatz to incorporate uncertainties in the model parameters. RESULTS: Our model results showed that all five tobacco control strategies were very cost-effective since they fell below the ceiling ratio of one GDP per capita suggested by the WHO. Increase in tobacco taxes was the most cost-effective strategy, while a workplace smoking ban was the least cost-effective option, with a cost-effectiveness ratio of US$5 and US$267, respectively. CONCLUSIONS: Even though all five interventions are deemed very cost-effective in the prevention of CVD in Tanzania, more research on budget impact analysis is required to further assess the government's ability to implement these interventions.

Equity impact analysis of medical approaches to cardiovascular diseases prevention in Tanzania.

Primary medical prevention of cardiovascular disease (CVD) has received low priority in Tanzania, despite evidence of the rising prevalence of CVD risk factors. Different guidelines have been proposed for medical CVD prevention, including the European Society of Cardiology (ESC) and the World Health Organization (WHO) guidelines, which recommend medical prevention for all individuals based on the consideration of single CVD risk thresholds. A third alternative is differentiated risk thresholds according to age. This paper compares the WHO and the differentiated risk threshold by age approaches against a baseline of no medical CVD prevention and a best scenario identical to the ESC approach in Tanzania. Assuming fixed budgets, we evaluate the guidelines according to three outcome measures, namely: efficiency, inequality and the combination of efficiency and inequality. We ran a Markov analysis for an estimated Tanzanian population at risk of CVD employing a 40 years time horizon to estimate the total expected costs and CVD deaths associated with provision of the different guidelines. The results were then used to calculate three outcomes: life expectancy at age 40 as a proxy for efficiency, the Gini coefficient (a measure of inequality), and the achievement index (which combines concerns of efficiency and inequality). Our results suggest that higher life expectancy (28.3 vs. 26.6 years) and more equally distributed health (Gini coefficient of 0.22 vs. 0.24) could be attained if medical CVD prevention was based on the differentiated risk threshold approach compared to the WHO single risk threshold, when the total cost of these approaches is the same. Preventing CVD based on differentiating risk thresholds by age seems to be the better alternative when concerns of both efficiency and inequality are considered important. However, further research on the country-specific distribution of CVD risk levels and budget impact analysis are important to assess the feasibility of its implementation.

Cost-effectiveness of medical primary prevention strategies to reduce absolute risk of cardiovascular disease in Tanzania: a Markov modelling study.

BACKGROUND: Cardiovascular disease (CVD) is a growing cause of mortality and morbidity in Tanzania, but contextualized evidence on cost-effective medical strategies to prevent it is scarce. We aim to perform a cost-effectiveness analysis of medical interventions for primary prevention of CVD using the World Health Organization's (WHO) absolute risk approach for four risk levels. METHODS: The cost-effectiveness analysis was performed from a societal perspective using two Markov decision models: CVD risk without diabetes and CVD risk with diabetes. Primary provider and patient costs were estimated using the ingredients approach and step-down methodologies. Epidemiological data and efficacy inputs were derived from systematic reviews and meta-analyses. We used disability- adjusted life years (DALYs) averted as the outcome measure. Sensitivity analyses were conducted to evaluate the robustness of the model results. RESULTS: For CVD low-risk patients without diabetes, medical management is not cost-effective unless willingness to pay (WTP) is higher than US$1327 per DALY averted. For moderate-risk patients, WTP must exceed US$164 per DALY before a combination of angiotensin converting enzyme inhibitor (ACEI) and diuretic (Diu) becomes cost-effective, while for high-risk and very high-risk patients the thresholds are US$349 (ACEI, calcium channel blocker (CCB) and Diu) and US$498 per DALY (ACEI, CCB, Diu and Aspirin (ASA)) respectively. For patients with CVD risk with diabetes, a combination of sulfonylureas (Sulf), ACEI and CCB for low and moderate risk (incremental cost-effectiveness ratio (ICER) US$608 and US$115 per DALY respectively), is the most cost-effective, while adding biguanide (Big) to this combination yielded the most favourable ICERs of US$309 and US$350 per DALY for high and very high risk respectively. For the latter, ASA is also part of the combination. CONCLUSIONS: Medical preventive cardiology is very cost-effective for all risk levels except low CVD risk. Budget impact analyses and distributional concerns should be considered further to assess governments' ability and to whom these benefits will accrue.

Cost-effectiveness of live oral attenuated human rotavirus vaccine in Tanzania.

BACKGROUND: Globally, diarrhoea is the second leading cause of morbidity and mortality, responsible for the annual loss of about 10% of the total global childhood disease burden. In Tanzania, Rotavirus infection is the major cause of severe diarrhoea and diarrhoeal mortality in children under five years. Immunisation can reduce the burden, and Tanzania added rotavirus vaccine to its national immunisation programme in January 2013. This study explores the cost effectiveness of introducing rotavirus vaccine within the Tanzania Expanded Programme on Immunisation (EPI). METHODS: We quantified all health system implementation costs, including programme costs, to calculate the cost effectiveness of adding rotavirus immunisation to EPI and the existing provision of diarrhoea treatment (oral rehydration salts and intravenous fluids) to children. We used ingredients and step down costing methods. Cost and coverage data were collected in 2012 at one urban and one rural district hospital and a health centre in Tanzania. We used Disability Adjusted Life Years (DALYs) as the outcome measure and estimated incremental costs and health outcomes using a Markov transition model with weekly cycles up to a five-year time horizon. RESULTS: The average unit cost per vaccine dose at 93% coverage is US$ 8.4, with marked difference between the urban facility US$ 5.2; and the rural facility US$ 9.8. RV1 vaccine added to current diarrhoea treatment is highly cost effective compared to diarrhoea treatment given alone, with incremental cost effectiveness ratio of US$ 112 per DALY averted, varying from US$ 80-218 in sensitivity analysis. The intervention approaches a 100% probability of being cost effective at a much lower level of willingness-to-pay than the US$609 per capita Tanzania gross domestic product (GDP). CONCLUSIONS: The combination of rotavirus immunisation with diarrhoea treatment is likely to be cost effective when willingness to pay for health is higher than USD 112 per DALY. Universal coverage of the vaccine will accelerate progress towards achievement of the child health Millennium Development Goals.

Economic cost of primary prevention of cardiovascular diseases in Tanzania.

Tanzania is facing a double burden of disease, with non-communicable diseases being an increasingly important contributor. Evidence-based preventive measures are important to limit the growing financial burden. This article aims to estimate the cost of providing medical primary prevention interventions for cardiovascular disease (CVD) among at-risk patients, reflecting actual resource use and if the World Health Organization (WHO)'s CVD medical preventive guidelines are implemented in Tanzania. In addition, we estimate and explore the cost to patients of receiving these services. Cost data were collected in four health facilities located in both urban and rural settings. Providers' costs were identified and measured using ingredients approach to costing and resource valuation followed the opportunity cost method. Unit costs were estimated using activity-based and step-down costing methodologies. The patient costs were obtained through a structured questionnaire. The unit cost of providing CVD medical primary prevention services ranged from US$30-41 to US$52-71 per patient per year at the health centre and hospital levels, respectively. Employing the WHO's absolute risk approach guidelines will substantially increase these costs. The annual patient cost of receiving these services as currently practised was estimated to be US$118 and US$127 for urban and rural patients, respectively. Providers' costs were estimated from two main viewpoints: 'what is', that is the current practice, and 'what if', reflecting a WHO guidelines scenario. The higher cost of implementing the WHO guidelines suggests the need for further evaluation of whether these added costs are reasonable relative to the added benefits. We also found considerably higher patient costs, implying that distributive and equity implications of access to care require more consideration. Facility location surfaced as the main explanatory variable for both direct and indirect patient costs in the regression analysis; further research on the influence of other provider characteristics on these costs is important.

Addressing inequity to achieve the maternal and child health millennium development goals: looking beyond averages.

BACKGROUND: Inequity in access to and use of child and maternal health interventions is impeding progress towards the maternal and child health Millennium Development Goals. This study explores the potential health gains and equity impact if a set of priority interventions for mothers and under fives were scaled up to reach national universal coverage targets for MDGs in Tanzania. METHODS: We used the Lives Saved Tool (LiST) to estimate potential reductions in maternal and child mortality and the number of lives saved across wealth quintiles and between rural and urban settings. High impact maternal and child health interventions were modelled for a five-year scale up, by linking intervention coverage, effectiveness and cause of mortality using data from Tanzania. Concentration curves were drawn and the concentration index estimated to measure the equity impact of the scale up. RESULTS: In the poorest population quintiles in Tanzania, the lives of more than twice as many mothers and under-fives were likely to be saved, compared to the richest quintile. Scaling up coverage to equal levels across quintiles would reduce inequality in maternal and child mortality from a pro rich concentration index of -0.11 (maternal) and -0.12 (children) to a more equitable concentration index of -0,03 and -0.03 respectively. In rural areas, there would likely be an eight times greater reduction in maternal deaths than in urban areas and a five times greater reduction in child deaths than in urban areas. CONCLUSIONS: Scaling up priority maternal and child health interventions to equal levels would potentially save far more lives in the poorest populations, and would accelerate equitable progress towards maternal and child health MDGs.