A cohort study of survival following discharge from hospital in rural Tanzanian children using linked data of admissions with community-based demographic surveillance.

BACKGROUND: To illustrate the public health potential of linking individual bedside data with community-based household data in a poor rural setting, we estimated excess pediatric mortality risk after discharge from St Francis Designated District Hospital in Ifakara, Tanzania. METHODS: Linked data from demographic and clinical surveillance were used to describe post-discharge mortality and survival probability in children aged < 5 years, by age group and cause of admission. Cox regression models were developed to identify risk factors. RESULTS: Between March 2003 and March 2007, demographic surveillance included 28,910 children aged 0 to 5 years and among them 831 (3%) were admitted at least once to the district hospital. From all the children under the demographic surveillance 57,880 person years and 1381 deaths were observed in 24 months of follow up. Survivors of hospital discharge aged 0-5 years were almost two times more likely to die than children of the same age in the community who had not been admitted (RR = 1.9, P < 0.01, 95% CI 1.6, 2.4). Amongst children who had been admitted, mortality rate within a year was highest in infants (93 per 1000 person years) and amongst those admitted due to pneumonia and diarrhoea (97 and 85 per 1000 person years respectively). Those who lived 75 km or further from the district hospital, amongst children who were admitted and survived discharge from hospital, had a three times greater chance of dying within one year compared to those living within 25 km (adjusted HR 3.23, 95% CI 1.54,6.75). The probability of surviving the first 30 days post hospitalization was 94.4% [95% CI 94.4, 94.9], compared to 98.8% [95% CI 97.199.5] in non-hospitalized children of the same age in the commuity. CONCLUSION: This study illustrates the potential of linking health related data from facility and household levels. Our results suggest that families may need additional support post hospitalization.

Setting priorities for knowledge translation of Cochrane reviews for health equity: Evidence for Equity.

BACKGROUND: A focus on equity in health can be seen in many global development goals and reports, research and international declarations. With the development of a relevant framework and methods, the Campbell and Cochrane Equity Methods Group has encouraged the application of an 'equity lens' to systematic reviews, and many organizations publish reviews intended to address health equity. The purpose of the Evidence for Equity (E4E) project was to conduct a priority-setting exercise and apply an equity lens by developing a knowledge translation product comprising summaries of systematic reviews from the Cochrane Library. E4E translates evidence from systematic reviews into 'friendly front end' summaries for policy makers. METHODS: The following topic areas with high burdens of disease globally, were selected for the pilot: diabetes/obesity, HIV/AIDS, malaria, nutrition, and mental health/depression. For each topic area, a "stakeholder panel" was assembled that included policymakers and researchers. A systematic search of Cochrane reviews was conducted for each area to identify equity-relevant interventions with a meaningful impact. Panel chairs developed a rating sheet which was used by all panels to rank the importance of these interventions by: 1) Ease of Implementation; 2) Health System Requirements; 3)Universality/Generalizability/Share of Burden; and 4) Impact on Inequities/Effect on equity. The ratings of panel members were averaged for each intervention and criterion, and interventions were ordered according to the average overall ratings. RESULTS: Stakeholder panels identified the top 10 interventions from their respective topic areas. The evidence on these interventions is being summarized with an equity focus and the results posted online, at http://methods.cochrane.org/equity/e4e-series . CONCLUSIONS: This method provides an explicit approach to setting priorities by systematic review groups and funders for providing decision makers with evidence for the most important equity-relevant interventions.

The challenge to avoid anti-malarial medicine stock-outs in an era of funding partners: the case of Tanzania.

BACKGROUND: Between 2007 and 2013, the Tanzanian public sector received 93.1 million doses of first-line anti-malarial artemisinin-based combination therapy (ACT) in the form of artemether-lumefantrine entirely supplied by funding partners. The introduction of a health facility ACT stock monitoring system using SMS technology by the National Malaria Control Programme in mid 2011 revealed a high frequency of stock-outs of ACT in primary care public health facilities. The objective of this study was to determine the pattern of availability of ACT and possible causes of observed stock-outs across public health facilities in Tanzania since mid-2011. METHODS: Data were collected weekly by the mobile phone reporting tool SMS for Life on ACT availability from over 5,000 public health facilities in Tanzania starting from September 2011 to December 2012. Stock data for all four age-dose levels of ACT across health facilities were summarized and supply of ACT at the national level was also documented. RESULTS: Over the period of 15 months, on average 29% of health facilities in Tanzania were completely stocked out of all four-age dose levels of the first-line anti-malarial with a median duration of total stock-out of six weeks. Patterns of total stock-out by region ranged from a low of 9% to a high of 52%. The ACT stock-outs were most likely caused by: a) insufficient ACT supplies entering Tanzania (e.g. in 2012 Tanzania received 10.9 million ACT doses compared with a forecast demand of 14.4 million doses); and b) irregular pattern of ACT supply (several months with no ACT stock). CONCLUSION: The reduced ACT availability and irregular pattern of supply were due to cumbersome bureaucratic processes and delays both within the country and from the main donor, the Global Fund to Fight AIDS, Tuberculosis and Malaria. Tanzania should invest in strengthening both the supply system and the health information system using mHealth solutions such as SMS for Life. This will continue to assist in tracking ACT availability across the country where all partners work towards more streamlined, demand driven and accountable procurement and supply chain systems.

Quick wins versus sustainability: options for the upscaling of insecticide-treated nets.

A review of the main elements determining strategic choices for the large-scale distribution of insecticide-treated nets (ITNs) clearly shows the need for multiple strategies. Mass distributions of free nets provide a unique opportunity to achieve quickly high coverage rates. However, there is also a need for additional approaches to 1) provide continuous provision of ITNs for newly pregnant women and their babies and 2) provide protection for the rest of the population. Targeted subsidies will continue to be an important tool to achieve the first objective, either through direct distribution of ITNs or through vouchers. To achieve objective 2, a strong and competitive commercial sector for ITNs seems to be a good option. It is clear that "one size doesn't fit all," and more experience needs to be gathered and shared. With planning and good promotion campaigns, these strategies can co-exist and re-enforce each other.

Creating an "enabling environment" for taking insecticide treated nets to national scale: the Tanzanian experience.

INTRODUCTION: Malaria is the largest cause of health services attendance, hospital admissions and child deaths in Tanzania. At the Abuja Summit in April 2000 Tanzania committed itself to protect 60% of its population at high risk of malaria by 2005. The country is, therefore, determined to ensure that sustainable malaria control using insecticide-treated nets is carried out on a national scale. CASE DESCRIPTION: Tanzania has been involved for two decades in the research process for developing insecticide-treated nets as a malaria control tool, from testing insecticides and net types, to assessing their efficacy and effectiveness, and exploring new ways of distribution. Since 2000, the emphasis has changed from a project approach to that of a concerted multi-stakeholder action for taking insecticide-treated nets to national scale (NATNETS). This means creating conditions that make insecticide-treated nets accessible and affordable to all those at risk of malaria in the country. This paper describes Tanzania's experience in (1) creating an enabling environment for insecticide-treated nets scale-up, (2) promoting the development of a commercial sector for insecticide-treated nets, and (3) targeting pregnant women with highly subsidized insecticide-treated nets through a national voucher scheme. As a result, nearly 2 million insecticide-treated nets and 2.2 million re-treatment kits were distributed in 2004. CONCLUSION: National upscaling of insecticide-treated nets is possible when the programme is well designed, coordinated and supported by committed stakeholders; the Abuja target of protecting 60% of those at high risk is feasible, even for large endemic countries.

When civil registration is inadequate: interim methods for generating vital statistics.

Comprehensive guidelines and tools to help countries rapidly improve their vital statistics systems, based on international best practice are now available. For many countries, however, attainment of timely, accurate statistics on births and deaths and causes of death will require years of strategic and prioritized investment, with technical assistance from WHO, the United Nations, and academia. In the meantime, however, countries will need accurate and unbiased data in order to measure progress with their health programs and broader development goals, such as the MDGs and the growing crisis of non-communicable diseases. This article has introduced some interim strategies that can yield adequate vital statistics and cause of death data as countries work to strengthen their civil registration systems. These methods mirror the skills, practices and advantages of complete and functioning civil registration and vital statistics systems, but for a sample of the population. They are based on the principle of rigorous and continuous data collection for a defined and manageable part of the population. Doing "smaller, representative" populations well rather than "larger populations poorly" will reduce the biases that would otherwise occur from missing data, incorrect application of data management procedures, poor data quality checking and lack of medical certification of causes of death. A critical component of this strategy is to routinely apply verbal autopsy methods to collect essential cause of death data. When properly applied, VA can yield population-based cause of death data of comparable quality to what is typically collected in hospitals in developing countries. Moreover, with the availability of automated methods to diagnose causes of death, it is now possible to obtain accurate cause of death data routinely, cheaply and quickly in resource-poor settings. The long-term goal of strengthening civil registration and vital statistics systems is to ensure that every birth and death is properly registered, and that causes of death are accurately certified. Stakeholders wishing to establish sentinel surveillance or sample registration should work in collaboration with national and local authorities responsible for civil registration and should support and promote the formal registration of births and deaths whenever possible. In addition, sentinel or sample registration systems should help strengthen the capacity of the health system to correctly certify the causes of death for each decedent.