Understanding the implementation of Direct Health Facility Financing and its effect on health system performance in Tanzania: a non-controlled before and after mixed method study protocol.

BACKGROUND: Globally, good health system performance has resulted from continuous reform, including adaptation of Decentralisation by Devolution policies, for example, the Direct Health Facility Financing (DHFF). Generally, the role of decentralisation in the health sector is to improve efficiency, to foster innovations and to improve quality, patient experience and accountability. However, such improvements have not been well realised in most low- and middle-income countries, with the main reason cited being the poor mechanism for disbursement of funds, which remain largely centralised. The introduction of the DHFF programme in Tanzania is expected to help improve the quality of health service delivery and increase service utilisation resulting in improved health system performance. This paper describes the protocol, which aims to evaluate the effects of DHFF on health system performance in Tanzania. METHODS: An evaluation of the effect of the DHFF programme will be carried out as part of a nationwide programme rollout. A before and after non-controlled concurrent mixed methods design study will be employed to examine the effect of the DHFF programme implementation on the structural quality of maternal health, health facility governing committee governance and accountability, and health system responsiveness as perceived by the patients' experiences. Data will be collected from a nationally representative sample involving 42 health facilities, 422 patient consultations, 54 health workers, and 42 health facility governing committees in seven regions from the seven zones of the Tanzanian mainland. The study is grounded in a conceptual framework centered on the Theory of Change and the Implementation Fidelity Framework. The study will utilise a mixture of quantitative and qualitative data collection tools (questionnaires, focus group discussions, in-depth interviews and documentary review). The study will collect information related to knowledge, acceptability and practice of the programme, fidelity of implementation, structural qualities of maternal and child health services, accountability, governance, and patient perception of health system responsiveness. DISCUSSION: This evaluation study will generate evidence on both the process and impact of the DHFF programme implementation, and help to inform policy improvement. The study is expected to inform policy on the implementation of DHFF within decentralised health system government machinery, with particular regard to health system strengthening through quality healthcare delivery. Health system responsiveness assessment, accountability and governance of Health Facility Government Committee should bring autonomy to lower levels and improve patient experiences. A major strength of the proposed study is the use of a mixed methods approach to obtain a more in-depth understanding of factors that may influence the implementation of the DHFF programme. This evaluation has the potential to generate robust data for evidence-based policy decisions in a low-income setting.

Inland valley rice production systems and malaria infection and disease in the forest region of western Côte d'Ivoire.

BACKGROUND: This study aimed to determine the epidemiological impact of rice cultivation in inland valleys on malaria in the forest region of western Côte d'Ivoire. The importance of malaria was compared in terms of prevalence and parasite density of infections and also in terms of clinical malaria incidence between three agro-ecosystems: (i) uncultivated inland valleys, (R0), (ii) inland valleys with one annual rice cultivation in the rainy season, (R1) and (iii) developed inland valleys with two annual rice cultivation cycles, (R2). METHODS: Between May 1998 and March 1999, seven villages of each agro-ecosystem (R0, R1 and R2) were randomly selected among villages pooled by farming system. In these 21 villages, a total of 1,900 people of all age groups were randomly selected and clinically monitored during one year. Clinical and parasitological information was obtained by active case detection of malaria episodes carried out during eight periods of five consecutive days scheduled at six weekly intervals and by cross-sectional surveys. RESULTS: Plasmodium falciparum was the principal parasite observed in the three agro-ecosystems. A level of holoendemicity of malaria was observed in the three agro-ecosystems with more than 75% of children less than 12 months old infected. Geometric mean parasite density in asymptomatic persons varied between 180 and 206 P. falciparum asexual forms per µL of blood and was associated with season and with age, but not with farming system. The mean annual malaria incidence rate reached 0.7 (95% IC 0.5-0.9) malaria episodes per person in R0, 0.7 (95% IC 0.6-0.9) in R1 and 0.6 (95% IC 0.5-0.7) in R2. The burden of malaria was the highest among children under two years of age, with at least four attacks by person-year. Then malaria incidence decreased by half in the two to four-year age group. From the age of five years, the incidence was lower than one attack by person-year. Malaria incidence varied with season with more cases in the rainy season than in the dry season but not with farming system. CONCLUSION: In the forest area of western Côte d'Ivoire, inland valley rice cultivation was not significantly associated with malaria burden.

Malaria transmission in relation to rice cultivation in the irrigated Sahel of Mali.

Seven cross-sectional entomological surveys were carried out from September 1995 to February 1998 in three irrigated rice growing villages and three villages without irrigated agriculture in the area surrounding Niono, located 350km north-east of Bamako, Mali. The transmission pattern differed markedly between the two zones. In the irrigated zone, the transmission of malaria was fairly constant over the seasons at a low level. In the non-irrigated zone, transmission was mostly below detection level during the dry season, whereas it was high toward the end of the rainy season. In the irrigated zone, high densities of mosquitoes were correlated with low anthropophily, low sporozoite indices and probably low survival rates. In the non-irrigated zone, mosquito densities were lower and these relationships were less pronounced. Differential use of mosquito nets in the two zones may have been an important factor in the observed differences in transmission. The presence of cattle may also have played an important role. Two mosquito-catching methods (human landing catch and spray catch) were compared.

Living in the paddies: a social science perspective on how inland valley irrigated rice cultivation affects malaria in Northern Côte d'Ivoire.

The potential impact of irrigated agriculture on water-related vector-borne diseases has been an increasing source of concern for researchers from the bio-medical sector. While most research on the potential impacts of irrigation on the health of local populations focuses on vector densities, levels of exposures, health services and technologies (prophylaxis, mosquito nets), we argue that it is essential to enlarge the scope of investigation and consider the complex mechanisms by which factors such as agriculture-generated changes in ecosystems, gender repositioning in the family organization as a result of access to new crops, and production activities combine together in increasing disease risks and producing new scenarios in the management of disease. This paper presents the results of an investigation of how transformations induced on the local society by the intensification of inland valley irrigated rice cultivation influence malaria health care systems and modulate risks to the health of local populations, within well-defined geographical boundaries in northern Côte d'Ivoire. Our results indicate that socio-economic transformations and gender repositioning induced, or facilitated, by the intensification of inland valley irrigated rice cultivation lead to a reduction of the capacity of women to manage disease episodes, contributing therefore to increase malaria incidence among farming populations.

The relationship between Anopheles gambiae density and rice cultivation in the savannah zone and forest zone of Côte d'Ivoire.

In 13 villages in the savannah zone and 21 villages in the forest zone of Côte d'Ivoire, the biting density of the principal malaria vector, Anopheles gambiae, was studied as a function of rice cultivation in the inland valleys in a 2-km radius around each village. In the savannah villages, during the main season cropping period, surface water on rice-cultivated and to a lesser extent on uncultivated inland valleys seems to contribute strongly to the A. gambiae population density. For the off-season cropping period (which starts after the first light rains in the savannah zone), correlations were weaker. Breeding sites other than in inland valleys may play an important role in the savannah zone. In the forest zone, however, the A. gambiae population density was strongly correlated with the surface water availability (SWA) in the rice-cultivated inland valleys, whereas the correlation with the SWA in other (uncultivated) inland valleys was weak. The requirement of sunlit breeding sites for A. gambiae might explain this difference between zones. In the forest zone, only inland valleys cleared for rice cultivation meet this requirement, whereas all other inland valleys are covered with dense vegetation. In the savannah zone, however, most undergrowth is burnt during the dry season, which permits sunlight to reach puddles resulting from the first rains.

Household-based malaria control in a highly endemic area of Africa (Tanzania): determinants of transmission and disease and indicators for monitoring - Kilombero Malaria Project

The Kilombero Malaria Project (KMP) attemps to define opperationally useful indicators of levels of transmission and disease and health system relevant monitoring indicators to evaluate the impact of disease control at the community or health facility level. The KMP is longitudinal community based study (N = 1024) in rural Southern Tanzania, investigating risk factors for malarial morbidity and developing household based malaria control strategies. Biweekly morbidity and bimonthly serological, parasitological and drug consumption surveys are carried out in all study households. Mosquito densities are measured biweekly in 50 sentinel houses by timed light traps. Determinants of transmission and indicators of exposure were not strongly aggregated within households. Subjective morbidity (recalled fever), objective morbidity (elevated body temperature and high parasitaemia) and chloroquine consumption were strongly aggregated within a few households. Nested analysis of anti-NANP40 antibody suggest that only approximately 30% of the titer variance can explained by household clustering and that the largest proportion of antibody titer variability must be explained by non-measured behavioral determinants relating to an individual's level of exposure within a household. Indicators for evaluation and monitoring and outcome measures are described within the context of health service management to describe control measure output in terms of community effectiveness