The Journey of Zanzibar's Digitally Enabled Community Health Program to National Scale: Implementation Report.

BACKGROUND: While high-quality primary health care services can meet 80%-90% of health needs over a person's lifetime, this potential is severely hindered in many low-resource countries by a constrained health care system. There is a growing consensus that effectively designed, resourced, and managed community health worker programs are a critical component of a well-functioning primary health system, and digital technology is recognized as an important enabler of health systems transformation. OBJECTIVE: In this implementation report, we describe the design and rollout of Zanzibar's national, digitally enabled community health program-Jamii ni Afya. METHODS: Since 2010, D-tree International has partnered with the Ministry of Health Zanzibar to pilot and generate evidence for a digitally enabled community health program, which was formally adopted and scaled nationally by the government in 2018. Community health workers use a mobile app that guides service delivery and data collection for home-based health services, resulting in comprehensive service delivery, access to real-time data, efficient management of resources, and continuous quality improvement. RESULTS: The Zanzibar government has documented increases in the delivery of health facilities among pregnant women and reductions in stunting among children younger than 5 years since the community health program has scaled. Key success factors included starting with the health challenge and local context rather than the technology, usage of data for decision-making, and extensive collaboration with local and global partners and funders. Lessons learned include the significant time it takes to scale and institutionalize a digital health systems innovation due to the time to generate evidence, change opinions, and build capacity. CONCLUSIONS: Jamii ni Afya represents one of the world's first examples of a nationally scaled digitally enabled community health program. This implementation report outlines key successes and lessons learned, which may have applicability to other governments and partners working to sustainably strengthen primary health systems.

Poverty, partner discord, and divergent accounts; a mixed methods account of births before arrival to health facilities in Morogoro Region, Tanzania.

BACKGROUND: Births before arrival (BBA) to health care facilities are associated with higher rates of perinatal morbidity and mortality compared to facility deliveries or planned home births. Research on such births has been conducted in several high-income countries, but there are almost no studies from low-income settings where a majority of maternal and newborn deaths occur. METHODS: Drawing on a household survey of women and in-depth interviews with women and their partners, we examined the experience of BBA in rural districts of Morogoro Region, Tanzania. RESULTS: Among survey respondents, 59 births (4 %) were classified as BBAs. Most of these births occurred in the presence of a family member (47 %) or traditional birth attendant (24 %). Low socioeconomic status was the strongest predictor of BBA. After controlling for wealth via matching, high parity and a low number of antenatal care (ANC) visits retained statistical significance. While these variables are useful indicators of which women are at greater risk of BBA, their predictive power is limited in a context where many women are poor, multiparous, and make multiple ANC visits. In qualitative interviews, stories of BBAs included themes of partner disagreement regarding when to depart for facilities and financial or logistical constraints that underpinned departure delays. Women described wanting to depart earlier to facilities than partners. CONCLUSION: As efforts continue to promote facility birth, we highlight the financial demands associated with facility delivery and the potential for these demands to place women at a heightened risk for BBAs.

Integrating HIV testing into cervical cancer screening in Tanzania: an analysis of routine service delivery statistics.

BACKGROUND: While the lifetime risk of developing cervical cancer (CaCx) and acquiring HIV is high for women in Tanzania, most women have not tested for HIV in the past year and most have never been screened for CaCx. Good management of both diseases, which have a synergistic relationship, requires integrated screening, prevention, and treatment services. The aim of this analysis is to assess the acceptability, feasibility and effectiveness of integrating HIV testing into CaCx prevention services in Tanzania, so as to inform scale-up strategies. METHODS: We analysed 2010-2013 service delivery data from 21 government health facilities in four regions of the country, to examine integration of HIV testing within newly introduced CaCx screening and treatment services, located in the reproductive and child health (RCH) section of the facility. Analysis included the proportion of clients offered and accepting the HIV test, reasons why testing was not offered or was declined, and HIV status of CaCx screening clients. RESULTS: A total of 24,966 women were screened for CaCx; of these, approximately one-quarter (26%) were referred in from HIV care and treatment clinics. Among the women of unknown HIV status (n = 18,539), 60% were offered an HIV test. The proportion of women offered an HIV test varied over time, but showed a trend of decline as the program expanded. Unavailability of HIV test kits at the facility was the most common reason for a CaCx screening client not to be offered an HIV test (71% of 6,321 cases). Almost all women offered (94%) accepted testing, and 5% of those tested (582 women) learned for the first time that they were HIV-positive. CONCLUSION: Integrating HIV testing into CaCx screening services was highly acceptable to clients and was an effective means of reaching HIV-positive women who did not know their status; effectiveness was limited, however, by shortages of HIV test kits at facilities. Integration of HIV testing into CaCx screening services should be prioritized in HIV-endemic settings, but more work is needed to eliminate logistical barriers. The coverage of CaCx screening among HIV care and treatment-enrolled women in Tanzania may be low and should be examined.

"I have grown up controlling myself a lot." Fear and misconceptions about sex among adolescents vertically-infected with HIV in Tanzania.

With increased access to HIV treatment throughout Africa, a generation of HIV positive children is now transitioning to adulthood while living with a chronic condition requiring lifelong medication, which can amplify the anxieties of adolescence. This qualitative study explored how adolescents in Tanzania with HIV experience their nascent sexuality, as part of an evaluation of a home-based care programme. We interviewed 14 adolescents aged 15-19 who had acquired HIV perinatally, 10 of their parents or other primary caregivers, and 12 volunteer home-based care providers who provided support, practical advice, and referrals to clinical services. Adolescents expressed unease about their sexuality, fearing that sex and relationships were inappropriate and hazardous, given their HIV status. They worried about having to disclose their status to partners, the risks of infecting others and for their own health. Thus, many anticipated postponing or avoiding sex indefinitely. Caregivers and home-based care providers reinforced negative views of sexual activity, partly due to prevailing misconceptions about the harmful effects of sex with HIV. The adolescents had restricted access to accurate information, appropriate guidance, or comprehensive reproductive health services and were likely to experience significant unmet need as they initiated sexual relationships. Care programmes could help to reduce this gap by facilitating open communication about sexuality between adolescents and their caregivers, providers, and HIV-positive peers.