RESUMEN
BACKGROUND: Assessments of subnational progress and performance coverage within countries should be an integral part of health sector reviews, using recent data from multiple sources on health system strength and coverage. METHOD: As part of the midterm review of the national health sector strategic plan of Tanzania mainland, summary measures of health system strength and coverage of interventions were developed for all 21 regions, focusing on the priority indicators of the national plan. Household surveys, health facility data and administrative databases were used to compute the regional scores. FINDINGS: Regional Millennium Development Goal (MDG) intervention coverage, based on 19 indicators, ranged from 47% in Shinyanga in the northwest to 71% in Dar es Salaam region. Regions in the eastern half of the country have higher coverage than in the western half of mainland. The MDG coverage score is strongly positively correlated with health systems strength (r = 0.84). Controlling for socioeconomic status in a multivariate analysis has no impact on the association between the MDG coverage score and health system strength. During 1991-2010 intervention coverage improved considerably in all regions, but the absolute gap between the regions did not change during the past two decades, with a gap of 22% between the top and bottom three regions. INTERPRETATION: The assessment of regional progress and performance in 21 regions of mainland Tanzania showed considerable inequalities in coverage and health system strength and allowed the identification of high and low-performing regions. Using summary measures derived from administrative, health facility and survey data, a subnational picture of progress and performance can be obtained for use in regular health sector reviews.
Asunto(s)
Servicios de Salud del Niño/organización & administración , Promoción de la Salud/organización & administración , Cobertura del Seguro/estadística & datos numéricos , Seguro de Salud/estadística & datos numéricos , Servicios de Salud Materna/organización & administración , Adolescente , Adulto , Niño , Preescolar , Femenino , Humanos , Lactante , Seguro de Salud/clasificación , Masculino , Asistencia Médica , Persona de Mediana Edad , Adulto JovenRESUMEN
In the health sector, planning and resource allocation at country level are mainly guided by national plans. For each such plan, a midterm review of progress is important for policy-makers since the review can inform the second half of the plan's implementation and provide a situation analysis on which the subsequent plan can be based. The review should include a comprehensive analysis using recent data - from surveys, facility and administrative databases - and global health estimates. Any midterm analysis of progress is best conducted by a team comprising representatives of government agencies, independent national institutions and global health organizations. Here we present an example of such a review, done in 2013 in the United Republic of Tanzania. Compared to similar countries, the results of this midterm review showed good progress in all health indicators except skilled birth attendance.
Dans le secteur de la santé, la planification et l'allocation des ressources au niveau national sont principalement guidées par les plans des pays. Pour chacun de ces plans, un examen à mi-parcours des progrès réalisés est important pour les responsables politiques, puisque cet examen peut donner des informations pour la deuxième moitié de la mise en Åuvre du plan et fournir une analyse de la situation à partir de laquelle la suite du plan peut se baser. L'examen devrait inclure une analyse complète utilisant les données récentes (obtenues à partir des bases de données des enquêtes, des établissements et de l'administration) et les estimations sanitaires mondiales. Toute analyse à mi-parcours des progrès réalisés doit être menée de préférence par une équipe comprenant des représentants des agences gouvernementales, des institutions nationales indépendantes et des organisations sanitaires mondiales. Nous présentons ici un exemple d'un tel examen, réalisé en 2012 dans la République-Unie de Tanzanie. Par rapport à d'autres pays similaires, les résultats de cet examen à mi-parcours montrent une progression satisfaisante de tous les indicateurs de santé, à l'exception de l'accouchement assisté par un soignant qualifié.
En el sector de la salud, la planificación y la asignación de recursos a nivel nacional se guían principalmente por planes nacionales. Para los planificadores de políticas es importante contar una revisión intermedia de los progresos de cada plan, ya que puede proporcionar información sobre la segunda mitad de la implementación del plan y un análisis de la situación en la que basar planes posteriores. La revisión debe incluir un análisis exhaustivo con datos recientes - a partir de encuestas y bases de datos administrativas y de los centros - y estimaciones mundiales de salud. La mejor manera de realizar cualquier análisis intermedio de los progresos es a través de un equipo integrado por representantes de organismos gubernamentales, instituciones nacionales independientes y organizaciones mundiales de salud. Aquí presentamos un ejemplo de ese tipo de revisiones, realizada en 2012 en Tanzania. En comparación con países similares, los resultados de este examen intermedio mostraron un progreso correcto en todos los indicadores de salud, excepto en la prestación de atención especializada en el parto.
Asunto(s)
Política de Salud , Prioridades en Salud , Objetivos Organizacionales , Bases de Datos Factuales , Países en Desarrollo , Salud Global , Planificación en Salud , Encuestas Epidemiológicas , Humanos , Práctica de Salud Pública , TanzaníaRESUMEN
BACKGROUND: Millions of individuals with malaria-like fevers purchase drugs from private retailers, but artemisinin-based combination therapies (ACTs), the only effective treatment in regions with high levels of resistance to older drugs, are rarely obtained through these outlets due to their relatively high cost. To encourage scale up of ACTs, the Affordable Medicines Facility--malaria is being launched to subsidize their price. The Government of Tanzania and the Clinton Foundation piloted this subsidized distribution model in two Tanzanian districts to examine concerns about whether the intervention will successfully reach poor, rural communities. METHODS: Stocking of ACTs and other antimalarial drugs in all retail shops was observed at baseline and in four subsequent surveys over 15 months. Exit interviews were conducted with antimalarial drug customers during each survey period. All shops and facilities were georeferenced, and variables related to population density and proximity to distribution hubs, roads, and other facilities were calculated. To understand the equity of impact, shops stocking ACTs and consumers buying them were compared to those that did not, according to geographic and socioeconomic variables. Patterning in ACT stocking and sales was evaluated against that of other common antimalarials to identify factors that may have impacted access. Qualitative data were used to assess motivations underlying stocking, distribution, and buying disparities. RESULTS: Results indicated that although total ACT purchases rose from negligible levels to nearly half of total antimalarial sales over the course of the pilot, considerable geographic variation in stocking and sales persisted and was related to a variety of socio-spatial factors; ACTs were stocked more often in shops located closer to district towns (p<0.01) and major roads (p<0.01) and frequented by individuals of higher socioeconomic status (p<0.01). However, other antimalarial drugs displayed similar patterning, indicating the existence of underlying disparities in access to antimalarial drugs in general in these districts. CONCLUSIONS: As this subsidy model is scaled up across multiple countries, these results confirm the potential for increased ACT usage but suggest that additional efforts to increase access in remote areas will be needed for the scale-up to have equitable impact. TRIAL REGISTRATION: Current Controlled Trials ISRCTN39125414.
Asunto(s)
Antimaláricos/provisión & distribución , Artemisininas/provisión & distribución , Etanolaminas/provisión & distribución , Fluorenos/provisión & distribución , Accesibilidad a los Servicios de Salud/economía , Farmacia/organización & administración , Antimaláricos/economía , Combinación Arteméter y Lumefantrina , Artemisininas/economía , Comercio/organización & administración , Participación de la Comunidad , Demografía , Combinación de Medicamentos , Costos de los Medicamentos , Etanolaminas/economía , Financiación Gubernamental , Fluorenos/economía , Accesibilidad a los Servicios de Salud/normas , Disparidades en Atención de Salud , Humanos , Entrevistas como Asunto , TanzaníaRESUMEN
BACKGROUND: WHO estimates that only 3% of fever patients use recommended artemisinin-based combination therapies (ACTs), partly reflecting their high prices in the retail sector from where many patients seek treatment. To overcome this challenge, a global ACT subsidy has been proposed. We tested this proposal through a pilot program in rural Tanzania. METHODS/PRINCIPAL FINDINGS: Three districts were assigned to serve either as a control or to receive the subsidy plus a package of supporting interventions. From October 2007, ACTs were sold at a 90% subsidy through the normal private supply chain to intervention district drug shops. Data were collected at baseline and during intervention using interviews with drug shop customers, retail audits, mystery shoppers, and audits of public and NGO facilities. The proportion of consumers in the intervention districts purchasing ACTs rose from 1% at baseline to 44.2% one year later (p<0.001), and was significantly higher among consumers purchasing for children under 5 than for adults (p = 0.005). No change in ACT usage was observed in the control district. Consumers paid a mean price of $0.58 for ACTs, which did not differ significantly from the price paid for sulphadoxine-pyrimethamine, the most common alternative. Drug shops in population centers were significantly more likely to stock ACTs than those in more remote areas (p<0.001). CONCLUSIONS: A subsidy introduced at the top of the private sector supply chain can significantly increase usage of ACTs and reduce their retail price to the level of common monotherapies. Additional interventions may be needed to ensure access to ACTs in remote areas and for poorer individuals who appear to seek treatment at drug shops less frequently. TRIAL REGISTRATION: Controlled-Trials.com ISRCTN39125414.