Health, wealth, and medical expenditures among the elderly in rural Tanzania: experiences from Nzega and Igunga districts.

BACKGROUND: The per capita health expenditure (HE) and share of gross domestic product (GDP) spending on elderly healthcare are expected to increase. The gap between health needs and available resources for elderly healthcare is widening in many developing countries, like Tanzania, leaving the elderly in poor health. These conditions lead to catastrophic HEs for the elderly. This study aimed to analyse the association between measures of health, wealth, and medical expenditure in rural residents aged 60 years and above in Tanzania. METHODS: The data of this study were collected through a cross-sectional household survey to residents aged 60 years and above living in Nzega and Igunga districts using a standardised World Health Organization (WHO) Study on Global Ageing and Adult Health (SAGE) and European Quality of Life Five Dimension (EQ-5D) questionnaires. The quality of life (QoL) was estimated using EQ-5D weights. The wealth index was generated from principal component analysis (PCA). The linear regression analyses (outpatient/inpatient) were performed to analyse the association between measures of health, wealth, medical expenditure, and socio-demographic variables. RESULTS: This study found a negative and statistically significant association between QoL and HE, whereby HE increases with the decrease of QoL. We could not find any significant relationship between HE and social gradients. In addition, age influences HE such that as age increases, the HE for both outpatient and inpatient care also increases. CONCLUSION: The health system in these districts allocate resources mainly according to needs, and social position is not important. We thus conclude that the elderly of lower socio-economic status (SES) was subjected to similar health expenditure as those of higher socio-economic status. Health, not wealth, determines the use of medical expenditures.

The impact of a community health worker intervention on uptake of antenatal care: a cluster-randomized pragmatic trial in Dar es Salaam.

The provision of high-quality antenatal care (ANC) is important for preventing maternal and newborn mortality and morbidity, but only around half of pregnant women in Tanzania attended four or more ANC visits in 2019. Although there is emerging evidence on the benefit of community health worker (CHW) interventions on ANC uptake, few large-scale pragmatic trials have been conducted. This pragmatic cluster-randomized trial, implemented directly through the public sector health system, assessed the impact of an intervention that trained public sector CHWs to promote the uptake of ANC. We randomized 60 administrative wards in Dar es Salaam to either a targeted CHW intervention or a standard of care. The impact of the intervention was assessed using generalized estimating equations with an independent working correlation matrix to account for clustering within wards. A total of 243 908 women were included in the analysis of our primary outcome of four or more ANC visits. The intervention significantly increased the likelihood of attending four or more ANC visits [relative risk (RR): 1.42; 95% confidence interval (CI): 1.05, 1.92] and had a modest beneficial effect on the total number of ANC visits (percent change: 7.7%; 95% CI: 0.2%, 15.5%). While slightly more women in the intervention arm attended ANC in their first trimester compared with the standard-of-care arm (19% vs 18.7%), the difference was not significant (RR: 1.02; 95% CI: 0.84, 1.22). Our findings suggest that trained CHWs can increase attendance of ANC visits in Dar es Salaam and similar settings. However, additional interventions appear necessary to promote the early initiation of ANC. This study demonstrates that routine health system data can be leveraged for outcome assessment in trials and programme evaluation and that the results are likely superior, both in terms of bias and precision, to data that are collected specifically for science.

Patients' pathways to cancer care in Tanzania: documenting and addressing social inequalities in reaching a cancer diagnosis.

BACKGROUND: This article investigates the extent and sources of late diagnosis of cancer in Tanzania, demonstrating how delayed diagnosis was patterned by inequities rooted in patients' socio-economic background and by health system responses. It provides evidence to guide equity-focused policies to accelerate cancer diagnosis. METHODS: Tanzanian cancer patients (62) were interviewed in 2019. Using a structured questionnaire, respondents were encouraged to recount their pathways from first symptoms to diagnosis, treatment, and in some cases check-ups as survivors. Patients described their recalled sequence of events and actions, including dates, experiences and expenditures at each event. Socio-demographic data were also collected, alongside patients' perspectives on their experience. Analysis employed descriptive statistics and qualitative thematic analysis. RESULTS: Median delay, between first symptoms that were later identified as indicating cancer and a cancer diagnosis, was almost 1 year (358 days). Delays were strongly patterned by socio-economic disadvantage: those with low education, low income and non-professional occupations experienced longer delays before diagnosis. Health system experiences contributed to these socially inequitable delays. Many patients had moved around the health system extensively, mainly through self-referral as symptoms worsened. This "churning" required out-of-pocket payments that imposed a severely regressive burden on these largely low-income patients. Causes of delay identified in patients' narratives included slow recognition of symptoms by facilities, delays in diagnostic testing, delays while raising funds, and recourse to traditional healing often in response to health system barriers. Patients with higher incomes and holding health insurance that facilitated access to the private sector had moved more rapidly to diagnosis at lower out-of-pocket cost. CONCLUSIONS: Late diagnosis is a root cause, in Tanzania as in many low- and middle-income countries, of cancer treatment starting at advanced stages, undermining treatment efficacy and survival rates. While Tanzania's policy of free public sector cancer treatment has made it accessible to patients on low incomes and without insurance, reaching a diagnosis is shown to have been for these respondents slower and more expensive the greater their socio-economic disadvantage. Policy implications are drawn for moving towards greater social justice in access to cancer care.

Traditional and Complementary Medicine in Tanzania: Regulation Awareness, Adherence and Challenges.

BACKGROUND: The demand for and use of Traditional and Complementary Medicine (T&CM) has recently increased worldwide drawing a public health attention including malpractice, which puts the health of its clients at risk. Despite efforts made by Tanzania to integrate T&CM in the health system to protect the clients, regulating the subsector has remained a challenge due to lack of information and operational factors facing the regulatory frameworks in Tanzania. The aim of this study was to determine the extent of imperfect information, regulation adherence and challenges among T&CM practitioners and regulators in Tanzania. METHODS: In-depth interviews were carried out with T&CM practitioners in Dar es Salaam Region in Tanzania, and officials from the Ministry of Health and the study municipals. Purposive and snowballing approaches were used to select study participants. Thematic data analysis was done with the help of NVIVO. RESULTS: Awareness of regulations and tools used for regulating the T&CM operations among practitioners was generally very low. There was fragmentation of knowledge on what they were practicing as well as on awareness of the regulations, and what is regulated. Practitioners argued that they cannot be controlled by conventional medical trained personnel. Regulators at municipal level reported to have had no knowledge, interest, and time to work on T&CM. Lack of adequately trained and qualified manpower, lack of financial resources, poor transport and other infrastructure at the municipal regulatory units aggravated non-adherence to regulations, and therefore rendered ineffectiveness to the regulatory framework. CONCLUSION: Existence of imperfect information on T&CM among regulators and practitioners affect effectiveness of T&CM regulatory process. Awareness of regulations among practitioners, presence of knowledgeable regulators, as well as capacity would facilitate adherence to regulations.

Health care costs associated with clinic visits for prevention of mother-to-child transmission of HIV in Dar es Salaam, Tanzania.

ABSTRACT: Early and appropriate antenatal care (ANC) is key for the effectiveness of prevention of mother-to-child transmission (PMTCT) of human immunodeficiency virus (HIV). We evaluated the importance of ANC visits and related service costs for women receiving option B+ to prevent mother-to-child transmission (MTCT) of HIV in Tanzania.A cost analysis from a health care sector perspective was conducted using routine data of 2224 pregnant women newly diagnosed with HIV who gave birth between August 2014 and May 2016 in Dar es Salaam, Tanzania. We evaluated risk of infant HIV infection at 12 weeks postnatally in relation to ANC visits (<4 vs ≥4 visits). Costs for service utilisation were estimated through empirical observations and the World Health Organisation Global Price Reporting Mechanism.Mean gestational age at first ANC visit was 22 (±7) weeks. The average number of ANC/prevention of MTCT visits among the 2224 pregnant women in our sample was 3.6 (95% confidence interval [CI] 3.6-3.7), and 57.3% made ≥4 visits. At 12 weeks postnatally, 2.7% (95% CI 2.2-3.6) of HIV exposed infants had been infected. The risk of MTCT decreased with the number of ANC visits: 4.8% (95% CI 3.6-6.4) if the mother had <4 visits, and 1.0% (95% CI 0.5-1.7) at ≥4. The adjusted MTCT rates decreased by 51% (odds ratio 0.49, 95% CI 0.31-0.77) for each additional ANC visit made. The potential cost-saving was 2.2 US$ per woman at ≥4 visits (84.8 US$) compared to <4 visits (87.0 US$), mainly due to less defaulter tracing.Most pregnant women living with HIV in Dar es Salaam initiated ANC late and >40% failed to adhere to the recommended minimum of 4 visits. Improved ANC attendance would likely lead to fewer HIV-infected infants and reduce both short and long-term health care costs due to less spending on defaulter tracing and future treatment costs for the children.

Health Related Quality of Life Post Labour Induction with Misoprostol Versus Dinoprostone At Muhimbili National Hospital in Dar Es Salaam, Tanzania: A cross Sectional Study.

BACKGROUND: Labour induction using Misoprostol or Dinoprostone results to similar maternal and foetal clinical outcomes. However, the clinical outcome measures have rarely been combined with effects of interventions on patients' health related quality of life. This study aimed to assess postpartum health related quality of life of parturient after labour induction with vaginal administration of misoprostol versus dinoprostone. METHODS: This was a comparative cross sectional study in which pregnant women who underwent labour induction with misoprostol and dinoprostone during the study period were included. Data were collected within 24 hours post-delivery using the 36 item short form health survey questionnaire which consists of 24 attributes distributed in five domains including bodily pains and physical performance three attributes each, mental health seven attributes, general health two attributes, social functioning six attributes and three attributes for labour induction satisfaction. We first estimated scores of all attributes in each domain using Likert scales and then the domain scores were converted into a 0 to 100 scales to express in percentage of total scores. Quality of life was compared in the two study groups using the independent samples T Test. Multivariate regression analysis was performed to control for marital status, gravidity, parity, baseline cervical status, time interval from induction to delivery and mode of delivery. RESULTS: Women who received misoprostol reported better health related quality of life compared to those who received dinoprostone (mean score 92.89 vs. 87.25;P<.00). Misoprostol group had significantly higher scores in all domains of health related quality of life; reduced bodily pain (93.76 vs. 84.19;P<.00), physical performance (83.64 vs. 73.58;P<.00), mental health (96.40 vs. 93.55; P<.00), general health (93.78 vs. 90.23;P=.01), social functioning (94.81 vs. 91.25;P<.00) and satisfaction perceptions (94.96 vs. 90.71;P<.00). CONCLUSION: Health related quality of life information is of particular value in routine care of natal and postnatal mothers. Current and updated guidelines should address the impacts of labour induction interventions on maternal health related quality of life, and encourage the use of quality of life information in provision of holistic natal and postnatal care services. Clinical trials are recommended to determine the effectiveness of labour induction with either of the two methods and address the historical adverse outcomes associated to the use of misoprostol.

Community health workers to improve uptake of maternal healthcare services: A cluster-randomized pragmatic trial in Dar es Salaam, Tanzania.

BACKGROUND: Home delivery and late and infrequent attendance at antenatal care (ANC) are responsible for substantial avoidable maternal and pediatric morbidity and mortality in sub-Saharan Africa. This cluster-randomized trial aimed to determine the impact of a community health worker (CHW) intervention on the proportion of women who (i) visit ANC fewer than 4 times during their pregnancy and (ii) deliver at home. METHODS AND FINDINGS: As part of a 2-by-2 factorial design, we conducted a cluster-randomized trial of a home-based CHW intervention in 2 of 3 districts of Dar es Salaam from 18 June 2012 to 15 January 2014. Thirty-six wards (geographical areas) in the 2 districts were randomized to the CHW intervention, and 24 wards to the standard of care. In the standard-of-care arm, CHWs visited women enrolled in prevention of mother-to-child HIV transmission (PMTCT) care and provided information and counseling. The intervention arm included additional CHW supervision and the following additional CHW tasks, which were targeted at all pregnant women regardless of HIV status: (i) conducting home visits to identify pregnant women and refer them to ANC, (ii) counseling pregnant women on maternal health, and (iii) providing home visits to women who missed an ANC or PMTCT appointment. The primary endpoints of this trial were the proportion of pregnant women (i) not making at least 4 ANC visits and (ii) delivering at home. The outcomes were assessed through a population-based household survey at the end of the trial period. We did not collect data on adverse events. A random sample of 2,329 pregnant women and new mothers living in the study area were interviewed during home visits. At the time of the survey, the mean age of participants was 27.3 years, and 34.5% (804/2,329) were pregnant. The proportion of women who reported having attended fewer than 4 ANC visits did not differ significantly between the intervention and standard-of-care arms (59.1% versus 60.7%, respectively; risk ratio [RR]: 0.97; 95% CI: 0.82-1.15; p = 0.754). Similarly, the proportion reporting that they had attended ANC in the first trimester did not differ significantly between study arms. However, women in intervention wards were significantly less likely to report having delivered at home (3.9% versus 7.3%; RR: 0.54; 95% CI: 0.30-0.95; p = 0.034). Mixed-methods analyses of additional data collected as part of this trial suggest that an important reason for the lack of effect on ANC outcomes was the perceived high economic burden and inconvenience of attending ANC. The main limitations of this trial were that (i) the outcomes were ascertained through self-report, (ii) the study was stopped 4 months early due to a change in the standard of care in the other trial that was part of the 2-by-2 factorial design, and (iii) the sample size of the household survey was not prespecified. CONCLUSIONS: A home-based CHW intervention in urban Tanzania significantly reduced the proportion of women who reported having delivered at home, in an area that already has very high uptake of facility-based delivery. The intervention did not affect self-reported ANC attendance. Policy makers should consider piloting, evaluating, and scaling interventions to lessen the economic burden and inconvenience of ANC. TRIAL REGISTRATION: ClinicalTrials.gov NCT01932138.

The effect of a community health worker intervention on public satisfaction: evidence from an unregistered outcome in a cluster-randomized controlled trial in Dar es Salaam, Tanzania.

BACKGROUND: There is a dearth of evidence on the causal effects of different care delivery approaches on health system satisfaction. A better understanding of public satisfaction with the health system is particularly important within the context of task shifting to community health workers (CHWs). This paper determines the effects of a CHW program focused on maternal health services on public satisfaction with the health system among women who are pregnant or have recently delivered. METHODS: From January 2013 to April 2014, we carried out a cluster-randomized controlled health system implementation trial of a CHW program. Sixty wards in Dar es Salaam, Tanzania, were randomly allocated to either a maternal health CHW program (36 wards) or the standard of care (24 wards). From May to August 2014, we interviewed a random sample of women who were either currently pregnant or had recently delivered a child. We used five-level Likert scales to assess women's satisfaction with the CHW program and with the public-sector health system in Dar es Salaam. RESULTS: In total, 2329 women participated in the survey (response rate 90.2%). Households in intervention areas were 2.3 times as likely as households in control areas to have ever received a CHW visit (95% CI 1.8, 3.0). The intervention led to a 16-percentage-point increase in women reporting they were satisfied or very satisfied with the CHW program (95% CI 3, 30) and a 15-percentage-point increase in satisfaction with the public-sector health system (95% CI 3, 27). CONCLUSIONS: A CHW program for maternal and child health in Tanzania achieved better public satisfaction than the standard CHW program. Policy-makers and implementers who are involved in designing and organizing CHW programs should consider the potential positive impact of the program on public satisfaction. TRIAL REGISTRATION: ClinicalTrials.gov, EJF22802.

Rethinking health sector procurement as developmental linkages in East Africa.

Health care forms a large economic sector in all countries, and procurement of medicines and other essential commodities necessarily creates economic linkages between a country's health sector and local and international industrial development. These procurement processes may be positive or negative in their effects on populations' access to appropriate treatment and on local industrial development, yet procurement in low and middle income countries (LMICs) remains under-studied: generally analysed, when addressed at all, as a public sector technical and organisational challenge rather than a social and economic element of health system governance shaping its links to the wider economy. This article uses fieldwork in Tanzania and Kenya in 2012-15 to analyse procurement of essential medicines and supplies as a governance process for the health system and its industrial links, drawing on aspects of global value chain theory. We describe procurement work processes as experienced by front line staff in public, faith-based and private sectors, linking these experiences to wholesale funding sources and purchasing practices, and examining their implications for medicines access and for local industrial development within these East African countries. We show that in a context of poor access to reliable medicines, extensive reliance on private medicines purchase, and increasing globalisation of procurement systems, domestic linkages between health and industrial sectors have been weakened, especially in Tanzania. We argue in consequence for a more developmental perspective on health sector procurement design, including closer policy attention to strengthening vertical and horizontal relational working within local health-industry value chains, in the interests of both wider access to treatment and improved industrial development in Africa.

Job satisfaction and turnover intentions among health care staff providing services for prevention of mother-to-child transmission of HIV in Dar es Salaam, Tanzania.

BACKGROUND: Option B+ for the prevention of mother-to-child transmission (PMTCT) of HIV (i.e., lifelong antiretroviral treatment for all pregnant and breastfeeding mothers living with HIV) was initiated in Tanzania in 2013. While there is evidence that this policy has benefits for the health of the mother and the child, Option B+ may also increase the workload for health care providers in resource-constrained settings, possibly leading to job dissatisfaction and unwanted workforce turnover. METHODS: From March to April 2014, a questionnaire asking about job satisfaction and turnover intentions was administered to all nurses at 36 public-sector health facilities offering antenatal and PMTCT services in Dar es Salaam, Tanzania. Multivariable logistic regression models were used to identify factors associated with job dissatisfaction and intention to quit one's job. RESULTS: Slightly over half (54%, 114/213) of the providers were dissatisfied with their current job, and 35% (74/213) intended to leave their job. Most of the providers were dissatisfied with low salaries and high workload, but satisfied with workplace harmony and being able to follow their moral values. The odds of reporting to be globally dissatisfied with one's job were high if the provider was dissatisfied with salary (adjusted odds ratio (aOR) 5.6, 95% CI 1.2-26.8), availability of protective gear (aOR 4.0, 95% CI 1.5-10.6), job description (aOR 4.3, 95% CI 1.2-14.7), and working hours (aOR 3.2, 95% CI 1.3-7.6). Perceiving clients to prefer PMTCT Option B+ reduced job dissatisfaction (aOR 0.2, 95% CI 0.1-0.8). The following factors were associated with providers' intention to leave their current job: job stability dissatisfaction (aOR 3.7, 95% CI 1.3-10.5), not being recognized by one's superior (aOR 3.6, 95% CI 1.7-7.6), and poor feedback on the overall unit performance (aOR 2.7, 95% CI 1.3-5.8). CONCLUSION: Job dissatisfaction and turnover intentions are comparatively high among nurses in Dar es Salaam's public-sector maternal care facilities. Providing reasonable salaries and working hours, clearer job descriptions, appropriate safety measures, job stability, and improved supervision and feedback will be key to retaining satisfied PMTCT providers and thus to sustain successful implementation of Option B+ in Tanzania.

The potential of task-shifting in scaling up services for prevention of mother-to-child transmission of HIV: a time and motion study in Dar es Salaam, Tanzania.

BACKGROUND: In many African countries, prevention of mother-to-child transmission of HIV (PMTCT) services are predominantly delivered by nurses. Although task-shifting is not yet well established, community health workers (CHWs) are often informally used as part of PMTCT delivery. According to the 2008 World Health Organization (WHO) Task-shifting Guidelines, many PMTCT tasks can be shifted from nurses to CHWs. METHODS: The aim of this time and motion study in Dar es Salaam, Tanzania, was to estimate the potential of task-shifting in PMTCT service delivery to reduce nurses' workload and health system costs. The time used by nurses to accomplish PMTCT activities during antenatal care (ANC) and postnatal care (PNC) visits was measured. These data were then used to estimate the costs that could be saved by shifting tasks from nurses to CHWs in the Tanzanian public-sector health system. RESULTS: A total of 1121 PMTCT-related tasks carried out by nurses involving 179 patients at ANC and PNC visits were observed at 26 health facilities. The average time of the first ANC visit was the longest, 54 (95% confidence interval (CI) 42-65) min, followed by the first PNC visit which took 29 (95% CI 26-32) minutes on average. ANC and PNC follow-up visits were substantially shorter, 15 (95% CI 14-17) and 13 (95% CI 11-16) minutes, respectively. During both the first and the follow-up ANC visits, 94% of nurses' time could be shifted to CHWs, while 84% spent on the first PNC visit and 100% of the time spent on the follow-up PNC visit could be task-shifted. Depending on CHW salary estimates, the cost savings due to task-shifting in PMTCT ranged from US$ 1.3 to 2.0 (first ANC visit), US$ 0.4 to 0.6 (ANC follow-up visit), US$ 0.7 to 1.0 (first PNC visit), and US$ 0.4 to 0.5 (PNC follow-up visit). CONCLUSIONS: Nurses working in PMTCT spend large proportions of their time on tasks that could be shifted to CHWs. Such task-shifting could allow nurses to spend more time on specialized PMTCT tasks and can substantially reduce the average cost per PMTCT patient.

Predictors of Patient Dissatisfaction with Services for Prevention of Mother-To-Child Transmission of HIV in Dar es Salaam, Tanzania.

BACKGROUND: Mother-to-child transmission (MTCT) of HIV remains a major source of new HIV infections in children. Prevention of mother-to-child transmission of HIV (PMTCT) using lifelong antiretroviral treatment (ART) for all pregnant and breastfeeding women living with HIV (Option B+) is the major strategy for eliminating paediatric HIV. Ensuring that patients are satisfied with PMTCT services is important for optimizing uptake, adherence and retention in treatment. METHODS: We conducted a facility based quantitative cross-sectional survey in Dar-es-Salaam, Tanzania, between March and April 2014, when the country was transitioning to the implementation of PMTCT Option B+. We interviewed 595 pregnant and breastfeeding women living with HIV, who received PMTCT care in 36 public health facilities. Predictors of overall dissatisfaction with PMTCT services were identified using a multiple logistic regression. RESULTS: Overall 8% of the patients expressed dissatisfaction with PMTCT services. Patients who perceived health care workers (HCW) communication skills as poor, had a 5-fold (OR 4.9, 95% CI 1.8-13.4) increased risk of dissatisfaction and those who perceived HCW capacity to understand client concerns as poor, had a 6-fold (OR 5.7, 95% CI 2.3-14.0) increased risk. Having a total visit time longer than two hours was associated with a 2-fold increased risk of being dissatisfied (OR 2.3, 95% CI 1.1-4.7). Every 30-minute increment in total visit time was associated with a 10% higher (OR 1.1, 95% CI 1.0-1.2) risk of being dissatisfied. The probability of being dissatisfied ranged from 4% (95% CI 2% - 6%) in the presence of patient-perceived good communication, good understanding of patient concerns, and a total visit time below two hours, to 70% (95% CI 47% - 86%) if HCW failed in all of these aspects. CONCLUSION: Patient dissatisfaction with PMTCT services was generally low; reflecting that quality of care was maintained during Tanzania's transition to Option B+ strategy aiming to increase the number of women initiating life-long ART in PMTCT clinics. Improved HCW communication with clients, their understanding of patient concerns and a reduction of the total visit time would further optimize women's overall satisfaction with PMTCT services in Tanzania.

Household perceptions towards a redistributive policy across health insurance funds in Tanzania.

BACKGROUND: The Tanzanian health insurance system comprises multiple health insurance funds targeting different population groups but which operate in parallel, with no mechanisms for redistribution across the funds. Establishing such redistributive mechanisms requires public support, which is grounded on the level of solidarity within the country. The aim of this paper is to analyse the perceptions of CHF, NHIF and non-member households towards cross-subsidisation of the poor as an indication of the level of solidarity and acceptance of redistributive mechanisms. METHODS: This study analyses data collected from a survey of 695 households relating to perceptions of household heads towards cross-subsidisation of the poor to enable them to access health services. Kruskal-Wallis test is used to compare perceptions by membership status. Generalized ordinal logistic regression models are used to identify factors associated with support for cross-subsidisation of the poor. RESULTS: Compared to CHF and NHIF households, non-member households expressed the highest support for subsidised CHF membership for the poor. The odds of expressing support for subsidised CHF membership are higher for NHIF households and non-member households, households that are wealthier, whose household heads have lower education levels, and have sick members. The majority of households support a partial rather than fully subsidised CHF membership for the poor and there were no significant differences by membership status. The odds of expressing willingness to contribute towards subsidised CHF membership are higher for households that are wealthier, with young household heads and have confidence in scheme management. CONCLUSION: The majority may support a redistributive policy, but there are indications that this support and willingness to contribute to its achievement are influenced by the perceived benefits, amount of subsidy considered, and trust in scheme management. These present important issues for consideration when designing redistributive policies.

Determinants of delay in care seeking among children under five with fever in Dodoma region, central Tanzania: a cross-sectional study.

BACKGROUND: Early diagnosis and timely treatment of malaria is recognized as a fundamental element to the control of the disease. Although access to health services in Tanzania is improved, still many people seek medical care when it is too late or not at all. This study aimed to determine factors associated with delay in seeking treatment for fever among children under five in Tanzania. METHODS: A three-stage cluster sampling design was used to sample households with children under five in Dodoma region, central Tanzania between October 2010 and January 2011. Information on illness and health-seeking behaviours in the previous four weeks was collected using a structured questionnaire. A multivariable logistic regression was used to investigate determinants of delay in treatment-seeking behaviour while accounting for sample design. RESULTS: A total of 287 under-five children with fever whose caretakers sought medical care were involved in the study. Of these, 55.4% were taken for medical care after 24 hours of onset of fever. The median time of delay in fever care seeking was two days. Children who lived with both biological parents were less likely to be delayed for medical care compared to those with either one or both of their biological parents absent from home (OR = 0.42, 95% CI: 0.24, 0.74). Children from households with two to three under-five children were more likely to be delayed for medical care compared to children from households with only one child (OR = 1.54, 95% CI: 1.04, 2.26). Also, children living in a distance ≥5 kilometres from the nearest health facility were about twice (95% CI: 1.11, 2.72) as likely to delay to be taken for medical care than those in the shorter distances. CONCLUSION: Living with non-biological parents, high number of under-fives in household, and long distance to the nearest health facility were important factors for delay in seeking healthcare. Programmes to improve education on equity in social services, family planning, and access to health facilities are required for better healthcare and development of children.

Evaluation of a community health worker intervention and the World Health Organization's Option B versus Option A to improve antenatal care and PMTCT outcomes in Dar es Salaam, Tanzania: study protocol for a cluster-randomized controlled health systems implementation trial.

BACKGROUND: Mother-to-child transmission of HIV remains an important public health problem in sub-Saharan Africa. As HIV testing and linkage to PMTCT occurs in antenatal care (ANC), major challenges for any PMTCT option in developing countries, including Tanzania, are delays in the first ANC visit and a low overall number of visits. Community health workers (CHWs) have been effective in various settings in increasing the uptake of clinical services and improving treatment retention and adherence. At the beginning of this trial in January 2013, the World Health Organization recommended either of two medication regimens, Option A or B, for prevention of mother-to-child transmission of HIV (PMTCT). It is still largely unclear which option is more effective when implemented in a public healthcare system. This study aims to determine the effectiveness, cost-effectiveness, acceptability, and feasibility of: (1) a community health worker (CWH) intervention and (2) PMTCT Option B in improving ANC and PMTCT outcomes. METHODS/DESIGN: This study is a cluster-randomized controlled health systems implementation trial with a two-by-two factorial design. All 60 administrative wards in the Kinondoni and Ilala districts in Dar es Salaam were first randomly allocated to either receiving the CHW intervention or not, and then to receiving either Option B or A. Under the standard of care, facility-based health workers follow up on patients who have missed scheduled appointments for PMTCT, first through a telephone call and then with a home visit. In the wards receiving the CHW intervention, the CHWs: (1) identify pregnant women through home visits and refer them to antenatal care; (2) provide education to pregnant women on antenatal care, PMTCT, birth, and postnatal care; (3) routinely follow up on all pregnant women to ascertain whether they have attended ANC; and (4) follow up on women who have missed ANC or PMTCT appointments. TRIAL REGISTRATION: ClinicalTrials.gov: EJF22802. Registration date: 14 May 2013.

Health care seeking behaviour and utilisation in a multiple health insurance system: does insurance affiliation matter?

BACKGROUND: Many countries striving to achieve universal health insurance coverage have done so by means of multiple health insurance funds covering different population groups. However, existence of multiple health insurance funds may also cause variation in access to health care, due to the differential revenue raising capacities and benefit packages offered by the various funds resulting in inequity and inefficiency within the health system. This paper examines how the existence of multiple health insurance funds affects health care seeking behaviour and utilisation among members of the Community Health Fund, the National Health Insurance Fund and non-members in two districts in Tanzania. METHODS: Using household survey data collected in 2011 with a sample of 3290 individuals, the study uses a multinomial logit model to examine the influence of predisposing, enabling and need characteristics on the probability of seeking care and choice of provider. RESULTS: Generally, health insurance is found to increase the probability of seeking care and reduce delays. However, the probability, timing of seeking care and choice of provider varies across the CHF and NHIF members. CONCLUSIONS: Reducing fragmentation is necessary to provide opportunities for redistribution and to promote equity in utilisation of health services. Improvement in the delivery of services is crucial for achievement of improved access and financial protection and for increased enrolment into the CHF, which is essential for broadening redistribution and cross-subsidisation to promote equity.

Local production of pharmaceuticals in Africa and access to essential medicines: 'urban bias' in access to imported medicines in Tanzania and its policy implications.

BACKGROUND: International policy towards access to essential medicines in Africa has focused until recently on international procurement of large volumes of medicines, mainly from Indian manufacturers, and their import and distribution. This emphasis is now being challenged by renewed policy interest in the potential benefits of local pharmaceutical production and supply. However, there is a shortage of evidence on the role of locally produced medicines in African markets, and on potential benefits of local production for access to medicines. This article contributes to filling that gap. METHODS: This article uses WHO/HAI data from Tanzania for 2006 and 2009 on prices and sources of a set of tracer essential medicines. It employs innovative graphical methods of analysis alongside conventional statistical testing. RESULTS: Medicines produced in Tanzania were equally likely to be found in rural and in urban areas. Imported medicines, especially those imported from countries other than Kenya (mainly from India) displayed 'urban bias': that is, they were significantly more likely to be available in urban than in rural areas. This finding holds across the range of sample medicines studied, and cannot be explained by price differences alone. While different private distribution networks for essential medicines may provide part of the explanation, this cannot explain why the urban bias in availability of imported medicines is also found in the public sector. CONCLUSIONS: The findings suggest that enhanced local production may improve rural access to medicines. The potential benefits of local production and scope for their improvement are an important field for further research, and indicate a key policy area in which economic development and health care objectives may reinforce each other.

Risk distribution across multiple health insurance funds in rural Tanzania.

INTRODUCTION: Multiple insurance funds serving different population groups may compromise equity due to differential revenue raising capacity and an unequal distribution of high risk members among the funds. This occurs when the funds exist without mechanisms in place to promote income and risk cross-subsidisation across the funds. This paper analyses whether the risk distribution varies across the Community Health Fund (CHF) and National Health Insurance Fund (NHIF) in two districts in Tanzania. Specifically we aim to 1) identify risk factors associated with increased utilisation of health services and 2) compare the distribution of identified risk factors among the CHF, NHIF and non-member households. METHODS: Data was collected from a survey of 695 households. A multivariate logisitic regression model was used to identify risk factors for increased health care utilisation. Chi-square tests were performed to test whether the distribution of identified risk factors varied across the CHF, NHIF and non-member households. RESULTS: There was a higher concentration of identified risk factors among CHF households compared to those of the NHIF. Non-member households have a similar wealth status to CHF households, but a lower concentration of identified risk factors. CONCLUSION: Mechanisms for broader risk spreading and cross-subsidisation across the funds are necessary for the promotion of equity. These include risk equalisation to adjust for differential risk distribution and revenue raising capacity of the funds. Expansion of CHF coverage is equally important, by addressing non-financial barriers to CHF enrolment to encourage wealthy non-members to join, as well as subsidised membership for the poorest.

Availability and affordability of anticancer medicines at the Ocean Road Cancer Institute in Dar es Salaam, Tanzania.

BACKGROUND: To ensure effective control of cancer, patients undergoing chemotherapy should get continuous supply of anticancer medicines. In Tanzania and other East African countries little is documented regarding the availability and affordability of anticancer medicines at the patient level. The number of anticancer medicines prescribed to the cancer patients and its cost implication is also not known. OBJECTIVE: To determine the availability of anticancer medicines to patients attending chemotherapy clinic at Ocean Road Cancer Institute (ORCI) in Dar es salaam, Tanzania. Also to find out the prices of anticancer medicines in private pharmacies and affordability by cancer patients treated at ORCI. METHODOLOGY: A cross-sectional study was carried out between February and May 2010 in patients receiving cancer chemotherapy at ORCI. A total of 384 adult cancer patients registered for chemotherapy were included in the study. Patients, health care providers at the chemotherapy department and dispensing personnel in the private pharmacies were interviewed regarding availability, accessibility and affordability of anticancer medicines. RESULTS: The mean anticancer medicines prescribed per patient was 2.01, with the mean cost for anticancer drugs reported by patients to be 106,300 shillings. The availability of medicines at the ORCI for the management of cancer patients was about 50% of all surveyed medicines. As a result more than 70% of patients did not get the prescribed anticancer medicines at the hospital. In the private pharmacies, the unit cost for anticancer medicines was very high, ranging from 2,500 to 744,000 shillings, which is equivalent to 1-7 months income of the patient. CONCLUSION: Availability of anticancer medicines at ORCI in Dar es Salaam is not adequate. As a result, some patients are required to buy anticancer medicines from private pharmacies. In these private pharmacies anticancer medicines are too costly and most patients are not covered by health insurance to purchase their medicines. Efforts should be made to increase budgetary allocation to ensure adequate and uninterrupted supply of anticancer medicines to cancer patients at ORCI.

From papers to practices: district level priority setting processes and criteria for family planning, maternal, newborn and child health interventions in Tanzania.

BACKGROUND: Successful priority setting is increasingly known to be an important aspect in achieving better family planning, maternal, newborn and child health (FMNCH) outcomes in developing countries. However, far too little attention has been paid to capturing and analysing the priority setting processes and criteria for FMNCH at district level. This paper seeks to capture and analyse the priority setting processes and criteria for FMNCH at district level in Tanzania. Specifically, we assess the FMNCH actor's engagement and understanding, the criteria used in decision making and the way criteria are identified, the information or evidence and tools used to prioritize FMNCH interventions at district level in Tanzania. METHODS: We conducted an exploratory study mixing both qualitative and quantitative methods to capture and analyse the priority setting for FMNCH at district level, and identify the criteria for priority setting. We purposively sampled the participants to be included in the study. We collected the data using the nominal group technique (NGT), in-depth interviews (IDIs) with key informants and documentary review. We analysed the collected data using both content analysis for qualitative data and correlation analysis for quantitative data. RESULTS: We found a number of shortfalls in the district's priority setting processes and criteria which may lead to inefficient and unfair priority setting decisions in FMNCH. In addition, participants identified the priority setting criteria and established the perceived relative importance of the identified criteria. However, we noted differences exist in judging the relative importance attached to the criteria by different stakeholders in the districts. CONCLUSIONS: In Tanzania, FMNCH contents in both general development policies and sector policies are well articulated. However, the current priority setting process for FMNCH at district levels are wanting in several aspects rendering the priority setting process for FMNCH inefficient and unfair (or unsuccessful). To improve district level priority setting process for the FMNCH interventions, we recommend a fundamental revision of the current FMNCH interventions priority setting process. The improvement strategy should utilize rigorous research methods combining both normative and empirical methods to further analyze and correct past problems at the same time use the good practices to improve the current priority setting process for FMNCH interventions. The suggested improvements might give room for efficient and fair (or successful) priority setting process for FMNCH interventions.