Improving quality of medical certification of causes of death in health facilities in Tanzania 2014-2019.

BACKGROUND: Monitoring medically certified causes of death is essential to shape national health policies, track progress to Sustainable Development Goals, and gauge responses to epidemic and pandemic disease. The combination of electronic health information systems with new methods for data quality monitoring can facilitate quality assessments and help target quality improvement. Since 2015, Tanzania has been upgrading its Civil Registration and Vital Statistics system including efforts to improve the availability and quality of mortality data. METHODS: We used a computer application (ANACONDA v4.01) to assess the quality of medical certification of cause of death (MCCD) and ICD-10 coding for the underlying cause of death for 155,461 deaths from health facilities from 2014 to 2018. From 2018 to 2019, we continued quality analysis for 2690 deaths in one large administrative region 9 months before, and 9 months following MCCD quality improvement interventions. Interventions addressed governance, training, process, and practice. We assessed changes in the levels, distributions, and nature of unusable and insufficiently specified codes, and how these influenced estimates of the leading causes of death. RESULTS: 9.7% of expected annual deaths in Tanzania obtained a medically certified cause of death. Of these, 52% of MCCD ICD-10 codes were usable for health policy and planning, with no significant improvement over 5 years. Of certified deaths, 25% had unusable codes, 17% had insufficiently specified codes, and 6% were undetermined causes. Comparing the before and after intervention periods in one Region, codes usable for public health policy purposes improved from 48 to 65% within 1 year and the resulting distortions in the top twenty cause-specific mortality fractions due to unusable causes reduced from 27.4 to 13.5%. CONCLUSION: Data from less than 5% of annual deaths in Tanzania are usable for informing policy. For deaths with medical certification, errors were prevalent in almost half. This constrains capacity to monitor the 15 SDG indicators that require cause-specific mortality. Sustainable quality assurance mechanisms and interventions can result in rapid improvements in the quality of medically certified causes of death. ANACONDA provides an effective means for evaluation of such changes and helps target interventions to remaining weaknesses.

Decentralization of birth registration to Local Government in Tanzania: the association with completeness of birth registration and certification.

BACKGROUND: In Tanzania only an estimated one-quarter of births are registered and certified. Birth registration uses a centralized system with geographic and cost barriers for families. A pilot decentralized birth registration system has been trialled in 11 of 26 regions, substantially increasing registration points, and enabling notification, registration and certification to occur in one step. OBJECTIVE: This study compares completeness of birth registration and certification and achievement of key birth registration milestones in two districts where the birth registration system decentralized and two districts with the existing centralized system. METHODS: Registration, notification, census and survey data were used to estimate birth registration completeness and quantify achievement of key registration milestones for births in 2012-16. These were compared between districts of Mbozi (decentralized in 2013) and Iringa (decentralized in 2016) and districts of Dodoma and Kibaha which remained centralized. RESULTS: For births that occurred from 2012 to 2016, completeness of birth registration/certification (by early 2017) was higher in districts that decentralized (Iringa 60%; Mbozi 52%) than remained centralized (Kibaha 36%; Dodoma 20%). Introduction of the decentralized system saw completeness for births registered within 12 months of occurrence increase in Iringa from 1% in 2014 to 67% in 2016, and in Mbozi from 15% in 2012 to 36% in 2013 before falling and subsequently increasing to 53% in 2016. In contrast, completeness in centralized districts did not increase. Although a higher proportion of births are notified in centralized than decentralized districts, registration and certification occurs for all notified births in decentralized districts but only one-third in centralized districts. CONCLUSIONS: Benefits of a decentralized system are more proximate registration points and the merging of notification, registration and certification steps. The findings, while demonstrating the immediate impact of the decentralized system on completeness, also show that continued efforts are necessary to sustain these improvements.

Newborn screening for sickle cell disease: an innovative pilot program to improve child survival in Dar es Salaam, Tanzania.

BACKGROUND: Sickle cell disease (SCD) is a recognized cause of childhood mortality. Tanzania has the fifth highest incidence of SCD (with an estimated 11 000 SCD annual births) worldwide. Although newborn screening (NBS) for SCD and comprehensive healthcare have been shown to reduce under-5 mortality by up to 94% in high-income countries such as the USA, no country in Africa has maintained NBS for SCD as a national health program. The aims of this program were to establish and evaluate NBS-SCD as a health intervention in Tanzania and to determine the birth prevalence of SCD. METHODS: Muhimbili University of Health and Allied Sciences conducted NBS for SCD from January 2015 to November 2016. Dried blood spot samples were collected and tested for SCD using isoelectric focusing. RESULTS: Screening was conducted on 3981 newborns. Thirty-one (0.8%) babies had SCD, 505 (12.6%) had sickle cell trait and 26 (0.7%) had other hemoglobinopathies. Twenty-eight (90.3%) of the 31 newborns with SCD were enrolled for comprehensive healthcare. CONCLUSIONS: This is the first report on NBS as a health program for SCD in Tanzania. The SCD birth prevalence of 8 per 1000 births is of public health significance. It is therefore important to conduct NBS for SCD with enrollment into a comprehensive care program.

Data Resource Profile: The sentinel panel of districts: Tanzania's national platform for health impact evaluation.

The Sentinel Panel of Districts (SPD) consists of 23 districts selected to provide nationally representative data on demographic and health indicators in Tanzania. The SPD has two arms: SAVVY and FBIS. SAVVY (SAmple Vital registration with Verbal autopsY) is a demographic surveillance system that provides nationally representative estimates of mortalities based on age, sex, residence and zone. SAVVY covers over 805 000 persons, or about 2% of the Tanzania mainland population, and uses repeat household census every 4-5 years, with ongoing reporting of births, deaths and causes of deaths. The FBIS (Facility-Based Information System) collects routine national health management information system data. These health service use data are collected monthly at all public and private health facilities in SPD districts, i.e. about 35% of all facilities in Mainland Tanzania. Both SAVVY and FBIS systems are capable of generating supplementary information from nested periodic surveys. Additional information about the design of the SPD is available online: access to some of SPD's aggregate data can be requested by sending an e-mail to [hmasanja@ihi.or.tz].

Post-stroke case fatality within an incident population in rural Tanzania.

BACKGROUND AND PURPOSE: To establish post-stroke case fatality rates within a community based incident stroke population in rural Tanzania. METHODS: Incident stroke cases were identified by the Tanzanian Stroke Incidence Project and followed-up over the next 3-6 years. In order to provide a more complete picture, verbal autopsy (VA) was also used to identify all stroke deaths occurring within the same community and time period, and a date of stroke was identified by interview with a relative or friend. RESULTS: Over 3 years, the Tanzanian Stroke Incidence Project identified 130 cases of incident stroke, of which 31 (23.8%, 95% CI 16.5 to 31.2) died within 28 days and 78 (60.0%, 95% CI 51.6 to 68.4) within 3 years of incident stroke. Over the same time period, an additional 223 deaths from stroke were identified by VA; 64 (28.7%, 95% CI 20.9 to 36.5) had died within 28 days of stroke and 188 (84.3%, 95% CI 78.1 to 90.6) within 3 years. CONCLUSIONS: This is the first published study of post-stroke mortality in sub-Saharan Africa from an incident stroke population. The 28 day case fatality rate is at the lower end of rates reported for other low and middle income countries, even when including those identified by VA, although CIs were wide. Three year case fatality rates are notably higher than seen in most developed world studies. Improving post-stroke care may help to reduce stroke case fatality in sub-Saharan Africa.

Stroke incidence in rural and urban Tanzania: a prospective, community-based study.

BACKGROUND: There are no methodologically rigorous studies of the incidence of stroke in sub-Saharan Africa. We aimed to provide reliable data on the incidence of stroke in rural and urban Tanzania. METHODS: The Tanzania Stroke Incidence Project (TSIP) recorded stroke incidence in two well defined demographic surveillance sites (DSS) over a 3-year period from June, 2003. The Hai DSS (population 159,814) is rural and the Dar-es-Salaam DSS (population 56,517) is urban. Patients with stroke were identified by use of a system of community-based investigators and liaison with local hospital and medical centre staff. Patients who died from stroke before recruitment into the TSIP were identified via verbal autopsy, which was done on all those who died within the study areas. FINDINGS: There were 636 strokes during the 3-year period (453 in Hai and 183 in Dar-es-Salaam). Overall crude yearly stroke incidence rates were 94.5 per 100,000 (95% CI 76.0-115.0) in Hai and 107.9 per 100,000 (88.1-129.8) in Dar-es-Salaam. When age-standardised to the WHO world population, yearly stroke incidence rates were 108.6 per 100 000 (95% CI 89.0-130.9) in Hai and 315.9 per 100,000 (281.6-352.3) in Dar-es-Salaam. INTERPRETATION: Age-standardised stroke incidence rates in Hai were similar to those seen in developed countries. However, age-standardised incidence rates in Dar-es-Salaam were higher than seen in most studies in developed countries; this could be because of a difference in the prevalence of risk factors and emphasises the importance of health screening at a community level. Health policy makers must continue to monitor the incidence of stroke in sub-Saharan Africa and should base future funding decisions on such data. FUNDING: The Wellcome Trust.

Effectiveness and cost of facility-based Integrated Management of Childhood Illness (IMCI) in Tanzania.

BACKGROUND: The Integrated Management of Childhood Illness (IMCI) strategy is designed to address major causes of child mortality at the levels of community, health facility, and health system. We assessed the effectiveness of facility-based IMCI in rural Tanzania. METHODS: We compared two districts with facility-based IMCI and two neighbouring comparison districts without IMCI, from 1997 to 2002, in a non-randomised study. We assessed quality of case-management for children's illness, drug and vaccine availability, and supervision involving case-management, through a health-facility survey in 2000. Household surveys were used to assess child-health indicators in 1999 and 2002. Survival of children was tracked through demographic surveillance over a predefined 2-year period from mid 2000. Further information on contextual factors was gathered through interviews and record review. The economic cost of health care for children in IMCI and comparison districts was estimated through interviews and record review at national, district, facility, and household levels. FINDINGS: During the IMCI phase-in period, mortality rates in children under 5 years old were almost identical in IMCI and comparison districts. Over the next 2 years, the mortality rate was 13% lower in IMCI than in comparison districts (95% CI -7 to 30 or 5 to 21, depending on how adjustment is made for district-level clustering), with a rate difference of 3.8 fewer deaths per 1000 child-years. Contextual factors, such as use of mosquito nets, all favoured the comparison districts. Costs of children's health care with IMCI were similar to or lower than those for case-management without IMCI. INTERPRETATION: Our findings indicate that facility-based IMCI is good value for money, and support widespread implementation in the context of health-sector reform, basket funding, good facility access, and high utilisation of health facilities.