The effects of community-based interventions on the uptake of selected maternal and child health services: experiences of the IMCHA project in Iringa Tanzania, 2015-2020.

BACKGROUND: Maternal and child health (MCH) improvement has been prioritised in resource-constrained countries. This is due to the desire to meet the global sustainable development goals of achieving a maternal mortality rate of 70 per 100000 live births by 2030. The uptake of key maternal and child health services is crucial for reducing maternal and child health mortalities. Community-Based Interventions (CBIs) have been regarded as among the important strategies to improve maternal and child health service uptake. However, a paucity of studies examines the impacts of CBIs and related strategies on maternal and child health. This paper unveils the contribution of CBIs toward improving MCH in Tanzania. METHODS: Convergent mixed method design was employed in this study. Questionnaires were used to examine the trajectory and trend of the selected MCH indicators using the baseline and end-line data for the implemented CBI interventions. Data was also collected through in-depth interviews and focus group discussions, mainly with implementers of the interventions from the community and the implementation research team. The collected quantitative data was analysed using IBM SPSS, while qualitative data was analysed thematically. RESULTS: Antenatal care visits increased by 24% in Kilolo and 18% in Mufindi districts, and postnatal care increased by 14% in Kilolo and 31% in Mufindi districts. Male involvement increased by 5% in Kilolo and 13% in Mufindi districts. The uptake of modern family planning methods increased by 31% and 24% in Kilolo and Mufindi districts, respectively. Furthermore, the study demonstrated improved awareness and knowledge on matters pertaining to MCH services, attitude change amongst healthcare providers, and increased empowerment of women group members. CONCLUSION: Community-Based Interventions through participatory women groups are vital for increasing the uptake of MCH services. However, the success of CBIs depends on the wide array of contextual settings, including the commitment of implementers of the interventions. Thus, CBIs should be strategically designed to enlist the support of the communities and implementers of the interventions.

Why do pregnant women in Iringa region in Tanzania start antenatal care late? A qualitative analysis.

BACKGROUND: When started early in pregnancy and continued up till childbirth, antenatal care (ANC) can be effective in reducing adverse pregnancy outcomes. While the proportion of women who attend ANC at least once in low income countries is high, most pregnant women attend their first ANC late. In Tanzania, while over 51% of pregnant women complete ≥4 visits, only 24% start within the first trimester. This study aimed to understand the factors that lead to delay in seeking ANC services among pregnant women in Tanzania. METHODS: This qualitative descriptive case study was conducted in two rural districts in Iringa Region in Tanzania. A total of 40 focus group discussions (FGDs) were conducted involving both male and female participants in 20 villages. In addition, 36 semi-structured interviews were carried out with health care workers, members of health facility committees and community health workers. Initial findings were further validated during 10 stakeholders' meetings held at ward level in which 450 people participated. Data were analysed using thematic approach. RESULTS: Key individual and social factors for late ANC attendance included lack of knowledge of the importance of early visiting ANC, previous birth with good outcome, traditional gender roles, fear of shame and stigma, and cultural beliefs about pregnancy. Main factors which inhibit early ANC attendance in Kilolo and Mufindi districts include spouse accompany policy, rude language of health personnel and shortage of health care providers. CONCLUSIONS: Traditional gender roles and cultural beliefs about pregnancy as well as health system factors continue to influence the timing of ANC attendance. Improving early ANC attendance, therefore, requires integrated interventions that address both community and health systems barriers. Health education on the timing and importance of early antenatal care should also be strengthened in the communities. Additionally, while spouse accompany policy is important, the implementation of this policy should not infringe women's rights to access ANC services.

Factors for late initiation of antenatal care in Dar es Salaam, Tanzania: A qualitative study.

BACKGROUND: Antenatal care (ANC) provided by a trained health care provider is important for monitoring pregnancy thereby reducing potential risks for the mother and child during pregnancy and delivery. The World Health Organization (WHO) recommends at least four ANC visits to all pregnant women. While the proportion of women who attend at least one ANC in low-income countries is high, most pregnant women start their first ANC attendance very late. In Tanzania only 24% of pregnant women start their first ANC attendance before the fourth month of pregnancy. While factors for the utilization of antenatal care in general have been widely studied, there is paucity of studies on the factors affecting timing of the first ANC attendance. This study aimed to understand individual, community, and health system factors that lead to the delay in seeking ANC services among pregnant women in Ilala Municipal in Dar es Salaam region, Tanzania. METHODS: A qualitative exploratory study, using in-depth interviews with 20 pregnant women and five health care workers was conducted in three different health facilities in Dar es Salaam Tanzania. Thematic analysis approach was used to analyse the data. RESULTS: Individual perceptions of antenatal care, past experience with pregnancy, fear of pregnancy disclosure, and socio-cultural beliefs were the key individual and social factors for late ANC attendance. Shortage of trained health care workers, lack of spouse's escort and health providers' disrespect to pregnant women were the main health system barriers to early ANC attendance. CONCLUSIONS: This study concludes that community members should be sensitized about the importance of early ANC attendance. Additionally, while spouse's escort policy is important for promoting PMTCT, the interpretation of the policy should not solely be left to the health providers. District and regional health officials should provide correct interpretation of this policy.

Perceptions on male involvement in pregnancy and childbirth in Masasi District, Tanzania: a qualitative study.

BACKGROUND: Despite the efforts to promote male involvement in maternal and child health, studies in low and middle income countries have reported that male participation is still low. While factors that hinder male partners from participating in maternal and child healthcare are well documented, there is dearth of studies on local perceptions about male involvement in pregnancy and delivery care. The main objective of this study was to explore local perceptions about male involvement in pregnancy and childbirth in Tanzania. METHODS: Semi-structured individual interviews were conducted with key respondents and a thematic approach was used to analyse data. RESULTS: The findings revealed that women preferred to be accompanied by their partners to the clinics, especially on the first antenatal care visit. Men did not wish to be more actively involved in antenatal care and delivery. Respondents perceived men as being breadwinners and their main role in pregnancy and child birth was to support their partners financially. The key factors which hindered male participation were traditional gender roles at home, fear of HIV testing and unfavourable environment in health facilities. CONCLUSION: This study concludes that traditional gender roles and health facility environment presented barriers to male involvement. District health managers should strengthen efforts to improve gender relations, promote men's understanding of the familial and social roles in reproductive health issues as well as provide male friendly services. However, these efforts need to be supported by women and the society as a whole.

'Unless you come with your partner you will be sent back home': strategies used to promote male involvement in antenatal care in Southern Tanzania.

BACKGROUND: Male involvement in pregnancy and childbirth has been shown to improve maternal and child health. Many countries have used different strategies to promote participation of men in antenatal care services. While many strategies have been employed to promote male participation in antenatal care, few have been evaluated to provide much-needed lessons to support wider adoption. OBJECTIVE: This study aimed at describing strategies that were used by health providers and the community to promote male participation in antenatal care services and challenges associated with the implementation of these interventions in Southern Tanzania. METHODS: We used qualitative data and analytical methods to answer the research questions. The study relied on semi-structured interviews with health providers, men and women, village and community leaders and traditional birth attendants. Data were analysed using a thematic approach. RESULTS: The findings of this study revealed that different strategies were employed by health providers and the community in promoting participation of men in antenatal care services. These strategies included: health providers denying services to women attending antenatal care without their partners, fast-tracking service to men attending antenatal care with their partners, and providing education and community sensitisation. The implementation of these strategies was reported to have both positive and unintended consequences. CONCLUSIONS: This study concludes that despite the importance of male involvement in pregnancy and childbirth-related services, the use and promotion of the male escort policy should not inadvertently affect access to antenatal care services by pregnant women. In addition, programmes aiming for men's involvement should be implemented in ways that respect, promote and facilitate women's choices and autonomy and ensure their safety. Furthermore, there is a need for sensitisation of health providers and policymakers on what works best for involving men in pregnancy and childbirth.

The Need for Global Application of the Accountability for Reasonableness Approach to Support Sustainable Outcomes Comment on "Expanded HTA: Enhancing Fairness and Legitimacy".

The accountability for reasonableness (AFR) concept has been developed and discussed for over two decades. Its interpretation has been studied in several ways partly guided by the specific settings and the researchers involved. This has again influenced the development of the concept, but not led to universal application. The potential use in health technology assessments (HTAs) has recently been identified by Daniels et al as yet another excellent justification for AFR-based process guidance that refers to both qualitative and a broader participatory input for HTA, but it has raised concerns from those who primarily support the consistency and objectivity of more quantitative and reproducible evidence. With reference to studies of AFR-based interventions and the through these repeatedly documented motivation for their consolidation, we argue that it can even be unethical not to take AFR conditions beyond their still mainly formative stage and test their application within routine health systems management for their expected support to more sustainable health improvements. The ever increasing evidence and technical expertise are necessary but at times contradictory and do not in isolation lead to optimally accountable, fair and sustainable solutions. Technical experts, politicians, managers, service providers, community members, and beneficiaries each have their own values, expertise and preferences, to be considered for necessary buy in and sustainability. Legitimacy, accountability and fairness do not come about without an inclusive and agreed process guidance that can reconcile differences of opinion and indeed differences in evidence to arrive at a by all understood, accepted, but not necessarily agreed compromise in a current context - until major premises for the decision change. AFR should be widely adopted in projects and services under close monitoring and frequent reviews.

Do Management and Leadership Practices in the Context of Decentralisation Influence Performance of Community Health Fund? Evidence From Iramba and Iringa Districts in Tanzania.

BACKGROUND: In early 1990s, Tanzania like other African countries, adopted health sector reform (HSR). The most strongly held centralisation system that informed the nature of services provision including health was, thus, disintegrated giving rise to decentralisation system. It was within the realm of HSR process, user fees were introduced in the health sector. Along with user fees, various types of health insurances, including the Community Health Fund (CHF), were introduced. While the country's level of enrolment in the CHF is low, there are marked variations among districts. This paper highlights the role of decentralised health management and leadership practices in the uptake of the CHF in Tanzania. METHODS: A comparative exploratory case study of high and low performing districts was carried out. In-depth interviews were conducted with the members of the Council Health Service Board (CHSB), Council Health Management Team (CHMT), Health Facility Committees (HFCs), in-charges of health facilities, healthcare providers, and Community Development Officers (CDOs). Minutes of the meetings of the committees and district annual health plans and district annual implementation reports were also used to verify and triangulate the data. Thematic analysis was adopted to analyse the collected data. We employed both inductive and deductive (mixed coding) to arrive to the themes. RESULTS: There were no differences in the level of education and experience of the district health managers in the two study districts. Almost all district health managers responsible for the management of the CHF had attended some training on management and leadership. However, there were variations in the personal initiatives of the top-district health leaders, particularly the district health managers, the council health services board and local government officials. Similarly, there were differences in the supervision mechanisms, and incentives available for the health providers, HFCs and board members in the two study districts. CONCLUSION: This paper adds to the stock of knowledge on CHFs functioning in Tanzania. By comparing the best practices with the worst practices, the paper contributes valuable insights on how CHF can be scaled up and maintained. The study clearly indicates that the performance of the community-based health financing largely depends on the personal initiatives of the top-district health leaders, particularly the district health managers and local government officials. This implies that the regional health management team (RHMT) and the Ministry of Health and Social Welfare (MoHSW) should strengthen supportive supervision mechanisms to the district health managers and health facilities. More important, there is need for the MoHSW to provide opportunities for the well performing districts to share good practices to other districts in order to increase uptake of the community-based health insurance.

Community participation in the decentralised district health systems in Tanzania: why do some health committees perform better than others?

Over the past two decades, community participation has emerged as an important dimension within decentralised district healthcare systems. In Tanzania, initiatives to strengthen community participation have focused on the formation of the health committees. Studies have reported variations in the performance of the committees. An exploratory case study design focusing on two districts was adopted to explore the differences in practice of the health facility committees in a well-functioning district and one that is not. In both study districts, the committees were in place. The most common activities of the health committees were assisting the clinic in day-to-day running. The health committees' influence on policy, planning and budgeting was limited. Managerial and leadership practices of the district health managers, including effective supervision and personal initiatives of the top-district health officials coupled with incentives, are the major factors for the good performance of the health facility committees and the boards. Inadequate training and low public awareness affected the performance of the committees. A greater role in governance and oversight is essential for effective and meaningful health committees. To achieve impact, health committees will require adequate training on the following: roles and functions of the health facility committees and the boards; interaction between the committees and the communities and the health workers; development of health plans and budgets at the local and district level; and monitoring and tracking. Copyright © 2015 John Wiley & Sons, Ltd.

Implementation of Community Health Fund in Tanzania: why do some districts perform better than others?

In early 1990s, Tanzania, like other African countries, introduced user fees in public health systems. Although user fees were considered important in promoting health, they appear to reduce people's access to health services. To counteract the detrimental effects of the user fees, various types of health insurances were introduced, including the Community Health Fund (CHF). Drawing from the review of minutes, health facility visits and key informant interviews, this study explored why implementation of the CHF in Tanzania has been more successful in some districts than in others. The findings indicate that in Lindi district, the enrolment rate for the CHF was very low. This was attributed to high premium rates, frequent drug stock-out, lack of trust by the community members to the health providers, low incentives and local politics. In contrast, in Iramba district, the performance was better. Availability of drugs in the health facilities, effective supervision, commitment of the top district-level officials and incentives to the health facility committees were the main factors that facilitated good performance of the fund in Iramba district. The focus of the implementation needs to be placed on the active engagement of the local-level leaders and politicians who are responsible for the implementation of the policy. Equally important is the availability of quality health services in the health facilities.

Implementation of pro-poor exemption policy in Tanzania: policy versus reality.

Like many other African countries, Tanzania has been implementing user fee policy in its health sector since the early 1990s. Accompanying user fee, mechanisms were designed that exempted the poor and vulnerable groups of the society from paying user charges. Although studies on the implementation of exemption policies in Tanzania exist, very few have documented the actual process of translating exemption policies into actions-the process of implementation. Drawing from policy analysis and implementation theories, this paper documents the implementation of the waiver (need-based exemptions) policy in Tanzania. The findings indicate that waiver systems, while potentially effective in principle, were ineffective in implementation. Lack of specification of criteria by which the poor could be identified made policy implementers at different levels to implement the policy in their own style. Low level of public awareness about the existence of waiver mechanisms hindered the poor to demand exemptions. Furthermore, fear of loss of revenue at the health facilities and ineffective enforcement mechanisms provided little incentives for local government leaders and health workers to communicate the policy to beneficiaries. It is concluded from this study that to better achieve the objectives of the pro-poor exemption policy, it is important to engage policy implementers more actively in the management and implementation of policies. Additionally, it is imperative to understand the behaviour and practices of policy implementers, especially district health managers, health workers and village and ward leaders, who may react negatively to new policies and implement the policies in ways contrary to what policy makers had intended.

Strengthening fairness, transparency and accountability in health care priority setting at district level in Tanzania.

Health care systems are faced with the challenge of resource scarcity and have insufficient resources to respond to all health problems and target groups simultaneously. Hence, priority setting is an inevitable aspect of every health system. However, priority setting is complex and difficult because the process is frequently influenced by political, institutional and managerial factors that are not considered by conventional priority-setting tools. In a five-year EU-supported project, which started in 2006, ways of strengthening fairness and accountability in priority setting in district health management were studied. This review is based on a PhD thesis that aimed to analyse health care organisation and management systems, and explore the potential and challenges of implementing Accountability for Reasonableness (A4R) approach to priority setting in Tanzania. A qualitative case study in Mbarali district formed the basis of exploring the sociopolitical and institutional contexts within which health care decision making takes place. The study also explores how the A4R intervention was shaped, enabled and constrained by the contexts. Key informant interviews were conducted. Relevant documents were also gathered and group priority-setting processes in the district were observed. The study revealed that, despite the obvious national rhetoric on decentralisation, actual practice in the district involved little community participation. The assumption that devolution to local government promotes transparency, accountability and community participation, is far from reality. The study also found that while the A4R approach was perceived to be helpful in strengthening transparency, accountability and stakeholder engagement, integrating the innovation into the district health system was challenging. This study underscores the idea that greater involvement and accountability among local actors may increase the legitimacy and fairness of priority-setting decisions. A broader and more detailed analysis of health system elements, and socio-cultural context is imperative in fostering sustainability. Additionally, the study stresses the need to deal with power asymmetries among various actors in priority-setting contexts.

Decentralization and health care prioritization process in Tanzania: from national rhetoric to local reality.

During the 1990s, Tanzania like many other developing countries adopted health sector reforms. The most common policy change under the health sector reforms has been decentralization, which involves the transfer of power and authority from the central level to local authorities. Based on the case study of Mbarali district in Tanzania, this paper uses a policy analysis approach to analyse the implementation of decentralized health care priority setting. Specifically, the paper examines the process, actors and contextual factors shaping decentralized health care priority setting processes. The analysis and conclusion are based on a review of documents, key informant interviews, focus group discussion, and notes from non-participant observation. The findings of the study indicate that local institutional contexts and power asymmetries among actors have a greater influence on the prioritization process at the local level than expected and intended. The paper underlines the essentially political character of the decentralization process and reiterates the need for policy analysts to pay attention to processes, institutional contexts, and the role of policy actors in shaping the implementation of the decentralization process at the district level.