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Abstract Introduction Scaling up public health interventions in the health systems of resource poor settings come with technical and operational challenges. Little is documented on scaling up complex health financing interventions and their related outcomes, especially the voluntary health insurance schemes. This study aimed to analyse the scale-up steps, successes and challenges of the improved community health fund (iCHF), a voluntary health insurance scheme in Tanzania, Methods In this paper, guided by the Expand Net framework (a scale-up framework for health system interventions), we present a systematic analysis of countrywide scale-up of the iCHF that started in 2019 and implemented in partnership between the government and development partners. We systematically collected information on the scale-up steps and the success and challenges. The collected data was analysed using descriptive statistics. Results The scale-up involved multiple steps and actions at different levels of the health system. The initial step involved gathering stakeholders’ views on scale-up options and strategies. The subsequent steps focused on mobilizing resources for scale-up, advocacy and promotion of the scheme through media, community leaders and role models, capacity building to implementing organs, institutionalizing the scale-up processes, intensifying the scale-upscale-up activities for expansion and spontaneous scale-up and technical backstopping to lower levels of the health system on the scale-up process. We found success and challenges as the scale-upscale-up progressed to mature stages. The success included acceptability and institutionalization of the scale-up activities and growing enrolments and funds in the scheme. The challenges included: the costs to sustaining advocacy and enrolments, equity in scale-upscale-up activities across regions, relying on top-down scale-upscale-up approaches, influence of contextual factors and lack of implementation research alongside the scale-upscale-up process. Conclusion This paper underscores the scale up steps and success and challenges of scaling-up a voluntary health insurance scheme in a resource-constrained health system. Sustaining the scale-upscale-up gains will require utilizing program data and experiences to sustainably improve the scheme performance while also harnessing support from stakeholders. Further research is needed to assess equity and quality of outcomes of the scale up.

Abstract Background Despite the global progress in bringing health services closer to the population, mothers and their newborns still receive substandard care leading to morbidity and mortality. Health facilities’ capacity to deliver the service is a prerequisite for quality health care. This study aimed to assess health facilities’ readiness to provide comprehensive emergency obstetric and newborn care (CEmONC), comprising of blood transfusion, caesarean section and basic services, and hence to inform improvement in the quality of care interventions in Tanzania. Methods A cross-sectional assessment of 30 CEmONC health facilities implementing the Safer Births Bundle of Care package in five regions of Tanzania was carried out between December 2020 and January 2021. We adapted the World Health Organization’s Service Availability and Readiness Assessment tool to assess amenities, equipment, trained staff, guidelines, medicines, and diagnostic facilities. Composite readiness scores were calculated for each category and results were compared at the health facility level. For categorical variables, we tested for differences by Fisher’s exact test; for readiness scores, differences were tested by a linear mixed model analysis, taking into account dependencies within the regions. We used p

This qualitative, focused critical ethnographic study explores how young people’s ‘lived SRH citizenship’ and their active roles realising their sexual and reproductive health (SRH) and rights, shape their agency and participation in decision-making in Malawi. Informed by postcolonial feminist and difference-centred citizenship theories, our findings reveal that age-based power differentials, systems of gerontocracy and a culture of adultism impede bona fide youth involvement in SRH policymaking, making young citizens’ participation more of an illusion than reality. Although democratisation and decentralisation aim to promote youth engagement, SRH policy spaces/processes lack institutionalised processes for integrating youth and remain dominated by donors and government. Collective efforts to build young citizens’ capacity and to support their engagement are essential for realising their active and meaningful participation in SRH decision-making. Recognising youth as equal members of society is vital to expose systemic gerontocracy/adultism, and democratise power to youth in Malawi, and beyond.

Introduction Achieving universal health coverage requires using research evidence to inform decision-making. However, little information is available on the use of research evidence in planning in lower middle-income countries, including Tanzania. This paper presents a protocol that aims to investigate the usage of research evidence in health planning, determinants and readiness of the planning team members to use knowledge translation tools in Tanzania.Methods and analysis This study will employ a sequential exploratory mixed-methods design, with participants selected from national, regional and council levels. Qualitative data will be collected through a maximum of 52 in-depth interviews and 12 focused group discussions until saturation. To collect quantitative data, a structured questionnaire will be used to survey 422 participants, and a document review will be conducted from health facilities. Qualitative data will be analysed using thematic analysis, while descriptive and inferential analyses will be employed for quantitative data.Ethics and dissemination The study participants will provide written informed consent, and all recorded data will be stored on a secured research server accessible only to the investigators. Ethical approval has been obtained from the University of Dodoma Research Ethics Committee (ref. MA.84/261/02/‘A’/64/91). The findings of this study will inform policymakers, researchers and implementers in the country on the use of research evidence in decision-making. We will disseminate our findings through publications, conferences, workshops and interactive communication with national, regional, council and health facility planning teams.

Abstract Background Even though trust is placed at the central point in ensuring proper functioning of the health systems, studies remain scant on how it affects both the implementation and uptake of COVID-19 response measures in low- and middle-income countries such as Tanzania. This study, therefore, explored the role of trust in the implementation and uptake of recommended COVID-19 response measures including vaccines from the perspective of health professionals in Tanzania. Methods This cross-sectional qualitative study was implemented in four of Tanzania’s thirty-one regions. Qualitative data was collected through 26 in-depth interviews held with regional and district disease outbreak response teams, district cold chain co-ordinators and health facility in-charges. In addition, five focus group discussions and seven group interviews were conducted with healthcare workers from the lower-level health facilities. Thematic analysis was conducted and applied the trust constructs. Results Interpersonal trust and health system trust emerged as two major themes in the study. Interpersonal trust was reported to stem from lack of transparency that instigated fear, worries, and confusion regarding the implementation and uptake of the recommended response measures. The distrust was mainly between health professionals in health facilities and those assigned to isolation centres as well as between patients and community members. On the other hand, the health system trust was shaped by mixed feelings regarding COVID-19 vaccine national decisions, and conflicting messages from national officials, politicians and religious leaders on COVID-19 responses, safety, and effectiveness of the vaccines. Questions surrounding the short duration of clinical trials, indeterminate post-vaccination protection duration, impotence-linked beliefs, freemasonry notion and unclear vaccinated cards information are other reported contributory factors to mistrust in the health system. However, after a comprehensive health education and experience in COVID-19 vaccination administration most professionals affirmed the effectiveness of the vaccines in limiting infections and its severe consequences. Conclusion Participants indicated limited trust at both interpersonal and health system levels aggravated by lack of transparency, unclear and conflicting messages on COVID-19 infections and response measures. Enforced transparency on pandemics alongside standardised messages from the reliable sources is crucial in enhancing trust in implementation and uptake of the recommended response measures.

Abstract Background Building health research capacity in low- and middle-income countries is essential to achieving universal access to safe, high-quality healthcare. It can enable healthcare workers to conduct locally relevant research and apply findings to strengthen their health delivery systems. However, lack of funding, experience, know-how, and weak research infrastructures hinders their ability. Understanding research capacity, engagement, and contextual factors that either promote or obstruct research efforts by healthcare workers can inform national strategies aimed at building research capacity. Methods We used a convergent mixed-methods study design to understand research capacity and research engagement of healthcare workers in Tanzania’s public health system, including the barriers, motivators, and facilitators to conducting research. Our sample included 462 randomly selected healthcare workers from 45 facilities. We conducted surveys and interviews to capture data in five categories: (1) healthcare workers research capacity; (2) research engagement; (3) barriers, motivators, and facilitators; (4) interest in conducting research; and (5) institutional research capacity. We assessed quantitative and qualitative data using frequency and thematic analysis, respectively; we merged the data to identify recurring and unifying concepts. Results Respondents reported low experience and confidence in quantitative (34% and 28.7%, respectively) and qualitative research methods (34.5% and 19.6%, respectively). Less than half (44%) of healthcare workers engaged in research. Engagement in research was positively associated with: working at a District Hospital or above (p = 0.006), having a university degree or more (p = 0.007), and previous research experience (p = 0.001); it was negatively associated with female sex (p = 0.033). Barriers to conducting research included lack of research funding, time, skills, opportunities to practice, and research infrastructure. Motivators and facilitators included a desire to address health problems, professional development, and local and international collaborations. Almost all healthcare workers (92%) indicated interest in building their research capacity. Conclusion Individual and institutional research capacity and engagement among healthcare workers in Tanzania is low, despite high interest for capacity building. We propose a fourfold pathway for building research capacity in Tanzania through (1) high-quality research training and mentorship; (2) strengthening research infrastructure, funding, and coordination; (3) implementing policies and strategies that stimulate engagement; and (4) strengthening local and international collaborations.

Abstract Background Family members experience an emotional crisis when their loved one is critically ill and admitted to a critical care unit (CCU). An extensive literature has explored optimal ways to interact with families in the critical care setting, including intervention studies. What is less explored are perceptions of family members in low-income settings including Malawi. In such settings, perceptions may differ as a consequence of different cultural practices and resource limitations (personnel and technology). Therefore, this study explored family members’ perceptions of their needs in CCUs at a tertiary hospital in Malawi. Study designs and methods The study used a qualitative descriptive design. Data were gathered through interviews with 12 participants who were purposively selected from immediate family members of patients hospitalized for 48 h or more in adult intensive care unit (ICU) and high dependency unit (HDU). The interviews were audio recorded and transcribed verbatim. Data analysis followed the steps of content analysis. Findings The following four themes were identified: perceived information, physical, and psychosocial needs, and coping mechanisms of the family members. The family members needed information about their patient’s progress frequently and viewed this as a priority compared to other needs such as comfort and food. Conclusion This study suggests that there should be a collaborative relationship between the CCU team and family members in order to meet their needs. Findings affirm the need for health professionals to develop guidelines or standards that promote frequent discussions with CCU family members as a means to provide support and lessen anxiety.

BackgroundThe use of data in decision making and planning in primary health care settings is critical for improving efficiency and health outcomes for patients and communities. Implementation research can be used to fully understand the effects, context, challenges, and facilitators of data use, as well as how to scale up data use interventions. However, in the context of low resource settings, little is known about how implementation research can be employed to assess the implementation and impact of data use interventions.MethodsWe will conduct a hybrid type 2 effectiveness-implementation study employing a mixed method controlled before and after design to measure the effects of data use interventions while simultaneously understanding the implementation of those initiatives. The controlled before and after entails measurement of the effects of the interventions at baseline and end line in a matched intervention and control health facilities using structured questionnaire to health workers (n = 440) and existing patients (n = 422) while also extracting selected health outcome variable from routine data in all participating health facilities (n = 80). The mixed methods component entails measuring the implementation outcomes (adoption, acceptability, fidelity and maintenance) and their moderators entails the integration of both quantitative and qualitative data collection, analysis, and interpretation (i.e. mixed methods) approach by using a structured questionnaire to implementers (health workers and managers) (n = 400). Experiential dimensions of implementation processes and moderators will be explored using qualitative interviews. Guided by implementation research theories and frameworks, a theory of change (TOC) is developed first to guide the evaluation of implementation processes and effects of the interventions. Descriptive and inferential statistics will be employed to analyze quantitative data whereas thematic analysis approach will be employed for qualitative data.DiscussionThis study is one of the first to test the simultaneous measurement of effects and implementation processes of data use interventions in the primary health care settings. Findings will support efforts to improve quality of services by optimizing scale up and sustainability of the data use initiatives in primary health care settings.

The novel Coronavirus disease 2019 (COVID-19) presents a major threat to public health but can be prevented by safe and effective COVID-19 vaccines. Vaccine acceptance among healthcare workers (HCWs) is essential to promote uptake. This study, aimed to determine the COVID-19 vaccination uptake and hesitancy and its associated factors among HCWs in Tanzania. We employed a convergent-parallel mixed-methods design among 1368 HCWs across health facilities in seven geographical zones in Tanzania in 2021. We collected quantitative data by using an interviewer-administered questionnaire and qualitative data, using in-depth interviews and focus group discussions. Participants in the quantitative aspect were conveniently selected whereas those in the qualitative aspect were purposively selected based on their role in patient care, management, and vaccine provision. Stata software version 16.1 was used in the analysis of quantitative data and thematic analysis for the qualitative data. Multiple logistic regression was used to assess the determinants of COVID-19 vaccine uptake. The median age of 1368 HCWs was 33, and the interquartile range was 28–43 years; 65.6% were aged 30+ years, and 60.1% were females. Over half (53.4%) of all HCWs received the COVID-19 vaccine, 33.6% completely refused, and 13% chose to wait. HCWs aged 40+ years, from lower-level facilities (district hospitals and health centers), who worked 6+ years, and with perceived high/very high risk of COVID-19 infection had significantly higher odds of vaccine uptake. The qualitative data revealed misinformation and inadequate knowledge about COVID-19 vaccine safety and efficacy as the key barriers to uptake. Nearly half of all HCWs in Tanzania are still unvaccinated against COVID-19. The predominance of contextual influence on COVID-19 vaccine uptake calls for interventions to focus on addressing contextual determinants, focusing on younger HCWs’ population, short working duration, those working at different facility levels, and providing adequate vaccine knowledge.

There has been widespread concern about the provision of quality education (QE) for all learners in all contexts, but research evidence to inform this debate is quite divergent and in most of cases the question about achieving this desire seems to be full of myths. This paper examines a selection of embedded myths about QE in Tanzanian education sector. The paper specifically aims at identifying the myths, their effects in education practice, and the appropriate ways to address them. The researcher's own experiences and voices from secondary school teachers, parents, and students were merged to inform the study. Merging of these voices helped this paper to have a major contribution towards a better understanding of myths and their adverse influence in education practice, and spotting some alternative modes of practice towards addressing them.

Abstract Background Development Assistance for Health (DAH) represents an important source of health financing in many low and middle-income countries. However, there are few accounts on how priorities funded through DAH are integrated with district health priorities. This study is aimed at understanding the operational challenges of engaging development partners in district health planning in Tanzania. Methods This explanatory mixed-methods study was conducted in Kinondoni and Bahi districts, representing urban and rural settings of the country. Data collection took place between November and December 2015. The quantitative tools (mapping checklist, district questionnaire and Development partners (DPs) questionnaire) mapped the DPs and their activities and gauged the strength of DP engagement in district health planning. The qualitative tool, a semi-structured in-depth interview guide administered to 20 key informants (the council health planning team members and the development partners) explained the barriers and facilitators of engagement. Descriptive and thematic analysis was utilized for quantitative and qualitative data analysis respectively. Results Eighty-six per cent (85%) of the development partners delivering aid in the studied districts were Non-Governmental Organizations. Twenty percent (20%) of the interventions were HIV/AIDS interventions. We found that only four (4) representing 25 % (25%) DPs had an MOU with the District Council, 56 % (56%) had submitted their plans in writing to be integrated into the 2014/15 CCHP. Six (6) representing 38 % (38%) respondents had received at least one document (guidelines, policies and other planning tools) from the district for them to use in developing their organization activity plans. Eighty-seven point 5 % (87.5%) from Bahi had partial or substantial participation, in the planning process while sixty-two point 5 % (62.5%) from Kinondoni had not participated at all (zero participation). The operational challenges to engagements included differences in planning cycles between the government and donors, uncertainties in funding from the prime donors, lack of transparency, limited skills of district planning teams, technical practicalities on planning tools and processes, inadequate knowledge on planning guidelines among DPs and, poor donor coordination at the district level. Conclusions We found low engagement of Development Partners in planning. To be resolved are operational challenges related to differences in planning cycles, articulations and communication of local priorities, donor coordination, and technical skills on planning and stakeholder engagement.

COVID-19 is a major public health threat associated with increased disease burden, mortality, and economic loss to countries and communities. Safe and efficacious COVID-19 vaccines are key in halting and reversing the pandemic. Low confidence in vaccines has been one of the factors leading to hesitancy. We aimed to assess the COVID-19 vaccine confidence (safety and effectiveness), associated factors, and its effects on vaccine uptake among general community members in Tanzania. This was a community-based cross-sectional survey conducted from December 2021 to April 2022 in six regions of Tanzania mainland and two regions in Zanzibar. Participants were interviewed using an electronic questionnaire. Multiple logistic regression models estimated odds ratios (ORs) and 95% confidence interval (CI) for factors associated with vaccine confidence. All analyses were performed using SPSS version 25.0. The study enrolled 3470 general Tanzanian community members; their mean age was 40.3 (standard deviation ±14.9) years, and 34% were males. The proportion of COVID-19 vaccine confidence was 54.6%. Geographical region, residence area, COVID-19 disease risk perception, and good knowledge of COVID-19 vaccines were significantly associated with COVID-19 vaccine confidence. Confidence in COVID-19 vaccines was associated with over three times higher odds of vaccine uptake. Confidence in COVID-19 vaccines was low in Tanzania. Innovative community engagement strategies and region-specific interventions are needed to improve comprehensive knowledge and address community perceptions and attitudes toward COVID-19 vaccines.

Vaccination is the most cost-effective way of preventing Coronavirus Disease 2019 (COVID-19) although there was a considerable delay in its institution in Tanzania. This study assessed health care workers' (HCWs) self-perceived infection risk and uptake of COVID-19 vaccines. A concurrent embedded, mixed methods design was utilized to collect data among HCWs in seven Tanzanian regions. Quantitative data was collected using a validated, pre-piloted, interviewer administered questionnaire whereas in-depth interviews (IDIs) and focus group discussions (FGDs) gathered qualitative data. Descriptive analyses were performed while chi-square test and logistic regression were used to test for associations across categories. Thematic analysis was used to analyze the qualitative data. A total of 1,368 HCWs responded to the quantitative tool, 26 participated in the IDIs and 74 in FGDs. About half of the HCW (53.6%) reported to have been vaccinated and three quarters (75.5%) self-perceived to be at a high risk of acquiring COVID-19 infection. High perceived infection risk was associated with increased COVID-19 vaccine uptake (OR 1.535). Participants perceived that the nature of their work and the working environment in the health facilities increased their infection risk. Limited availability and use of personal protective equipment (PPE) was reported to elevate the perceived infection risks. Participants in the oldest age group and from low and mid-level health care facilities had higher proportions with a high-risk perception of acquiring COVID-19 infection. Only about half of the HCWs reported to be vaccinated albeit the majority recounted higher perception of risk to contracting COVID-19 due to their working environment, including limited availability and use of PPE. Efforts to address heightened perceived-risks should include improving the working environment, availability of PPE and continue updating HCWs on the benefits of COVID-19 vaccine to limit their infection risks and consequent transmission to their patients and public.

Background In low- and middle-income countries, too, public–private partnerships in health insurance schemes are crucial for improving access to health services. Problems in the public supply chain of medicines often lead to medicine stock-outs which then negatively influence enrolment in and satisfaction with health insurance schemes. To address this challenge, the government of Tanzania embarked on a redesign of the Community Health Fund (CHF) and established a Prime Vendor System (Jazia PVS). Informal and rural population groups, however, rely heavily on another public–private partnership, the Accredited Drug Dispensing Outlets (ADDOs). This study takes up this public demand and explores the potentials, pitfalls, and modalities for linking the improved CHF (iCHF) with ADDOs. Methods This was a qualitative exploratory study employing different methods of data collection: in-depth interviews, focus group discussions, and document reviews. Results Study participants saw a great potential for linking ADDOs with iCHF, following continuous community complaints about medicine stock-out challenges at public health facilities, a situation that also affects the healthcare staff’s working environment. The Jazia PVS was said to have improved the situation of medicine availability at public health facilities, although not fully measuring up to the challenge. Study participants thought linking ADDOs with the iCHF would not only improve access to medicine but also increase member enrolment in the scheme. The main pitfalls that may threaten this linkage include the high price of medicines at ADDOs that cannot be accommodated within the iCHF payment model and inadequate digital skills relevant for communication between iCHF and ADDOs. Participants recommended linking ADDOs with the iCHF by piloting the connection with a few ADDOs meeting the selected criteria, while applying similar modalities for linking private retail outlets with the National Health Insurance Fund (NHIF). Conclusions As the government of Tanzania is moving toward the Single National Health Insurance Fund, there is a great opportunity to link the iCHF with ADDOs, building on established connections between the NHIF and ADDOs and the lessons learnt from the Jazia PVS. This study provides insights into the relevance of expanding public–private partnership in health insurance schemes in low- and middle-income countries.

BackgroundDespite acceleration of remote consulting throughout the COVID-19 pandemic, many health care professionals are practicing without training to offer teleconsultation to their patients. This is especially challenging in resource-poor countries, where the telephone has not previously been widely used for health care. ObjectiveAs the COVID-19 pandemic dawned, we designed a modular online training program for REmote Consulting in primary Health care (REaCH). To optimize upscaling of knowledge and skills, we employed a train-the-trainer approach, training health workers (tier 1) to cascade the training to others (tier 2) in their locality. We aimed to determine whether REaCH training was acceptable and feasible to health workers in rural Tanzania to support their health care delivery during the pandemic. MethodsWe developed and pretested the REaCH training program in July 2020 and created 8 key modules. The program was then taught remotely via Moodle and WhatsApp (Meta Platforms) to 12 tier 1 trainees and cascaded to 63 tier 2 trainees working in Tanzania’s rural Ulanga District (August-September 2020). We evaluated the program using a survey (informed by Kirkpatrick's model of evaluation) to capture trainee satisfaction with REaCH, the knowledge gained, and perceived behavior change; qualitative interviews to explore training experiences and views of remote consulting; and documentary analysis of emails, WhatsApp texts, and training reports generated through the program. Quantitative data were analyzed using descriptive statistics. Qualitative data were analyzed thematically. Findings were triangulated and integrated during interpretation. ResultsOf the 12 tier 1 trainees enrolled in the program, all completed the training; however, 2 (17%) encountered internet difficulties and failed to complete the evaluation. In addition, 1 (8%) opted out of the cascading process. Of the 63 tier 2 trainees, 61 (97%) completed the cascaded training. Of the 10 (83%) tier 1 trainees who completed the survey, 9 (90%) would recommend the program to others, reported receiving relevant skills and applying their learning to their daily work, demonstrating satisfaction, learning, and perceived behavior change. In qualitative interviews, tier 1 and 2 trainees identified several barriers to implementation of remote consulting, including lacking digital infrastructure, few resources, inflexible billing and record-keeping systems, and limited community awareness. The costs of data or airtime emerged as the greatest immediate barrier to supporting both the upscaling of REaCH training and subsequently the delivery of safe and trustworthy remote health care. ConclusionsThe REaCH training program is feasible, acceptable, and effective in changing trainees’ behavior. However, government and organizational support is required to facilitate the expansion of the program and remote consulting in Tanzania and other low-resource settings.

Abstract Introduction Micro-health insurance (MHI) has been identified as a possible interim solution to foster progress towards Universal Health Coverage (UHC) in low- and middle- income countries (LMICs). Still, MHI schemes suffer from chronically low penetration rates, especially in sub-Saharan Africa. Initiatives to promote and sustain enrolment have yielded limited effect, yet little effort has been channelled towards understanding how such initiatives are implemented. We aimed to fill this gap in knowledge by examining heterogeneity in implementation outcomes and their moderating factors within the context of the Redesigned Community Health Fund in the Dodoma region in Tanzania. Methods We adopted a mixed-methods design to examine implementation outcomes, defined as adoption and fidelity of implementation (FOI) as well as their moderating factors. A survey questionnaire collected individual level data and a document review checklist and in-depth interview guide collected district level data. We relied on descriptive statistics, a chi square test and thematic analysis to analyse our data. Results A review of district level data revealed high adoption (78%) and FOI (77%) supported also by qualitative interviews. In contrast, survey participants reported relatively low adoption (55%) and FOI (58%). Heterogeneity in adoption and FOI was observed across the districts and was attributed to organisational weakness or strengths, communication and facilitation strategies, resource availability (fiscal capacity, human resources and materials), reward systems, the number of stakeholders, leadership engagement, and implementer’s skills. At an individual level, heterogeneity in adoption and FOI of scheme components was explained by the survey participant’s level of education, occupation, years of stay in the district and duration of working in the scheme. For example, the adoption of job description was statistically associated with occupation (p = 0.001) and wworking in the scheme for more than 20 months had marginal significant association with FOI (p = 0.04). Conclusion The study demonstrates that assessing the implementation processes helps to detect implementation weaknesses and therefore address such weaknesses as the interventions are implemented or rolled out to other settings. Attention to contextual and individual implementer elements should be paid in advance to adjust implementation strategies and ensure greater adoption and fidelity of implementation.

Introduction Tanzania is adapting a shortened injectable-free multidrug resistant tuberculosis (MDR-TB) regimen, comprising new drugs such as bedaquiline and delamanid and repurposed drugs such as clofazimine and linezolid. The regimen is implemented using a pragmatic prospective cohort study within the National TB and Leprosy Programme and is accompanied by a process evaluation. The process evaluation aims to unpack the implementation processes, their outcomes and the moderating factors in order to understand the clinical effectiveness of the regimen. This protocol describes the methods employed in understanding the implementation processes of the new MDR-TB regimen in 15 regions of Tanzania.Methods This study adopts a concurrent mixed-methods design. Using multiple data collection tools, we capture information on: implementation outcomes, stakeholder response to the intervention and the influence of contextual factors. Data will be collected from the 22 health facilities categorised as dispensaries, health centres, district hospitals and referral hospitals. Health workers (n=132) and patients (n=220) will fill a structured questionnaire. For each category of health facility, we will conduct five focus group discussions and in-depth interviews (n=45) for health workers. Participant observations (n=9) and review documents (n=22) will be conducted using structured checklists. Data will be collected at two points over a period of 1 year. We will analyse quantitative data using descriptive and inferential statistical methods. Thematic analysis will be used for qualitative data.Ethics and dissemination This study received ethical approval from National Institute of Medical research (NIMR), Ref. NIMR/HQ/R.8a/Vol.IX/3269 and from the Mbeya Medical Research and Ethics Review Committee, Ref. SZEC-2439/R.A/V.I/38. Our findings are expected to inform the wider implementation of the new MDR-TB regimen as it is rolled out countrywide. Dissemination of findings will be through publications, conferences, workshops and implementation manuals for scaling up MDR-TB treatments.

Abstract Background Infrastructure development and upgrading to support safe surgical services in primary health care facilities is an important step in the journey towards achieving Universal Health Coverage (UHC). Quality health service provision together with equitable geographic access and service delivery are important components that constitute UHC. Tanzania has been investing in infrastructure development to offer essential safe surgery close to communities at affordable costs while ensuring better outcomes. This study aimed to understand the public sector’s efforts to improve the infrastructure of primary health facilities between 2005 and 2019. We assessed the construction rates, geographic coverage, and physical status of each facility, surgical safety and services rendered in public primary health facilities. Methods Data was collected from existing policy reports, the Services Availability and Readiness Assessment (SARA) tool (physical status), the Health Facility Registry (HFR), implementation reports on infrastructure development from the 26 regions and 185 district councils across the country (covering assessment of physical infrastructure, waste management systems and inventories for ambulances) and Comprehensive Emergence Obstetric Care (CEMONC) signal functions assessment tool. Data was descriptively analyzed so as to understand the distribution of primary health care facilities and their status (old, new, upgraded, under construction, renovated and equipped), and the service provided, including essential surgical services. Results Of 5072 (518 are Health Centers and 4554 are Dispensaries) existing public primary health care facilities, the majority (46%) had a physical status of A (good state), 33% (1693) had physical status of B (minor renovation needed) and the remaining facilities had physical status of C up to F (needing major renovation). About 33% (1673) of all health facilities had piped water and 5.1% had landline telecommunication system. Between 2015 and August 2019, a total of 419 (8.3%) health facilities (Consisting of 350 health centers and 69 District Council Hospitals) were either renovated or constructed and equipped to offer safe surgery services. Of all Health Centers only 115 (22.2%) were offering the CEMONC services. Of these 115 health facilities, only 20 (17.4%) were offering the CEMONC services with all 9 - signal functions and only 17.4% had facilities that are offering safe blood transfusion services. Conclusion This study indicates that between 2015 and 2019 there has been improvement in physical status of primary health facilities as a result constructions, upgrading and equipping the facilities to offer safe surgery and related diagnostic services. Despite the achievements, still there is a high demand for good physical statuses and functioning of primary health facilities with capacity to offer essential and safe surgical services in the country also as an important strategy towards achieving UHC. This is also inline with the National Surgical, Obstetrics and Anesthesia plan (NSOAP).

Abstract Background Health system performance is one of the important components of the health care delivery; its achievement depends on the quality of services rendered and the health system responsiveness of its beneficiaries. Health system responsiveness is a multi-dimensional concept and is usually measured through several domains. Health system responsiveness (HSR) remains to be a key indicator for evaluation of health system performance in any settings. This study aimed at assessing the situation of health system responsiveness in primary health facilities in Tanzania prior to introduction of the Direct Health Facility Financing (DHFF) program. Methods This was a cross sectional study conducted between January and February in 2018. We collected data from 42 primary health facilities (14 health centers and 28 dispensaries) where a questionnaire was administered to a total of 422 participants. The questionnaire collected information on attention, respect to dignity, clear communication, autonomy, access to care, respect to confidentiality and basic amenities. Descriptive analysis was done to determine the distribution of the variables whereas ANOVA and linear regression analysis was employed to discern the association between variables. Results More than 67% of participants had visited the same health facility more than 5 times. Sixty seven percent of the patients were residing within 5kms from the public primary health care facilities. The geographical access to health care scored the lowest (43.5% for Dispensaries and 36% for Health center) mean as compared to other domains of health system responsiveness. The highest score was in respect to confidentiality (86.7%) followed by respect to dignity (81.4%). Linear regression analysis revealed no statistical association between any of the social demographic features with the overall HSR performances. However, in post hoc analysis, Pwani and Shinyanga regions didn’t differ significantly in terms of their performances whereas those two regions differ from all other regions. Conclusion Based on the study findings health system responsiveness domains has performed relatively poor in many regions except for respect of dignity and confidentiality scored high of all the domains. Shinyanga and Pwani regions scored relatively well in all domains this could have been due to the effect of Results Based financing (RBF) in the respective regions. All in all the Government and other stakeholders in the health sector they should deliberately invest on the access to care domain as seem to be a challenge as compared to others.

Despite the global prioritization of addressing adolescent girls' and young women's sexual and reproductive health (SRH) and participatory rights, little research has examined their lived experiences in shaping their engagement in SRH decision-making processes in the global South. Further, few studies have explored how structural and societal factors influence their agency and participation. This critical and focused ethnography, informed by postcolonial feminist and difference-centred citizenship theories, conducted in Malawi (2017-2018) elicited perspectives of youth and key informants to help address these knowledge gaps. Our findings show that the effective implementation and uptake of global discourse on participation and gender equity is hindered by inadequate consideration of girls' and young women's local political, cultural and social realities. Many girls and young women demonstrate passion to participate in SRH policymaking as agents of change. However, patriarchal and gerontocratic political and social structures/institutions, and gendered and adultist norms and practices limit their active and meaningful participation in SRH decision-making. In addition, donors' roles in SRH policymaking and their prioritization of the "girl child" highlight an enduring postcolonial power over agenda-setting processes. Understanding young people's experiences of gendered participation and scrutinizing underlying systemic forces are critical steps toward realizing young women's SRH and participatory rights.

COVID-19 is a major public health threat associated with the increased global burden of infectious diseases, mortality, and enormous economic loss to countries and communities. Safe and efficacious COVID-19 vaccines are crucial in halting the pandemic. We assessed the COVID-19 vaccine uptake and associated factors among community members from eight regions in Tanzania. The interviewer-administered questionnaire collected data. Multiple logistic regression models determined the factors associated with vaccine uptake. The median age of 3470 respondents was 37 years (interquartile range of 29–50 years) and 66% of them were females. Only 18% of them had received the COVID-19 vaccine, ranging from 8% in Dar es Salaam to 37% in Simiyu regions. A third (34%) of those vaccinated people did not know which vaccine they were given. Significantly higher rates of COVID-19 vaccine uptake were among the respondents aged 30+ years, males, and with a history of COVID-19 infection. Unfavorable perceptions about vaccine safety and efficacy lowered the rates of vaccine uptake. Setting-specific interventions and innovations are critical to improving vaccine uptake, given the observed differences between regions. Efforts are needed to increase vaccine uptake among women and younger people aged less than 30 years. Knowledge-based interventions should enhance the understanding of the available vaccines, benefits, target groups, and availability.

Global health experts use a health system perspective for research on social health protection. This article argues for a complementary actor perspective, informed by the social resilience framework. It presents a Saving4Health initiative with women groups in rural Tanzania. The participatory qualitative research design yielded new insights into the lived experience of social health protection. The study shows how participation in saving groups increased women’s collective and individual capacities to access, combine and transform five capitals. The groups offered a mechanism to save for the annual insurance premium and to obtain health loans for costs not covered by insurance (economic capital). The groups organized around aspirations of mutual support and protection, fostered social responsibility and widened women’s interaction arena to peers, government and NGO representatives (social capital). The groups expanded women’s horizon by exposing them to new ways of managing financial health risk (cultural capital). The groups strengthened women’s social recognition in their family, community and beyond and enabled them to initiate transformative change through advocacy for health insurance (symbolic capital). Savings groups shape the evolving field of social health protection in interaction with governmental and other powerful actors and have further potential for mobilization and transformative change.

Objective Remote or mobile consulting is being promoted to strengthen health systems, deliver universal health coverage and facilitate safe clinical communication during coronavirus disease 2019 and beyond. We explored whether mobile consulting is a viable option for communities with minimal resources in low- and middle-income countries. Methods We reviewed evidence published since 2018 about mobile consulting in low- and middle-income countries and undertook a scoping study (pre-coronavirus disease) in two rural settings (Pakistan and Tanzania) and five urban slums (Kenya, Nigeria and Bangladesh), using policy/document review, secondary analysis of survey data (from the urban sites) and thematic analysis of interviews/workshops with community members, healthcare workers, digital/telecommunications experts, mobile consulting providers, and local and national decision-makers. Project advisory groups guided the study in each country. Results We reviewed four empirical studies and seven reviews, analysed data from 5322 urban slum households and engaged with 424 stakeholders in rural and urban sites. Regulatory frameworks are available in each country. Mobile consulting services are operating through provider platforms ( n = 5–17) and, at the community level, some direct experience of mobile consulting with healthcare workers using their own phones was reported – for emergencies, advice and care follow-up. Stakeholder willingness was high, provided challenges are addressed in technology, infrastructure, data security, confidentiality, acceptability and health system integration. Mobile consulting can reduce affordability barriers and facilitate care-seeking practices. Conclusions There are indications of readiness for mobile consulting in communities with minimal resources. However, wider system strengthening is needed to bolster referrals, specialist services, laboratories and supply chains to fully realise the continuity of care and responsiveness that mobile consulting services offer, particularly during/beyond coronavirus disease 2019.

Background: The use of data in decision making and planning in primary health care settings is critical for improving efficiency and health outcomes for patients and communities. Implementation research can be used to fully understand the effects, context, challenges, and facilitators of data use, as well as how to scale up data use interventions. However, in the context of low resource settings, little is known about how implementation research can be employed to assess the implementation and impact of data use interventions. Methods: We will conduct a hybrid type 2 effectiveness-implementation study employing a mixed method controlled before and after design to measure the effects of data use interventions while simultaneously understanding the implementation of those initiatives. The controlled before and after entails measurement of the effects of the interventions at baseline and end line in a matched intervention and control health facilities using structured questionnaire to health workers (n = 440) and existing patients (n = 422) while also extracting selected health outcome variable from routine data in all participating health facilities (n = 80). The mixed methods component entails measuring the implementation outcomes (adoption, acceptability, fidelity and maintenance) and their moderators entails the integration of both quantitative and qualitative data collection, analysis, and interpretation (i.e. mixed methods) approach by using a structured questionnaire to implementers (health workers and managers) (n = 400). Experiential dimensions of implementation processes and moderators will be explored using qualitative interviews. Guided by implementation research theories and frameworks, a theory of change (TOC) is developed first to guide the evaluation of implementation processes and effects of the interventions. Descriptive and inferential statistics will be employed to analyze quantitative data whereas thematic analysis approach will be employed for qualitative data. Discussion: This study is one of the first to test the simultaneous measurement of effects and implementation processes of data use interventions in the primary health care settings. Findings will support efforts to improve quality of services by optimizing scale up and sustainability of the data use initiatives in primary health care settings. [ABSTRACT FROM AUTHOR]

Abstract Background Social cohesion, defined as a glue holding society together, has been found to influence several aspects of human behavior. Social cohesion, being composed of social trust and social participation, is a social factor that may influence sexual behaviors. Unfortunately, studies investigating the influence of social cohesion on sexual behaviors among young people are scarce. This study examined the influence of social cohesion on safe sexual behavior among adolescents in rural Tanzania. Methods A cross-sectional study was conducted among 403 school adolescents of the Newala district, between May and August 2010. Socio-demographic characteristics, social cohesion (social trust and social participation) and sexual behavior (age at sexual debut, intention to use and reported condom use, number of sexual partners) were obtained through self-administered questionnaires. Data analysis was performed using descriptive statistics and binary logistic regression. Results Sexual debut at under 13 years of age was reported by 12% of the respondent. A majority (71%) reported multiple sexual partnerships and half of the participants reported to have used a condom at their last sexual encounter. The intention to use a condom was reported by 77% of the respondents. Having multiple sexual partnerships was associated with social trust only (odds ratio: 3.5, 95% CI 1.01–12.3) whereas reported condom use was related with social cohesion (odds ratio 4.8 95% CI 1.66–14.06). Social cohesion, trust or participation was not associated with young age at sexual debut or intention to use a condom. Being a female (odds ratio 2.07 95% CI 1.04–4.12.) was associated with intention to use a condom. Conclusion This study indicates that social cohesion and socio-demographic factors influence actual behavior performance and behavioral intentions. The findings point to the importance of collecting more evidence on social cohesion and sexual behaviors in different settings and designing interventions that enhance social cohesion among adolescents in order to reinforce positive sexual behaviors.

Abstract Background Globally, good health system performance has resulted from continuous reform, including adaptation of Decentralisation by Devolution policies, for example, the Direct Health Facility Financing (DHFF). Generally, the role of decentralisation in the health sector is to improve efficiency, to foster innovations and to improve quality, patient experience and accountability. However, such improvements have not been well realised in most low- and middle-income countries, with the main reason cited being the poor mechanism for disbursement of funds, which remain largely centralised. The introduction of the DHFF programme in Tanzania is expected to help improve the quality of health service delivery and increase service utilisation resulting in improved health system performance. This paper describes the protocol, which aims to evaluate the effects of DHFF on health system performance in Tanzania. Methods An evaluation of the effect of the DHFF programme will be carried out as part of a nationwide programme rollout. A before and after non-controlled concurrent mixed methods design study will be employed to examine the effect of the DHFF programme implementation on the structural quality of maternal health, health facility governing committee governance and accountability, and health system responsiveness as perceived by the patients’ experiences. Data will be collected from a nationally representative sample involving 42 health facilities, 422 patient consultations, 54 health workers, and 42 health facility governing committees in seven regions from the seven zones of the Tanzanian mainland. The study is grounded in a conceptual framework centered on the Theory of Change and the Implementation Fidelity Framework. The study will utilise a mixture of quantitative and qualitative data collection tools (questionnaires, focus group discussions, in-depth interviews and documentary review). The study will collect information related to knowledge, acceptability and practice of the programme, fidelity of implementation, structural qualities of maternal and child health services, accountability, governance, and patient perception of health system responsiveness. Discussion This evaluation study will generate evidence on both the process and impact of the DHFF programme implementation, and help to inform policy improvement. The study is expected to inform policy on the implementation of DHFF within decentralised health system government machinery, with particular regard to health system strengthening through quality healthcare delivery. Health system responsiveness assessment, accountability and governance of Health Facility Government Committee should bring autonomy to lower levels and improve patient experiences. A major strength of the proposed study is the use of a mixed methods approach to obtain a more in-depth understanding of factors that may influence the implementation of the DHFF programme. This evaluation has the potential to generate robust data for evidence-based policy decisions in a low-income setting.

Abstract Background Documentary evidence points to high unmet need for family planning across sub-Saharan Africa. Modern contraceptive use has been staggering over decades with unacceptable marginal increases given that one in three women still report unmet need in Ghana. This study sought to re-examine through a further analysis on the prevalence and determinants of unmet need for family planning in Ghana using married women extracted from the recent 2014 Ghana Demographic and Health Survey. Method Data was analyzed using univariate, bivariate, logistic and multinomial logistic regression models. Results Of the 4527 women, more than a third (35.17%) experienced unmet need of which 20.19% had unmet need for spacing while 14.98% reported unmet need for limiting. The logistic results showed that older aged women, being employed and women with higher ideal number of children were less likely to experience unmet need. However, women who did not know the couples’ preferred number of children, women who had more than one union and those with higher number of living biological children were more likely to report unmet need. From the multinomial model, an increase in age, residing in a rural area, and being employed were associated with lower risk of unmet need for spacing. Additionally, Women who did not know the couples’ ideal number of children, women who had higher age when they got married, and women with higher number of biological children were more likely to report unmet need for spacing. Women who had a higher number of ideal children, women who had secondary or higher education, women from higher socio-economic households, were less likely to report unmet need for limiting. . Conclusions We recommend the strengthening of contraception services in order to address the various age specific needs and women within the different socio-demographic sects so as to reduce unmet need. Addressing the needs of women with increasing number of living biological children is equally paramount.

INTRODUCTION: Quality improvement teams facilitate improvement in the performance of the health facilities and simultaneously improving the quality of health services. There is scanty information on the factors associated with performance of quality improvement teams. This study aimed to assess the perceptions of members of the quality improvement teams on the factors influencing the performance of quality improvement teams in regional referral hospitals in Tanzania. METHODS: A cross-sectional study was conducted in four regional referral hospitals in Tanzania. We used self-administered questionnaires to collect data from 61 members of quality improvement teams. Descriptive statistics were used to assess the perceived factors influencing team performance. Bivariate and multivariate logistic regression was used to test the association between perceptions of the team members and factors associated with team performance. RESULTS: The overall mean perception score on team performance was high at 27.51 ± 4.62. Five factors namely: training (83.6%); communication (75.1%); team cohesiveness (71.5%); clarity of roles and responsibility (70.2%); team size and composition (65.5%); and self-assessment and learning (56.2%) were considered as the main drivers of team performance. Inadequate management support obtained the lowest score (36.1%). Multivariable regression analysis established a significant association between training, communication, clarity of roles and responsibilities, team size and composition, self-assessment and learning, management support and team performance. CONCLUSION: Inadequate management support to the team was found to be a barrier to team performance. Managerial interventions should focus on provision of coaching and mentoring to the team while addressing resource challenges affecting the team performance.

Abstract Background Global health conceives the notion of partnership between North and South as central to the foundations of this academic field. Indeed, global health aspires to an equal positioning of Northern and Southern actors. While the notion of partnership may be used to position the field of global health morally, this politicization may mask persisting inequalities in global health. In this paper, we reflect on global health partnerships by revisiting the origins of global health and deconstructing the notion of partnership. We also review promising initiatives that may help to rebalance the relationship. Results and Discussion Historical accounts are helpful in unpacking the genesis of collaborative research between Northerners and Southerners – particularly those coming from the African continent. In the 1980s, the creation of a scientific hub of working relationships based on material differences created a context that was bound to create tensions between the alleged “partners”. Today, partnerships provide assistance to underfunded African research institutions, but this assistance is often tied with hypotheses about program priorities that Northern funders require from their Southern collaborators. African researchers are often unable to lead or contribute substantially to publications for lack of scientific writing skills, for instance. Conversely, academics from African countries report frustrations at not being consulted when the main conceptual issues of a research project are discussed. However, in the name of political correctness, these frustrations are not spoken aloud. Fortunately, initiatives that shift paternalistic programs to formally incorporate a mutually beneficial design at their inception with equal input from all stakeholders are becoming increasingly prominent, especially initiatives involving young researchers. Conclusion Several concrete steps can be undertaken to rethink partnerships. This goes hand in hand with reconceptualizing global health as an academic discipline, mainly through being explicit about past and present inequalities between Northern and Southern universities that this discipline has thus far eluded. Authentic and transformative partnerships are vital to overcome the one-sided nature of many partnerships that can provide a breeding-ground for inequality.

Background: Strengthening health systems through planned safety and quality improvement initiatives is an imperative to achieve more equitable, resilient, and effective care. And yet, years of organizational behavior research demonstrate that change initiatives often fall short because managers fail to account for organizational readiness for change. This finding remains true especially among surgical safety and quality improvement initiatives in low-income countries and middle-income countries. In this study, our aim was to psychometrically assess the construct validity and internal consistency of the Safe Surgery Organizational Readiness Tool (SSORT), a short survey tool designed to provide change leaders with insight into facility infrastructure that supports learning and readiness to undertake change. Materials and methods: To demonstrate generalizability and achieve a large sample size (n=1706) to conduct exploratory factor analysis (EFA) and confirmatory factor analysis (CFA), a collaboration between seven surgical and anesthesia safety and quality improvement initiatives was formed. Collected survey data from health care workers were divided into pilot, exploration, and confirmation samples. The pilot sample was used to assess feasibility. The exploration sample was used to conduct EFA, while the confirmation sample was used to conduct CFA. Factor internal consistency was assessed using Cronbach's alpha coefficient. Results: Results of the EFA retained 9 of the 16 proposed factors associated with readiness to change. CFA results of the identified 9 factor model, measured by 28 survey items, demonstrated excellent fit to data. These factors (appropriateness, resistance to change, team efficacy, team learning orientation, team valence, communication about change, learning environment, vision for sustainability, and facility capacity) were also found to be internally consistent. Conclusion: Our findings suggest that communication, team learning, and supportive environment are components of change readiness that can be reliably measured prior to implementation of projects that promote surgical safety and quality improvement in low-income countries and middle-income countries. Future research can link performance on identified factors to outcomes that matter most to patients. [ABSTRACT FROM AUTHOR]