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Background: Pharmaceutical supply chain management in low- and middle-income countries has received substantial attention to address the shortage of medicines at peripheral facilities. The focus has been on health system interventions, including the establishment of public-private partnerships (PPPs). In 2014, the United Republic of Tanzania began implementing the Jazia prime vendor system (Jazia PVS) with a contracted private wholesale supplier to complement the national medicines supply chain in public facilities. Few studies have investigated the acceptability of such a prime vendor system. This study analyses factors that contributed to the acceptability of Jazia PVS introduced in Tanzania. We used qualitative analytical methods to study experiences of Jazia PVS implementers in 4 districts in mid-2018. Methods: Data were drawn from 14 focus group discussions (FGDs), 7 group discussions (GDs) and 30 in-depth interviews (IDIs) with a range of actors involved in Jazia PVS. The study analysed 7 acceptability dimensions as defined in the acceptability framework by Sekhon et al. Framework analysis was adopted to summarise the results using a deductive and an inductive approach. Results: The findings show that participants’ acceptability of Jazia PVS was influenced by the increased availability of essential medicines at the facilities, higher order fulfilment rates, and timely delivery of the consignment. Furthermore, acceptability was also influenced by the good reputation of the prime vendor, close collaboration with district managers, and participants’ understanding that the prime vendor was meant to complement the existing supply chain. Intervention coherence, experienced opportunity cost and intervention burden, affective attitude and self-efficacy were also important in explaining the acceptability of the Jazia PVS. Conclusion: In conclusion, the most critical factor contributing to the acceptability of the Jazia PVS was the perceived effectiveness of the system in achieving its intended purpose. Districts purchasing directly from the prime vendor have a policy based on the possibility to increase availability of essential medicines at peripheral facilities in a low income setting; however, it is crucial to select a reputable and competent vendor, as well as to abide by the contractual agreements.

Introduction The WHO-promoted ‘My 5 moments for hand hygiene’ is designed to prevent the spread of infectious organisms in healthcare settings which occurs mostly via contaminated hands of healthcare workers (HCWs), items/equipment and the environment. Information on its implementation in Tanzania is needed. Objectives The main objective of the study was to assess knowledge, availability, and access to facilities for hand hygiene and the adherence to the WHO's five moments of hand hygiene by healthcare workers at Dodoma Regional Referral Hospital. The bacterial content of cell phones of HCWs was assessed as a source of microbial contamination. Methods This was a descriptive cross-sectional study. Three sets of data were collected through (i) questionnaires to assess knowledge, attitudes, and barriers to effective hand hygiene; (ii) observation to assess the adherence of five moments of hand hygiene; and (iii) laboratory examination of cell phones for bacterial contamination. Analysis used Statistical Package for Social Science (SPSS). Results Over 75% of HCWs had formal training on hand hygiene and had access to handwashing facilities, but only 63% were aware of the WHO five moments. Of 270 doctors, nurses, and healthcare students only 7 (2.6%) complied with expected action with no difference between groups. No hand hygiene was observed after touching cell phones. Thirty-four percent of sampled cell phones were contaminated with staphylococci species, which were resistant to penicillin and had varying resistance to erythromycin, clindamycin and gentamicin. Conclusions Hand hygiene is the most effective way to reduce the risk of healthcare-associated infections. However, many healthcare workers do not adhere to recommended hand hygiene despite training and the availability of handwashing facilities. The low practice of hand hygiene means that cell phones of healthcare workers can easily act as a reservoir of transmissible organisms. The use of cell phones as a source of contamination must be included in the interventional training of HCW.

Introduction One of the strategic objectives of the AMR national action plan is to improve public awareness and understanding of AMR. Changing people's behaviour is not easy and the older a person is, the more they are set in their ways. Schoolchildren are in their formative years, which is the right time to impart knowledge and best practices that will guide their behaviour in life. Importantly, students have links with families and communities and are future leaders. Roll Back Antimicrobial resistance Initiative (RBA Initiative) has been pioneering the use of youth as agents of change to increase AMR awareness, promote positive behavioural change and thus reduce treatment failure. Objectives The main objective was to equip young people (schoolchildren) with knowledge and skills to understand antimicrobial use and resistance and ability to pass the knowledge to their families, other students and community at large. Methods Through AMR clubs, RBA Initiative used different methodologies to engage and educate schoolchildren on AMR. These included classroom teaching, arts and crafts like songs, skits, drama, traditional dances and storytelling and fun videos. Further motivation for active participation was encouraged through competition. The content of the training included topics such as behaviour that fuels AMR, hand hygiene and sanitation, the impact of fake drugs and the One Health approach. Results In 2020, the project build the capacity of 160 students. Subsequently, these trained students have reached over 1000 fellow secondary school students, over 3000 primary school pupils and over 800 community members including family members with key AMR messages. Conclusions If engaged and empowered, young people are able to increase community knowledge and awareness regarding AMR as agents of change, contributing to the national action plan on AMR.

Introduction Antimicrobial resistance is still not given enough attention and the public is insufficiently aware of its existence, leading to behaviour, which propagates the rise of antimicrobial resistance (AMR). One of the objectives of Tanzania's national action plan on antimicrobial resistance is to improve awareness and understanding of antimicrobial use and resistance through effective communication, education and training. This task will need involvement of many stakeholders and sectors. Objectives To assess the knowledge, attitudes and practices toward antimicrobial use and resistance among students in three secondary schools in Dodoma city. Methods For this interventional pre-post comparative study, data were collected before and after training on antimicrobial use and resistance. Secondary school students from Mkonze, Merriwa and Kiwanja cha Ndege secondary school who are members of AMR school clubs participated. Training included classroom teaching and arts and crafts. We used quantitative and qualitative data collection methods by using self-administered paper-based structured coded questionnaires delivered to the students with the supervision of school guardians. Analysis was done through Excel and SPSS. Results Three aspects were investigated: awareness of ways to reduce AMR; knowledge that antibiotics cannot be used to treat flu and factors that contribute to AMR. Before the training knowledge of these was below 37%. Three months after the training knowledge had increased to above 90%. Conclusions Training of secondary school students significantly improved awareness, knowledge and attitude regarding antimicrobial use and antimicrobial resistance. AMR school clubs are an effective vehicle to raise awareness and mitigate the AMR crisis. Focus on students will lead to wider awareness in the community.

Low- and middle-income countries have been undertaking health finance reforms to address shortages of medicines. However, data are lacking on how medicine availability and stock-outs influence access to health services in Tanzania. The current study assesses the effects of medicine availability and stock-outs on healthcare utilization in Dodoma region, Tanzania. We conducted a cross-sectional study that combined information from households and healthcare facility surveys. A total of 4 hospitals and 89 public primary health facilities were surveyed. The facility surveys included observation, record review over a 3-month period prior to survey date, and interviews with key staff. In addition, 1237 households within the health facility catchment areas were interviewed. Data from the facility survey were linked with data from the household survey. Descriptive analysis and multivariate logistic regressions models were used to assess the effects of medicine availability and stock-outs on utilization patterns and to identify additional household-level factors associated with health service utilization. Eighteen medicines were selected as ‘tracers’ to assess availability more generally, and these were continuously available in ∼70% of the time in facilities across all districts over 3 months of review. The main analysis showed that household’s healthcare utilization was positively and significantly associated with continuous availability of all essential medicines for the surveyed facilities [odds ratio (OR) 3.49, 95% confidence interval (CI) 1.02–12.04; P = 0.047]. Healthcare utilization was positively associated with household membership in the community health insurance funds (OR 1.97, 95% CI 1.23–3.17; P = 0.005) and exposure to healthcare education (OR 2.75, 95% CI 1.84–4.08; P = 0.000). These results highlight the importance of medicine availability in promoting access to health services in low-income settings. Effective planning and medicine supply management from national to health facility level is an important component of quality health services.

Background Tanzania’s primary healthcare system suffers from a scarcity of financial and human resources that impedes its effectiveness to deliver dependable and uniform quality healthcare. Adherence to standard treatment guidelines (STG) can help provide more consistent and correct diagnoses and treatments and limit the irrational use of medicines and the negative health consequences that can occur as a result. The purpose of this study was to investigate prescribers’ adherence of their diagnoses and respective treatments to national STG and to identify potential areas for planning interventions. Methods A cross-sectional study on prescribers’ adherence to diagnosis and treatment, according to national STG, was conducted in 2012 in public primary healthcare facilities (HCF) in the Dodoma region of Tanzania. Information on 2886 patients was collected, prospectively and retrospectively, from 120 HCF across the Dodoma region using a structured questionnaire. Twenty-five broadly defined main illness groups were recorded and the nine most prevalent and relevant conditions were statistically analysed in detail. Results Diagnoses and related treatments were recorded and analysed in 2872 cases. The nine most prevalent conditions were upper respiratory tract infections (25%), malaria (18%), diarrhoea (9.9%), pneumonia (6.1%), skin problems (5.8%), gastrointestinal diagnoses (5%), urinary tract infections (4%), worm infestations (3.6%) and eye problems (2.1%). Only 1.8% of all diagnoses were non-communicable diseases. The proportion of prescribers’ primary diagnoses that completely adhered to national STG was 599 (29.9%), those that partially adhered totalled 775 (38.7%), wrong medication was given in 621 cases (30.9%) and no diagnosis or medication was given in nine cases (0.5%). Sixty-one percent of all patients received an antibiotic regardless of the diagnoses. Complete adherence was highest when worms were diagnosed and lowest for diarrhoea. The proportion of cases that did not adhere to STG was highest with patients with skin problems and lowest for malaria. Conclusion Prescribers’ general adherence to national STG in primary HCF in the public sector in Dodoma region is sub-optimal. The reasons are multifaceted and focused attention, directed at improving prescribing and pharmacotherapy, is required with a view of improving patient care and health outcomes.

Background The availability of medicines in public health facilities in Tanzania is problematic. Medicines shortages are often caused by unavailability at Medical Stores Department, the national supplier for public health facilities. During such stock-outs, districts may purchase from private suppliers. However, this procedure is intransparent, bureaucratic and uneconomic. Objectives To complement the national supply chain in case of stock-outs with a simplified, transparent and efficient procurement procedure based on a public-private partnership approach with a prime vendor at the regional level. To develop a successful pilot of a Prime Vendor system with the potential for national scale-up. Methods A public-private partnership was established engaging one private sector pharmaceutical supplier as the Prime Vendor to provide the complementary medicines needed by public health facilities in Tanzania. The Dodoma pilot region endorsed the concept involving the private sector, and procedures to procure complementary supplies from a single vendor in a pooled regional contract were developed. A supplier was tendered and contracted based on Good Procurement Practice. Pilot implementation was guided by Standard Operating Procedures, and closely monitored with performance indicators. A 12-step approach for national implementation was applied including cascade training from national to facility level. Each selected vendor signed a contract with the respective regional authority. Results In the pilot region, tracer medicines availability increased from 69% in 2014 to 94% in 2018. Prime vendor supplies are of assured quality and average prices are comparable to prices of Medical Stores Department. Procurement procedures are simplified, shortened, standardized, transparent and well-governed. Procurement capacity was enhanced at all levels of the health system. Proven successful, the Prime Vendor system pilot was rolled-out nationally, on government request, to all 26 regions of mainland Tanzania, covering 185 councils and 5381 health facilities. Conclusion The Prime Vendor system complements regular government supply through a regional contract approach. It is anchored in the structures of the regional health administration and in the decentralisation policy of the country. This partnership with the private sector facilitates procurement of additional supplies within a culture of transparency and accountability. Regional leadership, convincing pilot results and policy dialogue have led to national roll-out. Transferring this smaller-scale supply chain intervention to other regions requires country ownership and support for sustainable operations.

Background A compact pre-filled auto-disable injection (cPAD) presentation is being developed for the fully liquid pentavalent DTP-HepB-Hib vaccine. A cost analysis (CA) to compare this presentation with the presently used single-dose vial (SDV) and multi-dose vial (MDV) was conducted in Cambodia, Ghana, and Peru. Methodology The CA included the development of an excel-based costing model and considered the costs of vaccine, safe injection equipment, procurement, storage, transport and distribution, vaccine administration by health staff, medical waste management, start-up activities, as well as coverage, birth cohort, vaccine, and safe injection equipment wastage rates. The outcome was the change in cost per pentavalent fully immunized child (PFIC) for a switch to cPAD. Field visits to health facilities, and interviews with key informants from immunization services and regulatory authorities, were conducted to collect data and to test the costing model in country context. Cost data were also obtained from manufacturers, published price lists, and author estimates. A sensitivity analysis (SA) was conducted to explore possible variations in values of data collected. Results Based on vaccine price trends estimated for 2016, cPAD is less costly in Ghana [incremental cost per PFIC: $US−0.59 (−6.46 %)] than the current presentation (ten-dose MDV) and in Peru (SDV): $US−0.89 (−7.14 %). In Cambodia, cPAD is more costly than SDV: $US+0.33 (+3.90 %). Discussion and Conclusion The most significant cost item per PFIC is the vaccine (reflecting wastage rates) in all presentations. The dominance of the vaccine price per dose and, to a lesser extent, the wastage rates in the incremental cost per PFIC show potential to simplify future analyses. Other relevant considerations at country level for a change of presentation include the potential for improved safety with cPAD, planned introduction of other vaccines, environmental and safety issues, and financial sustainability. Electronic supplementary material The online version of this article (doi:10.1007/s40801-015-0010-0) contains supplementary material, which is available to authorized users.

Background Introduction of a health insurance scheme is one of the ways to enhance access to health care services and to protect individuals from catastrophic health expenditures. Little is known on the influence of socio-demographic and social marketing strategies on enrollment and re-enrollment in the Community Health Fund/Tiba Kwa Kadi (CHF/TIKA) in Tanzania. Methods This cross-sectional study employed quantitative methods for data collection between November 2014 and March 2015 in Singida and Shinyanga regions. Relationship between variables was obtained through Chi-square test and multivariate logistic regression. Results We recruited 496 participants in the study. Majority (92.7%) of participants consented to participate, with 229 (49.8%) and 231 (50.2%) members and non members of CHF/TIKA respectively. Majority (90.9%) were aware of CHF/TIKA. Majority of CHF/TIKA members and non-members (90% and 68.3% respectively) reported health facility-based sensitization as the most common social marketing approach employed to market the CHF/TIKA. The most popular marketing strategies in the country including traditional dances, football games, radio, television, news papers, and mosques/church were reported by few CHF and non CHF members. Multivariate Logistic regression models revealed no significant association between social marketing strategies and enrollment, but only socio-demographics; including marital status (AOR = 2.0, 95% CI 1.1–3.8) and family size (household with ≥ 6 members) (AOR = 1.5, 95% CI 1.0–2.5), were significant factors associated with enrollment/re-enrollment rate. Conclusions This study indicated that low level of utilization of available social marketing strategies and socio-demographic factors are the barriers for attracting members to join the schemes. There is a need for applying various social marketing strategies and considering different facilitating and impending socio-demographic factors for the growth and sustainability of the scheme as we move towards universal health coverage. Electronic supplementary material The online version of this article (doi:10.1186/s12913-017-2250-z) contains supplementary material, which is available to authorized users.

An observational time-motion study investigated logistic, programmatic and safety-related advantages and limits in the delivery of a fully liquid DTP–HepB–Hib combination vaccine versus a lyophilized combination vaccine requiring reconstitution. The study was conducted in 2006, observing 312 child vaccinations in a tertiary hospital setting in Kolkata, India. The time for vaccination was on average 46 s (35.12%) lower with the fully liquid vaccine (p < 0.05). In addition, the fully liquid combination was easier and potentially safer to handle and as well tolerated as the lyophilized formulation. Fully liquid combination vaccines have the potential to simplify immunization schedules, contribute to better resource management and improve efficiency of immunization programs.

Tanzania, a country with low access to essential drugs, receives substantial drug donations (DDs) as in-kind gifts. To support the ongoing health sector reform and to promote a good donation practice, stakeholders' and recipients' views on the appropriateness and acceptability of DDs are of particular interest. The objectives were to collect information on the situation of in-kind DDs in Tanzania, to assess the characteristics of the DD system in Tanzania and to collect stakeholders' and recipients' views on problematic areas in DD processes including all strategies of drug donation. Using a qualitative approach, data were collected through validated postal questionnaires in Swahili and English, which were sent out in June 2001 countrywide to stakeholders of all sectors and levels of decision-making involved in healthcare in Tanzania. Of 1,383 mailed questionnaires, 496 were returned, of which 411 (30%) were eligible for analysis. All respondents perceived in-kind DDs as an important resource to assure drug availability in a context of poverty. Half of the respondents were recipients of in-kind DDs. On average, an estimated 27% of the recipients' drug supply was covered through DDs. The main problem for recipients of all sectors involved in healthcare was the insufficient quantity of DDs for sustainable treatment. Representatives of the public sector asked for more transparency in the DD processes. NGOs and religious facilities with better developed structures raised problems such as shipment fees, insufficient infrastructure and training. Recipients suggested that optimizing communication would have the greatest impact on improving the DD processes. In Tanzania, DDs were highly accepted by recipients and stakeholders. The primary concern of DD recipients was less the quality of drugs, although quality assurance remained an ongoing concern, than the discrepancy between the recipients' needs and the donors' supply. DDs often failed to cover priority needs. Suggestions of recipients for DD process optimization corresponded fully with the principles of the Tanzanian and the World Health Organization (WHO) guidelines for DDs, with the call for better implementation of the guidelines among donors and recipients.

Objectives Tanzania suffers a severe shortage of pharmaceutical staff. This negatively affects the provision of pharmaceutical services and access to medicines, particularly in rural areas. Task shifting has been proposed as a way to mitigate the impact of health worker shortfalls.The aim of this study was to understand the context and extent of task shifting in pharmaceutical management in Dodoma Region, Tanzania. We explored 1) the number of trained pharmaceutical staff as compared to clinical cadres managing medicines, 2) the national establishment for staffing levels, 3) job descriptions, 4) supply management training conducted and 5) availability of medicines and adherence to Good Storage Practice. Methods A cross-sectional study was conducted in 270 public health facilities in 2011. A pre-tested questionnaire was administered to the person in charge of the facility to collect data on staff employed and their respective pharmaceutical tasks. Availability of 26 tracer medicines and adherence to Good Storage Practice guidelines was surveyed by direct observation. The national establishments for pharmaceutical staffing levels and job descriptions of facility cadres were analysed. Results While required staffing levels in 1999 were 50, the region employed a total of only 14 pharmaceutical staff in 2011. Job descriptions revealed that, next to pharmaceutical staff, only nurses were required to provide dispensing services and adherence counselling. In 95.5% of studied health facilities medicines management was done by non-pharmaceutically trained cadres, predominantly medical attendants. The first training on supply management was provided in 2005 with no refresher training thereafter. Mean availability of tracer medicines was 53%, while 56% of health facilities fully met criteria of Good Storage Practice. Conclusion Task shifting is a reality in the pharmaceutical sector in Tanzania and it occurs mainly as a coping mechanism rather than a formal response to the workforce crisis. In Dodoma Region, pharmacy-related tasks and supply management have informally been shifted to clinical staff without policy guidance, explicit job descriptions, and without the necessary support through training. Implicit task shifting should be recognized and formalized. Job orientation, training and operational procedures may be useful to support non-pharmaceutical health workers to effectively manage medicine supply.

Tanzania, a country with low access to essential drugs, receives substantial drug donations (DDs) as in-kind gifts. To support the ongoing health sector reform and to promote a good donation practice, stakeholders' and recipients' views on the appropriateness and acceptability of DDs are of particular interest. The objectives were to collect information on the situation of in-kind DDs in Tanzania, to assess the characteristics of the DD system in Tanzania and to collect stakeholders' and recipients' views on problematic areas in DD processes including all strategies of drug donation. Using a qualitative approach, data were collected through validated postal questionnaires in Swahili and English, which were sent out in June 2001 countrywide to stakeholders of all sectors and levels of decision-making involved in healthcare in Tanzania. Of 1,383 mailed questionnaires, 496 were returned, of which 411 (30%) were eligible for analysis. All respondents perceived in-kind DDs as an important resource to assure drug availability in a context of poverty. Half of the respondents were recipients of in-kind DDs. On average, an estimated 27% of the recipients' drug supply was covered through DDs. The main problem for recipients of all sectors involved in healthcare was the insufficient quantity of DDs for sustainable treatment. Representatives of the public sector asked for more transparency in the DD processes. NGOs and religious facilities with better developed structures raised problems such as shipment fees, insufficient infrastructure and training. Recipients suggested that optimizing communication would have the greatest impact on improving the DD processes. In Tanzania, DDs were highly accepted by recipients and stakeholders. The primary concern of DD recipients was less the quality of drugs, although quality assurance remained an ongoing concern, than the discrepancy between the recipients' needs and the donors' supply. DDs often failed to cover priority needs. Suggestions of recipients for DD process optimization corresponded fully with the principles of the Tanzanian and the World Health Organization (WHO) guidelines for DDs, with the call for better implementation of the guidelines among donors and recipients.

By the end of this chapter you should be able to: List a range of health professionals who handle medicines. Describe the role of doctors in the management of pharmaceuticals. List the steps involved in selecting a P-drug. List the information that should be included on all prescriptions and the reasons for it. Describe the characteristics of the eight star pharmacist. Indicate the levels in health care systems in which pharmacists are involved. Describe WHO initiatives concerning the training of pharmacists in low income countries. Describe the role of traditional healers in the management of medicines. Compare and contrast traditional medicine and complementary and alternative medicine. Describe how traditional and western medicine are becoming integrated.

By the end of this chapter you should be able to: Describe the main consequences of the non-rational use of medicines. Describe non-pharmacological factors that determine medicine use. List the three main types of indicators for medicine use. Explain the main features of educational, managerial and regulatory approaches to medicine use intervention. List three interventions to promote rational medicine use known to be effective and three known to be ineffective. Describe the roles of prescribers and dispensers in promoting rational medicine use. Describe the role of patients and public education in promoting rational medicine use.

By the end of this chapter you should be able to: Describe the global drug gap. List reasons for inequalities in access to essential medicines. Define accessibility, availability, acceptability and affordability in relation to medicines. Describe four strategies for improving access to medicines. Define neglected diseases and most neglected diseases. List factors leading to diseases being neglected. Describe three strategies for developing treatments for neglected diseases.

By the end of this chapter you should be able to: Explain the difference between quality assurance and quality control. List the circumstances where quality control efforts should be targeted. List categories of medicines on which quality assurance efforts should be focussed. Describe key elements of a quality assurance programme. Define a counterfeit medicine. Describe factors contributing to the proliferation of counterfeit medicines. Define an adverse drug reaction and explain the difference between Type A and Type B reactions. Describe the steps that should be taken to assess possible adverse drug reactions. List the types of adverse drug reaction that should be reported. Describe factors contributing to antimicrobial resistance. Explain consequences of antimicrobial resistance. List strategies that can be used to contain antimicrobial resistance.

Background Diphtheria (D), tetanus (T), pertussis (P), hepatitis B (HepB), invasive Haemophilus influenzae type b (Hib) disease, and measles cause substantial global morbidity and mortality. Methods This unique review highlights geographic differences in disease burden across certain countries in the African, Americas, Mediterranean, South-East Asian, and Western Pacific World Health Organization (WHO) regions, and relates this to vaccination coverage and local vaccine recommendations using the authors' countries as illustrations. Results Substantial differences were observed in the incidence of these diseases and in vaccination coverage between the countries studied. Disease incidence often reflected inadequate surveillance, but also variable or poor vaccination coverage. Vaccination coverage against HepB was particularly low in the African and South-East Asian WHO regions; vaccination coverage against invasive Hib disease was low in these regions and in the Eastern Mediterranean and Western Pacific WHO regions. Vaccination schedules within some countries in these regions do not include, or have only recently included, vaccinations against HepB and Hib disease. The use of DTwP–HepB–Hib (diphtheria, tetanus, whole-cell pertussis, HepB, Hib) combination vaccines has now been adopted by some countries to help increase vaccination coverage. Conclusions Vaccination coverage and vaccination schedules vary markedly between the countries studied, often according to the resources available. DTwP–HepB–Hib combination vaccines represent a cost-effective option, with the potential to substantially reduce the burden associated with these diseases by increasing coverage and compliance.