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Although gender mainstreaming has been long recognized as a strategy for addressing gender inequalities and associated negative health outcomes; its implementation has remained a challenge, even in the area of prevention of mother to child transmission of HIV (PMTCT). Despite recognition of gender in Tanzania's political arena and prioritization of PMTCT by the health sector, there is very little information on how well gender has been mainstreamed into National PMTCT guidelines and organizational practices at service delivery level. Using a case study methodology, we combined document review with key informant interviews to assess gender mainstreaming in PMTCT on paper and in practice in Tanzania. We reviewed PMTCT policy/strategy documents using the WHO's Gender Responsive Assessment Scale (GRAS). The scale differentiates between level 1 (gender unequal), 2 (gender blind), 3 (gender sensitive), 4 (gender specific), and 5 (gender transformative). Key informant interviews were also conducted with 26 leaders purposively sampled from three government health facilities in Mwanza city to understand their practices. The gender responsiveness of PMTCT policy/strategy documents varies, with some being at GRAS level 3 (gender sensitive) and others at GRAS level 4 (gender specific). Those which are gender sensitive indicate gender awareness, but no remedial action is developed; while those which are gender specific go beyond indicating how gender may hinder PMTCT to highlighting remedial measures, such as the promotion of couple counselling and testing for HIV. In addition, interviews on organizational processes and practices suggested that there has been little attention to the holistic integration of gender in the delivery of PMTCT services. The study has revealed limited integration of gender concerns in PMTCT policy documents. Similarly, health facility leader responses indicate perspectives and practices that pay little attention to the holistic integration of gender in the delivery PMTCT services. [ABSTRACT FROM AUTHOR]

In this paper we bring together ethnographic research carried out during two clinical prevention trials to explore identities, relations and political imaginations that were brought to life by these different technologies. We highlight the ways in which critical anthropological engagement in clinical trials can help us radically reconsider the parameters and standards of medical research. In the paper we analyse the very different circumstances that made these two trials possible, highlighting the different temporalities and politics of HIV and Ebola as epidemics. We then describe four themes revealed by ethnographic research with participants and their communities but mediated by the specific sociopolitical contexts in which the trials were taking place. In both countries we found materiality and notions of exchange to be important to participants' understanding of the value of medical research and their role within it. These dynamics were governed through social relations and moral economies that also underpinned challenges to Western notions of research ethics. The clinical trials offered a language to express both disaffection and disillusionment with the political status quo (often through rumours and anxieties) while at the same time setting the foundations for alternative visions of citizenship. Attached to these were expressions of 'uncertainty and hope' steeped in locally distinctive notions of destiny and expectations of the future. [ABSTRACT FROM AUTHOR]

Trusting behaviour is a cornerstone of cooperation and, hence, economic performance, not least in poorer communities where economic transactions often rely on informal agreements. But trusting behaviour is potentially costly since the counterpart may decide to defect. In this study, we investigate whether food scarcity influences the level of trusting behaviour in rural Tanzania by leveraging quasi-experimental variation in food supply induced by the harvest. Through a lab-in-the-field experiment, we document that farmers display lower levels of trusting behaviour during the lean season compared to the abundant season and show that the difference is explained by variation in food scarcity. [ABSTRACT FROM AUTHOR]

Although prepayment schemes are being hailed internationally as part of a solution to health care financing problems in low-income countries, literature has raised problems with such schemes. This paper reports the findings of a study that examined the factors influencing low enrolment in Tanzania's health prepayment schemes (Community Health Fund). The paper argues that district managers had a direct influence over the factors explaining low enrolment and identified in other studies (inability to pay membership contributions, low quality of care, lack of trust in scheme managers and failure to see the rationale to insure). District managers’ actions appeared, in turn, to be at least partly a response to the manner of this policy's implementation. In order better to achieve the objectives of prepayment schemes, it is important to focus attention on policy implementers, who are capable of re-shaping policy during its implementation, with consequences for policy outcomes. [ABSTRACT FROM AUTHOR]

Background Photography could be used to train individuals to diagnose trachomatous inflammation—follicular (TF) as trachoma prevalence decreases and to ensure accurate field TF grading in trachoma prevalence surveys. We compared photograph and field TF grading and determined the acceptability and feasibility of eyelid photography to community members and trachoma survey trainers. Methods A total of 100 children ages 1–9 y were examined for TF in two Maasai villages in Tanzania. Two images of the right everted superior tarsal conjunctiva of each child were taken with a smartphone and a digital single-lens reflex (DSLR) camera. Two graders independently graded all photos. Focus group discussions (FGDs) were conducted with community members and Tropical Data trainers. Results Of 391 photos, one-fifth were discarded as ungradable. Compared with field grading, photo grading consistently underdiagnosed TF. Compared with field grading, DSLR photo grading resulted in a higher prevalence and sensitivity than smartphone photo grading. FGDs indicated that communities and trainers found photography acceptable and preferred smartphones to DSLR in terms of practicalities, but image quality was of paramount importance for trainers. Conclusions Photography is acceptable and feasible, but further work is needed to ensure high-quality images that enable accurate and consistent grading before being routinely implemented in trachoma surveys. [ABSTRACT FROM AUTHOR]

Highlights the conference 'Uncertainty in Contemporary African Lives,' held April 9 to 11, 2003 in Usa River, Tanzania. Nordic Africa Institute's organization of the conference; Topics discussed, including how some the strategies for dealing with uncertainty themselves create risks; Different aspects of the complex viscisitudes that mark the lives of many people in the African continent.

Background In many regions of the world, little is known about meal structures, meal patterns, and nutrient intake because the collection of quantitative dietary intake is expensive and labor-intensive. Objectives We describe the development and field feasibility of a tablet-based Tanzania 24-h recall tool (TZ-24hr-DR) and dietary intakes collected from adults and children in rural and urban settings. Methods Using the Tanzanian food-composition table, the TZ-24hr-DR tool was developed on an Android platform using the Open Data Kit. The module provides food lists, meal lists, ingredient lists, quantity and amount consumed, breastfeeding frequency, and a recipe feature. Similar to the USDA Automated Multiple Pass Method, this TZ-24hr-DR contains review features such as time in-between meals, a summary of meals, and portion sizes. Results Dietary intake using TZ-24hr-DR was collected among 1) 845 children 0–18 mo of age enrolled in the Engaging Fathers for Effective Child Nutrition and Development in Tanzania (EFFECTS) trial (ClinicalTrials.gov identifier: NCT03759821) in Mara, Tanzania, and 2) 312 adult families from the Diet, Environment, and Choices of positive living (DECIDE) observational study in peri-urban Dar es Salaam. Interviewers were trained on paper-based methods with food models and tablet-based collection. Conversion to nutrient intake was readily linked and accessible, enabling rapid review and analysis. Overall, 2158 and 8197 dietary meal records were collected from the DECIDE study and EFFECTS trial, respectively. Among adults, 63% of men and 92% of women reported eating at home, and there were differences in protein, fat, and zinc. Food consumed outside the home typically occurs for the first 2 meals. Children's intake of nutrients increased with age; however, median micronutrient intakes for calcium, iron, zinc, and vitamin A remained below recommended nutrient intakes. Conclusions The TZ-24hr-DR is a field- and user-friendly tool that can collect large samples of dietary intakes. Further validation is needed. The tool is available freely for research purposes and can be further adapted to other contexts in East Africa. [ABSTRACT FROM AUTHOR]

There is increased awareness that success among small-scale entrepreneurs in developing countries requires more than microfinance, and that an important limiting factor for business growth is the level of human capital among the entrepreneurs. The present paper uses a randomized control trial to evaluate a business training program in Tanzania. Our results show that there is a positive average treatment effect on business knowledge. It also appears that training has a stronger effect on the entrepreneurs with less formal education. Paradoxically, these entrepreneurs are also less consistent in their participation in the training program. An important implication from our study is therefore that when providing business training, special care should be given to ensure high participation rates. [ABSTRACT FROM AUTHOR]

Trachoma, a disease caused by Chlamydia trachomatis , is the leading infectious cause of blindness. To fight it, endemic East African countries adopted the World Health Organization's SAFE Strategy, targeting surgery, antibiotics through mass drug administration (MDA), facial cleanliness and environmental improvement. Trachoma persists among nomadic communities along the Kenya–Uganda and Kenya–Tanzania borders. To address this, Kenya, Tanzania and Uganda launched synchronized MDA campaigns, simultaneously treating populations across borders. Successes included joint planning, community involvement and intergovernmental cooperation, although challenges remained in resourcing MDA cross-border focal points and in addressing coverage and funding. Novel strategies like synchronized joint cross-border MDA with community engagement are vital for sustainable trachoma elimination in these nomadic settings. [ABSTRACT FROM AUTHOR]

Background We explored reasons for continuing higher-than-anticipated prevalence of trachomatous trichiasis (TT) unknown to the health system in population-based prevalence surveys in evaluation units where full geographical coverage of TT case finding was reported. Methods A mixed-methods study in Ethiopia, Kenya, Nigeria and Tanzania was conducted. We compared data from clinical examination, campaign documentation and interviews with original trachoma impact survey (TIS) results. Results Of 169 TT cases identified by TIS teams, 130 (77%) were examined in this study. Of those, 90 (69%) were a match (both TIS and study teams agreed on TT classification) and 40 (31%) were a mismatch. Of the 40 mismatches, 22 (55%) were identified as unknown to the health system by the study team but as known to the health system by the TIS team; 12 (30%) were identified as not having TT by the study team but as having TT by the TIS team; and six (15%) were identified as unknown to the health system in the TIS team but as known to the health system by the study team based on documentation reviewed. Conclusions Incorrectly reported geographical coverage of case-finding activities, and discrepancies in TT status between TIS results and more detailed assessments, are the key reasons identified for continuing high TT prevalence. [ABSTRACT FROM AUTHOR]

Background The purpose was to assess an expansion of a previously published photographic four-step severity grading scale for trachomatous scarring (TS). Methods Images of everted eyelids of adult women in Tanzania were graded for the presence and severity of TS. The previous S3 grade was subdivided into two categories: S3A, one-third to <50% of the upper eyelid conjunctiva scarred; and S3B, 50% to <90%. The reliability and ease of use were evaluated. This new categorisation was then applied to images taken of the same women 5 y prior to evaluate whether it could help detect previously undetected progression. Results In total, 142 eyes at baseline and 418 eyes at follow-up after 5 y were graded as S3. Interobserver agreement using the expanded scarring grading scale was a kappa of 0.86. At baseline, 51 (35.9%) eyes were S3A and 91 (64.1%) were S3B. At follow-up after 5 y, 36.6% of the eyes that were previously documented as not having progressed were now detected as having progressed from S3A to S3B. S3B images were more likely to progress to S4 compared with S3A (OR 4.6, 95% CI 2.1 to 9.9). Conclusions Adding S3A and S3B is reliable and detects more scarring progression. It will be beneficial for future studies analysing TS in photographs. [ABSTRACT FROM AUTHOR]

Background There is an increasing demand for photography for trachoma prevalence surveys. In previous studies, digital single lens reflex (DSLR) images were superior to smartphone images, but newer-model smartphones and/or lens attachments may be able to bridge this gap. This study compares the image quality and ability to detect trachomatous inflammation – follicular (TF) of three camera types: a DSLR Nikon camera, an iPhone SE and an iPhone 13 Pro with a cell scope. Methods We surveyed 62 children ages 1–7 y from two Tanzanian communities. Upper tarsal conjunctiva images of both eyes were graded for TF by two standardized graders. The McNemar's test and a logistic regression model were used for analyses. Results The DSLR camera malfunctioned during the study, thus the iPhone SE and iPhone 13 Pro with cell scope were both more likely to take high-quality, gradable photographs (88% and 86%, respectively) compared with the DSLR camera (69%) (p<0.001 and p=0.02, respectively). TF was detected in gradable images from the iPhone SE (8.8%) and iPhone 13 Pro with cell scope (9.0%) at the same rate (p=1.0) as images from the DSLR camera (9.7%). Conclusion Smartphones with high-quality image capture, like the iPhone SE/13 Pro, have the potential for use in trachoma surveys if the proportion of gradable images can be improved. [ABSTRACT FROM AUTHOR]

Context Anemia and malaria are global health problems affecting >50% of pregnant women in sub-Saharan Africa and are associated with intrauterine growth restriction. The hormones fibroblast growth factor 21 (FGF-21) and growth differentiation factor 15 (GDF-15) are involved in metabolic regulation and are expressed in the placenta. No studies exist on FGF-21 and GDF-15 responses to exposures of malaria and anemia in pregnancy. Objective and Methods Using a prospective, longitudinal pregnancy and birth cohort of women with an average age of 26 years from a rural region in northeastern Tanzania, we examined if FGF-21 and GDF-15 levels in maternal blood at week 33 ± 2 (n = 301) and in cord blood at birth (n = 353), were associated with anemia and malaria exposure at different time points in pregnancy and with neonatal anthropometry. Results Among mothers at gestation week 33 ± 2, lower FGF-21 levels were observed after exposure to malaria in the first trimester, but not anemia, whereas GDF-15 levels at week 33 ± 2 were not associated with malaria nor anemia. In cord blood, moderate to severe anemia at any time point in pregnancy was associated with higher levels of FGF-21, whereas malaria exposure in the third trimester was associated with lower FGF-21 levels in cord blood. Negative associations were observed between cord blood FGF-21 and GDF-15 levels and neonatal skinfold thicknesses and birthweight. Conclusion Our results suggest that moderate to severe anemia throughout pregnancy associates with higher FGF-21 levels, and malaria in last trimester associates with lower FGF-21 levels, in the neonates, thereby potentially affecting the future cardiometabolic health of the child. [ABSTRACT FROM AUTHOR]

Regulatory infringements are extremely common in low-income countries, especially with respect to retail pharmaceutical sales. There have been few practical suggestions on public policy responses other than stricter regulatory enforcement, which governments are often unable, or unwilling, to do. This paper explores the challenges of regulating retail drug sellers, and potential solutions, through a case study of malaria treatment in rural Tanzania where small drug shops are a common source of medicine. [ABSTRACT FROM PUBLISHER]

Mediation analysis is a statistical technique that can be used to identify mechanisms by which intervention programs achieve their effects. This paper presents the results of a mediation analysis of Ngao, an acquired immunodeficiency syndrome (AIDS) education program that was implemented with school children in Grades 6 and 7 in Tanzania in the mid-1990s and evaluated using a controlled, group-randomized trial. The study examined which variables mediated the effect Ngao had in regard to (i) fostering positive attitudes towards people living with AIDS and (ii) decreasing intentions to be sexually active in the near future. Data from students who participated in a baseline and 12-month follow-up survey (n = 814) were analyzed. Results indicate that increasing exposure to AIDS information and increasing knowledge about human immunodeficiency virus transmission/prevention were significant mediators of the intervention's effect on alleviating the stigma associated with people living with AIDS. Moreover, encouraging more restrictive social norms about sexual intercourse was a significant mediator of the intervention's effect on decreasing students' intentions to be sexually active in the near future. Implications for future AIDS education programs for school children in this part of Africa designed to achieve similar goals are discussed. [ABSTRACT FROM AUTHOR]

We use a nationally representative field experiment in Tanzania to compare two teacher performance pay systems in public primary schools: a 'pay-for-percentile' system (a rank-order tournament) and a 'levels' system that features multiple proficiency thresholds. Pay for percentile can potentially induce socially optimal effort among teachers, while levels systems can encourage teachers to focus on students near passing thresholds. Despite the theoretical advantage of the tournament system, we find that both systems improved student test scores across the distribution of initial learning levels after two years. However, the levels system is easier to implement and is more cost effective. [ABSTRACT FROM AUTHOR]

Foraging opportunity and predation risk act as opposing influences on an animal's habitat use. "Landscapes of fear" (LOF), whereby one predicts the spatial distribution of predators or perceived predator presence using prey responses, are an important tool for modeling this conflict. LOF models examining perceived predation risk are often generated using a single behavioral metric, even though individuals can respond to predation pressure with multiple potential behaviors. Here, we expanded traditional LOF approaches by measuring three antipredator behaviors in wild red-tailed monkeys (Cercopithecus ascanius): aggregation, alarm calling, and vigilance. We predicted that each behavior would reveal spatially explicit regions of high risk, as each behavior may attend to different aspects of perceived predation risk. The use of different behaviors may depend upon factors such as vegetation type, age/sex class of an individual, and which other antipredator behaviors are being exhibited by group members. We collected data on two troops of monkeys in the Issa Valley, Tanzania for over 19 months and conducted 3189 group follows. We found that vegetation type varied in its effect on antipredator behavior. Monkeys conducted more antipredator behavior in more open vegetation types compared to more closed, riparian forests. The LOF models generated for each behavior mapped distinct and predominantly non-overlapping spatial regions of perceived predation risk, which was replicated across the two groups. This suggested that monkeys responded differently across their home range to specific perceived risks. Such spatially explicit behavior may indicate vegetation-specific predation risk or unique trade-offs in antipredator behavior throughout a heterogenous habitat. [ABSTRACT FROM AUTHOR]

Background Virological outcome data after programmatic transition from non-nucleoside reverse transcriptase inhibitor (NNRTI)-based to dolutegravir (DTG)-based antiretroviral therapy (ART) regimens in sub-Saharan Africa (SSA) outside of clinical trials are scarce. We compared viral suppression and associated factors in treatment-naïve people living with HIV (PLHIV) starting DTG- based versus NNRTI-based ART. Methods We compared virological suppression at 12 months, after treatment initiation in the two cohorts of participants aged ≥15 years, initiating DTG- and NNRTI-based ART. Drug resistance was assessed among participants with viremia ≥50 copies/mL on DTG. Results Viral suppression was achieved for 165/195 (85%) and 154/211 (73%) participants in the DTG- and NNRTI- cohorts, respectively (P = 0.003). DTG-based ART was associated with >2 times the odds of viral suppression versus NNRTI-based ART (adjusted odds ratio, 2.10 [95% confidence interval {CI}, 1.12–3.94]; adjusted risk ratio, 1.11 [95% CI, 1.00–1.24]). HIV-1 genotypic resistance testing (GRT) before ART initiation was done in 14 of 30 viremic participants on DTG, among whom nucleoside reverse transcriptase inhibitor (NRTI), NNRTI, and protease inhibitors resistance was detected in 0 (0%), 2 (14%) and 1 (7%), respectively. No resistance was found in the 2 of 30 participants with available GRT at the time of viremia ≥50 copies/mL. Conclusions Virological suppression at 1 year was higher in participants initiating DTG- versus NNRTI-based ART. In those with viremia ≥50 copies/mL on DTG-based ART, there was no pretreatment or acquired resistance to the DTG co-administered NRTIs, although the number of samples tested was small. [ABSTRACT FROM AUTHOR]

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

The importance of ill-health in perpetuating poverty is well recognized. In order to prevent the damaging downward spiral of poverty and illness, there is a need for a greater level of social protection, with greater cross-subsidization between the poor and wealthy, and the healthy and those with ill-health. The aim of this paper is to examine individual preferences for willingness to pre-pay for health care and willingness to cross-subsidize the sick and the poor in Ghana, South Africa and Tanzania. Household surveys in the three countries elicited views on cross-subsidization within health care financing. The paper examines how these preferences varied by socio-economic status, other respondent characteristics, and the extent and type of experience of health insurance in the light of country context. In South Africa and Ghana, 62% and 55% of total respondents, respectively, were in favour of a progressive financing system in which richer groups would pay a higher proportion of income than poorer groups, rather than a system where individuals pay the same proportion of income irrespective of their wealth (proportional). In Tanzania, 45% of the total sample were willing to pay for the health care of the poor. However, in all three countries, a progressive system was favoured by a smaller proportion of the most well off than of less well off groups. Solidarity has been considered to be a collective property of a specific socio-political culture, based on shared expectations and developed as part of a communal, historical learning process. The three countries had different experiences of health insurance and this may have contributed to the above differences in expressed willingness to pay between countries. Building and ‘living with’ institutions that provide affordable universal coverage is likely to be an essential part of the learning process which supports the development of social solidarity. [ABSTRACT FROM AUTHOR]

Global financing for the HIV response has reached unprecedented levels in recent years. Over US$10 billion were mobilized in 2007, an effort credited with saving the lives of millions of people living with HIV (PLHIV). A relatively unexamined aspect of the global HIV response is the role of the private sector in financing HIV/AIDS services. As the nature of the response evolves from emergency relief to long-term sustainability, understanding current and potential contributions from the private sector is critical. This paper examines trends in private sector financing, management and resource consumption related to HIV/AIDS in five sub-Saharan African countries, with a particular emphasis on the effects of recently scaled-up donor funding on private sector contributions. We analysed National Health Accounts HIV/AIDS subaccount data for Kenya, Malawi, Rwanda, Tanzania and Zambia between 2002 and 2006. HIV subaccounts provide comparable data on the flow of HIV/AIDS funding from source to use. Findings indicate that private sector contributions decreased in all countries except Tanzania. With regards to managing HIV/AIDS funds, non-governmental organizations are increasingly controlling the largest share of resources relative to other stakeholders, whereas private for-profit entities are managing fewer HIV/AIDS resources since the donor influx. The majority of HIV/AIDS funds were spent in the public sector, although a considerable amount was spent at private facilities, largely fuelled by out-of-pocket (OOP) payments. On the whole, OOP spending by PLHIV decreased over the 4-year period, with the exception of Malawi, demonstrating that PLHIV have increased access to free or subsidized HIV/AIDS services. Our findings suggest that the influx of donor funding has led to decreased private contributions for HIV/AIDS. The reduction in private sector investment and engagement raises concerns about the sustainability of HIV/AIDS programmes over the long term, particularly in light of current global economic crisis and emerging competing priorities. [ABSTRACT FROM AUTHOR]

This section presents abstracts of working papers, presented at the Spring Scientific Meeting of the British Geriatrics Society on April 6 and 7, 2006, including "The Role of Mannose As an Anti-Adhesive in the Oral Cavity," "Can We Determine the Prevalence of Parkinson's Disease in the Hai District of Tanzania" and "Casual Attributions and Treatment Seeking for Stroke in Dar-Es-Salaam, Tanzania."

This section presents abstracts of papers related to stroke, presented at the Spring Scientific Meeting of the British Geriatrics Society on April 6 and 7, 2006, including "The Utility of the Weigl Colour Form Sorting Test, As a Cognitive Screen in Stroke Survivors," "Aetiology of Stroke in an Incident Stroke Population in Tanzania: First 2 Year Data for the Tanzanian Stroke Incidence Project in the Hai District" and "3 Years On: Does Behavior Modification Affect Post Stroke Risk Factor Control?."

Economic development in sub-Saharan Africa under structural adjustment witnessed the upsurge of informal sector development—the development of unregulated labour-intensive activities, in part export-oriented. This paper argues that two factors played an important role in shaping the dynamics of informal sector development: (1) the process of the relative cheapening of wage goods as a result of their importation, partly financed through foreign aid, thereby lowering unit-labour costs in labour-intensive production, and (2) the processes at work of subsidising real wages by other forms of economic security as a result of multiple, diversified and spatially extended livelihood strategies. While these factors undoubtedly brought a new vitality to economic development, this paper questions the long-run sustainability of this new trend for two reasons. One is its dependence on foreign aid to finance imports. The other is that it does not appear to propel endogenous increases in productivity by achieving greater synergy in intersectoral linkages between agriculture and industry. [ABSTRACT FROM AUTHOR]

Health facility assessments (HFAs) assessing facilities' readiness to provide services are well-established. However, HFA questionnaires are typically quantitative and lack depth to understand systems in which health facilities operate-crucial to designing context-oriented interventions. We report lessons from a multiple embedded case study exploring the experiences of HFA data collectors in implementing a novel HFA tool developed using systems thinking approach. We assessed 16 hospitals in four countries (Benin, Malawi, Tanzania and Uganda) as part of a quality improvement implementation research. Our tool was organized in 17 sections and included dimensions of hospital governance, leadership and financing; maternity care standards and procedures; ongoing quality improvement practices; interactions with communities and mapping of the areas related to maternal care. Data for this study were collected using in-depth interviews with senior experts who conducted the HFA in the countries 1-3 months after completion of the HFAs. Data were analysed using the inductive thematic analysis approach. Our HFA faced challenges in logistics (accessing key hospital-based respondents, high turnover of managerial staff and difficulty accessing information considered sensitive in the context) and methodology (response bias, lack of data quality and data entry into an electronic platform). Data elements of governance, leadership and financing were the most affected. Opportunities and strategies adopted aimed at enhancing data collection (building on prior partnerships and understanding local and institutional bureaucracies) and enhancing data richness (identifying respondents with institutional memory, learning from experience and conducting observations at various times). Moreover, HFA data collectors conducted abstraction of records and interviews in a flexible and adaptive way to enhance data quality. Lessons and new skills learned from our HFA could be used as inputs to respond to the growing need of integrating the systems thinking approach in HFA to improve the contextual understanding of operations and structure. [ABSTRACT FROM AUTHOR]

Background Maternal micronutrient status is critical for child growth and nutrition. It is unclear whether maternal multiple micronutrient supplementation (MMS) during pregnancy and lactation improves child growth and prevents child morbidity. Methods This study aimed to determine the effects of prenatal and postnatal maternal MMS on child growth and morbidity. In this double-blind, randomized–controlled trial, 8428 HIV-negative pregnant women were enrolled from Dar es Salaam, Tanzania, between 2001 and 2004. From pregnancy (12–27   weeks of gestation) through to 6 weeks postpartum, participants were randomized to receive daily oral MMS or placebo. All women received daily iron and folic acid during pregnancy. From 6 weeks postpartum through to 18 months postpartum, 3100 women were re-randomized to MMS or placebo. Child-growth measures, haemoglobin concentrations and infectious morbidities were assessed longitudinally from birth to ≤18 months. Results Prenatal MMS led to modest increases in weight-for-age z-scores (mean difference: 0.050; 95% confidence interval: 0.002, 0.099; p  =   0.04) and length-for-age z-score (mean difference: 0.062; 95% confidence interval: 0.013, 0.111; p  =   0.01) during the first 6   months of life but not thereafter. Prenatal or postnatal MMS did not have benefits for other child outcomes. Conclusions Whereas maternal MMS is a proven strategy to prevent adverse birth outcomes, other approaches may also need to be considered to curb the high burdens of child morbidity and growth faltering. [ABSTRACT FROM AUTHOR]

We assessed the impacts of Tanzania's adolescent-focused Cash Plus intervention on depression. In this pragmatic cluster-randomized controlled trial, 130 villages were randomly allocated to an intervention or control arm (1:1). Youth aged 14–19 years living in households receiving governmental cash transfers were invited to participate. The intervention included an intensive period (a 12-session course) and an aftercare period (9 months of mentoring, productive grants, and strengthened health services). We examined intervention impacts on a depressive symptoms scale (10-item Center for Epidemiologic Studies Depression Scale score (range, 0–30)) and rates of depressive symptomatology (score ≥10 points on the scale), recorded at study baseline (April–June 2017), midline (May–July 2018), and endline (June–August 2019). Using intention-to-treat methodology, we employed logistic and generalized linear models to estimate effects for binary and continuous outcomes, respectively. Quantile regression was used to estimate effects across the scale. From 2,458 baseline participants, 941 intervention and 992 control adolescents were reinterviewed at both follow-ups. At endline, the intervention reduced the odds of depressive symptomatology (adjusted odds ratio = 0.67, 95% confidence interval: 0.52, 0.86), with an undetectable mean scale difference (risk difference = −0.36, 95% confidence interval: –0.84, 0.11). Quantile regression results demonstrated an intervention effect along the upper distribution of the scale. Integration of multisectoral initiatives within existing social protection systems shows potential to improve mental health among youth in low-resource settings. [ABSTRACT FROM AUTHOR]

Background Little is known about healthcare-seeking behaviour and barriers to care for cardiovascular disease (CVD) in sub-Saharan Africa. Methods Emergency department patients in Tanzania with acute CVD were prospectively enrolled. Questionnaires were administered at enrollment and 30 d later. Results Of 241 patients, 186 (77.2%) had visited another facility for the same illness episode (median symptom duration prior to presentation was 7 d) and 82 (34.0%) reported that they were initially unaware of the potential seriousness of their symptoms. Of the 208 (86.3%) patients completing follow-up, 16 (7.7%) had died, 38 (18.3%) had visited another facility for persistent symptoms, 99 (47.6%) felt they understood their diagnosis, 87 (41.8%) felt they understood their treatment and 11 (7.8%) could identify any of their medications. Predictors of 30 d survival with symptom improvement included medication compliance (p<0.001), understanding the diagnosis (p=0.007), understanding the treatment (p<0.001) and greater CVD knowledge (p=0.008). Conclusions Patients with CVD in Tanzania usually visit multiple facilities for the same illness episode, typically after prolonged delays. Only a minority understand their diagnosis and treatment, and such understanding is correlated with survival with symptom improvement. Patient-centred interventions are needed to improve the quality of cardiovascular care in Tanzania. [ABSTRACT FROM AUTHOR]

Primary eye care (PEC) is a vital component of primary healthcare (PHC) and is the cornerstone for the progress towards universal eye health coverage. While the concept of PEC is not new, with the increased focus of the global eye-health agenda on equity and people-centred care, it is critical to review experiences of delivering PEC in low- and middle-income countries and to identify common lessons learnt. This commentary builds on the available evidence and focuses specifically on three recently published evaluations of PEC in Sightsavers-supported programmes in Tanzania, Sierra Leone and Pakistan. It argues that systems thinking is critical in the delivery of PEC interventions, as only this approach can ensure that the integration of PEC into PHC is delivered in a comprehensive, coherent and sustainable way. [ABSTRACT FROM AUTHOR]

Mistreatment in childbirth is institutionalized in many healthcare settings globally, causing widespread harm. Rising concern has elicited research on its prevalence and characteristics, with limited attention to developing explanatory theory. Mistreatment, a complex systemic and behavioral phenomenon, requires social science theory to explain its persistence despite official norms that promote respectful care. Diane Vaughan's normalization of organizational deviance theory from organizational sociology emerged from studies of how things go wrong in organizations. Its multi-level framework provided an opportunity for analogical cross-case comparison to elaborate theory on mistreatment as normalized organizational deviance. To elaborate the theory, the Tanzanian public health system in the period of 2010-2015 was selected as a case. A broad Scopus search identified 4068 articles published on the health system and maternal health in Tanzania of which 122 were selected. Data was extracted using a framework based on the theory and reviews of mistreatment in healthcare. Relationships and patterns emerged through comparative analysis across concepts and system levels and then were compared with Vaughan's theory and additional organizational theories. Analysis revealed that normalized scarcity at the macro-level combined with production pressures for biomedical care and imbalanced power-dependence altered values, structures and processes in the health system. Meso-level actors struggled to achieve production goals with limited autonomy and resources, resulting in workarounds and informal rationing. Biomedical care was prioritized, and emotion work was rationed in provider interactions with women, which many women experienced as disrespect. Analogical comparison with another case of organizational deviance based on literature enabled a novel approach to elaborate theory. The emergent theory sheds light on opportunities to transform systems and routinize respectful care. Theory application in additional settings and exploration of other social theories is needed for further understanding of this complex problem. [ABSTRACT FROM AUTHOR]

In collision-type orogens, where high-pressure and ultrahigh-pressure (H P –UH P) metamorphism usually occurs, deeply subducted continental slabs with eclogitized mafic rocks often undergo recrystallization/overprinting with various geothermal gradients after the peak conditions at lower-to-middle-crustal levels. During the crustal stabilization, the transition from eclogite-to granulite-facies is common. We conducted metamorphic petrology and zircon geochronology on (1) bimineralic and (2) partially granulitized eclogites from the Neoproterozoic Ufipa Terrane (Southwestern Tanzania). Microtextural relationships and mineral chemistry define three metamorphic stages: eclogite metamorphism (M1), H P granulite-facies overprinting (M2), and amphibolite-facies retrogression (M3). The bimineralic eclogite has a basaltic composition and lacks M2 minerals. In contrast, the kyanite eclogite is characterized by a gabbro-dioritic whole-rock composition and contains inherited magmatic zircon. Although the matrix is highly granulitized, garnet and kyanite contain eclogite-facies mineral inclusions. Phase equilibria modeling revealed P–T conditions of 2.1–2.6 GPa and 650–860°C for the M1 stage and 1.4–1.6 GPa and 750–940°C for the M2 stage. Zircon with eclogite-facies mineral inclusions from the bimineralic eclogite lacks Eu anomaly in the REE patterns and yielded the M1 eclogite metamorphic age of 588 ± 3 Ma. Zircon overgrowths surrounding the inherited Paleoproterozoic magmatic cores in kyanite eclogite yielded 562 ± 3 Ma. A weak negative Eu anomaly in the REE patterns and the absence of eclogitic mineral inclusions suggest the zircon growths at the M2 H P granulite-facies metamorphic stage. These new data indicate an eclogite-to granulite-facies transition time of 26 ± 4 million years (Myr), suggesting a rate of H P rock exhumation toward a lower crustal level of 0.7–1.5 mm/year. Furthermore, the density evolution model indicates that buoyant host orthogneiss with low-density gabbro-dioritic eclogite plays an important role in carrying high-density basaltic eclogite. Our 2D thermomechanical modeling also suggests that a slab break-off with a lower angle subduction of <20° triggers the exhumation of the H P slab sliver with 20–30 Myr eclogite-to granulite transition time of large H P –UH P terranes in major collision zones. [ABSTRACT FROM AUTHOR]

Stakeholder analysis is widely recommended as a tool for gathering insights on policy actor interests in, positions on, and power to influence, health policy issues. Such information is recognized to be critical in developing viable health policy proposals, and is particularly important for new health care financing proposals that aim to secure universal coverage (UC).However, there remain surprisingly few published accounts of the use of stakeholder analysis in health policy development generally, and health financing specifically, and even fewer that draw lessons from experience about how to do and how to use such analysis. This paper, therefore, aims to support those developing or researching UC reforms to think both about how to conduct stakeholder analysis, and how to use it to support evidence-informed pro-poor health policy development. It presents practical lessons and ideas drawn from experience of doing stakeholder analysis around UC reforms in South Africa and Tanzania, combined with insights from other relevant material. The paper has two parts. The first presents lessons of experience for conducting a stakeholder analysis, and the second, ideas about how to use the analysis to support policy design and the development of actor and broader political management strategies.Comparison of experience across South Africa and Tanzania shows that there are some commonalities concerning which stakeholders have general interests in UC reform. However, differences in context and in reform proposals generate differences in the particular interests of stakeholders and their likely positioning on reform proposals, as well as in their relative balance of power. It is, therefore, difficult to draw cross-national policy comparisons around these specific issues. Nonetheless, the paper shows that cross-national policy learning is possible around the approach to analysis, the factors influencing judgements and the implications for, and possible approaches to, management of policy processes. Such learning does not entail generalization about which UC reform package offers most gain in any setting, but rather about how to manage the reform process within a particular context. [ABSTRACT FROM AUTHOR]

Modelling the likely financial resource requirements and potential sources of revenue for health system reform options is of great potential value to policy-makers. Models provide an indication of the financial feasibility and sustainability of such reforms and highlight the implications of alternative reform paths. There has been increasing use of financial models of health sector reform in recent years, particularly since the development of user-friendly software such as SimIns, which was developed by the World Health Organization (WHO) and Deutsche Gesellschaft für Technische Zusammenarbeit (GTZ). This paper outlines the process of developing country-specific spreadsheet-based models to explore the financial resource requirements of health system reform options in South Africa and Tanzania. Building one's own model, although time consuming, allows for greater flexibility and forces the analysts to give careful consideration to the assumptions underlying the model. The core variables in our models are: population, health service utilization rates and unit costs. The paper outlines the types of disaggregation of these variables, the range of possible data sources, key challenges with securing accurate data for each variable, and relevant evidence on which to base key assumptions, and how we went about addressing these challenges. We also briefly review how to model the revenue-generating potential of alternative sources of health care financing. The intention of the paper is to provide guidance for analysts who wish to develop their own models, and to illustrate, with reference to the South African and Tanzanian modelling experience, how one has to adapt to data constraints and context-specific modelling requirements. [ABSTRACT FROM AUTHOR]

A desire to enhance protection against health care costs and improve equity of access to health care lies at the core of many health sector financing initiatives. Until recently, international debates about financing and health equity have focused primarily on mechanisms to promote equity in relation to very specific elements of health systems. However, in recent years there has been growing interest in considering these equity challenges from a more systemic perspective. In this context, universal health coverage is becoming a rallying call, with a focus on how best universal coverage can be financed. This paper is the first in a special issue which presents a body of research whose overall aim was to critically evaluate existing inequities in health care financing and provision in Ghana, South Africa and Tanzania, and the extent to which health insurance mechanisms (broadly defined) could address financial protection and equity of access challenges. In this first paper we introduce the countries’ health systems, with a special emphasis on existing mechanisms for financial protection. We also identify in broad terms the key challenges for universal coverage, setting the scene for the subsequent papers. [ABSTRACT FROM AUTHOR]

Background: the World Health Organization estimates that more than one billion of the world's population are disabled. Disability is associated with increasing age and poverty, yet there are few reliable data regarding disability among the elderly in low-income countries. The aim of this study was to accurately document the prevalence of disability in those aged 70 years and over in a community-based setting in sub-Saharan Africa.Methods: we performed a community-based study of people aged 70 years and over in Hai, Tanzania. Participants underwent disability assessment using the culturally non-specific Barthel index (BI), and also clinical assessment for neurological disorders and memory problems.Results: in 2,232 participants, the age-adjusted prevalence of severe disability (BI < 15) was 3.7% (95% CI: 2.9–4.5) and the age-adjusted prevalence of moderate disability (BI: 15–18) was 6.2% [95% confidence interval (CI): 5.2–7.2]. Increasing age, female gender, memory problems and the presence of neurological disorders were all independent predictors of the presence of disability.Conclusion: in this study, the average disability level was lower than seen in most high-income countries. This may reflect increased mortality from disabling disease in low-income countries. Disability is likely to increase as the population of low-income countries ages and disease survival improves. [ABSTRACT FROM AUTHOR]

Background. Monitoring of antiretroviral treatment (ART) with human immunodeficiency virus (HIV) viral loads, as recommended in industrialized countries, is rarely available in resource-limited settings because of the high costs and stringent requirements for storage and transport of plasma. Dried blood spots (DBS) can be an alternative to plasma, but the use of DBS has not been assessed under field conditions in rural Africa. The present study investigates the performance of DBS in HIV viral load monitoring of patients who received ART in rural Tanzania. Patients and Methods. From November 2007 through June 2008, parallel plasma and DBS specimens were obtained from patients who received ART at Haydom Lutheran Hospital in rural Tanzania. DBS specimens were stored at tropical room temperature for 3 weeks before testing with the NucliSENS EasyQ HIV-1 v1.2 assay. Results obtained with DBS were compared with results obtained with use of a gold-standard plasma assay. Results. Ninety-eight plasma-DBS pairs were compared, and plasma viral loads ranged from <40 to >1,000,000 copies/mL. The correlation between plasma and DBS viral load was strong (R² = 0.75). The mean difference (± standard deviation) was 0.04 ± 0.57 log10 copies/mL, and only 8 samples showed >1 log10 copies/mL difference. HIV type 1 RNA was detected in 7%, 60%, and 100% of DBS specimens with corresponding plasma viral loads of 40-999, 1000-2999, and ⩾3000 copies/mL, respectively. Conclusions. DBS, in combination with the NucliSENS EasyQ HIV-1 v1.2 asay, performed well in monitoring HIV viral loads in patients who received ART in rural Tanzania, although the sensitivity was reduced when viral burden was low. The use of DBS can simplify virological monitoring in resource-limited settings. [ABSTRACT FROM AUTHOR]

Catastrophic payments and fairness in financial contributions for health care are becoming increasing concerns for many governments. Out-of-pocket financing for health care is common in many developing countries, including Tanzania. As part of the Multi-Country Evaluation of the Integrated Management of Childhood Illness (MCE-IMCI), the objective of this paper is to explore the determinants of variation and the level of out-of-pocket payments for child health care in rural Tanzania, with and without IMCI, using data from two household surveys conducted in 1999 and 2002. We analyzed data for 833 visits to health providers for 764 children who had been sick in the 2 weeks prior to the survey and who had sought care at a ‘Western’ or formal health care provider. We found evidence that IMCI was associated with lower out-of-pocket costs at government facilities (Tshs.3.5 compared with Tshs.6.9 without IMCI) and in NGOs (Tshs.95.1 compared with Tshs.267.3). Out-of-pocket payments were on average Tshs.110.1 when care was sought at government primary health care facilities running a cost-sharing scheme, about 15 times higher than in those not part of the scheme (p<0.0001). Those who visited NGO facilities paid about 30 times more than those seeking care at government facilities not operating the cost-sharing scheme (p<0.0001). In conclusion, there is no doubt that health care financing mechanisms and equitable access to government facilities have a major impact on household economic burden related to under-five illness. Increasing access to IMCI-based care, however, offers an additional opportunity to reduce out-of-pocket payments, mainly through more rational use of medicines. Increasing access to IMCI-based care would not only improve inequities in financial contributions, but also in health, an important consideration for its own sake. [ABSTRACT FROM AUTHOR]

This study examines local geopotential field modelling over a mountainous region in Tanzania using vector airborne gravity data. We use the adjusted spherical cap and rectangular harmonic analyses. Both methods are based on expansion of gravitational potential into a series of orthogonal harmonic basis functions of local support in such a way that the expansion coefficients are determined by gravity observations. All three components of gravity vector are simultaneously inverted to derive the geopotential coefficients. In order to evaluate the accuracy of the local models, independent checkpoints are selected within the study region and around its boundary and the computed gravity vectors are compared with the independent gravity observations. The results show an excellent agreement with root mean square error (RMSE) of < 1.6 mGal over the study area. On the contrary, the RMSEs of global geopotential models against the checkpoints data are 7 mGal for the models up to the maximum degree of 2190 (a resolution of ∼9.1 km) and 5 mGal to 5399 (∼3.7 km). Our local models are significantly more accurate than the state-of-the-art global models and fully exploit the airborne vector data with the measurement error of ∼1 mGal. We also present the regional models constrained only by radial (vertical) or by lateral (horizontal) gravity observations. Those models are considerably less accurate than the one from 3-D gravity data inversion. Lastly, the regional models are validated against topography data. It is found that the gravity–topography correlation is 0.8–0.9 at 100 km, 0.5 at 20 km and higher than the correlations of the global models at all frequencies. The gravity–topography admittances estimated from our regional models indicate ∼130 mGal km−1 and imply the effective density of 2500 kg m−3 for topographical mass. [ABSTRACT FROM AUTHOR]

Several interpretations of shear wave splitting measurements in East Africa have been proposed, but a comprehensive understanding of seismic anisotropy is lacking vis-à-vis geodynamic processes affecting the African Plate, in part because of geographically limited data coverage. Here, we report new shear wave splitting observations using PKS, SKS and SKKS phases recorded on 17 temporary AfricaArray seismic stations in northeastern Uganda and southeastern Tanzania that help fill key gaps in data coverage in non-volcanic regions of East Africa. The stations in northeastern Uganda straddle the Aswa shear zone, which separates the Neoproterozoic Saharan Metacraton (to the east) and the Palaeoproterozoic Northern Uganda Terrane (to the west). The stations in southeastern Tanzania are located mostly in Karoo basins formed within the Neoproterozoic Mozambique Belt. Our results show NNE fast polarization directions in northeastern Uganda, with splitting times between 1.0 and 1.5 s, and NE directions in southeastern Tanzania, with splitting times between 0.6 and 1.3 s. The NNE fast polarization directions in Uganda cannot be explained with oriented melt pocket (OMP) anisotropy in the lithosphere, as the stations are far from any volcanic fields, or fossil anisotropy resulting from the Neoproterozoic East African orogeny. They are, however, parallel to the flow direction of the African superplume and corroborate previous measurements from northern Uganda that were used to argue that the overall northerly orientation of fast polarization directions across East Africa can be attributed to sublithospheric mantle flow associated with the African superplume. The NE fast polarization directions in Tanzania cannot be explained with SE-oriented fossil anisotropy expected from the Mesozoic rifting of Madagascar from Africa or OMP anisotropy in the lithosphere. However, they are consistent with the overall northerly orientation of fast polarization directions in East Africa and can be attributed to either fossil anisotropy in the Mozambique Belt lithosphere resulting from the East African Orogeny or sublithospheric mantle flow associated with the African superplume. [ABSTRACT FROM AUTHOR]

Placement of pathology and laboratory medicine (PALM) services requires balancing efficiency (maximizing test volume) with equitable urban-rural access. We compared the association between population density (proxy for efficiency) and travel time to the closest facility (proxy for equitable access) across levels of Tanzania's public sector health system. We linked geospatial data for Tanzania from multiple sources. Data on facility locations and other geographic measures were collected from government and non-governmental databases. We classified facilities assuming increasing PALM availability by tier: (1) dispensaries, (2) health centres, (3) district hospitals and (4) regional/referral hospitals. We used the AccessMod 5 algorithm to estimate travel time to the closest facility for each tier across Tanzania with 500-m resolution. District-level average population density and travel time to the closest facility were calculated and presented using medians and interquartile ranges. Spatial correlations between these variables were estimated using the global Moran's I and bivariate Local Indicator of Spatial Autocorrelation, specifying a queen's neighbourhood matrix. Spatial analysis was restricted to 171 contiguous districts. The study included 5406 dispensaries, 675 health centres, 186 district hospitals and 37 regional/referral hospitals. District-level travel times were shortest for Tier 1 (median: [IQR]: 45.4 min [30.0-74.7]) and longest for Tier 4 facilities (160.2 min [107.3-260.0]). There was a weak spatial autocorrelation across tiers (Tier 1: -0.289, Tier 2: -0.292, Tier 3: -0.271 and Tier 4: -0.258) and few districts were classified as significant spatial outliers. Across tiers, geographic patterns of populated districts surrounded by neighbours with short travel time and sparsely populated districts surrounded by neighbours with long travel time were observed. Similar spatial correlation measures across health system levels suggest that Tanzania's health system reflects equitable urban-rural access to different PALM services. Longer travel times to hospital-based care could be ameliorated by shifting specialized diagnostics to more accessible lower tiers. [ABSTRACT FROM AUTHOR]

Informal payments for healthcare are widespread in sub-Saharan Africa. They are often regressive, potentially limiting access to quality healthcare, particularly for the most vulnerable, and can have catastrophic consequences for households. Yet there is little empirical research that uses theory-driven hypotheses to explore what influences informal payments and, especially, from health workers' perspectives. Consequently, we have explored the characteristics of health workers and facilities influencing informal payments in Tanzania, examining two hypotheses: health workers with power and position in the system are more likely to receive informal payments, and transparency and accountability measures can be bypassed by those who can game the system. We conducted a cross-sectional survey of 432 health workers from 42 public health facilities (hospitals and health centres) in 12 district councils from Pwani and Dar es Salam regions in Tanzania. Our dependent variable was whether the health worker has ever asked for or been given informal payments or bribes, while explanatory variables were measured at the individual and facility level. Given the hierarchical structure of the data, we used a multilevel mixed-effect logistic regression to explore the determinants. Twenty-seven percent of 432 health workers ever engaged in informal payment. This was more common amongst younger (<35 years) health workers and those higher in the hierarchy (specialists and heads of departments). Those receiving entitlements and benefits in a timely manner and who were subject to continued supervision were significantly less likely to receive informal payments. The likelihood of engaging in informal payments varied among health workers, consistent with our first hypothesis, but evidence on the second hypothesis remains mixed. Thus, policy responses should address both individual and system-level factors, including ensuring adequate and progressive health sector financing, better and timely remuneration of frontline public health providers, and enhanced governance and supervision. [ABSTRACT FROM AUTHOR]

Background: In response to the increasing burden of cancer in Tanzania, the Ministry of Health, Community Development, Gender, Elderly and Children launched National Cancer Treatment Guidelines (TNCTG) in February 2020. The guidelines aimed to improve and standardize oncology care in the country. At Ocean Road Cancer Institute (ORCI), we developed a theory‐informed implementation strategy to promote guideline‐concordant care. As part of the situation analysis for implementation strategy development, we conducted focus group discussions to evaluate clinical systems and contextual factors that influence guideline‐based practice prior to the launch of the TNCTG. Materials and Methods: In June 2019, three focus group discussions were conducted with a total of 21 oncology clinicians at ORCI, stratified by profession. A discussion guide was used to stimulate dialogue about facilitators and barriers to delivery of guideline‐concordant care. Discussions were audio recorded, transcribed, translated, and analyzed using thematic framework analysis. Results: Participants identified factors both within the inner context of ORCI clinical systems and outside of ORCI. Themes within the clinical systems included capacity and infrastructure, information technology, communication, efficiency, and quality of services provided. Contextual factors external to ORCI included interinstitutional coordination, oncology capacity in peripheral hospitals, public awareness and beliefs, and financial barriers. Participants provided pragmatic suggestions for strengthening cancer care delivery in Tanzania. Conclusion: Our results highlight several barriers and facilitators within and outside of the clinical systems at ORCI that may affect uptake of the TNCTG. Our findings were used to inform a broader guideline implementation strategy, in an effort to improve uptake of the TNCTGs at ORCI. Implications for Practice: This study provides an assessment of cancer care delivery systems in a low resource setting from the unique perspectives of local multidisciplinary oncology clinicians. Situational analysis of contextual factors that are likely to influence guideline implementation outcomes is the first step of developing an implementation strategy for cancer treatment guidelines. Many of the barriers identified in this study represent actionable targets that will inform the next phases of our implementation strategy for guideline‐concordant cancer care in Tanzania and comparable settings. Guidelines to improve and standardize oncology care in Tanzania were developed in 2020. This study utilized focus group discussions to assess the barriers and facilitators to guideline implementation at Ocean Road Cancer Institute. [ABSTRACT FROM AUTHOR]

Background Globally, large numbers of children die shortly after birth and many of them within the first 4 wk of life. This study aimed to determine the trends, patterns and causes of neonatal mortality in hospitals in Tanzania during 2006–2015. Methods This retrospective study involved 35 hospitals. Mortality data were extracted from inpatient registers, death registers and International Classification of Diseases-10 report forms. Annual specific hospital-based neonatal mortality rates were calculated and discussed. Two periods of 2006–2010 and 2011–2015 were assessed separately to account for data availability and interventions. Results A total of 235 689 deaths were recorded and neonatal deaths accounted for 11.3% (n=26 630) of the deaths. The majority of neonatal deaths (87.5%) occurred in the first week of life. Overall hospital-based neonatal mortality rates increased from 2.6 in 2006 to 10.4 deaths per 1000 live births in 2015, with the early neonates contributing 90% to this rate constantly over time. The neonatal mortality rate was 3.7/1000 during 2006–2010 and 10.4/1000 during 2011–2015, both periods indicating a stagnant trend in the years between. The leading causes of early neonatal death were birth asphyxia (22.3%) and respiratory distress (20.8%), while those of late neonatal death were sepsis (29.1%) and respiratory distress (20.0%). Conclusion The majority of neonatal deaths in Tanzania occur among the early newborns and the trend over time indicates a slow improvement. Most neonatal deaths are preventable, hence there are opportunities to reduce mortality rates with improvements in service delivery during the first 7 d and maternal care. [ABSTRACT FROM AUTHOR]

Background while the HIV epidemic remains a considerable challenge in sub-Saharan Africa, a dramatic reduction in the associated mortality has led to a fundamental shift in the public health priorities aimed at tackling multimorbidity. Against the unprecedented level of urbanisation taking place in Tanzania, the burden of multimorbidity and its consequences among ageing adults, in the form of costly inpatient hospitalisation, remain unquantified. Methods we used data from one of Africa's largest urban population cohort, the Dar es Salaam Health and the Demographic Surveillance System, to quantity the extent of multimorbidity (occurrence of 2 ≥ health conditions) and discordant multimorbidity (occurrence of conditions in 2 ≥ domains in mental health, non-communicable and communicable health) among 2,299 adults aged ≥40 years in Dar es Salaam, Tanzania. We fitted logistic regression models to investigate the association between multimorbidity and inpatient hospitalisation. Results the prevalence of multimorbidity and discordant multimorbidity were 25.3 and 2.5%, respectively. Although the severe forms of multimorbidity (2.0% with ≥4 health conditions) and discordancy were low, hospitalisation was significantly higher based on the regression analyses. Household food insecurity was the only socio-economic variable that was significantly and consistently associated with a greater hospitalisation. Conclusion we found an alarmingly high degree of multimorbidity among this ageing urban population where hospitalisation was driven by multimorbidity. As public health resources remain scarce, reducing costly inpatient hospitalisation requires multilevel interventions that address clinical- and structural-level challenges (e.g. food insecurity) to mitigate multimorbidity and promote long-term healthy independent living among older adults in Tanzania. [ABSTRACT FROM AUTHOR]

Talks about life of exiles at the Dakawa Development Centre, an African National Congress (ANC) settlement in Tanzania, from 1982 to 1992. Origins of Dakawa; Orientation and rehabilitation; Land, work, and industry in a South African enclave; Dilemma faced by the ANC in balancing humanitarian considerations with political imperatives; Improvement of social facilities.

Overprovision-healthcare whose harm exceeds its benefit-is of increasing concern in low- and middle-income countries, where the growth of the private-for-profit sector may amplify incentives for providing unnecessary care, and achieving universal health coverage will require efficient resource use. Measurement of overprovision has conceptual and practical challenges. We present a framework to conceptualize and measure overprovision, comparing for-profit and not-for-profit private outpatient facilities across 18 of mainland Tanzania's 22 regions. We developed a novel conceptualization of three harms of overprovision: economic (waste of resources), public health (unnecessary use of antimicrobial agents risking development of resistant organisms) and clinical (high risk of harm to individual patients). Standardized patients (SPs) visited 227 health facilities (99 for-profit and 128 not-for-profit) between May 3 and June 12, 2018, completing 909 visits and presenting 4 cases: asthma, non-malarial febrile illness, tuberculosis and upper respiratory tract infection. Tests and treatments prescribed were categorized as necessary or unnecessary, and unnecessary care was classified by type of harm(s). Fifty-three percent of 1995 drugs prescribed and 43% of 891 tests ordered were unnecessary. At the patient-visit level, 81% of SPs received unnecessary care, 67% received care harmful to public health (prescription of unnecessary antibiotics or antimalarials) and 6% received clinically harmful care. Thirteen percent of SPs were prescribed an antibiotic defined by WHO as 'Watch' (high priority for antimicrobial stewardship). Although overprovision was common in all sectors and geographical regions, clinically harmful care was more likely in for-profit than faith-based facilities and less common in urban than rural areas. Overprovision was widespread in both for-profit and not-for-profit facilities, suggesting considerable waste in the private sector, not solely driven by profit. Unnecessary antibiotic or antimalarial prescriptions are of concern for the development of antimicrobial resistance. Option for policymakers to address overprovision includes the use of strategic purchasing arrangements, provider training and patient education. [ABSTRACT FROM AUTHOR]

The Quaternary Tarosero volcano is situated in the East African Rift of northern Tanzania and mainly consists of trachyte lavas and some trachytic tuffs. In addition, there are minor occurrences of extrusive basalts, andesites and latites, as well as peralkaline trachytes, olivine trachytes and phonolites. Some of the peralkaline phonolites contain interstitial eudialyte, making Tarosero one of the few known occurrences for extrusive agpaitic rocks. This study investigates the genetic relationships between the various rock types and focuses on the peculiar formation conditions of the extrusive agpaitic rocks using a combination of whole-rock geochemistry, mineral chemistry, petrography, thermodynamic calculations, and major and trace element modelling. The Tarosero rocks formed at redox conditions around or below the fayalite–magnetite–quartz buffer (FMQ). During multi-level magmatic fractionation at depths between ∼40 km and the shallow crust, temperature decreased from >1100 °C at near-liquidus conditions in the basalts to ∼700 °C in the peralkaline residue. Fractional crystallization models and trace element characteristics do not indicate a simple genetic relationship between the trachytes and the other rock types at Tarosero. However, the genetic relationships between the primitive basalts and the intermediate latites can be explained by high-pressure fractional crystallization of olivine + clinopyroxene + magnetite + plagioclase + apatite. Further fractionation of these mineral phases in addition to amphibole and minor ilmenite led to the evolution towards the peralkaline trachytes and phonolites. The eudialyte-bearing varieties of the peralkaline phonolites required additional low-pressure fractionation of alkali feldspar and minor magnetite, amphibole and apatite. In contrast to the peralkaline trachytes and phonolites, the peralkaline olivine trachytes contain olivine instead of amphibole, thus indicating a magma evolution at even lower pressure conditions. They can be modelled as a derivation from the latites by fractional crystallization of plagioclase, clinopyroxene, magnetite and olivine. In general, agpaitic magmas evolve under closed-system conditions, which impede the escape of volatile phases. In the case of the extrusive agpaitic rocks at Tarosero, the early exsolution of fluids and halogens was prevented by a low water activity. This resulted in high concentrations of rare earth elements (REE) and other high field strength elements (HFSE) and the formation of eudialyte in the most evolved peralkaline phonolites. Within the peralkaline rock suite, the peralkaline olivine trachytes contain the lowest HFSE and REE concentrations, consistent with mineralogical evidence for formation at a relatively high water activity. The lack of amphibole fractionation, which can act as a water buffer of the melt, as well as the evolution at relatively low-pressure conditions caused the early exsolution of fluids and loss of water-soluble elements. This prevented a strong enrichment of HFSE and REE before the magma was finally extruded. [ABSTRACT FROM AUTHOR]

Objective The incidence of dementia in the sub-Saharan Africa is rising. However, screening tools for cognitive decline that fits their linguistic and cultural context are lacking. The aim of this study was to determine the accuracy of the Kiswahili version of Montreal Cognitive Assessment (K-MoCA) to detect mild cognitive impairment or dementia among older adults in the rural Tanzania. Methods We recruited 259 community-dwelling older adults in Chamwino district, Tanzania. The concurrent validity and discriminatory power of K-MoCA were examined by comparing its score with IDEA cognitive screening and psychiatrist's diagnosis using DSM-V, respectively. All the questionnaires were administered in face-to-face interview. Results K-MoCA demonstrated acceptable reliability (Cronbach's alpha = 0.780). Concurrent validity was evident by its significant correlation with the IDEA screening test (Pearson's r  = 0.651, p  < 0.001). Using the psychiatrist's rating as the reference, the optimal cut-off score for MCI and dementia was 19 and 15, respectively, which yielded the sensitivity of 70% and specificity of 60% for MCI, and sensitivity of 72% and specificity of 60% for dementia. Further analysis indicated that education and age influence performance on K-MoCA. Conclusion Overall, the K-MoCA is a reliable and valid tool for measuring cognitive decline. However, its limited discriminatory power for MCI and dementia may be compromised by the cultural irrelevance of some items. [ABSTRACT FROM AUTHOR]

Background: Evidence-based strategies for improving surgical quality and patient outcomes in low-resource settings are a priority.Objective: To evaluate the impact of a multicomponent safe surgery intervention (Safe Surgery 2020) on (1) adherence to safety practices, teamwork and communication, and documentation in patient files, and (2) incidence of maternal sepsis, postoperative sepsis, and surgical site infection.Methods: We conducted a prospective, longitudinal study in 10 intervention and 10 control facilities in Tanzania's Lake Zone, across a 3-month pre-intervention period in 2018 and 3-month post-intervention period in 2019. SS2020 is a multicomponent intervention to support four surgical quality areas: (i) leadership and teamwork, (ii) evidence-based surgery, anesthesia and equipment sterilization practices, (iii) data completeness and (iv) infrastructure. Surgical team members received training and mentorship, and each facility received up to a $10 000 infrastructure grant. Inpatients undergoing major surgery and postpartum women were followed during their stay up to 30 days. We assessed adherence to 14 safety and teamwork and communication measures through direct observation in the operating room. We identified maternal sepsis (vaginal or cesarean delivery), postoperative sepsis and SSIs prospectively through daily surveillance and assessed medical record completeness retrospectively through chart review. We compared changes in surgical quality outcomes between intervention and control facilities using difference-in-differences analyses to determine areas of impact.Results: Safety practices improved significantly by an additional 20.5% (95% confidence interval (CI), 7.2-33.7%; P = 0.003) and teamwork and communication conversations by 33.3% (95% CI, 5.7-60.8%; P = 0.02) in intervention facilities compared to control facilities. Maternal sepsis rates reduced significantly by 1% (95% CI, 0.1-1.9%; P = 0.02). Documentation completeness improved by 41.8% (95% CI, 27.4-56.1%; P < 0.001) for sepsis and 22.3% (95% CI, 4.7-39.8%; P = 0.01) for SSIs.Conclusion: Our findings demonstrate the benefit of the SS2020 approach. Improvement was observed in adherence to safety practices, teamwork and communication, and data quality, and there was a reduction in maternal sepsis rates. Our results support the emerging evidence that improving surgical quality in a low-resource setting requires a focus on the surgical system and culture. Investigation in diverse contexts is necessary to confirm and generalize our results and to understand how to adapt the intervention for different settings. Further work is also necessary to assess the long-term effect and sustainability of such interventions. [ABSTRACT FROM AUTHOR]

This article reports the findings from surveys of formal and informal institutions and their clients in Ghana, Malawi, Nigeria, and Tanzania. It investigates the hypothesis that reforming financially repressive policies would not be sufficient to overcome fragmentation of financial markets because of structural and institutional barriers to interactions across different market segments. The four countries have substantially fragmented financial markets, with weak linkages between formal and informal segments and interest rate differentials that cannot be adequately explained by differences in costs and risks. Nevertheless, the relatively low transaction costs and loan losses of informal institutions indicate that they provide a reasonably efficient solution to information, transaction cost, and enforcement problems that exclude their clients from access to formal banking services. The findings imply that financial liberalization and bank restructuring in the African context should be accompanied by complementary measures to address institutional and structural problems, such as contract enforcement and information availability, and to improve the integration of informal and formal financial markets. [ABSTRACT FROM AUTHOR]