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MUHTASARI Mojawapo ya matatizo yanayoikumba sekta ya afya Tanzania ni pamoja na vifo vya akina mama vinavyohusiana na uzazi na vya watoto wachanga. Juhudi za kuongeza ubora wa utoaji wa huduma za afya zimewekwa hususan katika eneo la afya ya mama na mtoto ili kutokomeza vifo hivi na kuhakikisha maisha yenye afya kwa kila mtoto mchanga na uzazi salama. Katika Tanzania takriban kila mwanamke mjamzito anahudhuria huduma za kliniki ya wajawazito angalau mara moja kwenye ujauzito wake, ingawa idadi ya uhudhuriaji kliniki ya wajawazito ni kubwa, kiwango cha ubora wa huduma kitolewacho wakati wa mahudhurio hayo bado hakiridhishi. Vilevile, mwamko wa kujifungua kwenye vituo vya kutolea huduma za afya hauendani na mwamko wa akina mama kuhudhuria kliniki ya wajawazito. Asilimia ya akina mama wanaojifungua kwenye vituo vya kutolea huduma za afya ni karibu nusu ya asilimia ya mahudhurio ya wajawazito kwenye vituo hivyo hivyo kwa ajili ya kliniki. Lakini pia ubora wa huduma za kujifungulia kituoni kwa idadi hiyo ndogo ya akina mama bado hairidhishi. Utafiti uliojikita kwenye “Kuboresha Uhai wa Mtoto Mchanga Kusini mwa Tanzania” ulibuniwa ili kupata taswira kuhusu namna ya kuimarisha mfumo wa afya kupitia jamii na vituo vya kutolea huduma za afya ili kutatua matatizo haya. Utafiti huu ulitekelezwa katika Halmashauri za Wilaya sita za mikoa ya Lindi na Mtwara, kusini mwa Tanzania. Eneo hili ni moja kati ya maeneo ambayo yanachangia kwa kiasi kikubwa kitaifa vifo vya watoto wachanga na vya akina mama wajawazito au mara tu baada ya kujifungua. Utafiti wa kizamivu ulifanyika katika kuandaaa, kutekeleza na kutathmini afua kwenye vituo vya kutolea huduma za afya kwa kutumia mbinu ya kuimarisha ubora katika Halmashauri ya Wilaya ya Ruangwa, Mkoa wa Lindi tangu mwaka 2010 mpaka 2011. Mbinu ya kuimarisha ubora iliyotumika ilitekelezwa kwa kuleta pamoja timu za watoa Huduma za Afya kutoka vituo tofauti tofauti vya kutolea huduma za afya, ambao wana lengo moja katika kufanya kazi kwa pamoja kwa kuzingatia utaratibu maalumu ili kuboresha utoaji huduma za uzazi kwa akina mama wajamzito na watoto wachanga. Mbinu hii ilifanya kazi kupitia washiriki kutoa mawazo yenye kuleta mabadiliko ya kuboresha mfumo uliopo, kufuatilia utekelezaji wa mabadiliko mara kwa mara kupitia ukusanyaji wa takwimu, kushirikishana uzoefu na kujifunza. Mada walizofanyia kazi zilijumuisha ushauri juu ya maandalizi ya kujifungua, mama kujifungulia kituoni, namna ya kutumia grafu ya uchungu, huduma baada ya kujifungua pamoja na chanjo. Ili kuweza kujifunza kama mbinu hii inafanya kazi na ni kwa namna gani iliweza kuleta mafanikio katika utoaji huduma, utafiti huu wa kizamivu unalenga kuelezea utekelezaji wa afua na kutathmini mtazamo wa watoa huduma za afya juu ya afua ya uimarishaji ubora kwa kupitia “qualitative study”. Utafiti huu una malengo matatu: 1.) Kuelezea uandaaji na utekelezaji wa afua ya uimarishaji ubora iliyotumika kwenye mradi wa INSIST; 2.) Kufanya mapitio ya tathmini ya mbinu za uimarishaji ubora wa afya barani Afrika - Kusini mwa Jangwa la Sahara kwa kupitia hatua kwa hatua tafiti zilizochapishwa; 3.) Kuelewa vikwazo na viwezeshi vya utekelezaji wa afua ya uimarishaji ubora miongoni mwa watoa huduma za afya katika Halmashauri ya Wilaya ya Ruangwa. Matokeo yanalenga katika kuchangia ushahidi wa kisayansi kuhusu na kwa namna gani afua za uimarishaji ubora zinavyoweza kupunguza maradhi na vifo vya mama wajawazito na watoto wachanga nchini Tanzania. Matokeo yetu yameashiria kwamba inawezekana kutumia mbinu za kuboresha utoaji huduma ili kuboresha mfumo wa afya kwenye ngazi za vituo vya afya na zahanati. Tofauti kati ya kada mbalimbali na viwango vya elimu vya watoa huduma za afya haileti kipingamizi kwenye matumizi ya mbinu za kuboreshaji utoaji huduma. Matumizi ya mbinu za uboreshaji utoaji huduma zilihamasisha na kuongezea ujuzi watoaji huduma za afya. Utoaji ushauri fasaha wakati wa ujauzito uliwaongezea uelewa mama wajawazito na familia zao kuhusu maswala ya ujauzito na kuwatia nguvu ya kuwasaidia kufanya maamuzi yakinifu kuhusu kujifungualia kwenye vituo vya kutolea huduma za afya. Kwa kumalizia, matokeo ya utafiti huu yametoa mafunzo yenye maslahi ambayo ni muhimu kuzingatia wakati wa kupanga tafiti za aina hii, zitakazo fanyika kwenye mazingira yanayofanana na ya Halmashauri ya Wilaya ya Ruangwa. Mapokeo ya mbinu za uimarishaji ubora katika mfumo wa afya haubagui uimarishaji wa mfumo wa afya bali unawezesha. Tunahitaji kuwa na uwiano katika kuwafikishia huduma za afya kwa wananchi na kuwapa huduma zenye ubora wa hali ya juu. SUMMARY Maternal and neonatal deaths are still major public health problems in Tanzania. Efforts to improve quality of healthcare delivery have been put in place especially in the area of maternal and neonatal health in order to reduce the number of deaths and to ensure healthy living for every woman and child. In Tanzania, almost every pregnant woman receives antenatal care at least once, however, despite this high coverage, the quality of services provided during the antenatal care is low. In addition, the number of institutional deliveries is not proportional to the level of antenatal care, i.e. the number of facility deliveries constitute almost half of the total number of at least one antenatal visit. Furthermore, the quality of care of these few facility deliveries is also a problem. Thus, a study focusing on "Improving Newborn Survival in Southern Tanzania(INSIST)" was designed to implement and evaluate cost effectiveness of interventions to improve neonatal survival in rural southern Tanzania.This setting is among the areas that accounts for the highest national maternal and neonatal mortality and morbidity. This PhD thesis focused on contributing to a better understanding of the development, implementation and evaluation of a health facility intervention using a quality improvement (QI) approach in Ruangwa district, Lindi region from 2010 to 2011. The following three objectives were achieved: 1.) To describe the development and implementation of the QI intervention used in INSIST project; 2.) To review evaluation of QI approaches in sub Saharan Africa through a systematic review of published literature; 3.) To understand barriers and facilitators of the QI intervention implementation among health care providers in Ruangwa district. Our findings demonstrated that it is feasible to apply QI techniques in improving health systems performance at dispensary and health center levels. The differences in healthcare cadres and level of education was not a barrier in using QI techniques. Use of QI methods motivated and built capacity of healthcare providers. Proper counselling sessions during pregnancy improved knowledge of pregnant women and their families on pregnancy related issues and empowered them to make informed decisions such as delivering their babies in healthcare facilities. In conclusion, this thesis reports a case that shares interesting and powerful lessons from the real-time project implementation experience that are worth taking into consideration when planning for future studies in similar settings. The use of QI methods facilitates the strengthening of health systems as we seek to balance high coverage of services with high quality of providing them.

BACKGROUND: Maternal and newborn mortality remain unacceptably high in sub-Saharan Africa. Tanzania and Uganda are committed to reduce maternal and newborn mortality, but progress has been limited and many essential interventions are unavailable in primary and referral facilities. Quality management has the potential to overcome low implementation levels by assisting teams of health workers and others finding local solutions to problems in delivering quality care and the underutilization of health services by the community. Existing evidence of the effect of quality management on health worker performance in these contexts has important limitations, and the feasibility of expanding quality management to the community level is unknown. We aim to assess quality management at the district, facility, and community levels, supported by information from high-quality, continuous surveys, and report effects of the quality management intervention on the utilization and quality of services in Tanzania and Uganda. METHODS: In Uganda and Tanzania, the Expanded Quality Management Using Information Power (EQUIP) intervention is implemented in one intervention district and evaluated using a plausibility design with one non-randomly selected comparison district. The quality management approach is based on the collaborative model for improvement, in which groups of quality improvement teams test new implementation strategies (change ideas) and periodically meet to share results and identify the best strategies. The teams use locally-generated community and health facility data to monitor improvements. In addition, data from continuous health facility and household surveys are used to guide prioritization and decision making by quality improvement teams as well as for evaluation of the intervention. These data include input, process, output, coverage, implementation practice, and client satisfaction indicators in both intervention and comparison districts. Thus, intervention districts receive quality management and continuous surveys, and comparison districts-only continuous surveys. DISCUSSION: EQUIP is a district-scale, proof-of-concept study that evaluates a quality management approach for maternal and newborn health including communities, health facilities, and district health managers, supported by high-quality data from independent continuous household and health facility surveys. The study will generate robust evidence about the effectiveness of quality management and will inform future nationwide implementation approaches for health system strengthening in low-resource settings. TRIAL REGISTRATION: PACTR201311000681314. Corrections in: Implementation Science 10 Article number: 152 DOI: 10.1186/s13012-015-0343-9