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ObjectiveTo assess existing knowledge related to methodological considerations for linking population-based surveys and health facility data to generate effective coverage estimates. Effective coverage estimates the proportion of individuals in need of an intervention who receive it with sufficient quality to achieve health benefit.DesignSystematic review of available literature.Data sourcesMedline, Carolina Population Health Center and Demographic and Health Survey publications and handsearch of related or referenced works of all articles included in full text review. The search included publications from 1 January 2000 to 29 March 2021.Eligibility criteriaPublications explicitly evaluating (1) the suitability of data, (2) the implications of the design of existing data sources and (3) the impact of choice of method for combining datasets to obtain linked coverage estimates.ResultsOf 3805 papers reviewed, 70 publications addressed relevant issues. Limited data suggest household surveys can be used to identify sources of care, but their validity in estimating intervention need was variable. Methods for collecting provider data and constructing quality indices were diverse and presented limitations. There was little empirical data supporting an association between structural, process and outcome quality. Few studies addressed the influence of the design of common data sources on linking analyses, including imprecise household geographical information system data, provider sampling design and estimate stability. The most consistent evidence suggested under certain conditions, combining data based on geographical proximity or administrative catchment (ecological linking) produced similar estimates to linking based on the specific provider utilised (exact match linking).ConclusionsLinking household and healthcare provider data can leverage existing data sources to generate more informative estimates of intervention coverage and care. However, existing evidence on methods for linking data for effective coverage estimation are variable and numerous methodological questions remain. There is need for additional research to develop evidence-based, standardised best practices for these analyses.

Abstract Background Neonatal mortality because of low birth weight or prematurity remains high in many developing country settings. This research aimed to estimate the sensitivity and specificity, and the positive and negative predictive values of newborn foot length to identify babies who are low birth weight or premature and in need of extra care in a rural African setting. Methods A cross-sectional study of newborn babies in hospital, with community follow-up on the fifth day of life, was carried out between 13 July and 16 October 2009 in southern Tanzania. Foot length, birth weight and gestational age were estimated on the first day and foot length remeasured on the fifth day of life. Results In hospital 529 babies were recruited and measured within 24 hours of birth, 183 of whom were also followed-up at home on the fifth day. Day one foot length Conclusion Measurement of newborn foot length for home births in resource poor settings has the potential to be used by birth attendants, community volunteers or parents as a screening tool to identify low birth weight or premature newborns in order that they can receive targeted interventions for improved survival

Abstract Background Delivery of two doses of intermittent preventive treatment of malaria during pregnancy (IPTp) is a key strategy to reduce the burden of malaria in pregnancy in sub-Saharan Africa. However, different settings have reported coverage levels well below the target 80%. Antenatal implementation guidelines in Tanzania recommend IPTp first dose to be given at the second antenatal visit, and second dose at the third visit. This investigation measured coverage of IPTp at national level in Tanzania and examined the role of individual, facility, and policy level influences on achieved coverage. Methods Three national household and linked reproductive and child health (RCH) facility surveys were conducted July-August 2005, 2006, and 2007 in 210 clusters sampled using two-stage cluster sampling from 21 randomly selected districts. Female residents who reported a livebirth in the previous year were asked questions about malaria prevention during that pregnancy and individual characteristics including education, pregnancy history, and marital status. The RCH facility serving each cluster was also surveyed, and information collected about drug stocks, health education delivery, and the timing of antenatal care delivery by clinic users. Results The national IPTp coverage had declined over the survey period being 71% for first dose in 2005 falling to 65% in 2007 (χ2 2.9, p = 0.05), and 38% for second dose in 2005 but 30% in 2007 (χ2 4.4, p = 0.01). There was no evidence of any individual factors being associated with second dose coverage beyond living in an urban area. Availability of sulphadoxine-pyrimethamine at RCH had decreased year on year from 85% of clinics in stock in 2005 to 60% in 2007 (χ2 20.6, p < 0.001). This reduction was evident in rural but not urban clinics. If safety recommendations and national antenatal care guidelines for IPTp delivery were followed, in 2007 only 76% of pregnant women could have received IPTp first dose and only 46% could have received second dose. Conclusion There is scope to improve IPTp first and second dose coverage at national scale within existing systems by improving stock at RCH, and by revising the existing guidelines to recommend delivery of IPTp after quickening, rather than at a pre-defined antenatal visit.

Abstract Background The Tanzania National Voucher Scheme (TNVS) uses the public health system and the commercial sector to deliver subsidised insecticide-treated nets (ITNs) to pregnant women. The system began operation in October 2004 and by May 2006 was operating in all districts in the country. Evaluating complex public health interventions which operate at national level requires a multidisciplinary approach, novel methods, and collaboration with implementers to support the timely translation of findings into programme changes. This paper describes this novel approach to delivering ITNs and the design of the monitoring and evaluation (M&E). Methods A comprehensive and multidisciplinary M&E design was developed collaboratively between researchers and the National Malaria Control Programme. Five main domains of investigation were identified: (1) ITN coverage among target groups, (2) provision and use of reproductive and child health services, (3) "leakage" of vouchers, (4) the commercial ITN market, and (5) cost and cost-effectiveness of the scheme. Results The evaluation plan combined quantitative (household and facility surveys, voucher tracking, retail census and cost analysis) and qualitative (focus groups and in-depth interviews) methods. This plan was defined in collaboration with implementing partners but undertaken independently. Findings were reported regularly to the national malaria control programme and partners, and used to modify the implementation strategy over time. Conclusion The M&E of the TNVS is a potential model for generating information to guide national and international programmers about options for delivering priority interventions. It is independent, comprehensive, provides timely results, includes information on intermediate processes to allow implementation to be modified, measures leakage as well as coverage, and measures progress over time.

Abstract Background Intermittent preventive treatment (IPTp) is efficacious in reducing the adverse outcomes associated with pregnancy-associated malaria, however uptake of the recommended two doses is low in Tanzania, and little is known of the timepoint during pregnancy at which it is delivered. This study investigated the timing of delivery of IPTp to pregnant women attending antenatal clinics (ANC), and the potential determinants of timely uptake. Methods Structured interviews were conducted with staff and pregnant women at antenatal clinics in northeast Tanzania, and antenatal consultations were observed. Facility-based and individual factors were analysed for any correlation with timing of IPTp uptake. Results Almost half the women interviewed first attended ANC during or before the fourth month of gestation, however 86% of these early attendees did not receive IPTp on their first visit. The timing of IPTp delivery complied closely with the national guidelines which stipulate giving the first dose at 20–24 weeks gestation. Uptake of at least one dose of IPTp among women who had reached this gestation age was 67%, although this varied considerably between clinics. At one facility, IPTp was not delivered because SP was out of stock. Conclusion Early uptake of IPTp was found to be hampered by factors external to health worker performance or women's individual preferences. These include insufficient drug stocks and an apparent lack of information to health workers on the reasoning for continued use of SP for IPTp when it has been replaced as a first-line treatment. In addition, an unexpectedly high proportion of women attend antenatal clinics before 20 weeks of pregnancy. While current policy denies the use of IPTp at this time, there is emerging, but incomplete, evidence that malaria in early pregnancy may contribute considerably to the burden of pregnancy-related malaria. Current policy may thus result in a missed opportunity for maximising the benefit of this intervention, and efforts to encourage earlier attendance at ANC alone are unlikely to improve uptake of IPTp. More evidence is needed to weigh the benefits of early IPTp use against theoretical risks of antifolate drugs in early pregnancy.

Abstract In Tanzania access to urban and rural primary health care is relatively widespread, yet there is evidence of considerable bypassing of services; questions have been raised about how to improve functionality. The aim of this study was to explore the experiences of health workers working in the primary health care facilities in Kilimanjaro Region, Tanzania, in terms of their motivation to work, satisfaction and frustration, and to identify areas for sustainable improvement to the services they provide. The primary issues arising pertain to complexities of multitasking in an environment of staff shortages, a desire for more structured and supportive supervision from managers, and improved transparency in career development opportunities. Further, suggestions were made for inter-facility exchanges, particularly on commonly referred cases. The discussion highlights the context of some of the problems identified in the results and suggests that some of the preferences presented by the health workers be discussed at policy level with a view to adding value to most services with minimum additional resources.

Abstract Background To reduce the intolerable burden of malaria in pregnancy, the Ministry of Health in Tanzania has recently adopted a policy of intermittent presumptive treatment for pregnant women using sulphadoxine-pyrimethamine (IPTp-SP). In addition, there is strong national commitment to increase distribution of insecticide treated nets (ITNs) among pregnant women. This study explores the determinants of uptake for both ITNs and IPTp-SP by pregnant women and the role that individual knowledge and socio-economic status has to play for each. Methods 293 women were recruited post-partum at Kibaha District Hospital on the East African coast. The haemoglobin level of each woman was measured and a questionnaire administered. Results Use of both interventions was associated with a reduced risk of severe anaemia (Hb Conclusion Individual knowledge of malaria was an important factor for ITN uptake, but not for IPTp-SP use, which was reliant on delivery of information by MCH systems. When both these interventions were used, severe anaemia postpartum was reduced by 69% compared to use of neither, thus providing evidence of effectiveness of these interventions when used in combination.

Objective To analyse the impact of community approaches to improving newborn health and survival in low-resource countries. Methods We updated previous meta-analyses of published cluster randomized trials of community-based interventions for neonatal survival. For each study we extracted baseline data on the context: geographical area; available facilities and staffing; immediate breastfeeding and facility births; and neonatal mortality. We also extracted data on the primary outcome (neonatal survival) and intermediate outcomes of the interventions (changes in immediate breastfeeding and facility births). We used forest plots and pooled sub-group analysis to seek patterns in associations between the effect size and the context or type of intervention (home-based counselling or women's groups). Findings We included 17 trials, spanning years from 2001 to 2013. A 25% reduction in neonatal mortality (relative risk, RR: 0.75; 95% confidence interval, CI: 0.69-0.80) was found when pooling six studies in settings with 44 or more deaths per 1000 live births. In lower-mortality settings (pooling six studies with 32 or fewer deaths per 1000 live births) there was no evidence of an effect. We observed some evidence that community approaches had a stronger effect in south Asia than in sub-Saharan Africa. Community approaches had a lower impact on neonatal mortality in settings where at least 44% of women delivered in a facility. Conclusion As neonatal mortality declined, the impact of community approaches on survival appeared to be lower, and the role of these approaches in supporting newborn care in weak health systems may need to be re-examined. Objectif Analyser l'impact des approches communautaires dans l'amelioration de la survie et de la sante des nouveau-nes dans des regions a faibles ressources. Methodes Nous avons actualise d'anciennes meta-analyses d'essais randomises en grappes publies, portant sur des interventions communautaires visant a ameliorer la survie neonatale. Pour chaque etude, nous avons extrait les donnees de reference sur le contexte: zone geographique, centres et effectifs disponibles; proportion de naissances dans un centre de soins et d'initiation immediate de l'allaitement; mortalite neonatale. Nous avons egalement extrait les donnees sur le principal critere etudie (survie neonatale) et les effets indirects des interventions (modification des pratiques en termes d'initiation immediate de l'allaitement et d'accouchement dans un centre de soins). A l'aide de graphiques en foret et d'une analyse groupee portant sur les sous-groupes nous avons recherche d'eventuels schemas d'association entre l'importance de l'impact et le contexte ou le type d'intervention (conseils a domicile ou participation a des reunions de groupes de femmes). Resultats Nous avons inclus 17 essais, couvrant la periode de 2001 a 2013. Une reduction de 25% de la mortalite neonatale (risque relatif: 0,75; intervalle de confiance de 95%: 0,69-0,80) a ete observee dans l'analyse groupee de six etudes realisees dans des regions dont le taux de mortalite etait de 44 deces ou plus pour 1 000 naissances vivantes. Dans les regions au taux de mortalite inferieur (analyse groupee de six etudes realisees dans des regions avec un taux de mortalite de 32 deces ou moins pour 1 000 naissances vivantes), aucun effet n'a ete constate. Plusieurs elements probants montrent que les approches communautaires ont eu un impact plus important en Asie du Sud qu'en Afrique subsaharienne. Les approches communautaires ont eu un impact plus faible sur la mortalite neonatale dans les regions oU au moins 44% des femmes accouchaient dans un centre de soins. Conclusion A mesure que la mortalite neonatale recule, les approches communautaires sur la survie neonatale semblent avoir moins d'impact. Le role de ces approches pour renforcer les soins neonataux dans les regions au systeme de sante fragile pourrait necessiter un reexamen. Objetivo Analizar el impacto de enfoques comunitarios para mejorar la salud y la supervivencia de los neonatos en paises con escasos recursos. Metodos Se actualizaron metaanalisis anteriores de ensayos aleatorizados de conglomerados publicados de intervenciones comunitarias de supervivencia de los neonatos. Para cada estudio, se extrajeron datos de referencia segun el contexto: zona geografica; centros y personal disponibles; lactancia inmediata y nacimientos en centros; y mortalidad neonatal. Tambien se extrajeron datos sobre los resultados primarios (supervivencia neonatal) y los resultados intermedios de las intervenciones (cambios de la lactancia inmediata y los nacimientos en centros). Se utilizaron parcelas y se realizaron analisis de subgrupos en busca de patrones asociativos entre el tamano del efecto y el contexto o tipo de intervencion (asesoria domestica o grupos de mujeres). Resultados Se incluyeron 17 ensayos desde el ano 2001 hasta el 2013. Se identifico una reduccion del 25% en la mortalidad neonatal (riesgo relativo: 0,75; intervalo de confianza (IC) del 95%: 0,69-0,80) al realizar seis estudios en centros con 44 o mas muertes por cada 1 000 nacidos vivos. En lugares con escasa mortalidad (se realizaron seis estudios con 32 muertes o menos por cada 1 000 nacimientos vivos) no se encontraron pruebas de un efecto. Se observaron algunas pruebas de que los enfoques comunitarios lograron un mayor efecto en el sur de Asia que en el Africa subsahariana. Los enfoques comunitarios tuvieron un menor impacto para la mortalidad neonatal en lugares en los cuales al menos un 44% de las mujeres daban a luz en un centro. Conclusion Dado que la mortalidad neonatal cayo, el impacto de los enfoques comunitarios sobre la supervivencia ha sido menor, y puede que sea necesario volveraexaminarla funcion de estos enfoques en el respaldo de la atencion para los recien nacidos en sistemas sanitarios pobres., Introduction Despite progress in reducing child deaths in the past 25 years, an estimated 2.6 million neonatal deaths occurred globally in 2015. (1) Sustainable development goal (SDG) 3 included the [...]

Objective To estimate effective coverage of maternal and newborn health interventions and to identify bottlenecks in their implementation in rural districts of the United Republic of Tanzania. Methods Cross-sectional data from households and health facilities in Tandahimba and Newala districts were used in the analysis. We Adapted Tanahashi's model to estimate intervention coverage in conditional stages and to identify implementation bottlenecks in access, health facility readiness and clinical practice. The interventions studied were syphilis and pre-eclampsia screening, partograph use, active management of the third stage of labour and postpartum care. Findings Effective coverage was low In both districts, ranging from only 3% for postpartum care in Tandahimba to 49% for active management of the third stage of labour in Newala. In Tandahimba, health facility readiness was the largest bottleneck for most interventions, whereas in Newala, it was access. Clinical practice was another large bottleneck for syphilis screening in both districts. Conclusion The poor effective coverage of maternal and newborn health interventions in rural districts of the United Republic of Tanzania reinforces the need to prioritize health service quality. Access to high-quality local data by decision-makers would assist planning and prioritization. The approach of estimating effective coverage and identifying bottlenecks described here could facilitate progress towards universal health coverage for any area of care and in any context. [TEXT NOT REPRODUCIBLE IN ASCII] [TEXT NOT REPRODUCIBLE IN ASCII] Objectif Estimer la couverture effective des Interventions de sante maternelle et neonatale et identifier les goulots d'etranglement dans leur mise en oeuvre, dans des districts ruraux de Republique-Unie de Tanzanie. Methodes Des donnees transversales, obtenues aupres de menages et d'etablissements de sante dans les districts de Tandahimba et Newala, ont ete utilisees dans l'analyse. Nous avons adapte le modele de Tanahashi pour estimer la couverture des interventions lors de leurs differentes etapes conditionnelles et identifier les goulots d'etranglement en termes d'acces, de disponibilite operationnelle des centres de sante et de pratiques cliniques. Les interventions etudiees portaient sur le depistage de la syphilis et de la preeclampsie, l'utilisation du partogramme, la prise en charge active du troisieme stade du travail et les soins post-partum. Resultats La couverture effective s'est revelee faible dans les deux districts : entre seulement 3 % pour les soins post-partum dans le district de Tandahimba et 49 % pour la prise en charge active du troisieme stade du travail dans le district de Newala. Dans le district de Tandahimba, le principal goulot d'etranglement identifie pour la plupart des interventions concerne la disponibilite operationnelle des centres de sante, tandis que pour le district de Newala, il s'agit de l'acces. Les pratiques cliniques ont aussi largement entrave le depistage de la syphilis dans les deux districts. Conclusion La faible couverture effective des interventions de sante maternelle et neonatale dans les districts ruraux de Republique-Unie de Tanzanie renforce la necessite de donner la priorite a la qualite des services de sante. Or, si les decideurs pouvaient acceder a des donnees locales de grande qualite, cela permettrait d'ameliorer les activites de planification et de hierarchisation. L'approche d'estimation de la couverture effective et d'identification des goulots d'etranglement qui est decrite ici pourrait favoriser les progres vers la couverture sanitaire universelle, dans tous les domaines de soin et tous les contextes. [TEXT NOT REPRODUCIBLE IN ASCII] Objetivo Estimar la cobertura efectiva de intervenciones de salud maternal y neonatal e identificar obstaculos en su implementacion en distritos rurales de la Republica Unida de Tanzania. Metodos En el analisis se utilizaron datos transversales de hogares y centros sanitarios de los distritos deTandahimba y Newala. Se adapto el modelo deTanahashi para estimar la cobertura de intervencion en etapas condicionales y para identificar obstaculos en la Implementacion en el acceso y la disponibilidad de los centros sanitarios y la practica clinica. Las intervenciones estudiadas fueron las pruebas para la sifilis y la preeclampsia, el uso del partograma, la gestion activa de la tercera etapa del parto y el postparto. Resultados La cobertura resulto ser poco eficaz en ambos distritos, desde solo un 3% en el postparto enTandahlmba hasta un 49% en la gestion activa de la tercera etapa del parto en Newala. En Tandahimba, la disponibilidad de los centros sanitarios era el obstaculo mas importante en la mayoria de intervenciones, mientras que en Newala el mayor obstaculo era el acceso. La practica clinica resulto ser otro obstaculo para las pruebas de sifilis en ambos distritos. Conclusion La ineficiente cobertura de las Intervenciones de salud maternal y neonatal en distritos rurales de la Republica Unida de Tanzania reafirma la necesidad de priorizar la calidad del servicio sanitario. Si quienes toman las decisiones pudieran acceder a datos locales de alta calidad, la planificacion y la priorizaclon mejorarian. El enfoque de estimar la cobertura efectiva e identificar los obstaculos aqui descritos podria facilitar el avance hacia una cobertura sanitaria universal en cualquier area de la atencion medica y en cualquier contexto., Identification des goulots d'etranglement entravant les interventions de sante maternelle et neonatale dans des districts ruraux de Republique-Unie de Tanzanie Identificacion de obstaculos en la ejecucion de intervenciones de salud [...]