Council Health Management Team Research Articles

“Once the government employs you, it forgets you”: Health workers’ and managers’ perspectives on factors influencing working conditions for provision of maternal health care services in a rural district of Tanzania

BackgroundIn many developing countries, health workforce crisis is one of the predominant challenges affecting the health care systems’ function of providing quality services, including maternal care. The challenge is related to how these countries establish conducive working conditions that attract and retain health workers into the health care sector and enable them to perform effectively and efficiently to improve health services particularly in rural settings. This study explored the perspectives of health workers and managers on factors influencing working conditions for providing maternal health care services in rural Tanzania. The researchers took a broad approach to understand the status of the current working conditions through a governance lens and brought into context the role of government and its decentralized organs in handling health workers in order to improve their performance and retention.MethodsIn-depth interviews were conducted with 22 informants (15 health workers, 5 members of Council Health Management Team and 2 informants from the District Executive Director’s office). An interview guide was used with questions pertaining to informants’ perspective on provision of maternal health care service, working environment, living conditions, handling of staff’s financial claims, avenue for sharing concerns, opportunities for training and career progression. Probing questions on how these issues affect the health workers’ role of providing maternal health care were employed. Document reviews and observations of health facilities were conducted to supplement the data. The interviews were analysed using a qualitative content analysis approach.ResultsOverall, health workers felt abandoned and lost within an unsupportive system they serve. Difficult working and living environments that affect health workers’ role of providing maternal health care services were dominant concerns raised from interviews with both health workers and managers. Existence of a bureaucratic and irresponsible administrative system was reported to result in the delay in responding to the health workers’ claims timely and that there is no transparency and fairness in dealing with health workers’ financial claims. Informants also reported on the non-existence of a formal motivation scheme and a free avenue for voicing and sharing health workers’ concerns. Other challenges reported were lack of a clear strategic plan for staff career advancement and continuous professional development to improve health workers’ knowledge and skills necessary for providing quality maternal health care.ConclusionHealth workers working in rural areas are facing a number of challenges that affect their working conditions and hence their overall performance. The government and its decentralized organs should be accountable to create conducive working and living environments, respond to health workers’ financial claims fairly and equitably, plan for their career advancement and create a free avenue for voicing and sharing concerns with the management. To achieve this, efforts should be directed towards improving the governance of the human resource management system that will take into account the stewardship role of the government in handling human resource carefully and responsibly.

Factors that hinder community participation in developing and implementing comprehensive council health plans in Manyoni District, Tanzania

BackgroundDecentralization of public health planning is proposed to facilitate public participation in health issues. Health Sector Reform in Tanzania places emphasis on the participation of lower level health facilities and community in health planning process. Despite availability of policies, guidelines, and community representative organs, actual implementation of decentralization strategies is poorly achieved. This study intended to find out factors that hinder community participation in developing and implementing Comprehensive Council Health Plan (CCHP).Materials and methodsA qualitative approach was conducted in this study with key informants from Health Facility Governing Committees (HFGC), Council Health Service Board (CHSB), and Council Health Management Team (CHMT). Data were collected using in-depth interviews. Data generated were analyzed for themes and patterns.ResultsFactors that hindered community participation included lack of awareness on the CCHP among HFGC members, poor communication and information sharing between CHMT and HFGC, unstipulated roles and responsibilities of HFGC, lack of management capacity among HFGC members, and lack of financial resources for implementing HFGC activities.ConclusionsThe identified challenges call for policy makers to revisit the decentralization by devolution policy by ensuring that local governance structures have adequate resources as well as autonomy to participate in planning and managing CCHP in general and health facility plans in particular.

Sustainability of health benefits: Challenges faced by councils health management teams in sustaining comprehensive emergency care services after project phase out. The case of Rufiji, Kilombero and Ulanga districts

Background: Attention to the sustainability of health intervention programs is increasing not only in developing countries but also in developed countries together with international development agencies. However, consensus on operational definitions of sustainability and determinants of sustainability is still at an early stage. While much progress has been made in the development of successful interventions to promote health, too few interventions achieve long term sustainability. Implementation of EMPOWER project in collaboration with World Lung Foundation (WLF) have increased accessibility of comprehensive emergency obstetric care (CEmOC) by upgrading health centers which were formerly not providing CEmOC services in the three rural districts in Tanzania. Although the WHO standards of CEmOC coverage in the project districts was above the requirement, but accessing these health facilities which provides CEmOC was so difficult due to various factors like geographical (mountains, rivers, seasonal roads), locations of these health facilities (like in one district the it was located at a corner of the district), unreliable referral system and poor functionality of these health facilities especially in terms of emergency preparedness etc. all these factors lead to less/poor accessibility to CEmOC. The upgraded facilities include Kibiti in Rufiji district, Mlimba in Kilombero district, Mwaya and Mtimbira in Ulanga district. Objective: To explore challenges of sustaining upgraded health centers and impact on service utilization after project phase out among rural communities in Tanzania.Methods: Purposeful criterion-based selection of the upgraded health centers (those providing CEmOC) was used in the three districts two years after project phase-out. Secondary data analysis of the quantitative data which was collected during and after the project was done. The following services were assessed; total number of facility deliveries, average number of cesarean section (CS), ante natal care (ANC) attendance, post natal care (PNC) attendance, family planning (FP) use and partograph to monitor the progress of labor. Qualitative data involved key informant interviews of council health management teams (CHMT) and facility in charges.Monitoring data, evaluation and observation of various CEmOC and MNCH related indicators were also done. Four upgraded health centers (Mwaya, Mtimbira, Mlimba and Kibiti) were used as case studies to generate learning reported in this paper.Results: Two years post project, the utilization of most of the services like number of deliveries and CS performed better and were maintained in upgraded health centers which receive regular assistance (Mwaya and Mlimba) than Kibiti health center which received minimal support. Health workers remained committed to sustain the practices promoted in the interventionsdespite of the noted challenges.Conclusions: Benefits of introduced health innovations such as upgrading of health centers for CEmOC can only be sustained if a sustainability strategies are integrated at early stages of project design and carried forward in routine district health planning processes.

Involving decision-makers in the research process: Challenges of implementing the accountability for reasonableness approach to priority setting at the district level in Tanzania

The past two decades have seen a growing call for researchers, policy-makers and health care providers to collaborate in efforts to bridge the gaps between research, policy and practice. However, there has been a little attention focused on documenting the challenges of dealing with decision-makers in the course of implementing a research project. This paper highlights a collaborative research project aiming to implement the accountability for reasonableness (AFR) approach to priority setting in accordance with the Response to Accountable Priority Setting for Trust in Health Systems (REACT) project in Tanzania. Specifically, the paper examines the challenges of dealing with decision-makers during the project-implementation process and shows how the researchers dealt with the decision-makers to facilitate the implementation of the REACT project. Key informant interviews were conducted with the Council Health Management Team (CHMT), local government officials and other stakeholders, using a semi-structured interview guide. Minutes of the Action Research Team and CHMT were analysed. Additionally, project-implementation reports were analysed and group priority-setting processes in the district were observed. The findings show that the characteristics of the REACT research project, the novelty of some aspects of the AFR approach, such as publicity and appeals, the Action Research methodology used to implement the project and the traditional cultural contexts within which the project was implemented, created challenges for both researchers and decision-makers, which consequently slowed down the implementation of the REACT project. While collaboration between researchers and decision-makers is important in bridging gaps between research and practice, it is imperative to understand the challenges of dealing with decision-makers in the course of implementing a collaborative research project. Such analyses are crucial in designing proper strategies for improved communication and for the utilisation of research projects over time.

Factors influencing the implementation of integrated management of childhood illness (IMCI) by healthcare workers at public health centers & dispensaries in Mwanza, Tanzania

BackgroundIntegrated Management of Childhood Illness (IMCI) was developed by the World Health Organization (WHO) and the United Nations International Children’s Fund (UNICEF) and aims at reducing childhood morbidity and mortality in resource-limited settings including Tanzania. It was introduced in 1996 and has been scaled up in all districts in the country. The purpose of this study was to identify factors influencing the implementation of IMCI in the health facilities in Mwanza, Tanzania since reports indicates that the guidelines are not full adhered to by the healthcare workers.MethodsA cross-sectional study design was used and a sample size of 95 healthcare workers drawn from health centers and dispensaries within Mwanza city were interviewed using self-administered questionnaires. Structured interview was also used to get views from the city IMCI focal person and the 2 facilitators. Data were analyzed using SPSS and presented using figures and tables.ResultsOnly 51% of healthcare workers interviewed had been trained. 69% of trained Healthcare workers expressed understanding of the IMCI approach. Most of the respondents (77%) had a positive attitude that IMCI approach was a better approach in managing common childhood illnesses especially with the reality of resource constraint in the health facilities. The main challenges identified in the implementation of IMCI are low initial training coverage among health care workers, lack of essential drugs and supplies, lack of onsite mentoring and lack of refresher courses and regular supportive supervision. Supporting the healthcare workers through training, onsite mentoring, supportive supervision and strengthening the healthcare system through increasing access to essential medicines, vaccines, strengthening supply chain management, increasing healthcare financing, improving leadership & management were the major interventions that could assist in IMCI implementation.ConclusionsThe healthcare workers can implement better IMCI through the collaboration of supervisors, IMCI focal person, Council Health Management Teams (CHMT) and other stakeholders interested in child health. However, significant barriers impede a sustainable IMCI implementation. Recommendations have been made related to supportive supervision and HealthCare system strengthening among others.

Availability of drugs and medical supplies for emergency obstetric care: experience of health facility managers in a rural District of Tanzania

BackgroundProvision of quality emergency obstetric care relies upon the presence of skilled health attendants working in an environment where drugs and medical supplies are available when needed and in adequate quantity and of assured quality. This study aimed to describe the experience of rural health facility managers in ensuring the timely availability of drugs and medical supplies for emergency obstetric care (EmOC).MethodsIn-depth interviews were conducted with a total of 17 health facility managers: 14 from dispensaries and three from health centers. Two members of the Council Health Management Team and one member of the Council Health Service Board were also interviewed. A survey of health facilities was conducted to supplement the data. All the materials were analysed using a qualitative thematic analysis approach.ResultsParticipants reported on the unreliability of obtaining drugs and medical supplies for EmOC; this was supported by the absence of essential items observed during the facility survey. The unreliability of obtaining drugs and medical supplies was reported to result in the provision of untimely and suboptimal EmOC services. An insufficient budget for drugs from central government, lack of accountability within the supply system and a bureaucratic process of accessing the locally mobilized drug fund were reported to contribute to the current situation.ConclusionThe unreliability of obtaining drugs and medical supplies compromises the timely provision of quality EmOC. Multiple approaches should be used to address challenges within the health system that prevent access to essential drugs and supplies for maternal health. There should be a special focus on improving the governance of the drug delivery system so that it promotes the accountability of key players, transparency in the handling of information and drug funds, and the participation of key stakeholders in decision making over the allocation of locally collected drug funds.

The dependency on central government funding of decentralised health systems: experiences of the challenges and coping strategies in the Kongwa District, Tanzania

BackgroundDecentralised health systems in Tanzania depend largely on funding from the central government to run health services. Experience has shown that central funding in a decentralised system is not an appropriate approach to ensure the effective and efficient performance of local authorities due to several limitations. One of the limitations is that funds from the central government are not disbursed on a timely basis, which in turn, leads to the serious problem of shortage of financial resources for Council Health Management Teams (CHMT). This paper examines how dependency on central government funding in Tanzania affects health activities in Kongwa district council and the strategies used by the CHMT cope with the situation.MethodsThe study adopted a qualitative approach and data were collected using semi-structured interviews and focus group discussions. One district in the central region of Tanzania was strategically selected. Ten key informants involved in the management of health service delivery at the district level were interviewed and one focus group discussion was held, which consisted of members of the council health management team. The data generated were analysed for themes and patterns.ResultsThe results showed that late disbursement of funds interrupts the implementation of health activities in the district health system. This situation delays the implementation of some activities, while a few activities may not be implemented at all. However, based on their prior knowledge of the anticipated delays in financial disbursements, the council health management team has adopted three main strategies to cope with this situation. These include obtaining supplies and other services on credit, borrowing money from other projects in the council, and using money generated from cost sharing.ConclusionLocal government authorities (LGAs) face delays in the disbursement of funds from the central government. This has necessitated introduction of informal coping strategies to deal with the situation. National-level policy and decision makers should minimise the bureaucracy involved in allocating funds to the district health systems to reduce delays.

Promoting community participation in priority setting in district health systems: experiences from Mbarali district, Tanzania

BackgroundCommunity participation in priority setting in health systems has gained importance all over the world, particularly in resource-poor settings where governments have often failed to provide adequate public-sector services for their citizens. Incorporation of public views into priority setting is perceived as a means to restore trust, improve accountability, and secure cost-effective priorities within healthcare. However, few studies have reported empirical experiences of involving communities in priority setting in developing countries. The aim of this article is to provide the experience of implementing community participation and the challenges of promoting it in the context of resource-poor settings, weak organizations, and fragile democratic institutions.DesignKey informant interviews were conducted with the Council Health Management Team (CHMT), community representatives, namely women, youth, elderly, disabled, and people living with HIV/AIDS, and other stakeholders who participated in the preparation of the district annual budget and health plans. Additionally, minutes from the Action Research Team and planning and priority-setting meeting reports were analyzed.ResultsA number of benefits were reported: better identification of community needs and priorities, increased knowledge of the community representatives about priority setting, increased transparency and accountability, promoted trust among health systems and communities, and perceived improved quality and accessibility of health services. However, lack of funds to support the work of the selected community representatives, limited time for deliberations, short notice for the meetings, and lack of feedback on the approved priorities constrained the performance of the community representatives. Furthermore, the findings show the importance of external facilitation and support in enabling health professionals and community representatives to arrive at effective working arrangement.ConclusionCommunity participation in priority setting in developing countries, characterized by weak democratic institutions and low public awareness, requires effective mobilization of both communities and health systems. In addition, this study confirms that community participation is an important element in strengthening health systems.

Feasibility and coverage of implementing intermittent preventive treatment of malaria in pregnant women contacting private or public clinics in Tanzania: experience-based viewpoints of health managers in Mkuranga and Mufindi districts.

BackgroundEvidence on healthcare managers’ experience on operational feasibility of malaria intermittent preventive treatment for malaria during pregnancy (IPTp) using sulphadoxine-pyrimethamine (SP) in Africa is systematically inadequate. This paper elucidates the perspectives of District Council Health Management Team (CHMT)s regarding the feasibility of IPTp with SP strategy, including its acceptability and ability of district health care systems to cope with the contemporary and potential challenges.MethodsThe study was conducted in Mkuranga and Mufindi districts. Data were collected between November 2005 and December 2007, involving focus group discussion (FGD) with Mufindi CHMT and in-depth interviews were conducted with few CHMT members in Mkuranga where it was difficult to summon all members for FGD.ResultsParticipants in both districts acknowledged the IPTp strategy, considering the seriousness of malaria in pregnancy problem; government allocation of funds to support healthcare staff training programmes in focused antenatal care (fANC) issues, procuring essential drugs distributed to districts, staff remuneration, distribution of fANC guidelines, and administrative activities performed by CHMTs. The identified weaknesses include late arrival of funds from central level weakening CHMT’s performance in health supervision, organising outreach clinics, distributing essential supplies, and delivery of IPTp services. Participants anticipated the public losing confidence in SP for IPTp after government announced artemither-lumefantrine (ALu) as the new first-line drug for uncomplicated malaria replacing SP. Role of private healthcare staff in IPTp services was acknowledged cautiously because CHMTs rarely supplied private clinics with SP for free delivery in fear that clients would be required to pay for the SP contrary to government policy. In Mufindi, the District Council showed a strong political support by supplementing ANC clinics with bottled water; in Mkuranga such support was not experienced. A combination of health facility understaffing, water scarcity and staff non-adherence to directly observed therapy instructions forced healthcare staff to allow clients to take SP at home. Need for investigating in improving adherence to IPTp administration was emphasised.ConclusionHigh acceptability of the IPTp strategy at district level is meaningless unless necessary support is assured in terms of number, skills and motivation of caregivers and availability of essential supplies.

Stakeholders’ participation in planning and priority setting in the context of a decentralised health care system: the case of prevention of mother to child transmission of HIV programme in Tanzania

BackgroundIn Tanzania, decentralisation processes and reforms in the health sector aimed at improving planning and accountability in the sector. As a result, districts were given authority to undertake local planning and set priorities as well as allocate resources fairly to promote the health of a population with varied needs. Nevertheless, priority setting in the health care service has remained a challenge. The study assessed the priority setting processes in the planning of the prevention of mother to child transmission of HIV (PMTCT) programme at the district level in Tanzania.MethodsThis qualitative study was conducted in Mbarali district, south-western Tanzania. The study applied in-depth interviews and focus group discussions in the data collection. Informants included members of the Council Health Management Team, regional PMTCT managers and health facility providers.ResultsTwo plans were reported where PMTCT activities could be accommodated; the Comprehensive Council Health Plan and the Regional PMTCT Plan that was donor funded. As donors had their own globally defined priorities, it proved difficult for district and regional managers to accommodate locally defined PMTCT priorities in these plans. As a result few of these were funded. Guidelines and main priority areas of the Ministry of Health and Social Welfare (MoHSW) also impacted on the ability of the districts and regions to act, undermining the effectiveness of the decentralisation policy in the health sector.ConclusionThe challenges in the priority setting processes revealed within the PMTCT initiative indicate substantial weaknesses in implementing the Tanzania decentralisation policy. There is an urgent need to revive the strategies and aims of the decentralisation policy at all levels of the health care system with a view to improving health service delivery.

Supply-related drivers of staff motivation for providing intermittent preventive treatment of malaria during pregnancy in Tanzania: evidence from two rural districts

BackgroundSince its introduction in the national antenatal care (ANC) system in Tanzania in 2001, little evidence is documented regarding the motivation and performance of health workers (HWs) in the provision of intermittent preventive treatment of malaria during pregnancy (IPTp) services in the national ANC clinics and the implications such motivation and performance might have had on HWs and services' compliance with the recommended IPTp delivery guidelines. This paper describes the supply-related drivers of motivation and performance of HWs in administering IPTp doses among other ANC services delivered in public and private health facilities (HFs) in Tanzania, using a case study of Mkuranga and Mufindi districts.MethodsInterviews were conducted with 78 HWs participating in the delivery of ANC services in private and public HFs and were supplemented by personal communications with the members of the district council health management team. The research instrument used in the data collection process contained a mixture of closed and open-ended questions. Some of the open-ended questions had to be coded in the form that allowed their analysis quantitatively.ResultsIn both districts, respondents acknowledged IPTp as an essential intervention, but expressed dissatisfaction with their working environments constraining their performance, including health facility (HF) unit understaffing; unsystematic and unfriendly supervision by CHMT members; limited opportunities for HW career development; and poor (HF) infrastructure and staff houses. Data also suggest that poor working conditions negatively affect health workers' motivation to perform for ANC (including IPTp) services. Similarities and differences were noted in terms of motivational factors for ANC service delivery between the HWs employed in private HFs and those in public HFs: those in private facilities were more comfortable with staff residential houses, HF buildings, equipment, availability of water, electricity and cups for clients to use while taking doses under direct observed therapy than their public facility counterparts. Employees in public HFs more acknowledged availability of clinical officers, nurses and midwives than their private facility counterparts. More results are presented and discussed.ConclusionThe study shows conditions related to staffing levels, health infrastructure and essential supplies being among the key determinants or drivers of frontline HWs' motivation to deliver ANC services in both private and public HFs. Efforts of the government to meet the maternal health related Millennium Development Goals and targets for specific interventions need to address challenges related to HWs' motivation to perform their duties at their work-places.

Improving district level health planning and priority setting in Tanzania through implementing accountability for reasonableness framework: Perceptions of stakeholders

BackgroundIn 2006, researchers and decision-makers launched a five-year project - Response to Accountable Priority Setting for Trust in Health Systems (REACT) - to improve planning and priority-setting through implementing the Accountability for Reasonableness framework in Mbarali District, Tanzania. The objective of this paper is to explore the acceptability of Accountability for Reasonableness from the perspectives of the Council Health Management Team, local government officials, health workforce and members of user boards and committees.MethodsIndividual interviews were carried out with different categories of actors and stakeholders in the district. The interview guide consisted of a series of questions, asking respondents to describe their perceptions regarding each condition of the Accountability for Reasonableness framework in terms of priority setting. Interviews were analysed using thematic framework analysis. Documentary data were used to support, verify and highlight the key issues that emerged.ResultsAlmost all stakeholders viewed Accountability for Reasonableness as an important and feasible approach for improving priority-setting and health service delivery in their context. However, a few aspects of Accountability for Reasonableness were seen as too difficult to implement given the socio-political conditions and traditions in Tanzania. Respondents mentioned: budget ceilings and guidelines, low level of public awareness, unreliable and untimely funding, as well as the limited capacity of the district to generate local resources as the major contextual factors that hampered the full implementation of the framework in their context.ConclusionThis study was one of the first assessments of the applicability of Accountability for Reasonableness in health care priority-setting in Tanzania. The analysis, overall, suggests that the Accountability for Reasonableness framework could be an important tool for improving priority-setting processes in the contexts of resource-poor settings. However, the full implementation of Accountability for Reasonableness would require a proper capacity-building plan, involving all relevant stakeholders, particularly members of the community since public accountability is the ultimate aim, and it is the community that will live with the consequences of priority-setting decisions.

Prevalence and causes of low vision among schoolchildren in Kibaha District, Tanzania

Low vision is a major cause of morbidity and has profound effects on the quality of life for many people as it inhibits/reduces mobility and economical well being of the affected individuals and their families. The objective of the study was to determine the magnitude and causes of low vision among primary school children in Kibaha district in Tanzania. Primary schoolchildren were recruited for the study. The inclusion criterion was individual child with low vision of less than 6/18. Visual examination was used for screening the children to identify those with vision less than 6 /18. Snellen's chart was used to measure visual acuity of the children with low vision. A total of 400 (6-17 years) schoolchildren were screened. Thirty-eight (9.5%) had low vision. The prevalence of low vision was statistically higher (N = 33; 87%) among 12-17years old than among 6-11 years old (13%) (P < 0.05). Of the 38 children with low vision, the prevalence in females (68%) was statistically higher than in males (32%). There were multiples causes of low vision among affected children. Congenital anomalies accounted for the largest proportion (65%) of the causes of low vision. In twenty-three (60%) of the children (12-17 years), low vision was due to retinopathies. Fifty-five percent of the children with refractive error were aged between 6-11 years. Among the cases, 8 (54%) had low vision caused by uncorrected refractive errors while the rest (46%) were due to other types of refractive errors. Two children had corneal scars; one with central and another with whole corneal scar. In conclusion, prevalence of low vision among schoolchildren in Kibaha district is high and increases with age. The main causes are congenital anomalies. There is need for an early detection of the possible causes and appropriate treatment to reduce the condition among schoolchildren. It is therefore important that the district Council Health Management Team establishes school eye screening programme for early detection and treatment. It is equally important to strengthen advocacy programme targeting schoolchildren, teachers and caregivers on the public health importance of low vision.

Enhancing disease surveillance reporting using public transport in Dodoma District, Central Tanzania

An efficient disease surveillance system is a prerequisite for an effective disease control programme. It is only when correct and timely reports about disease outbreaks reaches the responsible persons that prompt actions can be taken. Tanzania is in the process of strengthening its infectious disease surveillance system using an integrated approach. However, several constraints hamper the smooth implementation of the new strategy (Miller et al., 2003). Under the current Integrated Disease Surveillance and Response (IDSR) strategy, health facilities in Tanzania are required to immediately notify the district when they suspect an outbreak, and to provide week-ending reports for 7 outbreak-prone diseases, and monthlyreports for 13 priority diseases (Mboera, 2004). Vital epidemiological information available at most health facilities in Tanzania are not often readily available for decision making at the district and national levels. This is due to lack of adequate information exchange facilities and systems that allow for a rapid access of information available at one level or both levels. Epidemiological reporting between facility and district levels of health delivery system has remained poor due to lack of effective and efficient means of communication (Miller et al., 2003; Kajeguka & Mboera, 2003). In a recent study in 12 districts of Tanzania, the overall timeliness reporting from facility to district level was found to be 8% (0-19%) for weekly reports and 24% (3-56%) for montly reports (Gueye et al., 2005). Some routine paper reports are currently being picked up during supervision and outreach visits, but these visits are quite irregular. Some reports are sent by radio call and hard copies delivered in person. In this paper, we report the use of a participatory process in solving weekly epidemiological surveillance reporting problem in Dodoma Rural district in Tanzania. Dodoma Rural District (6o, 30’ to 8o0’S, 35o, 30’ to 37o 0’E) is located in the central plateaus in Tanzania at an elevation of about 800-1200m above sea level. The district consists of a number of mountain chains, between which are low-lying flat areas. A number of depressions are associated with these lower areas, which are generally waterlogged during the rainy season and have a tendency of salinity because of their limited outflow. The district has a dry Savannah type of climate characterised by a long dry season lasting between April and November. The average annual rainfall is 500800mm, which is normally a short single wet season lasting between December and March. The district is made up of 8 divisions, 48 wards, and 128 villages covering an area of 14,004 km. The district population is 495,176 made up of 96,686 households. The district is served by 81 health facilities (1 hospital, 6 health centres and 74 dispensaries). The nearest and furthest health facilities are 37 km and 145 km from the district capital, respectively (Mboera et al., 2005). The participatory process approach involved researchers from the National Institute for Medical Research, district council health management team (CHMT) and the in-charges of all facilities in the district. The CHMT and health workers were trained to carry out problem-solving participatory approach in the area of communication. Following the discussions, strategies were developed and documented. Eighty-one health facilities were involved in the discussion in four different sessions. During the discussion several means of communication were suggested by the participants. These included: public bus transport, radio calls, passenger train, mobile phones and bicycles. The use of public buses was given the highest priority.

Intermittent preventive treatment of malaria during pregnancy: a qualitative study of knowledge, attitudes and practices of district health managers, antenatal care staff and pregnant women in Korogwe District, North-Eastern Tanzania.

BackgroundIntermittent preventive treatment of malaria during pregnancy (IPTp) is a key intervention in the national strategy for malaria control in Tanzania. SP, the current drug of choice, is recommended to be administered in the second and third trimesters of pregnancy during antenatal care (ANC) visits. To allow for a proper design of planned scaling up of IPT services in Tanzania it is useful to understand the IPTp strategy's acceptability to health managers, ANC service providers and pregnant women. This study assesses the knowledge, attitudes and practices of these groups in relation to malaria control with emphasis on IPTp services.MethodsThe study was conducted in February 2004, in Korogwe District, Tanzania. It involved in-depth interviews with the district medical officer (DMO), district hospital medical officer in charge and relevant health service staff at two peripheral dispensaries, and separate focus group discussions (FGDs) with district Council Health Management Team members at district level and pregnant women at dispensary and community levels.ResultsKnowledge of malaria risks during pregnancy was high among pregnant women although some women did not associate coma and convulsions with malaria. Contacting traditional healers and self-medication with local herbs for malaria management was reported to be common. Pregnant women and ANC staff were generally aware of SP as the drug recommended for IPTp, albeit some nurses and the majority of pregnant women expressed concern about the use of SP during pregnancy. Some pregnant women testified that sometimes ANC staff allow the women to swallow SP tablets at home which gives a room for some women to throw away SP tablets after leaving the clinic. The DMO was sceptical about health workers' compliance with the direct observed therapy in administering SP for IPTp due to a shortage of clean water and cups at ANC clinics. Intensified sensitization of pregnant women about the benefits of IPTp was suggested by the study participants as an important approach for improving IPTp compliance.ConclusionThe successful implementation of the IPTp strategy in Tanzania depends on the proper planning of, and support to, the training of health staff and sustained sensitization of pregnant women at health facility and community levels about the benefits of IPTp for the women and their unborn babies.