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Focused Antenatal Care in Tanzania

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Focused Antenatal Care in Tanzania 2014 Focused COUNTRY-LEVEL PROGRAMMES COUNTRY-LEVEL Antenatal Care in Tanzania Delivering individualised, targeted, high-quality care In 2002, Tanzania’s Ministry of Health and Social Welfare implemented an ANC program adapted from the World Health Organisation’s focused ante- natal care (FANC) model. With four visits throughout pregnancy, FANC integrates care through health promotion, prevention, detection and treatment of existing diseases, and birth preparedness. While providing quality ANC is the first priority, the FANC model also recognises that the antenatal period is a key entry point for many women into the health system, and so the model integrates ANC with care and counselling related to several other conditions. autHORS ANNIE KEARNS, Women and Health Initiative & Maternal Health Task Force taYLOR HURST, Harvard School of Public Health JACQUELYN CaGLIA, Women and Health Initiative & Maternal Health Task Force ANA LANGER, Women and Health Initiative & Maternal Health Task Force overvIEW OF tanZANIA Constitution since 2012, aiming for completion in 2015 before the next general elections in October of that year.4 Tanzania, officially the United Republic of Tanzania, is an east African country lying just south of the equator and bordering the Demographics Indian Ocean, with Kenya to its north, Mozambique to its south, Since its first census in 1967, Tanzania’s population has grown and the Democratic Republic of the Congo, Burundi, Rwanda, from 12.3 million to 47.7 million.3 With an annual population and Uganda to its west.1 It is formed by two states – mainland growth of 3.1%, the population is projected to reach 81.9 million Tanzania and the islands of the semi-autonomous state of in 2030.5 The population density varies greatly across the country, Zanzibar (see Figure 1). They span a combined area of 947,480 with a density of 1,763 people per km2 in the capital city of Dar es km2, of which 883,000 km2 constitutes land.2 Salaam compared to the national average of 39 people per km2.2 A Figure 1: Map of Tanzania Table 1: Socioeconomic and demographic indicators INDIcator tanZANIA Population (millions)6 47.7 Urban population (%)5 27.2 Population under 15 (%)6 44.9 Population median age (years)6 17.5 Household size (mean)3 5.0 Human Development Index (HDI)5 0.476 Gross national income (GNI) per 570 capita (US$)7 Gini coefficient5 37.6 Population below national poverty line 28.2 (%)7 Mainland Tanzania and Zanzibar are divided into 21 and five regions, respectively. The 120 different ethnic groups that make Primary school enrolment, net (% / 97.6 / 49.3 up the country’s population are unified through the official % female)8 language of Kiswahili; English is used for administration and 5 higher education.3 Years of schooling (mean) 5.1 Historical and Political Context Literacy rate, adults ≥15 (%)6 73.2 Shortly after gaining independence from British colonial rule Access to improved water source 54.5 in 1961, mainland Tanzania (then known as Tanganyika) (% households)3 and Zanzibar joined in 1964 to form the United Republic of Tanzania. The country is now governed under a multiparty democracy, with presidential and national assembly elections With high rates of fertility and mortality, Tanzania has a held every five years.3 young population; 44.9% of its inhabitants are under 15 years of President Jakaya Kikwete is in the fourth year of his age. The population is predominantly rural, although the urban 3 second and last term in office. Tanzania has been reviewing its population has grown steadily from 6.4% to 27.2% since 1967. country-LEVEL PROGRAMMES 2014 2 Table 2: Health and Tanzania’s human development index (HDI) score in 2012 epidemiologic indicators was 152 out of 186 UN member states.5 More than half (54.5%) of households have access to an improved water source, but only INDIcator tanZANIA 13.3% have access to improved sanitation facilities.3 Some key socioeconomic indicators are shown in Table 1. Average life expectancy at birth 58.9 (years)5 Status of Women Tanzania ranks 119th out of 148 countries in the Gender Inequality Physicians (per 1,000 population)13 0.1 Index and 66th out of 136 countries in the Gender Gap Index.5,9 The literacy rates for women and men are 72.2% and 82.1%, Nurses and midwives (per 1,000 2.4 respectively. Among married adults, 88.6% of women are population)13 employed versus 99.5% of men. Compared to men, significantly fewer women are paid cash for their work and more than half HIV prevalence, adults 15–49 (%)6 5.8 are not paid at all. Among married couples, the vast majority of household decisions are made jointly or mainly by husbands, and Anti-retroviral therapy coverage in 40 women are infrequently the main decision-makers. Just 15.3% of people with advanced HIV (%)6 wives are the main decision-makers regarding their own health care, while only 9.1% are able to decide themselves whether to Anti-retroviral therapy coverage in 6 74 visit relatives.3 pregnant women living with HIV (%) Gender-based violence is still common; 33.0% and 20.3% of women have experienced physical and sexual violence, respectively. Furthermore, more than a third of these women did compared to the World Health Organization’s recommended 20 14 not tell anyone or seek any help.3 per 100,000. Despite strong health policies, limited resources Female genital cutting (FGC) was outlawed in 1998 by and capacity for implementation represent significant barriers 15 the Tanzanian Special Provision Act, but enforcement has been to improving health. Some important health indicators are difficult. Overall prevalence has been declining and recent summarized in Table 2. estimates are at 14.6%, but the practice is twice as common in Health system rural areas, being most common in the Manyara (70.8%) and The health system is organized into three levels of focus: (1) Dodoma regions (63.8%) compared to the lowest prevalence of community-level health facilities, (2) secondary and tertiary 3.5% in Dar es Salaam.3 hospitals, and (3) centralised policy-making and monitoring.14 Economy Patients go from the community level upwards as needed; Tanzania’s economy has been growing steadily for the last decade. patients will often start at village health services, and may be In 2013, the economy expanded by 7.1%, and inflation declined referred to dispensary services, health centre services, district 16 to 9.8% from 16.0% in 2012.4 Despite these improvements, most hospitals, regional hospitals, and referral hospitals. of Tanzania’s population remains poor and rural. 45% of the gross Seventy percent of public health financing comes from 2 domestic product (GDP) comes from agriculture, and 80% of the taxes. The National Health Insurance Fund Act, which population relies on agriculture for their livelihoods.10 was introduced in 1999, provides a social health insurance scheme for formal sector employees, covering about three HEALTH IN TANZANIA percent of the population. Since 2001, national support for Community Health Funds has brought these community-based Tanzania’s total expenditure on health was 7.3% of their GDP insurance schemes to 48 mostly rural districts.14 in 2011. However, 41.2% of total expenditure on health came Maternal and child health has been a priority component from external resources.6 For example, in 2011 Tanzania of national health policy since 2006.15 The Ministry of Health received $357.2 million from the President’s Emergency and Social Welfare is currently implementing its Third Health Plan for AIDS Relief (PEPFAR) and $46.9 million from the Sector Strategic Plan (2009–2015), developed in line with President’s Malaria Initiative (PMI).11,12 the National Strategy for Growth and Poverty Reduction, the Communicable diseases account for 78% of the years of life National Health Policy written in 2007, and the Millennium lost in Tanzania.13 Malaria is the number one overall cause of Development Goals (MDG).17 This includes the Reproductive mortality.2 The severe shortage of human resources remains and Child Health Strategic Plan, the main goal of which is to a problem; there are only 1–2 physicians per 100,000 people, reduce maternal, neonatal, and child morbidity and mortal- country-LEVEL PROGRAMMES 2014 3 Table 3: Maternal and child ity by strengthening health systems and increasing access to health indicators maternal and child health services.3 Nurses and midwives are regulated under the Tanzania INDIcator tanZANIA Nurses and Midwifery Council (TNMC), where the country’s 2,720 midwives are registered.18 Midwifery training is currently Total fertility rate (live births per 5.3 at an advanced diploma level, but discussions are taking place woman)6 to phase this out in favour of a midwifery bachelor’s degree. Maternal mortality ratio (per 100,000 460 Midwifery human resources are scarce, so nurse-midwives and live births)6 clinical officers are also trained in basic emergency obstetric Under-five mortality rate (per 1,000 76 and newborn care to increase availability of these services.15 live births)5 Infant mortality rate (per 1,000 live Maternal and child health 50 births)5 Maternal and neonatal mortality remains high in Tanzania Neonatal mortality rate (per 1,000 live despite improvements in recent years. Maternal mortality has 26 declined from 610 deaths per 100,000 live births in 2006 to births)3 460 in 2010.6 Yet the lifetime risk of maternal death remains Immunisation coverage, all basic, 18 66.2 1 in 23. Over the same period, neonatal mortality has fallen among 1-year-olds (%)3 slightly from 30 deaths per 1,000 live births to 26.3 Contraception prevalence rate (% of Maternal and child health indicators are listed in Table 3.
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