THE UNITED REPUBLIC OF TANZANIA

MINISTRY OF HEALTH AND SOCIAL WELFARE

Baseline survey on quality of paediatric care in Tanzania

NOVEMBER 2010

Published by the Ministry of Health and Social Welfare, Dar es Salaam, The United Republic of Tanzania.

© 2011 Ministry of Health and Social Welfare, The United Republic of Tanzania

Any part of this document may be reproduced in any form without the prior permission of the publisher provided that this is not for profit and that due acknowledgement is given.

Any reproduction for profit must be made with the prior permission of the publisher. Copies of this report may be obtained from: The Permanent Secretary Ministry of Health and Social Welfare P.O. Box 9083 Dar es Salaam Tel: 255 22 2120261 Fax: 255 22 2139951 Table of contents

Acknowledgments ...... i Abbreviations...... ii Executive summary...... iii Background ...... iii Objective ...... iii Methods ...... iii Results ...... iv Recommendations...... v Conclusion...... vi 1. Introduction...... 7 2. Background ...... 8 2.1 Tanzaniaʹs health system ...... 8 2.2 Quality of care in children ...... 9 2.3 Objective of the assessment ...... 11 3. Methods ...... 12 3.1 Scope of the survey ...... 12 3.2 Performance criteria...... 12 3.3 Grading performance ...... 12 3.4 Assessment teams ...... 14 3.5 Data entry and analysis...... 14 3.6 Statistical analysis ...... 15 4. Results ...... 15 4.1 Administrative review ...... 16 4.1.1 Overall performance ...... 16 4.1.2 Hospital support...... 17 4.2 Clinical assessment ...... 25 4.2.1 Paediatric ward ...... 25 4.2.2 Monitoring...... 25 4.2.3 Infection prevention and control...... 26 4.2.4 Care for children by qualified staff ...... 27 4.2.5 Case management...... 28 5. Newborn care...... 36 5.1 Delivery room/ward (nursery)...... 37 5.2 Delivery of newborn care...... 37 5.2.1 The neonatal resuscitation variables scored were:...... 37 5.2.2 For promotion of early breastfeeding and bonding the variables were: ...... 37 5.2.3 Clean delivery and newborn care variables were:...... 38 5.2.4 Prophylaxis variables were: ...... 38 5.3 Sick newborn/neonate care...... 38 6. Further data analysis of the survey findings...... 39 7. Discussion...... 45 7.1 Conclusion ...... 48 8. Recommendations at regional level...... 48 9. Recommendations at national level...... 48 10. References...... 49 11. Annexes: Tables showing the overall hospital performance by region...... 50

Acknowledgments

The Ministry of Health and Social Welfare (MOHSW) would like to extend its sincere appreciation to all the people who contributed to the development of this report. It is not possible to name all who have played a part in data collection and data entry; however the Ministry would like to mention a few whose particular dedication to this process made this report possible.

Acknowledgements go first to all those individuals who participated in the development of the data collection tool and the check list, as well as those who assisted with the data collection.

In the Reproductive and Child Health Section, MOHSW, we thank Drs Azayo Mary, Bundala Felix, Mr Meena John, Drs Msemo Georgina and Rusibamayila Neema.

The MOHSW is especially grateful to the WHO Country Office as well as WHO HQ for the financial and technical support provided, especially to Drs Hill Sue, Iriya Neemes and Shija Rose.

Finally, the MOHSW would like to thank the Principal Investigator and author of this report, Dr Kitundu Jesse from Muhimbili National Hospital, Department of Paediatrics, for leading this important work to its completion.

Baseline Survey on Quality of Paediatric Care in Tanzania -- Page i Abbreviations

APC Acute patient care ARI Acute respiratory infection AS Administrative score BF Breastfeeding CAS Clinical assessment score CPR Contraceptive prevalence rate CWS Childrenʹs ward score DPT3 Three doses of diphtheria, pertussis and tetanus vaccine EmOC Emergency obstetric care FBO Faith‐based organization IMCI Integrated management of childhood illness IMR Infant mortality rate IPD Inpatient Department IPTP Intermittent preventive treatment for malaria during pregnancy HSR Health System Reforms MDG Millennium Development Goal MNCH Maternal, newborn and child health MOHSW Ministry of Health and Social Welfare NMR Neonatal mortality rate OPD Outpatient Department ORS Oral rehydration solution ORT Oral rehydration therapy PAT Paediatrics Association Tanzania PHS Public health score PMTCT Prevention of mother‐to‐child transmission of HIV PNC Postnatal care ResoMal Rehydration solution for severe malnutrition RCHS Reproductive and Child Health Services RCM Referral care manual SAM Severe acute malnutrition SOP Standard operating procedure SM Standard met SPM Standard partially met SNM Standard not met TB Tuberculosis TS Treatment score TDHS Tanzania Demographic Health Survey U5MR Under‐five mortality rate WHO World Health Organization

Baseline Survey on Quality of Paediatric Care in Tanzania -- Page ii Executive summary

Background

This report outlines the preliminary results of an ongoing assessment survey on the quality of paediatric care conducted by the Ministry of Health and Social Welfare in the United Republic of Tanzania. Mainland Tanzania has 21 administrative regions and 113 districts. The country has a pyramidal referral structure of health care with public and private dispensaries, health centres and district, regional and national hospitals managed by the Government and by non‐governmental and faith‐based organizations. The survey reported here covers 69 hospitals managed by the Government and faith–based organizations across regions of Mainland Tanzania.

Millennium Development Goal 4 aims for a reduction in child mortality. Quality of care is an important factor in reaching this goal. While under‐five mortality has decreased in Tanzania, the rate in hospitals remains unacceptably high with 75% of these deaths occurring in the first 24 to 48 hours after admission. Most of these deaths are preventable and the application of appropriate measures, such as proper assessment, treatment and care, could reduce the number of deaths significantly.

Objective

The goal of the survey is to establish baseline data and identify gaps to be addressed in order to improve the quality of paediatric care in Tanzanian hospitals. The specific objectives of the survey are to:

• assess the administrative and logistics support in the provision of care for sick children; • assess the knowledge and skills of health workers in the management of care for common childhood illnesses; • assess the availability of essential medicines, supplies and equipment at health facilities necessary for the provision of quality care; • support the establishment of a system for improving the care of children in the respective facilities.

Methods

The World Health Organization’s generic tool for assessing the quality of hospital care for children was adapted to collect data for this survey. The WHO Pocket Book of Hospital Care for Children and an adapted referral care manual were used as standards for assessing case management. Data were collected in hospitals and health centres through observation and interviews by teams comprising three trained assessors from other facilities.

Baseline Survey on Quality of Paediatric Care in Tanzania -- Page iii The five areas assessed were administration, paediatric wards, clinical assessment, public health and treatment. Each area had key indicators to be measured, including the availability of essential medicines, adequate qualified staff, a separate paediatric ward, accurate clinical assessment and treatment of pneumonia, diarrhoea and malnutrition, reassessment after admission, and promotion of early breastfeeding.

The indicators used for scoring were divided into two categories. First, clinical tasks and standards with a strong bearing on the care of the child, the absence of which could be life threatening. They include the availability of emergency medicines and accurate clinical assessment and treatment for dehydration. The second category, essential tasks and standards, covers the availability of laboratory facilities for culture testing and failure to recognize a skin infection. Scoring was categorized as: standard met, standard partially met and standard not met. This method of scoring allows comparison between Government and non‐Government hospitals, between hospitals within the region and also between regions.

Results

The results varied greatly across the measured variables and from region to region. Overall the assessment results are poor, particularly in clinical assessment. They show that of the 82 variables measured none of the hospitals scored more than 75%. Of the 69 hospitals assessed, 42 60.9% had total scores of less than 50%. The highest scoring regions were Mwanza and Mbeya, while the lowest scoring regions were Lindi and Mtwara. Government hospitals scored lower than faith‐based hospitals in most of the areas assessed.

Emergency care, diarrhoea assessment, management of severe malnutrition and newborn care were among the worst scoring variables. Compared with the assessment of clinical conditions, HIV/AIDS testing, counselling and treatment performance were high scoring. The presence and availability of appropriate and adequate human resources scored poorly. Less than 25% of the facilities fully met the standards for qualified staff providing care to children, with over 50% of facilities partially meeting the standards.

The availability of standard treatment guidelines, essential medicines and equipment were among items assessed as part of the administration and paediatric ward assessments. Findings show a lack of adequate and updated treatment guidelines in all hospitals. The availability of essential medicines as per the Essential Medicines List was poor; with just over one third of hospitals having the medicines on the list. Less than 25% of the hospitals included in the survey had essential equipment and supplies.

Baseline Survey on Quality of Paediatric Care in Tanzania -- Page iv Recommendations

A number of recommendations were made:

• Revise and focus the National Reproductive and Child Health Strategic Plan with a priority on addressing areas that scored poorly in the survey. For example, assessment and records in emergency and paediatric wards are essential to initiate changes in paediatric quality of care. • Ensure all health facilities have updated clinical standard treatment guidelines for children and essential medicines lists, as they will strengthen the knowledge and clinical skills and hence the quality of care. • Improve the availability of essential medicines, especially emergency medicines, supplies and hospital and laboratory equipment. • Allocate trained staff in paediatrics to improve clinical assessment and diagnosis. • Implement a continuous education programme for medical staff. Training should be decentralized to the regional level to allow programmes to address the differing needs from region to region. The Paediatric Association of Tanzania should take the lead in coordinating continuous education programmes, with referral hospitals and medical teaching institutions responsible for conducting the training. • Introduce sharing‐learning sessions at the regional level for facilities to learn from each other. • Take into consideration the inadequate number of paediatricians and neonatologists. Clinical officers and midwife nurses should be allowed to train in general paediatrics and neonatology combined. This will reduce the current shortage of health workers with the necessary knowledge and skills for providing quality paediatric and newborn care at district and regional levels. • Improve the infrastructure for paediatric and neonatal wards in all hospitals by having separate outpatient and inpatient areas for children and newborns. • Strengthen monitoring, support and mentorship systems in order to achieve good quality of care. • As good quality care is costly, more Government funds should be allocated for improving the quality of care. • Increase advocacy for quality of care at all levels: policy‐makers, administrators, health workers, those in pre‐ and post‐medical training institutions and non‐health workers.

Baseline Survey on Quality of Paediatric Care in Tanzania -- Page v Conclusion

The overall performance of hospitals was poor in almost all areas. There were variations from region to region and between Government and non‐Government hospitals. Clinical assessment of children admitted to paediatric wards is very poor and is associated with misdiagnosis and inappropriate treatment.

While the child mortality rate has gone down, more effort is needed to reach Millennium Development Goal 4. Steps need to be taken nationwide to improve the situation. These measures should be based on a revived and more focused National Reproductive and Child Health Strategic Plan with priority given to those areas that scored poorly in this survey.

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1. Introduction

The United Republic of Tanzania is striving to improve the quality of its paediatric care with the aim of substantially reducing child mortality. Efforts to improve maternal, newborn and child heath service delivery have already resulted in considerable gains. Under‐five child mortality declined from 137 deaths per 1000 live births in 1996 to 81 deaths per 1000 live births in 2010.1 Tanzaniaʹs main goal is to improve the quality of paediatric care at all health facilities in an effort to reach Millennium Development Goal (MDG) 5, which calls for a reduction in the mortality of children under age 5 by 2015.

In 2006, Tanzania drew up a 10‐year plan to establish a framework for the integration of maternal, neonatal and paediatric care. In 2008 it became known as the National Reproductive and Child Health Strategic Plan (“One Plan”). In accordance with its strategy, the Ministry of Health and Social Welfare (MOHSW) is seeking to establish baseline data on quality of paediatric care that will allow better planning and more targeted interventions. The Ministry conducted an assessment of the quality of paediatric care in public and private hospitals and health centres throughout Mainland Tanzania.

Sustained availability and access to medicines suitable for children is an essential component of any strategy to improve paediatric care. In May 2007, the World Health Organization (WHO) World Health Assembly passed a resolution to strengthen and support activities to make medicines more readily available to children and to promote the development of evidence‐based treatment guidelines to ensure that drugs are used appropriately. Following this, WHO initiated the Better Medicines for Children (BMC) project in 2009, with funding from the Bill and Melinda Gates Foundation. The goal of the project is to improve access to essential medicines for children by addressing issues of availability, safety, efficacy and price.

One of the four objectives of the BMC project is to improve access to essential medicines for children in priority countries by promoting their inclusion in national essential medicines lists (EMLs), treatment guidelines and procurement schemes; working with drug regulatory authorities to expedite regulatory assessment of essential medicines for children; and

1 Tanzania Demographic and Health Survey 2009–2010. United Republic of Tanzania, 2010.

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developing measures to monitor and manage the prices of these medicines. Tanzania is one of the countries participating in the project.

This assessment will assist the projectʹs aims by indicating which hospitals and regions lack access to essential medicines for children and also lack guidelines for their appropriate use, which are important components for ensuring quality of care.

Results presented in this report cover 69 hospitals from 12 regions of Mainland Tanzania (Coast, Dodoma, Iringa, Kagera, Kigoma, Lindi, Mbeya, Morogoro, Mtwara, Mwanza, Shinyanga and Tabora). The hospitals were assessed between July 2009 and February 2010. The survey is ongoing in the remaining nine regions (Arusha, Dar es Salaam, Kilimanjaro, Manyara, Mara, Rukwa, Singida, Ruvuma and Tanga).

2. Background

The United Republic of Tanzania is a union between Tanganyika (Mainland Tanzania) and Zanzibar. Mainland Tanzania is divided into 21 administrative regions comprised of 113 districts with around 10 342 villages and 133 councils. Primary health care forms the basis of health‐care services, which have a pyramid structure. Both public and private providers work in dispensaries, health centres and at least one hospital at the district level. There are 4679 dispensaries and 481 health centres throughout the country. Notably, about 90% of the population lives within 5 kilometres of a primary health facility.

The Government owns 55 district hospitals, while 13 district hospitals are owned by faith‐ based organizations. Mainland Tanzania has 86 hospitals at first‐referral level (owned by the Government, parastatals1 and the private sector), 18 regional hospitals that function as referral hospitals for district hospitals, and eight consultancy and specialized hospitals.

Government staffing norms for health facilities exist, but are not fully met. When comparing these norms to staffing levels in all health facilities, only 35% of positions are filled by qualified health workers. This constitutes a severe human resource crisis.

2.1 Tanzania's health system

Referral pathway Tanzania has categorized health facilities into three main groups:

• dispensaries • health centres • hospitals Within the Government system, hospitals are further categorized as:

1 An organization or industry having some political authority and serving the state indirectly. (Oxford English Dictionary, 11th edition, 2009.) Also defined as: “A government‐owned corporation, state‐owned company, state‐owned entity, publicly owned corporation, government business enterprise, or parastatal is a legal entity created by a government to undertake commercial activities on behalf of an owner government.” (Wikipedia, http://en.wikipedia.org/wiki/Government‐owned_corporation.)

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• district hospital • regional hospital • national hospital • consultant or tertiary hospital • special hospital (e.g. Mirembe, Ocean Road Cancer Institute).

The referral pathway begins at the dispensary, and then leads to a health centre. Patients are referred to hospital by the health centre. In some cases, depending on the diagnosis or availability of beds a child may be referred directly to a district hospital. A child may also be referred from a district hospital directly to a consultant hospital without passing through a regional hospital. However, a dispensary must not refer beyond the district/regional hospital. As referral care must involve follow up, feedback is sent to the referring facility with clear instructions on management and the date of any follow‐up visits needed.

2.2 Quality of care in children

Generally, the quality of paediatric care has improved over the past 10‐15 years. For example, national Integrated Management of Childhood Illness (IMCI) coverage is 93.8%; measles immunization is 98.0%; and national oral rehydration treatment (ORT) coverage, 70.0%. Because of these gains, significant progress has been made in reducing child mortality, although neonatal mortality still remains high, at an average of 32 deaths per 1000 live births. This accounts for 47% of infant mortality, at a rate estimated at 68 deaths per 1000 live births.

The figure below shows trends in childhood mortality over the past 10‐15 years.

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Figure 1: Trends in early childhood mortality rates1

Red = Millennium Development Goals (MDGs) Blue = National mortality rate (NMR) Orange = Infant mortality rate (IMR) Purple = Under‐5 mortality rate (U5MR)

While overall child mortality has decreased, in hospital settings deaths among children remain unacceptably high. Seventy‐five per cent of these deaths occur within the first 48 hours of admission.

Most of these deaths are preventable and could be reduced significantly if appropriate measures were taken—including prompt referrals, appropriate assessment, treatment and care–when the patient arrives at the facility.

Studies2,3,4 have shown that about 10% of children seen at a first‐level health facility require a referral. Unfortunately, only 30% of these children are given a referral. Of those who do receive a referral, less than half are able to attend the referral appointment due to difficulty with transport, high cost, or perceptions of poor attitudes by health workers and poor quality of care.

1 Trends in early childhood mortality rates. Tanzania Demographic and Health Survey (TDHS), 2010. 2 Masanja H, de Savigny D, Smithson P, et al. Child survival gains in Tanzania: analysis of data from demographic and health surveys. The Lancet, Vol. 371, Issue 9620, 1276‐1283, 12 April 2008. 3 Tanzania Demographic and Health Survey 2010. United Republic of Tanzania. 4 Acute Paediatric Care Manual 2005. Muhimbili National Hospital, Department of Paediatrics and Child Health.

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Quality of care at the referral facility remains insufficient, with a significant number of deaths (50%) occurring within the first 24 hours of admission. Similarly, inpatient monitoring remains poor.1

• In 2007, an acute patient care (APC) concept was established at Muhimbili National Hospital (MNH) that improved paediatric quality of care. As a result, child mortality rates in general paediatric wards at MNH fell from 17% to below 10% in 2008‐2009. • In the first half of 2009, the APC concept was adapted and incorporated into the National Reproductive and Child Health Strategic Plan for implementation and supervision. • This plan was followed by training seminars for all staff—doctors and nurses—working in paediatric wards in all regional hospitals and referral hospitals (except Kilimanjaro Christian Medical Centre, but including Mnazi Mmoja Hospital in Zanzibar). • After completion of the training, both in Mainland Tanzania and Zanzibar, supportive supervision and mentorship was conducted in all 26 regional hospitals, including Mnazi Mmoja, to assess the establishment and functionality of acute paediatric units.

After national implementation, it was found that only 25% of hospitals in the area being assessed had established APC units and less than 10% were fully operational. The main reason given for poor implementation was lack of adequate staff at all facilities.

2.3 Objective of the assessment

The objective was to establish baseline data and identify strengths and weaknesses that may be used to plan interventions for improving paediatric quality of care in Tanzania. The survey is designed to assess the:

• administrative and logistic support in the provision of care for sick children; • knowledge and skills of health workers in the management of care for common childhood illnesses; • availability of essential medicines and supplies and equipment at health facilities necessary for provision of quality paediatric care.

The assessment supports the establishment of a system for improving care of children in health facilities.

1 Seven countries assessment report, IMCI baseline survey, JMP

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3. Methods

3.1 Scope of the survey

This project required continuous assessments of health facilities using adapted national assessment tools, followed by an improvement plan and evaluation. It also included supportive supervision and on‐site capacity building. The assessment, using an adapted WHO assessment tool – Assessment of the Quality of Care for Children in Hospitals – involved all systems within health facilities in all regions of Mainland Tanzania.

Areas that were assessed on the care of children under five years included: organization of health facilities; outpatient care; emergency care; emergency paediatric wards; diagnostic areas; dispensing pharmacies; kitchens; laundry facilities; and other relevant departments. Emphasis was placed on the assessment of the skills and knowledge of health workers in the management of emergencies, common clinical conditions and inpatient monitoring of seriously ill children. Newborn care was also assessed at all health facilities. The assessment covered provision of services during and after working hours, during the night, weekends and holidays. At the end of the survey, health‐facility management and staff were debriefed by assessment teams.

3.2 Performance criteria

The performance of health facilities and individual health workers was measured against agreed standards. The standards have been adapted from WHO standards of care and also took into consideration requirements and recommendations by different disease programmes. The WHO Pocket Book of Hospital Care for Children 2005 and adapted Referral Care manuals (RCMs), and the Integrated Management of Childhood Illness for High HIV Settings 2006 were used as standards for assessing case management.

3.3 Grading performance

The criteria used to grade performance were defined as the baseline for measuring the subsequent improvement of care. In addition, the performance of individual tasks was considered for provision of feedback and planning.

The tasks used as the basis for grading performance were divided into two categories.

A: Critical tasks or standards that have a strong bearing on the outcome of care of children, such as the availability of emergency drugs, failure to recognize dehydration, etc. These are identified with an asterisk in the assessment forms.

B: Essential tasks or standards. Failure to fully meet these standards or complete these tasks does not significantly impair care and is not life‐threatening, e.g. availability of culture facilities, failure to recognize skin infection, etc.

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The scoring was categorized as follows:

• STANDARD MET: All critical tasks were completed to standard. • STANDARD PARTIALLY MET: All critical tasks were completed to standard, but all or some of the essential tasks were missed. • STANDARD NOT MET: All critical and all essential tasks were not met. • The tool used during the assessment of tasks is summarized below.

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Table 1: Summary of the health facility assessment tool

Assessment area Information needed General information to be collected Types of service delivery areas Adequacy of facility and staffing Facility utilization and bed occupancy rates Morbidity and mortality Specific individual service Observe/assess activities carried out in these areas: Delivery areas Distance between services Reception Availability of essential equipment and drugs Emergency management Round‐the‐clock staff coverage Consultation room Quality of medical consultation and treatment Drug supplies and equipment Assess laboratory service provision Adequacy of: Paediatric ward Spectrum of tests performed and their quality Equipment and reagents Staff coverage Staff coverage of wards Staff knowledge about appropriate care of sick children Staff attitude Emergency treatment and procedures Presence of patient isolation areas Availability of necessary equipment and drugs Patient monitoring Feeding of severely malnourished children Role of mothers or care givers in child care Counselling mothers or care givers at time of discharge Patient follow‐up Communication with other facilities Children’s play and other stimulating facilities Adequacy of discharge procedures Newborn care Warmth and temperature control Infection prevention Nourishment and breastfeeding Resuscitation Respiratory support

3.4 Assessment teams

Eighteen people were recruited at the regional level for the assessment teams, drawn from district and regional level health facilities. Orientation of the teams was carried out by senior technical staff from a national quality improvement team. The teams, which each consisted of three people, conducted assessments in facilities other than their own. At the end of the assessment, feedback was given to health facility management and staff. Following the debriefing, the teams reconvened at the regional level to share their findings and agree on areas for improvement.

3.5 Data entry and analysis

The information obtained from the regions was sent to the Reproductive and Child Health Service (RCHS) Unit at MOHSW for data entry and analysis.

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3.6 Statistical analysis

A standard scoring system was used to assess the quality of care in different hospitals. If the facility was seen to have met the standard, it scored 3; if it partially met the standard it scored 2 and if the standard was not met, it scored 1. For statistical analysis, these scores were converted to: 0 instead of 1, 0.5 for 2 and 1 for 3 to allow the use of the statistical software SPSS version 15. The scoring was done such that, if during the assessment the facility was seen to have met the standard it scored one (1). If the standard was partially met, it scored 0.5 while if the standard was not met it scored 0. Scores were summed across the specific process, e.g. (hospital support) and also across all processes, and the summed total scores were categorized into 3 groups i.e. low (total score < 2), moderate (total score above 2 and below 4) and high quality above 4) as presented in some of the tables on performance. Cross tabulations were done by region to show any differences between hospitals in the same region and also between regions.

A further analysis of comparative performance of hospitals and regions was carried out using the ≤25 percentile as a cut‐off point for performance across all 69 hospitals in 12 regions. A score of 1 was given to the hospitals that performed ≤25 percentile. Five domains were constructed from the individual assessment items, using five key indicators that were scored and totalled.

These were:

Public health score = 7 Administration score = 11 Paediatric (children’s) ward score = 5 Clinical assessment score = 11 Treatment score = 10

Cross tabulations were done by domain to reveal the differences in performance between hospitals within the same region or in other regions and Spearman rho correlation coefficients were calculated using Stats Direct (version 2.7).

4. Results

The results present the overall performance in percentages in terms of administration, clinical assessment, paediatric (childrenʹs) ward, treatment and public health key indicators at national and regional levels. Bar chart results are presented in three colours: GREEN, meaning the standard was met, (critical and essential tasks were performed); YELLOW, the standard was partially met (all critical and some essential tasks were performed); and RED, the standard was not met (both critical and essential tasks were not performed). Detailed results for each chart are in the tables in the annexes, showing overall hospital performance by region.

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4.1 Administrative review

4.1.1 Overall performance

Sixty‐nine hospitals in 12 regions of Mainland Tanzania were assessed. There were two referral hospitals (Bugando and Mbeya), 14 private (non‐governmental), 12 regional and 41 public hospitals. Geographically, these hospitals were located all over Mainland Tanzania. Hospitals in the North Eastern Zone, however, were not assessed during the survey period (see the map above).

Findings:

Scores of the variables for individual sections were added up to establish overall scores. The total score based on 82 variables from each facility assessed, as reflected in the tables, ranged from a minimum of 14.5 (17.6%) to a maximum of 61.0 (74.3%) with one hospital scoring each extreme. None of the hospitals scored more than 61.5 (75%.) Only six hospitals scored 41 or more (≥50%) and 42 (60.9%) hospitals scored less than 41 (50%) of the total variable scores. Twenty‐one (30.4%) hospitals had missing variable values in two or more sections and they were not included in the final analysis.

Table 2: Summaries of the overall performance of hospitals, by region

REGION TOTAL SCORES (82) 100% <50% 50%+ Morogoro 5 (Berege, Kilosa, Mahenge, 1 (Morogoro) St Francis, Turiani) Iringa 3 (Iringa, Makete, Njombe) 0 Mbeya 3 (Chunya, Ileje, Kyela) 2 (Mbeya Rufaa, Mbozi) Coast 5 (Kisarawe, Mafia, 1 (Bagamoyo) Mukuranga, Tumbi, Utete) Lindi 6 (Kinyonga, Liwale, 0 Nachingwea, Nyagao, Ruangwa, Sokoine) Mtwara 4 (Ndanda, Ligula, Newala, 0 Tandahimba) Kigoma 5 (Heri Mission, Kabanga, 0 Kasulu, Kibondo, Kigoma Regional) Tabora 6 (Igunga, Kitete, Ndala, 0 Nzega, Sikonge, Urambo) Kagera 1 (Nyakahanga) 0 Shinyanga 2 (Kahama, Shinyanga) 0 Dodoma 5 (Kongwa, Kondoa, 0 Mpwapwa, Mkoani, Mvumi) Mwanza 2 (Geita, Sekotoure) 2 (Bugando, Sengerema)

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Figure 2: Hospital performance, by region

Key: Green bars show the overall number of hospitals with satisfactory performance >50%.

4.1.2 Hospital support

The assessment of hospital support involved six administrative items:

• availability of adequate and updated treatment guidelines; • performance reviews; • transport to referral; • availability of essential medicines (in the paediatric ward and the emergency area); • availability of essential laboratory tests; • availability of essential equipment and supplies.

4.1.2.1 Availability of adequate and updated treatment guidelines

Guidelines required were:

• access to a Referral Care Manual (RCM); • IMCI chart booklets and hospital pocket book; • Job Aids for children ‐ different charts, e.g. anthropometric measurement charts for interpretation, dehydration assessment charts, an algorithm for the ABC concept, a • motherʹs card for feeding a child up to 5 years of age), and the WHO Pocket Book of Hospital Care for Children guideline; • availability of standard operating procedure (SOPs) for neonates in the resuscitation area.

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These guidelines specifically recommended medicines for common illnesses including essential medicines.

Findings:

There was an alarming lack of adequate and updated treatment guidelines in all regions. Only one (1.5%) hospital—Morogoro Regional Hospital—met the standard and 25 (38%) hospitals partially met the standard. The majority of hospitals, 40 (60%) did not meet the standard. In Mtwara and Dodoma regions, none of the hospitals met the standard (score of zero) for guidelines. Among Government, non‐government and private hospitals, 60% did not have access at all to the required guidelines. Of the Government hospitals, 40% partially met the standard, as compared to non‐governmental and private hospitals where only 33% partially met the standard.

Figure 3: Summary of the availability of standard treatment guidelines in facilities, by region

Key: Green ‐ standard met; Yellow ‐ standard partially met; Red ‐ standard not met. GOVRT = Government, NOGRT =Non‐government

4.1.2.2 Performance reviews

Performance review indicators covered:

• if a database of patients existed in the hospital, including records of all paediatric deaths; • if regular mortality meetings were conducted to review paediatric deaths and if other staff meetings were held; • quality of care by reviewing staff knowledge and skills with regard to patient care (i.e. assessment, treatment, monitoring and patient flow) with relevant staff involved in the reviews.

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Findings:

Most of the hospitals did not satisfy the standards required for performance review. A total of 66 hospitals were analyzed instead of 69 as 3 hospitalsʹ data were missing from the data sheet, with no explanation given. Only six hospitals (9%) met standards for monitoring, quality of care and staff knowledge; other tasks were performed well. Of these six hospitals, two were in Mbeya region (Mbozi and Tukuyu), two in the Coast region (Bagamoyo and Utete), one in Iringa (Njombe) and one in Morogoro (Kilosa); 22 (33%) of hospitals partially met and 38 (58%) did not meet the standard.

Out of 18 NGO/private hospitals that were assessed in this category, only nine of these, 13.6% of the total number of 66 hospitals, partially met the standard. For Government facilities, 13 (19.6%) also only partially met the standard. The worst‐performing region was Shinyanga where none of the hospitals met any of the standards, whereas in Morogoro region this was the case with only one hospital.

Figure 4: Distribution of all hospitals with regard to findings on performance reviews, by region

4.1.2.3.1 Availability of medicines on the Essential Medicines List

A number of issues were assessed:

• whether the Essential Medicines List was available at health facilities; • whether essential medicines were available in the paediatric ward and emergency area and immediately accessible (a Category A critical requirement); • conditions of storage such that old stock is used first before its expiry date; • stock‐taking and supply systems were in place; • proper handling of medicines by nurses.

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Findings:

Thirty‐six percent of hospitals had medicines that were required on the Essential Medicines List. In (29) 42% of hospitals standards were not met. Morogoro, Lindi, Mtwara and Mwanza regions were a little better compared to other regions. Half of the hospitals in these regions met the standards. The worst‐performing regions were Iringa, Coast, Tabora and Shinyanga, which did not meet the Category A requirement. In regard to the availability of essential medicines, NGO/private hospitals were better off (>50%) as these hospitals had the required essential medicines; however, only 15 out of 51 (29%) of Government hospitals were satisfactory in this respect.

Figure 5: Distribution of availability of essential medicines, by region

4.1.2.3.2 Availability of emergency essential medicines and supplies

This item provided for the assessment of:

• the availability of essential medicines for emergency care (whether they were readily available). This was a Category A (critical) requirement.

Findings:

Only 19 (29%) hospitals met the standards, 33 (48%) of the hospitals failed to meet them. The worst performers were in the Iringa and Coast regions where Category A medicines and supplies were not available. Morogoro, Mbeya, Kagera and Mwanza performed much better than other regions. NGO hospitals performed a little better than public hospitals: 12 (66%) partially met the standards compared to only 22 (47%) of public hospitals.

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Figure 6: Number of hospitals with availability of essential medicines for emergency care, by region

4.1.2.4 Essential equipment and supplies

The assessment mainly focused on the availability of equipment and supplies on the essential equipment and supplies list at health facilities. The Category A (critical) requirement was for essential equipment to be safe and in working order.

Findings:

A total of 67 hospitals from 12 regions were assessed; two were dropped due to a lack of data. Fifteeen (22%) of the hospitals (public/NGO/private) had essential equipment and supplies available as per the standard. Only one of 16 (6.25%) NGO/private hospitals met the required standard for availability of essential equipment and supplies; whereas 14 out of 51 (27.5%) Government hospitals met the required standard. Half of the hospitals satisfactorily met the standard in the Mwanza and Lindi regions. However, 16 (24%) did not satisfy the standard, meaning that equipment and supplies were not adequate for children in Morogoro, Kigoma, Kagera and Dodoma.

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Figure 7: Number of hospitals with availability of essential equipment and supplies, by region

4.1.2.5 Availability of essential laboratory support for emergency care

Variables for this item were:

• the availability of emergency investigations; • timely return of results for diagnosis and treatment; • whether the cost of laboratory investigation was an impediment to the required management.

Findings:

Thirty three (49%) out of all the hospitals met the standards; the Mwanza and Mbeya regions performed the best. However, 20 (30%) of all hospitals did not meet the standards; in Mtwara, Tabora and Kagera regions, half of the hospitals failed to do so. NGO hospitals performed better in this area with 10 (56%) hospitals meeting standards as compared to only 23 (47%) of public hospitals. Five (28%) of the NGO and 10 (31%) of public hospitals did not meet the standards.

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Figure 8: Availability of essential laboratory support for emergency care, by region

4.1.2.6 Availability of essential equipment for emergency care

The survey assessed:

• the availability, safety and working order of essential equipment, including whether it was on the recommended essential equipment list for emergency care.

Findings:

The majority of hospitals (54%) did not meet the standards. Only 12 (18%) hospitals satisfied requirements: two were in Morogoro, two in Mbeya, one in the Coast region, four in Mtwara, and three in Mwanza. The Mtwara region performed well with only one hospital not meeting the standards. However, in the Iringa, Lindi, Tabora, and Dodoma regions, the majority of hospitals fell short of the standards.

For this parameter, NGO hospitals performed better than public hospitals: 22% versus 16%. Twenty‐eight (57%) public hospitals did not meet the standards, compared to only eight (44%) NGO hospitals. The same assessment tool that was used for public hospitals and for NGO hospitals.

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Figure 9: Distribution of hospitals with regard to availability of essential equipment, by region

4.1.2.7 Documentation of patient records is in place

The assessment on hospital documentation examined the following:

• the inpatient register; • patient files; • ward round books; • availability of monthly disease summary reports; • medical record keeping in general; • paediatric care (supportive care charts e.g. feeeding, medication, vital signs are recorded correctly and available); • whether information could be retrieved when needed.

Findings:

Only 25 (36%) of hospitals met required standards while nine (13%) fell below. In Tabora and Kagera regions 33.3% of the hospitals met the standard while in Lindi region none of the hospitals performed satisfactorily. With regards to the whole system for documentation of patients records, NGO hospitals performed better than public hospitals with 10 (56%) out of 18 meeting the standard, compared to only 15 (29%) out of 51 public hospitals.

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Figure 10: System for documentation of patients' records, by region

4.2 Clinical assessment

The Referral Care Manual (RCM), which is based on the Integrated Management of Childhood Illness (IMCI), was adopted by the Government in 2005. All the clinical variables that were assessed were taken from this manual, which is believed to be widely available, and implemented in all hospitals. RCM defines a framework for evaluating and improving standards of care.

4.2.1 Paediatric ward

Several important variables for quality of care were surveyed but have not been reflected in the data collected. Missing variables were: age groups admitted in paediatrics and number of staff allocated (doctors, nurses and medical attendants). In terms of patient care, these are variables that play a vital role in outcomes.

Only six variables were included in the analysis:

• location of the ward; if site easily accessible; • allocation of seriously ill children within the ward; • infection prevention and control; • accommodation for the mother/care giver; • documentation of patients; • number of trained staff.

4.2.2 Monitoring

This section focused on seriously ill children and covered four areas: receiving close attention, reassessment of admitted children, nursing care and a paediatric audit system in place. Close proximity of nursing staff to seriously ill patients may ensure that these children

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are cared for in a section where they receive close attention, and care is a Category A (critical) requirement.

From the four areas of the assessment the following variables were include in the analysis:

• proximity of seriously ill child to nursing staff; • presence of monitoring charts containing all patients’ details; • daily re‐assessment of newly admitted and seriously ill patients by both doctors and nurses; • availability of qualified nurse 24 hours a day and medicines provided according to plan; • availability of hospital paediatric care audit; • availability of all children’s files for audit and whether the information sought was used for improving quality of care.

Findings:

Almost half (49%) of the hospitals performed unsatisfactorily (standard not met) in patient monitoring. The Coast and Mtwara regions had the worst performance as no hospital met the standard. Only 22 (32%) hospitals satisfied this Category A requirement. Nearly half of these hospitals were in Morogoro, Mbeya, Dodoma and Mwanza; 11 (21%) met the standard partially and 25 (49%) did not meet the standard. Out of 69 hospitals assessed, 18 (26%) were NGO hospitals. Seven (10.1%) of NGO hospitals met the standard. Two (2.9%) partially met the standard.

4.2.3 Infection prevention and control

Infection prevention and control are important for preventing cross infection during hospitalization. Nosocomial‐acquired infections are very difficult to manage due to high antibiotic resistance. The assessment focused on staff behaviour, namely:

• hand washing before and after procedures and examinations; • ward cleanliness; • disposal of sharps in a special safety box.

Findings:

Performance was generally poor as only 30 (43%) of hospitals met standards and 46% partially met the standards. In the Lindi, Kigoma and Mwanza regions, half of the hospitals met the benchmark, whereas in Morogoro, Iringa, Coast and Shinyanga less than one third of the hospitals did so. There were poor standards of hygiene in general.

NGO/private hospitals performed better than public hospitals in infection prevention and control. While 46 (67%) of the hospitals met the standards, only 24 (35%) of the public hospitals did so.

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Figure 11: Infection control performance, by region

4.2.4 Care for children by qualified staff

Good‐quality paediatric care delivery depends on team work involving a significant number of experienced, trained staff. During this assessment attention was focused on:

• the availability of experienced medical personnel; • accessibility of doctors and nurses; • adequate staffing on all shifts.

Findings:

Less than a quarter (23%) of hospitals (both public and NGO) met the standard for the availability of qualified paediatric staff. In the Iringa and Tabora regions, half of the hospitals had qualified paediatric staff; Shinyanga, Coast and Dodoma regions had only one hospital each. Over half of the hospitals (51%) partially met the standard, whereas in Lindi, Mtwara, Kigoma and Kagera no hospitals partially met the standard.

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Figure 12: Number of hospitals with children cared for by qualified staff, by region

4.2.5 Case management

Items assessed were:

• triage staff able to implement decisions according to the guidelines when the emergency ward became busy. This was a Category A (critical) requirement; • skills for managing common emergency conditions; • whether treatment started promptly.

Findings:

Overall triage performance was very poor. More than 80% of hospitals were conducting triage that was not based on the guidelines as most staff lacked the required skills, even for common emergency conditions. Sixty‐seven hospitals were assessed; two were dropped due to lack of data. One Government hospital (1.5%) in the Tukuyu Mbeya region met the standards while 59 (88%) of hospitals did not.

4.2.5.1 Cough or difficulty breathing

Poor assessment of a child with a cough or difficulty breathing could easily lead staff to miss a diagnosis of pneumonia, which may cause death.

The following Category A (critical) variables were assessed:

• use of appropriate RCM guidelines for the assessment and classification of pneumonia and wheezing;

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• use of oxygen; appropriate antibiotics; appropriate treatment of tuberculosis; and correctly performed chest X‐ray; • adequate performance of the standards significantly improves the quality of care in this area.

Findings:

A total of seven variables were scored and one item–children in need of bronchodilators–was dropped because only a few hospitals had this information, which in itself is an indicator of problems with care. Only one hospital (1.4%) had a score of 0; i.e. standard not met due to inappropriate use of RCM.

Forty (71%) hospitals partially met the standard and seven (10.7%) met the standard. Hospitals that had missing variable values were excluded from the analysis. They were Biharamulo, Rubya and Kagera in the Kagera region, and Ludewa Hospital in Iringa region.

Figure 13: Cough or management of difficult breathing, by region

4.2.5.2 Diarrhoea

Similar methods for assessment were applied to obtain information on diarrhoea and five observations were made, two of these being children with severe malnutrition.

When not managed properly, diarrhoea can lead to dehydration and cause death. In order to assess the proper management of diarrhoea the following variables were evaluated in the following areas:

1. Assessment of dehydration: • was a correct assessment of dehydration carried out (IMCI) (this was a Category A critical requirement);

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• was a correct assessment of dehydration in children with severe malnutrition carried out; • were infants properly assessed for dysentery, persistent diarrhoea and severe malnutrition.

2. Management according to rehydration plan: • was there a correct treatment plan based on the assessment of dehydration (Category A) and fluid therapy; • were dehydration and shock appropriately assessed and managed; • was there an appropriate treatment plan for each patient; • were signs of dehydration monitored during rehydration.

3. Use of antibiotics and zinc: • were antibiotics, particularly for dysentery and cholera, used appropriately; • use of zinc for patients with acute and persistent diarrhoea; • feeding during diarrhoea (continued breast milk); • no use of anti‐diarrhoea medicines.

Findings:

Six variables were scored and overall performance was very poor as Category A standards were not met in most hospitals. Only 3 (4.3%) hospitals met the standard; 17( 24.6%) hospitals partially met the standard; and the majority 45 (65.2%) of the hospitals did not meet the standard. Four hospitals, (Kilolo, Biharamlo, Mpwapwa and Mvumi) had missing variable values for this area of the assessment.

Figure 14: Management of diarrhoea, by region

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4.2.5.3 Management of fever

Children presenting with fever have differential diagnoses and a thorough assessment is recommended.

The checklist for assessment of management of fever had four components; differential diagnosis of fever, and diagnosis and management of severe malaria, meningitis and measles.

The variables scored were:

• differential diagnosis of fever was properly carried out if children admitted with fever had a differential diagnosis for possible and likely conditions considered. Appropriate investigations were undertaken to establish a diagnosis; • if diagnosis of severe malaria was confirmed by laboratory investigations and if its treatment and associated complications (hypoglycaemia/convulsions) were managed as per guidelines (Category A critical requirement); • meningitis was ruled out if a lumbar puncture was performed, antibiotics were given immediately and proper monitoring was begun (Category A); • measles was ruled out after a proper assessment for complications, whether Vitamin A was given and patients were adequately fed; and whether appropriate investigations were taken.

Findings:

Overall, performance was poor with the majority 36 (52.2%) of hospitals not meeting the standard, as all Category A variables were missed. Nineteen (27.5%) hospitals partially met the standard, and four (5.8%) hospitals met the standard.

Nine (13.0%) hospitals, of which 6 (Biharamulo, Kagera, Mugana, Murgwa, Nyakahanga and Rubiya) were in the Kagera region, Ludewa in the Iringa region, Bukombe in the Shinyanga region and Nansio in the Mwanza region, had missing variable values so their scores could not be calculated.

4.2.5.4 Management of severe malnutrition

Children with severe malnutrition are often admitted to hospital and death rates during treatment (30‐50%) are high. This is as a result of poor treatment practices, lack of clinical guidelines and an inadequate number of qualified staff. Seven variables were scored:

• assessment of Category A (critical) nutritional status in all children by taking anthropometric measurement (length/height, weight); • correct interpretation of anthropometric measurements (Category A requirement);

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• appropriate treatment of infections; eye care and immunization; • management of severe anaemia and cardiac failure; • proper psychosocial stimulation; • checking for hypoglycaemia and hypothermia; • feeding and distribution of micronutrients and electrolytes.

Findings:

Overall performance of all hospitals was very poor as with other common clinical conditions. Thirteen hospitals (18.8%) failed to improve the nutritional status of patients. In most of the hospitals length/height or weight were measured but the results could not be interpreted due to lack of clinical guidelines and interpretation charts.

Checking for hypoglycaemia was impossible in most hospitals (>85%) due to lack of glucometers and strips. Proper monitoring was not done due to lack of monitoring charts and SOPs. Feeding was poor as calorie requirements were not met and there was a lack of ingredients for micronutrients. With such findings in 60 (87%) of hospitals the standard was not met, in 4 (5.8%) hospitals it was partially met and in 2 (2.9%) the standard was met. Three (4.3%) hospitals (Biharamulo and Rubya in the Kagera region and Nansio in Mwanza) had missing variable values (see Table 14).

4.2.2. HIV/AIDS management

HIV/AIDS management covers several areas but this section of the assessment mainly focuses on appropriate counselling and HIV testing, treatment and integration of care and treatment.

From this section, three tasks were scored as follows:

4.2.2.1 HIV testing and counselling when appropriate that focused on whether: all sick children assessed for possible HIV and AIDS, including early diagnosis; clinical signs of possible HIV infection identified according to the IMCI algorithm; HIV pre‐ and post‐counselling provided to parents/care takers and family.

4.2.2.2 Appropriate treatment of HIV and related conditions opportunistic infections were diagnosed and appropriately treated; prophylaxis of PCP given to all HIV infected children; immunization given according to expanded programmes for immunization; regular clinical follow up provided, and palliative and home care.

4.2.2.3 Integration of HIV care and treatment into general hospital services the assessment mainly looked at if there was continuum of care between the different levels of care, and at the existence of links between paediatric services.

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Findings:

In comparison to the other clinical conditions, HIV/AIDS overall performance was high. Only the Tabora and Lindi regions had poor performance, with Dodoma and Mwanza regions the top performers. Of the 69 hospitals, 21 (30.4%) hospitals met the standard, 29 (42.0%) hospitals partially met and only 18 (26.1%) hospitals did not meet the standard. One (1.5%) had missing variables and was not included in the analysis.

Figure 15: Hospital performance scores, by region

4.2.2.6 Supportive care

The section covers topics which were applicable to children with different diagnoses and looked at patient’s nutritional needs and promotion of breastfeeding.

The nutritional needs of patients were scored using the following variables:

• nutritional needs of all patients satisfied, according to age and ability to feed; • children less than six months old exclusively breastfed at least 10 times in 24 hours; • appropriate complementary feeding offered according to IMCI guidelines; • children two years and older offered meals three times a day and nutritious snacks twice a day; • nasogastric tube feeding is provided for seriously ill children unable to be fed orally, and IV‐glucose is not used as a source of calories for more than 24 hours; • the Category A requirement was for breastfed infants to continue to receive breast milk up to two years of age.

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The variables used for the promotion of breastfeeding were:

• all mothers of children two years or younger encouraged and helped to breastfeed (Category A requirement); • expressed breast milk given with a cup or through a nasogastric tube when the child is unable to suck; • bottle feeding and teats (pacifiers) not allowed and the hospital is certified baby friendly by the Ministry of Health.

Findings:

Sixty‐eight hospitals were assessed and one hospital had missing variables. Only 8 (11.8%) met the standards, 53 (76.8%) hospitals partially met and 7 (10.1%) did not meet the standards.

4.2.2.7 Mother/care taker and child-friendly services

Mother/care taker and child‐friendly services are important components of good quality patient care. For the assessment five areas were considered: motherʹs participation in childʹs hygiene regimen, availability of information and counselling, access to food for the mother, avoidance of unnecessary, painful procedures and child stimulation. From the five areas that were assessed the following variables were scored:

• the mother/care taker allowed to stay with the sick child at all times during hospital stay; • presence of rooming‐in (newborn were not admitted to the neonatal ward but stayed with their mother); • the participation of mothers/care givers in their child’s hygiene regimen; • availability of information to support mothers/care givers, focusing on care of the child during the hospital stay; • access to food for every mother/care giver staying with the patient; • unnecessary, painful procedures avoided; children able to feed are unnecessarily given parenteral (IM) medicines, children on 6 or 8 hourly parenteral medication receiving drugs through the IV route; • child sensory stimulation achieved by providing a paediatric care environment (toys and books) for the children admitted.

Findings:

Out of 69 hospitals, 68 hospitals were assessed and one hospital had missing variables and was not included in the analysis. Of the 68 hospitals, 2 (2.9%) hospitals met the standard, 38 (55.1%) hospitals partially met the standard and in 29 (42.0%) hospitals the standard was not met.

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4.2.2.8 Assessment for counselling

Proper communication is another essential element for quality patient care and is achieved mainly through proper counselling. Five areas were assessed related to proper counselling: the key elements of good counselling, availability and use of a mother’s card, provision of counselling on nutrition and home treatment, and counselling for the mother about her own health.

From the assessed areas, the following variables were used:

• if key elements of good counselling (listening, praise, advice and understanding) were applied; • the availability of an appropriate mother’s card and its use (e.g. the number of feeds per day, type of foods recommended and ways of feeding, whether breast, spoon or cup fed); • nutritional counselling was provided according to appropriate feeding recommendations after identification of feeding/breastfeeding problems; • provision of home‐treatment counselling, focusing on appropriate explanation of how to give treatment at home; • mother’s own health assessed, treatment provided and follow up arranged when the mother was sick, and her immunization was assessed; • if mother had access to family planning and was explained the available options, as well as receiving appropriate counselling on prevention of STI and HIV.

Findings:

In total 68 hospitals were analyzed and one hospital had missing variable values. Only 2 (2.9%) hospitals met the standard, 37 (53.6%) hospitals partially met the standard and 29 (42%) hospitals failed to meet the standard.

4.2.2.9 Discharge and follow-up

Good quality patient care includes continuum of care, taking into account the correct timing of discharge from hospital and proper follow up. Four tasks were scored: appropriate discharge process and criteria; mother/care giver given appropriate information; immunization checked; and appropriate arrangements made for follow up. Specific variables for each task were assessed: if feedback discharge form was written for the health facility which referred the sick children, explaining their condition and giving other information for the staff; checked if the mother was informed about the condition of the child, about feeding and danger signs and when to return immediately to the hospital; if immunization status checked before discharged and missing immunization given.

For the follow up, appropriate arrangements were made if:

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• follow up arranged at the same health facility that admitted the patient or the one closest to the patientʹs home within an agreed period depending on the diagnosis e.g. for anaemia within 2 weeks; • if children with disability given support by the facility or linking the child to other support organizations.

Findings:

The majority 46 (66.7%) hospitals from this section of the assessment did not meet the standard, 17 (24.6%) hospitals partially met the standard and only a small portion 5 (7.2%) hospitals met the standard. Sixty‐eight hospitals were scored and analyzed and one hospital had missing values so its score could not be calculated.

Figure 16: Performance scores on discharge and followup, by region

** Dodoma region scored zero (0) as none of the hospitals scored a point

5. Newborn care

Newborn care is one of the components of child health interventions. However, there is lack of integration of continuum of care through child health programmes e.g., IMCI and the Expanded Programme on Immunization (EPI) that do not cover newborn care in the first week of life.

• newborn care assessment is necessary to identify challenges or gaps that should be addressed in order to improve quality of care for the newborn in Tanzania. Three main tasks were focused on: the infrastructure, staffing and care both in the delivery room and on the ward.

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5.1 Delivery room/ward (nursery)

For the delivery room assessment the focus was on the availability of senior and other staff and other people such as nurse assistants who conducted delivery. In order to obtain a picture of the situation in the delivery room, the following were assessed:

• staffing during all shifts (number of staff by qualification); • medical staff (doctors, assistant medical officer AMO), clinical officer(CO), nurses, medical attendants) conducting delivery; • weekend staff coverage; • means of communication if senior staff are not available (such as telephone, sending a driver, watchman or medical attendant to call them.)

Findings:

Overall performance was very poor owing to poor staffing both in number and qualification. Only 5 (7.2%) hospitals met the standard, 53 (76.8%) hospitals partially met the standard and 10 (14.5%) did not meet the standard. Biharamulo Hospital (Kagera region) had data missing and hence was excluded from analysis.

5.2 Delivery of newborn care

The information sought focused on the delivery of a baby and the SOPs during the labour period and immediately after delivery. Therefore neonatal resuscitation, promotion of early breastfeeding and bonding, thermal control, clean delivery and newborn care and prophylaxis were the main areas assessed.

5.2.1 The neonatal resuscitation variables scored were:

• if resuscitation procedures correctly performed; • the availability and use of SOPs and clinical guidelines; • application of proper procedures according to clinical guidelines; • the availability and use of self‐inflating bags and appropriate masks for premature infants; • if warmth was observed maintained during resuscitation and care (thermal control).

5.2.2 For promotion of early breastfeeding and bonding the variables were:

• if a newborn had contact with mother immediately after birth; • early initiation of breastfeeding; • counselling of mothers on breastfeeding.

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5.2.3 Clean delivery and newborn care variables were:

• if clean and safe delivery procedures observed; • if sterile instruments were used; • if aseptic procedures were used for cord tying.

5.2.4 Prophylaxis variables were:

• if immunizations started according to EPI; • vitamin K was given; • routine eye prophylaxis; • appropriate antiretrovirals given to HIV‐exposed babies according to recommendations.

Findings:

Similar poor performance was also seen in this area as 35 hospitals (50.7%) did not meet the standard, 23 (33.3%) hospitals partially met the standard and only 5 (7.2%) of hospitals met the standard. Six (8.8%) hospitals had missing values and were not included in the analysis.

5.3 Sick newborn/neonate care

This section on the case management of sick newborn care in the ward focused on neonatal sepsis to find out if newborn babies were appropriately assessed, diagnosed and treated according to guidelines. The feeding guidelines of sick infants and those with low birth weight were followed.

This section also assessed if feeding and care of HIV‐exposed newborn, and nevirapine/ARV prophylaxis were given according to the Preventing Mother to Child Transmission (PMTCT) protocol and if counselling was provided.

Variables assessed were:

• neonatal sepsis suspected in young infants ‐ if diagnosis made was based on history, physical examination and laboratory investigations; • appropriate antibiotics given according to weight; • regular monitoring for treatment response and changes in condition; • availability of policy and guidelines on feeding low birth weight babies.

Findings:

Four variables were scored under this section; care of HIV was not included as during the survey period the service had not been established in most of the facilities. Sixty‐three hospitals were assessed, and six hospitals all in the Dodoma region (Dodoma Regional Kongwa, Kondoa, Mkoani, Mpwapwa and Mvumi) and Nansio Hospital in the Mwanza region had missing data so their scores could not be analysed. Fifty‐seven (82.6%) had not

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met the standard; while 4 (5.8%) partially met the standard and only one (1.4%) hospital met the standard.

6. Further data analysis of the survey findings

From the initial data analysis results, it was noted that a considerable number of variables were missing, for a variety of reasons, in almost all sections of the assessment. Therefore, in order to verify the initial findings, further analysis was needed using the ≤ 25 percentile as a reference cut‐off point of performance. Considering the most common variables that were scored in each section previously, five domains were identified each with five key indicators (relevant variables). The least scored variables, i.e. in only a few hospitals or missed variables, were not included in this assessment. The five domains identified for the final assessment score were: a) Public health (PH) • Promotion of breastfeeding. • Hygiene for mothers and children. • Vaccinations; immunization checked before discharge. • Appropriate care‐seeking by parents/care givers. • Nutrition; needs of all children admitted provided according to their condition. b) Administration (A) • Guidelines: availability of adequate and updated guidelines. • Proper triage: triage is performed in a systematic way. • Medical records: system for documentation of patient’s record, audit system. • Discharge and appropriate follow up. • Staffing: care of children by qualified staff. c) Children’s (paediatric) ward (CW) • Infection prevention and control. • Clean deliveries/unnecessary, painful procedures avoided. • Closest attention given to the most seriously ill/reassessed patients by both doctors and nurses. • Availability of essential laboratory tests/equipment. • Availability of essential medicines for children.

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d) Clinical assessment (A) • Malnutrition: whether severely malnourished children are properly assessed, rehydrated and monitored for hypoglycemia/hypothermia. If micronutrients and electrolytes are managed properly. • Cough/difficulty breathing: whether pneumonia is correctly assessed, classified and diagnosed. • Dehydration: whether dehydration is correctly assessed and the patient is rehydrated according to Rx Plan A, B or C. • Meningitis: whether meningitis is correctly assessed diagnosed and treated. • Fever: whether the differential diagnosis for severe malaria/complications and measles were done correctly according to clinical guidelines. e) Treatment (T) • Pneumonia: whether appropriate antibiotics are given (recommended, correct dose, route and duration). • Tuberculosis: whether appropriate anti‐TB treatment is given and a chest x‐ ray done. • Diarrhoea: whether zinc is given to all children with diarrhoea and if antibiotics are given properly. • Malnutrition: whether appropriate feeding (F75,F100, NFUT) is administered, and proper psychosocial stimulation given.

Results: By scoring the key indicators in each domain, 10 regions met the cut‐off point of ≤ 25 percentile see the table below.

Table 2: The total number of scores uses a cut-off point of below or equal to the ≤25 percentile level by region

Kagera Shinyanga Iringa Morogoro Coast Lindi Mtwara Kagera Dodoma Mwanza Mbeya 7/30 9/30 9/30 11/30 13/30 5/30 5/25 7/30 8/30 20/30 14/30

The highest scoring region was Mwanza 20/30 (66.6%), followed by Mbeya 14/30 (46.7%). The lowest scoring regions were Lindi with 5/30 (16.7%) and Mtwara 5/25 (20.0%).

Following the statistical analysis results, the Public Health domain score (17) was generally lower than the other scores with a mean difference from Clinical Assessment domain score = 3.72 that was statistically significant (P < 0.0001).

The Clinical Assessment domain scores (40) were higher than the Administration scores (19) (mean difference = 1.00, ( P = 0.0003) and Treatment scores (22) (mean difference = 0.9, (P = 0.0021) and all being statistically significant too.

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There were only weak correlations among the scores and the only statistically significant correlation was between Clinical Assessment and Treatment (Spearman’s rank correlation coefficient, or Spearman’s rho = 0.29, P = 0.018).

Findings (see Tables 2 and 3):

The highest scoring hospitals of all the five domains were two (2.9%) from Mwanza Region (Bugando and Sumvue) and five (7.2%) hospitals scored 4 domains. These were from Dodoma region (Kongwa), Coast region (Bagamoyo), Mwanza region (Sengerema), Mbeya region (Tukuyu) and Shinyanga region (Bukombe). Scores of 5 and 4 were graded as very good and good performance, respectively.

Eight (11.6%) hospitals scored 3 domains. These were from Iringa region (Makete and Mufindi), Morogoro region (Berega and Morogoro Municipal), Mwanza region (Geita) and Mbeya region (Mbeya Referral and Mbozi,) and Tabora (Ndala); all graded as having satisfactory performance.

The scoring of both 4 and 3 domains were not identical as their key indicators of each domain scored were different. This is a very important point to be taken into consideration during planning or when choosing the priorities for implementation. The majority, 54 (78.3%) of the hospitals had between zero and two domains, meaning their performance was poor (standard not met).

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Table 3: Summary of types of domain scored by each hospital in a region

Region Hospital No of Type domain Grade Un der score d doma in Name domain scored (INTERV)

Kagera 1 . Nyanyahanga 2 PHS/TS US ALL 2. Rubiya 2 CWS/TS US ALL 3. Mugana 0 0 P ALL

Sh inyang a 1 . Bukombe 4 CAS/PHS/AS/TS G CWS 2. Kahama 0 0 P ALL 3. Bariadi 0 o p ALL Iringa 1. Ma k e te 3 CAS/AS/TS S PHS/CW S 2. Mufindi 3 PHS/AS/TS S CA/CWS 3. Ludewa 0 0 P ALL 4. Njo m be o 0 p ALL Morogoro 1. Berega 3 CAS/AS/CWS S PHS/TS 2. Mo r o Mu nic ipal 3 CAS/AS/TS S PSH/CW S 3. Ma he nge 0 0 P ALL Lindi 1. Ny a gao 2 AS/CWS P CAS/PHS/TS 2. Kinyon ga 0 0 P ALL 3. Na chingwea 0 0 p ALL

Coast 1. Bagamoyo 4 CAS/PHS/AS/C G TS 2. Ma fia 1 WS P CAS/PHS/CWS/TS 3. Mk ur anga 1 AS P CAS/PHS/CWS/TS AS Mtwara 1. Ndanda 2 PHS/CWS P CAS/AS/TS 2. Newala 0 0 p ALL Dodoma 1. Kon gwa 4 CAS /AS/PHS/C G TS 2. Pwapwa o WS p ALL 0 Ki goma 1. Herri Mission 2 CAS/AS P PHS/CW S/TS 2. Kabanga 2 AS/CAS P PHS/CW S/TS 3. Kasulu 0 o p ALL Mwanza 1. Bugando 5 CAS/PHS/AS/C VG None WS/TS 2. Sumve 5 CAS/PSH/AS/C VG None WS 3. Seng erema 4 G CWS CAS/PHS/AS/TS 4. Geita 3 S AS/CWS CAS/PHS/TS 5. Sekoutoure 1 P CAS/AS/PHS/TS CWS Mbeya 1. Tukuyu 4 CAS/AS/CWS/T G PHS 2. Mbeya Referral 3 S S TS/PHS 3. Mbo z i 3 CAS/AS/CWS S TS/PHS 4. Kyela 3 CAS/AS/CWS S CAS/CWS 5. Ileje 1 PHS/AS/TS P CAS/PHS/CWS/TS AS Tabora 1. Nda la 3 CAS/AS/TS S PHS/CW S 2. Sikonge 0 0 p ALL

Key: VG = Very good; G = Good; S = Satisfactory, US = Unsatisfactory, and P = Poor. VG = scored all domains; G = scored four domains; S = scored three domains; US = scored two domains; and P = scored nothing.

The last column indicates the gaps of domains that require intervention. ALL means the five domains have not met the standard (unsatisfactory performance).

Table 4 further summarizes the overall performance of different variables in the areas assessed, using the key indicators scored from each per section. Red means that the standard was not met and green means that the standard was met. Most clinical variables were scored low (red) indicating poor performance.

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Table 4: THE OVERALL GENERAL PERFORMANCE OF ALL HEALTH FACILITIES WITH SCORES FOR KEY INDICATORS IN PERCENTAGES

%Score of %score of 1 3 AREA ASSESSED INDICATORS (Did not (Met meet standard standard) fully) Update guidelines 3 58 Performance reviews 9 55 Transport referrals 62 19 Essential medicines available 35 39 Essential laboratory test available 56 16 Essential equipment and supplies 19 22

1. ADMINISTRATION Qualified staff 28 19

Department layout 9 86 Essential medicines available 26 46 Essential laboratory support available 48 28 Systemic triage performed 3 84

2. EMERGENCY ENT DEPARTM Management follows Referral Care Manual 1 83

3.1.Administration Separate paediatric ward 56 13 Most attention to seriously ill 33 48 Infection prevention and control 43 12 Rooming in 68 3 Patient record in place 39 12 Audit in place 6 67 3.2 Case management 3.2.1. Pnuemonia Pneumonia severity assessed Pneumonia severity classified 74 17 Oxygen correctly given 62 19 Antibiotics 49 20 TB treatment 13 68 Chest X ray taken when needed 26 56 3. CLINICAL 3.2.2. Diarrhoea Dehydration correctly assessed 64 19 Correct rehydration plan 65 16 Rehydration modified for SAM 77 6 Antibiotic given correctly 62 19 Zinc suppl 68 13 3.2.3. Fever Differential diagnosis done 9 49 Severe malaria 30 33 Measles 32 30 Meningitis 25 41 3.2.4. Malnutrition Nutritional status correctly assessed 86 6 Hypoglycaemia 42 7 Antibiotics prescribed correctly 35 23 Vitamin supplementation 67 3 Appropriate feeding 81 1 3.2.5. HIV Counselling and testing 35 43 Treatment 58 22 All children fed 13 49 Mothers participate in care 65 6 Mothers informed of care 25 20

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%Score of %Score of 1 3 (Did not AREA ASSESSED INDICATORS (Met meet standard standard) fully) 3.2.6. Policy Reassessment by doctor after admin 42 19 Nurse monitoring 22 16 Auditing 6 33 Information of care 23 22 Immunization checked 32 38 Follow-up 49 14 Minimize painful procedures 45 20 Child stimulation 3 81

New-born resuscitation 26 33 Early breastfeeding 70 7 Thermal protection 14 43 Clean deliveries 77 1 Prophylaxis 36 9 Newborn treated 19 29 Feeding of sick and LBW 26 32 Jaundice HIV exposed 42 30

4. New-born Care Neonatal sepsis diagnosis 13 32

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7. Discussion

Improving patient care in hospitals is a complex and continuous multidimensional task. The delivery of patient care involves many systems working closely together. This assessment focused mainly on hospital support systems: health facility infrastructures, administration, information [statistics], medicines, supplies, laboratories and equipment, human resources; and hospital clinical systems including performance, clinical assessment, and treatment and care of common childhood illnesses (e.g. pneumonia, tuberculosis, diarrhoea, fever conditions, malnutrition, HIV/AIDS and neonatal care). All of these elements are essential to make the ʺwheelʺ of good quality of care rotate effectively. At the same time, it was also important to assess the quality of supportive care, counselling, monitoring and discharge, so as to complete the cycle of effectiveness in quality care.

The overall findings of this assessment show that performance in most hospitals is poor, especially in the area of clinical assessment, where the scores are even worse than non‐ clinical areas. Although in general performance is poor, there are regions, such as Mwanza and Mbeya, where most of the hospitals performed well. Some hospitals, such as Morogoro Regional Hospital and Bagamoyo District Hospital in the Coast region, also did better than others.

Better performance may be due to a number of reasons; one of them is financial support from external sources. For example, this is often seen in the Mwanza region where all the better‐ performing hospitals are supported by faith‐based organizations that are also subsidized by the Government. Additional support comes from medical teaching institutions that contribute research resources and hospital equipment, and create and provide training for hospital staff, so improving the quality of care. Bugando Referral Hospital in Mwanza region, Bagamoyo District Hospital in the Coast region and Mbeya Referral Hospital are good examples that benefit from this type of support.

Better service and patient management is reflected in those hospitals scoring ≥50% and where Clinical Assessment domain scores were higher than Administration scores (mean difference = 1.00, P = 0.0003) and Treatment scores (mean difference = 0.9, P = 0.0021) respectively. Similarly, those hospitals that performed well in the Administrative domain most likely had better monitoring and supervision systems in place compared to those hospitals that performed poorly. Most of the poor performing hospitals were the Government hospitals, due to their huge workload and understaffing, e.g., Sekoutoure Hospital in the Mwanza region.

The overall general performance of the facilities, presented by the use of key indicators in the assessed areas, showed that most indicators fully met the standard. However, although the standard was fully met, the majority of the indicators scored below 50% and there were only a few indictors that scored 50% or above.

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Performance in terms of infection prevention and control was one of the poorest as only 12% of the hospitals met the standard. Lack of sufficient water supply, disinfectants, protective gear and poor sanitation systems in all the low scoring facilities resulted in poor performance outcomes. In some of the hospitals, the hospital waste disposal systems were still not functioning properly.

Hand hygiene among health workers was also poorly practiced across the hospitals in the regions ‐ again justified using similar reasons of insufficient water supply and disinfectants. Apart from the lack of an adequate water supply, health workersʹ attitudes to hand hygiene could also have played a significant role in the poor performance ratings reflected in the assessment.

Clinical case management of common illnesses like pneumonia, diarrhoea, fever diagnosis, malnutrition, TB and HIV were also assessed and the general picture of hospitals’ performance was again poor in most regions. Only 19% of the hospitals met the standard on correctly assessing dehydration and administering antibiotics during diarrhoea. Sixteen percent of the hospitals correctly used the treatment plan for dehydration, but only 6% gave ResoMal for severe acute malnutrition (SAM) with diarrhoea, correctly.

These findings show that the majority (more than 80%) of hospitals performed badly, by missing critical as well as essential tasks. This was particularly the case in all the non‐ teaching hospitals with unsatisfactory performance.

The lack of clinical guideline use in non‐teaching hospitals compared to teaching hospitals (e.g. Bagamoyo, Coast region) probably contributed to the inadequate knowledge and skills related to diarrhoea among working staff. This led to incorrect assessment, diagnosis and treatment. Furthermore, the shortage of staff was one of the factors that directly increased the workload among working staff resulting in poor performance.

Malnutrition was another poorly performing area in which only a few (6%) hospitals met the standard on correct assessment of nutritional status, hypoglycaemia (7%) and appropriate feeding (1%). The reasons were similar to those for diarrhoea, with the lack of relevant guidelines and SOPs contributing to inadequate knowledge on malnutrition, and the shortage of qualified staff among the reasons contributing to poor performance.

In particular, appropriate feeding was impossible in most hospitals because the recommended treatment diets were not available. ResoMal, Plumpy’nut, F75, and F100 supplies are provided by the UNICEF Country Office, but the distribution of these supplies is left to the Government and governmental institutions. The failure of logistics in distribution was complicated even more by the lack of information on the requirements for diets and the lack of data on SAM sent from facilities to the UNICEF Country Office, so that supply needs remained unknown. Even when the data were available in the health facilities, there was still lack of knowledge and skills among health workers about the preparation and storage of F75 and F100 formulas. Using locally available cow’s milk and proper ingredients (maize or rice flour, groundnuts, amylasee‐rich flour and vegetable oil) as an alternative to commercial formulas was impossible due to staffʹs lack of skills and knowledge about the desired preparation. For these reasons 99% of hospitals did not meet the standard on feeding in cases of malnutrition.

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Only a small percentage (17%) of hospitals met the standard for assessment and classification of cough or difficulty in breathing (19%), and 20% of the hospitals administered antibiotics correctly. This corresponds to similarly low scores in the percentage of key indicators from this area on correct assessment and classification of pneumonia. Lack of better critical tasks performance due to a lack of guidelines, medicines and supplies e.g., availability of oxygen, equipment and qualified staff are the major factors in this area contributing to poor performance of incorrect assessment, diagnosis and treatment.

Knowing the dangers of pneumonia, it is absolute necessary to take this information seriously and provide all our efforts to improve on case management of pneumonia as number one priority.

As for tuberculosis (TB) treatment, 68% of hospitals fully met the standard, while 13% of them did not meet the standard on proper providing of anti‐TB treatment. 49% and 43% respectively of the hospitals met the standard fully for malaria and HIV/AIDS management having slightly poor performance comparatively to tuberculosis but better as compared to diarrhoea, malnutrion and pneumonia.

TB, malaria and HIV/AIDS exist as vertical programmes in Tanzania, that are fully funded by donors and have the capability of implementing their programmes, conducting continuous education, providing close supervision, and using their existing national clinical guidelines correctly. All of these contribute to better performance in these areas compared to others without such support. Although their performance is better it could be improved even further. For example, to address the lack of adequate staffing, integrating these programmes into other ʺnormalʺ services in the hospitals will significantly improve the staffing in all areas.

If we expect to reach the MDG targets by 2015, then care for newborns needs to be taken seriously as a first priority. Based on this assessment, the number of hospitals not meeting the required standards was significant and this requires immediate attention. Less than 40% of hospitals performed to the standard expected for newborn care. In most areas assessed the standards were not met; e.g. the delivery rooms were small and congested due to the high number of deliveries, making it difficult to clean the rooms properly. The lack of qualified staff made it impossible to work effectively because of the enormous workload. As a result it becomes hard to achieve high quality care of the newborn.

Having separate delivery rooms and neonatal wards is the only correct option for improving the performance of hospitals in this area and should be a priority, despite being costly. This will eventually reduce the congestion (overcrowding), make early breastfeeding initiation easier and reduce the rate of cross infections. Similarly, emphasis on neonatal resuscitation, diagnosis and sepsis treatment must be strengthened at the same time. In addition, addressing the challenges of insufficient funding, lack of appropriate, trained staff (doctors and nurses), providing continuing education on newborn care, guidelines, and medicines and supplies will be significant moves in the right direction for improving newborn care.

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7.1 Conclusion

Currently, the mortality trend in under‐fives has dropped, but based on the poor performance ratings of the assessment, there is still much to be done in all sections in general, and in newborn care in particular. The Government needs to make a serious effort to implement recommendations at the regional and national levels if Tanzania intends to meet the MDGs by 2015.

8. Recommendations at regional level

It is not possible from this report to draw up realistic recommendations to cover all the 12 regions because the general performance in individual regions varies greatly. Even hospitals within the same region vary, in terms of performance. Priorities will differ for hospitals in regions that performed better than their counterparts in other regions that performed poorly in some or all areas of quality of care.

Therefore, each region must plan independently depending on their performance rating. This will determine their choice of priorities and how they incorporate recommendations being made at the national level.

9. Recommendations at national level

A more focused strategic plan is needed with a priority on poor performing areas nationwide. Improved assessment through strengthening Emergency Triage, Assessment and Treatment (ETAT) and records at emergency and children’s wards are essential starting points to initiate change.

Availability of updated clinical standard treatment guidelines for children and essential medicines and supplies at all health facilities needs to be given priority as this will strengthen clinical skills and hence the quality of care.

Allocation of adequately trained staff in paediatric care is essential in order to improve clinical assessment and diagnosis.

Continuing education programmes for medical staff are needed. These should be decentralized to the regional level in order to identify priority areas within individual regions as performance in one region often differs from that in another. Referral hospitals and teaching institutions should take the responsibility for training. The Paediatrics Association Tanzania (PAT) should take a lead in coordinating continuing education programmes.

Learning sessions should be introduced at regional/zone level so that facilities can learn from each other.

The lack of adequate paediatricians and neonatologists should be addressed. Clinical officers and midwife nurses’ should be allowed to train in general paediatrics and neonatology combined. This will reduce the current shortage of health workers with the necessary

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knowledge and skills to provide quality paediatric and newborn care at district and regional levels.

There is a need to improve the infrastructures for both paediatric and neonatal wards in all hospitals by having separate OPD and IPD for children and new rooms/wards.

It is important to strengthen the current monitoring, support and mentoring systems in order to achieve good quality of care.

Good quality of patient care is costly and the Government needs to allocate more funds.

Advocacy on quality of patient care, as a continuous process, should be stressed at all levels from policy‐makers and administrators to health workers, pre‐ and post‐medical training institutions, and non‐health workers.

10. References

1. The National Road Map Strategic Plan to Accelerate Reduction of Maternal, Newborn and Child Deaths in Tanzania 2008‐2015. Dar es Salaam, Ministry of Health and Social Welfare, April 2008. 2. Assessment Tool for the Quality of Paediatric Care in Health Facilities, Ministry of Health and Social Welfare, November 2008. 3. Annual Reports, Acute Patients Care Unit, Muhimbili National Hospital, Department of Paediatrics and Child Health. (Unpublished reports 08/2009). 4. Masanja H, de Savigny D, Smithson P et al. Child Survival Gains in Tanzania: Analysis of Data from Demographic and Health Surveys. Lancet, Vol. 371, Issue 9620, 1276‐1283, 12 April 2008. 5. http://www.who.int/child_adolescent_health/en/ WHO Child and Adolescent Health and Development web site. 6. National Bureau of Statistics United Republic of Tanzania DHS Tanzania (2004‐ 2006). 7. Bryce J, Victoria CG, Habcht JP, Vaughan JP , Black RE et al. The Multi‐Country Evaluation of Integrated Management of Childhood Illness Strategy: Lessons for the Evaluation of Public Health Interventions. Am J Public Health, 94(3):406‐15, March 2004.

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11. Annexes: Tables showing the overall hospital performance by region

Table 1: OVERALL PERFORMANCE OF HOSPITALS, BY REGION

REGION SCORES TOTAL <50% 50%+ Morogoro 5 (Berege, Kilosa, Mahenge, 1 (Morogoro) 6 St Francis, Turiani) Iringa 3 (Iringa, Makete, Njombe) 0 3 Mbeya 3 (Chunya, Ileje, Kyela) 2 (Mbeya Rufaa, Mbozi) 5 Coast 5 (Kisarawe, Mafia, Mkuranga, 1 (Bagamoyo) 6 Tumbi, Utete) Lindi 6 (All) (Kinyonga, Liwale, 0 6 Nachingwea, Nyamagao, Ruangwa, Sokoine) Mtwara 4 (Ndanda, Ligula, Newala, 0 4 Tandahimba) Kigoma 5 (All) (Heri Mission, Kabanga, 0 5 Kasulu, Kibondo, Kigoma Regional) Tabora 6 (All) (Igunga, Kitete, Ndala, 0 6 Nzega, Sikonge, Urambo) Kagera 1 (Nyakahanga) 0 1 Shinyanga 2 (Kahama, Shinyanga) 0 2 Dodoma 5 (All) (Kongwa, Kondoa, 0 5 Mkoani, Mpwapwa, Mvumi) Mwanza 2 (Geita, Sekotoure) 2 (Bugando, Sengerema) 4

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Table 2: AVAILABILITY OF ADEQUATE AND UPDATED TREATMENT GUIDELINES, BY REGION

REGION Standard met Standard partially Standard not met TOTAL met Morogoro 1 (Morogoro 2 (Kilosa, 3 (Mahenge, 6 Hospital) St Francis) St Francis, Turiani) Iringa 0 3 (Iringa, Ludewa, 3 (Kilolo, Mufindi, 6 Makete) Njombe) Mbeya 0 2 (Mbeya, Mbozi) 3 (Chunya, Ileje, 5 (Tukuyu had Kyela missing data) Coast 0 3 (Bagamoyo, 3 (Mkuranga, 6 Kisarawe, Mafia) Tumbi, Utete) Lindi 0 2 (Nyangao, 4 (Kinyoga, 6 Ruangwa) Nachingwea, Sokoine, Liwale) Mtwara 0 0 5 (All) (Ndanda, 5 Newala, Mkoani, Ligula, Tandahimba) Kigoma 0 3 (Kabanga, 2 (Heri Mission, 5 Kasulu, Kigoma) Kasulu) Tabora 0 3 (Igunga, Ndala, 3 (Kitete, Nzega, 6 Urambo) Sikonge) Kagera 0 1 (Nyakahanga) 4 (Kagera Regional, 5 (Biharamulo had Mugana, Murgwa, a missing value) Rubiya) Shinyanga 3 (Shinyanga, 3 (Bariadi, Kahama, 6 Bukombe, Meatu) Maswa) Dodoma 0 0 5 (All) (Kongwa, 5 Kondoa, Mkoani, Mpwapwa, Mvumi) Mwanza 0 3 (Bugando, 1 (Geita) 4 (Sumve had a Nansio, missing value) Sengerema) TOTAL 1 (1.5%) 25 (38.5%) 39 (60%) 65

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Table 3: ASSESSMENT OF PERFORMANCE REVIEWS, BY REGION

REGION Standard met Standard partially Standard not met TOTAL met Morogoro 1 (Kilosa) 5 (Berega, 0 6 Mahenge, Morogoro Regional, St Francis, Turiani) Iringa 1 (Njombe) 2 (Ludewa, Makete) 3 (Iringa Regional, 6 Kilolo, Mufindi) Mbeya 2 (Mbozi, Tukuyu) 1 (Mbeya) 3 (Chunya, Ileje, 6 Kyela) Coast 2 (Bagamoyo, 1 (Kisarawe) 3 (Mafia, Tumbi, 6 Utete) Mkuranga) Lindi 0 2 (Nyangao, 4 (Kinyonga, 6 Ruangwa) Liwale, Nachingwea, Sokoine Mtwara 0 0 5 (All) (Ligula, 5 Mkoani, Ndanda, Newala, Tandahimba) Kigoma 0 3 (Heri Mission, 2 (Kasulu, Kigoma 5 Kabanga, Kibondo) Regional) Tabora 0 1 (Kitete) 5 (Igunga, Nzega, 6 Sikonge, Urambo) Kagera 0 1 (Rubya) 3 (Kagera Regional, 4 (Biharamulo and Mugana, Murgwanza had Nyakahanga) missing values) Shinyanga 0 0 6 (All) (Bariadi, 6 Bukombe, Kahama, Maswa, Meatu, Shinyanga) Dodoma 0 4 (Kongwa, 1 (Mkoani) 5 Kondoa, Mpwapwa, Mvumi) Mwanza 0 2 (Bugando, 3 (Nasio, Geita, 5 (Sumve had a Sengerema) Sekoutore) missing value) TOTAL 6 (9%) 22 (33%) 38 (58%) 66

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Table 4: AVAILABILITY OF ESSENTIAL MEDICINES AS PER ESSENTIAL MEDICINES LIST, BY REGION

REGION Standard met Standard partially Standard not met TOTAL met Morogoro 4 (Berega, 2 (Mahenge, 0 6 Morogoro Regional, St Francis) Kilosa, Turiani, Iringa 0 2 (Makete, Njombe) 4 (Iringa Regional, 6 Kilolo, Ludewa, Mufindi) Mbeya 2 (Kyela, Mbozi) 2 (Mbeya Regional, 2 (Chunya, Ileje) 6 Tukuyu,) Coast 0 1 (Bagamoyo) 5 (Kisarawe, Mafia, 6 Mkuranga, Tumbi, Utete) Lindi 4 (Kinyonga, 1 (Liwale) 1 (Nachingwea) 6 Nyangao, Ruagwa, Sokoine) Mtwara 3 (Ligula, Mkoani, 0 2 (Newala, 5 Ndanda) Tandahimba) Kigoma 2 (Heri Mission, 0 3 (Kabanga, 5 Kibondo) Kasulu, Kigoma Tabora 1 (Ndala) 2 (Kitete, Urambo) 3 (Igunga, Sikonge, 6 Nzega Kagera 2 (Nyakahanga, 1 (Kagera) 2 (Mugana, 5 (Biharamulo had Rubya) Murgwa) missing values) Shinyanga 1 (Bukombe) 2 (Kahama, Maswa) 3 (Bariadi, Meatu, 6 Shinyanga Regional) Dodoma 2 (Kondoa, 1 (Mkoani) 2 (Kongwa, 5 Mpwapwa) Mvumi,) Mwanza 3 (Bugando, 1 (Nansio) 1 (Geita) 5 (Sumve had a Sengerema, missing value) Sekoutore) TOTAL 24 (36%) 15 (22%) 28 (42%) 67

HOSPITAL Standard met Standard partially Standard not met TOTAL OWNERSHIP met Government 15 (29%) 14 (27%) 23 (44%) 52 Non-Government 9 (60%) 1 (7%) 5 (33%) 15 (Biharamlo, Murgwanza and Sumve had missing values)

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Table 5: AVAILABILITY OF ESSENTIAL MEDICINES FOR EMERGENCIES, BY REGION

REGION Standard met Standard partially Standard not met TOTAL met Morogoro 3 (Morogoro, 2 (Berega, St 1 (Mahenge) 6 Turiani, Kilosa Francis) Iringa 0 0 5 (Iringa Regional, 5 (Mufindi had a Kilolo Njombe, missing value) Ludewa, Makete, Mbeya 4 (Chunya, Ileje, 1 (Mbeya) 1 (Tukuyu) 6 Kyela, Mbozi) Coast 0 0 6 (Bagamoyo, 6 Kisarawe, Mafia, Mkuranga, Tumbi, Utete) Lindi 0 3 (Nyangao, 3 (Kinyonga, 6 Ruangwa, Sokoine) Nachingwea, Liwale) Mtwara 1 (Ligula) 1 (Tandahimba) 3 (Mkoani, Ndanda, 5 Newala) Kigoma 0 4 (Heri Mission, 1 (Kigoma) 5 Kabanga, Kibondo, Kasulu) Tabora 1 (Kitete) 1 (Igunga) 4 (Ndala, Nzega, 6 Sikonge, Urambo) Kagera 3 (Biharamulo, 1 (Murgwanza) 2 (Mugana, 6 Kagera Regional, Nyakahanga) Rubiya) Shinyanga 1 (Shinyanga) 0 2 (Bariadi, Meatu) 3 (Bukombe, Kahama and Maswa had missing values) Dodoma 2 (Mvumi, Kongwa) 1 (Mpwapwa) 2 (Kondoa, Mkoani) 5 Mwanza 4 (Bugando, 1 (Nansio) 1 (Geita) 6 Sekoutore, Samvue, Sengerema) TOTAL 19 (29%) 15 (23%) 31 (48%) 65

HOSPITAL Standard met Standard partially Standard not met TOTAL OWNER met Government 13 (28%) 9 (19%) 25 (53%) 47 Non Government 6 (33%) 6 (33%) 6 (33%) 18

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Table 6: DISTRIBUTION OF HOSPITALS WITH AVAILABILITY OF LABORATORY SUPPORT TESTS, BY REGION

REGION Standard met Standard partially Standard not TOTAL met met Morogoro 4 (Berega, Kilosa, 2 (Mahenge, 0 6 Morogoro Regional, St. Francis) Turiani) Iringa 2 (Iringa, Mufindi) 2 (Ludewa, 2 (Kilolo, Makete) 6 Njombe) Mbeya 3 (Mbeya, Mbozi, 2 (Kyela, Chunya) 1 (Ileje) 6 Tukuyu) Coast 4 (Bagamoyo, 0 2 (Mafia, Tumbi) 6 Kisarawe, Mkuranga, Utete) Lindi 5 (Kinyonga, 1 (Liwale) 0 6 Nyangao, Ruangwa, Sokoine, Nachingwea Mtwara 4 (Ligula, Mkoani, 0 1 (Tandahimba) 5 Ndanda, Newala) Kigoma 3 (Kabanga, 2 (Heri Mission, 0 5 Kibondo, Kigoma Kasulu) Regional) Tabora 1 (Nzega) 4 (Kitete, Ndala, 1 (Igunga) 6 Sikonge, Urambo) Kagera 2 (Murgwa, Rubiya) 1 (Kagera) 2 (Mugana, 5 (Biharamulo had Nyakahanga) a missing value) Shinyanga 3 (Bukombe, 1 (Meatu) 2 (Bariadi, 6 Maswa, Shinyanga) Kahama) Dodoma 3 (Kongwa, 1 (Mkoani) 1 (Kondoa) 5 Mpwapwa, Mvumi) Mwanza 5 (Bugando, Geita, 0 0 5 (Sumve had a Nansio, Sekoutore, missing value) Sengerema) TOTAL 39 (58%) 16 (24%) 12 (18%) 67

HOSPITAL Standard met Standard Standard not met TOTAL OWNERSHIP partially met Government 30 (59%) 12 (23.5%) 9 (17.5%) 51 Non-Government 9 (56%) 4 (25%) 3 (19%) 16 (Biharamlo and Sumve had missing values)

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Table 7: ESSENTIAL EQUIPMENT AND SUPPLIES ARE AVAILABLE

REGION Standard met Standard partially Standard not met TOTAL met Morogoro 0 5 (Berege, Kilosa, 1 (Mahenge) 6 Morogoro Regional, St Francis, Turiani) Iringa 2 (Iringa, Mufindi) 1 (Makete) 3 (Kilolo, Ludewa, 6 Njombe) Mbeya 2 (Kyela, Mbozi) 4 (chunya, Ileje, 0 6 Mbeya, Tukuyu) Coast 2 (Bagamoyo, 3 (Kisarawe, 1 (Mafia) 6 Utete) Mkuranga,Tumbi) Lindi 0 3 (Nyangao, 3 (Kinyonga, 6 Ruangwa, Sokine) Liwale, Nachingwea) Mtwara 1 (Ndanda) 3 (Ligula, Newala, 1 (Mkomaindo) 5 Tandahimba) Kigoma 0 3 (Heri Mission, 2 (Kabanga, 5 Kasulu, Kibondo) Kigoma) Tabora 1 (Igunga) 4 (Kitete, Ndala, 1 (Nzega) 6 Sikonge, Urambo) Kagera 0 4 (Kagera Regional, 1 (Mugana) 5 (Biharamulo had Murgwa, a missing value) Nyakahanga Rubiya) Shinyanga 1 (Bukombe) 4 (Kahama, Maswa, 1 (Bariadi) 6 Meatu, Shinyanga). Dodoma 0 3 (Kongwa, Kondoa, 2 (Mpwapwa, 5 Mkoani Mvumi) Mwanza 3 (Geita, Nansio, 2 (Bugando, 0 5 (Sumve had a Sengerema) Sekouture) missing value) TOTAL 12 (18%) 39 (58%) 16 (24%) 67

HOSPITAL Standard met Standard partially Standard not met TOTAL OWNERSHIP met Government 14 (27.5%) 25 (49%) 12 (23.5%) 51 Non-Government 1 (6%) 11 (69%) 4 (25%) 16 (Biharamlo, and Sumve had missing values)

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Table 8: INFECTION PREVENTION AND CONTROL, BY REGION

REGION Standard met Standard partially Standard not met TOTAL met Morogoro 2 (Berega, Turiani) 4 (Kilosa, Mahenge, 0 6 Morogoro, St Francis) Iringa 2 (Makete, Njombe) 3 (Iringa, Kilolo, 1 (Mufindi) 6 Ludewa) Mbeya 3 (Mbeya Regional, 2 (Chunya, Ileje) 1 (Kyela) 6 Mbozi, Tukuyu) Coast 2 (Mkuranga, 4 (Bagamoyo, 0 6 Utete) Kisarawe, Mafia, Utete) Lindi 3 (Nachingwea, 3 (Kinyonga, 0 6 Nyangao, Ruangwa) Liwale, Sokoine) Mtwara 2 (Ligula, Ndanda) 1 (Newala) 2 (Tandahimba, 5 Mkomaindo) Kigoma 4 (Heri Mission, 1 (Kasulu) 0 5 Kabanga, Kigoma Regional, Kibondo) Tabora 1 (Ndala) 4 (Igunga, Kitete, 1 (Nzega) 6 Nzega, Sikonge) Kagera 3 (Mugana, 2 (Kagera, 1 (Biharamulo) 6 Nyakahanga, Murgwanza) Rubiya) Shinyanga 2 (Maswa, 3 (Bukombe, 1 (Bariadi) 6 Shinyanga) Meatu, Kahama) Dodoma 2 (Kongwa, 3 (Dodoma 0 5 Kondoa) Regional, Mpwapwa, Mvumi) Mwanza 4 (Bugando, 2 (Geita, Nansio) 6 Sekouture, Sengerema, Samvue) TOTAL 30 (43%) 32 (46%) 7 (10%) 69

HOSPITAL Standard met Standard partially Standard not met TOTAL OWNER met Government 18 (35%) 27 (53%) 6 (12%) 51

Non-Government 12 (67%) 5 (28%) 1 (5%) 18

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Table 9: CARE FOR CHILDREN BY QUALIFIED STAFF, BY REGION

REGION Standard met Standard partially Standard not met TOTAL met Morogoro 2 (Kilosa, 3 (Berega, Moro 1 (Mahenge) 6 St Francis) Regional, Turiani) Iringa 3 (Njombe, Makete, 1 (Iringa) 2 (Kilolo, Ludewa) 6 Mufindi) Mbeya 2 (Mbeya, Tukuyu) 4 (Chunya, Ileje, 0 6 Kyela, Mbozi) Coast 1 (Bagamoyo) 3 (Mukuranga, 2 (Kisarawe, Mafia) 6 Tumbi Utete) Lindi 0 4 (Nachingwea, 2 (Kinyonga, 6 Nymagao, Liwale) Ruanga, Sokoine) Mtwara 0 3 (Ligula, Ndanda, 2 (Mkomaindo, 5 Newala) Tandahimba) Kigoma 0 3 (Kabunga, 2 (Heri Mission, 5 Kibondo, Kigoma Kasulu) Regional) Tabora 4 (Igunga, Ndala, 2 (Kitete, Sikonge) 0 6 Nzega, Urambo) Kagera 0 4 (Kagera Regional, 1 (Biharamulo) 5 (Rubya had a Mugana, Murgwa, missing value) Nyakahanga) Shinyanga 1 (Shinyanga) 2 (Kahama, Maswa) 3 (Bukombe, 6 Meatu, Bariadi) Dodoma 1 (Mkoani) 2 (Mpwapwa, 2 (Kongwa, 5 Mvumi) Kondoa)

Mwanza 2 (Bugando, 4 (Geita, Nansio, 0 6 Sumve) Sekoutore, Sengerema) TOTAL 16 (23.5%) 35 (51.5%) 17 (25%) 68

HOSPITAL Standard met Standard partially Standard not met TOTAL OWNER met Government 12 (23.5%) 25 (49%) 14 (27.5%) 51

Non-Government 4 (23.5%) 10 (59%) 3 (17.5%) 17 (Rubya had a missing value)

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Table 10: PERFORMANCE IN MANAGEMENT OF COUGH OR DIFFICULTY IN BREATHING, BY REGION

REGION SCORES TOTAL Standard not met Standard partially met Standard met FACILITIES Morogoro 4 (Berege, Kilosa, Morogoro 2 (Mahenge, Turiani) 0 6 Regional, St Francis) Iringa 5 (Iringa Regional, Kilolo, 0 1 (Makete) 6 Ludewa, Mfundi, Njombe) Mbeya 2 (Chunya, Ileje) 4 (Kyela, Mbeya Rufaa, 0 6 Mbozi, Tukuyu) Coast 5 (Kisarawe, Mafia, 0 1 (Bagamoyo) 6 Mkuranga, Tumbi, Utete) Lindi 5 (Kinyonga, Liwale, 1 (Sokoine) 0 6 Nachingwea, Nymagao, Ruangwa) Mtwara 5 (Ligula, Mkomaindo, 0 0 5 Ndanda, Newala, Tandahimba) Kigoma 5 (Heri Mission, Kabanga, 0 0 5 Kasuli, Kibondo, Kigo Regional) Tabora 5 (Igunga, Kitete, Nzega, 0 1 (Ndala) 6 Sikonge, Urambo) Kagera 1 (Mugana) 2 (Murgwanza, 0 3 Nyakahanga) Shinyanga 6 (Bariadi, Bukombe, 0 0 6 Kahama, Mswa, Meatu, Shinyanga Regional) Dodoma 1 (Mpwapwa) 3 (Kongwa, Kondoa, 1 (Mkoani) 5 Mvumi) Mwanza 3 (Nansio, Sekouture, 0 3 (Bugando, Geita, 6 Sengerema) Sumve) TOTAL 47 12 7 66

Table 11: PERFORMANCE IN DIARRHOEA MANAGEMENT, BY REGION

REGION SCORES TOTAL Standard not met Standard partially Standard met FACILITIES met Morogoro 5 (Berege, Kilosa, Mahenge, 1 (Morogoro) 0 6 St Francis, Turiani) Iringa 3 (Iringa, Kilolo, Ludewa) 2 (Mufindi, Njombe) 5 Mbeya 2 (Chunya, Ileje) 2 (Mbeya, Kyela) 2 (Tukuyu, Mbozi) 6 Coast 6 (Bagamoyo, Kisarewe, 0 0 6 Mafia, Mukuranga, Tumbi, Utete) Lindi 6 (Kinyonga, Liwale, 0 0 6 Nachingwea, Nyangao, Rungwa, Sokoine) Mtwara 4 (Ligula, Mkomaindo, 1 (Tandahimba) 0 5 Ndanda, Newala) Kigoma 3 (Kabunga, Kasulu, 2 (Heri Mission, Kigoma) 0 5 Kibondo) Tabora 5 (Igunga, Kitete Nzega, 1 (Ndala) 0 6 Sikonge, Urambo) Kagera 3 (Biharamulo, Mugana, 2 (Nyakahanga, Rubiya) 0 5 Murgwa) Shinyanga 4 (Bariadi, Kahama, Maswa, 2 (Bukombe, Shinyanga) 0 6 Meatu) Dodoma 2 (Mkoani, Mpwapwa) 2 (Kongwa, Mkoani) 0 4 Mwanza 2 (Sekotoure, Sengerema) 2 (Geita, Nansio) 1 (Bugando) 5 TOTAL 45 17 3 65

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Table 12: PERFORMANCE IN MANAGEMENT OF FEVER, BY REGION

REGION SCORES TOTAL Standard not met Standard partially Standard met FACILITIES met Morogoro 5 (Berega, Kilosa, Mahenge, 1 (St Francis) 0 6 Morogoro Regional, Turiani) Iringa 5 (Iringa Regional, Kilolo, 1 (Njombe) 6 Ludewa, Makete, Mufindi) Mbeya 1 (Chunya) 4 (Ileje, Kyela, Mbeya 1 (Tukuyu) 6 Regional, Mbozi) Coast 4 (Kisarawe, Mafia, 2 (Bagamoyo, Utete) 0 6 Mkuranga, Tumbi) Lindi 5 (Kinyonga, Nachingwea, 1 (Liwale) 0 6 Nyamagao, Ruagwa, Sokoine) Mtwara 5 (Ligula, Mkamaindo, 0 0 5 Ndanda, Newala, Tandahimbo) Kigoma 2 (Kasulu, Kibondo) 2 (Kigoma Regional, 1 (Heri Mission) 5 Kabanga) Tabora 4 (Igunga, Kitete, Nzega, 2 (Ndala, Sikonge) 0 6 Urambo) Kagera 6 (Biharmulo, Kagera 0 0 6 Regional, Mugana, Murgwa, Nyakahanga, Rubiya) Shinyanga 5 (Bariadi, Bukombe, 1 (Kahama) 0 6 Maswa, Meatu, Shinynga Regional) Dodoma 2 (Kondoa, Mpwapwa) 3 (Kongwa, Mkoani, 0 5 Muvumi) Mwanza 1 (Geita) 1 (Sekotoure) 3 (Bugando 5 Regional, Nansio, Sengerem) TOTAL 45 18 5 68 Table 13: PERFORMANCE IN MANAGEMENT OF SEVERE MALNUTRITION, BY REGION

REGION SCORES TOTAL Standard not met Standard partially Standard met FACILITIES met Morogoro 5 (Berega, Kilosa, 1 (Turianai) 0 6 Mahenge,Morogoro Regional, St Francis) Iringa 6 (Iringa Regional, 0 0 6 Kilolo,Ludewa, Makete, Mufindi, Njombe) Mbeya 5 (Chunya, Ileje, Kyela, 1 (Mbeya Rufaa) 0 6 Mbozi, Tukuyu) Coast 5 (Bagamoyo, Kisarawe, 1 (Bagamoyo) 0 6 Mafia, Mkuranga, Utete) Lindi 6 (Kinyonga, Liwale, 0 0 6 Nachingwea, Nyamagao, Ruagwa, Sokoine) Mtwara 5 (Ligula, Mkomaindo, 0 0 5 Ndanda, Newala, Tandahimba) Kigoma 5 (Heri Mission, Kabanga, 0 0 5 Kasulu, Kibondo, Kigoma Regional) Tabora 6 (Igunga, Kitete, Ndala, 0 0 6 Nzega, Sokoine, Urambo) Kagera 6 (Bihramulo, Kagera 0 0 6 Regional, Mugsna, Murgwa, Nyakahanga, Rubiya) Shinyanga 6 (Bariadi, Bukombe, 0 0 6 Kahama, Maswa, Meatu, Shinynga Regional) Dodoma 5 (Kongwa, Kondoa, 0 0 5 Mkoani, Mpwapwa, Mvumi) Mwanza 2 (Sekotoure, Geita) 1 (Nansio) 2 (Bugando, 5 Sengerema)

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TOTAL 62 4 2 68

Table 14: PERFORMANCE IN HIV/AIDS MANAGEMENT, BY REGION

REGION SCORES TOTAL Standard not met Standard partly met Standard met FACILITIES Morogoro 1 (Berega) 2 (Mahenge, St Francis) 3 (Kilosa, Morogoro 6 Regional, Turiani) Iringa 1 (Mufindi) 4 (Iringa Regional, 1 (Ludewa) 6 Kilolo, Makete, Njombe)

Mbeya 1 (Mbozi) 3 (Chunya, Ileje, Kyela) 2 (Mbeya Rufaa, 6 Tukuyu) Coast 1 (Mafia) 4 (Bagamoyo, Mkuranga, 1 (Kisarawe) 6 Tumbi, Utete) Lindi 4 (Kinyonga, Nachingwea, 2 (Liwale, Ruangwa) 0 6 Nyangao, Sokoine) Mtwara 2 (Newala, Tandahimba) 1 (Ndanda) 2 (Ligula, 5 Mkomaindo) Kigoma 1 (Heri Mission) 2 (Kasulu, Kibondo) 2 (Kabanga, 5 Kigoma) Tabora 3 (Igunga, Ndala, Nzega) 3 (Kitete, Sikonge, 0 6 Urambo) Kagera 2 (Kagera, Mugana) 2 (Murgwa, Rubiya) 1 (Biharamlo) 5 Shinyanga 2 (Bariadi, Shinyanga) 2 (Maswa, Meatu) 2 (Bukombe, 6 Kahama) Dodoma 0 1 (Kondoa) 4 (Dodoma 5 Regional, Kongwa, Kondoa, Mvumi) Mwanza 0 3 (Geita, Sekoutore, 2 (Bugando, 5 Sengerema) Nansio, Sumve) TOTAL 18 29 20 67

Table 5: PERFORMANCE IN SUPPORTIVE CARE, BY REGION

REGION SCORES TOTAL Standard not met Standard partly met Morogoro 3 (Mahenge, Kilosa, 3 (Berega, Morogoro, 6 St Francis) Turiani) Iringa 2 (Iringa, Kilolo) 4 (Ludewa, Makete, Mfindi, 6 Njombe) Mbeya 4 (Chunya, Ileje, Kyela, 1 (Mbeya Rufaa) 5 Mbozi) Coast 4 (Kisarawe, Mafia, Tumbi, 2 (Bagamoyo, Utete) 6 Mkuranga) Lindi 6 (Kinyonga, Liwale, 6 Nachingwea, Nyagao, Ruangwa, Sokoine) Mtwara 3 (Lingula, Newala, 2 (Mkomaindo, Ndanda) 5 Tandahimba) Kigoma 4 (Heri Mission, Kibanga, 1 (Kibondo) 5 Kasulu, Kigoma Regional) Tabora 6 (Igunga, Kitete, Ndala, 6 Nzega, Sikonge, Urambo) Kagera 4 (Biharamulo, Mugana, 2 (Kagera, Nyakahanga) 6 Murgwa, Rubiya) Shinyanga 3 (Bukombe, Shinyanga 3 (Bariadi, Maswa, Meatu) 6 Regional, Kahama) Dodoma 2 (Kondoa, Mvumi) 3 (Dodoma Regional, 5 Kongwa, Mpwapwa) Mwanza 2 (Geita, Sengerema) 4 (Bugando, Nansio, 6 Sekoutore, Samvue) TOTAL 43 25 68 ** Note: All 69 hospitals were assessed on supportive care and the standard was not met.

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Table 16: PERFORMANCE IN MOTHER/CARE TAKER AND CHILD FRIENDLY SERVICES, BY REGION

REGION SCORES TOTAL Standard not met Standard partially met Standard met FACILITIES Morogoro 2 (Berega, Kilosa) 4 (Mahenge, Morogoro 0 6 Regional, St Francis, Turiani) Iringa 4 (Iringa Regional, 2 (Kilolo, Mufindi) 6 Ludewa, Makete, Njombe) Mbeya 2 (Ileje, Mbeya 4 (Chunya, Kyela, Mbozi, 0 6 Rufaa) Tukuyu) Coast 3 (Kisarawe, Mafia, 3 (Bogamoyo, 0 6 Utete) Mkuranga,Tumbi) Lindi 3 (Liwale, 4 (Kinyonga, Nyamagao, 0 7 Nachingwea, Ruangwa, Sokoine) Luangwa) Mtwara 3 (Ligula, Newala, 2 (Mkomaindo, Ndanda) 0 5 Tandahimba) Kigoma 1 (Kasulu) 3 (Heri Mission, Kabanga, 1 (Kibondo) 5 Kigoma Regional) Tabora 4 (Igunga, Kitete, 2 (Ndala, Urambo) 0 6 Nzega, Sikonge) Kagera 1 (Biharamulo) 4 (Kagera Regional, 5 Mugana, Murgwa, Nyakakanga) Shinyanga 3 (Bariadi, Kahama, 3 (Bukombe, Maswa, 0 6 Meatu) Shinyanga Regional) Dodoma 1 (Mvumi) 4 (Dodoma Regional, 0 5 Kongwa, Kondoa, Mpwapwa) Mwanza 2 (Nansio, Sumve) 3 (Bugando, Geita, 1 (Sengerema) 6 Sekoutore) TOTAL 29 38 2 69 Table 17: PERFORMANCE IN DISCHARGE AND FOLLOW UP, BY REGION

REGION SCORES TOTAL Standard not met Standard partially met Standard met FACILITIES Morogoro 5 (Berege, Kilosa, 1 (Turiani) 0 6 Mahenge, Morogoro Regional, St Francis) Iringa 5 (Kilolo, Ludewa, 1 (Iringa) 0 6 Makete, Mufindi, Njombe) Mbeya 2 (Chunya, Mbeya 4 (Ileje, Kyela, Mbozi, 0 6 Rufaa) Tukuyu) Coast 4 (Kisarawe, Mafia, 1 (Tumbi) 1 (Bagamoyo) 6 Mukuranga, Utete) Lindi 6 (Kinyonga, Liwale, 0 0 6 Nachingwea, Nyagao, Ruagwa, Sokoine) Mtwara 3 (Ligula, Newala, 1 (Ndanda) 1 (Mkomaindo) 5 Tandahimba) Kigoma 2 (Kasulu, Kabanga) 3 (Heri Mission, Kibondo, 0 5 Kigoma Regional) Tabora 6 (Igunga, Kitete, 0 0 6 Ndala, Nzega, Sikonge, Urambo) Kagera 6 (Biharmulo, Kagera 0 0 6 Regional, Mugana, Murgwa, Nykahanga, Rubiya) Shinyanga 3 (Bukombe, Kahama, 3 (Bariadi, Meatu, 0 6 Maswa) Shinyanga) Dodoma 2 (Mkoani, Mpwapwa) 2 (Kongwa, Kondoa,) 1 (Mvumi) 5 Mwanza 2 (Geita, Sekoutore) 1 (Sengerema) 2 (Bugando, 5 Sumve) TOTAL 46 17 5 68

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Table 18: PERFORMANCE IN DELIVERY ROOM AND CARE OF THE NEWBORN, BY REGION

REGION SCORES TOTAL Standard not met Standard partially met Standard met FACILITIES Morogoro 0 6 (Berege, Kilosa, 0 6 Mahenge, Morogoro, St Francis, Turiani) Iringa 2 (Mufindi, Ludewa) 4 (Iringa, Kilolo, Makete, 0 6 Njombe) Mbeya 0 5 (Chunya, Ileje, Kyela, 1 (Mbeya Rufaa) 6 Mbozi, Tukuyu) Coast 1 (Kisarawe) 5 (Bagamoyo, Mafia, 0 6 Mkuranga, Tumbi, Utete) Lindi 2 (Kinyonga, Liwale) 4 (Nachingwea, 0 6 Nyamagao, Ruangwa, Sokoine) Mtwara 1 (Tandahimba) 4 (Ligula, Mkomaindo, 0 5 Ndanda, Newala) Kigoma 4 (Heri Mission, Kabanga, 0 4 Kasulu, Kibondo) Tabora 2 (Sikonge, Urambo) 4 (Igunga, Kitete, Ndala, 0 6 Nzega) Kagera 0 6 (Biharamulo, Kagera 0 6 Regional, Mugana, Murgwa, Nyakahanga, Rubiya) Shinyanga 1 (Bariadi) 5 (Bukombe, Kahama, 0 6 Maswa, Meatu, Shinyanga Regional) Dodoma 0 4 (Kondoa, Mkoani, 1 (Kongwa) 5 Mpwapwa, Mvumi) Mwanza 1 (Nansio) 2 (Sekotoure, Sengerema) 3 (Bugando, Geita, 6 Sumvue) TOTAL 10 53 5 68 Table 19: PERFORMANCE IN SICK NEWBORN/NEONATAL CARE, BY REGION

REGION SCORES TOTAL Standard not met Standard partially met Standard met FACILITIES Morogoro 4 (Berega, Kilosa, 1 (St Francis) 1 (Morogoro 6 Mahenge, Turiani) Regional) Iringa 6 (Iringa Regional, 0 0 6 Kilolo, Ludewa, Makete, Mufindi, Njombe) Mbeya 3 (Chunya, Ileje, 2 (Kyela, Mbozi) 1 (Mbeya Rufaa) 6 Tukuyu) Coast 5 (Kisarawe, Mafia, 1 (Bagamoyo) 0 6 Mukuranga, Tumbi, Utete) Lindi 6 (Kinyonga, Liwale, 0 0 6 Nachinmgwea, Nyngao, Ruangwa, Sokoine) Mtwara 4 (Mkomaindo, 1 (Ligula) 0 5 Ndanda, Newala, Tandahimba) Kigoma 2 (Kasulu, Kabanga) 2 (Heri Mission, Kabanga) 1 (Kibondo) 5 Tabora 4 (Kitete, Ndala, 2 (Igunga, Urambo) 0 6 Nzega, Sikonge) Kagera 4 (Biharamulo, 2 (Murgwanza, 0 6 Kagera Regional, Nyakahanga) Mugana, Rbiya) Shinyanga 5 (Bariadi, Bukombe, 1 (Kahama) 0 6 Maswa, Meatu, Shinyanga Regional) **Dodoma - - - 0 Mwanza 2 (Geita, Sekotoure) 2 (Nansio, Sengerema) 1 (Bugamdo) 5 TOTAL 45 14 4 63 ** In Dodoma, all facilities had data missing and they were not included in the analysis

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