i Foreword
The 2011 Health Information Bulletin is the sixth publication in the series of Health Bulletins produced by the Ministry of Health, Zanzibar through its Health Management Information System (HMIS) unit. The bulletin contains analyzed information predominantly from routine data collected from public and private health facilities, some survey data and health related studies during 2011.
Collected data from health facilities and programmes are compiled electronically at the district using the District Health Information Software (DHIS2). The Data management process is done participatory involving programmes managements staffs, health facilities in charges, District Health Management Teams (DHMTs), HMIS staffs, Mnazi Mmoja Hospital management staffs and Private Health Facilities.
Major areas covered in this report include details on International and National indicators namely – The Millennium Development Goals (MDG), Zanzibar Strategy for Growth and Reduction of Poverty (MKUZA) and Health Sector Annual work plan 2011 indicators. Sections on service utilization, data coverage and information from various programmes, and information on diseases surveillance are included.
Programmes whose data are presented include Integrated reproductive and Child Health, Integrated HIV, AIDS, TB and Leprosy components. Information on disease surveillance including communicable, non communicable and neglected tropical diseases is also included.
It is anticipated that this information will be used for monitoring and evaluation, local level planning and decisions making of the health sector for improvement of quality service provision and the subsequent enhancement of health care for meeting the public requirements.
MOHAMMED S. JIDDAWI (MD) PRINCIPAL SECRETARY MINISTRY OF HEALTH ZANZIBAR
i TABLE OF CONTENTS
FOREWORD ...... I
TABLE OF CONTENTS...... II
LIST OF TABLE...... VII
LIST OF FIGURES...... IX
LIST OF MAPS...... IX
ACKNOWLEDGEMENTS...... X
ACRONYMS...... XI
CHAPTER ONE...... 1
1. INTRODUCTION...... 1
CHAPTER TWO ...... 2
2. SOURCES OF HMIS DATA, QUALITY AND COVERAGE ...... 2
2.1 Primary data (Routine HMIS)...... 2
2.2 Types of Data captured by HMIS unit ...... 3
2.3 Coverage of report submission ...... 3
2.4 Timeliness of Reporting – example from immunization data...... 3
2.5 Data quality...... 4
CHAPTER THREE ...... 5
3. HEALTH SYSTEM...... 5
3.1 Hierarchy of Health System ...... 5
3.2 Utilization rate...... 5 3.2.1 Facilities OPD utilization rate (All age)...... 6 3.2.2 Facility OPD utilization rates under 5 years...... 6
CHAPTER FOUR...... 8
ii 4. MDG, MKUZA & ZHSSP INDICATORS ...... 8
4.1 Millennium Development Goal (MDG) ...... 8
4.2 MKUZA & HSSP...... 8
4.3 MKUZA II MONITORING...... 12
CHAPTER FIVE...... 14
5. DISEASE SURVEILLANCE ...... 14
5.1 Most common reported diagnosis for new patients under 5 years...... 14
5.2 Top 15 for age 5 years and above ...... 15
5.3 Common Diseases for all ages...... 16 5.3.1 Pneumonia (prevalence) ...... 16 5.3.2 Upper Respiratory Tract Infections (URTI) ...... 17
5.4 Epidemic Diseases ...... 18 5.4.1 Cholera ...... 18 5.4.2 Dysentry (Diarrhoea with Blood)...... 19
CHAPTER SIX...... 20
6. NON COMMUNICABLE DISEASES (NCDS) ...... 20
6.1 NCD from Routine HMIS data ...... 20 6.1.1 Diabetes Mellitus (DM) at Mnazi Mmoja Hosp. Diabetic Clinic...... 20 6.1.1.1 Number of Diabetic complications at Mnazi Mmoja in 2011 ...... 21 6.1.2 Road Traffic Accident (RTA), 2011...... 21
6.2 NCD risk factor survey 2011...... 22 6.2.1 Selected risk factors and prevalence of NCDs ...... 22 6.2.2 Some selected results for NCDs survey in Zanzibar...... 23 6.2.1.1 Overweight and obesity...... 23 6.2.1.2 Physical activity...... 24 6.2.1.3 Combination of risk factors...... 24 6.2.1.4 Raised blood pressure / Hypertension...... 24 6.2.1.5 Raised Blood Glucose levels / Diabetes ...... 24 6.2.1.6 Accidents and injuries ...... 25 6.2.1.7 Mental health...... 25
CHAPTER SEVEN ...... 26
7. CHILD HEALTH AND IMMUNISATION...... 26
7.1 Expanded Programme on Immunization (EPI)...... 26 7.1.1 The Overall Immunization Coverage ...... 27 7.1.2 BCG Coverage ...... 27 7.1.3 Under 1 year’s projection vs. BCG...... 28 7.1.4 Penta Coverage...... 29 iii 7.1.5 Measles coverage 2011 ...... 29 7.1.1.1 The measles cases in 2011 ...... 30 7.1.6 Fully Immunized...... 32
7.2 Immunization Drop-out ...... 32 7.2.1 Pentavalent 1-3 dropout rate ...... 33
7.3 Tetanus Toxoid Vaccine (TT) ...... 33 7.3.1 TT2+ to pregnant ...... 34 7.3.2 TT 2+ Coverage for WRA in Zanzibar 2011 ...... 34
CHAPTER EIGHT ...... 36
8. REPRODUCTIVE HEALTH...... 36
8.1 Family Planning ...... 36 8.1.1 Contraceptive prevalence Rate (CPR)...... 36 8.1.2 Couple Year Protection Rate (CYP) ...... 36 8.1.3 Family planning Users for long term method 2010 and 2011 ...... 38 8.1.4 Family planning new clients...... 39
8.2 Family Planning in Comprehensive Post Abortion Care (cPAC) ...... 40
8.3 Antenatal Care (ANC)...... 40 8.3.1 ANC first visit coverage...... 41 8.3.2 ANC first visit before 16 weeks...... 42 8.3.3 ANC first visits, Institutional Deliveries and Post Natal Visits coverage comparison...... 43
8.4 Test performed during Antenatal visits...... 43 8.4.1 HIV and Syphilis Prevalence...... 44
8.5 IPT 1 & IPT2 Coverage, 2011 ...... 44
8.6 High risk pregnancies...... 45 8.6.1 Pregnancy risk factors ...... 45 8.6.1.1 Malaria in pregnancy ...... 46 8.6.1.2 Severe Anaemia in pregnancy...... 47
CHAPTER NINE ...... 49
9. NUTRITION ...... 49
9.1 Nutrition Interventions through the Health Sector...... 49 9.1.1 Vitamin A supplementation of children aged 6-59 months - 2011...... 49 9.1.2 De-worming of pregnant women via Anti-helminthic Drugs ...... 50
9.2 Low birth weight rate (institutional)...... 51
9.3 Nutrition status from different surveys ...... 53 9.3.1 Micronutrient Nutritional Status ...... 53 9.3.2 Iodine Deficiency Disorders (IDD) in Zanzibar...... 53 9.3.3 Stunting, Underweight and Wasting...... 54
CHAPTER TEN...... 56 iv 10. DELIVERIES ...... 56
10.1 Overall Deliveries...... 56
10.2 Delivery institutional sites...... 56 10.2.1 Comparison between ANC attendant and Deliveries at PHCU and PHCU+...... 59 10.2.1 Rate of institutional deliveries...... 60 10.2.2 Home delivery...... 61
10.3 Institutional births and births attended by skilled personnel...... 61 10.3.1 Birth attended by skilled personnel Unguja and Pemba ...... 61 10.3.2 Birth attended by skilled personnel Zanzibar ...... 62
10.4 Emergency Obstetric Care (EmOC) ...... 62 10.4.1 Obstetric Complication and Interventions...... 63 10.4.2 Obstetric care and neonatal Interventions by Hospitals...... 63
10.5 Comprehensive Emergency Obstetric Care...... 64 10.5.1 Institutional caesarean section rate...... 64
10.6 Maternal Mortality ...... 65 10.6.1 Maternal Deaths ...... 65 10.6.2 Causes of Maternal Death...... 66
CHAPTER ELEVEN...... 68
11. HIV/AIDS ...... 68
11.1 HIV testing in the population ...... 68
11.2 HIV prevalence among tested by Demographic characteristics ...... 68
11.3 HIV care and treatment services ...... 70
CHAPTER TWELVE ...... 72
12. TUBERCULOSIS AND LEPROSY ...... 72
12.1 Tuberculosis...... 72 12.1.1 Gender and age characteristics of New smear positive patients...... 72 12.1.2 TB/HIV NOTIFICATION 2011 ...... 72 12.1.3 Treatment Result of New Smear Positive TB patients notified in 2010...... 73 12.1.4 Results of treatment of smear Negative and EP TB patients notified in 2010...... 73 12.1.5 Treatment Results of Re-treatment TB patients notified in 2010 ...... 74 12.1.6 Tuberculosis prevalence from 2005-2011...... 74
12.2 LEPROSY...... 74 12.2.1 Reconstructive Surgery ...... 75
CHAPTER THIRTEEN ...... 76
13. HOSPITAL IN-PATIENT DATA ...... 76
v 13.1 Hospitals in General...... 76 13.1.1 Bed Occupancy Rate ...... 76 13.1.2 Average length of stay ...... 77 13.1.3 Causes of admission...... 77 13.1.4 Hospital fatality rate ...... 78 13.1.5 Top ten Causes of deaths in Hospitals, 2011 ...... 78
ANNEX ...... 80
Annex A: HMIS/ DHIS Indicator descriptions...... 80
Annex B: Distribution of PHCU + in Unguja and Pemba...... 84 Distribution of PHCU + (Second line) in Unguja...... 84 Distribution of PHCU + (Second line) in Pemba ...... 85
vi LIST OF TABLE TABLE 1: FORM SUBMISSIONS BY TYPE OF FORM...... 3 TABLE 2: HEALTH FACILITY OPD UTILIZATION RATES BY ALL AGES PER DISTRICT...... 6 TABLE 3: OPD UTILIZATION RATE FOR UNDER 5YEARS ...... 7 TABLE 4: UTILIZATION RATES UNDER 5 YEARS (ALL SERVICES) ...... 7 TABLE 5: MILLENNIUM DEVELOPMENT GOAL (MDG) ...... 11 TABLE 6: MKUZA II HEALTH AND HEALTH RELATED INDICATORS...... 12 TABLE 7: UNDER 5 YEARS ‚‘TOP 15‘DIAGNOSIS, 2011 (N = 479,778) ...... 14 TABLE 8: TOP 15 DIAGNOSIS FOR AGE (5YEARS AND ABOVE), 2011 (N= 672,018)...... 15 TABLE 9: PNEUMONIA INCIDENCE FOR UNDER 5YEARS (%) 2008 TO 2011...... 17 TABLE 10: UPPER RESPIRATORY TRACT INFECTIONS INCIDENCE (ALL AGES), (%) FROM 2008 TO 2011 ...... 17 TABLE 11: NUMBER OF CHOLERA CASES (ALL AGES) ZANZIBAR – 2008 TO 2011 ...... 18 TABLE 12: DYSENTRY INCIDENCE (%) BY DISTRICTS, 2008 TO 2011...... 19 TABLE 13: SUMMARY OF MNAZI MMOJA DIABETIC CLINICS BY 2011 ...... 20 TABLE 14: NEW CASES OF DIABETIC COMPLICATIONS AT MNAZI MMOJA IN 2011...... 21 TABLE 15: NUMBER OF ROAD TRAFFIC ACCIDENT (RTA) REPORTED BY DISTRICT, 2010 VS. 2011 ...... 22 TABLE 16 : SELECTED RISK FACTOR PREVALENCE IN DIFFERENT COUNTRIES WHO, STATISTICS 2012 ...... 25 TABLE 17: IMMUNISATION COVERAGE UNDER ONE YEAR BY DISTRICTS, 2009 TO 2011 ...... 27 TABLE 18: UNDER 1 YEAR POPULATION PROJECTION VERSUS BCG VACCINATIONS > 1YRS BY DISTRICT ...... 28 TABLE 19: PENTAVALENT 1-3 DROPOUT RATE 2011 ...... 33 TABLE 20: TETANUS TOXOID VACCINE BY DISTRICT, 2009 TO 2011...... 34 TABLE 21: COUPLE YEAR PROTECTION RATE (CYP) INDICATOR CALCULATIONS...... 37 TABLE 22: COUPLE YEAR PROTECTION RATE (CYP) PER 1,000 COUPLES...... 37 TABLE 23: NUMBER OF FAMILY PLANNING USERS FOR LONG TERM METHODS 2010 VS. 2011 ...... 38 TABLE 24: PERCENTAGE OF NEW FAMILY PLANNING ACCEPTANCE RATE BY ZONE, 2008 TO 2011...... 39 TABLE 25: PERCENTAGE OF FAMILY PLANNING NEW CLIENTS BY DISTRICT 2010 VS. 2011 ...... 39 TABLE 26: CPAC REPORTS FOR 2011 ...... 40 TABLE 27: ANC FIRST VISITS COVERAGE BY ZONE, 2010 VS. 2011 ...... 41 TABLE 28: ANTENATAL FIRST VISITS BEFORE 16 WEEKS BY DISTRICT, 2010 VS. 2011 ...... 42 TABLE 29: ANC TESTING RATE ...... 43 TABLE 30: HIV & SYPHILIS PREVALENCE AT ANC, 2009 TO 2011...... 44 TABLE 31: IPT1&2 COVERAGE BY DISTRICTS AND ZONE - 2011 ...... 45 TABLE 32: NUMBER OF PREGNANT MOTHERS WHO ARE AT RISK FROM 2009 TO 2011...... 45 TABLE 33: PERCENTAGE FOR GROUP FOR PREGNANCY WHO ARE AT RISK 2011 ...... 46 TABLE 34: MALARIA RATE IN PREGNANT WOMEN ...... 46 TABLE 35: MALARIA IN PREGNANCY RATE BY DISTRICTS, 2010 VS. 2011 ...... 47 TABLE 36: SEVERE ANAEMIA RATE (%) IN 1ST ANC CLIENTS BY ZONE, 2010 AND 2011 ...... 47 TABLE 37: SEVERE ANAEMIA RATE AT ANC BY DISTRICT 2010 VS. 2011 ...... 48 TABLE 38: TRENDS IN PROPORTION OF HOSPITALS BIRTHS WITH LOW BIRTH WEIGHT, (2008 - 2011)...... 51 TABLE 39: MICRONUTRIENT NUTRITIONAL STATUS OF CHILDREN (YEAR)...... 53 TABLE 40: URINARY IODINE CONCENTRATION (MICROGRAMS/L) IN WOMEN OF 15–49 YEARS OF AGE...... 53 TABLE 41: PREVALENCE OF STUNTING AND UNDERWEIGHT IN CHILDREN (UNDER FIVE YEARS) IN PERCENTAGE AND ANNUAL AVERAGE CHANGE IN PERCENTAGE POINTS...... 54 TABLE 42: UNDER NUTRITION AMONG CHILDREN (UNDER 5 YEARS)...... 54 TABLE 43: TRENDS BY NUMBER OF INSTITUTIONAL DELIVERIES PER HEALTH FACILITY (2009-2011) ...... 58 TABLE 44: THE COMPARISON BETWEEN ANC VISITS AND DELIVERY BY HEALTH FACILITY...... 59 TABLE 45: PROPORTION OF EXPECTED DELIVERIES CONDUCTED IN HEALTH FACILITIES (2007 TO 2011)...... 60 TABLE 46: BIRTHS ATTENDED BY SKILLED PERSONNEL, 2007 TO 2011 ...... 62 TABLE 47: TYPE OF COMPLICATIONS IN MATERNITY WARDS, BY HOSPITAL, 2011...... 63 TABLE 48: OBSTETRIC CARE AND NEONATAL INTERVENTIONS...... 64 TABLE 49 : CAESAREAN SECTION RATE PER INSTITUTIONAL DELIVERY, (2009 TO 2011)...... 65 TABLE 50: TOTAL NUMBER OF MATERNAL DEATHS OCCURRED PER HOSPITAL, 2006-2011...... 66 TABLE 51 : INSTITUTIONAL MATERNAL MORTALITY RATIO, 2011 AND 2010 ...... 66 TABLE 52: HIV TESTING AMONG THE POPULATION BY DISTRICT, ZANZIBAR, 2010 AND 2011...... 68
vii TABLE 53: HIV PREVALENCE AMONG TESTED BY SEX, ZANZIBAR, FOR THE YEAR 2009, 2010 AND 2011...... 69 TABLE 54: HIV PREVALENCE AMONG TESTED BY AGE AND SEX, ZANZIBAR, 2011...... 69 TABLE 55: HIV PREVALENCE AMONG TESTED BY DISTRICT AND SEX, ZANZIBAR, 2011 ...... 69 TABLE 56: HIV POSITIVE CLIENTS RECEIVING HIV CARE AND TREATMENT SERVICES BY AGE AND SEX, 2011.....70 TABLE 57 : HIV +VE CLIENTS RECEIVING HIV CARE AND TREATMENT SERVICES BY HEALTH FACILITY, 2011...... 71 TABLE 58: DISTRIBUTION OF CASE NOTIFIED IN ZANZIBAR BY CATEGORY ...... 72 TABLE 59: NEW SMEAR POSITIVE BY AGE GROUP AND SEX FOR ZANZIBAR ...... 72 TABLE 60 : TB/HIV NOTIFICATION 2011 ...... 73 TABLE 61: TREATMENT RESULT OF NEW SMEAR POSITIVE TB PATIENTS NOTIFIED DURING YEAR 2010...... 73 TABLE 62: RESULTS OF TREATMENT OF SMEAR NEGATIVE AND EP TB PATIENTS NOTIFIED IN 2010...... 73 TABLE 63: TREATMENT RESULTS OF RE TREATMENT TB PATIENTS NOTIFIED IN 2010...... 74 TABLE 64: NOTIFICATION OF TUBERCULOSIS FROM 2005 – 2011 ...... 74 TABLE 65: NOTIFICATION IN 2011 ...... 74 TABLE 66: NOTIFICATION OF NEW LEPROSY CASES ...... 75 TABLE 67: AVERAGE LENGTH OF STAY UNGUJA VS. PEMBA ...... 77 TABLE 68: CAUSES OF ADMISSION IN ZANZIBAR HOSPITALS BY PERCENTAGE 2009 TO 2011...... 78 TABLE 69: ZANZIBAR HOSPITAL FATALITY RATE FROM 2008 TO 2011...... 78
viii LIST OF FIGURES
FIGURE 1: DATA FLOW DIAGRAM...... 2 FIGURE 2: PERCENTAGE OF TIMELINESS IN REPORTING BY DISTRICTS IN 2011...... 4 FIGURE 3: HIERARCHY OF SERVICE PROVISION ...... 6 FIGURE 4: TOP-10 NEW DIAGNOSIS IN ZANZIBAR HEALTH FACILITIES 5 YEARS+, 2011...... 15 FIGURE 5: PNEUMONIA INCIDENCE < 5YEARS UNGUJA VS. PEMBA 2008 TO 2011 ...... 16 FIGURE 6: BEHAVIOURAL RISK FACTORS AND NCDS WHICH WERE EXAMINED IN THE SURVEY ...... 23 FIGURE 7: THE PROPORTION OF THE POPULATION HAVING RISK OF METABOLIC COMPLICATIONS AS PER BMI...... 23 FIGURE 8: MEASLES CASES FOR PEMBA ZONE 2011 ...... 30 FIGURE 9: MEASLES CASES FOR UNGUJA ZONE -2011 ...... 31 FIGURE 10: PENTAVALENT 1-3 DROPOUT RATE - 2010 VS 2011 ...... 33 FIGURE 11: TT2+ FOR WRA ZANZIBAR...... 35 FIGURE 12: COUPLE YEAR PROTECTION RATE (CYP) PER 1,000 UNGUJA VS. PEMBA ...... 38 FIGURE 13: ANC FIRST VISITS COVERAGE BY ZONE, 2010 VS. 2011 ...... 41 FIGURE 14: FIRST ANTENATAL VISIT COVERAGE BY DISTRICTS ...... 42 FIGURE 15: ANC FIRST VISITS, INSTITUTIONAL DELIVERIES AND POST NATAL VISITS COVERAGE COMPARISON 43 FIGURE 16: HIV & SYPHILIS PREVALENCE AT ANC, 2009 TO 2011...... 44 FIGURE 17: TREND OF MALARIA IN PREGNANCY FROM 2007 TO 2011 ...... 46 FIGURE 18: VITAMIN A SUPPLEMENT FOR CHILDREN 6-59MONTHS - 2011...... 50 FIGURE 19: DE-WORMING COVERAGE FOR PREGNANT WOMEN...... 50 FIGURE 20: PERCENTAGE OF HOSPITALS LOW BIRTH WEIGHT, UNGUJA VS. PEMBA 2008 TO 2011 ...... 51 FIGURE 21: PERCENTAGE OF HOSPITALS LOW BIRTH WEIGHT ZANZIBAR, 2008 TO 2011...... 51 FIGURE 22: LOW BIRTH WEIGHT BY DISTRICTS FROM 2010 TO 2011 ...... 52 FIGURE 23: CHILD UNDER NUTRITION IN ZANZIBAR, 1992-2010...... 55 FIGURE 24 : DISTRIBUTION OF FACILITY DELIVERIES IN ZANZIBAR BY LEVELS ...... 60 FIGURE 25: ALL DELIVERIES IN ZANZIBAR BY LEVELS (HOME AND FACILITIES) ...... 61 FIGURE 26: BIRTHS ATTENDED BY SKILLED PERSONNEL ZANZIBAR (2007 TO 2011)...... 62 FIGURE 27 : TRENDS OF MMR IN ZANZIBAR (INSTITUTIONAL) FROM 2006 TO 2011...... 66 FIGURE 28: CAUSES OF MATERNAL DEATH IN PERCENTAGE 2011 ...... 67 FIGURE 29: HIV PREVALENCE AMONG TESTED BY DISTRICT, ZANZIBAR, 2010VS 2011 ...... 70 FIGURE 30: THE CHART BELLOW SHOW LEPROSY CASES DIAGNOSED IN 2011 ALL CASES ...... 75 FIGURE 31: BED OCCUPANCY RATE FOR ZANZIBAR HOSPITALS – (2010 AND 2011...... 76 FIGURE 32: AVERAGE LENGTH OF STAY BY HOSPITAL (2010 AND 2011) ...... 77 FIGURE 33: TOP TEN CAUSES OF DEATHS IN HOSPITALS, 2011 (N = 1943) ...... 79
LIST OF MAPS
MAP 1: CHOLERA OUTBREAK CASES COMPARISON IN PEMBA’S SHEHIA, 2009 TO 2011...... 18 MAP 2: BCG COVERAGE BY DISTRICT 2011...... 28 MAP 3: PENTAVALENT 3 COVERAGE UNDER-ONE YEAR BY DISTRICT, 2011...... 29 MAP 4: MEASLES COVERAGE IN ZANZIBAR 2011 ...... 30 MAP 5: MEASLES DISTRIBUTION CASES IN UNGUJA PHCUS...... 31 MAP 6: MEASLES CASES IN URBAN DISTRICT PHCUS ...... 31 MAP 7: FULLY IMMUNISED UNDER ONE YEAR COVERAGE, 2011 ...... 32 MAP 8: DISTRIBUTION OF DELIVERY HEALTH FACILITY UNGUJA AND PEMBA...... 57
ix Acknowledgements
This document is a product of joint concerted efforts and technical inputs from various stakeholders at different levels within and outside the Ministry of Health. On behalf of the Ministry of Health, the Health Management Information System (HMIS) Unit wishes to express its sincere thanks to all who participated in data collection, compilation and accomplishment of this bulletin.
It would be difficult to list the names of all who contributed to this bulletin, but to mention the few; we would like to acknowledge the special efforts made by Engineer Suleiman S. Ally Acting Head of HMIS, Ms. Zainab M. Mohd, Fatma Kh. Omar, Ms. Asha H. Ali from HMIS HQ, Ms. Sharifa Awadh Salmin Portfolio Coordinator GF round 8 Rafii J. Ali, Khamis H. Ukasha, Suleiman S. Hemed, Amour Lila, Faki Ismail Bakar from (DHMT), Mr. Suleiman Said, Omar Dadi Nahoda and Msanifu Othman from HMIS (Pemba Zone), Zeyana A. Hamid and Mlenge H. Mlenge of Epidemiology Unit, Abubakar Diwani SUZA, Others are from Pemba Zone Mr. Abdullah M. Ali, Abdulhamid A. Saleh – EPI Unit, Dr. Farhat J. Khalid from ZACP, Dr. Azzah Amin Said Nofly – IRCH, Issa Bakar Abdulrahman Environmental unit in the whole process of preparing this bulletin.
Special appreciation should go to Danida HSPS, Italian Cooperation( Ivo De Caneri Foundation -IdC), World Health Organisation as well as United Nations Population Fund (UNFPA) for their generous financial support in undertaking various HMIS activities and production of this Health Information Bulletin in particular. Sincere gratitude is directed to MOH consultants, Dr. Giovanna Paltrinieri of Ivo De Caneri Foundation, Mary Hadley and Jutta Adelin Jorgensen. Thanks to Lennard Hadley for his volunteer in designing the cover page for the bulletin.
The contribution of the Health Programme Managers for their full participation in producing this Bulletin is acknowledged. In particular in the quality of the information in this Bulletin was the result of the in depth analysis of the data relevant to their programmes.
The HMIS Unit expresses its heartfelt gratitude to all staff at the HMIS office, health facilities, DHMTs, ZHMTs and Mnazi Mmoja hospital who participated in data collection at the grass-root level, active contribution and important feedback provided during data cleaning and data use workshops.
Last but not least, to all those who contributed in one way or another in the availability and improvement of quality of health related data under HMIS. Without their participation and contributions this publication would not have been possible.
HMIS Unit, Ministry of Health P. O. Box 236 Zanzibar. E-mail: [email protected] URL: http://www.zanhealth.go.tz or http://www.hmis.zanhealth.go.tz
x Acronyms
ADD Acute Diarrheal Diseases ADLA Acute Dermatolymphangioadenitis AHB Annual Health Bulletin ANC Antenatal Clinic ARV Antiretroviral BCG Bacillus Calmette- Guérin BEmOC Basic Emergency Obstetric Care BOR Bed Occupancy Rate C/S Caesarean Section CEmOC Comprehensive Emergency Obstetric Care CFR Case Fatality Rate CPR Contraceptive Prevalence Rate CPT Cotrimoxazole Prophylactic Treatment CTC Care and Treatment Clinic DHIS District Health Information Software DKA Diabetes Ketoacidosis ENT Ear , Neck and Throat EPI Expanded Programme on Immunisation FANC Focused Antenatal Care FP Family Planning GIS Geographical Information System HIV and AIDS Human Immuno-deficiency Virus and Acquired Immuno-Deficiency Syndrome HMIS Health Management Information System ICT Immunochromatographic Card Test IEC Information, Education, and Communication IMCI Integrated Management of Childhood Illness IPT Intermittent Presumptive Treatment ITNS/LLINS Insecticides Treated Nets and Long Life Insecticides Nets MB Multibacillary MDA Mass Drug Administration MEEDS Malaria Early Epidemic Detection System MCH Mother and Child Health MDGS Millennium Development Goals MMR Maternal Mortality Ratio MMH Mnazi Mmoja Hospital MOHSW Ministry of Health and Social Welfare NBS 2002 TPHC National Bureau of Statistics 2002 Tanzania Population and Housing Census NCDS Non Communicable Diseases NHM – SCI Natural History Museum –Schistosomiasis Control Initiatives OPD Out Patient Department PAC Post abortion Care PIH Pregnancy Induced Hypertension
xi PB Paucibacillary PHCCs Primary Health Care Centres PHCUs Primary Health Care Units PHN Public Health Nurse PPH Post Partum Haemorrhage RCH Reproductive and Child Health RTA Road Traffic Accidents SMART Specific, Measurable, Achievable, Relevant and Time Bound STI Sexual Transmitted Infections STH Soil - Transmitted Helminthiasis TB Tuberculosis TBA Traditional Birth Attendant TB/HIV Tuberculosis/Human Immuno-deficiency Virus TDHS Tanzania Demographic and Health Survey THMIS Tanzania HIV and Malaria Indicator Survey TT Tetanus Toxoid URTI Upper Respiratory Tract Infection UTI Urinary Tract Infection WHO World Health Organisation WRA Women of Reproductive Age ZHSRSP II Zanzibar Health Sector Reform Strategic Plan II ZMCP Zanzibar Malaria Control Programme ZSGPR Zanzibar Strategy for Growth and Poverty Reduction
xii CHAPTER ONE 1. INTRODUCTION
The Annual Health Information Bulletin (AHB-2011) is the sixth annual publication in the series of AHB produced by the Ministry of Health under its Health Management Information System (HMIS) unit, Others AHB published on 2006, 2007, 2008, 2009 and 2010.
The bulletin provides information related to health service provision (both public and private) and demand for services. In addition it provides information on specific diseases and conditions presenting at the health facilities in Zanzibar. This information is intended for use in decision-making, planning of activities, monitoring and evaluation of health care delivery. The information in this bulletin has been aggregated from data collection tools that were designed to capture the routine health facility data, as well as information generated from periodic surveys. The HMIS is a well defined and functional system capable of providing complete, quality and up-to-date information that serves the need for providing relevant indicators to access the Millennium Development Goals (MDGs), Zanzibar Strategy for Growth & Poverty Reduction (ZSGPR II), Health Sector Strategic Plan (HSSP II) and health program performance.
The routine data are collected monthly from Primary Health Care Units and Centres (PHCUs & PHCCs), Private Dispensary, and different hospital departments through paper based system. The data are then compiled and analysed by using computerized through DHIS2 system at district. Hospital, Zonal, health programs and central level are using compiled data for further analysis.
Since 2009, HMIS has been using Geographical Information System (GIS) to analyse and portray information collected from health facilities. It is the concern of HMIS unit in collaboration with epidemiology unit to emphasise the utilization of GIS at all levels of Health Care System.
The quality of HMIS data has improved over the past six years. Regular audits are conducted and health workers reporting data are provided with encouragement and support. In Financial Year 2011 particular emphasis was put on the use of data at District and Hospital levels. The intended goals were both to further improve accurate and timely reporting and to increase the use of data to guide development of annual plans and for decision making using the data they have at hand.
Note: All series of the bulletins are available through the HMIS Website – www.hmis.zanhealth.go.tz
1 CHAPTER TWO
2. SOURCES OF HMIS DATA, QUALITY AND COVERAGE
The HMIS unit obtains its data from primary sources (routine data) and secondary sources (Tanzania Population and Housing Census-TPHC, National Surveys and other health related surveys). Routine data predominantly come from health facilities (Public and Private), while Census and Surveys data are obtained from The Office of Chief Government Statistician and from health programs, also the community data through health facilities. Human Resources data is obtained through the Human Resource Information System as a subset of HMIS data.
2.1 Primary data (Routine HMIS) Data are primarily collected in Health facilities (public and private) on daily basis using designed tally sheets and register books. The data are then summarised (manually) each month by health facilities operators, recorded on standardized paper tools and sent to the district offices. At district level and in the hospitals all data are entered into electronic database (DHIS2) and ready for an initial analysis. Zonal Medical Offices, Health Programs and Central level (HMIS), Epidemiology unit and management access, analyse and interpret data through online DHIS2 system. Annual Health Bulletins are disseminated at the Annual Joint Health Sector Review and ad hoc workshops and is published on the HMIS website. Hard and electronic copies are available through the Health Sector Reform Secretariat. Figure 1 shows the data flow profile.
Figure 1: Data flow diagram
2 2.2 Types of Data captured by HMIS unit There are two categories of data collection tools- monthly reporting forms for clinic and wards in hospitals and five different monthly summary forms used by PHCUs and PHCCs which are: 1. Immunization and Cold Chain Monitoring 2. Reproductive and Child Health 3. Disease Surveillance Report 4. STIs and HIV/AIDS Management 5. Maternity Ward Report
2.3 Coverage of report submission
Overall reporting coverage of HMIS tools continues to be high, with all forms reporting more than 95 percent for 2011. Disease surveillance is at (93.2%), Reproductive and Child Health (100%), Immunization & Cold Chain Monitoring (99.8%) and Maternity (99.4%). Since all health facilities (public and private) are providing diseases surveillance services, table below is also present breakdown of coverage for public and private. Reporting of Monthly diseases surveillance by the private health facilities remains lower than the public facilities, though there is an increase from 88.6 percent of 2010 to 91.2 percent of 2011. Reporting Reproductive and Child Health data has reached 100 percent, which is the expected rate for effective reporting coverage. Submission of maternity (99.4%) and Immunization & Cold chain monitoring (99.8%) although seems to be high but not good enough since are supposed to be at 100%
Table 1: Form submissions by type of form Form No. of unit Expected Form Coverage reporting form received (%) Reproductive and Child Health 152 1,824 1,824 100 Immunisation & Cold Chain 150 1,797 1,800 99.8 Monitoring Maternity 28 334 336 99.4 Diseases Surveillance 204 2,281 2,448 93.2
Average coverage Diseases Public 146 1,752 1,747 99.7 Surveillance Private 58 696 635 91.2
2.4 Timeliness of Reporting – example from immunization data. The HMIS data collection tools provide all the basic indicators for immunization program. The immunization indicators can manage the information users from National level to health facility level to analyze the data and take remedial action precisely. Basic data analysis is done at the health facility level while advanced analysis is done at district and national. A health facility is the administrative level where the vaccinations are taking place.
3 Health facilities send data to districts monthly for compilation and analysis. The districts monitor the timeliness of routine immunization reports monthly from each health facility
Figure 2: Percentage of timeliness in reporting by districts in 2011. The overall percentage of immunization timeliness reporting for 2011 is 75%. The National objective is to achieve timeliness of reporting that is greater than 80% at National level. Completeness of data is harmonized during the quarterly data cleaning meetings in each district.
2.5 Data quality
General condition of data quality is satisfactory due to several measures which have been taken to improve the quality of data. These include; Training on data managements at all levels of HMIS from National to health facilities Data use workshop, data cleaning and quality check exercise. Integrating Validation Rules functionality in DHIS2 database which automatically assist in detecting data errors Increasing of data users by different stakeholders are resulting the improvement of data quality. Sharing of data through online database (DHIS2) accelerate prompt data feedback from different users
However, there are some factors which still disturb the quality of data, thus are; Low commitments, knowledge and interest of data management for some staff especial doctors at hospital level Some Private hospital is not filling the forms, fill them by mistake or fill with a cooked data. Limited supportive supervision due to inadequate competent staff for doing data auditing.
4 CHAPTER THREE 3. HEALTH SYSTEM
3.1 Hierarchy of Health System
The Zanzibar health care system is made up of public and private sectors, with all people living within five kilometres of a public or private health facility. Recently, Zanzibar is far beyond that target. The majority of health care facilities are publically owned (34.6%). There are 80 private health facilities on Unguja, predominantly in Urban and West districts while on Pemba only eleven operating private health facilities are found. These are mostly situated in Chake-Chake district. In addition there are nine (11.2%) health facilities that are owned by Government defensive forces (Army, Police, JKU, KMKM and Prison); these facilities are categorized as Parastatal. The service delivery is supported and monitored by District Health Management Teams (DHMTs)
Health facilities in Zanzibar fall within three levels of health care delivery (see figure 3): i. Primary level :- Primary Health Care Units and Centres (PHCUs and PHCCs) ii. Secondary level: District Hospitals iii. Tertiary level: Mnazi Mmoja Hospital (including two specialized Hospitals).
There are 142 public health facilities; PHCUs (n=100) that provide Primary health care services PHCU+ (n=34) have been selected to provide additional services such as delivery, dental, laboratory and pharmacy services. (See Annex B) PHCCs (n=4) provide the same services as PHCU+, with the addition of inpatient and X ray services; District hospitals (n=3) (all in Pemba) provide second line referral services, including basic surgery Tertiary hospital (n=1) located in Unguja (Mnazi Mmoja Hospital) provides a full range of services and is intended as a referral hospital. Specialized hospitals (n=2) (Mwembeladu Maternity home and Kidongo Chekundu Mental Hospital) are located in Unguja and are administrated under the Mnazi Mmoja Hospital.
3.2 Utilization rate Utilization is a measure of how frequently people in a given catchment area use health facilities. Utilization rates provide an indication of the demand for a particular service and/or the availability of resources to provide that service. To some extent utilisation rates can guide District Health Management Teams or hospitals in the allocation of resources at the health facility level. “The Essential Health Care Package sets a target of one visit per adult per year to a health facility and 2.5 visits by a child under five years old”. 5 Figure 3: Hierarchy of service provision
3.2.1 Facilities OPD utilization rate (All age)
In year 2011, Zanzibar health facility OPD utilization rate is estimated to be 1.0; it means that on average every person in Zanzibar used a health facility OPD service once per year; thus meeting the EHCP target.. This rate is consistent with small increase with that of 2009 and 2010 (0.9). In 2011 OPD utilization rate of 0.9 in Unguja is slightly lower than that of Pemba (1.2); Differences are noted for individual districts (see Table 2). However, In Unguja Zone there is slight increase in utilization rate in all districts except West district. In Pemba there is a slight increase in utilization of OPD services in Wete and Mkoani, Chake Chake has decreased while Micheweni remained stable at 1.
Table 2: Health facility OPD utilization rates by all ages per District District 2009 2010 2011 Pemba Districts Chake Chake 1.0 1.7 1.4 Micheweni 0.9 1.0 1.0 Mkoani 0.7 0.7 0.9 Wete 0.9 1.0 1.5 Pemba 0.9 1.1 1.2 Unguja Districts Central 1.4 1.3 1.4 North A 1.0 1.0 1.2 North B 0.9 0.9 0.8 South 1.7 1.5 1.9 Urban 0.7 0.7 1.0 West 0.7 0.6 0.5 Unguja 0.9 0.8 0.9 Zanzibar 0.9 0.9 1.0
3.2.2 Facility OPD utilization rates under 5 years
Utilization rates for children under five are dependent on projections using under 5 years population based on the 2002 census data. HMIS data shows that OPD utilization rates for age under 5 years in Zanzibar are 2.1, i.e. each child under 5 years, on average, attended a facility for outpatient treatment at least twice in year 2011. This is close to the goal of 2.5 6 visits per year for this age group and is increasing over the past three years. OPD Utilization rate <5 continue to be lower in Pemba than in Unguja. Comparison between 2009 and 2011 shows a steady increase in OPD utilization in Micheweni, Mkoani, Wete, Central, North A, South, Urban, but a decrease in Chake Chake, North B and West (See table 3).
Table 3: OPD utilization rate for under 5years Districts 2009 2010 2011 Pemba Districts Chake Chake 1.7 2.8 2.4 Micheweni 1.6 1.6 1.8 Mkoani 1.2 1.1 1.4 Wete 2.0 2.0 2.6 Pemba 1.6 1.9 2.0 Unguja Districts Central 3.6 3.2 3.5 North A 1.9 2.2 2.7 North B 1.8 1.8 1.7 South 4.0 3.3 4.9 Urban 2.4 2.3 2.5 West 1.8 1.5 1.3 Unguja 2.3 2.1 2.2 Zanzibar 2.0 2.0 2.1
Utilization rates for all services for children under 5 years in the whole of Zanzibar have remained constant at 4.2 in 2009, 2010 and 2011. Closer analysis indicates the rise in Utilization rates <5 for all services in Pemba was offset by the slight decrease in Unguja in all Districts. In all districts in Pemba Utilisation rates for all services for children under 5 have increased over the past three years with exception of Chake Chake district. (See table 4).
Table 4: Utilization rates under 5 years (All services) Districts 2009 2010 2011 Pemba Districts Chake Chake 3.1 4.1 3.6 Micheweni 2.7 2.7 2.8 Mkoani 3.1 2.9 3.2 Wete 3.6 3.6 4.3 Pemba 3.1 3.3 3.5 Unguja Districts Central 7.5 7.2 7.6 North A 4.8 4.8 5.6 North B 5.8 5.5 5.3 South 9.5 8.7 10.9 Urban 4.9 4.6 4.7 West 4.1 4.1 3.3 Unguja 5.2 5.0 4.8 Zanzibar 4.2 4.2 4.2
7 CHAPTER FOUR 4.MDG, MKUZA & ZHSSP INDICATORS
4.1 Millennium Development Goal (MDG)
The UN (2000) Millennium Development Goals Programme committed countries rich and poor to eradicate poverty promote human dignity and equality and achieve peace, democracy and environmental sustainability. Concrete targets to promote development and reduce poverty were set and should be achieved by 2015 or earlier. Eight goals were set; three of which are directly related to health while the others have an indirect impact on health. The progress towards meeting the indicators for the three directly health related goals (goal 4 “reduce child mortality”, goal 5 “improve maternal health”, goal 6 “combat HIV/AIDS, malaria and other diseases”) and of the health indicators indirectly related to health (goal 1 “reduce poverty”) in Zanzibar is illustrated in Table 5.
4.2 MKUZA & HSSP The HMIS collects health-related data (to complement data obtained from national surveys) in annual basis for measuring the performance of Health sector and that can be used in Monitoring and evaluation of HSSP, MKUZA as well as MDG target. Table 6 contains selected health indicators collected from routine HMIS and from the national surveys (TDHS and THMIS).
8 Table 5: Millennium Development Goal (MDG) Indicators Target 2 015 1990 2002 2004/5 2006 2007 2008 2009 2010 2011 Status of Source Unicef Census TDHS progress Goal 1: Eliminate poverty % of underweight for age 19.5 39.9 Nil 19.0 19.9 Satisfactory in children under 5 years* National surveys % of stunting in children* 24.8 47.9 Nil 23.1 * * * 30.2 Unsatisfactory under 5 years Goal 4: Reduce child mortality Under-five mortality rate* 67 202 141 101 * * 79 * 73 Promising Census/National Survey
Infant mortality rate* 40 120 89 61 * * 54 * 51 Promising
Proportion of 1 year-olds 100 Na Na 82 87.1 88 86.5 95.8 77.7 85.7 On track HMIS Routine immunized against measles Goal 5: Improve maternal health Maternal mortality ratio ** 130 Na Na Na 528 365 422 279 287 284.7 More effort HMIS facility based needed Proportion of births 90 Na Na 51 62.5 47 44.5 43.1 49.2 47.1 Unsatisfactory National surveys/HMIS attended by skilled health personnel Goal 6: Combat HIV/AIDS, malaria and other diseases
Malaria prevalence rate* <49 49.2 46.2 44.6 * * < 1 Achieved THMIS/ZMCP _MIS
TB prevalence <24 24 Na 51 Na Na Na Na Na Na Survey is needed TB death Rate 5.5 Na Na Na 7.1 5.1 6.0 6 3.7% On track ZTLP Annual Report TB cure rate Na Na Na Na 85.0 82.0 88.9 83.3%
Malaria Death Rate ** Na Na Na Na Na 0.022 0.01 0.00 0.0 0.0 2
11 Goal 8 Develop A Global Partnership For Development: Target 17: In cooperation with pharmaceutical companies, provide access to affordable essential drugs in developing countries.
% share of the government budget to the health sector 8.10% 8.00% 9.60% 9.40 9.30% 5.30% 6.79% 6.35% MoH Chief Accountant’s Per capita total Office & POFEDP (Government, External and Budgeting Deportment complementary) allocation 26,937 27,205 25,308 28,322 25,853 22,599 to health
Note:* Indicators are available due to (TDHS and National Census), ** Available information from Health facilities.
12 4.3 MKUZA II MONITORING
The Ministry of Health (MOH) has taken considerable effort in monitoring MKUZA II and HSRSP II targets using routine data collected by HMIS. In assessing the MKUZA II targets of 2011, the bulletin of 2011 is providing a table 6 showing health and health related indicators which their availability are merely depends on MoH.
Table 6: MKUZA II HEALTH AND HEALTH RELATED INDICATORS Indicators Target 2010 2011 SOURCES GOAL 2.2: IMPROVED HEALTH DELIVERY SYSTEMS PARTICULARLY TO THE MOST VULNERABLE GROUPS B: INFANT AND CHILD MORTALITY (Reduce infant and under five mortality by 2015) Reduce neonatal mortality from 31/1000 in 2008 to 29 * DHS 15/1000 by 2015 Reduce infant mortality from 54/1000 in2008 to 51 * 48/1000 by 2015 Census/National Survey Reduce under-five mortality from 79/1000 in 2010 to 73 * 50/1000 by 2015
C: MATERNAL AND REPRODUCTIVE HEALTH Increase the proportion of from 51% in 2004 to 90% by 49.2 47.1 HMIS/National Survey births attended by skilled health 2015 personnel Increase percentage of births from 50% in 2008 to 60% by 42.2 43.2 HMIS delivered in health facilities 2015 Maternal mortality ratio from 473/100000 in 2007 to 287 284.7 HMIS- facility based reduced 170/100,000 by 2015 Increased use of modern from 9% in 2004 (TDHS, 12.4 * TDHS contraceptive 2004/05) to 20% by 2015 D. COMMUNICABLE DISEASES HIV prevalence rate among 15- from 0.6% in 2008 to 0.3% by 0.3 * ZACP- ANC Surveillance 24 years pregnant women 2015. reduced HIV prevalence rate among ZACP- ANC Surveillance general population maintained below 1% HIV prevalence rate among MARPs reduced by half 2015 HIV Prevalence among MSM from 12.3% in 2008 to 6.1% ZACP- ANC Surveillance reduced by 2015 HIV Prevalence among IDUs from 15.1% in 2008 to 7.5% ZACP- ANC Surveillance reduced by 2015 HIV Prevalence among CSW from 10.8% in 2008 to 5.4% ZACP- ANC Surveillance reduced by 2015 Morbidity and mortality ZACP- ANC Surveillance among people living with HIV & AIDS reduced by 80% by 2015 Incidence of malaria cases from 0.9% in 2008 to 0.5% 0.53 0.2 Routine HMIS reduced 2015 The percentage of under-five from 80% in 2009 to 100% by 71 * Malaria indicator survey sleeping under ITNs increased 2015 HIV/TB co-infection cases 51/100,000 in 2009 to reduced 24/100,000 by 2015 12 Reduce number of TB cases 369 in 2007 to 250 by 2015 270 280 ZTLP annual report E: NON-COMMUNICABLE DISEASES (NCDs) Strategic Plan for neglected tropical diseases implemented by 2015 F. HUMAN RESOURCES FOR HEALTH Proportion of skilled health from 52.6 % in 2009 to 60% personnel providing quality by 2015 EHCP services with particular focus on primary level increased GOAL 2.5 IMPROVE NUTRITIONAL STATUS OF CHILDREN AND WOMEN, WITH FOCUS ON THE MOST VULNERABLE GROUPS Underweight in children aged 6- 19% in 2010 to 15% by 2015 19.9 * 59 months National survey stunting in children aged 0-59 23% in 2010 to 20% by 2015 30.2 * months Anaemia in children aged 6-59 75% in 2010 to 60% by 2015 1.79 1.4 HMIS months This target need to be reviewed Anaemia in pregnant women 63% in 2010 to 40% by 2015 1.73 2.3 (baseline was not realistic) aged 15-49 year Goal 2.3: IMPROVED ACCESS TO WATER, ENVIRONMENTAL SANITATION AND HYGIENE B. ENVIRONMENTAL SANITATION AND HYGIENE The proportion of households from 83% in 2009 to 90% by * * Survey need to be done with access to basic sanitation 2015 increased
13 CHAPTER FIVE 5. DISEASE SURVEILLANCE
The outpatient morbidity data are obtained from public and private health facilities on a monthly basis. The information provided is derived from the standardized diseases surveillance reporting form that captures data on selected diseases, by sex and age, of clients as reported in health facilities. The diseases selected are priority public health concerns and reduction of which are likely to have major impact both socially and economically. In this section the most common diseases diagnosed at the health facilities are presented. The fifteen most frequently presenting diseases at health facilities (Top 15) for children under five years are ranked accordingly. Thereafter the ten most frequently presenting diseases for people aged five and above are ranked.
5.1 Most common reported diagnosis for new patients under 5 years
The HMIS data for 2011 show that the most common diseases reported for new patients are Upper Respiratory Tract Infections (URTI), Pneumonia, Diarrhoeal disease (exclude cholera and dystentry), skin diseases, conditions of the Ears Nose and Throat (ENT) and Head and neck, Intestinal worms, Eye diseases, Urinary Tract Infections (UTI), Trauma/ Injuries, Chicken pox, Dental diseases, Anaemia, (Moderate Acute Malnutrition), Dysentery, are the most common diagnosis reported in both private and public health facilities. Table 7 ranks the most common diseases as reported at all health facilities (private and public hospitals). This disease pattern (as presenting to a health facility) has been constant for the past five years.
Table 7: Under 5 years ‚‘Top 15‘Diagnosis, 2011 (N = 479,778) Diagnosis/Conditions NumberofnewCases Percentage URTI 178,495 37.2% Pneumonia 59,795 12.5% Diarrhoea (other than cholera and dystentry) 56,096 11.7% Skin diseases (other than leprosy, chicken pox) 39,551 8.2% ENT head and neck 26 ,413 5.5% Intestinal Worms 19,673 4.1% Eye diseases 15,609 3.3% Urinary Tract Infection (UTI) 13,453 2.8% Trauma / Injuries 11,445 2.4% Chicken Pox 7,583 1.6% Dental Diseases 4,279 0.9% Anaemia 3,627 0.8% Moderate Acute Malnutrition 3,101 0.6% Dysentery 2,408 0.5% Terminal hematuria/schistosomiasis 1,494 0.3%
14 5.2 Top 15 for age 5 years and above
In 2011 the most common diagnosis for new patients 5 years and above reported from all health facilities (private and public) are URTI, ENT head and neck, Skin other than leprosy, pox, Diarrhoea (other than cholera and Dysentry ), Dental Diseases, Trauma/Injuries, UTI, Intestinal Worms, Hypertension and Eye diseases, ( Table 8 )
Table 8: Top 15 Diagnosis for age (5years and above), 2011 (n= 672,018) Diagnosis Numberofnew Percentage Cases URTI 197,007 29.3% ENT head and neck 57,019 8.5% Skin (other than leprosy, chicken pox) 44,265 6.6% Diarrhoea (other than cholera and dystentry) 44,224 6.6% Dental Diseases 31,435 4.7% Trauma / Injuries 29,244 4.4% Urinary Tract Infection (UTI) 27,578 4.1% Intestinal Worms 26,911 4.0% Hypertension 22,483 3.3% Eye diseases 22,038 3.3% Anaemia 15,721 2.3% Pneumonia 15,212 2.3% Chicken Pox 10,315 1.5% Terminal hematuria/ Schistosomiasis 3,958 0.6% Dysentery 3,205 0.5%
Figure 4 shows top ten diagnosis for people aged 5 years and above
Figure 4: Top-10 new Diagnosis in Zanzibar health facilities 5 years+, 2011 N = 672,018
Other URTI diagnosis 29% Eye 25% diseases 3% Hypertensi on ENT head 3% UTI and neck 4% Intestinal Other 9% Worms Trauma / Dental Diarrhoea Other skin 4% Injuries Diseases diseases disease 4% 5% 7% 7%
15 5.3 Common Diseases for all ages 5.3.1 Pneumonia (prevalence)
Pneumonia is an infection of one or both lungs (the lower airways) caused by bacteria or viruses transmitted via aerosolized respiratory droplet spread. These droplets get into the air when the person infected with these germs during cough or sneezes. When a person breathes pneumonia causing germs into his lungs and his body’s immune system cannot prevent entry, the organisms settle in small air sac called alveoli and continue multiplying. Pneumonia and Acute respiratory infections (ARIs) represent the first cause of mortality among children under 5 years of age. In 2011 pneumonia is among the most frequent reasons for presenting at a health facility both for 5 years+ and for under 5 years of age. The accuracy of this data is reliant on accurate diagnosis by clinicians. WHO and UNICEF recommend the use of the Integrated Management of Childhood Illness (IMCI) strategy to diagnose and treat pneumonia in children under 5 years. As more health workers are trained in this programme the accuracy of the diagnosis of pneumonia is likely to improve.
Figure 5: Pneumonia incidence < 5years Unguja vs. Pemba 2008 to 2011
10
8 e g
a 6 t n e c
r 4 e P 2
0 2008 2009 2010 2011
Pemba Unguja
The incidence of pneumonia appears to be declining in Unguja steadily over the past four years while in Pemba the incidence rate appears to be relatively stable (see Figure 5).
For the year 2011 all districts in Unguja except North A, North B and South report a decreased incidence while in Pemba Micheweni, Wete and Mkoani districts report a higher incidence while Chake chake district reports a decreased incidence over the past two year from 8.7 (2010) to 7.3 (2011).
16 Table 9: Pneumonia incidence for under 5years (%) 2008 to 2011 District 2008 2009 2010 2011 Pemba Districts Chake Chake 7.5 4.3 8.7 7.3 Micheweni 11.4 9.7 9.0 9.1 Mkoani 4.7 3.4 2.8 3.1 Wete 8.6 7.9 7.5 8.6 Pemba Total 8.0 6.3 7.0 7.0 Unguja Districts Central 10.8 9.6 7.0 6.1 North A 9.4 7.4 5.2 5.4 North B 5.8 5.1 3.5 4.4 South 12.5 8.9 9.2 10.1 Urban 8.5 6.3 6.4 4.8 West 4.6 4.4 3.5 2.9 Unguja Zone 7.7 6.3 5.4 4.5 Zanzibar 7.8 6.3 6.0 5.4
5.3.2 Upper Respiratory Tract Infections (URTI) Upper respiratory tract infections (URTI) is the most common pathology for both adult and children. Upper respiratory tract infections (URTI) is the illnesses caused by an acute infection which involves the upper respiratory tract: nose, sinuses, pharynx or larynx. This includes: tonsillitis, pharyngitis, laryngitis, sinusitis, otitis media, bronchitis and the common cold. These illnesses are seldom fatal.
In 2011, URTI was the most common diagnosis reported in Zanzibar in both under and over 5 year olds. Over four consecutive years on both zones and all districts (with exception of North B and West), reported a definite increase in URTI. See table 10 below
Table 10: Upper Respiratory Tract Infections incidence (all ages), (%) from 2008 to 2011 Districts 2008 2009 2010 2011 Pemba Districts Chake Chake 21.2 27.9 34.3 34.4 Micheweni 15.1 25.4 28.7 32.0 Mkoani 15.1 21.0 20.7 24.5 Wete 20.0 31.77 38.3 46.4 Pemba 17.9 26.7 30.7 34.1 Unguja Districts Central 31.7 38.6 39.5 44.3 North A 21.9 24.3 26.7 33.6 North B 15.8 21.9 26.3 21.9 South 25.8 33.0 34.8 40.6 Urban 15.6 16.2 13.7 19.4 West 13.3 17.9 17.9 15.4 Unguja 17.9 21.3 21.3 23.0 Zanzibar 17.9 23.4 25.0 27.0
17 5.4 Epidemic Diseases 5.4.1 Cholera Cholera is a non invasive diarrhoea disease associated with poor sanitation. Zanzibar has been of experiencing seasonal epidemics of Acute Diarrheal Diseases (ADD) including cholera as most developing countries. The most common months during which cholera is reported coincide with the rainy season, i.e. the months of March to June and October to November every year. In 2011 there was no single case of cholera reported at a health facility in Zanzibar, whereas in previous years cholera epidemics were experienced (605 cases in 2009 and 248 cases in 2010. (see table 11 and map 1 ). These results may have been attributed to the positive impact of Oral Cholera Vaccination (OCV) intervention conducted by World Health Organisation.
Table 11: Number of cholera cases (all ages) Zanzibar – 2008 to 2011 District 2008 2009 2010 2011 Pemba Chake Chake 48 0 0 0 Micheweni 0 350 1 0 Mkoani 0 1 4 0 Wete 0 177 0 0 Pemba Total 48 528 5 0 Unguja Central 0 0 0 0 North A 0 1 51 0 North B 0 2 121 0 South 0 11 71 0 Urban 0 23 0 0 West 0 40 0 0 Unguja Total 0 77 243 0 Zanzibar 48 605 248 0
Map 1: Cholera outbreak cases comparison in Pemba’s Shehia, 2009 to 2011. Choleraoutbreak–2009 Choleraoutbreakin2010 Nocholeracases-2011
18 5.4.2 Dysentry (Diarrhoea with Blood)
Dysentry is an invasive diarrhoeal disease caused by bacteria presenting with bloody diarrhoea. In Zanzibar dysentery occurs as local epidemics especially during the rainy seasons along with other diarrhoea diseases.
In 2011 as shown in table 12, the incidence of Dysentery as reported by the health facilities has remained fairly constant in both Unguja and Pemba over the past four years at around 0.4 the only exception being Wete district, which reported an increases in the incidence rate while other Pemba districts have decreased in 2011. In Unguja, Urban district shows highest decrease;
Table 12: Dysentry incidence (%) by Districts, 2008 to 2011. District 2008 2009 2010 2011 Pemba Zone Chake Chake 0.65 0.48 0.58 0.5 Micheweni 0.59 0.30 0.48 0.4 Mkoani 0.20 0.39 0.29 0.2 Wete 0.35 0.33 0.32 0.5 Pemba 0.44 0.37 0.41 0.4 Unguja Zone Central 0.87 0.74 0.49 0.3 North A 0.34 0.33 0.14 0.3 North B 0.36 0.16 0.17 0.3 South 0.24 0.23 0.26 0.2 Urban 0.44 0.35 0.99 0.6 West 0.46 0.19 0.20 0.3 Unguja 0.46 0.32 0.50 0.4 Zanzibar 0.45 0.34 0.46 0.4
19 CHAPTER SIX 6. Non Communicable Diseases (NCDs) The MOH Zanzibar has identified and prioritized Non Communicable Diseases (NCDs) as a major concern of public health importance as it stipulated in Zanzibar Strategy for Growth and Poverty Reduction (ZSGPR) – MKUZA and Health Sector Reform Strategic Plan (HSSP). Diabetes Mellitus, Hypertension, Cancers, Road Traffic Accidents (RTA) are the most common NCDs presenting in the health facilities in Zanzibar.
6.1 NCD from Routine HMIS data Diabetes is one among the emerging Non Communicable Diseases (NCDs) affecting all age groups and both sexes. In the past few years, this disease had been increasing dramatically with multiple complications such as neuropathy, heart diseases and strokes, eye complications leading to blindness and diabetic foot ending in amputation. Some of the modifiable risk factors that contribute to developing diabetes (smoking, overweight, physical inactivity, inappropriate use of alcohol, and poor diet) also increase the risk of getting other NCDs such as Heart diseases, some types of cancer, and chronic lung disease. Therefore facility based diabetes prevalence can roughly be used as a proxy for prevalence of other NCDs if lacking reliable data.
6.1.1 Diabetes Mellitus (DM) at Mnazi Mmoja Hosp. Diabetic Clinic
The totals of 6,474 patients were registered in 2011 at Mnazi Mmoja Diabetic clinic, 44.04% were male while 55.96% were female. Others summary as shown in table 13 are: 1.96% of all patients attended at the clinic were children under 15 years, 17.83% were between 15 to 45 yrs of age 80.21% were above 45 years old. These reflect that DM in Zanzibar is not a disease of the aged population only but prevalent among adults in the reproductive age and children under 15 years. For newly diagnosed patient’s summary is narrated as follow: 332 (3.32%) of all 6,474 patients are newly diagnosed patients Out of 332 newly diagnosed patients 62 (18.67%) are classified as DM Type I, while 270 (81.33%) are classified as DM Type II.
Table 13: Summary of Mnazi Mmoja Diabetic Clinics by 2011 2011 Total
Categories < 15 years 15 - 45 yrs > 45 yrs All Number of Patient attended 127 (1.96%) 1,154 (17.83%) 5,193 (80.21%)
Male (attended) 46 540 2,264 44.04% Female (Attended) 81 614 2,929 55.96% New Diagnosed patients 12 105 215 3.32% T1 DM 12 50 0 18.67% T2 DM 0 55 215 81.33% 20 6.1.1.1 Number of Diabetic complications at Mnazi Mmoja in 2011
The most common complications of DM as seen at Mnazi Mmoja diabetes clinic are shown in table 14: Hypertension where 44.8% of all new diabetic patients also have hypertension, for newly diagnosed hypertension 64.5% were female and 35.5% were male This is followed by diabetic neuropathy (30.7%) of all diabetic new patients, for newly diagnosed neuropathy 41.3% were female and 58.7% were male Erectile dysfunction at 10.0% for all newly complications, foot complications with 7.1%, for newly diagnosed foot complication 29.2% were female and 70.8% were male Diabetes in pregnancy at 3.2%.
These figures indicate the possibility of existence of higher number of Diabetes and other NCDs in population.
Table 14: New cases of Diabetic complications at Mnazi Mmoja in 2011 Diagnosis Female Female Male Male Total % by case (%) (%) cases Diabetic with hypertension 98 64.5 54 35.5 152 44.8 Diabetes Neuropathy 43 41.3 61 58.7 104 30.7 Erectile dysfunction 0 0.0 34 100.0 34 10.0 Diabetic foot 7 29.2 17 70.8 24 7.1 Diabetes in Pregnancy 11 100.0 0 0.0 11 3.2 Stroke 2 50.0 2 50.0 4 1.2 Diabetic with Cataract 2 50.0 2 50.0 4 1.2 Other diabetic diagnoses 2 50.0 2 50.0 4 1.2 Diabetes ketoacidosis (DKA) 1 50.0 1 50.0 2 0.6
6.1.2 Road Traffic Accident (RTA), 2011
The number of Road Traffic Accidents has been decreased from 3,447 to 3,178 over the past year. The majority of injuries are among men (63.2%), reflecting on the Zanzibar culture resulting in more men being on the road than women. The number of accidents reported at the health facilities in table 15 (n=3,178). As it was expected, Urban district is leading with 37.8 percent followed by Chake Chake district with 13.0% of all reported cases of RTA.
21 Table 15: Number of Road Traffic Accident (RTA) reported by district, 2010 vs. 2011 District 2010 2011 Male 2011 Female 2011 Pemba Districts Chake Chake 717 414 296 118 Wete 512 255 138 117 Micheweni 190 111 87 24 Mkoani 77 94 64 30 Pemba 1,496 874 585 289 Unguja Districts Urban 732 1,202 732 470 North A 451 353 244 109 West 346 295 190 105 South 232 188 121 67 North B 99 38 24 14 Central 91 228 113 115 Unguja 1,951 2,304 1,424 880 Zanzibar 3,447 3,178 2,009 1,169
6.2 NCD risk factor survey 2011
Ministry of Health Zanzibar conducted a National NCD survey in June-July 2011 to estimate prevalence of risk behaviour and selected NCDs. Also risk behaviour and prevalence of injuries, and mental health status was assessed. As time goes on the Chronic non-communicable diseases (NCDs) such as cardiovascular diseases, cancers, chronic obstructive pulmonary disease and diabetes have become a major public health problem globally and is an emerging problem in developing countries to a degree where WHO calls it an epidemic. The survey was the first of its kind in Zanzibar.
Multi-stage sampling with stratification was used to include all districts in Zanzibar. 2,772 residents aged 25 to 64 years were sampled of which 98.2% was enrolled in the study. Unified and standardized protocols and tools were used. The field survey was conducted from June to July 2011 and each participant underwent a face to face interview, physical measurements and blood sample test. The completion rate was 94% among the enrolled participants.
Information on behavioural risk factors was collected. Body height and weight, waist and hip circumference and blood pressure were measured. Blood samples were collected to test blood glucose, cholesterol and triglyceride.
The risk factors mentioned below are all in different combinations related to an increased risk of developing mainly the four large groups of diseases Cardio-Vascular diseases (CVD), Diabetes mellitus (DM), Chronic Obstructive Lung Disease (COPD), and cancers.
6.2.1 Selected risk factors and prevalence of NCDs
Behavioural risk factors are associated with four key metabolic and/or physiological changes – raised blood pressure, increased weight, raised blood sugar and raised blood fats. These changes can have multiple effects. For instance, in addition to its direct role in diabetes, raised fasting blood glucose also increases the risk of CVDs. And the diseases are interlinked, for instance is Hypertension both a disease in itself and a risk factor for other CVDs such as Stroke and Heart Failure.
22 The risk of developing especially DM and CVD but also certain cancers is increasing the more risk factors the individual has. This has led WHO to say that if an individual has three or more of the risk factors smoking, physical inactivity, low intake of fruits and vegetables, raised blood pressure and overweight/obesity, the risk of developing one of the mentioned disease s is substantially increased.
Figure 6: Behavioural risk factors and NCDs which were examined in the survey
Intermediate risk Non-communicable Modifiable risk factors factors disease
•Tobacco •Raised BP •Diabetes •Alcohol •Overweight •Hypertension •Physical inactivity •Raised fasting glucose •Diet low in fruit and •Raised blood lipid vegetables
6.2.2 Some selected results for NCDs survey in Zanzibar
6.2.1.1 Overweight and obesity Being overweight can lead to adverse effects on blood pressure, levels of blood fats, and blood glucose metabolism. Being overweight or obese thus increases the risk of CVD, Diabetes, and a number of common cancers.
In the survey, the prevalence of obesity as a measure of ‘substantially increased risk’ for metabolic complications was found to be 14.3%. Prevalence of obesity was significant higher in urban than in rural areas (21.1% in Urban Unguja against 9.9% in rural Unguja and 7.4% in Pemba).
When waist-hip ratio (WHR) was used to determine ‘substantially increased risk’ the prevalence was found to be 33% among men and 72.6% among women. Especially for women WHR and Waist Circumference (WC) are more precise than Body Mass Index (BMI) to estimate metabolic risk because it is the abdominal fat which is the risk, not the weight as such.
Figure 7: The proportion of the population having risk of metabolic complications as per BMI.
Women
BMI WC WHR Men
0 20 40 60 80
23 Three out of four women, and one out of three men had unhealthy high WHR and hence at risk for metabolic complications as described in the beginning.
NB: Waist Circumference and Waist-Hip-Ratio. Cut-offs for substantial increased risk for men (M) and women (W): BMI > 30 kg/m²; Waist circumference 102 cm (M) and >88 cm (W), and Waist–hip ratio ≥ 0.9 (M) and 0.85 (F).
The levels of obesity seen in Zanzibar is far higher than what is observed in neighbouring countries and approaching levels seen in more developed countries. Furthermore, we saw that when using the more sensitive WHR instead of BMI for risk prediction there was a dramatic increase in those being at risk.
6.2.1.2 Physical activity The levels of physical activity was found to be overall high with difference between men having high levels at 80.0 (CI4.8) against women 50.7% (CI4.3). There was a significant difference between urban (50.1%) against rural areas (Unguja 72.5%; Pemba 81.1%) in prevalence of high levels of physical activity. The prevalence of people being physically inactive was 17.6% (CI3.1) with 7.4% (CI1.8) of men against 26.8 (CI4.6) of women, which seems to be average for the region.
6.2.1.3 Combination of risk factors
The five most important risk factors for developing especially Diabetes Mellitus (DM) and CVD are smoking, insufficient intake of fruits and vegetables, sedentary lifestyle, overweight/obesity and raised BP. In Zanzibar it was found that the prevalence among people of having three or more of these risk factors was 24.2% with slightly higher prevalence in urban than in rural areas. This means that roughly a quarter of the population between 25 and 64 yrs of age are at increased risk of developing a NCD in the (near) future.
6.2.1.4 Raised blood pressure / Hypertension Since Hypertension cannot be diagnosed on one single day’s blood pressure (BP) measurements the prevalence we got in the survey are of raised BP suggestive of Hypertension. The overall prevalence of raised blood pressure (BP) above 140/90 mmHg was 33.0% (CI±4.2). Among all 45-64 years old 60.7% (CI±4.1) had a BP suggestive of hypertension of any kind, and 34.4% (CI±4.4) had a BP suggestive of moderate to severe hypertension. There was no significant difference between the genders and urban or rural areas when it came to raised blood pressure.
World Health Report 2012 estimated that 27% of adults worldwide have raised blood pressure, and the figure is even higher in African countries, which have experiencing an increase in population prevalence of raised blood pressure in recent years. Some wealthier countries in the region reach prevalence of 40% or above. Zanzibar is hence placing itself in the high end globally concerning prevalence of raised blood pressure and at a level comparable to or just below other countries in the region (see table 16)
6.2.1.5 Raised Blood Glucose levels / Diabetes
Prevalence of raised fasting blood glucose indicating Diabetes Mellitus was 3.7% in the surveyed population, and Impaired Fasting Glucose, IFG, (also called pre-diabetes) was found to be at 2.8 %. 24 Diabetes Mellitus is a disease in itself however as mentioned, it also increases the risk of developing NCDs for example CVD.
Raised Blood Glucose levels places Zanzibar on the lower side when it comes to prevalence of Diabetes both regionally and globally. Considering the prevalence of risk factors leading to Diabetes, especially overweight and physical inactivity, it is very likely that the prevalence will increase continuously over coming years when the consequences of raised metabolic risk kicks in.
Table 16 : Selected risk factor prevalence in different countries WHO, Statistics 2012 Zanzibar Ethiopia Zambia Uganda Kenya Ghana South United Africa Kingdom Behavioural risk factors Smoking 7.3 2.4 10.1 6.8 9.3 4.4 14.0 17.3 Physical inactivity 17.6 17.9 15.2 * 15.4 16.1 51.1 66.5 Intermediate risk factors Overweight 36.6 7.4 15.7 19.9 18.7 28.9 65.4 64.2 Obesity 14.3 1.1 3.6 4.3 4.2 7.5 31.3 26.9 Raised BP 33.0 35.2 40.1 * 37.0 36.4 42.2 43.5 Raised FBG 3.7 * 6.1 * * 8.8 10.6 8.3 Raised cholesterol 24.5 * 26.2 * * 17.6 34.0 65.6 * Information is not available.
6.2.1.6 Accidents and injuries Prevalence of accidents leading to injuries within the last year was 13.2% with 4.5% of the population having been injured in a RTA and 9.9% in other accidents, mainly work related and of the types fall injury or cut wounds. The prevalence of protective behaviour on the road such as always fastening seat belt (5.9%) or wearing of helmet (15.7%) was assessed. Permanent disabilities due to accidents and injuries were not assessed.
6.2.1.7 Mental health The prevalence of self reported symptoms of anxiety/depression was 6.8 % when using a relatively high cut-off for positive symptoms. This was significantly higher than the prevalence of those already diagnosed with a mental disease (any diagnosis) which stood at 1.6%.
The results of the survey give invaluable information on the situation of selected NCDs and risk factors in Zanzibar and directions for interventions as well as future studies to undertake.
25 CHAPTER SEVEN 7. CHILD HEALTH AND IMMUNISATION
7.1 Expanded Programme on Immunization (EPI)
The goal of the immunization programme in Zanzibar is to contribute the reduction of morbidity and mortality for children under five years due to vaccine preventable diseases. Immunization is widely recognized as critical to achieve the Millennium Development Goals (MDGs). The Global Immunization Vision and Strategy (GIVS) tell regarding the contribution of immunization to achieve MDG-4: Vaccination against the eight targeted diseases is provided by EPI through strategies that include static (health facilities), outreach and national campaigns to ensure that all eligible children are reached. The international target for coverage of all antigens is 90% and 70% for Tetanus Toxoid administered to pregnant women.
The Penta 3 vaccine is used as proxy indicator to assess the performance of the immunization programme. This is the third (last) dose of Pentavalent which comprises Diphtheria, Pertussis, Tetanus, Hepatitis-B and Haemophilus influenzae type-B (introduced in Zanzibar in 2009).
The objectives of EPI is to achieve and maintain at least 90% vaccination coverage in Zanzibar, with each district achieving vaccination coverage of at least 90% and above. Also, to maintain poliomyelitis-free status until global eradication and subsequent certification are achieved. The Programme also aims to eliminate measles by 2015 from all districts and eliminate maternal and neonatal tetanus in Zanzibar by the end of 2011.
The population under one year used as the denominator to calculate immunization coverage is based on projections from the National Bureau of Statistics (NBS), 2002 Tanzania Population and Housing Census (2002 TPHC). The coverage over 100% for BCG could be a result of under estimation of the population projections used as denominator. Since the coverage of BCG is over 100% it is likely that the true coverage for fully immunized children is below the reported proportion (see section below). Summary of the routine immunization performance for all antigens and overall immunization coverage for 2009 to 2011 are depicted in the table 17 below.
26 Table 17: Immunisation coverage under one year by districts, 2009 to 2011
BCG (%) Penta – 3 (%) Measles (%) Fully Immunized (%) 2009 2010 2011 2009 2010 2011 2009 2010 2011 2009 2010 2011 Chake chake 97 114 103 79.1 77.3 79.5 85.7 62.5 76.2 85.5 61.6 74.1 Micheweni 82.1 83.2 81.5 66.4 64.4 70.1 63.6 53.7 65.7 62.6 52.2 63.4 Mkoani 70.7 76.9 71.7 63 60.6 61.1 67.2 55.9 61.3 67.1 56.2 61.2 Wete 109 109 135 88 81.7 100 95.2 67.9 98.7 89.9 65.6 98.1 Pemba 89.4 95.4 96.2 74 70.9 76.7 77.8 60 74.2 76.2 58.9 73.2 Central 104 104 115 116 130 126 128 113 121 124 108 115 North A 83.8 86.6 88.2 76.3 85.7 75.3 79.1 74.5 77.2 79.1 74.5 76.8 North B 81 87.5 88.8 73.2 80.3 80.5 86.8 81.5 84.4 63 75.4 81.1 South 81 86.4 97.8 112 109 121 119 103 115 118 102 110 Urban 214 201 213 90.3 121 116 97.4 110 120 90.9 101 107 West 114 122 98.5 102 108 75.8 111 91.4 80.2 109 87 74.5 Unguja 133 132 127 99.9 107 92.2 112 94.6 95 106 89.7 88.5 Zanzibar 112 114 113 87.5 89 85.2 95.8 77.7 85.7 91.8 74.6 81.6
7.1.1 The Overall Immunization Coverage The overall immunization coverage (Penta3) dropped from 89 percent in 2010 to 85.2 percent in 2011 which is below the national target (90%). However, three districts in Unguja (South, Urban, and Central) reported to be above coverage. West district has sharp decrease in coverage which alarming for more investigation. All districts in Pemba are below the target except Wete (100%). Zone wise Unguja (92.2%) is above the target while in Pemba (76.7%) is below target. (For more elaborative see table 17)
7.1.2 BCG Coverage
Bacille Calmette-Guerine (BCG) vaccine is given at birth or at first contact to health facility. The overall coverage rates reported exceeding 100% reflect the problem may be caused by inaccurate population data. The denominators (under one year) from census projections are likely to be underestimated in Unguja zone and over estimated in Pemba zone.
Zanzibar as a whole in 2011 reported 113.2 percent, Unguja recorded 127.3% while Pemba has increased from 95.4% to 96.2%, although Chake Chake and Wete Districts are still above the national target of 90%.
The exceptionally high BCG coverage reported in Urban districts can be explained by the tertiary hospital, Mnazi Mmoja being situated in this district where BCG vaccine is offered to the 10,000+ infants born in this hospital
27 Map 2: BCG coverage by district 2011 Key
7.1.3 Under 1 year’s projection vs. BCG.
As already mentioned, since total coverage for the whole of Zanzibar for BCG is reported as over 100% it is unlikely that the coverage for fully immunized children reflect the real situation and investigations are underway to resolve this issue.
There is a 15% discrepancy between the 2011 population projection from National Bureau of Statistics (NBS) and the total children vaccinated against BCG (see table18). This difference of nearly 8,344 children is mainly on Unguja (29%) and is almost the size of an average district.
Table 18: Under 1 year population projection versus BCG vaccinations > 1yrs by District District Projection BCG 2011 2011 Chake Chake 6,136 6,303 Micheweni 6,363 5,188 Mkoani 6,505 4,747 Wete 5,453 7,393 PEMBA 24,457 23,631 Central 2,254 2,610 North A 4,721 4,213 North B 2,835 2,533 South 1,080 1,057 Urban 7,777 16,630 West 10,895 10,746 UNGUJA 29,562 37,789 ZANZIBAR 54,019 61,420
28 7.1.4 Penta Coverage
During 2011, the overall Penta 3 coverage for Zanzibar was 85.2 %. In each of Pemba districts there was a welcome increase of between 2% and 6% from 2010 coverage rates. This decreased the gap between Unguja Penta 3 coverage and those of Pemba. While two districts in Unguja attained an increase in coverage of this vaccine (South and North B) the remaining districts reported a decrease in coverage. Particularly alarming is the decrease in coverage of West and Kaskazini A are below 80 percent which is far away from the national target (90%).
Map 3: Pentavalent 3 coverage under-one year by district, 2011 Key
7.1.5 Measles coverage 2011
Measles coverage has tremendously increased in Zanzibar from 77.7% (2010) to 85.7% (2011), there was a marked increase in all districts except for West in 2011. The stock outs that were linked to the low coverage rates in 2010 did not occur in 2011.
29 Map 4: Measles coverage in Zanzibar 2011 Key
7.1.1.1 The measles cases in 2011 Measles disease are being protected by measles vaccine, despite the ongoing measles vaccine services still there was outbreak of 1,211 Measles cases in Zanzibar. Out of these their vaccination statuses were as follows: 274 were vaccinated, 621 were unvaccinated and 316 were unknown. Regardless of the seriousness of the outbreak there is no death occurred.
7.1.1.1.1 Measles outbreak in Pemba zone
The outbreak in Pemba zone started in July in all district with up and down trend untill December. Chake Chake reported heighest number of cases.
Figure 8: Measles cases for Pemba Zone 2011
30 7.1.1.1.2 Measles outbreak in Unguja zone
The outbreak in Unguja zone started in May in West district while other districts started in July with up and down trend untill December. West district reported heighest number of cases.
Figure 9: Measles cases for Unguja Zone -2011
Map 5: Measles distribution cases in Unguja PHCUs Map 6: Measles cases in Urban District PHCUs
31 7.1.6 Fully Immunized
The overall Fully Immunized coverage has risen from 74.6 % in 2010 to 81.6% in 2011. The coverage increases are similar to those of the measles vaccine and they are intrinsically linked. Details of coverage rates are found in Map 7.
Map 7: Fully immunised under one year coverage, 2011 Key:
7.2 Immunization Drop-out Drop- outs in immunization refer to children who have used immunization services, but do not return for subsequent vaccinations. Drop out ratios should not exceed 10 percent; beyond that, it indicates a problem of either access or utilization of services. Calculation of dropout rates are particularly useful if coverage rates of over 100% are reported since they are related to children who have already presented at a facility rather than population projections for children under one year.
A negative dropout rate indicates that there are MORE children getting the later vaccines than those getting the earlier vaccines. Reasons for negative drop outs in districts can be due to movement of children between districts. However, more likely will indicate data inconsistency and poor data quality, poor understanding and filling of forms by facility staff, stock outs of some vaccines or inclusion of children above one year.
32 7.2.1 Pentavalent 1-3 dropout rate
Table 19: Pentavalent 1-3 dropout rate 2011 Zone Percentage Pemba 3.46 Unguja 2.89 Zanzibar 3.13
Figure 10: Pentavalent 1-3 dropout rate - 2010 vs 2011
30 26.5 24.1 25 18.8 20 16.1 15 10.5 11.4 11.2 11.1 8.93 10 6.40 4.52 4.96 5 3.45 0.4 0 -0.34
-5 -2.53 -3.54 -3.88 -2.90 -10 -6.6
2010
All districts in Zanzibar report a drop rate of less than 10 percent in 2011 which is completely difference in 2010, whereby only two districts was less than 10 percent. Many factors could explain the negative dropout rates in Wete, Central, North B and South Districts and should be under investigation.
In 2011, zero cases of Pertussis, Diptheria, Tetanus in children, Hib and Hepatitis-B were reported.
7.3 Tetanus Toxoid Vaccine (TT) Tetanus toxoid vaccination is provided during ANC visits as an intervention to protect newborns against neonatal tetanus. A woman with reproductive age is offered 5 doses of TT vaccine to provide full coverage for the newborn and her against tetanus following delivery. Pregnant women with an unknown vaccination history of full course of TT vaccine are offered a booster dose.
There are three indicators in the HMIS that are used to evaluate the degree of protection against neonatal tetanus. The indicators are: 1. TT2+ coverage for pregnant women (reports the proportion of pregnant women receiving the second TT vaccine during ANC visits) 33 2. Children born protected (reports the proportion of children whose mothers has received at least two doses of TT (TT2+) of complete vaccination course in the past). 3. Vaccination to WRA.
7.3.1 TT2+ to pregnant
The indicators related to children born protected and the TT2+ to pregnant women give different values. The two measures give different values, with children born protected showing 69.5 percent and TT2 at ANC at 46.3 percent. Both of these are slightly decrease consecutively from 2009 to 2011
Table 20: Tetanus Toxoid vaccine by district, 2009 to 2011 Children born protected Rate (%) TT2+ to Pregnant Women rate (%) 2009 2010 2011 2009 2010 2011 Chake Chake 75.4 74.8 80.5 64.4 58.9 45.7 Micheweni 75.7 73.0 77.5 53.9 33.1 34.5 Mkoani 65.2 61.7 63.0 46.0 28.9 35.2 Wete 83.7 82.2 82.7 65.6 68.1 63.9 Pemba Zone 75.2 73.1 75.9 57.7 47.9 44.7 Central 63.1 65.7 63.6 40.1 43.2 41.3 North A 72.5 76.8 71.5 36.1 37.2 39.9 North B 53.2 55.0 55.0 32.0 32.7 37.2 South 62.1 53.5 68.8 25.1 25.5 30.6 Urban 74.4 79.3 75.3 71.3 69.2 67.4 West 65.5 79.9 44.3 50.1 47.8 47.6 Unguja Zone 70.0 73.7 63.1 53.0 50.4 47.2 Zanzibar 71.6 74.3 69.5 65.5 53.3 46.3
The lower level of TT2+ coverage for pregnant women can be explained by the fact that many women are multiparous and have therefore received a full course of Tetanus Toxoid in previous pregnancies. There were no reported cases of neonatal tetanus in 2011.
7.3.2 TT 2+ Coverage for WRA in Zanzibar 2011
TT coverage of Women of Reproductive Age (WRA) (reports the proportion of women of reproductive age that have received full protection against TT in a given year). The process of vaccinating school girls with reproductive age against Tetanus is also provided on routine basis. In 2011, Zanzibar managed to vaccinate 6.7 percent of WRA with TT 2+, zone wise Pemba coverage is higher compared to Unguja.
34 Figure 11: TT2+ for WRA Zanzibar 8 6.7 8 6 7 6 5 4 3 2 1 0 Zanzibar Pemba Unguja
35 CHAPTER EIGHT
8. REPRODUCTIVE HEALTH
The role of the health sector in strengthening Reproductive Health (RH) is to ensure the availability and accessibility of good quality and essential reproductive health services to men, women and adolescents in Zanzibar.
Reproductive Health Services including Antenatal care (ANC), postnatal care (PNC), family planning (FP) and Syndromic Management of STIs are provided in Primary Health Care Units (PHCUs) throughout the country. Deliveries and post abortion care (PAC) services are provided in PHCU+, PHCC and Hospitals. In addition to the above services, Hospitals also offer blood transfusion and management of complications associated with delivery.
There are 156 health facilities offering RCH services in Zanzibar, of which 64 (41%) are located in Pemba and 92 (59%) in Unguja. These include 149 (96%) Government and 7(4%) are privately owned.
8.1 Family Planning Zanzibar has good Family Planning (FP) service infrastructure with most of the population living within five kilometres of a health facility. However, utilisation of these services, still remains below the National target. Data disaggregated by Zone indicates marked differences between Pemba and Unguja. Family Planning coverage and facility delivery rates are consistently lower in Pemba compared to Unguja
8.1.1 Contraceptive prevalence Rate (CPR)
Contraceptive prevalence Rate (CPR) is the Family Planning indicator which measures the level of FP use among WRA. In Zanzibar, this is measured after every four years through Tanzania Demographic health survey (TDHS). In 2009/2010 TDHS shows a CPR of 12.4 percent. Calculating CPR using routine data has not been possible due to unreliable data cumulatively collected with default and non-existing users that were not being updated routinely in registers and family planning cards. However, using Couple Year Protection Rate (CYP) as proxy indicator shows protection rate of unplanned pregnancy is at 20 percent for Unguja couples and 6 percent in Pemba.
8.1.2 Couple Year Protection Rate (CYP)
Couple Year Protection Rate refers to the estimated protection provided by contraceptive methods during a one year period, based on the volume of all contraceptives. It is calculated, using routine data by multiplying the number of each commodity distributed, taking into account the amount of that commodity needed to protect a couple from obtaining a birth for one year. The following table provides factors used to calculate CYP.
36 Table 21: Couple Year Protection Rate (CYP) indicator calculations Method Factor Method Factor Oral contraceptives (# of Cycles) / 13 Tubal Ligation (# Persons) X 10 Depo Provera injection (Vials) / 4 Male Sterilisation (# of Persons) X 15 Condom (Pieces) / 250 IUCD (Pieces) X 4 Implant (Pieces) X 4
Using the formula given above, table 22 presents estimations of couple year protection rates for 2009, 2010 and 2011. In both Islands injection is preventing more couple compared to other methods. While in Unguja every 1,000 couple (or WRA), 57 were protected by injection, in Pemba out of 1,000 couple, 21 were protected with this method. In Pemba the CYP by Injectable methods are found to be high followed by Implanon and tuba-ligation, and the least is CYP by condom with the ratio of 1 out of 1,000 couple. In Unguja the CYP by injection are found to be high followed by Implanon, and the least CYP is IUCD with ratio of 4 out of 1,000 couple.
Table 22: Couple Year Protection Rate (CYP) per 1,000 Couples CYP by Methods 2009 2010 2011 Pemba by Implanon 19.5 11.5 11.9 methods Injection 16.6 20.5 21.2 IUCD 3.3 4.4 3.6 Condoms 0.8 0.9 0.9 Oral Pill 14.4 7.5 10.4 Tuba ligation 3.2 3.6 11.9 Pemba CYP total 57.8 48.4 59.9 Unguja by Implanon 25.2 49.3 48.6 methods Injection 63.2 56.2 56.6 IUCD 1.6 5.3 3.7 Condoms 6.4 4.6 4.1 Oral Pill 44.1 16 22 Tuba ligation 7.2 1.3 5.9 Unguja CYP total 147.7 181.1 200.8 NB: Denominator used is WRA for each zone
The figure 12 illustrates an increased CYP in both Unguja and Pemba in 2011 compared to 2010. This means in 2011, in every 1,000 couple (WRA), 60 were protected from having unplanned pregnancy in Pemba, while in Unguja out of 1,000 couple (WRA), 201 was protected. Due to reality that the frequency of delivery is higher in Pemba compared to Unguja, the CYP in Pemba indicating the need of more community sensitization of family planning.
37 Figure 12: Couple year protection rate (CYP) per 1,000 Unguja vs. Pemba 250 201 200 e l p
u 181 o 150 c
0 148 0 0 , 100 1
r 58 e P 50 60 48 0 2009 2010 2011
Pemba CYP Unguja CYP
8.1.3 Family planning Users for long term method 2010 and 2011
Number of long term family planning users has highly increased in year 2011 compared to 2010. Users of BTL increased to almost double in 2011 compared to 2010. Vasectomy was performed once in Mkoani District. The increase in use of Implanon and BTL has been attributed to ease of administration, enhanced capacity of service providers, increased number of sites providing the services and improved quality of service provision. On the other hand, utilization of IUCD method has been dropped in 2011 (293) compared to 2010 (391) especially in Pemba.
Table 23: Number of Family planning Users for Long term methods 2010 vs. 2011 IUCD ML/LA (BTL) Implanon Vasectomy Districts 2010 2011 2010 2011 2010 2011 2010 2011 Chake Chake 22 17 13 57 206 276 0 0 Micheweni 8 0 - 0 70 92 0 0 Mkoani 82 32 10 64 19 185 0 1 Wete 26 9 8 5 30 98 0 0 Pemba 138 58 31 126 325 651 0 1 Central 14 10 9 1 259 279 0 0 North A 1 0 8 22 249 238 0 0 North B - 0 - 0 42101 0 0 South - 1 - 5 163 160 0 0 Urban 233 224 124 103 1,616 2257 0 0 West 19 0 4 4 169 367 0 0 Unguja 253 235 145 135 2,498 3402 0 0 Zanzibar 391 293 176 261 2,823 4,053 0 1
38 8.1.4 Family planning new clients
This indicator measures the proportion of all FP clients who have never used modern family planning methods before and thus shows how many women are taking such methods for the first time. However there are several problems with this indicator, as it poses difficulty to identify if the clients are really coming for the first time and not that they are new to this method; or whether they are coming back after stopping for some time from other health facilities.
In 2011, data shows significant increase in acceptance of family planning methods by new acceptors (5.25%) compared to previous years. Eventually, improvement has been met after declining continuously in 2009 and 2010, from 3.8% to 3.3% for Women of Reproductive Age (WRA).
Table 24: Percentage of new family planning acceptance rate by zone, 2008 to 2011 2008 2009 2010 2011 8
Pemba 1.8 2.0 1.8 2.74 e
g 6 a t
Unguja 5.9 4.9 4.1 6.44 n
e 4 c
Zanzibar 4.3 3.8 3.3 5.25 r e
P 2 Increase of Family planning acceptance 0 shows that the Family planning program 2008 2009 2010 2011 has gained its pace in sensitization and Pemba Zone Unguja Zone Zanzibar counselling in service delivery.
Table 25: Percentage of family planning new clients by district 2010 vs. 2011 District 2010 2011 10 Central 5.02 7.36 9 8 ChakeChake 2.8 3.86 7 Kaskazini A 2.63 3.78 6 5 Kaskazini B 2.42 5.49 4 Micheweni 1.76 2.40 3 2010 Mkoani 1.34 2.27 2 1 2011 South 3.5 6.95 0 Urban 5.68 9.16 West 2.99 4.69 Wete 1.45 2.35
The Figure 25 shows a tremendous increase in new FP acceptors for all districts in 2011 compared to 2010. Urban district still maintains the highest acceptance rate followed by central district. In general all Pemba districts have lower FP acceptors compared to Unguja Districts. North B has gained the highest increment (more than double) compared to all other districts 39 8.2 Family Planning in Comprehensive Post Abortion Care (cPAC)
According to International health community, cPAC is a strategy to reduce maternal mortality by treating complications related to abortion and providing post abortion family planning counselling and services to prevent repeated unplanned pregnancies (WHO). In cPAC services, Family Planning counselling must be given to all clients to avoid immediate conception soon after abortion. The counselling should be followed by FP Method after PAC which should last to at least three months.
Table 26: cPAC reports for 2011 Total Counsele FP Client d Method FP Counseling after PAC FP Method after PAC Pemba 1,385 800 494 1,565 1,202 450 Unguja 76.8% Zanzibar 2,282 2,002 944 67% 57.8% 62% 50% The table 26 represents total number of 35.7% 37% abortion cases attended, number of patients 28.8% 32% counselled, followed by a number of those who accepted family planning method. Usual, counselling is required to be provided at hundred percent (100%) of all post abortion Pemba Unguja Zanzibar patients. In 2011, only 67% of total clients received counselling in the whole of Zanzibar, 57% in Pemba and 76.8% in Unguja.
In the meantime, the family planning method after counselling is an indication of success in counselling of the service providers (convincing power) and is expected that number of FP Method after PAC should nearly be close to or just as much as FP Counselling after PAC. In contrary, only 944 (32%) out of 2,950 clients accepted FP methods. The graph above shows that the Family Planning method acceptance after counselling in the whole of Zanzibar is only 50%. Unguja has attained 37% of FP acceptance after counselling, whereby in Pemba it is 62%. According to HMIS data, Pemba population has demonstrated a lower acceptance rate in FP in general compared to Unguja; however, it has shown success in convincing a PAC client more effectively than Unguja which is considered to have a higher acceptance.
8.3 Antenatal Care (ANC) ANC is an important service for preparing mothers for safe delivery. Since the development of a roadmap to accelerate reduction of maternal mortality, ANC services have been given special focus. According to Focused Antenatal Care, ANC in Zanzibar offers: i. Early identification of risks associated with pregnancies. ii. Prevention of mother to child transmission of HIV (PMTCT). iii. Prevention, detection and management of anaemia (iron/folate supplementation). 40 iv. Prophylactic care such as Intermittent Presumptive Treatment (IPT) for malaria and Tetanus Toxoid (TT) immunizations. v. Detection and treatment of diseases such as malaria, worm infestation, Syphilis. vi. Information, education and counselling on nutrition, danger signs of pregnancy and individual plan for facility delivery.
8.3.1 ANC first visit coverage According to Focused Antenatal Care (FANC) guidelines, the first antenatal visit should take place within 16 weeks of pregnancy for early detection and management of problems.
Table 27: ANC first visits Coverage by Zone, 2010 vs. 2011 ANC before 16 weeks ANC 1st visit coverage 2009 2010 2011 2009 2010 2011 Pemba 10.0 8.6 16.7 69.8 69.2 73.4 Unguja 12.3 11.0 21.3 86.1 82.5 75.3 Zanzibar 11.5 10.2 19.6 79.7 77.3 74.6
Figure 13: ANC first visits Coverage by Zone, 2010 vs. 2011
100
80
60
40
20
0 2009 2010 2011
Pemba Unguja
According to table 27 ANC first visits within 16 weeks have almost doubled in both Unguja and Pemba. As with childhood vaccinations, the denominator used in ANC coverage calculation is Census projections of the number of expected deliveries based on the growth rate estimation.
As shown in table 27, ANC first visits coverage in Zanzibar has decreased from 79.7% (2009) to 77.3% (2010) and to 74.6 (2011). Over the past three years, Pemba has been improving in ANC 1st visit from 69.8 to 73.4 %. Conversely, in Unguja, the ANC 1st visit coverage has been continuously dropping (Figure 13).
The figure 14 below shows first antenatal visit coverage by districts in which slight discrepancy can be observed. Urban and Central districts account for over 80 percent while North B districts rank the lowest (58.8%) which are below 60 percent. There is a huge
41 decline in West Districts which alarm for need of follow up. Generally speaking there is increment of ANC visit coverage in Micheweni, Mkoani, Central, South and Urban districts.
Figure 14: First antenatal visit coverage by districts 100 93.6 91.3 87.5 90 80.1 79.2 75.9 80 75.3 75 77.5 75.1 76.3 71.8 72.7 65 67.9 65 63.1 e 70 58.8 g 56.9 59.9
a 60 t n
e 50 c r 40 e P 30 20 10 0
2010 2011
8.3.2 ANC first visit before 16 weeks
ANC first visits before 16 weeks has shown improvement compared to last year. In every district, there is a substantial improvement of nearly twice as much. This is a great achievement since the recommended First ANC visit must begin before the 16th week of conception.
Table 28: Antenatal first visits before 16 weeks by district, 2010 vs. 2011 District 2010 2011 ANC First Visit before 16 weeks Central 6.4 18.1 Chake-Chake 10.0 23.9 2010 2011 Kaskazini A 13.0 25.3 27.7 27.5 23.8 25.3 Kaskazini B 11.1 13.9 18 18.1 15.3 16 14.3 Micheweni 5.9 9.9 13 13.9 12 10 11.1 9.9 11.2 10 Mkoani 11.2 18.1 6.4 5.9 7 South 15.3 27.7 Urban 12.0 27.5 West 10.0 16.1 Wete 7.0 14.3
Central District has tripled its ANC First Visit to 18.1, Chake Chake, Urban and Wete more than doubled, and Kaskazini A South and Micheweni is almost twice as much. A district with a minimal increment is Kaskazini B.
42 8.3.3 ANC first visits, Institutional Deliveries and Post Natal Visits coverage comparison.
Even though ANC first visits in Zanzibar is not satisfactory (75.7%), but the Institutional Deliveries (43.2 %) and Post Natal visits (30.2 %) are even poor.
Zone wise, Pemba shows interesting information as ANC visits was high but unexpectedly women prefer to deliver at home as disclosed that, ANC first visits was 76.3 % but those who came back to deliver at facilities was only 32.5 %, then those who deliver at home came back again for Post Natal visits (45.3 %). In Unguja, it seems like mothers are losing interest with maternal health services as the steps goes on, 75.4 % attended for ANC first visits, 49.3 % of Institutional Deliveries and only 21.7 % came back for Post Natal services.
Figure 15: ANC first visits, Institutional Deliveries and Post Natal Visits coverage comparison
ANC 1st visit Institutional Delivery Postnatal_Attendance
75.4 76.3 75.7 49.3 45.3 43.2 21.7 32.5 30.2
Unguja Pemba Zanzibar
8.4 Test performed during Antenatal visits In accordance with Focus Antenatal Care Strategy, all pregnant women should be screened for anemia, malaria, HIV and Syphilis. However, routinely required HIV and Syphilis test for pregnant mothers are not yet regularly available in all health facilities. Malaria tests use rapid diagnostic tests (ELIZA) when a microscope and laboratory technician is not available. In 2011, out of 142 health facilities providing RCH services, only 51 health facilities provided PMTCT services, including Syphilis tests. The unavailability of tests for HIV and Syphilis among other services in RCH clinics is one amongst the reasons why mothers prefer to attend ANC clinics attached to the hospitals for quality ANC. In the hospitals ANC first visit clients are routinely tested for HIV, syphilis and malaria.
Table 29: ANC testing Rate HIV Malaria Syphilis 2010 2011 2010 2011 2010 2011 Pemba 77.55 63.4 23.14 37.9 52.66 37.0 Unguja 99.20 87.0 15.97 56.5 71.93 72.4 Zanzibar 91.58 78.3 18.49 49.7 65.15 61.3
43 HIV testing for ANC clients (Table 29) has dropped considerably from 91.6% (2010) to 78.3% (2011). This drop has been observed in both Unguja (87%) and Pemba (63%). On the other hand, Malaria testing for ANC clients has increased outstandingly from 18.5% (2010) to 49.7% (2011), with higher rise observed in Unguja from 16% (2010) to 56% (2011). Syphilis has dropped from 65.15% (2010) to 61.3% (2011). This drop has been contributed to a Pemba dramatic fall from 52.66% (2010) to 37 % (2011). However this information is not impressing since it is required that ANC clients receive 100% coverage of these services.
8.4.1 HIV and Syphilis Prevalence
In Zanzibar there has been a shocking increase of HIV and Syphilis in the year 2011. This increase of HIV prevalence is more than double in Pemba and more than tripled in Unguja. In 2009 there was 0.00% of syphilis in Unguja and Pemba; however in 2011 Syphilis has increased to 0.1 % in Pemba and 0.9% in Unguja. Statistics indicate that Unguja has higher prevalence of both HIV and syphilis than Pemba.
Table 30: HIV & Syphilis Prevalence at ANC, 2009 to 2011. HIV prevalence ANC Syphilis prevalence in ANC 2009 2010 2011 2009 2010 2011 Pemba 0.07 0.04 0.1 0.00 0.13 0.1 Unguja 0.39 0.21 0.7 0.00 0.32 0.9 Zanzibar 0.29 0.16 0.5 0.00 0.27 0.7
Figure 16: HIV & Syphilis Prevalence at ANC, 2009 to 2011. 1 0.5 Pemba 0 Unguja 2009 2010 2011 2009 2010 2011 Zanzibar
HIV Syphilis
8.5 IPT 1 & IPT2 Coverage, 2011 Intermittent Preventive Therapy (IPT) 1 & 2 is public health intervention aimed for treating and preventing Malaria for infants and pregnant women. For full protection of Malaria, pregnant mothers are supposed to receive two doses of IPT.
Unguja at 20.0 percent has a high coverage of IPT 2 (which is most useful indicator) compare to Pemba (17.0%). In line with high coverage in Unguja but data shows there is a drop out of IPT in Unguja compared to Pemba. Low coverage of IPT 2 may caused by delay of pregnant mothers to attend to ANC for first visit or low prevalence of malaria.
44 Table 31: IPT1&2 coverage by districts and Zone - 2011 District 2011 IPT1 coverage IPT2 coverage Central 35.64 in ANC clients in ANC clients ChakeChake 10.71 Pemba 21.7 17.0 Kaskazini A 17.96 Unguja 33.9 20.0 Kaskazini B 11.00 Zanzibar 29.5 18.9 Micheweni 8.05 Mkoani 17.17 South 27.51 Urban 12.46 West 11.22 Wete 9.35
8.6 High risk pregnancies A High risk pregnancy is the one in which some condition puts the mother at high risk for complications during or after the pregnancy and birth. Generally, it is very difficult to predict which individual women will encounter obstetric complications during delivery, but where quality and standards are maintained in a particular country, pregnancy complications are not expected to exceed 15% of all deliveries. Under normal conditions, however, every pregnant woman is considered at risk of getting obstetric complication and should be encouraged to deliver at health facilities as part of the delivery plan. It has been shown that utilisation of ANC services and deliveries by skilled attendants are correlated with lower maternal mortality.
8.6.1 Pregnancy risk factors There are factors that can be present to women before she become pregnant. These conditions can cause a high risk during pregnancy. A table below shows the trend of pregnant risk factors for ANC clients for three years from 2009 to 2011.
Table 32: Number of pregnant mothers who are at risk from 2009 to 2011 Data Element Name 2009 2010 2011 Pemba Pregnancy over 4 gravida 3,805 3,583 8,411 Pregnancy before 2 years from last birth 4,343 3,138 6,870 Pregnancy above 35 years 1,415 1,429 3,054 Pregnancy below 20 years - - 1,453 Previous scar - - 254 BOH 70 128 154 Total ANC first visit Pemba 15,063 15,624 17,164 Unguja Pregnancy over 4 gravida 4,596 3,866 11,052 Pregnancy above 35 years 1,856 1,694 5,911 Pregnancy before 2 years from last birth 4,331 3,202 5,981 Pregnancy below 20 years - - 3,171 Previous scar - - 710 BOH 153 352 282 Total ANC first visit Unguja 29,172 28,612 30,177 Zanzibar Total ANC first visit Zanzibar 44,235 44,236 57,284 45 The table 33 shows the percentage of common risk factors in 2011. These account 34 percent for women delivered to be over 4 gravida, 15.7 percent were above 35 years, 8.1 percent were below 20 years and pregnancy before 2 years from the last birth indicated to be 22.4 percent. The situation in Pemba seems more worse compare to Unguja with 49 percents of all ANC attendance were over 4 gravida and 40 percent were Pregnancy before 2 years from last birth.
Table 33: Percentage for group for pregnancy who are at risk 2011 Over 4 Above 35 Below 20 Pregnancy before 2 gravida years years years from last birth Unguja 36.6 19.6 10.5 19.8 Pemba 49.0 17.8 8.5 40.0 Zanzibar 34.0 15.7 8.1 22.4
8.6.1.1 Malaria in pregnancy Malaria used to be one of the main indirect causes of maternal complications and subsequent mortality until early 2000s, but since then, this course has been significantly reduced from 2007 and remains to be less than one percent from 2008 as shown in the table below.
Table 34: Malaria rate in pregnant women Zone 2007 2008 2009 2010 2011 Pemba 8.7 0.4 0.8 0.17 0.29 Unguja 10.1 0.4 0.5 0.14 0.33 Zanzibar 9.6 0.4 0.6 0.15 0.32
Figure 17 indicates slightly differentials in the prevalence of malaria amongst pregnant women between Unguja and Pemba whereby the prevalence is found to be higher in Pemba compared to Unguja. In 2010, Pemba and Unguja count 0.17 and 0.14 percents respectively, and 2011 Pemba are 0.29 percents and Unguja is 0.33. These results are in line with the results of overall reduction in malaria parasitaemia in the general population however there is slight increase in 2011 for both Unguja and Pemba.
Figure 17: Trend of Malaria in pregnancy from 2007 to 2011 12 10 8 Pemba
% 6 Unguja 4 Zanzibar 2 0 2007 2008 2009 2010 2011
46 Table 35 shows two years data of Malaria in pregnancy which has broken down to show the comparison among Districts. Wete, Mkoani, Urban and Mkoani districts shows slight decrease while there is an increase of malaria rate in Central, Chake Chake, Kaskazini A, Kaskazini B, Micheweni and South districts.
Table 35: Malaria in pregnancy rate by districts, 2010 vs. 2011 District 2010 2011 1
Central 0.31 0.5 e 0.8 g a Chake Chake 0.23 0.24 t 0.6 n e
c 0.4
Kaskazini A 0.04 0.12 r e
Kaskazini B 0.05 0.19 P 0.2 Micheweni 0.05 0.82 0 Mkoani 0.40 0.27 South 0.08 0.15 Urban 0.21 0.14 West 0.06 0.03 Wete 0.03 0.00 2010 2011
8.6.1.2 Severe Anaemia in pregnancy Women often become anaemic during pregnancy because the demand for iron and other vitamins is increased. Severe Anaemia (<7.0 gm / dl) in pregnancy can be a serious problem especially when haemorrhage occurs during or after delivery. It can also lead to premature birth, low birth weight, intrauterine foetal growth retardation and other related complications. In Zanzibar, this complication has decreased dramatically in last two years. It was 1.73 percent in 2010 and 0.86 percent in 2011.
Table 36: Severe Anaemia rate (%) in 1st ANC clients by zone, 2010 and 2011 Severe Anemia rate in pregnant 2.5 women (<7gm/dl %) 2 2.19 1.5 1.38 Pemba 2010 2011 1 0.8 Pemba 0.80 1.38 0.5 0.56 Unguja Unguja 2.19 0.56 0 Zanzibar 1.73 0.86 2010 2011
Rates of anaemia have brought in different results. Pemba which was better in 2010 (0.8%) has increased to 1.38% (2011), Unguja has sharp decrease from 2.19% to 0.56%
47 Table 37: Severe Anaemia rate at ANC by district 2010 vs. 2011 District 2010 2011 8 7
Central 0.88 0.00 e
g 6 a Chake Chake 0.98 2.17 t 5 n
e 4 c
Kaskazini A 1.64 0.47 r 3 e 2 Kaskazini B 1.98 0.91 P 1 Micheweni 0.88 0.54 0 Mkoani 0.45 0.60 South 1.34 1.56 Urban 2.36 0.19 West 2.75 6.81 Wete 0.78 0.73 2010 2011
48 CHAPTER NINE 9. Nutrition Zanzibar faces a double burden of malnutrition, both under nutrition and over nutrition, and is one of the most serious health and cross-sectoral problems affecting the entire population, especially newborns, infants, children and women of reproductive ages. In general, under nutrition in Zanzibar is estimated at 26% overall and chronic food insecurity is 4% (HBS 2010) and dependence on food purchase across all livelihoods is remarkably high. Despite progress made through different strategies and interventions, children and women in Zanzibar still continue to suffer from one or more forms of malnutrition including under nutrition: low birth weight (%), stunting (%), underweight (%), wasting, anaemia (%), and vitamin and mineral deficiencies as well as over nutrition (overweight and obesity). Malnutrition is a threat to the health and survival of children and women, the cognitive, emotional and physical development of the population, the educational performance of school children, and the future economic productivity of the nation.
9.1 Nutrition Interventions through the Health Sector Facility and community-based health service providers have a very important role to play in addressing malnutrition because they have frontline contact with those at greatest risk of malnutrition and its consequences, especially those most vulnerable pregnant, postpartum women up to children two years of age.
The following nutrition interventions are delivered through routine services in the health sector in Zanzibar:
Vitamin A supplementation of children aged 6-59 months Iron-folic supplementation of pregnant De-worming in pregnant women from the second trimester of pregnancy Growth monitoring
9.1.1 Vitamin A supplementation of children aged 6-59 months - 2011
Pre-school children (6 – 59month) are given vitamin A supplementation twice a year. The coverage of vitamin A in Zanzibar is extremely low at 14.9 percent. Unguja and Pemba also has low coverage of 16.4% and 12.9% respectively. Towards reaching the MDG4 goal of reducing under-five mortality, there should be sound political will to extend coverage to all children particularly the hard-to-reach and most vulnerable.
49 Figure 18: Vitamin A supplement for children 6-59months - 2011 20 16.4 14.9
e 15 12.9 g a t n
e 10 c r e
P 5
0 Pemba Unguja Zanzibar
9.1.2 De-worming of pregnant women via Anti-helminthic Drugs
De-worming for pregnant women is routinely done; this indeed has long term positive effect in terms of reducing anaemia and protein energy malnutrition. In Zanzibar mebendazole are dispensed to pregnant women for de-worming
Figure 19: De-worming coverage for pregnant women 60 52.6 50 44.3
t 40 n 29.7 e
c 30 r e
P 20 10 0 Pemba Unguja Zanzibar
De-worming coverage for pregnant women is less than 50 percent in Zanzibar while Unguja coverage (52.6%) is amazingly higher compared to Pemba (29.7%).
9.1.3 Growth Assessment Monitoring
Moderate Mulnutrition Severe Mulnutrition
10 8.6 8.3 8.5
e 8 g a t 6 n e
c 4 r e
P 2 0.6 1 0.7 0 Unguja Pemba Zanzibar
50 9.2 Low birth weight rate (institutional) Low birth weight is associated with increased infant mortality and therefore of concern to the Ministry of Health. Low birth weight is more common in multiple births, poor nutrition in pregnancy and premature delivery.
Table 38: Trends in proportion of hospitals births with low birth weight, (2008 - 2011) 2008 2009 2010 2011 Pemba 5.6 3.6 6.2 5.2 Unguja 7.6 5.5 8.5 11.4 Zanzibar 7.1 4.9 6.9 9.7
Figure 20: Percentage of hospitals low birth weight, Unguja vs. Pemba 2008 to 2011 12 11.4 10
e 8.5 g 8
a 7.6 t
n 6.2 e 6 Pemba c 5.6 5.5 5.2 r
e 4 P 3.6 Unguja 2 0 2008 2009 2010 2011
Figure 21: Percentage of hospitals low birth weight Zanzibar, 2008 to 2011 12 10 9.7 e
g 8 a t 7.1 6.9 n
e 6 c
r 4.9 Zanzibar e 4 P 2 0 2008 2009 2010 2011
The average proportion of low birth weight in health facility deliveries in Zanzibar in 2011 was 9.7 percent almost double the average proportion in 2009. The increase was noted in Unguja only where the proportion more than doubled in the past three years. Further investigations are underway to determine whether the reason for the increase was related to reporting or reflects a real increase in the incidence of low birth weight.
51 Figure 22: Low birth weight by districts from 2010 to 2011
20 17.43
e 15
g 11.87 12.03 a t 8.89 9.73 n 7.95
e 10 7.64
c 6.06 r 5.39 5.49 5.2 5.36
e 4.86 4.63 4.20 3.91 4 P 5 2.51 00.00 0
2010 2011
Further breakdown of data related to incidence of low birth weight indicates that only two districts reported an increased incidence, Wete and North A. The numbers of deliveries in the district situated in those health facilities for 2011 were 1564 and 1429 respectively. There was no evidence of a high proportion of multiple births at these two districts.
The posting of an obstetrician at Wete hospital in 2011 resulted in an increased number of referrals-in and an overall increase in the number of deliveries. Mnazi Mmoja Hospital is responsible for the care of all complications of delivery in Unguja Island, including premature births. A higher incidence of low birth weight infants is therefore expected in Urban District within which the hospital is situated. Further investigations into the increased incidence of low birth weight in North A District is underway.
52 9.3 Nutrition status from different surveys 9.3.1 Micronutrient Nutritional Status
Table 39: Micronutrient Nutritional Status of Children (year) Iron Status Anaemia Iodine Status Vitamin A Status
Coverage of % Iron Percentage Households the Coverage of Vitamin A Iron Status Deficiency1: of children percentage Vitamin A: Deficiency3 Testing: Children age with with no salt Children age Children Children age 6-59 months anaemia2 6-59 months age 6-59 6-59 months months Zanzibar 90.9% 34.7% 68.5% 7.3 % 89.4% 38.1%
Unguja 92.3% 43.3% 68% 7.7% 90.3% 31.3%
Pemba 89.1% 21.9% 69.3% 6.6% 88.1% 48.1%
Source: National Bureau of Statistics (NBS) [Tanzania] and ICF Macro. 2011. Micronutrients: Results of the 2010 Tanzania Demographic and Health Survey. Dar es Salaam, Tanzania: NBS and ICF Macro.
9.3.2 Iodine Deficiency Disorders (IDD) in Zanzibar
Iodine deficiency in Zanzibar is a public health problem, particularly in Pemba. DHS 2010 has revealed that 49% of households in Zanzibar consume adequately iodised salt (with 15 + ppm). The figures are lower in Pemba (24.1%) if compared with Unguja (63.7%). The lowest proportion of households consuming iodised salt was observed in Pemba North region (12.5%). According to MoH report of 2004 goitre prevalence in Zanzibar was 26%; and there was big difference between Unguja (21%) while in Pemba it was 32%. Table 40 describes urinary concentration of iodine of women aged 15 – 49 years of age.
Table 40: Urinary Iodine Concentration (micrograms/l) in Women of 15–49 years of age Regions <100 (%) <100-150 (%) 100-300 (%) >300 Unguja North 26,4 20.1 36.9 16.6 Unguja South 13.5 13.4 38.3 34.9 Town/West 16.0 12.6 35.1 36.3 Unguja 50.5 18.9 19.3 11.3 Pemba North 24.3 19.1 32.4 24.2 Pemba South 37.0 19.0 26.1 17.9 Pemba 18.1 14.5 36.0 31.4 Zanzibar 24.7 16.1 32.6 26.7 Source: Tanzania National Bureau of Statistics and ICF International. 2012. 2010 Tanzania Atlas of Maternal Health, Child Health, and Nutrition. Calverton, Maryland, USA: NBS and ICF International.
53 The summary Table 40 shows that women of reproductive age in Pemba North consume the least amount of iodised salt; and this can be judged from urinary iodine concentration they revealed (50.5%) of them had urinary iodine concentration of < 100 micrograms/l of urine. Pemba in general consumes lesser amount of iodised salt (37.0% below 100 micrograms/l of urine) than Unguja (18.1% below 100 micrograms/l of urine).
9.3.3 Stunting, Underweight and Wasting
The World Health Organization regards stunting as ‘very high’ if it is greater than 40 percent in a population.
Table 41: Prevalence of Stunting and Underweight in Children (under five years) in percentage and annual average change in percentage points Stunting Underweight
Annual Annual Change 2010 2005 1999 Change 2010 2005 1999 2005-2010 2005-2010 Zanzibar North 40.6 22.1 33.6 3.7 27.1 16.2 14.2 2.2 Zanzibar South 29.1 34.5 - -1.1 17.1 19.5 - -0.5 Urban West 19.6 20.6 -0.2 15.5 11.5 0.8 Pemba North 39.3 39.6 51.3 -0.1 23.9 17.0 32.3 1.4 Pemba South 31.3 31.1 - 0.0 18.6 16.0 - 0.5 Sources: Based on GDCGM (2011), and NBS and ICF Macro (2011)
Table 42: Under nutrition among Children (under 5 years) Stunting Underweight Wasting Moderate Severe Moderate Severe Moderate Severe
Zanzibar North 40.6 15.3 27.1 5.3 16.4 5.0 Zanzibar South 29.1 9.2 17.1 4.7 10.6 3.6 Town West 19.6 8.7 15.5 2.4 11.5 5.1 Pemba North 39.3 15.3 23.9 7.7 12.7 5.8 Pemba South 31.3 13.5 18.6 3.6 8.9 2.0 Source: NBS and ICF Macro (2011). Note: Estimates are preliminary. Prevalence rates of child under nutrition are estimated with reference to the WHO Child Growth Standards, adopted in 2006.
54 Figure 23: Child Under nutrition in Zanzibar, 1992-2010
55 CHAPTER TEN 10. Deliveries
The Ministry of Health recommends that all deliveries should be conducted at health facilities with the assistance of skilled birth attendants. In line with proper maternal and new born care the proposal of selecting 34 PHCU+ to provide additional services such as Deliveries, laboratory, dispensing and dental services was done so as to reduce hospital overloading. It was proposed to start with 20 facilities providing at least delivery services (two facilities in each district). In spite of this emphasis, however routine data collected through the HMIS indicates that more than half of expected deliveries occur outside the formal health system.
10.1 Overall Deliveries In 2011, the total number of facility deliveries reported in HMIS system was 27,502. This accounts for only 43.2% of all expected deliveries. According to the population projections from the 2002 census the number of expected deliveries in 2011 was 62,549 calculated using 4.5% of total population. Using this figure as the denominator the proportion of home deliveries for 2011 is 56.8%. Contrary to the Zanzibar Health Policy, which recommends all mothers to deliver in health center, home deliveries remain common practice in Zanzibar.
10.2 Delivery institutional sites In 2011 there are 34 health facilities that actively conducted deliveries. The table below show the distribution of deliveries health facilities. (See Map 8 for Mapping of Delivery facilities)
Facility type UNGUJA PEMBA ZANZIBAR Tertiary Hospital 1 0 1 Special Hospital 1 0 1 District Hospital 0 3 3 PHCC 2 2 4 PHCU+ 10 8 18 PHCU 4 2 6 Private 2 0 2 TOTAL 20 15 35
56 Map 8: Distribution of Delivery Health Facility Unguja and Pemba
Key
The data shows that, in accordance with the MOH policy to encourage normal deliveries to be conducted at Primary Health Care Units, an additional two PHCUs began conducting deliveries on Pemba and an additional six PHCUs in Unguja since 2009. In specific cases such as Maziwa Ng’ombe and Uroa the number of deliveries fluctuated from one year to the next. Low utilisation rates of other PHCU and PHCU+ compromise both the overall institutional delivery rates and the high burden on the hospitals.
57 Table 43: Trends by number of institutional deliveries per health facility (2009-2011) Total Deliveries Live birth Health Facilities 2009 2010 2011 2009_ 2010_ 2011 Pemba Chake Chake 2,536 2899 2,812 2,430 2,706 2,691 Abdallah Mzee 1,222 1318 1,490 1,201 1249 1,462 Wete District 1,093 1,193 1,608 1,080 1,189 1,564 Micheweni PHCC 463 552 625 455 548 590 Vitongoji PHCC 122 142 199 121 141 201 Wesha PHCU+ 117 136 158 115 137 158 Bogowa PHCU + 113 86 122 119 81 125 Makangale PHCU + 63 69 87 59 69 87 Maziwa Ng'ombe PHCU - 67 25 - 67 24 Pujini PHCU + 55 55 59 55 54 59 Wingwi PHCU + 3 20 28 3 21 28 Fundo PHCU + - 15 26 - 12 26 Junguni PHCU - - 43 - - 43 Kojani PHCU+ - - 5 - - 5 Konde PHCU+ - - 221 - - 224 Pemba (total) 5,787 6,552 7,508 5,638 6,274 7,287 Unguja Mnazi Mmoja 9,732 10,168 10,518 9,601 10,259 10,367 Mwembe Ladu 4,259 4,530 5,655 4,241 4,501 5,523 Kivunge PHCC 1,241 1,404 1,430 1,227 1,407 1,429 Al-rahma Private Hospital 111 423 786 109 457 771 Makunduchi PHCC 388 431 698 389 417 682 Fuoni PHCU + 234 248 264 236 233 293 Marie Stopes 211 113 - 210 114 - Chukwani Martenity Home 27 97 156 29 97 180 PHCU + Donge Vijibweni PHCU + - 68 106 - 70 105 Uroa PHCU 27 42 27 28 44 27 Bumbwini Misufini PHCU + 67 42 73 70 42 73 Nungwi PHCU + 53 33 68 54 34 68 Gomani PHCU + 9 8 7 9 8 7 Gamba PHCU - 4 2 - 4 3 Jambiani PHCU + 20 17 30 19 17 29 Muyuni PHCU + 4 5 18 4 4 19 Kendwa PHCU - - 46 - - 46 Kitope Church Dispensary - - 18 - - 17 Kitope PHCU - - 29 - - 29 Mahonda PHCU + - - 55 - - 55 Matemwe PHCU + - - 12 - - 12 Unguja (total) 16,383 17,633 19,998 16,226 17,708 19,735 Zanzibar 22,170 24,185 27,506 21,864 23,982 27,022
58 10.2.1 Comparison between ANC attendant and Deliveries at PHCU and PHCU+
It seems that the pregnant mothers prefer mostly to attend for ANC services but they do not turn back for delivery to a specific health facility, instead are either deliver at home or other health facilities. In Pemba Wesha PHCU (44.1%), Makangale (34.4%) shows that more than thirty percent of pregnant women are coming back to deliver at respective health facility, Maziwa Ng'ombe PHCU alarming for further investigation since its coverage dropped dramatically from 2010 to 2011 . In Unguja Chukwani with 67% is doing best followed by Donge vijibweni at 38.7% and Uroa at 31.8%. However, Uroa ANC/delivery coverage rate alarming for further investigation due to its amazing decrease from 66.7% of 2010 to 31.8 % in 2011. The other observation is at Fuoni PHCU, despite the presence of required human resource and capability but the coverage for 2010 and 2011 are under 20%, this also alarming for further investigation.
The table 44 shows the trend of proportion of women who have attended Antenatal Clinics at least once and deliver in the health facility.
Table 44: The comparison between ANC visits and Delivery by health facility 2010 2011 Health Facilities ANC Deliveries % ANC Deliveries % Pemba Wesha PHCU+ 374 136 36.4 358 158 44.1 Bogowa PHCU + 444 86 19.4 548 122 22.3 Makangale PHCU + 341 69 20.2 253 87 34.4 Maziwa Ng'ombe PHCU 346 67 19.4 302 25 8.3 Pujini PHCU + 306 55 18.0 270 59 21.9 Wingwi PHCU + 538 20 3.7 585 28 4.8 Fundo PHCU + 86 15 17.4 117 26 22.2 Junguni PHCU 227 - - 236 43 18.2 Kojani PHCU+ 179 - - 407 5 1.2 KondePHCU+ 548 - - 221 - Unguja Fuoni PHCU + 1685 248 14.7 1,742 264 15.2 Chukwani Martenity Home 201 97 48.3 233 156 67.0 PHCU+ Donge Vijibweni PHCU + 263 68 25.9 274 106 38.7 Uroa PHCU 63 42 66.7 85 27 31.8 Bumbwini Misufini PHCU + 290 42 14.5 254 73 28.7 Nungwi PHCU + 361 33 9.1 399 68 17.0 GomaniPHCU+ 199 8 4.0 194 7 3.6 Gamba PHCU 296 4 1.4 237 2 0.8 Jambiani PHCU + 127 17 13.4 171 30 17.5 Muyuni PHCU + 112 5 4.5 144 18 12.5 Kitope PHCU 56 - - 99 29 29.3 Mahonda PHCU + 279 - - 356 55 15.4 Matemwe PHCU + 309 - - 306 12 3.9
59 10.2.1 Rate of institutional deliveries
In 2011, the institutional deliveries were 43.2 percent of all expected deliveries. The institutional deliveries for Unguja and Pemba are still less than 50 percent of expected deliveries as it was in previous years.
Table 45: Proportion of expected deliveries conducted in health facilities (2007 to 2011) Deliveries in institutions 2007 2008 2009 2010 2011 Pemba 24.5 26.7 26.8 28.8 32.5 Unguja 46.7 47.8 48.0 50.7 49.3 Zanzibar 38.3 39.7 39.8 42.2 43.2
Overall, the proportion of institutional deliveries increased by 1.0% from 2010 to 2011, indicating that, with a birth rate of 4.5%, there was a slight overall increase in the number of mothers utilizing health facilities for delivery services during child birth. While the overall trend (for both Unguja and Pemba) for proportion of institutional deliveries was consistently increasing there was a slight decrease in Unguja in 2011 compared to 2010. The proportion of women who have attended Antenatal Clinics at least once and deliver in the health facility is 58% for 2011.
The proportion of deliveries conducted at the tertiary hospital remains alarmingly high. Maternity ward of Mnazi Mmoja Hospital 37% of the total deliveries for the whole of Zanzibar, while Mwembeladu hospital is included the proportion rises to 24% deliveries, district and PHCC hospitals 35% and only 4% is from PHCUs and PHCU+ which is said to be doing very few deliveries beyond the Ministry of health expectation to reduce work lord to the tertiary and district hospital. A breakdown of the number of deliveries for each facility is presented in figure 24.
Figure 24 : Distribution of Facility Deliveries in Zanzibar by levels . 37% of all facility deliveries occur at MMH. . 24% of all facility deliveries occurring at Mwembeladu . District and PHCC hospital contribute for 35% all facility deliveries . PHCUs and PHCU+ are still doing very few deliveries at 4% of all facility deliveries
60 10.2.2 Home delivery
Despite the major efforts taken by the Ministry of health of increasing institutional sites for delivery, still home delivery lead by 56 percent visas 44% of all institutional deliveries. This indicates that there should be sound strategies to overcome the problem of home deliveries.
Figure 25: All Deliveries in Zanzibar by levels (Home and Facilities) . Home deliveries is 56% . 16% of all Zanzibar registered deliveries occur at MMH, while 11% took place at Mwembeladu maternity . District and PHCC contributed 15% . PHCUs are still doing very few deliveries at 2% of all Zanzibar deliveries
10.3 Institutional births and births attended by skilled personnel.
WHO defines Skilled birth attendants as “an accredited health professional such as a midwife, doctor or nurse- who has been educated and trained to proficiency in the skills needed to manage normal pregnancies, child birth, immediate postnatal period, identification, management and referral of complication in women and newborns”. However, in Zanzibar PHNs grade B are also considered as skilled birth attendants. Home deliveries attended by skilled personnel are considered as births attended by skilled personnel. Traditional birth attendants and MCH AIDES, even if they receive a training course in obstetric care, are not considered as skilled birth attendants.
There is currently no strategy for mothers to be attended at home during delivery by a Ministry of Health employed health workers. Although 1,926 births were assisted by health workers outside the health facilities this practice is not encouraged and remains ‘informal’.
10.3.1Birth attended by skilled personnel Unguja and Pemba
In 2011 data shows that Pemba has significant lower percentages of delivering mothers attended by health staff (35.9%) compared to Unguja (53.4%). Although birth attended by skilled personnel increased in Pemba but the table 46 show that over the past five years has not reached 40 percentages of all deliveries. There is slight decreased in Unguja from 57.4% (2010) to 53.4% (2011) however over the past five years deliveries by skilled personnel has not reached 60%.
61 Table 46: Births attended by skilled personnel, 2007 to 2011 Deliveries by health staff 2007 2008 2009 2010 2011 Pemba 33.9 31.7 30.6 34.7 35.9 Unguja 55.2 52.6 51.0 57.4 53.4 Zanzibar 47.0 44.5 43.1 48.6 47.1 Note: Deliveries by health staff includes both at home and at facility.
10.3.2 Birth attended by skilled personnel Zanzibar Figure 26: Births attended by skilled personnel Zanzibar (2007 to 2011) In 2011 birth attended by skilled personnel including PHNB and MCH Aides was 47.1 percent of all deliveries, this shows slight decrease compared to 48.6 of 2010.The Figure 26 shows over the past five (5) years birth attended by skilled personnel did not reach even 50 percent of all expected deliveries . The MDG target remains at 90% by 2015.
10.4 Emergency Obstetric Care (EmOC) World Health Organisation estimates that at least 15 percent of all deliveries will result in a complication that requires emergency obstetric care and at least 5 percent will require Caesarean Section to prevent maternal and neonatal morbidity and mortality.
Basic Emergency Obstetric signal functions Administration of parenteral antibiotics Administration of parenteral oxytocic drugs Administration of parenteral anticonvulsants for pregnancy induced hypertension Performance of manual removal of placenta Performance of removal of retained products (e.g. vacuum aspiration) Performance of assisted vaginal delivery (e.g. ventouse, forceps)
Comprehensive Emergency Obstetric signal functions Performance of surgery (e.g. Caesarean section) Provision of blood transfusion.
The international standards stipulate that there should be four Basic EmOC facilities and one Comprehensive facility per 500,000 populations. Based on these standards, Zanzibar has made great strides in implementing EmOC in the last few years. There are 20 Health
62 facilities offering Basic Emergency Obstetric Care (BEmOC) in Unguja and 12 in Pemba. In addition two hospitals on Unguja and three on Pemba offering Comprehensive Care (CEmOC) although one additional hospital in Unguja offers comprehensive services but not on a 24 hours/seven days per week basis.
The distribution of CEmOC centres in Pemba is more even than in Unguja whereby only one public and one private hospital provide a full service. Marie Stopes has stopped providing basic and comprehensive obstetric services this year.
10.4.1 Obstetric Complication and Interventions
In view of being a referral hospital in Zanzibar Mnazi Mmoja Hospital recorded highest number of complications with abnormal presentation (2,427) remained most prominent. Further information regarding the obstetric complications is indicated by the table 47.
Table 47: Type of complications in maternity wards, by hospital, 2011 s a e i e
n n g s g o m o m a p i a d
e i
d l t u u h t a e h / n e t i a d t m r a t r a a a r a r s r i c r s a e c t
t a r i m l
m a a r p s i o l o l r u n e r s r a c n s b n m r r i P p l u e r r i p i a u e M f u e e o m m t e t r a e m t s e t u e s a - r l m o c t s n a n t e a t p m O s t e h e p v l e e e a s e a b s b t o a i b n n e u r a o l t o r R c i o e e
Health Facilities c a A p A h E F F D M O l O C P H P P R p m R u S S A Chake Chake District 59 46 32 1 19 0 93 32 59 47 40 26 4 7 35 Kivunge PHCC 35 30 23 0 8 0 3 94 71 8 7 15 1 10 55 Makunduchi PHCC 13 7 4 0 5 1 7 10 25 1 7 4 0 2 11 Micheweni PHCC 15 25 9 0 3 0 8 8 36 6 1 20 0 6 31 Mkoani District 28 12 19 0 14 2 121 5 29 2 8 21 0 0 13 Mnazi Mmoja 2,427 251 149 1 166 0 74 233 307 172 226 42 22 11 463 Vitongoji PHCC 5 2 2 0 0 0 0 0 13 7 1 2 0 0 0 Wete District 43 36 17 1 8 0 2 5 56 19 4 8 4 10 61 Grand Total 2,625 409 255 3 223 3 308 387 596 262 294 138 31 46 669
10.4.2 Obstetric care and neonatal Interventions by Hospitals
Since Mnazi Mmoja Hospital functions as a referral hospital in Zanzibar the BeMONC and CeMONC services are available at all time and the number of interventions are high compared to other health facilities. District hospitals in Pemba have reported similar values due to their capacity of delivering the BeMONC and CeMONC services.
63 Table 48: Obstetric care and neonatal Interventions a t n M n I o
e i / t c a a V x n l e r I i i
r s P o
i p e a f t r t s V c I
a o e n a
A
r t
n l d i o h e e i a o c n v t p i m i h l s v c s u t s u
u u o a u o n V u s e S r f I
r c e m t
e s V m t r s x a o e I n
m r
c l c e o R V i a s
e u
s a t i r l l c o t p i t s r o m a a
i R i y a c a u u u d n A b h n o g c i i g n n t o o t t G i c n a a a o x e n n P a l a
HF A A A B K M M M N O V Chake Chake 203 75 58 74 12 54 17 0 76 738 9 Kivunge PHCC 30 31 57 71 29 33 15 46 45 129 5 MakunduchiPHCC 5 4 11 9 1 9 3 29 18 203 0 Micheweni PHCC 35 16 7 19 53 18 20 55 12 386 2 Mkoani District 161 15 13 20 1 14 18 41 12 291 0 Mnazi Mmoja 2,001 278 1,540 475 307 284 43 24 1,722 6,450 20 VitongojiPHCC 1 0 5 0 0 0 1 5 2 37 0 Wete District 220 15 18 70 5 41 7 0 24 1,409 0 Grand Total 2,656 434 1,709 738 408 453 124 200 1,911 9,643 36
10.5 Comprehensive Emergency Obstetric Care Comprehensive obstetric care includes caesarean section and blood transfusion covering a full 24 hour service seven days per week. There are only six health facilities in Zanzibar, one of which is a private health facility that offers this service. An NGO that previously offered a full service has discontinued service provision.
World Health Organisation estimates that at least five percent of all deliveries require a Caesarean Section to prevent morbidity and mortality of neonates and mothers. An upper limit of all deliveries that would be expected to require a Caesarean Section is estimated to be 15 percent.
The overall proportion of caesarean rate in Zanzibar for the year 2011 stands at 4.07 percent based on the number of expected deliveries. This complies with the notion by WHO for preventing morbidity and mortality of mothers and the neonatal.
10.5.1 Institutional caesarean section rate.
The real institutional caesarean section rate Zanzibar for 2011 stands at 9.23 percent. The trend for three years has declined from 10.3 to 9.23 percent from 2009 to 2011. Unguja has slightly higher proportion of 11.4 percent while Pemba has 9.2 percent of caesarean section has been performed. Makunduchi PHCC started to perform caesarean section services in 2011 but cannot provide a full 24 hour service seven days per week.
Al-Rahma private hospital had the highest rate of caesarean sections of 33.33% in 2011 (above WHO standards); this is similar to the past three years followed by Mnazi Mmoja at 10.89 %. Marie Stope cut off the delivery services since November 2010. The Caesarean Section rates at the facilities in Unguja have remained constant over the past three years 64 while the District hospitals in Pemba show larger fluctuations. The decrease in the Caesarean section rate in Chake Chake hospital and corresponding increase in Wete hospital reflects the impact of the placement of a fully qualified obstetrician (supported by WHO).
Table 49 : Caesarean Section rate per institutional delivery, (2009 to 2011) Facility 2009 2010 2011 Deliveries C/S % Deliveries C/S % Deliveries C/S % Abdallah Mzee 1,222 110 9 1,328 125 9.4 1,490 134 8.99 Al-rahma 111 39 35.1 423 133 31.4 786 262 33.33 Chake Chake 2,536 327 12.9 2,827 272 9.6 2,812 189 6.72 Kivunge PHCC 1,241 Ns - 1,404 Ns - 1,514 4 0.26 Makunduchi PHCC 388 Ns - 430 6 1.4 698 9 1.29 Micheweni PHCC 463 Ns - 553 Ns - 625 Ns - Mnazi Mmoja 13,991 1638 11.7 14,698 1,887 12.8 16,173 1,761 10.89 Vitongoji PHCC 122 Ns - 137 Ns - 199 Ns - Wete District 1,093 46 4.2 1,193 10 0.8 1,608 189 11.75 Marie stope - - - 113 16 14.2 0 - - PHCU + - - - 1,016 Ns - 1,706 Ns - Zanzibar Hospitals 21,166 2,160 10.2 24,122 2,160 9 27,506 2548 9.23 ns – Service not yet started
10.6 Maternal Mortality 10.6.1Maternal Deaths
The International Classification of Diseases (ICD) definition of a maternal death is:- “the death of a woman occurring during pregnancy, childbirth or within 42 days of termination of the pregnancy from any cause related to or aggravated by the pregnancy or its management, irrespective the gestational age and site of the pregnancy, but not from incidental or accidental causes”.
Zanzibar does not have an effective system in place for recording births and deaths occurred in the community but data on maternal deaths is collected from health facilities through the routine HMIS. The following data represents deaths that occur in the health facilities only.
MMR is one of the indicators of MDGs of which the target is 130 deaths per 100,000 live- births in 2015. Due to its complexity in obtaining this indicator comprehensively, the institutional maternal mortality (health facility based) is used as proxy MMR. However, the index is incomplete since it excludes deaths that occur at community level while deliveries that commence in the community. It is also recognised that deliveries that are conducted at home and result in a complication, will be referred to a health facility. This decision is sometimes taken too late to prevent a maternal death. Available information on facility based MMR shows a slight decrease from 288 (2010) to 284.7 (2011), per 100,000 live births. Distribution of MMR is depicted in table 50. Unguja managed to reduce in number of MMR from 288.0 to 243.2, while the situation worsens in Pemba by increasing from 286.9 to 396.9. Number of maternal death at Mnazi Mmoja hospital decreased from 50 to 44 65 (2010 to 2011), but there is remarkable increase of maternal death from 2010 to 2011 at Abdallah Mzee Hospital and Wete Hospital.
Table 50: Total number of maternal deaths occurred per hospital, 2006-2011 Hospital 2006 2007 2008 2009 2010 2011 Abdallah Mzee District Hospital 2 4 2 5 2 7 Al-rahma Hospital * 0 0 0 0 0 0 BububuJeshiniHospital 0 0 0 0 0 0 Chake Chake District Hospital 12 11 12 12 11 13 KivungePHCCHospital 0 2 2 2 0 4 MakunduchiPHCCHospital 0 0 0 0 1 0 Micheweni PHCC Hospital 5 1 5 0 2 0 Mnazi Mmoja Referral Hospital** 67 51 62 37 50 44 VitongojiPHCCHospital 0 0 0 0 0 0 Wete District Hospital 6 0 3 5 3 9 Zanzibar 94 71 87 61 69 77 MMR 473 365 422 279 288 284.7 * Private hospital, ** Include Mwembeladu maternity home
Table 51 : Institutional maternal mortality ratio, 2011 and 2010 Live births Maternal Ratio per 100,000 (Institution) deaths Live birth 2010 2011 2010 2011 2010 2011 Pemba 6,274 7,287 18 29 286.9 396.9 Unguja 17,708 19,735 51 48 288.0 243.2 Zanzibar 23,982 27,022 69 77 287.5 284.7
Figure 27 : Trends of MMR in Zanzibar (Institutional) from 2006 to 2011.
10.6.2 Causes of Maternal Death.
The table 51 shows the actual numbers of maternal deaths by health facility and the figure 28 shows causes of death by percentages. The two main causes of death are Hypertensive disorder in pregnancy with 32% followed by Post-partum haemorrhage PPH with 22% followed by severe anaemia 14%. Sepsis and severe anaemia are still in low rate of 4% and 2 % respectively. 66 In 2010, Eclampsia was at 16%, Disseminated Intravascular Coagulation (DIC) was in third position with 14%, and Rupture of uterus (12%) was main cause of maternal death but did not appear in 2011.
The percentage of women dying from Post-partum haemorrhage is persistently higher than what it could be expected but probably quite consistent since a 1998 UNICEF study. Also the UNICEF study found that 27 % of all deaths were due to eclampsia, but the good news is 2011 there in no maternal death caused by eclampsia.
Figure 28: Causes of Maternal Death in percentage 2011
67 CHAPTER ELEVEN 11. HIV/AIDS
In Zanzibar, HIV counselling and testing services are provided in 68 sites, including 45 public health facilities, 7 NGOs, 7 parastatal and 9 private hospitals. Among them, 42 are in Unguja and 26 in Pemba which is distributed in all districts of Zanzibar. Out of these 68 sites, 10 are providing Provider Initiating Testing and Counselling (PITC), (5 in Unguja and 5 in Pemba). In addition, these services are also provided in outreach activities and during special events such as World AIDS Day, Zanzibar International Film Festival, village health days and other events.
11.1 HIV testing in the population
In 2011, a total of 49,587 people were counselled and tested; this is equivalent to 3.9% of the Zanzibar population. Out of them 23,796 (48%) were females and 25,791 (52%) were males. District wise, Urban had the highest proportion of people tested while North B had the least. A similar trend was seen in 2010.
Table 52: HIV testing among the population by district, Zanzibar, 2010 and 2011 District Population 2010 2011 Number tested Percent tested Number Percent tested for HIV for HIV tested for HIV for HIV Kaskazini A 105,522 4,059 3.8 1,672 1.6 Kaskazini B 71,895 2,804 3.9 739 1.0 Urban 274,802 21,992 8.0 26,195 9.5 West 208,403 24,885 11.9 4,769 2.3 Central 74,252 5,374 7.2 2,161 2.9 South 38,360 3,328 8.7 1,689 4.4 Wete 138,418 3,475 2.5 3,128 2.3 Micheweni 115,581 1,884 1.6 2,455 2.1 ChakeChake 120,789 2,856 2.4 4,881 4.0 Mkoani 125,812 1,800 1.4 1,897 1.5 Not specified - 588 - - - Zanzibar 1,273,834 73,045 5.7 49,587 3.9
11.2 HIV prevalence among tested by Demographic characteristics
Overall HIV prevalence among tested was 2.3%with the prevalence being equals among females (2.3%) than males (2.3%). There is a slight decline in HIV prevalence among tested in 2011 as compared to 2010 (2.4%) and 2009 (2.8%).
68 Table 53: HIV prevalence among tested by sex, Zanzibar, for the year 2009, 2010 and 2011 Female Male Total 2009 2010 2011 2009 2010 2011 2009 2010 2011 Number tested for HIV 33,096 35,641 23,796 36,653 37,404 25,791 69,749 73,045 49,587 Number HIV Positive 1,168 1,106 558 756 623 600 1,924 1,729 1,158 Percent HIV Positive 3.5 3.1 2.3 2.1 1.7 2.3 2.8 2.4 2.3
Among the people who were counselled and tested in 2011, HIV prevalence is highest in the age group 0-9 years. This can be explained by the fact that, individual aged between 5–15 years are not likely to be tested voluntarily but rather under heath providers advise particularly when the clinicians suspect the child may be HIV infected. In the age group of 15-24 years prevalence of HIV is higher for males (3.8%) than female (1.1%).
Table 54: HIV prevalence among tested by age and sex, Zanzibar, 2011 Female Male Age Group No. tested No.HIV % HIV No. tested for No.HIV % HIV (Years) for HIV positive positive HIV positive positive 0 – 9 142 15 10.6 144 11 7.6 10 – 14 191 9 4.7 89 4 4.5 15 – 24 11,473 126 1.1 7,090 270 3.8 25 – 34 8,190 241 2.9 11,729 129 1.1 35 – 44 2,903 126 4.3 4,722 112 2.4 45 - 54 743 28 3.8 1,544 59 3.8 55 + 154 13 8.4 473 15 3.2 Total 23,796 558 2.3 25,791 600 2.3
HIV prevalence is higher in Unguja than in Pemba. However, this difference is more remarkable among females where it is more than 2 times higher in Unguja than in Pemba (2.7% vs 1.2%). Central district has the highest HIV prevalence among tested (4.0%) and Micheweni has the least prevalence (0.7%). Comparison of HIV prevalence by district between 2010 and 2011 shows a declining trend in almost all districts except Urban, Central and Mkoani where there is a slight incline, whilst no changes for South and Wete districts. For detailed information refer table 55 below:
Table 55: HIV prevalence among tested by district and sex, Zanzibar, 2011 District Female Male %HIV + ve No. tested No. HIV % HIV No. tested No.HIV % HIV both sexes for HIV positive positive for HIV positive positive North A 807 18 2.2 866 8 0.9 1.6 North B 421 7 1.7 318 3 0.9 1.4 Urban 12,189 315 2.6 14,006 442 3.2 2.9 West 2,547 83 3.3 2,222 35 1.6 2.5 Central 1,052 52 4.9 1,109 35 3.2 4.0 South 845 12 1.4 844 13 1.5 1.5 Unguja 17,861 487 2.7 19,365 536 2.8 2.7 Wete 1,546 18 1.2 1,582 14 0.9 1.0 Micheweni 1,269 12 0.9 1,186 6 0.5 0.7 ChakeChake 2,237 33 1.5 2,644 30 1.1 1.3 Mkoani 883 8 0.9 1,014 14 1.4 1.2 Pemba 5,935 71 1.2 6,426 64 1.0 1.1 Zanzibar 23,796 558 3.9 25,791 600 3.8 3.8 69 Figure 29: HIV prevalence among tested by district, Zanzibar, 2010vs 2011 5 e v
i 4 t i
s 4 o P 2.9
V 2.8 2.8 I 3 2.7 2.5 H 2.4
f o 1.8 e 1.6 1.6 g 2 1.4 1.51.5 a 1.3 1.2 t 1 1 n 0.8
e 0.7
c 1 0.5 r e P 0 North A North B Urban West Central South Wete Micheweni Chake Mkoani Chake
District
2010 2011
11.3 HIV care and treatment services
There are currently 10 health facilities providing HIV care and treatment services in Zanzibar, 6 in Unguja and 4 in Pemba. Among these health facilities, 2 are new which is Makunduchi PHCC Hospital (Unguja) and Mkoani Hospital (Pemba). These services are provided both in public (9 clinics) and private (1 clinic) health facilities. By the end of 2011, a total of 6,175 HIV positive clients were enrolled in HIV Care and Treatment Clinics in these health facilities and among them 3,360 (54.4%) were on ARVs.
More of the female patients are on care (63%) and on ARVs (62%) compared to males. This is in line with HIV prevalence among HIV tested in Zanzibar whereby a higher proportion of females are found to be infected than males. Table 56 describe age and sex desegregation of client receiving HIV care and treatment services.
Table 56: HIV positive clients receiving HIV Care and Treatment services by age and sex, 2011 < 15 years ≥ 15 years Total
Female Male Female Male Female Male Cumulative number of HIV 262 289 3,632 1,992 3,894 2,281 positive clients on care Cumulative number of HIV 162 160 1,954 1,084 2,116 1,244 positive clients on ARVs
Majority of the patients on care and on ART (88%) are receiving HIV care and treatment services in Unguja. Again, this is concordant with HIV prevalence among HIV tested in Zanzibar whereby HIV prevalence is more than two times higher in Unguja than in Pemba.
Within Unguja, the bulk of the patients (74% of those on care and 75% of those on treatment) are at Mnazi Mmoja hospital. In Pemba, more of the patients are receiving the services (59% of those on care and 57% of those on ARVs) at Chake Chake hospital as compared to other health facilities.
70 Table 57 : HIV +ve clients receiving HIV Care and Treatment services by health facility, 2011 Health Facility Cumulative number of Cumulative number of HIV HIV positive clients on positive clients on ARVs care MnaziMmoja 4,037 2,243 Mwembeladu 578 323 Al-Rahma 189 86 BububuMillitary 331 154 Kivunge 293 155 Makunduchi 8 11 Unguja 5,436 2,972
Wete 243 128 Micheweni 52 31 Chake Chake 438 221 Mkoani 6 8 Pemba 739 388
Zanzibar 6,175 3,360
71 CHAPTER TWELVE 12. Tuberculosis and Leprosy
12.1 Tuberculosis
A total of 546 patients diagnosed in 2011, among those 511 (93.6%) were new patients. of which 280 (54.8%) were smear positive, 158 (30.9%) were smear negative and 73 (14.3%) were Extra- pulmonary TB patients.
Table 58: Distribution of case notified in Zanzibar by Category Type of patients AFB + AFB - EP TOTAL New 280 158 73 511 Relapse 12 12 Failure 5 5 Return to 9 9 control Others 9 0 9 TOTAL: 306 167 73 546
A total of 35 re-treatment patients were registered during this period, among them 12 (34.3%) were relapse and 5 (14.3%) were failure 9 (25.7%) were return to control and 9 (25.7%) were others.
12.1.1Gender and age characteristics of New smear positive patients.
Of the 546 patients diagnosed with TB at the health facilities, 177 (63.2%) were male and 103 (36.7%) were female.
Table 59: New smear positive by Age group and Sex for Zanzibar AGE Group 0 - 14 15 - 24 25 - 34 35 - 44 45 - 54 55 - 64 65 + Total Male 6 34 53 47 16 16 5 177 Female 7 30 30 17 9 6 4 103 Total 13 64 83 64 25 22 9 280
12.1.2TB/HIV NOTIFICATION 2011
A total of 546 TB patients enrolled in 2011 among them 201(36.8%) were female and 345 (63.2%) were male. Total tested for HIV were 470 (86%) whereby 83 (17.7%) were tested positive. TB/HIV patients transferred to CTC were 83 (100%) and all accepted and registered for HIV care. Total of 18 (21.7%) have started ART and all (100%) have started CPT.
72 Table 60 : TB/HIV NOTIFICATION 2011 Number Number Number Number Number Number Number of all TB tested HIV Referred registered stated started patients for HIV positive to CTC for HIV ART CPT care Sex FMFMFMFM FMFMFM SSP 103177 103153 2022 20 22 20 22 4 5 20 22 Others 98 168 78 136 20 21 20 21 20 21 3 6 20 21 Total 201345 181289 40 43 40 43 40 43 7 11 40 43
Number of TB patients tested for HIV reduced from 98.2% in (2010) to 86% in (2011) according to TB/ Leprosy Programme this was due to unavailability of test kits in the DCT centers.
12.1.3Treatment Result of New Smear Positive TB patients notified in 2010
A total of 270 new smear positive notified during the year 2010, among them 225 (83.3%) patients were cured, 3 (1.1%) were completed treatment, 3 (1.1%) were failure, 10 (3.7%) were died, 9 (3.3%) were defaulted and 20 (7.4%) were transferred out. Treatment success rate 84.4% (228 patients)
Table 61: Treatment Result of New Smear Positive TB patients notified during year 2010 categories No. Cured T. Comp Failure Died Defaulted T. Out TOTAL notified sex FMFMFMFMFM FMFMFM smear positive 99 171 88 137 2 103550 9416 99 171
12.1.4Results of treatment of smear Negative and EP TB patients notified in 2010
In this year 159 smear negative TB patients were reported among them 127 (80%) patients were completed their treatments, 18 (11.3%) were died, 2 (1.3%) were defaulted and 12 (7.5%) were transferred out.
Table 62: Results of treatment of smear Negative and EP TB patients notified in 2010 categories TOTA No. Failur Defaulte T. L notified Cured T. Comp e Died d Out sex FMFM FMFM FM FMFM FM smear 1 1 negative 68 91 0 0 57 70 0 0 0 8 0 2 1 1 68 91
73 12.1.5 Treatment Results of Re-treatment TB patients notified in 2010
In 2010, there were 28 re-treatment patients who were on treatments. The total of 16 (57.1%) were cured, 6 of them (21.4%) were treatment completed, 3 (10.7%) were died, 1 (3.6%) was defaulted and 2 (7.1%) were transferred out.
Table 63: Treatment Results of Re treatment TB patients notified in 2010 categories No. TOTAL notified Cured T. Comp Failure Died Defaulted T. Out sex FMFM FMFM FM FMFM FM Re treatment 6 22 3 13 2 4 0 0 1 2 0 1 0 2 6 22
12.1.6 Tuberculosis prevalence from 2005-2011
Table 64: Notification of tuberculosis from 2005 – 2011 Year AFB+ AFB- EP Relapse Failure/ Return to Total Others Control 2005 211 66 53 14 5 5 354 2006 238 41 44 9 7 5 344 2007 232 70 48 11 3 5 369 2008 265 69 73 14 4 3 428 2009 235 76 76 25 9 3 426 2010 270 85 66 14 11 3 449 2011 280 158 73 12 14 9 546
The trend of TB notification over seven consecutive years has been almost being the same, the increase is the result of intensive health education following sputum day.
12.2 LEPROSY A total of leprosy patients notified in this year are 81, among them 98.8% were new patients. Among new patients 65% were Multi bacillary (MB) and 35% were Pause bacillary (PB). 1 patient is a relapse after Dapsone (DDS).
Table 65: Notification in 2011 MB PB TOTAL New 52 28 80 ReturnafterDefault 0 0 0 Relapse after MDT 0 0 0 Relapse after DDS 0 1 1 Total: 52 29 81
74 Figure 30: The chart bellow show Leprosy cases diagnosed in 2011 all cases
60 50 40 30 20 10 0 MB PB
NB. MB patients are the majority hence delay reporting and cross infection is continuing. This indicates community awareness to be emphasized.
Table 66: Notification of New Leprosy Cases MB PB TOTAL Unguja 16 5 21 Pemba 36 23 59 Zanzibar 52 28 80
In 2011, a total of 80 new leprosy patients were diagnosed in Zanzibar. Among them MB were 52(65%) and PB were 28(35%).
A total of 59 leprosy patients diagnosed 2011 in Unguja. Among them 36 (61%) were MB and PB were 23 (39%).
Pemba Region notified 21 leprosy patients in 2011, among them 16 (76.2%) were MB, and 5 (23.8%) were PB patients.
12.2.1 Reconstructive Surgery
Total of 24 cases were screened, among them 8 were none leprosy and 16 were PALs with both surgical and medical problem. Among the 24 cases PALs 6 and 6 none PALs were scheduled for operation.
75 CHAPTER THIRTEEN 13. Hospital In-patient data
In-patient care in a hospital is usually more costly to the health sector than outpatient treatment and requires constant presence of health workers and supporting staffs. In- patient data is therefore an important aspect of health information. The information derived from these data includes; admissions and deaths with associated causes, discharges, bed occupancy, length of stay and others. This information is vital and useful in prevention and health care management.
13.1 Hospitals in General
13.1.1 Bed Occupancy Rate
Bed occupancy rate (BOR) measures effective and efficient performance of hospitals, bed occupancy rate is calculated by dividing the in-patient days (i.e. length of stay for each patient admitted) by the number of sanctioned beds for the hospital. Un-reporting of length of stay will result in an underestimation of the bed occupancy rate.
Zanzibar Health Sector Reform Strategic Plan II (ZHSRSP II) has set a minimum range of 60 percent to be accepted for a well run Hospital. The available information shows that the overall bed occupancy rate in all hospitals in Zanzibar has increased from 45.8 percent in 2010 to 49 percent in 2011. This falls below the target of 60 percent.
Makunduchi Primary Health Care Centre, with a bed occupancy rate of 63.2 percent, is the only hospital in Zanzibar that reached the given target. Kivunge Primary Health Care Centre has the lowest bed occupancy rate of all Zanzibar hospitals with a rate of 23.9 percent.
Figure 31: Bed occupancy rate for Zanzibar Hospitals – (2010 and 2011
70 63.2 60.3 60 51.9 51.1 50.5 53.1 48.5 48.9 50 42.4 41.2 39.9 38.4 32.4 40 28.6 30 23.9 24.7 20 10 2010 0 2011
76 13.1.2 Average length of stay
Average length of stay refers average number of days that patients stay in hospital. This is calculated by dividing the number of in patient days spent in the hospital divided by the total number of patients admitted. The patient days are calculated as the sum of the number of patients present on the wards at midnight every day. In Zanzibar, average length of stay for admitted patients stands at 2.2 days which is outside the excepted standard of 3 to 7 days. It has been observed in 2009, 2010 and 2011, admitted patients in Pemba zone tend to stay longer 2.9 days, 2.6 days and 2.4 days respectively, while in Unguja average length of stay has remained constant at 2.2 days throughout the last three years. The differences apparent between the seven hospitals are currently being investigated. Table 67 and figure 32 show the average number of days that patients remain in the ward per Zone and for individual hospitals.
Table 67: Average length of stay Unguja vs. Pemba Zone 2009 2010 2011 Pemba Zone 2.9 2.6 2.4 Unguja Zone 2.2 2.2 2.2 Zanzibar 2.5 2.3 2.2
Figure 32: Average length of stay by Hospital (2010 and 2011)
4.0 3.23.5 3.5 2.6 2.7 3.0 2.3 2.4 2.2 2.3 2.4 2.5 2.0 2.1 2.2 2.1 2.1 2.0 1.3 1.5 1.1 1.0 0.5 0.0
l l l e e e e e a a a g g g g a e t t t j i i l z a a a a p o t t t t a p p s
t t t t 2010 t s s M i
o m o o o o o o p a H C C C C l s
H H
l M l
i i i o i j e a 2011 a e e h n z g o t r d H k c e a r g n e b a u e n w n u A h f d W e v o e C i M n t
h i R K u e c i V k k a a M h M C
Pemba Zone Unguja Zone
13.1.3 Causes of admission.
For three consecutive years Zanzibar’s top ten causes of admission remain almost the same. In 2011 pneumonia became the leading cause of hospitalization accounting for 16.2% patients admitted followed by diarrhea disease with 16.1%. Hypertension and diabetic are non communicable diseases (NCDs) but have outnumbered some communicable diseases in terms of causes for admission to hospitals. In 2011 hypertension cases (7.2%) have been found at third position which has increased from 4.8% 2010. Other causes which also show
77 higher proportions of cases include incomplete abortion-dropping from 8.5% to 2.7%, hernia decreased from 5.0% to 2.4% and UTI decreased from 4.2% to 2.0 for 2009 to 2010 respectively. Soft tissue injuries and Asthma is new edition in 2010 ten leading causes. As in past few years, malaria did not appear in 2011 leading ten causes of admissions
Table 68: Causes of Admission in Zanzibar hospitals by Percentage 2009 to 2011 Causes of admission 2009 (%) 2010 (%) 2011(%) n =20,181 n = 40,128 n=44,579
Pneumonia 4.3 8.6 16.2 Diarrhea 13.6 13.9 16.1 Hypertension 8.9 4.8 7.2 Urinary Tract Infection 4.2 2 4.6 Severe Anemia 3.6 2 3.5 Asthma 3.5 1.8 3.5 Hernia 5 2.4 3.3 Soft Tissue Injuries 3.1 1.8 3.2 Fractures 4.5 2.3 2.4 Diabetes * * 2.2 Abortion incomplete 8.5 2.7 * Others 40.8 57.7 37.8
* Not a leading causes of admission.
13.1.4 Hospital fatality rate
Zanzibar hospital fatality rate in general has decreased from 4.1percent (2010) to 3.3percent (2011) for all diseases as reported. Hospital fatality rate has decreased dramatically in Pemba Zone from 7.7 percent (2010) to 3.5percent (2011) while in Unguja zone was increased from 2.6 percent (2010) to 2.9 percent (2011).
Table 69: Zanzibar hospital fatality rate from 2008 to 2011 Zone 2008 2009 2010 2011 Pemba 2.0 3.3 7.7 3.5 Unguja 2.8 5.1 2.6 2.9 Zanzibar (TOTAL) 2.6 4.6 4.1 3.3
13.1.5 Top ten Causes of deaths in Hospitals, 2011
As in previous years, in 2011 pneumonia has still topped the list of top ten deaths by accounting for 9.0 percent of all causes of hospital mortality; there is increase of 2.9 percent from 2010, followed by Severe Anaemia (7.0 %), Hypertension (6 %), septicaemia (4 %) and Cerebral Vascular Accident (4.0%).
78 Figure 33: Top ten Causes of deaths in Hospitals, 2011 (n = 1943)
Pneumonia Head Injury Septicaemia 9% 2% Hypertension/Severe 6% bacterial infection 4% Premature Other babyCelebral Diagnosis 4%Vascular 55% Accident 4% Anaemia Severe (<7 gm/dl) 7% Congestive Asphyxia Cardiac 3% Diabetes Failure 3% 3%
79 Annex
Annex A: HMIS/ DHIS Indicator descriptions
HMIS/ DHIS Indicator descriptions Indicator Type Numerator Denominator Description 1 Utilization rate OPD < No Totalheadcountunder Total population The rate of which the 5yrs five years at OPD under five years population under five years uses the OPD services of the facility. 2 Utilization rate (all No Total headcount under Total population The rate of which the service) <5yrs five years attended all under five years population under five years service uses all services of the facility (OPD +Immunization). 3 Utilization rate OPD No Totalheadcountallage Totalpopulation Therateofwhichthetotal (all Age) attended OPD population Attended OPD. 4 Underweight for age % Underweight for Total attendance Underweight for age under rate under 5 years age(red and grey cases) growth assessment 5yrs rate <5 yrs 5 Underweight for age % Underweight for age ( Total attendance for Underweight for age under 5 rate under 5yrs red) under 5 years growth assessment rate (severe) (severe) all (green, grey, red ) 6 Children under 5 years % Number of children Population under 5 Proportion of population < 5 weighed weighed under five years years attending growth years assessment. 7 Vitamin A coverage % Vitamin A supplement Target Population For the provision of vitamin under 5 years to children under 5 under 5 year (x2) A supplements years 8 Diarrhoea incidence % Diarrhoea cases under Population under 5 Prevalence of Diarrhoea in under 5 years 5 years years the catchment area for children under five years old. 9 Pneumonia incidence % Pneumonia < 5 years Population under 5 For measuring pneumonia under 5 years new years incidence in the catchment area. 10 Anaemia incidence % Anaemia cases under 5 Population under 5 Prevalence of Anaemia in the under 5 years years years catchment area for children under five years old. 11 URTI incidence under % URTI cases under 5 Population under 5 Prevalence of URTI in the 5 years years years catchment area for children under five years old. 12 Measles Incidence < 5 % Measles cases Population under 5 years years 13 Under 5 death rate per1K Death of children under Population under 5 Rate of deaths for under 5 5 hospital and years children including all community reported community deaths under 5 years and neonatal deaths reported by the maternity wards. 14 BCG under 1 year % BCG dose under 1 year Target population BCG doses given to children coverage under 1 year under 1 year by population under 1 year. 15 OPV1 under 1 year % Oral Polio 1st dose Target Population For Oral Polio 1 doses
80 coverage under 1 year coverage in the catchment area 16 OPV3 under 1 year % Oral Polio 3rd dose Target Population For Oral Polio doses coverage under 1 year coverage in the catchment area 17 DPT- HepB 3 under 1 % DPT- HepB 3 doses Population under 1 year coverage under 1 year year 18 Measles under 1 year % Measles dose under 1 Target population For the coverage of measles coverage year under 1 year in the catchment area 19 Fully immunized % Fully Immunized under Target Population Monitor the rate of full under 1 year coverage 1 year under 1 year immunized for children under 1yrs 20 DPT -HepB 1-3 Doses % DPT1 - DPT3 Doses DPT1 doses given It monitor how many didn't drop-out rate turn up for the DPT 3 after the DPT 1 21 Antenatal first visit % Antenatalfirstvisit Potentialantenatal Antenatal first visit coverage coverage clients in population 22 Antenatal visits before % Antenatal 1st visit All first visits Rate of the antenatal 1st 16weeks rate before 16 weeks visits attended before pregnancy being in 16 weeks 23 Children born % Children born Expected deliveries The indicator for the % of protected from protected from tetanus (4.5% of the total mothers delivering while Tetanus population ) protected from Tetanus 24 Malaria rate in % Pregnant women Antenatal first visits Pregnant women diagnosed pregnant women diagnosed for malaria for Malaria 25 Anaemia rate in % Pregnant women Total antenatal first Anaemia rate in pregnant pregnant women treated for anaemia visits women (11gm%) 26 Deliveries by health % Deliveries by health Expected deliveries All health facility deliveries + skilled attendant staff (4.5% of the total home deliveries attended by population ) health facility staff. 27 Institution Maternal per100K Maternal Deaths in the Live Births in the The ratio of institution Mortality Ratio ward ward maternal death in the ward 100 000 per and live birth in the ward 28 Delivery rate in facility % Pregnancy women All ANC cases Delivery rate in facility to to women under 20 under 20 years women under 20year. years 29 Low birth weight rate % Total live births under Total live births Rate of infants born with 2500 g weight < 2500g 30 Perinatal mortality per1K Still births + early Total births (live + Perinatal mortality rate in rate neonatal deaths (1-14 still) based on both community days) data and data from the maternity wards. 31 Still birth rate % Total still births Total births Rate of still birth (fresh + macerated) in facility, maternity ward and community those reported 32 Malaria incidence % Total Malaria Positive Total Population Malaria Incidences under 5 years cases at OPD 5years under 5 years 33 Malaria incidence rate % Total Malaria Positive Total population Malaria incidence rate (all (all ages) cases at OPD (all age ) ages), incl. malaria in pregnancy. 34 HIV prevalence in the % HIV tested positive All the clients tested Those clients who tested in tested clients the VCT centers
81 35 Male Urethral per1K Male Urethral STI treated new Male Urethral discharge discharge Syndrome discharge syndrome episode Syndrome rate rate treated 36 Condom distribution % Condoms distributed Male population Condoms distributed rate (HIV/STI clinics) over or equal to 15 through family planning years services and HIV/STI clinics. 37 Oral Pills new clients % Oral Pills new clients (WRA) coverage 39 Injection new clients % Injection new clients (WRA) Injection new clients’ coverage coverage in the WRA catchment population. 40 Condom new clients % Condom new clients (WRA) coverage 41 Tubal Ligation new % Tubal Ligation new (WRA) clients coverage clients 42 Family Planning new % Family Planning new (WRA) clients coverage clients 43 Couple Year Per K Oral pills items WRA multiply by 13 # of WRA protected by Oral Protection rate (CYP) dispensed Pills out of 1000 WRA per Oral contraceptives one year 44 Couple Year Per K Injection item WRA multiply by 4 # of WRA protected by Protection rate (CYP) dispensed injection out of 1000 WRA injection per one year 45 Couple Year Per K ML/LA (BTL)+ML/LA or WRA divide by 15 # of WRA protected by Tubal Protection rate (CYP) BTL after PAC Ligation out of 1000 WRA Tubal Ligation per one year 46 Couple Year Per K IUCD Dispensed WRA divide by 5 # of WRA protected by IUCD Protection rate (CYP) out of 1000 WRA per one IUCD year 47 Couple Year Implanon item WRA divide by 4 # of WRA protected by Oral Protection rate (CYP) dispensed Pill out of 1000 WRA per one Implanon year 48 Couple Year Number Condom WRA multiply by 250 # of WRA protected by Protection rate (CYP) dispensed condoms out of 1000 WRA Condoms per one year 49 IPT coverage in ANC % Total IPT Total antenatal first Coverage of IPT at ANC - all clients visits doses 50 HIV prevalence in % HIV tests positive Total ANC first visit antenatal care clients among ANC clients 51 Caesarean Section % Number of caesarean Expected delivery Rate of caesarean sections at Rate sections at the facility facilities providing delivery services. 52 Data Coverage EPI % Number of received Expected number of Based on DHIS2, submitted and captured EPI forms EPI forms EPI forms 53 Data Coverage RCH % Number of received Expected number of Based on DHIS2, submitted and captured RCH RCH forms RCH forms forms 54 Data Coverage Disease % Number of received Expected number of Based on DHIS2, submitted Surveillance (OPD) and captured OPD OPD Forms OPD forms Forms 55 Data Coverage % Number of received Number of expected Based on DHIS2, submitted Maternity Ward and captured Maternity Maternity Ward Maternity forms Ward forms forms 56 TT2+ to Pregnant % TT2+dosesgivento Estimated pregnant Women rate pregnant women women in population (4.5%) 82 57 AFP Incidence rate per100K AFP cases Total Population Proportion of population who are reported as having Acute Flaccid Paralysis. 58 Post Natal care before % PNC at 7 days Expected deliveries Proportion of deliveries 7 days rate (4.5% of the total coming for PNC before 7 population ) days. 59 HIV testing rate for % Antenatal client first Total antenatal first ANC client visit tested visits 60 DPT-HepB 1 under 1 % DPT-HepB 3 -dose Population <1 year year coverage given under 1 year coverage 61 Syphilis testing rate % ANC clients tested for ANC 1st visit for ANC client syphilis attendance 62 Syphilis prevalence in % ANC clients tested ANC clients tested antenatal care clients positive for syphilis for syphilis 63 IPT coverage in % IPT all Expected deliveries expected deliveries 64 Delivery complication % Total delivery Totaldeliveries Proportionofallinstitutional rate complications delivers for which complications were reported. 65 DPT-HepB 1 - measles % DTP-HepB 1st dose DTP-HepB 3rd dose The drop-out rate (how drop-out rate minus Measles 1st dose many children are losing out under 1 year of the immunization program between the 1st DPT-HepB and the Measles dose for < 1 year. 66 Deliveries in % Institutional deliveries Expected deliveries Proportion of expected institutions (4.5% of the total deliveries in institutions. population ) 67 Malaria confirmed % Malaria confirmed for population under Malaria confirmed incidence incidence under 5 under five years five years under 5 years years 68 Home delivery % Home delivery Expected deliveries Home deliveries attended by attended by TBA attended by TBA Traditional birth attended 69 Malnutrition under 5 % Malnutrition under five Population under years years five years 70 Family Planning per10K Total family Planning WRA Acceptors per 10000 new Clients WRA
83 Annex B: Distribution of PHCU + in Unguja and Pemba Distribution of PHCU + (Second line) in Unguja
URBAN DISTRICT
84 Distribution of PHCU + (Second line) in Pemba
85