www.sciedu.ca/jha Journal of Hospital Administration 2015, Vol. 4, No. 4 ORIGINAL ARTICLE Sustainability of health benefits: Challenges faced by councils health management teams in sustaining comprehensive emergency care services after project phase out. The case of Rufiji, Kilombero and Ulanga districts Josephine Shabani ,∗ Iddagiovana Kinyonge, Hadija Kweka, Selemani Mbuyita, Ahmed Makemba, Godfrey Mbaruku Ifakara Health Institute, Dar es Salaam, Tanzania Received: January 13, 2015 Accepted: April 3, 2015 Online Published: April 28, 2015 DOI: 10.5430/jha.v4n4p1 URL: http://dx.doi.org/10.5430/jha.v4n4p1 ABSTRACT Background: Attention to the sustainability of health intervention programs is increasing not only in developing countries but also in developed countries together with international development agencies. However, consensus on operational definitions of sustainability and determinants of sustainability is still at an early stage. While much progress has been made in the development of successful interventions to promote health, too few interventions achieve long term sustainability. Implementation of EMPOWER project in collaboration with World Lung Foundation (WLF) have increased accessibility of comprehensive emergency obstetric care (CEmOC) by upgrading health centers which were formerly not providing CEmOC services in the three rural districts in Tanzania. Although the WHO standards of CEmOC coverage in the project districts was above the requirement, but accessing these health facilities which provides CEmOC was so difficult due to various factors like geographical (mountains, rivers, seasonal roads), locations of these health facilities (like in one district the it was located at a corner of the district), unreliable referral system and poor functionality of these health facilities especially in terms of emergency preparedness etc. all these factors lead to less/poor accessibility to CEmOC. The upgraded facilities include Kibiti in Rufiji district, Mlimba in Kilombero district, Mwaya and Mtimbira in Ulanga district. Objective: To explore challenges of sustaining upgraded health centers and impact on service utilization after project phase out among rural communities in Tanzania. Methods: Purposeful criterion-based selection of the upgraded health centers (those providing CEmOC) was used in the three districts two years after project phase-out. Secondary data analysis of the quantitative data which was collected during and after the project was done. The following services were assessed; total number of facility deliveries, average number of cesarean section (CS), ante natal care (ANC) attendance, post natal care (PNC) attendance, family planning (FP) use and partograph to monitor the progress of labor. Qualitative data involved key informant interviews of council health management teams (CHMT) and facility in charges.Monitoring data, evaluation and observation of various CEmOC and MNCH related indicators were also done. Four upgraded health centers (Mwaya, Mtimbira, Mlimba and Kibiti) were used as case studies to generate learning reported in this paper. Results: Two years post project, the utilization of most of the services like number of deliveries and CS performed better and were maintained in upgraded health centers which receive regular assistance (Mwaya and Mlimba) than Kibiti health center which received minimal support. Health workers remained committed to sustain the practices promoted in the interventions ∗Correspondence: Josephine Shabani; Email: [email protected]; Address: Ifakara Health Institute, Po Box 78373, Dar es Salaam, Tanzania. Published by Sciedu Press 1 www.sciedu.ca/jha Journal of Hospital Administration 2015, Vol. 4, No. 4 despite of the noted challenges. Conclusions: Benefits of introduced health innovations such as upgrading of health centers for CEmOC can only be sustained if a sustainability strategies are integrated at early stages of project design and carried forward in routine district health planning processes. Key Words: Sustainability, Upgraded health centers 1.I NTRODUCTION ity by setting clear targets for improving maternal and child Annually, it is estimated that 536,000 women die worldwide health.[3] from pregnancy and childbirth related conditions, as do 11 In Tanzania, specific attempts have been made to address ma- million under-fives, of which 4.4 million are newborns, most ternal and newborn health challenges through the National [1] of these deaths occur in Sub Saharan Africa. According to Health Policy, Health Sector Reforms and the Health Sector the 2012 National Population and Housing Census, Tanzania Strategic Plan IV (2009-2015).[5] In addition to this, the Mainland is populated with 44,928,923, out of which 75% Reproductive and Child Health Strategy (2010-2015) has live in rural areas. The annual growth rate is 2.7% with life also been formulated to respond to the problem. Improving expectancy at birth being 54 years for males and 56 years for maternal and child health is also a major priority area in females. The current total fertility rate in Tanzania stands at the National Strategy for Growth and Reduction of Poverty 5.4, which is high. There are regional variations with urban (MKUKUTA) 2005-2010. One of the goals clearly outlined rural disparities, where rural women have higher fertility in the second cluster of the strategy is to improve survival, [2] rates than their urban counterparts. health and wellbeing of all children and women, as well as The Maternal Mortality Ratio in Tanzania has remained high other vulnerable groups. Under this goal, MKUKUTA sets for the last 10 years with no decline, the current level is esti- an operational target related to maternal and child health, mated at 454 per 100,000 live births while neonatal deaths is which is crucial in monitoring progress towards reducing estimated at 26 per 1,000 live births, this accounts for 47% morbidity and mortality among pregnant women, young girls of the infant mortality rate which is estimated at 51 per 1,000 and newborns. [2] live births. Although much progress has been made in the development In Tanzania, the high fertility rate combined with the low of successful interventions to promote health, too few in- contraceptive prevalence rate increase the lifetime risk of terventions achieve long term sustainability. As a result maternal death. Unfortunately, for the majority of women, sustainability has remained as one of the key challenges in especially the poor and disadvantaged groups, the pathway public health.[6] According to the International Fund for to safe motherhood are blocked by the underlying factors Agricultural Development (IFAD) report of 2009, sustain- that lead to delays in accessing appropriate care. These in- ability is defined as ensuring that the institutions supported clude: delays at individual, household and community levels through projects and the benefits realized are maintained and in making the decision to seek appropriate care; delay in continue after the end of the project. The US Agency for reaching the appropriate facility due to financial and geo- International Development in1988 also defined a sustainable graphical obstacles (transport); and delay at the facility in project as the one which is able to deliver an appropriate receiving appropriate care due to a weak health system and level of benefits for an extended period of time after major poor quality of care.[3,4] financial, managerial and technical assistance from an ex- ternal donor is terminated. Most of the innovations that are Initiatives to improve maternal and child health initially successful, fail to become part of the habits and rou- In 1989, Tanzania adopted the Safe Motherhood Initiative tines of the host organizations and communities, the major (SMI), following the official launch of the Global Safe Moth- challenge being the high dependency of donor funding to erhood Initiative in 1987 in Nairobi, Kenya. However, mater- sustain the program.[7] Over the years scientists have been nal and perinatal mortality rates have remained unacceptably struggling in fostering the sustainability of interventions in high in the country, as is the case in other African countries. community systems because they want to see the possibility Subsequently, the 1994 International Conference for Popula- of maintaining or increasing effects achieved during a re- tion and Development, and Millennium Development Goals search phase. Sustainability of health interventions is critical of 2000, highlighted the need to re-focus the strategies for because it is more than continuation of interventions since in reducing the persistently high maternal and new-born mortal- 2 ISSN 1927-6990 E-ISSN 1927-7008 www.sciedu.ca/jha Journal of Hospital Administration 2015, Vol. 4, No. 4 the long run it should result into the exchange of knowledge tute (IHI) launched EMPOWER project which implemented and resources.[8] In addition, the health providers who would a systems wide approach to address Maternal, Newborn and have gained “added skills” will be expected to provide better Child Health morbidity and mortality in Kigoma, Rufiji, Kilo- services on a long term basis. mbero and Ulanga District Councils . They major aim of the project was to increase access both basic and CEmOC. This Meanwhile health facility related interventions have gener- was done through skills development of health providers, cap- ated excitement, innovation, and exploration of alternative ital investment in terms of infrastructure development and approaches over the