Towards improved health service quality in Tanzania: An approach to increase efficiency and effectiveness of routine supportive supervision

Digital supportive supervision (DiSS) of maternal health, child health and nutrition (MCHN) service delivery in Rajasthan, India: study protocol for impact evaluation and cost-effectiveness analysis

BACKGROUND

A digital supportive supervision (DiSS) tool was developed and implemented in Rajasthan, India, to enhance the coverage and quality of maternal health, child health and nutrition (MCHN) services. This study aims to assess the impact and cost-effectiveness of DiSS compared to traditional paper-based supportive supervision.

METHODS AND ANALYSIS

A quasi-experimental research design incorporating interrupted time series regression analysis will be employed to evaluate the impact of DiSS. Two districts from the high DiSS intensity group, defined as having at least 25% of the MCHN sessions supervised digitally, will be randomly selected as intervention districts. Two comparator districts will be selected from the low DiSS intensity group (less than 25% of MCHN sessions supervised digitally) after matching with intervention districts based on three indicators-female literacy, proportion of population belonging to scheduled caste or tribe and coverage of four antenatal care visits. District-level monthly data on the number of beneficiaries using MCHN services will be obtained from the state's routine health management information system. Key informants involved in supervising MCHN sessions will also be interviewed to complement the quantitative findings. A mixed micro-costing methodology, incorporating top-down and bottom-up approaches, for assessing the cost of implementing supervision in either scenario. A decision model will estimate long-term health outcomes, in the form of quality-adjusted life years (QALY), in both the intervention and comparator groups. Cost-effectiveness of DiSS will be assessed by computing the incremental cost per QALY gained in the intervention versus comparator group.

ETHICS AND DISSEMINATION

The study has been approved by the Institute Ethics Committee of the PGIMER, Chandigarh, India (IEC No. IEC-03/2023-2671). The study results will be disseminated at research conferences and published in peer-reviewed journals.

A cluster randomized trial assessing the effect of a digital health algorithm on quality of care in Tanzania (DYNAMIC study)

Digital clinical decision support tools have contributed to improved quality of care at primary care level health facilities. However, data from real-world randomized trials are lacking. We conducted a cluster randomized, open-label trial in Tanzania evaluating the use of a digital clinical decision support algorithm (CDSA), enhanced by point-of-care tests, training and mentorship, compared with usual care, among sick children 2 to 59 months old presenting to primary care facilities for an acute illness in Tanzania (ClinicalTrials.gov NCT05144763). The primary outcome was the mean proportion of 14 major Integrated Management of Childhood Illness (IMCI) symptoms and signs assessed by clinicians. Secondary outcomes included antibiotic prescription, counseling provided, and the appropriateness of antimalarial and antibiotic prescriptions. A total of 450 consultations were observed in 9 intervention and 9 control health facilities. The mean proportion of major symptoms and signs assessed in intervention health facilities was 46.4% (range 7.7% to 91.7%) compared to 26.3% (range 0% to 66.7%) in control health facilities, an adjusted difference of 15.1% (95% confidence interval [CI] 4.8% to 25.4%). Only weight, height, and pallor were assessed statistically more often when using the digital CDSA compared to controls. Observed antibiotic prescription was 37.3% in intervention facilities, and 76.4% in control facilities (adjusted risk ratio 0.5; 95% CI 0.4 to 0.7; p<0.001). Appropriate antibiotic prescription was 81.9% in intervention facilities and 51.4% in control facilities (adjusted risk ratio 1.5; 95% CI 1.2 to 1.8; p = 0.003). The implementation of a digital CDSA improved the mean proportion of IMCI symptoms and signs assessed in consultations with sick children, however most symptoms and signs were assessed infrequently. Nonetheless, antibiotics were prescribed less often, and more appropriately. Innovative approaches to overcome barriers related to clinicians' motivation and work environment are needed.

Policy strategies for capacity building and scale up of the workforce for comprehensive cancer care: a systematic review

BACKGROUND

Patients with cancer in low- and middle-income countries experience worse outcomes as a result of the limited capacity of health systems to deliver comprehensive cancer care. The health workforce is a key component of health systems; however, deep gaps exist in the availability and accessibility of cancer care providers.

MATERIALS AND METHODS

We carried out a systematic review of the literature evaluating the strategies for capacity building of the cancer workforce. We studied how the policy strategies addressed the availability, accessibility, acceptability, and quality (AAAQ) of the workforce. We used a strategic planning framework (SWOT: strengths, weaknesses, opportunities, threats) to identify actionable areas of capacity building. We contextualized our findings based on the WHO 2030 Global Strategy on Human Resources for Health, evaluating how they can ultimately be framed in a labour market approach and inform strategies to improve the capacity of the workforce (PROSPERO: CRD42020109377).

RESULTS

The systematic review of the literature yielded 9617 records, and we selected 45 eligible papers for data extraction. The workforce interventions identified were delivered mostly in the African and American Regions, and in two-thirds of cases, in high-income countries. Many strategies have been shown to increase the number of competent oncology providers. Optimization of the existing workforce through role delegation and digital health interventions was reported as a short- to mid-term solution to optimize cancer care, through quality-oriented, efficiency-improving, and acceptability-enforcing workforce strategies. The increased workload alone was potentially detrimental. The literature on retaining the workforce and reducing brain drain or attrition in underserved areas was commonly limited.

CONCLUSIONS

Workforce capacity building is not only a quantitative problem but can also be addressed through quality-oriented, organizational, and managerial solutions of human resources. The delivery of comprehensive, acceptable, and impact-oriented cancer care requires an available, accessible, and competent workforce for comprehensive cancer care. Efficiency-improving strategies may be instrumental for capacity building in resource-constrained settings.

Quality of health service in the local government authorities in Tanzania: a perspective of the healthcare seekers from Dodoma City and Bahi District councils

BACKGROUND

Improvement and access to quality healthcare are a global agenda. Sustainable Development Goal (SDG-3) is committed to ensuring good health and well-being of the people by 2030. However, this commitment heavily depends on joint efforts by local authorities and the immediate service providers to communities. This paper is set to inform the status of health service provision in local authorities in Tanzania using the determinants for quality health services in Dodoma City and Bahi District.

METHODS

A cross-sectional research design was employed to collect data from 400 households in the Local Government Authorities. The five-service quality (SERVQUAL) dimensions of Parasuraman were adopted to gauge the quality of service in public healthcare facilities. Descriptive statistics were used to compute the frequency and mean of the demographic information and the quality of health services, respectively. A binary logistic regression model was used to establish the influence of the demographic dimensions on the quality of health services.

FINDINGS

The findings revealed that quality health services have not been realised for healthcare seekers. Further, the area of residence, education, and occupation are significantly associated with the perceived quality of health service delivery in the Local Government Authorities.

CONCLUSION

The healthcare facilities under the LGAs offer services whose quality is below the healthcare seekers' expectations. The study recommends that the Local Government Authorities in Tanzania strengthen the monitoring and evaluation of health service delivery in public healthcare facilities.

Availability and functionality of neonatal care units in healthcare facilities in Mtwara region, Tanzania: The quest for quality of in-patient care for small and sick newborns

BACKGROUND

Evidence shows that delivery of prompt and appropriate in-patient newborn care (IPNC) through health facility (HF)-based neonatal care and stabilization units (NCU/NSUs) reduce preventable newborn mortalities (NMs). This study investigated the HFs for availability and performance of NCU/NSUs in providing quality IPNC, and explored factors influencing the observed performance outcomes in Mtwara region, Tanzania.

METHODS

A cross-sectional study was conducted using a follow-up explanatory mixed-methods approach. HF-based records and characteristics allowing for delivery of quality IPNC were reviewed first to establish the overall HF performance. The review findings were clarified by healthcare staff and managers through in-depth interviews (IDIs) and focus group discussions (FGDs).

RESULTS

About 70.6% (12/17) of surveyed HFs had at least one NCU/NSU room dedicated for delivery of IPNC but none had a fully established NCUs/NSU, and 74.7% (3,600/4,819) of needy newborns were admitted/transferred in for management. Essential medicines such as tetracycline eye ointment were unavailable in 75% (3/4) of the district hospitals (DHs). A disparity existed between the availability and functioning of equipment including infant radiant warmers (92% vs 73%). Governance, support from implementing patterns (IPs), and access to healthcare commodities were identified from qualitative inquiries as factors influencing the establishment and running of NCUs/NSUs at the HFs in Mtwara region, Tanzania.

CONCLUSION

Despite the positive progress, the establishment and performance of NCUs/NSUs in providing quality IPNC in HFs in Mtwara region is lagging behind the Tanzania neonatal care guideline requirements, particularly after the IPs of newborn health interventions completed their terms in 2016. This study suggests additional improvement plans for Mtwara region and other comparable settings to optimize the provision of quality IPNC and lower avoidable NMs.

Advances in training of the specialized human resources for health in Tanzania: the case of Muhimbili University of Health and Allied Sciences

BACKGROUND

Increasing the number of specialized human resources for health is paramount to attainment of the United Nations sustainable development goals. Higher learning institutions in low-and middle-income countries must address this necessity. Here, we describe the 5-years trends in accreditation of the clinical and non-clinical postgraduate (PG) programmes, student admission and graduation at the Muhimbili University of Health and Allied Sciences (MUHAS) in Tanzania, highlighting successes, challenges and opportunities for improvement.

METHODS

This was a retrospective longitudinal study describing trends in PG training at MUHAS between 2015 and 2016 and 2019-2020. Major interventions in the reporting period included university-wide short course training programme to faculty on curricula development and initiation of online application system. Data were collected through a review of secondary data from various university records and was analyzed descriptively. Primary outcomes were the number of accredited PG programmes, number of PG applicants as well as proportions of applicants selected, applicants registered (enrolled) and students graduated, with a focus on gender and internationalization (students who are not from Tanzania).

RESULTS

The number of PG programmes increased from 60 in 2015-2016 to 77 in 2019-2020, including programmes in rare fields such as cardiothoracic surgery, cardiothoracic anesthesia and critical care. The number of PG applications, selected applicants, registered applicants and PG students graduating at the university over the past five academic years had steadily increased by 79, 81, 50 and 79%, respectively. The average proportions of PG students who applied, were selected and registered as well as graduated at the university over the past five years by gender and internationalization has remained stably at 60% vs. 40% (male vs. female) and 90% vs. 10% (Tanzanian vs. international), respectively. In total, the university graduated 1348 specialized healthcare workers in the five years period, including 45 super-specialists in critical fields, through a steady increase from 200 graduates in 2015-2016 to 357 graduates in 2019-2020. Major challenges encountered include inadequate sponsorship, limited number of academic staff and limited physical infrastructure for teaching.

CONCLUSION

Despite challenges encountered, MUHAS has made significant advances over the past five years in training of specialized and super-specialized healthcare workforce by increasing the number of programmes, enrollment and graduates whilst maintaining a narrow gender gap and international relevance. MUHAS will continue to be the pillar in training of the specialized human resources for health and is thus poised to contribute to timely attainment of the health-related United Nations sustainable development goals in Tanzania and beyond, particularly within the Sub-Saharan Africa region.

Not a Problem at All or Excluded by Oneself, Doctors and the Law? Healthcare Workers' Perspectives on Access to HIV-Related Healthcare among Same-Sex Attracted Men in Tanzania

Background: An increasing body of literature focuses on access to healthcare services for men who engage in sex with other men in Africa, but how healthcare workers conceive of this topic of healthcare workers’ views on men's care has not been much studied. Drawing on qualitative research, this article explores healthcare providers’ perspectives on access to HIV-related healthcare services among gender and sexuality diverse men in Tanzania. Methods: A qualitative study was conducted among healthcare workers in Dar es Salaam and Tanga, Tanzania in 2018/2019. Data collection entailed qualitative interviewing, focus group discussions and participant observation. A purposive sampling strategy was used to select study participants who varied with respect to age, education level, work experience, and the type and location of the facilities they worked in. A total of 88 participants took part in the study. Results: This paper describes four different discourses that were identified among healthcare workers with respect to their perception of access to healthcare services for men who have sex with men. One held that access to healthcare was not a major problem, another that some same-sex attracted men did not utilize healthcare services although they were available to them, a third that some healthcare workers prevented these men from gaining access to healthcare and a fourth that healthcare for gender and sexual minority persons was made difficult by structural barriers. Conclusion: Although these are four rather different takes on the prevailing circumstances with respect to healthcare access for same-sex attracted men (SSAM), we suggest that they may all be “true” in the sense that they grasp and highlight different aspects of the same realities. More education is needed to healthcare providers to enable them accept SSAM who seek healthcare services and hence improve access to healthcare.

Facilitators and barriers to effective supervision of maternal and newborn care: a qualitative study from Shinyanga region, Tanzania

Background: Despite routine supportive supervision of health service delivery, maternal and newborn outcomes have remained poor in sub-Saharan Africa in general and in Tanzania in particular. There is limited research evidence on factors limiting the effectiveness of supportive supervision in improving the quality of maternal and newborn care.

Objective: This study explored enablers of and barriers to supportive supervision in maternal and newborn care at the district and hospital levels in Shinyanga region in Tanzania.

Methods: This study employed a qualitative case study design. A purposeful sampling approach was employed to recruit a stratified sample of health system actors: members of the council health management team (CHMT), members of health facility management teams (HMTs), heads of units in the maternity department and health workers.

Results: This study identified several barriers to the effectiveness of supportive supervision. First, the lack of a clear policy on supportive supervision. Despite the general acknowledgement of supportive supervision as a managerial mechanism for quality improvement at the district and lower-level health facilities, there is no clear policy guiding it. Second, limitations in measurement of progress in quality improvement; although supportive supervision is routinely conducted to improve maternal and newborn outcomes, efforts to measure progress are limited due to shortfalls in the setting of goals and targets, as well as gaps in M&E. Third, resource constraints and low motivation; that is, the shortage of resources – CHMT supervisors, health staff and funds – results in irregular supervision and low motivation.

Conclusion: Besides resource constraints, lack of clear policies and limitations related to progress measurement impair the effectiveness of supportive supervision in improving maternal and newborn outcomes. There is a need to reform supportive supervision so that it aids and measures progress not only at the district but also at the health facility level.

"We do what we can do to save a woman" health workers' perceptions of health facility readiness for management of postpartum haemorrhage

Background: In many low-resource settings, in-service training is a common strategy to improve the performance of health workers and ultimately reduce the persistent burden of maternal mortality and morbidities. An evaluation of the Helping Mothers Survive Bleeding After Birth (HMS BAB) training as a single-component intervention in Tanzania found some positive albeit limited effect on clinical management and reduction of postpartum haemorrhage (PPH).

Aim: In order to better understand these findings, and particularly the contribution of contextual factors on the observed effects, we explored health workers’ perceptions of their health facilities’ readiness to provide PPH care.

Methods: We conducted 7 focus group discussions (FGDs) and 12 in-depth interviews (IDIs) in purposively selected intervention districts in the HMS BAB trial. FGDs and IDIs were audio-recorded, transcribed and translated verbatim. Thematic analysis, using both inductive and deductive approaches, was applied with the help of MAXQDA software.

Results: Health workers perceive that their facilities have a low readiness to provide PPH care, leading to stressful situations and suboptimal clinical management. They describe inconsistencies in essential supplies, fluctuating availability of blood for transfusion, and ineffective referral system. In addition, there are challenges in collaboration, communication and leadership support, which is perceived to prevent effective management of cases within the facility as well as in referral situations. Health workers strive to provide life-saving care to women with PPH despite the perceived challenges. In some health facilities, health workers perceive supportive clinical leadership as motivating in providing good care.

Conclusion: The potential positive effects of single-component interventions such as HMS BAB training on clinical outcome may be constraint by poor health facility readiness, including communication, leadership and referral processes that need to be addressed.

Going operational with health systems governance: supervision and incentives to health workers for increased quality of care in Tanzania

Improving the quality of care is increasingly recognized as a priority of health systems in low- and middle-income countries. Given the labour-intensive nature of healthcare interventions, quality of care largely depends upon the number, training and management of health workers involved in service delivery. Policies available to boost the performance of health workers-and thus the quality of healthcare-include regulation, incentives and supervision-all of which are typically included in quality improvement frameworks and policies. This was the case in Tanzania, where we assessed the role of selected quality improvement policies. To do so, we analysed data from a representative sample of Tanzanian government-managed health facilities, part of the 2014/15 Service Provision Assessment component of the Demographic and Health Survey. We constructed two healthcare quality indicators from data on patient visits: (1) compliance with Integrated Management of Childhood Illness (IMCI) guidelines and (2) patient satisfaction. Using multilevel ordered logistic regression models, we estimated the associations between the outcomes and selected indicators of incentives and supervisory activity at health worker and health facility level. We did not identify any association for the different indicators of top-down supervision at facility and individual level, neither with IMCI compliance nor with patients' satisfaction. Bottom-up supervision, defined as meetings between community and health facility staff, was significantly associated with higher patient satisfaction. Financial incentives in the form of salary top-ups were positively associated with both IMCI compliance and patient satisfaction. Both housing allowances and government-subsidized housing were positively associated with our proxies of quality of care. Good healthcare quality is crucial for promoting health in Tanzania not only through direct outcomes of the process of care but also through increased care-seeking behaviour in the communities. The results of this study highlight the role of community involvement, better salary conditions and housing arrangements for health workers.

Towards improved health service quality in Tanzania: contribution of a supportive supervision approach to increased quality of primary healthcare

Background

Universal Health Coverage only leads to the desired health outcomes if quality of health services is ensured. In Tanzania, quality has been a major concern for many years, including the problem of ineffective and inadequate routine supportive supervision of healthcare providers by council health management teams. To address this, we developed and assessed an approach to improve quality of primary healthcare through enhanced routine supportive supervision.

Methods

Mixed methods were used, combining trends of quantitative quality of care measurements with qualitative data mainly collected through in-depth interviews. The former allowed for identification of drivers of quality improvements and the latter investigated the perceived contribution of the new supportive supervision approach to these improvements.

Results

The results showed that the new approach managed to address quality issues that could be solved either solely by the healthcare provider, or in collaboration with the council. The new approach was able to improve and maintain crucial primary healthcare quality standards across different health facility level and owner categories in various contexts.

Conclusion

Together with other findings reported in companion papers, we could show that the new supportive supervision approach not only served to assess quality of primary healthcare, but also to improve and maintain crucial primary healthcare quality standards. The new approach therefore presents a powerful tool to support, guide and drive quality improvement measures within council. It can thus be considered a suitable option to make routine supportive supervision more effective and adequate.

Looking at the bigger picture: how the wider health financing context affects the implementation of the Tanzanian Community Health Funds

In Tanzania, the health financing system is extremely fragmented with strategies in place to supplement funds provided from the central level. One of these strategies is the Community Health Fund (CHF), a voluntary health insurance scheme for the informal rural sector. As its implementation has been challenging, we investigated different CHF implementation practices and how these practices and the wider health financing context affect CHF implementation and potentially enrolment. Two councils were purposively selected for this study. Routine data relevant for understanding CHF implementation in the wider health financing context were collected at council and public health facility level. Additionally, an economic costing approach was used to estimate CHF administration cost and analyse its financing sources. Our results showed the importance of considering different CHF implementation practices and the wider health financing context when looking at CHF performance. Exemption policies and healthcare-seeking behaviour influenced negatively the maximum potential enrolment rate of the voluntary CHF scheme. Higher revenues from user fees, user fee policies and fund pooling mechanisms might have furthermore set incentives for care providers to prioritize user fees over CHF revenues. Costing results clearly pointed out the lack of financial sustainability of the CHF. The financial analysis however also showed that thanks to significant contributions from other health financing mechanisms to CHF administration, the CHF could be left with more than 70% of its revenues for financing services. To make the CHF work, major improvements in CHF implementation practices would be needed, but given the wider health financing context and healthcare-seeking behaviours, it is questionable whether such improvements are feasible, scalable and value for money. Thus, our results call for a reconsideration of approaches taken to address the challenges in health financing and demonstrate that the CHF cannot be looked at as a stand-alone system.

Towards improved health service quality in Tanzania: appropriateness of an electronic tool to assess quality of primary healthcare

BACKGROUND

Progress in health service quality is vital to reach the target of Universal Health Coverage. However, in order to improve quality, it must be measured, and the assessment results must be actionable. We analyzed an electronic tool, which was developed to assess and monitor the quality of primary healthcare in Tanzania in the context of routine supportive supervision. The electronic assessment tool focused on areas in which improvements are most effective in order to suit its purpose of routinely steering improvement measures at local level.

METHODS

Due to the lack of standards regarding how to best measure quality of care, we used a range of different quantitative and qualitative methods to investigate the appropriateness of the quality assessment tool. The quantitative methods included descriptive statistics, linear regression models, and factor analysis; the qualitative methods in-depth interviews and observations.

RESULTS

Quantitative and qualitative results were overlapping and consistent. Robustness checks confirmed the tool's ability to assign scores to health facilities and revealed the usefulness of grouping indicators into different quality dimensions. Focusing the quality assessment on processes and structural adequacy of healthcare was an appropriate approach for the assessment's intended purpose, and a unique key feature of the electronic assessment tool. The findings underpinned the accuracy of the assessment tool to measure and monitor quality of primary healthcare for the purpose of routinely steering improvement measures at local level. This was true for different level and owner categories of primary healthcare facilities in Tanzania.

CONCLUSION

The electronic assessment tool demonstrated a feasible option for routine quality measures of primary healthcare in Tanzania. The findings, combined with the more operational results of companion papers, created a solid foundation for an approach that could lastingly improve services for patients attending primary healthcare. However, the results also revealed that the use of the electronic assessment tool outside its intended purpose, for example for performance-based payment schemes, accreditation and other systematic evaluations of healthcare quality, should be considered carefully because of the risk of bias, adverse effects and corruption.