Ebola outbreak in Nigeria and how it was managed

Figure 5 Source: Universal Health Coverage Assessment Tanzania (Mtei and Makawia 2014)

Whilst in the past the government has tried to implement free healthcare this proved unsustainable (McIntyre et al., 2008). The National Insurance Fund was introduced in 2001 for those in formal employment which has contributed to greater inequalities between those in formal and informal employment. In 2016 only 30% of the population were covered, leaving 35 million people paying privately (WHO 2018c). There are government targets for 80% of the population to be covered by 2020. However, given current coverage figures it is reasonable to suggest this target will not be met. There is also a plan to introduce a mandatory health insurance but, as yet has not been introduced (Mtei and Makawia 2014).

2.23 Health systems: Health outcomes

The effectiveness of a health system is assessed by a populations health (Sholnik 2012). It is only through analysis of a country’s health outcomes that the strengths, weaknesses and future challenges can be understood (Sholnik 2012).

Figure 6 below, shows the top ten leading causes of death in Tanzania (WHO 2012).

Figure 6: Source Tanzania Country Profile (WHO 2012)

Whilst the majority are communicable diseases, which are commonly seen in LMIC, there is an increasing prevalence of non-communicable diseases, more commonly seen in HIC. The burden of non-communicable diseases is likely to result in further previously unseen challenges, on the already fragile health system in Tanzania (Afnan-Holmes et al., 2015).

Tanzania has shown significant improvements in several of the MDGs including infant and child mortality as highlighted in Figure 7 below:

Figure 7: Source World Development Indicators (World Bank 2017)

These reductions are largely due to focused joint partnerships with international agencies to deliver vaccination and preventative health programmes (USAID 2018a).

Whilst these are seen as positive health outcomes and signs of strength in the health system they do not provide the full picture (Afnan-Holmes et al., 2015).

The rate of reduction in maternal mortality has been low, not just in relation to high income countries but also within the African region (Hanson et al., 2017).

This is a concern given the rate of economic and population growth in Tanzania and will be the detailed health issue discussed for the remainder of this report.

2.3 Maternal Health and Mortality in Tanzania

According to WHO the most up to date MMR in Tanzania remains at 398 per 100,000 live births with differences between 281-570 largely seen between urban and rural areas (WHO 2015c). The Sub-Saharan African regional MMR is 546 (WHO 2015c). Maternal mortality in Tanzania accounts for 18% of all deaths among women aged 15-49 (National Bureau of statistics 2015c). Mothers mean age at first birth is 17.7 years, (Bureau of National Statistics 2015). This is concerning as research shows mothers aged 15-19 are at increased risk of birth complications (Hanson et al., 2017).

The average fertility rate is 4.8 resulting in an average annual population growth of 2.75% (CIA 2018a). Contraceptive prevalence is low at just 38.4%in 2015-16 (CIA 2018a), this is another worrying indicator of poor maternal health in Tanzania as, data shows nations with low contraceptive rates often have higher levels of illegal abortions increasing maternal mortality risk (WHO 2016). Limited number of trained professionals, results in many women receiving inadequate care and advice (Manzi et al., 2012). WHO figures show an average of just 64% of births in Tanzania were attended by skilled workers in 2016 (WHO 2016). Whilst figures show 95% of women receive at least one episode of antenatal care (WHO 2015c), only 45% received four as recommended by WHO. This is only a slight increase from 41% in 2007 (WHO 2015c). Research also suggests women receive little information regarding pregnancy complications during antenatal care visits, resulting in increased mortality risk (Prytherch et al., 2012).

Figure 8 below, shows the leading causes of maternal mortality in Tanzania in 2014.

Figure 8 Source: Women and Children First: Countdown to Ending Preventable Maternal, Newborn and Child Deaths in Tanzania (United Republic of Tanzania Ministry of Health and Social Welfare 2015)

Accessing adequately supplied health care facilities due to distance and minimal transportation are also seen as barriers in reducing the MMR particularly in rural areas leading to greater health inequalities for women (Prytherch et al., 2012).

2.31 Impact of globalisation and global health initiatives on Maternal health in Tanzania

Since failing to meet the MDG for MMR in 2015, the Tanzanian government has launched two large scaled initiatives ‘Sharpened One Plan’ and ‘Big Results Now’ aimed at reducing health inequalities and the MMR by improving maternal, neonatal, child and adolescent health (McGill et al., 2015). These initiatives are being supported and largely funded by international organisations including significant financial backing from USAID and the UN (CSIS 2015). USAID Mission has played a key role in funding HIV/AID reduction programmes in Tanzania as it ranks as one of the highest prevalent nations (CSIS 2015). They also contributed $12million in 2014 directly to maternal and child health programs as well as $26 million to improve voluntary family planning activities which promote healthy timing/spacing of pregnancies (CSIS 2015).

Steps are also being taken to deliver improved training programmes to community health workers who deliver the maternal care, especially in rural areas (McGill et al., 2015).

The Tanzanian government has recognised the need to reduce wider social and economic inequalities and have goals to move from a low to middle income country by 2025 (Bureau of National Statistics 2017). They aim to reduce inequalities by improving access to improved sanitation, secure water sources and improve rates of education, in an attempt to reduce the vast differences between maternal mortality risk in urban and rural areas (Unicef 2014).

Whilst goals and initiatives are an important element of reducing the MMR in Tanzania, concerns remain over the government’s ability to deliver sustainable quality maternal health care given its reliance on external funding (Kruk and Mbaryku 2015). External funding is often targeted at specific issues for a limited amount of time (CSIS 2015). Longer term government solutions are required for improvements to become ingrained and sustainable within the health system (Kruk and Mbaryku 2015). This vulnerability is highlighted in programmes supported by GAVI who currently supply vaccines at only 20% of the current market cost, however once Tanzania’s GNI reaches $1580 (which given its ambitious goals for economic growth appears attainable), GAVI will then start a 5-year withdrawal process at the end of which full cost of vaccinations would be payable (CSIS 2015).

3 Global focus on improving maternal health

Whilst global maternal mortality was reduced by 44% between 1990-2015 the target of MDG 5 was for it to be reduced by 75% (UN 2015). This figure alone, highlights the continuing need for international, national and local organisations to focus on strategies to further improve MH, reduce the MMR, and ensure women receive care that not only means they survive pregnancy and childbirth but also allows them, their new born and their family to thrive during this time (UN 2015; WHO 2015a).

Whilst many countries, including Tanzania failed to achieve MMR targets, the WHO, UN and other international organisations have continued to push for even greater change in maternal, child and adolescent health, setting higher targets through SDG 3- Ensure healthy lives and promote well-being for all at all ages (UN 2015,). This has led to the development of global strategies such as The Global Strategy for Women’s, Children’s and Adolescents Health 2016-2030 as part of the: Every Woman Every Child Campaign and, Ending Preventable Maternal Mortality both published in 2015 (Every Woman Every Child 2015). Further recommendations of intrapartum care were also published by WHO earlier this year (2018) to support maternal and child service funding, focus and delivery (WHO 2018b).

Whilst global organisations, have accelerated their involvement and focus on MH, it is important to understand the complexities of delivering optimal healthcare within a specific context and the challenges faced by health professionals and organisations when attempting to bring about change (Sholnik 2012). This will be the focus of the following sections in which comparisons will be made between health systems in Tanzania and those in Norway which was ranked as having the highest levels of maternal healthcare in the Save the Children Mother’s Index report 2015 (Save The Children 2015).

3.1 Norway’s Maternal Healthcare: What it is and Why it works

Norway is seen by the World Bank as a high-income country with a stable and progressive economy, long life expectancy and positive health outcomes (World Bank Group 2018). WHO data shows Norway’s population was just over 5 million (WHO 2015d), with Norway ranked as the third least corrupt nation in 2017 (CIA 2018c) with a Gini coefficient index score of 27.5 in 2014 (World Bank 2015).

Norway’s healthcare system is funded on the principals of universal access and choice of provider (Lindahl 2016). It is financed by taxation with income related employee/employer contributions, with all residents being covered by the National Insurance scheme which is nationally managed (Lindahl 2016).

Health policy as well as hospital financing and management is centrally controlled by government, with local authorities responsible for the organisation and financing of primary health services dependent on local demand (Lindahl 2016).

Norway has some of the world’s lowest rates of infant and maternal mortality and spends 9.7% of GDP on health (CIA 2018c). It also has large healthcare work force with 319.32 nursing and midwifery personnel and 443 physicians per 10,000 of the population (World Bank 2018c). This surpasses WHO recommendations of workforce availability (WHO 2018b).

Maternal mortality was just 3 per 100,000 in 2015 with 99% of births attended by skilled health personnel and within hospital settings (WHO 2015d).

Expectant mothers usually attend 8 antenatal visits with their doctor or at health clinics run by midwives and specifically trained professionals. Once again exceeding global recommendations. Mothers can choose to receive care at either setting, or a combination of the two (Save the Children 2015).

Once the baby is born, mothers are expected to stay in hospital between 2-4 days, enabling them to readily access professional advice and support (Save the Children 2015). Norway offers substantial maternity and paternity pay with mothers being able to choose from 49 weeks at 100% pay or 59 weeks at 80% (Save the Children 2015). There is also a continued structured pathway for parents to receive professional support throughout the baby’s first few years (Save The Children 2015).

When looking at the new WHO recommendations for intrapartum care for a positive childbirth experience, it is possible to see how Norway could or already is meeting these recommendations, with WHO suggesting childbirth be seen as a unique and empowering experience for mothers (WHO 2018b). Norway allows choice of general practitioner, flexibility in who delivers antenatal care and services are delivered free to mothers (Save The Children 2015). These factors are likely to increase parental engagement and show evidence of a preventative approach to healthcare by allowing multiple opportunities to ensure parents receive individual care (WHO 2018b). This ensures sufficient care and advice is delivered and results in the early detection of complications, ensuring they are addressed to reduce mortality risk (WHO 2018b).

It is clear from the data presented here that Norway’s maternal healthcare services are of a significantly higher standard than that of Tanzania. The next section will discuss the challenges faced by LMIC such as Tanzania in achieving global targets for improving MH and reducing maternal mortality.

3.2 Delivery within Context

At a global level MH has been an area of increased interest in recent years (UN 2015).

However, it is one thing to publish statistics and best practice recommendations on MH and quite another to deliver improved services to reduce MMR and reach the next global targets.

This section will look at the monumental task for the health professionals of Tanzania, in trying to achieve these goals within the complexities of a nation that relies heavily on external donor funds to deliver its healthcare and, continues to have issues with corruption (CSIS 2015).

Research by Prytherch et al., in 2012, shows that whilst steps are being taken to increase antenatal visits and the number of births attended by skilled professionals in Tanzania, attempts to recruit and retain skilled staff, particularly in rural areas continues to be limited (Prytherch et al., 2012). Evidence shows some rural areas only have 35% of required workforce in place and up to 43% of those working were low level cadres (Manzi et al., 2012). Given that 70% of the population live in rural areas, gaps in service delivery and persistent inequalities are inevitable (Prytherch et al., 2012).

The paper also looked at reasons behind poor recruitment and retention, with workers reporting lack of motivation caused by poor financial reward, understaffing, poor health, safety and security and lack of essential medical supplies. Poor management and lack of support were also cited as causing low morale amongst healthcare workers (Prytherch et al., 2012).

Similar findings were published in research carried out in Southern Tanzania in which only 14% of the required nurses and 20% of clinical staff were employed (Manzi et al., 2012). On the day the survey was conducted, 44% of staff were not available to work. Data from the same quantitative study showed two thirds of reproductive and child health clinics received less than 3 visits from district government health teams in the six months prior to the survey (Manzi et al., 2012).

The survey highlighted the need for better efficiency in delivering health commodities and services to improve maternal healthcare (Manzi et al., 2012).

These challenges are not unique to Tanzania, research into factors influencing intrapartum care in a number of different countries also found issues around staff recruitment and retention relating to morale, lack of training/resources and poor living/working conditions (Munabi-Babigurmira et al., 2017).

Whilst this data shows issues at a local level in delivering even basic maternal healthcare, what it also represents is a fragile and disjointed health system (Kruk and Mbaruku 2015).

Much has been published on the MMR been an indicator of not just a nations health but also their economic stability (UN 2015).

Questions have been raised over long-term sustainability and level of national government financial investment in health-system reform (Kruk and Mbaruku 2015).

Tanzania relies heavily on global involvement to deliver its healthcare including, huge amounts of funding from USAID to deliver HIV/AIDS programmes, child and infant healthcare as well as vaccination programmes delivered at reduced cost by GAVI (CSIS 2015). Whilst these may appear to be positive contributions, they do not come without conditions, and significant international involvement in deciding how, where and for how long the financing will be delivered (CSIS 2015). This can lead to fragmented service delivery to meet the agendas of international nations and organisations without the best interests of the Tanzanian people consistently being prioritised (Kruk and Mbaruku 2015). For example, in 2013/2014 the top ten richest districts received 5 times the per capita budget of the poorest 10%. This increased to 6.4 times more in 2014/2015 (WHO 2016a). Evidence suggests that the limited increase in trained professionals but an increase in the number of facilities, is leading to even greater inequalities in quality of maternal healthcare particularly in rural areas (Afnan-Holmes et al., 2015).

Global health has become a commodity and like in any area of commerce financial and political gain are at stake (Sholnik 2012). The WHO has 194 member states and is funded through assessed contributions which are relative to a countries wealth and population and voluntary contributions (WHO 2018d). According to WHO 2018 assessed contributions accounted for 18% of contributions with 80% coming from voluntary contributions (WHO 2018d). Voluntary contributions are used as specified by the donating nation, meaning that increasingly maternal healthcare in Tanzania, is likely to be influenced by the political and economic climate in the larger financial contributors such as the U.S. who are the largest financial contributor to the WHO (KFF 2018).

Below Figure 9 shows the increase in voluntary contributions by the U.S to the WHO.

Figure 9: Source The US Government and the World Health Organization (KFF 2018)

This impact has been highlighted in recent years by the change in political administrations from those seen as taking a globalist approach to health, by increasing universal access to healthcare, to those with a more statist approach, who view the health outcomes of LMIC as a security threat, and one that needs to be controlled and measured (Rushton and Youde 2015).

Whilst it is true that increased data collection could be used to support the development of stable and long-lasting healthcare systems in LMIC, it would also provide international governments and organisations with greater scope of shaping the character and development of healthcare systems to align with their own political and economic priorities (Rushton and Youde 2015).

4 Conclusion

This report set out to understand MH as a global health issue, detailing the ongoing national approach by the Tanzanian government, to improve maternal healthcare with the aim of reducing MMR.

Evidence from primary research, policy resources, as well as theories of globalisation, demonstrate how an increased global political and economic interconnectedness has impacted on individual and nation population health outcomes.

4.1 Moving Forwards: Key points

The current Tanzanian national government’s narrative suggests a strong commitment to improving the health outcomes and reducing health inequalities for its population (McGill et al 2015). However, whilst improvements in infant and child mortality rates indicate a strengthening of the nation’s economic and political stability, higher than average MMR continues to highlight unequal wealth distribution, fragmented health coverage and fragile health systems (McGill et al., 2015).

Research demonstrates significant reliance on international agencies to deliver healthcare and improve population health outcomes, as well as unequal distribution of funds resulting in greater health inequalities being experienced by those in the most deprived areas (Prytherch et al., 2012).

National and international policies and frameworks are in place but have not consistently been successful in improving health outcomes (McGill et al., 2015).

This report has demonstrated the economic as well as moral case for sustainable improved overall health outcomes including reductions in MMR.

To improve the fragile health systems, maternal health outcomes and ensure the health of the nation is not continually reliant on external donor funds the following points should be considered:

* Ensure local and national long-term needs are taken into consideration by international organisations and NGOs through strengthened negotiation and unilateral partnerships.

* Increase population coverage of national health insurance policy to work towards universal access to healthcare.

* Increase in national financial and strategic investment in the development and management of the health system with greater accountability at all levels.

* Improve recruitment and retainment of workforce by increasing financial investment, and quality of management to address issues relating to morale of skilled and non-skilled healthcare workers delivering maternal healthcare-particularly in rural areas.

* Deliver maternal healthcare through already existing community programmes that saw significant reductions in national infant and child mortality rates. This has the potential to save money and increase coordinated healthcare delivery which is associated with improved health outcomes.

* Increase health promotion messages via state owned media, as the majority of the population has access to at least one mode of media communication (Bureau of National Statistics 2017).

Due to Tanzania’s historical and current political and economic climate, health improvements will take time, and the sustainability of advances already achieved remain to be seen.