THE REVOLUTIONARY GOVERNMENT OF ZANZIBAR

ASSESMENT OF THE AVAILABILITY OF HEALTH SERVICES IN TERMS OF

ACCESSIBILITY AND QUALITY OF HEALTH CARE

DRAFT REPORT

JAN 2010

PREAMBLEPREAMBLE

Assessment of the Availability of Health Service in terms of Accessibility andAssessment of the Availability of Health Service in terms of Accessibility and

Quality of Health Care in ZanzibarQuality of Health Care in Zanzibar

Overview

In order to reduce absolute poverty and promote the creation of wealth in a nation the

health of its people should be the priority. Poverty and ill-health are intertwined.

Poor countries tend to have worse health outcomes than better-off countries. Within

countries, poor people have worse health outcomes than better-off people. The

association between poverty and ill-health reflects causality running in both

directions. Illness or excessively high fertility may have a substantial impact on

household income and may even make the difference between being above and being

below the poverty line. Furthermore, ill-health is often associated with substantial

health care costs. But poverty and low income also cause ill-health. Poor countries,

and poor people within countries, suffer from a multiplicity of deprivations that

translate into high levels of ill-health. Poor people are thus caught in a vicious circle:

Fig 1: cycle of health and poverty1

poverty breeds ill-health, ill-health maintains poverty.

1 WHO of 376

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DRAFT

People with low incomes, particularly those who live in poverty, face particular

challenges in maintaining their health. They are more likely than those with higher

incomes to become ill, and to die at younger ages. They are also more likely to live in

poor environmental situations with limited health care resources—factors that can

compromise health status and access to care. Public programs play a vital role in

helping to reduce disparities in health by income by supporting health initiatives

targeted at those with low incomes and maintaining a safety net of health and social

services for the poor.

MKUZA realizing this it developed its first strategy defining its health goals in terms

of Social Services and Well being as stated in cluster 11. This document has assessed

progress of some of the health issues highlighted in MKUZA 1, to see the positive

gains and advice on the gaps to be addressed in MKUZA 11. The assessment of this

report has been done around the availability of health services in terms of

accessibility and the quality of health care in Zanzibar. These terms, accessibility,

quality and primary health care, are hereby defined below to present a general

understanding.

Accessibility of Health Care

Access to health care is an important component of an overall health system which

has a direct impact on the burden of disease that affects many countries in the

developing world. Measuring accessibility to health care therefore contributes to a

wider understanding of the performance of health systems within Zanzibar.

Accessibility to health care is concerned with the ability of the Zanzibar’s

population to obtain a specified set of health care services. In this context,

geographic accessibility is referred to as spatial or physical accessibility concerned

with the complex relationship which exists between the spatial separation of the

population and the supply of health care facilities.

Facilitating access is concerned with helping people to command appropriate

health care resources in order to preserve or improve their health. Access is a

complex concept and at least four aspects will be looked at in this document.

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1. If services are available and if there is an adequate supply of services, then

the opportunity to obtain health care exists, and a population may 'have access'

to services.

2. The extent to which the Zanzibar population 'gains access' also depends on

financial, organizational and social or cultural barriers that limit the

utilization of services. Thus access here will be measured in terms of

utilization depending on the affordability, physical accessibility and

acceptability of services and not merely adequacy of supply.

3. Assessment will also be done to the services available if there are relevant and

effective for the Zanzibar’s population to 'gain access to satisfactory health

outcomes'. The availability of services and barriers to access will be

considered in the context of the differing perspectives, health needs and

material and cultural settings of diverse groups in the Isle’s society.

4. Equity of services will also be assessed. Equity of access may be measured in

terms of the availability, utilization or outcomes of services. Both horizontal

and vertical dimensions of equity will be considered.

1.2 Quality of Health Care

In this assessment the word "quality" will refers to the merit or excellence of a thing

or activity. With respect to health care, it will concern the degree to which the

resources for health care or the services included in it correspond to specified

standards in Zanzibar. Those standards, if applied, are generally expected to lead to

desired results.

The objectives of quality assessment and the methods used to measure it must be

realistic. One must often be satisfied with estimates made on the basis of relatively

simple observations or relatively perfunctory records. Due to the Health Information

Management System still revolving and not capturing community data in Zanzibar,

one must therefore be cautious and selective in drawing conclusions using the existing

data.

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EXECUTIVE SUMMARY

Availability of Health Services in terms of Accessibility and Quality of Health

Care in Zanzibar

1.0 Overview:

Zanzibar National Strategies for Growth and Reduction of Poverty (MKUZA) have

been the guiding framework for growth and poverty reduction in the second half of

2000s. These second generation ZPRP generated a strong agenda, aiming at

sustaining broad-based growth whilst emphasizing quality of life and social

wellbeing and good governance. Efforts to implement MKUZA entailed aligning

sector strategies, programs and projects and LGAs plans. Efforts were also directed

at aligning various systems, processes, reforms, and programs with MKUZA.

Implementation of MKUZA recorded mixed achievement as indicated in various

reports2and will also be reflected in this report in all chapters

2. Objectives

This study rests on the two objectives:-

i. To provide overall status of the health indicators achievements, non-

achievements, and the reasons to each.

ii. To provide recommendations on what should be done to enhance

implementation, effectiveness of health indicators of the coming strategy

This document will be assessing the availability of Health services in terms of

accessibility, affordability and the quality of health care as stated in the TOR as well

as their relevance to MKUZA 1.

In so doing, the work is structured in a way that it covers all important issues ranging

from resources, their management, the challenges and finally the recommendations

that need to be incorporated in MKUZA phase II. This study is divided into 8

chapters which capture all areas related to health challenges.

2 (E.g. MAIRs, Sector Review, PHDR, etc).

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Chapter I is an introductory chapter that highlights the terms of reference and

provides the general background of MKUZA strategies geared toward poverty

reduction as per 2020 Vision, the Millennium Development goals and the overall

development goals.

Chapter II has dealt with the analysis of the status of Primary Health Care (PHC) in

terms of the availability of services in Zanzibar since the commencement of the

implementation of MKUZA.

Chapter III on the other hand, takes stock and assesses the status of Equipments and

supplies available at the lower level health facilities and has discussed about the

general delivery system.

Then follows Chapter IV. In this chapter, the devolution of responsibilities for the

health facilities and health planning to the Local Government Authorities are carefully

observed.

Chapter V Explores the financial mechanisms of the health services and the

regulatory frameworks which are important in underscoring the resources

management and utilization for the inclusive quality service provision within the

health sector.

Chapter VI is a continuation of the second chapter in the sense that it provides some

information regarding the factors behind the little progress in some health indicators

during the implementation of the MKUZA (1) strategy.

Chapter VII examines and assesses the climate changes and their contribution to the

increased health related problems. The indicators of climate changes are outlined and

related to the other sectors and the way they impact these sectors to the extent of

contributing to increased health spending budgets, costs, depletion of resources and

measures for the mitigation and preparedness for coping with the climate changes are

provided for the way forward particularly for policy makers in order to reconsider the

seriousness of changing climate as related to poverty reduction. Climate change is a

serious risk to poverty reduction and threatens to undo decades of development efforts.3

At the end of each chapter, a set of recommendations are given to address the gaps

identified and suggest a way forward to be incorporated in MKUZA (11).

3 Johannesburg Declaration on Sustainable Development stated (2008)

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TABLE OF CONTENT

Chapter OneBackground and Introduction of the Study

1.0 Overview 11.1 Introduction 11.2 Objective of the Study 31.3 Scope of the Study 31.4 Study Methodology 41.5 Limitation of the Study 4

Chapter Two –Status of Implementation of PHC in Zanzibar2.0 Overview 52.1 Introduction 62.2 Background and current health Environment in Zanzibar 72.3 Primary Heath Care Facilities 82.4 Service Utilization 102.5 Management of Primary Health Care 112.6 Components of Primary Health Care 122.6.1 Education about common Health Problems 122.6.1.1 Education Through Media 142.6.2 Maternal and Child Health including FP 152.6.2.1 Maternal Health 162.6.2.2 Focused Antenatal Care (FANC) 172.6.2.3 Family Planning 182.6.2.4 Delivery Service 192.6.2.5 Child Health Services 202.6.2.6 Immunization 202.6.2.7 Promotion of Proper Nutrition 222.6.2.8 Anemia 232.6.2.9 Vitamin A Deficiency 232.6.3 Adequate Supply of safe Water 232.6.4 Basic Sanitation 262.6.4.1 Challenges of Basic Sanitation 282.6.4.2 Constraints 292.6.5 Prevention and Control of Local Endemic Diseases and Appropriate

treatment for Common Diseases and Injuries29

2.6.5.1 Malaria 302.6.5.2 HIV and AIDS 312.6.5.2.1 HIV related Services 312.6.5.3 TB 332.6.5.4 Diabetes 342.6.5.5 Road Traffic Accident 342.7 Human Resource 352.8 Quality Assurance 382.9 Recommendation and the way Forward 39

Chapter three – Status of Equipment and Supplies at lower level of health service delivery system

3.0 Overview 43

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3.1 Introduction 443.1.1 Lower level health facilities 453.2 Zanzibar Health Delivery System and its mechanism 453.2.1 Lower level health delivery system 463.2.2 Equipment and Supplies 483.2.3 Equipment used for infection control 493.2.4 Drug availability 513.2.5 Immunization equipment and supplies 513.2.6 Laboratory equipment and supplies 523.3 General recommendation 53

Chapter four – Roles played by the devolution of responsibilities for health facilities and health planning to local government

4.0 Overview4.1 Introduction 554.1.1 Definition of Decentralization and types 554.1.2 Type of Administrative Decentralization 554.2 Background of local government in Zanzibar 564.2.1 The functions and Institutional arrangements and structure 574.2.2 Structure of Devolution and the health facilities in LGA 574.3 The health planning process 584.4 Recommendations of the further roles of devolution play in the LGA 59

Chapter five - Financing Mechanism of the Health Services and Financing Mechanism of the Health Services and Regulatory Frame-work of health insurance scheme in ZanzibarRegulatory Frame-work of health insurance scheme in Zanzibar

59

5.0 Overview 635.1 Introduction 635.2 Existing types of health financing mechanism in Zanzibar 645.2.1 Budgetary funding 645.2.2 Complementary financing 655.2.3 Health insurance scheme 665.2.4 Other financing mechanism of the health services 695.2.5 Health financing scheme regulatory system 715.3 Recommendation 725.3.1 Recommendations for government and external financing 735.3.2 Community health funds and community based health insurance and

cost sharing73

5.3.3 Recommendation and way forward for insurance 745.4 Way forward 755.5 Conclusion 76

Chapter six – factors behind little progress in some health indicators eg maternal and neonatal mortality

6.0 Overview 776.1 Introduction 776.2 Infant and Child Health 796.2.1 Neonatal health 796.2.2 Infant mortality 806.2.3 Under five childhood Diseases 806.2.4 Immunization 816.3 Maternal and reproduction health 82

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6.3.1 Maternal Mortality 83

6.3.2 Births attended by skilled attendants 846.3.3 Contraceptive prevalence rate 856.4 Communicable diseases 856.4.1 Malaria 856.4.2 HIV and AIDS 876.4.3 TB 886.5 Non Communicable disease 896.6 Substance abuse 906.7 Human resource Management 916.8 Recommendation 91

Chapter 7- Climate change and the health sector7.0 Overview 927.1 Introduction 927.2 Major health consequences of climate change 937.3 Recommended response to climate change 957.4 Conclusion 96

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List of Table Table I Population projection figure by districts 7Table 2 Distribution of Health facility by type 9Table 3 Inpatient, maternity and delivery beds by type of facility 10Table 4 Annual service utilization rate by districts 2007 vs 2008 11Table 5 Distribution of workplaces with trained peer educators, HIV

counselors and other medical personnel at work place selected by district

14

Table 6 Percentage of new family planning clients by zone 2007 vs 2008 18Table 7 Institutional birth and birth attended by skilled personnel 19Table 8 Immunization coverage under 1 year by Zone 21Table 9 Availability of immunization services by type of health facility 21Table 10 Common childhood disease under five 22Table 11 Malnutrition of children under five year 22Table 12 Distribution of facility by source of water and type of health

facility 26

Table 13 Distribution of facility by Source of Water and Districts 26Table 14 Providing ARVs by type of health facility page by district 31Table 15 Providing ARVs by District 31Table 16 HIV counseling and antibody test by type of health facility 32Table 17 Home base care HIV by district 32Table 18 Home base care HIV by type of health facility 33Table 19 HIV test for TB patients distribution by District 34Table 20 Road traffic accident by district 35Table 21 Number of health personnel by cadre 36Table 22 Comparison of distribution of personnel by district 37Table 23 Training of health workers 38Table 24 Distribution of public health facilities in Zanzibar 47Table 25 Percent of basic equipment by health facility 49Table 26 Percentage of health facility by using method of sterilization 50Table 27 Availability of Immunization services by health facilities 52Table 28 HIV Counseling and antibody Testing District 52Table 29 Nominal MOHSW spending, FY2003/04 – FY2008/09 (TSh 1m) 65Table 30 MKUZA health indicators ( Goal II) 78Table 31 Incidence of under 5 yrs childhood diseases 2007 Vs 2008 (health

bulletin 2008)80

Table 32 Immunization coverage under one year by zone, 2007 vs. 2008 82Table 33 ANC first visits (< 20 weeks): Coverage by zone, 2007 vs. 2008 82

Table 34 Institutional maternal mortality ratio by zone, 2008 83Table 35 Institutional births and births attended by skilled personnel, 2007

Vs 200885

List of Figures

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Figure 1: Cycle of Health and Poverty Page i

Figure 2: Trends of MMR in Zanzibar Page 17

Figure 3: Main types of Sterilization equipment Page 50

Figure 4: Drug availability Page 51

Figure 5: Structure of MORASD Page 58

Figure 6: Estimated Causes of Neonatal Deaths Page 79

Figure 7: The green house effect Page 93

Figure 8: Direction and magnitude of change of selected Page 95

health impacts of climate change

AcronymsACSM Advocacy, Communication and Social MobilisationANC Antenatal clinicBCG Bacillus Calmette- GuérinBEmOC Basic Emergency Obstetric Care

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BOR Bed occupancy rateBTL Bilateral Tuba ligationC/S Caesarean sectionCEmOC Comprehensive Emergency Obstetric CareCFR Case fatality rateCPR Contraceptive prevalence rateCTC Care and treatment clinicDHIS District Health Information SoftwareDPT HEP B Diptheria, Pertusis, Tetanus and Hepatitis BEPI Expanded Programme on ImmunisationFP Family PlanningGIS Geographical Information SystemHIV/AIDS Human Immuno-deficiency Virus/ Acquired Immuno-

Deficiency Syndrome HMIS Health Management Information SystemIMCI Integrated Management of Childhood IllnessIPT Intermittent Presumptive Treatment ITNS/LLINS Insecticides Treated Nets/Long Life Insecticides Nets MCH Mother and Child HealthMDGS Millennium Development GoalsMMR Maternal Mortality RatioMOHSW Ministry of Health and Social WelfareNBS 2002 TPHC National Bureau of Statistics 2002 Tanzania Population and

Housing Census NCDS Non Communicable DiseasesOPD Out Patient DepartmentPHCCs Primary Health Care CentresPHCUs Primary Health Care UnitsPHN Public Health NurseRCH Reproductive and Child HealthRTA Road Traffic AccidentsSTI Sexual Transmitted Infections TB TuberculosisTB/HIV Tuberculosis/Human Immuno-deficiency VirusTDHS Tanzania Demographic and Health SurveyTHMIS Tanzania HIV and Malaria Indicator SurveyTT Tetanus ToxoidUN United NationsURTI Upper Respiratory Tract InfectionWHO World Health OrganizationWRA Women of Reproductive AgeZHSRSP II Zanzibar Health Sector Reform Strategic Plan IIZMCP Zanzibar Malaria Control ProgrammeZSGPR Zanzibar Strategy for growth and poverty reduction.

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Chapter OneChapter One

Background and Introduction of The StudyBackground and Introduction of The Study

1.0 Overview:

In the current designed strategy, the goals of MKUZA are harmonized to year 2010 to

allow for the synchronization of the next phase. The Revolutionary Government of

Zanzibar () has resolved to develop successor strategies that will easily mesh into the

current one. To inform the succeeding strategies, it is imperative that a thorough

assessment of the status of current implementation especially in relation to MKUZA’s

achievement and non-achievement of goals be carried out. The overall review will

also provide lessons learned, areas where scaling up is needed, and areas where a

strategic review is called for.

1.1 Introduction

Zanzibar's national strategy for growth and reduction of poverty, known better by its

Kiswahili acronym Mpango wa Kukuza Uchumi na Kupunguza Umasikini (MKUZA)

has been the national guiding framework for growth and poverty reduction in the

second half of the decade 2000-2010. This second round of Poverty Reduction

Strategies (PRS) generated a strong agenda, aiming at sustaining broad-based growth

whilst emphasizing equity and good governance.

Administratively, Zanzibar has five regions, three in Unguja and two in Pemba. Each

region is subdivided into two districts, which make a total of ten districts for the

islands. There are also two sub-districts, one on each island. The lowest government

administrative structure at the community is the Shehia level.

Urbanization has been rapid with over 33.4% of the inhabitants living in towns while

66.6 % live in rural areas. Zanzibar economy relies much on agriculture (including

livestock and fishing) contributing an average of 38% of the GDP. Other main sectors

that contribute significantly to the economy are trade (including (tourism-25% of

GDP.

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Substantial progress has been made in improving social services (MKUZA Cluster II),

but there remains much room for improvement in the health sector. While Zanzibar has

made significant progress in reducing infant and child mortality and made some

progress in reducing child malnutrition, reducing neonatal and maternal mortality are

outstanding gaps in the health sector progress.

In addition, there is concern regarding problems due to climate and environmental

changes, which are leading to new outbreaks of diseases such as SARS and AVIAN flu,

Ebola and the resurgence of TB, malaria, and others with resistance to common

antibiotics. Even hitherto less significant diseases such as worm infestations and

typhoid fever. Chronic diseases such as bilharzias, and river blindness, which are posing

a fresh threat to humanity due to environmental changes although the linkage is yet to

be clearly established.

It is argued that these concerns relate to issues of availability of recommended mix of

resources and skills in the health sector, the constraints posed by shortage of health

professionals and the impact of climate change on the population through new and

unexpected zoonoses, and the increase of neglected endemic diseases.

Government plans to continue the expansion of health sector provisioning and

increasing availability, access and equity so as to address MDG 5 and 6. Challenges

anticipated in such expansion, include high running and maintenance costs to maintain

the recommended mix of health infrastructure, medical supplies, and human resources.

However, the government budgetary burden can be lessened and expansion continued if

non-traditional financing mechanisms are expanded, regulated, and sustained. To

address these concerns, the successor strategy should be informed which areas need up-

scaling of the on-going intervention and which new approach should be put in place.

1.2. Rationale for the study

A four-year Zanzibar Strategy for Growth and Reduction of poverty (ZSGRP) known as

the MKUZA is the second generation of national development frameworks to

implement the Vision 2020. Its implementation started in 2007 and ends in 2010. A

new strategy is required to succeed this strategy which has to undergo a series of

involvement of different stakeholders to design the next strategy. The second MKUZA

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is supposed to be a working document by the end of 2010. This calls for the review of

the first MKUZA to be able to start the process of developing the second MKUZA,

while incorporating all lessons learnt from the former. The MKUZA has been the

government implementation tool to achieve Vision 2020.

1.3. Objective of the assignment:

The Main Objective of the Assignment is:

“To asses the availability of Health Services in terms of accessibility and quality of

health in Zanzibar.” The findings from this study are intended to eventually improve the

availability of the required mix of services at various levels of the health system, so as

to ensure quality of health service delivery and their impact on the health outcomes.

1.4. Scope of work

This study will cover the following areas, among others:

(a) To assess the status of implementation of Primary Health Care (PHC)

(b) To assess the status of the equipment and supplies at lower levels of health service

delivery system

(c) To explore further roles to be played by the Local Government Authorities (LGA)

in the devolution of responsibilities for health facilities and health planning To

explore financing mechanisms of the health services and regulatory framework of

health insurance schemes that could make the sector sustainable and improve

quality of service delivery (e.g. through the use of cost-sharing mechanisms, user

fees, and risk pooling arrangements).

(d) To assess the factors behind little progress in some health indicators e.g. maternal

and neonatal mortality

(e) To advice on the impact of climate change on the health sector

(f) To provide a set of recommendations on required measures to address the identified

shortfalls and propose a way forward on how to improve implementation

effectiveness in the successor strategy.

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1.5. Study Methodology

In-depth desk-based review will be the main methodology for collecting the primary

data from the relevant documents which will include evaluation reports. Other literature

will synthesize key lessons learnt from past experiences as well as relevant learning

from the first MKUZA strategy.

The field survey will include semi-structure interview with a small number of

interviewees as key informant (health facilities during inventory search) and/or FGD for

small groups. KII in relevant organizations will also be used. This will include:

o Non participant direct observations

Observational behavior

o Participant observation

interview

1.6 Limitations of the study:

Power cuts:

The unreliable power supplies have made this study difficult in terms

of accessing electronic documents timely in some organizations that

were consulted.

Access to site visits

Lack of site visits have had serious repercussions on information

gathering as the study could have been of greater value if the report

would have included at least 10% of the site visits that had been

requested for provision of evidence based data.

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CHAPTER TWO CHAPTER TWO

Status of Implementation of Primary Health Care in Zanzibar Status of Implementation of Primary Health Care in Zanzibar

2 .O Overview:

This year marks the 32nd Anniversary of the Declaration on Alma-Ata on Primary

Health Care (PHC) in 1978. While the global health context has changed

remarkably, the values that lie at the core of Alma-Ata Declaration have been tested

and remain true. Yet, despite enormous progress in health nationally, our collective

failures to deliver in line with these values are painfully obvious and deserve our

greater attention.

We still see mothers suffering complications of labour without access to qualified

support, unacceptably high maternal mortality, children missing out essential

immunizations, home deliveries by unskilled health personnel. Road accidents are on

the rise as motor vehicle insurance premium escalate and rising direct payment for

care because of a lack of health insurance etc. These and many other everyday

realities of life personify the unacceptable yet avoidable shortfalls in the performance

of the third world health care system including Zanzibar.

In moving forward, it is important to learn from the past and, in looking back, it is

clear that MKUZA (11) can do better in the future. This section therefore, revisits the

ambitious vision of primary health care as a set of values and principles for guiding

the development of health systems. Therefore it represents an important opportunity

to draw on the lessons of the past, consider the challenges that lie ahead, and identify

major avenues for health systems to narrow the intolerable gaps between aspiration

and implementation.

These avenues are being assessed in this section as four sets of reforms that reflect a

convergence between the values of primary health care, the expectations of citizens

and the common health performance challenges that cut across all contexts. They

include4:

universal coverage reforms that ensure that health systems contribute to

health equity, social justice and the end of exclusion, primarily by moving

towards universal access and social health protection;

4 WHO PHC report-2008

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service delivery reforms that re-organize health services around people’s

needs and expectations, so as to make them more socially relevant and more

responsive to the changing world, while producing better outcomes;

public policy reforms that secure healthier communities, by integrating public

health actions with primary care, by pursuing healthy public policies across

sectors and by strengthening national and transnational public health

interventions; and

leadership reforms that replace disproportionate reliance on command and

control on one hand, and laissez-faire disengagement of the state on the other,

by the inclusive, participatory, negotiation-based leadership indicated by the

complexity of contemporary health systems.

While universally applicable, these reforms do not constitute a blueprint or a

manifesto for action. The details required to give them life in Zanzibar must be

driven by specific conditions and contexts, drawing on the best available evidence

involving the community asset. MKUZA (1) has demonstrated substantial progress

is possible. Doing better in the next MKUZA (II) strategy means that there is a

need to invest now in the ability to bring actual performance in line with

aspirations, expectations and the rapidly changing realities of the interdependent

healthy nation. United by the common challenge of primary health care, the time

is ripe, now more than ever, to foster joint learning and sharing across Zanzibar

to chart the most direct course towards health for all.

2.1 Introduction

Primary health care is defined as “the principal vehicle for the delivery of essential

health care in the most local level of a country's health system. This care is made

accessible at a cost the country and community can afford with methods that are

practical, scientifically sound and socially acceptable by that community.5 Everyone

in the community should have access to it without exclusions, and everyone should be

involved in it. Beside an appropriate treatment of common diseases and injuries,

provision of essential drugs, material and child provision of essential drugs, maternal

and child health, and prevention and control of locally endemic diseases and

immunization, it should also include educational programs to the community on

5 WHO – PHC report 1978

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prevalent health problems and methods of preventing them, promotion of proper

nutrition, safe water and sanitation.”

The population projection of Zanzibar shows a population growth from 981,754 in

2002 (2002 census) to 1,193,383 in 2008. Unguja Island has a population of 733,186

inhabitants (61.4%) while 459,197 inhabitants (38.5%) live in Pemba. According to

the 2002 census, Zanzibar population density is 400 persons per square kilometer, the

highest population density figure in Africa. Life expectancy at birth stands at 57

years.

Table 1: Population projection figures by districts 20086.

Districts 2008

Kaskazini A 99,186

Kaskazini B 66,687

Mjini 256,543

Magharibi 202,959

Kati 71,035

Kusini 36,776

Wete 127,923

Micheweni 106,219

Chake Chake 109,926

Mkoani 116,129

Total 1,193,383

Source: PSAM 2008-2009

2.2 Background and Current Health Environment in Zanzibar

Primary care is being implemented within the ongoing health sector reforms in

Zanzibar. The RGoZ initiated health sector reforms in 1994, but the implementation

was delayed because of the withdrawal of donor support in year 1995. However, in

year 2002 the government revisited the reforms as part of the Health Sector Strategic

Plans and linked it with the Zanzibar Poverty Reduction Plan (ZPRP). The main

thrust behind the Health Sector Reform Strategic Plan 2002-2007 (Zanzibar) was to

6 Based on the projection of 2002 census which was provided by the National Bureau of Statistics Office.

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improve the PHC through decentralization and empowerment of District health

services “to improve access, quality and efficiency of primary health services in the

districts and at lower level”7.

The great majority (95%) of Zanzibaris live within 5 kilometers of primary health

care facilities that provide curative, preventive and the health promotion services.

Health services have been delivered through Directorates of the MOHSW and

specialized vertical programs such as Reproductive and Child Health (RCH),

Zanzibar AIDS Control Programme (ZACP) and the Zanzibar Malaria Control

Program (ZMCP). Health services are decentralized, i.e. they are planned and

implemented at district and community levels. Health care financing in Zanzibar

depends much on development partners. HSF funding provides the major part of

funding for day to day operations of the DHMTs in running district health services.8

2.3 Primary Health Care Facilities

PHC is mostly implemented by primary health care facilities. These are referred to as

Lower level Health Facilities of Health Care Delivery which are Primary Health Care

Units (PHCU) Primary Health Care Units + (PHCU+) and Primary Health Care

Centers (PHCC). These PHC facilities provide the following health services9:-

1. Outpatient services, which include management of STI, IMCI and other

common diseases and injuries.

2. Maternal and child health services, which include growth-monitoring,

immunization, antenatal, inter natal and postnatal services.

3. Family planning and youth friendly services

4. Dental services ( only for PHCU+ and PHCC)

5. Health education and counseling

6. Environmental health services

7. Outreach services/community based health care services (including home

based and aging health care)

8. Inpatient services (only for PHCC)

9. Laboratory services including blood transfusion services

7 Refer to 8 strategies in Annexure no pg 8 P-SAM 2008/20099 Human resource for health5 -year development plan 2004/05 – 2008/09 October, 2004

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10. Consultation of special conditions/illness e.g. surgical, medical, pediatric and

gynecological care

11. Community health services including community based home care

12. Rehabilitation services

13. Minor surgery ( only for PHCC),

PHCUs are the main health service providers in Zanzibar and are considered the first

line facilities in all Zanzibar’s ten districts. To most people PHCUs are the first

contacts with basic health services. According to TDHS 2004-05 it recorded only 4.5% household

in Zanzibar lived a distance of 5 kilometer from the nearest PHCU facility. The growing number

of new health facilities has improved the accessibility of citizens to health care facilities

remarkably. The rise in number of health facility is reflected in the table below. The table shows

that a total number of health facilities rose from 134 in 2005 to 205 in 2007 10; which shows that

95%11 of the population is living within 5 km of the nearest PHC facility (2007). The situation to-

date is said to be even better. 12

Out of the 205 health facilities in Zanzibar, 134 are primary health care facilities.

Table 2: Distribution of Health Facilities by Type and District

DISTRICT PHCU (first line)

PHCU

(second

line)

Cottage

hospital

(PHCC)

District

hospital

Special

hospital

Tertiary

hospital

Other

Hospital

Other

type of

facility

Grand

Total

Central 19 1           4 24

Chake Chake 8 4 1 1 7 21

Micheweni 9 3 1 2 15

Mkoani 11 2   1 1 15

North A 7 4 1 2 14

North B 8 3   1 12

South 8 2 1 11

Urban 6 3   2 1 3 23 38

West 11 2   18 31

Wete 18 1   1 4 24

Grand Total 105 25 4 3 2 1 3 62 205

Source: P-SAM 2008-2009

10 P-SAM 2008-200911 EHCP-200712 Health bulletin 2009

Jan 20109

DRAFT

With the largest number of health facilities, primary health care is the foundation upon which the

Zanzibar’s health care system is built upon and thus needs more attention. For most people in

Zanzibar, PHC is their first point of contact with the health care system.

Table no 3: In-patients, Maternity, and Delivery Beds by Type of Facility

Type of Facility

Beds

Inpatient Maternity Delivery

PHCU (first line) 20 9 5

PHCU (second line) 17 31 17

Cottage hospital (PHCC) 88 20 7

District hospital 318 36 9

Special hospital 120 0 0

Tertiary hospital 46 0 3

Other Hospital 84 6 3

Other type of facility 4 0 1

Grand Total 697 102 45Source: PSAM 2009

It is where short-term health issues are resolved and the majority of chronic health conditions are

managed. It is also where health promotion and education efforts are undertaken, and where

patients in need of more specialized services are connected with secondary care.

2.4 Service Utilization.

Utilization of health facilities, thou slowly, is increasing from 0.2 in 2007 to 0.9 in

2008 respectively compared to two zones. This slight increase is still not satisfactory

in some health facilities as it tells us that there are still a percentage of people not

utilizing health facilities in one location for many reasons e.g. poor quality, and thus

compelled and instead utilizes in another location. These facilities need improvement

and upgrading to increase utilization (refer to annex no ). Service utilization for

children under-five years was higher in 2008 compared to five years earlier.

Jan 201010

DRAFT

Table 4: Annual service utilization rate by district, 2007 vs. 2008Utilization rate Utilization rate < 5 Utilization rate > 52007 2008 2007 2008 2007 2008

Chake Chake 0.9 1.1 1.6 1.9 0.7 0.9Micheweni 0.8 0.9 1.4 1.5 0.7 0.7Mkoani 0.6 0.7 1.0 1.1 0.5 0.6Wete 0.7 0.9 1.4 1.8 0.6 0.6Pemba, Total 0.8 0.9 1.3 1.6 0.6 0.7Central 1.2 1.4 2.5 3.0 1.0 1.1North A 1.1 0.9 2.0 1.8 0.8 0.7North B 0.6 0.7 1.2 1.3 0.5 0.5South 1.9 1.9 3.9 3.3 1.6 1.7Urban 0.5 0.9 2.0 2.9 0.3 0.5West 0.4 0.6 0.9 1.5 0.3 0.4Unguja, Total 0.7 0.9 1.7 2.2 0.5 0.6Zanzibar, Total 0.7 0.9 1.5 1.9 0.5 0.7

Source: Health bulletin 2008

2.5 Management of the Primary Health care

Health care reform has put in place the administrative structures necessary to support

the District Health System. However, the administrative reform must translate these

into improvements in service delivery. For the District Health System to achieve its

aim of providing high quality health services which are accessible to all Zanzibaris,

health care system reform (refer chapter 4 decentralization by devolution) will need to

take place at a variety of levels under LGA. Although progress has been uneven

across districts, in many areas the necessary administrative structures for

implementation of the district health system are now in place. The challenge is to

translate district commitment and administrative reorganization into real

improvements in health care delivery at local level by devolution. The District Health

Management Team has been the most appropriate vehicle for the delivery of primary

health care through its support efforts, and is seen as the prime vehicle for linking the

MOHSW with the community to bring positive change in the health outcomes by

integration local conditions and the needs within the District. This decentralization by

de-concentration (refer to chapter four) has limited meaningful/full participation of

the community in their PHC facilities thus not delivering the desired results of

providing quality and affordable health care that is accessible to all its people

Jan 201011

DRAFT

although Zanzibar has managed to have high coverage of health infrastructure. The

main concern therefore is but the quality of services which undermines the utilization.

2.6 Components of Primary Health Care

The code words "Primary Health Care" (PHC) were selected to describe the following

eight components in combination:

Education about common health problems and what can be done to

prevent and control them;

Maternal and child health care, including family planning;

Promotion of proper nutrition;

Immunization against major infectious diseases;

An adequate supply of safe water;

Basic sanitation;

Prevention and control of locally endemic diseases; and

Appropriate treatment for common diseases and injuries.

To succeed in implementing these components, Primary Health Care has got to base

on three pillars:-

Multi-sectoral approach,

Community participation and

Equity

2.6.1. Education about common health problems (Health Promotion or Disease

Prevention)

Health promotion has a very important place in PHC but it is not given the weight it

deserves even in MKUZA (1). The PoA for Financial Year 2008/09 reflects that from

the 14 activities proposed only 2 activities were fully achieved (14%) while only 3

activities (22%) were partially achieved13. The PHC as stated earlier is about

promoting prevention services than curative care services. Health promotion is the

best way and most cost effective way to compliment the PHC efforts. Health

promotion activities have been ongoing but needs to be scaled up to reach the most

vulnerably segment of the community.

13 HSPR 2009

Jan 201012

DRAFT

The health education unit conducted educational programs in some schools and

educational institutions14 Health promotion in schools has been very active and

ongoing and included promoting healthy learning environment safe and

environmentally friendly and easily accessible buildings, adequate water and

sanitation, healthy programme to address psychological and emotional health of

teachers and learners. (Refer to Annex No 1)

HIV and AIDS

HIV prevention programs are conducted in private, public as well as not for profit

educational institutions. Coverage varies between the insitution with 70.7 percent of

government facilities offering preventive programmes while 50% of not for profit

and 43.8 percent of private schools offer such preventive services.15.

HIV prevention and IEC/BCC, Post-exposure prophylaxis (PEP). MARPS

interventions are some of the interventions done by the MOHSW in collaboration

with stakeholders. (Refer to Annex 2). Workplace health promotion and preventive

programmes for HIV and AIDS have also been ongoing but are not compulsory. This

is the reason why some work places do not have these programs.

14 HSPR 2009 and P-SAM 2008-200915 P-SAM 2008-09

Jan 201013

DRAFT

Table 5: Distribution of Workplaces with Trained peer educators, HIV Counselors,

and other Medical Personnel at Workplaces selected from Districts:

:

District

Work places

with peer

educators

Peer-

Educators

HIV

Counselors

Other

Medical

Personnel

North A 1 3 0 4

North B 0 0 0 0

Central 3 8 1 10

South 2 3 2 1

Urban 3 10 4 0

West 3 4 0

Wete 1 10 25 0

Micheweni 1 1 1 0

Chake

Chake

2 2 0 0

Mkoani 1 1 0 1

Total 17 63 36 16

Source: P-SAM 2008-09

2.6.1.1. Education through Media and other means of Health promotion

Media has been used in health promotion by the MOHSW and in collaboration with

other vertical programmes. Malaria and HIV have had the biggest attention.

Employee examination and workplace inspections and counseling have been done

through the occupational health unit. Port health has also been a priority for the

MOHSW whereby in FY 2008/09, the unit inspected 137 foreign vessels (74.4%),

304 domestic vessels (76.5%) and fumigated 22 vessels. Passengers on these vessels

were screened (35,504 foreigners, 186,673 domestic and 61 crews examined) of

whom 2,854 were found unvaccinated for Yellow Fever.16

The MOHSW has made great efforts to conduct health promotion while fulfilling one

of the key elements of PHC. However, the quality of all these programs is not known.

16 HSPR 2009

Jan 201014

DRAFT

Here we are referring to indicators that measure the success of the health promotion in

meeting the health related needs of the population in a manner that is consistent with

local goals, national goals and resource constraints.

In MKUZA (1) there are no standardized indicators for health promotion are available

and this makes it difficult for measuring the quality of all the health promotion

interventions implemented. This is important so as to be assured that all these efforts

contribute to a positive PHC outcome. Community Health promotion interventions

especially those implemented by NGOs did not feature well in the documents that

were reviewed. The Health Promotion Unit in the MOHSW is underfinanced making

full implementation of its programmes difficult.

2.6.2 Maternal and Child Health Care, including Family Planning.

Maternal and child health is one of the most important MGD and MKUZA indicators

which have not been doing well in MKUZA (1). Services provided at the MCH/ANC

for mother and child health are as follows:

Pregnancy monitoring for early identification of risks and complications

Client’s counseling and examination services, including checking for high

blood pressure, anemia testing, early and effective treatment of infectious

diseases and other conditions.

Information, Education and Communication messages about nutritional intake,

danger signs of pregnancy and the need for facility delivery and proper child

care

Referrals for complicated cases

IMCI- immunization

Growth monitoring for children

Family planning after delivery

Post abortion friendly services and referrals

Inter natal and postnatal services

Malaria rapid test and SP doses-intermittent presumptive treatment for

pregnant women (IPT)

Voucher scheme for ITN

STI including HIV tests

Jan 201015

DRAFT

Consultation of special conditions/illnesses e.g. surgical, medical, pediatric

and gynecological care

PMTCT services

2.6.2.1 Maternal Health Maternal health highly depends on the accessibility, availability and the quality of

ANC delivery and postnatal services. Proper maternal care does not start and end

with a pregnancy. Good maternal care begins before pregnancy.

The current status in Zanzibar shows the presence of ANC services in all the PHC

units except for a few services such as inpatients and Laboratory services and

consultation for special conditions only available in PHCC and selected PHCUs+

facilities. This may give delays and may be contributory factors to low progress in

reducing maternal mortality and morbidity at this stage. (See a detailed discussed in

chapter 6).

The availability of ANC services in health facilities is still low, but shows an

improvement, 54% of all health facilities have ANC services now compared to 28%

which had had none in 2008/0917. PHCUs are the main providers of ANC services,

91.4% of all PHCU units provide ANC services. Despite the high attendance, only

12% of pregnant women started ANC during the first trimester as per national

guidelines. Health education is given in ANC so later ANC bookings have the

disadvantages of not getting all the health education given during ANC clinics.

Delivery in health facilities is said to be low 48.7%. Although the ANC attendance is

high 90%, only 51% are assisted by skilled personnel/attendant. Only 6% attend

postnatal care within 2 days after delivery and 7%18 within a week. In 2008-2009,

66% of all districts combined had ante-natal services and all districts had midwives

totaling 319 midwives. North B had the least number of only 2.2% while Wete district

had he highest at 26.3%.

In 2008 MMR was 422 per 100,000 compared to MMR 365 per 100,000 in 2007

( Causes of MMR refer to chapter 6).

17 Health Bulletin 200918 Roadmap to accelerate the reduction of maternal, newborn and child mortality in Zanzibar-2008

Jan 201016

DRAFT

Figure 2:Trends of MMR in Zanzibar 19(Institutional)

473

365

422

251

100

150

200

250

300

350

400

450

500

2006 2007 2008 2009 2010

Institutional MMR

MKUZA Target 2010

One of the limitations in recording MMR data in Zanzibar is that Zanzibar does not

have a functioning system in place for recording births and deaths taking place in the

community. The delay in accessing appropriate care contributes to the high level of

maternal mortality (and morbidity) in Zanzibar.

. The MKUZA target is to reduce MMR to 251 per 100,000 live births by 2010. The

situation shows that the institutional MMR is still far from the target warranting extra

efforts toward its achievement. Road Map for the acceleration of reduction of

maternal, newborn and child mortality was finalized in 2008, and disseminated among

stakeholders, key ministries, DHMTs on both islands and community leaders in 3

districts.

2.6.2.2 Focused Antenatal Care (FANC)

Services are in all PHCUs diagnosis and treatment and prevention of malaria in

pregnancy. Guidelines and training curricula have been developed. Advocacy

meetings to orient stakeholders about FANC were held. Plans to develop quality

assurance tools to assess standards at facilities are being worked on.

The MOHSW had developed an essential package for health services for community

health workers, but it is not yet in uses.

19 P-SAM 2008-2009

Jan 201017

DRAFT

Basic emergency obstetric care is available in 2 PHCC in Unguja, (Makunduchi and

Kivunge) and in 2 PHCC in Pemba (Vitongoji and Micheweni). These are serving as

referral facilities for the PHCUs.

2.6.2.3 Family Planning (FP)

Zanzibar has good FP service coverage with most population living within 5 km of a

health facility with the number of 65 FP service delivery points offering contraception

per 500,000 populations.

Present intervention has been focusing on long-acting FP methods (IUCD, implants,

vasectomy), resulting in an increase in new FP clients.

Advocacy done by high level political figures can make a big difference eg the FP

advocacy attended by Honorable First Lady Shadya Karume resulted into more

demand of FP.

Table 6: Percentage of new family planning clients by zone, 2007 vs. 2008.

Zone 2007 2008Pemba 1.3 1.8Unguja 4.8 5.9Zanzibar 3.4 4.3 Source Health bulletin 2009

In Zanzibar, the high fertility rate combined with the low contraceptive prevalence

rate (15%20) increases the lifetime risk of maternal death. A high proportion of

women (31%) have an unmet need of FP due to irregular and erratic supply of

contraceptives and the limited choice21. Qualified health personnel to administer FP

are lacking in some health facilities though training was provided to 17922 health staff

in all districts (detail discussed in chapter 6.). 200 Community Based Distributors

have been trained for the distribution of FP at community level through the health

facilities but all were women thus limiting and even eliminating male involvement

altogether7. Out of 205 health facilities in Zanzibar only 61.9% have FP guidelines.

This is an important tool to assist in providing services for FP23. MOHSW 20 Road map to accelerate the reduction of maternal, newborn and child mortality in Zanzibar 2008-201521 Road map to accelerate the reduction of maternal, newborn and child mortality in Zanzibar 2008-2015

22 PSAM-2008/0923 *P-SAM 2008-2009

Jan 201018

DRAFT

Performance report 2008 reported that the demand for FP was created through radio

and TV announcements, community meetings, house-to-house visits and posters/FP

materials in Health Facilities, and during where outreach services were conducted. A

total of 8 Health Facilities were equipped to provide long-acting and permanent FP

methods benefiting 1,240 clients. The number of FP service delivery points offering

contraception per 500,000 populations is 65 as reported by the MOHSW Health

Bulletin 2009. More community awareness is still needed involving the FBOs and

other stake holders is still needed. It is noted that in 2008 there was a low percentage

of new clients (4.3%) with a very slight increase (3.4%) compared to that of 2007.

2.6.2.4 Delivery services

Institutional birth assisted by skill workers has slightly increased but overall it is still

low. Delivery cases are less then ANC attendance (discussed in chapter 6)

Table 7: Institutional births and births attended by skilled personnel, 2007 Vs 2008*

ZoneDeliveries by health staff (%) Institutions Deliveries (%)2007 2008 2007 2008

Unguja 50.4 52.5 46.3 47.8Pemba 29.8 31.7 23.8 26.7Zanzibar 42.5 44.5 37.0 39.7

Note: Deliveries by health staff includes both at home and at facility.

The reduction of maternal mortality ratio is part of one of the MDGs, MKUZA and

ZHSRSP II. The MKUZA target is to reduce MMR to 251 per 100,000 live births by

2010. 24The situation shows that the institutional MMR is still far from the target

warranting extra efforts toward its achievement. To improve maternal health, gaps in

the capacity and quality of health systems and barriers to accessing health services

must be identified and tackled at all levels, down to the community

2.6.2.5. Child Health Services

24 Efforts should be made to investigate the quality of the health facilities giving delivery services. (Chapter six)

Jan 201019

DRAFT

Under Child health (CH), neonatal and children under fives will be considered. Child

Health Education/promotion is usually conducted during the ANC/MCH clinics. CH

services include:

Child health education (including nutrition), MCH clinics having integrated

management of childhood illnesses (IMCI) which includes immunization. Child

health is among the key components of the health care package in Zanzibar, whose

indicator shows slow progress and a great concern for the health sector.

Neonatal health directly depends on the health of the mother during pregnancy, during

labor and after delivery. Neonatal services in Zanzibar are almost non-existent and of

lower priority which has been given to address post-neonatal .25

Children under 5: Children under five are more susceptible to childhood diseases

because their immune systems are still not well developed. Integrated Management

of Childhood Illnesses (IMCI) strategy is introduced in all 10 districts, aiming to

benefit child survival, growth and development thus addressing the major causes of

childhood deaths, namely, malaria, respiratory tract infections, diarrheal diseases,

malnutrition, anemia and measles. IMCI is the key strategy for reducing child

morbidity and mortality in the developing countries. IMCI guidelines have been

revised to include management of neonatal infection, HIV/AIDS as well as the

inclusion of new approach on malaria diagnosis and the management of fever.26

2.6.2.6. Immunization:

Immunization services are available in all PHCUs to children under one year, except

for the Tetanus Toxiod which is given to pregnant women, in the ANC/MCH clinic.

The types of immunization available are BCG, DPT-HepB3, Measles and Tetanus

Toxiod.

25 Road map to accelerate the reduction of maternal, newborn and child mortality in Zanzibar 2008-2015? PSAM-2008/09

26 Health bulletin 2009

Jan 201020

DRAFT

Table 8: Immunization coverage under one year by zone, 2007 vs. 2008(Health Bulletin 2008)

2007 2008 2007 2008 2007 2008 2007 2008Pemba 89.7 98.6 65.4 71.7 73.3 73.4 77.8 72.6Unguja 111.5 121.1 91.4 89.0 100.7 97.2 93.1 94.6Zanzibar 101.3 111.0 79.2 81.2 87.9 86.5 85.9 84.7

Fully immunisedMeaslesZone BCG DPT-HepB 3

Source: Health Bulletin 2009

Nationally, the coverage is good at 89.1 percent in 2008 against 85.9 percent in 2007,

and is on the right track to reach the MKUZA target of 95 percent by 2010. The

districts with the lowest coverage are North B with 58.2 percent and Micheweni with

59.1 percent. This success has been reached due to the massive campaigns, IEC

materials displayed in all health facilities creating awareness, and ongoing

education/and training given at all MCH clinics with trained health workers.

Primary health care units provide the most immunization services as would be

expected27because of having a wider coverage of clients as shown below.

Table: 9 Availability of immunization services by type of Health Facilities.

SERVICE AVAILABILITYTYPE OF HEALTH FACILITY NO YESCottage hospital (PHCC) 4District hospital 3Other Hospital 2 1Other type of clinic 54 8PHCU (first line) 8 97PHCU (second line) 2 22Special hospital 1 1Tertiary hospital 2

Source: P-SAM 2008/2009

Through the MOHSW initiative, IMCI guidelines were developed and disseminated

to all PHC units so as to have proper and standardized treatment of the most common

childhood illness such as URTI (42.3%) Pneumonia and diarrhea(21%). The status of

the most common childhood disease in Zanzibar is illustrated below.

27 Annex Table no 9 Availability of Immunization services by type of health facility

Jan 201021

DRAFT

Table No: 10 Common Childhood Diseases for children under 5 in Zanzibar

ZoneDiarrhoea Pneumonia URTI Malaria* Measles2007 2008 2007 2008 2007 2008 2007 2008 2007 2008

Pemba 10.2 15.5 24.3 28.0 20.0 35.2 22.8 0.7 0.2 0.2Unguja 16.0 21.7 32.3 36.3 34.9 44.3 22.0 2.5 0.0 0.1Zanzibar 13.4 19.0 28.7 32.7 28.1 40.3 22.4 1.7 0.1 0.1

*Note: 28

2.6.2.7 Promotion of proper nutrition

Nutrition care and support is an important component in primary health care. Many

of the health conditions associated with diseases are influenced by bad nutrition. The

risk of malnutrition in Zanzibar is huge especially presently when food security is

very low. Among other factors climate change is responsible for the unpredictable and

disastrous climate. Zanzibar’s agriculture is fully dependent on rainfall (refer to

chapter 7 on effects of climate change), and therefore any change in rainfall pattern is

bound to have negative effect on agricultural products.

Infants and children feeding is another important component of child health. Breast-

feeding is universal in Zanzibar with over 98 percent of children with an average

duration of 21 months29. Fifty-four (54) percent of babies are breastfed within the first

hour of life

Table 11: Malnutrition of children under five (in %) 2007 vs. 200830

Zone2007 2008 2007 2008

Pemba 6.8 7.0 0.4 0.5Unguja 8.0 7.6 0.4 0.4Zanzibar 7.2 7.4 0.4 0.5

Total Malnutrition Severe Malnutrition

Source: Health bulletin 2008

Malnutrition is one indicator which shows low progress.. It is predominantly seen in

Pemba more then in Unguja. Health promotion on the proper nutrition to fight against

malnutrition is given in the ANC clinics. In almost all the PHCUs there are IEC

28 In 2007 Malaria data were based on both clinical and confirmed which implies Malaria was over diagnosed using syndromic management, while in 2008 only confirmed cases were considered. In most of the PHC units Malaria is now being diagnosed using rapid test

29 TDHS 2004/0530 Health Bulletin 2008

Jan 201022

DRAFT

materials displayed on proper nutrition. The prevalence of micronutrient deficiencies

is shown by level of anemia 75% and Vitamin A deficiency (VAD) is 41%. Among

women of reproductive age (15 – 49 years) the prevalence of anemia is 63% and

VAD is 37%31. Some of the reasons for malnutrition in Zanzibar are 1. Eating the

wrong type of food (mother when breast feeding and child feeding) 2. Not having

enough food.3. Growth monitoring training and supervision are been carried out by

trained staff at MCH clinics. Vitamin A supplementation and de- worming (in schools

also) was conducted for under fives with 89 percent and 93 percent success

respectively.

The MOHSW has developed a national Nutritional Strategic Plan 2008-2012 which

focuses on maternal and child nutrition and Non-Communicable Diet Related

Diseases. This strategy if translated into simple language will benefit a wider

community. Collaboration with the Ministry of Agriculture and other stakeholders to

design a strategy to promote the growing/cultivating and eating of the right food

through a national campaign could also make a difference.

2.6.2.8 Anemia:

It is estimated that 75 percent of children under five have some level of anemia32 Programs

have been put in place to tackle anemia in children, including infant feeding, micronutrient

supplementation, growth monitoring and nutrition promotion alongside use of ITN/LLINs,

2.6.2.9 Vitamin A Deficiency

Vitamin A Deficiency services is available in almost all PHCUs. Promotional I.E.C

materials are displayed in almost all the health facilities. Coverage for Vitamin A

supplementation is 78 percent at 9 months, 28 percent at 15 months, 28 percent at 21

months, and 31 percent for post-partum mothers33. In addition, Vitamin A

supplementation and de-worming campaigns are regularly conducted twice a year,

with year 2006 coverage at 89 percent and in February 2008 coverage at 83 percent34

31 Zanzibar Food Security and Nutritional Policy,200832 TDHS 2004/0533 Service statistics, MoHSW, 2003/0434 MoHSW report 2006

Jan 201023

DRAFT

Greater community awareness needs strengthening for sustainability of Vitamin A as

a routine supplementation and further increase in coverage.

2.6.3 Adequate supply of safe water

Inadequate access to clean water supply and sanitation is one of the fundamental facts

giving rise to the many health challenges facing Zanzibar today. This situation poses

a serious threat to the health, lives and livelihoods of too many of the citizens,

particularly women and female children, and will continue to work against the

poverty reduction efforts until the situation changes. But even for those who have

access to water and sanitation services, those services need to be improved and

sustained while remaining affordable.

The existence of clean and safe water in the community and especially in health

facilities is of uttermost importance to maintain a safe environment for the functioning

of the facility. However it was noted that not all communities and health facilities

clean and safe water. As an important component of PHC, in urban areas, the

coverage is intended to increase by 15% from 75% in 2005; to 90% by 2010; the rural

water supply service coverage is intended to increase by 14% from 51% in 2005 to

65% by 2010.MKUZA has its target set as from 75% in 2005 to 90% in 2010.

The Revolutionary Government of Zanzibar has and continues to implement water

supply and sanitation projects in various parts of Unguja and Pemba. The Zanzibar

Urban Water Supply Development Project funded by the Government of Japan

and the Zanzibar Sanitation and Drainage Program Phase II funded by Federal

Republic of German via the German Development Bank (KfW) are among the

ongoing projects. However, in some parts of Unguja and Pemba, people are still

been experiencing water shortages and poor sanitation services due to various

reasons such as lack of proper distribution systems, dilapidated water supply

infrastructure; limited human and financial resources to sustain water and sanitation

operation and maintenance; low stakeholder participation; lack of equipment for

collection and disposal of waste as well as for recycling solid and liquid waste

arrangements, lack of coordination of activities between water supply and sanitation.

The constraints on water related environment include salinity and intrusion risks in

the coastal areas, encroachment of water sources, depletion and degradation of ground

water reserves, poor management of drought and floods, and limited monitoring of

Jan 201024

DRAFT

groundwater.

Generally, efforts by the government to protect water sources including catchments

areas and corridors continue in promoting tree planting e.g. in Masingini catchments

area by fencing the area around Welezo waterworks. Government continues

registration of private water sources such as boreholes, pipes and hand dug wells for

quality control.

The Government of Zanzibar has an approved Water Policy that is supported by

Legislations. This Policy has set guidelines for proper and long time sustainable use

and management of water resources towards. Government development efforts in

Zanzibar aim, among others, at improving water supply and sanitation services to

both domestic and business entities as a means of achieving the targets set in Vision

2020 and Millennium Development Goals (MDGs) towards achieving better well-

being to its people, the Zanzibaris.35

In health facilities, districts with at least high coverage of piped water are urban ones

with at least 23 facilities getting piped water, West has 25 facilities with piped water

and, Wete which have 20 facilities with piped water respectively. Some districts with

few facilities that have piped water include North A that has 9 facilities accessing

piped water, North B 10, Central 8, and South 5. South is disadvantaged as far as safe

and clean water supply is concerned. Table below illustrates the uneven distribution

of facilities and sources of water.

Table no 12: Distribution of Facilities by Source of Water and Type of Facility36:

Type Piped water Covered Open Rain Surface Tanker Grand

35 MKUZA based MDG needs assessment report 200736 PSAM 2008/09

Jan 201025

DRAFT

well or

bore hole

well water water truck Total

Cottage hospital

(PHCC)

2 1       1 4

District hospital 3   3

Other Hospital 1 2 3

Other type of clinic 45 15 2 62

PHCU (first line) 64 20 13 6 2 105

PHCU (second line) 22 1 2 25

Special hospital 1   1 2

Tertiary hospital 1   1

Grand Total 139 39 15 8 1 3 205

Source: Zanzibar Service Availability Mapping 2008-2009

Table no 13: Distribution of Facilities by Source of Water and DistrictDistrict Piped

water

Covered well

or bore hole

Open

well

Rain

water

Surface

water

Tanker

truck

Grand Total Percent of

Facilities

with Unsafe

Source

North A 9 2 1 2 14 21.4

North B 10 1 1 12 8.3

Central 8 11 4 1 24 20.8

South 5 5 1 11 9.1

Urban 23 13 1 1 38 5.3

West 25 4 1 1 31 6.5

Wete 20   3 1 24 16.7

Micheweni 12   2 1 15 20.0

2.6.4. Basic Sanitation

Basic sanitation in Zanzibar is not satisfactory. Generally in Zanzibar, there is no

centralized sewerage system. The Zanzibar population policy reported that the

existence sanitary system operates inadequately and it is too old. The system cover

only 30% of the residents and comprehensive policy guideline for sanitation is not

available. In addition to that the excreta disposal in Zanzibar is a problem. House

hold with latrine reported as 65.7% for Unguja and 20.2% in Pemba. Zanzibar

Jan 201026

DRAFT

Municipal Council reported the rural sanitation services coverage as 60.5% and urban

sanitation and sewerage services coverage as 73% in 2007/2008.

Urban sanitation and sewerage services coverage have increased by 23% in 15 years;

from 49% in 1990 to 72% in 2005. This trend depicts an easy possibility of reaching

the target of 74.5% by 2015, even at the pace of slightly below 0.5% per year, keeping

in mind that only about 2.5% by 2015 is still outstanding. However, the sanitation

situation in rural areas is alarming!, although rural sanitation service coverage

increased by 28% in the same period; from 31% in 1990 to 59% in 2005, the

outstanding 6.5% increase of coverage in just remaining 8 years is overwhelmingly

challenging, especially when one concedes that the urban rise in service coverage is

partly due to the decline in poverty levels and more money multiplier effects in urban

areas than in rural areas.

The existing garbage dumping sites at Jumbi is now surrounded by the residential

areas which affect the public health of the community nearby and also not

environmental friendly, hence there is a proposal to construct a proper Sanitary

landfill at Kisakasaka of at least 15 hectares for solid waste disposal but due to

financial problems the proposal has not been implemented so far.

According to a report on sanitation for implementing MKUZA about 73.4% of the

households use pit latrines and 22.4% use flush toilets. The capacity of the Municipal

council to collect solid waste is 30% of the total wastes generated. With the

assistance from German, Zanzibar is in the process of implementing the Zanzibar

sanitation and drainage programme Phase II. This is a serious issue and can be one of

the factors slowing progress of other health indicators. Combined efforts are needed

to solve the given problem. Awareness programs should be continuously involving all

stakeholders including the media.

The directorate of public health which includes units for EH, occupational and port

health, reviewed Public health laws and other activities conducted to reduce the

occurrence of diarrhea and vector-borne diseases through preventive, surveillance and

control interventions. The EH unit, in collaboration with DHMTs, conducted

sanitation and hygiene educational activities in Central, South (Unguja), Wete and

Jan 201027

DRAFT

Chake Chake districts (Pemba) for district leaders and 65 (Unguja) and 100 (Pemba)

communities.37

Efforts have been made through the sector Ministry sponsored by different DPs, but

challenges still exists.

2.6.4.1 Challenges of Sanitation

As far as sanitation sector is concerned, experiences have shown the following

challenges:

Low service coverage

Meeting national and international commitments (Vision 2020, ZPRP,

MDGs, WSSD targets, etc)

Absence of sanitation policy

Most of the regulations, rules and bye-laws available are out dated and

therefore need to be reviewed in order to suit the requirements at the

moment e.g. sewerage regulations, etc.

Reviewing of policies, strategies and legislations

Putting in place institutional arrangement that reflects the changed role of

the Ministry for the sanitation sector

People are not willing to pay for services due to less awareness of

community participation, ownership and empowerment for the

Environmental Services

Public awareness raising and low sanitation education

In adequate financial status

Slow implementation of local government policy

Local government reform programme still remains pending and

incompleted

High rate of urbanization

Unrealistic tariffs, poor billing and revenue collection due to improper

database

Shortage of qualified and experienced personnel; and lack of working

facilities

Capacity building at all levels

37 HSPR-2009

Jan 201028

DRAFT

Low private sector involvement

2.6.4.2 Constraints

a) Economic

There is a need of reviewing the tariff rates and raising them to generate higher

revenues to cover operation and maintenance costs. More over, the institutionalized

adaptation of the existing tariff rates to annual inflation is considerably influenced by

the political circumstances.

b) Operation

The provision of regular waste water and solid waste disposal service is essential to

establish a safe environment for the residents and to ensure sustainable services

require the effective restructuring of the existing Municipal.

c) Financial

In adequate availability of mobilized resources in terms of Financial and Technical

support for the implementation of the target activities to achieve the MDGs and

MKUZA targets.

d) Gender

Lower awareness on gender issues in the society that prompts for behavior change

interventions.

2.6.5 Prevention and Control of Locally Endemic Diseases; and Appropriate

Treatment for Common Diseases and Injuries

The following have been identified as Zanzibar’s local endemic diseases:

Malaria

HIV/AIDS

Pneumonia and URTI

Diabetes

2.6.5.1 Malaria

Malaria has declined to low levels in Zanzibar, and careful planning is now underway

to prevent it from taking hold again. Indeed, Zanzibar is entering uncharted waters.

Jan 201029

DRAFT

Zanzibar should learn from this success and see how it may be replicated to address

other health indicators

However, this success is fragile due to several factors. On the Tanzania mainland,

just 20 miles away from Zanzibar, the prevalence of malaria infection in residents

remains high and travel between the two is very common. The species of mosquito

that can transmit malaria still exists in Zanzibar, so ongoing vigilance is critical. To

achieve the World Health Organization’s criteria for pre-elimination status (less than

1 case of confirmed malaria among 1,000 persons with fever), Zanzibar needs to

reduce malaria transmission even further.

What Zanzibar does in the coming years will be the true measure of its success with

malaria control. The strategies to maintain this success will also provide useful

information for other countries as they reduce malaria transmission.

Malaria was a leading cause of death 4 years ago now it ranks 4th and still shows signs

of decreasing, especially with the introduction of the new malaria treatment it is

expected to decrease more. Even though malaria campaigns have showed a positive

trend, continuous preventive measures should be adhered to, especially because of the

climate change; there is an existing treat to turn back the gains achieved.

2.6.5.2. HIV and AIDS

At present the prevalence rate of HIV and AIDS Zanzibar is 0.6 %, with 478 people

living with HIV and AIDS (270 women and 208 men). According to the public health

formula, approximately 20% of the people living with HIV and AIDS will be eligible

for ARV.

Table 14: Providing ARVs by type of Health Facility:

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Table 15: Providing ARVs by District:

DISTRICT NO YESGrand Total

Central 23 1 24Chake Chake 20 1 21Micheweni 14 1 15Mkoani 15 15North A 14 14North B 12 12South 10 1 11Urban 37 1 38West 31 31Wete 23 1 24Grand Total 199 6 205

2.6.5.2.1 HIV related services include:-

1. Counseling services

2. VCT services

3. Laboratory services

4. PMTCT

5. ARV services

6. Home-based care services

7. Counseling services

8. PRP & VDRL for syphilis services

Counseling and Antibody Testing Services

Jan 2010

TYPE NO YESGrand Total

Cottage hospital (PHCC) 2 2 4District Hospital 1 2 3Other Hospital 3 3Other type of clinic 62 62PHCU (first line) 104 1 105PHCU (second line) 25 25Special hospital 2 2Tertiary hospital   1 1Grand Total 199 6 205

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There are 73 health facilities which do not have this VCT service, 44 are PHCUs. 63

facilities have only counseling services and clients are referred to other facilities for

testing. This service needs to improve so that more people can be motivated to

undergo VCT under one roof.

Table 16: HIV counseling and antibody testing by Type of Health Facility:38

2008-2009

TYPE Counseling ONLY

 Neither (Counseling

NOR testing) Testing AND Counseling  Not stated T

Cottage hospital (PHCC) 1 3 4

District hospital     3   3

Other Hospital     3   3

Other type of clinic 6 29 15 12 62

PHCU (first line) 45 39 6 15 105

PHCU (second line) 11 5 6 3 25

Special hospital       2 2

Tertiary hospital     1   1

Grand Total 63 73 37 32 205

Most of the studies there have not been assessing the quality of care; this includes the

quality of VCT.

Home Based Care Services (HBC)

The availability of HBC is still low and also utilization is low indicating low demand

for the service. HBC done by other NGO’s are not well reflected.

Table 17: Home Based Care HIV by district:DISTRICT NO YES Grand Total

Central 19 5 24

Chake Chake 14 7 21

Micheweni 10 5 15

Mkoani 8 7 15

North A 8 6 14

North B 12 12

South 9 2 11

Urban 35 3 38

West 30 1 31

38 ZSAM 2008-2009

Jan 201032

DRAFT

Wete 19 5 24

Grand Total 164 41 205

Source: Health Bulletin 2009

Table 18: Home Based Care for HIV by type of Health facility:TYPE NO YES Grand Total

Cottage hospital (PHCC)   4 4

District hospital   3 3

Other Hospital 3 3

Other type of clinic 60 2 62

PHCU (first line) 84 21 105

PHCU (second line) 15 10 25

Special hospital 2 2

Tertiary hospital   1 1

Grand Total 164 41 205

Source: Health Bulletin 2009

For the HBC –HIV by type of facility, only first line and second line PHCU provided

the service. Since the PHCUs are the grassroots facilitators of health it is important to

have evidence based information that could strengthen the health provision in line

with the MDGs.

HIV services related to ARV availability were assessed in the HFs. Only 6 out of the

205 facilities visited were providing ARVs. Of those six facilities, 2 Cottage

Hospitals, 2 District Hospitals, 1 PHCU-first line and one Tertiary HF provide this

service

2.6.5.3 Tuberculosis Control

Mapping of TB control revealed that three categories of health facilities provide HIV

antibody testing for TB patients. Out of the 205 HFs, 64.4% were either providing

HIV testing to all TB clients or were providing referral to them.

Table 19: HIV testing for TB Patients distribution for District

Jan 201033

DRAFT

DISTRICT Provides

HIV

antibody

testing for all

TB patient

Provides

referral

TB patients

are not

routinely

tested

Not stated Grand

Total

Central 3 9 2 10 24

Chake Chake 1 13 2 5 21

Micheweni 1 12 2 15

Mkoani 2 11 1 1 15

North A 1 10 3 14

North B 1 7 2 2 12

South 1 5 5 11

Urban 3 20 7 8 38

West 2 9 20 31

Wete 1 20 2 1 24

Grand Total 16 116 16 57 205

Source: P-SAM 2009

2.6.5.4 Diabetes

This has been on the rise for four consecutive years. Diabetes is one among the

emerging Non Communicable Diseases (NCDs) affecting all age groups and both

sexes. Services have been introduced in the different health facilities.

Without Laboratory equipments and supplies no test can be conducted making

treatment by trial and error which can even be fatal. Not all PCHUs are well equipped

to manage Diabetes.

2.6.5.5 Road Traffic Accident

There were 2,050 RTA cases reported in 2007 and 3387 cases for 2008.This is

becoming a major health concern in Zanzibar. Urban district ranks the highest with

1275 cases, followed by Central district with 405 cases. First aid services are

available but not adequate in the PHCUs and complicated cases are usually referred.

Health facilities could be used as one of the opportunity to give road safe measures

Jan 201034

DRAFT

awareness using IEC or as part of the ongoing educations given by the health

personnel.

Table 10: Road Traffic Accidents by district, 2008.

Zone District 2007 2008

Pemba

Chake Chake 160 367Micheweni 98 68Mkoani 78 156Wete 526 318

Unguja

Central 306 405North B 203 33Urban 143 1275West 142 334South 170 182North A 224 249

Zanzibar   2050 3387Source: Health Bulletin 2009

2.7: Human Resources: Inadequate human resources are one among the reported and documented problems in

Zanzibar health care system. It has been recorded that, “acting upwards” has been

common in PHCUs. This is because of the inadequacy of health worker. The tables

4.1 and 4.2 provide the results on numbers of health workers by cadre for all Zanzibar

districts where a full facility census was carried out.

Table 21: Number of Health personnel by cadre.

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Medical StaffDensity per 10,000 Population

District Doctors AMOClinical Officers

All 3 Cadres Together

Projected District Population 2008

Doctors and AMO per 10,000 population

Central 0 2 11 13 71,035 0.3

Chakechake 1 8 14 23 109,926 0.8

Micheweni 0 2 0 02 106,219 0.2

Mkoani 2 2 0 04 116,129 0.3

North A 1 1 4 06 99,186 0.2

North B 1 0 1 02 66,687 0.1

South 0 3 0 03 36,776 0.8

Urban 38 33 24 95 256,543 2.8

West 10 9 32 51 202,959 0.9

Wete 2 10 4 16 127,923 0.9

Total 55 70 90 215 1,193383 1.01Source: PSAM 2009

Clinical Officers:

There are seen to be more in the urban and peri-urban districts. This may be because

some of them are also working in private hospitals after normal working hours to

increase their income. In most of the PHCUs Clinical officers or AMOs are managing

the facilities at the same time they have to be attending frequent trainings, seminars

and workshop given by vertical programmes or by DHMTs.

Nurses and Midwives

Table 4.2 summarizes the number of nurses, midwives and clinical officers by district.

All districts in Zanzibar reported a total of 237 nurses and 319 nurse-midwives. This

corresponds with 1.2 nurse and 2.7 nurse midwife per 10,000 population, and when

combined it accounts for nearly 5 nurses and midwives per 10,000 people.

Table 22: Comparison of distribution of paramedical by District Zanzibar,

Jan 201036

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P-SAM 2009

Para-Medical Staff

District Health Orderlies

Lab. Tech

Pharmacy. Dispensers

HIV Counselors

Com. Health Workers

Social Workers

Total Paramedical Excluding Health Orderlies

Central 25 10 3 13 6 0 29

Chakechake 36 21 8 38 5 0 72

Micheweni 32 5 2 14 3 0 23

Mkoani 63 9 3 14 12 0 38

North A 42 6 2 9 50 14 81

North B 16 1 1 11 25 12 50

South 36 4 2 26 25 0 57

Urban 86 65 28 18 1 0 112

West 53 29 13 27 14 6 89

Wete 76 24 7 15 11 0 57

Total 465 174 69 185 152 32 612

Paramedical:

From the study conducted by PSAM 2009, it revealed that there are 185 HIV

counselors in Zanzibar, 69 pharmaceutical dispensers and 174 laboratory technicians.

Health orderlies are the most numerous accounting for 465 with the maximum

number (86 = 18.5%) employed in urban. Only 2 districts of North A and North B

have been found to have Social workers in Zanzibar.

Missing cadres include health officers, dental assistants, health assistants, material

managers/pharmaceutical assistants, radiologists, malaria agents and Maternal and

Child Health Aides. Most of the officers are working in both public and private

health facilities.

Table 23 Training of Health workers:

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Area of Training CentralChake Chake

Micheweni Mkoani

North A

North B South Urban West

Wete

Grand Total

IMCI 16 31 24 19 18 16 19 7 17 34 201Safe Motherhood 8 22 18 19 15 13 24 13 9 19 160ASRH 6 11 13 3 32 5 0 4 2 11 87HIVAIDS Care 6 21 12 11 11 9 3 27 5 20 125Counseling HIVAIDS 9 32 11 16 8 10 4 20 5 12 127HIV AIDS T and C 13 22 4 12 6 11 11 31 22 15 147PMTCT Training 13 20 7 11 15 11 13 16 12 9 127FP Training 11 28 17 23 15 15 19 16 9 26 179STI Training 11 29 18 23 11 6 19 25 16 25 183STI Training 2 11 29 18 23 11 6 19 25 16 25 183Universal Precautions in Handling Blood 15 14 23 6 14 11 5 25 13 20 146Diagnosis Malaria 53 70 37 100 20 16 29 24 27 60 436Drug Management 6 26 26 16 16 7 5 5 8 30 145Diabetes Training 9 7 2 5 15 1 2 4 7 5 57HMIS Training 14 80 32 39 15 13 14 21 5 53 286Mental Health Training 0 20 9 5 6 6 3 2 6 24 81

Staff training has been an ongoing activity done by the MOHSW or by other

vertically programs in collaboration with the MOHSW. Recognizing the importance

of staff training, as to equip service providers with new knowledge of the existing

health problems and the emerging and neglected diseases that are not yet familiar to

majority of staff, it has been a priority for the MOHSW. Training is also an important

aspect of improving quality of care.

2.8 Quality Assurance:

While it has long been thought that the assessment and assurance of quality is a

luxury confined to the more developed countries, many now believe that quality is not

the domain of the richer countries alone. Quality assurance holds a great potential for

improving the quality of care, even in the most resource constrained health care

systems, in the primary health care settings, since it focuses on the process of health

care delivery. Great sensitivity and caution should be exerted, however, to adapt QA

methods to the prevailing cultural norms and values, the availability of resources and

local priorities, thus avoiding mere replication of Western methodology.

QA activities at health facilities should be supported and integrated by national

policies which provide an institutional and legislative framework, standards of care,

and a unified management information system containing quality indicators, training

and more. The need for strong national leadership in QA cannot be overemphasized.

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Finally, the academic community is called upon to support the quality improvement

efforts in Zanzibar, both through operational research and through research which

tests critical policy assumptions underlying the relationship between the process and

outcomes of care, as well as between the quality of care and other health system

variables, such as demand, costs and equity. From the viewpoint of service provision

in the PHCCs, the main factors identified that caused de-motivation among health

care workers working at primary health care facilities were heavy workload

accompanied by staff shortages, lack of professional staff, routine work characterized

by monotony.

2.9 Recommendations and Way Forward

In order to have successful PHC interventions to bring about positive outcomes two

types of interventions should be addressed namely:

The “hardware” interventions which includes upgrading of infrastructure, provision

of equipment and supplies, essential drugs, safe blood supply, Infection Prevention

and waste management measures.

The “software” interventions includes capacity building of the service providers and

others in clinical and non clinical skills and strengthening management support for

quality assurance (QA) approach through Change Agent, QA committees and

Hospital Management Committees (HMCs) and the communities at large. This has

the aim to promote accountability and motivation among all staff through an

appreciative approach, involving them as equals and enabling them to develop their

potential through technical training. It also entails the formation of QA teams to

identify barriers and develop local action plans; and directly address problems that do

not require funds or use locally available funds and make available resources for

larger requirements.

It will be important to put in place a legal and institutional framework for

strategic Plan for Quality of Health Care in Zanzibar that stipulates that

defines standards of each health facility and establish a "Quality Council"

whose members will be in charge of the establishment and execution of a

service-wide Quality of Assurance program.

The plan should call for legislation to define the authority, responsibility

and accountability of these Quality Councils.

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A manual for quality of care guiding the Quality Councils should also be

developed.

Efforts should be put underway to establish a "bill of rights" for patients

and to agree on standards of care for all health care providers, public, non-

governmental organizations, private or P&P.

Training members of QA teams, such as the Quality Councils, who need

special new skills to conduct their activities. In the short run, this requires

offering short-term courses in QA techniques for QA team members. In

the long run, QA needs to be incorporated into the formal training

curricula of medical, nursing and business schools in Zanzibar.

Establishing and incorporating quality of care indicators in national health

management information systems and the work of QA teams should be

facilitated to carry out routine collection of information with indicators

that reflect facets of quality, such as the availability of drugs, the

availability and state of repair of equipment items or the utilization of

different services provided at the facility, ability to pay

Primary health care facilities are health gatekeepers to the community and

it is important that they are not bypassed. To maximize their effectiveness,

health workers must be motivated, skilled and supported.

Despite relatively widely distributed urban and rural health care services in Zanzibar,

questions about the functionality of the primary health care facility (PHCF)

infrastructure still remain. There is a need to conduct studies to explore user

satisfaction with health services and quality of care given to users to analyze both

structural and process quality aspects of care given to users. The quality of health

services, their efficacy, efficiency, accessibility and viability depend mainly on the

performance of those who deliver them. Performance is associated with training

policies and improving health workers' availability and retention

Establishment of a rotation system and its implementation is necessary within the

districts and between staff of the same qualifications as a means of retaining

employees, maintaining skills and learning of new skills. Through such rotation for at

least two years they could go back to work in a district /regional hospital and another

group from there replace those in the PHC facility. This strategy will motivate them

Jan 201040

DRAFT

even further to meet and share experiences among themselves. This could be cost

effective rather than leaving the facility ill-equipped something which would be a

direct denial to the people in need of services.

Have a communication strategy in place that:-

A two way flow of information (both bottom up and top down)

There should be an open dialogue on issues pertaining to health issues at

community/village levels

Ensure transparency and accountability regarding resources management,

allocation and utilization and the value for money.

Ensure that communication between actors in the sector and their stakeholders

is provided in an appropriate manner and formats which will ensure proper

translation of planned actions and policy into viable actions.

Ensure that smooth facilitation of the process of service delivery is in place all

the time. 39

Further research is important in assessing how can the academic community

help to improve the quality of care in Zanzibar? We argue that four sets of

research questions need to be addressed, which we will treat in turn in the

following section.

The first question is how can QA best be implemented and what are the effects

on quality improvement? Such questions are the domain of operational

research. Quantitative and qualitative methods should be combined to analyze

the quality of the management and the delivery of PHC services in first-line

health facilities in Zanzibar.

A second set of research questions should shed more light on the assumed relationship

between the process of care and health outcomes. Studies should also be conducted at

the population level, in order to corroborate and quantify the assumed association

between the quality of care and population outcomes, such as mortality or morbidity.

Appropriate, low-cost techniques have been developed to assess the age- and cause-39 URT. July 2005: Communication Strategy for the national Strategy for Growth and Reduction of Poverty 2005/06-2009/10 as strategy that enables all stakeholders to take part effectively in poverty reduction and in this case all sectors, communities, villages, individual families and individuals.

Jan 201041

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specific mortality and incidence in Zanzibar through a prospective, population-based

design.

A third set of research should probe into the assumptions underlying the relationship

between quality of care and other health system variables such as demand, equity,

willingness to- pay, costs and revenues. Rigorous studies should compare the full

costs of quality assurance programs with their benefits in terms of cost savings and

incremental revenues. The crucial assumption that quality improvements lead to net

revenues remains still to be verified.

Another research topic is the relationship between quality and equity. Do patients of

differ in terms of income, wealth, gender or age? Do they receive care of the same

quality? If there is inequity in the quality of care, is it related to differences in the

price of care for these population subgroups? This leads us to the fourth and last

research question we suggest for future studies. How can we measure the quality of

primary care in Zanzibar? Comprehensive indicators are needed that capture both

inputs and processes and user satisfaction. Such indicators would allow a comparison

of the quality of care over time, across facilities and regions, and across different

types of providers, i.e. private, public, and non-governmental organizations. There

could all be combined in one comprehensive study.

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CHAPTER THREE CHAPTER THREE

Status of Equipment and Supplies at Lower Level of Health Service Delivery System Status of Equipment and Supplies at Lower Level of Health Service Delivery System

3.0 Overview3.0 Overview

The life cycle of a health technology (medical equipment and supplies) consists of

four main phases - provision, acquisition, utilization and maintenance. Procurement

is one of the key steps in the acquisition phase. As such it plays an important role in

ensuring that the right health sector goods (equipment, drugs, supplies etc.) are

available, in the appropriate places and in the required quantities. Good procurement

practices do not only lead to savings in acquisition costs, they also facilitate

downstream activities during the utilization phase, especially maintenance in the case

of equipment.

Drugs, medical supplies and equipment account for a high proportion of health care

costs. Health services in developing countries need to choose appropriate supplies,

equipment and drugs, in order to meet priority health needs especially for facilities at

lower levels and to avoid wasting limited resources. Making sure that health facilities

have adequate supplies, equipment and drugs is also essential if people are to have

confidence in health services and health workers. Medical supplies and equipment for

primary health care, covers effective procurement, management and maintenance of

basic supplies and equipment.

The term medical supplies mean different things to different people, and the

distinction between supplies and equipment is not always clear. In this report, we

have defined medical supplies and equipment as follows:

■ Supplies – items that need to be replaced on a routine basis, including: disposables,

single use items, e.g. disposable syringes and needles; expendables (sometimes also

called consumables), items that are used within a short time, e.g. cotton wool,

laboratory stains and tape; reusable items, e.g. catheters and sterilisable syringes;

and other items with a short life span, e.g. thermometers.

■ Equipment – capital equipment and durable items that last for several years, e.g.

beds, examination tables, sterilizers, microscopes, weighing scales and bedpans.

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3.1 Introduction

Equipment, drugs and supplies are very essential in care and treatment of various

diseases. In order to achieve MKUZA particularly Goal II, we need to invest more in

drugs, equipment and supplies. For the nation to realize healthy people; appropriate

and essential drugs, equipment and supplies need to be available and accessible to the

community through the health facilities.

3.1.1 Lower level health facilities

Lower level Health Facilities are the primary level of Health Care Delivery which is

comprises of Primary Health Care Units (PHCU) Primary Health Care Units +

(PHCU+)and Primary Health Care Centers (PHCC) which provide the following

health services40:-

Outpatient services, which include management of STI, IMCI and other

common diseases and injuries.

Maternal and child health services, which include growth-monitoring,

immunization, antenatal, inter natal and postnatal services.

Family planning and youth friendly services

Dental services ( only for PHCU+ and PHCC)

Health education and counseling

Environmental health services

Outreach services/community based health care services (including home

based and aging health care)

Inpatient services (only for PHCC)

Laboratory services including blood transfusion services

Antenatal, intra natal and postnatal services,

Consultation of special conditions/illness e.g. surgical, medical, pediatric

and gynecological care

Community health services including community based home care

Rehabilitation services

Minor surgery ( only for PHCC)

40 Human resource for health5 -year development plan 2004/05 – 2008/09 October, 2004

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3.2 Zanzibar health delivery system and its mechanism.

Zanzibar’s current Health Policy was passed by the House of Representative in 1999.

Health delivery system was among the priority areas addressed in this policy in order

to achieve better health services at all levels. This policy put emphasis on eessential

drugs, rational drug use and equipment.41

Presently Zanzibar does not have its own pharmaceutical industry; all of its

pharmaceutical demand is met through importation. There are two main sources of

drugs importation and the other used by the private sector through private source

importation and second used by the government-public institutions through the

Central Medical Store. The drugs, medical Supplies and equipments for the Public

sector are managed by the Drug Management Unit through the Central Medical Store

(CMS) in Unguja Island as its headquarters and Zonal Medical Store in Pemba. CMS

is the body responsible for the storage and distribution. The Drug Management Unit

is the overseer of the public pharmaceutical and equipment supplied from the central

level to the facility level. Zonal and District materials managers are responsible for

the supervision and distribution of drugs and medical supplies for the facilities. At the

facility levels, pharmaceutical assistants and other health workers are responsible for

the management and dispensing of drugs and medical supplies to the patients42.

The main donor supporting CMS (both financially and technically) is DANIDA

through the Health Sector Program Support (HSPS). Even the distribution of

equipment and supplies to the lowest level is supported by DANIDA. Apart from

paying salaries of the public civil servants working in CMS, the Government support

is minimum except during catastrophic emergencies like disease outbreaks when the

government supports actively. In such cases procurement of drugs is done in an ad-

hoc manner from private pharmacies as an immediate and short term solution while

waiting for procedure through MSD as a long time solution.

It was also revealed by a senior officer that the present budget for drugs and

equipment is highly donor dependent. This is alarming and should be considered as a

national security threat which should be urgently addressed. A good case to learn

41 Zanzibar Health Policy 199942 Zanzibar Pharmaceutical Sector Strategic Plan, 2007/8 –2011/12

Jan 201045

DRAFT

from is when DANIDA pulled out from supporting Zanzibar in 199543 which resulted

into the total collapse of the health system.

The CMS usually develops a yearly budget and plan of action which includes all the

country’s requirements and forwards it to DANIDA, who later pays MSD from the

Zanzibar –DANIDA account to deliver the goods to CMS.

3.2.1 Lower level health delivery systems

Health delivery services in Zanzibar are divided into Primary, Secondary and Tertiary

levels.

1. Primary level (Level 1)

This is the lowest level of health care delivery in the public health care structure.

It comprises the Primary Health Care Units (PHCU and PHCU+) and Primary

Health Care Centesr (PHCC).

2. Secondary level

Is the referral point from Primary Health facilities comprising of District Hospitals.

All these are located in Pemba (Wete, Chake Chake and Mkoani Hospital) and none

in Unguja.

3. Tertiary level

Mnazi Mmoja Hospital is the only tertiary hospital which is located in Unguja town

and it is the referral hospital for Zanzibar. Other specialized hospital includes

Mwembe Ladu (Maternity Home) and Kidongo Chekundu (Mental Hospital)44.

Primary level is considered the lowest level health provider, which is divided into:

Primary Health Care Units (PHCU) also recognized as the first line units

Primary Health Care Unit plus (PHCU+) also identified as second line

units

Primary Health Care Centers (PHCC) which are also known as Cottage

Hospitals

43 Zanzibar Health Policy 199944 MOHSW Performance Report,2009

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Table no 24: Distribution of Public Health Services in Zanzibar, 2009District Primary Health Care District

Hospitals

Other Hospitals

1st Line

PHCU

2nd Line

PHCU + PHCC

Tertiary Special

Urban 5 4 1 2

West 7 5

North A 9 3 1

North B 8 3

Central 18 4

South 7 2 1

Wete 17 3 1

Micheweni 8 3 1

Chake Chake 8 3 1 1

Mkoani 11 4 1

Total Zanzibar 98 34 4 3 1 2

Source: Zonal Health Management Team Unguja 2009

In 2008-2009 there were 54 PHCU in Unguja and 44 in Pemba. 21 PHCU + in

Unguja and 13 in Pemba, 4 Primary Health Care Centre, 2 Pemba and 2 in Unguja

which function as referral for Primary Health Care ( PHCU+) . In 2007 the Essential

Health Care Package reported the total number of health facilities as indicated below:-

PHCU 1 (First level) 104

PHCU 2 (Second line) known as PHCU+ 27

PHCC 4

District Hospital 3

Referral hospital 4 (the three district hospitals in Pemba are referred to as referral

hospital in Pemba)

Some of the PHCU were upgraded to PHCU+ in year 2008. Private hospitals procure

under the free market laws but the Zanzibar Drug Board has a mandate to ensure the

quality of drugs. Equipment and drugs are procured through the Medical Stores

Department in Tanzania mainland and are transported to the CMS for distribution to

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the health facilities through the zonal offices for the PHCUs and PHCCs only. The

package to be distributed to lower levels is uniform accordingly to the different levels,

(PHCUs and PHCUs, PHCC) and is referred to as the essential drugs Kit. This kit is

distributed quarterly to all facilities through the “push” mechanism without regarding

the size of the catchments area and burden of disease(trend) This may result into

either surplus or shortage (stock out) of certain supplies.

The planning process is not fully participatory since they used the push system in

acquiring the needs of primary health care facilities (PHCU and PHCU+), most of the

time only 60% of the request is fulfilled45.

Reallocation of excess drugs is done by the help of Zonal Material Managers, District

Material Managers and the CMS officers (sometimes) during their quarterly

supervision. These supervisions have resulted into an improvement of availability of

supplies since 2007..It is during these visits reallocation of supplies is identified and

done. The “pull” system (request from facilities) is being used by District Hospital

and Tertiary hospital. This reflects a more realistic demand from the district and

tertiary hospitals accordingly to the burden of disease.

3.2.2 Equipments and supplies:

The Essential Drug List is available at CMS while the essential equipment list is not a

standard list. There has been an attempt to prepare one standard essential equipment

list for all levels, which was supported by ADB but this document is not available at

present in the MOHSW. As reported by HSPS DANIDA the total amount of

1,684,219,207/- was spent for equipment, drugs and supplies in 2008/09 and budgeted

for 310,000,000/- in 2009/2010.The total expenditure for drugs, equipment and

supplies most of the time rises and surpasses the budget particularly during

emergency. On the other hand 0% was spent in 2007/08 and in 2008/09 for drug,

equipment and supplies by the Government of Zanzibar46.The above picture depicts

that equipment, supplies and medicine is not a priority of the MOHSW since it has

allocated no fund. There is an existence of the Zanzibar National Medicine list

developed in 2008 which acts as a guideline on the requisition of drugs by the CMS

45 CMS interview46 Estimate of Recurrent and Capital Revenue and Expenditure for the Year 2009/2010 Page 278

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for the lower level facilities and for the district and tertiary hospitals for the “pull”

system.

In a study done by MOHSW47 in collaboration with some stake holders 13 hospitals

were visited to see the status of basic equipment in those facilities. (Annex 3)

Table 25: Per cent of Basic equipment in health facilities by District:

 District BP-

Meter

Microscope Stethoscope Adult

Scale

Under

Five

Weighing

Refrigerator Oral

Thermometer

Resuscitation

Central 91.7 37.5 83.3 91.7 83.3 70.8 58.3 0.0

Chake

Chake

66.7 47.6 90.5 81.0 57.1 66.7 76.2 4.8

Micheweni 80.0 33.3 86.7 93.3 86.7 80.0 13.3 0.0

Mkoani 93.3 20.0 93.3 86.7 80.0 80.0 66.7 6.7

North A 85.7 42.9 78.6 85.7 57.1 85.7 57.1 21.4

North B 83.3 33.3 75.0 66.7 83.3 83.3 58.3 16.7

South 90.9 27.3 81.8 90.9 90.9 72.7 54.5 9.1

Urban 92.1 92.1 92.1 84.2 44.7 89.5 84.2 34.2

West 93.5 71.0 96.8 83.9 35.5 80.6 67.7 22.6

Wete 83.3 16.7 95.8 91.7 79.2 79.2 83.3 0.0

Source: P-SAM

The majority of facilities were seen to have an average range of more than 60% - 96%

availability per district48. Microscope and Resuscitation machine was found to be

minimal that could be reasoned by the low number of health facility having laboratory

and maternity services.

3.2.3. Equipments used for Infection Control

Autoclave and boiling pots are the most common methods of sterilization used in

Zanzibar health facilities (both private and public facilities). Almost 21% of the

visited facilities reported to use these types of methods followed use of sterilizer

which account for 16% of facilities.49

47 P-SAM 2008-0948 P-SAM 200949 P-SAM 2009

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The central district is leading for using boiling pots (almost 46%). Autoclaves are

used more in the Urban district.

Table 26: Percentage of health facility by using method of sterilization, PSAM

Autoclave

Boiling

pot

Pressure

pots Sterilizers Other

Kati 4.2 45.8 4.2 8.3 29.2

Chake Chake 28.6 19.0 0.0 33.3 19.0

Micheweni 6.7 6.7 0.0 6.7 60.0

Mkoani 13.3 13.3 0.0 20.0 53.3

Kaskazini A 21.4 7.1 0.0 28.6 21.4

Kaskazini B 8.3 8.3 0.0 8.3 50.0

Kusini 27.3 36.4 0.0 9.1 18.2

Mjini 39.5 18.4 0.0 18.4 18.4

Magharibi 25.8 29.0 3.2 12.9 22.6

Wete 12.5 16.7 0.0 8.3 62.5

Source: P-SAM 2008-2009

Fig 3: Main Types of sterilization equipment used by health facilities

Source: P-SAM 2008-2009

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3.2.4. Drug availability:

Drugs availability in the PHCUs are mostly through the essential drug kits which is

provided quarterly to all health facilities. The P-SAM studied four major drugs to see

their search its availability namely: injectable antibiotics, anti-malarial first line, anti-

hypertensive and oral re-hydration salts in health facilities at districts level .The

results showed that urban and west districts had the highest score for all the four

major drugs. This explains why patients used these facilities most frequently for

treatment. It is related to the assurance of accessing these drugs and supplies there.

Figure No 4: Drug Availability.

Source: P-SAM 2008-2009

3.2.5. Immunizations Equipment and supplies.

In order to succeed in immunization promotion the following equipment and supplies

should be available, Vaccines, vaccine cold chain and safety waste disposal kits (i.e.

safety boxes, incinerators) and well trained health and non health personnel( for

advocacy and campaigns e.g. social workers). Data by the end of 2008 shows some

improvements but the 90% target has been achieved only in few districts. (Refer to

table no Annexure )this shows that most health facilities are well equipped with

immunization supplies and equipment.

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Table 27: Availability of Immunization services by type of health facility

TYPE OF HEALTH FACILITY

NO SERVICE AVAILABILITY YES

Cottage hospital (PHCC) 4District hospital 3Other Hospital 2 1Other type of clinic 54 8PHCU (first line) 8 97PHCU (second line) 2 22Special hospital 1 1Tertiary hospital 2

Source: P-SAM 2009

3.2.6. Laboratory Equipment and supplies

The availability of laboratory equipment and supplies is satisfactory in Zanzibar.

Some districts like, (6.7%) are poorly equipped even without blood count services. In

urban district 32% of the facilities are providing blood count services which are

available to only 16%50 facilities. Hemoglobin test services are provided by 46% of

the facilities, 36 % glucose, 39% examine Malaria parasites using Giemsa stain and

22% perform RPR examination. North A, North B and South districts are not

providing RPR services. This can be because they don’t have the necessary

equipments and supplies, or no qualified personnel. There are 44 VCT center

available (public and private). HIV test can be performed in 20% of the total facilities.

Table 28 :HIV Counseling and antibody Testing District:

DISTRICTCounseling ONLY

Neither (counseling NOR testing)

Testing AND counseling Not stated

Grand Total

Central 7 6 3 8 24Chake Chake 6 7 8 21Micheweni 2 12 1 15Mkoani 7 4 3 1 15North A 10 2 1 1 14North B 7 1 2 2 12South 4 4 3 11Urban 4 15 11 8 38West 4 14 4 9 31Wete 12 8 4 24Grand Total 63 73 37 32 205

50 P-SAM 2008-2009

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Source: P-SAM 2008-2009

PMTCT services have been expanded and presently are available at all levels (not in

all facilities). 2065 people tested in 2007/8.

Records for NCD testing equipments and supplies are not available, though it is

recorded that the NCD are on the rise, and that if not well addressed immediately

they will overtake communicable diseases as the leading diseases of public health

importance. 51.

3.3. Recommendation

A Health delivery system of equipment and supplies at all levels needs to be

improved. A greater emphasis should be placed at the PHC level since it is the first

line facility. This can be done by the MOHSW showing full commitment through its

budget allocation and improving the procurement process.

1. Increase government budget to CMS as matter of urgency

o To show government commitment, for national security, ownership of

the programme and for sustainability

o To improve quality of care, by improving infrastructure, supplies

especially to PHCU ( to enter the pulling system)and motivation for

health personnel

o To facilitate regular monthly supervision and in-house training on

proper use of equipment and supplies

o To work with other stakeholders to increase community awareness of

the importance of utilization of services e.g. immunization , ARV,

VCT etc

2. To develop/adopt in a simple language training manuals for training at all levels on

the different equipment and supplies and the “pull” system (if opt to change from the

push system)

3. To develop indicators (MKUZA11) for assessing the situation of equipment and

supplies in all health facilities.

4. To develop data base at all levels to record all equipment and supplies in all

facilities. Those facilities where there are no computers; a simple manual system

51 Refer to Chapter six

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should be developed to help keep an updated list of the equipment and supplies,

recording its maintenance period and lifespan for safety.

5. To Advocate through the ministry of education to promote the increase of health

personnel e. g. Pharmacists, lab technicians to be able to work at the health facilities.

The shortages of appropriate personnel have been aired in almost all the documents

reviewed.

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CHAPTER FOUR CHAPTER FOUR

Roles Played by the Devolution of Responsibilities for Health Facilities and HealthRoles Played by the Devolution of Responsibilities for Health Facilities and Health

Planning to Local Government AuthoritiesPlanning to Local Government Authorities

4.0 Overview:

Devolution as one form of decentralization is a challenge for local government in Zanzibar. The reforms have all stressed the need for devolution to respect local government and for devolved local authorities to work in a constructive partnership.

Local governments are the most important stakeholders in the devolution reforms by providing the much needed political and material support and meaningful involvement of local community and authorities is vital in delivering devolution. .The quid pro quo of local government support for devolution has been a commitment in the devolution reforms to respect the role of local government

In Zanzibar, the form of decentralization that will be implemented is still not clear. There is still need

for clarification and a detail modus of operandi at the district level and below. Though operations are

not being implemented fully, functionally; a LGA has a legal status under the Act No 4 of 1995 In this

act, the local government legislation stipules the roles of local governments in its general terms as to:-

a) Formulate, coordinate and supervise the implementation of plans for economic, commercial,

industrial and social development;

b) Ensure the collection and proper utilization of revenue of the Council;

c) Make by-laws applicable throughout its area of jurisdiction; and

d) Consider, regulate and co-ordinate development plans, projects and programs of villages and

township councils within its area of jurisdiction.

In discussing the above roles it appears that, local governments have responsibilities to ensure the

economic and social development of the people at the areas of their jurisdiction. It is their

responsibility to provide primary services to the people at lower level.

4.1 Introduction

Devolution is a type of decentralization. Below we have looked at what

decentralization means and the type of decentralization.

4.1.1. Definition of Decentralization and types

Decentralization

Decentralization seeks to redistribute authority, responsibility and financial resources

for providing public services among different levels of governance. It is the transfer

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of responsibility for the planning, financing and management of public functions from

the central government or regional governments and its agencies to local

governments, semi-autonomous public authorities or corporations, or area-wide,

regional or functional authorities.

Decentralization brings government closer to the people and puts the decisions to

local people on resource allocation, and identification of services according to their

needs better known to them. The implementation of PHC is not possible without

decentralization because PHC must be people focused.

4.1.2 Types of Administrative Decentralization

Devolution

Devolution is an administrative type of decentralization. When governments devolve

functions, they transfer authority for decision-making, finance, and management to

quasi-autonomous units of local government with corporate status. Devolution usually

transfers responsibilities for services to local governments that elect their own elected

functionaries and councils, raise their own revenues, and have independent authority

to make investment decisions. In a devolved system, local governments have clear

and legally recognized geographical boundaries over which they exercise authority

and within which they perform public functions.

1.1.1.1 De-concentration

De-concentration is the redistribution of decision-making authority, financial and

management responsibilities among different levels of the national government. It is

merely shifting responsibilities from central government officials in the capital city to

those working in regions, provinces or districts, or it can create strong field

administration or local administrative capacity under the supervision of central

government ministries. This can be referred to as an extended hand of the central

Government.

Delegation

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Delegation is a more extensive form of decentralization. Through delegation central

governments transfer responsibility for decision-making and administration of public

functions to semi-autonomous organizations not wholly controlled by the central

government, but ultimately accountable to it. Governments delegate responsibilities

when they create public enterprises or corporations, housing authorities,

transportation authorities, special service districts, semi-autonomous school districts,

regional development corporations, or special project implementation units. Usually

these organizations have a great deal of discretion in decision-making. They may be

exempted from constraints on regular civil service personnel and may be able to

charge users directly for services. Example of such organization in Zanzibar is ZSSF.

4.2 Background to Local government in Zanzibar

In 1984, the government of Zanzibar laid downs the formation of local government,

which was stipulated in section 128(1), and (2) of the Zanzibar Constitution 1984.

In 1995, the Government of Zanzibar passed legislation to establish the Zanzibar

Municipal Council (Act number 3 of 1995), and in the same year, the legislation to

establish the District and Town Councils (Act number 4)

4.2.1 The functions and Institutional Arrangements and Structure of Local

Government

The laws that establish the local government in Zanzibar provide two categories of

local authorities - urban authorities and rural (District) authorities, as corporate

bodies. Under the first category, there is one Municipal Council (Zanzibar Municipal

Council) and three town councils (Mkoani Town Council, Chake Chake Town

Council and Wete Town Council). Under the second category there are nine district

councils (West, South, Central, North A, North B, Wete, Chake Chake, Mkoani and

Micheweni). The Local government administration is under the Ministry of Regional

Administration and Special Department (MoRASD) as shown in diagram 1. The

LGA’s then forms Municipal, town, and district councils. The Municipal council is

headed by the Mayor and for District and Town Councils are headed by Chairmen.

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Fig 5: Structure of the current Ministry of Regional Administrative and Special

Department (MoRASD)

Source: MoRASD 2009

4.2.2 Structure of Devolution and the health facilities in LGA

The health planning system was the role of central government before the 1964

revolution, and after the revolution, the government continued to plan and provide

health service to the people. At present the district through the DHMT spearhead the

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MoRASD

Department of Planning and Policy

Department of Regional Administration and Local Government

Department of Zanzibar Identity Card and Registration

Regional Administrations

District Administrations

Shehia

Municipal Council

District Council

Town Council

Department Officers Regional

Development Committee

District Development Committee

Co-ordinator of Special Departments

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planning process headed by the DMO. Through Act no 4 of 1995, the mandate to

LGA to “formulate, coordinate, and supervise the implementation of plans for the

economic, commercial, industrial and social development”52has been devolved to

Local Government. All sector officers (including the DMO) are stationed at their

councils and work under LGA authorities. At present the responsibilities and roles of

the LGA are being implemented by the different sector (vertically). Most of the

decisions are done centrally in the MOHSW leaving the minor decision to the DHMT

Collaboration of the LGA and DHMT is mostly at ad-hoc when issues arises where

all need to be involved e. g. in epidemic campaigns etc

Devolution has not taken place in the Ministry of Health. The districts works as an

extended hand of the MOHSW and not as an independent management and decision-

making body. This type of decentralization is known as de-concentration, whereby

the community does not have the power over their own facilities, management is top

down and the communities are still considered as the recipients of services and not as

most important stakeholder and owners of facilities. The DHMT is accountable to the

MoHSW and not to the LGA.

4.3 The Health Planning Process:

Health planning at the primary health level is done through the District Health

Management team headed by the District Medical Officer as part of the centralized

planning. The plan is then forwarded to the ZHMT for further discussions and

approval ready to be presented to the MOHSW for final approval to be incorporated

in the health POA. In one of the PHCU+, selected as a pilot for decentralization by the

MOHSW, was visited by the consulting team, and found that the facility and the

community had an organized community health team which was not involved in the

DHMT meetings nor had power to allocate funds for use to improve their facility

from their own revenue collected.

4.4 Recommendations for further roles devolution can play in the LGA

Social well-being in Zanzibar has traditionally been thought of as the domain

primarily of central government. Over the past two decades, this centralist model was

supposed to disappear. Local government was now supposed to have a legislated 52 Laws of Zanzibar 1995-1996 Act no 4 section 5 (1)a

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mandate to pursue social well-being; schooling and health care delivery. All these

functions were practically to be devolved from the centre. Central government

agencies should increasingly see their role as collaborative, influential, and focused

on building on the strengths of local communities rather than dictating what should

happen; the private sector should begin to accept the challenge of corporate social

responsibility. Community organizations and NGOs should be asked to play a role in

deciding on outcomes, not simply delivering outputs. The most important thing is that

communities themselves should decide their own destiny by playing an active role in

building their society from the “inside out” for sustainability.

The challenges to better social outcomes should be the priority of the LGA. The Local

Government Act No 4 of (1995) requires councils to promote “the social (including

health), economic, environmental, and cultural well-being of communities” Local

government has the opportunity and the obligation to help every citizen realize their

potential. Councils’ areas of activity should range across many areas that directly

impact on social well-being, such as the prevention of infectious disease, regulation of

gambling and alcohol outlets and other risk environments, and design facilities for

sport and physical activity.

Councils also have responsibility for areas that impact indirectly, but often

significantly, on social wellbeing. These include economic development, transport,

urban design and development, environmental planning, parks and open spaces, and

Resource Management. All these have health impacts, either positively or negatively

so they should be monitored. LGAs are in better position to do this if well

empowered.

Role of Local Government in Achieving better health for all in Zanzibar can be

implemented in two broad approaches to improve effectiveness of local government’s

involvement in social well-being including better health for all:

Option 1: a collaborative approach, which

Maintains the current accountabilities of central and local government, but

bases actions by both levels of government on a jointly agreed social and

health strategy for the medium and long term, and jointly agreed on critical

social and health issues that will be priority areas for action in the medium

term, and mandates collaborative action across all sectors

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Option 2: A community devolution approach, which gives a community social and

health bodies/committees, which would include the chief executives of central

government, social/health agencies, the power to make decisions on the social and

health strategy and critical health issues as above, and the power to

a. Decide on the redistribution of resources that may be necessary to make real

progress on their critical issues, and

b. Set performance standards for services and targets for changes in social wellbeing.

In both approaches, the social and health boards/committees should be a direction

setting, not a service delivery body. The critical difference between the two models is

that the first is based upon collaboration across sectors and on influencing central

government, and the second upon local decision-making power, where central

government agencies are part of the decision-making body. The consultancy team

recommends the second option because it really brings power to the communities and

it assures ownership, accountability and sustainability.

It is recommended that the LGA and the MOHSW

1. Accept the principles for redesign of the governance arrangements to set up a

functional LGA structure that will help achieve:

a. The attainment of health needs to be thought of as a system involving

many players.

b. The core elements of any new system should be formally mandated.

C. The need to have strong leadership and advocates for social and health issues.

d. There must be a decisive formulation of the issues, and clear public

articulation in local terms.

e. Critical capacities must be built into the structure and funded: social

mapping; analytical and research capacity; making sure the vision and values

are driven through into action.

f. Critical participation must be built into the structure and funded: for an

inclusiveness society

g. Effective consultation on the right issues is more important than

comprehensive consultation on everything or setting standards.

h. The core decision-making body must include all those who have

accountability for social and health outcomes, and can commit resources. This

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means central government must be a part of the structure, not simply linked by

process.

i. The decision-making body must be big enough to redistribute resources to

achieve health goals. This means also that the core decision-making body

should be district and local level, and local boundaries in central and local

government should be aligned.

j. Community audit should be done every year and feedback given to the

society, at the district as well as the local level.

k. Action should take place as close to the ground as is feasible and analytical

and research capacity (including place-based social mapping) should serve

district, local, and issue-specific actions.

2. All stakeholders should agree on the common elements of the new arrangements

for improving health for all at community level.

a. Minister for Health responsible for being the central champion for health in

Zanzibar has to lead the government’s decision-making processes, particularly

during the annual budget cycle

b. The district council being responsible for articulating the vision for local

communities and the values that will guide its decisions

c. Local decision-making body (the health Issues Board) whose members

would be the community members

There are important opportunities for all of these functions to contribute to

improved social well-being outcomes. Not all of these opportunities are being

realized at present. Overall, meaningful involvement of councils in social

issues is not seen to take part of in the improvement and the identification of

social well-being outcomes. Zanzibar’s should look for, greater coordination

of planning processes, and agreement with across sectors about critical social

issues.

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CHAPTER FIVE CHAPTER FIVE

Financing Mechanism of the Health Services and Regulatory Frame-work of HealthFinancing Mechanism of the Health Services and Regulatory Frame-work of Health

Insurance Schemes in ZanzibarInsurance Schemes in Zanzibar

5.0 Overview

The fundamental step a country can take to promote health equity is to move towards

universal coverage: universal access to the full range of personal and non-personal

health services that people need, with social health protection. Whether the

arrangements for universal coverage are tax based or are organized through social

health insurance, or a mix of both, the principles are the same: pooling pre-paid

contributions collected on the basis of ability to pay, and using these funds to ensure

that services are available, accessible and produce quality care for those who need

them, without exposing them to the risk of catastrophic expenditures. Universal

coverage is not, by itself, sufficient to ensure health for all and health equity -

inequalities persist in countries with universal or near-universal coverage – but it

provides the necessary foundation.

The Zanzibar public health sector is funded through a mix of financing mechanisms,

including general revenue of the Revolutionary Government of Zanzibar (RGoZ)

disbursed to the Ministry of Health and Social Welfare (MoHSW) through the

Ministry of Finance and Economic Affairs (MoFEA; external funding through

development partners (DPs),and cost-sharing, i.e. user-fees from patients53.

5.1 Introduction

Definition of health financing mechanism

Health financing refers to the collection of funds from various sources (e.g.

government, households/individuals, businesses, and donors), pooling them to share

financial risks across larger population groups, and using them to pay for services

from public private health or public private partnership-care providers54.

53 MOHSW PER- 200854 WHO, The world health report 2000: Health systems: improving performance, Geneva, World Health Organization, 2000.

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5.2 Existing Types of Health financing mechanism in Zanzibar

1. Budgetary funding

i. Government Expenditure on health (Tax revenue)

ii. External Financing of the Health Sector

2. Public private partnership

E.g. Rahaleo

3. Complementary funds

i. Cost sharing or user fees sometimes called household out

of pocket expenditure)

4. Medical Budget Management – . e.g. tourist hotels

5. Social Medical Benefits

i. Social health funds ZSSF

6. Health Insurance schemes in Zanzibar

i. Private Health insurance

ii. Public Health insurance

5.2.1 Budgetary Funding

Government Financing on Health (Domestic or Tax revenue)

Tax revenues have many advantages for financing universal health coverage. One of

the foremost advantages is that, it effectively pools health risks across a large

contributing population. In such systems, individuals contribute indirectly to the

provision of health services through taxes on income, purchases, property, capital

gains, and a variety of other items and activities. In contrast to systems that rely on

affiliation to an insurer (whether public or private), this system mobilizes funds from

everyone regardless of their health status, income, or occupation.

Though tax based financing seemed to have upper hand, it is cumbersome. At the

highest level, decisions have to be made over how much of general government

revenues should be dedicated to health services. Complaints of under funding are

common in Tax Based Systems. Spending in health is closely tird with politics and

political decisions that often force governments to weigh tradeoffs between health and

roads, education, defense and other public expenditure. When general revenues are

substantial and other needs are less pressing, the likelihood of increasing spending on

health through such a process is greater55. But the opposite is not always the case.

55 (J.P.Dunne et al.1984).

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Government and External expenditure on the Health Sector

Public spending in the health sector includes the funds from the Ministry of Finance

(MOFEA) budget allocation, development partner’s support and user-fees from

patients amounting to TSh20bn in FY2007/08. (40%- RGoZ, DPs- 59%, user fee 1%)

which equates to TSh16, 578 per capita.56Or $13.7 per capital, less by 60 percent to

what WHO target (CMH) 57(US $ 34 per capital) for an estimated basic package of

health services costs.

This falls way short of the recommended 15% of the budget by the Abuja Declaration,

and the 12% that the MoHSW included as a target in its Health Sector Reform

Strategic Plan II. Currently RGoZ budget for Health is 6 % of the total budget of

2009/2010. Looking at the trend of the budget from 2003/04 the health budget is

increasing but it has not reached the above target.

Table 29: Nominal, MOHSW spending, FY2003/04-FY2008/09(Tshs 1m)

FY2003/04 FY 2004/05 FY2005/06 FY2006/07 FY2007/08 2008/09

Bdgt Expd Bdgt Expd Bdgt Expd Bdgt Expd Bdgt Expd Bdgt

Recurrent 6,342 4,744 6,011 4,814 6,108233

5,775 6,351 6,489 8,384 7,562 9,553

Development

211 30 222 5 291 270 239 800 405 1,550

Total 6,553 4,774 6,233 4,819 6,349 6,066 6,621 6,727 9,184 7,967 11,103% growth, year on year

10% 12% -5% 1% 2% 26% 4% 11% 39% 18% 21%

Source: Study 2010

5.2.2. Complementary Financing (Cost sharing or User fees)

Complementary Financing or cost sharing is when the user pays a contribution for the

health services rendered. Cost sharing in health services was introduced in Zanzibar

as one among the strategies to sustain and develop the health sector. The scheme was

introduced as a strategy in the 1999 Health Policy, as well as in the two successive

Health Sector Reform Strategic Plans of the Ministry of Health and Social Welfare

(MOHSW). Implementation has begun in some places but is currently ad-hoc, un-

standardized, and unregulated. Cost-sharing has predominantly been introduced first,

56 MOHSW PER 200857 World Health Organization’s Commission on Macroeconomics and Health (CMH)

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for the referral level (secondary and tertiary care), and subsequently for the primary

level. I.e. Primary Health Care Centers and Units58. The scheme has encountered a

number of obstacles and challenges which resulted in ineffective introduction and

operation of the scheme. In the rapid assessment study on the ability to pay the

findings shows that; majority of Zanzibaris are financially incapable of sharing the

cost of health services due to the high level of income poverty.59

The introduction of cost sharing mechanism was aimed at generating income for

improving service provision and at the same time maintaining universal access to the

improved health care. In the same spirit of maintaining universal access, the MOHSW

put mechanisms to enable those who cannot afford to pay to be waived the fee and get

the service without discrimination. This is implemented in MMH and other district

Health facilities and pilot programmes at PHCUs for example Raha Leo health facility

where the community participated in identifying the needy who are eligible for

exemption.

5.2.3 Health Insurance scheme

This is a mandatory contributory scheme to social or private insurance schemes,

providing income replacement or supplement in case of sickness, employment injury,

disability, old age, un- employment or maternity and other family obligations are

administratively feasible to implement and enforce only when employees have legally

binding contracts with their employers.

The implementation of such schemes presents a challenge when it comes to covering

the self – employed or employees whose employment is not formalized in any legal

sense. In Zanzibar such schemes have originated from Tanzania mainland, where

they are used to cover employees who are either working in the ministries or

institutions that are in the union Government such as e.g. MOHA, BOT or MoID or

for the companies and organizations that have branches in Zanzibar with their

institution being covered from the mainland e.g. international organizations, banks,

etc

58 A study to define an affordable and sustainable mechanism for cost-sharing at primary level health facilities in Zanzibar 31 March 2008

59 Ability to pay study 2007

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Two schemes exists under this schemes

i) Private Health insurance (AAR, MEDEX, Strategies etc)

ii) Public Health insurance (NHIF

i) Private Health Insurance

Private health insurance is another alternative for people who can afford to pay the

premiums and would like to get health security or supplementary insurance for

benefits which are not covered by the social health insurance system. Unlike taxation

and social security, which are commonly viewed as promoting equity, private

insurance often inflict visions of unequally access, large numbers of uninsured people,

and elite health care for the rich. Experience indicates that, unregulated or poorly

designed private health insurance systems can indeed worsen inequalities, provide

coverage only for the young and healthy, and lead to cost escalation due to the much

exclusion their schemes hold. However; well managed private insurance plays a

positive role in improving access and equity in provision of health financing schemes.

ii) Social health Insurance: formal sector

Social health insurance is part of the development of social protection, especially for

people who can contribute for health care as prepayment on a regular basis, either

through their employment benefits or by state social assistance for the population

groups who are not economically active. The process of development progresses

through stages by covering both salaried and self-employed workers and their family

dependants in both the public and private sectors.

There is an argument that; comprehensive health insurance is the major cause of cost

inflation because neither doctors nor patients have incentives to consider the cost

effectiveness of proposed treatments. Full health insurance benefits can induce the

enrollees to increase unnecessary service utilization, so called 'consumer moral

hazard’, because the insurance provides the beneficiaries with very low or no

marginal costs. In tax-funded systems, the population contributes indirectly via taxes,

whereas in social health insurance systems, workers and enterprises generally pay in

via contributions based on salaries

A move towards social health insurance (SHI) is a core element of the government’s

health financing policy. Example of the National Health Insurance Fund (NHIF) in

the mainland, was established in 1999, began its operations in 2001, and currently

covers all public servants at both central and local government levels together with up

to 5 other family members. The National Social Security Fund (NSSF), to which all

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formal sector workers contribute has developed a health insurance benefit package for

members, (this is seen by some people as a duplication of the NHIF. ZSSF) and has

also an intention of providing health /medical benefit for its members as explained

below. It is still not operational.

Zanzibar Social Security Fund was established under the Zanzibar Social Security

Fund Act, No.2 of 1998 subsequently amended by the Zanzibar Social Security Fund

Act, No.9 of 2002 and re – enacted by the Act No.2 of 2005. By law, coverage of all

employees in Zanzibar by the ZSSF is mandatory. Self employed workers can join the

scheme on a voluntary basis. The presence of comprehensive social protection is vital

in any society because every one’s income security is endangered in the case of

sickness, disability, old age, and unemployment, a death in the family, maternity or

other family obligations such as the need to provide care to children or those who are

sick.

The ZSSF does have provision for medical cover as stipulated in the ZSSF Act 2005,

the first schedule of section 26 (1) as follows;

Distribution: (2) The monies contributed by members and their employers

shall be for:

Benefits.

(a) Retirement, survivor’s and disability benefits 12.0%

(b) Medical and mate 3.0%

TOTAL 15.0%

Under this Act, the members contribute to the fund total amount of 15%, where by

12% goes to the retirement, survivor’s and disability benefits and 3% goes to medical

benefits and maternity. The average employees in the public sector receive a salary of

about Tshs 100,000/ per month. That means their contribution is about 5,000 per

month plus the employers contribution of Tshs 10,000/ per month makes up the 15%

which is contributed to ZSSF. Out of this only 3000/ goes to medical and maternity

benefits. An average Zanzibaris family consists of five members. It is not a realistic

that 3000 Tshs will be sufficient to meet the health demands of this family salary.

Since ZSSF does not work using the risk pooling model the low income group will be

more vulnerable.

NHIF

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This scheme is managed by a semi-autonomous body under the MOHSW in the

mainland. In Zanzibar it is used by the employees who are working in the union

government.

On the mainland, NHIF is funded through a 3% employee payroll deduction matched

by government contribution. The scheme has a defined benefit package, and

members are free to access services at any accredited facility of their choice.

Government facilities are automatically accredited while faith based and private

providers have to conform to MOHSW standards. Fee for service has been adopted

as the provider payment mechanism. It was stated that 88% of claims had been

reimbursed at January 2005, with providers using the revenues to improve service

quality. Private sector share of claims is slightly higher than public. NHIF scheme is

an administered by independent body answerable to the Ministry of Health;

administration costs are limited by law to 8%.

Stated benefits of the scheme include assurance of access to services for members, a

shift in attitude from apathy to ownership, and competition between providers

resulting in improved quality. Problems include limited fraud, inadequate numbers of

participating pharmacies, and failure of some public facilities to meet standards.

5.2.4 Other financing mechanisms of the Health service

i. Medical Budget Management

ii. Community based Health financing

iii. Community Based Health insurance

i) Medical Budget Management

Medical Budget Management (MBM) exists in some institutions or private companies

where the organization has a medical budget for its employees and their families

which is paid to selected health facilities.

ii) Community based Health financing (informal sector)

Community financing for health is referred to as a mechanism whereby households in

a community (the population in a village, district or other geographical area, or a

social-economic or ethnic population group), finance or co-finance the current and/or

capital costs associated with a given set of health services, thereby also having some

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involvement in the management of the community financing scheme and organization

of health services.60

MKUZA stipulates the need of introducing community-based health financing but its

implementations has not yet been realized fully. There are some pilot projects which

are at presently being implemented in various areas. The CHF is a voluntary scheme,

which enables a household to pay when they have funds rather than at the time of

illness, and members are entitled to access services at the primary health facilities and

in some councils, including the district hospital.

Currently in Tanzania mainland the CHF is operating in 69 of the 92 councils (URT

2006). Membership contributions are decided at the council level, and each household

contributes the same amount of fee, which varies between councils from Tshs 5000/

to 10,000/ Tanzania shillings per year (MOH 2005). Households are given a card that

allows them to access health care for the whole year before renewing the membership.

CHF has its own problems as experienced in the Tanzania mainland. It is difficult to

obtain consistent information on how much is generated as revenue and how much is

spent through the CHF61. Another problem with this scheme is the issue of low

enrolment rate and early drop-outs in membership,62 Furthermore, in many schemes,

enrolment has been found to go down where it was once relatively high. The scheme

also shows that in some districts such as Igunga district the majority (60%) better off

house holds joined the scheme compared to 33% of the poorest households.

Membership premiums are decided at the council level and revenues from premium

are matched by a grant from government to respond to that which is found in the

NHIF for civil servants while enhancing equity between the two schemes. Funds are

managed by the Council Health Services Board and health facility committees.

CHF revenues accounting for up to 20% of the value of Other Charges (non-salary

government funds) in some councils, are included in Council health plans, and are

used largely for quality improvements.

60 Community health Insurance, WHO discussion paper No.1 2003

61 (MOHSW TZM 2004; 2005; 2006). 62 (Chee, Smith et al.2002;Shaw 2002;Msuya, Jutting et al.2004;Musau 200 4; Mhina 2 005)

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The team feels this scheme can be used for the informal sector but emphasis on

community empowerment and involvement in the designing and management of

health services is of uttermost importance. The community has the potential role in

meeting the costs of those unable to pay through membership cards contributions and

the government (central or local) has an obligation to contribute through subsidies.

iii) Community based health Insurance

CBHI is any program that is managed and operated by a community-based

organization, other than government or a private for-profit company, that provides

risk-pooling to cover the costs (or some part thereof) of health care services.

Beneficiaries are associated with, or involved in the management of community-based

schemes, at least in the choice of the health services it covers. It is voluntary in

nature, formed on the basis mutual aid, and covers a variety of benefit packages.

CBHIs can be initiated by health facilities, NGOs, trade unions, local communities,

local governments or cooperatives and can be owned and run by any of these

organizations.

The system tends to be pro-poor since they strengthen the demand for health care in

poor rural areas, and enable low-income communities to articulate their own

healthcare needs. CBHIs face constraints related to their small size, limited access to

management and technical insurance skills, and by the quality and accessibility of

local health care service providers. CBHIs often fail, and when this occurs, it is

usually due to weaknesses in management, financing, or a combination of the two. In

addition, the poorest groups are unlikely to become members of CBHIs because they

are generally unable to afford the premiums.

5.2.6 Health financing schemes regulatory system

There is, no specific regulatory framework for private health insurance or social

health insurance, thus in practice, the General Insurance Act of 1996 is used. This

regulates all kinds of insurance firms in Tanzania mainland and Zanzibar. The ethical

part of the schemes is regulated by the Medical Board, which practically does not

have the mandate to hold the private insures accountable. The lack of a separate

health insurance regulation of these schemes is a growing concern in Tanzania

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(MOHSW 2007) because such schemes are largely left to operate with little oversight

or co-ordination.

The Tanzania CHF Act of 2001 gives direction on the implementation of the

Community Health Fund and more importantly it directs all the councils to initiate the

implementation of the Community Health Fund. Some have argued that the

mandatory nature of the regulation (installed before the scheme had embedded itself

in many districts), may in itself pose a challenge for the development of the CHF,

since it does not allow flexibility in the way the schemes are organized in what is

often seen as very different settings. Community based health Insurance schemes

(CBHI) are registered as NGOs and registration is regulated under the Non-

Government Organizations Act, of 2002.

5.3 Recommendations:

There is an urgent need to search for an appropriate health financing mechanism that

is suitable for the Zanzibaris and culturally accepted. From the options described

above and from other existing schemes, there is not one scheme that will fit the entire

population of a country. A mix of schemes has got to be designed so as to have an

inclusive programme that will carter for all. Some of the things the schemes need to

consider are the employment status that is those who are in formal employment and

those in informal employment and those who are un-employed. Secondly the scheme

has got to consider the social status of the community it wants to serve.

In order to have evidence based decision making scheme it is suggested that a

complementary study to harmonize the studies already done (cost sharing (ability to

pay) study, waiver scheme etc) is needed. This study should involve both the

community and the employees. It should also involve the ZSSF, MOHSW,

MOLYWC, MOFEA, and other direct stakeholders to see where the different

schemes could collaborate and where they could compliment each other in the

intention of having a wide coverage. The following are, recommendations regarding

the nature of schemes to support access to services for various social groupings:-

5.3.1 Recommendations for Government and External Financing

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1. There is need to focus on public financing on subsides for the poorest public and

primary health care; and for the creation of community and social health

insurance, so as to reach the majority of Zanzibar’s population

2. With public funding, it is important to consider not just mobilization but also the

allocation of resources; in terms of equity.

3. Concerns were raised regarding the share of public funding actually reaching the

primary Health level (dispensary, health centre); some felt that there is a lack of

transparency in the disbursement and reporting; and in allocation between

administration and health service delivery; More funds should be allocated to the

PHC for prevention and primary care which is cost effective and it will limit

expenditure in secondary care

4. Dependency on external resources is perhaps inevitable, but problematic, due to

the lack of predictability, and the potential of changing of priorities by donors.

The example of the new “funds” (e. g. GFATM, GAVI, PEPFAR) for selected

diseases and their relative restrictiveness should be noted in the light of the 1995

lesson where health budget support was cut for political reasons.

5. Continued advocacy for increasing the health sector budget share towards the

agreed Abuja target as well at achieving WHO target spending on health;

6. More attention must be focused on improvement of income tax system as other

taxes are already quite a heavy burden and tend to be regressive;

7. Further research on the potential (and disadvantages) of funding through private

foundations and agencies, and public-private partnerships should be done.

8. Continued efforts to strengthen the efficiency and equity of existing resource use,

with the allocation basis for drugs and medical supplies, and incentives to retain

health workers. This has been highlighted in most of the documents reviewed and

the sites visited as areas needing further attention.

5.3.2 Community Health Funds and Community based health insurance and

cost sharing

1. CHF is an appropriate financing mechanism particularly for poorer, more rural

populations so it must be encouraged.

2. Introduction of CHF is advised in terms of exemption and waiver

implementation to ensure both broader risk pooling and protection for the poor

and other priority groups

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3. Improved information and sensitization is required in order to ensure that the

population is cognizant of the availability of free services for some groups

while at the same time acknowledging the continuous challenges that the

sector confronts in the areas of funding and human resources for health;

4. Train communities to conduct fund raising through community activities, DP

or matching grant schemes or from other Stakeholders to support their

initiatives when initiating, expanding or when rolling -out. CHF schemes

5. Need for transparency on cost-sharing revenues and expenditures to the

community (accountability).

6. There is a need to empower the communities to have greater ownership and

decision making on their local facility e.g. expenditure in the facilities for

sustainability

7. Use of revenues to cross-subsidize service delivery, from less to more poor,

from more to less healthy;

5.3.3 Recommendations and way forward for insurance

1. To undergo a participatory survey to study if such a system as NHIF could be

replicated but tailor made and replicated to fits the Zanzibar culture or if ZSSF

could review its investment policy to improve focus on health-related

projects, and to enhance its benefits to reduce need for referral abroad.

2. The need for establishment of a body to regulate the health insurance industry

and the assurance of consistency between the different schemes before the

establishment of an insurance scheme and for the private schemes that will be

introduced in Zanzibar

3. Attention is required to ensure that competition is efficient, rather than having

schemes which result in double-taxation and duplication;

4. Decision is required early on what an affordable benefit package would be

suitable of leaving it opens for the private sector to maximize on profits while

excluding others (elderly, HIV infected, people with chronic illness etc).

5.4 Way Forward

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From all the schemes that are being implemented in Zanzibar (and under the union) a

programme audit is suggested so as to take stock of all the existing schemes and the

performance and progress, then to evaluate and consolidate those options. Points to

bear in mind include the principles of “fair financing”, i.e. protection from

catastrophic cost; distribution of the burden of finance according to ability to pay; and

of benefits according to need.

There is a need to improve both the quantity and quality of information for monitoring

and evaluation of financing mechanisms, including the need for disaggregated data to

better explore who, if anyone, is being excluded.

Accepting that government subsidy towards the universal coverage of the population

in one or other insurance scheme is probably the ideal, other actions towards this

include clarification and the role of the regulator, and priority to be given to

identification of the poor for waivers, with government subsidy of CHF cards for a

period of two years for those identified

The breadth of coverage – The proposed social health insurance should be

proportionally to the population that enjoys social health protection must expand

progressively to encompass the uninsured, i.e. the population groups that lack access

to services and social protection against the financial consequences of taking up

health care.

The depth of coverage must also grow, expanding the range of essential services that

are necessary to address people’s health needs effectively, taking into account demand

and expectations, and the resources society is willing and able to allocate to health.

The determination of the corresponding “essential package” of benefits can play a key

role, provided the process is conducted appropriately.

The third dimension, the height of coverage, i.e. the portion of health-care costs

covered through pooling and pre-payment mechanisms must also rise, diminishing

reliance on out-of pocket co-payments at the point of service delivery.

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5.5 Conclusions

Access to funds at the time of illness is a critical issue for households in Zanzibar, and

one that causes short and long term difficulties for families. Health insurance for

those who can pay premium, is regarded as the best method to protect households

from health payments that may be disastrous, and a move towards social health

insurance should be the core element of the Government’s health financing policy.

There is a strong feeling within the Zanzibar community that those who are able to

contribute should contribute. The CHF, in particular, is seen as the main way of

attaining universal coverage for the poor especially in the rural communities, since it

can have the widest coverage.

There is also a need to address equity concerns between the proposed CHF and other

prepayment schemes given that, for example, NHIF members in Tanzania mainland

receive a subsidy, which substantially exceeds the annual per capita spending on

health.

The objectives of health financing are to make funding available, ensure choice and

purchase of cost effective interventions, give appropriate financial incentives to

providers, and ensure that all individuals have access to effective health services63.

Thus health financing, has the objective of ensuring that sufficient financial resources

are made available, so that people are guaranteed access to effective personal and

public health care. The mix of social insurance like NHIF, Private insurance and CHF

could all work to serve the different groups in Zanzibar. MKUZA11 should stress on

developing an alternate financing mechanism to support the over burden health sector.

CHAPTER SIX CHAPTER SIX

63 Carrin G,James C, Social health insurance: Key factors affecting the transition towards universal coverage, International Social Security Review,58(1):45–64,2005.

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Factors behind Little Progress in Some Health Indicators eg Maternal and NeonatalFactors behind Little Progress in Some Health Indicators eg Maternal and Neonatal

MortalityMortality

6.0 6.0 Overview

Regular progress reports from health facilities are one of the tools used to determine

how well health sector performs according to the Plan of Action (PoA) inline with

MKUZA, MDGs and Vision 2020. It provides both qualitative and quantitative

information on achievement, constrains encountered during implementation and

funding sources. What is lacking in the regular reports is the community/stakeholders

audit to be incorporated in the Monitoring and Evaluation of health indicators.

6.1 Intoduction

In order to highlight the factors responsible for little progress in some of the health

indicators it is necessary to go through the health indicators set by Zanzibar National

Strategy for Growth and Reduction of Poverty MKUZA. These indicators have been

developed to guide prioritization of interventions that have been stipulated in the

Millennium Development Goals, Vision 2020. All of which have targets and goals64

which address MNCH issues.

In the given health indicators, maternal, newborn and child health care are among the

priority interventions in the Health Sector Reform Strategic Plan II (2006-2011)

aimed at improving quality of life of women, newborns, children and adolescents.

The major elements of care includes antenatal, delivery, newborn, postnatal, child and

family planning.

Despite efforts to improve provision of quality health services, the question of

maternal, newborn and child mortality remains a leading public health problem in

Zanzibar with little progress. Most of the maternal and child health services are

provided at the primary health level (PHCUs and PHCCs) where the quality of services

is still weak 65

Table. 30: Selected MKUZA health indicators

Selected MKUZA / MoH&SW indicatorsBaseline MKUZA data

Target (2010)

2004-2005 2007 200866

64 MKUZA Targets and Goals (See Annex 3)65 Chapter two- Status of PHC

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TDHSA. Infant and Child HealthInfant mortality rate per 1,000 live birth 61 57 61 - 54*Under-five mortality rate per 1,000 live birth 101 71 101 - 79*Proportion of fully immunized children under 1 year Percent

85 95 85 85.9** 89.1*

B. Maternal and Reproductive HealthMaternal mortality ratio (per 100,000 live births) 377 251 468** 365** 422**% Births attended by skilled attendants 49 60 49 42.5** 44.5**% contraceptive prevalence rate for modern method 10 15 9 - -% contraceptive prevalence rate any modern method 15 20 15 - -C. Communicable Diseasesi)MalariaPercentage of under-fives having prompt access to and receiving appropriate management for febrile illness

13 70 48.3 - 34*

% Percentage of under-fives sleeping under ITNs 37 90 21.7 - 58.5*% Malaria Case Fatality Rate 2.1 0.5 - - 3.3**ii)HIV and AIDS% HIV prevalence among 15-24 years – pregnant 1 0.5 1 - 0.5**Proportion of population with comprehensive correct knowledge of HIV and AIDS for women

44 80 44.6 - 29*

Proportion of population with comprehensive correct knowledge of HIV and AIDS for men

20 80 23.2 - 30*

% of condom use among women at last higher risk sex 34 80 - - 18.6**Proportion of the stigma surrounding HIV and AIDS population (expressing acceptance of 4 measures of attitude as per TDHS)

76 60 26.4 M22.1 F

- 43* men34.4*female

iii)TB% TB death rate 8 5 - 6**% TB cure rate 80 85 - 82**% HIV screening in TB patients 20 100 - 96**D. Non Communicable Disease (NCD)Prevalence survey for NCD - - - - -E. Substance Abuse - -Prevalence survey for Substance Abuse - - - - -Operationalised detoxification and rehabilitation services for substance abusers F. Human Resource ManagementPrimary Health Facilities established agreed norms for trained staff with attention to gender

- - - - -

6.2 Infant and Child Health

6.2.1 Neonatal Health

This section will include infant Health referring to a child from birth to 72 hrs. Child

health refers to a child from 1-5years of age.

66 * Tanzania HMIS, 2007-2008.

** Derived from health facility based data

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In Tanzania including Zanzibar, the causes of newborn deaths include infections (28

percent), premature birth (27 percent), asphyxia (26 percent), congenital anomalies (7

percent), diarrhea (25 percent), tetanus (2 percent) and other causes (7 percent)67. It is

also observed that newborn services are currently almost non-existent in Zanzibar. 68

The factors contribute to the high number (28%) of neonatal deaths from infection

includes under-recognition of illness, delay in care seeking by the family, and lack of

access to appropriately-trained health workers and the absence of quality services to

manage the illness. Even if quality services are available, the cost of treatment is

beyond the reach of many. It is particularly poignant that many neonatal deaths occur

in the community, without the child ever having had contact with the health services

they needed.

Figure: 6 Estimated Causes of Neonatal Deaths

Source: Lawn JE, et al, Opportunities for African Newborn 2006, based on

TDHS 2004/05 data

6.2.2 Infant mortality

Infant mortality has shown only a slight decline in the last decade. Factors leading to

deaths of children below five years are mostly preventable and avoidable if

symptoms of their ill health are detected early; a home remedy is provided or if

referral is done in a timely manner. Causes of infant mortality are similar to the

general cause of children under five. Similarly at health facilities, correct and

67 TDHS 2004/05

68 WHO Report 2004/2005 and ZACP 2004/2005

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prompt treatment is delayed due to a weak health system, awareness of the early

symptoms and lack of appropriate skills.

Evidence shows a significant reduction in infant mortality from 75 per 1,000 live

births in 1996 to 61 per 1,000 live births in 2004 to 54 in 2008 and a slight decline in

under five mortality from 107 to 101 in 2005 to 79 in 200869. The ongoing health

promotions, IMCI, PMTCT and malaria decline are some of the factors responsible

for positive progress. Despite this progress, other diseases namely Pneumonia and

URTI have increased. If not address adequately it will wipe the success already

achieved.

6.2.3 Under 5 yrs childhood diseases

The common childhood diseases are namely, Diarrhea, Acute respiratory infections

(including pneumonia) malaria and measles. Anemia is now recognized as an

important cause of morbidity and mortality in African children admitted to hospitals

but is rarely cited as a cause of death outside hospitals. This is probably because the

diagnosis of anemia by verbal autopsy and morbidity interviews in the community is

unusual and unreliable. Health promotion is needed to increase here.

Table 31: Incidence of under 5 yrs childhood diseases 2007 Vs 2008 (health

bulletin 2008)70

Zone

Diarrhea Pneumonia URTI Malaria* Measles

2007 2008 2007 2008 2007 2008 2007 2008 2007 2008

Pemba 10.2 15.5 24.3 28.0 20.0 35.2 22.8 0.7 0.2 0.2

Unguja 16.0 21.7 32.3 36.3 34.9 44.3 22.0 2.5 0.0 0.1

Zanzibar 13.4 19.0 28.7 32.7 28.1 40.3 22.4 1.7 0.1 0.1*Note: In 2007 Malaria data were based on both clinical and confirmed which implies Malaria was over diagnosed

using syndromic management, while in 2008 only confirmed cases were considered.

Diarrhea Diseases

Diarrhea – Has a prevalence of 19.0 percent in 2008, compared to13.4 percent in

2007. One of the reasons is the problem of clean and safe water supply facing

Zanzibar. Among those with diarrhea only 36 percent of children were reported to

receive ORS.

69 Page 28 Health sector performance report 200970 PSAM 2008/09

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Acute respiratory infections account for eight (8) percent of childhood illnesses in

Zanzibar71, among which 66 percent received treatment at a health facility thus 34

percent do not receive treatment from the health facility. This could be one of the

reasons why there is an increase of childhood diseases. Reasons why the 34 percent

do not attend health facilities must be further explored and addressed.

Pneumonia and URTI

These two are among the top ten diseases in Zanzibar; Pneumonia has increased from

28.7 in 2007 to 32.7 percent in 2008 while URTI has increased from 28.1 percent in

2007 to 40.3 percentage in 2008. These diseases have portrayed increasing trend by

becoming the first and second leading causes of morbidity respectively, replacing

diseases like malaria and diarrhea which had previously leading.

Malaria

Due to the comprehensive interventions done in Zanzibar from 2007 to-date, a

remarkable decrease has been noted. Malaria prevalence rate has dropped from 22.4

percent in 2007 to 1.7 percent in 2008. This is a best practice; the strategies used

could be used to address the other health indicators.

6.2.4 Immunization

Fully Immunization coverage for children less than 1 year has increased from 85

percent in 2005 to 89.1percent in 2008. However, the target for this indicator was to

reach 95 percent by 2010. Target will be reached if services will trickle down to the

rural community but due to low number of trained health workers.72

Table 22: Immunization coverage under one year by zone, 2007 vs. 2008

2007 2008 2007 2008 2007 2008 2007 2008Pemba 89.7 98.6 65.4 71.7 73.3 73.4 77.8 72.6Unguja 111.5 121.1 91.4 89.0 100.7 97.2 93.1 94.6Zanzibar 101.3 111.0 79.2 81.2 87.9 86.5 85.9 84.7

Fully immunisedMeaslesZone BCG DPT-HepB 3

Source: Health Bulletin 2008

71 TDHS 2004/0572 Health Bulletin 2008

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The above table shows a decline from 77.8 percent in 2007 to 72.6 percent in 2008 for

Immunization coverage under one year while for Unguja an increase from 93.1 in

2007 to 94.6 in 2008.

6.3 Maternal and Reproductive Health

This includes: antenatal care, malaria in pregnancy, delivery care, postnatal care,

Family planning, adolescent health, PMTCT, Maternal mortality and morbidity and

post abortion care

ANC

Antenatal care monitors health during pregnancy, as well as the health and

development of your baby. It can help predict possible problems with pregnancy or

the birth, so action can be taken to avoid or treat them. It is also a place where

expecting mother are educated about the various issues concerning their pregnancies

and their child. ANC should start from 8-12 weeks of pregnancy to gain the

comprehensive value of ANC.

Table 33: ANC first visits (< 20 weeks): Coverage by zone, 2007 vs. 2008

2007 2008 2007 2008Pemba 96.0 83.5 32.0 27.3Unguja 88.0 95.2 41.0 37.6Zanzibar 93.0 90.7 38.0 33.9

ZoneAntenatal first visit coverage First visit before 20 weeks rate

Source: P-SAM 2008-2009

Statistics show that overall first visit (which is the percentage of pregnant women

receiving ANC check up at least once during pregnancy) coverage is high, but early

booking before 20 weeks for ANC services shows decline trend(only 12%)73. Some of

the reasons being poor quality of services, this situation needs to be look into

critically to find the cause and address the problem.

6.3.1 Maternal Mortality

73 Road map for the acceleration of maternal and child health mortality in Zanzibar 2008

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The Maternal mortality ratio (MMR) base line indicator was 377 deaths per 100,000

in 1999 to the target of 215 per 100,000 deaths by the year 2010. The trend is seen to

increase from 377 - 1999, 468-2004/05, 528 -2006, 365-2007).422-200874.

Table 34: Institutional maternal mortality ratio by zone, 200875

ZoneTotal Live births

No of Maternal deaths

Ratio per 100,000 Live births

Pemba 5177 22 425.0Unguja 15450 65 420.7Zanzibar 20627 87 421.8

Reasons for maternal death

Maternal mortality in Zanzibar, mainly a result of severe bleeding during and after

delivery and eclampsia, exacerbated by inadequate skilled attendants, a negative

attitude among staff and lack of facilities in primary healthcare units.

The four major direct causes all maternal deaths which are:

Severe bleeding-Hemorrhage (mostly bleeding postpartum), 28%

Unsafe arbotion-19%

Infections (also mostly soon after delivery)-11%,

Eclampsia -17% and

Obstructed labour.-11%

All these cases are exacerbated by inadequate skilled attendants, a negative attitude

among staff and lack of facilities in primary healthcare units.

Other indirect causes are:76

HIV and AIDS

Poor quality care at some health facilities resulting into poor utilization of

services (inadequate equipments and supplies referred to chapter three)

74 Health bulletin 200975 P-SAM 2008-200976 Factors inhibiting utilization of RHC-2008, and Road map to accelerate the reduction of maternal newborn and child mortality in Zanzibar 2008-2015

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Poor utilization of FP services ( some FBO consider sin using contraceptives)

Poor women empowerment,

Lack of adequate skilled attendants

Religious and traditional myths e. g. old age stigma

Socio-economic factors e.g. poverty, illiteracy, women abuse being

overworked during pregnancy especially in rural area etc

Malaria

Anemia

6.3.2 Births attended by skilled attendants

Births that have been captured in the different surveys were only institutional births

which is all assumed to be done by skilled attendants. Home delivery might be done

by skilled or nor skilled attendant eg TBAs.

Birth delivery in health facilities has increased from 37.0 percent in 2007 to 39.7

percent in 2008. This shows a slight increase from 2007 to 2008 but from the baseline

data shows a decrease from 49 percent- 200577 to 37 percent in 2007 to 39 percent in

2008. Identified cause of this are harsh language of service providers, absenteeism of

health work from their workplaces, poor referral system, inadequate male

involvement in RHC, lack of money to pay for service and delivery kits and transport

and corruption.78 Other factors are the same as the ones listed above as the causes of

indirect causes of maternal mortality

77 MKUZA baseline78 Factors inhabiting utilization of RHS in Zanzibar-2008

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Table 35: Institutional births and births attended by skilled personnel, 2007 Vs

200879

Zone

Deliveries by health staff

(%) Institutions Deliveries (%)

2007 2008 2007 2008

Unguja 50.4 52.5 46.3 47.8

Pemba 29.8 31.7 23.8 26.7

Zanzibar 42.5 44.5 37.0 39.7

Note: Deliveries by health staff includes both at home and at facility.

Fewer than 50 percent of the pregnant women in Zanzibar give birth in health

facilities; the rest give birth at home with mostly assistance from traditional birth

attendants, this contributes to the maternal and child mortality.

6.3.3 Contraceptive Prevalence Rate (Family Planning (FP))

Studies have shown that the use of FP can reduce maternal mortality by a quarter.80

With infant mortality remained high at nearly 10 deaths per 1,000 live births. Close

to one-quarter of all births are unplanned and 40 percent of women remain in dire

need of reproductive health services.81 In Zanzibar, the high fertility rate combined

with the low contraceptive prevalence rate (for all methods the data remain constant at

15 percent as the base line set – for modern method 9 percent which drop from 10

percent base line of MKUZA82) increases the lifetime risk of maternal death. A high

proportion of women (31%) have an unmet need of FP due to irregular and erratic

supply of contraceptives and the limited choice83.

6.4 Communicable Diseases

6.4.1 Malaria

79 Health bulletin 200880 Fredman 2004-200581 IRIN Africa/Tanzania-200982 Road map to accelerate the reduction of maternal, newborn and child mortality in Zanzibar 2008-201583 Road map to accelerate the reduction of maternal, newborn and child mortality in Zanzibar 2008-2015

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There is increasing evidence that aggressive malaria control is having a large impact

on all-cause child mortality. Significant reductions in mortality are now being

demonstrated in parts of Zanzibar where target levels of intervention coverage have

been achieved. In some cases these reductions are even greater than expected from

prior data. This suggests that aggressive malaria control could be the leading edge for

many African countries to reach, by 2015, the target of a two thirds reduction in child

mortality as set forth in the Millennium Development Goals and thus meet MKUZA

targets.

Under five having prompt access to and receiving appropriate management for febrile

illness.

Malaria is the common cause of fibril illness in Zanzibar which can cause febrile

seizure resulting into convulsions in children. With an integrated package of malaria

interventions supported by multiple partners and stakeholders over the past five years,

Zanzibar has made dramatic strides in controlling malaria. In fact, compared with

five years ago, malaria is now rare.

This indicator has shown improvement due to the decrease in malaria incidences

which was among one of the contributory factor, massive awareness through media

and MCH clinics, (resulted into families stocking malaria drugs) at home resulting

into prompt treatment availability of malaria drugs/syrup funded by Global Fund for

HIV and malaria and USAIDS. Health human resource development to the PHC level,

malaria diagnostic equipments which all of these interventions has contributed to the

improvement of the above indicator from 13 percent in 2005 to 34 percent in

2007/2008. The MKUZA target was set to reach 70 percent by 2010; this requires

serious measures to reach the target.

Percentage of under five Sleeping under ITN

This indicator has slightly increased from 37 percent in 2005* to 58.5 percent in

2007/2008. The progress is said to be satisfactory but still has not reached the

MKUZA target of 90 percent by 2010. The improvement was the result of the

community based massive awareness campaign which involved all stakeholders and

subsidized mosquito net under the voucher scheme. More campaign is needed to help

reach the given MKUZA target.

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Malaria fatality rate

A newborn starts being vulnerable to malaria at four months of age when the maternal

immunity to diseases diminishes. Children infected with the parasite will then start

getting two to five malarial fevers every year. In fact, addressing child health cannot

be done without addressing malaria. With the recorded dramatic success in

combating malaria; through unity and determination Zanzibar has also reduce

maternal and child deaths that was caused by malaria though other causes remain

high. Malaria fatality rate has shown to decrease of the from 2.1 percent in 200584 to

1.5 percent in 2008 percent but the indicator is still behind the target set at 0.5

percent by 2010. It is assumed that by 2010 this indicator will reach the MKUZA

target as success are continuing been seen from health facility reports.

6.4.2 HIV/AIDS

HIV Prevalence among 15 to 24 years pregnant women

This had a baseline of 1% in 200585 and the target for 2010 was 0.5 %. This target has

been accomplished in year 2008. This a result of improvement of HIV services

including expansion of PMTCT service and the availability of free ARV in at list one

facility in 60% of the districts.86 HIV centers have increase since 2005, training of

counselors, peer educators and medical. HIV counseling and testing is widely

available in all district hospitals, PHCC and some selected PHCUs

Proportional population with comprehensive correct knowledge of HIV and AIDS.

This target has been segregated into gender, from 20% -2005 to 80%-2010 and 44%-

2005 to 80%- for men and women respectively. In the year 2007/08 awareness for

women has decrease to 29% and men increased to 30%.87 A number of initiatives

have been going on e. g. Media programs, school and workplace programs, MCH

awareness programs etc PEs and counselors have been trained. Though BCC is

usually very difficult to measure and quantify but it is translated into outcomes which

can be measures e.g. VCT and PMTCT rates increasing, proper use of condoms

increasing, Decreasing of STI case, families talking openly about HIV and AIDS etc

84 *MKUZA base line85 MKUZA baseline86 P-SAM 2008-200987 HIV/AIDS and Malaria indicator survey 20o7/08

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Increase condom use among women at last higher risk sex

The baseline data is 34% in 2005 and the target is 80%.by 2010. 2008 data shows a

decrease to 18.6%.

This is difficult to measure being behaviour; data relies on the person telling the truth.

Condom utilization can be one of the indicators, but this again does not always

translated to condom use.

Stigma surrounding HIV and AIDS

Stigma is one of the factors known to hinder the efforts for preventing HIV in the

community. Self stigma is also seen as a factor contributing to low utilization of

available health care services. The MKUZA baseline (the proportion of stigma

surrounding HIV and AIDs population using attitude indicators) was 76% and the

target set is to reduce it to 60 by the year 2010. From the 2004/05 TDHS data it

shows that stigma in women was 22.1% and in men was 26.4 %while in 2008 stigma

data shows that stigma in men is 43% and in women is 34.4 %(health bulletin 09).

The stigma rates shows to decline but still it has not reached the MKUZA targets of

60% by 2010.The main reason is the lack of comprehensive awareness programs

especially down to the communities at lower and to the risk groups eg drug users

and homosexual.

6.4.2. Tuberculosis

The number of newly diagnosed TB patients has been almost static since 2000, at

slightly over 350 patients in 2000 to 369 in 2007. In 2008, a total of 428 patients were

diagnosed, among them 407 (95%) were new patients. Out of 428 new patients 265

(65%) were smear positive, 69 (17%) smear negative and 73 (18%) were extra

pulmonary TB patients. A total of 21 re-treatment patients registered during 2008,

among them 14 (66.7%) were relapse and 7 (33.3%) were failure and return to

control.

TB-Death rate

This MKUZA indicator’s baseline is 8% and the target is 5% by the year 2010. The

indicator shows an improvement and in the year 2008 the rate was 6%. This

improvement may be due to expanded service from specialized hospital to all public

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health facilities and in some selected private Health facilities88 Intensive training

done down to the shehia- meaningful involvement of the community, awareness

campaigns,

TB- Cure rate

MKUZA’s baseline 80% to target 85% by the 2010. The TB-cure rate was 82% in

2007, and 82% in 200889. The cure rate was expected to increase because of the

multi-involvement of stakeholder in awareness creating but results are stagnant; this

may be because of the Multi-drug resistance that has been detected and also the

complicity of the treatment of TB-HIV patients.

HIV screening in TB patients

MKUZA baseline was set at 20% and the target is 100% by the year 2010. In 2009 it

has been recorded 96% of HIV screening was done to TB patients 30 women and 23

men were diagnosed HIV/TB positive out of 327 patients (2009) while the number

was less in 2008, 22 women and 21 men out of 259. (2008)90

6.5 Non- communicable Disease (NCD)

Prevalence survey for key NCD should be conducted by 2010

Non-communicable diseases are a group of diseases whose causation is not linked to

any known pathogen. For example, diabetes, hypertension, osteo-arthritis and

epilepsy are not linked to bacterial causation directly. For the non-communicable

diseases, there were several variables in the PSAM which were able to assist in the

analysis. For example, the guideline on the integrated management of Adult Illnesses

(IMAI) includes issues on non-communicable diseases. These diseases are predicted

to overtake communicable diseases by 2020.91 Causes change in local dietary pattern

and obesity. (27% women are overweight or obese and 40% (town and west)

The variables which were asked in the PSAM 2008-2009 were IMAI guidelines and

the basic equipments such as blood pressure machine, measurement of blood glucose

88 MOHSW Budget speech 200989 Health bulletin 2009 90 MOHSW Budget speech200991 Essential Health Package 2007

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and availability of adult weighing scale.92 MKUZA had set target that by 2010

prevalence survey for key NCD should be conducted. No survey is has been done.

NCD activities. In 2008, hypertension moved up from the 3 rd in 2006 to the 2nd cause

of death (7.6%) and diabetes moved up to 7 th from 10th in 2006 (5%)93. Monthly

outreach visits were made to Kivunge and Makunduchi PHCCs to conduct diabetes

and hypertension clinics where clients were assessed and managed, and health

workers received on-the-job training94. The above data are from health facilities only,

a comprehensive survey is needed.

6.6 Substance Abuse

The problem is the many, more than 250 unofficial ports, smugglers arrive by sea in

traditional dhows, and stowing heroin amid ice transported from mainland Tanzania

and other ports is difficult to control. High rates of HIV among addicts threaten to

affect the general population as growth in heroin trafficking through east Africa is

making the narcotic more available. The problem is the increase in drug use95.

Prevalence survey for substance abuse by 2010

Operationalize detoxification and rehabilitation services for substance abusers by

2010. The survey was not conducted but the only available data are from HIV

substance abuse research report of 2007. The findings shows that; 39 percent of

substance users are injecting drug users of which 46 percent are sharing needles and

9.1 percent are flash blood. The medium age of drug debut was 18 years. Heroin and

marijuana were found to be commonly used drug in Zanzibar with 73 percent and 72

percent respectively. The factors behind the substance uses are peer pressure which

score 47.8 percent, good time 15.4 percent for female and 19 for male, frustration 7.7

percent for female and 6.6 percent for male, unemployment 6.4 percent for male.

92 P-SAM 2008-200993 HMIS unpublished data, 2008.94 HSPR-200995 Reuters.- 2009

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6.7 Human Resource management

About 75% establish PHC facilities established agreed norms for trained staff with

attention to gender balance by 2010. From all documents review, no information of

any survey or study was recorded to be able to get percentage reached to-date, but

various trainings have been ongoing from college of health science, other institution,

and different donor sponsor training and even in-house conducted by the HMTs. The

inventory needs to be done so as to identify the gaps.

6.8 Recommendations:

Generally implementation of Goal II has shown slow progress. This is seen from the

relative health indicators discussed above. It is not without doubt that the RGoZ

through the Ministry of Health and Social Welfare has done recommendable work to

improve some of the health indicators which have resulted into positive progress with

some visible reflection like the case of declining of malaria cases in Zanzibar.

Ministry of Health should contract an independent consultant or firm

undertake a comprehensive psycho socio studies which will include health

indicators covering:-Substance uses, prevalence of NCD, maternal mortality

and why there is increasing community delivery.

Learning from the experience of malaria success, the comprehensive efforts

which were community focused with meaningful involvement/participation of

community which was seen as the driven force toward its success. This is

something which can be replicated to address the other indicators which has

shown no, stagnant or little progress. Primary health care is the engine to

drive these forces to success thus needs improvement. MKUZA II should

emphasize on meaningful community involvement.

CHAPTER SEVEN CHAPTER SEVEN

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Climate Change and the Health Sector Climate Change and the Health Sector

7.0 Overview 7.0 Overview

The main consequences of climate change include temperature rise, sea level rise,

decrease in rainfall, decrease in water resources, extreme weather events including

more/frequent and severe droughts and floods. In the coming years and decades,

climate change will continue to affect many sectors of the economy including water

resources, agriculture, food security, human settlements, fisheries coastal zones and

public health.

The climate of small island states, like Zanzibar, is influenced by large ocean-

atmospheric interactions such as trade winds, El Niño and the monsoons; tropical

cyclones and hurricanes are also important components of the climate, as well as sea-

level rise. These climate characteristics, combined with their particular

socioeconomic situations make coastal countries in the world most vulnerable to

climate change.

7.1. Introduction

The purpose of this chapter is to outline the climate change concerns in Zanzibar, and

highlight some regional responses, challenges, best practices and table potential

recommendations for the management and mainstream of issues related to climate

change in the health sector. Climate changes effects are already being felt, and human

activities are a principal cause.

Climate change is occurring at an unprecedented rate throughout the world largely

because of human activity. Global warming is caused by rising fossil fuel burning

and land use changes which cause emission of greenhouse gases (GHGs) such as

carbon dioxide (CO2), nitrogen dioxide (N2O and methane (CH4).

Figure 7 : Greenhouse effects

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914-11-2001 DJG12-I

From IPCC 2001 HadleyCentre

GJJ99 3Hadley Centre for Climate Prediction and Research

The greenhouse effect

SUNSome solar radiation isreflected by the earth’s

surface and the atmosphere

ATMOSPHERE

Solar radiationpasses through theclear atmosphere

EARTHMost solar radiation is absorbedby the surface, which warms

Some of the infraredradiation is absorbedand re-emitted by thegreenhouse gases.

The effect of this is towarm the surface

and the loweratmosphere

Infrared radiationis emitted from theEarth’s surface

Although emission of greenhouse gases in Africa is low (about 3.5%) compared to

other regions, the continent is one of the most vulnerable to climate change and

climate variability.

Climate change poses a serious threat to development and poverty reduction in the

poorest and most vulnerable regions of the world. Minimizing the impacts of climate

change requires adaptation. The impact of climate change on health status is different

in developing versus industrialized countries. In developing countries, rising

temperatures and humidity have facilitated the spread of many vector borne infectious

diseases including malaria, dengue and encephalitis. The increasing prevalence of

morbidity and mortality from these infectious diseases has had several negative

consequences such as:

1. Decreasing economic productivity,

2. Increasing medical costs, and

3. Taxing already tenuous health care systems in poor countries.

The rising frequency of extreme climatic events such as floods and droughts, render

developing countries with increasingly less time to recover from economic and social

crises arising from extreme climatic changes. .

7.2. Major Health Consequences of Climate Change

Although climate change is a global phenomenon, its consequences will not be evenly

distributed. Scientists agree that developing countries and small island nations like

Zanzibar will be the first and hardest hit. In outlining consequences, there are Five

major health consequences of climate change which need to be clearly understood as

they are extremely sensitive to climate change. These are:-.

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1. Agriculture:

The agricultural sector is extremely sensitive to climate variability as rising

temperatures, more frequent droughts and floods can compromise food security.

Increases in malnutrition are expected to be severe especially in countries where large

populations depend on rain-fed subsistence farming. Malnutrition, much of it caused

by periodic droughts, is already responsible for estimated deaths of about 3.5 million

people each year.

2. Potential deaths and injuries

More frequent extreme weather events mean more potential deaths and injuries

caused by storms and floods. In addition, floods can always be followed by outbreaks

of diseases, such as cholera, especially when water and sanitation services are

damaged or destroyed. Storms and floods are already among the most frequent and

deadly forms of natural disasters.96

3. Water Scarcities;

The consequences of water scarcities are a threat to hygiene while excess water due to

more frequent and torrential rainfall will increase the burden of diarrhea disease being

spread through contaminated food and water. Diarrhea is a serious disease that is a

result of contaminated water and unhygienic practices related to food preparation,

basic health practices and excreta disposal this maybe due to water scarcity. Diarrhea

is also one of the causes of childhood morbidity (8.6%) and childhood deaths. It is

also one of the reasons of childhood malnutrition (Under 5yrs)

Heat Waves,

Heat waves, especially in urban areas “heat islands”, can directly increase morbidity

and mortality, mainly to the elderly people with cardiovascular or respiratory disease.

Apart from heat waves, higher temperatures can increase ground-level ozone and

hasten the onset of the pollen season, contributing to asthma attacks and other

allergies. This can be the reason of the rapid increase of URTI and Pneumonia in

96 Annexure no 2 page…..

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childhood illnesses becoming the 1st and 2nd leading causes of morbidity respectively

replacing malaria and diarrhea97

4. Geographical Distribution

Changing temperatures and patterns of rainfall are expected to alter the geographical

distribution of insect vectors98 that spread infectious diseases such as malaria and

dengue with greatest public health problem. This can indeed wipe out the successes

already gained from the Malaria control programmes in Zanzibar.

Figure 8: Direction and magnitude of change of selected health impacts of

climate change

Source: IPCC Working Group II (2007) Chapter 8.

7.3. Recommended Responses to Climate Change7.3. Recommended Responses to Climate Change

The first MKUZA strategy was silent about the climate change. It is recommended

that the second strategy should mainstream climate change as a matter of urgency.

The dual challenge of responding to climate change aimed at avoiding the

unmanageable changes by taking measures to mitigate and manage the impact, and to

manage the unavoidable consequences through adaptation. All researches should

consider the following as vital elements in responding to the climate change for the

purpose of poverty reduction and mitigation, health promotion and disease control.97 Health Bulletin-200898 Refer to Malaria annexure 2 page …….

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The RGoZ should initiate and facilitate the development of a multisectoral

National Climate Change Response Policy and incorporate sector-specific

components with health lenses.

ii The government should continue to pro-actively build the knowledge base and

the capacity to adapt to the inevitable impacts of climate change, most

importantly by enhancing early warning (involving the weather forecast

department) and disaster reduction systems and in the roll-out of basic services,

water resource management, infrastructure planning, agriculture biodiversity

and in the health delivery system.

Studies should be done to redefine the competitive advantage and structurally

transformation of the local communities and identify their asset based and

strengths at all levels to scaled up and address the impact of climate.

• Research on climate change and health must be placed more firmly within the

context of improving community health and health equity rather than being

considered as a stand-alone issue.

• Risk assessment is needed to inform decision makers about the broad range of health

impacts from climate change at national and local levels.

• Research on the health effects to be mitigated and adapted in other sectors as to help

to avoid harm and identify opportunities for health promotion. (High level of

collaboration is needed)

7.4. Conclusion

This chapter has provided highlights on climate change in relation to health concerns.

It has addressed the concerns that Climate change as one of the greatest threats to the

planet and its people. If Climate change is unmanaged and un-mitigated, it has the

potentials to undermine the already achieved levels of advancement especially in the

least developed countries of which Zanzibar is a part. Mainstreaming of the climatic

changes issues into MKUZA is necessary as the consequences tabled in this analysis

have a bearing on the health status of the nation. Zanzibar’s own development goals

(MKUZA) and the Millennium Development Goals can not be achieved without

conscious and potential interventions that prioritize climate changes as an aspect of

development, peace and harmony for its people. Zanzibar has got to commit

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resources to engage fully in this process as part of the health strategy. Climate change

has a contribution in shaping the health policy through evidence based researches and

well informed decision making. This is in line with the fact that, Climate change has

important health-related consequences which contribute greatly to the emergence and

re-emergence of infectious diseases, heat stress, and respiratory illnesses,

demonstrates how global climate change interacts with the complex and rapidly

changing social-political environment and consequently determine the security of

individuals, communities and the society. Effects are observed in both chronic and

acute disease, spanning both developing and industrialized countries. With the

increasing frequency of climate-related “natural disasters” such as flood and drought,

governments and institutions unprepared for coping with climate change must bare

the threat to their health and economics.

It is therefore necessary for local and international government to collaborate and

find long lasting solutions as this should be considered as part and parcel of the

development issues that have greater influence on poverty and vulnerability

something being fought as envisaged in the Visions 2020 and 2015 and the

millennium development Goals.

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