2023 UVA Global Health Case Competition Case

The Center for Global Health Equity Presents the 2023 Global Health Case Competition Case Study: The Fight for Equitable Prevention and Treatment of Tuberculosis in Tanzania Authors: Noura Abousy, Emma Morris, Navya Annapareddy, and Sophia Bufalino with guidance and contributions from: Dr. Stellah Mpagama, Kibong’oto Hospital; Dr. Scott Heysell, University of Virginia; Bibie Said, Kibong’oto Hospital

Photo: A Global Fight: Battling Tuberculosis in Tanzania. (2020, July 24). The Borgen Project. https://borgenproject.org/a-global-fight-battling-tuberculosis-in-tanzania/

Table of Contents: I. II. III.

Introduction

Historical Overview of Tanzania

Tuberculosis and Other Health Issues in Tanzania IV.

Tanzanian Initiatives

V.

International Initiatives

VI.

Remaining Challenges

VII.

Summary and Your Task

I. ​

Introduction: Case Study Before embarking on a six-hour journey to Haydom Lutheran Hospital with her young

granddaughter in tow, Hadija* rounds up her poultry. She must find a way to come up with 50,000 Tanzanian shillings (USD $22) to pay for their round-trip fare. Just one visit to Haydom costs Hadija some 25 percent of her average monthly income of 200,000 Tanzanian shillings.

“During the early period,” she recounts, “I had to sell sunflowers so I could find a way to transport this child. When I finished the sunflowers, I turned to selling chickens.” In times of extreme financial hardship, Hadija relies on community leaders to help defray her travel costs.

Prior to departing the village, she must also seek out a trustworthy person to stay behind and care for another child in her home who has epilepsy. “The little money I earn is spent on children,” she shares. “Nowadays, what I get is spent on transport.”

At 4 o’clock a.m., Hadija and Grace, 7, who receives her anti-TB medication refills in Haydom, set off on foot with a flashlight. Escorted by a family member, they walk for two hours until they reach the motorcycle taxi (boda boda) stand at dawn. An impassable gorge and bushy terrain make it impossible for taxi drivers, even bicycles, to reach Hadija’s home. She implores the motorcycle driver to agree to a reasonable fee to take them to a bus stand, where they will begin the final two-hour leg of their journey. “Since there is just one boda boda,” Hadija explains, “you have to beg him a lot.”

Once in Haydom, Hadija forgoes meals and spends 3,000 shillings on Grace’s food instead. “I have not been eating; I cannot lie,” she says. “It is better my child eat well. I have been not eating the food, as it is difficult to get the money. I rarely take the food. I let the child eat and be satisfied then afterwards, I may eat.” When asked what type of support would be helpful to families with a child diagnosed with TB, she identified transportation money as her sole need. “To me, that is all,” she says. “On the family side, we are going to fight like we always do.”1 While many parts of the world have the convenience of ordering Ubers and Taxis at a click of a button, accessing metro stops, and driving motor vehicles, Hadija’s life revolves around looking for affordable transportation means to access the most basic necessities. Even then, her travel is exhausting and is not sustainable: 2 hours of walking could mean that Hadija would not be able to accompany her daughter if she herself became sick. Not only is transportation an uphill battle, but the costs to TB clinical visits and appointments exacerbate this

financial burden. Average expenditures for one TB clinic visit can be 18,000 TZS (USD 8$) to 55,000 TZS (USD $24), which can already be costly to families due to unpredictable transportation means. In fact, the average percent of monthly income spent on one TB clinic appointment can be 18%, emphasizing how seeking out treatment for TB causes health shocks within families.

Hadija is one example of a strong and persevering caregiver who is pushing and fighting for her daughter to get proper treatment. However, what does this mean for those who are not able to make the intensive and harsh process of accessing adequate health care?

II.

Historical Overview of Tanzania

Location and Demographic of Tanzania Tanzania – which includes the islands of Zanzibar, Pemba, and Mafia – is the largest country in East Africa. With a population size estimated to be around 62 million people, there are more than 120 African tribal groups in the area. 1 The majority of Tanzanians are of Bantu descent, including tribes such as the Sukuma,Chaga, Haya, Hehe, and Nyamwezi. Asian (particularly Indian) and European groups exist in a very small minority, steadily decreasing due to rural-urban migration, modernization, and politicization. Of note, Tanzania does not have one single politically or culturally dominant ethnic group, despite being exposed to Christian missionary groups and Western education throughout the colonial period.

Acknowledging that historical sources often represent a Western worldview, understanding contemporary Tanzania requires understanding the impact that the colonizing powers had and still continue to have on the region. Tanzania was under German rule from 1880 to 1919, and then the British took control from 1919 to 1961. Both European powers had developed a system to export cash crops in order to maximize economic profit in the region by exploiting African peasant farmers in a labor system who were, most often, under the control of European plantation owners. Ultimately, colonization led to social, political, and economic policies that were determined based on the demands and needs of Britain and Germany with little regard to the

needs of the African population. 2 For example, these powers implemented Western healthcare infrastructures that prioritized the health and accessibility of the European settlers, but did not account for African peasant farmers who were subject to unjust working and living conditions.

Ultimately, the health infrastructure was not readily equipped nor appropriate to address the critical needs of the existing African population, which contributed to the overall deterioration of health and well-being for the African population. For example, at independence in 1961, Tanzania only had less than twenty African physicians working. 3 Even years and years after independence, a study conducted in 2009 demonstrated that teaching institutions for health trainees still face major constraints like lack of qualified students, inconsistent water supply, and shortage of financial resources and faculty.4 Ultimately, Tanzania was able to achieve independence in 1961 under the leadership of Julius Nyerere, who aimed to eradicate the colonial systems set in place. After sparking dialogue and developing negotiations with the British, Nyerere spearheaded the independence of Tanzania with goals centered on economic independence from foreign powers, racial and tribal harmony, and dismantling the systematic inequalities perpetuated by European powers. Most notably, he adapted a socialist outlook (Ujamaa) in order to create a communal setting that relied on universal sharing of property and production. This generated a communal and egalitarian society that worked against urbanization and large industrialization in order to maintain an agrarian system.

However, many policies enacted post-colonization led to counterproductive consequences for the country. Productivity decreased to the extent that Tanzania was forced to rely on international aid, contrary to its intended goals of becoming self-sufficient. For example, about 70% of the health capital budget in the late 1970’s came from international governments.5 While there were plans to offer benefits to the working class through building more schools, hospitals, and agricultural services, few of these promises were kept because the country had scarce resources to provide to its people. As a result, many of the farmers were left in poor and desperate conditions with little to no access to basic necessities because there was no money available to be allocated, as promised.6 Culture in Tanzania With Tanzania being home to several to several ethnicities and races, it is no surprise that this country is rich in many different traditions and customs. One common theme is that the role

of family is integral to almost all social and recreational life in Tanzania, with clanship systems being the most common among ethnic groups. Tanzanian culture is largely Swahili, an Arab and African mix. Although most groups ethnic groups speak their own language, most citizens are fluent in the national language of Swahili. The use of a single language was part of a successful effort to encourage people from different parts of the country to communicate with one another and to identify as one people. The second official language is English, a consequence of the British colonial period.

A number of Tanzania’s significant cultural institutions are located in Dar es Salaam, an urban area located on the perimeter of the country, like museums and monuments. Dar es Salaam has been quoted as being the fastest growing urban center in Sub-Saharan Africa, with the 2012 National Census showing that this region accounted for 10% of the total population.7 It has been noted that most residents live in unplanned settlements denoted by substandard infrastructure and lack of basic public services and facilities. Additionally, Dar es Salaam accounts for most of the economic activity and income generation in Tanzania. Unfortunately, due to a heavy use of natural resources, environmental degradation continues to be an issue in Tanzania as there has been a sharp decrease in the quality of urban living conditions. Specifically, uncollected solid waste is the source of many diseases in Dar es Salaam, and small-scale industries have polluted the groundwater and soil. The urban poor population in the region have been the most affected from the environmental degradation.8 With respect to religion, a 2020 survey estimated that approximately 63 percent of the population identifies as Christian, 34 percent as Muslim, and 5 percent practice other religions.10 Education Attainment Tanzania achieved nearly universal access to primary education in 2007. Despite this advancement, the enrollment of children in primary-school has been declining. It has been estimated that there are around 2 million children between the ages of 7-13 who do not attend school. Additionally, almost 70% of children within the age range of 14-17 are not enrolled in secondary education. Wealth inequality poses a major challenge to education attainment.

Children from poorest families are around 3x less likely than those from the wealthiest families to obtain primary schooling. For those children who do obtain education, they typically do not receive solid learning outcomes that are foundational to future education, such as literacy and life

skills, which ultimately hinders their future performance. In Tanzania, girls, children from poor families, and children with disabilities are the most vulnerable to dropping out of school.9 III.

Tuberculosis & Other Global Health Issues in Tanzania

Main Health Issues in Tanzania The health issues faced by Tanzania include maternal, perinatal, and malnutrition-related conditions, which constitute 65 percent of total deaths. Communicable diseases like HIV, tuberculosis, and malaria are affecting the region as well and comprised on average 56% of the population’s mortality as of 2016 according to the WHO.11 In addition, the country also has “periodic cholera outbreaks, leprosy hotspots, food-borne & water-borne pathogens, as well as other neglected tropical diseases.”12 Regarding communicable diseases, one cause of the spread is the lack of sanitation infrastructure, clean water and non-utilization of health services in rural areas. Roughly 60% of urban areas, by contrast, have access to clean water, sanitation measures, and electricity. Although the Tanzanian population as a whole continues to be adversely affected by communicable diseases, public health initiatives have mostly focused on investments improving child rates for children.13 Overview of Tuberculosis & Its Impact Before the COVID-19 pandemic, tuberculosis (TB) was the global leading cause of death from an infectious agent, but has remained stagnant over the past decade.14 However, the COVID-19 has exacerbated health disparities globally leading to an increase in TB-related mortality rates worldwide.15 TB is a curable and preventable communicable disease caused by the bacteria Mycobacterium tuberculosis, which most frequently affects the lungs, causing coughing. This highly contagious disease is spread person-person through droplets from coughing, sneezing, and/or spitting. The disease can take both latent and active forms. The latent form can be triggered into an active, transmittable form if one’s immune system is compromised through becoming sick with another infection or malnourished, for example.

TB is also the leading cause of death among those infected with HIV. More specifically, those infected with HIV are 18 times more likely to develop an active form of TB if they have the latent form than those uninfected.14 This is because once someone is infected with HIV the virus attacks the body’s own immune cells that would usually contain the latent TB infection, and then the TB infection can replicate and spread unchecked. Similarly, in the WHO African region, 85 percent of TB patients had a documented HIV test result, causing a cyclical

interaction.16 The socioeconomic determinants of health are directly related to the increased risk of TB infection for certain populations, and many co-determine risk for HIV. For example, other risk factors for TB infection include being malnourished, male, living in poverty, experiencing food insecurity, substance abuse, using certain drugs for instance cancer drugs, being an ethnic minority, and having poor water and sanitation measures.17 All age groups are at risk. The structural determinants include “global socioeconomic inequalities, high levels of population mobility, and rapid urbanization and population growth”, which can therefore increase the distributions of the key social determinants of TB infection.18 Vaccination is not the main approach to reducing TB-related mortality because although it exists, it is only effective for preventing the severe forms of TB in early childhood. The current treatment for TB includes a variety of drugs that need to be taken consistently for 6 to 9 months.

If treatment medications are taken inconsistently or stopped too soon, the patient can become sick again. Different forms of TB such as multi-drug resistant (MDR) TB, a form of the disease that does not respond effectively to medications, can be especially difficult and expensive to treat.19 Tuberculosis in Tanzania Tanzania is one of the top 30 countries with the highest rates of TB, and consequently, a high mortality rate from the infection. Tuberculosis is a growing threat to the region for several reasons. The initial increase in TB incidence starting in the 1980s was initially thought to be because of early detection and better measures for testing, “but it soon became clear that HIV infections were influencing this increase.” More specifically, “the population attributable risk for 1990 was in the order of 30%, which means that, without HIV, the increase in TB cases seen after 1985 would not have occurred.”20 As Tanzania has an extremely high prevalence rate of HIV, TB creates an increased risk of mortality in the country. However, the country has made significant progress for the prevention/treatment of HIV and TB. According to the 2021 Global Tuberculosis Report, Tanzania is one of the countries to have achieved a 20% reduction in TB incidence between 2015 and 2020. Similarly, efforts from the End TB strategy in combination with increased HIV testing in the

African region were able to achieve the highest coverage of concurrent HIV and TB diagnosis as of 2020 out of any other region.41 People with diabetes also represent a group that is adversely affected by TB. For example, people with diabetes have a 1.5x higher risk of developing TB than those without.42 Furthermore, people who use drugs represent an underserved group affected by the disease due to the higher distribution of other risk factors, key social determinants that lead to TB infection, and poor access to quality healthcare services. Tanzania also has high rates of illicit drug use, especially heroin. “It is estimated that about 250,000 drug users [2], of which 25,000 to 50,000 are identified as injecting drugs live in Tanzania.” The relationship between TB infection and drug use is related to the social determinants of health, such as unstable housing with limited ventilation and/or sanitation facilities. People who use drugs also have markedly higher rates of HIV infection, which only amplifies the risk for TB infection and mortality. 21 Additionally, “illicit drugs increase susceptibility to various infections including Mycobacterium tuberculosis due to impairment of the cell mediated immune response” and can mask the symptoms of TB.22 Treatment methods are widely accessible in Tanzania if one is able to navigate through barriers to diagnosis and access to a TB treatment facility. Once diagnosed, medications for TB treatment are available at a dispensary level at most but not all local pharmacies. When first diagnosed, patients commonly receive their treatment at a regional TB clinic. Data regarding TB diagnosis and treatment are only measured in terms of those who are registered as starting TB treatment (known as a case notification). Those who may have a positive diagnostic test for TB, or those that are diagnosed with TB by a clinician without a positive diagnostic test, but do not later receive follow-up care are not counted as a TB case. Therefore, data are lacking with respect to the patients that cannot gain access to treatment because of barriers in accessing high quality diagnostics, receiving diagnostic results, and linking to services for further TB treatment and support. Care coordination and tracking cases for follow-up is relatively developed as all TB cases are registered with the Ministry of Health, but this is dependent upon staffing and coordination of locations of diagnostics and public health clinics responsible for TB treatment.23 Furthermore, several barriers including transportation to treatment facilities exist. For example, one study found that 58% of families and caregivers of children with TB identified transportation as a barrier to treatment.1 Despite increased detection of TB in Tanzania, there are still prevalent issues with diagnosis. The main issues with diagnosis include a combination of limitations in the most

advanced diagnostic tools and a lack of empowerment of frontline healthcare workers to test symptomatic patients. The most common diagnostic tool is a smear microscopic test, which is considered an insensitive test as it often underdiagnoses TB. Molecular testing for tuberculosis DNA is a more sensitive test, but is now a commercial product subject to its own set of stockouts. The most common molecular test is the GeneXpert MTB/RIF test, referred to as “Xpert.” The international consensus is for all people presumed to have TB to have an Xpert test performed. However, there are both logistical and technological challenges in the use of this type of diagnostic machine, which compromises access. Similarly, a chest x-ray would also be recommended in the diagnosis of TB, which can have further technological issues as well. Some diagnostic tests can be free, but may require health insurance. This leads to the point about the low empowerment of frontline healthcare workers to test patients for TB. More specifically, the patient may benefit from recognizing the symptoms of TB. Yet, both patients and providers are subject to misconceptions about who is more susceptible to get TB. For example, many people believe that only people with HIV or alcoholics or adults get TB. For healthcare providers different factors such as monetary incentives and worries surrounding the patient’s ability to afford the test might lead them to inappropriately recommend testing for some people and not for others.24, 25 Health Systems Challenges in Tanzania The main health system challenges in the treatment of TB include the linkage from diagnosis to care and the fact that there are inadequate human resources to deliver quality health services to the Tanzanian population in general. Compared to South Africa, a country that also suffers from a significant TB burden, Tanzania has a 14% higher overall communicable disease mortality rate and a significantly lower GDP.26 This suggests possible health system and funding challenges combating the spread of communicable diseases in Tanzania. According to data from the World Bank, Tanzania had roughly 0.6 physicians and 0.7 hospital beds per 1,000 people as of 2014.27 The WHO lists prevention and primary care services as some of the most urgent health system challenges, as well as access to medical care in rural areas, funding for

health services, poor healthcare infrastructure, and a general shortage of healthcare professionals.28 IV.

Tanzanian Initiatives In order to address the high prevalence of tuberculosis in the region, a variety of

organizations have already laid out new strategies to combat this growing public health crisis.

Notably, the National Tuberculosis and Leprosy Programme (NTLP) was founded by the Ministry of Health and Social Welfare in 1977 and is part of the Epidemiology and Disease Control section. They propose several objectives to address tuberculosis which include increasing case detection rates by addressing disadvantaged groups such as elderly, prisoners, miners, and diabetics, facilitating enrollment of treatment and detection of MDR-TB by increasing access of new diagnostic technologies, ensuring that TB patients are tested for HIV, and supporting implementation of accessible and equitable treatment and diagnosis services for patients.29 Additionally, this organization oversees the distribution of drugs and supplies, providing health education to patients and communities, and record-keeping.

What makes NTLP effective is that it prioritizes community engagement in the TB response, which has been proved to be a highly effective way in improving health outcomes. For example, this organization was able to empower the people of Tanzania by consolidating community members as health volunteers to carry out home-based treatment support. This organization is instrumental in empowering people to know their rights as patients and play a more active role in order to advocate for their own community. Likewise, they all work together to bring awareness and education about these health concerns.

During the program’s implementation, it became difficult to maintain consistent data collection methods and thus complicated the ability to monitor the progress of TB at the community level. To circumvent this problem, NTLP established a standard community-based and monitoring and evaluation system (M&E system) that would better organize data collection and help with coordination among NTLP and TB stakeholders. Additionally, the organization created a way to report community referrals through an electronic system instead of a paper system, which helped improve data collection, accuracy, efficiency, and communication.

Despite these advances made by NTLP, there are remaining challenges to address.

Tuberculosis, a disease of poverty, is perpetuated by one’s social and economic status, and those that are marginalized tend to have the most difficulty accessing treatment. For example,

transportation and diagnostic costs of treatment may place a heavy burden on a low-income individual living in a rural area in Tanzania. Even if these resources are available, they may not be equitably accessible to those that are disadvantaged. Recently, the government of Tanzania announced that it will begin implementing new proposals and strategies to achieve more SDGs by 2030 (Sustainable Development Goals). Some of these new strategies include expanding diagnostic services with improved technology, targeting more vulnerable populations by addressing barriers to treatment and diagnosis, and continuing to address MDR-TB and HIV.30 V.

International Initiatives Many international organizations have been involved in helping Tanzania reach its goals

of working against the rise of tuberculosis in the region. USAID is one of the many organizations that has supported NTLP, for example. As mentioned beforehand, the NTLP prioritizes community engagement and recognizes it as a crucial step in empowering communities and those that are marginalized. USAID helps carry out these goals by conducting mass campaigns for TB diagnosis and screening in prisons, slums, sites that have heavy drug use, mining areas, and other high-risk areas. They also help train TB survivors and community-health workers to conduct trace-contacting and develop approaches to prevention and early diagnosis.13 Another notable organization is the Global Fund that has actively worked against the development of malaria and tuberculosis by acting as the region’s leading financier; it works to fund the health sector in order to support Tanzanian initiatives. For example, with Global Fund support, an initiative known as the Q1 in TB Case Detection was introduced in 2016 which aimed to provide TB screening at each entry point of health facilities. This was accomplished through extensive coordination and cooperation with NTLP in order to prioritize the priorities of local and national actors. In fact, after 18 months of implementation, the Global Fund was able to increase notification of childhood TB cases, increase suspicion of TB among health workers, and overall increase the national TB case notification by twelve percent.31 Overall, Tanzania has historically received a large proportion of foreign aid which has helped with service delivery of treatment and diagnostics for TB. However, a case study conducted in 2016 showed that this fails to be sustainable and forces Tanzania to rely on foreign aid funding, thus exacerbating inequality gaps. Additionally, many of the organizations may not address the fundamental issues and are not holistic in their approach. Likewise, sometimes these organizations are not the most transparent in their implementation to the people of Tanzania.32

VI.

Remaining Challenges There are several remaining challenges for you to address when considering proposals to

mitigate tuberculosis in Tanzania. Consider solutions that address some or all of these challenges when creating your plan.

Regional Disparities Healthcare providers and locations in rural areas in Tanzania are much sparser than in urban and more densely populated areas. The urban population of Tanzania is distributed across major regional cities like Dar Salaam. As Tanzania’s capital, Dar Salaam is a major commercial and cultural center that also hosts a concentrated amount of healthcare institutions, both public and private providers. While urban areas make strides towards health care offerings, estimates place the urban population number of Tanzania around 21,000,000 people and the rural population estimate as nearly twice this at 38,000,000 people. Accordingly, nearly 65% of the population resides in rural areas whose health and civil infrastructure levels can vary greatly when compared to their urban counterparts, making health care deficits more pronounced.

The government of Tanzania has been implementing a series of policy and provider level reforms since the 1990s. Part of this campaign created a large degree of decentralization in the public healthcare system.33 The distribution of healthcare facilities in Tanzania follows a pro-rich distribution, meaning that the distribution of physicians clinical staff like nurses are highly correlated with a given region’s affluence, and thus have a tendency to cluster in urban areas.34 Following this, the distribution of certain medical supplies and drugs, such as anti hypertensive and obstetric drugs, have been found to be biased towards more affluent populations rather than proportional to the actual population.

Stigma and Discrimination Stigma of having had or being a carrier of tuberculosis remains a barrier to care in Tanzania and surrounding areas. Studies have shown that much of the stigma with tuberculosis is its association with HIV and AIDS (which in turn have additional stigma associated with them) as well as the stigma of contagious transmission itself.35 The former stigma is often driven by the fact that HIV, AIDS, and TB have a high co-infection rate in many areas of Tanzania and neighboring countries, due to the immunocompromising nature of HIV and AIDS among other reasons. TB has also historically been associated with marginalized groups and this fear is compounded by lack of information on the nature of its transmission. This can lead to individuals

avoiding seeking treatment out of fear of being identified and then facing social ostracization or isolation. Finally, various mixed method studies have shown that elevated levels of stigma can consistently prevent appropriate treatment regardless of gender, religion, and age categories.

Alternative Treatment Approaches In addition, it is critical to consider the social and cultural importance of myth or alternative treatment in Tanzania’s healthcare system. A type of myth or alternative treatment can consist of herbal medicine or consulting a traditional healer. For example, studies have been conducted on how a large majority of Tanzanian patients use herbal medicine as a way to treat and cure themselves from cancers. Likewise, some patients rely on a local traditional healer to seek guidance, commonly in rural areas due to inaccessibility of health centers. Therefore, rural communities would not have access to the biomedical resources when modern medical interventions may be needed - like TB diagnosis and treatment. 36 Shortage of Trained Health Care Providers The World Health Organization recommends a ratio of 20 clinical health care workers for every 10,000 individuals in a country. Tanzania, as a country of over 40 million people, routinely suffers from shortages of trained healthcare providers and instead has a ratio of only about 5 clinical health care workers per 10,000 individuals.37 This lack of providers has direct effects on healthcare outcomes and creates a strain on the national system of health care institutions. One clear example of this is Tanzania’s elevated maternal mortality rate, which is 25% more than that of neighboring Kenya. While the government has committed to employing and training thousands of healthcare workers in coming years, the majority being directed towards rural areas, the effects of a sustained lack of providers in many areas remains pronounced.

Public vs. Non-public Providers Studies in Tanzania have shown that there is a lower level of trust in public healthcare facilities when compared to non-public or independent healthcare providers.38 Adding to this challenge is the fact that many communities, especially in rural areas, face high travel times and other obstacles to utilizing their primary health center (PHC). Those previously having the disease can be reinfected and this risk is compounded if the treatment course is not fully completed. Patients cite lack of diagnostic capabilities, lack of appropriate medication, limited hours, poor services, and a lack of skilled staff as reasons why they would rather seek alternative

means of care at hospitals or other healthcare facilities beside their PHC.39 Many villages also are unable to pay the community fee associated with access to public healthcare options.

Occupational Risks Tanzania is heavily dependent on the agriculture, industrial, and mining sector. However, there are not enough safety measures and regulations put into place to protect workers from occupational risks in these fields. It is estimated that 70% of people live and work in the agricultural field, yet this sector also has the highest rates of death and injury. In fact, in 2002, a tragic story highlighted the dangers that take place in the mining industry when 40 workers were suffocated to death. However, there are similar stories that go unreported because Tanzania does not have a reliable coordinated national reporting system. Miners are continuously at risk for contracting tuberculosis due to exposure of silica dust, inadequate working conditions that are poorly ventilated and crowded.. Due to an inadequate surveillance system, it is more complicated to implement legislation to protect workers because they are not brought to the attention of those who can advocate for lower-middle class workers. Regarding occupational health services, they do exist, but less than 5% of those working in these industries have access to them. Lack of knowledge and skills of occupational diseases, shortage of health professionals, and lack of funding are a few of the barriers affecting equitable health services for the working population in Tanzania. 40, 41 VII.

Summary and Your Task The goal of mitigating tuberculosis in Tanzania will require engaging diverse

stakeholders and reflecting on the unique needs of its various populations.42 Through your planning, you should reflect on how to engage with community-based stakeholders (ie: the public, patients, health centers, and clinicians) as well as the government at various levels. Be sure to address cultural, social, economic factors when creating your plan. Your task is to incorporate a program that: ● Works to deliver a comprehensive initiative with an emphasis on equality of access to health educational resources and inequality reduction ● Considers areas and populations that are disproportionately affected by the social determinants of contracting tuberculosis and healthcare inequalities, especially in rural and other underserved areas

● Mobilizes the community to work towards empowerment for tuberculosis mitigation while working to reduce misconceptions or educational gaps ● Strengthens community involvement with key stakeholders such as the community and healthcare providers and locations In addition, there are several central questions to take into consideration, but do not feel the need to answer all of them: (1) How will your program properly advance tuberculosis mitigation in the population despite the difficulties associated with treating those in underserved populations or areas? (2) How do we assure accessibility and active engagement between communities, individuals, and stakeholders? (3) How would you consider long-term impacts such as the surge caused by COVID-19 in conjunction with the remaining challenges? (4) What funding sources have you incorporated into your proposed solution and how much will it ultimately cost? If there are stages to your solution, be sure to consider each stage individually as well as the total cost. Provide also a budget and rationale for your proposal that makes sense to achieve your desired goals. Your team may choose to focus on one aspect of ensuring a comprehensive program or take on multiple projects.

Good luck!

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Special thanks to Hamna Shafiq, Eliza Piche, Cyrena Matingou, and Julia Barua for research and editing contributions!