TheCenterforGlobalHealthEquityPresentsthe 2023GlobalHealthCaseCompetition
CaseStudy:TheFightforEquitablePreventionandTreatmentofTuberculosisinTanzania
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
https://borgenprojectorg/a-global-fight-battling-tuberculosis-in-tanzania/
TableofContents:
I. Introduction
II. HistoricalOverviewofTanzania
III. TuberculosisandOtherHealthIssuesinTanzania
IV. TanzanianInitiatives
V. InternationalInitiatives
VI. RemainingChallenges
VII. SummaryandYourTask
Photo: A Global Fight: Battling Tuberculosis in Tanzania (2020,July24) TheBorgenProjectI. Introduction:CaseStudy
Beforeembarkingonasix-hourjourneytoHaydomLutheranHospitalwithheryoung granddaughterintow,Hadija*roundsupherpoultry. Shemustfindawaytocomeupwith 50,000Tanzanianshillings(USD$22)topayfortheirround-tripfare.JustonevisittoHaydom costsHadijasome25percentofheraveragemonthlyincomeof200,000Tanzanianshillings. “Duringtheearlyperiod,”sherecounts,“IhadtosellsunflowerssoIcouldfindawayto transportthischild. WhenIfinishedthesunflowers,Iturnedtosellingchickens.” Intimesof extremefinancialhardship,Hadijareliesoncommunityleaderstohelpdefrayhertravelcosts. Priortodepartingthevillage,shemustalsoseekoutatrustworthypersontostaybehindandcare foranotherchildinherhomewhohasepilepsy. “ThelittlemoneyIearnisspentonchildren,” sheshares.“Nowadays,whatIgetisspentontransport.”
At4o’clocka.m.,HadijaandGrace,7,whoreceivesheranti-TBmedicationrefillsin Haydom,setoffonfootwithaflashlight. Escortedbyafamilymember,theywalkfortwohours untiltheyreachthemotorcycletaxi(bodaboda)standatdawn. Animpassablegorgeandbushy terrainmakeitimpossiblefortaxidrivers,evenbicycles,toreachHadija’shome.Sheimplores themotorcycledrivertoagreetoareasonablefeetotakethemtoabusstand,wheretheywill beginthefinaltwo-hourlegoftheirjourney.“Sincethereisjustonebodaboda,”Hadija explains,“youhavetobeghimalot.”
OnceinHaydom,Hadijaforgoesmealsandspends3,000shillingsonGrace’sfood instead.“Ihavenotbeeneating;Icannotlie,”shesays.“Itisbettermychildeatwell.Ihave beennoteatingthefood,asitisdifficulttogetthemoney. Irarelytakethefood.Iletthechild eatandbesatisfiedthenafterwards,Imayeat.” Whenaskedwhattypeofsupportwouldbe helpfultofamilieswithachilddiagnosedwithTB,sheidentifiedtransportationmoneyasher soleneed.“Tome,thatisall,”shesays. “Onthefamilyside,wearegoingtofightlikewe alwaysdo.”1
WhilemanypartsoftheworldhavetheconvenienceoforderingUbersandTaxisata clickofabutton,accessingmetrostops,anddrivingmotorvehicles,Hadija’sliferevolves aroundlookingforaffordabletransportationmeanstoaccessthemostbasicnecessities.Even then,hertravelisexhaustingandisnotsustainable:2hoursofwalkingcouldmeanthatHadija wouldnotbeabletoaccompanyherdaughterifsheherselfbecamesick. Notonlyis transportationanuphillbattle,butthecoststoTBclinicalvisitsandappointmentsexacerbatethis
financialburden.AverageexpendituresforoneTBclinicvisitcanbe18,000TZS(USD8$)to 55,000TZS(USD$24),whichcanalreadybecostlytofamiliesduetounpredictable transportationmeans.Infact,theaveragepercentofmonthlyincomespentononeTBclinic appointmentcanbe18%,emphasizinghowseekingouttreatmentforTBcauseshealthshocks withinfamilies.
Hadijaisoneexampleofastrongandperseveringcaregiverwhoispushingandfighting forherdaughtertogetpropertreatment.However,whatdoesthismeanforthosewhoarenot abletomaketheintensiveandharshprocessofaccessingadequatehealthcare?
II. HistoricalOverviewofTanzania
Location and Demographic of Tanzania
Tanzania–whichincludestheislandsofZanzibar,Pemba,andMafia–isthelargest countryinEastAfrica.Withapopulationsizeestimatedtobearound62millionpeople,thereare morethan120Africantribalgroupsinthearea.1 ThemajorityofTanzaniansareofBantu descent,includingtribessuchasthe Sukuma,Chaga,Haya,Hehe,andNyamwezi.Asian (particularlyIndian)andEuropeangroupsexistinaverysmallminority,steadilydecreasingdue torural-urbanmigration,modernization,andpoliticization.Ofnote,Tanzaniadoesnothaveone singlepoliticallyorculturallydominantethnicgroup,despitebeingexposedtoChristian missionarygroupsandWesterneducationthroughoutthe colonialperiod.
Acknowledgingthathistoricalsourcesoftenrepresenta Westernworldview,understandingcontemporaryTanzania requiresunderstandingtheimpactthatthecolonizingpowers hadandstillcontinuetohaveontheregion.Tanzaniawasunder Germanrulefrom1880to1919,andthentheBritishtook controlfrom1919to1961.BothEuropeanpowershad developedasystemtoexportcashcropsinordertomaximize economicprofitintheregionbyexploitingAfricanpeasant farmersinalaborsystemwhowere,mostoften,underthe controlofEuropeanplantationowners.Ultimately,colonization ledtosocial,political,andeconomicpoliciesthatwere determinedbasedonthedemandsandneedsofBritainandGermanywithlittleregardtothe
needsoftheAfricanpopulation.2 Forexample,thesepowersimplementedWesternhealthcare infrastructuresthatprioritizedthehealthandaccessibilityoftheEuropeansettlers,butdidnot accountforAfricanpeasantfarmerswhoweresubjecttounjustworkingandlivingconditions. Ultimately,thehealthinfrastructurewasnotreadilyequippednorappropriatetoaddressthe criticalneedsoftheexistingAfricanpopulation,whichcontributedtotheoveralldeteriorationof healthandwell-beingfortheAfricanpopulation.Forexample,atindependencein1961, TanzaniaonlyhadlessthantwentyAfricanphysiciansworking.3 Evenyearsandyearsafter independence,astudyconductedin2009demonstratedthatteachinginstitutionsforhealth traineesstillfacemajorconstraintslikelackofqualifiedstudents,inconsistentwatersupply,and shortageoffinancialresourcesandfaculty.4
Ultimately,Tanzaniawasabletoachieveindependencein1961undertheleadershipof JuliusNyerere,whoaimedtoeradicatethecolonialsystemssetinplace.Aftersparkingdialogue anddevelopingnegotiationswiththeBritish,NyererespearheadedtheindependenceofTanzania withgoalscenteredoneconomicindependencefromforeignpowers,racialandtribalharmony, anddismantlingthesystematicinequalitiesperpetuatedbyEuropeanpowers.Mostnotably,he adaptedasocialistoutlook(Ujamaa)inordertocreateacommunalsettingthatreliedon universalsharingofpropertyandproduction.Thisgeneratedacommunalandegalitariansociety thatworkedagainsturbanizationandlargeindustrializationinordertomaintainanagrarian system.
However,manypoliciesenactedpost-colonizationledtocounterproductiveconsequences forthecountry.ProductivitydecreasedtotheextentthatTanzaniawasforcedtorelyon internationalaid,contrarytoitsintendedgoalsofbecomingself-sufficient.Forexample,about 70%ofthehealthcapitalbudgetinthelate1970’scamefrominternationalgovernments.5 While therewereplanstoofferbenefitstotheworkingclassthroughbuildingmoreschools,hospitals, andagriculturalservices,fewofthesepromiseswerekeptbecausethecountryhadscarce resourcestoprovidetoitspeople.Asaresult,manyofthefarmerswereleftinpoorand desperateconditionswithlittletonoaccesstobasicnecessitiesbecausetherewasnomoney availabletobeallocated,aspromised.6
Culture in Tanzania
WithTanzaniabeinghometoseveraltoseveralethnicitiesandraces,itisnosurprisethat thiscountryisrichinmanydifferenttraditionsandcustoms.Onecommonthemeisthattherole
offamilyisintegraltoalmostallsocialandrecreationallifeinTanzania,withclanshipsystems beingthemostcommonamongethnicgroups.TanzaniancultureislargelySwahili,anAraband Africanmix.Althoughmostgroupsethnicgroupsspeaktheirownlanguage,mostcitizensare fluentinthenationallanguageofSwahili.Theuseofasinglelanguagewaspartofasuccessful efforttoencouragepeoplefromdifferentpartsofthecountrytocommunicatewithoneanother andtoidentifyasonepeople.ThesecondofficiallanguageisEnglish,aconsequenceofthe Britishcolonialperiod.
AnumberofTanzania’ssignificantculturalinstitutionsarelocatedinDaresSalaam,an urbanarealocatedontheperimeterofthecountry,likemuseumsandmonuments.DaresSalaam hasbeenquotedasbeingthefastestgrowingurbancenterinSub-SaharanAfrica,withthe2012 NationalCensusshowingthatthisregionaccountedfor10%ofthetotalpopulation.7 Ithasbeen notedthatmostresidentsliveinunplannedsettlementsdenotedbysubstandardinfrastructureand lackofbasicpublicservicesandfacilities.Additionally,DaresSalaamaccountsformostofthe economicactivityandincomegenerationinTanzania.Unfortunately,duetoaheavyuseof naturalresources,environmentaldegradationcontinuestobeanissueinTanzaniaastherehas beenasharpdecreaseinthequalityofurbanlivingconditions.Specifically,uncollectedsolid wasteisthesourceofmanydiseasesinDaresSalaam,andsmall-scaleindustrieshavepolluted thegroundwaterandsoil.Theurbanpoorpopulationintheregionhavebeenthemostaffected fromtheenvironmentaldegradation.8
Withrespecttoreligion,a2020surveyestimatedthatapproximately63percentofthe populationidentifiesasChristian,34percentasMuslim,and5percentpracticeotherreligions.10
Education Attainment
Tanzaniaachievednearlyuniversalaccesstoprimary educationin2007.Despitethis advancement,theenrollmentofchildreninprimary-schoolhasbeendeclining.Ithasbeen estimatedthattherearearound2millionchildrenbetweentheagesof7-13whodonotattend school.Additionally,almost70%ofchildrenwithintheagerangeof14-17arenotenrolledin secondaryeducation.Wealthinequalityposesamajorchallengetoeducationattainment.
Childrenfrompoorestfamiliesarearound3xlesslikelythanthosefromthewealthiestfamilies toobtainprimaryschooling.Forthosechildrenwhodoobtaineducation,theytypicallydonot receivesolidlearningoutcomesthatarefoundationaltofutureeducation,suchasliteracyandlife
skills,whichultimatelyhinderstheirfutureperformance.InTanzania,girls,childrenfrompoor families,andchildrenwithdisabilitiesarethemostvulnerabletodroppingoutofschool.9
III. Tuberculosis&OtherGlobalHealthIssuesinTanzania Main Health Issues in Tanzania
ThehealthissuesfacedbyTanzaniaincludematernal,perinatal,andmalnutrition-related conditions,whichconstitute65percentoftotaldeaths.CommunicablediseaseslikeHIV, tuberculosis,andmalariaareaffectingtheregionaswellandcomprisedonaverage56%ofthe population’smortalityasof2016accordingtotheWHO.11 Inaddition,thecountryalsohas “periodiccholeraoutbreaks,leprosyhotspots,food-borne&water-bornepathogens,aswellas otherneglectedtropicaldiseases.”12 Regardingcommunicablediseases,onecauseofthespread isthelackofsanitationinfrastructure,cleanwaterandnon-utilizationofhealthservices inrural areas.Roughly60%ofurbanareas,bycontrast,haveaccesstocleanwater,sanitationmeasures, andelectricity AlthoughtheTanzanianpopulationasawholecontinuestobeadverselyaffected bycommunicablediseases,publichealthinitiativeshavemostlyfocusedoninvestments improvingchildratesforchildren.13
Overview of Tuberculosis & Its Impact
BeforetheCOVID-19pandemic,tuberculosis(TB)wasthegloballeadingcauseofdeath fromaninfectiousagent,buthasremainedstagnantoverthepastdecade.14 However,the COVID-19hasexacerbatedhealthdisparitiesgloballyleadingtoanincreaseinTB-related mortalityratesworldwide.15 TBisacurableandpreventablecommunicablediseasecausedby thebacteria Mycobacterium tuberculosis,whichmostfrequentlyaffectsthelungs,causing coughing.Thishighlycontagiousdiseaseisspreadperson-personthroughdropletsfrom coughing,sneezing,and/orspitting.Thediseasecantakebothlatentandactiveforms.Thelatent formcanbetriggeredintoanactive,transmittableformifone’simmunesystemiscompromised throughbecomingsickwithanotherinfectionormalnourished,forexample.
TBisalsotheleadingcauseofdeathamongthoseinfectedwithHIV.Morespecifically, thoseinfectedwithHIVare18timesmorelikelytodevelopanactiveformofTBiftheyhave thelatentformthanthoseuninfected.14 ThisisbecauseoncesomeoneisinfectedwithHIVthe virusattacksthebody’sownimmunecellsthatwouldusuallycontainthelatentTBinfection, andthentheTBinfectioncanreplicateandspreadunchecked.Similarly,intheWHOAfrican region,85percentofTBpatientshadadocumentedHIVtestresult,causingacyclical
interaction.16 Thesocioeconomicdeterminantsofhealtharedirectlyrelatedtotheincreasedrisk ofTBinfectionforcertainpopulations,andmanyco-determineriskforHIV.Forexample,other riskfactorsforTBinfectionincludebeingmalnourished,male,livinginpoverty, experiencing foodinsecurity,substanceabuse,usingcertaindrugsforinstancecancerdrugs,beinganethnic minority,andhavingpoorwaterandsanitationmeasures 17Allagegroupsareatrisk.The structuraldeterminantsinclude“globalsocioeconomicinequalities,highlevelsofpopulation mobility,andrapidurbanizationandpopulationgrowth”,whichcanthereforeincreasethe distributionsofthekeysocialdeterminantsofTBinfection.18
VaccinationisnotthemainapproachtoreducingTB-relatedmortalitybecausealthough itexists,itisonlyeffectiveforpreventingthesevereformsofTBinearlychildhood.Thecurrent treatmentforTBincludesavarietyofdrugsthatneedtobetakenconsistentlyfor6to9months. Iftreatmentmedicationsaretakeninconsistentlyorstoppedtoosoon,thepatientcanbecome sickagain.DifferentformsofTBsuchasmulti-drugresistant(MDR)TB,aformofthedisease thatdoesnotrespondeffectivelytomedications,canbeespeciallydifficultandexpensiveto treat.19
Tuberculosis in Tanzania
TB,andconsequently,a uberculosisisagrowingthreattotheregionforseveral TBincidencestartinginthe1980swasinitiallythoughttobe becauseofearlydetectionandbettermeasuresfortesting,“butitsoonbecameclearthatHIV ,“thepopulationattributableriskfor TBcasesseen hasanextremelyhighprevalencerateof TBcreatesanincreasedriskofmortalityinthe ,thecountryhasmadesignificant progressfortheprevention/treatmentofHIVandTB. uberculosisReport, anzaniaisoneofthecountriestohaveachieveda TBincidencebetween2015and TBstrategyin combinationwithincreasedHIVtestinginthe
AfricanregionwereabletoachievethehighestcoverageofconcurrentHIVandTBdiagnosisas of2020outofanyotherregion.41 Peoplewithdiabetesalsorepresentagroupthatisadversely affectedbyTB.Forexample,peoplewithdiabeteshavea1.5xhigherriskofdevelopingTBthan thosewithout.42 Furthermore,peoplewhousedrugsrepresentanunderservedgroupaffectedby thediseaseduetothehigherdistributionofotherriskfactors,keysocialdeterminantsthatleadto TBinfection,andpooraccesstoqualityhealthcareservices. Tanzaniaalsohashighratesofillicit druguse,especiallyheroin.“Itisestimatedthatabout250,000drugusers[2],ofwhich25,000to 50,000areidentifiedasinjectingdrugsliveinTanzania.”TherelationshipbetweenTBinfection anddruguseisrelatedtothesocialdeterminantsofhealth,suchasunstablehousingwithlimited ventilationand/orsanitationfacilities.Peoplewhousedrugsalsohavemarkedlyhigherratesof HIVinfection,whichonlyamplifiestheriskforTBinfectionandmortality.21 Additionally, “illicitdrugsincreasesusceptibilitytovariousinfectionsincluding Mycobacterium tuberculosis duetoimpairmentofthecellmediatedimmuneresponse”andcanmaskthesymptomsofTB.22
TreatmentmethodsarewidelyaccessibleinTanzaniaifoneisabletonavigatethrough barrierstodiagnosisandaccesstoaTBtreatmentfacility.Oncediagnosed,medicationsforTB treatmentareavailableatadispensarylevelatmostbutnotalllocalpharmacies. Whenfirst diagnosed,patientscommonlyreceivetheirtreatmentataregionalTBclinic.DataregardingTB diagnosisandtreatmentareonlymeasuredintermsofthosewhoareregisteredasstartingTB treatment(knownasacasenotification).ThosewhomayhaveapositivediagnostictestforTB, orthosethatarediagnosedwithTBbyaclinicianwithoutapositivediagnostictest,butdonot laterreceivefollow-upcarearenotcountedasaTBcase.Therefore,dataarelackingwith respecttothepatientsthatcannotgainaccesstotreatmentbecauseofbarriersinaccessinghigh qualitydiagnostics,receivingdiagnosticresults,andlinkingtoservicesforfurtherTBtreatment andsupport.Carecoordinationandtrackingcasesforfollow-upisrelativelydevelopedasallTB casesareregisteredwiththeMinistryofHealth,butthisisdependentuponstaffingand coordinationoflocationsofdiagnosticsandpublichealthclinicsresponsibleforTBtreatment.23 Furthermore,severalbarriersincludingtransportationtotreatmentfacilitiesexist.Forexample, onestudyfoundthat58%offamiliesandcaregiversofchildrenwithTBidentifiedtransportation asabarriertotreatment.1
DespiteincreaseddetectionofTBinTanzania,therearestillprevalentissueswith diagnosis.Themainissueswithdiagnosisincludeacombinationoflimitationsinthemost
advanceddiagnostictoolsandalackofempowermentoffrontlinehealthcareworkerstotest symptomaticpatients.Themostcommondiagnostictoolisasmearmicroscopictest,whichis consideredaninsensitivetestasitoftenunderdiagnosesTB.Moleculartestingfortuberculosis DNAisamoresensitivetest,butisnowacommercialproductsubjecttoitsownsetof stockouts.ThemostcommonmoleculartestistheGeneXpertMTB/RIFtest,referredtoas “Xpert.”TheinternationalconsensusisforallpeoplepresumedtohaveTBtohaveanXperttest performed.However,therearebothlogisticalandtechnologicalchallengesintheuseofthistype ofdiagnosticmachine,whichcompromisesaccess.Similarly,achestx-raywouldalsobe recommendedinthediagnosisofTB,whichcanhavefurthertechnologicalissuesaswell.Some diagnostictestscanbefree,butmayrequirehealthinsurance.Thisleadstothepointaboutthe lowempowermentoffrontlinehealthcareworkerstotestpatientsforTB.Morespecifically,the patientmaybenefitfromrecognizingthesymptomsofTB.Yet,bothpatientsandprovidersare subjecttomisconceptionsaboutwhoismoresusceptibletogetTB.Forexample,manypeople believethatonlypeoplewithHIVoralcoholicsoradultsgetTB.Forhealthcareproviders differentfactorssuchasmonetaryincentivesandworriessurroundingthepatient’sabilityto affordthetestmightleadthemtoinappropriatelyrecommendtestingforsomepeopleandnotfor others.24,25
Health Systems Challenges in Tanzania
ThemainhealthsystemchallengesinthetreatmentofTBincludethelinkagefrom diagnosistocareandthefactthatthereareinadequatehumanresourcestodeliverqualityhealth servicestotheTanzanianpopulationingeneral.ComparedtoSouthAfrica,acountrythatalso suffersfromasignificantTBburden,Tanzania hasa14%higheroverallcommunicabledisease mortalityrateandasignificantlylowerGDP.26 Thissuggestspossiblehealthsystemandfunding challengescombatingthespreadof communicablediseasesinTanzania.According todatafromtheWorldBank,Tanzaniahad roughly0.6physiciansand0.7hospitalbedsper 1,000peopleasof2014.27 TheWHOlistsprevention andprimarycareservicesassomeofthe mosturgenthealthsystemchallenges,aswellasaccesstomedicalcareinruralareas,fundingfor
healthservices,poorhealthcareinfrastructure,andageneralshortageofhealthcare professionals.28
IV. TanzanianInitiatives
Inordertoaddressthehighprevalenceoftuberculosisintheregion,avarietyof organizationshavealreadylaidoutnewstrategiestocombatthisgrowingpublichealthcrisis. Notably,theNationalTuberculosisandLeprosyProgramme(NTLP)wasfoundedbythe MinistryofHealthandSocialWelfarein1977andispartoftheEpidemiologyandDisease Controlsection.Theyproposeseveralobjectivestoaddresstuberculosiswhichinclude increasingcasedetectionratesbyaddressingdisadvantagedgroupssuchaselderly,prisoners, miners,anddiabetics,facilitatingenrollmentoftreatmentanddetectionofMDR-TBby increasingaccessofnewdiagnostictechnologies,ensuringthatTBpatientsaretestedforHIV, andsupportingimplementationofaccessibleandequitabletreatmentanddiagnosisservicesfor patients.29Additionally,thisorganizationoverseesthedistributionofdrugsandsupplies, providinghealtheducationtopatientsandcommunities,andrecord-keeping.
WhatmakesNTLPeffectiveisthatitprioritizescommunityengagementintheTB response,whichhasbeenprovedtobeahighlyeffectivewayinimprovinghealthoutcomes.For example,thisorganizationwasabletoempowerthepeopleofTanzaniabyconsolidating communitymembersashealthvolunteerstocarryouthome-basedtreatmentsupport.This organizationisinstrumentalinempoweringpeopletoknowtheirrightsaspatientsandplaya moreactiveroleinordertoadvocatefortheirowncommunity.Likewise,theyallworktogether tobringawarenessandeducationaboutthesehealthconcerns.
Duringtheprogram’simplementation,itbecamedifficulttomaintainconsistentdata collectionmethodsandthuscomplicatedtheabilitytomonitortheprogressofTBatthe communitylevel.Tocircumventthisproblem,NTLPestablishedastandardcommunity-based andmonitoringandevaluationsystem(M&Esystem)thatwouldbetterorganizedatacollection andhelpwithcoordinationamongNTLPandTBstakeholders.Additionally,theorganization createdawaytoreportcommunityreferralsthroughanelectronicsysteminsteadofapaper system,whichhelpedimprovedatacollection,accuracy,efficiency,andcommunication.
DespitetheseadvancesmadebyNTLP,thereareremainingchallengestoaddress. Tuberculosis,adiseaseofpoverty,isperpetuatedbyone’ssocialandeconomicstatus,andthose thataremarginalizedtendtohavethemostdifficultyaccessingtreatment. Forexample,
transportationanddiagnosticcostsoftreatmentmayplaceaheavyburdenonalow-income individuallivinginaruralareainTanzania.Eveniftheseresourcesareavailable,theymaynot beequitablyaccessibletothosethataredisadvantaged.Recently,thegovernmentofTanzania announcedthatitwillbeginimplementingnewproposalsandstrategiestoachievemoreSDGs by2030(SustainableDevelopmentGoals).Someofthesenewstrategiesincludeexpanding diagnosticserviceswithimprovedtechnology,targetingmorevulnerablepopulationsby addressingbarrierstotreatmentanddiagnosis,andcontinuingtoaddressMDR-TBandHIV.30
V. InternationalInitiatives
ManyinternationalorganizationshavebeeninvolvedinhelpingTanzaniareachitsgoals ofworkingagainsttheriseoftuberculosisintheregion.USAIDisoneofthemanyorganizations thathassupportedNTLP,forexample.Asmentionedbeforehand,theNTLPprioritizes communityengagementandrecognizesitasacrucialstepinempoweringcommunitiesand thosethataremarginalized.USAIDhelpscarryoutthesegoalsbyconductingmasscampaigns forTBdiagnosisandscreeninginprisons,slums,sitesthathaveheavydruguse,miningareas, andotherhigh-riskareas.TheyalsohelptrainTBsurvivorsandcommunity-healthworkersto conducttrace-contactinganddevelopapproachestopreventionandearlydiagnosis.13
AnothernotableorganizationistheGlobalFundthathasactivelyworkedagainstthe developmentofmalariaandtuberculosisbyactingastheregion’sleadingfinancier;itworksto fundthehealthsectorinordertosupportTanzanianinitiatives.Forexample,withGlobalFund support,aninitiativeknownastheQ1inTBCaseDetectionwasintroducedin2016which aimedtoprovideTBscreeningateachentrypointofhealthfacilities.Thiswasaccomplished throughextensivecoordinationandcooperationwithNTLPinordertoprioritizetheprioritiesof localandnationalactors.Infact,after18monthsofimplementation,theGlobalFundwasableto increasenotificationofchildhoodTBcases,increasesuspicionofTBamonghealthworkers,and overallincreasethenationalTBcasenotificationbytwelvepercent.31
Overall,Tanzaniahashistoricallyreceivedalargeproportionofforeignaidwhichhas helpedwithservicedeliveryoftreatmentanddiagnosticsforTB.However,acasestudy conductedin2016showedthatthisfailstobesustainableandforcesTanzaniatorelyonforeign aidfunding,thusexacerbatinginequalitygaps.Additionally,manyoftheorganizationsmaynot addressthefundamentalissuesandarenotholisticintheirapproach.Likewise,sometimesthese organizationsarenotthemosttransparentintheirimplementationtothepeopleofTanzania.32
VI. RemainingChallenges
Thereareseveralremainingchallengesforyoutoaddresswhenconsideringproposalsto mitigatetuberculosisinTanzania.Considersolutionsthataddresssomeorallofthesechallenges whencreatingyourplan.
Regional Disparities
HealthcareprovidersandlocationsinruralareasinTanzaniaaremuchsparserthanin urbanandmoredenselypopulatedareas.TheurbanpopulationofTanzaniaisdistributedacross majorregionalcitieslikeDarSalaam.AsTanzania’scapital,DarSalaamisamajorcommercial andculturalcenterthatalsohostsaconcentratedamountofhealthcareinstitutions,bothpublic andprivateproviders.Whileurbanareasmakestridestowardshealthcareofferings,estimates placetheurbanpopulationnumberofTanzaniaaround21,000,000peopleandtherural populationestimateasnearlytwicethisat38,000,000people.Accordingly,nearly65%ofthe populationresidesinruralareaswhosehealthandcivilinfrastructurelevelscanvarygreatly whencomparedtotheirurbancounterparts,makinghealthcaredeficitsmorepronounced. ThegovernmentofTanzaniahasbeenimplementingaseriesofpolicyandproviderlevel reformssincethe1990s.Partofthiscampaigncreatedalargedegreeofdecentralizationinthe publichealthcaresystem.33 ThedistributionofhealthcarefacilitiesinTanzaniafollowsapro-rich distribution,meaningthatthedistributionofphysiciansclinicalstafflikenursesarehighly correlatedwithagivenregion’saffluence,andthushaveatendencytoclusterinurbanareas.34 Followingthis,thedistributionofcertainmedicalsuppliesanddrugs,suchasantihypertensive andobstetricdrugs,havebeenfoundtobebiasedtowardsmoreaffluentpopulationsratherthan proportionaltotheactualpopulation.
Stigma and Discrimination
Stigmaofhavinghadorbeingacarrieroftuberculosisremainsabarriertocarein Tanzaniaandsurroundingareas.Studieshaveshownthatmuchofthestigmawithtuberculosisis itsassociationwithHIVandAIDS(whichinturnhaveadditionalstigmaassociatedwiththem) aswellasthestigmaofcontagioustransmissionitself.35 Theformerstigmaisoftendrivenbythe factthatHIV,AIDS,andTBhaveahighco-infectionrateinmanyareasofTanzaniaand neighboringcountries,duetotheimmunocompromisingnatureofHIVandAIDSamongother reasons.TBhasalsohistoricallybeenassociatedwithmarginalizedgroupsandthisfearis compoundedbylackofinformationonthenatureofitstransmission.Thiscanleadtoindividuals
avoidingseekingtreatmentoutoffearofbeingidentifiedandthenfacingsocialostracizationor isolation.Finally,variousmixedmethodstudieshaveshownthatelevatedlevelsofstigmacan consistentlypreventappropriatetreatmentregardlessofgender,religion,andagecategories.
Alternative Treatment Approaches
Inaddition,itiscriticaltoconsiderthesocialandculturalimportanceofmythor alternativetreatmentinTanzania’shealthcaresystem.Atypeofmythoralternativetreatmentcan consistofherbalmedicineorconsultingatraditionalhealer.Forexample,studieshavebeen conductedonhowalargemajorityofTanzanianpatientsuseherbalmedicineasawaytotreat andcurethemselvesfromcancers.Likewise,somepatientsrelyonalocaltraditionalhealerto seekguidance,commonlyinruralareasduetoinaccessibilityofhealthcenters.Therefore,rural communitieswouldnothaveaccesstothebiomedicalresourceswhenmodernmedical interventionsmaybeneeded-likeTBdiagnosisandtreatment. 36
Shortage of Trained Health Care Providers
TheWorldHealthOrganizationrecommendsaratioof20clinicalhealthcareworkersfor every10,000individualsinacountry.Tanzania,asacountryofover40millionpeople,routinely suffersfromshortagesoftrainedhealthcareprovidersandinsteadhasaratioofonlyabout5 clinicalhealthcareworkersper10,000individuals.37 Thislackofprovidershasdirecteffectson healthcareoutcomesandcreatesastrainonthenationalsystemofhealthcareinstitutions.One clearexampleofthisisTanzania’selevatedmaternalmortalityrate,whichis25%morethanthat ofneighboringKenya.Whilethegovernmenthascommittedtoemployingandtraining thousandsofhealthcareworkersincomingyears,themajoritybeingdirectedtowardsruralareas, theeffectsofasustainedlackofprovidersinmanyareasremainspronounced.
Public vs. Non-public Providers
StudiesinTanzaniahaveshownthatthereisalowerleveloftrustinpublichealthcare facilitieswhencomparedtonon-publicorindependenthealthcareproviders.38 Addingtothis challengeisthefactthatmanycommunities,especiallyinruralareas,facehightraveltimesand otherobstaclestoutilizingtheirprimaryhealthcenter(PHC).Thosepreviouslyhavingthe diseasecanbereinfectedandthisriskiscompoundedifthetreatmentcourseisnotfully completed.Patientscitelackofdiagnosticcapabilities,lackofappropriatemedication,limited hours,poorservices,andalackofskilledstaffasreasonswhytheywouldratherseekalternative
meansofcareathospitalsorotherhealthcarefacilitiesbesidetheirPHC.39 Manyvillagesalsoare unabletopaythecommunityfeeassociatedwithaccesstopublichealthcareoptions.
Occupational Risks
Tanzaniaisheavilydependentontheagriculture,industrial,andminingsector.However, therearenotenoughsafetymeasuresandregulationsputintoplacetoprotectworkersfrom occupationalrisksinthesefields.Itisestimatedthat70%ofpeopleliveandworkinthe agriculturalfield,yetthissectoralsohasthehighestratesofdeathandinjury.Infact,in2002,a tragicstoryhighlightedthedangersthattakeplaceintheminingindustrywhen40workerswere suffocatedtodeath.However,therearesimilarstoriesthatgounreportedbecauseTanzaniadoes nothaveareliablecoordinatednationalreportingsystem.Minersarecontinuouslyatriskfor contractingtuberculosisduetoexposureofsilicadust,inadequateworkingconditionsthatare poorlyventilatedandcrowded..Duetoaninadequatesurveillancesystem,itismorecomplicated toimplementlegislationtoprotectworkersbecausetheyarenotbroughttotheattentionofthose whocanadvocateforlower-middleclassworkers.Regardingoccupationalhealthservices,they doexist,butlessthan5%ofthoseworkingintheseindustrieshaveaccesstothem.Lackof knowledgeandskillsofoccupationaldiseases,shortageofhealthprofessionals,andlackof fundingareafewofthebarriersaffectingequitablehealthservicesfortheworkingpopulationin Tanzania.40,41
VII. SummaryandYourTask
ThegoalofmitigatingtuberculosisinTanzaniawill requireengagingdiverse stakeholdersandreflectingontheuniqueneedsofitsvariouspopulations.42 Throughyour planning,youshouldreflectonhowtoengagewithcommunity-basedstakeholders(ie:the public,patients,healthcenters,andclinicians)aswellasthegovernmentatvariouslevels.Be suretoaddresscultural,social,economicfactorswhencreatingyourplan.Yourtaskisto incorporateaprogramthat:
● Workstodeliveracomprehensiveinitiativewithanemphasisonequalityofaccessto healtheducationalresourcesandinequalityreduction
● Considersareasandpopulationsthataredisproportionatelyaffectedbythesocial determinantsofcontractingtuberculosisandhealthcareinequalities,especiallyinrural andotherunderservedareas
● Mobilizesthecommunitytoworktowardsempowermentfortuberculosismitigation whileworkingtoreducemisconceptionsoreducationalgaps
● Strengthenscommunityinvolvementwithkeystakeholderssuchasthecommunityand healthcareprovidersandlocations
Inaddition,thereareseveralcentralquestionstotakeintoconsideration,butdonotfeel theneedtoanswerallofthem:(1)Howwillyourprogramproperlyadvancetuberculosis mitigationinthepopulationdespitethedifficultiesassociatedwithtreatingthoseinunderserved populationsorareas?(2)Howdoweassureaccessibilityandactiveengagementbetween communities,individuals,andstakeholders?(3)Howwouldyouconsiderlong-termimpacts suchasthesurgecausedbyCOVID-19inconjunctionwiththeremainingchallenges?(4)What fundingsourceshaveyouincorporatedintoyourproposedsolutionandhowmuchwillit ultimatelycost?Iftherearestagestoyoursolution,besuretoconsidereachstageindividuallyas wellasthetotalcost.Providealsoabudgetandrationaleforyourproposalthatmakessenseto achieveyourdesiredgoals.Yourteammaychoosetofocusononeaspectofensuringa comprehensiveprogramortakeonmultipleprojects.
Goodluck!
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Special thanks to Hamna Shafiq, Eliza Piche, Cyrena Matingou, and Julia Barua for research and editing contributions!