FOR decades, Reproductive Maternal Neonatal Child and Adolescent Health (RMNCAH) has been among the top health priorities of the government of the United Republic of Tanzania.
Yet, maternal mortality ratio in Tanzania remains relatively high with approximately 238 deaths per 100,000 live births (2020), which is beyond the ambitious Sustainable Development Goal (SDG) 3 target less than 70 per 100,000 births.
Similarly, infant mortality rate in Tanzania remains to be 34.1 per 1,000 births, whereas SDG 3 target requires neonatal mortality to at least be as low as 12 per 1,000 live births, and under-five mortality to be at least as low as 25 per 1,000 live births.
Statistical values show that although there has been great improvement in Tanzania over the past years, there is still a long way to go. It is not surprising to see the proposed proportion of the governmental budget for the 2023/24 fiscal year dedicated to RMNCAH in Tanzania.
Minister for Health, Hon Ummy Mwalimu has proposed to strengthen the implementation of vaccination interventions for children by allocating Sh114.3 billion, strengthening health care delivery through provision of medical equipment, medicines and safe blood by allocating Sh205 billion, and strengthening RMNCAH services specifically to reduce maternal and infant deaths by allocating Sh16.2 billion.
Hon Mwalimu has also proposed to allocate Sh83 billion to human resource planning to strengthen availability of health service providers, including community health workers, in which the Ministry of Health has also proposed to initiate an 'Integrated Community Health Workers' Programme'.
Nevertheless, it is of great importance to consider the mechanisms of maximising results from limited fiscal resources.
This includes communicating with stakeholders including multilateral/bilateral partners and Non-Governmental Organisations (NGOs) to better coordinate their efforts that align with the Tanzanian national strategic plan.
Well-integrated and well-coordinated Programmes whether that is government funded, or donor-funded, may bring synergistic effect that can bring immediate impact on the community (an example will be explored in the next paragraph).
Adding on, in the case of ameliorating RMNCAH, it is vital to not only consider vertical approaches (such as direct provision of RMNCAH services) but also horizontal approaches simultaneously which would strengthen primary healthcare and the health system of the nation.
An example of 'optimal integration and coordination' to improve RMNCAH can be explored through the 'Three Delays Model' framework. This framework proposes that pregnancy-related mortality is due to three delays, first being the delay in deciding to seek care (socioeconomic and cultural factors), second being the delay in reaching care (accessibility), and the third being the delay in receiving adequate care (quality of care).
Keep in mind that both accessibility and quality of care may be factors that affect the first delay. Multi-faceted barriers from delay one to three hamper access and utilisation of emergency obstetric care in Tanzania, and hence an optimal-coordination would mean having to coordinate Programmes that can intervene in each delay so that none of the delays will take place and ultimately those who are in need of care can receive timely and adequate services.
Korea Foundation for International Healthcare (KOFIH), a government-affiliated organisation under the Ministry of Health and Welfare of the Republic of Korea, has been supporting Tanzanian health sector through bilateral ODA (grant aid) projects.
KOFIH has been implementing projects such as 'Health System Strengthening Project Focused on RMNCH in Pwani Region" from 2016 to 2023, as well as 'Capacity Strengthening Project on Emergency Obstetric and Newborn Care (EmONC) in Dodoma Region' from 2021. Specific activities include provision of medical equipment and ambulances, refurbishment of health facilities, and capacity building of healthcare providers.
KOFIH supported activities mainly focused on improving the third delay- 'receiving adequate care', although procurement of ambulances may have contributed to improve the second delay, 'accessibility'.
As mentioned in prior, 'synergistic effect' will take place with great integration and coordination of different RMNCAH Programmes.
Recently, 'mmama initiative', an innovative emergency referral and transport system which enables pregnant women to contact local taxi drivers through an app, was launched nationwide to tackle the delay in reaching care (accessibility).
M-mama initiative has started in regions that have been supported by KOFIH including Dodoma region from November 2022, and in Pwani region from September 2023.
What I expect to see in the near future is the synergistic effect of KOFIH supported activities and m-mama intervention which will hopefully show through the reduction in maternal and infant mortality.
I believe that what may seem to be the simplest - delay in decision to seek care (delay one)- may actually be the most difficult delay to tackle.
This is because the first delay is induced by socio-political, cultural and economic determinants which cannot be transformed in a short duration of time.
For example, even with the introduction of one dose human poliomavirus (HPV) targeting school-aged girls from 9 to 14 supported by Gavi, the Vaccine Alliance (GAVI), without proper demand due to lack of education or awareness among parents, the first delay will hamper the uptake of HPV vaccination.
Thus, KOFIH has considered to incorporate sensitisation of HPV vaccination and raise awareness to create demand whilst GAVI focuses on the supply side during the second phase of the RMNCAH project in Pwani Region (2023-2027).
Beyond the socio-political, cultural and economic determiants of health, other approaches which affect the decision to seek and receive healthcare such as gender transformative approaches, youth friendliness, mode of communication (IEC/BCC) are as equally important.
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Gender transformative approaches seek to challenge gender inequality by transforming harmful gender norms and relations, while working towards redistributing power, resources, and services more equally, and is a vital component to consider when dealing with RMNCAH in Tanzania.
As a matter of fact, it is widely known that male involvement in RMNCAH is likely to improve RMNCAH outcomes.
Likewise, youth friendly services (YFS) encourage health-seeking behaviours among youths, which is vital when considering the high adolescent pregnancy rate in Tanzania. Last but not least, Information Education Communication (IEC) and Behaviour Change Communication (BCC) will promote positive health behaviours which are appropriate to the current social conditions.
Having an IEC and BCC approach is expected to have a positive impact on healthcareseeking behaviour including improved Antenatal care (ANC) and Postnatal care (PNC visits), uptake of HPV vaccination and other RMNCAH services.
All in all, intersectoral and multisectoral approach is vital to ameliorate RMNCAH, and will contribute to strengthening primary health care and ultimately the health system of Tanzania. As discussed in prior, well-integrated and well-coordinated RMNCAH Programmes implemented by different health partners will enable synergistic effect which will immediately show impact on the health of the community in Tanzania.
Written by Ms Hayoung Gloria Kim, Country Office Coordinator of KOFIH Tanzania Office
