Using Research to improve reproductive, maternal, newborn, child, and adolescent health services in primary health care in Tanzania: highlights from the international primary health care conference

¹Department of Obstetrics and Gynecology, Muhimbili University of Health and Allied Sciences, Tanzania, ²Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium, ³Global Health Institute, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium, ⁴Department of Public Health, University of Dodoma, Dodoma, Tanzania, ⁵Department of Health, Social Welfare and Nutrition Services, President's Office - Regional Administration and Local Government, Dodoma, Tanzania, ⁶School of Public Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania, ⁷School of Dentistry, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania, ⁸Mathematics Department, University of Dar es Salaam, Dar es Salaam, Tanzania

^&Corresponding author
Amani Idris Kikula, Amani Idris Kikula, Department of Obstetrics and Gynecology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania

Introduction    

The United Republic of Tanzania is striving to achieve its Global commitments to SDG 3, which aims to reduce the Maternal Mortality Ratio to less than 70 per 100,000 live births, Under-five Mortality Rate to less than 25 per 1000 live births, and the Neonatal Mortality Rate to less than 12 per 1000 live births by 2030 [1]. Reports from the Tanzania Demographic and Health Survey - TDHS (2022), Household Census (2022), United Nations (2023), and Routine data (2022) show an over 80% decline in the maternal mortality ratio at 104 from 556 deaths per 100,000 live births in 2015 [2-5]. The TDHS (2022) shows a decline in the under-five mortality rate per 100 live births from 67 in 2016 to 43 in 2022 [5] while the neonatal mortality rate per 1000 live births has not gained significant improvement over the years, from 26 in 2010 to 22 in 2022 [5-7].

Several political and policy interventions have been ascribed to contribute to the achievements in improving maternal and newborn health in Tanzania. These include the launch of the Strategy for Primary Health Care Development under President Jakaya Mrisho Kikwete (2007), Reproductive, Maternal, Neonatal, Child and Adolescent Health (RMNCAH) Sharpened One Plan by Kikwete (2014 - 2016) [8-10]. There was also the construction of Comprehensive Emergency obstetric and Neonatal Care (CEmONC) health facilities under his excellency President John Pombe Magufuli and her excellency President Samia Suluhu Hassan (2015-to date). The launch of the “Jiongeze Tuwavushe Salama” campaign under President Samia Suluhu Hassan (2018) and the signing of nutritional contracts between the president and regional commissioners under President Samia Suluhu Hassan (2022) have been cited as one of the catalysts for these documented changes [11,12]. Additionally, there has been a noted increase in training and deployment of the health workforce in specialized competencies responding to RMNCAH [8]. Apart from these initiatives, there were guiding documents developed for policy guidance on health in Tanzania, which included, but were not limited to, the national health policy, One Plan, and the health sector strategic plans [9,13,14], which provide a guiding direction for health planning and promotion.

Primary health care (PHC) plays a vital role in the implementation of all strategies and interventions developed by the government, including those related to RMNCAH. PHC forms the base of the pyramidal structure of health care services and is Tanzania´s health system foundation. About 98% of all health facilities in Tanzania are primary healthcare facilities, including dispensaries, health centers (most of them being CEmONC centers), and district hospitals [15]. In line with its mandate of overseeing and implementing policies, guidelines, and setting standards, the President's Office-Regional Administration and Local Government (PO-RALG) organized the first iPHC from 25^th to 27^th March 2024. The conference aimed to promote research dialogue and share best practices to strengthen the quality of PHC services, striving to effectively attain national health goals. More specifically, the conference aimed to provide a platform for sharing progress and discussion of national and international efforts in PHC system strengthening.

The PHC serves over two-thirds of the Tanzanian population seeking RMNCAH services. This makes the documentation of the efforts and progress through research presented at this conference, being crucial for increasing the scientific evidence at this level. This will enhance understanding, achievements, planning for the future, and making informed decisions from lessons learnt [16]. This paper extracts the progress of RMNCAH services and ongoing interventions in the PHC setup based on the abstracts submitted and presented at the first iPHC conference.

Methods     

Study design : we conducted a desk review from 1^st July to 12 July 2024 to analyze all abstracts submitted to the conference. Out of 290 total abstracts, 145 were accepted, with 40 falling within the RMNCAH subtheme. Out of these, only 25 authors agreed for their work to be used for research publication purposes. Table 1 shows the steps taken in sorting the submitted abstracts for the iPHC to the final abstracts used for analysis. Of the included abstracts, four were excluded due to findings not emanating from the primary health care setup. Thus, current findings are based on a total of 25 analyzed abstracts. The information collated from the abstracts was supplemented by a review of audio recordings from the conference sessions, including forum discussions and keynote speeches, to get an overall picture of the conference proceedings. These were accessed through the conference digital portal [17]. None of the information from the audio was used in the analysis process. Descriptive content analysis was used to inductively develop codes and categories [18,19]. The desk review was done by AIK and LK, first independently, then followed by analysis of generated evidence through author triangulation of the codes. Information from the audio recordings was triangulated during the category formation phase. The developed categories were further discussed among the other authors, and upon final agreement, we developed three categories.

Results     

From the 25 abstracts included in the final analysis, we identified areas that the authors focused on. We grouped these as categories, which included: 1. Research on perinatal and preventive health care services 2. Research on improving pediatric, adolescent, and youth health, and 3. crosscutting improvements in the provision of PHC RMNCAH services in Tanzania. Table 1 summarises the linkage of the categories with codes.

Research in perinatal and preventive health care services: authors highlighted numerous efforts that were implemented to enhance perinatal health care services within Primary Health Care (PHC), covering the pregnancy, delivery, and post-natal periods. During pregnancy, preventive strategies for pre-eclampsia, such as using lower doses of calcium and addressing the delay in seeking health care by employing mobile service providers (m-mama) have proven effective. Additionally, empowering perinatal healthcare workers through peer experts had significantly improved the uptake of intermittent preventive treatment (IPT) services, increased HIV screening among men, enhanced skills retention in emergency obstetric care, and reduced unnecessary cesarean sections. When it came to postnatal care (PNC) services awareness, the authors showed that it remained low among women and care providers responsible for delivering these services. While other submitted abstracts showed that pairing women with service champions or peer health educators for family planning and HIV services had notably increased the uptake and compliance with these services, particularly in the immediate postpartum period. Furthermore, the utilization of community health workers (CHWs) for community sensitization improved family planning uptake among post-delivery mothers in these facilities. These are ´low-hanging fruit´ in the improvement of postnatal care services.

Crosscutting improvements in provision of RMNCAH services in Tanzania: in councils with well-documented services, notable milestones were presented to be achieved in the provision of sexual and reproductive health care (SRH). One key milestone was the marked improvement in the quality of basic and comprehensive emergency obstetric services. This advancement was attained through deliberate and collective engagement efforts at all levels of the health system. Another significant milestone was the successful enhancement of service delivery, which reflected the sustained commitment to improving maternal and child health outcomes through the improvement of human resources, facilities, and medical supplies. However, it was important to address the persistent delays in seeking existing SRH services at PHC facilities, which remained a critical area for further improvement.

Discussion     

This paper documents efforts in place by multiple stakeholders to improve RMNCAH services within the PHC setup, as presented during the iPHC conference. We highlight the research findings on service delivery within the PHC setting in reproductive health, perinatal, pediatric, adolescent, and youth services. This is also coupled with the documentation of the presented crosscutting improvements within the RMNCAH in the PHC setup. The primary healthcare system offers unique circumstances for conducting research conduct and utilizing the generated evidence to inform practice [20]. Historically, there has been an overreliance on generated evidence from secondary and tertiary-level facilities to inform practice across the spectrum of health service delivery in the country [21]. Considering the differential level of resources and diverse context variabilities across health facility levels, this evidence has not always been able to be successfully implemented in the PHC setting. The lack of nuance in the proposed interventions has largely resulted in suboptimal gains within the PHC setup. Among the efforts put in place, the iPHC conference offered a forum for all stakeholders working in the PHC to share research findings generated at this level. This is believed to stimulate and enhance evidence-based practice within the PHC using evidence generated from within.

The area of RMNCAH, where the majority of services, by policy, are to be offered freely or by cost-sharing in Tanzania, requires not only to be approached using a different lens but should be prioritized since it serves over 95% of the Tanzanian population [22]. It's within this same area where funding for research or research training is minimal, rendering the healthcare workers with minimal skills and motivation for using the massive existing data to inform their practice [23,24]. This goes in parallel with a multitude of donor-funded research projects developed outside the PHC setup but operating within the Tanzanian PHC context. With this in mind, there is a need for an adaptable modality to capacitate frontline stakeholders in generating evidence from the PHC to inform their practice, with the native spearheading the research activities. A highlight from the submitted abstracts during the conference showed how peer learning can improve the uptake of a multitude of RMNCAH services. Pairing with capacitated peers of first-time mothers improved the uptake of postnatal care services offered. But also, when providers were trained by peers on obstetric emergencies, the retention of skills was observed to be lasting. Hand in hand with this, the use of family planning-capacitated community health workers significantly improved the uptake of family planning services in the involved communities. This has been observed in other fields of health service provision elsewhere and theorized to be due to the trainees or recipients being easily relatable to the people providing the information [25-27] as underpinned by the social constructivism theory [28]. We call for the generation of more evidence in other spheres of RMNCAH services to utilize peer learning within the PHC set up to scale up more of the ongoing services.

Most submitted abstracts were based on efforts to improve antenatal care and delivery services. As important as this area is for the promotion of a positive perinatal experience for the mother and her family, other areas need similar attention within the PHC. Of particular interest, due to the demographic pattern, adolescent health needs further attention, as they cover over a quarter of the country´s population, and they need specialized attention to address their challenges [29]. For all the analyzed abstracts, the majority were donor-funded research or funded projects in the councils or facilities. While this is the case for most other areas in the global community, the PHC RMNCAH requires substantial capacitation and self-funding for its research activities. This will not only promote ownership of the findings but also generate a culture for context-specific evidence-based practice [24,30]. For this paper, we limited ourselves to submitting abstracts upon submission, and authors agreed for the abstracts to be used for publication. This excluded abstracts that may have added value to the described research efforts on RMNCAH within the PHC in Tanzania. However, the selected abstracts for this work gave an overview of the efforts put forward in enhancing research in PHC while also showing the existing potential that, if utilized, can build on the already existing research framework to inform practice in this health niche. Despite this, we acknowledge the descriptive nature of the results, which were mainly due to only having access to the abstracts and not the full manuscripts or research reports.

Conclusion     

The primary health care setup offers a forum for RMNCAH research, which, when fully utilized, can generate valuable, needed evidence to ensure the resilience of the health system. This can be attained through investment in research funding and research capacitation of the PHC workforce.

Competing interests     

The authors declare no competing interest.

Authors' contributions     

Conceptualization: Amani Kikula, Leonard Katalambula, Jackline Ngowi, and Kasusu Klint Nyamuryekung'e, Pius Kagoma, James Kengia. Formal analysis: Amani Kikula, Leonard Katalambula. Writing-original draft: Amani Kikula, Leonard Katalambula, James Kengia. Validation: Amani Kikula, Davis Amani, James Kengia, Bruno Sunguya, Charles Mahera, Paulo Chaote Kasusu Klint Nyamuryekung'e, Rashid Mfaume, Grace Magembe. Writing-review and editing: Amani Kikula, Jackline Ngowi, Pius Kagoma, James Kengia, Kasusu Klint Nyamuryekung'e, Ali Said. All the authors have read and agreed to the final manuscript.

Table and figure     

Table 1: analysis process showing the development of the categories from the meaningful units

Figure 1: flow of selection of the abstracts for analysis

References