Leveraging primary healthcare to address the double burden of disease and advance universal health coverage: lessons from Tanzania´s First International Primary Healthcare Conference

¹School of Public Health, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania, ²Department of Obstetrics and Gynaecology, Muhimbili University of Health and Allied Sciences, Tanzania, ³Department of Public Health, University of Dodoma, Dodoma, Tanzania, ⁴President´s Office, Regional Administration and Local Government, Dodoma, Tanzania, ⁵Department of Mathematics, University of Dar es Salaam, Dar es Salaam, Tanzania

^&Corresponding author
Jackline Eugene Ngowi, School of Public Health, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania

Introduction    

Primary healthcare forms the main gateway to the health system, serving over half of the population in most settings [1]. It is supposed to be structured in such a way that it promotes principles of universal access and equitable coverage; comprehensive care emphasizing disease prevention and health promotion; community and individual participation in health policy, planning, and provision; intersectoral action on health determinants; and appropriate technology and cost-effective use of available resources [2]. Thus, well-equipped and properly functioning PHCs are vital for improved and ensured quality healthcare.

Persistent burden of communicable diseases and rapidly rising prevalence of both injuries and non-communicable diseases present a significant challenge to resource-constrained and poor health systems in low-and middle-income countries (LMICs), including Tanzania [3,4]. Addressing these demands requires policy and structural reforms, increased investment in infrastructure, human and financial resources, referral and community health systems, among others, at the primary healthcare level [5,6]. Prior research has underscored the necessity of a holistic approach, emphasized community-based interventions, and integrated services at primary care facilities [5-7]. However, the specific mechanisms required for successful implementation and the variations in effectiveness across different approaches remain poorly understood [5,6]. Various strategies have been implemented in Tanzania to address this challenge, yet their mechanisms and efficacy may differ [8,9]. Understanding the strengths and weaknesses of these approaches is essential for tailoring interventions to local contexts and optimizing healthcare delivery.

Tanzania has made relevant policies change to advance the Universal Health Coverage (UHC) agenda. Several commitments, reforms, and actions have targeted key dimensions of UHC, such as equity, quality, and financial risk protection for health [9-11]. The Tanzania health system is decentralized, with the PORALG overseeing health services at the primary healthcare level, comprising the community dispensaries, health centers, and district hospitals. As the first point of service, primary health facilities in Tanzania offer screening, case detection, management, and referral when needed [9].

In 2024, PO-RALG launched the first International Primary Health Care Conference to draw lessons from available evidence and generate actionable recommendations, and optimize primary healthcare for quality service delivery and enhanced patient outcomes. The three-day conference convened diverse stakeholders, including policymakers, religious organizations, development partners, implementing partners, primary healthcare providers, regional and district medical teams, and academic institutions from within and outside Tanzania. The theme for the conference was “PHC as a Vehicle for the Journey to Achieve UHC in Tanzania.” This paper summarizes key lessons from the conference on how Tanzania is leveraging primary healthcare to advance universal health coverage and address the double burden of disease.

Methods     

Design and context: the conference committee received a total of 290 abstract submissions, 145 of which were accepted, including 30 focusing on communicable diseases and NCDs. Six of the abstracts were later excluded for not originating from the PHC setting. We conducted a thorough desk review of the abstracts and other relevant conference documents to identify themes, presentations, and proceedings on progress towards attaining UHC in Tanzania. The conference also involved keynote speeches, panels, and satellite discussions. All materials were compiled in the form of abstract books and conference proceedings, which were subsequently reviewed to generate valuable insights for this manuscript.

Data collection: the data collection involving document review was informed by the research questions of what progress is and what measures are needed to accelerate efforts towards attaining UHC Tanzania. We reviewed conference documents and summarized information on successes, challenges, and recommendations for attaining UHC in Tanzania. JEN and MK independently conducted this process, after which the authors triangulated the codes.

Data analysis: descriptive content analysis was used to develop categories that guided the results for this write-up inductively [12,13]. Synthesis of the abstracts was done to develop meaningful and condensed units. Then, codes were developed and created, which informed the formation of categories. Information from the audio recordings was transcribed and translated verbatim, and relevant data were extracted. These data were then triangulated with information from other conference documents during the category formation phase. The other authors received the codes and categories for discussion, and upon final agreement, we developed specific categories.

Ethical consideration: ethical approval was not required for this evaluation due to the nature of the evidence used. The evaluation team included scientists and researchers from the Muhimbili University of Health and Allied Sciences, the Ministry of Health, PO-RALG, and other implementing partners.

Results     

From the analysis, we identified six categories emerging from the conference discussions and reviewed documents, namely: data-driven decision-making, sustainable financing for PHC service integration, integration of NCD services into existing programs, the role of community health workers in care continuity, political will in driving health interventions, and capacity building for improved health system performance.

Data-driven decision-making in PHC: by leveraging routinely collected and primarily gathered data, policymakers gain valuable insights into community health issues, risk factors, and demographics. These insights inform the design and implementation of interventions tailored to specific needs, ultimately leading to more effective disease control and prevention outcomes. An exemplary demonstration of this theme is the initiative to combat schistosomiasis in rural villages of the Kilimanjaro region. By analyzing DHIS and primarily household data collected through prevalence studies and interviews, policymakers identified the escalating prevalence of schistosomiasis and its associated risk factors. The information led to targeted interventions of mass drug distribution, and educational campaigns were initiated to address the issue. The combination of data-driven decision-making and community engagement led to significant progress in mitigating the impact of schistosomiasis and improving public health outcomes in the affected villages.

Challenges and opportunities in PHC funding for service integration: adequate funding supports the operationalization of PHC facilities, leading to better service delivery and higher uptake of health services, highlighting the importance of financial resources. A substantial portion of these funds comes from donor organizations, creating a disparity in performance between funded and unfunded facilities, with the latter struggling to maintain service standards. A review of the national Prevention of Mother-Child Transmission (PMTCT) data comparing donor-funded and non-funded facilities revealed that donor-funded facilities had significantly higher rates of antiretroviral therapy (ART) initiation and HIV testing for exposed infants within the first two months of birth. Discussions from the healthcare financing forum emphasized a shift from donor-dependent to domestic funds generation through health insurance schemes, community healthcare funding, and national insurance as a key area for sustainability.

Barriers to systematically integrating NCD services in other existing programs: an exploratory study among key stakeholders revealed factors affecting the integration of NCDs into vertical programs like HIV/AIDS healthcare services in Tanzania. Human resources and funding were crucial organizational factors for successful integration. These efforts are hindered by perceived additional costs and the differing priorities of donors. Funds are often earmarked for specific purposes, restricting facilities' ability to allocate resources where they are most needed, thus impeding a holistic approach to healthcare delivery.

The role of community health workers in patient support for continuum of care: community health workers play a significant role in supporting patients across the continuum of linkage to patient care. In Mahenge, CHWs were trained to prevent epilepsy-related accidents, distribute anti-seizure medications, and monitor seizure-related events every month. This led to earlier symptom recognition and reduced stigma surrounding epilepsy. Community health workers facilitated communication between healthcare providers and the community, enhancing care coordination. A follow-up assessment showed decreased seizure episodes for those who attended and had frequent clinic visits.

Political will as a driver of interventions in health: analysis from the m-mama program evaluation elaborated on the benefit of policymakers' buy-in in program sustainability and scale-up. The government's involvement is central in mobilizing resources and maintenance, including budgeting, staffing, and infrastructure. Early involvement and co-creation with policymakers are vital for maintaining the momentum and efficacy of health interventions.

Capacity building for health system performance: capacity building at both facility and community levels enhances service delivery, patient outcomes, and overall system performance. For instance, a study tracking healthcare workers and community workers in NCD clinics reported improved patient outcomes through improved adherence and overall high patient satisfaction. Capacity building is also crucial for effective service integration demonstrated in the incorporation of gender-based violence (GBV) in family planning services. HCWs received training to identify GBV/VAC (Violence Against Children) survivors and refer them to appropriate care. The approach led to an increased number of reported incidents over the year and timely referrals. At the community level, awareness initiatives further addressed individual and community norms hindering survivors from accessing integrated services.

Discussion     

This paper documents the lessons from the first IPHC in Tanzania regarding providing strategies for service delivery in the PHC setting in an effort to achieve UHC. The conference underscores the importance of data in planning evidence-based interventions for a particular health challenge. Analyzing and utilizing routinely collected data offers valuable insights into disease trends, leading to understanding disease prevalence, treatments, and outcomes [14-16]. This highlights the need for high-quality data entry and systematic evaluation to enhance the value of healthcare research and management [14,15]. The quality of data and its utilization is a significant concern in LMICs, including Tanzania, and are attributed to the limited capacity for data extraction, interpretation, and analysis. Thus, it is essential to ensure quality data collection and synthesis through regular and refresher training for healthcare providers and facility administrators [14,15]. Proper understanding and use of data will prevent jeopardizing implementation efforts and sustain gains [17]. Triangulation of findings from the administrative data and programs can potentially inform data-driven decisions [18,19]. Dissemination to stakeholders in respective departments and electronic archives will prevent duplication of work and form a basis for further analysis and monitoring of trends over time. It also fosters transparency, accountability, and democratization of the research processes, allowing a sound, evidence-based analysis of the impacts of health policies [20].

The convergence of NCDs and infectious diseases in LMICs presents new challenges and new opportunities to enact responsive changes in policy and research [21]. The data from the conference provide evidence that the integration of services at PHC facilities in Tanzania is still suboptimal. Integrating NCD services into infectious diseases vertical programs can potentially address the double burden of diseases [22]. Integration of services encourages the improvement of health service delivery across disease conditions and levels of care to address the combined burden of diseases [23]. It also enhances clinical outcomes for patients with NCDs, like hypertension and chronic infectious diseases such as HIV [24]. Historically, many funds have been allocated to addressing infectious diseases and maternal and child health (MCH) in Tanzania. However, the growing double disease burden threatens the efforts made over the years. Of the total spent on health care, HIV/AIDS programs account for a sizeable 27%, malaria for 19%, and reproductive health for 18% [25]. Integrating NCD long-term or palliative care with an HIV care program is a win-win situation since both cater to long-term care and support as a part of the program [24]. For instance, gestational diabetes has a greater risk of poor outcomes in pregnancy; hence, control of gestational diabetes in the MCH programs can help. There are many different service integration models, and more information is needed on the country's context, cost, and capacity required.

Data from the conference provides evidence that achieving the ambitious goal of universal health coverage (UHC) necessitates a well-supported health financing system. Healthcare financing in Tanzania, like in many resource-strained countries, is significantly supported by international donors, who contribute up to 40% of the health budget. While donor funding provides substantial benefits, it also presents challenges due to its inflexibility and lack of sustainability, weakening the country's progress towards UHC. Despite its proven cost-effectiveness, externally funded service integration faces challenges in initiation and implementation [26]. Therefore, mobilizing more local resources and fostering innovative approaches is imperative to ensure equitable access to quality healthcare for all citizens. LMICs should consider health financing system reforms to accelerate progress toward UHC [27]. Financing reforms should, therefore, not only consider how to generate funds for health care but also explicitly address the full range of affordability, availability, and acceptability barriers to access to achieve equitable financing and benefit incidence patterns [28].

Community health workers play a significant role in supporting patients through continuous linkage to care, advancing service delivery, and improving patient outcomes. Their effectiveness in prevention, health promotion, and curative services, with proven cost-effectiveness, is well documented in both NCDs and communicable diseases [29-32]. However, CHW programmes face persistent challenges, including poor planning, uncoordinated involvement of multiple implementing partners, disease-specific and siloed structures, weak integration with the formal health system, competition among non-governmental organizations (NGOs), and unclear roles and responsibilities [33,34]. Compounding these challenges are parallel initiatives that receive separate funding, operate independently, and report in isolation, limiting collaboration, shared learning, and sustainability. To advance progress toward UHC, the World Health Organization recommends embedding CHW programmes within national health systems, with clearly defined roles, fair incentives, ongoing training, strong community linkages, sustainable funding, and coordinated action at all levels [35].

The IPHC conference brought together a dynamic and well-mixed group of stakeholders to discuss outputs from their work, challenges, and lessons learned. This further complements the government´s effort in providing and implementing health services in Tanzania and shows the country's political will towards achieving universal health coverage. Understanding evidence and the sociocultural context positively influences political will and has successfully improved other health services [36]. This calls for more open dialogues and platforms where stakeholders in health can share their findings. An established repository for research reports will be a good start for all to share findings, receive inputs from others, and avoid duplication of effort.

A unique feature of the conference was the presentation of case studies and best practices from the healthcare providers, usually directly involved in service provision. This presents a strong case for capacity building on data quality, management analysis, and interpretation issues. The involvement of healthcare providers in ongoing research projects or programs is a good starting point and will ensure retention of skills by the end of the programs, promoting sustainability. Policy interventions are also crucial to support the integration of services and foster a flexible healthcare system capable of simultaneously addressing infectious diseases and NCDs. By focusing on prevention and early intervention at the PHC level, Tanzania can mitigate the dual burden of diseases and improve health outcomes for its population.

Conclusion     

Utilizing data for informed decision-making in primary healthcare enables policymakers to design targeted interventions. Sustainable funding through local mobilization is essential for consistent service delivery. Integrating NCD services with existing programs faces challenges due to resource constraints and donor priorities. Community health workers improve health outcomes by enhancing care coordination. Political will is crucial for health intervention success and uptake. Capacity building at the facility and community levels improves healthcare outcomes. Therefore, a collaborative, multi-stakeholder approach that actively engages policymakers, healthcare providers, and communities is essential for strengthened PHC and achievement of UHC.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

Conceptualization: Jackline Eugene Ngowi, Mageda Kihuya, Amani Kikula. Formal analysis: Jackline Eugene Ngowi and Mageda Kihuya. Writing-original draft: Jackline Eugene Ngowi, Mageda Kihuya, James Tumaini Kengia. Validation: Amani Kikula, Davis Elias Amani, Belinda Njiro, Pius Kagoma, James Kengia, Bruno Sunguya, Charles Mahera, Paulo Chaote, Kasusu Klint Nyamuryekung'e. Writing-review and editing: Jackline Eugene Ngowi, Mageda Kihuya James Tumaini Kengia, Pius Kagoma, Davis Elias Amani, Amani Kikula, Kasusu Klint Nyamuryekung'e, Bruno Sunguya. All the authors have read and agreed to the final version of this manuscript.

Acknowledgments     

The authors wish to extend sincere gratitude to the Ministry of Health (MoH) in Tanzania, the President’s Office-Regional Administration and Local Government (PORALG), MUHAS and UDOM, the World Health Organization (WHO), UNICEF, and all implementing partners for their invaluable support and guidance throughout the first International Primary Healthcare Conference 2024 held in Dodoma, Tanzania.

References