Tanzania

Background

The Government of Tanzania recognizes the importance of family planning and maternal health to both the nation’s health and economy, and is one of the few countries with a national costed implementation plan for family planning. Despite its commitment to these important issues, an underfunded health sector and decentralized health care services continue to plague the health of women and their families. As a result, maternal and newborn mortalities remain high, and 25 percent of women continue to experience unmet demand for family planning. With current fertility and mortality rates remaining stable, Tanzania’s population is projected to reach 66.8 million by 2025—which could have detrimental effects on the economy and health of the population.

The Tanzanian government, like many others in sub-Saharan Africa, has pledged to curb maternal and newborn death rates, expand the use of contraceptives, and reduce the average number of children borne by each woman. To meet these national and international goals, however, the government will need to back its political commitments with increased financial investments in family planning and maternal, newborn and child health (MNCH). To date, funding from donors has helped the country improve in these areas, yet there is great concern among advocates that progress will not be sustained without ensuring increased government resources.

A New Approach to Advocacy (National)

Working with Pathfinder International and with support from the US Agency for International Development Tanzania Mission, E2A instituted a new approach to advocacy, which was designed to ensure the Government of Tanzania’s investments in family planning and MNCH services have the greatest possible impact. Through this approach, the E2A/Pathfinder team gained greater understanding of the reasons why advocacy efforts to date have not yielded desired results and developed a program that included specific and appropriate advocacy asks for key stakeholder groups. These groups included policy makers, influential and religious leaders, civil society advocates (including the media), and Council Health Management Teams. The ultimate aim of these efforts was to increase national and district commitments to contraceptive services regardless of external funding.

The E2A/Pathfinder team in Tanzania learned from surveys with parliamentarians and religious leaders that both groups generally support family planning. Religious leaders expressed a particular willingness to encourage family planning use, and efforts are ongoing to mobilize both groups to advance family planning acceptance and funding. As another way to strengthen the platform for advocacy, the E2A/Pathfinder team commissioned a research policy paper on the demographic dividend based on an economic analysis of the situation in Tanzania. That paper, written by the University of Dar es Salaam Economics Department, highlights the impact of rapid population growth on education, employment, the health sector, and the economy. You can read key findings from that paper, here.

In addition to these activities, other efforts to develop an effective approach to advocacy included:

• Convening meetings of an established advocacy network of civil society organizations to identify, articulate, and establish consensus on concrete advocacy asks that are appropriate for each of the four stakeholder groups mentioned above.
• Holding quarterly forums with family planning/MNCH advocacy organizations to review successes and setbacks, and to determine ways of addressing the challenges and advancing family planning and MNCH issues.

Expanding Method Mix through the Community-Based Provision of Standard Days Method® (Shinyanga Region) and Use of a Mobile App

E2A is also working with Pathfinder International in the Shinyanga region of Tanzania to introduce the Standard Days Method® (SDM) as part of the national response to reducing unmet need for family planning. Shinyanga is a rural and largely Catholic community with inadequate health infrastructure, significant challenges to family planning service delivery, and socio-cultural issues that impede women’s access to family planning services. The total fertility rate in the region, at 7.1 children per woman, exceeds the national average, and the contraceptive prevalence rate of 13 percent among married women is less than half the national rate.

To improve access to high-quality family planning services in Shinyanga, E2A and Pathfinder International have engaged 230 community health workers who are supported by the district health system in the areas of supervision, commodity supplies, referrals, and reporting. The approach applied by the E2A team entails these elements: introduction of SDM using the Balanced Counseling Strategy through use of a mobile application by community health workers, project staff, and supervisors; and a pay-for-performance scheme that encourages outreach by community health workers. This approach has resulted in many more clients being reached by community health workers with family planning counseling and services and the majority of those reached accepting a family planning method.

The mobile application being used was developed by D-tree International, and helps the community health workers to apply the Balanced Counseling Strategy. The strategy guides community health workers through a well-defined protocol to educate the client about all available methods, and draws on the client’s fertility intentions and personal preferences to enable her to choose an appropriate method. Among the 230 community health workers, the mobile application has supported the introduction of SDM, counseling on all methods, provision of short-acting contraceptives, and referral of clients to health facilities for injectables and long-acting reversible contraceptives. The application sends the community health workers follow-up reminders and referral confirmations, and is used with paper-based job aides. The mobile application also alerts project staff and supervisors about issues the community health workers may be encountering in the field. The project trained 36 health facility supervisors to use tablets to view performance data and send messages to community health workers about contraceptive stocks and planned outreach services.

The pay-for-performance scheme rewards the community health workers for meeting targets in terms of new client recruitment and referral follow-up. The system pays community health workers through mobile money using the mobile application and includes real-time performance tracking. The next phase of the project will focus on development of supervisory tools to further transfer monitoring and management of the project to the local government.

Interventions with First-Time Parents

E2A, as part of its work in Shinyanga District, added interventions specifically focused on young married women and first-time mothers—that is, young women under the age of 25 who are pregnant or have a child—to the community-based family planning program. These interventions sought to encourage the healthy timing and spacing of pregnancy (HTSP), reducing unintended pregnancies among this underserved population by increasing access to broader contraceptive choice. The interventions included:

• Training young mothers to facilitate small groups of first-time mothers, where they discussed HTSP, family planning, sexual and reproductive health (SRH), HIV, and MNCH
• Conducting activities that help first-time mothers build their problem-solving skills and better negotiate the pressures they face to have children
• Training community health workers and facility-based providers to provide appropriate counseling for first-time mothers
• Engaging with communities to encourage first-time mothers to access and use SRH services
• Engaging key influencers to ensure they become part of an enabling environment that supports first-time mothers and their partners to use contraception

E2A adapted Pathfinder International’s training modules aimed at meeting the reproductive health needs of young married women and first-time parents to conduct the activities with first-time mothers.

Strengthening Pre-Service Education using the Training Resource Package for Family Planning

Pre-service education plays a critical role in developing the required professional competencies of nurses and midwives and prepares them for service provision in the long-term. Investing in strengthening pre-service education therefore constitutes an efficient use of resources toward improving maternal and newborn health through the delivery of quality family planning services. This is why E2A—with a mandate to strengthen family planning and reproductive health service delivery globally—promoted use of and supported adaptation of the Training Resource Package for Family Planning (TRP) to strengthen pre-service education on family planning in Tanzania and Uganda. E2A worked with several partners on this effort including the East, Central and Southern Africa Health Community (ECSA) and its college of nursing (ECSACON), Pathfinder International, the IBP Imitative as well professional associations, regulatory councils, national ministries of health and education, and nursing and midwifery schools in the two countries. A similar process was followed in the two countries, including:

• Discussions with ECSA, the local ECSACON chapter, nursing and midwifery councils, and nursing leadership to better understand the policy environment, challenges the countries needed to address through application of the TRP, and to clarify expectations.
• Review of curricula, training resources, and capacities.
• Three-day orientation and planning workshop with representatives of ECSACON, national nursing and midwifery service managers, nursing and midwifery council leadership, in-service training managers, and representatives from each nursing and midwifery training program. The main objectives of the three-day workshops were to: familiarize the participants with current family planning/reproductive health training in pre-service education to gain a better understanding of how the TRP could be applied to address current gaps in training; obtain an overview of family planning in-service training curricula and training materials that could provide local guidance service delivery guidelines and standards to be included in pre-service education curricula; review curricula and regional family planning training materials that could be used in alignment with the TRP; and clarify expectations and plan for a follow-on workshop.
• Five-day workshop on comptency-based training skills, contraceptive technology update, the new Medical Eligibility Criteria related to family planning, revision of family planning curricula content and learning outcomes, and demonstration of TRP using selected modules.