The National Road Map Strategic Plan -2008 - 2015

United Republic of Tanzania

Ministry of Health and Social Welfare

The National Road Map Strategic Plan

To Accelerate Reduction of Maternal, Newborn

and Child Deaths in Tanzania

2008 - 2015

April 2008

2ii

When a woman

undertakes her biological

role of becoming

pregnant and undergoing

childbirth, the society has

an obligation to fulfil her

basic human rights,

which include the right to

life, liberty social

security, maternity

protection and non

discrimination.

The National Road Map Strategic Plan -2008 - 2015

iii

TABLE OF CONTENTS

Abbreviations ............................................................................................................................................ iv

Foreword.................................................................................................................................................... vii

Acknowledgements................................................................................................................................... viii

Chapter 1:

Overview................................................................................................................................................... 1

1.1 Introduction..................................................................................................................................... 1

1.2 Initiatives to Improve Maternal, Newborn and Child Health in Tanzania...................................... 1

1.3 Rationale for the Strategic Plan to Accelerate Reduction of Maternal,

Newborn and Child Deaths in Tanzania.......................................................................................... 2

Chapter 2:

SituationAL Analysis of maternal, newborn and child health in tanzania................................................ 3

2.1 Maternal Health............................................................................................................................... 3

2.2 Newborn Health .............................................................................................................................. 6

2.3 Child Health ................................................................................................................................... 8

2.4 Cross Cutting Issues ....................................................................................................................... 11

Chapter 3:

Strategic FRAMEWORK.......................................................................................................................... 15

Chapter 4:

Implementation Framework...................................................................................................................... 18

Chapter 5:

Strategic plan and activities – 2008-2015 ................................................................................................ 24

Chapter 6:

MONITORING FRAMEWORK ............................................................................................................. 47

ANNEXES

SWOT Analysis......................................................................................................................................... 57

Inputs for Improving MNCH at All Levels............................................................................................... 71

Relevant Policy Documents ...................................................................................................................... 42

Most Cost Effective Interventions Based on Evidence to Date for Reduction of

Perinatal and Neonatal Mortality............................................................................................................... 83

Evidence-Based Interventions that Influence Child Health...................................................................... 84

Evidence-Based Interventions for MNCH................................................................................................ 85

Where Does Tanzania Stand in Terms of MNCH Service Delivery?........................................................ 88

Essential MNCH Medicines, Equipment and Supplies............................................................................. 90

Glossary..................................................................................................................................................... 92

REFERENCES.......................................................................................................................................... 93

ABBREVIATIONS

ADDOS Accredited Drug Dispensing Outlets

AIDS Acquired Immuno Deficiency Syndrome

ALu Artemether Lumefantrine

AMO Assistant Medical Officer

ANC Antenatal Care

ARH Adolescent Reproductive Health

ARI Acute Respiratory Tract Infection

BCC Behaviour Change Communication

BEmOC Basic Emergency Obstetric Care

BFHI Baby Friendly Hospital Initiative

BMI Body Mass Index

CBD Community Based Distributor

CBIMS Community Based Information Management System

CBO Community Based Organization

CCHP Comprehensive Council Health Plan

CEmOC Comprehensive Emergency Obstetric Care

CHMT Council Health Management Team

c-IMCI Community Integrated Management of Childhood Illness

CPR Contraceptive Prevalence Rate

CSO Civil Society Organization

DHR Director Human Resources

DPS Director Preventive Services

EmOC Emergency Obstetric Care

ENC Essential Newborn Care

EPI Expanded Programme on Immunization

FANC Focused Antenatal Care

FBO Faith Based Organization

FP Family Planning

HIV Human Immuno Deficiency Virus

HMIS Health Management Information System

HPV Human Papilloma Virus

HSSP Health Sector Support Programme

ICPD International Conference on Population and Development

IDWE Infectious Disease Week Ending report

IEC Information Education and Communication

IMCI Integrated Management of Childhood Illness

IMR Infant Mortality Rate

IPT Intermittent Preventive Treatment

ITN Insecticide Treated Net

IYCF Infant Young Child Feeding

The National Road Map Strategic Plan -2008 - 2015

KMC Kangaroo Mother Care

LLINs Long Lasting Insecticide Treated Nets

LSS Life Saving Skills

MDGs Millennium Development Goals

MKUKUTA Mkakati wa Kukuza Uchumi na Kupunguza Umaskini Tanzania (The National Strategy for

Growth and Reduction of Poverty)

MMAM Mpango wa Maendeleo wa Afya ya Msingi (The Primary Health Services Development

Programme)

MMR Maternal Mortality Ratio

MNCH Maternal, Newborn and Child Health

MNT Maternal and Newborn Tetanus

MoAFSC Ministry of Agriculture, Food Security and Cooperatives

MoCDGC Ministry of Community Development, Gender and Children

MoEVT Ministry of Education and Vocational Training

MoFEA Ministry of Finance and Economic Affairs

MoHSW Ministry of Health and Social Welfare

MoICS Ministry of Information, Culture and Sports

MoID Ministry of Infrastructure Development

MoLEYD Ministry of Labour, Employment and Youth Development

MVA Manual Vacuum Aspiration

NACP National AIDS Control Programme

NBS National Bureau of Statistics

NGOs Non Governmental Organization

NMCP National Malaria Control Programme

NMW Nurse Midwife

NORAD Norwegian Development Cooperation

NPEHI National Package of Essential Health Interventions

NPERCHI National Package of Essential Reproductive and Child

Health Interventions

ORS Oral Rehydration Solution

ORT Oral Rehydration Therapy

PAC Post Abortion Care

PHAST Participatory Hygiene and Sanitation Transformation

PHC Primary Health Care

PHSDP Primary Health Services Development Programme

PMNCH Partnership for Maternal, Newborn and Child Health

PMO-RALG Prime Minister’s Office, Regional Administration and Local Government

PMTCT Prevention of Mother to Child Transmission

POPSM President’s Office – Public Service Management

QIRI Quality Improvement and Recognition Initiative

RED Reaching Every District

REC Reaching Every Child

RCH Reproductive and Child Health

RCHS Reproductive and Child Health Section

RHMT Regional Health Management Team

RTI Reproductive Tract Infection

SM Safe Motherhood

SMI Safe Motherhood Initiative

SNL Saving Newborn Lives

SRH Sexual and Reproductive Health

STI Sexually Transmitted Infection

SWOT Strengths, Weaknesses, Opportunities and Threats

TAMWA Tanzania Media Women Association

TASAF Tanzanian Social Action Fund

TBA Traditional Birth Attendant

THIS Tanzania HIV/AIDS Indicator Survey

TDHS Tanzania Demographic and Health Survey

TFNC Tanzania Food and Nutrition Centre

TFR Total Fertility Rate

TGNP Tanzania Gender Networking Group

TPMNCH Tanzanian Partnership for Maternal, Newborn and Child Health

TRCHS Tanzania Reproductive and Child Health Survey

TSPA Tanzania Service Provision Assessment

TT Tetanus Toxoid

UNFPA United Nations Population Fund

UNICEF United Nations Children Fund

VVF Vesico Vaginal Fistula

WB World Bank

WHO World Health Organization

WRATZ White Ribbon Alliance Tanzania

ZRCH Zonal Reproductive and Child Health

The National Road Map Strategic Plan -2008 - 2015

vii

FOREWORD

Reduction of maternal, newborn and child deaths is a high priority for all, given the persistently high maternal,

newborn and child morbidity and mortality rates over the past two decades in African countries, Tanzania

included. It is one of the major concerns addressed by various global and national commitments, as reflected

in the targets of the Millennium Development Goals, Tanzania Vision 2025, the National Strategy for Growth

and Reduction of Poverty (NSGRP-MKUKUTA), and the Primary Health Services Development Program

(PHSDP-MMAM), among others.

Maternal deaths are caused by factors attributable to pregnancy, childbirth and poor quality of health services.

Newborn deaths are related to the same issues and occur mostly during the first week of life. Child health

depends heavily on availability of and access to immunizations, quality management of childhood illnesses

and proper nutrition. Improving access to quality health services for the mother, newborn and child requires

evidence-based and goal-oriented health and social policies and interventions that are informed by best practices.

Development of this plan for reducing maternal, newborn and child mortality is in line with the tenets of the

New Delhi Declaration 2005. Tanzania and other countries committed to develop one national MNCH plan for

accelerating the reduction of maternal, newborn and child deaths, in order to improve coordination, align

resources and standardize monitoring. Further support for incorporating child health interventions into this plan

was voiced by various stakeholders and development partners following the April 2007 launch of the Tanzania

Partnership for Maternal, Newborn and Child Health (TPMNCH). The National Road Map Strategic Plan to

Accelerate Reduction of Maternal, Newborn and Child Deaths in Tanzania (2008 – 2015) was subsequently

developed as Tanzania’s national response to the renewed commitment to improve maternal, newborn and child

care. The Reproductive and Child Health Section (RCHS) of the Ministry of Health and Social Welfare

(MoHSW), in collaboration with a number of different stakeholders,has developed this strategic plan to guide

implementation of all maternal, newborn and child health interventions in Tanzania.

The National Road Map Strategic Plan stipulates various strategies to guide stakeholders for Maternal, Newborn

and Child Health (MNCH), these include the Government, development partners, non-governmental

organizations, civil society organizations, private health sector, faith-based organizations and communities, in

working together towards attainment of the Millennium Development Goals (MDGs) as well as other regional

and national commitments and targets related to maternal, newborn and child health

It is the expectation of the Government, particularly the MoHSW, that all stakeholders will make optimal use

of this strategic framework to support the implementation of maternal, newborn and child health interventions,

as this is in line with the National Health Policy and existing MNCH standards, guidelines and protocols.

The Government highly values your partnership in working towards realization of the objectives of the National

Road Map Strategic Plan to Accelerate Reduction of Maternal, Newborn and Child Deaths. Together, we can

improve the health of Tanzanian mothers, babies and children, and build a stronger and more prosperous nation.

Professor David Homeli Mwakyusa (MP),

Minister for Health and Social Welfare

viii

The National Road Map Strategic Plan -2008 - 2015

ACKNOWLEDGEMENTS

The MoHSW wishes to express its gratitude to the many individuals and development partners who worked with

the Ministry in the development of “The National Road Map Strategic Plan to Accelerate Reduction of Maternal,

Newborn and Child Deaths in Tanzania, 2008 – 2015”. The completion of the document is a result of extensive

consultations and collaboration with various stakeholders including the RCHS of the MoHSW, development

partners, interested organizations as well as committed individuals.

The MoHSW would like to acknowledge all those stakeholders who contributed in one way or another to the

successful development of the document. The Ministry particularly wishes to acknowledge the invaluable

contribution of the PMNCH Country Support Working Group: Dr. Nancy Terreri (UNICEF HQ); Dr. Ciro

Franco (BASICS, USA); and Dr. Koki Agarwal (ACCESS/Jhpiego, USA). The MoHSW also acknowledges

the contribution of the technical group members: Dr. Theresa Nduku Nzomo (WHO/AFRO Harare); Dr. Sam

Muziki (WHO/AFRO Harare); Dr. Thierry Lambrechts (WHO/HQ); and local Consultants led by Dr. Ali Mzige

and Dr. Rosemary Kigadye. Other national technical experts who contributed in the development include: Dr.

Catherine Sanga (RCHS, MoHSW), Dr. Neema Rusibamayila (IMCI, MoHSW), Dr. Georgina Msemo

(IMCI/SNL, MoHSW), Dr. Mary Kitambi (EPI, MoHSW); Ms. Lena Mfalila (RCHS/SMI, MoHSW); Dr.

Elizabeth Mapella (ARH, MoHSW); Ms. Hilda Missano (TFNC); Dr. Rutasha Dadi and Dr.Chilanga Asmani

(UNFPA); Dr. Theopista John, Dr.Josephine Obel and Dr. Iriya Nemes (WHO Tanzania); Dr. Asia Hussein

(UNICEF, Tanzania); and Maryjane Lacoste (ACCESS/Jhpiego, Tanzania).

The Ministry would also like to acknowledge Ms. Hassara Maulid (MoHSW) for her secretarial work with the

initial drafts of this document.

Lastly, the Ministry would like to acknowledge technical and financial support provided by EC, WHO, UNFPA,

UNICEF and One UN Fund for the development and printing of the MNCH strategic plan.

Wilson C. Mukama

Permanent Secretary, MoHSW

The National Road Map Strategic Plan -2008 - 2015

CHAPTER 1:

OVERVIEW

Purpose of the document

This document has been conceived for various purposes. The health of the mother is closely linked to the health

and survival of the child. In addition, the socio-economic level of the mother and the maternal health status

(HIV/AIDS, malaria, nutrition) has an impact on the survival of the child. Thus the primary purpose of “One

Integrated Maternal Newborn and Child Health Strategic Plan” is to ensure improved coordination of

interventions and delivery of services across the continuum of care. Another purpose of the document is to

guide implementation across operational levels of the system so that policy drawn at national level will be

carried out at the district and community levels, with support from the regional level. It is anticipated that a joint

strategy will contribute to more integrated implementation, improved services, and ultimately a significant

reduction in morbidity and mortality of Tanzanian women and children.

1.1 Introduction

The total population of Mainland Tanzania is estimated to be 39,384,223 (as of July 2007)

. Most of the

population (75%) resides in the rural area. The annual growth rate is 2.9% with life expectancy at birth being

54 years for males and 56 years for females

The total fertility rate in Tanzania has been consistently high over the past ten years and currently stands at 5.7

children per woman. There are regional variations with urban-rural disparities, where rural women have higher

fertility rates than their urban counterparts

The Maternal Mortality Ratio (MMR) has remained high for the last 10 years

without showing any decline and

is currently estimated to be 578 per 100,000 live births

. While significant progress has been made to reduce

child mortality in Tanzania, the neonatal mortality rate remains high at 32 per 1,000 live births, and accounts

for 47% of the infant mortality rate which is estimated at 68 per 1,000 live births.

The critical challenges in reducing maternal, newborn and child morbidity and mortality comprise two

categories:

(a) Health system factors - inadequate implementation of pro-poor policies, weak health infrastructure, limited

access to quality health services, inadequate human resource,shortage of skilled health providers, weak referral

systems, low utilization of modern family planning services, lack of equipment and supplies, weak health

management at all levels and inadequate coordination between public and private facilities.

(b) Non health system factors- inadequate community involvement and participation in planning,

implementation, monitoring and evaluation of health services, some social cultural beliefs and practices, gender

inequality, weak educational sector and poor health seeking behaviour.

1.2 Initiatives to improve maternal, newborn and child health in Tanzania

Maternal and child health services were established in Tanzania in 1974. In 1975 the Expanded Programme of

Immunization (EPI) was initiated to strengthen immunization services for vaccine preventable childhood

diseases. Tanzania adopted the Safe Motherhood Initiative (SMI) in 1989, following the official launch of the

Global Safe Motherhood Initiative in 1987 in Nairobi, Kenya.Subsequently, the 1994 International Conference

for Population and Development (ICPD) emphasized access to comprehensive reproductive health services and

rights.In response to the ICPD Plan of Action, Tanzania established the Reproductive and Child Health Section

(RCHS) within the Ministry of Health and developed a National Reproductive and Child Health Strategy.

CIA World Fact Book, March 2008

Census, 2002

TDHS 2004/05

Maternal Mortality ratio was 529/100,000 live births in TDHS 1996

TDHS 2004/05

In 1996 Tanzania adopted the Integrated Management of Childhood Illness (IMCI) approach for reduction

of childhood morbidity and mortality. Various nutrition interventions have also been adopted including the

Baby Friendly Hospital Initiative (BFHI) in 1992, the Code of Marketing Breast Milk Substitutes in 1994

and Vitamin A Supplementation in 1997. Tanzania developed its National Strategy on Infant and Young Child

Feeding and Nutrition in 2005.

In Tanzania, specific attempts have been made to address maternal, newborn and child health (MNCH)

challenges through the National Health Policy (revised in 2003), the Health Sector Reforms and the Health

Sector Strategic Plan (2003-2007). Furthermore, the Reproductive and Child Health Strategy (2005-2010) and

the National Road Map Strategic Plan to Accelerate the Reduction of Maternal and Newborn Mortality (2006-

2010) were also formulated to respond to these challenges.

Improving MNCH is also a major priority area in the National Strategy for Growth and Poverty Reduction

(NSGPR/MKUKUTA) 2005-2010which has three major interlinked clusters

. One of the goals clearly outlined

in the second cluster of the strategy is to improve the survival, health and well being of all children and women

and of especially vulnerable groups. Under this goal, there are four operational targets related to maternal and

child health for monitoring progress towards achieving MDGs 4 and 5.

The Health Sector Support Programme III (2008 – 2012) will incorporate and address MNCH issues in terms

of alignment with Government policies, resource mobilization and donor harmonization. The newly initiated

Primary Health Service Development Programme, (PHSDP/MMAM) 2007 – 2017, will address the delivery

of health services to ensure fair, equitable and quality services to the community and is envisioned to be the

springboard for achieving good health for Tanzanians.

The Tanzania MNCH Partnership was officially launched in April 2007 to re-focus the strategies for reducing

the persistently high maternal, newborn and child mortality rates, through adopting the One Plan and setting

clear targets for improved MNCH.

1.3Rationale for the Strategic Plan to accelerate reduction of maternal, newborn and child

deaths in Tanzania

Annually, it is estimated that536,000 women

worldwide diefrom pregnancy- and childbirth-related conditions,

as do 11,000,000 under-fives, of which4.4 million are newborns. Most of these deaths occur in Sub Saharan

Africa. Tanzania is one of the ten countries contributing to 61% and 66% of the global total of maternal and

newborn deaths, respectively. In Tanzania, the estimated annual number of maternal deaths is 13,000, the

estimate for under-fives is 157,000, and newborn deaths are estimated at 45,000

. In committing to MDGs 4

and 5, the Government of Tanzania agreed to reduce the under-five mortality rate by two-thirds and reduce the

maternal mortality ration by three-quarters, by 2015.

Maternal, newborn and childoutcomes are interdependent; maternal morbidity and mortality impacts neonatal

and under-five survival, growth and development. Thus service demand and provision for mothers, newborns

and children are closely interlinked. Integration of MNCH services demands reorganization and reorientation

of components of the health systems to ensure delivery of a set of essential interventions for women, newborns

and children. A focus on the continuum of care replaces competing calls for mother or child, with a focus on

high coverage of effective interventions and integrated MNCH service packages as well as other key

programmes such as Safe Motherhood (SM),Family Planning (FP), Prevention of Mother to Child Transmission

(PMTCT) of HIV, Malaria, EPI, IMCI, Adolescent Health andNutrition. Sustained investment and systematic

phased scale up of essential MNCH interventions integrated in the continuum of care are required.

The National Road Map Strategic Plan -2008 - 2015

Cluster 1: Growth and Reduction of Income Poverty; Cluster 2: Improved

quality of life and social well being; Cluster 3: Good governance and

accountability.

Maternal Mortality Estimates 2005, WHO, UNICEF, UNFPA, World Bank

Opportunities for Africa’s Newborns 2006, the Partnership for MNCH

The National Road Map Strategic Plan -2008 - 2015

CHAPTER 2:

SITUATIONAL ANALYSIS OF MATERNAL, NEWBORN

AND CHILD HEALTH IN TANZANIA

Introduction

Maternal, newborn and child health care is one of the key components of the National Package of Essential

Reproductive and Child Health Interventions (NPERCHI) focusing on improving the quality of life for

women, adolescents and children. The major components of the package include:

• antenatal care;

• care during childbirth;

• care of obstetric emergencies;

• newborn care;

• postpartum care;

• post abortion care;

• family planning;

• diagnosis and management of HIV/AIDS including PMTCT,

other sexually transmitted infections and • reproductive tract

infections (STI/RTI);

• prevention and management of infertility;

• prevention and management of cancer;

• prevention and management of childhood illness;

• prevention and management of immunisable diseases;

• nutrition care.

In spite of the good coverage of health facilities, not all components of the services are of good quality and

provided to scale; hence, maternal, newborn and child mortalities remain a major public health challenge in

Tanzania.

2.1 Maternal Health

• Antenatal care

According to TDHS (2004/05), 94% of pregnant women make at least one antenatal care (ANC) visit

and 62% of women have four or more ANC visits. The number of pregnant mothers in Tanzania making

four or more ANC visits appears to have declined slightly from 70% in1999

. However, the quality of

antenatal care provided is inadequate. About 65% of the women have their blood pressure measured and

54% have blood samples taken for haemoglobin estimation and syphilis screening. About 41% have

urine analysis done and only 47% are informed of the danger signs in pregnancy.

Approximately 80% of pregnant women received at least 1 dose of tetanus toxoid (TT), and 56% of women

received two or more TT doses

. Younger mothers, women in their first pregnancy, women of the higher

education and wealth strata and urban women are more likely to receive two or more doses of TT.

Despite high ANC attendance, only 14% of pregnant women start ANC during the first trimester as per the

national guidelines. The median number of months that women are pregnant at their first visit is 5.4. One-

third of women do not seek ANC until their sixth month or later

. However, early booking has an advantage

for proper pregnancy information sharing and pregnancy monitoring.

TRCHS 1999

TDHS 2004/05

When a woman

undertakes her biological

role of becoming

pregnant and undergoing

childbirth, the society

has obligation to fulfil

her basic human rights

and that of her child.

• Malaria in pregnancy

Pregnancy alters a woman’s immune response to malaria, particularly in the first malaria-exposed

pregnancy, resulting in more episodes of severe infectionand anaemia, all of which contribute to a

higher risk of death. Malaria is estimated to cause up to 15 % of maternal anaemia, which is more

frequent and severe in first pregnancies. Malaria is a significant cause of low birth weight which is the

most important risk factor for newborn death and is also a risk factor for stillbirth.

Efforts to combat malaria among pregnant mothers are being scaled up. Pregnant women are supposed to

receive two doses of SP for intermittent preventive treatment (IPT) of malaria during routine antenatal care

visits. However, according to TDHS (2004/05), only 22% of pregnant women attending the ANC clinic

receive the complete course of IPT, and only 16% use Insecticide Treated Nets (ITNs). Recent data from

the National Malaria Control Programme (NMCP) indicate that the proportion of pregnant women sleeping

under ITNs has increased to 28%

• Intrapartum care

Only 47% of all births in Tanzania occur at health facilities and 46% of all births are assisted by a skilled

health worker. Out of the 53% of births which take place at home, 31% are assisted by relatives, 19% by

traditional birth attendants (TBAs) and 3% are conducted without assistance. As expected, births to women

in the highest wealth quintile are more likely to be assisted by a skilled birth attendant (87%) than women

in the lowest quintile (31%)

Emergency obstetric care services are crucial for handling complicated deliveries. Findings from TDHS

(2004/05) revealed that only 3% of all babies were delivered by caesarean section – this figure is below

the WHO-recommended standard of 5-15%, and is partially due delay in timely referral, lack of skilled

attendance and functioning blood banks at most hospitals and health centres. About 64.5% of public

hospitals provide Comprehensive Emergency Obstetric Care (CEmOC), whereas only 5.5% of public health

centres are providing Basic Emergency Obstetric Care (BEmOC)

. Furthermore, the referral system has

serious challenges including limited number of ambulances; unreliable logistics and communication

systems; and inadequate community-based facilitated referral systems.

• Postnatal care

Postnatal care is an important component of good maternal and baby health care is not very well utilized

in Tanzania. Eighty-three percent of women who delivered a live baby outside the health facility did not

receive a postnatal check-up, and only 13% were examined within two days of giving birth as

recommended. Women in the highest income quintiles were more likely to receive a timely postnatal check-

up compared to those in the lowest quintiles

Prevention of Mother-to- Child Transmission of HIV

The key to ensuring an HIV-free start in life is prevention of HIV transmission to children by preventing

HIV in mothers. PMTCT interventions include testing and counselling for HIV, antiretroviral prophylaxis

for HIV-infected pregnant women and their exposed children, treatment of eligible women, counselling and

support for infant feeding, safer obstetric practices and family planning to prevent unintended pregnancies

in HIV-infected women. By September 2007, there were about 1,311 PMTCT sites established within

reproductive and child health (RCH)clinics throughout the country

. Additional sites need to be established

to provide services as close to the community as possible. The goal, objectives and strategies to scale up

quality PMTCT services are stipulated in the Health Sector Strategy for HIV/AIDS (2008-2012).

The National Road Map Strategic Plan -2008 - 2015

NMCP-MoHSW 2007

TDHS 2004/05

MoHSW, 2006. Situation Analysis of Emergency Obstetric Care for Safe

Motherhood in Public Health Facilities in Tanzania

TDHS 2004/05

NACP 2007

The National Road Map Strategic Plan -2008 - 2015

Integration of PMTCT interventions in ANC, nutrition programmes, IMCI and other HIV/AIDS

services enhances opportunities for reducing paediatric HIV and its associated deaths.

• Nutrition

Maternal nutrition during the pre- and postnatal periods is extremely important for the outcome of

pregnancy as well as infant feeding. A good and adequate balanced diet, as well as vitamin and mineral

supplementation, improves birth outcome and maternal well-being.

Underweight status contributes to poor maternal health and birth outcomes. Overall, 10% of Tanzanian

women of reproductive age (15–49 years) are considered to be undernourished, having a Body Mass Index

(BMI) of less than 18.5. Women living in rural areas are more affected compared to those living in urban

areas

Maternal under-nutrition, is often reflected in the proportion of children born with low birth weight (below

2.5 kg). Representative data on the prevalence of low birth weight babies is not readily available but

estimates from UNICEF suggest that 10 % of Tanzanian newborns are low birth weight

Pregnant women are particularly vulnerable to anaemia due to increased requirements for iron and folic

acid. According to TDHS (2004/05), 48% of women aged 15-49 years were found to be anaemic, whereas

58% of pregnant women and 48% of breast-feeding mothers were anaemic. Ten percent of pregnant women

took iron tablets for at least 90 days, while about half (52%) took iron tablets for less than 60 days, and 38%

did not take iron tablets at all. Haemorrhage is the most frequent cause of maternal deaths, and pregnant

women who are anaemic are more vulnerable to postpartum haemorrhage.

• Family planning

Spacing the intervals between pregnancies canprevent 20 to 35% of all maternal deaths

. However, family

planning services continue to face challenges in meeting clients’ expectations and needs. Despite having

high knowledge of contraceptives (90%), only 26 % of married women use any method of contraception,

with only 20% using a modern method. The most commonly used methods are injectables (8%), pills (6%)

and traditional methods (6%)

. Current usage of any modern method is higher among sexually active

unmarried women than among married women (41% and 26%, respectively). To be noted is the fact that

the percentage of married women using any method of contraception has changed little from the 1999

TRCHS. The total demand for FP among married women is 50%, while 22% have an unmet need for FP

Factors contributing to low contraceptive prevalence include low acceptance of modern FP methods, erratic

supplies of contraceptives with limited range of choices, limited knowledge/skills of providers and

provider’s bias affecting informed choice. The situation is worsened by limited spousal communication,

inadequate male involvement and lack of adolescent-friendly health services and misconceptions about

modern family planning methods. In an attempt to improve access to family planning services, community-

based programmes are being implemented in 46 mainland districts; however, this represents less than half

of all districts in the country.

• Challenges in accessing quality care

Data from TDHS (2004/05) revealed that the major barriers perceived by women in accessing delivery

health services include lack of money (40%), long distance to health facility (38%), lack of transport (37%),

and unfriendly services (14%). The high rate of home deliveries is also attributable to a malfunctioning

referral system, inadequate capacity of health facilities in terms of available space, skilled attendants and

commodities, and other socio-cultural aspects affecting the pregnant women. Additional factors include

gender inequalities in decision-making and access to resources at household-level.

TDHS 2004/05

State of the World’s Children Report, 2008

Singh S. et al. 2004. Adding it Up: The Benefits of Investing in Sexual and

Reproductive Health Care. Washington D.C. and New York: The Alan Guttmacher

Institute and UNFPA.

TDHS 2004/05

• Maternal morbidity and mortality

According to TDHS (2004/05), the maternal mortality ratio is estimated at 578/100,000 live births.

Major direct causes of maternal mortality include obstetric haemorrhage, obstructed labour, pregnancy

induced hypertension, sepsis and abortion complications.

It is estimated that abortion complications contribute to about 20% of maternal deaths worldwide

. In

Tanzania, induced abortion is illegal hence the actual magnitude of the problem is not known. However,

several attempts have been made to document the severity of the issue – in Hai District, for example, it was

reported that nearly a third of maternal deaths are related to unsafe abortion (Mswia et al, 2003

). Post

abortion care (PAC) services can significantly reduce maternal mortality due to unsafe abortions; however,

only 5% of health facilities in Tanzania currently provide this service

Indirect causes leading to poor maternal health outcomes are malaria, anaemia, and HIV/AIDS. With

specific regard to HIV, prevalence in Tanzania is estimated to be 7% in adults aged 15-49 years, with

prevalence among women being higher (8%), compared to 6% among men

2.2 Newborn Health

• Newborn morbidity and mortality

Tanzania is among those countries that have had success in reducing child mortality, but there has been no

measurable progress in reducing neonatal deaths. The neonatal mortality rate was 40.4 per 1,000 live births

in 1999 and 32 per 1,000 live births in 2004/05. Up to 50% of neonatal deaths occur in the first 24 hours

of life, with over 75% of them arising in the first week of life. Newborn mortality is a sensitive indicator

of the quality of care provided during the antenatal period, delivery and immediate postnatal period.

According to modelled estimates for Tanzania, 79% of newborn deaths are due to three main causes:

infections including sepsis/pneumonia (29%), birth asphyxia (27%); and complications of preterm birth

(23%) (Figure 2). Sepsis was the most common cause of death noted in a study conducted in Mbulu and

The National Road Map Strategic Plan -2008 - 2015

Figure 1: Direct Causes of Maternal Deaths

Source: The World Health Report, 2005

The World Health Report, 2005

Mswiaet al, 2003. Community Based Monitoring of Safe Motherhood in United

Republic of Tanzania

TDHS 2004/05

THIS, 2003/04

The National Road Map Strategic Plan -2008 - 2015

Hanang districts of rural northern Tanzania

. Many of these conditions are preventable and closely

linked to the absence of skilled birth attendance at delivery. Eighty-six percent (86%) of neonatal

deaths in Tanzania are also low birth weight, many of whom are preterm. On average in Tanzania, new

born deaths are 67% higher in the poorest families as compared to the wealthier families, and the

majority of deaths occur in rural areas

Low birth weight (birth weight less than

2500 grams) and preterm birth (less than

36 completed weeks of gestation) together

contribute to 28% of neonatal deaths

globally

. The recent Tanzania DHS

(2004/05) asked mothers to estimate

whether their infant was “very small,

small, average, or large”. They were also

asked to report the actual birth weight, if it

was known. The TDHS data cite a

neonatal mortality of 86% in the five-year

period prior to the survey among

“small/very small” newborns. However,

other all-cause mortality estimates indicate

a mortality rate of 23% for preterm infants

(who are most likely also of low birth

weight.).

• Continuum of care

It is important to address the coverage of interventions along the continuum of care from pregnancy,

neonatal period, infancy and childhood. It is critical to note that the coverage of essential interventions is

lowest at the time when needed most: that is, during child birth and the early neonatal period when

more than 50% of maternal and newborn deaths occur (Figure 3).

Source: 2004/5TDHS

Figure 2: Estimated Causes of Neonatal Deaths

Figure 3: Coverage of Interventions along the Continuum of Care in Tanzania

Source:Opportunities for Africa’s Newborns, Lawn JE, et al 2006

Hinderraker et al, 2003

TDHS, 2004/05

Lancet Neonatal Survival Series, 2005

• Other challenges

Furthermore, quality newborn and child care faces other challenges including poor health infrastructure

and referral for neonatal care, child care and poor skills of service providers related to inadequate

incorporation of neonatal content in pre-and in-service training curricula. A recent study conducted in Dar

es Salaam in 2005 showed that none of the primary and secondary level health facilities was providing

basic/essential newborn care.

2.3 Child Health

• Immunization

The Expanded Programme of Immunization (EPI) has performed well over the

past decade with immunization coverage of 71% for all vaccines for children 12-

23 months (TDHS, 2004/05). Currently the policy is to provide each child with

one dose of BCG, four doses of OPV, three doses of DTP-HB and one dose of

measles vaccine. As expected, children born to mothers in the lowest wealth

quintile are less likely to be fully immunized than those born to mothers in the

highest wealth quintile.

Pneumonia is one of the major contributors towards under five mortality and it accounted for 21.1% of

underfive deaths in 2006. The Lancet series on child survival identifies Hib vaccine as an intervention that

could reduce underfive mortality due to pneumonia by 20%. Plans are under way to consider introduction

of Hib and pneumococcal vaccines in the national policy.

Measles outbreaks are still happening despite high measles routine immunization coverage (above 80% in

almost all districts). Tanzania has been implementing the Reaching Every District (RED) strategy to

improve immunization coverage for all antigens including measles but also conducting periodic measles

supplementation immunization campaigns after every three years.

The achievement of TT and polio vaccines is evident by the significant reduction in neonatal tetanus deaths

and polio cases. The last polio case in the country was identified in 1996; however, there is a high risk of

wild polio virus importation from polio-endemic countries. In this regard polio eradication initiatives need

to be sustained until polio is eradicated.

Tanzania is close to achieving Maternal Neonatal Tetanus (MNT) elimination; however,there are still

some pockets in high risk districts. Implementation of MNT elimination strategies will focus more in high

risk districts.

• Integrated Management of Childhood Illness

Case management of common childhood illness is a key step to reducing child mortality. Appropriate

management of malaria, pneumonia, diarrhoea and dysentery can reduce under five mortality by 5, 6, 15

and 3% respectively. The IMCI strategy has been implemented at scale in Tanzania from 1996 with all

districts implementing at different levels of coverage. Tanzania was part of an IMCI inter-country evaluation

and the results were encouraging, but issues around quality of care and supervision were noted

IMCI has been found to be an effective delivery strategy for various child survival interventions and has

contributed to a 13% mortality reduction over a two-year period in those districts in Tanzania where it has

been implemented

. Management of diarrhoeal disease has been improved to include low osmolarity oral

rehydration solution (ORS) and zinc supplementation. The IMCI clinical guidelines have been updated

accordingly and have also included the newborn, HIV/AIDS and strengthened nutrition.

The National Road Map Strategic Plan -2008 - 2015

MCE Report, 2005

Only 20% of women

receive Vitamin A

supplementation

within 2months

after childbirth.

The National Road Map Strategic Plan -2008 - 2015

• Prevention and management of malaria

Malaria contributes to 23% percent of under five mortality in Tanzania

. Use of ITNs contributes to

7 percent reduction of overall deaths among under-fives

. Only 47% of under fives in Tanzania sleep

under ITNs

. ITNs are distributed through the health system by vouchers, as well as by free distribution of

long lasting insecticide treated nets (LLINs) through catch up campaigns and replacement campaigns to

replace worn out ITNs in the period 2008 – 2012 when appropriate.

Malaria management has been improved using the combination therapy of Artemether and Lumefantrine

(ALu). The MoHSW is training district focal persons for both IMCI and malaria and regional focal

persons for coordination of malaria and IMCI interventions. Since a good proportion of caretakers seek

treatment outside of the health facility,the MoHSW is also training the private sellers to dispense basic

essential drugs to the community through Accredited Drug Dispensing Outlets(ADDOs).

• Care seeking

Care seeking for sick children needs to be improved. The TDHS 2004/05showed that among children with

symptoms prior to the survey, half of the children (57%) with symptoms of Acute Respiratory Infection

(ARI) or fever and 47% of children with diarrhoea were taken to a health facility. Those in urban areas were

more likely than rural children to be taken to the health facility. However, a vast majority of the children

with diarrhoea (70%) were also given some form of ORT and 54% were given a solution prepared from

ORS.

In Tanzania, although access to health services is good, many people seek care when it is too late or not

at all. Attention should be paid to the fact that only 57% of under-fives receive anti- malarial treatment

within 24 hours of developing symptoms. In this perspective the MoHSW has always prioritized

community IMCI (c-IMCI) as a way of identifying danger signs among under-fives and when to seek

care.

• Nutrition

Nutrition indicators for under-fives have shown some improvement over the years but undernutrition is still

widely prevalent in Tanzania. Stunting, underweight status and wasting among children aged 0-59 months

have reduced from 44%, 29% and 5% in 1999 to 38%, 22% and 3% respectively

. Anaemia is also highly

prevalent among under-fives with 72% of all 6-59 months children being anaemic. The main causes of

anaemia are nutritional deficiency, intestinal worms and malaria.

Optimal breastfeeding can reduce under-five mortality by up to 13%

. The majority of Tanzanian babies

are breastfed, for a median duration of 21 months. Fifty-four percent (54%) are breastfed up to two years.

However,initiation of breastfeeding within one hour of birth is only 59% and the exclusive breastfeeding

rate (0-5 months of age) is estimated to be 41%

. Early complementary feeding is common with 39% of

infants below 3 months already introduced to complementary foods

. About 12% of infants are not

complemented at the age of 6-7 months. Furthermore feeding frequency during complementation is too low

(about 2-3 feeds a day),nutrient density is low and the preparation and feeding practices are often unsafe

Children 2 – 5 years old are fed family foods; however, feeding frequency and nutrient density are also

inadequate in this group.

Coverage of health workers trained on infant and young child feeding is low and only 68 have been

accredited as baby friendly

. Training on Essential Nutrition Actions (Vitamin A supplementation, exclusive

breastfeeding, complementary feeding, iodine) is in the early stages of implementation. Coverage of

Country Health System Fact Sheet 2006, WHO

Lancet Child Survival Series, 2003

TNVS Survey, 2007

TDHS, 2004/05

Lancet Child Survival Series, 2003

TDHS, 2004/05

Communication with TFNC, April 2008

appropriate facility management of severe malnutrition is still low and community management of

severe malnutrition has not been implemented.

Vitamin A deficiency is the leading cause of preventable blindness in children and raises the risk of disease

and death from severe infections. Vitamin A supplementation twice a year has been estimated by the World

Bank (1993) to be one of the most cost-effective health interventions, yet in Tanzania the coverage is only

20%

. Currently the biannual Vitamin A supplementation campaign is the main strategy to combat vitamin

A deficiency and it is estimated that the coverage is 85%

Iodine deficiency during pregnancy has a great impact on physical and mental development of the foetus

and is related to poor educational outcomes and productivity. In Tanzania the prevalence of goitre among

school children is estimated at 7%

. Salt iodation is the most effective strategy for the control of iodine

deficiency. However,currently only 75% of households consume iodated salt

• Child morbidity and mortality

Although the most recent Demographic Health Survey (TDHS, 2004/5) has shown decline in under-five

and infant mortality by 24% and 31% respectively to 112 and 68 per 1,000 live births, the infant and under-

five mortality rates in Tanzania are still unacceptably high. Every year about 154,000 children die before

reaching their fifth birthday. In addition, as expected,the mortality rates are highest in the lowest, second

and middle wealth quintiles (137, 156 and 147, respectively) as compared to the highest wealth quintile

(93).

Although under-fives constitute about 16% of the population, they account for 50% of the total mortality

burden for all ages. Most of these deaths are due to preventable diseases. Malaria, pneumonia, diarrhoea,

HIV/AIDS and neonatal conditions account for over 80% of deaths. Malnutrition is a contributory factor

to about fifty percent of all deaths.

The under-five mortality rate for children whose mothers were less than 20 years of age when they gave

birth is 157/1,000, versus 120/1,000for children whose mothers were in their twenties. Children whose birth

order is seven or higher have a mortality rate of 151/1000, compared with 121/1,000for those born second

or third.

The National Road Map Strategic Plan -2008 - 2015

TDHS, 2004/05

Helen Keller International, 2004/05

TFNC, 2004/05

NBS and TDHS 2004/05

The National Road Map Strategic Plan -2008 - 2015

• Adolescents

Adolescents constitute a significant proportion of the population, at about 31%

. A high percentage of

adolescents are sexually active and practice unsafe sex. Consequently, the majority of them are highly

vulnerable to SRH problems that include adolescent pregnancy and early child bearing, the complications

arising from unsafe abortion, and STIs including HIV/AIDS

. In Tanzania, more than half of young women

under the age of 19 are pregnant or already mothers, and the perinatal mortality rate is significantly higher

for young women under the age of 20 (at 56 per 1,000 pregnancies) than it is for women aged 20-29 (at 39

per 1,000 pregnancies), and older women aged 30-39 (32 per 1,000 pregnancies). Obtaining permission to

access services is a greater obstacle for young women age 15-19 than for their older counterparts. Young

women age 15-19 also cited not knowing where to go as a barrier to accessing services

. Hence the need

to invest in adolescent sexual reproductive health (SRH) services, including HIV/AIDS is paramount given

the fact that SRH needs are not only basic human rights but that adolescents form

a significant section of the population and bear a disproportionate burden of

disease with regards to reproductive ill-health and HIV prevalence

2.4 Cross-Cutting Issues

• National Policies and Guidelines

Tanzania has mainstreamed maternal, newborn and child survival into its national

health policy.The services for maternal, newborn and child health are exempted

from cost sharing. However, the exemption policy faces difficulties in its

implementation at lower level due to lack of clarity on how to effect the

exemption mechanisms.

Several national policy documents have been developed targeting improvement of reproductive and child

health services, which include maternal and newborn health. However, certain professional regulations

and legislations contribute to compromised implementation of the policies.

The MoHSW and partners have developed several clinical national protocols; however,there is need to have

an integrated protocol. Although training on RCH interventions has been ongoing nationally through the

MoHSW, district councils and NGOs, the quality of the trainings, transfer skill to practice and follow up

Figure 4: Causes of Deaths for Children Aged less than Five Years,

in the Year 2006*

Source: WHO, 2006

Census, 2002

National Adolescent Health and Development Strategy, 2004-2008

TDHS, 2004/05

Good governance is

participatory,

consensus-oriented,

accountable,

transparent,

equitable, and

follows the rule of

law.

supervision are still challenges that need to be addressed. National capacity development is also

compromised by poor working environment; low geographical coverage; weak integration of gender and

human rights issues.

• Community Mobilization and Participation

Community-based maternal, newborn and child health interventions are crucial in complementing services

at the health facility level. Since the Alma Ata Declaration on Primary Health Care (PHC) in 1978 and the

subsequent health sector reforms initiated in 2000, there has been increased focus on community

participation in the delivery of health services. Community participation has been strengthened further by

local Government reforms, which interface the health sector within the overall Government policy of

decentralization by devolution. In Tanzania communities play an increasingly important role in the

development of the Comprehensive Council Health Plans (CCHPs) through the decentralised district

planning framework. Further community participation has been strengthened through community

representation on the Council Health Service Boards and Health Facility Governing Committees.

Though a few districts have been successful in involving communities in the process of planning,

monitoring and evaluation of health services, their participation is still compromised by the low capacity

of health boards and health facility governing committees and inadequate outreach activities.

Other challenges include weak partnership between clients and service providers, which is compounded

by low awareness of clients’ and service providers’ rights and obligations; low public awareness of

reproductive health matters such as management of pregnancy, newborn care and child care and related

complications, socio-cultural barriers; gender inequalities, low women empowerment; and myths and

misconceptions of various health-related issues.

• Water, Sanitation and Hygiene

The proper sanitation, hygiene and use of safe water are vital in containing the spread of water borne and

water related diseases. The TDHS(2004/0) also showed that during the two weeks that preceded the survey

13% of children under-five had diarrhoea. The rate was highest among children 6-11 months old(25%).

Less than half of all households are within 15 minutes of their drinking water supply. Nineteen percent of

urban households have water piped into their compound and 33% from neighbours’ taps while rural

households primarily rely on public wells both open and protected (43%)and rivers and streams (18%) for

their drinking water. About a half of households (47%) have improved toilets.

Improved household water, sanitation and promotion of key hygiene behaviour changes will be critical to

complement and strengthen the essential health package. Various community-based interventions are being

implemented to improve hygiene and sanitation such as Participatory Hygiene and Sanitation

Transformation (PHAST) and c-IMCI.

• Human Resources

Human resources for health is a crisis in the country with only one-third of posts filled. The situation is

worse especially for the lower-level health facilities, where dispensaries and health centres have

shortages of 65.6% and 71.6% respectively

. This has a major impact on maternal, newborn and

childcare, most significantly recognizable in the lack of skilled attendants during childbirth. Efforts are

being made by MoHSW to recruit additional skilled health providers but challenges remain such as poor

skills mix; non-attractive incentive and salary packages; poor motivation; inadequate performance

assessment; rewarding systems; retention of staff especially in remote and hard to reach areas;.

• Monitoring and Evaluation

The National Road Map Strategic Plan -2008 - 2015

MoHSW, 2006

The National Road Map Strategic Plan -2008 - 2015

Monitoring and evaluation play a critical management function by assessing whether implementation

of programmes proceeds according to plan and leads to the desired outcomes. Monitoring of maternal,

newborn and childhood health in Tanzania has been implemented through HMIS, annual RCH reports,

TDHS, Tanzania Service Provision Assessment (TSPA), maternal and perinatal death review reports,

Infectious Disease Week Ending Report (IDWE) and other health facility and household surveys. Some of

the limitations in reporting maternal, newborn and child deaths are the problem of incorrect and incomplete

recording, proper case definition, data management, source of information (i.e. facility versus community-

based data) and methods of estimation. Further, the use of process indicators is critical for evaluation of

implementation. However,process indicators are not widely used at all levels. In order to achieve coherent

and useful data for monitoring and evaluation of maternal, newborn and child health in Tanzania it is crucial

to strengthen the current health information system to address the information gaps for maternal, newborn

and child care.

• Advocacy and Resource Mobilization

Although there has been advocacy and commitment at different levels in addressing maternal, newborn and

child health issues, the meagre budget allocation to the health sector has been a hindrance to effective

implementation of the Essential RCH Package. During FY 2005/06, the health budget allocation was Tsh.

453.2 billion, which is 10.1% of the total Government budget, below the recommended Abuja target of

15%. Due to other competing health priorities such as malaria, HIV/AIDS and tuberculosis, the budget

allocation for reproductive and child health is still limited.

Opportunities and synergies for addressing maternal, newborn and child health include introduction and

scaling up of the TASAF II initiative, which will enable communities to address their infrastructure

development needs, logistics and human capacity gaps, in order to provide appropriate maternal, newborn

and child care interventions and services. The existence of the Joint Rehabilitation Fund,District Demand

Driven Initiative, GAVIand Global Fund for AIDS, TB and Malaria, also provide opportunities for the

districts to strengthen maternal, newborn and child health interventions.

• Partnerships and Coordination

Maternal, newborn and child health interventions need to be addressed in the context of a multi-sectoral

approach. Partnerships, resources and more effective and coordinated programmes at all levels are

increasingly needed to reach the MDGs.

Due to other competing health priorities such as

Malaria, HIV/AIDS and Tuberculosis, Reproductive

and Child Health budget is still limited. This has

affected implementation of comprehensive

interventions on maternal, family planning and

newborn care.

The National Road Map Strategic Plan -2008 - 2015

Strategic Plan

The National Road Map Strategic Plan -2008 - 2015

CHAPTER 3:

STRATEGIC FRAMEWORK

Maternal, Newborn and Child Health Strategic Plan

The development of the MNCH Strategic Plan to Accelerate Reduction of Maternal, Newborn and Child Deaths

is a response to the New Delhi Declaration (April 2005) which urged all countries to develop strategies to

reducing the persistently high rates of maternal, newborn and child deaths in order to reach MDG 4 and 5. This

plan is expected to contribute to the achievement of MKUKUTA and MMAM goals and targets, as well as

objectives and targets of other existing national programmes, interventions and strategies, which focus on

improving MNCH.

This strategic plan aims to address maternal, newborn and child health and accelerate mortality reduction in an

integrated manner addressing the continuum of care. The rationale for taking the integrated approach relies on

a number of factors:

1. Specific interventions delivered in a specific time frame have multiple benefits.

2. Linking interventions in packages can reduce costs, facilitate greater efficiency in training, monitoring and

supervision, and strengthen supply systems.

3. Integration of services increases uptake and promotes continuation of positive behaviours

4. Integration maximizes programme achievements

3.1. Vision

A healthy and well-informed Tanzanian population with access to quality MNCH services, which are

affordable, sustainable and accessible through an effectively functioning health system.

3.2. Mission

To promote, facilitate and support in an integrated manner, the provision of comprehensive, high impact

and cost-effective MNCH services, in order to accelerate reduction of maternal, newborn and child

morbidity and mortality.

3.3. Goal

To accelerate the reduction of maternal, newborn and childhood morbidity and mortality, in line with

MDGs 4 and 5, by 2015.

3.4.Objectives

The following are the objectives for the MNCH Strategic Plan, which should be met by the end of the year

2015.

3.4.1. To reduce maternal mortality from 578 to 193 per 100,000 live births.

3.4.2. To reduce neonatal mortality from 32 to 19 per 1000 live births

3.4.3. To reduce under-five mortality from 112 to 54 per 1000 live births

3.5 Operational targets to be achieved by 2015

1. Increased coverage of births attended by skilled attendants from 46% to 80%.

2. Increased immunization coverage of DTP-HB 3 and Measles vaccine to above 90% in 90% of the

districts.

3. New EPI vaccines introduced (Hib, Pneumoccocal, Human Papilloma Virus (HPV) and Rota Virus

vaccines).

4. Reduced stunting and underweight status among under-fives from38% and 22% to 22% and 14%,

respectively.

5. Increased exclusive breast feeding coverage from 41% to 80 %

6. PMTCT services provided to at least 80% of pregnant women, their babies and families.

7. 90% of sick children seeking care at health facilities appropriately managed.

8. Increased coverage of under-fives sleeping under ITNs from 47% to 80%.

9. 75% of villages have community health workers offering MNCH services at community level.

10. Increased modern contraceptive prevalence rate from 20% to 60%

11. Increased coverage of CEmOC from 64% of hospitals to 100% and of BEmOC from 5% of health

centres and dispensaries to 70%

12. Increased proportion of health facilities offering Essential Newborn Care to 75%.

13. Increased antenatal care attendance for at least 4 visits from 64% to 90%

14. Increased number of health facilities providing Adolescent friendly reproductive health services to

80%

3.6.Strategies

3.6.1. Advocacy and resource mobilizationfor MNCH goals and agenda in order to promote, implement, and

scale up evidence-based and cost-effective interventions, and allocate sufficient resources to achieve

national and international goals and targets;

3.6.2. Health System strengthening and capacity development at all levels of the health sector and ensuring

quality service delivery to achieve high population coverage of MNCH interventions in an integrated

manner;

3.6.3. Community mobilization and participation to improve key maternal, newborn and child care practices,

generate demand for services and increase access to services within the community;

3.6.4. Fostering partnership to implement promising interventions among Government (as lead), donors,

NGOs, the private sector and other stakeholders engaged in joint programming and co-funding of activities

and technical reviews;

3.6.5.Information, education and communication /behavioural change communication (IEC/BCC).

Promotion of appropriate reproductive health behaviours is critical in accelerating reduction of maternal,

newborn and child deaths. With implementation of the MNCH Strategic Plan, the use of IEC/BCC

approaches for positive behaviour adoption and create demand for quality maternal, newborn and child care.

3.7.Guiding Principles

The following principles will guide the planning and implementation of the MNCH Strategic Plan in order

to ensure effectiveness, ownership and sustainability of the initiative in Tanzania:

• Continuum of Care: Ensuring provision of the continuum of care from pregnancy, childbirth and

neonatal period through childhood and across all services levels from family/household, community,

and primary facility to referral care.

• Integration: All efforts will be made to implement the proposed priority interventions at various levels

The National Road Map Strategic Plan -2008 - 2015

of the health system in a coherent and effective manner that is responsive to the needs of the

mother, the newborn and the child.

• Evidence-based approach: ensuring that the interventions promoted through the plan are based

on priority needs, up-to-date evidence, and are cost-effective.

• Complementarities: Building on existing programmes by taking into account the comparative

advantages of different stakeholders in the planning, implementation and evaluation of MNCH

programmes.

• Partnership: Promoting partnership, coordination and joint programming among stakeholders

including the regional secretariat, district councils, private sector, faith-based sector, academia,

professional organizations, civil society organizations, as well as communities, in order to improve

collaboration and maximize on the available limited resources by avoiding duplication of effort

• Addressing underlying causes of high mortality: Taking a multi-sectoral and partnership approach

to address the underlying causes of maternal, newborn and child death such as, transport, nutrition, food

security, water and sanitation, education, gender equality and women empowerment to ensure

sustainability.

• Shared responsibility: The family/household is the primary institution for supporting holistic growth,

development and protection of children. The community has the obligation and the duty to ensure the

survival and health of mothers and children and ensuring that every child grows to its full potential.

The state, on the other hand, has the responsibility for developing a conducive legislation and public

service provision for survival, growth and development.

• Division of labour for increased synergy: Defining roles and responsibilities of all players and

partners in the implementation, monitoring and evaluation of the activities for increased synergy.

• Appropriateness and relevance: Interventions must rely on a clear understanding of the status and

local perceptions of MNCH in the country.

• Transparency and accountability: Promoting a sense of stewardship, accountability and transparency

on the part of the Government as well as stakeholders for enhanced sustainability.

• Equity and accessibility: Supporting scaling-up of cost-effective

interventions that promote equitable access to quality health

services with greater attention to the youth, poor and most

vulnerable children and groups, especially in rural and underserved

areas.

• Phased planning, and implementation: Promoting

implementation in clear phases with timelines and benchmarks that

enable re-planning for better results. Building and strengthening

existing health infrastructures will be a priority.

• Human rights and gender in health: The right to life is a basic

human right. Mainstreaming gender throughout the programme

and adopting a human rights approach as the basis of planning and

implementation is important. It is also critical to understand that

children’s rights are important human rights and therefore need to

be respected at all times in order to uphold the dignity that enables

child development and participation.

For majority of women,

especially the poor and

disadvantaged groups,

the pathway to safe

motherhood is blocked

by the underlying

factors that lead to

delays in accessing

appropriate care.

CHAPTER 4:

IMPLEMENTATION FRAMEWORK

4.1 Introduction

The MNCH Strategic Plan has been designed to accelerate the reduction of maternal newborn and child deaths

with the aim of attaining MDGs 4 and 5 by 2015. It should be implemented jointly by all stakeholders as a multi-

sectoral strategy for comprehensive reproductive and child health care.

Good governance is a critical element for successful implementation of the strategic plan, right from central level

to the grass root level. Good governance is participatory, consensus-oriented, accountable,transparent, equitable,

and follows the rule of law. It assures that corruption is minimised, and voices of the most vulnerable in society

are heard in decision making.

The MNCH Strategic Plan will be implemented in collaboration with relevant stakeholders, which include

related Ministries and agencies, development partners, the civil society, community based organisations,

professional associations, faith-based organisations, voluntary agencies, and the private sector, among others.

4.2. Specific Roles and Responsibilities of Different Levels

4.2.1 Ministry of Health and Social Welfare (National Level)

The MoHSW will mobilise resources and advocate for reduction of maternal, newborn and child deaths. It will

also be responsible for the overall technical leadership, guidance and advice on the implementation and

monitoring of the strategic plan. The following will be the specific roles and responsibilities of the various

Directorates of the MoHSW.

i) Directorate of Policy and Planning will ensure adequate budget allocation for MNCH and mainstreaming

of MNCH indicators into policy frameworks. The HMIS Unit will facilitate the monitoring of all indicators

from routine data collection systems including community-based data through Community Based

Management Information System (CBMIS).

ii) Directorate of Hospital Services will ensure availability of essential drugs, supplies, equipment and

diagnostics by facilitating efficient procurement and distribution to all levels of service delivery.

iii) Directorate of Human Resource and Development. The training department will be responsible to review

and update pre- and in-service curricula to ensure relevant issues for MNCH are adequately addressed.

The department will also promote accelerated training of mid-level cadres in order to increase the available

number of skilled health workers, and will facilitate effective development, recruitment and deployment

of skilled health workers at health units to address the human resource crisis

. This will be done in

collaboration with the Prime Minister’s Office - Regional Administration and Local Government

(PMORALG) , the President’s Office - Public Service Management (POPSM) and Ministry of Finance

and Economic Affairs..

iv) Directorate of Preventive Services will supervise and coordinate all activities with respect to all

sections under its charge for the realisation of the strategic plan objectives. It will particularly undertake

the following activities:

• Advocate for the implementation of the MNCH Strategic Plan by

• Coordinate the implementation, monitoring of MNCH activities

• Involve and collaborate with various stakeholders at all levels for planning and implementation of the

MNCH Strategic Plan

The National Road Map Strategic Plan -2008 - 2015

MMAM

The National Road Map Strategic Plan -2008 - 2015

• Facilitate capacity development at national, zonal, regional and district levels by developing

protocols and training packages for MNCH

• Design and develop IEC/BCC materials with stakeholders and disseminate them to the intended

users

• In collaboration with the procurement unit, facilitate procurement of communication equipment and

its installation at hospital, health centres and selected dispensaries

• Identify and propose disaggregated indicators and update monitoring data collection tools to include

process indicators for EmOC, newborn care, nutrition, postnatal care, child care and Adolescent health

including functioning monitoring and evaluation systems and userfirendly data base

• Review and harmonize existing CBMIS, in collaboration with the district councils

• Facilitate integration of nutrition actions in maternal, newborn and child care programmes.

• Promote research on MNCH including FP and nutrition

• Capacity developemnt for the implementation of maternal, newborn, child and Adolescent health

4.2.2 Zonal Level

• Disseminate the MNCH Strategic Plan to their respective districts

• Support capacity development in MNCH in the districts

• Zonal Training Centres and ZRCH coordinator maintain effective partnership with key stakeholders

(MoHSW- RCHS, RHMTs, CHMTs, NGOs, CBOs etc)

• Conduct and build research capacity in the regions and districts

4.2.3 Regional Level

• Provide technical support for effective planning and implementation of the integrated MNCH activities in

the CCHPs.

• Coordinate, monitor and supervise MNCH activities in the region

• Technical support for training and ensuring quality in service provision

• Support districts in analysis and utilization of MNCH data and disseminate/report to the national level

4.2.4 District Level

• Disseminate MNCH Strategic Plan to all stakeholders in the District Council including NGOs, FBOs and

other private sector partners.

• Incorporate MNCH activities into the CCHPs

• Coordinate and supervise all MNCH activities planned and implemented by all stakeholders in the district

• Provide technical support for quality MNCH services

• Capacity development for facility and community MNCH interventions

• Follow up maternal, perinatal, neonatal and child death reviews at health facility (dispensaries, health

centres, district hospitals, regional hospitals, as well as voluntary agencies and private hospitals) and

community levels

• Council Management Teams and District Health Boards to ensure adequate resource allocation for

implementation and monitoring of the MNCH interventions

4.2.5 Health Facility (Dispensary, Health Centre and Hospital)

• Incorporate MNCH activities into facility health plans

• Provide quality MNCH services

• Implement quality improvement approaches such as Quality Improvement and Recognition Initiative

(QIRI), Pay for Performance, Integrated Management Cascade and Collaborative Approach

• Ensure timely availablity of essential equipment, supplies and drugs for service MNCH provision

• Conduct maternal, perinatal, neonatal and child death reviews, involving the community

• Health facility committees to monitor and ensure quality MNCH service provision

• Provide technical and supportive supervision to community interventions

4.2.6 Community

The Village Government and Ward Development Committee through the Primary Health Care (PHC)

committee and health facility governing committee will be responsible for supervision andimplementation

of MNCH activities in their areas. Other responsibilities include:

• Facilitate development and monitoring of community MNCH action plans

• Mobilize the community to participate in community interventions

• Establish and/or strengthen CBMIS

• Leverage community resources for the implementation of MNCH interventions

4.2.7 Roles and Responsibilities of other Ministries

Key Ministries should be involved to ensure that the reduction of maternal, newborn and child mortality is

high on their agenda. These include Ministry of Finance and Economic Affairs (MoFEA), PMORALG,

Ministry of Community Development Gender and Children (MoCDGC), Ministry of Education and

Vocational Training (MoEVT), Ministry of Agriculture, Food Security and Cooperatives (MoAFSC),

Ministry of Labour, Employment and Youth Development (MoLEYD), Ministry of Infrastructure

Development (MoID), Ministry of Communication, Science and Technology (MoCST), and Ministry of

Information, Culture and Sports (MoICS).

i) Ministry of Finance and Economic Affairs

• Give priority to health, especially MNCH, in budget guidelines for allocation of resources

• Increase financial resources for health and especially implementation of MNCH activities as guided by the

MNCH Strategic Plan

ii) Prime Minister’s Office Regional Administration and Local Government

• Provide technical support to regions and councils for planning and implementation of CCHPs

• Mobilize funds to support implementation of CCHPs including CBMIS

• Support infrastructural development, rehabilitation and maintenance to improve access for MNCH services

• Include maternal, perinatal, newborn and child health indicators in the national health sector monitoring

and evaluation framework.

iii) Ministry of Education and Vocational Training

• Promote universal access to education, especially education for girls and women

• Review and update components of MNCH and SRH in various school and pre-service curricula in

collaboration with MoHSW particluarly on provision of adolescent friendly services

iv) Ministry of Agriculture, Food Security and Cooperation

• Promote food security at household, community, district and national levels

v) Ministry of Community Development, Gender and Children

• Support community development extension workers to supervise and identify problems and derive solutions

for MNCH in the local context

• Facilitate the establishment of community mechanisms to support emergency transportation for MNCH

services

• Advocate for gender issues to improve MNCH decision-making at all levels

• Support and promote rights-based approach to programming for MNCH

• Advocate for revision of laws, legislations and policies to improve MNCH

• Promote parental support for adolescents to access information and health services

vi) Ministry of Infrastructure Development

• Improve road networks to facilitate access to services at primary and referral levels, especially in rural

areas where the majority of Tanzanians live

The National Road Map Strategic Plan -2008 - 2015

vii) Ministry of Labour, Employment and Youth Development

• In collaboration with the MoHSW and the MoCDGC, develop a Youth Communication Strategy

• Develop capacity for life skills and livelihood young people

• Advocate for adoption of maternity protection conventions (ILO, convention 183)

viii)Ministry of Communication, Science and Technology

• Promote the development, availability of and access to appropriate technology to support MNCH service

provision

ix) Ministry of Information, Culture and Sports

• Promote positive RH behaviours including early health care seeking for MNCH services.

• Disseminate information aimed at promoting early care seeking behaviour for MNCH and use of

preventive care services

4.2.8 Roles and Responsibilities of Development Partners

• Provide technical and financial support for the coordination, planning, implementation, capacity

developemnt and monitoring and evaluation of MNCH services

• Advocate for increased global and national commitment to the reduction of maternal, newborn and child

morbidity and mortality

• Mobilise and allocate resources for the implementation of MNCH interventions

4.2.9 Roles and Responsibilities of Civil Society Organisations (NGOs, FBOs, CBOs, Professional

Associations)

• Advocate for the rights of women and children.

• Forge partnership with different stakeholders including political leaders to promote MNCH

• Implement community based strategies to promote healthy behaviours during pregnancy, child birth, post

partum period, childhood and adolescence

• Complement governement efforts in the provision of quality MNCH services

• Disseminate the MNCH Strategic Plan to accelerate the reduction of maternal, newborn and child morbidity

and mortality

• Mobilize and allocate resources for implementation of the MNCH Strategic Plan

4.2.9 Roles and Responsibilities of Private Sector

• Complement Government efforts in the provision of quality MNCH services

• Invest in commodites and supplies for MNCH interventions

4.2.10 Role of Training and Research Institutions

• Undertake relevant MNCH research to provide evidence for policy directions and implementation guidance

• Review and update curricula to ensure relevant MNCH issues are adequately addressed

• Provide technical advice and updates on current developments on MNCH and SRH to policy makers

4.3.Key Strategies to be Implemented

4.3.1. Advocacy and Resource Mobilization

In advocating for improved MNCH, the following issues will be emphasized:

• Increased budget allocation for MNCH interventions including FP and nutrition. The target is to mobilize

resources from internal and external sources in order to complement the Government’s efforts towards

reducing maternal, newborn and childhood deaths

• Revision of laws, legislations and policies that hinder effective provision of maternal, newborn and

childcare services

• Improved production, employment, deployment and retention of a skilled health work force at all levels

4.3.2. Health Systems Strengthening and Capacity Development

Health system strengthening for MNCH involves improving; service delivery; health workforce;

information; medical products , vaccines and technologies; financing; and leadership/ governance as well as

managing interactions among them, so that more equitable and sustained improvements across services and

health outcomes will be achieved.

4.3.2.1 Capacity development

• The strategy aims to increase the number of skilled health work force required, as well as the knowledge

and skills of existing service providers and supervisors so that quality care is provided.

• User friendly protocols will be developed/reviewed and the mechanisms for making essential commodities

for MNCH, including FP,available will be strengthened

• Basic and comprehensive EmOC as well as essential newborn services will be strengthened at dispensaries,

health centres and hopsitals

• Skills for planning and management of MNCH services, including FP and Nutrition, will be imparted to

the CHMTs.

• Necessary infrastructure, logistics and equipment support will be provided for the effective delivery of the

comprehensive MNCH packages.

4. 3. 2.2 Referral systems

• Referral systems will be improved to ensure equitable access to quality MNCH services through making

appropriate means of transportation available and improve linkages between community and referral

facilities

• Communications equipment (e.g., radio calls and mobile phones) will be installed in hospitals, health

centres and selected dispensaries.

• Community emergency committees will be established and oriented to emergency preparedness and

response.

• Maternity waiting homes will be established where appropriate.

4.3.2.3 Research, Monitoring and Evaluation

• Capacity building for conducting operational research will be strengthened at all levels. Districts will be

encouraged to identify research priority areas according to their needs.

Essential monitoring tools and indicators will be developed and mainstreamed into the HMIS. Data will be

generated periodically to monitorthe milestones and improvement of services provided at health facilities.

• Periodic reviews and reporting will be carried out every two years to assess progress. A mid-term review

will be conducted between 2010 – 2011, and an end of term review will be conducted in 2015 to report on

the attainment of the MDGs.

4.3.3. Community Mobilization

• Communities will be mobilised to participate fully in initiatives aimed at improving maternal, newborn and

child care by:

• Educating and sensitising them on community-based MNCH interventions

• Mobilizing resources at the village level for MNCH including emergency referral as well as building and

The National Road Map Strategic Plan -2008 - 2015

strengthening health facilities.

• Orienting the facility governing committees to the MNCH Strategic Plan to ensure effective

implementation of the plan at the health facility and community levels

• Re-institutionalizing quarterly village health days

4.3.4: Information Education and Communication (IEC)/Behaviour Change Communication (BCC)

• Use of IEC/BCC approaches will be intensified towards adoption of positive behaviours for quality MNCH

including nutrition and adolescent sexual reproductive health.

• The IEC/BCC activities will target community-based initiatives particularly in addressing birth

preparedness, with an emphasis on birth planning for individual couples, transport in case of emergency,

and promotion of key MNCH practises at the household and community levels.

4.3.5: Fostering Partnership and Accountability

Effective implementation of the MNCH Strategic Plan will entail fostering and establishing strategic

partnerships to improve coordination and collaboration between communities, partners and among programmes

as well as galvanizing resources for long term sustainable actions for MNCH.

• Coordinate regular planning, implementation, monitoring and evaluation of MNCH activities to assess

progress towards attainment of the MDGs

The goal of this National

Strategic Plan is to accelerate

the reduction of maternal,

newborn and child mortality and

morbidity, and the atteinment of

the MDGs 4 and 5 in Tanzania.

Timeframe Strategic

Objective/

Output

Activities

09 10

14 15

Process Indica tors Responsible Person Resources

Needed in

US dollars

5.1 Advocacy and Resour ce Mobilisation

5.1.1.1Cost the package for

maternal, newborn and child

health including FP and nutrition

by establishing:

•

Unit cost per i nterve ntion p er

area;

•

Operational costs;

•

Recurre nt costs.

X X X The package for

maternal, newborn and

child health including

FP and nutrition costed

and in place.

MoHSW

(RCHS, Policy and

Planning)

Development Pa rtners

Research Institutions

80,000

5.1.1.2. Conduct Advocacy for

maternal newborn and child care

through Deliver Now for

Women a nd Children ca mpaign

5.1.1.3 Develop an advocacy

package targeting the following:

MoHSW, PMO-RALG, MoFEA

and other relevant line ministries,

partners, parliamentarians (using

REDUCE/ALIVE and other

materials) to mobilise human and

financial resources from

Government, political and

community leaders.

XX X

X X X

Number of advocacy

events conducted

annually

Advocacy package

developed and

disseminated.

MoHSW

(RCHS, HEU)

Development Pa rtners

CSOs

Professional

Associations Academic

and Research

Institutions

Media

200,000

5.1.1

Budget allocation

for health,

particularly for

maternal,

newborn & child

health including

FP and nutrition

increased at all

levels.

Strategic Output

Indicator:

Budget for

maternal, newborn

and child health

including FP and

nutrition increased

by 50% by 2015.

5.1.1.4 Identify focal persons

among members of parliament

and other influential leaders to

advocate for maternal, newborn

and child health.

5.1.1.5 Provide support to MNCH

champion and other focal persons.

Numbers of influential

leaders advocating for

maternal, newborn and

child health identified.

MoHSW (RCHS)

Development Pa rtners

CSOs

The National Road Map Strategic Plan -2008 - 2015

CHAPTER 5: STRATEGIC PLAN AND ACTIVITIES: 2008 -2015

Timeframe Strategic

Objective/

Output

Activities

08 09 10

12 13 14 15

Process Indica tors Responsible Person

Resources

Needed in

US dollars

5.1.1.6 Conduct advocacy meetings to

policy/decision - makers on the

MNCH Strateg ic Plan, to s upport

implementation of the stra tegy at the

central, regional and district levels.

5.1.1.7 Lobby with the governm ent for

subsidy on ITNs in order to ensure

equitable access to the materials by a ll

vulnerable groups.

Number of advocacy

meetings conducted

Subsidy policy on ITN for all

vulnerable group in place

MoHSW (RCHS)

CSOs

Professional Associations

Development Pa rtners

680,000

5.1.1.8 Establish and conduct Mother-

Baby Day/ Week, annually at all

levels through:

• Pub lic awareness campaigns

(media/rallies/debates).

• Programme communication

development.

X X X X X X X X Mother-Baby Day/Week

commemora ted

MoHSW, Ministerial

Department Agencies

(MDAs)

Media

Development Pa rtners

CHMTs

Professional Associations

CSOs

400,000

5.1.1.9 Advocate for bi-annual Child

and village health days at all levels

through :

• Public awareness campaigns

• Programme Communication

development

5.1.1.10 Sensitize RHMTs and CHMTs

of the importance of including child

and village health days in the CCHPs

5.1.1.11 Train, establish and support

Media Groups to report on MNCH

Proportion of villages

conducting semi annual

child health day

Proportion of CCHPs with

budget allocation for Village

Health Days

Number of established

media groups

MoHSW, MDAs

Media

RHMTs

CHMTs

NGOs,

Professional Associations

Village Governments

Development P artners

600,000

100,000

The National Road Map Strategic Plan -2008 - 2015

Timeframe

Strategic Obje ctive/

Output

Activities

09 10

11 12

13 14 15

Process Indica tors

Responsible Person Resources Needed in

US dollars

5.1.2.1 Review regula tions and

legislations related to the

provision of maternal, newborn

and child care.

X X Number of

regulations, laws and

policies to support

effective provision of

quality maternal,

newborn and child

care reviewed.

MoHSW (RCHS)

Professional

Associations

Development Pa rtners

Medical Council

Nurses & Midwives

Council CSOs

60,000

5.1.2

Regulations, laws

and policies to

support effective

implementation of

maternal, newborn

and Child health

reviewed.

Strategic Output

Indicator:

Number of regulations

approved by regulatory

bodies.

Number of laws

approved by regulatory

bodies.

5.1.2.2 Advocate for review and

adoption of laws such as the

Marriage Act of 1970, and the

Sexual Offence Special Provision

Act (SOSPA) of 1998 that

influence maternal, newborn and

child health.

X X Laws affecting

maternal and

newborn health

reviewed and

adopted.

MoHSW,

Ministry of Justice and

Constitutional Affairs

MCDGC, MDAs,

Development Pa rtners,

Professional

Associations

CSOs

120,000

The National Road Map Strategic Plan -2008 - 2015

STRATEGIC PLAN AND ACTIVITIES: 2008 -2015

Timeframe

Strategic Obje ctive/

Output

Activities

08 09

10 11 12 13

Process Indica tors

Responsible Person

Resources

Needed in

US dollars

5.1.3

Implementation of

the exemption

policy for maternal

and child health

strengthened.

Strategic Outp ut

Indicator:

Exemption policy

effectively

implemented.

5.1.3.1 Advocate for exemption

policy on MNCH to be effected

in voluntary and public health

facilities ( Service Agreement)

Proportion of public

and voluntary health

facilities implementing

the Exemption Policy.

MoHSW (RCHS & Policy

and Planning)

Health professional

association s

Private sector

CSOs

25,000

The National Road Map Strategic Plan -2008 - 2015

Timeframe Strategic Obje ctive/

Output

Activities

09 10 11 12 13

14 15

Process Indica tors Responsible Person

Resources

Needed in

US dollars

5.1.4.1 Advocate for review of the

1999 Human Resources

Establishment (and 2006 proposed

revision) in line with skilled

attendance require ments for

maternal, newborn and child care.

X X Human Resource

Establishment of

MoHSW (1999)

reviewed.

MoHSW (DHR, DAP)

PMO-RALG

PO- Public Service

Manageme nt

MoFEA

Health professional

association s, CSOs

Development Pa rtners

62,000

5.1.4.2 Advocate for recruitment and

deployment of skilled health

workers at all levels of care.

X X X X X X X X Proportion of

districts with

appropriate

number of skilled

health workers.

MoHSW

PMO-RALG

Health professional

association s

Development Pa rtners

CSOs

37,000

5.1.4

Employment,

deployment and

retention o f skilled

health workers at all

levels of care

improved.

Strategic Output

Indicator:

Number of skilled

health workers

increased to 100% of

established need by

2015

5.1.4.3 Advocate to the Governme nt

to motivate skilled health workers

by providing a package of incentives

in order to ensure optimum

performance.

X X X X X X X X Types of Incentive

package provided

by the

Government at all

levels.

Proportion of

districts providing

incentive packages

MoHSW (DHR, DAP,

Policy & Planning)

PMO-RALG

PO-Public Service

Manageme nt

MoFEA

Health professional

associations

CSOs

66,000

The National Road Map Strategic Plan -2008 - 2015

STRATEGIC PLAN AND ACTIVITIES: 2008 -2015

Timeframe

Strategic

Objective/

Output

Activities

10 11

12 13

Process Indica tors

Responsible Person Resources Needed in

US dollars

5.2. Health Systems Strengthening and Capacity Development

5.2.1

Knowledge and

skills of

supervisor s and

service pr ovider s

on maternal,

newborn and

child care

including FP and

nutrition

increased.

Strategic Output

Indicator:

Maternal, newborn

and child health

service provided

according to

standards.

5.2.1.1 Review/deve lop user-friendl y

protocols for antenatal care, postnatal

care, newb orn and chi ld care, EmOC ,

FP and nutrition. Specific activities

include:

• Deve lop/adapt/review and

disseminate Community

Maternal, Newborn and Child

Care packages

• Deve lop/adapt/review

standards job aides and tools for

MNCH service provision

• Deve lop/adapt/review and

disseminate Nutrition Packa ges

including ENA, SAM, IYCF/BFHI

•

Review EPI guidelines for

inclusion of new vaccines

• Adapta tion of Essential Newborn

Care (ENC) and Kangaroo Mother

care guideli nes (KMC)

• Adap tation and adoption of the

new child growth standards and

charts

X X X X Protocols on

antenatal care,

EmOC, newborn

care, severe

malnutrition,

growth monitoring,

child care and

postnatal care

developed and

adopted by the

MoHSW.

MoHSW (RCHS,

DHS HEU)

Development

Partners

Health professional

associations

CSOs

147,000

The National Road Map Strategic Plan -2008 - 2015

Timeframe Strategic

Objective/

Output

Activities

08 09

10 11

13 14 15

Process Indica tors Responsible

Person

Resources Needed in

US dollars

5.2.1.2 Support pre-service traini ng

institutions to provide updated and

competency-based teaching on

maternal, newborn and child care

including FP and nutrition (LSS-

EmOC, ENC, KMC FAN C, PAC, FP,

newborn care, nutrition, BFHI, IYCF,

SAM, PMT CT , IMCI , ETAT , Ref erra l

Care Package, Immunization) by:

• Updating pre-service curricula to

address current changes in

maternal, newborn and child

care including FP and nutrition

• Developing and providing an

orientation package and other

educational materials to tutors and

clinical preceptors.

•

Update and standardize

knowledge, clinical and teaching

skills of tu tors and cli nical

preceptors at medical, nursing and

parame dical schoo ls.

• Provide schools and clinical

practice sites with necessary

teaching and clinical practice

materials and equipment

X X X X X X X X 1000 tutors/clinical

preceptors from

various institutions

updated on

maternal and

newborn care

including FP and

nutrition.

All preservice

MNCH curricular

components

updated

All preservice

institutions

provided with

necessary teaching

materials,

equipment and

supplies

MoHSW (RCHS,

PMTCT, TFNC)

Human Resource

Development

and Training

Health Training

Institutions

Regulatory

bodies

Private

institutions

CSOs

Development

Partners

680,000

5.2.1.3 Update knowledge and sk ills

of supervi sors on ma ternal , newbo rn

and child care including FP, nutrition

and supervisory skil ls (LSS-EmOC,

ENC, KMC, FANC, P AC, FP,

newborn care, nutrition, BFHI, IYCF,

PMTCT , IMCI, ETAT, Referral Care

Package, immuniza tion)

X X X X X X X X 910 CHMT

members (130

Councils), and 147

Zonal and RHMT

members, all

updated in

supervisory skills.

MoHSW (RCHS,

DRH)

Development

Partners

CSOs

1,525,000

The National Road Map Strategic Plan -2008 - 2015

STRATEGIC PLAN AND ACTIVITIES: 2008 -2015

Timeframe Strategic

Objective/

Output

Activities

08 09 10 11

13 14 15

Process Indica tors Responsible

Person

Resources Needed in

US dollars

5.2.1.4 Update knowledge and skills

of service providers on maternal,

newborn and child care including

FP and nutrition (LSS-EmOC, ENC,

KMC, FANC, PAC, PNC, FP, ENA,

IMCI, ETAT, BFHI, IYC F, PMTCT,

SAM, immunization) and link the

interventions to malaria, HIV/AIDs,

and STIs control programmes.

X X X X X X X X Number of service

providers trained in

MNCH service

delivery

MoHSW (RCHS),

District Councils,

and Development

Partners.

CSOs

Private institutions

Health

pProfessional

associations

7,000,000

5.2.1.5 Review maternal, peri natal

and child deaths at all levels (facility

& community).

• Train service provider on

maternal, perinatal and child

death reviews

• Develop a system to review child

deaths

•

Employ/train the community

health wor kers to conduc t verba l

autopsies

Produce weekly, monthly, quarterly

and annual summary reports of

maternal, perinatal and child death

reviews

X X X X X X X X Proportion of health

facilities with

maternal, perinatal

and child deaths

review reports.

Proportion of

facilities with health

workers tra ined in

maternal, perinatal

and child death

review

MoHSW (RCHS)

PMORALG

MoCDGC

RHMTs

CHMTs

CMTs

700,000

The National Road Map Strategic Plan -2008 - 2015

Timeframe

Strategic Obje ctive/

Output

Activities

08 09

12 13 14 15

Process

Indicators

Responsible

Person

Resources

Needed in

US dollars

5.2.2

Planning and

management

capacity fo r

maternal and

newborn care

including FP and

nutrition

strengthe ned.

Strategic Output

Indicator:

Relevant sector

(Ministry of Finance,

MoHSW) allocating

15% of the Health

budget for maternal

and newborn care.

5.2.2.1 Train CHMT/RHMTs on

evidence-based planning

in order to

ensure that strategic interve ntions on

maternal newborn and child care

including FP and nutrition are

incorporated in the CCHP and

implemented.

X X X X X X X X Proportion of

CHMTs and

RHMT’s trained

on planning for

MNCH

Proportion of

districts with

increased budget

allocation for

maternal

newborn and

child health

interventions in

CCHPs.

MoHSW

(RCHS,

Policy and

Planning

Unit) District

Councils

Development

Partners.

290,000

Examples of tools to be used include Plan Rep, costin

tools and other relevant sources of information

The National Road Map Strategic Plan -2008 - 2015

STRATEGIC PLAN AND ACTIVITIES: 2008 -2015

Timefram e Strategic Obj ective/

Output

Activities

09 10 11 12 13 14 15

Process

Indicato rs

Responsibl e

Person

Resources

Needed in

US dollars

X X X X X X X X Proportion of

health facilities

providing Ba sic

EmOC in the

MoHSW

(Directorates

of Preventive

80,800,000

X X X X X X X X Proportion of

health facilities

providing

MoHSW

(Directorates

of Preventive

and

Hospital

Services),

48,400,000

5. 2.3

Basic (BEmOC) an d

Compre he nsiv e

EmOC

(CEmOC)and

newborn services at

all levels

strengthened.

Strategic Output

Indicato r:

% of health facilities

provid ing BEmO C

and CEmOC and

Essential Newborn

care

and

PMO-RALG.

APHTA

PRINMAT

Development

Partner and

UN Agencies

essential newborn

care

Comprehensive

EmOC and

essential newborn

care

Number of A MOs

trained using

tailor made

curricula r

and Hospital

Services)

PMO-RALG,

CSOs

Private sector

Every population of 500,000, at least 4 Basic EmOC are needed (See Glossary for components of Basic and Comprehensive EmOC)

Every population of 500,000, at least 1 comprehensive EmOC is needed (See Glossary for components of Basic and Comprehensive Em

OC)

5.2.3.1 Strengthen the capacity of all

dispensaries and all health centres to

provide BEmOC, essential newborn care

and KMC through:

• Deployment of skilled health workers

(Nurse midwives, Clinical Officers,

laboratory assistants)

• Provision of essential equipment and

supplies.

• Infrastructural improvement for

service delivery (Delivery room,

postnatal room, laboratory)

5.2.3.2 Strengthen the capacity of all

hospitals and upgrade 50% of health

centres to provide CEmOC and

essential newborn care through:

• Deployment of skilled health workers

(Nurse midwives, MO, AMOs,

Anaesthetists, Laboratory technicians)

• Provision of essential equipment and

supplies.

• Infrastructural improvement for

service delivery (Operating theatres,

Labour ward, Blood storage facilities,

incinerators)

• Establish neonatal and KMC units

5.2.3.3 Develop and conduct tailor made

training for AMOs and Nurses to

provide CEmOC, Essential Newborn

and child health services

The National Road Map Strategic Plan -2008 - 2015

Timeframe Strateg ic Objective/

Output

Activities

09 10 11 12 13 14 15

Process

Indicators

Responsible

Person

Resources

Needed in

US dollars

5.2.4.1 Forecast demand, procure and

supply essential commodities and

supplies for maternal, newborn and

child care

including contraceptives.

Emphasi s to be put on:

•

Essential obstetric supplies and

medicines for ANC, delivery and

postpartum.

•

Newborn resuscitation kits, supplies

and drugs.

•

Contraceptives (pills, IUCD,

implants, injectables and condoms).

•

Vaccines

•

Laboratory reagents.

•

Paediatric emergency equipment

(oxygen concentrator, glucometers,

ambu bags, suction, infusion pumps)

and IMCI drugs and supplies

•

Supplies for therapeutic feeding for

managemen t of severe acute

malnutrition

X X X X X X X X Percentage of

health facilities

with stock-outs of

essential

commodities,

supplies and

medicines for

maternal,

newborn and

child care

including

contraceptives.

MoHSW

(Directorate of

Hospital Services,

RCHS and MSD)

District Councils,

Development

Partners

CSOs

Private sector

400,000,000

5.2.4

Mechanisms for

availability of

essential

commodities,

supplies and

medicines for

maternal, newborn

and child health

including family

planning

strengthe ned.

Strategic Output

Indicator:

Essential

commodities, supplies

and medicines for

maternal, newborn

and child care

available all the time

at every health facility

5.2.4.2 Revive and/or esta blish

maintenance units for various equipment

at the hospital level.

X X X X X X X Proportion of

hospitals with

functioning

equipment

maintenance

units.

MoHSW (RCHS,

Directorate of HS)

RHMTs

District Councils

100,000,000

Essential Newborn equipment and supplies (See An nex 8)

The National Road Map Strategic Plan -2008 - 2015

STRATEGIC PLAN AND ACTIVITIES: 2008 -2015

Timeframe Strategi c Objective/

Output

Activities

08 09 10 11 12 13

14 15

Process

Indicators

Responsible

Person

Resources

Needed in

US dollars

5.2.5.1 Procure and install communication

equipment (Two way radio

communication, phones) in district

hospitals, selected health centres and

dispensaries.

X X X X X X X X Proportion of

health units with

2way Radio

communication

equipment

MoHSW/

RCHS

District

Councils

Development

Partners

CSOs

Private sector

2,800,000

5.2.5.2 Procure and utilise ambulances for

referral purposes, at least one per district

hospital and one per health centre and

selected dispensaries.

5.2.5.3 Procure motorbike Amb ulance for

Health Centre /dispensaries where

applicable

5.2.5.4 Provide sufficient fuel for

vehicles/motorbik es

5.2.5.5 Conduct maintenance services for

communication equipments and

vehicles/motorbik es

X X X X X X X X Proportion of

health facilities

with functioning

ambulances and

motorbikes for

referral.

MoHSW

RCHS

PMORALG

MoID

District

Councils

Development

Partners

CSOs

Private sector

6,000,000

5.2.5

Referral system at

all levels

strengthe ned.

Strategic Output

Indicator:

Functional ref erral

systems in place at all

levels

5.2.5.6 Orient regional and district health

committees on obstetric, newborn and

child emergency preparedness

X X X X X X X X Proportion of

regional/district

health

committee s

oriented on

emergency

preparedness.

MoHSW/

RCHS

ZTCs

RHMTs

CHMTs

Development

Partners

CSOs

1,000,000

The National Road Map Strategic Plan -2008 - 2015

Timeframe

Process

Indicators

Responsible

Person

Resources

Needed in

US dollars

Strategic Obje ctive/

Output

Activities

08 09 10 11 12

5.2.5.7 Orient other support staff

(community health workers,

ambulance drivers and attendants) on

emergency and response

preparedness.

X X X X X X X X Number of health

facilities with

support staff

oriented on

emergency and

response

preparedness.

MoHSW/

RCHS

ZTCs,

RHMTs

CHMTs,

Developmen

t Partners

CSOs

1,000,000

5.2.5.8 Establish/revive community

emergency committee in every

villag e to mobil ise commun ity

resource for emergency transport and

for blood donors.

X X X X X X X X Proportion of

villages with

functioning

emergency

committees for

MNCH

PMORALG

MoCDGC

MoHSW/

RCHS,

District

Councils

CHMT

Village

Government

Developmen

t Partners

CSOs

300,000

5.2.5.9 Establish maternity wai ting

homes where applicable.

X X X X X X X X Proportion of

health facilities

(where

applicable)

linked to

functioning

maternity

waiting homes.

MoHSW/

RCHS

District

Councils

CHMTs

Village

Government

Developmen

t Partners

CSOs

Private sector

500,000

The National Road Map Strategic Plan -2008 - 2015

STRATEGIC PLAN AND ACTIVITIES: 2008 -2015

Timeframe Strate gic Objective /

Output

Activities

08 09 10

11 12

13 14 15

Process

Indicators

Responsible

Person

Resources

Needed in

US dollars

Research, Monitoring and Evaluation

5.2.6.1 Develop and update

monitoring and evaluation

framework for MNCH

5.2.6.2 Update monitoring data

collection tools to include EmOC

process indicators and other missing

information on nutrition, post abortal

care, postnata l care, newbo rn and

child care and referral forms, register

for referral, log-books.

X X Monitoring and

evaluation

framework for

MNCH in place

Monitoring data

collection tools

updated

MoHSW (HMIS

Unit)

NBS (Poverty

Monitoring

Unit)

CHMT and

Development

Partners

45,000

5.2.6

HMIS capacity to

capture information

on maternal, neonatal

and child indicator s

including FP and

nutrition improved.

Strategic Output

Indicator :

Key Maternal, newborn

and child health

indicators reported

annually through HMIS

5.2.6.3 Produce, disseminate

,distribute updated data collection

tools at all levels.

X X X Proportion of

facilities using

updated data

collection tools

MOHSW

(RCHS, HIS)

MSD

CHMTs

CSOs

Private sector

500,000

The National Road Map Strategic Plan -2008 - 2015

Timeframe Strate gic Objective /

Output

Activities

08 09 10

11 12

13 14 15

Process

Indicators

Responsible

Person

Resources

Needed in

US dollars

5.2.7.1 Orient health service

providers/supervi sors on MNCH

monitoring and evalua tion

framework and effective data

management (data collection, analysis

and utilization.)

X X X X X X X X Number of health

service

providers/

supervisors

oriented on data

management.

MoHSW (HMIS

Unit)

RHMTs

CHMTs

1,000,000

5.2.7.2. Conduct supportive

supervision for MNCH in both public

and private health facilities.

5.2.7.3 Conduct follow up of health

workers after training on MNCH

packages.

Proportion of

health facilities

receiving

quarterly

supportive

supervision.

Proportion of

health workers

that received

follow up after

training on

MNCH packages

yearly

MoHSW

(Inspectorate

Unit, RCHS)

RHMTs

CHMTs

CSOs

850,000

5.2.7

Monitoring and

evaluation framework

for MNCH

strengthened and

implemented.

Strategic Output

Indicator :

Progress on Maternal,

newborn and child health

status/trends reported.

5.2.7.4 Conduct periodic surveys on

quality of care, client satisfaction and

care seeking be haviour in selected

districts and factors facilitating or

hindering access for maternal,

newborn and child care.

5.2.7.5 Conduct Biennial Rev iew

meetings to assess progress on the

implementation.

Number of

surveys

conducted on

quality assurance

of service

delivered.

Number of

review meetings

conducted

MoHSW

PMORALG

Development

Partners

Research

institutions

NBS

Academic

institutions,

Health

professional

association s

CSOs

The National Road Map Strategic Plan -2008 - 2015

STRATEGIC PLAN AND ACTIVITIES: 2008 -2015

Timeframe Stra tegic Objecti ve/

Output

Activities

08 09

10 11

12 13 14 15

Process

Indicators

Responsible

Person

Resources

Needed in

US dollars

5.2.7.6 Document and share b est

practices on maternal, newborn and

child health.

X X X X X X X X Number of best

practices

documented and

scaled up.

MoHSW/

RCHS

CSOs

Development

Partners

Private sector

100,000

5.2.7.7 Institutionalize materna l,

newborn and child mortality review

approaches at all levels

•

Vital registration system

(birth and death)

• Confidential enq uiry

• Near miss sur veys

• Mortality surv eys

• Verbal autopsy

• Other appropriate review

mechanisms

X X X X X X X X Number and type

of MNCH

mortality review

reports.

MoHSW/

RCHS

RHMTs,

CHMTs

Facilities

Village

Governments

RITA

NBS

Research and

academic

institutions

Development

Partners

CSOs

200,000

The National Road Map Strategic Plan -2008 - 2015

Timeframe Strategi c Objective/

Output

Activities

08 09 10 11 12

14 15

Process

Indicators

Responsible

Person

Resources

Needed in

US dollars

5.2.8.1 Review and harmonize existing

community based management

information tools.

X X X Harmonized

communit y based

management

information tools

in place

RCHS

HMIS

PMO-RALG,

RHMTs

CHMTs

Development

Partners

CSOs,

Village

Governments

18,000

5.2..8.2 Orient village Govern ments on

the community based management

information tools.

X X X X X X X X Proportion of

village

Government

members

oriented on

communit y based

data

management.

RCHS

HMIS

PMO-RALG

RHMTs

CHMTs

Development

Partners

CSOs

Village

Governments

600,000

5.2.8

Community based

management

information system

strengthe ned.

Strategic Output

Indicator:

Community based

data effectively

collected and used in

planning

5.2.8.3 Train community health worke rs

and other service providers on

community based information

management.

X X X X Proportion of

communit y

health workers

and service

providers trained

on data

management.

RCHS

HMIS

PMO-RALG

RHMTs

CHMTs

Village

Governments

Development

Partners

CSOs

900,000

The National Road Map Strategic Plan -2008 - 2015

STRATEGIC PLAN AND ACTIVITIES: 2008 -2015

Timeframe Strategi c Objective/

Output

Activities

08 09 10 11 12 13 14 15

Process

Indicators

Responsible

Person

Resources

Needed in

US dollars

5.2.9 Capacity for

conducting MNCH

operational

research

strengthe ned

Strategic output

indicator:

Evidence on MNCH

available for planning

and programme

development

5.2.9.1 Identify MNCH operational

research priorities

5.2.9.2 Conduct MNCH operational

research and document and disseminate

results

XXXXX

Number of

MNCH

operational

researches

conducted

MoHSW-

RHCS,

Research and

academic

institutions

1,000,000

The National Road Map Strategic Plan -2008 - 2015

Timeframe Stra tegic Objecti ve/

Output

Activities

08 09

11 12

14 15

Process Indica tors Responsible

Person

Resources

Needed in

US dollars

5.2.10.1 Adapt quality assurance

approaches for MNCH (QIRI, PIA, COPE,

Collaborative)

X X Number of quality

assurance

approaches adapted

MoHSW

(RCHS,

Inspectorate

unit) RHMTs

District

Councils

CHMTs

Development

Partners

CSOs

50,000

5.2.10

Quality assurance

and management

(supervision, client

satisfaction,

performance

assessment)

strengthened.

Strategic Outp ut

Indicator:

Proportion of health

facilities delivering

MNCH services

according to

nationally defined

service standards

5.2.10.2 Orient supervisors and service

providers on quality assurance methods

for MNCH services.

5.2..10.3 Orient service provider s on the

Client Health Charter as tool to improve

relationship with client.

5.2.10.4 Update code of conduct and job

description.

5.2.10.5 Orient health facility committees

and district health boards on Client

Service Charte r to ensure s atisfactor y

client-service relationship.

Number of

supervisors and

service providers

oriented on quality

assurance

approaches.

Proportion of health

service providers

oriented on Client

Service Charter at

all levels.

Code of conduct and

job description

updated.

Proportion of health

facility committees

and district health

boards oriented on

client-service

relationship at all

levels.

MoHSW(RCHS,

Inspectorate

unit) RHMTs

District

Councils

CHMTs,

Development

Partners

CSOs

400,000

The National Road Map Strategic Plan -2008 - 2015

STRATEGIC PLAN AND ACTIVITIES: 2008 -2015

Timeframe Stra tegic Objecti ve/

Output

Activities

09 10

12 13

14 15

Process Indica tors Responsible

Person

Resources

Needed in

US dollars

5.3 Community Mob ilisation

5.3.1

Community based

maternal, newborn

and child health

care including FP

and nutrition

strengthened

Strategic Outp ut

Indicator:

Maternal, newborn

and child health care

services provided at

community leve l

5.3.1.1 Train community based hea lth

workers on MNC care including

community IMCI.

5.3.1.2 Train Employed CHW on

Comprehensive Maternal, Neonatal and

child Package.

5.3.1.3 Re-instutionalize quarte rly villag e

health days

5.3.1.4

Conduct monthly outreach and

mobile clinic services for MNCH.

5.3.1.5 Provide comm unity hea lth

workers with necessary

equipment, commodities,

supplies and transport.

5.3.1.6

Develop and implement

incentive mechanism for

communit y health workers

X X X X X X X X Proportion of

villages with

communit y health

workers

, trained

on maternal,

neonatal and child

health issues

including nutrition

and FP.

Proportion of

villages conducting

village health days.

Proportion of

dispensaries and

health centres

conducting

monthly outreach

and mobile clinic

services.

Proportion of

villages with

incentive

mechanism for

communit y health

workers.

MoHSW/RCHS

, MoCDGC

PMORALG

RHMTs,

District

Councils

CHMTs,

Village

Governments,

Development

Partners

CSOs

2,800,000

Required ratio 1/30 households

The National Road Map Strategic Plan -2008 - 2015

Strategic Obje ctive/ Activities Timeframe Process Responsible Resources

Output 08 09 10

11 12

13 14 15 Indicators Person Needed in

US dollars

5.3.2.1

Sensitize community leaders

and communities on

participatory planning ,

implementation an d monitoring

of communit y bas ed MNCH

interventions.

X X X X X X Proportion of

villages with

community

leaders and

members

sensitised on

maternal,

newborn and

child health

issues.

Proportion of

villages plans

with MNCH

activities.

MoHSW/

RCHS,

MoCDGC

PMORALG

District

Councils

CHMTs,

Communities

CSOs

Development

Partners

2, 500,000

5.3. 2

Community

participation in

maternal newborn

and child health

care increase d.

Strategic Outp ut

Indicators

Community leaders

and members

participating actively

in MNCH issues

5.3.2.2

Orient health facility committees

and district health boards on

Client Service Charter to ensure

satisfactory client-service

relationship

X X X X X X X X Proportion of

health facility

committees and

district health

boards oriented

on client-

service

relationship at

all levels.

MoHSW,

District

Councils

500,000

The National Road Map Strategic Plan -2008 - 2015

STRATEGIC PLAN AND ACTIVITIES: 2008 -2015

Timeframe Stra tegic Objecti ve/

Output

Activities

09 10

12 13 14 15

Process Indica tors Responsible

Person

Resources

Needed in

US dollars

5.4 Behaviour Change

5.4.1

Key community

and household

practises for

maternal, newborn

and child care

improved .

Strategic Outp ut

Indicator:

Improved practises

for maternal,

newborn and child

health care at all

levels.

5.4.1.1 Design, develop IEC/BC C

messages and material s for community

members (men , women and adolescents)

for specific maternal newborn and child

issues, with emphasis on:

• Postnatal and Newborn care ;

•

Advantages of early attendance to

health facilities (ANC);

• Birth preparedness;

• Essential nutritional practices and

actions for maternal newborn and

child;

• Causes of maternal, newborn and

child deaths and identification of

Danger signs;

• Early Car e seeking and compliance

• Home mana gement of common

childhood illness

• D isease p reven tion (ITN’s,

immunization, hygiene and

sanitation)

• Interventions to prevent HIV and

Mother to Child transmission of HIV

• Re positioning family pla nning

• Prev ention on early and unwa nted

pregnancies

• Role of men in Maternal newborn

and child health care

X X X X

X IEC/BCC messages

and materials

addressing specific

maternal and

newborn issues

developed for

communit y

members.

MoHSW,

PMORALG,

MoCDGC,

MoEVT, MoISC

District

Councils,

CHMT’s,

Village

Government,

Development

Partners ,

Media , CSOs,

100,000

The National Road Map Strategic Plan -2008 - 2015

Timeframe Strategic Obje ctive/

Output

Activities

08 09 10

11 12

13 14

Process Indica tors Responsible

Person

Resources

Needed in

US dollars

5.4.1.2 Disseminate and distribute

IEC/BCC messages and mate rials for

community members through different

media.

5.4.1.3 Develop the capacity of

community theatre groups to

disseminate MNCH messages

Proportion of IEC/BCC

materials disseminate d

through different media

(Road shows, TV, R adio

etc).

Number of community

theatre groups

established to disseminate

MNCH messages

MoHSW ,

PMORALG

MoCDGC

MoEVT, MoISC

District Councils

CHMTs, Village

Governments,

Development

Partners , Media

CSOs.

4,000,000

350,000

5.5 Fostering Partnership

5.5.1.1 Orient partners on One MNCH

Strategi c Plan

5.5.1.2 Conduct joint planning and

coordination meetings with

stakeholders/partne rs for maternal,

newborn and child care at all levels

5.5.1.3 Conduct quarterly PMNCH

committee meetings

5.5.1.4 Conduct bi-annual PMNCH

forum

Number of orientation

sessions on One MNCH

Strategi c Plan cond ucted

Number of joint pl annin g

and coordination

meetings conducted

Number of PMNCH

committee meetings held

annually

Number of PMNCH fora

held

MoHSW/RCHS

MOCDGC,

PMORALG

Regional

Secretariat

District Councils

Development

Partners Health

professional

association s

CSO ‘s

65,000

5.5.1

Partnership and

coordination for

MNCH activities at

all levels improved.

Strategic Output

Indicator:

Coordinated response

and leveraging of

resources for MNCH

activities.

5.5.1.4 Provide support to the PMNCH

secretariat for Partnership co-ordination

X X X X X X X X Functional secretariat for

partnership in place

MoHSW

Development

Partners Health

professional

association s

CSO ‘s

G RAND TOTA L US$6 74

,030,000

The National Road Map Strategic Plan -2008 - 2015

STRATEGIC PLAN AND ACTIVITIES: 2008 -2015

The National Road Map Strategic Plan -2008 - 2015

CHAPTER 6

MONITORING FRAMEWORK

Maternal, newborn and child care programmes will be evaluated based on an agreed set of indicators, both

qualitative and quantitative. Routine health information systems currently track outputs such as number of

admissions, management of childhood illnesses, immunization, antenatal care, births, and caesarean sections.

There is little information on quality of maternal and newborn care, such as intrapartum care, stillbirth rate,

babies receiving resuscitation and outcome, and percentage of newborns receiving essential newborn care.

List of indicators to assess MNCH Progress

a) Indicators at National level:

Sources of data will be a combination of HMIS, District Health Surveys, Household surveys, Health Facility

surveys, Demographic Health Surveys (DHS), Tanzania Service Provision Assessment surveys (TSPA),

Roll back Malaria M&E surveys and financial records. Collected data will be grouped according to gender,

age groups, income/wealth quintiles, geographical location (rural and urban) as well as ethnic groups.

b) Community Indicators:

• Proportion of communities that have set up functional emergency preparedness committees and plans

for MNCH including FP and nutrition

• Proportion of pregnant women that have birth preparedness plans

• Proportion of women and children who needed referral who went for referral

• Proportion of women with knowledge of danger signs of obstetric, neonatal and child health

complications

• Proportion of district management task forces and committees with representation from communities

• Proportion of facilities with a designated staff responsible for community health services

• Proportion of villages conducting quarterly village health days

• Proportion of villages with community health workers implementing MNCH interventions

• Coverage of access to potable water (improved drinking water source)

• Coverage of improved latrines

• Use of solid fuels for cooking

• Households’ care-seeking rate for diarrhoea, malaria and pneumonia

• ITN use in under-fives and pregnant women

c) Neonatal Indicators

• Neonatal mortality rate

• Prevalence of low birth weight

• Early initiation of breast feeding (within the first hour)

• Proportion of district hospitals that have functional newborn resuscitation facilities in the delivery

room

• Number of perinatal deaths (still births, deaths within the first seven days of life)

• Postnatal care attendance rate

• Proportion of district hospitals implementing Kangaroo Mother Care for management of Low Birth

Weight

• Proportion of district hospitals that are accredited baby friendly

• Postnatal vitamin A coverage

The National Road Map Strategic Plan -2008 - 2015

d) Family Planning Indicators

• Contraceptive prevalence rate by method, by age group, by socio economic quintiles

• Met need for FP by age group.

• Total fertility rate.

• Age specific fertility rates

• Number of individuals accepting contraceptives new acceptors

• Number of FP service delivery points per 500,000 population offering full range of contraceptive

information counselling and supplies.

e) Maternal Health Indicators:

• Maternal mortality ratio

• Proportion of deliveries taking place in a health facility

• Proportion of births assisted by a skilled attendant

• Proportion of facilities offering BEmOC services and CEmOC services

• Coverage of met need for obstetric complications (coverage of women with obstetric complications that

have received EmOC out of all women with obstetric complications)

• Caesarean sections as a percentage of all live births

• Case Fatality Rate for obstetric complications

• Proportion of first level facilities (PHC) with two or more skilled attendants

• Percentage of pregnant women attended at least once by skilled personnel; percentage attended by

skilled personnel at least four times

• Proportion of HIV positive women provided with ARV’s during pregnancy

• Proportion of pregnant women with access to PMTCT services

• Prevalence of positive syphilis serology in pregnant women

• Percentage of pregnant women tested and treated for syphyllis

• Percentage of pregnant women receiving two doses of SP

• Percentage of service delivery points providing youth friendly services

f) Child Health Indicators

• Under-five mortality rate

• Exclusive breastfeeding rate <4 and <6 months

• Continued breastfeeding rate 6-23 months

• Timely complementary feeding rate

• Under-weight prevalence

• Stunting prevalence

• Wasting prevalence

• Vitamin A supplementation coverage (under-fives)

• Anti-malarial treatment in under-fives (within 24 hours of onset of fever, appropriateness)

• Antibiotic treatment for pneumonia and dysentery

• ORS and zinc treatment in management of diarrhoea

• Proportion of health facilities with 60% of health workers trained on IMCI

The National Road Map Strategic Plan -2008 - 2015

• Measles immunization coverage

• DTP- HB3 immunization coverage (Hib coverage after introduction)

• Proportion of HIV positive children accessing ARV

• Proportion of HIV exposed infants accessing ARV prophylaxis

g) Increased Political Will and Commitment Indicators:

• Proportion of Government budget allocated to health

• Proportion of MoHSW/ district budget allocated to MNCH and FP

• Availability of policies addressing increased coverage for skilled care

• Development plans integrating MNCH (Development Vision 2025, MKUKUTA, MMAM,HSSP)

h) Indicators for Measuring Progress of the MNCH Strategic Plan

• Existence of Partnership for Maternal Newborn and Child Health (Partnership)

• Total resources mobilized for MNCH Strategic Plan

• Biennial implementation report tracking progress on indicators listed above

Table 2 : Results based Matrix

MKUKUT A broad outc omes :

• Improved quality of life and social well-being, with particular focus on the poorest and most vulnerable groups.

• Reduced inequalities in outcomes (e.g. e ducation, survival, heal th) across g eographic, income, ag e, gender and other gr oups.

MKUKUTA (Goal 2.2): To improve survival and well-being of all children and women and of especially vulnerable groups.

MKUKUTA (Goal 2.5): To ensure effec tive system s to permit universal acc ess to quality and affordable publi c service s.

Roadmap Operation targets:

1. Increased coverage of births attended by skilled attendants from 46% in 2004/5 to 80%.

2. Increased immunization coverage of DTP-HB 3 and Measles vaccine to above 90% in 90% of the districts.

3. Introduced new vaccines to EPI (Hib, Pneumoccocal, Human papiloma (HPV) and rota virus vaccine) .

4. Reduced stunting and underweight among under-fives from _38% and 22% to 22% and 14% respectively.

5. Increased exclusive breast feeding coverage from 41% to 80 %

6. PMTCT services provided to at least 80% of pregnant women, their babies and families.

7. 90% of sick children seeking care at health facilities appropriately managed.

8. Increased coverage under-fives sleeping under ITN’s from 16% to 80% .

9. 75% of villages have community health workers offering MNCH services at community level.

10. Increased modern contraceptive prevalence rate from 20% to 60%

11. Increased coverage of comprehensive EMOC from 64% of hospitals to 100% and basic EMOC from 5% of Health centres and Dispensaries to 70%

12. Increase the number of health facilities offering Essential Newborn Care to 75%.

13. Increased antenatal care attendance for at least four visits from 64% to 90%

Focus Area Indicators of Results Means of Verification Assumptions

6.1 Advocacy and Resource Mobilisation

Increased budget allocation for health

especially for maternal and newborn

services at all levels.

• 15% of Government budget

allocate d to health

• % Health budget available to

cater for maternal, newborn and

child health services at all levels

•

Budget for maternal, newborn and

child health including FP and

nutri tion in creas ed by 50% by 2015

• Medium Ter m Expenditure

Framework (MTEF ) cash flow at

central level.

• Comprehensive Council Heal th

Plan cash flo w at dis trict l evel.

• Cash and receipt at all levels.

• Public Expenditure Review

reports

• HIPC funds allocate d to health.

• Stable economic growth.

• Basket fund avail able

• Commitment by donors/ partners

The National Road Map Strategic Plan -2008 - 2015

Table 2: Results based Matrix

Focus Area Indicators of Results Means of Verification Assumptions

Regulations/ laws/policies that

hinder effective implementation of

maternal and newborn care by

relevant regulatory bodies reviewed.

• Number of regulati ons and law s

approved by regulatory bodies

• Policy documents available for

implementation.

• Willingness of regulatory bodies to

review and endorse policy documents.

Implementation of the exemption policy

for maternal and child health

strengthened.

•

Exemption policy effectively

implemented

• Exemption policy guidelines in

place at all facility levels.

• Survey fin dings.

• Exemption mechanisms implemented

according to policy.

Employment, deployment and retention

of skilled health workers at all levels of

care improved.

Number of skill ed health workers

increased to 100% by 2015

•

• Human resource survey

• Health Statistics Abstract

•

6.2 Health Systems Strengthening and Capacity Development

Knowledge and skills of supervisors and

service providers on maternal, newborn

and child care including FP and

nutrition increased.

• Proportion of health facilities

providing quality maternal and

newborn car e.

• Maternal, newborn and chil d

health servi ce provide d

according to standards.

• Proporti on of under-fives

receiving correct anti-mal arial

treatment.

• Proporti on of under-fives

receiving appropriate anti-biotic

treatment for pneumonia and

dysentery.

• Proporti on of under-fives

receiving ORS and zinc tre atment

in management of diarrhoea

• Percen tage of pr egnant w omen

receiving to doses of SP

• Percen tage of pr egnant w omen

tested and treate d for syphili s

• Train ing and follow up reports

• Health facility survey

• Services statistics

• Tanzania Service Provision

Assessment (TSPA),

• Service Availability Mapping

(SAM)

• Roll b ack malar ia (RBM ) survey

• Resources for updating knowledge and

skills available.

• Avail abili ty of personnel to be traine d.

The National Road Map Strategic Plan -2008 - 2015

Focus Area Indicators of Results Means of Verification Assumptions

• Relevant sectors (Ministr y of

Finance, MoHSW) allocating at

least 15% of Government budget

for .health

•

MoHSW allocating 15% of the

Health budget for maternal and

newborn care

• Train ing reports MTEF cash

flow at all levels.

• CCHP cash flow at district level.

• Cash and receipt at all levels.

• Public Expenditure Review

reports

• Planning and management tools

available.

• Stable economic growth.

• Basket fund avail able

• Commitment by donors/ partners

• Evidence-based maternal and

newborn care planning at RCHS

and CHMT

• Planning documents.

• CCHPs

• MTEF

• Personnel av aila ble.

Planning and management capacity for

maternal and newborn car e including FP

and nutrition strengthened.

• Proportion of districts with inc reased

budget allocation for maternal

newborn and child health

interventions in

CCHP

• CCHP cash flow • Stable economic growth.

• Basket fund avail able

• % of health facilities providing Basic

and comprehensive EmOC and

Essential Newborn care

• Health facility survey

• service statistics (TSPA, SAM)

• CHMT and HF managers tra ined on how

to measure/ use the i ndica tors.

• Availability of funds

• Avail ability o f skilled a ttendants

• Proportion of births assisted by a

skilled attendant

• Demogr aphic Health Surve y,

Household surveys

• Avail ability o f skilled a ttendants

• Proporti on of caesare an sections

as a percentage of live births.

• Service statistics • Avail ability o f skilled a ttendants

• Case fata lity rate due to obstetric

complications.

• Service statistics • Avail ability o f skilled a ttendants

Basic and Comprehensive EmO C and

newborn services at all levels

strengthened.

• Essential commodities, supplies

and medicines for maternal,

newborn and child care available

all the time at every health facility

• Inventory r eports

• Health facility surveys (TSPA)

• Annual Contr aceptive

Procurement Tables (CPTs)

• Monthly contraceptive stock

status reports from MSD

• Adequate resource availa ble

• Political w ill and commitment

The National Road Map Strategic Plan -2008 - 2015

Results based Matrix

Focus Area Indicators of Results Means of Verification Assumptions

Mechanisms for availabi lity of essent ial

commodities, supplies and medicines

for maternal, newborn and child health

including family planning

strengthened.

• Essential commodities, supplies

and medicines for maternal,

newborn and child care available

all the time at every health facility

• Inventory r eports

• Health facility surveys (TSPA)

• Annual Contr aceptive

Procurement Tables (CPTs)

• Monthly contraceptive stock

status reports from MSD

• Adequate resource available

• Political will and commitment

Referral System

Referral system at all levels

strengthened.

• Func tional re ferra l systems in

place at all levels

• Percentage of all women with

major obstetric complications

treated in EmOC facilities (met

obstetric need)

• Percentage of referred under-

fives who actually go for referral

• Specia l Survey

• Service statistics reports

• Availability of funds to improve referral

system

• Willingness of community members to

participate in emergency preparedness

Research, Monitoring and Evaluation

HMIS capacity to cap ture information on

maternal, neonatal and child indicators

including FP and nutrition improved.

• Key Mat ernal, newborn and child

health indicators reported annually

through

HMIS

• Health statistics reports

• Health Statistics Abstract

• HMIS reviewed to incorporate maternal

and newbor n health ind icator s

The National Road Map Strategic Plan -2008 - 2015

Focus Area Indicators of Results Means of Verification Assumptions

Monitoring and evaluation framework for

MNCH strengthened and implemented.

• Progress on Maternal, ne wborn and

child health status/ trends reported.

o Maternal mortality rate

o Under-five mortali ty rate

o Infant mortality rate

o Neonatal morta lity rate

o Contraceptive prevalence

rate by method, by age

group, by socio economic

quintiles

o Under weight, stunti ng

rate

o Exclusive Breast Feeding

rate

o Measles immunization

coverage

o DTP-HB3 immuniz ation

coverage

• Proportion of health facilities

receiving quart erly supportive

supervision.

• Proportion of health workers that

received follow up a fter trai ning on

MNCH packages yearly

• Number of surveys co nducted on

quality assurance of service delivered.

• Number and type of MNCH

mortality review reports.

Birth registration rate

• Special reports/surveys

• Service statistics reports

• Supervision reports

• Mortality review and

notification reports

• Demographic health survey,

• Census

• Vital statistics

• Adequate resources to conduct

Operational Resea rch

• Capacity to conduct research

Community based ma nagement

information system strengthened.

• Community based data effectively

collected and used in

planning.

• Community development plans.

• CBMIS d ata ava ilable

• Adequate resources to fac ilitate planning

at community level.

• Capacity and capability of the community

members to use evidence based

information for planning.

Quality as surance and management

(supervision, client satisfaction,

performance assessment) strengthened.

• Proportion of health facilities

delivering MNCH services according

to nationally defined service

standards

•

Proportion of cli ents satisf ied

with materna l and newborn

services

• Health facility and household

Surveys

• Service statistics

• Supervision reports

• Standards for quality improvement will

be implemented.

The National Road Map Strategic Plan -2008 - 2015

Results based Matrix

Focus Area Indicators of Results Means of Verification Assumptions

to health facil ity for care sick/

postnatal

• Percentage of pregnant women

attended at least once by skilled

personnel; percentage attended by

skilled personnel at least four times

• Households care seeking rate for

diarrhoea, malaria, pneumonia and

neonatal conditions

The National Road Map Strategic Plan -2008 - 2015

ANNEX 1

SWOT ANALYSIS

(A) Maternal Care

STRENGTHS WEAKNESSES OPPORTUNITIES THREATS

(i) Policy Issues

•• E xistence of national policies

which address maternal health

such as the National Health

Policy, Reproductive and Child

Health Policy, MKUKUTA,

MMAMetc.

• The National Health Policy and

the Reproductive and Child

Health Policy emphasise a

multisectoral approach to

reproductive health issues, which

include male involvement.

• The National Health Policy

promotes the right of all women

to access quality reproductive

health servi ces.

• Existence of va rious tools such as

the RCH Strategy, RCH Essential

Package and policy guidelines

which address maternal heal th.

• Maternal health is reflected i n

the District Planning Guideline

as one of the key repr oductive

and child health interventions.

• Existence of establishment/

manning level (1999) of health

staff for health delivery tiers

• Some existing health cadres have

been reviewed (MCHA,

RMA/CA upgrading)

• Minimal budget allocation to health sector

especially maternal health (at all levels)

• Weak multisectoral linkages at al l levels in

addressing maternal health

• The RCH strategy have not been able to

prioritise key interventions to reducing

maternal death

• Inadequate dissemination and interpretation

to user-friendly formats of RCH policies,

strategy and guidelines.

• Some managers and supervisors at al l levels

are not familiar with policies and guidelines

related to RCH

• CCHP do not comprehensively addressing

RH/maternal and child health interventions

• RCH Coordinator not full member of CHMT

but more of co-opted member (in some

districts) as such not able to influence district

health plans

• Manning level not implemented accordingly

due to insufficient linkages and mixed roles of

HS and LG.

• Establishment/manning level of staff has not

been reviewed according to recent

developments in RCH care (PMTC T, VCT,

ARH/YFS)

• Current deployment system doesn’t follow the

manning level guidelines.

• Development partners and

Government aligning to

joint support accordi ng to

Joint Assistance Strategy.

• Existence of Health basket

funds to support dist rict

health servi ces

• Establishment of MNC

partnership at central level

• Existence of Government

led SWAPs, MOH Technical

committee an d

subcommittee that can be

used to push Maternal and

Newborn hea lth is sues

• Exist ing Annual Hea lth

Sector Reviews have taken

into consideration

RH/Matern al heal th issues

• Political will and

commitment is showing

positive signs towards

addressing maternal health

(DHA tool)

• Existen ce of Health SWAPS

• Zonal RCH reviews Care

and Treatment Plan gives

opportunity to mainstream

maternal health care

• More focus on HIV/AIDS than

RH/Matern al heal th

• Short time tow ards

attainment of MDGs

• Bigger propor tion of health

sector budget is donor

dependant.

• Donor driven initiatives

• Reproductive health concept

may be overridden by

maternal heal th (threat of

returning to old MCH concept)

• Competing priority

programmes

• HIV/AIDS

• Human resou rces

• Logistic Management

capacity

• TBA policy review and part of

the Annual Health Sector

Review milestone

The National Road Map Strategic Plan -2008 - 2015

ANNEX 1: SWOT ANALYSIS

STRENGTHS WEAKNESSES OPPORTUNITIES THREATS

•

Exemption poli cy for de liveries

and all RCH services

• Decentralisation of health

services to district level (advance

health sector r eforms)

• Existence of va rious financ ial

resources to health sector at the

district level (Basket, Block,

District o wn source, cost sh aring,

NHIF, CHF e tc)

• Existence of Paramedical,

Medical and Nursing

Institutions for pre-service

training

• Existence of training guidelines

on PAC, LSS, FP, PMTCT+, STI,

FANC

• Availability of committed

Development Partners

supporting RH/maternal health

• MTEF allocated funds for

procurement of contraceptives

• Maternal nutrition linked with

child nutrition in the RCH

package

• Community based RCH

guidelines, strategic plan (draft)

available

• Infrastructure at all levels

overseeing health services -

national, regional, district and

community

• Inadequate number of skilled service

providers that can be trained and capture the

knowledge required on specific skills.

• Some skilled providers are not allowed to do

life saving skills procedures due to statutory

regulations e.g. IV drip g iving, manual

removal of retained placenta, MVA usage.

• There's no mechanism to assess pre-

qualification of service providers in terms of

attitude and psychological behaviour before

joining nursing and medical schools.

• Weak incentive package to service providers

• Poor motivation and inadequate performance

assessment and rewarding of service

providers

• Inconsistency of Skilled attendance definition

and how do we attain Skilled attendance in

our settings

• Inadequate Plans for human resource

development including continuing education

on maternal health issues

• Lack of continuing education among tutors at

pre-service and regional institutions.

• Poor interpretation and implementation of

exemption policy for maternal health

• Informal payments hinders implementation of

exemption policy

• Due to minimal allocation to RCH services,

women are asked to purchase or come with

essential supplies/drugs for delivery since

they are frequently out of stock

• Existe nce of Annual RMO s,

DMOs and RCH Meetings

as fora to discuss

RH/maternal and newborn

issues

• Increasin g Government

and DPs attention on

addressing Human

resource crisis

• Presence of guidelines from

FCI on caring behaviours

among service providers

• Ongoing review on

incentive package for health

care providers

• Introduction of OPRA at all

levels.

• MKUKUTA

• Existing plans of

strengthening and

expanding ZTC for in-

service trainings.

• Overstretching of health

system as per current

development which is already

compromise d.

The National Road Map Strategic Plan -2008 - 2015

STRENGTHS

WEAKNESSES

OPPORTUNITIES

THREATS

•• L ack of costed RCH package including

maternal health that can justify how much

is being exempted

•

• At all levels there has been slow follow up

and scaling up of interventions relate d to

maternal health

•

• Inadequate documentation of evidence

based intervention focus ing on maternal

health

•

• Untimely/Irregular review of Pre-Service

training curriculum to include current

maternal heal th developments.

•

• Lack of postnatal guides

•

• Policy not allowing MVA kit to be made

available except when there's presence of

skilled attend ant and after being trained.

•

• Poor coordination and linkages between

different acto rs from cent ral to lo cal level.

•

• Existence of verti cal progr amme/projects

support to RH (including FP/maternal

health)

•

• Weak linkages between Directorates of

Preventive, Hospital and Training at MOH

•• PMNCH prom otes need

for MNCH Strategic Plan

where all partners buy in

•

• Existence of Reproductive

Health Commodity

Security commi ttee under

Govt leadership

•

• Existence of IYCF

strategy

•

• Maternal nutrition

aspects integrated into

Infant and young child

feeding strategy

•

• Existence of Health

insurance (NHIF) and

some coming up

•

• Birth and death

registration (vital

statistics) in place in few

villages which can be

adopted in the rest of the

country.

•

• Existing health MCH

structure from

community to hospital

level

•

• Use of alternative service

providers to support

health system such as

retired health skilled

staff, performance

contract and Retention

schemes in MKUKUTA

•• Inadequate linkages and collaboration

between RCH Section wi th TFNC and

PMTCT Unit

The National Road Map Strategic Plan -2008 - 2015

STRENGTHS WEAKNESSES OPPORTUNITIES THREATS

•

Role of TBA in prevention of m aternal

mortality is unclear. (Role remains unclear

in the strategies. Weaknesses in SWOT

should guide strategies

• CHF exist in most areas but with lim ited

use of the funds for maternal hea lth care

• Few districts have implemented community

based RCH program

• Village health committee not legal ly

recognised.

• Shortage o f Skilled attendan ce (more

pronounced in rural are as)

• Unattractive working condition especially in

rural areas

(ii) Health Systems

• Presence o f ZRCHCO, RRCH Co

and DRCHCo

• Service delivery points well

distri buted to consultan t,

regional and district hospitals

followed by health centres and

dispensaries.

• Indent system for obtaining

essential drugs and supplies

• Integration of FP and HIV/AIDS

condom supply/request at

district level

• Health services including maternal care not

operating for 2 4 hours

• Low know ledge on SRH among serv ice

providers

• Despite training on Focused ANC, there's still

problem in its implementation due to attitude

and low educational background of

providers who cannot capture the skills;

inadequate supplies such as Hb, RPR,

contraceptives etc.

• Limited t raining of Service provid ers on PAC,

FP, LSS

• RH services not youth friendly

• Inadequate/inappropriate EmOC (basic and

comprehensive services) at facility level

• Existence of both priv ate

and public health facilities

that provide mate rnal

health services.

• Plan to strengthen ZTC

• Existence of good practices

on youth friendly serv ices

(AYA, UMATI, UNICEF

supported interventions)

• Existence of good

practices/research on

maternal care improvement

(though a few)- FCI, WDP,

Care, TEHIP, QIRI

• Overwhelming the ZTC

capacity

• Cultural barriers

The National Road Map Strategic Plan -2008 - 2015

STRENGTHS

WEAKNESSES

OPPORTUNITIES

THREATS

•• L ocal Government authorities

reforms are supporting

implementation of HSR

•

• Presence of referral structure

within the health delivery sy stem

•

• Most of essential RCH services

are in place (ANC, Intrapartum/

obstetric, FP, STI, Immuni zation,

PMTCT, Post partum ) IMCI at all

levels.

•• L ack of functioning of blood banks at hospital

and health centre level

•

• Inadequate cove rage of PAC services

•

• Essential equipment, supplies and drugs on

maternal care including FP not readily

available

•

• Bottlenecks in procurement of drugs, supplies

and equipment (both ways district level and

MSD)

•

• Fragmented program support in provision of

essential supplies e.g. syphilis screening

reagents

•

• Facility buildings and providers’ attitude not

accommodating male and y outh friendly

services

•

• Presence of vast Geogr aphical a rea with poo r

transport/roa ds, inadequate health faci lities

and therefore poor geographical accessibility

to EMOC

•

• Inadequate ambulances within the country

•

• Many health units do not h ave reliable

communication system (radio call, m obile)

•

• Lack of protocols on specific maternal

health/obstetric care

•

• Counselling skills on FP, PAC, PMTCT and

maternal nutrition not adequately provided

by service providers

•

• Limited postnatal c are due to lack of guidelines

•• Blood safety programme

•

• Existence of RHMT and

CHMT whi ch coor dina tes

district health activities

including maternal health

care

•

• Currently Joint

Rehabilit ation Progr amme

has been initiated at distri ct

level which can be used to

accommodate structure

improvement for maternal

and newborn care

•

• Existence of mobile

communication network in

rural areas

•

• Presence of job aid f or

EMOC

(iii) Support Systems

• Existence of Community

development officers at district

and ward level.

• Premises of most health facilities are

inadequate and non-user friendly (privacy,

space)

• Inadequate awareness and advocac y on

maternal complications/care at all levels

including health facilities support staff

The National Road Map Strategic Plan -2008 - 2015

STRENGTHS

WEAKNESSES

OPPORTUNITIES

THREATS

(iv) Planning, Monitoring and Evaluation

• Planning decentralised to

district level

• Monitoring of Maternal death

done through week ending

reporting, HMIS, DHS and

Annual ZRCH Co reports

• Presence of HMIS in all health

delivery systems

• Supervision system in place

• Presence of health facili ty

committee an d dist rict boa rds in

majority of districts

• Presence of CHMT in all districts

• Poor mainstreaming of maternal hea lth

intervention into CCHP and thereafter into

Overall Council Plans as such intervention is

not addressed Multisectora l.

• Centralization of services/health plans at

CHMT level and less on lower level

• District Health planning process rarely take

into consideration inclusion of other relevant

multi sectoral officers (Education,

Agriculture, Engineer, Community

development) in addressing maternal heal th

issues.

• Inadequate capacity of CHMT to plan for RCH

activities including maternal health

• Poor recor d keeping and theref ore plannin g is

not evidence based

• Most CHMTs still see RCH including

maternal health interventions as

donor/project supported and n ot

responsibility of district budgets

• Family Planning given less priority in

planning at district level (CCHP).

• Conflicting priorities during joint supervision

• District health boards and

health facility committees

present according t o set

guidelines

• Existence of TE HIP tool

though has limit ation on

RCH intervention package

• Proposal for records

management improvement

has been made to MoHSW

• Process and i mpact

indica tors h ave been

identified and defined in

recently released RCH

strategy

• Existence National EMOC

survey document will

provide benchmark of

EMOC situation

countrywide.

• Insufficient involvement of other stakeholders

in the district during planning process,

monitoring and evaluation

• Village and war d plans n ot capturing

maternal and newborn interventions/issues

• Maternal health indic ators used a re mainly

impact and less/none on process indicators

• Some EMOC process indicators are difficult

to calculate since some data is not captured in

the routine HMIS/f acili ty based d ata rec ords.

• Inadequate utilisation of data/indicators for

planning purpose and prioritisation at all

• Introduction of m aternal

and perinatal death

reviews

• Existence of va rious

national surveys (Census,

DHS, THIS) that can giv e

picture on RCH situation

• Current there's demand

driven capacity building

initiative (piloted in lake

zone regions) that requires

district to demand for

The National Road Map Strategic Plan -2008 - 2015

STRENGTHS WEAKNESSES OPPORTUNITIES THREATS

levels.

• Inadequate functioning of HMIS

• Lack of disaggregated data by sex and age

specific

• Insufficiently capturing data from private

health faci lities

• Weak/absence of Community Based

Management Information System

• Poor documentation of clients notes including

treatment plan, referr al notes at fac ility level

• Low coverage of supervision

• Lack of comprehensive and integrated

Supervision tool and process

• Inadequate accountability among service

providers and managers/supervisors

• Weak system for monitoring and add ressing

clients complaints/suggestions

• Poor supp ortiv e supervi sion d ue to

inadequate skills, commitment and attitude.

trainings (under DANIDA

support)

• Quality of Care framework

to consolidate supervisory

tools

• Presence of Client health

service charter and

Guidelines on roles and

responsibilities of HF

committees/district

boards.

(v) Community

• Presence of Primar y Health

Committee/Village health

committees that discuss issues on

maternal health.

• Presence of c-IMCI corps

• Presence of Community Base d

RCH Strategic pl an, guideline s

• Community recognised as key

stakeholders in both Local Govt

and health sector reforms.

• Local Government reforms have

a structure/link d own to the

village level.

• Weak implementat ion of distr ict guide of

involving community

• Low populati on coverage

• Limited male invo lvement on issues related to

maternal health

• Obstetric emergencies are not considered by

the Community emergency committee

• Community plans not incorporated into the

CCHP.

• Weak capacity of health facility committees

and district boar ds

• The process of developing bylaws and the

time it takes to be effected.

• Inadequate outreach services due to poor

planning, inadequate resources.

• Inadequately functioning village health

committees since they're not facilitated.

• Presence of O& OD

planning process

• Allocation of 10% of CCHP

funds to community

interventions.

• Presence of TASAF II th at

provides financi al support

for community based social

service delivery.

• Presence of community

mobilization and

empowerment initiatives on

reproductive health.

• Existence of the CBD

programme

• Health facilit ies committees

and district health boards

• Presence of harmful

traditional practices that can

adversely affect maternal and

newborn e.g. tak ing herbs tha t

have oxytoxic effects can lead

to ruptured uterus.

The National Road Map Strategic Plan -2008 - 2015

STRENGTHS WEAKNESSES OPPORTUNITIES THREATS

• Knowledge on Birth preparedness is poor

among communities

• Community not awar e of their rights and

obligations in improving maternal health care

• Gender inequalities existing in the community

contributes to poor mate rnal health outcome s

• Low awa reness on reproductive system

functions and pregnancy related issues such

as danger signs/complications

recognised legally

• Ability of communities to

devise by-laws to add ress

issues related t o maternal

health such as v iole nce,

delivery at homes, etc.

• Existence of Community

based maternal health care

system in some areas

• Existence of client health

service charter

• Existence of CSOs/NGOs

(vi) Public-Private Partnership

• One of components of HSR

strategy

• Presence of active Association of

Private Hospitals in Tanzania

and PRINMAT

• Non-for profit sect or (FBOs)

providing mate rnal ca re

especially in rural areas.

•

• Inadequate coordination in planning and

implementation am ong partners at central

and district level

• Partnership poli cy guidelin es present but

more visible/known at central level and less

at district level.

• Some Private health facilities/CSOs not

submitting data to district/central level

• Majori ty of Private for Profit prov ide services

on other health issues and less on materna l

health care

• Faith based organizations providing limited

maternal services (no FP service provided)

• Some CSOs that are pro-life provide negative

information on contraceptives.

• Existence of Profes sional

associations (AGOTA,

TAMA)

• Existence of advocacy

groups that are non-health

professionals (TAMWA,

TGNP, TAWLA, Private

media companies, WRA)

• Competition for recognition

and resources between public

and private sector.

The National Road Map Strategic Plan -2008 - 2015

(B) Newborn Care

STRENGTHS WEAKNESSES OPPORTUNITIES THREATS

(i) Policy Issues

• National health policy includes

child heal th

• National strategy on Infant and

Child Nutrition and plan of action

in place

• Policy guideline on RCH available

and reflecting neonatal health care

• Availability of PMTCT and HIV

Care and treatm ent guides that

integrates neonatal care

• Exemption pol icy for und er-fives

includes neonatal health

services/care

• Institutionalisati on of IMCI within

the MoHSW struct ure/RCHS

• IMCI deals with neonate from 8

day of life

• C-IMCI promotes community

maternal care and lactation

• Established postnatal follow up

first week of life

• Establishment of baby friendly

hospital services within some

hospitals

• Reviewed LSS manual

incorporated Newborn care

according to WHO guidelines

• Availability of committed

development partners supporting

newborn heal th

• Neonatal care obtaining limited

budget allocation within the health

sector/RCH services

• Nursing training not comprehensively

addressing neonatal care

• Age specific interventions for 0-1

months are not well spelt out in policy

guides on RCH

• Policy guideline to manage newborn

care is lacking

• Routine healt h dat a lack s neonat al

health progress including

community-base d data.

• Lack of unders tanding on the

magnitude of neonatal health

problems

• IMCI does not ad dress fir st week of

life

• Facility IMCI does not includ e home

care and care seeking for newborns

• Lack of concentration on maternal

care and im munizati on and absen ce

of a guide

• Inadequate availa bility of

paediatricians and neonatal nurses

• Lack of cost ing of Neonatal c are

package

• Lack of postnat al guide thus not

incorporating newborn care

• Decentralis ation of health services to di strict

level (advan ce health sector reforms) c an

accommodate newborn care

• Financial resource allocation to the district

level (from various sources)

• Establishment of MNC partnership at central

level

• On going reviews of MoHSW in addressing

human resource cri sis

• Existence of ZTC, Nursing and Medical

schools

• HIV Care and Treatment Plan give

opportunity to mainstream newborn care.

• Coverage of IMCI case management High

adding first week could rapidly increase

coverage

• Donors, partners interested to support

incorporation of newborn care

• Policy guide on Infant and early feeding for

newborn introduced

• Existence of Health b asket funds to support

district health services

• Existence of Govt led SWAPs, MoHSW

Technical co mmittee an d subcommi ttee that

can be used to push Maternal and NB health

issues

• Existence of Annual RMOs, DMOs and RCH

Meetings a forum to discuss RH/maternal

and newborn issues

• Short time tow ards

attainment of MDGs

• For mother not aw are

of their HIV sero-

status

• Multiplicity of

guidelines

overwhelms service

providers

• HIV pregnant mothers

face stigma/dilemma

in infant feeding

options

• Bigger propor tion of

health sector bud get is

donor dependant

• Donor driven

initiatives??

• Harmful practises

and beliefs

• Women not

empowered

• Traditional practises

hindering postnatal

attendance

The National Road Map Strategic Plan -2008 - 2015

STRENGTHS WEAKNESSES OPPORTUNITIES THREATS

(ii) Health Systems

• Infrastructure at all levels

overseeing health services -

national, regional, district and

community

• Presence o f ZRCHCO, RRCH Co

and DRCHCo

• Service delivery points well

distri buted to consultant, r egional

and district hospitals foll owed by

health centres an d dispens aries.

• Lack of appropriate resuscitation

equipment and suppli es e.g. infusion

pumps, injectables phenobarbitone etc

• Unattractive workin g condition

especially in rural areas

• Health services including neonatal

care not operating for 24 hours

• HMT are unaware in addressing

neonatal hea lth issues

• Limited training of Service providers

on LSS which has a component of

neonatal ca re

• Inadequate/in appropriate EMOC

(basic and comprehensive services) at

facility level

• Some neonat al suppl ies/ equipments

are not made available at MSD

• Poor supply plan at service delivery

point/distri cts

• Neonatal services are not adequately

provided by majority for public and

private health facilities

• Facility buildings not s uitable

providing neonat al services

• Kangaroo method for low birth

weight babies in resource poor

countries has not been adopted.

• Under-fives care does not focus age

specific with special needs, as a result

neonatal are not taken into

consideration, especially the 1

week

• Existence of Paediatric Association of

Tanzania (PAT) and other health

professional associations.

• The ongoing Joint Rehabilitation Funds

within districts can facili tate improving

buildings to provide neonatal care

• Presence of District Nursing Officer and

Hospital matron that can focus on neonatal

care

• Presence of Indent system for obtaining

essential drugs and supplies

• Plan to strengthen ZTC

• Existence of RHMT and CHMT which

coordinates district health activities

including maternal & newborn care

• Rehabilitation of health facilit ies

• Partners ready to support

• Overwhelming the ZTC

capacity

(ii) Systems Support

• Local Government authorities

reforms are supporting

implementation of HSR

• There's vast Geographical are a with

poor transport/roads, inadequate

health facilities and therefore poor

geographical accessibility to EMOC

• Currently Joint Rehabil itation Pr ogramme

has been initiated at district level which can

be used to accommodate structure

improvement for maternal and newborn care

The National Road Map Strategic Plan -2008 - 2015

STRENGTHS WEAKNESSES OPPORTUNITIES THREATS

• Presence of referral structure

within the health delivery sy stem

• Inadequate am bulances wi thin the

country

• Many health units do not h ave

reliable communication system

(radio call, mobile)

• Inadequate awareness and advocac y

on Neonatal care at all levels

including health facilities support

staff

• Existence of mobile communication network

until ru ral a reas

(iv) Planning, Monitoring and Evaluation

• Planning decentralised to district

level

• Poor mainstreaming of neonatal

health intervention into CCHP

• Centralization of services/health

plans at CHMT level and less on

lower level

• Inadequate capacity of CHMT to plan

for RCH activities including neonatal

health

• Poor record keeping and therefore

planning is not evidence based

• District health boards and health faci lity

committees present accor ding to set

guidelines

• Proposal for records management

improvemen t has been made to MoHSW

• Introduction of m aternal an d perinatal death

reviews

(v) Community

• Presence of HMIS in all health

delivery systems

• Supervision system in place

• Presence of health facili ty

committee an d dist rict boa rds in

majority of districts

• Presence of CHMT in all districts

•

• Inadequate functioning of HMIS

• Lack of disaggregated data by sex

and age specific

• Weak/absence of Community Based

Management Information System

• Supervision undertaken is not

comprehensive and does not captur e

neonatal ca re

• Weak implementation of distr ict

guide of involving community

• Quality of Care framework to consolidate

supervisory tools

• Presence of Client health service charter and

Guidelines on rol es and respons ibilitie s of HF

committees/district boards.

• Presence of O& OD planning process wh ich

involves the community

• According to district health planning guides

there's 10% funds allocated for community

intervention

• Conflicting priorities

during joint

supervision

• Presence of harmful

traditional practices

that can adversely

affect maternal and

newborn

The National Road Map Strategic Plan -2008 - 2015