• 1

    United Nations Development Programme, Human Development Report, 2003. New York: Oxford University Press.

  • 2

    National Bureau of Statistics, 2003. Tanzania 2002 Population and Housing Census. General report January 2003.

  • 3

    Tanzania Ministry of Health, 2002. National Health Policy Revised.

  • 4

    Ministry of Health, Dar es Salaam, Tanzania, 2002. Health Sector Reform Program of Work 1999–2002.

  • 5

    Ministry of Health, Tanzania

  • 6

    Tanzania Poverty Reduction Strategy Paper, October 2000.

  • 7

    Knirsch C, Mecaskey J, Chami-Khazraji Y, Kilima P, West S, Cook J, 2003. Trachoma Elimination and Public Private Partnership: The International Trachoma Initiative (ITI). Chlamydial Infections: Proceedings of the Tenth International Symposium on Human Chlamydial Infections. San Francisco: International Chlamydial Symposium, 485–494.

  • 8

    Comprehensive Council Health Plans, 2003.

  • 9

    President’s Office – Regional Administration and Local Government, 2003. Comprehensive Council Health Plans for 20 Trachoma Endemic Districts. January 2003

  • 10

    Tanzania Ministry of Health - Second Health Sector Strategic Plan 2003–2006. Reforms Towards Delivering Quality Health Services and Client Satisfaction. April 2003.

 

 

 

 

INTEGRATION OF TRACHOMA CONTROL INTO PRIMARY HEALTH CARE: THE TANZANIAN EXPERIENCE

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  • 1 International Trachoma Initiative, New York, New York

Tanzania was among the first countries to launch a trachoma control program with support from the International Trachoma Initiative (ITI) using surgery, antibiotics, facial cleanliness, and environmental improvement (SAFE) strategy with azithromycin. More than one million children less than 10 years of age in Tanzania have active disease and an estimated 54,000 people have trichiasis. Since 2000, Tanzania has implemented major health sector reform that have been carried out in three phases in 114 districts. A key aspect of the reform process is the policy of developing locally distributed essential health packages that then serve as the basis of the comprehensive council health plan. In 2002, the Tanzania Ministry of Health in collaboration with the ITI, the World Bank, and the office of the President embarked on a program of information for districts where trachoma is endemic but where no control program has been launched. Clear goals for the trachoma control program have been reviewed and discussed by the districts and as a result trachoma control was integrated into the comprehensive council health plans for 2003. This is expected to expand in 2004 and 2005. This work is presented as a model for the support and integration of disease-specific control efforts into the primary health care system.

INTRODUCTION

The Tanzanian effort to eliminate blinding trachoma took shape with the adoption of a national plan for prevention of blindness in 1998. Because Tanzania had played an active role in the research leading to the formulation of a trachoma control strategy, it was among the first countries to receive support from the International Trachoma Initiative (ITI) to assist with the execution of this plan. The Tanzania program aims for trachoma control through expanded implementation of the World Health Organization-recommended surgery, antibiotics, facial cleanliness, and environmental improvement (SAFE) strategy. This community-based approach combines curative and preventive interventions that integrate easily into a broader array of national and district-specific public health and community development priorities.

Located in the eastern Africa region, Tanzania is among the poorest countries in the world with communicable diseases ranking prominent among the leading causes of morbidity and mortality.1 Tanzania consists of the union of the Tanzania mainland and the islands of Zanzibar. The total population is 34 million for both mainland and Zanzibar as reported in the Tanzania Population and Housing Census 2002.2 The Tanzanian mainland is administratively divided into 21 regions and 114 districts. The district is the key operational level charged with the responsibility of coordination and integration of health services In Tanzania.3 As such, the district is seen as the official link to the communities.

Tanzania, like many other countries in the region, is in the process of instituting health sector reform. The reform process is being implemented in phases, whereby phase I (2000) covered 37 districts, followed by 45 districts in phase II (2001) and the final 31 districts were incorporated beginning in January 2003. A primary thrust of the reform is decentralization of health care activities to the district, promoting full engagement of all relevant constituencies in establishing more responsive systems for financing and delivering health care services.

A key product of the reform process was the adoption of essential health packages of services (EHPs) defined at the district level. The development of a district-specific EHP entailed integration of basic health services, improvement of management systems, and targeting resources for controlling diseases of local priority at the primary care level. The basic tool for integration is the comprehensive council health plan (CCHP).4 The CCHP identifies areas of priority basing on locally available epidemiologic data and health service statistics in light of a nationally defined essential health package and charts out activities to be undertaken on an annual basis. Integration of any program area into the CCHP strengthens prospects for sustainability while building local ownership and constituency.

MAGNITUDE OF TRACHOMA AND SCOPE OF THE PROGRAM

Data on the distribution and magnitude of diseases such as trachoma in Tanzania are incomplete. Available data suggest that the severity of trachoma varies from district to district and region to region in Tanzania. Provisional estimates suggest that perhaps 54,000 people have trichiasis, with more than one million children less than 10 years old having active disease.5 The disease is thought to be most severe in central and northeastern parts of the country, as shown in Figure 1.

The Tanzania trachoma control program adopted the health reform framework by focusing on district-level planning through the national eye care program. Although much of Tanzania mainland is endemic for trachoma, data on disease distribution was incomplete. The program has adopted a two-prong strategy of program development and advocacy where data existed and survey and assessment where it did not. As a result, a growing number of trachoma-endemic districts are integrating trachoma into their locally defined EHPs.

The Tanzanian effort received a subsequent boost with the initiation of ITI support following Trachoma Expert Committee review of the national program plan in April 1999. The Minister of Health launched the first phase (1999–2000) of ITI-supported SAFE strategy programming in July 1999. Program implementation entailed the Ministry of Health as lead partner, with other implementation partners including Helen Keller International, World Vision, the Kongwa Trachoma Project, ChristofelBlinden Mission, Sustainable Environmental Management Actions, Sight Savers International, and the United Nations Children’s Fund. The Ministry’s Center for Educational Development in Health-Arusha serves as fiscal agent and organizing partner,

The goal of the program was to eliminate blinding trachoma by the year 2020. The specific objectives were 1) to reduce the backlog due to trichiasis by 50% by the end of 2005; 2) to reduce follicular active trachoma (TF) in children by 50% by the end of 2005; 3) to increase the proportion of clean faces by 50% among children less than 10 years old by 2005; and 4) to increase the level of latrine use by 50% in communities affected by the disease by the year 2005.

The SAFE strategy was introduced in six districts in 1999 and by 2002 a total of 10 districts were covered, as shown in Figure 2. Within districts the program started with six villages and expanded, as shown in Table 1. The total population covered by the program in 2002 was more than 500,000 people, as summarized in Table 2. Plans are underway for considerable expansion in 2004 and 2005.

Integration into primary health care.

Since the 1970s, nongovernmental organizations (NGOs) have supported the government to deliver public health and community development activities. With national policy articulated at the central level, the implementation of these activities has been organized at the district level. Trachoma control in Tanzania was initially organized through both NGO and district level organizations. With integration, the role of NGOs remain crucial, and much appreciated, but has shifted from program management to technical support.

Trachoma control in Tanzania was supported largely through the NGO partner network through 2000. As the program expanded to areas where NGOs were not active, support shifted to flow directly through district structures. With this transition, program activities focused on implementation of SAFE at community level through the Ministry of Health\District Eye Care Coordinator. National level staff continued to provide technical support and guidance towards achievement of program objectives.

During the course of program implementation, a number of issues came up, which demanded attention if Tanzania were to attain its goal of eliminating blinding trachoma by the year 2020. There was a pressing need to increase the pace of expansion both within and among districts to attain nationwide coverage. A related issue was ownership, with trachoma control being viewed as a special program that was not the responsibility of the district leadership. It was also observed that while program activities were more expensive than anticipated, it might be possible to strengthen program support through the so-called basket fund of pooled donor resources to cover operating expenses associated with the delivery of trachoma control services.6

Because of their technical and organizational requirements, the component services of trachoma control, the SAFE strategy, could be integrated into the existing health care delivery system in line with the health ongoing policy and health sector reform. It was Tanzanian policy to promote integration to improve the efficiency and effectiveness of health services. The policy emphasizes the need to integrate special programs into the general health services as a way of maximizing the use of the meager resources available. The initial path towards integration was the inclusion of trachoma control into the CCHP.

In 2002, the Tanzania Ministry of Health in collaboration with ITI, the World Bank, and the Presidents Office-Regional Administration and Local Government (PO-RALG) embarked on an advocacy initiative for district leaders of 20 trachoma endemic districts in late 2002. There were two key messages: 1) trachoma is a public health problem in their districts, and 2) the SAFE strategy using Zithromax® donated by Pfizer Inc has shown remarkable results in the areas were it has been applied. As a result of this advocacy the trachoma control program was able to expand and to incorporate 10 new districts into the program from January 2003, as shown in Figure 2.7

The inclusion of trachoma control into the comprehensive council health plan for 2003 was a major step forward, not only for trachoma control but also as a model for other specific program efforts such as elimination of lymphatic filariasis. While integration of trachoma into the district planning process was a good in itself, it also provided an opportunity for the districts to access different sources of funding, e.g., basket, block grants, and council funds. The total amount allocated for trachoma control in the 10 districts for the year 2003 was US $187,000.8 The allocation of these resources among the new districts is outlined in Table 3 and 4. Preparation for additional expansion using this mechanism is underway for 2004 and 2005.

CONCLUSION

Integration of trachoma control into the comprehensive council health plans of 2003 is viewed as a success story in the health sector reform effort in Tanzania. The mobilization of resources for trachoma control has not only provided a breakthrough to the implementation of activities but also increased accountability and ownership of the program by the district leadership. Through this expansion, we hope our ultimate goal of eliminating trachoma by the year 2020 maybe realized on time if not earlier. Because trachoma is a disease of poverty, of those living beyond the end of the road, there is an ongoing need to ensure that political support is sustained if Tanzania is to succeed in eliminating blinding trachoma.

This early success should not diminish appreciation of the scope of the task ahead. Serious questions remain about how to establish efficient and effective programs in new districts with low capacity and poor infrastructure. Another challenge revolves around mobilizing NGOs from different sectors with different expertise to focus on trachoma in a manner consistent with their own capacities and mandates for operation, such as water, sanitation, and health education. Given that trachoma is a disease targeted for elimination in a defined time frame, there is a pressing need to develop mechanisms for monitoring of program implementation that is agreeable to stakeholders.

The context of reform within both the health and local government sectors has provided a good environment for the integration of trachoma control into the comprehensive council health plan in Tanzania.9 When district authorities have been provided with information about the burden of trachoma and the benefits of its control, they have found motivation to seek basket fund support for trachoma control activities. Further opportunities to control trachoma and other neglected disease may come with the economic recovery initiatives undertaken by the government. The possibility of tapping debt relief funds, although still a speculative, is a distinct possibility. Funding notwithstanding, the process of advocating for the integration of trachoma control has brought national leadership to the effort to eliminate blinding trachoma. Trachoma may remain the world’s leading cause of preventable blindness, but with the attention of the agencies such as the PO-RALG, the prospect for elimination in Tanzania is that much brighter.10

Table 1

Villages per district covered by the program 1999–2002

District1999200020012002
Dodoma Rural6121824
Kondoa6121825
Kongwa6121924
Mpwapwa6121826
Kilosa6121824
Manyoni6121825
Iringa Rural121824
Rombo1014
Simanjiro66
Monduli6
Total3684143198
Table 2

Population coverage by district in 2002

DistrictEstimated population
Monduli15,078
Dodoma Rural72,880
Kondoa73,592
Kongwa112,384
Mpwapwa74,945
Iringa Rural44,664
Rombo51,238
Simanjiro9,852
Kilosa72,001
Manyoni61,400
Total588,034
Table 3

Mature districts: other sources of funds for trachoma control (US$) FY 2003*

DistrictBasket fundOther NGOsCouncil fundBlock grant
* FY = fiscal year; NGOs = non-governmental organizations.
Simanjiro3,0973,199
Iringa21,809
Manyoni6,2404,8453,837
Kilosa9,826
Mpwapwa12,078
Dodoma Rural2,845
Kongwa1,90411,738
Kondoa5,464
Rombo6,868
Monduli17,8484,0213,840
Total87,9803,1998,86719,415
Grand Total119,462.76
Table 4

New districts: other sources of funds for trachoma control (US$) FY 2003*

DistrictBasket fundCHFBlock grantCouncil OCCouncil funds
* FY = fiscal year; CHF = community health fund; OC = other charges.
Singida Rural6,81910,262.0
Iramba4,4465,856.0
Masasi4,742
Nzega1,3052,497.09,000
Igunga116
Meatu3,200
Shinyanga Rural2,6171,441
Rufiji2,6842,470
Nachingwae6,293
Lindi Rural4,221
Subtotal36,32810,2628,4432,49710,442
Grand total$67,971
Figure 1.
Figure 1.

Distribution and magnitude of trachoma in Tanzania.

Citation: The American Journal of Tropical Medicine and Hygiene Am J Trop Med Hyg 69, 5_suppl_1; 10.4269/ajtmh.2003.69.5_suppl_1.0690029

Figure 2.
Figure 2.

Program expansion of trachoma control in Tanzania.

Citation: The American Journal of Tropical Medicine and Hygiene Am J Trop Med Hyg 69, 5_suppl_1; 10.4269/ajtmh.2003.69.5_suppl_1.0690029

Authors’ address: Jeffrey W. Mecaskey, Edith Ngirwamungu, and Peter M. Kilima, International Trachoma Initiative, 441 Lexington Avenue, 16th Floor, New York, NY 10077, Telephone: 212-490-6460, Fax: 212-490-6461, E-mail: mecaskey@trachoma.org.

REFERENCES

  • 1

    United Nations Development Programme, Human Development Report, 2003. New York: Oxford University Press.

  • 2

    National Bureau of Statistics, 2003. Tanzania 2002 Population and Housing Census. General report January 2003.

  • 3

    Tanzania Ministry of Health, 2002. National Health Policy Revised.

  • 4

    Ministry of Health, Dar es Salaam, Tanzania, 2002. Health Sector Reform Program of Work 1999–2002.

  • 5

    Ministry of Health, Tanzania

  • 6

    Tanzania Poverty Reduction Strategy Paper, October 2000.

  • 7

    Knirsch C, Mecaskey J, Chami-Khazraji Y, Kilima P, West S, Cook J, 2003. Trachoma Elimination and Public Private Partnership: The International Trachoma Initiative (ITI). Chlamydial Infections: Proceedings of the Tenth International Symposium on Human Chlamydial Infections. San Francisco: International Chlamydial Symposium, 485–494.

  • 8

    Comprehensive Council Health Plans, 2003.

  • 9

    President’s Office – Regional Administration and Local Government, 2003. Comprehensive Council Health Plans for 20 Trachoma Endemic Districts. January 2003

  • 10

    Tanzania Ministry of Health - Second Health Sector Strategic Plan 2003–2006. Reforms Towards Delivering Quality Health Services and Client Satisfaction. April 2003.

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