Vol1 Prelims - research.ncl.ac.uk; ; Newcastle University

ADULT MORBIDITY AND MORTALITY PROJECT

Volume 1 A Ten-Year Community-Based Perspective


United Republic of Tanzania

THE POLICY IMPLICATIONS OF TANZANIA’S MORTALITY BURDEN

Volume 1 A Ten-Year Community-Based Perspective

MINISTRY OF HEALTH

THE POLICY IMPLICATIONS OF TANZANIA’S MORTALITY BURDEN

MINISTRY OF HEALTH United Republic of Tanzania


Foreword Every country needs good information on the health of its people. Measuring health from the traditional facility based approach while useful for inputs into health policy need to be combined in some fashion to achieve the goal of providing a holistic measure of population health. The evolving Tanzanian demographic and epidemiological structure characterized by high morbidity and mortality at all ages, has necessitated reconsideration of how the health of the population should be measured. It is also common knowledge that many Tanzanian people are poor and have limited access to health care facilities and services. In particular, services for both women and children are severely constrained and many of them receive no-formal services and there are growing evidence that they die at home. It is therefore clear that the health events and death that take place in many areas of Tanzania are not captured by the existing information systems. The approach used by the Adult Morbidity and Mortality Project in sentinel demographic and mortality surveillance has provided a means to rectify this deficiency. Sentinel surveillance is not new in Tanzania’s health system. It is a tool used by the Ministry of Health in disease-specific systems such as those for HIV prevalence in women attending antenatal clinics and malaria drug resistance. Now, the surveillance of cause-specific mortality allows the Ministry of Health to estimate the largest portion (about 80%) of the burden of disease that affects the population. Any system that generates information that is not used is a waste of resources. Information from sentinel sites of the National Sentinel Surveillence system (NSS) has been used in a variety of ways. At the district level, Council Health Management Teams have used the district mortality burden profiles from the sentinel sites in the annual planning process. At the national level, data from different sites have been compared and contrasted to show the diversity in health and poverty conditions in the Tanzanian population. Sentinel data can also be pooled to make broad national estimates of Tanzania’s disease burden. This pooling of sentinel surveillance data is new for Tanzania, and will benefit from the input of many stakeholders, and from cross-comparison (where possible) with other sources of national estimation such as the national census and Demographic and Health Surveys. Sentinel mortality surveillance in Tanzania has made the following contribution to the overall health sector reform in general and health information in particular: • It has complemented facility-based information from sources like the Health Management Information System (HMIS); • It has provided reliable estimates for small geographic areas and so reveals the diversity of health conditions in Tanzania; • It has simplified national data collection related to specific diseases. For example it has been very useful in monitoring trends in the prevalence of important diseases (e.g. HIV/AIDS); • It has furnished information that vital registration is currently unable to provide; • It is more cost-effective and feasible than carrying out a series of nationally representative surveys;

• It avoids the need to establish surveillance in all parts of the country, which would be prohibitively expensive; • It can be used to validate information previously collected by other information systems. The report, which is summarized in these volumes (1-4), synthesizes the output of the Ministry of Health’s Adult Morbidity and Mortality Project Phase-2. AMMP has played a crucial role in generating and disseminating essential information from sentinel demographic surveillance systems for the equitable development of the Tanzanian people. The project has done so by providing representative, longitudinal burden of disease and poverty estimates for informed decisions on health policy, planning, monitoring and evaluation at the district, regional and national levels. The report in these volumes is addressed to a wide set of readers who share an interest in Tanzanian health issues and policy, and includes people in the Ministry of Health, and other government ministries, non-governmental organisations, development partners and members of the Tanzania public. Each chapter is set in a unique health and poverty related perspective but there are common threads and shared scenarios that reflect and can be used by many sub-Saharan countries. This report complements other systems in Tanzania that provides health and poverty related information that is crucial in understanding the Tanzania situation and in influencing policy and reform process. The development of community based information system in Tanzania should be taken further to explore the “on the ground realities” and the real needs of the majority of our people. It is therefore expected that under the leadership of the Ministry of Health, the National Sentinel Surveillance System will be developed.

Anna M. Abdallah (MP) MINISTER OF HEALTH

Table of Contents THE POLICY IMPLICATIONS OF TANZANIA’S MORTALITY BURDEN VOLUME 1: A TEN-YEAR COMMUNITY-BASED PERSPECTIVE Foreword by the Honourable Minister of Health Table of Contents 13

Acknowledgements/Shukran

14

From the Project Director

20

From the Assistant Director-General, Evidence and Information for Policy, World Health Organization

21

List of Abbreviations

23

The Policy Implications of Tanzania’s Mortality Burden: Introduction

27 28

Part I. The Information Environment in Tanzania, 1997 – 2003 Chapter 1 The Purpose of AMMP-2: Health and Demographic Information Systems in Tanzania, 1997–2003 Chapter 2 Costs and Results of Information Systems for Health Sector Reform, Poverty Monitoring, and Local Government Reform in Tanzania Chapter 3 The Vision of a National Sentinel Surveillance System of Linked Demographic Surveillance Sites for Health and Poverty Monitoring in Tanzania Chapter 4 The Impact of AMMP on Evidence-Based Policy and Practice

40

66

82 101 102 122

149 150 176

284

366

Part II. Description of Sentinel Area Populations and Representativeness of a ‘National Sentinel Population’ Chapter 5 Description of Population Structures and Components of Change in Sentinel Areas Chapter 6 How Representative Are Pooled Sentinel Area Data for National Estimates? A Comparison of Demographic and Housing Indicators in a National Sentinel Population with Alternative Data Sources Part III. The Policy Implications of Inequalities in Tanzania’s Mortality Burden Chapter 7 Progress Toward National Health Sector, Poverty Reduction, and Millennium Development Goals: Inequalities in Key Indicators Chapter 8 Inequalities in Intervention-Addressable Mortality and Health Service Use: How Would Health Service Priorities Based on Burdens in the Poorest Sentinel Villages and Wards Differ from Those of the Least Poor? Chapter 9 Trends in Cause-Specific Mortality: Main Findings and Implications of Mortality Inequalities Contributors and Acknowledgements, Volume 1

THE POLICY IMPLICATIONS OF TANZANIA’S MORTALITY BURDEN VOLUME 2: COLLECTED PUBLICATIONS AND REPORTS Table of Contents Introduction to Volume 2 Part I: Articles, Book Chapters, and Correspondence 1.

Kitange, HM and ABM Swai, The Tanzanian WHO Interhealth Project. Practical Diabetes Digest, 1990. 1: p. 148-149.

2.

McLarty, DG, C Pollitt, and ABM Swai, Diabetes in Africa. Diabetic Medicine, 1990. 7(8): p. 670-684.

3.

Ramaiya, KL, ABM Swai, DG McLarty, et al., Improvement in glucose tolerance after one year of follow-up in a Hindu community in Africa. Diabetes Research and Clinical Practice, 1990. 10: p. 245-255.

4.

Swai, ABM, DG McLarty, F Sherrif, et al., Diabetes and impaired glucose tolerance in an Asian community in Tanzania. Diabetes Research and Clinical Practice, 1990. 8: p. 227-234.

5.

Mwaluko, GMP, ABM Swai, and DG McLarty, Non-communicable disease, in Health and Disease in Tanzania, G. Mwaluko, W. Kilama, P. Mandara, et al., Editors. 1991, Harper Collins Academic: London. p. 219-237.

6.

Ramaiya, KL, AB Swai, DG McLarty, et al., Prevalences of diabetes and cardiovascular disease risk factors in Hindu Indian subcommunities in Tanzania. BMJ, 1991. 303: p. 271-276.

7.

Ramaiya, KL, ABM Swai, DG McLarty, et al., Impaired glucose tolerance and diabetes mellitus in Hindu immigrants in Dar es Salaam. Diabetic Medicine, 1991. 8: p. 738-744.

8.

Swai, AB, H Kitange, DG McLarty, et al., No deterioration of oral glucose tolerance during pregnancy in rural Tanzania. Diabetic Medicine, 1991. 8: p. 254-257.

9.

Swai, AB, DG McLarty, HM Kitange, et al., Study in Tanzania of impaired glucose tolerance: methodological myth? Diabetes, 1991. 40: p. 516-520.

10. Swai, ABM, HM Kitange, G Masuki, et al., Is diabetes mellitus related to undernutrition in rural Tanzania? BMJ, 1992. 305: p. 1057-1062. 11. Swai, AB, DG McLarty, BL Mtinangi, et al., Diabetes is not caused by cassava toxicity. A study in a Tanzanian community. Diabetes-Care, 1992. 15(10): p. 1378-1385. 12. Kitange, H, ABM Swai, PM Kilima, et al., Anaemia is a major public health problem in Tanzania. Health Policy and Planning, 1993. 8: p. 413-418. 13. Kitange, HM, AB Swai, G Masuki, et al., Coronary heart disease risk factors in sub-Saharan Africa: studies in Tanzanian adolescents. Journal of Epidemiology and Community Health, 1993. 47(4): p. 303-307. 14. Kitange, H, ABM Swai, DG McLarty, et al., Schistosomiasis prevalence after administration of praziquantel to school children in Melela village, Morogoro region, Tanzania. East African Medical Journal, 1993. 70: p. 782-786.

15. Mlingi, NV, VD Assey, ABM Swai, et al., Determinants of cyanide exposure from cassava in a konzo-affected population in northern Tanzania. International Journal of Food Science and Nutrition, 1993. 44(13): p. 137-144. 16. Swai, ABM, DG McLarty, HM Kitange, et al., Low prevalence of risk factors for coronary heart disease in rural Tanzania. International Journal of Epidemiology, 1993. 22(651-659). 17. Kitange, H, ABM Swai, G Masuki, et al., Perinatal mortality in rural Tanzania. World Health Forum, 1994. 15: p. 82-84. 18. Kitange, HM, H Machibya, J Black, et al., Outlook for survivors of childhood mortality in sub-Saharan Africa: Adult Mortality in Tanzania. BMJ, 1996. 312: p. 216-220. 19. Aspray, T, H Kitange, P Setel, et al., Disease Burden in sub-Saharan Africa (letter). Lancet, 1998. 351(April): p. 9110. 20. Kitange, H, F Mugusi, and P Setel, The burden of non-communicable diseases. Africa Health, 1998. 20( July): p. 17-18. 21. Unwin, N, G Alberti, T Aspray, et al., Economic globalisation and its effect on health. BMJ, 1998. 316: p. 1401-1402. 22. Smide, B, DR Whiting, F Mugusi, et al., Self-perceived health in urban diabetic patients in Tanzania. East African Medical Journal, 1999. 76(2): p. 67-70. 23. Quigley, MA, D Chandramohan, P Setel, et al., Validity of data-derived algorithms for ascertaining causes of adult death in two African sites using verbal autopsy. Tropical Medicine and International Health, 2000. 5(1): p. 33-39. 24. Rashid, S, TJ Aspray, R Edwards, et al., The pitfalls of measuring changes in smoking habits. Tropical Doctor, 2000. 30: p. 160-161. 25. Setel, P, Y Hemed, N Unwin, et al., Six-Year Cause-Specific Adult Mortality in Tanzania: Evidence from Community-based Surveillance in Three Districts 19921998. Morbidity and Mortality Weekly Report., 2000. 49(19): p. 416-419. 26. Setel, P, D Whiting, Y Hemed, et al., Educational status is related to mortality at the community level in three areas of Tanzania, 1992-1998. Journal of Epidemiology and Community Health, 2000. 54: p. 936-937. 27. Walker, RW, DG McLarty, HM Kitange, et al., Stroke mortality in urban and rural Tanzania. Lancet, 2000. 355(9216): p. 1684-1687. 28. Alberti, G, Non-communicable diseases: tomorrow’s pandemics. Bulletin of the World Health Organization, 2001. 79(10): p. 907. 29. Boulle, A, D Chandramohan, and P Weller, A case study of using artificial neural networks for classifying cause of death from verbal autopsy. International Journal of Epidemiology, 2001. 30: p. 515-520. 30. Chandramohan, D, B Greenwood, J Cox, et al., Relationship between malaria endemicity and acute febrile illness mortality in children. Bulletin of the World Health Organization, 2001. 79(4): p. 375-376. 31. Chandramohan, D, P Setel, and M Quigley, Misclassification error in verbal autopsy: can it be adjusted? International Journal of Epidemiology, 2001. 30(3): p. 509-514.

32. Moshiro, C, R Mswia, K Alberti, et al., The importance of injury as a cause of death in sub-Saharan Africa: results of a community-based study in Tanzania. Public Health, 2001. 115: p. 96-102. 33. Setel, P, Y Hemed, D Whiting, et al., The worst of two worlds: Adult mortality in Tanzania. Insights Health, 2001. 1(March): p. 3-4. 34. Unwin, N, P Setel, S Rashid, et al., Non-communicable diseases in sub-Saharan Africa: where do they feature in the health research agenda? Bulletin of the World Health Organization, 2001. 79(10): p. 947-953. 35. Bovet, P, AG Ross, J-P Gervasoni, et al., Distribution of blood pressure, body mass index, smoking habits, and associations with socio-economic status in Dar es Salaam, Tanzania. International Journal of Epidemiology, 2002. 31: p. 240-247. 36. Jagoe, K, R Edwards, F Mugusi, et al., Tobacco smoking in Tanzania, East Africa: population-based smoking prevalence using expired alveolar carbon monoxide as a validation tool. Tobacco Control, 2002. 11: p. 210-214. 37. Mswia, R, D Whiting, G Kabadi, et al., Dar es Salaam Demographic Surveillance System, in Population and Health in Developing Countries. Volume 1: Population, Health, and Survival in INDEPTH Sites, The INDEPTH Network, Editor. 2002, International Development Research Centre: Ottawa. p. 143-150. 38. Mswia, R, D Whiting, G Kabadi, et al., Hai District Demographic Surveillance System, in Population and Health in Developing Countries. Volume 1: Population, Health, and Survival in INDEPTH Sites, The INDEPTH Network, Editor. 2002, International Development Research Centre: Ottawa. p. 151-158. 39. Mswia, R, D Whiting, G Kabadi, et al., Morogoro Rural Demographic Surveillance System, in Population and Health in Developing Countries. Volume 1: Population, Health, and Survival in INDEPTH Sites, The INDEPTH Network, Editor. 2002, International Development Research Centre: Ottawa. p. 165-172. 40. Mwageni, E, D Momburi, Z Juma, et al., Rufiji Demographic Surveillance System, in Population, Health and Survival in Developing Countries. Volume 1: Population, Health, and Survival in INDEPTH Sites, The INDEPTH Network, Editor. 2002, International Development Research Centre: Ottawa. p. 173-181. 41. Mswia, R, M Lewanga, C Moshiro, et al., Community-based Monitoring of Safe Motherhood in the United Republic of Tanzania. Bulletin of the World Health Organization, 2003. 81(2): p. 87-94. 42. Setel, P, Non-Communicable Diseases, Political Economy and Culture in Africa: Anthropological Applications in an Emerging Pandemic. Ethnicity and Disease, 2003. 13[suppl2]: p. 149-153. 43. Setel, P and Y Hemed, Box 1.1: Sentinel vital registration in the United Republic of Tanzania, in World Health Report 2003. Shaping the Future, World Health Organization, Editor. 2003, World Health Organization: Geneva. p. 7. 44. Whiting, DR, L Hayes, and NC Unwin, Challenges to health care for diabetes in Africa. Journal of Cardiovascular Risk, 2003. 10: p. 103-110.

45. Bryce, J., Victora, C.G., Habicht, J.-P., et al., The Multi-Country Evaluation of the Integrated Management of Childhood Illness Strategy: Lessons for the Evaluation of Public Health Interventions. American Journal of Public Health, 2004. 94(3): p. 406-415. 46. Setel, PW, L Saker, NC Unwin, et al., Is it Time to Reassess the Categorization of Disease Burdens in Low-Income Countries? American Journal of Public Health, 2004. 94(3): p. 384-388. Part II: Theses and Selected Reports, Working Papers and Presentations List of Theses 1.

Amaro, RA, An Assessment of the Causes of Maternal Mortality for Tanzania Women: A Case Study of Hai District. MSc. 1998, Queen Margaret College: Edinburgh.

2.

Boulle, A, The role of neural networks in public health practice: a case study in cause of death classification. MSc. 1999, University of London School of Hygeine and Tropical Medicine: London.

3.

Dawson, SG, Developing Location-Specific Measures of Socio-Economic Status in Partially Subsistent Economies. PhD. 1997, University of Liverpool: Liverpool.

4.

Kissima, J.G.N, An Analysis of Under-Five Mortality Rates and their Causes in Developing Countries: Implications for Hai District, Tanzania. MSc. 1995, Queen Margaret College: Edinburgh.

5.

Makundi, A. Community Social Valuation: Disability and Disease in Two Selected Communities: Temeke and Moshi Districts, Tanzania. MSc. 2000, University of Bergen: Bergen.

6.

Madden, M, Assigning Adult Causes of Death via Verbal Autopsy using Dataderived Algorithms, MS. 2002, Brigham Young: Provo.

7.

Masawe, GJ, Measurement of the Prevalence of Arthritis in the Hai District, Tanzania, MSc. 1994, Queen Margaret College: Edinburgh.

8.

Mayunga, J.S. Handling health data in a GIS environment: geo-referencing and analysis: the case study of Dar es Salaam, Tanzania. MSc. International Institute for Geo-Information Science and Earth Observation: Enschede, The Netherlands.

9.

Mkamba, M.S.A. The Measurement of Determinants of Injury due to Road Traffic Accidents in Tanzania. MSc. 1995, Queen Margaret’s College: Edinburgh.

10. Nguluma, M. An Anti-Smoking Health Education Project for the Morogoro District of Tanzania. Diploma in Primary Health Care. 1992, Queen Margaret’s College: Edinburgh. 11. Smide, B. Self-care, foot problems and health in Tanzanian diabetic patients and comparisons with matched Swedish diabetic patients. PhD. 1999, Uppsala University: Uppsala.

Selected Reports, Working Papers, and Presentations 1.

Ministry of Health and AMMP Team, The Policy Implications of Adult Morbidity and Mortality. End of Phase 1 Report. (Executive Summary). 1997, United Republic of Tanzania: Dar es Salaam.

2.

Ministry of Health and AMMP Team, The Intervention-Addressable Burden of Mortality Among Children Under 5 in AMMP Districts (July 1992-June1998). Preliminary Analysis. (Technical Report No. 5). 1999, Ministry of Health, United Republic of Tanzania: Dar es Salaam.

3.

Setel, P, N Mndeme, M Lewanga, et al., Analysis of Newsletter Readership in AMMP Demographic Surveillance System Areas 1998-1999. Technical Report No. 6. 2000, Ministry of Health, Adult Morbidity and Mortality Project & Health Information and Research Section, Department of Policy and Planning: Dar es Salaam.

4.

Adult Morbidity and Mortality Project and National Sentinel Surveillance Teams (Tanzanian Ministry of Health), Seminar on Poverty and the Burden of Disease in Tanzania, March 5-8, 2001. Summary of Proceedings. 2001, Ministry of Health, United Republic of Tanzania: Dar es Salaam.

5.

Mwinyi, HA. Information for Strengthening Health Reforms: A Tanzanian Perspective. A Speech by the Honourable Dr Hussein Ali Mwinyi (MP), Deputy Minister of Health, United Republic of Tanzania to the Commonwealth Regional Health Secretariat Health Ministers Meeting October 23 – 26, 2001. Speech given at Commonwealth Regional Health Secretariat Health Ministers Meeting. 2001. Dar es Salaam.

6.

National Sentinel Surveillance System and Adult Morbidity and Mortality Project, Progress in Safe Motherhood in Tanzania during the 1990s: findings based on NSS/AMMP monitoring. (Working Paper No. 1). 2001, Adult Morbidity and Mortality Project, Ministry of Health: Dar es Salaam.

7.

Setel, P, V Mkusa, and and the AMMP Team, Comprehension of Swahili Verbal Autopsy Forms. AMMP Technical Report No. 7. 2001, Adult Morbidity and Mortality Project & Health Information and Research Section, Department of Policy and Planning, Ministry of Health, United Republic of Tanzania: Dar es Salaam.

8.

Abeyasekera, S and P Ward, Models for Predicting Expenditure per Adult Equivalent for AMMP sentinel surveillance sites. 2002, Adult Morbidity and Mortality Project, Tanzanian Ministry of Health: Dar es Salaam.

9.

National Sentinel Surveillance System and Adult Morbidity and Mortality Project Team, Setting Priorities in Health Care: use of diverse information perspectives at the district level in Tanzania. (Working Paper No. 4). 2002, United Republic of Tanzania Ministry of Health: Dar es Salaam.

10. National Sentinel Surveillance System and Adult Morbidity and Mortality Project Team, Community-Level Trends and Inequalities in Acute Febrile Illness mortality in Tanzania 1996-2001: a case for ‘socio-geographic’ targeting of interventions? (Working Paper No. 6). 2002, United Republic of Tanzania Ministry of Health: Dar es Salaam.

11. Clark, S, P Setel, K Kahn, et al. The Role of AIDS/TB in Mortality Patterns in East and Southern Africa: Evidence from Four Demographic Surveillance Sites. Paper presented at Empirical Evidence for the Demographic and Socioeconomic Impacts of AIDS. 2003. Durban, South Africa. 12. National Sentinel Surveillance System and Adult Morbidity and Mortality Project Team, Suitability of Participatory Methods to Generate Variables for Inclusion in an Income Poverty Index. (Working Paper No. 9). 2003, United Republic of Tanzania Ministry of Health: Dar es Salaam. 13. Setel, P, O Sankoh, C Mathers, et al., Improving Systems for Monitoring and Measurement of Vital Events. An issues paper prepared for the Health Metrics Task Force Meeting, World Health Organization, Glion, Switzerland, November 2003. 2003, World Health Organization, Evidence and Information for Policy: Geneva. Contributors and Acknowledgements, Volume 2

THE POLICY IMPLICATIONS OF TANZANIA’S MORTALITY BURDEN VOLUME 3: FIELD OPERATIONS AND VALIDATION STUDIES Table of Contents Introduction to Volume 3 Part I. Methods, Forms, and Capacity Requirements Chapter 1 Baseline and Update Household Enumeration Surveys: Procedures, Sample Enumeration Forms, and Capacity Requirements Chapter 2 Conducting Mortality Surveillance: Data Collection, Coding Procedures, Core VA Forms, ICD-10 Coding, and Proposed Tabulation List Chapter 3 Surveillance Package/Open Source Software and Data Set Guide Part II. Modelling, Validation and Cross-Comparison of Tools Chapter 4 Estimating the Optimum Size for Sentinel Mortality Surveillance Sites Chapter 5 Development, Validation, and Performance of a Rapid Consumption Expenditure Proxy for Measuring Income Poverty in AMMP/National Sentinel Surveillance System Areas Chapter 6 Preliminary Results of Validation Study on Core Verbal Autopsy Forms Contributors and Acknowledgements, Volume 3

THE POLICY IMPLICATIONS OF TANZANIA’S MORTALITY BURDEN VOLUME 4: MORTALITY BURDEN PROFILES FROM SENTINEL SITES, 1994-2002 Table of Contents Introduction to Volume 4 Dar es Salaam – Dar es Salaam Sentinel Surveillance Area Mortality Burden Profiles, 1994-2002 Chapter 1 1994 Chapter 2 1995 Chapter 3 1996 Chapter 4 1997 Chapter 5 1998 Chapter 6 1999 Chapter 7 2000 Chapter 8 2001 Chapter 9 2002 Hai District– Northern Sentinel Surveillance Area Mortality Burden Profiles, 1994-2002 Chapter 10 1994 Chapter 11 1995 Chapter 12 1996 Chapter 13 1997 Chapter 14 1998 Chapter 15 1999 Chapter 16 2000 Chapter 17 2002 Chapter 18 2002 Morogoro District – East-Central Sentinel Surveillance Area Mortality Burden Profiles, 1994-2002 Chapter 19 1994 Chapter 20 1995 Chapter 21 1996 Chapter 22 1997 Chapter 23 1998 Chapter 24 1999 Chapter 25 2000 Chapter 26 2001 Chapter 27 2002 Annex 1 Annex 2

Cause Groups and ICD Codes Allocation of Causes to Broad Cause, Broad Care Need, and Intervention-Addressable Categories

Contributors and Acknowledgements Volume 4

THE POLICY IMPLICATIONS OF TANZANIA’S MORTALITY BURDEN CD-ROMS Disk 1 Disk 2 Disk 3

The Policy Implications of Tanzania’s Mortality Burden (Volumes 1-4) Surveillance Package Open Source (SPOS V.1.0) Installation CD AMMP-2 Analysis Module and Baseline Data (Bootable CD)

This publication is an output of the Adult Morbidity and Mortality Project (AMMP). AMMP is a project of the Tanzanian Ministry of Health, funded by the Department for International Development (UK), and implemented in partnership with the University of Newcastle upon Tyne. The views expressed are not necessarily those of DFID.

Acknowledgments/Shukran In Tanzania giving thanks is an important duty when a group of individuals has shared an experience—be it a celebration, a meal, a meeting, or, in this case, a project. The honour of giving thanks to those who made the Adult Morbidity and Mortality Project, Phase 2 (AMMP-2), a possibility, then a reality, and now a proud achievement, falls to the Ministry of Health. The groups named below brought many qualities to the task of improving health information systems in Tanzania through the wide application of sentinel demographic and mortality surveillance. Chief among them have been: dedication, altruism, volunteerism, insight, patience, humour, wisdom, and intelligence. None of the accomplishments of the project would have been possible without them, and they may all take justifiable pride in having made a measurable difference in health services, policy, and information in Tanzania, and in setting an example that other countries can hope to emulate.

M.J. Mwaffisi PERMANENT SECRETARY MINISTRY OF HEALTH

Dar es Salaam, June, 2004

AMMP-2 Project Steering Committee The AMMP-2 Team Dar es Salaam/Dar es Salaam Sentinel Site Team Hai District/Northern Sentinel Site Team Morogoro District/East-Central Sentinel Site Team Igunga District/West-Central Sentinel Site Team Kigoma Ujiji/Western/Small urban sentinel site National Sentinel Surveillance System Task Group and Secretariat University of Newcastle upon Tyne Scientific Advisory Group Verbal Autopsy Validation Team and Coders DFID Project Team, Tanzania PriceWaterhouseCoopers Project Management Support

Our greatest debt of thanks is to the residents of the Dar es Salaam, Hai, Igunga, Kigoma, and Morogoro sentinel demographic surveillance areas—more than 450,000 Tanzanians—who have allowed us, year after year, for more than a decade to enter their homes, ask many questions, and benefit from their knowledge and experience—even in the midst of grieving for their loved ones.

Volume 1: A Ten-Year Community-Based Perspective 13

From the Project Director Dedication and contribution of ideas in setting up a community-based health information system is essential and the preparation of these volumes has been no exception. I have placed great value on the vivid exchange of experiences in this daunting work with many colleagues in the districts, Ministry of Health and other people within Tanzania and outside the country. The intent to write these volumes has its roots in the early days of AMMP-2. The project team felt an immense responsibility to share the experiences of phase one and phase two of the project with all stakeholders. As Director, and senior member of the Ministry of Health I also have special obligation and duty to the Ministry of Health, districts and development partners to document as clearly as possible all tools, results and publications for two reasons. First, understandably, the communities and districts in which AMMP worked have always been keen to receive feedback on the information collected from them and its implications for their health. Secondly, since the project is under the Ministry of Health and is funded by DFID, it is imperative that the project presents the tools used, the data collected and its implication to policy. I therefore would like to acknowledge the contributions from a number of people. The project would not be able to fulfil these obligations without their contribution.

Dr. Y. Hemed PROJECT DIRECTOR AMMP

Dar es Salaam, June, 2004

The AMMP-2 Team Philip Setel, Technical Advisor David Whiting, Data Services Manager Namsifu Mndeme, Deputy Director KGMM Alberti, UK Project Co-ordinator Nigel Unwin, Project Advisor Mariana Lugemwa, Project Secretary Robert Mswia, Project Statistician Mary Lewanga, Junior Project Statistician and Assistant Administrator Candida Moshiro, Project Statistician Honorati Masanja, Project Statistician Zaharani Juma, Rufiji DSS Data Manager Veronica Mkusa, Community Participation Field Coordinator Hazel Glass, Project Administrator Henry Mwanyika, Information Systems Officer Gregory Kabadi, Assistant Data Services Manager William Krekamoo, Verbal Autopsy Validation Coordinator Charles William, Data Entry Clerk Dorothy Lyimo, Data Entry Clerk Rukia Mwamtemi, Data Entry Clerk Gertrude Peter, Data Entry Clerk Violet Kiwelu, Data Entry Clerk Juma Mfinanga, Driver/Mechanic Mtoro Mbogakwaga, Driver/Mechanic Mustapha Kahise, Driver/Mechanic Saidi Ali Mtambo, Office Support AMMP/National Sentinel Surveillance System Site Teams Dar es Salaam/Dar es Salaam sentinel site Mr Iddi Nyundo, Municipal Director Temeke Mr John Lubuva, Municipal Director Ilala Dr Deogratius Mtasiwa, Regional Medical Officer/City Medical Officer for Health Dr Louisa Masayanyika, Municipal Medical Officer for Health Temeke Dr Judith Kahama, Municipal Medical Officer for Health Ilala Dr Gaspar Rutaindurwa, Programs Coordinator Municipal Medical Officer for Health Dr Seif Rashid, Research Coordinator Ilala Dr Mashombo Mkamba, Research Coordinator Temeke Juma Peba, Key Informant Rajabu Furahisha, Key Informant

14 The Policy Implications of Tanzania’s Mortality Burden: AMMP-2 Final Report

Saidi Ally Lugongo, Key Informant Leons M Kazimili, Key Informant Maulid Kandunda, Key Informant Thomas Matete, Key Informant Mustapha Shawa, Key Informant Kazumari Chitwanga, Key Informant Gayo Kasembe, Key Informant Mwajuma Mbogo, Key Informant James Lema, Enumerator Yusuf Makongoro, Enumerator Paul Nzuki, Enumerator Agnes Mbuya, Enumerator Zuhura Madafa, Enumerator Saidi Kubenea, Enumerator Emmanuel Hinjo, Enumerator Blandina Mhina, Enumerator Catherine Masegese, Enumerator Mwajabu Mpogo, Enumerator Joyce Nkondola, Enumerator John S Bwana, Enumerator Berlina Job, VA Supervisor Ayoub Kibao, VA Supervisor Mohamed Sultani, Driver Sarah Mwafalo, VA Interviewer Burton Ngewe, VA Interviewer Stanley Lwiza, VA Interviewer Lilian Mnzava, IEC Coordinator Alice Samaluku, IEC Coordinator Hai District/Northern sentinel site Mr Gebra Msuya, Former District Executive Director Mr Francis Miti, District Executive Director Dr Gabriel Masuki, District Medical Officer Dr John Kissima, VA Supervisor/DSS Coordinator Mr Goodwill Massawe, VA Supervisor Mr Ally Mhina, VA Supervisor Mr Adess Moshy, VA Supervisor Mr Richard Amaro, VA Supervisor Kapanyaeli Kileo, Enumerator Bakari Mdoe, Enumerator Sophy Darabu, Enumerator Julitha Malisa, Enumerator Husna Mshana, Enumerator Eline Lema, Enumerator Paul Kiria, Enumerator Elieshi Kimaro, Enumerator Light Ever Shoo, Enumerator Restituta Kyara, Enumerator Anna Shoo, Enumerator Cyril Paul, Enumerator Honorathy Shayo, Enumerator Ndenimbora Urassa, Enumerator

Fura Ulomi, Enumerator Edna Stephen, Enumerator Christopher Somba, Enumerator Penina Munissi, Enumerator Joseline Kalalu, Enumerator Christopher Munissi, Enumerator Abuu Haji Lema, Enumerator Athanasia Mushi, Enumerator Hafsa Mchomvu, Enumerator Hawa Mohamed, Enumerator Christine W Kimaro, Enumerator Tanbaly Ulomi, Enumerator Comfort Ndosi, Enumerator Dora J Mushi, Enumerator Lucas A Kirango, Enumerator Christine Malisa, Enumerator Judith Ng’unda, Enumerator Sankwakwe Mwasha, Enumerator Leah Urassa, Enumerator Julian Mfuru, Enumerator Clemence Kulaya, Enumerator Gregoria Mallya, Enumerator Happyness Kweka, Enumerator Flora Mollel, Enumerator Abuu Bakari Mkilindi, Enumerator Genes Jacob, Enumerator Felicia Ritte, Enumerator Mariamu Mhando, Enumerator Veronica Mlay, Enumerator Elikawokoru Ngowi, Enumerator Peter Kimario, Enumerator Veronica T Massawe, Enumerator Dora Kimaro, Enumerator Dockneth Massawe, Enumerator Eliamin Kiamro, Enumerator Ombeni G Mushi, Enumerator Rose F Lema, Enumerator Emanuel I Mushi, Enumerator Ernesta P Mmari, Enumerator Godbless Mushi, Enumerator Adela Hillary, Enumerator Kaanankira Urassa, Enumerator Agapati Lyari, Former Enumerator Late Anicet Ernest, Former Enumerator Nanyori Njolowike, Former Enumerator Samwel Massawe, Former Enumerator Godwin Urio, Former Enumerator Theresia Shayo, Former Enumerator Evaline Mushi, Former Enumerator Stella Mmassy, Former Enumerator Esmond Mushi, Former Enumerator Elisamehe Matemba, Former Enumerator


Thomas Lema, Former Enumerator Clotilda Moshi, Former Enumerator Late Lawrence Chaki, Former Enumerator Gladness Augustino Shoo, Former Enumerator Ndeshitira Ndossa, Former Enumerator Late Teddy Marawiti, Former Enumerator Late Charles Mwashombe, Former Enumerator Ester Swai, Former Enumerator Monyiaichi Makundi, Former Enumerator Hosiana Munuo, Former Enumerator Remenes Mushi, Former Enumerator Asia Mjema, Former Enumerator Antony E Makuta, Former Enumerator Epimack Nyaki, Former Enumerator Evarest Mushi Kweka, Former Enumerator Ezrom Mmary, Former Enumerator Hamadi Munissi, Former Enumerator Redfan Shao, VA Interviewer Amani A Mariki, VA Interviewer Godwin Makere , VA Interviewer Ezra S Kimaro, VA Interviewer Peter A Mboya, VA Interviewer Khalfan Mwanga, VA Interviewer Goodluck Lyimo, VA Interviewer Niconory Ndossa, VA Interviewer Rose P Sembwana, VA Interviewer Morogoro District/East-Central sentinel site Mr John Gille, Former District Executive Director Mr Maurice M Sapanjo, District Executive Director Dr Haruna M S Machibya, District Medical Officer Peter Nkulila, VA Supervisor Joel Kalula, VA Supervisor Mkay Nguluma, VA Supervisor Asha Sankole, Former VA Supervisor Joseph Lifa, VA Supervisor Mrs Moshi Hassan, Office Support Said Ngaluma, VA Interviewer George Anyosisye, VA Interviewer Asheri Galahenga, VA Interviewer Ibrahim Katole, VA Interviewer Edmond Mneney, VA Interviewer Amadeus Mwananziche, VA Interviewer Mohamed Mwenda, VA Interviewer Daniel Kubingwa, VA Interviewer Philemon Mpanduka, VA Interviewer Richard Faraay, VA Interviewer Athuman Kabago, VA Interviewer Eric Mshana, VA Interviewer Flora Ngasa, VA Interviewer Juma Kidando, VA Interviewer Rogers Ally, VA Interviewer

Angella Ndomba, VA Interviewer Amandus Kimaryo, VA Interviewer May Msoffe, VA Interviewer Ally Lwambano, VA Interviewer Maira Mborwe, VA Interviewer Saad Hasani, VA Interviewer Mwanamisi Mbuluma, VA Interviewer Phillip Lumbe, VA Interviewer Acrey Raymond, VA Interviewer Twaha Ngallawa, VA Interviewer Donatus Jaka, VA Interviewer Antony Swila, VA Interviewer Lazaro Mdeka, VA Interviewer Late Ndaki Mazigo, VA Interviewer Dr John Mkambu, VA Interviewer Jaga Mkamila, VA Interviewer Bernadetha Mihalu, VA Interviewer Dr Abbas Kashindye, VA Interviewer Fabian Semweja, VA Interviewer Alfred Mapunda, VA Interviewer Elieskia Mbwambo, VA Interviewer Leodigar Foyan, VA Interviewer Gaudensia Ndegea, VA Interviewer Tatu P Bugwema, Enumerator Karl Lingwanda, Enumerator Enelesi Udandali, Enumerator Iddi Biwi, Enumerator Bernadeta Mihalu, Enumerator Freddy Matangalu, Enumerator Godson Kiboko, Enumerator Hashim Ally, Enumerator Juma Maulidi, Enumerator Kibwana Kiwaya, Enumerator Alfred Dennis, Enumerator Omari Mohamed, Enumerator Grace Chuma, Enumerator Martha Daniel, Enumerator Lician Pius, Enumerator Mussa R Mahita, Enumerator Judith J Wahindi, Enumerator Clementina Mzeru, Enumerator Florian Karoli, Enumerator Daudi S Mkunde, Enumerator Paulina Oswald, Enumerator Fortunata Mughunda, Enumerator Omari Mlimka, Enumerator Iddi Rashid Pangalugome, Enumerator Mohamed Chenga, Enumerator Mbwana Abdallah, Enumerator Thomas Mbega, Enumerator Richard James, Enumerator Ramadhani Hasani, Enumerator


Omari Nguruwe, Enumerator Ramadhani Ally, Enumerator Bartholomeo Mbega, Enumerator Saida Mkopi, Enumerator Omari Ngalula, Enumerator Huseni Saidi, Enumerator Juma Majimoto, Enumerator Hemedi Bahari, Enumerator Amiri Kibwana Msumi, Enumerator Zaina Ally, Enumerator Habibu Mbegu, Enumerator Reginald Fabiani, Enumerator Ramadhani Magesa, Enumerator Fabian Motto, Enumerator Hasani Patrick, Enumerator Selemani Meli, Enumerator Ezekiel Kinyamasongo, Enumerator Shabani Mwalimu, Enumerator Daniel Zangira, Enumerator Anzidoli Adamu Deva, Enumerator Hamisi Diwani, Enumerator Amina Malekela, Enumerator Hamza Ramadhani, Enumerator Abdallah Kibwana, Enumerator Bakari Kikwesha, Enumerator Rashid Dutilo, Enumerator Felician Temba, Enumerator Late Samwel Daudi, Enumerator Donald Kulwa, Enumerator Mrs Christina Wimbe, Enumerator James Kaluma, Enumerator Omari Hamisi, Enumerator Nasoro Ramadhani, Enumerator Ramadhan Changaluma, Enumerator Petronila Wahindi, Enumerator Grace M Tarimo, Enumerator Mohamed Simba, Enumerator Omari Nasoro, Enumerator John Ulomi, Enumerator Abdalla Omari, Enumerator Salum Mhando, Enumerator Shaibu Rashid, Enumerator Leah Msonga, Enumerator Abubakari Ally, Enumerator Ester Claude, Enumerator Mohamed Ismail Salum, Enumerator Athumani Mlangwa, Enumerator Starehe Mwinjuma, Enumerator Nyakitambulio Mohamed, Enumerator Adam Abdala, Enumerator Salum Mwahilo, Enumerator Mohamed Lukinga, Enumerator

Maria Saidi, Enumerator Ally Msemwa, Enumerator Mohamed Komola, Enumerator Mwamshindo Kondo, Enumerator Teresia Mwafalo, Enumerator Rashidi Beku, Enumerator Idd Dengeu, Enumerator Kamili Masudi, Enumerator Maimuna Iddi, Enumerator Salum Kisimikwe, Enumerator Henirika Elias, Enumerator Celsus Makalilo, Enumerator Abasi Kibukila, Enumerator Igunga District/West-Central sentinel site Ms Jane Mutagurwa, Former District Executive Director Mr Samwel A Mashindike, District Executive Director Dr L G Mhina, District Medical Officer Mr Maiko Sonyo, Former District Treasurer Ms Joyce Mlemeta, District Treasurer Mr Abdalah Mohamed, Accountant Mr Joachim Kabeya, DSS Coordinator Mr Hassan Kapamba, VA Supervisor Dr Donacian Kamara, VA Supervisor Mr Simsokwe Chapewa, VA Supervisor Mr Frednand Kibandiko, VA Supervisor Isaya Kamonjo, VA Interviewer Issa Garimo, VA Interviewer John Seif, VA Interviewer Twaha Hussein, VA Interviewer Sylivian Kakeyule, VA Interviewer Gudila Massawe, VA Interviewer Fabian Malekela, VA Interviewer Secilia Mtuka, VA Interviewer Masanja Dwese, VA Interviewer William M Kabuta, Enumerator Maria M Maganga, Enumerator Hindu M Magalu, Enumerator Masudi M Masudi, Enumerator Fatuma D Manzuzu, Enumerator Sida Kurubone, Enumerator Mwajuma Mohamed Kulwa, Enumerator Kombe Mwandu Mhoja, Enumerator Saidi Amour Saidi, Enumerator Simon Busongo, Enumerator Petro Matheo Ndulila, Enumerator Masessa Petro, Enumerator Halima Salum, Enumerator Jonathan S Gyunda, Enumerator Mwajuma Msalika, Enumerator Elizabeth Mwandu, Enumerator


Simon Fulana, Enumerator Agnes Matheo Lubisi, Enumerator Michael Petro, Enumerator Paulo Richard, Enumerator Daudi H Kigoni, Enumerator Laurent Ganza Mgalula, Enumerator Samson Petro Yatuba, Enumerator Ngodoki John, Enumerator Mihambo Msayu, Enumerator Marco John, Enumerator Vera Rwiza, Enumerator Nkwabi Kuhala Gwashi, Enumerator Paschal Mathew Mkangwa, Enumerator Kassimu S Ngele, Enumerator Alex N Sakarani, Enumerator Issa Kassim Moshi, Enumerator Ali Mgalula, Enumerator Shija Bundala Selengeta, Enumerator Peter Rutabagisha, Enumerator Hassan Sheli, Enumerator Joseph Samwel Biganio, Enumerator Dotto Mboje, Enumerator Patrick Maige Masesa, Enumerator Tumaini D Wanjeru, Enumerator Joseph M Shimba, Enumerator Joseph Kambu Gimbagu, Enumerator Elidadi B Balikulije, Enumerator Richard M Ilago, Enumerator Simon B Gilgis, Enumerator Gideon S Makebe, Enumerator Laurent S Kaneneka, Enumerator Marko T Luziga, Enumerator Busongo Makwaya Shija, Enumerator Fabian B Kigalu, Enumerator Ramadhani Maganga Mlekwa, Enumerator Karol H Luzwilo, Enumerator Stephano Matheo Madundo, Enumerator Kimola Maganga, Enumerator Masasi Shija Masenga, Enumerator Catherine N Shabani, Enumerator Amos Kanyesu Maganga, Enumerator Paul Kasidi Mbuke, Enumerator Elias K Kadamila, Enumerator Julaeli Msai Timoth, Enumerator Patrick M Masunga, Enumerator Joseph D Kidai, Former Driver Alex Mtabika, Driver Kigoma Ujiji/Western/Small urban sentinel site Alcuin Ndungwi, Town Executive Director Dr Shaban Mkoko, District Medical Officer Mwailwa Pangani, Accountant

Thomas L Ndayanse, DSS Coordinator Eliezer N Rusota, VA Supervisor Malimi K Ntemiseni, VA Supervisor John Bilatata, VA Interviewer Neema J Mwangoka, VA Interviewer Richard H Juma, VA Interviewer Alfred Katunzi, VA Interviewer Mhanuzi D Mhanuzi, VA Interviewer Frank F Mputa, VA Interviewer Sunday Rajabu Toyi, Enumerator Nuru Sadiki Bashange, Enumerator Kassimu Issa Mnee, Enumerator Shabani Magera, Enumerator Mussa Idd Kafungo, Enumerator Moshi Hamisi Mao, Enumerator Tofiki Haruna Tofiki, Enumerator Juma Ibrahimu Ntulagara, Enumerator Mwajuma Kilibila Kengwa, Enumerator Zuberi Seleman Kaongo, Enumerator Bondo Maulid Bondo, Enumerator Njuji Jafari Nguge, Enumerator Malilo Hamisi Malilo, Enumerator Juma Said Amani, Enumerator Abasi Mrombo, Enumerator Twaha Omari Kifungo, Enumerator Abeid Bilali Mafumo, Enumerator Athuman Bilenge Kinje, Enumerator Shaban Bonifas, Driver University of Newcastle upon Tyne Scientific Advisory Group Prof Anne Mills Dr Adeline Kimambo Prof Basia Zaba Dr Daniel Chandramohan Prof Hans Rosling Dr Lara Wolfson Verbal Autopsy Validation team and Coders Dr Hamisi Mponezya, Coder Dr R Kutaga, Coder Late Dr K Mchatta, Coder Dr A Moshi, Coder Dr F Mugusi, Coder Mohamed Irema, VAV FBA Manager Ms Grace Massawe, VAV Interviewer Ms Lucie Adagi, VAV Interviewer Gulamhussein Ismail Kilasama, VAV Interviewer Hussein Mkwawa, VAV Interviewer Grace Moshi, VAV Interviewer Ephrem Mapunda, VAV Interviewer Matilda Mrawa, VAV Interviewer


Emiliana Assenga, VAV Interviewer David A Kalamule, VAV Interviewer Cenan P Ukugani, VAV Interviewer Dr Jesca Rwebangila, Coder Dr Nazma Dharsee, Coder Dr Adam Juma, Coder Dr Lawrence Lekashingo, Coder Dr Joyce Maswi, Coder Dr Protas Ndayanga, Coder Dr Dafrosa Lyimo, Coder Dr Sylvia Mamkwe, Coder Dr Hilary Ngude, Coder Dr Alphonsina Nanai, Coder Dr Grace Shayo, Coder Dr Olyvia Rusizoka, Coder, Dr Angela Lyimo, Coder Dr Ibrahimu Mteza, Coder Dr Amos Kahwa, Coder

Dr Rugola Mtandu, Coder Dr Ramadhani Abdallah, Coder Dr Vera Juma, Coder Dr Michael Emilian, Coder Dr Annette Almeida, Coder Dr Esther Ngadaya, Coder Dr Erick Aris, Coder Dr Sajida Julius, Coder Dr Fadhlun Mohamed, Coder Dr Jamhuri Kitange, Coder Dr E Mdachi, Coder PriceWaterhouseCoopers Project Management Support Mabel Shuma Shane Barker Charlotte Wedd Farida Hussein

About the Photographs and Personal Narratives Since 1992, day in and day out, field workers participating in sentinel mortality surveillance visited the houses of more than 50,000 people who lost parents, children, spouses, relations, and friends. We have all been transformed by the experiences of listening to the loss and suffering of others, knowing that in so many cases this loss was possibly avoidable. We have used photographs and narratives on the dividing pages between Parts 1, 2, and 3 in this volume to evoke reflection on the part of readers about the human faces and voices behind all of these statistics. The individuals who appear in the photographs used in this publication all gave permission for their images to be used in a research report. When children were photographed, permission was obtained from parents. The personal narratives that appear on the same pages as the photographs are adapted from the verbal autopsy histories collected by AMMP since 1992. The narratives in no way refer to the individuals depicted in the photographs.


From the Assistant Director-General, Evidence and Information for Policy World Health Organisation Just as the doctor lives by the motto ‘know thy patient’ so too must the public health practitioner adhere to the equivalent ‘know thy population.’ Unfortunately, in many parts of the poor world today, we in public health do not know our populations nearly well enough. This is especially the case in Africa where vital events including births and deaths are not registered in any systematic way in the majority of countries. The sad implication of this is that where people are not counted, it is clear that their lives are also not valued: “they don’t count.” All is not bleak however, and this book is built on an intrepid and critically important public health pioneering effort to “know thy population” in Tanzania starting in the early 1990s under the visionary leadership of the late Professor DG McLarty. Based on the outstanding need to develop an understanding of the population’s health in Tanzania, Professor McLarty and colleagues established the AMMP—a health information system to capture vital events, health states and socio-economic conditions of the population in discrete but distinct regions of Tanzania. The sustained efforts over a decade have resulted in invaluable insights into the population’s health in Tanzania that are found in this volume. The findings of distinct mortality and cause of death patterns both between and within districts has helped to illuminate the nature of health challenges for health policy and programming in Tanzania. More importantly, perhaps, is that the manner in which the AMMP operated has engendered a strong sense of local ownership and understanding of these data thus fostering a strong connection between the generation of evidence and its translation to knowledge that guides policy and action. As such, the AMMP initiative and this book represent a major contribution to the population health in Africa.

Dr Tim Evans Assistant Director-General Evidence and Information for Policy WORLD HEALTH ORGANIZATION


List of Abbreviations AMMP-2 ANC CEP CHMT CSPD CWIQ DALY DANIDA DFID DHS DSS EA EPI HERA HMIS IDS IDWE IHDRC IMCI LGRP M&E NACP NBS NHBS NIMR NMS NSS PMMP PORALG PSU SAVVY SES SRS TACAIDS TANESA TEHIP TSh YLL

Adult Morbidity and Mortality Project, Phase 2 Antenatal clinic Consumption Expenditure Proxy Council Health Management Team Child Safety, Protection, and Development Core Welfare Indicators Questionnaire Disability Adjusted Life Year Danish Agency for Development Assistance UK Department for International Development Demographic and Health Surveys Demographic Surveillance System Enumeration Areas Expanded Program on Immunization Health Research for Action Health Management Information System Integrated Disease Surveillance Infectious Disease Week Ending Ifakara Health Development and Research Centre Integrated Management of Childhood Illness Local Government Reform Program Monitoring and evaluation National AIDS Control Programme National Bureau of Statistics National Household Budget Survey National Institute for Medical Research National Master Sample National Sentinel System Poverty Monitoring Master Plan President’s Office of Regional Administration and Local Government Primary Sampling Units Sample Registration with Verbal Autopsy Socio-economic status Sample Registration System Tanzania Commission for AIDS Tanzania and Netherlands Support AIDS Research Center Tanzania Essential Health Interventions Project Tanzania Shillings Year of Life Lost


The Policy Implications of Tanzania’s Mortality Burden: Introduction Accurate statistics on basic demographic events are the EXECUTIVE SUMMARY foundation of rational health and public policy. Tanzania is one country where an awareness of the mounting need for information is acutely felt. In 1999 the Ministry of Health launched a five-year second phase of the Adult Morbidity and Mortality Project (AMMP) in partnership with the University of Newcastle upon Tyne and with increased support from DFID. This report documents and summarises the accomplishments and lessons learned from the second project phase. Accurate statistics on basic demographic events are the BACKGROUND TO THE foundation of rational health and public policy. The need for AMMP FINAL REPORT reliable, frequently-updated statistics is rapidly increasing. For example, 189 countries have accepted the Millennium Development Goals as a framework for poverty reduction and sustainable development. Most countries lack the data that are urgently required to measure progress toward these goals at the country level. In addition, data are needed to evaluate progress in health sector reforms and the impact of poverty-reduction initiatives at the sub-national level. Unfortunately, reliable vital registration is lacking for the vast majority of the world’s poorest countries. In Sub-Saharan Africa, for example, only four countries have vital registration systems that produce data considered usable by WHO [1]. In particular, data on both the number and causes of deaths in developing countries are virtually non-existent. Although the picture has been improving for infant and child mortality, reliable information on adult mortality levels, let alone causes, continues to be virtually non-existent. Tanzania is one country where an awareness of the mounting need for such information is acutely felt and where some new approaches to meeting this need have been pioneered. These efforts have centred on the development of new methods for and applications of demographic surveillance systems and the data they produce. (See Box 1.) In 1992 the Ministry of Health established the Policy Implications of Adult Morbidity and Mortality Project (AMMP-1) in partnership with the Muhimbili University College of Health Sciences and the University of Newcastle upon Tyne, with funding from the UK Department for Volume 1: A Ten-Year Community-Based Perspective 23

Box 1. What is a Demographic Surveillance System? A demographic surveillance system, or DSS, is generally defined as the ongoing and complete enumeration of vital events, including births, deaths, and in- and out-migrations in a geographicallydefined population. Monitoring of population health outcomes, such as causes of death, poverty conditions, or incidence and prevalence of particular diseases of public health importance usually complements the demographic baselines produced in DSS. Tanzania has the most DSS sites in Africa (eight), and the five sites supported by AMMP comprise the largest DSS in Africa. Conventionally used as platforms for intervention research, DSS sites have started to make unique contributions in the areas of health sector reform and poverty monitoring.

International Development (DFID).1 The initial project purposes were to establish baseline data on levels and causes of adult mortality in three selected districts, to inform health policy and priority setting, and to inform the implementation of cost-effective interventions on the leading causes of the burden of disease. In order to provide the evidence base for these objectives, AMMP developed a set of methods for conducting demographic surveillance, ‘verbal autopsy’ tools for determining the cause structure of mortality at the community level [2-5], and a validated tool to monitor income poverty conditions [6]. AMMP-1 concluded in 1997. During this period, it had become the major source of community-based mortality information in the country and had begun to influence major health policy initiatives including the first National Package of Essential Health Interventions [7], a change in Ministry of Health policy for malaria chemotherapy, and the scaling up of the social marketing of insecticide- treated bed nets for malaria prevention. The findings of the first three years of the project were published in The Policy Implications of Adult Morbidity and Mortality End of Phase 1 Report [8]. In 1999, the Ministry of Health launched a five-year second phase of AMMP in partnership with the University of Newcastle upon Tyne and with increased support from DFID. The objectives of AMMP-2 included improving the national representativeness of data by expanding DSS to a greater number of districts; supporting the Ministry of Health to establish a National Sentinel System for Health and Poverty Monitoring based on DSS in the Department of Policy and Planning; and facilitating Districts to make best use of the information generated by DSS. In addition, the project was to disseminate information and tools to key users in Tanzania both inside and outside of the Ministry of Health to international audiences.


This report documents and summarises the accomplishments STRUCTURE OF and lessons learned from the second project phase. Volume 1 THE REPORT takes into account the specific need for policy-relevant information and indicators of population health and survival in several contexts including: • A renewed emphasis on statistics, cost-effective information systems, and the use of information for policy, planning, monitoring, and evaluation; • The needs of a decentralized health system for ‘userfriendly’ information that can inform and facilitate action; • The fundamental link between poverty reduction and health and the imperative to ensure that needs of the least well off members of society are reaching the eyes and ears of decision-makers; and • The increasing awareness of the importance of understanding the health situation of adults in Tanzania. Volume 2 collects many of the publications produced by or in association with AMMP since its inception in 1992. These publications have been some of the most important outputs of the project. Volume 3 represents a compendium of the methods and tools developed in AMMP over more than a decade. It also includes validations of the methods. This volume is intended to aid those who may wish to adopt or adapt AMMP methods to other settings and to provide documentation of the development, validity, and performance of these tools in the field. Volume 4 contains annual mortality burden profiles for each sentinel area for the years 1994-2002. The profiles were developed to aid Council Health Management Teams (CHMTs) in the annual production of comprehensive council health plans. The documents seek to inform council health planners about (a) the extent of the mortality burden that might be addressed by proven and available interventions and intervention packages, and (b) which intervention packages correspond to high levels of addressable mortality. It is our hope that the legacy of AMMP-2, including this report, the skills transferred, and the systems now handed over fully to our partners in local and national government will contribute to the larger goal that guided the second phase of the project: To decrease morbidity and mortality in Tanzania from conditions that are particularly likely to cause suffering and disadvantage to poor people, and are amenable to health service interventions.


NOTES

1

For more information about AMMP, please visit the project

website at http://www.ncl.ac.uk/ammp

REFERENCES

1. Mathers, C., Inoue, M., Lopez, A., et al., Overview of Global Mortality Data Sources. 2003, Evidence and Information for Policy, World Health Organization: Geneva. 2. Mswia, R., Whiting, D., Kabadi, G., et al., Hai District Demographic Surveillance System, in Population and Health in Developing Countries. Volume 1: Population, Health, and Survival in INDEPTH Sites, The INDEPTH Network, Editor. 2002, International Development Research Centre: Ottawa. p. 151158. 3. Mswia, R., Whiting, D., Kabadi, G., et al., Morogoro Rural Demographic Surveillance System, in Population and Health in Developing Countries. Volume 1: Population, Health, and Survival in INDEPTH Sites, The INDEPTH Network, Editor. 2002, International Development Research Centre: Ottawa. p. 165172. 4. Mswia, R., Whiting, D., Kabadi, G., et al., Dar es Salaam Demographic Surveillance System, in Population and Health in Developing Countries. Volume 1: Population, Health, and Survival in INDEPTH Sites, The INDEPTH Network, Editor. 2002, International Development Research Centre: Ottawa. p. 143150. 5. National Sentinel Surveillance System, Report of Workshop on Drafting Core Verbal Autopsy Tools for use by sites contributing mortality data to the NSS. 2001, Department of Policy and Planning, Ministry of Health, United Republic of Tanzania: Dar es Salaam, Tanzania. 6. Abeyasekera, S. and Ward, P., Models for Predicting Expenditure per Adult Equivalent for AMMP sentinel surveillance sites. 2002, Adult Morbidity and Mortality Project, Tanzanian Ministry of Health: Dar es Salaam. 7. National Package of Essential Health Interventions in Tanzania. 1998, Ministry of Health, United Republic of Tanzania: Dar es Salaam. p. 1-24. 8. Ministry of Health and AMMP Team, The Policy Implications of Adult Morbidity and Mortality. End of Phase 1 Report. 1997, United Republic of Tanzania: Dar es Salaam. 9. Binka, F., Ngom, P., Phillips, J., et al., Assessing population dynamics in a rural African society: the Navrongo Demographic Surveillance System. Journal of Biosocial Science, 1999. 31(3): p. 375-391. 10. Tollman, S.M. and Zwi, A.B., Health system reform and the role of field sites based upon demographic and health surveillance. Bulletin of the World Health Organization, 2000. 78(1): p. 125-134.


PART I The Information Environment in Tanzania, 1997– 2003 For three days my child seemed confused … he had a high fever and a terrible headache. We took him to the hospital. They gave him a quinine drip and a transfusion, but it was too late. His condition worsened …

1 The Purpose of AMMP-2: Health and Demographic Information Systems in Tanzania, 1997–2003

EXECUTIVE SUMMARY The Adult Morbidity and Mortality Project, Phases 1 and 2, has helped to heighten awareness in Tanzania of the importance of community-based data on survival and cause-specific mortality for health policy and planning. The project’s second phase (AMMP-2) was undertaken to consolidate these accomplishments and to help the Ministry of Health and local councils to establish, manage, and utilise a permanent information system for the continued production of reliable information on disease burdens, mortality, and poverty. The aims of AMMP-2 were to enhance capacity for data collection, management, analysis, and use at the district and ministry levels; disseminate information and tools to key users; and deliver to the Ministry of Health and district partners validated and consolidated tools for establishing and operating sentinel demographic and mortality surveillance. While rooted in the health sector and health sector reform, AMMP-2 was one of several initiatives in Tanzania to improve the quality of information and its use over the past five years. As of 2003, fifteen different systems operated under four different government offices, ministries, and the National Bureau of Statistics (NBS). Given that other information systems are facility-based, AMMP’s main contribution in the health sector has been to produce reliable, longitudinal, community-based, cause-specific mortality data, to link these to poverty measures, and to participate in the evaluation of major intervention initiatives such as the social marketing of insecticide-treated bed nets, the integrated management of childhood illness, and the safe motherhood initiative. Outside the health sector, the data produced by local councils and the Ministry of Health through AMMP has complemented other routine and administrative data sources in monitoring the national poverty reduction strategy, contributes to local government reform monitoring and evaluation, and is in the process of being incorporated into the information strategy of the Tanzania Commission for AIDS (TACAIDS).


KEY POINTS ■

■

■

■

■

■

■

AMMP has helped to heighten awareness in Tanzania of the importance of community-based data on survival and cause-specific mortality for health policy and planning. AMMP-2 assisted the Ministry of Health and local councils to establish, manage, and utilise a permanent information system for the continued production of reliable information on disease burdens, mortality, and poverty. The aims of AMMP-2 were to enhance capacity for data collection, management, analysis and use at the district and ministry levels; disseminate information and tools to key users; and deliver to the Ministry of Health and district partners validated and consolidated tools for establishing and operating sentinel demographic and mortality surveillance. AMMP had its roots in Tanzania’s health sector reform process and contributed to the needs of decentralized planning at the district level and evidence-based policy at the Ministry of Health. The main contribution of AMMP in the health sector has been to produce reliable, longitudinal, community-based cause-specific mortality data, to link these to poverty measures, and to participate in the evaluation of major intervention initiatives such as the social marketing of insecticide-treated bed nets, the integrated management of childhood illness, and the safe motherhood initiative. Outside the health sector, a National Poverty Monitoring Master Plan (PMMP) was created to assess the country’s progress toward the goals of the poverty reduction strategy. The PMMP articulates a vision for the production, dissemination, and use of information. The network of linked DSS sites developed under AMMP was incorporated into this strategy. Other countries, including Indonesia, Egypt, and Brazil are assessing the possibilities for implementing variants of an AMMP-type system and cause-specific mortalitysurveillance in particular.

The first phase of the Adult Morbidity and Mortality Project GOALS OF AMMP-2 (AMMP-1) was implemented from 1992 to 1997 and helped to heighten awareness in Tanzania of the importance of community-based data on survival and cause-specific mortality for health policy and planning [1]. The data generated by AMMP-1, which focussed primarily on adult health, had never before been available to policy makers in Tanzania. The lessons learned from phase one were seen as a crucial complement to other information sources at both the national and district levels, and began the process of establishing a ‘sentinel’ demographic and mortality surveillance system for Tanzania to produce long-term reliable data. The project’s second phase (AMMP-2) was undertaken to consolidate these accomplishments and to facilitate the Ministry of Health and local councils to establish, manage, and utilise a permanent information system for the continued production of community-based information on disease burdens, mortality, and poverty. This chapter explains the goals of the AMMP-2, describes the context of national and district-level information systems in which the second phase was implemented, and positions it in relation to other information sources—in particular for monitoring and evaluation—in Tanzania. Volume 1: A Ten-Year Community-Based Perspective 29

In the past five years the demand for high-quality information has increased at all levels in Tanzania. AMMP-2 was implemented in the context of numerous reform efforts to meet this demand and had input into many of them. The overall project goal was to contribute to evidence-based, equitable health care and development in Tanzania, with a focus on diseases particularly likely to cause suffering among the poorest members of society. This was to be accomplished by facilitating the Ministry of Health to establish a sustainable sentinel system for the long-term production of reliable community-based disease and mortality burden information through the techniques of sentinel demographic and mortality surveillance. (See Box 1.1.) The specific outputs of AMMP-2 were to: (1) Enhance capacity and sustainability for data collection, management, analysis, and use at the district level; (2) Facilitate the Ministry of Health to establish capacity to operate a permanent information system in partnership with local councils, based on techniques of demographic surveillance developed under AMMP; (3) Disseminate information and tools to key users both in and outside the health sector, and both nationally and internationally; and (4) Deliver to the Ministry of Health and district partners validated and consolidated tools for establishing and operating sentinel surveillance.

THE CONTEXT OF First and foremost, AMMP had its roots in Tanzania’s health INFORMATION NEED sector reform process. This reform has been built on a set of related propositions, namely: • Decentralization of planning to district councils and council health management teams supported by evidence-based policy guidance from the Ministry of Health, which will lead to; • Greater accountability of council health services to the populations they serve, which will lead to; • Improved health services and improved health status of the population. Information for planning, policy development, monitoring, and evaluation underpin all these facets of health reform at the community, district, regional, and national levels. AMMP-2, however, was just one of several initiatives in Tanzania to improve the quality of information and its use. In order to understand the project’s role in health development, then, it is necessary to consider the context of information need in which


Box 1.1 Sentinel Demographic & Mortality Surveillance in Tanzania The purpose of sentinel surveillance is to use data collected in a set of carefully selected sites, representing different strata of the population, to gain an estimate of the extent of the burden of disease and poverty conditions for use in district-level planning and for national policy, planning, monitoring, and evaluation. Sentinel surveillance is not new in Tanzania. It is a tool used by the Ministry of Health in disease-specific systems such as those for HIV prevalence in women attending antenatal clinics and malaria drug resistance. In agriculture, sentinel sites are used to detect food scarcity and to monitor the prevalence of insect infestations. Surveillance of cause-specific mortality will allow the Ministry of Health to estimate the largest portion (about 80 percent) of the burden of disease. In implementing sentinel demographic surveillance, Tanzania is joining other countries such as China and India where a variety of approaches are used to obtain a better understanding about levels and causes of mortality. In fact, both the Chinese and Indian systems have drawn upon the work of AMMP in refining their methods of cause-specific mortality surveillance. Sentinel mortality surveillance in Tanzania has the following advantages: • Useful for monitoring trends in the prevalence of mortality due to the most important causes (e.g. HIV/AIDS, malaria, respiratory and diarrhoeal infections, injuries and accidents, and certain noncommunicable diseases); • Provides reliable estimates for small geographic areas and so reveals the diversity of health conditions in Tanzania; • Complements facility-based information from sources like the Health Management Information System (HMIS); and • Avoids the need to establish surveillance in all parts of the country, which would be prohibitively expensive. Information from sentinel sites can be used in a variety of ways. At the district level, Council Health Management Teams can use district ‘mortality burden profiles’ from the sentinel sites that they most closely resemble to aid in the annual planning process. At the national level, data from different sites can be compared and contrasted to show the diversity in health and poverty conditions in the Tanzanian population. A sentinel vital registration system can be a valuable and cost-effective complement to routine health information systems, surveys and censuses. There is ample scope for the adaptation of these proven tools and techniques to other national and regional contexts. They would be particularly useful in settings where routine vital registration has not reached a high enough level of coverage to provide accurate data about the numbers of births, deaths, and causes of death in the population.

the project operated. This context consisted of information systems and structures and practices relating to the production, dissemination, and use of data on health and poverty for the purposes of monitoring, evaluation, planning, and policy formulation. Information demand and use have been changing at all levels in Tanzania—from the national to the district level. They have


developed particularly rapidly since the early to mid-1990s. Table 1.1 lists the major government reform efforts that rely on demographic and health information for M&E and the government bodies responsible for them. While some of the impetus for evidence-based reform has come from multi- and bilateral donors and the programmes and initiatives they support, Tanzanian institutions have been proactive in setting the pace of reform and shaping the process. Several government sectors and civil society groups now have discrete strategies for the sustained use of high quality information. By engaging in this process, AMMP responded to the needs for health and population data in Tanzania and to new demands for povertymonitoring data. Table 1.1 Reform Efforts Requiring Monitoring and Evaluation and Government Bodies Responsible Reform Effort Health Sector Reform Local Government Reform Poverty Reduction Strategy Tanzania AIDS Commission

Routine M&E Activity Health Statistics Abstract, Public Health Sector Performance Profiles LGRP Monitoring & Evaluation Programme Poverty Monitoring Master Plan TACAIDS Monitoring & Evaluation Programme

Government Body Ministry of Health President’s Office of Regional Administration and Local Government Vice President’s Office/ National Bureau of Statistics (as convener) Prime Minister’s Office

Table 1.2 lists the major information systems operated by the Tanzanian government that are sources of health and demographic data and indicators.1 As of 2003, fifteen different systems were operating under four different government offices, ministries, and the National Bureau of Statistics (NBS). The Ministry of Health houses nine of these systems, while NBS has been in charge of the three nationally representative household surveys, plus the national census. Tanzania’s civil and vital registration is located in the Ministry of Justice and Constitutional Affairs, and a system of village demographic registers sponsored largely by UNICEF is present in several districts under the auspices of the President’s Office of Regional Administration and Local Government. Within the health sector, information systems are divided primarily between the departments of Policy and Planning and Preventive Services. The latter manages the Infectious Disease Week Ending reports; Tuberculosis/Leprosy; HIV/STD/AIDS; Acute Flaccid Paralysis/Poliomyelitis; and the planned Integrated Disease Surveillance system (IDS). The former houses the Health Information and Research Section. This section contains the Health Management Information System (HMIS) and the nascent National Sentinel System


Table 1.2 Health and Demographic Information Systems in Tanzania and Key Characteristics Information system National Housing and Population Census National Household Budget Survey Demographic and Health Survey Labour Force Survey Village Register Vital Registration Infectious Disease Week Ending TB/Leprosy Sentinel HIV surveillance Integrated Disease Surveillance Health Management Information System NSS: Ifakara Demographic Surveillance System NSS: Rufiji Demographic Surveillance System NSS: Adult Morbidity and Mortality Project – Phase 2 NSS: Demographic Surveillance System at Tanzania and Netherlands Support AIDS Research Centre

Government Body or Ministry National Bureau of Statistics National Bureau of Statistics National Bureau of Statistics National Bureau of Statistics President’s Office of Regional Administration and Local Government Ministry of Justice and Constitutional Affairs Ministry of Health Ministry of Health Ministry of Health Ministry of Health Ministry of Health Ministry of Health

Year Established 1967 1991/2 1991 1985 1979 1999 1986 1987 2002 1993 1996

Ministry of Health

1998

Ministry of Health

1992

Ministry of Health

1994

(NSS) of linked demographic surveillance sites for health and poverty monitoring. It also houses the Health Systems Research Unit. These systems have been positioned to serve the reform agenda in a number of ways. Some, such as the HMIS and AMMP and the emerging IDS system have emphasised both district and national-level data collection, analysis, and use. Others, such as the surveillance operated under the National AIDS Control Program and the TB and Leprosy control programme, have remained more centralised and focussed on national-level monitoring and evaluation to inform policy, practice, and national indicators and targets. In 1998, five systems for infectious disease reporting were reviewed for performance and response [2, 3]. Assessments were conducted in three regions at the regional, district, and health facility levels. The exercise revealed common constraints and issues of implementation experienced by health information systems in many developing countries. These included: fragmentation of activities along ‘vertical programme’ lines, inadequate levels of core and support activities at all levels, and low levels of data analysis and use. At the same time, these systems were generally well supplied with forms and registers; had good levels of training; had adequate laboratory facilities; and conducted outbreak investigation [3, p 200]. The advantages of joining many of the vertical systems into the IDS were recognised.


A review of the HMIS and AMMP in 2000 [4] lent further support to an overall health information strategy aimed at streamlining data sources and collection efforts and building on the complementarities of facility community-based information systems. The mid-term review of AMMP re-emphasised the importance of community-based health outcome data collected through sentinel sites in Dar es Salaam (Temeke and Ilala Municipalities), East-Central Tanzania (Morogoro District, Morogoro Region), and Northern Tanzania (Hai District, Kilimanjaro Region) NSS [5]. The review encouraged a careful approach to the sampling and selection of additional sentinel districts. Given that other information systems are facilitybased, AMMP’s main contribution in the health sector has been to produce reliable, longitudinal, community-based causespecific mortality data, to link these to poverty measures, and to participate in the evaluation of major intervention initiatives such as the social marketing of insecticide-treated bed nets, the integrated management of childhood illness, and the safe motherhood initiative [6]. Outside the health sector, major monitoring and evaluation (M&E) efforts are being put in place that draw in indicators and information produced by some or all of the systems listed in Table 1.1. Most of these are multi-sectoral programmes, such as the Poverty Reduction Strategy and the Poverty Monitoring Master Plan (PMMP) [7]. In 1999 and 2000, Tanzania joined a growing group of nations receiving debt relief under the Heavily Indebted Poor Countries/Poverty Reduction Strategy Paper process of the multilateral lenders [8]. A National Poverty Monitoring Master Plan (PMMP) was created to assess the country’s progress toward the goals of the poverty reduction strategy. The PMMP articulates a vision for the production, dissemination, and use of information. While the PMMP focuses largely on charting progress at the national level in priority sectors (including health), it also speaks to the relationship of national M&E and information production to the increasing needs of districts. The plan points out that the impact of existing investments generation in Tanzania was limited by several factors including: • Lack of coordination in information generation; • Poor communication between data producers and consumers; • Long delays between collection, analysis, and dissemination of data; and • Insufficient use by policy and decision makers. In order to bring about an improvement in this situation, the PMMP proposed a framework built upon existing information 34 The Policy Implications of Tanzania’s Mortality Burden: AMMP-2 Final Report

systems. This framework calls for national surveys to generate statistical information at the national and (occasionally) subnational levels; administrative data from local government, sectoral ministries, and sentinel sites to produce more detailed sub-national data for comparison with national survey results; and in-depth research and analysis to provide explanations for trends. Within the PMMP framework, the network of linked DSS sites developed under AMMP was located in the ‘routine and administrative data sources’ working group. This technical working group is comprised of information systems operated through line ministries as part of their routine and administrative functions for M&E, policy, and planning. Substantial investments have been made in the development of routine health management information systems [9], and administrative data sources at the local level where bottom-up participatory planning has become a sine qua non of the ongoing Local Government Reform [10, p 2]. National surveys such as the Demographic and Health Surveys [11-14] have also become integrated into the national Poverty Monitoring Master Plan (PMMP). The planned National Sentinel System for monitoring the burden of disease based on linked demographic surveillance sites [15] is also part of this vision. Aside from the PMMP, two other major M&E programmes outside the health sector rely on the types of health and demographic data produced by demographic surveillance: the Local Government Reform Programme and TACAIDS. Local Government Reform seeks to monitor progress in many processes of local governance but also defines successes in terms of having a positive impact on indicators of health and survival. Similarly, TACAIDS tracks inputs and outputs in preventing wider spread of HIV and mitigating the impact of AIDS, but it also relies on outcomes such as measurable behaviour change, HIV incidence and prevalence in sentinel populations, and AIDS-related mortality.

Within the context of these initiatives and the information systems they rely on for M&E and planning, sentinel DSS data complement other sources in a number of important ways. As noted above, the Ministry of Health recognises that resources going into the production of health information need to be rationalised, and that community-based data is a vital part of the overall picture. Preliminary proposals for a minimum health information package point in this direction [16]. As Figure 1.1 shows, sentinel systems (including those based on the linking and coordination of DSS sites in Tanzania), form part of a three-pillar information system.

THE RELATIONSHIP OF AMMP-2 TO OTHER INFORMATION SOURCES


Figure 1.1 Minimum Health Information Package, Ministry of Health

The poverty monitoring strategy is comprised of four technical working groups (Figure 1.2): censuses and surveys; routine and administrative data sources; research and analysis; and dissemination. As mentioned above, AMMP and the NSS are part of the routine and administrative working group under the President’s office of Regional Administration and Local Government. The PMMP views routine data sources as central to poverty monitoring for two main reasons: they provide data at regular intervals that are usually shorter than most repeated surveys; and coverage of most of these systems is high enough to allow disaggregated analysis at the district or ward level [7, p 34]. These advantages, however, are set against some significant shortcomings in data quality, reporting, and coordination. A total of 29 poverty-monitoring indicators are produced by routine systems, of which six are contributed by AMMP [7, p 35]. Figure 1.2 Structure of Poverty Monitoring and Technical Working Groups


The Local Government Reform Programme is establishing its own local system for M&E and planning, while seeking to address some of the weaknesses of existing routine systems. In doing so, the government is seeking to ensure that only the most essential data are collected and that they are well managed, analysed, and used at the local level. Information on population structure, growth, and size is part of this essential knowledge base, and the reform programme has looked to AMMP and other sources as a way of cross-comparing registration systems that, to date, have not produced reliable population information [17]. AMMP and the NSS are also part of the M&E plans of TACAIDS in monitoring national progress in confronting the HIV epidemic in Tanzania. In this context, demographic surveillance sites can provide key outcome indicators about the AIDS-related mortality burden [18], as well as serve as a platform for monitoring and measuring behaviour change.

Since the end of the project’s first phase, AMMP has been one of the primary sources of community-based demographic and health information and the main source of cause-specific mortality data for Tanzania. The primary mission of the second project phase has been to ensure that the Tanzanian government would have capacity to manage, maintain, expand, and utilise a National Sentinel System of linked demographic surveillance sites. Sample registration systems, which are related to sentinel demographic surveillance, already play an important role in countries such as China and India. Other countries, including Indonesia, Egypt, and Brazil are assessing implementing variants of such systems, and cause-specific mortality surveillance in particular (A Lopez: personal communication). The mortality surveillance tools used in these other settings are likely to rely heavily upon the core techniques developed by the Tanzanian Ministry of Health. Although AMMP has been based in the health sector and in health sector reform, it has also contributed to other, multi-sectoral reform efforts where health, demographic, and poverty data are required for M&E and policy. Those who are designing the information systems for all of these reform efforts have recognised the value of the nascent NSS and have built their information plans taking it into account. 1

Surveys repeated periodically on a multi-year cycle (e.g. the Demographic and

CONCLUSIONS

NOTES

Health Surveys) were considered to be information systems.

1.

Ministry of Health and AMMP Team, The Policy Implications of Adult Morbidity and Mortality. End of Phase 1 Report. 1997, United Republic of Tanzania: Dar es Salaam.

REFERENCES


2.

3.

4.

5.

6.

7. 8. 9.

10.

11.

12.

13.

14.

15.

Brown, W., Nsubuga, P., and Eseko, N., Assessment of Infectious Disease Surveillance Systems in Tanzania. 1999, Ministry of Health, United Republic of Tanzania; World Health Organization; U.S. Centers for Disease Control and Prevention and the Environmental Health Project: Dar es Salaam. Nsubuga, P., Eseko, N., Tadesse, W., et al., Structure and performance of infectious disease surveillance and response, United Republic of Tanzania, 1998. Bulletin of the World Health Organization, 2002. 80(3): p. 196-203. Health Research for Action, Review of Health Management of Information System (HMIS/MTUHA) and Adult Morbidity and Mortality Project (AMMP). 2000, Health Research for Action (HERA): Reet. Rosling, H., Mshinda, H., Mdoe, M.R., et al., Adult Morbidity and Mortality Project-2. Output to Purpose Review. 19-28 August. 2001, Ministry of Health: Dar es Salaam. Mswia, R., Lewanga, M., Moshiro, C., et al., Community-based Monitoring of Safe Motherhood in the United Republic of Tanzania. Bulletin of the World Health Organization, 2003. 81(2): p. 87-94. United Republic of Tanzania, Poverty Monitoring Master Plan. 2001, Dar es Salaam: Government Printers. United Republic of Tanzania, Poverty Reduction Strategy Paper (PRSP). 2000: Dar es Salaam (Government Printers). Ngatunga, S.E. A Brief on the Role of the HMIS in the Implementation of Health Sector Reforms in Tanzania. Paper presented at Workshop on Lessons Learned in Health Sector Reform. 1998. Bagamoyo, Tanzania: Ministry of Health, Policy and Planning Division. JICA, Assessment of Data Collection System(s) and Use in Planning at Regional, Council and Sub-Council Levels. 2002, Japan International Cooperation Agency ( JICA):Dar es Salaam. Bureau of Statistics [Tanzania] and Macro International, Tanzania Demographic and Health Survey 1991/1992. 1993, Dar es Salaam and Calverton (MD): Bureau of Statistics and Macro International. Bureau of Statistics [Tanzania] and Macro International, Tanzania Demographic and Health Survey 1996. 1997, Dar es Salaam and Calverton (MD): Bureau of Statistics and Macro International. Weinstein, K.I., Ngallaba, S., Cross, A.R., et al., Tanzania Knowledge, Attitudes and Practices Survey 1994. 1995, Dar es Salaam: Bureau of Statistics, Planning Commission, United Republic of Tanzania. Bureau of Statistics [Tanzania] and Macro International Inc, Tanzania Reproductive and Child Health Survey 1999. 2000, National Bureau of Statistics and Macro International Inc.: Dar es Salaam, Tanzania & Calverton, MD. Adult Morbidity and Mortality Project and National Sentinel Surveillance Teams (Tanzanian Ministry of Health). Toward a National Sentinel Surveillance System for Health and Poverty Monitoring in Tanzania. Paper presented at American Public


Health Association Annual Meetings. 2001. Atlanta. 16. Health Information and Research Section, Stakeholders Consultative Meeting on the Development of a Minimum Package of Health Information, Moshi. 2001, Department of Policy and Planning, Ministry of Health, United Republic of Tanzania: Dar es Salaam. 17. Kobb, D., Piloting a National Monitoring and Evaluation System. Version Two. 2000, Urban Authorities Partnership Programme and Local Government Reform Programme: Dar es Salaam. 18. Clark, S., Setel, P., Kahn, K., et al. The Role of AIDS/TB in Mortality Patterns in East and Southern Africa: Evidence from Four Demographic Surveillance Sites. Paper presented at Empirical Evidence for the Demographic and Socio-economic Impacts of AIDS. 2003. Durban, South Africa


2 Costs and Results of Information Systems for Health Sector Reform, Poverty Monitoring, and Local Government Reform in Tanzania

EXECUTIVE SUMMARY 1 There is a growing demand for new knowledge about the costeffectiveness of information systems in Tanzania. Donors, government, and national programme managers are becoming increasingly knowledgeable consumers of data- and information-generation tools for monitoring and evaluation (M&E). In order to aid in the use of scarce M&E resources, it would be helpful to have an understanding of what returns an investment in any of the various M&E methodologies might be likely to bring. Decision-making in this area is complex. Managers must be cognisant of the tradeoffs between total system costs, recurrent costs, quality of data, scope of indicator coverage, human capacity demands, frequency of indicator generation, level of data disaggregation, and costs denominated by the population benefiting from programmes being monitored or evaluated. In carrying out this investigation our overall aim was to better equip managers to make decisions about the use of new M&E assets or to assist them if they choose to reallocate existing human and financial resources. In doing so, we had three specific objectives. First, we sought to develop a methodology for assessing the comparative costs and results of the principal health and demographic information systems used to provide indicators for major M&E initiatives in Tanzania. Second, we sought to provide stakeholders with information for decisionmaking by assessing and comparing options for carrying out long-term M&E programmes in poverty reduction and health. Third, we hoped to stimulate further discussion on approaches for assessing the cost-effectiveness of information systems. This chapter presents a participatory assessment of the costs and results of Tanzanian information systems carried out in 2002/2003. The findings are based on cost and output data provided by 11 information systems in four government ministries, offices, and executive agencies. We collected data using questionnaires, face-to-face interviews with system managers, and field visits. Results were assessed in terms of a composite list of 38 health, demographic, and poverty indicators taken from the Poverty Monitoring Master Plan, Public Health Sector Performance Profile, District Health Plans, and Local


KEY POINTS Coverage of Health and Poverty Indicators ■ Ten of the 11 information systems included in the study generate routine indicators of health and poverty. ■ Most have had significant impact through research, analysis, and dissemination unrelated to M&E indicator production. ■ The current set of information systems can calculate all of the selected poverty and health indicators (save one) from published M&E guidelines for four major poverty reduction and reform programs. ■ Most indicators are available from multiple sources. ■ Half of the information systems in Tanzania collect 12 or more of the 38 required health, demographic, and poverty indicators. ■ The majority of systems use multiple quality assurance strategies to ensure data quality, regardless of differences in sampling and coverage. ■ Nine systems can provide local authorities with indicators, though coverage of these systems either across or within districts (other than the national census) is very limited. ■ Two systems are capable of generating indicators for the entire Tanzanian population, and four others can do so for the Tanzanian mainland. Comparative Costs ■ Estimates of the systems costs should be interpreted with caution, as it was not possible to obtain cost data of uniform type and quality from all systems, and capital costs were frequently unavailable. ■ The large national surveys had the highest per participant costs (up to $20), followed by the demographic surveillance systems (up to $3). ■ The annualized per capita costs for nine of 11 information systems were less than $0.10. ■ Based on the data collected for this study, approximately $0.53 in total is spent per year for every Tanzanian on information systems capable of generating poverty, health, and survival indicators needed for national programs of monitoring and evaluation. Relationship between Cost, Coverage, and Quality Assurance ■ Three systems have participating populations above 100,000 and costs below $1,000,000. Two of these produce national-level indicators. ■ Three systems have coverage below 100,000 and system costs of $1,000,000 or greater. One of these produces nationally representative indicators. ■ The census and the two facility-based routine systems all produce national estimates and have the highest participating populations along with the highest costs. Of these, the census has the most rigorous quality assurance procedures. ■ Five systems have samples of 100,000 or more and per participant costs of $1.00 or less. ■ Tanzania’s demographic surveillance systems and the Demographic and Health Surveys produce half or more of the required M&E indicators. DHS per participant costs are between six and 23 times higher than for demographic surveillance. ■ Five systems produce from zero to 12 indicators with per participant costs ranging from about $0.10 to about $0.60.


Government Reform Program. Findings were fed back to participants at a workshop and revisions to the assessment made on the basis of that activity. We hope that the comparative costs and results presented here may assist in any expansion or consolidation of information collection efforts.

BACKGROUND, AIMS, Background AND OBJECTIVES Demand for information is acutely felt at all levels in Tanzania.

The need for reliable, current, and longitudinal indicators of demographic and health conditions is rapidly escalating. With certain notable exceptions, such as fertility and family planning, there is widespread agreement that the impact of investments in health of the past twenty to thirty years in most developing countries is largely unknown and unknowable. For example, it has recently been concluded that reliable data do not exist globally to evaluate progress towards reducing maternal mortality ratios, an indicator with high levels of inequality among nations [1]. The reason usually cited for this lack of data is the absence of functioning and reliable information systems to produce repeated measures of representative and appropriate indicators. Poverty reduction (with health as a priority sector), health sector reforms, sector-wide approaches, and global health initiatives such as the Global Fund to Combat AIDS, TB, and Malaria come with major obligations to monitor and evaluate progress and impact. At the same time, decentralization of responsibilities for local planning has encouraged the spread of evidence-based approaches to policy and practice. This creates an increased demand for high-quality information on local health conditions. Major monitoring and evaluation (M&E) plans are being put in place to assess progress in poverty reduction (through the Poverty Monitoring Master Plan (PMMP)[2]), the national fight against AIDS, malaria control, local government reform [3], and health sector reform [4]. Substantial investments have been made in the development of routine health management information systems [5], and administrative data sources at the local level where bottom-up participatory planning has become a sine qua non of the ongoing Local Government Reform [3, p 2]. In addition, national surveys such as the Demographic and Health Surveys [6-9] have become integrated into the PMMP, and the Ministry of Health is establishing a National Sentinel System for monitoring the burden of disease based on linked demographic surveillance sites [10].


In Tanzania, those responsible for producing indicators and reporting on progress in the health sector are faced with important decisions about how best to invest resources for M&E. How are they to objectively evaluate their options? Based on what criteria should additional resources be put into, say, a facility-based health information system versus repeated nationally representative surveys, a one-off evaluation study, or a more innovative community-based information system? Initial efforts have been made to streamline health information systems [11], but guidance about best practice is lacking. A review of the published literature yielded no formal studies of the cost effectiveness of information for policy and decisionmaking.2 Aims and Objectives This survey of costs and results of information systems was intended to accomplish three aims: (1) To develop a methodology for assessing the comparative costs and results of the principal health and demographic information systems used to provide indicators for major M&E initiatives in the country; (2) To provide government, development partners, and the scholarly community in Tanzania with information to aid decision-making by assessing and comparing options for M&E systems in poverty reduction and health; (3) To stimulate further discussion on approaches for assessing the cost-effectiveness of information systems. We did not attempt a formal cost-effectiveness study, nor was it our aim to formally rate the quality of the indicators produced by the systems or system performance. Additionally, we did not undertake an analysis or critique of the process by which specific indicators were selected in various M&E programmes or the population subgroups they intend to represent.

Again, there is currently no scholarship on the comparative costs and effectiveness of information systems. Hence there was no established methodology that could be readily applied or adapted to this study. Our protocol development, methods, and study tools are described in detail elsewhere [14]. Here we briefly describe elements of the study design.

METHODS

Selection Criteria and Sample We attempted to include all systems in Tanzania that had the ability or potential to produce health, demographic, and poverty indicators required in the M&E programmes of the


PMMP, health sector reform, and local government reform (Local Government Reform Program: private communication). The full list of indicators published as of 2002 and the M&E programs for which they are required are contained in Table 2.1.3 Table 2.1 Indicators Included in the Study by Topic and Source Indicator Socio-economic Characteristics 1 Headcount ratios for- basic needs poverty line 2 Headcount ratios for- basic needs poverty line (rural) 3 Headcount ratios for- food poverty line 4 Asset ownership (as a proxy for income poverty) 5 Proportion of working age population not currently employed 6 Overall GDP per growth anum 7 GDP growth of agriculture per annum 8 Percent of rural roads in maintainable condition 9 Girl/boy ratio in primary education 10 Girl/boy ratio in secondary education 11 Transition rate from primary to secondary 12 Literacy rate or literacy rate of population aged 15+ 13 Net primary enrolment 14 Gross primary enrolment 15 Drop-out rate in primary school 16 Percent of students passing Std 7 with grade A,B,C 17 Percent/proportion of households with access to safe and clean water 18 Proportion of child-headed houses 19 Proportion of children in the labour force 20 Proportion of children in the labour force and not going to school 21 % of elderly living in a household where no one is economically active 22 Ratio of reserves to monthly inputs 23 Districts covered by active AIDS awareness campaign Mortality and Survival 24 Infant mortality rate 25 Under-five mortality rate 26 Life expectancy 27 Maternal mortality rate or maternal mortality ratio Adult and Child Health 28 Percent of ARI in under-fives 29 Prevalence of diarrhoea in under-fives Proportion of children