Tanzania was the fourth country site for the GREAT Network’s in-country guideline prioritization and implementation planning work. In November 2014, local stakeholders including clinicians, healthcare providers, healthcare administrators, researchers/academics, non-governmental organizations, policymakers, and professional associations from Tanzania gathered as participants of a two-day workshop that involved focus group discussions followed by a prioritization meeting.
Informed by joint consultations with Ifakara Health Institute, PATH, WHO, and the Ministry of Health Tanzania, the following four maternal guidelines have been selected as key priorities for implementation activities in Tanzania:
- Prevention and Treatment of Post-Partum Haemorrhage (2012);
- Prevention and Treatment of Pre-Eclampsia/Eclampsia (2011);
- Induction of Labour (2011);
- Augmentation of Labour (2014).
Key objectives of the in-person workshop included:
- To identify barriers and facilitators to the implementation of the priority guidelines in Tanzania; and
- To develop a cross-cutting, multi-level implementation strategy to improve the use of the guidelines.
Multiple methods were used to collect data on priorities, barriers and facilitators, as well as to determine potential implementation strategies for the four identified guidelines in Tanzania. Primary data collection occurred during an in-country two-day workshop involving focus group discussions, a ranking exercise, and small and large group discussions to explore barriers and facilitators, identify guideline priority areas, and develop action-oriented and tailored implementation strategies. Prior to the workshop, a survey was administered to inform workshop proceedings.
The process of selecting priority maternal and perinatal health recommendations and exploring barriers and facilitators to implementation of the four priority WHO guidelines yielded rich information to inform implementation planning in Tanzania.
Findings from the focus group discussions described issues at the level of the health care system, which included factors related to policies and wider systemic conditions in Tanzania that can affect implementation of the WHO guideline recommendations. These factors included: access to resources; continuity of care; monitoring and evaluation; policies; and dissemination of guidelines. Issues at the level of the health care provider that may affect guideline implementation were prevalent, and included: beliefs, attitudes, and buy-in about the use of guideline recommendations; knowledge and skills needed to implement the guidelines; as well astraining, coaching, and professional development around guideline implementation. Finally, issues at the level of the patient/community that may affect guideline implementation included: health-seeking behaviour and preferences for care; community champions; and socioeconomic status.
The ranking exercise resulted in a participant-driven assessment of the feasibility of 12 guideline recommendations that were deemed to be priorities in Tanzania. Within subsequent small group discussions, multiple implementation strategies were suggested to overcome barriers.
Key messages that emerged from the pre-workshop and workshop activities are as follows:
- Drug procurement, management, and distribution practices are not operating optimally. Key suggestions to improve drug ordering and monitoring across the country included accountability measures for timely request and reporting, and implementing cost-sharing programs. There is a need to ensure that oxytocin is stored at 2–8 degrees (Celsius) at all levels of handling to maintain the cold chain system. This may minimize “drug waste” (i.e., medications expiring or becoming unstable due to storage).
- Ensure access to equipment such as refrigerators for drug storage, and basic supplies such as gloves and blood pressure cuffs. Budgeting for essential equipment and supplies can be improved in a Comprehensive Council Health Plan to ensure adequate funding.
- Recruitment and retention strategies focusing on rural areas in particular should be strengthened to ensure adequate human resources for health. Cross-training of existing staff in maternal and perinatal health so that they can be re-distributed within and across facilities as needed may reduce the burden on overworked teams in all areas of Tanzania.
- Increased opportunities for training are essential to improve the implementation of guideline recommendations, with more focus on pre-service training and a refresher course for in-service training. The training should be competency- based, and should include continuing medical education, supportive supervision and mentorship programs.
- A focus on interprofessional training and promotion of a collaborative health care team model was cited as a key area for improvement that could improve attitudes, buy-in, and provider confidence in implementing a guideline recommendation.
- There is a need to create more formal linkages between the various levels of health care facilities to better coordinate and standardize maternal health care for the community. Opportunities to form linkages through technology (e.g., telemedicine) are currently being piloted in Tanzania.
- There is a need for wider dissemination of guidelines beyond distributing them directly to users. This could be achieved through strategies such as mass media campaigns, educational materials and community champions.
Many of the barriers, facilitators, and resultant implementation strategies identified regarding the four WHO maternal and perinatal guidelines are applicable to other priority areas in health care; therefore, these findings can inform and be integrated into future barrier and facilitator assessments and guideline implementation planning initiatives in Tanzania.
For full details about this project please read our final report.