Delivery of integrated infectious disease control services under the new antenatal care guidelines: a service availability and readiness assessment of health facilities in Tanzania

Tanzania is among countries with leading maternal and child mortality rates in the world. With an estimated under five (U5) mortality rate of 54 deaths per 1000, Tanzania ranks 51st in global U5 mortality rank [1]. Notwithstanding, it has made significant progress in combating neonatal mortality. Between 2000 and 2012, Tanzania experienced a consistent annual decrease rate of 4.3% in neonatal mortality [1]. Afnan-Holmes et al. [2] forecast that if this trend should continue, Tanzania is likely to achieve child health target by 2030.

Regarding maternal health, the United Nations Development Program’s (UNDP) report on the millennium development goals [3] indicates that Tanzania failed to achieve Millennium Development Goals (MDG) target 5.2 as maternal mortality rate stood at 133 deaths per 100,000 live births at 2015. Progress has fallen below targets as annual reduction rate was only 3.4% between 1990 and 2013 [2].

While still births and pregnancy haemorrhage contribute majorly to neonatal and maternal deaths respectively, the impact of infectious diseases especially Human Immunodeficiency Virus (HIV), Malaria and Tuberculosis (TB) during and post pregnancy has been noted by several authors [4–6]. Dreyfuss et al. [6] in a cohort study of 822 HIV positive women found that disease progression to Acquired Immunodeficiency Syndrome (AIDS) and low birth weight were significant outcomes experienced in Tanzania. Similar to this finding, a systematic review by Mullick et al. [7] found that HIV infection during pregnancy in South Eastern Tanzania was significantly associated to chorioamnionitis and low birth weight. As confirmed by previous studies, the prevalence of HIV/TB comorbidity during pregnancy in Tanzania is overwhelming. Mtei et al. [8] in a trial among 94 HIV – positive women found that 71% had been comorbid with TB. Malaria during pregnancy has significant maternal and neonatal outcomes within the Tanzanian context. A study in Northern Tanzania [4] found that not only does malaria increases the risk of anaemia and low birth weight but also, significantly increased the risk of premature delivery (OR 3.2 95% CI, 1.5–7.0).

As a response to the devastating impact of Malaria, TB and HIV infection during pregnancy in this context, the Tanzanian Ministry of Health first adapted and implemented the focused antenatal care model in 2002 [9]. Under this policy, first antenatal care should commence before 16 weeks of pregnancy and should be integrated among other interventions including screening for infectious diseases [9]. Although focused antenatal care (FANC) is intended to mitigate utilisation barriers and improve health of women during pregnancy, challenges around optimal FANC utilisation (4+ visits) largely remain in Tanzania. According to the demographic and Health Survey [10], of the 97.7% women that had first antenatal care, only 42.8% had attained the optimal number of visits (four or more visits). Additionally, median of first antenatal care visit was at 19.7 weeks.

In spite of the lingering health systems challenges which has resulted in lower FANC attendance [11], the Tanzanian Ministry of Health recently agreed to the implementation of the new model of antenatal care. This model requires pregnant women to receive a minimum of eight focused antenatal care visits in lieu of four integrated visits [12].

Ahead of national scale implementation of this new FANC model, we aim to understand the capacity of the health system to deliver an integrated infectious disease (HIV, Malaria and TB) control services in response to the increasing impact of infectious diseases among pregnant women. Furthermore, by adapting the World Health Organisation’s service availability and readiness assessment tool, this study contributes to the limited research of infectious disease control service with antenatal care and further offers technical areas for consideration when scaling integrated infectious disease services with antenatal care.

The aim of the study was to assess service readiness of Tanzanian health facilities to integrate HIV, Malaria and Tuberculosis under the new recommendations of the World Health Organisation. This also included the extent to which the components of service integration resulted in actual service delivery. Based on the SARA framework, components of service integration was constructed under five main domains. Findings from this study has demonstrated that having all components of service integration were significantly associated with receipt of integrated service during antenatal care. Among the five components of integration, the study found that training an ANC health worker in all disease areas were the strongest determinant to receipt of an integrated service during ANC sessions.

The conceptualisation of receipt of integrated care during antenatal care in this study was based on five set parameters. The adjusted odds of having these parameters and receipt of integrated care were determined as having a positive relationship. Based on these findings, this study supports Foreit et al. [16]‘s assertion that the prime determinant of integrated care during antenatal care is having trained staff on site. It was found that the adjusted odds of having a trained staff on site and receipt of integrated care by pregnant women were 2.6 times and up to 4.5 times during antenatal care. While it is inadequate to claim complete integration based on just availability of trained staff, it is an important and key step in ensuring that pregnant women receive all the requisite HIV, Malaria and TB services. Towards the implementation of the new WHO ANC guidelines, it is relevant for Tanzanian public health planners to consider training all health workers in all disease areas.

The significance of training health staff in disease areas have been noted by several authors. Ouma et al. [17] noted that all components of malaria service delivery were higher among facilities that had health staff engaged in a donor funded training in malaria. Furthermore, the authors contend that training a health worker in malaria does not merely improve service delivery, but it also improves pregnant women’s experience during antenatal care which eventually improves coverage of future ANC services [17]. Welty et al. [18] also observed that HIV voluntary screening and counselling had increased significantly from 50.7 to 96.2% (p > 0.01) after training health workers on HIV care.

Although organising on-the-job training programs has been recognised as a key determinant to successful ‘training’ and knowledge transfer, its sustainability would be assured when backed with quality improvement procedures [19]. Batalden and Davidoff [19] identifies three quality improvement areas which could complement routine trainings of health workers. These are; 1. Generating contextual evidence to guide training of health workers, 2. Routine capacity building and 3. Consistent measurement of performance improvement.

Generating contextual evidence during trainings of health staff ensures that context-specific issues are incorporated into training programs. Context-tailored trainings responds to local needs and demands of health workers. In addition, Batalden and Davidoff [19] argues that incorporating routine on-the-job capacity building strengthens quality improvement and further ensures that policy and practice are consistent during all times of service delivery. Finally, creating mechanisms to measure performance of health workers before and after training programs would ensure that individual health worker capacity is taken into consideration during planning and targeting of training programs. Effective performance measurement also ensures that subsequent capacity building programs are tailored to respond to identified areas where majority of health workers may deem as a ‘weakness’. Allen and Brownstein [20] on an assessment of community health workers’ training programs in the United States reinforced the significance of incorporating effective performance measurement before and after training programs. They further recommend that adding qualitative exit interviews strengthens quality improvement even more.

This study has argued that integration of health services is an effective mechanism to increase coverage and to reduce the impact of infectious diseases during pregnancy. Using the SARA framework, it was found that the strongest determinant of receiving integrated care during antenatal session was having a trained staff in all disease areas on site. Unexpectedly, the model found that having antenatal care services and ID service on the same site had no association to receiving integrated care.

Towards readiness to integrate infectious disease control with antenatal care services under the new recommendations, strengthening capacity of health workers to administer this care will be crucial in higher coverage of services. Supportive quality improvement is crucial in this process and as such incorporating different techniques for continuous support to health workers ensures latest policy and practice are consistent. As illustrated by Batalden and Davidoff, driving this process with evidence even yields maximum benefits on the health system as a whole. Health workers are central to the process of supportive quality improvement and it is relevant to create a down-to-top heath needs assessment that continuously informs capacity building sessions.

Finally, while complete integration of ID services at ANC may seem distant in Tanzania, health authorities should take the initial short term step of effectively co-locating these services according to the identified determinants. As lessons have shown, the nuanced effectiveness of this strategy will gradually encourage other key health actors to pursue overall integration and devolution of health services.