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Health care for chronic diseases in rural Tanzania

Mwangome, M.N.

2016

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citation for published version (APA)

Mwangome, M. N. (2016). Health care for chronic diseases in rural Tanzania: Including non-communicable

diseases in primary care towards health for all.

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Chapter 1

Chapter 1

'ĞŶĞƌĂů/ŶƚƌŽĚƵĐƟŽŶ

13

ŚĂƉƚĞƌϭ'ĞŶĞƌĂů/ŶƚƌŽĚƵĐƟŽŶ

“Health for all in the 21stĐĞŶƚƵƌLJ͟ŝƐĂϭϵϵϴtŽƌůĚ,ĞĂůƚŚKƌŐĂŶŝnjĂƟŽŶ;t,KͿĚĞĐůĂƌĂƟŽŶ ƚŚĂƚ ŵŽƐƚ ĐŽƵŶƚƌŝĞƐ ĂƌĞ ƐƚƌŝǀŝŶŐ ƚŽ ĞŶƐƵƌĞ ĨŽƌ ƚŚĞŝƌ ĐŝƟnjĞŶƐ ;ϭͿ͘ dŚŝƐ ŵĞĂŶƐ ƚŚĂƚ Ăůů ƉŽƉƵůĂƟŽŶƐ͕ŝŶĐůƵĚŝŶŐƉĂƟĞŶƚƐǁŝƚŚĐŚƌŽŶŝĐĚŝƐĞĂƐĞƐ͕ƌĞĐĞŝǀĞƚŚĞƋƵĂůŝƚLJĂŶĚƐĂĨĞŚĞĂůƚŚ ƐĞƌǀŝĐĞƐƚŚĞLJŶĞĞĚ͘ƉŝĚĞŵŝŽůŽŐŝĐĂůƚƌĂŶƐŝƟŽŶŝƐĐŚĂŶŐŝŶŐƚŚĞƉĂƩĞƌŶŽĨŚĞĂůƚŚĂŶĚĚŝƐĞĂƐĞ ŝŶ ƚŚĞ ǁŽƌůĚ͕ ĂŶĚ ĐĞƌƚĂŝŶůLJ ŝŶ ůŽǁͲ ĂŶĚ ŵŝĚĚůĞͲŝŶĐŽŵĞ ĐŽƵŶƚƌŝĞƐ ;>D/ƐͿ͘ dŚĞ ƚƌĂŶƐŝƟŽŶ ŝƐĚĞƐĐƌŝďĞĚĂƐĂƐŚŝŌŝŶƚŚĞƉĂƩĞƌŶŽĨŵŽƌƚĂůŝƚLJĂŶĚĚŝƐĞĂƐĞƐƵĐŚƚŚĂƚĂĐƵƚĞŝŶĨĞĐƟŽƵƐ ĚŝƐĞĂƐĞƐĂƌĞƐůŽǁůLJďĞŝŶŐƌĞƉůĂĐĞĚďLJĚĞŐĞŶĞƌĂƟǀĞĂŶĚůŝĨĞƐƚLJůĞĚŝƐĞĂƐĞƐĂƐƚŚĞƉƌŽŵŝŶĞŶƚ ĐĂƵƐĞƐ ŽĨ ĚŝƐĞĂƐĞ ĂŶĚ ĚĞĂƚŚ͘ dŚŝƐ ƐŚŝŌ ŝƐ ĐůŽƐĞůLJ ůŝŶŬĞĚ ƚŽ ƚŚĞ ŝŶĐƌĞĂƐĞĚ ŵŽĚĞƌŶŝnjĂƟŽŶ͕ ŝŶĚƵƐƚƌŝĂůŝnjĂƟŽŶ ĂŶĚ ƵƌďĂŶŝnjĂƟŽŶ ƚŚĂƚ ŚĂǀĞ ůĞĚ ƚŽ ĐŚĂŶŐŝŶŐ ůŝĨĞƐƚLJůĞƐ ĂŶĚ ŝŶĐƌĞĂƐŝŶŐ ůŝĨĞ ĞdžƉĞĐƚĂŶĐLJ;Ϯ͕ϯͿ͘ĞĐĂƵƐĞŽĨƚŚŝƐƚƌĂŶƐŝƟŽŶ͕>D/ƐĂƌĞĞdžƉĞƌŝĞŶĐŝŶŐĂŶŝŶĐƌĞĂƐŝŶŐďƵƌĚĞŶ ŽĨŶŽŶͲĐŽŵŵƵŶŝĐĂďůĞĚŝƐĞĂƐĞƐ;EƐͿ͕ǁŚŝůĞƚŚĞďƵƌĚĞŶŽĨĐŽŵŵƵŶŝĐĂďůĞĂŶĚĚĞĮĐŝĞŶĐLJ ĚŝƐĞĂƐĞƐƉĞƌƐŝƐƚƐ͕ĐĂƵƐŝŶŐǁŚĂƚŝƐŬŶŽǁŶĂƐƚŚĞ͚ĚŽƵďůĞďƵƌĚĞŶ͛ŽĨĚŝƐĞĂƐĞƐ;ϯͿ͘EƐĂƌĞ currently the biggest killers in the world, having caused 38 million deaths (68% of all global ŵŽƌƚĂůŝƚLJͿĂŶĚĐŽŶƚƌŝďƵƚĞĚƚŽĂƐƵďƐƚĂŶƟĂůůŽƐƐŽĨĚŝƐĂďŝůŝƚLJͲĂĚũƵƐƚĞĚůŝĨĞLJĞĂƌƐ;>zƐͿŝŶ ϮϬϭϮ;ϰ͕ϱͿ͘>D/ƐďĞĂƌƚŚĞďƌƵŶƚŽĨEƐ͕ĂƐϴϬйŽĨƚŚĞǁŽƌůĚ͛ƐEͲƌĞůĂƚĞĚĚĞĂƚŚƐ;ϰͿĂŶĚ ƚǁŽƚŚŝƌĚƐŽĨ>zƐůŽƐƚǁŽƌůĚǁŝĚĞĂƌĞŝŶƚŚĞƐĞĐŽƵŶƚƌŝĞƐ;ϲͿ͘zĞƚƚŚĞƐĞĐŽƵŶƚƌŝĞƐĂƌĞĂůƐŽ ƐŚŽƵůĚĞƌŝŶŐŵŽƐƚŽĨƚŚĞďƵƌĚĞŶŽĨƚŚĞϱ͘ϲŵŝůůŝŽŶĚĞĂƚŚƐĂŶĚϭϲϲŵŝůůŝŽŶ>zƐůŽƐƚĂŶŶƵĂůůLJ to HIV, malaria and tuberculosis globally (7). The sub-Saharan African region, for instance, had 25.8 million people living with HIV and a reported 790,000 HIV-related deaths in 2014, which represented 70% of prevalence and 66% of deaths globally (8).

Chapter 1

14

ŵŽƌĞĚĂLJƐĂŶĚŵĂĚĞƐĞǀĞŶƟŵĞƐŵŽƌĞŽƵƚƉĂƟĞŶƚǀŝƐŝƚƐƚŚĂŶŶŽŶͲĚŝĂďĞƚĞƐƉĂƟĞŶƚƐůŝǀŝŶŐ near them (15). The burden of chronic diseases on the health system is further worsened by the fact that chronic diseases are increasingly occurring in parallel. This is referred to as ĐŚƌŽŶŝĐŵƵůƟͲŵŽƌďŝĚŝƚLJ;ŵŽƌĞƚŚĂŶŽŶĞĐŚƌŽŶŝĐĚŝƐĞĂƐĞŝŶŽŶĞƉĂƟĞŶƚͿĂŶĚŝƐŬŶŽǁŶƚŽ ŝŶĐƌĞĂƐĞƚŚĞĐŽŵƉůĞdžŝƚLJŽĨƚŚĞŵĂŶĂŐĞŵĞŶƚŽĨƚŚĞĐŽͲĞdžŝƐƟŶŐĐŽŶĚŝƟŽŶƐ;ϭϲ͕ϭϳͿ͘ /ƚŚĂƐďĞĞŶƐƵŐŐĞƐƚĞĚƚŚĂƚŝƚŝƐŵŽƌĞĞĐŽŶŽŵŝĐĂůůLJƐĞŶƐŝďůĞƚŽƉƌĞǀĞŶƚͶƌĂƚŚĞƌƚŚĂŶƚƌĞĂƚ ͶĐŚƌŽŶŝĐĚŝƐĞĂƐĞƐĂƚĂůůůĞǀĞůƐĨƌŽŵŝŶĚŝǀŝĚƵĂůƚŽŐůŽďĂů;ϭϴͲϮϭͿ͘ůƚŚŽƵŐŚƚŚŝƐŝƐƚƌƵĞ͕ƚŚĞƌĞ ŚĂǀĞƐŽĨĂƌďĞĞŶǀĞƌLJůŝŵŝƚĞĚEƉƌĞǀĞŶƟŽŶĞīŽƌƚƐŝŶ>D/Ɛ͘ĚĚŝƟŽŶĂůůLJ͕EƉƌĞǀĞŶƟŽŶ ŝŶƚĞƌǀĞŶƟŽŶƐƚĂŬĞƟŵĞƚŽLJŝĞůĚƌĞƐƵůƚƐ͕ǁŚŝůĞƚŚĞŝŶĐŝĚĞŶĐĞŽĨEƐĐŽŶƟŶƵĞƐ;ϮϮͿ͕ŵĂŬŝŶŐ ŝƚ ŶĞĐĞƐƐĂƌLJ ƚŽ ĂůƐŽ ĨŽĐƵƐ ŽŶ ĐĂƌĞ ĂŶĚ ƚƌĞĂƚŵĞŶƚ ŽĨ ƚŚŽƐĞ ĂůƌĞĂĚLJ ĂŋŝĐƚĞĚ͘ ,ŽǁĞǀĞƌ͕ health services required to diagnose and treat NCDs are not fully formed in LMICs. For ĞdžĂŵƉůĞ͕ĂϮϬϭϭƌĞǀŝĞǁĞƐƟŵĂƚĞĚƚŚĂƚϴϱйŽĨĚŝĂďĞƚĞƐƉĂƟĞŶƚƐŝŶƐƵďͲ^ĂŚĂƌĂŶĨƌŝĐĂǁĞƌĞ ƵŶĚŝĂŐŶŽƐĞĚ;ϮϯͿ͕ŝŶĚŝĐĂƟŶŐĂǁĞĂŬŶĞƐƐŽĨŚĞĂůƚŚƐLJƐƚĞŵƐŝŶƚŚĞƐĞĐŽƵŶƚƌŝĞƐƚŽŝĚĞŶƟĨLJĂŶĚ care for them. Focusing on care and treatment is also mandated by the large NCD-related ŵŽƌďŝĚŝƚLJĂŶĚŵŽƌƚĂůŝƚLJďƵƌĚĞŶĂŵŽŶŐƚŚĞŵŽƐƚĞĐŽŶŽŵŝĐĂůůLJƉƌŽĚƵĐƟǀĞƉŽƉƵůĂƟŽŶƐŝŶ >D/Ɛ ;Ϯϰ͕ ϮϱͿ͕ ǁŚŝĐŚ ĂĚǀĞƌƐĞůLJ ĂīĞĐƚƐ ďŽƚŚ ŶĂƟŽŶĂů ĚĞǀĞůŽƉŵĞŶƚ ŝŶŝƟĂƟǀĞƐ ĂƐ ǁĞůů ĂƐ household-level economic standing (26). It is also especially important to focus on care and ƚƌĞĂƚŵĞŶƚŽĨƵŶĐŽŵƉůŝĐĂƚĞĚĚŝƐĞĂƐĞƚŽƉƌĞǀĞŶƚƚŚĞĚĞǀĞůŽƉŵĞŶƚŽĨĐŽŵƉůŝĐĂƟŽŶƐ͕ďĞĐĂƵƐĞ the management of uncomplicated NCDs costs a lot less than managing complicated ones (27). Global-level health policies also support care and treatment as one focus area in the ĞīŽƌƚƐƚŽĐŽŶƚƌŽůEƐ͘&ŽƌŝŶƐƚĂŶĐĞ͕ƚŚĞŐůŽďĂůĂĐƟŽŶƉůĂŶĨŽƌƚŚĞƉƌĞǀĞŶƟŽŶĂŶĚĐŽŶƚƌŽů ŽĨEƐϮϬϭϯʹϮϬϮϬŚĂƐĂƐŽŶĞŽĨŝƚƐƚĂƌŐĞƚƐƚŽƌĞĚƵĐĞƚŚĞƌĞůĂƟǀĞƌŝƐŬŽĨƉƌĞŵĂƚƵƌĞĚĞĂƚŚ ĨƌŽŵƚŚĞĨŽƵƌŵĂũŽƌEƐ͕ĂŶĚĂƐŽŶĞŽĨŝƚƐŽďũĞĐƟǀĞƐ͕ƚŽƐƚƌĞŶŐƚŚĞŶĂŶĚŽƌŝĞŶƚŚĞĂůƚŚ systems to be able to prevent and control NCDs (28).

'ĞŶĞƌĂů/ŶƚƌŽĚƵĐƟŽŶ 15 ƉĂƟĞŶƚƐǁŚŽŝŶŝƟĂƚĞĚZdŝŶ>D/ƐĂƩĂŝŶĞĚǀŝƌĂůůŽĂĚĐŽŶƚƌŽůĂŌĞƌϭϮŵŽŶƚŚƐŽĨƚƌĞĂƚŵĞŶƚ ;ϯϰͿ͘,ŽǁĞǀĞƌ͕ĐĂƌĞĂŶĚƚƌĞĂƚŵĞŶƚŽĨ,/sŝŶ>D/ƐĨĂĐĞƐƐƵďƐƚĂŶƟĂůĐŚĂůůĞŶŐĞƐ͕ŝŶĐůƵĚŝŶŐ ƵŶƐƵƐƚĂŝŶĂďůĞĮŶĂŶĐŝŶŐ͘DĂŶLJĞůŝŐŝďůĞƉĂƟĞŶƚƐĨŽƌZdĂƌĞƐƟůůƵŶƌĞĂĐŚĞĚ͕ƵƉƚŽϭϬйŽĨ ƉĂƟĞŶƚƐŝŶŝƟĂƟŶŐZdĚŝĞǁŝƚŚŝŶϭϮŵŽŶƚŚƐ͕ĂŶĚƌĞƚĞŶƟŽŶŽĨƉĂƟĞŶƚƐŝŶĐĂƌĞĂŶĚƚƌĞĂƚŵĞŶƚ ŝƐƐƟůůƵŶƐĂƟƐĨĂĐƚŽƌLJ;ϯϯͿ͘

As one of the LMICs, Tanzania is also experiencing the double burden of disease. The ŝŶĐƌĞĂƐŝŶŐƉƌĞǀĂůĞŶĐĞŽĨEƐŝƐĞdžĞŵƉůŝĮĞĚďLJƚŚĞƌŝƐŝŶŐƉƌĞǀĂůĞŶĐĞŽĨƚLJƉĞϮĚŝĂďĞƚĞƐ͘ In the 1980s, this prevalence was at 0.8% in urban and 0.9% in rural areas, rising to 4.0% ŝŶƵƌďĂŶĂŶĚϭ͘ϯйŝŶƌƵƌĂůĂƌĞĂƐŝŶϮϬϬϬ;ϯϱͿ͕ĂŶĚĞƐƟŵĂƚĞĚŝŶĂŶĂƟŽŶĂůƐƵƌǀĞLJĂƚϵ͘ϭйŝŶ 2012 (36). Furthermore, NCDs accounted for 31% of deaths in the country in 2014 (37). As ĂŶĞdžĂŵƉůĞŽĨĂƉĞƌƐŝƐƟŶŐĐŽŵŵƵŶŝĐĂďůĞĚŝƐĞĂƐĞ͕ƚŚĞ,/sƉƌĞǀĂůĞŶĐĞŝƐƐƟůůĂƚƚŚĞůĞǀĞůŽĨ a generalized epidemic in Tanzania despite having decreased from its peak of 7% in 2004 to ϱ͘ϭйŝŶϮϬϭϮ͘;ϯϴͿ͘dŚĞƐĞĐŚĂŶŐĞƐŝŶŚĞĂůƚŚĂŶĚĚŝƐĞĂƐĞƉĂƩĞƌŶƐĂƌĞĂůƐŽĂīĞĐƟŶŐƚŚĞƌƵƌĂů areas of Tanzania, as shown by the rising prevalence of type 2 diabetes in rural areas from Ϭ͘ϵйŝŶƚŚĞϭϵϴϬƐƚŽϭ͘ϯйŝŶϮϬϬϬ;ϯϱͿĂŶĚƚŚĞŚŝŐŚ,/sͬ/^ƉƌĞǀĂůĞŶĐĞŝŶƌƵƌĂůdĂŶnjĂŶŝĂ ŽĨϰ͘ϱйŝŶϮϬϭϮ;ϯϴͿ͘dŚĞƌĞŝƐĂůƐŽĞǀŝĚĞŶĐĞŽĨƉƌĞǀĂŝůŝŶŐĐŽŵŵŽŶEƌŝƐŬĨĂĐƚŽƌƐͶŝ͘Ğ͘ ƉŽŽƌ ĚŝĞƚĂƌLJ ŝŶƚĂŬĞ͕ ƌĞĚƵĐĞĚ ƉŚLJƐŝĐĂů ĂĐƟǀŝƚLJ͕ ĂůĐŽŚŽů ĂďƵƐĞ ĂŶĚ ƚŽďĂĐĐŽ ƵƐĞ Ͷ ŝŶ ƌƵƌĂů dĂŶnjĂŶŝĂ;ϯϵ͕ϰϬͿ͘dŚĞŽĐĐƵƌƌĞŶĐĞŽĨĐŚƌŽŶŝĐŵƵůƟͲŵŽƌďŝĚŝƟĞƐŚĂƐĂůƐŽďĞĞŶĚŽĐƵŵĞŶƚĞĚ ŝŶdĂŶnjĂŶŝĂ͘ŽͲŵŽƌďŝĚŝƟĞƐŽĨƚƵďĞƌĐƵůŽƐŝƐĂŶĚĚŝĂďĞƚĞƐ;ϰϭͿĂŶĚŽĨ,/sĂŶĚŚLJƉĞƌƚĞŶƐŝǀĞ heart diseases (40, 42) have been demonstrated. Furthermore, in a rural district, stroke has been associated with HIV and diabetes (43).

dŚĞƋƵĞƐƟŽŶƚŚĞŶĂƌŝƐĞƐŽĨŚŽǁŚĞĂůƚŚƐLJƐƚĞŵƐŝŶdĂŶnjĂŶŝĂĂŶĚŽƚŚĞƌ>D/ƐĐĂŶĚĞĂůǁŝƚŚ ƚŚĞ ŝŶĐƌĞĂƐŝŶŐ ďƵƌĚĞŶ ŽĨ ĐŚƌŽŶŝĐ ĚŝƐĞĂƐĞƐ ǁŚŽƐĞ ƌĞƋƵŝƌĞŵĞŶƚƐ ĂƌĞ ĚŝīĞƌĞŶƚ ĂŶĚ ǁŚŽƐĞ ƉƌĞƐĞŶƚĂƟŽŶƐ ĂƌĞ ŝŶĐƌĞĂƐŝŶŐ ŝŶ ĐŽŵƉůĞdžŝƚLJ ĚƵĞ ƚŽ ĐŚƌŽŶŝĐ ŵƵůƟͲŵŽƌďŝĚŝƚLJ͕ ŐŝǀĞŶ ƚŚĞŝƌ resource-limited circumstances.

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16

of the current delivery of these services can contribute to and expand the evidence base for NCD service provision in rural areas in LMICs.

The thesis addresses this knowledge gap andĂŝŵƐƚŽŝŶǀĞƐƟŐĂƚĞƐĞƌǀŝĐĞƉƌŽǀŝƐŝŽŶĂŶĚƵƐĞ

for HIV and diabetes in rural areas in Tanzania in order to inform the design of chronic care ƐĞƌǀŝĐĞƐ͘

ĂĐŬŐƌŽƵŶĚ

ϭ͘ϭ,ĞĂůƚŚĐĂƌĞƐLJƐƚĞŵŝŶdĂŶnjĂŶŝĂ

The United Republic of Tanzania is a union of mainland Tanzania and Zanzibar, which is a ƐĞŵŝͲĂƵƚŽŶŽŵŽƵƐĞŶƟƚLJ͘,ĞĂůƚŚŝƐŽŶĞŽĨƚŚĞƐĞĐƚŽƌƐƚŚĂƚŝƐŶŽƚĂĚŵŝŶŝƐƚĞƌĞĚƵŶĚĞƌƚŚĞ union (51). This thesis is based in mainland Tanzania. Tanzania is located in East Africa. In ϮϬϭϮ͕ŝƚŚĂĚĂƉŽƉƵůĂƟŽŶŽĨϰϯ͕ϲϮϱ͕ϯϱϰƉĞŽƉůĞ;ϱϮͿ͘ƚƚŚĞƟŵĞŽĨƚŚĞƐƚƵĚLJ͕ŵĂŝŶůĂŶĚ dĂŶnjĂŶŝĂǁĂƐĂĚŵŝŶŝƐƚƌĂƟǀĞůLJĚŝǀŝĚĞĚŝŶƚŽϮϱƌĞŐŝŽŶƐĂŶĚϭϱϰĚŝƐƚƌŝĐƚƐ;ϱϮͿ͕ĂŶĚŽǀĞƌϳϬйŽĨ ƚŚĞƉŽƉƵůĂƟŽŶůŝǀĞĚŝŶƌƵƌĂůĂƌĞĂƐ;ϰϱͿ͘

ϭ͘Ϯ,ĞĂůƚŚƐƚĂƚƵƐĂŶĚŐŽǀĞƌŶŵĞŶƚƐƚƌĂƚĞŐŝĞƐ

'ĞŶĞƌĂů/ŶƚƌŽĚƵĐƟŽŶ

17

dĂŶnjĂŶŝĂ͛ƐŚĞĂůƚŚŝŶĚŝĐĂƚŽƌƐĂƌĞĐŽŵƉĂƌŝŶŐǁĞůůƚŽƚŚŽƐĞŽĨŽƚŚĞƌĨƌŝĐĂŶĐŽƵŶƚƌŝĞƐ͕ĚĞƐƉŝƚĞ ďĞŝŶŐ ŽŶĞ ŽĨ ƚŚĞ ƉŽŽƌĞƐƚ ĐŽƵŶƚƌŝĞƐ ŝŶ ƚŚĞ ǁŽƌůĚ͘ dŚĞ ŚĞĂůƚŚ ƐƚĂƚƵƐ ŽĨ ŝƚƐ ƉŽƉƵůĂƟŽŶ ŚĂƐ ĐŽŶƟŶƵĞĚ ƚŽ ŝŵƉƌŽǀĞ ŝŶ ƌĞĐĞŶƚ LJĞĂƌƐ͘ ĞƚǁĞĞŶ ϮϬϬϬ ĂŶĚ ϮϬϭϮ͕ ůŝĨĞ ĞdžƉĞĐƚĂŶĐLJ Ăƚ ďŝƌƚŚ for both sexes increased by 11 years, compared to an average increase in the WHO Africa ƌĞŐŝŽŶŽĨƐĞǀĞŶLJĞĂƌƐ͘^ŝŵŝůĂƌůLJ͕ƵŶĚĞƌͲĮǀĞĐŚŝůĚŵŽƌƚĂůŝƚLJĚĞĐůŝŶĞĚĨƌŽŵϭϲϳͬϭ͕ϬϬϬŝŶϭϵϵϬƚŽ ϴϭͬϭ͕ϬϬϬŝŶϮϬϭϬ͕ĂŶĚƚŚĞt,KĞƐƟŵĂƚĞĚƚŚĂƚŝƚǁĂƐϱϳͬϭ͕ϬϬϬŝŶϮϬϭϯ;ϱϯͿ;ϱϰͿ͘ůƚŚŽƵŐŚ ,/sƉƌĞǀĂůĞŶĐĞŝƐƐƟůůŚŝŐŚ͕Ăƚϱ͘ϭйŝŶϮϬϭϮ͕ŝƚŝƐĂƌĞŵĂƌŬĂďůĞĚĞĐůŝŶĞĨƌŽŵϳйŝŶϮϬϬϯͬϬϰ;ϯϴͿ͘ EƐĂŶĚƚŚĞŝƌƌŝƐŬĨĂĐƚŽƌƐĂƌĞĐŽŵŵŽŶŝŶdĂŶnjĂŶŝĂ͕ĂƐĂϮϬϭϮŶĂƟŽŶĂůƐƵƌǀĞLJƌĞǀĞĂůĞĚ;ϯϲͿ͘ The health sector is guided by a strategic plan whose current version was approved in 2015 ĨŽƌƚŚĞƉĞƌŝŽĚϮϬϭϱʹϮϬϮϬ͘dŚĞŵĂŝŶƐƚƌĂƚĞŐŝĐŽďũĞĐƟǀĞƐŽĨdĂŶnjĂŶŝĂ͛ƐDŝŶŝƐƚƌLJŽĨ,ĞĂůƚŚ and Social Welfare (MoHSW) have to do with quality improvement of primary health care ƐĞƌǀŝĐĞƐ͕ ŝŶĐůƵĚŝŶŐ Ă ŐƌĂĚƵĂů ŝŶĐƌĞĂƐĞ ŝŶ ĚŝĂŐŶŽƐƟĐ ĂŶĚ ƚŚĞƌĂƉĞƵƟĐ ĐĂƉĂĐŝƟĞƐ ĨŽƌ EƐ͖ ŝŵƉƌŽǀŝŶŐ ĞƋƵŝƚĂďůĞ ĂĐĐĞƐƐ ƚŽ ƐĞƌǀŝĐĞƐ͖ ĂĐŚŝĞǀŝŶŐ ĂĐƟǀĞ ĐŽŵŵƵŶŝƚLJ ƉĂƌƚŶĞƌƐŚŝƉƐ͖ ĂŶĚ ĂĐŚŝĞǀŝŶŐĂŚŝŐŚĞƌƌĂƚĞŽĨƌĞƚƵƌŶŽŶŝŶǀĞƐƚŵĞŶƚŝŶŚĞĂůƚŚŝŶƚĞƌǀĞŶƟŽŶƐďLJĂĚĚƌĞƐƐŝŶŐƚŚĞ ƐŽĐŝĂůĚĞƚĞƌŵŝŶĂŶƚƐŽĨŚĞĂůƚŚ;ϱϱͿ͘ĞůŽǁ͕ƚŚĞŚĞĂůƚŚƐLJƐƚĞŵŝŶdĂŶnjĂŶŝĂŝƐďƌŝĞŇLJƉƌĞƐĞŶƚĞĚ ĂĐĐŽƌĚŝŶŐƚŽƚŚĞƐŝdžĞůĞŵĞŶƚƐŽĨĂŚĞĂůƚŚƐLJƐƚĞŵĂĐĐŽƌĚŝŶŐƚŽƚŚĞt,K;ϱϲͿ͗ĂĚŵŝŶŝƐƚƌĂƟŽŶ Žƌ ŐŽǀĞƌŶĂŶĐĞ͕ ƐĞƌǀŝĐĞ ŽƌŐĂŶŝnjĂƟŽŶ͕ ĮŶĂŶĐŝŶŐ͕ ƚŚĞ ŚĞĂůƚŚ ǁŽƌŬĨŽƌĐĞ͕ ŚĞĂůƚŚ ŝŶĨŽƌŵĂƟŽŶ and the supplies management system.

ϭ͘ϰWƵďůŝĐĂĚŵŝŶŝƐƚƌĂƟŽŶŝŶdĂŶnjĂŶŝĂ

Chapter 1

18

ϭ͘ϲ,ĞĂůƚŚƐĞƌǀŝĐĞŽƌŐĂŶŝnjĂƟŽŶ

dĂŶnjĂŶŝĂ͛Ɛ ŚĞĂůƚŚ ƐĞƌǀŝĐĞƐ ĂƌĞ ƉƌŽǀŝĚĞĚ ƚŚƌŽƵŐŚ ϲ͕ϴϴϵ ŚĞĂůƚŚ ĨĂĐŝůŝƟĞƐ ;ŝŶ ϮϬϭϯͿ͕ Ϯϲй ŽĨ ǁŚŝĐŚĂƌĞƉƌŝǀĂƚĞůLJŽǁŶĞĚ;ϱϳͿ͘dĂďůĞϭ͘ϮƐŚŽǁƐƚŚĞĚŝƐƚƌŝďƵƟŽŶŽĨƚŚĞƐĞĨĂĐŝůŝƟĞƐĂĐĐŽƌĚŝŶŐ to their level and ownership. Although village health posts are listed as the lowest level of ŚĞĂůƚŚĨĂĐŝůŝƚLJŝŶdĂŶnjĂŶŝĂ͕ĚĂƚĂĂďŽƵƚƚŚĞŵĐŽƵůĚŶŽƚďĞĨŽƵŶĚ͘WƌŝǀĂƚĞŚĞĂůƚŚĨĂĐŝůŝƟĞƐĂƌĞ ŽƌŐĂŶŝnjĞĚƵŶĚĞƌƚŚƌĞĞƵŵďƌĞůůĂƐƚŚĂƚƌĞƉƌĞƐĞŶƚƚŚĞŝƌŝŶƚĞƌĞƐƚƐ͗ƚŚĞƐƐŽĐŝĂƟŽŶŽĨWƌŝǀĂƚĞ ,ĞĂůƚŚ &ĂĐŝůŝƟĞƐ ŝŶ dĂŶnjĂŶŝĂ͕ ƚŚĞ ŚƌŝƐƟĂŶ ^ŽĐŝĂů ^ĞƌǀŝĐĞƐ ŽŵŵŝƐƐŝŽŶ ĂŶĚ ƚŚĞ EĂƟŽŶĂů Muslim Council of Tanzania (BAKWATA) (60).

dĂďůĞϭ͘Ϯ͘ŝƐƚƌŝďƵƟŽŶŽĨŚĞĂůƚŚĨĂĐŝůŝƟĞƐŝŶdĂŶnjĂŶŝĂĂĐĐŽƌĚŝŶŐƚŽŽǁŶĞƌƐŚŝƉ;ϮϬϭϯͿ  ϭϳ   ŵĞĚŝĐĂůŽĨĨŝĐĞƌǁŚŽŚĞĂĚƐƚŚĞ,DdƌĞƉƌĞƐĞŶƚƐƚŚĞŚĞĂůƚŚƐĞĐƚŽƌŽŶƚŚĞĚŝƐƚƌŝĐƚĐŽƵŶĐŝů͘ ,DdƐƉůĂŶ͕ĚĞůŝǀĞƌĂŶĚŽǀĞƌƐĞĞŚĞĂůƚŚƐĞƌǀŝĐĞƐŝŶƚŚĞĚŝƐƚƌŝĐƚ͕ŵĂŬŝŶŐƚŚĞŵƚŚĞƵŶŝƚŽĨ ĚĞĐĞŶƚƌĂůŝnjĂƚŝŽŶ;ϱϱ͕ϱϴͿ͘ZĞŐŝŽŶĂůŚĞĂůƚŚŵĂŶĂŐĞŵĞŶƚƚĞĂŵƐĂƌĞƌĞƐƉŽŶƐŝďůĞĨŽƌŽǀĞƌƐĞĞŝŶŐ ƚŚĞǁŽƌŬŽĨƌĞŐŝŽŶĂůƌĞĨĞƌƌĂůŚŽƐƉŝƚĂůƐĂŶĚƉƌŽǀŝĚŝŶŐƚĞĐŚŶŝĐĂůĂŶĚĂĚŵŝŶŝƐƚƌĂƚŝǀĞƐƵƉƉŽƌƚƚŽƚŚĞ ,DdƐǁŝƚŚŝŶƚŚĞŝƌƌĞŐŝŽŶ͘ĞŶƚƌĂůůLJ͕ƚŚĞDŽ,^tƉƌŽǀŝĚĞƐƚĞĐŚŶŝĐĂůƐƵƉƉŽƌƚ͕ǁŚŝůĞƚŚĞWƌŝŵĞ DŝŶŝƐƚĞƌ͛ƐKĨĨŝĐĞƉƌŽǀŝĚĞƐĂĚŵŝŶŝƐƚƌĂƚŝǀĞƐƵƉƉŽƌƚƚŽƚŚĞƌĞŐŝŽŶĂůĂŶĚĚŝƐƚƌŝĐƚŚĞĂůƚŚƚĞĂŵƐ͘ /ŶƚĞƌŶĂƚŝŽŶĂůƌĞůĂƚŝŽŶƐ͕ďƵĚŐĞƚŝŶŐĂŶĚƉŽůŝĐLJĨŽƌŵƵůĂƚŝŽŶĂƌĞƐƚŝůůŚĂŶĚůĞĚĐĞŶƚƌĂůůLJ;ϱϱ͕ϱϴͿ͘/Ŷ ƉƌĂĐƚŝĐĞƚŚŽƵŐŚ͕ƚŚĞƌĞĂƌĞĐŚĂůůĞŶŐĞƐŽĨĚĞĐĞŶƚƌĂůŝnjĂƚŝŽŶŝŶƚŚĞŚĞĂůƚŚƐĞĐƚŽƌ͕ǁŚŝĐŚŝŶĐůƵĚĞ ƉŽŽƌƉĂƌƚŝĐŝƉĂƚŝŽŶŽĨĐŽŵŵƵŶŝƚŝĞƐŝŶƉůĂŶŶŝŶŐĨŽƌŚĞĂůƚŚ͕ŝŶƐƵĨĨŝĐŝĞŶƚĨƵŶĚĂůůŽĐĂƚŝŽŶƐ͕ĚĞůĂLJĞĚ ĚŝƐďƵƌƐĞŵĞŶƚŽĨĂůůŽĐĂƚĞĚĨƵŶĚƐĨƌŽŵĐĞŶƚƌĂůŐŽǀĞƌŶŵĞŶƚĂŶĚŝŶƚĞƌĨĞƌĞŶĐĞďLJƉŽůŝƚŝĐŝĂŶƐŝŶ ĚĞĐŝƐŝŽŶͲŵĂŬŝŶŐŝŶĚŝƐƚƌŝĐƚĐŽƵŶĐŝůƐ;ϱϵͿ͘

ϭ͘ϲ,ĞĂůƚŚƐĞƌǀŝĐĞŽƌŐĂŶŝnjĂƚŝŽŶ

dĂŶnjĂŶŝĂ͛ƐŚĞĂůƚŚƐĞƌǀŝĐĞƐĂƌĞƉƌŽǀŝĚĞĚƚŚƌŽƵŐŚϲ͕ϴϴϵŚĞĂůƚŚĨĂĐŝůŝƚŝĞƐ;ŝŶϮϬϭϯͿ͕ϮϲйŽĨǁŚŝĐŚ ĂƌĞƉƌŝǀĂƚĞůLJŽǁŶĞĚ;ϱϳͿ͘dĂďůĞϭ͘ϮƐŚŽǁƐƚŚĞĚŝƐƚƌŝďƵƚŝŽŶŽĨƚŚĞƐĞĨĂĐŝůŝƚŝĞƐĂĐĐŽƌĚŝŶŐƚŽƚŚĞŝƌ ůĞǀĞůĂŶĚŽǁŶĞƌƐŚŝƉ͘ůƚŚŽƵŐŚǀŝůůĂŐĞŚĞĂůƚŚƉŽƐƚƐĂƌĞůŝƐƚĞĚĂƐƚŚĞůŽǁĞƐƚůĞǀĞůŽĨŚĞĂůƚŚĨĂĐŝůŝƚLJ ŝŶdĂŶnjĂŶŝĂ͕ĚĂƚĂĂďŽƵƚƚŚĞŵĐŽƵůĚŶŽƚďĞĨŽƵŶĚ͘WƌŝǀĂƚĞŚĞĂůƚŚĨĂĐŝůŝƚŝĞƐĂƌĞŽƌŐĂŶŝnjĞĚƵŶĚĞƌ ƚŚƌĞĞƵŵďƌĞůůĂƐƚŚĂƚƌĞƉƌĞƐĞŶƚƚŚĞŝƌŝŶƚĞƌĞƐƚƐ͗ƚŚĞƐƐŽĐŝĂƚŝŽŶŽĨWƌŝǀĂƚĞ,ĞĂůƚŚ&ĂĐŝůŝƚŝĞƐŝŶ dĂŶnjĂŶŝĂ͕ƚŚĞŚƌŝƐƚŝĂŶ^ŽĐŝĂů^ĞƌǀŝĐĞƐŽŵŵŝƐƐŝŽŶĂŶĚƚŚĞEĂƚŝŽŶĂůDƵƐůŝŵŽƵŶĐŝůŽĨdĂŶnjĂŶŝĂ ;<tdͿ;ϲϬͿ͘ dĂďůĞϭ͘Ϯ͘ŝƐƚƌŝďƵƚŝŽŶŽĨŚĞĂůƚŚĨĂĐŝůŝƚŝĞƐŝŶdĂŶnjĂŶŝĂĂĐĐŽƌĚŝŶŐƚŽŽǁŶĞƌƐŚŝƉ;ϮϬϭϯͿ  >ĞǀĞůŽĨĨĂĐŝůŝƚLJ WƌŝǀĂƚĞ;йͿ 'ŽǀĞƌŶŵĞŶƚ;йͿ dŽƚĂů ŝƐƉĞŶƐĂƌLJ ϭ͕ϰϰϰ;ϮϰйͿ ϰ͕ϰϲϵ;ϳϲйͿ ϱ͕ϵϭϯ ,ĞĂůƚŚĐĞŶƚƌĞ ϮϮϮ;ϯϭйͿ ϰϴϵ;ϲϵйͿ ϳϭϭ ,ŽƐƉŝƚĂůΎ ϭϰϬ;ϱϱйͿ ϭϭϰ;ϰϱйͿ Ϯϱϰ  ϭϴ   dŽƚĂůĨĂĐŝůŝƚŝĞƐŝŶϮϬϭϯ ϭ͕ϴϬϲ;ϮϲйͿ ϱ͕ϬϳϮ;ϳϰйͿ ϲ͕ϴϳϴ Ύ,ŽƐƉŝƚĂůĂƐĂůĞǀĞůŽĨŚĞĂůƚŚĨĂĐŝůŝƚLJĂďŽǀĞŚĞĂůƚŚĐĞŶƚƌĞ͕ŝŶĐůƵĚŝŶŐĚŝƐƚƌŝĐƚ͕ƌĞŐŝŽŶĂůĂŶĚƌĞĨĞƌƌĂů ŚŽƐƉŝƚĂůƐ ^ŽƵƌĐĞ͗DŽ,^t͕,Z,ƌĞƉŽƌƚϮϬϭϯͬϭϰ WƵďůŝĐŚĞĂůƚŚƐĞƌǀŝĐĞƐĂƌĞƉƌŽǀŝĚĞĚĨŽůůŽǁŝŶŐĂŚŝĞƌĂƌĐŚLJĨƌŽŵƚŚĞŐƌĂƐƐͲƌŽŽƚƐůĞǀĞůŽĨƚŚĞǀŝůůĂŐĞ ŚĞĂůƚŚƉŽƐƚƐƵƉƚŽƌĞĨĞƌƌĂůŽƌƐƉĞĐŝĂůŝƐƚŚŽƐƉŝƚĂůƐ͘dŚĞŚŝŐŚĞƌůĞǀĞůƐĂƌĞƐƵƉƉŽƐĞĚƚŽƉƌŽǀŝĚĞ ŝŶĐƌĞĂƐŝŶŐůLJƐŽƉŚŝƐƚŝĐĂƚĞĚĂŶĚǁĞůůͲĚĞĨŝŶĞĚƐĞƌǀŝĐĞƐ;ϱϱͿ͘dĂďůĞϭ͘ϯƉƌĞƐĞŶƚƐƚŚŝƐŚŝĞƌĂƌĐŚLJ͘ dĂďůĞϭ͘ϯ͘>ĞǀĞůƐŽĨĨĂĐŝůŝƚŝĞƐĂŶĚƐĞƌǀŝĐĞƐƚŚĞLJƐŚŽƵůĚƉƌŽǀŝĚĞ ĚŵŝŶŝƐƚƌĂƚŝǀĞ ůĞǀĞů >ĞǀĞůĂŶĚƚĂƌŐĞƚ ƉŽƉƵůĂƚŝŽŶ ^ĞƌǀŝĐĞƐƉƌŽǀŝĚĞĚ ĂĚƌĞƐŽĨƐĞƌǀŝĐĞ ƉƌŽǀŝĚĞƌƐ  dƌĞĂƚŵĞŶƚ ĂďƌŽĂĚ &ŽƌƐĞƌǀŝĐĞƐŶŽƚĂǀĂŝůĂďůĞŝŶdĂŶnjĂŶŝĂ͘WĂƚŝĞŶƚƐĂƌĞƌĞĨĞƌƌĞĚ ĂďƌŽĂĚŽŶŐŽǀĞƌŶŵĞŶƚƐƵďƐŝĚLJ͘ Ͳ ŽŶĞĂŶĚ ŶĂƚŝŽŶĂů ZĞĨĞƌƌĂůͬƐƉĞĐŝĂůŝƐƚ ŚŽƐƉŝƚĂůƐ ŽŵƉƌĞŚĞŶƐŝǀĞƐƉĞĐŝĂůŝƐƚƐĞƌǀŝĐĞƐ dĞĂĐŚŝŶŐĂŶĚƌĞƐĞĂƌĐŚ ^ƉĞĐŝĂůŝƐƚĚŽĐƚŽƌƐZĞŐŝƐƚĞƌĞĚŶƵƌƐĞƐ ZĞŐŝŽŶ ZĞŐŝŽŶĂů ŚŽƐƉŝƚĂůƐ ^ĞƌǀŝĐĞƐŽĨĨĞƌĞĚĂƚĚŝƐƚƌŝĐƚŚŽƐƉŝƚĂůƐƉůƵƐ͗ ^ƉĞĐŝĂůŝƐƚƐĞƌǀŝĐĞƐŝŶǀĂƌŝŽƵƐĨŝĞůĚƐ ƐƵĐŚĂƐƉƐLJĐŚŝĂƚƌLJ͕ĞĂƌ͕ŶŽƐĞĂŶĚ ƚŚƌŽĂƚ;EdͿ͕ŽƉŚƚŚĂůŵŽůŽŐLJ͕ ĚĞŶƚŝƐƚƌLJ͕ŝŶƚĞŶƐŝǀĞĐĂƌĞ͕ ŐLJŶĂĞĐŽůŽŐLJĂŶĚŽďƐƚĞƚƌŝĐƐ͕ ƌĂĚŝŽůŽŐLJ͕ƉĂƚŚŽůŽŐLJ͕ŚŝŐŚĞƌͲůĞǀĞů ƐƵƌŐŝĐĂůĂŶĚŵĞĚŝĐĂůƐĞƌǀŝĐĞƐ  ^ƉĞĐŝĂůŝƐƚĚŽĐƚŽƌƐ DĞĚŝĐĂůĚŽĐƚŽƌƐ ZĞŐŝƐƚĞƌĞĚŶƵƌƐĞƐ ŝƐƚƌŝĐƚ ŝƐƚƌŝĐƚ ŚŽƐƉŝƚĂůƐ ^ĞƌǀŝĐĞƐŽĨĨĞƌĞĚĂƚŚĞĂůƚŚĐĞŶƚƌĞƐƉůƵƐ͗ KƚŚĞƌŐĞŶĞƌĂůƐĞƌǀŝĐĞƐ /ŶͲƐĞƌǀŝĐĞƚƌĂŝŶŝŶŐ ŽŶƐƵůƚĂƚŝŽŶĂŶĚƌĞƐĞĂƌĐŚŝŶƚŽ ĐŽŵŵƵŶŝƚLJͲďĂƐĞĚŚĞĂůƚŚĐĂƌĞ ƉƌŽŐƌĂŵŵĞƐ DĞĚŝĐĂůĚŽĐƚŽƌƐƐĞƌǀĞŝŶ ƐŽŵĞŽĨƚŚĞĚŝƐƚƌŝĐƚ ŚŽƐƉŝƚĂůƐ͖ DĂŶLJĂƌĞƌƵŶďLJ ĂƐƐŝƐƚĂŶƚŵĞĚŝĐĂů ŽĨĨŝĐĞƌƐ;DKƐͿ͖ ƐƵƉƉŽƌƚĞĚďLJĐůŝŶŝĐĂů ŽĨĨŝĐĞƌƐĂŶĚ ĞŶƌŽůůĞĚĂŶĚƌĞŐŝƐƚĞƌĞĚ ŶƵƌƐĞƐ ŝǀŝƐŝŽŶ ,ĞĂůƚŚ ĐĞŶƚƌĞ WƌĞǀĞŶƚŝǀĞ͕ƉƌŽŵŽƚŝǀĞ͕ŽƵƚƉĂƚŝĞŶƚ͕ĐƵƌĂƚŝǀĞ͕ŵĂƚĞƌŶŝƚLJ͕ ůŝŶŝĐĂůŽĨĨŝĐĞƌƐŝĚĞĚďLJĞŶƌŽůůĞĚ  ϭϴ   dŽƚĂůĨĂĐŝůŝƚŝĞƐŝŶϮϬϭϯ ϭ͕ϴϬϲ;ϮϲйͿ ϱ͕ϬϳϮ;ϳϰйͿ ϲ͕ϴϳϴ Ύ,ŽƐƉŝƚĂůĂƐĂůĞǀĞůŽĨŚĞĂůƚŚĨĂĐŝůŝƚLJĂďŽǀĞŚĞĂůƚŚĐĞŶƚƌĞ͕ŝŶĐůƵĚŝŶŐĚŝƐƚƌŝĐƚ͕ƌĞŐŝŽŶĂůĂŶĚƌĞĨĞƌƌĂů ŚŽƐƉŝƚĂůƐ ^ŽƵƌĐĞ͗DŽ,^t͕,Z,ƌĞƉŽƌƚϮϬϭϯͬϭϰ WƵďůŝĐŚĞĂůƚŚƐĞƌǀŝĐĞƐĂƌĞƉƌŽǀŝĚĞĚĨŽůůŽǁŝŶŐĂŚŝĞƌĂƌĐŚLJĨƌŽŵƚŚĞŐƌĂƐƐͲƌŽŽƚƐůĞǀĞůŽĨƚŚĞǀŝůůĂŐĞ ŚĞĂůƚŚƉŽƐƚƐƵƉƚŽƌĞĨĞƌƌĂůŽƌƐƉĞĐŝĂůŝƐƚŚŽƐƉŝƚĂůƐ͘dŚĞŚŝŐŚĞƌůĞǀĞůƐĂƌĞƐƵƉƉŽƐĞĚƚŽƉƌŽǀŝĚĞ ŝŶĐƌĞĂƐŝŶŐůLJƐŽƉŚŝƐƚŝĐĂƚĞĚĂŶĚǁĞůůͲĚĞĨŝŶĞĚƐĞƌǀŝĐĞƐ;ϱϱͿ͘dĂďůĞϭ͘ϯƉƌĞƐĞŶƚƐƚŚŝƐŚŝĞƌĂƌĐŚLJ͘ dĂďůĞϭ͘ϯ͘>ĞǀĞůƐŽĨĨĂĐŝůŝƚŝĞƐĂŶĚƐĞƌǀŝĐĞƐƚŚĞLJƐŚŽƵůĚƉƌŽǀŝĚĞ ĚŵŝŶŝƐƚƌĂƚŝǀĞ ůĞǀĞů >ĞǀĞůĂŶĚƚĂƌŐĞƚ ƉŽƉƵůĂƚŝŽŶ ^ĞƌǀŝĐĞƐƉƌŽǀŝĚĞĚ ĂĚƌĞƐŽĨƐĞƌǀŝĐĞ ƉƌŽǀŝĚĞƌƐ  dƌĞĂƚŵĞŶƚ ĂďƌŽĂĚ &ŽƌƐĞƌǀŝĐĞƐŶŽƚĂǀĂŝůĂďůĞŝŶdĂŶnjĂŶŝĂ͘WĂƚŝĞŶƚƐĂƌĞƌĞĨĞƌƌĞĚ ĂďƌŽĂĚŽŶŐŽǀĞƌŶŵĞŶƚƐƵďƐŝĚLJ͘ Ͳ ŽŶĞĂŶĚ ŶĂƚŝŽŶĂů ZĞĨĞƌƌĂůͬƐƉĞĐŝĂůŝƐƚ ŚŽƐƉŝƚĂůƐ ŽŵƉƌĞŚĞŶƐŝǀĞƐƉĞĐŝĂůŝƐƚƐĞƌǀŝĐĞƐ dĞĂĐŚŝŶŐĂŶĚƌĞƐĞĂƌĐŚ ^ƉĞĐŝĂůŝƐƚĚŽĐƚŽƌƐZĞŐŝƐƚĞƌĞĚŶƵƌƐĞƐ ZĞŐŝŽŶ ZĞŐŝŽŶĂů ŚŽƐƉŝƚĂůƐ ^ĞƌǀŝĐĞƐŽĨĨĞƌĞĚĂƚĚŝƐƚƌŝĐƚŚŽƐƉŝƚĂůƐƉůƵƐ͗ ^ƉĞĐŝĂůŝƐƚƐĞƌǀŝĐĞƐŝŶǀĂƌŝŽƵƐĨŝĞůĚƐ ƐƵĐŚĂƐƉƐLJĐŚŝĂƚƌLJ͕ĞĂƌ͕ŶŽƐĞĂŶĚ ƚŚƌŽĂƚ;EdͿ͕ŽƉŚƚŚĂůŵŽůŽŐLJ͕ ĚĞŶƚŝƐƚƌLJ͕ŝŶƚĞŶƐŝǀĞĐĂƌĞ͕ ŐLJŶĂĞĐŽůŽŐLJĂŶĚŽďƐƚĞƚƌŝĐƐ͕ ƌĂĚŝŽůŽŐLJ͕ƉĂƚŚŽůŽŐLJ͕ŚŝŐŚĞƌͲůĞǀĞů ƐƵƌŐŝĐĂůĂŶĚŵĞĚŝĐĂůƐĞƌǀŝĐĞƐ  ^ƉĞĐŝĂůŝƐƚĚŽĐƚŽƌƐ DĞĚŝĐĂůĚŽĐƚŽƌƐ ZĞŐŝƐƚĞƌĞĚŶƵƌƐĞƐ ŝƐƚƌŝĐƚ ŝƐƚƌŝĐƚ ŚŽƐƉŝƚĂůƐ ^ĞƌǀŝĐĞƐŽĨĨĞƌĞĚĂƚŚĞĂůƚŚĐĞŶƚƌĞƐƉůƵƐ͗ KƚŚĞƌŐĞŶĞƌĂůƐĞƌǀŝĐĞƐ /ŶͲƐĞƌǀŝĐĞƚƌĂŝŶŝŶŐ ŽŶƐƵůƚĂƚŝŽŶĂŶĚƌĞƐĞĂƌĐŚŝŶƚŽ ĐŽŵŵƵŶŝƚLJͲďĂƐĞĚŚĞĂůƚŚĐĂƌĞ ƉƌŽŐƌĂŵŵĞƐ DĞĚŝĐĂůĚŽĐƚŽƌƐƐĞƌǀĞŝŶ ƐŽŵĞŽĨƚŚĞĚŝƐƚƌŝĐƚ ŚŽƐƉŝƚĂůƐ͖ DĂŶLJĂƌĞƌƵŶďLJ ĂƐƐŝƐƚĂŶƚŵĞĚŝĐĂů ŽĨĨŝĐĞƌƐ;DKƐͿ͖ ƐƵƉƉŽƌƚĞĚďLJĐůŝŶŝĐĂů ŽĨĨŝĐĞƌƐĂŶĚ ĞŶƌŽůůĞĚĂŶĚƌĞŐŝƐƚĞƌĞĚ ŶƵƌƐĞƐ ŝǀŝƐŝŽŶ ,ĞĂůƚŚ ĐĞŶƚƌĞ WƌĞǀĞŶƚŝǀĞ͕ƉƌŽŵŽƚŝǀĞ͕ŽƵƚƉĂƚŝĞŶƚ͕ĐƵƌĂƚŝǀĞ͕ŵĂƚĞƌŶŝƚLJ͕ ůŝŶŝĐĂůŽĨĨŝĐĞƌƐŝĚĞĚďLJĞŶƌŽůůĞĚ Public health services are provided following a hierarchy from the grass-roots level of the village health posts up to referral or specialist hospitals. The higher levels are supposed to provide ŝŶĐƌĞĂƐŝŶŐůLJƐŽƉŚŝƐƟĐĂƚĞĚĂŶĚǁĞůůͲĚĞĮŶĞĚƐĞƌǀŝĐĞƐ;ϱϱͿ͘dĂďůĞϭ͘ϯƉƌĞƐĞŶƚƐƚŚŝƐŚŝĞƌĂƌĐŚLJ͘

'ĞŶĞƌĂů/ŶƚƌŽĚƵĐƟŽŶ 19  ϭϴ   dŽƚĂůĨĂĐŝůŝƚŝĞƐŝŶϮϬϭϯ ϭ͕ϴϬϲ;ϮϲйͿ ϱ͕ϬϳϮ;ϳϰйͿ ϲ͕ϴϳϴ Ύ,ŽƐƉŝƚĂůĂƐĂůĞǀĞůŽĨŚĞĂůƚŚĨĂĐŝůŝƚLJĂďŽǀĞŚĞĂůƚŚĐĞŶƚƌĞ͕ŝŶĐůƵĚŝŶŐĚŝƐƚƌŝĐƚ͕ƌĞŐŝŽŶĂůĂŶĚƌĞĨĞƌƌĂů ŚŽƐƉŝƚĂůƐ ^ŽƵƌĐĞ͗DŽ,^t͕,Z,ƌĞƉŽƌƚϮϬϭϯͬϭϰ WƵďůŝĐŚĞĂůƚŚƐĞƌǀŝĐĞƐĂƌĞƉƌŽǀŝĚĞĚĨŽůůŽǁŝŶŐĂŚŝĞƌĂƌĐŚLJĨƌŽŵƚŚĞŐƌĂƐƐͲƌŽŽƚƐůĞǀĞůŽĨƚŚĞǀŝůůĂŐĞ ŚĞĂůƚŚƉŽƐƚƐƵƉƚŽƌĞĨĞƌƌĂůŽƌƐƉĞĐŝĂůŝƐƚŚŽƐƉŝƚĂůƐ͘dŚĞŚŝŐŚĞƌůĞǀĞůƐĂƌĞƐƵƉƉŽƐĞĚƚŽƉƌŽǀŝĚĞ ŝŶĐƌĞĂƐŝŶŐůLJƐŽƉŚŝƐƚŝĐĂƚĞĚĂŶĚǁĞůůͲĚĞĨŝŶĞĚƐĞƌǀŝĐĞƐ;ϱϱͿ͘dĂďůĞϭ͘ϯƉƌĞƐĞŶƚƐƚŚŝƐŚŝĞƌĂƌĐŚLJ͘ dĂďůĞϭ͘ϯ͘>ĞǀĞůƐŽĨĨĂĐŝůŝƚŝĞƐĂŶĚƐĞƌǀŝĐĞƐƚŚĞLJƐŚŽƵůĚƉƌŽǀŝĚĞ ĚŵŝŶŝƐƚƌĂƚŝǀĞ ůĞǀĞů >ĞǀĞůĂŶĚƚĂƌŐĞƚ ƉŽƉƵůĂƚŝŽŶ ^ĞƌǀŝĐĞƐƉƌŽǀŝĚĞĚ ĂĚƌĞƐŽĨƐĞƌǀŝĐĞ ƉƌŽǀŝĚĞƌƐ  dƌĞĂƚŵĞŶƚ ĂďƌŽĂĚ &ŽƌƐĞƌǀŝĐĞƐŶŽƚĂǀĂŝůĂďůĞŝŶdĂŶnjĂŶŝĂ͘WĂƚŝĞŶƚƐĂƌĞƌĞĨĞƌƌĞĚ ĂďƌŽĂĚŽŶŐŽǀĞƌŶŵĞŶƚƐƵďƐŝĚLJ͘ Ͳ ŽŶĞĂŶĚ ŶĂƚŝŽŶĂů ZĞĨĞƌƌĂůͬƐƉĞĐŝĂůŝƐƚ ŚŽƐƉŝƚĂůƐ ŽŵƉƌĞŚĞŶƐŝǀĞƐƉĞĐŝĂůŝƐƚƐĞƌǀŝĐĞƐ dĞĂĐŚŝŶŐĂŶĚƌĞƐĞĂƌĐŚ ^ƉĞĐŝĂůŝƐƚĚŽĐƚŽƌƐZĞŐŝƐƚĞƌĞĚŶƵƌƐĞƐ ZĞŐŝŽŶ ZĞŐŝŽŶĂů ŚŽƐƉŝƚĂůƐ ^ĞƌǀŝĐĞƐŽĨĨĞƌĞĚĂƚĚŝƐƚƌŝĐƚŚŽƐƉŝƚĂůƐƉůƵƐ͗ ^ƉĞĐŝĂůŝƐƚƐĞƌǀŝĐĞƐŝŶǀĂƌŝŽƵƐĨŝĞůĚƐ ƐƵĐŚĂƐƉƐLJĐŚŝĂƚƌLJ͕ĞĂƌ͕ŶŽƐĞĂŶĚ ƚŚƌŽĂƚ;EdͿ͕ŽƉŚƚŚĂůŵŽůŽŐLJ͕ ĚĞŶƚŝƐƚƌLJ͕ŝŶƚĞŶƐŝǀĞĐĂƌĞ͕ ŐLJŶĂĞĐŽůŽŐLJĂŶĚŽďƐƚĞƚƌŝĐƐ͕ ƌĂĚŝŽůŽŐLJ͕ƉĂƚŚŽůŽŐLJ͕ŚŝŐŚĞƌͲůĞǀĞů ƐƵƌŐŝĐĂůĂŶĚŵĞĚŝĐĂůƐĞƌǀŝĐĞƐ  ^ƉĞĐŝĂůŝƐƚĚŽĐƚŽƌƐ DĞĚŝĐĂůĚŽĐƚŽƌƐ ZĞŐŝƐƚĞƌĞĚŶƵƌƐĞƐ ŝƐƚƌŝĐƚ ŝƐƚƌŝĐƚ ŚŽƐƉŝƚĂůƐ ^ĞƌǀŝĐĞƐŽĨĨĞƌĞĚĂƚŚĞĂůƚŚĐĞŶƚƌĞƐƉůƵƐ͗ KƚŚĞƌŐĞŶĞƌĂůƐĞƌǀŝĐĞƐ /ŶͲƐĞƌǀŝĐĞƚƌĂŝŶŝŶŐ ŽŶƐƵůƚĂƚŝŽŶĂŶĚƌĞƐĞĂƌĐŚŝŶƚŽ ĐŽŵŵƵŶŝƚLJͲďĂƐĞĚŚĞĂůƚŚĐĂƌĞ ƉƌŽŐƌĂŵŵĞƐ DĞĚŝĐĂůĚŽĐƚŽƌƐƐĞƌǀĞŝŶ ƐŽŵĞŽĨƚŚĞĚŝƐƚƌŝĐƚ ŚŽƐƉŝƚĂůƐ͖ DĂŶLJĂƌĞƌƵŶďLJ ĂƐƐŝƐƚĂŶƚŵĞĚŝĐĂů ŽĨĨŝĐĞƌƐ;DKƐͿ͖ ƐƵƉƉŽƌƚĞĚďLJĐůŝŶŝĐĂů ŽĨĨŝĐĞƌƐĂŶĚ ĞŶƌŽůůĞĚĂŶĚƌĞŐŝƐƚĞƌĞĚ ŶƵƌƐĞƐ ŝǀŝƐŝŽŶ ,ĞĂůƚŚ ĐĞŶƚƌĞ WƌĞǀĞŶƚŝǀĞ͕ƉƌŽŵŽƚŝǀĞ͕ŽƵƚƉĂƚŝĞŶƚ͕ĐƵƌĂƚŝǀĞ͕ŵĂƚĞƌŶŝƚLJ͕ ůŝŶŝĐĂůŽĨĨŝĐĞƌƐŝĚĞĚďLJĞŶƌŽůůĞĚ  ϭϵ   ϱϬ͕ϬϬϬ ƉĞŽƉůĞ ŝŶƉĂƚŝĞŶƚƐĞƌǀŝĐĞƐ͕ĞŵĞƌŐĞŶĐLJƐƵƌŐĞƌLJĂŶĚďůŽŽĚƚƌĂŶƐĨƵƐŝŽŶ ĂŶĚůĂďŽƌĂƚŽƌLJƐĞƌǀŝĐĞƐ ŶƵƌƐĞƐ tĂƌĚ ŝƐƉĞŶƐĂƌLJ ϲ͕ϬϬϬƚŽ ϭϬ͕ϬϬϬ ƉĞŽƉůĞ WƌĞǀĞŶƚŝǀĞ͕ƉƌŽŵŽƚŝǀĞ͕ ŽƵƚƉĂƚŝĞŶƚ͕ĐƵƌĂƚŝǀĞĂŶĚŽƵƚƌĞĂĐŚ ĐĂƌĞ ůŝŶŝĐĂůĂƐƐŝƐƚĂŶƚƐ͖ ƐƐŝƐƚĞĚďLJĂŶĞŶƌŽůůĞĚ ŶƵƌƐĞ sŝůůĂŐĞ sŝůůĂŐĞ ŚĞĂůƚŚ ƉŽƐƚƐ фϱ͕ϬϬϬ ƉĞŽƉůĞ ŽŵŵƵŶŝƚLJͲďĂƐĞĚƉƌĞǀĞŶƚŝǀĞĂŶĚ ƉƌŽŵŽƚŝǀĞŚĞĂůƚŚƐĞƌǀŝĐĞƐ sŝůůĂŐĞŚĞĂůƚŚǁŽƌŬĞƌƐ sŝůůĂŐĞŚĞĂůƚŚǁŽƌŬĞƌƐсƐƚĂĨĨǁŚŽŚĂǀĞƵŶĚĞƌŐŽŶĞĂƐŚŽƌƚƚƌĂŝŶŝŶŐĂƌĞĞdžƉĞĐƚĞĚƚŽƌƵŶĂǀŝůůĂŐĞŚĞĂůƚŚ ƉŽƐƚ ŶƌŽůůĞĚŶƵƌƐĞсƐĞĐŽŶĚĂƌLJƐĐŚŽŽůŐƌĂĚƵĂƚĞǁŝƚŚƚǁŽLJĞĂƌƐŽĨƚƌĂŝŶŝŶŐŝŶŶƵƌƐŝŶŐĐĂƌĞŽĨŵŝŶŽƌĂŝůŵĞŶƚƐ ZĞŐŝƐƚĞƌĞĚŶƵƌƐĞсƐĞĐŽŶĚĂƌLJƐĐŚŽŽůŐƌĂĚƵĂƚĞǁŝƚŚƚŚƌĞĞŽƌŵŽƌĞLJĞĂƌƐŝŶŶƵƌƐŝŶŐƐĐŚŽŽůĂŶĚůĞŐĂůůLJ ĂƵƚŚŽƌŝnjĞĚ;ƌĞŐŝƐƚĞƌĞĚͿƚŽƉƌĂĐƚŝƐĞĂĨƚĞƌĞdžĂŵŝŶĂƚŝŽŶďLJĂƐƚĂƚĞďŽĂƌĚŽĨŶƵƌƐĞĞdžĂŵŝŶĞƌƐ ůŝŶŝĐĂůĂƐƐŝƐƚĂŶƚсƐĞĐŽŶĚĂƌLJƐĐŚŽŽůŐƌĂĚƵĂƚĞǁŝƚŚƚǁŽLJĞĂƌƐŽĨƚƌĂŝŶŝŶŐŝŶĂŶĂƚŽŵLJ͕ƉŚLJƐŝŽůŽŐLJ͕ ŚLJŐŝĞŶĞ͕ĚŝĂŐŶŽƐƚŝĐŵĞƚŚŽĚƐ͕ĂŶĚƚƌĞĂƚŵĞŶƚŽĨĐŽŵŵŽŶŝůůŶĞƐƐĞƐ ůŝŶŝĐĂůŽĨĨŝĐĞƌсƐĞĐŽŶĚĂƌLJƐĐŚŽŽůŐƌĂĚƵĂƚĞǁŝƚŚƚŚƌĞĞLJĞĂƌƐŽĨďĂƐŝĐĐůŝŶŝĐĂůƚƌĂŝŶŝŶŐ DKсĐůŝŶŝĐĂůŽĨĨŝĐĞƌƐǁŝƚŚĂĨƵƌƚŚĞƌƚǁŽLJĞĂƌƐŽĨĐůŝŶŝĐĂůƚƌĂŝŶŝŶŐ ^ŽƵƌĐĞ͗ĚĂƉƚĞĚĨƌŽŵDŽ,^t,Z,ƌĞƉŽƌƚϮϬϭϰ ůƚŚŽƵŐŚƉƌŝŵĂƌLJĐĂƌĞŝƐƐƵƉƉŽƐĞĚƚŽďĞƉƌŽǀŝĚĞĚĂƚƚŚĞǀŝůůĂŐĞŚĞĂůƚŚƉŽƐƚƐ͕ĚŝƐƉĞŶƐĂƌŝĞƐĂŶĚ ŚĞĂůƚŚĐĞŶƚƌĞƐ͕ƚŚĞŚŝĞƌĂƌĐŚLJŽĨƐĞƌǀŝĐĞƐĚŽĞƐŶŽƚĂůǁĂLJƐĨƵŶĐƚŝŽŶĂƐĞdžƉĞĐƚĞĚ͕ĂŶĚŚŝŐŚĞƌͲůĞǀĞů ĨĂĐŝůŝƚŝĞƐŽĨƚĞŶŽĨĨĞƌƉƌŝŵĂƌLJĐĂƌĞƐĞƌǀŝĐĞƐ;ϲϭͿ͘dŚĞǀŝůůĂŐĞŚĞĂůƚŚƉŽƐƚƐĂƌĞĂůƐŽŶŽƚĐŽŶƐŝƐƚĞŶƚůLJ ƉƌĞƐĞŶƚŝŶĂůůĚŝƐƚƌŝĐƚƐ͘DŽƐƚĚŝƐƚƌŝĐƚŚŽƐƉŝƚĂůƐĂƌĞŐŽǀĞƌŶŵĞŶƚͲŽǁŶĞĚ͘,ŽǁĞǀĞƌ͕ĂĨĞǁĚŝƐƚƌŝĐƚƐ ƌĞůLJŽŶŚŽƐƉŝƚĂůƐŽǁŶĞĚďLJĨĂŝƚŚͲďĂƐĞĚŽƌŐĂŶŝnjĂƚŝŽŶƚŚĂƚĂƌĞĚĞƐŝŐŶĂƚĞĚĂƐĚŝƐƚƌŝĐƚŚŽƐƉŝƚĂůƐ ;ϲϭͿ͘ ϭ͘ϲ&ŝŶĂŶĐŝŶŐ͕ŚĞĂůƚŚǁŽƌŬĨŽƌĐĞ͕ŝŶĨŽƌŵĂƚŝŽŶƐLJƐƚĞŵƐĂŶĚƐƵƉƉůŝĞƐŵĂŶĂŐĞŵĞŶƚ KŶĞŽďũĞĐƚŝǀĞŽĨdĂŶnjĂŶŝĂ͛ƐŚĞĂůƚŚĨŝŶĂŶĐŝŶŐƉŽůŝĐLJŝƐ͞ƚŽĞŶƐƵƌĞƚŚĂƚƐƵĨĨŝĐŝĞŶƚƌĞƐŽƵƌĐĞƐĞdžŝƐƚ ƚŽĞŶĂďůĞŚĞĂůƚŚĐĂƌĞƉƌŽǀŝĚĞƌƐƚŽĚĞůŝǀĞƌĂďĂƐŝĐƉĂĐŬĂŐĞŽĨŚŝŐŚͲƋƵĂůŝƚLJŚĞĂůƚŚĐĂƌĞƐĞƌǀŝĐĞƐ͟ ;ϲϮͿ͘dŚĞƚŽƚĂůďƵĚŐĞƚĂƌLJĂůůŽĐĂƚŝŽŶĨŽƌŚĞĂůƚŚŝŶƚŚĞĨŝŶĂŶĐŝĂůLJĞĂƌϮϬϭϯͬϭϰǁĂƐdĂŶnjĂŶŝĂŶ

Chapter 1

20

ϭ͘ϲ&ŝŶĂŶĐŝŶŐ͕ŚĞĂůƚŚǁŽƌŬĨŽƌĐĞ͕ŝŶĨŽƌŵĂƟŽŶƐLJƐƚĞŵƐĂŶĚƐƵƉƉůŝĞƐŵĂŶĂŐĞŵĞŶƚ

KŶĞŽďũĞĐƟǀĞŽĨdĂŶnjĂŶŝĂ͛ƐŚĞĂůƚŚĮŶĂŶĐŝŶŐƉŽůŝĐLJŝƐ͞ƚŽĞŶƐƵƌĞƚŚĂƚƐƵĸĐŝĞŶƚƌĞƐŽƵƌĐĞƐ exist to enable health care providers to deliver a basic package of high-quality health ĐĂƌĞƐĞƌǀŝĐĞƐ͟;ϲϮͿ͘dŚĞƚŽƚĂůďƵĚŐĞƚĂƌLJĂůůŽĐĂƟŽŶĨŽƌŚĞĂůƚŚŝŶƚŚĞĮŶĂŶĐŝĂůLJĞĂƌϮϬϭϯͬϭϰ was Tanzanian shillings 1,498 billion (USD 863 million at end of 2014), which at 8.2% of ƚŚĞǁŚŽůĞďƵĚŐĞƚŝƐƐƟůůďĞůŽǁƚŚĞϭϱйĂŐƌĞĞĚŝŶƚŚĞďƵũĂĐŽŵŵŝƚŵĞŶƚ;ϲϯͿ͘ŌĞƌƚŚĞ ŝŶƚƌŽĚƵĐƟŽŶŽĨƵƐĞƌĨĞĞƐŝŶϭϵϵϰ͕ĂǁĂŝǀĞƌƉŽůŝĐLJǁĂƐĚĞƐŝŐŶĞĚƚŽĞŶƐƵƌĞƚŚĂƚǀƵůŶĞƌĂďůĞ ŐƌŽƵƉƐ͕ƐƵĐŚĂƐĐŚŝůĚƌĞŶ͕ĞůĚĞƌůLJĂŶĚĐŚƌŽŶŝĐĚŝƐĞĂƐĞƉĂƟĞŶƚƐ͕ĐĂŶĂĐĐĞƐƐĞƐƐĞŶƟĂůŚĞĂůƚŚ ƐĞƌǀŝĐĞƐ ;ϲϰͿ͘ ,ŽǁĞǀĞƌ͕ ĞǀĂůƵĂƟŽŶƐ ŽĨ ƚŚŝƐ ƉŽůŝĐLJ ŚĂǀĞ ƐŚŽǁŶ ƚŚĂƚ ŝƚ ŝƐ ŶŽƚ LJŝĞůĚŝŶŐ ƚŚĞ ĚĞƐŝƌĞĚĞīĞĐƚŽĨƉƌŽƚĞĐƟŶŐǀƵůŶĞƌĂďůĞƉŽƉƵůĂƟŽŶƐĨƌŽŵĐĂƚĂƐƚƌŽƉŚŝĐĞdžƉĞŶĚŝƚƵƌĞŽŶŚĞĂůƚŚ ƐĞƌǀŝĐĞƐ;ϲϱͿ͘dŚĞŝŶĞīĞĐƟǀĞŶĞƐƐŽĨƚŚĞƉŽůŝĐLJŝƐĨƵƌƚŚĞƌŝůůƵƐƚƌĂƚĞĚďLJĂƐƚƵĚLJƚŚĂƚĨŽƵŶĚ ƚŚĂƚ ŚŽƵƐĞŚŽůĚƐ ǁŝƚŚ Ă ĐŚƌŽŶŝĐ ĚŝƐĞĂƐĞ ƉĂƟĞŶƚ ƐƉĞŶĚ ŽŶ ĂǀĞƌĂŐĞ ϮϮй ŵŽƌĞ ŵŽŶĞLJ ŽŶ ŚĞĂůƚŚĐĂƌĞƚŚĂŶƚŚŽƐĞǁŝƚŚŽƵƚƐƵĐŚĂƉĂƟĞŶƚ;ϲϲͿ͘dŚĞdĂŶnjĂŶŝĂŶŐŽǀĞƌŶŵĞŶƚŝƐĞdžƉůŽƌŝŶŐ ŝŶŶŽǀĂƟǀĞĂŶĚĐŽŵƉƌĞŚĞŶƐŝǀĞŚĞĂůƚŚĮŶĂŶĐŝŶŐŵĞĐŚĂŶŝƐŵƐ͕ŝŶĐůƵĚŝŶŐƚŚĞĞƐƚĂďůŝƐŚŵĞŶƚ ŽĨĂƐŝŶŐůĞŶĂƟŽŶĂůŚĞĂůƚŚŝŶƐƵƌĞƌ͕ƚŽƌĞĂůŝnjĞŝƚƐĐŽŵŵŝƚŵĞŶƚƚŽƵŶŝǀĞƌƐĂůŚĞĂůƚŚĐĂƌĞ͕ĂŶĚ ƚŚĞ ĞƐƚĂďůŝƐŚŵĞŶƚ ŽĨ ƚŚĞ /^ dƌƵƐƚ &ƵŶĚ͕ Ă ůŽĐĂů ĨƵŶĚ ĨŽƌ ,/sͬ/^ ĐĂƌĞĂŶĚ ƚƌĞĂƚŵĞŶƚ ƚŽĞŶƐƵƌĞƐƵƐƚĂŝŶĂďŝůŝƚLJŽĨĮŶĂŶĐŝŶŐĨŽƌ,/sĐĂƌĞĂŶĚƚƌĞĂƚŵĞŶƚ;ϲϳͿ͘ŽƚŚƚŚĞƐĞƌĞƋƵŝƌĞ ƐŝŐŶŝĮĐĂŶƚƌĞĨŽƌŵƐŝŶůĞŐŝƐůĂƟŽŶ͕ďƵĚŐĞƟŶŐĂŶĚĐŽŽƌĚŝŶĂƟŽŶŝŶŝŵƉůĞŵĞŶƚĂƟŽŶĂŶĚƐŽĂƌĞ likely to take some years before they are realized.

dŚĞŚĞĂůƚŚƐLJƐƚĞŵŚĂƐŽŶůLJĂŶĞƐƟŵĂƚĞĚϱϴйŽĨƚŚĞŚĞĂůƚŚǁŽƌŬĨŽƌĐĞ;ƉƌŽĨĞƐƐŝŽŶĂůĂŶĚ ŶŽŶͲƉƌŽĨĞƐƐŝŽŶĂůͿŶĞĞĚĞĚ͕ƐŽƚŚĞƐŚŽƌƚĂŐĞŝŶdĂŶnjĂŶŝĂŝƐƐƟůůĐƌŝƟĐĂů͕ĂŶĚŵŽƌĞƐĞǀĞƌĞŝŶ ƌƵƌĂů ĂƌĞĂƐ ;ϱϳ͕ ϲϴͿ͘ WƌŝŵĂƌLJ ĐĂƌĞ ĨĂĐŝůŝƟĞƐ ďĞĂƌ ƚŚĞ ďƌƵŶƚ ŽĨ ƚŚŝƐ ƐŚŽƌƚĂŐĞ ĐŽŵƉĂƌĞĚ ƚŽ ŚŝŐŚĞƌͲůĞǀĞůŚĞĂůƚŚĨĂĐŝůŝƟĞƐ͘/ŶϮϬϭϯ͕ĨŽƌŝŶƐƚĂŶĐĞ͕ĚŝƐƉĞŶƐĂƌŝĞƐŚĂĚĂƐŚŽƌƚĂŐĞŽĨϳϬ͘ϲй (37,597 workers), followed by health centres at 62.5% (14,224 workers) and then district ŚŽƐƉŝƚĂůƐĂƚϯϬ͘ϭй;ϮϬ͕ϵϰϴǁŽƌŬĞƌƐͿ;ϱϳͿ͘īŽƌƚƐƚŽďƵŝůĚƚŚĞĐĂƉĂĐŝƚLJŽĨŚĞĂůƚŚǁŽƌŬĞƌƐƚŽ ďĞƩĞƌƉƌŽǀŝĚĞƐĞƌǀŝĐĞƐĨŽƌEƐŚĂǀĞďĞĞŶŽŶŐŽŝŶŐ͕ĂůďĞŝƚŝŶƚĞƌŵŝƩĞŶƚůLJ͕ĨŽĐƵƐĞĚŽŶĂĨĞǁ regions of the country and largely driven by disease interest groups (35).

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ƐLJƐƚĞŵϮ;,/^ϮͿ,D/^ŶĂƟŽŶĂůůLJ;ϳϬͿ͘dŚĞĞīĞĐƚƐŽĨƚŚŝƐƐLJƐƚĞŵŽŶƚŚĞƉƌŽďůĞŵƐŝĚĞŶƟĮĞĚ ŝŶƚŚĞϮϬϬϳĂƐƐĞƐƐŵĞŶƚĂƌĞLJĞƚƚŽďĞĞǀĂůƵĂƚĞĚ͘ƚĨĂĐŝůŝƚLJůĞǀĞů͕ŝŶĞĸĐŝĞŶĐŝĞƐŝŶƚŚĞ,D/^ have been associated with the lengthy and laborious nature of the system, lack of training, ŝŶĂĐƟǀĞƐƵƉĞƌǀŝƐŝŽŶ͕ĂŶĚƐƚĂīǁŽƌŬůŽĂĚǁŚŝĐŚũĞŽƉĂƌĚŝnjĞƐƚŚĞƋƵĂůŝƚLJŽĨƚŚĞŝŶĨŽƌŵĂƟŽŶ ĐŽůůĞĐƚĞĚ;ϳϭͿ͘/ŶdĂŶnjĂŶŝĂ͛ƐƉƵďůŝĐĨĂĐŝůŝƟĞƐ͕ƚŚĞƐĂŵĞ,D/^ǁŝƚŚŝŶĨĂĐŝůŝƟĞƐŝƐĂůƐŽƌĞĐŽƌĚŝŶŐ ĐĂƌĞĂŶĚƚƌĞĂƚŵĞŶƚŝŶĨŽƌŵĂƟŽŶĨŽƌEƐ͘

ZĞŐĂƌĚŝŶŐƐƵƉƉůLJĐŚĂŝŶŵĂŶĂŐĞŵĞŶƚ͕ĂϮϬϭϮƌĞǀŝĞǁƐŚŽǁĞĚƚŚĂƚĞƐƐĞŶƟĂůŵĞĚŝĐŝŶĞƐǁĞƌĞ ŶŽƚ ĂǀĂŝůĂďůĞ ŝŶ ŚĞĂůƚŚ ĨĂĐŝůŝƟĞƐ͕ ŝŶĐůƵĚŝŶŐ ƐŽŵĞ EͲƌĞůĂƚĞĚ ŵĞĚŝĐĂƟŽŶƐ͕ ŵĂƚĞƌŶĂů ĂŶĚ child health products, family planning products and malaria drugs, while the availability ŽĨĂŶƟƌĞƚƌŽǀŝƌĂůŵĞĚŝĐĂƟŽŶ;ZsƐͿǁĂƐŵƵĐŚďĞƩĞƌ;ϳϮͿ͘dŚĞƌĞǀŝĞǁĨƵƌƚŚĞƌĨŽƵŶĚƚŚĂƚ funding for non-HIV medicines and supplies was inadequate. The Medical Stores Department (MSD) is the unit within the MoHSW that is responsible for the procurement, storage and ĚŝƐƚƌŝďƵƟŽŶ ŽĨ ŚĞĂůƚŚͲƌĞůĂƚĞĚ ĞƋƵŝƉŵĞŶƚ͕ ĐŽŵŵŽĚŝƟĞƐ ĂŶĚ ŵĞĚŝĐĂƟŽŶ ;ϳϮͿ͘ dŚĞ ƌĞǀŝĞǁ ĨŽƵŶĚƚŚĂƚŶŽƚĂůůƉƌŽĚƵĐƚƐůŝƐƚĞĚŝŶƚŚĞĞƐƐĞŶƟĂůŵĞĚŝĐŝŶĞƐůŝƐƚĂƌĞƌŽƵƟŶĞůLJƐƚŽĐŬĞĚďLJƚŚĞ D^͘>ĞĂĚĞƌƐŚŝƉĂŶĚĂĐĐŽƵŶƚĂďŝůŝƚLJŵĞĐŚĂŶŝƐŵƐĂƚĚŝīĞƌĞŶƚůĞǀĞůƐĨƌŽŵƚŚĞĐŽŵŵƵŶŝƚLJ to the ministry were unclear. Furthermore, supply chain management advisors provided ŵŽƌĞĐƌŝƟĐĂůŽǀĞƌƐŝŐŚƚĂŶĚŵĂŶĂŐĞŵĞŶƚŽĨ,/sͲƌĞůĂƚĞĚĚƌƵŐƐ;ZsƐͿĂŶĚůĂďŽƌĂƚŽƌLJŝƚĞŵƐ within the zones compared to the management of other non-HIV-related products (72). EƐƵƉƉůŝĞƐĂŶĚŵĞĚŝĐĂƟŽŶĂƌĞƉĂƌƚŽĨƚŚĞŶŽŶͲ,/sͲƌĞůĂƚĞĚŵĞĚŝĐŝŶĞƐĂŶĚƐƵƉƉůŝĞƐ͘

ϭ͘ϳ,/sĐĂƌĞĂŶĚƚƌĞĂƚŵĞŶƚŝŶdĂŶnjĂŶŝĂ

Chapter 1

22

ƉƌĂĐƟĐĞƐĂŶĚĂůƐŽƚŽƚŚĞƋƵĂůŝƚLJĂŶĚŽƌŐĂŶŝnjĂƟŽŶŽĨƚŚĞĐĂƌĞĚĞůŝǀĞƌĞĚ;ϳϳ͕ϳϴͿ͘ĞƐƉŝƚĞƚŚĞ progress made in providing HIV care and treatment at primary care level, the programme ĨĂĐĞƐĐŚĂůůĞŶŐĞƐǁŚŝĐŚŝŶĐůƵĚĞƚŚĞŚŝŐŚƌĂƚĞƐŽĨƵŶĚŝĂŐŶŽƐĞĚƉĂƟĞŶƚƐ;ĂƚĂďŽƵƚϯϬйͿĂŶĚ ǁĞĂŬŶĞƐƐĞƐŽĨƌĞƚĂŝŶŝŶŐĚŝĂŐŶŽƐĞĚ,/sƉĂƟĞŶƚƐŝŶƚŚĞĐŽŶƟŶƵƵŵŽĨĐĂƌĞ;ϳϵͿ͘

ϭ͘ϴŝĂďĞƚĞƐĐĂƌĞĂŶĚƚƌĞĂƚŵĞŶƚŝŶdĂŶnjĂŶŝĂ

'ĞŶĞƌĂů/ŶƚƌŽĚƵĐƟŽŶ

23

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ϴ͘ hE/^͘ &ĂĐƚ ƐŚĞĞƚ ϮϬϭϱ͘ hE/^͕ ϮϬϭϱ͘ ǀĂŝůĂďůĞ ĨƌŽŵ ŚƩƉ͗ͬͬǁǁǁ͘ƵŶĂŝĚƐ͘ŽƌŐͬƐŝƚĞƐͬ ĚĞĨĂƵůƚͬĮůĞƐͬŵĞĚŝĂͺĂƐƐĞƚͬϮϬϭϱϬϵϬϭͺ&ĂĐƚ^ŚĞĞƚͺϮϬϭϱͺĞŶ͘ƉĚĨ  ΀ŝƚĞĚ ŽŶ ϭst _{March 2016]}

ϵ͘ ƚƵŶZ͕:ĂīĂƌ^͕EŝƐŚƚĂƌ^͕<ŶĂƵů&D͕ĂƌƌĞƚŽD>͕ELJŝƌĞŶĚĂD͕ĞƚĂů͘Improving responsiveness ŽĨ ŚĞĂůƚŚ ƐLJƐƚĞŵƐ ƚŽ ŶŽŶͲĐŽŵŵƵŶŝĐĂďůĞ ĚŝƐĞĂƐĞƐ͘ The Lancet. 2013; 381(9867):690-7. ϭϬ͘ t,K͘ EŽŶͲĐŽŵŵƵŶŝĐĂďůĞ ŝƐĞĂƐĞƐ͘ ϮϬϭϲ͘ ǀĂŝůĂďůĞ ĨƌŽŵ͗ ŚƩƉ͗ͬͬǁǁǁ͘ǁŚŽ͘ŝŶƚͬƚŽƉŝĐƐͬ

ŶŽŶĐŽŵŵƵŶŝĐĂďůĞͺĚŝƐĞĂƐĞƐͬĞŶͬ͘΀ŝƚĞĚϮϬϭϲϮϳƚŚDĂƌĐŚ΁

11. Deeks SG, Lewin SR, and Havlir DV. dŚĞĞŶĚŽĨ/^͗,/sŝŶĨĞĐƟŽŶĂƐĂĐŚƌŽŶŝĐĚŝƐĞĂƐĞ͘ The Lancet. 2013; 382(9903):1525-33.

12. Mills A. ,ĞĂůƚŚĂƌĞ^LJƐƚĞŵƐŝŶ>ŽǁͲĂŶĚDŝĚĚůĞͲ/ŶĐŽŵĞŽƵŶƚƌŝĞƐ͘ New England Journal of Medicine. 2014; 370(6):552-7.

ϭϯ͘ ůůŽƚĞLJW͕ZĞŝĚƉĂƚŚ͕zĂƐŝŶ^͕ŚĂŶ<͕ĂŶĚĚĞͲ'ƌĂŌŝŬŝŶƐ͘ZĞƚŚŝŶŬŝŶŐŚĞĂůƚŚͲĐĂƌĞƐLJƐƚĞŵƐ͗ ĂĨŽĐƵƐŽŶĐŚƌŽŶŝĐŝƚLJ͘ The Lancet.377(9764):450-1.

ϭϰ͘ ^ŚĞƌŝWƌƵŝƩ^͕:ŽŶŶĞƉƉŝŶŐͲ:ŽƌĚĂŶ͕:ĞƐƷƐD͕&ĞƌŶĄŶĚĞnjşĂnjD<͕ĚŶĂŶ<ŝƐĂ͕:ŽƐŚƵĂ<ůĂƉŽǁĞƚ al. /ŶŶŽǀĂƟǀĞĂƌĞĨŽƌŚƌŽŶŝĐŽŶĚŝƟŽŶƐ͗ƵŝůĚŝŶŐůŽĐŬƐĨŽƌĐƟŽŶ. Geneva: Noncommunicable diseases and Mental Health, WHO, 2002.

15. Brown JB, Ramaiya K, Besançon S, Rheeder P, Tassou CM, Mbanya J-C, et al. Use of medical services ĂŶĚŵĞĚŝĐŝŶĞƐĂƩƌŝďƵƚĂďůĞƚŽĚŝĂďĞƚĞƐŝŶ^ƵďͲ^ĂŚĂƌĂŶĨƌŝĐĂ͘ PLoS One. 2014; 9(9):e106716. 16. Borgermans L, De Maeseneer J, Wollersheim H, Vrijhoef B, and Devroey D.  ƚŚĞŽƌĞƟĐĂů

Chapter 1

24

ϭϴ͘ ĞĐĐŚŝŶŝ D͕ ^ĂƐƐŝ &͕ >ĂƵĞƌ :͕ >ĞĞ zz͕ 'ƵĂũĂƌĚŽͲĂƌƌŽŶ s͕ ŚŝƐŚŽůŵ ͘ Tackling of unhealthy ĚŝĞƚƐ͕ƉŚLJƐŝĐĂůŝŶĂĐƟǀŝƚLJ͕ĂŶĚŽďĞƐŝƚLJ͗ŚĞĂůƚŚĞīĞĐƚƐĂŶĚĐŽƐƚͲĞīĞĐƟǀĞŶĞƐƐ͘The Lancet. 2010; 376(9754):1775-84.

19. Engelgau MM, Karan A, and Mahal A. dŚĞĐŽŶŽŵŝĐŝŵƉĂĐƚŽĨEŽŶͲĐŽŵŵƵŶŝĐĂďůĞŝƐĞĂƐĞƐŽŶ ŚŽƵƐĞŚŽůĚƐŝŶ/ŶĚŝĂ͘'ůŽďĂůŝnjĂƟŽŶĂŶĚŚĞĂůƚŚ͘ϮϬϭϮ͖ϴ;ϭͿ͗ϭͲϭϬ͘

20. Canning D. dŚĞĞĐŽŶŽŵŝĐƐŽĨ,/sͬ/^ŝŶůŽǁͲŝŶĐŽŵĞĐŽƵŶƚƌŝĞƐ͗ƚŚĞĐĂƐĞĨŽƌƉƌĞǀĞŶƟŽŶ͘The :ŽƵƌŶĂůKĨĐŽŶŽŵŝĐWĞƌƐƉĞĐƟǀĞƐ͘ϮϬϬϲ͖ϮϬ;ϯͿ͗ϭϮϭͲϰϮ͘

21. Kankeu HT, Saksena P, Xu K, and Evans DB. dŚĞĮŶĂŶĐŝĂůďƵƌĚĞŶĨƌŽŵŶŽŶͲĐŽŵŵƵŶŝĐĂďůĞĚŝƐĞĂƐĞƐ ŝŶ ůŽǁͲĂŶĚ ŵŝĚĚůĞͲŝŶĐŽŵĞ ĐŽƵŶƚƌŝĞƐ͗ Ă ůŝƚĞƌĂƚƵƌĞ ƌĞǀŝĞǁ͘ Health Res Policy Syst. 2013; 11:31. ϮϮ͘ dĂĚĚĞŝ ͕ 'ŶĞƐŽƩŽ Z͕ &ŽƌŶŝ ^͕ ŽŶĂĐĐŽƌƐŝ '͕ sĂŶŶƵĐĐŝ ͕ ĂŶĚ 'ĂƌŽĨĂůŽ '͘ LJĐůŝŶŐ WƌŽŵŽƟŽŶ

ĂŶĚ EŽŶͲŽŵŵƵŶŝĐĂďůĞ ŝƐĞĂƐĞ WƌĞǀĞŶƟŽŶ͗ ,ĞĂůƚŚ /ŵƉĂĐƚ ƐƐĞƐƐŵĞŶƚ ĂŶĚ ĐŽŶŽŵŝĐ ǀĂůƵĂƟŽŶ ŽĨ LJĐůŝŶŐ ƚŽ tŽƌŬ Žƌ ^ĐŚŽŽů ŝŶ &ůŽƌĞŶĐĞ͘ PLoS One. 2015; 10(4):e0125491. 23. Dalal S, Beunza JJ, Volmink J, Adebamowo C, Bajunirwe F, Njelekela M, et al. Non-communicable

ĚŝƐĞĂƐĞƐŝŶƐƵďͲ^ĂŚĂƌĂŶĨƌŝĐĂ͗ǁŚĂƚǁĞŬŶŽǁŶŽǁ͘/ŶƚĞƌŶĂƟŽŶĂů:ŽƵƌŶĂůŽĨƉŝĚĞŵŝŽůŽŐLJ͘ϮϬϭϭ͖ 40(4):885-901.

24. Pierre-Louis AM, Ferl K, Wadhwani CD, Harnam N, Meiro-Lorenzo M. ^ĞƫŶŐƚŚĞ^ƚĂŐĞƚŽĚĚƌĞƐƐ ƚŚĞƵĂůŚĂůůĞŶŐĞŽĨD'ƐĂŶĚEƐ. The World Bank, 2014.

Ϯϱ͘ ůŝ D<͕ ZĂďĂĚĄŶͲŝĞŚů ͕ &ůĂŶŝŐĂŶ :͕ ůĂŶĐŚĂƌĚ ͕ EĂƌĂLJĂŶ <s͕ ĂŶĚ ŶŐĞůŐĂƵ D͘ ^LJƐƚĞŵƐ ĂŶĚ ĐĂƉĂĐŝƚLJƚŽĂĚĚƌĞƐƐŶŽŶĐŽŵŵƵŶŝĐĂďůĞĚŝƐĞĂƐĞƐŝŶůŽǁͲĂŶĚŵŝĚĚůĞͲŝŶĐŽŵĞĐŽƵŶƚƌŝĞƐ͘ Science ƚƌĂŶƐůĂƟŽŶĂůŵĞĚŝĐŝŶĞ͘ϮϬϭϯ͖ϱ;ϭϴϭͿ͗ϭϴϭĐŵϰͲĐŵϰ͘

26. Su TT, Kouyaté B, and Flessa S. Catastrophic household expenditure for health care in a low-ŝŶĐŽŵĞ ƐŽĐŝĞƚLJ͗ Ă ƐƚƵĚLJ ĨƌŽŵ EŽƵŶĂ ŝƐƚƌŝĐƚ͕ ƵƌŬŝŶĂ &ĂƐŽ͘ ƵůůĞƟŶ ŽĨ ƚŚĞ tŽƌůĚ ,ĞĂůƚŚ KƌŐĂŶŝnjĂƟŽŶ͘ϮϬϬϲ͖ϴϰ;ϭͿ͗ϮϭͲϳ͘

27. Schwartz JI, Guwatudde D, Nugent R, Kiiza CM. >ŽŽŬŝŶŐĂƚŶŽŶͲĐŽŵŵƵŶŝĐĂďůĞĚŝƐĞĂƐĞƐŝŶhŐĂŶĚĂ ƚŚƌŽƵŐŚĂůŽĐĂůůĞŶƐ͗ĂŶĂŶĂůLJƐŝƐƵƐŝŶŐůŽĐĂůůLJĚĞƌŝǀĞĚĚĂƚĂ͘'ůŽďĂůŝnjĂƟŽŶĂŶĚŚĞĂůƚŚ͘ϮϬϭϰ͖ϭϬ;ϭͿ͗ϭ͘ Ϯϴ͘ tŽƌůĚ,ĞĂůƚŚKƌŐĂŶŝnjĂƟŽŶ͘'ůŽďĂůĂĐƟŽŶƉůĂŶĨŽƌƚŚĞƉƌĞǀĞŶƟŽŶĂŶĚĐŽŶƚƌŽůŽĨŶŽŶĐŽŵŵƵŶŝĐĂďůĞ ĚŝƐĞĂƐĞƐϮϬϭϯͲϮϬϮϬ͘ϮϬϭϯ͘ǀĂŝůĂďůĞĨƌŽŵǁǁǁ͘ǁŚŽ͘ŝŶƚͬŶŵŚͬĞǀĞŶƚƐͬŶĐĚͺĂĐƟŽŶͺƉůĂŶͬĞŶͬ΀ŝƚĞĚ on 7th _{March 2016]} Ϯϵ͘ ^ƚƌĂƩŽŶ/D͕ĚůĞƌ/͕EĞŝů,t͕DĂƩŚĞǁƐZ͕DĂŶůĞLJ^͕Ƶůů͕ĞƚĂů͘ƐƐŽĐŝĂƟŽŶŽĨŐůLJĐĂĞŵŝĂ ǁŝƚŚŵĂĐƌŽǀĂƐĐƵůĂƌĂŶĚŵŝĐƌŽǀĂƐĐƵůĂƌĐŽŵƉůŝĐĂƟŽŶƐŽĨƚLJƉĞϮĚŝĂďĞƚĞƐ;h<W^ϯϱͿ͗ƉƌŽƐƉĞĐƟǀĞ ŽďƐĞƌǀĂƟŽŶĂůƐƚƵĚLJ͘D:͘ϮϬϬϬ͖ϯϮϭ;ϳϮϱϴͿ͗ϰϬϱͲϭϮ͘

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ƌĞƐŽƵƌĐĞͲĐŽŶƐƚƌĂŝŶĞĚĞŶǀŝƌŽŶŵĞŶƚƐ͗ĐŚĂůůĞŶŐĞƐĨŽƌƚŚĞŶĞdžƚĚĞĐĂĚĞ͘:ŽƵƌŶĂůŽĨƚŚĞ/ŶƚĞƌŶĂƟŽŶĂů AIDS Society. 2012; 15(2):17334. ϯϰ͘ DĐDĂŚŽŶ :,͕ ůůŝŽƩ :,͕ ĞƌƚĂŐŶŽůŝŽ ^͕ <ƵďŝĂŬ Z͕ ĂŶĚ :ŽƌĚĂŶ DZ͘ sŝƌĂů ƐƵƉƉƌĞƐƐŝŽŶ ĂŌĞƌ ϭϮ ŵŽŶƚŚƐ ŽĨ ĂŶƟƌĞƚƌŽǀŝƌĂů ƚŚĞƌĂƉLJ ŝŶ ůŽǁͲĂŶĚ ŵŝĚĚůĞͲŝŶĐŽŵĞ ĐŽƵŶƚƌŝĞƐ͗ Ă ƐLJƐƚĞŵĂƟĐ ƌĞǀŝĞǁ͘ ƵůůĞƟŶŽĨƚŚĞtŽƌůĚ,ĞĂůƚŚKƌŐĂŶŝnjĂƟŽŶ͘ϮϬϭϯ͖ϵϭ;ϱͿ͗ϯϳϳͲϴϱ͘ 35. Ramaiya K. WĞƌƐŽŶĂů sŝĞǁ͗ dĂŶnjĂŶŝĂ ĂŶĚ ĚŝĂďĞƚĞƐͶĂ ŵŽĚĞů ĨŽƌ ĚĞǀĞůŽƉŝŶŐ ĐŽƵŶƚƌŝĞƐ͍ BMJ: ƌŝƟƐŚDĞĚŝĐĂů:ŽƵƌŶĂů͘ϮϬϬϱ͖ϯϯϬ;ϳϰϵϮͿ͗ϲϳϵ͘ 36. WHO. ^dWǁŝƐĞ ĂƉƉƌŽĂĐŚ ƚŽ ĐŚƌŽŶŝĐ ĚŝƐĞĂƐĞ ƌŝƐŬ ĨĂĐƚŽƌ ƐƵƌǀĞŝůůĂŶĐĞ͕ dĂŶnjĂŶŝĂ. WHO; 2012 ΀ƵƉĚĂƚĞĚϮϬϭϯ͖ĐŝƚĞĚϮϬϭϯϭ͕ϭϮ΁͖ǀĂŝůĂďůĞĨƌŽŵ͗ŚƩƉ͗ͬͬǁǁǁ͘ǁŚŽ͘ŝŶƚͬĐŚƉͬƐƚĞƉƐͬhZͺdĂŶnjĂŶŝĂͺ &ĂĐƚ^ŚĞĞƚͺϮϬϭϮ͘ƉĚĨ͘΀ŝƚĞĚϱth _{Feb 2016]}

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ϰϰ͘ ŝĞƐĂƌĞD͕<ŚĂŶŐzͲ,͕ƐĂƌŝĂW͕ůĂŬĞůLJd͕ŽǁĂŶD:͕&ĂƌnjĂĚĨĂƌ&͕ĞƚĂů͘/ŶĞƋƵĂůŝƟĞƐŝŶŶŽŶͲ ĐŽŵŵƵŶŝĐĂďůĞ ĚŝƐĞĂƐĞƐ ĂŶĚ ĞīĞĐƟǀĞ ƌĞƐƉŽŶƐĞƐ͘ The Lancet. 2013; 381(9866):585-97. 45. Ministry of Finance, Tanzania. WŽƉƵůĂƟŽŶ ĚŝƐƚƌŝďƵƟŽŶ ďLJ ĂŐĞ ĂŶĚ ƐĞdž͘ Dar es Salaam 2013.

ǀĂŝůĂďůĞ ĨƌŽŵ ŝŚŝ͘ĞƉƌŝŶƚƐ͘ŽƌŐͬϮϭϲϵͬϭͬAgeͺ^ĞdžͺŝƐƚƌŝďƵƟŽŶ͘ƉĚĨ ΀ŝƚĞĚ ϯϬth _{Mar 2016]}

Chapter 1 26 47. JICA. WŽǀĞƌƚLJƉƌŽĮůĞ͗hŶŝƚĞĚZĞƉƵďůŝĐŽĨdĂŶnjĂŶŝĂ͘:ĂƉĂŶĂŶŬĨŽƌ/ŶƚĞƌŶĂƟŽŶĂůŽŽƉĞƌĂƟŽŶ͕ ϮϬϬϲ͘ǀĂŝůĂďůĞĨƌŽŵǁǁǁ͘ũŝĐĂ͘ŐŽ͘ũƉͬĂĐƟǀŝƟĞƐͬŝƐƐƵĞƐͬƉŽǀĞƌƚLJͬƉƌŽĮůĞͬƉĚĨͬƚĂŶnjĂŶŝĂͺĞ͘ƉĚĨ͘΀ŝƚĞĚ 18th _{Mar 2016]} 48. USAID. h^/ͬdĂŶnjĂŶŝĂ ,ĞĂůƚŚ ^LJƐƚĞŵ ƐƚƌĞŶŐƚŚĞŶŝŶŐ ^ƚƌĂƚĞŐLJ͗ ϮϬϭϯͲϮϬϭϴ. 2013. Available ĨƌŽŵ ŚƩƉƐ͗ͬͬǁǁǁ͘ƵƐĂŝĚ͘ŐŽǀͬƐŝƚĞƐͬĚĞĨĂƵůƚͬĮůĞƐͬĚŽĐƵŵĞŶƚƐͬϭϴϲϬͬh^/йϮϬdйϮϬ,^^йϮϬ ^ƚƌĂƚĞŐLJйϮϬ^ĞƉƚйϮϬϯϬйϮϬ&/E>͘ƉĚĨ΀ŝƚĞĚϰth _{Mar 2016]}

49. Ministry of Health and Social Welfare. TĂŶnjĂŶŝĂ^ĞƌǀŝĐĞǀĂŝůĂďŝůŝƚLJĂŶĚZĞĂĚŝŶĞƐƐƐƐĞƐƐŵĞŶƚ ZĞƉŽƌƚϮϬϭϮ͘ Dar Es Salaam. 2013.

50. Strasser R, Kam SM, and Regalado SM. ZƵƌĂů ,ĞĂůƚŚ ĂƌĞ ĐĐĞƐƐ ĂŶĚ WŽůŝĐLJ ŝŶ ĞǀĞůŽƉŝŶŐ ŽƵŶƚƌŝĞƐ͘ŶŶƵĂůƌĞǀŝĞǁŽĨƉƵďůŝĐŚĞĂůƚŚ͘ 2016; 37(5):1-18.

ϱϭ͘ t,K͘ŽƵŶƚƌLJŽŽƉĞƌĂƟŽŶ^ƚƌĂƚĞŐLJĂƚĂ'ůĂŶĐĞ͗hŶŝƚĞĚZĞƉƵďůŝĐŽĨdĂŶnjĂŶŝĂϮϬϬϵ͘ǀĂŝůĂďůĞ ĨƌŽŵ͗ŚƩƉ͗ͬͬǁǁǁ͘ǁŚŽ͘ŝŶƚͬĐŽƵŶƚƌŝĞƐͬƚnjĂͬĞŶͬ͘΀ŝƚĞĚϭϲth _{Feb 2016]}

52. Ministry of Finance, Tanzania. ϮϬϭϮWŽƉƵůĂƟŽŶĂŶĚ,ŽƵƐŝŶŐĞŶƐƵƐ͗ƉŽƉƵůĂƟŽŶĚŝƐƚƌŝďƵƟŽŶďLJ ĂĚŵŝŶŝƐƚƌĂƟǀĞĂƌĞĂƐ. Dar es Salaam. 2013.

ϱϯ͘ EĂƟŽŶĂůƵƌĞĂƵŽĨ^ƚĂƟƐƟĐƐ͘dĂŶnjĂŶŝĂĞŵŽŐƌĂƉŚŝĐĂŶĚ,ĞĂůƚŚƐƵƌǀĞLJϮϬϭϬ. Dar es Salaam. 2011. 54. WHO. t,KĐŽƵŶƚƌLJƐƚĂƟƐƟĐƐ͗hŶŝƚĞĚZĞƉƵďůŝĐŽĨdĂŶnjĂŶŝĂ͘ϮϬϭϲ͘ǀĂŝůĂďůĞĨƌŽŵ͗ŚƩƉ͗ͬͬǁǁǁ͘

ǁŚŽ͘ŝŶƚͬĐŽƵŶƚƌŝĞƐͬƚnjĂͬĞŶͬ͘΀ŝƚĞĚϮϬϭϲϭϲͬϬϮ΁͘

55. Ministry of Health and Social Welfare. ,ĞĂůƚŚ ^ĞĐƚŽƌ ^ƚƌĂƚĞŐŝĐ WůĂŶ /s :ƵůLJ ϮϬϭϱͲ :ƵŶĞ ϮϬϮϬ͗ ZĞĂĐŚŝŶŐ Ăůů ,ŽƵƐĞ ,ŽůĚƐ ǁŝƚŚ YƵĂůŝƚLJ ,ĞĂůƚŚ ĂƌĞ͘ Dar es Salaam. 2015. ϱϲ͘ tŽƌůĚ ,ĞĂůƚŚ KƌŐĂŶŝnjĂƟŽŶ͘ ǀĞƌLJďŽĚLJ͛Ɛ ďƵƐŝŶĞƐƐͲͲƐƚƌĞŶŐƚŚĞŶŝŶŐ ŚĞĂůƚŚ ƐLJƐƚĞŵƐ ƚŽ ŝŵƉƌŽǀĞ

ŚĞĂůƚŚ ŽƵƚĐŽŵĞƐ͗ t,K͛Ɛ ĨƌĂŵĞǁŽƌŬ ĨŽƌ ĂĐƟŽŶ͘ ϮϬϬϳ͘ǀĂŝůĂďůĞ ĨƌŽŵ ŚƩƉ͗ͬͬǁǁǁ͘ǁŚŽ͘ŝŶƚͬ ŚĞĂůƚŚƐLJƐƚĞŵƐͬƐƚƌĂƚĞŐLJͬĞǀĞƌLJďŽĚLJƐͺďƵƐŝŶĞƐƐ͘ƉĚĨ΀ŝƚĞĚϭϭth _{Mar 2016]}

57. Ministry of Health and Social Welfare. ,ƵŵĂŶZĞƐŽƵƌĐĞƐĨŽƌ,ĞĂůƚŚĂŶĚ^ŽĐŝĂůtĞůĨĂƌĞŽƵŶƚƌLJ WƌŽĮůĞϮϬϭϯͬϮϬϭϰ͘ar Es Salaam. 2014.

58. Bradley S, Kamwendo F, Masanja H, de Pinho H, Waxman R, Boostrom C, et al. ŝƐƚƌŝĐƚŚĞĂůƚŚŵĂŶĂŐĞƌƐ͛ ƉĞƌĐĞƉƟŽŶƐŽĨƐƵƉĞƌǀŝƐŝŽŶŝŶDĂůĂǁŝĂŶĚdĂŶnjĂŶŝĂ͘ Human Resources for Health. 2013; 11:43-9. ϱϵ͘ &ƌƵŵĞŶĐĞ'͕ELJĂŵŚĂŶŐĂd͕DǁĂŶŐƵD͕ĂŶĚ,ƵƌƟŐͲ<͘ŚĂůůĞŶŐĞƐƚŽƚŚĞŝŵƉůĞŵĞŶƚĂƟŽŶŽĨ ŚĞĂůƚŚƐĞĐƚŽƌĚĞĐĞŶƚƌĂůŝnjĂƟŽŶŝŶdĂŶnjĂŶŝĂ͗ĞdžƉĞƌŝĞŶĐĞƐ ĨƌŽŵ<ŽŶŐǁĂĚŝƐƚƌŝĐƚĐŽƵŶĐŝů͘ Global ,ĞĂůƚŚĐƟŽŶ͘ϮϬϭϯ͖ϲ͘ ϲϬ͘ tŚŝƚĞ:͕K͛,ĂŶůŽŶ͕ŚĞĞ'͕DĂůĂŶŐĂůŝůĂ͕<ŝŵĂŵďŽ͕ŽĂƌĂƐĂ:͕ĞƚĂů͘WƌŝǀĂƚĞ,ĞĂůƚŚ^ĞĐƚŽƌƐƐĞƐƐŵĞŶƚ in Tanzania͘ tŽƌůĚ ĂŶŬ WƵďůŝĐĂƟŽŶƐ͖ ϮϬϭϯ͘ ǀĂŝůĂďůĞ ĨƌŽŵ ŚƩƉ͗ͬͬĚŽĐƵŵĞŶƚƐ͘ǁŽƌůĚďĂŶŬ͘ŽƌŐͬ ĐƵƌĂƚĞĚͬĞŶͬϮϬϭϯͬϬϵͬϭϴϮϳϯϮϰϮͬƉƌŝǀĂƚĞͲŚĞĂůƚŚͲƐĞĐƚŽƌͲĂƐƐĞƐƐŵĞŶƚͲƚĂŶnjĂŶŝĂ͘ ΀ŝƚĞĚϭϬƚŚ &Ğď ϮϬϭϲ΁ 61. Kwesigabo G, Mwangu MA, Kakoko DC, Warriner I, Mkony CA, Killewo J, et al. Tanzania’s health

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27 63. Ministry of Finance, Tanzania. 'ŽǀĞƌŶŵĞŶƚ ƵĚŐĞƚ ĨŽƌ &ŝŶĂŶĐŝĂů zĞĂƌ  ϮϬϭϯͬϭϰ͗  ŝƟnjĞŶƐ͛

ƵĚŐĞƚ ĚŝƟŽŶ͘ ϮϬϭϯ͘ ǀĂŝůĂďůĞ ĨƌŽŵ ŚƩƉ͗ͬͬǁǁǁ͘ŵŽĨ͘ŐŽ͘ƚnjͬŵŽĨĚŽĐƐͬďƵĚŐĞƚͬŝƟnjĞŶƐйϮϬ ƵĚŐĞƚͬ/d/E^йϮϬh'dͺйϮϬŶŐůŝƐŚͺϮϬϭϰͺϭϱͺWƵďůŝƐŚ͘ƉĚĨ͘ ΀ŝƚĞĚ Ϯϵth _{Mar 2016]}

64. Kida T and Mujinja GM. dŚĞ/ŵƉůŝĐĂƟŽŶƐŽĨ,ĞĂůƚŚ^ĞĐƚŽƌZĞĨŽƌŵƐŝŶdĂŶnjĂŶŝĂ͘ The Economic ĂŶĚ^ŽĐŝĂůZĞƐĞĂƌĐŚ&ŽƵŶĚĂƟŽŶĂŶĚhEW͕ϮϬϭϰ͘ǀĂŝůĂďůĞĨƌŽŵĞƐƌĨ͘Žƌ͘ƚnjͬĚŽĐƐͬd,ZͲWͲϴ͘ƉĚĨ͘ ΀ŝƚĞĚϮϲth _{Mar 2016]}

65. Mtei G and Mulligan J. ŽŵŵƵŶŝƚLJ ŚĞĂůƚŚ ĨƵŶĚƐ ŝŶ dĂŶnjĂŶŝĂ͗  ůŝƚĞƌĂƚƵƌĞ ƌĞǀŝĞǁ͘ Ifakara ,ĞĂůƚŚ ZĞƐĞĂƌĐŚ ĂŶĚ ĞǀĞůŽƉŵĞŶƚ ĞŶƚƌĞ͕ /ĨĂŬĂƌĂ͘ ϮϬϬϳ͘ ǀĂŝůĂďůĞ ĨƌŽŵ ŚƩƉ͗ͬͬĐŝƚĞƐĞĞƌdž͘ŝƐƚ͘ ƉƐƵ͘ĞĚƵͬǀŝĞǁĚŽĐͬĚŽǁŶůŽĂĚ͍ĚŽŝсϭϬ͘ϭ͘ϭ͘ϱϭϲ͘ϭϵϲϮΘƌĞƉсƌĞƉϭΘƚLJƉĞсƉĚĨ͘ ΀ŝƚĞĚ Ϯϯrd _{Feb 2016]}

66. Counts CJ and Skordis-Worrall J. Recognizing the importance of chronic disease in driving ŚĞĂůƚŚĐĂƌĞĞdžƉĞŶĚŝƚƵƌĞŝŶdĂŶnjĂŶŝĂ͗ĂŶĂůLJƐŝƐŽĨƉĂŶĞůĚĂƚĂĨƌŽŵϭϵϵϭƚŽϮϬϭϬ͘ Health policy and planning. 2015; czv 081. ϲϳ͘ <ĂƟĞ tĞƐƚͲ^ůĞǀŝŶ ĂŶĚ ƵƩĂ ͘ WƌŽƐƉĞĐƚƐ ĨŽƌ ^ƵƐƚĂŝŶĂďůĞ ,ĞĂůƚŚ &ŝŶĂŶĐŝŶŐ ŝŶ dĂŶnjĂŶŝĂ͘ ϮϬϭϱ͖ ǀĂŝůĂďůĞ ĨƌŽŵ͗ ŚƩƉ͗ͬͬǁǁǁ͘ŚĞĂůƚŚƉŽůŝĐLJƉƌŽũĞĐƚ͘ĐŽŵͬƉƵďƐͬϴϬϰͺ dĂŶnjĂŶŝĂ,ĞĂůƚŚ&ŝŶĂŶĐŝŶŐƌŝĞĨƵƉĚĂƚĞ&/E>͘ƉĚĨ͘΀ŝƚĞĚϲth _{Mar 2016]} ϲϴ͘ DĂƌŝ ,ŝĐŬŵĂŶŶ ZDͲ ĂŶĚ ƌŝŶ ƵƩĂ͘ ^ƚƌĞŶŐƚŚĞŶŝŶŐ dĂŶnjĂŶŝĂ͛Ɛ ,ĞĂůƚŚ ^LJƐƚĞŵ͗ ^ƵƉƉŽƌƟŶŐ ƉƌŝŽƌŝƚLJŝŶƚĞƌǀĞŶƟŽŶƐƚŽĐĂƚĂůLJnjĞĐŚĂŶŐĞ͘ϮϬϭϰ͘ǀĂŝůĂďůĞĨƌŽŵŚƩƉ͗ͬͬǁǁǁ͘ŚĞĂůƚŚƉŽůŝĐLJƉƌŽũĞĐƚ͘ ĐŽŵͬŝŶĚĞdž͘ĐĨŵ͍ŝĚсƉƵďůŝĐĂƟŽŶƐΘŐĞƚсƉƵď/ΘƉƵď/Ěсϯϵϳ͘΀ŝƚĞĚϳth _{Mar 2016].}

69. Ministry of Health and Social Welfare. ƐƐĞƐƐŵĞŶƚŽĨdĂŶnjĂŶŝĂ͛ƐŚĞĂůƚŚŝŶĨŽƌŵĂƟŽŶƐLJƐƚĞŵ. 2007. ϳϬ͘ ,ĞĂůƚŚ /ŶĨŽƌŵĂƟŽŶ ^LJƐƚĞŵ WƌŽŐƌĂŵŵĞ͘ ŝƐƚƌŝĐƚ ŚĞĂůƚŚ ŝŶĨŽƌŵĂƟŽŶ ƐLJƐƚĞŵ Ϯ͘ 2013 Available

ĨƌŽŵ͗ŚƩƉ͗ͬͬǁǁǁ͘ĚŚŝƐϮ͘ŽƌŐͬŝŶĂĐƟŽŶ΀ĐŝƚĞĚϮϬϭϲϭϵͬϬϰ΁͘

71. Nyamtema AS. ƌŝĚŐŝŶŐƚŚĞŐĂƉƐŝŶƚŚĞ,ĞĂůƚŚDĂŶĂŐĞŵĞŶƚ/ŶĨŽƌŵĂƟŽŶ^LJƐƚĞŵŝŶƚŚĞĐŽŶƚĞdžƚ ŽĨ Ă ĐŚĂŶŐŝŶŐ ŚĞĂůƚŚ ƐĞĐƚŽƌ͘ D DĞĚŝĐĂů /ŶĨŽƌŵĂƟĐƐ ĂŶĚ ĞĐŝƐŝŽŶ DĂŬŝŶŐ͘ ϮϬϭϬ͖ ϭϬ͗ϯϲͲ͘ 72. Naomi Printz JA, Brian Serumaga, and Dirk Van Wyk. dĂŶnjĂŶŝĂ͗^ƚƌĂƚĞŐŝĐZĞǀŝĞǁŽĨƚŚĞEĂƟŽŶĂů

^ƵƉƉůLJŚĂŝŶĨŽƌ,ĞĂůƚŚŽŵŵŽĚŝƟĞƐ. 2013.

ϳϯ͘ WƌŝŵĞDŝŶŝƐƚĞƌ͛ƐKĸĐĞ͕dĂŶnjĂŶŝĂ͘dĂŶnjĂŶŝĂ͛ƐƚŚŝƌĚŶĂƟŽŶĂůŵƵůƟͲƐĞĐƚŽƌĂůĨƌĂŵĞǁŽƌŬŽŶ,/sͬ /ƐϮϬϭϯͬϭϰƚŽϮϬϭϳͬϭϴ. Dar Es Salaam. 2013.

74. Tanzania Commission for AIDS (TACAIDS). Care and Treatment͘ϮϬϭϲ΀ǀĂŝůĂďůĞĨƌŽŵ͗ŚƩƉ͗ͬͬǁǁǁ͘ ƚĂĐĂŝĚƐ͘ŐŽ͘ƚnjͬŝŶĚĞdž͘ƉŚƉ͍ŽƉƟŽŶсĐŽŵͺĐŽŶƚĞŶƚΘǀŝĞǁсĐĂƚĞŐŽƌLJΘůĂLJŽƵƚсďůŽŐΘŝĚсϰϲΘ/ƚĞŵŝĚсϮϯϬ͘ ΀ŝƚĞĚϮϬϭϲϮϴƚŚDĂƌĐŚ΁

ϳϱ͘ DŝůůƐ:͕EĂĐŚĞŐĂ:͕ƵĐŚĂŶ/͕KƌďŝŶƐŬŝ:͕ƩĂƌĂŶ͕^ŝŶŐŚ^͕ĞƚĂů͘ĚŚĞƌĞŶĐĞƚŽĂŶƟƌĞƚƌŽǀŝƌĂů ƚŚĞƌĂƉLJŝŶƐƵďͲ^ĂŚĂƌĂŶĨƌŝĐĂĂŶĚEŽƌƚŚŵĞƌŝĐĂ͗ĂŵĞƚĂͲĂŶĂůLJƐŝƐ͘ Jama. 2006; 296(6):679-90. 76. Kapesa A, Magesa D, William A, Kaswija J, Seni J, Makwaya C. ĞƚĞƌŵŝŶĂŶƚƐŽĨŝŵŵƵŶŽůŽŐŝĐĂů

ĨĂŝůƵƌĞ ĂŵŽŶŐ ĐůŝĞŶƚƐ ŽŶ ƚŚĞ ĮƌƐƚ ůŝŶĞ ƚƌĞĂƚŵĞŶƚ ǁŝƚŚ ŚŝŐŚůLJ ĂĐƟǀĞ ĂŶƟƌĞƚƌŽǀŝƌĂů ĚƌƵŐƐ ŝŶ Ăƌ ĞƐ ^ĂůĂĂŵ͕ dĂŶnjĂŶŝĂ͘ ƐŝĂŶ WĂĐŝĮĐ :ŽƵƌŶĂů ŽĨ dƌŽƉŝĐĂů ŝŽŵĞĚŝĐŝŶĞ͘ ϮϬϭϰ͖ ϰ͗^ϲϮϬͲ^ϰ͘ 77. Bodenheimer T, Lorig K, Holman H and Grumbach K. WĂƟĞŶƚƐĞůĨͲŵĂŶĂŐĞŵĞŶƚŽĨĐŚƌŽŶŝĐĚŝƐĞĂƐĞ

Chapter 1

28

ϳϴ͘ ƉƉŝŶŐͲ:ŽƌĚĂŶ :͕ WƌƵŝƩ ^͕ ĞŶŐŽĂ Z ĂŶĚ tĂŐŶĞƌ ͘ /ŵƉƌŽǀŝŶŐ ƚŚĞ ƋƵĂůŝƚLJ ŽĨ ŚĞĂůƚŚ ĐĂƌĞ ĨŽƌ ĐŚƌŽŶŝĐ ĐŽŶĚŝƟŽŶƐ͘ Quality and Safety in Health Care. 2004; 13(4):299-305. 79. Ministry of Health and Social Welfare. /ŵƉůĞŵĞŶƚĂƟŽŶŽĨ,/sͬ/^ĂƌĞĂŶĚdƌĞĂƚŵĞŶƚ^ĞƌǀŝĐĞƐ

in Tanzania. Dar es salaam: NACP, 2013.

80. Barker C. AD, and the One Health Study Team. ^ƵƐƚĂŝŶĂďŝůŝƚLJ/ŵƉůŝĐĂƟŽŶƐĨŽƌdĂŶnjĂŶŝĂ͛Ɛ&ŽƵƌƚŚ ,ĞĂůƚŚ^ĞĐƚŽƌ^ƚƌĂƚĞŐŝĐWůĂŶ͕ϮϬϭϱͬϭϲʹϮϬϭϵͬϮϬ͗&ŝŶĂŶĐŝĂů͕,ĞĂůƚŚ^LJƐƚĞŵ͕ĂŶĚ/ŵƉĂĐƚŶĂůLJƐĞƐ Using the OneHealth Tool͘&ƵƚƵƌĞƐ'ƌŽƵƉ͕ϮϬϭϱ͘ǀĂŝůĂďůĞĨƌŽŵŚƩƉ͗ͬͬǁǁǁ͘ŚĞĂůƚŚƉŽůŝĐLJƉƌŽũĞĐƚ͘ ĐŽŵͬƉƵďƐͬϱϮϳͺ&/E>dKŶĞ,ĞĂůƚŚƌĞƉŽƌƚ͘ƉĚĨ΀ŝƚĞĚϮϲƚŚ&ĞďϮϬϭϲ΁

81. Ministry of Health and Social Welfare. ĐƟŽŶ WůĂŶ ĨŽƌ ƚŚĞ WƌĞǀĞŶƟŽŶ ĂŶĚ ŽŶƚƌŽů ŽĨ EŽŶ ŽŵŵƵŶŝĐĂďůĞŝƐĞĂƐĞƐŝŶdĂŶnjĂŶŝĂϮϬϭϱƚŽϮϬϮϬ. Dar es Salaam. 2015.

ϴϮ͘ DŝŶŝƐƚƌLJ ŽĨ ,ĞĂůƚŚ ĂŶĚ ^ŽĐŝĂů tĞůĨĂƌĞ ;DŽ,^tͿ ΀dĂŶnjĂŶŝĂ DĂŝŶůĂŶĚ΁͕ DŝŶŝƐƚƌLJ ŽĨ ,ĞĂůƚŚ ;DŽ,Ϳ ΀ĂŶnjŝďĂƌ΁͕EĂƟŽŶĂůƵƌĞĂƵŽĨ^ƚĂƟƐƟĐƐ;E^Ϳ͕KĸĐĞŽĨƚŚĞŚŝĞĨ'ŽǀĞƌŶŵĞŶƚ^ƚĂƟƐƟĐŝĂŶ;K'^Ϳ͕ĂŶĚ /&/ŶƚĞƌŶĂƟŽŶĂůϮϬϭϱ͘dĂŶnjĂŶŝĂ^ĞƌǀŝĐĞWƌŽǀŝƐŝŽŶƐƐĞƐƐŵĞŶƚ^ƵƌǀĞLJ;d^WͿϮϬϭϰͲϭϱ͘Dar es Salaam, dĂŶnjĂŶŝĂ͕ ĂŶĚ ZŽĐŬǀŝůůĞ͕  DĂƌLJůĂŶĚ͕ h^͗ DŽ,^t͕ DŽ,͕ E^͕ K'^͕ ĂŶĚ /& /ŶƚĞƌŶĂƟŽŶĂů͘ ϮϬϭϱ͘ 83. Janmohamed MN, Kalluvya SE, Mueller A, Kabangila R, Smart LR, Downs JA, et al. Prevalence of

ĐŚƌŽŶŝĐŬŝĚŶĞLJĚŝƐĞĂƐĞŝŶĚŝĂďĞƟĐĂĚƵůƚŽƵƚͲƉĂƟĞŶƚƐŝŶdĂŶnjĂŶŝĂ͘BMC Nephrology. 2013; 14(1):1-5. 84. Cleland CR, Burton MJ, Hall C, Hall A, Courtright P, Makupa WU, et al. ŝĂďĞƟĐƌĞƟŶŽƉĂƚŚLJŝŶ

dĂŶnjĂŶŝĂ͗ƉƌĞǀĂůĞŶĐĞĂŶĚƌŝƐŬĨĂĐƚŽƌƐĂƚĞŶƚƌLJŝŶƚŽĂƌĞŐŝŽŶĂůƐĐƌĞĞŶŝŶŐƉƌŽŐƌĂŵŵĞ͘ Tropical DĞĚŝĐŝŶĞΘ/ŶƚĞƌŶĂƟŽŶĂů,ĞĂůƚŚ͘ϮϬϭϲ͖Ϯϭ;ϯͿ͗ϰϭϳͲϮϲ͘

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