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Tanzania
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Tanzania | Morogoro ART/PMTCT Improvement Collaborative
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Collaborative Profile
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Tanzania | Mtwara ART/PMTCT Collaborative
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Collaborative Profile
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Tanzania | Lindi ART/PMTCT Collaborative
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Collaborative Profile
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Cross-sectional examination of service delivery and costs of community- and home-based care in Tanzania
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Publications
This baseline evaluation in the Tanga District of Tanzania will evaluate the current scope of Home-Based Care (HBC) services and associated roles and responsibilities across stakeholders to inform the development of a framework and standard operating procedures for the HBC program.
This baseline evaluation will address six questions:1. How has the widespread provision of ARVs changed the scope and mandate of HBC in Tanzania?2. What is the current scope of HBC services that are being provided?3. How have changes brought by the provision of ARVs affected the relationships and roles of NGOs in providing services to PLWA?4. What are the expectations of patients, health workers and the MOH of the HBC standards of practice? (What are the essential services that should be provided?)5. What are the deficiencies in the current HBC practices?Answering these questions will inform the development of a framework and standard operating procedures (SOP) for HBC in Tanzania. SOPs are written procedures, based on national HBC guidelines, which will provide a detailed description of processes or steps to be followed in performing specific tasks (both clinical and non-clinical) related to delivery of particular healthcare interventions. The goal for developing SOPs for HBC is to provide guidance to providers and managers in the field on procedures for effective and efficient implementation of quality HBC services in line with the National HIV and AIDS Quality Improvement Guidelines and current best practices in the National HBC Guidelines.This will be a prospective cross-sectional study that examines HBC from the perspective of the three principle components of the health system: the providers, patients, and implementing partners. Both quantitative and qualitative data collection methods will be used. In-depth interviews will be the primary source of information. Quantitative data will be collected on the demographic and health characteristics of patients and HBC workers and details of the home visit (frequency, time taken, services provided, support needed, etc). Qualitative data sought include expectation and perceptions of HBC services from all perspectives, the important components of HBC, and the main perceived problems facing the delivery of HBC service as identified by HBC workers, implementing partners and patients. Furthermore, through discussions with all stakeholders suggestions on how to practically improve quality and optimize the functioning of the HBC system will be collected. -
Tanzania | Iringa Region Infant Feeding Improvement Collaborative
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Collaborative Profile
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Tanzania | Tanga Region ART/PMTCT Improvement Collaborative
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Collaborative Profile
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Strengthening systems and improving health outcomes in Tanzania
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Publications
In 2007, USAID asked HCI to work in collaboration with the Dutch agency PharmAccess International (PAI) to assist the Ministry of Health and Social Welfare (MoHSW) of Tanzania, regional and district level stakeholders, and implementing partners to set up a harmonized QI program for ART and PMTCT services in line with the MoHSW’s National Quality Improvement Framework. This short report describes HCI's approach to develop and promote a harmonized QI plan for ART and PMTCT services countrywide using a uniform set of QI tools, indicators and a reporting process integrated into the existing MoHSW monitoring and evaluation channels.
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Community Health Worker Programs: A Review of Recent Literature
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Community Resource
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Malaria Rapid Testing by Community Health Workers is Effective and Safe for Targeting Malaria Treatment: Randomised Cross-Over Trial in Tanzania
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Community Resource
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Strengthening Community Health Systems to Improve Health Care at the Community Level
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Publications
This short report summarizes the ways in which the USAID Health Care Improvement Project (HCI) is working with local groups and partners to apply quality improvement (QI) methods within the Community Health System in order to strengthen the impact of CHWs and other service providers at the community level, while at the same time increasing sustainability of programmatic impacts. Currently carrying out activities in more than 30 countries globally, HCI seeks to develop the capacity of health systems to apply modern QI approaches to make essential services better meet the needs of underserved populations; improve efficiency and outcomes; reduce costs from poor quality; and improve health worker capacity, engagement, and performance.
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Implementing the HMC Resolution on Task Shifting- Focus on Injectables. Evidence Review and Development of Country Workplans
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Community Resource
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Sequential Validity of Quality Improvement Team Self-assessments in Tanzania
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Publications
Emerging evidence indicates that collaborative improvement is a cost-effective way to improve health care quality in diverse cultures. Such improvement generally relies on data from quality improvement (QI) teams’ own assessment of their facility’s performance and results. The validity of self-assessment data is important to both the teams themselves and to the collaborative as a whole: These data provide QI teams with the information they need to identify quality problems and to learn whether their actions actually improved quality.This report presents the results of an investigation of sequential validity of self-assessment by service providers in an improvement collaborative in the Mtwara Region of Tanzania. Study objectives were to determine the validity of self-assessments by the QI teams and whether validity improved during the first year of the collaborative.The study was carried out in nine health care facilities participating in an improvement collaborative in Mtwara Region of Tanzania, during its first 10 months of activity. The collaborative is addressing HIV/AIDS care, particularly as it relates to antiretroviral therapy (ART) and the prevention of mother-to-child transmission of HIV (PMTCT).The research team defined eight activities in the self-assessment process that can influence the validity of the information that results: 1) writing the records, 2) storing and retrieving records, 3) selecting records from which to abstract data, 4) abstracting data from the selected records, 5) summarizing the abstractions, 6) the agreement of computer and written records, 7) the quality and use of computer records, and 8) communicating the summary data (results related to improving the quality of care) to other members of the QI team and the clinical staff. The team then developed and tested forms and procedures for measuring the validity of the information each activity produced.The study found significant upward trends in measurement scores occurred for the tasks of writing the record, selecting the sample, the use of computer results, and communicating results. No significant change in validity occurred in storing and retrieving records, abstracting or summarizing selected records, or agreement of written records with computer records. However, some of these activities started high and remained high throughout the study: For retrieving records, validity was close to 100% in the first and last two measurements for most cases; for abstracting records, a small increase occurred in validity during the study for all three indicators but was significant for only one of them; and for summarizing abstracts, errors were zero or close to it throughout the study. Changes in validity were roughly the same for all three indicators.Over the course of the study, validity either improved or started and remained high for most self-assessment activities; none decreased. The communication activity, which differs from the others in that it does not contribute directly to the validity of the performance scores reported by the QI teams, had a very low end-of-study score across all sites, suggesting limited use of data for QI activities. With few exceptions, this study shows that self-assessment as part of Mtwara improvement collaborative provided valid data and improved as the collaborative matured. This finding—coupled with the result that some steps in the self-assessment process, such as storing and retrieving records and communicating results, are not always done well—suggests the need to address these activities early in a collaborative. The finding that the validity of abstracted data between QI teams and the gold standard set by the expert reviewers was not statistically different is especially encouraging.
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Spread of PMTCT and ART Better Care Practices through Collaborative Learning in Tanzania
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Publications
The Tanzania National AIDS Control Program (NACP) and PEPFAR initiated the Partnership for Quality Improvement (PQI) in 2007 to develop and promote a harmonized quality improvement (QI) plan for antiretroviral therapy (ART) and prevention of mother-to-child transmission (PMTCT) services countrywide. The partnership included PEPFAR’s HIV/AIDS care and treatment implementing partners, with technical leadership from the USAID Health Care Improvement Project (HCI), implemented by University Research Co., LLC (URC), and PharmAccess International (PAI).
The PQI introduced the “Improvement Collaborative” strategy to generate better care practices to improve care provided to those needing HIV and AIDS services and has developed improvement collaboratives in four regions. Collaborative improvement is built on multiple teams working on a common aim and sharing learning about what works to achieve results more rapidly. This study evaluates peer-to-peer learning among health workers and the spread of better care practices within regions and across regions in the PQI ART/PMTCT collaboratives in Tanzania.This cross-sectional evaluation used quantitative and qualitative methods to measure use of mechanisms for exposure and sharing of change ideas, changes implemented, and factors that facilitated or hindered sharing and uptake of change ideas. Data were collected in three regions (Tanga, Morogoro, and Mtwara) in a total of 25 sites. URC/Tanzania staff collected data through interviews and focus group discussions with team members, Council Health Management Teams, Regional Health Management Teams, implementing partners, and the NACP during the period of February to May 2010.The evaluation found that across the three regions, the great majority of ideas were “borrowed” from other teams, indicating that ideas of other teams are the main sources of adopted changes. The most commonly used (and also the most favored methods) of presenting information about changes were oral presentations with visuals, written descriptions, provision of tool/materials, evidence on effectiveness and warnings to avoid failures. Simplicity of the change idea was most frequently listed as the most important factor to try an idea, while a perceived lack of necessity was the top reason not to try. External support was the most important factor favoring implementation, while lack of technical support was the top hindering factor.The results of the study indicate that shared learning and spread of better care practices or effective changes is taking place both within and across the three regional collaboratives studied. Teams desired relatively detailed information about “how to do” the changes they were exposed to. Results also show that not all changes were equally spreadable; spread depended on how straight-forward was their implementation and whether it required authority or resources beyond the purview of the facility. Additional mechanisms for sharing learning across regions are needed, as well as mechanisms within regions that build on existing structures and meeting opportunities. -
The Partnership for Quality Improvement to Improve PMTCT and ART Services in Tanzania: Assessment of Results, Capacity, and Potential for Institutionalization
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Publications
The USAID Health Care Improvement Project was asked by USAID in 2007 to assist the Tanzanian Ministry of Health and Social Work (MoHSW), regional and district level stakeholders, and implementing partners to set up a national Quality Improvement (QI) program for ART/PMTCT services in line with the Tanzania National Quality Improvement Framework. The QI program soon became known as the Partnership for Quality Improvement (PQI). The main aims of the PQI were to: 1) Build capacity for a harmonized QI approach among the many implementing partner organizations working this area, thereby accelerating the speed of and increasing the resource pool for QI in Tanzania; 2) Strengthen capacity for QI at national, regional, district and health facility levels (particularly in light of recent health care reforms to decentralize health services); and 3) Demonstrate the effectiveness of QI collaborative methods in improving patient outcomes in a limited number of regions (a prototype prior to spreading to additional regions).
HCI worked with the National AIDS Control Program (NACP) and the Dutch NGO PharmAccess to develop and implement the PQI. PQI was first launched in Tanga in May 2008 in partnership with AIDS Relief; the second region, Morogoro was included in February 2009, with Family Health International (FHI); and the third region, Mtwara, was added in June 2009 with The Clinton Health Access Initiative (CHAI) and Elizabeth Glaser Pediatric AIDS Foundation (EGPAF). CHAI and EGPAF also committed their own funding and began to replicate PQI in late 2009 to the Lindi region.
The evaluation study examined how well the PQI has worked in the three first regions (Tanga, Morogoro, and Mtwara) and identified how the approach could be further strengthened or modified for spread to other regions in Tanzania in the future.
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Improving Care for People with Chronic Conditions in East Africa
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Publications
Until recently, malaria and other acute infectious diseases were the leading causes of mortality and morbidity in East Africa, and the health systems in the region were generally designed to manage acute conditions. Now with the advent of the HIV pandemic and increasing prevalence of non-communicable diseases, health systems are struggling to manage people with chronic conditions. Helping health systems change from the acute care model to one which has structures and processes in place to help people living with chronic conditions manage their condition at home will require transformation at many levels. HCI is working with the Ministries of Health in Uganda and Tanzania to make these changes. This flyer describes current efforts supported by HCI to promote the use of the Chronic Care Model, an evidence-based set of principles for improving chronic condition care that has been endorsed by the World Health Organization.
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Baseline Assessment of HIV Service Provider Productivity and Efficiency in Tanzania
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Publications
Tanzania, like many other countries in Africa, is facing a severe shortage of qualified health professionals. Only 35% of positions in government health facilities have been filled, leaving Tanzania in the wake of burgeoning human resources for health crisis. According to the Annual Health Statistical Abstract from 2008, the national average of the population per medical officer was 64,000, 31,000 per assistant medical officer, and 7,000 per clinical officer. The shortage of health professionals has been exacerbated by the HIV/AIDS pandemic and other communicable diseases such as malaria and TB.
In an effort to improve the quality of care of HIV services delivered in Tanzania, the USAID Health Care Improvement Project (HCI) and the Ministry of Health and Social Welfare (MOHSW) began implementing a partner improvement collaborative in the Mtwara region in nine care and treatment centers in June of 2009. The aim of the collaborative is to apply QI methods to ART and PMTCT services in order to ensure a high quality of care is being delivered to clients. The collaborative is now looking to integrate HR interventions into its work in order to improve efficiency of service delivery, and strengthen health worker performance and engagement. Health worker productivity and engagement are integral to improving efficiency as they determine what tasks health workers perform and how engaged and motivated they are to perform at a high level.In collaboration with the Government of Tanzania, HCI designed a baseline assessment of HIV/AIDS service providers to gather information on productivity and engagement. The information gathered from this baseline assessment will be used to develop a set of HR improvement packages based on best practices that will be integrated into the ongoing ART collaborative. The baseline was conducted in six sites in the region of Mtwara from June 30th- July 6th, 2010.The assessment identified several areas where human resource management systems can be improved to strengthen provider efficiency and productivity and improve the quality of HIV/AIDS service delivery. All health workers should be provided with written job descriptions that clearly align their tasks and goals. Without written job descriptions, it is impossible to implement strong performance management. Recognition and reward systems can be improved to ensure that health workers get the acknowledgement and praise they deserve when they perform well. The process for performance evaluations needs to be communicated clearly with lower level facilities. Facility managers and providers should also learn how to set performance objectives. Promotion and career advancement opportunities are somewhat rare, which may affect worker motivation. The majority of employees are moderately engaged, regardless of the type of facility or the position they hold, but specific areas of engagement, such as recognition and materials, could be improved. Productivity appears to vary throughout the day with providers being very productive in the morning when patients arrive and productivity levels decreasing dramatically in the afternoon when client loads are low. Client flow does not appear to be a problem, but is something that should continue to be monitored since client loads can vary dramatically by day. -
Health Workforce Competency and Facility Readiness for Safe Deliveries in Tanzania
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Publications
Tanzania, like many East, Central and Southern African Countries, is facing high maternal and newborn mortality and morbidity rates. The percentage of women delivering at health facility under care of a skilled attendant in Tanzania is estimated to be 46%.
Recognizing the value of studies of the competency of healthcare providers and their working environment, the East, Central and Southern Africa Health Community (ECSA-HC) in collaboration with Ministry of Health and Social Welfare (MOHSW) Tanzania conducted this study aiming at determining the competency levels of health providers, and enabling factors provided by the facility and the health system.
The study was conducted in 2008 in eight districts within four regions of Tanzania Mainland: Kisarawe and Bagamoyo (Coast Region), Singida Rural and Manyoni (Singida Region), Njombe and Mufindi (Iringa Region), and Muheza and Korogwe (Tanga Region). The assessment comprised of two parts to which each participant was subjected: (1) A knowledge test consisting of 50 multiple choice and true/false questions covering several topics mainly infection prevention, uncomplicated labor and delivery, prevention and management of hemorrhage, immediate care of the newborn including newborn resuscitation and prevention and management of sepsis. The test was scored using a predetermined answer key; (2) Assessment of five skill areas - (i) active management of the third stage of labor (AMTSL), (ii) manual removal of placenta, (iii) bimanual uterine compression (iv) immediate newborn care, and v) neonatal resuscitation by observing participant performance of each procedure on an anatomical model. Each participant was assessed in these five areas by trained observers.
The findings indicated that providers performed average in several areas (1) the average score for knowledge test was 56%, with the scores progressively improving with ranking of facility category from 50% for dispensaries to 58% for district hospitals and also with increasing qualifications from 45% among medical attendants to 62% among Medical Officers and AMOs. (2) The average score for skills of active management of the third stage of labor skill and manual removal of the placenta were 55.3% and 54.5% respectively. Bimanual uterine compression, immediate newborn care (36%) and neonatal resuscitation (25%) were generally poorly performed compared to the others. There were no statistically significant differences between different facility and cadre levels: Nonetheless, it was realized that providers appreciated feedback and performance was observed to improve immediately on some of infection prevention steps.
Regarding facility readiness, some key medicines such as antibiotics and haematenics were available in most health facilities. However, lives saving medicines such as oxytocin and magnesium sulphate were not in stock in more than 60% of the facilities. Organization and sustainability of referral/counter-referral systems and use of maternal and neonatal health standards were also poor.
It is concluded that gaps to provision of quality maternal and newborn services exist with regard to competency of health personnel, infrastructure and referral systems. There is also indication that minimal investment in training on specific approaches for prevention and management of life-threatening complications will significantly contribute to the reduction of maternal and neonatal mortality and morbidity. It is recommended that the MOHSW and stakeholders design and implement strategies to ensure sustained improvement of service providers’ capacity, the support systems at health facilities including infrastructure, supplies and equipment, as well as strengthening referral and counter-referral systems, to ensure safe deliveries in health facilities.
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Spread of PMTCT and ART Better Care Practices through collaborative learning in Tanzania
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Publications
This evaluation takes place in the context of the “Partnership for Quality Improvement” (PQI) initiative in Tanzania. The partnership was initiated in 2007 by the Tanzania National AIDS Control Program (NACP) and PEPFAR to improve the quality of ART/PMTCT services in Tanzania through the implementation of a harmonized approach to modern quality improvement. At the time of this report, the Health Care Improvement Project (HCI) and PharmAccess International (PAI) are providing technical leadership to facilitate shared learning among ART/PMTCT collaboratives managed by implementing partners (FHI, CHAI. EGPAF, AIDS Relief etc.) and regional health management teams in Tanga, Morogoro, Mtwara and Lindi.
Within the partnership, learning developed within one partner’s collaborative should lead to rapid uptake of effective changes by other teams, leading to desired level of results for all teams. Sharing this learning should not be limited just within that region or that implementing partner, but spread to other regions supported by other partners as well. This ability to build on learning within regions, within partners, across regions and across partners is important for efficient achievement of better care and better outcomes for people affected by HIV and AIDS.Research questions/objectives:This evaluation seeks to study the mechanisms and results of the spread of better care practices in the Partnership for Quality Improvement. Identifying facilitating and hindering factors for shared learning and spread will help determine how learning among peers and spread of better care practices can be strengthened within the PQI context. The specific objectives of this evaluation are:1. To describe the various steps involved in the change process including the origin of ideas, their testing and implementation and their subsequent spread to other teams.2. To determine the various internal and external factors influencing the change process and identify means to augment the effects of favorable factors and remove barriers.3. To explore the role of the higher levels of the health system and collaboratives in catalyzing the spread of best practices and their scale up.The lessons learnt from this evaluation will provide guidance to quality improvement programs in other countries for strengthening learning among peers and improving spread within a collaborative approach or in other quality improvement efforts.Methodology:This is a cross-sectional evaluation which involves both quantitative and qualitative methods of data collection. All sites in the 3 regions (Tanga, Morogoro and Mtwara) whose collaboratives have been operative for more than 6 months were included in this evaluation (total of 29 facilities). Data was collected by interviewing the quality improvement focal person of facility teams and through focus group discussions with QI team members.Results:Results of the evaluation showed that the improvement collaborative is indeed facilitating sharing of ideas. Across the three regions, the great majority of ideas are “borrowed “from other teams, managers and coaches; with Tanga and Morogoro borrowing almost 70% of ideas, while in Mtwara 40% of the ideas had been borrowed. This indicates that ideas gained from participating in the collaborative are the main sources of adopted changes. The HCI/Tanzania project team composed a list of 16 effective changes (as of January 2010. Of these 16 effective change ideas teams had tried an average 12.6 changes per facility. Four of these 16 changes were tried by all facilities: issuing a 2 month supply for clients living far away; reorganizing patient charts for easy retrieval, establishing a mother-child register to link children to their HIV+ mother; and issuing Co-trimoxazole in the Reproductive Health Clinics.Learning sessions and coaching were the primary mechanisms for being exposed to or sharing changes with other teams, but other meetings, site visits, and phone calls were also used. Teams desired detailed information about “how to carry out” the changes they are being exposed to. Not all changes were found to be equally spreadable – spread of ‘better care practices” depended upon how straight-forward their implementation is and whether teams possessed the authority or resources to implement the activity. Staff engagement and staff resistance were cited as important factors impacting the implementation of a change. Implementation also depended upon external technical support, facility leadership and capacity for change. At present, the sharing across collaboratives has been mainly dependent on the role of the HCI/PAI team to create the linkages across collaboratives and regions. Additional mechanisms for sharing learning across a network of regions are needed, as well as mechanisms for sharing learning within a region that build on existing structures and opportunities. -
Sustainabilitiy of the Effectiveness of a PMTCT Counselor Training Program during National Scale-up | Tanzania
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Publications
This study evaluated whether a PMTCT Infant Feeding Counseling Program that includes training of counselors, facility supervisors and facility staff, counselor job aids, and mother take-home brochures was fully implemented in program facilities and yields healthier, better nourished infants at 6 months of age than a PMTCT program without it, comparing program exposure, nutritional status and heath history of 190 infants at 6 months of age from 4 intervention facilities and 4 matched control sites. Home visits using in-depth, semi-structured interviews, weight measurement and direct observation were done with 190 mothers (and their children) who received PMTCT antenatal counseling at one of the 8 study facilities and who recently delivered. Program exposure was measured by the mother’s report of receiving a take-home brochure at the antenatal counseling session; health history in terms of infants’ infectious disease episodes from birth to six months, and nutritional status based on weight-for age at 6 months adjusted for birthweight. Read more in the final report.
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Health Workforce Competency and Facility Readiness for Safe Deliveries | Tanzania
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Publications
The maternal mortality ratio in Tanzania is estimated to be 578/100,000.1 A great majority of these deaths are due to obstetric complications, 90% of which can be avoided. Some obstetric complications can be predicted and most are treatable if women receive high quality care when needed.2 Care provided by a competent Skilled Birth Attendant (SBA) during labor, delivery and in the immediate postpartum period is a key component of quality obstetric care. The percentage of deliveries assisted by a SBA has become a proxy indicator for reducing maternal mortality.3
Despite the wide coverage of training service providers on Basic and Advanced Life Saving Skills in Tanzania since 2003, there is limited information on maternal and newborn care provider competency or the impact of these trainings. Therefore, the need to determine the competency levels of the service providers and functionality of the health systems was urgent.Research questions/objectivesThe research objectives of this study were three-fold:1.To determine the current competency levels of the workforce attending to women and newborn during labor, delivery and the immediate postpartum period (first 24 hours)2. To determine the facility readiness for provision of care during labour, delivery and immediate postpartum period.3. To provide recommendations for quality improvement in the delivery facilities.MethodologyThe study was conducted in eight districts within four regions of Tanzania Mainland, namely Kisarawe and Bagamoyo (Coast Region), Singida Rural and Manyoni (Singida Region), Njombe and Mufindi (Iringa Region), and Muheza and Korogwe (Tanga Region). The assessment comprised two parts: (1) a knowledge test consisting of 50 multiple choice and true/false questions covering several topics inlcuding infection prevention, uncomplicated labor and delivery, prevention and management of hemorrhage, immediate care of the newborn including newborn resuscitation and prevention and management of sepsis. The test was scored using a predetermined answer key. And (2) assessment of five skill areas - (i) active management of the third stage of labor (AMTSL), (ii) manual removal of placenta, (iii) bimanual uterine compression (iv) immediate newborn care, and v) neonatal resuscitation by observing participant performance of each procedure on an anatomical model. A total of 194 service providers from these facilities participated. Each participant was assessed in these five areas by trained observers.Health facilities were evaluated using a checklist for the existence of the essential and enabling factors. These included: human resource, medical waste management, availability of water and source of light, essential medicines, equipment and supplies, functionality of referral system, and availability and use of maternal and newborn guidelines standards.Results/FindingsThe average score for the knowledge test was 56%, with the scores progressively improving with ranking of facility category from 50% for dispensaries to 58% for district hospitals and also with increasing qualifications from 45% among medical attendants to 62% among Medical Officers and AMOs. The average score for active management of the third stage of labor and manual removal of the placenta were 55.3% and 54.5% respectively. Bimanual uterine compression, immediate newborn care (36%) and neonatal resuscitation (25%) were generally poorly performed compared to the others. There were no statistically significant differences between different facility and cadre levels.Regarding facility readiness, some key medicines such as antibiotics and haematenics were available in most health facilities. However, live-saving medicines such as oxytocin and magnesium sulphate were not in stock in more than 60% of the facilities. Organization and sustainability of referral/counter-referral systems and use of maternal and neonatal health standards were also poor.These findings indicate that gaps to provision of quality maternal and newborn services exist with regard to competency of health personnel, infrastructure and referral systems. There is also indication that minimal investment in training on specific approaches for prevention and management of life-threatening complications will significantly contribute to the reduction of maternal and neonatal mortality and morbidity.
1. World Health Organization 2006. Making a Difference in Countries: Strategic Approachto Improving Maternal and Newborn Survival and Health. Department of MakingPregnancy Safer. WHO: Geneva, Switzerland.http://www.who.int/making_pregnancy_safer/documents/wa3102006ma/en/index.html2. World Health Organization, 2004. Maternal Mortality in 2000: Estimates developed byWHO, UNICEF and UNFPA). WHO: Geneva, Switzerland.3. National Bureau of Statistics (NBS) [Tanzania] and ORC Macro. 2005. TanzaniaDemographic and Health Survey, 2004-5. Dar es Salaam, Tanzania. National Bureau ofStatistics and ORC Macro.
