Who Tanzania Report - World Health Organization

INTRODUCTIONIntroductionThis report covers the period of two years - 2018 and 2019 - andreflects the work accomplished over these 24 months. It highlightsthe delivery of results achieved in supporting the country andcollaborating with partners to improve health outcomes inTanzania.The WHO Country Office (WCO) played a critical advisory rolewith respect to the development of health policies andstrategies, technical guidelines and mechanisms to implementnorms and standards. It provided technical policy advice,contributed to sustainable capacity-building, strengthenedmanagement capacity and provided health leadership bycoordinating efforts at the national, regional and district levels.Achievements outlined in this report were made possiblethrough strong national leadership, good governance, andcollaboration with multilateral and bilateral partners and localand international nongovernmental and civil societyorganizations.The report is organized around the priority areas (Fig. 1)outlined in the Country Cooperation Strategy (CCS) for theperiod of 2016-2020 for the United Republic of Tanzania namely: reducing the morbidity and mortality caused bycommunicable diseases through appropriate and effectiveinterventions; reducing the burden of noncommunicable diseases (NCDs)through health promotion and reduction, prevention,treatment and monitoring of the risk factors; contributing to Reproductive, Maternal, Newborn, Child andAdolescent Health (RMNCAH) and well-being, promotion ofhealth through addressing the social determinants ofhealth; strengthening health systems to improve the quality, equityin access and utilization of health services; and providing support for developing the minimum InternationalHealth Regulations (IHR) (2005) core capacities andstrengthening the capacity to implement disaster riskmanagement.FIGURE 1: Priority areas of the Country Cooperation Strategy 2016-2020Reducing the burden ofnoncommunicable diseasesReducing the morbidity and mortalitycaused by communicable diseasesThis report isorganised aroundthese priority areas:Providing support for developing the minimumInternational Health Regulations core capacitiesStrengthening health systems toimprove health servicesContributing to Reproductive, Maternal,Newborn, Child and Adolescent HealthWHO Tanzania Biennial Report vii

CHAPTER 101EFFECTIVELEADERSHIP ANDPARTNERSHIPS FORHEALTHviii WHO Tanzania Biennial Report

CHAPTER 1The mission of the WHO Programme in Tanzania is topromote the attainment of the highest sustainable levelof health by all people living in the country throughcollaboration with the Government and other partnersin health, and the provision of technical and logistic support tocountry programmes.The WHO technical cooperation in the country is coordinated bythe WHO Country Office (WCO) which comprises 52 staffmembers stationed at the main office in Dar es Salaam,sub-offices in Zanzibar and Dodoma, and field offices in Tanga,Mwanza, Kigoma and Iringa.The WCO collaborates with multilateral and bilateral partners,and local and international nongovernmental and civil societyorganizations. The organization is an active player in the SectorWide Approach (SWAp) and participates in the Delivering as OneUN Framework in Tanzania. WHO is also a Secretariat to theDevelopment Partners Group for Health (DPG H). The WCOseeks harmonization and alignment of partners’ support withthe national priorities and health sector development.The Country Cooperation Strategy (CCS) for the period of2016-2020 in the United Republic of Tanzania outlines the visionof WHO’s work in the country. The CCS priorities advanceimplementation of the country’s Health Sector Strategic Plan IV.In undertaking its work, the WCO Tanzania conducts activitiesacross four technical programme clusters (Fig. 2). These arethe Health Systems Strengthening (HSS); Disease Preventionand Control (DPC); HIV/AIDS, Tuberculosis and Malaria (ATM)and the Family and Reproductive Health (FRH) Clusters. In linewith the vision of the WHO Transformation Agenda, the CountryOffice clusters implement and report on 20 programmatic andmanagerial key performance indicators (KPIs).The WHO Representative leads programmatic clusters, withoperational support from the Country Support Unit (CSU), whichis directly supervised by the Operations Officer and generalsupervision by the WHO Representative and the DirectorGeneral Management Cluster at Regional Office. In Zanzibar,the sub-office is headed by a Public Health Administrator whoprovides support to Zanzibar in collaboration with the mainWCO staff.FIGURE 2: Country Office programmatic clustersActivities are conductedacross four technicalprogramme clustersWCO TanzaniaHealth SystemsStrengthening(HSS)DiseasePrevention andControl (DPC)HIV/AIDS,Tuberculosis andMalaria (ATM)Family andReproductiveHealth (FRH)WHO Tanzania Biennial Report 1

CHAPTER 102REDUCING THEBURDEN OFCOMMUNICABLEDISEASES2 WHO Tanzania Biennial Report

CHAPTER 2WHO scaled up coverage of cost-effectiveinterventions for prevention and treatment tosupport Tanzania in tackling communicablediseases. In 2018 and 2019, WCO support oncommunicable diseases targeted HIV, tuberculosis, malaria,viral hepatitis, neglected tropical diseases (NTDs), and vaccinepreventable diseases, including hepatitis.HIV/AIDSThe HIV response in Tanzania is guided by the Health Sector HIVStrategic Plan 2017-2022 and the National Multi-SectorialFramework (NMF) 2018-2023, both aligned to the global90-90- 901 targets. The government of Tanzania steers thecoordination, implementation and monitoring of interventionssupported by implementing partners. The country has ageneralized epidemic with pockets of hotspots of key andvulnerable populations.An estimated 1.5 million people were living with HIV in 2018.Annual AIDS-related deaths have dropped from 27,000 in 2016to 24,000 in 2018. The country manages an antiretroviralprogramme that has over 1.1 million people living with HIV(PLHIV) accessing treatment (Fig. 3).FIGURESituationininTanzaniaTanzania2018in 2018 (Source: THIS Report (2016/2017))FIGURE3:X:HIVHIV/AIDSPeople living with HIV1.5 MILLIONAIDS deaths201627, 000201824, 000People on ARTs1.1 MILLIONNew ARTs690, 000 by Sept. 20191 y 2020, at least 90% of PLHIV should know their HIV status, 90% of those who are diagnosed HIV should be initiated on antiretroviral treatment,Band 90% of those on treatment should achieve durable viral load suppression.WHO Tanzania Biennial Report 3

CHAPTER 2FIGURE 4: HIV Treatment Cascade basedon the Tanzania HIV Impact Survey (THIS)Report (2016/2017)Proportion of total HIV positive individuals (%):ALL60.9%93.7%87%DiagnosedOn agnosedOn sedOn treatment4 WHO Tanzania Biennial ReportVirallysuppressedIntroducing New ART FormulationsIn this biennial (2018-2019), the WCO supported the transition tomore efficient dolutegravir (DTG)-based formulations asfirst-line regimens for adolescents and adults and optimizedregimens for children. After successful consultative advocacyefforts, the paediatric technical working groups (TWGs) and theMinistry of Health, Community Development, Gender, Elderlyand Children (MOHCDGEC) revised the National HIV and AIDSguidelines to incorporate the new formulations containing DTGfor adolescents and adults, and newer optimized regimens inchildren. The new drugs were introduced through well-plannedand monitored phases. First, DTG drugs were introduced innational and referral hospitals in March 2019, followed byregional hospitals in May 2019 and finally district facilities inJuly of the same year.Tackling Low Viral Load TestingWCO collaborated with the MOHCDGEC and other stakeholdersto develop the VL Sample Referral and Results FeedbackGuidelines that integrated HIV and TB sample referrals. It isexpected that this will raise the number of PLHIV who test theirviral load (VL) and get their results on time.The WCO works with the Government to scale up accessto HIV prevention, diagnosis, care and treatment servicesas outlined in the Country Cooperative Strategy (CCS)2016- 2020.Responding to ART Drug ResistanceThe WCO collaborated with the MOHCDGEC and otherstakeholders to respond to the increase in drug resistance tofirst-line regimens noted among PLHIV in Tanzania and the restof sub-Saharan Africa. The WCO supported the development ofthe first five-year National HIV Drug Resistance Prevention andControl Plan (2018- 2022). Additionally, the WCO supported thedevelopment of the 2016 – 2017 HIV Drug Resistance AnnualReport (Fig. 4) and guided the National Health LaboratoryQuality Assurance and Training Centre’s (NHLQATC) initialpreparation of HIV drug resistance (HIVDR) surveillance. TheWCO, the National AIDS Control Program (NACP) and theUniversity of Dar es Salaam (UDSM) incorporate HIVDR earlywarning indicators in the District Health Information Software 2(DHIS2) system, which will be upscaled to all care and treatmentcentres (CTCs) that have electricity upon successful piloting.Targeted HIV TestingTo strengthen focused and targeted testing, the WCO, incollaboration with other partners, supported the MOHCDGEC todevelop the Accelerated Plan on HIV Testing Services (HTS)2019/2020. The plan prioritized interventions in geographicalareas and populations based on the remaining burden of

Monge/WHOCHAPTER 2unidentified PLHIV. To fasttrack its implementation, the WCOsupported contextualizing the plan in nine high-burden regionsand developing focused, targeted and prioritized HIV testingbased on burden. The plan will also facilitate response tostockouts of rapid HIV test kits experienced in 2018.Key PopulationsThe WCO funded an assessment of key and vulnerablepopulation (KVP) services and has reviewed findings andrecommendations that will inform policies and enablingenvironments for improving utilization of KVP services.For Zanzibar, WHO oriented the Zanzibar HIV Programme,Ministry of Health (MOH) on the WHO pre-exposure prophylaxis(PrEP) guidelines, including justification for PrEPimplementation in the local context.HIV InformationIn strengthening the quality of HIV information for enhancedprogrammatic decision-making, the WCO supported thedevelopment of HIV and other health dashboards in DHIS usingWHO standard data analyses packages. This went hand in handwith the training of national and subnational staff in data useand health information strengthening. WHO facilitated thedevelopment of an Electronic TB and Leprosy (ETL) module andTB dashboard in DHIS2 and the subsequent training of allregional TB focal persons on the use of the ETL module.Support has also been provided in the development of a TBdashboard that supports quick decision-making at bothnational and subnational levels.WHO Tanzania Biennial Report 5

CHAPTER 2TuberculosisIn 2019, WHO estimated Tanzania to have an annual TB burdenof 142,000 TB cases, which is a 13.4% decline compared to year2015.This means that the country is on track to achieve the 2020milestone of reducing TB burden by 20% from the baseline ofyear 2015. The positive decline is also noted in the reduction ofTB deaths by 27% in 2018 compared to 2015, whereas the 2020milestone is a 35% reduction in TB deaths (Fig. 5). Data reportedin 2018 show an increase in case notification compared toprevious years (Fig. 6). Notified cases present only 53% of the TBburden in 2018.The United Republic of Tanzania is among the 30 countrieswith the highest burden of tuberculosis globally.FIGURE 5: Progress towards 2020 Goals inElimination of TB in Tanzania2015(Baseline)TB burdenTB deaths100%100%27%decreasefrom 201513.5%decreasefrom efrom 20156 WHO Tanzania Biennial Report65%The WCO supported the development of a comprehensiveframework for finding missing TB cases, which now guides thenational TB programme and partners on approaches andsupport required to improve case detection and bringing TBpatients to treatment.Framework on Finding TB Missing CasesIn line with global recommendations and support from the StopTB Partnership, the WCO facilitated the introduction of paediatricfixed-dose anti-tuberculosis drug formulations that are morepalatable and therefore minimize the risk of under-dosing orover-dosing for children. The WCO supported the National TBand Leprosy Programme (NTLP) to establish the TB communityTechnical Working Group that will engage communities asguided by the national guidelines on ENGAGE-TB.One of the priority global targets in ending TB is protecting TBpatients and their households from the catastrophic costscaused by TB. The WCO and the Ministry of Health and WHOHeadquarters mapped the current social protection landscapeand identified platforms and/or opportunities that could supportthe needs of people affected by TB.WHO supported monitoring the implementation of the TBDrug Resistance Survey. The findings show no increase inDR TB among new and re-treatment patients.Findings show that there are no specific policies to offer socialprotection for TB patients and only TB patients with multi-drugresistant TB receive transport allowances. The findings of thisassessment will supplement ongoing national TB Patient CostSurveys that began in 2019.73%20%projecteddecreasefrom 2015More than 50% of TB cases in Tanzania are attributedto undernourishment caused by poverty, worsened bythe direct and indirect costs related to TB diagnosis andtreatment.

CHAPTER 2FIGURE 6: Notified TB cases from 2012 - 2018MalariaRevitalizing the Drive to End Malaria201874686Year of 5732201250000638925500060000650007000075000Numbers of casesViral HepatitisThe international community has set a goal to end hepatitis by2030. The WCO supported the development of the Viral HepatitisStrategic Plan for Tanzania Mainland (2018-2022) and theZanzibar National Strategic Plan (2019-2023). The plans willguide programming and resource mobilization. The WCOsupported the MOHCDGEC to collect baseline data on hepatitisB and C and submitted national data, for the first time, to theGlobal Hepatitis Reporting System (GHRS) in 2018.In July 2018 and 2019, MOHCDGEC and WHO officiated duringthe commemoration of World Hepatitis Day in both MainlandTanzania and Zanzibar. During the commemorations, Zanzibarlaunched the Viral Hepatitis Strategic Plan.In February 2018, WHO supported the National Malaria ControlProgram (NMCP) on Mainland Tanzania to carry out a MidTerm Review (MTR) of the National Strategic Plan (NSP) in aconsultative meeting with malaria experts globally includingthe Global Malaria Programme (GMP) and WHO AFRO. Overall,the recommendations suggested a major review of the currentNational Strategic Plan for Prevention and Control of Malaria(NMSP) 2015-2020 towards a strategic direction that wouldlead to greater impact. The justification for a supplementarystrategy was the steady decline in the incidence of the diseaseand the diversity in transmission intensity. On top of that, theGlobal Technical Strategy for Malaria (GTS) 2016-2030recommends that endemic countries, including Tanzania,should conduct an epidemiological stratification of malaria tooptimize the implementation of the recommended malariainterventions.The epidemiological stratification, which was performed by theNMCP in collaboration with WHO and other malaria partners,identified four epidemiological strata and one operationalstratum. The epidemiological strata are: very low, low, moderateand high. The urban setting was identified as the onlyoperational stratum.In 2018, the WCO supported the MOHCDGEC to submit forthe first time national data in the Global Hepatitis ReportingSystem.WHO Tanzania Biennial Report 7

CHAPTER 2FIGUREMacro-stratification;malariaFIGURE7: X:HIV/AIDS in Tanzania2018 epidemiological and operational strataKageraGeitaMaraSimiyuMwanzaCount of atumEpi strataEpi non epi strataVery Low33Low65Moderate66High1111Urban-1Total2626Very lowLowRuvumaMtwaraModerateHighBeyond the epidemiological stratification, the NMCP, incollaboration with WHO and partners, developed appropriateintervention packages suitable for each stratum. This is a majormilestone for the malaria control programme in the country andwill go a long way to enhance value for money.initiative, a country-led response to reignite and refocus thefight against malaria based on Global Technical Strategyrecommendations and targets.High Burden to High Impact Initiative in TanzaniaThe World Malaria Report 2017 shows that around 71% of theestimated malaria deaths occurred in 10 countries in subSaharan Africa (Burkina Faso, Cameroon, Democratic Republicof the Congo, Ghana, Mali, Mozambique, Niger, Nigeria, Ugandaand the United Republic of Tanzania) and India. Consequently,WHO has put forward the “High Burden to High Impact (HBHI)”8 WHO Tanzania Biennial Report Mkama/WHOIntroducing Malaria Case-Based Surveillance in TanzaniaThe WCO worked with the NMCP to develop a protocol forCase-Based Surveillance (CBS) of malaria in Tanzania. Theprotocol is built on the epidemiological stratification thatclassified malaria disease burden in Tanzania into high,moderate, low and very-low (Fig. 7). The protocol is aligned tothe Global Technical Strategy for Malaria (GTS) 2016-2030ensuring that all cases in the low to very-low areas in thecountry are characterized, treated and investigated timely whileidentifying, managing and clearing further transmission inrespective communities. An internal review of the draft CBSprotocol is underway.HBHI foundational activities triggered impetus for change.Now NMCP and WCO Tanzania are packaging evidence toequip a country-wide advocacy drive.

CHAPTER 2The WCO guided the process of assessing Tanzania’s politicalwill, case management, surveillance, monitoring andevaluation, vector control, partner mapping and social andbehaviour change communication to end malaria. Thisassessment showed progress and gaps in malaria controlefforts in Tanzania and mapped stakeholders and their roles inmalaria control. Subsequently, partners defined Tanzania’scapacities to reduce malaria burden according to four responseelements: political will to reduce malaria deaths; strategicinformation to drive impact; better guidance, policies andstrategies; and coordinated national malaria response. TheHBHI foundational activities created impetus for change inseveral strategic areas to aid in curbing the disease.The SNP is one of the distribution strategies used to sustaininsecticide-treated bed net (ITN) coverage levels above 85% ofthe target set by the MOHCDGEC through the national malariastrategic plan. The programme distributes nets to primaryschool children to deliver to households.The China-UK-Tanzania Pilot Project on Malaria ControlAlongside an independent consultant, the WCO is theinternal evaluator of the China- UK- Tanzania Tripartite pilotproject on malaria control that deploys Chinese experiencein malaria control to the African context combining localexpertise and technology.Implemented by the National Institute of Parasitic Diseases,China CDC and Ifakara Health Institute in Tanzania fromApril 2015 to June 2018, the first phase of the projectsought to: WHO Attacking mosquito vector species that have become resistantto insecticidesThe malaria team facilitated and monitored the distribution oflong-lasting insecticidal nets (LLINs), which are treated with achemical substance (synergist), Piperonyl butoxide (PBO). Thechemical is

Tanzania for the achievements made in 2018 and 2019 and for prioritizing the health sector in the national budget allocations. We would like to express our sincere gratitude to the Government of Tanzania, development partners, local nongovernmental organizations and members of the communities for their support. WHO Tanzania Country Office is