International University of Africa

Faculty of Medicine and Health Sciences

African Medical Students Association

Health Problems in Africa: Is there any hope left?
10 11 January 2013 AD/ 28 -29 Safar 1434 AH Khartoum - Sudan

Major Health Problems in East Africa

Tanzania

Prepared by:

Mastura Abubakar Abdu, MBBS Year 3; Rashid Masoud Saed, MBBS, Year 2

-29-

COUNTRY BACKGROUND Tanzania is in East Africa on the Indian Ocean. To the north are Uganda and Kenya; to the west, Burundi, Rwanda, and Congo; and to the south, Mozambique, Zambia, and Malawi.Tanzania contains three of Africa's best-known lakesVictoria in the north, Tanganyika in the west, and Nyasa in the south. Mount Kilimanjaro in the north, 19,340 ft (5,895 m), is the highest point on the continent. The island of Zanzibar is separated from the mainland by a 22-mile channel. Land area: 342,100 sqmetre (886,039 sq km); total area: 364,898 sq mi (945,087 sq km)

Climate
Tanzania has a tropical climate. In the highlands, temperatures range between 10C and 20C (50F and 68F) during cold and hot seasons respectively. The rest of the country has temperatures rarely falling lower than 20C (68F). The hottest period extends between November and February (25C - 31C, or 77F - 88F) while the coldest period occurs between May and August (15C - 20C, or 59F - 68F).

-30-

Tanzania has two major rainfall regions. One is unimodal (December - April) and the other is bimodal (October -December and March - May). The former is experienced in southern, south-west, central and western parts of the country, and the latter is found to the north and northern coast. In the bimodal regime the March - May rains are referred to as the long rains whereas the October - December rains are generally known as short rains.

Country Health Indicators

Basic Indicators Under-5 mortality rank Under-5 mortality rate, 1990 Under-5 mortality rate, 2010 Infant mortality rate (under 1), 1990 Infant mortality rate (under 1), 2010 Neonatal mortality rate, 2010 Total population (thousands), 2010 000 Annual no. of births (thousands), 2010 Annual no. of under-5 deaths (thousands), 2010 GNI per capita (US$), 2010 Life expectancy at birth (years), 2010 Total adult literacy rate (%), 20052010* Primary school net enrolment ratio (%), 2007-2009* 1862 133 530 57 73 97 to the top 41 155 76 95 50 26 45,039,

-31-

Major causes of death in Tanzania

DISEASE 1.HIV/AIDS 2.INFLUENZA AND PNEUMONIA 3.MALARIA 4.DIARRHEA DISEASE 5.STROKE 6.CORONARY HEART DISEASE 7.LOW BIRTH WEIGHT 8.BIRTH TRAUMA 9.MARTENAL CONDITIONS 10.VIOLENCE NUMBER OF DEATH 90551 53689 PERCENTAGE(%) 20.52 12.17

36945 35549 21973 19086

8.37 8.06 4.98 4.33

17318 17303 14036 10357

3.93 3.92 3.18 2.35

HEALTH SYSTEM IN TANZANIA

The Government, Parastatal Organization, voluntary organization, Religions Organization, Private Practitioners and Traditional Medicine, provides health Services in Tanzania. The referral System (structure) starts from the community level (village) up to the treatment abroad. The following pyramid, shows Health Service System (Structure) in Tanzania Health Services System (Structure). The health system and especially the Governments referral system assumes a pyramidal pattern of a referral system recommended by health planners, that is from dispensary to

-32-

Consultant Hospital (Better Health In Africa, 1993). The structure of health services at various levels in the country is as follows: 1. Village Health Service. This is the lowest level of health care delivery in the country. They essentially provide preventive services which can be offered in homes. Usually each village Health post have two village health workers chosen by the village government amongst the villagers and be given a short training before they start providing services. 2. Dispensary Services Is the second stage of health services. The dispensaries cater for 6,000 to 10,000 people and supervise all the village health posts in its ward. 3. Health Centre Services: A health Centre is expected to cater for 50,000 people which is approximately the population of one administrative division. 4. District Hospitals: The district is a very important level in the provision of health services in the country each district is supposed to have a district hospital. Government always negotiate with religious organisations to designate voluntary hospitals. 5. Regional Hospitals Every region is supposed to have a hospital. Regional Hospital offer similar services like those agreed at district level, however regional hospitals have specialists in various fields and offer additional services which are not provided at district hospitals. 6. Referral/Consultant Hospitals This is the highest level of hospital services in the country presently there are four referral hospitals namely, the Muhimbili National Hospital which cater the eastern zone; Kilimanjaro Christian Medical Centre (KCMC) which cater for the northern zone, Bugando Hospital which cater for the western zone; and Mbeya Hospital which serves the southern Highlands.

-33-

Health Facilities 2002 -2003:

Facility Govt. Consultancy/Specialized Hospitals Regional Hospitals District Hospitals Other Hospitals Health Centers Dispensaries Specialized Clinics Nursing Homes Private Laboratories Private X-Ray Units 4 17 55 2 409 2450 75 0 18 5 2 0 0 6 6 202 0 0 3 3 Agency Parastatal Vol/Rel 2 0 1 3 5 6 48 612 4 0 9 2 Private 0 0 0 2 0 1 6 663 22 6 184 16 Others 2 28 1

Source: Ministry of Health Statistical Abstract The distribution of Health Facilities has a heavy rural emphasis because more than 70% of the population lives in rural areas. In 2010 the number of hospitals has increased to 223 hospitals where by 89 are government, 90 faith-based hospitals, 37 private and 8 parastatal.

Number of Medical Schools

Tanzania has major six medical schools and several colleges and health institutions that provide health education in the country. They offer degrees and post graduate degrees in medicine, pharmacy, dentistry, and environmental health sciences. Also there several health colleges and institutions that provides other medical specialties like nursing, laboratory technicians, medical officers and also diploma in pharmacy.

-34-

FREQUENT DIAGNOSED DISEASES

Non communicable diseases
1. 2. 3. 4. 5. 6. 7. Cardiovascular diseases Cancer Chronic respiratory disease Diabetes Hypertension Injuries others

All non communicable diseases account for 27% of all deaths in Tanzania in which cardiovascular diseases account for 12%,injuries 8%,cancer 3% respiratory diseases for 3%,diabetes 2% and other non communicable diseases account for 7%. Non communicable diseases contribute 35% of mortality due to diseases while 65% is from communicable disease

Communicable disease
1. 2. 3. 4. 5. HIV/AIDS Malaria Pneumonia Diarrhea diseases Tuberculosis

HIV/AIDS in Tanzania
The survey interviewed and took blood samples from more than 9,000 women aged 15-49 and close to 7,000 men aged 15-49 in all 26 regions of Tanzania. The results indicated a 4.7% HIV prevalence rate among men and a 6.8% rate among women. This is a slight improvement over the 2003-04 survey which found rates of 6.3% and 7.7% respectively. Iringa recorded the highest rate of 14.7% (previously 13.4%) followed by Dar es Salaam at 8.9% (previously 10.9%), Mbeya at 7.9% (previously 13.5%) and Shinyanga at 7.6% (previously 6.5%). Zanzibar had the lowest prevalence rate at 0.6%. Age-wise, the highest prevalence was among the 35-39 age group (10%).

-35-

The survey also collected information on knowledge of HIV, attitudes and behavioral aspects. Over 98% of respondents had heard about HIV/AIDS. 68.6% of women and 76.3% of men knew that condoms can reduce the risk of contracting HIV, while 82% and 86.6% knew that limiting sex to one uninfected partner who has no other partners would reduce the risk. 85% and 89% where aware that abstaining from sexual intercourse is another recognized prevention method.

HIV Prevalence Tanzania

2001 Adults (15+)and children Low estimate High estimate Adults(15+) Low estimate High estimate Children(0-14) Low estimate High estimate Adult rate (15-49) (%) Low estimate High estimate Women rate(+15) Low estimate High estimate 1 400 000 1 300 000 1 500 000 1 200 000 1 100 000 1 300 000 120 000 100 000 130 000 7.0 6.5 7.4 740 000 680 000 790 000 2007 1 400 000 1 300 000 1 500 000 1 300 000 1 200 000 1 400 000 140 000 130 000 150 000 6.2 5.8 6.6 760 000 710 000 810 000

HIV PREVELENCE AMONG YOUNG PEOPLE

-36-

Prevalence among 15-24 years old Low estimate High estimate

male 0.5 0.4 0.7

female 0.9 0.5 1.2

ESTIMATED NUMBER OF DEATHS DUE TO AIDS

Adults and children Low estimate High estimate 2001 110 000 99 000 130 000 2007 96 000 860000 110 000

-37-

Malaria
Malaria is still a major public health problem in the United Republic of Tanzania, as the leading cause of inpatient and outpatient consultations. Ninety three percent of the populations live in areas where malaria is transmitted for at least one month per year. Although Tanzania has been on the forefront in promoting the use of insecticide treated nets (ITNs), there are still between 60000 and 80000 malaria attributable deaths estimated per year, mainly children under the age of five. The disease is one of the main obstacles to the economical development of the country. The malaria situation in Zanzibar, the group of islands off the north-eastern coast of the Tanzania mainland, is a bit different than the one on the mainland. Over the past decade Zanzibar has reached very low levels of malaria endemicity due to rapidly scaling up of current anti malarial interventionsand it is now one of the regions that is planning to eliminate the disease. Planning and evaluating cost-effective strategies for the control and even more, the elimination of malaria, requires contemporary, high spatial resolution maps of the disease distribution as well as reliable estimates of the number of infected people. These measures will help tracking the progress and documenting reduction in parasitemia rates as a result of control. Some earlier attempts to describe the situation of malaria transmission in Tanzania were based on analysis of historical parasite prevalence data.

Epidemiology of Malaria
In Tanzania, malaria is the major cause of morbidity and mortality, accounting for about 30% of all hospital admissions and around 15% of all hospital deaths. Severe anemia and cerebral malaria are the two main causes of death due to malaria. Malaria transmission and level of exposure to malaria infected mosquito bites varies with season, altitude, economic status, breeding sites and agro ecological systems. Multifaceted malaria control strategies are yielding significant results

-38-

Progress over the last decade:2000-2010 Significant declines in parasite prevalence18% of children aged 659 months tested positivefor malaria in mainland Tanzania; expected to be even lower. Significant urban/rural difference in prevalenceRelative decline in anemia ~30% over 3 years only! Significant declines in under five mortality: 45%With regard to Malaria, 56% of the households covered in the study owned some type of mosquito net (increased from 46% observed in the 2004-05 survey). 37% of children under age five years and 36% of pregnant women slept under a mosquito net. Children and pregnant women in urban areas were found to be twice more likely to use mosquito nets than their rural counterparts. The overall prevalence of malaria in young children in Tanzania was 18%. In rural areas, 20% of children carried the malaria parasite compared to 7% in urban areas. Kagera had the highest prevalence of malaria among young children (42%) while Arusha had the lowest with less than 1%.

-39-

Influenza and Pneumonia

Pneumonia is the second biggest killer of children in Tanzania, after malaria. Over the next couple of years the government hopes that this statistic will change following the introduction of vaccines against Haemophilusinfluenzae type b in 2009, and pneumococcal disease in 2010. Although Tanzania has made good progress in reducing child mortality, pneumonia remains a serious problem, causing 21% of deaths in children under5 years of age. New vaccines could reduce cases, especially since Tanzania has achieved a high coverage 90% for routine immunizations

-40-

Diarrhea
Diarrheal diseases are a leading cause of morbidity and mortality among young children in low-income countries. Although oral rehydration has been shown to reduce early child mortality, the diarrhea-specific mortality in children less than 5 years of age in Africa has been estimated at about 10.6 per 1,000. Diarrhea is the fourth most common diagnosis in inpatients and outpatients and the fourth most common cause of death in admitted children. A number of different social, political, and economic factors are present in Tanzania which contribute to the constant morbidity from acute and persistent diarrhea, as well as intermittent epidemics of cholera and dysentery are common to this region of the world. Morbidity and mortality from childhood diarrhea, whether due to invasive enteropathogens such as Shigella or the most common rotavirus, are further compounded by inappropriate household case management. A hospital-based prospective study including all children admitted to the Diarrhea Unit during the study period. Data was collected using content analysis checklists. A total of 50 children were admitted during the study period. Acute watery diarrhea was the commonest type of diarrhea (90%). Most of the patients stayed in the ward for 4 to 10 days. Commonly associated diseases apart from diarrhea were found to be malaria, pneumonia and malnutrition. The diarrhea mortality among children at the MNH diarrhea unit as reflected in this study was very high. It has generally been believed that many; if not most of the childhood deaths associated with diarrhea in developing countries are the result of acute dehydration. Undoubtedly, acute diarrhea represents a substantial proportion of the diarrheal deaths, but it may be less a predominant cause than initially believed as the frequent misuse of antibiotics. Among the 50 patients admitted in the diarrheal unit, 45 (90.0%) had acute Watery Diarrhea, 29 (58.0%) died during the study. However, 3 (6.0%) of the studied patients had dysentery and they all died. Of the 29 patients who died in this study, 16(55.2%) were male patients, and of the 21 patients who recovered and were discharged, 7(33.3%) were female patients. Among the 50 patients studied, Malaria 35(70.0%) followed by Pneumonia 16(32.0%) and malnutrition 12(24.0%), were the leading conditions associated with diarrhea among the studied patients.

-41-

Undoubtedly acute dehydrating diarrhea represents a substantial proportion of the diarrheal deaths. In this study, of the 58% patients who died, 89.7% patients had Acute Watery Diarrhea and 10.3% has Dysentery. These finding are supported by the findings from a study6 done in four countries (India, Bangladesh, Brazil, and Senegal) which indicated that acute watery diarrhea accounted for about 35% (25-46%) of all diarrheaassociated deaths

Tuberculosis
Routine data obtained from the National Tuberculosis and Leprosy Programme (NTLP) of Tanzania has shown a constant increase in the notified number of tuberculosis (TB) cases since 1982. Possible causes

-42-

include an improved reporting system, improvement in health services after the introduction of short course chemotherapy (SCC), and human immunodeficiency virus (HIV) infection. The Incidence of tuberculosis (per 100;000 people) in Tanzania was last reported in 2010, according to a World Bank report published in 2012. Incidence of tuberculosis is the estimated number of new pulmonary, smear positive, and extra-pulmonary tuberculosis cases. Limited information on the different M. tuberculosisfamilies, M.bovis and NTM Is restricted to small geographical areas of Tanzania. Different M. tuberculosis strains have distinctive epidemiological and clinical characteristics; Virulence, clinical presentation, appear to be strain dependent. Diverse spoligotypes families were found from all zones of the country. Common families were CAS, LAM, EAI. The Beijing family was 7% and all patients were from eastern and southern Tanzania with 80% reported from DSM. Dar es Salaam contributed significantly to all main families reported. The spoligitypes families identified were not either significantly associated with drug resistance or poor treatment outcomes. No M.bovis was identified, therefore this study aimed at identification strains M. tuberculosis, M. bovis and NTM in relation to treatment outcomes and drug resistance.

PREVALENCE OF TB IN TANZANIA 2002-2010

-43-

HEALTH WORKFORCE
The health workforce in Tanzania has declined in the past decade over 35% between 1994/1995 and 2005/2006 due to migration outside the countries or from rural to urban areas, and other factors like age of most medical practitioners. In 2006 the country had only 1336 doctors in a population of 38.9milnlion people, where by 445 of them worked in private hospitals. This gave a ratio of 1:25000 where by the recommended (WHO) ratio is 1:10000.The ratio of nurses is 0.39 for 1000 population and 0.25 clinical staff for 1000 population while the world average for health workers per 1000 is 9.3. The 2005 proposed national level of staff in health sector should be 1,25,924 health worker but only 35,202 were available representing a deficit of over 72% and the decline will continue to be more serious in the current proposal of one hospital for every district and one health center for each ward and a dispensary for each village. The current health situation is less than 40,000 excluding non professional staffs, this constitutes a very low number of health worker per population.

-44-

Gender has also been noted to be one of the important issues in health workforce distribution. A common picture is given by nurses where majority are females.

CONCLUSION
1. Most of the African countries are in a poor socio-economic state which makes them suffer the burden of the disease with no appropriate management towards them. Major health problems in Tanzania are brought about by the poor socio economic standard of the country. 2. Heath problems in Tanzania have been one of the majorcauses of morbidity and mortality which affect the productivity of the country and there by adversely affecting the development of this country. 3. Limited awareness and appropriate knowledge in the communities toward the diseases including their (risk factors,causes,mode of their transmission and preventive measures) have been one of the factors that contribute to late reporting and consequently delayed diagnosis and lack of appropriate treatment.

-45-

RECOMMENDATIONS
1. Improvement in data collection and the flow of information in health information system so as to provide easy access to health information and publications, this will simplify different activities like research and planning also will facilitate the accessibility of the country to foreign aids through mult-donors. 2. All health statistical data and records should be documented and published with periodic updating of information (yearly) inmedia that can make them easily accessible locally and even internationally. This will help in identifying the health status and ranking the disease that affect it regionally 3. As far as the deficit in workforce is concerned the gap should be bridged by increasing the number of standard medical schools that will also provide qualified students in medical fields 4. Increase provision of scholarships in medical field so as to increase the number of graduates who will serve their communities from this burden of diseases and explore more capable student in different regions of the country. 5. Post graduates students should be given opportunities for further studies to increase the number of specialists In various fields 6. Provision of incentives to health workers by building conducive environment in their working fields

-46-