This project aims to improve access to health services and quality of care for mothers and children in Tanzania through an implementation research study. The study is being conducted in two districts of Iringa Region in Tanzania by a research team led by the University of Dar es Salaam in collaboration with HealthBridge Foundation of Canada. The project involves integrating demand and supply side interventions through women's groups and health facility quality improvement committees. Baseline data collection was completed in 2016 and endline evaluation is planned for 2019. Key findings from baseline include transportation costs as a barrier to care and poor provider attitudes negatively impacting quality of care. The project is ongoing with monthly women's group meetings and health facility quality improvement meetings planned for 2017.

1. Project Title: Improving Access to Health Services and Quality of
Care for Mothers and Children in Tanzania
Implementation Research Team
Dr. Stephen Maluka (PI), University of Dar es Salaam, Tanzania
Dr. Robert Salim (Co-PI), Regional Secretariat, Iringa, Tanzania
Dr. Khadija Begum (Co-PI), HealthBridge Foundation of Canada
Prof. Peter Kamuzora, University of Dar es Salaam, Tanzania
Prof. Esther Dungumaro, University of Dar es Salaam, Tanzania
Dr. Dereck Chitama, Muhimbili University of Health & Allied Sciences, Tanzania
Dr. May Alexander, Iringa Municipal Health Office, Iringa, Tanzania

2. IMCHA Project Overview
Background
• An Implementation Research project on ‘integrating demand and supply side health
system governance to improve maternal, newborn and child health services in rural
Tanzania’
• Project locations: Two Districts of Iringa Region of Tanzania (Kilolo and Mufindi)
• Implemented by Institute of Development Studies at the University of Dar es Salaam,
Tanzania in collaboration with HealthBridge Foundation of Canada
• The main aim of the project is to adapt, develop and cost interventions to integrate
demand and supply sides of health systems and evaluate their effects on maternal,
newborn and child health outcomes in order to inform policy and scale up in Tanzania.

3. Research questions/objectives
• Understand the processes and context at the community and health facility level that
affect acceptability, quality, equity and utilization of maternal, newborn and child health
services.
• Understand the mechanisms by which the integrated demand and supply side
interventions may influence the acceptability, quality, equity and utilization of MNCH
services.
• Assess the impact of community level and health facility level interventions on
acceptability, quality, equity and utilization of MNCH services
• Understand costing and health systems implications of integrated demand and supply side
health system strengthening interventions to improve acceptability, quality, equity and
utilization of MNCH services in order to identify lessons for scale-up.
IMCHA Project Overview

4.  Methods
• Conceptual framework: adopts a health system approach to address three delays in care
seeking and treatment at the health facilities for MNCH services
• A Participatory Action Research design (PAR)
• Action research team to carry out four main intervention components:
 Women Participatory Learning and Action Groups meetings (community-based
demand side PAR)
 Strengthening Health Facility Quality Improvement Committee (facility-based supply
side PAR)
 Strengthening Health Facility Governing Committee
 Integrated demand and supply side collaborative learning sessions
• Evaluation design involves a pre-post assessment and includes comparison site
 Baseline assessment –completed in 2016 (quantitative HHS, HFA and exit interviews
and qualitative social and gender assessment (IDIs, FGDs)
 Endline evaluation – planned in 2019
IMCHA Project Overview

5. IMCHA Project Implementation
Results to Date/Key Lessons Learned
 Completed baseline qualitative data collection in 18 villages and quantitative household and health facility
exit surveys in 38 villages (intervention and comparison)
 Initiated our first cycle of community-based Women’s Participatory Learning and Action Group (WPLAG)
intervention
Conducted orientation meetings in twenty (20) intervention villages
20 women participatory learning and action groups were formed in all 20 intervention villages.
Provided training to all women who will be involved in the implementation of community-based
demand-side WPLAG intervention component of the project
A total of 400 women forming 20 WPLAG in 20 villages received the training to conduct monthly
WPLAG meetings
 Identified and provided training to forty community health workers (CHWs) and six community
development officers (CDOs).
Forty CHWs (2 from each village) designated as Women Group Facilitators (WGFs) of the project will
be responsible for facilitating monthly meetings conducted by the WPLAGs
six CDOs (3 from each district) who are designated as Community Intervention Supervisors (CISs) of
the project would provide supervisory support to the WPLAG monthly meetings

6. Results to Date/Key Lessons Learned
 Though women do not perceive that receiving permission to seek care is not a problem,
men tend to be responsible for household decision-making and women perceived
themselves as having narrow decision-making space
 Women delay seeking antenatal care due to fear of judgment by health care providers
and/or their community (due to their wealth, marital status, age, failure to abide by child
spacing recommendations, fear of being screened for HIV)
 Men are not engaged or involved in their partner’s health and health decision-making
during pregnancy, delivery and post-natal care due to many social barriers to their
involvement
 The primary barrier to reaching a health facility is that transportation to a health facility is
costly
 The primary barriers to obtaining quality care are that: 1) health care providers, particularly
nurses, often have poor attitudes toward patients (which may also act as a deterrent to care
seeking); 2) health facilities experience frequent drug stock outs and equipment shortages

7. Challenges in Implementation and Mitigation Strategies
 During the team inception workshop in November 30th to December 4th 2015, we decided to
reduce the scope of the project to focus only on the period of care from pregnancy, labour and
immediate postnatal care (within 6 weeks of delivery), excluding pre-pregnancy (e.g. family
planning) and child health (e.g. prevention and treatment of childhood illness)
 We faced challenges in terms of forming Quality Improvement Teams (QITs) in the health facilities
to address delay 3 - receiving appropriate care at the health facilities
 Initially, a Quality Improvement Team was planned to comprise of representatives from the
various provider roles within the facilities for example, a Matron, Nurse Midwife, Clinical Officer,
Laboratory Technician and Data Clerk. However, most of the health facilities, particularly
dispensaries have two or three staff which makes it difficult to form a QIT. We are forced to
change the nature and composition of QITs to include some members of the health (user)
committees

8. IMCHA Project Implementation
Implementation Research Team – Focus on Capacity Strengthening
 2 PhD students have been recruited and engaged in various capacity
strengthening trainings on research methodology and the design of the study
tools, data collection, coding as well as data analysis
 All research team members received training on social and gender analysis
provided by Lisa MacDonald, HealthBridge’s gender advisor
 1 project team member and a PhD candidate attended training on costing in
Nairobi Kenya in 2016 organized by the Health Policy Research Organization
(HPRO)
 2 research team members & 1 PhD student received training on mixed-methods
organized by the HPRO
 2 research team members received capacity building on strategic planning &
policy engagement organized by the HPRO

9. Next Steps (Plan for 2017) and Areas for Collaboration
 We will conduct monthly meetings with women groups and women group
facilitators from May 2017 to prioritize maternal and child health problems,
develop and implement strategies to address the prioritized problems
 We will meet with health facility quality improvement teams on a monthly basis
from June 2017 to prioritize maternal and child health problems, develop and
implement strategies to address the prioritized problems
 We will also conduct collaborative learning sessions (review meetings) after
every six months where we will engage the Ministry of Health and Social Welfare
and Prime Minister’s Office Regional Administration and Local Government
(PMORALG) Officials

10. Thank You!