62949 RepRoducTIve HealtH at a GLANce June 2011 TANZANIA country context Tanzania: MdG 5 Status Tanzania is among the most politically stable countries in MdG 5A indicators Africa and, since 2000, has maintained a robust annual Maternal Mortality Ratio (maternal deaths per 100,000 live 790 rate of economic growth of 5 to 7 percent.1 Prudent mac- births) UN estimatea roeconomic policies, market–oriented reforms and debt Births attended by skilled health personnel (percent) 50.6 relief have resulted in a suitable environment for Tanzania’s MdG 5B indicators steady growth. Despite the high rate of economic growth in Contraceptive Prevalence Rate (percent) 34.4 recent years, poverty remained high at 33.6 percent. Adolescent Fertility Rate (births per 1,000 women ages 15–19) 116 Tanzania’s large share of youth population (44 percent of Antenatal care with health personnel (percent) 95.9 the country population is younger than 15 years old2) pro- Unmet need for family planning (percent) 25.3 vides a window of opportunity for high growth and pov- erty reduction—the demographic dividend. For this op- Source: Compiled from multiple data sources. a 2010 DHS estimated MMR at 454 per 100,000 live births. portunity to result in accelerated growth, the government needs to invest more in the human capital formation of its youth. This is especially important in a context of deceler- ated growth rate arising from the global recession and the MdG Target 5A: Reduce by Three-quarters, between country’s exposure to high volatility in commodity prices. 1990 and 2015, the Maternal Mortality Ratio Gender equality and women’s empowerment are impor- Tanzania has made insufficient progress over the past two decades tant for improving reproductive health. Higher levels of on maternal health and is not on track to achieve its 2015 targets.5 women’s autonomy, education, wages, and labor market participation are associated with improved reproductive Figure 1 n Maternal mortality ratio 1990–2008 and 2015 target health outcomes.3 In Tanzania, the literacy rate among fe- 1000 males ages 15 and above is 66 percent.2 Girls enrollment in 827 860 920 920 790 800 primary schools is comparable to boys with a 99 percent ratio of female to male primary enrollment.2 Eighty-nine 600 MDG Target percent of adult women participate in the labor force2 that 400 220 mostly involves work in agriculture. Gender inequalities 200 are reflected in the country’s human development ranking; 0 Tanzania ranks 138 of 157 countries in the Gender-related 1990 1995 2000 2005 2008 2015 Development Index.4 Source: 2010 WHO/UNICEF/UNFPA/World Bank MMR report. Greater human capital for women will not translate into The 2010 DHS estimated MMR at 454 per 100,000 live births. greater reproductive choice if women lack access to repro- ductive health services. It is thus important to ensure that health systems provide a basic package of reproductive World Bank Support for Health in Tanzania health services, including family planning.3 The Bank’s new Country Assistance Strategy under preparation (P122530) is scheduled to be approved by the Bank’s Executive Board on June 7, 2011. current project: P105093 TZ-Health Sector Dev II – Add Fin (FY08) ($60m) P119067 TZ-Health Sector Dev II – Add Fin (FY10) ($40m) pipeline project: P125740 Basic Health Services Project ($100m) previous Health project: THE WORLD BANK P082335 TZ-Health Sector Development II (FY04) ($65m) n Key challenges Figure 3 n use of contraceptives among married women by wealth quintile High fertility 60 Fertility remains high. Total fertility rate (TFR) fell slightly from 50 12.9 40 34.4 Overall (All methods) 8.0 6.3 births per woman in 1991–92 to 5.6 in 1999 but remained the 37.7 30 34.6 same till 2007–2008; it then decreased slightly to 5.4 in 2010.6, 7 20 3.7 4.8 5.4 21.9 23.2 TFR among women in the lowest wealth quintile is more than 19.2 10 twice those in the highest wealth quintiles (Figure 2).6 Disparities 0 exist between women in rural areas at 6.1 births per woman com- Poorest Second Middle Fourth Richest pared to 3.7 for those in urban areas, and vary by education levels Modern Methods Traditional Methods at 7.0 births per woman with no education, and 3.0 with second- Source: DHS Final Report, Tanzania 2010. ary education or above.7 Unmet need for contraception is high at 25 percent7 indicat- Figure 2 n Total fertility rate by wealth quintile ing that women may not be achieving their desired family size.9 8 7 7.0 6.8 Fear of side effects and opposition to use are the predomi- 6.1 6 5.4 overall nant reasons women do not intend to use modern contracep- 5 4.7 4 3.2 tives in future. Twenty-eight percent of women not intending to 3 use contraception indicated fear of side effects or health concerns 2 1 as the main reason while 25 percent expressed opposition to use, 0 primarily by themselves, their husband, or due to their religion.10 Poorest Second Middle Fourth Richest Cost and access are lesser concerns, indicating further need to Source: DHS Final Report, Tanzania 2010 . strengthen demand for family planning services. Adolescent fertility rate is high affecting not only young women and their children’s health but also their long-term education and poor pregnancy outcomes employment prospects. Births to women aged 15–19 years have the highest risk of infant and child mortality as well as a higher risk of mor- While majority of pregnant women use antenatal care, institu- bidity and mortality for the young mother.3, 8 In Tanzania, there are 116 tional deliveries are less common. Over 95 percent of pregnant reported births per 1,000 women aged 15–19 years.7 women receive antenatal care from health professionals (doctor, clinical officer/assistant clinical officer, nurse or midwife, and Early childbearing is high and more frequent among the MCH aide) with 43 percent having the recommended four or poor. Forty four percent of women are either mothers or are more antenatal visits.7 However, a smaller proportion, 51 percent pregnant with their first child by age 19. Teenagers in the lowest deliver with the assistance of skilled medical personnel predomi- wealth quintile are more than twice as likely to start childbearing nantly in the public sector.7 While 93 percent of women in the early as women in the highest wealth quintile (28 percent and 13 wealthiest quintile delivered with skilled health personnel, only percent, respectively). 33 percent of women in the poorest quintile obtained such as- sistance (Figure 4).7 Additionally, 34 percent of women with no Use modern contraception has been increasing. Use of mod- education delivered with skilled health personnel as compared ern contraception among married women has increased from 7 percent in 1991 to 20 percent in 2004 and to 27 percent in 2010.7 Injectables are the most commonly used method among mar- Figure 4 n Birth assisted by skilled health personnel (percentage) ried women at 11 percent followed by the pill at 7 percent.7 Use by wealth quintile of long-term methods such as intrauterine device and implants 100 90.4 are negligible. There are socioeconomic differences in the use of 80 modern contraception among women: it is 18 percent of women 63.3 60 with no education use modern contraception as compared to 35 50.6% overall 47.0 percent of women with secondary education or higher, and 25 40 33.0 35.8 percent for rural women versus 34 percent for urban women.7 20 Use of modern contraceptives is 38 percent among women in the 0 highest wealth quintile and 19 percent among those in the poor- Poorest Second Middle Fourth Richest est quintile7 (Figure 3). Source: DHS Final Report, Tanzania 2010. to 86 percent of women with secondary education or higher that using a condom in every intercourse prevents HIV, about while 83 percent of urban as 42 percent of rural women delivered 50% percent of them report having used condom at last inter- with skilled health personne.7 Further, 58 percent of all pregnant course (Figure 5). This gap widens among older aged women women are anaemic (defined as haemoglobin < 110g/L) increas- likely due to the fact that the chances of using condoms as a form ing their risk of preterm delivery, low birth weight babies, still- of contraception diminishes with marriage. birth and newborn death.11 According to the 2010 DHS, nearly two-thirds of women percent never received postnatal care. Figure 5 n Knowledge behavior gap in HIv prevention among young women According to the 2010 DHS, nearly two-thirds of women per- 90% cent never received postnatal care 80% 70% Nearly half of women who indicated problems in accessing 60% health care cited concerns regarding inability to afford the ser- 50% 40% vices or long distance (Table 1).10 30% 20% Table 1 n Barriers in accessing health care (women age 15–49) 10% 0% Reason % 15–19 years 20–24 years At least one problem accessing health care 35.5 Knowledge Condom use at last sex Getting money needed for treatment 24.1 Source: DHS Final Report, Tanzania 2010 (author’s calculation). Distance to health facility 19.2 Not wanting to go alone 10.5 Getting permission to go for treatment 2.4 Source: DHS Final Report, Tanzania 2010. Technical Notes: Human resources for maternal health are limited with only Improving Reproductive Health (RH) outcomes, as outlined in the RHAP, includes addressing high fertility, reducing unmet demand for 0.008 physicians per 1,000 population but nurses and midwives contraception, improving pregnancy outcomes, and reducing STIs. are slightly more common, at 0.242 per 1,000 population.2 The RHAP has identified 57 focus countries based on poor The high maternal mortality ratio at 790 maternal deaths per reproductive health outcomes, high maternal mortality, high 100,000 live births indicates that access to and quality of emer- fertility and weak health systems. Specifically, the RHAP identifies high priority countries as those where the MMR is higher than gency obstetric and neonatal care (EmONC) remains a challenge.5 220/100,000 live births and TFR is greater than 3.These countries are also a sub-group of the Countdown to 2015 countries. Details of the RHAP are available at www.worldbank.org/population. STIs/HIv/AIdS is a public health concern The Gender-related Development Index is a composite index HIV prevalence is moderately high in Tanzania but women developed by the UNDP that measures human development in the are one of the most vulnerable groups. The adult population same dimensions as the HDI while adjusting for gender inequality. that has HIV is 5.7 percent; prevalence among females is signif- Its coverage is limited to 157 countries and areas for which the HDI icantly higher than among males (6.6 percent and 4.6 percent, rank was recalculated. respectively).6 Eighty-nine percent of women and 81 percent of men know that HIV can be transmitted through breast milk. Seventy-five percent of women and 67 percent of men know that the likelihood of pass- correspondence details ing HIV from mother to child can be reduced by drugs.7 This profile was prepared by the World Bank (HDNHE, PRMGE, and AFTHE). For more information contact, Samuel Mills, Tel: 202 473 9100, There is a large knowledge-behavior gap regarding condom email: smills@worldbank.org. This report is available on the following use for HIV prevention. While most young women are aware website: www.worldbank.org/population. n Key Actions to Improve RH outcomes Strengthen gender equality Reducing maternal mortality • Support women and girls’ economic and social empowerment. • Promote institutional delivery through provider incentives and Increase school enrollment of girls. Strengthen employment possibly, implement risk-pooling schemes. Provide vouchers prospects for girls and women. Educate and raise awareness on to women in hard-to-reach areas for transport and/or to cover the impact of early marriage and child-bearing. cost of delivery services. • Educate and empower women and girls to make reproductive • Target the poor and women in hard-to-reach rural areas in the health choices. Build on advocacy and community participation, provision of basic and comprehensive emergency obstetric care and involve men in supporting women’s health and wellbeing. (renovate and equip health facilities). • Address the inadequate human resources for health by training Reducing high fertility more midwives and deploying them to the poorest or hard-to- reach districts. • Address the issue of opposition to use of contraception and promote the benefits of small family sizes. Increase family • Strengthen the referral system by instituting emergency trans- planning awareness and utilization through outreach cam- port, training health personnel in appropriate referral proce- paigns and messages in the media. Enlist community lead- dures (referral protocols and recording of transfers) and estab- ers and women’s groups and emphasize community-based lishing maternity waiting huts/homes at hospitals to accommo- distribution date women from remote communities who wish to stay close to the hospital prior to delivery. • Provide quality family planning services that include coun- seling and advice, focusing on young and poor populations. • During antenatal care, educate pregnant women about the im- Highlight the effectiveness of modern contraceptive methods portance of delivery with a skilled health personnel and getting and properly educate women on the health risks and benefits postnatal check. Encourage and promote community partici- of such methods. pation in the care for pregnant women and their children. • Promote the use of ALL modern contraceptive methods, in- cluding longterm methods, through proper co1unseling which Reducing STIs/HIv/AIdS may entail training/re-training health care personnel. • Integrate HIV/AIDS/STIs and family planning services in rou- • Strengthen post-abortion care (treatment of abortion compli- tine antenatal and postnatal care. cations with manual vacuum aspiration, post-abortion family • Lower the incidence of HIV infections by strengthening planning counseling, and appropriate referral where necessary) Behavior Change Communication (BCC) programs via mass and link it with family planning services. media and community outreach to raise HIV/AIDS awareness and knowledge. References: 1. The World Bank, Tanzania: Country Brief. . 8. WHO 2011. Making Pregnancy Safer: Adolescent Pregnancy. 2. World Bank. 2010. World Development Indicators. Washington DC. Geneva: WHO. http://www.who.int/making_pregnancy_safer/top- 3. World Bank, Engendering Development: Through Gender Equality ics/adolescent_pregnancy/en/index.html. in Rights, Resources, and Voice. 2001. 9. Samuel Mills, Eduard Bos, and Emi Suzuki. Unmet need for contra- 4. Gender-related development index. http://hdr.undp.org/en/media/ ception. Human Development Network, World Bank. Available at HDR_20072008_GDI.pdf. http://www.worldbank.org/hnppublications. 5. Trends in Maternal Mortality: 1990–2008: Estimates developed by 10. National Bureau of Statistics (NBS) [Tanzania] and ORC Macro. WHO, UNICEF, UNFPA, and the World Bank. 2005. Tanzania Demographic and Health Survey 2004-05. Dar es 6. Tanzania Commission for AIDS (TACAIDS), Zanzibar AIDS Salaam, Tanzania: National Bureau of Statistics and ORC Macro. Commission (ZAC), National Bureau of Statistics (NBS), Office of 11. Worldwide prevalence of anaemia 1993–2005: WHO global da- the Chief Government Statistician (OCGS), and Macro International tabase on anaemia/Edited by Bruno de Benoist, Erin McLean, Inc. 2008. Tanzania HIV/AIDS and Malaria Indicator Survey 2007- Ines Egli and Mary Cogswell. . Macro International Inc. TANZANIA RepRoducTIve HeALTH AcTIoN pLAN INdIcAToRS Indicator Year Level Indicator Year Level Total fertility rate (births per woman ages 15–49) 2010 5.4 Population, total (million) 2008 42.5 Adolescent fertility rate (births per 1,000 women ages 15–19) 2010 116 Population growth (annual %) 2008 2.9 Contraceptive prevalence (% of married women ages 15–49) 2010 34.4 Population ages 0–14 (% of total) 2008 44.7 Unmet need for contraceptives (%) 2010 25.3 Population ages 15–64 (% of total) 2008 52.3 Median age at first birth (years) from DHS 2010 19.5 Population ages 65 and above (% of total) 2008 3.1 Median age at marriage (years) 2010 18.9 Age dependency ratio (% of working-age population) 2008 91.4 Mean ideal number of children for all women 2010 4.9 Urban population (% of total) 2008 25.5 Antenatal care with health personnel (%) 2010 95.9 Mean size of households 2004/05 5 Births attended by skilled health personnel (%) 2010 50.6 GNI per capita, Atlas method (current US$) 2008 440 Proportion of pregnant women with hemoglobin <110 g/L 2008 58.2 GDP per capita (current US$) 2008 496 Maternal mortality ratio (maternal deaths/100,000 live births) 1990 880 GDP growth (annual %) 2008 7.5 Maternal mortality ratio (maternal deaths/100,000 live births) 1995 920 Population living below US$1.25 per day — — Maternal mortality ratio (maternal deaths/100,000 live births) 2000 920 Labor force participation rate, female (% of female population ages 15–64) 2008 88.8 Maternal mortality ratio (maternal deaths/100,000 live births) 2005 860 Literacy rate, adult female (% of females ages 15 and above) 2008 66.3 Maternal mortality ratio (maternal deaths/100,000 live births) 2008 790 Total enrollment, primary (% net) 2008 99.6 Maternal mortality ratio (maternal deaths/100,000 live births) target 2015 220 Ratio of female to male primary enrollment (%) 2008 98.6 Infant mortality rate (per 1,000 live births) 2008 67 Ratio of female to male secondary enrollment (%) — — Newborns protected against tetanus (%) 2008 81 Gender Development Index (GDI) 2008 138 DPT3 immunization coverage (% by age 1) 2010 86.1 Health expenditure, total (% of GDP) 2007 5.3 Pregnant women living with HIV who received antiretroviral drugs (%) 2005 5.6 Health expenditure, public (% of GDP) 2007 3.5 Prevalence of HIV, total (% of population ages 15–49) 2007 6.2 Health expenditure per capita (current US$) 2007 21.7 Female adults with HIV (% of population ages 15+ with HIV) 2007 58.5 Physicians (per 1,000 population) 2006 0.008 Prevalence of HIV, female (% ages 15–24) 2007 0.9 Nurses and midwives (per 1,000 population) 2006 0.242 poorest-Richest poorest/Richest Indicator Survey Year poorest Second Middle Fourth Richest Total difference Ratio Total fertility rate DHS 2010 7.0 6.8 6.1 4.7 3.2 5.4 3.8 2.2 Current use of contraception (Modern method) DHS 2010 19.2 21.9 23.2 34.6 37.7 27.4 –18.5 0.5 Current use of contraception (Any method) DHS 2010 22.9 26.7 28.6 42.6 50.6 34.4 –27.7 0.5 Unmet need for family planning (Total) DHS 2010 30.8 27.3 29.0 23.5 16.3 25.3 14.5 1.9 Births attended by skilled health personnel DHS 2010 33.0 35.8 47.0 63.3 90.4 50.6 –57.4 0.4 (percent) Tanzania policies and Strategies that have Influenced development partners Support for Reproductive Health in Reproductive Health Tanzania • Population issues have been included as a substantive thematic The DPs in the health sector actively coordinate sector dialogue area in the new MKUKUTA structure and subsequent dialogue and activities through the Health Sector WG. Under the Sector-Wide structure allowing government, development partners, private Approach, eleven members contribute to the Health Basket Fund: sector, civil society and academia to engage in its performance Canada, Denmark (Lead from July 2011), Germany, Ireland, Netherlands, and public expenditure review on an annual basis. Norway, Switzerland, One UN, UNFPA, UNICEF, and World Bank (Lead • Government efforts to slow population growth by expanding fam- until June 2011). ily planning services though re-launching its Green Star National Family Planning campaign and adopting innovative ways which Japan, USA, and WHO also participate in the WG. USA as well as the include community based distribution programmes, social mar- Global Fund for AIDS, Tuberculosis, and Malaria contribute a substantial keting and franchising, public private partnerships and linking sum to disease targeted programs. In 2010/11 financing from the Global family planning with HIV prevention efforts with dual protection Fund amounted to approximately US$225 million or 49 percent of the total strengthening Contraceptive Logistic Management System for MoHSW budget. contraceptive supplies and increased allocation of funds under the contraceptive budget line of the MOHSW’s MTEF. US Government funding for PEPFAR is not included in the government budget, and was expected to reach US$358 million for the USG fiscal year • Tanzania has effective health system that reaches down to and which ended September 30, 2010. Other USG commitments are expected to engages meaningfully the community including young people total US$80 million, for an overall USG total of US$438 million. FY11 funding and Tanzania continues to invest in implementing its Health Sector Strategic Plan III and health sector reforms with a focus is expected to remain at similar levels. on strengthening Primary Health Care. Challenges in the health WHo: safe motherhood system particularly in the areas of human resources for health, health management information systems and health care financ- uNFpA: Reproductive health and rights ing are being addressed. uNIceF: child protection; under-5 mortality • The Government has finalized and is implementing the National HIV prevention strategy and its corresponding two-year action uSAId: Health systems strengthening; skilled birth attendance and HIV/ plan (2009/10–2011). Preventing new infections among young AIDS people is key to ensuring an AIDS free generation. SIdA: Women’s rights; Girls’ education • Tanzania has achieved improvements in educational enrollment and retention, especially for girls at the secondary and tertiary cIdA: Healthcare workforce and HIV level and for older Tanzanians, adult education programmes AuSAId: Safe Motherhood (EMOC) especially for rural women helps correct past inequalities. The government would be passing legislation that will amend the GIZ: Gender mainstreaming 1971 Marriage Act and bar marriage before age 18 and efforts to integrate population and family life education (POP-FLE) includ- WB: Safe motherhood ( EMOC) and Health financing, support to ing sexuality and life skills education in the schools system with secondary education complementary outreach programmes for out-of-school youth Sdc: Safe motherhood (EMOC) and health Financing are underway • Tanzania, in its efforts to empower women and ensure gender HMIS and decentralization equality has economic strategies, structures, policies and laws dANIdA: Pharmaceutical and strengthening + HIV/AIDS that recognize women as vital in development. Job creation in- cluding equal access to employment for male and female youth JIcA: Strengthening health management at regional level is a priority. Pooling partners ( WB, RN, Ireand, UNFPA, CIDA, GTZ, DANIDA, • Tanzania’s National Population Policy Implementation Strategy Norway, UNICEF, CDC ): Health system strengthening and improvement (2007) provides an effective framework for the needed multi-sec- of service delivery toral, multi-dimensional and integrated approach to population and development. • Reactivation of the Parliamentary Committee on Population and Development and the Tanzanian Council on Population and Development has begun to create accountability for the Policy’s implementation.