Tackling Access to Antenatal Care through Situation Rooms: Tanzania Sustains Maternal Health Gains under Local Council Leadership

Authors: Masanja S. Lumaneja, Jenny Mwanza, Stella Mujaya and Jenifer Chapman (bios at the bottom of the blog)

Today, the world celebrates International Women’s Day 2024, coming together under the theme ‘Invest in women: Accelerate progress.’ The day is an opportunity to spread awareness on the challenges women face and reflect on ways to achieve full gender equality.

Improving female health outcomes is a key part of this wider struggle, as women’s unique healthcare needs are often overlooked, minimized, and underfunded. Maternal health demands even greater efforts, as tens of thousands of women die annually during and following pregnancy and childbirth, mostly from preventable causes.[1]

One cost effective method of improving pregnancy outcomes and reducing neonatal mortality rates is early antenatal care (ANC), also known as prenatal care.[2] The World Health Organization (WHO) recommends eight ANC visits with a trained healthcare provider, stressing the importance of initiating ANC as early as possible in pregnancy.[3]

In Tanzania, just 62% of pregnant women complete four ANC visits, and the infant mortality rate is 238 per 100,000 live births (compared with 21 in the United States and around 6 in the European Union).[4]

In response, as part of the Tanzanian Health Sector Strategic Plan V 2021-2026 (HSSP), the government introduced a goal to improve the proportion of pregnant women attending their first ANC visit before 12 gestational weeks from 27% to 60% by 2026.

To achieve this goal, the government of Tanzania sought to implement a set of healthcare quality improvement measures customized to the local context. However, at the time, decision makers at the local level—Council Health Management Teams (CHMTs)—faced two significant impediments: although they were charged with ensuring that facility-based healthcare workers were prepared to provide ANC services, they had limited access to maternal health data; and ANC coverage had proven to be a consistently stubborn indicator to improve in the years prior to 2021.

With the launch of the five-year HSSP, the Tanzanian President’s Office, Regional Administration and Local Government (PO-RALG) requested support from the United States Agency for International Development (USAID) to strengthen CHMTs’ ability to analyse and use data to improve health outcomes.
 

Our approach

Data for Implementation (Data.FI), a global five-year project funded by USAID, supported the CHMTs to implement a “Data Use for Improvement” strategy in Dar Es Salaam and Dodoma regions. We worked with the government to establish Situation Rooms–technology-enabled physical spaces that follow a standardized approach for frequent, fast-paced data analysis and review.

During Situation Room meetings, key decision makers assess progress against key, prioritized indicators, identify inefficiencies in healthcare delivery, discuss reasons for under-performance, and agree on actions to course-correct service delivery to improve health outcomes. For maternal health, stakeholders prioritized addressing early booking of ANC visits (before 12 weeks’ gestation). They believed that women who could be linked to antenatal care quickly would be more likely to complete the recommended eight ANC visits and deliver in a health facility, thereby decreasing infant mortality.

CHMTs were laser focused on improving results. Council staff supported health workers to implement change ideas and tracked steady progress in the percentage of pregnant women who competed their first ANC visit before 12 weeks gestation across the four councils–from 22% in the pre-implementation phase to 33% during the implementation phase. Results continued to improve under council leadership after Data.FI support concluded, reaching 39% in the four intervention councils, well above the national average of 27%. We also documented an increase in women completing four ANC visits (in the pre-implementation phase, 13,595 women completed ANC4 and 19,586 women were completing ANC4 in the sustenance phase each month).

This approach emphasized long-term sustainability from the outset, and the CHMTs have developed sustainability plans to ensure that this initiative continues after Data.FI support concluded in December 2023. In addition to naming Situation Room Champions to lead the data review meetings on a weekly basis, three of the four councils have successfully included funding for the Situation Room strategy in the Comprehensive Council Health Plans and budgets, effective July 2023–June 2024.

As we reflect on two years of implementation, three components of the program have proven important: ensuring PO-RALG leadership in the design process; improving data access at Council level; and investing in skills building to enable CHMTs to translate insights from data into tangible actions.

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PO-RALG Data.FI focal person, Mary Shadrack (seated right) and Stella Mujaya, Data.FI Tanzania Country Lead, (seated left), listen to the district medical officer from Kongwa District Council Dr. Thomas Samwel, as he explains the improved health outcomes in his council since the beginning of Data.FI support. August 2023. Photo by Data.FI/Tanzania.

PO-RALG driving the process

A vital component to sustain this initiative’s momentum has been the active and engaged leadership of government officials within the PO-RALG.

Specifically, in 2021 the PO-RALG formed a multi-disciplinary Technical Advisory Group (TAG) to design the quality improvement activity in collaboration with Data.FI, work inspired by the “Makole Model,” a domestic initiative designed to improve client satisfaction and increase hospital revenue. Members of the national-level TAG were trained to design quality improvement projects with the CHMTs. Using participatory techniques, the CHMTs created diagrams describing the primary and secondary drivers that impact early access to ANC, ranging from community outreach and improved quality of services to investments in health worker training, information systems, and commodity management. The PO-RALG assumed a natural leadership role and provided guidance to CHMTs as they adapted solutions to the local context. Under PO-RALG guidance, Data.FI mentored CHMTs to apply a standardized approach to conducting Situation Room meetings, relying on participant engagement tools to identify and prioritize problems, while setting targets appropriate for each council.

Access to Data

Prior to 2021, data to support informed decisions at the council level were captured and stored across different, unlinked information systems. In addition, access to these information systems at the council level was limited to data managers, while focal points for maternal health, vaccination, and HIV programs lacked access to monthly analyses. With the launch of the Situation Rooms, Data.FI supported the integration of data into one system and CHMTs were granted access to the Integrated Monitoring and Evaluation System (iMES), a centralized, online platform in DHIS2 used by the PO-RALG and regional and local government authorities for viewing key health and management indicators. During a two-year period, more than 90 CHMT officials across the four councils regularly accessed the newly developed data visualizations that allowed them to drill down on these indicators by time and geography. Many members of the CHMT logged into the iMES for the first time under this initiative, discovering dashboards that could help inform their daily work.

When we first began thinking about how to improve ANC services for women, the practice was that the Reproductive, Maternal, Newborn, Child and Adolescent Health coordinator conducted all the supervisory visits for maternal health independently. As we engaged the CHMT to work on the multiple drivers affecting access to care, all members increasingly saw the role they could play. We realized that to make real progress, we needed to combine forces and conduct integrated supervision visits. The shift in team culture was palpable; we began working together because we were accountable for delivering the progress against our council-level target for ANC booking before 12 weeks.

Dr. Emmanuel Biya – District AIDS Control Coordinator (DACC) – Kinondoni MC

Conclusion – Optimizing supportive supervision for improved accountability  

With equitable access to more comprehensive data, CHMTs fundamentally changed how facility supervision visits were organized. Deployment plans were made to maximize the human resources available to cover the most marginalized health facilities, prioritizing those with the lowest performance. Since all members of the CHMTs had participated actively in the quality improvement planning process, multiple visits could be conducted simultaneously, thereby multiplying the supervisory capacity and optimizing the funds available. Investments in the Situation Room, and training in quality improvement methods, translated into increased agency and better use of resources to meet programmatic targets.

All this has led to substantial improvements in maternal health outcomes, and has helped build the infrastructure and technical expertise required to sustain and accelerate this progress. The Situation Rooms were expanded in 2022 to include nine additional councils, and their management was fully transitioned to local government leadership in late 2023.

Much remains to be done in Tanzania, and the progress observed is fragile. Still, the work put in thus far proves that determined action and locally responsive technical support can lead to cost-effective and systematic improvements, as well more robust service delivery that is more responsive to women’s unique needs.

Continuing to prioritize and invest in women’s health is therefore a vital priority for 2024 and beyond.

Authors:

Masanja Lumaneja is a public health specialist, medical doctor, and graduate of the London School of Hygiene and Tropical Medicine. He worked for the Data.FI project in Tanzania for over two years, serving a vital in-country role as Quality and Measurement Advisor.

Jenny Mwanza is a Senior Technical Advisor for Data.FI. She has over 20 years of experience designing and scaling domestic and international public health projects, and currently leads Data.FI’s Data Use for Improvement workstream across eight countries.

Stella Mujaya is a committed public health specialist with 18+ years of experience working with the Tanzania Government and International NGOs. She served as The Palladium Group’s Country Representative in Tanzania for over four years, and during that time also worked as the Data.FI Country Director.

Jenifer Chapman is a global health leader with 20+ years of experience working to improve health outcomes and equity in low resource settings in partnership with governments, donors, and international and local organizations. She served as Data for Implementation (Data.FI) Project Director from 2019-2023.

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[1] https://www.who.int/news-room/fact-sheets/detail/maternal-mortality

[2] “The effect of antenatal care follow-up on neonatal health outcomes: a systematic review and meta-analysis” https://publichealthreviews.biomedcentral.com/articles/10.1186/s40985-018-0110-y#:~:text=Conclusions-,The%20present%20systematic%20review%20and%20meta%2Danalysis%20revealed%20that%20antenatal,who%20had%20antenatal%20care%20visits.

[3] https://data.unicef.org/topic/maternal-health/antenatal-care/#:~:text=The%20World%20Health%20Organization%20(WHO,improve%20women%27s%20experience%20of%20care

[4] https://www.cia.gov/the-world-factbook/field/maternal-mortality-ratio/country-comparison/

[5] https://www.cia.gov/the-world-factbook/field/maternal-mortality-ratio/country-comparison/