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Tanzania Non-communicable
Diseases and Injuries
Poverty Commission:
Findings and
Recommendations
August 2020
The Tanzania NCDI Poverty Commission Report
The Tanzania NCDI Poverty Commission Report
TABLE OF CONTENTS
Tanzania NCDI Poverty Commission: List of members iv
List of Tables v
List of Figures vi
Acronyms & Abbreviations vii
Acknowledgements viii
Executive Summary ix
1. Background 1
2. Review of literature on the burden of NCDIs in Tanzania 3
2.1 Data sources 3
2.2 Overall scope of burden of disease due to NCDIs in Tanzania 3
2.3 Scope of previous studies on NCDIs in Tanzania 6
2.3.1 Cardiovascular diseases 6
2.3.2 Diabetes Mellitus 7
2.3.3 Anemia, sickle cell diseases and goitre 7
2.3.4 Digestive diseases 8
2.3.5 Mental Health 8
2.3.6 Neurological Diseases 8
2.3.7 Respiratory diseases 9
2.3.8 Neoplasms 9
2.3.9 Other NCDs 10
2.3.10 Injuries 10
3. NCDI risk factors by socioeconomic status 12
3.1 Hypertension 12
3.2 Diabetes 12
3.3 Smoking and alcohol consumption 14
3.4 Overweight and obesity 14
4. ReviewofpoliciesandhealthnancingforNCDIsinTanzania 16
5. NCDI Service availability 18
5.1 Diabetes services 18
5.2 Cardiovascular services 22
5.3 Chronic Respiratory Disease services 25
5.4 Trauma and injury-related services 27
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The Tanzania NCDI Poverty Commission Report
5.5 Mental Health & Epilepsy services 27
5.6 Cancer services 27
6. Expanding NCDI Priority Conditions 29
6.1 Interventions for Expanded NCDI Health Sector Capacity 29
6.2 Integration and Delivery of Expanded NCDI services 37
6.3 Affordability and Fiscal Space for the Proposed Interventions 40
7. Key Findings 41
8. Recommendations and Next Steps 41
References 42
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The Tanzania NCDI Poverty Commission Report
TANZANIA NCDI POVERTY COMMISSION:
LIST OF MEMBERS
COMMISSION CO-CHAIRPERSONS
Prof Ayoub Magimba
Ministry of Health, Community Development,
Gender, Elderly and Children, Directorate of
Curative Services, NCD Section
Dr Mary Mayige
National Institute of Medical Research
COMMISSIONERS
Dr Sarah Maongezi
Ministry of Health, Community Development,
Gender, Elderly and Children, Directorate of
Curative Services, NCD Section
Dr Janneth Mghamba
Ministry of Health, Community Development,
Gender, Elderly and Children, Directorate of
Preventive Services, Epidemiology
Prof Julie Makani
Muhimbili University of Health and Allied
Sciences
Dr Mariam Kalomo
Ministry of Health, Community Development,
Gender, Elderly and Children, Directorate of
Curative Services, NCD Section
COMMISSION COORDINATOR
Mr. Gibson Kagaruki
National Institute of Medical Research
LANCET NCDI POVERTY
COMMISSION SECRETARIAT ADVISORY
& RESEARCH SUPPORT
Dr. Gene Bukhman
NCD Synergies Project, Partners In Health;
Program in Noncommunicable Diseases and Social
Change, Department of Global Health & Social
Medicine, Harvard Medical School
Dr. Neil Gupta
NCD Synergies Project, Partners In Health;
Program in Noncommunicable Diseases and Social
Change, Department of Global Health & Social
Medicine, Harvard Medical School
Dr. Alex Kintu
Program in Noncommunicable Diseases and Social
Change, Department of Global Health
& Social Medicine, Harvard Medical School
Matthew Coates
Program in Noncommunicable Diseases and Social
Change, Department of Global Health & Social
Medicine, Harvard Medical School
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The Tanzania NCDI Poverty Commission Report
LIST OF TABLES
Table 1: Estimated risk for non-ideal cardiometabolic risk factor
levels in Tanzania by socioeconomic factors 13
Table 2: Priority NCDI conditions in Tanzania by disease category
(Source: Tanzania NCDI Poverty Commission) 29
Table 3: Cost-effectiveness,nancialriskprotection,andequity
scores for selected health sector interventions for expanded
NCDI services in Tanzania 31
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The Tanzania NCDI Poverty Commission Report
LIST OF FIGURES
Figure 1: Leading causes of burden of disease in Tanzania between
1990 and 2015, GBD study 4
Figure 2: Burden of Disease by Age for Tanzania in 2015, GBD Study 4
Figure 3: Burden of NCDIs by disease category for Tanzania in 2015,
GBD Study. 5
Figure 4: NCDI risk factor attribution by disease category in Tanzania
in 2015, GBD Study 5
Figure 5: IdentiedPublishedliteratureonNCDsinTanzaniabased
on search criteria 6
Figure 6: ProlesofindividualswithhypertensioninTanzania 12
Figure 7: ProlesofhypertensiveindividualsinTanzaniabywealth
quintile,settingandeducationlevel 13
Figure 8: ProlesofindividualswithdiabetesinTanzania 14
Figure 9: ProlesofindividualswithdiabetesinTanzaniabywealth
quintile,settingandeducationlevel 14
Figure 10: Expenditure on NCDs in Tanzania, 2012 to 2016 16
Figure 11: Expenditure on injuries in Tanzania, 2012 to 2016 17
Figure 12: Rural versus Urban availability of NCDI services in Tanzania 19
Figure 13: Availability of NCDI services by health facility level in Tanzania 20
Figure 14: Availability of NCDI services by health facility ownership
in Tanzania 20
Figure 15: Availability of Diabetes Mellitus services at district and region
level hospitals in Tanzania 21
Figure 16: Availability of hypertension services at district and region
level hospitals in Tanzania 22
Figure 17: Availability of heart failure services at district and region
level hospitals in Tanzania 23
Figure 18: Availability of asthma services at district and region level
hospitals in Tanzania 24
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The Tanzania NCDI Poverty Commission Report
ACEI Angiotensin Converting Enzyme inhibitors
ALL Acute Lymphoblastic Leukemia
AML Acute Myeloid Leukemia
BMC Bugando Medical Centre
CHS Catastrophic Health Spending
COPD Chronic Obstructive Lung Disease
CVD Cardiovascular Diseases
DALYS Disability Adjusted Life Years
DCP 3 Disease Control Priority 3
DHS Demographic and Health Survey
DSS Demographic Surveillance Site
ECG Echocardiography
FNA Fine Needle aspiration
GBD Global Burden of Disease
HIV HumanImmunodeciencyVirus
HR HPV High Risk Human Papilloma Virus
KCMC Kilimanjaro Christian Medical Centre
MoHCDGEC Ministry of Health, Community Development, Gender,
Elderly and Children
NCDI Non- Communicable Diseases and Injuries
NEHCIP National Essential Health Care Interventions Package
NGO Non-Governmental Organisation
NIMR National Institute for Medical Research
ORCI Ocean Road Cancer Institute
PEP Post Exposure Prophylaxis
PIH Partners in Health
RHD Rheumatic Heart Disease
RTA RoadTrafcAccident
SCD Sickle Cell Disease
SES Socio Economic Status
SPA Service Provision Assessment
THE Total Health Expenditure
UHC Universal Health Coverage
USD United States Dollars
WHO World Health Organisation
YLD Years Lived with Disability
YLL Years of Life Lost
ACRONYMS & ABBREVIATIONS
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The Tanzania NCDI Poverty Commission Report
ACKNOWLEDGEMENTS
The development of this report would not have been possible without the
joint support of individuals and organisations who contributed tirelessly
into the development of this report. Special thanks go to the Tanzanian
Ministry of Health, Community Development, Gender, Elderly and
Children (MoHCDGEC), NCD Synergies / Partners in Health, Department
of Global Health and Social Medicine at Harvard Medical School, the Lancet
Commission on Reframing Non-communicable Diseases and Injuries for the
Poorest Billion, National Institute for Medical Research, National Bureau of
Statistics, and other NCDI stakeholders, individuals and organizations. We
particularly thank members of the Tanzania NCDI Poverty Commission for
their time and dedication to this project.
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The Tanzania NCDI Poverty Commission Report
EXECUTIVE SUMMARY
Non-communicable diseases and Injuries (NCDIs) are increasing globally and
disproportionately affect the poor, especially those in low- and middle-income
countries. Despite the increased burden of NCDIs, investment in interventions
to halt the burden is still low despite increased awareness of the problem at the
global level.
The Tanzania NCDI Poverty Commission was established in collaboration with
the Lancet Commission on Reframing Non-Communicable Diseases and Inju-
ries for the Poorest Billion with the objective of raising awareness of NCDIs in
Tanzania and their relationship with poverty. This also includes an assessment
of readiness of the health system to respond to NCDIs in order to further pro-
pose cost-effective interventions for priority NCDI conditions. This report pres-
ents a summary of the burden of NCDIs in Tanzania from a review of published
literature and analysis of global burden of disease data and analysis of data
from the Service Provision Assessment and NCD National Surveys. The report
also includes a set of proposed priority NCDIs interventions and the proposed
estimatesoftheinvestmentrequiredforimplementation.
ThendingsofthisreportconrmthatNCDIscausesignicantburdenofdis-
ease in Tanzania, accounting for 41% of all DALYs, including disability and pre-
mature mortality, and that the burden of NCDIs has doubled in the past 25 years.
While it has been described that 80% of the global NCDI burden is attributed to
lifestyle factors, namely poor diet, lack of physical activity, smoking and alcohol
consumption, this report showed that 79% of the NCDIs DALYs cannot be ex-
plained by the traditional behavioural and metabolic risk factors. Further anal-
ysis is needed to unpack the risk factors underlying the increase in the burden
of NCDIs, including lack of treatment of conditions leading to chronic diseases
and the linkage between infectious diseases and NCDs, which tend to be more
pronounced in low-income settings. Furthermore, over 60% of NCDI DALYs in
Tanzania are from conditions other than Cardiovascular Diseases (CVD), Can-
cer, Diabetes and Chronic Respiratory Diseases (COPD). One of the objectives
of the review was to disaggregate data by poverty and socio-economic indices.
For example, evidence from the literature review showed that some NCDI con-
ditions, such as stroke and diabetes, are more prevalent in urban areas, while
other conditions, such as anaemia, cervical cancer, and esophageal cancer are
more prevalent in rural areas. There is a need to describe the burden of NCDIs
disaggregated by socio economic indices to best target the interventions to the
rightpopulations.Morestudiesareneededtollthegapintheknowledgeof
NCDI risk factors especially in poor populations.
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The Tanzania NCDI Poverty Commission Report
Although included in the essential services package, the availability of NCDIs
services were limited overall and there was high variability between rural and
urban areas, with lower availability and readiness in rural areas. There were
also barriers to accessing treatment for certain conditions, such as hypertension
and diabetes, which was more pronounced in rural and lower socioeconomic
groups. Positive ndings were noted, however, where specic interventions
were implemented, such as the National Diabetes Programme. Access to care
was also impacted by lack of resources.
Using a priority setting process supported by local data and expertise, this com-
missionidentiedanexpandedsetof48NCDIconditionsforattentionandpri-
ority to appropriately capture the full burden of NCDIs affecting Tanzanians.
In addition to common conditions such as hypertensive and ischemic heart dis-
ease, type II diabetes, and chronic respiratory disease, we encourage inclusion of
additional conditions with a high burden of disease that particularly affect the
young and the poor, such as rheumatic and congenital heart diseases, sickle cell
disease and hematologic malignancies, severe chronic respiratory diseases, type
1 diabetes, women’s malignancies, severe mental health conditions, and injuries.
This commission also selected 53 previously described evidence-based cost-ef-
fectivehealth sector interventionsto ll thegap for NCDIservices to achieve
UHC. This set of interventions includes services for NCDs, mental health, in-
juries, palliative care, rehabilitative care and represents medical, surgical, psy-
chosocial,andcommunity-basedapproachesthat wouldrequireintegrationat
multiple levels of the health care system. Existing capacities need to be upgrad-
ed, including guidelines, human resources, and training. Overall, the combined
annual incremental cost of this comprehensive set of NCD, mental health, and
surgical interventions is estimated to be USD $702.9 million, or approximately
$12.26 per capita annually, which represents 35.6% of total current health expen-
diture or 1.32% of GDP.
There is a need to describe the burden of NCDIs disaggregated by socio eco-
nomicindicesto best targetinterventions.Morestudiesareneeded to llthis
knowledge gap, and systematic inclusion of socioeconomic indicators in disease
registries, health facility reporting, and household surveys such as the Tanza-
niaDemographicandHealthSurvey.Adetailedanalysis of possible nancing
mechanisms,as well asa formalscal space analysis,would greatly facilitate
target setting and feasibility assessment of inclusion of key NCDI interventions
in essential health package and national health insurance to help achieve univer-
sal health coverage. Participation is needed from all sectors, particularly from
patients and civil society, policy-makers, academia, and clinicians. Advocacy
and discussion with these stakeholders may result in greater awareness and
high-level commitments to combat an expanded group of NCDIs in Tanzania.
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The Tanzania NCDI Poverty Commission Report
This report has highlighted the increased burden of NCDIs and that the poor
and those in rural areas are also affected. The agenda for NCDIs needs to rec-
ognise the local burden of disease and include additional conditions that are
causingsignicantburdenlocallyandaffecttheyoung,suchasepilepsy,sickle
cell disease, rheumatic and hypertensive heart diseases, violence, etc, while also
afrmingtotheglobalrecommendations.ServicesforNCDIsrequiredramatic
strengthening, especially interventions that respond to the needs of the poor. Fi-
nally, there is a need to identify sustainable funding for NCDIs and other chron-
ic conditions as the current out-of-pocket expenditures and free treatment policy
will not be feasible in the long run and can exacerbate the cycle of poverty as the
burden of NCDIs continue to rise.
XI
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The Tanzania NCDI Poverty Commission Report
1. Background
GlobalpoliciesforNon-communicableDiseases(NCDs)havenotyetbenetted
the world’s poorest people. Despite two United Nations High-Level meetings on
NCDs in 2011 and 2018, and their inclusion under target 3.4 of the Sustainable
Development Goals, development assistance for NCDs has stalled, and there
has been little evidence of progress on domestic investment to address NCDs
and injuries (NCDIs) in the poorest. In Tanzania, there have been strong initia-
tives to address and combat NCDIs. In 2008, the Tanzanian Ministry of Health,
Community Development, Gender, Elderly and Children (MoHCDGEC) estab-
lished the NCD Division, whose function is to coordinate the design, implemen-
tation and monitoring of policies to address NCDIs. In 2009, the MoHCDGEC
also launched the National Noncommunicable Disease Strategy, an 8-year plan
for risk factor reduction and health system strengthening. Building on this ini-
tiative, in 2016, the MOHCDGEC further developed the Strategic and Action
Plan for the Prevention and Control of Non Communicable Diseases in Tanzania
(2016-2020), which provided a more updated and detailed approach to address-
ing NCDIs in Tanzania.
In September 2015, the Lancet launched the Commission on Reframing NCDs
and Injuries for the Poorest Billion (Lancet NCDI Poverty Commission).1 This
Commission hypothesized that for the populations living in the most extreme
poverty, the endemic burden of NCDIs is much less dominated by preventable
lifestyle risk factors and their associated diseases (e.g. coronary artery disease
and type 2 diabetes) than it is in other populations. Given this epidemiology, the
response to NCDIs among the poorest must be framed in terms of policies that
address material poverty and integrated health service delivery strategies. These
strategies should complement the existing WHO-supported agenda focused on
prevention of emerging behavioural risk factors and their associated diseases.
In 2016, the MOHCDGEC established the Tanzania NCDI Poverty Commission
to explore the epidemiology, response, and potential actions for NCDIs affecting
the poorest populations in Tanzania. The objectives of this Commission were to:
• Establish the burden of disease of NCDIs in Tanzania, particularly in rela-
tion to socioeconomic risk factors
• Understand and document the availability and coverage of health sector
services for NCDIs in Tanzania
• PrioritizeNCDI conditionsthatrequireinterventioninTanzania,empha-
sizing those causing highest morbidity and mortality, with a particular
focus on those that affect the worst off or cause severe disability and those
thatareinequitablyaddressedforthoselivinginpoverty.
• Propose a package of cost-effective interventions to address priority NCDIs
in Tanzania
2The Tanzania NCDI Poverty Commission Report
• Estimate the cost and potential impact of these interventions
• Highlight the voices of those impacted by NCDIs particularly those living
in poverty
This report summarizes existing and available data regarding the NCDI disease
burden and coverage of NCDI interventions in relation to socioeconomic risk
factors in Tanzania and proposes potential cost-effective health sector inter-
ventions for an expanded set of NCDI priorities. It is the hope of this Commis-
sionthatthesendings can inform dialogue amongrelevantstakeholdersand
provide next steps to be undertaken to address NCDIs in Tanzania.
2. Review of literature on the burden of
NCDIs in Tanzania
The aim of this review was to evaluate the scope of literature on NCDIs in Tan-
zania to achieve the following goals:
i. Identify available data sources on NCDIs in Tanzania, including published
studies, population surveys and health facility surveys
ii. Quantify the burden of NCDIs and their associated risk factors by socio-
economic factors in Tanzania using existing data sources
iii. Assess the availability and coverage of NCDI services by socioeconomic
factors in Tanzania using existing data sources
iv. Assemblerelevantexpertsandstakeholderstoreviewanddiscussndings
in relation to policy and health system interventions
v. Detail next steps to be undertaken by this Commission to better inform
strengthened and expanded NCDI interventions in Tanzania
2.1 DATA SOURCES
Several data sources were used for assessing the burden of disease in Tanza-
nia. One of these was a detailed analysis of the Global Burden of Disease (GBD)
study’s ndings on the burden disease due to NCDIs in Tanzania.2 This was
conducted through the GBD online visualization tool and the datasets linked to
it. The second source was a systematic review of published studies on NCDIs in
Tanzania. This involved searching PubMed for studies in humans that had been
published between January 1st 2006 and July 31st 2016. Search terms included
level 2 NCDI categories as dened by GBD Study combined with the word
“Tanzania”. Studies were classiedas relevantfor further reviewif theycon-
taineddataonprevalence,riskormortalityfromNCDIs,preferablystratiedby
socioeconomic and poverty or by geographic location; reported distributions of
3
The Tanzania NCDI Poverty Commission Report
types of NCDI cases among admissions and deaths at health facilities; or if they
had details on interventions for NCDIs. For studies that used data from national
surveys, we further referred to published literature on the original surveys to
abstract relevant data. For example, national estimates for hypertension and
diabetes were abstracted from STEPS survey reports.3 The third source of data
involved a secondary analysis of several surveys that previously collected data
on NCDIs in Tanzania. These included the WHO supported Stepwise Approach
to Surveillance on NCDs, the Tanzania Service Provision Assessment Survey
and the Service Availability and Readiness Assessment Survey.
2.2 OVERALL SCOPE OF BURDEN OF DISEASE DUE TO NCDIS IN
TANZANIA
Figures 1 shows a comparison of the top causes of burden of disease in Tanzania
between 1990 and 2017. There was a reduction in rankings for many communi-
cable, maternal, neonatal and nutritional conditionals. During the same period,
there has been was increase in rankings for almost all NCDIs. Currently, NCDIs
are more prevalent than communicable diseases at almost all ages, and more
than 65% of all prevalent NCDIs occur before age 40 (Figure 2).
Figure 1: Leading causes of burden of disease in Tanzania between 1990 and 2017, GBD study
1. Respiratory infections & TB
2. NTDs & malaria
3. Maternal & neonatal
4. HIV/AIDS & STIs
5. Enteric infections
6. Other non-communicable diseases
7. Other infections
8. Nutritionaldeciencies
9. Cardiovascular diseases
10. Unintentional injuries
11. Neoplasms
12. Mental disorders
13. Digestive diseases
14. Neurological disorders
15. Diabetes & chronic kidney disease
16. Transport injuries
17. Chronic respiratory
18. Musculoskeletal disorders
19. Self-harm & violence
20. Skin diseases
21. Sense organ diseases
22. Substance use
1. Maternal & neonatal
2. Respiratory infections & TB
3. Other non-communicable diseases
4. HIV/AIDS & STIs
5. NTDs & malaria
6. Cardiovascular diseases
7. Nutritionaldeciencies
8. Enteric infections
9. Neoplasms
10. Other infections
11. Unintentional injuries
12. Mental disorders
13. Digestive diseases
14. Neurological disorders
15. Diabetes & chronic kidney disease
16. Musculoskeletal disorders
17. Chronic respiratory
18. Transport injuries
19. Skin diseases
20. Self-harm & violence
21. Sense organ diseases
22. Substance use
Leading causes of burden of disease
in Tanzania between 1990 and 2017
Both sexes, All ages, DALYs per 100,000
1990 RANK 2017 RANK
Communicable,
maternal, neonatal, and
nutritional diseases
Non-communicable
diseases
Injuries
4The Tanzania NCDI Poverty Commission Report
Less than 40% of the burden of disease caused by NCDIs in Tanzania is due to
cardiovascular diseases, chronic respiratory conditions, cancer and diabetes –
thefour NCDIsidentiedbytheWorldHealth Organizationastoptargetsfor
prevention and control (Figures 3). A large proportion (79%) of NCDI DALYs are
not attributable to behavioral or metabolic risk factors measured in GBD models.
This may support the hypothesis that there are other underlying socio economic
and cultural risk factors that are underpinned by poverty (Figures 4).
Figure 2: Burden of Disease by Age for Tanzania in 2017, GBD Study
Figure 3: Burden of NCDIs
by disease category for
Tanzania in 2017, GBD Study.
Diabetes and
kidney diseases
Burden of NCDIs by Disease Category
5%
Chronic
respiratory
diseases
4%
Neoplasms
10%
Cardiovascular
diseases
12%
Digestive diseases
6%
Skin and subcutaneous
diseases
4%
Sense organ diseases
3%
Substance use disorders
2%
Neurological
disorders
6%
Mental
disorders
8%
Musculoskeletal
disorders
5%
Other
non-communicable
diseases
25%
Unintentional
injuries
8%
Transport
injuries
4%
Self-harm and
interpersonal
violence
4%
Burden of Disease by Age in 2017
0
500,000
1,000,000
1,500,000
2,000,000
2,500,000
3,000,000
3,500,000
1 to 4
5 to 9
10 to 14
15 to 19
20 to 24
25 to 29
30 to 34
35 to 39
40 to 44
45 to 49
50 to 54
DALYs
Communicable, maternal, neonatal, nutritional diseases NCDs Injuries
55 to 59
60 to 64
65 to 69
70+
5
The Tanzania NCDI Poverty Commission Report
As seen in Figure 4, cardiovascular diseases have the greatest variability in
riskfactors.Thismayreectbothischemicriskfactorssuchashypertension,
obesity, and smoking, as well as environmental, infectious, or social risk factors
for non-ischemic cardiomyopathies, including rheumatic heart disease, post-
partum, and other cardo myopathies. “Cirrhosis and other liver diseases”
have a considerable portion of behavioural risk factors, presumably alcohol
use. Neoplasms and mental and substance abuse both also have some
risk attributed to behavioural factors, though minimally so. Diabetes, as
expected, has a considerable proportion of risk associated with metabolic and
behavioural factors. Both “chronic respiratory diseases” and “musculoskeletal
diseases”demonstrateasignicantportionofenvironmentalrisk,presumably
fromindoorcookingandoverallairqualityintheformerandoccupational
exposures in the latter. Overall, however, aside from cardiovascular diseases,
all other categories demonstrate approximately half or more of disease that is
not attributable to behavioural or metabolic risk factors modelled within the
GBD study.
2.3 SCOPE OF PREVIOUS STUDIES ON NCDIS IN TANZANIA
The literature search yielded 1,161 published studies on NCDIs in Tanzania from
2006-2016.Twentypercent(N=345)wereselectedasrelevantbasedonpredened
criteria.One-hundredandfty-veofthesehaddetailsonlinksbetweensocio-
economic factors and NCDIs (Figure 5). There were no studies on cirrhosis and
chronic liver disease or on musculoskeletal disorders with details on how socio-
NCDI Risk Factor Attribution by Disease Categoryin 2017
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Neoplasms
Cardiovascular diseases
Chronic respiratory diseases
Diabetes and kidney diseases
Digestive diseases
Neurological disorders
Mental disorders
Substance use disorders
Skin and subcutaneous diseases
Sense organ diseases
Musculoskeletal diseases
Other NCDs
Injuries
Behavioral Environmental
Metabolic
Behavioral Environmental
Behavioral Metabolic
Environmental Metabolic
Behavioral
Environmental
Metabolic
Burden not attributable
to GBD risk factors
Figure 4: NCDI risk factor attribution by disease category in Tanzania in 2017, GBD Study
6The Tanzania NCDI Poverty Commission Report
economic factors in Tanzania affect these conditions. Categories that have the
largest proportions of relevant studies included injuries, neoplasms, cardiovas-
cular diseases and mental health conditions, all with 30% of studies categorized
as relevant. Most of the literature on NCDIs in Tanzania is from studies that were
conducted in urban settings and regional or referral hospitals.
2.3.1 CARDIOVASCULAR DISEASES
A large proportion of literature on NCDIs in Tanzania is on hypertension. The
national prevalence of hypertension among adults aged 25-64 is 26% with no
difference by sex.3 No studies have assessed regional differences but one study
found similar proportions of individuals with hypertension in urban and rural
areas of Mwanza.4 People living in rural areas were however more likely to
be unaware of their hypertension and therefore less likely to be on treatment.
Over 90% of hypertensive people in Tanzanian are not on blood pressure med-
ication and individuals that are diagnosed with hypertension often do not seek
therequiredhealthcare.3,4 A study in Mwanza region found that only a third
of patients that are diagnosed with hypertension seek care during the next 12
months.4 Lack of symptoms and the cost of treatment were listed as the most
common reasons for not seeking care.
Published Literature on NCDs in Tanzania
29
13
101
206
178
207
42
104
232
238
9
0
35
70
15
47
64
8
29
34
34
4
0
18
33
4
25
43
0
6
17
5
050 100 150 200 250 300
350
Other NCDs
Neurological disorders
Neoplasms
Musculoskeletal disorders
Mental health and substance abuse
Injuries
Digestive diseases
Diabetes, blood, urogenital, endocrine
Cardiovascular diseases
Cirrhosis and other liver conditions
Chronic respiratory conditions
With SES indicators Relevant studies Met search criteria
329
Figure 5: Identied Published literature on NCDs in Tanzania based on search criteria
7
The Tanzania NCDI Poverty Commission Report
Hypertension-related diseases are the leading cause of deaths (after HIV) at
Bugando Medical Centre, and the leading cause of deaths due to NCDs (34%).5
The hospital mortality rate for these conditions at this referral hospital was 19.5
per 100 admissions and the leading causes of deaths were hypertensive stroke
(37 per 100 admissions), hypertensive renal disease (29 per 100 admissions),
hypertensive heart failure (17 per 100 admissions) and hypertensive emergen-
cies (9 per 100 admissions).
There have been more studies on stoke than on ischemic heart disease in Tan-
zania. This is in part due to The Tanzania Stroke Incidence Project, one of the
few population-based cohorts on stroke in sub-Saharan Africa.6 This study doc-
uments incident stroke cases in the rural demographic surveillance site (DSS)
in Hai district and an urban DSS in Dar es Salaam. Between 2003 and 2006, the
age adjusted incidence of stroke was 109 per 100,000 in Hai and 315 per 100,000
in Dar es Salaam. These estimates are comparable to annual gures from the
GBD Study.2 There has also been a gradual increase in the mean age and pro-
portion individuals admitted with stroke that are women.6 Over 80% of cases of
stroke that present at health facilities are due ischemia7 and a large proportion of
these die within 3 to 7 years.8 By WHO estimates, Tanzania had the 6th highest
number of Ischemic Heart Disease deaths in sub-Saharan Africa with 191,000
deaths in 2008.9
The commonest causes of heart failure in patients seen at Muhimbili National
Hospital, Dar es Salaam are hypertension (45%), cardiomyopathy (28%), rheu-
matic heart disease(12%), and ischemic heart disease (9%).10 Individuals diag-
nosed with heart failure in Tanzania are on average younger than those from
high income settings and hypertension is gradually becoming a more important
risk factor for heart failure than rheumatic heart disease (RHD). There are no
published studies on the burden of RHD and other cardiomyopathies in Tanza-
nia. According to the GBD there were 1,140 per 100,000 cases of RHD in Tanzania
in 2016, with a large majority aged between 5 and 40 years.
2.3.2 DIABETES MELLITUS
According to the 2012 Tanzania STEPS survey, the prevalence of diabetes in
adults aged 25 to 64 years was 8% in males and 10% in females.3 Over 90% of
people in this survey had never been assessed for diabetes and over 90% people
found to be diabetic were newly diagnosed. The prevalence of diabetes in urban
settings of Kilimanjaro is double that of rural areas (10% vs. 5%)11. Adherence
to antidiabetic therapy is generally low as shown by a study in Dar-es-Salaam
that reported adherence rates of 60% at one week and 71% at three months.12 The
most common reasons for the poor adherence were high medication costs (57%),
disappearance of symptoms (18%) and medication side effects (12%).
8The Tanzania NCDI Poverty Commission Report
About half of diabetics in Tanzania were estimated to have complications such
as diabetic retinopathy13 and diabetic foot.14 The proportions of reported compli-
cations do not differ by sex, education and locality (rural and urban).13 In one
study, a third of patients attending a diabetic clinic in Dar es Salaam had diabetic
foot and 10% had undergone major amputation.14 Some studies have also looked
at the cost of managing diabetes and its complications, and found that annual
costs for complications like haemodialysis and diabetic foot ulcers are too expen-
sive for both patients and the government.15 For example, the cost of treating dia-
betic foot ulcers at referral hospitals ranges from $102 for uncomplicated ulcers
to $3000 for complicated ones.
2.3.3 ANEMIA, SICKLE CELL DISEASES AND GOITRE
Forty-vepercentofwomenaged15to59yearsand58%ofchildrenaged6to
59 months in the 2015 Demographic and Health Survey (DHS) were anaemic.16
Children with mothers that had at least secondary education are less likely to be
anaemic than those with no education (prevalence: 54% vs. 66%). Children from
householdsofthelowestwealthquintilearemorelikelytobeanemicthanthose
fromthehighestquintile(prevalence:50%vs.64%).Althoughalargeproportion
of this is due to infectious and nutritional causes, the resulting chronic anaemic
states can have an impact on other NCDs.
In 2012, 6 per 1000 live births in Tanzania had Sickle Cell Disease (SCD) resulting
in 11,877 new cases of SCD per year.17 Annual mortality rate of SCD in Tanza-
nia was 1.9 per 100 person-years between 2004 and 2009.18 An estimated 10,313
children aged 5 years or younger with SCD are estimated to die every year,
thereby contributing 7% of overall deaths of children aged 5 years or below.17
Thesegures aremuch higher than thosereported bythe GBD Study,which
estimated mortality rate at 4.2 per 100,000 in 2007 and 1,717 deaths for that year.
The prevalence of goitre in children aged 6 to 9 years living in goitre-endemic
districts reduced from 61% in 1980 to 12% in 2004.19 In 2007, 83% of households
iodinedecientinTanzaniamainlandand64%ofhouseholdinZanzibarwere
using iodized salt.20
2.3.4 DIGESTIVE DISEASES
Only a few studies have been published on digestive diseases in Tanzania. One
of these was conducted at Bugando Referral Hospital and found that obstructed
hernias were the commonest cause (33%) of dynamic bowel obstruction.21 Other
causes included obstructive bands (19%), volvulus (17%), malignancies (12%),
and intestinal tuberculosis (9%). A second study from the same hospital reported
gastric cancer as the commonest malignant cause of gastric outlet obstruction and
9
The Tanzania NCDI Poverty Commission Report
peptic ulcer disease as the commonest benign cause.22 Congenital pyloric steno-
sis is the commonest (13%) cause of gastric outlet obstruction in children.23 The
majority (91%) of patients that presented with obstruction in this study under-
went surgery while the rest were managed conservatively. In another study at
Kilimanjaro Christian Medical Center the commonest causes of upper GI bleed-
ing were esophageal varices (42%), duodenal ulcers (15%), hemorrhagic gastritis
(8%), gastric ulcers (5%) and Mallory Weiss tears (2%). Conservative medical
therapy was carried out in 52% of the cases, whereas endoscopic therapy and
surgical intervention was used in 47% and 2% of cases respectively. Mortality
rates in the above three studies in patients that presented with digestive diseases
ranged from 14% to 19%.
2.3.5 MENTAL HEALTH
The GBD Study estimates that over 7 million Tanzanians currently have mental
and substance abuse disorders. There are no nationally representative studies
thatusedprimarydatatoverifythisgurebutmultiplestudiesexistfromdif-
ferentpartsofthecountry.Alcoholuseandabuseisoneofthemostfrequently
studied area in this category.24–28 The prevalence of alcohol use and abuse is higher
in men,27 with regional differences in the alcohol consumption. For example,
alcohol use is more common in Kilimanjaro than in Mwanza. These patterns are
mostly due to social and cultural differences as opposed to economic drivers.
The age of onset of alcohol intake is below 18 years for most people who take
alcohol28 and several studies have linked alcohol intake to risky sexual behav-
ior.24,26 Fewer studies have been published on abuse of other substances but there
is evidence of concerning rates of injection drug use and other illicit drugs in
urban settings.25,29,30 It was estimated that 50,000 Tanzanians were using opiates
in 2011.31
Over 1.5 million people are estimated to be have depressive disorders in Tanza-
nia, the majority being women.2Thisisconsistentwithndingsfromprimary
data that found a low prevalence (3%) of depression and anxiety in Dar-es-Sa-
laam.32 There are however higher rates of these conditions reported in HIV pos-
itive individuals.33 Intimate partner violence by men has also been shown to be
a contributing factor to depression in Tanzanian women.34 There were no pub-
lished studies comparing rates of mental health by socio-economic status.
2.3.6 NEUROLOGICAL DISEASES
Fourteen million Tanzanians are estimated to have some form of neurological
disorder, the majority of whom are age 40 years or younger2. There have been
several studies on neurological conditions in elderly individuals from Hai dis-
10 The Tanzania NCDI Poverty Commission Report
trict40–42. The prevalence of neurological conditions in this population is 15%, a
large proportion of which are tension and migraine headaches. Of individuals
identiedwithneurologicdiseases,only65%accessedmedicaltreatment.42 Only
14% of patients had been diagnosed prior to the survey and 10% had received
treatment for their conditions. Patients are more likely to seek treatment for con-
ditions with high levels of disability.
There is a low prevalence of neurological diseases that are commonly associated
with aging.35 In 2009, the age-adjusted prevalence of Alzheimer’s Disease and
vascular dementia was 3.0% and 2.6% in 2009.35 Likewise, another study found a
low prevalence of Parkinson’s disease in adults aged 50 years or older, with only
3 of 1,269 individuals being diagnosed with the disease.36
The estimated prevalence of epilepsy from population-based surveys is between
1 to 2.7 per 1000 with a preponderance in women.37,38 About half of individuals
with epilepsy are reported to have active disease and approximately 70% of epi-
lepsypatientsdonotaccessrequiredtreatment.38
Th prevalence of tension-type headaches in Tanzania has been estimated to be
20% with regional differences.39 The prevalence of tension headaches in Mbulu
district is 7% with higher rates reported in women and aged 41 to 50 and men
aged 60 years or older.39 In 2003, the prevalence of migraine headaches in
Manyara region was 28% with an annual attack rate of 18 episodes.40
Several studies have looked at eyesight and related conditions. One assessed
400 children aged 6 to 17 years old in Kibaha and found poor vision in 9.5% of
them.41 Females in this study were more likely to have poor vision than males
and congenital anomalies were the most common cause of poor vision. The prev-
alence of bilateral blindness in a population-based study in individuals aged 50
years or older from Kilimanjaro was reported to be 2.4%, with most of this due to
cataracts.42 The estimated prevalence of blindness in children in the same region
is 17 per 100,000. A study in 256 randomly selected diabetic patients in Zanzi-
bar found that 65% of them had diabetic retinopathy and that 20% had visual
impairment.43 Only 10% of patients in this study had undergone an eye check-up
in the past year.
2.3.7 RESPIRATORY DISEASES
The few studies that have been carried out in this category are on asthma and
chronic respiratory disorders that are as a result of occupational hazards. A study
conducted in secondary school children (n=610) in rural (Bagamoyo) and urban
(Ilala) areas reported a prevalence of asthma was 12.1% in Bagamoyo and 23%
in Ilala.44 Another cross-sectional study in Manyara among children aged 9-10
years found a prevalence of 24% with severe symptoms in 5% of them in last
one year.45 Several studies have reported severe chronic respiratory symptoms
among workers in coffee, sisal, cement and coal factories.46–48
11
The Tanzania NCDI Poverty Commission Report
2.3.8 NEOPLASMS
The Tanzanian Ministry of Health estimates that 40,000 new cases of cancer
occur each year.49Cervical canceris most frequentcancer inTanzania.50 More
than 7,300 women were diagnosed with cervical cancer in Tanzania in 2016 and
over 4200 died from the disease that year.50 A cross-sectional study in appar-
ently healthy women aged 25-59 years in Dar es Salaam (N=10,374) found that
4.8% had stage 1 to stage 3 cervical cancer.51 The prevalence of high risk human
papilloma virus (HR HPV) in Tanzania is 20% and ranges from 15% in women
with normal cytology to 94% in women with high grade cervical cancer.52 The
prevalenceofHR HPV isalsosignicantly higher inwomen from rural areas
and in HIV positive women. A large proportion of women that are diagnosed
with cervical cancer in Tanzania present in advanced stages when curative care
can no longer be considered.53 Factors associated with late presentation relate
to poor access and utilization of health care services.53–55 It is also estimated that
only 10% of cervical cancer cases are seen at tertiary centers that can provide
requiredcare,80%ofwhopresentwithlatestagecancer.
The age-standardized prevalence of breast cancer in Tanzania 19.4 per 100,000
women and breast cancer represents 14% of new cancer cases.56 There were an
estimated 1,500 deaths due to breast cancer in Tanzania in 2016.2 Most women
diagnosed with breast cancer present at advanced stages.57–59 The mean age at
breast cancer diagnosis is 52 years, the majority being postmenopausal multip-
arous women.59 There is high awareness of breast cancer in Dar es Salaam with
98% of women in one survey reporting knowledge of the disease.60 However
only 50% of them were knowledgeable on common symptoms of breast cancer.
Also, although half of them were aware of self-breast exams, 40% of them did
not practice it. The commonest histological type of breast cancer seen is invasive
ductal carcinoma and almost half of the cases are both estrogen and proges-
terone receptor negative.58 The most optimal choice of management in women
diagnosed with breast cancer is usually mastectomy with adjuvant chemother-
apy and hormonal therapy.57 Five-year survival rates are estimated to be only
21%, with 17% of women experiencing local tumor recurrences.57
A study in 184 patients that presented with gastric outlet obstruction at Bugando
Medical Center found that cancer was the most common malignant cause impli-
cated.22 The majority of (92%) of patients diagnosed with gastric cancer at this
hospital present at advanced stages and the male to female ratio is 3:1.61 Almost
all patients are treated surgically with chemotherapy reported in less than a
quarterofthem.Postoperativecomplicationsoccurinoverathirdofthesurgical
casesand ve-yearsurvivalrateinthisstudywasonly7%.Anothercommon
gastro-intestinal cancer in Tanzania is esophageal cancer, which is more preva-
lent in rural than urban areas and in males with a sex ratio of 2:1.62 Esophageal
cancer has also been reported to be more prevalent in the central and eastern
parts of Tanzania.63
12 The Tanzania NCDI Poverty Commission Report
There was a 6-fold increase in documented cases of colorectal cancer at two
hospitals in Dar es Salaam in the period between 2005 and 2015.64 There are
no sex-differences in the prevalence of colorectal cancer and 60% of diagnosed
patients are between the ages of 40 and 69 years. A cross-sectional study in 322
patients diagnosed with colorectal cancer in Mwanza found that almost all (98%)
were surgically managed.65 Post-operative complications, cancer recurrence and
morality were reported in 26%, 19% and 11% respectively.65
Commonly diagnosed pediatric cancers in Tanzania include leukemia and
Burkitt’s Lymphoma.66,67 A chart review of 106 cases of leukemia diagnosed at
Ocean Road Cancer Institute between 2008 and 2010 revealed that 77% were
due to acute lymphoblastic leukemia (ALL) and 24% due to acute myeloid leu-
kemia (AML).66 The majority (84%) of ALL cases and 35% of AML cases achieved
complete remission after chemotherapy leading to a 2-year event-free survival
of 33% for ALL but none (0%) for AML. This is in comparison to only one sur-
vival in 20 children that were diagnosed with leukemia at this center in 2005. A
survey in 6 hospitals from Mwanza and Mara estimated a 1.4:1 male to female
ratio for Burkitt lymphoma.67 Its incidence is estimated to have peaked in 2001
and thereafter gradually declined. Tumors occur at a younger mean ag in boys
as compared to girls (6.8 vs. 7.6 years) and boys are more likely to have facial
tumors (50% vs. 36%)
2.3.9 OTHER NCDS
Dental disorders, skin disorders and congenital diseases in this category. A
study conducted in rural Kilimanjaro (n=1,435) found that 75% of participants
haddentaluorosisand4%hadjuvenileskeletaluorosis.68 Factors associated
with these conditions included low body mass index, drinking well water, not
beingweanedoffbananasandtheuseofuoridesaltsincookingduringchild-
hood. The prevalence of dental carries in children aged 3 to 5 years in Moshi
was reported to be 30%.69 Similarly, 20% of children examined in a school based
survey were found to have carries, with a higher prevalence in children from
rural areas. Another study assessed access to dental care in two refugee camps in
Kigoma and found that extractions accounted for 96% of procedures performed.
Two studies on skin disorders were relevant for further review. One population
based study conducted in Dar es Salaam reported the prevalence of any skin dis-
order of 57%.70 A large proportion of these (30%) are infectious dermatoses with
supercialfungalinfections,withtineacapitisbeing the most common(20%).
The majority of the affected children (67%) did not seek any medical assistance.
The second study documented skin disorders in 55% of children, with tinea ver-
sicolor as the leading cause (26%). Other common conditions included pyo-
derma and dermatophytoses, scabies and eczematous lesions.71
13
The Tanzania NCDI Poverty Commission Report
A hospital based study from Mwanza (n=455) reported a prevalence of congeni-
tal anomalies of 29%, with most anomalies in the central nervous system (CNS),
musculoskeletal system and digestive tract.72Maternalfactorsthatweresigni-
cantly associated with congenital anomalies included the lack of peri-conception
useoffolicacid,amaternalageofabove35yearsandaninadequateattendance
to antenatal clinic.
2.3.10 INJURIES
Injuries have been studied more extensively in Tanzania when compared to
other NCD categories. Although none of these are national studies, existing lit-
erature on injuries is from different geographical regions including both urban
and rural settings. Road trafc accidents (RTAs) are a common cause of fatal
and non-fatal injuries in Tanzania.73–75 The GBD study estimates that there were
over 460,000 people involved in RTA and over 57,000 deaths were due to RTAs
2016. A large proportion of these involve young males that ride motorcycles in
with no helmets.73Alcoholintoxicationhasbeenidentiedasacommoncause
of severe cases of injuries due to RTAs.74 The median duration of admission for
RTA patients ranges from 12 to 33 days, depending on the severity of the injuries
with longer duration observed in patients with lower limb injuries. A study
in Bugando Referral Hospital reported an RTA mortality rate of 16%,75 while
another found that though motorcycle accidents are more common, their mor-
tality rate is lower than that for motor vehicles.76
Other common causes of injuries include burns, animal bites and intentional
injuries.77–80 A community-based study in Dar es Salaam found that burns rep-
resent 16% of reported injuries in children.78 Annual exposure to rabies in two
rural districts in northwestern Tanzania has been estimated to be between 6 and
141 per 100,000, with a higher risk in pastoralists and households that have
dogs79. Post-exposure prophylaxis in this study reduced the mortality rate by
27%. Some of the barriers to PEP include long-travel distances and drug stock-
outs.80
Intentional causes are also common causes of injuries.21,81 One study reported
observed suicide rates in a hospital-based surveillance study to be low.81 Instead
almost all (97%) of intentional injuries are due to interpersonal violence, with
most of this in young males. Gunshot wounds account for 12% of all intentional
injuries and poverty, employment and alcohol-use are common factors reported
in cases of intentional injuries.
14 The Tanzania NCDI Poverty Commission Report
3. NCDI conditions and risk factors
by socioeconomic status
Thereislimiteddatafromprimarystudiesthatdescribestheinuenceofsocio-
economic factors on NCDIs. Therefore, we explored additional large survey
data on NCDIs and NCDI risk factors disaggregated by socioeconomic status.
3.1 HYPERTENSION
According to the STEPs survey,3 the majority (74%) of survey participants found
to have raised blood pressure were never previously diagnosed (Figures 6-7).
Less than a third of those who had been previously diagnosed were accessing
treatment. There was no association between income and odds of having raised
blood pressure but individuals with tertiary education level were associated
with higher odds of having hypertension (Table 1). Being employed was also
associated with higher odds of raised blood pressure.
3.2 DIABETES
Socioeconomic gradients were observed in individuals with raised blood sugar.
Seventy-seven percent of individuals with raised blood glucose were previously
not diagnosed, and only half of those that had been previously diagnosed were
accessingtreatment(Figure8-9).Individualsoflowerwealthquintile,lessedu-
cation, and those from a rural setting were all less likely to have prior blood
glucose assessment.
Figure 6: Proles of individuals with hypertension in Tanzania
Profiles of Individuals with Hypertension
Cardiovascular
diseases
53%
Newly diagnosed,
ever measured
21%
Previous diagnosed
not treatment
18%
Previous
diagnosed, on
treatment and BP
controlled
3%
Previous
diagnosed on
treatment, not
controlled
5%
15
The Tanzania NCDI Poverty Commission Report
Profiles of Hypertensive Individuals in Tanzania
by Wealth Quintile, Setting and Education Level
Newly diagnosed,
never measured
Newly diagnosed,
ever measured
Previous diagnosed
not on treatment
Previous diagnosed on
treatment, not controlled
Previous diagnosed
on treatment, controlled
Wealth status, setting and highest education level
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
1st quintile
2nd quintile
3rd quintile
4th quintile
None
Primary
Secondary
Tertiary
5th quintile
Rural
Urban
% of Respondents
Figure 7: Proles of
hypertensive individuals in
Tanzania by wealth quintile,
setting and education level
Table 1: Estimated risk for non-ideal cardiometabolic risk factor levels in Tanzania by socioeconomic factors
Characteristic Raised Blood Pressure
a
AOR (95% C.I.)
Raised Blood Glucose
b
AOR (95% C.I.)
Overweight or Obese
c
AOR (95% C.I.)
WEALTH STATUS
1st quintile Ref
Ref Ref
2nd quintile 1.04 (0.65-1.64) 0.93 (0.50-1.74) 0.77 (0.38-1.59)
3rd quintile
1.20 (0.76-1.89)
0.78 (0.40-1.52) 1.21 (0.56-2.58)
4th quintile 1.07 (0.60-1.92) 0.76 (0.41-1.43) 1.36 (0.62-3.02)
5th quintile 0.94 (0.65-1.35) 1.18 (0.63-2.18) 1.45 (0.73-2.88)
EDUCATION
None Ref
Ref Ref
Primary 1.13 (0.86-1.47) 0.70 (0.47-1.06) 1.18 (1.27-2.52)
Secondary 1.14 (0.77-1.67) 0.84 (0.50-1.44) 3.01 (2.00-4.80)
Tertiary 2.34 (1.31-4.15) 0.80 (0.41-1.56) 4.70 (2.63-8.39)
SETTING
Rural Ref
Ref Ref
Urban 1.07 (0.87-1.31) 1.20 (0.91-1.56) 2.20 (1.76-2.75)
SEX
Male Ref
Ref Ref
Female 1.07 (0.85-1.34)1.09 (0.83-1.45) 4.06 (2.88-5.72)
EMPLOYED
No Ref
Ref Ref
Yes 1.25 (1.00-1.58) 0.85 (0.56-1.28)1.42 (1.07-1.87)
MARITAL STATUS
Single e Ref
Ref Ref
Married or cohabiting 1.13 (0.90-1.42) 0.98 (0.64-1.50) 1.77 (1.37-2.29)
Adjusted Odds Ratio (AOR),
Condence Interval (CI)
a Raised blood pressure
dened as systolic blood
pressure ≥140 mmHg or
diastolic blood pressure ≥
90 mmHg or currently on
treatment for hypertension
b Raised blood glucose
dened as a fasting blood
glucose of >= 7.0 mmol/L
d Overweight dened as
Body mass index ≥ 25 kg/
m2; Obesity dened as
BMI ≥ 30 kg/m2
e Includes widowed and
separated
Estimated Risk for Non-ideal Cardiometabolic Risk
Factor Levels in Tanzania by Socioeconomic Factors
16 The Tanzania NCDI Poverty Commission Report
Profiles of Individuals with Diabetes
Newly diagnosed
never measured
70%
Newly diagnosed,
ever measured
6%
Previous diagnosed
not on treatment
11%
Previous diagnosed
on treatment,
controlled
6%
Previous
diagnosed on
treatment, not
controlled
7%
3.3 SMOKING AND ALCOHOL CONSUMPTION
There are no marked differences by income, education level and setting (rural or
urban) in alcohol consumption.3 Results from DHS survey also showed that about
1% and 14% of women and men, respectively, were current tobacco smokers and
nearly all smokers were daily smokers.16 The proportion of women that smoke
was unchanged between 2004 and 2010. On the contrary, the percentage of men
who smoke has been declined from 22% in 2004, 21% in 2010, and 14% in 2015.
Older men are more likely to be smokers than younger ones – 33% of men aged
45-49 years were smokers as compared to only 1% aged 15-19 years. There is an
inverse pattern between the prevalence of smoking among men with increasing
education and wealth. The prevalence of smoking any tobacco was 23% among
men without any formal education as compared to 7% in those with at least
secondary education. The prevalence of smoking any tobacco was 18% and 11%
amongmenwithlowestandhighwealthquintile,respectively. Smoking rates
are similar in urban areas and rural areas.
3.4 OVERWEIGHT AND OBESITY
In 2012, 26% of Tanzania’s aged 25 to 64 were overweight and 9% were obese.
The two conditions were more prevalent in women than in men (37% and 15%
vs. 15% and 2%). Urban residence, higher education attainment and being
employed were all associated with increased risk for overweight and obesity
(Tables 1). Those with tertiary education were almost 5 times more likely to be
overweight or obese than those with no formal education, while those in urban
settings are twice as likely than individuals in rural areas.
Figure 8: Proles of individuals with diabetes in Tanzania
17
The Tanzania NCDI Poverty Commission Report
4.Reviewofpoliciesandhealthnancing
for NCDIs in Tanzania
The 2015-2020 Health Sector Strategic Plan highlighted the increasing proportions
of individuals with NCDs in Tanzania and laid out several strategies for address-
ing them, including community-based prevention, health promotion activities,
and early treatment and rehabilitation.82 MoHCDGEC plans to implement these
strategies by integrating NCD care with existing services for other conditions
TanzaniaandhashadtwoStrategicPlansspecicforaddressingNCDs.83,84 The
rstplancoveredtheperiodbetween2008and2018,anditfocusedonincreasing
public awareness of NCDs and associated risk factors, promoting preventative
activities for NCDs, strengthening the capacity of health workers to diagnose
and manage NCDs, and strengthening community-based programs to address
NCDs.83 Building on the successes of the initial plan, MoHCDGEC launched a
second 5-year strategic plan in 2016 whose overall target was to reduce NCD-re-
lated mortality by 25% by 2025.84 This would be achieved by increasing advo-
cacy for NCD prevention and control, strengthening leadership, governance and
multisectoral collaboration in addressing NCDs, reorienting the health system to
address NCDs through promotive, preventative, curative and rehabilitative ser-
vices, and strengthening national capacity for NCD surveillance, evidence-based
planning and monitoring and evaluation. This plan also laid out targets indi-
cators and indicators that would be used to assess progress. The government
hasalsodevelopedseveraldisease-specicpoliciesandcontrolprograms,such
as the National Eye Care Strategic Plan (2011-2016), Mental Health Act (2008),
Figure 9: Proles of individuals with diabetes in Tanzania by wealth
quintile, setting and education level
Profiles of Individuals with Diabetes in Tanzania
by Wealth Quintile, Setting and Education Level
Newly diagnosed,
never measured
Newly diagnosed,
ever measured
Previous diagnosed
not on treatment
Previous diagnosed on
treatment, not controlled
Previous diagnosed
on treatment, controlled
Wealth status, setting and highest education level
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
1st quintile
2nd quintile
3rd quintile
4th quintile
None
Primary
Secondary
Tertiary
5th quintile
Rural
Urban
% of Respondents
18 The Tanzania NCDI Poverty Commission Report
Tobacco Products Regulations Act (2014), Occupational Health and Safety Policy
(2009), and Cancer Control Strategy (2013-2022).
The 2013 Standard Treatment Guidelines & National Essential Medicines List
provides detailed guidance for health providers on the diagnosis and manage-
ment of common NCDIs in line with international standards.85 The medicines
list was also developed to be consistent with the WHO recommendations under
existing conditions in Tanzania, so as to simplify the drug supply mechanisms
throughout the country. However, although these guidelines specify NCDI drugs
that are expected at different tiers of the health system, some commonly used
NCDI drugs for NCDIs are not expected to be provided at low-level health units.
For example, oral hypoglycaemics can only be provided at Council or higher
level hospitals. In 2018, MOHCDGEC launched updated standard treatment
guidelines which improved access to NCD medications at lower levels of care.
A review that was commissioned by MoHCDGEC found that a minimum health
benetspackagethatcontainsfundingforcommoninandoutpatientservices,
as well as drugs on the essential drug list (including some for NCDIs), would
cost 34 dollars per capita.86
Government contribution as percent of total health expenditure (THE) was 64%
in 2016. In the same year, 7.80% of THE was on NCDs, and 0.64% on injuries.
Expenditure on NCDs in Tanzania increased from 45 million US dollars (USD) in
2012 to 154 million USD in 2016, translating to an increase in per capita expendi-
ture on NCDs from 2.73% to 8.74% (Figure 10).87 Domestic funding on NCD ser-
vices in this 4-year period increased by over 300% (34 million USD to 144 million
USD). Almost half (47%) of health care spending on NCDs is used to compensate
employees. Total health expenditure on injuries has remained relatively constant
from 2012 (14 million USD) to 2016 (13 million USD) (Figure 11).
Figure 10: Expenditure on NCDs in Tanzania, 2012 to 2016
Expenditure on non-communicable
disease, Tanzania 2012-2016
0
1
2
3
4
5
6
7
8
9
10
20
40
60
80
100
120
140
160
180
2012 2014 2015 2016
Per capita expenditure (USD)
Millions USD
Domestic funding*
* In millions of US dollars, left axis
External funding in USD per capita,
right axis
External funding*
0
19
The Tanzania NCDI Poverty Commission Report
Expenditure on Injuries, Tanzania 2012-2016
0
1
2
3
4
5
6
7
8
9
10
0
20
40
60
80
100
120
140
160
180
2012 2014 2015 2016
Per capita expenditure (USD)
Millions USD
Domestic funding*
* In millions of US dollars, left axis
External funding in USD per capita,
right axis
External funding*
5. NCDI Service availability
The Ministry of Health has developed a National Essential Health Care Inter-
ventions Package (NEHCIP 2013) that includes expected standards for delivery
of non-communicable disease and injuries (NCDIs) services by different types of
health facilities. By these standards, dispensaries are expected to provide long-
term care for mild to moderate hypertension and diabetes including routine
monitoring of blood pressure and blood glucose. Dispensaries are expected to
offer clinical dia¬¬gnosis, early detection and referral for neoplasms, as well as
palliative care for patients with terminal cancer. With regards to injuries, these
facilities are expected to provide rst aid, pain relief and antibiotic cover for
injuries and, refer those who need blood transfusion. For mental conditions, dis-
pensaries should offer early detection and long-term follow up of psychoses,
epilepsy and mental retardation. Health workers at these facilities are expected
to refer complicated NCDIs to higher level health facilities.
In addition to services provided by dispensaries, health centers are expected to
treat cardiac and diabetic emergencies, have in-patient services for minor inju-
riesincluding intravenousuids and gastric lavage, andto offerbriefadmis-
sion to patients with psychoses and psychological disorders. Referral hospitals
are expected to provide a tertiary level specialised and super-specialised care
for NCDIs such as dialysis, kidney transplants, cardiac surgeries and implants,
orthopaedic implants and neurosurgeries. By 2014, no standards were yet set for
clinics; another level of health facilities that is included in this review.
Figure 11: Expenditure on injuries in Tanzania, 2012 to 2016
20 The Tanzania NCDI Poverty Commission Report
According to the 2014 Service Provision Assessment (SPA) survey for Tanzania,
there was low availability of most NCDI services. Only 26% of surveyed facil-
ities had the ability to provide services for diagnosing and managing diabetes,
16% for hypertension, 4% for asthma and 9% for basic surgical services. Health
facilities in rural settings generally had lower availability of NCDI services when
compared to those in urban areas (Figure 12). Although service availability was
generally better in higher level health facilities, the overall availability of these
services at the hospital level was still lower than expected for all NCDI areas
measured, including diabetes (26%), hypertension (16%), asthma (4%), and sur-
gical services (9%). Clinics were more likely to have non-surgical NCDI services
than dispensaries and for some conditions, they were also better than health
centers (Figure 13). However, most of the clinics that surveyed were private-for-
protorrunbynon-governmental organizations.Governmentowned(public)
health facilitates generally had lower availability of health services than pri-
vately owned or those managed by faith-based facilities and non-governmental
organizations (Figure 14).
5.1 DIABETES SERVICES
By national standards, dispensaries were expected to have services to screen for
blood glucose, treat mild diabetes with oral hypoglycemic drugs and to keep
resources for following up patients in long-term care. Health centers should
provide the same care and also be able to treat diabetic emergencies, while
hospitals are expected to be to provide care for all types of diabetic conditions.
However, according to the 2014 SPA survey, with the exception of some districts
bordering Lake Tanganyika, most districts had at least one district or regional
level hospital that had services for providing long-term diabetic care (Figure 15).
The bulk of this care was in hospitals, where 58% had the ability to provide long-
term care and monitoring of diabetes (Figure 13). This proportion is much higher
than the 7% observed for health centers and 2% for dispensaries. Diabetes care
is more likely to be available in urban settings than in rural areas (31% vs. 21%,
Figure 12).
Similar trends were observed for ability to manage diabetes emergencies where
75% of hospitals could provide services for managing diabetic ketoacidosis as
compared to only 11% of health centers and 2% of dispensaries. Less than 20% of
health centers and dispensaries had the ability to manage hypoglycemia. These
low numbers are mostly due to lack of drugs needed for long-term care of dia-
betes. For example, 78% of health centers had functioning glucometers and test
strips for monitoring blood glucose, but only 5% had the necessary drugs for
managing diabetes. Only 10% of health centers had insulin, 22% had Gliben-
clamide, and 27% had metformin. Health facilities generally had intravenous
uidsformanagingdiabetesemergencies-almostall(92%)healthcentersand
21
The Tanzania NCDI Poverty Commission Report
79% of dispensaries had either ringers lactate or normal saline. Drugs for dia-
betes were more available in faith-based and NGO-funded organizations. For
example, 61% of faith-based organizations had metformin as compared to 54%
inprivate-for-prothospitalsandonly18%inpublichospitals.
Despite these numbers, diabetes service provision is generally better in Tanza-
nia when compared to other conditions in this analysis (Figures 16-18). In addi-
tion, Tanzania has a fair geographical distribution of health units that can diag-
nose and treat diabetes (Figure 15). This may be due to the presence of several
interventions supported by the World Diabetes Foundation and other partners
including the National Diabetes Program89 as well as strong advocacy by the
Tanzania Diabetes Association which collaborates with the Ministry of Health to
implement interventions throughout the country.90
Figure 12: Rural versus Urban availability of NCDI services in Tanzania
Rural Versus Urban Availability
of NCDI Services in Tanzania
21
8
2
18
4
31
29
7
39
2
0
5
10
15
20
25
30
35
40
45
Diabetes
mellitus
Hypertension Asthma Mental health Basic surgical
services
% of health facilities with services
Rural Urban
22 The Tanzania NCDI Poverty Commission Report
Private, for prot
Figure 13: Availability of NCDI services by health facility level in Tanzania
Figure 14: Availability of NCDI services by health facility ownership in Tanzania
Availability of NCDI Services by
Health Facility Level in Tanzania
5
20
10 8
0
24133
710
2
26
3
58
40
10
70
23
0
10
20
30
40
50
60
70
80
Diabetes mellitus Hypertension Asthma Mental health Basic surgical services
% of health facilities with services
Clinic Dispensary Health center Hospital
Availability of NCDI Services by
Health Facility Ownership in Tanzania
27
8
1
20
3
19
32
11
26
2
43
31
8
44
8
0
5
10
15
20
25
30
35
40
45
50
Diabetes
mellitus Hypertension Asthma Mental health Basic surgical
services
Public Private for profit Faith based/NG0
% of health facilities with services
23
The Tanzania NCDI Poverty Commission Report
5.2 CARDIOVASCULAR SERVICES
According to the national standards, dispensaries were expected to provide
routine blood pressure checks and treat mild to moderate hypertension. In
addition to services provided at dispensaries, health centers were expected to
manage cardiac emergencies and refer complicated cases to hospitals. Eighty-
sevenpercentofsurveyedhealthfacilitieshadfunctioningequipmentformea-
suring blood pressure. This high percentage was observed in both urban and
rural settings, and at all levels of health facilities, regardless of who managed
the hospital (public, private or faith-based/NGO). On the contrary, only 13% of
healthfacilitieshadtwoofthethreerst-linedrugs(beta-blockers,ACEinhib-
itors and thiazide diuretic) for managing hypertension. Forty percent of hos-
Availability of Diabetes Mellitus Services at
District and Region Level Hospitals in Tanzania
Tanzania
Chake Chake
Tunduma
Buhemba
Uvinza
Utete
Same
Njombe
Ndareda
Ndala
Mpanda
Mohoro
Mbamba Bay
Manda
Mahenge
Liwale
Kisiju
Kibau
Kasanga
Ikola
Ifakara
Chunya
Sumbawanga
Songea
Singida
Musoma
Mbeya
Lindi
Iringa
Bukoba
Tunduru
Tukuyu
Tarime
Pangani
Nzega
Ngudu
Newala
Nachingwea Mtwara
Mbulu
Matambwe
Masasi
Manyoni
Korogwe
Kondoa
Kilwa Masoko
Kilwa Kivinje
Kibondo
Kasulu
Handeni
Geita
Tabora
Shinyanga
Mwanza
Moshi
Morogoro
Kigoma
Kilosa
Bagamoyo
Tanga
Arusha
Zanzibar
Dar es Salaam
Dodoma
Mwanza
Dar es Salaam
Dodoma
Yes (125)
No (75)
Waterbody
Regional Boundary
Diabetes Mellitus
Figure 15: Availability of Diabetes
Mellitus services at district and region
level hospitals in Tanzania
24 The Tanzania NCDI Poverty Commission Report
pitals had at least two of the drugs compared to 9% of health centers, 2% of
dispensaries and 10% of clinics. Drug availability was better in urban than in
rural settings (25% versus 9%) and in private and faith-based/NGO facilities
than public facilities (25%, 27% and 9% respectively). Most health facilities there-
fore had the ability to diagnose and monitor hypertension (87%), but only 16%
could offer treatment. Forty-eight percent of hospitals were able to diagnose and
treat hypertension compared to only 9% of health centers, 3% dispensaries and
10% at clinics. According to the SPA survey, there was a fair geographical distri-
bution of district and regional level hospitals that could diagnose and manage
hypertension (Figure 16). However several districts including Katavi, Songwe
and Rukwa did not have any hospitals to provide this care. In other districts like
Lindi, Kigoma and Mbeya the available care was in areas that might be too far
for some patients to access.
With respect to services for managing congestive heart failure, 14% of health
facilities did not have scales for measuring body weight. This included 60%
of hospitals and 35% of health centers. In addition, 7% of scales reported and
observed at health facilities were non-functional. Overall, there was a low avail-
ability (26%) of equipment required for monitoring heart failure (blood pres-
sure apparatus, stethoscope and weight scale). In addition, only 27% of health
facilitieshaddrugsrequiredformanagingcongestiveheartfailure.Ofthefacil-
ities surveyed, only 29% of had services for managing congestive heart failure,
the majority being hospitals (59%) and health centers (28%). Nationwide, the
geographic distribution of hospitals with services for heart failure were largely
similar to that for hypertension (Figure 17).
OneoftheconsequencesofthelowavailabilityofCVDservicesarecatastrophic
health expenditures in patients with some CVD conditions. A study in patients
hospitalized with these conditions in Mwanza, Dar es Salaam and Zanzibar
found catastrophic health spending (CHS) in all income groups.92 Those from
rural areas were also twice as likely to have CHS than urban residing patients.92
Furthermore, 75% of patients in this study reported a decrease in income due to
CVD-related hospitalization.
Specialized cardiac services are available at some regional and all tertiary hospi-
tals, including access to investigations such as ECG or echocardiography. Open
heart surgery is available at Jakaya Kikwete Medical Centre in Muhimbili hospi-
tal, Bugando Medical Center and Aga Kham hospital. The centers also provide
services for rheumatic heart disease, congenital heart conditions, and ischaemic
heartdisease,thoughservicesarelimitedbystafngshortagesandfunding.
25
The Tanzania NCDI Poverty Commission Report
Availability of Hypertension Services at
District and Region Level Hospitals in Tanzania
Tanzania
Chake Chake
Tunduma
Buhemba
Uvinza
Utete
Same
Njombe
Ndareda
Ndala
Mpanda
Mohoro
Mbamba Bay
Manda
Mahenge
Liwale
Kisiju
Kibau
Kasanga
Ikola
Ifakara
Chunya
Sumbawanga
Songea
Singida
Musoma
Mbeya
Lindi
Iringa
Bukoba
Tunduru
Tukuyu
Tarime
Pangani
Nzega
Ngudu
Newala
Nachingwea Mtwara
Mbulu
Matambwe
Masasi
Manyoni
Korogwe
Kondoa
Kilwa Masoko
Kilwa Kivinje
Kibondo
Kasulu
Handeni
Geita
Tabora
Shinyanga
Mwanza
Moshi
Morogoro
Kigoma
Kilosa
Bagamoyo
Tanga
Arusha
Zanzibar
Dar es Salaam
Dodoma
Mwanza
Dar es Salaam
Dodoma
Yes (101)
No (133)
Waterbody
Regional Boundary
Hypertension
Figure 16: Availability of hypertension
services at district and region level
hospitals in Tanzania
26 The Tanzania NCDI Poverty Commission Report
5.3 CHRONIC RESPIRATORY DISEASE SERVICES
There are no set standards for management of chronic respiratory disease ser-
vices at different health facility levels. The SPA survey showed that there was low
availabilityofdrugsrequiredformanagingasthma(Figures12-14).Ofallfacil-
ities surveyed, 24% had salbutamol, 4% had beclomethasone inhalers and 48%
had prednisolone. Only 3% of the facilities had all the three drugs. There was a
lowproportionoffacilitiesthathadbothdrugsandequipmentfordiagnosisand
managing asthma (4%). The low availability of asthma services is also evident in
Availability of Heart Failure Services at
District and Region Level Hospitals in Tanzania
Tanzania
Chake Chake
Tunduma
Buhemba
Uvinza
Utete
Same
Njombe
Ndareda
Ndala
Mpanda
Mohoro
Mbamba Bay
Manda
Mahenge
Liwale
Kisiju
Kibau
Kasanga
Ikola
Ifakara
Chunya
Sumbawanga
Songea
Singida
Musoma
Mbeya
Lindi
Iringa
Bukoba
Tunduru
Tukuyu
Tarime
Pangani
Nzega
Ngudu
Newala
Nachingwea Mtwara
Mbulu
Matambwe
Masasi
Manyoni
Korogwe
Kondoa
Kilwa Masoko
Kilwa Kivinje
Kibondo
Kasulu
Handeni
Geita
Tabora
Shinyanga
Mwanza
Moshi
Morogoro
Kigoma
Kilosa
Bagamoyo
Tanga
Arusha
Zanzibar
Dar es Salaam
Dodoma
Mwanza
Dar es Salaam
Dodoma
Yes (163)
No (60)
Waterbody
Regional Boundary
Heart Failure
Figure 17: Availability of heart failure
services at district and region level
hospitals in Tanzania
27
The Tanzania NCDI Poverty Commission Report
geographical distribution of district and regional hospitals that can provide this
care(Figure16).Thelowgureswereseeninbothurbanandruralareas,across
alllevelsofhealthfacilitiesirrespectiveofwhethertheywerepublic,for-prot
or managed by non-governmental organizations. This is mostly due to the low
prioritization of these conditions as compared to infectious diseases and other
NCDIs.
Availability of Asthma Services at District
and Region Level Hospitals in Tanzania
Tanzania
Chake Chake
Tunduma
Buhemba
Uvinza
Utete
Same
Njombe
Ndareda
Ndala
Mpanda
Mohoro
Mbamba Bay
Manda
Mahenge
Liwale
Kisiju
Kibau
Kasanga
Ikola
Ifakara
Chunya
Sumbawanga
Songea
Singida
Musoma
Mbeya
Lindi
Iringa
Bukoba
Tunduru
Tukuyu
Tarime
Pangani
Nzega
Ngudu
Newala
Nachingwea Mtwara
Mbulu
Matambwe
Masasi
Manyoni
Korogwe
Kondoa
Kilwa Masoko
Kilwa Kivinje
Kibondo
Kasulu
Handeni
Geita
Tabora
Shinyanga
Mwanza
Moshi
Morogoro
Kigoma
Kilosa
Bagamoyo
Tanga
Arusha
Zanzibar
Dar es Salaam
Dodoma
Mwanza
Dar es Salaam
Dodoma
Yes (24)
No (219)
Waterbody
Regional Boundary
Asthma
Figure 18: Availability of asthma
services at district and region level
hospitals in Tanzania
28 The Tanzania NCDI Poverty Commission Report
5.4 TRAUMA AND INJURY-RELATED SERVICES
National guidelines require dispensaries to provide rst-aid services, and to
offer pain relief and antibiotics for injuries. Health centers should provide the
same care with the additional capacity to admit patients that need more criti-
cal care, such as burn victims. Hospitals should offer more intensive services,
including surgery. According to the 2012 SARA survey, availability of surgical
services was variable at the health center level, including 78% for acute burn
management, 80% for wound debridement and 20% for closed fracture manage-
ment.Similargureswereseenatthehospitallevelat80%,34%and81%respec-
tively.Thispatternwasalsoobservedforitemsrequiredforprovidingsurgical
services. A third of hospitals had oxygen for use in surgical procedures, 78% had
needle holders, 94% had sutures, 35% had retractors, 63% had scalpels and 62%
had scissors. Overall, very few rural and urban health facilities could provide
services for common injuries (4% and 2% respectively). There were also no major
differencesinobservedpatternsbyownershipstatus(public,private-forprot
or faith-based/NGO). Regarding training, only 8% percent of facilities had pro-
viders with previous training in basic surgical skills. 30% of hospitals had pro-
viders with basic surgical skills as compared to only 10% at health centers. There
were no major differences in availability of skilled providers between urban and
rural facilities (10% versus 7%).
In 2017 MOHCDGEC in collaboration with Safe Surgery 2020 launched the
National Surgical Obstetrics and Anaesthesia Plan to improve surgical services
in the country.88 The goal of this plan was to strengthen the surgical health system
in Tanzania by improving service delivery, infrastructure, human resource, infor-
mationandtechnologymanagement,aswellasnanceandgovernance.
5.5 MENTAL HEALTH & EPILEPSY SERVICES
The 2007 National Health Policy contained a strategy for improving mental
health services in Tanzania.89 This strategy set several goals including increased
training of health workers that can manage mental health conditions, establish-
ing psychiatric rehabilitation facilities in each region and increasing the number
of mental health care beds at each district hospital to at least 20. Some progress
has been observed in these indicators. For example, the number of health facil-
ities that can provide mental health services increased from 9 in 2007 to 124 in
2011.90
However,in2014,only25%ofallhealthfacilitiesinTanzaniahadrstlinedrugs
for managing chronic depression and acute psychosis. As observed for other
NCDIs, service availability for mental health was higher in urban than rural
areas (39% vs. 18%), in hospitals compared to health centers (70% vs. 26%) and
in faith-based/NGO facilities than in public facilities (44% vs. 20%).
29
The Tanzania NCDI Poverty Commission Report
5.6 CANCER SERVICES
In 2013, MOHCDGEC designed a ten-year national cancer control strategy. This
included a detailed roadmap for developing and implementing a comprehen-
sive response to the increasing burden of cancer in Tanzania.49 As a result, several
cancer registries are now available for tracking cancer trends in Tanzania. These
include a hospital-based cancer registry at the National Cancer Institute – Ocean
Road Cancer Institute (ORCI), a pathology-based cancer registry at Muhimbili
National Hospital, and a population-based cancer registry in Kilimanjaro.
An assessment of breast cancer services recently published by Susan G. Komen in
collaboration with the MoHCDGEC.56 found that services for early detection of
breast cancer are available in regional referral hospitals where staff perform clin-
ical breast exams in symptomatic patients. Some referral hospitals are also able
toperformneneedleaspiration(FNA)biopsieswhicharethensenttocenters
with pathology labs. These hospitals offer surgery for women diagnosed with
breast cancer; however, there is limited capacity. Some zonal hospitals including
Bugando Medical Center (BMC) in Mwanza and Kilimanjaro Christian Medical
Centre(KCMC)aremoreequippedtodiagnoseandmanagebreastcancercases.
The bulk of breast cancer services are provided by specialized units in Dar es
Salaam, at ORCI, Muhimbili National Hospital and Aga Khan Hospital. Mam-
mograms and FNA biopsies are available at ORCI, and treatment options at this
center include surgery, chemotherapy and radiotherapy. Muhimbili National
Hospital provides mammography and partners with ORCI for treatment
options. Aga Khan Hospital, a private facility provides comprehensive breast
cancer diagnosis and management services including all those listed above. In
addition, the Aga Khan Hospital hosts free camps for breast cancer diagnosis.
Given the high grade of most cervical cancer cases diagnosed, treatment options
are mainly palliative. The Ministry of health therefore plans to implement a
comprehensive prevention strategy by updating the Tanzania’s current immu-
nization schedule to include two doses of Human Papillomavirus vaccine in
school-going girls91.Thisvaccinationprogramwillrsttarget14year-oldgirls
in2018and2019,followedby9to14yearoldsin2020,andnally9yearoldsin
subsequentyears.
30 The Tanzania NCDI Poverty Commission Report
6. Priority Setting for NCDIs in Tanzania
6.1 EXPANDING PRIORITY NCDI CONDITIONS
This review has demonstrated a complex and diverse burden of NCDIs in Tan-
zania, which has been partially addressed through global and national policies
andprograms.However,signicantgapsremain.TheTanzaniaNCDIPoverty
Commission therefore aimed to use existing data and local expertise to generate
an expanded list of priority NCDIs for consideration in national programs and
policy frameworks. Four globally recognized metrics were used in this priority
settingexercise–burdenofdisease,severity,disability,andequity.92 For burden
of disease, the commission analyzed and ranked the number of disability-ad-
justed life-years (DALYs) for each condition.2 Severity of each condition was
measured as the average years of life lost (YLLs) per death, while disability was
quantiedas the numberof years oflife livedwith disability (YLDs).Finally,
toidentifyconditionswiththelargestequitygapsintermsofhealthoutcomes,
the commission compared the rate of DALYs per 100,000 population for each
condition in Tanzania to that of high-income countries. The commission ranked
190 NCDI conditions from the GBD 2017 study along these metrics. A composite
scorewasthencalculatedforeachconditionasaweightedaverageofthequartile
ranks for each conditionof the four metrics. The 50 conditions with the highest
composite score were presented to commissioners for expert review. From this
list, the commissioners selected 34 conditions that (1) contribute substantially
toadversehealthoutcomesandeconomicconsequences,(2)havefeasibleand
effective health sector interventions, and (3) are consistent with policy and strate-
gies established by the Government of Tanzania.84,85 The commissioners selected
an additional 14 conditions from outside the top 50 conditions that they believed
also to meet the above criteria and important to include in the prioritized NCDI
conditions or were paired with evidence-based interventions that were priori-
tized for the health system. The 48 selected conditions are displayed in Table 2.
31
The Tanzania NCDI Poverty Commission Report
Disease Category Prioritized Conditions
Respiratory Asthma, chronic obstructive pulmonary disease
Cardiovascular – behavioral &
metabolic etiologies Hypertensive heart disease, hemorrhagic stroke, ischemic stroke, ischemic heart disease*
Endocrine Diabetes mellitus
Cardiovascular - other etiologies Rheumatic heart disease, endocarditis
Cancers
F
emale - Cervical cancer, ovarian cancer, breast cancer*
Other - Prostate cancer, colorectal cancer*, esophageal cancer*
Hematologic - Non-Hodgkin lymphoma, Hodgkin lymphoma, childhood leukemias*
Mental Health Alcohol use disorders, major depressive disorders*, anxiety disorders*, bipolar disorders*, dementia*
Neurologic & Musculoskeletal Epilepsy, rheumatoid arthritis*, osteoarthritis*
Congenital Sickle cell disorders, congenital heart abnormalities, neural tube defects, digestive congenital
disor-ders
Liver Cirrhosis and other chronic liver diseases due to hepatitis B, Cirrhosis due to alcohol use
Kidney Chronic kidney disease due to glomerulonephritis
Oral Oral health
Sensory Organs Vision, Hearing
Injuries – Accidental Poisonings, drowning, burns, falls, venomous animal contact, non-venomous animal contact
Injuries – Non-accidental Physicalviolencebysharpobject,rearm,orothermeans;self-harmbyothermeans
Injuries–Roadtrafc Motor vehicle road injuries, pedestrian road injuries
Other surgical conditions Paralytic ileus and intestinal obstruction, appendicitis
6.2 INTERVENTIONS FOR EXPANDED NCDI HEALTH SECTOR
CAPACITY
The Tanzania NCDI Poverty Commission sought to recommend a package
cost-effective interventions in the health sector that could be implemented to
address NCDIs prioritized by the commissioners. Evidence based-information
on cost-effective interventions in the health sector for the selected NCDI condi-
tions was obtained from the third edition of Disease Control and Priorities group
(DCP3).93 The DCP3 has recently recommended an evidence-based package of
health-sector interventions for Essential Universal Health Coverage (EUHC) in
low-middle and low-income countries. This recommended package includes
65 interventions targeted for NCDIs. The DCP3 group provided expert commit-
tee rankings for three key intervention metrics based on available global data.
Thesemetricswerecost-effectiveness,nancialriskprotectionandprioritization
fortheworstoff(equity).92Interventionsforcost-effectivenessandequitywere
rankedfrom0to4,andthosefornancialriskprotectionfrom0through6,with
0 representing the lowest value in each metric. The DCP3 group also provided an
averagedirectunitcostforimplementationperbeneciaryinlow-incomecoun-
tries.DCP3additionallyidentiedasub-setoftheseconditionsasa“high-pri-
ority package” (HPP), which are interventions that would be recommended as
highest priority in resource-constrained settings. The commission estimated the
Table 2: NCDI conditions prioritized by the Tanzania
NCDI Poverty Commission, by disease category
*Conditions that were added by expert review or
alignment with prioritized health-sector interventions
32 The Tanzania NCDI Poverty Commission Report
total number of individuals in Tanzania requiring each intervention annually
based on disease prevalence and incidence estimated from GBD 2017. The total
costtoreachallbeneciariesannuallywascalculatedforeachintervention.
Basedonthediseaseburdenaddressedandthecost,cost-effectiveness,nancial
riskprotection,andequity-generatingpropertiesdescribedabove,thecommis-
sion selected 53 interventions for consideration for introduction and/or scale-up
in Tanzania. These prioritized interventions are comprehensive, including inter-
ventions for NCDs, mental health, injuries, palliative care, rehabilitative care. The
interventions represent medical, surgical, psychosocial, and community-based
approaches at multiple levels of the health care system, from population level
interventions to specialized referral hospitals. Multi-sectoral interventions and
policy-based initiatives were not included in this analysis.
The commission assigned a baseline coverage level, according to available liter-
ature and from expert knowledge from commissioners. The commissioners also
assigned a target coverage level to be achieved for each intervention by the year
2030. Based on prior programmatic scale-up experience, a 30% absolute cover-
age increase was determined to be a reasonable incremental coverage increase
by 2030. The total cost of implementing the selected interventions was estimated
by multiplying the direct unit cost (adjusted for Tanzania health sector costs)
by the estimated Tanzanian population in need. Direct costs included those for
personnel,equipment,laboratoryanddiagnosticservices,drugsandothercon-
sumables. A 50% indirect cost, was added to the direct cost to account for facility
level expenses, such as, rent, maintenance and utilities. An additional 17% indi-
rect cost was also added for non-facility-level costs like those for supply chain
and health information systems. The incremental cost for each intervention was
then estimated by multiplying the total of the above costs by the coverage incre-
ment.
Selected interventions for addressing prioritized NCDI conditions and their
costs are presented in Table 3. These interventions included some that already
exist within Tanzania’s health care system, and others that are yet to be intro-
duced.UsingthemostrecentNationalHealthAccountguresfor2016foratotal
health expenditure (THE) of USD $1.97 billion (USD $35.5 per capita) and a gross
domestic product of USD $53.3 billion, the incremental annual investment for
the prioritized NCD interventions is USD $459 million, which would represent
23.3% of current THE (0.86% of GDP) or approximately USD $8.01 per capita
annually.94 The total for prioritized mental health interventions is USD $70.5
million, which would represent 3.6% of THE (0.13% of GDP) or an additional
USD $1.23 per capita annually. The total for prioritized surgical interventions is
USD $172.7 million, which represents another 8.8% of THE (0.32% of GDP) or
USD $3.01 per capita annually. Overall, combining the incremental cost of NCD,
mental health, and surgical interventions is USD $702.9 million, representing
35.6% of THE and 1.32% of GDP, or approximately $12.26 per capita annually.
The subset of interventions designated in the “high-priority package” by DCP
would cost USD $378.9 million annually ($6.61 per capita), which would repre-
sent 19.2% of THE (0.71% of GDP).
33
The Tanzania NCDI Poverty Commission Report
Condition Intervention
Cost-
Effectiveness
Rating
Financial
Risk
Protection
Rating
Equity
Rating
Baseline
Coverage
(%)
Target
Coverage
(%)
Incremental
Cost (USD)
Health
System
Level
Respiratory
Low-dose inhaled corticosteroids and
bronchodilators for asthma and for
selected patients with COPD
1 3 1 20 50 102,475,475
Health
Center
Management of acute exacerbations
of asthma and COPD using systemic
steroids, inhaled beta-agonists, and, if
indicated, oral antibiotics and oxygen
therapy
1 4 1 20 50 54,209,169
District
Hospital
Self-management for obstructive lung
disease to promote early recognition
and treatment of exacerbations
0 0 0 20 50 11,336,155
—
Tobacco cessation counselling, and
use of nicotine replacement therapy in
certain circumstances
4 2 1 30 60 13,608,491
Health
Center
Breast Cancer
Treat early stage breast cancer with
appropriate multimodal approaches,
including generic chemotherapy,
with curative intent, for cases that
are referred from Health Center and
District hospitals following detection
using clinical examination
4 4 1 20 50 211,275
Regional,
Zonal, and
National
Referral
Hospitals
Cervical
Cancer
Opportunistic screening for cervical
cancer using visual inspection or
HPV DNA testing and treatment of
precancerous lesions with cryotherapy
3 3 1 11 41 2,306,327
Health
Center
School-based HPV vaccination for girls
3 3 1 50 80 3,105,559
Community
Treatment of early-stage cervical cancer
0 4 1 20 50 91,885
District
Hospital
Colorectal
Cancer
Treat early stage colorectal cancer with
appropriate multimodal approaches,
including generic chemotherapy,
with curative intent, for cases that
are referred from Health Center and
District hospitals
3 5 1 20 50 184,888
Regional,
Zonal, and
National
Referral
Hospitals
Childhood
Cancers
Treat selected early-stage childhood
cancers with curative intent in pediatric
cancer units/hospitals
2 5 2 20 50 460,829
Regional,
Zonal, and
National
Referral
Hospitals
Palliative Care
Palliative care and pain control services
0 4 1 10 40 36,123,872 Health
Center
Palliative Care
Combination therapy for persons with
multiple risk factors to prevent CVD
(primary prevention)
2 2 1 20 50 13,427,487 Health
Center
Long term management of IHD, stroke,
and PVD with aspirin, beta blockers,
ACEi, and statins (as indicated), for
secondary prevention
2 2 1 10 40 27,853,193 Health
Center
Management for acute critical limb
ischemia with unfractionated heparin
and revascularization if available, with
amputation as a last resort
0 0 0 10 30 7,553,090
Regional,
Zonal, and
National
Referral
Hospitals
34 The Tanzania NCDI Poverty Commission Report
Condition Intervention
Cost-
Effectiveness
Rating
Financial
Risk
Protection
Rating
Equity
Rating
Baseline
Coverage
(%)
Target
Coverage
(%)
Incremental
Cost (USD)
Health
System
Level
Cardiovascular
Diseases
Mass media messages concerning
healthy eating or physical activity
4 1 1 20 50 242,915
Population
Screening and management of
hypertensive disorders in pregnancy
1 3 3 30 60 133,569
Health
Center
Use of aspirin in case of suspected
myocardial infarction
4 2 1 20 50 1,188
Health
Center
Use of community health workers to
screen for CVRD using non-lab-based
tools for overall CVD risk, improving
adherence, and referral to primary
health Centers for continued medical
management
0 0 0 20 50 956,235
Community
Use of percutaneous coronary
intervention for acute myocardial
infarction where resources permit
3 4 1 20 50 9,598,364
Regional,
Zonal, and
National
Referral
Hospitals
Use of unfractionated heparin, aspirin,
and generic thrombolytics in acute
coronary events
2 4 1 20 50 17,182,038
District
Hospitals
Medical management of acute heart
failure
4 5 3 20 50 36,969,392
District
Hospital
Medical management of chronic heart
failure with diuretics, beta-blockers,
ace-inhibitors, and mineral-ocorticoid
antagonists
4 4 3 30 60 18,103,760
Health
Center
Rheumatic
Heart Disease
Secondary prophylaxis with penicillin
for rheumatic fever or established RHD
0 1 1 5 50 516,479
Health
Center
Treatment of acute pharyngitis in
children to prevent rheumatic fever
4 2 1 20 35 1,032,958
Health
Center
Diabetes
Mellitus
Diabetes self-management education
0 0 0 10 40 2,246,367 —
Diabetic retinopathy screening via
telemedicine, followed by treatment
using laser photocoagulation
3 2 1 20 50 3,314,436
Regional,
Zonal, and
National
Referral
Hospitals
Prevention of long-term complications
of diabetes through blood pressure,
lipid, and glucose management as well
as consistent foot care
4 2 1 20 50 36,563,569 Health
Center
Screening for diabetes in all high-risk
adults
4 2 1 10 40 3,364,237 Health
Center
Screening for diabetes in pregnant
women
1 3 3 30 60 9,566,644 Health
Center
Chronic Kidney
Disease
Treatment of hypertension in kidney
disease, with use of ACEIs or ARBs in
albuminuric kidney disease
2 2 1 20 50 6,245,635 Health
Center
Cirrhosis;
Alcohol and
Tobacco Use
Disorders
Screening and brief intervention for
alcohol use disorders
3 2 1 20 50 1,169,382 Health
Center
Mass media messages concerning use of
tobacco and alcohol
4 1 1 20 50 242,915
Population
35
The Tanzania NCDI Poverty Commission Report
Condition Intervention
Cost-
Effectiveness
Rating
Financial
Risk
Protection
Rating
Equity
Rating
Baseline
Coverage
(%)
Target
Coverage
(%)
Incremental
Cost (USD)
Health
System
Level
Sickle Cell
Disease
In settings where sickle cell disease
is a public health concern, universal
newborn screening followed by
standard prophylaxis against bacterial
infections and malaria
4 2 3 0 30 3,437,615
District
Hospital
Congenital
Disorders
Provide iron and folic acid
supplementation to pregnant women,
as well as food/caloric supplementation
to pregnant women in food insecure
households
3 3 3 21 51 14,310,547
Health
Center
Oral Health
Oral health promotion in schools
0 1 1 20 50 1,729,564
Community
Vision
Vision pre-screening by teachers; vision
tests and provision of ready-made
glasses on-site by eye specialists
2 2 1 20 50 2,075,477
Community
Hearing
Targeted screening for congenital
hearing loss in high-risk children using
otoacoustic emissions testing
1 3 3 20 50 131,639
Health
Center
Rheumatoid
Arthritis
Combination therapy, including
low-dose corticosteroids and generic
disease-modifying antirheumatic
drugs (including methotrexate), for
individuals with moderate to severe
rheumatoid arthritis
0 0 0 20 50 3,050,000
District
Hospital
Dementia
Interventions to support caregivers of
patients with dementia
0 3 1 20 50 485,629
Health
Center
Epilepsy
Management of epilepsy using generic
anti-epileptics
4 4 3 25 55 2,722,376
Health
Center
Substance
Abuse
Provision of harm reduction services
suchassafeinjectionequipmentand
opioid substitution therapy to people
who inject drugs
4 5 2 5 35 233,055
Health
Center
Assault and
Violence
Education campaigns for the prevention
of gender-based violence
0 0 0 20 50 5,704,030
Population
Post gender-based violence care
including, counselling, provision of
emergency contraception, and rape-
response referral (medical and judicial)
0 0 0 20 50 4,748,264
Health
Center
NCD subtotal incremental cost 459,026,046
36 The Tanzania NCDI Poverty Commission Report
Condition Intervention
Cost-
Effectiveness
Rating
Financial
Risk
Protection
Rating
Equity
Rating
Baseline
Coverage
(%)
Target
Coverage
(%)
Incremental
Cost (USD)
Health
System
Level
Depression and
Anxiety
Management of depression and anxiety
disorders with psychological and
generic antidepressant therapy
3 4 1 10 40 16,976,695
Health
Center
Mass media messages concerning
sexual and reproductive health; and
mental health for adolescents
4 2 1 20 50 30,586,636
Population
Bipolar
Disorder
Management of bipolar disorder using
generic mood-stabilizing medications
and psychosocial treatment
2 4 2 20 50 20,210,078
Health
Center
Psychotic
Disorders
Management of schizophrenia using
generic anti-psychotic medications and
psychosocial treatment
2 4 2 20 50 2,737,092
Health
Center
NCD subtotal incremental cost 70,510,501
Condition Intervention
Cost-
Effectiveness
Rating
Financial
Risk
Protection
Rating
Equity
Rating
Baseline
Coverage
(%)
Target
Coverage
(%)
Incremental
Cost (USD)
Health
System
Level
Surgical
Services
Elective surgical repair of common
orthopaedic injuries (e.g., meniscal and
ligamentous tears) in individuals with
severe functional limitation
0 0 0 20 50 7,648,800
Regional,
Zonal, and
National
Referral
Hospitals
Basicrst-levelhospitalsurgical
services
0 0 0 20 50 98,879,210
District
Hospital
Basic outpatient surgical services
0 0 0 20 50 10,019,760
Health
Center
Basic outpatient surgical services
0 0 0 20 50 52,471,901
District
Hospital
Expandedrst-levelhospitalsurgical
services*
0 0 0 15 45 1,318,389
Regional,
Zonal, and
National
Referral
Hospitals
Specialized surgical services*
0 0 0 15 45 2,373,101
Regional,
Zonal, and
National
Referral
Hospitals
Surgical subtotal incremental cost 172,711,161
Grand incremental cost 702,247,708
High yield priority interventions for achieving universal health coverage.
37
The Tanzania NCDI Poverty Commission Report
6.3 INTEGRATION AND DELIVERY OF EXPANDED NCDI SERVICES
The health sector interventions prioritized by this commission would require
integration at different levels of the Tanzania health system (Figure 19). At the
community level, where very few NCD interventions are currently being offered,
we propose adding preventative messages on behaviors associated with health
promotion and disease prevention such as healthy eating and physical activity,
as well as tobacco and alcohol use cessation. We also propose school-based HPV
vaccination and considering the use of teachers to screening and provision of
ready-made glasses. Community and school-based NCD interventions will also
requirepriorsensitizationandshouldbecarriedoutinaculturallyappropriate
manner using the local language (Swahili). The use of schools to delivery some
interventions will require multisectoral planning with the Ministry of Educa-
tionaswellasputtingintoplacemechanismsofreferringchildrenthatrequire
further follow up to appropriate levels of care.
The 2014 Service Provision Assessment (SPA) survey for Tanzania found low
availability of most NCDI services at health centers – only 7% could offer ser-
vices for diabetes, 10% for hypertension, 2% for asthma, 26% for mental health
and 3% for basic surgical services.16 We propose that health centers offer a more
extensive list of NCDI interventions, including the following: Screening and
intervention of alcohol use disorders and tobacco use, treatment of asthma and
COPD, screening for cervical cancer and treatment of precancerous lesions, palli-
ative care and pain control services, primary and secondary prevention on CVD,
medical management of chronic heart failure, screening and management of
hypertensive disorders in pregnancy and diabetes in pregnant women, second-
ary prophylaxis of rheumatic fever or established RHD and treatment of acute
pharyngitis to prevent rheumatic fever, screening for diabetes and prevention
of long-term complications of diabetes, treatment of hypertension in kidney
disease, screening for congenital hearing loss in high-risk children, management
of epilepsy , post gender-based violence care including, counselling, provision of
emergency contraception, and rape-response referral, provision of harm reduc-
tionservicessuchassafeinjectionequipmentandopioidsubstitutiontherapy
to people who inject drugs, management of depression and anxiety disorders,
management of bipolar disorder. Integration of these interventions with existing
serviceswillrequiredidacticandin-servicetrainingofclinicalstaffondetection,
diagnosis and management of NCDIs. The expanded list of services offered at
healthcenterswillnecessitateprocuringessentialequipmentanddrugsthrough
the existing supply chain mechanisms, and the use of current out and in-patient
infrastructure, with renovations where needed.
Recent national surveys found moderately high availability of NCDI services at
hospitals in Tanzania – service availability at hospitals was 23% for basic surgical
services, 40% for hypertension, 10% for asthma and 58% for diabetes mellitus
38 The Tanzania NCDI Poverty Commission Report
and 70% for mental health disorders.16 We propose the expansion of interven-
tions that are available at district hospitals to improve access to services of severe
NCDs.Wespecicallyproposethefollowinginterventionsatthislevel:medical
management of acute exacerbations of asthma and COPD, treatment of ear-
ly-stagecervicalcancer,medicalmanagementofacuteheartfailure,basicrst-
level hospital surgical services and medical management of moderate to severe
rheumatoid arthritis. Once again existing staff and infrastructure can be used to
deliver these services. Nurses and medical assistants can be trained to deliver
these interventions, with oversight and ongoing mentorship by physicians and
thenecessarypharmaceuticalandequipmentshouldbeprocuredthroughexist-
ing supply chain mechanisms. These interventions should be implemented in
linewith existingdisease-speciccontrolplans.For example,theORCIhasan
ongoing training program for cancer prevention and control that can be imple-
mented in all district hospitals.
Thenal andtop level of the health system, zonal, regional and referralhos-
pitals, is reserved for patients with the highest illness severity. To date, ORCI
is the only specialized center for cancer treatment. We propose that all referral
and specialized hospitals provide multimodal treatment of early stage breast
cancer that includes surgery, radiation, chemotherapy, and hormonal therapy. In
addition, these hospitals should also provide, services for diabetic retinopathy
via telemedicine, medical management of critical limb ischemia, and special-
ized surgical services. In line with the MOHCDGEC plan, improved access to
these interventions, will reduce the cost that the Tanzanian government incurs
on treating patients who are referred abroad due to lack of infrastructure and
expertise in the country.82
Referral
And
Specialized
Hospitals
39
The Tanzania NCDI Poverty Commission Report
Figure 19: Proposed integration of selected NCDI interventions into Tanzania health system levels
Referral
And
Specialized
Hospitals
> Treat early stage breast cancer, colorectal and childhood cancers using appropriate multimodal
approaches and with curative intent
> Management for acute critical limb ischemia with unfractionated heparin and revascularization
if available, with amputation as a last resort
> Use of percutaneous coronary intervention for acute myocardial infarction where resources permit
> Diabetic retinopathy screening via telemedicine, followed by treatment using laser
photocoagulation
> Elective surgical repair of common orthopedic injuries (e.g., meniscal and ligamentous tears) in
individuals with severe functional limitation
> Expandedrst-levelhospitalsurgicalservices
> Specialized surgical services
> Management of acute asthma and COPD using systemic steroids, inhaled beta-agonists, oral
antibiotics and oxygen therapy
> Treatment of early-stage cervical cancer
> Use of unfractionated heparin, aspirin, and generic thrombolytics in acute coronary events
> Medical management of acute heart failure
> Where sickle cell disease is a concern, universal newborn screening and standard prophylaxis against
bacterial infections and malaria
> Combination therapy for moderate to severe rheumatoid arthritis including low-dose corticosteroids
and generic disease-modifying drugs
> Basicrst-levelhospitalsurgicalservices
> Basic rehabilitation services
> Screening and intervention of alcohol use disorders and tobacco use
> Low-dose corticosteroids and bronchodilators for asthma and for patients with COPD
> Opportunistic screening for cervical cancer using visual inspection or HPV DNA testing and
treatment of precancerous lesions
> Palliative care and pain control services
> Combination therapy for person at high risk for cardiovascular diseases (primary prevention)
> Long term management of IHD, stroke and PVD with aspirin, beta blockers, ACEIs and statins
(secondary prevention)
> Use of aspirin in case of suspected myocardial infarction
> Medical management of chronic heart failure with diuretics, beta-blockers, ace-inhibitors, and
mineralocorticoid antagonists
> Screening and management of hypertensive disorders in pregnancy and diabetes in pregnant women
> Secondary prophylaxis of rheumatic fever or established RHD and treatment of acute pharyngitis to
prevent rheumatic fever
> Screening for diabetes in all high-risk adults and prevention of long-term complications of diabetes
> Treatment of hypertension in kidney disease, with use of ACEIs or ARBs in albuminuric kidney disease
> Iron and folic acid supplementation to pregnant women, and food supplementation to women in
food insecure households
> Targeted screening for congenital hearing loss in high-risk children using otoacoustic emissions testing
> Interventions to support caregivers of patients with dementia
> Management of epilepsy using generic anti-epileptics
> Post gender-based violence care including, counseling, provision of emergency contraception, and
rape-response referral
> Provisionofharmreductionservicessuchassafeinjectionequipmentandopioidsubstitutiontherapy
to people who inject drugs
> Management of depression and anxiety disorders with psychological and generic antidepressant
therapy
> Management of bipolar disorder using generic mood-stabilizing medications and psychosocial
treatment
> Management of schizophrenia using generic anti-psychotic medications and psychosocial treatment
> Basic outpatient surgical services
{
{
District
Hospital
Level
Health
Center
Level
{
> Mass media messages gender based violence, healthy eating, physical activity, tobacco use and
alcohol use
> School-based HPV vaccination for girls
> Vision prescreening by teachers; vision tests and provision of ready-made glasses on-site by eye
specialists
> Use of community health workers to screen for cardiovascular diseases, improve adherence and
referral to primary health centers
Population/
Community
Level
{
40 The Tanzania NCDI Poverty Commission Report
6.4 AFFORDABILITY AND FISCAL SPACE FOR THE PROPOSED
INTERVENTIONS
This commission prioritized an expanded set of interventions for NCDIs
in Tanzania in accordance with best estimates of the national NCDI disease
burden and best available evidence on health sector interventions. Though the
total cost of these interventions is a substantial proportion of the overall total
health expenditure, this commission believes that this level of expenditure is
commensurate with the enormous burden of morbidity and mortality caused
by NCDs, injuries, mental health conditions, and chronic pain and disability.
Furtherresearchisrequiredtoestimatethepotentialreturnonsuchinvestment,
which we believe would be well justied in terms of human and economic
benets.
Inorderto generateandmobilizefundsfornancingtheseinterventions,this
commission supports several strategies previously proposed by the MOHCDGEC.
These include regulatory mechanisms for fair pricing of pharmaceuticals in
the public and private sector, efcient procedures to access funds generated
byhealth facilities throughinsurance,and timely andadequate disbursement
of funds for procurement of commodities and supplies.82 We also support
specic proposals to increase scal space, which include earmarked taxation
mechanisms on unhealthy behaviours such as tobacco and alcohol, surcharges
on automobile registrations or insurance, levies on airline taxes or international
departures,or proportionsof value addedtaxes.Efciencygenerationcanbe
enhanced through better integration of services in the health system. Efforts
should be made to maintain and align donor funding towards the national
strategic plan for addressing NCDIs in Tanzania. This will help optimize cross-
sectional efforts and funding. Finally, the commission highly supports the
government’s current commitment, investment, and efforts towards achieving
Universal Health Coverage, which would serve as a foundation for high-priority
cost-effective interventions to address NCDIs in Tanzania. We highly encourage
greaterpartnershipstoconsideradditionalnancing sourcesand strategies to
achieve this ambitious and worthwhile goal for the health and prosperity of all
Tanzanians.
41
The Tanzania NCDI Poverty Commission Report
7. Key Findings
• NCDIs are an important problem in Tanzania. NCDIs currently comprising
41% of all death and disability in Tanzania and have almost doubled over the
past 25 years.
• NCDIs affect young populations in Tanzania. Although deaths from NCDIs
may occur later in life, over two-thirds of the health burden of NCDIs occurs
before age 40.
• NCDIs are diverse in Tanzania. Over 60% of the NCDI DALYs are from
conditions other than CVD, cancer, diabetes, and chronic respiratory diseases.
Prominent NCDIs in Tanzania also include rheumatic and congenital heart
diseases, hematologic malignancies, severe chronic respiratory diseases,
type 1 diabetes, women’s malignancies, severe mental health conditions, and
injuries. Some NCDI conditions, such as stroke and type II diabetes are more
prevalent in urban areas, while other conditions, such as anaemia, cervical
cancer, and esophageal cancer are more prevalent in rural areas.
• Risk factors for NCDIs are complex and may differ by socioeconomics.
79% of NCDI DALYs in Tanzania are not attributed to traditional behavioral
or metabolic risk factors. Traditional risk factors for NCDIs are present in
poorer populations, but may differ according to risk factor. For example,
there is a much lower prevalence of obesity among adults in the lowest
quintiles.
• NCDI services are limited. Although included in essential service packages,
the availability of services for NCDIs are limited and variable. Even at the
hospital level, less than half of all hospitals provide major NCDI services,
and the readiness for key diseases is even lower. Availability is lowest in
rural, public facilities.
• Access to NCDI services may be worse for poorer populations. There are
barriers in access to treatment for common diseases such as hypertension
and diabetes faced by people in lower quintiles of wealth and in rural
areas.Individualsinlowerquintileswerelesslikelytohavebeenscreened,
diagnosed, or treated for common conditions such as hypertension and
diabetes.
• Financing for NCDIs is limited. Only 7.8% of Tanzania’s total health
expenditure is on NCDs and 0.64% on injuries. Expenditure on NCDs
increased from 45 million USD in 2012 to 154 million USD in 2016 (2.73% to
8.74% per capita), expenditure on injuries has remained relatively constant
in the same period (~14 million USD).
42 The Tanzania NCDI Poverty Commission Report
8. Recommendations and Next Steps
• We must broaden the NCDI agenda in Tanzania. This commission
recommends an expanded set of 48 NCDI conditions for attention and
priority to appropriately capture the full burden of NCDIs affecting
Tanzanians. In addition to common conditions such as hypertensive and
ischemic heart disease, type II diabetes, and chronic respiratory disease,
we encourage inclusion of additional conditions with a high burden of
disease that particularly affect the young and the poor, such as rheumatic
and congenital heart diseases, hematologic malignancies, severe chronic
respiratory diseases, type 1 diabetes, women’s malignancies, severe mental
health conditions, and injuries.
• Evidence-based interventions for NCDIs are needed to achieve UHC.
This commission recommends 53 previously described evidence-based
cost-effectivehealthsectorinterventionstollthegapforNCDIservicesto
achieve UHC. This set of interventions includes services for NCDs, mental
health, injuries, palliative care, rehabilitative care and represents medical,
surgical,psychosocial,andcommunity-basedapproachesthatwouldrequire
integration at multiple levels of the health care system. Existing capacities
need to be upgraded, including guidelines, human resources, and training.
• More investment in NCDIs are needed. Overall, the combined annual
incremental cost of this comprehensive set of NCD, mental health, and
surgical interventions is estimated to be USD $702.9 million, or approximately
$12.26 per capita annually, which represents 35.6% of total current health
expenditure or 1.32% of GDP. A detailed analysis of possible nancing
mechanisms, as well as a formal scal space analysis, would greatly
facilitate target setting and feasibility assessment of inclusion of key NCDI
interventions in essential health package and national health insurance to
help achieve universal health coverage. Return-on-investment case studies
for NCDI interventions are also needed.
• More data is needed on NCDIs in Tanzania. There is a need to describe
the burden of NCDIs disaggregated by socio economic indices to best
target interventions. More studies are needed to ll this knowledge gap,
and systematic inclusion of socioeconomic indicators in disease registries,
health facility reporting, and household surveys could further provide this
information.
• Greater stakeholder engagement is required. Participation is needed
from all sectors, particularly from patients and civil society, policy-makers,
academia, and clinicians. Advocacy and discussion with these stakeholders
may result in greater awareness and high-level commitments to combat an
expanded group of NCDIs in Tanzania.
43
The Tanzania NCDI Poverty Commission Report
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