WOMEN and CHILDREN FIRST A review of progress in implementation of the recommendations of the Commission on Information and Accountability for Women’s and Children’s Health in Tanzania

May 2014

Ministry of Health and Social Welfare, United Republic of Tanzania United Republic of Tanzania

Ministry of Health and Social Welfare

Contents

WHO Library Cataloguing-in-Publication Data Guidance for national tuberculosis programmes on the management of tuberculosis in children – 2nd ed. 1.Tuberculosis – diagnosis. 2.Tuberculosis – therapy. 3.Tuberculosis – prevention and control. 4.Child. 5.Tuberculosis, Multidrug-Resistant. 6.National Health Programs. 7.Guideline. I.World Health Organization ISBN 978 92 4 154874 8

(NLM classification: WF 200)

Recommendations of the Commission on Information and Accountability...... 1 The Commission’s 10 recommentdations ............................................................. 1 Implementing the Commission’s recommendations ........................................... 3 Results: Progress towards MDG 4 and MDG 5...................................................... 5 Progress and challenges in implementing the accountability framework ........ 7

Maternal death surveillance and response ........................................................ 8



Tracking Resources ........................................................................................... 9

Compacts ........................................................................................................ 9

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Monitoring results........................................................................................... 10



eHealth and Innovation .................................................................................. 10



National oversight: Health reviews and countdown ........................................ 11



Transparency, advocacy and outreach ............................................................. 13

Conclusion ......................................................................................................... 14

partners in and outside of government - are held accountable for keeping our promises. By taking action now, we can accelerate progress on the Millennium Development Goals (MDGs), and of the Commission on Information and put Tanzania on track to achievingRecommendations the targets set for women and Accountability children in the One Plan II, aligned to the Health Sector Strategic In September 2010, in an effort to Plan (HSSP) IV by 2020, with the ultimate aim of ending all“...Improving the accelerate progress towards the health of women and Millennium Development Goals preventable maternal, newborn and child deaths by 2035.children is a matter (MDG 4 and 5), the SecretaryW

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General of the United Nations launched the Global Strategy for Women’s and Children’s Health. It mobilized many commitments and actions which need to be tracked.

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that is very close to my heart. I am very passionate about getting the opportunity to do something to help save the lives and improve the living conditions of many innocent children and mothers...”

This policy brief outlines a collaborative, multi-sectoral effort to analyse progress so far for Tanzania’s women and children, Accountability for financial resources and results is critical to and to develop focused national priorities for further action. The the objectives of the Global Strategy. At the request of the Secretary-General of the United Nations, a Commission on Tanzanian Countdown to 2015 Country Case Study1, along with Information and Accountability for Women’s and Children’s other important analyses of Tanzania’s Health (COIA)health was established, and co-chaired development by the President of the United Republic of Tanzania, His Excellency Mr. progress, including the HSSP III Midterm Review2 and the One Jakaya Kikwete and the Prime Minister of Canada, the Right Honourable Stephen Harper. The agreed upon an accountability framework which included 10 recommendations, Plan Midterm Review3, have theirCommission findings summarized in these which was launched in September 2011 in New York. pages. Together, and in full alignment with A Promise Renewed4, The Commission’s accountability framework is based on three interconnected processes monitor, review and act – which are aimed at learningis and not, continuous improvement. The these analyses shed light on what–framework is working and what links accountability for resources to the results they produce. It places accountability soundly where itand belongs: at the country with the active engagement of governments, on which Tanzanians are being reached who islevel,being left communities and civil society, and with strong links between country-level and global mechanisms. behind. They enable policymakers to focus planning, action, The Commission’s 10 recommendations and resources – as defined in the Sharpened One Plan (2014 – The 10 recommendations focus on ambitious, but practical actions that can be taken by all countries and – all partners. Whereverthey possible, the recommendations build on and strengthen 2015) and the One Plan II (2015 - 2020) where will be most existing mechanisms. effective in saving lives of women and children. Accountability for effective implementation will be strengthened through the National and Regional RMNCH Scorecards, which allow transparent monitoring and evaluation of progress towards national strategic goals (Figure 1). Together, let us hold ourselves, and each other, accountable for keeping our promises to Tanzania’s women and children. Let us

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A review of progress in implementation of the recommendations of the Commission on Information and Accountability for Women’s and Children’s Health in Tanzania

Better information for better results 1. Vital events: By 2015, all countries have taken significant steps to establish a system for the registration of births, deaths and causes of death, and have well-functioning health information systems that combine data from facilities, administrative sources and surveys. 2. Health indicators: By 2012, the same 11 indicators on reproductive, maternal and child health, disaggregated for gender and other equity considerations, are being used for the purpose of monitoring progress towards the goals of the Global Strategy.

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Implementing the Commission’s recommendations

The recommendations of the Commission are aimed at the 75 low and lower-middle income countries that account for more than 95% of maternal and child deaths in the world. The recommendations were translated into a multi-stakeholder workplan that evolved around seven priority areas that cover the cycle of monitoring, review and remedy or action.

3. Innovation: By 2015, all countries have integrated the use of Information and Communication Technologies in their national health information systems and health infrastructure. Better tracking of resources for women’s and children’s health 4. Resource tracking: By 2015, all 74 countries where 98% of maternal and child deaths take place are tracking and reporting, at a minimum, two aggregate resource indicators: (i) total health expenditure by financing source, per capita; and (ii) total reproductive, maternal, newborn and child health expenditure by financing source, per capita. 5. Country compacts: By 2012, in order to facilitate resource tracking, “compacts” between country governments and all major development partners are in place that require reporting, based on a format to be agreed in each country, on externally funded expenditures and predictable commitments. 6. Reaching women and children: By 2015, all governments have the capacity to regularly review health spending (including spending on reproductive, maternal, newborn and child health) and to relate spending to commitments, human rights, gender and other equity goals and results. Better oversight of results and resources: nationally and globally 7. National oversight: By 2012, all countries have established national accountability mechanisms that are transparent, that are inclusive of all stakeholders, and that recommend remedial action, as required. 8. Transparency: By 2013, all stakeholders are publicly sharing information on commitments, resources provided and results achieved annually, at both national and international levels. 9. Reporting aid for women’s and children’s health: By 2012, development partners request the Organisation for Economic Co-operation and Development, Development Co-operation Directorate (OECD-DAC) to agree on how to improve the Creditor Reporting System so that it can capture, in a timely manner, all reproductive, maternal, newborn and child health spending by development partners. In the interim, development partners and the OECD implement a simple method for reporting such expenditure. 10. Global oversight: Starting in 2012 and ending in 2015, an independent ‘‘Expert Review Group’’ is reporting regularly to the United Nations Secretary-General on the results and resources related to the Global Strategy and on progress in implementing this Commission’s recommendations.

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In February 2012, Tanzania hosted a subregional workshop The Commission’s on the Commission’s recommendations for 10 countries. All accountability country teams which include representatives of government, framework has civil society, development partners, UN agencies and, from been very useful for some countries,parliamentarians,conducted a self-assessment. The Tanzania mainland and Zanzibar self-assessments of the Tanzania and has current situation in terms of accountability for health with catalysed a number special reference to women’s and children’s health were of critical actions for subsequently discussed at a three-day workshop of national the improvement of stakeholders in April 2012 in Dar es Salaam. A country women’s and children’s roadmap was put together which took into consideration the health. current investments in accountability-related work in Tanzania. The roadmap identified priority areas for catalytic support from the funds for support to the implementation of the Commission’s recommendations.

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A review of progress in implementation of the recommendations of the Commission on Information and Accountability for Women’s and Children’s Health in Tanzania

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Tanzania has multiple major partners that support the government and others in strengthening accountability, especially through support of data collection and analysis. Examples include U.S. government supported household surveys and a national health and demographic surveillance system, the Netherlands, Norway and the Global Fund support the facility-based information system, the World Health Organization (WHO) and the U.S. Agency for International Development (USAID) support national health accounts, the United Nations Children’s Emergency Fund (UNICEF) birth registration, the World Bank pay-for-performance schemes, etc.

Results: Progress towards MDG 4 and MDG 5

In 2013, Tanzania received US$ 350 000 catalytic funds for the implementation of the roadmap through the WHO country office, including US$ 100 000 for Zanzibar. Funds were allocated to all seven workstreams of the country accountability framework. The largest amounts were budgeted to civil registration and vital statistics system (CRVS) and maternal death surveillance and response.

Figure 1

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MDG 4: Reduce the mortality rate of children under the age of five (U5MR) by two thirds by 2015 Tanzania has achieved remarkable progress in child survival. The most recent household survey, the Tanzania DHS 2010, shows that child mortality (under-five) was 81 per 1 000 live births for 2006-2010, which was lower than the 91 for 2003-07.

Tanzania has achieved remarkable progress in child survival

The data from the household surveys are used to predict the mortality rate for 2012 by the United Nations. These predictions of under-five mortality show that child mortality was estimated at 55 per 1 000 live births in 2012. The infant mortality rate was 38 per 1 000 live births in 2012. The declines in the infant and child mortality rate have accelerated significantly between 2000 and 2012. This implies that Tanzania has already reached its target for MDG 4, one of the three countries in the African region (the other two are Liberia and Malawi).

However, similar progress in newborn survival has not been achieved: neonatal mortality – deaths in the first 28 days of life – has declined at only about half the speed of child mortality. Newborn deaths now make up 40% of all deaths in under-five children in Tanzania.

Figure 2 Child immunization coverage in Tanzania is high with more than 90% of children receiving pentavalent and measles vaccines. Tanzania has improved its coverage in recent years and campaigns may have contributed. Its immunization coverage rates are among the highest in the African region. Coverage is high in all socioeconomic groups and almost all regions are over 90%.

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A review of progress in implementation of the recommendations of the Commission on Information and Accountability for Women’s and Children’s Health in Tanzania

MDG 5a: Reduce maternal mortality ratio (MMR) by three quarters by 2015 Tanzania has made insufficient progress in maternal survival between 1990 and 2013. The last Demographic and Health Survey (DHS) in 2010 showed a maternal mortality ratio of 454 per 100 000 live births for the period 2004-2010. According to the UN predictions using all survey data and other factors, maternal mortality was 414 per 100 000 live births in 2013. This means that approximately 7 900 women died during pregnancy, delivery or within the first six weeks after delivery in 2013. Tanzania is well off target to achieving the MDG objective.

Figure 3 Virtually all pregnant women attend antenatal care but make too few visits and come too late in pregnancy. Deliveries with skilled birth attendance are increasing gradually, but the improvements are considerably slower than in most other countries in eastern Africa, especially in rural areas, and are well off the national 80% target for 2015. According to the health facility data of the Ministry of Health, 56% of all deliveries took place in health facilities in 2012. The service availability and readiness assessment in 2012 showed only modest progress in the availability of basic obstetric and newborn services compared to three years earlier.

MDG 5b: Provide universal access to family planning and reproductive health services Figure 4 Tanzania has increased the modern Contraceptive Prevalence Rate (CPR) from 7% in 1990 to 27% in 2010, with the increase between 2005 and 2010 largely attributable to an increase amongst rural women. However, the unmet need for family planning − the proportion of women whose family planning needs are not satisfied − has remained constant at about a quarter of women.

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Progress and challenges in implementing the accountability framework Civil registration and vital statistics systems (CRVS) By 2015, all countries have taken significant steps to establish a system for the registration of births, deaths and causes of death The primary responsibility for the registration of births and deaths lies with the Registration Authority (RITA), which is under the Ministry of Justice and Constitution Affairs. Currently, there is considerable emphasis on advocacy to enhance the demand for registration. The system is paper-based and still cumbersome for citizens who often have to travel long distances to the district registration office to get registered and obtain a certificate. Coverage rates remain low. The 2012 census shows that only 15% of the Tanzanians on the mainland have registered their birth. In Zanzibar, 71% of persons had been registered with the authorities. These figures are very similar to the results of the DHS in 2010. Urban children have considerably higher registration coverage than rural children 44% and 10% respectively.

Figure 5 There are several initiatives to improve the situation.With the support of UNICEF, an under-five births registration system is implemented in a pilot region with plans for further expansion. The pilots include decentralizing the current district-based registration services to ward and village levels, as well as registration in health facilities at the time of delivery or first immunization. An electronic message is sent to the central registration system at RITA. A paper with evidence of registration is provided to the mothers; a formal birth certificate can be obtained from the district registration office upon payment. Birth registration went up from 8% to 37% in the pilot region. The government is piloting the “6 to 18 initiative”, aiming to ensure that all children who are in school are registered. Considerable investments are also made by the National Electoral Commission in voter registration (18 years and above) and a national ID card (supported by Denmark’s Development Cooperation, DANIDA). Death registration coverage figures are even lower than for births, as hospitals (where only about 6% of all deaths occur) do not have death registration systems in place and there is little incentive to register for most relatives of the deceased. There is no reliable information on the causes of death on the mainland and in Zanzibar.

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A review of progress in implementation of the recommendations of the Commission on Information and Accountability for Women’s and Children’s Health in Tanzania

There are several activities that aim to improve the situation, at least for vital statistics. The new health facility reporting system of the Ministry of Health (DHIS) has allowed the introduction of the International Classification of Diseases (ICD) for the coding of causes of death. The Ifakara Health Institute, in collaboration with the National Bureau of Statistics, the Ministry of Health and the Center for Disease Control and Prevention (CDC), is implementing a health and demographic surveillance system where information on birth and death with a cause of death (using verbal autopsy) is collected from communities in a national sample of 23 districts. All of these activities, however, are occurring without a strong overall national plan for registration of all births and deaths, and persons. A national comprehensive assessment of the CRVS will start mid-2014, led by RITA, involving multiple sectors.This assessment will look into the current systems, the legal and institutional environment, and the potential for innovative approaches, and should form the basis for an integrated plan. The UN Economic Commission for Africa, WHO, UNICEF, the United Nations Population Fund (UNFPA) and others are supporting the assessment.

Maternal death surveillance and response Countries monitor quality of care provided in health services and take steps to make improvements... Guidelines for the review of maternal and perinatal deaths have been in place since 2006. Many districts hold review meetings at the local level but the country-wide coverage of the system of reporting and review has been an issue. The current guidelines have been reviewed and updated to take into account the new WHO/CDC guidelines on maternal death surveillance and response.The country guidelines are in the process of dissemination to all regions. Maternal death is a notifiable event which is part of the weekly reporting system of the Integrated Disease Surveillance and Response (IDSR) system. An electronic reporting system, using SMS, has been rolled out into a handful of districts. The reports, which include 28 notifiable conditions as well as maternal deaths and malaria, are forwarded to the overall health management information system for compilation and analysis. Zanzibar completed an Emergency Obstetric Care (EmOC) survey of all health facilities in 2012. The EmOC survey was combined with an assessment of the readiness of all other health services: Service Availability and Readiness Assessment (SARA). A full report is available, showing that there are still major gaps in the availability and readiness of services for women and children. Also the mainland completed a large SARA in 1 297 health facilities in 23 districts of the health and demographic surveillance programme, showing gaps in service delivery in several critical areas. The situation was very similar to 2008/09.

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Tracking Resources By 2015, 50 countries bear tracking and reporting, at a minimum, two aggregate resource indicators…. Compacts By 2012, in order to facilitate resource tracking, compacts between country governments and all major development partners... The recommendations of the COIA resulted in increased emphasis on harmonization of the different systems of financial tracking. These systems include Public Expenditure Reviews (PER), National AIDS Spending Account, Public Expenditure Tracking Survey (PETS) and National Health Accounts. The efforts have been focused on harmonizing the systems into one regular ...The recommendations of system of health accounts. The 2012/13 National the COIA resulted in increased Health Accounts exercise includes subaccounts emphasis on harmonization for all major health and disease programs and is of the different systems of near completion. This includes expenditure for financial tracking… reproductive, maternal, newborn and child health. In conjunction with the planning and budgeting for the 4th health sector strategic plan (to commence in 2016), the government has instructed all programme and related plans to be developed to use the UN OneHealth Tool for costing. The main challenge is now to institutionalize the NHA to become an annual exercise, based on simplified automated systems and standardized data collection. Some steps have already been taken such as automation of certain data sets and standardization of the collection of data on resources from partners.This needs to be combined with adequate capacity, within the Ministry, and with country institutions such as the Ifakara Health Institute, National Institute for Medical Research, the National Bureau of Statistics and the University of Dar es Salaam. The capacity strengthening focuses on data analysis and communication of results to enhance the use of the information. Until recently, Zanzibar had never conducted an NHA. The first NHA was completed by the Ministry of Health in 2013, and capacity was built. Since this was the first NHA, there were no subaccounts. Costing of the strategic plan 2012-16 is ongoing. Tanzania has no formal IHP+ compact, but development partners and government are working together in several fora, including overall health sector coordinating committees with several technical committees (e.g. health financing, monitoring and evaluation). An important part is the basket funding, which includes the funding of several donors for flexible district health funding of on average US$ 1.50 per person per year.

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A review of progress in implementation of the recommendations of the Commission on Information and Accountability for Women’s and Children’s Health in Tanzania

Monitoring Results By 2015, all countries have taken significant steps to strengthen health information systems... Tanzania has good data for monitoring progress and performance for most indicators. The main data sources are regular household surveys (Demographic and Health Surveys, HIV and malaria indicator surveys, TB prevalence survey, and national panel survey), routine facility reports, facility assessments (SARA in 2008/09 and 2012) and administrative data sources. The national health and demographic surveillance system (SAVVY), operated by the Ifakara Health Institute, is now operational and is providing data on cause of death patterns in the community. After several years of field testing in Pwani Region, the web-based district health information system (DHIS 2.0) became operational on the mainland in August 2013. Zanzibar already moved to using DHIS several years ago. Districts enter information from all facilities into the computer which is connected with the central …, the web-based district health management information system. This will health information system enhance completeness and timeliness of reporting, and allow much faster analysis of results. The roll- (DHIS 2.0) became operational out of the facility reporting system was based on on the mainland in August the national Monitoring and Evaluation Strategy 2013… Initiative (MESI) which presents a single plan to which all partners are invited to contribute.The roll-out of the district health information system is supported by Health and Social Services and Local Government, with financial support from the Global Fund, Netherlands and Norway. The new system can provide a basis for improvement of data quality, more rapid analysis of national results, more local analysis of progress and data sharing. A database of all health facilities, including the GPS coordinates, is in its final stages. In the context of the midterm review of the Health Sector Strategic Plan (HSSP III) in 2013, an in-depth analysis of all available data was conducted by a team consisting of the health information unit of the Ministry of Health and Social Welfare, National Institute of Medical Research, Ifakara Health Institute and the World Health Organization. The team prepared a comprehensive objective picture of progress and performance and included, for a detailed analysis, the regional situation in terms of health system strength and coverage of interventions. The analysis included levels and trends in all 11 indicators recommended by the Commission.

eHealth and Innovation By 2015, all countries are implementing national eHealth strategies and web-based systems to report data…

The Tanzania national eHealth strategy 2013-2018 was launched in September 2013. It was developed as part of the national

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…. The Tanzania national eHealth strategy 2013-2018 was launched in September 2013….

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Monitoring and Evaluation Strategy Initiative (MESI). An eHealth steering committee has been established. The national eHealth steering committee provides the overall leadership and governance of the implementation of the strategy, with the Ministry of Health as the secretariat. There are many practical applications with innovative approaches using electronic devices.These applications can promote the quality and utilization of services, as well as accountability. As part of the new eHealth strategy, an inventory of existing systems is made in an effort to develop one common system that is well governed in line with the national strategy. Examples of recent improvements and innovations include: n

Logistics Management Information System: an electronic system (eLMIS) has been developed and is in the process of roll-out to the whole country.

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Rapid SMS for malaria: for some medicines and commodities, real-time systems are in place, such as the monitoring of stockouts of ACT for malaria treatment by the Malaria Programme.

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SMS for women and children: there are several SMS systems in place that send reminders for antenatal care and delivery through SMS, allow women and girls to ask questions about reproductive health, and send health promotion messages. Examples are m4RH, Wazazi nipendeni, WiredMothers. In Zanzibar, it was shown that skilled birth attendance rates went up after the SMS reminders programme was initiated.

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Facility reporting system: DHIS 2.0 is the web-based reporting system of health facility data on services. The data are entered at the district level and sent on a monthly basis to the Ministry of Health central unit.The system was piloted during 2009-2012 in one region, and became operational in the whole country in September 2013.

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Telemedicine: aims to connect all referral hospitals to provide services throughout the country, led by the Ministry of Science and Technology.

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Health workforce: the Human Resources for the Health Information System (HRHIS) is now electronic. The mainland system is gradually expanding and all districts have entered information electronically. Zanzibar now has a real-time register.

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Notifiable conditions reporting: the integrated disease surveillance and response programme is sending information using mobile phones for its 28 diseases, plus maternal deaths and malaria. This system is being rolled out.

National oversight: Health reviews and countdown By 2012, all countries have established national accountability mechanisms that are transparent...

Both Tanzania mainland and Zanzibar have a five-year health sector strategic plan. The HSSP III 2009-2015 on the mainland includes a core set of indicators, targets and regular review processes. Maternal and child health indicators and issues are very prominent in the overall health sector reviews. Most indicators recommended by the Commission are tracked, as part of a set of about 40 core indicators and all indicators are part of the programme plan monitoring component.

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A review of progress in implementation of the recommendations of the Commission on Information and Accountability for Women’s and Children’s Health in Tanzania

The annual reviews are informed by performance reports prepared through technical committee, involving development partners, country institutions and the Ministry of Health, including a synthesis of all available data from multiple data sources. In 2012-13, the midterm review of the five-year plan was conducted. This involved an extensive analytical report of progress and performance, prepared by the Ministry of Health and Social Welfare, in collaboration with the National Institute for Medical Research, Ifakara Health Institute and WHO.

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In the context of the post-2015 development agenda,Tanzania’s citizens were asked to prioritize 15 areas. Over 37 000 responded, mostly through an SMS. Health came in third place, after education and better job opportunities. An honest and responsive government was ranked 7th, which was lower than in other countries in Africa or globally. Tanzanian citizens appeared to be more concerned about security issues.

Transparency, advocacy and outreach The annual health sector reviews include district and regional participation, as well as development partners, civil society and parliamentarians. Technical committees meet extensively prior to and post reviews, and discuss the implications for the operational plans. In Zanzibar, the health sector strategic plan does not yet have a monitoring and evaluation plan that can be used at regular reviews. It will be drafted in 2014. Sikika is a national NGO focused on health governance, including transparency and accountability. Sikika is also involved in the annual health sector reviews. One of its current priorities is to focus on mobilizing and advocating for the right to health in the new constitution which is being drafted. Other civil society organizations, such as the White Ribbon Alliance, Evidence4Action (E4A) and Save the Children, are specifically concerned about accountability for women’s and children’s health issues. The national strategic plan for the accelerated …In the context of the postreduction of maternal, newborn and child deaths 2015 development agenda, in Tanzania 2008-2015 (also referred to as the Tanzania’s citizens were “One Plan”) was also reviewed in 2014. This led to asked to prioritize 15 areas. the formulation of a “Sharpened One Plan” for the remaining time until the MDG target year 2015, Over 37000 responded, mostly resulted in the plan 2016-2020, and also brought through an SMS. Health came in more recent global initiatives such as A Promise in third place, after education Renewed (for ending preventable maternal, and better job opportunities… newborn and child deaths). The sharpened plan used the evidence on progress to refocus the interventions and focus on poorly performing regions. Tanzania joined the Open Government Partnership (OGP) Initiative in September 2011.  It aims to make the Government business more open to its citizens in order to improve public service delivery, government responsiveness, combat corruption and build greater trust. As stipulated under the Tanzania OGP Action Plan of 2012/2013, the OGP commitments are focused on four pillars, namely transparency, accountability, citizens’ participation, technology and innovation.  The main focus is on the Health, Education and Water sectors. Some of the activities include greater transparency on the budget, web-based platform to provide feedback on government services, updating of Client Service Charters in the Education, Health and Water sectors.

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By 2013, all stakeholders are publicly sharing information on commitments, resources provided and results achieved annually, at both national and international levels

A high level political event, involving President Kikwete, Women and children first: Countdown to ending preventable maternal, newborn and child death, will be held in May 2015. The event brings together multiple developments, which were summarized in an accompanying policy brief. This included the Tanzanian Countdown to 2015 Country Case Study, the HSSP III Midterm Review, the One Plan Midterm Review, and the commitments related to A Promise Renewed. To accelerate actions towards achieving the MDGs, a Sharpened One Plan (2014-2015) was formulated. In addition, the basis was laid for the One Plan II (2015-2020) which will be linked to the new health sector strategic plan IV which will start in 2016. Accountability for effective implementation will be strengthened through the national and regional Reproductive, Maternal, Newborn and Child Health (RMNCH) scorecards, which allow transparent monitoring and evaluation of progress towards national strategic goals. Several civil society organizations are active in the field of women’s and children’s health. For instance, the White Ribbon Alliance is an NGO working on women’s health issues. It runs a national advocacy campaign under the motto “Wajibika Mama Aishi” (“be accountable so that mothers can survive childbirth”), begun in the remote region of Rukwa in 2013. One of the pillars of the campaign is advocating for the implementation of Tanzania’s One Plan Road Map, in which half of all health centres should provide comprehensive emergency obstetric and newborn care by 2015. The campaign is also asking citizens to sign a petition asking for a special budget line and adequate funds for comprehensive emergency care. Another example is Mama Ye! : a campaign about making life-saving changes for Tanzania’s mothers and babies, supported by E4A, a multi-year programme which aims to improve maternal and newborn survival in sub-Saharan Africa in selected countries with support from the Department for International Development (DFID). It runs an interactive website and organizes activities such as a launch of a campaign to save the lives of Tanzanian mothers and babies in Arusha City, marked by a major voluntary blood recruitment and donation drive in which more than 1 000 donors participated. E4A is also launching a national scorecard for the quality of institutional care.

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A review of progress in implementation of the recommendations of the Commission on Information and Accountability for Women’s and Children’s Health in Tanzania

The parliamentarians’ Group for Safe Motherhood advocates for maternal health issues in parliament and elsewhere. The parliamentarians participated in the annual White Ribbon Day to commemorate women who have died in childbirth (15 March) and also met with the Prime Minister to advocate for maternal health issues. There is also a family planning “club” of parliamentarians which partly overlaps with the Group for Safe Motherhood. The media regularly cover maternal health issues. Newspapers regularly have articles in conjunction with global events or national stories. Also radio and TV are used. For instance, ITV Radio 1 committed significant resources to making sure that people get the right information on women’s health. In some cases, a media story focuses on specific local issues, resulting in an improvement, such as the case of mothers at a clinic where they were paying for reproductive health cards which were supposed to be free of charge.

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Conclusion The Commission’s accountability framework has been very useful for Tanzania and has catalysed a number of critical actions for the improvement of women’s and children’s health. During the last year, Tanzania has seen considerable progress in implementing the country accountability framework and the recommendations of the Commission. Many actions and activities related to enhancing accountability for health with a focus on women and children have been initiated or accelerated. The accountability framework and the catalytic funding have been instrumental in strengthening coordination and enhancing the efficiency of investments. In Tanzania, this is primarily achieved by supporting the government to convene all stakeholders, conduct assessments, support the development one common plan, and carry out sound assessments of progress that involve government and independent country institutions. Such processes have been initiated for almost all priority areas of the accountability framework, such as eHealth, health information systems, maternal death surveillance and response, and resource tracking. Such a process is also in the pipeline for CRVS. Accountability for women’s and children’s health will remain a critical issue in the coming years both at national, regional, district and individual levels. Building upon the achievements so far, more can be done to strengthen country plans and their implementation with the alignment of national and international stakeholders, to improve quality and access to services, further strengthen the evidence-based comprehensive inclusive reviews of progress and performance, address issues identified through reviews and other avenues, and enhance the role of civil society organizations and Parliament.

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