Document(s) 10 of 10

The Principal Research Objective is to document burden of disease for priority setting and to quantify changes in the burden of disease to assess impact of reforms.

Since February 1999 Dr. E.A. Mwageni, the Rufiji DSS Station Manager at Ikwiriri, has not had a "computer-free day" With the input of field supervisors, enumerators, key informants and data personnel, the station is a beehive of activities throughout the week, sometimes, week-ends and holidays not withstanding. It is the nerve centre of the health impact research in relation to health interventions using the Direct Demographic Surveillance System (DSS).

Like the other research components, this path addresses research questions which demand the skills of a wide range of disciplines. Among those harnessed for this particular component are health anthropology, health demography, health sociology, health systems analysis, development studies, population studies, health statistics, health economics, nutritionists and epidemiology. All the required skills have however been obtained from Tanzanian institutions.

The health impact study on the effectiveness of investments in health is crucial in the context of the World Development Report '93 which proposes the use of what is known as the Disability Adjusted Life Year (DALY) to measure burden of disease and cost-effectiveness. In Sub-Saharan Africa most DALYs are lost through premature mortality. Half of all DALYs are lost by children under five years of age. This means that much of the impact of the advocated essential health interventions will probably result from improvements in child survival.

The Demographic Surveillance System (DSS) is thus a major community based research component of TEHIP that also provides the sampling frame for other community based survey work of TEHIP and others. The Rufiji DSS is funded and managed as a collaboration between TEHIP and the Adult Morbidity and Mortality Project.

Although impacts on mortality, morbidity and household behaviours will not begin to be evident until later in the course of TEHIP, baseline status was established early.

The need to quantify the BOD and use it as a monitor in health services and health studies is justified by several reasons. The indicator can assist in setting health service priorities, both curative and preventive. In addition it is possible to use it for identifying groups that are disadvantaged in terms of health provision and thus devise interventions that target these groups. The BOD monitoring can as well be of use in setting additional health research priorities. This indicator also provides a comparable measure of output for intervention, programme and sector evaluation and planning. In this respect, the main thrust of TEHIP, increasing capacity to plan and deliver effective health interventions at district level, can be evaluated using the findings of this Component.

Measuring the BOD is a crucial exercise in any health system. The BOD could feed into a useful tool for effective planning as well as evaluation of health services and interventions. In many populations, the BOD is a reflection of the amount of investment in the health sector and also consequences of operations that safeguard or damage health. As far as TEHIP is concerned, the quantification of the BOD is a crucial strategy towards evidence based planning since it has dual purposes. Firstly, it can be used as a tool to assist districts, especially the DHMTs, in their planning processes and secondly, as a tool to assess the impact of various health interventions, developments and reforms so far introduced in the districts.

Module C-1 employs a longitudinal direct demographic surveillance system DSS) to collect health status data. It involves a continuous surveillance at household level for demographic and socio-economic statistics such as age, sex, household demographic composition, aspects of nuptiality, births, deaths, migration, education and occupation. The DSS is considered as the most relevant methodology to obtain up-to-date and accurate data on the impact of interventions on health where mortality is high and vital registration system is either non-existent or incomplete. Using households as the main unit of analysis is not unique to Rufiji DSS or Tanzania. The approach developed by the Population Council at Navrongo, Ghana, is now used in Rufiji, Kilombero and Ulanga in Tanzania and in about eleven sites across Africa. The Adult Morbidity and Mortality Project also conducts DSS surveillance in Hai, Morogoro and Dar es Salaam.

The Rufiji DSS approach uses a population size between 70,000 and 100,000 combining both census taking and use of key informants. It begins by baseline data collection using pre-coded forms. Then after every four months an update survey is conducted to capture events such as migration and nuptiality issues concurrently. The major role of key informants is to report all births and deaths as they occur in the study area. The key informants consist of community leaders. In addition the DSS conducts verbal autopsies on all registered deaths to ascertain their main and underlying causes. The interviews are normally conducted on a person or relative who was caring for the deceased at the time of death.

Outputs

The DSS data can, among others, generate the following distributions: Direct and underlying cause of death, population size and structure, average household size, household leadership by gender, relationship with head of household, population distributions, population movement and trends in terms of births.

The information obtained in the course of the impact research is shared with the beneficiaries and utilized in planning. "We have two sessions a year with the DHMTs and whenever they want any information from what we have collected we provide it", said Dr. Mwageni. TEHIP research project, in all fronts, has started to pay dividends. So far annual plans of both districts covered by the project do reflect efforts of the researchers and the enthusiasm of the District Health Managements Teams to work out realistic plans based on reliable information.

Document(s) 10 of 10