scholarly journals Maternal Death Surveillance and Response in Tanzania: Comprehensiveness of narrative summaries and action points from maternal death reviews

2020 ◽  
Author(s):  
Ali Said ◽  
Andrea B. Pembe ◽  
Siriel Massawe ◽  
Claudia Hanson ◽  
Mats Malqvist
Keyword(s):  
Maternal Death ◽  
Demographic Characteristics ◽  
Health Facilities ◽  
World Health ◽  
Action Plans ◽  
Maternal Deaths ◽  
Middle Income ◽  
Middle Income Countries ◽  
Sequence Of Events ◽  
Surveillance And Response

Abstract Background Maternal deaths reviews are proposed as one strategy to address high maternal mortality in low and middle-income countries, including Tanzania. Review of maternal deaths relies on comprehensive documentation of medical records that can reveal the sequence of events leading to death. The World Health Organization’s and the Tanzanian Maternal Death and Surveillance (MDSR) system propose the use of narrative summaries during maternal death reviews for discussing the case to categorize causes of death, identify gaps in care and recommend action plans to prevent deaths. Suggested action plans are recommended to be Specific, Measurable, Attainable, Relevant and Time bound (SMART). To identify gaps in documenting information and developing recommendations, comprehensiveness of written narrative summaries and action plans were assessed. Methods A total of 76 facility maternal deaths that occurred in two regions in Southern Tanzania in 2018 were included for analysis. Using a prepared checklist from Tanzania 2015 MDSR guideline, we assessed comprehensiveness by presence or absence of items in four domains, each with several attributes. These were socio-demographic characteristics, antenatal care, referral information and events that occurred after admission. Less than 75% completeness of attributes in all domains was considered poor while 95% and above were good/comprehensive. Action plans were assessed by application of SMART criteria and according to the place of planned implementation (community, facility or higher level of health system).Results Almost half of narrative summaries (49%) scored poor, and only1% scored good/comprehensive. Summaries missed key information such as demographic characteristics, time between diagnosis of complication and commencing treatment (65%), investigation results (47%), summary of case evolution (51%) and referral information (47%). A total of 285 action points were analysed. Most action points, 242(85%), recommended strategies to be implemented at health facilities and were mostly about service delivery, 120(42%). Only 42% (32/76) of the action points were deemed to be SMART.Conclusions Abstraction of information to prepare narrative summaries used in the MDSR system is inadequately done. Most recommendations were unspecific with a focus on improving quality of care in health facilities

scholarly journals Maternal Death Surveillance and Response in Tanzania: Comprehensiveness of narrative summaries and action points from maternal death reviews

2020 ◽  
Author(s):  
Ali Said ◽  
Andrea B. Pembe ◽  
Siriel Massawe ◽  
Claudia Hanson ◽  
Mats Malqvist
Keyword(s):  
Maternal Death ◽  
Demographic Characteristics ◽  
Health Facilities ◽  
World Health ◽  
Action Plans ◽  
Maternal Deaths ◽  
Middle Income ◽  
Middle Income Countries ◽  
Sequence Of Events ◽  
Surveillance And Response

Abstract Background Maternal deaths in Tanzania and other low and middle income countries occur both in and outside health facilities. Review of maternal deaths relies on comprehensive documentation of medical records that can reveal sequence of events leading to death. The World Health Organization’s and the Tanzanian Maternal Death and Surveillance (MDSR) system propose the use of narrative summaries during maternal death reviews for discussing the case to categorize causes of death, identify gaps in care and recommend action plans to prevent deaths. Suggested action plans are recommended to be Specific, Measurable, Attainable, Relevant and Time bound (SMART). To identify gaps in documenting information and developing recommendations, comprehensiveness of written narrative summaries and action plans were assessed. Methods A total of 76 facility maternal deaths that occurred in two regions in Southern Tanzania in 2018 were included for analysis. We assessed the comprehensiveness of summaries and action plans using a prepared checklist from Tanzania MDSR guideline of 2015. Presence or absence of items in four domains each with several attributes was recorded. These were socio-demographic characteristics, antenatal care, referral information and events that occurred after admission. Less than 75% completeness of attributes in all domains was considered poor while 95% and above was good/comprehensive. Action plans were assessed by application of SMART criteria and according to place of planned implementation (community, facility or higher level of health system).Results Almost half of narrative summaries (49%) scored poor, and only 1% scored good/comprehensive. Summaries missed key information such as demographic characteristics, time between diagnosis of complication and commencing treatment (65%), investigation results (47%), summary of case evolution (51%) and referral information (47%). A total of 285 action points were analysed. Most action points 242(85%) recommended strategies to be implemented at health facilities and they were mostly 42(42%) on service delivery. Only 42% (32/76) of the action points were deemed to be SMART.Conclusions Abstraction of information to prepare narrative summaries used in MDSR system is inadequately done. Action plans in MDSR system are mostly recommended to sub standard care in health facilities but are not specific on the issues to be addressed.

scholarly journals Maternal Death Surveillance and Response in Tanzania: Comprehensiveness of narrative summaries and action points from maternal death reviews

2021 ◽  
Author(s):  
Ali Said ◽  
Andrea B. Pembe ◽  
Siriel Massawe ◽  
Claudia Hanson ◽  
Mats Malqvist
Keyword(s):  
Maternal Death ◽  
Demographic Characteristics ◽  
Health Facilities ◽  
World Health ◽  
Action Plans ◽  
Maternal Deaths ◽  
Middle Income ◽  
Middle Income Countries ◽  
Sequence Of Events ◽  
Surveillance And Response

Abstract Background Maternal deaths reviews are proposed as one strategy to address high maternal mortality in low and middle-income countries, including Tanzania. Review of maternal deaths relies on comprehensive documentation of medical records that can reveal the sequence of events leading to death. The World Health Organization’s and the Tanzanian Maternal Death and Surveillance (MDSR) system propose the use of narrative summaries during maternal death reviews for discussing the case to categorize causes of death, identify gaps in care and recommend action plans to prevent deaths. Suggested action plans are recommended to be Specific, Measurable, Attainable, Relevant and Time bound (SMART). To identify gaps in documenting information and developing recommendations, comprehensiveness of written narrative summaries and action plans were assessed. Methods A total of 76 facility maternal deaths that occurred in two regions in Southern Tanzania in 2018 were included for analysis. Using a prepared checklist from Tanzania 2015 MDSR guideline, we assessed comprehensiveness by presence or absence of items in four domains, each with several attributes. These were socio-demographic characteristics, antenatal care, referral information and events that occurred after admission. Less than 75% completeness of attributes in all domains was considered poor while 95% and above were good/comprehensive. Action plans were assessed by application of SMART criteria and according to the place of planned implementation (community, facility or higher level of health system).Results Almost half of narrative summaries (49%) scored poor, and only1% scored good/comprehensive. Summaries missed key information such as demographic characteristics, time between diagnosis of complication and commencing treatment (65%), investigation results (47%), summary of case evolution (51%) and referral information (47%). A total of 285 action points were analysed. Most action points, 242(85%), recommended strategies to be implemented at health facilities and were mostly about service delivery, 120(42%). Only 42% (32/76) of the action points were deemed to be SMART.Conclusions Abstraction of information to prepare narrative summaries used in the MDSR system is inadequately done. Most recommendations were unspecific with a focus on improving quality of care in health facilities

scholarly journals Maternal Death Surveillance and Response in Tanzania: Comprehensiveness of Maternal Deaths Narrative Summaries and Action Points from Death Reviews

2020 ◽  
Author(s):  
Ali Said ◽  
Andrea B. Pembe ◽  
Siriel Massawe ◽  
Claudia Hanson ◽  
Mats Malqvist
Keyword(s):  
Maternal Death ◽  
Medical Records ◽  
Causes Of Death ◽  
Demographic Characteristics ◽  
Standards Of Care ◽  
Action Plans ◽  
Maternal Deaths ◽  
Sequence Of Events ◽  
Surveillance And Response ◽  
Community Facility

Abstract BackgroundReview of maternal deaths relies on comprehensive documentation of medical records that can reveal sequence of events that led to death. Maternal Death and Surveillance (MDSR) system recommends the use of narrative summaries during maternal death reviews to discuss the case and categorize medical causes of death, identify gaps in care and recommend action plans to prevent deaths. Suggested action plans are recommended to be Specific, Measurable, Attainable, Relevant and Time bound (SMART). To identify gaps in documenting information and planning recommendations, comprehensiveness of written narrative summaries and adequacy of action plans according the MDSR guideline were assessed. MethodsA total of 76 facility maternal deaths that occurred in two regions in Southern Tanzania in 2018 were included for analysis. We assessed the comprehensiveness of narrative summaries and action plans using a prepared checklist from MDSR guideline of 2015. Presence or absence of items in four domains each with several attributes was recorded on the checklist. The domains were socio-demographic characteristics, antenatal care, referral information and events that occurred after admission. Less than 75% completeness of attributes in all domains was considered poor while >94% was good/comprehensive. Action plans were assessed by application of SMART criteria and according to place of planned implementation (community, facility or higher level of health system). Results Two-thirds of summaries (66%) scored poor, and none were scored as good/comprehensive. Summaries missed key information such as demographic characteristics, information of events that occurred in community (16%), time between diagnosis of complication and commencing treatment (65%), investigation results (47%), summary of case evolution (51%) and referral information (47%). A total of 285 action plans were analysed. Most action plans 242(85%) were allocated to health facilities for implementation and they were mostly 42(42%) on service delivery. Only 42% (32/76) of the action plans were deemed to be SMART.ConclusionsAbstraction of information to prepare narrative summaries used in MDSR system is inadequately done. Action plans and recommendations in MDSR system are mostly for facility sub standards of care and are not specific on the issues to be addressed.

scholarly journals Causes of maternal deaths and delays in care: Comparison between routine Maternal Death Surveillance and Response system and an obstetrician expert panel in Tanzania

2020 ◽  
Author(s):  
Ali Said ◽  
Mats Malqvist ◽  
Andrea B. Pembe ◽  
Siriel Massawe ◽  
Claudia Hanson
Keyword(s):  
Maternal Death ◽  
Causes Of Death ◽  
Expert Panel ◽  
World Health ◽  
Cross Sectional ◽  
Maternal Deaths ◽  
Surveillance And Response ◽  
Independent Expert ◽  
Underlying Causes ◽  
Three Phases

Abstract Background To reduce maternal mortality Tanzania introduced Maternal Death Surveillance and Response (MDSR) system in 2015 as recommended by World Health Organization (WHO). All health facilities are to notify and review all maternal deaths inorder to recommend quality improvement actions to reduce deaths in future. The system relies on consistent and correct categorization of causes of maternal deaths and three phases of delays. To assess its adequacy we compared the routine MDSR categorization of causes of death and three phases of delays to those assigned by an independent expert panel with additional information from Verbal Autopsy (VA). Methods Our cross-sectional study included 109 reviewed maternal deaths from two regions in Tanzania for the year 2018. We abstracted the underlying medical causes of death and the three phases of delays from MDSR system records. We interviewed bereaved families using the standard WHO VA questionnaire. The obstetrician expert panel assigned underlying causes of death based on information from medical files and VA according to International Classification of Disease to Death in Pregnancy Childbirth and Puerperium (ICD-MM).They assigned causes to nine ICD-MM groups and identified the three phases of delays. We used Cohen`s K statistic to compare causes of deaths and delays categorization.Results Comparison of underlying causes was done for 99 deaths. While 109 and 84 deaths for expert panel and MDSR respectively were analyzed for delays because of missing data in MDSR system. Expert panel and MDSR system assigned the same underlying causes in 64(64.6%) deaths (K statistic 0.60). Agreement increased in 80(80.8%) when causes were assigned by ICD-MM groups (K statistic 0.76). The obstetrician expert panel identified phase one delays in 74(67.9%), phase two in 24(22.0%) and phase three delays in all 101(100%) deaths that were assessed for this delay while MDSR system identified delays in 42(50.0%), 10(11.9%) and 78(92.9%).The expert panel found human errors in management in 94(93.1%) while MDSR system reported in 53(67.9%) deaths.Conclusions MDSR committees performed reasonably well in assigning underlying causes of death. The obstetrician expert panel found more delays than reported in MDSR system indicating difficulties within MDSR teams to critically review deaths.

scholarly journals Assessing Implementation of Maternal and Perinatal Death Surveillance and Response in Rwanda

2020 ◽  
Vol 17 (12) ◽  
pp. 4376
Author(s):  
Edwin Tayebwa ◽  
Felix Sayinzoga ◽  
Jacqueline Umunyana ◽  
Kusum Thapa ◽  
Efugbaike Ajayi ◽  
...  
Keyword(s):  
Quality Improvement ◽  
Maternal Death ◽  
Perinatal Death ◽  
Health Concern ◽  
Middle Income ◽  
Middle Income Countries ◽  
Surveillance And Response ◽  
Modifiable Factors ◽  
Facility Level

Maternal deaths remain a major public health concern in low- and middle-income countries. Implementation of maternal and perinatal deaths surveillance and response (MPDSR) is vital to reduce preventable deaths. The study aimed to assess implementation of MPDSR in Rwanda. We applied mixed methods following the six-step audit cycle for MPDSR to determine the level of implementation at 10 hospitals and three health centers. Results showed various stages of implementation of MPDSR across facilities. Maternal death audits were conducted regularly, and facilities had action plans to address modifiable factors. However, perinatal death audits were not formally done. Implementation was challenged by lack of enough motivated staff, heavy workload, lack of community engagement, no linkages with existing quality improvement efforts, no guidelines for review of stillbirths, incomplete medical records, poor classification of cause of death, and no sharing of feedback among others. Implementation of MPDSR varied from facility to facility indicating varying capacity gaps. There is need to integrate perinatal death audits with maternal death audits and ensure the process is part of other quality improvement initiatives at the facility level. More efforts are needed to support health facilities to improve implementation of MPDSR and contribute to achieving sustainable development goal (SDG) 3.

scholarly journals Categorization of medical causes of maternal deaths and delays in care: Comparison between routine Maternal Death Surveillance and Response system and an obstetrician expert panel in Tanzania

2020 ◽  
Author(s):  
Ali Said ◽  
Mats Malqvist ◽  
Andrea B. Pembe ◽  
Siriel Massawe ◽  
Claudia Hanson
Keyword(s):  
World Health Organization ◽  
Maternal Death ◽  
Expert Panel ◽  
World Health ◽  
Cross Sectional ◽  
Maternal Deaths ◽  
Surveillance And Response ◽  
Cause Of Deaths ◽  
Health Organization ◽  
Three Phases

Abstract Background To reduce high maternal mortality Tanzania introduced Maternal Death Surveillance and Response (MDSR) system in 2015 as recommended by World Health Organization. All health facilities are supposed to identify, notify and review all maternal deaths inorder to recommend quality improvement actions to prevent deaths in future. The system relies on consistent and correct categorization of causes of maternal deaths and three phases of delays. To assess its adequacy we compared the routine MDSR categorization of cause of deaths and care delays with those assigned by an obstetrician expert panel with additional information from Verbal Autopsy (VA). Methods Our cross-sectional study included 109 reported and reviewed maternal deaths from two regions in Tanzania for the year 2018. We abstracted the recorded underlying medical cause of death and reported delays of care from MDSR system records. We interviewed bereaved families using the standard World Health Organization VA questionnaire. The obstetrician expert panel assigned underlying medical cause of deaths based on information from medical files and VA according to International Classification of Disease to Death in Pregnancy Childbirth and Puerperium (ICD-MM).They assigned causes to nine ICD-MM groups and identified the three phases of delays. We used Cohen`s K statistic and proportional differences to compare causes of deaths and delays in care categorization. Results Ten deaths were excluded in analysis of underlying medical causes and 25 for delays. Expert panel and MDSR system assigned same underlying medical cause for 64.6% of deaths, K statistic 0.60. The agreement increased (80.8%) when causes were assigned by ICD-MM groups, K statistic 0.76. The obstetrician expert panel identified phase one delays in 67.9%, phase two in 22.0% and phase three delays in 100% of the deaths while MDSR system identified delays in 50.0%, 11.9% and 92.9% respectively. The expert panel found human errors in management in 93.1% while MDSR system reported in 67.9% of deaths. Conclusion The MDSR committees performed reasonably well in assigning the underlying cause of deaths. The obstetrician expert panel found more delays to care than what was reported in MDSR system indicating difficulties within MDSR teams to critically review.

Defining Preterm Birth and Stillbirth in the Western Pacific: A Systematic Review

2021 ◽  
pp. 101053952110260
Author(s):  
Mairead Connolly ◽  
Laura Phung ◽  
Elise Farrington ◽  
Michelle J. L. Scoullar ◽  
Alyce N. Wilson ◽  
...  
Keyword(s):  
Preterm Birth ◽  
National Level ◽  
Health Indicators ◽  
Western Pacific ◽  
World Health ◽  
Middle Income ◽  
Middle Income Countries ◽  
Definition Of ◽  
Health Organization ◽  
The Impact

Preterm birth and stillbirth are important global perinatal health indicators. Definitions of these indicators can differ between countries, affecting comparability of preterm birth and stillbirth rates across countries. This study aimed to document national-level adherence to World Health Organization (WHO) definitions of preterm birth and stillbirth in the WHO Western Pacific region. A systematic search of government health websites and 4 electronic databases was conducted. Any official report or published study describing the national definition of preterm birth or stillbirth published between 2000 and 2020 was eligible for inclusion. A total of 58 data sources from 21 countries were identified. There was considerable variation in how preterm birth and stillbirth was defined across the region. The most frequently used lower gestational age threshold for viability of preterm birth was 28 weeks gestation (range 20-28 weeks), and stillbirth was most frequently classified from 20 weeks gestation (range 12-28 weeks). High-income countries more frequently used earlier gestational ages for preterm birth and stillbirth compared with low- to middle-income countries. The findings highlight the importance of clear, standardized, internationally comparable definitions for perinatal indicators. Further research is needed to determine the impact on regional preterm birth and stillbirth rates.

scholarly journals Tuberculosis and Non-Communicable Disease Multimorbidity: An Analysis of the World Health Survey in 48 Low- and Middle-Income Countries

2021 ◽  
Vol 18 (5) ◽  
pp. 2439
Author(s):  
Brendon Stubbs ◽  
Kamran Siddiqi ◽  
Helen Elsey ◽  
Najma Siddiqi ◽  
Ruimin Ma ◽  
...  
Keyword(s):  
Health Survey ◽  
Low Income ◽  
World Health ◽  
Low Income Countries ◽  
Multivariable Logistic Regression Analysis ◽  
World Health Survey ◽  
Middle Income ◽  
Middle Income Countries ◽  
The World ◽  
Low And Middle Income

Tuberculosis (TB) is a leading cause of mortality in low- and middle-income countries (LMICs). TB multimorbidity [TB and ≥1 non-communicable diseases (NCDs)] is common, but studies are sparse. Cross-sectional, community-based data including adults from 21 low-income countries and 27 middle-income countries were utilized from the World Health Survey. Associations between 9 NCDs and TB were assessed with multivariable logistic regression analysis. Years lived with disability (YLDs) were calculated using disability weights provided by the 2017 Global Burden of Disease Study. Eight out of 9 NCDs (all except visual impairment) were associated with TB (odds ratio (OR) ranging from 1.38–4.0). Prevalence of self-reported TB increased linearly with increasing numbers of NCDs. Compared to those with no NCDs, those who had 1, 2, 3, 4, and ≥5 NCDs had 2.61 (95% confidence interval (CI) = 2.14–3.22), 4.71 (95%CI = 3.67–6.11), 6.96 (95%CI = 4.95–9.87), 10.59 (95%CI = 7.10–15.80), and 19.89 (95%CI = 11.13–35.52) times higher odds for TB. Among those with TB, the most prevalent combinations of NCDs were angina and depression, followed by angina and arthritis. For people with TB, the YLDs were three times higher than in people without multimorbidity or TB, and a third of the YLDs were attributable to NCDs. Urgent research to understand, prevent and manage NCDs in people with TB in LMICs is needed.

scholarly journals Maternal mortality in six low and lower-middle income countries from 2010 to 2018: risk factors and trends

2020 ◽  
Vol 17 (S3) ◽  
Author(s):  
Melissa Bauserman ◽  
Vanessa R. Thorsten ◽  
Tracy L. Nolen ◽  
Jackie Patterson ◽  
Adrien Lokangaka ◽  
...  
Keyword(s):  
Risk Factors ◽  
Maternal Mortality ◽  
Maternal Deaths ◽  
Middle Income ◽  
Maternal Risk ◽  
Live Births ◽  
Middle Income Countries ◽  
Risk Of Death ◽  
Increased Risk ◽  
Over Time

Abstract Background Maternal mortality is a public health problem that disproportionately affects low and lower-middle income countries (LMICs). Appropriate data sources are lacking to effectively track maternal mortality and monitor changes in this health indicator over time. Methods We analyzed data from women enrolled in the NICHD Global Network for Women’s and Children’s Health Research Maternal Newborn Health Registry (MNHR) from 2010 through 2018. Women delivering within research sites in the Democratic Republic of Congo, Guatemala, India (Nagpur and Belagavi), Kenya, Pakistan, and Zambia are included. We evaluated maternal and delivery characteristics using log-binomial models and multivariable models to obtain relative risk estimates for mortality. We used running averages to track maternal mortality ratio (MMR, maternal deaths per 100,000 live births) over time. Results We evaluated 571,321 pregnancies and 842 maternal deaths. We observed an MMR of 157 / 100,000 live births (95% CI 147, 167) across all sites, with a range of MMRs from 97 (76, 118) in the Guatemala site to 327 (293, 361) in the Pakistan site. When adjusted for maternal risk factors, risks of maternal mortality were higher with maternal age > 35 (RR 1.43 (1.06, 1.92)), no maternal education (RR 3.40 (2.08, 5.55)), lower education (RR 2.46 (1.54, 3.94)), nulliparity (RR 1.24 (1.01, 1.52)) and parity > 2 (RR 1.48 (1.15, 1.89)). Increased risk of maternal mortality was also associated with occurrence of obstructed labor (RR 1.58 (1.14, 2.19)), severe antepartum hemorrhage (RR 2.59 (1.83, 3.66)) and hypertensive disorders (RR 6.87 (5.05, 9.34)). Before and after adjusting for other characteristics, physician attendance at delivery, delivery in hospital and Caesarean delivery were associated with increased risk. We observed variable changes over time in the MMR within sites. Conclusions The MNHR is a useful tool for tracking MMRs in these LMICs. We identified maternal and delivery characteristics associated with increased risk of death, some might be confounded by indication. Despite declines in MMR in some sites, all sites had an MMR higher than the Sustainable Development Goals target of below 70 per 100,000 live births by 2030. Trial registration The MNHR is registered at NCT01073475.

scholarly journals Assessment of the core and support functions of the integrated disease surveillance and response system in Zanzibar, Tanzania

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Fatma Saleh ◽  
Jovin Kitau ◽  
Flemming Konradsen ◽  
Leonard E. G. Mboera ◽  
Karin L. Schiøler
Keyword(s):  
Infectious Disease ◽  
Early Detection ◽  
Disease Surveillance ◽  
Health Facilities ◽  
Outbreak Detection ◽  
World Health ◽  
Support Functions ◽  
The Core ◽  
Surveillance And Response ◽  
Facility Level

Abstract Background Disease surveillance is a cornerstone of outbreak detection and control. Evaluation of a disease surveillance system is important to ensure its performance over time. The aim of this study was to assess the performance of the core and support functions of the Zanzibar integrated disease surveillance and response (IDSR) system to determine its capacity for early detection of and response to infectious disease outbreaks. Methods This cross-sectional descriptive study involved 10 districts of Zanzibar and 45 public and private health facilities. A mixed-methods approach was used to collect data. This included document review, observations and interviews with surveillance personnel using a modified World Health Organization generic questionnaire for assessing national disease surveillance systems. Results The performance of the IDSR system in Zanzibar was suboptimal particularly with respect to early detection of epidemics. Weak laboratory capacity at all levels greatly hampered detection and confirmation of cases and outbreaks. None of the health facilities or laboratories could confirm all priority infectious diseases outlined in the Zanzibar IDSR guidelines. Data reporting was weakest at facility level, while data analysis was inadequate at all levels (facility, district and national). The performance of epidemic preparedness and response was generally unsatisfactory despite availability of rapid response teams and budget lines for epidemics in each district. The support functions (supervision, training, laboratory, communication and coordination, human resources, logistic support) were inadequate particularly at the facility level. Conclusions The IDSR system in Zanzibar is weak and inadequate for early detection and response to infectious disease epidemics. The performance of both core and support functions are hampered by several factors including inadequate human and material resources as well as lack of motivation for IDSR implementation within the healthcare delivery system. In the face of emerging epidemics, strengthening of the IDSR system, including allocation of adequate resources, should be a priority in order to safeguard human health and economic stability across the archipelago of Zanzibar.

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