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ITED REP

UNITED REPUBLIC OF TANZANIA

 
Ministry of Health and Social Welfare

CMT 04211 Health


Policy and Medical Ethics
NTA Level 4 Semester 2
Student Manual
 
 
 
 
 
 
 
 
 
 
 
 
 
 
August 2010  
 
 
   
Copyright © Ministry of Health and Social Welfare – Tanzania 2010

CMT 04211 Health Policy and Medical Ethics NTA Level 4 Semester 2 Student Manual
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Table of Contents

 
Acknowledgements .................................................................................................. iv 
Introduction .............................................................................................................. ix 
Abbreviations ........................................................................................................... xi 

Module Sessions
Session 1: National Health Policy..............................................................................1 
Session 2: National Health Guidelines ....................................................................11 
Session 3: National Guidelines for Management of HIV and AIDS and for
Prevention of Mother-to-Child Transmission of HIV .............................................31 
Session 4: National Health Guidelines for Malaria and for Collaborative
TB/HIV Activities ....................................................................................................37 
Session 5: Ethical Theories and Principles in Medical Practice ..............................43 
Session 6 : Confidentiality in Medical Practice .......................................................49 
Session 7 : Rights of the Client/Patient ...................................................................55 
Session 8: Rights of the Health Care Provider ........................................................61 
Session 9: Laws Related to Medical Practice ..........................................................65 
Session 10: Negligence in Medical Practice ............................................................71 
Session 11: Relationship Between Law and Confidentiality...................................77 
Session 12: Legal Issues Related To Consent in Medical Practice .........................83 

CMT 04211 Health Policy and Medical Ethics NTA Level 4 Semester 2 Student Manual
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Background and Acknowledgements
In April 2009, a planning meeting was held at Kibaha which was followed up by a Task
Force Committee meeting in June 2009 at Dodoma and developed a proposal which guided
the process of the development of standardised Clinical Assistant (CA) and Clinical Officer
(CO) training materials which were based on CA/CO curricula. The purpose of this process
was to standardize the entire curriculum with up-to-date content which would then be
provided to all Clinical Assistant and Clinical Officer Training Centres (CATCs/COTCs).
The perceived benefit was that, by standardizing the quality of content and integrating
interactive teaching methodologies, students would be able to learn more effectively and that
the assessment of students’ learning would have more uniformity and validity across all
schools.

In September 2009, MOHSW embarked on an innovative approach of developing the


standardised training materials through the Writer’s Workshop (WW) model. The model
included a series of three-week workshops in which pre-service tutors and content experts
developed training materials, guided by facilitators with expertise in instructional design and
curriculum development. The goals of WW were to develop high-quality, standardized
teaching materials and to build the capacity of tutors to develop these materials.

The new training package for CA/CO cadres includes a Facilitator Guide, Student Manual
and Practicum. There are 40 modules with approximately 600 content sessions. This product
is a result of a lengthy collaborative process, with significant input from key stakeholders and
experts of different organizations and institutions, from within and outside the country.

The MOHSW would like to thank all those involved during the process for their valuable
contribution to the development of these materials for CA /CO cadres. We would first like to
thank the U.S. Centers for Disease Control and Prevention’s Global AIDS Program
(CDC/GAP) Tanzania, and the International Training and Education Center for Health (I-
TECH) for their financial and technical support throughout the process. At CDC/GAP, we
would like to thank Ms. Suzzane McQueen and Ms. Angela Makota for their support and
guidance. At I-TECH, we would especially like to acknowledge Ms. Alyson Shumays,
Country Program Manager, Dr. Flavian Magari, Country Director, Mr. Tumaini Charles,
Deputy Country Director, and Ms. Susan Clark, Health Systems Director. The MOHSW
would also like to thank the World Health Organization (WHO) for technical and financial
support in the development process.

Particular thanks are due to those who led this important process: Dr. Bumi L.A.
Mwamasage, the Assistant Director for Allied Health Sciences Training, Dr. Mabula Ndimila
and Mr. Dennis Busuguli, Coordinators of Allied Health Sciences Training, Ministry of
Health and Social Welfare, Dr. Stella Kasindi Mwita, Programme Officer Integrated
Management of Adults and Adolescent Illnesses (IMAI), WHO Tanzania and Stella M.
Mpanda, Pre-service Programme Manager, I-TECH.

Sincere gratitude is expressed to small group facilitators: Dr. Otilia Gowele, Principal, Kilosa
COTC, Dr. Violet Kiango, Tutor, Kibaha COTC, Ms. Stephanie Smith, Ms. Stephanie
Askins, Julie Stein, Ms. Maureen Sarewitz, Mr. Golden Masika, Ms. Kanisia Ignas, Ms.
Yovitha Mrina and Mr. Nicholous Dampu, all of I-TECH, for their tireless efforts in guiding
participants and content experts through the process. A special note of thanks also goes to

CMT 04211 Health Policy and Medical Ethics NTA Level 4 Semester 2 Student Manual
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Dr. Julius Charles and Dr. Moses Bateganya, I-TECH’s Clinical Advisors, and other Clinical
Advisors who provided input. We also thank individual content experts from different
departments of the MOHSW and other governmental and non-governmental organizations,
including EngenderHealth, Jhpiego and AIHA, for their technical guidance.

Special thanks goes to a team of I-TECH staff namely Ms. Lauren Dunnington, Ms.
Stephanie Askins, Ms. Stephanie Smith, Ms Aisling Underwood, Golden Masika, Yovitha
Mrina, Kanisia Ignas, Nicholous Dampu, Michael Stockman and Stella M. Mpanda for
finalising the editing, formatting and compilation of the modules.

Finally, we very much appreciate the contributions of the tutors and content experts
representing the CATCs/COTCs, various hospitals, universities, and other health training
institutions. Their participation in meetings and workshops, and their input in the
development of content for each of the modules have been invaluable. It is the commitment
of these busy clinicians and teachers that has made this product possible.

These participants are listed with our gratitude below:

Tutors
Ms. Magdalena M. Bulegeya – Tutor, Kilosa COTC
Mr. Pius J.Mashimba – Tutor, Kibaha Clinical Officers Training Centre (COTC)
Dr. Naushad Rattansi – Tutor, Kibaha COTC
Dr. Salla Salustian – Principal, Songea CATC
Dr. Kelly Msafiri – Principal, Sumbawanga CATC
Dr. Joseph Mapunda - Tutor, Songea CATC
Dr. Beda B. Hamis – Tutor, Mafinga COTC
Col Dr. Josiah Mekere – Principal, Lugalo Military Medical School
Mr. Charles Kahurananga – Tutor, Kigoma CATC
Dr. Ernest S. Kalimenze – Tutor, Sengerema COTC
Dr. Lucheri Efraim – Tutor, Kilosa COTC
Dr. Kevin Nyakimori – Tutor, Sumbawanga CATC
Mr. John Mpiluka – Tutor, Mvumi COTC
Mr. Gerald N. Mngóngó –Tutor, Kilosa COTC
Dr. Tito M. Shengena –Tutor, Mtwara COTC
Dr. Fadhili Lyimo – Tutor, Kilosa COTC
Dr. James William Nasson– Tutor, Kilosa COTC
Dr. Titus Mlingwa – Tutor, Kigoma CATC
Dr. Rex F. Mwakipiti – Principal, Musoma CATC
Dr. Wilson Kitinya - Principal, Masasi ( Clinical Assistants Training Centre (CATC)
Ms. Johari A. Said – Tutor, Masasi CATC
Dr. Godwin H. Katisa – Tutor, Tanga Assistant Medical Officers Training Centre (AMOTC)
Dr. Lautfred Bond Mtani – Principal, Sengerema COTC
Ms Pamela Henry Meena – Tutor, Kibaha COTC
Dr. Fidelis Amon Ruanda – Tutor, Mbeya AMOTC
Dr. Cosmas C. Chacha – Tutor, Mbeya AMOTC
Dr. Ignatus Mosten – Ag. Principal, Tanga AMOTC
Dr. Muhidini Mbata – Tutor, Mafinga COTC
Dr. Simon Haule – Ag. Principal, Kibaha COTC
Ms. Juliana Lufulenge - Tutor, Kilosa COTC
Dr. Peter Kiula – Tutor, Songea CATC

CMT 04211 Health Policy and Medical Ethics NTA Level 4 Semester 2 Student Manual
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Mr. Hassan Msemo – Tutor, Kibaha COTC
Dr. Sangare Antony –Tutor, Mbeya AMOTC

Content Experts
Ms. Emily Nyakiha – Principal, Bugando Nursing School, Mwanza
Mr. Gustav Moyo - Registrar, Tanganyika Nursesand Midwives Council, Ministry of Health
and Social Welfare (MOHSW).
Dr. Kohelet H. Winani - Reproductive and Child Health Services, MOHSW
Mr. Hussein M. Lugendo – Principal, Vector Control Training Centre (VCTC), Muheza
Dr. Elias Massau Kwesi - Public Health Specialist, Head of Unit Health Systems Research
and Survey, MOHSW
Dr. William John Muller - Pathologist, Muhimbili National Hospital (MNH)
Mr. Desire Gaspered - Computer Analyst, Institute of Finance Management (IFM), Dar es
Salaam
Mrs. Husna Rajabu - Health Education Officer, MOHSW
Mr. Zakayo Simon - Registered Nurse and Tutor, Public Health Nursing School (PHNS)
Morogoro
Dr. Ewaldo Vitus Komba - Lecturer, Department of Internal Medicine, Muhimbili University
of Health and Allied Sciences School (MUHAS)
Mrs. Asteria L.M. Ndomba - Assistant Lecturer, School of Nursing, MUHAS
Mrs. Zebina Msumi - Training Officer, Extended programme on Immunization (EPI),
MOHSW
Mr. Lister E. Matonya - Health Officer, School of Environmental Health Sciences (SEHS),
Ngudu, Mwanza.
Dr. Joyceline Kaganda - Nutritionist, Tanzania Food and Nutrition Centre (TFNC),
MOHSW.
Dr. Suleiman C. Mtani - Obstetrician and Gynecologist, Director, Mwananyamala Hospital,
Dar es salaam
Mr. Brown D. Karanja - Pharmacist, Lugalo Military Hospital
Mr. Muhsin Idd Nyanyam - Tutor, Primary Health Care Institute (PHCI), Iringa
Dr. Judith Mwende - Ophthalmologist, MNH
Dr. Paul Marealle - Orthopaedic and Traumatic Surgeon, Muhimbili Orthopedic Institute
(MOI),
Dr. Erasmus Mndeme - Psychiatrist, Mirembe Refferal Hospital
Mrs. Bridget Shirima - Nurse Tutor (Midwifery), Kilimanjoro Chrician Medical Centre
(KCMC)
Dr. Angelo Nyamtema - Tutor Tanzania Training Centre for International Health (TTCIH),
Ifakara.
Ms. Vumilia B. E. Mmari - Nurse Tutor (Reproductive Health) MNH-School of Nursing
Dr. David Kihwele - Obs/Gynae Specialist, and Consultant
Dr. Amos Mwakigonja – Pathologist and Lecturer, Department of Morbid Anatomy and
Histopathology, MUHAS
Mr. Claud J. Kumalija - Statistician and Head, Health Management Information System
(HMIS), MOHSW
Ms. Eva Muro, Lecturer and Pharmacist, Head Pharmacy Department, KCMC
Dr. Ibrahim Maduhu - Paediatrician, EPI/MOHSW
Dr. Merida Makia - Lecturer Head, Department of Surgery, MNH
Dr. Gabriel S. Mhidze - ENT Surgeon, Lugalo Military Hospital
Dr. Sira Owibingire - Lecturer, Dental School, MUHAS
Mr. Issai Seng’enge - Lecturer (Health Promotion), University of Dar es Salaam (UDSM)

CMT 04211 Health Policy and Medical Ethics NTA Level 4 Semester 2 Student Manual
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Prof. Charles Kihamia - Professor, Parasitology and Entomology, MUHAS
Mr. Benard Konga - Economist, MOSHW
Dr. Martha Kisanga - Field Officer Manager, Engender Health, Dar es Salaam
Dr. Omary Salehe - Consultant Physician, Mbeya Referral Hospital
Ms Yasinta Kisisiwe - Principal Nursing Officer, Health Education Unit (HEU), MOHSW
Dr. Levina Msuya - Paediatrician and Principal, Assistant Medical Officers Training Centre
(AMOTC), Kilimanjaro Christian Medical Centre (KCMC)
Dr. Mohamed Ali - Epidemiologist, MOHSW
Mr. Fikiri Mazige - Tutor, PHCI-Iringa
Mr. Salum Ramadhani - Lecturer, Institute of Finance Management
Ms. Grace Chuwa - Regional RCH Coordinator, Coastal Region
Mr. Shija Ganai - Health Education Officer, Regional Hospital, Kigoma
Dr. Emmanuel Suluba - Assistant Lecturer, Anatomy and Histology Department, MUHAS
Mr. Mdoe Ibrahim - Tutor, KCMC Health Records Technician Training Centre
Mr. Sunny Kiluvia - Health Communication Consultant, Dar es Salaam
Dr. Nkundwe Gallen Mwakyusa - Ophthalmologist, MOHSW
Dr. Nicodemus Ezekiel Mgalula -Dentist, Principal Dental Training School, Tanga
Mrs. Violet Peter Msolwa - Registered Nurse Midwife, Programme Officer, National AIDS
Control Programme (NACP), MOHSW
Dr. Wilbert Bunini Manyilizu - Lecturer, Mzumbe University, Morogoro

Editorial Review Team


Dr. Kasanga G. Mkambu - Obstertric and Gynaecology specialist, Tanga Assistant Medical
Officers Training Centre (AMOTC)
Dr. Ronald Erasto Msangi - Principal, Bumbuli COTC
Mr. Sita M. Lusana - Tutor, Tanga Environmental Health Science Training Centre
Mr. Ignas Mwamsigala - Tutor (Entrepreneurship) RVTC Tanga
Mr. January Karungula - RN, Quality Improvement Advisor, Muhimbili National Hospital
Prof. Pauline Mella - Registered Nurse and Profesor, Hubert Kairuki Memorial University
Dr. Emmanuel A. Mnkeni – Medical Officer and Tutor, Kilosa COTC
Dr. Ronald E. Msangi - Principal, Bumbuli COTC
Mr. Dickson Mtalitinya - Pharmacist, Deputy Principal, St Luke Foundation, Kilimanjaro
School of Pharmacy
Dr. Janeth C. Njau - Paediatrician/Tutor, Kibaha COTC
Mr. Fidelis Mgohamwende - Labaratory Technologist, Programme Officer National Malaria
Control Programme (NMCP), MOHSW
Mr. Gasper P. Ngeleja - Computer Instructor, RVTC Tanga
Dr. Shubis M Kafuruki - Research Scientist, Ifakara Health Institute, Bagamoyo
Dr. Andrew Isack Lwali - Director, Tumbi Hospital

Librarians and Secretaries


Mr. Christom Aron Mwambungu - Librarian MUHAS
Ms. Juliana Rutta - Librarian MOHSW
Mr. Hussein Haruna - Librarian, MOHSW
Ms. Perpetua Yusufu - Secretary, MOHSW
Mrs. Martina G. Mturano -Secretary, MUHAS
Mrs. Mary F. Kawau - Secretary, MOHSW

CMT 04211 Health Policy and Medical Ethics NTA Level 4 Semester 2 Student Manual
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IT support
Mr. Isaac Urio - IT Consultant, I-TECH
Mr. Michael Fumbuka - Computer Systems Administrator – Institute of Finance and
Management (IFM), Dar es Salaam

 
Dr. Gilbert Mliga
Director of Human Resources Development, Ministry of Health and Social Welfare

CMT 04211 Health Policy and Medical Ethics NTA Level 4 Semester 2 Student Manual
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Introduction
Module Overview
This module content has been prepared to enhance learning of students of Clinical Assistant
(CA) and Clinical Officer (CO) schools.. The session contents are based on the sub-enabling
outcomes of the curricula of CA and CO. The module sub-enabling outcomes are as follows:
5.1.1 Provide Care According to Ethical Guidelines
5.1.2 Maintain Confidentiality in Medical Practice Including Disclosure of HIV and TB
5.1.3 Recognise Self and Patients/Clients Rights
5.1.4 Perform According to Legal Requirements
5.2.1 Operate within Boundaries of Client Service Charter
5.2.2. Recognize the National Health Policy and Policy Guidelines for Malaria, HIV and
AIDS, TB, Leprosy and Reproductive and Child Health services

Who is the Module For?


This module is intended for use primarily by students of CA and CO schools. The module’s
sessions give guidance on contents and activities of the session and provide information on
how students should follow the tutor when he/she teaches the module. It also provides
guidance and necessary information for students to read the materials on his/her own. The
sessions also include different activities which focus on increasing students’ knowledge,
skills and attitudes.

How is the Module Organized?


The module is divided into 12 sessions; each session is divided into several sections. The
following are the sections of each session:
• Session Title: The name of the session.
• Learning Objectives – Statements which indicate what the student is expected to have
learned at the end of the session.
• Session Content – All the session contents are divided into subtitles. This section
includes contents and activities with their instructions to be done during learning of the
contents.
• Key Points – Each session has a step which concludes the session contents near the end
of a session. This step summarizes the main points and ideas from the session.
• Evaluation – The last section of the session consists of short questions based on the
learning objectives to check if you understood the contents of the session. The tutor will
ask you as a class to respond to these questions; however if you read the session by
yourself try answering these questions to evaluate yourself if you understood the session.
• Handouts – Additional information which can be used in the classroom while the tutor is
teaching or later for your further learning. Handouts are used to provide extra information
related to the session topic that cannot fit into the session time. Handouts can be used by
the students to study material on their own and to reference after the session. Sometimes,
a handout will have questions or an exercise for students to answer.

How Should the Module be Used?


Students are expected to use the module in the classroom and clinical settings and during self
study. The contents of the modules are the basis for learning Health Policy and Medical
Ethics. Students are therefore advised to learn all the sessions including all relevant handouts
and worksheets during class hours, clinical hours and self study time. Tutors are there to
provide guidance and to respond to all difficulty encountered by students. One module will

CMT 04211 Health Policy and Medical Ethics NTA Level 4 Semester 2 Student Manual
ix
be assigned to 5 students and it is the responsibility of the tutor to do this assignment for easy
use and accessibility of the student manuals to students.

CMT 04211 Health Policy and Medical Ethics NTA Level 4 Semester 2 Student Manual
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Abbreviations
AMTSL Active Management of Third Stage of Labour
CHGC Council Hospital Governing Committee
CHMT Council Health Management Team
CHMT Council Health Management Team
CHSB Council Health Service Board
HMIS Health Management Information System
HRH Human Resources for Health
HSR Health Sector Reforms
HSSP III Health Sector Strategic Plan Three
ICT Information Communication Technology
ILO International Labour Organization
IMR Infant Mortality Rate
MCP Malaria Control Programme
MDGs Millennium Development Goals
MMR Maternal Mortality Rate
MNCH Maternal, Newborn and Child Health
NGOs Non-Governmental Organization
PHC Primary Health Care
PITC Provider Initiated Testing and counselling
PMORALG Prime Minister’s Office Regional Administration and Local Government
PMTCT Prevention of Mother To Child Transmission
PPH Post Partum Haemorrhage
PPP Public Private Partnerships
RHMT Regional Health Management Team
RRHB Regional Referral Hospital Boards
RRHMT Regional Referral Hospital Management Team
RTIs Reproductive Tract Infections
SOPs Standard Operating Procedures
UN United Nations
WHO World Health Organization

CMT 04211 Health Policy and Medical Ethics NTA Level 4 Semester 2 Student Manual
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CMT 04211 Health Policy and Medical Ethics NTA Level 4 Semester 2 Student Manual
xii
 Session 1: National Health Policy
Learning Objectives
By the end of this session, students are expected to be able to:
• Define health policy
• Explain the background of National Health Policy
• Describe objectives of the National Health Policy
• List health policy statements
• Link the National Health Policy with national and international initiatives

Definition of Terms
• Policy: Statement on how the government is to achieve its goals and objectives with
regard to a specific area such as health, education, agriculture. It can be described as a
deliberate plan of action to guide decisions and achieve rational outcome(s).
• Policy may also refer to the process of making important organizational decisions,
including the identification of different alternatives such as programs or spending
priorities, and choosing among them on the basis of the impact they will have.
• Health policy: A visionary program of action adopted by the government to have a
healthy society, with improved social wellbeing that will contribute effectively to
personal and national development.

Background of the Current National Health Policy


• The National Health Policy of 1990 was revised and approved in 2007.
• Ongoing socio-economic changes, new government directives, emerging and re-emerging
diseases and changes in science and technology necessitated updating the policy.
• The resource constraints (especially human resources) constitute the major problem for
not being able to cope adequately with health problems.
• The vision of the government is to have a healthy society, with improved social wellbeing
that will contribute effectively to personal and national development.
• The mission is to provide basic health services in accordance to geographical conditions,
which are of acceptable standards, affordable and sustainable.
• The health services will focus on those most at risk and will satisfy the needs of the
citizens in order to increase the lifespan of all Tanzanians.

Objectives of the National Health Policy


• The health services in Tanzania focus on those most at risk and satisfy the needs of the
citizens in order to increase the lifespan of all Tanzanians.
• Specifically the government aims to:
o Reduce morbidity and mortality in order to increase the lifespan of all Tanzanians by
providing quality health care
o Ensure that basic health services are available and accessible
o Prevent and control communicable and non-communicable diseases
o Sensitize the citizens about the preventable diseases
o Create awareness to individual citizen on his/her responsibility on his/her health and
health of the family

CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 1: National Health Policy 1
o Improve partnership between public sector, private sector, religious institutions, civil
society and community in provision of health services
o Plan, train, and increase the number of competent health staff
o Identify and maintain the infrastructures and medical equipment
o Review and evaluate health policy, guidelines, laws and standards for provision of
health services

Key Elements of the National Health Policy

Activity: Small Group Discussion

Instructions
You work in small manageable groups and use Tanzania National Health Policy Booklet
to identify the key elements of the National Health Policy. Your group will have 15
minutes to complete the task. One group will present their findings and other groups will
participate in discussion.

National Health Policy Statements


• The 2007 National Health Policy provides policy statements regarding provision of health
services in different areas.
• These policy statements are the key areas of focus for the National Health Policy, they
include the following:
o Preventive services: Control disease incidences and disability.
o Epidemics: Control communicable diseases, especially diseases coming from outside
the country.
o Non-communicable diseases: Promote healthier lifestyles and treat adequately
o Maternal and child health: Reduce maternal and child mortality in line with
Millennium Development Goals (MDGs).
o Reproductive health: Make services available, especially for youth and men.
o Primary health care: Make it accessible for all citizens.
o Health education and advocacy: Convey that every individual can improve his or her
health status.
o Environmental health: Promote a sustainable healthy environment for the whole
community.
o Occupational health: Protect and improve workers’ health status.
o Curative care: Deliver safe health care services to the community.
o Medicines and supplies: Ensure quality and availability of sufficient medicines and
supplies.
o Safe blood transfusion: Make safe blood available throughout the country
o Mental health: Promote mental health in the community and prevent illnesses.
o Traditional medicine and traditional midwifery
o Increase coordination and partnerships
o Cells and genome: Develop proper use of technology of genetic engineering.
o Control of food, medicines, etc.: Ensure goods are safe and meet defined standards.
o Diagnosis of diseases: Provide accurate diagnosis and forensic investigations.
o Quality improvement and standards: Attain agreed minimum standards.
o Coordination in health sector: Create participatory, transparent and sustainable system
for all stakeholders.
o Human resources development: Provide sufficient staff with required mix of skills.

CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 1: National Health Policy 2
Linkage of the National Health Policy with National and International
Initiatives

Vision 2025
• Tanzania Vision 2025 is a document providing direction and a philosophy for long-term
development.
• Tanzania wants to achieve by 2025, a high quality of livelihood for its citizens, peace,
stability and unity, good governance, a well-educated and learning society and a
competitive economy capable of producing sustainable growth and shared benefits.
• The document identifies health as one of the priority sectors contributing to a higher
quality livelihood for all Tanzanians.
• This is expected to be attained through strategies, which will ensure realisation of the
following health service goals:
o Access to quality primary health care for all
o Access to quality reproductive health service for all individuals of appropriate ages
o Reduction in infant and maternal mortality rates by three quarters of levels in 1998
o Universal access to clean and safe water
o Life expectancy comparable to the level attained by typical middle-income countries
o Food self sufficiency and food security
o Gender equality and empowerment of women in all health parameters

National Strategy for Growth and Reduction of Poverty (MKUKUTA)


• The MKUKUTA aims to foster greater collaboration among all sectors and stakeholders.
• It has mainstreamed cross-cutting issues (gender, environment, HIV and AIDS,
disability, children, youth, elderly, employment and settlements).
• All sectors are involved in a collaborative effort rather than segmented activities;
therefore this document is of crucial importance for the MOHSW strategies.
• The MKUKUTA seeks to increase ownership and inclusion in policy making through
addressing laws and customs that delay development and negatively affect vulnerable
groups.
• The strategy identifies three clusters of broad outcomes:
o Growth and reduction of income poverty
o Improvement of quality of life and social well-being
o Good governance
• Health is part of the second cluster listed above

Millennium Development Goals


• There are eight Millennium Development Goals (MDGs) to be achieved by 2015.
• These goals respond to the world's main development challenges.
• There are eight MDGs, 18 targets and 39 indicators. The eight goals are:
o Eradicate extreme poverty and hunger
o Achieve universal primary education
o Promote gender equality and empower women
o Reduce child mortality
o Improve maternal health
o Combat HIV and AIDS, malaria and other diseases
o Ensure environmental sustainability

Note: MDG Goals 4, 5 and 6 are specific to health.

CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 1: National Health Policy 3
Refer to Handout 1.1: MDGs and Health Sector Reforms

Health Sector Reforms


• Health Sector Reforms (HSR) started in 1994; the HSR is on-going and continuous.
• The aim of health sector reform is to improve access, quality and efficiency of health
service delivery systems.
• Primary health care is adopted as the most cost-effective strategy to improve the health of
the people.
• The major focus of the HSR is to strengthen the district health services, and strengthen
and re-orient secondary and tertiary service delivery in hospitals in support of primary
health care.
• HSR also aims at strengthening support services from the central level, in the MOHSW,
and in agencies and training institutions.
• The HSR introduced a programmatic approach, replacing the project approach, in order to
promote continuity of activities.
• Initially a work plan was developed that defines the priorities of the reforms; this was
replaced in 2003 by the Health Sector Strategic Plan (HSSP) II.

Primary Health Care (PHC)


• PHC (Primary Health Care) is a vision, first adopted in Alma Ata (1978) and recently
revived (WHO, 2008) as ‘PHC now more than ever’.
• PHC is not the same as primary level services. The main principles of PHC are (which
were the same in 1978 as they are today):
o Community participation
o Multi-sectoral action
o Appropriate technology
o Acceptability and affordability through focus on essential services that should be
available to all through fair sharing of the financial burden of illness.
• PHC reforms (2008) are comprised of four interlinking groups:
o Universal coverage reforms moving toward universal access and social health
protection
o Service delivery reforms reorganizing health services as primary care around people’s
needs and expectations
o Public policy reforms integrating public health actions (multi-sectoral approach) with
primary care and by pursuing healthy public policies across sectors
o Leadership reforms that replace the approaches of ‘command and control’ and laissez-
faire disengagement of the state, with a leadership style appropriate for the
complexity of contemporary health systems

Health Sector Strategic Plan Three (HSSP III)


• The MOHSW has developed a framework to reform the health sector in order to improve
the impact of health services at all levels in the country.
• The emphasis of the strategic health plan is on council health services, where most of the
essential health services are provided close to the communities, and on hospital services
to save lives of people who cannot be treated in first line health facilities.
• The thrust is to significantly improve the quality of essential health services, and to make
Council Health Management Teams (CHMTs), council health providers and hospital
management boards more accountable to the community.

CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 1: National Health Policy 4
• The Health Sector Strategic Plan III promotes delegation of authority.
o This means that the dispensaries, health centres and hospitals should be the key actors
in the planning process.
o It also means that they will be held responsible for implementing what they have
planned.
Refer to Handout 1.2: Strategies of Health Sector Strategic Plan III

• To improve health status of the people, the types of services described below are
emphasized.

Types of Services
• Health promotion
o This includes activities to increase behaviour change and to ensure that lifestyles of
individuals are conducive to personal development and environmental safety.
• Community participation and ownership
o These are the keys to success of the primary health service delivery programme.
• Preventive health services
o These prevent diseases by promoting optimal nutrition and control of infectious
disease transmission, reduce epidemics and improve working environments to
maintain the highest standards of occupational health.
• Care and treatment (curative services)
o These services correctly treat diseases and conditions to reduce complications or
death by improving quality and quantity of care to patients and ensuring availability
of basic services and supplies.
• Rehabilitation services
o These are services to patients such as physical rehabilitation, mental rehabilitation and
psychological support to vulnerable groups.
• Provision of care to the chronically ill and the elderly
o This includes catering for life-long treatment like hypertension, diabetes, AIDS
patients on ARVs, renal conditions, cancer and any other chronic conditions.

Levels in the Health Sector


• Council health services (in district or municipality), consisting of:
o Household and community health
o Dispensaries and health centres (public and private)
o District hospital and other hospitals (public and private)
• Regional health services, consisting of:
o Regional referral hospitals
o Regional health management teams
• National level services, consisting of:
o Specialized hospitals and special hospitals (public and private)
o Training institutions, Zonal Health Resource Centres (ZHRCs)
o Ministries, departments and agencies

Hospital Reforms
• Hospital reforms refer to:
o ‘A strategy to strengthen management systems, structures, values, methods and
capacity’

CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 1: National Health Policy 5
o ‘Introduction of quality improvement mechanisms in hospitals so that these reforms
are able to solve health care delivery problems themselves as well as improve quality
of health services provided in line with the ongoing health sector reforms’
• There has been growing concern that the services delivered at hospitals are not up to
expected standards.
• Therefore MOHSW over a period of time realized that there are various needs and
difficulties that are common to hospitals all over the country.
• The main areas of concern to address include:
o Inadequate planning
o Inadequate management and control of resources
o Inability to deliver the range and level of diagnostic and treatment services expected
from the hospitals
o Shortage of human resources and inappropriate mix of skills
o Low work morale
o Poor attitudes towards patients
o Inadequate funding for a long time which led to deterioration of equipment,
infrastructure and transport
o Poor preventive maintenance planning of hospital facilities and equipment

Objectives of the Hospital Reforms


• Overall objective: ‘delivery of quality health services and client satisfaction’
• Specific objectives are to:
o Develop annual hospital plans and budgets that are in line with National Planning
Guidelines
o Set supportive monitoring and accountability systems within the hospital structure
o Provide quality health services
o Establish effective committees in line with National Guidelines
o Manage health resources effectively
o Develop preventive maintenance mechanisms of hospital infrastructure

Structures in Support of the Hospital Reforms Process


• In support of the hospital reforms, the MOHSW in collaboration with the Prime
Minister’s Office Regional Administration and Local Government (PMORALG) has
agreed to form service provision support structures. These are:
o Council Health Service Board (CHSB)
o Council Health Management Team (CHMT)
o Council Hospital Governing Committee (CHGC)
o Regional Health Management Team (RHMT)
o Regional Referral Hospital Boards (RRHB)
o Regional Referral Hospital Management Team (RRHMT)

Key Points
• Health policy is a visionary program of action adopted by the government to have a
healthy society, with improved social wellbeing that will contribute effectively to
personal and national development.
• The mission of the government is to provide basic health services in accordance to
geographical conditions, which are of acceptable standards, affordable and sustainable.
• Health policy links with other national and international initiatives such as:
o Vision 2025

CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 1: National Health Policy 6
o National Strategy for Growth and Reduction of Poverty (NSGRP / MKUKUTA)
o Millennium Development Goals
o Primary Health Care (PHC)

Evaluation
• What is health policy?
• What are the objectives of the National Health Policy?
• What are the key elements of the National Health Policy?

References
• UNDP. (2005). A Practical Plan to Achieve the Millennium Development Goals;
Investing in Development’ Millennium Project. New York: United Nations Development
Programme.
• MOHSW. (2004). District Integrated Management Cascade. Dar es Salaam, Tanzania:
Ministry of Health and Social Welfare.
• MOHSW. (2008). Health Sector Strategic Plan (HSSP) III. Dar es Salaam, Tanzania:
Ministry of Health and Social Welfare.
• MOHSW. (2007). National Health Policy. Dar es Salaam, Tanzania: Ministry of Health
and Social Welfare.

CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 1: National Health Policy 7
Handout 1.1: MDGs and Health Sector Reforms

MDG Unfulfilled Health Sector Related Problems


MDG 1- Reduction of abject poverty Malnutrition, vitamin deficiencies and nutritional
and hunger anaemia and other micronutrient deficiency
conditions.
MDG 2 – Primary education Communicable diseases, intestinal worms and
associated early pregnancies, diarrhoeas,
Information/Education/Communication (IEC)
approach not effective without formal education. This
has a negative impact on child health and maternal
health as well.
MDG 3 – Empowerment of women HIV/AIDS, high maternal deaths, pregnancy-
(good governance indicator) associated illnesses, and malnutrition
MDG 4 – Reduction of child mortality High infant mortality rate, increase under five
(child health) mortality rate, frequent pregnancies to the mothers
after child death, increased MMRs
MDG 5 – Maternal health and reduction Increased mortalities, increased poverty and
of MMR malnutrition, HIV/AIDS transmission rate increased,
poor health of the children and orphans left behind
MDG 6 – HIV and AIDS, Malaria, TB Poverty, high morbidity and mortalities in all pop-
& ther diseases. groups, Increased IMR, increased under 5 MR,
Increased MMR, overburdening of the health care
delivery systems
MDG 7 – Environmental, water and Malaria, Onchocerciasis, cholera, typhoid, diarrhoea,
sanitation, personal hygiene trachoma, intestinal worms, Filariasis and all other
water-born, water-based and water related conditions
including skin infections increased
MDG 8 – International relations and Under-funding, under-human resourced, under-
donor coordination managed, reduction of inputs to the health system,
under-governed. (common characteristics of heavily
indebted poor countries [HIPC])

CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 1: National Health Policy 8
Handout 1.2: Strategies of Health Sector Strategic Plan III

The MOHSW has identified eleven strategies which the health sector should achieve during
the period of implementation:

Strategy 1: District Health Services


1. Increase accessibility to health services based on equity and gender balanced needs
2. Improve quality of health services

Strategy 2: Referral Hospital Services


1. Increase access for patients in need of advanced medical care
2. Improve quality of clinical services in hospitals

Strategy 3: Central Support


1. Enhance decentralisation of MOHSW headquarters
2. Strengthen governance in the MOHSW
3. Strengthen the operational planning process of MOHSW headquarters
4. Institutionalise traditional and alternative health practice in the established health
sector

Strategy 4: Human Resources for Health (HRH)


1. Develop policies and regulations on human resources for health & social welfare,
coherent with government policies
2. Strengthen HRH planning
3. Maximise effective utilisation of HRH
4. Increase production and improve quality of training (pre-service, in-service and
continuous education) with support of ZHRCs
5. Improve use of HRC applied research for planning and advocacy

Strategy 5: Health Care Financing


1. Reduce the budget gap in the health sector by mobilising adequate and sustainable
financial resources
2. Enhance complementary financing for provision of health services, increasing the
share in the total health budget to 10% by 2015
3. Improve equity of access to health services
4. Improve management of complementary funds raised at local level
5. Increase efficiency and effectiveness in use of financial resources

Strategy 6: Public Private Partnerships (PPP)


1. Ensure conducive policy and legal environment for operationalisation of the PPP
2. Ensure effective operationalisation of PPP
3. Enhance PPP in the provision of health and nutrition services

CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 1: National Health Policy 9
Strategy 7: Maternal, Newborn and Child Health
1. Increase access to Maternal, Newborn and Child Health (MNCH) services
2. Strengthen the health systems to provide quality MNCH and nutrition services

Strategy 8: Disease Prevention and Control


1. Improve disease surveillance of communicable and non-communicable diseases
2. Enhance community participation in health promotion and disease prevention
3. Improve disease case management in health facilities through integrated disease
control activities at health facility level
4. Improve home-based treatment and care

Strategy 9: Emergency Preparedness and Response


1. Establish systems at all levels for immediate emergency response to health disasters
and disasters leading to health problems

Strategy 10: Social Welfare and Social Protection


1. To operationalise the Social Welfare Strategic Plan (2008)
2. To integrate social welfare and health offices at regional and council level
3. To ensure gender-sensitive socio-economic wellbeing and to establish an efficient
4. system for delivery of social welfare services
5. To improve social protection in the community

Strategy 11: Monitoring & Evaluation (M&E) and Research


1. To develop a comprehensive M&E and research strategy for the health and social
welfare sector
2. Strengthen integrated systems for disease surveillance
3. Strengthen integrated routine HMIS
4. Introduce data aggregation and sharing systems based on ICT
5. Enhance surveys and operational research

CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 1: National Health Policy 10
 Session 2: National Health Guidelines
Learning Objectives
By the end of this session, students are expected to be able to:
• Define policy guideline
• List different national health policy guidelines
• Describe objectives of different health policy guidelines

Definition of the Health Policy Guidelines


• Guideline: Any document that aims to streamline particular processes according to a set
routine.
• A guideline can also be defined as a protocol to follow when performing a certain
activity.
• Guidelines may be issued by and used by any organization (governmental or private) to
make the actions of its employees or divisions more focused and of high quality.

Overview of the Health Policy Guidelines


• Guidelines are intended to provide directions to supervisors, and service providers who
are responsible for provision of health services in different health facilities within society.
• They assist in monitoring and evaluation of services at all levels and also assist trainers to
set training priorities, identify resources and formulate training strategies and plans based
on needs at various levels.
• Guidelines help supervisors in allocating resources among alternative needs.
• The guidelines are developed to accommodate advance and approaches to alleviate the
burden of diseases.
• Guidelines demonstrate collaboration and linkages between inpatient and community
based management and provide guidance on how health care providers from both sides
will work together.
• Health policy guidelines provide standard operating procedures (SOPs) in the delivery of
health services so that as many Tanzanians as possible have access to quality services.

Application of the Guidelines


• The developed guidelines are aimed at improving service delivery at different levels in
health facilities and the community at large.
• The users (target group) of these guidelines are:
o The medical staff members responsible for providing health care services at all levels
in public or private health care facilities
o National policy makers (MOHSW and PMORALG), Regional and District Health
Management Teams (RHMTs and CHMTs), responsible for developing implementing
and evaluating the Health Care Waste Management Plans at Central, Regional and
District Levels
o Members of training and research institutions
o International organizations and Non-Governmental Organizations (NGOs) involved in
the funding and technical support to health care services in Tanzania

CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 2: National Health Guidelines 11
Description of Different Health Guidelines
• Aiming at improving health services delivery within the country; various guidelines have
been formulated by the Ministry of Health and Social Welfare to guide health work
providers and other high authority in planning and decision making.

National Guideline for Screening and Treatment of Syphilis during Pregnancy


• Have been developed by MOHSW with the purpose of providing health service providers
with guiding principles on how screening and treatment of syphilis in pregnancy should
be done throughout the country.

Refer to Handout 2.1: Summary of National Guideline for Screening and


Treatment of Syphilis During Pregnancy

National Guideline on Management of Acute Malnutrition


• The guidelines have been developed to accommodate recent advances and approaches to
alleviate the burden of diseases associated with malnutrition and to contribute to the
reduction of morbidity and mortality in infants and children under five years in Tanzania.
• Studies have revealed that children suffering from severe malnutrition have 5 to 20 times
higher risk of death compared to well-nourished children.
• Severe acute malnutrition can be a direct cause of child death, or it can act as an indirect
cause by dramatically increasing the case fatality rate in children suffering from common
childhood illness such as pneumonia and diarrhoea.

Refer to Handout 2.2: Summary of Management of Acute Malnutrition National


Guideline

National Guidelines for Reproductive and Child Health Communication Strategy


• The purpose of the guideline is to outline the strategic framework for a unified
reproductive and child health communication strategy that will also contribute to the
implementation of the national reproductive health and child survival strategy and the
national population policy.
• The reproductive and child health strategy, among other things, advocates action towards
the reduction in maternal and child mortality and morbidity, provision of quality
reproductive health services, provision of IEC and counselling, male participation, control
of STIs including HIV and AIDs and operational research.

Guidelines for Use of Uterotonics in Active Management of Third Stage of Labour


• The key elements in this guideline are postpartum haemorrhage, available uterotonics for
active management of third stage of labour (AMTSL), treatment and prevention of post
partum haemorrhage (PPH).

Refer to Handout 2.3: Summary of National Guidelines for more information on


RCH and Use of Uterotonics in Active Management of Third Stage of Labour

CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 2: National Health Guidelines 12
National Guidelines for the Management of HIV and AIDS
• The National Guidelines for Clinical Management of HIV and AIDS; was produced only
a few years ago. However, recent developments and experience in the field of HIV and
AIDS care and treatment has made it necessary for the country to come up with another
edition of these guidelines, to reflect the changes that have taken place.
• This will help to improve the quality of care and treatment of HIV and AIDS has been
expanded to give clinicians more flexibility in providing quality care.

National Guidelines for Prevention of Mother to Child Transmission (PMTCT)


• The National Guidelines for PMTCT of HIV summarize national recommendation for
delivery of prevention of mother to child transmission programme services.
• They are intended to promote and support the delivery of quality HIV prevention, care,
and treatment and support services.

Refer to Handout 2.4: Summary of National Guidelines for more information on


Management of HIV and AIDS and PMTCT

National Guidelines for Voluntary Counselling and Testing (VCT)


• The National Voluntary Counselling and Testing Guidelines have been developed to
provide VCT service providers and managers with a framework within which to operate
and for clients to be informed of their rights.
• The guideline provides standard operating procedures (SOPs) in the delivery of VCT so
that as many Tanzanians as possible have access to quality VCT services.

Guidelines for HIV Testing and Counselling in Clinical Settings


• Provider Initiated Testing and Counselling (PITC) refers to HIV testing and counselling
which is recommended by health care providers to persons attending health care facilities
as a standard component of medical care.
• The major purpose of such testing and counselling is to enable specific decisions to be
made and/or specific medical services to be offered that will not be possible without
knowledge of the person’s HIV status.

Refer to Handout 2.5: Summary of National Guidelines for more information on


Voluntary Counselling and Testing (2005) and Provider Initiated Testing and Counselling
guidelines

National Infection Prevention and Control (IPC)


• The material in this infection prevention and control pocket guide is divided into topics.
• Each topic stands on its own. The topics are arranged in such a way that the reader needs
to know some basic IPC principles.
• The first principle of IPC is ‘The disease transmission cycle’. This is described briefly
under standard precautions.

Health Care Waste Management National Policy


• These guidelines have been developed by MOHSW to ensure proper handling and
treatment of health care waste at different levels in health facilities and the community at
large.
 

CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 2: National Health Guidelines 13
Refer to Handout 2.6: Summary of National Guidelines for more information on
Infection Prevention and Control (IPC) and Health Care Waste Management guidelines

Guidelines for Home Based Care (HBC) Services in Tanzania


• HBC services are being developed to initiate the impact of increased morbidity and
mortality from HIV and AIDS and other chronic illness.
• Family members will be expected to play a major role in provision of HBC services.

Guidelines for the Management of Malaria for Health Service Providers


• The goal of appropriate malaria diagnosis and treatment is to reduce morbidity, mortality
and socio-economic losses, thus, the guideline for diagnosis and treatment of malaria
aims at promoting prompt, effective and safe treatment of malarial disease at health centre
and dispensary levels.

Refer to Handout 2.7: Summary of National Guidelines for more information on


Home Based Care Service and Management of Malaria for Health Service Providers
guidelines

National Guidelines for Management of Sexually Transmitted and Reproductive Tract


Infections
• Effective management of STIs and RTIs is one of the cornerstones of their control, as it
prevents the development of complication and recurrence, decreases the spread of those
infections and HIV in the community and offers a unique opportunity for targeted
education about reproductive health.
• Among others, the objective of the guideline is to recommend prevention and care
practices for clients who have or may be at risk of acquiring STIs/RTIs.

 Refer to Handout 2.8: Summary of National Guidelines for Management of


Sexually Transmitted and Reproductive Tract Infections

National Guidelines for Management of HIV and AIDS for Frontline Workers
• This document is intended to provide guidelines for health care workers on various
aspects of care and support.
• Frontline workers include health care workers involved in the provision of nursing care,
treatment of opportunistic infections, prevention of transmission of the infection,
counselling and care during pregnancy, labour and postnatal period.
• The document also contains a section on continuum of care which emphasizes the
delivery of comprehensive care at home at various levels of health care system.

National Policy Guidelines for Collaborative TB/HIV Activities


• TB and HIV and AIDS pose significant global public health problems. TB and HIV are
overlapping epidemics. Both have been declared global emergencies demanding global
attention.
• The World Health Organization (WHO) declared TB to be a global emergency in 1993,
and the United Nations (UN) declared HIV and AIDS to be a global emergency in 2001.
UN member countries and other international organizations have committed themselves
to addressing the TB and HIV/AIDS crises with urgency.

CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 2: National Health Guidelines 14
• But efforts to address the two problems have been carried out separately, resulting in an
inadequate global impact on the dual epidemics. The guideline is aimed at providing
guidance in collaborative TB/HIV activities.
• The policy stated the objectives of collaborative TB/HIV activities as follows:
o To establish the mechanisms for collaboration between TB and HIV and AIDS
programmes.
o To reduce the burden of TB in people living with HIV and AIDS.
o To reduce the burden of HIV in TB-infected patients.

Refer to Handout 2.9: Summary of National Guidelines for more information on


Management of HIV and AIDS for Frontline Workers and Policy Guidelines for
Collaborative TB/HIV Activities

Key Points
• Guidelines are an essential part of the larger process of governance.
• These are standards, protocols, and procedures that govern day-to-day operations of an
organization and that determine who provides what care to which clients.

Evaluation
• What is a guideline?
• Mention at least five national health guidelines for Tanzania.
• If you have a patient in your ward and you want to perform an HIV test, which
Guideline(s) will you refer to?

References
• MOHSW. (2004). National guidelines for Screening and Treatment of Syphilis during
Pregnancy. Dar es Salaam, Tanzania: Ministry of Health and Social Welfare.
• MOHSW. (2005). Management of Acute Malnutrition National Guidelines. . Dar es
Salaam, Tanzania: Ministry of Health and Social Welfare.
• MOHSW. (2008). Guidelines for use of Uterotonics in Active Management of 3rd Stage of
labour. . Dar es Salaam, Tanzania: Ministry of Health and Social Welfare.
• NACP. (2009). National Guidelines for the Management of HIV and AIDS, 3rd Edition.. .
Dar es Salaam, Tanzania: Ministry of Health and Social Welfare, National AIDS Control
Programme.
• NACP. (2007). National Guideline of Prevention of Mother-To-Child Transmission of
HIV. Dar es Salaam, Tanzania: Ministry of Health and Social Welfare, National AIDS
Control Programme.
• NACP. (2005). National Guidelines for Voluntary Counselling and Testing. Dar es
Salaam, Tanzania: Ministry of Health and Social Welfare, National AIDS Control
Programme.
• MOHSW. (2007). National Infection Prevention and Control Guidelines for Healthcare
Services in Tanzania. . Dar es Salaam, Tanzania: Ministry of Health and Social Welfare.
• NACP. (1999). Guidelines for Home Based Care Services in Tanzania. Dar es Salaam,
Tanzania: Ministry of Health and Social Welfare, National AIDS Control Programme.
• MOHSW. (2006). Healthcare Waste Management National Policy Guideline, Health
Education Unit. . Dar es Salaam, Tanzania: Ministry of Health and Social Welfare.

CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 2: National Health Guidelines 15
• NACP. (2007). Guidelines for HIV Testing and Counselling in Clinical Setting.Dar es
Salaam, Tanzania: Ministry of Health and Social Welfare, National AIDS Control
Programme.
• MOHSW. (2006). Guidelines for the Management of Malaria for Health Service
Provider. MCP. Dar es Salaam.
• NACP. (2007). National guidelines for Management of Sexually Transmitted and
Reproductive Tract Infections, 1st Edition. Dar es Salaam, Tanzania: Ministry of Health
and Social Welfare, National AIDS Control Programme.
• NACP. (2003). Guidelines for Management of HIV/AIDS for Frontline Workers. Dar es
Salaam, Tanzania: Ministry of Health and Social Welfare, National AIDS Control
Programme.
• NACP/NTLP. (2008). Nation Policy Guidelines for Collaborative TB/HIV Activities. Dar
es Salaam, Tanzania: Ministry of Health and Social Welfare, National AIDS Control
Programme/National TB/ and Leprosy Control Program.

CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 2: National Health Guidelines 16
Handout 2.1: Summary of National Guideline for Screening
and Treatment of Syphilis During Pregnancy

Overview
The national guidelines for screening and treatment of syphilis in pregnancy have been
developed by MOHSW with the purpose of providing health service provider with guiding
principles on how screening and treatment of syphilis in pregnancy should be done over the
country. Sexually transmitted infections (STIs) are of public health importance because are
highly preventable; cause considerable morbidity, consume resources to manage and are
know to facilitate sexual transmission of Human Immunodeficiency Virus (HIV)

Definition
Syphilis is a sexually transmitted disease caused by a spirochete called Treponema pallidum.
Transmission can also occur through blood transfusion and vertically from a pregnant mother
to the foetus. It can also be acquired through contact with blood contaminated materials. The
infection is systemic from the outset, capable of involving every organ of the body.
Clinically, syphilis can be staged as primary, secondary, latent and tertiary syphilis. Signs and
symptoms of primary syphilis occur from 10-90 days after the initial exposure, while those of
secondary syphilis may occur 1-6 months after the primary infection. In latent syphilis, there
is infection but no signs or symptoms of the disease. Latent syphilis is divided into early and
late latent syphilis. Early latent syphilis refers to having syphilis (but no signs or symptoms)
for 2 years or less, while late latent syphilis refers to having syphilis for more than 2 years.
Signs and symptoms of tertiary syphilis may occur from 1-10 years after the initial infection
although in some cases it may take up to 50 years.

Rationale for the guidelines


Despite the fact that syphilis screening and treatment is being implemented in Tanzania, this
has been limited in terms of coverage and quality. However, there is an urgent need to expand
and strengthen this service throughout the country in a standardized manner and ensure high
quality service. These guidelines are intended to provide directions to supervisors and service
providers who are responsible for provision of syphilis screening and treatment to pregnant
women. However, because pregnant women may have other health problems besides syphilis,
these guidelines should be used alongside other guidelines, which may be available or
developed.

Key Elements for Management of Syphilis in Pregnancy


The following elements should be observed when implementing a syphilis screening and
treatment programme:
• Universal screening of syphilis in pregnancy offered to all pregnant women.
• All health facilities providing ANC services should offer this and other essential services.
• Early screening at booking should preferably be done early in the first trimester during
the first visit.
• Onsite services: Preferably, all efforts should be made to do syphilis screening 'on-site’
with the use of a rapid and simple test.
• Use of rapid tests: The use of rapid tests for screening is encouraged so that results and
treatment can be obtained on the same day.
• Pre and post-test counseling should be provided to all clients.

CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 2: National Health Guidelines 17
• Promotion of ANC services: All ANC services including syphilis screening and treatment
should be provided as an integrated comprehensive package.

Objectives of the Guidelines


The objectives of these guidelines are to:
• Provide guidance to all health service providers working in ANC and dealing with
syphilis screening and treatment at all levels countrywide.
• Assist health planners in planning and designing of syphilis screening and treatment
programmes/activities, set service objectives and identify required resources.
• Assist service providers in identifying and ensuring key commodities such as screening
tests and appropriate antibiotics are budgeted for and available to implement the program.
• Assist them in monitoring and evaluation of these services at all levels.
• Assist trainers to set training priorities, identify resources and formulate training
strategies and plans based on needs at various levels.
• Help supervisors in allocating resources and use it as a monitoring tool.

Guideline Contents
The guideline is composed of key components included in the process of managing syphilis
in pregnancy. These components include:
• Health education
• Management of syphilis in pregnancy
• Training and capacity building
• Logistic support
• Supportive supervision
• Monitoring and evaluation

CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 2: National Health Guidelines 18
Handout 2.2: Summary of Management of Acute Malnutrition
National Guideline

Overview
• The guidelines have been developed to accommodate recent advance and approaches to
alleviate the burden of diseases associated with malnutrition and to contribute to the
reduction, in infant and under five morbidity and mortality in Tanzania.
• Studies have revealed that children suffering from severe malnutrition have 5 to 20 time’s
higher risk of death compared to well-nourished children.
• Severe acute malnutrition can be a direct cause of child death, or it can act as an indirect
cause by dramatically increasing the case fatality rate in children suffering from common
childhood illness such as pneumonia and diarrhoea.
• The 55th World Health Assembly endorsed the global strategy for infant and young child
feeding, which recommends actively searching for malnourished infants and young
children so that they can be identified and treated.
• The development of the community-based approaches for the management of severe
acute malnutrition provides a new impetus for putting this recommendation into practice.
• Therefore this approach, along with preventive action is added to the list of interventions
to reduce infant and child mortality the vision of Tanzania by 2025.
• The guidelines in this document address the management of acute malnutrition, in the
community and in health facilities throughout the country depending on the degree of
severity and associated complications. These will provide a framework for the proper
management of acute malnutrition in Tanzania.

Nutrition Situation in Tanzania


• Infant and child mortality remains high in Tanzania. The under five child mortality rate is
(12 per 1000 live birth and the infant mortality rate is 68 per 1000 live births. Source:
TDHS 2004-2005).
• One out of nine children in Tanzania dies before his/her fifth birthday. Around 53% of
under five childhood morbidity are associated with malnutrition (UNICEF, 2006).

Objective
The ultimate goal of the guidelines is to reduce child mortality in Tanzania by giving
clear guidance on improving the quality of the management of acute malnutrition in
the light of new scientific evidence and technological advances.

Specific Objectives
• Provide practical, task-orientated guidance to health care providers involved in the in-
patient management of severe acute malnutrition in health facilities.
• Provide practical guidance to health care providers working at grass-root levels to engage
and equip communities to treat moderate acute malnutrition and uncomplicated cases of
severe acute malnutrition within the community.
• Demonstrate collaboration and linkages between inpatient and community based
management and provide guidance on how health care providers from both sides will
work together.
• Describe how inpatient and community-based management will be implemented within
the existing health system in Tanzania.

CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 2: National Health Guidelines 19
• Describe the provisions that are necessary to support the above strategy including
procurement, logistics and storage, and how these will be made available.
• Provide guidance to health care providers to monitor and evaluate the implementation of
the strategy to ensure a continuous process of learning and improvement.

Components Included in this Guideline


• Intergrated management of acute malnutrition; this will take place both in communities
and inpatient health facilities
• Management of acute malnutrition at health care facilities
• Community-based management of acute malnutrition
• Procurement, storage and logistics
• Coordination and implementation

CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 2: National Health Guidelines 20
Handout 2.3: Summary of National Guidelines for:
A. RCH
B. Use of Uterotonics in Active Management of Third Stage of
Labour

Guideline A: Reproductive and Child Health Communication Strategy


• Tanzania is experiencing a high population growth that has led to a relatively young
population. Population projection for the year 2000 and 2010 indicate that the population
of Tanzania is around 33 and 43 million, respectively.
• The purpose of this document is to outline the strategic framework for a unified
reproductive and child health communication strategy that will also contribute to the
implementation of the national reproductive health and child survival strategy and the
national population policy.
• The reproductive and child health strategy among other things, advocates action towards
the reduction.
• In maternal and child mortality and morbidity, provision of quality reproductive health
services, IEC and counselling, male participation, control of STIs including HIV and
AIDS, and operational research.

Rationale
• For a number of years, the government has been the main provider of health services in
the country. Most of the planning and management of health issues where done at the
central level through vertical programmes.
• This encouraged a cumbersome and fragmented management hierarchy of health-service
delivery including those for reproductive and child health.
• Another rationale for strategy is the lack of integrated RCH communication, strategies,
which could be used by the government, private sector and NGOs.

Key Elements
The RCH Progamme in Tanzania will focus on five thematic areas, namely:
• Maternal health
• Family planning (FP)
• Adolescent Reproductive Health (ARH)
• Infant and child health
• STIs, HIV and AIDS
These areas were seen as key areas for the improvement of reproductive and child health
countrywide.

Guideline B: Use of Uterotonics in Active Management of Third Stage of Labour


• Improving maternal health and reducing maternal mortality have been key concerns of
several international summits and conferences since the late 1980s, including the
Millennium Summit in 2000.
• One of the eight Millennium Development Goals (MDG’s) is reducing the maternal
mortality ratio by three quarters 2015. The key elements in this guideline are:
o Postpartum haemorrhage
o Available uterotonics for AMTSL (Active Management of Third Stage of Labour)
o Treatment of post partum haemorrhage
o Prevention of PPH away from health facilities

CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 2: National Health Guidelines 21
Handout 2.4: Summary of National Guidelines for:
A. Management of HIV and AIDS
B. PMTCT

Guideline A: Management of HIV and AIDS


• Since the first three AIDS cases were reported in Tanzania in 1983, the HIV epidemic has
spread rapidly to all districts and communities and has affected all sectors of the society.
• During the year 2003, a total of 18,929 AIDS cases were reported to the National AIDS
Control Programme (NACP) from the 21 regions bringing the cumulative total of
reported cases since the epidemic started to 176,102.
• The national guideline for clinical management of HIV and AIDS was produced only a
few years ago. However, recent developments and experience in the field of HIV and
AIDS care and treatment has made it necessary for the country to come up with another
edition of these guidelines to reflect the changes that have take place.
• This will help to improve the quality of care and treatment of HIV and AIDs has been
expanded to give clinical more flexibility in providing quality care.
• Due to observed changes and developments the number of regions to be used for care and
treatment of HIV and AIDS has been expanded to give providing quality care. Areas
covered in this guideline include:
o Organization of HIV and AIDS care and treatment
o HIV and AIDS prevention
o HIV prevention in a health care setting
o Laboratory tests for HIV and AIDS
o Management of common symptoms and opportunistic infections in HIV and AIDS
adolescents and adults
o Paediatric HIV and AIDS- related conditions
o Antiretroviral therapy in adults and adolescents
o ARV therapy infants and children
o TB and HIV co- infective
o HIV and AIDS in pregnancy
o Counselling related to HIV testing and treatment adherence
o Management of mental health problem in HIV and AIDS
o Community and home based care for people living with HIV and AIDS
o Nutrition in HIV and AIDs

Guideline B: PMTCT
• The National guidelines for prevention of mother to child transmission of HIV summarize
national recommendation for delivery of prevention of mother to child transmission
(PMTCT) programme services.
• The national PMTCT guidelines are intended to promote and support the delivery of
quality HIV prevention, care, and treatment and support services.
• HIV prevention in mothers and families mother to child transmission (MTCT) of HIV
refers to the transmission of HIV infection from HIV infected mother to their infants.
MTCT can occur during pregnancy, labour and delivery and breast feeding. Without
intervention; the overall risk of MTCT is approximately 25 – 45%.
• Key elements in these guidelines are:
o Overview of HIV prevention in mothers and families
o Stigma and discrimination associated with HIV and AIDS

CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 2: National Health Guidelines 22
o Counselling and testing
o Specific interventions to prevent MTCT
o Infant feeding in the context of HIV infection
o Comprehensive care and support for mothers and families with HIV infection
o Safe and supportive care in the work setting
o PMTCT programme management, monitoring, supervision and logistics

CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 2: National Health Guidelines 23
Handout 2.5: Summary of National Guidelines for:
A. Voluntary Counselling and Testing
B. Provider Initiated Testing and Counselling

Guideline A: Voluntary Counselling and Testing (VCT, 2005)


• The provision of HIV and AIDS related counselling services in Tanzania started in 1988,
three years after the first three AIDS cases were identified in Tanzania.
• At the beginning, these services were provided manly by faith-based organizations and
NGOs to client who sought such services.
• In 1989, the joint Tanzanian-Norwegian AIDS project (MUTAN) started implementing
activities in Tanzania (Arusha and Kilimanjaro Region).

Purpose and Rationale for the VCT Guidelines


• The National Voluntary Counselling and Testing Guidelines have been developed to
provide VCT service providers and managers with a framework within which to operate
and for clients to be informed of their rights.
• The guidelines provide standard operating procedures (SOPs) in the delivery of VCT so
that as many as possible Tanzanians have access to quality VCT services.
• The key elements in this guideline are as follows:
o Definitions, fundamentals, key principles and benefits of VCT
o Management of VCT services: roles and responsibilities of all levels
o Voluntary counselling and testing sites
o HIV and AIDS
o HIV testing
o Infrastructure, human resources and basic organization of VCT sites
o Accreditation of VCT sites

Guideline B: Provider Initiated Testing and Counselling (PITC)


• PITC refers to HIV and counselling which is recommended by health care providers to
persons attending health care facilities as a standard component of medical care.
• The major purpose of such testing and counselling is to enable specific decisions to be
made and/or specific medical services to be offered that will not be possible without
knowledge of the person’s HIV status.

Rationale
• Currently there is a global and national movement to accelerate universal access to HIV
prevention, treatment care and support services for PLHIV. This calls for urgent scaling
up of HIV testing and counselling using different approaches.
• This will allow early identification and hence increase the number of HIV infected
persons who access care, treatment and support services.
• In Tanzania, knowledge of one’s HIV status has mainly been through VCT where by
clients proactively seek HIV testing and counselling services. In PITC, health care
providers initiate HIV testing and counselling to persons attending health facilities with
informed consent.

These guidelines include guidance on the aspects including implementation of PITC; process
and elements of PITC; HIV testing; ethical and legal considerations; supply chain
management; and supervision, monitoring and evaluation.

CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 2: National Health Guidelines 24
Handout 2.6: Summary of National Guidelines for:
A. Infection Prevention and Control (IPC)
B. Health Care Waste Management

Guideline A: Infection Prevention and Control (IPC)


• The Ministry of Health and Social Welfare is committed to ensuring safe, quality health
care services are provided to its people countrywide.
• Infection (communicable diseases) can spread through various routes, for example
airborne droplet blood and other body fluids, content (direct and indirect), faecal-oral
food borne and vector-borne.
• The emergency of HIV and AIDS has complicated the whole picture of infection
prevention and control by increasing the number of people at risk of infection. Increased
number of TB cases and prevalence of cholera in some part of Tanzania, call for special
attention safe and effective prevention and control.

Purpose of the Guidelines


• This pocket guide has been developed by the Ministry of Health and Social Welfare of
Tanzania to aid health care provider in health care facilities and else where to understand
and evidence-based IPC practices.

Content organization
• The material in this infection prevention and control pocket guide is divided into topics.
Each topic stands on its own. The topics are arranged in such a way that the reader needs
to know some basic IPC principles. The first principle of IPC is ‘The disease transmission
cycle’ Each topic is described briefly under the Standard Precautions section.

Other topic includes


• Transmission-based precautions
• Hand hygiene
• Personal protective equipment
• Safe handling of sharps during procedures.
• Post exposure prophylaxis (PEP guidelines)
• Skin preparation prior to surgical procedures
• Preventing infection related to use of intravascular devices
• Preventing catheter-related urinary tract infections
• Instrument processing
• Health care waste management
• Traffic flow and activity patterns
• Central sterilization supply department
• Processing linen house keeping
• Clean water
• Infection prevention in home based care setting

Users of the Guide


The expected users of the pocket guide include:
• All health care provider and trainers from government, faith-based, private for profit/not
for profit and NGO health facilities and institutions.

CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 2: National Health Guidelines 25
• People working at community level to promote quality health care services, including
front line health care providers, facility health management committee and home based
care workers.
• Individuals, group and international organization engaged in healthcare service provision.
• Policymakers, health managers, program officers and health administrators.
• Various health team including regional and council health management teams.

Guidelines B: Health Care Waste Management National Policy


• Safe management of health care is a key issue to control and reduce noso-comial
infections inside a health facility and to ensure that the environment outside is well-
protected.

Health Care Waste


• This includes all the waste hazardous or not, generated during medical activities. It
embraces activities of diagnosis as well as preventive curative and palliative treatments in
the field of human and veterinary medicine.
• Other terminologies are:
o Non-infectious waste
o Highly infectious waste
o Pathology waste
o Pharmaceutical waste
o Cytotoxic waste
o Radioactive waste
o Special hazardous waste
o Effluents
o Noso-comial infections
o Home-based infectious waste
o On-site transportation
o Personal protective equipment

Application of the Guidelines


• These guidelines have been developed by the Ministry of Health and Social Welfare to
ensure proper handling and treatment of health care waste at different levels in health
facilities and the community at large.
• The users (target group) of these guidelines shall be:
o The medical staff members responsible for providing health care services at all levels
in public or private health care facilities
o National policy makers (MOHSW and PMO-RALG) Regional and District Health
Management Teams (RHMTS and CHMTs) responsible for developing implementing
and evaluating the health care waste management plans at central, regional and
district levels
o Members of training and research institutions
o International organization and Non-Governmental Organizations (NGOs) involved in
the funding and technical support of health care services in Tanzania

CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 2: National Health Guidelines 26
Handout 2.7: Summary of National Guidelines for:
A. Home Based Care Service
B. Management of Malaria for Health Service Providers

Guideline A: Home Based Care Services (HBC)


• HBC services are being developed to initiate the impact of increased morbidity and
mortality from HIV and AIDS and other chronic illness. Family members will be
expected to play a major role in provision of home based care services.
• Key elements for this:
o Quality of home basic care
o Referral system
o Supervision guideline and monitoring tools
o Community involvement and role of traditional healers in home based care services

Guideline B: Management of Malaria for Health Service Providers


• Malaria is still the most common dangerous disease in Tanzania. It ranks number one in
terms of morbidity and mortality especially in children below five years of age and
pregnant women.
• The clinical features of malaria vary from mild to severe, according to the infecting
species of the parasite, the patient’s state of immunity, the intensity of the infection and
the presence of conditions such as malnutrition, anaemia and other diseases.

Goals
• The goal of appropriate malaria diagnosis and treatment is to reduce morbidity, mortality
and socio-economic losses.
• This guideline for diagnosis and treatment of malaria was developed in 2006. The
purpose is to promote prompt, effective and safe treatment of malarial disease at health
centre and dispensary levels.

Choice of Anti-malarial Drugs


The following anti-malarial drugs are recommended in Tanzania:
• The first line drug is Artemether/Lumefantrine (ALU)
• The second line drug, where Artemether/Lumefantrine has failed or is contraindicated is
quinine.
• The drug of choice for treatment severe malaria is quinine.
• The first line drug for pregnant women during first trimester and children under 5kg is
quinine.

These guidelines include the following contents


• Principles of malaria management
• Management of uncomplicated malaria
• Management of severe malaria
• Management malaria in pregnancy
• Management of malaria in the neonates and infants below 5 kgs
• Management of anaemia
• Pharmacorigilance
• Appendices

CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 2: National Health Guidelines 27
Handout 2.8: Summary of National Guidelines for
Management of Sexually Transmitted and Reproductive Tract
Infections
Introduction
• Sexually Transmitted Infection (STI) is a group of infections that are predominantly
transmitted through unprotected sexual contact with infected person.
• Reproductive Tract Infections (RTIs) are infections of genital tract.
• Not all reproductive tract infections are sexually transmitted. STI refers to the way of
transmission whereas RTI refers to the site where the infections develop.

Rationale
• Effective management of STIs and RTIs is one of the cornerstone of their control, as it
prevents the development of complication and recurrence, decreases the spread of those
infections and HIV in the community and offers a unique opportunity for targeted
education about reproductive health.

Objectives of the Guidelines


The objectives of the guidelines are to enable the user of the document to:
• Use it as a reference manual and resource material for providing STI/RTI services
• Recommended prevention and care practices for clients who have or may be at risk of
acquiring STIs/RTIs
• Use for pre-service and or in-service health provider education and training
• Use as a service of updating service providers of STI/RTI services
• Use as an evidence based recommendation and self education tool for health care
providers on the prevention, treatment and diagnosis of STI/RTI
• Use as a management tool for harmonizing and improving policies, programmers, and
training on the prevention and management of STI/RTI

Key Elements in this Guideline


• Introduction to STI/RTIs
• Detecting STIs/RTs
• STI/RTI education and counselling
• Preventing STIs/RTIs and their complications
• Promoting prevention of STI/RTI and use of services
• STI/RTI assessment during routine family planning visits
• STI/RTI assessment in pregnancy, child and the postpartum period
• Management of symptomatic STIs/RTIS
• STI/RTI complications related to pregnancy, miscarriage induced abortion and
postpartum period
• Sexual violence
• Monitoring and evaluation

CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 2: National Health Guidelines 28
Handout 2.9: Summary of National Guidelines for:
A. Management of HIV and AIDS for Frontline Workers
B. Policy Guidelines for Collaborative TB/HIV Activities

Guidelines A: Management of HIV and AIDS for Frontline Workers


• The Ministry of Health continues to build the capacity of the health care providers in the
area of HIV and AIDS prevention, care and support through among after things
development of guideline for management of the HIV and AIDS.
• In 1989, the first guidelines were produced and reviewed in 1990. Those guidelines,
defined the mandate for all levels of the health system and the cadres of health personnel.
• In April 2002, a guideline for clinical management of HIV and AIDS was produced.

Purpose of Guideline
• This document is intended to provide guidelines for health care workers on various
aspects of care and support.
• These include nursing care, treatment of opportunistic infections, prevention of
transmission of the infection, counselling and care during pregnancy, labour and postnatal
period.
• The document also containing a section on continuum of care which emphasizes the
delivery of comprehensive care at home at various levels of health care system.

Content of This Guideline


• Background and situation of HIV and AIDS
• Protective measures
• HIV and AIDS in the laboratory
• Comprehensive care and support for people living with HIV and AIDS
• HIV and AIDs and pregnancy

Guidelines B: National Policy Guidelines for Collaborative TB/HIV Activities


• TB and HIV and AIDS pose significant global public health problems. TB and HIV are
overlapping epidemics. Both have been declared global emergencies demanding global
attention.
• The World Health Organization (WHO) declared TB to be a global emergency in 1993,
and the United Nations (UN) declared HIV and AIDS to be a global emergency in 2001.
UN member countries and other international organizations have committed themselves
to address the TB and HIV and AIDS crises with urgency. But efforts to address the two
problems have been carried out separately, resulting in an inadequate global impact on the
dual epidemics.
• At the global level, the World Health Organization (WHO) formulated an interim policy
in 2004 to guide member sates in implementing collaborative TB/HIV activities.
• The policy stated the objectives of collaborative TB/HIV activities as follows:
o To establish the mechanisms for collaboration between TB and HIV and AIDS
programmes
o To reduce the burden of TB in people living with HIV and AIDS
o To reduce the burden of HIV in TB-infected patients
• These objectives laid the basis for development of policy guideline on collaborative
TB/HIV activities in Tanzania

CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 2: National Health Guidelines 29
CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 2: National Health Guidelines 30
 Session 3: National Guidelines for Management of
HIV and AIDS and for Prevention of Mother-to-Child
Transmission of HIV
Learning Objectives
By the end of this session, students are expected to be able to:
• Explain the background and rationale of National Guidelines for Management of HIV and
AIDS and for Prevention of Mother-to-Child Transmission of HIV (PMTCT)
• Describe the objectives of National Guideline for PMTCT
• Describe key elements of the National Guideline for the Management of HIV and AIDS
and for PMTCT

Background and Rationale of the National Guidelines for Management of


HIV and AIDS

Background
• Since the first three AIDS cases were reported in Tanzania in 1983, the HIV epidemic has
spread rapidly to all districts and communities and has affected all sectors of the society.
• During the year 2003 a total of 18,929 AIDS cases were reported to the National AIDS
Control Programme (NACP) from the 21 regions bringing the cumulative total of
reported cases since the epidemic broke to 176,102.
• The National Guidelines for Clinical Management of HIV and AIDS was produced only a
few years ago.
• However, recent developments and experience in the field of HIV and AIDS care and
treatment has made it necessary for the country to come up with another edition of these
guidelines to reflect the changes that have taken place.
• This expansion of the guidelines will help to improve the quality of care and treatment of
HIV and AIDS and to give clinicians more flexibility in providing quality care.

Rationale
• HIV and AIDS is a rapidly evolving field. This is particularly true in the field of care and
treatment of individuals infected with HIV.
• Newer and more potent drugs are continuously being developed and used; and knowledge
of the existing drugs in terms of efficacy, as well as short and long-term side effects is
becoming clearer as we gain more experience.

Key Elements of Guidelines for Management of HIV and AIDS

Activity: Small Group Discussion

Instructions
You will work in small manageable groups to discuss the key elements of HIV and AIDS
Guidelines for 10 minutes. One group will present their findings and other groups will
participate in discussion.

• The National Guidelines for Management of HIV and AIDS has 16 chapters which
consist of the following key elements:

CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 3: National Guidelines for Management of HIV and AIDS and PMTCT 31
Organization of HIV and AIDS Care and Treatment
• This part provides guidance on the identification of people living with HIV and AIDS in
need of care and treatment and sensitization of communities. It further explains scope and
organization of care and treatment services by highlighting staffing and team approach,
patient visit plans, medical records systems, reporting and monitoring.
• Certification of health facilities to deliver HIV and AIDS care and treatment with
tabulated minimum criteria to start/expand ART for hospitals are detailed in this section.

HIV and AIDS Prevention


• This part provides a guide for treatment and prevention of sexually transmitted infections,
prevention of mother to child transmission of HIV, condom programming, workplace
HIV and AIDS policy and programme for health sector and prevention of HIV
transmission through blood transfusion.
• It also gives a detailed guidance on HIV and AIDS prevention for sex workers and other
vulnerable groups, voluntary counselling and testing (VCT), family planning services,
reduction of stigma and discrimination and male circumcision.

HIV Prevention in a Health Care Setting


• HIV and other blood pathogens may be transmitted in health care settings from a patient
to a health worker, from a health worker to a patient or from a patient to patient.
• This section of the guidelines therefore provides a detailed infection, prevention and
control measures, i.e. adherence to standard precautions, use of personal protective
equipment, proper health care waste management, processing of instrument by
decontamination, cleaning and sterilization and observing safe work practices.

Laboratory Tests for HIV and AIDS


• The guideline identifies laboratory testing as an important integral part of HIV and AIDS
care and treatment.
• This section gives guidance for the HIV testing in adults and children over 18 months,
infection diagnosis for children under 18 months.
• It also explains the importance of test for various reasons such as for monitoring disease
progress and treatment safety, monitoring responses to antiretroviral treatment and for
diagnosing opportunistic infections.
• Laboratory safety procedures, sample storage and transportation procedures also form
part of this section.

Management of Common Symptoms and Opportunistic Infections in HIV and AIDS


Adolescents and Adults
• This part highlights clinical features and treatment of the common symptoms encountered
in person infected with HIV, prevention of common opportunistic infections and offers
guidance to their management and diagnosis and treatment of some opportunistic illness
seen in persons infected with HIV.

Antiretroviral Therapy in Adults and Adolescents


• This part explains about the benefits of more extensive use of potent ART therapy for
HIV, which includes significant improvements in the safety and tolerability of regimens
used for initial treatment.

CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 3: National Guidelines for Management of HIV and AIDS and PMTCT 32
• Thus, it identifies the current existing and commercially available ART drugs under 5
main categories, i.e. binding and fusion inhibitors, nucleoside reverse transcriptase
inhibitors, non-nucleoside reverse transcriptase inhibitors, nucleotide reverse transcriptase
inhibitors and protease inhibitors.
• Guidance in treatment using ARV drugs in adult and adolescents and recommended ARV
drugs in Tanzania are detailed explained in this part.

ARV Therapy Infants and Children


• Since all ART drugs approved for treatment of HIV infection may be used for children,
the guide provides a detailed explanation on the goals of therapy for children, criteria for
initiating ART in children, breastfeeding and ART, recommended first-line ARV regimes
in infants and children, clinical assessment of infants, reasons for changing therapy and
finally recommended second line ARV therapy for the group.

TB and HIV Co-Infection


• Under this part of the guideline, the following are detailed: TB management in HIV and
AIDS patient, management of patients co-infected with HIV and TB, collaborative
TB/HIV interventions and finally, TB infection control in health care and congregate
settings.

HIV and AID in Pregnancy


• This part gives guidance to care and treatment of HIV and AIDS in pregnancy based on
UN recommendations in the following strategic areas: primary prevention of HIV among
women of reproductive age, prevention of unintended pregnancies among women living
with HIV, prevention of HIV during pregnancy and treatment, care and support for
women living with HIV.

Counselling Related to HIV Testing and Treatment Adherence


• This part of the guideline looks at counselling as it relates to the two modes of
counselling for HIV testing: provider initiated testing counselling (PITC) and the standard
voluntary counselling and testing (VCT) that is client-initiated.
• It also looks at counselling as it relates to ART adherence.

Other Areas
• The guideline also gives detailed guidance in the management of mental health problems
in HIV and AIDS, community and home based care for people living with HIV and
AIDS, and nutrition in HIV and AIDS.

Background, Objectives and Rationale of the Guidelines for PMTCT

Background
• The National Guidelines for Prevention of Mother-to-Child Transmission of HIV
(PMTCT) of 2007 summarizes national recommendation for delivery of prevention of
mother to child transmission (PMTCT) programme services.
• The guidelines are based on national HIV and AIDS policies and replace that of March
2004.

CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 3: National Guidelines for Management of HIV and AIDS and PMTCT 33
Activity: Large Group Discussion

Instructions
You will be given copy of the PMTCT Guidelines to read the introductory part and identify
key messages. You will be required to contribute in large group discussion.

Objectives and Rationale of PMTCT Guideline


• The National PMTCT guidelines are intended to promote and support the delivery of
quality HIV prevention, care, treatment and support services.
• They provide an important reference for PMTCT programme and health care workers. In
addition to defining standards for patient care, the guideline should be referred to when
developing institutional policies and procedures, training and quality assurance initiative
for PMTCT programmes.
• The PMTCT guidelines focus on maternal, child and family health. They are intended to
be used together with other relevant guidelines and protocols, including those for clinical
management of HIV and AIDS, tuberculosis (TB) and malaria, as well as for HIV
counselling and testing and infant feeding.

Key Elements of Guidelines for PMTCT

Activity: Small Group Discussion

Instructions
You will work in small manageable groups to discuss and agree on “key elements of the
guideline.” Your group will have 10 minutes. One group will present their findings and
other groups will participate in discussion.

• The National Guidelines for the Prevention of Mother-to-Child Transmission of HIV


(PMTCT) has 16 chapters which consist of the following key elements:

Overview of HIV Prevention in Mothers and Families


• This part of guideline gives the basic facts about mother-to-child transmission of HIV,
goal of Tanzania’s PMTCT programme, and detailed four elements of a comprehensive
approach to PMCTC.

Stigma and Discrimination Associated With HIV and AIDS


• Explanation of HIV stigma and discrimination accompanied by their relevant definition
are covered in this part of the guidelines.
• Actions to reduce stigma in PMTCT programmes and the roles of managers and strategies
for reducing HIV-related stigma in PMTCT programmes fall under this part.

Counselling and Testing


• This part explains roles of the health care worker in counselling and testing, gives a
detailed explanation on the benefits and risks of HIV testing for women, and provides
guidance on when counselling and testing should occur.
• Guiding principles of counselling and testing, HIV counselling and testing strategy, pre-
test HIV information, post-test counselling and support, and how to counsel couples are
explained in detail.

CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 3: National Guidelines for Management of HIV and AIDS and PMTCT 34
• Counselling pregnant women with special needs, testing women of unknown HIV status
at the time of labour and delivery, quality assurance and control and national
recommendations for HIV testing in PMTCT programme are covered.

Specific Interventions to Prevent MTCT


• This part guides on the PMTCT services during ANC, essential ANC for women with
HIV infection, ARV treatment for PMTCT, care and HIV-infected women during labour
and delivery and immediate post delivery care of HIV-exposed infants.
• Furthermore, management of HIV-infected women and their infants in the immediate
postpartum period are covered in this part of the guidelines.

Infant Feeding In the Context of HIV Infection


• Among other things, this part explains about transmission of HIV through breast milk,
risks associated with mixed feeding before 6 months of age, national recommendations
for safer infant feeding, counselling for safer infant feeding and exclusive breastfeeding
for the HIV-infected mother.
• Replacement feeding options for the HIV-infected mother, general guidelines for
counselling mothers on replacement feeding and nutritional requirements for the lactating
mother are covered in this part of the guideline.

Comprehensive Care and Support for Mothers and Families with HIV Infection
• In this part of the guideline, comprehensive care, treatment and support, postpartum care
and support, care and support of HIV-exposed and HIV-infected infants and children,
common signs and symptoms of HIV infection in infants and diagnosis of HIV in infants
and young children are explained in detail.

Safe and Supportive Care in the Work Setting


• Standard precautions, hand hygiene, personal protective equipment, handling of sharps,
contaminated equipment and other materials and creation of safe working environment
are among the things that guidelines explains as means of reducing occupational risk.

PMTCT Programme Management, Monitoring Supervision and Logistics


• As PMTCT expands, there is a need to describe the PMTCT programme management and
establish a monitoring system.
• This part provides an overview of the National PMTCT programme, monitoring and
evaluation system and indicators, and supportive supervision as the key areas towards
success of the programme.

Finally, among other things, the document is annexed with the following:
• HIV prevalence in women and men
• Post-test counselling checklists
• National recommendations: ART prophylaxis regimens to prevent MTCT
• Advantages and disadvantages of infant feeding options for HIV-infected mothers
• Steps to express and pasteurise breast milk
• How to feed an infant from a cup
• Comprehensive care for PMTCT of HIV

CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 3: National Guidelines for Management of HIV and AIDS and PMTCT 35
Key Points
• The Guidelines for Management of HIV and AIDS consist of:
o Organization of HIV and AIDS Care and treatment in health facility
o HIV and AIDS prevention and HIV prevention in health care settings
o Laboratory tests for HIV and AIDS
o Management of common symptoms and opportunistic infections in HIV and AIDS
o Antiretroviral therapy in adults, adolescents, infants and children
o TB and HIV co- infection
o HIV and AIDS in pregnancy
o Counselling related to HIV testing and treatment adherence
• National PMTCT Guidelines focus on maternal, child and family health, and intend to
promote and support the delivery of quality HIV prevention, care, treatment and support
services.
• PMTCT Guidelines should be referred to when developing institutional policies and
procedures, training and quality assurance initiative for PMTCT programmes.

Evaluation
• What is the rationale for National Guidelines for Management of HIV and AIDS?
• What are the key elements of the guidelines for the Management of HIV and AIDS?
• What is the rationale for National Guidelines for PMTCT?
• Mention key elements of the PMTCT guideline.
• If you want to recommend pasteurization for a pregnant mother, which part of the
PMTCT Guidelines would you refer to?

References
• NACP. (2009). National Guidelines for the Management of HIV and AIDS (3rd ed). Dar
es Salaam, Tanzania: Ministry of Health and Social Welfare, National AIDS Control
Programme.
• NACP. (2009). National Guidelines for the Prevention of Mother-to-Child Transmission
of HIV (PMTCT). Dar es Salaam, Tanzania: Ministry of Health and Social Welfare,
National AIDS Control Programme.

CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 3: National Guidelines for Management of HIV and AIDS and PMTCT 36
 Session 4: National Health Guidelines for Malaria and
for Collaborative TB/HIV Activities 
Learning Objectives
By the end of this session, students are expected to be able to:
• Explain the background of Guidelines for Malaria and for Collaborative TB/HIV
Activities
• Describe the rationale and objectives of National Guideline for Malaria and for
Collaborative TB/HIV Activities
• Describe key elements of the National Guideline for Malaria and for Collaborative
TB/HIV Activities

Background, Objectives and Rationale of the Malaria Guideline


• Malaria is still the most common dangerous disease in Tanzania. It ranks number one in
terms of morbidity and mortality, especially in children below five years of age and
pregnant women.
• The clinical features of malaria vary from mild to severe, according to the infecting
species of the parasite, the patient’s state of immunity, the intensity of the infection and
the presence of conditions such as malnutrition, anaemia and other diseases.
• The National Guidelines for Malaria Diagnosis and Treatment is a revised and updated
version of a similar guideline that was issued in the year 2000.
• The year 2000 version was revised following a major change in drug policy whereby the
former first line drug Chloroquine was replaced with Sulphodoxine-Pyrimethamine (SP).

Objectives
• The broad objective of this guideline is to provide standard management reference for the
care of patients with malaria. They form part of the National Drug Policy.
• These recommendations represents the minimum level of care that patients should expect
at different level of health care in public and private sectors.
• Specifically, the objectives of the guideline are to:
o Stipulate at all level of health care delivery that specific antimalarial drugs should be
made available at all times
o Promote prompt and accurate malarial diagnosis
o Promote rational antimalarial drug management
o Promote intermittent preventive treatment for malaria in pregnancy
o Provide consistent guidance to prescribers and users on the appropriate use of
chemoprophylaxis for specific at- risk groups
o Provide information to health care managers and service providers on the detection of
antimalarial drug resistance

Rationale
• The rationale for the guideline was a result of increased resistance of the malaria parasites
to antimalarial monotherapies, in order to preserve the efficacy and effectiveness of the
existing drugs and to ensure an optimal cure.

CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 4: National Health Guidelines for Malaria and for Collaborative TB/HIV Activities 37
Key Elements of National Malaria Guidelines

Activity: Small Group Discussion

Instructions
You will work in small manageable groups to discuss “the key elements of the national
malaria guidelines. Your group will be given a copy of the guideline if available. Your
group will have 10 minutes to complete the task. One group will present their findings and
other groups will participate in discussion.

• The National Guidelines for Malaria Diagnosis and Treatment has 16 chapters which
consist of the following key elements:

Introduction
• Explains background or history of malaria, diagnosis and treatment in Tanzania.
• Further highlights on the guidelines’ broad objectives and specific, rationale and choice
of antimalarial drugs.

Management of Malaria and Health Care Delivery in Tanzania


• Explains the different levels or categories of health service delivery in the context of
Tanzania.
• It gives details on staffing, diagnosis, type of service provided, treatment available
starting from home, dispensary, health centre and hospital.

Diagnosis of Malaria
• This part explains clinical features of malaria, assessment of the patient and laboratory
investigations.
• Provides details on the clinical assessment of the patient and gives distinguishing features
of uncomplicated malaria in relation to age groups, clinical and laboratory features of
severe malaria.

Management of Uncomplicated Malaria


• Explains clinical features of uncomplicated malaria, and combination therapy, first line
and second line drug treatment.
• Explanation of treatment includes provision of rapid and long-lasting clinical and
parasitological cure, reduction of morbidity including malaria-related anaemia and halting
the progression of simple disease into severe and potentiality fatal disease.

Management of Severe Malaria


• Elaborates features of severe malaria by highlighting clinical features and its description.
• It further tabulates the clinical features and laboratory indices of severe malaria in adults,
children and their prognostic values.
• Treatment and management of malaria at different levels of service delivery including
home, dispensary, health centre and hospital form part of this section.
• Explains monitoring of patient with severe malaria including important observations and
their implications during treatment of severe malaria.
• Emergency management of severe malaria including convulsions, hypoglycaemia,
hypotension, pulmonary oedema and metabolic acidosis are also explained in this part
including ways to respond.

CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 4: National Health Guidelines for Malaria and for Collaborative TB/HIV Activities 38
Anaemia and Malaria
• Provides the definition of anaemia and gives the clinical presentation of anaemia and its
classification and management of life threatening anaemia associated with malaria when
it is severe, or mild/moderate.

Management of Malaria in Pregnancy


• The section highlights on the effects of malaria on pregnancy, clinical features and
management of both uncomplicated and severe malaria in pregnancy, anaemia associated
with malaria in pregnancy, and its management for mild/moderate or severe.
• The section is concluded by explaining how to prevent malaria during pregnancy using
intermittent preventive treatment and Insecticide Treated Net (ITNs).

Management of Malaria in the Neonate and Infants below 5kg


• This part consists of clinical features of malaria, management of neonatal malaria
including investigations, treatment, nursing care and monitoring.
• It further gives explanation on how to manage malaria in infants below two months and
below 5kg.

Malaria and HIV Co-Infection


• The introductory part of this section explains that both diseases are endemic in Tanzania,
and describes clinical features of malaria in HIV and AIDS for both uncomplicated and
severe cases.
• It also explains the diagnosis and treatment of uncomplicated and severe malaria in HIV
and AIDS, malaria and HIV and AIDS in pregnancy, effects of malaria on HIV-infected
children and its prevention.

Therapeutic Efficacy of Antimalarial Drugs


• This chapter explains the non-response to an antimalarial treatment and the causes of non-
response to treatment. Also classification of treatment failures is well tabulated in this
section.

Malaria Chemoprophylaxis
• The section explains the indication for malaria chemoprophylaxis and its recommendation
for use in various groups, i.e. patients with anaemia, non-immune travellers and non-
immune pregnant women.

Malaria Epidemics
• Gives the definition of malaria epidemic as the occurrence of new cases of malaria clearly
exceeding the number expected at that particular time and place.
• The section explains measures to be considered during malaria epidemics and diagnosis
in the event of malaria epidemics.

Other Sections
• In this guideline, the last chapters are about public health education on malaria case
management, other antimalarial drugs available in Tanzania, management of antimalarial
drugs and pharmaco vigilance which are set of activities related to the detection,
assessment and prevention of drug adverse reaction.

CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 4: National Health Guidelines for Malaria and for Collaborative TB/HIV Activities 39
Background, Rationale and Objectives of the TB/HIV Guideline
• TB and HIV and AIDS pose significant global public health problems.
• TB and HIV are overlapping epidemics.
• Both have been declared global emergencies demanding global attention.
• The World Health Organisation (WHO) declared TB to be a global emergency in 1993,
and the United Nations (UN) declared HIV and AIDS to be a global emergency in 2001.
• UN member countries and other international organisations have committed themselves
to address the TB and HIV and AIDS crises with urgency.
• Efforts to address the two problems have been carried out separately, resulting in an
inadequate global impact on the dual epidemics.
• There is an increasing recognition of the need to strengthen collaboration between
national TB and HIV and AIDS programmes and other stakeholders in countries around
the world because of the overlapping nature of TB and HIV infection.
• There is evidence that HIV infection weakens the immune system, thereby fuelling the
TB epidemic among people living with HIV and AIDS (PLHIV). On the other hand, TB
is the main opportunistic infection and leading cause of deaths among PLHIV.
• In many countries, TB cases have been increasing together with rising HIV prevalence. In
sub-Saharan Africa, for instance, a fourfold rise in TB cases related to the HIV epidemic
has been reported.
• The situation in Tanzania is not different from that in many sub-Saharan countries.

Rationale
• A review of the implementation of collaborative TB/HIV activities that took place in
2005 showed that TB/HIV activities had been established, but there was no national
policy framework to guide the implementation process.
• Thus, a policy framework was needed to guide stakeholders in scaling up collaborative
TB/HIV activities to address the dual epidemics.

Specific Objectives of the Collaborative TB/HIV Policy Guidelines


The policy guidelines have the following specific objectives:
• To provide a framework for all stakeholders in implementing collaborative TB/HIV
activities in Tanzania.
• To identify various areas, possibilities, and opportunities for collaboration among the
NACP, NTLP, and other stakeholders in providing comprehensive care and support for
people living with TB/HIV co-infection.
• To provide guidance in establishing mechanisms for collaboration among the national TB
and HIV programmes and other stakeholders.
• To ensure that there are regular joint working sessions to inform implementing partners
and stakeholders about collaborative TB/HIV activities.
• To provide a framework that will facilitate integrated capacity building in care provision,
prevention, research, monitoring, and evaluation of collaborative TB/HIV activities.
• To guide and support the design and implementation of effective collaborative TB/HIV
activities in the country.
• Seek political commitment of the government to support mobilisation of resources for
collaborative TB/HIV activities.
• To coordinate and harmonise collaborative TB/HIV activities implemented in the country
by various stakeholders.

CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 4: National Health Guidelines for Malaria and for Collaborative TB/HIV Activities 40
Key Elements of the National TB/HIV Guidelines

Activity: Small Group Discussion

Instructions
You will work into small manageable groups to discuss the key components of the
collaborative TB/HIV policy guidelines for 10 minutes. Your group will be given a copy of
the guideline if available. One group will present their findings and other groups will
participate in discussion.

Rationale for the Policy Guideline


• This part gives the TB/HIV situation in Tanzania by giving statistics for the two diseases.
• Importance of the policy guideline is explained in this part.

Goal and Objectives of Collaborative TB/HIV Policy Guidelines


• Highlights goal for the policy guideline, objectives of the policy guidelines which
includes overall and specific objectives and the guiding principles of the policy
guidelines.

Collaborative TB/HIV Activities


• Activities that are going to be implemented jointly are explained in this part of the
guideline. They include establishment of mechanism for collaboration between TB and
HIV and AIDS programmes by setting up of effective coordinating bodies for TB/HIV
activities at all levels.
• Establishment of committees at national, regional, district, health facility together with
their functions are explained in detail.
• Various policy statements concerning joint TB/HIV planning, resource mobilization,
capacity building, advocacy, communication, social mobilization, patient empowerment
and community involvement and monitoring of the activities, operational research and
others are clearly stated.

Key Points
• The National Guidelines for Malaria Diagnosis and Treatment are an essential part of the
larger process of governance.
• They are standards, protocols, and procedures that govern day-to-day operations of within
health sector and that determine who provides what care to which clients.
• The National Guidelines for Collaborative TB/HIV Activities is one dimension of the
Government of Tanzania’s efforts to combat the dual epidemics of TB and HIV.
• The vision of these policy guidelines is to create a sound framework and guiding
principles for best practices of rationality, effectiveness, efficiency, and consistency in
developing and implementing strategies for collaborative TB/HIV activities.

Evaluation
• What is the rationale for National Guidelines for Malaria Diagnosis and Treatment?
• Mention key elements of the guidelines for malaria.
• What is the rationale for National Guidelines for Collaborative TB/HIV Activities?
• List key elements of the National guidelines for collaborative TB/HIV activities.
• If you were asked to establish a TB/HIV committee at your centre, which topic would you
refer to in the guideline?

CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 4: National Health Guidelines for Malaria and for Collaborative TB/HIV Activities 41
References
• MCP. (2006). National Guideline for Malaria Diagnosis and Treatment. Dar es Salaam,
Tanzania: Ministry of Health and Social Welfare, Malaria Control Programme.
• NACP/NTLP. (2009). National Guidelines for Collaborative TB/HIV Activities.. Dar es
Salaam, Tanzania: Ministry of Health and Social Welfare, National AIDS Control
Programme/National TB and Leprosy Control Programme.

CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 4: National Health Guidelines for Malaria and for Collaborative TB/HIV Activities 42
 Session 5: Ethical Theories and Principles in Medical
Practice
Learning Objectives
By the end of this session, students are expected to be able to:
• Define common terms related to ethical theories and principles in medical practice
• Identify major ethical theories in medical practices
• Identify the importance of systematic study of ethics to medicine
• Identify the ethical principles in medical practice
• Analyze ethical principles in medical practice
• Apply ethical principles when managing patients/clients

Definition of Terms
• Ethics: A systematic study of what a persons’ conduct and actions ought to be with
regard to himself or herself, other human beings and the environment.
• The word ethics originated from the Greek word ‘ethos’ meaning customs or character.
• It is concerned with judgement about what is right or wrong conduct.
• Virtue: Moral excellence, goodness and rightness.
• It is also defined as conformity of one’s life and conduct to moral and ethical principles,
uprightness, and rectitude.

Virtue Ethics
• Refers to a virtue of character as a health practitioner rather than rules governing conduct
or consequences of any action by a health practitioner.
• Virtue ethics demands the practitioner to exercise loyalty, devotion and trustworthiness,
good temperament, compassion and integrity.

• Bioethics: A system of standards arising from the professional agreement to determine,


sanctions, and justify the interaction of biomedical professional and patient.

Ethical Principle
• Is a basic concept by which behaviour can be judged. Ethical Principles help people to
make decisions, because they serve as a standard with which to measure actions.
• Governing rules of conduct, as code of conduct by which life and action can be directed,
or as generalization that provide a basis for reasoning.
• A principle is an established rule of action to be followed in implementing a set of
activities.

Values
• Is something of worth or excellence or that which is esteemed, prized, or highly regarded.
• Values refer to one’s evaluative judgement about what one believes is good or what
makes something desirable.

CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 5: Ethical Theories and Principles in Medical Practice 43
Ethical Theories
Consequentialism or Utilitarianism
• This is a moral theory that holds that an action is judged as good or as bad in relation to
the consequence, outcome or end result that is derived from it.
• According to the utilitarianism school of thought, right action is that which has great
utility or usefulness. Utilitarianism holds that the only factors that make actions good or
bad are the outcomes, or end results, that are derived from them.

Non-Consequentialism or Deontological Ethics


• Deontological theories of ethics are based upon rationalistic view that rightness or
wrongness of an act depends upon nature of the act rather than its consequences.
• The term is taken from the Geek word for duty.
o For example, a man needs money to feed his family. He knows that he will not be
able to repay it but sees that nothing will be lent to him if he does not promise to
repay it at a certain time.
o Deontological ethics advocates against giving wrong promises disregarding the
outcome of the wrong promise, hence this man should not give the wrong promise.

Importance of Systematic Study of Ethics to Medicine


• Helps in understanding the origin and process of ethical and moral thinking.
• Enables health care workers to recognise situations with ethical and moral implications
and make coherent and logical ethical decisions based upon recognised ethical principles
and theories.
• Equips medical practitioners with knowledge necessary for making right decisions in
issues and situations that have element of ethical or moral uncertainty and dilemma.

Types of Ethical Principles


• There are five types of ethical principles:
o The value of life principle
o The principle of goodness or rightness
o The principle of justice or fairness
o The principle of truth telling or honesty
o The principle of individual freedom

The Value of Life Principle


• This principle requires the medical practitioner to value human life and honour the
patients’/clients’ wishes regarding quality of life.
• It demands to recognize life as basic and important, but also life should be recognized as
having an end. Yet no life should be ended without strong justification such as in the
situation whereby life of a pregnant woman is threatened by the presence of the fetus.
• In addition, when a medical practitioner becomes negligent, he threatens the life of the
patient; when life of a patient is valued, a medical practitioner will not ignore any
instruction on patient’s care.
• This explains why individuals should never be treated as mere means of achieving your
objective, but always as a unique individual who will benefit from the results.
• When medical practitioner takes part in unethical activities such as abortion, euthanasia
or suicide they infringe upon this principle.

CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 5: Ethical Theories and Principles in Medical Practice 44
The Principle of Goodness or Rightness
• This principle demands that human beings attempt to do three things:
o Promote goodness over badness (evil) and do good (beneficence)
o Cause no harm or badness (non-maleficence)
o Prevent badness or harm (non-maleficence)

Goodness or Rightness
• Individuals and societies, groups and cultures have different values and ideas of what
‘good’ implies.
• Certain things, however, seem to be generally recognizable as good. Examples of these
things are life, pleasure, happiness, truth, knowledge, beauty, love, friendship, self-
expression, freedom, peace, honour and security.
• A medical practitioner is obliged to avoid harm or injury/hurt to the patients/clients in all
aspects by demonstrating high level of competence in her/his practices.
• This principle provides justification for condemning any act that unjustly injures a person
or causes them to suffer an avoidable harm.

The Principle of Justice and Fairness


• Issues of justice are increasingly important in health care where dwindling resources force
us to make choices that are (or appear to be) not just.
• The little resources available have to be shared fairly.
• Distribution of resources should be done without being influenced by the socio-economic
position of clients, race, religion or sex.
• A health practitioner who adheres to this principle has the opportunity to utilize the
available resources adequately
• Therefore the health practitioner minimizes unnecessary complaints from customers,
conflicts within working area and creates a sense of commitment and good relationship
among staff for the benefits of the patient/client and the organization.
• One way that health practitioners exercise their responsibilities for allocation of resources
is by avoiding wasteful and inefficient practice even when the patient requests for them.
Examples of resource allocation include:
o Staff duty allocation
o Use of time
o Distribution of resources such as consultation rooms, examination gloves,
stethoscopes and BP machines
• In dealing with these allocation issues health practitioners must not only balance
principles of compassion and justice but also which approaches to justice are preferable.
These approaches include:
o Utilitarian- Resources should be distributed according to the principle of maximum
benefit for all
o Egalitarian- Resources should be distributed strictly according to the need
o Restorative-Resources should be distributed so as to favour the historically
disadvantaged
o Libertarian- Resources should be distributed according to market principles
(individual choice conditioned by ability and willingness to pay, with limited charity
care for the destitute)

CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 5: Ethical Theories and Principles in Medical Practice 45
Activity: Case Study

Instructions
Read the scenario below, and then answer the questions.

Scenario: You are the in-charge of a health centre where resources are limited and you have
few in store. Most of the patients are in a bed without bed sheets. On the same day you
receive a seriously ill patient who is the daughter of the council chairperson. You decide to
provide this patient with a new bed sheet from the store and you allocate one nurse to ensure
the wellbeing of this patient.

Questions
• What do you think about this practice?
• Is it fair? Explain.
• What can be done to ensure justice and fairness in a situation like this?

The Principle of Truth Telling and Honesty (Veracity)


• This is very important for the relationship with clients and colleagues. Without truth-
telling, society would not function properly.
• We go to hospital because we are sure that we shall get treated, and not otherwise.
• Truth does not merely mean giving information in health care.
• It means adequate and right information in order for the patient to make a decision.
• Patients and clients have to rely on professionals to give them information necessary to
make their own decisions.
• Medical practitioners share their knowledge and skills with patients and clients, rather
than impose on them, so that patients and clients can take responsibility for their own care
and well-being.

Activity: Example

Instructions
Read the following example of the ethical principle of ‘truth telling and honesty’.
• A patient came to hospital with uterine fibroid, and the doctor promised to remove the
fibroid and leave the uterus intact. However, in the process of the operation, he did total
hysterectomy without informing the patient. Two years later, the patient learned at the
infertility clinic that her uterus was removed and she can never get pregnant.

Note: The lesson here is that health workers should be truthful on patient’s condition and
outcomes of care.

The Principle of Individual Freedom (Autonomy)


• This principle is also called the principle of autonomy and it enables a client/patient in
making any choice as he/she wishes.
• Sometimes freedom is restricted in the interest of the public.
• In general, health care providers are required to obtain consent because they respect an
individual’s right to freedom.
• An individual has the freedom to make choices about issues that affect him/her.

CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 5: Ethical Theories and Principles in Medical Practice 46
• The concept of autonomy involves respect, the ability to determine personal goals, the
capacity to decide on a plan of action, and the freedom to act on the choice which has
been made.
• It involves consent, which is a process whereby patients are informed of possible
outcomes, possible alternatives and risks of their treatment.
• Managing clients without consent will result in non-compliance. Autonomy also values
patient’s advance directives.
• In some situations, not all patients are competent to make decisions themselves.
o Examples include young children, individuals affected by certain neurological and
mental health conditions and those who are temporarily unconscious. These patients
require substitute decision-makers, usually a next of kin or significant others.

Activity: Case Study

Instructions
Read the scenario below, and then answer the questions.

Scenario: A 15-year-old girl comes to the Reproductive and Child Health Clinic (RCH)
where you are working and she requests an oral contraceptive. The next day her mother
confronted you for giving her daughter oral contraceptive without her consent.

Questions
• What is your opinion concerning the reaction of that mother?
• Do you think it was ethically proper for the health worker to offer contraceptives?

Other Ethical Principles


• A set of other ethical principles often cited in medical texts are those described by
Beuchamp and Childress (1994) in their book; ‘Principles of Biomedical Ethics’.
• They are so well known that they have been called ‘The Georgetown Mantra’ as the
authors were from Georgetown University. These include the following:
o The principle of respect for autonomy - meaning state of self governance
o The principle of non-maleficence - meaning not doing harm to others
o The principle of beneficence - meaning charitable or generous (promote the wellbeing
of others)
o The principle of justice - meaning being fair in resource allocation and fairness

Key Points
• There are five types of ethical principles that are important in providing quality care:
o The value of life principle
o The principle of goodness or rightness
o The principle of justice or fairness
o The principle of truth telling or honesty
o The principle of individual freedom

Evaluation
• Define common terms related to ethical theories and principles.
• List two major ethical theories.
• Identify the importance of systematic study of ethics to medicine.

CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 5: Ethical Theories and Principles in Medical Practice 47
References
• Beuchamp and Childress. (1994). Principles of Biomedical Ethics. Oxford: Oxford
University Press.
• Burkhardt, Margareth A., and Nathaniel, A.K. (2007). Ethics and Issues in Contemporary
Nursing (3rd ed.). New York: Thomson.
• CIOMS. (1993). International Ethics Guidelines for Biomedical Research Involving
Human Subjects. Geneva: Council for International Organizations of Medical Sciences.
• Furrow, Dwight (2005). Ethics: Key Concepts in Philosophy. New York: Continuum.
• Mellish, J.M. and Paton, Frieda, (1999). An Introduction to the Ethics of Nursing.
Capetown: Heinemenn.
• The Tanzania Medical Practitioners and Dentist Ordinance.
• Williams, John R. (1942). Medical Ethics Manual. World Medical Association, Inc.

CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 5: Ethical Theories and Principles in Medical Practice 48
 Session 6 : Confidentiality in Medical Practice 
Learning Objectives
By the end of this session, students are expected to be able to:
• Define confidentiality
• Explain the principles of confidentiality in medical practice
• Describe the importance of confidentiality in medical practice
• Identify limitations of confidentiality in medical practice

Definition of Terms
• Confidentiality: The ethical principle that requires non-disclosure of private or secret
information with which one is entrusted.
• In research, confidentiality refers to the researcher’s assurance to participants that
information provided will not be made public or available to anyone other than those
involved in the research process without participants consent.
• The obligation to respect confidentiality applies when a person has information in
confidence.

Principle of Confidentiality in Medical Practice


• The medical practitioner’s duty to keep patient information confidential has been a
cornerstone of medical ethics since the time of Hippocrates.
• Hippocratic Oath states: ‘What I may see or hear in the course of treatment or even
outside of the treatment in regard of life of men, which in no account one must spread
abroad, I will keep to myself holding such things shamefully to be spoken about’.
• The World Medical Association International Code of Medical Ethics requires that: ‘A
physician shall preserve absolute confidentiality on all he knows about his patient even
after the patient has died’. However, other codes reject this absolutist approach to
confidentiality.
• The high value that is placed on confidentiality has three sources: autonomy, respect for
others and trust.
o Autonomy relates to confidentiality in that personal information about an individual
belongs to him or her and should not be known to others without his or her consent.
o When an individual reveals personal information to another, a medical practitioner or
nurse for example, or when information comes to light through a medical test, those
who have access to the information are bound to keep it confidential unless authorised
to divulge it by the individual concerned.
o Confidentiality is also important because human beings deserve respect. One
important way of showing them respect is by preserving their privacy.
o In addition, the basis of trust between the patient and healthcare professionals is the
ethical and legal standard of confidentiality that healthcare professionals are expected
to uphold.
o Without an understanding that their disclosures will be kept secret, the patient might
withhold personal information.
o This will hinder medical providers in their efforts to provide effective interventions or
to obtain public health goals.

CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 6: Confidentiality in Medical Practice 49
Activity: Case Study

Instructions
Read the scenario below, and then answer the questions.

Scenario
A medical practitioner was playing pool with his colleague, during that time they were
discussing about the seriousness of a tumour of one school teacher. This conversation was
overheard by a relative of the patient and the patient was informed.

Questions
• Was the practitioner right to discuss this issue at that location?
• Do you think the patient will prefer again being attended by this doctor? Why?

The Importance of Confidentiality in Medical Practice


• A confidential relationship arises whenever one person entrusts confidential information
of another person.
• Confidential information is known as secrets.
• Where the person to whom the information has been entrusted or conveyed is a medical
practitioner, the patient has the right to believe that this confidential information will not
be conveyed to others without the patient’s consent and that it will only be used for the
purpose for which it has been given.
• The trust which the patient places in the medical practitioner can be viewed as the basis of
a healthy practitioner-patient relationship.
• Two important aspects of confidentiality are identified:
o To limit access to information
o To make provision for communication on intimate and other sensitive, personal
matters
• Vulnerable patients, and in this instance particularly the dying patient, would be more
willing to reveal personal information and secrets and personal information of the patient
should not be shared unnecessarily.
• Confidentiality should be viewed as the basis of a confidential relationship in which the
practitioner is accountable for her/his practice.
• In the execution of this professional accountability she/he will not disclose any
information which is obtained during the care of the patient, except with the consent of
the patient or a person who may make decisions on behalf of the patient, or if the court
requires such a disclosure.
• Professional Pledge of Service for medical professional states in as follows; ‘I will hold in
confidence all personal matters coming to my knowledge’.

Dispute Relating to Confidentiality


• Health care personnel are obliged both legally and ethically to maintain strict
confidentiality in respect of the patient.
• If this obligation is not met, it may be viewed as a serious ethical offence and disciplinary
actions may be taken.
• Most institutions lay down strict policy measures in respect of the confidentiality of
patient information
• It is the practitioner’s duty to acquaint him or herself with these measures to prevent
being held accountable for the disclosure of confidential information.

CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 6: Confidentiality in Medical Practice 50
• Anyone who feels that the disclosure of confidential information in certain instances is
morally justifiable or even obligatory bears a burden of proof which cannot be denied.

Limitations/Challenges to the Requirement to Maintain Confidentiality


• Routine breaches of confidentiality occur frequently in most healthcare institutions, for
example:
o Many individuals, i.e. doctors, nurses, laboratory technicians, and students, require
access to patient’s health in order to provide adequate care to that person and, for
students to learn how to practice medicine.
o When patients speak a different language than their caregivers, there is a need for
interpreters to facilitate communication.
o In cases of patients who are not competent to make their own medical decisions, other
individuals have to be given information about them in order to make decisions on
their behalf and to care for them.
o Medical practitioners routinely inform family members of deceased persons about the
cause of death.
• These breaches of confidentiality are usually justified, but they should be kept to a
minimum and those who gain access to confidential information should be made aware of
the need not to spread it any further than is necessary for the patient’s benefit.
• Another generally acceptable reason for breaching confidentiality is to comply with legal
requirements. For example, there is a law for mandatory reporting of patients who suffer
from designated (notifiable) diseases such as cholera.
• In addition to those breaches of confidentiality that are required by law, medical
practitioner may have ethical duty to impart confidential information to others who could
be at risk of harm from the patient. There are two situations in which this can occur:
o When a patient tells a psychiatrist that he intends to harm another person
o When a physician is convinced that an HIV-positive patient is going to continue to
have unprotected sexual intercourse with his spouse or other partners

Activity: Case Study

Instructions
Read the scenario below, and then answer the question.

Scenario: You are a passenger in a public bus. Upon boarding a bus from Kibaha to Dar es
Salaam, Dr. X realized that the driver is a person who is attending epileptic clinic at his
hospital. Alarmed by likelihood of accident if the drive gets an attack, Dr. X stood up and
loudly announced to all passengers that your life is in danger as the driver is epileptic, and
any time he can get an accident, then he disembarked from the bus.

Question
• Was the action taken by Dr. X proper?

• Conditions for breaching confidentiality when not required by law are:


o The expected harm is believed to be imminent
o Serious (and irreversible)
o Unavoidable except by unauthorised disclosure
o Greater than the harm likely to result from the disclosure

CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 6: Confidentiality in Medical Practice 51
• In determining the proportionality of these respective harms, the medical practitioner
needs to assess and compare the seriousness of the harm and the likelihood of their
occurrence.
o In case of doubt, it would be wise to seek expert advice.
o When a medical practitioner has determined that the duty to warn justifies an
unauthorised disclosure, two further decisions must be made.
ƒ Whom should the medical practitioner tell?
ƒ How much to tell?
o The disclosure should contain only that information necessary to prevent the
anticipated harm and should be directed only to those who need the information in
order to prevent the harm.
o In case of HIV-positive patient, disclosure to a spouse or current sexual partner may
not be unethical and, indeed, may be justified when the patient is unwilling to inform
the person at risk. Such disclosure should require that all of the following conditions
are met:
ƒ The partner is at risk of infection of HIV and has no any other reasonable means
of knowing the risk
ƒ The patient has refused to inform his or her sexual partner
ƒ The patient has refused an offer of assistance by the physician to do so on the
patient’s behalf
ƒ The healthcare provider has informed the patient of his or her intention to disclose
the information to the partner
o In medical care of suspected and convicted criminals, healthcare provider should
safeguard confidentiality by not revealing details of the patient’s medical conditions
to prison authorities without first obtaining the patients consent.

Key Points
• Confidentiality is the ethical principle that requires non-disclosure of private or secret
information with which one is entrusted.
• A confidential relationship arises whenever one person entrusts confidential information
of another person.
• Professional Pledge of Service for medical professional states in as follows; ‘I will hold in
confidence all personal matters coming to my knowledge’.
• Health care personnel are obliged both legally and ethically to maintain strict
confidentiality in respect of the patient.
• There are few exceptions whereby the health care practitioner is obliged to reveal some of
the patient’s information relevant authority/persons only.

Evaluation
• What is confidentiality?
• Why should medical personnel keep confidentiality?
• What are the limitations of confidentiality in medical practice?

References
• Beauchamp, T.L., & Childress, J. (2001). Principles of Biomedical Ethics (5th ed.). New
York: Oxford University Press.
• Burkhardt, Margareth A. & Nathaniel, A.K. (2007). Ethics and Issues in Contemporary
Nursing (3rd ed.). New York: Thomson.

CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 6: Confidentiality in Medical Practice 52
• CIOMS. (1993). International Ethics Guidelines for Biomedical Research Involving
Human Subject. Geneva: Council for International Organizations of Medical Services.
• Devettere, R.J. (1995). Practical Decision Making in Health Care Ethics: Cases and
Concepts. Washington, DC: Georgetown University.
• Furrow, Dwight. (2005). Ethics: Key Concepts in Philosophy. New York: Continuum.
• Mason, J.K., McCall Smith R.A., and Laurie G.T. (1999). Law and Medical Ethics.
London: Butterworths.
• Mellish, J.M. and Paton, Frieda. (1999). An Introduction to the Ethics of Nursing.
Capetown: Heinemenn.
• Tanzania National Health Research Forum. (2001). Guidelines on Ethics for Health
Research in Tanzania. Dar es Salaam, Tanzania.
• The Tanzania Medical Practitioners and Dentist Ordinance.
• Williams, John R. (1942). Medical Ethics Manual. World Medical Association, Inc.

CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 6: Confidentiality in Medical Practice 53
CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 6: Confidentiality in Medical Practice 54
 Session 7 : Rights of the Client/Patient 
Learning Objectives
By the end of this session, students are expected to be able to:
• Define the terms right, patient, culture and values
• Identify rights of the patient/client
• Identify the culture and values that influence comprehensive health care
• Demonstrate the application of the patient rights when providing medical service

Definition of Terms
• Rights: Is a privilege or fundamental power to which an individual is entitled unless is
revoked by law or given up voluntarily.
o Are social or economical privileges to which some has to claim legally or morally
• Patient/Client: Is any person who receives medical attention, advice, care or treatment
often ill or injured.
• Culture: Is defined as a belief, value, norms and customs of a specific group.
• Values: Are particular characteristics or qualities, which single out a person, department,
an institution, or an organisation to be recognised as it is.
o Value is something that is perceived as desirable or ‘the way things ought to be’ (Ellis
& Dean, 2000; Husted & Husted, 2001).

The Rights of the Patient/Client


• Any person who seeks health services deserves specific rights, and health workers are
obliged to safeguard them.
• The client/patient has the right to:
o Be treated with compassion, love and respect
o Information about his/her health conditions, prescribed treatment and procedures
o Complain, review and appeal in accordance with established procedures
o Privacy and confidentiality
o Refuse services if they do not meet the required needs and standards
o Access to health services, facilities and information according to their needs
o Informed consent, self-expression and choice of care
o Know hospital rules and regulations that apply to his or her conduct as a patient

Right to be Treated with Compassion, Love and Respect


• Compassion: Is an emphatic feeling.
o Longman Dictionary of Contemporary English (1990) defines compassion as
sympathy for suffering of others, causing a desire to help them.
o It is often characterised by actions, wherein a person acting with compassion will seek
to aid those they feel compassionate for.

Examples of Compassion
• A patient with cancer of the oesophagus had no spiritual counselling before. Once a
clinician touched on this aspect the patient said, ‘Oh yes I really and badly wanted to see
a priest’, the priest was called and after a spiritual session the patient died peacefully.

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Session 7: Rights of the Client/Patient 55
• A reason commonly given by mothers who opt for delivery at home is lack of compassion
by health providers in the facilities.
o A young woman had her first delivery in nearby hospital. The abusive language she
underwent from the nurses made her decide never to deliver in that health facility
again. Instead, she had her second and third deliveries at another health facility where
she claimed there was more compassion.
o Some patients prefer to go to certain hospitals because they believe there is more
compassion.

Right to Information
• Information is something, which gives knowledge in the form of facts and news.
• The patient has the right to receive adequate and appropriate information about any
proposed medical care as the patient may need to give informed consent or to refuse the
course of treatment.
• In some situations, such as when a patient is asked to sign a document that he/she has not
read, cannot read or could not understand it from the beginning, the patient’s/client’s right
to information and participation in medical care has not been observed.

Activity: Case Study

Instructions
Read the scenario below, and then answer the question.

Scenario: Mrs. M and her family were involved in a motorcar accident whereby her husband
and her two children died on the spot. Mrs. M was brought to the hospital unconscious with
head injury. After gaining consciousness, she kept on asking for her husband and her two
children. The clinician made up a story to conceal the fact fearing that by telling her the truth
might result in upsetting her emotions and worsen her condition.

Question
• Was the clinician doing right by concealing the truth to the patient? Explain.

Right to Privacy
• Privacy is defined as a desirable state of being away from other people so that they cannot
see or hear what you are doing. Refers to ones ownership of one’s body or information
about oneself.
• Right to privacy is important in order to establish communication and a trusting
relationship so that the person is able to submit his/her body during medical care.
• Privacy for patient’s body, information and their hospital documents is one of the
observed human rights when providing care. Clinicians should safeguard patient’s
privacy in order to maintain his/her human dignity.

Right to Confidentiality
• Confidentiality is defined as ensuring that information will not be made public and will be
accessible only to those authorised to have access.
• Confidentiality is one of the cornerstones of information security.
• Patients give confidential information to health practitioners voluntarily believing that it
will help in their receiving correct diagnoses and appropriate treatment.

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Session 7: Rights of the Client/Patient 56
• We observe confidentiality because we respect our clients and their autonomy and it is the
essential element of building trust in relationships.
• It is a duty of health practitioners to maintain confidential information revealed to them
by their patients/clients and shall not disclose the information to unauthorised people.
• However, in the process of caring for patients, health practitioners shall share this
information with other members of health-care team for continuity of care.

Right to Self Determination (Consent)


• Consent: Is defined as the granting of permission by the patient for another person to
perform an act regarding the medical care.
• All procedures in health require patient’s consent as an indication for acceptance to what
is planned for him/her.
• However, in the event of an emergency where there is a need to save life or to prevent
more harm, health practitioners may proceed to provide services without waiting for the
consent.
• In addition, in the event that the client is unconscious, has mental illness or is below age,
somebody else such as a spouse/parent/guardian can give permission on his/her behalf as
he/she cannot sign the consent about the procedure. The consent can be given in writing
or verbally.

Activity: Case Study

Instructions
Read the scenario below, and then answer the question.

Scenario: A patient came to hospital with an obstructed labour and refused to be operated
saying ‘I cannot undergo this because I believe I will deliver in a normal way’. Then medical
practitioner did not proceed with the operation recognising the right of the patient to give
consent. But this resulted that, the patient was not operated immediately and child was born
with low APGAR score.

Question
Was the health provider right?

Culture in Medical Practice


• We must be culturally sensitive when rendering services.
• Cultural sensitivity is the ability to incorporate the patient’s cultural perspective when
assessing the situation and hence modifying medical care in order to match with the
patient’s culture.
• Each culture understands the life process differently. If we ignore the patient’s culture we
may find ourselves labelling the patient as being uncooperative or strange.
• Culture may influence individual feelings and the way to express those feelings. For
example in pain some keep quiet, others shout or cry.

Implication of Culture in Rendering Health Services


• Culture is a design for living. It provides a set of norms and values that offer stability and
security for the society and plays major roles in motivating behaviours. The variety of
cultural groups in our society reinforces the need for the health practitioner to understand
and appreciate cultural diversity.

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Session 7: Rights of the Client/Patient 57
• The medical profession has a duty to train practitioners to provide care which is
meaningful and sensitive to the needs of patients of all cultures. It is important that a
practitioner should carefully consider the following cultural rights of the client:
o Recognition of his/her own cultural orientation, meaning that there is need for
medical practitioners to analyse their own beliefs which may influence their
willingness to care for other people
o Understanding of the importance of the patient’s perspectives in that it enables the
medical practitioner to identify differences and then to find ways of working with
such differences.
o Development of communication skills in order to examine the patient’s perspectives;
the health provider cannot identify a patient’s perspectives or involve the patient in a
discussion if for some reasons the patient is unable to communicate effectively
• Identification of issues and factors which influence provision of care to people of other
cultures is an important aspect in provision of effective medical care

Example of Culture in Rendering Health Services


• Many cultures have specific customs relating to the death of the family member. This
could give the medical practitioner an indication of how she spends time with the dying
person, the care of the body after death and the patterns of mourning.
• Secondly, many cultures have specific customs relating to childbirth.
o For examples in some cultures males are not accepted to assist a woman in labour.
• If a medical practitioner who is managing a patient with specific cultural customs is
sensitive to these customs, it will be of great value to the patient.

Values of a Health Practitioner


• Values are lasting beliefs that are important to individuals, groups and cultures, and
therefore they strongly influence medical care.
• Often the medical practitioner is faced with making decisions that affect clients’ values
and involve conflicting moral values and ethical dilemmas. Understanding what personal
values are and how they affect behaviour assists in delivering quality medical care.
• The core values which are expected to be adhered by medical practitioners in Tanzania
are as follows:
o Diligence to duty
o Maintaining and ensuring excellence
o Loyalty to authority in general
o Abide to other relevant codes of conduct, for example the Public Service Code of
Conduct
o Integrity
o Courtesy to clients
o Respect for the law
o Proper use of official information
o Team work spirit
o Compassion

Core Management Values


• Impartiality in service provision
• Provision of quality services
• Ethical conduct
• Equity in access to health services

CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 7: Rights of the Client/Patient 58
• Client confidentiality and privacy
• Respect for colleagues and clients
• Individual right to health care
• Affordability of care
• Partnership in health care provision

Key Points
• A right is a privilege or fundamental power to which an individual is entitled unless it is
revoked by law or given up voluntarily.
• Any person who seeks health services deserves specific rights, and health workers are
obliged to safeguard them.

Evaluation
• What are the patient’s/client’s rights?
• Identify the culture and values that influence comprehensive health care in your area.

ASK students if they have any comments or need clarification on any points.

References
• Beauchamp, T.L., & Childress, J. (2001). Principles of Biomedical Ethics (5th ed.). New
York: Oxford University Press.
• Burkhardt, Margareth A. & Nathaniel, A.K. (2007). Ethics and Issues in Contemporary
Nursing (3rd ed.). New York: Thomson.
• CIOMS. (1993). International Ethics Guidelines for Biomedical Research Involving
Human Subject. Geneva: Council for International Organizations of Medical Services.
• Devettere, R.J. (1995). Practical Decision Making in Health Care Ethics: Cases and
Concepts. Washington, DC: Georgetown University.
• Furrow, Dwight. (2005). Ethics: Key Concepts in Philosophy. New York: Continuum.
• James H. Husted & Gladys L. Husted. (2001). Ethical Decision Making in Nursing and
Health Care. Springer Publishing Company.
• Kathryn Ellis & Hartley Dean. (2000). Social Policy and the Body: Transitions in
Corporeal Discourse. Macmillan, Basingstoke.
• Mason, J.K., McCall Smith R.A., and Laurie G.T. (1999). Law and Medical Ethics.
London: Butterworths.
• Mellish, J.M. and Paton, Frieda. (1999). An Introduction to the Ethics of Nursing.
Capetown: Heinemenn.
• Tanzania Medical Practitioners Code of Vonduct.
• Tanzania National Health Research Forum. (2001). Guidelines on Ethics for Health
Research in Tanzania. Dar es Salaam, Tanzania.
• The Tanzania Medical Practitioners and Dentist Ordinance.
• Williams, John R. (1942). Medical Ethics Manual. World Medical Association, Inc.

CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 7: Rights of the Client/Patient 59
CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 7: Rights of the Client/Patient 60
 Session 8: Rights of the Health Care Provider 
Learning Objectives
By the end of this session, students are expected to be able to:
• Define the terms right, health provider
• Identify health provider’s rights
• Describe guidelines on health and safety programs for health providers
• Identify responsible stakeholders for health provider safety
• Describe compensation rights for health providers injured at work

Definition of Terms
• Health care provider: A person who has acquired the expert knowledge base in health
matters, decision-making skills and clinical competencies for practical practice, the
characteristics of which are shaped by context and/or country which he/she is legally
allowed to practice.
• Right: Is a privilege or fundamental power to which an individual is entitled unless is
revoked by law or given up voluntarily.
o Also is defined as social, economical or privileges to which some has to claim legally
or morally.

Rights of the Health Care Provider


• Health providers are falling ill, incurring workplace injuries, and suffering from exposure
to workplace hazards. As a result, the global community is losing critical members of the
healthcare team, compounding the already existing staff crisis.
• This needless attrition seriously impairs the fulfilment of the United Nations Millennium
Development Goals (MDGs) and affects the ability to meet primary health care needs.
These challenges can be effectively resolved if health providers’ rights are respected.
• The International Labour Organization (ILO) acknowledged the need for safe and health
workplaces 30 years ago (ILO convention 157). This shows that the health practitioner
has the right to remain safe from hazards/injuries happening in the course of their
employment.

Activity: Small Group Discussion

Instructions
You will work in small groups to discuss and list rights of health care provider. Record your
answers. One group will present their responses and other will share in the discussion.

• Basic human rights of all Tanzanians are provided in the Constitution of the United
Republic of Tanzania.
• Together with these rights, the health care provider has the right to:
o Recognition of their competence and potential as well as respect for their human
action
o Health providers have the right to opportunities for professional advancement
o Practice in an environment that allows them to act in accordance with professional
standards and authorised scopes of practice

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Session 8: Rights of the Health Care Provider 61
o Work in an environment that supports and facilitates ethical practice in accordance
with Code of Professional Conduct
o Negotiate the condition of their employment, either as individuals or collectively in
all practice setting
o Work in an environment that is safe to herself/himself and to her/his patients
o Fair compensation for her/his work consistent with their knowledge, experience and
professional responsibility
o Freely advocate for themselves and their patients/clients
o Get rest, leisure time and family life
o Compensation for injuries happening in the course of their work

Activity: Case Study

Instructions
Read the scenario below, and then answer the question.

Scenario
Clinician X is working in a rural health centre for 6 years. He feels that in order to execute
high quality care, he needs to advance himself further by enrolling in a degree program. He
applies to the university and is granted admission. He wrote a letter to the employer in order
to be released for his studies.

The employer reads the letter, bangs the table and says ‘What is this? Nonsense! A clinical
officer for a degree? No way’! He calls the clinician and tells him that permission is not
granted for him to go for the studies.

Questions:
1. What right has the clinician been denied?
2. What further action should the clinician take to get his right?
3. What is the best way of dealing with such an employer?

Key Points
• Right is a privilege or fundamental power to which an individual is entitled unless is
revoked by law or given up voluntarily.
• Health care providers have right to; recognition, professional advancement, better
enabling environment, negotiation, fair compensation and time for rest and family

Evaluation
• Please mention the different rights of health providers.
• Can a volunteer explain the guidelines on health and safety programs for health
providers?
• Can someone please identify responsible stakeholders for health provider safety?

References
• Beauchamp, T.L., & Childress, J. (2001). Principles of Biomedical Ethics (5th ed.). New
York: Oxford University Press.
• Burkhardt, Margareth A. & Nathaniel, A.K. (2007). Ethics and Issues in Contemporary
Nursing (3rd ed.). New York: Thomson.

CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 8: Rights of the Health Care Provider 62
• Devettere, R.J. (1995). Practical Decision Making in Health Care Ethics: Cases and
Concepts. Washington, DC: Georgetown University.
• Furrow, Dwight. (2005). Ethics: Key Concepts in Philosophy. New York: Continuum.
• Mason, J.K., McCall Smith R.A., and Laurie G.T. (1999). Law and Medical Ethics.
London: Butterworths.
• Mellish, J.M. and Paton, Frieda. (1999). An Introduction to the Ethics of Nursing.
Capetown: Heinemenn.
• Tanzania Medical Practitioners Code of Vonduct.
• The Tanzania Medical Practitioners and Dentist Ordinance.
• Williams, John R. (1942). Medical Ethics Manual. World Medical Association, Inc.

CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 8: Rights of the Health Care Provider 63
CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 8: Rights of the Health Care Provider 64
 Session 9: Laws Related to Medical Practice  
Learning Objectives
By the end of this session, students are expected to be able to:
• Define law, constitutional law, statutory law, administrative law, common law and public
law
• Recognise the relationship between ethics and law
• Describe sources of law
• Describe the differences between criminal and private law

Definition of Terms

Activity: Group Discussion

Instructions
Work in small groups to define law. Record your responses. One group will present and other
group will share in the discussion.

• Law: A system of binding rules of action or conduct that govern the behaviour of people
in respect to relationship with others and with the government.
• Laws, meant to reflect the moral belief of a given population, are designed by groups of
people serving in official capacity.
• The law establishes rules that define our rights and obligations, and sets penalties for
people who violate them. Law also describe how government will enforce the rules and
penalties.
• In general, laws ensure the safety of the citizens, protects properties, promote non-
discrimination, regulate the professions, provide for the distribution of public goods and
services, and protects the economic and environmental interests of the society.

Constitutional Law
• A constitution is a formal set of rules and principles that describe the powers of a
government and the rights of the people.
• The principles laid out in a constitution, coupled with description of how these principles
are to be interpreted and carried out, forms the basis of constitutional law.

Statutory/Legislative Law
• These are formal laws written and enacted by the Parliament or local government
legislatures. Because many people think that every problem in the society can be solved
by passing a law, legislature makes more and more laws to satisfy the demand of the
society.

Administrative Law
• Administrative law consists mainly of the legal powers granted to administrative agencies
by legislative bodies and the rules that the agencies make to carry out their powers. It
involves the operation of government agencies.

CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 9: Laws Related to Medical Practice 65
• The state sets up administrative agencies to do the work of the government. These
agencies regulate such activities as education, public health, social welfare programs and
professions.
o The Medical Council of Tanganyika is example of these types of agencies.

Common Law
• Is a law system based upon earlier court ruling in similar cases. This type of law is also
known as case law. Earlier court ruling in similar cases are also known as precedents.

Public Law
• Is a law which deals with a person’s rights and obligations in relation to the government
and describes the various divisions of government and their powers. One important
branch of public law is criminal law.

Relationship Between Ethics and Law

Activity: Case Study

Instructions
Read the scenario below, and then answer the questions.

Scenario
A medical practitioner has placed a huge advertisement on the service he is providing and
expresses how good he is in managing complicated surgeries.

Questions
1. Is this ethically appropriate?
2. Did he break any law?
3. Is this both a legal and ethical issue?

• Laws are intended to reflect popular belief about ‘rightness and wrongness’ of a particular
acts and are, like ethics, built upon moral foundation.
• In most countries laws represent an attempt to codify ethics. One would expect that laws
would be congruent with prevailing moral values of the society.
• For example, most people would agree that the murder of innocent person is an immoral
act. Laws that prohibit murder reflect this ethical standard. Murder of the innocent is both
ethically and legally prohibited in every culture.

Sources of Law
• At least four different sources of law affect the practice of medicine: constitutional law,
statutory (legislative) law, administrative law, and common law.
• Additionally, law can be divided into two main branches: private law and public law.

Constitutional Law
• The Constitution of the United Republic of Tanzania is the preeminent source of this
country’s law. Ensuring legal rights and responsibilities of citizens and establishing
general organisation of the government, constitutional law supersedes all other laws.

CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 9: Laws Related to Medical Practice 66
• The Bill of Rights of the United Republic of Tanzania Constitution guarantees each
citizen the rights, among others, of equal protection, freedom of speech, freedom of
movement, freedom of religion.
• A medical practitioners’ action should take into account these basic rights. Bills of Rights
are consistent with the ethical principles of autonomy, confidentiality, respect of person
and veracity.
• These same rights that apply to patients also apply to medical practitioners. As
participants in the health care system, we cannot be forced to forfeit our constitutionally-
guaranteed rights.

Statutory/Legislative Law
• Statutory or legislative law has more power because it is passed by the parliament of the
United Republic of Tanzania.
• It has disadvantages such as, it is not easy to be reviewed and it cannot cover technical
details of the service it intends to regulate.

Administrative Law
• The state set up administrative agencies to do the work of the government. These
agencies regulate such activities as education, public health, social welfare programs and
professions.
• The law establishing these administrative agencies and regulation/rules/by-laws issued by
these agencies are sources of law.
• Rules propagated by the administrative bodies carry the same weight as other law.

Common Law
• Tanzania and other English-speaking countries have a common law system as one source
of law.
• Judicial decisions depend on previous court ruling as the guidance in making subsequent
ruling.

Differences Between Criminal and Private Law


Criminal Law
• Criminal law is a branch of public law which deals with crime.
• A crime is an actions considered harmful to the society.
• Even though a crime might be committed against a particular person, the government
considers the commission of the serious act such as murder, to be harmful to all society.
• Crimes range in seriousness, from public drunkenness to murder.
• Criminal law defines these offences and sets rules for the arrest, the appropriate procedure
to ensure due process and the punishment of offenders.
• Felonies are serious crimes that carry significant fines and jail sentences. Example of
felonies includes manslaughter.
• Medical practitioners are rarely accused of felonies in the course of practice. However,
this can occur. For example, it is possible that those participating in unauthorised removal
of life support from terminally ill patient could be accused of murder. This can apply to
abortions too.
• A misdemeanour is a less serious crime and is usually punishable by a fine, a short jail
sentence or both. Example of misdemeanours includes disturbing the peace, slapping
patients or giving injection without consent.

CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 9: Laws Related to Medical Practice 67
Private Law
• It is also called civil law. It determines a person’s legal rights and obligations in many
kinds of activities that involve other people. These activities include everything from
borrowing or lending money to signing a job contract.
• There are six branches of private law: contract and commercial law, tort law, property
law, inheritance law, family law, and corporation law.
• Non-compliance with private law generally leads to monetary compensation granted to
the injured or complaining party.
• Branches of private law that are most applicable to medical practice are:
o Contract law
o Tort law

Contract Law
• A contract is a binding legal agreement that is enforceable in a court of law.
• Contract law is based on the principle saying ‘agreements are to be kept’. Breach of
contract is recognized by the law and remedies can be provided.
• Medical practitioners do not normally enter into contractual relationship with patient. The
patient usually enters into a contract with a hospital.
• If a health practitioner were to act negligently or unprofessionally, the patient who suffers
the damage could hold either the practitioner or the hospital liable on the basis of
contract.
• However, if the practitioner were to be in private practice, the contract clearly exists
between the practitioner and the patient. A breach of this contract will be subject to
normal legal remedies applied to contract.

Key Points
• The law establishes rules that define our rights and obligations, and sets penalties for
people who violate them.
• The main four different sources of law affect the practice of medicine are: constitutional
law, statutory (legislative) law, administrative law, and common law.

Evaluation
• Define law, constitutional law, statutory law, administrative law, common law and public
law.
• Explain the relationship between ethics and law.
• What are the differences between criminal and private law?

References
• Beauchamp, T.L., & Childress, J. (2001). Principles of Biomedical Ethics (5th ed.). New
York: Oxford University Press.
• Burkhardt, Margareth A. & Nathaniel, A.K. (2007). Ethics and Issues in Contemporary
Nursing (3rd ed.). New York: Thomson.
• CIOMS. (1993). International Ethics Guidelines for Biomedical Research Involving
Human Subject. Geneva: Council for International Organizations of Medical Services.
• Devettere, R.J. (1995). Practical Decision Making in Health Care Ethics: Cases and
Concepts. Washington, DC: Georgetown University.
• Furrow, Dwight. (2005). Ethics: Key Concepts in Philosophy. New York: Continuum.

CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 9: Laws Related to Medical Practice 68
• Mason, J.K., McCall Smith R.A., and Laurie G.T. (1999). Law and Medical Ethics.
London: Butterworths.
• Mellish, J.M. and Paton, Frieda. (1999). An Introduction to the Ethics of Nursing.
Capetown: Heinemenn.
• Tanzania Medical Practitioners Code of Vonduct.
• Tanzania National Health Research Forum. (2001). Guidelines on Ethics for Health
Research in Tanzania. Dar es Salaam, Tanzania.
• The Tanzania Medical Practitioners and Dentist Ordinance.
• Williams, John R. (1942). Medical Ethics Manual. World Medical Association, I

CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 9: Laws Related to Medical Practice 69
CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 9: Laws Related to Medical Practice 70
 Session 10: Negligence in Medical Practice  
Learning Objectives
By the end of this session, students are expected to be able to:
• Define negligence
• Describe factors necessary to establish negligence
• Explain action which can be taken on a negligent practitioner
• Describe factors which can help to minimize negligence

Definition of Terms

• Negligence: The omission to do something that a reasonable person, guided by those


ordinary considerations which ordinarily regulate human affairs would do, or doing
something which a reasonable and prudent person would not do.
• The definition above indicates that negligence can be cause by an action and also by an
omission (lack of action).
• An example of negligence caused by action is like when a person throws rocks in a crowd
of people. There is no law against throwing rocks in the air. However, within a crowd of
people this is not an act of a reasonable person. Although the person throwing rocks has
no intention of harming others, resultant injury would be the outcome of negligence.
• A health worker who pours liquid on the floor in a patient’s room would be held to the
same standard, i.e., a reasonable person would recognise that wet floors often causes falls,
and would immediately clean the floor and warn people who may be walking in the
vicinity.
• In other situations, negligence can also occur as a result of omission. Act of negligence in
medical practice can be judged upon the criteria of the knowledge and abilities expected
of a reasonable and prudent medical practitioner, as opposed to a reasonable and prudent
person.
• Because the knowledge base of medicine is broad, technical and specific to the
profession, these criteria go far beyond those required of ordinary person.

Factors Necessary to Establish Negligence


• Behaviour is considered negligent if the reasonable man unlike, the doer, would:
o Reasonably have foreseen the possibility that his conduct would harm another in his
person or property and thereby cause his unlawful damage.
o Have taken reasonable steps to prevent the damage.

• Brief criteria for testing someone’s conduct for negligence can be stated as follows:
o Would a reasonable man placed in the doer’s position:
ƒ Have anticipated (foreseen) the possibility of harm?
ƒ Have taken steps to prevent such harm?
o Did the doer’s conduct deviate from the above mentioned standards?
ƒ If so, the doer was negligent, if not, he is not negligent.

CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 10: Negligence in Medical Practice 71
Establishing Negligence in Order to Get Compensation
• In event that a client who has suffered harm because of negligent action of the health
worker, and the client have instituted claims for compensation in a court of law, the
following conditions must be proved:
o That the defendant was under a recognized legal duty to provide care
o That the legal duty extended to cover the claimant in the particular circumstances
o That the defendant breached that legal duty
o That as a result of that breach of duty by the defendant, the claimant suffered loss or
damage or injury
o That the loss, damage or injury was the proximate result of the breach of duty by the
defendant

Activity: Case Study

Instructions
Read the scenario below and then answer the questions.

Scenario
A medical practitioner was examining a mother in labour pain at a health centre.
Unfortunately, he did not examine foetal heart rates. After several hours of delayed labour,
the mother delivered a still birth. It was established that the baby went through a period of
foetal distress which would have been noted by the practitioner if he would have taken
foetal heart rate.

Questions
• Was this practitioner negligent or not?
• Why?

Action Taken on a Negligent Practitioner


• A negligent medical professional will be subjected to disciplinary proceedings from his
professional regulatory authority such as the Medical Council of Tanganyika,
administrative disciplinary proceedings from his employer and also he can be subjected to
the court of law for compensation.
• In some extremes, negligent behaviour can also be considered as a crime, particularly
when there is extreme recklessness or involvement with illegal practice such as abortion.
• In dealing with a negligent behaviour, the professional regulatory authority will base its
charges on the professional code of conduct and the pledge that the professionals declared
at the beginning of their professional life.
• The regulatory authorities will just look at the conduct of the professional in order to
conclude if the conduct was in accordance to the code of conduct.
• A health practitioner’s conduct may also be contrary to administrative regulations at the
place of work.
o For example, if a facility has a hospital care used for bringing staffs on call to the
hospital at night, an administrative directive may direct that the car must stay at the
hospital compound.
o If a negligent health worker decides to stay with the hospital car at his house, it could
delay bringing in an anaesthetist to the hospital.
o This could lead to maternal death. Negligence like this may also lead to administrative
disciplinary action.

CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 10: Negligence in Medical Practice 72
• In addition, the same negligent conduct can lead to the victim claiming for compensation
in a civil case. The claimant may be the patient or his next of kin, and the defendant can
be the health practitioner or the hospital.
• The claimant may demand compensation citing negligent conduct of the practitioner that
if not for the negligence in providing transport to bring in the anaesthetist, the patient
wouldn’t suffered the injury or death.
• The claimant will sue the hospital because it is the responsibility of the hospital to ensure
that it employs practitioners who are competent and of the right conduct.
• Also, in many health facilities, clients do not come to be seen by a specific practitioner,
rather they are coming to be attended by the hospital.
• Another reason for suing the hospital is because it is much more likely to get
compensation from the hospital than getting from a practitioner.
• Some of the medical practitioners’ actions might be crimes. Crimes are dealt with the
Penal Code and the Criminal Procedures Act.
• In Tanzania it is a crime to conduct abortion or assist in conducting abortion. In a
problem like this, the practitioner will be charged by the police and punishments will
include fine or imprisonment or both fine and imprisonment.

Activity: Case Study

Instructions
Read the scenario below and then answer the questions.

Scenario
A two-year-old child was admitted in a certain hospital due to complicated malaria. He was
put under IV quinine. On the third day his grandmother noticed that his left hand has turned
bluish and is very cold. It was later established that the hand has become gangrenous due to
forgotten tourniquet and it was amputated. Several practitioners and nurses have attended this
child during his three days stay.

Questions
1. Was the gangrene due to negligence?
2. Who was negligent? Why?

Factors Which Can Help to Minimize Negligence Complaints


Activity: Group Discussion

You will work in groups to discuss the steps to take when in practice, in order to minimise
negligence at their workplaces. Record your answers. One group will present their responses
and other will share in the discussion.

• Commonly, negligence happens when the medical practitioner does not follow
established protocol or standard operational procedure. We come across situations
whereby practitioners have opted for short cuts or just followed the way the institution
operates instead of following approved guidelines.
• The following points must be observed in order to minimise negligence:

CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 10: Negligence in Medical Practice 73
o Documentation: It helps in informing other members of health care team of actions
already taken in a care of patients. In event of charges brought against the practitioner,
documentation will help in proving what has been done to the patient.
o Communication: Often, lack of effective communication has led to many grievances.
Sometimes the client is not sufficiently informed about a procedure and expected side
effects or complications.
ƒ In many occasions, the way the medical practitioner speaks to clients may cause
more misunderstanding leading to serious unwanted consequences.
ƒ The practitioner may become rude, arrogant or even assault the clients verbally.
Client may want to see that the medical practitioner has realised her weakness and
similar consequences may not happen to another patient.
o Responsible/accountable conduct: A responsible health worker will respond
appropriately and effectively to the needs of the clients. In addition, they must be
personally accountable for their action. If practitioners will observe these
requirements, complaints will become fewer.

Key Points
• Negligence is the omission to do something that a reasonable person, guided by those
ordinary considerations which ordinarily regulate human affairs would do.
• A negligent medical professional will be subjected to disciplinary proceedings from his
professional regulatory authority or by court in cases of crime.
• Some of the medical practitioners’ actions might be crimes. Crimes are dealt with the
Penal Code and the Criminal Procedures Act.
• In Tanzania, it is a crime to conduct abortion or assist in conducting abortion.
• In order to minimise negligence, the following should be encouraged: documentation,
communication, and responsible/accountable conduct of health providers.

Evaluation
• Ask students to mention some of the examples that might be interpreted as negligent that
they have observed in their daily life
• What are the steps to establish negligence?
• Which steps will the students as health care workers do to minimize negligence?

References
• Beauchamp, T.L., & Childress, J. (2001). Principles of Biomedical Ethics (5th ed.). New
York: Oxford University Press.
• Burkhardt, Margareth A. & Nathaniel, A.K. (2007). Ethics and Issues in Contemporary
Nursing (3rd ed.). New York: Thomson.
• CIOMS. (1993). International Ethics Guidelines for Biomedical Research Involving
Human Subject. Geneva: Council for International Organizations of Medical Services.
• Devettere, R.J. (1995). Practical Decision Making in Health Care Ethics: Cases and
Concepts. Washington, DC: Georgetown University.
• Furrow, Dwight. (2005). Ethics: Key Concepts in Philosophy. New York: Continuum.
• Mason, J.K., McCall Smith R.A., and Laurie G.T. (1999). Law and Medical Ethics.
London: Butterworths.
• Mellish, J.M. and Paton, Frieda. (1999). An Introduction to the Ethics of Nursing.
Capetown: Heinemenn.
• Tanzania Medical Practitioners Code of Conduct.

CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 10: Negligence in Medical Practice 74
• Tanzania National Health Research Forum. (2001). Guidelines on Ethics for Health
Research in Tanzania. Dar es Salaam, Tanzania.
• The Tanzania Medical Practitioners and Dentist Ordinance.
• Williams, John R. (1942). Medical Ethics Manual. World Medical Association, Inc.

CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 10: Negligence in Medical Practice 75
CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 10: Negligence in Medical Practice 76
 Session 11: Relationship Between Law and
Confidentiality  
Learning Objectives
By the end of this session, students are expected to be able to:
• Define confidentiality
• Describe the scope of duty of confidentiality
• Mention limitations of duty of confidentiality
• Describe consequences arising from the breach of confidentiality

Definition of Terms
• Confidentiality: The statutory protected right afforded to (and duty required of)
specifically designated health professionals not to disclose information obtained during
consultation with a patient.
• It originates from the concept of confiding and trust.
• Healthcare clients are willing to share their private information with health service
providers because they trust that the information will not be accessed by other persons.

Scope of the Duty to Confidentiality


• One of the most fundamental ethical obligations owed by a medical practitioner to his/her
patient is to respect the confidence of his patient.
• This has long been a central premise our approach to medicine can be seen from the fact
that the Hippocratic Oath states:
o ‘What so ever things I see or hear concerning the life of men, in my attendance on the
sick or even apart there from, which ought not to be noised abroad, I will keep silence
thereon, counting such things as sacred secretes’.

Confidence
• The health professionals have long accepted a professional obligation of respect a
patients’ medical confidence. Health profession regulatory authorities have insisted that
patients have the right to expect that information about them will be held in confidence by
their doctors.
• Confidentiality is central to trust between doctors and patients. Without assurance about
confidentiality, patients may be reluctant to give doctors the information they need in
order to provide good care.
• If a health worker is asked to provide information about their patients, they should:
o Seek patient’s consent to disclosure wherever possible, whether or not he judge that
the patient can be identified from the disclosure
o Anonymous data where unidentifiable data will serve the purpose
o Keep the disclosure to the minimum necessary.

Health Worker’s Responsibility to Confidence


• A health worker must always be prepared to justify his decision in accordance with the
guidance.
• Breaches of the regulatory authority guidelines may expose a practitioner to disciplinary
proceedings with the possible consequences of:
o If found guilty, the practitioner may be suspended, cautioned or even deleted from the
registers.

CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 11: Relationship between Law and Confidentiality 77
• Confidentiality and right to privacy are also protected in the Constitution of the United
Republic of Tanzania.
• A duty of confidence is established when confidential information comes to the
knowledge of a person (the confidant) in circumstances where he has notice, or is held to
have agreed, that the information is confidential. This duty is related to the duty of the
priests who gains information in their professional capacity.
• The information can be acquired from observation, conversation or examination. The
duty still exists even if the information is not released deliberately or is released
inadvertently.
• The fact that information has been anonymised does not of itself remove the duty of
confidence.
• Importance of sharing information in the medical field is understood. However, it is
reminded that health workers are supposed to ensure that anyone whom they disclose
personal information understands that it is given to them in confidence which, they have
to respect.

Activity: Case Study

Instructions
Read the scenario below and answer the questions. Record your answers on a piece of paper.
One group will present their responses and other will share in the discussion.

Scenario
While playing Bao in the evening, two clinical officers were also discussing the extent of
tearing experienced by one patient at their health centre during delivery. One of the two
clinical officers was in fact working in paediatric ward and had nothing to do with patients
admitted in the labour ward.

Questions
• By sharing this information with another clinical officer, was this practitioner guilty of
breaching duty to confidentiality?
• Give examples of situations whereby it is allowed to share patients’ confidential
information with other health worker.

Limitations of Duty of Confidentiality


• There is unequivocal view that confidential patients’ information is protected from
disclosure by law.
• However, in some situations the confidential information is shared by other people. These
situations are:
o With consent of the patient him/herself
o Confidentiality can be broken without patients consent for the following reasons:
ƒ For the intention of preventing a crime
ƒ For protection of the rights and freedom of others such as in case of serious
communicable diseases
o When it is for the patient’s own interest to do so and when it is undesirable on
medical ground to seek such consent.
ƒ When failure to disclose appropriate information would expose the patient, or
someone else, to a risk of death or serious harm.

CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 11: Relationship between Law and Confidentiality 78
• In disclosing confidential information regarding a patient who is not competent to give
consent due to various factors such as unconsciousness, it should be believed that he
would have allowed the procedure to proceed and that only information relevant to
treating or caring for the patient should be disclosed to relevant people only.
• Disclosure without consent to employers, insurance companies, or any other third party,
can be justified only in exceptional circumstances, for example, when they are necessary
to protect others from risk of death or serious harm.

Activity: Case Study

Instructions
Read the scenario below and answer the questions. Record your answers on a piece of paper.
One group will present their responses and other will share in the discussion.

Scenario
In a British case of W v Egdell [1990]1 All ER 835, (1989) 4 BMLR 96 (CA), a consultant
psychiatrist decided to send a copy of his medical report to the Ministry of Health in addition
to the Medical Tribunal where he was supposed to send it. The report was on a criminal
schizophrenic patient who was applying for review so that he could be transferred to a less
secure hospital. The doctor suspected that his critical report may have not reached relevant
authorities, hence creating a chance of the patient to be released.

Questions
1. Was it proper for this consultant to breach confidentiality?
2. What actions would have made his action wrong?

Consequences Arising From the Breach of Confidentiality


• Health practitioners who fail to keep patients’ information confidential may face two
legal consequences. The professional regulatory authority may summon the practitioner
under the law controlling that profession.
• Keeping information confidential is one of the pillars of proper conduct in medical
practice, and failure to observe this may be labeled as professional misconduct. The
practitioner will be disciplined according to guidelines provided under respective law.
• In addition, the patient would be able to claim damages for improper disclosure of
information about his health even if he suffered no financial loss as a result. Improper
disclosure may lead to loss of society cohesion, injury to feelings, job loss or even
interference with the prospects of promotion.
• This claim is submitted under the requirement of tort.
o Tort is a civil wrong which entitles a person who is injured by its commission to claim
(compensation) damages for loss suffered.
o Tortuous liability arises from the breach of duty primarily fixed by law.
o Damages for breach of duty may take in any forms such as physical injury to a person
(assault or battery), physical damage to property, damage to financial interests, to
injury to one’s reputation.
o Liability for tort is directed to persons who committed the wrong.
o In some cases however vicarious liability is ordered. This is where an action that is
tort is an action between persons natural or body corporate.
o The general rule of law imposes liability upon a master for torts committed by his
servants acting in the course of his employment.

CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 11: Relationship between Law and Confidentiality 79
• Publication of a defamatory statement in respect of another person without lawful
justification.
o Can be written or spoken. Action of one can also defame another.
o There are two kinds of defamation, namely:
ƒ Slander (when spoken)
ƒ Libel (if made in a permanent form and visible)

Activity: Case Study

Instructions
Read the scenario below and answer the questions. Record your answers on a piece of paper.
One group will present their responses and other will share in the discussion.

Scenario
A court in Scotland considered a case AB vs. CD whereby a claimant demanded
compensation from a doctor who has disclosed to the priest that the claimant’s wife has given
birth to a full term baby six months after marriage. The claimant won the damage as the court
held that there was a duty on the part of the doctor not to reveal confidential information
about his patients unless he was required to do so in court or if the disclosure is conclusive to
the end of science.

Questions
What medical practitioner was supposed to do?

Key Points
• The most fundamental ethical obligations owed by a medical practitioner to his patient
are to respect the confidence of his patient.
• Health profession regulatory authorities have insisted that patients have the right to expect
that information about them will be held in confidence by their doctors.
• Confidentiality is central to trust between health providers and patients.

Evaluation
• Define confidentiality.
• Explain the scope of the duty of confidentiality.
• Mention limitations of duty of confidentiality.

References
• Beauchamp, T.L., & Childress, J. (2001). Principles of Biomedical Ethics (5th ed.). New
York: Oxford University Press.
• Burkhardt, Margareth A. & Nathaniel, A.K. (2007). Ethics and Issues in Contemporary
Nursing (3rd ed.). New York: Thomson.
• CIOMS. (1993). International Ethics Guidelines for Biomedical Research Involving
Human Subject. Geneva: Council for International Organizations of Medical Services.
• Devettere, R.J. (1995). Practical Decision Making in Health Care Ethics: Cases and
Concepts. Washington, DC: Georgetown University.
• Furrow, Dwight. (2005). Ethics: Key Concepts in Philosophy. New York: Continuum.
• Mason, J.K., McCall Smith R.A., and Laurie G.T. (1999). Law and Medical Ethics.
London: Butterworths.

CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 11: Relationship between Law and Confidentiality 80
• Mellish, J.M. and Paton, Frieda. (1999). An Introduction to the Ethics of Nursing.
Capetown: Heinemenn.
• Tanzania Medical Practitioners Code of Conduct.
• Tanzania National Health Research Forum. (2001). Guidelines on Ethics for Health
Research in Tanzania. Dar es Salaam, Tanzania.
• The Tanzania Medical Practitioners and Dentist Ordinance.
• Williams, John R. (1942). Medical Ethics Manual. World Medical Association, Inc.

CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 11: Relationship between Law and Confidentiality 81
CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 11: Relationship between Law and Confidentiality 82
 Session 12: Legal Issues Related To Consent in
Medical Practice 
Learning Objectives
By the end of this session, students are expected to be able to:
• Define consent in medical practice
• Describe the forms of consent in medical practice
• Mention requirements for true consent in medical practice
• Mention legal implications from lack of consent in medical practice

Definition of Terms
• Consent: The clinical principle that each person has a right to self determination and is
entitled to have their autonomy respected finds its expression in law through the notion of
consent.
o Any intentional touching of a person without lawful justification or without their
consent amount to the tort of battery and may also constitute a criminal offence.
o The law relating to consent is one of the most important to medical law, serving as the
means of protecting and preserving the right of the patient to decide what is to happen
to him/her.
o Consent can be in the form of expressed or implied.
• Expressed consent: Is when the patient explicitly agrees to what is proposed by the
doctor, it does not need to be set out in any specific form and it does not need to be in
writing.
o The vast majority of time when a patient is touched, it is done in the examination
rooms where none of apparatus of consent is present.
• Consent forms: Have been part of hospital procedure for a long time.
o The form usually covers statements like ‘I confirm that I have explained the
operation, investigation or treatment, and such appropriate options as are available
and the type of anaesthetic, if any proposed to the patient in terms which in my
judgement are suited to the understanding of the patient and/or to one of the parents or
guardians of the patient’.
o The form is signed by both the doctor and the patient.
o Most of forms have a statement saying ‘I understand that any procedure in addition to
the investigation or treatment described on this form will only be carried out if it is
necessary and in my best interests and can be justified for medical reasons.’

Implied Consent
• Consent may just be implied meaning the client did not expressly authorise the doctor to
conduct a procedure.
• Actions often speak louder than words. Holding up one bare arm to a doctor at a
vaccination point is as clear as agree as if it were expressed in words.
• Even silence and inaction may, in some circumstances, be interpreted as expression of
willingness.
• Failure to resist or protest indicates consent if a reasonable person who is aware of the
consequences and capable of protest or resistance would voice his objection. A girl who
is silent to an amorous proposal, cannot, afterwards complain of assault.

CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 12: Legal Issues Related To Consent in Medical Practice 83
Requirements for a True Consent in Medical Practice
• There are three relevant issues which have to be determined:
o Did the patient have capacity in law? (Was the patient competent to give consent?)
o Was the person giving consent appropriately informed before hand?
o Was the consent voluntarily given?
• Each of these issues may be analyzed by reference to the nature and extent of the doctor’s
duty, that is, to inform or to ensure voluntariness and competence.
• The need for consent derives from the law’s respect for patient’s right to decide. Consent,
therefore, has a positive and a negative property.
• This means it is an exercise to make one’s own decisions to say ‘yes’ (consent) or to say
‘no’ (refuse).
• It is also a right to change one’s mind. Hence the patient may withdraw their consent to
treatment. Obviously, this could be done before the procedure but it may also be done
during the procedure.

General Issues
• In court issues, responsibility of proving absence of consent rests on the patient.
• Liability in trespass results in responsibility for all the consequence of the trespass and
may be concurrent with criminal liability for assault.
• Consent must be to the actual physical ‘invasion’ in issue. It is a battery if the patient
consents to removal of his left leg and the surgeon removes the right leg.
• Surgery may be authorized either by a provision in a standard consent form or by defence
of necessity.
• Further treatment must be shown to be necessary at the time of the original operation.
• Doing surgery for removing woman’s ovaries without express consent, or any non-
consensual treatment may constitute serious professional misconduct.
• It is not sufficient that the doctor believes that what she/he does is in patient’s best
interests or that 99% of patients would have consented.
• Advance directive of the patient must be respected.
• Failure to provide adequate information is actionable. It is the doctor’s duty to provide
not just competent treatment, but competent advice as well.
• Consent for detained mental patients must be obtained for non-mental problems.

Activity: Case Study

Instructions
Read the scenario below and answer the questions. Record your answers on a piece of paper.
One group will present their responses and other will share in the discussion.

Scenario: In a famous British case, Re T., (adult: refusal of treatment) [1992] 4 All ER 649
(CA) in which an adult woman, apparently a Jehovah’s Witness, refused a life-saving blood
transfusion. The judge concluded that her decision was legally effective on the basis that the
patient was competent to understand the serious nature of her decision. The judge further said
that this decision was right even though most would find it unreasonable and irrational.

Questions
What are your opinions on this decision regarding the right to decide on any matter even if it
is going to affect the client?

CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 12: Legal Issues Related To Consent in Medical Practice 84
Legal Implications from Lack of Consent
• Non-consensual medical treatments entitle the patient to sue for damages for battery
which is committed.
• It is also possible to base a claim on the tort of negligence, which is the theory that the
doctor has been negligent in failing to obtain the consent of the patient.

Action for Battery


• An action for battery arises when the plaintiff has been touched in some way by
defendant when there has been no consent, expressed or implied, to such touching.
• All that the plaintiff needs to establish in such an action is that the defendant wrongfully
touched him/her. It is unnecessary to establish loss as a result of the touching and,
therefore there is no problem as to the causation of damages to be overcome.
• By contrast, in an action based on tort of negligence, the plaintiff must establish that the
defendant wrongfully touched him and that the negligence of the defendant in touching
him without consent has led to injury for which damages are thought.
• There is a problem of factual causation to be tackled and, for this reason, the action for
battery is an easier option for the plaintiff’s point of view.
• The action for battery is appropriate where there has been no consent at all to the physical
contact in question. Thus, an action for battery is a suitable remedy if the patient has
refused to submit to a procedure but the doctor has nevertheless, gone ahead in the face of
that refusal.

Activity: Case Study

Instructions
Read the scenario below and answer the questions. Record your answers on a piece of paper.
One group will present their responses and other will share in the discussion.

Scenario
A surgeon was taken to court because when he was on duty, he operated on a lump on the
back of the patient while the patient had actually consented to the operation on his toe. On his
defence, the surgeon said that he noticed the lump and believed that instead of waiting for
another operation, he believed that removing the lump would spare the patient extra
suffering.

Question
Was the surgeon right or wrong in this case? Give reasons on whatever answers you provide.

Acton for Negligence


• In essence, the aggrieved patient is claiming: ‘You did not inform me of possible risk
involved. If you had informed me, I would not have consented to the procedure. You have
failed in your duty of care, and as a result, I have sustained injury’.
• The problem of negligence based on lack of consent is, therefore, that of causation. The
court must be satisfied that the cause of the patient’s injury is due to the defendant’s
failure to obtain valid consent of the patient was.
• To satisfy this requirement, the patient must prove that he would not have given his
consent had he had the information of which he was allegedly deprived.

CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 12: Legal Issues Related To Consent in Medical Practice 85
Key Points
• Consent forms have been part of hospital procedure for a long time.
• Any intentional touching of a person without lawful justification or without their consent
amounts to the tort of battery and may also constitute a criminal offence.
• A patient’s right to choice is not limited to decisions which others might regard as
sensible.

Evaluation
• Define consent in medical practice.
• Describe the forms of consent in medical practice.
• Mention requirements for true consent in medical practice.

References
• Beauchamp, T.L., & Childress, J. (2001). Principles of Biomedical Ethics (5th ed.). New
York: Oxford University Press.
• Burkhardt, Margareth A. & Nathaniel, A.K. (2007). Ethics and Issues in Contemporary
Nursing (3rd ed.). New York: Thomson.
• CIOMS. (1993). International Ethics Guidelines for Biomedical Research Involving
Human Subject. Geneva: Council for International Organizations of Medical Services.
• Devettere, R.J. (1995). Practical Decision Making in Health Care Ethics: Cases and
Concepts. Washington, DC: Georgetown University.
• Furrow, Dwight. (2005). Ethics: Key Concepts in Philosophy. New York: Continuum.
• Mason, J.K., McCall Smith R.A., and Laurie G.T. (1999). Law and Medical Ethics.
London: Butterworths.
• Mellish, J.M. and Paton, Frieda. (1999). An Introduction to the Ethics of Nursing.
Capetown: Heinemenn.
• Tanzania Medical Practitioners Code of Conduct.
• Tanzania National Health Research Forum. (2001). Guidelines on Ethics for Health
Research in Tanzania. Dar es Salaam, Tanzania.
• The Tanzania Medical Practitioners and Dentist Ordinance.
• Williams, John R. (1942). Medical Ethics Manual. World Medical Association,

CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 12: Legal Issues Related To Consent in Medical Practice 86
The  development  of  these  training  materials  was  supported  through  funding  from  the  President’s  Emergency  Plan  for  AIDS  Relief 
(PEPFAR)  through  the  U.S.  Department  of  Health  and  Human  Services,  Health  Resources  and  Services  Administration  (HRSA) 
Cooperative Agreement No. 6 U91 HA 06801, in collaboration with the U.S. Centers for Disease Control and Prevention’s Global AIDS 
Programme (CDC/GAP) Tanzania.  Its contents are solely the responsibility of the authors and do not necessarily represent the official 
views of HRSA or CDC. 

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