Kim Mwamelo,1 Peter Nyella2 and Adrian Fitzgerald3
Malnutrition remains a major public health challenge in Tanzania, driven by complex factors such as water stress, gender inequality, and poor access to services. Irish Aid in Tanzania supports nutrition through a multisectoral approach to address nutrition-sensitive and specific challenges in regions of focus. After the first case of Covid-19 was reported in Tanzania, Irish Aid adapted a two-pronged approach to ensuring continuity of nutrition services before and during the Covid-19 pandemic. Through adapting its existing partnerships and engaging new partnerships, Irish Aid contributed to (1) mitigating the impact of the pandemic in Tanzania, and (2) safeguarding essential services, including nutrition. This article summarises Irish Aid’s approach and provides recommendations for building back better.
Nutrition, resilient systems, gender equality.
Malnutrition remains a major public health challenge in Tanzania, where an estimated 32 per cent of children under five are stunted, 29 per cent of women of reproductive age are anaemic, and 30 per cent of women of reproductive age are obese or overweight (MoHCDGEC 2018). While the country overall is food sufficient, pockets of food insecurity exist: unpredictable weather, pests, and reduced use of agriculture inputs, especially fertiliser, further threaten food availability (Ministry of Agriculture 2019). Tanzania is also highly vulnerable to climate change due to its reliance on natural resources. Trends show that temperature increases, changes in precipitation, and extreme weather events are becoming more frequent. Tanzania recently became a water‑stressed country (World Bank 2017). The increased burden of not only sourcing water for domestic use, but also coping with lower yields in food crops and reduction in firewood availability falls disproportionally on women and girls.
Gender dynamics are a key challenge: women and girls carry a disproportionate labour burden (including during pregnancy and lactation), lack decision-making power and control of family resources, and face high rates of gender-based violence (GBV). Rates of teenage pregnancy are high, with 27 per cent of girls aged 15–19 having begun childbearing (MoHCDGEC 2016). Further, pregnant schoolgirls are not allowed to continue attending public schools, potentially trapping both mother and child in a cycle of poverty and poor nutrition. Access to basic health care remains a challenge – only 61 per cent of women delivered their last child in a health facility, and only half of women sought treatment for their child’s fever (ibid.). This article summarises Irish Aid in Tanzania’s approach to nutrition, before and during the Covid-19 pandemic.
Recognising the complex nature of malnutrition, Irish Aid’s support to nutrition at the local level in Tanzania combines multiple services – nutrition, primary health care, GBV response, and sexual and reproductive health (SRH) – to holistically address the needs of women and children, focusing on the most vulnerable, including women and children in the country’s underserved regions. Its approach aims to build sustainable systems that prioritise prevention, community ownership, and positive behaviour change, to help improve nutritional outcomes among women and children. This comprehensive approach combining nutrition-sensitive and specific interventions was developed in the Ruvuma Region in Southern Tanzania, and over four years resulted in a reduction in stunting (44 per cent to 33 per cent), acute malnutrition (8 per cent to 5 per cent), and an increase in facility deliveries (70 per cent to 91 per cent) across the three programme districts (COUNSENUTH 2019). Overall, the region saw a 7 per cent decline in stunting over the same period (MoHCDGEC 2018). Irish Aid has scaled up this approach in three regions of Tanzania.
Irish Aid has supported the roll-out of 557 community health workers (CHWs) in seven districts across the country, who are an accessible source of preventive and basic curative services. Together with village leaders and health-care providers from the nearest health facility, CHWs organise village health and nutrition days, which combine primary care services (child growth monitoring and promotion, antenatal services, immunisation) with social behaviour change communication, including cooking demonstrations using locally available ingredients, showcasing model home gardens, and information on the importance of dietary diversity. CHWs act as the link between communities and primary health facilities, including follow-up and referral of any malnourished children and pregnant women.
To address gender barriers to nutrition, Irish Aid supports an innovative, community-led approach to local planning known as the Transformative Reflective Leadership Approach (TRLA). The TRLA brings together village leadership and key community members (including religious and traditional leaders, teachers, medical providers, CHWs, and youth representatives) in a participatory process that allows them to identify key challenges within their communities, understand how it impacts the health and wellbeing of women and children, and identify practical solutions to address these challenges using their own efforts and resources.
Key to ensuring good nutrition is to address GBV and teenage pregnancies. Ireland supports capacity building of structures that respond to GBV at a district level (such as police, social welfare, and medical departments) and local level (through village and ward leaders, teachers, and community members). Simultaneously, Ireland raises community awareness of GBV and challenges social norms that enable such violence to take place. To prevent adolescent pregnancy and childbirth, and its associated health and nutrition risks to both mother and infant, Ireland supports sexual and reproductive health and rights (SRHR) education for adolescents and young people, with a strong focus on keeping girls in school.
On 16 March 2020, the first case of Covid-19 was reported in Arusha, Tanzania. The Government of Tanzania’s initial response was swift, closing primary and secondary schools, instituting mandatory quarantine for travellers, and expanding sanitation measures. Large gatherings were prohibited, though marketplaces and places of worship remained open. The Ministry of Health, Community Development, Gender, Elderly and Children (MoHCDGEC) developed a Covid-19 National Response Plan which aimed to expand a number of key services, most notably: surveillance, risk communication, and community engagement; laboratory services and case identification; case management and water, sanitation and hygiene; coordination, operations, and logistics; and psychosocial support to communities as well as frontline workers. Development partners, including bilateral and multilateral agencies, were invited to contribute technically and financially to the National Response Plan.
Ireland’s approach to Covid-19 was twofold: (1) to mitigate the impact of the pandemic, and (2) to safeguard essential services particularly for women and children. This was achieved by adapting its existing programmes and partnerships, as well as engaging new strategic partners, taking into account duty of care to partners and beneficiaries alike. In order to mitigate the impact of Covid-19, urgent support to the health-care system to scale up testing, surveillance, and case management was needed, alongside the protection of frontline workers. Evidence from other contexts has found high rates of Covid-19 infections in health-care workers (Felice et al. 2020; Jeremias et al. 2020). Considering the underlying deficiencies in the Tanzanian health‑care system – which has an approximately 50 per cent staffing gap – the need to protect health-care workers was particularly urgent.
Additionally, the maximum capacity for intensive care units (ICUs) nationally is about 500 beds, and there is very little availability of oxygen concentrators (and even fewer ventilators). In partnership with UNICEF and the World Health Organization (WHO), and in support of the government’s Covid-19 National Response Plan, Ireland supported the procurement of personal protective equipment for health-care providers, as well as expanding case detection and surveillance respectively. Addressing the human resources for the health gap was crucial. By adapting its existing programmes that are designed to strengthen community and primary health-care systems, Ireland supported the hiring of 68 health-care workers and a further 334 CHWs to support the case management and community surveillance of Covid-19. Aligning Ireland’s support to the National Response Plan allowed for better and streamlined coordination of responses, putting its support into context and allowing for the identification of areas that required more support.
Evidence from previous pandemics has found a reduced utilisation of essential services during such outbreaks, including reproductive and child health services (Wilhelm and Helleringer 2019). In order to safeguard essential services, reprogramming was undertaken in collaboration with partners and local government authorities. The goal of reprogramming was to ensure that the provision of key services was sustained, including community and primary health-care services and GBV prevention and management, as an already strained health-care system is forced to divert resources to support the Covid-19 response. Ireland maintained its support to primary health care through the Health Basket Fund (Development Partners Group Tanzania n.d.), the largest on-budget grant to the MoHCDGEC to support primary health-care facilities. While most local-level interventions were based on large community events, these were immediately scaled down to one-on-one outreach events but were maintained throughout the pandemic to ensure the availability of community-based growth monitoring and promotion and SRHR services.
Funds were reprogrammed to expand the availability of clean water in strategic locations such as health facilities and village government offices, to ensure the continuity of service provision while also supporting Covid-19 prevention. During this time, an increase in GBV and violence against children was anticipated, partly as a result of children and girls being at home due to the school closures, and also due to the economic challenges faced by households. Messaging on GBV was developed and disseminated on local radio channels and in the public spaces that remained open (such as markets and places of worship). Support to GBV prevention and response structures was expanded to include handwashing facilities and soap, to ensure that both the responders and survivors were protected. To assist schoolgirls to remain engaged in school activities, Ireland supported the development of radio sessions that provided classes remotely.
The outbreak of Covid-19 in Tanzania, as in other parts of the world, is still developing. As of January 2021, only 509 cases and 21 deaths had been officially reported. No new official numbers have been reported since May 2020, and preventive measures have since been relaxed with schools opening in June. However, the Ministry of Health continues to encourage preventive measures and provides regular messaging through various channels. Ireland continues to participate in the coordination structures of the Covid-19 response plan, providing technical support and ensuring the needs of the most vulnerable are not ignored.
The Covid-19 pandemic has shed light on the need to go beyond interventions that address a single aspect of nutrition, and rather, build resilient local systems that can be harnessed to respond to shocks such as disease outbreaks. Local interventions should holistically address the needs of the most vulnerable. As governments and development partners continue to plan on building back after the crisis, it is essential to strengthen local‑level engagement so that structural barriers, such as gender dynamics, are addressed.
Coordination and collaboration with national and local governments is also critically important. Alignment with government plans and interventions is essential for better coordination and sustainability, to ensure that supported interventions are relevant to the needs of the community. By providing technical support to governments, bilateral and multilateral organisations can also help to ensure that plans and policies address the needs of the furthest behind first, including women, youth, and children.
The pandemic has highlighted the importance of building flexibility and adaptability into development programmes, both in terms of service delivery (the need to adapt from large community-based events to one-on-one activities), and in embracing new ways of working (such as remote monitoring and teleworking). Ireland’s adaptive programming has helped to maintain health and nutrition services, and expand GBV messaging and support, whilst responding to the pandemic. Key donor requirements such as monitoring and oversight can be fulfilled remotely, provided that all stakeholders are willing to work differently and adapt to the changing context – highlighting the importance of strong communication and trust as a foundation for all partnerships.
* This IDS Bulletin issue has been produced thanks to funding from the Government of Ireland. The opinions expressed here belong to the authors, and do not necessarily reflect those of Irish Aid or IDS. It was produced as part of the Strategic Partnership between Irish Aid and IDS on Social Protection, Food Security and Nutrition.
† The authors would like to thank the Government of Tanzania, and the Ministry of Health, Community Development, Gender, Elderly and Children (MoHCDGEC). We would also like to thank our partners working in health and nutrition: UNICEF Tanzania; UNFPA Tanzania; WHO Tanzania Country Office; the Centre for Counselling, Nutrition and Health Care (COUNSENUTH); Amref Health Africa and the Benjamin Mkapa Foundation. Funding to support our programming is provided by Ireland’s Department of Foreign Affairs.
1 Kim Mwamelo, Reproductive Health and Nutrition Programme Manager, Embassy of Ireland, Dar es Salaam, Tanzania.
2 Peter Nyella, Health Programme Manager, Embassy of Ireland, Dar es Salaam, Tanzania.
3 Adrian Fitzgerald, Chargé d‘Affaires and Head of Development Cooperation, Embassy of Ireland, Dar es Salaam, Tanzania.
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© 2021 The Authors. IDS Bulletin © Institute of Development Studies | DOI: 10.19088/1968-2021.110
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non Commercial 4.0 International licence (CC BY-NC), which permits use, distribution and reproduction in any medium, provided the original authors and source are credited, any modifications or adaptations are indicated, and the work is not used for commercial purposes.
The IDS Bulletin is published by Institute of Development Studies, Library Road, Brighton BN1 9RE, UK. This article is part of IDS Bulletin Vol. 52 No. 1 March 2021 ‘Building a Better World: The Crisis and Opportunity of Covid-19’; the Introduction is also recommended reading.