1. Implementation of Public Policies on HIV and AIDS in Tanzania: Assessing Effectiveness on Coverage of HIV Prevention Services in Rural Areas

2. Coverage of HIV Prevention Services Coverage of HIV Prevention service refers to the extent to which the HIV prevention services are interactive with people for whom the services are intended. The effectiveness of the interaction is explained by three indicators… -The extent to which services are available (availability coverage) -The extent to which services are accessible (accessibility coverage) -The extent to which services are acceptable (acceptability coverage)

3. Levels Explained Availability Coverage – Human Resource – Health facilities – Drugs (ARVs& drugs for OIs) – Equipments e.g. CD4 counting machines, X rays machines etc Accessibility Coverage Distance to the health facilities Travel time Waiting time Affordability (transport costs) Acceptability Coverage – Cultural/religious beliefs – Taste and class

4. Rationale of the Study Despite higher reported levels of HIV policy implementation in Tanzania there still many gaps; Huge regional heterogeneity (1.5% in Manyara region) to 14.8% (Njombe region) Infection rates in some regions remain significantly high and are on the increase.-increase 1.5%-2% in 7 regions Impressive reductions have occurred in more urban areas than in non-urbanized ones. In urban areas, HIV prevalence declined for 3% from 10.9% 2008 to 7.0% in 2012. On the contrary, in rural areas, HIV prevalence declined for only 1.3% from 5.3% in 2004 4.0% in 2012.

5. Research Question Why are the HIV prevention services producing contrasting results across regions in Tanzania? The study assumes that HIV policy implementation as far as coverage of HIV prevention services is concerned has been inadequate. The study is set out to evaluate the extent to which HIV prevention service coverage have been attained and evaluate their adequacy in halting the spread of the epidemic within regions in Tanzania.

6. Specific Research Questions The study is guided by three questions To what extent are HIV prevention services available in the rural areas? To what extent are the HIV prevention services accessible by the rural population? To what extent are the HIV prevention services acceptable by the rural population?

7. METHODOLOGY Areas of the study (Njombe region -14.8% HIV prevalence; Dodoma region – 2.9% HIV prevalence rate/higher infection rates among men & Dar es salaam – Centre for most gov’t institutions Qualitative Emancipatory approach was used in the collection of primary data through Interview and FGDs Secondary data was collected through documentary review technique

8. Population of the study and Sample size Population of the study included key informants from government institutions e.g. TACAIDS, NACP, PMO-RALG; Officials from CSOs and ordinary citizens (including PLHIV) Sample size: 155 respondents (120 were ordinary citizens in FGDs) Purposive sampling technique was used for selection of respondents.

9. Findings: Availability Coverage 1. There is a serious shortage of health personnel for health service provision in the study areas e.g. Bahi district in Dodoma region needs 693 health workers but only 219 workers are available...deficit of 474 workers. 2. The density of health facilities was noted to be less adequate both in terms of their number and their distribution across the population e.g. Bahi district for example does not have a district hospital.

10. Cont…. The distribution of the health facilities is skewed favouring the urban areas Available facilities in the rural areas were observed to be in poor condition and less reliable. Dispensaries closing at 1600hrs and not opening during the week end. 3. Drugs: Though ARVs were adequate and freely provided but were only provided in the district hospitals; to most people this involved travelling.

11. Cont….. 3.Drugs for treatment of opportunistic infections were constantly out of stock. 4. Equipments such as CD4 counting machines and X rays machine were only available at district/regional hospital. They are not adequate, constantly breaking down and technicians are not available when needed.

12. Findings: Accessibility Coverage Physical accessibility to services is hampered by long distances to health facilities, travel time and waiting time in health facilities. 1.Distance: Only 25.8% of people in rural areas are within 5km from the health facility compared to 53.5% in urban areas 2.Travel time- was identified as a barrier to those who wanted to access ART services…ARVs were only provided in district hospitals..to many participants, the hospital was quite distant

13. Cont… But…Sometime people bypass the nearest health facilities for other reasons i.e. seeking for more quality services and confidentiality purposes 3.Waiting time: Because of shortages of health workers, people are force to wait for hours before they are attended ( 3-6hrs). Long waiting queue were reported to put pressure on health workers and hence affecting the quality of services being delivered

14. Cont…. 4. Travel costs: Because health facilities are urbanized people incur more cost to travel to these facilities. Again, inability of the government to spend more in health sector and weak mechanism to reduces health financial burden to individuals, forces people to dig deeper in their pocket (out-of-pocket- expenditure)

15. Findings: Acceptability Coverage Levels of acceptability of some particular services were greatly influenced by target’s cultural and religious belief, gender and age. Male circumcision was observed to be very low in Njombe region mainly for cultural reasons. Condom use by youth was less approved by adults, with women expressing lesser approval compared to men. Men also expressed less approval to condom use particularly by married women.

16. Cont…. Condom use is detested by dominant religions Class and taste of target population had minimal influence on people’s attitude towards some services. Few number of health facilities particularly in the rural areas coupled with high poverty levels limit people choice to pick services according to their class and taste. Because of these factors, the available services and facilities are the only choice to many.

17. END: Asante Sana..!