Tanzania Commission for Science and Technology

The factors determining gradients of biodiversity are a fundamental yet unresolved topic in ecology. While diversity gradients have been analysed for numerous single taxa, progress towards general explanatory models has been hampered by limitations in the phylogenetic coverage of past studies. By parallel sampling of 25 major plant and animal taxa along a 3.7 km elevational gradient on Mt. Kilimanjaro, we quantify cross-taxon consensus in diversity gradients and evaluate predictors of diversity from single taxa to a multi-taxa community level. While single taxa show complex distribution patterns and respond to different environmental factors, scaling up diversity to the community level leads to an unambiguous support for temperature as the main predictor of species richness in both plants and animals. Our findings illuminate the influence of taxonomic coverage for models of diversity gradients and point to the importance of temperature for diversification and species coexistence in plant and animal communities.

BACKGROUND: Mental illness may cause a variety of psychosocial problems such as decreased quality of life of the patient's family members as well as increased social distance for the patient and the family caring for the patient. Psychosocial challenges are enhanced by the stigma attached to mental illness, which is a problem affecting not only the patient but also the family as a whole. Coping mechanisms for dealing with mentally ill patients differ from one family to another for a variety of reasons. The aim of the study was to determine the psychosocial problems of mental illness on the family including the coping strategies utilized by family members caring for a person with mental illness. METHOD: A qualitative study was conducted, involving four focus group discussions and 2 in-depth interviews of family members who were caring for patient with mental illness at Temeke Municipality, Dar es Salaam. Purposive sampling procedure was used to select participants for the study. Audio-recorded interviews in Swahili were conducted with all study participants. The recorded interview was transcribed and qualitative content thematic analysis was used to analyse the data. RESULTS: Financial constraints, lack of social support, disruption of family functioning, stigma, discrimination, and patients' disruptive behaviour emerged as the main themes in this study. Acceptance and religious practice emerged as the major coping strategies used by family members. CONCLUSION: Familial care for a person with mental illness has its advantages, yet it has multiple social and psychological challenges. Coping strategies and skills are important for the well-being of the caregiver and the patient. Addressing these psychosocial challenges requires a collaborative approach between the health care providers and government so that the needs of the family caregivers and those of the patients can be addressed accordingly.

BACKGROUND: Tanzania is among the countries with a high maternal mortality ratio. However, it remains unclear how information and education on danger signs of pregnancy translate into appropriate actions when a woman recognizes danger signs. This study aimed to determine women's knowledge of obstetric danger signs during pregnancy and their subsequent healthcare seeking actions. METHODS: The study design was a health facility-based cross-sectional study. Quantitative data were collected through interviewer-administered questionnaires. Descriptive and inferential statistics were used to analyze the data. The study enrolled 384 women from two health centers in Kinondoni Municipality, Dar es Salaam, Tanzania. A woman who had not mentioned any danger sign was categorized as having no knowledge, mentioned one to three danger signs as having low knowledge, and mentioned four or more danger signs as having sufficient knowledge. RESULTS: Among the 384 participants, 67 (17.4%) had experienced danger signs during their pregnancy and reported their healthcare seeking actions after recognizing the danger signs. Among those who recognized danger signs, 61 (91%) visited a healthcare facility. Among the 384 participants, five (1.3%) had no education, 175 (45.6%) had primary education, 172 (44.8%) had secondary education, and 32 (8.3%) had post-secondary education as their highest educational levels. When asked to spontaneously mention the danger signs, more than half of the participants (n = 222, 57.8%) were able to mention only one to three danger signs. Only 104 (31%) had correct knowledge of at least four danger signs and nine (2.7%) were not able to mention any item. The most commonly known pregnancy danger signs were vaginal bleeding (81%); swelling of the fingers, face, and legs (46%); and severe headache (44%). Older women were 1.6 times more likely to have knowledge of danger signs than young women (OR 1.61; 95% CI 1.05-2.46)". CONCLUSION: Women took appropriate healthcare seeking action after recognizing danger signs during pregnancy. However, the majority had low knowledge of pregnancy danger signs. Additional studies are warranted to address the knowledge gap and to plan interventions for improving health education under limited resource settings.

There is longstanding evidence that immunoglobulin G (IgG) has a role in protection against clinical malaria, and human antibodies of the cytophilic subclasses are thought to be particularly critical in this respect. In this cohort study, 286 Burkinabè children 6 months to 15 years old were kept under malaria surveillance in order to assess the protective role of antibody responses against four antigens which are currently being evaluated as vaccine candidates: apical membrane antigen 1 (AMA1), merozoite surface protein 1-19 (MSP1-19), MSP3, and glutamate-rich protein (GLURP). Total IgG, IgM, and IgG subclass responses were measured just before the malaria transmission season. The incidence of malaria was 2.4 episodes per child year of risk. After adjusting for the confounding effects of age, the level of total IgG to GLURP was strongly associated with reduced malaria incidence (incidence rate ratio associated with a doubling of total IgG, 0.79; 95% confidence interval, 0.66 to 0.94; P = 0.009.); there was a borderline statistically significant association between the level of total IgG to MSP3 and malaria incidence and no evidence of an association for total IgG to AMA1 and to MSP1-19. Of the IgG subclass responses studied, only IgG3 and IgG4 against GLURP and IgG1 against AMA1 were associated with reduced risk of clinical malaria. There was no evidence of an interaction between responses to AMA1 and baseline parasitemia in their effects on malaria incidence. Currently included in malaria vaccine formulations for clinical trials in humans, these blood-stage antigens, AMA1 and GLURP, offer good prospects for malaria vaccine development.

BACKGROUND: Antigen-specific antibody-mediated immune responses play an important role in natural protection against clinical malaria, but conflicting estimates of this association have emerged from immuno-epidemiological studies in different geographical settings. This study was aimed at assessing in a standardized manner the relationship between the antibody responses to four malaria vaccine candidate antigens and protection from clinical malaria, in a cohort of Ghanaian children. METHODS: Standardized ELISA protocols were used to measure isotype and IgG subclass levels to Apical Membrane Antigen 1 (AMA1), Merozoite Surface Protein 1-19 (MSP119), Merozoite Surface Protein 3 (MSP3) and Glutamate Rich Protein (GLURP) antigens in plasma samples from 352 Ghanaian children, aged three to 10 years with subsequent malaria surveillance for nine months. This is one of a series of studies in different epidemiological settings using the same standardized ELISA protocols to permit comparisons of results from different laboratories. RESULTS: The incidence rate of malaria was 0.35 episodes per child per year. Isotype and IgG subclasses for all antigens investigated increased with age, while the risk of malaria decreased with age. After adjusting for age, higher levels of IgG to GLURP, MSP119, MSP3 and IgM to MSP119, MSP3 and AMA1 were associated with decreased malaria incidence. Of the IgG subclasses, only IgG1 to MSP119 was associated with reduced incidence of clinical malaria. A previous study in the same location failed to find an association of antibodies to MSP119 with clinical malaria. The disagreement may be due to differences in reagents, ELISA and analytical procedures used in the two studies. When IgG, IgM and IgG subclass levels for all four antigens were included in a combined model, only IgG1 [(0.80 (0.67-0.97), p = 0.018)] and IgM [(0.48 (0.32-0.72), p < 0.001)] to MSP119 were independently associated with protection from malaria. CONCLUSION: Using standardized procedures, the study has confirmed the importance of antibodies to MSP119 in reducing the risk of clinical malaria in Ghanaian children, thus substantiating its potential as a malaria vaccine candidate.

This paper compares and contrasts changing rural–urban linkages drawing on research in six case study areas in Mali, Nigeria and Tanzania. The aim of the research was to gain a better understanding of the ways in which the livelihoods of rural and urban households rely on both rural-based and urban-based resources, and on exchanges between urban and rural areas. The paper describes changes in farming systems under the impact of urban expansion, with special attention to access to land and other natural resources such as water, and also access to markets and the role of traders, especially small-scale operators. It also examines how changing rural and urban contexts, as well as wider national and regional contexts, affect patterns of income diversification and mobility, especially the differential impacts with regard to women and men and to young and older people. Finally, it analyzes the role of the case studies’ urban centres in the economic and social development of their surrounding regions.

SUMMARY The paper provides an overview of experiences in Tanzania to date in ‘scaling up’ Participatory Forest Management (PFM) from what has until recently been a ‘project-driven’ approach to one that is mainstreamed and embedded within national and local government institutions. It highlights the valuable role that projects have played in influencing policy, developing new models and tools, but also some of the pitfalls of the project approach, particularly with regard to local expectations, the lack of sustainability and failure to integrate within local institutions and systems. In addition, the paper assesses the degree to which different models of Participatory Forest Management (PFM) have delivered on their two main policy objectives — sustainable forest management and improved rural livelihoods. The paper outlines some of the enabling factors as well as constraints to further dissemination and scaling-up of PFM in Tanzania — looking at political, institutional, social and economic dimensions.

School dropout is absenteeism from school for no good reason for a continuous number of days. Addressing this challenge requires a thorough understanding of the underlying issues and effective planning for interventions. Over the years machine learning has gained much attention on addressing the problem of students dropout. This is because machine learning techniques can effectively facilitate determination of at-risk students and timely planning for interventions. In order to collect, organize, and synthesize existing knowledge in the field of machine learning on addressing student dropout; literature in academic journals, books and case studies have been surveyed. The survey reveal that, several machine learning algorithms have been proposed in literature. However, most of those algorithms have been developed and tested in developed countries. Hence, developing countries are facing lack of research on the use of machine learning on addressing this problem. Furthermore, many studies focus on addressing student dropout using student level datasets. However, developing countries need to include school level datasets due to the issue of limited resources. Therefore, this paper presents an overview of machine learning in education with the focus on techniques for student dropout prediction. Furthermore, the paper highlights open challenges for future research directions.

Adaptation to already discernible climate changes, particularly an increase in extreme events, is an urgent task for all nations. This article argues that adaptation is an urgent priority, especially for the developing world, to build a resilient society. For poor nations, poverty alleviation is the main policy driver, although changes in livelihood strategies are driven by a range of factors. Using a case study, direct and indirect adaptation is examined with reference to the specific livelihoods of the Chagga people on Kilimanjaro, Tanzania. Evidence suggests that coping strategies to maintain livelihood systems can work against long-term adaptation to climate change, unless there is linkage to poverty alleviation. Linking climate change adaptation to project development through notions of additionality does not carry sufficient leverage to simultaneously address poverty alleviation and climate change. It is suggested that, rather than micro-economic project management, a broader macro-economic frame be established. A rights-based approach is argued as a vital driver for informing financial, institutional, political and technological policies and instruments.

OBJECTIVES: To evaluate the impact of the Tanzania National Voucher Scheme on the coverage and equitable distribution of insecticide treated nets, used to prevent malaria, to pregnant women and their infants. DESIGN: Plausibility study using three nationally representative cross sectional household and health facility surveys, timed to take place early, mid-way, and at the end of the roll out of the national programme. SETTING: The Tanzania National Voucher Scheme was implemented in antenatal services, and phased in on a district by district basis from October 2004 covering all of mainland Tanzania in May 2006. PARTICIPANTS: 6115, 6260, and 6198 households (in 2005, 2006, and 2007, respectively) in a representative sample of 21 districts (out of a total of 113). INTERVENTIONS: A voucher worth $2.45 ( pound1.47, euro1.74) to be used as part payment for the purchase of a net from a local shop was given to every pregnant woman attending antenatal services. MAIN OUTCOME MEASURES: Insecticide treated net coverage was measured as household ownership of at least one net and use of a net the night before the survey. Socioeconomic distribution of nets was examined using an asset based index. RESULTS: Steady increases in net coverage indicators were observed over the three year study period. Between 2005 and 2007, household ownership of at least one net (untreated or insecticide treated) increased from 44% (2686/6115) to 65% (4006/6198; P<0.001), and ownership of at least one insecticide treated net doubled from 18% (1062/5961) to 36% (2229/6198) in the same period (P<0.001). Among infants under 1 year of age, use of any net increased from 33% (388/1180) to 56% (707/1272; P<0.001) and use of an insecticide treated net increased from 16% (188/1180) to 34% (436/1272; P<0.001). After adjusting for potential confounders, household ownership was positively associated with time since programme launch, although this association did not reach statistical significance (P=0.09). Each extra year of programme operation was associated with a 9 percentage point increase in household insecticide treated net ownership (95% confidence interval -1.6 to 20). In 2005, only 7% (78/1115) of nets in households with a child under 1 year of age had been purchased with a voucher; this value increased to 50% (608/1211) in 2007 (P<0.001). In 2007, infants under 1 year in the least poor quintile were more than three times more likely to have used an insecticide treated net than infants in the poorest quintile (54% v 16%; P<0.001). CONCLUSIONS: The Tanzania National Voucher Scheme was associated with impressive increases in the coverage of insecticide treated nets over a two year period. Gaps in coverage remain, however, especially in the poorest groups. A voucher system that facilitates routine delivery of insecticide treated nets is a feasible option to "keep up" coverage.

Tanzania launched its first National Action Plan (NAP) on antimicrobial resistance (AMR) in 2017 to reduce the burden of AMR in the country and contribute to the global response. We aimed to analyze the implementation of the NAP on AMR in Tanzania using the governance framework. In-depth interviews were conducted with human and animal health practitioners and national-level policy actors. We adapted Chua's AMR governance framework to analyze the development and implementation of the NAP in Tanzania. Implementation of the NAP has realized several achievements, including: (i) the establishment of a functioning Multi-Sectoral Coordinating Committee for coordinating the implementation of AMR activities; (ii) existence of governance structure; (iii) establishment of human and animal surveillance sites; (iv) creation of AMR awareness in the community and (v) availability of guidelines at the health facility level to ensure AMR stewardship. However, some dimensions of the governance areas, including reporting and feedback mechanisms, accountability, transparency and sustainability of AMR plans, are not effectively implemented. Addressing these challenges should involve strengthening the collaboration of the different sectors involved at different NAP implementation levels by careful planning and coordination, and provision of adequate resources to ensure sustainability.

To meet UNAIDS' 90-90-90 treatment goals, effective approaches to HIV testing services (HTSs) are urgently needed. In 2015, a cross-sectional study was conducted to evaluate effectiveness and feasibility of partner notification for HTS in Tanzania. Men and women newly diagnosed with HIV were enrolled as index clients, listed sexual partners, and given options to notify and link their partners to HTS. Of 653 newly diagnosed individuals, 390 index clients were enrolled, listed 438 sexual partners, of whom 249 (56.8%) were successfully referred. Of 249 partners reaching the facilities, 96% tested for HIV, 148 (61.9%) tested HIV+ (all newly diagnosed), and 104 (70.3%) of partners testing positive were enrolled into HIV care and treatment. Results showed good acceptability, feasibility and effectiveness, as evidenced by high uptake of partner notification among newly diagnosed individuals, over half of listed partners successfully referred, and a very high positivity rate among referred sexual partners.

Abstract Background Antimicrobial resistance (AMR) represents one of the biggest threats to health globally. This cross-sectional study determined knowledge, attitudes and practices (KAP) regarding antimicrobial use (AMU) and AMR among communities of Ilala, Kilosa and Kibaha in Tanzania. Method A semi-structured questionnaire was used to collect socio-demographic and KAP data through face-to-face interviews. Responses related to the triad of KAP were assigned scores that were aggregated for each participant. Linear regression analysis was conducted to determine predictors of KAP scores. Results The study enrolled 828 participants from the three districts. A total of 816 (98.6%) were aware of antimicrobials, and 808 (99%, n = 816) reported to have used them. Antimicrobials were mainly used to treat cough (68.0%), urinary tract infections (53.4%), diarrhoea (48.5%) and wounds (45.2%). The most frequent sources of antimicrobials were health facility (65.0%, n = 820) and pharmacies/basic drug shops (53.7%). The median AMU knowledge score was 5 (IQR = 4, 7) and that of AMR was 26 (IQR=23, 29). The median AMU attitudes score was 32 (IQR: 29, 35) and that of AMR was 19 (IQR=17, 22). The median AMU practice score was 3 (IQR: 3, 3). The KAP scores were significantly influenced by increased participant’s age (β adj =0.10; 95% CI: 0.05, 0.15) and level of education, being lower among those with primary education (β adj =5.32; 95% CI: 3.27, 7.37) and highest among those with college/university education (β adj =9.85; 95% CI: 6.04, 13.67). Conclusion The study documented a moderate level of KAP regarding AMU and AMR in the study districts. The participant's age and level of education were significantly associated with participant's KAP scores. The observed inadequate knowledge, inappropriate attitude, and practices of AMU and AMR should be considered as alarming problems that require immediate actions including policy formulation and planning of community-based mitigation measures.

This article interrogates the concept of ‘working people’. Lenin and other classical Marxists commonly used terms like labouring people, working people, or rural poor. Typically, they were used as descriptive, or, at best, as terms of political art rather than theoretical science. The inspiration in this article for the use of the term ‘working people’ comes from Walter Rodney. Building on previous work, the article relates the concept of working people to a modified definition of primitive accumulation under neo-liberalism, that is, as a process of surplus extraction by capital based on expropriation of a part of necessary consumption of the producer. It is argued that this is the material basis common to all sectors of what is here understood as working people.

BACKGROUND: Relapse in people with schizophrenia is a major challenge for mental health service providers in Tanzania and other countries. Approximately 10% of people with schizophrenia are re-admitted due to relapse at Muhimbili National Hospital (MNH) Psychiatric Unit each month. Relapse brings about negative effects and it results in a huge burden to patients, their families, the mental health sector and the country's economy. So far no study has been done to address relapse in Tanzania. The purpose of the study was to explore perspectives on risk and protective factors influencing relapse of people with schizophrenia and their caregivers attending Muhimbili National Hospital Psychiatric Out-patient Department, Dar es Salaam, Tanzania. METHODS: A qualitative study was conducted, involving in-depth interviews of seven people with schizophrenia who are out-patients and their seven family caregivers at MNH. Purposive sampling procedure was used to select participants for the study. Audio recorded in-depth interviews in Swahili language were conducted with all study participants. The recorded information was transcribed and analyzed using NVivo 9 computer assisted qualitative data analysis software. RESULTS: Personal risk and protective factors for relapse, environmental risk and protective factors for relapse and suggestions to reduce relapse were the main themes that emerged from this study. People with schizophrenia and their caregivers (all of whom were relatives) perceived non adherence to antipsychotic medication as a leading risk factor of relapse; other risks included poor family support, stressful life events and substance use. Family support, adherence to antipsychotic medication, employment and religion were viewed as protective factors. Participants suggested strengthening mental health psycho-education sessions and community home visits conducted by mental health nurses to help reduce relapse. Other suggestions included strengthening the nurse-patient therapeutic relationship in provision of mental health care. CONCLUSIONS: This study calls for improvement in mental health care service delivery to individuals with schizophrenia. Establishing a curricular in mental health nursing that aims to produce competent mental health nurse force would improve nursing practice in mental health care service delivery.

BACKGROUND: This paper presents the prevalence of human immunodeficiency virus (HIV) and syphilis infections among women attending antenatal clinics (ANC) in Tanzania obtained during the 2003/2004 ANC surveillance. METHODS: Ten geographical regions; six of them were involved in a previous survey, while the remaining four were freshly selected on the basis of having the largest population among the remaining 20 regions. For each region, six ANC were selected, two from each of three strata (urban, peri-urban and rural). Three of the sites did not participate, resulting into 57 surveyed clinics. 17,813 women who were attending the chosen clinics for the first time for any pregnancy between October 2003 and January 2004. Patient particulars were obtained by interview and blood specimens were drawn for HIV and syphilis testing. HIV testing was done anonymously and the results were unlinked. RESULTS: Of the 17,813 women screened for HIV, 1,545 (8.7% (95% CI = 8.3-9.1)) tested positive with the highest prevalence in women aged 25-34 years (11%), being higher among single women (9.7%) than married women (8.6%) (p < 0.07), and increased with level of education from 5.2% among women with no education to 9.3% among those at least primary education (p < 0.001). Prevalence ranged from 4.8% (95% CI = 3.8%-9.8%) in Kagera to 15.3% (95% CI = 13.9%-16.8%) in Mbeya and was; 3.7%, 4.7%, 9.1%, 11.2% and 15.3% for rural, semi-urban, road side, urban and 15.3% border clinics, respectively (p < 0.001). Of the 17,323 women screened for syphilis, 1265 (7.3% (95%CI = 6.9-7.7)) were positive, with highest prevalence in the age group 35-49 yrs (10.4%) (p < 0.001), and being higher among women with no education than those with some education (9.8% versus 6.8%) (p < 0.0001), but marital status had no influence. Prevalence ranged from 2.1% (95% CI = 1.4%-3.0%) in Kigoma to 14.9% (95% CI = 13.3%-16.6%) in Kagera and was 16.0% (95% CI = 13.3-18.9), 10.5% (95% CI = 9.5-11.5) and 5.8% (95% CI = 5.4-6.3) for roadside, rural and urban clinics, respectively. Syphilis and HIV co-infection was seen in 130/17813 (0.7%). CONCLUSION: The high HIV prevalence observed among the ANC clinic attendees in Tanzania call for expansion of current voluntary counselling and testing (VCT) services and access to antiretroviral drugs (ARV) in the clinics. There is also a need for modification of obstetric practices and infant feeding options in HIV infection in order to prevent mother to child transmission of HIV. To increase uptake to HIV testing the opt-out strategy in which all clients are offered HIV testing is recommended in order to meet the needs of as many pregnant women as possible.

Abstract Background The emergence and spread of antimicrobial resistance (AMR) present a challenge to disease control in East Africa. Resistance to beta-lactams, which are by far the most used antibiotics worldwide and include the penicillins, cephalosporins, monobactams and carbapenems, is reducing options for effective control of both Gram-positive and Gram-negative bacteria. The World Health Organization, Food and Agricultural Organization and the World Organization for Animal Health have all advocated surveillance of AMR using an integrated One Health approach. Regional consortia also have strengthened collaboration to address the AMR problem through surveillance, training and research in a holistic and multisectoral approach. This review paper contains collective information on risk factors for transmission, clinical relevance and diversity of resistance genes relating to extended-spectrum beta-lactamase-producing (ESBL) and carbapenemase-producing Enterobacteriaceae, and Methicillin-resistant Staphylococcus aureus (MRSA) across the human, animal and environmental compartments in East Africa. Main body The review of the AMR literature (years 2001 to 2019) was performed using search engines such as PubMed, Scopus, Science Direct, Google and Web of Science. The search terms included ‘antimicrobial resistance and human-animal-environment’, ‘antimicrobial resistance, risk factors, genetic diversity, and human-animal-environment’ combined with respective countries of East Africa. In general, the risk factors identified were associated with the transmission of AMR. The marked genetic diversity due to multiple sequence types among drug-resistant bacteria and their replicon plasmid types sourced from the animal, human and environment were reported. The main ESBL, MRSA and carbapenem related genes/plasmids were the bla CTX-Ms (45.7%), SCCmec type III (27.3%) and IMP types (23.8%), respectively. Conclusion The high diversity of the AMR genes suggests there may be multiple sources of resistance bacteria, or the possible exchange of strains or a flow of genes amongst different strains due to transfer by mobile genetic elements. Therefore, there should be harmonized One Health guidelines for the use of antibiotics, as well as regulations governing their importation and sale. Moreover, the trend of ESBLs, MRSA and carbapenem resistant (CAR) carriage rates is dynamic and are on rise over time period, posing a public health concern in East Africa. Collaborative surveillance of AMR in partnership with regional and external institutions using an integrated One Health approach is required for expert knowledge and technology transfer to facilitate information sharing for informed decision-making.

BACKGROUND: Every year, more than a million of the world's newborns die on their first day of life; as many as two-thirds of these deaths could be saved with essential care at birth and the early newborn period. Simple interventions to improve the quality of essential newborn care in health facilities - for example, improving steps to help newborns breathe at birth - have demonstrated up to 47% reduction in newborn mortality in health facilities in Tanzania. We conducted an evaluation of the effects of a large-scale maternal-newborn quality improvement intervention in Tanzania that assessed the quality of provision of essential newborn care and newborn resuscitation. METHODS: Cross-sectional health facility surveys were conducted pre-intervention (2010) and post intervention (2012) in 52 health facilities in the program implementation area. Essential newborn care provided by health care providers immediately following birth was observed for 489 newborns in 2010 and 560 in 2012; actual management of newborns with trouble breathing were observed in 2010 (n = 18) and 2012 (n = 40). Assessments of health worker knowledge were conducted with case studies (2010, n = 206; 2012, n = 217) and a simulated resuscitation using a newborn mannequin (2010, n = 299; 2012, n = 213). Facility audits assessed facility readiness for essential newborn care. RESULTS: Index scores for quality of observed essential newborn care showed significant overall improvement following the quality-of-care intervention, from 39% to 73% (p <0.0001). Health worker knowledge using a case study significantly improved as well, from 23% to 41% (p <0.0001) but skills in resuscitation using a newborn mannequin were persistently low. Availability of essential newborn care supplies, which was high at baseline in the regional hospitals, improved at the lower-level health facilities. CONCLUSIONS: Within two years, the quality improvement program was successful in raising the quality of essential newborn care services in the program facilities. Some gaps in newborn care were persistent, notably practical skills in newborn resuscitation. Continued investment in life-saving improvements to newborn care through the health services is a priority for reduction of newborn mortality in Tanzania.

Summary Physiological and energetic mechanisms have been proposed to constrain body sizes of organisms along climatic gradients; however, these provide contrasting predictions. While Bergmann's rule predicts increases in body sizes in cooler climates resulting from physiological constraints, energy‐based community assembly rules suggest declines in the mean body size of species caused by increased extinction probabilities for large‐bodied species in low‐energy habitats. We tested these contrasting hypotheses by quantifying trait distributions in bee communities along a 3·6‐km elevational gradient at Mt. Kilimanjaro. Traditionally, intra‐ and interspecific trait shifts along environmental gradients have been investigated in isolation. However, a surge of theoretical approaches and studies on plants demonstrated that the explicit integration of trait variation among and within species can be essential for identifying the mechanisms that shape traits and related ecosystem functions along environmental gradients. We therefore studied variation in body size and related morphological traits at both the intra‐ and interspecific level. We found support for both physiological constraints and energy‐based community assembly rules as drivers of trait distribution in bee communities along elevational gradients, which, however, affected different levels of biotic organization, that is the population and community level. While the number of bee species with large body sizes declined with elevation, individuals within species became on average larger, resulting in contrasting trends in morphometric parameters at the community versus population level. Furthermore, body size within bee communities became less variable at higher elevations, largely as a result of a non‐random, directive loss of species, but paralleled by a decline in intraspecific variance, suggesting intensified filtering effects with increasing elevation. Similar patterns were found for other functional traits related to the foraging ecology of bees (tongue length, relative forewing length). We conclude that along climatic gradients both physiological and energetic constraints shape trait distributions of pollinators, but at different levels of biological organization. A lay summary is available for this article.

BACKGROUND: Progress towards reaching Millennium Development Goals four (child health) and five (maternal health) is lagging behind, particularly in sub-Saharan Africa, despite increasing efforts to scale up high impact interventions. Increasing the proportion of birth attended by a skilled attendant is a main indicator of progress, but not much is known about the quality of childbirth care delivered by these skilled attendants. With a view to reducing maternal mortality through health systems improvement we describe the care routinely offered in childbirth at dispensaries, health centres and hospitals in five districts in rural Southern Tanzania. We use data from a health facility census assessing 159 facilities in five districts in early 2009. A structural and operational assessment was undertaken based on staff reports using a modular questionnaire assessing staffing, work load, equipment and supplies as well as interventions routinely implemented during childbirth. RESULTS: Health centres and dispensaries attended a median of eight and four deliveries every month respectively. Dispensaries had a median of 2.5 (IQR 2-3) health workers including auxiliary staff instead of the recommended four clinical officer and certified nurses. Only 28% of first-line facilities (dispensaries and health centres) reported offering active management in the third stage of labour (AMTSL). Essential childbirth care comprising eight interventions including AMTSL, infection prevention, partograph use including foetal monitoring and newborn care including early breastfeeding, thermal care at birth and prevention of ophthalmia neonatorum was offered by 5% of dispensaries, 38% of health centres and 50% of hospitals consistently. No first-line facility had provided all signal functions for emergency obstetric complications in the previous six months. CONCLUSIONS: Essential interventions for childbirth care are not routinely implemented in first-line facilities or hospitals. Dispensaries have both low staffing and low caseload which constrains the ability to provide high-quality childbirth care. Improvements in quality of care are essential so that women delivering in facility receive "skilled attendance" and adequate care for common obstetric complications such as post-partum haemorrhage.