Contextualizing Child Poverty in Tanzania: Legal Framework, Social Services, and the State of HIV/AIDS and Malaria

Transcription

1 Contextualizing Child Poverty in Tanzania: Legal Framework, Social Services, and the State of HIV/AIDS and Malaria Graduate Program in International Affairs, The New School Assiati Chikuwa, Jeremy Haynes, Louisa Lippi, Sarina Cipriano, Tashi D. Shakya Enrique Delamonica, Mark Johnson, Alberto Minujin, To The UNICEF Tanzania Country Office and the Global Study on Disparity UNICEF HQ December

2 Executive Summary Children are disproportionately vulnerable to poverty and suffer the most from its effects. It is estimated that 90 percent of children in Tanzania are deprived in one way or another; therefore breaking the cycle of poverty starts with addressing issues that affect children. To do this, it is imperative that policies and programs are enacted to ensure the fulfillment of their basic economic and social rights, including access to clean water and sanitation, health care, education and protection. As children voices are not heard during the policy and budgeting process, their needs can easily be overlooked. It is imperative that children s needs are brought to the forefront of the national agenda. Children s vulnerability is multifaceted; therefore the response must address the holistic needs of children. Over the past few years Tanzania s economy has experienced increased growth. In 2004, the GDP growth was a 6.7 percent outpacing averaged GDP for all of Africa, which was approximately 5.1 percent. Currently, the GDP is $860 per person and the economy is expected to grow by 7 percent this year. (The Economist) Despite this growth, poverty in the country remains pervasive and the benefits of the recent growth have not been evenly distributed among the population. Tanzania is considering amendments of several of its key policies that directly affects the wellbeing and quality of life of children through the proposed Children s Law Act ; which will take into account; Employments and Labor Relations Act, the Laws of Inheritance and Succession and the Law of Marriage Act, The Primary Education Development Program and the Sector- Wide Approach to health programming. These policies impact are beginning to demonstrate positive changes in key social indicators, such as access to education, water and sanitation, healthcare, and protection. Infant and underfive mortality rates have been steadily declining; between the IMR declined from 88 to 68 per 1,000 live births and the U5MR decreased from 147 to 126 per 1,000 live births over the same period. Gross primary school enrollment has been increasing from 77.6 percent in 1990 to percent in

3 While gains have been made in these critical areas towards reducing non-income indicators of child poverty, disparities still remain. Improved access to healthcare facilities, especially for rural populations, is crucial to equitable poverty reduction. The urban/rural divide is also evident in the access to improved water sources and sanitation facilities; safe water available to 54 percent of the rural population versus 73 percent of urban population. It is evident that Tanzania is committed to reducing poverty and disparities among children. However, policy and program gaps still remain. While the elimination of user fees for school resulted in a tremendous increase in enrollment, increases in facilities and quality-trained teachers have not kept pace. This has lead to low retention and competition rates. Poverty, disease and ignorance are closely interlinked and each is a determinant of the other. The chapter on HIV/AIDS and Malaria will review the impact of HIV/AIDS and Malaria in Tanzania. HIV/AIDS and malaria are by far the most common disease and causes of death in Tanzania. Almost seven percent of the population is living with HIV/AIDS and more than 30 percent of the population is infected with Malaria. Morbidity and mortality from these two diseases have a major socio-economic impact on individuals, communities and nations, due to the vicious cycle of poverty, disease and ignorance. In Tanzania, morbidity due to HIV/AIDS and Malaria leads to irrecoverable losses in productivity, reduced income, strain on health care, and damage on the economy. If not controlled, continuing rise in incidence of HIV/AIDS and Malaria may threaten the overall national development. I. Legal and Policy Framework for Children Tanzania has demonstrated a strong commitment towards the reduction of poverty and the protection of human rights, especially the rights of children. Tanzania has ratified: The Convention on the Rights of the Child (CRC) The Convention on the Worst Forms of Child Labor The African Charter on the Rights and Welfare of the Child 3

4 Tanzania qualified for the World Bank s High Indebted Poor Countries (HIPC) Initiative in 2000 and releasing it from its debt servicing commitments thereby allowing it to mobilize resources for poverty reduction through increased support to social sectors. Tanzania's framework for poverty reduction is outlined National Strategy for Growth and Reduction of Poverty (commonly referred to by its Swahili acronym, MKUKUTA). Through MKUKUTA, the equitable reduction of poverty in terms of income and non-income indicators has been put at the top of the national agenda. MKUKUTA has incorporated issues related to children's rights and vulnerabilities. There have also been the developments of a number of policies and national action plans that address the concerns of children, especially those of the most vulnerable children (MVC). The Child Development Policy of 1996 has undergone an extensive revision incorporating issues related to HIV and AIDS, and is pending approval by the Cabinet. According to the report dated 20 October 2004, (CRC/C/70/add.26 of the government of Tanzania to the Committee of the CRC) the formation of a harmonized, comprehensive Children's Law Act, is currently under consideration. It is noted in this report that the Government is currently working for a standardized definition of a child in order to be in conformity with Constitution of United Republic of Tanzania, the National Child Development Policy, the CRC, and the African Charter on the Rights of the Welfare of the Child, which defines a child as a person under the age of 18 years old. However, disparities still exist in legislation. As it stands now, there are varying definitions of a child depending on the legal framework. According to the Customary, Islamic or Hindu Law, the age of majority is determined on the basis of attaining puberty. In the Statuary Law, a child is defined according to the context. It is clear that there is a need to harmonize the definition of a child and young person under Tanzanian Law. The Government is in the process of amending pieces of legislation to conform to the CRC principles and other international humanitarian laws. The following ranges of laws in regard to the definition of the child can be observed in Tanzania: In the Primary School (Compulsory Enrolment and Attendance) Rule: a child is one who has attained the age of 7 years but not attained the age of 13. In the Criminal Procedure Act of 1985: a child is a person under the age of 16 years. 4

5 In the Law of Marriage Act. No. 5 of 1997: a male can enter into marriage at the age of 18 years. A female can enter into marriage at the age of 15 years. In the law of Contract Ordinance, cap.433: it prohibits persons under 18 years to enter into contracts. Additionally, several pieces of social protection legislation exist to address the needs of vulnerable children however; the definition of vulnerability remains vague and undefined. This can be problematic when creating programs targeting vulnerable children and/or in the standardization of program implementation, thereby falling short of providing a comprehensive social safety net for children. i. Child Exploitation and Abuse While efforts have been made to protect children from abuse and exploitation the measures can be deemed inadequate. The sexual exploitation of children in Tanzania is a silent problem that needs to be voiced and addressed properly. According to the report of Tanzania to the CRC committee (CRC/C/70/Add.26) there is no data available regarding sexual exploitation including prostitution, pornography and trafficking, and the number of children with access to recovery and other assistance programs. However, in the Committee of CRC (CRC/C/TZA/CO/2) report, of June 2001 on the implementation of the CRC, the CRC committee is concerned at the information provided by the state party (CRC/C/70/Add.26, page 59) that the phenomenon of children prostitution is growing quickly and steadily. Poverty is a major factor contributing to girls involvement in child prostitution. Due to limited educational and vocational skills, as well as the lack of a social safety-net, girls, particularly those aged 10 to 17, often resort to prostitution. It is therefore important for the government of Tanzania to strengthen its legislative measures and develop an effective and comprehensive policy that addresses the exploitation of children, including the factors that place children at risk of such exploitation. The government is also about to embark on a study of laws related to human trafficking, with a view to addressing gaps and disparities in the legislation. Tanzania acceded to the United Nations Protocol to Prevent, Suppress and Punish Trafficking in Persons, Especially Women and Children, supplementing the United Nations Convention against 5

6 Transnational Organized Crime. The UNICEF Innocenti Research Centre conducted a study in 2000, which concluded that the structure of trafficking in Tanzania involves moving children from rural to urban areas. The trafficking of children can constitute a structural impediment to achieving Millennium Development Goal 2, since trafficked children are denied access to school. As trafficking is common in both Mainland Tanzania and Zanzibar, efforts to reduce incidences of trafficking need strengthening. Legislative efforts to protect children from hazardous work and from the worst forms of child labor have been implemented including the Employments and Labor Relations Act and the Time Bound Program (TBP) for the elimination of the Worst Forms of Child Labor, which was launched in Geneva in June According to its report to the Committee on the CRC (CRC/C/70Add.26), the government of Tanzania highlights that The Time Bound Program aims to combat the worst forms of child labor and has some success in withdrawing children from such work and providing them with suitable alternative, as well as preventing children from engaging in hazardous labor in the first place. The program is being in eleven pilot districts: Ilala, Kinondoni, Temeke, Arusha, Uraban, Arumeru, Simanjiro, Iringa Rural, Mufaindi, Iramba, Kondoa, and Urambo. In implementing the TBP, the government established the National Inter- Sectoral Coordination Committee (NISCC) at national level to oversee and coordinate intervention activities against child labor in general and the worst forms of child in particular. At the local level, the government has formed District Child Labor Sub-Committees and appointed District Child Labor Coordinators responsible for monitoring and coordinating intervention activities at district level. It is important to note that Tanzania has raised the minimum age of employment from 12 to 14 years, which is still in noncompliance with the CRC. While in Zanzibar, the Constitution has set the age for paid employment of 18 years. In Zanzibar, new policies have been enacted such as the Employment Act. No. 11/2005 which strictly protects children from being employed and the Protection of Spinsters and Single Parent Act, No. 4/2005 which protects the right of a pregnant student an education, who otherwise may have been expelled. The government of Zanzibar has also established an Interdisciplinary Task Force, to combat child abuse, especially sexual abuse. Its members are police officers, lawyers, medical doctors and social welfare officers. The government of Zanzibar is in the process of 6

7 domesticating the Optional protocols to the CRC, that is, the Optional Protocol on Involvement of Children in Armed Conflict and on the Sale of children, Child Prostitution and Child Pornography. As Tanzania continues to host to the largest refugee population in Africa there are serious concerns about the extent to which refugee children suffer from sexual exploitation. It has been reported that many refugee children in Tanzanian camps, have been faced to sexual abuse by Tanzanian police. Further study should be undertaken to exam the extent to which the Government of Tanzania is caring for such children and protecting them sexual assault. In order to strengthen policies and create targeted sexual abuse interventions more research needs to be conducted in order to know the prevalence of sexual assault and which groups are the most vulnerable particularly orphans, refugees and trafficked children. ii. Birth Registration and Early Marriage Efforts to ensure birth registration need to be strengthened. While Tanzania had Births and Death Registration Ordinance since 1920, less than 10 percent of children are registered. Birth registration offers a child an identity and proof of nationality and without being registered a child can become marginalized and deprived of his/her rights. Ensuring that children have proper registration can help in inheritance matter and it combat property grabbing. In order to sensitize people to the importance of birth registration, some government institutions are beginning to demand the provision of a birth certificate as a condition for enjoying access to certain rights. This type of intervention runs the risk of excluding a large portion of unregistered children from receiving essential services, as indicated by evidence from other countries. Gaps between policy and practice still exist. There are the difficulties in ensuring the birth registration of children particularly in rural areas; a system should be implemented to ensure that children in most remote places and vulnerable children, particularly street children, are registered in order to benefit from government assistance and protection. The government is reviewing discriminatory laws for the protection girls and women. The Laws of Inheritance and Succession and the Law of Marriage Act, No.5 of 1971 are undergoing review 7

8 with a view of incorporating the best interests of children. The current marriage policy set the minimum age for marriage at 15 for girls and 18 for boys it should establish one legal minimum age for marriage, at an internationally acceptable level, for both boys and girls. While the current inheritance and succession law bars women from inheriting property. This is of particular concern, as more and more women and children are losing husbands and fathers to AIDS, they run the risk of being disposed of their land and their means of survival. In regards to birth registration, Zanzibar has established a Birth Registration Office in all districts and shehias. This is in conformity with domestic law governing births and deaths. The Births and Deaths Registration Decree requires parents of the child to notify the Registrar of births within forty-two days of the birth of the child. A form is available at the Shehia office, as a first step in obtaining birth certificate from the District Registrar s office. The law has gone further by providing that where a birth has taken place in prison, hospital, orphanage/quarantine station, the duty to give such information shall lie with the officer in charge of the institution. iii Adoption: The procedure for formal and informal foster care and adoption services in Tanzania is outlined in the Adoption and Foster Care (Article 21 of the National Guidelines for Care and Protection of Orphans and Vulnerable Children in Institutional Care). It is important to note that the Adoption Order stipulates that adoption shall not be granted to any applicant who is not residing within the East African Territories. However, the proposed harmonized Children s Law of Tanzania Mainland is taking into consideration the protection of children and cooperation in respect with to inter-country adoption so that the Adoption Ordinance Cap. 375, is in conformity with the CRC. According to the report of Tanzania to the CRC committee (CRC/C/70/Add.26), under Article 9 of the Zanzibar National Constitution, adoption is strictly discouraged. Section 156 of the Penal Decree of Zanzibar strictly prohibits engaging in the act of buying, selling or bartering of any person for money or for any other consideration. It is also an offense for a person to arrange for, or assist a child to travel to a foreign country. Additionally, it is an offense to obtain an affidavit of consent from a pregnant woman for money or their consideration for the adoption of her 8

9 unborn child, or the falsification of any birth record or register, or impersonation of the mother or assistant. Zanzibar and Mainland Tanzania had similar legislation regulating adoption practice. Zanzibar is a Muslim country and Sharia law does not permit adoption. Therefore, Zanzibar adoption legislation discriminates against non-muslims who wish to adopt. Furthermore, child abduction is an offense. According to section 123 Penal Decree, it is unlawful for any person to take an unmarried girl out of custody or protection of her legal caregivers. Anyone who pleads guilty under this section is liable to punishment in prison for three years - this is consistent with Article 35 of the CRC. Main Findings There are four different sets of laws applicable in Tanzania, namely national legislation, specific legislation for the region of Zanzibar, Islamic Law and Customary law. It would be necessary for them to be combined effectively so as to avoid discrimination between regions or population groups. It is important to note that the differences between Customary Laws and CRC constitute serious concerns to children s rights. For instance, in Zanzibar, all issues concerning child care are dealt with under Islamic jurisprudence for the Muslims who are the majority and secular law for non- Muslims. In regards to the Customary Law, amendments are being introduced to raise the minimum age for marriage of girls from 15 to 18 year of age. In view of the contradiction between national and customary law, it would be interesting to know how the government intends to ensure that legislation is implemented effectively; in order to change cultural attitudes, the government should consider implementing an awareness raising campaign. Finally, in Tanzania, there is need for reliable information for data collection, conformity of the laws in Zanzibar and the rest of other parts of the country. Children should enjoy the same rights throughout the country. For example, it is understood that in Zanzibar young women could be prosecuted for becoming pregnant under the age of 21, but that elsewhere in the country this is not the case. The government of Zanzibar inaugurated a Policy for Child Survival, Protection and Development (CSPD) in October The policy provides a broad framework for the 9

10 protection of Children s rights including Child participation in matters of concern to children. Even though, the State has reviewed certain discriminatory legislation to ensure that children s rights are not breached, there are concerns that discrimination against certain groups still exists especially against pregnant girls. While enacting a policy is the first step towards ensuring the rights of a child, measures must be taken to ensure that the policy is implemented by all relevant stakeholders. Additionally, mechanism should be in place to ensure that all responsible for ensuring the rights of children are held accountable. It is essential that the blue print for child rights is a reality. II. Social Service Interventions In 2000, with cooperation with the IMF and the World Bank, Tanzania adopted its first Poverty Reduction Strategy, and one of its main goals was to improve the quality of life and social wellbeing of ordinary Tanzanians. To do this, major reforms in the service sector were implemented; seven years later these efforts have resulted in a number of positive improvements, but Tanzania still has a long way to go. Assisting in this process is Tanzania s relationship with the international donor community. Tanzania is among Africa s largest recipient of donor aid. 42 percent of the nation s budget in will come from donors. (World Bank to Loan ) Since the mid-1990 s Tanzania has seen a consistent increase in aid. In 2002, Official Development Assistance (ODA) accounted for 13.2 percent of Tanzania s Gross National Income, or net ODA per capita of $35. The UK s Department for International Development (DFID) is acknowledged to be the most important donor in supporting national anti-poverty and sector development policies in Tanzania. Development assistance increased from $89 million in to $111 million in The second largest and most influential donor is the World Bank, which gave $174 million to Tanzania in In comparison, the World Bank offered a similar figure, $168 million to Ghana. In rank order, Japan, the Netherlands, European Union, Denmark, Italy, the United States, Sweden, and the IMF round out the top ten donors of gross ODA to Tanzania (CHIP). The social sectors, such as education, healthcare and water and sanitation, benefit most from the infusion of resources from the donor community. 10

11 i. Education Tanzania has outlined certain operational targets in its MKUKUTA for ensuring access to education. One targeted achievement is for 90 percent of primary and secondary schools to have adequate number of skilled teachers by Unfortunately, only one teacher training college was added from 2005 to (The Economic Survey 2006). If schools are to have more skilled teachers then the infrastructure for teaching, training and education must be in place. On a positive note, the number of students in government teachers colleges grew from 24,463 in 2005 to 26,681 in 2006 (The Economic Survey 2006). Yet the student to teacher ratio is worsening over time, not improving. In 2001, the student teacher ratio in primary schools was 46 to 1; in 2004 it was 59 to 1 (Tanzania Poverty and Human Development Report 2005). At the secondary school level, the teacher-pupil ratio in 2005 was 1:22 and dropped to 1:29 in Primary education has made significant progress compared to other sectors, but the delivery of this service still needs improvement. The Primary Education Development Program (PEDP) was successful in increasing the Gross Enrollment Rate from 77.6 percent in 1990 to percent in Similarly, the Net Enrollment Rate grew from 58.8 percent in 1990 to 90.5 percent in 2004 (National Strategy for Growth and Reduction of Poverty). However, net attendance rates are much lower indicating a clear need to improve quality and ensure retention. (Source: UNICEF, Info by Country, Tanzania) The increase in the Gross Enrollment Rate has had both a positive and negative impact on education. Teacher training and classroom construction has lagged behind this massive (34 percent) increase in primary school net enrollment over a five-year period. The PEDP has not only focused on expansion of enrollment, but on constructing classrooms, deploying more teachers, and improving the quality of teachers and teaching materials. The government has pledged to maintain its policy of no primary school fees, and send well-qualified teachers to all areas with special incentives for teachers to work in remote or hardship areas of the country. (National Strategy for Growth and Reduction of Poverty) While there has been an increase in qualified primary school teachers in the past several years, the increase is not equal across all regions. For example, between 2001 and 2004, the areas of 11

12 Dar es Salaam, Arusha, Iringa, Kigoma, Mbeya, Lindi, and Shinyanga experienced over a 20 percent increase in qualified teachers. Change was hardly noticeable in places like Kilimanjaro and Singida. Then there are regions where the situation became worse and the number of students without qualified teachers grew. Between 2001 and 2004, Mara and Mtwara had a 30 percent increase in the pupil/student ratio (Poverty and Health Development Report 2005, 17). Increased teacher training is critical in maintaining the rise in school enrollment and will be fundamental for helping Tanzania reach its goals set out in its poverty reduction strategy. In 2006, there were 14,700 primary schools, up from 14,257 in Over the same period, there were 2,289 secondary schools. While the government has done a good job boosting primary school enrollment, only 8% of children attend secondary school, up from 6% in 2000 (Poverty and Health Development Report 2005, 18-19). This number may increase due to the larger number of primary school students that are now reaching the age to attend secondary school, but there is still a deficiency in the number of secondary schools and qualified teachers. ii. Healthcare Services A Sector Wide Approach (SWAP) in health has been in place since 1998, and a number of reforms are currently underway. However, several obstacles still exist to equitable access to health care. The National Strategy for Growth and Reduction of Poverty indicates the main challenges to be long distances to health facilities, inadequate and unaffordable transport systems, poor quality of care, shortage of skilled providers, poor governance, and accountability mechanisms. The government has placed emphasis on preventative health, with implementation of universal basic health services. The Ministry of Health determines the location for establishing new health facilities according to population. However, population growth has outpaced the number of new facilities, leading to an unbalanced facility/population ratio. (Tanzania National Website Health) 12

13 User fees for health services were introduced in the 1990s under the influence of international donors. The aim was to increase funds and improve services; however, it resulted in the exclusion of the poor and vulnerable from the health system. Since then waivers and exemptions for the extreme poor, pregnant women and children under five have been implemented. However, the policy is often burdensome and complicated and often results in the impoverished forgoing medical care due to their inability to pay (Laterveer, Munga and Schewezrel). Six out of ten children under the age of five die at home without ever having contact with health services (National Strategy for Growth and Reduction of Poverty). Overall health care services in Tanzania are lacking in manpower, rural coverage, and quality of care. In 2004, the Government of Tanzania only paid for 43.6 percent of the total expenditure on health in Tanzania, while 56.4 percent was from private sources. This amount of government expenditure on health was only 4 percent of the gross domestic product of Tanzania in 2004 (WHO Statistical Information System). There has also been decrease in the number of trained medical personnel attending to births and the number of births that occurred in health facilities (National Strategy for Growth and Reduction of Poverty). Despite the challenges faced, many key indicators for public health have improved. For example, between 1996 and 2004 infant mortality has gone from 88 per 1,000 live births to 68 per 1,000, immunization rates have increased, and the HIV prevalence has gone down from 7.7 percent to 6.7 percent (Poverty and Human Development Report). The state is working in partnership with other actors to increase access to the health system. While the state runs 87 hospitals, 331 health centers, and 3,038 health dispensaries, other partners manage 124 hospitals, 140 health centers, and 1,499 health dispensaries (The Economic Survey 2006: Health). Access to health care services varies widely depending on location. In urban settings, only 2 percent of the population is not within 5 kilometers of a health dispensary and within 10 kilometers of a hospital. In rural settings, 32 percent of the population is not within 5 kilometers 13

14 of a health dispensary and 64 percent are not within 10 kilometer of a hospital (Poverty and Human Development Report). This distance combined with a poor transportation system and the other factors already mentioned above makes access to health care services difficult, and subsequently 90 percent of all child deaths are from preventable causes. Tanzania faces a serious shortage of healthcare workers. Worldwide, 57 countries have a shortage of healthcare workers; 36 of the 57 countries are in Africa. In 13 Sub-Saharan countries which comprise the World Health Organization s Africa Region, for every 100 physicians and 100 nurses and midwives, there are 6 new doctors and 6.4 new nurses and midwives produced each year. Tanzania is above average, with 8.4 newly graduated physicians for every 100 physicians in the workforce. However, Tanzania only has 3 new nurses or midwives enter the work force for every 1,000 that are currently active. Tanzania loses 2.4 percent of doctors and 2.2 percent of nurses and midwives to pre-mature (under 60 years) mortality. These figures are on par with the rest of the region, and likely due to high levels of HIV and AIDS infections (Kinfu, Mercer). The World Health Organization concludes that even if there were no healthcare worker outflows from migration, it would take approximately 36 years for the number of doctors and 29 years for nurses and midwives to reach the level of 2.28 healthcare professionals needed in order to reach important Millennium Development Goals in these countries (Kinfu, Mercer). iii. Water & Sanitation Services Tanzania faces the challenge of expanding water and sanitation services to both rural and urban areas of the country. Water is directly correlated with health of the poor because unsafe water supplies often lead to diseases such as cholera and malaria. Tanzania established operational targets for increased access to safe and affordable water, including 65 percent of the rural population having access by and 90 percent of the urban population having access in the same period (National Strategy for Growth and Reduction of Poverty). In 2006, the Environmental Health Unit of the Tanzania government established the Health and Clean Environment Program. This program was established in several localities including Dar es Salaam, Iringa, Mtwara, Mara, and Rukwa. The goal of this program is to have councils design and implement environment health programs at the local level. (The Economic Survey 2006: 14

15 Health) This type of community-based approach is effective because it empowers people enact appropriate interventions. As of 2006, approximately 47 percent of rural households did not have access to safe sources of drinking water. These people often must travel long distances to obtain water, with the burden of work falling on women and children (National Strategy for Growth and Reduction of Poverty). Some districts have less than 10 percent of rural households with access to improved sources of drinking water. (HDR) Urban water supply coverage is higher, but not sufficient. As of 2002, 73 percent of the urban population had a supply of water, but only 17 percent in 2003 had proper sewage services (National Strategy for Growth and Reduction of Poverty). As of 2004, 17 percent of city and municipal urban areas had sewage facilities. (HDR) In comparison, Tanzania s neighbor, Kenya, has 89 percent urban and 46 percent rural water coverage, and 56 percent urban and 43 percent rural sanitation coverage. (UNICEF-WES) Sub-Saharan Africa as a region has a 58 percent coverage rate of people using improved sources of drinking water and 36 percent improved access to sanitation facilities (UNICEF-WES). III. HIV/AIDS IN TANZANIA The main objective of this chapter on HIV/AIDS and Malaria is to discuss the prevalence of HIV/AIDS and Malaria cases in Tanzania. In order to analyze the prevalence rates, it is important to dwell into the characteristics surrounding the diseases. Knowledge of HIV/AIDS, access to health services, income, education and national policies are all core determining factors in the prevalence of these diseases. Health of an individual depends largely on access to health services, availability of health provisions, adequate food and drinking water, income, education and attitudes surrounding health. Conversely, all these dependent factors are reflective of development of a nation. Development is improving people's lifestyles through improved education, incomes, skills development and employment. The graph below is an attempt to show that in determining the health of one country, it is important to look into development aspect at the same time. In context of least developing countries that have low economic development, the characteristics are weak education systems, weak health systems and low employment opportunities. Figure 1. 15

16 Because of weak state infrastructure, i.e., weak education systems, inefficient and unaffordable health services, the prevalence and spread of HIV /AIDS and preventable diseases like Malaria can be further at risk. While illiteracy can hamper one s knowledge and prevention of diseases, weak health systems worsens the situation since first there are no adequate health services and facilities and second, one cannot afford even those basic health services or the expensive antiretroviral or anti-malarial drugs. The question of affording health services is further demarcated by the low income of the families since there aren t enough employment opportunities and often those income earners have to stay at home in order to take care of the sick at home. The official report of the Prime Minister s Office of Tanzania, cites that the increase in HIV/AIDS cases have resulted in reduced life expectancy, productivity, reduced growth in GDP and increase in the dependency ratio, poverty, infant and child mortality as well as the growing numbers of orphans. Prevalence of HIV/AIDS along with other diseases such as Malaria could equivalently be the cause of low national development in Tanzania. Diseases such as HIV/AIDS and Malaria can cause a strain not only on health services but can also drain out families income with purchases and expenditure on medicines, extra food and support materials. Many families are losing income earners. In most cases, income earners are forced to stay at home to care for relatives 16

17 who are ill. This means for e.g., one person suffering from HIV/AIDS equals to two since the caretaker cannot go to work thus further reducing income. The situation is worse when patients leave behind orphans and children with a possible threat of Mother to Child Transmission (MTCT). Diseases dramatically affect labor, setting back economic activity and social progress. The economy of a country is more affected when vast majority of people suffering from diseases or living with HIV/AIDS are young people between the ages of The overall long-term development is affected because the spread and prevalence of diseases is impacting the supply as well as demand of education. Fewer children are going to schools than in the past simply because of the increase in number of children infected with HIV, deaths due to Malaria or have become orphans. With reduced labor, reduced income, low education and high rates in diseases, national development of Tanzania is negatively affected. Tanzania Demographic Trends: Demographic trends and commitment to health Total population (millions), Total population (millions), Public health expenditure (% of GDP), Private health expenditure (% of GDP), Health expenditure per capita (PPP US$), Human development index (HDI) value, GDP per capita (PPP US$) (HDI), Life expectancy at birth (years) (HDI), Source: Human Development Report 2006 (Figure 2) Tanzania ranks as one of the poorest countries in the world as the graph above indicates. GDP per capita in 2004 was US$ 674. (Figure 2) More than 50 percent of the population lives below the poverty line. (Figure 4) In addition to poverty, life expectancy of a Tanzanian stands at a low 45 years. This also means that AIDS is erasing decades of progress made in extending life expectancy. With a total population of 37 million, the government spent only 2.4 percent of its GDP for health in 2003 that increased to four percent in (See figure 4.) 17

18 HIV/AIDS prevalence rates: Acquired immunodeficiency syndrome (AIDS) is the one of the most serious public health and development challenges in the sub-saharan Africa and stays true in the case of Tanzania also. According to the ( ) Tanzania HIV Indicator Survey (THIS), seven percent of adults between the ages were infected with the human immunodeficiency virus (HIV), the virus that causes AIDS. The first AIDS cases in Tanzania were reported in the Kagera region in By 1987, AIDS cases were reported in all regions of the country. In that year, the National AIDS Control Program (NACP) was established. But AIDS cases continued to increase in Tanzania. In most studies conducted, it is reported that adult prevalence rate of HIV/AIDS in Tanzania is around 6.5 percent. (Figure 4) According to UNAIDS estimates, 1.6 million Tanzanians were living with HIV/AIDS at the end of 2003; of them, 1.5 million were adults, and adult HIV prevalence was 8.8 percent. By the end of 2005, approximately 1.4 million adults (6.5%) were living with HIV in the Tanzania, a number slightly higher than the total percentage of people living with HIV/AIDS in Sub-Saharan Africa (6.1%). (See. Figure 4) The overall HIV prevalence is slightly higher among women than men in all areas of the country. Urban residents have considerably higher infection levels than rural residents. (10.9 percent vs. 5.3 percent) The data here indicates HIV prevalence increases with wealth. Infection rates are three times higher among those in the highest wealth quintile than those in the lowest wealth quintile. 1 United Republic Of Tanzania/Ministry Of Health Tanzania Mainland/National AIDS Control Program, Surveillance of HIV and Syphilis Among Antenatal Clinic Enrollees: : Dar Es Salaam. ic_enrollees.pdf 18

19 For both men and women, HIV prevalence increases with education. Adults with secondary or higher education are 50 percent more likely to be infected with HIV than those with no education. Source: Tanzania HIV/AIDS Indicator Survey (THIS) Core HIV/ AIDS Indicators Indicator Value (year) Deaths due to HIV/AIDS (per population per year) 365 (2005) Deaths due to HIV/AIDS (children under five) 9.3 (2000) Contraceptive prevalence rate (%) (2005) People with advanced HIV infection receiving (ARV) 18 (2006) combination therapy (%) HIV-infected pregnant women who received antiretroviral (ARV) 6.0 (2005) combination therapy for PMTCT (%) Total expenditure on health as percentage of GDP 4.0 (2004) Adult literacy rate (%) 69.4 (2004) Population living below the poverty line 57.8 (2001) Source: WHO 3 (Figure 3) Analysis of the above data table: For every 100,000 Tanzanian, almost 6000 people are infected with HIV/AIDS, out of which 365 people die each year. 9.3% percent of children (under five years of age) die due to HIV/AIDS, a number that alternatively depicts the range of MTCT. The data is presumable when the percentage of HIV-infected pregnant women, who received anti-retroviral combination therapy for Pre MTCT, is only six percent. Only seven percent of the total HIV infected population receives ARV while only 18 percent of the people with advanced HIV infection receive the ARV therapy. This could be due to various reasons; it could be problem with accessing the drugs they may live far from clinics that provide the medication. The cost of the 2 Contraceptive prevalence rate is an indicator of health, population, development and women's empowerment. It also serves as a proxy measure of access to reproductive health services 3 World Health Organization Core Health Indicators- the latest data from multiple WHO sources 19

20 ARVs could also be another determining factor. For the majority of Tanzanians, taking the ARVs may take a back seat to more pressing daily needs. They are forced to choose between their daily square meal and the expensive ARVs. In addition to poverty, lack of education and stigma can also be a part of the problem. Patients need to be educated on the correct use of drugs, since many of the cases in Africa reported developing resistance. There is also stigma attached to the disease with not many people wanting to take medications in workplaces or have to constantly hide it from people around them. COUNTRY PROGRESS INDICATORS Date Estimate Source Adult prevalence of HIV (15-49 years) % HDR Adult prevalence of HIV ( % UNAIDS years) Sub-Saharan Africa % of HIV-infected men and women receiving % 4 UNAIDS ARV Knowledge of HIV prevention methods ( % DHS 24 years)% - female Knowledge of HIV prevention methods ( % DHS 24 years)% - male Reported condom use at last higher risk sex % HDR (15-24 years)% - female Reported condom use at last higher risk sex % HDR (15-24 years)% - male % of young people aged 15 to 24 who used a 2007 Men % UNAIDS condom last time they had sex with a casual partner Women % (Figure 4) In January 2004, Tanzania's Global Fund Country Coordinating Mechanism reported that heterosexual transmission accounted for 82 percent of HIV infections; transmission from mother to child represented six percent of infections. 5 In Tanzania, knowledge of AIDS is widespread almost all women and men have heard of AIDS but knowledge of prevention is limited. Less than half of population groups between the ages of 15-24, know of two ways of preventing HIV. In addition, the percentage of the use of condom is less than half. This indicates that while condoms are cheap, most people do not have the knowledge that condoms are the effective way 4 UNAIDS country profile, 5 Tanzania Global Fund Country Coordinating Mechanism, Round 4 Proposal: Filling critical gaps for Mainland Tanzania in the national response to HIV/AIDS in impact mitigation for Orphans & Vulnerable Children, Condom Procurement, Care & Treatment, Monitoring and Evaluation, and National Coordination. 2004: Dar es Salaam. 20

21 to reduce the spread of HIV as well as Sexually Transmitted Diseases (STDs). On the other hand, there could be a stigma attached to purchasing condoms (may associate condoms with HIV) or in some cases, women may have been pressured to have sex without condoms. This way, like many African countries, socio-cultural contexts and gender differences affect people s attitudes towards these measures that might prevent them from using condoms. Policies and strategies should be implemented to promote safe sex but the more pressing need is defining gender roles. Addressing issues of gender equity and promoting equal participation of men and women in negotiating safer sexual practices is highly desirable, and women have the right and should be encouraged to say NO to unsafe sex. 6 Women should be encouraged to make decisions on sex, health and family. CHILDREN AND YOUNG PEOPLE GENERALIZED EPIDEMICS 7 Children aged 0 to 14 living with HIV [ ] Orphans aged 0 to 17 due to AIDS [ ] School attendance among orphans 73.0% School attendance among non-orphans 90.0% Source: UNAIDS (Figure 5) According to the National Aids Control Program (NACP) surveillance, youth account for over 60% of the new HIV infections in Tanzania ,000 children between the ages of 0-17 years were orphaned due to AIDS in HIV/AIDS pandemic has also meant the rapidly growing orphan population. Orphans are more susceptible to food poverty and diseases due to obvious lack of provider and caretaker. Orphans also do not have the incentives to go to schools neither do they receive any guidance. They are the neglected population, which adds on to the high dependent population in Tanzania. 6 The United Republic of Tanzania, Prime Minister s Office, National Policy on HIV and AIDS. Dar es Salaam September UNAIDS country profile, 8 National AIDS Control Program, United Republic of Tanzania, HIV/AIDS/STD Surveillance,

22 REGIONAL DIFFERENCES: Kagera 5.6% ( ) Dodoma 6.2% ( ) Kilimanjaro 6.3% ( ) Mtwara 7.1% ( ) Dar es Salaam 12.8% ( ) Mbeya. 16.0% ( ) Source: Tanzania Ministry of Health (Figure 6) 9 There are large regional differences in HIV prevalence in Tanzania (see table above). Infection rates vary widely in different regions of Tanzania. About 16 percent of men and women, age living in Mbeya and Iringa regions carry HIV infection. In Dar es Salaam 12.8 percent of adults are infected with HIV. HIV infection is lowest in Kagera region. In Mbeya and Iringa, the worst - affected regions in the country, HIV infection levels ranged between 15% and 19% in several urban areas in On the other hand, high HIV prevalence has been observed at rural antenatal sites in the Mbeya region in NATIONAL AIDS POLICIES AND RESPONSES: In recent years, Tanzania has demonstrated growing political commitment to fight HIV/AIDS, giving the issue high priority for resource mobilization and setting up new structures to integrate HIV/AIDS strategies with other development sectors. National HIV/AIDS Control Program (NACP) 11 : In response to the HIV/AIDS epidemic, the Government of Tanzania, with technical assistance from the World Health Organization s Global Program on AIDS (WHO-GPA), formed the NACP in 1988 under the Ministry of Health. The program includes developing strategies to prevent, control, and mitigate the effect of the HIV/AIDS epidemic, through health education, multi-sectoral response, and community participation. 9 The United Republic Of Tanzania Ministry Of Health Tanzania Mainland National AIDS Control Program Surveillance of HIV and Syphilis Among Antenatal Clinic Enrollees _Enrollees.pdf 10 National Bureau of Statistics Tanzania and ORC Macro, The United Republic of Tanzania, Prime Minister s Office, National Policy on HIV and AIDS. Dar es Salaam September

23 Tanzania Commission for AIDS (TACAIDS) 12 : TACAIDS was established in early 2001 to allow leaders at the highest levels of government to mobilize an accelerated, multi-sectoral and multi-faceted response to the epidemic. The Commission guides national policy, acts as a clearinghouse for AIDS activities, and helps mobilize additional funds to fight the epidemic on a national level. TACAIDS is also designed to monitor and evaluate progress, to mobilize resources, and undertake advocacy. The National Policy on HIV/AIDS 13 was adopted in November The policy allowed for communities to work within a framework and coordination to design appropriate interventions to prevent the transmission of HIV/AIDS and other STIs, to protect and support vulnerable groups, and mitigate the social and economic impact of HIV/AIDS. Joint UN Team on AIDS 14 : This team was established in June 2006 with a joint program of support and a joint budget of pooled resources, streamlining UN support to the government. RECOMMENDATIONS: Each sector of public, private, non-governmental organizations and faith based organizations should work to create more awareness on HIV and AIDS. Local communities in rural and urban areas should be reached out for a participatory approach to implement the various HIV/AIDS programs. Local government authorities, as leaders of the various communities, should be in the forefront in the war against the epidemic and should work to plan and implement cost effective HIV/AIDS interventions. While interventions could take years to be applied, there should be a direct approach to this problem. The government should initiate micro-enterprises and local development strategies for the affected population. In the community, focus should be on reducing the stigma attached to diseases, especially HIV/AIDS. The intervention can work only if people come forward for testing and cure. 12 The United Republic of Tanzania, Prime Minister s Office, National Policy on HIV and AIDS. Dar es Salaam September The United Republic of Tanzania, Prime Minister s Office, National Policy on HIV and AIDS. Dar es Salaam September

24 Overall, the Tanzanian government s effort for HIV/AIDS should focus on the youth population which is at most risk and most vulnerable. Young people in Tanzania need to be well informed about HIV and AIDS and safe sex and the government should monitor the youth population s pattern and behavior. MALARIA IN TANZANIA Malaria, Child Poverty and Disparity While malaria clearly impacts children under five most severely, the various dimensions of child poverty influence risk levels and the ability for children to access care and treatment. Children with less access to basic services, poor nutrition, parents with lower levels of education and weakened immune systems are more at risk for contracting and dying from malaria. In Tanzania, urban, educated and prosperous women use bed nets consistently more frequently than rural, less educated, poorer women. Excluding education level, this correlation also applies to children. Children living in urban areas are twice as likely to sleep under a mosquito net as children in rural areas. Additionally, children in the highest wealth quintile are four times more likely to sleep under a mosquito net than children in the lowest wealth quintile 15. In Tanzania, rural poor children with less educated parents have higher rates of malnutrition and under five mortality rates which directly relates to their risk of contracting malaria and suffering its consequences. Disabled children and orphans are also at greater risk than other children because in general they are poorer. Disabled children frequently live in extreme poverty combined with social exclusion. Lacking economic and social support, they are less likely to have access to mosquito nets (and even less so to ITNs) and are less likely to access costly treatment if infected. The Situation The malaria situation in Tanzania presents a grim picture. In comparison, malaria takes a greater direct toll on the population than does AIDS. But similar to AIDS, malaria is also a result of poverty. Malaria accounts for 30 percent of the national burden of disease and loss of 15 Demographic and Health Survey Malaria,

25 productivity in Tanzania, where the disease is endemic throughout much of the country. 16 The endemic condition of malaria in Tanzania is a solid proof that the country is not going in the direction of development in the near future. With 30 percent of people affected by the disease, and one child dying every five minutes, the country definitely has to bear the brunt of increased health cost, food supplies, and medicine supplies, provide access to safe drinking water and sanitation. The whole population of 37 million is at risk of malaria making it the third largest population at risk of malaria in Africa after Nigeria and the Democratic Republic of Congo. 17 The majority of Tanzanians suffer from malaria, a preventable disease that can have a serious negative impact on pregnant women and young children. In Tanzania each year, over 16 million people are infected, with 100,000 dying. Around 40,000 of those who lose their lives are children, with a child dying after every 5 minutes. 18 Malaria is the number one killer among children in Tanzania. 19 Malaria is the leading cause of outpatient and inpatient attendance in hospitals and is the leading cause of death among adults and children in Tanzania. 20 In 2003 there were 10,712,526 malaria cases reported and 14,156 reported deaths due to malaria 21. It is also a major concern among pregnant women and children under five. It affects people with impaired immunity and children under five the most because they have not developed any level of immunity from previous exposure. In 2003, 45% of all malaria cases were among children under five years of age. 22 Malaria during pregnancy is a major contributor to low birth weight, infant mortality, maternal anemia, spontaneous abortion and stillbirth. The graph below indicates general health and development in Tanzania, which shows high under-five mortality rate (116 for every 1000 live births). The data also indicates that almost 25% of women are illiterate that correlates to the average number of child per women (5.7%). This means necessities such as 16 RBM Baseline Survey Tanzania, 2001 [PDF], in 9 districts (Chunya, Iringa, Lake Victoria, Lushoto, Magu, Morogoro, Mpwapwa, Rufiji, Tunduru) and 30 IMCI districts 17 Ministry of Health Government of Tanzania 2000: Health Statistics Abstracts. (Edited by: Health Management Information System and Government of Tanzania) 18 Head-on with number one killer disease, Bilal Abdul-Aziz, 19 Presidents Malaria Initiative, Saving Lives in Africa, 20 Ministry of Health Government of Tanzania 2000: Health Statistics Abstracts. (Edited by: Health Management Information System and Government of Tanzania) 21 WHO Tanzania Country Profile, WHO Tanzania Country Profile,

26 food, income, mother s care and attention, household facilities have to be shared among the six children in addition to other members in the family. General Health and Development Indicators (DHS Data; 2004 Preliminary Report) Indicator Infant mortality rate (per 1,000 live births) Under-five mortality rate (per 1,000 live births) % of women with no education 28.5% 27.1% 24.2% Total fertility rate (children per women) % of women who received antenatal care from a trained health professional 89.3% 92.5% 94.3% % of children fully immunized 70.5% 68.3% 71.1% % of children with acute respiratory infection or fever taken to a health facility 69.6% 67.5% -- % of pregnant women attending an ANC at least once 93.5% 96% 94.3% (Figure 7) Preventive measures: Use of Mosquito Nets: The use of insecticide-treated mosquito nets, or ITNs, is a primary health intervention to reduce malaria transmission in Tanzania. Local studies demonstrate that the use of insecticide - treated nets can drastically reduce malaria related mortality and halve the number of malaria-related illnesses. Accordingly, the government of Tanzania was the first in Africa to lift all taxes and related duties on imported, insecticide-treated nets for the prevention of malaria. While treatment remains an expensive commodity, nets are not always available for free and indoor residual spraying is not a primary component of Tanzania s malaria strategy. Ultimately, the poorest and most vulnerable children living in rural areas are going to continue to suffer the impact of malaria at rates alarmingly higher than children from wealthier, better educated, urban families. Total net use in Tanzania is 46% out of which 74% of the net use is in the urban area % of all households own at least one mosquito net, however only 23% own at 23 UNICEF Statistics on Malaria. 26

27 least one insecticide treated net. 24 Use of nets is higher in urban areas,even though malaria is more common in rural areas. Only 14 % of rural households own an insecticide-treated bed nets (ITN) while almost half of urban households own an ITN despite the fact that malaria is more common in rural areas. 25 Ownership of ITNs in Zanzibar 28% Ownership of ITNs in Mainland 23% Highest % of households with at least one ITN Dar es Salaam 61% Lowest % of households with at least one ITN Manyara 8% and Iringa 7% Households in the highest wealth quintile with at least one ITN 56% Households in the lowest wealth quintile with at least one ITN 6% Source: The Demographic Health Survey (TDHS) (Figure 8) Source: Demographic and Health Survey (TDHS) (Figure 9) Figure 9 shows the percentage of children under five who slept under a mosquito net the night before the survey. Roughly one-third of children under five slept under a mosquito net the night before the survey. However, only 16 percent slept under an ITN. The survey has found that use of any mosquito net or ITN is higher in urban areas (63:40) than in rural areas (24:10) where nets are more required. 24 DHS Tanzania Demographic and Health Survey 27