Tanzania: Service Quality

The Staha study (“respect” in Swahili) was implemented in two districts in the Tanga region of Tanzania starting in 2011 with the goal of reducing disrespect and abuse during childbirth through a two-part intervention.1 Community members and health system stakeholders designed the intervention by consulting baseline data on disrespect and abuse in the districts. Through this process, implementers decided upon two interventions: 1) an adapted client service charter on norms and standards for mutual respect and respectful care to display in facilities, and 2) a quality improvement process for identifying drivers of disrespect and implementing targeted facility-level changes. Examples of interventions that were identified through the second intervention include: a private admissions area, curtains for exams, transparent systems for supply stock outs, and customer satisfaction exit interviews. The suite of interventions was assessed through self-reported disrespectful care. The odds of disrespectful and abusive care were reduced by 66%, with process indicators suggesting that that intervention contributed to these changes. Additionally, these effects were found to be sustained even a year after facilitation by Staha concluded. A number of resources from the Staha project including but not limited to baseline and end line surveys, in-depth interview guides, and focus group discussion guides can be found on the Averting Maternal Death and Disability website.

Another project in Tanzania implemented two different interventions in a large referral hospital in the city of Dar es Salaam.2 Like the Staha study, this project conducted a baseline study and a multi-stakeholder participatory intervention selection process to identify relevant interventions for the setting. The two interventions selected were Open Birth Days and a Respectful Maternity Care Workshop. Open Birth Days were designed to improve patient knowledge of and preparation for birth. This was intended to fill a gap in knowledge identified by both patients and providers. Additionally, patients engaged in a discussion about patient rights and received a copy of the Universal Rights of Childbearing Women. The Respectful Maternity Care Workshop provided training on respectful care to providers, using an adapted version of the World Health Organization’s Health Workers for Change curriculum.2 After the six-session workshop, providers worked together to develop action plans to improve the issues they identified. Although the evaluation of this program was unable to assess the impact on disrespect and abuse, both interventions were received positively by patients and providers. Additionally, providers had increased knowledge, ability to empathize, and improved job satisfaction, and patients felt that they had more positive interactions with providers. Both this project and the Staha study demonstrate the effectiveness of participatory planning to identify and execute interventions related to disrespect and abuse. Although both of these projects are not specific to primary health care, the strategies and lessons learned from these projects can be easily translated to any health care setting.


  1. Kujawski SA, Freedman LP, Ramsey K, Mbaruku G, Mbuyita S, Moyo W, et al. Community and health system intervention to reduce disrespect and abuse during childbirth in Tanga Region, Tanzania: A comparative before-and-after study. PLoS Med. 2017;14(7):1–16.
  2. Ratcliffe HL, Sando D, Lyatuu GW, Emil F, Mwanyika-Sando M, Chalamilla G, et al. Mitigating disrespect and abuse during childbirth in Tanzania: an exploratory study of the effects of two facility-based interventions in a large public hospital. Reprod Health [Internet]. 2016;13(1):79. Available from: http://reproductive-health-journal.biomedcentral.com/articles/10.1186/s12978-016-0187-z