Monique Oliff

Summary: Objectives  To synthesise data from four recent studies in Tanzania examining maternal syphilis screening and its operational implementation in routine antenatal clinics (ANC), drawing lessons for strengthened antenatal services for the prevention of mother‐to‐child transmission (PMTCT) of HIV.Methods  The impact of untreated maternal syphilis was examined in a retrospective cohort of 380 Tanzanian women. Effectiveness and cost‐effectiveness of screening and single dose benzathine penicillin treatment were prospectively examined in 1688 pregnant women. Observation, interviews and facility audits were carried out in health facilities within nine districts to determine the operational reality of syphilis screening.Results  Overall, 49% of women with untreated high titre syphilis experienced an adverse pregnancy outcome compared with 11% of uninfected women. Stillbirth and low birthweight rates among those treated for high‐ or low‐titre syphilis were reduced to rates similar to those for uninfected women. The economic cost was $1.44 per woman screened and $10.56 per disability‐adjusted life year saved. In the operational study, only 43% of 2256 ANC attenders observed were screened and only 61% of seroreactive women and 37% of their partners were treated. Adequate training, continuity of supplies, supervision and quality control are critical elements for strengthened antenatal services, but are frequently overlooked.Conclusions  Maternal syphilis has a severe impact on pregnancy outcome. Same‐day screening and treatment strategies are clinically effective and highly cost‐effective, but there are significant challenges to implementing syphilis screening programmes in sub‐Saharan Africa. Current PMTCT interventions present an opportunity to reinforce and improve syphilis screening. Increasing PMTCT coverage will involve similar operational challenges to those faced by syphilis screening programmes.

Universal access to comprehensive reproductive health services, integrated into a well-functioning health system, remains an unfulfilled objective in many countries. In 2000-2001, in Tanzania, in-depth interviews were conducted with central level stakeholders and focus group discussions held with health management staff in three regional and nine district health offices, to assess progress in the integration of reproductive health services. Respondents at all levels reported stalled integration and lack of synchronisation in the planning and management of key services. This was attributed to fear of loss of power and resources among national level managers, uncertainty as to continuation of donor support and lack of linkages with the Health Sector Reform Secretariat. Among reproductive health programmes, sexually transmitted infection (STI) control alone retained its vertical planning, management and implementation structures. District-level respondents expressed frustration in their efforts to coordinate STI service delivery with other, more integrated programmes. They reported contradictory directives and poor communication channels with higher levels of the Ministry of Health; lack of technical skills at district level to undertake supervision of integrated services; low morale due to low salaries; and lack of district autonomy in decision-making. Integration requires a coherent policy environment. The uncoordinated and conflicting agendas of donors, on whom Tanzania is too heavily reliant, is a major obstacle.