Global health often entails partnerships between institutions in low- and middle-income countries (LMICs) that were previously colonized and high-income countries (HICs) that were colonizers. Little attention has been paid to the legacy of former colonial relationships and the influence they have on global health initiatives. There have been recent calls for the decolonization of global health education and the reexamination of assumptions and practices under pinning global health partnerships. Medicine’s role in colonialism cannot be ignored and requires critical review. There is a growing awareness of how knowledge generated in HICs defines practices and informs thinking to the detriment of knowledge systems in LMICs. Additionally, research partnerships often benefit the better-resourced partner. In this article, the authors offer a brief analysis of the intersections between colonialism, medicine, and global health education and explore the lingering impact of colonialist legacies on current global health programs and partnerships. They describe how “decolonized” perspectives have not gained sufficient traction and how inequitable power dynamics and neocolonialist assumptions continue to dominate. They discuss 5 approaches, and highlight resources, that challenge colonial paradigms in the global health arena. Furthermore, they argue for the inclusion of more transfor mative learning approaches to promote change in attitudes and practice. They call for critical reflection and concomitant action to shift colonial paradigms toward more equitable partnerships in global education.

BackgroundThe Millennium Development Goal No 4 (MDG 4) requires countries to scale up interventions addressing malnutrition and other immediate determinants of burden of disease among children to reduce child mortality by two thirds by 2015, which is this year. Whereas globally some achievements have been registered, under-nourishment remains a significant problem in some developing countries such as Tanzania. This study set out to estimate the extent of stunting and its associated determinants to assess the progress made thus far towards achieving MDG 4 in Tanzania.MethodsA random sample of 678 households with under-five children was selected from two randomly selected wards of Kongwa district in Dodoma region, Tanzania. The WHO anthropometric calculator, which computes Z-scores using a reference population, was used to process the anthropometric measurement data taken from all the participants. Children with height for age Z-score of less than 2 were categorised as stunted and coded as 1 and the rest were coded as 0. Proportions of stunting were compared using the chi-square test to determine the association between stunting and the independent variables. Multivariate logistic regression analysis was carried out to determine the Adjusted Odds Ratio (AOR) of the independent determinants of stunting. The cut-off for significant association was set at p = 0.05. All these analyses used the STATA 12 software.ResultsAbout half (49.7 %) of the children were stunted. This stunting was associated with belonging to households where the head of family was young (<35 years) (AOR = 0.67, 95 % CI 0.47–0.96, p = 0.031), young age of the mothers (AOR = 1.54, 95 % CI 1.06–2.24, p = 0.023), and economic variables such as owning a cellular phone (AOR = 0.66, 96 % CI 0.46–0.94, p = 0.023).ConclusionsStunting was highly prevalent in Kongwa district despite general improvements in child nutritional status at the national level. Household characteristics and economic status were found to play a major role in child health. In this regard, disaggregated analyses are therefore important in identifying resilient areas in need of concerted efforts for the MDG 4 to be achieved nationwide.

IntroductionPeople in many low-income countries access medicines from retail drug shops. In Tanzania, a public-private partnership launched in 2003 used an accreditation approach to improve access to quality medicines and pharmaceutical services in underserved areas. The government scaled up the accredited drug dispensing outlet (ADDO) program nationally, with over 9,000 shops now accredited. This study assessed the relationships between community members and their sources of health care and medicines, particularly antimicrobials, with a specific focus on the role ADDOs play in the health care system.MethodsUsing mixed methods, we collected data in four regions. We surveyed 1,185 households and audited 96 ADDOs and 84 public/nongovernmental health facilities using a list of 17 tracer drugs. To determine practices in health facilities, we interviewed 1,365 exiting patients. To assess dispensing practices, mystery shoppers visited 306 ADDOs presenting one of three scenarios (102 each) about a child’s respiratory symptoms.Results and DiscussionOf 614 household members with a recent acute illness, 73% sought outside care—30% at a public facility and 31% at an ADDO. However, people bought medicines more often at ADDOs no matter who recommended the treatment; of the 581 medicines that people had received, 49% came from an ADDO. Although health facilities and ADDOs had similar availability of antimicrobials, ADDOs had more pediatric formulations available (p<0.001). The common perception was that drugs from ADDOs are more expensive, but the difference in the median cost to treat pneumonia was relatively minimal (US$0.26 in a public facility and US$0.30 in an ADDO). Over 20% of households said they had someone with a chronic condition, with 93% taking medication, but ADDOs are allowed to sell very few chronic care-related medicines. ADDO dispensers are trained to refer complicated cases to a health facility, and notably, 99% of mystery shoppers presenting a pneumonia scenario received an antimicrobial (54%), a referral (90%), or both (45%), which are recommended practices for managing pediatric pneumonia. However, one-third of the dispensers needlessly sold antibiotics for cold symptoms, and 85% sold an antibiotic on request. In addition, the pneumonia scenario elicited more advice on handling the illness than the cold symptoms scenario (61% vs. 15%; p<0.0001), but overall, only 44% of the dispensers asked any of the shoppers about danger signs potentially associated with pneumonia in a child.ConclusionADDOs are the principal source of medicines in Tanzania and an important part of a multi-faceted health care system. Poor prescribing in health facilities, poor dispensing at ADDOs, and inappropriate patient demand continue to contribute to inappropriate medicines use. Therefore, while accreditation has attempted to address the quality of pharmaceutical services in private sector drug outlets, efforts to improve access to and use of medicines in Tanzania need to target ADDOs, public/nongovernmental health facilities, and t...

The aim of this study was to determine the acceptability of HIV counseling and testing and participation in a mother-to-child HIV-1 transmission intervention study using antiretroviral therapy in Dar es Salaam, Tanzania, one of the sites for the Joint United Nations Program on AIDS (UNAIDS) multicenter Petra trial. HIV testing was offered to all pregnant women who visited three prenatal clinics in Dar es Salaam before 34 weeks' gestation. Group or individual pretest counseling was performed by trained midwives. Laboratory diagnosis of HIV infection was based on two sequential anti-HIV enzyme-linked immunosorbent assays. Posttest counseling was given 2 weeks later to women who wished to know their HIV status. HIV testing was offered to a total of 10,010 pregnant women from June 1996 to May 1998, of whom 76.4% (7647 of 10,010) agreed to be tested. The prevalence of HIV-1 infection was 13.7% (1050 of 7647). Overall, 68.1% (5205 of 7647) returned for their results. Of the HIV-1-seropositive respondents, 27.4% (288 of 1050) agreed to participate in the Petra trial after fulfilling the eligibility criteria. Only 16.7% (48 of 288) of the enrolled women disclosed their positive HIV serostatus to their sexual partners. The main reasons for not disclosing the HIV serostatus were fear of stigma and divorce. Sixty percent (29 of 48) of the informed sex partners agreed to be tested for HIV and 69% (20 of 29) tested HIV seropositive. Pregnancy recurrence rate was 4.4 per 100 women years (18 pregnancies during 408 women years of follow-up) with 10 of 18 (55.6%) women not wanting to carry the pregnancy to term. In conclusion, this information is useful in planning intervention programs for prevention of mother-to-child HIV-1 transmission and it shows that improvements are required in counseling.

BackgroundPeople in low-income countries purchase a high proportion of antimicrobials from retail drug shops, both with and without a prescription. Tanzania’s accredited drug dispensing outlet (ADDO) program includes dispenser training, enforcement of standards, and the legal right to sell selected antimicrobials. We assessed the role of ADDOs in facilitating access to antimicrobials.MethodsWe purposively chose four regions, randomly selected three districts and five wards per district. Study methods included interviews at 1200 households regarding care-seeking for acute illness and knowledge about antimicrobials; mystery shoppers visiting 306 ADDOs posing as a caregiver of a child with 1) pneumonia, 2) mild acute respiratory infection (ARI), or 3) a runny nose and request for co-trimoxazole; and audits of antimicrobial availability and prices at 84 public health facilities (PHFs) and 96 ADDOs.ResultsFour hundred sixty seven (76 %) members from 367 (77 %) households had recently sought care outside the home for acute illness; 128 had purchased antimicrobials, of which 61 % had been recommended by a doctor or nurse and 32 % by an ADDO dispenser. Only 29 % obtained the antimicrobial at a PHF, whereas, 48 % purchased them at an ADDO. Most thought that ADDOs are convenient place for care, usually have needed medicines, and have high quality services and products, contrasting with 66 % who reported dissatisfaction with PHF waiting times and 56 % with medicine availability. One-third (34 %) of mystery shoppers presenting the mild ARI scenario were inappropriately sold an antimicrobial and 85 % were sold one on request; encouragingly, 99 % presenting a case of pneumonia received either an antimicrobial, referral to a trained provider, or request to bring the child for examination. Overall, 63 and 60 % of the 15 tracer antimicrobials were in stock in ADDOs and PHFs, respectively; ADDOs had significantly more antimicrobial formulations for children available (83 vs. 51 %). Of 369 records of antimicrobial sales in 47 ADDOs, 63 % were dispensed on prescription.ConclusionADDOs have increased access to antimicrobials in Tanzania. Community members see them as integral to the health system. Antimicrobials are overused due to poor ADDO dispensing, poor PHF prescribing, and inappropriate public demand. Multi-pronged interventions are needed to address all determinants.Electronic supplementary materialThe online version of this article (doi:10.1186/s13756-015-0075-2) contains supplementary material, which is available to authorized users.