Document(s) 2 of 10

The phrase that best describes the attitude emerging from the decade-long experience of the Tanzania Essential Health Interventions Project (TEHIP) is "cautious optimism."

The hopefulness stems mostly from the fact that TEHIP has produced good news about a subject where the outlook invariably has been bleak. The essential aim of the project -- which evolved as a unique collaboration between Tanzania's Ministry of Health and Canada's International Development Research Centre (IDRC) -- was to test a proposition put forth in the World Bank's World Development Report 1993. That report suggested that mortality and morbidity rates in developing countries could be significantly reduced even with modest resources if health care funding was allocated to cost-effective health interventions more in line with the prevailing local "burden of disease."

More than 10 years on, the TEHIP experience indicates that this idea is indeed solid. In two Tanzanian districts, annual budgets are recast to address the local burden of disease -- targeting funds on a more selective list of health interventions in proportion to the impact of specific diseases. The resulting improvements in the health picture in those districts have dramatic, encouraging implications. They confirm that many deaths that currently occur in developing countries are preventable. They show that we have the knowledge to deliver better quality health care (and thereby to save lives) now, without waiting for additional expenditure or the design of new drugs and vaccines.

In the course of arriving at these conclusions, the project has also developed a set of practical managerial and technical tools that can be adapted to fit other health care settings and potentially be put into use in other developing countries. TEHIP provides model approaches that can be adapted for use in a variety of circumstances -- and which cannot be dismissed as a one-time anomaly.

Meanwhile, the "caution" in that phrase "cautious optimism" stems from a number of factors, not least of which is the realization that "scaling up" the project's innovations (as requested by the Ministry of Health) remains a daunting task. In addition, we are well aware that some of the lessons learned over the course of the project's work appear to contradict current conventional wisdom. For example, our direct involvement with district health managers has convinced us of the necessity of taking an "integrated" approach to health care reform -- that is, to combine new interventions into coherent packages that make practical, everyday sense to health care practitioners at the village level and upwards. However, much of the world seems to be moving in the opposite direction: opting for a "vertical"' approach that seeks to improve health by dealing with diseases individually, in isolation, one at a time. This, we believe, frequently results in a fragmentation of service delivery that puts extra stress on the all-important health system and especially the health care worker on the front line. Such weakened delivery of essential health care compromises the ability of the health system to reduce the burden of disease.

Invariably, this subject of reform and support to health systems in Africa comes down not to abstract theoretical formulations but to real people in real situations. Consider, for example, the tables and charts that appear throughout this book, documenting changing mortality rates in two Tanzanian test districts, Rufiji and Morogoro. As you look at those graphics, we urge you not to think about the pictures you see as numbers or statistics. Instead, think about them as representations of real people -- people with families that grieve, people who had rich lives before them, people who should have lived.

For years, development workers have encouraged people who once would have been silent to contribute their ideas and perspectives -- they seek out the "community voice" and the voices of the disenfranchised. You can think of those thick black lines on paper as an important contribution by people who died too soon because of inadequate health care. The experiences of the dead should be heeded as much as those of the living. That many of those people died from illnesses that could have been cured or prevented -- if the health system had adequate resources and capacity -- is tragic. Yet, it is hoped that we will find some solace if learning from their fate -- understanding why they died and how the health system failed them -- helps prevent similar needless deaths in the future. We need to discern the patterns behind those deaths, so that others can live longer and healthier lives.

TEHIP expresses its profound gratitude to the people and health care providers of Morogoro and Rufiji districts, who accomplished so much and who made the achievements documented in this book possible. Full details of individual acknowledgements are included in Appendix 1.

Don de Savigny
Research Manager, Tanzania Essential Health Interventions Project
International Development Research Centre, Canada

Harun Kasale
Project Coordinator, Tanzania Essential Health Interventions Project
Ministry of Health, Tanzania

Conrad Mbuya
Research Coordinator, Tanzania Essential Health Interventions Project
Ministry of Health, Tanzania

Graham Reid
Project Manager, Tanzania Essential Health Interventions Project
International Development Research Centre, Canada

August 2004

Document(s) 2 of 10