Documento(s) 6 de 10

One of the paradoxes emerging from a successful demonstration project -- even one as wide in scope as TEHIP -- is that once the program winds down, its work has only just begun. The project demonstrated some positive impact from the innovations it tested. Intensive follow-up, dissemination of findings, and promotion of new and successful approaches are needed.

Accomplishing those goals is neither simple nor easy. Yet fairness demands that innovations such as the tools, which have clearly helped to improve the mortality and burden of disease pictures in Rufiji and Morogoro, must be made available to other districts within Tanzania and to other countries. That is why IDRC crafted an "exit strategy" designed to ensure that the management tools, supportive interventions, innovative practices, and new ideas generated during TEHIP's life will continue to flourish and improve the effectiveness of district health systems long after the project itself has ended.

The work initiated by TEHIP can be seen as a two-stage process. The first stage was the development, testing, refinement, and trial use of the products and strategies during the lifespan of the project. The second phase is the promotion of these products and strategies more widely within the Ministry of Health and to the huge number of additional districts that have not yet benefited from their use.

It should be noted that -- since the tools and strategies now exist -- the second, "roll-out" phase is much less costly than the research and development phase that preceded it. No new research or development of new products is required at this stage; that would be "reinventing the wheel." Mostly, adapting the tools for use in other districts (and, indeed, other countries) depends on the provision of local data. That data is less difficult to produce than it might have been several years ago, since Demographic Surveillance Systems (DSSs) are increasingly used throughout the developing world. Another critical requirement for the "roll-out" phase is training: health planning teams and community-level health workers in other districts need to know what the tools can do for them and how to use them. Spreading new knowledge to various levels within the health system therefore requires the cultivation of new cadres of trainers -- the agents of change who can communicate new methods and ideas to essential workers in communities and in district offices.

As TEHIP ends as a project, the second phase of work is well underway. The Ministry has taken ownership of the tools and innovations and, with international funding -- primarily from the United Nations Foundation -- is now laying the base for their use throughout Tanzania.

Some of the specific "roll-out" measures now underway are as follows:

• Ministry of Health zonal training centres (ZTCs) are being strengthened and coordinated into a network capable of delivering quality curricula to health workers. These centres will provide continuing education to upgrade the skills of existing health workers and will train new workers. The workers will be trained in essential interventions such as IMCI and in new, forthcoming interventions that will address HIV/AIDS. In addition, ZTCs will be an important vehicle for rolling out the tools. For example, training in the community voice and the district health accounts tools is now being offered by ZTCs. Use of ZTCs to promote the tools throughout Tanzania will show that these tools are sustainable and can endure beyond TEHIP since their promotion to the remaining districts will be accomplished using local staff exclusively.

• The United Nations Foundation (with administrative support from WHO) has funded the roll out of the entire tool kit to 11 other Tanzanian districts. Additionally, by August 2004, DHMTs in approximately half of the country had been trained in the use of the burden of disease profile and the district health accounts tools. It is hoped that all districts will have those two essential planning tools by the start of the 2005 planning cycle. In addition, interest in the tools has been expressed outside of Tanzania. DANIDA (the Danish International Development Agency) has put the budget-mapping tool on extended trial; WHO is planning to test the same tool in Ghana; and the Rockefeller Foundation is interested in adapting it to Uganda. South Africa has also expressed a general interest in the TEHIP approach. Finally, the INDEPTH Network has been training DSS sites elsewhere in Africa and Asia in the use of the burden of disease profile tool.
• The management cascade and the manual to guide community-led rehabilitation of health facilities have been adopted by Tanzania's Ministry of Health. The cascade has been introduced to other districts and the Ministry is poised to do the same with the facility rehabilitation tool. Increasingly, the widespread benefits of these programs are being recognized at a national level within Tanzania. The cascade system, for instance, has been praised for its effectiveness in devolving responsibility to lower levels within the health system. It has thus had a positive impact on morale by providing new challenges and increased job satisfaction for workers in the communities. In addition, the cascade's impact in giving local communities greater access to lab diagnostics is seen as increasingly important as the country gears up for new responses to HIV/AIDS. Community rehabilitation of health facilities, meanwhile, has been embraced largely because of its sustainability, cost-effectiveness, and lack of reliance on specialized expertise.

Other ideas and strategies that were incorporated into plans created by Rufiji and Morogoro DHMTs -- as a result of those teams' use of the planning tools and input -- have captured the attention of planners at various levels. They will likely come into wider use, promising further improvement in health indicators. For example:

• IMCI -- a strategy originally devised by WHO -- became an obvious choice for district planners searching for cost-effective health interventions after the tools illustrated that a huge proportion of the local burden of disease resulted from a small, interconnected web of childhood illnesses. Once IMCI was adopted by districts and brought into practice through the funding top-up, its ancillary benefits became obvious. For one, IMCI -- by encouraging the practitioner to look at the patient as a whole person rather than as merely the host for a particular disease -- has in many cases increased the quality and sensitivity of care by returning the focus to the patient rather than the illness. For another, it soon became apparent that diagnosing and treating a wide range of (sometimes coexisting) illnesses was more cost-efficient than first imagined. Now, there are plans to expand the use of "integrated" treatment regimes to other illnesses. For example, WHO has led the development of the Integrated Management of Adolescent and Adult Illness (IMAI) program -- the so-called "adult version" of IMCI. IMAI is now at an advanced stage. In addition, there is renewed interest in revising and updating similarly integrated maternal care programs.
• Within Tanzania, the presence of TEHIP as a conduit for research to find its way into the health system -- that is, its function of promoting research as an influence on health care planning and practice -- has stimulated ideas about the need for a new mechanism to package and synthesize the best and most recent research for use by political decision-makers. IDRC has provided initial funding to investigate what form such a national-scale health policy "observatory" might take. This health research observatory has been tentatively named
  the "Duluti Institute" after a landmark meeting of health researchers and policymakers in Duluti, Arusha, Tanzania.
• Tanzania is extending the reach of Demographic Surveillance Systems (DSSs). The DSS in Rufiji is now being operated by the Ifakara Health Research and Development Centre, which also operates DSS sites in 2 other districts. The INDEPTH Network promises more integrated work in demographic surveillance between countries.

Finally, it should be noted that TEHIP has never advocated a static approach to dealing with health care needs -- instead, it has encouraged flexibility and responsiveness to changing conditions. Given the promise of a general improvement in the functioning of Tanzania's health system -- an improvement for which TEHIP is partly responsible -- we expect that health authorities will reassess their goals and approaches in reaction to changed circumstances. One such realignment already underway is the shift in emphasis from cost-effectiveness to a more specific concern with equity. With the promise that a greater segment of the population will have access to effective health care services, it has become incumbent upon officials to address the equity issue by examining how they can reach out to the remaining segments of society that haven't benefited from overall advances. One example of this is the government's new approach to allotting basket funding. It has been decided that districts where there is hardship will receive an "equity premium" -- a per capita allowance that is slightly above the national average.

One way of understanding this "cost-effectiveness versus equity" issue is to think of the health system as a car. A few years ago, the entire system wasn't working well -- the car was only firing on two cylinders and the tires were flat. The Rufiji and Morogoro cases demonstrated that taking an initial efficiency approach could get the car running again: well-targeted investments could produce good results that serve the majority of the population. But there is no reason to stop there. There are other health issues -- such as equity -- to be addressed. The question for society at large becomes: Now that the car is working again, where shall we go? This is a social policy question, rather than a technical one, that will need to be asked continually.

Documento(s) 6 de 10