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The Tanzania Essential Health Interventions Project (TEHIP) was inspired by the World Bank's World Development Report 1993 Investing in Health (WDR '93). This was the first World Development Report to focus on the challenges facing health care systems around the world. WDR '93 highlighted the need for global health reform, citing systemic problems that hinder the delivery of services and reducing death and illness. These include a huge imbalance in health care spending (more resources go toward expensive but less effective interventions such as tertiary care and CAT scans rather than simpler interventions like primary care); the inefficient use of available resources; rising health care costs; and inequitable access to health services. Investing in Health also noted that these problems are often compounded in low income economies by highly centralized decision making, wide fluctuations in health budgets, and low motivation of health care workers.

Given the scarcity of available health resources, especially in low-income countries, WDR '93 proposed that health planning and priority setting should be based on the principles of "burden of disease" and "cost-effective analysis" — i.e., "getting the best value for money." It also asserted that improving and maintaining the health of the population is an integral and vital part of any country's social and economic development plan and policies. The report went on to predict that the provision of cost-effective packages of essential interventions "reaching 80% of the population could result in a 32% reduction in the burden of disease in low-income countries and 15% in middle-income countries."

FROM DIAGNOSIS TO TREATMENT: THE ROAD TO TEHIP

In October 1993, Canada's International Development Research Centre (IDRC) organized an international conference in Aylmer, Québec, to examine the recommendations from Investing in Health. The conference attracted representatives from the World Health Organization (WHO), the World Bank, other donor agencies, nongovernmental organizations, and from developing countries. IDRC commissioned three major think-pieces to focus the discussions.

WDR '93 had argued that, while it may not be easy to establish health service priorities based on burden of disease measurements, governments could realize greater benefits from existing health resources. Investing in Health, however, focused on a global rather than a district level. Delegates at the Aylmer conference concluded that the report's thesis held sufficient potential in an area where the need was great, that its feasilibility should be investigated without delay. They also agreed on the need to strengthen the relevance, quality, and contribution of health research to health reform.

The conference had two principal outcomes. First, participants recommended that the WHO should establish a process to narrow the health research gap (less than 10% of health research spending around the world is used to address 90% of the global disease burden priorities). As a result, WHO now houses the Global Forum for Health Research, which aims to help correct this gap by focusing research efforts on those diseases that pose the heaviest health burden and by facilitating collaboration between public and private sector partners. The second outcome was the decision that IDRC would field-test the WDR thesis.

Launching TEHIP

The Aylmer conference recommendations led IDRC, with support from the Canadian International Development Agency (CIDA), to begin preparations for what is now known as TEHIP. Its founders decided that, to properly address the issues of burden of disease and cost effectiveness in the context of health reforms and decentralization, the project should focus on improving the planning and management of health services at the district level. In recommending this approach, they believed that the project's findings would have extremely important implications for the future development of health care systems, not only in the "host" country where the project would be staged, but in other developing countries as well.

In 1994, IDRC sent letters to the ministries of health of seven eastern and southern African countries to explain the background and broad scope of the initiative, and to invite letters of interest. Tanzania was the first country to express interest. A group representing IDRC, WHO, the World Bank, and other interested parties spent three weeks in Tanzania in late November and early December 1994. Joined by representatives from Tanzania's Ministry of Health and the National Institute of Medical Research, the group met with officials from other Tanzanian ministries, the main organizations conducting health research in this country, and representatives of the major health donors in Tanzania. As a result of these meetings, it was decided that Tanzania would become the host country.

Why Tanzania?

To improve health care, Investing in Health advocated a devolution of responsibility to local authorities. The reform of Tanzania's health care sector fits with this approach (see TEHIP and Tanzania's Health Reforms in the right-hand column). Also, Tanzania is one of the poorest countries in the world and hence could potentially benefit from a project of this scope.

Did you know? Tanzania's GDP per capita is just US$210. Tanzania has one of the highest burden of disease in the world. Some 100,000 Tanzanians die from malaria each year, out of a total population of 34 million. And 80-90% of the children are anemic.

Several districts were proposed as study sites by the Tanzanian Ministry of Health, and visited during the pre-launch assessment period. By April 1995, Rufiji and Morogoro Rural had been selected as representative of ordinary rural Tanzanian districts. In October 1996, an agreement to launch TEHIP was signed between the governments of Tanzania and Canada. The TEHIP Office was established at the National Institute for Medical Research in Dar es Salaam in January 1997. TEHIP's research activities began later that year. Also during 1997, the first financial support to the district health plans of Rufiji and Morogoro Rural was provided by TEHIP.

Related Links

• IDRC Reports, April 1994: "Health Research that Matters"

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