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Improving Health Care in Tanzania: The Tanzania Essential Health Interventions Project

2000-06-02

[Photo: Demonstrating the use of an insecticide-treated bednet to community members.]

Malaria has long been one of the biggest killers in Tanzania and the Morogoro Rural District is no exception. Yet treating and preventing malaria has not been one of the largest items in the district's health budget.

Using a tool developed by the Tanzania Essential Health Interventions Project (TEHIP), health officials in Morogoro analysed their budget priorities against the disease burden borne by the district's people. The analysis showed that malaria accounts for 30 % of the years of life lost because of deaths and debilitating illnesses.

Shifting priorities

As a result, the district health management team has shifted its budget priorities and is now putting a larger emphasis on malaria. The budget for malaria prevention and treatment programs increased from 5 % of total spending in 1996 to 25 % in 1998.

"TEHIP has empowered the district to work out its plans and implement them with autonomy," says Dr Harun Machibya, the Morogoro District Medical Officer.

Collaborative initiative

This move is just one of the successes of TEHIP, a collaboration between Tanzania's Ministry of Health and the International Development Research Centre (IDRC). TEHIP is currently one of IDRC's largest programs, with two full-time IDRC staff, CA$16.5 million in funding, and a time frame of at least four years. Other partner organizations include the World Bank, World Health Organization, the United Nations Children's Fund, and the Canadian International Development Agency.

The idea of TEHIP is to improve the health of Tanzanians not by spending lots more money but by planning spending more efficiently, according to where the needs are greatest. This approach — known as "evidence-based planning" — is at the heart of TEHIP.

Health spending

Tanzania has an annual health budget that works out to about $4 per person. In rural areas, the per capita spending is even less. "We're probably not going to get a lot more money for health in this country, but we're looking at how can we get the most out of the little that is spent," says Graham Reid, TEHIP Project Manager. "You don't need much money to get the system running more efficiently."

What is needed, says Dr Reid, is better planning, based on evidence. So, for the past three years, Tanzanian researchers and health workers have been working together in two of the country's 117 districts — Morogoro and Rufiji — to determine the local people's greatest health needs.

Village-level consultations

This involved consulting the people by visiting their villages and asking questions. It was essential to conduct the research outside of the health centres because many people often don't go to these facilities even when they're ill, says Don de Savigny, TEHIP Research Manager. "If districts plan based on [the population's] attendance at a health facility, they will get it wrong," he says, adding that between 80 and 90 % of Tanzanians die at home.

Local research allows districts to develop their own health policies based on the evidence they uncover, rather than having policies imposed on them from the top. Tanzania's district health management teams are facing growing responsibilities as the government reforms the health sector and decentralizes decision-making.

Decentralization

Today, salaries, drugs, and guidelines come from the central government, but little else. TEHIP complements this decentralization by giving districts the tools they need to develop their own local priorities and plan their budgets, explains Dr Reid. "The tools we have are now in hot demand." Among them are tools for analysing cost information, the burden of disease, and community voice.

Using these tools, the district health management teams in both Morogoro and Rufiji found that improvements in their communication and transport systems would lead to more effective health care. In response, both teams obtained two-way radios, a four-wheel-drive vehicle, motorcycles, and bicycles while the team in Rufiji, which spans a wide river delta, also invested in a motorboat. The districts determined that the benefits of getting supplies to their health centres on time were greater than the capital costs.

Impacts

These are not the only tangible changes. For example, health centres are now investing in preventive programs, such as the use of inexpensive insecticide-treated bednets to reduce the mosquito bites that cause malaria. In addition, districts have decided to rehabilitate health facilities by teaming up with local communities to share the cost of labour and materials and subsequently handing them over to these communities to maintain in good working order. And at a national level, the government is examining its anti-malarial drug policy and acknowledges that TEHIP is making a significant contribution to the country's health sector reform.

According to the project team, there has also been a significant improvement in the quality of scientific inquiry among the Tanzanian health researchers. Moreover, TEHIP is helping to foster a culture of critical analysis at the district level.

Increased patient visits

Even patients are noticing the effects of TEHIP-supported health sector reforms and returning to health facilities that they had previously criticized for poor service or a lack of drugs. "More patients are coming to us because they know they will be attended well and get the prescribed medicine," says Shadrack Bushiri of Kibiti Health Centre in Rufiji.

As the program enters its fourth year, what remains to be seen is TEHIP's ultimate impact on people's health. "Change cannot be effected overnight," says Dr de Savigny. "It will take time to measure the benefits and that is another one of the goals of this complex and interesting project."

Mike Crawley is a freelance writer currently based in East Africa. (Photo: courtesy of TEHIP)

If you have any comments about this article, please contact mag@idrc.ca .

For more information:

IDRC Reports, April 1994: Health Research that Matters

Bednets for Malaria Control, by Robert Bourgoing

Children's Health in Ghana's North, by Jason Lothian

The Essential Health Interventions Project: Improving Health Care in Tanzania, by Kanina Holmes

Essential Health Interventions Project (EHIP)

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