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The challenges that face Africa in the sphere of health care are formidable and often daunting. After decades of stagnant or worsening poverty and health indicators across the continent, the Millennium Development Goals (MDGs) -- adopted by the United Nations at its Millennium Summit of September 2000 -- have set benchmarks for improvements in the health picture. If accomplished, the MDGs would represent major advances in the well-being and survival rate of millions of people. Those goals envision that by 2015 child mortality can be reduced by two thirds, that maternal mortality can be reduced by three quarters, and that infectious diseases such as malaria, tuberculosis, and HIV/AIDS -- which threaten to do even more damage tomorrow than they do today -- can be held in check and indeed reversed.

Are these goals realistic? In Tanzania, recent experience in the large rural districts of Rufiji and Morogoro gives us cause for optimism. Over 4 years, child mortality within these districts (with a combined population of more than 700 000) has fallen by more than 40%, which puts them well on the way to achieving the MDG related to child health. We attribute these gains not to a single intervention but to a range of simple measures to improve health system efficiency and to allocate health funds more in proportion to the local causes of mortality (quantified using data collected from Demographic Surveillance Systems).

The underlying proposition behind this achievement -- that health could be significantly improved by adopting a minimum package of health interventions to respond directly, and cost-effectively, to evidence about the local burden of disease -- was one of the key proposals put forward in the World Development Report 1993: Investing in Health (World Bank 1993). Around the same time, Tanzania was embarking on health reforms centering on the decentralization of health planning authority (which would enable districts to allocate funds more in line with local health needs). Therefore, it made sense for Tanzania to accept an offer to host the Essential Health Interventions Project, which aimed to test the World Development Report 1993's central hypothesis.

In the beginning, no one could have made an intelligent guess at what the outcome of that initiative would be. Today, however, we can clearly state that we have been overwhelmed by the results of that decision. Using a series of interrelated management tools created by the Tanzania Essential Health Interventions Project, or TEHIP (as the project would become known), district health teams have been able to vastly improve their local health systems' efficiency, leading to startling health improvements such as the dramatic reduction in child mortality mentioned above. Those tools -- of which there are more than originally envisioned -- continue to be indispensable to the districts' health planning. They allow district health planners to do much more with the marginal increases in funding currently available -- proving that it is possible to begin to improve health significantly while working for more substantial increases in budgets, provided that resources are allocated more rationally and the system is strengthened.

In the coming years, the enhanced performance of the overall health system may prove to be a critical cornerstone for new initiatives in health care, as countries such as Tanzania adopt new therapies and treatments for HIV/AIDS, for instance. It is obvious that good management, motivated health workers, and functional networks of communication and transportation are required for such new treatments to reach the people who need them and for those treatments to be used effectively.

Given the dramatic successes achieved in the Rufiji and Morogoro districts, it is a moral imperative for Tanzania and its health partners to support the widespread promotion and dissemination of the very tools and strategies that led to those improvements and to address the immediate and recurring problem of "going to national scale" with the toolkit. We have already made a start on this by expanding to an additional 9 districts, which together constitute the two entire regions of Coast and Morogoro. However, there is an urgent need to facilitate practical and cost-effective national scaling up by improving the pre-service and in-service training "machinery."

As this book goes to press, the Ministry of Health is moving ahead, within its TEHIP partnership, to provide a plan and a budget for a consolidated and strengthened Ministry of Health Zonal Training Centre Network around the country. In the immediate term, however, it will be crucial to keep the momentum going as we move from "best practice" to national scale-up. It is vital that these dramatic improvements in district health systems not only reach all corners of this large country of Tanzania but also our neighbours in the countries that constitute sub-Saharan Africa and, for that matter, all the nations of the world. For, as we all know, diseases recognize no borders and successes in any one country should be shared.

It is my sincere hope that this book will promote and strengthen the case that evidence-based planning and prioritization, combined with simple tools to improve health system delivery, is a strategy that makes sense. It is a strategy that challenges communities to forge robust partnerships for the future and it holds great promise for other developing countries confronting similar challenges.

M.J. Mwaffisi (Ms)
Permanent Secretary, Ministry of Health,
United Republic of Tanzania

August 2004

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