Document(s) 4 of 9

Cost tracking captures true costs
Measuring burden of disease
Facelift engages community voice
Social marketing triggers demand for nets
Addressing leading causes of death

Cost tracking captures true costs

Several types of costs must be considered when estimating the total resources needed to carry out an intervention. Some of these costs are difficult to calculate with accuracy. However, TEHIP will be measuring costs of interventions, diseases and of running health facilities so as to get information to be used in planning health services delivery.

In order to test cost effectiveness, cost information is a necessary tool. The Cost Tracking System was designed, developed and is being implemented to produce cost information which will be used by DHMTs in Morogoro Rural and Rufiji districts, and other users, for planning and decision making.

The Cost Tracking System captures and processes statistical and cost data, variable and fixed costs. Capturing of statistical data is done by the health workers at health facilities while cost data is gathered by the cost accountants located at the District level.

Implementation of the Cost Tracking System started in October, 1997 by the selection and training of accountants who are responsible for managing and supervising implementation of the system in their respective districts. Two accountants from each district were trained in computer use and the cost tracking system. Two data entry clerks, one from each district, were also recruited and trained in the Cost Tracking System

District Health Management Teams (DHMTs) and other District officials were later sensitized and introduced to the Health Sector Reforms, TEHIP supportive activities, the Cost Tracking System and how the system fits in the overall framework of Health Sector Reform.They were also informed as to how it would help them in planning the delivery of health services in a cost effective way. The training of front line health workers, who are implementors of Cost Tracking System in their respective health facilities, was also conducted. A total of 151 frontline health workers from the two districts had been trained as of September 1998.

Measuring burden of disease

Measuring burden of disease is an overwhelming task but its outcome has far reaching consequences. It is a useful tool in the planning process and assessing the impact of interventions. The issue of burden of disease and cost-effectiveness measurements is integral to the development of the district health plan.. Burden of disease was defined by Musgrove (1994) as the total amount of healthy life years lost, to all causes, whether from premature mortality or from some degree of disability over some period of time. These disabilities can be physical or mental. A given disease, deficiency, or trauma may produce more than one kind of health damage, and a given disability may arise from more than one cause. The burden of disease can in principle be attributed to distinct risk factors, each of which may contribute to the likelihood to severity of one or more diseases or conditions.

At any moment, the burden of disease in a population is a reflection of both the amount of health care already being provided and the effects of all other actions that protect or damage health. For Investing in Health, an attempt was made to estimate the burden of disease against a common measure, both globally and by region, and to estimate the cost-effectiveness of interventions against the various conditions that contribute to the burden.

The Global Burden of Disease survey conducted for Investing in Health attempted to move beyond traditional surveys that focused only on mortality to include conditions that lead to disability (such as residual paralysis or depression), and to quantify their effects on individuals and the health system. On the basis of the International Classification of Diseases, diseases were classified into 109 categories that covered most possible causes of death and disability.

Burden of disease measurements serve two purposes within the framework of TEHIP:

• as a tool to assist districts in their planning process, and
• as a research tool to assess the impact of the intervention(s).

Facelift engages community voice

Facility rehabilitation is being used as an entry point to engage the "community voice" in the whole process of health planning and implementation in the district. In order to meet minimum standards in health facilities for the effective and secure delivery of essential health interventions, TEHIP Districts set aside a modest amount of funds to complement efforts of the district authorities and communities to improve their health centres and dispensaries.

The participation of local communities in developing rehabilitation plans and through contribution of labour and materials in carrying out the improvements and maintenance was emphasized as a precondition.

The main objectives are to promote ownership to the local communities of the local health facilities; impart appropriate skills to both the local community and leadership on labour based construction and maintenance; and develop and put in place a sustainable mechanism for operation and maintenance.

With guidance from a local consultancy team, vested with experiences in community labour based methodologies, TEHIP carried out a demonstration exercise to three dispensaries in each of the two districts using the community labour based methods.

In Morogoro district three dispensaries have been refurbished. These are Mikese, Hembeti and Mtombozi. In Rufiji, dispensaries in Mkongo, Nyambunda and Hanga are in final stages of completion.

The district authorities in Morogoro decided to hand over the dispensaries to the communities so that they could continue maintaining them and carry out minor repairs on a sustainable and cost effective basis.

The handover ceremonies took place on November 25th and 26th, 1998. Ownership certificates were presented to the chairman of the respective village governments in ceremonies attended by, among others , the Constituency Member of Parliament , Mr. Semindo Pawa; Chairman of Morogoro District Council , Mr. Charles Malyaga; the District Executive Director , Mr. John Gille; District Administrative Secretary , Mr. G. Linga. TEHIP was represented by Drs. Graham Reid and H. Kasale.

The Guest of Honour , the Regional Nursing Officer, Mrs. Anna Gutapaka underscored the importance of continuous maintenance of the rehabilitated health facilities. She urged the communities to engage themselves in other development activities for example, water supply, schools and agricultural activities using the same approach.

The villagers expressed their enthusiasm and promised to continue making similar moves in refurbishing the staff quarters.

The exercise has clarified the way forward in rehabilitating other health facilities in the districts.

Social marketing triggers demand for nets

Malaria is among the most frequently reported cause of death and disease in Tanzania. About 16 million cases are reported per year and accounts for more than 20% of all child deaths.

Both Rufiji and Morogoro districts have identified the use of insecticide treated mosquito nets treated (ITNs) as among the most viable interventions against Malaria.

Promotion of ITNs is underway as a collobarative effort of various programmes. Population Services International (PSI), responsible for social marketing and communication for AIDS control activities, in collaboration with the National Malaria Control Programme (NMCP) in Ministry of Health, are carrying out a DFID funded project called ‘SMITN’ which stands for "Social Marketing of Insecticide Treated Nets".

The purpose of the project is to develop and demonstrate strategies for the promotion and sale of branded nets and insecticide for net treatment using a social marketing approach.

In order to reduce mortality rates caused by malaria an ITN programme has been launched in the TEHIP programme areas making use of PSI experiences. In Rufiji District, phase one covers 22 villages in three divisions namely Kikale, Mkongo and Mbwera.The first consignment of 3000 nets has been sold and the next consignment has been ordered.

TEHIP research will document trends in household behaviours in relation to malaria, malaria prevention, mosquitos and ITNs including expenditure behaviours.

In Morogoro District the first phase covers 41 villages in three divisions - Mlali, Mikese and Ngerengere. On June 21, 1998 PSI launched ITN amid an enthusiastic crowd at Mlali village with full participation of the DHMT.

As community surveys and training of animators continue demand for ITNs are increasing. Morogoro has ordered 5,250 more nets 16,000 insecticide tabs and promotional materials.

According to the ITN Coordinator for Morogoro District, Mr. L.N. Mbombwe "Our big task is to improve the programme by doing thorough supervision, monitoring and evaluation in order to make the project sustainable."

Addressing leading causes of death

The two Districts participating in TEHIP have chosen Integrated Management of Childhood Illnesses( IMCI) as one of the major strategies for cost-effective under five mortality and morbidity reduction.

Morogoro Rural District has a population of 525,000 inhabitants living in 215 villages. The probability of dying by age five is 188 per 1000, and the five leading causes of child mortality are acute febrile illness (including malaria), diarrhea, pneumonia, malnutrition and AIDS.

Rufiji District has a population of 172,000 inhabitants living in 91 villages. Under-five mortality, estimated at 191 per thousand in the 1992 DHS, is the first health priority of the district. The leading causes of attendance at health facilities are malaria (27%), URTI (9.6%), diarrhoea (8.3%), anemia (7.4%) and intestinal worms (5%). Prevalence of anemia in under- fives is 40%. All the major leading causes of death in the two districts are well addressed by the IMCI approach.

Tanzania is presently in the early stages of implementing IMCI in seven districts Morogoro being one of them.The training component is well underway.

Two week- course schedules with 14 to 17 participants each are used during training of peripheral health workers. In view of non clinicians managing more than 30% of health facilities in Rufiji, two special three- week- course schedules for health workers with learning difficulties were used.

With WHO and TEHIP support, health worker training is taking place at a rapid pace in both districts.In Morogoro, 93% of health facilities (HF) have been covered with at least one trained health worker , and 81% in Rufiji. Training activities are continuing and full training coverage is expected in both districts by July 1999.

TEHIP support to IMCI implementation in the country in general has been in areas of provision and sharing of training materials during training sessions. Participants coming from other districts not involved in the project have been invited to attend training sessions organized by Rufiji and Morogoro districts.

Experiences from IMCI implementation in the two districts have been found useful to other districts starting to implement IMCI in the country. The experiences in training, referral problems, provision of drugs and follow-up of trained workers have also been shared at international level in meetings organized by WHO AFRO for English speaking countries.

The same experiences are being used to provide an opportunity for the implementation of the WHO sponsored Multi Country IMCI evaluation.

Document(s) 4 of 9