Document(s) 3 of 9

THE ISSUE

A profound health crisis -- major components of which include malaria, HIV/AIDS, tuberculosis, malnutrition, and anemia -- has gripped sub-Saharan Africa for many years. This interlocking web of problems has been compounded by a lack of health care resources and poverty. Recently, however, the international community has committed substantial new funding to resolve this crisis.

But will new funding alone produce the desired results? The Tanzania Essential Health Interventions Project (TEHIP) was formed to test the hypothesis that health care spending would have a greater impact if directed toward cost-effective interventions aimed at the largest contributors to the local burden of disease.

A unique collaboration between Canada's International Development Research Centre (IDRC) and the Tanzanian Ministry of Health, TEHIP provided local health-planning teams in two large Tanzanian districts with tools, strategies, and modest funding increases that have allowed them to target their new resources on the largest contributors to burden of disease and to improve the efficiency of on-the-ground health care delivery.

The result has been a large decrease in mortality rates in both districts, particularly amongst children. Those declines put the districts of Rufiji and Morogoro well on their way to reaching the UN Millennium Development Goal of achieving a reduction in child mortality of two thirds by 2015 and, in the process, providing hope where often the outlook has been bleak.

THE RESEARCH

Information collected through local demographic surveillance systems was used to establish health-intervention priorities in the two districts. TEHIP then developed a series of simple, easy-to-use, computer-based tools to help district health planners allocate their budgets more in proportion to their local burden of disease priorities. The burden of disease profile tool, for example, presents quickly understood graphic representations of "intervention addressable shares" of burden of disease, allowing planners to allocate their funding in ways that promise significant reductions in mortality. These tools can be adapted for use elsewhere -- simply through the provision of local statistical inputs -- and are now being introduced for use by planners in other Tanzanian districts.

Using the new tools, the district health management teams reoriented their budgets to place greater emphasis on major causes of mortality such as malaria and a cluster of childhood illnesses. The teams discovered, however, that to effectively address these conditions, it was necessary to increase capacity both at the level of the village clinic and throughout the health system. Subsequently, the teams invested a portion of their modest top-up funds in programs such as new training for clinicians in integrated management of childhood illnesses and in the development of an integrated management cascade, designed to enhance communications and the effectiveness of supervisors, and to increase the efficiency of routine systemic functions, such as the delivery of drugs.

Within a short period, levels of patient satisfaction began to increase and attendance at health facilities rose. In both districts, mortality rates fell dramatically for children and significantly for adults.

LESSONS AND RECOMMENDATIONS

Extensive experience in two large-population districts in Tanzania shows that investing in health systems -- to increase the efficiency of health care delivery and to target the most pressing health problems -- can lead to impressive results. The fundamental lesson TEHIP draws from this is that international institutions and various levels of government must consider the strengthening of health systems a high priority, alongside the introduction of new therapies, drugs, and vaccines.

The development of management tools and strategies also proved to be invaluable aids to the district health teams seeking to improve health services in their areas. The TEHIP group invites other developing countries to consider using these same tools and strategies since they are designed to be adaptable to other national contexts.

Some other important lessons and recommendations:

• Programs to invest in health systems should take advantage of the synergies that come with combining research and development functions into an integrated program. This strategy makes it possible for research to be acted upon quickly and for program development to be refined and improved through simultaneous feedback provided by researchers.

• Investing in human resources is crucial. Delivery of scaled-up health services ultimately depends on well-supported primary care providers. Investment in training of personnel -- including initial training, retraining, continuing education, and the development of new curricula -- is particularly important.

• There needs to be significant investment in critical infrastructure, such as community clinics, vehicles to transport supplies and people, and information and communications technologies.

• Funding and implementation priorities must be based on local-level, evidence-based plans that consider the local burden of disease rather than being determined by the priorities of international donors.

• Health-related development projects should have an exit strategy that ensures the effective transfer of ownership and control to local-level stewards.

• There is a need for health observatories that can package health- and poverty-related information in ways that decision-makers can understand and act upon. Sample or sentinel surveillance systems can provide this data and are essential in countries where vital event registration does not exist.

Document(s) 3 of 9