Document(s) 3 of 7

What the DHMT Does
DHMT: Movers and Shakers in Health Care Delivery
The Challenges of building the Capacity of DHMTs in Problem Solving
Using Reliable health Information Decision Making
Defining Characteristics of INDEPTH Settings
Computers make light work of Chores
Sentinel DSS Shows good Results in Tracking Burden of Disease
On the Move: Animators promote use of ITNs in communities
The core questions of TEHIP in the context of Decentralization

What the DHMT does

The District Health Management Team is headed by the District Medical officer. Its functions include:

• Reviewing development plans in the district (including private and NGOs)
• Preparation of annual health plans after consultation with all stake holders.
• Implementation of health services based on district health plans and in accordance with national rules and regulations.
• Initiation and promotion of partnership with other health providers and other sectors to enhance collaboration and partnership in the district.
• Putting in place mechanisms that enhance proper collaboration and communication at all levels of the health service.
• Strengthening Health management information to ensure effective use of data for planning and taking appropriate health interventions.
• Fostering of health system research and analysis in the district and utilization of findings to improve health status.
• Identification of training needs in the district and staff development plan for proper career development of staff.
• Establishing functional committees to enhance community participation especially at health centre, community and household level so as to encourage community participation.
• Monitoring of all health performance in the district and taking corrective action where required.
• Ensuring proper management and availability on a regular basis of resources within the budget. This includes personnel, drugs and medical supplies.
• Ensuring the support of all initiates for local mobilization of resources.

DHMT: Movers and shakers in health care delivery

Peter Nkulila, a clinical officer and member of the Morogoro Rural Health Management Team (DHMT) is proud of his job and role in planning but he has some reservations when he discusses about logistics. Moving medical supplies from the District Headquarters to some of outlying health facilities is often a nightmare in the 19,250 square kilometre district with a dominant mountainous terrain.

“Some facilities have no access road at all,” Nkulila said as he narrated about a dispensary in Lumba Chini, in Morogoro Rural which is not reachable by a motor vehicle and therefore not easy to estimate the exact time from the district headquarters.

Supplies to that facility are off loaded at Singisa Mission and a messenger is sent out to scale the rugged mountain to inform workers at the uphill facility of the new arrival. The supplies would eventually be carried by a porter at a fee and not many are enthusiastic to brave the ascent which normally takes at least two hours.

As Morogoro Rural health workers struggle to ascent highlands in order to deliver supplies and discharge other services, some three hundred kilometres away, rowing boats have to be used to reach villages and health facilities surrounded by flood water in Rufiji District. Delivering supplies and supervision work is complicated when Rufiji river swells and increases its width by about 15 kilometres in some areas. But even when flood water is not posing a challenge boats still have to be used to reach villages scattered in the Rufiji Delta zone.

There are more intriguing stories of the logistic difficulties that have to be endured to reach health facilities in the TEHIP districts. The long rainy season which normally runs from March to May is blamed for many of the woes. The rains wash away sections of the rural roads rendering some of the facilities inaccessible. When they have to use alternative routes in some areas the distance may increase even three fold which means more fuel and man-hours lost.

In view of the logistic problems both districts DHMTs obtained four wheel vehicles, motorbikes and bicycles. Rufiji with an extensive flood plain, a myriad of wetlands and a delta area, obtained a boat which is used all year round to reach some facilities.

The DHMT bear the burden of ensuring that supplies are delivered to all government health facilities in their district. However, that is not their only test of endurance and concern. They have a more formidable task of ensuring the delivery of high quality, cost effective district health services that takes into consideration equity of access.

Performing their functions without the necessary resources and tools has invariably been an impossible mission. In the project districts the capacity of DHMTs to be functional and effective has been enhanced. “What we are doing today is implementing ideas conceived many years ago but could not be carried out”, said Nkulila.

The Challenges of building the Capacity of DHMT's in Problem Solving

The Strengthening of Health Administration and Resource Management (SHARMs) within the context of health sector reforms project originated from discussions between Tanzania Essential Health Interventions Project (TEHIP) and the Primary Health Care Institute, Iringa. The project was preceded by a rapid training needs assessment among representatives of Morogoro Rural and Rufiji District Health Management Teams (DHMTs). The results of the appraisal indicated that there was an immediate need in management support to the two DHMTs focussing primarily on improvement of the capacity of the DHMTs to implement their plans.

The Primary Health Care Institute was commissioned to execute the management support programme following presentation and discussion of detailed project proposal with the TEHIP project management. The strategy that was selected for use in the project was that of building the capacity of DHMTs in problem-solving with regard to day-to-day problems that impede implementation. The strategy or method was in fact an adaptation of the “Strengthening of Health Management” Process as developed by WHO.

The project took off on March 26, 1998 with preliminary visits to each of the districts during which the project was explained to the DHMT and District authorities. Tentative timetables and other organizational issues were also agreed upon.

Definitive project activities were conducted over a 9 month period, between April 26 to December 31, 1998. Similar sets of activities were carried out in each of the two districts. Thus, initial ten-day start-up workshops were conducted which were followed by two-to-three-month implementation periods. Three-day follow-up visits were conducted in the middle of the implementation periods. Review workshops, also of ten-day duration each, were then conducted after the implementation period following another two to three months of implementation four-day final review meetings were carried out.

The project was well received by the DHMTs. The level of active participation by all individuals was high. The main strength of the method is the fact that it enhances problem solving and analytical skills which are qualities required of all managers. For similar reasons, its potential for initiating a sustainable process in health management development is high since the facilitators do not need formal training in management.

Of course building capacity within the DHMTs to address problem solving is only one aspect. This entry point has stimulated the identification of other areas of management needs by the DHMTs themselves and has resulted in a "knock-on" effect. The DHMTs now function better as a team than than before and hold regular meetings with agendas. This has led to more efficient delegation of tasks among DHMTs members and thus shared responsibilities towards improving district health service delivery. An indication of the success of this practical approach to management skill building has been regular production of quarterly financial and technical reports for the district health plans.

In the long term, these capacity building elements, after appropriate pilot exercise will form the essential components of a DHMT management "tool-kit. It is envisaged that this will complement the existing DHMT Management Training Course Modules which will be offered through the Ministry of Health Zonal Training Centres.

Using Reliable Health Information in Decision Making

Bringing reliable health information to bear on policy and planning in resource constrained countries is still a far cry in the world's poorest countries. For large parts of the world's population there remains a void in vital health information. Without population based data, health services rarely reach those at greatest risk, many of whom die without any contact with the health system.

The imperative for a reliable information base to support health development has never been greater.

A critical contribution to this is the experience of a limited, but increasing number of field stations which have, as their foundation, continuous monitoring of geographically defined populations that can generate high quality, population-based health and demographic data.

These data are able to inform priority setting, policy decisions and the allocation of resources. These data also lead to highly focused intervention-oriented, research agenda, including a range of health, social, economic and behavioral studies.

It was against that background that at a meeting in Dar-es-Salaam, in November 1998, members of field sites based on demographic and health surveillance convened to establish an International Network of field sites with continuous Demographic valuation of Populations and their Health in Developing Countries (INDEPTH). Seventeen field sites, drawn from 13 countries in Africa and Asia, participated in this constituting meeting.

The INDEPTH founding document was drafted, debated and adopted by all the member sites, a coordinating committee and chair were unanimously elected, and seven initial work groups were formed. The prime purpose of the Network will be to substantially enhance the capabilities of INDEPTH field sites through;

• Technical strengthening
• Methodological development
• Widened applications to policy and practice
• Increased interaction between site leaders, researchers and managers

Much of this can be effectively addressed through bringing these field stations into ongoing and effective contact, so providing opportunities to;

• Continuously improve the methods and technologies used in resource-poor settings
• Cultivate cross-national activity and broaden the scope of research
• Build capacity at individual and institutional levels
• Strengthen the interface of research with policy and practice
• Improve the validity and generalisability of findings

Computers Make light Work of Chores

A. S. Kashindye has reached retiring age but as he was about to bid farewell to the job he was doing for several decades, that was when enthusiasm started and he began to enjoy it. "Now I can complete a month's job within three days and with accuracy," said Kashindye, an accountant with the Morogoro Rural District Council. Ironically the computer Kashindye now sees as his best and dependable tool had given him sleepless nights when rumours if its imminent coming spread in the district headquarters like bush fire.

When it was confirmed in 1997 that computers would be brought to the accounts section of the District Council, he was sure that the technology would dislodge him from his job. I was restless because I am not computer literate and I have heard stories of computers displacing people in work places.' he said. But, fortunately, what he dreaded hasn't happened. In his office a the District Council headquarters, are two computers daily churning out accounts figures, budgets write-ups and research data for TEHIP and the District Council.

Kashindiye now boasts of the marvels of computerization. Although his office has been using computers for hardly one year he cannot figure out proper accounting and data analysis without the use of a computer. The computer system in his office has, among others, a spread sheet programme which has made his work easier. The District Council is now in the process of computerizing it own accounting system.

Anecdotes and fantasies of the wonders of computerization are widespread in both districts where TEHIP is undertaking its project. There are no computers at Kibiti Health Centre in Rufiji district but Ali Msumi, who takes care of all medical records believes that once he gets access to a computer the hardships of keeping records and tallying figures would be over. Had he not visited Ikwiriri, about 20 kilometres from the Centre, in recent months he would probably not have such imagination. Msumi saw a computer for the first time when he called at TEHIP Research Station at Ikwiriri to deliver cost tracking forms. After a demonstration by a data entry clerk he was struck with awe and then he realized that there was a missing tool in his operations. A computer is what he would like to lay his hands on in order to simplify his work. Over the past six months he has experienced an increase in patients coming to the facility, a change which are more or less doubled his work load. His job is more tasking now than ever as he has to compile information required by the Heath Management Information System.

A the time being installing computers at the government health centres like Kibiti is still a far cry but TEHIP's initiatives do indicate that it is a viable undertaking. Just as Kashindye's fears have been allayed, so will Msumi's dreams be realized when the process being tested by TEHIP proves positive and their benefits are widely disseminated.

Sentinel DSS shows good results in tracking burden of Disease

In Morogoro rural district, the Tanzanian Ministry of Health's Adult Morbidity and Mortality and the Tanzania Essential Health Interventions Project (AMMP and TEHIP) work to support the use of evidence in health priority setting and resource allocation. SInce, 1992, AMMP has maintained a Demographic Surveillance System (DSS) among more than 300,000 people in three locations, including Morogoro. The DSS, which uses 'verbal autopsies" to determine cause of death, could form one part of a national surveillance system to track the burden of disease.

AMMP records over 2,000 deaths per year in Morogoro per year among a population of over 100,000. 85% of residents live within 5 km of a health facility, yet over 80% deaths occur at home; in 41% of cases, there is no contact with the formal health sector before death. DSS has shown that acute febrile illness (query malaria) is responsible for 44.7% of years of life lost (YLLs) among under fives. Health facility data have routinely indicated malaria as the leading cause of facility attendance, admissions, and in-patient mortality. Despite this, malaria was not given prominence in district health plans or budgeting.

In 1997, TEHIP introduced evidence based planning to Morogoro. This allowed more detailed analysis of the disease burden by District Health Management Teams, who used it to influence priority settings, budgeting and selection of cost effective interventions. This led to increased investment, selection and delivery of interventions effective for malaria cure and prevention: the Integrated Management of Childhood Illnesses (IMCI) Package, and the social marketing of Iinsecticide Treated Nets (INTs). To date, these programmes have reached 75% and 28% of the argeted populations for IMCI and ITNs respectively. AMMP and TEHIP continue to monitor this trend toward evidence planning, and its impact.

ON THE MOVE: Animators promote use of ITNS in Communities.

In order to fight malaria, the number one killer disease in the district, Morogoro rural district has embarked on the use of Insecticides Treated Nets as one of the most cost-effective strategies towards the control of malaria.

To promote the use of ITNs, the District Health Management Team (DHMT) has identified 85 animators in the current 155 villages covered with the ITNs activities.

The identification of the animators was done in collaboration with village governments. The animators with the cooperation of the peripheral front-line health workers will promote the use of ITNs, encourage communities to re-treat their mosquito nets and respond to their questions or problems that might arise.

The animators are currently being provided with bicycles to ease the traveling within their localities.

Document(s) 3 of 7