A joint health strategy for Tanzania

German Technical Cooperation (GTZ) has supported Tanzania’s health system for a long time. Noted in the early days of independence for its generally high standards of care, the system's resources today are increasingly stretched to the limit. Rapid population growth, under-funding, under-staffing and AIDS have thwarted its performance. Mortality rates for mothers and infants are among the highest in the world.

The Tanzanian government is addressing the situation with a health reform programme that was launched in 1994. Key elements include decentralisation, civil service reform, the introduction of customer charges and more cooperation between public and private institutions. Since 1998, this reform programme has been embedded in the national sector wide approach (SWAP), the goals and strategies of which were defined in conjunction with development partners.

It is not easy to implement this complex reform. German donor organisations have abandoned their strategy of supporting individual projects. This approach had been based on the assumption that the results of pilot projects would be helpful for local decision-makers when drafting a coherent sector policy. Some 1,200 projects – supported by more than 30 international donors – were undertaken, but the task of planning and evaluating them proved too much for the health ministry. It was impossible to systematically analyse the results.

The architects of German development policy learnt their lesson. The Tanzanian government has developed its health programme in conjunction with several donors. Its aim, as stated by the ministry in Dar es Salaam is “to improve the health and well-being of all Tanzanians with a focus on those at most risk and to encourage the health system to be more responsive to the needs of the people”. The programme consists of six coordinated elements focusing on district management, HIV/AIDS, reproductive health, health funding, further education and, finally, cooperation with private-sector providers. Major German development agencies, such as the KfW Development Bank and InWEnt were involved in designing the programme and continue contributing. The emphasis is on cooperation with the relevant sections of the health ministry so that all activities are embedded in the national policy. The programme is operational in four of Tanzania’s 22 regions and reaches some 15 percent of the country's 33 million population.


Innovative approaches

Two key instruments are being used. These are basket financing and an annual sectoral review. Apart from Germany, six other donors are involved in the financing arrangement (UK, Denmark, Ireland, Switzerland, Netherlands and the World Bank). In 2002, they pooled a total of some 40 million dollars that add up to roughly a fifth of Tanzania’s health sector budget. This money is transferred directly to the health ministry. The idea of basket financing is to supplement the government’s budget, which merely covers salaries and other current expenses, in order to permit additional activities and to improve health services. Germany’s Federal Ministry for Development (BMZ) has been involved in the basket financing since 2000. The coordinator of the German health programme has a seat and a vote in the Basket Financing Committee (BFC), which decides on the way the model evolves.

The decision to participate in a basket financed model was not easy for the German side. Many in positions of responsibility resented not being able to say exactly what was happening with German euros. Other countries, too, remain sceptical about basket financing as a development policy tool. The United States and Japan continue to prefer bilateral cooperation. – mainly for internal and ideological reasons concerning, for instance, AIDS and family planning. The Tanzanian government, however, while still seeing scope for bilateral cooperation, has indicated that it prefers joint approaches.

The second important new tool in the SWAP framework is the annual joint review. This is a meeting attended by spokespersons from every section of the health ministry, representatives of the decentralisation ministry as well as delegates from all development partners and civil society organisations. The idea is to check whether the health sector is moving towards the objectives that have been jointly defined in various documents. Preliminary objectives and indicators are analysed, audits and major sectoral issues (information systems, financing et cetera) discussed and recommendations made for the coming year. The partners agree that the annual review is an important forum for developing health policy.

In view of these sweeping reforms, is there still a role for technical consultancy in the Tanzanian health sector? The British have made their position very clear and are withdrawing from technical consultancy and even from basket financing. In future, London wants to focus exclusively on budget support and directly subsidize Tanzania's national budget.

The German side, however – along with most of the other development partners – regards the British decision as precipitate and believes that effective implementation of the health reform programme will require technical advice. Particularly in rural Tanzania, there is still evidence of serious shortcomings in the management of the programme. Advice (for example concerning the creation of health plans, the development of effective anti-AIDS strategies and the establishment of health insurance systems) is still requested by the partner. Other areas where assistance is sought include setting up computerised information systems, the introduction of quality management and better cooperation between public and private providers.

In this context, the traditional multi-level approach of German Development Cooperation is proving efficient. The aim is to systemically work at various levels (village, district, region, health ministry) and to help partners translate the gathered experience into reasonable policy. Front-line assistance is provided by DED personnel (doctors, economists, quality managers) assigned to district hospitals while CIM and GTZ staff serve as consultants at regional and ministerial levels.

In spite of reform euphoria, however, it must be said that the entire process needs very careful monitoring. It is still too early to say for certain whether the reforms will be successful. The following critical questions need to be asked and honestly answered:
1. Are mother and infant mortality indicators improving?
2. Is the staffing situation improving?
3. Are HIV/AIDS infection rates falling? Is SWAP the right approach for issues such as HIV/AIDS or reproductive health, where success depends on multi-sector strategies?
4. Are the transaction costs of the reform process (with innumerable meetings, conferences and strategy discussions) acceptable?

For good reason, Tanzania's health reform programme is raising high expectations. The process is flanked by a gentle economic upswing, the country ranks among the most peaceful in Africa and the foundations of democracy are in place.