Review of the State of Health in Tanzania 2004

\ud The Ministry of Health has mandated an independent review of the State of Health in Tanzania for there the year 2004. The objective was to provide an overview on the health situation in Tanzania, to assess if have been improvements in public health service delivery, to comment on the Tanzanian’s perception of health services, discuss equity in accessing health care, to identify successes and challenges and to provide. The methodology was to utilise existing documented data and other available information. The suggestions for improvements. An international and a national consultant were assigned to undertake the review. list of documents consulted, not always quoted, is in the annexe. In terms of understanding changes in health status, there were few reliable and recent data available at national level. Consequently the consultants were left with data, most of which had already been used in the 2001 review. Main “new” data sources compared to the 2001 State of Health Review were the 2002 Census, data from National Sentinel Sites and recently an in-depth study has been undertaken in 10 districts of Tanzania, as well as the first representative sero-survey published by TACAIDS in 2004. To obtain additional qualitative information 51 interviews with stakeholders were conducted. Health has many determinants, and only a few of these are directly influenced by the health care delivery system. As for the underlying determinants of health, unfortunately many crucial factors in Tanzania have not changed for the better since the last review. Most importantly, poverty is still rampant. Also, the negative consequences of poor school enrolment of girls in the past are only becoming visible as now, as these girls have become women and poor female education is a known determinant of infant health. The fact that the HMIS reports a slight decline in of maternal deaths reported in hospitals does unfortunately not mean that there is really less mortality, because a large proportion of deliveries, particularly in rural areas do not take place in health facilities, and even there skilled assistance is not guaranteed. The close relationship between the density of skilled staff and maternal mortality and the absence of skilled staff in rural areas make it unlikely that the high maternal mortality figures have declined since 2001. The HIV/AIDS prevalence, which was published for the first time in a nationwide representative sample in 2004, is comforting in the sense that the results – a 7% prevalence in the reproductive age group – are lower than feared, on the basis of the surveillance of blood donors. Although 7% (with considerable variation within the country, age groups and sex) is still high and rates HIV/AIDS as a leading cause of mortality of adults for years to come. A widely neglected issue in this context is the increasing number of HIV/AIDS orphans, their number already getting close, if not above 1’000’000. Exact figures are not available. Although this is as much a social as a health problem, the potential negative impact on the health status of these children and adolescents is obvious. A number of health problems do receive only limited attention. A recent study revealed that in at least one of every ten households there is one case of disability. Non-communicable diseases are on the increase and epidemiological transition is most certainly a reality, at least in urban areas. Infant mortality is internationally used to compare the health and well-being of populations across and within countries. The 2002 census data show overall minimal changes for the better. In particular the wide range between Arusha (58/1’000 LB) and Lindi (217/1’000) has not changed. However, there are some encouraging improvements in national sentinel and project sites in terms of reduced IMR/CMR/U-5MR and even maternal mortality, it is at this point in time impossible to tell if the health status of Tanzanians has substantially improved since the last review and one will have to wait for the results of the DHS 2005 to see if the long-term trend of a declining IMR/CMR/U-5MR, which has started in 1978, has continued. The data availability is better as far as the health systems input situation is concerned, as annual reviews both for health sector performance as well as for the overarching goal of poverty reduction are taking place. There is a wide consensus amongst directly involved stakeholders and development partners that the performance of the health system has improved, although it is still a patchy progress. It is obvious that the funding situation has improved substantially, although it is still far away from the recommended figures by the Macroeconomic Commission on Health. The human resource crisis is becoming increasingly urgent, particularly in the context of starting scale-up of ARV treatment and also in terms of reaching skilled birth attendance targets, which will require a substantial increase in human resources for health. Little is known about the professional quality of care, but misdiagnosing of severe malaria seems to be common, and might be only the tip of the iceberg, possibly hiding a dark picture. Findings are not conclusive. A recent study in ten districts found very high positive approval, even though certain complaints were documented. These results are in stark contrast to other studies, which paint a rather bleak image of user-unfriendly health services, where corruption is not uncommon. Policies are in place to promote equity in accessing health care, but reality still has a long way to go before reaching the ambitious goals. Exemption schemes are far from being functional and there is evidence that the poor have difficulties in accessing health facilities. There is also ample evidence of gender imbalances, such as early childbearing, early onset of sexual activity and early marriages, Female Genital Mutilation is widespread, and despite being unlawful the practice to force pregnant girls out of school is frequent. There are numerous achievements of the health care delivery system. This review could not deliver a ranking of successes, but just highlight on the basis of stakeholders and development partners’ comments a few success stories: TB-control programme is a success, IMCI has shown impact and the potential for rapid gains in survival rates. In general terms the planning capacity of the various stakeholders, particularly at district level has improved and in particular the burden of disease focussed planning has shown impact, and contributed to the decrease of IMR/CMR/U-5MR in the NSS. The commitment of the GoT to health sector reform and the continued donor support to Tanzania is commendable Improving maternal, newborn and child health (MNCH) in all its facets is in spite of achievements through ICMI a challenge ahead. HIV/AIDS morbidity and mortality is and will be on the top of the agenda. However, in addition to these major challenges, “neglected” diseases and non-communicable health problems will require attention. This will be closely linked to the human resource crisis, which is already a reality today, for example in the field of obstetrical care, but which will be further aggravated through the human resource requirements of the treatment and care programmes. Quality of care needs improvement, and linked to it, is the strengthening of health information systems, including the maintenance of the NSS. Two challenges, for the present and the future, which need strong improvements, but which go beyond the health sector are good governance and equity. It is not conclusive if health has really improved in Tanzania since the last review. However, taking a positive attitude there have probably been improvements in infant mortality rates, even though it is not clear to what extent these improvements documented in the national sentinel sites reflect also the situation at national level. Even though shortcomings persist, the health care delivery system is in better shape than before. A drop of bitterness remains issues related to equity and gender balance, where there is still major room for improvement. The consultants do not claim to have obtained a comprehensive overview of the Tanzanian health system and suggest therefore only with modesty to focus on three areas: The human resource crisis in the health sector needs urgent attention and fast and concerted action. The human resource crisis is an example where joint action across sectors is necessary to find a solution. Without the necessary human resources not much progress in health service delivery will be achieved in the future and in particular in terms of achieving the “health” - MDGs. However, it is acknowledged that solving this problem goes beyond the MoH and the Ministry of Education, and includes a variety of governmental and non-governmental stakeholders The burden of disease approach in setting priorities should certainly be pursued, and it has been shown to be an impressive success in a number of districts. However, there are some health problems (non communicable diseases, neglected diseases) not fully covered by these exercises, and which should not be neglected and should receive more attention. Health status cannot be influenced without addressing basic questions of equity in access to health services. Improvements in the area of removing financial barriers are important, but equally important are gender-related barriers, and it is crucial that efforts should be strengthened to abolish these barriers If another “State of Health Review” should be anticipated in the future, it is strongly recommended to have it timed to the availability of a major new set of health information, such as a DHS or a \ud Census exercise