This is a historic evaluation. It is (probably) the first ever sector evaluation which is fully in line with the 2005 Paris Declaration on Aid Effectiveness: The evaluation was led by Tanzania’s Ministry of Finance and looks into an entire sector and the role and contributions of all domestic and external stakeholders including government authorities at all levels, civil society organisations, and the private sector in Tanzania; and all development partners, bilateral and multilateral. The aim is not limited to improving the performance of individual donors, but to feed into Tanzania’s Third Health Sector Strategic Plan covering 2008-15 and to give recommendations on how all stakeholders can best contribute towards \ud
the plan. The Evaluation was carried out from December 2006 to September 2007 by a consortium of COWI, Denmark; Goss Gilroy, Canada; and EPOS, Germany. Team Leader was Ted Freeman of GGI, Canada. Six development partners: Belgium, Canada, Denmark, Germany, the Netherlands and Switzerland were the major funders of  the direct cost of the evaluation. The management of the evaluation was conducted by a management group comprising of Denmark, Germany and Tanzania.\u

Ministry of Finance,Tanzania, MFT

English

Digital Library of the Tanzania Health Community

November 2007 • November 2007
evaluationsummary
JOINT ExTERNAL EVALUATION OF THE 
HEALTH SECTOR IN TANzANIA: 1999-2006
This is a historic evaluation. It is (probably) 
the first ever sector evaluation which is 
fully in line with the 2005 Paris Declaration 
on Aid Effectiveness: The evaluation was 
led by Tanzania’s Ministry of Finance and 
looks into an entire sector and the role and 
contributions of all domestic and external 
stakeholders including government au-
thorities at all levels, civil society organisa-
tions, and the private sector in Tanzania; 
and all development partners, bilateral 
and multilateral. The aim is not limited to 
improving the performance of individual 
donors, but to feed into Tanzania’s Third 
Health Sector Strategic Plan covering 2008-
15 and to give recommendations on how all 
stakeholders can best contribute towards 
the plan. The Evaluation was carried out 
from December 2006 to September 2007 
by a consortium of COWI, Denmark; Goss 
Gilroy, Canada; and EPOS, Germany. Team 
Leader was Ted Freeman of GGI, Canada. 
Six development partners: Belgium, Can-
ada, Denmark, Germany, the Netherlands 
and Switzerland were the major funders of 
the direct cost of the evaluation. The man-
agement of the evaluation was conducted 
by a management group comprising of 
Denmark, Germany and Tanzania.
Overall conclusions
The joint entry of the Government of Tan-
zania (GoT) and the Development Partners 
(DPs) into a Sector Wide Approach (SWAP) 
to collaborative development work in the 
health sector has largely been a success. It 
has strengthened national ownership and 
secured higher levels of both domestic and 
external financial resources for health, and it 
has, to some extent, replaced fragmentation 
and loosely or non-coordinated projects and 
programmes by mechanisms for co-operation 
and dialogue which aim at rallying all stake-
holders behind national priorities.
This has delivered real improvements. For 
example,  infant and child mortality have 
been reduced significantly and drug avail-
ability and services have improved at health 
facilities. Contributions to the Health Basket 
Fund in particular have contributed towards 
improvements of health services at the local 
level. But much remains to be done: maternal 
mortality remains at alarming levels, and 
reforms to improve hospital care and public 
private partnerships have lagged behind.
Global Health Initiatives and large multi-coun-
try bilateral programmes have injected huge 
and much-needed resources into diseases 
that are national priorities, but they remain 
largely outside existing health planning 
and management systems. This distorts 
local priorities and threatens sustainability. 
Significant positive changes have taken place 
during the period under review, but further 
improvements are needed for Tanzania to 
meet the Millennium Development Goals on 
health and to reap the potential benefits of 
the reforms.
Background: A health sector in poor shape
During the 1990s, the health sector in Tanza-
nia faced a period of stagnation. Local health 
services suffered from severe shortages of 
essential drugs, equipment and supplies, 
and health staff lacked motivation. The sec-
tor also suffered from fragmentation: there 
was little cooperation between the public    
    A truly joint exercise.
  No less than eight government agencies, more than 20 development partners, several non-government organisations, 
  faith-based organisations, civil society organisations as well as the private sector were engaged in the joint evaluation 
  exercise. In addition, more than 300 community members took part in focus group discussions during the evaluation 
  which included field studies in six districts.
sector, faith-based organisations, and private 
health service providers. There was also 
little coordination of support to the sector 
by Development Partners. Moreover, health 
services were severely under-funded, with 
public health sector spending at USD 3.46 
per capita.
A new scene was set
In reaction to this, the Government of Tanza-
nia (GoT) and Development Partners (DPs) 
in the mid-90’s initiated a joint process to 
improve the situation. By 1999, this resulted 
in the first major health sector strategic plan 
and an agreement that support to the health 
sector should take place within the frame-
work of a Sector Wide Approach (SWAP). 
A ‘Programme of Work’ and a subsequent 
Health Sector Strategic Plan 2 (HSSP2) set 
the scene for comprehensive health sector 
reforms aimed at addressing the deficiencies 
in the sector and achieving the goals and 
targets for health as set out in the Millennium 
Development Goals (MDGs) and Tanzania’s 
Poverty Reduction Strategies (PRS I and the 
National Strategy for Growth and Reduction of 
Poverty/MKUKUTA). Priority areas of strategic 
intervention included:
Strengthening district health services;
Transforming the role of the central    
  Ministry of Health and Social Welfare    
into a facilita tive policy organisation;
Improving Government and     
Development Partner relations to    
  enhance harmonisation and to    
  pool external and Tanzanian    
  resources for health in a closer    
  and more effective partnership.
Extra money for health, but more is needed
The new approach was followed up by extra 
money for health, from both domestic and 
external sources: From 1999 to 2006, esti-
mated total public expenditures for health in 
Tanzania tripled, from USD 143.6 million to 
USD 427.5 million in real terms. In the same 
•
•
•
time period the domestic share of those 
expenditures rose from 46 to 56%.
Public spending on health per-capita rose
from an estimated USD 4.1 in 2000 to USD
9.2 by 2005. This was, however, below the
GoT target of USD 12.0 at that time. GoT has 
also yet to meet its own target of allocating 
15% of total government spending to health. 
While these figures do not take into account 
significant ‘off budget’ funding, with escalat-
ing costs for health, due to expensive new 
malaria, HIV/AIDS and other drugs, it is clear 
that increased funding is required for Tanza-
nia to meet the health related MDGs. 
Assessment of Tanzania’s health sector 2007
District health services strengthened
What has really worked and made a differ-
ence in the health sector in Tanzania has
been the devolution of responsibilities for
health facilities and health planning to
Local Government Authorities. A key factor
was the establishment of the Health Basket
Fund and Block Grants. Not only did they
provide extra financial resources. Perhaps
more importantly, they secured stable and
predictable funding, which made local plan-
ning and budgeting possible and contributed
towards improvements in service quality at
health facility level. Interviews with focus
groups confirm the overall impression that
services at local health facilities have indeed
improved.
Problems at hospitals remain unsolved
Hospital reform has been slower than other
aspects of health sector reform. While budg-
ets for regional hospitals have increased, 
they remain underfunded and lack qualified 
staff and the full requirement of essential 
drugs. They also continue to suffer from seri-
ous overcrowding, as the referral system is 
not working effectively. This also increases 
costs, as many people are treated at a high er 
level than necessary.
Better infrastructure, but more needs to 
be done
The proportion of health facilities in a good
state of repair increased over the period as a
result of major construction and renovation
activities. Still, many health facilities, includ-
ing even some hospitals, lack running water,
electricity and communication equipment.
While steps have been taken to address the 
2004 findings, where more than half of the 
health facilities in rural areas were reported 
to be at the point of collapse, this should be 
a continued focus before new facilities are 
built. In contrast, new facilities for HIV/AIDS
are mushrooming financed by sharply in-
creased funding earmarked for HIV/AIDS.
Competition could improve drug supply
The supply of drugs, equipment and other 
medical supplies provided by the Medical 
Stores Department (MSD) has improved over 
the evaluation period, but shortages and 
delays in delivery are still common. More 
competition should increase efficiency and 
ensure better availability of drugs at facilities. 
The supply of new and expensive anti-malaria 
and anti-retroviral drugs (ARV), by contrast, 
is excellent thanks to well-funded vertical 
programmes. However, unfortunately this 
has been at the expense of the essential 
drug supply and these programmes should 
increase efforts to assist the MSD system as 
a whole.
Still not equal access to health services 
Equal access to health services in Tanzania 
remains a problem, and the benefits of 
improved health services – and HIV/AIDS Pro-
grammes in particular – are thus not  shared 
equitably. Some of the constraints to equi-
table access are outside the direct control of 
the health sector as they are based on geo-
graphic isolation and high transport costs. Nevertheless, the sector has not responded 
effectively to address these constraints.
Make better use of trained health staff
Tanzania has faced a severe shortage of
skilled health sector workers throughout
the evaluation period and continues to do
so, despite some improvements in quantity
(small) and quality (more significant) of the
health staff. The challenge is not only to train
more health staff, but to make better use of
the health staff Tanzania actually produces.
From 1994 to 2004 Tanzania produced more
than 23,000 health graduates. Of these, the
government employed less than 4,000 (16%).
More effective management of human 
resources to raise productivity is required.  
In addition, ensuring that health facilities in 
remote rural areas are staffed is critical, as 
this is where the greatest unmet health needs 
exist. 
HIV/AIDS effort struggles to meet targets
HIV/AIDS was included as a special strategy
in the Health Sector Strategy Plan 2. This has
contributed towards a more effective national
response to the disease, but important chal-
lenges remain like limited rural coverage
and lower participation by males.
External funding for HIV/AIDS has seen a
huge increase and was budgeted to reach
almost USD 350 million in 2006/07. This has
boosted HIV/AIDS treatment and care, and
made new and expensive  anti-retroviral 
drugs (ARV) available for free. Still, achieve-
ments fall far short of set targets – in 2006, 
60,000 Tanzanians received ARV drugs, while 
the target was at least 150,000 people – and 
coverage of HIV/AIDS services like Prevention 
of Mother to Child Transmission are still low 
compared to needs.
Involve Faith Based Organisations
40% of the health facilities in Tanzania are
operated outside government, mainly by Faith
Based Organisations (FBO), which have a 
long tradition in Tanzania, but also by other 
private health service providers. They attract-
ed many public health workers in the 1990’s, 
but this trend has been reversed in recent
years due to increases in salaries for public 
health workers. The improved formal and 
informal dialogue between the GoT and DPs 
has tended to marginalise FBO’s and other 
private health service providers and efforts
should be made to involve all stakeholders
in dialogue and planning.  Overall progress in 
public private partnership has been weak in 
comparison to the other reforms.
Assessment of the Development Partnership
in health
Improved, but cumbersome partnership
The development of formal structures for
dialogue in the health sector has helped to
maintain a common sense of direction among
stakeholders and foster harmonisation, but 
the structures are cumbersome and should 
be streamlined. Improved alignment and 
harmonisation have relieved GoT of some 
of the burdens of dealing with a multitude 
of individual Development Partners. Some 
DP’s adhering to agreed procedures, though, 
feel that they have lost access to GoT, which 
concentrate on stand-alone projects and 
the new Global Health Initiatives.  The SWAP 
arrangement set up in 1999 committed all 
health stakeholders, including Global Health 
Initiatives, to put all activities in the health 
sector under one common sector-wide 
program. Despite improvements, this target is 
still far from being met.
More predictable funding
The share of DPs health funding that is 
on-budget has risen significantly. This has
several advantages: While off-budget funding
from various sources makes it impossible to
predict what resources are actually available
for health, on-budget spending facilitates
planning and improves predictability and
transparency. Also on-budget funding has 
been found to be more likely to be released 
on time and according to pledges and can be 
used much more effectively.  
What aid modalities work best?
A mix of all available project and programme
aid modalities are in use in the health sector
in Tanzania. Though an assessment of the dif-
ferent aid modalities is desirable to enhance
aid effectiveness, it is not possible to make
a definitive assessment, but some observa-
tions can be made.
Projects: are valued for their timeliness
and flexibility; in short, their ability to ‘get
things done.’ On the other hand, government
authorities are sometimes unaware of
projects within their area and it is not pos-
sible to predict what comes where and when.
Projects also tend to be supply-driven with
limited local ownership. Contrary to expecta-
tions, the SWAP has neither led to a decline
in the number of externally funded projects
nor in project funding for health, but despite
the rise in the number and value of projects,
more external funding is now subject to the
budgetary process of the GoT.
Sector support programmes: are mostly
project aid using government systems. The
biggest advantage of these programmes is
their predictability. The dilemma of DPs is
that their influence diminishes as ‘their’ fund-
ing is processed through the governmental
mechanisms.
The Health Basket Fund stands out among
aid modalities
The Health Basket Fund has played a
particularly important role in strengthening
district level health services. In 2005, when
the health basket was increased significantly,
it led to a notable 28% increase in health
finances to councils. The biggest advantage
of this aid modality is the predictability. TheNovember 2007 •
DANIDAS KOMMENTARER
Key health indicators and targets
Indicator 1999 2004/05 MDG Goals (2015)
Infant Mortality Rate 99 68 40
Under Five Mortality Rate 147 112 47
Maternal Mortality Rate N/A 578 133
Percentage of births attended by 
trained personnel
36 46 90
% HIV/AIDS Prevalence among 
Adults
9.4 7 <5.5
Number of People Living With 
HIV/AIDS
and Receiving Anti-Retro-Viral 
Drugs (ARV)
N/A 125,312 in AIDS Care and Treat-
ment and 60,341 on ARVs
100,000 by Dec 2006
(Tanzania’s National Strategy for 
Growth and Reduction of 
Poverty)
Public health sector spending 
per capita
USD 4.1 (2000) USD 9.2 USD 43 
The figures suggest that indicators, which can be addressed through large-scale vertical program interventions, have shown positive change. 
For example, immunisation, malaria treatment, and other focused interventions can reduce child mortality, while reducing maternal mortality 
requires much broader interventions.
   
  Health spending key figures FY 2006
  Total public spending on health    USD 560 million (incl. on- and off-budget)
  Domestic share       56% (incl. General Budget Support)
  External share        44%
planning of the use of basket funds has been
largely in the hands of the councils and they
know precisely how much funding is coming.  
The Health Basket is jointly funded by eight 
donors and provides flexible funds which use 
government’s own procedures. 
A disputed newcomer: The Global Health
Initiatives 
The new global health funds are not an aid
modality, but rather a mixture of projects 
using government and parallel systems. 
Because of the vast amounts of funding 
involved they have profound ramifications, as 
the continuing rapid and significant increase 
in resources for HIV/AIDS in Tanzania shows. 
This has been relevant to addressing a critical 
problem and a national health priority, but 
given the sheer volume of HIV/AIDS funding,
almost USD 350 million expected for 2006/07
– as compared to total public spending on 
health of USD 561 million in 2005/06 (in
current prices) – it is hardly surprising that
HIV/AIDS funding also tends to distort priori-
ties and draw staff away from, for example,
maternal and child health services. The 
increasing number of and funding by Global 
Health Initiatives and large bilateral pro-
grammes threaten to destabilise health sec-
tor planning and prioritising as they remain 
largely outside established coordination 
and alignment mechanisms. Of the almost 
USD 350 million budgeted for 2006/07 for 
HIV/AIDS, it was expected that almost USD 
300 million would remain outside govern-
ment accounts.
General Budget Support: The increase in 
GBS overall has resulted in more money for 
the health sector and greater amounts of 
funding which is GoT owned and managed.  
Given that GBS is flexible money which the 
MoF can allocate according to country priori-
ties, there is concern that health will lose out 
in relation to other needs. This was illustrated 
by DfID’s decision to move its funding from 
the Health Basket Fund to General Budget 
Support. This resulted in a net loss to the 
health sector which, in relation to the overall 
share of the government budget, has only just 
been regained after four years. 
Recommendations
The GoT and DPs should maintain  
  the SWAP and make every effort to    
  increase funding for health and to    
  align and harmonise existing and    
  potentially new off budget funding    
  as much as possible.
A target should be set for the per   
  centage of public health expendi   
  tures to be allocated to Local Gov   
  ernment Authorities.
Already agreed reforms in the    
  health sector should be consoli   
  dated before focus turns to new    
  reforms.
Concrete steps should be taken to    
  accelerate progress in hospital    
  reform and public private partner ship.
Effective action to reduce maternal    
  mortality and improve health services for  
  deliveries should be taken.
Improving equity of access to    
  health services should be a cross-cutting  
  theme of the next Health Sector Strategic  
  Plan.
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Joint External Evaluation of the Health Sector in Tanzania:1999-2006

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Joint External Evaluation of the Health Sector in Tanzania:1999-2006

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