report state of health Tanzania by 9kk4nW9

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									                                                                                   Swiss Centre for
                                                                                   International Health®




Unapproved Draft: for comment only Draft 10274-03-
05



                     Review of the State of Health
                          in Tanzania 2004


                                 2728 MarchApril 2005


           Independent Technical Review on behalf of the Ministry of Health,
the President’s Office Regional and Local Government and the Government of Tanzania



                          The review team:
                                                         Nicolaus Lorenz
                                                         Cyprian Mpemba




Correspondence to:
                Swiss Centre for International Health®    Socinstrasse 57, Postfach, CH-4002 Basel
                        Telephone +41 61 284 82 29        Fax +41 61 271 86 54
                    Email:nicolaus.lorenz@unibas.ch       Internet: http://www.sti.ch
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Table of contents
1. ABBREVIATIONS AND ACRONYMS .........................................................................................................................434


2. ACKNOWLEDGEMENTS ..............................................................................................................................................645


3. EXECUTIVE SUMMARY ...............................................................................................................................................756


4. INTRODUCTION ...........................................................................................................................................................1178
4.1. Terms of Reference of the State of Health in Tanzania 2004 Assessment                                                                                                 1178
4.2. Methodology                                                                                                                                                           1278


5. BACKGROUND OF THE REVIEW ............................................................................................................................1389
5.1. Tanzania Joint Health Sector Review 2005                                                                                                           1389
5.2. The State of Health in Tanzania, 2001,: Summary of main findings                                                                                   1389


6. FINDINGS ...................................................................................................................................................................151011
6.1. The health situation in Tanzania in 2004                                                                                                                                  151011
6.2. Health outcomes                                                                                                                                                           171112
6.3. Health service delivery                                                                                                                                                   261815
6.4. People’s perception of public health care services                                                                                                                        312217
6.5. Disparities and inequities (including gender imbalances) in accessing public health care services                                                                         322217


7. BEST PRACTICES/SUCCESSES AND FUTURE CHALLENGES .....................................................................352418
7.1. Best practices                                                                                                                                                              352418
7.2. Challenges                                                                                                                                                                  372519
   7.2.1. Morbidity/Mortality related issues .................................................................................................................... 372519
   7.2.2. Health Service Delivery area ............................................................................................................................ 372519
   7.2.3. Equity ............................................................................................................................................................... 382620


8. SUGGESTIONS AND RECOMMENDATIONS .....................................................................................................392621


9. ANNEXES ...................................................................................................................................................................412823
9.1. Responses from National partners:                                                                                                                                        412823
9.2. Responses of international partners (bilateral, multilateral and int. NGOs):                                                                                             472826
9.13. Documents consulted                                                                                                                                                     532830
9.24. People interviewed                                                                                                                                                      613233
9.35. Programme of the review (not yet complete!)                                                                                                                             623234

Figures and , Boxes and Figures

Tables:

Table 1: Demography of Tanzania
112
Table2: Total Fertility Rate
112
Table 3: Morbidity (community)
123
Table 4: Morbidity (facility based)
123
Table 5: Main causes of mortality
134
Table 6: Maternal Mortality
145
Table 7: Maternal Mortality 2000 – 2003 according to HMIS
145
Table 8: Infant/Child and under-5 mortality rates Table 9: HIV/AIDS
156
Table 9: HIV/AIDS
156



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Table 10: HIV/AIDS details
167
Table 11: Nutritional status
167
Table 12: OPD attendance per capita
189
Table 13: Births attended by skilled attendants
189
Table 14: Vaccination coverage
1920
Table 15: % of under-5s with malaria attack/fever getting appropriate treatment within 24h of onset
1920
Table 16: GoT allocation to health
201
Table 17: State of public health facilities
201
Table 18: Economic inequities
223
Table 19: Gender inequities
223
Table 20: Urban-rural inequities
234

Figures:

Figure 1: Life expectancy 1978 – 2002
112
Figure 2: Morbidity in 10 districts, as seen in OPDs
134
Figure 3: Percentage of severe underweight of under-5s (weight for age)
178
Figure 4: Stockouts of tracer drugs
212

Box:

Box 1: Indicators of State of Health Review 2001




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1. Abbreviations and Acronyms


AIDS                Acquired Immune Deficiency Syndrome
AMMP                Adult Morbidity and Mortality Project
AMO                 Assistant Medical Officers
APTHA               Association of Private Hospitals in Tanzania
ARC                 AIDS Related Complex
ARI                 Acute Respiratory Infection
BCG                 Bacille Calmette-Guerrin
CCHP                Comprehensive Council Health Plan
CCSS                Chair Council Social Services
CHF                 Community Health Fund
CHMT                Council Health management TeamCMR                     Child Mortality Rate
CSPD                Child Survival Programme Development
DANIDA              Danish International Development Agency
DFID                Department for International Development
DED                 District Executive Director
DHS                 Demographic and Health Survey
DMO                 District Medical Officer
DPLO                District Planning Officer
DPT                 Diphteria Pertussis Tetanus
DT                  District Treasurer
GAVI                Global Alliance for Vaccines and Immunization
GFATM               Global Fund to fight HIV/AIDS, Tuberculosis and Malaria
GoT                 Government of Tanzania
GSK                 GlaxoSmithKline
GTZ                 Deutsche Gesellschaft für Technische Zusammenarbeit
HHBS                Household Budget Survey
HIV                 Human Immunodeficiency Virus
HMIS                Health Management Information System
HSPS                Health Sector Programme Support
HSSP                Health Sector Strategic Plan
IMCI                Integrated Management of Childhood Illnesses
IMR                 Infant Mortality Rate
ITN                 Insecticide Treated Net
LB                  Live birth
LGA                 Local Government Authority
LF                  Lymphatic Filariasis
MCH                 Mother and Child Health
MDA                 Mass Drug Administration (in the context of LF-control)
MDGs                Millennium Development Goals
MNCH                Maternal, Newborn and Child Health
MoF                 Ministry of Finance
MoH                 Ministry of Health
MTEF                Medium Term Expenditure Framework
MUCHS               Muhimbili University College of Health Sciences
NACP                National AIDS Control Programme
NHIF                National Health Insurance Fund
NIMR                National Institute for Medical Research
NSS                 National Sentinel Sites
NTLP                National Tuberculosis and Leprosy Programme
OPD                 Out Patient Department
PER                 Public Expenditure Review
PMTCT               Prevention of Mother to Child HIV Transmission
PORALG              Presidents’ Office Regional Administration and Local Government
PPP                 Public Private Partnership
PRS                 Poverty Reduction Strategy
R&AWG               Research and Analysis Working Group
RCH                 Reproductive and Child Health
RMO                 Regional Medical Officer
SCIH                Swiss Centre for International Health®
SDC                 Swiss Agency for Development and Cooperation
STI                 Sexually Transmitted Infection
SWAp                Sector Wide Approach
TBA                 Traditional Birth Attendants
TEHIP               Tanzania Essential Health Interventions Project
UNICEF              United Nations Children’s Fund
U-5MR               Under five Mortality Rate
URT                 United Republic of Tanzania
USAID               United States Agency for International Development
WB                  World Bank


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WHO                 World Health Organization
WHR                 World Health Report




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2. Acknowledgements

The consultants would like to thank all partners for the excellent preparation of my the
reviewvisit and all the support we have received during the assignment. In particular we
would like to thank Ms Jacqueline Mahon for her excellent support in facilitating access to the
vast literature and her support in setting up meetings with international stakeholders. OAlso
our thanks go also to Mr. JJ Rubona, Head Health Information and Research section of the
Ministry of Healthhead HMIS, who facilitated the work from his side and set up meetings
with key informants of the MoH.

Last, but not least we would like to thank to the numerous stakeholders and development
partnersctors, who are listed in an annex of this report, and who gave us their valuable time
and shared their views so freely with us.

We are looking forward to discussing the details of the report during the upcoming joint
health sector review meeting on 4 April 2005.



Nicolaus Lorenz, MD
Cyprian Mpemba, PhD
Consultants




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3. Executive Summary
Introduction:
T Thhe Ministry of HealthoHMoH has mandated an independent review of the State of Health in Tanzania for
the year 2004. The objective was to provide an overview on the health situation in Tanzania, to assess if there
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 suggestions
for improvements. An international and a national consultant have looked into the matterwere assigned to
undertake the review..

Methodology: The methodology was to exploit basicallyutilise existing documented data and other available
information. However, in order to obtain also the opinion of The 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
 In addition stakeholders,almost 4051 standardized interviews ofwith stakeholders were also conducted.

Findings, health situation: Health has many determinants, and only a few of these can beare directly influenced
by the health care delivery systems. As for the context underlying determinants of health, unfortunately many
crucial factors in Tanzania have not changed for the better since the last review. Most importantly , Ppoverty is
still rampant. Also, tThe 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. FThe foodThe Food situation has not improved and both low birth weight as well as stunting in children
under five is still widespread.. 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. and ANC CHECK aAlthough 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.


In the terms of understanding changes in health status, there were few reliable and recent data available is was a
problem of the review was the unavailability of recent data for the at national level. Consequently the consultants
were left with data, most of which had already been used in the 2001 review. data from However, a number of
studies havedhad been performed since 2001, namely National Sentinel Sites and only recently an in-depth study
has been undertaken in 10 districts of Tanzania, and as well as athe first representative sero-survey in 20043 of
the National AIDSids Control Programme, which provided to some extent the possibility to comment on the
recent state of health.

In spite of some encouraging improvements in national sentinel and project sites in terms of a reduced infant,
child and even maternal mortality, it is at this point in time simply impossible to tell if the health status of
Tanzanians has substantially improved since the last review. Even though there are changes for the better in



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some urban areas, the situation has worsened in some rural areas, tcensus data Only once the results of the DHS
2004
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 some urban areas, however, the
situation has not improved overall. In particular the wide range between Arusha (having a rate of 58/1’000 LB)…
and Lindi (217/1’000) Mtwara has not changed. However, there are Therefore, in spite of 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 reducing IMR/CMR/U-5MR, which has started in 1978, has continued.
 will be available, a sensitive judgement on the health status 2004 of Tanzanians in 2004 will be possible. The
fact that the HMIS reports less maternal deaths in hospitals does not necessarily mean that there is less mortality,
because a large proportion of deliveries does not receive have any skilled assistance. The relationship between
the density of skilled staff and maternal mortality is known, and TanzaniaZTZ has a number of factors, which
would make it unlikely that high maternal mortality figures have changed declined.

The news on HIV/AIDS- prevalence, which have beenwereas determined in 2004 for the first time in a
nationwide manner in 2003 areis comforting in the sense that they are withwith the results – a 7% prevalence in
of the reproductive age group – areindicate lower figures lower lower than feared, although 7% (with
considerable variation in urban and rural areas) is still higheven though this prevalence is high enough and and
rates makes (and will continue to make) HIV/AIDS as a leading cause of mortality of adults. A widely
neglected issue in this context is the increasing number of HIV/AIDS -orphans. 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 has started, at least in the urban areas years ago.

Findings, health service delivery: The data availability was 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 is a patchy progress. It is
obvious that the funding situation has improved substantially, (aleven though it is still far away from the
recommended figures by the Macroeconomic Commission on Health). tThe ) the human resource crisis is
becoming increasingly extremely urgent, particularly in the context of starting scale-up the beginning of large
scale of ARV- treatment and also in terms of reaching order to act on the lack of skilled birth attendance
targetsdelivery assistance to name just two problem areas, which will require a substantial increase in of 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; people’s perception: Findings areConcerning the population’s perception of health, there are
obviously very mixed findings not conclusive. The 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..
Although the perceived quality of care seems to be positive (largely influenced by the availability of drugs), an
explanation of the poor obstetrical coverage is linked to the poor quality women receive in facilities. Little is
known about the professional quality of care. A recent study showing frequent misdiagnosing of severe malaria
in Northern Tanzania might be another tip of an iceberg, possibly hiding a dark picture.

Findings, equity: PAs far as equity is concerned, One has to acknowledge that policies are in place to promote
equity it equity in order to facilitate accessing health care, but reality still has a far long way to go before to
reaching the ambitious goals. Exemption schemes are far from being functional and there is evidence it is
documented that the poor have difficulties in accessing health facilities. There is also ample evidence of Not yet
enough is known about the 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. and even less is undertaken to bridge this gap. However, there is multiple
evidence from multiple sources for gender inequalities having an impact on health in Tanzania. Just to mention
two examples: Female Genital Mutilation is widespread, and despite being unlawfuleven though not according to


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law the practice to force pregnant girls out of school is frequent. The presumably high Maternal Mortality is a
further case in point for injustice for women.


Successes: TNevertheless there are numerous also 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: The high vaccination coverage is and the treatment completion rates for 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 are impressivein the NSS. The commitment of the GoT to health sector reform and the
continued donor support to Tanzania is commendable. , to mention but two examples.. These and other success
stories should be an encouragement to continue with the ongoing health sector reform, which will ultimately
address a number of issues mentioned above and it is certainly acknowledged that the policies are in place,
howeveralthough , reality - as some studies indicate - is a far cry from the health sector reform goals of,
guaranteeing universal access. Also worth mentioning Worthwhile to mention as well that is the quality of the
interaction betweenof the various Tanzanian stakeholders and the donor community is working well, which also
providesingproviding also a basis to address the pending problems.

Challenges: 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 is necessary. Two challenges,
for the present and the future, which need strong improvements, but which go beyond the health sector are good
governance and equity.

Conclusion: 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.


Suggestions: The consultants do not claim to have obtained a comprehensive overview of the Tanzanian health
system and recommend suggest therefore only with modesty to focus on a or – rather underline – a numberthree
of areas, which have been proposed beforehand and the recommendations do not claim to be complete:

         The human resource crisis in the health sector needs urgent attention and fast and concerted action. The                                 Formatted: Bullets and Numbering
          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                                  Formatted: Bullets and Numbering
          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:.

                     Maternal mortality is probably the most neglected health problem in Tanzania.                                                 Formatted: Bullets and Numbering

                     With the objective to achieve a continuum of care an increased focus on Maternal, Newborn                                     Formatted: Bullets and Numbering
                     and Child Health, including adolescents is necessary. Although not as much a social as a health
                     problem, the issue of the increasing numbers of orphans should be properly addressed.




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                     Neglected diseases (Lymphatic Filariasis, Schistosomiasis, but also Trachoma) should be and                                  Formatted: Bullets and Numbering
                     could be addressed. In particular the issue of Lymphatic Filariasis should be closely followed,
                     as there is a free treatment available, and the potential economic impact on the population is
                     important. However, the positive side effect of de-worming of MDA and its positive impact on
                     anaemia – a widespread syndrome which contributes to morbidity and mortality in Tanzania –
                     could be considered as well.

                     Epidemiological transition is taking place in urban areas. The fact that there is seemingly a bias                           Formatted: Bullets and Numbering
                     towards the urban areas should not hide the problem of the urban poor. More research into this
                     issue would be helpful.

        Health status cannot be influenced without addressing basic questions of equity in access to health                                      Formatted: Bullets and Numbering
         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.
                                                                                                                                                 Formatted: Bullets and Numbering



Recommendation: If another “State of Health Review” should be anticipated in the future, it is strongly
recommended to have it time-wise coordinateed to with the availability of a major new inventoryset of health
information, such as a DHS or a Census exercise. In addition it is suggested to continue to make use of the NSS-
sites, as these will not only provide reliable data for informed decision making, but they could also be used to
optimize existing an d experimental approaches
                                                                                                                                                  Formatted: Bullets and Numbering




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   HThe humanHuman resource crisis in the health sector will needs urgent attention and fast and concerted
       concerted action. The human resource crisis – is an example a case in point 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
       Ministry of Education, and includes but in a variety of sectors and both 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 an impressive success. However there are exist other
       some health problems, not fully captured by these exercises, and which should not be completely
       neglected and should receive more attention:
                 oMaternal mortality is probably the most neglected health problem in Tanzania.
                 oWith the objective to achieve a continuum of care an increased focus on Maternal, Newborn
                     and Child Health, including also adolescents is necessary. Although not as much a social
                     as a health problem, the issue of the increasing numbers of orphans should be properly
                     addressed.
                 oIn a narrow sense neglected diseases (Lymphatic Filariasis, Schistosomiasis, but also
                     Trachoma) should be and could be addressed.
                 oIn particular the issue of Lymphatic Filariasis should be closely followed, as there is a free
                     treatment available, and the potential economic impact on the population is important –
                     however also the cost to deliver. However, the positive side effect of de-worming of MDA
                     and its positive impact on anaemia – a wide spread syndrome which contributes to
                     morbidity and mortality – in Tanzania – should be considered as well.
   Epidemiological transition is taking place in urban areas. The fact that there is seemingly a bias towards the
       urban areas should not hide the problem of the urban poor. More research into this issue would be
       helpful.
   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 thatand efforts should be strengthened to abolish these barriers. .

    “I know that I do not know”. This statement of Socrates exaggerates the situation in Tanzania. However,
        there is some Tanzanian reality in it, in the sense that there is a wealth of information available. H,
        however, it is frequently difficult to find and often badly underutilisedsed.underused.
   It will be important to address the issue of strengthening further the capacities to use for information for
        decision making.
   Seemingly obvious, but Information management it will become more important with the major additional
        funding now available to the health sectorcoming in, whose disbursementich which will be heavilyvery
        much linked to performance. Data on the degree of the target achievement will be crucial.
   Compile available information in a more structured way. The creation of a structure within MoH to collect
        all relevant information could alleviate this situation. A Health Information Centre, which would have
        the remit to go beyond the classical information collection of a HMIS, HIS, but rather as a focal point
        for all typessorts of studies and data related to health being collected or published in Tanzania.
        oIf another “State of Health Review” should be anticipated for the future, it is recommended to have it
        fine- tuned with the availability of a major new inventory of health information, such as a DHS. In
        addition it is recommended to make more use of the NSS-sites, as these will not only provide reliable
        data for informed decision making, but they could also be used to optimize existing and test
        experimental approaches



4. Introduction

4.1. Terms of Reference of the State of Health in Tanzania 2004 Assessment

        The consultancy has drawn on the considerable volume of data currently available in order to arrive at
        conclusions whether or not health service delivery is improving in the public sector, which areas are
        improving faster than others and how to further escalate progress towards the identified Health Sector


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        Strategic Plan goals, the National Strategy for Growth and Reduction of Poverty goals (NSGRP/PRS)
        and the Millennium Development Goals (MDGs). Specifically the consultancy’s expected outputs were:

                   To provide a comprehensive overview of the health situation in Tanzania in 2004;
                   To assess health status outcomes linked to the PRS/HSSP objectives and goals, especially in
                    the areas of fertility, mortality, morbidity and nutritional status.
                   To assess whether there has been improvements in service delivery.
                   To assess people's perceptions of public health care services including private for non profit
                    health services in Tanzania.
                   To identify disparities and inequities (including gender imbalances) in accessing public health
                    care services
                   To identify best practices/successes and current/future challenges to the Sector in terms of
                    progress.
                   To make suggestions and recommendations that may assist the Sector to further improve the
                    health service delivery in Tanzania.


4.2. Methodology

        Due to the limited time available, it was not possible to collect primary data, but the review has drawn
        on the large body of data and reports already available. The consultants basically relied on documents
        being provided through the technical committee, which is working on the Health Sector Performance
        Profile. Some additional literature search was undertaken. In order to provide some continuity and
        comparison possibility, the same set of criteria which had been identified in the 2001 State of Health
        Review were used for this review. In addition the attempt was undertaken to assess on the basis of the
        available literature and documentation people’s perception. In order to provide a basis for comparison it
        was attempted to use the same health outcome and health service delivery indicators which had been
        applied as for the review of the State of Health in Tanzania 2001. Furthermore the provided documents
        and literature listed in the annexe wasere searched for information on the perception of the population
        and on equity in order to identify possible disparities and inequities in accessing health care in Tanzania.

        In order to comment on the health status of a population, it would be necessary to have population based
        data. Facility based data, as they are produced through the a HMIS are usually not reflecting the
        situation in the population, because usually many health events outside facilities go unreported..
        Nevertheless available HMIS and the annual RMO report 2003, the annual RCH Report 2004 and the
        most recent annual DMO Report covering 2003 were used.

        Demographic surveys and sentinel data are more reliable, although they later often have the problem of
        being sufficiently representative. The same applies for studies in specific regions or in the context of
        projects, which might generate valid data, which is then however difficult to generalize. As for
        nationwide data the 2002 Census, 2002 HBS and the HIV seroprevalence study of 2003 (TACAIDS,
        2004) and to a limited extent data generated in the context of international agencies was used.

        National Sentinel Sites data and the recent in-depth study by a team lead by NIMR-staff (Makundi et al,
        2005) were used.

        In addition to this formal analysis of data and information, a series of non-representative interviews with
        key stakeholders has taken place in order to obtain the opinion of these stakeholders pertaining to the
        State of Health in Tanzania and to get a better understanding of relevant issues. The input of these
        stakeholders was used to compile a list of best practices and future challenges. readers of this report
        can judge themselves on how pertinent these opinions are, but the authors of the report did
        not want to side-line these opinions and perceptions, as they come from knowledgeable
        stakeholders and are therefore important.
        A summary of these 37 interviews can be found in the annex.




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5. Background of the Review

5.1. Tanzania Joint Health Sector Review 2005

        The annual Joint Health Sector Review provides an opportunity for all stakeholders in the Health Sector
        to come together to review past performance over the previous year, deliberate on critical aspects
        influencing implementation, reach joint conclusions and collectively make commitments on selected
        issues for the coming year.

        The Tanzanian health sector has been undergoing far-reaching reforms since the mid-1990s and has
        adopted a Sector-Wide Approach (SWAp). The reforms are being implemented at all levels and involve
        fundamental changes in many critical areas of the sector. The complexity of the current reforms and the
        challenges ahead are quite immense. Therefore, close monitoring and evaluation of the health sector’s
        performance over time is quite imperative. To this effect, the health sector stakeholders have agreed to a
        set of indicators for the monitoring of the Health Sector Strategic Plan (HSSP) whilst at the same time
        also directly linked to the implementation of the Poverty Reduction Strategy (PRS) and the (National
        Strategy for Growth and the Reduction of Poverty (NSGRP)).

        As such the Health Sector is now under increasing pressure to be able to demonstrate tangibly that it is
        moving in the right direction, making progress towards improved service delivery and health outcomes
        (MDGs, PRS goals, HSSP goals). At the most recent Joint Health Sector Review, held in March 2004, it
        was stressed on several occasions during the meeting, that there was a real need "to obtain objective
        information by which to take the pulse of the health sector". Thus, it was agreed and subsequently a
        milestone was developed that an independent study on the State of Health in Tanzania would be
        undertaken for the next review whilst at the same time complementing the work of the Health Sector
        Performance Profile Update. This would follow a similar successful studyreview, which was undertaken
        in 2001 and was favourably received by all stakeholders


5.2. The State of Health in Tanzania, 2001, Summary of main findings
        The 2001 report focussed on 16 indicators, which had then been used in the health sector performance
        profile:

        Box 1 Indicators of State of Health Review 2001

           Health Status outcomes

                     Top 6 causes of morbidity and mortality among OPD attendees:
                     IMR
                     Maternal Mortality Rate
                     Proportion of deaths of women of child-bearing age due to maternal causes
                     Proportion of children under one year with severe malnutrition
                     Proportion of under-five children with severe malnutrition
                     Proportion of under-five case fatality due to malaria
                     Prevalence of HIV infection among antenatal clinic attendees

           Health service delivery

                     Total OPD attendance per capita
                     Proportion of births attended by skilled attendants
                     Proportion of children under-one year fully immunised
                     Malaria cases as percent of all under five cases presenting at OPD
                     Total government public allocation to health per capita
                     Total government & donor (budget and off-budget) allocation to health per capita
                     Proportion of public health facilities in a good state of repair
                     Percentage of public health facilities without any stock out of 4 tracer drugs and 1 vaccine
                 




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      A major problem in 2002, when the last review had wasbeen written, was the large number of
      indicators, for which information was either unavailable or of “uneven” quality.

      Morbidity trends clearly highlighted Malaria as the single largest cause of both morbidity and mortality,
      closely followed by ARI.

      No reliable, population- based, data on HIV were available for the 2001 review and information was
      linked to blood donors or antenatal clinics data, which have the known question marks about their being
      representative for the general population.

      IMR was 99 per 1’000 based on data of 1999 and there was some speculation on whether IMR might be
      being possibly on the increaseing. The report speculated that IMR might be on the increase.


      Inequity as such did not receive much attention in the 2001 report, although it was stated that only 13%
      of rural under-5s fives slept under bed nets compared to 48% of urban children.

      In terms of service delivery/health systems’ performance the report referred to of 45% of the population
      living within 1 km of a health facility, 45% within 5 km, and 93% living within 10 km. However it was
      stated that there was a widespread need of rehabilitation.


      The proportion of Aattended births issue with a declined from 44% in (1992) to 36% (in 1999) with
      urban-rural differentials and differences related to the education of the mother.


      Already in 2001 immunisation coverage was stable and high, but there were disparities across rural-
      urban groups. Per capita OPD-contacts in 2001 were 0.71/year across ages, a comparatively good
      value.

      The human resource crisis was not discussed in detail in the 2001 State of Health Report although crisis
      was looming even then as it goes back to the mid 90’s when the total health workforce decreased from
      around 67’000 to 49’000 in 2002, with the population increasing at the same time from 25 million to 33
      million inhabitants.

      Already in 2001 public health expenditure was around 6$ per capita. Although public spending for
      health had increased in percentage terms, it had decreased in absolute terms.

      On the positive side one could observe in 2001 already changes in intra-health expenditure with more
      focus on preventive services.




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6. Findings


6.1. The health situation in Tanzania in 2004

             According to WHO1, “many factors combine together to affect the health of individuals and
             communities. Whether people are healthy or not, is determined by their circumstances and environment.
             To a large extent, factors such as where we live, the state of our environment, genetics, our income and
             education level, and our relationships with friends and family all have considerable impacts on health,
             whereas the more commonly considered factors such as access and use of health care services often
             have less of an impact.” Health has many determinants, and only a few of these can be directly
             influenced by health systems. Health determinants can be categorised as: personal behaviour and
             lifestyles; influences within communities which can sustain or damage health; living and working
             conditions and access to health services; and general socio-economic, cultural and environmental
             conditions.

             Today it is general widely acknowledged that poverty is a major factor influencing health
             (OECD/WHO, 2003). There has been with the exception of Dar es Salaam only little reduction in
             income poverty (NBS HBS, 2002), which stands at 35.7 % of the Tanzanian population living below the
             basic needs poverty line and 18.7% of the population living below the national fo (include reference).
             The picture is the same for foood poverty line. Both figures have slightly improved compared to
             1991/92, when they stood at 38.6% for the basic needs and 21.6% for the food poverty line.

             Income poverty has (include reference). In spite of exemption policies this has implications for the
             access to health care, even in rural areas (Armstrong Schellenberg et al, 2003) and continues to make
             access more difficult for the poor in Tanzania (ETC Crystal, 2004). The relationship withof food
             poverty on the prevalence on of malnutrition isis also obvious.
             .
             This is somewhat in contrast to the fact that there has been since the mid-1990s a steady growth of the
             GDP, which is since 2002 in line with the PRSP targets (URT, R&AWG, 2003)include reference).
             However,It is not the place here to discuss the reasons for this varying developments. As recently stated
             in the NSGRP (URT, Vice President’s Office, 2005) this is a question of a growing income inequality in
             Tanzania, which cannot be discussed here.


             Roads do not just play a role in the access to markets, but they are also a determinant in access to
             referral services, for example in the context of obstetrical care. The condition of most roads is classed as
             being badly maintained, and most of the rural roads are of this category (URT, R&AWG, 2003).



             Unemployment in Tanzania a largely urban phenomenon in Tanzania has not changed in recent years,
             but it has implications on health as well, as it is linked to poverty (NBS HBS, 2002).


             There have been stagnant primary school enrolment ratios in the late 1990s,. These which have
             improved substantially in the meantimepast years (NBS HBS, 2002). However, in the short run, the bill
             for the stagnant enrolment in the 1990s, and in particular the decrease of the enrolment of girls (the ratio
             girls/boys decreased from 0.97 to 0.94) in the past will have to be paid, because of the close link
             between poor maternal education and poor child health, when the girls of those generation come into the
             reproductive age. The low figures of female literacy particularly in rural areas, are not promising
             knowing the close link between maternal education and child health. (include references).

             Although improvements in the access to use of safer water sources have taken place, primarily the
             therenon-poor population has benefited, whilst for the poor access to safe water is still the exception

1
    http://www.who.int/hia/evidence/doh/en/


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      have been little changes in distance to water sources and average water consumption has not increased.
      (NBS HBS, 2002).(reference)

      The number of orphans is increasing and in 2004 it is estimated that there might be up to were more
      than1’000’000 800’000 orphans living in Tanzania (UNAIDS/WHO, 2004). (include reference). Mostly
      due to the HIV/AIDS epidemic the impact of this social problem on the health status of children and
      adolescents still needs to be assessed in detail.

      Governance has has clear implications on access. A recent report (Permanent Secretary, President’s
      Public Service Management, 2005) highlighted that the average civil servant makes 45% of his or her
      salary out of bribes. Although this is a general figure and does not apply to the health sector in
      particular, it is difficult to imagine that the health sector is exceptionally better than the general public
      service. The consequences for the access to health care. are obvious. However there is also light, in the
      governance area. There are is an increase in the reporting of corruption cases in the health sector, but
      but also in more general terms, the fact that nearly all local authorities have now annualconduct annual
      audits, are indicating indicates that the system is moving into the right direction.

      If it comes to health it is difficult to assess the situation in comparison to the last State of Health Review
      in 2001, because basically little new information has become available since the last review. Health
      figures are discussed further down, but it is important to highlight here again, that all health outcomes
      are not, or at least not only a result of the performance of the health system.
      However, there are positive signs coming from the national sentinel sites (include references), indicating
      that there have been improvements in some areas, most importantly in terms of child mortality.

      The overall impression is that the general framework conditions relevant for health have not health has
      not significantly changed improved in Tanzzania since 2001. To put it in more positive terms, it has not
      deteriorated, what could have been expected on the background of the HIV/AIDS epidemic




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6.2. Health outcomes
The timing of the review was a bit premature, as the results of the DHS 2004 were not – yet – available. In
addition the review faced the difficulties outlined in the methodology chapter above in particular that data
generated through HMIS does not necessarily reflect the situation in the population and are for a number of other
reasons to be treated with caution. For this reason in case of absence of other nationwide data, NSS-data and the
recent in-depth study of byNIMR (reference) were used
6.2.1.   Population                                                                                                                               Formatted: Bullets and Numbering


         The population on Tanzania Mainland is 33,584,607 (16,427,702 - males, 17,156,905 - females). The
         population of Zanzibar is 984,625 (482,619-males, 502,006-females). The annual population growth
         rate is 2.9 percent (Census, 2002). 75 percent is a rural population. The following table shows the
         population by age group and sex distribution.

                                      Table 21: Demography of Tanzania
                                :
                                        Age (years)             Total (%)        Males (%)       Females (%)
                                        0–4                        17               17              16
                                        5 – 14                     27               28              27
                                        15 – 49 (WRA)              45               44              46

                                        0 – 14                      44               45                43
                                        15 - 64                     52               51                53
                                        65 and over                  4               4                 4
                                       Source: Census 2002



6.2.1.   Life expectancy                                                                                                                          Formatted: Bullets and Numbering


         The life expectancy at birth for Tanzanians is 54 years for males and 56 years for females (Census,
         2002). There has been a sharp increase from 44 years in1978 to 50 years in 1988. The slowing down of
         the increase since 1988 is most probably linked to HIV/AIDS.

         Figure 1: Life expectancy 1978 - 2002
            60 years




            40 years

                              1978                1988                    2002
         Census 1978/1988/2002 data



6.2.2.   Fertility                                                                                                                                Formatted: Bullets and Numbering

                                Table2: FTotal Fertility data Ratefrom various national censuses

                                        1988 (Census)               6.5
                                        1996 (TDHS)                 5.8



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                                      1999 (TRCHS)                5.6
                                      2002 (Census)               6.3

                                                National census (1988/2002) and DHS (92, 96, 99) data
                   1988-2002
       The Total Fertility Rate has decreased continuously since 1998. The increase from 1999 to 2002 census
       is difficult to interpret at this point in time. The upcoming TDHS 2005 will probably clarify this
       question.
6.2.3. Top 6 causes of morbidity and mortality                                                                                                  Formatted: Bullets and Numbering


       Community based morbidity data is scarce. The HBS 2002 produced the following data:

       Table 33: Morbidity (community)

           Year referred to                                                2000/01 ♂    2000/01 ♀                   Total
           Values                              Fever/Malaria                     68.7 %          70.1 %                        69.3 %
           Children (< 15 years)               Diarrhoea                         14.1 %          14.7 %                        14.4 %
                                               Accident                           3.0 %           1.8 %                         2.5. %
                                               Dental                             2.4 %           2.3 %                          2.4 %
                                               Skin conditions                    2.9 %           4.3 %                          3.6 %
                                               Eye                                7.4 %           6.8 %                          7.1 %
                                               Ear, nose and throat              10.7 %          10.5 %                        10.5 %
                                               Other                             12.3 %          11.7 %                        12.0 %
                                               Multiple                          17.8 %          19.3 %                        18.5 %
           Value                               Fever/Malaria                     60.4 %          59.9 %                        60.1 %
           Adults (15 years+)                  Diarrhoea                          9.7 %          10.1 %                          9.9 %
                                               Accident                           8.7 %           2.4 %                          5.0 %
                                               Dental                             5.1 %           6.1 %                          5.6 %
                                               Skin conditions                    2.2 %           2.0 %                          2.1 %
                                               Eye                                5.2 %           5.2 %                          5.2 %
                                               Ear, nose and throat               7.8 %           9.2 %                          8.6 %
                                               Other                             25.1 %          29.2 %                        27.5 %
                                               Multiple                          19.9 %          19.6 %                        19.7 %
           Source and year reported                                           NBS HBS 2000/01
           Validity for health status in       Yes                       Yes            yes                         yes
           population measured
           Representative for Tanzania?        Yes                       Yes                   yes                  yes


       This disease pattern clearly shows a predominance of communicable diseases, but chronic disease
       (“hidden” in other health problems) are not as uncommon as it is for example reported on the basis of
       facility based data (presented further down). Little information is available on non-communicable
       diseases and in the NSS the burden of diseases linked to this class of health problems is being reported
       to be around 8% (NSS, 2004) of the total burden of disease. This is in contrast to WHO-figures, which
       estimates that in Sub-Saharan Africa non-communicable diseases are increasing.
        A particular issue is tobacco and smoking. Data for Tanzania is scarce. In the Tobacco Atlas (WHO,
       2002) it is shown that Tanzania belongs to the countries in sub-Saharan Africa with the highest rates of
       smoking in adults. Of males age 15 and older 40-49%, and 10-19% females 15 years and older are
       estimated to smoke in Tanzania. In Dar es salaam a study (Jagoe et al, 2002) showed 27% of adult
       males and 5% of adult females smoking in a middle income area. The study comparing results with
       former work in Tanzania, indicated an increase in smoking prevalence.
       More common and routinely more or less available are morbidity d. and available dData which are
       generated in health facilities. Also in the NSS, morbidity is determined on the basis of facility data.
       This method has the inherent shortcoming of emphasising acute, often communicable disease. The
       prevalence of chronic conditions tends to be underestimated, for the simple reason that patients suffering
       from these conditions are not using health facilities as frequently as patients with acute health problems.

       Table 44: Morbidity (facility based)

         Year referred to                      2001                               2002                          2003
         Indicator/Value (all age groups)      Malaria (55%)                      Malaria (55%)                 Malaria (53%)
                                               ARI (21%)                          ARI (19%)                     ARI (18%)
                                               Diarrhoea (9%)                     Diarrhoea (11%)               Diarrhoea (9%)
                                               Pneumonia (8%)                     Pneumonia (8%)                Pneumonia (11%)
                                               Intestinal worms (7%)              Intestinal worms (7%)         Intestinal worms (9%)
                                               Eye infections                     Eye infections                Eye infections



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           Year referred to                       2001                              2002                          2003
           Source and year reported               RMO Report 2003                   RMO Report 2003               RMO Report 2003
           Validity for health status in          Yes, with limitations, as         Yes, with limitations, as     Yes, with limitations, as
           population measured                    based on partly incomplete        based on partly               based on partly
                                                  HMIS and the inherent             incomplete HMIS and the       incomplete HMIS and the
                                                  facility bias                     inherent facility bias        inherent facility bias
           Representative for Tanzania?           Yes, with limitations, as         Yes, with limitations, as     Yes, with limitations, as
                                                  based on partly incomplete        based on partly               based on partly
                                                  HMIS and the inherent             incomplete HMIS and the       incomplete HMIS and the
                                                  facility bias                     inherent facility bias        inherent facility bias

         With the limitations mentioned above, Tthe pattern of top 6 causes of morbidity and mortality has not
         changed in recent years. and in the different age groups.

         Figure 12: Morbidity in 10 districts, as seen in OPDs




                     40
                     35
                     30
                     25

           %         20
                     15
                     10
                       5
                       0
                                     1999              2000                 2001                 2002                 2003
                                                                            Year


                           Malaria          ARI      Diarrhea        Pnemonia           Intestinal Worms          Eye Infections

         Source: Makundi et al, 2005As for morbidity (in terms of admission to OPD) in all age groups (reference):

                            oMalaria                                                                                                              Formatted: Bullets and Numbering
                            oAcute Respiratory Infections
                            oDiarrhoeal diseases
                            oPneumonia
                            oIntestinal Worms
                            oEye infections.
         It is noteworthy howeveHowever, one should keep in mindr, that reporting morbidity and mortality
         observed in health facilities is closely linked to the performance of the health system and in particular of
         its staff. If staff is not sufficiently qualified, misdiagnosis and consequently misreporting is likely to
         happen. This seems to be particularly the case for malaria, where frequent misdiagnosis takes place
         (Reyburn et al, 2004). For obvious reasons this leads to an overestimation of this – probably
         nevertheless most important – public health problem in children in Tanzania.


6.2.4.   As forMain causes for mortality                                                                                                          Formatted: Bullets and Numbering


         The data presented further down is contrary to the morbidity data community (“verbal autopsies”) based
         and reflects therefore a picture closer to reality.
         :
         Table 5: Main causes of mortality

           Year referred to                                                           1994 - 2002
           Indicator/Value           Under-5s:            5 – 14 years:                  15-59 years                      60+ years
                                     Malaria/acute        Malaria/acute febrile          HIV/AIDS/Tuberculosis            Malaria/acute febrile


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                                   febrile illness        Illness                         Malaria/acute febrile           illness, diarrhoeal
                                   Still birth,           Diarrhoeal diseases             illness,                        diseases, cardiovascular
                                   Peri-natal causes      HIV/AIDS/Tuberculosis           Diarrhoeal diseases,            problems, acute
                                   Diarrhoeal             ARI                             Cardiovascular problems         respiratory infections
                                   diseases Acute         Unintentional injuries          and unintentional               and neoplasms
                                   respiratory                                            injuries
                                   infections
           Source and year                                                        NSS, AMMP, 2003
           reported
           Validity for health     Reliable data for the three NSSsentinel sites (Hai, Morogoro, Dar es Salaam)
           status in
           population
           measured
           Representative for      Inherent limitations of a NSS
           Tanzania?


         oMalaria/acute febrile illness, peri-natal causes and still birth, diarrhoeal diseases and acute respiratory                                Formatted: Bullets and Numbering
infections are the leading causes of mortality in the under five year old children.
         oHIV/AIDS/Tuberculosis, malaria/acute febrile illness, diarrhoeal diseases, cardiovascular problems
and unintentional injuries are the leading causes in the age group 15-59,
         oMalaria/acute febrile illness, diarrhoeal diseases, cardiovascular problems, acute respiratory infections
and neoplasms are the leading causes for mortality in the over 60 years age group.

        It is noteworthy however, that the reporting of morbidity and mortality is closely linked to the
performance of the health system and in particular its staff. If staff is not sufficiently qualified, misdiagnosis and
consequently misreporting is likely to happen. This seems to be particularly the case for malaria, where frequent
misdiagnosis takes place (see reference further down). For obvious reasons this leads to an overestimation of this
– probably nevertheless most important – public health problem in children in Tanzania.



         Data is based on estimated number of deaths each year in the sentinel sites in Tanzania from the leading
         five causes of death in each of the mentioned four age groups.


6.2.5. Maternal mortality2                                                                                                                           Formatted: Bullets and Numbering
is (presumably) very high
         Table 6: Maternal Mortality

           Year referred to                                2001                             2001                              2000
           Indicator/Value                            ~230/100’000                       543/100’000                     1’500/100’000
           Source and year reported                HMIS, 2002 and RCHS                    NSS, 2004                WHO/UNICEF/UNFPA,
                                                       Report 2004                                                            2004
           Validity for health status in           HMIS-data with known           Limited; part of the data is    It is based on estimations,
           population measured                        facility-bias +                      missing                with input from agencies’
                                                                                                                       Tanzanian offices
           Representative for Tanzania?             HMIS-data with known            Limitations of the NSS       Yes with the limitations of a
                                                       facility-bias+                                            global modelling approach
                                                                                                                     and a wide margin of
                                                                                                                           uncertainty


         Little to no recent nationwide data is available and figures are mostly speculative or refer tofrom
         specific non-representativethe NSS settings. But even there data seems to be partly missing (AMMP et
         al., 2004).

         Maternal mortality rates/or the ratio are not easy to ascertain and tono generalize izable data are
         availablefor the whole of Tanzania. The rates produced through the HMIS (see Table 6 further down)
         oscillate around 230/100’000, but indicate a decrease in the past years. The true picture is certainly not
         so good worse. WHO/UNICEF(UNFPA Various sources (references2004) estimate that the true figure
         could to be somewhere between 529 per 100,000 live births and possibly up to 21’0500 per 100’000

         2
           We mean here Maternal Mortality Ratio (number of maternal deaths per 100,000 live births) when writing “Maternal
         Mortality”



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       live births. . Even though there is a wide margin of uncertainty, the Thlatter figure would is means that
       up to up to 3250’000 women possibly die annually due to pregnancy related causes in Tanzania. To use
       a picture from the airline industry this number is equivalent to the crashing of a fully seated Fokker 100
       of Tanzania Airlines almost every working day.

       Haemorrhage is the leading cause, followed by sepsis, obstructed labour, eclampsia and finally abortion
       This order has not changed in recent years, and is typical for a country like Tanzania with a high MMR.

       Table 7: Maternal Mortality 2000 – 2003 according to HMIS

        Year of            Women of Reproductive        Number of Maternal                    Estimated Maternal Mortality Rates
        measurement        Age Recorded Delivered       Deaths                                (MMR)
              2000                   724,790                      1,809                                250/100,000 live births
              2001                   774,920                      1,946                                251/100,000 live births
              2002                   858,153                      2,111                                246/100,000 live births
              2003                   937,425                      2,082                                222/100,000 live births
       Source: Annual Reproductive and Child Health Report, 2004.


       Little to no information is available on those who survive complicated labour with sequelae, such as
       fistulae, but estimates go up to 250,000 per year (Women's Dignity Project, UNFPA and MOH,
       Tanzania Fistula Survey 2001, Women's Dignity Project, 2002Second Health Sector Strategic Plan,
       2003 – 2008). 26 percent of adolescent girls have their first birth by 19 years, which is a known
       contributing factor to high maternal mortality rate, and have an additional risk of lifelong morbidity.
       The poor maternal health is not only an indication of a serious problem with maternal healthpoor
       reproductive health, but also of women’s low status in Tanzania’s society and poor access to basic
       health services. It is thus and a sensitive indicator for the prevailing gender imbalance.

       The explanations for this deplorable situation are complex, but are clearly linked to the low percentage
       of deliveries assisted by skilled professional staff3. Such staff is not widely available in first line
       facilities in Tanzania. As it has been shown internationally (Ananad and Baernighausen, 2004) and is
       supported by the WHO, there is a clear linkage between maternal, but also infant/maternal mortality and
       the density of staff. Less skilled staff in maternities clearly translates into higher mortality rates.




                   A recent study in Northern Tanzania (Olsen et al, 2004) concluded: “it is neither the
                   mothers’ ignorance nor their lack of ability to get to a facility that is the main barrier
                   to receiving quality care when needed, but rather the lack of quality care at the
                   facility.”

       Fertility                                                                                                                                Formatted: Bullets and Numbering



                    Year
                    Value
                    Source
                    Validity for health
                    status in population
                    measured
                    Representative for
                    Tanzania



6.2.6. Infant and Child Mortality Rate4 and under-5 Mortality Rate                                                                              Formatted: Bullets and Numbering




        4
          We have added under five mortality rate, as they cover a larger life span and reflect to some extent also the impact of other
       factors, such as immunizations, and malnutrition


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         Table 8: Infant/Child and under-5 mortality rates

             Year referred to                                   2002                          2002                         2002
             Indicator/Value                               IMR: 95/1’000                 CMR: 66/1’000               Under-5: 153/1’000
                                                         [Mainland 95/1’000            [Mainland 66/1’000           [Mainland 154/1’000
                                                         Zanzibar 89/1’000]            Zanzibar 59/1’000]           Zanzibar 141/1’000]
             Source and year reported                       Census, 2002                  Census, 2002                 Census, 2002
             Validity for health status in
                                                               Yes+++                        Yes+++                        Yes+++
             population measured
             Representative for Tanzania                       +++Yes                        Yes+++                        Yes+++


         The latest nationwide data is stemming from the 2002 census. These average figures do not indicate a
         majoronly minimal improvements improvement compared to the previous State of Health Review,
         which was based on 1998 figures. .
         The Census 2002 still shows a very large variation in between regions, urban and rural areas, which are
         difficult to interpret in a summary way, as under-5 mortality rates are influenced by numerous factors.
         As in previous years the Arusha and Kilimanjaro Region have with 58/1’000 LB and 67/1’000 LB the
         best under-5 mortality rates, while Lindi and the Mtwara region have with 217/1’000 LB and 212/1’000
         by far the worst under-5 mortality rates.

         However, the detailed analysis some whilst there has been On the basis of the available data it is
         difficult to interpret these differences and to establish causal relationships. A possible better economic
         development in these areas is possible, albeit it is not as dramatic as to fully explain the changes. For the
         Dar es Salaam context it is furthermore difficult to comment as possible intra-urban differentials cannot
         be extracted from the available data.

         The census 2002 data are consistent with findings of the NSS in Morogoro and Rufji, which produced
         similar results. In these National Sentinel Sites , for example in Morogoro, which is a mutual
         confirmation of the validity of the NSS-data and the census data.

         Basically no recent IMR-data for the national level are available. Estimates for Child mortality are for
         m/f (per 1000) 163/144. (Reference)
         The DHS 2004 will provide up to 2002 information. On the basis of the NSS an impressive decrease in
         child under five mortality rates of more than 4308% in Morogoro and 55% for Rufji has been observed
         (NSS, reference2004). Although these figures are reliable as they are based on comparatively large
         samples and data quality assurance measures have been in place, one has to be aware that these
         decreases in IMR/Child Mortality rates were observed in districts, which do not necessarily reflect the
         reality of all Tanzanian districts, because they ut of districts which had ave received partly substantial
         accompanying input in terms of strengthening the improvement of health services and one will wait to
         see for the results of the DHS 2005 before one will be able to judge, if the . downwards trend which has
         been observed since 1978 has continued.




                The national average rates are within the confidence intervals of the 1999 DHS data
and indicate a very modest change if any downwards at best.




 6.2.7. HIV/AIDS5                                                                                                                                 Formatted: Bullets and Numbering


         5
           We comment not on the prevalence of HIV infection among antenatal clinic attendees, but rather on the sero-prevalence of
         HIV in the population in the reproductive age group, as this figures provides a picture, which is closer to the reality.


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      Table 9: HIV/AIDS

        Year referred to                                      2003                       End 2003
        Indicator/Value                                       7%                   8.8 % (6.4% - 11.9%)
        Source and year reported                   TACAIDS, 2004                         UNAIDS
        Validity for health status in              First RA population-             Estimation based on
        population measured                        based sero-prevalence            various data sources
                                                   study
        Representative for Tanzania                 Most realistic data so far      Limited, estimation
                                                          in Tanzania



      HIV/AIDS continues to be the single most important health threat to public health in Tanzania. Its true
      importance in terms of burden of mortality might be hidden in a number of the reported causes of death
      in Tanzania. Furthermore tThe NACP (2004) estimates that only one in 14 AIDS cases are reported, a
      total of 188’000 cases (98’000 female/90’000 male) are likely to have occurred, which considering the
      still problematic supply of ARVs causes an estimated loss of 187’000 loss of lifves fro in the year 2003.

      TACAIDSNACP found assumes on the basis of the 2004 sero-prevalence study that 7 % of the
      population in the age group 15 – 49 are living with about 1.6 million people living with HIV/AIDS in
      Tanzania. This figure is lower than one could have expected from previous sentinel surveillance sites
      (blood donors). However, it cannot be interpreted as an “all clear” sign for HIV/AIDS. Previous figures
      were not representative enough and cannot be directly compared to the now obtained prevalence rates in
      2003. Furthermore the total figure of 7% in the light of the differences presented above simply show
      how difficult averages are to be interpreted, and that seemingly “good” or relatively good news do not
      hold strong, if one has a closer look. The following figures are interesting for the understanding of the
      distribution of the burden of theis pandemic.


                                         Table 10 : HIV/AIDS details
                                         , of which 1.5 million were adults and 500,000 were children (needs to be checked ,
                              as it adds up to 2 million people, include reference).
                                                                                 % HIV +
                                           Urban                                 10.9 %
                                           Rural                                  5.3 %
                                           Male                                   6.3 %
                                           Female                                 7.7 %
                                           Mbeya Region                          13.5 %
                                           Iringa Region                         13.4 %
                                           DSM Region                            10.9 %
                                           TACAIDS, 2004

      Noteworthy is the clear gender difference: In Mbeya 15.2% of tested women were HIV-positive
      (compared to 12.4% of men) and in Dar 12.2% of tested women were positive compared to 9.4% of
      tested men.. The age group most affected in women is the 30 – 34, in which 12.9% are HIV positive,
      and for men 40 – 44, where 12.3 % are positive.


      The total figure of 7% is less than one could have expected from previous sentinel surveillance sites.
      However, it cannot be interpreted as an “all clear” sign for HIV/AIDS. Previous figures were not
      reliable enough and cannot be directly compared to the now obtained prevalence rates. Furthermore the
      total figure of 7% in the light of the differences presented above simply show how difficult averages are
      to be interpreted, and that seemingly “good” or relatively good news do not hold strong, if one has a
      closer look.
      Apart from ringing further alarm bells in the high prevalence regions, the fact that women are obviously
      carrying most of the burden of this disease should receive particular attention.

      Widely neglected in this context is the increasing number of orphans. Exact figures (CHECK
      TACAIDS; NACP) are not available, but it is estimated (UNAIDS) that there are close to 1’000’0000
      orphans already, living in Tanzania. The social web is already tearing.




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6.2.8. Nutritional status                                                                                                                       Formatted: Bullets and Numbering

       Table 11: Nutritional status



         Year referred to                                      2003               2003
         Indicator/Value                              Low birthweight: 13%        moderate/severe stunting: 9.18%
         Source and year reported                   In Unicef, 2004, referring    Makundi et al. 2005
                                                    to DHS-data, which had
                                                    beeen reanalysed in June
                                                    2003
         Validity for health status in                         Yes                Limited to the ten districts
         population measured
         Representative for Tanzania                           Yes                Large variation within the 10 districts
                                                                                  make it difficult to extrapolate to the
                                                                                  national level


       About 13% (UNICEF, 2004, re-analysing DHS data of 1999) of children are born with a birth weight of
       under 2500 grams. This is a sensitive indicator for the health status of a population.


       In a recent overview paper on health in Tanzania (Smithson, 2005) correctly highlighted the fact that
       due to the overall low utilization of delivery facilities only a minority of babies are actually weighed at
       birth. …..


             Percentage of moderately/severely underweight under-5s
                  Year
                  Value
                  Source
                  Validity for health
                  status in population
                  measured
                  Representative for
                  Tanzania


       WHO estimates that under nutrition is an underlying cause of 53% of deaths of children under five years
       of age. On this background the above mention figures latest available figure (include reference)
       indicating 44% of stunting (reference) implying significant chronic PEM and 30 percent are under
       weight (acute malnutrition) [RCHS, 1999]. This isare not good news, and might continue to be an
       obstacle for health outcomes for years to come.




                              Figure 23: Percentage of% severe underweight of under-5s (weight for age)




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                     About 16% (13%?, I recall a lower figure!) of children are born with a birth weight of
                     under 2500 grams, which is also a sensitive indicator for the health status of a




                                             14.00
                                             12.00
                                             10.00
                                              8.00
                                              6.00
                                              4.00
                                              2.00
                                              0.00
                                                           1999             2000            2001            2002            2003
                                                                                           Year
                     population.
                     Makundi, et al., 2005


         The proportion of under-5 with moderately or severe underweight is in the 10-district study (Makundi et
         al., 2005) 9.18% in 2003, which is not a statistically significant decline compared to 1999 figures.
         Furthermore there are enormous variations, ranging from 0.37% to 26% in the 10 districts.
         . Unfortunately no

         In addition, tThe rural population has pronounced micronutrient deficiencies. Poor food safety,
         inadequacy in feeding and micronutrient deficiencies, such as iron, iodine and vitamin A, and frequent
         illness put children at high risk of suffering from and eventually dying from of PEM.

         Poor nutrition is not only a problem of children, but also of their mothers. The high rate of
         micronutrients deficiencies in women manifest themselves also in approximately 14 percent of women
         in the high land and 80 percent in coast areas being anaemic during pregnancy, and about 25 percent of
         maternal death is associated with anaemia:. Although this anaemia is mostly influenced by malaria,
         Nnearly 70 percent of women continue also to be vitamin A deficient, despite the apparent high rate of
         vitamin A supplementation coverage of over 90 percent in 2002. (include reference)


               Other health problems:

 Non-communicable diseases;                                                                                                                       Formatted: Bullets and Numbering
                          , coastal region, 2004Only with the limitations of the NSS
                 Little information is available on non-communicable diseases and in the NSS the
         burden of diseases linked to this class of health problems is being reported to be around 8% of
         the total burden of disease (reference). This is in contrast to WHO-figures, which estimates
         that in Sub-Saharan Africa non-communicable diseases are increasing (reference).

6.2.7.
  Neglected disease issue                                                                                                                         Formatted: Bullets and Numbering


         The National LF-elimination programme has found in a nationwide mapping exercise that Lymphatic
         Filariasis is prevalent virtually all over Tanzania, meaning that is the total 35 million population of
         Tanzania are is at risk of contracting this disease (Malecela-Lazaro M., 2004). With a comparatively
         simple mass drug administration (MDA) this disease could be prevented and, eventually eradicated. The


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        necessary drugs are given provided by the pharmaceutical company GlaxoSmithKline for free, and have
        the positive side effect of addressing partsdestroying some of the different types of the intestinal
        helminths, which contribute to the morbidity of all, but particularly the young age groups. However,
        Ffor the time being MDA is only used on in Zanzibar, Mafia Island and parts of the coastal region.
        Recently it has been proposed to linking LF and other neglected disease control programmes with
        malaria control programmes in particular ITN-based programmes (Molyneux et al, 2004).
        .




 6.2.8. Disability is widely neglected                                                                                                           Formatted: Bullets and Numbering


        Disability and handicap is not yet widely perceived as a problem, as it does not contribute significantly
        to mortality. However, a recent study (Makundi, 2004), estimated that at least in one person out of each
        ten households at least one personlives with a disability is living. Using data from the end 90’ it is
        estimated (TzPPA, 2004) that there are now more than 3.5 million people living with a disabilities in
        Tanzania. Of these approximately 28% are physically impaired, 27 % are visually impaired, 20% are
        deaf, 8% are mentally impaired, 4% have multiple impairments (TzPPA, 2004). Detailed figures are not
        available, but Thisdisabilities translates, into ….. millions of lost DALYs which are lost in Tanzania,
        and which are not yetreally accounted for.




6.3. Health service delivery

        The GoT, supported by the donor community has engaged in a fundamental reform process of the health
        sector. These efforts are starting to produce tangible results, but although there are certainly
        improvements in some areas there is stagnation in others.

 6.3.1. Total OPD attendance per capita                                                                                                          Formatted: Bullets and Numbering

        Table 12 : OPD attendance per capita

            Year measured                                 2000          2001              2002               2003
            Indicator/Value                                                0.71 for
                                                           0.5          73/114 (64%)
                                                                                                 0.7                0.8
                                                                          districts
            Source and year reported                    National          National            National          National
                                                        Malaria            Malaria            Malaria           Malaria
                                                        program            program            program           program
                                                        database          database            database          database

            Validity for health status in                  yes          Yes               yes                yes
            population measured
            Representative for Tanzania                    Yes          Limited           yes                yes
                                                                        because of
                                                                        limited
                                                                        availability of
                                                                        reportsyes


        According to the HMIS, the OPD attendance per capita has been rising from 0.5 /year/capita in 2000 to
        0.8 /year/capita in 2003. This increase seems to be a positive development, because it is generally
        assumed that a once yearly contact per capita with health services would have to be expected. However,
        these results reflect also the known problems of the HMIS . can be demonstrated with OPD attendance.



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           Reporting is incomplete and covers partly only 60% of all districts and thus it is difficult to state that
           there have been improvements over the years.

           However, if one looks into under five attendance in the Morogoro region, the picture looks different and
           shows an increase from 4.0/ year/capita in 2000 to 5.8 /year/capita in 2003. This is in by an international
           comparison standards rather high (reference). It is nNoteworthy that the figures rate prior to the
           introduction of IMCI wereashad been only 2.9/year/capita.




           !

    6.3.2. Proportion of births attended by skilled attendants6                                                                                     Formatted: Bullets and Numbering

           Table 13: Births attended by skilled attendants

                       Year measured                                      2004                             2003
                       Indicator/Value                        51% (for poorest quintile)                   80%
                                                              83% (for richest quintile)
                       Source and year reported             Economic Development                Makundi et al. 2005
                                                            Initiatives, 2004
                       Validity for health status in          Limited to rural Shinyanga            Limited to the ten
                       population measured                                                                districts
                       Representative for Tanzania            Yes, in terms of highlighting        Yes, to some extent+
                                                              socio-economic inequalities



           Coverage of The figure is notoriously low with around 80% in urban and just around 30% in rural
           settlements is notoriously low and has seemingly not changed for the better over years. A recent study in
           rural districts noted a substantially higher figure of around 80% (Makundi et al.NIMR,, 2005).
           However, the authors conclude themselves that this is most probably an overestimation as all female
           workers at the dispensary level are considered to be skilled, which is clearly not the case. The reasons
           for poor coverage, particularly in rural areas, where it is about 50% of the urban figures, are not entirely
           conclusive, but as stated above, the poor quality of services is a contributing major factor. This poor
           quality is closely linked to the availability or rather non-availability of qualified staff in the health sector
           in general and delivery care in particular. , which has been reducStaff has been reduced in 1995 from
           67’000 to 47’000 in 2002. The impact of this reduction is becoming fully visible only in recent years.
           Professional Sstaff is today insufficient both in numbers as well as in qualification.

           Tanzanian women seem to be aware of this fact. A recent study in Northern Tanzania (Olsen et al, 2004)
           concluded: “it is neither the mothers’ ignorance nor their lack of ability to get to a facility that is the
           main barrier to receiving quality care when needed, but rather the lack of quality care at the facility.”



6
   The indicator "proportions of births attended by skilled health personnel" represents the percentage of all births attended by a skilled
health worker. The term ‘skilled attendant’ refers to a health professional - such as midwife, doctor or nurse - who has been educated and
trained to proficiency in the skills needed to manage normal (uncomplicated) pregnancies, childbirth and the immediate postnatal period,
and in the identification, management referral of complications in women and newborns" (WHO, 2004). TBA or on the job-trained-staff is
explicitly excluded from the category “skilled health personnel”.




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       Also cost can be prohibitive (TzPPA, 2004). This might be also one of the explanations for the strong
       discrepancy between the high antenatal clinic attendance and the low assisted delivery rate.




6.3.3. Improvement of Vvaccination coverage                                                                                                                                                       Formatted: Bullets and Numbering

       Table 14 : Vaccination coverage
             Year measured         1999                                                                    2000                 2001                        2002               2003
             Indicator/Value       BCG (80%)                                                               BCG (85%)            BCG (90%)                   BCG (88%)          BCG (96%)
                                   DPT (76%)                                                               DPT (79%)            DPT (92%)                   DPT (89%)          DPT (95%)
                                   Polio3 (72%)                                                            Polio3 (71%)         Polio3 (74%)                Polio3 (93%)       Polio3 (90%)
                                   Measles (72%)                                                           Measles (73%)        Measles (73%)               Measles (89%)      Measles (90%)

             Source and            EPI surveillance                                                        EPI surveillance     EPI surveillance            EPI surveillance   EPI surveillance
             year reported         report/NIMR                                                             report/NIMR          report /NIMR                report /NIMR       report /NIMR
             Validity for
             health status in
             population                                                                     Yes                    Yes                  Yes                        Yes                Yes
             measured
             Representative
             for Tanzania                                                                   Yes                    Yes                  Yes                        Yes                Yes



       Since 1999 there has been a steady rise of vaccination coverage, which and has reached in 2003 rates of
       close to 90%. Subsequently the incidence of immunizable vaccine preventable diseases has decreased
       dramatically. In 2003 less than only 700 800 measles cases were reported and no major epidemic has
       taken place since (annual EPI-report, 2003).
                                                                                      100

                                                                                       95

                                                                                       90   Figure 4: Vaccination coverage
                                                                                       85
                                                            % immunisation coverage




                                                                                       80                                                                Measles
                                                           100                                                                                           Polio3
                                                                                       75                                                                BCG
                                                            95                                                                                           DPT3
                   URT- EPI-Annual Report, 2003
                                 70
                                                            90
                                                                                       65
                                                            85
                                 % immunisation coverage




                                                                                       60
                                                            80                                                                                     Measles
                                                                                       55                                                          Polio3
                                                            75                                                                                     BCG
                                                                                       50
6.3.4. Malaria cases as percent of all under five cases presenting at OPD
                                                            70                                    1999      2000     2001      2002      2003
                                                                                                                                                   DPT3
                                                                                                                                                                                                  Formatted: Bullets and Numbering
                                                                                                                     Years
                                                            65

       At the time of this review the HMIS had compiled produced figures only for for the year 2001, when
                                60

       60% of under five case were reported to suffer from Malaria. In 2002 this figure was down to 43%. At
                                55

       first sight this indicates an improvement, however, the problem in interpreting these data is again the
                                50
                                      1999  2000    2001    2002    2003
       percentage of reports not received. In 2001 36% of districts had not provided the information. In 2002
                                                    Years

       only 4% of districts had not provided data.


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          A If one considers a finding of a study (recent study (Reyburn et al, 2004) found which stated that
          “....in Tanzania, malaria is commonly over-diagnosed in people people presenting with severe febrile
          illness, especially in those living in areas with low to moderate transmission and in adults. This is
          associated with a failure to treat alternative causes of severe infection. Diagnosis needs to be improved
          and syndromic treatment considered. Routine hospital data may overestimate mortality from malaria by
          over twofold”.

          Table



          Figure 155: % of under-5s with malaria attack/fever
          getting appropriate treatment within 24h of onset

                                                                            2001          2003
                                                       Correct action        11            27
                                                       Wrong action          37            38
                                                           No action         52            35

             Mwita, A., 2005

          In spite of improvements between 2001 and 2003, still more than 70% of actions are not correct. This
          might indicate a possible tip of the iceberg, as there are obviously major problems in the quality of
          diagnosis in Tanzania and subsequently the problems with the quality of care. the figures mentioned
          above become quite meaningless.

          The importance to address quality of care has been shown in the context of the Integrated Management
          of Childhood Illness, where the impact of adequately trained health workers on the observed quality of
          care of under-5s could be demonstrated in rural Tanzania (Armstrong Schellenberg et al, 2004).




  6.3.5. Total government public allocation to health per capita and Total government & donor                                                      Formatted: Bullets and Numbering
         (budget and off-budget) allocation to health per capita and relation to total budget

          Table 16: GoT allocation to health

            Financial Year                                                 2001/02        2002/03       2003/04       2004/05        2005/06
            Total government public allocation to health per
            capita                                                           3’363          4’487         5’078         4’631          5’478
            (Council and MoH Headquarters in Thsh)

            Total government and donor (budget and off-budget)
            allocation to health per capita-National Health budget
                                                                             4’896          6’573         8’316         8’998         12’727
            in Tshhs
            Health in relation to the total GoT excluding debt and
            interest payments = the ‘discretionary budget’
                                                                               8%           8.7%          8.9%          8.5%           8.7%
          MoF in Health Sector PER Updates FY 04/05                                                             1 US$ = 1’100 TSh (needs to
be checked)


          There have been obvious improvements of the funding basis and the sector has both in nominal and real
          terms of , although there is widespread criticism that the increases beyond 2003/04 are due to an
          increase in “off-budget” aid. its share of the overall discretionary budget in FY04 and FY05. This is
          largely but not exclusively driven by external funding. However, the Sector is currently (and probably
          will be) challenged by existing demands and new demands, as it is becoming increasingly more costly to
          provide health care - new vaccines, more expensive and effective anti-malarials, essential commodities
          and scaling up cost effective interventions (including routine immunisation, VCT, ITNs, IMCI).

          On the positive sideHowever , the allocation within the sector has seemingly seen recent improvements
          with a constant increase the proportion of resources allocated to peripheral levels. A needs based
          resource allocation formula that is being applied to both GoT Health Block grants and District basket
          resources, covering both Personal Emoluments (PE) and other charges. This formula was developed to


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       ensure a more equitable distribution of resources at the district level. The formula has 4 components that
       are used in the allocation of resources to the districts: Population (70%), Mileage (10%), Poverty level
       (10%) and Under-5 mortality (10%).




       It is also widely appreciated that recently stringent criteria have been introduced to
       improve allocation mechanism and gear resources towards districts in special need
       (rural, isolated, poor populations)

6.3.6. Proportion of public health facilities in a good state of repair                                                                                                     Formatted: Bullets and Numbering

                                                   Table 17: State of public health facilities

                                                       Year measured                               2003                                         2003
                                                       Indicator/Value                      80% of Hospitals                               For ex. 51% of
                                                                                          70% of Health Centres                        dispensaries requiring
                                                                                            55% of Hospitals                                an upgrade
                                                       Source and year reported           Makundi et al., 2005                        3 Regions Health Study,
                                                                                                                                      2004
                                                       Validity for health status in                    10 districts                      Mara, Mtwara and
                                                       population measured                                                                     Tabora
                                                       Representative for                                                               +With limitationsNot
                                                                                                With limitations +
                                                       Tanzania                                                                              necessarily


       Although there have been improvements the infrastructure is far from being in a good state of repair and
       will continuous capital investment. 81 % of hospitals, 75% of health centres and 55% of dispensaries
       were reported to be in a good state of repair. In terms of equipment aA study in Mara, Mtwara and
       Tabora three regions revealed partly very poor levels of equipment at dispensary level (Three Regions
       Health Study, 2004)include reference).



6.3.7. Percentage of public health facilities without any stock out of 4 tracer drugs and 1                                                                                 Formatted: Bullets and Numbering

                                                  25



                                                                                         21.1
                                                  20
              Mean proportion of stock out days




                                                                                         Amoxycilline




                                                  15                                                                            15.4




                                                                                                                                                             10.7   11.05
                                                          10.5
                                                  10

                                                          8.09                                           Egometrine
                                                          6.98                           6.6                                    6.6
                                                                                         6.16                                                                6.4      6.4
                                                                                                                                                                     5.89
                                                  5                                                                                                          5.1
                                                                                                                                3.95
                                                                                                                       PPF



                                                  0
                                                  1999                            2000                                   2001                         2002          2003
                                                                                                                         Year

       vaccine


                                                   Figure 46: Stockouts of drugs


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                                                      25



                                                                            21.1
                                                      20
                  Mean proportion of stock out days




                                                                            Amoxycilline




                                                      15                                                         15.4




                                                                                                                               10.7   11.05
                                                             10.5
                                                      10

                                                             8.09                          Egometrine
                                                             6.98           6.6                                  6.6
                                                                            6.16                                               6.4      6.4
                                                                                                                                       5.89
                                                      5                                                                        5.1
                                                                                                                 3.95
                                                                                                        PPF



                                                      0
                                                      1999           2000                                 2001          2002          2003
                                                                                                          Year



              Makundi et al, 2005: Assessing Trends in the overall performance of the health sector in Tanzania


        There have been improvements at the national level, but Iin spite of the improvements of the drugs
        supply chain, there are still frequent stock outs of vital drugs. For example Amoxycilline had an average
        of more than 140 stock out days/month in each year over the past four years. Strangely there are also
        stock out days for Ergometrine – a key drug to prevent post-partum haemorrhage. This is difficult to
        explain, as the number of assisted deliveries is low and the drug as such has not much commercial value.
        The situation is very similar both at the health centre as well as at the dispensary level. Although the
        stock out can be explained by the kit system, it is surprising that seemingly no in-depth
        analysisaction/correction of the drug supply system has taken place to correct this situation.

        It can be reasonably anticipated that the ongoing change to an indent system will improve the situation,
        although a careful monitoring of drug utilisation in relation to morbidity seen will have to take place to
        avoid similar experiences.




                                                                                                                                                 Formatted: Bullets and Numbering
6.3. 6.4. People’s perception of public health care services


        As stated above, the per capita utilisation seems to have increased in the past years. In Morogoro region
        the increase in under 5 consultations is impressive (include reference). It has increased to more than four
        contacts per year – even excluding preventive contacts. This is high and needs further exploration as it
        might indicate serious health problems. On the other hand it is This can be interpreted as such also an
        expression of trust of the population., even though people’s positive perception of health services is
        closely linked to the availability or non-availability of drugsApproval rates of facilities as recently
        determined by a study in ten districts (Makundi et al, 2005) are very high. A positive finding of this
        study is also that there is a very high awareness of the health sector reform programme. In this study,
        satisfaction with the quality of care was more than 90% of persons interviewed being more or less
        satisfied with services. This is an improvement compared to the Houshold Budget Survey of 2002,
        where only 68 % were satisfied. In both assessments, the most important criterion for people’s positive
        perception of health services is the availability or non-availability of drugs.


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         Surveys in rural Shinyanga and Kagera (Economic Development Initiatives, 2004) revealed also high
         satisfaction rates, with two thirds of users being satisfied with the quality of care which they obtained
         the health services.

         , but as the poor coverage in assisted deliveries indicates, people are quite conscious about their health
         seeking behaviour and subsequently selective in what type of health services they use. A recent report
         (Permanent Secretary, President’s Public Service Management, 2005) stated that the average Tanzanian
         civil servant makes 45% of his or her salary out of bribes. No specific reference to the health sector was
         made. However it is Oon this background it is not surprising that a recent numerous qualitative studiesy
         and papers (TzPPA, 2004; GMWG-MP, 2004; Schwerzel/REPOA, 2003; Women’s Dignity Project,
         2004; SDC, 2003) highlight indicated that the outright corruption is common in the health sector .
         comes second (after the police) for under the table payments.



6.5. Disparities and inequities (including gender imbalances) in accessing public health
care services

         Inequities of various kinds are still frequent and many examples can be found. It has to be noted though,
         that numerous policies, plans, guidelines and laws are in place to address inequities and disparities,
         although they are sometimes difficult to locate (Vargas-Barón, 2004).

  6.5.1. Poor – rich inequalitiesdisparities                                                                                                      Formatted: Bullets and Numbering



         Table 18: Economic inequities

           Year measured                                1999                           2000/2001                          2002
           Indicator/Value                   % of children under 5 who        Reason for not using             Child with fever receiving
                                             are severely stunted             health services:                 appropriate treatment:
                                             21.0 % for poorest quintile      8.4 % for poorest quintile       31% for poorest quintile
                                             7.1 % for richest quintile       4.5 % for richest quintile       62% for richest quintile

           Source and year reported          World Bank, HNP-Status           NBS HBS, 2002                    Armstrong Schellenberg et
                                             1999                                                              al, 2003
           Validity for health status in               Yes                                 Yes                 Yes
           population measured
           Representative for Tanzania                    Yes                              Yes                 NSS limitations


         The figures above are just examples, but highlight that Ssocio-economic differences are still linked to
         account for most of the inequality and inequityies in accessing health care have been demonstrated for a
         long time in Tanzania. The poorest quintile of Tanzanians has to spend 3.2% of their income on health,
         compared to 2.9% of the richest quintile (NBS HBS, 2002). This is phenomenon, which can be
         observed in expenditure for other basic services as well and goes in hand with These inequities have not
         yet been successfully addressed a growing income inequality in Tanzania (URT, Vice President’s
         Office, 2005).through the exemption schemes in place. However, even though the voucher system does
         not work in ensuring the poor access to health in general terms, the voucher system is working fine in
         the context of ITN-distribution. … reference to be added!




6.5.2.
                                                                                                                                                  Formatted: Bullets and Numbering




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Gender inequalities


         Table 19: Gender inequities

          Year measured                            2002                                2000/01                           2000/01
          Indicator/Gender/Value            % HIV-positive in 15-49         Illiteracy of adults living in   % of ill/injured age group 45-
                                                                                      rural areas            54 in 4wks prior to enquiry
                                               ♀                ♂               ♀                  ♂               ♀                ♂
                                            7.7 %       6.3 %                41 %                 24%          40 %                28 %
          Source and year reported        TACAIDS, 2004                   NBS HBS, 2002                      NBS HBS, 2002
          Validity for health status in            yes                              Yes                                 yes
          population measured
          Representative for Tanzania                  yes                              Yes                                yes

         The higher prevalence of HIV among females is among other factors a result of what the NACP (2004)
         described “females … at a disadvantage position when it comes to negotiating for sex”. Not surprising
         in this context is also the finding that consistent condom use varies by gender: in recent studies
         (TACAIDS/Healthscope/HCP, 2004; FHI, 2005) unmarried male respondents reported significantly
         more often that they always used a condom with their most recent sex partner, than women did.

         The high rate of illiteracy of rural women is not only an expression of gender inequity, but is also a
         contributing factor to poor health status of their children.

         Women are suffering from more morbidity than men at all ages, with the exception of the under-5,
         where boys have higher morbidity levels (NBS HBS,2002).

         The TzPPA (2004) found that acts of rape, domestic violence and gender-related abuse are frequent, but
         are commonly not well documented. Sexual and gender-based violence in general terms is wide spread,
         for example, but not only in the multiple refugee communities in Tanzania.

         In short, there is ample evidence about 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. (GMWG-MP, 2004; Blackden et
         al, 2004).

         Gender related inequalities are not widely recognized. However, there is multiple evidence for gender
         inequalities having an impact on health in Tanzania. Female Genital Mutilation is widespread and even
         though not according to law the practice to force pregnant girls out of school is frequent. Sexual and
         gender-based violence is wide spread, for example, but not only in the multiple refugee communities.
         The – presumably – very high MMR (see above) reflectsing at least in part the difficulties women have
         in accessing (preventive and curative) health care and is another is a shocking triking point in case.
         (include reference).


6.5.3.              Urban-rural inequalities                                                                                                    Formatted: Bullets and Numbering

         Table 20: Urban-rural inequities



          Year measured                           2000/01                            2000/01                          2000/01
          Indicator/Gender/Value            IM/CM/U-5M per 1’000            Distance to a hospital less         % of population using
                                                 Live births                       than 20 km                  improved drinking water
                                                                                                                       sources
                                             Urban             Rural        Urban         Rural                 Urban           Rural
                                           78/49/123         99/70/162    99% (DSM)       58%                    92               62
                                                                          90% (other)
          Source and year reported                Census 2002                  NBS HBS, 2002                        NBS HBS, 2002
          Validity for health status in               Yes                             Yes                                Yes
          population measured
          Representative for Tanzania                  Yes                              Yes                               Yes




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      Urban-rural Iinequalities are striking and well documented. The general trend is that indicators are
      worse in rural area than in urban environments. Improvements of health indicators, in particular
      IMR/CMR/U-5MR, have been better were better in urban areas in recent years (Census, 2002).
      y are in favour of the urban environment.
      However, little is known about intra-urban differentials, where – as experience from other countries
      indicates - the urban poor are sometimes even more disadvantaged than the rural population in general.
      For HIV the trend plays also in the opposite direction. HIV/AIDS is much more frequent in urban
      environments than in rural areas.




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7. Best practices/successes and future challenges

7.1. Best practices

         In this context only a selection of best practices can be presented. The criteria for inclusion here seem
         arbitrary, but are based on opinions and comments obtained from interviews with stakeholders.
         The. This listing is by no means exhaustive, but intends to but reflects only that numerous laudable
         initiatives in the health sector are going on in Tanzania.:

      7.1.1. Morbidity/Mortality related issues

                    Some vertical programmes, like the TB-programme have had a very positive impact and have                                     Formatted: Bullets and Numbering
                     become an international landmark of good practice in the field of TB-control.

                    IMCI has been successfully introduced in a number of districts and it could be shown that rapid                              Formatted: Bullets and Numbering
                     gains in the quality of case management and ultimately in terms of child survival can be
                     achieved. However the need to have had for this success the presence of a functional
                     decentralized health system and the use of practical health system planning tools has been
                     highlighted.

                    Not the most important problem at this point in time, but it is good practice of the GoT to have                             Formatted: Bullets and Numbering
                     climbed on the bandwagon of fighting tobacco. This will help not only to avoid that economic
                     growth evaporates in smoke but also will have a positive impact on the health status of the
                     Tanzanian population.

      7.1.2. Health Service Delivery area

                    As mentioned above, the burden of disease focussed planning has shown impact: Burden of                                      Formatted: Bullets and Numbering
                     disease based budget allocation has shown a rapid and positive impact in reducing infant and
                     under-5 mortality in the NSS districts. Allocation procedures are further refined by applying
                     additional criteria, such as distance and poverty indices in order to channel resources to the
                     districts, which are most in need.

                    The overall planning capacity of the various stakeholders in the regions and districts has                                   Formatted: Bullets and Numbering
                     improved, even though many are still in a learning process. The improved funding basis of the
                     health system has facilitated this process, because now decision makers in the district do not
                     just have the planning responsibility but also some resources to take over this implementation
                     responsibility.

                    Commitment of the GoT and the donor community has improved the funding basis of the                                          Formatted: Bullets and Numbering
                     health system. Coordination and collaboration between the various stakeholders is constructive
                     and provides the basis for further strengthening of the health sector.

      7.1.3. Equity

                    Unfortunately there are not many concrete results in terms of improving equity and reducing
                     disparities. However, it is a positive that numerous laws, regulations and guidelines are in place
                     to address equity issues. Combined with an increased awareness of the importance of equity the
                     foundation has been laid for improvements.
                                                                                                                                                 Formatted: Bullets and Numbering
      The overall planning capacity of the various stakeholders in the regions and districts has
      improved.

       The successful, albeit still slow scaling up of social marketing of ITN and the impact on                                                  Formatted: Bullets and Numbering
Malaria


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     Burden if disease focussed planning has shown impact: Burden of disease based budget                                                      Formatted: Bullets and Numbering
   allocation has shown a dramatic positive impact in reducing infant and under five mortality in
   the observed districts. Allocation procedures are further refined by applying additional criteria,
   such as distance and poverty indices in order to channel resources to the districts, which are
   most in need.

     Commitment of the GoT and SWAp of the donor community has improved the funding basis                                                      Formatted: Bullets and Numbering
   of the health system.

     Some vertical programmes, like the TB-programme have had a very positive impact and are                                                   Formatted: Bullets and Numbering
   international landmarks of good practice

      The successful introduction of iodised salt to fight goitre (include reference)                                                          Formatted: Bullets and Numbering


                                   Last but not least it is a good practice of the GoT to have climbed on the
                                   bandwagon of fighting




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7.2. Challenges

        Challenges are lying ahead in all areas mentioned above.: In the morbidity/mortality related issues,
        service delivery issues, and last but not least equity and the strive to reducetion of disparities will need
        to be addressed issues. All this will take place in the context of the general social and economic
        development of Tanzania, which is in itself a titanic an even larger challenge.

        7.2.1. Morbidity/Mortality related issues

                   Maternal, newborn and child health
                    ThiImproving s Maternal, newborn and child health is a huge challenge ahead. So far little
                    achievement to the respective MDGs has been achieved. This is difficult to understand as most
                    of the necessary interventions are known, comparatively cheap and thus most of the related
                    morbidity and mortality could be prevented. The issue of the nutritional status of children
                    needs special attention, although improving for example nutritional status changing the
                    situation is not only dependent on the performance of the health system, but on a positive
                    general development of Tanzania.

                   HIV/AIDS- and TB morbidity and mortality
                    WAlthough as the sero-prevalence study (NACP, 2004) has indicated the situation is not as bad
                    as it had be feared and without being too pessimistic the worst is probably still to come with
                    this epidemic. The care and treatment approaches still have to demonstrate that it works. It will
                    be important to maintain the high level of performance of the TB-control measures, as the
                    quality of life and the life expectancy of many HIV/AIDS patients can be easily improved. The
                    impact on increasing the number of HIV/AIDS orphans needs still to be evaluated and
                    appropriate interventions – which will go far beyond the health sector – will need to be
                    developed. .

                   MNCH and the big “3” contribute certainly most to the major burden of disease and require
                    utmost attention. However, typical neglected diseases like Lymphatic Filariasis,
                    Schistosomiasis and Trachoma because together with the further increasing non-communicable
                    diseases, not to forget traffic and occupational accidents will become possibly earlier expected
                    factors which influence the health status of Tanzanians.



        7.2.2. Health Service Delivery area

                   Human resource crisis
                    The scale and scope of the crisis is well known and need not to be presented here again. The
                    challenge is to translate this “knowledge”, not only into an “attitude” but also action that is
                    policy decisions and eventual financial commitments.

                   Vertical programmes:                                                                                                         Formatted: Bullets and Numbering
                    The influx of the funds in the context of treatment and care has started. It is widely perceived
                    as a risk that this massive influx of resources will have an impact on the “internal brain drain”
                    of already scarce human resources. Less funded programmes like maternal, newborn and child
                    health might loose attention.

                   Quality of care
                    Quality of care is closely linked to the human resource crisis, because staff insufficient in
                    numbers and qualification simply cannot deliver good quality of care. Quality of care has also
                    an economic dimension in the sense that poor quality wastes resources and harms eventually
                    the most important resource Tanzania has: its people.

                   To know what is actually going on.
                    A strengthening of the information systems is vital and has also been known for a long time.
                    Whilst it is certainly important to maintain existing routine information systems, it will be a

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                  challenge to keep the National Sentinel Sites functional in order to obtain the necessary
                  information for informed decision making. Apart from the routine and sentinel systems, there is
                  ample information and experience available in Tanzania. However, it is is sometimes difficult
                  to get hold of it. It will be a challenge to make all the information available for the informed
                  decision making.
                  It is widely acknowledged that relevant health information is frequently difficult to find and
                  often badly underutilised. A strengthened information management will become more
                  important with the major additional funding now available to the health sector, as the
                  disbursement will be even more than in the past linked to performance. To have reliable data
                  on the degree of target achievement will be crucial to secure continuation of funding.

            Vertical programmes:                                                                                                              Formatted: Bullets and Numbering
                The influx of the funds will only start. It is widely perceived as a risk that the massive influx
                will have an impact on the utilisation of human resources.

                 Governance in the health sector:
                  Good governance in the health sector is as important in the health sector as in any other sector.
                  Working in health sector should be done according to the highest professional standards and
                  the respect of rules and regulations. According to these neither corruption nor poor medical
                  practice have a place.

      7.2.3. Equity

                 To ensure equity in terms of (financial, geographic and cultural) access will be probably the
                  largest challenge as it is linked to the above mentioned points as well as to changes in culture
                  and attitude when it comes to a gender balanced development




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8. Suggestions and Recommendations


         The consultants jdo not claim to have a comprehensive oust had a overview of the health situation in
         Tanzania and therefore they would not dare to provide major recommendations, but rather
         suggestrecommend or – rather underline – a number of areas, which could receive particular attention.
         Most of them have have been proposed beforehand by others and by no means the list claim to be
         recommendations do not claim to be complete:

               o     HThe humanHuman resource crisis in the health sector will needs urgent attention and fast and
                     concerted action. It isThe human resource crisis – is an example a case in point 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 but in a variety of
                     governmental and non-governmental stakeholders.

               o     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 an impressive success.
                     However there are exist other some health problems, which are not fully capturovered by these
                     exercises, and which should not be neglected and should receive more attention:

                     o     Maternal mortality is probably the most neglected health problem in Tanzania.

                     o     With the objective to achieve a continuum of care an increased focus on Maternal,
                           Newborn and Child Health, including also adolescents is necessary. Although not as much
                           a social as a health problem, the issue of the increasing numbers of orphans should be
                           properly addressed.

                     o     In a narrow sense neglected diseases (Lymphatic Filariasis, Schistosomiasis, but also
                           Trachoma) should be and could be addressed.

                     o     In particular the issue of Lymphatic Filariasis should be closely followed, as there is a free
                           treatment available, and the potential economic impact on the population is important –
                           however also the cost to deliver. However, the positive side effect of de-worming of MDA
                           and its positive impact on anaemia – a wide spread syndrome which contributes to
                           morbidity and mortality – in Tanzania – cshould be considered as well.

                     o     Epidemiological transition is taking place in urban areas. The fact that there is seemingly a
                           bias towards the urban areas should not hide the problem of the urban poor. More research
                           into this issue would be helpful.
                     o     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 thatand efforts should
                           be strengthened to abolish these barriers.

        o “I know that I do not know”. This statement of Socrates exaggerates the situation in Tanzania.                                          Formatted: Bullets and Numbering
However, there is some Tanzanian reality in it, in the sense that there is a wealth of information available. H,
however, it is frequently difficult to find and often badly underutilisedsed.underused.

         oIt will be important to address the issue of strengthening further the capacities to use for information                                Formatted: Bullets and Numbering
for decision making.


         oSeemingly obvious, but Information management it will become more important with the major                                              Formatted: Bullets and Numbering
additional funding now available to the health sectorcoming in, whose disbursementich which will be heavilyvery
much linked to performance. Data on the degree of the target achievement will be crucial.



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          oCompile available information in a more structured way. The creation of a structure within MoH to                                      Formatted: Bullets and Numbering
collect all relevant information could alleviate this situation. A Health Information Centre, which would have the
remit to go beyond the classical information collection of a HMIS, HIS, but rather as a focal point for all
typessorts of studies and data related to health being collected or published in Tanzania.

         oIf another “State of Health Review” should be anticipated for the future, it is recommended to have it                                  Formatted: Bullets and Numbering
         timed fine- tuned with the availability of a major new inventory of health information, such as a DHS or
         Census.. In addition it is suggested recommended to continue to make more use of the NSS-sites, as
         these dwillo not only provide reliable data for informed decision making, but they could also be used to
         optimize existing and test experimental approaches




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9. Annexes



  9.1. Responses from National partners:




          Has there been an improvement of the health status of the Tanzanian population in general and adolescents in
          particular since 2001?

          Yes                                                                     No

          Generally,                                                                There are some signs of deterioration due to                 Formatted: Bullets and Numbering
                                                                                  poor nutrition, especially in rural areas where life
                                                                                  is notably more difficult.
            Tanzanian looks healthier.                                                                                                           Formatted: Bullets and Numbering

            The health of the Tanzanians has improved, “in                           There are no remarkable changes in rural areas.
          comparison to previous years” and might be due to the
                                                                                    Marginalized sub population groups in rural
          - majority of people having access to health services                   areas are not healthier, as they still use local health
                                                                                  services- this leads to a high mortality.

          -existence of free services for those who cannot afford                                                                                Formatted: Bullets and Numbering
          health care                                                               Increased rates of adolescent pregnancy or HIV
                                                                                  infection pose a great threat to the health of the
                                                                                  people.
          -presence of Community Health Funds and exemption
          mechanisms
                                                                                    There are some negligible improvements of the
                                                                                  health status of the Tanzania population but
            There has been some improvement, mainly due to an                     MMR, IMR and HIV prevalence are especially
          increased level of education which promotes a change of                 high in rural areas.
          attitude towards the health status.

            There have been improvements as regards to

          -available services

          -seminars offered to people (e.g. education on HIV/AIDS
          for adolescents).

            In the urban setting some improvements can be seen.

            There is an improvement, due to the multi-sectoral
          collaboration practiced in Tanzania supporting the state
          of health of the Tanzanian population.

            There has been some improvement, for instance an

          -improved nutritional status of the general population




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        and an

        -increased awareness of health issues and an increased
        health seeking behavior can be seen.

         There has been an improvement in some areas, in
        particular in the urban setting.

          There is improvement, both in quantity and quality
        and there is more concern for the adolescent population
        group.

          There is an improvement, in some areas there has been
        an increase of

        -dispensaries, health centers and hospitals

        -doctors, AMOs, COs, nurses and HO

        -diseases treated due to improved diagnosis and patient
        management.

            - continued health education and media.




        Has there been an improvement in health service delivery for the population in general and adolescents in
        particular since 2001? Please explain

        Yes                                                                           No

        ● Definitely yes, there has been an increase of                                 Human resources are deteriorating at many
                                                                                      facilities.
        -drug supplies                                                                                                                         Formatted: Bullets and Numbering
                                                                                        High turn over of staff e.g. in Mwanza there
        -diagnostic services                                                          are 1-10 qualified staff, 50% of rural staff are
                                                                                      professionally unqualified.

        -access to services
                                                                                       DED just fill the gaps without increasing the
                                                                                      number of staff members.
        -facility rehabilitation
                                                                                        The handling of environmental aspects at
        -re-allocation of resources for all services and cost sharing–                rural area units is still questionable.
        the community responds to cost sharing.
                                                                                        Concerning mortality and burden of
          Preventive services such as immunization have improved                      diseases, not much improvement can be seen
        and curative services are good.                                               as we have a history of e.g. pregnant women,
                                                                                      no food, long distances, nobody caring and we
          There has been an increase in the number of dispensaries,                   remain unprotected.
        especially in rural areas.
                                                                                        Failure of some people to pay towards cost
          Number of staff (employment of nurses).                                     sharing.

                                                                                        The framework is weak and there are few



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            Transportation exists in some villages.                                   health care providers e.g. Medical Officers.

         Training of service providers particularly on FP, RH,                          The doctor- patient ratio is still
        SMI.                                                                          inappropriate.

          The increased number of health facilities has improved
        health service delivery.

         Women attend MCH services due to the presence of
        maternity waiting homes and hospital delivery wards.

            There is an improved referral system in some districts.




        In your opinion, what does the population think about the public health care system in Tanzania?

        Yes (positive)                                                                No (negative)

        ●     Number of facilities, OPD and patient attendance have                     There are complaints about treatment
                                                                                      (bribery, corruption, miss-management ).
              increased.
                                                                                        Public health care services in Tanzania are
                                                                                      corruptive, are burdened with too much
            Distance has decreased.                                                                                                            Formatted: Bullets and Numbering
                                                                                      bureaucracy and without money you don’t
                                                                                      receive services.
            Facilities have been repaired.
                                                                                        There is a shortage of staff in government
            People have the right to receive health services.                         facilities.

          Peoples faith in health services has increased as the                         Being told to buy drugs from outside/
        number of people attending public compared to private                         private pharmacies is discouraging for people.
        services has increased and people are less likely to seek
        health care in the traditional sector.

            Public health services have improved.

            Customers care and are satisfied.




        Do you believe that there have been changes for the better or worse in equity and / or gender balance
        necessitating public health services?

        Yes                                                                           No

        Changes are observed because                                                    Although we have a good policy and
                                                                                      strategy, what we talk about or what is
                                                                                      documented does not reflect what is actually
          Women access facilities more than men and if you are poor                                                                            Formatted: Bullets and Numbering
        you don’t necessarily die anymore.                                            been done in the field.


            There is a very good policy in place.                                       There is little change for the better in equity
                                                                                      and gender as the people’s perception on
                                                                                      gender is very low.
          Equity is observed more in public facilities as compared to
        private facilities which are more business oriented.
                                                                                        Women mortality is high, especially in rural



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          Equity and gender balance is observed in public health                      areas/villages.
        care services, especially for reproductive and child health.
                                                                                        Mission charges are high.
          Efforts have been observed to mainstream gender equity in
        existing public health care programs, reference are
        documented in form of standard guidelines, strategies and
        policy documents.




        Do you have any best practice/success, which comes to your mind regarding health status and health service
        delivery?

        Best practice/success                                                         Challenges

          Drugs improved                                                               Human resources are WORSE and hence                     Formatted: Bullets and Numbering
                                                                                      have an effect on the workforce (TB/HIV).
          Essential supplies and equipment
                                                                                        Recruitment of a large number of staff
          Staff are decentralized                                                     without paying attention to qualified staff as
                                                                                      currently practiced by the councils.

          Decrease of maternal death

          Good coverage of vaccination, Vit. A, measles

          Decrease of number of deaths (e.g. malaria, cholera)

          Decrease of cases of active trachoma in epidemic area (due
        to mass campaign/treatment)

          Introduction of sexual and reproductive health education.

          ANC attendance

          DOTS in treatment of TB is a success story.

          Provision of bed nets to ANC is excellent.

          Cost sharing program accepted by the community.

          Equal distribution of funds.

          Decentralization is hoped to be translated to the people.

         Introduction of reforms and focused MTEF, strategic plan,
        POW.

          More funds for management services and rehabilitation.

          More people are reporting to health facilities.

          More specialists in almost all the fields.

          Development/presence of guidelines and standards for the




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           delivery of health services.

            Success in the implementation of Integrated Management
           Childhood Illness (IMCI) strategies in some districts.

            IEC/BCC interventions whereby majority are
           knowledgeable of family planning, HIV and Malaria.




Any other comments?

 Few initiatives of quality of care need to be expanded throughout the country                                                                    Formatted: Bullets and Numbering

 Increase community participation




PROPOSED RECOMMENDATIONS/SUGGESTIONS FROM THE FIELD

 Support/institutionalize public health teaching centers (colleges, universities, AMO training)                                                   Formatted: Bullets and Numbering

 Establish a functional system to replace dropouts (recruitments of skilled staff)

 Health education programs to the marginalized rural population

  Establish Programs/mechanisms to educate/inform policy makers on a regular basis about the health status progress
of the Tanzanian population, and in particular the state of health of the Tanzanian population should relate to
preventive measures and the Millennium Development Goals (MDGs) which focus on public health reduction of
MMR, IMR.

  Government and community to solicit an appropriate approach which will ensure the social health insurance fund is
benefiting the people. Findings indicate that SHIF does not help the poorer/workers and their families as in most cases
patients use their own funds to receive/get medicine. In addition, it has been reported that there is no transparent, or
justifiable criteria on the type of medicine which will be given to members (prescribed drugs are not available for use
and instead, patients buy medicine at the nearest pharmacy), otherwise, NHIF should widen or include other services
(schools, income generating activities and the like).

  The population increase should be functional for a better health of all Tanzanians. Experts should develop/design
appropriate mechanisms to improve services (education, infrastructure, and the like).

  Employment of trained health providers was proposed to be coordinated by the MoH to avoid filling the job with
anyone who applies for the job (“favoritism”) instead of employing qualified staff. Correspondingly, improve ratio of
doctors to patients – refine recruitment policy (MoH produce staff, set minimum staffing levels, PO-LARG do the
rest).
 Include ARVs in NHIF

  Improve work environment of health, including better salaries and other benefits, (may reduce corruption including
bribery).

 Continued training on health status for Tanzanians at different levels (Facility, community).

 Use of media, mass campaigns to improve health of the Tanzanian population.




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  Community as a key stakeholder to improve state of health by planning/initiation of sustained/innovative programs
that will support their lives.

 It has been proposed that the state of health for the Tanzanian population should be looked at at three levels

 Individual - behavior is a changing agent

 outside the health sector – community is a changing agent

  sector specific – provision of preventive measures and services are important factors and hence measuring the state
of health is a compounding approach, for instance, when we look at chronic stunting, (why reflecting as an indication
of health sector?) mortality has several factors embodied, so many other sectors are involved.

  In brief: So many things depend on education, community, (geographical disparities) and therefore multi-
disciplinary efforts are needed. The question is how?




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9.2. Responses of international partners (bilateral, multilateral and int.
NGOs):



     Has there been an improvement of the health status of the Tanzanian population in general and adolescents in
     particular since 2001? (Responses from multiple stakeholders)

     Yes                                     No                                                              Don’ know

        Yes there has been.                    Although there are indications that                             Yes and no, a mixed               Formatted: Bullets and Numbering
                                             improvements have been made in some areas, less                 picture can be seen.
       Yes, there seems to be an             improvements have been made in other areas as
     overall improvement. IMR is             indicated by the MMR. Some agencies seem to                       Interpretation of the
     going down.                             have an interest to keep figures high.                          MMR is difficult, as
                                                                                                             there are many
       C-section rate has                      There has not really been an improvement.                     contradicting figures.
     increased in Tanga, but                 However, it is difficult to come up with a final
     hasn’t reached the expected             statement as reliable, nationwide figures are                     There are also doubts
     rate by far.                            available.                                                      whether there is a real
                                                                                                             stabilization of the HIV-
       Immunisable diseases are                No, people are not healthier.                                 endemic, as the data
     going down.                                                                                             from 2004 provides the
                                               Despite of a decrease of immunisable diseases,                first really reliable
                                             the fear exists that stunting of children will                  figures.
        Health has improved a
     little bit.                             increase.
                                                                                                              MMR figures are
                                               There is still a predominance of communicable                 unknown.
       There is more demand
     from the people, reflecting             diseases, but epidemiological transition is already
     that health awareness of the            taking place.                                                     For example MMR
     population has increased.                                                                               figures are unknown.
                                               Epidemiological transition is taking place with               However at a national
                                             an increased prevalence of non-communicable                     level, the % of assisted
       Immunisable disease                                                                                   deliveries is going down,
     prevalence has gone down.               diseases such as hypertension, diabetes, but the
                                             same trend can also be seen for cancers and traffic             which may indicate a
                                             accidents.                                                      high MMR.


                                               People used to be healthier in the late 60s and
                                             early 70s.

                                               Health status has not improved dramatically, in
                                             particular there is a considerable backlog of
                                             pregnancy related morbidity (fistulae).

                                              Not much has changed. Childhood malaria and
                                             maternal mortality are still rampant.

     Has there been an improvement in health service delivery for the population in general and adolescents in
     particular since 2001? Please explain

     Yes                                                                   No




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   Drugs are now widely available in health facilities.                    There have been frequent stock outs of
                                                                         contraceptives.
      The decentralisation process is successful.                                                                                              Formatted: Bullets and Numbering
                                                                            Staffing is a huge problem.
    The situation is improving. The financial
   management used to be weak, but has improved.                            HMIS is not working well.

     The decentralisation process is successful, even if                   There is no interest of the MoH to provide good
   regions and districts are still involved in the learning              and reliable data.
   process.
                                                                           The health sector is one of the most corrupt sectors
    Better services are provided, in particular there are                in Tanzania.
   more drugs available.
                                                                           Logistics are still poor, and in particular the MSD
      Services have clearly improved.                                    is often not able to deliver in a timely manner.

     Funding of the health sector has dramatically                         The Three Regions Study has highlighted severe
   improved.                                                             shortcomings.

      Planning capacities have become much better.                         Infrastructure improvements are catching up very
                                                                         slowly.
     Decentralisation, although not yet finished, is
   successfully developing.                                                The internal brain drain (towards NGOs and
                                                                         international organizations in Tanzania) is
     There seems to be a higher patient orientation than                 increasing.
   before.
                                                                           The Human Resource crisis is a big problem.
      The vaccination coverage has gone up.                              However, it is rather a problem of
                                                                         insufficient/inappropriate recruitment procedures
                                                                         than a problem of the availability of staff.
      Yes, vaccination coverage has gone up.
                                                                           Corruption is widespread. Up to 45% of an
      Availability of drugs.                                             average civil servant’s salary stem from bribery.
                                                                         Probably this is also the case for the health sector.
      Financial resources exist.
                                                                            Reproductive health services have become worse.
     Hospitals tend to be better off than first line
   facilities.                                                             No funding has been available for RH commodities
                                                                         and training for quite some time.




   In your opinion, what does the population think about the public health care system in Tanzania?

   Yes (positive)                                                         No (negative)

     Tanzanians do not complain. However, the                               The rather negative public opinion on health                       Formatted: Bullets and Numbering
   community pharmacies in general and the availability                   services has not really changed.
                                                                                                                                               Formatted: Bullets and Numbering
   of drugs have contributed to a general satisfaction with
   health services.                                                         Studies show that the population is generally not
                                                                          very happy with services they receive.
     Difficult to comment on as a foreigner. However, one
   has the impression that people today have a “brighter”                   Services are generally “youth-unfriendly”, despite
   look on their face, if one visits many health facilities.              a good youth policy being in place.
   The widespread availability of drugs has certainly
   helped.
                                                                            Health workers’ attitudes are an important




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                                                                          barrier for the access to health services.

                                                                            The general attitude is pretty bad. People make a
                                                                          difference between the “orange uniform” staff,
                                                                          which is rather unfriendly and “white uniform”
                                                                          staff, which tends to have a better reputation.

                                                                            People know that they do not get good services in
                                                                          first line facilities and therefore directly go – if they
                                                                          can afford it – to the hospital level.




   Do you believe that there have been changes for the better or worse in equity and / or gender balance
   necessitating public health services?

   Yes                                                                    No

      User fees are not really a barrier to services.                       There have been no changes – for the worse or the                  Formatted: Bullets and Numbering
                                                                          better - in equity.
     It is very positive that funding allocation criteria
   nowadays includes poverty criteria Exemption                             There are still financial barriers, limiting access of
   schemes/policies have been elaborated.                                 the poor.

      User fees as such are not a problem.                                  Urban areas are still privileged compared to rural
                                                                          areas.

                                                                           Health worker’s attitudes are an important
                                                                          barrier determining access health services.

                                                                            No improvements are noted, although efforts have
                                                                          been undertaken.

                                                                           No improvements. Basically it is still “no money,
                                                                          no care”.

                                                                            Although exemption schemes etc. have been
                                                                          elaborated, they are not implemented.

                                                                           There are doubts if the most vulnerable
                                                                          population groups are reached.

                                                                           Equity has not improved, might even have become
                                                                          worse. Factors, which have not been addressed, are:
                                                                          Providers’ attitude, cost and distance.

                                                                            Inequity is still a reality mainly in terms of urban-
                                                                          rural differences.

                                                                            Does not have documented experience, but is
                                                                          convinced that there is a negative gender bias in the
                                                                          context of STI –treatment.

                                                                            It is always difficult to probe equity if the basic



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                                                                          package of health care services is not available.

                                                                            Access in geographical terms is still an issue, as
                                                                          transport costs are high and therefore limit
                                                                          accessibility.




   Do you have any best practice/success and future challenges, which come to your mind regarding health status
   and health service delivery?

   Best practice/success                                                     Challenges

      Drug supply has improved.                                                Human Resource Crisis                                           Formatted: Bullets and Numbering

     New allocation formula to allocate resources to the                       CMS is still a headache
   districts is remarkable as it also considers the poverty
   dimension.                                                                  The “big” diseases, like HIV/AIDS, Malaria
                                                                             and Tuberculosis
      Most hospital services have improved.
                                                                               Quality of care
     Reproductive health has widened up, and is not limited
   anymore to family planning alone.                                           Vertical programmes, in particular the
                                                                             GFATM, might hamper progress, as for example
      Private sector inclusion is positive.                                  through the internal brain drain.

      Equipment in some facilities has improved.                               Safety at the workplace is an issue.

      Scaling up of IMCI                                                       Concerning patient handling there is room for
                                                                             improvement. For example the ethics of
      Private-public partnership                                             professional councils are not respected.


      Decentralisation                                                        Motivation in general, and payment in
                                                                             particular of staff is a big problem.

     Planning capacities of the health system exist at all
   levels.                                                                     Human resources recruitment policies are
                                                                             insufficient.

     National Health Insurance Fund and accreditations
   schemes go with it.                                                         The absorption capacities of the system are
                                                                             limited.

      NTLP
                                                                               Outreach services have gone down.

     The national Malaria programme in general and ITNs
   in particular are quite a success.                                          Lack of understanding of TBAs and traditional
                                                                             healers.

     Health Sector Strategy is pointing into the right
   direction.                                                                  The data management capacities, be it a Health
                                                                             Management information system or a Health
                                                                             information system are weak.
      Prioritization is comparatively well done.
                                                                               Even available information is not appropriately
    Donor coordination (at least bilateral agencies                          used.
   participating in the basket) has been exceptionally good.
                                                                               The average civil servant currently earns
      Immunization coverage is very good.                                    126$/month, which is 11% more than in 2003.

      If HIV/AIDS prevalence is really about 7%, this is good                  There is no clear Human Resource development


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   news and might be associated with awareness campaigns.                    strategy in place.

      Awareness of condoms has increased dramatically.                         Problems exist related to good governance.

     N° of medical training facilities has increased (today                    Health Financing
   there are five, compared to one a few years ago). Zonal
   training.                                                                   There has been no real general success and
                                                                             progress has been rather slow and patchy. There
     IDD, the prevalence of goitre has gone down                             are some advances, some standstills, and
   dramatically.                                                             sometimes even drop backs. For example the
                                                                             MSD has seen better days.
      Vitamin A distribution has increased dramatically.
                                                                               The vertical and extensive HIV/AIDS funding
      Integrated Mother and Child Health interventions.                      might be a threat for general health sector
                                                                             performance.

     Even though salaries currently only reach 84% of the
   target, this is quite extraordinary in the regional context.               For the time being only 5% of the population
                                                                             have subscribed to the CHF.

     For many technical aspects, there are clear policies in
   place.                                                                      More leadership at MoH-level is required, the
                                                                             health sector is too much donor-driven.

     Community based distribution of condoms has been
   increased and is a success story.                                           The economic situation of Tanzania and the
                                                                             resulting poverty is a major challenge.

      Coordination between GoT and donors is quite good.
                                                                               Adequate monitoring systems, such as
                                                                             Demographic Surveillance Systems need to be in
      Decentralisation is on track.                                          place.

     Human resource categories have been reduced from 38                       Health financing in general and in particular
   to 13, which indicates the right direction has been taken                 waivers/vouchers/exemptions schemes really need
   towards a more rational human resource policy.                            to work.

      Community awareness on health issues has risen.                          Health facility management still needs support
                                                                             and both regional and district level might have
      Councils have been committed so far.                                   difficulty to provide the necessary support.


      More budget is available.

    Voluntary counselling and treatment is working quite
   well.




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      Any other comments?
                                                                                                                                               Formatted: Bullets and Numbering
          Next State of Health Review should be better coordinated with DHS
          “Do not get impatient, change takes time!”
         The sustainability question has to be raised, even in times of abundance
         Once corruption is established , it gets very expensive to get rid of it
         Three issues need to be addressed: access, accountability and quality of care
         Health cannot be regarded in an isolated way, it is part of a wider picture
         Sharing information is still a crucial issue
        The notion that not everything related to health is the responsibility of the MoH
      and that
                                         working across boarders is important still has to gain
      momentum




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      9.13. Documents consulted


                 AMMP/URT/DFID/University of Newcastle Upon Tyne, The Policy Implications of Tanzania's Mortality                             Formatted: Bullets and Numbering
                  Burden, Vol 2, Collected Publications and Reports, June 2004
                 AMMP/URT/DFID/University of Newcastle Upon Tyne, The Policy Implications of Tanzania's Mortality
                  Burden, Vol 4, Mortality Burden Profiles from Sentinel Sites, 1994 -2002, June 2004
                 AMREF, Community-centred lifeskills education. Programme to promote sexual and reproductive health
                  among out of school youth. January 2003
                 Anand, S.; Baernighausen, T.; Human Resources and Health Outcomes.. Joint Learning Initiative.
                  December 2003
                 Armstrong Schellenberg J.R.M et al Effectiveness and cost of facility based Integrated Management of                         Formatted: Bullets and Numbering
                  Childhood Illness in Tanzania..; The Lancet Vol 364, October 30, 2004
                 Armstrong Schellenberg J.; Bryce, J.; de Savigny, D.; Lambrechts, Th.; Mbuya, C.; Mgalula, L.;
                  Wilczynska, K.; The effect of Integrated Management of Childhood Illness on observed quality of care of
                  under-fives in rural Tanzania. Health Policy and Planning (19)1, 2004
                 Armstrong Schellenberg, J. et al.; Inequities among the very poor: Health care for children in rural                         Formatted: Bullets and Numbering
                  southern Tanzania. The Lancet. Vol 361 February 15, 2003
                 Armstrong Schellenberg J.R.M et al Effectiveness and cost of facility based Integrated Management of                         Formatted: Bullets and Numbering
                  Childhood Illness in Tanzania..; The Lancet Vol 364, October 30, 2004Babalola S. SURVEY ON
                  SEXUAL ATTITUDES AND BEHAVIORS AMONG TANZANIAN YOUTH: BASELINE
                  ASSESSMENT IN FIVE REGIONS – MARCH 2004.
                                                                                                                                               Formatted: Bullets and Numbering
                  Bureau of Statistics Census Data: IMR/CMR/U5MR, National Census 2002, Dec 2004
                  Bureau of Statistics Planning Commission Demographic Health Survey 1996, 1997                                                Formatted: Bullets and Numbering
                  Bureau of Statistics Tanzania Reproductive and Child Health Survey 1999, November 2000
                 de Savigny D. et al., Fixing Health Systems. IDRC, 2004
                 Dewji, I.; Literature Review of Tanzanian Specific Literature on Maternal Mortality and Morbidity; Care
                  International in Tanzania, , 31 January 2005
                 DHS Secretariat, Health, Nutrition, Population and Poverty Statistics, Tanzania 2000, 2003
                 Economic Development Initiatives; Rural Shinyanga CWIQ. Baseline survey on poverty, welfare and
                  services in rural Shinyanga Districts.. August 2004
                 Economic Development Initiatives Rural Kagera CWIQ. Baseline survey on poverty, welfare and
                  services in rural Kagera Districts.. April 2004
                 ETC Crystal; Equity Implications of health sector user fees in Tanzania. Do we retain the user fee or do
                  we set the user f(r)ee? Analysis of the literature and stakeholder views... July 2004
                 ETC Crystal, Equity Implications of Health Sector User Fees in Tanzania, commissioned by REPOA,
                  May 2004
                 Gender Macro Working Group Analysis of Gender Issues from the ALAT consultative meetings at
                  regional, district and village levels. A consultancy report to TRACE, September 2004
                 Goodman et al; Retail supply of malaria-related drugs in rural Tanzania: risks and opportunities. Tropical
                  Medicine and International Health., Volume 9, N°6 pp655-663, June 2004
                 GTZ Repro Project, Risk sexual behaviour, KAP among youths at Kichangani Ward, Tanga District,
                  Tanzania, 2002
                 GMWG-MP- PRS II Review from a Gender Perspective, Gender Mainstreaming Working Group-Macro
                  Policies
                 Gwatkin D. R., et al. Socio-Economic Differences in Health, Nutrition and Population in Tanzania. The
                  World Bank HNP Thematic Group; May 2000
                 HERA, Technical Review of Health Services delivery at district level, Draft Report, March 2004
                 HERA, Technical Review of Health Services delivery at district level, Final Report, March 2003
                 IHRDC; Burden of Disease Profile 2002, Kilombero and Ulanga District, 2002 McKinsey;Tanzania
                  Human Resources for Health, July 2004,
                 Jagoe K., et al; Tobacco smoking in Tanzania, East Africa: population based smoking prevalence using
                  expired alveolar carbon monoxide as a validation tool; Tobacco Control 2002;11:210-214; 2002
                 Khan M. M. et al Partners for Health Reformplus; Geographic Aspects of Poverty and Health in
                  Tanzania: Does living in a poor area matter?, October 2003
                 Kimberly Smith, Abt Associates, Inc. G. Larsen; Evaluation of GAVI Immunization Services Support
                  Funding. Case Study: Tanzania;, June 2004
                 Kraut, A.; Nyenga, M.;Mvumilwa Augustino, M.; Schuemer, C.; Summary of the follow-up reproductive
                  health needs assessment in the process of evaluating a CBD programme in Lushoto Division, Lushoto
                  District. Tanzanian-German Programme to support health, April 2004
                 Lungo H. Health information systems Project Tanzania. Development of the District Health Information
                  Systems. University of Dar es salaam. 2003 (?)


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                 Makundi E.A., Hiza, P.; Kiszinza, W.; Mwisongo, A.;Mcharo, J.; Senkoro, K.; Mubyazi, G.; Malebo, H.;                         Formatted: Bullets and Numbering
                  Magesa, S.; Munga, M.; Kamugisha, M.; Rubona J.; Kwesi, E.; Mdoe, R.; Kalinga, R.; Simba, D.;
                  Malecela, M.; Kitua, A.Y.: Assessing Trends in the overall performance of the health sector in Tanzania,
                  2005
                 Makundi et al. NIMR, Assessment of burden of disability in Tanzania: Findings from situation analysis,                       Formatted: Bullets and Numbering
                  September 2004
                 Malecela-Lazaro M., Overview of the Tanzania Lymphatic Filariasis Elimination Programme,                                     Formatted: Bullets and Numbering
                  2004
                 MEASURE Tanzania Reproductive and Child Health Facility Survey, National Bureau of Statistics,                               Formatted: Bullets and Numbering
                  Tanzania and Evaluation, 1999
                 Medical Service Corporation International (MSCI); THE THREE REGIONS HEALTH STUDY                                             Formatted: Bullets and Numbering
                  (MARA, MTWARA, AND TABORA) Part I and II,
                 Molyneux D. H.; Nantulya V.M, Linking disease control programmes in rural Africa: a pro-poor strategy                        Formatted: Bullets and Numbering
                  to reach Abuja targets and millennium development goals. BMJ;328:1129-1132 (8 May), 2004
                 Msambichaka, L.A., Mjema, G., D., Mushi, D.P Assessment of the impact of exemptions and waivers on
                  Cost Sharing Revenue collection in Public Health Services,., August 2003
                 Muhondwa, E.; THE STATE OF HEALTH IN TANZANIA, 2001 March 2002
                                                                                                                                               Formatted: Bullets and Numbering
                 Mwita, A., Malaria treatment, when to change policy and cost implications; A Presentation made to HSR
                                                                                                                                               Formatted: Bullets and Numbering
                  Preparatory Meeting 15-17th March, 2005
                 NACP; HIV/AIDS/STI Surveillance Report, January – December 2003, Report Number 18, Ministry of
                  Health, , October 2004
                 NACP; National AIDS control programme, Behavioural Surveillance Surveys Among Youths, 2002,
                  Ministry of Health, March 2004
                 NBS; Census Data: IMR/CMR/U5MR, National Census 2002, Dec 2004                                                               Formatted: Bullets and Numbering
                 NBS; Planning Commission Demographic Health Survey 1996, 1997
                 NBS (National Bureau of Statistics) Tanzania Reproductive and Child Health Survey 1999, November
                  2000
                 NBS, Household Budget Survey FY01, July 2002                                                                                 Formatted: Bullets and Numbering
                 NBS/Macro International, Tanzania Demographic and Health Survey 1992, 1992
                 NBS/Macro International, Tanzania Demographic and Health Survey 1996, 1996,
                 NBS/Macro International Tanzania Reproductive and Child Health Survey 1999, 1999
                 NBS/Macro Group, Tanzania Reproductive and Child Health Facility Survey 1999, NBS/Macro
                  International 1999 HIV/AIDS Indicator Survey, Executive Summary, 2005
                 OECD/World Health Organization. Poverty and Health; DAC-Guidelines and Reference Series, 2003
                 Olsen, Ø.E.; Ndeki, S.; Norheim, O.F.; Complicated deliveries, critical care and quality in emergency
                  obstetric care in Northern Tanzania. International Journal of Gynecology and Obstetrics (2004), 87, 98 –
                  108; 2004
                 PORALG Report of the Meeting of High level decision makers from the MoH and the President’s office
                  regional Administration and local Government . 20 August 2004
                 REPOA, Policy and Service Satisfaction Survey, Main Survey Results, Oct 2003
                 Reyburn, H., et al.; Overdiagnosis of malaria in patients with severe febrile illness in Tanzania: a
                  prospective study, BMJ 2004; 329:1212; 20 November, 2004
                 RHMT/GTZ Repro Impact of school-based information in Lindi Region, , 1999
                 RMO report (in Kiswahili): JAHURI YA MUUNGANO WA TANZANIA: WIZARA YA AFYA.
                  RIPOTI YA HUDUMA ZA AFYA TANZANIA BARA 2003: Imetayarishwa na Sekretriat: Afya Makao
                  Makuu, Dar Es Salaam. September 2004
                 Rønsholt, F. et al. Results-Oriented Expenditure Management. Country Study – Tanzania. Overseas
                  Development Institute. March 2003
                 Smithson, P.; Health in Tanzania. What has changed, what hasn't, and why?, Commissioned by DFID
                  (Tanzania), , January 2005
                 Salgado, R., Tanzania child Health Assessment: Will the child health millennium goals be achieved in
                  Tanzania?, BASICS, Draft, December 2004
                 SDC, Views of the Poor, May 2003
                 Semali, I.A.J; Understanding Stakeholders’ Roles in Health Sector Reform Process in Tanzania: The
                  Case of Decentralizing the Immunization Programme.., PhD Thesis University of Basel, 2003
                 TACAIDS; HIV-prevalence in Tanzania, 2004                                                                                    Formatted: Bullets and Numbering
                 TACAIDS/Healthscope/HCP Tanzania Youth Survey. March, 2004
                 Tanzania Social Action Fund (TASAF). Community Service Delivery Survey (CSDS) for
                  Morogoro Rural District. May 2002
                 The World Bank Tanzania Social Sector Review, November 1999                                                                  Formatted: Bullets and Numbering
                 The World Bank, Tanzania. A Country Status Report on Health and Poverty (Health, Nutrition, and
                  Population inputs for the PRSP and HIPC process), Draft version 2, January 2003



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                 The World Bank, Growth, Inequality and simulated poverty paths for Tanzania, 1992 -2002. World Bank
                  Policy Research Working Paper 3432, October 2004
                 The World Bank, HNP-Indicators Tanzania, 1999
                 TEHIP Brief N°1-N°5; Overview, District Burden of Disease Profile, District Health Accounts, Rural
                  Health Facility Rehabilitation, The district Integrated Management Cascade, 2000 – 2003
                 TGPSH, Situation Analysis of youth (health) centres in Tanzania, September 2004
                 UNICEF, Situation Analysis of Children in Tanzania, January 2002
                  URT, Health Statistics Abstract 2002, Vol II, Inventory Statistics, June 2002
                  HSR Secretariat; Tanzania Joint Annual Health Sector Review, 15th-17th of March 2004, Report of
                  proceedings, April 2004
                 UNICEF/WHO; Low Birthweight, Country, regional and global estimates; UNICEF, New York, 2004
                 UNAIDS/WHO, Epidemiological Fact Sheet on HIV/AIDS and sexually transmitted diseases. Update
                  2004, 2004
                 UNFPA and MoH, Tanzania Fistula Survey 2001, Women's Dignity Project , Aug 2002
                 Unwin, N., et al. Noncommunicable diseases in sub-Saharan Africa: Where do they feature in the health
                  research agenda?, Bulletin of the World Health Organization, 2001
                 URT, Health Sector PER Update FY2004, April 2004
                 URT, District Health Interventions Profile 2004, Tanzania Rural Coastal Districts, 2004
                 URT, Health Statistics Abstract 2002, Vol II, Inventory Statistics, June 2002                                                Formatted: Bullets and Numbering
                 URT; HSR Secretariat; Tanzania Joint Annual Health Sector Review, 15th-17th of March 2004, Report
                  of proceedings, April 2004
                 URT Health Statistics Abstract 2002, Vol I, Burden of Disease and Health Facility Utilisation Statistics, ,                  Formatted: Bullets and Numbering
                  June 2002
                 URT, Poverty Monitoring Secretariat, Indicators for Performance Assessment in the context of the
                  Tanzania Poverty Reduction Strategy, February 2003
                 URT, Second Health Sector Strategic Plan (HSSP), July 2003-June 2008, April 2003
                 URT, Second Health Sector Strategic Plan (HSSP), July 2003-June 2008, Vol II, Annexes, April 2003
                 URT, Burden of Disease Profile 2002, Coastal Zone, 2002
                 URT; MoH, Joint Health Sector Review. Sectoral Performance Indicators Update 2003.
                 URT, Ministry of Health, Health Information, Research and Statistics Section Health Statistics Abstract
                  1997,
                 URT, Ministry of Health, Health Information, Research and Statistics Section Health Statistics Abstract
                  1998,
                 URT; Ministry of Health. Commodity availability for selected health products: Baseline survey for                            Formatted: Bullets and Numbering
                  integrated logistics system; October 2003
                                                                                                                                               Formatted: Bullets and Numbering
                URT Ministry of Health, Health Information, Research and Statistics Section Health Statistics Abstract
                                                                                                                                               Formatted: Bullets and Numbering
                 1999, Volume 1 Morbidity and Mortality Statistics,
                URT, Ministry of Health, Health Information, Research and Statistics Section Health Statistics Abstract
                 1999, Volume 2, Inventory Statistics,
                URT; Permanent Secretary President’s Office Public Service Management. Quarterly Report, Oct-Dec
                 2004 and Mid-year Progress; Public Service Reform Programme; January 2005
                URT, Poverty Reduction Strategy, The Third Progress Report FY03, April 2004
            Women's Dignity Project; Poor people's experience of health services in Tanzania, 2004
            Women's Dignity Project; In their own words: poor women and health services, 2004
            Smithson, P.; Health in Tanzania. What has changed, what hasn't, and why?, Commissioned by DFID
                 (Tanzania), , January 2005
            Salgado, R., Tanzania child Health Assessment: Will the child health millennium goals be achieved in
                 Tanzania?, BASICS, Draft, December 2004
            Bureau of Statistics Census Data: IMR/CMR/U5MR, National Census 2002, Dec 2004
                URT; Vice President’s Office; National Strategy for Growth and Reduction of Poverty, , Jan 20045
            URT, Poverty Reduction Strategy, The Third Progress Report FY03, April 2004
                URT, R&AWG; Poverty and Human Development Report 2003, 2003
                URT; MoH, Health Information for decision-making: Reconciling systems and approaches. Report from                             Formatted: Bullets and Numbering
                 a workshop., 10 February 2004
                URT. Joint Ministry of health and president’s office. Regional Administration and Local Government;
                 Health Basket and Health Block Grants Guidelines for the disbursement of funds, preparation of
                 comprehensive council health plans, financial and technical reports by councils. 12 December 2003
                URT, R&AWG;, Poverty and Human Development Report 2002, 2002
                URT (2003). Ministry of Health: The first District Medical Officers Annual Meeting Report: Quality                            Formatted: Bullets and Numbering
                 Health Service Delivery in Tanzania: The District Focus. mMorogoro, Tanesco Conference Hall. June 9-
                 13, 2003
                URT; Ministry of Health (2004). Annual Reproductive and Child Health Report. Arusha AICC October
                 2004


Draft 100305----------------------------------------------------------------------------------------------------------------------------- 55
                                               State of Health in Tanzania 2004
            Draft discussion at the Health Sector Review meeting on 4 April 2005comment onlyFinal version 28 April 2005 100305




               URT, TzPPA; Vulnerability and Resilience to Poverty in Tanzania – Causes, Consequences and Policy
                Implications, 2002/2003 Tanzania Participatory Poverty Assessment (TZPPA), Main Report, 2004
               Vargas-Barón E., Country Support Team for ECD and HIV/AIDS; Policy Analyses and
                Recommendations on early childhood development and HIV/AIDS in Mainland Tanzania and Zanzibar,
                November 2004
               WHO/UNICEF/UNFPA; Maternal Mortality in 2000; WHO, 2004
               Women's Dignity Project, UNFPA and MOH, Tanzania Fistula Survey 2001, Women's Dignity Project,                                 Formatted: Bullets and Numbering
                Aug 2002.
               Women's Dignity Project; Poor people's experience of health services in Tanzania, 2004                                         Formatted: Bullets and Numbering
               Women's Dignity Project; In their own words: poor women and health services, 2004
                World Programme, Tanzania, strategic country gender assessement. 30 June 2004
            NBS, Household Budget Survey FY01, July 2002
            URT Health Statistics Abstract 2002, Vol I, Burden of Disease and Health Facility Utilisation Statistics, ,
                June 2002
            URT, Health Statistics Abstract 2002, Vol II, Inventory Statistics, June 2002
            HSR Secretariat; Tanzania Joint Annual Health Sector Review, 15th-17th of March 2004, Report of
                proceedings, April 2004
            URT, Second Health Sector Strategic Plan (HSSP), July 2003-June 2008, April 2003
            URT, Second Health Sector Strategic Plan (HSSP), July 2003-June 2008, Vol II, Annexes, April 2003
            URT, Burden of Disease Profile 2002, Coastal Zone, 2002
            IHRDC; Burden of Disease Profile 2002, Kilombero and Ulanga District, 2002
            URT, District Health Interventions Profile 2004, Tanzania Rural Coastal Districts, 2004
            DHS Secretariat, Health, Nutrition, Population and Poverty Statistics, Tanzania 2000, 2003
            McKinsey;Tanzania Human Resources for Health, July 2004,
            UNFPA and MoH, Tanzania Fistula Survey 2001, Women's Dignity Project , Aug 2002
            SDC, Views of the Poor, May 2003
            URT, TzPPA; Vulnerability and Resilience to Poverty in Tanzania – Causes, Consequences and Policy
                Implications, 2002/2003 Tanzania Participatory Poverty Assessment (TZPPA), Main Report, 2004
            ETC Crystal, Equity Implications of Health Sector User Fees in Tanzania, commissioned by REPOA, May
                2004
            Msambichaka, L.A., Mjema, G., D., Mushi, D.P Assessment of the impact of exemptions and waivers on
                Cost Sharing Revenue collection in Public Health Services,., August 2003
            NBS/Macro International, Tanzania Demographic and Health Survey 1992, 1992
            NBS/Macro International, Tanzania Demographic and Health Survey 1996, 1996,
            NBS/Macro International Tanzania Reproductive and Child Health Survey 1999, 1999
            NBS/Macro Group, Tanzania Reproductive and Child Health Facility Survey 1999, NBS/Macro
                International 1999 HIV/AIDS Indicator Survey, Executive Summary, 2005
            REPOA, Policy and Service Satisfaction Survey, Main Survey Results, Oct 2003
            AMMP/URT/DFID/University of Newcastle Upon Tyne, The Policy Implications of Tanzania's Mortality
                Burden, Vol 2, Collected Publications and Reports, June 2004
            AMMP/URT/DFID/University of Newcastle Upon Tyne, The Policy Implications of Tanzania's Mortality
                Burden, Vol 4, Mortality Burden Profiles from Sentinel Sites, 1994 -2002, June 2004
            URT, Health Sector PER Update FY2004, April 2004
            Ministry of Health, Health Information, Research and Statistics Section Health Statistics Abstract 1997,
            Ministry of Health, Health Information, Research and Statistics Section Health Statistics Abstract 1998,
            Ministry of Health, Health Information, Research and Statistics Section Health Statistics Abstract 1999,
                Volume 1 Morbidity and Mortality Statistics,
            Ministry of Health, Health Information, Research and Statistics Section Health Statistics Abstract 1999,
                Volume 2, Inventory Statistics,
            Makundi et al. NIMR, Assessment of burden of disability in Tanzania: Findings from situation analysis,
                September 2004
            MEASURE Tanzania Reproductive and Child Health Facility Survey, National Bureau of Statistics,
                Tanzania and Evaluation, 1999
            Bureau of Statistics Planning Commission Demographic Health Survey 1996, , 1997
            National Bureau of Statistics Tanzania Reproductive and Child Health Survey 1999, , November 2000
            The World Bank Tanzania Social Sector Review, , November 1999
            Ismat Dewji, I.; Literature Review of Tanzanian Specific Literature on Maternal Mortality and Morbidity;
                Care International in Tanzania, , 31 January 2005
            Emily Vargas-Barón E., Country Support Team for ECD and HIV/AIDS; Policy Analyses and
                Recommendations on early childhood development and HIV/AIDS in Mainland Tanzania and Zanzibar,
                November 2004
            HERA, Technical Review of Health Services delivery at district level, Draft Report, March 2004
            HERA, Technical Review of Health Services delivery at district level, Final Report, March 2003



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                                               State of Health in Tanzania 2004
            Draft discussion at the Health Sector Review meeting on 4 April 2005comment onlyFinal version 28 April 2005 100305




            Poverty Monitoring Secretariat, Indicators for Performance Assessment in the context of the Tanzania
                  Poverty Reduction Strategy, February 2003
            The World Bank, Tanzania. A Country Status Report on Health and Poverty (Health, Nutrition, and
                  Population inputs for the PRSP and HIPC process), Draft version 2, January 2003
            The World Bank, Growth, Inequality and simulated poverty paths for Tanzania, 1992 -2002. World Bank
                  Policy Research Working Paper 3432, October 2004
                 Youthnet/fhi Iringa Youth Behavior Survey. Preliminary findings., November 2004
                 Youthnet, Iringa Youth Behavior Survey – Findings and Report. February 2005                                                  Formatted: Bullets and Numbering
              National AIDS Control Programme; HIV/AIDS/STI Surveillance Report, January – December 2003, Report
                                                                                                                                               Formatted: Bullets and Numbering
            Number 18, Ministry of Health, , October 2004
              National AIDS control programme, Behavioural Surveillance Surveys Among Youths, 2002, Ministry of
            Health, March 2004
              UNICEF, Situation Analysis of Children in Tanzania, January 2002
              TEHIP Brief N°1-N°5; Overview, District Burden of Disease Profile, District Health Accounts, Rural Health
            Facility Rehabilitation, The district Integrated Management Cascade, 2000 – 2003
              D. de Savigny D. et al., Fixing Health Systems. IDRC, 2004
              Kraut, A.; Nyenga, M.;Mvumilwa Augustino, M.; Schuemer, C.; Summary of the follow-up reproductive
            health needs assessment in the process of evaluating a CBD programme in Lushoto Division, Lushoto District.
            Tanzanian-German Programme to support health, April 2004
              World Programme, Tanzania, strategic country gender assessement. 30 June 2004
              RHMT/GTZ Repro Impact of school-based information in Lindi Region, , 1999
              TGPSH, Situation Analysis of youth (health) centres in Tanzania, September 2004
              (GMWG-MP) PRS II Review from a Gender Perspective, Gender Mainstreaming Working Group-Macro
            Policies
              Permanent Secretary President’s Office Public Service Management. Quarterly Report, Oct-Dec 2004 and
            Mid-year Progress; Public Service Reform Programme; January 2005
              Gender Macro Working Group Analysis of Gender Issues from the ALAT consultative meetings at regional,
            district and village levels. A consultancy report to TRACE, September 2004
              GTZ Repro Project, Risk sexual behaviour, KAP among youths at Kichangani Ward, Tanga District,
            Tanzania, 2002
              AMREF, Community-centred lifeskills education. Programme to promote sexual and reproductive health
            among out of school youth. January 2003
              Youthnet, Iringa Youth Behavior Survey – Findings and Report. February 2005
              Goodman et al; Retail supply of malaria-related drugs in rural Tanzania: risks and opportunities. Tropical
            Medicine and International Health., Volume 9, N°6 pp655-663, June 2004
              Armstrong Schellenberg J.R.M et al Effectiveness and cost of facility based Integrated Management of
            Childhood Illness in Tanzania..; The Lancet Vol 364, October 30, 2004
              M. M. Khan et al Partners for Health Reformplus; Geographic Aspects of Poverty and Health in Tanzania:
            Does living in a poor area matter?, October 2003
              ETC CrystalSchwerzel, P. et al; Equity Implications of health sector user fees in Tanzania. Do we retain the
            user fee or do we set the user f(r)ee? Analysis of the literature and stakeholder views... July 2004
              PORALG Report of the Meeting of High level decision makers from the MoH and the President’s office
            regional Administration and local Government . 20 August 2004
              Lungo H. Health information systems Project Tanzania. Development of the District Health Information
            Systems. University of Dar es salaam. 2003 (?)
              MoH, Joint Health Sector Review. Sectoral Performance Indicators Update 2003.
              Armstrong Schellenberg, J. et al.; Inequities among the very poor: Health care for children in rural southern
            Tanzania. The Lancet. Vol 361 February 15, 2003
              Rønsholt, F. et al. Results-Oriented Expenditure Management. Country Study – Tanzania. Overseas
            Development Institute. March 2003
              MoH, Health Information for decision-making: Reconciling systems and approaches. Report from a
            workshop., 10 February 2004
              The United Republic of Tanzania. Joint Ministry of health and president’s office. Regional Administration
            and Local Government; Health Basket and Health Block Grants Guidelines for the disbursement of funds,
            preparation of comprehensive council health plans, financial and technical reports by councils. 12 December
            2003
              Economic Development Initiatives; Rural Shinyanga CWIQ. Baseline survey on poverty, welfare and
            services in rural Shinyanga Districts.. August 2004
              Economic Development Initiatives Rural Kagera CWIQ. Baseline survey on poverty, welfare and services in
            rural Kagera Districts. Economic Development Initiatives. April 2004
              Reyburn, H., ; ….. , Kitua, A. et al.; Overdiagnosis of malaria in patients with severe febrile illness in
            Tanzania: a prospective study, BMJ 2004; 329:1212; 20 November, 2004
              Kimberly Smith, Abt Associates, Inc. G. Larsen; Evaluation of GAVI Immunization Services Support
            Funding. Case Study: Tanzania; Kimberly Smith, Abt Associates, Inc. G. Larsen, June 2004
              Semali, I.A.J; Understanding Stakeholders’ Roles in Health Sector Reform Process in Tanzania: The Case of
            Decentralizing the Immunization Programme.., PhD Thesis University of Basel, 2003


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                                               State of Health in Tanzania 2004
            Draft discussion at the Health Sector Review meeting on 4 April 2005comment onlyFinal version 28 April 2005 100305




              Anand, S.; Baernighausen, T.; Human Resources and Health Outcomes.. Joint Learning Initiative. December
            2003
              Olsen, Ø.E.; Ndeki, S.; Norheim, O.F.; Complicated deliveries, critical care and quality in emergency
            obstetric care in Northern Tanzania. International Journal of Gynecology and Obstetrics (2004), 87, 98 – 108;
            2004
            OECD/World Health Organization. Poverty and Health; DAC-Guidelines and Reference Series, 2003
            UNICEF/WHO; Low Birthweight, Country, regional and global estimates; UNICEF, New York, 2004
            K Jagoe, et al; Tobacco smoking in Tanzania, East Africa: population based smoking prevalence using expired
            alveolar carbon monoxide as a validation tool; Tobacco Control 2002;11:210-214; 2002
            Unwin, N., et al. Noncommunicable diseases in sub-Saharan Africa: Where do they feature in the health
            research agenda?, Bulletin of the World Health Organization, 2001
            UNAIDS/WHO, Epidemiological Fact Sheet on HIV/AIDS and sexually transmitted diseases. Update 2004,
            2004
            WHO/UNICEF/UNFPA; Maternal Mortality in 2000; WHO, 2004
            URT (2003). Ministry of Health: The first District Medical Officers Annual Meeting Report: Quality Health
            Service Delivery in Tanzania: The District Focus. morogoro, Tanesco Conference Hall. June 9-13, 2003
            RMO report (in Kiswahili): JAHURI YA MUUNGANO WA TANZANIA: WIZARA YA AFYA. RIPOTI
            YA HUDUMA ZA AFYA TANZANIA BARA 2003: Imetayarishwa na Sekretriat: Afya Makao Makuu, Dar
            Es Salaam. September 2004
            Ministry of Health (2004). Annual Reproductive and Child Health Report. Arusha AICC October 2004
            Mwita, A., Malaria treatment, when to change policy and cost implications; A Presentation made to HSR
            Preparatory Meeting 15-17th March, 2005
            Gwatkin D. R., et al. Socio-Economic Differences in Health, Nutrition and Population in Tanzania. The World
            Bank HNP Thematic Group; May 2000
            World Bank, HNP-Indicators Tanzania, 1999




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                                               State of Health in Tanzania 2004
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      9.2. People met and interviewed

               People met                                   Organisation

               M. Bangser                                   Women’s Dignity Project
               F. Schleimann                                Royal Danish Embassy
               A. Hingora                                   MoH
               S. Nyawaa                                    MoH
               Magoma                                       MoH
               EA. Makundi                                  NIMR
               D. Simba                                     School of Public Health & Social Sciences-MUCHS
               J. McLaughlin                                World Bank
               B. Schmidt-Ehry                              GTZ
               R. Külker                                    GTZ
               F. Ndjau                                     MoH
               A. A. Mzige                                  MoH
               G. Luciola                                   Acquire
               J. Dunlop                                    USAID
               K. McDonald                                  UNICEF
               S. Agbo                                      UNICEF
               S. Kimmata                                   UNICEF
               J. Titsworth                                 DFID
               L. Devillé                                   Consultant PPP
               J. Dusseljee                                 Consultant PPP
               D. Robinson                                  Care International
               M. Kimambo                                   CSS
               G. Reid                                      TEHIP
               M. Tiedeman                                  Youth net
               J. Mahon                                     SDC
               D. Sipora Temu-Usiri                         UNFPA
               C. Schuemer                                  GTZ
               Z. Maimu                                     Dutch embassy
               N. Iteba                                     UNFPA
                M. Mautalo                                  Ag RMO Dodoma
               Muhamela                                     Ag Chief Nursing Officer (MoH)
               Mrs Hamza                                    Administrator (MoH)
               E. Nagawe                                    WHO
               P. Mapunda                                   Director, CEEM
               F. Lwilla                                    Programme Officer TB & Leprosy (MoH)
               R. Mandike                                   Deputy Programme Manager NMCP (MoH)
               Kitambi                                      Prgramme manager EPI (MoH)
               E. Mapella                                   RCHS (MoH)
               Maarifa                                      Ag MOi/c Dodoma
               C. Nyaki                                     Priest Catholic Church Mpwapwa Dodoma
               Kitambulio                                   PORLAG
               Maganga                                      PORLAG
               S. Eubore                                    Community Development Officer Mpwpwa
               M. Nassoro                                   Obstetrician Gynecologist Dodoma
               R. Mgina                                     Ag RNO Dodoma
               Alhaji Sheikh Omari, K.                      The trustee of Mpwapwa Islamite
               L. Masumbi                                   Rev. Anglican
               L. Kasumbe                                   PORLAG
               S. Kimboka                                   TFNC (MoH)
               S. Bingi                                     District Community Development Officer Kondoa




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                                               State of Health in Tanzania 2004
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      9.3. Programme of the review
               Date                              Time       People met and organisations

               Wednesday, 9/2/05                  9:00      State of Health Review Group
               Thursday, 10/2/05                 10:00      Technical Subcommittee
               Friday, 11/2/05                    8:00      M. Bangser, Women’s Dignity Project
                                                  9:30      F. Schleimann, Royal Danish Embassy
                                                 10:30      A. Hingora, MoH and S. Nyawa
                                                 11:30      Administrator and?
                                                 12:00      M. Magoma, Ministry of Health
               Saturday, 12/2/05                 10:00      Health Sector Performance Profile Group (EA.
                                                            Makundi, D. Simba, JJ Rubona)
               Monday, 14/2/05                   10:00      J. McLaughlin, World Bank
                                                 12:00      B. Schmidt-Ehry, GTZ
                                                 15:30      F. Ndjau,MoH
                                                 17:00      A.. Mzige, MoH
                                                            M. Mautalo-Dodoma
                                                            R. Mgina Dodoma
                                                            M. Nasoro- Dodoma
                                                            Bingi- Dodoma
                                                            Maarifa- Dodoma
                                                            Masumbi- Dodoma
                                                            Kitabulilo-PORLAG
                                                            Maganga-PORLAG
               Tuesday, 15/2/05                             C. Nyaki Dodoma Mpwpwa
                                                            S. Eubore- Mpwapwa
                                                            Alhaji Sheikh Omari, K. (Mpwapwa)
                                                            Kasumbe-PORLAG
                                                 9:45       G. Luciola Acquire
                                                 13:00      J. Dunlop, USAID,
                                                 14:00      R. Külker, GTZ
                                                 15:00      K. McDonald S. Agbo, S. Kimmata, UNICEF,
                                                 9:00       J. Titsworth, DFID
                                                 13:00      L. Devillé, et al. list to be completed (health economist,
                                                            plus former Chief medical officer
               Thursday, 17/2/05                 8:00       D. Robinson, Care International
                                                 10:00      M. Kimambo, CSS
                                                 12:00      G. Reid, TEHIP
                                                 13:30      M. Tiedeman, Youthnet
                                                 15:00      J. Mahon, SDC
                                                 10:00      Development partners reproductive health & child
                                                            health group and JJ Rubona
               Tuesday, 22-24/2/05               10:00      P. Mapunda CEEM
                                                 12:20      Mandike Malaria Programme
                                                 13:30      Mapella RCHS
               Thursday, 25/28/2/05              10:30      Lwilla TB & Leprosy
                                                 13:30      Kitambi (EPI)
               Tuesday, 8/3/05                   12:00      S Kimboka (TFNC)
               Thursday, 10/3/05                 10:00      NACP (Meeting failed)
                                                 15:00      CMO (Meeting failed)
               Tuesday, 15/3/05                  15:00      Presentation of the first Draft Report to Joint Technical
                                                            Preparartory Meeting
               Monday, 4/4/05                    11:00      Presentation of second Draft Report to the Annual Joint
                                                            Health Sector Review
               Monday, 18/4/05                   10:00      Debriefing JJ Rubona, J. Mahon, and Health Sector
                                                            Performance profile team




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                                               State of Health in Tanzania 2004
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      9.4. People interviewed

                                 People met                            Organisation
                                 M. Bangser                            Women’s Dignity Project
                                 F. Schleimann                         Royal Danish Embassy
                                 A. Hingora                            MoH
                                 S. Nyawaa                             MoH
                                 Magoma                                MoH
                                 EA. Makundi                           NIMR
                                 D. Simba                              School of Public Health&Social Sciences-MUCHS
                                 J. McLaughlin                         World Bank
                                 B. Schmidt-Ehry                       GTZ
                                 R. Külker                             GTZ
                                 F. Ndjau                              MoH
                                 A. A. Mzige                           MoH
                                 G. Luciola                            Acquire
                                 J. Dunlop                             USAID
                                 K. McDonald                           UNICEF
                                 S. Agbo                               UNICEF
                                 S. Kimmata                            UNICEF
                                 J. Titsworth                          DFID
                                 L. Devillé                            Consultant PPP
                                 J. Dusseljee                          Consultant PPP
                                 D. Robinson                           Care International
                                 M. Kimambo                            CSS
                                 G. Reid                               TEHIP
                                 M. Tiedeman                           Youthnet
                                 J. Mahon                              SDC
                                 D. Sipora Temu-                       UNFPA
                                 Usiri
                                 C. Schuemer                           GTZ
                                 Z. Maimu                              Dutch embassy
                                 N. Iteba                              UNFPA

                                 Not yet
                                 complete!




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                                               State of Health in Tanzania 2004
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                  9.5. Programme of the review (not yet complete!)


                          Date                              T          People met and organisations
                                                            i
                                                            m
                                                            e
                          Wednesday,                                   State of Health Review Group (List of names)
                          9.2.05                            9
                                                            :
                                                            0
                                                            0
                          Thursday,                         1          Technical Subcommittee ….(check for exact
                          10.2.05                           0          title)
                                                            :
                                                            0
                                                            0
                          Friday,                                      M. Bangser, Women’s Dignity Project
                          11.2..05                          8
                                                            :
                                                            0
                                                            0
                                                                       F. Schleimann, Royal Danish Embassy
                                                            9
                                                            :
                                                            3
                                                            0
                                                            1          A. Hingora, MoH and S. Nyawa
                                                            0
                                                            :
                                                            3
                                                            0

                                                            1          Administrator and?
                                                            1
                                                            :
                                                            3
                                                            0
                                                            1          M. Magoma, Ministry of Health
                                                            2
                                                            :
                                                            0
                                                            0
                          Saturday,                         1          Health Sector Performance Profile Group
                          12.2.05                           0          (EA. Makundi, D. Simba, JJ Rubona)
                                                            :
                                                            0
                                                            0
                          Monday,                           1          J. McLaughlin, World Bank
                          14.2.05                           0
                                                            :
                                                            0
                                                            0




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                                               State of Health in Tanzania 2004
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                                                            1          B. Schmidt-Ehry, GTZ
                                                            2
                                                            :
                                                            0
                                                            0
                                                            1          F. Ndjau,MoH
                                                            5
                                                            :
                                                            3
                                                            0
                                                            1          A.. Mzige, MoH
                                                            7
                                                            :
                                                            0
                                                            0
                                                                       Add people, places etc. of your trip
                                                                       to Dodoma
                          Tuesday,
                          15.2.05

                                                            9          G. Luciola Acquire
                                                            :
                                                            4
                                                            5
                                                            1          J. Dunlop, USAID,
                                                            3
                                                            :
                                                            0
                                                            0
                                                            1          R. Külker, GTZ
                                                            4
                                                            :
                                                            0
                                                            0
                                                            1          K. McDonald S. Agbo, S. Kimmata, UNICEF,
                                                            5
                                                            :
                                                            0
                                                            0
                          Wednesday,
                          16.2.05                           9          J. Titsworth, DFID
                                                            :
                                                            0
                                                            0
                                                            1          L. Devillé, et al. list to be completed (health
                                                            3          economist, plus former Chief medical officer
                                                            :
                                                            0
                                                            0

                          Thursday,                         8          D. Robinson, Care International
                          17.2.05                           :
                                                            0
                                                            0




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                                               State of Health in Tanzania 2004
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                                                            1          M. Kimambo, CSS
                                                            0
                                                            :
                                                            0
                                                            0
                                                            1          G. Reid, TEHIP
                                                            2
                                                            :
                                                            0
                                                            0
                                                            1          M. Tiedeman, Youthnet
                                                            3
                                                            :
                                                            3
                                                            0
                                                            1          J. Mahon, SDC
                                                            5
                                                            :
                                                            0
                                                            0




                          Friday,
                          18.2.05                           1          Development partners reproductive
                                                            0          health&child health group and JJ Rubona
                                                            :
                                                            0
                                                            0
                          Date when
                          You met more
                          people
                          Date when
                          You met more
                          people




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                                               State of Health in Tanzania 2004

								
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