Background 1 Health Situation

During the 1990s health data pointed towards stagnation or deterioration of health indi- cators except of some successes in immunization coverage of children, TB treatment and in the accessibility to contraceptives. Most recently, the data show a positive trend resum- ing around 2000 and most of Tanzania’s health indicators today either compare with or are above Sub-Saharan average (Annex 1). The latest Tanzania Demographic Health Survey (TDHS) 2004-05 shows a rapid decline in infant mortality and the under-five mortality has fallen more than targeted. Tanzania has achieved high rates of immuniza- tion and Vitamin A supplementation. Life expectancy at birth is a little better than the regional average.

Despite of the improvements, some health indicators remain of concern. The poor nutri- tional status of children under the age of five still counts as one of the main health prob- lems: approximately one in five children is underweight; almost 40% of children under five are short for their age and approximately 13% of them are severely stunted. Malaria continues to be a major public health concern, especially among pregnant women and children under five. Hospital based data indicate a mortality rate of 12% of under-fives

due to Malaria. Maternal mortality (MM) is still unbearable high. Linked with maternal mortality is a plateau in the total fertility rate at 5.7, which evidently did not decline over the last eight years. The fact that the use of modern methods has tripled in the last 15 years shows some encouraging momentum and also suggests women may be using con- traception rather than controlling fertility with abortion. 94% of mothers received ante- natal care for their most recent birth from a trained provider. Professional personnel attend 46% of the deliveries and 47% of the women deliver at a health facility.

New data from the national HIV survey show better results than expected. Nationally, prevalence among the population aged 15-49 stands at 7% with figures in urban areas double as high as in rural areas. There are serious regional disparities in regard of HIV/ AIDS. Though the beginning of a decline in HIV prevalence is encouraging – the epi- demic will continue to undermine development and the attainment of the MDGs and national targets.

2.2 Equity Aspects

With a per capita income of 330 USD (2004) Tanzania remains one of the poorest coun- tries in the world. The proportion of the population below the national food poverty line was 18.7% and that below the national basic needs poverty line was 35.7% in 2000/01. The proportion of poor households differs greatly between regions and districts. Tan- zania’s poor undoubtedly suffer a greater burden of ill health than their more privileged counterparts. This is apparent for various health indicators, including infant and under- five mortality, malnutrition and anaemia. Substantial differences between rich and poor and between urban and rural exist. In the TDHS, over half of the poorest quintile cited distance to facility and transport as the biggest problems. In contrast, less than 20% of urban women and those from the highest quintile encountered these problems. Further- more, the single biggest problem encountered by women in seeking health care was ‘get- ting money for treatment’.

2.3 The National Planning Frameworks

The current national frameworks are the Tanzania Development Vision 2025, the Medium Term Plan from 2000, the National Strategy for Growth and Reduction of Poverty from 2005 (NSGRP; in Swahili: MKUKUTA), and Sector Policies and Strategies. MKUKUTA is the national framework, which accords high priority to pov- erty reduction in Tanzania’s development agenda. It identifies three clusters outcomes aimed at achieving Vision 2025 and the Millennium Development Goals (MDGs): (i) growth and reduction of income poverty; (ii) improvement of quality of life and social well being and (iii) good governance.

The NSGRP/MKUKUTA prioritises outcomes, which benefit the poor. Where health sector is concerned, these include: improvement of child nutrition, reduction of malaria and HIV/AIDS morbidity and mortality, and water programmes. The operational targets for 2010 for improved survival, health and well being of children and women and espe- cially of vulnerable groups include: (i) reduced infant mortality from 95 in 2002 to 50 per 1,000 live births, (ii) reduced child (under-five) mortality from 154 to 79 per 1000 live births (iii) reduced hospital based malaria related mortality among under-fives from 12% in 2002 to 8%, (iv) reduced prevalence of stunting in under-fives from 43.8% to

20%, (v) reduced prevalence of wasting in under-fives from 5.4% to 2%, (vi) reduced maternal mortality from 529 to 265 per 100,000, (vii) increased coverage of births attended by trained personnel from 50% to 80%, and various indicators related to the HIV/AIDS pandemic including reduced HIV prevalence among women of 15-24 years from 11% in 2004 to 5%.

In 2002, the Government adopted the Tanzania Assistance Strategy, which sets out a coherent framework for the management of external resources and for government coop- eration with the DPs. The strategy promotes good governance, accountability, capacity building, and improved effectiveness in aid delivery, in a spirit of transparency and trust between the government and the DPs. In response to the strategy and to adapt to the PRSP, most of the DPs elaborated a country assistance strategy, which spells out priorities and objectives for their actions as well as principles guiding their collaboration with the government. As a further step towards alignment with the Government’s strategy (in par- ticularly the MKUKUTA) and in line with the international move towards alignment and harmonisation, major DP organisations together with the Government are currently finalizing the Joint Assistance Strategy of Tanzania that is meant to replace the individ- ual country strategies over time.

2.4 Health Sector Policies and Plans

The revised National Health Policy (NHP) of 2003 takes account of the Health Sector Reform (HSR) and wider government strategies impacting on health. Its vision is “to improve the health and well being of all Tanzanians with a focus on those most at risk, and to encourage the health system to be more responsive to the needs of the people”. Areas for which the NHP provides detailed guidance include the devolution of responsi- bility for health services provision to councils, human resources development, health sec- tor financing, public private partnership, and relationship with cooperating partners. The Programme of Work 1999-2002 and subsequently the Second Health Sector Strategic Plan (HSSP 2) 2003-08 build the guiding framework for the implementation of Government policy and sector reforms as well as DPs’ assistance. Current activities within the health sector are directed by the MTEF, which operationalizes the strategies articulated in the HSSP and MKUKUTA and aims at reflecting government and exter- nally funded activities. The MTEF is linked to the Integrated Financial Management System to enable comparison of spending in relation to stated policy priorities.

Previous annual reviews have documented considerable achievements in health policy development and reform processes in the health sector. These include effective decen- tralisation of planning, budgeting and health service provision to the district level. Accelerated by the Local Government Reform (LGR) since 2000, local government authorities and council health management teams play a crucial role in these contexts. Comprehensive council health plans create the basis for decentralized management and the council basket funding mechanism.

In efforts to address the financing difficulties and shortfalls in the health sector budget allocation, the MOHSW embarked on far-reaching health financing reforms with new responsibilities assigned to local councils; the introduction of new financing schemes for health care, including the stepwise introduction of health insurance for the formal and informal sector and the introduction of pre-payment schemes and fee-for-services.

Continuing efforts are made to raise quality of care through standardisation and closer monitoring, including the formulation and introduction of a comprehensive package of essential health interventions.

Considerable challenges remain. Key obstacles in provision of and access to health serv- ices include long distances to health facilities, inadequate and unaffordable transport sys- tems, and continuous limited quality of care. The single most worrying aspect of the health system is the deterioration in health personnel. The public sector as well as the non-for-profit private sector suffers a massive drainage of skilled personnel, which dispro- portionably impacts on rural health services. Availability of essential drugs improved, however, recurrent shortages continue to occur reducing access to adequate care in case of sickness. The health management information system, though focus of extensive DPs’ support since many year, is still far from satisfactory functioning. The regional structures – as the “prolonged arm of the MOHSW” – are still struggling with their role and func- tion as competent coordinators and supervisors.

In light of the large investment needs and the increasing costs of the health interventions, the system is faced with a widening resource gap in recurrent funding. To achieve the MDGs for health a rise to USD 43 per capita over the next 10 years is projected driven inter alia by the cost of HIV/AIDS related interventions and the cost to combat endemic diseases such as Malaria. This compares to USD 11 spent on health today, out of which approximately USD 6 are borne by the patients themselves. With the exemption of the financial year 2003/04, the support of the DPs increased steadily over the years. In 2004/05, the share of “off-budget” donor funding (e.g. the share which is disbursed through donor-specific mechanisms) was about 50-55% of the total external financing of the sector.

2.5 Collaborative Programmatic Support to the Health Sector

In 1998, DPs’ support in the health sector was coordinated in from of a SWAP followed by subsequent basket funding arrangements in 2000. A number of DPs shifted their approaches from the former direct project support to the collaborative programmatic approach and joint funding mechanisms. It was expected for example that the SWAP would promote comprehensive planning which facilitates the effective use of scarce resources; that it would reduce transaction costs and increase capacities of planners and managers and transparency of financial management.

The SWAP in Tanzania today is known as one of the more advanced examples of coop- erative programme support and partnership between Government and DPs in the region. Within the framework of SWAP, most of the DPs support the implementation of the HSSP; however, a significant share of donor support is still disbursed through direct project/programme funding. Most recently, the sector financing mechanisms have been questioned in the ongoing debate over the respective merits of general budget support versus sector baskets particularly in view of the shift of relevant financing partners from sector basket to general budget support.

Also other changing conditions and dynamics in the health sector, such as the HIV/ AIDS epidemic, malaria and tuberculosis create a significant challenge for the health care system. Concerns were expressed that the answer of the international community by introducing large global funding initiatives such as Global Fund to fight AIDS,

Tuberculosis & Malaria, Clinton Foundation, President’s Emergency Plan for AIDS Relief, Global Alliance for Vaccines & Immunization and others. These, if not integrated in the collaborative processes, might undermine the aim of the Paris Declaration and jeopardize the efforts and achievements of the programmatic sector approach.

2.6 District Self-Assessment

The MOHSW through the Health Sector Reform Secretariat (HSRS) will support ran- domly selected districts to carry out a self-assessment of health sector performance and cooperation modalities at district level in the eight health zones. This approach will foster the involvement and thus the ownership of local authorities for the evaluation results and will provide an indispensable input to the inception phase. The self-assessment will be completed by the end of 2006 prior to the start of the planned Joint External Evaluation activities in the beginning of 2007. The MOHSW will be responsible for the ToR, the planning, preparation and the implementation as well as the results of the self-assessment and might apply standard tools (such as tested assessment instruments elaborated by WHO). The MOHSW will make sure that the data and information from different districts are disaggregated to ensure comparability of the district performances. The MOHSW will organize a stakeholder meeting including the external evaluation core team where the district representatives will present the results of the self-assessment as a starting point for the Joint External Evaluation. The results of the self-assessment of the districts will be critically analysed during the inception phase and validated in the field studies of the evaluation.