PAPER III: Health sector reform and STI/AIDS control in Tanzania

The health sector reform in Tanzania had many similarities with the health sector reforms in other African countries in the 1990s. The health systems in many African low-income countries suffered from varying degrees of dysfunction many years before the HIV epidemic. The malfunction of the public health service could be traced back to the attempt to achieve complete coverage through an expansion of the public service systems in the 1960s and 1970s (Smith and Bryant, 1988). The expansion was not accompanied by simultaneous economic growth. This eroded the financial base for the intended free health service. Development aid covered a large part of the cost for the construction of facilities and training of staff, but not for recurrent expenditure.

The status of the health system in Tanzania

Information from different sources consistently indicated that the Tanzanian health system was functioning poorly throughout the 1990s. According to the Ministry of Health the public service system suffered from the lack of financial resources, low staff morale, drug shortages as well as

a lack of equipment and supplies (Ministry of Health, 1998). During the five-year period 1990-95 10% of government expenditure was allocated to health, which corresponded to an annual budget of only 3.5 USD (exchange rate) per capita. The decline of per capita expenditure on health started already in the 1970s. The per capita expenditure declined further by about 40%

from 1991/2 to 1997/8. The entire national health budget was set at 120 million in 1997/8.

Before the health sector reform that was initiated in 1995 around 70 % of government health expenditure went to the district level and below. This corresponded to 2.8 USD per capita for the basic primary health care packages that are an essential part of the reform plan. This was 1/3 of the 9 USD (13 USD including water and sanitation) that the World Bank, at that time, estimated to be necessary for such a package (World Bank, 1993). The inadequate funding resulted in a decline of wages. Real public sector wages had started falling earlier and fell, for example, by over 50% during the 1970s in Sub Saharan Africa (Cartier-Bresson, 1999). At the end of the 1990s the drug supplies were also under funded by 40 to 50%. Informants at district and facility level reported that the drug supplies often did not last for more than 3 weeks per month. The infrastructure was oversized in relation to both existing financial and human resources and in relation to the national economy. The little service provided was often of low quality (Maier and Urassa, 1997). Thus, the entire system was imbalanced in terms of the different types of resources needed for service provision when the health sector reform was initiated in the middle of the 1990s.

STI/HIV Control and health sector reform in Tanzania

Health education through the mass media was probably the main factor behind the broad knowledge of HIV/AIDS and the routes of transmission that was gained in the second half of the 1990s and captured in KAP-surveys (knowledge, attitudes and practices surveys) (Bureau Of Statistics, 1997). Reports and field visits strongly suggested that the screening of blood for transfusion achieved a high coverage already at the beginning of the 1990s. STI control through the syndromic approach was gradually expanded and by the end of 1999 covered all hospitals and health centres in 12 of the 20 regions in the country as summarized in reports to the EU (Annual report. Project 8 ACP/TA/021, 1999). However, condom use remained low as indicated by commissioned reports and a DHS report (Bureau of Statistics, 1997) as well by information from informal sources. Some changes in sexual behaviour, especially as regards the reduction in the number of partners also took place, maybe particularly in the highly affected regions

Table 7. Main findings and conclusions regarding Health Sector Reform and STD/AIDS Control in Tanzania (paper III).

Issue Findings

Conclusions

The health system Inefficient, imbalanced system oversized in relation to the national economy;

Either the system size should be reduced or additional resources secured

STI/HIV control and HSR

Good knowledge of the disease and its transmission in the population; STI control and blood screening scaled up; lack of political commitment, resistance from religious leaders, sexual matters not openly discussed;

interventions limited in scale even in high-risk populations; low condom use Need for strong vertical input to maintain efficiency in HIV control;

implementation through the integrated system only when it has capacity and sufficient resources; below a certain resource level the service output in integrated systems is likely to be lower than in systems based on vertical programmes

The donor–recipient

relationship Donors have shifted from supporting vertical programmes to supporting the whole system. They control both the reform and much of the HIV control activities. Plans have been based on international templates.

Need for a shift of initiative and responsibility to aid recipients; donors should be reactive not pro-active; need for system-wide analysis which includes HIV control

(Kwesigabo, 1998). Throughout the period 1997 to 1999 there was a lack of political commitment and political hesitancy dominated, presumably because of a fear of negative reactions from the constituencies, as reported in West Africa (Caldwell, 1999) and also in Tanzania (pc Mng’ong’o 2004). Only at the end of 1999 did President Mkapa declare HIV/AIDS a national disaster. There were additionally strong reactions from religious leaders, who opposed many of the control efforts, in particular the encouragement of the use of condoms.

The issues around sexual behaviour patterns were almost never publicly debated. Most control interventions were of limited scale even among high-risk populations, such as commercial sex workers and the military. Communities had only been involved to a very limited extent.

In 1998 the third Multi-sectoral Medium Term Plan was formulated. Although it was more focused than previous plans it was still comprehensive and aimed at covering all government sectors and all districts. It had wide ambitions, which included the strengthening of the position of women and ‘the reduction of poverty leading to sexual survival strategies’.

The health sector reform that started around 1995 was part of a larger Local Government reform in Tanzania. A parallel Civil Service Reform is also ongoing. The health sector reform implies

service delivery through a decentralised integrated system of governance. It also aims at improving process-related problems such as financial management and the quality of care. But it does not directly address the main problem of the health sector: the shortage of resources and the imbalance between the production factors for service provision, i.e. the staff, the funds, the drugs and diagnostic material, and the infrastructure. The shortage of funding for the intended service provision was hardly ever addressed at donor meetings and when brought to the table it was met by silence.

There is little experience of decentralised integrated systems in Tanzania. Tanzania has for a long time been a one-party state with a highly centralised government system. There are few examples of integrated programmes in Tanzania. UNICEF has run a highly successful integrated child survival programme (CSPD) in several regions for many years (UNICEF, 1996), but there are few other examples. In spite of the lack of experience of integrated approaches and a shortage of evidence, the integration policy was strongly advocated by many donors. It was thus proposed in a donor commissioned consultancy report that the NACP should be dismantled; the epidemiology unit of the NACP shifted to the general epidemiological services of the Ministry of Health, the training in HIV control shifted to the training department of the ministry etc.

(Decosas et al. 1997).

The donor-recipient relationship

Before the 1990s donors supported the establishment of vertical health programmes. This was based on the preference for the cost-effectiveness of single interventions rather than on concerns for the function of the entire health system. This shifted at the beginning of the 1990s when donors started to support the reform of the health sector as part of a more holistic view of service delivery. Donors became highly proactive and exerted strong influence on both the health sector reform and the HIV control activities throughout the 1990s.