15 September 2000

Tanzania: Health Sector Reforms Explained

Dar Es Salaam — Tanzania has unveiled a public health sector reform programme aimed at improving the health of its population at a low cost while the government gradually relinquishes the responsibility of health services delivery.

Due to persistent economic and manpower constraints, the country could not attain its post-independence goal of good health for its citizens before the turn of the century.

Under the new programme, the government has committed itself to create an enabling environment for both public and private institutions to improve the quality, accessibility and availability of essential health and medical care.

"The immediate challenge before us is how to get adequate capacity of human, financial and material resources for implementation of the necessary reforms," Dr Amos Mwakilasa, senior official in the health ministry, said. "We have resource constraints in all areas."

There are imbalances in deployment and distribution of what is available. Patients bypass their next-door district hospitals to seek medical care from distant facilities, Mwakilasa told the annual meeting of the Medical Association of Tanzania.

Inadequacy of resources at primary health care levels in districts, he said, has prompted a concentration of patients in the country's four referral hospitals - two of which are run by the government and the others owned by religious institutions.

In addition, HIV/AIDS and re-emerging diseases like tuberculosis were causing constraints on limited resources of district hospitals.

Meanwhile, medical experts in the country have criticised the government for making a snail's pace in building up capacity for health delivery and reducing dependency on referral hospitals in other countries.

Members of the association wondered why it was taking the government a long time to train and have medical specialists posted to district hospitals.

"Where is the emphasis in terms of human resources development for health sector reform?, association Vice President Prof. Y.J.S. Mashalla queried.

Since the government has ceased to be the sole provider of health services, he said, medical practitioners should have a clear mind of the proposed reforms in the sector.

"We are going to complement the government initiative. As implementers, if we don't understand the whole concept of reform, implementation of this initiative will be very difficult," he added.

The main purpose of health sector reform in Tanzania, according to the government's Chief Dental Surgeon, Dr H.J. Mosha, is to strengthen the referral system in line with the primary health care strategy.

The strategy seeks to involve communities and individuals in the management of their health through respective local authorities and health committees.

In principle, Tanzania maintains a pyramidal referral system for patients from primary health care units through district and regional hospitals to the national referral medical centres. Most of the health facilities are under public ownership.

As Tanzania's economy went down since the 1980s, quality and availability of services from public hospitals also deteriorated. Efficiency and effectiveness of management of government hospitals declined.

Access of the poor and vulnerable members of communities to hospital care became remote and the situation was more severe in large multifunctional hospitals.

The new programme is designed to give the health ministry a breathing space in order to formulate policies and plans for provision of equitable hospital care that is affordable to individual citizens.

Each hospital will have its own reform task force to advise and assist the management in planning and monitoring the restructuring process based on particular needs of its clientele.

Because modern management practice requires Tanzania's hospitals to apply business strategy and tactics, there will be routine external auditing in order to know real costs of their services on the basis of resource consumption rather than just cash.

The government will require each reforming hospital to have key performance targets and achievements that will be published in order to provide transparency and enhanced accountability.

Health ministry officials told PANA that income-generating measures are to be introduced in all public hospitals, but with due regard to poor patients and vulnerable groups such as children and women.

Government has with effect from the current fiscal year increased budgetary allocation to the health sector to 14 percent of the national budget. Though Tanzanians welcome the move and the health sector reform, they see corruption in the health ministry as a chronic frustrating disorder.

A presidential commission, led by Judge Joseph Warioba, four years ago probed the extent of corruption in the public service and came out with a report that put the health ministry on the third rung from the top of the ladder of corruption-ridden institutions in Tanzania.

Ministry officials, however, argue that staff motivation, new remuneration packages and transparency under the reform programme would help stamp out corruption.

But people who have to grease the palms of hospital staff, even for collection of bodies of their relatives from mortuaries, don't believe it.

Reform must go deeper into the hearts of all workers in the health sector so as to put a human feeling in whatever they do for the care of patients.

Corruption in Tanzania's public hospitals, it is claimed, leads many patients to refer themselves to clinics of traditional healers where quality of care can be cause for terrible nightmares.

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