Arusha — Twenty-eight year old Rehema Shomari of Msanga Mkuu, a sprawling village in Mtwara at the southern end of Tanzania is uncharacteristic of most African villagers, with seemingly very little to worry about her health and that of her two children. Hardly 500 metres from her tin-roofed family house is a dispensary, sufficiently stocked with essential drugs and within a stone's throw distance is a protected well, gushing clean and safe water.

"We are blessed, things have changed here and with the dispensary at the centre of the village we are assured of good health," she said as she sat on a slab at a corner of her house verandah waiting for her children to come home from school also within easy reach in the village.

Shomari is grateful that she has access to basic social services and she no longer has to board an overcrowded boat to Mtwara town about 20 km away for health services. To her and the rest of the 6,250 villagers served at the dispensary the facility is their lifeblood. "We hardly now hear of deaths in the neighbourhood," added Shomari.

At the dispensary, Adorat Kapinga, the clinician in-charge is equally rejoicing at the state of his facility in health services delivery. "I think the number of deaths has declined in recent years. I have only recorded four deaths in three years." He had no comparison figures but he opined that what he believed to be low mortality rate was a reflection of improved health services delivery.

More than 1, 500 kilometers from Shomari's village, at Ujiji in Western Tanzania 30-year-old Asha Ramadhani also has a similar and promising story to tell. She and her three children have not had major health problems, thanks to the health centre serving about 18,000 people, many of them being petty farmers' and fishermen's families on the shores of Lake Tanganyika. The health centre despite the surrounding large population is almost free of outpatients by noon. Within some few hours in the morning the clinical personnel at the spacious and well kept facility had already attended all the patients and prescribed them with medicine that is readily available at the centre.

According to Neema Mwangoka, in-charge of the facility, the number of patients attending the facility has been declining in recent years, a telling detail that health services are to a large extent meeting the needs of the facility's catchment area. This means there is no reason for many of them to frequently attend the health centre.

What actually has changed the villagers' health conditions from consistently ailing and complaining people to apparently satisfied recipients of vastly improved health services is not the health facilities that have been brought closer to the people. It is a new approach to local health planning and delivery as well as evidence-based interventions. Little do the end users of the facilities know that between 1997 and 2004 the Ministry of Health Essential Health Interventions Project (TEHIP) developed and tested a range of tools and supportive strategies to directly strengthen the planning and prioritization of essential health interventions so as to improve health services delivery. The task was performed against the backdrop of prevailing Health Sector Reforms.

End users of the health facilities may not also know that they are now reaping rewards of the Ministry of Health project supported by Canada's International Development Research Centre (IDRC). The project major task was to test the 1993 World Development Report, Investing in Health, that an integrated package of minimum essential public and clinical health interventions could significantly reduce overall disease pattern burden in low-income countries.

What distinguished TEHIP from other health projects implemented in Tanzania's rural areas was its unique and continuous interplay of both research and development elements. Whereas researchers were busy in the project areas of Rufiji and Morogoro regions gathering reliable information addressing the real needs of the people, health stakeholders in the two districts put into practical experience findings from researchers and received support to rehabilitate their dilapidated health facilities. During the project's tenure, social scientists, health workers, animators and informants worked around the clock with communities and health management teams busy collecting and analyzing data that helped test certain principles of "process" that eventually had rewarding application. Research findings were continually incorporated into new tools and district health service delivery started to improve early on in the project without having to await the final outcomes and results, as is the normal case with most projects.

TEHIP's efforts resulted into coining some powerful tools which when applied went a long way to proving that the health of a population can be dramatically improved by planning spending more efficiently and that even a small budget can yield good results.

The resultant "toolbox" included the district burden of disease profile tool which elaborately shows health needs at the community level. It repackages population health information in a way that district planners can easily understand. The tool turns district health planners' outlook from mere budgeting to actual prioritization and allocation of the scarce resources into effective interventions which address all the major components of the prevailing burden of disease. In most districts of Tanzania, malaria contributes immensely to the burden of disease, so with guidance from the use of the tool, priority is given to interventions to address the disease. When evidence was lacking STD's, for example received a negligible share of total health spending, about 3%. Evidence on the burden of STDs resulted in an increase of the share, in project areas, to about 9.5%. Proportions were also substantially increased for malaria and Integrated Management of Childhood Illnesses (IMCI).

A district health accounts tool maps district health budgets and expenditures in relation to the burden of disease and other criteria. With this tool in hand, Council Health Management Teams (CHMTs) readily see how a district's limited resources are distributed according to the plan's priority. In 2007 the Ministry of Local Government, encouraged by the Ministry of Health incorporated the District Health Accounts Tool into its PlanRep software giving health the distinction of being the only sector with an in-built priority setting tool. It is mandatory now for all districts in Tanzania to use the hybrid PlanRep tool in planning at both the budgeting and accounting stages.

TEHIP's toolbox also includes a supervision arrangement labeled Integrated Management Cascade which ensures that supervision is delegated to staff at selected health facilities. The cascade centres are linked to CHMTs and each health centre is responsible for a group of dispensaries. The network is woven so conveniently into the system that it is also used for delivering drug kits and bed nets; collecting reports; and implementing national campaigns such as immunization programmes.

Also found necessary in healthcare delivery is strengthening of health management. The tool with the Kiswahili banner Uimarishaji wa Menejimenti ya Afya katika wilaya na mikoa and famous by its acronym NUMA incorporates a series of approaches to strengthen health management and administration. It addresses crucial aspects of management mainly confidence, team dynamic and problem solving skills of CHMTs.

A community-driven health facility rehabilitation tool inspired participation of local communities to contribute labour and materials in carrying out improvement and maintenance of health facilities.

In implementing these tools, the IMCI intervention became the number one priority, the flagship of the whole endeavour. IMCI focuses on the well-being of the whole child. It addresses five major childhood diseases: malaria, pneumonia, diarrhea, measles and malnutrition. Malaria, the number one killer disease in sub-Sahara Africa, is also targeted in the all-embracing strategy by provision of insecticide treated bed-nets and drugs to prevent malaria in pregnancy. IMCI strategy was developed by WHO and UNICEF and its main components include case management, improved health systems and improved family and community practices. TEHIP gave the strategy a new lease of life by backing it with scientific evidence.

The outcome of TEHIP's seven years of research and development are monumental and have redefined health services planning and provision. After undertakings in Rufiji and Morogoro districts with a joint total population of 800,000 a significant reduction of the burden of disease of 50% in under 5 year old children and about 20% in adults was recorded. In both districts the introduction of TEHIP tools saw improvement in budget allocation.

When positive results of the project started to unfold five years after piloting evidence-based planning, the Ministry of Health was convinced that implementing specific interventions in non-experimental stage could also lower death rates in other districts. The dramatic results of the Research and Development work left no doubt of the efficiency and effectiveness of the tools. For the Ministry of Health, now with another docket of Social Welfare, the biggest question was how to go about disseminating country-wide what have proved to be tools of survival. It was important to find existing and appropriate "vehicles" for delivering innovative health services, institutions that are not dependent on research funding and that would continue to survive and flourish even when the project came to an end.

Embedded in the Ministry of Health and Social Welfare are institutions known as Zonal Health Resource Centres (ZHRCs). There are eight such centres, covering the entire 945,000 sq kms or 365,000 sq miles of the country and which serve important roles in the Tanzania health sector. ZHRCs, apart from providing pre-service training and other support to the country's 120 health colleges, which train most of the country's health personnel, also support district's personnel through the delivery of in-service education. ZHRCs also have a role to play in health systems research on major public health problems. To the Ministry of Health and Social Welfare the centres are considered as "a bird in the hand" as far as scaling up the use of the tools is concerned. The ministry appreciates the ZHRCs potential pivotal role in the health system and therefore accorded them the new function of rolling out essential health interventions and tools countrywide.

The Centres have been bracing to perform the role since 2006 through the coordination of a three-year interim project known as the National Expansion of TEHIIP Tools and Zonal Rollout (NETTS/ZORO). At the outset it was realized that to set ZHRCs in motion for the scale-up of the tools would require substantial development of human resources, coordination and equipment. The Ministry of Health and Social Welfare sought additional funds from the World Bank and CIDA to supplement USAID support to undertake the task.

With strengthened capacities in terms of training, equipment and administration support, the centres were brought to new heights and a status that enables them to undertake these new and expanded roles. The tools and interventions, at varying coverage levels, have now been disseminated across the country. Results of what the zonal centres have done so far make them a beacon of hope in relieving Tanzania of its staggering burden of disease and realizing the Millennium Development Goals for health by 2015.

The redefining of ZHRCs already has a motivating effect among staff of the Centres and training institutes. Apparently the new zonal function has also encouraged frontline health workers and CHMTs members who are the fundamental movers in health planning and services provision. Dr. Bakari Mwinchande of the Lake Zone Health Training Centre based in Mwanza is optimistic about the future of the Centres in scaling up the use of health interventions. "The future is bright for the health system in Tanzania. Planning has been made a lot easier and more realistic. We are happy to find out during follow-up that what we taught is being practiced, appreciated and is yielding positive results," he remarked confidently.

His statement was underscored by the Director of Human Resources for Health in the Ministry of Health and Social Welfare Dr. Gilbert Mliga who also sees a great future of the strengthened ZHRCs in linking the ministry with health services providers and acting as conduits in the dissemination of interventions and policies. The ministry, he said, was proposing a new structure to give ZHRC more autonomy in playing their roles.

But as scientists, ministry officials, facilitators and planners count the successes of evidence-based interventions, front line workers and end users of the health facilities would only see the value of the approach if the roll-out system is formally legalized and the momentum is sustained. The approach has demonstrated the potential to reverse negative trends and grim statistics. Thus, a decentralized training system able to scale-up evidence-based tools, strategies and interventions is crucial in assisting the nation realize national health and poverty reduction goals. Stakeholders voice that there should be a strong push forward towards strengthening zonal centres in order to capacitate districts in planning and delivery of essential health interventions and addressing urgent health worker shortages, all current challenges to the Ministry Health and Social Welfare.