Tanzania is marking 50th Anniversary since its independence in December this year. During this period Tanzanians need to recapitulate on the progress they have attained in developing systems that will assure sustainable development .Health system development is a fundamental one in the development process as it is widely known that a nation with poor health cannot attain optimal development. Recalling the widely agreed definition of health by the World Health Organization (WHO) which states that "Health is the state of complete physical mental, and social well-being and not merely the absence of disease”, health is thus considered the very center of persons' well being and development. It is today widely acknowledged that health is an important component of the development process in the sense that it can help or hinder national development, and that other forces of development can add to or detract from health. Universal health coverage focuses on access to health care and social protection for all citizens.
In 1961 when Mainland Tanzania gained its independence under the Mwalimu Julius Kambarage Nyerere, the health sector was medically oriented and sidelined promotive, preventive and social protection interventions. Soon after independence, more efforts were invested in improving health and social services. This policy change was beneficial to the majority of Tanzanians who live in rural areas because the services provided in the colonial era were favoring the elites and the well to do in the society who live in urban areas.
With the introduction of the Arusha Declaration in 1967, Tanzania pursued a health policy that aimed at providing equal and free access to health facilities and services to the entire population. This was indeed a bold and revolutionary step and stemmed from Mwalimu Nyerere's basic principle and conviction that improving the health and wellbeing of all Tanzanians was the way forward to sustainable development. Health care provision was reoriented to reach rural and urban communities and include the poor who could not afford the costs of health care. Health services were provided free of charge by the government in all public health facilities, while voluntary agencies charged modest fees. Given the reality that over 80% of the population lived in rural areas; development of the rural health infrastructure was given high priority.
Hospitals were built in each region and there was also a shift on emphasis from curative to preventive services, hence increasing the range of interventions offered to the communities. These measures allowed the majority of Tanzanians to have access to health services and improve the quality of life. For instance, by 1992 about 72% of the population lived within 5 km of a health facility and 93% lived within 10 km. The life expectancy increased from 35 years in 1961 to 53 in 1983 (which latter on fell to below 50 years as a result of AIDS). The Arusha declaration marked the health for all strategy that was later on emphasized by the Global movement towards primary health care as declared by the World Health Organization in Alma Atta in 1978 . Since then, in the health sector there has been only incremental policy changes that are in line with the Alma Atta declaration.
The introduction of user fees arrangements in health care services that were introduced in response to Structural Adjustment Programs in 1990s by the World Bank and IMF, marked the major health sector reforms in the history of Tanzania ( as elsewhere in the developing countries). From the eyes of those who introduced such policies, they considered these reforms to be beautiful and suitable for the developing countries including Tanzania. The aftermath of these policies include been documented elsewhere and include increased inequalities . Other countries like Uganda decided to abolish the user fee policies which are a result of the policies . The situation immediately after independence could be of similar picture, but after the Arusha declaration, the government committed itself to providing free health services in all government health facilities and banned the private practice. This policy being more socialistic and embracing the solidarity ideology had its own weakness but to a large extend, had a potential to achieving universal health coverage especially to the poor rural Tanzanians.
Revisiting the contemporary Tanzania health policy document, there are such issues as exemption and waivers for the poor , but the reality at the ground is that the poorest of the poor do not know that there are such exemptions, and they are either subjected to catastrophic expenditures or denied to access health care when they fall sick. Since, the Arusha declaration is a history, and the policy on user fees is leading to inequalities, it is a high time to advocate for its abolition and/or find the alternative (if the state cannot provide free services to all of its citizens) in order that we move towards universal health coverage, whereby all citizens in the formal and informal sector will have access to quality health care without being exposed to impoverishment as a result of catastrophic health expenditures .
The establishment of social health insurance through National health insurance fund (NHIF) has increased access to health services for the formal sector employees ensuring social protection to this group. This is one of the important achievement in celebrating 50 years of independence, however, establishing it is one thing, and making it functional and really meet its objectives is another thing. The later, needs viable functioning health care system with availability of health facilities that have adequate health care workers and medicines. We have heard of success in some regions that clients with NIHF cards are attended well, but still in some places, when one presents with the NHIF card is not attended on time, much attention is to those who can provide “informal payment” or simply a bribe. This fact has been revealed by many clients who have attended several public hospitals including the National hospital but the steps taken to avert this seems to be unsatisfactory.
Coverage of social health insurance needs to go hand in hand with the quality of services rendered to the beneficiaries and cover employees in the private sector. On the other hand, the informal sector depends on community based health insurance for social protection, there is a need to strengthen the community health fund in the district health system and make it community driven.
In this year, Tanzania celebrates 16 years since establishment of community health fund (CHF) in all districts in Tanzania. The objectives of CHF, as stipulated in the Community Health Fund Act of 2001 include: (i) To mobilize financial resources from the community for provision of health care services to its members; (ii) To provide quality and affordable health care services through sustainable financial mechanism; and (iii) To improve health care services management in the communities through decentralization by empowering the communities in making decisions and by contributing on matters affecting their health.
However, the CHF scheme suffers from low enrollment rates in most of the districts with no viable strategies to increase the enrollment. The challenges are in the availability of medicines in health facilities and lack of trust on the managers of the scheme or simply the community does not see that they own this scheme due to the bureaucratic procedures attached to management of funds and other procedures of the scheme, “is rather a government thing than a community thing”. These are issues that need to be addressed. CHF should be seen by policy makers, practitioners and beneficiaries as a stride forward to universal coverage for all citizens especially the poor. A call for high political will and leadership towards making it a reliable scheme in the Tanzanian district health system is advocated. Importantly, making CHF community driven might be a way forward to its success.
Revisiting the important metrics such as life expectancy, quality of life, mortality and morbidity, one will realize we are in the step further. However, we may be termed as laggards when compared with other developing countries that have the same age. The life expectancy has increased from 35 to 58 years regardless of sex, this is somehow promising. However, what strategies are in place to improve the life expectancy of a Tanzanian to be similar to our fellows in developed countries? This can be a fundamental question that those in policy making should put forward, in that respect every responsible citizen should think of holding the government accountable in order that the life expectancy of the future Tanzanians improves. In Japan for example, in the period of 50 years, the life expectancy at birth have increased from 50 years for men and 54 years for women to 79.6 for men and 86.4 for women. This year Tanzania celebrates its 50th anniversary with the slogan of Tumethubutu, tumeweza na tunazidi kusonga mbele that literally means that despite all challenges we have managed and we are optimistic for the future. Let us expect that in the next 50 years the life expectancy will be like that of developed countries.
When it comes to maternal and child health, there is vast litany in reduction of maternal and child mortality through various political slogans, declarations and commitments, leaders forums, high level consultations, activism and directives in election manifesto since independence, to what results, one might reasonably ask, given the increasing of unavoidable maternal and child mortality. In 1961 the maternal mortality was 451 per 100, live births, in the 70s through 80s it fell below 200 per 100,000 live births but in 90s to date the mortality have increased to more than 400 per 100,000 live births. It may be right for the government to address that there is a remarkable achievement in maternal and child mortality and that we are approaching to achieve the millennium goals. But, do these achievements match with the government investment in maternal and child health? Thanks for the development partners through the Millennium development have used the objective measurements in tracking the progress in such objective measures despite the wider social economic situations.
The MMAM strategy that aims at constructing health facilities in every village seems to be an ambitious and based on the biomedical model, that emphasizes on treatment and sidelines prevention and health promotion components. Fundamental questions that were supposed to be asked by those responsible were to be like this, why do people get sick, how enabling is their environment? Is distance the only reason to make them not access health services? Who are providing services in the health facility they visit?
To be fair, and for reasons that are not hard to understand, agencies, development partners , the government and civil society leaders have found it hard to strengthen the health system that can ensure universal health coverage, but has embarked in operational issues with interests that in a broad sense marginalizes the poor. For example, when you compare the distribution of human resource for health in the country, you find that there are places that had experienced shortage of human resource since independence, and others who have never experienced such a problem, but no viable strategies in place to address this inequality in health service provision. What we see, are the mushrooming organizations that lures human resource for health by promising incentives on deployment to hard to reach areas and later on leave those health workers mainstreamed in the public service that operates in a business as usual with no sensitivity to the inequalities that exist between places. The point here is that there should be public policies that acknowledges these inequalities on health workforce and provides needs according to the environment.
Formidable challenges in strengthening the health system still remain unsolved. Maternal and infant mortality is still unacceptably high. Only mortalities that occur in hospitals that are reported, the rural community is more experienced with unacceptable number of mortalities that happen at community level without even being attended by a dispensary health worker due to affordability and lack of trust on the quality of services provided in our facilities. Less than 50% of Tanzanians are attended by skilled health workers, most of these workers are in urban areas, there is a devastating scarcity of human resource for health in rural areas, and thus, rural areas of Tanzania face human resource for health crisis in umber and motivation. Those with health related degrees are very scarce in rural areas, especially doctors and pharmacists.
Universal health coverage can be realized if there is political will and effective governance, these are the key to health-system reform. Policy makers must prioritize health in their governmental budgets and move health financing for universal coverage to the top of the political agenda.
Therefore, a number of positive as well as negative experiences in the Tanzanian health care system during the 50 years of independence may be used to shape the future health systems that embrace the universal health coverage concept.
In 1961 when Mainland Tanzania gained its independence under the Mwalimu Julius Kambarage Nyerere, the health sector was medically oriented and sidelined promotive, preventive and social protection interventions. Soon after independence, more efforts were invested in improving health and social services. This policy change was beneficial to the majority of Tanzanians who live in rural areas because the services provided in the colonial era were favoring the elites and the well to do in the society who live in urban areas.
With the introduction of the Arusha Declaration in 1967, Tanzania pursued a health policy that aimed at providing equal and free access to health facilities and services to the entire population. This was indeed a bold and revolutionary step and stemmed from Mwalimu Nyerere's basic principle and conviction that improving the health and wellbeing of all Tanzanians was the way forward to sustainable development. Health care provision was reoriented to reach rural and urban communities and include the poor who could not afford the costs of health care. Health services were provided free of charge by the government in all public health facilities, while voluntary agencies charged modest fees. Given the reality that over 80% of the population lived in rural areas; development of the rural health infrastructure was given high priority.
Hospitals were built in each region and there was also a shift on emphasis from curative to preventive services, hence increasing the range of interventions offered to the communities. These measures allowed the majority of Tanzanians to have access to health services and improve the quality of life. For instance, by 1992 about 72% of the population lived within 5 km of a health facility and 93% lived within 10 km. The life expectancy increased from 35 years in 1961 to 53 in 1983 (which latter on fell to below 50 years as a result of AIDS). The Arusha declaration marked the health for all strategy that was later on emphasized by the Global movement towards primary health care as declared by the World Health Organization in Alma Atta in 1978 . Since then, in the health sector there has been only incremental policy changes that are in line with the Alma Atta declaration.
The introduction of user fees arrangements in health care services that were introduced in response to Structural Adjustment Programs in 1990s by the World Bank and IMF, marked the major health sector reforms in the history of Tanzania ( as elsewhere in the developing countries). From the eyes of those who introduced such policies, they considered these reforms to be beautiful and suitable for the developing countries including Tanzania. The aftermath of these policies include been documented elsewhere and include increased inequalities . Other countries like Uganda decided to abolish the user fee policies which are a result of the policies . The situation immediately after independence could be of similar picture, but after the Arusha declaration, the government committed itself to providing free health services in all government health facilities and banned the private practice. This policy being more socialistic and embracing the solidarity ideology had its own weakness but to a large extend, had a potential to achieving universal health coverage especially to the poor rural Tanzanians.
Revisiting the contemporary Tanzania health policy document, there are such issues as exemption and waivers for the poor , but the reality at the ground is that the poorest of the poor do not know that there are such exemptions, and they are either subjected to catastrophic expenditures or denied to access health care when they fall sick. Since, the Arusha declaration is a history, and the policy on user fees is leading to inequalities, it is a high time to advocate for its abolition and/or find the alternative (if the state cannot provide free services to all of its citizens) in order that we move towards universal health coverage, whereby all citizens in the formal and informal sector will have access to quality health care without being exposed to impoverishment as a result of catastrophic health expenditures .
The establishment of social health insurance through National health insurance fund (NHIF) has increased access to health services for the formal sector employees ensuring social protection to this group. This is one of the important achievement in celebrating 50 years of independence, however, establishing it is one thing, and making it functional and really meet its objectives is another thing. The later, needs viable functioning health care system with availability of health facilities that have adequate health care workers and medicines. We have heard of success in some regions that clients with NIHF cards are attended well, but still in some places, when one presents with the NHIF card is not attended on time, much attention is to those who can provide “informal payment” or simply a bribe. This fact has been revealed by many clients who have attended several public hospitals including the National hospital but the steps taken to avert this seems to be unsatisfactory.
Coverage of social health insurance needs to go hand in hand with the quality of services rendered to the beneficiaries and cover employees in the private sector. On the other hand, the informal sector depends on community based health insurance for social protection, there is a need to strengthen the community health fund in the district health system and make it community driven.
In this year, Tanzania celebrates 16 years since establishment of community health fund (CHF) in all districts in Tanzania. The objectives of CHF, as stipulated in the Community Health Fund Act of 2001 include: (i) To mobilize financial resources from the community for provision of health care services to its members; (ii) To provide quality and affordable health care services through sustainable financial mechanism; and (iii) To improve health care services management in the communities through decentralization by empowering the communities in making decisions and by contributing on matters affecting their health.
However, the CHF scheme suffers from low enrollment rates in most of the districts with no viable strategies to increase the enrollment. The challenges are in the availability of medicines in health facilities and lack of trust on the managers of the scheme or simply the community does not see that they own this scheme due to the bureaucratic procedures attached to management of funds and other procedures of the scheme, “is rather a government thing than a community thing”. These are issues that need to be addressed. CHF should be seen by policy makers, practitioners and beneficiaries as a stride forward to universal coverage for all citizens especially the poor. A call for high political will and leadership towards making it a reliable scheme in the Tanzanian district health system is advocated. Importantly, making CHF community driven might be a way forward to its success.
Revisiting the important metrics such as life expectancy, quality of life, mortality and morbidity, one will realize we are in the step further. However, we may be termed as laggards when compared with other developing countries that have the same age. The life expectancy has increased from 35 to 58 years regardless of sex, this is somehow promising. However, what strategies are in place to improve the life expectancy of a Tanzanian to be similar to our fellows in developed countries? This can be a fundamental question that those in policy making should put forward, in that respect every responsible citizen should think of holding the government accountable in order that the life expectancy of the future Tanzanians improves. In Japan for example, in the period of 50 years, the life expectancy at birth have increased from 50 years for men and 54 years for women to 79.6 for men and 86.4 for women. This year Tanzania celebrates its 50th anniversary with the slogan of Tumethubutu, tumeweza na tunazidi kusonga mbele that literally means that despite all challenges we have managed and we are optimistic for the future. Let us expect that in the next 50 years the life expectancy will be like that of developed countries.
When it comes to maternal and child health, there is vast litany in reduction of maternal and child mortality through various political slogans, declarations and commitments, leaders forums, high level consultations, activism and directives in election manifesto since independence, to what results, one might reasonably ask, given the increasing of unavoidable maternal and child mortality. In 1961 the maternal mortality was 451 per 100, live births, in the 70s through 80s it fell below 200 per 100,000 live births but in 90s to date the mortality have increased to more than 400 per 100,000 live births. It may be right for the government to address that there is a remarkable achievement in maternal and child mortality and that we are approaching to achieve the millennium goals. But, do these achievements match with the government investment in maternal and child health? Thanks for the development partners through the Millennium development have used the objective measurements in tracking the progress in such objective measures despite the wider social economic situations.
The MMAM strategy that aims at constructing health facilities in every village seems to be an ambitious and based on the biomedical model, that emphasizes on treatment and sidelines prevention and health promotion components. Fundamental questions that were supposed to be asked by those responsible were to be like this, why do people get sick, how enabling is their environment? Is distance the only reason to make them not access health services? Who are providing services in the health facility they visit?
To be fair, and for reasons that are not hard to understand, agencies, development partners , the government and civil society leaders have found it hard to strengthen the health system that can ensure universal health coverage, but has embarked in operational issues with interests that in a broad sense marginalizes the poor. For example, when you compare the distribution of human resource for health in the country, you find that there are places that had experienced shortage of human resource since independence, and others who have never experienced such a problem, but no viable strategies in place to address this inequality in health service provision. What we see, are the mushrooming organizations that lures human resource for health by promising incentives on deployment to hard to reach areas and later on leave those health workers mainstreamed in the public service that operates in a business as usual with no sensitivity to the inequalities that exist between places. The point here is that there should be public policies that acknowledges these inequalities on health workforce and provides needs according to the environment.
Formidable challenges in strengthening the health system still remain unsolved. Maternal and infant mortality is still unacceptably high. Only mortalities that occur in hospitals that are reported, the rural community is more experienced with unacceptable number of mortalities that happen at community level without even being attended by a dispensary health worker due to affordability and lack of trust on the quality of services provided in our facilities. Less than 50% of Tanzanians are attended by skilled health workers, most of these workers are in urban areas, there is a devastating scarcity of human resource for health in rural areas, and thus, rural areas of Tanzania face human resource for health crisis in umber and motivation. Those with health related degrees are very scarce in rural areas, especially doctors and pharmacists.
Universal health coverage can be realized if there is political will and effective governance, these are the key to health-system reform. Policy makers must prioritize health in their governmental budgets and move health financing for universal coverage to the top of the political agenda.
Therefore, a number of positive as well as negative experiences in the Tanzanian health care system during the 50 years of independence may be used to shape the future health systems that embrace the universal health coverage concept.
