Tanzania is gearing up for an overhaul of its health care sector that could prove transformational by ensuring universal insurance coverage and greatly broadening the opportunities for outside service providers. The past decade-and-a-half has seen considerable successes in public health, with major communicable diseases brought under control and steady rises in expenditure. Primary care has also grown, bringing the system closer to citizens. However, gaps remain and provision has lagged behind the changing demographics of an urbanising country and an increasingly dynamic economy. The government’s latest strategy looks to address these shortcomings and build a more efficient system that focuses resources on the neediest.
Progress
In its most recent country cooperation strategy, the World Health Organisation (WHO) noted that over recent years Tanzania has made “impressive progress” in most public health indicators. The country has met Millennium Development Goals (MDGs) targets set out by the UN in 2000 to be achieved by 2015. The MDGs committed member states to making progress in eight areas of development, including child mortality, maternal health, AIDS, malaria and hunger. Over the past decade alone, life expectancy at birth has risen from just 51 years to 62 years on average for both sexes, placing Tanzania above regional figures and on a par with the norm for countries with similar income levels.
The challenges the country is facing are familiar to many lower-income tropical countries, including communicable diseases, and maternal, newborn and childhood illnesses – all leading causes of mortality. While tropical diseases and malnutrition are also serious concerns, non-communicable diseases (NCDs) are on the rise as demographics and lifestyles change.
Challenges
Meanwhile, there are risks from disease outbreaks, such as the cholera outbreak that started in August 2015. While the number of new cases dropped off towards the end of the year, it rose again in the early months of 2016, with more than 24,000 cases by April. The WHO attributed the outbreak largely to poor sanitation and lack of access to improved drinking water – with the water supply poorly monitored and chlorinated – and the low utilisation rate of improved latrines. The outbreak was tackled by focusing on affected districts and communities, with support from international partners. Authorities at the local and national level are continuing to work on prevention, with an emphasis on sanitation and education. In addition, Tanzania has one of the world’s highest tuberculosis (TB) infection rates, with 164,000 cases reported in 2015.
Despite these challenges, the country has made considerable strides in confronting the spread of disease. The WHO praised Tanzania’s progress in enhancing the regulation of medicines and medical devices, though it notes that counterfeit products still make their way to market. The proportion of adults infected with AIDS dropped from 7% in 2003 to 5.1% in 2012. The spread of malaria has also been reduced, with prevalence falling from 18% in 2008 to 14% in 2015.
Medical Products
A portion of this success can be attributed to the Tanzania Food and Drugs Authority, which regulates the quality, safety and efficacy of such medications. A quality assurance programme is undertaken through inspections, screenings and pre-qualified WHO laboratory analyses of product samples.
Medications at a variety of pharmaceuticals outlets undergo routine inspections, at which point they are analysed to identify substandard and counterfeit products. This is part of wider efforts to curb the prevalence of ineffective or imitation medications.
Previous Sector Strategies
Outlined in the 2015-20 Health Sector Strategic Plan (HSSP IV), Tanzania has set broad targets for mandating, monitoring and evaluating sector policies. The first HSSP was initiated in 1999 and lasted through 2004. Its development was partly the result of a 1993 appraisal of the health care system, itself undertaken after the severe economic crisis of the 1980s. The health system had been affected by the downturn, both in terms of financing and management, and it became apparent that an overhaul was needed. A reform package was introduced in 1994, which proposed measures designed to increase system resilience and improve outcomes, including decentralising decision-making, introducing user fees and promoting public-private partnerships (PPPs).
The HSSP III ran from 2009 to 2015 and focused on delivering commitments under the UN’s MDGs. More broadly, it aimed to improve access to care and facility management, pushing forward PPPs and tackling infectious diseases such as malaria, as well as NCDs. The strategy also pledged to improve financing and insurance coverage to provide universal health care.
Rising Spending
Per capita spending on health care reached $137.49 at purchasing power parity in 2014, the last year for which figures were available, up from $106.40 in 2010, according to the WHO. In constant exchange rate terms, expenditure per capita nearly doubled between 2009 and 2014, rising from $25.70 to $51.30. Sector outlays are shared between the government and private sources, with the state accounting for 46%, or $63.83 of per capita spending in 2014. Public and private spending are set to continue to rise in the coming years, yet sizeable gaps persist. A 2014 report by UK-based NGO Chatham House suggested a minimum of $86 per person was required to provide basic health services, meaning the government falls short of its aims to ensure universal quality coverage.
Low-income Tanzanians face additional burdens when seeking treatment. E4A-MamaYe, a maternal and child health organisation which focuses on sub-Saharan Africa, said in a 2015 report that upfront costs place a burden on lower socio-economic households. The share of out-of-pocket costs accounted for around 33% of the total spending on health care between 2010 and 2013, well above the recommended maximum of 20%.
Government Expenditure
The 2001 Abuja Declaration, of which Tanzania is a signatory, committed African Union countries to set aside a minimum of 15% of their government budgets for heath. While the country achieved this between 2006 and 2009, expenditure slipped to an average of 11% of the budget from 2010 onward. The government’s expenditure on health care as a proportion of GDP hovered around 2.5% in 2014, beneath the 5% recommended by Chatham House. This is partly because government revenues comprise such a low proportion of GDP – at 15.8% in 2013 – making Tanzania one of just 32 countries in the world with state revenues below 20% of the total. “There are challenges in financing infrastructure projects, while there are shortages of medicine and equipment in some parts of the country,” Tony Naleo, a health planning and management specialist working in Tanzania, told OBG. “These issues are partly due to management, but also partly to do with the availability of funding.”
Private Sector
The private health sector is an increasingly important part of the system. As of 2014, the last year for which data was available, there were 39 private hospitals with a total of 1187 beds, and 78 private health centres with 800 beds. In addition, there were 40 private clinics, 26 private dental clinics, five private eye clinics and 22 private maternity homes. The private sector has traditionally focused mainly on urban areas. Costs are often relatively high by local standards, making access to private care largely a preserve of the affluent and expatriates. However, the spread of private health insurance has seen this pattern shift somewhat.
“The private sector has grown on the back of new opportunities to enter the market in the past five to 10 years,” Naleo told OBG. “Austerity has meant that investment is not circulating at the rate it once was, but the potential is still there, from a growing middle class and from expatriates. The situation will improve, and health insurance co-financed by employers is helping.”
Budget Allowance
A total of TSh1.98trn ($900.6m) was allocated to the 2016/17 health care budget, accounting for 9.2% of the total government spending, excluding the costs of debt servicing. Spending prioritised the provision of quality services to all citizens, with TSh646bn ($293.8m) assigned to primary care, a priority area for the government as it seeks to provide better access to on-the-ground care in local communities, which eases pressure on hospitals.
Some TSh251.5bn ($114.4m) was set aside for procurement of medicines, medical equipment and reagents – via the Medical Stores Department, an autonomous division under the Ministry of Health, Community Development, Gender, Elderly and Children (MoH) – including TSh71bn ($32.3m) for outstanding debts. A further TSh4bn ($1.8m) was allotted for equipment for Jakaya Kikwete Cardiac Institute, Muhimbili Orthopaedic Institute, Ocean Road Cancer Institute and Mbeya Zonal Referral Hospital. Several specific diseases are also addressed in the budget, with TSh24.5bn ($11.1m) allocated to cancer examination, a TB and leprosy control programme, the treatment of chronic TB and for psychiatric services. AIDS remains a leading health care challenge; as such, the government set aside TSh80.8bn ($36.8m) to prevent and treat the condition in 2016/17. Upgrading and expanding health care infrastructure is an ongoing project, with TSh18.8bn ($8.6m) designated for rehabilitating regional hospitals and completing those under construction, as well as a further TSh10.1bn ($4.6m) for improvement of infrastructure and services in zonal and national hospitals.
New Vision
Reaffirming Tanzania’s commitment to providing all households with quality health care, the HSSP IV was implemented in July 2015 and will run until June 2020. The plan follows the Tanzania Development Vision 2025, which aims to increase access to quality primary care and reproductive health services; reduce infant and maternal mortality rates; provide universal access to clean water and sanitation; and raise life expectancy to middle-income-country norms.
The current HSSP IV has five strategic objectives: first, making measurable improvements in primary care to deliver a range of services in local communities; second, improving equitable access to services focusing on regions with higher disease burdens and vulnerable demographic groups; third, the implementation of a community partnership in the health sector to enhance interaction with the population and make the system more responsive to the needs of citizens; fourth, getting a higher rate of return on investment through improved management and strategic partnerships, including PPPs; and fifth, ensuring better collaboration with other sectors and organisations, including health promotion and protection in policymaking more broadly.
Policy Priorities
Following these goals, the HSSP IV outlines a number of concrete policies and strategy objectives to be rolled out. Each is designed to provide opportunities for the private sector and foreign partners in areas related to consultancy, ICT services, and supply of equipment and pharmaceuticals.
Under the first strategy objective, policies include a stronger certification and ratings system for facilities that will link performance to insurance payments, incentivising raising standards and channelling resources to the best-performing clinics and hospitals. New performance management systems are expected to strengthen the quality of care and reduce corruption.
The second objective deals with improving the integration of social welfare and health services, increasing collaboration with NGOs and other agencies, and focusing on gender equality. Meanwhile, to improve return on investment, the government aims to increase the use of ICT in resource allocation to strengthen decision-making, communication and logistics. This pillar includes the rollout of the health financing system, as well as the use of additional funds, including sin taxes. Additionally, the government aims to improve the environment for investment by mobilising non-governmental and private sector partners to promote health and well-being.
Changing Lifestyles
There may be particular scope for the private sector to address the rising pressure on the system from NCDs, as well as changing health care demand patterns. The HSSP IV acknowledges this growing burden and pledges to “gradually step up the diagnostic and therapeutic capacities for NCDs” by allotting TSh340bn ($154.6m) to NCDs and mental health – another area that would benefit from more funding – in 2015/16, and nearly doubling this figure over the five-year lifespan of the programme to TSh674bn ($306.6m) in 2020/21. However, funds from the HSSP IV to tackle malaria will ease over the period, from TSh260bn ($118.3m) to TSh185bn ($84.1m).
As Tanzanians live longer and urbanisation affects lifestyles, NCDs are becoming increasingly prevalent. “Tanzania needs more facilities for senior citizens, palliative care and home-based care,” Sulaiman Shahabuddin, regional CEO for Aga Khan Health Services East Africa, part of the international developmental organisation Aga Khan Development Network (AKDN), told OBG. “Meanwhile, there are only two hospitals with catheterisation laboratories for cardiac care and six or seven MRI labs in a country of 51m people.”
AKDN estimates that 85,000 Tanzanians per year will develop cancer by 2030, which some feel has not been fully addressed, partly due to a focus on more immediate issues. “Tanzania has had a policy of supporting primary health, and there have been maternal and child health initiatives, but the last five to 10 years have seen an emergence of NCDs, such as diabetes and hypertension,” Naleo told OBG. “Policies and strategies have not changed enough to meet this emerging threat. A significant proportion of urban adults are exhibiting signs of the sort of health problems one sees in the developed world, including obesity. Cancer is becoming a huge problem, as the costs of chemotherapy, radiotherapy and hospitalisation are tremendous.”
Project Spend
The total cost of the five-year HSSP IV is an estimated TSh21.9trn ($10bn), with annual expenses rising from TSh4trn ($1.8bn) in 2015/16 to TSh4.9trn ($2.2bn) in 2019/20. Taking into account population growth projections, the average per capita cost will hover at around $42 per year. Annual expenditures going towards human resources is the single largest cost, with TSh740bn ($336.6m) being spent in 2015/16 and increasing to TSh1trn ($454.8m) in 2019/20.
Overall, TSh602bn ($273.8m) will be allotted for AIDS, with that cost growing to TSh644bn ($292.9m) in 2019/20. Infrastructure investment received an allocation of TSh590bn ($268.3m) in 2015/16, rising to TSh610bn ($277.4m) in 2016/17, before easing down to TSh565bn ($257m) in 2019/20. There is a question of whether current funding structures will be sufficient to cover this large and growing outlay, and new forms of financing may be required to bridge the gap.
Single System
The need for increased funding is acknowledged as a pressing challenge. The HSSP IV recognises that current spending levels are unsustainable, particularly given the desire to ensure universal coverage. However, despite funding gaps, the government has committed to implementing the single-payer National Health Insurance Scheme (NHIS) countrywide by 2020, by identifying new levies and special taxes.
Tanzania operates a range of health insurance programmes focused on different population segments. These include the Community Health Fund aimed at those in rural areas; the Tiba Kwa Kadi for those working in informal sectors; the National Health Insurance Fund, compulsory for those employed in the public sector, and covering their dependants; and social health insurance benefits under the National Social Security Fund, an organisation managing social benefits for non-government workers. Implementing a single-payer system will extend coverage to all citizens, while reducing costs associated with running overlapping schemes.
New Financing
The Health Financing Strategy (HFS) 2015-25 will streamline health financing by consolidating the insurance schemes and capitalising on economies of scale, administrative efficiencies and pooled risk. This entails the creation of the NHIS, covering all Tanzanians and funded through compulsory contributions from companies and higher-income groups with subsidies of up to 100% for the lowest-income citizens.
Tanzania aims to boost domestic revenues. This will be of particular importance if the country moves up towards middle-income status, leading to a tapering down of international aid. Nonetheless, the government expects to use some donor cash, as well as taxes, to fund the NHIS and supplement necessary payments. The government is considering increasing sin taxes further to boost the health care budget, and raising levies on vehicle insurance to fund the medical costs of Tanzania’s high road traffic accident rate. Data published by the WHO in 2014 showed that 10,740 deaths, or 3% of total fatalities, were caused by traffic accidents.
The HFS was drawn up with the support of a range of sector stakeholders, and aims to create a more efficient and sustainable model of resource expansion and allocation overall. A major priority is to ensure that all citizens have access to a standard minimum package of primary and secondary care services, with a particular emphasis on ensuring that low-income groups and the disadvantaged have access. The goal is to expand treatment and services covered by the plan over time.
The NHIS will transfer funds to facilities for medical supplies and maintenance of infrastructure. Meanwhile, services including environmental health, health promotion and some community-level health care will continue to be funded directly by the MoH and the Prime Minister’s Office – Regional Administration and Local Government of Tanzania. A top priority of the new system will be ensuring that resource allocation is efficient and keeps pace with changing demands.
Outlook
The progress that Tanzania has made in recent years in tackling communicable diseases, expanding primary care and improving most major public health indicators shows that the country is on the right track. Nonetheless, there are gaps in the system, with challenges in areas such as maternal health and the risk of a growing funding gap. The HSSP IV looks to address these concerns, with support from international partners and a growing role for the private sector. The first two years of the programme have seen ambitious plans run up against the government’s pressing need to consolidate the budget, but as growth picks up again and the fiscal outlook improves, there is an opportunity to push ahead with reforms and big projects outlined in the strategy. With funds tight, the role of the private sector can be ever more important, and private and foreign players can look to opportunities in provision, financing, supply and consultancy.
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