CHAPTER 6: NUTRITION AND THE CONTROL OF DISEASES

Introduction
Malaria
Acute respiratory infections (ARI)
Diarrhoea and vomiting
Measles
HIV and AIDS
The Health Services

Introduction

According to the 1990 health institutional based records diseases of high endemicity related to undernutrition in Tanzania include malaria, respiratory infections, diarrhoea and recently AIDS.

Table 44: Frequent causes of attendance to health facilities and leading causes of deaths in hospitals in Tanzania in 1990

Diseases	Frequency of death	Relative frequency of attendance
1. Malaria	14	23
2. Pneumonia	11	10
3. Diarrhoea/vomiting	10	10
4. Nutritional disorders	7	9
5. Conditions of early infancy	5	9
6. Measles	4	9
7. Anaemia	4	9
8. Tuberculosis	3	9
9. Cardiac diseases	3	9
10. Tetanus all forms	2	9
11. Upper resp infection	9	20
12. Skin conditions	9	6
13. Accidents	9	4
14. Eye diseases	9	4
15. STDs (excluding AIDS)	9	3
16. Intestinal worms	9	2
17. Pregnancy complications	9	2

Source: Ministry of Health 1991

Malaria

Malaria is the leading cause of out-patient attendance; often the leading cause of hospital admissions and among the commonest cause of death. Attacks of malaria are more serious in children than in adults and very often growth faltering in children is due to repeated attacks of malaria. The disease is endemic in most of the country with areas above 3000 metres fairly free from the anopheles mosquito, its principal vector. The pattern of malaria mirrors that of anaemia thus stressing the importance of malaria in the causation of anaemia. On the other hand anaemia which is an important cause of maternal mortality where haemorrhage occurs in already anaemic mothers is a major complication of malaria.

Table 45: The commonest causes of admission and death in children underfive years

Disease	Admission (percent)	Death (percent)
1. Malaria	40.8	23.0
2. Diarrhoea and vomiting	23.4	16.0
3. Malnutrition: severe protein energy undernutrition and anaemia	14.1	24.6
4. Respiratory tract infections	7.7	16.4
5. Immunicable diseases (mainly measles, TB and tetanus)	3.1	6.6
6. Others	10.9	13.4
Total	100.0	100.0
Number of cases	6,925	888

Source: Kimati V.P, 1989

In Tanzania malaria transmission and case fatality have reached alarming proportions. Because control and treatment have become increasingly difficult due to both parasite and vector resistance to the most cost-effective drugs (chloroquine) and insecticides; malaria prophylaxis in children and pregnant women is becoming more expensive as alternative drugs to chloroquine have to be used.

Lessons learned from the national malaria control programme and control of malaria in the JNSP/CSD programme areas indicate the necessity to establish a first line and second line treatment system, where the cheapest and reasonably cost effective drug (still chloroquine in many parts of Tanzania) will be used to treat most cases. Recurrent malaria would then need second line more expensive drugs. For those not responding to second line drug treatment and for emergency cases a referral hospital system or to a Rural Health Centre with diagnostic facilities to confirm malaria appears to be the feasible option of keeping costs down and to limit accelerating resistance to second line drugs. However, this system may pose risks to individuals and to pregnancy outcomes.

For this system to function properly, parents, village health workers, and other “health animators” have to make sure that prompt and correct dose treatment using chloroquine is done in all suspected cases of malaria. Chloroquine is already available in village health posts, dispensaries, and is sold on the counter in most village shops. Second line drugs and diagnostic facilities have to be made available at RHC and hospitals for treating referred cases. In order to have referral points as close to the community as possible it may be advisable to equip some few dispensaries with referral facilities and comprehensively equip the district hospital to function as the final referral point.

This system has to be combined with efforts to reduce malaria transmission. Households and communities have to take measures to reduce or treat vector breeding sites, screening of houses and application of insecticides. Information for families about how to improve their health through advocacy like the UNICEF booklets on “Facts for Life” translated into Kiswahili as “Ukweli Kuhusu Maisha” need to be emphasized.

The use of permethrin impregnated bed-nets has been shown to be effective in the pilot tests in Iringa, Mtwara, Morogoro and Zanzibar. The use of these nets for children under five and for pregnant women have shown reductions of malaria morbidity rates by 35-46 percent in underfives and by 36-41 percent in adults in the trial areas [URT/UNICEF, 1990]. The annualized cost of the permethrin impregnated bed nets is 260 Tshs. which is less than $1.50. In comparison the not so successful vector control programmes in Zanzibar, Dar-Es-Salaam and Tanga was estimated to cost $2 per person for imported materials alone in 1982.

Acute respiratory infections (ARI)

Upper respiratory infections like colds combined with pneumonia make up the second commonest cause of out-patient consultations. In most community surveys, common colds are the most prevalent signs of disease in children. Inadequate care of these mild cases of ARI plus poor nutritional status are probably the main reasons for the high number of deaths and complicated cases of ARI. According to the Tanzania Health Profile 1991 issued by the Ministry of Health, in 1990 ARI accounted for 30 percent of the attendances in health facilities and pneumonia was the second leading cause of death [URT/MOH, 1991]. In the 1984-85 survey of MCH clinics in five regions, 10.5 percent of outpatients aged under five years were diagnosed as suffering from acute respiratory infections; pneumonia accounted for 37 percent of these and was associated with measles in half the cases [URT/UNICEF, 1990]. According to survey records of MCH clinics in 1981 measles was commonly associated with deaths from pneumonia. The rate of severe undernutrition was three times higher among children who died than among those who survived. Measles is also known to be associated with xerophthalmia due to vitamin A deficiency in about two thirds of the cases [Foster et al 1986 and Pepping et al 1988].

An effective way to reduce the severity of acute respiratory infections is, therefore, to improve the nutritional status of the underfive year children and immunization against measles, tuberculosis and whooping cough.

A number of ARI control activities supported by UNICEF are already underway in Kilimanjaro, Mtwara and Iringa as part of an integrated primary health care effort including control of diarrhoea diseases (CDD), malaria, water and sanitation [UNICEF, DAR, 1991]. Activities include development of information, education and communication and training materials for use in villages and in health facilities, training of health staff and Village Health Workers (VHWs), provision of antibiotics and baseline surveys. The ARI control programme in Bagamoyo supported by GTZ has been shown to lead to nutrition improvement as well [Neuvians, 1987]. The success of ARI control in Bagamoyo has led to the development of a national policy and treatment guidelines for village health workers and first and second level referral facilities by the Ministry of Health.

Diarrhoea and vomiting

The third most common cause for outpatient attendance in Tanzania is diarrhoea. Children aged under five years are estimated to have three to five episodes of diarrhoea per year. The specific cause cannot be identified in most cases, but the majority are probably caused by the wide variety of viruses and rotaviruses. Typhoid, amoebiasis, cholera and bacillary dysentery are the causative agents in a minority of cases. The case-fatality ratio is about ten percent, usually from dehydration. The use of oral rehydration therapy has been shown to be an effective treatment for such dehydration. Eight million sachets of oral rehydration salts (ORS) are distributed annually to rural dispensaries and health centres through the Essential Drugs Programme. There is inadequate knowledge of the proper use of ORS however. A communication programme is being implemented by the Diarrhoeal Disease Control Programme of the Ministry of Health to improve knowledge about proper use of ORS and use of home made fluids, thin porridge, “uji”, in preventing dehydration.

Measles

Until very recently, measles was one of the three major killers of children in Tanzania, estimated to account, with its complications of diarrhoea, pneumonia, and malnutrition, for about ten percent of child deaths. However, the reported cases of measles have gown down in the share of morbidity from 0.8 percent to 0.2 percent between 1984 and 1988 [TFNC 1990b]. The absolute number of measles cases reported were over 11,000 annually for the three year period 1985-88 and were down to 4405 cases in 1989. The decline of measles cases coincided with the increase in measles immunisation coverage for one year olds which went up from 76 percent in 1986 to 83 percent in 1988. Data from 42 sample health units show a dramatic decrease in reported case numbers from 700 new cases per month in 1981 to 220 in 1986 [URT/UNICEF 1990]. As already noted the universal child immunization (UCI) programme initiated in 1986 significantly decreased the magnitude of measles as a cause of malnutrition. For example: In 1984 a survey in Iringa reported 20 percent of deaths of children under five to be due to measles [Msamanga 1990]. By 1987 after immunization rates had been increased, under 7 percent of children were reported to be due to measles according to the study conducted in Iringa over a period of 16 months starting from April 1986. Measles immunization was found to reduce clinical cases by 70 percent.

In an outbreak of measles in Korogwe District in 1990 about 90 percent of the reported cases were among children who had not been vaccinated [URT/UNICEF 1990]. The challenge now is to maintain the high rates of measles vaccination achieved.

HIV and AIDS

Sexually transmitted diseases are among the commonest causes of outpatient attendance in Tanzania. In 1986 gonorrhoea alone ranked third in the Rukwa region after malaria and diarrhoea [World Bank, 1989]. Before the AIDS outbreak STDs ranked second in Kagera region. Thus the current outbreak of AIDS must be seen against this background of pervasive STD infection.

Figures from various sources all indicate that the HIV/AIDS epidemic continue to increase at alarming rates throughout Tanzania since the first three cases were diagnosed in Kagera region in 1983 [National AIDS control Programme, 1991]. Since then the cumulative number of cases notified in Tanzania mainland have increased from 3 to 27,396 as of June 1991 (table 46). The most severely affected regions are Dar-Es-Salaam, Kagera, Mbeya and Coast.

Table 46: Cumulative number of notified cases of AIDS in Tanzania mainland by region (1983* - June 1991)

Region	1986	1987	1988	1989	1990	1991	Population ('000)	Rate**	Rank
Arusha	10	47	217	429	579	703	1352	52	15
Coast	4	79	224	413	705	910	638	143	4
DSM	471	1470	3093	5203	7195	8474	1361	623	1
Dodoma	7	47	105	247	211	278	1238	23	20
Iringa	3	68	305	374	612	1109	1209	92	6
Kagera	847	1665	2142	2543	3164	3479	1326	262	2
Kigoma	3	50	109	243	434	529	855	62	13
Kilimanjaro	36	207	455	570	854	1023	1109	92	5
Lindi	1	9	45	111	394	472	647	73	9
Mara	3	30	99	139	326	326	971	34	18
Mbeya	16	208	747	1042	3764	3764	1476	255	3
Morogoro	11	88	247	339	819	819	1223	67	10
Mtwara	5	23	95	173	557	557	889	63	12
Mwanza	54	171	448	644	1590	1590	1878	85	7
Rukwa	1	5	90	94	164	164	695	24	19
Ruvuma	20	45	76	187	394	394	783	50	16
Shinyanga	8	31	144	227	667	667	1773	38	17
Singida	6	74	197	284	445	445	792	56	14
Tabora	6	59	232	510	877	877	1036	85	8
Tanga	13	80	210	335	816	816	1284	64	11
Tanzania	1525	4456	9280	14107	22055	27396	22534	98	-

Source: NACP, Surveillance Report No. 5, August 1991

* In 1983, there were only 3 cases in Kagera region, in 1984 there were 109 cases nationally, 106 being in Kagera, 2 in Tabora and one in Kilimanjaro. In 1985 there were 404 cases, 322 being in Kagera, 51 in Dar-Es-Salaam, 15 in Mwanza, 8 in Kilimanjaro and one each for Iringa and Mtwara.

** Rate per 100,000

The reported figures are biased by many factors including double reporting, under-reporting, under-diagnosis as well as delays of reporting to the Ministry of Health. The reported figures would reflect the real trend if the following assumptions were met:- a) all AIDS cases report to health facilities b) all AIDS cases are correctly diagnosed c) a functional reporting system from the regions to the Ministry of Health is in place in all the regions.

Since the interpretation of AIDS case trends must be done in the light of HIV sero-prevalence data, a large pool of HIV infection already exist in the population. Based on age adjusted blood donor sero-prevalence the estimated number of HIV infected persons as of June 1991 was 673,330 of whom 304,019 (45.2 percent) were males and 369,311 (54.8 percent) were females [NACP 1991, Swai and Asten 1991]. Taking into account future infections that might occur in the years to come an increasing number of AIDS cases will likely continue to be documented up to and beyond the year 2000.

Two groups are of a particular importance as far as HIV/AIDS is concerned: antenatal clinic attenders and adolescents. Data from the National AIDS Control Programme's surveillance system show that among pregnant women attending antenatal clinics the HIV sero-prevalence is increasing. In a period of little over a year from 1990 to 1991 the prevalence increased from 10 percent to 16 percent in Mbeya; from 8 percent to 14 percent in Mwanza and from 20.8 percent to 23.3 percent in Bukoba. The effect on the infant mortality rate will be considerable as 30 percent of children born to these women will die from AIDS within the first few years of their lives. Children escaping infection with HIV (up to 11 percent) are unlikely to have a mother (or any parent) still alive by the end of the century. Data from blood transfusion services throughout the country suggest that the problem is virtually nationwide [NACP 1991].

Increasingly AIDS is manifesting in children as severe malnutrition. A study [Mgone et al 1991] done in Dar es Salaam in 200 children with severe malnutrition and a similar number of controls matched for age, sex, and area of residence showed a prevalence of HIV-1 antibodies of 25.5 percent in the malnourished group as compared to only 1.5 percent in the controls. The sero prevalence rate was equally high in malnourished children above the age of 18 months as in those below this age (25.5 percent). The prevalence rate was higher in children with marasmus (38.2 percent) as compared to children with marasmic-kwashiorkor (12.3 percent) or kwashiorkor (12.2 percent). The prevalence of clinical features known to be associated with AIDS was higher in the HIV sero-positive malnourished children as compared to the sero-negative children. Thus it is important to rule out HIV infection in malnourished children especially those with marasmus.

The second group of great concern are adolescents 15-19 year olds and the 20 - 24 year age group. Among 15 - 19 year olds, the percentage seropositive was 0.0 percent in 1987, increased rapidly thereafter, and reached 5.4 percent by 1990 [NACP 1991]. Among the 20 - 24 year group, prevalence increased fourfold from 1.6 percent to 6.4 percent between 1987 and 1990. Further analysis revealed that the situation among adolescents was more serious for girls than boys.

Based on the number of AIDS cases reported during the 1990's and even assuming that further transmission of HIV would cease as from now, out of the estimated present number of approximately 700,000 HIV infected persons, 450,000 will develop AIDS during the remainder of this decade. If transmission continues up to 1995 at a rate of 1 percent new HIV infections per year, 750,000 will have developed AIDS by the year 2,000 [NACP 1991 and Swai and Asten 1991].

The rapid spread of AIDS will have far-reaching implications in Tanzania over the next decade. Most HIV infected individuals will die in the prime of their life or before. This will directly or indirectly affect a larger number of people who as relatives or friends will incur various costs on account of the AIDS victims themselves; or as survivors may be left in greater poverty or as earners, employers or self-employed may experience productivity losses. In addition there is the problem of the likelihood of the resurgence of AIDS induced diseases like tuberculosis which has already started to be felt [Pallangyo 1991].

The overall effect is probably demographic changes in the composition of the population and work force. Rising mortality in the adult population will leave behind a younger, inexperienced and less educated and trained population which may affect the economy in the medium and long term. Health services will come under increasing pressure as AIDS victims and AIDS induced disease victims compete for the limited resources. All these will negate progress made on the reduction of child mortality and malnutrition rates.

As a response to the AIDS epidemic the government of Tanzania in collaboration with the World Health Organisation planned a five year mid-term plan of action in 1988 and formed the National Aids Control programme (NACP) in the same year to implement the plan [Nyamuryekung'e 1991]. Considerable progress has been achieved since then. Facilities for screening of blood donors have been established in all referral and regional hospitals and most district hospitals. A sentinel surveillance system has been established and a national information, education and communication campaign reinforced by a massive distribution of condoms is been conducted. The objective is to raise public awareness about the disease, its transmission and self-protection measures. The need to change sexual behaviour has also been strongly emphasized. By 1990 awareness studies conducted showed an awareness level of more than 90 percent irrespective of sex, adult age group, education, religion and geographical location [Swai and Asten 1991]. But this encouraging level of public awareness and knowledge has not been followed by changes in sexual behaviour.

In the light of the above facts, there remains an urgent need to review programme strategies, in order to come up with interventions which will bring rising trends to a halt. AIDS has no cure, and it is unlikely that any vaccines or “delaying” treatments that can be applied on a large scale in Tanzania will be available soon.

Thus in this situation two major approaches need to be pursued. The first is to strengthen measures to decrease the spread of HIV infection. The second is to strengthen and develop measures to reduce the effects of illness and deaths on survivors in the family and in the community.

A revised strategy is now been developed by the NACP which involves a number of strategic actions. Efforts in the control of other sexually transmitted diseases (STDs) are being strengthened since their presence significantly increases the likelihood of HIV transmission. Continuation of IEC efforts, but with greater emphasis on initiating and pursuing constructive dialogue at family and community level as well as among certain key groups such as women's groups, bar/hotel owners and staff, parents, national service and military staff, transport companies and long distance drivers is being strengthened. There are also efforts aimed at reducing the need for blood transfusion by improving the prevention of anaemia [TFNC 1991] and other diseases like malaria. It will also be important to identify groups and communities which have been successful in controlling the spread of HIV/AIDS and to ensure that their experience is shared with others.

The strain on the traditional care systems for AIDS orphans by relatives or neighbours imposed by the AIDS pandemic is becoming severe. Women have been particularly strained as care for severely ill husbands or relatives and additional children of relatives of AIDS victims add to their already heavy workload and resource deficiencies. Thus an important strategy in the control of AIDS in the 1990's will have to put increasing emphasis on social and economic factors in addition to medical factors. Direct external support will be needed to ensure that orphaned children receive education and that their rights e.g. for inheritance are respected.

The Health Services

Systems for health care delivery
Health care facilities
Health care personnel
Accessibility to health care
Health care quality
Health financing
Health care in need of treatment

A well functioning system for the delivery of health services is important for the control and prevention of diseases which as we have already noted are an immediate cause of malnutrition. Most of the health actions related to nutrition are implemented through the Primary Health Care (PHC) strategy.

Health education which is an important means of providing people with access to knowledge and information to help improve their nutritional status and overall health is also part of the strategy.

Systems for health care delivery

Health services in Tanzania are provided through four systems:- the traditional healers; the Government's modern system; the Non-Governmental Organizations (NGOs) and the private modern health service providers. The Government provides for 70 percent of the modern health service free from direct user charge while the rest is provided by voluntary agencies at modest fees and a few private individuals at cost-benefit rates.

The traditional system seems to be the most extensive in the rural areas and is comprised of traditional “doctors”, traditional birth attendants (TBA), Herbalists, Sorcerers etc. The estimated number of traditional healers is about 40,000 or one traditional healer for every 650 people [MOH 1991]. Traditional Birth Attendants (TBAs) number about 32,000 or 4 TBAs in each of the 8,000 registered villages of whom 3,000 were trained in 1990. The persistence of the traditional system related to witchcraft is among the major impediments to the development of a health culture, behaviour and even general development.

Traditional health providers charge directly for their services in cash or in kind. Many people in both the urban and rural areas consult the traditional doctor before they go to the modern health sector. In some instances this health seeking behaviour results into unnecessary conflicts, suffering and sometimes deaths. In other instances traditional health systems are very useful. The Government has recognized the importance of the traditional system in overall health care and has incorporated some of the service providers like TBAs in some of the training programmes. A traditional Medicine Research Institute has been formed and the Government supports a Traditional Healers Association and a Traditional Medicine Policy has already been drafted.

Traditional healers are known to handle many nutrition related diseases. For example a study in Mbozi district, Mbeya region showed that traditional healers were very useful in the community-based follow up of children being discharged from nutrition rehabilitation units and thus reduced the default rate [Van Roosmanlen-Wiebenga, 1988]. We also have some information regarding the use of high energy density foods by traditional healers who try to treat AIDS victims.

With the exception of grade one services in a few regional and consultant hospitals, the Government delivers all types of health services free from direct user charge. This policy emanated from the Arusha declaration of 1967 which proclaimed “Ujamaa” and Self reliance as the national ideology directed the provision of free health services to all Tanzanians and as close as possible to their homes with a shifting emphasis from curative to preventive care.

Much of the widespread health care services infrastructure that is evident in the rural areas today is a result of a 1971 re-emphasis of the policy and was built between 1972 and 1982 [SIDA 1987]. It is impressive to put on record that the basic philosophy and strategy underlying this policy is consistent with the Primary Health Care (PHC) approach to achieve health for all by the year 2000 which was recommended by member states of the World Health Organization (WHO) ten years later at the World Health Assembly in 1977 and unanimously adopted as the Alma-Ata declaration in 1978.

Health care facilities

The delivery system is among the most extensive in Africa and is done through a network of facilities at the central, regional, district, divisional, ward and village levels. These facilities are designed for both primary contact between the user and the provider and for referral of patients to the appropriate next level of care should the initial contact not be equipped to deal with the health problem under consideration.

a) At the lowest level the village health worker (VHW) trained in basic first aid, sanitation and nutrition education make referral to

b) the dispensary, which is staffed by at least one rural Medical Aid (RMA) and capable of providing basic curative and preventive care, who in turn make referral to

c) the Rural Health Centre (RHC) staffed by a Medical Assistant (MA), who is better trained than the RMA but offering basically similar services and assisted by about eight trained health workers with some bed capacity of about 15; who would make referral to

d) the district hospital which is usually staffed by at least one graduate Medical Officer (MO) with assistance from several categories of trained health personnel, offering both primary and more sophisticated outpatient and inpatient and preventive care; who would make referral to

e) the regional hospitals offering similar services to those of the district hospital but with more sophistication in diagnosis and treatment and qualified health personnel and lastly would make referral to f) the Zonal Consultant hospitals offering the same services to those of the regional hospital but with more sophistication in diagnosis, specialized treatment and equipment.

The number of health facilities has been gradually increasing as shown in fig 7. Government-owned dispensaries increased from 875 in 1961 to 1,425 by 1971, 2,600 by 1980 and 2,644 by 1984 - an increase of 200 percent. The ratio of population to dispensary fell from 1:11,700 in 1961 to 1:6,800 in 1981, and then increased to 1:8,100 by 1989 due to higher population growth rates than the rate of construction of new health facilities. By 1984 each dispensary served about 2-4 villages, and 70 percent of the population being within 5 km walking distance. Population per medical assistant or RMA was reduced from 17,703 persons in 1961 to 5,205 in 1984.

Figure 7: The growth of health facilities in Tanzania (1961-1989)

Source: Planning Commission, “Economic Survey”, various issues

The rural population per dispensary to indicate physical accessibility is shown in map 6.

Map 6: Rural population per dispensary in Tanzania, 1989

Source: United Republic of Tanzania, Bureau of Statistics, “National Socio-Economic Profile of Tanzania, 1989” Dar es Salaam, 1989

Health care personnel

In 1987, there were about 900 medical officers and 517 assistant medical officers trained and practising in Tanzania or one for every 16,000 population [URT, 1991]. Significant progress has been made in the training of mid-level personnel where emphasis has been placed. Over 3,000 medical assistants and 5,000 rural medical aides have been trained, or one for every 2,800 population. Tanzania has now over 4,000 nurses and over 3,000 Maternal and Child Health Aides (MCHA) or one for every 3,200 population; and 436 health officers and over 1,200 health assistants or one for every 13,800 population. Unlike in other African countries most of the health personnel are concentrated in the rural areas.

Accessibility to health care

The level of health care accessibility throughout the country is rare in a country as poor as Tanzania [MOH, 1989]. An evaluation of health services conducted at the time of the population census in 1978 showed that 72 percent of the rural population lived within five km of a health facility and 93 percent within 10 km [MOH, 1989]. In the PHC review of 1984; the situation was found to be the same: 73 percent of the rural population in the six represented regions surveyed lived within 5 km of a health facility as were 95 percent of all urban households [MOH/WHO, 1984].

There is also evidence to indicate that the health facilities particularly at the primary level are actually been utilized as shown by high attendance rates and coverage by specific programmes [Kavishe, 1990]. For example, the average per capita utilization of outpatient care in 1972 was 4.3 and remained the same during a health inventory in 1978 [MOH. 1989]. During both years, more than two thirds of the outpatient visits were made to the lowest level facility (the dispensary) increasing from 72 percent in 1972 to 84 percent in 1978.

Specific programme coverage statistics are also impressively high. The evaluation of the MCH of 1981 [MOH, 1982] estimated that 85 percent of all pregnant women received antenatal care and more than 55 percent of all deliveries took place at a health institution. The PHC review of 1984 indicated that these figures had increased to 95 percent for antenatal coverage and to 60 percent respectively for institutional deliveries for the six regions surveyed (Iringa, Morogoro, Arusha, Lindi, Rukwa and Shinyanga). For Dar-Es-Salaam 80 percent of the deliveries had been attended by a trained health worker. The 1991/92 DHS showed that 53 percent of deliveries took place in a health facility. In the 1984 review, an average of 90 percent of the rural children had been seen twice or more by a qualified trained worker (93 percent in Dar-Es-Salaam); 75 percent had a growth chart in rural areas (85 percent in Dar-Es-Salaam) and almost all children who had seen a health worker had been weighed at least twice.

The most remarkable public health achievement in Tanzania during the last half of the 1980s was universal child immunisation (UCI). Under the UCI programme, children were immunized against six major diseases - measles, tuberculosis, tetanus, poliomyelitis, diphtheria and whooping cough. When a national programme for immunisation was established in 1981; the vaccination coverage for measles was a mere 31 percent and only 22 percent for a complete course of three vaccinations against polio [URT/UNICEF, 1990]. A national infrastructure of trained staff and cold chain operations was established and in 1986 President Alli Hassan Mwinyi personally endorsed an accelerated programme to achieve universal child immunization by 1988. From a coverage survey conducted in early 1989, the immunisation coverage rate against each of the six major childhood diseases for children aged 1 to 2 years rose from 53 percent in 1986 to 83 percent by the end of 1988 thus surpassing the global goal of 80 percent by 1990 two years before the target date.

Tanzania was the first large sub-Saharan African country to reach this goal. This achievement was possible through the development of a clearly defined objective and well developed plan of operations which made it possible to mobilize external funding for the programme. At the same time a strong social mobilization of parents to bring their children for vaccination; of communities to organize vaccination days in their villages; and health staff to perform outreach services so that every child could be reached empowered households and communities to assess, analyze and take appropriate action.

A major hindrance in sustaining these achievements is the present cost of the immunization programme which stands at $7 per child [URT/UNICEF 1991 and Davis 1990]. Already efforts have started to reduce this cost largely through reducing the wastage rate of vaccines by having well announced special vaccination days in clinics and outreach services rather than opening new vials on demand as it is currently practised.

Health care quality

Though according to estimates health workers spend on average about three minutes for patient consultation; and despite the limited training and almost lack of continuing education of primary health staff patient management has been noted as satisfactory. Medical supplies in the rural areas has been enhanced by the development of a national list of essential drugs, consisting of 192 items and their regular provision through the essential drug programme (EDP) since 1984 [MOH/WHO/DANIDA, 1985]. By prepacking and delivering the drugs directly to the health facility using a kit system, and by bulk purchasing and use of an international tender system the cost of providing these drugs has been at about US $ 0.5 per person per annum [URT/UNICEF, 1990].

However, the quality of medical care over the last decade has deteriorated sharply. This is reflected in an increasing maternal mortality and a perceived general increase in hospital mortality. Moreover, the unprecedented strikes by health personnel during 1992, is a reflection of the low morale which has permeated the health system. It is not uncommon to find health personnel charging for otherwise user free service. The deterioration is also reflected in peoples readiness to go to private health services even where government services are available. The deterioration is a result of government inability to meet on a user free basis, the increasing medical services of the growing population in an environment of severe economic deterioration.

Health financing

The financing of the health sector in Tanzania is complex due to the policy of decentralization of 1972 which was further strengthened for the health sector in 1984/85. As a result Government funding for health is channelled through four main sources:- (i) the Ministry of Health (MOH) budget (ii) the Ministry of Regional Administration and Local Government (MORALG) which was incorporated into the Prime Minister's Office in 1991 (iii) revenues of the District and Urban Councils from development levy and other revenues and (iv) the Prime Minister's Office budget. Although some small charge may be levied for higher quality rooms in a few hospitals, Government health care is provided free from user charge. Users of Voluntary Agency facilities pay some fees on a cost sharing basis. A considerable amount of money may be spent on the traditional private sector but estimates on such expenditures are difficult to obtain. Communities are known to contribute in health care through the construction of dispensaries and health posts and the payment of Village Health Workers (VHW) in cash or in kind. Greater community participation and contribution for health care is a culturally acceptable form of resource mobilization.

Thus the very impressive developments in the health care system over the past two decades described earlier have been possible due to a number of factors which include an equitable rural based national health policy; government commitment for its implementation; donor support; contributions of the community in cash and in kind; and contributions of voluntary agencies.

Multilateral and bilateral donors have also contributed large amounts of resources to health care in Tanzania over the past decade. Together with private church and lay NGOs based mainly in Europe and North America they provide substantial recurrent and development assistance in the form of finance, manpower and material supplies to the health sector. The health sector is only second to the agricultural sector as a recipient of foreign aid, sometimes taking nearly 15 percent of bilateral technical assistance which sometimes accounts for between two thirds and three quarters of development health spending.

DANIDA through UNICEF has been the most important contributor to the medical supplies in Tanzania since 1983 [URT/UNICEF, 1990]. Between 1983 and 1987 DANIDA gave nearly US $ 30 million in drugs and medical supplies. From 1989 the annual inflow for pharmaceutical supplies from DANIDA has been estimated at about $11 million.

Thus, whatever reservations may be harboured by some quarters the achievements in the health sector signify a cost-effective use of resources amidst an appalling economic situation and show that we do not have to wait for social economic development before setting up effective health delivery systems.

Health care in need of treatment

From the mid-1980s delivery of health services has faced two major problems. First, the increase in uncoordinated vertical programmes managed by external assistance teams (e.g. EPI, EDP diarrhoea programme, etc) has led to duplication of effort, intra-bureaucratic conflicts and, in some cases at least, weakening of the goal of community empowerment. Second, it has become increasingly difficult to sustain the level of delivery of health services attained in the seventies due to dwindling state funds and changing policy emphasis enforced by the World Bank/IMF conditionalities. Thus during the ERP period (1986-92) the policy of “free medicare for all” was abandoned with the introduction of user charges.

The health budget of 1990/91 illustrates the sustainability problem. Out of the shs. 13,649 million allocated to health, some shs. 5,440 million or about 40 percent was consumed by importation of drugs. This would suggest that at the present level of budgetary allocations, health programmes are virtually un-affordable, unless drugs are produced locally and cheaply or there is heavy reduction of administrative costs in the delivery of health services. High price of drugs in private dealers' shops (due to shortages in government health facilities) is currently forcing a significant section of the poor to relapse back to the traditional medicine-men who have also become commercialized.

In addition to a decline in public spending on health, a number of donors have shifted their support to the productive sectors in support of the economic recovery programme. As a result, the health system that has been put in place is deteriorating due to lack of resources for maintenance of physical structures, procurement of essential equipment and supplies, and low morale of personnel. With the possible exception of immunisation there is evidence to indicate that this has resulted into both quantitative and qualitative deterioration of the health services.

Furthermore, the rapid population growth has continued to stretch available resources. While the current provision of medical facilities and trained and skilled medical personnel in most categories meets the targeted goals of the Ministry of Health at the national level despite regional variations; the demands on these services in order to provide the current level of services will continue to rise with the population growth. Despite the priority given to the social services (health included) in the second Economic Recovery Programme (ERP2) through the Priority Social Action Programme (PSAP); the rapid population growth and the rising costs with a deterioration of real income are unlikely to favour a significant increase in public real per capita levels of health expenditure in the near future.

Thus the increasing cost of meeting the health needs of the population through a user free system is among the most immediate concern of national leaders [Kavishe 1990 and Wagao 1990]. Unless alternative health financing is forthcoming, a further decline is to be expected. The Government is already looking into the possibility of establishing user cost-sharing systems but this has to be done with utmost care. Using direct cost recovery user charges is a regressive alternative because many patients will not be able to pay. This may also have an effect on the most vulnerable groups by discouraging the utilization of preventive services whose relevance may not be immediately seen. The cost sharing systems used by voluntary agencies may provide a starting point but the quality of care should be drastically elevated to that offered by these agencies for the system to work. Insurance systems for workers and farmers may be started through their employers or co-operative unions and there are indications that this may be a better system than the direct user charge whether for purposes of cost-sharing or cost-recovery. Already Rombo district in Kilimanjaro region is experimenting with a health insurance system of an annual contribution of 200 Tshs. under the leadership of the current member of Parliament, Mr. Basil Mramba. Under the present conditions the question is not whether to find alternative sources, but how. The decision for cost-sharing has already been made, what is being awaited is its implementation.