Tanzania Essential Health Interventions Project (TEHIP)

TEHIP's research strategy is informed by the notion of fostering the "community voice" through participatory action research (PAR). All of TEHIP's field research activities are undertaken by Tanzanian researchers, who are recruited and trained. TEHIP selected two districts, Rufiji and Morogoro, as test sites for the locally-based, interactive research project. The TEHIP team acquired a fleet of bicycles, on which they dispatched researchers door-to-door. Across the district, they asked whether anyone had been sick or died lately, and, using a survey technique known as the "verbal autopsy," they guessed about the medical causes. The answers were fed into a computer programme that produced an epidemiological picture of what diseases were killing how many people and how many years of life were being lost, then weighted those deaths for impact on each household.

In an effort to strengthen and reorganise the health system to be able to address those causes of mortality, TEHIP again focused on fostering local participation. The project worked out a system that took supervisory responsibility for rural clinics out of the hands of the district medical officer and devolved it down a chain of command, giving new opportunities to local staff members to have a say in how their facilities should be run. The strategy here involved motivating and energising staff to take a greater interest in how to provide better care by listening to them. In an effort to then facilitate the process of communicating what drugs they needed, every clinic got a radio and a motorbike in an effort to shave days off the process of notifying the district office about outbreaks.

Health workers, mostly nurses or paramedics rather than doctors, were given a simple algorithm to show how to treat common symptoms. In most cases, the cheapest treatments are offered first. For example, for malnutrition, advice is first offered on breast-feeding. When this is not enough, cheap vitamin-A pills are prescribed. AIDS is tackled through education, condoms, and antibiotics to heal open sores. To address malaria, the health workers encourage people to use inexpensive, TEHIP-subsidised insecticide-treated bed nets (ITNs).

Other aspects of the project have focused on building the capacity of the District Councils (incorporating the Council Health Management Team, or CHMT) to carry out health management and administration. The 3-module, 15- to 18-month "Strengthening Health Management" (SHM) training course features various face-to-face workshops designed to increase the confidence and skills of CHMTs. "Ten Steps to a District Health Plan" is a workbook containing handouts which provide simplified theoretical bases for every step in the health planning process, as well as facilitation notes. Assistance has also been provided to guide the selection and ordering of computer equipment in both the CHMT office and the district accounts office. Local private sector companies have, through TEHIP, provided training in word processing, use of spread sheets and email, and other computing skills.

Health, Children, HIV/AIDS, Nutrition.

The project's roots lie in the 1993 World Development Report, in which the World Bank recommended that economically poor countries focus their efforts on the diseases that cause the most deaths. The report's authors speculated that raising per capita health-care spending to just $12 per citizen per year might bring mortality down by 25%. Tanzania spends $8 a year on the health of each of its citizens (in Canada, the figure tops $2,700). TEHIP offered to top up Tanzania's contribution by $2 a year, provided that the new spending was carefully directed. But there is no record of vital statistics in Tanzania, and 80% of people die at home. IDRC had to design a way to assess what was killing people.

One research finding, which informed the project's focus, was that large portions of the participating districts' budgets were being spent on comparably insignificant diseases. In 1996, for example, malaria was responsible for 30% of years lost, but received just 5% of the districts' budgets. Top childhood diseases such as diarrhoea, pneumonia, and malnutrition were responsible for 28% of the lost years, but got just 13% of the budget. But tuberculosis, at 4% of the burden of disease, got 22% of the money.

Another finding was that central planning was lacking in the health-care systems. For instance, a package of drugs came from a central store in Dar es Salaam each month - the same ones to each clinic, regardless of whether the area had a high rate of malaria or an epidemic of sleeping sickness. The key drugs quickly ran out, and sick people who came to clinics found there were no drugs to fill their prescriptions, so they stopped coming.

According to TEHIP, in Rufiji and Morogoro districts, malaria alone accounts for 30% of all the healthy years of life lost due to deaths. Moreover, children up to age 5 bear 62.6% of the total burden of disease in these districts, compared to 37.4% for older people. Large studies in The Gambia, Ghana, and Kenya have documented a 17-63% reduction in overall child mortality as a result of ITN use.